Caring Hearts (July - September, 2021) Vol 08, Issue No.09

Heart Care Foundation was established on the World Heart Day of 2005. In a span of over 15
years the Foundation was able to launch and run successfully the following projects in the
field of heart care in the State of Kerala.

Save 1000 hearts, Save a life, Installation of AED’s Caring hearts’
1000 lives, Save a lifetime (Automated External a quarterly
1000 families Defibrillator) Magazine

Heart Bands Life time achievement award’ World heart day
for eminent doctors in the (September 29)
field of Cardiology. Celebration

Hrudayasangamam Social ‘Hridayapoorvam,
excellence award Alangad’

Dear Members of the Heart Care Foundation, let me, to begin

with, wish you all, a very healthy and hearty life. As we are going
through a pandemic time, and knowing that the viral disease
produce various types of illnesses, even in the post infection stage,
we need to be extremely cautious in treating the illness as well as
watching out for any post infection complications.

I personally feel that we are living in a safer time now than the
year before with much more treatment modalities, which are
proved scientifically, are available currently, it is very important
that rather than ignoring the disease, to avail the advance treatment, not only to treat the
disease but also to prevent complications after the disease. Nevertheless it is always better not
to have an infection by being careful, adhering to the stipulated precautions like wearing
masks, social distancing as well as proper sanitization.

September has got two important celebrations. One is the World Heart Day which is coming
on the 29th of September, which the Heart Care Foundation used to celebrate in grand
manner every year. Because of the Covid and its related issues, we could not celebrate World
Heart Day last year as well. But let me wish you all a very healthy and heart healthy
especially life during this year and the years to come.

The 2nd celebration is the World Physiotherapy Day on the 8th of September. Physiotherapy
and rehabilitation are major part the Heart Care Foundation has been focusing over the
years, especially after developing a heart attack or undergoing an angioplasty or bye-pass
surgery, rehabilitation and reintegration into the society has been the major areas where the
Heart Care Foundation was focusing on. So these two celebrations in September add a
special interest to our members as well as the readers of this magazine.

Before I conclude, let me once again pray and hope that we will be able to meet sometime in
the near future overcoming the covid scare on a physical platform and share the joy and
happiness of being together as we always used to enjoy over the last decade or so.

Wishing you all good health and God’s choicest blessings

Yours sincerely,

Dr. Jose Chacko Periappuram
Chairman HCF

JULY-SEPTEMBER, 2021|CARING HEARTS|03

Advisory Board Members CONTENTS
• Mr. C.J. George 03 Chairman’s Message
• Mr. Alex Muthoot 05 Editor’s Page
• Dr. V.P.Kuriyipe 06 Covid & Children
• Mr. Johnson Mathew K 12 Psychiatric Manifestations of Covid
• Fr. Johnson Vazhappilly 14 Covid & Endocrine diseases
• Fr.Jose Alex Oruthayapilly 18 Heart problems after Covid
• Dr. Junaid Rehman 22 Neurological manifestations of Covid
• Dr. V.P.Gangadharan 26 HCF Archives
• Mr.Justice(Rtd) Cyriac Joseph 28 What are Covid-19 vaccines and how do they work?
• Mr.Justice (Rtd)Kurian Joseph 30 HCF News
• Mr. Bipin Andrews 31 The Post Covid Dilemma
• Dr. Philip Augustine 33 Long Covid: What is it and what are the symptoms?
• Mr. Shibu Philips 34 Nutrition Care during Covid-19
• Dr. M.R.Rajagopal 42 Home Quarantine during COVID-19 - Do’s and Don’ts
• Fr. (Dr)Paul Karedan 43 Resuming physical activities after COVID-19 infection
• Mr. E K Premachandran 44 Nutritional recomendations while recovering from Covid
• Adv. Bijoy Cheriyan 44 Recommended assessment &
• Mr. Bindu Madhav
• Mr. M.I.George testing after Covid-19 recovery
• Mr. John Poomkudy 45 Post-Covid complications found in 30% of
• Mr. Nelson Pavunny
• Adv. Peeyus A. Kottam recovered patients in all age groups
• Mr. M.K.Babu 46 Post Covid Resipiratory Excercises
• Mr. K.N.Marzook 48 We need your help...
• Mr. Mathew Tharakan 51 HCF Trustees
• Mr.Justice (Rtd) K. Narayana Kurup
• Mr. Stanley Kunjipalu
• Mr. T.A.Varkey
• Mr. T.P.Tomy
• Dr. Gregor Williams

Trust Members
• Dr. Jose Chacko Periappuram (Chairman)
• Mr. Raju Kannampuzha (Secretary)
• Adv. K.K.Chacko Anathanam
• Mr. George E.P.
• Dr. Jacob Abraham
• Dr. Jo Joseph

Medical Panel
• Dr. Rony Mathew Kadavil (Chairman)
• Dr. Jayakumar T. K
• Dr. Alexander Thomas
• Dr. Ali Faizal
• Dr. Anand Sreenivasan
• Dr. G.Babu Vasudevan
• Dr. C.G.Bahuleyan
• Dr. Binu Ramesh
• Dr. Geevar Zachariah
• Dr. George Jacob
• Dr. Govindan Unni
• Dr. Jaideep C Menon
• Dr. V. L. Jayaprakash
• Dr. Johny Joseph
• Dr. Mathew Abraham
• Dr. P.P.Mohanan
• Dr. Rajan Joseph Manjooran
• Dr. Saji Kuruttukulam
• Dr. Edwin Francis
• Dr. Thomas Mathew

Editorial Panel
• Mr.P.Krishna Kumar (Chief Editor)
• Dr. Jo Joseph
• Mr. Dinesh P. Thampi
• Dr. Nisha Vikraman
• Mr. Dominic J. Mechery

Programme Co-Ordinator
• Mr.Stephan Pascal

Executive Director
• Mr. Dominic J. Mechery

Conceived, Edited & Designed by
• [email protected]

04|CARING HEARTS|JULY-SEPTEMBER

Starting with an apology and panic ensues.

