The Future of the COVID-19 Pandemic – An Interview with Dr. Panagis Galiatsatos
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Nearly two years ago, the world shut down with the rise of the COVID-19 pandemic. Even as schools and stores reopen and people return, in part, to socializing sans face masks, the prevalence of new variants and pandemic fatigue unearth questions about the virus and the real damage it may cause on lungs and the future.
To clarify confusions about the imminent course of the pandemic, Hola Cultura spoke with Dr. Panagis Galiatsatos, assistant professor of medicine at the Johns Hopkins University School of Medicine. A specialist in lung health, Dr. Galiatsatos explains the impact of COVID-19 on the lungs, highlighting the differences between past variants and Omicron, in the first of a two-part article series. In the second part, he discusses the future of the pandemic and the disproportionate impact on the Latinx and other minority communities.
As a pulmonary and critical care medicine physician, what can you tell us about how COVID-19 affects people’s lungs?
Some people may have developed nothing more than a bad cold or slight shortness of breath, all the way to people necessitating hospitalizations, if not critical care resources. Why it’s important to recognize is because infections will cause a spectrum of a disease. It won’t cause one specific thing — I mean, some viruses do. This one doesn’t. It impacts an organ, and that outcome depends on how much virus you breathed in. What are some predisposing factors you have? What are some genetic predisposition factors you have? So, a variety of other individual, genetic and contextual level factors will tell us what it’s exactly going to do to the lungs.
The other parts to this are the variances and the lungs. You can think of them as three parts: airways, tissue and the blood supply. The virus has changed a little bit in what part of the lungs it impacts. Early on, with the variances from Alpha, Beta, Gamma and Delta, it seemed to be more [damaging to] lung tissue. A lot more COVID pneumonias were happening. Early on, patients would develop a dry cough, all the way to shortness of breath and low levels of oxygenation. For some patients, that’s it, the infection caused a lung infection. For others, it escalated to pneumonia. And for others, it escalated actually to a pathological syndrome known as ARDS, acute respiratory distress syndrome. The syndrome is a constellation of symptoms brought on by a disease that was brought on by an infection. Those are the patients who ended up in my intensive care unit necessitating oxygen, as well as interventions meant to relieve their excessive work of breathing. Sometimes we had to put them on a mechanical ventilator.
The newest variant, Omicron, also impacts the lungs, but it seems to be more airway centric. So, these patients are still going to develop a cough, but it tends to be more mucus producing. Coughing is still there, but it’s more productive. That’s key. There will be some level of shortness of breath, but it’s not as much hypoxemia-driven — meaning oxygenation dropping — as its predecessors.
Shortness of breath really is more of an issue because of air struggling to get out. When you take a deep breath, your lungs expand, airways expand. You breathe out, lungs get smaller, airways get smaller. Well, those airways are narrowed even more because of all the secretions and a struggle to breathe out. Regardless of the variant, SARS-CoV-2 impacts the lungs. Omicron is sort of different, but, honestly, it’s still the same symptoms, depending on what part of the lungs it infects.
Specifically, how is COVID-19 different from the flu or other infections that impact the lungs?
SARS CoV-2 still probably causes the same rates of dire lung related issues as, say, influenza; probably less compared to some more sinister viruses, like parainfluenza; definitely more compared to other viruses like enterovirus or rhinovirus. Even if your rate [of infection] is 1% — you’re gonna get a lot of people still sick. That’s why this became a pandemic.
It is by far the Goldilocks [principle]. Plenty of people are going to survive it. That’s actually advantageous to the virus. Remember, if we die — not to sound morbid — but if we die, so does the virus. The virus needs us to live. The virus will be great if, and only if, it can get in us and then, leave us. Why we call it a pandemic is because enough people got sick to overwhelm your typical hospitals and health care systems, that 1 to 2%. That’s the Goldilocks number.
This is on par with some other viruses that we’ve seen. But at such high transmission rates that we were seeing, we’ve never seen anything else rival [the coronavirus] before. That’s what got our concern: It just spread like wildfire. It’s gonna take down a sufficient amount of people that would overwhelm the health system.
