CME INDIA Presentation by Dr N K Singh, Admin/Inputs from Dr Akash Kumar Singh, Baroda and Dr Saibal Guha, Patna.

COVID-19 pandemic continues unabated. Most of the near and dear to you are in the grip of the bizarre virus, about which we hardly know enough. We are facing asymptomatic infection to life-threatening and fatal disease around us.

We are observing and reading reports of patients with persistent severe symptoms and even substantial end-organ dysfunction after SARS-CoV-2 infection

Nobody knows the long-term consequences of this new disease.

What is the POST ACUTE COVID Illness?

 (At present agreed definition)

  • Post-acute COVID-19 is defined as the presence of symptoms extending beyond 3 weeks from the initial onset of symptoms and chronic COVID-19 as extending beyond 12 weeks.
  • Post-acute COVID-19 (“long COVID”) seems to be a multisystem disease, sometimes occurring after a relatively mild acute illness.
Covid symptoms after 3 or more weeks
Courtesy: BMJ

Not all recovered cases develop it:

  • A recent US study found that only 65% of people had returned to their previous level of health 14-21 days after a positive test.
  • Around 10% of patients who have tested positive for SARS-CoV-2 virus remain unwell beyond three weeks, and a smaller proportion for months.
  • In India too, similar pattern is being observed.

What our experts observe?

Dr Saibal Guha, Diabetologist, Physician, Patna:

Out of the 84 COVID patients in my clinic registry:

  1. Post-COVID malaise/ fatigue was found in about 60% even after 1 month of detection.
  2. Persistent DOE was there in about 25% till about 3 weeks after detection.
  3. Loss of appetite persisted in most for about 4 weeks after detection.

For post-COVID management:

  1. Spirometry exercises for all having DOE as a symptom.
  2. Steam inhalation had symptomatic relief for persistent cough/ throat irritation.
  3. Prone breathing for 15 minutes daily for 1 month after detection for all who had DOE.
  4. Anticoagulant for one month further for all having persistent high d-dimer even after 2 weeks of detection.

 Dr Akash  kumar Singh,Internist, Baroda,Gujrat:

As the COVID19 epidemic gets to its 7th month in India and having discharged close to thousand cases of COVID19 from our set up and having treated hundred plus patients on OPD basis, following are my observations on the post covid status of my patients health

  1. Fatigue and lack of energy seems to be the most common sequalae of COVID-19 infection which can last for a long time i.e. am seeing some patients in second month too suffering from this particular complaint
  2. Some patients have dyspnoea which persists after COVID-19 infection particularly in those patients who came off late from oxygen dependency or were oxygen dependent when sent home. Two of my patients recovered from dyspnea to walk few kilometers daily but again developed dyspnoea which was thoroughly investigated with all non invasive methods only to find no conclusive cause. They were restarted on oral steroids and have made partial recovery.
  3. Dry cough has persisted in few patients but have resolved in all except those who developed lung fibrosis or bronchitis post COVID-19 infection or had bronchitis as comorbidity.
  4. Headaches, heaviness of head, psychiatric disturbances in form of low grade depression was also seen in 4-5 percent patients. Insomnia is seen in few patients. Behavioural changes are also seen particularly in the elderly subset of patients post COVID-19. Impairment of hearing is also a feature which I saw in my elderly recovered covid19 patients
  5. 4-5 patients who were discharged in normal condition and with normal parameters including d-dimer developed acute MI and were readmitted for its management. All of these responded to thrombolytic therapy and could be stabilised on medical management
  6. Loss of weight is also an important post COVID-19 sequale. Many patients lost weight, some to the tune of 5-10% of their weight. Also elderly patients are more liable to get into the weight loss, fatigue, poor intake and generalised weakness cycle.
  7. Loss of taste and smell recovered partially or completely is most of the patients by 2 months post COVID period but 3-4 patients still complaint of excess salty sensation. Even if the salt is less in food, they feel the food is very salty. This is a very peculiar and specific complaint in my covid19 patients.

The above have been observed by me.