is never good. However, The editorial team of Caring Hearts thus decided that
when one is due, there this edition be dedicated to the complications wrought by
should not be any COVID. Post COVID COMPLICATIONS is the theme
hesitation either! So let me and we have tried to include most of the medical specialties
start with an apology for that COVID seems to have a bearing on. Each article,
delaying the edition of written by a specialist of his/her field has tried to explain
Caring Hearts for the 2nd how COVID affects their area of concern, in as much
quarter due to the stringent detail as possible. We also have brought in specialists
movement restrictions COVID imposed. The delay was so who have tried to address our concerns by explaining
much that we could not hope to catch up and so we are how the complications brought in by COVID could be
making this a special edition, a mega one, that we hope you understood and tackled. Children have suffered the most,
will accept as a makeup edition. I would say. Their very nature is being curtailed, be it
studies or playing. Intermingling is as important to their
COVID has been amongst us for more than 18 months now growth as is their food and the very air they breathe. How
and there seems to be no end in sight. Despite the valiant long can we deny that and expect them to grow normal?
efforts of our health workers and stringent safety protocols The issues that this Covid isolation has undoubtedly
imposed by the government, the pandemic is very much wrought in their lives are yet to manifest.
omnipresent, seemingly having a will of its own. Now it is up
to each one of us, to look out for ourselves and our own, Before I conclude, I must draw your attention to a major
understand how and why Covid spreads and learn to live annual event that HCF used to conduct without fail.
with the pandemic. Let me spare a grateful thought – where World Heart Day, which falls on 29th September, used to
would we be but for our doctors, nurses, other health be a grand affair, with all HCF members and other
workers and support staff, who reported for duty every day, dignitaries present. HCF’s panel used to select and
willingly, stepping into a literal war zone, so that we all honor an eminent personality for his or her contribution
could stay safe at home. “When going gets tough, the tough to the society and bestow HCF’s Life Time Achievement
gets going”, so the age old saying goes and time and again, award for the year on them. Like in 2020, we will be
it’s been proven, thankfully! missing it this year as well.

All over the world, COVID has taken its toll and still it’s Another important event is the World Physiotherapy Day
inexorable march goes on. It’s become a matter of “when” that just got over on 8th September. Physiotherapy and
rather than if someone acquires COVID. Fortunately, for Rehabilitation are the 2nd most important event after
many, the suffering was minor but for some, the ordeal was undergoing an angioplasty or bye-pass surgery for a
really terrible and prohibitively expensive. Worse was when patient. Bringing the patient back into mainstream society
hospitals could not handle the inflow and the very air we is the most prominent goal of HCF. We will be missing
breathe became a premium. Many lost their lives and this function as well.
curiously, very many lost their lives just after they recovered
from COVID, which was even more alarming. Many seemingly Such functions play a very large role in creating a bond
healthy youngsters lost their lives, due to various organ between patients, his peers and his doctors, giving them
failures or stroke. Many suffered chronic depression during the confidence to resume their life normally, and for the
and after COVID and the enforced complete isolation was family to accept that their beloved is no more a fragile
beyond many. Sleep disorder, fatigue and breathlessness patient.
were frequent complaints of many. When disasters and
calamities are seen on news or read in papers, we can watch Let us hope and pray that all such normalcies will soon
or read them with a certain detachment but when it happens be back in our lives.
to our near and dear, almost on a daily basis, fear settles in
KRISHNA KUMAR

JULY-SEPTEMBER, 2021|CARING HEARTS|05

Dr. Abraham K Paul, 1. Can children get COVID-19? There are no medicines or pills
Consultant Pediatrician, Yes. It’s possible for anyone, of any proven to prevent coronavirus
Indira Gandhi Co operative age, to contract COVID-19 – infection in any person. We have
Hospital, Kochi. including children. vaccines available , which mainly
protect against disease. At present,
The second wave of COVID- 2. Why are more children in India the vaccines are approved for
19 in India has left parents testing positive for COVID-19 use in adults and children above 18
looking for information on during the period? years.
protecting their children and steps to One feature of the new wave is that
take if their child or a family member now entire households are becoming The best way to protect children is
has symptoms of COVID-19, or tests infected with the virus, more so than to continue to follow COVID-19
positive. Here are answers to some of in the first wave. appropriate behaviours.
the questions faced by parents
regarding health of their children. We still need to be cautious and · Always maintain a physical
continue to follow COVID-19 distance and stay home as
appropriate behaviours strictly. Its much as possible, unless going
also important to be aware how for medical treatment or
children are feeling each day. urgent supplies.

3. I am worried. How can I prevent · Wear masks when you are
my child from getting a COVID-19 outside and make sure the face
infection? mask is covering your nose.

06|CARING HEARTS|JULY-SEPTEMBER, 2021

Children above 2 years of age 4. How do I protect my children if 16-45% of
can also wear a mask. a family member tests positive for infected children
COVID-19? have no
· Continually wash hands with symptoms. Must
soap or use a 70% sanitizer, To start with, do not panic. Your common
making sure the whole surface family member with COVID-19 symptoms are
of the hand is covered. needs to isolated in a room if fever 70%, cough
possible. Avoid contact by other 39%, vomiting
· Get vaccinated – everyone family members. Always wear mask. 32%, dyspnoea
above 18 years of age is 30% some have
eligible. 5. How do we manage different fatigue, loss of
COVID-19 situations in the family smell, abdominal
· Avoid attending public at home? pain, decreased
functions, avoid social appetite
gatherings and avoid group If anyone in the family has COVID-
play. 19, the doctor will advice you all to
isolate at home.
· Discuss, demonstrate and
reiterate the importance of Here’s how to manage different
COVID-19 Appropriate situations in the home, depending on
Behaviour (CAB) with your who in the family has COVID-19.
children.
This means that every case of fever
If a mother and her Let children stay with their mother, unless their or cough in your child could be
child / children are mother is too sick to care for them or is hospitalized COVID-19 – especially if a family
COVID-19 positive member is suffering from COVID-19
For infants, mothers should continue breastfeeding or as recently recovered from the
as much as is possible and feasible virus.

