Impact of COVID 19 infection on cardiopulmonary functions of a cohort of national level athletes in Sri Lanka

Limited evidence exists regarding adverse effects on cardiovascular and pulmonary function in adults affected by covid 19 infection. We describe the cardiopulmonary functions in a cohort of national level athletes with recent covid infection. 42 healthy athletes were evaluated after at least a 10-day period of quarantine after mild covid infection.44% females [n=19] and 56% males [n=23]. The age range was 15 - 38 years. The commonest persistent symptoms were difficulty in breathing (4.8%), cough (7%) and chest tightness (4.8%). PCFS (post covid functional score) was 0 in 93%. The CXR and 6-minute walk test were normal in all. The spirometry was normal in 83% (n=35). The mean FEV1 were 2.68l and 3.75l;mean FVC were 3.09l and 4.6l in females and males respectively. The mid expiratory flow rate (FEF 25-75) was less than the predicted lower limit of normal in 52.4%(mean=2.8L). Cardiac abnormalities were detected in 7%;moderate interventricular septal dyssynchrony, global hypokinesia with mild LV dysfunction and mild pulmonary hypertension. 13 players with persistent difficulty in breathing and chest tightness who had otherwise normal spirometry and echo were referred for CPET. Only 6 players had CPET due to limited resources: evidence of deconditioning (n=3) and cardiac limitation with poor O2 pulse (n=3). 78% (n=33) had normal cardiopulmonary assessment and were referred for graduated return to practice. Abnormalities were identified in 21% (n=9). Mid expiratory flow was reduced in 53% indicating possible effect on peripheral airways post covid. Evaluation of athletes and guidelines on return to practice after covid infection are an important and timely need.

Evaluation of functional capacity by cardiopulmonary exercise testing in patients with postCOVID19 syndrome

Introduction: The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), has become a major health problem worldwide. In certain patients, the symptoms associated with SARS-CoV-2 infection persist beyond twelve weeks from the onset of the disease, so the objective of this study was to assess the functional capacity of these patients using the cardiopulmonary exercise test (CPET). Method(s): Single-center retrospective study conducted in patients who suffered from COVID-19 and presented dyspnea and/or persistent exertional fatigue after infection. The clinical characteristics of the included patients and the parameters of the CPET were evaluated, between March and December 2021. Result(s): CPET was performed on 18 patients who met the inclusion criteria. The mean time from the date of diagnosis of COVID-19 infection and the performance of the CPET was 468 +/- 129 days. Demographic characteristics are shown in figure 1. When analyzing lung function, all of them presented normal spirometry and a mean diffusion of 83.4 +/- 14.16%. Overall, a poor training index was observed in 61.1% together with ventilatory inefficiency in 55.4% of the patients [CO2 equivalents were elevated (> 35)]. No cardiovascular or metabolic alterations were observed. Conclusion(s): Our data suggest that patients who have suffered from COVID-19 and persistent fatigue and dyspnea, have ventilatory inefficiency in approximately 55% of cases, along with significant physical deconditioning.

Falls Prevention: Community Exercise Programme, Reducing Risk of Falls, Deconditioning and Loneliness in Frail Elderly Patients

Introduction Covid has had a devastating effect on the Elderly, resulting in deconditioning, increased falls and loneliness. Tailored exercises can reduce falls in people aged over 65 by 54% and participation in physical activity reduces the risk of hip fractures by 50%, currently costing the NHS 1.7 billion per year in England. This 8-week intervention delivered by trained volunteers in patient's homes, aims to reduce deconditioning, loneliness and the risk, incidence and fear of falling (FOF) amongst frail patients post-discharge from hospital. Method A gap in service was identified in Frail patients discharged from hospital, at risk of falling and awaiting community physiotherapy. A steering group was set up including acute and community therapists, volunteers and carers to design a collaborative intervention to bridge the gap. At risk patients were identified and referred by ward therapists supported by the hospital volunteering team. Volunteers were trained to deliver an 8 weeks programme of progressive exercises in patients' homes with additional signposting to appropriate statutory and voluntary services. Qualitative and quantitative outcome measures were taken at week 1 and week 8 of the intervention Results 91.5% total health outcomes improved or maintained by average: - FOF reduced by 22.5% - 180 degree turn improved by 43% - 60 sec Sit to Stand improved by 14.75% - Timed Up And Go improved by 15.5% - Confidence to cope at home improved by 15% - Pain / discomfort (self-reported) improved by 18.75% - Overall health (self-reported) improved by 8.5% Conclusion(s) Targeted exercise at home with skilled volunteers can improve functional fitness and health outcomes in a frail elderly population at risk of falls when discharged home from hospital. The programme increases patients' connectivity to local voluntary and community sector services. Volunteers' mental health improves by engaging in meaningful service.