The treatment is on case to case basis and involves a lot of counselling and supplementation with vitamins which also may be having a placebo effect. Some patients need anti anxiety or anti depressant drugs. Steroids for persistent or recurrent dyspnoea with close follow up. But there has not been any specific approach which I could generalise to majority of our patients

The average time from the onset of symptoms to joining the job in my OPD based home care COVID-19 patients has been minimum 15 days  to 20 days. However in the indoor patients the duration from onset of disease to their joining the job has been minimum 20 days. The period of rest is directly proportional to the severity of the disease. However, peculiarly some companies have the practice of letting the employees resume only if their RT PCR is negative for COVID-19, in which case it may take more time for the COVID-19 patients to resume their jobs.

To which category your patient belongs?

Broadly, such patients can be divided into,

  1. Serious Category – who may have serious sequelae (such as thromboembolic complications).
  2. Non-specific clinical picture category – dominated by fatigue and breathlessness.
  3. Rehabilitation Category – whose acute illness required intensive care, have been covered elsewhere.

A telephone survey conducted by CDC shows Return of work hampered:

  • 35% of 274 symptomatic respondents reported not having returned to their usual state of health 2 weeks or more after testing, including 26% among those aged 18-34 years (n = 85), 32% among those aged 35-49 years (n = 96),47% among those aged 50 years or older (n = 89).
  • Older than 50 years and the presence of 3 or more chronic medical conditions were associated with not returning to usual health within 14 to 21 days after receiving a positive test result.

Why some are unlucky?

  • It is not known why some people’s recovery is prolonged.
  • Persistent viraemia due to weak or absent antibody response.
  • Relapse or reinfection.
  • Inflammatory and other immune reactions.
  • Deconditioning (adaptation to less demanding environment).
  • Mental factors such as post-traumatic stress.

It is so frustrating to get post-COVID symptoms

  • Post-acute COVID-19 symptoms vary widely. Most common symptoms are Fatigue and dyspnoea.
  • Long term symptoms, most commonly cough, low grade fever, and fatigue, all of which may relapse and remit.
  • Shortness of breath.
  • Chest pain.
  • Headaches, neurocognitive difficulties.
  • Muscle pains and weakness.
  • Gastrointestinal upset.
  • Metabolic disruption (such as poor control of diabetes).
  • Thromboembolic conditions, Depression and other mental health conditions.
  • Rashes – skin rashes can take many forms including vesicular, maculopapular, urticarial, or chilblain-like lesions on the extremities (so called COVID toe).

Even so-called mild COVID-19 may be associated with long term symptoms, most commonly cough, low grade fever, and fatigue, all of which may relapse and remit.

Pathogenesis standpoint

  • May be direct tissue invasion by the virus (possibly mediated by the presence of angiotensin-converting enzyme 2 receptor).
  • Profound inflammation and cytokine storm.
  • Immune system damage.
  • Hypercoagulable state.
  • Combination of above factors.

Cardiovascular Myocardial injury

  • Myocardial inflammation and myocarditis.
  • Cardiac arrhythmias.
  • An increased incidence of heart failure as a major sequela of COVID-19 is of concern.

 Pulmonary

  • Persistent symptoms with radiologic abnormalities consistent with pulmonary dysfunction such as interstitial thickening and evidence of fibrosis.
  • Compounded on cardiovascular comorbidity (either pre-existing or incident from COVID-19,) persistent decline in lung function.

Neurologic

  • Most common long-term neurologic symptoms after COVID-19 – headache, vertigo, and chemosensory dysfunction (e.g. anosmia and ageusia).
  • Stroke is an uncommon consequence of acute COVID-19.
  • Encephalitis/ seizures.
  • Major mood swings and “brain fog” – reported up to 2 to 3 months after initial illness onset.

Emotional Health and Well-being

  • Feelings of isolation and loneliness.
  • A sense of hopelessness.
  • Increasing reports of lingering malaise and exhaustion akin to chronic fatigue syndrome.
  • Greater risk of depression, anxiety, posttraumatic stress disorder, and substance use disorder.

What tests are required?

  • Anaemia should be excluded in the breathless patient.
  • Lymphopenia is a feature of severe, acute COVID-19.
  • Elevated biomarkers may include C reactive protein (for example, acute infection), white cell count (infection or inflammatory response).
  • Natriuretic peptides (for example, heart failure).
  • Ferritin (inflammation and continuing prothrombotic state).
  • Troponin (acute coronary syndrome or myocarditis).
  • D-dimer (thromboembolic disease).
  • Troponin and D-dimer tests may be falsely positive, but a negative result can reduce clinical uncertainty.