If a mother is If no other childcare options are available, and the 6. How does COVID-19 affects
COVID-19 posi- mother is not too sick or hospitalized, she can take children?
tive, but her child / care of her childrenHowever, while doing so she
children are must continue to:- COVID-19 affects in the different
negative people in different ways. People of
Take the best possible sanitization measures. any age can be infective and transmit
Wear a double mask properly. the virus. However, older people and
Maintain physical distance. those with pre-existing medical
If possible, isolate to a separate room. conditions are more likely to develop
severe illness from it.
If a child tests Parents can continue to take care of the child
positive for COVID- However, by caring for their child, parents should. 16-45% of infected children have no
19 and their parents
are negative Use a proper mask. symptoms. Must common symptoms
Wear personal protective equipments (PPE)
including gloves - for their own protection are fever 70%, cough 39%, vomiting

Avoid leaving children with confirmed, or suspected 32%, dyspnoea 30% some have
COVID-19 with their grandparents.
fatigue, loss of smell, abdominal

Elderly people are at very high risk of serious pain, decreased appetite. Children
disease from COVID-19. So, unless a child’s status
is corona negative, they should not be left with, or be infected with COVID-19 have also
in contact with, their grandparents.
been reported to develop a

multisystem inflammatory syndrome

in children (MSI – C). They can

present with >>>

JULY-SEPTEMBER, 2021|CARING HEARTS|07

rash, conjuctivitis redness around spreaders of the virus. In fact, the If your child has been in contact with
the COVID-19 positive person, but
mouth, hands, feet, shock, cardiac capacity of children to spread the does not have any symptoms, you
should remain watchful for symptoms
dysfunction, bleeding problems, infection much less as compared to until 14 days after the initial contact.

abdominal symptoms mimicking adults. If at any point within the 14 days after
contact, the child develops symptoms
appenditis or peritonitis. 9. What should I do if my child as like a fever, cough, runny nose,
vomiting, loose stools etc. then you
7. Which children are at risk of symptoms of COVID-19? should get them tested for COVID-19.

getting severe illness from COVID- Seek medical attention. You should also get your child tested
19? if they have any symptoms, even if
If advised by the doctor, then ; you aren’t sure if they have been in
Children with pre-existing major close contact with someone who has
disease might be at higher risk of · Get your child tested for tested positive for COVID-19 or has
getting severe illness from COVID- COVID-19. symptoms.

19. For example, a heart, kidney or · Isolate / stay at home Medical advice from the child’s
designate pediatrician / family doctor/
liver disease, or malignancies. 10. When should I get my child health facility should be sought for
children who have any symptoms.
Children with obesity, diabetes, tested for COVID-19?

asthma or chronic lung disease, sickle
cell disease, or immunosuppression Get your child tested for COVID-19 if ;

might also be at increased risk for · Family members, that your

severe illness from COVID-19. child has been in contact

· Record temperature and
oxygen saturation with a
pulse oximeter if available at
home, every six hours.
Measure their temperature
frequently. If it is more than
100 degree F, then you can
do tepid sponging with tap
water and give them syrup or
tablet paracetamol. If fever is
>100 F, give paracetamol 10-
15mg/kg/dose.

Severe cases that develop acute with, test positive for · Continue to follow good
respiratory distress and certain other COVID-19. hand and respiratory hygiene
complications, will require practices like regular
management in the ICUs. · Your child has symptoms of handwashing with soap so
COVID-19. that your child is protected
8. Are children super-spreaders of against other viruses and
the virus? · Your child has a fever that bacteria causing diseases.
continue beyond on three
No. Children being super-spreaders days. · Continue to follow personal
is a myth. The latest studies have protective measures for
revealed that children are not super- 11. Do all children need to be yourself and your child. Your
tested for COVID-19? child should wear a surgical

08|CARING HEARTS|JULY-SEPTEMBER, 2021

mask anytime they are Children with pre-existing major
around people. Change the disease might be at higher risk of
mask after eight hours of getting severe illness from COVID-
continuous wear. Caregivers 19. For example, a heart, kidney or
interacting with the child liver disease, or malignancies.
should wear gloves and a
mask. your child contracts serious disease. To eliminate all traces of the virus on

· Feed your child home-cooked In such children, preventive care and your hands, a quick scrub and a rinse
food and keep them well
hydrated. Give plenty of some extra precautions at home to wont cut it. Below is a step-by-step
liquids and give a soft and
light diet. avoid infection are important. If such process for effective handwashing.

· One may give Vitamin C, a child contracts an infection, it is · Step 1 : Wet hands with
zinc to boost overall health advisable to consult your doctor for running water
and immunity. Other specific advice about ongoing
nutritional supplements like medications. · Step 2 : Apply enough soap
syrup multivitamin, vitamin to cover we hands
D, calcium can be given as 14. My child tested COVID-19
per their doctor’s advice. positive one week ago. He is due · Step 3 : Scrub all surfaces
for his routine vaccinations in two of the hands – including the
· Be watchful for danger signs weeks. What should I do? back of hands, between
(explained below). If any of fingers and under nails – for
these signs are present, seek Routine immunization can be at least 20 seconds.
urgent medical advice at your continued two weeks after the child
nearest hospital. is asymptomatic (of COVID · Step 4 : Rinse thoroughly
infection). If a child needs some with running water
12. What are the danger signs and
symptoms to monitor in children higher medications such as high dose · Step 5 : Dry hands with a
with COVID-19 at home?
steroids, which suppresses the clean cloth or single use
If your child is isolating at home with
COVID-19, it’s important to know, components of patient immunity, towel.
and look out for the following five
symptoms: immunization needs to be deferred for 17. What precautions can my
three months after the medication. family take against COVID-19
1. High fever lasting beyond three
days 15. Should my child wear a mask? while travelling?
If your child is above two and willing
2. Decreased oral intake by the child While travelling, all parents should
to wear a mask, assist them in
3. Child becoming lethargic wearing their mask properly and over follow standard hygiene measures for
their nose. Create fun games around themselves and their children:
4. Increasing respiratory rate
wearing a masks. WHO also · Wear your mask and ensure
13. My child has a chronic disease.
Do I continue his steroid treatment recommends that if children under your children always do the
or other treatment?
five years wear a mask, a parent or same during the journey and
Most of the treatment of pre-existing
diseases need not be altered unless other guardian should be within when outside your

direct line of sight of the child to accommodation (including

supervise the safe use of the mask. while taking photographs).

