Platypnoea–orthodeoxia syndrome in COVID-19

Abstract

Platypnoea–orthodeoxia syndrome (POS) is a rare entity characterised by respiratory distress and/or hypoxia developing in the sitting/upright posture, which is relieved in the supine posture. It is caused by cardiac, pulmonary and non-cardiopulmonary diseases. COVID-19 can have varying respiratory manifestations including acute respiratory distress syndrome (ARDS) and sequelae-like pulmonary fibrosis. POS has been rarely reported in patients with COVID-19. Here we report a case of POS in a patient recovering from severe COVID-19 ARDS. As he was gradually mobilised after his improvement, he had worsening dyspnoea in the sitting position with significant relief on assuming a supine posture. He was diagnosed with POS after ruling out other causes of POS. He was treated with oxygen support in upright posture and chest physiotherapy was continued, to which he showed improvement. POS is a rare manifestation of COVID-19 which needs awareness as it can be diagnosed easily and can respond to continued supportive care.

Patent Foramen Ovale and Ascending Aortic Dilatation Causing Platypnea-Orthodeoxia Syndrome

“…POS is characterized by upright dyspnea (platypnea) and concomitant arterial desaturation (orthodeoxia), improving in the supine position. A fall in SaO2 of >5% or PaO2 of >4 mmHg upon transitioning from supine to upright/sitting position is essential for diagnosis [4].…”

“…In POS, the pathophysiology of arterial desaturation involves mixing deoxygenated venous blood with oxygenated arterial blood through a shunt. Both anatomical and functional aberrations are usually needed for this shunting to occur, which is exaggerated in the upright posture, resulting in the characteristic feature of POS [4]. Anatomical aberrations include intracardiac shunts, intrapulmonary shunts, hepatopulmonary syndrome, ventilation-perfusion mismatch, or a combination of these.…”

“…In intracardiac shunts, the stretching of atria with upright positioning causes the defect, whether an ASD or PFO, to widen and change orientation with a consequent increase in the shunting of deoxygenated blood. With intrapulmonary shunts, the shunting mechanism increases pulmonary vascular resistance, subsequently increasing right atrial pressure, leading to a reversal of the left-to-right pressure gradient [4,5]. Additionally, pulmonary arteriovenous malformations, often seen in the setting of cirrhosis due to an imbalance in the ratio of pulmonary vasoconstrictors and vasodilators, may result in shunt physiology and the failure to oxygenate venous blood adequately [6].…”

A study on the morbid histopathological changes in COVID‐19 patients with or without comorbidities using minimally invasive tissue sampling

“… 3 , 4 It can range from a mild, self‐limiting pulmonary insult to frank acute respiratory distress syndrome (ARDS) requiring invasive mechanical ventilation with poor clinical outcomes 5 and various complications. 6 , 7 , 8 , 9 , 10 Other organ systems are also affected apart from the respiratory system with protean manifestations. Involvement of the cardiovascular system, gastrointestinal tract, kidneys, and liver have been reported ranging from asymptomatic laboratory aberrations to multiorgan failure related to cytokine storm.…”

Pneumothorax and pneumomediastinum in patients with COVID-19: A retrospective study from tertiary care institute in India

“…SARS-CoV-2 primarily affects the lung parenchyma with features ranging from mild selflimiting upper respiratory infection to critical acute respiratory distress syndrome (ARDS). A myriad of extra-parenchymal manifestations has been documented in the backdrop of COVID-19 such as pulmonary embolism, pleural effusion, empyema, cavitation and cyst formation (2)(3)(4)(5). Pneumothorax (PTX) and pneumomediastinum (PM), defined as gas in the pleural cavity and the mediastinum respectively, has also been reported in association with COVID-19, although not as frequently as lung parenchymal involvement.…”