Persisting exertional dyspnea and perceived exercise intolerance after mild Covid-19: a critical role for breathing dysregulation?

Background: After mild Covid-19, a subgroup of patients reports post-acute sequelae of Covid-19 (PASC), in which exertional dyspnea and perceived exercise intolerance are common. Underlying pathophysiological mechanisms remain incompletely understood. We studied outcomes from cardiopulmonary exercise test (CPET) in these patients. Method(s): In this observational study, we included patients referred for the analysis of PASC after mild Covid-19 in whom CPET was performed after standard clinical work-up turned out unremarkable. Cardiocirculatory, ventilatory and metabolic response to, and breathing patterns during exercise at physiological limits were analyzed. Result(s): Twenty-one patients (76% female, mean age 40y) who reported severe fatigue (CIS-fatigue >= 35), dyspnea (mMRC 2 (IQR1-2)) and disability in physical role functioning (SF-36) underwent CPET at 32 weeks (IQR 22-52) after Covid-19. Mean peak oxygen uptake was 99% (SD13) of predicted with normal anaerobic thresholds at 62% (SD11) of predicted oxygen uptake. No cardiovascular or gas exchange abnormalities were detected. Twenty out of the 21 patients (95%) demonstrated breathing dysregulation, existing of ventilatory inefficiency (29%), abnormal course of breathing frequency and tidal volume (57%), and acute or chronic respiratory alkalosis in resting blood gases (67%). Conclusion(s): In the absence of deconditioning, breathing dysregulation may explain the experienced exertional dyspnea and exercise intolerance in patients with PASC after mild Covid-19.

Motor and Sensory Balance Deficits Seen in People Immediately Following Covid-19

PURPOSE/HYPOTHESIS: Patients with cardiorespiratory dysfunction, such as COPD, have postural instability and increased risk of falls compared to age matched controls. Given that COVID-19 is defined as a respiratory condition, it could be presumed that these patients may demonstrate the same balance deficits. Ninety percent of patients with a history of COVID-19 report at least one neurological symptom, and these neurological symptoms could potentially result in alterations in balance. The act of maintaining upright posture or balance depends on both sensory and motor responses. It has been previously demonstrated that people post-COVID have motor and sensory balance deficits including vestibular dysfunction after leaving the acute care institution. The purpose of this study was to determine and characterize balance in patients COVID recovered (off airborne isolation but not discharged from the hospital). NUMBER OF SUBJECTS: Twenty-five subjects were recruited. Mean age was 55.6 +/- 11.3 years, 17 males, 8 females, mean length of time since diagnosed with COVID-19 was 34 +/- 15 days. All subjects had a primary or secondary diagnosis of COVID-19 during hospitalization and were considered COVID recovered (off-airborne isolation but not discharged from the hospital) and were receiving care in an acute inpatient hospital. MATERIALS AND METHODS: Following consent, subjects completed the Activityspecific Balance Confidence Scale (ABC), a questionnaire about symptoms of dizziness, the Timed Up&Go (TUG) and the modified Clinical Test of Sensory Interaction and Balance (mCTSIB). Subjects had vital signs monitored before, during, and after the examination. RESULT(S): There were no differences in clinical test scores based on age (<65 or >=65) or order of testing. Using age appropriate normative scores, all subjects had abnormal scores on the TUG indicating difficulty with motor balance, 88% had abnormal scores on the ABC indicating low confidence in performing balance activities, and 48% of the subjects had abnormal scores on Condition 4 of the mCTSIB indicating difficulty using vestibular information for balance. There was no correlation between the clinical test scores and age, length of time with COVID-19, or O2changes during testing. Surprisingly, there was no correlation between the scores on the clinical balance tests. CONCLUSION(S): Both young and older adults present with motor and sensory balance deficits acutely following a COVID-19 infection. Subjects have low perceptions of their ability to balance that may impact their function as they are discharged. CLINICAL RELEVANCE: People acutely post-COVID-19 may have balance deficits. These deficits may be due to immobility and deconditioning. It is recommended that people acutely post COVID-19 receive education and interventions to increase mobility, improve balance, and specifically receive activities that stimulate the vestibular system. It is also recommended that people acutely post-COVID-19 have these balance deficits and perceptions of balance function be considered in discharge planning.

