CME INDIA Presentation by Dr. Bhavin Jankharia.
- He is presently Consultant Radiologist at “Picture This by Jankharia.” He is the Trustee of Radiology Education Foundation (REF), a non-profit institution started in 1996 with the aim to foster radiology education among students and consultants.
- He has served as President of Indian Radiological and Imaging Association (IRIA) from January 2014 to January 2015. He was the editor-in-chief of the Indian Journal of Radiology & Imaging (IJRI) from 2009 to 2013.
- His main interests are cardiothoracic radiology, image-guided interventions and musculoskeletal imaging, mainly rheumatology and bone tumors.
- His latest book is titled “Computed Tomography of Interstitial Lung Diseases” and is available online.
Enigma of post COVID lung fibrosis is most feared complication at present. But there is HOPE and apart from hype of antifibrotic drugs, we need to look beyond it.
3 Post COVID Cases, 3 Messages:
Case 1:
- This 43-years old man has typical changes of ground glass and crazy-paving at presentation.
- One week later, the lesions have resolved significantly with residual ground glass, reticular opacities and a thin band.
- Message no 1:
- Most patients follow this pattern.
Case 2:
- This middle-aged individual had bad disease and was hospitalized for over a month.
- The first scan shows significant lung involvement. 3 weeks later, the lesions have started regressing / melting. Another 5 weeks later, there is some further improvement.
- The question remains – How much of this is permanent? Which of these lesions will eventually melt away / regress?
- Message No 2:
- The patient is improving clinically though slowly. Only time will tell as we see more and more patients coming for follow-up.
Case 3:
- This 47-years old had COVID-19 in mid-June. Her CT scan of 16 Jun shows typical subpleural areas of ground glass.
- In most patients, these resolve completely or with residual subtle ground glass or reticular opacities, as we have been seeing.
- This lady had particularly severe disease and the scan of 25 Jul shows traction bronchiectasis and distortion of architecture with volume loss, findings that are suggestive of fibrosis.
- Her repeat scan of 25 Sep shows further volume loss with definite fibrosis.
- Message No 3:
- This is not a common occurrence in most COVID-19 patients, but when there is honeycombing or traction bronchiectasis with architectural distortion, that is the time we can say for sure that there is post-COVID fibrosis.
CME INDIA Learning Points:
- FAQs on COVID-19 by the AIIMS e-ICUs and Ministry of health India, has asked physicians not to use antifibrotics such as pirfenidone (to prevent lung fibrosis).
- The increase of LDH reflects tissue destruction and is regarded as a common sign of cell damage. In patients with severe pulmonary interstitial disease, the increase of LDH is significant and is one of the most important prognostic markers of lung injury.
- The prevalence of post COVID-19 fibrosis will become apparent in time, but early analysis from patients with COVID-19 on hospital discharge suggests that more than a third of recovered patients develop fibrotic abnormalities.
- Abnormal immune mechanisms initiate and promote pulmonary fibrosis It starts possibly as a consequence of a cytokine storm. Dysregulated release of matrix metalloproteinases during the inflammatory phase of ARDS causes epithelial and endothelial injury. VEGF and cytokines such as IL 6 and TNFα are also implicated in the fibrotic process.
- It remains unclear why certain individuals are able to recover from such an insult. Others develop accumulation of fibroblasts and myofibroblasts and excessive deposition of collagen resulting in progressive pulmonary fibrosis. Why? Mystery is deep.
- Pirfenidone and nintedanib are the two approved antifibrotic drugs that, despite having different modes of action, are both effective in attenuating the rate of lung function decline and are widely considered to improve life expectancy.
- The use of antifibrotic therapies could also be under consideration based on the pulmonary fibrotic disease observed after COVID-19 recovery.
- Pirfenidone exerts antifibrotic, antioxidative and anti inflammatory properties.
- Since there is no effective treatment strategy to reduce ARDS associated lung injury and fibrosis, it could be suggested that pirfenidone could attenuate lung injury based on published data showing that pirfenidone reduces LPS induced acute lung injury and subsequent fibrosis by suppressing NLRP3 inflammasome activation.
Source: Pulmonary fibrosis in the aftermath of the COVID-19 era (Review) Article in Experimental and therapeutic medicine – July 2020 DOI: 10.3892/etm.2020.8980
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Post Covid care needs to be standardized pan India.
Certain observations
1. The vast majority make good recovery with mucolytic, low dose steroid (both systemic plus inhaled), Lasilactone, montelukast 2. A daily six minute walk test helps predicting recovery in the absence of regular CT scan 3. It’s very difficult to predict yet, which lung will deteriorate further ie POST COVID FIBROSIS but any one with predisposing factors and prolonged NIV/ Ventilation at more risk 4. Antifibrotic NOT to use in all cases 5. Riociguat to be encouraged where CTPA positive and prolonged raised DDimers
Excellent comment
Short simplified well written
In Long low dose steroid is only possibility as cost of Ricociguat is beyond to almost 95 percent people 5000 to 10000 dollars per month traditional anti pulmonary hypertensives like Bosantan or Ambrisantan costing moderately and having experience may be comfertable option though lnferior option
Only time will tell how much residual fibrosis remains after 2 years and how much symtoms remain ithink no symptoms no treatment moderate symptoms mild drugs only severe patient you can experiment to improve his conditions including Lung transplant
Excellent review. Use of Perfinedone and nintedanib should be restricted to eligible patients. We require guidelines regarding this to dispel confusion
Nice review