– Good morning or afternoon, ladies and gentlemen. Welcome to session one of COVID Survivor Series, breathing techniques. So, before we start, just in case anybody has not been here before, understand that there’s a difference for the people who have had COVID, and are post-COVID, and are what we call long-haulers, and for everybody else, okay? So, for COVID patients, what we’re seeing is a very mixed bag of energy. Some days, it’s very high. Some days, it’s very low. Some days, the symptoms are very strong. Sometimes, they’re not as strong, they’re better, and it doesn’t always seem to be any rhyme or reason as to why that is. So, if you have had COVID, if you’re post-COVID, if you’re a long-hauler, et cetera, et cetera, et cetera, the key is always going to be to err on the side of caution, to err on the side of doing less rather than more. So this is gonna be a weekly meeting, okay? Every Monday at 12:00 noon, we’re gonna do a meeting, and I’ll let you know that this is not a virtual background, this is actually my Bonsai garden, but here’s the key, what we do today, you can do for the whole week, okay? Because what’s very important with COVID-19 and people who particularly are in the category of what we’re calling long-haulers, which are people who have had the virus, gotten over the virus, but still, weeks and months later, are experiencing symptoms, is that, sometimes, you can overdo it by even one little tiny bit, and that can set you back, okay? This is a hugely inflammation-based condition, and the key to all of this is reducing inflammation, and calming inflammation. So everything we’re gonna do today is gonna be towards relaxation. Yes, she is eating my Bonsai. So, the key is, we are starting to believe, and we’re starting to get more and more information that COVID’s hugely inflammatory-based, and if we can quiet the inflammation, people are gonna start to get better. The other thing that we know is that COVID affects many different systems, and that’s why the symptom load is so different, okay? For each patient. So, what we are going to do today, for some of you, it may feel like we’re not even doing anything, okay? But take my word for it. By doing these breathing techniques, we are quieting the sympathetic nervous system, we’re increasing parasympathetic output, which is healing. Sympathetic nervous system is fight or flight, parasympathetic is rest, digest, and heal, and it’s so much more important that you don’t overdo it, or that we err on the side of under-doing it, throw the stone, let the pool ripple, because some people will do something today, and even feel good doing it, and even feel good after doing it, and then, after that, the next day, they don’t feel good. So think about it like this. We’re gonna throw one tiny pebble at a time, we’re gonna see the impact of that, and as you feel better, we’re going to move forward. And I’m gonna ask everybody to just please make sure you’re muted, and we’re gonna start. So today is gonna be breathing session number one, okay? Part of the breathing, in addition to taking breaths in and out, is to try to quiet our minds, okay? To try and, to quiet the anxiety, because even thinking about something stressful, or being under stress, puts out adrenaline into our system, and this is not healthy for us. This is very pro, this is very excitatory, it gets the nervous system revved up, and that’s the opposite of what we want. The other thing that we’re seeing with patients with COVID is, we’re seeing something called dysautonomia. What that means is that the vital signs’ response, or the body’s physiologic response, is not always equal and commensurate with the activity they’re doing, meaning that I may raise my hand like this, and my heart rate may shoot all the way up disproportionate to that. So please understand that, even though this is gonna seem gentle, we want gentle. Even though this is gonna seem calming, we want calming. Now, for those of you that are not used to any type of breathing, or mindfulness, or meditation, this may be irritating to you, okay? But trust me, this is gonna be your best friend. Go with it, humor me, okay? And each day that you feel good for this week, I want you to repeat. But do it every day for the next week, and if you do it every day for the next week, and you feel good, next week, we’re gonna up the ante a little bit. Any questions before we start? No? Good. All right, so, take it nice and easy. As always, if you feel anything unusual or uncomfortable, tired, dizzy, chest pain, pressure, squeezing, dizziness, nausea, anything like that, please stop immediately. Remember, err on the side of caution, okay? I want you to do everything today sitting, and what I’d like you to do is, I’d like you to get your feet on the floor. I don’t want you leaning, if possible, so get your feet