Breathe 2022   Organisers: Rosalba Courtney, Tania Clifton-Smith and Scott Peirce 

 

I had been all set to go in person to this conference in Hawaii, then COVID struck and it had to be postponed. But I recently attended a fantastic on-line version of the meeting.

There was a wide range of interesting talks but for now I will focus on COVID, especially long COVID as that is what many Buteyko educators are likely to encounter.

OVERALL SUMMARY BREATHING AND LONG COVID from Breathe 2022

• Long COVID symptoms are commonly associated with breathing dysregulation
• Hyperventilation is the most common breathing problem but this is usually not suspected or tested in patients
• Mounting evidence that breathing retraining is an important part of management of long COVID syndrome
• Care must be taken not to push too hard but to pace. Even reducing breathing can cause crashes, and best to avoid cueing “air hunger” initially

And for anyone who wants more detail read on.

WHO definition of long COVID:

Post COVID-19 condition is defined as the illness that occurs in people who have a history of probable or confirmed SARS-CoV-2 infection; usually within three months from the onset of COVID-19, with symptoms and effects that last for at least two months. The symptoms and effects of post COVID-19 condition cannot be explained by an alternative diagnosis.

(Several of the speakers prefer the 4 week point for definition of long COVID).

 

Umakanth Katwa (Pediatric pulmonologist and sleep medicine Boston Children’s hospital).

He gave a great presentation on COVID and said that even though children are unlikely to get it severely, you can get occasional atypical presentation. Acute COVID can give bronchitis, interstitial pneumonia, ARDS (acute respiratory distress syndrome) and sepsis with multi organ failure (MIS-C or multisystem inflammatory syndrome in children) which can be fatal. Heart failure common and rash.

He said that long COVID should be suspected If symptoms persist for over four weeks, with the patient testing negative for COVID for at least a week.

Symptoms:

Fatigue (53%), Shortness of breath (43%), Joint pain (27%), Poor exercise tolerance dizziness, headaches, brain fog, chest pain, trouble speaking, muscle aches, loss of sense of smell, anxiety or depression POTS (postural orthostatic tachycardia syndrome), insomnia

From his earlier studies he said the incidence is 30 to 90% have long COVID at six months after the acute infection and the pathophysiology is an enigma.

He reported that risk factors for long COVID include:

Obesity, cardiac conditions, inflammatory disorders, age. It’s unclear if there’s a genetic susceptibility and it can affect anyone, they may not necessarily have had severe COVID acutely.

The most common symptoms long term respiratory symptoms are: shortness of breath (most common), persistent cough, sleep hypoxemia (especially in those with severe lung involvement), tachypnea, exercise intolerance and hyperventilation.

He quoted from a paper by Motiejunaite et al (from January 2021, Frontiers in Physiology) that suggested hyperventilation could be a possible explanation for long lasting exercise intolerance in mild COVID survivors.

He speculated on the origin of the hyperventilation:

Hyperactivity of activator systems, or failure of inhibitory systems

Consequences of alveolar hyperventilation are well known, most importantly a decrease in depolarization threshold of cell membranes that is to become “sensitised).

Neuronal hyperexcitablity, imbalance in the autonomic nervous system.

The hyperventilation in long COVID can be at baseline or intermittent or just occur with exercise. Hyperventilation induced hypocapnia can cause a multitude of extremely disabling symptoms dyspnea chest tightness, tachycardia, chest pain fatigue dizziness and syncope (fainting) at exertion.

Hypocapnia due to the Bohr effect, less oxygen released to tissues.

Hyperventilation syndrome in long COVID and anxiety, breathing dysregulation may contribute to anxiety attacks in teenagers following COVID. It’s commonly seen in children and teenagers with anxiety and panic. Evaluating breathing retraining is critically important in management of these young patients with minimal or no medications.

POTS/orthostatic intolerance/orthostatic hypotension prevalence: 10 to 40% post COVID Mechanisms of pots in COVID hypovolemia could include, fever, loss of appetite and decreased food fluid intake, cardiac deconditioning, blood pooling, autoimmunity, cytokine storm, inflammation chronic neural dysregulation, auto antibodies interact with autonomic ganglion 75% of patients with POTS positive for anti-acetylcholine receptor antibodies that could respond to immunotherapy.

Breathing rehabilitation in long COVID, 3 publications:

In patients with long COVID, exercise capacity, functional status, dyspnea, fatigue and quality of life improved after six weeks of personalised interdisciplinary pulmonary rehab (Respiration February 2022).

