Skill Checkup: An 81-Year-Old Woman With Dyspnea, Nearly Incessant Cough, and Body Aches

Enrico Brunetti, MD


November 07, 2022

For patients with severe COVID-19, oxygen saturation < 90% on room air, signs of pneumonia, or signs of severe respiratory distress, the WHO COVID-19 guidelines strongly recommend corticosteroids (dexamethasone), interleukin 6 (IL-6) receptor blockers (tocilizumab and sarilumab), and Janus kinase inhibitors (baricitinib), noting that all three agents may be used as combined treatment. The panel also offers a conditional recommendation for the use of remdesivir in patients with severe disease.

NICE guidelines suggest that dexamethasone should be offered to patients in hospital with COVID-19 who need supplemental oxygen, or, if dexamethasone is not available, either hydrocortisone or prednisolone. A prophylactic dose of a low molecular weight heparin should be given within 14 hours of hospital admission.

For patients who are hospitalized, the WHO recommends against convalescent plasma and colchicine, which should only be used only in research settings. Ruxolitinib and tofacitinib should only be applied when neither baricitinib nor IL-6 receptor inhibitors are available.

Of note, patients who are older or with comorbidities, frailty, or impaired immunity are more likely to develop severe pneumonia, which could lead to respiratory failure and mortality. For this reason, NICE guidelines stress that patients with cough should be encouraged to sit in a prone position to allow for effective coughing.

The patient is started on treatment with corticosteroids; IL-6 receptor blockers and baricitinib are soon added, with dose adjustment on the basis of frailty. After 4 days, the patient is in acute hypoxemic respiratory failure and is not responding to current treatment.


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