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Is Covid-19 leaving a long-term scar on the lungs?

Sujeet Rajan | Updated on July 03, 2020 Published on July 03, 2020

Supportive care needs to be brought into focus

Intuitive medicine has been the order of the day. Instinct too is part of clinical medicine, but it tends to play a much larger role when evidence is still in the process of being collated.

As a respiratory physician with significant interest in lung fibrosis, my instinct tells me mortality due to lung fibrosis is now heading upwards, as a possible fallout of Covid-19. Lung fibrosis, put simply, is scar formation in the lungs that is usually permanent, can potentially progress and significantly impede oxygen transfer from lung structure and small airways, to the blood.

In a flashback to previous avatars of coronavirus SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome), both had lower prevalence, and lung fibrosis post-SARS/MERS was also not common. This time around, though, you have a much more common virus and (seemingly already) more lung fibrosis after the infection. I have already seen seven patients with post-Covid lung fibrosis, one has died and one is very ill on a ventilator. The other five are definitely worse off in breathing than they were before Covid. This is going to be a real issue after Covid-19, if not already.

But there’s also some reassuring news. What happens to the average patient with lung fibrosis during the pandemic? Most of our patients seem well. They are possibly more protected at home for their sheer age, immuno-suppressant therapy, general debility and/or co-morbidity and they seem to be developing much less Covid than other patients with hypertension, diabetes, heart disease and obesity. If they do develop Covid, they will be even worse off after Covid than they are today.

Anti-fibrotic drugs (pirfenidone or nintedanib) may help here, but we can’t be sure. It was thought that patients on immunos-uppressants may be more susceptible to Covid, but I’m not seeing that either — they too seem to be somewhat ‘protected’. The pessimist may say they’ll get it later, but I am not buying that.

Take a look at asthma, for instance. Though some data suggests that asthmatics maybe at greater risk for Covid — the Centers for Disease Control and Prevention even put it at the top of their list of risk factors — I realised that had more to do with listing by alphabetical order, not because of evidence. I have yet to see a single controlled asthmatic of mine (on regular inhaled steroids) coming into hospital with Covid — and we have seen 400 + Covid patients admitted with us.

Some researchers are seeing a trend towards protection of asthmatics from Covid — we don’t know why. With data from the Recovery trial (Oxford University), one could hypothesise it is the inhaled steroid protecting them. So my message to asthma patients is, keep using your steroid inhaler regularly! Especially during this pandemic. Controlled asthma protects — uncontrolled asthma is bad news, and definitely so, during a viral pandemic.

A French study is recruiting patients for anti-fibrotic drugs, three months after they have suffered from Covid infection. I believe three months is too late to start. Based on early post-infection CT scans, these patients may need to be on an anti-fibrotic drug much sooner.

Three key principles

As we grapple with Covid 19, I believe it can be managed on three basic principles: by reducing viral replication, treating the hyper-immune response if it occurs and good supportive care. The last factor (though definitely implementable) doesn’t seem to be happening the way it should. Distanced from relatives and caregivers, the severely ill Covid-19 patient is completely disconnected from his loved one, and also bereft of meaningful conversations with healthcare workers — themselves immersed in their hazmat suits, and the work on hand. As one of my resident doctors put it, “all they may need is a conversation and a hand on their shoulder, even if it’s gloved” — that itself is rare these days. There needs to be increasing discussion on supportive and end-of-life care for many of these lung fibrosis patients after Covid (and even non-Covid), heading towards chronic oxygen support at home, or even (when that doesn’t help), ventilatory support. Ventilatory support can be non-invasive with a tight-fitting mask covering the nose/mouth or both, or invasive (with a tube placed in the windpipe).

We need to remember that invasive ventilation is uncomfortable, and rarely helps improve quality of life in progressive lung fibrosis. Palliative and supportive care services will be the need of the hour to ensure that despite their illness, these patients get the best possible quality of life, for as long as they live.

The writer is Consultant Respiratory Physician, Interstitial Lung Diseases/ILD Clinic, Bombay Hospital Institute of Medical Sciences and Bhatia Hospital, Mumbai. Views are personal

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Published on July 03, 2020
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