Pulmonary rehabilitation is a feasible safe and effective therapeutic option in COVID-19 patients independent of disease severity (ERJ Open res 2021).

Hyperventilation and symptoms of long COVID can be treated with breathing retraining and rehabilitation.

Summary:

• Long COVID symptoms are predominantly associated with breathing
• Hyperventilation is most common breathing problem but this is usually not suspected or tested in patients
• Breathing retraining is an important part of management of long COVID syndrome

Todd Davenport, (Professor in the Department of Physical Therapy at the University of the Pacific in Stockton, California) an expert in chronic fatigue or myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) presented a case study of a woman with “deconditioning” she had been sick with the respiratory virus but not hospitalised. It was 2020 so it couldn’t be confirmed as COVID. She recovered to 75% fitness for three months and then she decided to do a hard workout to kickstart her recovery and she got brain fog fever shortness of breath for three days -this is PEM Post Exertional Malaise). It’s very typical of ME/CSF and very common in long COVID. And it’s not just fatigue, it’s more than just tired. He described that with long COVID, PEM and fatigue can increase with time even when some of the respiratory symptoms are getting less. Although shortness of breath tends to persist,  pulmonary rehab can cause “crashes” and PEM by exceeding the patient’s aerobic threshold. In both long COVID and chronic fatigue syndrome you can find PEM and impaired systemic oxygen extraction (possibly related to hyperventilation?)

Two physiotherapists, Sam Holtzhausen (Cape Town) and Jessica DeMars (Canada), who specialise in pulmonary rehab reported on success stories in long COVID. Physical therapists working with people with long COVID should measure and validate the patient’s experience. Post exertional symptom exacerbation (PESE) or PME (post exertional malaise) must be considered, and rehabilitation needs to be carefully designed based on individual presentation. Beneficial interventions might first ensure symptom stabilization via pacing, a self-management strategy for the activity that helps minimize PEM.

No inspiratory muscle training if patient is unstable, normalise breathing first and watch out for PEM or you could “crash them” with breathing exercises.

Breathing retraining helps with some symptoms but is not the “cure-all”. Jessica said how she thought she could help these patients, which was true, but was not what she expected. She had to learn and re-learn, and part of what we do is to provide some support for these very challenging patients.

 

James Hall (Consultant Respiratory Physician at the Royal Brompton Hospital (RBH) and Institute of Sport Exercise and Health (ISEH), UCL) spoke on COVID in athletes

Catching acute COVID

Professional athletes and regular serious exercisers less likely to be hospitalised with acute COVID.

Risk factor for “couch potatoes” as big as those with poorly controlled diabetes! (data from ZOE study) ~9%

Long COVID:

Big deal for athletes to have symptoms that stop them competing or training for >4 weeks. 1 in 4 not ready compared with other common viruses,  only 1-20.

Actually athletes have a similar chance as the general population of getting LONG COVID, and the symptom burden and pattern similar.

He divided the breathing problems into 1)EILO, exercise-induced laryngeal spasm, 2) exercise-induced bronchospasm-after peak exercise (asthma, beta agonists effective), 3)BPD or breathing pattern disorder

Lower respiratory symptoms big problem in returning to sport (above neck symptom, loss of sense of smell, stuffy nose not too bad).

SOB (shortness of breath) 58%

Long COVID clinic

• Unexplained fatigue
• Inappropriately high heart rate in response to exercise
• Can’t catch a breath (disproportionate breathlessness).

Tidal volume erratic and high. Inefficient breathing.

Coaches must not push athletes too hard when returning them to post long COVID fitness.

 

Summary

Take home, mounting evidence that breathing retraining can help with many symptoms of long COVID, but care must be taken not to push too hard but to pace. Even reducing breathing can cause crashes, and best to avoid cueing “air hunger” initially.

A note of caution from a colleague Hadas Golan

This is my personal experience seeing many people with long COVID. Breathing retraining is not a “cure all”. We have to stay humble, and avoid oversimplifying their symptoms to hyperventilation. I think an interesting question is why do they hyperventilate (which they definitely do, I see patients with ETCO2 levels around 20mmHg)? We need to be careful not to correct hyperventilation too quickly, because it might be parafunctional (serve some function).”

One of the organisers, Dr Rosalba Courtney, had acute COVID during the meeting and shared with us that she was getting some relief with humming on the outbreath, pausing for a count of 4 before breathing in the resultant higher (presumably as humming is known to increase Nitric oxide levels in the sinuses) levels of NO that may be anti-viral.