on the floor. Your knees should be at about a 90-degree angle. Your hips should be at about a 90-degree angle, and what I want you to do is, I want you to just, for now, put your hands on your knees. Before you do anything specific, I want you to just kinda take stock of your body. I want you to see how you feel. If you have a headache, is your head throbbing, pushing, squeezing, stabbing? Do you feel any tension in your neck or your shoulders? What about your chest? How’s your breathing? Try to take a deep breath right now, and see how much the air goes in. So, just nice and easy. And for the next 20 or 30 minutes, I’m gonna ask you to breathe in through your nose, and out gently through your mouth in what we call pursed lips. So let’s start with a nice, deep breath in through your nose, and then blow out gently, pursed lips. Now, a lot of people make the mistake of giving the instruction that you should be smelling the flowers and blowing out the candles. Blowing out the candles is actually the opposite of what we want, because the harder you blow, the more air trapping we’re actually going to get. So, think of it as soup on a spoon that you want to cool, but you don’t want to blow the soup all over the room, so it’s breathing in, and nice, easy breaths. Now, from a postural position, okay? I want you to pay attention to the fact that, as human beings, we do a lot of things in front of us, okay? We do a lot of things like work on the computer, cook, this, that, the other thing. We don’t do anything, really, behind us, so we wind up with very tight muscles in our chest, in our abdomen, and we wind up with a rounded shoulder. And just put your hands like this for a moment, and take a deep breath in, and it’s hard to do, right? So think about the impact of your posture, and your respiratory system, and how they relate to each other. So now, first, sit up, and just, if your hands are flat on your knees, I just want you to turn your thumbs out, and arch your back. So this is the most open you can be, right? So do you feel how, by just simply turning your thumbs out, and sticking your chest out, and arching your back, now take the breath, and that should allow it to go a little bit deeper. Show of nodding heads, are you feeling it? Okay. Hands on your knees, nice and easy, close your eyes. And the first series, we’re gonna breath in for a count of two through your nose. When you blow out, we’re not gonna time it, I just want you to blow out for as long as you need to to empty your lungs, and then return to the breathing in for two. So it might be breathe in, in, and purse your lips, and let it go for as long as you need. Then you might take a one-second pause, and then we’re gonna go back to the two. So I’m gonna start with you by counting. After the third or fourth one, I’m gonna stop counting so that you can go at your own pace and that it’s not distracting for you. If you want to close your eyes, close your eyes. When your eyes are closed, if you feel them getting heavy, don’t resist it, go with it. If you feel like you’re going into a bit of a meditative state, don’t resist it, go with it. If you feel like your head wants to nod down, don’t resist it, go with it. That’s the sweet spot, that’s what we’re looking for, that’s the quieting of the sympathetic nervous system, and the enhancement of the parasympathetic nervous system. Again, if anything feels uncomfortable, please stop. Nice, easy breathing, in through your nose for a count of two. And blow it out gently. Breathe in, in, and blow. If you want to try to time your exhalations, try to breathe in for a count of two, and out for a count of four, and we’re gonna breathe in, in, and blow, two, three, four. Breathe in, in, and blow, two, three, four. Breathe in, in, and blow, two, three, four. And breathe in, in, and blow, two, three, four. Nice, quiet, normal breathing. Nice, quiet, normal breathing. The next thing we’re gonna do is another set of breathing in for two, and out for four. I’m gonna count you for three, and then you’re gonna go at your own pace. Breathe in, in, and then blow, two, three, four. Pay attention and let your shoulders get heavier and relax into your arms. Deep breath in, in, and blow, two, three, four, as you enjoy the sounds of New York City traffic. Breathe in, in, and blow, two, three, four. And last time, nice deep breath in, in, and blow, two, three, four. And relax, the nice, quiet rhythm. Try not to overthink if any stressful or unpleasant thoughts pop into your head. Just acknowledge them, say hello to them, and blow them away. One more set, breathing in for two and out for four. Nice, deep breath in, in, and blow, two, three, four. Nice deep breath in, in, and blow, two, three, four. Nice deep breath in, in, and blow, two, three, four. Okay, I want you to spread your legs apart. You