Slides for the Weitzman ECHO session on COVID-19 "Long Haulers" as presented on Jan 6, 2021

1. COVID-19 “Long Haulers”
January 6, 2021

2. CME Credit
• Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State
Medical Society to sponsor continuing medical education for physicians. The
Bridgeport Hospital Yale New Haven Health designates this live activity for a
maximum of one (1) AMA PRA Category 1 CreditsTM. Physicians should claim only
credits commensurate with the extent of their participation in the various
activities.
• This activity has been planned and implemented in accordance with the Essential
Areas and policies of the Accreditation Council for Continuing Medical Education
through the joint sponsorship of Bridgeport Hospital Yale New Haven Health and
the Weitzman Institute. Bridgeport Hospital Yale New Haven Health is accredited
by the Connecticut State Medical Society to provide continuing medical education
for physicians.
• The content of this activity is not related to products or services of an ACCME-
defined commercial interest; therefore, no one in control of content has a relevant
financial relationship to disclose and there is no potential for conflicts of interest.

3. COVID-19
“Long Haulers”
6 Jan 2021
www.nationaljewish.org/

4. 21,044,020 cases on 1/5/21 with 357,156 deaths https://coronavirus.jhu.edu/map.html
COVID-19 in the United States

5. COVID-19 in the United States
https://coronavirus.jhu.edu/covid-19-daily-video

6. COVID-19 in the United States
https://coronavirus.jhu.edu/covid-19-daily-video

7. COVID-19 Cumulative Cases:
Curve Seen Accelerating Upwards

8. COVID-19 Vaccinations – Too Slow?
https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html

9. News Headlines
-4.6 million in the US received a
COVID-19 vaccine, far short of ~ 20
million before the end of Dec
-Federal health officials: rollout had a slower-
than-expected start and “did not have a clear
understanding as to why”
- CDC reported 365,294 people in nursing
homes and long-term-care centers had
been given shots through a federal
program, though more than 2.5 million
doses had been distributed for those
facilities
Highly contagious COVID-19 strain
found in upstate New York, Gov.
Cuomo says
COVID-19 Live Updates: Virus Cases
in U.S. Prisons Top 500,000Source: New York Times

10. Resources
• Nuvance health ~1900 articles reviewed:
https://spark.adobe.com/page/sCbcTIGxitEdM/
• CDC:
https://www.cdc.gov/coronavirus/2019-ncov/index.html
https://emergency.cdc.gov/coca/calls/2020/
• WHO:
https://www.who.int/emergencies/diseases/novel-coronavirus-2019
• Johns Hopkins:
https://coronavirus.jhu.edu/map.html
• Others
https://www.thelancet.com/coronavirus
https://covidactnow.org/

11. COVID-19 “Long Haulers”
Emma Kaplan-Lewis, MD - Infectious Disease Attending,
Elmhurst Hospital Center, NYC Health and Hospitals
Jesse Durrance, MD - Pulmonology and Critical Care Fellow,
Elmhurst Hospital Center, NYC Health and Hospitals

12. Agenda
• Discuss epidemiology of post acute symptoms
related to COVID-19
• Case Presentation: Infectious Disease Perspective
• Case Presentation: Pulmonology/Critical Care
Perspective
• Key Takeaways
• Discussion/Q+A

13. Terminology and Epidemiology
• Post acute sequelae or ‘Long COVID’ or ‘Long Hauler’: persistent symptoms beyond 3 weeks
from initial symptom onset
• ‘Chronic COVID’: Symptoms extending beyond 12 weeks from symptom onset
• Pathophysiology: Permanent organ damage from the acute infection, ongoing inflammation
 Difficult to discern from deconditioning and sequelae from overall pandemic (lifestyle
changes, social isolation, more sedentary)
• Frequency:
 Mild disease: 35% adult patients with + COVID test in outpatient setting reported ongoing
symptoms median of 16 days after positive test
 Moderate-Severe: post hospitalization, mean 60 days since symptom onset (36 days since
hospital discharge), 87.4% reported persistent symptoms, 44.1% reported worsened QOL.
Most common symptoms: fatigue, dyspnea, joint pain, chest pain

