(upbeat electronic music) - Welcome, my friends, to the Bob and Brad podcast
produced by Bob and Brad, the two most famous physical
therapists on the internet. I am Bob, and I'm exactly one
half of the Bob and Brad team. Today, we're gonna talk
about how to rehab your lungs after COVID-19, pneumonia, and or surgery. By the way, before I go any further, I do wanna mention that I
had some recent surgery. And so if I sound like I'm drunk or slurring my words both may be true. No, I did have surgery and it's numb and there's some scar tissue there, and it's making me difficult to talk. Today, my guest is Doctor, I'm gonna screw up this name, but Sigfredo Aldarondo,
and he's a board certified internal medicine, critical care, pulmonary disease and
pulmonology physician. He earned his medical degree from the University of Puerto Rico. He went on to complete his
internship in medical residency, this is what I'm talking about, at the Veterans Administration
Hospital in Washington, DC. He completed his medical training with a fellowship at
Brooke Army Medical Center in Fort Sam, Houston, Texas. Dr. Aldarondo, thanks
so much for joining us. Okay. Welcome to the
program, Dr. Aldarondo. I probably screwed it up already. I'm just gonna call you Doctor. Really appreciate you taking the time. Really some valuable knowledge that we can glean from you, and I'm gonna go ahead
and get started off. Now you're a pulmonologist, correct? - Correct. Yeah. - Would you explain what, to
the lay person, what that is? - Well, a pulmonologist is somebody who has done a sub-specialty after doing an internal
medicine residency, a subspecialty training
or further training, you call that a fellowship
in pulmonary medicine. So concentrating... - On the lungs. - On the lungs, right,
concentrating on lung diseases, all diverse types from the
chronic, mundane to severe, to acute and chronic, the whole spectrum. But basically we devote
our skills and energies in the diagnosis and
treatment of lung diseases. - So am I right in
saying that in some cases you're kind of the lead guy, like suppose there's a
patient with lung cancer, but maybe in a different case, you may be called in for a consult? - Correct. Actually, in the acute setting, in the inpatient setting, the majority of the times that
we get involved in the care of somebody is when we're asked to see some patient as a consultant. - I see. - If the pulmonary problem is the most important severe one, we basically take the lead directing. In the outpatient setting
it's a bit different because yeah, we see patients
as a consultant as well, but patients who have primarily a severe chronic lung problem, we pretty much become
their main anchor physician in caring for them
throughout their illness. - So have you been seeing
many COVID patients, and are you the lead person on those? - Many times we are. The answer to your first question is of course, yes, unfortunately yes. Both in the acute and the chronic setting. And in many of these we are
actually the main physician. We do collaborate quite a bit
in this particular disease with infectious disease
consultants as well. So usually we are collaborating with an infectious
disease physician as well. - Gotcha. Got you. Are people with lung
problems at a higher risk for obtaining COVID or are
they just more at a higher risk for having more severe issues? - Yeah, rather the latter. No, there is no evidence that by having any certain
type of lung disease, you're more likely to get infected. The infection seems to be more
of a function of the virus itself that is highly
infectious and contagious. However, if you get infected and you have chronic lung problems, yeah, you're more likely to
have more severe complications. - Would you mind taking a minute to talk about maybe patients with moderate to severe COVID and what kind of things are going on physiologically
with those patients? - Sure. So the virus is
primarily a respiratory virus. It reaches the host through the airways, usually the nasal passages, and the initial symptoms are related to the respiratory illness. The patient may experience
mild systemic symptoms. The majority of the patients
by the way, will have a mild clinical course, the majority. And in some cases, actually
be totally asymptomatic which is the treacherous portion of this that you may be totally symptomatic and yet transmit the
virus to somebody else who then may not do that well. But the mild presentation
is pretty much very vague and very much similar to
the common cold, okay. You may have a little headache, a little nasal congestion,
maybe a low grade fever, and within a few days you're over it. However, what we're seeing is that, unlike the common cold, there is a substantial number of patients that will progress into
a more severe phase. In which case now they, by the way, the incubation period
with the delta mutation, delta variant, is shorter. So we're talking three days between infection and symptoms onset. So the next phase, if you will, the patient will have now
