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Weitzman ECHO COVID-19 “Long Haulers”

  1. 1. COVID-19 “Long Haulers” January 6, 2021
  2. 2. CME Credit • Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State Medical Society to sponsor continuing medical education for physicians. The Bridgeport Hospital Yale New Haven Health designates this live activity for a maximum of one (1) AMA PRA Category 1 CreditsTM. Physicians should claim only credits commensurate with the extent of their participation in the various activities. • This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Bridgeport Hospital Yale New Haven Health and the Weitzman Institute. Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State Medical Society to provide continuing medical education for physicians. • The content of this activity is not related to products or services of an ACCME- defined commercial interest; therefore, no one in control of content has a relevant financial relationship to disclose and there is no potential for conflicts of interest.
  3. 3. COVID-19 “Long Haulers” 6 Jan 2021
  4. 4. 21,044,020 cases on 1/5/21 with 357,156 deaths COVID-19 in the United States
  5. 5. COVID-19 in the United States
  6. 6. COVID-19 in the United States
  7. 7. COVID-19 Cumulative Cases: Curve Seen Accelerating Upwards
  8. 8. COVID-19 Vaccinations – Too Slow?
  9. 9. News Headlines -4.6 million in the US received a COVID-19 vaccine, far short of ~ 20 million before the end of Dec -Federal health officials: rollout had a slower- than-expected start and “did not have a clear understanding as to why” - CDC reported 365,294 people in nursing homes and long-term-care centers had been given shots through a federal program, though more than 2.5 million doses had been distributed for those facilities Highly contagious COVID-19 strain found in upstate New York, Gov. Cuomo says COVID-19 Live Updates: Virus Cases in U.S. Prisons Top 500,000Source: New York Times
  10. 10. Resources • Nuvance health ~1900 articles reviewed: • CDC: • WHO: • Johns Hopkins: • Others
  11. 11. COVID-19 “Long Haulers” Emma Kaplan-Lewis, MD - Infectious Disease Attending, Elmhurst Hospital Center, NYC Health and Hospitals Jesse Durrance, MD - Pulmonology and Critical Care Fellow, Elmhurst Hospital Center, NYC Health and Hospitals
  12. 12. Agenda • Discuss epidemiology of post acute symptoms related to COVID-19 • Case Presentation: Infectious Disease Perspective • Case Presentation: Pulmonology/Critical Care Perspective • Key Takeaways • Discussion/Q+A
  13. 13. Terminology and Epidemiology • Post acute sequelae or ‘Long COVID’ or ‘Long Hauler’: persistent symptoms beyond 3 weeks from initial symptom onset • ‘Chronic COVID’: Symptoms extending beyond 12 weeks from symptom onset • Pathophysiology: Permanent organ damage from the acute infection, ongoing inflammation  Difficult to discern from deconditioning and sequelae from overall pandemic (lifestyle changes, social isolation, more sedentary) • Frequency:  Mild disease: 35% adult patients with + COVID test in outpatient setting reported ongoing symptoms median of 16 days after positive test  Moderate-Severe: post hospitalization, mean 60 days since symptom onset (36 days since hospital discharge), 87.4% reported persistent symptoms, 44.1% reported worsened QOL. Most common symptoms: fatigue, dyspnea, joint pain, chest pain
  14. 14. Terminology and Epidemiology (cont.) Most Common Reported Symptoms: – Fatigue – Dyspnea – Cough – Arthralgia – Chest pain – Ongoing smell/taste dysfunction – Headache – ‘Brain fog’ (cognitive dysfunction, memory impairment) – Depression/anxiety, mood changes – Other important sequelae: Metabolic disruption: new or worse diabetes, Organizing pneumonia, Permanent kidney injury, PTSD, Myocarditis
  15. 15. Long Term Symptoms Carfì A, Bernabei R, Landi F, et al. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603-605
