Apr 2, 2021
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The insidiousness of postcoid complications. The intricacies of pulmonary fibrosis

The correspondent asked about the troubles that may arise after an illness. Head of the Laboratory for Vaccine Prophylaxis and Immunotherapy of Allergic Diseases of the Research Institute of Vaccines and Serums. Mechnikov RAMS, professor, MD Mikhail Kostinov and ego student –Assistant of the Department of Hospital Therapy of the Pediatric Faculty of the Russian National Research Medical University named after Pirogova Nadezhda Kryukova

What determines the outcome?

– Mikhail Petrovich, Nadezhda Olegovna, is there a world problem of pneumofibrosis? Is this issue discussed elsewhere besides Russia?

MK: The effect of “frosted glass” (a manifestation in the lungs of processes in which there is a decrease in the density of lung tissue – Ed.) Was revealed by the Chinese. And this means that we were not the first to start dealing with the problem of pulmonary fibrosis – specific changes in the lung tissue that disrupt breathing after a previous illness.

NK: A lot of information comes from different countries that pulmonary fibrosis can be reversible. Sometimes we see this in the clinic as well. Of course, the patients are completely different, but we proceed from what lesions of the lung tissue were during the disease and what it later resulted in.

MK: There is a problem, but the disease has a favorable outcome, which depends on many, many factors.

– What is the danger of the disease and when is the outcome favorable?

MK: The outcome of pulmonary fibrosis may depend on the person’s age, the severity of the disease, timely treatment prescribed, the person’s immune system, on his chronic pathology of the bronchopulmonary system, autoimmune diseases and other factors. Therefore, if we take about 15% lung damage in a young man who is on his feet, and the same damage in a person who is over 40 or 60 and has a lot of other diseases, we will see different outcomes from each other. The reasons for the regression of the inflammatory process are also in direct relationship with the human immune system and the treatment of pneumofibrosis, as well as further rehabilitation. This is a long process, it may not be limited to a month, but drag on for two, three, or even more.

The recovery process should be guided by a pulmonologist or therapist. The correct sequence of actions, a sufficient list of studies are important, which is associated with the choice of a certain treatment tactics, including not only drug methods. Now in the West, in this regard, they talk about physiotherapy, ultrasound, exercise therapy, swimming, walking, massages, etc.

NK: Conditionally, patients can be divided into those who have small foci of pneumofibrosis, when neither hospitalization nor interventions are required, because there is a high probability that fibrosis will regress, and into those who have moderate and severe (from 25% – Ed.) damage to the lung tissue, when different courses are possible. We observe such patients – they need respiratory support, and rehabilitation can last for six months.

There are also patients with a protracted course – up to 8 months, some of them are prescribed oxygen concentrators as temporary palliative care. Such people require treatment in a hospital, where they undergo an acute period and fibrosis, as we can see from the data of computed tomography (CT), is still allowed.

Not only the lungs

– What is the danger of pneumofibrosis?

MK: The trouble is, it’s not just the lungs that suffer from lung disease. It is known that when oxygen supply is limited, if gas exchange does not occur, further complications arise in the work of the cardiovascular and nervous systems. The heart begins to work more – deformation appears, various pathologies are formed in the entire cardiovascular system, because lung damage does not occur apart from vascular damage. And then – an increase in pressure with possible hypertension, blood clots can also come off.

Then a nervous rollback begins, because depression develops from a lack of oxygen, people simply lose their desire to live. Memory fails – a person may be asked to leave work, because labor productivity falls. If left untreated, this condition may not be limited to 6 months or a year, but persist forever.

The process of rehabilitation of such patients is a new direction, we must now develop and develop it. Psychologists, cardiologists, neuropathologists and endocrinologists will have to work here.

Complexity of diagnosis

– Is there any difficulty in diagnosing pulmonary fibrosis, how can it be suspected and complications can be prevented?

MK: Complexity always exists, because not every patient is diagnosed with differential diagnosis. It happens that when studying lung damage, one accidentally reveals a disease that had not been previously paid attention to.

NK: It is necessary to diagnose pulmonary fibrosis, and take into account that the patient could never undergo CT scan in his life. Or maybe he even had some kind of respiratory symptoms in the form of shortness of breath, decreased exercise tolerance, etc., but he did not pay attention. Then you need to contact a therapist or pulmonologist.

MK: If the patient knows his diseases, then it is necessary to be observed in dynamics. I know still young people who had asthma for the first time against such a background. And all because there was a trigger. And if there is an allergic altered reactivity, it gets worse.

– Are there recommendations for the management of patients with pulmonary fibrosis?

MK: Until the end, I can not say about the officially recognized ones. The main thing is that now we need to act so that the treatment is the same throughout Russia and that they know what methods are available for the study of those patients who have suffered pulmonary diseases.

Already last spring, in the midst of a pandemic, doctors asked if we had any programs for prophylactic medical examination of such patients, i.e. the request in practice was ahead of the recommendations that came out later. I believe that such recommendations should become the standard.

NK: As far as I know, there is a manual for the rehabilitation of patients after COVID-19. And with pulmonary fibrosis, anti-fibrotic therapy is recommended and really actively used (it happens in the form of suppositories or injections).

Therapy – if indicated

– What patient can and should suspect he has pneumofibrosis?

NK: It depends on the focus of the pulmonary lesion. A small focus of pneumofibrosis, of course, does not manifest itself clinically. If this is a more extensive lesion of the lung tissue (over 50%), then there may be a decrease in exercise tolerance, the development of shortness of breath, cough, and a decrease in oxygen saturation in the blood. Then, of course, you can suspect a problem and perform a CT scan to confirm the diagnosis.

MK: When, when walking on a walk or climbing stairs, you stop at each flight, you feel that there is not enough air

– At what stage is it better to apply therapy against pulmonary fibrosis?

NK: If indicated. If, after examining the functions of the lungs, performing a CT scan, excluding a predisposition to thrombosis, there are indications that therapy is needed, of course, it is carried out.

MK: Criteria for assessing the severity of the course and damage to the bronchopulmonary system should be developed. And a single step-by-step approach, because after the examination, some patients will be treated on an outpatient basis, some in a hospital, and some in a mixed way.

There should be specific prevention of the release of hyaluronic acid into the bronchopulmonary apparatus. Prescribe drugs that can inhibit its further release – so that new painful areas do not form in the lungs. And there are such drugs in Russia.

Studies have shown that the appointment of an anti-fibrotic drug (for example, bovgialuronidase azoxymer) has an inhibitory effect, preventing the disease from spreading towards severe pulmonary fibrosis. This drug is prescribed for both the treatment and prevention of pulmonary fibrosis.

I am sure that in the next six months there will be new Russian recommendations that will show which methods and drugs can and should be prescribed for pulmonary fibrosis with the risk of its development. But while new methods are being developed, we will not be able to leave patients – we will apply what we know, which can have an impact on the restoration of lung tissue.

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