E16: Breathing Difficulties with Long COVID ft. Michelle Harkins

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Professor Michelle Harkins MD explores persistent breathing issues following COVID-19 with Dr Funmi Okunola MD. Discussing common symptoms like breathlessness, chest tightness, and fatigue, along with underlying causes such as lung damage and anxiety. Listeners will gain valuable insights into effective diagnosis and management strategies, empowering them to better understand and address post-COVID respiratory challenges.

Breathing difficulties in Long COVID often include breathlessness, chest tightness, cough, and fatigue. Persistent symptoms can stem from conditions like pulmonary embolism, fibrosis, and dysautonomia. Diagnosis involves pulmonary function tests, chest x-rays, and ruling out non-COVID causes. Disrupted breathing patterns due to stress and anxiety also contribute, requiring thorough evaluation and tailored management strategies.

Guest – Prof Michelle Harkins

Note: The podcast has no bias. All conflicts of interest are highlighted with individual guests.

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Podcast Overview:

Key Symptoms of Breathing Difficulties in Long COVID

Common symptoms: breathlessness, chest tightness, cough, wheezing, and fatigue.
Breathing issues often persist beyond 4-6 weeks post-infection.
Pulmonary embolism, fibrosis, and dysautonomia can occur.

Diagnosing and Managing Long COVID Breathing Issues

Investigations: pulmonary function tests, chest x-rays, and oxygen level monitoring.
Importance of ruling out non-COVID causes such as anemia and pneumonia.

Breathing Pattern Disorders in Long COVID

Disrupted breathing patterns can lead to breathlessness.
Causes: dysautonomia, stress, and anxiety.
Diagnosis involves careful history, physical exams, and pulmonary function testing.

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Podcast Transcript:

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Episode 16 – Breathing Difficulties with Long COVID ft. Prof Michelle Harkins MD

[00:00:00] Funmi Okunola: The information in this podcast is provided for informational purposes only. You should not use any information discussed in this podcast and related materials to make medical or healthcare related decisions. Always consult your physician or other qualified healthcare provider with regards to diagnosing and managing your medical condition. Any medications or treatments, including any discussed in this podcast should be initiated and managed by a qualified healthcare professional.

Funmi Okunola: Welcome to Long COVID – The Answers. Today’s Episode is called “Breathing Difficulties in Long COVID”. I’d like to introduce Professor Michelle Harkins. Professor Harkins is a Professor of Medicine at the School of Medicine at the University of New Mexico in the United States of America. She is the Division Chief Of Pulmonary Critical Care and Sleep Medicine Co-Chief of the Adult Center for Critical Care.

Professor Harkins managed many COVID-19 survivors during the pandemic in the Medical Intensive Care Unit. She continues to conduct research on COVID- 19 and Long COVID, and plays an active role in Project ECHO, a telehealth program that provides real time education and case discussions for community health practitioners and their families – the management of Long COVID in the community. Professor Harkins recently spoke at the Health Education, Labor and Pensions or HELP Senate committee on Long COVID hosted by Senator Bernie [00:01:00] Sanders in the U.S. in January 2024. Welcome Michelle.

Michelle Harkins: Thank you. Thanks for having me.

Funmi Okunola: Michelle, do you have any conflicts of interest to declare?

Michelle Harkins: I do not.

Funmi Okunola: Okay, so around one in four adults who are hospitalized with COVID-19 and one in six not hospitalized experience persistent breathing difficulties beyond four weeks after a SARS-CoV-2 or coronavirus infection. Breathing problems in Long COVID can exist on their own or be part of multi- organ problems caused by the coronavirus directly or pre-existing or separate problems.

Michelle, what are the common symptoms of breathing difficulties that a person with Long COVID has?

Michelle Harkins: I find most patients feel breathlessness, mostly with exertion, but sometimes even at rest. They may have a cough, wheeze, or sleep pattern or even sleep apnea, chest [00:02:00] tightness and chest pain. Those are the most common ones that I see.

