Monday, 6. April 2020
Many people with chronic lung diseases such as asthma, COPD and cystic fibrosis are worried about the spread of coronavirus. They are among those most at risk, regardless of their age. We discussed the current situation, risks and experience with COVID-19 infections in patients with chronic lung disease with the lung specialist Prof. Dr. Fischer on 27 March 2020.
Prof. Dr. Rainald Fischer: In the past few weeks, the risk of infection has increased for everyone. And that, of course, includes patients with lung disease. This especially affects people who have socialised with other people as usual over the past three to four weeks. A few days ago, I talked to one of my patients, who has the hereditary disease cystic fibrosis (CF). His partner tested positive for coronavirus. She suspects that she was infected during a meeting at work. You can assume that the CF patient will have been infected by his partner. Both the partner and the CF patient developed mild COVID-19 symptoms. The CF patient was not tested because he did not have severe symptoms. A test would not have resulted in any action in terms of medical intervention. The CF patient had to go into quarantine for 14 days anyway. Restrictions are currently being placed on the tests, as there are currently limited testing options.
Prof. Dr. Rainald Fischer: Over the past week, we have had 20 suspected cases, all of which have tested negative. The suspected cases included asthmatics, COPD patients and patients with cystic fibrosis. A few days ago, there was a telephone conference with 23 cystic fibrosis outpatient departments in Germany to discuss coronavirus in CF patients. Three outpatient departments each reported three COVID-19 cases among their CF patients. There are also five confirmed cases of COVID-19 in cystic fibrosis patients from London. All those affected had mild symptoms and none had to be hospitalised. We are currently aware of about ten cases in cystic fibrosis patients* in Germany, all of which had mild symptoms. These isolated cases give rise to optimism and are a hopeful sign that CF patients are not more severely affected by COVID-19 than healthy individuals. I would like to emphasise here that there are only ten isolated cases. There are no studies to confirm this suspicion.
Prof. Dr. Rainald Fischer: The patients were middle aged, so between 25 and 45 years old. Both men and women were affected. Many of those affected had limited or very limited lung function with an FEV1 value of around 50%. None needed oxygen support. Patients were infected by family members, friends or acquaintances. Most CF patients tend to be careful and avoid large groups of people for their own protection, irrespective of coronavirus. So none of them had been to a coronavirus party or anything like that.
Prof. Dr. Rainald Fischer: It may be a coincidence that the ten CF patients we mentioned had a mild case of COVID-19. We will have to wait and see before we can confirm this suspicion. According to experts, the major wave of infections may be yet to come in Germany. And so we should expect to see more infections among CF patients in the next few weeks. Only when there is a growing number of COVID-19 cases in CF patients will we see if the current, mild cases were a fluke or if this tends to be the rule.
Nonetheless, there are currently assumptions and presumptions floating around as to why patients with cystic fibrosis may be better armed against coronaviruses than previously assumed. The backdrop to this is that it appears that severe cases of COVID-19 are often associated with a high level of what are known as cytokines. These are messenger substances of the cells that are released when we have an infection. A release of very high levels of cytokines leads to severe symptoms in the lungs and can also continue in other parts of the body. It is suspected that the immune system in patients with cystic fibrosis does not respond to the coronavirus with such an extreme release of cytokines. Patients with CF often have infections and inflammation. The immune system is already used to this condition, so to speak. As a result, it is possible that patients with cystic fibrosis do not respond as severely to coronavirus. But I would again like to emphasise that this is only a suspicion arising from the current situation. There are no data to confirm this suspicion. It is, however, an approach that is worth pursuing so as to better understand the virus and the effects of COVID-19 on patients with cystic fibrosis. This is why efforts are underway to compile documentation on coronavirus in the German cystic fibrosis register.
Prof. Dr. Rainald Fischer: For asthmatics, I do not see a COVID-19 infection as any more critical than in the general public (comment to editors: explanations are in the first interview). This is not the case in patients with COPD, especially patients who already have a constant oxygen saturation of under 93-94% or those who require oxygen. These people would be at great risk if they were to become infected, as they are less likely to be able to tolerate a drop in saturation. In our practice we are not taking this lightly.
Prof. Dr. Rainald Fischer: Self-isolation, disciplined hygiene and keeping your distance is the order of the day. People with lung disease should stick very strictly to this. It is essential at the moment that they avoid becoming infected. Hospitals are telling us that the number of severe cases requiring ventilation is rising. This is why we have to be extremely careful. Coronavirus is highly contagious. We can see this in the case of another patient with cystic fibrosis. He was infected during a five minute drive with an acquaintance who had no symptoms and who tested positive for the virus a few days after the drive. A small, enclosed space, no fresh air because the windows were closed, sitting too close together – under these conditions it is very easy for coronavirus to quickly pass from one person to another. You should always bear this in mind and consider it whatever you are doing in your day-to-day life.
Prof. Dr. Rainald Fischer: Nebulisation helps patients enormously to cough up phlegm from the lungs. This is why nebulisation is an important component of the treatment of patients with cystic fibrosis, for instance. Respiratory patients who use a nebuliser should continue to do so.
