Remote clinician-based home management of COVID-19 associated pneumonia in a resource limited setting

The coronavirus disease (COVID-19) pandemic has resulted in an increased number of patients that require respiratory support in terms of oxygen and ventilation. Due to the burden on the healthcare system there has been a shortage of hospitals beds in both the public and private sector. This has led to many patients being managed at home. Currently there is no consensus regarding best practice guidelines in terms of treatment of this subset of patients. We hereby present a case of a patient who was treated using appropriate respiratory support (a combination of low ow oxygen therapy via nasal prongs or face mask as high ow oxygen was not available), oral corticosteroids and anti-coagulants managed by remote clinician intervention. We also include our home management protocol.

declared the current COVID-19 outbreak a public health emergency of global concern and ultimately a pandemic. 1 With the rapid rise in COVID-19 cases, hospitals worldwide are reporting shortages of essential resources namely intensive care unit (ICU) beds, medical equipment and personal protective equipment (PPE) which is placing pressure on the health care system. Many institutions have postponed and/or cancelled elective and non-urgent procedures to conserve resources and limit exposure. 1,2 In South Africa, the critical care capacity and resources of hospitals, in particular, ICU/High care beds and high ow oxygen devices are constrained and poses a great challenge within the current COVID-19 scenario and is placing immense pressure on the provision of healthcare. Patients with respiratory failure require much higher concentrations of oxygen that can be achieved by specialised high ow nasal cannula devices or mechanical ventilation. 3 Healthcare practitioners are seeking alternative solutions to safely manage patients at home, even those with COVID-19 pneumonia. With the abovementioned constraints and resource limitations, the possibility of remote clinician based home management of patients with COVID-19 associated pneumonia should be considered.

Case Presentation
In June 2020, a 41-year-old female nursing manager with a history of chronic rhino-sinusitis presented with myalgia, headache and a postnasal drip with no documented COVID-19 exposure. The patient consulted with her local general practitioner (GP) who diagnosed acute sinusitis and prescribed amoxicillin, nasal decongestants and analgesics.
On day 3, the symptom severity escalated however up until this stage no pyrexia was evident. The patient returned to the GP as her symptoms were not improving and a real-time reverse transcription-polymerase chain reaction (rRT-PCR) nasopharyngeal swab was taken. She was advised to isolate with a clinical diagnosis of COVID-19 infection due to the fact that she was a frontline healthcare worker.
On day 4, pyrexia of greater than 38°C and dyspnoea ensued and the patient went to her nearest Accident & Emergency unit (A&E unit). No co-morbidities were noted.
A Chest X-Ray was completed ( gure 1A) and she was diagnosed with bronchopneumonia.
The rRT-PCR of her nasopharyngeal swab returned positive for SARS-CoV-2 but the patient's clinical condition did not meet the institution's criteria for hospital admission.

TREATMENT
Since the patient did not meet the hospital admission criteria, she was advised to self-isolate at home and follow a prescribed home care protocol as recommended by the clinician. She was instructed and guided on how to monitor her oxygen saturation and respiratory rate, and to return to the A&E unit if she de-saturated or if her condition deteriorated. The patient was advised to start Vitamin C, D and Zinc supplementation.
Home oxygen at two litres per minute was initiated via nasal canulae. The patient was placed in a prone position. Oxygen saturation immediately improved to 93% but the respiratory rate remained persistently high above 20 bpm. Rivaroxaban 10mg twice daily orally was initiated.
A reduced FVC with normal FEV1% may only suggest restriction Low vital capacity, which is perhaps due to restriction of lung volumes.

DIFFERENTIAL DIAGNOSIS
Initially the patient presented with non-speci c acute symptoms that may be in keeping with a common viral infection (rhinoviruses, non-SARS-CoV-2 coronaviruses and in uenza virus). However, with the pyrexia and cough one needs to consider community-acquired pneumonia and SARS-CoV-2. 4 The lymphocytosis clearly signi ed a viral aetiology.

OUTCOME AND FOLLOW UP
On the evening of day 12, the patient felt worse and prednisone 50mg orally per day was initiated by the clinician. Oxygen saturation at this point was 94%, pulse 101 beats/min, respiratory rate 44 breaths/min (bpm) and blood pressure was 82/66 mmHg.
The patient returned to the A&E unit where her respiratory rate was assessed to be 24 bpm. In view of the tachypnoea she was offered an admission bed however declined due to personal reasons.
The patient's clinical course improved overnight and on day 13, her respiratory rate was 22 bpm. On day 14, her clinical pattern had shown improvement with a respiratory rate consistently below 20 bpm and to the extent that the she was able to walk for the rst time in days.

