COVID Recovery & Rehab Series: Pulmonary Manifestations of COVID-19 with Robert Kaner, MD! Wednesday, 7/15/2020


Good evening, ladies and gentlemen, welcome to another edition of pulmonary wellness foundation lecture series 2020. This is our new mini series. No, it is not the hunger games. It is the COVID 19 long haulers, recovery and rehabilitation program. My guests this evening. Well, my hosts with me this evening about salon white from ultimate pulmonary wellness, paren, Bishop, who is a paramedic paramedic firefighter from Florida, who is also a long hauler and the innovator of the first long hauler survey from the patient perspective and Marcela Devita, chief patient officer of the pulmonary wellness foundation, and then chief of our scientific section tonight, dr. Robert Kaner is a pulmonary and critical care medicine doctor from Cornell New York hospital. He’s tied with one other person as the smartest person. I know he and Marcelo to Beto will be having a kickboxing fight to settle it once and for all in two weeks.


Thank you for joining us this evening, Rob dr. Caner. Thank you so much for being here again. I don’t know how you, I don’t know how you deal with us, but thank you for being here. Incidentally, dr. Caner is also a COVID survivor, so he’s been there, done that, and we have a lot to get through tonight, ladies and gentlemen. So we’re going to start right off. So dr. Caner, if you could just tell us what are the most common things you’re seeing in patients that present either to the emergency room or their doctor’s office? Well, I think that the symptoms of acute Coburn infection are pretty well known to everyone watches, TV or newspaper. So I don’t have to go through those, but in terms of what we’re seeing in the office there are people that have persistent respiratory symptoms following COBIT infection.


So a lot of people complain of chest tightness or a big feeling like they can’t take a deep breath. We’re seeing a lot of people that have wheezing, cough following Cobin infection. There are people who complain of shortness of breath with exertion and there are different severities of respiratory failure for some people who have actually developed different forms of interstitial lung disease and required more advanced treatments for that. So we’re seeing a wide variety of different symptoms of presentations. Have you noticed that change? So, so for those


Of you that don’t know where here in New York city, dr. Kaner works at one of the busiest hospitals in the city, they saw a ton of COVID patients. Are you, are you seeing different things now than when we were kind of at our peak?


We are. So I think that when we were at the peak, we were all concentrated on people that had acute respiratory failure. So at one point our hospital was basically transformed into a giant intensive care unit. And we had over 200 patients who were intubated with acute COBIT infection. Fortunately that’s dramatically improved. And we have very few intubated patients left in the hospital, although there, I still saw him. And so what we’re seeing now is people with milder symptoms who are presenting for medical care with a lot of the manifestations that have just described.


And how is it decided who gets admitted versus who gets sent home? Like I know at the beginning, like, unless you were really imminent, like you were sent home and a lot of those patients, it seems you know, like if this were any other time in history, like if we brought those patients to the ER, they would have been admitted or they would have gone right to the ICU. And it seems like a lot of them long haulers, especially were kind of those people who were not sick enough to be admitted then, and then sort of sent home to fend for themselves.


Yeah, that’s exactly right. And so the, I think that the key triage point in the emergency room is are you in respiratory failure and do you require supplemental oxygen or not? If you don’t then go home. And if you’re lucky enough to have a pulse oximeter monitor your oxygen saturation at home or come back, if you’re really short of breath if you required oxygen, then those people generally got admitted to the hospital.


And, and what would you say what diagnostic tests should be done? And keep it keep in mind, obviously with tonight, we’re going to talk about respiratory. We do have cardiology and neuro and GI coming up in the next two weeks, but what pulmonary tests should people be getting kind of as a standard?


Well, I think most people would get a chest X Ray in the emergency room. Early on, we were not doing very many cat scans of the chest. Even though that wouldn’t be a standard diagnostic procedure for someone who is had an unknown cause of respiratory failure or had some type of interstitial lung disease. And it was mostly based on the fact that it could be easily done at the bedside in the emergency room without having to move the patient without having to potentially expose others in the hospital to someone who is acutely infected and potentially infectious for others.


And a lot of the long haulers have this question that you know, they’re very short of breath. They have other respiratory symptoms, their chest X rays are coming up clear. What tests should these patients be getting and what should they be asking their doctor?


Well, I think the first thing they should do is talk to their doctors because I’ve found from my personal experience that many of those patients have either subclinical or over broncospasm. So COVID like any other respiratory virus can cause wheezing can cause cough. And sometimes those symptoms are very responsive to the kinds of inhalers that we prescribed for people with asthma. So for people that are very symptomatic with wheeze and or cough that’s related to broncospasm, that is narrowing of the airways. Those symptoms will often be dramatically improved with an inhaler that contains a combination of a steroid and a long acting beta agonist, which would be a standard treatment for someone who had asthma.


Okay. and what about the role of nebulizers? I know at the beginning they were saying don’t nebulize and it was a little bit unclear as to whether that was because it was bad for the patient or because they didn’t want to aerosolize the virus.


Well, early on, it was because certainly in the hospital we didn’t want to aerosolize the virus. So we would completely avoid nebulizers in someone that we knew had an acute COVID infection. And if you were at home and you have other family members and you have an acute COBIT infection, the same considerations would apply.


Do you think that long haulers should, so one of the issues that a lot of people have is that they have difficulty either a getting care in the first place, B getting doctors to take their symptoms seriously or simply that their doctor doesn’t have a lot of experience with COVID. So how do you recommend that patient try to manage and get through the diagnostic,


The process to make sure nothing’s getting missed? Well access to care is a, is a huge problem at this time. Many doctor’s offices are either closed or they’re only doing video, but I think if you’re able to start out with a video visit, I think that’s infinitely better than nothing. Because many of those problems that I just described and I’m thinking of several patients that I saw myself today could be diagnosed with a careful history during a video visit. So I think you should try to take advantage of that to at least get yourself into the medical system.


Okay. Thank you. A lot of people have normal oxygen saturations, even though they’re extremely short of breath. How, how is this explained and how can somebody use that information to help them?


Well, the short answer is it’s an observation that I don’t think we totally understand. The long answer is some of these people are experiencing airflow obstruction. Broncospasm like I just described and they might be helped by an asthma type of inhaler. And the, some people have abnormality in the gas exchanging part of the long, that’s not readily apparent on chest X, right? So a cat scan of the chest is a lot more sensitive for picking up more subtle Manresa PEs stations that viral loop Unitas. And that’s not unique to COVID, but it’s certainly been reinforced by what we’ve seen during COVID. So and someone who’s really bothered by shortness of breath and they had an initial chest X Ray, then the cat scan would be the next diagnostic tool. And very often we find that there are subtle pulmonary infiltrates on the cat scan that are due to COVID.


They couldn’t see on the chest. But there are people that even have a clear cat scan who still complain of shortness of breath. So one important consideration is to rule out pulmonary embolism, blood clots in the lungs. So we know that there’s a significant incidents of blood clotting, P penis thrombosis, and then pulmonary emboli in individuals who have acute COBIT infection. So that has to be evaluated. And then there are some people have gone through that whole evaluation and we still don’t know why they’re short of breath. So they deserve a cardiac evaluation because there have been some individuals who’ve developed cardiac manifestations following COBIT. And I know you’re going to devote another whole program to that. So I won’t talk about that. But even after that evaluation is done, so we ruled out an obvious lung infiltrate. We ruled out airway obstruction, we ruled out pulmonary emboli and we ruled out a heart problem. There are still people who feel short of breath, and I don’t have already explanation in that case for why they feel short of breath. But there are people who have that symptom without an obvious explanation. That’s all I can say.


