COVID-19 from Intensive Care Unit to Outpatient Clinic

Additional Info

• Audio File:uf_health_shands/ufhs056.mp3
• Doctors:Alzghoul, Bashar;Mehta, Hiren
• Featured Speaker:Bashar Alzghoul, MD | Hiren Mehta, MD
• Guest Bio:Bashar Alzghoul, MD is a Pulmonologist at UF Health and Assistant Professor of Medicine at UF College of Medicine. 
  
  Hiren Mehta, MD is a Pulmonologist, UF Health Assistant Professor of Medicine.
• Transcription:Melanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to join us today, as we discuss COVID-19 from intensive care unit to outpatient clinic. Joining me in this thought leader conversation panel is Dr. Bashar Alzghoul, he's a Pulmonary and Critical Care Specialist at UF Health Shands Hospital and an Assistant Professor of Medicine at the University of Florida College of Medicine. And Hiren Mehta, he's a Pulmonologist and the Medical Director of the Intensive Care Unit at UF Health Shands Hospital. And he's an Associate Professor of Medicine at the University of Florida College of Medicine. Doctors, thank you so much for joining us today. What an important episode this is. Dr. Mehta, I'd like to start with you. Can you help us to understand the best practices and standard of care for COVID-19 patients in the ICU at UF Health Shands Hospital?
  
  Hiren Mehta, MD (Guest): Thank you very much for having me on the call and on the podcast. So, you know, it's been more than 18 months that we've been dealing with COVID-19. And what we have seen is we have seen the disease evolve from the original surge early in the year to a new surge that we had later in the year, a month or two ago.
  
  And when the patients end up in the intensive care unit, the main reason why they end up is because they're having severe respiratory distress. And as they approach the intensive care unit, we focus on a couple of aspects of management. One is from a breathing standpoint, how can we help a patient who is struggling to breathe and we quickly escalate based on patient's needs from high flow oxygen to non-invasive ventilation to having them on a mechanical ventilator.
  
  Once the patients get on a mechanical ventilator, we closely follow their blood gases, see how their oxygenation is doing and if need be, we put them on high PEEP, high FIO2 settings. We start paralyzing them, if the compliance of the lung is not good. We also start them on inhaled pulmonary vasodilators like Flolan, nitric oxide.
  
  And despite of all the measures, if the patient's still struggling to breathe and still struggling to oxygenate, then we prone them. And that's really the ventilator management aspect of it. From a medication aspect, we have all these patients on steroids, as we know that dexamethazone has improved mortality in patients with severe COVID-19 pneumonia.
  
  We also have some form of IL6 inhibitors. The most common go-to is tocilizumab. As again, that's that has shown to improve mortality in these patients. Despite of all these measures, if we can not help the patients to oxygenate and ventilate then the rescue mortality really is veno venus ECMO. We do offer venovenus ECMO as a bridge to recovery or as a bridge to lung transplantation.
  
  Bashar Alzghoul, MD (Guest): Yeah. I would like to, you know, to second, as you know, the second surge that you have the, of this year, we noticed a lot of, for example, pneumothorax and a lot of pneumomediastinum that we didn't see as, as often in the first. Which basically just adding to what Dr. Mehta said disease did evolve indeed. Maybe it's that because there's a different variant or maybe the patient population was a little bit different, but that's, what we noticed as well.
  
  Host: Well, thank you so much, gentlemen. So Dr. Alzghoul, is there any available literature about long-term care, outpatient care for COVID-19 patients if and when they get out of the ICU? What do we know that we didn't know a year ago about long hauler complications, you know, post COVID complications?
  
  Dr. Alzghoul: That's a very important question. And I'd like to, you know, to highlight that we as pulmonologists and it terms of this, we get to see the full spectrum of the disease. So when you see the patients, when they're at their sickest point in the ICU, when they are proned and paralyzed, and when everyone is starting to give up on those patients, but we, you know, we continue high standard care for them; and then we get to see them on the floor after they were downgraded from the medical ICU to the floor, with a tracheostomy tube. And then we get to see them after they leave the hospital in a long-term facility. And then we get to see them in our clinic and I've had, you know, extremely happy, the last two weeks when I was on the pulmonary consult service, taking care of these patients in the medical floor, and I've seen the patient that I took care of two or three months ago in the ICU. At that time when they where in the ICU, they were proned, on high ventillator settings. They were like on dialysis. And then I took care of them just last week, the same patients, I was like taking you know, decanulating their tracheostomy tubes while they were on the floor. I'd maybe decanulated at least five or six patients in one day, which is unprecedented. Like when generally speaking patients will get posts ICU tracheostomy, that thing usually stays for a prolonged period of time.
  
