Pulmonologist: Corona risk group is made up differently than expected

Interview

The pulmonologist explains why pneumonia is not the leading cause of death in Covid-19

There are many myths surrounding the novel coronavirus, which triggers Covid-19 lung disease, which has not yet been investigated. Never before has the population examined science so closely that it publishes almost daily new information about the routes of infection, the course of the disease, or the exact cause of death.

Forensic medicine findings are receiving increasing attention. Although the Robert Koch Institute initially said that crown deaths should not be autopsied so that doctors don’t become infected with the virus, opinion is now becoming more prevalent: Examining patients who died from Covid-19 can provide valuable insight for the living. Legal practitioner Klaus Püschel came to the following conclusion in an interview with the “Frankfurter Allgemeine Zeitung” (“FAZ”):

Alexandar Tzankov, head of the autopsy department at the Basel University Hospital, also reported in the “Süddeutsche Zeitung” that the fewest number of victims died of pneumonia. In return, almost none of those who died from Covid-19 were free of previous illnesses.

So what exactly do people die of if they have a fatal course of the disease after being infected with Sars-CoV-2? And what is the role of working with pathologists to learn more about Covid-19? Watson spoke to pulmonologist Thomas Voshaar about this. He is Chief Physician at Bethanien Moers Hospital and President of the Association of Pneumological Clinics (VPK).

watson: Alexandar Tzankov, head of the autopsy department at the University Hospital of Basel, recently told the Süddeutsche Zeitung that very few deaths in the crown had pneumonia. However, an alteration in the microcirculation of the lungs is visible. What does that mean exactly?

Thomas Voshaar: This is a disorder of the blood circulation in the lungs that affects the smallest blood vessels. So the oxygen exchange process no longer works or no longer works completely. This complicates gas exchange in addition to actual pneumonia.

What does this disorder mean for people with previous illnesses, old age, overweight or for smokers? Who is it more dangerous for?

We have observed that the risk groups that could be most affected by Covid-19 disease are different from what was thought at the beginning of the pandemic. We have found that patients with diabetes or hypertension, that is, high blood pressure, are more likely to experience a severe course of the disease, regardless of age.

Old age does not automatically place the patient in the risk group unless they have previous illnesses. Even with smokers or asthmatics it is still not known for sure how high the risk of serious illness is. Otherwise, we have observed that young people are more likely to survive the disease, which is also due to the fact that they are less likely to suffer from previous diseases.

Is this disorder of the microcirculation of the lungs common? Or is it a particularly rare symptom that is specific to the coronavirus?

The microcirculation of the lungs is also altered in other viral infections. That is why I would not say that it is a specific feature of Covid 19 disease, but it is common. It can aggravate the symptoms of pneumonia. We do not yet know if a microcirculatory disorder occurs significantly in all Covid pneumonia.

Why are patients not ventilated earlier?

Because artificial respiration can also damage the lungs, especially if ventilation is required for a long period of time. During the crown crisis, reports from the United States just told us that about 80 percent of all ventilated patients die. Chinese studies indicate a death rate of around 50 percent. There are no figures available for Germany in this regard, but they will probably be a little better because we reacted to the crisis from the beginning and therefore gained more time and peace for the conscientious and individualized treatment of patients.

Are there effective alternatives to artificial ventilation?

When a patient with difficulty breathing enters our hospital, we first try to stabilize the breath with the addition of oxygen. The patient breathes spontaneously, that is, independently. If there is no improvement in the condition, ventilation is performed using CPAP. Spontaneous breathing is supported by overpressure. In the next step, CPAP ventilation can be combined with the oxygen supply. Only when the patient would threaten to die otherwise, will artificial intubation be initiated and ventilation started.

Does it happen that you receive especially young patients in your clinic?

So far we have had a total of 40 coronavirus patients, one of whom has died. We recently received a man under the age of 30, but he did not suffer from shortness of breath when he was taken in. We were able to determine Covid disease 19, but the lungs were almost unaffected. Because of this, the man suffered from ventricular tachycardia, a severe arrhythmia that can quickly lead to death. If we hadn’t received the man on time, he probably would have died.

