What is the cause of a new left lower lobe collapse on computed tomography (CT) scan in a patient with Chronic Obstructive Pulmonary Disease (COPD) and a recent diagnosis of Coronavirus Disease 2019 (COVID-19)?

From the Guidelines

The left lower lobe collapse in a patient with COPD and recent COVID-19 diagnosis is most likely due to mucus plugging from excessive secretions, inflammation, and impaired mucociliary clearance caused by both conditions, and management should focus on aggressive airway clearance techniques and medical therapy to reduce inflammation and improve secretion clearance. The patient's condition, as described, with a recent diagnosis of COVID-19 and underlying COPD, presents a complex clinical scenario where the respiratory system is compromised by both the viral infection and the chronic obstructive pulmonary disease. According to the multinational consensus statement from the Fleischner Society 1, thoracic imaging, including CT scans, plays a crucial role in the management of COVID-19, especially in assessing the severity of respiratory disease and guiding treatment decisions.

Given the CT findings of a new left lower lobe collapse, the primary concern is to address the potential causes of this collapse, which could include mucus plugging, inflammation, or possibly a complication related to COVID-19 such as pulmonary embolism, although the latter is less directly implied by the information provided. Management strategies should prioritize improving airway clearance and reducing inflammation.

• Aggressive airway clearance techniques are essential and include chest physiotherapy with postural drainage, deep breathing exercises, and incentive spirometry.
• Nebulized bronchodilators such as albuterol 2.5mg every 4-6 hours and ipratropium 0.5mg every 6-8 hours can help improve airflow by relaxing bronchial muscles and reducing secretions.
• Consideration should be given to adding nebulized hypertonic saline (3-7%) to help liquefy secretions, making them easier to clear.
• Adequate hydration is critical to thin secretions and make them more manageable for the patient.
• If there are signs of bacterial superinfection, such as purulent sputum, appropriate antibiotics should be initiated promptly.
• For severe cases not responding to these measures, bronchoscopy may be necessary to mechanically remove mucus plugs.
• Systemic corticosteroids, like prednisone 40-60mg daily for 5-7 days, may be beneficial in reducing airway inflammation.
• Supplemental oxygen should be provided to maintain oxygen saturation above 88-92%, with caution regarding flow rates in COPD patients to avoid inducing respiratory depression.

This approach is guided by the principles of managing both the acute complication (lobe collapse) and the underlying conditions (COPD and COVID-19), with a focus on improving morbidity, mortality, and quality of life outcomes for the patient. The management plan is tailored to address the specific pathophysiological changes associated with both conditions, aiming for optimal recovery and minimizing the risk of further complications.

From the Research

Possible Causes of Left Lower Lobe Collapse in a COPD Patient with COVID-19

• The left lower lobe collapse in a COPD patient with COVID-19 could be due to various factors, including increased risk of serious complications from COVID-19, such as pneumonia or acute respiratory distress syndrome (ARDS) 2.
• The collapse could also be a result of the patient's underlying COPD condition, which can cause airway obstruction and increase the risk of lung collapse 3.
• Additionally, the use of inhaled medications, such as corticosteroids, may not be effective in preventing lung collapse in COPD patients with COVID-19, and may even increase the risk of serious adverse events 4.

Management of COPD Patients with COVID-19 and Left Lower Lobe Collapse

• Patients with COPD and COVID-19 should continue their regular therapy, including inhaled corticosteroids, and follow standard algorithms for pharmacological and non-pharmacological management of COPD 3.
• Close monitoring and follow-up are essential to prevent delays in diagnosis and initiation of appropriate therapy, which can negatively affect the patient's prognosis 3.
• Management of COVID-19 in COPD patients may still warrant standard-of-care exacerbation treatment with antimicrobial agents and corticosteroids, as well as modalities to treat acute respiratory failure 5.
• Patients with COPD and COVID-19 who are treating their illness at home should self-isolate, use nebulizers with precautions to avoid viral aerosolization, and frequently disinfect room surfaces 5.

Treatment Options for Left Lower Lobe Collapse in COPD Patients with COVID-19

• Inhaled corticosteroids may be effective in reducing the risk of admission to hospital or death, and increasing the resolution of all initial symptoms at day 14, in COPD patients with mild COVID-19 symptoms 4.
• However, the evidence is uncertain regarding the effect of inhaled corticosteroids on serious adverse events, and more research is needed to determine their safety and efficacy in COPD patients with COVID-19 4.
• Other treatment options, such as antimicrobial agents and modalities to treat acute respiratory failure, may be necessary to manage the patient's condition, and should be guided by standard-of-care protocols and clinical judgment 5.