Prof. Dr. Rainald Fischer: Nasal rinsing has long been recommended as a preventative therapy and to treat viral colds or hay fever. The effect of nasal rinses is achieved by mechanical cleaning, where the nasal mucosal linings are rinsed. Mucus, dried mucus or pathogenic intruders such as pollen and germs (viruses or bacteria) are washed away. Nasal rinses can therefore be considered an easy and also possibly helpful measure. After all, viruses that are flushed out of the nose cannot do any more harm.
Prof. Dr. Rainald Fischer: Any contact with the outside world bears a theoretical risk. But given that this situation will last for several months to come and you cannot postpone a doctor’s visit indefinitely, patients are at some point going to have to see their doctor. This is not so urgent in stable as it is in unstable patients. In reality, in our practice we are currently seeing about 30 to 40 percent of patients cancelling their appointments or simply not turning up. Patients are staying away because they are afraid they will be infected. We try to keep the risk of infection as low as possible. We have removed lots of the chairs in the waiting room so that we can ensure there is a distance of two metres. The windows in the waiting area and the practice rooms are opened to ensure there is good air circulation. The practice staff wear face masks to avoid unwittingly passing on the virus if they have an undetected infection with COVID-19. In the lung function room there is an air disinfector with UV light to keep the virus concentration as low as possible. If patients with acute symptoms visit the practice, they are separated from patients who do not present with acute symptoms and are examined by different staff. But there are also unrecorded cases of coronavirus that have passed under the radar. For this reason, it makes sense to wear a face mask even with patients who have no symptoms of coronavirus so that if you do come into contact with an infected patient, you reduce the amount of virus you inhale.
Prof. Dr. Rainald Fischer: This is the case for cystic fibrosis. From June 2020, video consultations should be an option as part of a project launched by the Innovation Fund. The lung function test is carried out with a mobile spirometer from home. However, this doesn’t address the problem that blood and sputum have to be regularly examined in patients with cystic fibrosis. This can only be done by coming to an appointment to see the doctor in the practice.
Prof. Dr. Rainald Fischer: I do not think that it makes much sense to increase self-monitoring. That is probably just going to make you feel even more anxious and is going to be an even greater mental strain. However, if patients notice that they are getting an airway infection or symptoms, it is advisable for them to monitor so that they can keep an eye on the progression. In this case it would probably be best to measure oxygen saturation, but only under instruction from a doctor because the values can sometimes fluctuate.
Prof. Dr. Rainald Fischer: Yes, and for two reasons. Firstly, anyone can spread the virus without realising that they are doing so. By wearing a face mask everyone reduces the risk of inadvertently infecting others. Secondly, it appears that the severity of the progression of a COVID-19 infection depends on the amount of virus breathed in or to which a person is exposed. Patients with lung disease should especially do everything they can to lower the amount of virus they may inhale. If a patient with lung disease has to leave the house and go out in public, including a visit to the doctor, he should wear a face mask.
Prof. Dr. Rainald Fischer: There is nothing objectionable to wearing a face mask, so patients with lung disease shouldn’t shy away from doing so. I suspect that in the long term will we end up where Asian countries are now, where wearing a face mask is quite normal. Generally speaking, FFP3 masks offer the best protection. But these are very difficult to get your hands on at the moment. This is why patients can also resort to wearing home-made masks and pad them with certain materials, such as nursing pads or cotton wool pads. And I must remind you that face masks does not offer absolute protection. But this kind of barrier may help to reduce the amount of viruses that reach the lungs somewhat, and thereby possibly minimise the severity of the disease. This is even more important in patients with lung disease than in healthy individuals. But the best protection against infection with coronavirus is self-isolation. I am sorry to have to spell it out so clearly.
Prof. Dr. Rainald Fischer: I personally advise anyone able to do so to have as little contact with others as possible. The risk of infection will probably rise over the coming weeks and months. Even after the peak there is still a risk of infection. So even after the peak, the safest thing to do would be to continue strict self-isolation until there is a chance of a vaccine. But that is a very long way off. It is probably unrealistic to keep it up. Patients should definitely avoid crowds of people and close contact with others over the next months. If you leave the house or meet with other people - obviously only a few - it can help to wear a face mask. It would also be helpful to know who is already immune. But that is also going to take a while.
*Calculate the number: Three CF patients tested positive. One case where COVID-19 was not confirmed in a test, where an infection is, however, very likely based on the symptoms and close contact with a partner who tested positive to COVID-19.
About Prof. Dr. Rainald Fischer:
Prof. Dr. Rainald Fischer is a specialist for internal medicine in private practice, with a subspecialty in lung and bronchial medicine, specialty of emergency medicine, sleep medicine and allergy medicine in Munich-Pasing. Before that he worked as an internist and lung specialist, most recently as a senior physician at the Innenstadt Munich university hospital. Prof. Dr. Rainald Fischer is a founding member and president of the German Society for Alpine and Expedition Medicine, and a member of the cystic fibrosis physicians working group.
NOTE: This interview with Prof. Dr. Fischer was conducted on 27 March 2020. The statements were made based on the information available at that time.
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