Originally posted 21st Aug 2020; Updated: 1st Sept. 2020.

Q: What is the protocol for residual lung dysfunction post Covid19 which is very common in patients who have suffered lung affection to the tune of 30 percent or more?

CME INDIA Discussion:

Dr Raju Sharma, Jamshedpur: Now a lot of post Covid home or post discharges are coming. Two scenarios:

• One without cough but had a lung involvement
• Second no lung involvement but now having cough

Dr Atri Gangopadhyay, Pulmonologist, Ranchi: Very early to predict, post discharge focus on:

1. Local hygiene
2. Anti-inflammatory

• Inhaled steroid/mucolytic/montelukast/postural drainage/coenz Q10
• After 1 week/2 week- spirometry, to note down baseline FEV1, FVC
• Repeat same after one month, if not much improvement, then further measures like antifibrotic/ systemic steroid/lung biopsy

Dr Akash Singh, Baroda: Some of the doctors are using steroids say prednisolone 40 mg on discharge and tapering them down gradually over 4-6 weeks and pirfenidone for cases who take very long to get off O2 or are discharged on O2 to home.

Dr Nishith Kumar, Pulmonologist, Ranchi: 

• One thing is clear that the extent of lung fibrosis is positively correlated with the duration & severity of Covid related pneumonia. One study indicated that the prevalence rate of lung fibrosis in cured Covid 19 patients at 9 months after discharge is about 21%. 
• Pulmonary Thrombo Embolism is another pulmonary issue which may affect people post-COVID-19 recovery. All the high-risk patients in whom we did CT 

Pulmonary A angiography (In Orchid Medical Centre, Ranchi) turned out to be positive for PTE.

• Elevated D Dimer >2000 in Covid pt is a definite Predictor for PTE. 
• Newer NOACS (apixaban/Dabigatran/rivaroxaban etc) should be considered on Discharge & CTPA should be considered in all patients with markedly elevated D Dimer wherever possible/feasible. 
• Quite a few of my patient (especially those who are old & suffered from severe disease) still require (after 1-2 weeks post discharge) support of home oxygenation even after discharge and recovery. But of course they are getting better & better day by day & their supplemental oxygen requirement is gradually going down. 
• It is still not known whether post Covid fibrosis will be progressive or not. If progressive like IPF then antifibrotics like Nintedanib /Pirfenidone may have a place…if not progressive & static (as in post infective sequelae eg Tuberculosis) anti fibrotic won’t be of much help..we can only wait and see how it behaves in future..Inhaled corticosteroid/ Oral corticosteroid post discharged are all being used post discharge to prevent lung fibrosis but efficacy is currently unknown.

Post Covid Lung Fibrosis – An Emerging problem around you.. What to do?

Asks Dr Sanjay Gandhi, Pune: Can you please guide regarding use of Perfenidine in post Covid fibrosis prevention?

Dr. Virendra Singh, Pulmonologist, Jaipur:

• Post COVID fibrosis is a serious complication. It may be observed as early as 3-4 weeks after onset of symptoms. I have seen 2 patients. I used steroids in tapering doses. In 6 weeks time there was some radiological clearance. 

Though there may be argument “Is fibrosis reversible?”

Earlier we have published 2 cases of post swine flu fibrosis. In those cases also steroids were useful. 

My personal belief is to use steroids in early stage. However, there is also a logical potential of use of antifibrotic therapy such as Pirfenidone and Nintadanib in patients with post COVID fibrosis.

Dr Vivek Gumber, Resident Smbt medical college, Nashik: from CME INDIA-3: Sir can you tell is there any role of firperidone in covid patients to prevent fibrosis in mild to moderate disease? Any guideline or if to be given in which patients?

Dr Atri Gangopadhyay, Chest Phy Ranchi: Very pertinent question;

• Researchers very early noticed that the fibrosis in covid survivors is very much like an end stage fibrotic lung disease ie UIP Pattern. 

In fact, there is a common etiology too (hypothetical) – recurrent microembolism. 

• That is why, they have tried pirfinedone in those severe covid survivors. 
• But again, in many patients three months down the line, there has been improvement in lung function even in patients without pirfinedone, so currently, there is no definite role of pirfinedone, and there is no statement/guideline to support or refute it too

*Compiled by Dr NK Singh

Update: Discussion on 01/09/2020

Dr Suresh Bishnoi Internal Medicine specialist, Sirsa, Hariyana: Patient with h/o HTN in past, recently diagnosed DM 2, presented with post COVID (21st day of 1st +ve COVID report.) Now RTPCR negative, afebrile c/o DOE.HRCT suggestive of post COVID sequelae? Fibrosis. Kindly guide about treatment

Dr Nishith Kumar, Pulmonogist, Ranchi: Pulmonary fibrosis or scarring after Covid-19 pneumonia is a common sequela…21st day is still too early…What’s the resting SPO2, D Dimer value? May consider to get a CTPA done if dyspnoea is significant.

Dr Atri Gangopadhyay, Pulmonologist, Ranchi:

1. Rule out ongoing thromboembolism- D dimer and anticoagulation

2. Rule out ongoing inflammation- CRP and oral corticosteroid

3. Mucolytic

4. Bronchodilator

5. 6 min walk distance monitoring daily

6. PFT monitoring weekly

7. Tab aldactone

If persist for four weeks, then antifibrotic (pirfenidone)

Dr N. K. Singh: Why Aldactone. How it works?

Dr Atri Gangopadhyay: Exact unknown..

1. Some steroid like action

2. Diuresis relieving load

Dr Mrs Deb Dutta, Pulmonologist, Ranchi:  21st day of first covid report. 1st to rule out thromboembolism and ongoing inflammation, markers   to be sent, if possible lower limb doppler, ctpa whatever feasible .2nd to rule out infections… ct may or may not be very helpful.

Dr Gaurabh Gupta, New Delhi: Sir instead of Pirfenidone may prefer nintedanib. In summary, the two antifibrotic drugs needs to be chosen based on patient’s premorbid conditions, availability of drugs, ADR monitoring and switching from one to another has been possible and doable in view of difference in tolerability of two drugs.  So far in particularly COVID cases nintedanib has been used. In CoVID case reports indicate benefit. More data is awaited as we go along. As of today, we are not having a definite for or against one molecule over another

Dr Atri: The main problem with NINTEDANIB is the abnormal cost

Dr Gaurabh Gupta, New Delhi: Yes, that is an issue

https://erj.ersjournals.com/content/52/suppl_62/PA2953

https://erj.ersjournals.com/content/54/suppl_63/PA1727

All India Institute of Medical Sciences, New Delhi National e-ICU on COVID-19 management:

Any role of antifibrotic in prevention of lung fibrosis?

There is no evidence to support the use of antifibrotic agents like pirfenidone in preventing COVID related fibrosis and hence should not be used. (AIIMS National webinar).

CME INDIA Tail Piece

Pulmonary fibrosis is a frequent complication in patients with viral pneumonia-induced acute respiratory distress syndrome. However, CT scans have shown that the signs of pulmonary fibrosis after viral pneumonia can partially regress over time. It seems plausible that alveolar regeneration may also occur in patients with less severe viral pneumonia, and to speculate that such regeneration functions to help to restore lung function and even resolve pulmonary fibrosis. New  observations open the door for future studies to elucidate the mechanisms that regulate human alveolar regeneration after acute lung injury and facilitate to prognosticate the outcomes of COVID-19 patients(Pulmonary alveolar regeneration in adult COVID-19 patients Cell Research (2020) 30:708–710; https://doi.org/10.1038/s41422-020-0369-7)

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