Climbing a flight of stairs still leaves Divya* breathless. Her sleep cycle, she says, hasn’t been the same since June, when she tested positive for SARS-CoV-2, the virus that causes COVID-19. And although, it’s been nearly three months since the 28-year-old Chennai resident was discharged from the hospital, COVID-19 has taken a toll on her health in ways she has never experienced before.
“I have insomnia. My sleep cycle has been completely disturbed,” says Divya, who adds that stress has also affected her menstruation cycle, with her period now more far apart than earlier. “I would be able to climb a flight of stairs easily earlier, but the same activity now leaves me breathless,” she says.
Divya is one of thousands of people complaining of a range of health issues after recovering from COVID-19. To follow-up with patients who may have short-term and long-term health complications, the Tamil Nadu government in August announced that all major government hospitals in the state would have a post-COVID-19 clinic. One such clinic has been launched at the Kilpauk Medical College (KMC) Hospital in Chennai.
For patients who complain of milder issues, such as excessive tiredness, muscular and skeletal pain, as well as mental health issues, a separate post-COVID-19 care clinic has been set up for them, said Dr P Vasanthamani, Dean of KMC. “These patients can be managed in the OP (out-patient), by just giving psychological support, multivitamins, immunity boosters, immunomodulators, and diet advice,” says Dr Vasanthamani.
According to the Union Ministry of Health and Family Welfare (MohFW), around 80% of people recover from COVID-19 without any special treatment. Around 1 in 6 COVID-19 patients get a severe infection and have difficulty in breathing, with senior citizens and those with comorbidities particularly at risk.
But there are many patients who continue to suffer from breathlessness even after 25 days in hospital and despite testing negative for the coronavirus. “This is because their lungs are damaged due to fibrosis (scarring or stiffness of lungs),” explains the KMC Dean, “Their oxygen saturation falls even for simple activities.” These patients, who remain in the hospital, are treated in the post-COVID ward.
The walk test
The hospital’s physical medicine department came up with a protocol to help rehabilitate patients who suffer from lung damage. To begin with, these patients who are in the post-COVID-19 ward are grouped into two categories — those whose oxygen saturation is above 90% and those below 90%.
Dr Paranthaman, Professor of Medicine at KMC, says doctors first assess the extent of lung damage in a COVID-19 patient. “If oxygen saturation is very low, less than 90%, the patient should not move out of bed. Anytime, his/her health condition may worsen.”
Patients whose oxygen saturation don’t drop below 90% are asked to do yoga, meditation and perform various breathing exercises like balloon blowing, pranayama, breathing through the mouth etc.
Doctors also perform a simple walk test to assess the patient’s lung capacity. The walk test is categorised into one-minute, five-minute and six-minute sessions to test the patient’s lung capacity.
To begin with, doctors ask patients to gently walk around the hospital bed, taking the assistance of another person. The exercises are gradually increased depending on the patient’s tolerance to exercise. “Then we will ask them to walk inside the room, if they are able to do this, then we ask them to walk outside the corridor,” says Dr Paranthaman, “If the oxygen saturation is less than 95% then we do a one-minute walk test. If the oxygen saturation is over 95%, we give them a six-minute walk test. If he is able to perform this, then we step up the exercises. If everything is OK, we ask them to climb up the stairs to one storey.” Physiotherapy is also given to some patients, he adds.
Based on their progression, they are counselled and then discharged, says Dr Vasanthamani, who adds that patients whose saturation falls for day-to-day activities can use oxygen concentrators at home.
Other hospitals in the state have also been carrying out pulmonary rehabilitation for patients with lung damage, albeit through already established departments. Dr P Senthur Nambi, Infectious Diseases Specialist at Apollo Hospitals, says there is no ‘magic treatment’ for patients with lung damage and while physiotherapy and rehabilitation is essential, it can take anywhere between four to six weeks for a person’s lungs to recover and for the individual to be able to perform normal activities like walking or climbing stairs.
He explains that the post-COVID health problems depend on the patient’s clinical status at the time of admission and the recovery during their hospital stay. “Patients with mild infection don’t have a problem after discharge. But patients with moderate to severe infection, those with pneumonia, requiring oxygen support, ICU and ventilator care, have issues post COVID-19,” says Dr Nambi.
Dr JV Peter, Director of Christian Medical College (CMC), Vellore, says that the institute has seen only a few cases where COVID-19 patients have suffered lung damage. “I think the use of steroids has reduced the post inflammatory sequelae (injury), or post-COVID sequelae that many are reporting. In our subset of patients, we haven’t seen many who have developed it,” says Dr Peter.
The CMC Director adds, “Patients who need prolonged ventilation, or those who have not had immunomodulatory drugs, that is steroids, are the ones who may develop fibrosis. We have a pulmonary department which has a pulmonary rehab programme. Other diseases with fibrosis, people who have very little exercise tolerance, have improved their capacity. Once they come off the ventilator, they do have a programme. But if the fibrosis is very severe, then lung transplant is the only option.”
Blood clots, cardiac ailments and psycho-social issues
Dr Nambi points out that COVID-19 is not a respiratory disease alone, and affects the body from head to toe. “COVID-19 stimulates the vascular system, so there is inflammation of blood vessels. It could be arteries supplying blood to the brain, heart and lungs, plus a deep venous system of legs or thighs. At times, we are seeing two or three patients where the blood flow to the intestine or colon is also affected. We find increased incidence of blood vessel related problems in patients with COVID-19, either during admission or post discharge. This is something which is unique to COVID-19,” says the specialist.
Listing out issues like thrombosis of blood vessels, deep vein thrombosis, Dr Nambi observes that COVID-19 causes blood clots in the lungs, and can also affect blood flow to the brain, increasing the incidents of stroke. Patients with underlying cardiac problems can also suffer from heart failure, triggered by COVID-19. “There could be chest pain, angina, coronary syndromes,” he says.
As far as treatment goes, Dr Nambi says that in the case of blood clots, low-molecular weight heparin is given for most patients with moderate to severe infection during hospitalisation and at the time of discharge, patients are asked to take these oral anticoagulants for a minimum of two to four weeks.
Beyond a host of short-term and long-term physical health complications, Dr Nambi says, the biggest problem recovered COVID-19 patients face is social stigma. “Psycho-social aspects are seen in all classes of patients who have been diagnosed with COVID-19, where they are stigmatised, and feared. There is also the fear of reinfection which is actually very, very miniscule,” he says, adding that all this manifests in individuals as insomnia, panic attacks, and mental trauma.
“So that is a bigger issue, people will require psychological counselling, mental support — both professionally and in terms of friends and family members. And they may require medicines,” he notes.
*Name changed