Lung scintigraphy with SPECT/CT in the assessment of post COVID-19 respiratory complications

Aim/Introduction: The evolution of the COVID-19 pandemic has led to the appearance of a spectrum of pulmonary parenchymal and vascular pathology related to the disease, including the development of fibrosis and chronic thromboembolic disease. The aim of this study is to assess the utility of lung scintigraphy with SPECT/CT in the respiratory complications in post-COVID patients. Material(s) and Method(s): Retrospective-prospective study that included 55 consecutive patients aged 27 to 84 years (55+/-11 y.o., 31 women) from April/2020 to January/2022, from two nuclear medicine centers in Uruguay and one in Argentina. Patients presented with dyspnea (n=52), chest pain (n=1), right heart failure (n=1) or O2 desaturation (n=1). Lung scintigraphy with 99mTc-MAA included planar images and SPECT/CT of the chest. Twenty-three patients underwent ventilation scintigraphy with 99mTc-DTPA. All the patients had a negative RT-PCR test for SARS CoV-2. Result(s): Most common risk factors included age > 55 years in 29 patients, diabetes in 10, obesity in 18 and hypertension in 30. Nine patients had asthma or COPD. Thirty-eight patients required hospitalization (8 in moderate care, 23 in ICU). All patients required O2 and received thromboprophylaxis during the illness. Only 4 patients had D-dimers, elevated in all of them. Six patients had Doppler ultrasound, negative in all of them. Seven patients had previous CT angiography, positive in 2. SPECT/CT was positive for pulmonary embolism (PE) in 10 patients (18%). Nine of them had ventilation studies. All presented typical segmental and/or subsegmental V/Q mismatches predominantly in the upper lobes and middle lobe. Thirteen patients (24%) presented matched defects, 11 of them with structural alterations on CT. CT abnormalities consisted of a reticular pattern with ground glass areas, consolidation foci and bilateral bronchiectasis. Two patients presented pleural effusion and 1 pericardial effusion. 3 patients with mismatched defects associated CT alterations. In clinical follow-up, all patients positive for PE were anticoagulated and improved after treatment. None of the patients presented PE during the acute phase of the disease. Conclusion(s): SPECT/CT lung scintigraphy is a useful tool to identify PE in patients with post-COVID syndrome. Beyond its advantages in the detection of small-vessel defects and the evaluation of chronic PE compared to CT angiography, the hybrid technique can demonstrate persistent pulmonary alterations that may explain the symptoms, separating the hemodynamic sequelae of deconditioning from limitations related to respiratory dysfunction in a new clinical situation that has the potential to become a public health problem.

