Editor's note: Find the latest long COVID news and guidance in Medscape's Long COVID Resource Center.

Long COVID: The name says it all. It's an illness that, for many people, has not yet stopped.

Eric Roach became ill with COVID-19 in November 2020, and he's still sick. "I have brain fog, memory loss," says the 67-year-old Navy veteran from Spearfish, SD. "The fatigue has just been insane."

Long COVID, more formally known as post-acute sequelae of COVID (PASC), is the lay term to describe when people start to recover, or seem to recover, from a bout of COVID-19 but then continue to suffer from symptoms. For some, it's gone on for 2 years or longer. While the governments of the U.S. and several other countries formally recognize the existence of long COVID, the National Institutes of Health (NIH) has yet to formally define it. There's no approved treatment, and the causes are not understood.

Here's what is known: Long COVID is a post-viral condition affecting a large percentage of people who become infected with the coronavirus. It can be utterly debilitating or mildly annoying, and it is affecting enough people to cause concern for employers, health insurers, and governments.

First, the Many Symptoms

According to the CDC, long COVID symptoms may include:

  • Tiredness or fatigue that interferes with daily life

  • Symptoms that get worse after physical or mental effort (also known as "post-exertional malaise")

  • Fever

  • Difficulty breathing or shortness of breath

  • Cough

  • Chest pain

  • Fast-beating or pounding heart (heart palpitations)

  • Difficulty thinking or concentrating (sometimes referred to as "brain fog")

  • Headache

  • Sleep problems

  • Dizziness when standing

  • Pins-and-needles feelings

  • Change in smell or taste

  • Depression or anxiety

  • Diarrhea

  • Stomach pain

  • Joint or muscle pain

  • Rash

  • Changes in menstrual cycles

"People with post-COVID conditions may develop or continue to have symptoms that are hard to explain and manage," the CDC says on its website. "Clinical evaluations and results of routine blood tests, chest x-rays, and electrocardiograms may be normal. The symptoms are similar to those reported by people with ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome) and other poorly understood chronic illnesses that may occur after other infections."

Doctors may not fully appreciate the subtle nature of some of the symptoms.

"People with these unexplained symptoms may be misunderstood by their health care providers, which can result in a long time for them to get a diagnosis and receive appropriate care or treatment," the CDC says.

Health professionals should recognize that long COVID can be disabling,the U.S. Department of Health and Human Services says. "Long COVID can substantially limit a major life activity," HHS says in civil rights guidance. One possible example: "A person with long COVID who has lung damage that causes shortness of breath, fatigue, and related effects is substantially limited in respiratory function, among other major life activities," HHS says.

How Many People Are Affected?

This has been difficult to judge because not everyone who has had COVID-19 gets tested for it and there are no formal diagnostic criteria yet for long COVID. The CDC estimates that 19% of patients in the U.S. who have ever had COVID-19 have long COVID symptoms.

Some estimates go higher. A University of Oxford study in September 2021 found more than a third of patients had symptoms of long COVID between 3 months and 6 months after a COVID-19 diagnosis. As many as 55% of COVID-19 patients in one Chinese study had one or more lingering symptoms 2 years later, Lixue Huang, MD, of the China-Japan Friendship Hospital in Beijing, and colleagues reported in the journal Lancet Respiratory Medicine in May.

According to the CDC, age is a factor. "Older adults are less likely to have long COVID than younger adults. Nearly three times as many adults ages 50-59 currently have long COVID than those age 80 and older," the CDC says. Women and racial and ethnic minorities are more likely to be affected.

Many people are experiencing neurological effects, such as the so-called brain fog, according to Ziyad Al-Aly, MD, of the Washington University School of Medicine and the VA St. Louis Health Care System, writing in the journal Nature Medicine in September. They estimated that 6.6 million Americans have brain impairments associated with COVID infection.

"Some of the neurologic disorders reported here are serious chronic conditions that will impact some people for a lifetime," they wrote. "Given the colossal scale of the pandemic, and even though the absolute numbers reported in this work are small, these may translate into a large number of affected individuals around the world — and this will likely contribute to a rise in the burden of neurologic diseases."


It's not clear what the underlying causes are, but most research points to a combination of factors.Suspects include ongoing inflammation, tiny blood clots, and reactivation of what are known as latent viruses, or those that linger quietly in your body without causing damage. In May, Brent Palmer, PhD, of the University of Colorado School of Medicine, and colleagues found people with long COVID had persistent activation of immune cells known as T-cells that were specific for SARS-CoV-2, the virus that causes COVID-19.

COVID-19 itself can damage organs, and long COVID might be caused by ongoing damage. In August, Alexandros Rovas, MD, of University Hospital Munster in Germany, and colleagues found patients with long COVID had evidence of damage to their capillaries. "Whether, to what extent, and when the observed damage might be reversible remains unclear," they wrote in the journal Angiogenesis.

People with long COVID have immune responses to other viruses, such as Epstein-Barr -- evidence that COVID-19 might reactivate latent viruses. "Our data suggest the involvement of persistent antigen, reactivation of latent herpesviruses, and chronic inflammation," immunobiologist Akiko Iwasaki, PhD, of the Yale University School of Medicine, and colleagues wrote in a study posted in August that had not yet been peer-reviewed for publication.

This might be causing an autoimmune response. "The infection may cause the immune system to start making autoantibodies that attack a person's own organs and tissues," the NIH says.

There could be other factors. A study by Harvard researchers found that people who felt stressed, depressed, or lonely before catching COVID-19 were more likely to develop long COVID afterward. "Distress was more strongly associated with developing long COVID than physical health risk factors such as obesity, asthma, and hypertension," Siwen Wang, MD, a research fellow with Harvard University'sT.H. Chan School of Public Health, said in a statement. Plus, nearly 44% of those in the study developed COVID-19 infections after having been assessed for stress, Wang and colleagues reported in the journal JAMA Psychiatry.

Vaccine Protection

There's evidence that vaccination protects against long COVID, both by preventing infection in the first place, but also even for people who have breakthrough infections.

A meta-analysis covering studies involving 17 million people found evidence vaccination might reduce the severity of COVID-19 or might help the body clear any lingering virus after an infection.

"Overall, vaccination was associated with reduced risks or odds of long COVID, with preliminary evidence suggesting that two doses are more effective than one dose," Cesar Fernandez de las Penas, PhD, of King Juan Carlos University in Madrid, Spain, and colleagues wrote.

A team in Milan, Italy, found unvaccinated people in their study were nearly three times as likely to have serious symptoms for longer than 4 weeks compared to vaccinated volunteers. Writing in July in The Journal of the American Medical Association, Elena Azzolini, MD, PhD, an assistant professor atthe Humanitas Research Hospital, said the team found two or three doses of vaccine reduced the risk of hospitalization from COVID to 16% or 17% compared to 42% for the unvaccinated.


With no diagnostic criteria and no understanding of the causes, it's hard for doctors to determine treatments.

Most experts dealing with long COVID, even those at the specialty centers that have been set up at hospitals and health systems in the U.S.,recommend that patients start with their primary care doctor before moving on to specialists.

"The mainstay of management is supportive, holistic care, symptom control, and detection of treatable complications," Trish Greenhalgh, MD, professor of primary care health sciences at the University of Oxford, and colleagues wrote in the journal The BMJ in September. "Patients with long COVID greatly value input from their primary care clinician. Generalist clinicians can help patients considerably by hearing the patient's story and validating their experience … (and) making the diagnosis of long COVID (which does not have to be by exclusion) and excluding alternative diagnoses."

Evidence is building that long COVID closely resembles other post-viral conditions -- something that can provide clues for treatment. For example, several studies indicate that exercise doesn't help most patients.

But there are approaches that can work. Treatments may include pulmonary rehabilitation; autonomic conditioning therapy, which includes breathing therapy; and cognitive rehabilitation to relieve brain fog. Doctors are also trying the antidepressant amitriptyline to help with sleep disturbances and headaches; the antiseizure medication gabapentin to help pain, numbness, and other neurological symptoms; and drugs to relieve low blood pressure in patients experiencing postural orthostatic tachycardia syndrome (POTS).

The NIH is sponsoring studies that have recruited just over 8,200 adults. And more than two dozen researchers from Harvard; Stanford; the University of California, San Francisco; the J. Craig Venter Institute; Johns Hopkins University; the University of Pennsylvania; Mount Sinai Hospitals; Cardiff University; and Yale announced in September they were forming the Long COVID Research Initiative to speed up studies.

The group, with funding from private enterprise, plans to conduct tissue biopsy, imaging studies, and autopsies and will search for potential biomarkers in the blood of patients.


CDC: "Long COVID or Post-COVID Conditions."

CDC National Center for Health Statistics: "Nearly One in Five American Adults Who Have Had COVID-19 Still Have 'Long COVID.'"

National Institutes of Health: "Long COVID," "Long COVID symptoms linked to inflammation."

PLoS Medicine: "Incidence, co-occurrence, and evolution of long-COVID features: A 6-month retrospective cohort study of 273,618 survivors of COVID-19."

The Lancet Respiratory Medicine: "Health outcomes in people 2 years after surviving hospitalisation with COVID-19: a longitudinal cohort study."

Angiogenesis: "Persistent capillary rarefication in long COVID syndrome."

PLoS Pathogens: "SARS-CoV-2-specific T cells associate with inflammation and reduced lung function in pulmonary post-acute sequalae of SARS-CoV-2."

Lancet eClinical Medicine: "Impact of COVID-19 vaccination on the risk of developing long-COVID and on existing long-COVID symptoms: A systematic review."

JAMA Psychiatry: "Associations of Depression, Anxiety, Worry, Perceived Stress, and Loneliness Prior to Infection With Risk of Post–COVID-19 Conditions."

U.S. Department of Health and Human Services: "Guidance on 'Long COVID' as a Disability Under the ADA, Section 504, and Section 1557."

Long COVID Research Initiative:"Introducing LCRI."

Nature Medicine: "Long-term Neurologic Outcomes of COVID-19."

The BMJ: "Long covid—an update for primary care."

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When you think of treating a disease or health issue, odds are your mind jumps to medications and lifestyle changes. But there’s also biofeedback.

Biofeedback is a method of gathering information about physiological functions in the body, so you can learn how to harness those changes to improve health and performance, according to the Association for Applied Psychophysiology and Biofeedback. It’s used by doctors, physical therapists, psychologists, and other healthcare professionals to manage and treat various health issues, such as urinary incontinence, anxiety, and chronic pain.

“Basically, biofeedback is any feedback that the patient receives about their body in the moment to help them figure out what their body is doing, so they can improve coordination and awareness,” says Nora Arnold, DPT, a physical therapist with the Johns Hopkins Rehabilitation Network who specializes in pelvic health.

There are many ways to receive biofeedback. A practitioner may attach sensors to your scalp to monitor brain activity, your abdomen or chest to monitor your breathing patterns or heart rate, or any number of other places on your body, per the Mayo Clinic.

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The lungs are two of the most important organs that are affected by the coronavirus, which leads to Covid infection in the respiratory system. It has been noticed that while most patients recover completely after the infection, at least 5 per cent to 10 per cent experience prolonged symptoms that last for several months or even years. This is known as ‘long Covid‘.

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Dr Vishal Sehgal, the president of Portea Medical says “pulmonary rehabilitation” can improve a person’s lung function, their exercise performance, quality of life, and even counter any anxiety associated with the condition.

“Pulmonary rehabilitation is symptom-based; it requires a multi-pronged approach to deal with the various related complications. It is a holistic plan that comprises preliminary patient assessment followed by medicinal treatment, lifestyle modifications, physical exercise, nutritional support, self-awareness and psychological counselling,” he says.

According to the expert, some major aspects of a rehabilitation programme are as follows:

1. Physical activity

Physical activity can significantly improve the quality of daily living. From low-impact training for the chest and back muscles, to more intense forms of exercise, there is a range of activities that can help. Under the guidance of a trained specialist, these are done depending on individual progress and capacity, says Dr Sehgal.

2. Breathing techniques

Breathing techniques can help alleviate the pressure on the lungs. There are different types of breathing techniques including those that are part of yoga that can help in case the patient experiences symptoms of breathlessness, he adds. “For instance, pranayama — the ancient practice of breath control — helps in improving multiple aspects of physical health, including lung function.”

3. Diet and lifestyle

A balanced diet helps in boosting immunity and overall wellness. It can also help in alleviating certain symptoms of long Covid, the doctor states. “Those who are put under a pulmonary rehab programme are given a diet rich in complex carbohydrates and fibres, as well as other micronutrients. In case a patient lacks access to a proper rehabilitation facility at hospitals, it is possible to do this process at home.”

“People who survive Covid-19 can experience long-term consequences: respiratory, neuropsychiatric, cardiovascular, hematologic, gastrointestinal, renal, and endocrine. There is a rapid increase in the burden of long Covid which calls for strategies that can help improve outcomes over time,” says Dr Sehgal, adding that on World Lung Day, it is important to understand and discuss these strategies as well as take precautions and prevent the spread of the virus further.

