By Matthew Perez, Victor Beauvil, RRT, PhD, Sarah Khan MD, Arunabh Talwar, MD, FCCP
The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread quickly to all parts of the world, and this pandemic continues to result in significant morbidity and mortality. SARS-CoV-2 is one of seven types of coronavirus, including the ones that cause severe diseases like Middle East Respiratory Syndrome (MERS) and Severe acute respiratory syndrome (SARS). The other coronaviruses cause most of the colds that affect us during the year but aren’t a serious threat for otherwise healthy people.
COVID-19 is a disease caused by SARS-CoV-2 that generally involves the lungs. In the lungs, SARS-CoV-2 invades the type 2 pneumocytes by binding to the angiotensin-converting enzyme 2 [ACE2] receptors present on the cell membrane (Figure 1). This ultimately results in damage to the lungs due to the release of toxic effects of cytokines liberated in the inflammatory response to the virus and significant inflammation. Covid pneumonitis is the most common manifestation of this viral infection, though other cardiac, gastrointestinal, and neurologic features may also be involved at the onset.
Coronavirus disease 2019 (COVID-19) symptoms can vary widely. Some people have no symptoms at all, while others may have mild illness, but few develop moderate and severe disease. Severe illness from COVID-19 is defined as hospitalization, admission to the intensive care unit (ICU), intubation or mechanical ventilation, or death. Those most affected by COVID-19 are those of advanced age and those with pre-existing chronic medical conditions, particularly diabetes, obesity, cardiac conditions like systemic hypertension, or other immunosuppressed conditions. It is intuitive to believe that patients with underlying chronic lung conditions may have an increased risk of severe pneumonia and poor outcomes when they develop COVID-19. This may be related to poor underlying lung reserves or increased expression of ACE2 receptors in small airways.
Coronavirus and Its Effects on Patients with COPD
There seems to be a relationship between smoking and Covid infection. Some have suggested an association of smoking with a risk for poor outcome in COVID-19 .
As nicotine has previously been associated with upregulation of ACE2 , which is the main receptor for SARS-CoV-2 to attach to the alveolar macrophages , this makes the clinical case for the importance of emphasizing smoking and vaping cessation. Respiratory therapists can take a lead in motivating and helping people quit smoking.
The COVID-19 pandemic has put patients with COPD and other comorbidities at high risk for poor outcomes . Though the actual impact of COVID-19 on COPD patients needs to be determined, there is no denying the fact that once infected with SARS-CoV-2 pneumonia, lung function in COPD patients can deteriorate rapidly, leading to respiratory failure . It has been suggested that patients with pre-existing COPD have more than three times higher risk of mortality and severe COVID-19. There is a need to identify patients with pre-existing COPD during the pandemic so that early interventions can be aimed at this group of patients .
To begin with, COPD patients are of advanced age and are more likely to have comorbidities, including hypertension, CHD, CVD, and CKD, which are also high-risk factors for developing COVID-19 infection. Viral infections are common causes of acute exacerbation of COPD and may lead to respiratory failure in many patients . Thus, it is possible to see that COVID-19 patients with COPD are at increased risk of severe acute exacerbation of COPD, which may lead to respiratory failure.
Access to pulmonary rehabilitation (PR) is a key issue for patients with COPD. This crisis highlights a need for improved, remotely supervised physical therapy programs that utilize telehealth technology to advise patients on appropriate at-home exercise that is tailored to their specific needs. There is a paucity of high-quality research on this topic . It is well known that participation in pulmonary rehabilitation enhances exercise capacity, reduces depression and anxiety, and improves Health-Related QoL (HRQoL), fatigue, and the strength of respiratory muscles in patients with various forms of respiratory disorders. Others have highlighted the importance of PR for patients recovering from moderate to severe COVID-19 . The respiratory therapist plays a vital role in pulmonary rehabilitation. Identifying patients who are eligible for pulmonary rehabilitation, assessing the individual patient prior to entry into the program, providing education regarding the patient’s disease, and actively participating in the exercise and training programs are all the responsibilities of an RRT operating in the environment of pulmonary rehabilitation. Interested therapists may complete the Pulmonary Rehabilitation Certificate Course, offered through a partnership between the American Association for Respiratory Care (AARC) and the American Association of Cardiovascular and Pulmonary Rehabilitation.
Table 1 Long-Term Effects of COVID-19
• Seen in many patients after any critical illness and includes loss of muscle mass, neuromuscular weakness, fatigue, dyspnea, decreased exercise tolerance, joint contractures.
• Substantial muscle wasting and neuromuscular weakness, which may persist for months.
Mental Health Impairment
• High incidence of anxiety, depression, and insomnia.
Long-Term Pulmonary Impairment
• Persistent pulmonary symptoms are common after COVID-19.
• Persistent pulmonary infiltrates at six-month interval may be seen in some patients.
• There is a suggestion that some patients may develop pulmonary fibrosis following COVID-19 infection.
• Persistent myocardial inflammation post-Covid.
Coronavirus and Its Effect on Patients with Asthma
Asthma is a heterogeneous condition, characterized by a type 2 eosinophilic inflammation in more than 50% of those with a formal asthma diagnosis. Early in the COVID-19 pandemic, there was a concern that people with asthma were at higher risk for acquiring Covid pneumonitis or poor outcomes. It was believed that like other respiratory viral infections, coronaviruses might exacerbate asthma symptoms, particularly in severe or uncontrolled patients. However, that has not been borne out in the various studies. People with asthma have a lower risk than those without asthma of acquiring COVID-19 and have similar clinical outcomes .
Several reasons have been suggested for the lower severity of COVID-19 in asthmatics. To begin with, lower interferon levels in people with asthma are hypothesized to be protective against cytokine storms . There is also a suggestion that immunomodulatory activities of inhaled asthma medications (in particular, inhaled steroids) may have a protective role in asthmatics .
In vitro studies have shown inhibitory actions of budesonide on coronavirus HCOv-229E replication and cytokine production, which may have clinical implications. This conclusion gained credence from the fact that dexamethasone lowered the incidence of death in severe COVID-19 patients receiving respiratory support . A recent study used prevalence data from 150 studies conducted worldwide to assess whether asthma increases the risk of morbidity and severity of COVID-19. The results of the analysis do not provide clear evidence of increased risk of COVID-19 diagnosis, hospitalization, severity, or mortality due to asthma . These findings could provide some reassurance to people with asthma regarding its potential to increase their risk of severe morbidity from COVID-19. Until more data emerges about asthma and its relationship to COVID-19 infection, it is crucial that patients with asthma and other allergic diseases such as allergic rhinitis maintain their controller medications of inhaled corticosteroids without making any dose adjustment on their own. RRTs can help reinforce compliance with asthma medications to their patients .
Patients with COPD and asthma post-Covid may have a persistent feeling of dyspnea, muscular weakness, and other post-Covid long-term sequelae as outlined in Table 1. Respiratory therapists managing these patients must be aware of these long-term problems faced by patients with COVID-19.
Authors: Matthew Perez, Farmingdale State College, East Farmingdale, NY, Victor Beauvil, RRT, PhD, Mandl School, The College of Allied Health, New York, NY. Sarah Khan MD, and Arunabh Talwar, MD, FCCP, Northwell Health, Department of Pulmonary, Critical Care and Sleep Medicine, New Hyde Park, NY.
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