What are the recommendations for a post-COVID patient on prednisone (20 mg/day) with no history of asthma or chronic obstructive pulmonary disease (COPD), experiencing shortness of breath and hypoxemia (oxygen saturation 94%), without access to oxygen therapy or inhalers?

Immediate Management of Post-COVID Dyspnea with Borderline Hypoxemia

For this post-COVID patient with SpO2 94% and dyspnea on prednisone 20 mg daily, initiate nebulized bronchodilators immediately—specifically salbutamol 2.5-5 mg or ipratropium bromide 0.25-0.5 mg via air-driven nebulizer—as this provides rapid symptomatic relief without requiring oxygen therapy or inhalers. 1

Oxygen Therapy Decision

• Do not initiate supplemental oxygen at SpO2 94%, as the British Thoracic Society recommends starting oxygen only when SpO2 falls below 92% in COVID-19 patients, with strong recommendation for oxygen when SpO2 <90% 1

• The current saturation of 94% falls within the target range of 94-98% for patients without risk factors for hypercapnic respiratory failure 1, 2

• Monitor closely for deterioration—if SpO2 drops to <92%, begin supplemental oxygen at 2-6 L/min via nasal cannulae, targeting SpO2 94-98% 1, 3

Nebulized Bronchodilator Therapy (Primary Recommendation)

• Administer nebulized salbutamol 2.5-5 mg OR ipratropium bromide 0.25-0.5 mg immediately for symptomatic relief of dyspnea 1

• Use air-driven nebulizer, not oxygen-driven, to avoid unnecessary oxygen exposure and potential complications 1

• If response is inadequate after initial dose, combine both agents (salbutamol plus ipratropium) in the same nebulizer 1

• Nebulization should take approximately 10 minutes for bronchodilators 1

• Repeat dosing can be given at 4-6 hourly intervals, but may be used more frequently if required 1

Corticosteroid Considerations

• Continue the current prednisone 20 mg daily—the patient is already on systemic corticosteroids which is appropriate for post-COVID management 1, 4

• The typical course for acute exacerbations is prednisolone 30 mg/day for 7-14 days, so the current 20 mg dose is reasonable 1

• Administer prednisone in the morning (prior to 9 am) to minimize adrenal suppression 4

• Do not abruptly discontinue—taper gradually when clinically appropriate 4

Non-Pharmacological Interventions

• Position the patient upright (sitting in a chair if possible) to optimize ventilation and reduce work of breathing 5, 2

• Provide a hand-held fan directed at the face, as this is recommended by the British Thoracic Society as first-line treatment for breathlessness when oxygen saturation is normal 2

• Offer reassurance, as anxiety naturally accompanies breathlessness and can worsen the sensation 5

Monitoring Parameters

• Measure respiratory rate immediately—a rate >30 breaths/min requires urgent escalation even with adequate SpO2 1, 3

• Monitor vital signs including heart rate, blood pressure, and mental status at least twice daily 3

• Reassess oxygen saturation every 1-2 hours initially, then at least twice daily once stable 3

• Consider arterial blood gas if clinical condition appears worse than SpO2 suggests, or if there is concern for hypercapnia 2

Critical Warning Signs Requiring Escalation

• Respiratory rate >30 breaths/min indicates respiratory distress requiring immediate intervention 1, 3

• SpO2 dropping below 92% mandates initiation of supplemental oxygen 1

• SpO2 <85% requires high-flow oxygen at 15 L/min via reservoir mask 1, 3

• Worsening mental status, inability to speak in full sentences, or signs of respiratory exhaustion warrant urgent medical evaluation 1

Alternative Considerations if Nebulizers Unavailable

• If nebulizers are truly unavailable, consider low-dose opioids (morphine 2-4 mg IV) for relief of breathlessness, though this is typically reserved for palliative settings 5, 2

• Positioning and fan therapy become even more critical in resource-limited settings 2

Common Pitfalls to Avoid

• Do not use oxygen-driven nebulizers in this patient—air-driven systems prevent unnecessary oxygen exposure 1

• Do not withhold bronchodilators based on absence of asthma/COPD history—post-COVID patients can have bronchospasm and airway inflammation that responds to bronchodilators 1

• Do not stop prednisone abruptly—gradual tapering is essential to prevent adrenal crisis 4

• Do not rely solely on SpO2—respiratory rate and work of breathing are crucial parameters that may indicate deterioration before oxygen saturation falls 1, 3