14. Terminology and Epidemiology (cont.)
Most Common Reported Symptoms:
– Fatigue
– Dyspnea
– Cough
– Arthralgia
– Chest pain
– Ongoing smell/taste dysfunction
– Headache
– ‘Brain fog’ (cognitive dysfunction, memory impairment)
– Depression/anxiety, mood changes
– Other important sequelae: Metabolic disruption: new or worse diabetes,
Organizing pneumonia, Permanent kidney injury, PTSD, Myocarditis

15. Long Term Symptoms
Carfì A, Bernabei R, Landi F, et al. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603-605

16. Case #1
73 F w/ Osteogenesis Imperfecta type 3, osteoporosis, HIV (CD4 > 1000, VL UD), HTN
3/31-4/9: Hospitalized with COVID-19 pneumonia, needed 02, no intubation. Symptoms: cough, shortness
of breath, fever, loss smell and taste. Discharged on home 02 for ~ 2 weeks
4/24 post d/c follow up: Mild dyspnea, not using 02 very much, still impaired taste and smell, traumatized
by hospital experience but relieved she survived, has 2 friends who passed away from COVID-19
6/26: Reports chronic sore throat post COVID and ongoing loss of taste, decreased appetite.
Deconditioned and frail. Referred to PM&R for PT
10/7: Feels COVID symptoms have returned- cough at night, shortness of breath worse at night and
exertion, ongoing decreased smell/taste impacting appetite. CXR and TTE ordered. Recommended r/p
COVID testing. Rx Mirtazapine 7.5mg QHS
11/18: CXR clear with cardiomegaly, TTE w/ diastolic dysfunction. Reports hard to walk b/c of shortness of
breath, slowly progressive. No chest pain/pressure. Extreme fatigue on some days
11/24: Televisit - worse dyspnea, advised to go to ED, declined but will come to clinic next day
11/25: Seen in clinic, afebrile, 99% room air but desaturated 82-85% after ambulating 1-2 min. HR to 110s
while ambulating. RR 28 at rest. Lungs clear, Cardiac exam with tachycardia (regular) and faint systolic
murmur, no LE edema or JVD. Sent to ED

17. DDX
• PE
• Unstable angina
• CHF
• Pneumonia
• Interstitial lung disease/diffusion abnormality
• ? Other

18. Case #1: CXR

19. Case #1: TTE
• TTE - impaired left ventricular relaxation pattern with
elevated left atrial pressure, grade II diastolic
dysfunction. Small partially organized pericardial
effusion

20. Case #1 Continued
11/26-12/2: Hospitalized
• TTE bedside with moderate pericardial effusion, no
tamponade
• CTA with no PE, D-dimer negative, r/p COVID PCR negative
• Monitored in CCU then medical floor
• 02 sat remained stable and weaned off 02
• Discharged without 02 and recommended outpatient PFTs
Current status: Referred to cardiology and pulmonology,
continue PT for deconditioning and trying to get outpatient 02
covered

21. Case #2
51 F with HIV, (CD4 600, VL UD) non- IDDM, epilepsy, HTN, prior smoker (quit 10 y prior)
Admitted 1/15-1/30 for leg weakness, UTI and pneumonia. Reports ‘couldn’t walk’ and shortness of breath and fever,
required supplemental 02 no intubation. No COVID test done. CT report (no imaging because outside hospital) with
bibasilar ground glass opacities)
3/18: Non productive cough for weeks, no dyspnea, MSK pain- back and ribs, ? Pleuritic
6/24: Ongoing MSK pain- L. rib , waxing and waning cough and shortness of breath (mild)
 COVID IGG + , PCR negative
8/26: Left upper back pain worse on inspiration, cough has improved
 Sent for CTA: diffuse ground glass opacities bilateral with bibasilar alveolar airspace opacities.
9/25: Pulmonology apt for ongoing intermittent mild dyspnea and cough and abnormal CT findings, ddx: viral infection,
post COVID syndrome (ab +), plan for TTE and r/p CT chest 3 mo
 Dobutamine stress echo- negative for ischemia, normal contractility and EF
9/30: Complaints of dry cough, intermittent sore throat. No fevers
12/22: Ongoing intermittent cough, energy improved, on and off mild dyspnea
 COVID PCR negative
 Repeat CTA: Stable LLL subpleural predominant groundglass opacities with reticulation/interlobular
thickening. Interval increase in the extent of the RLL subpleural predominant groundglass opacities with
reticulation/intralobular thickening. No honeycombing. Findings nonspecific and can represent interstitial
disease/organizing pneumonia

22. Case #2: Initial CT (8/26/20)

23. Case #2: Follow-Up CT (12/22/20)
4 months later

24. Case #2
Current status: repeat CT with ? Organizing
pneumonia- to see pulmonology next month
(? Tx steroids). Ongoing intermittent sore throat and
dry cough, generally improving.

