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The Implications of COVID-19 for Patients with Pulmonary Disease

Authors: C Lee Cohen and Carolyn D’Ambrosio

COVID-19 is rapidly becoming a dominant healthcare concern, not just in large urban hospitals but in smaller practices as well. On March 27, 2020, the USA surpassed all other nations in terms of burden of disease.1 The economic, social, and health impacts are unparalleled in the era of modern medicine. COVID-19 has wide-reaching implications, particularly for patients with pulmonary diseases, who are particularly at risk for untoward events. As of March 28, 2020, of the patients who were confirmed COVID-positive in the USA, 9.2% had underlying chronic lung disease.2 In one study in China, having chronic obstructive pulmonary disease (COPD) conferred a mortality hazard ratio of 2.681, even after adjusting for smoking status.3 Little is known about the effects of the disease in people with other lung conditions, though some of the difference between mortality outcomes in men and women in Wuhan (2.8% versus 1.7%, respectively) was attributed to a possible difference in the prevalence of smoking between the two genders.4 Overall, case fatality for people with COVID-19 and chronic lung disease (a composite of many different lung conditions) in China, was 8% as of late February.5

For outpatient management of patients with pulmonary disease and without COVID-19, many programs are moving to optimizing telehealth consultation. It is particularly challenging to screen patients in a respiratory clinic for respiratory symptoms. With the near-universal geographic distribution of the pandemic and the rising incidence of community exposure (e.g., getting coronavirus without a known contact) it is no longer sufficient to screen by symptoms, exposures, or travel.  The distribution of symptoms for COVID-19 is also quite variable and wide, from asymptomatic to fever (44–94%), cough (68–83%), sore throat (14–61%), shortness of breath (19–40%), fatigue (32%), headache (14%), muscle aches (11%), upper respiratory symptoms (sore throat, rhinorrhea, nasal or sinus congestion; 5–25%), gastrointestinal symptoms (nausea, vomiting, diarrhea; 4–9%), and now reports of anosmia as well.5–11

While certain aspects of care, such as pulmonary function tests, are hard to accomplish from afar, many practices feel it is safer to accomplish what can be done from afar. Telehealth is newly reimbursable by the Centers for Medicare and Medicaid Services.12 Where patients do need to be seen, Centers for Disease Control and Prevention (CDC) guidelines regarding social distancing are being observed. Where possible, patients are given surgical masks to wear as these do cut down, by roughly 50%, the number of respiratory droplets released in to the environment.13

The management of patients with COVID-19 and underlying pulmonary conditions is quite complex. If possible, screening should be done via phone or drive-through testing facilities to avoid patients with pulmonary disease without COVID-19 being infected in waiting areas. Generally, indications for inpatient hospitalization vary locally but tend to include high risk for decompensation and vital-sign abnormalities (particularly low pulse oximetry). Respiratory decompensation can progress rapidly with duration between symptom onset and ventilator need ranging from 3.0–12.5 days, median 10 days.7,14

Anecdotally, once respiratory distress begins, patients decompensate quite rapidly, and are sometimes intubated within 12–24 hours of arrival to the hospital. For patients with pulmonary disease, a lower threshold for monitoring in-hospital should be observed. Early conversations about goals of care, particularly regarding wishes toward intubation, should be conducted as soon as patients are admitted. Our data are limited, but most case series show mortality rates in the 60–80% range once intubated (86% in a correspondence from SA Ñamendys-Silva;15 66% in an ICNARC report from the UK16). One can imagine this is higher in patients with pulmonary disease.

Intubated patients with COVID-19 tend to develop an acute respiratory distress syndrome (ARDS), though this disease has some unique clinical features including relatively preserved lung compliance. Patients anecdotally tend to be “recruitable” with airway recruitment maneuvers, positive end-expiratory pressure (PEEP), and proning. There is speculation that this could be due to changes in surfactant production or microthrombi in pulmonary vasculature, but the overall understanding of disease pathophysiology is still very unknown. On autopsy, microthrombi and cellular debris are found, as are evidence of diffuse alveolar damage. The overall course of disease, once intubated, seems to be long. Our colleagues in Italy and Wuhan have warned that 2-week ventilator courses are common.

There are a number of drugs on trial (524 trials at the time of writing),17 and newly a five-person observational study of use of convalescent plasma;18 but no therapeutic option has yet become standard practice. Many are using combination of hydroxychloroquine, thought to work by inhibition of viral entry and reproduction as well as immune modulation. However, use is limited to expert consensus at this time, as data are still limited.19 QTC monitoring is required due to the risk of torsades de pointes.