Now, those lung injuries, the permanence of them depends on the patient. The lungs do need to heal. You’ll have some symptoms, even if you survive this. If you [broke] your bone, you’re going to take months before you walk again on it. That’s just healing. From a lung standpoint, it’s the same concept. You got some lung scars from the pneumonia? It’s going to take some time for your lungs to develop scars. Could those be permanent? It’s variable. It depends on the patient. I will say, if you’ve been vaccinated, it’s unlikely to be permanent. So, yes, COVID-19 does a lot of similar biological things that other viruses do. Why it’s gotten concern is because of one factor: It’s just happening at such higher rates. That’s the big differentiating factor.
What is the medical community seeing when it comes to COVID-related lung damage? What is the typical outcome?
There’s a spectrum — mild, moderate and severe. [But those categorizations are] really meant for epidemiological reasons and research reasons.
Mild, you have COVID symptoms, you stay home. That’s it. Moderate means you need hospitalization, maybe a bit of oxygen, and you’re OK. Severe means that you need critical care resources, intensive care and so forth. So, COVID-19 can cause a spectrum of disease to the lungs.
From my standpoint, it does what other viruses can do. It can cause bad bronchitis, it can cause pneumonia — depending on the patient, depending on some genetic factors, but definitely depending on age and other pre-existing conditions. That bronchitis, that pneumonia may be too much for them. But I always try to tell every patient, “You’ve got to think of your body like a house, you’ve got to think of an infection like a fire.” If that house has always been unsteady, well, that fire is going to destroy it. It’s going to knock it down. But if that house is well built — good concrete, good bones — the second the fire hits, nothing happens in the house. You put it out, everything’s still fine. You move on.
What is the worst outcome you’ve seen?
From my standpoint, being a critical care doctor, yes, I’ve seen the worst of the worst. That’s the most heartbreaking thing for me because an ICU is never going to get people’s attention by numbers. ICUs make up less than 10% of the typical hospital’s rooms. Think of one of the community hospitals we have: 300 beds, only 12 ICU beds. That’s it. People usually need hospitals for other reasons, not so much for critical care purposes.
The fact that we had to make more critical care beds just meant that more severe cases of COVID were happening at higher rates. What we saw was a lot of patients needing lots of oxygen. That was key to helping them survive. Regardless of what I had to offer patients as a tool, they still needed support. Oftentimes it was oxygenation … I had to put them on mechanical ventilation. I saw a lot of patients like that.
The other dire thing about COVID is if I have to put a breathing tube in you, those patients, who required mechanical ventilation invasive, were usually like that for weeks. This is the part that now separates my prior experience with other infections to my experience with COVID-19. Think of a bad staphylococcus, MRSA, pneumonia infection. I always bragged, “I can get you better in 30 days. I may have to put a breathing tube in you, but we have good antibiotics. Kill the infection, take the breathing tube out, you’re good.” To this day, we don’t have a cure for COVID. The weapons we’ll throw at it in a hospital are all supportive and meant to stop the massive inflammation it causes. It doesn’t stop the virus. So, with that said, these patients often required tracheostomies — taking the breathing tube out of their mouth and putting it into a surgically made fold.
This past weekend, I returned to the hospital to care for the intermediate group, meaning they’re not sick enough to be in the ICU, but they’re not healthy enough to be on the regular floor. I took care of six patients who had COVID in December. All six had the tracheotomy. They’ve been breathing from a breathing machine for the last three months. That’s very typical for severe COVID-19 patients — to require a breathing machine, to get a tracheostomy, and the machine is helping them breathe. Is it permanent? No. But when will they get better? Probably in 12 months, if I have to give a family an honest opinion. 80% of those months will be spent on the machine. For the other 20%, it’s them coming off the machine. So, those are by far some of the worst cases.
