Respiratory Perspective of post covid recovery

1. Post-Covid Recovery: A Respiratory
Perspective
Dr Gyanshankar Mishra
MBBS MD(Respiratory Medicine) DNB(Respiratory
Diseases) MNAMS FNCCP(I)
Associate Professor, Respiratory Medicine, IGGMC
Nagpur

2. Post Covid
Terminologies
• Post-COVID-19 : Symptoms extending
beyond 3 weeks from a positive report for
COVID-19 infection.
• Acute post-COVID-19: Symptoms extending
beyond 3 weeks from the onset of first
symptoms,
• Chronic post-COVID-19: Symptoms extending
beyond 12 weeks.
• “Long COVID”: Signs and symptoms that
continue or develop after acute COVID-19. It
includes both ongoing symptomatic COVID-
19 (from 4 to 12 weeks) and post-COVID-19
syndrome (12 weeks or more).

4. Paths of Post-Covid Respiratory Recovery
Resolution
Post Covid
Pulmonary
Fibrosis/ Sequelea
Post Covid Airway
disease/ bronchitis
Post Covid
Secondary
Respiratory
Infection

5. High Risk
Patient Groups
for developing
post-COVID-19
complications
1. Elderly patients (age
>60 years).
2. Co-morbidities
(diabetes mellitus,
hypertension, coronary
artery disease, etc).
3. Patients requiring
oxygen on discharge
from COVID-19
management.
4. Patient who required
non-invasive ventilation
(NIV) or mechanical
ventilation (MV) during
COVID-19 management.
5. Pre-existing chronic
respiratory diseases.

6. Post Covid Respiratory
symptoms and symptomatic
approach to them

7. Common Post Covid Symptoms
Cough, low-grade fever and fatigue,
followed by shortness of breath,
chest pain, headache, muscle pains
and weakness, gastrointestinal upset,
etc.

8. Cough
• Infection:
• Fever, purulent sputum
• Chest X-ray, Sputum examination: gram stain culture, fungus, CBNAAT, CBC
• Antibiotics
• Post Covid Bronchitis /Hyper-responsive airways:
• Cough+/- breathlessness, Rhonchi may be present
• Inhaled Therapy (MDI with Spacer /DPI): Bronchodilator + Corticosteroids
• (e.g.Formoterol + Budesonide)
• Breathing Techniques: Diaphragmatic breathing, slow deep breathing, pursed lip
breathing
• Cough suppressants
• Yoga

9. Cough

10. Breathlessness
• Primary driver of breathlessness is VIRAL INTERSTITIAL PNEUMONIA
which affects the diffusion capacity of the lungs.
• Pulse oximetry and 6Minute Walk Test
• Target SpO2> 94%
• If 93% or less than supplemental O2 therapy may be required
• Breathing control techniques/ exercises
• If airway involvement is there/ Rhonchi +
• Inhaled Therapy (MDI with Spacer /DPI): Bronchodilator +
Corticosteroids
• (e.g.Formoterol + Budesonide)

11. Breathlessness

12. Post Covid Chest Pain

13. Investigations in the post covid Phase
Blood investigations: CBC,
CRP, D-DIMER, Blood Sugar,
Thyroid function tests
Sputum/ BAL: Gram Stan
Culture, CBNAAT, Fungus
KOH mount/ Culture
CT SCAN Thorax: HRCT Scan
Thorax vs CECT Thorax/
CTPA
SpO2 at rest and 6 minute
walk test: Desaturation of
≥4% on 6MWT is clinically
significant
PFT:(Spirometry/DLCO):
Obstructive or restrictive
lung defect.
ECG, 2D Echo: PAH, Covid
Myocarditis

14.  83 hospitalised covid patients were followed up over a period of 1 year after discharge.
 Significant reduction in DLCO, with a median of 77% of predicted (IQR 67–87) at 3 months,
76% of predicted (68–90) at 6 months, and 88% of predicted (78–101) at 12 months after
discharge.
 At 12 months after discharge, radiological changes persisted in 20 (24%) patients.
 Impaired DLCO associated with female sex (odds ratio 8·61 [95% CI 2·83–26·2; p=0·0002)
and radiological abnormalities were associated with peak HRCT pneumonia scores during
hospitalisation (1·36 [1·13–1·62]; p=0·0009).