Some of these symptoms occur for several weeks after the original COVID infection, but if they really persist beyond that four- or six-week period, then it’s important to seek medical advice.

Funmi Okunola: What causes of breathing difficulty are related to a previous COVID-19 infection?

Michelle Harkins: The main pulmonary manifestations from COVID are pulmonary embolism, or a blood clot that goes to the lungs, pulmonary fibrosis, which is scarring of the lungs, or a pneumothorax, a collapse of the lung, or a pneumo-reactive airway cyst.

We also see vocal cord disease or tracheal stenosis, especially if they’ve been on a ventilator for a while, and then there are a large group of patients with breathlessness and cough and chest tightness or chest pain without significant objective findings. Patients can have breathlessness for [00:03:00] more than four to twelve weeks post their infection.

Some also may have some dysautonomia with tachycardia and palpitations with dyspnea, which really is probably POTS disease, which is postural orthostatic tachycardia syndrome. Some patients also have cardiac issues such as tachycardia or myocarditis that may cause shortness of breath as well, and then some patients have underlying lung disease, then get a COVID infection and now have worsening of their underlying asthma or COPD for example.

Funmi Okunola: Great, great. For our non-medical listeners, cardiac is heart, and could you briefly, I mean we’ve talked about it in other Episodes, but just in case somebody’s watching this episode in isolation, what is dysautonomia?

Michelle Harkins: Dysautonomia is where your heart rate, for example, may increase greatly when you stand up from sitting. It’s a dysregulation based [00:04:00] on your nervous system getting palpitations or having blood pressure drop depending on what you’re doing. So, it’s where the normal nervous system changes, and you have abnormal responses with your heart rate for example.

Funmi Okunola: Yeah. So, the way I like to understand it, is that it’s a dysregulation of your automatic nervous system, isn’t it? Or autonomic, the bits of the nervous system that you don’t actively control, like your heart, your breathing, all the brain does this automatically. So, they become dysregulated.

Michelle Harkins: Absolutely.

Funmi Okunola: What are non COVID causes of breathing difficulties that a person with Long COVID could present with?

Michelle Harkins: Well, patients could come in with shortness of breath from a variety of reasons, and so looking for other causes – shortness of breath on exertion, such as anemia, that could be a problem, or a low blood count.[00:05:00] Patients could have thyroid problems or just be really deconditioned from their COVID infection, and maybe they’ve had weight gain, and that can contribute to shortness of breath, and deciding whether these things were related to developing COVID or not, but looking for other things that may be impacting their ability to do their activities daily.

Patients may also come in with totally new things like pneumonia or a new viral infection. So, they may have more acute symptoms, and again, like I mentioned, underlying lung disease that may have gotten worse, but that might have been because of their COVID infection.

Funmi Okunola: Yeah. So, you have always got to have your head on a swivel with this disease and not just tunnel in on any one thing. You’ve got to remember the broader aspects of medicine. That’s what this is sounding like.

Michelle Harkins: Absolutely. Because you have to think like a good general practitioner and in putting [00:06:00] things in, always do a good history and physical. Is this something that is COVID-related, or is this something that has developed in the Long COVID patient, or is it something not related to that at all? So always doing your good basic workup, history and physical is key to trying to help sort these things out.

Funmi Okunola: Excellent. What are the red flag or danger signals in the medical history that a physician should look out for and what serious conditions would these indicate?

Michelle Harkins: I always look closely at the vital signs and look for hypoxia, so low oxygen levels, especially with exertion because that’s important. That’s something you can treat with oxygen, but you need to know why that is happening. Other more acute symptoms – sudden shortness of breath, sudden chest pain, hurting when you’re taking a deep breath, might suggest a pulmonary embolism or a blood clot that’s gone to the lungs. Other chest tightness that worsens as you exercise or worsens as you’re [00:07:00] even doing minimal activity, could be coronary artery disease or angina.

Something we’d worry about is having a problem with the arteries in your heart. They could become blocked and give you a heart attack, for example. If patients are very progressive, shortness of breath at rest, and exertion that makes me wonder what’s going on, what is happening because usually symptoms start, and then over time they get a little bit better in the Long COVID patient.