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While advanced technological and infrastructural developments have made life easier for all of us, they have also had a disastrous impact on the environment, particularly on air quality. Air pollution has become one of the biggest problems of our time. Fine particulate matter polluting the air can easily penetrate your bloodstream and adversely impact your overall health, especially your lungs. According to the data collected by the World Health Organization (WHO), ambient air pollution was the cause of 4.2 million deaths in 2016 and is estimated to lead to about 16 percent of all lung cancer deaths.

So, how can you keep your lungs healthy while living in a polluted city? Here we’re revealing how a few lifestyle tips can keep lungs healthy.

Follow these 9 tips to keep lungs healthy and strengthen them to fight pollution:

1. Keep an eye on pollution forecast

There are many applications and websites that provide nearly accurate predictive outdoor air quality reports every day. With their colour-coded system, these apps help you comprehend just how much pollution you will expose yourself to when you step outside that day.

2. Stay indoors on bad AQI days

Spend as much time indoors as you can, particularly on days when the pollution forecast or the AQI (air quality index) shows an alarming number. In case you need to step out, wear a high-quality face mask at all times to avoid inhaling harmful particles in the air.

3. Don’t exercise outdoors

Whenever the pollution levels are high, avoid exercising outdoors. Walking, jogging or any other strenuous activities that might increase your breathing rate can lead to the inhalation of harmful particles present in the air.

4. Drink enough water

Drinking enough water can help in flushing toxins out of your body. It is advisable to drink at least 8 to 10 glasses of water every day to stay hydrated.

tips to keep lungs healthy
Don’t reduce your water intake. Image Courtesy: Shutterstock

5. Maintain a healthy diet

One of the best ways to resist harmful effects of air pollution is by building up your immunity against infections. For this, maintaining a healthy diet rich in vital nutrients like vitamins C and E is essential. Make sure that your diet is packed with the nutrients to keep up the health of your respiratory tract.

6. Quit smoking

You need to quit smoking now, especially if you live in a polluted city. Nothing is more damaging to your lungs than smoking cigarettes. The harmful chemicals in cigarettes compounded with the harmful particles in the air can be immensely damaging to your lungs.

7. Get an air purifier

The air inside your home can also be polluted, sometimes even more than the air outside. For this reason, it is a smart choice to invest in an air purifier. Make sure to keep your air purifier clean and replace its filter frequently.

8. Practice breathing exercises

Practicing breathing exercises every day can prove to be helpful in improving lung functions. Some of these exercises include belly breathing and pursed lip breathing.

tips to keep lungs healthy
Breathing properly in the morning can improve lung health. Image courtesy: Shutterstock

9. Go green!

Make sure you do everything you can towards reducing air pollution and improving air quality. To do your bit, you can consume less energy in your homes, use hand-powered equipment, and take a bike, walk, or carpool whenever possible.


With air pollution posing such a huge risk to your lung health as well as overall well-being, it is best to follow the above-mentioned measures, especially if you are living in a polluted city. If you experience any respiratory problems or symptoms of lung issues, consult with a doctor right away.

Air pollution, if not more, is as dangerous and harmful to the human body as has been smoking over the years. It’s time we realize it is harmful and take preventive measures to safeguard ourselves from this growing menace.

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Every year, World Lung Day is celebrated on September 25 to advocate lung health and spread awareness. Lung disease is any problem that arises in the lungs and prevents it from working properly. Lung disease is divided into three main types - airway diseases, lung tissue diseases and lung circulation diseases.

The lungs, just like any other part of your body, age with time and that's why they need extra attention and care. People don't understand the importance of healthy lungs until they experience a breathing problem. After the Covid-19 pandemic took over the world, millions across the globe showed signs of weak lungs and reported breathing issues.

In 2022, it's crucial that we look after the health of our lungs and take precaution against harmful diseases that can make our breathing difficult. After all, the lungs are a crucial part of the respiratory system as they carry oxygen from the air and pump it through the body's airways and air sacs. The oxygen is then absorbed into the bloodstream and carried to the heart via the blood vessels.

Understanding the three main types of lung disease:

Airway Diseases

These harmful diseases impact the tubes that carry oxygen, making it difficult for people to breathe.

Lung Tissue Diseases
These diseases affect the structure of the lung tissue, which then makes it difficult for the lungs to function properly and diffuse oxygen from the airways into the bloodstream.

Lung Circulation Diseases

This type of disease impacts the blood vessels in the lungs. These diseases affect the way blood flows from the heart to the rest of the body.

Most Common Lung Diseases:

Most common lung diseases emerge from one or more of these three main types. Here are the most common lung diseases:


Millions of people across the country suffer from asthma and have difficult breathing. Though there's no cure for this disease, the person can lead a healthy and normal life with the help of right treatment and managing the asthma.

The disease can be managed by working with a healthcare provider to develop a plan to keep your asthma under control by understanding your trigger and learning of simple ways to limit your exposure, understanding your medication, learning self-management skills and more.

Chronic Obstructive Pulmonary Disease (COPD)
This disease includes Chronic Bronchitis and Emphysema and is a long-term lung disease that makes it hard to breathe but is often preventable and treatable.


Most commonly referred to as bronchitis, acute bronchitis is a lower respiratory infection that impacts the air tubes of the lungs and usually comes on suddenly and can last for a week to 10 days.

Tips To Prevent Lung Diseases:

Stop smoking as it increases your risk of lung cancer. According to several reports, smokers are 12 to 13 times more likely to die from COPD than nonsmokers.

Exercise. Getting a regular workout will really help your health. It will not only make you fitter but also improve your overall health. When you workout, your heart beats faster and your lungs work harder.

Get some fresh air. It's no secret that we are exposed to pollutants on a daily basis. So give your lungs the much needed break and reduce the exposure to harmful air by making your home smoke-free zone, dusting your furniture, improving the indoor air ventilation by opening a window, avoid synthetic air fresheners, candles, and wear a good mask when you go outside.

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Neil Lydon jokes with program co-ordinators Lisa Curtis and Robyn Palk. (Megan Macalpine/CBC - image credit)

Neil Lydon jokes with program co-ordinators Lisa Curtis and Robyn Palk. (Megan Macalpine/CBC - image credit)

As Neil Lydon adjusts the seat on a recumbent stepper machine, he chuckles, looking back on his first days in the Saint John-based pulmonary rehabilitation program.

"I was never brought up with sports, and I see a machine and I think, 'Oooh … effort,'" he says.

After living with chronic obstructive pulmonary disease, or COPD, for more than a decade, a respirologist referred Lydon to the promising pilot initiative. There is no cure for COPD, but the program aims to build a patient's stamina and, ultimately, keep them out of the hospital.

"Blood oxygen is low, so you use up whatever energy you've got pretty quickly," he said.

"My doctor said, 'Maybe we'll try you on some meds,' and in the end I wound up on two different medications, and he thought it would be a good idea to get some physicality into the program.

"It sort of got me out of my inertia."

Megan Macalpine/CBC

Megan Macalpine/CBC

Lydon said the gym wasn't an environment he was familiar with, but then he found he could use the machines that best suited his fitness level at that time.

"I tried the treadmill, but I got very winded, very quickly on that … I did push my limits on the step machine," he says. "I increased that from three or four hundred steps up to 1,700-and-something by the time I'd finished. It took about half an hour."

The rehab program is a research project and is infused with students from the New Brunswick Community College and the University of New Brunswick. Students from a number of disciplines, such as respiratory therapy, nursing and pharmacy technology, work almost one-on-one with the seniors who take part.

To be eligible, participants have to be at least 60 years old and living with moderate to severe COPD with nothing to disqualify them, like a recent heart attack, uncontrolled blood pressure or being at risk for falls.

One in five seniors

Tammie Fournier, a respiratory therapist and chair of Allied Health programs for NBCC, says one in five New Brunswick seniors have COPD.

"People living with COPD experience shortness of breath and they have a chronic cough. The combination of those two symptoms would lead to inactivity which inevitably worsens with their condition," Fournier said.

"So the worsening shortness of breath and cough and decrease in activity really become this vicious cycle that robs people with COPD of their quality of life over time."

This program is meant to break that cycle, and Fournier says it's shown some exciting results.

Submitted by Robyn Palk

Submitted by Robyn Palk

"One person decided not to sell their home after completing the clinic reduced their shortness of breath while climbing their stairs," she said. "Two other participants both gained enough strength to travel to Toronto and receive life-saving lung transplantation."

In a computer lab-turned-gym at NBCC's Allied Health Education Centre on the UNB campus, the seniors in the program build their endurance using gym equipment, free weights and drumming exercises.

Besides helping participants increase their stamina, the program also teaches them how to properly take their medications to get the most out of them and what to do if symptoms suddenly get worse.

Robyn Palk, the co-ordinator of the program, says a participant told her that information helped her avoid calling an ambulance after accidentally inhaling fumes while she was cleaning her oven. The woman thought back to classes on breath techniques and was able to take control of her breathing, Palk said.

"The hospitals are full," Palk said. "You don't want to be short of breath and having to wait in an emergency room for an extended period of time. If there are steps you can take at home to keep yourself out of hospital, that's really important right now."

Big savings

New Brunswick spends $23 million annually on COPD, Fournier said, which equates to about 3,100 hospital admissions at $7,400 per admission.

"The program is decreasing the risk of lung attack in 80 men and women, or about 0.14 per cent of our New Brunswick COPD population," she said. "So by extension, if each one of those participants reduces their admission to hospital by only one, this could save almost $600,000 of health-care spending on those 80 people alone."

Funding for the program comes from the Healthy Seniors pilot project, a $75-million provincial and federal initiative to research ways to better support the aging population.

However, the funding ends in 2023, Fournier said, and they're now looking for a source of sustainable funding to ensure it can continue.

Megan Macalpine

Megan Macalpine

"I've been a respiratory therapist,and Robyn has as well, for over 20 years now," said program co-ordinator Lisa Curtis. "This is the most rewarding work we've ever done because we get to spend so much more time with people than you do in acute care."

Curtis says over the course of the program, they get to watch participants go from barely making it into the building to coming in with a smile, and getting on a treadmill and walking for 30 minutes.

What happens to the research?

Curtis and Palk say they've been in contact with other institutions across Canada hoping to set up their own programs, and they've developed a how-to manual or toolkit for getting a program started.

They've also been selected to present at an international conference on COPD.

Neil Lydon hopes more people hear about the program that's helped him.

"I think people who are out there who have COPD, they might not realize … there is a program that will assist them in dealing with it, getting some relief," Lydon said.

"It's important to get the word out."

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Healthcare Personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, home healthcare personnel, physicians, technicians, therapists, phlebotomists, pharmacists, dental healthcare personnel, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).

Healthcare settings refers to places where healthcare is delivered and includes, but is not limited to, acute care facilities, long-term acute-care facilities, nursing homes, home healthcare, vehicles where healthcare is delivered (e.g., mobile clinics), and outpatient facilities, such as dialysis centers, physician offices, dental offices, and others.

Source control: Use of respirators, well-fitting facemasks, or well-fitting cloth masks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control devices should not be placed on children under age 2, anyone who cannot wear one safely, such as someone who has a disability or an underlying medical condition that precludes wearing one safely, or anyone who is unconscious, incapacitated, or otherwise unable to remove their source control device without assistance. Face shields alone are not recommended for source control. At a minimum, source control devices should be changed if they become visibly soiled, damaged, or hard to breathe through.  Further information about source control options is available at:  Masks and Respirators (cdc.gov)

Cloth mask: Textile (cloth) covers that are intended primarily for source control in the community. They are not personal protective equipment (PPE) appropriate for use by healthcare personnel. Guidance on design, use, and maintenance of cloth masks is available.

Facemask: OSHA defines facemasks as “a surgical, medical procedure, dental, or isolation mask that is FDA-cleared, authorized by an FDA EUA, or offered or distributed as described in an FDA enforcement policy. Facemasks may also be referred to as ‘medical procedure masks’.”  Facemasks should be used according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Other facemasks, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.

Respirator: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by CDC/NIOSH, including those intended for use in healthcare.

Airborne Infection Isolation Rooms (AIIRs):

  • AIIRs are single-patient rooms at negative pressure relative to the surrounding areas, and with a minimum of 12 ACH (6 ACH are allowed for AIIRs last renovated or constructed prior to 1997).
  • Air from these rooms should be exhausted directly to the outside or be filtered through a HEPA filter directly before recirculation.
  • Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized.
  • Facilities should monitor and document the proper negative-pressure function of these rooms.

Immunocompromised:  For the purposes of this guidance, moderate to severely immunocompromising conditions include, but might not be limited to, those defined in the Interim Clinical Considerations for Use of COVID-19 Vaccines

  • Other factors, such as end-stage renal disease, may pose a lower degree of immunocompromise. However, people in this category should still consider continuing to use of source control while in a healthcare facility.
  • Ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.

Close contact: Being within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period with someone with SARS-CoV-2 infection.