16. How can I help my child to · Washing hands properly
wash their hands properly?
with soap. >>>

JULY-SEPTEMBER, 2021|CARING HEARTS|09

· Carrying sufficient hand Considering the benefits of sessions should continue to the extent
sanitizer. breastfeeding and the significant role possible and as permitted within the
of breastmilk in the transmission of local COVID-19 response context.
· Avoiding close contact with other respiratory viruses, a mother However, standard infection
anyone who is coughing or can continue breastfeeding while prevention measures should be in
sneezing while at your hotel applying all the necessary precaution place to minimize the risk of COVID-
accommodation. e.g. wear a medical mask while 19 transmission to all staff and
breastfeeding the baby, wash your visitors to the health facility.
18. Can pregnant women pass hands with soap and water or use
coronavirus onto their unborn alcohol-based hand rub before It is especially important that children
child/children? feeding and routine clean and receive all the vaccines scheduled at
disinfect surfaces around you. birth and in the first two years of life.
At this time, there is not enough These vaccines may vary according to
evidence to the fact that the virus is 20. Is it safe to vaccinate national recommendations. Any
transmitted from a mother to her children during the COVID- interrupted immunization services for
baby during pregnancy or the 19 pandemic? any age goups should be resumed and
potential impact this may have on the
baby.

WHO recommends that all routine vaccinations be
administered as scheduled, even during the COVID-19
pandemic. There is currently no evidence that the COVID-

19 pandemic poses any specific risk linked to vaccination

Pregnant women should continue to WHO recommends that all routine catch-up vaccinations offered as
follow appropriate precautions to vaccinations be administered as quickly as possible. Timely
protect themselves from exposure to scheduled, even during the COVID- vaccination is key to protect young
the virus and seek medical care early, 19 pandemic. There is currently no and old from serious and life-
if experiencing symptoms, such as evidence that the COVID-19 threatening infectious diseases and to
fever, cough or difficulty breathing. pandemic poses any specific risk avoid the accumulation of
linked to vaccination. Potential unvaccinated groups and potential
19. Is it safe for a mother to contact with an infectious disease is loss of community immunity.
breastfeed if she is infected with not a contraindication for routine 21. Does vaccination increases a
coronavirus? immunization. Routine immunization child’s risk of becoming infected

10|CARING HEARTS|JULY-SEPTEMBER, 2021

with COVID-19 or of developing regarding COVID-19 and vaccines be administered?
the disease? vaccination and general principles of
vaccination of patients with At the moment, there is no specific
Based on experience with other infectious diseases should applied. evidence of a potential impact of
infectious diseases, vaccination According to these principles, COVID-19 on vaccination response
against one disease does not weaken a vaccination will not influence the or vice versa. Systematic COVID-19
person’s immune response to another course of infectious disease in a child testing before routine vaccination is
disease. There is currently no who might already be infected but not currently required or
evidence that vaccination would who is not yet symptomatic at the recommended. Any patient with a
increase the risk of a child becoming time of vaccination or a child who negative COVID-19 test can be
infected with COVID-19 or affect the becomes infected soon after vaccinated at any time if their
course of the disease in a child who vaccination. Neither will the child’s clinical condition allows.
has been inadvertently vaccinated potential infection influence the
during furthermore, continuing routine safely or efficacy of the vaccine that 26. How many days after a
vaccination of children during the is administered. negative COVID-19 test can the
COVID-19 pandemic will protect tuberculin test be administered?
them from vaccine-preventable 24. Is COVID-19 a
diseases (VPD). Ensuring that the contraindication for vaccination? There is no known interference
immunization sessions are conducted between the COVID-19 test or
in a facility with adequate infection Mild symptoms such as fever and/or COVID-19 and the tuberculin test.
prevention measures will minimize cough are not necessarily a
any potential risk of chidren getting contraindication for vaccination. In 27. Does the BCG vaccine protect
COVID-19. line with normal procedures, the against COVID-19?
health-care provider should make
22. Why is vaccination particularly recommendations based on a risk In addition to preventing tuberculosis
important during the COVID-19 benefit assessment (severity of infection, the bacilli Calmette-Guerin
pandemic? symptoms and risk and severity of (BCG) vaccine has beneficial effects
VPDs). If the practitioner decides on the immune system that protect
Any disruption of immunization against vaccination on that day, the against a wide range of other
services, even for short periods, would normal vaccination schedule for the infections and the vaccine is used
leave a community and especially child should be resumed as soon as routinely to treat bladder cancer.
children at immediate risk of Vaccine possible after he or she recovers. Two clinical trails are underway to
Preventable Diseases (VPDs). By look at whether the BCG vaccine
adding to the number of susceptible There is no vaccine against COVID- could have a role in protecting
individuals already present in a 19 at this time. Over 100 candidate health-care workers and other
community, this would put community vaccines are in clinical trials or vulnerable individuals against severe
protection at risk and increase the preclinical evaluation. WHO is COVID-19, but so far there is no
likelihood of VPD outbreaks. Such working with all stakeholders to evidence that the BCG vaccine
outbreaks may result in VPD related ensure that once a safe and effective protects people against infection with
illnesses and deaths and an increased vaccine becomes available it will be the novel coronavirus.
burden on health-care systems already equitably distributed. Now more than
strained by the response to the ever, all health-care workers should WHO therefore does not
COVID-19 outbreak. ensure that they are up to date with recommended BCG vaccination for
the recommended vaccinations the prevention of COVID-19. WHO
23. Is it dangerous to vaccinate a according to their national schedules. continues to recommend neonatal
child during the incubation period BCG vaccination in countries or
of COVID-19? 25. How many days after a settings with a high incidence or
negative COVID-19 test can tuberculosis.
There is currently no specific evidence

JULY-SEPTEMBER, 2021|CARING HEARTS|11

according to a new study. According Depression & Anxiety
to the research published in the lancet
on November 9, 18% of covid During and following Covid-19
patients developed a mental health infections patients are at increased
issue within three months of risk for depression and anxiety. While
diagnosis. Their risk was doubled depressive and anxiety “symptoms”
compared to people who did not are more common than formal mood
have covid-19. or anxiety “diagnosis” in covid-19
survivors, a significant proportion of
Dr. Daya Pacal C Covid -19 is likely to have important patients meet diagnostic criteria for a
MBBS, DPM neuropsychiatric effects in long term psychiatric disorder.
Consultant- Psychiatry and short term. Over 30% of patients
Govt Mental Health Centre, hospitalized with covid-19 exhibit Depression and anxiety symptoms
Thrissur cognitive impairment, depression and following Covid-19 are more likely to
anxiety that persists for months after be in females and those with infected
Nearly 20% Covid – 19 patients discharge. These symptoms are even family members, post infection
developed a mental health issue more common in patients who physical discomfort, severe infections
like depression, anxiety or dementia required intensive care for severe elevated inflammatory markers and
within three months of diagnosis, effects of the virus. prior psychiatric diagnosis.

