Good evening, ladies and gentlemen, welcome to another evening and another, in another episode of the post COVID rehabilitation and recovery series, my guest this evening is somebody very smart and very nice. Dr. Hooman por is an assistant professor in the department of medicine, pulmonary critical care and sleep medicine department, as well as the department of cardiology. He is also the originator of PERT, which if you don’t know what part is it is the pulmonary embolism response team, which sounds very exciting. Welcome dr. Pore. Thank you so much for being here this evening. Thank you for inviting me though. All right. So our, our group, our crew tonight is a combination of patients, clinicians, and many long haulers and both, but what I’d love to talk about, and I know that you are really on the super front lines. And I’d love to just talk a little bit about what you were seeing initially and how that’s kind of evolved for us over time.
Yeah, I mean this has been, feels like it was decades ago when this first came. And it’s only been a few months, which is frightening, but you know, we were obliterated here in New York early in, you know, March, April, may. And part of the issue that was so complex was beyond just the sheer number of patients and the acuity of disease. But the fact that we didn’t even really know what we were dealing with and part of the problem was that this disease particularly the most severe form where patients are in the ICU you know, has been characterized as what’s called the acute respiratory distress syndrome. And that’s a respiratory disease where the there’s inflammation in the lungs, usually from like a, an infection like the flu or some other kind of inflammatory process. And that inflammation causes fluid to build up in the lungs and it makes oxygen difficult to kind of get into the, into the body.
It makes the lung stiff and people have respiratory distress and they’re on ventilators. And we’ve had decades of experience of how to treat that and we know optimal management and so on. But we were kind of tricked with this virus because there were a lot of characteristics that were very different compared to a regular ERDs. And you know, as a result people were doing all kinds of different therapies and different tests to figure out what was actually going on. And we’re still learning. You know, what this disease is about you know, early on in, at Mount Sinai you know, we have ICU that are specific for specific conditions. We have a medical ICU that has 14 beds. We have a cardiac ICU that takes care of cardiac conditions. The cardiothoracic ICU surgical ICU, all of these ICU were converted into Colbert ICU.
And all of these patients that were on ventilators were, were put in these ICU and then additional ICU work you’re filled with these patients. And we had something close to 120 or so patients at one time on ventilators. We were putting two patients in one room often because we couldn’t you know, manage this, we converted the entire lobby into beds, which I don’t know if you’ve been into the Mount Sinai lobby, it’s this big, you know, atrium, they, they shut it down and they literally brought in engineers and construction and they built, you know, tons of beds. We didn’t actually ultimately need to use it. Central park had you know, patients were on ventilators. And so it was you know, a horrifying moment at that time or patients were extraordinarily sick with the disease. We didn’t know how to treat, we didn’t really understand. And you know thankfully you know, over time things improved from the standpoint of the numbers going down with social distancing and guidelines to prevent disease transmission. However I’m concerned that it’s coming back now.
Do you think that like as far as you know, one thing that I saw is that a lot of people who I think normally would have been admitted to the ER, were told to stay home you know, or people would show up to the ER with, you know, or, or would be taken by ambulance, you know, who would at any other time, but you certainly admitted to the ER, if not the ICU and they were, they were not even admitted oftentimes or not even allowed in because they were told they probably S you know, swing it. Do you think that that played a role in, in, in let’s say long haulers or people who are known as long haulers?
I mean, to be honest I don’t think that was at that time, the wrong thing to do for a number of reasons, the first is it would be one thing. If we had a therapy to offer that, that if we had something to say, take this drug, take this therapy, it will make you better come to the hospital. We can give this to you. But instead what ends up happening is at that time, patients would come in and they they would be put in a room. They could have, you know, no family members, if you’re all alone you know, with overworked you know, overwhelmed staff and if they weren’t, as they probably would be better off at home I think the situation is a little bit different now because we do have therapies. And we do have a better understanding of the disease that can help, you know, alter the course of the disease. You know, it’s, it’s not groundbreaking. It’s not like, you know, a therapy that cures all. But I think, you know, if patients are sicker and they do show up earlier we may have you know, therapies and interventions that, that ultimately help outcomes early on and, and perhaps later on.
Gotcha. Gotcha. What I would love to do is I would love to start with the respiratory system and then go to cardiac. What are the things that you saw early on, and for people that were not admitted to the hospital that are long haulers now that are having difficulty getting care, what testing would you like to see them see them get? And you know, what things would you be looking for?
Yeah, I mean, so as I was going back, the, the, the main issue with this disease is you’re still going to understand you know, we’re characterizing the, the severe form that says acute respiratory distress syndrome. And what we started to recognize was that their lungs were not that stiff. And as a result there were also many patients who had very low oxygen levels that were not in respiratory distress. This is sort of the patients with very low oxygen levels, but just send it in, they’re kind of texting or, you know and that’s a sign that the lungs are not stiff. And so when that, when that’s the case the first kind of, part of the lung that we start to to question if it’s affected are the blood vessels of the lungs and early on when this was happening the the way many patients kind of presented and look, they all looked like they were having blood clots in their lungs, quite frankly.
And as a result, we, you know, started giving therapies like breaking blood, you know, blood thinners and giving medications to break up the clots. And you know, there are, there’s a lot of you know, unfortunately autopsy studies that have shown that there are kind of blood clots in patients. And so that seems to be playing a role. Another thing is that it seems that many patients have very abnormally, dilated blood vessels to the lungs. So the blood vessel is lungs are, are not constricting appropriately. They’re very dilated, too much blood is going through them. And as a result oxygen levels are going very low. And so this is a very a problem that clearly affects the blood vessels in the lungs both causing them to dilate and also causing them to form clots. But it also causes inflammation in the lungs.
