Blind spots in the treatment of COVID-19

The operating requirement of lifeguards is to tilt the thoracic cavity of the drowning person downward and maintain an angle > 30°, otherwise it will be difficult to effectively drain the water in the lungs. It can be inferred from this that expelling the airway secretions from the patient’s lungs requires a larger tilt angle and a longer time.

How can we tell if this treatment is effective? Healthy individuals have to expectorate （or swallow into the stomach）multiple times a day. However, some patients with COVID-19 cease to expectorate by the mid stage of the disease, and are the most susceptible to the development of severe disease. Thus, the treatment is considered effective if the patient begins expectorating after adopting this method. Furthermore, the effect can be verified after multiple expectorations using CT images.

2. Combination with available mucolytics

The mucus of patients with COVID-19 is viscous and does not have the same fluid properties as the water that accumulates in the lungs of a drowning person. Hence, rapid expectoration may not be achieved by improved positional therapy alone. Therefore, the author recommends using a variety of certified mucolytics to assist this procedure. The research group headed by Jacobson found that hyaluronic acid is overexpressed in severe COVID-19, and is most likely responsible for the production of jelly-like airway secretions. Thus, we can consider using hyaluronidase, which is a certified drug that is commonly used in cosmetic surgery.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410499/

There are a number of existing certified medications that have the ability to thin viscous phlegm that can be used, including acetylcysteine, chymotrypsin, bromhexine, ambroxol, carbocisteine, erdosteine, and fudosteine. In addition, the forensic scientist Liu Liang found during autopsies that this viscous airway secretions immediately dissolved upon contact with alcohol. This is consistent with Jacobson's theory of a jelly-like mucus plug composed of hyaluronic acid hydrogel since the latter can be easily dissolved by alcohol. Therefore, patients can also try inhaling nebulized alcohol, but care must be given to the level of pain perceived by the patient as the application of alcohol can be painful to an epidermal injury, and may lead to similar results in this case.

Some studies have reported the application of the drugs listed above, but not in conjunction with the use of correct expectoration positions. Without the ciliary action of the lungs, the normal sitting and supine positions will have the opposite effect. Thus, even if the viscosity of the mucus is reduced, it will remain in the lungs without being expelled, and may even follow the direction of gravity and flow deeper down the lung. This may be because these studies overlooked the possibility of severe damage to the pulmonary cilia, resulting in a complete loss of function. Instead, they believed that once the mucus has been thinned, the body would be able to expel it spontaneously in the normal prone or kneeling position, which has been sufficient for other forms of pneumonia with less severe damage to the pulmonary cilia. However, this is not the case for patients with severe COVID-19, which is why it is important for mucolytics to be combined with proper expectoration positions.

　　Common methods of medical treatment, such as oral administration, injection, or inhalation of nebulized solutions, can all be considered for the application of mucolytics.

In addition, given the possibility of inflammation caused by the destruction of pulmonary BECs by SARS-CoV-2, the inhalation of nebulized broad-spectrum antibiotics and alcohol into the lungs should also be considered for the elimination of secondary inflammation.

3. Perform expectoration procedures in the early stages the disease.

During my discussions with medical staff about this treatment method, they were always more concerned about severely ill patients. However, I believe that the expectoration treatment should be initiated even in mild cases. This is because mildly ill patients can position themselves, whereas once they develop severe illness, they may be physically too weak or even semi-conscious, and will require the assistance of 2–3 medical staff for maintaining the required position over a long period of time. The challenge is even greater for patients on ventilator support. Hence, the delay will increase the medical costs.

　　Therefore, the author suggests that treatment with mucolytics and expectoration at a downward incline should begin as soon as the patient begins to show mild symptoms of mucus build-up, or even when they are asymptomatic, but have stopped normal expectoration, and while the patient is still capable of basic self-care. This will greatly reduce the number and probability of conversion from mild to serious illness, and also reduce the workload of medical staff.

At present, physicians tend to wait until the patient experiences difficulties in breathing before attempting induced expectoration, and this approach is incorrect. This is because patients have different physical constitutions, and some may have less severe mucus build-up, however, a small amount of accumulated mucus in the lungs for a long period may still lead to extensive bacterial and fungal growth, which will eventually induce an cytokine storm ,this is why some patients suddenly experience cytokine storms during their recovery. Therefore, regular induction of expectoration is necessary depending on whether the patient can cough up airway secretions spontaneously and the duration of their disease. Induced expectoration should be performed in all patients who have been ill for longer than a given period and are unable to achieve spontaneous expectoration. This will prevent long-term mucus build-up in the patient's lungs and the extensive growth of bacteria and fungi.

　　According to available case statistics, a higher number of patients were noted who were admitted to ICU and subsequently recovered and had more severe sequelae than patients who were asymptomatic or mildly ill. This is especially the case for pulmonary fibrosis, an irreversible condition, which does not have a specific drug regimen. This point suggests to us that intercepting the disease at the mild stage will not only reduce the mortality rate, but also the distress caused by sequelae.