dr.

Eric Daniel Tenda, DIC, PhD, SpPD, FINASIM

Division of Respirology and Critical Illness, Dept. of Internal Medicine,
Faculty of Medicine, Universitas Indonesia, RSUPN Dr Cipto Mangunkusumo.
Board of World Association for Bronchology and Interventional Pulmonology (WABIP)
 CURRICULUM VITAE
• Nama Lengkap : dr. Eric Daniel Tenda, DIC, Ph.D, SpPD, FINASIM
• Institusi :
• Divisi Respirologi dan Penyakit Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran
Universitas Indonesia RSUPN Dr. Cipto Mangunkusumo, Jakarta, Indonesia
• Pendidikan:
• Dokter Umum (2004): Fakultas Kedokteran Universitas Sam Ratulangi
• Spesialis Penyakit Dalam (2012): Fakultas Kedokteran Universitas Indonesia
• Fellow in Interventional Pulmonology (2013-2015): Malaysia, The Netherlands, United Kingdom
• Senior Clinical Research Fellow in Interventional Pulmonology and Cancer (2020): Royal Brompton
Hospital, National Heart and Lung Institute, Imperial College London, UK
• PhD in Interventional Pulmonology: National Heart and Lung Institute, Imperial College London, UK
• Jabatan :
• PIC Intervensi Pulmonologi, Divisi Respirologi dan Penyakit Kritis, Departemen IPD, FKUI-RSCM
• Ketua Research Group, Artificial Intelligence and Digital Health, The Indonesian Medical Education
and Research Institute (IMERI), FKUI.
• Board of World Association of Bronchology and Interventional Pulmonology (WABIP)
• Board Member of Screening and Early Detection, The International Association for the Study of
Lung Cancer (IASLC)
 Pandemic Timeline
WHO released EUA for
“novel coronavirus”
First case of Covid-19 in Pfizer/BioNTech vaccine
Full genetic sequence B117
reported Indonesia reported in B1351,
D614G Protein P.1 reported Indonesia B16172,
Viral pneumonia Officially named: substitution became in Japan B16173 in
case reported from Covid-19 widespread Indonesia
China

31 Dec 11 Jan 11 Feb 2 Mar Jul 31 Dec Jan Mar May

2019 2020 2021
9 Jan 13 Jan 6 Mar Oct Feb

“novel coronavirus”
identified E484K reported
in the UK
WHO distributed RT-PCR B16173
protocol of diagnostics reported in
India & B117
reported in the
UK
WHO published open database of
vaccine-related research
EDT – PIT IPD 2021 Ariel Pradipta, Eric Daniel Tenda, for Next Gene Sequencing, Genomik Solidaritas Indonesia (GSI)
 Key Question 1:
Epidemiological and
Case Definition

EDT – PIT IPD 2021

 The Scale of the SARS CoV-2 Pandemic is Tremendous
Diunduh: https://infeksiemerging.kemkes.go.id/dashboard/covid-19

Mengingat besarnya jumlah kasus COVID-19 ; Laporan Pasien Post

COVID sehubungan dengan gejala klinis yang menetap: Maka
SANGAT DIPERLUKAN SCIENTIFIC RESEARCH terkait
PASC / LONG COVID
EDT – PIT IPD 2021

But not all COVID-19 RECOVERY IS THE SAME

 Varying Definitions of When PASC Starts
• OFID: Framework of PASC estimated 3 weeks post infection

• CDC JAMA: Proposed framework of timeline --> suggests 4 weeks post

infection

• Guidelines from the UK’s National Institute for Health and Care
Excellence (NICE), the Scottish Intercollegiate Guidelines Network
(SIGN), and the Royal College of General Practitioners (RCGP).

• Their breakdown are as follows:

• Acute COVID-19: signs and symptoms of COVID-19 for up to 4 weeks

• On-going symptomatic COVID-19: signs and symptoms of COVID-19 from 4 to 12

weeks.

• Post-COVID-19 syndrome: signs and symptoms that develop or after an infection

consistent with COVID-19, continue for more than 12 weeks and are not explained by
and alternative diagnosis

EDT – PIT IPD 2021

 Post-Acute Sequelae / Long COVID-19

Subacute/ongoing symptomatic
COVID-19
Post-acute COVID-19: (4-12 weeks)
(Persistent symptoms and/or
delayed or long-term
complications of COVID-19)

Chronic/post COVID-19 syndrome

Terms: (>12 weeks)
1. Long COVID
2. Post-Acute Sequelae of SARS-SARS-CoV-2 Infection (PASC)
3. Post-Acute COVID-19
4. Chronic `COVID-19
5. Post-COVID Syndrome

