Pandemic: an optimist's opinion

Life after the pandemic

Natalia Leskova, "In the World of Science" No. 6, 2020
The article was published on the portal "Scientific Russia"

COVID-19 is a new infection, against which there are no specific drugs and vaccines yet. In many ways, its complications were also unexpected. For some, all this causes panic moods and anxious expectations. But not from our interlocutor – Andrey Georgievich Malyavin, professor of the Moscow State Medical and Dental University named after A.I. Evdokimov, chief freelance pulmonologist of the Ministry of Health of Russia for the Central Federal District, Secretary General of the Russian Scientific Medical Society of Therapists. What is the basis of the scientist's optimism and what causes his fears?

– Andrey Georgievich, today it becomes clear that after overcoming the pandemic, we will be left with a number of problems that will also require solutions. Which of them, in your opinion, will be the most acute?

– I would single out four directions. First of all, these are the consequences of the disease itself, which today can be described as microthromboendotheliitis. This is a systemic lesion, and not only of the lungs. This is primarily a lesion of blood vessels with the formation of microthrombs, as a result of which many systems suffer: respiratory, excretory, cardiovascular, endocrine, gastroenterological, etc. The second point is the consequences of treatment, because the drugs that are currently prescribed are unsafe and we often face the consequences of their exposure. The third is the exacerbation of chronic diseases, a change in the nature of their course, which also requires correction. And the fourth problem is psychological. I don't know if this is a direct effect of vascular disorders in the brain or just such a situation, but situational depressions are already pronounced quite clearly.

– Let's focus on the first point in more detail. What somatic disorders can be expected? I have heard about gross fibrous changes in lung tissue that do not disappear for a long time.

– There is a problem with the lungs. Now people are often scared of pneumosclerosis. However, in most cases there is nothing fatal here. Pneumosclerosis with small lesions, which we usually encounter, has no significant clinical significance. Although, of course, it is necessary to restore the diffusion ability of the lungs. There are a number of medical techniques that help ensure the patency of the respiratory tract, especially if there is an obstruction. To do this, you need to recruit poorly ventilated areas of the lungs and make them breathe.

– Is this, in fact, breathing exercises?

– Including. There are also breathing simulators – these are motivating breath spirometers, streaming, volumetric. These are expiratory and post-expiratory simulators that create little resistance on exhalation, simulators with oscillation, which, among other things, are more effective and contribute to the liberation of the respiratory tract. There are quite a lot of them registered in Russia, they are affordable and inexpensive. The so-called interpulmonary percussion ventilation technique is more advanced. The percussionist is a wonderful device, but, unfortunately, it is not widespread in Russia. Medication support is also important. If there is an obstruction, bronchodilators are used, if there is sputum retention, mucolytics. The issue under discussion is the appointment of steroid drugs. In principle, there is logic in this. I don't know why they are rarely used both in the acute period and after it. I am in favor of prescribing small doses of steroids, because it is traditionally effective for the treatment of vasculitis with lung damage. An important point is the appointment of direct anticoagulants, and their use should be quite long. With this infection, as is already known, microthrombs are formed, which means that something needs to be done with them.

– Andrey Georgievich, before the COVID-19 epidemic, few people had heard about computed tomography, and now they can't get to this study. What do you say about this?

– It is pointless and harmful to do a CT scan every three days, because it gives a noticeable radiation load. In order to assess the extent of the lesion, you need to look at the lungs no more than once a month. In addition, it is necessary to evaluate the diffusion capacity of the lungs, for which there are also special devices. You can also perform spirometry, if the epidemiological situation allows it. Very often COVID-positive patients face the problem of cardiovascular lesions. In the acute period, blood pressure often decreases even in hypertensive patients. It needs to be normalized. Particular attention should be paid to angiotensin converting enzyme inhibitors, which are indicated in this situation. And, oddly enough, statins: their role is traced not only in the normalization of the lipid spectrum – they have a pronounced anti-inflammatory pleiotropic effect. Heart failure often debuts or worsens during treatment. ACE inhibitors, selective beta blockers, spironolactone are used here, in rare cases ivabradine and diuretics will be needed.

– We know that most seriously ill patients suffer from obesity and diabetes mellitus. This means that a difficult situation is also developing in endocrinology.

– It's true. It is associated with both the disease and the use of drugs. Diabetics, as we know, already have a lesion of small vessels, so all these problems are most acute for them. Here you just need to correct the therapy of hypoglycemic drugs, monitor this. Gastroenterology in COVID-19 is mainly liver damage, largely associated with drug exposure, resulting in signs of liver failure. To solve this problem, there are a number of drugs that allow you to correct the situation. Another important point is night apnea. Unfortunately, few people in our country are dealing with this problem. But I think that overweight people in our country mostly die precisely because no one pays attention to night apnea. Doctors do not prescribe CPAP therapy to these patients at night. And during the period of reconvalescence, you also need to pay attention to this. After all, this problem is very easily diagnosed and effectively treated with the help of modern technological devices. 