Do you think the arrhythmia found is related to Covid 19 disease?

We assume this, because it was caused by an inflammation of the heart muscle. This occurs with and without a microcirculation disorder. The virus can directly affect the heart muscle. We also know about cardiac involvement from other viral infections like influenza. It is unclear whether the phenomenon of microcirculation disorder also plays a role here.

What we also found: Some of the 19 Covid patients had strokes. These are blood clots that, when released, fire into the lungs like a torpedo. They then clog the pulmonary arteries through which oxygen-poor blood flows from the heart to the lung. If one or more pulmonary arteries are blocked, the pressure in them increases and the heart may no longer be able to apply the pressure required for adequate blood flow to the lungs.

What other abnormalities are there in Covid-19 compared to classical pneumonia?

After performing a computed tomography (CT) scan on all of our crown patients, we were able to determine that with Covid-19 both lungs are almost always inflamed, and classical pneumonia is usually just one. Otherwise, the lung records of our patients show a wide range of inflammation patterns: while the lungs are hardly affected in some, the other two wings are cloud-shaped or almost completely covered. This may or may not be related to the stage of the disease. There is no uniformity. We also note some atypical symptoms for lung diseases.

For example?

One of our employees, who had been infected with the coronavirus outside the hospital, informed us that shortly before the disease began, he suddenly could no longer smell his shower gel in the shower. For this reason, we noticed the symptom of loss of smell and taste very early in our clinic. Another employee who had been infected abroad was unable to play the guitar for three weeks because he had lost the feeling in his fingers.

What does it mean that the symptoms are so varied and unusual?

We can’t say exactly that yet. As already mentioned, we can presumably assume that the virus can cause inflammation in vascular cells throughout the body, and that it also affects the nervous system, as suggested, for example, by loss of smell and taste. However, we can only obtain more accurate information by carefully examining deceased crown patients.

As doctors in the clinic we work with the living: it is even more important for us to compare the findings of the pathologists with our knowledge, that is why we are in regular contact with many of them. The fear of infection during an autopsy is probably unfounded. Because the virus is transmitted mainly by humans through droplets, which are released by speaking or coughing and inhaled by the other person.

Medical examiner Klaus Püschel discovered that there are many causes of death from Covid-19 disease. He recently said in an interview with the “FAZ”: “There is no ‘the’ dead crown, as the statistics suggest.” what do you think about his declarations?

The fact is, we still don’t know enough about the disease. Currently there is no clear distinction as to whether a patient has died or has a crown. For example, if a patient has heart disease, it is possible that in ten years he will die of a heart attack. However, these ten years could be killed by the corona virus. In order to determine the exact cause of death in such a case, we need to do more autopsies and work more closely with pathologists.

What conclusions do you hope to draw from pathologists examining Covid 19 victims?

For us clinicians working with crown patients in daily clinical practice, it would be important to know: Did people die breathing spontaneously? Or have they been artificially ventilated for some time? The first would die suddenly, while the second had already taken various measures up to the time of death. In this way, we could better understand how far away the damage caused by artificial ventilation is. So my question to pathologists is: What is the difference between someone who died despite mechanical ventilation and someone who was still breathing on their own at the time of death?

Pathologists may also make more precise statements about how other organs, such as the heart, liver, or kidneys, are affected by the disease. It would also be important to examine the brain more closely on a separate autopsy. If, for example, the coronavirus affects the brain stem, which is also responsible for respiration, this would be a valuable finding.

Does that mean that the lungs do not play a central role in Covid 19 disease?

The disease can affect the body in several ways. But the lungs are in the foreground – most of the problem still lies in bilateral pneumonia and shortness of breath. However, it is important to examine the rest of the body as well. After all, patients have already died of Covid-19 without their lungs being affected or even shortly after discharge from the hospital, when the lungs already seemed to be healed.