more severe systemic symptoms, headache, persistent fever, cough. Now the cough becomes more evident. And at that point, the patient will have a
completely normal chest x-ray. They will have normal oxygenation and nothing alarming yet, okay. When that starts happening, then unfortunately there
is a very thin threshold to then develop more severe symptoms. That's why acknowledging
the likelihood of infection, acknowledging your
underlying comorbidities, that's the time when intervening with monoclonal antibodies
can make a huge difference in mitigating the
evolution of the illness. So, unfortunately, we've seen that. I just saw a patient earlier today, two hours ago, who has, hopefully will be okay, but
has been hit pretty hard. And he was asking me that same question. Why did he get this? And I said, well, unfortunately I cannot
answer that question for you. He should have. There's an under utilized
in our community, but anyway, that's the moderate phase in which the patient
will have some symptoms, and at that point, the likelihood of progression
is now significantly higher. And, unfortunately, once
the flood gates open, now, the severity of the illness
is not the virus anymore, it's actually the inflammatory response of the host against the virus. That's why the treatment
early on that can work against the virus, which
is the monoclonal antibody, and an anti-viral agent that we use in the hospital called Remdesivir is only helpful early on
because that basically is a drug that is directed at
repressing the viral replication and its secondary problems. Once the severity of
the illness increases, and the problem now is
the systemic inflammation. Now we're talking other
things that we try to do, which is why we use
corticosteroids, dexamethasone, and we use other agents that
are directed at blocking the impact of those proteins that are released, the
interleukins, particularly IL-6. So we use another monoclonal
antibody called Tocilizumab or other drugs, another one's Baricitinib. Basically these drugs are now trying to block the inflammatory response, okay, and they do help a bit, but it is no way to predict
once the patient crosses the barrier who is gonna be the one that will deteriorate quickly,
end up on a ventilator. Right now, I just saw a
patient who is 31 years old, completely healthy,
obviously unvaccinated, who is on a ventilator and his lungs are destroyed, destroyed. - Oh, my gosh. - You know 31 years
old, previously healthy. So we have a subset of people that will progress to that degree, and we don't know what are the risk factors for that to happen. Now we know that those are
immuno-incompetent transplant patients or immunosuppressed
for other reasons will be more likely to progress and
will likely (indistinct). But, you know, we have
seen patients like that who actually did well. So it is not as a guarantee. - It's just a mystery. - What we know. It is, what we do know, I just have to lead to the
most recent recommendations regarding the booster
shot is that those people that are immunocompromised
may not benefit much at all from the vaccine. - Oh, really? - Yeah, their antibody
response or the immune response to the vaccine is completely dwarfed or significantly less potent, if you will, than the normal host. So people that are vaccinated
who know are less likely to be protected by the
vaccine are the ones that should be front row
to get the booster shot. - This inflammatory response, how does it present itself? I mean, what are some of the damages that the high-level
inflammation can present? - Good question. The most striking and
prevalent problems are the respiratory apparatus. So the lung injury that results in severe drops in oxygenation
or respiratory failure, okay. But also may be associated with endothelial inflammatory changes, so the lining... - The lining. - The lining of the blood
vessels is impacted, so that there is a
preponderance of thrombosis, so there's a high risk for... - So blood clots. - Blood clots. Blood clots in
the venous and arterial too. - Oh, really? - Yes, and that may be associated
with coronary ischemia, with cerebral strokes, for example, and venous thromboembolism. So blood clots in the lower extremities that reach the pulmonary vasculature, which is by the way, one of the reasons why we
always use anticoagulant therapy on our patients as a preventive measure. - So, at what level are you talking about? Are we talking about the
bronchi, bronchioli, or alveoli? I mean, any level of that? - The most striking and
most important level or site where this is relevant is the alveolus. - Sure, the blood exchange, sure. - The alveolar capillary membrane. Yeah, in the beginning, all the respiratory tract is affected. So there's a lot of bronchitis, early on, cough, and not only just cough. Mainly these patients
have this severe pain. The tracheal bronchitis is
really out of proportion to other things that they really complain to you of severe pain, which is one of the reasons we... Mainstay of therapy includes inhaled corticosteroids on our patients. And aside from this, (indistinct). But to answer your