I’ll tell you the one that will haunt me, that I speak to my therapist about. It was a patient, young mom, pregnant. We couldn’t get her to breathe, even with a machine giving her 100% oxygen. So, we had to do something called ECMO, extracorporeal membrane oxygenation. The concept of ECMO is — actually the irony of that is because she’s pregnant, the concept is like a fetus. A fetus doesn’t breathe. A fetus’s blood gets oxygenated from the mom. Blood comes in from the mom and goes back to the mom so the mom can oxygenate it. ECMO is a similar concept. We put hoses — literally think of these catheters as the size of a garden hose — and put them into the brains of the patient, remove their blood, oxygenate it and give it back to the patient. That patient died, so that child’s first days of life were spent without its mom. And that’s not an unusual story. I have some other colleagues who experienced the same thing. COVID made a lot of kids into orphans. That’s the most heart-wrenching thing that I’ve come across.
What are the typical treatments for lung damage?
When we think of an immune system, it’s not just about battling the microbes. There’s another side to it that deals heavily with recovery. So, that analogy; the house. One part of the immune system puts out the fire, but there’s a completely different part of the immune system that comes in and sweeps the ashes out. That’s also efficient and necessary. And this is why we advocate for people to get vaccinated.
Through a lot of these conversations, people always say, “I have a strong immune system.” That is not the proper way of thinking about it. I would [rebut] with an analogy. So, you like sports. Your favorite team is Tottenham, a soccer team. They’re in the gym all week training, but they have no idea who they’re going to play on Sunday. If they don’t know who they’re gonna play, the odds aren’t that great that they’re going to win. They don’t know, “How aggressive do I need to be?” You may overreact to a team. If you gave that same team the playbook — this is who you’re playing Sunday, here are their weaknesses — you’re going to be more efficient. You’ll know exactly who to start, etc. That’s what vaccines do for us. It gives our immune system a memory to know how to strategically fight an infection — not just fight the infection, but how to do it efficiently and how to efficiently recover from it.
The vaccine trains that immune system to be smart. That’s key. You want a smart immune system, not just strong. So, the long recovery will fall into two categories. Is this healing and your symptoms are just part of healing? If that’s the case, I do everything possible to tell them that they can’t suffer another lung injury. If you have asthma, let’s control it. Do you have emphysema? Let’s control it really well. What control means is being on your proper inhalers and avoiding a repeat infection, because if your lungs get another infection, it may make things permanent. Again, going back to the bone analogy. If your bone broke, and was put back together, you’re gonna be in a lot of pain as you try to walk on it. Doesn’t mean the bone isn’t healed. It just means recovering is going to hurt. If you snap it again, you’re setting yourself back from properly healing.
So, when patients come to me, the first thing I do is hear their symptoms. I get some lung imaging. I may even get some lung function test — how strong are your lungs? But it’s all about the symptoms. What I’m looking for is, do they feel like they are improving? When I ask them about improving I’m not asking them, “If you’re streaming Netflix all day, are you short of breath?” I’m asking, “If you were a four-mile-a-day walker, can you walk four miles again? If you can’t, how close are you to getting to that?” So, I hear their symptoms and hear if it’s part of healing. If it is, my job is to make sure they don’t suffer a setback. That’s key here.
Why this is important is because there is another side of the coin; there are patients who are going to improperly heal. How do I differentiate [between proper and improper healing?] I still listen to symptoms. But also, this is where I look at the CAT scans, the imaging of the chest. So, if I hear a patient’s symptoms are improving, and they get the CAT scan that just [shows what] looks like scarring from the infection, I do everything possible to let them heal. But if I get that same CAT scan, and there’s no improvement after about four weeks of COVID, [and] on the CAT scan, I can see sets of active inflammation, that’s when I realize that this is improper healing. It’s not COVID-centric anymore, it’s just improper healing in the immune system.
I give them medications to shut off that improper healing, like prednisone, or steroids, essentially. The reason why this has to be a very thoughtful conversation is because if I miscalculate — if they are properly healing, and I’ve given prednisone, prednisone is going to stop that proper healing. [But] if this is improper healing, the prednisone is the right thing.
