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Chapter 24 Coordinating Care for Patients With Infectious Respiratory Disorders
index [BMI] greater than 30), respiratory disease, auto- immune disorders, mental health disorders, physical or developmental disabilities, and lifestyle (e.g., smoking, substance abuse). Worldwide, there is concern over disparities in case rates, outcomes, and deaths among minority communities. The influence of systemic health disparities places these groups at higher risk for preexisting conditions (e.g., dia- betes, cardiovascular disease, asthma, and obesity), which increases their risk of severe disease. Socioeconomic factors that heighten the possibility of exposure and subsequent development of severe COVID-19 illness are multifam- ily living arrangements, inability to suspend working due to financial insecurity, absence of sick time offered by employers, and unemployment and housing insecurity. In the United States, ethnic minorities and people of color are at heightened risk for exposure, severe illness, hospital- ization, and death. Pathophysiology Coronaviruses are enveloped RNA viruses belonging to a group of known coronaviruses causing respiratory illness, ranging from the common cold to acute respiratory failure. Viral infections, in general, are critical because mutations occur at high rates, resulting in newer strains (variants) with differing viral behaviors. Viral access to host genetic material is required for viral replication to occur. SARS-CoV-2 binds to cell receptors and deposits messenger RNA (mRNA) inside the host cell using the ACE2 receptors. These ACE2 receptors are found in cell membranes of the lungs, heart, kidney, and intestines and throughout the arterial vasculature. Viral particles are released from the infected host cell and enter other cells to continue to replicate. The high rate of ACE2 expression of lung epithelial cells accounts for the damage to airways. Expression of ACE2 by the arterial vasculature is thought to activate the intrinsic pathway of the clotting cascade resulting in the hypercoagulable state associated with COVID-19 disease. The main mechanism of transmission of COVID-19 has been established as close contact (within 6 feet) with respiratory droplets expressed by an infected person during coughing, sneezing, laughing, singing, and talking, or by infected droplets landing in the eyes, nose, or mouth by inhalation or direct transference of viral particles on the hands (Fig. 24.2). There is also evidence that aerosoliza- tion of the virus occurs during various procedures per- formed in the healthcare setting (e.g., nebulizer delivery, incentive spirometry, flutter valve, oxygen delivery, airway suctioning, and during intubation), increasing the possibil- ity of spread and infection. Viral survival time on a variety of surfaces has been examined and is dependent on tem- perature, humidity, viral load deposited, and porousness of the surface. Antibody production occurs as part of the humoral immune response to disease. To date, variable immune
response among recovered hosts has been observed and does not appear to correlate with symptom or illness sever- ity. Antibody detection in the serum of recovered or vac- cinated hosts can be seen approximately 2 to 3 weeks after infection/inoculation. The duration of protection is also variable among individuals and can be evident for up to 4 to 6 months. The actual protection provided by natural expo- sure and antibody production is still being investigated.
Safety Alert
Any hospitalized patient presenting with symptoms suggesting a high clinical sus-
picion of COVID-19 infection should be placed in a single occupancy negative pressure room with the door closed. If single occupancy rooms or negative pressure rooms are not available, WHO recommends cohorting patients according to their COVID status of suspected, probable, or confirmed, in consultation with healthcare infection and prevention experts. Aerosolized interventions should be performed using airborne precautions with a closed system filter mechanism to avoid viral spread. All personnel present should wear personal protective equipment (PPE) required for airborne, contact, and droplet isolation. Clinical Manifestations COVID-19 symptoms can range from no symptoms to life-threatening in severity and can develop from 2 to 14 days after exposure (close contact with an infected person). Indi- viduals infected with COVID-19 are considered conta- gious from 2 days before symptom presentation or positive COVID test up to 5 days after symptoms resolve without the use of medications. Symptoms include fever, cough, rhinorrhea, dyspnea, tachypnea, headache, fatigue, myalgias, new-onset anos- mia and/or ageusia (loss of smell/taste), and gastrointesti- nal disorders (e.g., nausea, vomiting, diarrhea). Occasional instances of cutaneous manifestations have also been reported. Higher-risk patients may initially present with mild to moderate symptoms and progress quickly to severe illness over the course of 5 to 10 days. It is important to note that some patients who are admitted to the hospi- tal have generally been experiencing symptoms for up to 1 week. For this reason, any admitted patient who develops a new or increasing oxygen requirement should be closely monitored for a rapid decline in their condition. See Table 24.5 for classification of COVID-19 disease.
Interprofessional Management Medical Management
The COVID-19 pandemic presented an urgent and mon- umental challenge to researchers and clinicians to quickly develop guidelines for management of individuals in the
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