  16. 16. Case #1 73 F w/ Osteogenesis Imperfecta type 3, osteoporosis, HIV (CD4 > 1000, VL UD), HTN 3/31-4/9: Hospitalized with COVID-19 pneumonia, needed 02, no intubation. Symptoms: cough, shortness of breath, fever, loss smell and taste. Discharged on home 02 for ~ 2 weeks 4/24 post d/c follow up: Mild dyspnea, not using 02 very much, still impaired taste and smell, traumatized by hospital experience but relieved she survived, has 2 friends who passed away from COVID-19 6/26: Reports chronic sore throat post COVID and ongoing loss of taste, decreased appetite. Deconditioned and frail. Referred to PM&R for PT 10/7: Feels COVID symptoms have returned- cough at night, shortness of breath worse at night and exertion, ongoing decreased smell/taste impacting appetite. CXR and TTE ordered. Recommended r/p COVID testing. Rx Mirtazapine 7.5mg QHS 11/18: CXR clear with cardiomegaly, TTE w/ diastolic dysfunction. Reports hard to walk b/c of shortness of breath, slowly progressive. No chest pain/pressure. Extreme fatigue on some days 11/24: Televisit - worse dyspnea, advised to go to ED, declined but will come to clinic next day 11/25: Seen in clinic, afebrile, 99% room air but desaturated 82-85% after ambulating 1-2 min. HR to 110s while ambulating. RR 28 at rest. Lungs clear, Cardiac exam with tachycardia (regular) and faint systolic murmur, no LE edema or JVD. Sent to ED
  17. 17. DDX • PE • Unstable angina • CHF • Pneumonia • Interstitial lung disease/diffusion abnormality • ? Other
  18. 18. Case #1: CXR
  19. 19. Case #1: TTE • TTE - impaired left ventricular relaxation pattern with elevated left atrial pressure, grade II diastolic dysfunction. Small partially organized pericardial effusion
  20. 20. Case #1 Continued 11/26-12/2: Hospitalized • TTE bedside with moderate pericardial effusion, no tamponade • CTA with no PE, D-dimer negative, r/p COVID PCR negative • Monitored in CCU then medical floor • 02 sat remained stable and weaned off 02 • Discharged without 02 and recommended outpatient PFTs Current status: Referred to cardiology and pulmonology, continue PT for deconditioning and trying to get outpatient 02 covered
  21. 21. Case #2 51 F with HIV, (CD4 600, VL UD) non- IDDM, epilepsy, HTN, prior smoker (quit 10 y prior) Admitted 1/15-1/30 for leg weakness, UTI and pneumonia. Reports ‘couldn’t walk’ and shortness of breath and fever, required supplemental 02 no intubation. No COVID test done. CT report (no imaging because outside hospital) with bibasilar ground glass opacities) 3/18: Non productive cough for weeks, no dyspnea, MSK pain- back and ribs, ? Pleuritic 6/24: Ongoing MSK pain- L. rib , waxing and waning cough and shortness of breath (mild)  COVID IGG + , PCR negative 8/26: Left upper back pain worse on inspiration, cough has improved  Sent for CTA: diffuse ground glass opacities bilateral with bibasilar alveolar airspace opacities. 9/25: Pulmonology apt for ongoing intermittent mild dyspnea and cough and abnormal CT findings, ddx: viral infection, post COVID syndrome (ab +), plan for TTE and r/p CT chest 3 mo  Dobutamine stress echo- negative for ischemia, normal contractility and EF 9/30: Complaints of dry cough, intermittent sore throat. No fevers 12/22: Ongoing intermittent cough, energy improved, on and off mild dyspnea  COVID PCR negative  Repeat CTA: Stable LLL subpleural predominant groundglass opacities with reticulation/interlobular thickening. Interval increase in the extent of the RLL subpleural predominant groundglass opacities with reticulation/intralobular thickening. No honeycombing. Findings nonspecific and can represent interstitial disease/organizing pneumonia
  22. 22. Case #2: Initial CT (8/26/20)
  23. 23. Case #2: Follow-Up CT (12/22/20) 4 months later
  24. 24. Case #2 Current status: repeat CT with ? Organizing pneumonia- to see pulmonology next month (? Tx steroids). Ongoing intermittent sore throat and dry cough, generally improving.