Infectious Complications of Lung Transplant for COVID-Associated Lung Injury (CALI)

Background. More than 200 orthotopic lung transplants (OLT) have been performed in the United States for patients (pts) with severe CALI. While some outcomes have been reported to generally be good, we conducted this study to describe the infectious outcomes. Methods. After IRB approval, a retrospective case review was conducted of pts at Northwestern Memorial Hospital who had undergone OLT for CALI between June 1, 2020 and January 31, 2022. Data was collected from our Enterprise Data Warehouse and primary chart review to describe pts demographics and epidemiology of infectious complications. Results. 35 OLTs were included (33 bilateral, 2 single lung;see Table 1). In the two weeks prior to transplant, 65.7% of pts were treated for bacterial, fungal, or mycobacterial infections (Table 2). Post-transplant, 32 (91.4%) of OLTs developed infections (Table 2), with most (28, 80%) developing pneumonia within 30 days of transplant. Five (14.3%) pts had airway complications, 7 (20%) pts required hemodialysis, and 3 (8.6%) pts died within one year of follow-up. Conclusion. Infections remain a significant cause ofmorbidity post-OLT forCALI. Enhanced immunosuppression, long ICU stays post-tx, high rates of primary graft dysfunction and deconditioning likely contributed to this high rate of infection. A matched control group is being collected to compare these outcomes to other OLT pts. (Figure Presented).

[Functional evaluation in patient with critical SARS-CoV-2 disease: Cohort study in a third level hospital rehabilitation unit]. / Evaluación funcional tras SARS-CoV-2 crítico. Estudio de cohortes de la unidad de rehabilitación en un hospital de tercer nivel.

INTRODUCTION: SARS-COV-2 pneumonia is a highly contagious respiratory disease that causes respiratory, physical and psychological dysfunctions. We present the results of patient assessment when they were discharged from the ICU. MATERIAL AND METHOD: Cohort study of patients affected by SARS-COV-2 pneumonia admitted to the intensive care unit from 01/10/2020 to 31/07/2021. We collect sociodemographic data, personal history, ICU and hospital stay, Barthel, FAC and mMRC (pre-admission/initial assessment/discharge), development of osteomuscular and/or neurological pathology and need for rehabilitation treatment. RESULTS: A total of 341 patients were evaluated, of which 224 met criteria. The average age was 63 years (68.75% men). Mean ICU/hospital stay were 27/44 days. They were assessed by physiatry, after that, we provide a guide developed by physiatry, solving doubts about the disease and setting exercises of intensity and progressive difficulty, to be carried out during the admission and at home. Neurological pathology was present at 42.86% patients, of whom a 83.33% were peripheral nervous system disease. The total of the sample needed respiratory physiotherapy and a 72.32% motor physiotherapy. CONCLUSIONS: In our study, a high number of patients have needed rehabilitation treatment in order to get functional recovery, highlighting the development of post-COVID neurological pathology. SARS-COV-2 generates other complications, not only respiratory, subsidiary to be assessed and treated by rehabilitation services for a comprehensive recovery that minimizes sequelae.

An Exercise Prescription as a Novel Management Strategy for Treatment of Long COVID.

Mechanisms causing the post-acute sequelae of SARS-CoV-2 (long COVID) remain elusive, but the clinical phenotype is consistent with cardiac deconditioning. We report a case series of patients with long COVID whose symptoms improved/resolved with exercise and present exercise training as a novel therapeutic strategy for management of long COVID syndrome. (Level of Difficulty: Intermediate.).

Cardiopulmonary Exercise Testing Distinguishes between Post-COVID-19 as a Dysfunctional Syndrome and Organ Pathologies.

(1) Background: Dyspnea is one of the most frequent symptoms among post-COVID-19 patients. Cardiopulmonary exercise testing (CPET) is key to a differential diagnosis of dyspnea. This study aimed to describe and classify patterns of cardiopulmonary dysfunction in post-COVID-19 patients, using CPET. (2) Methods: A total of 143 symptomatic post-COVID-19 patients were included in the study. All patients underwent CPET, including oxygen consumption, slope of minute ventilation to CO2 production, and capillary blood gas testing, and were evaluated for signs of limitation by two experienced examiners. In total, 120 patients reached a satisfactory level of exertion and were included in further analyses. (3) Results: Using CPET, cardiovascular diseases such as venous thromboembolism or ischemic and nonischemic heart disease were identified as either cardiac (4.2%) or pulmonary vascular (5.8%) limitations. Some patients also exhibited dysfunctional states, such as deconditioning (15.8%) or pulmonary mechanical limitation (9.2%), mostly resulting from dysfunctional breathing patterns. Most (65%) patients showed no signs of limitation. (4) Conclusions: CPET can identify patients with distinct limitation patterns, and potentially guide further therapy and rehabilitation. Dysfunctional breathing and deconditioning are crucial factors for the evaluation of post-COVID-19 patients, as they can differentiate these dysfunctional syndromes from organic diseases. This highlights the importance of dynamic (as opposed to static) investigations in the post-COVID-19 context.