  But these patients, because they got the and they got standard of care high quality care throughout the hospitalization; we were able to decanulate a lot of these patients. And to answer your question, you know, these longterm complications of post COVID infection actually depend, it does, there are a lot of valuables in the in discussion.
  
  So it depends like when, how sick was the patient to start with, the comorbidities, the body mass index of the patient coming into the illness. And then how, how difficult was the hospital course? Whether it was it was complicated by acute kidney injury, whether he required the analysis, whether there was a superimposed infection and whether, you know, all of these variables play in, into the term complications and the long-term complications can vary from mild symptoms, like such as fatigue, shortness of breath, cough which even in the patients with mild COVID disease, it can be as high as maybe 30 to 40% of those patients suffer from symptoms like that. It can be also some other psychologic symptoms that are related to their stay in ICU. The ICU stay by itself can be extremely traumatic and these patients can have like post-traumatic stress disorder kind of symptoms, anxiety. They can start having flashbacks and then there are other long-term complications, you know, whether they had like a myocarditis during their stay, you can have a long term heart failure. Whether they had acute kidney injury. They can be on dialysis for a prolonged period of time and then relate it to the COVID infection itself of the lungs.
  
  They can suffer from a long term, like fibrotic lung disease that sometimes can be irreversible and sometimes can be treatable and sometimes can be recoverable, but require a long period of time. So it's it's a wide spectrum of complications, that depends really on how, how bad was the disease to start with and, you know, the comorbidities of the patient and all that.
  
  Dr. Mehta: May I say something Doctor Alzghoul. There've been some talk and some thought about the antifibrotic medications, like pirfenidone, et cetera, which is used for our interstitial lung disease patients and some people are looking into it. What are your thoughts on anti-fibrotic medications for post COVID fibrosis?
  
  Dr. Alzghoul: Yeah, that's a, that's a really interesting and important question. So there's to my knowledge there are a couple of clinical trials now, clinical trials in India, and there was another international clinical trial looking at fibrotic medications that Dr. Mehta is referring to, pirfenidone and an antagonist, basically.
  
  So there's, early in the pandemic even like, outside the US especially outside the US, there has been a lot of off label use of pirfenidone early on trying to see if it does have any benefit, because it does have some theoretical benefit that it might protect the pneumocytes and other cells if the patient is suffering from cytokine storm. There's a theoretical benefit it might prevent the lung fibrosis. So some people have been using it as off-label use, but to this date, I'm not aware of any clinical trial that's proves the benefit of these two medications. I think I'm going to stay optimistic.
  
  I think maybe, or it makes sense to follow or to start using these medications early on, rather than wait after the patient comes and see them in the clinic. But I would wait for the results of the clinical trial.
  
  Host: Dr. Mehta, then can you tell us what kinds of services and care you provide at the University of Florida College of Medicine, and UF Health Shands Hospital in terms of recovery and discharge. Tell us a little bit about the importance of the multidisciplinary approach for these patients.
  
  Dr. Mehta: That's a great question, Melanie. As you know, anything that we do in intensive care unit requires a multi-disciplinary approach. Anytime you have the sickest of the sick patients that you're taking care of, you need all hands on deck. So to give you an example, when we were our surge and we took care of the COVID-19 patients, it truly was a team effort in the best sense that you will ever see. And this starts with the nurses who are taking care of these patients, constantly monitoring these patients, making sure they're oxygenating well, making sure that they're getting their medications, making sure that they are getting their blood draw and blood gases and everything.
  
  The respiratory therapist who played a significant role in helping manage the airways of these patients. Also adjusting the ventilators, checking the blood gases, following up on the blood gases and taking care of the ventilators. In the acute phase, physicians who made admissions, who admitted these patients to the intensive care unit, took care of the medications that they need, did the procedures that they need, including, you know, dialysis catheters, central lines, intubations, everything that goes on along with it, monitoring these patients for response, updating the families. Then pharmacy played a significant role with all the medications. Some of these medications are highly specialized medications and they helped us work very closely with our teams and helped us get those medications through the pharmacy in a timely manner.
  