question, it's the air sacs, the alveoli is the... - Sure. Why do you
think the loss of smell? - Well, the olfactory sensors that we have in our nasal passages,
it is the first barrier, is the nasal mucosa. By the way, we have a high concentration of nitric oxide in the
upper respiratory tract. So the inflammatory,
there is efferent sensors or nerve efferents in
the (indistinct) tract that also have to do with the sense of smell and taste as well. So basically it's a secondary casualty. The thing about it is that
there is, in some cases, it's thought that that
becomes an important thing to identify because it may herald CNS complications or encephalitis. It is not really proven to be the fact, but there's some speculation
that there is a correlation between that event and
the severe headaches and sometimes even encephalitis
some of these patients have. But it is just part of the
respiratory tract, okay. - My gosh. That was really
a cascade of events. So are ventilators considered
harmful now or helpful, or where are we at with that right now? - It's funny, you asked me that question 'cause the same patient I
was telling you about was telling me, my wife just told me, call me, don't let them
put you on a ventilator because we have two people that went on ventilators then died. - Sure. - And I said, look, the issue is, look at it differently,
when the disease escalates to that level, that you
need mechanical ventilation. It's a big flag that it's
a very serious now illness, and your lungs are failing. So nobody will put you on
a ventilator just because. The fact that it's done means
that your lungs are failing. Now back to your question. In the beginning of the pandemic there was this notion that we wanted to avoid mechanical ventilation because it was potentially
damaging and this and that. Well, the answer to your question is when mechanical ventilation
is necessary, it is done. It allows the clinician
to, in a more reliable way, ensure that the oxygenation
to the body's maintained. It gives you an opportunity
to do what proning. What we do is put the
patient on their tummy to improve their oxygenation by improving the relationship between blood flow and oxygenation, and it allows you to care
for the patient better. - Gotcha. - There's always a downside. So intubation, mechanical
ventilation needs to be done in a certain way so that we
follow certain guidelines so that the lungs are not
injured in the process. So we've learned a lot about how to manage respiratory failure over the years, and we apply that information on how we deal with COVID patients. So there's no contraindication to intubate and initiate mechanical ventilation, but when it happens, rather do it in a semi-elective way than in a rush at three
o'clock in the morning when the patient has respiratory arrest. And by the way, for the sake of the personnel caring for the patient gives
you everybody to have their PPE on, the protection so that it can be done in a safe way so we don't spread the virus around others that are caring for the patient. So that needs to be taken into account. - And that is a big concern. Also, when you able to move along further and start rehabbing the muscles, you gotta be aware that
they're still symptomatic or could cause symptoms, I mean... - Sure. Well, not that it causes symptoms, patients that are rehabbing, like any other patient who is recovering from respiratory failure and acute devastating critical illness, they will be weak. Generalized weakness is a well known entity in the ICU. So COVID patients are no different. So we do initiate, within our means, everything that we can
to rehab these patients. But in this case, you're right, Bob, is the fact that we have to be mindful this patient may still be contagious. And so how we do that, we are mindful of that, our respiratory therapists
know that very well, and the patient is instructed. They explain what to do, and if they do anything that'll be potentially aerosol generating,
they'll be by themselves when they do that. - Sure, gotcha. So we've kind of talked a little bit about the medical portion,
medical management of COVID. So now I'd like to move
on to more the training that would go on for the
respiratory muscle training, when would that occur, and at what point would you
initiate that after COVID? - Thank you for the question. If I have a patient who
is cognitively functional, that is able to cooperate
and follow commands, and the patient's oxygenation
now has stabilized, and they're basically not
requiring their bi-pap or non-invasive ventilation
or invasive ventilation, basically they're oxygenated
with a nasal canula. So they have access, their lips, oral cavity now is available for exercising of different types. That's the patient that
I would initiate that. Like anybody else who has now been subject to an acute injury, respiratory injury. So what we do is we encourage
the patients to participate with a series of... we do emphasize mobility