Therapeutic Exercise Protocols for People Recovering After Covid-19: A Tele-Health Approach

Post-Covid-19 syndrome occurs in at least half survivors, that claim to suffer from a mild to severe deconditioning syndrome, fatigue, muscle wasting and pain, dizziness, very low tolerance to minimal efforts, depression and anxiety, when they not will suffer from post-critical neurological syndrome and peripheral neuropathies. Telemedicine and telerehabilitation could be decisive solutions to safely take care and follow these patients in the recovery phase, as well as to alleviate the burden of healthcare structures, in order to reach the majority of people and in the presence of the need for social distancing. The study aims at verifying the feasibility and level of users’ satisfaction of a tele-health service that provide therapeutic education protocols for people recovering from Covid-19. An average of 350 accesses per day have been registered on the platform since 31 March to 30 June 2020. 50 people answered the users’ satisfaction questionnaire and declared no side effects and a good effectiveness (median 7.5/10) to manage fatigue and anxiety. Most subjects (66%) were people hospitalized for Covid-9 and discharged home (32,6%,) or exclusively treated at home (27,6%), instead, 11,6% of subjects were still convalescent in hospital. In conclusion, tele-health was appreciated, safe and possibly useful to integrate rehabilitative management of subjects recovering from Covid-19. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Exercise performance before and after introduction of elexacaftor/tezacaftor/ivacaftor (Kaftrio®) in Scottish children with cystic fibrosis: a 2-centre retrospective study

Objectives: Elexacaftor/tezacaftor/ivacaftor (ETI) combination therapy - Kaftrio® was approved for use in the UK in August 2020 for those aged >12 years. Our study aimed to study the effects of ETI therapy on lung function and exercise performance. Methods: Two-centre retrospective analysis of clinical data obtained during patients’ annual review assessments. Patients had undergone spirometry and static lung volume measurements followed by an incremental maximal ramp cardiopulmonary exercise testing (CPET) performed on a cycle ergometer. Data were analysed using a paired sample t-test. Results: Lung function improvement did not reach statistical significance. Of note, four patients had a baseline (pre-ETI) FEV1 belowthe lower limit of normal (LLN <-1.64 Z scores), and one improved their FEV1 from 41% predicted to 87% with Kaftrio®. Five had a VO2peak% predicted below the LLN (< 85% predicted) prior to treatment and 8 post treatment. Therewas a significant fall in VO2peak % predicted, p = 0.03. However, this was not seen in the VO2peak relative to bodyweight, p = 0.07. There was also a significant fall in VO2 at anaerobic threshold (AT) as a % of predicted VO2peak, p = 0.01. Table 1. (Table Presented) (Table Presented) Conclusions: This real-world study suggests Kaftrio® does not improve exercise capacity in the majority of CF patients. It is hypothesised that the lack of improvement may be due to a reduced physical activity over the study period as a result of feeling better on Kaftrio® and also the SARSCoV2 pandemic. The decrease in VO2 at AT would support the hypothesis of physical deconditioning. The reasons for not seeing statistical differences in lung function are likely to represent the relatively high baseline FEV1 alongside small study numbers. In summary, whilst having the potential to be a performance-enhancing drug, performance gains on Kaftrio® can only occur if matched by training, and studies to investigate the training potential of Kaftrio® are required.

Telerehabilitation program for older adults on a waiting list for physical therapy after hospital discharge: study protocol for a pragmatic randomized trial protocol.