I’ve seen patients who are sitting on a couch, on a chair doing nothing, and we see their heart rate kind of cycling up and cycling back down and same thing with oxygen saturation. So no change in activity, their sat may go 96, 95, 92, 89, 88, and then cycle back up. What, what would you think that has?


Well, when you see those wide variations in oxygen saturation without any activity from the medical standpoint, the differential diagnosis for that phenomenon is very short. Number one, it’s an artifact. So someone has a lot of nail Polish on their finger and the pulse oximeter is not accurately reading their true oxygen saturation. And you see those wild fluctuations in the in the oxygen saturation. And I had a patient yesterday who I did a six minute walk test on specifically because of post COVID shortness of breath without any other explanation. And on the initial testing for saturation dropped to 86%, and then it went back up to 93% without any intervention just while she was walking. So we repeated the test using a forehead probe that goes around the forehead and her saturation on that test with 99%. It didn’t change.


So that’s a good example of how artifacts can be introduced, but let’s say that it’s not an artifact and it’s a real finding the most common reason to have those wide swings in oxygen. Saturation would be someone who has add elect disas at the base of their lung and in a non COBIT situation. We would typically see that in someone who’s developed postoperative and electricity. So I, I frequent pulmonary consult that will get in the hospital is from a surgical service. Someone is two or three days post op. They had abdominal surgery, or they had gynecologic surgery and their oxygen saturation is, keeps dropping and they’re they had a, a CT scan that shows they don’t have any pulmonary emboli and almost invariably that’s due to add electrolysis. So that means that there’s collapsed at the basis of the lung, which is something that occurs very typically following surgery, particularly with a long surgery that involves general anesthesia.


And there we’ll see very wide swings in the accident saturation. And at a time when the accident saturation is low, if we ask them to hyperventilate so that they’re really moving as much air as possible, we can see their oxygen saturation go from the eighties into the high nineties, without any other maneuver. And that’s a physiologic effect in someone who has significant and electricity. And I think in some people with COVID we actually see a similar kind of phenomenon. So I think that sometimes it’s physiologic. So that’s a very long winded answer to a short question,


But it helped a lot. And it makes a lot of sense when somebody’s sitting on the couch and they are hypo ventilating, so they’re not taking deep breaths and their sides are 86. Is there any potential downside to that? Like, should that person be oxygenated? Does that person have the same risk as let’s say the COBD patient or the PF patient who’s chronically hypoxic?


I think it’s different. And part of the reason it’s different is that some of the secondary effects of chronic hypoxia, particularly the development of secondary pulmonary hypertension take a long time. So over a short timeframe, I don’t think it’s quite as dangerous. But another potential explanation for low saturation is if someone has hypercapnic respiratory failure. So what that means is that their carbon dioxide in their blood is above where it should be. And for reasons that are complex and I won’t go into all the physiology even if the oxygenation aspect of your lung is working normally, then if the, if the bellows function of your lung, which is necessary to remove carbon dioxide from your body is not working normally, and the carbon dioxide level in your blood goes up, the oxygen saturation has to go down.


Even though your lungs are working perfectly as an oxygenation machine, the physiologic reasons for that are complex. We probably don’t want to talk about that right now, but it’s important to recognize that high carbon dioxide level could be the cause of a low oxygen, and that has a completely different set of causes than the ones I’ve talked about up until now. So that can be caused by things that affect the brainstem brain function. It can be caused by neuromuscular weakness. And I know you’re going to have a whole show about the neurological effects of COVID. So I’ll just throw that out there without going into a lot of detail.


Okay. Is there any correlation between what some people have been told as thicker blood? Like I’ve heard people say they they’re taking their blood and it’s thick and putting like


No, I, I, I lost you for a minute, but I think what you’re asking about is there any risk of the hypercoagulability that is been commonly observed in COVID patients? And the answer is yes. And the risk, as I mentioned before, is that they develop blood clots, deep venous thrombosis, which can then develop into pulmonary emboli and pulmonary embolus can be fatal or life threatening. So that is a potentially serious complication of acute COBIT infection.


And what about for long haulers? So like people who are at home and are still having a lot of these symptoms, because like my impression is that a lot of these patients who were sent home, anything could have happened in those three month period. Right. They could have had clots, they could have had strokes, they could have had embolize. I mean, what, what should these patients be doing now to figure out what’s going on and what they can do about it?


Well, I think as I said before, they should seek medical attention and it, when someone has persistent exercise limitation, following COBIT infections, then we have to think about all the things that we just mentioned. And you have to systematically look for them. And if you don’t look for blood clots, you won’t find them, you don’t look for heart muscle problems, you won’t find them. So, yeah,


And we hear a lot about micro clots or people, you know, who’ve had clots all over their body. How do you, how do you go about finding that? What do you, what do you need for that?


That’s actually a difficult diagnosis to make. Most of the reports were from autopsies for people who’ve died from overwhelming respiratory failure due to COVID. And it was observed in the in the microscopic vessels, in the lung. So it’s thought that the type of coagulation defect that occurs in COVID is due to dysfunction of the endothelial cells. So we go, those are the cells that blood vessels in normally they, they provide an anticoagulant surface. So that clots don’t form within your blood vessels. If those cells are perturbed for one reason or another, you could spend a long time talking to you about potential mechanisms cause, but nobody really knows why that happens. But if, if, if those cells are perturbed, then clots can form in small blood vessels. And that seems to be what’s happening in COBIT infection. The only clue that that’s happening is to, I mean, look for evidence of large clots or do a measurement that looks at the development and breakdown of acute clot.


So there’s a blood test you can do called the D dimer, which is often sky high and people who have acute COBIT infection. And those that have very high levels are at higher risk for developing both large vessel clots on the Venus and the arterial side, as well as these microscopic clots. And the, the treatment for that is anticoagulation. Now, at this point in time, we’re not sure whether the dosing, what the dosing should be and there’s controversy about that. But I think everyone agrees that at least a prophylactic dose of anticoagulation is a good idea in that situation. So if you’re having that problem, it’s really hard to discover unless specific blood tests are done.


And what’s the drug of choice for anticoagulation?


Well, it depends on the situation, but in the acute setting, it’s usually either heparin, which is given by intravenous infusion or low molecular weight heparin, which is given by subcutaneous injection for people that have generally stabilized and you know, that they have a plot, but their their physiology isn’t disrupted and they don’t need to be admitted to the hospital. Then the newer oral anticoagulant agents are great because they’re easy to take there once or twice a day, and you don’t have to get blood tests to monitor them. They’re fixed dosing. So they’re easy to use. And they have a lower incidence of bleeding than the other types of agents. So they become the drug of the therapy of choice for outpatients, with stable clots.


What about again, you know, the group of long haulers that we talked to and the group along haulers that I see on a regular basis, many of them are not getting care. They’re having difficulty getting access to the healthcare system. A lot of people ask is, is it a good idea for them to be taking aspirin on a daily basis?