can open your eyes now, put your elbows on your knees, and lean forward. This should be a fairly comfortable position for breathing for you. So, if you feel like you’re having difficulty, put yourself in this position, and see if this can restore or reset your breathing. Come back up, and this time, what we’re gonna do is, as you breathe in, you’re gonna slowly bring your shoulders up and back, squeezing your shoulder blades together. As you do that, your hands will slide back on your knees to your thighs, and you’re gonna hold and relax. Again, if anything causes you any pain or discomfort, please do not do it, and then just go back to the regular breathing. So, nice and easy, shoulders up as you breathe in, and squeeze them back as your hands slide up your thighs, and then blow out as your hands go back. Nice, deep breath in. Nice, deep breath in, as your shoulders come back, and… Nice, deep breath in, as your shoulders come back, and blow, come back to resting position. Nice, easy breaths. Everyone doing okay? All right, we’re gonna do one more exercise, and this time, what we’re gonna do is, as we breathe in, our arms are gonna come up as if we’re saying thank you, and then you’re gonna turn your hands over and push down. Imagine your hands are in something kinda sticky, like a maple syrup, or something like that, or a chocolate pudding, or whatever they used to put in the tank at the bar you used to go to for Jell-O wrestling night, and nice and easy. This time, we’re gonna breathe in for three, and out for five. Don’t go fast, don’t go any faster than I go, nice and easy. So we’re gonna open up our thumbs, or our thumbs are gonna point out to the side, breathing in, two, three, and hold, and arms are gonna turn around, and push gently in the water, blow, two, three, four. Nice, deep breath in. And blow it out. Nice, deep breath in. And blow it out. Last time, nice, deep breath in, and hands on your knees, eyes closed, nice, quiet breathing. If you wanna put your head down, put your head down, whatever position’s most comfortable for you. I want you to stay with your eyes closed about a minute, and I want you knowing any change. Nice, easy breathing in through your nose, out gently through your mouth. Nice, deep breath in. Nice, deep breath in. And out. Again, if you feel your head getting heavy, don’t fight it, go with it. If you feel your eyelids getting heavy, don’t try to keep them open, let them close. And at this point, if you feel like you wanna let your head hang down, rest. Nice, easy breathing. If and only if, and when and only when you are ready, feel free to gently open your eyes, and return to this space in peace, and in calm, and gratitude, because, even though this time is a struggle, we are still alive, and for that, we are grateful, remembering that not every day is perfect, and not every day is great, but there is some good, and greatness, perfection. Nice, easy breathing. Nice, easy breathing. And relax. And if you would like to, if you have any comments, or feedback, or you’d like to share how you’re feeling at this time, I would love to hear it. Feel free to unmute yourself. As an alternative, you can feel free to stare at me blankly, that’s okay too. Karen.
– Yes. When you first started, I felt like I needed to take a really, really deep breath, and I couldn’t get beyond here. It was, like, stuck here. I couldn’t seem to get a deep breath, and then I wanted to cough.
– Okay, so Karen, if you don’t mind, and feel free to just put your hand up if you don’t want to tell me, did you have COVID?
– [Karen] No.
– Okay, so whether you did or you didn’t, okay? Understand that the airways are lined with smooth muscle, okay? It’s muscle that contracts and relaxes when it’s supposed to, so the airways dilate and they constrict. If you feel like you cannot take a deep breath in, okay? Imagine if your muscle was very tight, when we got to the point that that muscle was overstretching, it might snap back on us, right? And that’s the cough mechanism there. So, if that’s the case, you have to become aware of your breathing so that you just back off a little bit. So, if this is too far for me to stretch, then I’m just gonna come, and I’m gonna stretch to here, and that will loosen the muscle, and that will also loosen the smooth muscle in the airways as well, and for many people that have scar tissue in their lungs, or who had pneumonia, or who had, you know, things like atelectasis, this is a process that will happen over time, but go only as far… We don’t want you to go into a spasmodic cough, and today, we only went up to a count of three, okay? In the future, or as you feel more comfortable with this, we will go up to higher levels, and when we go up to those higher levels, what that will means is that you’re going to be able to take a deeper breath.