And you know, for some people that inflammation seems to get better for some people that inflammation results in scarring, and as a result that scarring results in you know, exercise intolerance and inability to do the things that they were able to do prior to disease. And that’s not to mention, you know, all of the other organ systems that are often infected as well, including things like, you know, the kidney neurologic issues, the heart. And so, you know, it’s, again only been a few months since this, this disease has, has, you know, come here. So we don’t have obviously experience or data with respect to the natural history and what the course of this is. I’ve seen, you know, a number of patients in my clinic. Who’ve had COVID you know, either patients who have had it and have stayed home and weren’t very sick, but are still having kind of persistent symptoms that are, you know, intermittent and they come and go. And then I have patients who’ve been, you know, very sick in the hospital. Who’ve had significant scarring in their lungs and you know, other issues related we don’t know what the course of this will be whether this will get better whether there are therapies that can help alter the course of this. And you know, it’s unfortunately a a black box right now.
So, I mean, I think the question that everybody has is, is the scarring a, is, is the scarring ever gonna go away? I’ve heard people say, you know, typically no is the scoring with going to be progressive. And I guess the answer is still, we don’t know at this time, right. You know, the,
The unfortunate aspect is we are extrapolating from other diseases and other conditions. And so that’s why you know, when someone has classical acute respiratory distress syndrome from say influenza, and they have a certain finding on their cat scan later on we know exactly, you know, the likelihood of what will happen here. We can say it might be similar to that, but you would be foolish to do so. And part of the horror that I had during the initial COVID spread was that patients were not behaving the way that we expect it to the behave behave acutely. In that generally when, when they’re on ventilators you know, they require a ventilator basically is a machine that pushes air in so that you don’t have to pull airing and it also can deliver high amounts of oxygen. And so the way that we know that a patient is getting better is that we don’t have to push as hard and the amount of oxygen we give goes lower and lower and lower, and then, you know, patients get better.
And then we take the two about in all is good. And that’s usually how the acute respiratory distress syndrome, you know, behaves patients with COVID. And again, the PTSD I have from this is that patients would get better and then they would, you know, the tube would come out and then all of a sudden they would have a cardiac arrest out of the blue, or all of a sudden, you know, the, the tube would go back in or all of a sudden, and it was this you know, unclear, natural history of you pretending, like we knew, like we had control of the situation and we understood what was going on yet. It was just all over the place. And it was very hard to predict on the flip side there were times when patients were on the ventilators for weeks upon weeks, upon weeks upon weeks, and under any other circumstance, you would give a prognosis to a family and say, you know, given the experience that we have with patients with, you know, classical ERDs and, you know, the, the survival or functional capacity of your loved one is close to zero, and they would walk out of the hospital.
And so I kind of have the same view of the longterm complications of this in that quite frankly, I don’t know. And I think it needs to be properly studied. You know, in the sense that you know, perhaps this is a short term effect perhaps it’s a longterm effect, perhaps it’s an intermittent effect and, you know, you of all people know, I know better than most that, you know, shortness of breath is not from one cause. And they’re, you know, many, many different causes of shortness of breath and inability to exercise because all of your organs work together to help you do the things that you need to do and do them well and do them, you know, at high levels and when one or a couple of them are off, you can become limited. And so that includes things like, you know, your lungs in terms of how well they can expand and not the blood vessels of the lungs and how they can extract oxygen the heart and how well it pumps the blood vessels everywhere else in terms of how it can you know, regulate blood flow, how blood can come back to the heart, and then even just the sensation of breathing and the sensation of of everything that’s going on, all of these things can possibly be altered.
And, you know, we need to figure out, you know, does everyone end up in the same way, or are there some people that are like type a and type B and type C and we can treat them accordingly. But what I can say is that you know, it definitely has affected people longterm you know, patients I’ve seen steadily make improvements. But you know, the concern is that at some point in time, they will plateau and that plateau is not back to their normal baseline or something that they would find appropriate.
Yeah. You know, I have a similar feeling to you, which is that there’s kind of like everything that I thought I knew pre COVID and then it’s like everything post COVID is like brand new start because chest pain doesn’t mean what chest pain used to mean shortness of breath doesn’t mean when shortness of breath used to mean. And with, with this group, you know, I’ve spent a lot of time with long haulers and it’s like a hundred people could have the same symptom and it can come from something totally different really fascinating and, and scary at the same time. Can I, can I ask you to explain a little bit what does what does it mean when somebody has ground glass opacity?
Yeah. So when we look at a scan of the lungs, the cat scan of the lungs you know, the lungs are obviously filled with air and you should basically see black stuff and not the normal lung with some areas of you know, where the vessels are and where the airways go. If there’s white stuff in the lungs and that white stuff, doesn’t completely obliterate the image and it looks like ground glass kind of crushed glass. And you can see the underlying images that’s ground glass opacities, and that is a reflection of essentially fluid and the air SACS and that fluid in the air SACS can occur. Because the capillaries in the, in the lung, the blood vessels in the lungs are leaky. And when they leak, they spill over into the air sex. And when that happens obviously oxygen can’t get into the blood vessels of the lungs in that area. And so you know, that’s one of the ways, obviously that COVID causes this issue
And that’s different than fibrosis, correct.
Right. So fibrosis is, so again, this is the kind of the classic acute respiratory distress syndrome paradigm. We call this also acute lung injury. So when the lung gets injured so the lung is basically made out of airways that lead to be sex where capillaries or blood vessels go by. And when they meet that’s where gas is exchanged, oxygen goes into the blood and carbon dioxide comes out, and then you breathe that out when when there’s inflammation in the lungs. So you get an infection or you have, you know, an infection in your body, these capillaries and the and the alveoli, which are the air SACS can become very leaky. And when they leak fluid leaks into the air sacks, and as a result gas and oxygen, can’t go in here. And when they leak into the lungs, the lungs become very boggy and very stiff.