Well, that’s a tough one. You know, I think ideally you would speak with a medical professional before starting any medication, including aspirin. It sounds like a benign thing to do, but it may, it might not be certain situations. So I would hesitate to advise a group of people that they ought to all start aspirin, even at a low dose, I think talk with a healthcare professional first about your ideas about that


And what other lab tests should people be getting as a, as a routine kind of diagnostic?


Well, it depends on the situation what your symptoms are. So I don’t think that there’s one set of labs that is specific for everyone. If you are, if clotting is a concern, then the D dimer tests that I mentioned might be a good test to get. Or if there’s a real concern about pulmonary embolize and a CT scan with intravenous contrast, that’s designed to look for pulmonary emboli might be the better test for people who’ve been very sick and they have persistent shortness of breath. I think that routine blood tests that measure blood counts in kidney and liver function are a good way to start because we know that some people would coven infection can actually develop renal failure and sometimes renal failure, isn’t obvious until it’s very, very in stage. So I think those types of basic labs are good places to start.


And can you talk a little bit about the type of pneumonia that you see in COVID? Is that similar to like other types of pneumonia that you see, or is there something specific about it?


It’s not really that similar. So the thing that is complicated about this is there are many different patterns of pneumonia that we’ve seen so far. It doesn’t look like a routine pneumococcal, pneumonia. It looks more like a routine pneumococcal pneumonia would often be a very dense area of consolidation. That means the lung on an X Ray normally looks black because the lung is mostly composed of airspaces during pneumonia that black can turn to white because there are inflammatory cells that are the body calls in to fight off the infection. And in a typical pneumococcal pneumonia, which is the most common type in an outpatient very often there’s one segment or one lobe of the lung that looks very densely consolidated. Whereas the rest of the lung one’s relatively is normal. That’s not the pattern we’re seeing with COBIT, we’re seeing a more hatchy kind of infiltrate.


So it’s not dense consolidation, but it looks wider than normal and it takes many different patterns. So it can be a fate infiltrate that appears in one spot, it can be in multiple spots. And then there are secondary patterns that we’ve come to recognize that are part of this COVID respiratory infection pattern. So often there are very correctable infiltrates. In other words, on the edges of the lung, that would be very unusual for a garden variety of community acquired pneumonia. There’s a pattern that we’ve seen frequently in people who have respiratory failure following Kobe, which is called organizing pneumonia. So that looks more like focal areas of consolidation that don’t necessarily correspond to specific segments of the lung. And they’re often multiple. And again, this looks different from a garden variety of community acquired pneumonia. And then in people that have the worst type of respiratory failure where they’re really requiring tremendous amount of the of oxygen and they develop the what’s called the Ute respiratory distress syndrome.


So these people are generally in an intensive care unit, they may require mechanical ventilation or very high flow oxygen, and they have a very characteristic pattern where you see infiltration that involves usually the lower zones of the lung more than the upper zones. And they start to develop claps at the basis of the lung, and they’re very, very sick. So we’ve seen all these different patterns and it is for the most part, they are different than just a routine pneumococcal pneumonia that you would see in an outpatient what’s your Zodiac sign cancer


Cancer. That makes sense. All right. Well,


My birthday was yesterday, by the way,


Birthday, Rob, I, did you get the cake I sent you, it’s a co it’s a coy cake made with real fish. So I’m gonna throw some words out there. You might know what a few of them mean. Okay. Put these in perspective for us as they relate to COVID. We talked about adolescent ASIS, which is partial collapsed and expansion of


The lung. What is the role of pleural effusion, pleurisy or pleuritis are we seeing plural stuff?


Yeah, so that’s a great question. And I didn’t even get into talking about plural manner.


No, I try man. You know, I try, you know, I try.


So one of the consequences of COVID pneumonia that we’ve seen a lot of is secondary bacterial pneumonias, which are often complicated by lung abscesses and empyemia, which means that the infection has broken out through the surface of the lung, into the space between the lung and the chest wall. And that’s a situation where someone is usually pretty sick there. They have fever, they have high white count. They feel awful. They’re treated with intravenous antibiotics. And very often they require a chest tube or even surgical intervention to clean up the infection in the floral space. And we’ve seen numerous cases that have occurred following a COVID respiratory infection. And most of, most of the people are hospitalized because they’re so sick, but we’ve also seen this in outpatients and they require many weeks of treatment with antibiotics to clear up the problem, but fortunately it’s treatable.


Okay. So let me ask you this. So when we talk about things like ground glass, opacity scarring and fibrosis so my impression is, you know, like again, I think a lot of people got sent home. I feel like if we could’ve gotten them, you know, kind of doing different things early, we could have really helped with respect to preventing complications of the lung, things like chest therapy and things of that nature for the people that are showing ground glass opacities scarring. How did that happen? So fast? Like what’s the mechanism by which people started looking like chronic lung disease patients, if you know


Well, the short answer is, I don’t know, but what we’ve observed is that so first of all, what is ground glass opacities? I think I should explain what that is. So I talked about consolidation with a lung looks bright white on the chest X Ray versus the normal lung that looks black, ground glass opacities are sort of halfway in between. They look kind of whitish, but they’re not bright white. And the reason they’re called ground glass opacities is that for those of you who are, are as old as me, you remembered that in high school chemistry lab, you use something called sintered glass. So it’s that frosted glass. And that’s what the X Ray looks like. It looks like frosted glass. And the reason that that appearance occurs is when there’s some airspaces in the long that are filled up with something which could be fluid from pulmonary edema, it could be live, it could be inflammation could be scarring.


We don’t know what it is just by looking at an extra image, but some of them are filled up with something and some of them remain open and full of air. And so when you sum all those images together, and so it’s a two dimensional picture of a three dimensional object, the overall effect of that is this ground glass appearance. And the thing that’s characteristic about ground glass is it looks like the normal architecture of the lung is present. So we’re seeing the normal structures through this centered glass kind of appearance. So that’s what a ground glass opacity is. It has a different implication in people that have chronic interstitial lung diseases. And what’s different about it is that when there’s distortion of the normal lung architecture, then we know that there’s been fibrosis scarring and that’s usually permanent when there’s ground glass opacity, and there’s no architectural distortion, it’s a condition that may be completely reversible.


And if it’s inflammation, it may be treatable. If it’s fluid, it may be treatable in a totally different way. And the infection may be treatable in a totally different way. So when we see ground glass, it makes us think, well, we don’t know what this is, but it’s something that probably could get better if we had the right diagnosis and the right treatment. On the other hand, if we see very advanced scarring like we do with some of our patients that have advanced interstitial lung disease who have pulmonary fibrosis, that’s a different story. We don’t know what the incidents and the natural history of both of those observations are. So I’m in the process of trying to develop a registry to specifically address that question. And the questions we’re gonna ask are what is the incidents and what is the natural history of interstitial lung disease in individuals who survived respiratory failure, Holden, and the study we’re planning is going to be a registry, but people will come back at regular intervals to have pulmonary function tests and cat scan, and we’ll draw their blood to look at biomarkers of various types.


And we’re, it’s going to be a consortium that’s going to include Columbia, NYU and Cleveland clinic and Ingelheim is going to be the sponsor. And we’re very late in the stages of trying to get that off the ground right now. So hopefully we’ll be able to provide some answers to those questions.


So as a patient, who’s hearing that they have this scarring and they have this fibrosis, what can we expect?