Source: Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, Cook JR, Nordvig AS, Shalev D, Sehrawat TS, Ahluwalia N. Post-acute COVID-19 syndrome. Nature Medicine. 2021
Apr;27(4):601-15. EDT – PIT IPD 2021
 Source: Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, Cook JR, Nordvig AS, Shalev D, Sehrawat TS, Ahluwalia N. Post-acute COVID-19 syndrome. Nature medicine. 2021 Apr;27(4):601-15.
EDT – PIT IPD 2021
 N=300, HCW in Sweden 60 days post-compared
SARS-COV2 POSITIVE versus NEGATIVE

• 26%(Pos) versus 9%(Neg) had 1+ symptom

• 8 months? è 15% (Pos) versus 3% (Neg)

• 8-15% versus 4% said that it interfered with work

social or home life
Havervall S, Rosell A, Phillipson M, Mangsbo SM, Nilsson P, Hober S, Thålin C. Symptoms and Functional Impairment Assessed 8
Months After Mild COVID-19 Among Health Care Workers. JAMA. 2021 May 18;325(19):2015-2016.
EDT – PIT IPD 2021
 N=1600 subjects in USA 60 days post discharge

• 33% persistent symptoms

• 19% worsening symptoms
• Dyspnea (24%) ; Shortness of Breath (17%) ; Cough
(15%) ; Loss of taste or smell (12%)
Chopra V, Flanders SA, O'Malley M, Malani AN, Prescott HC. Sixty-Day Outcomes Among Patients Hospitalized With
COVID-19. Ann Intern Med. 2021;174(4):576-578. doi:10.7326/M20-5661
EDT – PIT IPD 2021
EDT – PIT IPD 2021
EDT – PIT IPD 2021
 Key Question 2:
Who Should Get Follow Up?
Who Gets PASC?
Hospitalised Outpatient

Older or 1 Week 3 Weeks

Co-Morbidities
Younger and No 1 Week NA unless new symptoms

Co-morbidities

• Please get detailed information about how COVID-19 was treated, duration of
illness, types of intervention
• NO NEED to re-test the patient for SARS-CoV-2
EDT – PIT IPD 2021
EDT – PIT IPD 2021
 Characteristics, Symptoms Clusters of Long COVID
(long-hauler) Patients

Old age Female

Require Had
hospital multisystem
assessment disease from
for the start of
symptoms illness

Source: Sudre CH, Murray B, Varsavsky T, Graham MS, Penfold RS, Bowyer RC, Pujol JC, Klaser K, Antonelli M, Canas LS, Molteni E.
Attributes and predictors of long COVID. Nature medicine. 2021 Apr;27(4):626-31. EDT – PIT IPD 2021
Characterizing the COVID-19 illness experience to inform the study of post-acute sequelae and recovery: a qualitative study
Edda I. Santiago-Rodriguez, Andres Maiorana, Michael J. Peluso, Rebecca Hoh, Viva Tai, Emily A. Fehrman, Yanel Hernandez, Leonel Torres, Matthew A. Spinelli, MonicaGandhi, J.
Daniel Kelly, Jeffrey N. Martin, Timothy J. Henrich, Steven G. Deeks, John A.Sauceda
medRxiv 2021.03.10.21253330; doi:https://doi.org/10.1101/2021.03.10.21253330 EDT – PIT IPD 2021
EDT – PIT IPD 2021
 Possible Predictors of Long COVID
“Early disease features were predictive of duration”
- Sudre et al.

Source: Sudre CH, Murray B, Varsavsky T, Graham MS, Penfold RS, Bowyer RC, Pujol JC, Klaser K, Antonelli M, Canas LS, Molteni E. Attributes and predictors of long COVID. Nature medicine. 2021 Apr;27(4):626-31.
EDT – PIT IPD 2021
 Possible Predictors of PASC / Long COVID
“Early disease features were predictive of duration”
- Sudre et al.

So, the proposed

conclusion of who may
develop PASC are:
1. Increasing age (up to 70)
2. Increasing BMI
3. Female Sex
4. > 5 symptoms during first week
of illness
5. Pre-existing; activity-limiting
conditions
6. Lower socioeconomic status

Source: Sudre CH, Murray B, Varsavsky T, Graham MS, Penfold RS, Bowyer RC, Pujol JC, Klaser K, Antonelli M, Canas LS, Molteni E. Attributes and predictors of long
EDT – PIT IPD 2021
COVID. Nature medicine. 2021 Apr;27(4):626-31.
 Key Question 3:
What is the Biology of PASC / Long COVID?