But if things are progressing, they may have a worsening scarring of the lungs. They could actually even have neuromuscular disease, something that has started that’s new where their muscles don’t function well, or their nerves are not telling their muscles to function well. There are a lot of other things that could happen, but the progressive acute symptoms that are new should make you concerned.

Funmi Okunola: Excellent. What percentage of red flag conditions occur in Long [00:08:00] Haulers and in what timeframe?

Michelle Harkins: Well, I see patients discharged needing oxygen. But that usually improves over time, and most of them are able to wean off in about four to six months, sometimes a little bit longer. It was actually reported initially that patients that had COVID are very high risk for blood clots and pulmonary embolism – the blood clot that goes to the lung.

Some of the initial reports suggested this was an increased risk over the next six months to a year of about 25%. Now that’s been questioned, and so more recent data, and others that we talk about, meta-analyses and looking at other databases, have suggested that increased risk of a blood clot is actually really much lower.

Still probably more than someone who did not get COVID, but really in that 2 to 3% potentially in our Post COVID pulmonary clinic, we [00:09:00] saw that about 14% of our patients had a lung collapse. 11% had that stenosis in the trachea or basically a scarring down in the trachea after they were on the ventilator, and about 20% in the earlier years did have a pulmonary embolism. But I think all of these complications have become less common, especially as our treatments improved for treating Acute COVID, but we don’t see as many of these severe complications or pulmonary complications in the more recent COVID patients because they haven’t been hospitalized, and they’re not on a ventilator.

Funmi Okunola: Yeah, so those more serious complications were those that were mostly hospitalized.

Michelle Harkins: That tends to be true. Now you can have severe pulmonary symptoms without hospitalization. I’ve seen patients that had a blood clot to the lung who were not hospitalized, or they had a collapse of the lung and had a [00:10:00] lot of scarring in their lung six weeks after an infection where they were just at home. So, it doesn’t have to be a severe disease, but those that were in an ICU and had a severe disease are more likely to develop Long COVID and maybe have more severe symptoms.

Funmi Okunola: Okay, thank you. Are there any helpful investigations that a family physician should do for a Long Hauler with breathing difficulties?

Michelle Harkins: Well, I think doing a good history and physical is going to help determine if you need to do further work. That would include potentially pulmonary function tests where you’re measuring the actual function of the lung, inhaling and exhaling. You might want to consider a chest x-ray, and I always measure oxygen saturations because whether they’re sitting at rest as well as when they walk around in your clinic, I pay attention to their breathing pattern. Do they look like they’re relaxed? Are they breathing normally per se? and [00:11:00] with some patients, if you’re not sure, you might want to do an echocardiogram or an EKG – that could be reasonable too. If your history pushes you in that direction, the ultimate test is a cardiopulmonary exercise test which evaluates all causes of shortness of breath, but this is not practical.

I don’t even order it very often in my pulmonary patients because it’s not readily available. That’s your gold standard in looking at causes for shortness of breath. But in a patient with Long COVID and post exertional malaise, that may actually worsen their symptoms. So, a good history and physical, maybe a chest x ray, measure their oxygen levels, and consider pulmonary function testing.

Funmi Okunola: Excellent. Most breathing difficulties in Long COVID have been labeled as a breathing pattern disorder. Can you please explain this term?

Michelle Harkins: Breathing pattern disorder is really a condition where [00:12:00] the normal pattern of breathing gets disrupted. Now, like you mentioned before, that is dysautonomia – messing up your autonomic system that you don’t really even think about. This is what breathing pattern disorder is. It causes symptoms like breathlessness and it’s really inefficient breathing, and it can be related to hyperventilation or very shallow ventilation, irregular breathing patterns that can be triggered by activity, stress or anxiety, and it really affects the patient’s quality of life and their functional status. I think of this as a chronic or recurrent condition where your normal pattern of breathing or biomechanical pattern is disrupted, and it results in shortness of breath and other symptoms that aren’t fully explained by what you’re doing in your tests or in your exam.