BACKGROUND: Delays in starting physical therapy after hospital discharge worsen deconditioning in older adults. Intervening quickly can minimize the negative effects of deconditioning. Telerehabilitation is a strategy that increases access to rehabilitation, improves clinical outcomes, and reduces costs. This paper presents the protocol for a pragmatic clinical trial that aims to determine the effectiveness and cost-effectiveness of a multi-component intervention offered by telerehabilitation for discharged older adults awaiting physical therapy for any specific medical condition. METHODS: This is a pragmatic randomized controlled clinical trial with two groups: telerehabilitation and control. Participants (n=230) will be recruited among individuals discharged from hospitals who are in the public healthcare system physical therapy waiting lists. The telerehabilitation group will receive a smartphone app with a personalized program (based on individual's functional ability) of resistance, balance, and daily activity training exercises. The intervention will be implemented at the individuals' homes. This group will be monitored weekly by phone and monthly through a face-to-face meeting until they start physical therapy. The control group will adhere to the public healthcare system's usual flow and will be monitored weekly by telephone until they start physical therapy. The primary outcome will be a physical function (Timed Up and Go and 30-s Chair Stand Test). The measurements will take place in baseline, start, and discharge of outpatient physical therapy. The economic evaluations will be performed from the perspective of society and the Brazilian public healthcare system. DISCUSSION: The study will produce evidence on the effectiveness and cost-effectiveness of multi-component telerehabilitation intervention for discharged older adult patients awaiting physical therapy, providing input that can aid the implementation of similar proposals in other patient groups. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (ReBEC), RBR-9243v7 . Registered on 24 August 2020.

Disorders of Taste and Olfaction by COVID- 19- Patients- A functional and morphological Study

Purpose We investigated the prevalence of smell and/or taste loss and the clinical characteristics and recovery in a cohort of consecutive patients treated by two COVID-19 reference hospitals and evaluated the late persistence of hyposmia. Material and Methods 53 consecutive RT-PCR diagnosed patients (23 males, 30 females, 42,54 ± 10, 95 years) who had been hospitalized between January- June 2021 in the COVID-19 care wards were contacted, excluding patients with cognitive disorders and severe deconditioning. These patients (Group A) have been examined twice, once direct after leaving the hospital, and once again 4-6 weeks later. The patients- nasal and oral mucosa (Fungiform Papillae on tongue-s tip-fPap) were examined with a contact endoscope. Their olfaction was also examined with Sniffin' Sticks. As control-group we have examined 53 healthy subjects (Group B). Results Significant alterations in form and vascularization of fPap have been detect, specially by the first examination. Patients EGM-Thresholds of both measurements are higher than those of healthy subjects, although those of the second one are clearly lower. The same results have been found using Schniffin- Sticks. Discussion Our findings suggest that COVID-19 can produce a mild to profound neuropathy of multiple cranial nerves, which are responsible for the regeneration of fPap and the transmission of the chemical stimuli.

Impact of Covid-19: Preserving Services for Patients with Multiple Sclerosis during a Global Pandemic

