Pneumonia is the most notorious complication of the COVID-19 pandemic. It can send patients to the emergency room gasping for air, put them on ventilators and leave them in intensive care longer than previous pneumonia types. Worst of all, of the nearly 990,000 deaths from confirmed or presumed COVID-19 alone (excluding deaths from influenza), those related to pneumonia include about 513,000 Americans to date, according to the Centers for Disease Control and Prevention.
The good news is that COVID-19 vaccines and boosters now help protect vulnerable people from virus infection or complications. Both established and effective new medications can combat pneumonia early and limit damage to the lungs. Here’s what you need to know about COVID-19 pneumonia today.
What Is Pneumonia?
Pneumonia is an inflammation of the lung tissue. It’s caused by a number of viral infections, such as the influenza (flu) virus or SARS-CoV-2 — the culprit in COVID-19. Bacteria and certain types of fungus can also give rise to pneumonia.
With pneumonia, the lungs become inflamed and fill with fluid, which reduces their ability to extract oxygen from the air you breathe and send it onward to other parts of the body. According to Dr. Albert A. Rizzo, chief medical officer of the American Lung Association, patients may have a more or less severe response to pneumonia depending on several factors, including:
— Preexisting comorbidities and general state of overall health.
— How virulent the organism is.
— How heavily exposed someone is to the infectious agent. “If they came into close proximity with someone who was spewing out a lot of viral load and they inhaled a lot of droplets, that would increase their risk of more severe illness,” Rizzo says.
In some cases, COVID-related pneumonia can result from the coronavirus infection itself, or can result from a secondary infection from another virus or bacteria after infection with the coronavirus.
[READ: Latest Treatments for COVID-19.]
What Makes COVID-19 Pneumonia Different?
COVID-19 pneumonia is even more challenging than other forms of pneumonia because this particular coronavirus is extremely virulent, Dr. Jonathan Parsons, associate director of clinical services in the division of pulmonary, allergy, critical care and sleep medicine at the Ohio State University Wexner Medical Center, told U.S. News earlier in the pandemic. “Although other viruses cause pneumonia, with this virus, we’re seeing pneumonia more frequently and more severely,” Parsons said.
What’s made COVID-19 dangerous is that it’s coming from a completely new virus that humans haven’t encountered before, meaning that we have no immunity, Parsons explained. Patients were arriving at the emergency department sick but not critically ill, but then their condition would rapidly deteriorate, he said.
Now, vaccines offer protection against COVID-19 and more is known about how to treat it. Even so, COVID-19 brings added concerns. COVID-19 pneumonia tends to occur in both lungs, according to the American Lung Association. And it appears to affect the lungs for a longer time period than other forms of pneumonia.
Prolonged, persistent inflammatory action appears to be a key difference with SARS-CoV-2, says Dr. Scott Budinger, chief of pulmonary and critical care medicine at Northwestern University Feinberg School of Medicine and Northwestern Medicine in Chicago. His group’s research included comparing lung-cell samples from patients with bacterial or viral pneumonia sources including COVID-19, published in January 2021 in the journal Nature.
The COVID-19 virus attacks multiple parts of the lung, after which the infection spreads slowly but extensively throughout the lung over many days or several weeks. Damage throughout the body may therefore be longer-lasting as the devastating infection lingers.
For patients hospitalized with COVID-19 pneumonia, their average intensive care unit stays are significantly longer than what’s typical for other forms of pneumonia, making it such a devastating illness for the health care system, Budinger says. “Patients with other types of pneumonia, bacterial or viral pneumonias, historically have a median ICU stay of about four days,” he notes. “For SARS-CoV-2, that median time is 14 days.” So, having two intubated patients with COVID-19 equates to one ICU bed for an entire month.
COVID-19 Pneumonia Symptoms
How sick you get when you get any kind of infection depends in large part on how your immune system responds. Symptoms signal that the body is ramping up its immune response to fight an invading pathogen. “When you start getting a fever and a cough and mucus, that’s (signs of) the body fighting the virus,” Rizzo says.
Patients with COVID-19 pneumonia experience symptoms including:
— Shortness of breath.
— Sweating and shaking chills.
— Chest tightness.
— Nausea or vomiting.
— Confusion or changes in mental status.
Some patients go on to develop COVID-19-associated respiratory distress syndrome, a form of lung failure. With ARDS, fluid leaks into lung air sacs called alveoli. This prevents the lungs from filling with air as they should, causing levels of oxygen in the blood to decrease. Patients with ARDS sometimes need to go on a ventilator for respiratory support. ARDS, which may cause permanent lung scarring, can be fatal.
Prevention and Treatment
Vaccination has made a huge difference in preventing COVID-19 cases and reducing complications like severe pneumonia.
Once vaccination was underway, “the overwhelming majority of patients that we saw in the ICU, certainly after the fall of 2021, were unvaccinated,” Budinger says. Among vaccinated patients with COVID-19, he adds, “without exception, the only people in our intensive care unit who had severe disease were immunocompromised.”
Treatments such as monoclonal antibodies and antiviral medications also are changing the COVID-19 pneumonia picture, offering alternatives or additions to standard steroid drug regimens and treating COVID-19 before it gets to the point of severity.
Oral Antiviral Pills
In December 2021, two new oral antiviral drugs received emergency-use authorizations from the Food and Drug Administration to treat mild-to-moderate COVID-19 in patients at high risk for hospitalization:
— Paxlovid. Available by prescription, Paxlovid is taken orally twice daily for five days. Manufactured by Pfizer, it combines the antiviral drug nirmatrelvir with ritonavir, which boosts nirmatrelvir’s action. It’s indicated for adults or children ages 12 and older who are at risk for severe disease progression. Although early supplies were limited, Paxlovid is now more accessible.
