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Post-Acute COVID-19 Care: Case 11

eConsult Clinical Question

A 26-year-old male patient has post-acute COVID related dyspnea. I am recommending an increase in Advair Diskus to 500mcg-50mcg today as he has noticed improvement with the lower dose. Would you add a long-acting muscarinic antagonist (LAMA) if he is still not well controlled? Should he have PFTs, ECHO and/or chest CT completed or are you seeing relatively normal workup in patients with dyspnea after COVID?

eConsult Response

A 26-year-old male with history of COVID has persistent symptoms of shortness of breath and brain fog and fatigue. He is a non-smoker. He has no history of lung or heart disease. His exam was normal with a 02 sat of 99% a BMI of 26 with clear lungs and no edema. Labs showed a normal chest x-ray and normal spirometry although the peak flow was low. He has slowly been improving and the Advair has helped. I didn't see if he was vaccinated for COVID. His past medical history is noted for fatigue, mood disorder, vitamin D deficiency and COVID. 

His story is common and there is no single treatment to resolve his symptoms. You need to be sure there are no pulmonary emboli or cardiac dysfunction. Pulmonary fibrosis would be unlikely with normal spirometry and a normal CXR. Vitamin D deficiency needs to be corrected and I agree with using an inhaled corticosteroids/long-acting beta2 agonist or just an inhaled corticosteroid. There is not much of a role for LAMAs. There is some data that vaccination after COVID can help with post COVID symptoms

Assessment:  Post COVID dyspnea & Vitamin D Deficiency

My recommendations are as follows: 

  1. Get the Vit D level to above 35
  2. Continue Advair 500/50 twice a day
  3. Check a D-Dimer and if elevated he would need a CT angiogram
  4. No long-acting muscarinic antagonist (LAMA)
  5. No chest CT for now
  6. I would get an echocardiogram
  7. Hold on PFTs for now but do if without better in 6-8 weeks
  8. Get him vaccinated if he has not done so - it might help. 

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.