Recent evidences also suggest that Suicidal indications are also elevated
psychiatric illness is both a risk factor following Covid-19 diagnosis. There
for and consequence of covid-19. have been numerous case reports of
covid-19 patients attempting to kill

12|CARING HEARTS|JULY-SEPTEMBER, 2021

Covid -19 is likely to have important
neuropsychiatric effects in long term and
short term. Over 30% of patients
hospitalized with covid-19 exhibit cognitive
impairment, depression and anxiety that
persists for months after discharge

themselves during or prior to Chloroquine and
hospitalization. Hydroxychloroquine which were

Post Traumatic Stress Disease previous main stays of Covid-19

(PTSD) care, can cause hallucination and

PTSD was one of the most common other psychotic symptoms. The risk
psychiatric diagnosis among is exacerbated in patients receiving
survivors of SARS & MERS. Not combination therapy with Lopinavir
surprisingly, the prevalence of PTSD and Ritonavir. The administration of
among covid-19 survivors appears to high dose Corticosteroids, which
large ranging from 20-30%. The most remains one of of the few effective
common risk factors identified to date treatments for severe covid-19
for PTSD / PTSS following SARS- infection can cause psychotic
COV-2 infection are younger age, symptoms.

female gender, need for ICU care and Substance Use Disorders (SUD)

having a past psychiatric history. Screening for substance use disorder

Interestingly a study comparing will be an important part of follow up

patient’s with covid-19, who were care for covid-19 survivors. Patient’s

discharged from Emergency with SUD’s are more susceptible to

Department to those who required In Covid-19 due to social and public

Patient hospitalization, being restrictions implemented during the

hospitalized was found to protect pandemic. Across all patients with

against PTSD. covid-19, those with comorbid

Psychotic Disorders SUD’s are more likely to require
hospitalization (40.1% Vs 30.1%) or

There have been several cases reports die (9.6% Vs 6.6%).

from multiple countries detailing first Scientific understanding of the
episode of psychotic symptoms in impact of covid-19 continues to
Covid-19 patients. There are evolve rapidly. There are emerging
insufficient data to clarify a typical data concerning for a wide range of
presentation of Covid-19 psychosis, neuropsychiatric sequelae following
but notable disorganization and SARS COV-2 infection. Clinical
confusional features have been trials are also urgently needed to
described. clarify optimal treatment strategies for

Covid-19 treatment may also neuropsychiatric and other potential long

precipitate psychosis, specifically term impacts of covid-19.

JULY-SEPTEMBER, 2021|CARING HEARTS|13

19 and other endocrine disorders such as adrenal and thyroid disorders. This
article deals with the current evidence about the impact of COVID-19 on
human endocrine system.

DIABETES & COVID-19 INFECTION

Dr. Arun S. Menon, MD CCT FRCP Impact of COVID-19 on patients with diabetes.
HOD & Senior Consultant Survival rate is dramatically reduced in subjects
Endocrinologist with diabetes infected with SARS-CoV-2.
Dept of Endocrinology
Lisie Hospital, Kochi

COVID- 19 pandemic shows no
sign of remitting in the near
future and has left patients and
doctors with more questions than
answers when it comes to predicting
the long term outcome. Of all the pre-
existing noncommunicable diseases,
diabetes seems to have a definite yet
complex association with COVID-19
infection. Similarly, there seems to be
some relationship between COVID-

14|CARING HEARTS|JULY-SEPTEMBER, 2021

Are patients with diabetes at higher COVID-19 & DIABETES
risk of contracting COVID -19
infection?

Available data seems to suggest that
the occurrence of COVID-19
infectionis not higher in patients with
diabetes. However, those with
diabetes seem to develop more severe
COVID -19 infection with higherdeath
rates.The prevalence of diabetes and
obesity was higher in individuals
admitted to hospital compared to those
treated at home.A survey from
England showed that nearly one third
of patients with COVID-19 dying in
hospital had type 2 diabetes with
double the risk of dying compared
with patients without diabetes.

What are the risk factors that affect
the outcomes in COVID -19 infection?

Age, Sex, Race, Cardiac risk factors

Age and male sex are risk factors for High blood pressure disease compared with patients
worse outcomes in COVID-19, with is by far the most without obesity.
those aged 80 years and older having a frequent risk factor
12-times higher risk compared with seen in patients with Does poor glucose control affect the
those aged 50–59 years and males COVID-19. Patients outcome of COVID-19?
having twice the risk as females. Non- with COVID-19 also
white ethnic groupsseem to be at have a high Poor glucose control before hospital
greater risk compared with white prevalence of cardiac admission, as indicated by HbA1c
people suggesting a racial difference disease concentrations, was associated with a
in infection pattern.A higher high risk of in-hospital death. It has
prevalence of cardiac risk factors such frequent risk factor seen in patients also been noted thatthere is a higher
as high blood pressure, diabetes, and risk of a ICU admission, mechanical
obesity could be the reason for the with COVID-19. Patients with ventilation, and deathin patients with
poorer outcome in these minority high blood glucose at admission.
populations. However, in India, COVID-19 also have a high New diagnosis of diabetes andhigh
Pakistan, and Bangladesh, despite a blood glucose at admissioncan
high prevalence of diabetes and prevalence of cardiac further worsen COVID-19 outcomes.
deprivation, a relatively low COVID-
19 mortality has been reported so far. disease.Obesity and diabetes increase Are all medications for diabetes safe
This finding suggest that there may be to take during or after COVID 19
a geographical or climatic effect on risk of excessive blood clotting or infection ?
the spreading of the infection.
thromobosis that might contribute to In the presence of mild COVID-19,
High blood pressure is by far the most usual glucose-lowering medications
worse prognosis. Six-times for patients with diabetes could be
continued if the patient eats and
increased risk of severe COVID-19
>>>
has been reported in patients with a

body mass index (BMI) of more than

25 kg/m² and those with fatty liver

JULY-SEPTEMBER, 2021|CARING HEARTS|15

drinks adequately and a more people with diabetes who develop COVID-19 infection?
frequent blood glucose-monitoring
regimen is implemented. Patients People with diabetes with COVID-19 are at a higher risk of developing
admitted to hospital for severe complications and higher mortality. Given the high worldwide prevalence of
COVID-19 need modifications to diabetes, these individuals represent a large vulnerable segment of the
their diabetes therapy, including COVID-19 population. We should be aware of the risk of new onset diabetes,
withdrawing ongoing treatments and worsening of pre-existing diabetes and acute diabetes complication posed by
initiating insulin therapy. Such a COVID-19 infection.
decision is based on the severity of
COVID-19, nutritional status, risk of COVID & THYROID
hypoglycaemia, renal function, and
drug interactions. COVID- 19 CAN LEAD TO SUBACUTE
THYRODITIS IN SOME CASES