The frequency with which patients require mechanical ventilation (about 5%)20 leads experts to believe that without severe Wuhan-like social restrictions and lock down there is likely to be a ventilator shortage. This is already being seen in New York City. This shortage leads to the positing of shared ventilators, challenging for myriad reasons, most notably that PEEP and tidal volume cannot be controlled or optimized separately for each patient. The ASA, SCCM, APSF, AARC, AACN, and CHEST societies have issued a joint consensus statement against using single ventilator for multiple patients.21 It also has led to considerable debate about how to ration medical care if this becomes necessary, as outlined in this excellent article by Douglas White.22

This disease has fundamentally changed, in a short time, how we deliver quality care to patients with pulmonary disease. And while it is hard to imagine positives in this circumstance, one can imagine a world where some of the patient-centered elements of our new care practices (such as infection control practices and telehealth options) remain even after COVID is contained.

 

References

  1. CNN Health. US coronavirus cases reach more than 101,000 as reported deaths hit new daily high. 2020. Available at: https://edition.cnn.com/2020/03/27/health/us-coronavirus-friday/index.html (accessed April 7, 2020).
  2. Centers for Disease Control and Prevention. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. Available at: cdc.gov/mmwr/volumes/69/wr/mm6913e2.htm (accessed April 7, 2020).
  3. Guan W-J, Liang W-H, Zhao Y, et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis. Eur Respir J. 2020:2000547.
  4. Broad Institute. Evolving epidemiology and impact of non-pharmaceutical interventions on the outbreak of coronavirus disease 2019 in Wuhan, China. A webinar with Xihong Lin presented on March 20, 2020 and available at: youtube.com/watch?v=aQ9KIO1eXTA&feature=youtu.be (accessed April 15, 2020).
  5. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). 2020. Available at: who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf (accessed April 7, 2020).
  6. Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State. JAMA. 2020: doi: 10.1001/jama.2020.4326. [Epub ahead of print].
  7. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395:507–13.
  8. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020; doi: 10.1056/NEJMoa2002032. [Epub ahead of print].
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  11. Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. JAMA. 2020; doi: 10.1001/jama.2020.3204. [Epub ahead of print].
  12. Centers for Medicare and Medicaid Services. Medicare telemedicine health care provider fact sheet. 2020. Available at: cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet (accessed April 7, 2020).
  13. van der Sande M, Teunis P, Sabel R. Professional and home-made face masks reduce exposure to respiratory infections among the general population. PLoS One. 2020;3:e2618.
  14. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395:1054–62.
  15. Ñamendys-Silva SA. Respiratory support for patients with COVID-19 infection. Lancet Respir Med. 2020;8:e18.
  16. Intensive Care National Audit and Research Centre. Report on 775 patients critically ill with COVID-19. 2020. Available at: icnarc.org/About/Latest-News/2020/03/27/Report-On-775-Patients-Critically-Ill-With-Covid-19 (accessed April 7, 2020).
  17. gov. Available at: https://clinicaltrials.gov/ct2/results/details?cond=COVID+19&draw=1&rank=46 (accessed April 7, 2020).
  18. Shen C, Wang Z, Zhao F, et al. Treatment of 5 critically ill patients with COVID-19 with convalescent plasma. JAMA. 2020; doi: 10.1001/jama.2020.4783. [Epub ahead of print].
  19. Multicenter collaboration group of Department of Science and Technology of Guangdong Province and Health Commission of Guangdong Province for chloroquine in the treatment of novel coronavirus pneumonia. Expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia [Article in Chinese]. Zhonghua Jie He He Hu Xi Za Zhi. 2020;43:E019.
  20. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020; doi: 10.1001/jama.2020.2648. [Epub ahead of print].
  21. Anesthesia Patient Safety Foundation. Joint Statement on Multiple Patients Per Ventilator. 2020. Available at: apsf.org/news-updates/joint-statement-on-multiple-patients-per-ventilator/ (accessed April 7, 2020).
  22. White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA. 2020; doi: 10.1001/jama.2020.5046. [Epub ahead of print].

 

Author information:
C Lee Cohen, Fellow, Harvard-Brigham and Women’s Hospital, Pulmonary and Critical Care Fellowship Harvard Medical School, Boston, MA, USA; Carolyn D’Ambrosio, Director, Harvard-Brigham and Women’s Hospital, Pulmonary and Critical Care Fellowship; Associate Professor of Medicine, Harvard Medical School, Boston, MA, USA

Disclosures: C Lee Cohen and Carolyn D’Ambrosio have no financial or non-financial relationships or activities to declare in relation to this article.

Support: Commissioned, edited and supported by Touch Medical Media.

Published: 15 April 2020

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