It’s not really a disease process, but rather an [00:13:00] alteration of the breathing pattern. I actually see this in many of my severe asthma patients. It can co-exist with asthma. So, it’s in that pattern they are breathing with their upper airway, and they may have paradoxical movement of their vocal cords. For example, when we breathe in, our vocal cords open, but in dysfunctional breathing or paradoxical vocal fold maneuver, when the patient breathes in, their vocal cords actually close. So, they don’t get air in, and they can feel very breathless. In general, breathing should return to normal once our challenge or exercise or whatever has passed, but a lot of times it just persists, it doesn’t return to normal, and then you get habitually breathing in this inefficient, dysfunctional type of way, and that can cause some of the breathlessness.

Funmi Okunola: How is breathing pattern disorder [00:14:00] diagnosed?

Michelle Harkins: Well, usually in patients that have breathing pattern disorder, the physical exam is normal, and your pulmonary testing is normal as well as your oxygen level and chest x-ray. But there can be clues. On the pulmonary function test, for example, there can be clues on that inspiratory loop at the bottom. So, patients breathe in and sometimes that bottom loop is closed, a little flattened or it looks different each time they do the test.

That might be a clue, but the key is really to watch their breathing pattern in the clinic and with exertion and take a good history. Sometimes if I’m seeing someone and their oxygen is a little on the low side, I may put them on an oximeter which measures your oxygen level and I have them take four big, deep breaths, and then watch for their saturations to improve. Then when they’re not thinking about it, it drops back down to that low baseline level, [00:15:00] and that suggests hypoventilation where they’re not really breathing deep – maybe they’re just using their upper chest for breathing. I look for tachycardia and a variety of other non-respiratory symptoms.

You know, patients may give you the history themselves. They feel like they can’t get any air in, they may do excessive sighing, or they have really aggressive throat clearing repeatedly with you and multiple symptoms just from walking around in the clinic. So, in my asthma population, I actually physically look for vocal cord dysfunction by doing a laryngoscopy.

I have access to a scope, and I can watch the breathing pattern change and induce some of their symptoms. It’s common in asthma, but it is also common in Post COVID. So, do they have voice changes? Are they using accessory muscles or mouth breathing? and there are some specific [00:16:00] questionnaires for this too that can be used.

I don’t particularly use them because I have the luxury of sitting there with them and really home in on their breathing patterns. But there’s a breathing pattern assessment tool, and there’s other dyspnea scales that you might be able to use to help you determine if this person has breathing pattern disorder.

Funmi Okunola: What causes the asymmetrical closing of the vocal cords, for example, has anybody worked that out?

Michelle Harkins: It probably has several causes, and one can be heartburn or reflux. So, if patients have a lot of heartburn and reflux, they have that, they have swelling in the upper airway, they may have a lot of post-nasal drip as well as inflammation, and then a stressor may happen. Then the patient breathes in, and they don’t use their normal breathing techniques, and it becomes habitual.

There are several things that are suggested. Anxiety and stress may exacerbate this [00:17:00] condition. Reflux, postnasal drip, or some things that go along with that, and usually if you have swelling of the vocal cords and you can actually tell them, you can look with a scope and tell if its reflux related.

Some people that use inhalers may have extra candida or a thrush or a yeast if they haven’t cleared their throat well. So, there are other things that can add into why that upper airway may be more swollen dysfunctional when the patient is stressed.

Funmi Okunola: How can breathing pattern disorder be managed in the community, i.e. primary care?

Michelle Harkins: I send all my patients to speech therapists if I suspect breathing pattern disorder, again, from the history, and then I send them to speech therapists, and there are a host of exercises that the patient can do. I think making the patient aware that this is [00:18:00] part of their issue, maybe not total, but part of their issue may be this vocal cord disfunction or other breathing pattern disorder, and then giving them breathing exercises and teaching them the breathing techniques can be helpful. I encourage people managing what triggered these episodes to start.