And it’s very difficult to, to, to breathe in the lungs over time. We’ll try to heal that. And whenever you, for example, injure yourself, or you get a scar, and that’s your body’s way of of healing your body does the same thing in your lungs. Ideally it wouldn’t form scores but in some cases it will form scars and that scarring makes the lungs even stiffer. And for now we’ve used scarring in the lungs as sort of a permanent situation, that something that doesn’t go away, but with all things COVID nothing is kind of sentence.
We don’t know. So, so is it accurate to say that if you do see it, a cat scan with ground glass opacity, that there’s a possibility that that’s going to resolve over time?
Yeah. So, and when you compare this to, cause there are many, many lung diseases, you know, obviously outside of COVID where we see patterns that look like ground glass, and we see patterns that look like scarring fibrosis, and in general, the patterns that have the ground glass those have a reasonable probability of going away. Those that have scarring and fibrosis don’t really ever go away. There is the possibility that the ground glass kind of converts into fibrosis cause that is for some people, a healing process, there are some lung diseases where the main problem is, is a abnormal way of healing. You just start forming scars all over the place in the lungs
And what would be a classic treatment like for, for ground glass opacity, if there is one,
Right? So, you know, if, if, if the ground glass opacity is because of inflammation the, the treatment really is to tame down the inflammation and the therapies that we use to tame them, inflammation include, you know things like steroids, corticosteroids, and in fact steroids are one of the treatments that we have that have with the clinical trial demonstrated you know, a survival benefit. And so that is something that patients who have that we give them steroids. And so if you treat the underlying infection and the underlying inflammation, then that those ground glass opacities will ideally go away and, and lead to outcomes that are good. The other things that you know, REM disappear as an antiviral drug against the virus that has clinical trials that have demonstrated improved outcomes.
So those are really the two main therapies that we have that seemed to improve patient outcomes. They don’t cure you, like, it just simply reduces the percentage of people that get worse. And it does you know, have a benefit in terms of survival. All the other therapies are kind of still being tested out. And, you know, there are a million and a half clinical trials right now you know, looking at different kinds of anti inflammatory drugs drugs that target very specific pathways that cause the inflammation I’m running a clinical trial on drugs that break up blood clots in the lungs for a subset of people. So again, it’s not a one size fits all type scenario. But that’s yeah, we’re growing glasses.
Thank you. One of the challenges that a lot of our patients have had is they have certainly earlier on, they had difficulty with people taking their symptoms. Seriously. A lot of people thought that it was in their head or anxiety or things like that. When should somebody really insist or seek out the help of a pulmonologist?
I mean, I think, you know, symptoms being in your head is a possibility, but it should be the absolute last possibility in that you know, there are as part of the, the causes of shortness of breath there are neurologic and psychiatric reasons why someone can be short of breath, but we, we view, or I personally view that as what I call a diagnosis of exclusion. And so personally, when you evaluate a patient who has shortness of breath period the things that you want to really evaluate are things that are dangerous, that you can do something about or things that you know, if you don’t catch or you don’t identify they will get worse because, you know, you would otherwise have had therapies to have to adjust it doing diagnostic tests that will just identify, you know, something that there is no treatment for.
You know, if it’s not invasive by all means, if it’s invasive, then you know, that’s something that might not be so helpful. But part of this is that if you are having symptoms, I think it’s appropriate to bring them up to your healthcare professional. And if they’re not being taken seriously, then they think you need to see a new doctor. And it’s being taken seriously doesn’t necessarily mean do every test in the book. It does mean though to, to have someone that that’s listening and addressing those concerns and trying to, you know, put the pieces together as to why or why not certain organs and systems may or may not be functioning well and what needs to be done going forward.
Gotcha. And can you explain what the difference is between, like, what can you find out on a chest X Ray, and what could you find out on a cat scan? And then what’s the difference between contrast versus non-contrast? Yeah, so
Sex rate is just a very blunt tool where the extra beams go from front to back and you look at the film and you see this two dimensional image of of, of the lungs, the lungs and the chest and everything, as you obviously know, are not two dimensional. It’s three dimensional. And the cat scan is basically many, many tiny, tiny x-rays that go down like this, and we can look at it kind of like slices. This way we can look at it, slices this way. We can look at it in many different ways. And so it gives you very fine detail as to what’s going on in the lungs. When you are trying to look at the blood vessels of the lungs particularly when you’re looking for blood clots you would need something that lights up during the cat scan, and that’s when we give intravenous contrast. And so in the hospital, and we’re concerned about blood clots and pulmonary embolism that’s the treatment of the diagnostic test of choice is a, is a CT of the chest with intravenous contrast.
Gotcha. Thank you. And do you have a sense, like so many people wind up with normal tests, so normal, normal chest X Ray, normal cat scan in many cases, normal PFT, but there’s still short of breath. Any thoughts on that?
Yeah, and I that’s, that’s probably the most aggravating situation. And it’s, it’s a little presumptuous, I think for someone who has those symptoms to tell a medical professional that they’re having those symptoms and tests are done, and the medical professional says you’re fine. Because clearly that patient is not fine. And it simply is that those tests and have not elucidated what’s going on. Unfortunately I personally have seen a number of patients. Who’ve had this situation where at the end of the day, patients have exercise and tolerance and they get short of breath and it’s, it’s unclear why. But I think you know, there are many, many possibilities. I have a lot of kind of research ideas as to, you know, what possible things could be going on in some of these patients that can cause shortness of breath.
