Emergencies preparedness, response

Clinicians hold virtual conference on management of SARS patients

26 March 2003

Today, 80 clinicians from 13 countries participated in an electronic “grand rounds” on clinical features and treatment for patients with Severe Acute Respiratory Syndrome, known as SARS. Their discussion, organized by the WHO network of clinicians focused on features of the disease at presentation, treatment and progression of the disease, prognostic indicators and discharge criteria. No therapy demonstrated any particular effectiveness. Clinicians agreed that a subset of SARS patients, perhaps 10%, decline and need mechanical assistance to breathe. These people often have other illnesses which complicates their care. In this group, mortality is high.

Based on their experiences with patients, SARS clinicians are drawing the following conclusions:

Disease presentation:
All of the clinicians described presentations of SARS patients and a general consensus is agreed that presentation is relatively consistent across all nations. Presentation is of a prodromal illness with a sudden onset of high fever. In a great number of cases this sudden, high fever is associated myalgia, chills, rigors and non-productive cough. At presentation (which is often three to four days after onset of symptoms), a large proportion of patients have characteristic changes on chest x-rays.

Disease progression:
Following presentation, chest x-rays continue to worsen and most patients demonstrate bilateral changes with interstitial infiltrations (fluid build-up between cells in the lungs). These infiltrations produce x-rays with a characteristic cloudy appearance. Patients then fall into one of two groups. The majority, 80 to 90% of patients at day six or seven, show improvement in signs and symptoms. A second smaller group, progress to a more severe form of SARS, many of whom develop acute respiratory distress syndrome and require mechanical ventilatory support. Mortality associated with the more severe group is high, however, a number of patients have remained on ventilator support for prolonged periods of time. Mortality in the severe group appears to be linked to a patient’s other illnesses (co-morbid factors).

Prognostic indicators:
Generally, patients over 40 with other illnesses are more likely to progress to the severe form of the disease.

Numerous antibiotic therapies have been tried to date with little clear effect. Ribavirin with or without use of steroids has been used in an increasing number of patients. But in the absence of clinical indicators, its effectiveness has not been proven. Currently the most appropriate management measures are general supportive therapy, insuring the person is hydrated and treated for subsequent infections.

What next:
Planning these grand rounds regularly. The clinicians will be involved in establishing management guidelines (treatment, management of patients and contacts, discharge).

The participants agreed to “meet” regularly using electronic communications and to rapidly develop international guidelines for the care of SARS patients.