25. Case # 3
64 F with insomnia, no other medical history
PCR+ for COVID 12/1, managed outpatient, repeat PCR negative 12/19
Frequent headaches, described as if someone ‘grabbing her head and pain
behind eyes’. Not improved with Tylenol or OTC NSAIDS
Waiting for neurology referral, no prior history of chronic headache
syndrome, in meantime getting NCHCT

26. Post-COVID Headaches Management
• If less than 8d/m: treat as needed with OTCs
• If more than 8-10d/m, daily preventative medication needed to avoid medication
overuse:
– Cut down on OTCs if taking >10d/m as that can cause worsening of headache
frequency/severity.
– Topiramate: start 25mg QHS and increase by 25mg weekly to 100mg daily (typically 50mg
BID). Better for migraine headaches (photo/phonophobia, nausea). Can cause grogginess/may
worsen brain fog so I'd avoid if that's a major issue. Don't use if prior kidney stones, glaucoma.
– Amitriptyline: start 10-25mg QHS and can increase up to 50-75mg QHS as needed. Good
option if poor sleep/insomnia. Generally avoid if on other anti-depressants, but such a low
dose that it's generally ok to add on if needed.
– Duloxetine: start 30mg daily but good dose is 60mg daily. Helpful for paresthesias and this is
full anti-depressant dose so good if there's untreated depression but avoid if on other anti-
depressants. Also activating so take in daytime, and take with food as it can cause some
nausea.
– Valproate/Depakote: 250mg daily to BID. Can cause nausea, weight gain, tremors etc. Second
line because of side effect profile but a good headache medication so worth a try if other
options limited. Avoid in anyone with liver issues.

27. Post-COVID Headaches Management (cont.)
• If constant headache/"status" headache:
– Start daily preventative.
– Can also provide short course of steroids (Medrol Dose Pack) to try and break headache. Anecdotally not
much luck with steroids and Post-COVID patients but still worth a try. Avoid if contraindications to steroids.
– If steroids not an option, can also do a 3-5 day course of diclofenac 50mg BID. Since its a longer acting NSAID,
it can also break the headache cycle. Take with food, monitor for GI issues (standard NSAID concerns).
• Other things:
– Tizanidine can be helpful if taken daily, especially if there seems to be a tension component or neck pain.
Typically start lower dose at bedtime and increase as needed since its sedating.
– Other things/non medication environmental modification:
• Sleep: if poor sleep that can worsen headaches. Can treat as above with meds that help headaches and
also sleep (i.e. amitriptyline) or can try melatonin
• Water: recommend at least 2-3L daily
• Caffeine: can help with headache but can also cause headache if drinking a lot. Recommend cutting
down if excessive use.
• Preventatives can take up to 4 weeks to really start working, so don’t stop them if no
immediate improvement. Only to stop if experience side effects that are really bothersome.
If mild side effects, encourage to try continuing and see if they go away since there's
only so many medication options.

28. Management of Post-Acute and
Chronic COVID
• Diagnostic (depending on symptoms reported and history): PFTs, TTE, CTA,
D-dimer, troponin, pro-BNP, CRP
• CXR at 12 weeks post discharge, also for new or worsening symptoms
• A1c, close glucose monitoring for diabetics
• Ambulatory 02 saturation
• Consider pulmonology/ pulmonary rehab, cardiology referral if ongoing
severe symptoms

29. Management of
Chronic COVID
Greenhalgh T, Knight M, A’Court C, et al.
Management of post-acute covid-19 in primary
care. BMJ. 2020;370:m3026

30. Clinical Cases from the
Pulmonary/Critical Care
Perspective

31. Case #4
53 y.o. Hispanic male with PMH of HTN presented with 2 weeks progressive SOB
associated with cough and fever
• 3/26/20 - 9/4/20: admitted with Severe COVID-19 Pneumonia: requiring intubation
on hospital day 2 after failing NIPPV – subsequent prolonged mechanical ventilation.
• Course complicated by:
– Tension pneumothorax x 2 (different sides)
• Persistent pulmonary-pleural fistula and loculated pneumothorax
– Septic Shock with empyema
– Renal failure requiring RRT
– MDRO infection in lung
• 5/28/20 – Trach done
• Decannulation 7/27/20
• Discharged Home 9/4/2020 on 4L NC, using walker, to care of wife with
VNS/Rehab/DME arranged.

