Beyond the headlines and in the cold realities of hospital wards, the COVID-19 pandemic has wreaked havoc as physicians scramble to come up with a list of new protocols to manage the influx of highly contagious patients.
The COVID-19 pandemic has already upended the neatly divided lines in the hospital wards. In the past, separate specialties tended to stay apart from each other, only meeting during multidisciplinary meetings. The urgency of the COVID-19 pandemic during its heyday meant that for the first time, everyone needed to come together and compromise to make room for adequate COVID-19 care.
Then came the clinical nightmare: how do we continue to treat COVID-19 patients with significant comorbidities? Should physicians continue to prioritize treating the comorbidities, or should we hold out until the COVID-19 results come back negative? It is this bargaining that makes medicine such a live profession, yet it can be a real nightmare for those calling the shots.
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A study published in the journal Pulmonary Hypertension looked into the care of pulmonary arterial hypertension (PAH) patients during the COVID-19 pandemic, and has outlined a few key principles that may be worth keeping in mind.
Read more about PAH treatment
Purpose and Scope
The authors felt this study was needed because “there is a lack of formal guideline consensus and scientific evidence to direct PAH providers and patients on best practices for COVID-19-infected and COVID-affected PAH patients.” Fair enough; hence, the authors decided to piece together one that can be used by physicians treating COVID-affected PAH patients.
The only caveat is that “this document is not meant to be all-inclusive nor to give specific in-hospital management of a PAH patient with COVID-19, as the evidence for such advice is currently lacking, but rather to assist in patient care and management to prevent hospitalization and improve clinical care during this pandemic.” Like with all good research papers, more data in the future means better answers.
For the sake of brevity, we will look at 2 main recommendations from this paper: one for stable PAH patients, and the other for unstable PAH patients.
Stable PAH Patients
The cardinal rule when it comes to stable PAH patients without COVID-19 is this: prevent getting the disease in the first place at all costs. Regardless of the presenting state of the PAH patients, the authors recommend common anti-pandemic measures, such as social distancing and avoiding nonessential travel. This is because PAH patients are fragile and can be prone to rapid deterioration.
One of the best ways to continue treating PAH patients while keeping them safe from COVID-19 is by deploying telehealth programs, although those are limited in that physicians cannot physically touch and examine their patients.
Read other rare disease-related COVID-19 articles:
PAH patients are already used to coming into the hospital for routine testings such as “echocardiograms, RHCs, six-minute walks, and laboratory tests,” the study authors wrote. However, in an age in which avoiding COVID-19 is key, it may be worth reevaluating the necessity of these routine testings, and whether lessening their frequency can be useful in avoiding possible COVID-19 contact.
Unstable Patients
Let’s run through a few facts regarding COVID-19:
- Most patients confirmed with COVID-19 present with pneumonia.
- Patients diagnosed with COVID-19 who also have comorbidities have higher mortality rates.
- Approximately 20%-30% of patients with COVID-19 and pneumonia require additional respiratory support in intensive care units.
These statistics show us why it is paramount that patients who have an established diagnosis of PAH take all the necessary precautions to avoid catching COVID-19.
However, given the prevalence of COVID-19, if a patient with PAH suddenly deteriorates, COVID-19 infection must be included among the differentials. This is especially true if this occurs during hospitalization.
In the experience of the study authors, “hypoxia and systemic inflammatory response syndrome with patients with PAH and COVID-19 is difficult to treat.” Acute respiratory distress syndrome (ARDS) also becomes more common in patients with PAH and COVID-19.
Read more about PAH complications
Because of the fragile nature of patients with PAH and COVID-19, it can be difficult to decide which intervention to start the patient on, as they all come with their own set of benefits and risks. However, “in a febrile PAH patient, consideration should be given to starting empiric, broad-spectrum antibiotics at the onset of fever” to prevent opportunistic bacterial infection, the study authors recommend.
In patients with shock, with or without COVID-19, “the role and route of PAH-specific therapies should be discussed with a PH expert,” the authors wrote. In general, PAH-specific treatment should continue. Nitric oxide (NO) should be considered in lieu of other agents that lower blood pressure.
Treating Covid-19 Patients With Dangerous Comorbidities
With so much of the scientific community still learning about COVID-19 and its variants, it is challenging to establish fixed guidelines on how COVID-19 patients with significant comorbidities should be treated.
Since this study was published, vaccines have become widely available in the US. Because one of the guiding principles for patients with chronic illness is to avoid contracting COVID-19, the presence and the availability of vaccines should encourage every person to register for one if they haven’t already done so.
As COVID-19 still ravages parts of the world, doctors are having to make the heartbreaking decision on whether to continue treatment in moderately ill patients or to put their full attention towards critically ill patients. This is an unenviable dilemma, but in countries where the virus is still out of control, the principles outlined in this study remain useful: isolate patients with chronic illnesses, and if they are diagnosed with COVID-19, use an innovative approach that prioritizes saving lives.
As physicians confront the deadly presence of multiple diseases in one patient, it is inevitable that treating protocols change as data is accumulated. As physicians, we need to have the agility to adapt to research-backed best practices as and when they become available.
References
Ryan JJ, Melendres-Groves L, Zamanian RT, et al. Care of patients with pulmonary arterial hypertension during the coronavirus (COVID-19) pandemic. Pulm Circ. Published online April 29, 2020. doi:10.1177/2045894020920153
Vaccines for Covid-19. Centers for Disease Control and Prevention. Updated May 23, 2021. Accessed July 15, 2021.
