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Long Road to Recovery

Months after their return home, many Covid-19 patients are still fighting to heal and get back to normal. But because of premature hospital discharges and lasting lung and kidney damage, for some the fight will be even harder

By NewsChina Updated Jul.1

Workers resume construction on a skyscraper in downtown Wuhan, Hubei Province, April 24

Medical supplies are uploaded to a cargo plane at Tianjin Binhai International Airport, April 17

A Covid-19 patient is treated at Caidian District People’s Hospital in Wuhan, Hubei Province, February 6, 2020

Wu Jing, 31, was a nurse working at a tertiary hospital in Wuhan when she contracted Covid-19. Showing severe symptoms, she was hospitalized for 44 days - mostly in the ICU.  

By the time she was discharged on February 19, Wu was so weak she had to undergo two months of physical rehab.  

She does one hour of light exercise every day, but still gets short of breath with minimal exertion, like walking a little faster than normal.  

Not counting imported cases from abroad, there were around 300 Covid-19 patients in Chinese hospitals as of April 22. Less than 100 were severe patients.  

Like Wu, most of China’s nearly 83,000 confirmed cases have since left hospital. But for many, going home does not guarantee a smooth recovery.  

Hard to Breathe
Wu developed a high fever on December 27 and was taken to Wuhan Puren Hospital four days later. She was experiencing shortness of breath, and her health deteriorated over the following days. On January 4, she was transferred to Wuhan Jinyintan Hospital, a key hospital for treating Covid-19. 

She was on a ventilator in the ICU for more than a month. Fortunately, her health improved, and she moved to a general ward on February 12. One week later she tested negative and was sent home.  

However, her latest radiology report revealed severe lung damage: bronchiectasis and large blisters in both lungs. Her doctor prescribed daily oxygen therapy at home.  

“I would gasp for breath when I walked. When I’m still, my oxygen saturation remains at 93 percent (normal level), but once I move it immediately drops to 80 percent,” she told NewsChina. Shortness of breath is a problem for many former Covid-19 patients.  

On April 1, our reporter met Li Qiang, a 56-year-old Covid-19 patient at the rehab clinic of Hubei Provincial Hospital of Traditional Chinese Medicine (TCM), the first established in Hubei for discharged Covid-19 patients.  

Li arrived at Wuhan Sixth Hospital on January 18, five days after he first showed symptoms. He was discharged on February 10.  

More than two months later, Li is still struggling to breathe. “I feel short of breath as soon as I quicken my pace,” Li said.  

Before leaving hospital, Li said his doctor did not tell him about the lesions on his lungs. Li’s discharge report read there had been “evident improvement,” but during a follow-up exam on February 24, he was told the infections still covered a sizeable area of his lungs. 

“I’m really confused about the hospital’s criteria for discharge. It’s so unclear. My radiology report just says there is ‘evident improvement’ to the lesions on my lungs, which meets the standards for discharge. But to what extent the lesions have healed isn’t clear,” Li told NewsChina.  

Lin Qiping had similar concerns about his mother’s hospital discharge on March 20. In early January, Lin’s mother, who is over 70, experienced severe shortness of breath. One day, her oxygen saturation dropped from 90 percent to 70 percent. She was diagnosed with Covid-19 on January 10 and hospitalized for over two months: 24 days in the ICU and then 44 days in a general ward.  

The hospital told Lin’s mother that her discharge was “collectively decided by a group of experts.” “No severe cough, no fever, an evident improvement of respiratory symptoms,” her discharge report read.  

“But my mother is still very weak. She has labored breathing and often coughs up phlegm,” Lin said. “The doctor said that [X-rays] still show shadows in my mother’s lungs. It might take six months to a year to recover her lung function. If she doesn’t get better by then, it’s considered permanent damage.” 

‘Substantial Improvement’
In interviews with NewsChina, many patients shared the same doubts over hospital standards for discharge and have concerns about their health.  

One said he was discharged a month earlier without receiving his radiology report. He still feels a chronic tightness in his chest. “I have to take a deep breath to feel better,” he said.  

Another was informed that her lungs had improved, but she still quickly fatigues when she does housework. “I start breathing heavily hard every time I mop the floor or do something else,” she said.  

According to the seventh edition of Clinical Guidance for Covid-19 Pneumonia Diagnosis and Treatment issued by the Chinese National Health Commission, criteria for discharge include normal body temperature for three days or more, significant improvement of respiratory symptoms, a substantial improvement of acute lesions and two consecutive nucleic acid tests. 

But there is no clear consensus in the medical community on what qualifies as “substantial improvement.” 

