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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 63-69

Problems of management of non-corona respiratory diseases in the era of COVID-19


1 Department of Pulmonary Medicine, Jindal Clinics, Chandigarh, India
2 Department of Medicine, Division of Pulmonary Medicine, Alberta Respiratory Centre, University of Alberta, Edmonton, AB, Canada

Date of Submission25-Apr-2020
Date of Decision06-Jun-2020
Date of Acceptance10-Jun-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Surinder K Jindal
Jindal Clinics, SCO 21, Sector 20 D, Chandigarh - 160 020
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_30_20

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  Abstract 


This pandemic, COVID-19 caused by the novel coronavirus SARS-CoV-2, has not only devastated the public health, but also posed an immense impact on the societal, economical, and geopolitical conditions. The severe stress on essential health services has also adversely affected the prevalence, recognition, and management of non-COVID diseases. In particular, the management of respiratory diseases has suffered the most because of the clinical similarities between COVID-19 and non-COVID flu, respiratory allergies, pneumonias, and respiratory failure. Because of these similarities, some of the patients tend to avoid seeking treatment lest they be diagnosed as COVID-19 infection. Diagnostic tests such as spirometry and invasive investigations (bronchoscopies and thoracoscopies) are avoided by physicians for the fear of spread of the infection. Patients with acute worsening of asthma and chronic obstructive pulmonary disease requiring nebulization therapy are thus not even entertained by medical facilities. Many patients themselves are often afraid of inhalation therapy. In this article, we have summarized the problems faced by the patients suffering from respiratory disorders and their physicians as well as some of the important issues related to their therapy during this pandemic.

Keywords: Asthma, chronic obstructive pulmonary disease, coronavirus, COVID-19, respiratory diseases


How to cite this article:
Jindal SK, Jindal A, Moitra S. Problems of management of non-corona respiratory diseases in the era of COVID-19. Int J Non-Commun Dis 2020;5:63-9

How to cite this URL:
Jindal SK, Jindal A, Moitra S. Problems of management of non-corona respiratory diseases in the era of COVID-19. Int J Non-Commun Dis [serial online] 2020 [cited 2020 Oct 23];5:63-9. Available from: https://www.ijncd.org/text.asp?2020/5/2/63/288251




  Introduction Top


After the Spanish-flu epidemic in 1918 which most of people of this generation had not confronted, the COVID-19 pandemic has struck the world like no other disease in the last several decades. The most recent Swine-flu 2009 pandemic was similarly devastating but not as widespread and fearsome as COVID-19. Both those pandemics were caused by influenza (H1N1) virus. On the other hand, the COVID-19 pandemic caused by coronavirus (SARS-CoV-2) seems to be more infectious, rapidly spreading all over the world, causing serious respiratory illness and increased mortality. It is not surprising that there is an all-out administrative and medical focus on COVID-19 all over the world, and India is no different. However, the pandemic has caused a great setback to the health-care infrastructure in an effort to contain the noncommunicable diseases.


  Non-COVID Diseases Top


On a real-time basis (per week), COVID-19 has become a major cause of mortality [1] [Figure 1]. However, it has no match compared to other deaths caused by other established risk factors such as tobacco smoking, air pollution, high blood pressure, and obesity, which are estimated to kill 160,000, 200,000, 94,000, and 71,000 people, every week, respectively.[1] The COVID-19 pandemic is also responsible for an unwanted compromise for non-COVID problems. This is particularly so with reference to most respiratory diseases which mimic COVID-19 both clinically and therapeutically.
Figure 1: Global deaths per week, 2020. The Economist

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  General Difficulties of Diagnosis and Management Top


Problems due to lockdown conditions

General practitioners and specialists, particularly pulmonary physicians, find it difficult to manage their patients as they would have normally done. Patients find it even more difficult to seek treatment for respiratory symptoms and fevers. Each such patient is looked down upon with suspicion and often shunted down from one place to another. In fact, patients with these symptoms tend to avoid seeking treatment for fear of stigma and isolation. Restriction of movement and closure of shops are undoubtedly essential to reduce the transmission and community spread of the virus, albeit make it difficult for patients to seek medical advice and undergo treatment. In addition, there is either nonavailability or scarcity of essential drugs and other medical supplies.

