Featured Guest:

Ted F. Shaub, M.D. was born and raised in the Akron area and was the first sub-specialist to join Summa Physicians Inc. He is married and a father of four boys. The goal of his practice is to reduce suffering and prolong quality of life.

Dr. Brian Bauman was raised in the Akron area. He attended medical school at Case Western Reserve University in Cleveland. Following his residency and fellowship at the University of Michigan, he returned to Akron to practice at Summa Health System. He volunteers at Open M clinic in Akron and spends his free time with his wife and children. He specializes in pulmonary medicine (pulmonary critical care) and lung nodules, with expertise in advanced bronchoscopy (EBUS and navigational bronchoscopy).

Transcript:

Scott Webb: We've learned a lot about COVID-19 since the beginning of the pandemic, especially those who experienced symptoms long after their initial illness, otherwise known as long-haulers. Joining me today for a look at COVID long-haulers from pulmonary cardiac and neurological perspectives are pulmonologist, Dr. Brian Bauman; And cardiologist, Dr. Ted Shaub; all of whom work at and help patients at Summa Health.

This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. So doctors, thanks so much for your time today. It's hard to believe we're in our third year of COVID-19, and we're still talking about COVID-19, both people who have sort of short-term symptoms and treatment, I guess, but also the long-haulers. And that's really what we want to talk about today, is the effects on people longterm. And just to kind of set the scene a little bit, Dr. Bauman, if you could explain to folks, what does it generally mean to be a COVID-19 long-hauler?

Dr. Brian Bauman: A long-hauler, I don't know where the term came from, honestly, but it's essentially people with persistent symptoms after the acute phase of the infection has resolved. So most people, who get COVID will initially get some sort of viral syndrome, which often includes a fever and sometimes respiratory complaints, sometimes just a runny nose or sneezing, similar to a cold or a flu virus. And then oftentimes, there's a delayed response that occurs anywhere from about one to two weeks after that initial phase, which we still consider the acute phase of COVID, but it is probably an immune-mediated response and that's where the severe lung injury can occur. But those parts are all part of the initial acute phase of COVID. And then, after people recover from those things, usually a period of months after having had COVID infection, some people develop persistent symptoms, which are oftentimes multi-system. So it can affect not just your breathing, but almost any system in the body, such as the brain, the heart, the joints, the skin, et cetera. And so those are kind of the people we're talking about when we talk about long-haulers.

Scott Webb: Yeah. And I was going to ask you, is there a sort of a down period or a lag where the acute symptoms have passed before what we're now calling long-hauler symptoms would present. And as you said, it can be a number of months and, geez, like we didn't have enough to worry about with COVID-19. Now, we have to wonder, after we've recovered from the acute symptoms, are we potentially a long-hauler? And if we are a long-hauler, I want to have you talk a little bit about what some of those persistent symptoms might be and specifically persistent pulmonary COVID-19 symptoms.

Dr. Brian Bauman: Actually, a lot of the people don't necessarily recover and then develop long-hauler. They actually just never have resolution of a lot their symptoms. There may be a period where their breathing gets better, their fevers go away, but then oftentimes, they have persistent shortness of breath. The most common long-lasting symptoms would be fatigue, is probably the biggest one, just severe fatigue. Oftentimes, shortness of breath or cough. And then, oftentimes, people have difficulty concentrating or have memory issues. And those are some of the more common ones. But there's also, like I said, it can really affect any organ in the body. And so some people get persistent joint symptoms, they get rashes, people lose their hair sometimes, cardiac things that Dr. Shaub can comment on more, but a lot of people get a syndrome, we call POTS syndrome or kind of an inappropriate tachycardia or a kind of a racing heart rate syndrome that tends to happen to people after they've had COVID-19. Some people can have actual cardiac dysfunction too, where their heart doesn't pump, or they get inflammation of the heart itself. And that can give chest pain symptoms or can be related to shortness of breath. And there's a myriad of other problems, but I would say the most common things would be persistent shortness of breath, fatigue, and sometimes memory issues.

Scott Webb: Well, it all sounds entirely awful. And I guess the natural follow-up, is there a concern? Are you and other experts concerned that some folks, some long-haulers just may never fully or completely recover from COVID-19?