15. n=83

16. Management
Strategies

17. Post Covid
Pulmonary
Fibrosis
Clinical c/o: Cough,
Breathlessness
Evaluation: SpO2 </=
94% or significant
desaturation on 6 MWT
Radiologicaly: HRCT
Scan thorax (Specifically
look for Traction
bronchiectasis/ Honey
combing)
PFT/ DLCO: Restrictive
pattern with decreased
DLCO

18. Treatment options for POST COVID PULMONARY FIBROSIS
• Resting SpO2 </= 93 % : Oxygen therapy required.
• Corticosteroids:
• No robust evidence of CORTICOSTEROIDS in post covid lungs
• Low dose steroids for a duration of 4 to 6 weeks in hypoxic patients who
have post covid sequelea (GGO/ Interstitial septal thickening on HRCT).
No role in established fibrosis (Traction bronchiectasis/ Honey combing
on HRCT).

19. • Corticosteroids are indicated for a duration of not more than 10
days in hypoxic covid patients.
• Currently there is no evidence of any benefit beyond it.

20. In Post covid ILD (predominantly organizing pattern) steroid
therapy for 3 weeks resulted in DLCO and FVC improvement
along with Symptomatic and radiological resolution.
However the sample size was only 30 patients with no control
group. Thus the improvement could also represent slow natural
recovery.

21. POST COVID PULMONARY FIBROSIS..
• Antifibrotics:
• No robust evidence of ANTIFIBROTICS in post covid lungs.
• Pirfenidone & Nintedanib
• Pirfenidone dose in IPF is 800 mg TID.
• (LFT monitoring and avoidance of sunlight)
• Nintedanib dose in IPF is 150 mg BID. Caution is needed if patient is on
anticoagulation. (Recently Approved for progressive fibrosing ILDs in USA and Japan)
• Eg: nintedanib increases effects of dabigatran by anticoagulation. Use
Caution/Monitor. Nintedanib is a VEGFR inhibitor and may increase the risk
of bleeding; monitor patients on full anticoagulation therapy; monitor closely
for bleeding and adjust therapy as needed .

22. Role of Anti Fibrotics in Post-Covid Fibrosis
• Fibrosis with fibroblasts and honeycombing has clearly been demonstrated in
autopsies and explanted lungs of patients with SARS-C0V-2
• Biological rationale for the use of both pirfenidone (works by downregulation of
the production of growth factors and procollagens I and II) and nintedanib (Tyrosine
kinase inhibitor) in COVID-ILD:
1. Known to inhibit experimental lung injury and inhibit IL-6, IL-1, and IL-1B
2. Pirfenidone has both antifibrotic and anti-inflammatory properties, inhibits the
AT1R/p38 MAPK pathway, decreases angiotensin II, and angiotensin II type 1
receptor, as well as angiotensin-converting enzyme (ACE) expression
Vitiello A et al Lung India 2021;38:S129-30.
In Idiopathic Pulmonary Fibrosis (IPF), anti-fibrotics
(Pirfenidone, Nintedanib) are recommended to slow
the rate of fibrosis progression.
They DO NOT REVERSE FIBROSIS in IPF.
Their Role in Post COVID pulmonary fibrosis is
Experimental/ based on hypothesis.

23. • A case series of 5 patients showing clinico-radiological
improvement after pirfenidone therapy.
• Limitations:
• 1. Small sample size
• 2. Study design: No control group

24. • Chest Physiotherapy starts right from the ICU
• It has a very important role after discharge of the post covid
patients

25. Simple Breathing
Techniques
• Blow as you go: Breath in before you make the effort. Breathe out
when you make the effort.
• Paced Breathing: Breathe in for 1 step. Breathe out for next 2/3 steps.
Diaphragmatic Breathing

26. Incentive
spirometry

27. Post Covid Obstructive
Airway disease
• Prevalence of small airway obstructive diseases is
likely to increase with time among post-COVID-19
patients with documented residual radiographic
abnormalities.
• Clinical evaluation (Breathlessness, Rhonchi+), chest
X-Ray, HRCT scan Thorax, PFT
• Management can be done with inhaled
bronchodilators, inhaled corticosteroids and oral
methylxanthines.
• Symptomatic relief : Pulmonary Rehabilitation and
Yoga

28. Consideration of new Venous thrombo-embolic diseases
• COVID-19 is an inflammatory and hypercoagulable state with an increased risk of
thromboembolic events.
• COVID-19 may predispose patients to thrombotic disease, both in the venous and
arterial circulations, because of excessive inflammation, platelet activation,
endothelial dysfunction, and stasis.
• Investigations :D-dimer, duplex ultrasonography, other coagulation studies and
computed tomographic pulmonary angiogram (CTPA)
• Patients with higher risk are typically discharged from hospital with 10 days of
extended thromboprophylaxis.
• Confirmed venous thromboembolism should be treated with therapeutic-dose
anticoagulation for 3 months.

