What is the best course of action for an elderly COVID-19 (Coronavirus Disease 2019) positive patient presenting with symptoms of dyspnea (shortness of breath), chest congestion, wheezing, and fever, who has not responded to over-the-counter (OTC) medications?

Management of Elderly COVID-19 Positive Patient with Respiratory Symptoms

This elderly COVID-19 positive patient with dyspnea, chest congestion, wheezing, and fever who has failed OTC medications requires immediate medical evaluation, likely hospitalization, and consideration for antiviral therapy with remdesivir if within 7 days of symptom onset, along with supplemental oxygen and corticosteroids if hypoxemic. 1, 2, 3

Immediate Assessment and Triage

Seek immediate expert consultation given the presence of dyspnea in an elderly COVID-19 patient, as this represents critical escalation requiring specialized management. 1 The most appropriate specialists include:

• Pulmonologist or internist with COVID-19 experience for initial evaluation 1
• Critical care specialist if signs of severe respiratory failure develop 1
• Infectious disease specialist depending on institutional resources 1

Critical Red Flags Requiring ICU-Level Care

Immediately escalate to critical care if any of the following are present: 1

• SpO2 <90% on room air or <94% at sea level 4, 1
• Respiratory rate >30 breaths/minute 4
• Bilateral pulmonary infiltrates on imaging 1
• Need for mechanical ventilation consideration 1

Common pitfall: Do not delay consultation waiting for test results or imaging, as clinical deterioration in COVID-19 can be rapid, particularly in elderly patients. 1 The median time from symptom onset to ARDS is 7-12 days, but acute deterioration can occur suddenly. 1

Antiviral Therapy

Initiate remdesivir (VEKLURY) immediately if the patient meets criteria: 3

Dosing for Adults

• Loading dose: 200 mg IV on Day 1 3
• Maintenance dose: 100 mg IV once daily from Day 2 3
• Duration: 3 days for non-hospitalized high-risk patients; 5 days for hospitalized patients not requiring mechanical ventilation (may extend to 10 days if no clinical improvement) 3

Critical Timing

• Must be initiated within 7 days of symptom onset for non-hospitalized patients 3
• Treatment should begin as soon as possible after diagnosis 3
• Remdesivir shows modest benefit in time to recovery in severe disease, though no statistically significant mortality benefit 5

Administration Requirements

• Only administer in settings with immediate access to medications for severe infusion/hypersensitivity reactions and ability to activate EMS 3
• Administer by IV infusion only 3
• Perform hepatic laboratory testing and prothrombin time before starting and monitor during treatment 3

Corticosteroid Therapy

Administer dexamethasone if the patient requires supplemental oxygen: 5

• Dexamethasone improves mortality for treatment of severe and critical COVID-19 5
• This represents the strongest evidence-based intervention for severe disease 5

Oxygen and Respiratory Support

Initial Oxygen Therapy

• Administer high-flow oxygen to maintain adequate oxygenation 6
• Monitor continuously through pulse oximetry 6
• Target SpO2 ≥90% 1

High-Flow Nasal Cannula (HFNC)

• When used appropriately, HFNC may allow patients to avoid intubation and does not increase risk for disease transmission 5
• Consider for patients with persistent hypoxemia despite conventional oxygen 5

Mechanical Ventilation (if required)

• Low tidal volume ventilation: 6-8 mL/kg 6
• PEEP titration: 6-15 cmH2O to prevent atelectasis 6
• Slower respiratory rate with smaller tidal volumes 6

Bronchodilator Therapy for Wheezing

Administer inhaled bronchodilators for the wheezing component: 6

• Continue bronchodilators even if intubation becomes necessary (can be administered through endotracheal tube) 6
• In the outpatient setting, 28.2% of patients with post-COVID respiratory symptoms used bronchodilators with benefit 7

Symptomatic Management

For Cough

• Avoid lying flat as this makes coughing ineffective 2
• Simple measures first: honey if not contraindicated 2
• For distressing cough: short-term codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 2

For Fever

• Paracetamol (acetaminophen) rather than NSAIDs 2
• Fever typically peaks around 5 days after exposure 2

For Breathlessness

• Positioning: sitting upright to increase ventilation 2
• Pursed-lip breathing: inhale through nose, exhale slowly through pursed lips 2
• Leaning forward with arms bracing a chair to improve ventilatory capacity 2
• Recognize that breathlessness causes anxiety, which further worsens breathlessness 2

Hydration

• Adequate fluid intake (no more than 2 liters per day) to avoid dehydration 2

Critical Monitoring

Signs of Clinical Deterioration

• Development or worsening of shortness of breath indicating progression to pneumonia 2
• Persistent hypoxemia despite supplemental oxygen 1
• Bilateral chest infiltrates on imaging 1
• Moist rales, weakened breath sounds, or dullness on percussion 4

Laboratory Monitoring

• D-dimer elevation (>1 μg/mL) is an important predictor for fatal outcomes and thromboembolism 4
• Monitor for pulmonary embolism, which can present identically to COVID-19 pneumonia (dyspnea, cough, fever) 4, 8

Thromboprophylaxis

Initiate primary antithrombotic prophylaxis if the patient becomes immobilized: 4

• Low-molecular-weight heparins are first choice 4
• Elderly COVID-19 patients with respiratory symptoms are at particularly high risk for venous thromboembolism 4
• Critical pitfall: Pulmonary embolism can be overlooked in COVID-19 patients as symptoms overlap completely 8

Infection Control

• Ensure appropriate isolation measures to prevent transmission to caregivers 2
• Airborne precautions required before any specialist evaluates the patient 1

Treatment Escalation Planning

Establish a clear treatment escalation plan immediately given the risk of rapid deterioration in elderly COVID-19 patients. 2 This discussion should occur as soon as possible and involve the patient and/or surrogate decision-maker. 4 Consider that a familiar environment is likely preferred over hospital transfer for patients with advanced dementia or severe comorbidities. 4

Alternative Diagnoses to Consider

While treating for COVID-19, maintain awareness of potential co-infections or alternative diagnoses: 9, 10, 8

• Bacterial superinfection (including atypical organisms like Nocardia in immunocompromised patients) 9
• Pulmonary embolism (can present identically to COVID-19 pneumonia) 8
• Drug intoxication (if altered mental status present) 10

Do not assume all symptoms are attributable to COVID-19 alone, particularly if the patient fails to improve with standard therapy. 8