Discussion
The COVID-19 pandemic has created an unprecedented strain on the healthcare systems of many countries. 5 At the zenith of the COVID-19 outbreak in China, there were not enough critical care beds available. 6 In Gambia, beds and personnel trained in critical care are limited to tertiary hospitals, as assessed; therefore, mortality associated with COVID-19 is likely to exceed the reported case fatality rate of 2.3%. 7 This is likely in a multitude of under-resourced countries. Critically ill patients are likely to end up in general wards and those cases requiring treatment in general wards are likely to be turned away from hospital.
With hospital resources currently constrained, managing patients presenting with mild cases and who do not require high ow oxygen, or ventilation (invasive or non-invasive), with remote clinician advice may be a viable option to consider. In order to have a successful outcome, there should be a nurse or at least a competent adult on site to monitor the patient and report back to the clinician. Preferably, there should be a video link to the access the doctor remotely however in extremely under-resourced areas, a telephone link should be su cient. 8 Furthermore, there should be an ambulance service available to transfer a deteriorating patient to a hospital.
Our remote clinician-based home management protocol involved the monitoring of vital signs, oxygen via nasal cannula titrated to achieve oxygen saturation of 92% to 96%, pronation for 2 hours and then a seated break for 15 to 30 minutes, Rivaroxaban 10mg orally 12 hourly, Prednisone at 0.75mg per kg body weight, and Vitamin C, D and Zinc supplementation. 9 Pronation has been shown to be of value in improving oxygenation by reducing shunt fraction. Selfpronation has been recommended albeit with high ow nasal oxygen (HFNC). 10 Slessarev et al. in 2020, reported that the prone position results in more even distribution of lung tissue leading to further uniform alveolar distribution and pulmonary perfusion and thereby improving oxygenation which prevents worsening of dyspnea, reduces lung oedema and progression of the disease. The authors proposed that HFNC can meet oxygen demands while allowing patients to manage their body position independently through self-proning. In addition to preserving ventilator capacity which is already restricted, routine use of HFNC combined with self-proning can be broadly applied to COVID-19 patients with hypoxemia and normal work of breathing. This care approach would be bene cial to under-resourced countries where hitech ICU techniques may not be available. 10 Current evidence suggests that the coagulation cascade is signi cantly disrupted during SARS-CoV-2 infection and predisposes patients to thrombosis due to excessive in ammation, platelet activation, stasis and endothelial dysfunction. 11,12 The case report by Di Tiano et al. This case report represented a mild case of COVID-19 associated pneumonia that we managed successfully without hospital admission. While we do not advocate that patients with COVID-19 associated pneumonia be managed at home routinely, it does show that managing milder cases in their homes may greatly assist in preventing the overloading of hospital capacity thereby saving those resources for the moderate and severe cases

Conclusion
The critical care capacity and resources in both public and private hospitals, in particular, ICU/High care beds and medical equipment are constrained posing a great challenge within the current COVID-19 scenario and is placing immense pressure on the provision of healthcare. In South Africa we are already experiencing our peak in certain provinces with the rest of the country set to follow within a short space of time and with the remainder of most of the African continent to follow. Therefore, the possibility of remote clinician based home management of patients with COVID-19 associated pneumonia should be considered. Further research will likely prove that remote clinicianbased monitoring or arti cial intelligence monitoring of patients on home oxygen may hold the key to preventing the collapse of healthcare systems in under-resourced countries due to the COVID-19 pandemic.
Teaching points: The Covid19 pandemic has resulted in a demand for hospital beds. There is a group of patients that may be managed via remote home based care.
There is no consensus regarding protocols for home based care, we thus provide a framework that was used to successfully manage this condition. ( Table 1) Careful selection of patients and remote physician care may be a viable model during the covid19 pandemic.

Declarations
The Patient consented to the use of the clinical information for the purpose of the written case report.
Availability of supporting data: all data are available on request to the corresponding author, Shivesh.maharaj@wits.ac.za Competing interests: None to declare Funding: The study is funded by the authors Authors' contributions: SM and NK conceived the study and SM identi ed the data. NK extracted the data and undertook the analyses, assisted by KH .SM prepared the initial draft the paper which both authors revised. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. Acknowledgements: Dr F Lambert and P Patel for their assistance  Table   Table 1: Clinician-based home management protocol for COVID-19 patients with associated pneumonia Figure 1 Left: 1a)Chest X-Ray on Day 4. Right: 1b0Chest X-Ray on Day 12