But it, it will take time and, and, you know, large studies for this to be kind of better characterized. The one thing I would say is that, you know, listen to your body and if you are having symptoms and if you are short, you know, short of breath so acknowledge that that’s the case and to realize that you’re not crazy you’ve had, you know, an infection that’s doing something or has done something and that, you know, hopefully with time there’ll be more answers that will help elucidate what’s going on and ideally therapies to make people feel better. Yeah. On the flip side, maybe your symptoms will go away. You know, and part of this, the, the strange thing about this disease is that the symptoms are often episodic for a subset of patients. Like they feel fine. And then all of a sudden they start randomly having chest pain. Their heart rate goes up and they can’t walk and then they feel fine again. And it, it, it, it would drive people nuts if like you have this uncertainty about what’s going on and you think you’re having a heart attack every second, or you think you’re having a blood clot or think, you know, something else is going on. But you know, unfortunately that’s the reality of the situation.
You know, what I, what I’ve found with a lot of patients is that contrary to like cardiac patients or pulmonary patients that we’ve seen in the past where our goal is to push them, there’s a very, very fine line between, you know, moving forward and setting back. So it’s like people could do a minute, two minutes, three minutes, but that three minute and 15 second Mark something happens where it’s like the cutoff switch and, you know, it can really set people back. So even with our bootcamp, we’ve had to scale it back significantly. And I think a huge amount of it is inflammation based. And, you know, I have this idea of like some of inflammation or net inflammation in the whole body. I dunno, it’s very so, so let me ask you this. So besides the chest X Ray cat scan, pulmonary function tests, are there any other tests that you think that people should have if they’re not finding the cause of their shortness of breath? Do you think maybe even the test is just not available yet or doesn’t exist yet?
Yeah, I mean so part of the, you know, I would view the workup of, of, or the, you know, the diagnostic test that one does for COVID you know, our post COVID to be just the diagnostic test that someone does for shortness of breath and exercise intolerance, period. And so basically what you’re trying to do is evaluate all the parameters that play a role in people being able to exercise. So that includes heart function. So an echocardiogram should be done for people who you know, are short of breath. And that’s basically to look to see if, you know, the, the heart’s pumping well. If there are any valuable problems or if there are signs that their blood clots in the lungs you can see that, you know, if the right side of the hardest failing and if you have pulmonary pretension, which is, you know, I feel and then imaging like a chest X Ray, and then a cat scan is more fine detail.
We’ll show you some stuff. And then pulmonary function tests are essentially breathing tests that allow evaluation of how much air can come in and out of the lungs how well oxygen can be, can be extracted in the lungs. And then you know, if those are kind of unrevealing then there are some more advanced tests where you know, an exercise test, for example where we can see how much exercise you can do, like on a bike and see how much oxygen you can use, the more oxygen you can consume, the more fit you are, and everything is working in tune. It’s kinda like the Gatorade commercials when people have the mask on the exercise bike, and that’s called the karma cardiopulmonary exercise test. We’re actually contemplating doing those types of tests in patients who are short of breath and having a catheter to measure the pressures in the heart and the lungs you know, to see what kind of changes are occurring that may describe you know, patients that’s a little bit more advanced and, and not something that you know, we’re doing just yet.
But that probably will be you know, what’s down there down the road,
Call me when you’re ready for that. I have some ideas too. What about the heart? What kind of, what kind of hard tests should people be getting? So again, people are getting EKG is their normal people are getting echos, they’re normal, but we’re hearing a lot of studies recently about heart damage and cardiac MRI. What could you tell us about that?
Yeah, I mean, it’s it’s, it’s unclear what that actually means. You know, there are tests that indicate that there may be kind of inflammation in the heart and if there is inflammation in the heart, it may be what we say is a subclinical, which means it doesn’t really cause anything. And if it doesn’t cause anything and it goes away, that’s kind of like a no harm, no foul. If there was you know, there are viruses that actually do affect the heart really badly and when they do so they cause significant heart damage and the heart stops basically pumping appropriately and they go into Hartford failure. We aren’t necessarily seeing that. I mean, there are cases in the hospital acutely that we see it’s called myocarditus and that doesn’t happen. You know, it hasn’t necessarily been described you know, frequently in kind of the postcode way in the same way that this subclinical inflammation is that that we’re seeing
Some of the numbers of people who are asymptomatic are, are kind of scary when it, when they talk about how many people’s hearts are affected later on. How serious is that? And for example, how worried should somebody be about exercising or as clinicians? How, how worried should we be about pushing somebody during exercise from a cardiac perspective?
I mean, personally, I, again, this is based just on gestalt and the small amount of experience I have, but you know, I, I think patients should do as much as they can, the two and I, it’s the kind of you know, advice I give patients who have any kind of cardiopulmonary disease is that you, the point of exercise is to get short of breath. If you’re not getting short of breath, you’re not exercising. But that if you develop chest pain, or if you develop lightheadedness, those are kind of hard stop. Like, you know, that’s when we definitely stop. But that you should push yourself to some degree of shortness of breath. And that you know, we haven’t necessarily seen people exercising and, and, you know, dropping dead you know, post COVID at least as, as, as far as I know.
So I think it’s, it should be viewed as a cardiopulmonary condition of unclear, you know, mechanism and exercise, you know, should be done. And, you know, you obviously no better than, than, than everybody that the point of exercise, I mean, there are a million and a half benefits for it. But that you know, with exercise, you’re able to basically do more with what you have. And so if you have a compromised cardiopulmonary system and you know, you can only walk like two blocks you know, the goal of doing exercise and, and an exercise program is to be able to walk four blocks to walk 10 blocks. You know, I personally, I can’t run a marathon but if I wanted to do that, I would have to train and do an program. And so someone who has, you know, a cardiopulmonary condition COBIT is, you know, a cardiopulmonary condition, the goal may not be 26 miles and maybe, you know, three flights of stairs. And so I think that’s the you know, the goal for exercise and it’s a critical component because that’s one of the main complaints that people have is I’m, I’m short of breath. I can’t do this. And one of the things that can improve your exercise tolerance is exercise irrespective of what the underlying condition is.