Is it reflux? Maybe that needs to be treated. Maybe they need to learn to manage their stress, and that could be important, but there are several breathing exercises that can be done, concentrating on the diaphragm. I think teaching patients how to be aware of how they breathe – so putting a hand on their chest and on their abdomen, and when you breathe in, really concentrating on that abdomen moving forward, that diaphragm, so breathing deeper. There are also things you can have patients do. I have them thrust their jaw forward. If they feel like they can’t get air in up top and they know they have, I’m [00:19:00] suspecting they have rather this dysfunctional breathing, they can just thrust their jaw forward, that opens up that voice box or the larynx to help get air through.

There are other breathing techniques you can do. There’s a sniff breath technique where patients can sniff in a few times, like three times, and then breathe out through pursed lips. I can demonstrate for you if you like, but they just breathe in, so sniffing three times and then breathing out with pursed lips. That kind of helps open up and gets them to train themselves to breathe more normally.

Funmi Okunola: How can a Long Hauler help themselves with all of that?

Michelle Harkins: If they have breathing issues, and maybe they haven’t gotten to their primary care provider first, just think about yoga, Tai Chi, [00:20:00] concentrating on their breathing could be helpful, or paying attention to the patterns. Are they doing shallow breathing? So, there are those techniques, and they could do that to see if it helps. If the patient has gone into the primary care provider, teaching them breathing techniques, making sure there’s not any additional issues like asthma or reactive airways disease. Potentially you could try an inhaler to see if that makes their symptoms better. Then if it’s not clear, then maybe they need to refer on.

Funmi Okunola: Okay. Well, you kind of answered my last question which is what do you think about practicing alternative therapies such as yoga, Tai Chi, and other relaxation strategies to help ease breathing pattern disorders? There’s no evidence base, but what do you think?

Michelle Harkins: I think it’s an excellent idea. I have several patients that do that. They have taken yoga classes or specific [00:21:00] breathing technique classes and Tai Chi, and I think it really helps the issue once they can focus on relaxing. Then part of these courses or this work is also on appropriate breathing patterns and deep breathing techniques, and I think the two work together well to try to help with some of their breathlessness.

Funmi Okunola: Right. Are there any key points of this podcast that you would like to summarize?

Michelle Harkins: Well, in our pulmonary clinic I tend to follow the British thoracic guidelines on pulmonary evaluation of the patient that comes in from a COVID infection and just doing basic evaluation, looking at a good history and a physical for the pulmonary issues.

Simple testing like a chest x-ray or an oximeter reading and pulmonary function tests or even a six-minute walk can be the first [00:22:00] steps. If you find something more severe, maybe a more advanced scan of the lungs might be appropriate, but also looking for dysfunctional breathing patterns and suggesting alternative therapies can help if all your testing and your exam is normal.

Fortunately, I’ve noticed that the majority of patients do improve over time. They may not be back to normal, and there may be that this is their new normal, but they can learn to manage their disease, and one thing that I tend to also do is consider a pulmonary rehab referral for appropriate patients where they can feel more confident and learn to do a specific exercise or specific things in a supervised setting.

Funmi Okunola: Oh, that was just such a wonderful interview, Michelle. We’re so grateful that you took the time from your busy schedule to come and enlighten us today. Again, thank you [00:23:00] for all that you do for long haulers and the medical profession in educating us and how to manage Long COVID.

Michelle Harkins: Well, thank you for the invitation. It’s been a pleasure.

Funmi Okunola: Please join us for next week’s Episode of Long COVID – The Answers.

Funmi Okunola: Some questions for listeners to consider.

What are your top five takeaways from this Episode?

How will this Episode change your practice or perception of this disease?

What will you do to act on what you’ve learned?

Please discuss your thoughts on our social media outlets such as Twitter or X, our website blog, Instagram, Facebook, LinkedIn.

Please rate this Episode.EPISODE 16 – BREATHING DIFFICULTIES WITH LONG COVID – with Professor Michelle Harkins MD