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Ongoing breathing problems continue after COVID

The patient noted it became especially hard to breathe when he was lying flat. He said trying to draw in a breath felt like hitting a wall. He spent the next six months sleeping upright in a recliner.

In September 2022, I saw Joe Potter, a 40-year-old patient who flew to Philadelphia from Kansas to be treated for a rare condition.

As with all new patients, I first took his medical history, which included a yearlong quest for answers as to what caused his ongoing breathing problems.

Joe’s symptoms became apparent in April 2022 after getting COVID.

Not long after recovering, he experienced ongoing shortness of breath. He ended up in the ER with double pneumonia and was prescribed standard medications.

But after completing the treatment, his breathing problems persisted. His primary care doctor referred him to a local pulmonologist.

Joe noted it became especially hard to breathe when he was lying flat. He said trying to draw in a breath felt like hitting a wall. He spent the next 6 months sleeping upright in a recliner.

His pulmonologist referred him for a sleep study, which showed his oxygen levels while sleeping dipped dangerously low. He was prescribed a bilevel positive airway pressure, also known as BiPAP. The device includes a mask that fits over the nose and/or mouth and blows air via a tube into the airways to keep them open while you sleep.

Despite better sleep with the BIPAP machine, his problems continued. He had to stop working as a welder due to job-site dust and grime that exacerbated his breathing troubles. Nor could he play in his beloved local softball league because he couldn’t run to first base without losing his breath.

Joe’s pulmonologist continued with more tests. After a bronchoscopy, a procedure to look in the airway and lungs using a thin flexible tube, his doctor thought a collapsed trachea might be the cause.

He was diagnosed with tracheobronchomalacia (TBM), where the walls of the airway are weak and collapse when a patient breathes or coughs. Because the condition is so rare, his pulmonologist suggested he seek surgical treatment at a specialized center and referred him to me.

When Joe arrived at Temple University Hospital, I ordered a bronchoscopy to confirm TBM and determine the best course of treatment. His results showed some airway collapse but it was not severe, nor was he coughing, which is another prominent symptom of TBM.

The problem runs deeper

A CT scan of his chest showed his diaphragm, the main muscle that facilitates breathing, was slightly elevated on both sides. I sent him to get a sniff test to confirm my hunch.

The sniff test uses x-ray video to see how your diaphragm moves when you inhale quickly. Normally when you sniff, the diaphragm moves down. If it moves upward on inhale, that signals dysfunction, which is what we saw on Joe’s test.

An ultrasound ultimately revealed the true diagnosis: bilateral diaphragmatic paralysis, an uncommon condition.

The diaphragm is a thin, dome-shaped muscle that sits beneath the lungs and heart. When the diaphragm contracts, it moves downward, allowing the lungs to expand in the chest cavity and air to move into the lungs as one inhales. When it relaxes, it moves upwards, causing a decrease in lung size as one exhales.

When this muscle is weakened, it may become harder for a person to breathe. This is called diaphragm paralysis, a condition that is often misdiagnosed and undertreated.

It is caused by damage to the phrenic nerve, which runs through your spine, neck, heart, and lungs and controls the diaphragm. Phrenic nerve damage is often caused by trauma, such as spinal cord injury, or neurologic diseases such as ALS.

It can also be caused by viral infections, which I believe was the case for Joe, given his COVID history. I have seen an uptick in cases of diaphragm paralysis since the COVID pandemic and worldwide studies have shown patients who had COVID may experience long-term diaphragm weakness.

Some patients can benefit from losing weight or starting a pulmonary rehab program to reduce the burden on the diaphragm. For those with an impaired quality of life like Joe, surgery can offer a long-term solution.

If the cause is thought to be a viral infection, we recommend waiting six months to a year after infection as there are reports of the phrenic nerve recovering on its own. That did not happen for Joe, so in January 2023, he had surgery to correct the paralysis on his right diaphragm.

Plication is a minimally invasive procedure performed robotically through small incisions to reshape the diaphragm by suturing it onto itself to make it more stiff and flat, allowing the lung more room to expand and therefore helping the patient breathe better.

Following the first surgery on the right diaphragm, he could once again breathe while lying flat. He returned to some normal everyday activities with more ease.

In telemedicine follow-up appointments, he noted that he still felt some resistance when drawing in a breath so we brought him back for surgery in October to correct the paralysis on his left side.

He’s now breathing completely normally with no feeling of obstruction. He returned to work in January and is even running again.

Dr. Charles Bakhos is a thoracic surgeon at Temple University Hospital and Vice Chief of the Department of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University.