Lung clinic brings diverse expertise to COVID patients

NEW HAVEN — While COVID-19 can be a debilitating respiratory disease, the list of possible symptoms is long, and treating patients grows more complex.

Doctors at the Winchester Chest Clinic at Yale New Haven Hospital, who have been seeing COVID patients since March, have been “learning while treating,” Dr. Jennifer Possick, the clinic’s medical director, said, while forming a network of specialists to care for those who have suffered from the disease.

The doctors found, in their own practices and in talking with colleagues, that COVID patients, after they had left the hospital, and even if they did not need to be hospitalized, still were suffering from shortness of breath and extreme fatigue, among other symptoms. Now, when patients come to Winchester, there is a specialized program to treat them known as the Winchester Chest Recovery Clinic for COVID-19.

“These were patients who had been sick, were past the real acute phase of their illness, but were still very, very symptomatic,” Possick said. “They were very fatigued, but they were also just winded with normal activity. So we started talking about how could we put together a clinical program that would serve to evaluate these people, support their recovery, and also acknowledge the fact that we still had a whole lot to learn about the later phases of this disease.”

According to Dr. Denyse

Lutchmansingh, lead clinician at Winchester, while pulmonologists like her and Possick focus on lung disease, “it became very apparent very quickly after interacting with a few patients, and from experience in the ICU, that COVID was more than a lung problem. It was a multisystem problem.”

COVID patients have reported cardiac problems, including rapid heartbeat, known as tachycardia, and cognitive issues, such as memory loss, confusion and

dizziness, Lutchmansingh said. “And so what we did — and the intent was always to be a multidisciplinary clinic — is we started reaching out to varying subspecialists, and we were also fortunate that some of them also recognized problems and reached out to us.”

She said the doctors formed “a group of go-to specialists who had similar interest in seeing patients who had COVID-19,” who collaborate on cases. So far, two cardiologists, a dermatologist, an ear, nose and throat specialist and neurologists have become involved, and psychiatry will be included soon, as well. Physical therapists also are a major part of the team, helping patients regain their strength and ability to go about their daily lives.

“We’ve been able to leverage different pieces of expertise among different people, connect them quickly with the patient through the help of telehealth,” Possick said.

A conference is planned so that the specialists can discuss different types of cases they’ve encountered. It will answer “the thing that patients have always complained about in the past: Why don’t my doctor’s talk?” Lutchmansingh said. “This actually is meant to facilitate the doctors involved in care talking to each other and then proceeding with the plan.”

Each case is different and many present situations that haven’t been seen in other respiratory diseases. “We’re very honest with our patients from the get-go that this is learning while treating, this is not a matter of treating diseases that have been known and established and well-researched for many years,” Possick said.

“This is a situation where we’re treating conditions that bear a lot of similarities to other things we’ve treated, either other viral pneumonias, even other coronavirus infections … but also is a unique situation, affecting people in a unique way,” she said. However, they expect to find “common themes and therefore common interventions that we can pursue,” she said.

Some patients may have had lung conditions before contracting COVID, such as asthma or the chronic disease known as COPD, which can be treated with inhalers. “In other cases, there may be more chronic lung damage that’s been done,” Possick said, but whether COVID will permanently scar the lungs hasn’t been determined yet, she said.

Many patients, having been inactive for a long period of time, will need rehabilitation in order to increase endurance. When someone becomes breathless simply by walking from one room to another, exercise becomes difficult to endure.

“There’s a big part of this that is about addressing deconditioning, rebuilding endurance and teaching people how to exert themselves in ways where they can still mitigate their breathlessness” with breathing techniques and ways to increasing exercise, Possick said.

Physical therapy helps by strengthening the muscles used in breathing, Lutchmansingh said. “We actually think about breathing in terms of three things. There’s the lung, the heart itself … and the muscle component,” she said. The problems with muscle strength are exacerbated by people staying inactive because of the pandemic. People don’t realize how much less exercise they’re getting.

“I tell them, think of themselves as athletes. They’re trying to build themselves back up to where they were,” she said.

“They usually think about going to the gym,” Possick said. “They don’t think about the fact that they used to go to the grocery store and run all their other errands and take their child to the park and go to work.”

The doctors have seen more serious issues as well, with some patients appearing to have problems with the nervous system that helps regulate the function of internal organs, such as the heart.

“Part of what we’re observing, and this is anecdotal at best, is that people have a really exaggerated heart rate response to fairly minimal exercise,” Possick said. “The heart rate goes way up and, in some cases, patients are describing having their heart rate bounce between very fast and very slow.”

This is yet another symptom whose connection to COVID has yet to be determined, she said. “And, unfortunately, that’s the answer to a lot of questions right now is that we simply don’t know,” Possick said.