SARS-CoV-2 Illness Severity Criteria (adapted from the NIH COVID-19 Treatment Guidelines)

The studies used to inform this guidance did not clearly define “severe” or “critical” illness. This guidance has taken a conservative approach to define these categories. Although not developed to inform decisions about duration of Transmission-Based Precautions, the definitions in the National Institutes of Health (NIH) COVID-19 Treatment Guidelines are one option for defining severity of illness categories. The highest level of illness severity experienced by the patient at any point in their clinical course should be used when determining the duration of Transmission-Based Precautions. Clinical judgement regarding the contribution of SARS-CoV-2 to clinical severity might also be necessary when applying these criteria to inform infection control decisions.

Mild Illness: Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging.

Moderate Illness: Individuals who have evidence of lower respiratory disease by clinical assessment or imaging, and a saturation of oxygen (SpO2) ≥94% on room air at sea level.

Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level (or, for patients with chronic hypoxemia, a decrease from baseline of >3%), ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%.

Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.

In pediatric patients, radiographic abnormalities are common and, for the most part, should not be used as the sole criteria to define COVID-19 illness category. Normal values for respiratory rate also vary with age in children, thus hypoxia should be the primary criterion to define severe illness, especially in younger children.

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When we think of chest pain, we usually think about heart attacks.

According to the American Heart Association (AHA), a heart attack occurs when the blood flow that brings oxygen to the heart muscle is severely reduced or cut off completely, which can be fatal. Heart attack pain can last for hours if untreated.

A heart attack is the most serious symptom of coronary artery disease (CAD), the most common type of heart disease. CAD can produce a type of chest pain called angina.

Angina may feel like pressure or squeezing in your chest and typically happens when you are physically exerting yourself. The discomfort can also be felt in your:

  • Shoulders
  • Arms
  • Neck
  • Jaw
  • Abdomen
  • Back

Angina pain may even feel like heartburn, but it is short lived and typically doesn't last longer than 10 minutes.

If you're experiencing chest pain, it's important to get it checked out, ASAP. Don't hesitate to call 911, especially if it's a new symptom that you've never had before, the pain comes and goes, or the pain gets worse.

All chest pain should be checked out by a healthcare professional. They can determine if it's angina, heart attack pain, or something else.

Chest pain isn't always caused by a heart attach. Some causes can be mild, like heartburn, others can be dangerous, like pancreatitis.

You might be wondering how someone could mistake the symptoms of acid reflux for a heart attack, but there's a reason why it's called heartburn, after all.

Gastroesophageal reflux occurs when a person's stomach contents—including the gastric acids that help break down food—back up into the esophagus, the tube that connects the throat and stomach.

Stomach acid is highly acidic, hence, the burning sensation behind your breastbone; on the pH scale, it scores about a 1 according to the Environmental Protection Agency (EPA) falling somewhere between battery acid and vinegar.

Our stomachs are lined with protective membranes that shield it from the corrosive effects of acid, while our esophagus is not.

The occasional reflux is fairly common and probably nothing to worry about, but if you're experiencing it twice a week or more, you may have gastroesophageal reflux disease (GERD).

Left untreated over time, GERD can cause asthma, chest congestion, and a condition called Barrett's esophagus, which may increase your chances of developing a rare type of cancer, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

It's possible for someone to mistake a strained chest muscle for something more serious, like a heart attack, said Christine Jellis, MD, PhD, a Cardiology Specialist at Cleveland Clinic.

"I had a patient who came in with chest pain, and he was worried he was having a heart attack," said Dr. Jellis. "After taking his history, I learned he had moved [to a new house] and hadn't lifted heavy furniture in years. But he did the right thing, coming in."

Healthcare providers don't expect people to be able to tell the difference between a heart attack and a pulled chest muscle, said Dr. Jellis, but a good way to check is that if you can press on the wall of the chest and it feels even more painful, it's more likely to be a musculoskeletal injury than a problem with your heart.

Costochondritis is an inflammation of the tissue (cartilage) connecting your ribs to your breastbone, according to MedlinePlus.

It's a common and benign (or non-threatening) cause of chest wall pain. But if it's new to you, it's a good idea to get it checked out by a medical professional anyway.

Although healthcare providers can't always pinpoint what triggered the condition, the causes can range from viral infections to chest injuries.

Typically, people feel a type of pressure on their chest wall and—similar to a strained muscle—a tenderness when they press on the area.

In this case, a healthcare provider will probably start by taking your medical history and doing a physical exam. "A physician is going to want to rule out cardiac and other serious issues first," said Dr. Jellis. "It'll most likely be a diagnosis by exclusion."

If you do have costochondritis, the pain typically goes away in a few days or weeks; taking over-the-counter painkillers can help.

The virus that causes chickenpox lingers in your body long after the spots have faded. In fact, the varicella-zoster virus can reactivate in adulthood (usually in people older than 50) as a disease called shingles.

The first symptoms include itching and burning skin. If the area over the chest is affected, someone might mistake this new pain for a heart attack or other cardiac issue, said Salman Arain, MD, an interventional cardiologist at Houston and the Memorial Hermann Heart & Vascular Institute-Texas Medical Center.

A few days later, however, the telltale rash can appear, followed by blisters.

If you think you have shingles, call a healthcare provider ASAP. Antiviral medications can lessen the pain and shorten the duration of the symptoms, but only if you take them within 72 hours of the rash appearing.

If it's too late to take antivirals, a healthcare provider can prescribe a prescription painkiller.

Pericarditis is a condition where there is inflammation in the layers of tissue that surround the heart (called the pericardium).

In 80%–85% of cases, pericarditis is caused by a viral infection, as reported in a 2022 review published in Current Cardiology Reports.

Other causes include bacterial infections, which are less common, and fungal infections, which are rare, according to MedlinePlus. Although there can be other causes as well.

Pain is present in most cases and is described as sharp or stabbing. The pain is located on the left side or front part of the chest, but it can also occur in the neck, shoulder, back, or abdomen.

It's more intense with lying down, breathing deeply, coughing, or swallowing, and it improves with sitting up and leaning forward, which is unique to this condition.

Although pericarditis is usually harmless, according to Dr. Arain, it can really impact your quality of life.

A healthcare provider may diagnose your condition after ordering a CT scan, EKG, or chest X-ray.

Chances are, however, your pericarditis will clear up in a few days or weeks simply through resting or taking over-the-counter pain medicine like ibuprofen, which also helps quell inflammation.

Just because a person's chest pain isn't related to a heart attack doesn't mean that it isn't dangerous. One example: acute pancreatitis—the sudden inflammation of the pancreas, which is located just behind the stomach, says NIDDK.

"Intense abdominal pain can radiate up to the chest," said Dr. Arain. "And the pain from pancreatitis is usually a deep-seated, intense pain."

Oftentimes, pancreatitis occurs when gallstones (hard, pebble-like pieces of material usually made of hardened cholesterol, according to NIDDK) trigger inflammation in the pancreas—something that's more likely to occur in women than men.

If you think you have pancreatitis, get medical attention right away; you'll probably have to stay in the hospital for a few days to get antibiotics, IV fluids, and pain medication.

A healthcare provider will also want to do blood work and order other tests, like a CT scan or abdominal ultrasound.

Chest pain can have a number of pulmonary (lung) causes. Because the lungs and heart are both located in the chest, it can be easy to confuse the origin of the pain.

Pleuritic chest pain occurs when the lining of your lungs (the pleura) becomes inflamed. This can cause "sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling," according to a 2017 article published in the American Family Physician.

While not related to a heart attack, this type of chest pain can also be serious and is another reason you'll want to get your symptoms checked out by a medical professional.

Pulmonary embolism is the most common serious cause of pleuritic chest pain and is life threatening.

Pulmonary embolism occurs when there is a blockage in a lung artery. This blockage can damage the lungs and cause low oxygen levels in your blood, which can damage other organs as well, according to MedlinePlus.

Pneumonia can also cause pleuritic chest pain. Pneumonia is an infection of the lungs and can range from mild to severe, depending on the cause, according to MedlinePlus. Chest pain from pneumonia will occur when you breathe or cough.

If you've had some type of injury or trauma to your chest, a broken or bruised rib can also cause chest pain. Breathing, coughing, and moving your upper body can be very painful if you've injured your rib.

Having a panic attack can certainly feel like a heart attack; people often believe they're dying when they are having one.

In addition to chest pain, symptoms can include a pounding heart, sweating, shaking, nausea, dizziness, and a feeling of going crazy. It's your body's fight-or-flight response kicking in, according to the American Psychological Association.

Panic attacks tend to crop up suddenly with no warning. People can experience them for a variety of reasons, including:

  • Having a family history of panic attacks
  • A history of childhood trauma
  • Dealing with major life changes and ongoing stress (such as a serious illness of a loved one)
  • Experiencing a traumatic event (such as a robbery or car accident)

If you think you've experienced a panic attack, it can be helpful to visit a healthcare provider. They can rule out any physical issues with your heart, which can help put you at ease.

A provider may also refer you to a mental health professional who can help you treat and manage your symptoms.

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What does "Pulmonary Fibrosis" mean?  
The word “pulmonary” means lung and the word “fibrosis” means scar tissue— similar to scars that form on the skin from an old injury or surgery. So, in its simplest sense, pulmonary fibrosis (PF) means scarring in the lungs.

Pulmonary fibrosis is a lung disease that occurs when lung tissue becomes damaged and scarred. This thickened, stiff tissue makes it more difficult for your lungs to work properly. As pulmonary fibrosis worsens, people can become progressively more short of breath.

The scarring associated with pulmonary fibrosis can be caused by a multitude of factors. But in most cases, doctors can't pinpoint what's causing the problem. When a cause can't be found, the condition is termed idiopathic pulmonary fibrosis.

The lung damage caused by pulmonary fibrosis can't be repaired, but medications and therapies can help ease symptoms and improve quality of life. For some patients, a lung transplant might be appropriate.

Symptoms of Pulmonary Fibrosis:  
The most common symptoms of pulmonary fibrosis are dry, persistent cough and shortness of breath. Symptoms may be mild or even absent early in the disease process. As the lungs develop more scar tissue, symptoms worsen. Shortness of breath initially occurs with exercise, but as the disease progresses patients may become breathless while taking part in everyday activities, such as showering, getting dressed, speaking on the phone, or even eating.

Due to a lack of oxygen in the blood, some people with pulmonary fibrosis may also have “clubbing” of the fingertips. Clubbing is a thickening of the flesh under the fingernails, causing the nails to curve downward. It is not specific to pulmonary fibrosis or idiopathic pulmonary fibrosis and occurs in other diseases of the lungs, heart, and liver, and can also be present at birth.

How Do Doctors Recognize and Diagnose Pulmonary Fibrosis? 
There are three consequences of pulmonary fibrosis. Doctors use these consequences to recognize that someone has PF:

1. Stiff Lungs. Scar tissue and inflammation make your lungs stiff. Stiff lungs are hard to stretch, so your breathing muscles have to work extra hard just to pull air in with each breath. Your brain senses this extra work, and it lets you know there’s a problem by triggering a feeling of breathlessness (or “shortness” of breath) while exerting yourself.

Also, stiff lungs hold less air (they shrink a bit). Doctors take advantage of this “shrinking” to diagnose and track the disease using breathing tests (called Pulmonary Function Tests) that measure how much air your lungs can hold. The more scar tissue your lungs have, the less air they will hold.

2. Low blood oxygen. Scar tissue blocks the movement of oxygen from the inside of your air sacs into your bloodstream. For many people living with pulmonary fibrosis, oxygen levels are only reduced a little bit while resting, but their oxygen levels drop quite a bit during activity. The brain can sense these low oxygen levels, triggering breathlessness.

Doctors will check your oxygen levels to see if they drop after walking, which could be a clue that PF might be present. Doctors also often prescribe oxygen to be used through a nasal cannula or a facemask during activity and sleep for those with PF. As pulmonary fibrosis progresses, oxygen may be needed 24 hours a day and flow rates may increase.

3. “Crackles" lung sounds. Your doctor may have told you that “crackles” were heard in your lungs. Crackles (also called “rales”) sound like Velcro being pulled apart.

They are heard in many lung diseases because any type of problem affecting the air sacs (such as PF, pneumonia, or a buildup of fluid in the lungs from heart failure) can cause crackles. Some people with pulmonary fibrosis don’t have crackles, but most do.

Can pulmonary fibrosis be reversed? 
Unfortunately, lung damage due to pulmonary fibrosis is permanent (not reversible). Getting diagnosed and starting treatment as early as possible may help your lungs work better, longer.

How is pulmonary fibrosis treated? 
Most pulmonary fibrosis treatments focus on easing symptoms and improving your quality of life.

Your provider may recommend one or more treatments: 
• Medication: Two medications — pirfenidone (Esbriet®) and nintedanib (OFEV®) —may slow down lung scarring. These medications can help preserve lung function.

• Oxygen therapy: Giving your body extra oxygen helps you breathe more easily. It may also increase your energy and strength.

• Pulmonary rehabilitation: Staying active in this special exercise program may improve how much (or how easily) you can do everyday tasks or activities.

