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Post-Acute COVID-19 Care: Case 10

eConsult Clinical Question

A 50-year-old male, healthy prior to COVID diagnosis three months ago resulting in prolonged ICU stay, with acute respiratory distress syndrome (ARDS), cardiac arrest now with severe pulmonary fibrosis and a severe, constant cough. He is using albuterol with inconsistent and mild relief. He is also uninsured. Would oral steroids be helpful here? Or other recommendations to help?

eConsult Response

A 50-year-old former smoker had COVID pneumonia complicated by intubation with ARDS, cardiac arrest, atrial fibrillation, and streptococcal bacteremia 3 months ago. He apparently has severe pulmonary fibrosis with a relentless severe cough. This is despite Breo 100 - Tessalon 100 and albuterol prn. He has shortness of breath even at rest. Meds and allergies were reviewed. 

The post COVID syndromes are hard enough to treat and he has pulmonary fibrosis on top of that with a history of smoking. It is possible he had some chronic obstructive pulmonary disease (COPD) at baseline and now has pulmonary fibrosis superimposed which could be from COVID or oxygen toxicity or ARDS. Pulmonary fibrosis can cause cough. The relentless cough can also be complicated by occult reflux due to high abdominal pressure. Pulmonary fibrosis is not very treatable, and it is reasonable to think about lung transplant although usually patients are on supplemental O2 at the time of referral. 

My plans and suggestions are as follows:

  1. High resolution CT of the chest  
  2. 5 days of prednisone 40mg to see if any substantive impact
  3. Change Breo to Trelegy 200
  4. Increase Tessalon to 200mg three times a day
  5. Start gabapentin 100mg three times a day increasing to 300mg three times a day as tolerated for cough
  6. exercise oximetry on room air
  7. omeprazole 40mg by mouth twice a day for 30 days.

These real-life examples have some limitations. Given the evolving recommendations and guidance on COVID-19 care, these cases should not be considered complete or definitive and may not reflect the most up-to-date guidance.