“We do see that a lot of these patients do seem to slowly improve over time. But as opposed to something like influenza, the timeline is really protracted. It’s really long,” she said. Patients she is seeing now were among the first to come down with COVID in March and early April. They may have come off oxygen and improved some, but “they still have a ways to go,” she said.

After their evaluation at the clinic, even those patients who were not sick enough to go to the hospital, whose X-rays did not show a major decrease in lung function, “were described as [having ] decreased endurance, decreased ability to sustain themselves from lack of muscle use. And they were recommended for outpatient PT,” Lutchmansingh said.

“That’s not what one would expect from a patient who had just mild disease,” she said. “We expect decreased endurance from a patient who was in the intensive-care unit or somebody who was intubated on a ventilator. So it tells us the musculoskeletal component and the strength component is more important than one would have originally thought, regardless of severity.”

In fact, Possick said, patients who have had milder cases of COVID are teaching them the most about how it affects different systems in the body. “I’m listening to what they describe and the symptoms that they are struggling with, they are really no different than the patients who are coming out of protracted hospital stays,” she said.

In fact, those who were hospitalized had a head start in recovering from COVID because they had physical and occupational therapy in the hospital and may have spent time in a short-term rehabilitation center before going home, Possick said. Those who had milder cases “have been at home, in some cases trying to return to work, trying to continue to take care of kids, and not addressing this aspect of their own recovery directly,” she said. “They’re frankly exhausted and very short of breath.”

They also have higher expectations, thinking they can go back to living at the pace they did before COVID, Possick said. “And one of the messages that we’re trying to bring to patients is that what they’re experiencing is normal and, at least based on our experience, that they need to be patient with their own healing. But that just because you didn’t require hospitalization doesn’t mean that you don’t require time to recover.”

Possick said fatigue and shortness of breath are “subtle and insidious” symptoms that patients, especially young people who may have never seen a doctor for anything serious, don’t expect to deal with. While the age of patients ranges from young adults to the elderly, Possick said many older patients have not yet been seen at the clinic.

“Frankly, some of the … oldest and most frail patients have not made it to us yet because they’re still at nursing facilities and have not been well enough to come or allowed because there’s very restrictive policies right now on going to physician visits,” she said.

For some patients, anxiety about the pandemic is masked by physical symptoms. “So you’ll have people say things like, ‘I used to like going out with my family and friends,’” Lutchmansingh said. “‘Now when I go out, I feel my heart race, or I feel more short of breath when I get to the grocery,’ but they’re not doing anything differently than before.”

Sleep may be disrupted by waking up short of breath, or because of heart palpitations or nightmares, Possick said. It may be difficult to tell whether the symptoms are from COVID or from being isolated during the pandemic.

“It’s difficult to parse it out from the isolation because people aren’t able to connect with their normal support systems that get them through difficult things and illnesses,” Possick said. “They’re isolated from family, isolated from friends, community organizations, like church. And so it’s hard when they report that they’re feeling more anxious, more alone, even depressed, whether that is a manifestation of the circumstance or the illness, probably both.”

The doctors said they hope people will call the Winchester Clinic as soon as they have symptoms, when they can be treated with inhalers or perhaps steroids. If they come to the clinic in a year, they may have irreversible lung damage, with little that can be done.

Not all complications will appear right away, particularly blood clots that can cause serious problems, both in the long and short terms, Possick said. “A lot of what we’re doing is directing early evaluation down different pathways to try and detect problems when they’re intervenable,” she said. “But at the same time, trying to guide people down a path of pulmonary rehabilitation so that they are, from a physical standpoint, recovering optimally and managing their symptoms well.”

Part of the task is to keep people active so symptoms don’t get worse. “You don’t want to be breathless and you get breathless when you walk, so you don’t walk,” Possick said. “It’s logical, but it’s self-defeating because then it requires even less activity to produce the same symptoms. And that’s a cycle we’re trying to break.”

But as their lung function improves, patients feel relief that they are getting better, she said. “It alleviates a lot of the specter of worry about, ‘are my lungs damaged now for the rest of my life?’ Because we hope that for the majority of cases, that answer is no, and that they return to normal.”

The pandemic has given Winchester the opportunity for patients to receive care for a diverse set of diseases. “The spirit of collaboration in a time of crisis has been crucial to this,” Possick said. “Both that our colleagues have been generous and accessible during a time where everybody is stretched thin, that people really do care about doing all they can for these survivors, that patients have been incredibly generous in bringing us inside their experience and being really candid about what they’ve gone through. … It really is learning in real time.

“We hope that the world won’t need a post-COVID clinic forever, of course, but anything we learn here will be applicable in other situations.”

The clinic is located at 789 Howard Ave. For more information, call 203-785-4198.

edward.stannard@hearst mediact.com

Yale University Dr. Denyse Lutchmansingh

Yale University Dr. Jennifer Possick