• Lung transplant: A lung transplant replaces one or both diseased lungs with a healthy lung (or lungs) from a donor. It offers the potential to improve your health and quality of life. A lung transplant is major surgery, and not everyone is a candidate. Ask your provider if you may be eligible for a lung transplant.

Can pulmonary fibrosis be cured? 
No cure for pulmonary fibrosis exists today. But researchers around the world are working to change that.

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This interim guidance is intended to assist with the following:

  1. Determining the duration of restriction from the workplace for HCP with SARS-CoV-2 infection.
  2. Assessment of risk and application of workplace restrictions for asymptomatic HCP with exposure to SARS-CoV-2.

Guidance addressing recommended infection prevention and control practices including use of source control by HCP is available in Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Employers should be aware that other local, territorial, tribal, state, and federal requirements may apply, including those promulgated by the Occupational Safety and Health Administration (OSHA).

Evaluating Healthcare Personnel with Symptoms of SARS-CoV-2 Infection

HCP with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays.

When testing a person with symptoms of COVID-19, negative results from at least one viral test  indicate that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected.

  • If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining work restrictions and confirming with a second negative NAAT.
  • If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test.

For HCP who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses.

Return to Work Criteria for HCP with SARS-CoV-2 Infection

The following are criteria to determine when HCP with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. After returning to work, HCP should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen.  If symptoms recur (e.g., rebound) these HCP should be restricted from work and follow recommended practices to prevent transmission to others (e.g., use of well-fitting source control) until they again meet the healthcare criteria below to return to work unless an alternative diagnosis is identified.

HCP with mild to moderate illness who are not  moderately to severely immunocompromised could return to work after the following criteria have been met:

  • At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7)and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications, and
  • Symptoms (e.g., cough, shortness of breath) have improved.

*Either a NAAT (molecular) or antigen test may be used.  If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later

HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met:

  • At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7).

*Either a NAAT (molecular) or antigen test may be used.  If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later

HCP with severe to critical illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met:

  • At least 10 days and up to 20 days have passed since symptoms first appeared, and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications, and
  • Symptoms (e.g., cough, shortness of breath) have improved.
  • The test-based strategy as described below for moderately to severely immunocompromised HCP can be used to inform the duration of work restriction.

The exact criteria that determine which HCP will shed replication-competent virus for longer periods are not known. Disease severity factors and the presence of immunocompromising conditions should be considered when determining the appropriate duration for specific HCP. For a summary of the literature,  refer to Ending Isolation and Precautions for People with COVID-19: Interim Guidance (cdc.gov)

HCP who are moderately to severely immunocompromised may produce replication-competent virus beyond 20 days after symptom onset or, for those who were asymptomatic throughout their infection, the date of their first positive viral test.

  • Use of a test-based strategy (as described below) and consultation with an infectious disease specialist or other expert and an occupational health specialist is recommended to determine when these HCP may return to work.

Test-based strategy

HCP who are symptomatic could return to work after the following criteria are met:

  • Resolution of fever without the use of fever-reducing medications, and
  • Improvement in symptoms (e.g., cough, shortness of breath), and
  • Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT.

HCP who are not symptomatic could return to work after the following criteria are met:

  • Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT.

Return to Work Criteria for HCP Who Were Exposed to Individuals with Confirmed SARS-CoV-2 Infection

Exposures that might require testing and/or restriction from work can occur both while at work and in the community.  Higher-risk exposures generally involve exposure of HCP’s eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if these HCP were present in the room for an aerosol-generating procedure.

Other exposures not classified as higher-risk, including having body contact with the patient (e.g., rolling the patient) without gown or gloves, may impart some risk for transmission, particularly if hand hygiene is not performed and HCP then touch their eyes, nose, or mouth. When classifying potential exposures, specific factors associated with these exposures (e.g., quality of ventilation, use of PPE and source control) should be evaluated on a case-by-case basis.  These factors might raise or lower the level of risk; interventions, including restriction from work, can be adjusted based on the estimated risk for transmission.

For the purposes of this guidance, higher-risk exposures are classified as HCP who had prolonged1 close contact2 with a patient, visitor, or HCP with confirmed SARS-CoV-2 infection3 and:

  • HCP was not wearing a respirator (or if wearing a facemask, the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask)4
  • HCP was not wearing eye protection if the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask
  • HCP was not wearing all recommended PPE (i.e., gown, gloves, eye protection, respirator) while present in the room for an aerosol-generating procedure

Following a higher-risk exposure, HCP should:

  • Have a series of three viral tests for SARS-CoV-2 infection.
    • Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test.  This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5.
    • Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days.  Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of NAAT is recommended.  This is because some people may remain NAAT positive but not be infectious during this period.

Work restriction is not necessary for most asymptomatic HCP following a higher-risk exposure, regardless of vaccination status.  Examples of when work restriction may be considered include:

  • HCP is unable to be tested or wear source control as recommended for the 10 days following their exposure;
  • HCP is moderately to severely immunocompromised;
  • HCP cares for or works on a unit with patients who are moderately to severely immunocompromised;
  • HCP works on a unit experiencing ongoing SARS-CoV-2 transmission that is not controlled with initial interventions;

If work restriction is recommended, HCP could return to work after either of the following time periods:

  • HCP can return to work after day 7 following the exposure (day 0) if they do not develop symptoms and all viral testing as described for asymptomatic HCP following a higher-risk exposure is negative.
  • If viral testing is not performed, HCP can return to work after day 10 following the exposure (day 0) if they do not develop symptoms.

In addition to above:

HCP with travel or community exposures should consult their occupational health program for guidance on need for work restrictions. In general, HCP who have had prolonged close contact with someone with SARS-CoV-2 in the community (e.g., household contacts) should be managed as described for higher-risk occupational exposures above.


  1. For this guidance an exposure of 15 minutes or more is considered prolonged. This could refer to a single 15-minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period. However, the presence of extenuating factors (e.g., exposure in a confined space, performance of aerosol-generating procedure) could warrant more aggressive actions even if the cumulative duration is less than 15 minutes. For example, any duration should be considered prolonged if the exposure occurred during performance of an aerosol generating procedure.
  2. For this guidance it is defined as: a) being within 6 feet of a person with confirmed SARS-CoV-2 infection or b) having unprotected direct contact with infectious secretions or excretions of the person with confirmed SARS-CoV-2 infection. Distances of more than 6 feet might also be of concern, particularly when exposures occur over long periods of time in indoor areas with poor ventilation.
  3. Determining the time period when the patient, visitor, or HCP with confirmed SARS-CoV-2 infection could have been infectious:
    1. For individuals with confirmed COVID-19 who developed symptoms, consider the exposure window to be 2 days before symptom onset through the time period when the individual meets criteria for discontinuation of Transmission-Based Precautions
    2. For individuals with confirmed SARS-CoV-2 infection who never developed symptoms, determining the infectious period can be challenging. In these situations, collecting information about when the asymptomatic individual with SARS-CoV-2 infection may have been exposed could help inform the period when they were infectious.
      1. If the date of exposure cannot be determined, although the infectious period could be longer, it is reasonable to use a starting point of 2 days prior to the positive test through the time period when the individual meets criteria for discontinuation of Transmission-Based Precautions for contact tracing.
  4. While respirators confer a higher level of protection than facemasks and are recommended when caring for patients with SARS-CoV-2 infection, facemasks still confer some level of protection to HCP, which was factored into this risk assessment if the patient was also wearing a cloth mask or facemask


Healthcare Personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, home healthcare personnel, physicians, technicians, therapists, phlebotomists, pharmacists, dental healthcare personnel, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). For this guidance, HCP does not include clinical laboratory personnel.

Immunocompromised:  For the purposes of this guidance, moderate to severely immunocompromising conditions include, but might not be limited to, those defined in the Interim Clinical Considerations for Use of COVID-19 Vaccines.

SARS-CoV-2 Illness Severity Criteria (adapted from the NIH COVID-19 Treatment Guidelines)

The studies used to inform this guidance did not clearly define “severe” or “critical” illness. This guidance has taken a conservative approach to define these categories. Although not developed to inform decisions about duration of Transmission-Based Precautions, the definitions in the National Institutes of Health (NIH) COVID-19 Treatment Guidelines are one option for defining severity of illness categories. The highest level of illness severity experienced by the patient at any point in their clinical course should be used when determining the duration of Transmission-Based Precautions.

Mild Illness: Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging.

Moderate Illness: Individuals who have evidence of lower respiratory disease, by clinical assessment or imaging, and a saturation of oxygen (SpO2) ≥94% on room air at sea level.

Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2 <94% on room air at sea level (or, for patients with chronic hypoxemia, a decrease from baseline of >3%), ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300 mmHg, or lung infiltrates >50%.

Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.

In pediatric patients, radiographic abnormalities are common and, for the most part, should not be used as the sole criteria to define COVID-19 illness category. Normal values for respiratory rate also vary with age in children; thus, hypoxia should be the primary criterion to define severe illness, especially in younger children.

Fever: For the purpose of this guidance, fever is defined as subjective fever (feeling feverish) or a measured temperature of 100.0oF (37.8oC) or higher. Note that fever may be intermittent or may not be present in some people, such as those who are elderly, immunocompromised, or taking certain fever-reducing medications (e.g., nonsteroidal anti-inflammatory drugs [NSAIDS]).

Facemask: OSHA defines facemasks as “a surgical, medical procedure, dental, or isolation mask that is FDA-cleared, authorized by an FDA EUA, or offered or distributed as described in an FDA enforcement policy. Facemasks may also be referred to as ‘medical procedure masks’.”  Facemasks should be used according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Other facemasks, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.

Respirator: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by CDC/NIOSH, including those intended for use in healthcare.

Cloth mask: Textile (cloth) covers that are intended primarily for source control in the community. They are not personal protective equipment (PPE) appropriate for use by healthcare personnel. Guidance on design, use, and maintenance of cloth masks is available.

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Editor’s note: Find more information about long COVID in Medscape’s Long COVID Resource Center.

Sept. 22, 2022 – Entrepreneur Maya McNulty, 49, was one of the first victims of the COVID-19 pandemic. The Schenectady, NY, businesswoman spent 2 months in the hospital after catching the disease in March 2020. That September, she was diagnosed with long COVID.

“Even a simple task such as unloading the dishwasher became a major challenge,” she says.

Over the next several months, McNulty saw a range of specialists, including neurologists, pulmonologists, and cardiologists. She had months of physical therapy and respiratory therapy to help regain strength and lung function. While many of the doctors she saw were sympathetic to what she was going through, not all were.

“I saw one neurologist who told me to my face that she didn’t believe in long COVID,” she recalls. “It was particularly astonishing since the hospital they were affiliated with had a long COVID clinic.”

McNulty began to connect with other patients with long COVID through a support group she created at the end of 2020 on the social media app Clubhouse. They exchanged ideas and stories about what had helped one another, which led her to try, over the next year, a plant-based diet, Chinese medicine, and vitamin C supplements, among other treatments.

She also acted on unscientific reports she found online and did her own research, which led her to discover claims that some asthma patients with chronic coughing responded well to halotherapy, or dry salt therapy, during which patients inhale micro-particles of salt into their lungs to reduce inflammation, widen airways, and thin mucus. She’s been doing this procedure at a clinic near her home for over a year and credits it with helping with her chronic cough, especially as she recovers from her second bout of COVID-19.

It’s not cheap – a single half-hour session can cost up to $50 and isn’t covered by insurance. There’s also no good research to suggest that it can help with long COVID, according to the Cleveland Clinic.

McNulty understands that but says many people who live with long COVID turn to these treatments out of a sense of desperation.

“When it comes to this condition, we kind of have to be our own advocates. People are so desperate and feel so gaslit by doctors who don’t believe in their symptoms that they play Russian roulette with their body,” she says. “Most just want some hope and a way to relieve pain.”

Across the country, 16 million Americans have long COVID, according to the Brookings Institution’s analysis of a 2022 Census Bureau report. The report also estimated that up to a quarter of them have such debilitating symptoms that they are no longer able to work. While long COVID centers may offer therapies to help relieve symptoms, “there are no evidence-based established treatments for long COVID at this point,” says Andrew Schamess, MD, a professor of internal medicine at Ohio State Wexner Medical Center, who runs its Post-COVID Recovery Program. “You can’t blame patients for looking for alternative remedies to help them. Unfortunately, there are also a lot of people out to make a buck who are selling unproven and disproven therapies.”

Sniffing Out the Snake Oil

With few evidence-based treatments for long COVID, patients with debilitating symptoms can be tempted by unproven options. One that has gotten a lot of attention is hyperbaric oxygen. This therapy has traditionally been used to treat divers who have decompression sickness, or the bends. It’s also being touted by some clinics as an effective treatment for long COVID.

A very small trial of 73 patients with long COVID, published this July in the journal Scientific Reports, found that those treated in a high-pressure oxygen system 5 days a week for 2 months showed improvements in brain fog, pain, energy, sleep, anxiety, and depression, compared with similar patients who got sham treatments. But larger studies are needed to show how well it works, notes Schamess.

