key: cord-1014013-17abbp5j
authors: Rutenberg, David; Tuch, Howard; Zhang, Yumeng
title: HYDROMORPHONE USED AS ADJUNCTIVE THERAPY FOR RESPIRATORY DISTRESS IN SEVERE COVID-19
date: 2021-10-31
journal: Chest
DOI: 10.1016/j.chest.2021.07.1709
sha: c3da6354683cb77b5daef006dbc34d2f24b2b781
doc_id: 1014013
cord_uid: 17abbp5j

nan

INTRODUCTION: COVID-19 continues to be a health concern of global proportions. The virus primarily causes respiratoryrelated symptoms. Manifestations of the disease range from asymptomatic, to respiratory distress, to death. Much research has been done to uncover treatments for the virus. Currently, the NIH recommends only a few primary and adjunctive therapies for COVID-19. Opioids, which can treat pain and dyspnea, should be considered as adjunctive therapy for COVID-19. Treatment of pain and dyspnea may improve gas exchange and depressive symptoms. We present a case of a patient with severe COVID-19 who improved with hydromorphone (HM) combined with standard therapy.

CASE PRESENTATION: Mr S is a 64-year-old male with a past medical history of hypertension who presented to the hospital with dyspnea and syncope. Ten days prior, the patient had fever, dry cough, fatigue, and myalgia. Outpatient COVID-19 test was positive. Vital signs showed blood pressure 142/69, pulse 97, respirations 38, temperature 101 F, pulse oximeter 44% on room air. He was alert and oriented but ill-appearing. Labs showed positive COVID-19, C-reactive protein 32.38 mg/dL (range 0.01-0.5), ferritin 1103 ng/mL (range 21.8-274.7), white blood cell 16.21 10*3/uL (range 4.6-10.2), negative COVID IgG antibodies. Chest xray showed bilateral lower lobe airspace disease. He was placed on heated high-flow nasal cannula (HHFNC) 60L/100% FiO2 with inhaled epoprostenol and admitted to the intensive care unit. He was treated with intravenous (IV) dexamethasone, IV bumetanide, albuterol and ipratropium nebulizers, and placed in prone position. On hospital day (HD) 3, due to worsening hypoxemia, severe dyspnea, fatigue, generalized pain, and hopelessness, the patient sought comfort measures. Palliative care (PC) was consulted for goals of care. PC started a HM patient-controlled analgesia pump, 0.2 mg every 10 minutes on-demand to better assess patient goals when symptoms were more controlled. On HD4, the patient's hypoxemia, pain, and respirations improved. He had a stronger will to continue treatment. On HD8, he was weaned from HHFNC to nasal cannula (NC). On HD9, he required NC with exertion. He was discharged to home on HD11.

DISCUSSION: Perception and drive for breathing is processed by multiple regions of the brain's cortex and brainstem. Hypoxemia leads to dyspnea and tachypnea. Tachypnea may cause poor gas exchange from low tidal volumes. Tachypnea often leads to respiratory fatigue and intubation. Research has shown opioids can safely depress in the brain the sensation of dyspnea and reduce tachypnea without adverse effect. This could lead to improved oxygenation by improving respiratory mechanics and tidal volume, as well as diminishing work of breathing.

CONCLUSIONS: Our patient avoided death after he was treated with opioids. By treating dyspnea with opioids alongside standard COVID-19 therapies, patient outcomes may improve.

COVID-19 Treatment Guidelines. National Institutes of Health