– [Karen] Okay, all right. Thanks, yeah, ’cause I have bronchiectasis, so I know there’s scarring.
– So, the other thing about bronchiectasis is that you’re gonna have mucus, okay? And sometimes, this breathing, even though it may make you feel a little bit worse, what it means, in many cases, is that we’re actually moving air into places that you haven’t had it for a while, and that we could actually be bringing up mucus as well.
– [Karen] Wonderful, yeah, yeah, I need to bring it up if it’s there, I need to bring it up, yeah.
– And particularly, Karen, one other suggestion for you is that you could do these exercises lying on your left side and your right side, because that will help the mucus drain from the lower lobes.
– [Karen] Okay, okay.
– Anyone else? I wanna just go to the chat quickly.
– [Female Participant] Noah, sorry, somebody is asking to explain the breathing out through your lips bit.
– Okay, so why do we blow out through pursed lips? Okay, if you’ve ever had a pulmonary function test, okay, you know that they ask you to take a deep breath in, and then blow out hard, and blow, blow, blow, blow, blow, blow, blow, blow, blow. The harder you blow, the more airway collapse we get, okay? One of the hallmarks that we’re seeing with COVID is what we call a restrictive lung pattern, which means that you’re having difficulty taking a deep breath, and not that there’s a difficulty exhaling, but there’s difficulty inhaling, and then exhale is very quickly. When you exhale in an uncontrolled manner, there’s more airway collapse, and more alveolar collapse, okay? The alveola are the air sacks. So, by blowing out through pursed lips, what we’re doing is, if you think about, let’s say, like, a garden hose, and you put your hand over part of it, right? That creates a back pressure or a forward pressure, so you have more pressure going in that direction. When we purse our lips, we create a back pressure into the airways that helps to prevent both airway collapse and alveolar collapse. And I’m gonna go to the chat, and just run through these questions. “Is Kiddo eating your Bonsai?” Yes, Kiddo was eating one of my Bonsai. She’s sneaky, thank you for saving it. “My exercise delay is two to 16 hours.” Okay, so Joel, excellent. So here’s the thing, if your exercise delay, I think what you’re saying, Joel, and feel free to unmute, but I believe what you’re saying is that you feel good when you’re actually doing the activity. Two to 16 hours later, that’s when you get hit. And what are you getting hit with?
– [Joel] It feels like a truck. I’m really tired and fatigued.
– Tired and fatigued. Is there pain?
– [Joel] Nope.
– No pain, so just exhausted.
– [Joel] Yeah, just exhausted, and just, everything, I wouldn’t call it pain, just everything just doesn’t feel like it wants to do much of anything.
– Okay, so Joel, you’re exactly who I’m talking to, okay? So, it’s great that you know your range is two to 16 hours, okay? So my suggestion to you would be, wait until at least tomorrow afternoon to see how you feel, okay? Because, like I said, what we’re seeing with a lot of COVID patients, is that they… Joel, how do you feel right now? You feel okay?
– [Joel] Yeah, I feel okay. It’s 70 watts on a bicycle to do that. If I stay under 50, then I’m okay. I go to 70, then it’s bad news.