as much as we can, so that means getting off their back - Getting movement, yeah. - As you know, in your field
you do all that sort of thing. But the thing that is
many times overlooked is the importance of exercising
the respiratory muscles. And so we provide our patients... I am a strong believer, which is why I'm here talking
to you today, in part, of the importance of rehabbing
our respiratory muscles. But we do that when the
patient's oxygenation now allows us to do that. They're obviously stable in other regards. They don't have any,
recovering from a major stroke or have cardiac issues
or major arrhythmias. The same rationale we
follow for other patients that are recovering from
acute respiratory injury. - So pneumonia, or maybe
even just after surgery, it would be the same thing? - Sure. Yes. - Well, how do you train the person safely without getting infected yourself? - Well, we demonstrate that to them, okay. I have one of the devices here. I can show it. This is the device that we use. - It's called the Breather. - It's called the Breather. So it has a port for inhalation
and one for exhalation, and you can separately adjust
resistance for each side. So we basically assess... well, the patient is
instructed how to hold it, how to properly place your lips
around it and the technique. And then we demonstrate, we actually have a glass window we can actually look through... - Gotcha. - and observe the patient at a distance. Now we also, everybody's
wearing N-95 and PPE, so you can step back several feet, even in the room and observe the patient as they're doing that. So you don't need to be
there in front of them. And we observe how they perform, and they're instructed
to initiate the process, it takes a while to get reinforced, to be reeducated until they
basically get the hang of it. But it's a way to exercise, not only the diaphragm or the inspiratory, expiratory muscles. The belly muscles, the core muscles, all those things are part of it, so you think of that for a moment, but there is a number of muscles
in the thorax and abdomen all participating in the
process of ventilation. - And they all got very weak. - Completely, right, for a
number of reasons particularly if they had been on
mechanical ventilation. Because we know that from day one, once you initiate mechanical inhalation, the diaphragm starts to weaken and gets thinner and thinner. We know that by ultrasound measurements. So everybody, but
particularly those patients who have been on mechanical ventilation. - That's very interesting. I mean, that's a big thick muscle that covers the lower end
of the abdomen. So, yeah. Yeah, Brad always brings it
up when he goes deer hunting. That when he dresses a deer
you can see the diaphragm. But I wanna make that point again, that you can actually
adjust the resistance going, breathing in and breathing out. I think, what is it? Four or five levels of resistance? - For inhalation there are five and for exhalation there are six. - Oh, gotcha. I'm guessing most people start at one. - Yeah, most of 'em start at one, but one is hardly any resistance. So many times I end up starting
our patients at level two right off the bat. You can tell their effort is not... So we get feedback from them (indistinct) do they experience fatigue? At what point they experience it. We try to try to hit 10 reps, inhalation exhalations twice a day, and sometimes three times a day. - Yeah. I wanna make this point too. I mean, you were saying you
can do this with oxygen. So like, if you have COPD, you can do this to try to
improve your responses. - Well, actually, Bob,
this type of rationale to use respiratory muscle
training started 40 years ago, mostly for COPD patients, and it's called
respiratory muscle training because doing that, you'd show that you increase
respiratory muscle strength and patients' endurance improves. So they're able to carry out more tasks, the shortness of breath decreases. So when you do rehabbing
or pulmonary rehabilitation in our program we incorporate
respiratory muscle training always as one of the
interventions that we do. So for COPD, it's been a
no-brainer for many, many years in our institution and many others that respiratory muscle
training, it's helpful. Now, what we have done is we have learned that respiratory muscle
dysfunction and or weakness are not only the domain of COPD patients. It happens a lot. Happens to patients with
congestive heart failure. Happens to our patient post-operatively. Patients are being mechanically ventilated for a number of reasons on day two, day three, day four, afterwards, so it is a very prevalent issue both in acute, subacute,
and chronic stages. - Which makes total sense. You know, you realize how
weak you get after surgery on the visible muscles, so it's obvious that
the muscles inside are also getting weaker, so
they have to be addressed. And I think with COPD,
you know, if you can, for somebody, the goal
might just to be able to go out and get the mail again or play with their grandchild. I mean, they may not be big goals, but you can change the trajectory