And what about the use of oxygen? So a lot of people they do de saturate, but they are never offered oxygen in the same way that somebody with COPD or pulmonary fibrosis might be, do you think they need to be on oxygen?
I mean, if people have low oxygen levels at rest not moving, they definitely need to be on oxygen. That’s an easy one. If people have normal oxygen levels at rest and then their oxygen levels drop with exertion, when they walk, that becomes some, a little bit more complex because, you know, it’s unclear whether giving oxygen in that situation at least on a day to day basis changes outcomes in patients. We know in CLPD, for example, at least in this one study where they did that, it didn’t really alter the, the final outcome of, of patients in terms of how well they did and you know, a number of metrics. I personally think that if, if you do desaturation and you have oxygen, you might as well use it. And you know, I I think it also will allow you to exercise more because one of the reasons why people become short of breath is that their oxygen levels go low. And this is a way that can augment that. I would not want exercise because you don’t have oxygen.
Yeah. I mean, we’ve been very successful with our PF patients and our pH patients by giving them a ton of oxygen. I can’t wait to get into the lab and start trying it with some of the post COVID long Waller’s. I think we’re going to have similar results. I’m going to go to some questions from the chat, if that’s okay. Would you suggest that long haulers with recurring symptoms pursue steroids?
I, I would not. You know, part of this is, you know, I wouldn’t pursue therapies. That’s the one thing I would say I would pursue help and you know, medical attention. But I would not be your own physician and, you know push for particular therapies. If you find a physician that, you know, you trust and explain things well, and you know, then I would go that route. Because part of this is it’s very unclear. You know, steroids are not a benign therapy. They’re they’re therapies that we use for inflammation because they reduce inflammation, but they’re immunosuppressants. So they shut down your immune system. And you’re now at risk for infections longterm steroid use increases your risk of diabetes and wound healing and osteoporosis and all kinds of things. So you know, they should be used judiciously and, and and with people who have experienced in terms of, you know, what they’re doing, again, a lot of people are extrapolating.
I’m guilty of this myself and, you know, giving you know, therapies in the ICU for patients. It was based solely on the physiology that I was seeing and not based on, you know, guidelines and clinical trials, because the virus, I don’t think been here for two months. And so I think you know, I would be cautious of also the pop media kind of discussions of therapeutics have kind of learned their lessons with hydroxychloroquine in that you know, these therapies can be dangerous and maybe ineffective. So you have to, you know seek, seek help from people that, you know, hopefully know what they’re doing, and hopefully they know more as time goes on.
Don’t don’t pursue the Clorox, right?
No, I mean, again, you can kind of spray it here and there, but okay.
Got it. Okay. does diaphragmatic breathing help prevent the lungs from worsening?
I don’t think there’s any breathing exercise necessarily that alters the lung itself in terms of inflammation and scarring. I do think exercise or breathing exercises and so on may assist with your sensation of breathing and how you kind of handle shortness of breath and handle that anxiety that comes when you’re short, you’re short of breath. But it doesn’t actually affect, you know, the architecture or anything with respect to your lungs.
So this is a very common question for people with symptoms, shortness of breath, exercise, and tolerance, but every test comes back normal. Where does that person go?
I, you know, I would probably just follow with, with a doctor and there may be kind of a monitoring of symptoms because at the end of the day part of this is also to track symptoms. And if you take you know, other conditions, for example you know, posts, you know, classic RDS or critical illness or even, you know, things like a blood clot that may, may not be as severe or asthma or anything like this, where you may have symptoms that are pretty severe at the beginning you may have attacks and exacerbations but there’s a clinical course that it kind of follows. And the what interventions are done are based on that clinical course. So it’s different if you have symptoms and it’s like, you know, once a week you get a little bit shorter breath at a particular time of day, versus if you’re completely short of breath and you can barely walk half a block and you used to be able to, you know, jog every day.
And you want to know the trajectory of how this is going. If if the status quo right now is not good, but your overall trajectory is getting better in medicine in general, that usually means you’ll hopefully continue to Annette trajectory. If things are kind of stable and they stay the same it may mean that it will kind of stay the same when you really should be concerned if, as if things are getting worse. That’s when you need to kind of you know figure out if something’s actually going on.
Can you talk a little bit about the different types of chest pain? One of the things we’re hearing from people, you know, between the neck and the gut we know a lot of people have reflux. We know a lot of people are reporting pain kind of in this area, but it doesn’t seem to be the classic chest pain that we worry about. Let’s say like a coronary insufficiency. What can that be? I mean, it’s, it’s so commonly reported.
Yeah. I mean that, it’s, it also, you know, it’s very frustrating because you know, you should be cautious when, you know, as medical professionals, I sometimes don’t think we speak well to patients. And in, in that, when someone says they’re having chest pain our response, when we’ve ruled out the kind of things that may be dangerous are, don’t worry about it. And that’s not really, you know, the, the important aspect is in our minds, we’re thinking, all right, is this reflective of something that’s going to kill this patient, like a heart attack, a blood clot you know, and then when we’ve ruled those out, we say, okay, well, we don’t really care about it, whereas the patient’s actually having symptoms of chest pain and that can be disconcerting. And so it’s but from a patient standpoint, it’s important to in your own mind kind of characterize that in a, in a similar way, there are you know, pains that are harbingers of bad things things that are trying to basically, you know, scream for help.
