Presentation given to ACE-Naperville on 09/10/2020

1. COVID-19 –
A LUNG DOC’S
PERSPECTIVE
M. Patricia George MD
ACE Naperville Meeting Sept 10, 2020

2. PERSPECTIVE
• I’m here to answer your questions to the best of my ability
• This is living through a new disease, about which we are continuing to learn
so much every single week
• Some of what I say now will hopefully be true in weeks to come, but there is
a chance we will be completely new information and understanding one
month from now
• What I say are my opinions and NOT the opinions of my employer, National
Jewish Health
• Let’s chat

3. COVID-19
• Basics about SARS-CoV2
• The second wave?
• Chronic manifestations?
• Colorado
• Personal experience

4. CORONAVIRUSES
Many types, diverse infect bats
7 known to infect humans. 4 are
endemic globally and responsible for
10-30% of URIs (mild = common cold)
3 have been highly pathogenic
SARS – 2002 – SARS-CoV
8098 infected, 774 died
MERS – 2012 – MERS-CoV
2494 infected, 898 deaths (11/19)
SARS-CoV2 – 2019
Paules CI, Marston HD, Fauci AS. JAMA 2020; 323: 707-8
Photo from https://www.nature.com/articles/d41586-020-00502-w

5. Wiersinga W J et al. Pathophysiology,
Transmission, Diagnosis, and Treatment of
Coronavirus Disease 2019 (COVID-19). JAMA
2020; 324: 782-93

6. 2019-NCOV à SARS-COV-2
Coronaviridae Study Group of the International Committee on
Taxonomy of Viruses. Nature Microbiology 2020; 5: 536-544

7. SARS-COV-2
Viral S protein binds to ACE2 to enter cells
Wiersinga W J et al. JAMA 2020; 324: 782-93
Gheblawi M et al. Circ Res 2020; 126: 1456-1474

8. TRANSMISSION AND
PRESENTATION
• Respiratory droplets from face-to-
face contact and (to a lesser
degree) contaminated surfaces
• Incubation period (exposure to
symptom onset): average 5 (IQR
2-7)days
• Median time from symptom
onset to hospitalization: 7 (IQR 3-
9) days
• Median age of hospitalized
patients between 47-73 years
• Among those hospitalized with
COVID-19, 75-86% are over 50
years old
Wiersinga W J et al. JAMA 2020; 324: 782-93
People
infected
with
SARS-CoV-2

9. HIGHER RISK OF DEATH WITH AGE
Wiersinga W J et al. JAMA 2020; 324: 782-93

10. COVID-19 RISK BY AGE GROUP
https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html

11. COVID-19 RISK BY RACE/ETHNICITY
https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html

12. COVID-19 RISK BY MEDICAL
CONDITION
https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html

13. PRESENTATION
• Common complications in hospitalized patients with COVID-19:
• Pneumonia (75%)
• Acute respiratory distress syndrome (ARDS) (15%)
• Acute liver injury(19%)
• Cardiac injury (cardiac enzyme leak, heart failure, myocarditis, arrhythmias) (7-
17%)
• Prothrombotic coagulopathy leading to blood clots (10-25%)
• Acute kidney injury(9%)
• Neurologic manifestations (impaired consciousness, stroke) (3%)
• Shock (6%)
• Rare complications in hospitalized patients
• Cytokine storm and macrophage activation syndrome
Wiersinga W J et al. JAMA 2020; 324: 782-93

14. WHAT IS ARDS?
• Acute respiratory distress syndrome
• Serious lung injury that causes low
oxygen levels
• Fluid builds up inside the tiny air sacs in
the lungs à Loss of surfactant (helps
keep the air sacs open) à low oxygen
levels à Can turn into scar tissue
Normal Lung: Cardinal-Fernandez P et al. Annals
ATS 2017; 14: 844-850
Wiersinga W J et al. JAMA 2020; 324: 782-93

15. PROPOSED STAGING - COVID-19
Siddiqi HK, Mehra MR. COVID-19 illness in native and immunosuppressed states: A
clinical−therapeutic staging proposal. J Heart Lung Transplantation 2020; 39: 405-7

16. TREATMENTS
• Asymptomatic/Presymptomatic – No further testing or
treatment
• Mild illness - There are insufficient data to recommend
either for or against any antiviral or immune-based
therapy in patients with COVID-19 who have mild illness
• Moderate illness – lower respiratory disease on
exam/imaging and SpO2 > 92% on room air at sea
level
• Severe illness - SpO2 <94% on room air at sea level,
respiratory rate >30, PaO2/FiO2 <300 mmHg, or lung
infiltrates >50%
• Critical illness – ARDS, septic shock, cardiac
dysfunction, elevated inflammation (cytokine storm)
Images from JAMA patient pages
COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National
Institutes of Health. Available at https://www.covid19treatmentguidelines.nih.gov/. Accessed [09/08/2020].

17. TREATMENTS: ANTIVIRAL THERAPY
• Remdesivir - reduced time to clinical recovery in patients with severe COVID-
19 on nasal cannula oxygen
• Insufficient data to recommend for/against use in mild or moderate disease, or in
patients who need O2 through more than a nasal cannula
• Patients with severe disease but on simple nasal cannula (not HFNC, BiPAP,
ventilator, ECMO) – Recommend remdesivir for 5 days or until hospital discharge
• Hydroxychloroquine +/- Azithromycin – Recommend against use in COVID-19
except in a clinical trial
• Lopinivir/ritonavir or HIV protease inhibitors - Recommend against use in
COVID-19 except in a clinical trial
• Ivermectin – Recommend against use in COVID-19 except in a clinical trial
COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National
Institutes of Health. Available at https://www.covid19treatmentguidelines.nih.gov/. Accessed [09/08/2020].

18. TREATMENTS: ANTI-INFLAMMATORY
AND IMMUNOTHERAPIES
• Dexamethasone – Recommend 6 mg/day for
10 days or hospital discharge in patients
requiring supplemental oxygen (on or off the
ventilator)
• If dexamethasone not available, okay to use an
alternative steroid (methylprednisolone,
prednisone)
• IL-6 inhibitors (tocilizumab, sarilmab, siltuximab)
– Recommend against use of IL-6 inhibitors
except in a clinical trial
COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National
Institutes of Health. Available at https://www.covid19treatmentguidelines.nih.gov/. Accessed [09/08/2020].

19. TREATMENTS: CONVALESCENT
PLASMA
COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National
Institutes of Health. Available at https://www.covid19treatmentguidelines.nih.gov/. Accessed [09/08/2020].

20. CHRONIC MANIFESTATIONS
• Big picture: TBD

21. OUR EXPERIENCE IN COLORADO
July 16

22. ANTICIPATING THE SECOND
WAVE?
• Influenza 1918 – Second Wave
• Sept – Nov 1918
• Will we see a second wave or just
smoldering and case resurgences
from relaxation of social
distancing?
https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html

23. NYC

24. THANK YOU