of your outcome, I think. I know the answer to this 'cause I've looked up the research myself, but there is research backing respiratory muscle training, correct? - Lots. - Yes. I thought so too. Yeah, plenty of them. And I got a kind of an
interesting question. So when I was in the hospital,
always working with patients, you would see a lot of this spirometer. Now, the incentive spirometer, that's really not a training device. I mean, it's not a muscle
training device, is it? - No, it is not. There are different ways to describe it. Some of them I will not
use the comparisons here or the metaphor, but it has
actually been acknowledged by the proper institutions that
incentive spirometry doesn't really do a whole lot. What you do basically is
you see in the chamber what your volumes are. - Sure. - So by seeing your volume go up, it may incentivize you
to do a little better, - Sure. - But you're not really doing
much work when you do that. It's like trying to lift, you pretend you're lifting weights and you move your arms, but
you don't have any weight. - Right, right. - Adding weights, now you're doing work. Now, your muscles are meeting resistance. Now you're recruiting mitochondria. The mitochondrial density
of the muscle improves. You improve the efficiency and so forth. So this is so much different and better. So I tell my patients, one day, they always get an
incentive spirometer there it's like guaranteed. Somebody will park one
there and say that's okay, but you're gonna do this
(indistinct) for the looks. - I think, it seems like
the incentive spirometer is kind of, just a feedback mechanism. - Yeah, it's a visual feedback, right, but it's not much work at all, right. - Are there other devices? I mean, I thought I saw some devices that handle one end of it like the inspiration and not expiration. - There are other products in the market. There's another that is
often used or has been, but for the majority of the ones out there that are competitors, whatever, they only provide the
inspiratory muscle resistance. - Gotcha. - Our device is created by, he was a respiratory therapist
who actually created that, and the name of the
company is named after her. The PN comes from her name. PN Medical. So it was quickly
recognized to her credit and others that collaborated with her that, hey, you know,
expiratory muscle function the components of inspiration,
you don't only inhale. You have to exhale. And when you cough, you exhale. When you speak, when
you phonate, you exhale. - Good point. - So there are number of muscles
there that are important, and if you can maximize the
efficiency and endurance of the whole shebang there on inspiratory and expiratory muscles you're doing the patient a good service. There's actually data
coming out very nicely in other issues that are
not only ventilation, such as dysphonia,
dysphagia, stroke patients, they have upper respiratory
muscle weakness. By using this device, you
improve phonation time, you improve, potentially,
improve the ability to cough, which is important to clear the airways and prevent excessive mucous buildup and infection and so forth. - So I do wanna mention that website. We'll have it down below,
too, in the comments, but www.pnmedical.com, pretty simple. And like you were saying, it can be used with people who
are having trouble speaking, would that include Parkinson's disease? - Yes, yes. - Okay, and I wonder if you'd just mention real quickly too, sleep apnea, it's such a big problem too now. I thought there's been some research that shows that it may help with that too. - Yeah. There's some data, and I don't think the
data is as solid as it is with COPD and demonstrating the importance in diaphragmatic or
respiratory muscle strength and so forth, but if you
can improve the muscle tone of the upper airways,
okay, and decrease a bit that airway collapse that
happens during sleep, and you can improve your sleep pattern by coupling respiratory muscle training with proper breathing and
relaxation and so forth, and your sleep quality improves, you actually see some benefits from that. But I don't think to be honest, that we can connect the dots and say that if you use this device you're gonna mitigate your sleep apnea. No, you can't really say that, but it's just one more thing in terms of sleep hygiene and respiratory function. And if you have obstructive lung disease, if you have respiratory
muscle weakness already, then it makes sense to do everything you can to optimize that. So that even in your sleep you may not see as much
secondary consequences. - Yeah. It's certainly
not gonna be bad for you. - No, not at all, of course. - So let's say you have a
person here that's recovering from COVID or has COPD or
has dysphonia or whatever. And I mean, they can initiate
this on their own, right, they don't need a prescription? - No, they don't. And the website actually
provides the information for the patients and there's
informational didactic videos, and a lot of resources
