The American College of Chest Physicians is a dedicated organization of pulmonologists, thoracic surgeons, and interested medical specialties focused on diseases of the chest. This organization is widely recognized for its work on acute and chronic respiratory failure and venous thromboembolism. It should come as no surprise that the college’s annual meeting CHEST 2020 had considerable attention on the emerging pandemic of our century.
As the COVID-19 pandemic continues to play out across the globe, the CHEST 2020 annual meeting appropriately brought the emerging science from bench to bedside. While much is understood about the virus and its transmission, much mystery remains in understanding how the virus causes this fatal disease in humans. There is an early and exponential viral replication phase which almost always occurs in the ambulatory setting. Unfortunately, the only approved antiviral therapy, remdesivir, is advised only for late-stage patients presenting typically two weeks or longer with dyspnea the need for oxygen. At this stage, the two major pathologies are not viral replication, but cytokine storm and endothelial injury and pathological micro-thrombosis. For these processes, there are supportive data for the use of corticosteroids and antiplatelet/antithrombotic agents. Because all of these treatments are only recommended for use in COVID-19 in severely symptomatic patients who are hospitalized and requiring oxygen, there remains a large treatment gap. If therapies are only applied in the hospital according to guidelines, then there is no opportunity for community treatment to reduce hospitalization and death. The treated mortality for COVID-19 requiring any form of oxygen is ~12%, and for those who require mechanical ventilation, the death rate is ~23%. Thus, the hospital and late treatment cannot be considered an adequate safety net.
The safe application of the National Institutes of Health guidelines for COVID-19 appears to be in those under age 50 years with no comorbidities. In this group, there is broad agreement that only if severe symptoms develop, no treatment is warranted. However, for those over 50 years in age, or at any age with comorbidities (including heart, lung, or kidney disease, diabetes, obesity, and cancer) ahead of the results of clinical trials, it is prudent to employ an ambulatory regimen to reduce the risk of hospitalization and death. This calls for the immediate use of at least two safe off-target antivirals (zinc sulfate, hydroxychloroquine, ivermectin, azithromycin, or doxycycline). At day five, or during the onset of pulmonary symptoms, corticosteroids should be used (inhaled budesonide, prednisone, hydrocortisone, and dexamethasone). In those with heart or lung disease, or patients with high thromboembolic risk, low-molecular-weight heparin or a novel oral antithrombotic should be prescribed. This approach advances treatment that would have started in the hospital into the home and on an emergency basis, is believed to have a reasonable chance of reducing hospitalization or death. Future CHEST meetings are expected to update the audience on the rapid pace of clinical trial reports concerning early ambulatory therapy for COVID-19, which is the only treatment approach that has the possibility of reducing hospitalization and its complications, including death.
In conclusion, the American College of Chest Physicians has taken a leadership role in understanding and responding to the COVID-19 pandemic. It is becoming clear that contagion control has failed to quash the viral outbreak and that we must turn our attention to immediate-early treatment to reduce the burgeoning tide of acutely ill patients in the community before hospitalization is needed. Prompt ambulatory treatment is an important pillar of global pandemic response that should have an equal policy and press visibility along with contagion control, late-stage treatment, and vaccination.
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