What is the next step in managing a 64-year-old male with COVID-19 (Coronavirus Disease 2019) on day 3, experiencing increasing shortness of breath (dyspnea) and bilateral effusions in the bases on chest X-ray?

Management of COVID-19 Patient with Increasing Shortness of Breath and Bilateral Pleural Effusions

The patient requires immediate oxygen supplementation, close monitoring, and hospital admission for management of COVID-19 pneumonia with bilateral pleural effusions.

Initial Assessment and Management

• Provide supplemental oxygen to maintain peripheral oxygen saturation above 90-96% 1
• Position the patient upright to improve ventilatory capacity and reduce airway obstruction 1
• Assess severity of respiratory distress through vital signs monitoring, particularly respiratory rate (severe if >30 breaths/min) 1
• Obtain arterial blood gas analysis to evaluate hypoxemia severity and acid-base status 1

Diagnostic Workup

• Complete blood count to assess for lymphopenia, which is common in COVID-19 2
• C-reactive protein and other inflammatory markers to determine disease severity 2
• Consider closed pleural fluid sampling for diagnostic purposes to rule out other etiologies 2
  • Pleural effusions are uncommon in typical COVID-19 pneumonia (only 3% of cases) but can occur 3
  • Analysis should include cytology to exclude malignancy 2
• Consider chest CT scan for further evaluation of lung parenchyma and to assess for pulmonary embolism, which is a known complication of COVID-19 1

Treatment Approach

Respiratory Support

• Start with conventional oxygen therapy via nasal cannula or face mask 1
• If respiratory distress persists or worsens despite conventional oxygen therapy, consider:
  • Higher flow oxygen delivery systems 1
  • Positioning techniques including leaning forward with arms bracing a chair to improve ventilatory capacity 1
• Monitor for signs of respiratory failure requiring advanced respiratory support 1, 4

Pharmacological Management

• Consider remdesivir if within 7 days of symptom onset 5
  • Loading dose of 200 mg IV on day 1, followed by 100 mg IV daily 5
  • Treatment duration of 5 days for hospitalized patients not requiring mechanical ventilation 5
• For management of fever and discomfort, paracetamol is preferred over NSAIDs 1
• For distressing cough, consider codeine linctus or codeine phosphate tablets 1
• If the patient has moderate to severe breathlessness and is distressed, consider morphine sulfate immediate-release 2.5-5 mg every 2-4 hours as required 1

Management of Pleural Effusions

• If pleural effusions are contributing significantly to respiratory compromise, therapeutic thoracentesis may be considered 2
• Closed tracheal suction is mandatory if the patient requires intubation 1

Monitoring and Follow-up

• Continuous monitoring of oxygen saturation, respiratory rate, and other vital signs 1
• Regular reassessment of respiratory status and response to therapy 1
• Serial chest imaging to monitor disease progression 1
• Monitor for clinical deterioration, particularly around days 5-10 of illness when respiratory symptoms often peak 3

Special Considerations

• COVID-19 pneumonia with pleural effusions may represent a more severe or atypical presentation 2
• The presence of bilateral effusions in COVID-19 may indicate:
  • Severe inflammatory response 2
  • Possible secondary bacterial infection 1
  • Cardiac involvement or fluid overload 1
• Respiratory muscle weakness may contribute to dyspnea in COVID-19 patients and should be considered in the assessment 1

Prognosis and Complications

• Severity of chest radiographic findings typically peaks at 10-12 days from symptom onset 3
• Approximately 20% of COVID-19 patients require hospital admission due to severe disease, with one-third of these needing intensive support 6
• Monitor for potential complications including pneumothorax, pneumomediastinum, and pulmonary embolism 7, 1