What is our next move? Well, I think the good news for patients is that there are several reports, which I would describe as preliminary, but there’s more than one of case series, mostly from Europe because their peak of their epidemic was ahead of the one that happened in New York. That pretty much show there’s improvement and the vast majority of people. And very often they’re given steroids. But whether they are, or not improvement generally occurs, not necessarily complete resolution, but most people are getting better. So I think that’s the good news. So improvement in the fibrosis. Right. Well, we don’t know that it’s fibrosis again, we see ground glass opacities. We see an organizing pneumonia pattern, the actual in stage fibrosis, we don’t see very often. And we see evolution in people where we have serial cat scans. We very often see evolution of the abnormalities and they do tend to improve over time.


And I would think that timing is really important for this as far as early treatment. Right. So I mean, my impression, and again, in a lot of the patients I’ve seen, I often wonder, like, had we gotten to these patients in week one could some of that have been prevented, do you think


It’s a great question. And I don’t, I don’t know the answer. I mean, we’ve when we’ve been trying to individually, well, we’ve been trying to make these decisions. They’ve been highly individualized for each person. There is a study that came out recently, again from Europe. It was a multicenter study, but it was a very, very large number of patients where they gave a moderate dose of steroids to people who were in respiratory failure, in the intensive care unit with a huge covenant infection. And the outcomes were better and people that were treated with steroids. So you may be right. It may be correct that starting to do rides earlier is better. We don’t know a hundred percent for sure, but that data certainly suggested it. But I think that, you know, the, the concern was starting steroids is that the the principal host defense against viral infections of almost any type, but certainly coronaviruses is a type of cellular immunity that student T cells, the T cells are important in fighting a lot of different kinds of infections.


And when we give T-cells, we know that I I’m sorry, would we give steroids? We know we want that T cell response. So in individuals we’re having a lot of active, viral replication. The concern is that we may be blocking the main host defense against the virus. And that’s why we don’t just hand out steroid to everybody. But as time goes on and viral replication has stopped and we’re dealing with a lot of these inflammatory consequences where there’s no viral replications and it might be safer to give steroids. And that that’s what we’re doing. So nobody knows what the optimal timing or the optimal dose of steroid treatment is in this setting. We’re kind of learning more about this every day as we go along.


What is your favorite color? Blue. Blue. Okay, awesome. What about your thoughts on people? So a lot of people have been told all of a sudden that they have asthma or COPD after having COVID. So people who were normally you know, before this healthy athletic, is this actually asthma, is it airway inflammation? Can people develop COPD as a result of COVID?


I think it’s way too soon to label anyone as having COPD as a result of Cogan. I think to say that someone has asthma is probably accurate in some cases where people are wheezing and they respond to asthma treatments. And we haven’t done very much pulmonary function testing because of safety concerns with, with that testimony reality. But our lab just opened up a couple of weeks ago. So we don’t have a lot of information about documenting airflow obstruction post COVID, but I think it’s fair to say that some people haven’t asthma syndrome or syndromes and whether that will become chronic asthma or whether it’s just a onetime thing that’s going to resolve after weeks or months. And they’ll never be bothered by it again too soon to know


What about so a lot of people are seeing chronic cough. Some people have a dry cough, some people have this hacking spasmodic cough, and some people have a productive cough. Can you talk a little bit about that?


So cough is an important symptom of many different types of respiratory diseases. Not just COVID it’s as you know, it’s a symptom of interstitial lung diseases where cough can be very debilitating many people, and we don’t have a lot of good treatments for cough. And there are a lot of research studies going on that are at new therapies for cough, and I’ve participated in some of those studies, but in COVID I, we talked about the potential for asthma treatment to help people with coughing wheezing. There are other types of inhalers that are used for CLPD that might potentially be helpful to palliate that symptom and people that are suffering from cough. And that’s something that could be considered. And beyond that, most of the treatments for cough are really symptomatic and they’re trial and error.


There’s no proven therapy, but I would also think about other mechanisms of cough that occur following Cobin infection or following other types of infection. So one common reason that people have a cough that doesn’t respond to treatment is because they’re having reflux. Reflux, flex is a really common problem, and you don’t even have to be aware of having heartburn if there’s reflux of acid and you just don’t want to stop esophagus, that can cause a cough flax without the acid actually hitting your vocal chords or getting into your lungs. But many times when people that are having gross reflux, the acid is hitting their vocal chords and that causes them to cough. And if they go to an ear, nose and throat doctor who looks at global scope, they’ll see redness adjacent to the vocal chords, which is very characteristic of a reflux. Another common cause of cough is a postnasal drip. And that can be caused by allergies, which of course are very common this time of the year COVID or no COVID. And so people that have postnasal drip from allergies may cough, and it may not have anything to do with COPD. So there are potentially a lot of other causes that could be contributing. And it’s helpful to seek medical advice about what the most likely mechanism is because some of these mechanisms are very treatable


And, and so hoarseness is, is the feeling of the lump in the throat? Would that also be possibly reflux or postnasal drip? It could, yes. And again, I know you mentioned earlier that everything should be taken in the context of medical opinions and seeing a physician first. A lot of people ask over the counter allergy medications over the counter, you know, privacy, proton pump inhibitors bad idea, see a doctor first, or is it worth a shot?


Well, I think, you know, it’s always I’m bias and I think it’s always a good idea to get professional advice first five, if you’re someone who has chronic allergies. So, you know, like I know that every August I’m going to start getting itchy eyes and runny nose and sneezing because I have a ragweed allergy and I know that every year, if I take the anti-histamines my symptoms will be better and maybe nasal steroids, which are now over the counter. So I can treat that myself and I don’t need to see a doctor. But many people are having these symptoms and they don’t know what’s causing, so


You’re a doctor and your wife’s a doctor, so you’re going to see a doctor no matter what. So, you know, is that worth a shot?


I’m not going there cause you’re going to tell her what I said. So the, there are other people who are obviously having influence that’s something that you could relatively safely treat with an old fashioned type of drug called an H two blocker and the one that’s readily available and very safe is called homeowner D. So it’s a generic for Pepcid and it’s over the counter. It’s very, very safe. It has very few side effects. It doesn’t have any important drug interactions. The proton pump inhibitors are more effective treatment for reflux and the H two blockers, but they have a lot of potential side effects. They have potential drug interactions. So if you need a proton pump inhibitor, you can get it, you can buy you know, Prilosec over the counter. But I think you should seek medical advice at the same time.


Rob, I got to tell you, I got nervous for a second. I thought you were going to mention the old Pepto-Bismol there, but I’m glad you didn’t. So my next question is what do you think the role of respiratory muscle training is? And like things like incentive, spirometry, positive expository pressure devices,


You mean in, in respiratory failure caused by COVID?


No, I mean, I mean like a lot of, so, so this group is primarily people who are long haulers, many who weren’t hospitalized, but that are still having issues with not being able to take a deep breath that are still having issues with coughing when they try to take a deep breath or shortness of breath or the, you know, the production of mucus and not being able to clear it, or even the feeling that they have mucus, but not sure if they even have it. So should, you know, do you recommend incentive spirometry? Do you re recommend things like the aerobic or the flutter valve or the acapella?