It is postulated that metformin is Majority of mild to moderate COVID 19 patients do not develop any
beneficial for COVID-19 infection as problems with their thyroid gland. However, a significant proportion of those
it might prevent virus entry into with severe disease manifest with abnormalities in thyroid function tests.
target cells. SGLT2-inhibitors may Subacute Thyroiditis ie an inflammation of thyroid gland is well described
also has antiviral effect and they after COVID. Overactive thyroid ie thyrotoxicosis hasbeen reported to occur
could reduce the viral load. DPP-4 after patients recover from COVID-19. Some patients might develop
inhibitors are associated with a low underactive thyroid disease or hypothyroidism. Those patients presenting with
risk of hypoglycaemia and can be thyroiditis can initially develop fever, palpitations, weight loss, neck
used for a wide renal function range. tenderness, swallowing difficulty which improved over next few weeks with
Because of the risk of developing or without supporting therapy. Eventually some of these patients will develop
low blood glucose , sulfonylureas permanent hypothyroidism and require thyroxine replacement.
should be stopped in these patients,
particularly if oral intake is poor. Others who develop autoimmune hyperthyroidism will present with weight
loss, palpiations, sweating, prominent eyes and a goitre (neck swelling) and
How does COVID-19 therapies may need long term treatment depending on their response and progression.
affect diabetes?
COVID & OTHER ENDOCRINE GLANDS
Treatment with chloroquine or
hydroxychloroquine can cause Does adrenal gland get affected by COVID- 19?
hypoglycaemia, particularly in
patients on insulin or sulfonylureas, Adrenal dysfunction in COVID 19 has been reportedin several studies. Low
because of their effects on insulin serum cortisol and ACTH have been documented in COVID 19 patients. The
secretion, degradation, and action. levelsare found to be lower in patients with more severe disease especially
Antiviral drugs such as lopinavir and
ritonavir could lead to
hyperglycaemia and worsen
glycaemic control. Glucocorticoids
have been used in patients with
COVID-19 with severe acute
respiratory distress syndrome as
symptomatic and anti-inflammatory
treatment. Their use, however, can
markedly worsen blood glucose
levels.

What is the overall prognosis in

16|CARING HEARTS|JULY-SEPTEMBER, 2021

EFFECT OF COVID-19 ON ENDOCRINE SYSTEM 4. Be aware of sick day rules in
Endocrine and metabolic aspects of the COVID-19 pandemic December 2020 diabetes in case of infection by
COVID-19.

5.Do not discontinue diabetes or
thyroid medications without advice
from your doctor.

6. Seek advice from your doctor in
case you develop fluctuating blood
glucose reading sor become
symptomatic

7. Those patients withadrenal
insufficiency should double the dose
of steroids if pyrexial / unwell.

critically ill.Adrenal insufficiency can occur even in asymptomatic andmild 8. If persistent non-specific
COVID 19 patients. Vascular complications or bleeding into the adrenals can symptoms such as tiredness after
also occur.All this can lead to adrenal insufficiency which can present with COVID infection for which no other
symptoms such as tiredness, lethargy, light headness, low blood glucose, low cause could be found, consider new
blood pressure and low sodium levels. onset thyroid disorders or cortisol
deficiency or pituitary disorders.
Is pituitary gland function affected by COVID- 19?
SUMMARY
Regarding pituitary dysfunction, data are again scanty. There are some
reported cases of pituitary apoplexy, a condition where the blood supply to COVID -19 infection can cause
part of the gland is cut off, which ultimately leads to multiple hormone short term dysfunction due to its
deficiencies. Some patients are noted to have high levels of prolactin which effect on many endocrine organs.
can affect the menstrual periods. Diabetes is the most common co-
occurrence with new onset diabetes
Can gonadal function beaffected by COVID 19 ? or worsening of preexisting diabetes.
Other endocrine disorders are less
Serum testosterone levels ie male hormone were found to be lower in common but can cause varying
patientswith severe COVID 19 as compared to mild or moderate cases. It is degree of morbidity. Evaluation of
unclear whether this is similar to what is observed in many critical illness or endocrine functions might
whether it is specific to COVID – 19. berequired in those patients with
nonspecific symptoms which are not
What is the long term prognosis for those developing endocrine dysfunction? explained by the sequale of COVID
infection. The long term implications
The long term implications of these hormones is not well understood as there on the endocrine function especially
is insufficient follow-up so far of such cases. Some thyroid and adrenal in severe cases of COVID are not
disorders can lead to permanent replacement in the long term. known but certainly needs to be
studied closely in the next few years.
GENERAL ADVICE TO PATIENT WITH PREEXISTING Those with preexisting endocrine
ENDOCRINE DISORDERS disorders should take extra
precautions during and after an
1.Adequately protect yourself and ask for COVID-19testing if exposed. infection to avoid complications.
2. Avoid unnecessary routine appointments in person.
3. If you have diabetes, closely monitor glucose control.

