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We have expanded the Michigan Medicine News Break to include Twitter Space conversations with Michigan Medicine experts. Today's episode is a conversation about COVID and overall lung health shared by three experts from the Division of Pulmonary and Critical Care Medicine. COVID-19 has affected all of us in some way, and unfortunately doesn't seem to be going anywhere anytime soon. Dr. MeiLan Han, Chief of the Division of Pulmonary and Critical Care Medicine at University of Michigan Health, Dr. Hallie Prescott and Dr. Thomas Valley, also of the Division of Pulmonary and Critical Care Medicine, dive into what the pandemic has taught us about lung health in general, lung health implications of long COVID and how we can apply lessons learned to better support overall lung health in the future.

Transcript

Speaker 1 (00:02):

Welcome to Michigan Medicine News Break, your destination for news and stories about the future of healthcare. We've expanded the News Break to include Twitter Space conversations with Michigan Medicine experts.

Kelly Malcom (00:18):

Welcome to Michigan Medicine's first ever Twitter Spaces chat. I am Kelly Malcom. I am a research communicator here at Michigan Medicine, and thank you so much for joining us. Today we are here to discuss COVID, specifically recovering from COVID, preventing COVID, and overall lung health. COVID-19 has affected all of us in some way, and unfortunately doesn't seem to be going anywhere anytime soon, but today we're here with several experts who are going to touch on some of these issues, and hopefully provide some insight. Specifically, we have Dr. MeiLan Han, who is the Chief of the Division of Pulmonary and Critical Care Medicine here at University of Michigan Health. We have Dr. Hallie Prescott, who's also of the Division of Pulmonary and Critical Care Medicine, and we have Dr. Thomas Valley, who is also of the Division of Pulmonary and Critical Care Medicine. Dr. Han, are you here? Can you say hello?

Dr MeiLan Han (01:37):

Hello Kelly. Thank you for getting us started off. I'm really excited to try out this new format, [inaudible 00:01:44] a new thing for us, and I'm excited to be joined by two of our experts in pulmonary and critical care who really have done quite a bit of work and research both in severe lung injury, as well as COVID. Dr. Prescott and Dr. Valley, would you like to quickly introduce yourselves?

Dr Hallie Prescott (02:09):

Hi, this is Hallie Prescott. I'm a pulmonary critical care physician at University Michigan, and also a researcher focused on recovery from sepsis, and also COVID-19. Thanks for hosting us today.

Dr Thomas Valley (02:23):

Hi, and I'm Tom Valley. Thanks for having us today. I am an Assistant Professor at the University of Michigan, also in pulmonary and critical care. In addition to taking care of patients after they leave the intensive care unit, my research focuses on trying to understand how we deliver care, both in the ICU and afterwards.

Dr MeiLan Han (02:46):

So one of the things that we've all been struggling with, and when I say we, I mean us as a division, but also us as a community and a society, is just grappling with COVID-19 from many, many levels. We as care providers, particularly for pulmonary disease I think, have an extremely unique perspective having seen it firsthand. So, what we wanted to try to do with this session today was to talk a little bit about what we're seeing in the hospital, particularly during the surge, but also a little bit about what we're seeing now for patients that have recovered from COVID-19, and what people can be doing, if, for instance, they are recovering, or recovered, or want to just try to protect themselves against future lung injury.

Dr MeiLan Han (03:40):

I'm going to go ahead and jump right into it. We have a few questions. The first one, and I'm going to direct this one at you, Dr. Valley. When we think about a patient being in the ICU, and many of our listeners probably have never even set foot in an ICU, from a patient perspective, from a physician perspective, what does severe COVID look like? What does the recovery pathway from severe [inaudible 00:04:10]?