Well, for people let’s take the pre COVID era in people who have bronchiectasis. So that’s a condition where your airways and large, and often you have a lot of mucus production, difficulty clearing secretions. Those devices that you just mentioned are very important to aid with airway clearance. So we prescribed them, we rely upon them. They’re a key Keystone of treatments, similar considerations apply to people that have chronic Mai infection, mycobacterium avium because those people can have a lot of trouble with secretions, particularly if they have more advanced disease. And those devices are very helpful in that situation, in the COVID post COVID situation. We don’t have enough experience to know if those kinds of devices will be effective or not. I would imagine that for people that have a lot of mucus production and I have difficulty bringing it up that there’s very little downside to trying one of those devices. So I don’t really see any problems with that.


And what about, I’m sorry, go ahead. No, I was just gonna say let’s talk at the same time. One, two. So, Rob no, go ahead. I’m sorry. Go ahead. When you asked about respiratory muscle


And I think we have seen rarely and maybe we’re under recognizing this. Maybe it’s more common than we know, cause we’re not looking for it hard enough. But in people who have respiratory failure, following Kobe, there are individuals who have respiratory muscle weakness, and this is much more common in people who’ve been in the intensive care unit have been on mechanical ventilators have had, you know, weeks of sedation maybe even had paralysis to help them survive the respiratory failure. Those people very often do have neuromuscular weakness and they might benefit from respiratory muscle training, but that’s a very select subgroup of people who were incredibly sick, you know, and had a near death experience in the intensive care.


Do you recommend, do you think there’s any benefit or downside to humidifiers or dehumidifiers?


There is potential benefit and there’s potential downside. So let me give you the downside. Pers humidifiers are notorious for getting mold growing in them and especially this time of the year. And you know, that one of my favorite diseases is hypersensitivity unites and one of the most common causes of that is mold. So I really don’t want people to do anything that’s going to expose to more mold spores and they’re already exposed. So if you use a humidifier, make sure that you thoroughly clean it and dry it every week, so that there’s no chance that mold is going to grow in that humidifier. And then aerosolized the spores for you to breathe in that’s bad, bad, bad. So that’s the downside. The good side is that for people that have very dry secretions in their airways, humidifying the air and making those secretions more liquid may make it easier to cough them up. So in people that use chronic supplemental oxygen we typically humidify the oxygen supply by introducing a water bottle into the circuit so that the oxygen bubbles through the water bottle and picks up humidity before the person brings it in. So there’s no question that it can be beneficial in that kind of a situation


Be equally or, or something you might suggest also.


Yeah. For people who have trouble mobilizing secretions a hot shower creates a lot of steam and the steam is good. It has the same kind of effect as as a humidifier, maybe even more so. So people that have a lot of difficulty with chronic secretions from bronchiectasis, cystic fibrosis or advanced Mai infection will often report that when they’re really having trouble, they go in a hot shower and it really helps them cross stuff up. So I think that’s good. But again just be aware that there are people who’ve acquired Mai infections from their shower head it’s ubiquitous, it can live in the water. And that has been a source of MEI infection. When it’s been thoroughly investigated,


Do you believe that people who’ve had COVID would be more likely to get an Mai infection than if they didn’t have COVID?


I have no idea.


And if you were an animal, what type of animal would that?




This is a tough crowd. I gotta be honest with you. This is a, this is a tough room. You know, this is different than my usual Tuesday, Thursday night crowd. Alright, Rob, it seems like towards the beginning of the pandemic, more patients were being put on ventilators than they are now. Is that true? And if so, I mean, besides the numb, why is that? What have you learned about that?


Well, the initial thinking about the safety of the medical staff was that the sooner we intubated someone put them on a ventilator, it was a closed circuit and we weren’t aerosolizing the virus to cause secondary infections in the staff. And that made sense at the time that everyone was afraid of Kevin COVID and a lot of doctors, nurses, respiratory therapists, hospital staff develop the infection and many died from it. So it was you know, it was a rational idea. We came to learn that we can safely treat individuals who have acute coven infection with all of the PPE, with keeping them in a room that separate with minimizing interactions, with putting a HEPA filter in their room. There’s lots of stuff that we do now that allows us to use noninvasive ventilation. So we have oxygen mass. We have a nasal cannula device that’s called high flow oxygen. And that high flow system can often provide enough oxygen to people so that we can keep their oxygen at a safe level without having to intubate them and put them on a mechanical ventilator. And now we know how to do that safely and people that have colored infections. So that’s why I think less people are getting into B


Awesome. Many people complain of varying types of chest discomfort. So pressure tightness, squeezing, burning. Some people have it on inspiration. Some people have it on exploration. You know, what are these things mean? What can we glean? What information can we glean from that? And, and when do we think it’s like an acute coronary syndrome that we have to treat as an emergency? I tried to make it simple. Sorry.


Yeah, it’s a great question. Because any time someone has those symptoms, we always have to think about, well, maybe it’s not a lung problem. Maybe it’s actually their heart. And we know that in COVID decides to increase incidents of venous thromboembolism with venous thromboembolism. There’s also an increase incidents of arterial thrombosis. And if you get an arterial thrombosis in your corner artery, you have a heart attack. So and sometimes the symptoms of a heart attack are very difficult to distinguish. As you pointed out in your leading question. So that’s one of the reasons that I, an advocate of talking to a medical professional, hopefully can help sort through those issues of whether it’s really a hard problem or it’s really a lung problem, truly an airway problem. It’s really a lungs rankable problem. It’s an upper airway problem. There’s a lot of possibilities. And you know, if you can’t figure this out by yourself at home, that’s not a big surprise. And sometimes it’s hard for us to figure it out too.


I mean, and what I find even, you know, based on, on my experience and my, you know, my EMS background is that things that we once thought looked one in one direction. Now they don’t necessarily mean, would you say that if in doubt, I’m going to do my, my Johnny Cochran, if in doubt, check it out. I’m like, so if you’re in doubt, if you think you’re having an acute problem, you’re, you’re going


No doubt. Right, right. Okay. Gotcha.


Why is lying flat difficult for so many people?


Well, it’s not just COVID infection. It’s very many respiratory and cardiac problems. If you’re upright it puts your diaphragm at a mechanical advantage. So if you have gravity helping you to push down your diaphragm and expand your lungs, almost no matter what the cause of the breathing difficulty is, you’re gonna feel better in that in that configuration. So it’s pretty universal that people with respiratory problems breathe better sitting up and they do line down to for heart failure. It’s true for almost all types of lung disease.


And what about the impact of sleep apnea in heart failure? I’m sorry in, COVID sorry. Zoned out for a second there. Like what are you seeing a lot of sleep apnea in COVID is caused by COVID is it exacerbated by COVID?


Those are all great questions and I honestly don’t know the answer. And I think that because of the quarantine related to COVID, we haven’t been testing a lot of people that we would normally test. And it’s only just starting that we’re starting to do, especially some home sleep test. So I don’t think anybody knows the answer to that


Many long haulers get short of breath from simple things like walking a block up and down a flight of stairs, walking to the bathroom, which has a massive impact on daily life. So this is leading to rehab. Do you think that people should be resting? Should people be getting more active? What’s your feeling if you have one on that?


