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There is a transformation in the protocols for pulmonary disease management post-COVID-19: Dr Raghavendra MK

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Dr Raghavendra MK, pulmonologist, Manipal Hospitals, Jayanagar, Bengaluru details the impact of COVID-19 and points out that it can cause long-term damage to lungs even in mild to moderately ill patients. He also highlights the importance of a robust and comprehensive post-COVID-19 care programme for better recovery of patients and reversal of damage caused by COVID-19, in an interview with Lakshmipriya Nair

Can the COVID-19 virus cause long-term damage to lungs even in mild and moderately ills patients? If yes, tell us about the huge disease burden of respiratory disorders and pulmonary ailments that India might have to face in the times to come?

The COVID-19, caused due to the novel coronavirus, is posing an unprecedented global health crisis. The disease is spreading without any bias to the young, adults, and the elderly. It causes significant changes in the lungs. The important question that arises is whether the patients recovered from this disease have lung capacity like pre-COVID, or there is long-term damage to lungs even in mild to moderately ill patients. Many people who had survived the disease may end up contracting chronic end-stage lung disease, and a surgery or lung transplant may be required in such patients in the future. Because of the significant damage to lungs in infected and recovered COVID-19 patients, India is all set to witness a high pulmonary disease burden in the future. Some of the common respiratory ailments that lead to long term complications are:

Chronic cough: Several patients may continue experiencing chronic cough as a complication of COVID-19. The patient may experience the post-viral cough that may continue for at least three weeks to eight weeks.

Fibrotic lung disease: Pulmonary fibrosis is one of the most common complications faced by COVID-19 recovered patients. Radiographic, clinical, and autopsy data available indicates that pulmonary fibrosis causes severe acute respiratory distress syndrome (SARS) and the Middle East respiratory syndrome (MERS) pathology.

Bronchiectasis: It is a condition characterised by permanent enlargement of airway parts that results in swelling and easily collapsible airway. The patient may experience excessive mucus production with a chronic cough. COVID-19 may cause severe bronchiectasis in a previously healthy person.

Pulmonary vascular disease: Pulmonary vascular abnormalities are a common presentation in COVID-19 patients. It includes the mosaic perfusion patterns and vessel enlargement. Endothelial dysfunction may in COVID-19 be due to hypoxia, lung coagulopathy, inflammation, and oxidative stress.

Impairment of diffusion capacity: Impairment of diffusion capacity is seen in patients while discharged from the hospital. It is important to perform routine pulmonary function tests in such patients.

Restrictive ventilatory defect: Because of the permanent damage to the lungs, the patients with COVID-19 have a restrictive ventilatory defect. This condition restricts the expansion of the lungs resulting in reduced lung volume, increased breathing, and low oxygenation or ventilation.

Obstructive airway disease: COVID-19 infection may result in various obstructive airway diseases such as asthma, COPD, and bronchitis that may continue even after the recovery from infection.

How should the healthcare system in India prepare to minimise this burden? Do we have any global examples that can be emulated?        

COVID-19 has caused serious implications on the health of the people. The people who had recovered from this highly contagious infection may have to suffer from post-infection complications either permanently or for at least a significant part of their life. To combat the complications that chases the patients even after recovery, India should consider the following measures:

Guidelines for long term complications: Robust guidelines should be framed for the patients who have recovered from COVID-19. The Government should ensure that these guidelines should reach the people so that they can be effectively implemented. The guidelines should suggest the possible complications and the adequate care required in a different scenario. An expert group comprising the AIIMS Delhi experts and representatives of ICMR and WHO’s India office for framing the guidelines.

Increase in healthcare infrastructure and funding: It is important to note that the complications of COVID-19 may put an economic and psychological burden on patients, especially o the lower-income group. Many people, in the future, may not able to opt for medical treatment due to payment issues, leading to increased complications and disease burden. India should invest in healthcare infrastructure to provide adequate facilities for such people.

Increase the number of testing: India should increase the number of testing to diagnose the infection at an early stage. This will help in the initiation of early treatment and reduced long-term complications. By adopting strategic planning, India can achieve a high number of testing. However, there would be a requirement of the additional workforce, scaling-up for sample collection, and increased level of transportation.

Following speed, scale, and equity: To combat the COVID-19 virus, India should speed up our efforts as any delay may cost lives and increase complications. Adequate facilities should be scaled-up to reach as many people as possible. India should divert the resources to that part where there is the greatest risk.