Dr. Brian Bauman: There's definitely that concern. And it's been interesting to follow this as the pandemic has progressed. And we at Summa set up our post-COVID, we call it post-COVID clinic because it deals with people who are recovering from acute infection, as well as people who may have persistent long-hauler symptoms. So we see both kind of groups of patients. But by doing that, we've been able to really see what happens to people because, being a new disease, nobody really knew what to expect. And the good news is that most people who haven't had a discrete severe lung injury, so excluding the people who were in the hospital on ventilators or had respiratory failure, most of the people who have a long-hauler COVID with multiorgan symptoms get better over time. That is good news. Sometimes it can take months to even years, but the vast majority do get better. I would say most people actually, their symptoms resolve with kind of a general good healthcare. And there are some people who don't completely get better, but their symptoms don't completely resolve, but they do improve. And so that's been a nice thing to see watching these patients over time is that we do see them improve. And really, I think the key is just really taking good care of them in general. So taking care of their other health issues, making sure you focus on exercise programs, good diet, lots of sleep, and really making sure that any other medical condition they have is really optimized.

Scott Webb: Yeah. I'm glad we had you on because it's good to hear some good news. Unfortunately, COVID-19 has been around long enough now that we've had the years to know whether or not most folks would fully recover. And it's good to hear that most do. And Dr. Shaub, I want to bring you in, let's talk about cardiac conditions, let's talk about post COVID-19 syndrome that can affect athletes and, just in general, how does COVID-19 affect the heart.

Dr. Ted Shaub: Fortunately, it's actually unusual to affect the heart. We've been following this, like you had said, and Dr. Bauman had said, for a number of years now, and we see a number of athletes in my practice post-COVID. Most initially, the athletes that we were seeing, because we really didn't know exactly what to do for the first year and a half, two years, is that we were evaluating all the dynamic athletes, those are the folks who play football, basketball, soccer, that run up and down the court. If they have a diagnosis of COVID, we were clearing them to get back to their sport of choice. In most of those kids who quite frankly were feeling well, there were a group of students that also they realize that when they got back onto the track, court or field, that when they were running up and down and doing their activities, that they were short of breath. This was in the acute phase, meaning within the first one to three weeks post their infection. And quite frankly, their lungs were still healing. This would not be a long-hauler. These are just folks that the lungs are still healing. And we just said, "Look, it's going to take some time." For a number of those folks, we would give them inhalers or a steroid inhaler, or even a steroid tablet to take to bridge them until their lungs got better.

It was interesting initially when COVID came out, there was a large study that came out that was not randomized, that came out of Ohio State and with very good intentions in which they looked at a number of athletes that had COVID-19. Fortunately, none of those athletes were ill, but they scanned these students and found that they had a possibility where a percent of them could have had myocarditis or actually scarring of the heart. And that set up a lot of angst amongst everyone, including the NCAA and high schools and all colleges in general. And what we found was that these changes that we see with the heart, both inflammation and potential scarring could actually be a normal finding in young, healthy, dynamic competitive athletes, meaning if you took prior to COVID and scan these students, they would find these findings on the cardiac MRI, which is what Ohio State used. It could be a normal finding just because of there's such a dynamic in the athlete and they work hard.

Fortunately, what we found over the last several years that actually myocarditis in this group, it's not unheard of, but it is unusual. For a number of the universities locally, we screen the Division One students with an EKG prior to even coming onto the field, meaning when they're coming in July to play football or get ready for fall, we would scan these kids with an EKG, we had that record in our hands. So when they develop COVID, we would repeat the EKG and use that for comparison. Quite frankly, I've seen a lot of student athletes. I probably have just seen one that may have had myocarditis. And that was from one of the universities in Southern Ohio and that student recovered.

I agree with Dr. Bauman, that most of the folks that aren't so sick, that they get into the intensive care situation, that most of them actually do well at least from a cardiac standpoint. Again, we look at these student athletes as two-fold. We have the initial where their lungs are just recovering, because this is a virus that affects the lungs. Then, you have the long-haulers. And again, they're separated by time, not necessarily a grouping of symptoms, because both have symptoms, but it's just the time. If we're two months out and we're still dealing with shortness of breath and wheezing and decreased exercise tolerance, and then it's more related to what Dr. Bauman does on a day to day basis, rather than a cardiac. We screen them with an EKG, good physical examination and an echocardiogram. And most of the time, we see just good hearts that are structurally normal.

