nutritional advice and psychological therapies . Finally , patients are referred for autonomic rehabilitation that uses breath control , isometric exercise , submaximal aerobic exercise with gentle progression and pacing , while patients are continually monitored for their exertional tolerance [ 29 ].
Breathing keystone of rehabilitation
Breathing techniques are an important part of many rehabilitation protocols for Long COVID . They are particularly important in patients who have dysfunctional breathing , hyperventilation and breathing pattern disorders . Dysfunctional breathing has been found in around 88 % of Long COVID patients , with persistent breathlessness and symptoms such as tachycardia , chest pain , fatigue , dizziness and syncope at exertion , as well as exercise intolerance that could not be either explained by organ damage or associated with sub-clinical pathology of the lungs and heart [ 7 , 37 , 38 ]. Inclusion of breathing retraining into rehabilitation programs gives these patients a tool for managing symptoms and psychological distress while also improving exercise intolerance [ 7 , 28 , 38 , 39 ].
Chronic hyperventilation , with CO2 levels below 30 mmHg , is a common
Breathing techniques are an important part of many rehabilitation protocols for Long COVID . They are particularly important in patients who have dysfunctional breathing , hyperventilation and breathing pattern disorders . finding in patients with Long COVID [ 37 ]. The hyperventilation may be related to an abnormality of ventilatory control or failure of inhibitory systems ( endorphins ) in the aftermath of pulmonary infection . The effects of hyperventilation are seen in most systems of the body . Hyperventilation-induced hypocapnia can cause a multitude of disabling symptoms such as dyspnea , tachycardia , chest pain , fatigue , dizziness and syncope at exertion .
Even in cases where CO2 levels are normal , Long COVID patients can present with excessively rapid , irregular and chaotic breathing patterns [ 40 ]. These abnormal patterns of breathing can interfere with cardiorespiratory homeostasis because they reduce pre-load of the right atrium , create uneven lung ventilation and ventilation perfusion mismatch . They contribute to dynamic collapse of the airway and reduce the vagally mediated baroreflex response [ 40 ].
Breathing retraining approaches that teach patients how to correct hyperventilation and normalise breathing patterns at rest and during graded exercise rehabilitation are being used by physiotherapists , rehabilitation specialists and breathing trainers . A precision approach based on assessment is ideal . However , even simple breathing exercises that bring awareness to relaxation of breathing muscles and teach more co-ordinated breathing patterns can improve respiratory parameters and improve symptoms [ 41 ].
In Conclusion
The multisystem effects and complexity of Long COVID symptoms mean that patients need multidisciplinary treatment . Long COVID is also unpredictable , and the trajectory of the illness varies according to the extent of lingering infection , psychological factors , autoimmune and inflammatory responses and many other factors [ 20 ]. Identifying obstacles to healing , managing triggers and promoting factors such as optimal diet , nutritional supplementation , sleep , rest , pacing , stress reduction and breathing retraining offer means to support healing by improving the physical , mental and emotional conditions of patients .
Acknowledgements- Thanks to Zoe Steele and Imogen Collyer for their assistance with previous versions of this article .
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