Some of these public health interventions, especially the mass use of facemasks in crowded places, may have a positive impact by reducing the overall prevalence of other air-borne infections.[2] For example, mass masking in Hong Kong has caused a precipitous fall in the laboratory detection of influenza and all other respiratory viruses.[3] Face covers of any kind as already practiced in India may also prove to be an effective and sustainable measure.[4]

Face-to-face consultations

Treating and managing patients with respiratory diseases has become a matter of concern for the physicians as well as for the patients and their families. Lack of adequate facilities in India's primary health-care centers, particularly in rural areas, drives no less than a thousand patients with respiratory problems to a tertiary care hospital, every day.[5] It has now become very difficult to provide consultations, treatment, and interventions to this huge patient population who visit either an outpatient department in a tertiary care hospital or visit a privately-run clinic or hospital. There are some reports on improvised methods for regular consultation to patients, for example for dermatological patients.[6] Whether those methods are applicable in respiratory clinics, is a point of debate.

There is even a greater chance for the physicians to get infected when facing patients in crowded clinics and that might lead to a complete breakdown of health-care system, particularly in a country like India where there are only 0.8 doctors per 1000 population.[7] Telemedicine provides a better alternative in such a situation where the outpatients could be advised through virtual platforms. However, there are issues related to privacy of the patients and other legal bindings particularly when used informally in the absence of an informed consent.[8] There are several other barriers of telemedicine through virtual audio–visual interfaces which in India cannot totally replace the personal visit to the doctor. Some physicians have reported satisfactory feedbacks from their patients when providing consultations through personal and encrypted social media platforms, like WhatsApp.[9],[10]

Interventional and surgical procedures

Scarcity of personal protective equipment, particularly required for physicians who are prone to be exposed to the patients' breathing zone, makes it even more difficult for respiratory physicians to practice. Nowadays, a pulmonologist has to rely completely on the patient-reported symptoms because there is no scope for physical examination and lung function tests. There are obvious chances of underdiagnosis and sometimes, misdiagnosis. Interventional procedures (such as bronchoscopies and thoracoscopies) as well as elective surgical procedures are not undertaken and therefore delayed.

We specifically focus on various aspects related to the burden, diagnosis, and management of noncorona respiratory diseases:

  1. Acute conditions: flu and pneumonias, tuberculosis (TB)
  2. Chronic conditions: Asthma and allergies; chronic obstructive pulmonary disease (COPD); interstitial lung diseases (ILDs), malignancies, and others.



  Acute Respiratory Diseases Top


The novel coronavirus which belongs to the beta-coronavirus genus is a respiratory virus with universal involvement of respiratory tract. There are two important issues related to coronavirus infection (COVID-19) and respiratory disease:

  1. Differential diagnosis from other acute respiratory illnesses (infections and allergies)
  2. Coronavirus infection precipitating acute exacerbation of a chronic respiratory disease (CRD).


COVID-19 respiratory illness

Respiratory illness in COVID-19 typically consists of mild, moderate, and severe illness, almost 80%–85% of patients present with mild disease due to involvement of upper respiratory tract (nose, sinuses, pharynx, and larynx) usually within 2–11 days (median 5–6 days) of exposure to infection.[11] Acute illness is characterized by flu-like symptoms (such as fever, chills, headache, and malaise; cough which is usually dry; anosmia, loss of appetite, nausea, abdominal discomfort, vomiting, and diarrhea). The illness is severe in about 15% of patients with occurrence of pneumonia. Almost 60% of patients have cough; patients now develop breathlessness which is quite distressing and may be accompanied by hypoxemia. Pneumonia can sometimes develop rapidly within a matter of hours. Illness is critical in about 5% of patients characterized by acute respiratory distress syndrome and severe respiratory failure. These patients may go on to develop septic shock, and/or multiple organ failure. These patients require to be managed in intensive care units. Severe disease is more commonly seen in the elderly and male patients usually with concomitant comorbid conditions (hypertension, cardiac disease, diabetes, malignancy, and other chronic diseases).[12] The disease is generally milder with rare mortality in children than adults.[13]

Incidentally, both asthma and COPD are not commonly reported as important comorbid conditions for COVID-19. The trend is almost same from not only China, but also Italy and the USA.[14],[15],[16] It is unclear whether this can be attributed to a protective immunological effect of the underlying respiratory disease or to the therapies such as inhaled corticosteroids being used for their management.[17]

Non-COVID acute respiratory infections

While both influenza-like illness and severe acute respiratory illness are important respiratory illnesses due to SARS-CoV-2 infection, it is important to remember that these acute diseases are also common due to non-coronavirus infections. To a limited extent, some common clinical features can help to differentiate between common cold, flu, and allergic catarrh [Table 1].
Table 1: Some common clinical features to differentiate different causes of acute upper respiratory tract catarrh

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Cough is the most common presenting complaint (30%) at the primary care setting in India with population prevalence of around 5%–10%.[18],[19] Upper respiratory tract infections (most often of viral origin) were the cause of cough in 12.2% of patients, whereas lower respiratory tract infections were reported in 8.1% of patients in the primary care setting.[19] Lower respiratory tract infections (bacterial, viral, and other community-acquired pneumonias) are common in both the healthy population and in patients with comorbid conditions. Most of these conditions present with similar clinical picture as seen with COVID-19 disease. Making a correct diagnosis is a challenge in the absence of specific clinical features and laboratory tests for diagnosis.

Allergic rhinitis and bronchial asthma

Acute presentation of noninfectious conditions such as allergic rhinitis (AR) and bronchial asthma can also simulate COVID-19 infection. AR is a very common condition and an important cause of morbidity. Different investigators have reported a prevalence of around 11% among both adults and children.[20],[21] Sneezing, rhinorrhea, and cough are the important symptoms of AR, which make it difficult to distinguish from COVID-19. Asthma is another common and troublesome illness present in around 3%–5% of the general population in India.[22],[23] Asthma frequently presents in association with AR, which makes it even more difficult for management.[24] Factually, each prescription for an antihistaminic, an anti-tussive agent, an analgesic, or even a bronchodilator is viewed with suspicion for a possible case of COVID-19.

Asthmatics need to take care to prevent virus-induced exacerbations. Adequate asthma management is, therefore, critical to implement. It is important for patients with asthma to keep their asthma under control. Stopping a controller medication will put the person at risk for developing an asthma exacerbation. Patients must not stop their corticosteroid inhaler. Stopping the steroid inhaler could put the patient at higher risk of complications with infections as it would impair asthma control. It is also important not to share the inhaler and/or other devices such as the spacers, nebulizers, or other accessories. It is recommended to use a metered-dose inhaler with a spacer to relieve acute symptoms. Use of nebulizers should be avoided as they generate aerosols which carry a high risk of transmitting viral infections. However, there could be situations when a nebulizer is absolutely required. In such a situation, it is of utmost importance to follow Good Nebulization and Infection Control practices.

Treatment of an asthma exacerbation often requires a visit to the emergency department for urgent care, where the individual has a much higher risk of being exposed to someone with an infection. In the current pandemic, continuing to keep asthma under control, the patient is actually reducing the chance of exposure to viral infections.

Acute exaggeration of chronic respiratory diseases

Upper respiratory catarrh of infectious origin is an important cause of acute exacerbation of CRDs such as asthma. Viral respiratory tract infections can lead to asthma expression in patients at risk of disease or loss of control in patients with existing disease.

As of today, there is no evidence of increased corona infection rates in patients with asthma. It can, however, be estimated that patients with moderate-to-severe asthma are likely to have a greater risk for more severe disease. Acute infection is also an important cause of acute exaggeration of other chronic lung diseases such as COPD and ILD, causing worsening of clinical condition of the underlying disease. It is, therefore, likely that COVID infection worsens the preexisting, non-COVID respiratory illness. We already encounter patients with chronic lung diseases showing positive evidence of coronavirus infection. Such patients are likely to suffer from more severe illness requiring intensive care. They also show an increased probability of death from the acute episodes.

Tuberculosis

The clinical effects of COVID infection in patients with TB are not yet known. However, it is obvious that the epidemiological and behavioral alterations are going to adversely impact the disease treatment and control. The health-care services are greatly stressed due to the COVID pandemic. Medical and public health personnel, who were already scarce, are all engaged in activities required for the containment of COVID transmission and spread. None or only a few are left to look after TB control and other health programs. As stated earlier, mass adoption of various sustainable public health interventions may however help to limit the spread of TB which, like COVID, is an air-borne infection.

In 2017, the Prime Minister of India, Shri. Narendra Modi had given the call for TB elimination by 2025; the Revised National TB Control Programme was subsequently redrawn and renamed as National TB Elimination Programme (NTEP).[25],[26] A national strategic plan was laid out with several targets to achieve TB elimination. The COVID pandemic has pushed the NSP and NTEP to the background. Both fiscal and workforce resources are limited. Patients on Directly Observed Therapy, Short-course have missed their treatment doses for several weeks. We are yet to see the final data and the outcomes of treatment only after sometime. This can be however anticipated that the damage is already done and the NTEP targets may be difficult to achieve in time.


  Chronic Obstructive Pulmonary Disease Top


COPD is a progressive and disabling disease with a heavy morbidity and mortality. Globally, it is one of the most common causes of death and loss of disability-adjusted life years.[27] In India, the disease prevalence accounts for over 3.5% of the general population of over 35 years of age.[22],[28] There is a very high burden of CRDs in India amounting to around 93 million people. Of them, around 37 million suffer from asthma and about 56 million from COPD and other chronic conditions.[29] COPD in fact has affected India in almost an epidemic-like situation.[30]

Whether COPD is a risk factor for COVID-19 infection remains debatable. Allergic diseases, asthma, and COPD were not the risk factors among 140 hospitalized patients of COVID-19 infection.[31] However, COPD patients are likely to have a higher risk of more severe illness due to COVID-19 as shown in a meta-analysis of seven studies which included a total of 1592 COVID-19 patients, of whom 314 (19.7%) had severe disease with over five-fold increased risk of severe COVID-19 infection.[32],[33],[34] The case fatality rate of patients with CRD and COVID-19 infection was also reported to be higher.

Important clinical features and management principles can be summarized as follows:

COVID-19 infection in chronic obstructive pulmonary disease patients

Besides the symptoms of COVID-19 infection, these patients are also more likely to experience breathlessness and require hospitalization. They are likely to present with aggravated features of respiratory failure and managed accordingly. Oxygen administration and assisted ventilation may be required depending on the state of respiratory failure.

COVID-negative, chronic obstructive pulmonary disease patients

The general management of COPD is that patients should continue their treatment for COPD as usual during the COVID-19 outbreak. They should not stop taking other drugs including corticosteroids.[35] They should ensure that all other precautions are taken and adequate supply of drugs as well as oxygen (if on domiciliary long-term oxygen therapy) is available for a sufficient period of time, at least for a month. It is also important that other supportive therapies including the normal nutrition and fluids are available as earlier. COPD patients are advised to be physically active, practice moderate-to-vigorous physical activity at home, if not possible outside. Lower physical activity level in COPD patients might aggravate symptoms. Rehabilitation therapy should also be continued preferably at home. As COPD patients may require oxygen therapy, an alternative arrangement of home oxygen therapy could be useful to manage sudden exacerbation.


