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DOI: 10.1055/s-0041-1732340
Nebulized Heparin for Post-COVID-19-Related Hypoxia
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To the editor
The pulmonary manifestations of coronavirus disease 2019 (COVID-19) may require a long time follow-up and a special therapeutic approach (such as pulmonary rehabilitation, supplementary oxygens, etc.).[1] [2] [3] This may end with pulmonary fibrosis that necessitates long time oxygen therapy.[4] Most of these patients are hospitalized because of oxygen supply need that exceeds the capacity of portable or home oxygen concentrator devices.[5] Nebulized and/or inhaled unfractionated heparin is investigated in some disease conditions. Some examples of these are smoke inhalation-related lung injuries, adult respiratory distress syndrome (ARDS), and pulmonary fibrosis. These trials were all safe and successful somewhat.[6] [7] [8] Here, we report two cases of post-COVID-19-related disabling respiratory distress conditions that were treated with nebulized unfractionated heparin administration.
The first case was that of an 81-year-old female COVID-19 patient. She was admitted to our hospital's intensive care unit (ICU) for mechanical ventilation support. A three day pulse 250 mg and 80 mg maintenance dose of IV methylprednisolone was started. Also, she had received diuretics and different antibiotics. After 24 days of ICU unit care, she has been transmitted to our medical world with a 10 L O2 supply using a non-rebreather (NRB) facemask. Her ICU maintenance treatment of subcutaneous low molecular weight heparin (LMWH) enoxaparin sodium 0.6 mL twice daily, methylprednisolone 40 mg PO daily continued. During her seventh day of follow-up at our medical ward, N-acetylcysteine 300 mg IV thrice daily was also initiated. Despite these maintenance therapies, her O2 need was not decreased. On the 14th day of medical ward follow-up, still, her O2 requirement was 8 to 10 L (to keep pulse oxymetry oxygen saturation [sO2] at 92%). The ground glass appearances, bronchial dilatations, and cardiomegaly are evident in her chest CT ([Fig. 1]). Her insistence on home discharge was continued even at this critical level of O2 supply need. After a thorough search for possible nonharmful therapeutic approaches at these conditions, the suggestion of using nebulized heparin was made by the first author. In addition to the COVID-19 inpatient written consent form, this treatment was discussed with the patient and her first-degree kin. After a positive response, the first dose of 10,000 IU UFH (Koparin [Kocak Farma Ltd. Co.]) was administered by nebulizer for 1 hour (diluted in 3 mL of 0.9% NaCl solution). At the next day of this treatment, her oxygen need was decreased to 5 L (sO2 was 92%) (without any noted side effects). So, the dose of nebulized UFH increased to twice daily thereafter. At the end of third day of nebulized UFH treatment, her sO2 became 94% (with only a 4 L nasal O2 supply). Because of her insistence, she was discharged home with a portable O2 concentrator treatment support. On the 10th day of discharge, she has contacted by phone. She claimed that she is doing well. Her sO2 is approximately 95% (with a 3–4 L O2 supply) ([Table 1] for the progress).
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The second case was that of a 67-year-old male COVID-19 patient. His chest CT shows consolidations, ground-glass appearance, and bronchial dilations ([Fig. 1]). On the 17th day of admission, NRB facemask O2 support was not successful in keeping his sO2 levels above 92%. So, heated and humidified high-flow nasal oxygen support was started. Supportive maintenance steroid and LMWH were all given. On the 29th day of hospital admission, O2 needs were settled at 10 L (with sO2 levels of 90–91%). With the courage of positive results of our nebulized UFH therapy in the above first case, we discussed this treatment option with this patient too. After a positive response, as in the above previous patient, this UFH treatment was initiated as 10,000 IU twice daily. On the day of starting this treatment, the sO2 level was 91% (with a 10 L NRB facemask O2 supply). The day after starting this therapy, his sO2 was raised to 93% (with an 8 L O2 supply). As in the first case, this patient was discharged on the fifth day of completion of UFH therapy with a 2 to 3 L O2 supply need only (sO2 = 94%) ([Table 1]).
Publication History
Received: 04 May 2021
Accepted: 16 June 2021
Article published online:
30 July 2021
© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Georg Thieme Verlag KG
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