29. Post Covid Secondary Respiratory
Infections
• TB : Cough with expectoration/Fever> 2 weeks Constitutional symptoms:
Loss of weight, loss of appetite: Sputum CBNAAT/ Chest Xray. Treatment: ATT
• Bacterial Infection: Cough with purulent expectoration, fever, Inv: CBC,
Sputum Gram stain/ culture, Chest Xray: Antibiotics
• Fungal Infections (Aspergillus/Mucor): Cough, fever, breathlessness not
responding to standard antibiotics. Risk factors: immunosuppression/ HIV/
Diabetes. Radiological: Cavity/ Nodules. Sputum/ BAL: KOH mount/ Culture.
Treatment: antifungals (Amphotericin B/ Posaconazole /Voriconazole/
Itraconazole)

30. Covid Vaccination in Post-Covid Patients
• Deferring the COVID-19 vaccination in the following scenario:
1. Individuals having lab test proven SARS-2 COVID-19 illness: COVID-19
vaccination to be deferred by 3 months after recovery.
2. SARS-2 COVID-19 patients who have been given anti-SARS-2 monoclonal
antibodies or convalescent plasma: COVID-19 vaccination to be deferred by
3 months from the date of discharge from the hospital.
3. Individuals who have received at least the 1st dose and got COVID-19
infection before completion of the dosing schedule: the 2nd dose should be
deferred by 3 months after clinical recovery from COVID-19 illness.
National Expert Group on Vaccine Administration for COVID-19 (NEGVAC) 19/5/21 accepted by MoHFW, Govt of India

31. Case Scenario
• 40 year old female housewife
• Covid + on 23/4/21, admitted on 26/4/21
• Chief complaints of fever, cough, weakness, loss of taste and shortness of breath since 4 days.
• Patient tested negative on repeat nasopharyngeal swab for COVID 19 on 14th day of admission.
• During hospital stay till date patient received the following: intravenous antibiotics (
piperacillin+tazobactam, meropenem, ceftriaxone, doxycycline, Coamoxiclav ), antivirals
(remdesivir), corticosteroids (methylprednisone) and anticoagulant( Enoxaparin), Pirfenidone, Chest
Physiotherapy
• Patient’s clinical condition improved with oxygen requirement decreasing and was weaned from Bi-
PAP mode of ventilation on admission to nasal prongs at 2lo2/min currently.

32. 23/5/21 26/6/21 12/7/21
Serial Chest Xrays

33. HRCT
Scan
THORAX
9/7/21
1. Multiple areas of interstitial septal thickening with ground
glass opacities seen in bilateral lungs, lobular and peripheral
in location suggestive of sequela to covid 19 pneumonia in
resolving phase (with a CT Severity score of 16/25).
2. Mild diffuse bronchiectatic changes were seen in bilateral
lungs.

34. 3 months after Covid Positive Testing –
POST COVID FIBROSIS
Chief complaints since 4 days
Duration of Hospital Stay: 88 days
Duration of ICU stay: 83 days
Duration of NIV with O2: 30 days
Duration of Oxygen support: 88 days (inclusive of NIV)
Duration of Steroid Therapy: 28 days
Day of starting steroid therapy (from day of symptom onset): day 5
Duration of Antifibrotic therapy (Pirfenidone):70 days
Day of starting Pirfenidone therapy (From day of Onset of
symptoms):15 days
Patient received standardized treatment including Remdesivir/
Anticoagulant, etc.
Comorbidities: Nil
Recovery
from Post
Covid
Fibrosis is a
SLOW
Process

35. Take Home Message
Risk factors for Post Covid
Respiratory sequalae: Elderly,
Comorbidities, Mechanical
Ventilator/NIV/O2 support,
High CT severity Scores, Pre-
existing Respiratory diseases.
Clinical evaluation is
important.
Management of post-covid
sequalae is mainly
symptomatic with unproven
role of steroids or
antifibrotics.
6MWT is simple test for
monitoring exercise tolerance.
Chest physiotherapy/
Breathing exercises should be
included in post-covid
management.