  25. 25. Case # 3 64 F with insomnia, no other medical history PCR+ for COVID 12/1, managed outpatient, repeat PCR negative 12/19 Frequent headaches, described as if someone ‘grabbing her head and pain behind eyes’. Not improved with Tylenol or OTC NSAIDS Waiting for neurology referral, no prior history of chronic headache syndrome, in meantime getting NCHCT
  26. 26. Post-COVID Headaches Management • If less than 8d/m: treat as needed with OTCs • If more than 8-10d/m, daily preventative medication needed to avoid medication overuse: – Cut down on OTCs if taking >10d/m as that can cause worsening of headache frequency/severity. – Topiramate: start 25mg QHS and increase by 25mg weekly to 100mg daily (typically 50mg BID). Better for migraine headaches (photo/phonophobia, nausea). Can cause grogginess/may worsen brain fog so I'd avoid if that's a major issue. Don't use if prior kidney stones, glaucoma. – Amitriptyline: start 10-25mg QHS and can increase up to 50-75mg QHS as needed. Good option if poor sleep/insomnia. Generally avoid if on other anti-depressants, but such a low dose that it's generally ok to add on if needed. – Duloxetine: start 30mg daily but good dose is 60mg daily. Helpful for paresthesias and this is full anti-depressant dose so good if there's untreated depression but avoid if on other anti- depressants. Also activating so take in daytime, and take with food as it can cause some nausea. – Valproate/Depakote: 250mg daily to BID. Can cause nausea, weight gain, tremors etc. Second line because of side effect profile but a good headache medication so worth a try if other options limited. Avoid in anyone with liver issues.
  27. 27. Post-COVID Headaches Management (cont.) • If constant headache/"status" headache: – Start daily preventative. – Can also provide short course of steroids (Medrol Dose Pack) to try and break headache. Anecdotally not much luck with steroids and Post-COVID patients but still worth a try. Avoid if contraindications to steroids. – If steroids not an option, can also do a 3-5 day course of diclofenac 50mg BID. Since its a longer acting NSAID, it can also break the headache cycle. Take with food, monitor for GI issues (standard NSAID concerns). • Other things: – Tizanidine can be helpful if taken daily, especially if there seems to be a tension component or neck pain. Typically start lower dose at bedtime and increase as needed since its sedating. – Other things/non medication environmental modification: • Sleep: if poor sleep that can worsen headaches. Can treat as above with meds that help headaches and also sleep (i.e. amitriptyline) or can try melatonin • Water: recommend at least 2-3L daily • Caffeine: can help with headache but can also cause headache if drinking a lot. Recommend cutting down if excessive use. • Preventatives can take up to 4 weeks to really start working, so don’t stop them if no immediate improvement. Only to stop if experience side effects that are really bothersome. If mild side effects, encourage to try continuing and see if they go away since there's only so many medication options.
  28. 28. Management of Post-Acute and Chronic COVID • Diagnostic (depending on symptoms reported and history): PFTs, TTE, CTA, D-dimer, troponin, pro-BNP, CRP • CXR at 12 weeks post discharge, also for new or worsening symptoms • A1c, close glucose monitoring for diabetics • Ambulatory 02 saturation • Consider pulmonology/ pulmonary rehab, cardiology referral if ongoing severe symptoms
  29. 29. Management of Chronic COVID Greenhalgh T, Knight M, A’Court C, et al. Management of post-acute covid-19 in primary care. BMJ. 2020;370:m3026
  30. 30. Clinical Cases from the Pulmonary/Critical Care Perspective
  31. 31. Case #4 53 y.o. Hispanic male with PMH of HTN presented with 2 weeks progressive SOB associated with cough and fever • 3/26/20 - 9/4/20: admitted with Severe COVID-19 Pneumonia: requiring intubation on hospital day 2 after failing NIPPV – subsequent prolonged mechanical ventilation. • Course complicated by: – Tension pneumothorax x 2 (different sides) • Persistent pulmonary-pleural fistula and loculated pneumothorax – Septic Shock with empyema – Renal failure requiring RRT – MDRO infection in lung • 5/28/20 – Trach done • Decannulation 7/27/20 • Discharged Home 9/4/2020 on 4L NC, using walker, to care of wife with VNS/Rehab/DME arranged.