Dr Thomas Valley (04:11):

Absolutely. Such an important question. Maybe I'll start by just describing what is severe COVID. Severe COVID, we tend to define by those individuals who have to be hospitalized. So, you don't even have to be in the intensive care unit to have "severe COVID". While we generally classify different forms of COVID whether mild, moderate, or severe, that severe group we say is someone who had to go to the hospital. Oftentimes, most of those individuals are requiring oxygen when they're in the hospital. When we talk about what happens in the intensive care unit, what really separates the intensive care unit from other parts of the hospital is the, if you want to call it intensive or aggressive care that we're able to provide that keeps people alive, whether it's high levels of oxygen, whether it's putting people on breathing machines, whether it's putting them on other forms of life support to keep them alive, all with the hopes that their body will eventually recover from the COVID that they're suffering from.

Dr Thomas Valley (05:19):

Once those individuals leave the ICU, they are working to recover from their COVID, and what we know is what we've started to learn over the past two years now, and that is that individuals who are recovering from COVID go through a lot. We're learning more and more about what these individuals are recovering from. We can say from these large studies that have looked at people who've been hospitalized for COVID and then leave the hospital, there are really large categories of symptoms that individuals who are recovering from COVID suffer from. I'd say the most common is shortness of breath. By some estimates, somewhere between 50 to 75% of patients who are recovering from severe COVID have symptoms of shortness of breath or fatigue. Those are really the two most common symptoms that we're seeing in individuals recovering from COVID. Then there's a long list of other symptoms that people are reporting after they're recovered from COVID, whether it's loss of taste, loss of smell, cough, as well as a lot of other symptoms and problems that people suffer from.

Dr Thomas Valley (06:37):

We're still trying to grapple exactly why that is happening, and it can be difficult to treat some of these things, because not every person who comes to us that we take care of has objective findings. By some estimates, somewhere between 10 to 20% of people with severe COVID have changes to their lungs, scarring, or changes that we see on a CT scan. So a lot of the people who are suffering from shortness of breath don't actually have anything that we can exactly put our finger on that says, this is the reason why you have shortness of breath, which can make it very difficult, both for the patient and for the clinicians taking care of them to try to figure out what to do. If we don't know exactly why they're feeling this way, it can be difficult to figure out what's going on and how to fix it. So, those are some of the main things that we're seeing. A lot of folks with shortness of breath. A lot of folks with fatigue, and then other symptoms as well that are tough to exactly pinpoint why they happen.

Dr MeiLan Han (07:46):

Thanks so much for those great insights, Dr. Valley. One of the things I keep thinking about, and that maybe many people don't realize, is that severe COVID or ARDS can be caused by a lot of things, not just COVID. So this is something that we've actually been, as critical care physicians, dealing with for a very long time. Despite the fact that we've all been working on this, we didn't actually have a lot of great really specific treatments even before the pandemic. So, for me, just looking at this with a more global lens, we needed more research in this before, and we need more even now, but one of the other things that a lot of critical care physicians have been thinking about is how does COVID differ from other severe lung diseases, and how does COVID recovery differ perhaps from other recoveries, from other causes of ARDS? I was going to ask Dr. Prescott to give us her thoughts on that.

Dr Hallie Prescott (09:01):

Yeah, great. Thanks MeiLan. It's of course a great question, and of course resonates with me. I've been studying recovery from sepsis for the past 10 years or so, so I'll give a little bit of just historical background. I think as early, or as recently as about maybe 20 years ago, there was just this widespread assumption that as long as patients survived their hospitalization, they would go on to recover well, and be as they were before they were hospitalized. I think that that belief reflects our optimism that our patients will go on to recover and do well after they leave the intensive care unit where we're taking care of them. Also maybe reflects a little bit of the fragmentation of the healthcare system that as intensive care doctors, we may not see our patients back, so we kind of fill in the blanks.

Dr Hallie Prescott (09:52):

But about 20 years ago, the first cohort were done that followed patients after critical illness, after they were in the intensive care unit with a severe pneumonia, or on the ventilator, or with Acute Respiratory Distress Syndrome, and they said, "How are they doing at three months, six, one year after their illness?" Consistently, the studies have shown that many people struggle. We see that there's increased rates of cognitive impairment, sort of like dementia. We see difficulty with physical function, so people have difficulty doing things like walking independently, or transferring from a bed to a chair and back. We see that about something around half of patients with sepsis after the intensive care unit who are working beforehand, are still not back to their normal working about six months later.