It was interesting what Dr. Bauman said that we see this tachycardia post COVID. I clearly see that. And quite frankly, I don't think we know the cause of that. I think it's multifactorial. Is it's their lungs? Is it deconditioning? Does this virus actually affect the conducting system of the heart in ways that we don't really know? But fortunately, most of these student athletes do quite well.

Dr. Brian Bauman: It is interesting that the tachycardia syndrome, there's several other cardiologists that work with us and some data out there that COVID has a predilection for nerves. And so it's probably not actually the virus attacking the nerves, but the immune response to the virus that then attacks nerves in the body. And there's some thought that the tachycardia syndrome may actually be a nerve problem, not a heart problem. The nervous system actually controls our heart rate and the virus can affect the nerve that tends to keep the heart rate normal or going slower. And so there's some thought that it's related to a nerve issue. And it doesn't actually damage the heart necessarily, but it does give people symptoms.

Scott Webb: And of course, Dr. Shaub, none of us really want COVID-19. But does it help to be young and healthy if we just simply can't avoid contracting it? In other words, when we think long-term or think in terms of long-haulers, is the prognosis better for the young and healthy?

Dr. Ted Shaub: It's interesting. And these studies have been done in December, the CDC released data that looked at young people, meaning 12 through 17. Those are young and we see high schoolers, so we see in mid-teens on up. But the chances of being hospitalized with a COVID infection, that's just hospitalized, that doesn't mean not sick at home, recovering, but hospitalized was about between five and six out of 100,000. So young people do well. But you have to look do they have cystic fibrosis? Do they have underlying pulmonary disease, type 1 or type 2 diabetes? Are they obese? Are they immunologically suppressed? Those are the kids that we really worry about, but those are the kids that typically are not the athletes that we see.

Your point is well made, that the healthy kids usually does very well. And those studies have been done, a nice large study of almost 7,000 dynamic professional athletes across the United States and in Europe were looked at and essentially none got so sick they had to be hospitalized with significant issues. So it's a very unusual problem to affect the heart. That's what we've learned. Yes, it can, but it is unusual and that's fortunate. Most of the issues were in Dr. Bauman's line, is more pulmonary.

Dr. Brian Bauman: I think Dr. Shaub would agree too though, and this is kinda what I stress to people when I talk about vaccination, for example, is that the odds of getting very ill or dying from COVID when you're young and healthy are very low. But we do see a fair number of people who get more of the long lasting symptoms, and it's actually interesting in our practice in our clinic here. We don't see very many long-hauler people, long-hauler patients who have been hospitalized with COVID. Most of them never got treated for COVID specifically. They didn't get antivirals, they did not get steroids. And those tend to be the people who get the long lasting symptoms. And that includes young, healthy athletes. And Dr. Shaub can comment, we've taken care of together, a number of patients who developed pretty significant long-lasting shortness of breath primarily as a result of COVID that prevented them from competing in their sport that they maybe have a scholarship, for example.

The good news about it is that a lot of those patients actually develop asthma. It's not necessarily a direct injury to the lung from COVID. It's priming of the immune system that then triggers another disease state that is immunologically-mediated. And the good news about asthma is it's very treatable as Dr. Shaub mentioned with steroids, with inhalers and a lot of those patients get better fairly quickly once you get them on treatment for asthma.

Dr. Ted Shaub: What we also found, a lot of the student athletes would say, "Look, I don't want to get vaccinated. I'm not going to get sick with this. We know that the chance of me being hospitalized is low." However, what I tell them is similar to what Dr. Bauman just said, that if you would get this infection and it affects your lungs, it could actually just squeeze out the entire season. You wouldn't be able to play, meaning if you're in the middle of or the beginning of football season or basketball season or whatever season you're in and you get this infection, you could be out for weeks to months during the prime of your career in college or in high school playing your sport. So we're recommending to athletes to get vaccinated to prevent significant issues that would prevent them from recovering and get back on the field.

Scott Webb: Yeah, absolutely. The vaccines, boosters and everything. Thank you both. And you both stay well.

To learn more about the Summa health post COVID clinic, or to make an appointment visit Summa health.org/lung.

And if you found this podcast to be helpful and informative, please share it on your social channels and check out the entire podcast library for additional topics. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well, and we'll talk again next time.