And those are things like you know, the, the blood vessels of your heart becoming narrow with plaque and possibly leading to a heart attack. You know you can have blood clots in your lungs that can, that can be causing that in general, when you have those the more you stress your cardiopulmonary system, the more chest pain that you get. And so if you’re sitting around and you randomly get a chest pain, and then it comes and goes, and it’s kind of extremely random that is much less concerning for a cardiopulmonary reason than if you walk in every single time you walk, you get chest pain, because that’s basically saying that when you are asking your heart and lungs to do more, it hurts. And so that’s when my kind of ears like go up when
I, when I hear, you know, yeah, I get chest pain every time I walk. That’s more concerning to me. Another kind of pain when there’s a, the lungs don’t actually have nerves inside them for pain. It’s on the outer portion that have nerves. And sometimes when you get inflammation on the outer part of the lungs that can hurt when you breathe in, that’s called pleuritic chest pain. So the pleura is what lines, the lungs when there’s inflammation and you breathe in, it rubs against the chest wall and, and that can hurt. So sometimes people have pain when they breathe in the COVID stuff though, it’s random and it’s pain. That’s like here, it’s there, it’s all over the place. It comes and goes, it’s at rest. It wakes them up. It, you know, it’s usually not associated with, with exertion and doing and stuff.
And so that’s why you know, I think, again, this is just my gut feeling that it may involve kind of the nerves, perhaps that like the nerves are kind of malfunctioning and it’s giving the sensation of a pain. I mean, not the sensation. I mean, that is what pain is. But that’s not to say that, you know, patients aren’t experiencing it, it’s important to help distinguish that from things that are dangerous. And, you know, as a patient who may be experiencing this if the important things have been ruled out, you can kind of rest assured that like, yeah, I get this annoying pain, it’s annoying, but it’s not going to kill me. And I’m just going to kind of acknowledge that it’s there acknowledged that it’s not in my head. But that it’s, it’s, you know, the important things have been ruled out
Many patients report sort of a, not an immediate discomfort during exercise and sometimes not even a few hours later, but often the next day. So they’ll report, you know, particularly post exertion, malaise exhaustion and some people’s kind of what seemed like dis autonomic symptoms come back from that. Do you have a sense of what that could be coming from?
Yeah, and I mean, I was actually just thinking about this yesterday. A lot of these symptoms that I think are very similar to a condition called kind of chronic fatigue syndrome and a condition called pots, which is postural orthostatic, orthostatic tachycardia syndrome. And you know, the pot syndrome is a syndrome where the, the main problem is that the veins of your body need to constrict to get blood, to come back to your heart. And so when you stand up, your veins need to constrict, or when you exercise, they need to constrict to get blood, to go back to your heart. So it can pump it. Patients with pots have an abnormality where they can’t do that. And so they, you know, the blood doesn’t come back to their heart, their heart races, they get short of breath, they’re they may get dizzy and they can barely do stuff. And then this is also associated often with what’s called chronic fatigue syndrome where are just wiped
Out after they do anything, they want to sleep for hours. And part of the issue is that many people don’t believe in this disease and they call them. They’re crazy. And, and I, and I’m, and I’m starting to think that this post COVID is a similar scenario where you know, patients are being seen by physicians. There are all these tests are being done, and they’re like, you’re fine. Go on with your life. You’re, you’re crazy. And the one thing I want to emphasize is that it would be a little bit weird if this many people went crazy. So, you know, clearly there’s, there’s something going on. And just because we, as, you know, the medical community can’t characterize, it doesn’t mean something isn’t going on. You know, I can tell you that a lot of people are trying to put together programs to help, you know, figure this out and ideally, you know, come up with therapies to, to mitigate these symptoms and make people feel better so they can do more and get on with their lives. But in the meantime you know, it involves a, you know, a degree of patients on people who are unfortunately affected by this you know, and the symptoms can be very debilitating.
Yep. Yeah, I think, you know, that’s the one area where I’ve started to see a pattern with patients, thankfully you know, for a lot of patients where it seems like they have these pots, like, you know, syndromes and you know, where we could get them, you know, on compression garments or get them really electrolyte it up and things like that. That’s, that’s where I’m hoping to really see some, some exciting things. Once we get back into the, into the clinic. I, what about the role of, of like Bronco, dilators and inhaled steroids here? Like, do you think there’s any benefits?
Yeah, I mean, it’s hard to know. I mean, most, most patients don’t really have, I mean, strangely again, a lot of patients are going to be better characterized with you know, what’s going on. And I think it, it doesn’t seem like, you know, so something like the flu or even like other respiratory viruses they often affect the airways. And you know, often people will develop asthma like syndrome afterwards and, and quite frankly, as Matics are often very at risk for developing asthma exacerbations when they get the flu or when they get other these viruses. And that’s not what we’re seeing with COVID COVID is not really acting like a true respiratory virus in the same way that these other respiratory viruses are acting COBIT is really like attacking blood vessels in very weird ways. And it happens to be attacking blood vessels in the lungs. And so it’s with respect to like Bronco, dilators that as far as I know, it doesn’t seem like patients really have abnormal airways in terms of you know, twitchy airways that caused them to constrict, like you would have with, you know, asthma and CLPD. If you happen to take
It and you feel better do it, you know, and, and you’re, and most, most I can tell you most pulmonologists you know, their goal is to make people feel better. And if, if a, if an inhaler, you know, subjectively makes you feel better I would use it. I would not use it just because you think it would. And it doesn’t because I would only really do that. If there’s actual evidence that, Hey, take it, it’s good for you. You know, we don’t have that eminence
EFT evidence or, or or symptomatic evidence
More like clinical trial evidence. If, for example, you said that post COVID, if we gave patients this inhaled therapy, even if they don’t feel better, six months later, they will either, you know, or something important will happen. Whereas if you take something and you immediately feel better, I mean, I would do it because, you know, there’s, there’s rationale to do that.
Or are there any supplements that you recommend regularly to patients anti-inflammatories or anything?
Not really. I mean, there’s no nothing that, you know, I think a good, healthy nutritional diet, like is important irrespective of whether you have covered or not. So but yeah, I don’t think there are any real supplements that I could point out that would have any specific effects.