For patients who were not admitted to ICU, British Thoracic Society (BTS) guidance on follow-up of COVID-19 patients who have had a significant respiratory illness:

  • Follow-up with a chest X-ray at 12 weeks and referral for new, persistent, or progressive symptoms.
  • For those with evidence of lung damage (such as persistent abnormal chest x ray and oximeter readings), referral to a respiratory service is recommended.
  • Subsequent early referral to pulmonary rehabilitation.

Holistic support while avoiding over-investigation and treatment:

  • Most but not all patients who were not admitted to hospital – recover well with four to six weeks of light aerobic exercise (such as walking), gradually increasing in intensity as tolerated.
  • Those returning to employment may need support to negotiate a phased return.

Dr Arvind Arya, Internist, Jamshedpur says:

Usually join office after 14 days of home quarantine post-COVID Negative report – this practice is being followed.


CME INDIA Learning Points:

  • Protocol for Management of COVID-19 after the first three weeks appears a new necessity.
  • Approximately 10% of people experience prolonged illness after COVID-19.
  • Give holistic support, symptomatic management. Give hope that most of patients will recover spontaneously. Advise them for gradual increase in activity.
  • Home pulse oximetry will be helpful in monitoring breathlessness.
  • New, persistent, or progressive respiratory, cardiac, or neurological symptoms are indications for specialist assessment.
  • Large numbers of patients will experience long-term sequelae. Multidisciplinary approach will provide therapeutic interventions to mitigate the adverse physical and mental health.


CME INDIA Tail Piece

1. Breathing techniques suggested by BTS:

  • About 80% of the work of breathing is done by the diaphragm. After illness or general deconditioning, the breathing pattern may be altered, with reduced diaphragmatic movement and greater use of neck and shoulder accessory muscles. This results in shallow breathing, increasing fatigue and breathlessness, and higher energy expenditure.
  • The “breathing control” technique is aimed at normalising breathing patterns and increasing the efficiency of the respiratory muscles (including the diaphragm) resulting in less energy expenditure, less airway irritation, reduced fatigue, and improvement in breathlessness.
  • The patient should sit in a supported position and breathe in and out slowly, preferably in through the nose and out through the mouth, while relaxing the chest and shoulders and allowing the tummy to rise. They should aim for an inspiration to expiration ratio of 1:2. This technique can be used frequently throughout the day, in 5-10-minute bursts (or longer if helpful).
  • Other breathing techniques – such as diaphragmatic breathing, slow deep breathing, pursed lip breathing, yoga techniques, Buteyko – are used in strategies to manage patients’ breathing patterns and breathlessness but require specialist advice to identify which technique best suits each patient.

2. Pulse oximetry in post-acute COVID-19, is it needed (BTS) ?

  • Self-monitoring of oxygen saturations over three to five days may be useful in the assessment and reassurance of patients with persistent dyspnoea in the post-acute phase.
  • Especially those in whom baseline saturations are normal and no other cause for dyspnoea is found on thorough evaluation.
  • An exertional desaturation test should be performed as part of baseline assessment for patients whose resting pulse oximeter reading is 96% or above but whose symptoms suggest exertional desaturation (such as light-headedness or severe breathlessness on exercise).
  • In the absence of contraindications, such patients should be invited to repeat the oximeter reading after 40 steps on a flat surface (if self-testing remotely) and then after spending one minute doing sit-to-stand as fast as they can (if supervised on site). A fall of 3% in the saturation reading on mild exertion is abnormal and requires investigation.
  • British Thoracic Society guidelines define the target range for oxygen saturation as 94-98% and a level of 92% or below as requiring supplementary oxygen (unless the patient is in chronic respiratory failure).
  • In the context of a normal assessment (history, examination, and appropriate investigations) without red flags, an oxygen saturation of 96% or above and the absence of desaturation on exertional tests is very reassuring.
  • Oximeter readings persistently in the 94% – 95% range or below (indicating substantially farther down the oxygen-haemoglobin desaturation curve) require assessment and investigation.
  • Appropriate adjustments should be made for patients with lung disease and known hypoxia — in whom the range of 88% – 92% is considered acceptable.

Further Reading:

1. BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3026 (Published 11 August 2020) Cite this as: BMJ 2020;370:m3026

2. jama_del_rio_2020_vp_200214_1601660718.77023.pdf


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