Zheng Ruiqiang, a member of the Chinese National Health Commission and director of the ICU of the Subei People’s Hospital of Jiangsu Province, said that a radiology report showing at least 50 percent improvement is substantial enough.  

Hospitals in Shenzhen follow the city’s own treatment guideline, which defines it as a 50 percent reduction of lesion area or 50 percent decrease in lesion density.  

But many doctors said that vague discharge criteria could lead to misdiagnoses.  

Speaking to NewsChina on condition of anonymity, a doctor at a designated Covid-19 hospital in Wuhan said that many patients at the time of discharge still had problems with breathing and walking. Some, he observed, showed no obvious signs of recovery. Such loose standards put discharged patients at risk of experiencing more severe symptoms than those newly hospitalized.  

Guo Wei, an associate senior physician at the department of infectious disease, Tongji Hospital, Huazhong University of Science& Technology, said that “substantial improvement of lesions” is not a reliable metric.  

“The extent of improvement varies from person to person, which is too hard to quantify and depends solely on a doctor’s judgment,” Guo said. 

Guo said that recovery of lung functionality is a more quantifiable indicator. “Before patients leave hospital, we should make sure they do not need daily oxygen therapy and their oxygen saturation should be 95 percent or above,” Guo told NewsChina.  

He added that in early February, lack of beds and overcrowding forced hospitals to loosen their standards for discharge. Many patients like Wu Jing were sent home, even though their oxygen saturation was still low and unstable. 

Professor Luo Fengming checks a CT image in an ICU ward at Wuhan Red Cross Hospital, February 28, 2020

Rehab and Treatment
On March 16, Wu Jing went for a follow-up at the rehab clinic of Hubei Provincial Hospital of TCM. Her husband kept her company as she walked on a treadmill for six minutes.  

By the third minute, her oxygen saturation dropped to 90 percent and her average respiratory rate was 25 breaths per minute. The normal rate of an adult is 12 to 20.  

“I was so exhausted that I was panting like mad. It felt like I had just ran an 800-meter race,” Wu said.  

But after 15 days of physical rehab, a second walking test did not show any improvement in her endurance.  

“The virus has caused lung structure damage, which is very difficult to recover from fully,” Ke Jia, senior pulmonologist at the Hubei Provincial Hospital of TCM, told NewsChina.  

“But since the lesions on her lungs are not large, there’s a chance that her lung function would mostly return to normal if she continues with rehab.”  

The Shanghai Public Health Clinic Center has discharged 370 Covid-19 patients. The center opened a rehab clinic after its first patient left hospital. Most discharged patients have visited the clinic for follow-up treatment.  

Lu Hongzhou, Party Secretary of the Shanghai Public Health Clinic Center, points out that most patients with milder symptoms recover quickly and those with moderate symptoms recover within weeks. However, severe patients, who account for 5 percent of the total, have developed pulmonary fibrosis and could take years to heal. 

Besides pulmonary dysfunction, many discharged patients reported changes in their senses of smell and taste and showed abnormal blood glucose levels.  

“Normally, we can use medications to restore the patient’s blood glucose levels, but now even after four or more medications, they still don’t work,” Xiao Mingzhong, a physician at the department of infectious diseases, Hubei Provincial Hospital of TCM and head of the hospital’s rehab center, told NewsChina.  

“Our solution is to adopt multi-disciplinary treatment - apart from letting our patients undergo rehab treatment, we enlist an endocrinologist to bring their blood glucose levels under control,” Xiao told NewsChina.  

Kidney dysfunction is also a common symptom among many Covid-19 patients.  

Zheng Xia, an ICU physician at the First Affiliated Hospital of Zhejiang Medical College, was transferred to Wuhan Jinyintan Hospital as part of the Zhejiang medical team on January 23. She returned to Zhejiang on April 3.  

During her first days at Wuhan Jinyintan Hospital in January, Zheng found that four out of the six patients in her care showed a conspicuous spike in serum creatinine, an indicator of kidney dysfunction.  

In the early phases of the disease, pulmonary dysfunction and metabolic acidosis (acid accumulation in the body) from kidney lesions could be fatal. In later phases, however, many patients recovered from kidney dysfunction with treatments such as hormone therapy. 

“But we’re still uncertain whether it is the virus or the lack of oxygen that causes the kidney damage,” she said. 

“Our current understanding of Covid-19 is still superficial. There are too many unknowns,” Zheng told NewsChina. “Hormone treatments for Covid-19 patients haven’t been as widely adopted as they were during SARS in 2003. But there are many patients undergoing long-term hormone therapy, the side effects of which still need observation,” she added.