“It’s very expensive – roughly $120 per session – and there just isn’t the evidence there to support its use,” he says.

In addition, the therapy itself carries risks, such as ear and sinus pain, middle ear injury, temporary vision changes, and, very rarely, lung collapse, according to the FDA.

One “particularly troubling” treatment being offered, says Kathleen Bell, MD, chair of the Department of Physical Medicine and Rehabilitation at the University of Texas Southwestern Medical Center, is stem cell therapy. This therapy is still in its infancy, but it’s being marketed by some clinics as a way to prevent COVID-19 and also treat long-haul symptoms.

The FDA has issued advisories that there are no products approved to treat long COVID and recommends against their use, except in a clinical trial.

“There’s absolutely no regulation – you don’t know what you’re getting, and there’s no research to suggest this therapy even works,” says Bell. It’s also prohibitively expensive – one Cayman Islands-based company advertises its treatment for as much as $25,000.

Patients with long COVID are even traveling as far as Cyprus, Germany, and Switzerland for a procedure known as blood washing, in which large needles are inserted into veins to filter blood and remove lipids and inflammatory proteins, the British Medical Journal reported in July. Some patients are also prescribed blood thinners to remove microscopic blood clots that may contribute to long COVID. But this treatment is also expensive, with many people paying $10,000-$15,000 out of pocket, and there’s no published evidence to suggest it works, according to theBMJ.

It can be particularly hard to discern what may work and what’s unproven, since many primary care providers are themselves unfamiliar with even traditional long COVID treatments, Bell says. She recommends that patients ask the following questions:

  • What published research is there to support these claims?
  • How long should I expect to do this treatment before I see an improvement?
  • What are the potential side effects?
  • Will the medical provider recommending the treatment work with your current medical team to monitor progress?

“If you can’t get answers to these questions, take a step back,” says Bell.

Sorting Through Supplements

Yufang Lin, MD, an integrative specialist at the Cleveland Clinic, says many patients with long COVID enter her office with bags of supplements.

“There’s no data on them, and in large quantities, they may even be harmful,” she says.

Instead, she works closely with the Cleveland Clinic’s long COVID center to do a thorough workup of each patient, which often includes screening for certain nutritional deficiencies.

“Anecdotally, we do see many patients with long COVID who are deficient in these vitamins and minerals,” says Lin. “If someone is low, we will suggest the appropriate supplement. Otherwise, we work with them to institute some dietary changes.”

­This usually involves a plant-based, anti-inflammatory eating pattern such as the Mediterranean diet, which is rich in fruits, vegetables, whole grains, nuts, fatty fish, and healthy fats such as olive oil and avocados.

Other supplements some doctors recommend for patients with long COVID are meant to treat inflammation, Bell says, although there’s not good evidence they work. One is the antioxidant coenzyme Q10.

But a small preprint study published in The Lancet this past August of 121 patients with long COVID who took 500 milligrams a day of coenzyme Q10 for 6 weeks saw no differences in recovery than those who took a placebo. Because the study is still a preprint, it has not been peer-reviewed.

Another is probiotics. A small 2021 study published in the journal Infectious Diseases Diagnosis & Treatment found that a blend of five lactobacillus probiotics, along with a prebiotic called inulin, taken for 30 days, helped with long-term COVID symptoms such as coughing and fatigue. But larger studies need to be done to support their use.

One that may have more promise is omega-3 fatty acids. Like many other supplements, these may help with long COVID by easing inflammation, says Steven Flanagan, MD, a rehabilitation medicine specialist at NYU Langone in New York who works with long COVID patients. Researchers at the Mount Sinai School of Medicine in New York are studying whether a supplement can help patients who have lost their sense of taste or smell after an infection, but results aren’t yet available.

Among the few alternatives that have been shown to help patients are mindfulness-based therapies – in particular, mindfulness-based forms of exercise such as tai chi and qi gong may be helpful, as they combine a gentle workout with stress reduction.

“Both incorporate meditation, which helps not only to relieve some of the anxiety associated with long COVID but allows patients to redirect their thought process so that they can cope with symptoms better,” says Flanagan.

A 2022 study published in BMJ Open found that these two activities reduced inflammatory markers and improved respiratory muscle strength and function in patients recovering from COVID-19.

“I recommend these activities to all my long COVID patients, as it’s inexpensive and easy to find classes to do either at home or in their community,” he says. “Even if it doesn’t improve their long COVID symptoms, it has other benefits such as increased strength and flexibility that can boost their overall health.”

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When you're feeling stressed or having trouble sleeping, it can sometimes be difficult to get out of that headspace and calm down. But the solution may be as easy as taking deep breaths in and out in a specific rhythm.

A breathing technique—dubbed the 4-7-8 method—has been growing in popularity in recent years thanks to Andrew Weil, MD, who has been teaching the method since the 1980s.

As the name implies— the technique involves breathing in for four seconds, holding that breath for a count of seven, and then exhaling for eight seconds while making a whooshing sound by placing the tongue behind the front teeth. After four repetitions, a person should ideally feel a sense of calm.

"Over time…after you practice it for six weeks or eight weeks, there is a real shift in the balance between the parasympathetic and sympathetic nervous system, resulting in lower heart rate, lower blood pressure, improved digestion, better circulation," Dr. Weil, founder and director of the Andrew Weil Center for Integrative Medicine at the University of Arizona College of Medicine, told Health. " It's also the most effective anti-anxiety measure that I've ever come across."

Here's a closer look at how breathing affects our sense of relaxation, how the 4-7-8 method can promote better sleep, and the easiest ways to incorporate it into your daily routine.

The 4-7-8 technique actually comes from pranayama, or yogic, breathing, Dr. Weil explained. Under this umbrella, there are hundreds of other different techniques for controlling breath that promote health or mindfulness in various ways.

This specific type of breathing engages the diaphragm, explained Todd Arnedt, PhD, professor of psychiatry and neurology and director of the behavioral sleep medicine program at Michigan Medicine at the University of Michigan. This is the opposite of the kind of breathing we do when we're stressed.

"When we're anxious, we tend to do a lot of short, quick breaths, breathing from our chest," Arnedt told Health. "[4-7-8 breathing] sort of redirects you to breathe from your belly and from your diaphragm. And there are a whole host of positive physiological responses that go along with that breathing and help to put you in that relaxed state."

Some of these positive outcomes from diaphragmatic breathing may include improved cognitive function and lower cortisol, or stress, levels, as well as improved quality of life. For the 4-7-8 method more specifically, research found that the practice can help improve blood pressure and heart rate variability.

It may seem strange that something as simple as breathing can have such a big effect on our health, but the connection between breath and the parasympathetic nervous system is likely why we see so many health benefits from the practice.

"Our autonomic nervous system is made up of two main parts, the sympathetic and the parasympathetic," Raj Dasgupta, MD, pulmonary critical care and sleep medicine specialist at Keck Medicine of the University of Southern California, and spokesperson for the American Academy of Sleep Medicine, told Health. "The sympathetic is going to be our fight or flight per se, and in general, that may increase your heart rate, may increase your breathing. And when you activate the parasympathetic nervous system, we kind of refer to that as a rest and digest."

Breathing in this specific ratio—four seconds in, seven seconds of holding at the top, and eight seconds of exhaling—activates the parasympathetic nervous system and helps our body relax, slowing the heart rate, helping with digestion, and lowering stress hormones. Breathing in through your nose and then holding your breath also humidifies and filters the air, and opens up the lungs, Dr. Dasgupta added.

Because it can help relax the body, the 4-7-8 technique can be a good one to incorporate, especially if a person is dealing with stress or has any kind of insomnia.

"As it relates to sleep, we often encourage people to engage in these kinds of practices in the last hour or so before they go to bed, in concert with a good positive, wind down routine," Arnedt said. "This 4-7-8 breathing technique or other mindfulness and relaxation strategies can often be a good part of a good wind down routine—that again, sets the stage for sleep to happen."

Doing this breathing technique can also be useful to help lull a person back to sleep if they wake up in the middle of the night, he added.

Besides making sleeping easier, being able to make your body more relaxed and more ready for sleep should help with a host of other issues as well. Poor sleep quality and not getting enough sleep are linked to a number of health issues—everything from heart disease to depression. Having a simple tool to get you ready for sleep could be a great tool to stay on top of your health.

But the 4-7-8 breathing technique does more than promote sleep, and can be used by anyone at any point throughout the day, Dr. Weil said. It also increases in effectiveness the more that a person does it, so as long as you feel well, "you cannot do it too frequently," Dr. Weil wrote on his website.

"I do it in the morning when I first get up. I do it in the evening when I get into bed to fall asleep, and I do it anytime during the day that I may feel anxious or I want to relax more," he said.

The 4-7-8 breathing technique is fairly simple, Dr. Weil explained, which is in part why he recommends it so widely. You can do it standing, lying down or sitting, he explained, though if you're sitting, it's best to sit upright and have both feet on the floor.

"It's also totally simple, it's very time effective. The practice, it just takes a minute or two a day, no equipment," Dr. Weil added. "And it's an utterly simple technique."

Even though it's simple, for some it can take some getting used to.

"You can think of it as a skill. It's probably not something that you're going to be good at right away. It's likely something like practicing the piano or another instrument, or learning how to throw a baseball," Arnedt said. "It's something that's gonna take a little bit of time for you to master and be good at."

For people with underlying heart or lung issues, Dr. Dasgupta added, it can sometimes be challenging to hold their breath for a full 7 seconds. Breathing out for a longer period of time may also feel a bit strange—it expels a lot of CO2 from our lungs, he explained, which can sometimes make us feel lightheaded. The experience has to be tailored to the individual.

"The technique by itself per se, isn't the magic bullet. We definitely encourage people to use this breathing technique with other relaxation techniques," Dasgupta said. "But this is something that is safe for most people."

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Why rehabilitation post lung transplant is critical to ensure optimum success of procedure

Human lungs. Image courtesy Pearson Scott Foresman/Wikimedia Commons

Lung transplant is an established treatment for patients with end-stage lung disease. It is a surgical procedure to replace a diseased or failing lung with a healthy lung, usually from a deceased donor.

Several modifiable pre- and post-transplant factors contribute to a wide range of physiological and psychological changes which need to be addressed and effectively managed.

It is well established that rehabilitation plays a major role in the pre and post-operative management of patients. It involves working in partnership with the patient, their family and caregivers and a comprehensive multidimensional medical team- towards a common goal of maximising the potential and independence of the patient and to promote a holistic health. It is the process of helping an individual achieve the highest level of function, independence, and to enhance their overall quality of life.

Global review of literature depicts that with the involvement of a multidisciplinary team of experts contributes greatly to the well-being of the patient.

The rehabilitation team typically includes physical therapist, exercise physiologist, psychologist and nutritionist.

The transplant trajectory is complex and intensive, and patients usually experience this period as extremely stressful. Along with the functional impairment – the patients also undergo significant degree of emotional distress. With the prevalence rates of anxiety and depression being high in transplant candidates and recipients, there is a strong need for psychological rehabilitation along with physical rehabilitation for their overall holistic wellbeing. Pre- and Post-transplant psychological support is an important, but overlooked, element in optimising transplant outcomes, particularly in lung transplant recipients who have some of the highest rates of complications and distress following transplantation.

In order to evaluate exercise capacity and function in lung transplant candidates and recipients, a combination of aerobic testing, muscle function, mobility testing and assessment of physical activity is utilised. Along with this- a comprehensive psycho-social assessment is carried out where patient’s understanding regarding the medical illness, process of transplant, willingness/desire for treatment, compliance and care of lifestyle factors, along with the patient’s present emotional and mental state, past psychiatric history is elicited. Based on the test results, a comprehensive rehabilitation programme is planned.

Rehabilitation can be divided into two broad categories:

1. Pre-operative Rehabilitation or Prehabilitation
2. Post-operative rehabilitation


Participating in a supervised pulmonary rehabilitation programme is recommended to assist with prevention of further deterioration and improvement in symptoms, understanding of the condition and enhancing the quality of life. The goal is to promote a better functional recovery post-transplant. Most of the patients awaiting transplant are recommended to be subjected to prehabilitation as indicated.

The prehabilitation is feasible and improves the quality of life by:

• Effective chest clearance and lung expansion techniques
• Maintaining or improving physical activity levels
• Maintaining or improving cardiorespiratory fitness
• Preparing the patient for the transplant surgery
• Psychological interventions to enhance coping

Post-operative rehabilitation

Inpatient rehabilitation

Early post-operative rehabilitation

Post-operative rehabilitation starts immediately after surgery once the patients is stabilised, where the initial focus is on maintenance of bodily systems, as well as to assist the patient with the weaning of ventilator/supplemental oxygen and facilitate early mobility.

It typically begins in ICU and then continues in wards with the goal to improve:

• pulmonary hygiene and lung capacity
• General mobility
• Functional capacity
• Muscle strength and endurance
• Emotional coping
• Facilitate discharge from the hospital

Rehabilitation in wards can be further escalated to frequent walking, cycling, strengthening and stair climbing.