for the patients can use. And there's a lot of
research there, by the way, that they can tap on. It's always best to do
this with the consent and encouragement of your
physician or provider, but no, you don't need a prescription. What is important is though
that there's a rationale for it, that there is a clarity of
purpose that the patient is not barking up the wrong tree by doing so they expect
there are some completely unrealistic expectations, right. But if you recognize that
you are in this group, and you mentioned COVID,
Bob, I'm here to tell you, as you know, we're
dealing with an explosion of acute post-COVID syndrome
or the (indistinct). And this is something
that is still relevant that we're trying to understand. But the generalized weakness, fatigue, shortness of breath in
diverse forms and so forth is part of it, and there's
some other patients that have the (indistinct) as well added to that in different ways. We're looking into that, And actually we're participating,
will be participating very soon with a major
academic center in the how to, by incorporating
respiratory muscle training, among other things, how we can help these patients
to deal with this entity, which is, it's just a big deal. I'm seeing in my practice every day two or three new patients post-COVID. - Sure. - By the way, you don't need to have a severe COVID infection to have the post-COVID manifestations. The majority of these
patients actually had a mild illness. - Really? - Mild. And then this secondary wave of what may be a post-acute event, post-inflammatory state
is what we're seeing. So it is deceiving when you think, well, I just had a mild... No, it actually has
nothing to do with that. - Yeah. It's funny, I had
pneumonia several years back and a pretty severe case, and I recovered, and then months later I was at the dentist and my dental hygienist used
to be a respiratory therapist, and she still could pick up
on the wheezing that I had, and that was months later. So it's amazing, like you said, the weakness can completely
manifest itself years later or months later yet. With the Breather, I
wanna just mention too, I saw the videos on training. These are really excellent videos. I mean, I realize it's better to be with maybe a professional 'cause they can give you feedback, but these are really
easy to follow lessons, and they do better than we do trying to explain how to use it. I'm also gonna mention, I know this is a kind of on the side, but I had a little bit
of interest in this. They have the Breather for, and I don't know if you
know anything about this, but they have the Breather
for basically athletics. Now my son was a big runner in college, and I really am upset that I couldn't have tried this with him because I didn't know about it. But I think it would've gave him an edge, it just makes so much sense to me that it would have been a way to focus on strengthening
the muscles that he needed. - Yeah. So actually I have
another one here with me. We call it the Breather Fit. - Sure. - This is the one... - That's the one for athletes. - Exactly. And basically this
came out of a appreciation that people at high
performance situations, mostly the athletes or
professional athletes and so forth, they are, whatever they're... and they were maybe swimmers, divers, and track, whatever, they do experience a
little edge in improvement. And the data around that is significantly thinner, lighter that what we have on the clinical side, but there's enough information there, and some of these anecdotal,
and studies are in progress that we have seen an enormous interest, and that's what led to the difference between this one and the other is that the resistance settings
are significantly higher. - That's make sense. - Significantly higher
for a completely healthy individual would not really
benefit much from doing this. - Yeah, to me, it makes sense. Like as a runner, you
know, you're running, you think you strengthen
your running muscles when you do this, but you actually need to
include some weight training to strengthen the muscles
that you're running with too otherwise your muscles
have become too efficient and they don't work as hard. So it's the same with, to me, it makes sense that the lungs, the accessory muscles, the diaphragm, also could use a little boost with athletics especially swimming and running, I feel. That's just again, kind of a side, but I didn't have any other
questions, Dr. Aldarando, is there anything else you
wanted to cover at this point? - Well, to me, so let's to be clear, we're talking respiratory function. We're talking about the
process of ventilation, right. It's basically the bellows
system that allows us to create negative pressure so
that we get an inflow of gas. Then the gas reaches the
alveoli, the air sacs and oxygenation happens, but oxygenation would not happen unless you had the ability
to ventilate, right. And that ventilation is
what's impaired progressively with COPD patients and that effort that goes with ventilation