EDT – PIT IPD 2021

 PASC / Long COVID-19
Symptoms by Organs

EDT – PIT IPD 2021

Crook H, Raza S, Nowell J, Young M, Edison P. Long covid—mechanisms, risk factors, and management. bmj. 2021 Jul 26;374.
 Post-COVID-19
Pulmonary Fibrosis (PCPF)

Hypoxia and Lung Failure in COVID-19

Compensatory mechanisms to maintain oxygen delivery
such as increased respiratory effort, hypoxic EDT – PIT IPD 2021

vasoconstriction, and cardiac output are thought to

eventually lose efficacy with increasing COVID-19
severity. With a further reduction in functional lung
capacity, hypoxia becomes life-threatening and
frequently necessitates intensive care support.
• Mechanisms contributing to COVID-19 severity
include increased dead space ventilation
secondary to endothelial inflammation and
microthrombi, an elevated diffusion barrier
secondary to alveolitis and pulmonary oedema,
and right-to-left shunt formation secondary to
atelectasis, which is related to increased oedema
and fibrosis in the long term; these mechanisms
collectively reduce gas-exchange capacity.
ΔP=change in pleural pressure. ΔV=change in
volume. PaO2=partial pressure of arterial oxygen.
Osuchowski MF, Winkler MS, Skirecki T, Cajander S, Shankar-Hari M, Lachmann G, Monneret G, Venet F, Bauer M, Brunkhorst FM, Weis S, Garcia-Salido A, Kox M, Cavaillon JM, Uhle F, Weigand MA, Flohé SB, Wiersinga WJ,
Almansa R, de la Fuente A, Martin-Loeches I, Meisel C, Spinetti T, Schefold JC, Cilloniz C, Torres A, Giamarellos-Bourboulis EJ, Ferrer R, Girardis M, Cossarizza A, Netea MG, van der Poll T, Bermejo-Martín JF, Rubio I. The COVID-19
puzzle: deciphering pathophysiology and phenotypes of a new disease entity. Lancet Respir Med. 2021 Jun;9(6):622-642
EDT – PIT IPD 2021
• In conclusion, with the analysis of pulmonary
function, physical performance, oxygenation and
radiological findings four months after COVID-19 our
study adds to the growing body of evidence on post
COVID-19 trajectories.
• We identified DLCO %-predicted at four months
as the single most important factor associated
with severe/critical respiratory COVID-19 which
translates to reduced walking distance and
oxygen desaturation on exercise. EDT – PIT IPD 2021
 Tatalaksana PASC / LONG COVID

EDT – PIT IPD 2021

 Tatalaksana Long COVID

EDT – PIT IPD 2021

 Ladds E, Rushforth A, Wieringa S, Taylor S, Rayner C, Husain L, Greenhalgh T. Developing services for long COVID: lessons from a study of wounded healers. Clin Med (Lond).
EDT – PIT IPD 2021 2021 Jan;21(1):59-65. doi: 10.7861/clinmed.2020-0962. Erratum in: Clin Med (Lond). 2021 Mar;21(2):160.
Vehar S, Boushra M, Ntiamoah P, Biehl M. Post-acute sequelae of SARS-CoV-2 EDT – PIT IPD 2021 Trisha Greenhalgh et al. BMJ 2020;370:bmj.m3026
infection: Caring for the 'long-haulers'. Cleve Clin J Med. 2021 May 3;88(5):267-
©2020 by British Medical Journal Publishing Group
272. doi: 10.3949/ccjm.88a.21010. PMID: 33941600.
Source: Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, Cook JR, Nordvig AS, Shalev D, Sehrawat TS, Ahluwalia N. Post-acute COVID-19 syndrome. Nature medicine. 2021 Apr;27(4):601-15.
 Show this slide to
your patients

EDT – PIT IPD 2021

 Key Point: Take Home Points
• There is no one “PASC” or “Long-COVID”. Each patient
is unique and there are some common symptoms
clusters.
• All that “Long-Hauls” IS NOT COVID.
• Please avoid anchoring and keep differential
diagnosis broad throughout.
• The biological aspects of PASC / Long COVID is still
under investigation in multiple organ systems
• The Care of Patients with Long COVID or PASC is new
and evolving.
• A comprehensive MULTIDISCLIPINARY approach is
important to address long-term physical, pulmonary,
cognitive and mental health symptoms.
• Lots of uncertainty remains and further research will
help outline best next steps.

EDT – PIT IPD 2021

Strong Leadership and
Collaborative Efforts

eric.tenda@ui.ac.id ericdanieltenda_official
 PANDUAN PEMBERIAN HIGH
FLOW NASAL CANNULA
(HFNC)

Raoof S, Nava S, Carpati C, Hill NS. High-Flow, Noninvasive Ventilation and Awake
(Nonintubation) Proning in Patients With Coronavirus Disease 2019 With Respiratory Failure.
Chest. 2020 Nov;158(5):1992-2002. doi: 10.1016/j.chest.2020.07.013