  32. 32. Case #4 Follow Up • 9/10/20: Scheduled for follow up at primary care clinic – no show • 11/18/20 : Pulmonary follow up – Tolerating 1L NC on ambulation- no O2 at rest (keeps it on) – Persistent tachycardia – Mild sore throat persists • Issues: – Exercise tolerance vs O2 demand (real and perceived) – Assuming personal / family life – Nagging worry – Post-Traumatic Stress Disorder – Cultural / Language Barriers to ongoing care
  33. 33. Case #4 Follow Up • Pulmonary Function Tests: – Moderate Restriction – No obstruction • 6-minute walk test – Off O2 – 66% of predicted – Saturation >92% on RA – HR to >140
  34. 34. Case #4 Follow Up: Imaging
  35. 35. Case #4 Follow Up • Psychiatry: – 12/2/20: no show • Neurology: – Frequent luxation of shoulders (reportedly had this from prior) – Sent for tests / tele-medicine visit – 12/21/20: in-person visit for PMR regarding rehab therapy of B/L upper extremities • Cardiology: Follow up as needed • Pulmonary: continues to follow up in outpatient clinic – Anti-fibrotics are under study – Inhalers: On ICS/LABA therapy (evidence limited and indeterminate) – PT / Rehab / O2 supplementation – PFT Trend- under study
  36. 36. Post-Intensive Care Syndrome: COVID Patients • PICS (Post-intensive care syndrome) • Constellation of health issues that linger after critical illness – after discharge (wide range of incidence =/?? Detection) • Cognitive Impairment occurs in up to 25% of patients – Associated with delirium during hospitalization (sedation and COVID) • Psychological Health Impairment – PTSD, Anxiety, Depression • Functional Impairment (>25% of patients) – ICU Acquired neuromuscular weakness – Prolonged mechanical ventilation / Sedation / Paralytics / MOF • Family / Caregiver PICS - beyond just the patient Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: An overview. J Transl Intern Med. 2017;5: 90–92.
  37. 37. Post-Intensive Care Syndrome Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, et al. Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders’ conference. Crit Care Med. 2012;40: 502–509.
  38. 38. PICS in COVID-19 Patients • PICS: patients have an elevated rate of re-admission – Those with ALI/ARDS have higher rate of readmission (80%) – Longer index admission associated with higher healthcare cost after index admission – Degree of inflammation associated with development of PICS – Significant impact on home finances and ability to re-enter the workplace • In COVID: – Oxygen Demand: has the capacity to decrease • 6MW test and PFTs help with objectivity – Physical Therapy Remains extremely important – Totality of PICS in COVID-19 patients is not yet fully appreciated -Ruhl AP, Lord RK, Panek JA, Colantuoni E, Sepulveda KA, Chong A, et al. Health care resource use and costs of two-year survivors of acute lung injury: An observational cohort study. Ann Am Thorac Soc. 2015;12: 392–401. -Bangash MN, Owen A, Alderman JE, Chotalia M, Patel JM, Parekh D. COVID-19 recovery: potential treatments for post-intensive care syndrome. Lancet Respir Med. 2020;8: 1071–1073.