There’s one last component of all of this: One out of four patients with severe COVID develop a superinfection months or weeks later. That could be an insidious fungal infection. I have to be really cautious that that’s not what’s happening here, because if I give them prednisone, it knocks their ability to fight off that fungal infection.
Lungs that are injured, what do you do afterward? Listen to the patient and their symptoms, get some imaging of their lungs, and try to understand if their symptoms are on par with proper healing, or improper healing, or a superimposed infection. Then we battle that.
How prevalent is it to need a lung transplant due to damage caused by COVID? Can you explain the process to us?
There’s one last group — it’s not uncommon — that I’ll mention. They may develop what’s called an interstitial lung disease, a post COVID-19 interstitial lung disease. The interstitial is the lung tissue. It gets so ravaged, so scarred, that they can’t do anything, and they’re requiring lots and lots of oxygen. Now, these are sometimes patients that survived COVID. Other times, these are patients in the hospital, still fighting COVID. These are patients that we discuss either starting treatments to help with this improper scarring or even considering them for a lung transplantation. But if improper scarring is so abundant [in a person’s lungs], we call that ILD: interstitial lung disease. We try to give them not just steroids anymore; we give them actual medications targeting fibrosis. Fibrosis is the medical term for scar. We give them interventions for shutting off the scarring. If we can’t, because it keeps building up, and it’s improper scarring, then we do discuss lung transplantation with them.
Does health insurance typically cover the cost or not?
Insurance has been an issue, because what insurance doesn’t like is new things. Do you know how many times I’m on the phone, saying that my patient has post-COVID-19 lungs, and they respond, “Well, we don’t have a diagnosis for that.” No, of course they don’t. It’s new.
My frustration with insurance companies is they’re still working at the pre-pandemic pace. They haven’t adapted to the time of the pandemic, because they’ll fight me. They’ll say, “They’re not authorized for this treatment.” I respond that this is a new disease. I can’t think inside a box, because there is no box. We’re learning from these patients in real time. So, the biggest frustration of the insurance companies is they fight me. “This medication is not authorized for what you’re using it for.” I’m well aware, because this is a new disease. I will say nine out of 10 times, insurance companies approve it. One out of 10 they will [sign off], just not on the first go around.
But that’s the biggest frustration. Even when I have a peer-to-peer [with a healthcare professional working for an insurance company], they’ll ask, “How do you know this is working?” I’ll say, “I don’t. I’m trying. We’re all doing our best.” Did the doctors in the 80s who discovered AIDS have to get prior authorization? We’re doing our best. So, that’s the biggest frustration I have. It’s not so much access to insurance; it’s the inability of insurance to adapt to this time.
Since you’re the director of the tobacco treatment clinic, how would you say COVID pneumonia lungs compare to smoker lungs?
The biggest thing is a lot of these post COVID-19 lungs. A typical bad smoker’s lung got that way over 40-50 years of smoking. A COVID-19 person’s lungs got there within three months. … I think all of us have now seen smoking as the worst imaginable thing. It has robbed families of so many loved ones. [It causes] cancers and COPD (Chronic Obstructive Pulmonary Disease). COVID can make your lungs look like that in three months. Smoking got you there in 50 years. I mean, that is mind blowing. There are some subtle differences. So, I can’t say a postCOVID lung looks like a smoker lung, but the damage done is the same overall. Different parts get injured from COVID versus a smoker lung, but equally, horribly bad. It’s just one got there in 50 years, the other one got there in three months.
This interview Q&A has been edited by Hola Cultura for length and clarity. Read Part Two of this interview here.
This story was produced by Hola Cultura’s Storytelling Program for Experiential Learning. S.P.E.L. brings together young people between 16 and 25 and the organization’s professional staff to produce stories and special projects for Hola Cultura’s online magazine. Aimée Eicher and Denise Casalez The society and culture group conducted and edited the interview.
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