Dr Hallie Prescott (10:45):

So when COVID happened, a lot of us who'd been researching this for the past decade, said, "Oh my goodness, this is what we've been seeing before." Before it was in the background, but all of a sudden, all around the world, so many people all sick, all with the exact same thing, all at once. I think a lot of these concerns really got a lot more attention, but in terms of how does things look after COVID, versus after sepsis or other severe pneumonias? I think that in general, there's more similarities than differences, but the question's always a little bit hard to answer just because recovery can look so different just from one patient to another. So common challenges are cloudy thinking, or fatigue and shortness of breath, or anxiety, or depression.

Dr Hallie Prescott (11:42):

Those are all common symptoms, but fortunately, most patients don't have all of those things. What it looks like for any one patient is different. All of those things that we saw commonly after pneumonia and sepsis in studies over the past 10, 15 years, we're now seeing as well, the same challenges in patients recovering from COVID. So overall, more similarities than differences, but there's maybe a few things that are more particular for COVID, things like the loss of taste and loss of smell. Those things are more prominent in COVID. Headaches, so maybe a few symptoms, but overall, I think what we're learning now is very similar to what we've been seeing. There's now a lot more attention to this problem, like MeiLan mentioned. We did not have good solutions before, so hopefully this serves as a catalyst or a motivation to accelerate the development of interventions to help promote recovery, and to implement those types of interventions in different healthcare settings.

Dr MeiLan Han (12:46):

Thank you for those insights, Dr. Prescott. I think, as you mentioned, COVID is making... It's bringing to the forefront problems that we as pulmonary and critical care physicians were aware of for a long time, but there were always patients, but it just didn't get as much, probably attention as it deserved. Now the number of patients that are suffering are so much larger that I think this is clearly an area that's screaming for more research, more treatments. One of the things that I think a lot of us have been pondering is why do some patients get really, really sick from COVID-19, and some have very mild or asymptomatic infections? I think to me, some of the most fascinating research that's come out of the pandemic relates to understanding this concept of what I'm going to call preexisting lung injury, and your risk for both contracting SARS-CoV-2, and then the severity of illness.

Dr MeiLan Han (13:49):

So, there was an interesting study that was actually done in Oregon looking at the impact of wildfires in the American West. Some researchers from Harvard looked at this brief time for exposure, and found that during this high pollution time from the particulate matter in the air from the wildfires, there were roughly 20,000 more cases of COVID, and almost a thousand more deaths. Most of those people probably, short of there having been a pandemic, we would never have known that you could have that kind of lung injury just from breathing in air pollution. There was another study that was actually spearheaded here at the University of Michigan by some of our colleagues in pathology, and when they looked at a subset of patients with long-haul COVID, they actually were surprised that when they looked at CT scans that happened to have been done on those patients before they developed COVID-19, there was actually preexisting lung injury. There was preexisting inflammation.

Dr MeiLan Han (14:52):

We do a really bad job in this country at diagnosing lung disease in general. For instance, COPD, one of our most chronic lung diseases, only about half of the roughly 30 million individuals in the United States who have it are diagnosed. Based on the data that I'm seeing come out, I firmly believe that either undiagnosed full blown preexisting lung disease, or some more subtle form of lung injury that we're just not good about picking up, we don't screen very well for lung disease in this country, is contributing to injury from COVID-19. A real wake-up call that we have to start focusing more clearly as both people in the community, but also as physicians, on trying to protect lung health, understand lung health, and try to decrease inflammation, because it's clear that some of this preexisting lung injury is increasing risk for severe disease.

Dr MeiLan Han (15:57):

So, one of the other things that we're also seeing here at the University of Michigan for sure is what we're calling long-haul COVID. Dr. Prescott, you alluded to that as well. I think the last estimates I saw suggest we have roughly 11 million Americans with long-haul COVID. It's huge. We're, as a healthcare system, struggling to understand how to better treat it, how to diagnose it. We know that there's so many different forms that it can take, and one of the other things that I think is really concerning is that we know that not all patients have been similarly impacted. I was wondering, Dr. Valley, if you could comment on what we're learning about long-haul COVID, and do you think that there are certain communities, or certain sub-segments of the population that are more vulnerable?