  39. 39. Case #5 51 y.o. Male, no significant PMH, previously admitted for severe COVID-19 PNA at OSH- Ventilated – Trach – Decannulated • Course c/b failed extubation x 3, MRSA-VAP- Trach / PEG • Admitted 3/18/20 for COVID-19 PNA – Trach (4/23/20) – Decannulated (5/15/20) - Discharged (5/18/20) Home • 6/18- admitted at OSH for acute exacerbation of “Asthma” discharged on steroids and inhalers • 6/24- ED Visit at OSH for Dyspnea: duo-nebs – steroids, H1 blocker, inhalers- discharged • 6/26- ED Visit at OSH for Dyspnea: duo-nebs – steroids, discharged with 5 day steroid course • 6/28- admitted for Dyspnea, Hypoxia- stridor identified- underwent tracheal balloon dilation (7/1)- steroid taper, discharged with improved symptoms (7/2) with follow up scheduled
  40. 40. Case #5: Initial Imaging
  41. 41. Case #5: Spirometry and Imaging
  42. 42. Case #5 Continued • 7/23: Re-admitted with progressive Dyspnea  Noted to have voice change • 7/25: Repeat balloon dilation with temporary improvement  Quickly relapsed with O2 demand (5L NC constantly)  No obvious stridor on exam  PFTs post dilation
  43. 43. Case #5 Follow Up • 8/3: Patient underwent tracheal ring resection  Trach placed during procedure  Quickly decannulated (before discharge) • 8/10: Discharged home • Follow up with Speech for rehab therapy  Continues to have improvement. Mild raspy voice, otherwise asymptomatic  No requirement for supplemental oxygen
  44. 44. Post-COVID “Long Hauler” Take-Home Messages • Oxygen supplementation: titration (as much physiologically as psychologically) – 6MW test / PFTs should be done at baseline and to monitor disease evolution • Inhalers: individual patient decision (LABA/ICS) • Anti-fibrotics: under investigation • Rehab therapy: extremely important- facilitation is key • PICS: weakness / cognition / depression / anxiety / PTSD / caretakers • Dyspnea: keep a broad differential in mind • Follow-up: elimination of barriers to healthcare access
  45. 45. Barriers to Follow-Up Care • Disproportionate burden on racial / ethnic minority groups in hospitalization and death rates – Heavy Disease Burden on groups already vulnerable by traditional determinants of health indexes • Post-index hospitalization and Access to Care: – Language and Cultural Barriers • Navigation of the health system for testing / follow-up appointments • Insurance navigation – Economic Barriers: • Rehabilitation • DME – access to oxygen, prescriptions / refills • Home care : burden of care falls on family • Bread-winners: significant compromise in familial access to income
  46. 46. COVID-19 for the “Long Haul” Questions Regarding Each Patient: 1. What ongoing issues are they facing? — Biological — Psychological — Social 2. Who is best-suited to address those issues? 3. What are the barriers the patient / family face in meeting their needs (from HCP perspective)? 4. How can we (individual providers / system) anticipate and help meet those demands?
  47. 47. References • accessed 12/28/20 • Carfì A, Bernabei R, Landi F, et al. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603-605. • del Rio C, Collins LF, Malani P. Long-term health consequences of COVID-19. JAMA. 2020. doi:10.1001/jama.2020.1971 • Fraser E. Long term respiratory complications of covid-19. BMJ. 2020;370:m3001. doi:10.1136/bmj.m3001 • Greenhalgh T, Knight M, A’Court C, et al. Management of post-acute covid-19 in primary care. BMJ. 2020;370:m3026 • Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network— United States, March-June 2020. MMWR Morb Mortal Wkly Rep. 2020;69:993-998. • Sardari A, Tabarsi P, Borhany H, et al. Myocarditis detected after COVID-19 recovery, European Heart Journal – Cardiovascular Imaging. 2020. icon • Lambert NJ and Survivor Corps. COVID-19 “Long Hauler” Symptoms Survey Report. Indiana University School of Medicine; 2020. wls-covid-symptom-study-doc.pdf • Halpin, SJ, McIvor, C, Whyatt, G, et al. Postdischarge symptoms and rehabilitation needs in survivors of COVID‐19 infection: A cross‐sectional evaluation. J Med Virol. 2020; 1– 10 • UK COVID Symptom study: term?fbclid=IwAR1RxIcmmdL-EFjh_aI- accessed 12/28/20
  48. 48. Thank You! To learn more about The Path Forward series To view previous COVID-19 sessions: