Algorithmic approach in the management of COVID-19 patients with residual pulmonary symptoms

Abstract

Coronavirus-19 emerged about 3 years ago and has proven to be a devastating disease, crippling communities worldwide and accounting for more than 6.31 million deaths. The true disease burden of COVID-19 will come to light in the upcoming years as we care for COVID-19 survivors with post-COVID-19 syndrome (PCS) with residual long-term symptoms affecting every organ system. Pulmonary fibrosis is the most severe long-term pulmonary manifestation of PCS, and due to the high incidence of COVID-19 infection rates, PCS-pulmonary fibrosis has the potential of becoming the next large-scale respiratory health crisis. To confront the potentially devastating effects of emerging post-COVID-19 pulmonary fibrosis, dedicated research efforts are needed to focus on surveillance, understanding pathophysiologic mechanisms, and most importantly, an algorithmic approach to managing these patients. We have performed a thorough literature review on post-COVID-19 pulmonary symptoms/imaging/physiology and present an algorithmic approach to these patients based on the best available data and extensive clinical experience.

Keywords: Acute respiratory distress syndrome; coronavirus-19; post-COVID-19 syndrome; post-COVID-19 syndrome-pulmonary fibrosis; proposed management of post-COVID pulmonary symptoms.

Figure 1

A 66-year-old male with COVID-19 pneumonia. (a) Axial contrast-enhanced chest CT image demonstrates acute lower-lobe predominant bilateral ground-glass opacities (arrows). (b) Axial noncontrast chest CT image performed 1 month later demonstrates substantially improved ground-glass opacities (white arrow), new superimposed curvilinear opacities (curved arrow), and reticulation (white arrowhead), associated with mild architectural distortion and traction bronchiectasis (black arrowhead), consistent with mild pulmonary fibrosis. (c) Axial noncontrast chest CT image performed 6 months after initial CT shows unchanged mild fibrosis. CT: Computed tomography

Figure 2

A 63-year-old male with COVID-19 pneumonia. (a and b) Axial contrast-enhanced chest CT images demonstrate bilateral upper lobe-predominant ground-glass opacities (black arrows) and lower lobe-predominant consolidation (*), consistent with COVID-19 and acute lung injury. Pneumomediastinum is also visible (black arrowheads). (c) Axial noncontrast chest CT image through the upper lobes, performed 7 months after initial CT, demonstrates peripheral predominant ground-glass opacities (white arrows) and reticulation (white arrowheads), associated with architectural distortion and traction bronchiectasis/bronchiolectasis (black arrowheads), consistent with pulmonary fibrosis. (d) Axial noncontrast chest CT image through the lower lobes, performed 7 months after initial CT, shows more pronounced fibrosis, characterized by GGO (white arrow) and reticulation (white arrowhead) with architectural distortion and traction bronchiectasis/bronchiolectasis (black arrowheads). GGO: ground-glass opacity, CT: Computed tomography

Figure 3

Surveillance and management algorithm for COVID-19 survivors