Objective: To survey the impact of the Covid-19 pandemic, (April 2020-April 2021), on access to specialist care for people with multiple sclerosis (PwMS) within the Belfast Health and Social Care (HSC) Trust. Background: The challenges of healthcare service provision have been significantly heightened during the covid-19 pandemic. For PwMS, access to healthcare is of permanent importance, and has been greatly challenged during this timeframe. Design/Methods: In March/April 2021, we posted an anonymised survey to 2342 pwMS receiving care in the Belfast HSC Trust. Data was analysed on returns received by mid-May 2021. Results: In total, 1072 (45.8%) pwMS responded, mean age 53 years, female: male 2.6:1. Of these, 895 (84.2%) were ambulant with or without aid. Wheelchair use was reported in 14.6%. Relapsing remitting MS, Secondary progressive MS and primary progressive MS patients made up 67.7%, 15.5% and 5.9% of indicative responses, respectively. In all, 179 (17%) experienced a confirmed relapse during the pandemic, with 37.4% of these receiving steroids. Perceived delays in appointments were most frequent in: clinic review (17.9%), imaging (13.3%), physiotherapy (11.6%). Over half (52.8%) reported no delays. In total, 64.5% were taking disease-modifying therapy (DMT), most frequently: dimethyl fumarate (34.9%), betainterferon (18.0%), teriflunomide (12.4%). With new DMT commencement during the pandemic, 11.5% experienced delay. In those already DMT-established, 6.6% had a delay with infusion, 4.3% in switching DMT, whilst 89% experienced no delay. Only 2.0% of pwMS on DMT had their treatment stopped directly due to Covid-19. During the pandemic, 13.8% pwMS reported difficulty contacting the MS team, while 40.7% reported physical deconditioning. A majority (88%) had received a covid-19 vaccine dose. Conclusions: Whilst most patients experienced normal standard care, Covid-19 has impacted service provision for some pwMS, with delays reported across a multi-faceted service. The downstream effects of this may be seen moving beyond the pandemic.

Review of Integrative Therapies for Management of Post-COVID Dysautonomia

Methods: We reviewed reports of post COVID dysautonomia and management strategies pursued to understand best practices and provide a primer for clinicians to guide patient management. We reviewed the literature for case reports of post COVID dysautonomia and compiled the cases into a table. Treatment approaches and outcomes were aggregated into an algorithm for management guidance. Results: Ten studies regarding post COVID dysautonomia were reviewed. Strategies included conservative approaches such as fluids, salt consumption, compression stockings, abdominal binders and head of bed elevation as well as strength building such as yoga, resistance exercise, and recumbent physical activity. Moreover, psychosocial support including cognitive behavioral therapy, biofeedback, and support groups were emphasized along with pharmacologic remedies such as midodrine, ivabradine, fludrocortisone, intravenous immunoglobulin, gabapentin, and topical lidocaine in additoin to interventions such as enhanced external counterpulsation. Primary and secondary outcomes included self-report surveys, autonomic laboratory testing, hand grip strength and heart rate variability. Background: Growing numbers of cases of dysautonomia after acute COVID-19 infection are being reported involving previously healthy patients. This post-COVID dysautonomia is predominantly characterized by lingering neurologic and cardiovascular dysfunction including tachycardia, orthostatic intolerance, migraine, exercise intolerance, fatigue, and cognitive impairment. Anxiety, insomnia, and uncertainty surrounding the COVID-19 pandemic present additional risk factors for sympathetic overdrive and deconditioning. Best management strategies and practice guidelines for this patient population remains unknown. Conclusion: Our review suggests consideration of an integrative, multimodal treatment approach involving physical activity, mental well-being, nutrition, stress management, and medication. These primarily facilitate management of dysautonomia, but rarely lead to complete symptom resolution. Despite the uncertainty associated with post-COVID dysautonomia, patient validation, education, and lifestyle approaches provide the cornerstone of management. Since post-COVID dysautonomia will comprise an increasing number of care consultations, clinician awareness, prompt diagnosis, and personalized management are essential.