– Well, are you trying to convey to medical officials the importance of all these recommendations?

– We are currently forming methodological recommendations for rehabilitation from the Russian Scientific Medical Society of Therapists. It lists all the techniques ranging from breathing exercises and ending with medications and instrumental methods. The other day I was at the Ministry of Health, talking with Deputy Minister E.G. Kamkin. They were very interested in our proposals. We will definitely take them through the Ministry of Health, send them to all interested parties. And many are interested. Every day I get calls from the chief specialists of various regions, authorized representatives of the society of therapists. Everyone needs such recommendations because they don't know what to do. But everyone wants simple solutions. And they cannot be, because the formation of a complex of rehabilitation measures should proceed from a specific situation. It is necessary to choose a certain scheme from this set of possibilities, focusing on indications and compatibility. It can be very simple, but it can also be complicated. We offer a syndrome-pathogenetic approach: we treat not the diagnosis, but its manifestations, syndromes.

– Do you want to say that domestic medicine has proved itself well? But there is so much criticism of her now.

– The criticism is often fair, and it concerns the current situation of largely unreasonable, short-sighted optimization of healthcare. But at the same time, the pandemic has shown the effectiveness of traditional Russian mobilization medicine, which was created by N.I. Pirogov. All these restrictive measures, measures to mobilize forces, staged evacuation, although they were not very successfully applied, but still worked, and therefore we do not have the highest mortality. We have all this in our traditions. And this is very good. The syndrome approach is also a tradition of the Russian therapeutic school.

– What drugs for the prevention of COVID-19 do you consider effective?

– Unfortunately, I cannot answer this question, because there is no convincing data on this. We appeal only to the position of evidence-based medicine, we do not need witchcraft techniques. Many of the drugs currently recommended are not only useless, but also dangerous. Interferons can provoke a cytokine storm that occurs with this disease. There is a lot of controversy around the preventive effect of hydroxychloroquine, which they are trying to give to all patients, at least in Moscow. The result is negative. No effects were found in terms of preventing severe flow. WHO has stopped clinical research in this direction. Antiviral drugs that are used in the case of this infection are not initially sharpened for coronavirus, they are used to treat influenza or AIDS. And these are completely different things. Therefore, there are practically no bright results. As for monoclonal antibodies, a number of different drugs are already being used. This is a point anti-inflammatory therapy. It is also not so harmless, because it treats a viral infection, but at the same time leaves a person helpless against bacterial infections. Therefore, such treatment is used only in severe cases. I think there will be an accumulation of material – and gradually there will be an understanding of which treatment scheme is most effective here. In the meantime, there are a lot of questions.

– What questions are you concerned about first of all?

– Here is an interesting and not very clarified situation: it seems that we understand that this is a lesion of the endothelium, that plasma is moving into the interstitial space in the lungs, and in the future hyaline membranes are formed there, fibrosis is going on. But, as it turned out, this process does not take place in two weeks of the acute phase of the disease, but, perhaps, much longer. Therefore, fibrous changes persist for a long time. But the same syndrome approach is important here. There is respiratory insufficiency – so we give oxygen support and non-invasive ventilation of the lungs. No means you don't need to.

– At the same time, a huge number of ventilators were purchased, the use of which, as it turned out, with COVID-19 gives a mortality rate of up to 90%.

– You're right: it's better not to bring it to the ventilator. Resuscitation and intubation are associated with ventilator-associated pneumonia and other complications. The mortality rate is really very high. Therefore, we need to do everything to postpone this process.

– Andrey Georgievich, why exactly did this virus cause such a flurry of public attention? It seems that humanity has faced both epidemics and pandemics before.

– Each virus is unique. But nothing supernatural happened. I have to say that now there are not so many complications that the same pandemic flu causes. Here is a situation with a high degree of contagion. For some reason, this virus is very tenacious: it lives in the external environment, so there is a massive infection. But, in essence, it cannot be considered as a heavyweight. It is inferior to the same SARS coronavirus that humanity encountered in 2003. However, the contagiousness and widespread spread of COVID-19 caused particular concern. And, of course, the microvascular feature of the lesion also turned out to be very unusual. It is also distinguished by prolonged infection, slow development of pathomorphological and functional disorders. But in general, there is nothing fantastic here.

