Palliative care in Post-Covid – with a focus on PC_ILD

 

Author: Dr Rajam Iyer

Consultant Pulmonologist and a Palliative Care Physician at P. D. Hinduja Hospital & Medical Research Center Mumbai

The Covid-19 pandemic has unleashed a tsunami of suffering, loss and unprecedented grief.

Unfortunately we are now seeing the trail of distressing devastating symptoms that the pandemic is leaving behind in patients. These symptoms are collectively now being called “Post-Covid” / “Long Covid”.

We as health care professionals are learning about the clinical presentations every day, as it is a new and evolving phenomenon. What we do know is that these symptoms leave the patients with debilitation and poor quality of life.

Palliative care by definition addresses “health related suffering” of patients and caregivers and the issues addressed are not just physical. The emotional, psychological, social, spiritual and financial devastation due to the pandemic is staggering.

The role of palliative care during the pandemic is crucial from triage, patient selection to ICU, control of distressing symptoms, end of life care and management of distress of patients, caregivers and health care professionals. The need for palliative care in post covid is heightened with the long tail that it is leaving behind.

List of Post-covid symptoms

Suggested causes for post covid symptoms

• Persistent viraemia (weak or absent antibody response)
• Relapse or reinfection
• Inflammatory or other immune reactions
• Deconditioning
• Mental factors (PTSD)

PC-ILD

As seen with previous viral pandemics, SARS/MERS due to the small size of the virion particle, viruses cause interstitial pneumonia. Being a novel corona virus, the immune response towards the novel corona virus results in cytokine storm, severe inflammation and Adult respiratory distress syndrome.

Pre-disposing factors

• Advanced age
• Severe illness
• Prolonged ICU/ hospital stay
• Mechanical ventilation
• History of smoking
• Chronic alcoholism
• Higher levels of CRP/IL-6

The acute severe inflammation is typically seen as “ground glass opacities” with or without consolidation, crazy-paving pattern, interstitial thickening, parenchymal bands mainly in bilateral lower lobes. The inflammation heals by fibrosis and wide-spread scarring.

Interstitial thickening, air bronchogram, irregular interface, coarse reticular pattern, parenchymal bands, and pleural effusion were seen more commonly in the fibrosis group on high resolution scan of the thorax.

Clinical features of PC-ILD

This fibrosis results in patients suffering distressing breathlessness, cough, hypoxemia. The overwhelming symptom affects the quality of life as increases dependence on activities of daily living. Patients are bed-bound and suffer emotional, psychosocial and existential pain.

A fair proportion of patients are normal adults, pre-covid.

Evaluation of PC-ILD,

A detailed history clinical examination and review of serial images followed by investigations such as

1. Bloods: CBC- to rule out anemia
2. Arterial blood gas- to record hypoxemia
3. Complete pulmonary function test with bronchodilator reversibility- Flow rates for airway diseases and volumes and capacity for detection on parenchymal abnormality.
4. Diffusion capacity- DLCo
5. 6 MWT- walk test to record desaturation on exercise
6. 2D-ECHO- to assess cardiac function
7. HRCT scan if the lung function documents restrictive abnormality with reduced DLCo.

Management of Breathlessness:

Breathlessness is one of the commonest symptoms seen in post-covid patients. It can be due to multiple causes. Once the patient is breathless, it can worsen his anxiety thereby breathlessness. Both these restrict movement of the patient increasing his deconditioning, as explained by the Breathing-Thinking-Functional Model.

PC-ILD multi-disciplinary team approaches to break this vicious cycle that patients are trapped in.

Non-Pharmacological management of breathlessness:

• Position
• Blowing of a hand-held fan in front of the face
• Breathing techniques- purse lip, prolonged exhalation
• Physiotherapy and rehabilitation with oxygen
• Huff puff to clear secretions
• Postural Drainage
• Conserving Energy:
  • Planning
  • Pacing
  • Prioritizing
  • Positioning

Pharmacological management of PC-ILD

• Oxygen to maintain saturation between 88-92% at all times.
• Steroids-active inflammation seen on HRCT
• Anti-fibrotics- Perfinidone and Nintadanib available. No clear cut role. In patients where the pattern of fibrosis is progressive as noticed by worsening CT scan imaging, its worth trying as in other progressive ILD’s. Both these drugs have severe gastrointestinal side-effects, so the physician must weigh the risk and benefits.
• Low dose Morphine- invaluable in helping the patient cope with breathlessness, co-operate for physiotherapy and slowly build back stamina, muscle mass, and regain independence

Natural Course of PC-ILD

As seen in the figure below, majority of patients do slowly recover, at around 12 weeks.

A few remain same, hence requiring holistic support for patients and caregivers.

Not many progress, but the ones who do have a guarded long term prognosis.

Summary

We are now in the second year of the pandemic. The medical profession has come together in sharing protocols, exchanging thoughts in diagnosis, treatment and prevention.

Yet, the bizarre nature, multi-organ involvement, varied presentations of the illness is constantly teaching us every day. The post covid symptoms are also multi-systemic, and challenging to manage. It requires a holistic multi-disciplinary team for an overall control of symptoms and to assist patients and caregivers to as normal quality of life as before the infection.

This can be best managed with integration of palliative care in care of covid positive patients during and after the illness.

References

1. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19https://doi.org/10.1016/j.jinf.2020.08.029
2. Udwadia ZF, Koul PA, Richeldi L. Post-COVID lung fibrosis: The tsunami that will follow the earthquake. Lung India 2021;38:S41-7.
3. Peter M George, Athol U Wells, R GisliJenkins. Pulmonary fibrosis and COVID-19: the potential role for antifibrotic therapy
4. thelancet.com/respiratory Vol 8 August 2020
5. Post Covid19, Patient information pack. NHS. https://www.homerton.nhs.uk/download/doc/docm93jijm4n6743.pdf?amp;ver=13452