Reversible platypnea-orthodeoxia in COVID-19 acute respiratory distress syndrome survivors

Abstract

Platypnea-orthodeoxia syndrome (POS) is a rare clinical syndrome characterized by orthostatic oxygen desaturation and positional dyspnea from supine to an upright position. We observed POS in 5 of 20 cases of severe 2019 novel coronavirus (COVID-19) pneumonia, which demonstrated persistently elevated shunt fraction even after liberation from mechanical ventilation. POS was first observed during physiotherapy sessions; median oxygen desaturation was 8 % (range: 8-12 %). Affected individuals were older (median 64 vs 53 years old, p = 0.05) and had lower body mass index (median 24.7 vs 27.6 kg/m², p = 0.03) compared to those without POS. While POS caused alarm and reduced tolerance to therapy, this phenomenon resolved over a median of 17 days with improvement of parenchymal disease. The mechanisms of POS are likely due to gravitational redistribution of pulmonary blood flow resulting in increased basal physiological shunting and upper zone dead space ventilation due to the predominantly basal distribution of consolidative change and reported vasculoplegia and microthrombi in severe COVID-19 disease.

Keywords: Coronavirus; Critical care; Pneumonia; Rehabilitation; Respiratory physiology.

Fig. 1

Clinical details and CT thorax findings of individuals with platypnea-orthodeoxia syndrome. POS: platypnea-orthodeoxia syndrome, SpO₂: oxygen saturation by pulse oximetry, IMV: invasive mechanical ventilation, ICU: intensive care unit, PSV: pressure-support in cmH₂O, PEEP: positive end-expiratory pressure in cmH₂O, FiO₂: fraction of inspired oxygen, INO₂: intranasal supplemental oxygen, PC: pressure-control in cmH₂O, HFNC: high flow nasal cannula, ‘-’: not measured.

Fig. 2

Proposed pathophysiological mechanism of platypnea-orthodeoxia syndrome in severe COVID-19 illness.