Well, in general, they should be getting more active. Resting is not good. But there are exceptions to that. So if someone is in right heart failure, if they have severe pulmonary hypertension, that’s been caused by their pulmonary emboli, or they have cardiomyopathy, that’s not being treated those types of problems, it’s dangerous to exercise. So again and again, I sound like a broken record, but get advice from a medical professional, if you don’t have any serious heart problems, if you don’t have serious blood clots, if you don’t have serious respiratory failure, then get exercise. It, all of us, including me became deconditioned during quarantine because we’re mostly sitting around and they went out once a day to go and buy groceries and came back, but we weren’t exercising. I wasn’t playing tennis. You know, we all got deconditioned to some extent. And if you really have a lung issue that really limits you from doing things, as you know, it becomes a self fulfilling cycle where you don’t want to do anything. Cause it makes you feel short of breath itself, limit your exercise. So to break out of that cycle, you got to get moving and that’s where it’s up to you, Noah.


Well, you want to know something. That’s very interesting. So my team has been seeing a lot of COVID patients. You know, our thinking is, is evolving, of course. And one of the things, you know, we, we, we did develop a bootcamp two years ago that was specifically designed for people to start at an extremely low level. What we’re finding is that for a lot of the COVID patients, especially the long haulers, even that lowest level is too much exercise. Or what we’ll see is we’re seeing patients who you take one step, cool, two steps, cool, three steps, good. You take that fourth step and you’re in bed for a week after that. What do you think that could be related to? So the things we’re talking about dysautonomia you know but is there anything that you can think of, of why somebody, you know, cause it, it gets very difficult to know how much do we push and what we’re actually doing to keep is cutting way, way back and inching along.


I’m again, sounding like a broken record. You need a medical evaluation in that situation. There’s no question that deconditioning has played a big role in the exercise of invitation that everyone with COVID has experienced, but it’s not the whole story. I mean, even people that are severely deconditioned can walk more than three steps. So something else


I will, I was exact, I just want to be clear. I didn’t mean specifically three steps. What I meant was that there, you know, it’s like, we seem like we’re moving in a forward progression, but then there’s like that slight, slightly overdone it. And it’s almost like you flooded the engine so similar to like a post-polio patient or an ms. Patient or a fibromyalgia patient where you really almost have to like throw this tiny stone, let the pool ripple and even like how they feel like I’ve seen many people who feel good during the workout and have even felt good later that day. And then the next day they’re shot.


Yeah. I don’t have a simple explanation for that. And you know, you, your points are well taken. Maybe they have some subtle neuromuscular problem that we haven’t diagnosed yet. But this is something that’s complex and we’re gonna have to find out


Overtime. I think too. I agree. It is really fascinating. I noticed you skipped over the question about what animal you would be if you were an animal, but we can move on it’s okay. So what, what can you say about vaccinations? Right. So we’re about to hit flu season. Our people with COVID are you recommending they get solu shots? Are you recommending they get Pneumovax or are they more at risk for getting those vaccines? Or


I’m not aware that there’s any increased risk. So I’m recommending that they get the usual vaccines that they would normally get.


And do you have a sense, I mean, people ask this question a lot, but I’m going to ask you what you think. So a lot of our patients are PF patients. Our PA’s patients are COPD. Patients said, you know what? I know if I get COVID, I’m not going to make it. A lot of our patients made it. What’s your sense of you know, COVID patients like I, and I hate to ask, you know, questions like this, but they come up so often from patients. So do you think that, like, how do you, what do you say to a COVID patient as number one, in many places that the virus is not under control and it is in fact escalating and we’re about to come into flu season. Do you think people should be going out, getting around if they do you know, going back to work and how can they protect themselves?


Okay. That’s a great question. And I get that all the time. I think that if you are in a situation where you potentially could be exposed, I’m going to differ somewhat in my advice from what the CDC recommends. And I think that if despite all the hoopla about coronavirus, persisting on surfaces for a long time and blah, blah, blah, and that may all be true. I think that the source of the infection in the vast majority of people is aerosols. So I think if you have an underlying lung condition and you want to protect yourself from aerosols, the current state of the art is that the best protection is in, in 95 masks. This is not what public health authorities are recommending, but if you have lung disease and you want to protect yourself, I think that’s the best protection. So in, in 95, mass is something that you can’t buy probably at your local convenience store.


You probably have to get it from a surgical supply store. It’s hard to order on the internet they’re, they’re sold out. And I’m not talking about the mass. I have little valves in them. I’m not talking about the cloth mass. I’m not talking about the surgical masks, that the handout, where you come to the hospital, I’m talking about a real end 95 masses, PPE. Now they’re expensive. And they also, people complain that they’re hard to breathe with. Even if you have normal lungs, they’re hard to breathe. So but the truth is they offer the best protection. That’s why we use them in the hospital when we’re taking care of COVID patients. So if you really want to protect yourself, that’s what I would recommend.


Are you recommending a fit test and 95 or an 95 that you could get at home Depot?


A fit test is always better for an in 95 mask.


I mean, how likely is that that a patient can, can get a fit test? I mean, is that even a possibility for most people?


Yeah, probably not. So I don’t, I don’t have any specific advice. You can take your best guess. I mean, they basically come in regular and small, so take your best shot. You want to make sure that there’s a piece of metal that you clip, you clip tightly around your nose and you want to make sure that it forms a good seal. You should actually see the mask billowing out and billowing in while you are while you’re breathing. If you see that, then you know, you have a good seal.


What about for the patient that says, you know what? I have COPD, I have pulmonary fibrosis, or I have a condition and HIPAA doesn’t allow you to ask me what it is. I am, I am exempt from wearing a mask. What do you think of that?


I think it’s really, really dangerous. I think that people who say that they can’t use a mask and the, they want to be exempted from it are fooling themselves because they’re putting themselves at risk. It doesn’t help them to avoid their risk of the virus that they go out without a mask. It just more risks. And so I’ve faced this situation with a number of different patients and I’ve just told them outright, no, I’m not going to write you a letter that you can’t wear a mask because the person is being hurt by them. You you’re putting yourself at risk. So I have strong feelings about that. And I think if you feel that because of your underlying one condition or your claustrophobia or anything else, you can’t wear a mask, then don’t call out.


I have no business. I agree with you a thousand percent. I mean, do you feel the same way about like service animals in particular? I saw there was one person who, a service peacock that she took on a plane. Like, would you be open to a, a note about a service peacock? This is really degenerated and I’m not gonna go there. Well, Rob, I’m going to give you, I’m going to tell you, we got through all the questions. So we’re going to go to the audience please chat a chat post your chat questions. And we are actually in really good time. We did speed round all the way through. So first of all, let me say thank you so much. Dr. Caner for being here, that was a tremendous wealth of information in a very short amount of time. And don’t worry people if you missed any of it because we have recorded it and we will be posting it on Just kidding. It’s going to be on the pulmonary wellness foundation. This is the tough, this is a tough room. I feel like I’m just starting out again. So it’s going to be on the pulmonary wellness foundation website where all of our information is. So we’re going to go to some questions from the, from the chat, unless Karen, do you have questions stashed that you wanna, that you want to throw out there?


You’re muted. Okay. Wait, I’m going to read your lips. Okay.


So just going back to the cold and flu question, dr. Caner how do you think somebody like myself who is still a long holler would be able to fight off something like the flu or the cold would you consider us to be immunocompromised right now? Would it be safe to take the typical medications you would take with a cold or flu? Should you come into contact and contract that while still dealing with long haul issues?