INFLAMMATION, EXERCISE CAPACITY, CHRONOTROPY, and SYMPTOMS in POST-ACUTE COVID-19

Background: Cardiopulmonary symptoms and reduced exercise capacity can persist after SARS-CoV-2 infection. Mechanisms of post-acute sequelae of COVID-19 ("PASC" or "Long COVID") remain poorly understood. We hypothesized that systemic inflammation would be associated with reduced exercise capacity and pericardial/myocardial inflammation. Methods: As part of a COVID recovery cohort (NCT04362150) we assessed symptoms, biomarkers, and echocardiograms in adults >2 months after PCR-confirmed SARS-CoV-2 infection. In a subset, we performed cardiac magnetic resonance imaging (CMR), ambulatory rhythm monitoring (RM), and cardiopulmonary exercise testing (CPET) >12 months after acute infection. Associations between symptoms and oxygen consumption (VO2), cardiopulmonary parameters and biomarkers were evaluated using linear and logistic regression with adjustment for age, sex, BMI, and time since infection. Results: We studied 120 participants (median age 51, 42% female, and 47% had cardiopulmonary symptoms at median 7 months after acute infection). Elevated hsCRP was associated with symptoms (OR 1.32 per doubling, 95%CI 1.01-1.73, p=0.04). No differences in echocardiographic indices were found except for presence of pericardial effusions among those with symptoms (p=0.04). Of the subset (n=33) who underwent CMR at a median 17 months, all had normal cardiac function (LVEF 53-76%), 9 (27%) had pericardial effusions and none had findings suggestive of prior myocarditis. There were no differences on RM by symptoms. On CPET, 33% had reduced exercise capacity (peak VO2 <85% predicted). Individuals with symptoms had lower peak VO2 compared to those reporting recovery (28.4 vs 21.4 ml/kg/min, p=0.04, Figure). Elevated hsCRP was independently associated with lower peak VO2 after adjustment (-9.8 ml/kg/min per doubling, 95%CI-17.0 to-2.5;p=0.01, Figure). The predominant mechanism of reduced peak VO2 was chronotropic incompetence (HR 19% lower than predicted, 95%CI 11-26%;p<0.0001, Figure). Chronotropic incompetence on CPET correlated with lower peak HR during ambulatory RM (p<0.001). Conclusion: Persistent systemic inflammation (hsCRP) is associated with pericardial effusions and reduced exercise capacity > 1 year after acute SARS-CoV-2 infection. This finding appears to be driven mainly by chronotropic incompetence rather than respiratory compromise, cardiac pump dysfunction, or deconditioning. Evaluation of therapeutic strategies to target inflammation and/or chronotropy to alleviate PASC is urgently needed.

Post-COVID-19 perspectives: Pulmonologists’ point of view

More than 5 millions of people in France have presented a SARS-CoV-2 infection. In the previous coronavirus epidemics (SARS-CoV, Mers-CoV), patients have developed pulmonary sequelae with dyspnoea, DLCO decrease and/or fibrosis lesions. The purpose of this review was to evaluate the respiratory sequelae and to do a summary of the main respiratory symptoms after a COVID-19 infection and their aetiologies. The four main causes of dyspnoea are respiratory sequelae, deconditioning, hyperventilation and classical causes of dyspnoea. The main respiratory sequelae were DLCO alteration and fibrosis pattern. Actually, the prevalence of these respiratory sequelae is unknown.

Perspectives post-COVID-19 : le point de vue des pneumologues

Résumé Plus de 5 millions de personnes en France ont présenté une infection par le SARS-CoV-2. Lors des précédentes épidémies de coronavirus (SARS-CoV, Mers-CoV), les patients ont développé des séquelles pulmonaires avec une dyspnée, une diminution de la capacité de diffusion du monoxyde de carbone et/ou des lésions de fibrose. Le but de cette revue était d’évaluer les séquelles respiratoires et de faire une synthèse des principaux symptômes respiratoires après une infection au COVID-19 et de leurs étiologies. Les quatre principales causes de dyspnée sont les séquelles respiratoires, le déconditionnement, l’hyperventilation et les causes classiques de dyspnée. Les principales séquelles respiratoires étaient l’altération de la capacité de diffusion du monoxyde de carbone et le schéma de fibrose. La prévalence de ces séquelles respiratoires est actuellement inconnue. Summary More than 5 millions of people in France have presented a SARS-CoV-2 infection. In the previous coronavirus epidemics (SARS-CoV, Mers-CoV), patients have developed pulmonary sequelae with dyspnoea, DLCO decrease and/or fibrosis lesions. The purpose of this review was to evaluate the respiratory sequelae and to do a summary of the main respiratory symptoms after a COVID-19 infection and their aetiologies. The four main causes of dyspnoea are respiratory sequelae, deconditioning, hyperventilation and classical causes of dyspnoea. The main respiratory sequelae were DLCO alteration and fibrosis pattern. Actually, the prevalence of these respiratory sequelae is unknown.