Coronavirus patients can suffer long-term lung and heart damage, early rehab program may help: Study
People could recover faster if they undergo rehabilitation as soon as possible after coming off ventilators or leaving intensive care, suggests expert
People hospitalized with Covid-19 can suffer long-term lung and heart damage and have breathlessness and coughing several weeks after being discharged, according to an analysis of patients infected with the coronavirus. Researchers found that at the time of their first visit, six weeks post-discharge from the hospital, more than half of the patients had at least one persistent symptom, predominantly breathlessness and coughing, and scans still showed lung damage in 88% of patients. However, by the time of their next visit 12 weeks after discharge, the symptoms had improved and lung damage was reduced to 56%.
"The bad news is that people show lung impairment from Covid-19 weeks after discharge. The good news is that the impairment tends to ameliorate over time, which suggests the lungs have a mechanism for repairing themselves," says Dr Sabina Sahanic in her presentation at the European Respiratory Society International Congress. She is a clinical PhD student at the University Clinic in Innsbruck and part of the team that carried out the study.
Close to 60% of patients also had heart problems after six weeks, but this may be only indirectly linked to Covid-19, a sign of the severity of the disease in general, say experts. "The findings show the importance of implementing structured follow-up care for patients with severe Covid-19 infection. Importantly, CT unveiled lung damage in this patient group that was not identified by lung function tests. Knowing how patients have been affected long-term by the coronavirus might enable symptoms and lung damage to be treated much earlier and might have a significant impact on further medical recommendations and advice," explains Dr Sahanic.
The authors recruited coronavirus patients who were hospitalized at the University Clinic of Internal Medicine in Innsbruck, the St Vinzenz Hospital in Zams, or the cardio-pulmonary rehabilitation center in Münster, Austria. The current study is an analysis of the first 86 patients enrolled between April 19 and June 9. Over 150 patients are now participating in the research.
The patients were scheduled to return for evaluation six, 12 and 24 weeks after their discharge from the hospital. During these visits, clinical examinations, laboratory tests, analysis of the amounts of oxygen and carbon dioxide in arterial blood, lung function tests, computed tomography (CT) scans and echocardiograms were carried out. The average age of the 86 patients included in the presentation was 61 and 65% of them were male. Nearly half of them were current or former smokers. An estimated 65% of hospitalized Covid-19 patients were overweight or obese. Eighteen (21%) had been in an intensive care unit (ICU), 16 (19%) had had invasive mechanical ventilation and the average length of stay in the hospital was 13 days.
The results reveal that 56 patients (65%) showed persistent symptoms at the time of their six-week visit. Breathlessness (dyspnoea) was the most common symptom (40 patients, 47%), followed by coughing (13 patients, 15%). By the 12-week visit, breathlessness had improved and was present in 31 patients (39%), but 13 patients (15%) were still coughing.
Tests of lung function included FEV1 (the amount of air that can be expelled forcibly in one second), FVC (the total volume of air expelled forcibly) and DLCO (a test to measure how well oxygen passes from the lungs into the blood). These measurements improved between the visits at six and 12 weeks. At six weeks, 20 patients (23%) showed FEV1 as less than 80% of normal, improving to 18 patients (21%) at 12 weeks, 24 patients (28%) showed FVC as less than 80% of normal, improving to 16 patients (19%) at 12 weeks, and 28 patients (33%) showed DLCO as less than 80% of normal, improving to 19 patients (22%) at 12 weeks. At this stage, it is too early to have results from the evaluations at 24 weeks.
The CT scans showed that the score that defines the severity of overall lung damage decreased from eight points at six weeks to four points at 12 weeks. Damage from inflammation and fluid in the lungs caused by the coronavirus, which shows up on CT scans as white patches known as “ground glass” also improved: it was present in 74 patients (88%) at six weeks and 48 patients (56%) at 12 weeks.
At the six-week visit, the echocardiograms showed that 48 patients (58.5%) had “dysfunction of the left ventricle of the heart at the point when it is relaxing and dilating (diastole)". Biological indicators of heart damage, blood clots and inflammation were all significantly elevated, write authors. Heart results at 12 weeks are not presented. "We do not believe left ventricular diastolic dysfunction is specific to Covid-19, but more a sign of severity of the disease in general. Fortunately, in the Innsbruck cohort, we did not observe any severe coronavirus-associated heart dysfunction in the post-acute phase. The diastolic dysfunction that we observed also tended to improve with time," says Dr Sahanic.
Rehabilitation program helps patients
According to another presentation, coronavirus patients can recover faster if they undergo rehabilitation as soon as possible after coming off ventilators or leaving intensive care. Yara Al Chikhanie, a PhD student at the Dieulefit Santé clinic for pulmonary rehabilitation and the Hp2 Lab at the Grenoble Alps University, France, told the virtual Congress that the sooner Covid-19 patients started a pulmonary rehabilitation program after coming off ventilators, the better their recovery.
Patients with severe Covid-19 can spend weeks in intensive care on ventilators. The lack of physical movement, on top of the severe infection and inflammation, leads to severe muscle loss. The muscles for breathing are also affected, which weakens the breathing capacity. Pulmonary rehabilitation, which involves physical exercises and advice on managing symptoms, including shortness of breath and post-traumatic stress disorder, is crucial for helping patients to recover fully, explains the researcher.
Al Chikhanie used a walking test to evaluate the weekly progress of 19 patients who had spent an average of three weeks in intensive care and two weeks in a pulmonary ward before being transferred to the Dieulefit Santé clinic for pulmonary rehabilitation. Most were still unable to walk when they arrived, and they spent an average of three weeks in rehabilitation. The walking test measured how far the patients could walk in six minutes. In the beginning, they were able to walk an average of 16% of the distance that, in theory, they should be able to walk normally if healthy. After three weeks of pulmonary rehabilitation, this increased to an average of 43%, which was a significant gain but still a serious impairment. Patients who started rehabilitation in the week after coming off their ventilators progressed faster than those who were admitted after two weeks.
"The most important finding was that patients who were admitted to pulmonary rehabilitation shortly after leaving intensive care progressed faster than those who spent a longer period in the pulmonary ward where they remained inactive. The sooner rehabilitation started and the longer it lasted, the faster and better was the improvement in patients’ walking and breathing capacities and muscle gain," says Al Chikhanie in the report. According to the author, how soon patients can start rehabilitation depends on the patients being judged medically stable by their doctors. "Despite the significant improvement, the average period of three weeks in rehabilitation wasn’t enough for them to recover completely. These findings suggest that doctors should start rehabilitation as soon as possible, that patients should try to spend as little time as possible being inactive and that they should enroll with motivation in the pulmonary rehabilitation program," recommends Al Chikhanie.
Commenting on both presentations, Thierry Troosters, president of the European Respiratory Society, who was not involved in any of the studies, said it is clear from both that rehabilitation, including physical and psychologic components, should be available for patients as soon as possible and it should continue for weeks, if not months, after they have been discharged from hospital to give patients the best chances of a good recovery.
"Dr Sahanic’s presentation is important because it is one of the first, comprehensive prospective follow-ups of these patients and shows the serious, long-term impact of Covid-19 on the lungs and heart. It is sobering to hear that more than half of the patients in this study showed damage to their lungs and hearts 12 weeks after hospital discharge and that nearly 40% were still suffering from symptoms such as breathlessness. Al Chikhanie’s research shows how essential it is for patients to start pulmonary rehabilitation as soon as they are physically able to do so. Governments, national health services and employers should be made aware of these findings and plan accordingly," suggests Troosters, a professor in rehabilitation Sciences at KU Leuven, Belgium.