And as far as cardiac arrhythmias, are there some that you’re seeing more than others? Are you seeing things besides just like tachycardias? Okay.
Personally I’ve only really been seeing just, you know, sinus tachycardia, just people’s whose heart rate, just kind of race. And there are a lot of them, my colleagues that got sick and you know, it, it’s interesting to be able to talk to physicians who have an intimate understanding of physiology and disease who will go through the disease process themselves because they speak about it in a different language. And it’s really interesting patient, you know, one of my colleagues, she her heart rate would just race. And she was very short of breath and her oxygen wouldn’t go low and she got the, you know, billion dollar workup of tests. And at the end there were just kind of like, you know, I don’t know. And I the problem with this disease is that, you know, it is acting, as you said, like a dysautonomia, like the automatic autonomic nervous system isn’t working, you know, appropriately hearts are racing, you know, normally hearts race, for reasons that are appropriate. And maybe that this is some kind of inappropriate reason, unclear. Yeah.
Is there a role for beta blockers there?
If, if the primary problem that the, is that the heart’s doing this by itself then yes, if the heart is doing it in response to a physiologic reason, then you’re blunting that physiologic reason. So I’ve had some patients were on beta blockers and they actually feel worse. Their heart rate goes down, but they feel worse. And so it’s not that the high heart rate at heart, the high heart rate is the problem. It’s that there’s a problem, and you’re trying to fix it with a high heart rate. And if you bring that heart rate down, you may be actually causing more symptoms.
Gotcha. Gotcha. Do you think that once somebody gets to a certain point, like for example, once a long hauler has hit, let’s say the six month Mark or the three month Mark, are they still at risk for clots? Are they still worried? Do they need to worry about the same things that we see early on?
So far I think, no. Partly because, I mean, I, I basically hear about every blood clot that happens in this hospital. And the thing that was kind of crazy about what was going on early on was that patients would have COVID it would come into the hospital, they would be fine and be ready to go discharge. They would go home. And three days later, they come up with a come back with a blood clot or the presenting symptom was that they were having shortness of breath and then they have blood clots and then we test them and they have Kobe. So it’s, it’s very clear that early on COVID increases your risk for blood clots. I have not seen patients who have gone home after COVID months out, come back with blood clots. So you know, and we’ve had lots of patients here with COVID. So I think that in all likelihood that risk of increased blood clots is early on and, and probably Wayne’s precipitously.
Awesome. That’s that’s good to know. What does it mean if you de saturate when you’re sitting, but when you move around your SATs go up deeper breath. So,
I mean, this actually brings up a fascinating point in that at the risk of not getting too technical. One of the one of the crazy abnormalities that as I mentioned though, we were seeing was that the, you know, in the very sick people especially the you know, patients on ventilators, their lungs were not stiff, but their oxygen levels were extremely, extremely low. And so this was kind of screaming issues with the blood vessels, the lungs, and one of my colleagues, she’s a neurologist. And she we noted that patients had a lot of, especially the very sick ones in the ICU had a lot of neurologic issues. They weren’t waking up, they were delirious they’re on ventilators. And she had this machine, it’s an ultrasound of the brain. And it’s an ultrasound of the blood vessels of the brain.
And there’s a helmet that you put on and when you put this helmet on, you can look at the blood flow in the brain and you can walk from this machine for hours and if a tiny little blood clot or something goes by that vessel, it’ll have a little blip. And so she was hypothesizing that perhaps you know, patients were not waking up because you know, they’re prone to developing blood clots and that they were throwing blood clots into their brain and that we were just weren’t detecting it. So she put these things on a bunch of the patients with COVID in the ICU, or weren’t waking up and didn’t see any blood clots. But what she did do was something called the bubble study. And this is where you know, a test that’s done to look for a small hole in the heart called the pump Peyton of Valley.
When you take a saline and put a little air in it and shake it up and inject it vein, it should basically go back to the right side of the heart and then into the lungs, the blood vessels of the lungs. And then once it reaches the tiny capillaries of the lungs, because the bubbles are bigger than the capillaries, they should get stuck and then they should kind of disappear and you should never see any signs of it ever again, if on the other hand, you have a hole in your heart it will go into the right side of your heart, cross into the left side of the heart, and then it will kind of go to the brain or some of them will go to the brain and this machine will pick it up. Yeah. And so when she did this, she noted that she did seven patients and she noted that nine of them had these bubbles when she injected them.
And so, so it’s important to note that only about 20% of people in, you know, world have a hole in their heart. And so when this happened, she was like, there’s no way that, you know, this percentage of people had had a hole in the heart and she called me and I literally had like a cup of coffee in my hand. I almost dropped it when she told me, because what this indicated was that these bubbles weren’t going through the heart, these bubbles are actually going through the lung. And it was indicating that the blood vessels of the lungs are abnormal dilated. And so they were abnormally dilated, and they were very similar to a condition called Tapatio pulmonary syndrome, which is a disease of patients with liver disease, where the blood vessels of lungs get abnormal dilated. And so one of the weird things with hepatopulmonary syndrome is that when patients sit up there, oxygen level is actually lower than when they lie down, they’re actionable actually goes up and that’s because more blood flow goes to the bottom of the lungs when you’re sitting up.
And that’s where the blood vessels are dilated when they, I doubt that’s what’s happening. And so we actually did this study on a whole bunch of other patients and were able to show that close to 90% of patients had had evidence of these bubbles and that the worst your auction, well, the more bubbles you had, right. So one thing that I actually want to do going forward, you know, once I got funding and so on is to see whether these long haulers, these people who are, you know, are they short of breath because the blood vessels of the lungs are ignored and we dilated. And so there’s a lot that’s happening in terms of, you know, abnormal, you know, blood or issues, whether it’s in the lungs, whether it’s yeah. Elsewhere that we really know about. So you know, if you, if your auction goes up, when you, when you I think you said when you’re sitting in de saturate, but when you move your SACS go up there are a number of possibilities. But that you know, this abnormal blood vessel could be, could be playing a role. That’s a good thing, though. It sounds go up when you exercise.