I don’t know any reason that you couldn’t take the usual medications for cold and flu. I’m not aware that any of those are unsafe whether people that have had previous coven infection are more susceptible to getting new viruses. I don’t think we, we know the data on that. We just don’t know. That’s a good question. I don’t know the answer.


And the other question that dr. Greenspan touched on so myself, along as a lot of other long hollers a lot of your advice was to talk to our medical professionals. When dr. Greenspan was talking about us having trouble yeah, some people are having trouble getting into a doctor in general, but I would say, unfortunately for like 80% of us only do go to a doctor. They’re dismissing us. They’re not believing us. They’re telling us we’ll be fine in a couple of weeks. And they’re very unfamiliar with the long haul process, the issues post COVID and any treatments. So what is out there for us to point our doctors in the right direction, because at this point it feels like we’re the ones educating them and we have to be our own advocate. And it’s really hard to go to your doctor with all of these issues in a pandemic on top of the physical and mental things that you’re dealing with and the person who’s supposed to be helping you kind of just sends you on your way. What can you say to help us with that?


I can say that the answer is in what you just stated that sometimes you have to be your own advocate and you may have to educate your physician about some of these postcode problems, because not everyone is going to have the degree of familiarity that we have having been in, you know, the hotspot of the pandemic when it hit and having a much broader experience than most physicians will have. So I don’t know how to solve that problem, but I think the seeds of the solution are in what you said, you have to be your own advocate and you may have to educate your physician about what to do. There’s a wealth of resources for physicians. You know, physicians are busy, they don’t have time to read everything. And so there is plenty of stuff out there, but it’s hard, even for people that are really interested in, in COVID as an academic topic to keep up with all the papers that are published every day.


I mean we mostly have groups of people that are interested who share articles with each other because there’s too many there’s stuff, literally coming out every single day. And the field is very fast moving. The things that we thought were true six weeks ago are no longer true. So it’s a really, you know, difficult situation. So I wish I had some better advice for you, but I think what you said is right, you may have to be your own advocate and you may have to educate your position. It’s a tough spot to be in because you’re, you know, you’re, you’re exhausted, you’re fighting these physical things, you’re fighting the emotional stuff, and then it’s like, you have to do work for that for the medical community. So it’s a real tough spot to be in. Rob, you mentioned inhaled steroids before. What about oral steroids? How are those being used or IB steroids? Well, IV steroids are being used in the intensive care unit and people who have certain types of respiratory failure, oral steroids are being used to treat people who develop different patterns, interstitial lung disease


That I talked about following covert




What about people have inflammation in the airways that never did before? How likely is it that that’s going to be able to resolve? I think it’s pretty likely, but it may take a really long time. And if, you know, for people that have wheezing as I said inhaled steroids are relatively safe and they might be beneficial as people. What do you consider? What do you consider a really long time? Cause I, I know what this, you know, a lot of weeks to months. Okay. Yeah. Cause you know, and that’s one thing that I, you know, I try to impress upon people because I know it’s, it’s like, you know, when you’re taking like a road trip, it’s like, are we are we there yet? Are we there yet? Are we there yet? And it’s like, people expect things to happen.


Like, well, I did the exercise yesterday and I don’t feel any better. You know, one thing that I just want to impress upon people is that you’re only gonna get better as fast as your slowest system. Okay. So even though you’re doing things that are moving in the right direction, like you could be making progress, but you may not see it for a little while. So don’t get discouraged. You know, I mean, I know there’s a lot of tension, a lot of stress, a lot of anxiety in this community and rightfully so, I’m definitely not minimizing it. But you know, keep in mind that this is so new. And as dr Kaner said, I mean, things change very quickly and we are learning you know, we’re learning every week. So to hang in there, I know, you know, another thing is like, I talk about our community of, of, of chronic lung disease patients and chronic you know, heart disease patients.


And, and I, this was like the first time in history when our community actually has an advantage over the general population, because it’s like, we’ve been preparing for this for decades. You know, we’ve been staying in, in cold and flu season. We’ve been wearing masks. If we think we’re going to be exposed, we’ve been using the hand sanitizers for people who are normally, you know, used to being super fit going about their day. Some people say I’ve never been to adopt or in their lives. It’s a big shock to your system. So, you know, try to have patients. This is a very inflammation, mediated disease. It’s a very sympathetic, nervous system fight or flight type of disease. And I think a lot of what we have to be doing is really working on quieting the system, things like meditation, deep breathing exercises, and that’s what we’ve started. You know, that’s what we’ve started offering to people. Rob should what about like vitamins supplements, vitamin K vitamin C any, before I get to that I just want to reemphasize what you just said, which is the


Experience. And a lot of people who maybe had no health problems beforehand and were really hit hard by the virus in the aftermath. Most people get better, but for some people it’s taken many, many months before they really feel back to themselves. So my overall advice would be don’t despair. Most people are going to get better, but it’s like my long suffering piano teacher used to say when I was growing up, which was Rome wasn’t built in a day. So you just can’t expect to feel all better after a day or a week or even a month. It takes a really long time. And I know from my own personal experience, having had a mild COVID infection the fatigue persisted for many weeks even now I find I’m sleeping more than I used to. And my stamina is still probably not a hundred percent of the water was pre COVID.


So don’t be discouraged. It does get better, but the timescale in which it gets better is long vitamins. And there’s no specific information about vitamins. The only, I think a good epidemiologic study that related vitamins to outcome and COVID was a study that was done in Scandinavia. And it was a retrospective study involving thousands of peoples. What they found was that people who had low vitamin D levels had a higher risk of a poor outcome from COVID. So the one thing that I can say, I think we’re pretty good insurance is that if your vitamin D level is really low and you get COVID you’re at increased risk. So it would make sense if your vitamin D levels are low to get them back up into the normal range, but you should do that anywhere. Any other vitamins? I have no idea.


Flintstones ladies and gentlemen, I’ll be here all week, try to fish. What do you think about the possibility of contracting covert through your eyes? Well, we all wear eye protection in hospitals, so I think that, you know, there have been documented cases where that’s occurred. Do I think that that’s the most common route to get infected? No, it’s still the aerosol inhalational route, but I mean, I, protection is part of the package of PPE when we’re taking care of people that we know have coven infections, we learned goggles. What about like walking the street or going to


The grocery store? Do people need face shields?


Well, walking in the street? I don’t think so. I think the risk of getting it is very low, but I think the risk of getting COVID outdoors is much, much lower than it is in a closed indoor situation. So if you look at, you know, the studies that have been done about the dynamics of aerosols aerosols can hang around for hours in a closed space. So if you’re indoors, even opening a window and creating a lot of, a little bit of air flow, we’ll do a lot to just pay aerosols. So if you’re, if you’re indoors, that means you’re in a grocery store, you’re in a hardware store where people are together in a closed space. If you’re really concerned about getting infected, I think you should wear some kind of like protection, whether it’s Cognos or a face shield or whatever you have.


Rob from someone whose initials are TB. I don’t know if she wants to be publicly revealed, but it’s happy birthday. Dr. Caner, you did an amazing job asking, asking those questions, but I think she means answering. I’m still wondering what I’m still wondering, what animal you would be. If you were an animal of dr. Kainer, you mentioned your registry. Can that be potentially expanded to become a survivorship study similar to the one st. Jude has for childhood cancer survivors, longterm followup with patients.