is now increased, and it's a vicious cycle that results in less and less activity, and the less activity, more weakness. And that vicious cycle is what pulmonary rehab breaks, right. So we try to, in a safe way, retrain that individual to exercise, and not only they discovered mentally and emotionally what it's like to be this way, but there's a muscle memory
that is awakened, if you will. - Oh, sure. Makes sense. - And so this applies to
anybody else out there who is, by virtue of severe kyphosis, for example, - Oh, sure. - (indistinct) the spine,
the thoracic cage is deformed or scoliosis or post-polio patients, or a number of entities in
which the rib cage is altered, you know, ventilation becomes
more and more challenging. You can break that vicious cycle by doing this type of thing. And the other thing I'd like to say is that I've become more and
more aware of the importance of core muscle strength
in terms of patients, particularly the elderly,
regarding their gait, posture and balance, and the number one cause of
trauma in this country is falls. As I tell my patients, it's not falling from the roof, it's falling from your feet, and it's devastating when it happens - It is. - and sometimes lethal. Anyway, my point is that if you look at the respiratory muscle
strength on these patients, 90% of them, they have a
decreased what we call MIP, maximum inspiratory pressure
or expiratory pressure. In our lab we measure that. So my point is that
patients who may not have a primary pulmonary problem, but because of lifestyle or because of the musculoskeletal
issues or other things, and experienced progressive weakness, they actually may benefit. They should benefit from any
kind of physical therapy, occupational therapy process, but in conjunction with that, they should also should not ignore the benefit of training the respiratory, and more than respiratory,
I call it my core muscles because these muscles share functions. It's not only ventilation, but also balance and gait and so forth. - So I would think that would apply also to cardiac patients. - Absolutely. - Yeah. I would think that, I mean, has your hospital
or clinic, have they been incorporating that as a matter of? - We do. In a cardiac rehab program, it is not a mainstay or
a standard thing to do. It happens more spotty there than we would in a pulmonary program. In our patients in the
floors with cardiac issues and so forth with heart failure, I do very often because I
have a sensitivity for that, but I look for it and when
I identify that it is, but it's been shown patients who have congestive heart failure, these patients will have
respiratory muscle weakness. And actually by exercising
their respiratory muscles indirectly may actually
decrease sympathetic tone, and it has a beneficial
impact on cardiac function because of decreased afterload. Basically improves cardiac function when you unload that
increased adrenaline surge that comes from weak respiratory muscles. So it's another physiologic phenomenon that we know happens which
plays out to some degree in many of these patients. - I would think certainly in the patient who's underwent a CABG or some type of cardiac surgery that... - Indeed. Indeed, Bob, actually,
there's studies showing that pre and post operatively
for open heart surgery. It doesn't have to be CABG, it could be a valve replacement. If you optimize respiratory
muscle function before and use it immediately post-op, you decrease the reintubation rates. You increase the weaning process, so they extubate even faster, and they actually progress better. And remember, everybody who has surgery, one of the goals is to get them
mobilized on the first day, up on their feet and so forth, but if you're very short of breath, it's gonna be more difficult to do that. So if you improve the
patient's respiratory function, ventilatory function, the
respiratory muscle dysfunction is not as key, they can be more
engaging with the mobility, the PT and OT and so
forth at the same time. - I mean, you could start
this, as we mentioned already, you could start this with oxygen on, you can start it in bed, you could start it in a wheelchair. I mean, that's the advantage of this. - The beauty of it, yeah,
very simple and safe. - I wanna say, too, this is
not a real expensive device. - Oh, no. Compared to many
things, it's dirt cheap. - Yeah, it is, it's dirt cheap. That's what really attracted us to it because our goal at the end of the day, and I'm sure yours is too, I mean, we're trying to help
as many people as we can. I mean, that's our outright goal. And before I'm put into the cold earth, I wanna know that I was helping people and helping a lot of people. Well, Dr. Aldarando, please. Thanks again for joining us. And we got the website, www.pnmedical.com, we'll have it down below. Leave comments for Dr. A, and he might respond, who knows, but we don't hold him to
it because he's a busy man especially with COVID right now. So thanks again, Doctor, for joining us. - Thank you, Bob, it's been a pleasure. (upbeat electronic music)
