Dr. Sumit Sengupta (great pulmonologist based in Kolkata) writes: This is a personal summary of the COVID situation (without going into nuances or details) with some references meant for non-specialists and some recommendations for various situations.

They are based on ballpark figures, approximations and estimates and are therefore not written in stone and will change with time. Ordinarily these discussions are face to face with a specialist & tailored to specific situations in each patient, but these are extraordinary times.

If 100 patients get COVID-19 : 85 will settle with no treatment at all. 15 of these 100 will develop SpO2 (oxygen saturation) levels of 93 and below (usually between days 8 to 122) and should be hospitalized.

10 of these 15 will settle with nasal oxygen up to 6 litres /minute, steroids, prophylactic anticoagulants and occasionally Tocilizumab. Remdesivir may be given at this stage but it does not decrease deaths. Convalescent plasma has not been found to be beneficial3–7.

The other 5 will require critical care and escalation of respiratory support with non-invasive ventilation /CPAP or HFNC (High flow nasal cannula) oxygen. 3 out of 5 will settle down and be discharged. 2 will need to be intubated and invasively ventilated. 1 of these 2 survive.

Even under ideal conditions 1 of 100 symptomatic covid patients may die8. If hospital beds are not available all 5 who get critically ill and perhaps half of those who become hypoxic will die – increasing deaths to about 10 in 100.

Asymptomatic patients in general do not get hypoxic or die. The infection fatality rate (including both symptomatic and asymptomatic patients) is estimated at 0.3% retrospectively looking at positive serology9,10.

PREHOSPITAL CARE There is no proven treatment for non-hospitalized patients and in particular HCQS11–13, Azithromycin14, Doxycycline15, Vitamin C16, Vitamin D17, Zinc16 and Favipiravir18,19 do not work and is not recommended. Ivermectin not recommended because of poor qualitydata

3,6 and trials showing lack of efficacy20 . Colchicine21 and inhaled Budesonide22,23 have some data as prehospital treatment, but their efficacy is still debated. If used Colchicine is given 0.5mg twice daily for 3 days ,then once daily up to 14 days (Colchicine cannot be used

in kidney or liver disease and pregnancy). Budesonide has been used via inhaler 800mcg twice daily. There is a signal of reduced hospital admissions with these medications which need to be confirmed by more robust trials. PREHOSPITAL CARE IN PATIENTS WHO SHOULD BE HOSPITALIZED

With the onset of hypoxia (defined as SpO2 <94) the patient should be in hospital but may not find a bed. In these extenuating circumstances it is reasonable to start treatment with Dexamethasone 6 mg (OR Methylprednisolone 32 mg OR Prednisolone 40 mg) once daily after breakfast

for 10 days along with prophylactic anticoagulation (Either Rivaroxaban 10 mg once daily OR Apixaban 2.5 mg twice daily orally). The patient and their carers must be warned that a substantial proportion of such patients will deteriorate and likely die if not treated in hospital.

Please note that starting steroids before the patient becomes hypoxic is likely to HARM the patient.
Dr Sumit Sengupta MD, MRCP (UK), CCST (UK) in Respiratory Medicine, FRCP(London)

@moubanerjee28