So, so just so I understand, are you saying that the, the significance of the blood of the blood vessel being dilated in the lung is that if, if it wasn’t dilated, normally it would have got caught by the lung. It wouldn’t have made its way through the circulation.
Yeah. So the, the, the CA the bubble would get stuck in the capillary, and then it would just kind of disappear. Right? It’s not that it would be a PE, but that it would just the, the bubbles are very, very tiny and they don’t do anything. And then they just kind of dissolve away. So you never see it again. It’s not that the bubbles are causing problems. It’s just a marker that the blood vessels are abnormally, dilated. Otherwise it would have been stopped. Right? So the lungs are very smart. They, they try to have the right amount of blood flow going to the right amount of air coming in. If you have too much blood going to this certain amount of air, then that blood doesn’t get oxygen enough oxygen. So
Very often patients are having kind of relapses and, you know, remission and exacerbation. Do you have a sense that when they do have these relapses, and I know the answer to so many of these questions is we don’t know yet, but do you, do you have a sense that when they do have these relapses, that that’s actually interfering with their healing process, or do you think it’s just sort of, could it be growing pains improvement?
Yeah, I mean, I think, you know, my best guess is the virus acutely over a week, two weeks, three weeks causes some kind of damage in some kind of, you know lasting effects on the, on, on, you know, different parts of the body, the heart, the lungs, the nerves, the blood vessels, the brain, et cetera. And in some ways that the body has kind of been rewired, it’s almost like if you think about a house that’s been put on fire you know, the fire is the virus and it’s causing this damage, but once you put out the fire, you you’re left with kind of, you know, damaged, you know, parts of the house. And so that area may have kind of exacerbations in the sense that you’re not really kind of, it’s not functioning the way it normally does and kind of worsens, and it gets better worse, worsens.
It gets better. But I don’t think that’s necessarily the virus sitting there causing that problem. And it may be that things have just kinda been rewired or, or you know, inflammation has caused changes where things are not working as they normally would. And the is that things would get better, but at the same time, it, it may unfortunately be, I hate to use this term, but the kind of new normal that, that, that may be occurring. And until there’s a therapy that fixes that new normal or addresses the symptoms that occur with that I think the most important thing is to, you know, be insightful with your own symptoms and find out what are the things that provoke it and what are the things that make it better. And, you know, if, if it is that, you know, I would take, you know, pages out of the chronic fatigue syndrome type playbook, then, you know, they cause there’s no real therapy for chronic fatigue syndrome.
But there’s a lot of behavioral things that can be done that can help mitigate the effects of it. Which mean, you know, if you, aren’t going to do something, you know, that’s going to exhaust you to, to allow yourself to rest and not schedule crazy things the next day. You know, and to, you know, take the stress off yourself by you know, not being down on yourself that you can’t do a lot of these things and set yourself up for success and not failure when this happens. And it’s an unfortunate reality. And you know, the hope is that there will be a better understanding of the disease and therapies will help, you know, with the symptoms and the effects. But you know, in the meantime, the people that know the most about the disease are those that are suffering from it. And so, you know, if do things that make you feel better and try to avoid things that make you feel worse. The one thing I would say is I still do think that intermittent exercise is important, otherwise I wouldn’t be here. But I think you know you have to kind of be in tune with your body.
Last question, what is the role of electrolytes and all this? I don’t think there’s any special electrolyte or, you know, electrolyte that needs to be enhanced or replenished beyond that, which is the normal situation. You know, I think in general, you know, again, the patients that I generally take care of, they need to stay away from salt because if salt buildup and fluid buildup and, and fluid in their body and in their lungs. But in terms of COVID I don’t really know. I mean, I I’ve, I’ve seen some pots patients in the past and I tell them they need to drink as much salt as possible, and we eat as much salt and drink as much water as possible. I’m wondering if covert is being a similar thing, and I think you know, if there are kind of patterns that, you know, you notice in yourself, I think that’s something interesting to bring up to, you know, people that study this, or, you know, your, your doctors and be like, yeah, you know, when I get dehydrated, I get short of breath or when this happens and you yourself will kind of know better than others because right now, no one knows.
Yeah. You know, I want to thank you so much for being here tonight. And I want to thank you so much more for everything that you’ve done. I know you’ve been through the ringer and my heart feels for you. And you know what I mean, when I say, if there’s anything I could do for you, it doesn’t have to be medically related. I wash cars, walk dogs, babysit, I’m happy to do it. But I just want to say, thank you so much for being here. I know you’re busy. I know you’re tired and it’s greatly appreciated, and I hope your your clinic is up and running soon because I know again, of all the therapies that I think would patients would most benefit from you know, after having gone through this is exercise. And I think you know, for, for patients to develop the self confidence to do so, and to learn the appropriate way to do it, and then also to learn the appropriate way to handle the, the symptoms that come with exercise and shortness of breath because you know, the benefits of exercise and, you know, cardiopulmonary rehab can’t be understated and that you’re able to do more.
And then that improves your mood, which then makes you do more. And it’s basically this you know, very virtuous cycle. And I mean, I used to send all my patients to know a pretty COVID you know, from pulmonary hypertension and will, you know, continue to do so when you open up. So thank you so much. All right, ladies and gentlemen, thank you so much for being here, dr. Port, thank you so much. Greatly appreciated. I don’t know. I can’t unmute everybody, but Beth, is there a reason why I can’t I want to give him the audio the audio facts. So thank you so much. Thank you so much for mine. Have a great night. Everybody