Outpatient rehabilitation

An outpatient rehabilitation programme may begin as soon as possible after hospital discharge. A tailor-made exercise programme is prescribed keeping in mind individual patient goals. The outpatient rehabilitation programme facilitates regaining the muscle mass and strength lost during prolonged illness and the disuse associated with prolonged illness along with adequate emotional coping to regain a sense of normalcy in their day to day lives.

The comprehensive programme typically includes:

• Aerobic exercises
• Resistance training
• Flexibility exercises
• Breathing retraining
• Psycho-social counselling
• Nutritional intervention which makes it an efficacious rehabilitation programme

Remotely monitored (tele-health) home based exercise, or pedometer based walking interventions might serve as alternatives to supervised outpatient rehabilitation interventions in the long-term post-transplant phase.
Both inpatient and outpatient rehabilitation have proven to be beneficial for patients before and after lung transplant by improving exercise capacity, promote adaptive coping and overall quality of life.

With recent research showing reduced risk of cumulative mortality in patients of lung transplant- which was attributable to Pre and Post-Transplant rehabilitation, and with other studies depicting greater survival rates among patients even after five years- Rehabilitation should be seen as an essential service offered across all levels of the health care system. We encourage patients to enrol in rehabilitation programme pre-operatively and continue the journey post operatively for an optimal gold standard of care.

The author is Consultant – Rehabilitation and Sports Medicine, Sir HN Reliance Foundation Hospital. Views are personal.

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Breathing into a paper bag has become a symbol of hyperventilating and anxiety attacks. It’s used to help balance your breathing.

This technique is helpful during an anxiety attack and panic attack because it can help regulate hyperventilation.

Hyperventilation or “overbreathing” happens when you have rapid or shallow breathing. People having an anxiety or panic attack sometimes hyperventilate.

When you hyperventilate, you exhale too much air. This can decrease the amount of carbon dioxide (CO2) you have in your blood.

But isn’t less carbon dioxide good for you? Actually, having very low carbon dioxide levels in your blood causes an imbalance in your body.

Low carbon dioxide also leads to low oxygen levels. This can lower blood and oxygen flow to your brain.

Symptoms of low CO2 levels

Low blood carbon dioxide causes many of the symptoms you have when you hyperventilate, like:

Breathing into a paper bag is a technique that can help you regulate hyperventilation. It works by putting some of the lost carbon dioxide back into your lungs and body. This helps to balance oxygen flow in your body.

However, breathing into a paper bag must be done properly and may not work for everyone. Medical research on using it to help hyperventilation is divided on whether it really works.

Some case studies don’t recommend using this breathing technique.

Other medical review studies find that breathing into a paper bag can help some patients with hyperventilation.

To use a paper bag to help you breathe when you’re hyperventilating, follow these steps:

  • Hold a small paper bag (the kind used for lunches) over your mouth and nose.
  • Take 6 to 12 normal breaths.
  • Remove the bag from your mouth and nose.
  • Take a few breaths.
  • Repeat as needed.

Do’s and don’ts

  • Don’t breathe into a paper bag for more than 12 breaths.
  • Do remove the paper bag from your mouth and nose after 12 breaths.
  • Do hold your own paper bag for breathing. If someone else holds it for you, they may not know when you’ve taken up to 12 breaths.

Yes. Always use a small paper bag, not a plastic one. A plastic bag doesn’t work the same way and can be dangerous.

The thin plastic can get sucked into your mouth when you’re breathing in. This can be especially dangerous for smaller children and older adults.

The paper bag technique won’t help an asthma attack and can even make it worse, because you may not get enough oxygen into your body.

Don’t use this breathing technique if you have any heart or lung conditions.

Also, breathing can be more difficult than normal if you’re at a high altitude. Breathing into a paper bag won’t help with elevation changes in breathing.

Only use the bag method if you’re sure you’re having an anxiety attack. Other causes of hyperventilating include an asthma attack, fever, or other illnesses.

You might have other anxiety symptoms like:

Other remedies to help you calm down during an anxiety attack or when you’re hyperventilating include:

  • deep belly breathing
  • laying down on a sofa, bed, or floor
  • putting your head down between your knees
  • breathing through pursed lips, like you’re whistling
  • breathing in and smelling an essential oil or a scent you like
  • holding your breath for 10 to 15 seconds
  • breathing slowly into your own cupped hands
  • breathing through alternate nostrils (hold one nostril closed at a time)
  • breathing in through your nose and out through your mouth
  • jogging or walking briskly while breathing in through your nose and out through your mouth

Tell your healthcare provider or mental health professional if you have symptoms of an anxiety attack often or hyperventilate frequently.

Get urgent medical help if you:

  • hyperventilate for longer than 30 minutes
  • think you’ll faint or lose consciousness
  • don’t feel better after trying home remedies during an anxiety or panic attack
  • experience severe or frequent symptoms

Breathing into a paper bag may help you breathe better during an anxiety or panic attack. This breathing technique can help some people regulate hyperventilation. However, it may not work for everyone.

You can hyperventilate for many reasons, including some health conditions. You may need other medical treatments, including oxygen therapy and medications.

Call 911 if you hyperventilate for longer than 30 minutes or begin to lose consciousness. You may need urgent medical care.

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Patients with acute unstable chest wall injuries who were receiving mechanical ventilation experienced modest benefits with operative treatment, a randomized trial suggested.

In a modified intention-to-treat analysis involving 207 patients, those who underwent surgery to stabilize rib fractures had more ventilator-free days (VFDs) versus those who did not undergo surgery during the first 28 days after injury (22.7 vs 20.6 days), but this difference did not reach significance (mean difference 2.1 days, 95% CI -0.3 to 4.5, P=0.09), reported Niloofar Dehghan, MD, of the CORE Institute in Phoenix, Arizona, and colleagues.

However, a prespecified subgroup analysis of patients on mechanical ventilation at the time of randomization favored the operative group (mean difference 2.8 VFDs, 95% CI 0.1-5.5), they noted in JAMA Surgery.

"The potential advantage was primarily observed in the subgroup of patients at the time of randomization," Dehghan and team wrote. "We found no benefit to operative treatment in patients who were not ventilated."

Overall, lower mortality rates were seen in the operative group (0% vs 6%, P=0.01), while other secondary endpoints such as rates of complications (pneumonia, sepsis, tracheostomy) and length of hospital stay (median 16 vs 16.5 days) were similar.

Differences between the subgroups of patients ventilated and non-ventilated at the time of randomization were also similar for complications. A higher trend for mortality was seen in the subgroup who were ventilated at the time of randomization (P=0.06).

After highlighting the "methodological flaws" in the study in an accompanying editorial, Anthony G. Charles, MD, MPH, and colleagues of the University of North Carolina at Chapel Hill, concluded that "this trial demonstrates no role for routine surgical fixation of non-ventilated patients."

"However, it does not adjudicate the need for routine operative management of mechanically ventilated patients with unstable chest wall injuries," they noted. "A larger prospective randomized study with standardization of critical care management will be needed."

Unstable chest wall injuries, including flail chest, are often caused by blunt force trauma, which increases the risk for morbidity and mortality, Dehghan's group noted. Many complications can arise from these types of injuries, such as severe pulmonary restriction, chest wall instability, or even loss of lung volume, resulting in more patients requiring prolonged ventilation.

Nonoperative management strategies -- consisting of intubation, chest tube drainage, and intermittent positive-pressure ventilation, among others -- are the most common treatments for severe chest wall injuries, but these have not always led to the most optimal outcomes. While many prior studies have found improved outcomes with operative treatment for carefully selected patients, data are mixed on whether operative or nonoperative treatment is superior.

For this study, Dehghan and colleagues enrolled 207 patients ages 16 to 85 with acute unstable chest wall injuries and randomized them 1:1 to operative treatment with plate and screws (n=108) or nonoperative treatment (n=99) across 15 sites in the U.S. and Canada from October 2011 to October 2019. The nonoperative group received the standard of care, including pain management, chest tube drainage, chest physiotherapy/pulmonary toilet, or ventilation, if needed.

Baseline characteristics were similar between groups. Mean age was 53, and three-fourths were men. Most had injuries caused by motor vehicle collisions (30-37%), falls (17-26%), or motorcycle collisions (13-15%). Mean number of rib fractures was 10.

Common conditions included pneumothorax (89%), hemothorax (76%), and pulmonary contusion (54%). The most common types of plates used during surgery were pelvic reconstruction plates (53%) and pre-contoured locking rib plates (43%). Notably, 43% of patients received mechanical ventilation.

Six patients died while hospitalized, all in the nonoperative group. Four operative patients required repeat surgery.

Dehghan and team noted that their trial was "underpowered to detect statistical significance in outcomes that were potentially clinically significant" due to the small sample size. Variations in care may also have occurred across centers.

  • author['full_name']

    Zaina Hamza is a staff writer for MedPage Today, covering Gastroenterology and Infectious disease. She is based in Chicago.


This study was supported by the AO Foundation, Canadian Institutes of Health Research, and Physician Services.

Dehghan reported relationships with Acumed, AO International, Bioventus, Canadian Institutes of Health Research, ITS, Physician Services, Springer, Stryker, and Wolters Kluwer.

Co-authors reported relationships with Acumed, AO Foundation, AO International, Bioventus, Canadian Institutes of Health Research, DePuy Synthes, Elsevier, ITS, Medtronic, Orthopaedic Trauma Association, Physician Services, Stryker, Smith&Nephew, Springer, Synthes, Swemac, and Wolters Kluwer.

Charles and co-authors reported no conflicts of interest.

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Rehabilitation is care that can help you get back, keep or improve abilities that you need for daily life. These abilities may be physical, mental and/or cognitive (thinking and learning). You may have lost them because of a disease or injury, or as a side effect from a medical treatment. Rehabilitation can improve your daily life and functioning.

Rehabilitation is for people who have lost abilities that they need for daily life. Some of the most common causes include: injuries and trauma, including burns, fractures (broken bones), traumatic brain injury, and spinal cord injuries; stroke; severe infections; major surgery; side effects from medical treatments, such as from cancer treatments; certain birth defects and genetic disorders; developmental disabilities; and chronic pain, including back and neck pain.

The overall goal of rehabilitation is to help you get your abilities back and regain independence. But the specific goals are different for each person. They depend on what caused the problem, whether the cause is ongoing or temporary, which abilities you lost and how severe the problem is.

For example, a person who has had a stroke may need rehabilitation to be able to dress or bathe without help; an active person who has had a heart attack may go through cardiac rehabilitation to try to return to exercising; and someone with a lung disease may get pulmonary rehabilitation to be able to breathe better and improve their quality of life.

When you get rehabilitation, you often have a team of different health care providers helping you. They will work with you to figure out your needs, goals and treatment plan. The types of treatments that may be in a treatment plan include:

■ Assistive devices, which are tools, equipment and products that help people with disabilities move and function.

■ Cognitive rehabilitation therapy to help you relearn or improve skills such as thinking, learning, memory, planning and decision making.

■ Mental health counseling.

■ Music or art therapy to help you express your feelings, improve your thinking and develop social connections.

■ Nutritional counseling.

■ Occupational therapy to help you with your daily activities.

■ Physical therapy to help your strength, mobility and fitness.

■ Recreational therapy to improve your emotional well-being through arts and crafts, games, relaxation training and animal-assisted therapy.

■ Speech-language therapy to help with speaking, understanding, reading, writing and swallowing.

■ Treatment for pain.

■ Vocational rehabilitation to help you build skills for going to school or working at a job.

Depending on your needs, you may have rehabilitation in a provider’s offices, a hospital, a clinic or an inpatient rehabilitation center. In some cases, a provider may come to your home. If you get care in your home, you will need to have family members or friends who can come and help with your rehabilitation.

The aim of rehabilitation is to restore good health and function to those who have been affected by potentially disabling disease or traumatic injury. A rehabilitation team consists of certified physical, occupational and speech therapists. Although each therapy has a different focus, there is a unified goal of helping each person achieve their highest level of independence.

Physical therapy focuses on walking, balance, strength and gross motor tasks. Occupational therapy focuses on everyday activities such as dressing, bathing and fine motor skills. Speech therapy focuses on improving a person’s ability to communicate as well as addressing swallowing and feeding issues.

Certified therapists help patients find strength and rediscover independence during a challenging time. According to a recent report, 2.41 billion individuals worldwide live with conditions that would benefit from rehabilitation services, with approximately one in three individuals requiring rehabilitation services throughout the course of their illness or injury.

Rehabilitation is the care needed when a person is experiencing or is likely to experience limitations in everyday functioning due to aging or a health condition, including chronic diseases or disorders, injuries or trauma. It is an essential health service to optimize everyday functioning and ensure the highest possible standard of health and well-being.

Courtesy of MedlinePlus from the National Library of Medicine
To Your Health is provided by the staff of Boulder City Hospital. For more information, call 702-293-4111, ext. 576, or visit bchcares.org.