It’s something that we need to talk about and we need to identify funding for, but I’m happy to discuss that, but that’s a whole nother discussion.


I mean, this is a hard question to answer, but you know, what do you think about people with CLP de NTM bronchiectasis surviving COVID?


Well, there clearly are survivors, but, you know, we worry that people with underlying respiratory conditions have less reserved if they get infected. So the data on CLPD is not very robust at this point. So I think that remains to be determined.


I think so many of our COPD patients have just stayed home. You know, I’m, I’m, I’m so grateful to say that I haven’t heard of one single patient in our group that we’ve lost. So I, I commend them for, you know, again, we we’ve been preparing for this for a long time. I didn’t mean me, but thank you. Dry, hot or cold air bothers me the most. So turning up the humidity on my C-PAP from two to three and later to four, seems to help me sleep with less restlessness, keeping the humidifier running helps to perhaps it’s just the background noise. That wasn’t a question that was a comment. After, after, after a severe GI infection, my doctor gave me a coarse of B12 shots, which helped my fatigue. Would this help long haulers with fatigue?


I’m not a big advocate of B12 excepted people that are really deficient. So you’re at probably asking the wrong person. I, you know, I’m not going to give individual medical advice. I situation where I don’t really know all the details. So I’ll have to defer the answer to that question.


What are they using for inflammation and Bronco spasm? If a person is allergic to corticosteroids,


True allergy to corticosteroid in my mind probably doesn’t exist. So, I mean, it might be that you were allergic to some preservative or something in the steroid preparation. But I don’t believe that’s a thing.


What do you think about kids going back to school?


It’s tough. It’s really tough. There is no good answer. No question that kids benefit from being in school studying online is not the same thing. On the other hand. We know that kids, especially small ones are reservoirs of virus. Anyone who’s been a parent and has had small children come home and get them sick all winter long understands that that’s just the way things are. And so the actual morbidity and mortality of the virus in children seems to be quite low, but it seems to be quite low, but the danger is they’re going to infect their teachers. They’re going to infect the people who work in the school, then they’re going to come home and in fact, their grandparents with disastrous results. So I think that we have to really think this through very carefully and make sure we’re doing it in a safe, a manner as we can. And you know, this is like the Supreme court. We’re, we’re balancing apples and oranges. We have to restart the economy, but if we don’t do it safely in the end, it’s going to backfire. And I think it’s the same thing.


I’m four months in Steele still feel myself starting to black out at times. It happened in front of my pulmonologist at that want more up to work two weeks ago. And it didn’t seem to be a pulmonary issue, but it unsettled her enough that she put me in a wheelchair and literally literally took me to the ER, no one can figure out why sometimes my O two drops, sometimes it doesn’t next stop is his cardiologist. Any other ideas, Ron? Nice.


Yeah, go ahead.


And so you know, one of the things that we’re seeing a lot in patients is something called dysautonomia and dysautonomia, you know, just like it sounds. So we have the autonomic nervous system. That’s responsible for regulating things in our body and it’s not working as it should. So in other words, we walk across the room, maybe normally that would be a 10 beat rise in our, in our heart rates. But we’re seeing a 50 point rise in patients or people are standing up and, you know, their blood pressure is dropping because their blood is pooling in the legs and under normal circumstances, we’d see you know, we’d see the vessels constrict to return that Venus, you know, blood flow back to the central core. One thing that we’ve started experimenting with that seems to be working well with patients is compression leggings.


And the reason for that is because it creates kind of a mechanical pressure that kind of does the work for the vasculature and those that will actually allow you to start being more active, because if you stand up and all of a sudden you feel like you’re going to pass out or black out, you really don’t have much choice. You have to sit down, right. But that prevents you from doing the things that are actually going to help to retrain the autonomic nervous system. So we have to look for other ways on the outside and these compression socks or particularly compression leggings have helped with that and can allow you to actually start doing more. You become more fit, you retrain the autonomic nervous system. And I think that’s going to be the big, a big focus of rehab as we go forward. And, you know, feel free to reach out to me if you want to talk about this further.


Let me make a comment. I think that the point that you brought up is great. I also think that the person who asked the question would be well-served to see a cardiologist. There are potentially fatal heart diseases that are readily treatable that a cardiologist could diagnose and treat and prevent a, an annoying problem from becoming a fatal problem. So if you feel like passing out, you need to get that checked out that is potentially has a fatal problem underlying it. And so that’s a serious symptom that warrants medical attention. I wouldn’t just brush it off.


And you said that’s your next step? Right? Is cardiology. Yeah. Okay, awesome. When do you think COVID started in the U S


I think it started last fall. And the reasons that I think that are too long to discuss it in the next 30 seconds, we’re going to have to end, but I think it started last fall.


Final question. Do you think people can recontract COVID?


I think I had it twice myself, so yes, really?


Was it different first time versus the second time? No, it was, it was the same. Yeah. Okay. Dr. Caner, I want to say thank you so much for being here. This was fantastic. A ton of information. Ladies and gentlemen, we’re going to unmute you all so that you can unabashedly show your appreciation for dr. Painter.


Thank you all for your attention and all the great questions and Noah, thank you for giving me all those great questions.


Always a pleasure. And ladies and gentlemen, ladies and gentlemen, I just want to tell you a little bit of a couple of things. So number one is I’m. Karen, do you want to talk about your survey for a moment? Okay.




Sorry. Karen, hang on. I muted you by mistake


Survey. One is for confirmed case long haulers. It is really a study on your symptoms and your experiences survey. It’s about to hit 1500 responses. Survey two is for suspected and unconfirmed cases. Because they’re, as you know, many of you who clearly had COVID, he tested negative for flu and everything else you’re dealing with all these symptoms, but you were unable to obtain a test at the time you were sick. So I created a study for you guys as well, and it also takes a more driven data driven approach. So I will be sending that out to you. I’m not sure if I can get in this chat before we end, but I will be sending it out to you guys. It’ll be on my page. I posted it in all the other Facebook pages and I’m sure


I also send it in a post-meeting. We could send it in a post-meeting email. Okay.


Yeah, definitely. If you have not contributed to those it would be greatly appreciated if you did. Again, we are trying to perk the ears of the medical community and like many of, you know, it’s hard to get your doctors to believe you. So this is part of that movement to try and do. So


Ladies and gentlemen, one more announcement this Sunday, July 19th, seven o’clock to 8:30 PM. We will have an open discussion and Q and a session support group style and Q and a session that will be with Karen and myself and some of the pulmonary wellness foundation team. Our team is also doing consultations free of charge only donation basis. So if that is helpful to you, even if we don’t know the answers, we can point you in the right direction. And next Wednesday, July 22nd, seven o’clock to eight 30 gastrointestinal and hepatic manic manifestations and nutritional considerations in COVID with gastroenterologists, Rheem Shariah who was the author of a big study that just came out jazz GI and hepatic manifestations of two 19 novel Corona virus in a large cohort of infected patients from New York clinical implications. And again, I have to thank you, dr. Caner for that intro. Our team came together very, very quickly. So ladies and gentlemen, thank you so much for your attention. Thank you for being here. Hang in there, keep the faith. You can do this work the program, ladies and gentlemen, work the program and have a great evening.