Dr Thomas Valley (16:51):

Yeah, I think that's an area that we need to be increasingly cognizant of, especially in an area of science, an area of medicine, an area of research where we don't know much, and we're learning every day. So, it's difficult for medical practitioners to try to figure out exactly why their patient is suffering from symptoms like shortness of breath, and fatigue, and cloudy thinking. It can very much depend on who you as a patient is seeing, on whether you get someone who recognizes the problems that you're facing. We might not be able to solve all the problems, but we can at least recognize that you are going through what you're going through, that these are common manifestations of surviving COVID. Sometimes people go and see a practitioner, and come away feeling like their symptoms weren't recognized, that they weren't valued.

Dr Thomas Valley (18:00):

Part of that is because it's tough as a practitioner to try to think through what's happening when we have trouble finding objective abnormalities, but that doesn't change the fact that it's quite clear that survivors of COVID are suffering and going through a lot, even in the face of not having those clear abnormalities that we typically look for, whether on chest x-ray, or CT scan, or on lab values. When we think through who receives care where, I think there's a tendency thinking about whether patients who survived COVID should receive their care in a specialized place that specializes in surviving COVID.

Dr Thomas Valley (18:51):

There aren't that many places like that around the country, and as we build our knowledge base, and as we build an expertise for individuals who are surviving COVID, I think it's important to consider who the people are that are being seen in those places. How are we selecting the patients that we care for? How are we making sure that we are not creating inequities in our care, in terms of who survives COVID, and how we treat their symptoms? I think it's really important that as we move forward, we really think through not only how we're treating survivors of COVID, but making sure that we're providing care to all those who need it.

Dr MeiLan Han (19:35):

Yeah. Those are such important thoughts Tom. We live here in Michigan, and we know, for instance, that while Detroit only saw a fraction of our COVID cases, they saw a relatively huge proportion of the deaths. We know that Detroit has a large African-American community, and so there have been huge concerns about access to care, and access to good treatment, and whether, preexisting care, just general care that we get for all sorts of things like diabetes, and heart disease, et cetera, may have impacted how people have fared from COVID. There continue to be concerns about patients, and having access to some of these specialized clinics that you mentioned that have expertise in caring for patients with COVID, or even getting patients appropriate... Who's getting follow-up even, after they're being discharged?

Dr MeiLan Han (20:39):

This is definitely something that I know you and Dr. Prescott are actively looking at. I wanted to turn our attention for a moment also to what are we actually seeing now in clinic? We've been in the middle of this pandemic for a little over two years now, and so we're all seeing all sorts of types of patients, and we're seeing them right after they contract COVID, but then we've also had some time to follow up some of these patients over longer periods. I was wondering Dr. Prescott, if you could just address a little bit about the variety of things that you're seeing, and maybe also to give people some advice just about if they are having persistent symptoms, what should they talk to their doctors about? What can potentially be done?

Dr Hallie Prescott (21:31):

Yeah, great questions. So I'll share a little bit about my experience. I do outpatient pulmonary clinic, and so the most common patients that I've seen are patients who have either new shortness of breath after COVID, or who have had worsening shortness of breath and exercise limitation. Some of these things have been discussed a little bit earlier, but I typically will do an evaluation of lung function. So, looking at breathing tests, and looking at chest x-ray, or CT scan, and I get a handful of patients where I can see that there's worsening of underlying lung disease, but that's the minority. Most of the patients, their lung function is similar to what it was prior to being hospitalized for COVID. Nonetheless, their symptoms are much worse, more shortness of breath, able to walk shorter distances before having to stop and rest, not able to carry in the groceries, or walk up the stairs. I think a lot of this has to do with just the global effect of being sick. I think one of the most common things I'll do in clinic is counsel people about what activity is safe to do.

