Rehabilitation of patients with platypnea-orthodeoxia syndrome in COVID-19 pneumonia: Two case reports

Abstract

Platypnea-orthodeoxia syndrome, characterized by dyspnoea and arterial desaturation while upright, is a rare complication of acute respiratory distress syndrome. We report here 2 patients with COVID-19 pneumonia, who were diagnosed with platypnea-orthodeoxia syndrome during commencement of rehabilitation, 18 and 9 days respectively after admission to the intensive care unit. Both patients presented with normocapnic hypoxaemia. One patient required mechanical ventilation with supplemental oxygen during intensive care, while the other required high-flow nasal oxygen therapy. The manifestations of platypnea-orthodeoxia syndrome were most prominent during physiotherapy, when verticalization was attempted, and hindered further mobilization out of bed, including ambulation. This report describes the clinical manifestations of platypnea-orthodeoxia syndrome and the rehabilitative strategies carried out for these 2 patients. The platypnea-orthodeoxia syndrome in these patients resolved after 65 and 22 days respectively from the day of detection. This report highlights this potentially under-recognized phenomenon, which may be unmasked during rehabilitation of patients with COVID-19 pneumonia. Good functional outcomes were achieved with a combination of verticalization training with supplemental oxygen support, respiratory techniques training and progressive endurance and resistance training, whilst awaiting resolution of the platypneaorthodeoxia syndrome. LAY ABSTRACT Platypnea-orthodeoxia syndrome can be a rare complication in severe pneumonia. Patients with platypnea-orthodeoxia syndrome experience decreasing oxygen levels when assuming upright positions. This can interfere with walking and other activities that require an upright posture. We report here 2 patients with platypnea-orthodeoxia syndrome in severe COVID-19 pneumonia and describe their journey to recovery whilst undergoing rehabilitation and physical therapy. The various strategies that were helpful included the use of additional oxygen, special breathing techniques, as well as reducing the pace of the exercises delivered. By the end of their rehabilitation programmes, the 2 patients were able to walk without the need for additional oxygen. The platypnea-orthodeoxia syndrome resolved after 22 and 65 days from the day of detection.

Platypnoea-Orthodeoxia Syndrome in COVID-19

“…To the best of our knowledge, after a systematic and thorough literature search the coexistence of POS and COVID-19 was previously described by few authors [4,[7][8][9][10][11][12] , showing some differences with our case (Table 2). We observe that 83% of the cases described in the literature were male and the median age was 67.5 years old, while our patient was an 84-year-old woman.…”

Severe Pneumonia Caused by SARS-CoV-2: A Novel Cause of Platypnoea-Orthodeoxia Syndrome

“…POS is often recognized during motor rehabilitation, with positional changes evidencing the underlying intrapulmonary shunt [ 4 ] . Early rehabilitation in dorsal decubitus is essential to maintain muscle and joint activity while the patient readapts to orthostatism [ 7 ] . Although there are no established protocols yet for this specific pathology, these patients benefit from verticalization training with oxygen therapy and a respiratory rehabilitation program which includes learning breathing techniques, resistance training, and physical reconditioning.…”

Platypnea Orthodeoxia Due to a Patent Foramen Ovale and Intrapulmonary Shunting After Severe COVID-19 Pneumonia

“…The present case highlights the multiple interrelated mechanisms of shunting in patients with COVID-related lung disease and a PFO. Eight prior cases of POS after COVID-19 pneumonia have been reported to date but none with a known PFO [ 7 – 9 ]. Of these cases, only 3 patients had echocardiography to rule out the presence of a PFO [ 7 – 9 ].…”

“…Eight prior cases of POS after COVID-19 pneumonia have been reported to date but none with a known PFO [ 7 – 9 ]. Of these cases, only 3 patients had echocardiography to rule out the presence of a PFO [ 7 – 9 ]. In patients with persistent positional oxygen requirements at follow-up, quantifying shunt fraction over time through multiple modalities can guide treatment decisions.…”

“…Recent reports have documented the development of POS in patients who are recovering from severe COVID-19 infection [ 7 – 9 ]. The underlying mechanism of lung damage in COVID-19 patients is complex.…”