  Interstitial Lung Diseases Top


ILDs are a group of lung disorders characterized by progressive lung fibrosis, which leads to lung shrinkage and ultimately respiratory failure and death. The group includes a wide variety of disorders including connective tissue diseases, vasculitis, environmental diseases, hypersensitivity pneumonia, sarcoidosis, and idiopathic ILDs, including others. These disorders account for a significant proportion of cases presenting in a respiratory clinic.[36],[37]

The time taken for the diagnosis of an ILD can vary from a few days to months, depending on the setting. This requires multiple outpatient department visits, investigations such as pulmonary function tests (PFT), and bronchoscopic or surgical lung biopsy. COVID-19 has immensely impacted the diagnosis of these diseases. The requirement of social distancing and the imposition of lockdowns worldwide may lead to an increase in the diagnostic time for these patients. In addition, both PFTs and bronchoscopic procedures are aerosol generating, and most guidelines have restricted their use temporarily to prevent health-care workers from infection. Surgical lung biopsy is a procedure with high morbidity and recommended for difficult cases or specific situations. Again, there is a risk for the health-care workers from infection and also chances of nosocomial infection from the hospital environment.[37],[38],[39]

The treatment of ILDs involves use of immunosuppressive treatments such as steroids, methotrexate, hydroxychloroquine, azathioprine, and antifibrotic agents. Supportive treatment includes pulmonary rehabilitation, oxygen supplementation, and noninvasive ventilation. These patients are candidates for lung transplantation also. In addition, acute exacerbations and infections are well known and require treatment such as increase in immunosuppression and antibiotics, respectively.[37]

We know that the use of steroids early in the course of COVID-19 leads to a worse outcome. This is especially problematic in the treatment of ILDs because almost all patients are initially treated with steroids. There is also the apprehension that patients on immunosuppression might be more prone to acquire COVID. In addition, there is no evidence to say what will happen when patients on antifibrotic agents develop COVID.[40],[41],[42]

There was a postulation that hydroxychloroquine sulfate, an antimalarial used for the treatment of autoimmune disorders and ILDs, may be helpful in the prophylaxis and treatment of COVID. This led to an artificial shortage of the medicine, and many patients already on the drug had difficulty in purchasing it, while some were able to get it only at exorbitant rates. Lockdown measures led to a shortage in the availability of supportive equipment such as oxygen cylinders and concentrators. Also severely affected were pulmonary rehabilitation programs which include physiotherapy training, diet and nutrition management, and counseling.

Lastly, acute exacerbations of ILD are well-known phenomena, in which there is an increase in the underlying inflammation with worsening of symptomatology with high probabilities of superadded infections. Differentiation from COVID infection is difficult but essential, as these episodes are accountable for high mortality.[41]


  Lung Malignancies Top


Lung cancer is one of the most common cancers worldwide. In addition to the fact that these patients have cancer, the common presence of comorbidities complicates issues. In addition, most of these patients are in the advanced age groups and are smokers. They have high chances of getting all sorts of infections in view of their baseline status and the use of toxic chemo- and radio-therapeutic regimens.

An early report from Italy during the current COVID pandemic showed that of 3200 deaths up to that time, 19.4% were patients with cancer. Other active comorbidities included hypertension (76.5%), diabetes (37.3%), cardiac disease (37.3%), atrial fibrillation (26.5%), and chronic kidney disease (17.5%). The presence of two comorbidities was associated with 25.7% of deaths, while the presence of three comorbidities was associated with 47% of deaths.[42]

Treatment of lung cancer relies heavily on invasive techniques such as bronchoscopy and lung biopsies. Furthermore, therapeutic bronchoscopy procedures are useful in the palliative care of these patients. As bronchoscopy is a high aerosol-generating procedure, there is a high chance of infection among the health-care workers. Consequently, its use has been significantly restricted by all international societies.[43]

Treatment of lung cancer involves the use of chemotherapy and radiotherapy. Evidence is starting to accumulate that these toxic therapies may be associated with a worse outcome in these times. There is confusion when to initiate therapy and whether to continue therapy for patients who have already started with it. In addition, elective procedures such as lobectomies and pneumonectomies are being delayed.[44],[45]

The way forward

In summary, it may be stressed that noncommunicable respiratory diseases as well as non-COVID infections including TB continue to exist even though the COVID-19 infection heavily dominates the news media and medical press. While we must not let our guard down in any way against the coronavirus, we need to continue to use our resources against other diseases. One hopes that effective strategies to handle these problems are developed along with the measures to control the pandemic and limit its damage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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