32. Case #4 Follow Up
• 9/10/20: Scheduled for follow up at primary care clinic – no show
• 11/18/20 : Pulmonary follow up
– Tolerating 1L NC on ambulation- no O2 at rest (keeps it on)
– Persistent tachycardia
– Mild sore throat persists
• Issues:
– Exercise tolerance vs O2 demand (real and perceived)
– Assuming personal / family life
– Nagging worry – Post-Traumatic Stress Disorder
– Cultural / Language Barriers to ongoing care

33. Case #4 Follow Up
• Pulmonary Function Tests:
– Moderate Restriction
– No obstruction
• 6-minute walk test
– Off O2
– 66% of predicted
– Saturation >92% on RA
– HR to >140

34. Case #4 Follow Up: Imaging

35. Case #4 Follow Up
• Psychiatry:
– 12/2/20: no show
• Neurology:
– Frequent luxation of shoulders (reportedly had this from prior)
– Sent for tests / tele-medicine visit
– 12/21/20: in-person visit for PMR regarding rehab therapy of B/L upper extremities
• Cardiology: Follow up as needed
• Pulmonary: continues to follow up in outpatient clinic
– Anti-fibrotics are under study
– Inhalers: On ICS/LABA therapy (evidence limited and indeterminate)
– PT / Rehab / O2 supplementation
– PFT Trend- under study

36. Post-Intensive Care Syndrome:
COVID Patients
• PICS (Post-intensive care syndrome)
• Constellation of health issues that linger after critical illness – after discharge
(wide range of incidence =/?? Detection)
• Cognitive Impairment occurs in up to 25% of patients
– Associated with delirium during hospitalization (sedation and COVID)
• Psychological Health Impairment
– PTSD, Anxiety, Depression
• Functional Impairment (>25% of patients)
– ICU Acquired neuromuscular weakness
– Prolonged mechanical ventilation / Sedation / Paralytics / MOF
• Family / Caregiver PICS - beyond just the patient
Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: An overview. J Transl Intern Med. 2017;5: 90–92.

37. Post-Intensive Care Syndrome
Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, et al. Improving long-term outcomes after discharge from
intensive care unit: Report from a stakeholders’ conference. Crit Care Med. 2012;40: 502–509.

38. PICS in COVID-19 Patients
• PICS: patients have an elevated rate of re-admission
– Those with ALI/ARDS have higher rate of readmission (80%)
– Longer index admission associated with higher healthcare cost after index
admission
– Degree of inflammation associated with development of PICS
– Significant impact on home finances and ability to re-enter the workplace
• In COVID:
– Oxygen Demand: has the capacity to decrease
• 6MW test and PFTs help with objectivity
– Physical Therapy Remains extremely important
– Totality of PICS in COVID-19 patients is not yet fully appreciated
-Ruhl AP, Lord RK, Panek JA, Colantuoni E, Sepulveda KA, Chong A, et al. Health care resource use and costs of two-year survivors of acute
lung injury: An observational cohort study. Ann Am Thorac Soc. 2015;12: 392–401.
-Bangash MN, Owen A, Alderman JE, Chotalia M, Patel JM, Parekh D. COVID-19 recovery: potential treatments for post-intensive care
syndrome. Lancet Respir Med. 2020;8: 1071–1073.

39. Case #5
51 y.o. Male, no significant PMH, previously admitted for severe COVID-19 PNA at OSH-
Ventilated – Trach – Decannulated
• Course c/b failed extubation x 3, MRSA-VAP- Trach / PEG
• Admitted 3/18/20 for COVID-19 PNA – Trach (4/23/20) – Decannulated (5/15/20) - Discharged
(5/18/20) Home
• 6/18- admitted at OSH for acute exacerbation of “Asthma” discharged on steroids and inhalers
• 6/24- ED Visit at OSH for Dyspnea: duo-nebs – steroids, H1 blocker, inhalers- discharged
• 6/26- ED Visit at OSH for Dyspnea: duo-nebs – steroids, discharged with 5 day steroid course
• 6/28- admitted for Dyspnea, Hypoxia- stridor identified- underwent tracheal balloon dilation
(7/1)- steroid taper, discharged with improved symptoms (7/2) with follow up scheduled

