Corticosteroid therapy and bronchodilator therapy may improve symptoms in children with long-term COVID

October 21, 2022

3 minute read

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According to a recent case report, daily treatment with inhaled corticosteroids and bronchodilators may help children with reversible peripheral airway obstruction and pulmonary hyperinflation after developing persistent dyspnea despite normal spirometry.

This dyspnea often develops after infection with SARS-CoV-2, Nathan Rabinovitch, MD, MPH, pediatric allergist and immunologist at National Jewish Health, and colleagues wrote in the study, published in The Journal of Allergy and Clinical Immunology: In Practice.

Physicians should assess children with post-COVID dyspnea and exercise intolerance for reversible small airway obstruction and pulmonary hyperinflation, the researchers suggested. Source: Adobe Stock

The case study

In the case study, researchers described a 17-year-old Hispanic boy who developed COVID-19 in November 2020. Symptoms included severe shortness of breath and decreased exercise tolerance that persisted through next 5 months.

The prescribed treatment started with a fluticasone metered dose inhaler (MDI) 110 and an albuterol MDI, then changed to a fluticasone/salmeterol 115 MDI. However, the patient’s compliance was poor and he took his inhalers without using a spacer.

But the patient still reported an improvement in his exercise tolerance when he took his medication, and the researchers reported that he was able to walk on a treadmill for 5 minutes before shortness of breath set in. begin.

The patient had no previous diagnosis of asthma, episodes of wheezing or recurrent bronchitis. In addition, skin tests for 23 aeroallergens were negative. Evaluation by a behavioral specialist revealed no significant anxiety or depression.

Other presentations included normal FEV11 predicted percentage (97%) and FEV11 to forced vital capacity (0.81).

According to the researchers, 7.5 minutes of cycling exercise test reproduced the patient’s dyspnea symptoms via real-time laryngoscopy without any significant decrease in FEV1.1hyperventilation or adduction of the vocal cords.

The patient also had moderately increased hyperinflation (149%) with a normal residual volume (RV) to total lung capacity (TLC) ratio of 24 via plethysmography.

In addition, the patient had a percent increase in peripheral airway resistance (44% of total airway resistance) based on resistance measurement at 5 Hz – 20 Hz (R5-R20).

The researchers considered his 56% decrease from baseline in small airway reactance, measured by the area under the curve of R5 at the resonance frequency (AX), to be also significantly reversible.

The patient was then prescribed two puffs of fluticasone 44 daily and two puffs of albuterol before exercise in addition to using proper spacing technique, while slowly increasing his exercise regimen.

Three months later, the patient was able to exercise vigorously with marked improvements in shortness of breath. Although his AX response to albuterol continued to be significantly elevated, with a 51% decrease from baseline, his R5-R20/R5 decreased to 12.5% ​​of total lung resistance.

The researchers then concluded that the obstruction and hyperinflation of this patient’s predominantly small airways contributed to his dyspnea and exercise intolerance.

Other patients, recommendations

This patient was one of 50 children with post-COVID dyspnea assessed by the researchers, most demonstrating increased RV and/or RV/TLC, elevated R5-R20/R5 or AX reversibility with albuterol.

The researchers also noted that FEV1 methacholine reactivity was sometimes present in these children, although most of them did not have low FEV11 percent predicted or significant FEV11 reversibility after albuterol.

Most of these patients had no previous diagnosis of asthma or treatment with asthma medication. Those who did had non-persistent asthma before COVID-19, and only one had taken corticosteroids daily.

Overall, these children showed improvement in small airway resistance with albuterol and/or pulmonary hyperinflation, with nearly all reporting at least partial improvements in dyspnea and improvements in antihypertensive intolerance. exercise with inhaled corticosteroid therapy, with or without long-acting beta-2 agonists.

Although R5-R20 levels also decreased in these patients, the researchers continued, they did not normalize in all cases, indicating potential long-term changes in the airways.

Symptoms continued to decrease in these children as they maintained their medication and exercise regimens, but some of these improvements were likely due to the natural course of the disease as well, the researchers wrote.

Based on these findings, the researchers recommended that the potential contribution of reversible small airway obstruction and pulmonary hyperinflation be assessed in children with post-COVID dyspnea and exercise intolerance, as well as anxiety, dysautonomia and vocal cord dysfunction.

Physicians should also initiate sustained trials of asthma medications and slowly increase exercise intensity in patients who meet these criteria, as their spirometry is often normal, the researchers concluded.

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