Implementing global strategy: The global strategic objectives include mobilise information about preventing COVID-19; Control by diagnosing and isolating the infected patients; suppress transmission to various policies including social distancing; reduce the death rate by providing medical care to the patient and; develop new therapies to treat the infection.

The importance of post-COVID care is becoming increasingly clear to prevent long-term complications. What will be the most important aspects to be considered while drawing out a strategy for it?

People recovering from COVID-19 infection are suffering from long term complications. Although the infection predominantly affects the respiratory system, serious damage is also done to various other organ systems like the cardiovascular system (heart), urinary system (kidneys), and brain. The quality of life is significantly impacted due to chronic fatigue, malaise, and joint pain with increased risk of blood clotting. Thus, a suitable strategy should be formulated for treating the patient in such a way that current infection managed and future complications are prevented or minimised. The following points should be worth considering while creating a suitable strategy for managing COVID-19 patients:

Comprehensive information about the medical history of the patient: While initiating the treatment and call for further diagnosis, detailed information about the medical history of the patient should be made available to the doctor. This will help in analysing and managing possible complications. For example, patients with obesity and cancer are at increased risk of venous thromboembolism.

Post-COVID-19 rehabilitation: Patients with COVID-19 infection are not only affected physically, but there is also a serious impact on the psychological health of the patient. The patient may suffer from ICU delirium, anxiety, depression, and post-traumatic stress disorder. Evidence-based rehabilitation intervention should be provided to patients.

Using evidence-based treatment: While formulating the strategy for managing the long-term complications of COVID-19, an evidence-based approach should be used. This is because very little is known about the virus, and the disease and using a random treatment strategy may backfire.

Recovery of damaged lungs depends upon the age and severity of the condition.  Although it is too early to evaluate the recovery of patients and reversal of damage caused by COVID-19, through better management during the post-COVID-19 phase, there are chances that the patients may be able to recover from mild to moderate damage. The pulmonary rehabilitation program comprises resistance training and aerobic training and helps to enhance muscle strength and exercise capacity.

Manipal Hospital has a robust and comprehensive post-COVID-19 care programme that prevents disease progression and minimises or prevents complications. This programme also involves consultation after two weeks of recovery to evaluate the condition of the patient.

So, are we seeing a transformation in clinical management protocols for pulmonary disease management as a result of COVID-19? If yes, can you share the salient details?

There is indeed a transformation in the management protocols for pulmonary disease management post-COVID-19. An aggressive approach towards the diagnosis and management of the pulmonary disease is warranted. More advanced technologies are being incorporated in the respiratory disease management. The infrastructure should be improved to diagnose the presence and severity of the disease. Following are some of the salient features for protocol transformation of pulmonary disease management:

Therapeutic pulmonary telerehabilitation: Therapeutic pulmonary telerehabilitation was in the budding stage in India before COVID-19 and was under recognised in the management of respiratory diseases. However, after the COVID-19, things will certainly be changed for telerehabilitation. Various hospitals such as the Manipal Hospital have initiated this service and may continue it even when this pandemic gets over.

Advanced diagnostic laboratories: A rise in spending on improving the healthcare infrastructure is surely on the cards. The healthcare professionals will require the accurate medical diagnosis of the patient to manage the disease as well as the complications. Further, to tackle the increased number of patients, there will surely be an increase in healthcare facilities.

Social distancing and mask to avoid contagious respiratory infections: Apart from the novel coronavirus, various other pathogens cause communicable respiratory disease. These diseases include influenza and tuberculosis. People would continue to maintain social distancing and wear a mask in case they suffer from any of the communicable diseases. This helps in reducing the disease burden.

Hygienic habits: People will maintain proper hygiene through sanitisation or by frequently washing their hands. This results in a decrease in overall respiratory patients.

The COVID-19 pandemic has increased the pathological understanding of the respiratory disease and their association and impact on other organs. There is increased knowledge and skills of the pulmonologists about handling the severe cases of respiratory diseases. Because of the involvement of other organs in COVID-19, the pulmonologists have interacted more than ever with the doctors of other departments, thereby increasing interprofessional communication. In response to the pandemic, the doctors should work outside the usual competencies. The pulmonologists improved cross-skilling by working beyond their capabilities.

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