JULY-SEPTEMBER, 2021|CARING HEARTS|17

do you tell if your symptoms are which can cause blood vessel
heart-related, and what can you inflammation, damage to very small
expect if they are? vessels and blood clots, all of which
can compromise blood flow to the
What are the possible heart issues heart or other parts of the body.
after COVID-19? Severe COVID-19 is a disease that
affects endothelial cells, which form
Dr. Jo Joseph COVID-19, the disease caused by the the lining of the blood vessels,
SARS-CoV-2 coronavirus, can
MD, DM (AIIMS) damage heart muscle and affect heart Heart Rate and COVID-19
Cardiologist, function.
Lisie Hospital After you have had COVID-19, if you
There are several reasons for this. are experiencing a rapid heartbeat or
For people who have had The cells in the heart have palpitations you should contact your
COVID-19, lingering COVID- angiotensin converting enzyme-2 doctor. A temporary increase in heart
19 heart problems can (ACE-2) receptors where the rate can be caused by a lot of
complicate their recovery. coronavirus attaches before entering different things, including
cells. Heart damage can also be due dehydration. Make sure you are
Some of the symptoms common in to high levels of inflammation drinking enough fluids, especially if
coronavirus “long-haulers,” such as circulating in the body. As the body’s you have a fever. Symptoms of a
palpitations, dizziness, chest pain and immune system fights off the virus, rapid or irregular heart rhythm may
shortness of breath, may be due to the inflammatory process can damage include:
heart problems — or, just from some healthy tissues, including the
having been ill with COVID-19. How heart. Feeling your heart beat
rapidly or irregularly in your
Coronavirus infection also affects the chest (palpitations)
inner surfaces of veins and arteries,

18|CARING HEARTS|JULY-SEPTEMBER, 2021

Feeling lightheaded or Type 2 heart attacks are more common There are
many symp-
dizzy, especially upon with COVID-19,This heart attack can toms reported
in the post-
standing be caused by increased stress on the COVID period,
and there are
Chest discomfort heart, such as a fast heartbeat, low multiple poten-
blood oxygen levels or anemia, tial causes for
What are the signs that I may have because the heart muscle isn’t getting these symp-
developed a heart problem after enough oxygen delivered in the blood toms
COVID-19? in order do this extra work. We have

There are many symptoms reported in seen this in people with acute
the post-COVID period, and there are coronavirus disease, but it is less
multiple potential causes for these common in those who have survived
the illness
symptoms.

Severe fatigue is common after Blood tests have shown that during

infection with the coronavirus, just as COVID-19, some people have
it is after any serious illness. Many elevated levels of a substance called

people experience shortness of

breath, chest pain or palpitations.

Any of these problems could be

related to the heart, but they could

also be due to other factors, including

the aftermath of being very ill,

prolonged inactivity and spending

weeks convalescing in bed.

POTS after COVID-19. People
recovering from the coronavirus
sometimes show symptoms of a
condition known as POTS (postural
orthostatic tachycardia syndrome).
Researchers are exploring whether or
not there is a link.

POTS isn’t directly a cardiac troponin in their blood, along with What about heart problems in
problem, but a neurologic one that
affects the part of the nervous system EKG changes and chest pain. Elevated children after COVID-19?
that regulates heart rate and blood
flow. The syndrome can cause rapid troponin levels are a sign of damaged In general, children who get sick
heartbeats when you stand up, which heart tissue. Sometimes this is from a with the coronavirus do not have
can lead to brain fog, fatigue, heart attack. This is less commonly serious problems as often as adults
palpitations, lightheadedness and seen after COVID-19. do. But a very rare complication of
other symptoms.
During acute COVID-19, elevated COVID-19 called multisystem
Is a heart attack more likely after
COVID-19? troponin levels with an abnormal EKG inflammatory syndrome in children,

A type 1 heart attack, caused by a are linked to higher mortality, but not or MIS-C, can cause serious heart
blood clot blocking one of the heart’s
arteries, is rare during or after in patients with a normal EKG damage, cardiogenic shock or death.
COVID-19 infection.
>>>

JULY-SEPTEMBER, 2021|CARING HEARTS|19

Children who survive MIS-C can be shortness of breath or leg swelling Is heart damage caused by COVID-
left with abnormal heart rhythms and after COVID-19, you should contact 19 permanent?
stiffened heart muscle that prevents your doctor, who may recommend if symptoms are due to a cardiac
the heart from relaxing normally and evaluation by a cardiologist if tests cause, recovery depends on the
beating properly. MIS-C has some indicate you are at risk. severity of injury. Very few people
similar characteristics to Kawasaki have a severe heart attack, such as an
disease. A sign of heart failure is shortness of acute myocardial infarction, or MI,
breath, but this has many other due to COVID-19
Shortness of Breath or Chest Pain potential causes, including COVID- Still, heart imaging can reveal minor
After COVID-19: Are these signs of related pneumonia and other changes in the heart muscle of some
an emergency? noncardiac causes. Symptoms of COVID-19 survivors. Post notes that
heart failure may include: some studies on athletes recovering
Shortness of Breath
Shortness of breath, from the coronavirus have shown
You want to consult a doctor if any some scarring, but stresses that some
of your symptoms are severe, of these studies did not compare these
especially shortness of breath. results with those who had not had
COVID-19. How long these minor
Shortness of breath by itself is not changes persist — and how they affect
always a sign of a serious problem, heart health — are not yet known.
but if you have that symptom along Experts are developing protocols and
with low O2 (below 92%), that is a recommendations for which athletes
reason to be concerned. Sometimes should get cardiac testing before
people are short of breath with returning to play.
exertion after COVID-19 because
they have been less active for a long
time and need to gradually build their
fitness level back up.

COVID-19 Chest Pain

What about lingering chest pain, especially with exertion
another common post-COVID
complaint? Chest pain may be Fatigue
nothing serious, but if you are having
severe chest pain, get help, especially Shortness of breath when
if it is persistent or if you are also lying down
having nausea, shortness of breath or
lightheadedness: These could Leg swelling
be symptoms of a heart attack
Frequent urination at night
“If you have chest pain when you (Note: frequent urination at
inhale, you might have lung night in men is a common
inflammation. Sudden, severe chest symptom of an enlarged
pain could be a due to clot in the prostate.)
artery to the lungs.