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This is a guest post with Jasmine St Cliere for content pitches please email [email protected]

Breathing is the very first and last thing you do in this world, in this body of yours. Something we have in common with all other living things on this earth, is that in some way, the breath is present. The action of breathing itself is involuntary, meaning our bodies are capable of doing it without conscious thought. What I am fascinated by is what happens when we do give it the power of thought and become interested in the intention.

How should I be breathing?

This is breathing we want to be doing to avoid brain fog and fatigue and to provide our cells with the optimal amount of oxygen to carry out day-to-day tasks. Jasmine St Cliere

Ideally, we are looking to be breathing in and out through our nose the majority of the time. Nasal breathing filters the air as well as slowing down the rate at which we bring it into the body. Functionally, we want to be breathing out and wide into the thorax, utilising the space within our rib cage and the full depth of our lungs. This is breathing we want to be doing to avoid brain fog and fatigue and to provide our cells with the optimal amount of oxygen to carry out day-to-day tasks. The versatility of Breathwork makes it accessible as a form of meditation, right through to enhancing athletic performance and everything in between. By learning different techniques and how to adapt the breath, we can create physiological shifts, using this to energise, to calm or to assist in deep soulful healing.

The Intelligence of the Breath

The amazing truth about the breath, is that it is able to ride the full spectrum of our autonomic nervous system. Every breath in is an activation, an acceleration and every breath out is a deactivation, a deceleration. Humans are capable of this amazing process called co-regulation, meaning that neurotransmitters in our brain are able to subconsciously recognise the state of others around us, causing us to shift our internal system, as we begin to sync. The breath is one of the factors that governs that. The speed, rhythm and depth of how others around us are breathing, can communicate the physiological state that a body is in. Our systems begin to match to the quality of breath around us, as our nervous systems interact and start to calibrate.

We may not even notice that we shift into this style of breathing, but our bodies are reading off one another and often copying.Jasmine St Cliere

This of course has its advantages and its disadvantages. If we are on the tube at rush hour, for example, many commuters will be in a mild anxious state from either work pressure, transport delays, the loud noises etc and this can cause stress-induced breathing. This can be seen in short shallow breaths taken into the upper chest or shoulder region of the body. We may not even notice that we shift into this style of breathing, but our bodies are reading off one another and often copying. We may notice, ‘I can sense I am not breathing much at all right now… and I feel uncomfortable about how many people are this close to me.’ With this awareness, we may then start to breathe a little deeper, perhaps a little slower, to calm not only ourselves but those around us in that setting.

We may also have experienced the opposite, for example being around your favourite yoga teacher seems to relax you when they press down on the tops of your feet in savasana. For you it might be your best friend or a family member, in other words, it’s that person who automatically gives you all the good vibes. They are most probably in a calm, centred and regulated state and being around them causes your system to co-regulate. Our body’s intelligence registers, ‘I like this, I feel good, I feel safe.’ The response is often steady and slower breathing. If there is one way of noticing how safe you feel in your body at any given time, it is the quality of your breath.

Breathing to Aid Stress

In a state of stress, the breath is often the last thing on our minds. Yet if we are to stop for a moment and observe how we are breathing in that state, we may notice the breathing is quick, short or sharp, moving the upper chest, fueling that anxious energy. The good news is, breath awareness is a really effective tool to combat the effects of stress. If we are able to take ourselves away from the stressful situation, to pause for a moment and focus on the exhalation becoming slow and deep, we can stir significant shifts in the brain wave state, lower the heart rate and help us manage unwanted emotions that overwhelm. This slower breathing communicates safety to the body which is a feeling we often need a reminder of in this fast-paced world.

The Healing Potential of the Breath

While functional breathing really is the most important type of breathing, because it is what we do all day every day, there is increasing popularity with Breathwork that brings about deep states of healing. 

Holotropic, Transformational and Rebirthing Breath are just a few modalities that stem from the Conscious Connected Breathwork lineage. This is a breathing technique that comes in and out through the mouth in one circular motion, with no pause at either end.

While breathing through the nose is of course what we should be doing in our day-to-day, an active mouth breath can bring about a clear connection with self, altered states of consciousness and deep emotional release.

Jasmine St Cliere

While focusing on an active inhale, this breathing is a healthy stimulation of your sympathetic nervous system, in other words, the part that says ‘let’s go, let’s move’. Which has often been repressed or unable to be expressed in traumatic moments in our lives, however great or small. The breath carries you into a deeply embodied state where you are able to process and integrate what the body needs to discharge or experience, in order to heal.

Remember that while on different parts of the spectrum, trauma can be experienced from nearly being hit by a bus and trauma can be experienced from a severe car accident. Your brain might be able to see perspective but your body cannot, your experience is your experience and we can learn not to compare it to that of others.

The great thing about the breath is that it is accessible to absolutely everyone and you only need yourself to start connecting with it.

3 breathing techniques for beginners:

Whether you are a beginner or not, we can all benefit from simple breathing techniques and sometimes the simpler, the better.

1. Even Breath Count

In this technique, we start to equalise the breath. Most of us naturally have a sporadic breathing pattern, meaning there is no regular rhythm in the way we breathe.

  • For this technique start by noticing your breath, how you are breathing
  • Starting to extend the breath, beginning to count 3, 2, 1 as you inhale,
    and 3, 2, 1 as you exhale.
  • Repeat this for a total of 5-10 minutes.
  • As you grow in confidence and comfortability with this, you can extend
    the breath to 4, even 6 or 8.

2. Two-Part Exhale

Research states that we rarely breathe with our full lung capacity, meaning we take only partial exhales and then as a result can only breathe a sub-optimal inhale.

  • Begin by breathing consciously in and out through your nose.
  • Taking a normal breath in, as you exhale breathe out emptying 80% of
    your lungs. Repeating this until it feels comfortable.
  • Now taking a breath in, as you exhale breathe out 80% then pause, then
    breathe out the full 100% and pause. Repeating until it feels
  • Lastly, taking a breath in, exhale out 80% pause, exhale to 100% pause,
    now see if you can push out an extra 5 or 10% more air. Removing stale air from the lungs. Repeat for 10 more rounds.

3. Two-Part Inhale

Once the lungs are fully emptied we can start to look at deepening the in breath, optimising the lung capacity.

  • Begin by breathing consciously in and out through your nose.
  • Breathing out to prepare, as you inhale, breath in to 80% full. Then
    exhale. Repeating this until it feels comfortable.
  • Breathing in to 80% then pause, breathing in to 100% and pause. Then
    exhale. Repeating until it feels comfortable.
  • Lastly, breathe in to 80% pause, breathe in to 100% pause, now see if
    you can take in an extra 5 or 10% more air into the lungs. Filling the body up completely. Repeat for 10 more rounds.

If you are interested in being guided, Jasmine works with movement, breath and sound, with individuals in a group setting or 1:1 basis. 

To enquire about either in person or online bookings please see Jasmine’s website or connect with her on Instagram.

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The pleura is a vital part of the respiratory tract. Its role is to cushion the lung and reduce any friction that may develop between the lung, rib cage, and chest cavity.

Each pleura (there are two) consists of a two-layered membrane that covers each lung. The layers are separated by a small amount of viscous (thick) lubricant known as pleural fluid.

OpenStax College / Wikimedia Creative Commons

There are a number of medical conditions that can affect the pleura, including pleural effusions, a collapsed lung, and cancer. When excess fluid accumulates between the pleural membranes, various procedures may be used to either drain the fluid or eliminate the space between them.

This article outlines what the pleurae are, what they do, and what conditions can affect them and impact respiratory health.

The plural form of pleura is pleurae.

Anatomy of the Pleura

There are two pleurae, one for each lung, and each pleura is a single membrane that folds back on itself to form two layers. The space between the membranes (called the pleural cavity) is filled with a thin, lubricating liquid (called pleural fluid).

The pleura is comprised of two distinct layers:

  • The visceral pleura is the thin, slippery membrane that covers the surface of the lungs and dips into the areas separating the different lobes of the lungs (called the hilum).
  • The parietal pleura is the outer membrane that lines the inner chest wall and diaphragm (the muscle separating the chest and abdominal cavities).

The visceral and parietal pleura join at the hilum, which also serves as the point of entry for the bronchus, blood vessels, and nerves.

The pleural cavity is also known as the intrapleural space. It contains pleural fluid secreted by the mesothelial cells. The fluid allows the layers to glide over each other as the lungs inflate and deflate during respiration (breathing).

What the Pleura Do

The structure of the pleura is essential to respiration, providing the lungs with the lubrication and cushioning needed to inhale and exhale. The intrapleural space contains roughly 4 cubic centimeters (ccs) to 5 ccs of pleural fluid, which reduces friction whenever the lungs expand or contract.

The pleura fluid itself has a slightly sticky quality that helps draw the lungs outward during inhalation rather than slipping round in the chest cavity. It creates surface tension that helps maintain the position of the lungs against the chest wall.

The pleurae also serve as a division between other organs in the body, preventing them from interfering with lung function and vice versa.

Because the pleura is self-contained, it can help prevent the spread of infection to and from the lungs.

Conditions That Affect the Pleura

A number of conditions can cause injury to the pleura or undermine its function. Harm to the membranes or overload of pleural fluid can affect how you breathe and lead to adverse respiratory symptoms.


Pleurisy is inflammation of the pleural membranes. It is most commonly caused by a viral infection, but may also be the result of a bacterial infection or an autoimmune disease (such as rheumatoid arthritis or lupus).

Pleuritic inflammation causes the membrane surfaces to become rough and sticky. Rather than sliding over each other, they membranes stick together, triggering sharp, stabbing pain with every breath, sneeze, or cough. The pain can get worse when inhaling cold air or taking a deep breath. It can also worsen during movement or shifts in position. Other symptoms of pleurisy include fever, chills, and loss of appetite.

Pleural Effusion

A pleural effusion occurs when excess fluid accumulates in the pleural space. When this happens, breathing can be impaired, sometimes significantly.

Congestive heart failure is the most common cause of a pleural effusion, but there is a multitude of other causes, including lung trauma or lung cancer (in which effusion is experienced in roughly half of all cases).

A pleural effusion can be very small (detectable only by a chest x-ray or CT scan) or be large and contain several pints of fluid. Common symptoms include chest pain, dry cough, shortness of breath, difficulty taking deep breaths, and persistent hiccups.

Malignant Pleural Effusion

A malignant pleural effusion refers to an effusion that contains cancer cells. It's most commonly associated with lung cancer or breast cancer that has metastasized (spread) to the lungs.


Pleural mesothelioma is a cancer of the pleura that most often is caused by occupational exposure to asbestos. Symptoms include pain in the shoulder, chest or lower back, shortness of breath, trouble swallowing, and swelling of the face and arms.


Pneumothorax, also known as a collapsed lung, can develop when air collects in the pleural cavity. It may be caused by any number of things, including chest trauma, chest surgery, and chronic obstructive pulmonary disease (COPD). In addition to shortness of breath, there may be crepitus, an abnormal crackling sound from just under the skin of the neck and chest.

Spontaneous pneumothorax is a term used to describe when a lung collapses for no apparent reason. Tall, thin adolescent males are at the greatest risk for spontaneous pneumothorax, although females can also be affected. Risk factors include smoking, connective tissue disorders, and activities such as scuba diving and flying in which atmospheric pressure changes rapidly.

Pneumothorax can often heal on its own but may sometimes require thoracentesis to extract any accumulated air from the pleural cavity.


Hemothorax is a condition in which the pleural cavity fills with blood, typically as a result of traumatic injury or chest surgery. Rarely, a hemothorax can happen spontaneously due to a vascular rupture.

The main symptom of hemothorax is pain or a feeling of heaviness in the chest. Others include a rapid heartbeat, trouble breathing, cold sweats, pale skin, and a fever, all indications that prompt medical attention is needed.

Frequently Asked Questions

  • Does COVID cause pleural thickening?

    Research has demonstrated that coronaviruses, like COVID-19 and Middle Eastern respiratory syndrome coronavirus (MERS-CoV) can cause pleural thickening. In some cases, this has been associated with poorer outcomes.

  • Is pleural effusion life-threatening?

    Pleural effusion, or fluid build-up in the pleural space, is a serious but treatable condition. It can be caused by a number of diseases, including cancer. If left untreated, fluid can continue to build up and impact breathing.

  • Is pleural thickening serious?

