By Brian Dunleavy
In May, Brazilian President Jair Bolsonaro famously (or infamously) referred to COVID-19 as the " little flu ".
Clearly, the grim death toll attributed to the virus, in his country and elsewhere, has proven him wrong, but the research presented during the European Respiratory Society International Congress on September 7 should also make him take note.
Together, the two studies suggest that COVID-19 patients may suffer long-term lung and heart damage, although for many, it resolves over time.
For the first article, researchers working in a COVID-19 hotspot in Austria recruited their first 86 consecutive patients in May and early June (they now have more than 150 enrolled). Patients returned for assessment 6, 12, and 24 weeks after discharge from St. Vinzenz Hospital in Zams and underwent clinical examination, laboratory testing, arterial blood oxygen and carbon dioxide levels, pulmonary function tests (FEV1 and DLCO), computed tomography (CT) scans, and echocardiograms at each visit.
The mean age of the patients included was 61 years, and 65% were male. Almost half were current or former smokers, and 65% were overweight or obese. Overall, 21% had been in an intensive care unit (ICU), and 19% had required invasive mechanical ventilation. The mean hospital stay was 13 days.
En la primera visita, el 65% de los pacientes tenían al menos 1 síntoma persistente de COVID-19, más comúnmente dificultad para respirar (47%) y tos (15%). Las tomografías computarizadas todavía mostraban evidencia de daño pulmonar (manchas blancas conocidas como «vidrio esmerilado») en el 88% de los pacientes. En total, el 23% de los pacientes mostró valores de FEV1 <80% de lo normal, 33% medido a <80% de lo normal con DLCO.
Además, en la visita de 6 semanas, los ecocardiogramas mostraron que el 59% tenía disfunción del ventrículo izquierdo del corazón y los indicadores biológicos de daño cardíaco, coágulos de sangre e inflamación estaban todos significativamente elevados.
Sin embargo, en el momento de su próxima visita, 12 semanas después del alta hospitalaria, el 56% de los pacientes mostró evidencia de daño pulmonar en la tomografía computarizada. La falta de aire estaba presente en el 39% de los pacientes y el 15% todavía tenía tos. En general, el 21% y el 22% de los pacientes midieron <80% del formal en FEV1 y DLCO a las 12 semanas, respectivamente. Los resultados de la evaluación de 24 semanas están pendientes.
Patients who require hospital treatment due to moderate to severe COVID-19 will show persistent symptoms weeks after discharge, primarily including shortness of breath on exertion and fatigue,” study co-author Ivan Tancevski, MD, associate professor at University Clinic in Innsbruck, Austria, told Contagion® . “However, people should be encouraged by our findings because… our data indicate that the symptoms will resolve and the lungs and heart will recover. All patients recovering from a severe course of COVID-19 were offered cardiopulmonary rehabilitation at a local rehabilitation center, and they benefited from it. Muscle weakness and breathing problems improved critically with appropriate training.”
He added: "It would be important to implement that structured follow-up care whenever possible."
In the second article, researchers used a gait test to assess the weekly progress of 19 patients who had spent an average of 3 weeks in the ICU and 2 weeks in a pulmonary ward before being transferred to a pulmonary rehabilitation clinic. Most were still unable to walk upon arrival and spent an average of 3 weeks in rehabilitation.
The 6-minute walk test measured how far patients could walk in 6 minutes. Initially, they could walk an average of 16% of the distance they should theoretically be able to walk normally if they were healthy. However, after 3 weeks of pulmonary rehabilitation, this increased to an average of 43%, an improvement, but still evidence of impairment.
“Severely ill COVID-19 patients require longer stays in the ICU and under mechanical ventilation via intubation and [are] inactive during long-term hospitalization causing severe symptoms, especially reduced lung capacities and volumes, loss of muscle mass and fatigue, and limitations in walking that can last a long time,” co-author Yara Al Chikhanie, a PhD student at the Dieulefit Santé clinic for pulmonary rehabilitation at the University of the Alpes in Grenoble, France, told Contagion® , adding that the group plans to follow up for 6 months and 1 year-up in these patients.
“Due to the severity of the symptoms, patients required supervised pulmonary rehabilitation to recover; the four-week course of regular pulmonary rehabilitation was insufficient,” he added. “Long-term lung damage and physical limitations persisted, and the psychological impact of the new illness and the ICU experience was severe.”
Wise words, perhaps, for Bolsonaro and other world leaders.