What is the treatment for pulmonary fibrosis due to COVID-19?

Treatment for Pulmonary Fibrosis due to COVID-19

For patients with COVID-19-related pulmonary fibrosis, a comprehensive treatment approach including pulmonary rehabilitation training, corticosteroids for acute cases, and consideration of antifibrotic therapy is recommended, with rehabilitation care implemented as early as possible to improve outcomes. 1, 2

Acute Management of COVID-19 Respiratory Failure

Ventilation Strategies

• For mechanically ventilated adults with COVID-19 and ARDS:
  • Use low tidal volume ventilation (4-8 mL/kg of predicted body weight) 1
  • Target plateau pressures <30 cm H2O 1
  • Consider higher PEEP strategy (>10 cm H2O) with monitoring for barotrauma 1
  • Implement prone positioning for 12-16 hours in moderate to severe ARDS 1

Pharmacological Interventions for Acute COVID-19

• Corticosteroids are strongly recommended for patients requiring oxygen or ventilatory support
  • Dexamethasone 6 mg daily for up to 10 days is the standard regimen 2
• Consider remdesivir as soon as possible after diagnosis of symptomatic COVID-19 2
• Appropriate anticoagulation is recommended for all hospitalized patients 2
• Empirical antibacterial coverage should be considered but can be de-escalated within 48 hours if cultures are negative and the patient is improving 1

Management of Post-COVID Pulmonary Fibrosis

Pulmonary Rehabilitation

• Implement rehabilitation care as soon as possible once the patient is stable 1
• Include combined exercise (aerobic with strength), respiratory exercises, and specific respiratory muscle training 1
• Incorporate breathing techniques like pursed-lip breathing and coordinated breathing training 2
• Consider positioning techniques such as sitting upright and leaning forward with arms bracing 2
• Traditional Chinese exercises like Baduanjin, Tai-chi, and 6-character breathing exercise may be beneficial 1

Pharmacological Management

• Despite theoretical benefits, the recent FIBRO-COVID trial showed that pirfenidone did not significantly improve lung function or fibrotic score on HRCT compared to placebo after 6 months 3
• For breathlessness management, consider opioids such as morphine sulfate (2.5-5 mg every 2-4 hours as needed) for moderate to severe symptoms 2
• For patients with eGFR <30 mL/min, use oxycodone instead of morphine 2

Monitoring and Follow-up

Diagnostic Evaluation

• Assess pulmonary function through:
  • Forced vital capacity (FVC)
  • Diffusion capacity for carbon monoxide
  • 6-minute walking distance 1
• Imaging evaluation:
  • Chest X-ray for initial assessment
  • High-resolution CT to evaluate extent of fibrotic changes 1
  • Consider MRI in selected cases to assess myocardial involvement 1

Follow-up Schedule

• Schedule virtual follow-up 1-2 weeks after diagnosis 2
• Monitor for persistent symptoms including cough, dyspnea, exertional dyspnea, and poor oxygen saturation 4
• Continue follow-up for at least 12 months, as most fibrotic changes may improve within the first year, but approximately 20% may show progression in 5-10 years 5

Special Considerations

Risk Factors for Developing Post-COVID Pulmonary Fibrosis

• Older age
• Chronic comorbidities
• Use of mechanical ventilation during acute phase
• Female sex 4

Pitfalls and Caveats

• Despite theoretical benefits, current evidence does not support routine use of antifibrotic drugs like pirfenidone for post-COVID pulmonary fibrosis 3
• Avoid staircase (incremental PEEP) recruitment maneuvers in mechanically ventilated patients 1
• Avoid routine use of inhaled nitric oxide 1
• Be aware that procalcitonin may be elevated in COVID-19 due to inflammatory activation rather than bacterial co-infection 1

The management of post-COVID pulmonary fibrosis remains challenging with limited high-quality evidence. While pulmonary rehabilitation shows promising results for improving quality of life and lung function, pharmacological interventions specifically targeting fibrosis have not yet demonstrated significant benefits in clinical trials.