  Once they got through that acute phase, and I apologize if I missed out on anyone because you know, when you're running an operation and taking care of these sick patients, everybody from supply chain to our environmental services; everybody plays a role in taking care of these patients to the highest administration. Once these patients started getting a little better and they moved along the system, that's when the physical therapy, occupational therapy, rehab, speech therapy, nutrition all that came into play and helped them because the patients being on ventilator and being in the ICU, lost a lot of muscle mass.
  
  And so they all help mobilize the patients, get them stronger and get them through the next step to the, out of the intensive care unit to an intermediate care unit and eventually out of the hospital. So it, it truly was a team effort in the best sense that I've seen. Dr. Alzghoul, I don't know if I missed out on anybody or if you want to add on anyone.
  
  Dr. Alzghoul: As I said earlier, we in the pulmonary and critical care division, we continue to see these patients, even when they leave the ICU, because you know, a lot of these patients end up with a tracheostomy tube and the tracheostomies, they need a respiratory therapist and they need a pulmonologist sometimes to take care of them.
  
  Especially if they have complications, we have an advanced interventional pulmonary service. If there's like any tracheal stenosis or any airway complications, we have an interventional pulmonary service that can take care of that. And we, in the pulmonary service, we continue to see these patients on, on our consult service while they are in the hospital.
  
  And when they leave to one of our sister LTak facilities until you know, we, we get them to the decannulation point. And if we reach a point where these patients are requiring a lot of oxygen after a prolonged period of time, let's say eight to 12 weeks or so we also have an advanced and high volume lung transplant program.
  
  We worked with our colleagues in the lung transplant program and we refer those patients at that point to, for evaluation for lung transplant. A lot of the time, it's very important to recognize some of the other acute events that happened during the hospitalization. These post COVID patients, they can suffer from pulmonary embolism.
  
  They can suffer from lung abscesses, super-imposed pneumonias, so sometimes they have long-term organizing pneumonia. So that's why we continue to see them. And we evaluate on case by case basis and we treat them accordingly. Once they leave the hospital, we see them in our clinic you know, depending on how sick the patient was and how old, and depending on the co-morbidities, we either see them six to eight weeks or so after discharge.
  
  And we try to allocate them to, for the available resources, you know. If they need the psychology help, if they need cardiology assessment, if they need a extensive cardio, pulmonary rehab and all of that, we help these patients achieve that goal. And from pulmonary standpoint, if they need any long-term treatment, like some inhaler therapy or management of their volume status to diagnose, if they have like a new pulmonary embolism or pulmonary hypertension, we still see them in our clinic and deal with these long-term complications as well.
  
  Host: Well, thank you for that. So, I'd like to give you each a chance for some final thoughts. So Dr. Alzghoul, can you tell us a little bit how Tele-health has augmented your ability to care for COVID patients after discharge? What's involved? We've talked a little bit about follow-up. Can you tell us a little bit about the difference in care for patients that are discharged home versus patients that are discharged to a supervised residential care for recovery and available resources for longterm management of post COVID fibrosis, including lung transplant.
  
  Dr. Alzghoul: Yeah. So even the patients that go home from the hospital, even the patients that have mild to moderate disease, there was some studies out there. So just think that maybe 10 to 20% of these patients after a month of discharge, they are still, they still have some degree of disability.
  
  They still cannot do their, what they used to do before hospitalization. I'm not talking about the sickest patients that were in the ICU. I'm talking about, patients who just went to the hospital with COVID, where on couple of liters oxygen and then were discharged. They still suffer from some long-term symptoms.
  
  So that's why during the pandemic, we managed, you know, we increased the number of the patients that we see in our clinic, by utilizing the Telehealth service, you know, we are able to reach those patients at home and have some you know, a long distance encounters with them to see how they are doing.
  
  And without having them come to the healthcare system and being exposed to catching an infection or especially if they're not able to drive themselves. And so, so Telehealth has extended our abilities to, to reach these patients. Now as for, for the patients that go to rehab facilities or long-term care facilities you know, as I said, we do have a rehab, like a rehab facility associated with our hospital and as well as a long-term facility that we have here, and our group also continues to see these patients while they are there.
  