    Not necessarily, but it depends on the underlying cause. Because multiple conditions can cause thickening of the pleurae, it's important to be evaluated by a healthcare provider and get proper treatment.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Charalampidis C, Youroukou A, Lazaridis G, et al. Pleura space anatomyJ Thorac Dis. 2015;7(Suppl 1):S27–S32. doi:10.3978/j.issn.2072-1439.2015.01.48

  2. Kass SM, Williams PM, Reamy BV. Pleurisy. Am Fam Physician. 2007;75(9):1357-64.

  3. Bintcliffe OJ, Lee GY, Rahman NM, Maskell NA. The management of benign non-infective pleural effusions. Eur Respir Rev. 2016;25(141):303-16. doi:10.1183/16000617.0026-2016

  4. Karkhanis VS, Joshi JM. Pleural effusion: diagnosis, treatment, and managementOpen Access Emerg Med. 2012;4:31–52. doi:10.2147/OAEM.S29942

  5. Dixit R, Agarwal KC, Gokhroo A, et al. Diagnosis and management options in malignant pleural effusionsLung India. 2017;34(2):160-6. doi:10.4103/0970-2113.201305

  6. Rossini M, Rizzo P, Bononi I, et al. New perspectives on diagnosis and therapy of malignant pleural mesotheliomaFront Oncol. 2018;8:91. doi:10.3389/fonc.2018.00091

  7. Aghajanzadeh M, Dehnadi A, Ebrahimi H, et al. Classification and management of subcutaneous emphysema: a 10-year experienceIndian J Surg. 2015;77(Suppl 2):673–677. doi:10.1007/s12262-013-0975-4

  8. Mitani A, Hakamata Y, Hosoi M, et al. The incidence and risk factors of asymptomatic primary spontaneous pneumothorax detected during health check-upsBMC Pulm Med. 2017;17:177. doi:10.1186/s12890-017-0538-8

  9. Pumarejo Gomez L, Tran VH. Hemothorax. In: StatPearls [Internet].

  10. National Library of Medicine: Medline Plus. Hemothorax.

  11. Carotti M, Salaffi F, Sarzi-Puttini P, et al. Chest CT features of coronavirus disease 2019 (COVID-19) pneumonia: Key points for radiologists. Radiol Med. 2020;125(7):636-646. doi:10.1007%2Fs11547-020-01237-4

  12. American Society of Clinical Oncology. Fluid around the lungs or malignant pleural effusion.

  13. Yale Medicine. Fluid Around the Lungs (Pleural Effusion).

  14. Alfudhili KM, Lynch DA, Laurent F, Ferretti GR, Dunet V, Beigelman-Aubry C. Focal pleural thickening mimicking pleural plaques on chest computed tomography: Tips and tricksBJR. 2016;89(1057):20150792. doi:10.1259%2Fbjr.20150792

Additional Reading

By Lynne Eldridge, MD

 Lynne Eldrige, MD, is a lung cancer physician, patient advocate, and award-winning author of "Avoiding Cancer One Day at a Time."

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UPDATED guidelines for the management of chronic obstructive pulmonary disease (COPD) include both non-pharmacological and pharmacological strategies to reflect the importance of a holistic approach to clinical care for people living with the disease.

Developed by the Lung Foundation Australia and the Thoracic Society of Australia and New Zealand, and published as a summary in the MJA, the guidelines include 26 recommendations addressing:

  • case finding and confirming diagnosis – confirmation by spirometry, blood eosinophil levels, behaviour and risk factors (smoking, treatment adherence, self-management skills, physical activity, comorbid conditions);
  • optimising function – non-pharmacological therapies, pharmacological therapies, managing comorbid conditions, palliative care, lung volume reduction surgery, pulmonary rehabilitation, non-invasive ventilation;
  • preventing deterioration – smoking cessation, immunisation, oxygen therapy, prophylactic antibiotics, biologic therapies, palliative care, home bilevel ventilation;
  • developing a plan of care; and
  • managing exacerbations – pharmacological management, non-invasive ventilation, and multidisciplinary care.

“About one in 13 Australians over the age of 40 years is estimated to have chronic obstructive pulmonary disease (COPD),” wrote the authors, led by Associate Professor Eli Dabscheck, a respiratory and sleep physician from Melbourne’s Alfred Hospital.

“In 2018, COPD was the leading cause of potentially preventable hospitalisations, the third leading specific cause of total disease burden, and the fifth leading cause of death in Australia. The impact of COPD is even greater among Indigenous Australians compared with non-Indigenous Australians.”

Non-pharmacological therapies for COPD include walking and structured exercise, as well as pulmonary rehabilitation to improve breathlessness, exercise performance, physical activity level and health status. Pharmacological therapies, including short- and long-acting inhaled bronchodilators, inhaled corticosteroids (ICS), and long-acting β-agonists, are evaluated in the guidelines.

The full guidelines are available at copdx.org.au/.

Supervised injecting centres: 21 years of evidence

TWENTY-one years after the establishment of the Uniting Sydney Medically Supervised Injecting Centre (MSIC), research shows that, rather than becoming a “honeypot”, the MSIC has led to improved and sustained public amenity, leading to a call for the establishment of more supervised injecting facilities. Associate Professor Carolyn Day, from the University of Sydney, and colleagues wrote in the MJA that they had “addressed key questions regarding [supervised injecting facility (SIF)] operations and contend that there is sufficient evidence to support SIF rollout and expansion”. “Good policy, with clear legislation and careful management of clients within a harm reduction framework, can and does alleviate problems that may be perceived as inherent to the operation of such services. Given the solid evidence, current governments, in Australia and elsewhere, should expand SIF services without unnecessary protracted trial periods. The key challenge in SIF expansion is supporting legislation. Questions regarding the scientific and operational merit of SIFs have been answered. After 21 years of success, it is time for robust support for further services to be implemented both within Australia and internationally.”

Neurological manifestations of COVID-19 in adults and children

An international group of researchers, including from Australia, have detailed the differences in neurological manifestations of COVID-19 in adults and children in an article published in Brain. Researchers analysed data from the International Severe Acute Respiratory and emerging Infection Consortium cohort across 1507 sites worldwide from 30 January 2020 to 25 May 2021 – 161 239 patients (158 267 adults, 2972 children) admitted to hospital with COVID-19 and assessed for neurological manifestations and complications were included. “In adults and children, the most frequent neurological manifestations at admission were fatigue (adults: 37.4%; children: 20.4%), altered consciousness (20.9%; 6.8%), myalgia (16.9%; 7.6%), dysgeusia (7.4%; 1.9%), anosmia (6.0%; 2.2%), and seizure (1.1%; 5.2%). In adults, the most frequent in-hospital neurological complications were stroke (1.5%), seizure (1%), and central nervous system (CNS) infection (0.2%). Each occurred more frequently in [intensive care unit (ICU)] than in non-ICU patients. In children, seizure was the only neurological complication to occur more frequently in ICU vs. non-ICU (7.1% vs. 2.3%, P < .001). Stroke prevalence increased with increasing age, while CNS infection and seizure steadily decreased with age. There was a dramatic decrease in stroke over time during the pandemic. Hypertension, chronic neurological disease, and the use of extracorporeal membrane oxygenation were associated with increased risk of stroke. Altered consciousness was associated with CNS infection, seizure, and stroke. All in-hospital neurological complications were associated with increased odds of death. The likelihood of death rose with increasing age, especially after 25 years of age.”

Counting steps important but faster cadence matters too

Research published in JAMA Internal Medicine, including authors from the University of Sydney, has found that accumulating more steps per day (up to about 10 000) may be associated with a lower risk of all-cause, cancer, and cardiovascular disease (CVD) mortality and with lower incidence of cancer and CVD, and that higher step intensity may provide additional benefits. The authors analysed data from 78 500 participants in the UK Biobank for 2013–2015, including adults aged 40–79 years. Participants were invited by email to partake in an accelerometer study. Registry-based morbidity and mortality were ascertained through October 2021. “The study population … was followed for a median of 7 years during which 1325 participants died of cancer and 664 of CVD (total deaths 2179). There were 10 245 incident CVD events and 2813 cancer incident events during the observation period. More daily steps were associated with a lower risk of all-cause ([mean rate of change (MRC)], −0.08; 95% CI, −0.11 to −0.06), CVD (MRC, −0.10; 95% CI, −0.15 to −0.06), and cancer mortality (MRC, 95% CI, −0.11; −0.15 to −0.06) for up to approximately 10 000 steps. Similarly, accruing more daily steps was associated with lower incident disease. Peak-30 cadence was consistently associated with lower risks across all outcomes, beyond the benefit of total daily steps,” the authors reported. “Steps performed at a higher cadence may be associated with additional risk reduction, particularly for incident disease.”

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Do you have trouble sleeping? Use these tips to improve it 1:44

(CNN Spanish) — Falling asleep or recovering from an anxiety attack may be easy with a 1-2-3 count, but some experts believe a different set of numbers—4-7-8—might be an even better solution.

The 4-7-8 technique is a relaxation exercise that involves inhaling for a count of four, holding your breath for a count of seven, and exhaling for a count of eight, explained Dr. Raj Dasgupta, an associate clinical professor in the College of Keck Medicine of the University of Southern California, via email.

Also known as “relaxing breathing,” the 4-7-8 technique has ancient roots in pranayama, which is the yogic practice of regulating the breath, but was only popularized in 2015 by integrative medicine specialist Dr. Andrew Weil.

“A lot of sleep difficulties are due to people trying to fall asleep but their minds are buzzing,” said Rebecca Robbins, a professor of medicine at Harvard Medical School and an associate scientist in the division of sleep and circadian disorders. at Brigham and at Boston Women’s Hospital. “But exercises like the 4-7-8 technique give you a chance to practice being at peace. And that’s exactly what we should do before we go to bed.”

Do you have trouble sleeping? Use these tips to improve it 1:44

“It doesn’t ‘put you to sleep,’ but instead reduces anxiety to increase the chances of falling asleep,” explained Joshua Tal, a clinical psychologist in New York State.

How 4-7-8 works

The 4-7-8 method doesn’t require any specific equipment or preparation, but it’s recommended that you sit up straight when learning the exercise, according to Weil. Practicing in a calm, quiet place might help, Robbins said. Once the technique is mastered, it could work while lying in bed.

Throughout the practice, the tip of the tongue should be placed against the ridge of tissue behind the upper front teeth, while exhaling through the mouth around the tongue. Then, follow these steps, according to Weil:

  • Exhale fully through your mouth, making a whooshing sound.
  • Close your mouth and inhale calmly through your nose to a mental count of four.
  • Hold your breath while you count to seven.
  • Exhale through your mouth, making a whooshing sound as you count to eight.
  • Repeat the process three more times for a total of four breath cycles.

Maintaining the ratio of four, then seven, then eight is more important than the time you spend in each phase, according to Weil.

“If you have trouble holding your breath, speed up the exercise but keep the ratio (constant) of the three phases. With practice, you can slow down and get used to inhaling and exhaling more and more deeply,” the specialist advised on his website. .

The 4-7-8 is a technique to reduce anxiety and fall asleep

The 4-7-8 is a technique to reduce anxiety and fall asleep

What Research Shows

When you’re stressed, your sympathetic nervous system (responsible for your fight or flight response) is overactive, leaving you feeling overstimulated and not ready to relax and transition to sleep, Dasgupta said. “An active sympathetic nervous system can cause a rapid heart rate as well as rapid, shallow breathing.”

The 4-7-8 breathing practice can help activate the parasympathetic nervous system (responsible for rest and digestion), which reduces sympathetic activity, he added, putting the body in a state more conducive to restful sleep. Activating the parasympathetic system also gives an anxious brain something to focus on besides the question “why am I not sleeping?”

While its proponents swear by the method, more research is needed to establish clearer links between 4-7-8 and sleep and other health benefits, Joshua Tal added.

“There is some evidence that 4-7-8 breathing helps reduce symptoms of anxiety, depression and insomnia when compared before and after the intervention; however, to my knowledge, there are no large randomized controlled trials specifically on 4-7-8 breathing, Tal said. “Research on (the effect of) diaphragmatic breathing on these symptoms is generally patchy, with no clear connection due to poor study quality.”

A team of researchers from Thailand studied the immediate effects of 4-7-8 breathing on heart rate and blood pressure in a group of 43 healthy young adults. After the participants had these health factors and their fasting blood glucose measured, they performed 4-7-8 breaths for six cycles in three sets, interspersed with one minute of normal breathing between each set. Researchers found that the technique improved participants’ heart rate and blood pressure, according to a study published in July.

“If you’re doing some of these activities, what we see is (an) increase in the amplitude of theta and delta (brain) waves, indicating that you’re in the parasympathetic state,” Robbins said. “The slow breathing of the 4-7-8 technique reduces the risk of cardiovascular disease and type 2 diabetes and improves lung function,” he added.

what to expect

The 4-7-8 technique is relatively safe, but if you’re a beginner, you might feel a little dizzy at first, Dasgupta said.

“Normal breathing is a balance between inhaling oxygen and exhaling carbon dioxide. When this balance is disturbed by exhaling more than is inhaled, it causes a rapid reduction in carbon dioxide in the body,” he explained. “Low carbon dioxide levels lead to narrowing of the blood vessels that supply blood to the brain. This reduction in blood supply to the brain causes symptoms such as dizziness. This is why it is often recommended to start slowly and practice three to four cycles until you feel comfortable with the technique.

The more you practice the 4-7-8 technique, the better it will come out, and the more tools your body and mind will have for managing stress and anxiety, Dasgupta said. Some people combine this method with other relaxation practices such as progressive muscle relaxation, yoga, mindfulness or meditation.

Uncontrolled stress can manifest early as sleep difficulties, Robbins said. “But when we can manage our stress throughout the day (and) implement some of these breathing techniques, we can put ourselves in the driver’s seat instead of being victims of the events that happen in our lives.”

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