Dr Hallie Prescott (22:48):

I had a patient once who came and told me that, well, when he came home from the hospital, he was feeling short of breath when he would walk around in his house. He assumed that that must mean that it was unsafe for him to walk around, and so he told me he's sitting in his chair waiting to get better for a couple weeks now, but nothing was getting better. Reminded me how important it was to counsel patients about the need to gradually increase activity. There was actually studies, gosh, randomized clinical trials 20 years ago now where patients after the ICU, after pneumonia, after sepsis, were half of them assigned to doing a structured exercise program. Things like walking, and just trying to each day do a little bit more, recognizing that you might only be able to do a few minutes, but the next day do a little bit more, or do a few minutes and stop and rest, but then do it again in the afternoon.

Dr Hallie Prescott (23:41):

Patients who were on these structured exercise programs were able to do more quickly. So that's one of the things I spend a lot of time counseling patients on is that it's fairly normal or common that people are achy, that they're short of breath, but it's important to continue to try to gradually increase what you're doing day-by-day. It can be frustrating and challenging, because a lot of times progress does not occur day-by-day. It's hard to build back endurance. I'll always often tell my patients to keep a diary. Write down what they did, how far they were able to walk. It can be really motivating, I think, to see progress that occurs week-to-week, or month-to-month, to see that the work that people are putting into recovery is paying off, even if that's hard to see one day to the next. So, that's the things that I'm seeing most commonly in my clinic right now.

Dr MeiLan Han (24:39):

Those are such great tips for listeners Dr. Prescott, just in terms of thinking about the problem is, I think with activity, it's use it or lose it. So when you are inactive after being sick, it's important to remember that part of it is just not necessarily your lungs, it might be the rest of you that needs to get slowly back into shape, and it can all impact how you feel. Dr. Valley, do you want to comment at all on what you're seeing in post-COVID clinic, and the types of things you're encouraging patients to talk to their doctors about?

Dr Thomas Valley (25:14):

Yeah, absolutely. I think what I've found interesting is particularly in the more recent waves of COVID, is that we're seeing more individuals who are really sick, but they're sick in different ways than the patients that we took care of in the first waves. The first waves, a lot of people were on ventilators, whereas on these more recent waves, we're seeing lots of people who were on high levels of oxygen for long periods of time, but didn't necessarily need ventilators. As a result, it just seems like it's tough to parse out how much of this is related to the patients who had COVID early, versus how we treated those patients with COVID early, putting them on ventilators early, versus tolerating maybe some marginal oxygen levels for longer periods of time, versus the sequela that wrapped up the people who were older and sicker who got COVID early, and then we treated them in certain ways, versus what we're seeing now, whether it's less severe COVID, or whether it's just our tolerance and ability to care for this group of patients.

Dr Thomas Valley (26:32):

I'm seeing a lot more folks who are just on high levels of oxygen for long periods of time, and that's why they're in the ICU. As a result, I'm seeing more folks who have single organ failure. They had lung problems, and that's why they were in the ICU, and they were on oxygen for a real long time, as opposed to what we typically think of in a post-ICU clinic, which is oftentimes when people go to an intensive care unit, they might have one problem that they go in for, but then they have a lot of other problems come up.

Dr Thomas Valley (27:08):

They might come in with pneumonia, and then they get kidney failure, and then they have weakness, and all these other things that pop up as a result of the first problem that comes up. I found it interesting that a lot of the patients that I've cared for more recently in our post-ICU clinic at the VA have been really that isolated lung problem, high levels of oxygen for long periods of time, and have generally seemed, I'd say, less sick than some of the other patients that we more consistently think of as post-ICU patients.

Dr MeiLan Han (27:45):

Yeah. Thank you so much for that Dr. Valley. It's really interesting, at least in my own clinic, what a huge spectrum I'm seeing. I have some patients, for instance, who are previously healthy. You see some pneumonia on the CT scan, and then they get better quite quickly. The abnormalities take a month or two to resolve, but they're back to where they were. Then I have other patients who are almost a year and a half out now, and are still struggling. We know rehospitalizations after COVID is a major issue. I can think of one patient in particular I have that struggled with blood clots, and a second admission, and fluid around the lungs, and now I'm seeing something completely unexpected, which is that this particular patient had some mild asthma before they contracted COVID, and now the airway disease is much, much worse than it was before, which I think is perhaps a little bit less common pattern than what we've seen with other types of scarring abnormalities for severe COVID.