– Okay, so let me give you a suggestion for COVID patients, if you are finding that you’re having a big impact after the workout, whether it’s later today, the next day, or the day after, then what we need to do is, we need to scale your workout way back, and then restart from scratch. So, in other words, if you’re doing 10 minutes, okay? Because you used to do 30 minutes, okay? And then you feel it, okay? So, in other words, you’re used to doing 30 minutes before you had COVID, now you do 10 minutes, and then you’re exhausted, back it off to five minutes, back it off to three minutes, back it off to two minutes. So, for those of you that have been in bootcamp, okay? You know that bootcamp starts on day one with four minutes, and what I say to you about day one is, if you can’t do four minutes straight, do two minutes and two minutes, and if you can’t do two minutes and two minutes, do one minute, one minute, one minute, one minute, but I’m gonna tell you this, and you know, I’m a cardio pulmonary physical therapist, so my inclination is to push people. With COVID, the inclination must be to go less than you think you should do, and every day or two that you feel good, then you’re ready to go forward, so if you do it today, and you feel bad tomorrow or worse tomorrow, then you either rest a day, or you do the same thing today, but you don’t go forward. We don’t go forward until you have a day that you’ve worked out, and the following day, you feel either the same or better. Does that make sense? And the thing is, we’re already long-haulers, right? So the idea is that slow and steady is going to be the key to your success. Pushing and overdoing is going to trigger a setback because it’s too stimulating of the nervous system, and it’s not a cardiovascular limitation, and it’s not a respiratory limitation. My gut feeling is that this is both neurologic and/or dysautonomic, and dysautonomic is neurologic, but I think that that’s our limiting factor, and as I’ve been saying, COVID will heal only as quickly as our slowest system, which means that, if we’re walking with a group, the group stays at the pace of the slowest individual. So keep that in mind, because what we don’t want, we don’t want setbacks. I will walk you through this over the next several weeks and months, and hopefully not years. Hopefully, you’re gonna be better way before that, but as long as it takes, we will walk through it, but if we don’t know where the landmines are, we must wait until we know the ground is clear. Okay, does that make sense, Joel?
– [Joel] Yeah. I have another meeting to go to.
– Go for it, have a good one.
– [Joel] Thanks.
– “Hi, Noah. “Whenever it feels like I need “to take a deep breath and can’t…” Again, if you feel like you need to take that deep breath and you can’t, just back it off a little bit. If you can only breathe in for one, breathe in for one, but do it gently, okay? This is not gonna work for you, so if you say, for this moment in time, I can only breathe in for one and out for one, then that looks like this. And the reason why breathing in for one is not the best is because we never get the air past the windpipe by doing that, okay? But it’s a good warmup. So, in the same way, if we were stretching our hamstrings, we don’t go right to full stretch, we start gently. Over a few minutes of that breathing in for one and out for one, you may find that your airways loosen up, and you may get that two, and the goal is that, over time, your best days will get better and more fulfilling of air, and your worst days will not be as bad. ♪ Tch, tch, tch-tch ♪ ♪ Tch-tch, tch, tch-tch ♪ ♪ Tch-tch, tch, tch ♪ “What is the special effect “of breathing out via the nose?” Covered that. “Having trouble getting the volume loud enough.” Sorry, we are outside, that’s why. So I wanted to bring you guys to the garden, but in future, if that’s distracting, I will do it indoors. “Help me relax and calm down my breathing.” In, pursed lips, create a back pressure. “Hear you fine now and the other lady, “but when doing the breathing, “I could hardly hear you.” Okay. “Very healing and soothing. “My breathing is not what it was before COVID, “but is improving.” Great. “Still have a lot of burning in chest and tightness. “I’m antibody-positive.” Tch, tch, tch, tch, tch, tch, tch, tch, tch, tch. “I’ve never actually done your bootcamp yet.” Okay, other questions, comments, other just responses. How do you guys feel? Okay, guys, remember, even if it doesn’t feel like we didn’t work hard, trust me, this is doing something, because right now, it’s like the fire is burning in you, right? And we can’t start cleaning up and restoring until we put the fire out. Think of it like that. It’s a process, okay? Little by little, we’re starting to understand this process. Anything you can tell me, or share with me, or share with my team is a help to us, okay? Because this is a six-month-old condition. We are learning along with you, and nobody knows it better than you. Feel free to reach out to me at any time. My email is noah@pulmonarywellness.org, or noah@covidpt.org, or feel free to reach out to me on Facebook, and also, my team is doing COVID consultations, so if you want to talk your case over specifically with my team, please feel free to reach out to us, and we are not charging for them, they are free and donation-based only, so don’t let that be a reason not to reach out to us. Have a great day, my friends, and this is a big week, this is a big week. So, Wednesday night, Robert Kaner, pulmonologist extraordinaire, interstitial lung disease specialist from Cornell, 7:00 p.m., hope to see you there. Have a wonderful day. Feel good, breathe, be happy, life is still good, we will get through this.