  And we help them achieve their goals. We help them go through the physical therapy to gain their strength and build up their muscles. And we follow them until they get decannulated while they are over there or until they get discharged from those facilities. And then we hook them up with our, our clinic as outpatients.
  
  Host: What amazing and wonderful work you both are doing and thank you so much. Dr. Mehta, last word to you. Are there any drugs or investigational therapies that you find exciting right now for COVID? What can you share about what you're doing at UF Health Shands Hospital? Wrap this all up for us with anything exciting that you can share with other providers about where you see this going or what you hope to see happen.
  
  Dr. Mehta: So that's a bit, a big question, Melanie, because as you know that despite of all the research and all the efforts that have been focused on COVID for the last two years, we still struggle. We still struggled with surge. We had a lot of mortality and we had a lot of morbidity with this.
  
  So, I mean, when you asked me this question, there's two parts to it. One is what's actually happening and what I hope that would happen. So what's actually happening is that the medical community and the scientific community in general has made COVID its priority over the last two years. Never, ever in the history of medicine have we seen a vaccine for a viral illness being so effective and rolled out at a pace that we saw for COVID. So, so that just tells you the pace at which the research is going on in the field. And the research is focusing on everything from preventing COVID, which includes vaccination, to targeting COVID early on in the disease so that we can prevent these patients from getting admitted in the hospital and being as sick as they are.
  
  And that includes monoclonal antibody. And recently there's another medication, which is hopefully going to get approval soon, which is going to be a pill. It's an antiviral medication, which is going to prevent patients from, once the patients are diagnosed with COVID from having severe illness. So the research is focusing on that part. The research is focusing currently on aspects that include, once these patients are hospitalized, how can we best help them to get better quicker and not end up in the intensive care unit?
  
  And that is everything from steroids to antivirals, to anticoagulation and different types of anticoagulation modality to prevent this patient from getting critically ill. And once they do get critically ill, there has been a lot of research focusing on how quickly to get them better without causing significant damage to their lungs.
  
  And again, that we talked about tocilizumab and IL6 inhibitors for that, so on and so forth. When it comes to UF Health, UF Health from the beginning of the pandemic has been very active in clinical trials for COVID. We have so far had at least 10 active trials that we have enrolled COVID-19 patients for.
  
  And that included patients from, included patients who are in the intensive care unit, not in the intensive care unit, on the regular floors. These include multinational studies. Multi-institutional studies and investigator initiative projects locally. So UF Health has been very active when it comes to research, on this front as well.
  
  What I really hope is that we find that and I think the prevention is the going to be the biggest deterrent and the vaccines are so far proven, very effective. And as any virus, I think this virus is going to continue to mutate. And I hope that we continue to find effective prevention for ever mutating coronavirus. And we don't have to deal with the surges in 21st century where we can prevent it.
  
  Host: I just didn't know if Dr. Alzghoul, did you have any little final thoughts? Cause I kind of asked you a lamer little question then Dr. Mehta, who got to really get into the meat of it. Do you have anything you want to add before I wrap it up?
  
  Dr. Alzghoul: Yeah, absolutely. So it's two things. So as Dr. Mehta said, prevention, I hope everyone would get vaccinated. I got a, in my vaccine, all of, all of the people in our division got vaccinated. I hope everyone in the community will get vaccinated. So that as Dr. Mehta said we won't have to deal with some of those surges and with the winter and early spring.
  
  And the other thing, what I found is it's the little things, just be patient. What these patients need is time. And what we need to do as healthcare providers is to provide evidence based medicine to help them recover in this long journey of recovery. They need time. We just need to follow the guidelines and we need to be patient with them.
  
  And as I said, I've seen a patient, many patients actually, who were extremely sick on ECMO, got tracheostomy, where paralyzed, where proned; I've seen them recover. I've seen them go home and see their family. I've seen them watch a soccer game after three months of being ill. So we just need time and need to provide evidence-based medicine during that time.
  
  Host: What an amazing episode and so informative. Really, really great information you shared today. And thank you so much for coming on with us and sharing your incredible expertise the both of you. Thank you again. To refer your patient or to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters.
  
  That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.
• Hosts:Melanie Cole, MS
• Post Test URL:https://cme.ufl.edu/mededcast/