Dr MeiLan Han (28:54):

So, this was sort of an unexpected finding. I think we've got probably quite a bit to learn. I think for me as a clinician and a researcher, one of the things that's really been striking to me is just that I hope that one of them that people are hearing is that [inaudible 00:29:17] and do a lot of work for us. They were probably a little bit more fragile than we realized. I think it took a respiratory pandemic to probably realize that the lungs, when they suffer severe injuries, sometimes they don't really have a good way to recover, and we certainly need more treatments. Now that doesn't mean that I don't think a lot of our patients are going to get somewhat better. I think that they are, and we're certainly working towards that, but we need a lot more research to try to understand how to try to keep that inflammation less when people get really sick, and how to try to help lungs recover, and get back to normal as much as possible.

Dr MeiLan Han (30:05):

I'm just curious as we get towards the close here, I'm always pushing for spirometry. That's our number one test. If there are patients out there who've been told that they had oh, just... They're either getting blown off, or they're wondering about whether they have lung disease, my usual number one advice is ask your doctor for spirometry, which is our most simple lung function test, and whether you can have that done. That's one great place to start with trying to understand your lungs and whether there's an issue, but to be honest, regardless of those results, if you're out there and you're recovered from COVID, and you're still short of breath, ask to get seen by a pulmonologist or a center like the University of Michigan that has expertise in taking care of patients after COVID. I'm just going to ask both Dr. Prescott, and then Dr. Valley for their final thoughts, and then toss it back to Kelly for close. So, Dr. Prescott any final advice for any listeners out there?

Dr Hallie Prescott (31:11):

Thank you. Yeah, I completely agree with the advice you just gave. I think that long COVID has just brought such attention to this issue. For a long time, I think there was patients after sepsis and pneumonia that I think felt very isolated, and there's just been, I think, a huge patient-driven attention to these issues that we're seeing after COVID. I think that that's one of the most powerful things that can happen that will then drive research, and drive solutions going forward. So I just want to thank all the patients that have raised awareness, and the profile of the issues that patients are experiencing after COVID.

Dr MeiLan Han (31:52):

Thank you so much, Dr. Prescott. Dr. Valley, any final thoughts for our listeners?

Dr Thomas Valley (31:59):

Yeah, I also want to echo, MeiLan, what you mentioned, and Hallie, what you said. If you're not feeling well, then it's important to get evaluated, and see what could be going on. We might not always be able to fix the problem, but what we can do is recognize that you're going through some [inaudible 00:32:23] lot of patients with COVID are going through, and work towards trying to get you feeling better. I think that's incredibly important to be [inaudible 00:32:33] to make sure that we rule out important, but also potentially life-saving things, and then try to figure out what can we get better? How much of this is related to the things that others are suffering from, or how much of these things are unique to an individual survivor?

Dr MeiLan Han (32:53):

Thank you so much Dr. Valley and Dr. Prescott for joining me for this. One of our goals at Michigan Medicine and in the Division of Pulmonary and Critical Care, we want to provide information that's of value to the community. I firmly believe that knowledge is power, and the more that you know about your own health, the better advocate you can be for yourself and for your loved ones. So thanks to everyone for joining me, and I'm [inaudible 00:33:17].

Kelly Malcom (33:19):

Thank you, Dr. Han, Dr. Prescott, and Dr. Valley for this extremely informative discussion about COVID, and thanks to all of our listeners for joining us on our very first Michigan Medicine Twitter Space chat. For anyone who missed the start of our discussion, you can replay a recording of a Space up to 30 days after the original broadcast, and be on the lookout for future Spaces on our Twitter page. Take care, and stay safe out there. Thanks.