Antithrombosis in Patients with COVID-19 - Episode 5

Underlying Respiratory Comorbidities and COVID-19

Transcript:Gregory Piazza, MD, MS: Of these patients who are going into the ICU [intensive care unit] with COVID-19 [coronavirus disease 2019], a lot of them have underlying respiratory comorbidities, such as COPD [chronic obstructive pulmonary disease] or asthma. How much of that is a risk for having a complicated disease course with COVID-19? How do you manage that from the prevention standpoint up to when you have to ventilate these patients?

Victor Tapson, MD, FCCP, FRCP: One aside I’m going to mention is that I’ve talked to a couple of colleagues now, and none of us with busy pulmonary hypertension centers have seen a case of COVID-19 in a patient with pulmonary hypertension yet. I don’t know why that is. It might just be coincidence, and we’ll see. But I wonder. There’s maybe some genetics influence here.

Gregory Piazza, MD, MS: Could it be that they’re on anticoagulation, Vic?

Victor Tapson, MD, FCCP, FRCP: It could be. We haven’t even seen the COVID-19 infection yet. I’m even wondering if somehow the BMPR2 gene mutation plays a role here. It’s an interesting point, Greg. I’m certainly not going to stick my neck out too far, but I would love to look at that a little further. To get at your point, if someone comes in with ILD [interstitial lung disease], COPD, or emphysema, I think they’re more susceptible. This disproportionate hypoxemia that Alex mentioned is a big point. It’s similar to a big PE [pulmonary embolism]. It’s dead space ventilation. You’re seeing infiltrates of your hypoxemia, and you’ve got underlying emphysema or ILD. You’re already on 6 liters of oxygen at home. I think your risk is higher.

Do…patients benefit by using prone ventilation in those situations or not? Is it better to delay intubation or not to delay intubation? 15 years ago, we didn’t use high-flow oxygen. Now we use high-flow oxygen. People are on 40 liters per minute of oxygen, and that’s a ton of oxygen. For many people, you can stave off an intubation longer if you’re careful and monitor oxygenation carefully. But you don’t want to wait too long and have a crash intubation. We’re lucky. I’m not in the room intubating patients now. We have very good anesthesiologists who do that and do it very quickly.

Yes, I think these patients with underlying lung disease clearly have a higher risk of doing poorly. I want to keep sticking an optimistic point in there. I’ll tell you, at some of these ICUs, as we get more experience, we have done a really great job. We’ve gotten elderly patients with bad lung disease off ventilators, but not all of them. While it’s a problem and, clearly, does increase the complication rate, we’re getting better at dealing with it.

Alex Spyropoulos, MD, FACP, FCCP, FRCPC: Greg, can I make a statement?

Gregory Piazza, MD, MS: Absolutely, Alex.

Alex Spyropoulos, MD, FACP, FCCP, FRCPC: You’re a penultimate optimist, but I’ll say something pessimistic. What’s interesting to me, Vic, is that when you look at the literature—albeit very low-quality data, but also our own experience at Northwell Health—these patients, whether they’re in the ICU or not, seem to have breakthrough clots, despite being given what were previously adequate anticoagulant regimens. Despite being on chemoprophylaxis, we’re seeing a lot of patients experience breakthrough clots and be “resistant” to these types of regimens. We have one nonpublished experience at Northwell Health and have found a prevalence, screening with lower-extremity 2-point ultrasounds in the ICU of DVT [deep vein thrombosis], as high as 40%. Indeed, some of the most recent data out of Europe are suggesting a prevalence that high, 30% to 40%, using screening methods. To me, it’s fascinating. There’s something about this disease that’s very thrombogenic and very resistant to the usual modalities that we’ve used for the last two decades or so.

Victor Tapson, MD, FCCP, FRCP: I think it’s a real dilemma, Alex, because I still have equipoise randomizing patients who are on enoxaparin 40 mg once a day versus a more aggressive regimen who come in with COVID-19 and no proven DVT yet, maybe with criteria including high-inflammatory markers, D-dimer, etc. But it worries me more and more, as the week goes on. I think we’re going to get data here. Maybe it’ll be your study, Alex. We’ll get some data here pretty soon, and I hope we can make better decisions, because I’m starting to worry more and more that prophylaxis alone may not be enough.

Alex Spyropoulos, MD, FACP, FCCP, FRCPC: I couldn’t agree with you more.

Transcript Edited for Clarity