40. Case #5: Initial Imaging

41. Case #5: Spirometry and Imaging

42. Case #5 Continued
• 7/23: Re-admitted with
progressive Dyspnea
 Noted to have voice
change
• 7/25: Repeat balloon
dilation with temporary
improvement
 Quickly relapsed with
O2 demand (5L NC
constantly)
 No obvious stridor on
exam
 PFTs post dilation

43. Case #5 Follow Up
• 8/3: Patient underwent tracheal
ring resection
 Trach placed during procedure
 Quickly decannulated (before
discharge)
• 8/10: Discharged home
• Follow up with Speech for
rehab therapy
 Continues to have
improvement. Mild raspy
voice, otherwise asymptomatic
 No requirement for
supplemental oxygen

44. Post-COVID “Long Hauler”
Take-Home Messages
• Oxygen supplementation: titration (as much physiologically as
psychologically)
– 6MW test / PFTs should be done at baseline and to monitor disease evolution
• Inhalers: individual patient decision (LABA/ICS)
• Anti-fibrotics: under investigation
• Rehab therapy: extremely important- facilitation is key
• PICS: weakness / cognition / depression / anxiety / PTSD / caretakers
• Dyspnea: keep a broad differential in mind
• Follow-up: elimination of barriers to healthcare access

45. Barriers to Follow-Up Care
• Disproportionate burden on racial / ethnic minority groups in hospitalization
and death rates
– Heavy Disease Burden on groups already vulnerable by traditional determinants
of health indexes
• Post-index hospitalization and Access to Care:
– Language and Cultural Barriers
• Navigation of the health system for testing / follow-up appointments
• Insurance navigation
– Economic Barriers:
• Rehabilitation
• DME – access to oxygen, prescriptions / refills
• Home care : burden of care falls on family
• Bread-winners: significant compromise in familial access to income

46. COVID-19 for the
“Long Haul”
Questions Regarding Each Patient:
1. What ongoing issues are they facing?
— Biological
— Psychological
— Social
2. Who is best-suited to address those issues?
3. What are the barriers the patient / family face
in meeting their needs (from HCP perspective)?
4. How can we (individual providers / system)
anticipate and help meet those demands?

47. References
• https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/late-sequelae accessed 12/28/20
• Carfì A, Bernabei R, Landi F, et al. Persistent symptoms in patients after acute COVID-19. JAMA.
2020;324(6):603-605.
• del Rio C, Collins LF, Malani P. Long-term health consequences of COVID-19. JAMA. 2020.
doi:10.1001/jama.2020.1971
• Fraser E. Long term respiratory complications of covid-19. BMJ. 2020;370:m3001.
doi:10.1136/bmj.m3001
• Greenhalgh T, Knight M, A’Court C, et al. Management of post-acute covid-19 in primary care. BMJ.
2020;370:m3026
• Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom duration and risk factors for delayed return to
usual health among outpatients with COVID-19 in a multistate health care systems network—
United States, March-June 2020. MMWR Morb Mortal Wkly Rep. 2020;69:993-998.
• Sardari A, Tabarsi P, Borhany H, et al. Myocarditis detected after COVID-19 recovery, European
Heart Journal – Cardiovascular Imaging. 2020. https://doi.org/10.1093/ehjci/jeaa166external icon
• Lambert NJ and Survivor Corps. COVID-19 “Long Hauler” Symptoms Survey Report. Indiana
University School of Medicine; 2020. https://dig.abclocal.go.com/wls/documents/2020/072720-
wls-covid-symptom-study-doc.pdf
• Halpin, SJ, McIvor, C, Whyatt, G, et al. Postdischarge symptoms and rehabilitation needs in survivors
of COVID‐19 infection: A cross‐sectional evaluation. J Med Virol. 2020; 1– 10
• UK COVID Symptom study: https://covid.joinzoe.com/post/covid-long-
term?fbclid=IwAR1RxIcmmdL-EFjh_aI- accessed 12/28/20

48. Thank You!
To learn more about The Path Forward series
WeitzmanLearning.org/the-path-forward
To view previous COVID-19 sessions:
WeitzmanLearning.org/coronavirus