– What lifestyle have you personally chosen to avoid encountering the virus?

– I obey the order of the university and am in self-isolation in the country. We carry out the training process remotely, and for the Russian Scientific Medical Society of Therapists we also conduct a number of events in an online format. But you have to go out, including on television. Planned hospitalization has now begun in Moscow, and we are opening our Centrosoyuz clinic. This is our base hospital, which will specialize in the rehabilitation of patients with COVID-19. We have a lot of things, both research and medical, and in this situation it would be a sin not to help people.

– What do you have?

– Therapeutic gymnastics, all simulators that are allowed in the Russian Federation, oxygen therapy, percussionist, coughers, two–level sipaps, bipaps, ventilation support, halocamera - a very useful technique, including from the point of view of psychological relief and stimulation of mucociliary clearance. We have both body cameras that allow us to measure residual volumes, and a special device that measures the volumes of nitrogen leaching. This is a more modern technique. We can look at the diffusion of gases. Not to mention routine ultrasound examinations, echocardiography, etc. And there are trained people, which is very important. I don't even know what we don't have. I say this with pride, because I do not know of any other such institution in the Russian Federation, and I have traveled and looked a lot.

– Andrey Georgievich, your words inspire optimism. Although, to be honest, not all of your colleagues are the same. Do you think we will be able to overcome the current situation without fatal losses?

– I think it will succeed. Now, fortunately, we are not faced with such a severe infection, which have already been in the history of mankind. Let's remember the smallpox, the plague in the Middle Ages, the Spanish flu in the early twentieth century, which claimed up to 100 million lives. Here are the really scary things.

– Some experts call the current coronavirus the Spaniard of the XXI century. Do you disagree with them?

– No, absolutely not. This is incomparable in terms of the volume and severity of the lesion. But all these diseases were also new once. Now is the time when we can study all this faster and influence it. Of course, we don't know everything at the moment. But we try, we make mistakes, we try to do something. Currently, 140 vaccines are being prepared worldwide. Certain hopes are also pinned on them. Maybe not one hundred percent. But that's okay. There are also security issues. You can't make a safe vaccine quickly, in a few months. There's no need to be hasty. There is a proper clinical practice that determines the procedure for the study of any drug. Despite all these "buts", let's not create panic moods. We have more than 40% of people who are asymptomatic. And this means that there is a formation of collective immunity, that is, immunity to new infections. There is an accumulation of such people. With this in mind, I hope there won't be any serious big spikes. I think the situation with the coronavirus will be identical to the flu. Pandemic outbreaks will not become too frequent – once every eight to ten years.

– However, it mutates as quickly as the flu, that is, the vaccine will have to be created anew every time.

– There is a difficulty here, because it has not yet been possible to create a universal vaccine. However, we have already achieved a lot. Such a number of deaths even from pandemic influenza, as it was before, is no longer there. And the science of creating vaccines is also not standing still. More and more effective and less toxic drugs are being created, although the first vaccines were not harmless at all. When the polio vaccine was created, it was launched early and there were a large number of deaths. Nevertheless, we have made an effective and safe vaccine that is used by the whole world. We have practically no polio in our country for many decades. We have defeated smallpox, and this is also a viral disease. Effective vaccines against human papillomavirus have appeared. There is a breakthrough in the prevention of retroviruses – hepatitis B and C, HIV infection. The antiretroviral vaccine is a very complicated story, but now there are very encouraging results. Therefore, I think that in addition to the negative effects of the pandemic, there are at least two positive aspects.

– What are they?

– Firstly, we paid attention to medicine. For a long time we were faced with its deficit: the residual principle of financing, endless reforms that did not lead to anything good. Now, I think people have realized how important medicine is. And attention will be paid to her. The second is a surge in the development of biotechnologies, as well as new possibilities for mathematical support of biological processes, when there is no longer a need to perform an insane number of experiments. Before our eyes, new genetic engineering technologies are being born that allow us to operate with nucleic acids. These are very serious achievements, and I am glad that we live in such an interesting time.

– What do you have concerns about?

– Haste and what I call kulibinism cause concerns. I respect I.P. Kulibin, he is a wonderful scientist, but the question here is that we sometimes think like this: here I did something on my knee, and now I will try how it will work. I'll give you a concrete example. Information suddenly appeared on the Web that the FMBA suggests using a gas emitting ultraviolet light to kill viruses inside the respiratory system. Such messages make the hair stand on end. Probably, ultraviolet light will kill viruses, but it will also kill the very sensitive ciliated epithelium, which protects the lungs. Why such sophisticated methods to kill the virus if it dies from simple influences? Therefore, such kulibinism is dangerous.

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