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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 84-86

How to find the solution to epidemics of coronavirus induced acute respiratory syndromes?


1 Department of Ophthalmology, Narela Polyclinic and Health Complex, Delhi, India
2 Department of Ophthalmology, Maulana Azad Medical College, Delhi, India

Date of Submission02-Apr-2020
Date of Decision28-Apr-2020
Date of Acceptance05-May-2020
Date of Web Publication2-Jul-2020

Correspondence Address:
Ojasvini Bali
55-D, 3rd Floor, DDA Flats, Kalidas Road, Gulabibagh, Delhi - 110 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_34_20

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How to cite this article:
Bali J, Bali O. How to find the solution to epidemics of coronavirus induced acute respiratory syndromes?. J Clin Ophthalmol Res 2020;8:84-6

How to cite this URL:
Bali J, Bali O. How to find the solution to epidemics of coronavirus induced acute respiratory syndromes?. J Clin Ophthalmol Res [serial online] 2020 [cited 2020 Nov 27];8:84-6. Available from: https://www.jcor.in/text.asp?2020/8/2/84/288843



Dear Editor,

Coronaviruses are positive-strand enveloped nucleocapsid RNA viruses. Genomically and serologically, they are divided into four genera: alpha, beta, gamma, and delta. About 10%–30% of all upper respiratory tract infections in adults are caused by coronaviruses. Four human coronaviruses (HCoVs), namely HCoV 229E, NL63, OC43, and HKU1, have become endemic globally.[1] From the turn of the millennium, major epidemics by zoonotic HCoVs have been reported, which manifested as a severe acute respiratory syndrome in 2002–2003, which affected people with fatalities reported and the middle-east-respiratory-syndrome in 2012. The latter has been causing small epidemics is some countries. The conflict of humans with wild animals as they progressively invade the shrinking wild habitats lies at the core of these zoonotic diseases. The current pandemic was reported from a cohort of patients with pneumonia traced to Huanan Seafood Market at Wuhan, the capital of Hubei Province in China. Novel coronavirus disease 2019 (COVID-19) infections have been associated with acute respiratory distress syndrome (ARDS) requiring ventilation in 5%–10% of individuals. The incidence of complications is presumed to be higher in advanced age compared to the other age cohorts. Multi-organ dysfunction syndrome and myocarditis have also been reported in recent studies.[2]

This infection is associated with fever, shortness of breath, cough, myalgias, and high incidence of pneumonia. Background glass and infiltration in lower lobes are often seen on computed tomography. Recruitment of inflammatory cells and a “cytokine storm” both have been associated with the sudden respiratory distress that is encountered in these patients. It has been postulated that the spike protein S of COVID-19 attaches to the ACE 2 receptors in the lower respiratory tract. Lower receptor incidence in the upper respiratory tract seems to explain the predominant lower lobe manifestations. Severe exfoliation of the alveolar epithelium, alveolar septal widening, alveolar septal damage, organized alveolar space infiltration, necrosis, and pulmonary interstitial arteriolar wall damage seems to indicate that inflammatory response plays a major role in the pathology.

The management of the infection is primarily supportive. Oxygen support to maintain oxygen saturation >90% with conservative fluid management and empirical antibiotics is the mainstay of therapy. Lung protective ventilation with low tidal volume, low plateau pressure, high PEEP, and permissive hypercarbia to protect lung ventilation for getting adequate Spo2 targets is recommended. A low-volume, low-pressure ventilation protocol targeting a tidal volume of 6 ml/kg by body weight, a plateau airway pressure (pplat) of ≤30 cm H2O and SpO2 88%–93% or PaO2 55–80 mm Hg (7.3–10.6 kPa) reduced mortality in ARDS a heterogeneous population of patients.[3] Fluid management should be conservative to avoid the worsening of pulmonary edema. Ventilation is resorted to in case of ARDS as per the RDS. Net guidelines. Several vaccinations are in development, and one, “mRNA-1273” developed by the National Institute of Allergy and Infectious Diseases and Moderna Inc, has gone into phase I development also.[4] However, all these vaccines will have a long incubation period before they become available to the general public. Antivirals such as Oseltamivir, Hydroxychloroquine, Remdesivir, and Lopinavir/Ritonavir have been tried in experimental therapy, but the results are not very favorable. Extracorporeal mechanical oxygenation is a promising alternative for severe cases of ARDS.

The current efforts on ventilators and vaccines maybe a slightly misplaced strategy for this disease. There seems to be some merit in the observations that the displaced iron from heme and the free porphyrin itself may be acting as the triggers of the cytokine storm leading to an endothelial vascular thrombosis. We may be re-examining the direct endotracheal intubation and ventilation at some point of time [Figure 1], [Figure 2], [Figure 3]. Research needs to focus on the chemical mediators and management of the downstream regulator of the cytokine storm, as well as the development of better methods and easy availability of extracorporeal mechanical oxygen machines. These are essential in the interim period when the cytokine storm is being managed using pharmacological modulators.
Figure 1: Cytokine storm in coronavirus

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Figure 2: Signaling pathways in coronavirus- intracellular schematic

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Figure 3: Signaling pathways in coronavirus- leucocyte recruitment

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This is not the last zoonotic COVID we are likely to encounter. Such intense lockdown cannot be made a norm to overcome such infections. Therefore, we need to fund research into the management of the cytokine storm and making cheaper machines for extracorporeal mechanical oxygenation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
de Wit E, van Doremalen N, Falzarano D, Munster VJ. SARS and MERS: Recent insights into emerging coronaviruses. Nat Rev Microbiol 2016;14:523-34.  Back to cited text no. 1
    
2.
Hui DS, I Azhar E, Madani TA, Ntoumi F, Kock R, Dar O, et al. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health-the latest 2019 novel coronavirus outbreak in Wuhan, China. Int J Infect Dis 2020;91:264-6.  Back to cited text no. 2
    
3.
Sud S, Friedrich JO, Taccone P, Polli F, Adhikari NK, Latini R, et al. Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: Systematic review and meta-analysis. Intensive Care Med 2010;36:585-99.  Back to cited text no. 3
    
4.
NIH Clinical Trial of Investigational Vaccine for COVID-19 Begins. National Institutes of Health (NIH); 2020. Available from: https://www.nih.gov/news-events/news-releases/nih-cli nical-trial-investigational-vaccine-covid-19-begins. [Last accessed on 2020 Mar 31].  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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