ABSTRACT
Rationale: Acute respiratory distress syndrome (ARDS) due to severe viral pneumonia has been shown to cause impaired lung function and persistent radiological abnormalities several years after recovery. Severe COVID-19 causes ARDS in a minority of patients. Corticosteroids were used in previous viral pandemics and have been shown to reduce mortality and severity of COVID-19 infection. The use of high-dose pulsed methylprednisolone and the long-term pulmonary and functional outcomes following its use in severe COVID-19 have not been widely studied. Methods: A retrospective review of electronic records of patients treated with high-dose pulsed methylprednisolone (1000mg once daily for 3 days, followed by 40mg Prednisolone daily reducing by 5mg every 3 days until a stable dose of 10mg) during the first wave of the COVID-19 pandemic in the UK was done. Baseline demographics, microbiological, and radiological data were collected. Survivors were followed at 3 months post-discharge with a CT pulmonary angiogram (CTPA), spirometry, gas transfer, and 6-minute walk test (6MWT). Results: 15 patients were treated. 14 had ARDS whilst one had paediatric multisystem inflammatory syndrome, myocarditis, and mild respiratory failure. Mean age was 51 years. 13 patients were male. 5 patients died (4 male, 1 female), 4 due to COVID-19 infection and 1 due to myocardial infarction. 1 patient developed viral encephalitis and 1 developed a subdural haemorrhage, both of which resolved without specific treatment. 6 patients had follow-up lung function. The most common abnormalities were a low diffusion capacity for carbon monoxide (DLCO) and total lung capacity (TLC) (5 patients each) with DLCO having the lowest mean predicted value (58%), followed by TLC (67%). 10 patients completed follow-up CTPA. The most common CT abnormalities at 3 months were parenchymal bands (7/10, 70%) and 5 developed fibrosis. 8 patients completed a 6MWT. Mean distance walked was 405 metres (standard deviation (SD) 87.4m)/65% predicted (SD 18.5%). Conclusions: In this cohort of severely unwell patients with COVID-19 at 3 months, abnormalities in pulmonary function, CT appearance, and exertional capacity were unsurprisingly common. However, all patients treated at an early stage of their disease survived suggesting there might be some benefit when used sufficiently early, although conclusions about the effect on mortality are not possible with this study. This treatment has been shown to improve outcomes in a small randomized controlled trial. We believe our findings support the need for larger trials to clarify its impact and define the optimal timing for treatment.
ABSTRACT
Introduction Current guidelines for follow up of COVID-19 patients are based on experience with outbreaks with Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS), with the aim to identify patients likely to develop post infectious fibrosis. The COVID-19 pandemic is on a much larger scale and requires investigation regarding the most effective way to follow up these patients. Methods We set up a pathway to allow us to screen selected discharged patients to identify those who required further investigations. Discharged patients were identified following admission between March and June 2020 using electronic hospital records. Patients who were not suitable to be called were excluded, and a letter was written to their GP explaining this. All other patients were called approximately 6 weeks after discharge. Information was collected including ongoing symptoms, admission radiological changes, and selected questionnaires. Patients with ongoing symptoms were invited back for investigations and face-to-face appointment, and anyone without symptoms but x-ray changes was invited for repeat X-ray at 10 weeks. Results Of the 828 admissions, 281 died, and a further 182 were unsuitable to call. Of those called, 88% (321) answered, and 65 remained symptomatic and were seen in clinic. 154 people required a repeat chest x-ray, 8 subsequently had a CT thorax and clinic review. 56 people did not attend for follow-up x-ray and were discharged. Of the 73 people seen, 59 had interstitial changes based on radiological criteria;29 of these were resolving inflammation which did not require further follow up as the patients were also clinically improving. 30 patients, 11 with fibrotic changes, required observation or treatment. Four patients received oral prednisolone and 7 had received intravenous methylprednisolone earlier. In the symptomatic group, PEs, pulmonary hypertension, adenocarcinoma in situ and breathing pattern disorders were also diagnosed. Conclusion Less than 10% of patients required treatment with steroids after admission with COVID-19 infection. This is lower than previous estimates following MERS/SARS infection. Interestingly, severe radiology changes did not predict the likelihood of developing fibrosis. The screening telephone clinic was a useful way of identifying those with ongoing symptoms who required further investigation.