— Molnupiravir. Also a prescription drug, molnupiravir is taken every 12 hours for five days. Manufactured by Merck, capsules contain the single antiviral agent. It’s indicated for adults 18 and older who are not hospitalized but are at risk for severe disease progression. Molnupiravir is not advised for use during pregnancy.
For either drug, it’s recommended to start treatment within five days of symptom onset. To fill these prescriptions, you can find pharmacies that have COVID-19 antivirals through your state’s health department website.
Baricitinib (Olumiant), is an oral drug used to treat hospitalized adult and pediatric patients who are at least two years old, and who require either supplemental oxygen, mechanical ventilation or extracorporeal membrane oxygenation, or ECMO. Baricitinib, which belongs to the drug class called janus kinase inhibitors, works by decreasing immune system activity in order to reduce inflammation.
Certain intravenous drugs are frequently used for hospitalized patients with severe COVID-19 pneumonia. In some cases, these drugs can be given in outpatient settings like clinics or doctors’ offices.
— Remdesivir (Veklury). Made by Gilead Sciences, remdesivir is an antiviral drug. Remdesivir is often given along with the steroid drug dexamethasone for hospitalized patients who require supplemental oxygen.
— Monoclonal antibodies. These drugs are laboratory-made proteins that act similarly to human antibodies made by the immune system. Patients with COVID-19 may receive the monoclonal antibody treatment tocilizumab (Actemra), an intravenous drug for severely ill patients made by Roche.
Not surprisingly, people who are treated early do better. As the pandemic continued, Budinger says, it became clear that therapies like steroids or other drugs were most effective when administered to people as soon as they came to the hospital with low oxygen levels and needed supplemental oxygen, but who didn’t yet require a mechanical ventilator.
“Stopping the inflammatory circuit early seemed to be more effective,” Budinger says. “Now we have a whole suite of tools that we can use as patients show they’re at high risk.”
Still-newer drugs to treat COVID-19 pneumonia are being developed and going through clinical trials. An experimental drug called Auxora may help patients with severe or critical COVID-19 pneumonia. The intravenous medication, manufactured by CalciMedica, based in La Jolla, California, has shown positive results in clinical trials compared to standard pneumonia care among small groups of hospitalized patients.
Auxora inhibits the harmful CRAC channel immune-system response that was identified by Budinger and colleagues at Northwestern. Now, Northwestern and other facilities are conducting mid-stage clinical trials comparing how patients on ventilators who have COVID-19 pneumonia respond to Auxora versus patients on a placebo treatment.
A study published on April 8, 2022, in the journal Critical Care found the use of Auxora was related to shorter hospital stays and lower mortality rates in patients with COVID-19 pneumonia. The study included 284 patients in 17 U.S. medical centers.
People who are admitted to the hospital with COVID-related pneumonia are offered supportive care that seeks to reduce the severity of symptoms, such as supplemental oxygen to help boost a patient’s ability to get oxygen to the rest of the body. In some cases, a bronchodilator medication can help open up the airways to improve a patient’s ability to breathe.
Certain patients may be turned onto their stomachs for part of each day to help facilitate better oxygenation. This practice, called proning, makes a difference and “goes back a number of years,” Rizzo says. It was first developed as a means of helping patients recover from acute respiratory distress syndrome.
Intubation and mechanical ventilation may also be required for some patients with COVID pneumonia. This may be helpful in cases where the patient is really struggling to breathe because their breathing muscles get too fatigued by fighting against the fluid that’s built up in the lungs.
Once that patient is on mechanical ventilation, getting them off again has proven difficult because the need for ventilator support signals that the infection is very severe and that there’s likely additional damage that’s occurred in the lungs and possibly other internal organs.
In addition, when the machine is doing the work of breathing for you, your respiratory muscles — which have already been weakened and fatigued by worsening pneumonia — may need a long while to regain adequate strength to support you breathing on your own.
Long COVID, in which COVID-19 effects last for months after the original infection passes, may affect patients who are discharged from the hospital and recovering at home. Among a multitude of effects, many patients struggle with ongoing shortness of breath and excess fatigue. Post-COVID rehabilitation can help people learn to pace themselves and slowly build back their endurance and breathing capacity.
Pneumonia: Not Going Away
In some fundamental ways, COVID-19 pneumonia is the same as its predecessors. For example, it isn’t unique in terms of which groups are more vulnerable. “Pneumonia is a disease of older adults — older adult men, historically,” Budinger says. “We actually have not seen any difference in the median age for people with COVID-19 in our ICU compared with patients with other pneumonias, and we see a similar male predominance.”
Other forms of pneumonia will likely crop up in the not-too-distant future, Budinger says. It’s important to remember that since 2000, four epidemics or pandemics with emerging respiratory viruses have occurred, he says.
Devastating viral outbreaks similar to COVID-19 (SARS-CoV-2), severe acute respiratory syndrome (SARS-CoV), Middle East respiratory syndrome (MERS-CoV) and influenza A (H1N1 and H3N2) will likely arise again, Budinger says. What’s needed now, he says, is to explore the bigger environmental and public health reasons behind why these respiratory infections keep appearing to drive preventive efforts.
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Update 04/28/22: This story was previously published at an earlier date and has been updated with new information.