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Post Covid Breathlessness


We already know from the SARS (Severe Acute Respiratory Syndrome/ SARS-CoV-1) and MERS (Middle East Respiratory Syndrome/ MERS-CoV) outbreaks that CoV (Covid) infections cause long term lung problems. So it would ring true that this would also happen in SARS-Cov-2 (Covid-19/coronavirus).

In the research paper of 2017 “Follow-up chest radiographic findings in patients with MERS-CoV after recovery” lung fibrosis developed in a substantial number of patients who had recovered.

In the SARS-CoV-1 outbreak lung fibrosis was again found - “Long-term bone and lung consequences associated with hospital-acquired severe acute respiratory syndrome: a 15-year follow-up from a prospective cohort study” - Zhang et al https://www.nature.com/articles/s41413-020-0084-5

A Canadian study by Shah et al documented the respiratory outcomes for hospital patients after the initial acute covid-19 infection. https://thorax.bmj.com/content/early/2020/12/02/thoraxjnl-2020-216308 At 3 months 50% of these patients still had lung abnormalities. 20% still had ongoing breathlessness and 20% had a persisting cough.

Of course these studies have been on hospitalised patients, those severe enough to be admitted, but studies such as COVERSCAN are showing that those with "mild/moderate" acute Covid infections still can have organ damage. https://www.medrxiv.org/content/10.1101/2020.10.14.20212555v1.full.pdf

They showed that 33 % had lung impairment as a result of the acute Covid-19.

Dr Peter George, a respiratory consultant from the Royal Brompton Hospital, recently held an educational webinar for doctors to discuss the long term effects of the acute Covid-19 infection and I thought I would share his findings with you. He states:

"Respiratory complications of Covid-19 are common and can be serious. As yet there is no hard research data but anecdotally there is experience that it is significant".

These are the cases that he discussed:

Post Covid Pulmonary Emboli

This patient presented with breathlessness on exertion. They felt tired and breathless when climbing the stairs. There was no chest pain and palpitations (rapid heart rate) but this can occur. They sounded wheezy and breathless on talking. Investigations were blood tests, ECG, CXR and ECHO

Followed by a HRCT and CTPA.

ECG - electrocardiogram which looks at the heart's rhythm and electrical activity

CXR - chest xray

ECHO - echocardiogram which looks at the structures of the heart and how well it's pumping

HRCT - high resolution computerised tomography which looks at the lung tissue and airways, specifically inflammation

CTPA - CT pulmonary angiogram which looks for blood clots in the lung


Results showed the patient had a raised D-Dimer (a blood test to look for blood clots) and large pulmonary emboli on the CTPA.

The patient was given a blood thinner (Rivaroxaban) and made a full recovery.

Dr George went on to note that patients can remain prothrombotic (the blood is thicker which can lead to increased clouting of the blood which leads to thrombosis/ clots) for many months after the initial infection.

This can lead to blood clots during this period and not necessarily during the initial acute illness.

Post Covid Pulmonary Fibrosis

This patient presented with persistent breathlessness, chest tightness and an ongoing cough.

All blood tests and initial investigations were normal.

Spirometry testing - The patient went on to have spirometry testing ( breathing in and out of a tube, the same way they diagnose asthma) which was normal apart from something called the TLCO which was 50% of the normal level. The TLCO is a measurement of the carbon dioxide transfer across the lungs. It shows the ability of the lungs to take oxygen from the air, transfer it across the tiny air sacs (alveoli) and into the circulation for the cells to use to make energy.

The HRCT scan showed:

  • Consolidation - persisting lung inflammation and congestion

  • Interstitial lung disease (ILD) - an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe and get oxygen to the bloodstream. The damage from ILDs is often irreversible and gets worse over time.

  • Early pulmonary fibrosis.


The patient was started on high dose steroids to reduce the inflammation and try to prevent further fibrosis.

The patients TLCO improved from 50 to 70%.

They will need long term follow up due to the pulmonary fibrosis.


Post Covid Breathing Pattern Disorder

This patient had persistent breathlessness on exertion and sometimes at rest.

They had normal blood tests, Lung function tests and HRCT scan. Heart investigations were also normal. The patient was referred to respiratory physiotherapist and a breathing pattern disorder was diagnosed. A breathing pattern disorder is when your body seems to have "lost" the ability to breath in the correct way. It is managed by physiotherapy and other adjuvant therapies such as yoga. I shall discuss this further in my next post.


From Dr Georges experience he feels that those with persistent breathlessness need investigating further as respiratory complications of Covid-19 are common and can be serious. He says people should be investigated early citing 12 weeks if breathlessness is still occurring.

Obviously those with acute chest pain, acute shortness of breath, worsening breathlessness, unexplained chest pain and confusion should be seen urgently.


These are the investigations that should be done at your local doctors if you are still feeling short of breath:

FBC, CRP, Ferritin, D- dimer, LDH, BNP, LFT's, U&E's, troponin, CK

ECG

CXR

ECHO

If these don't reveal anything do not be discouraged. If you are still breathless make sure you are referred to a Long Covid clinic or to respiratory/cardiology both specialities can deal with breathlessness.

I include the current BMJ guidelines "Management of post-acute covid-19 in primary care" for your reference.

https://www.bmj.com/content/370/bmj.m3026



References


https://www.bmj.com/content/370/bmj.m2426?fbclid=IwAR1mirCatERvp5XqPSEhgOZXsF6yWUxa-Mt2ocxeqS-JVDYa_LsokIbIDLM


https://www.medscape.com/viewarticle/938683_4?fbclid=IwAR0K7zs0RUeyR-DKPa-cS6O7hf3MfjY53bI73qF8rzpGUZKTrJOYo3ddkv4


https://www.ersnet.org/the-society/news/covid-19-patients-suffer-long-term-lung-and-heart-damage-but-it-can-improve-with-time?fbclid=IwAR1OUW-kvwcCXMFv-OGFyH_GVBTD1Yvv1E4zX8huq19PCExwETpyWMjR7sA


https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-01286-5?fbclid=IwAR3oVRxJMykQIUxDDAD55wOy8UL9F8VICpANEzzyabeJvA_e_8qh8-ziajA


https://www.ajronline.org/doi/pdf/10.2214/AJR.20.23034?fbclid=IwAR38l5MR_xcmz9aWrcPZxfhssV-yYuE4j9nkKk6z-9tbCGFBTsz-wj6AgRY


https://www.nature.com/articles/d41586-020-02598-6?fbclid=IwAR1qS16BxpLMsu05B8cBR0qszhE4HlJwPPKiFMKV1m_GYO5NNt5gFFeQ_mQ#ref-CR1


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