Heart Failure and COVID-19

A diagnosis of heart failure after
COVID-19 is rare. But if you have

20|CARING HEARTS|JULY-SEPTEMBER, 2021

COVID-19 can also affect the Research shows that there is still a
strength of the heart pumping, but lot to learn about lasting heart
subtle abnormalities in heart pumping effects on people who have had
are not likely to cause people COVID-19. In some cases, patients
problems. are left with signs of heart damage
A person recovering from COVID-19 that may call for continued
may benefit from physical monitoring
therapy, breathing exercises, and
most of all, time. Post advises anyone Can heart problems show up long signs of heart damage that may call
recovering from COVID-19 should after COVID-19 recovery? for continued monitoring.
expect a gradual course of recovery,
and should not expect a rapid return If you have had COVID-19, German study in which cardiac MRIs
recovered and feel all right now, were conducted on 100 people who
to their normal activity levels. should you worry? Are heart had the coronavirus and survived.
Can having COVID-19 make an problems likely to show up later on? The researchers saw abnormal
existing heart condition worse? findings in 78 of these patients.
A heart condition could be Post emphasizes that many of these Compared with those who had not
exacerbated by severe COVID, questions do not have clear answers had COVID-19, these patients
but not likely after mild or yet. SARS-CoV-2 was isolated in showed evidence of scarring and
asymptomatic cases But the 2019, and the vast majority of inflammation of the heart muscle and
effects of the coronavirus on COVID-19 survivors have only been its surrounding tissue (pericardium).
preexisting heart disease are not recovering for several months. It is However, this study was limited by
yet known. hard to know exactly how the disease the lack of an appropriate
will affect people’s hearts long term, comparison group, and subsequent
and this is just one area of intense studies have found a much lower
concern among researchers. incidence of myocarditis in those
who had a prior COVID-19
the National Institutes of Health is infection.
working with dozens of academic
medical institutions to track COVID- Another small study assessed 26
19 survivors’ health. Study groups, college athletes who had COVID-19
such as one called C4R, with mild symptoms or none at all.
are consolidating patient data to help Cardiac MRI showed that these
predict the long-term impact of the students had normal EKGs and
coronavirus on health and continuing normal levels of a substance called
care. troponin, which when elevated can
indicate heart problems. Four of
Research on Heart Problems After them had heart muscle inflammation
COVID-19 (myocarditis), and two of these had
inflammation of the pericardium
Research shows that there is still a (pericarditis).
lot to learn about lasting heart effects
on people who have had COVID-19.
In some cases, patients are left with

JULY-SEPTEMBER, 2021|CARING HEARTS|21

Organization officially announced membrane. In the host cell, viral RNA
COVID-19 a pandemic. multiplies and viral proteins are
synthesized. Viral proteins reassemble
Lungs are the most severely affected with the viral genome, forming new
organ in covid 19.Neurological virus particles. New virus particles
manifestations are common in are released in new uninfected cells,
advanced stages of the disease. thus, virus spread takes place.
The Virus
Central nervous system (CNS)
Dr.Jobin Mathew invasion and crossing of the blood–
brain barrier
DNB, MNAMS, DM (Neurology)

District Hospital, Thodupuzha

Coronavirus disease 2019 The SARS-CoV-2 virus is a novel The SARS-CoV-2 virus can enter into
(COVID-19) is caused by a coronavirus, consisting of a single- the brain through blood and through
novel coronavirus termed as strand positive-sense RNA genome. olfactory nerves in nose.
“severe acute respiratory syndrome SARS-CoV-2 virus entry, into the host Comorbidities, like diabetes and
coronavirus-2 (SARS-CoV-2)”. cells, is a complex process. After hypertension, enhance the viral entry
COVID-19 disease was first seen in binding to the receptor present on the
Wuhan, China, in December 2019, host cell, the enveloped virus fuses its
when a series of patients presented envelope with the host cell
with pneumonia. COVID-19 has very
rapidly spread worldwide and on
March 11, 2020, the World Health

22|CARING HEARTS|JULY-SEPTEMBER, 2021

into brain.In COVID-19, alterations in COVID-19 affects brain,blood vessels of
blood pressure control increases risk brain and nerves of various parts of body.
of cerebral vascular complications. Covid vaccine can also produce
neurological symptoms. Loss of smell
Coagulopathies (anosmia) Headache, body pain and
tiredness are common initial neurological
symptoms

COVID-19 infection produces COVID-19 produces various levels Myelitis
abnormalities in blood clotting
mechanism of body.There is more of altered sensorium, ranges from
chance of blood clotting in brain and
other organs.Coagulopathies in confusion, delirium, stupor to coma.
COVID 19 predispose to stroke and
seizures. Altered sensorium, in COVID-19, is

Neurologic manifestations associated with an increased risk of
COVID-19 affects brain,blood vessels
of brain and nerves of various parts of death.Virus directly infects brain
body. Covid vaccine can also produce
neurological symptoms. Loss of smell producing meningitis or encephalitis.
(anosmia) Headache, body pain and
tiredness are common initial It can affect clotting mechanism of
neurological symptoms. Severe
neurological complications are body producing stroke.Stroke can be
because of direct viral invasion,
immunological reaction, or decreased due to blood clotting in
oxygen supply to brain.
arteries(blood vessels carrying pure
The commonest manifestations are
lack of smell,lack of blood) of brain which is more
taste(Ageusia),dizziness and
headache. More serious CNS common.Blood clotting in venous
manifestations included
stroke,seizures and impaired system(blood vessels carrying impure
consciousness. Vision impairment,
neuralgic pain are other blood) of brain is also common in
manifestations.
covid 19 infection,which is otherwise Virus can affect spinal cord
Encephalopathy/Encephalitis less common. Venous infarct can lead also.Spinal cord at thoracic level is
to paralysis of one or both sides of commonly affected.It can lead to
body,seizures and altered sensorium. weakness of both lowerlimbs
When lungs are seriously (paraplegia) along with involuntary
affected,oxygen supply to brain is passing of urine.
decreased which produces chemical

changes in brain leading to seizures Stroke

and loss of consciousness

Corticosteroid-responsive In COVID-19, coagulopathies
encephalopathy, acute disseminated enhance the risk of cerebral arterial
encephalomyelitis, and immune- and venous thrombosis. Stroke can
mediated acute hemorrhagic present as sudden onset of inability
necrotizing encephalopathy are other
cause of altered level of >>>
consciousness in COVID 19.Virus
can affect various parts of
brain.When the area controlling
respiration is affected,it can produce
breathing difficulty and apnoea

JULY-SEPTEMBER, 2021|CARING HEARTS|23

to talk fluently,deviation of angle of Headache lower limbs producing difficulty in
mouth to one side and weakness of walking. As disease
arms and legs of one side of Headache is a common initial progress,weakness involves body
body(hemiplegia),Inability to symptom of COVID-19.Anxiety,stress ,upperlimb and muscles of
understand what is told and giving and lack of adequate sleep are the face.Patient becomes bed
irrelevant answers,inability to talk common reasons for headache. Pre- ridden.When muscles controlling
(aphasia) inability to talk existing migraine may get worse respiration are paralysed,it can be
fluently(dysarthria) are the speech because of COVID-19-related stress. fatal requiring ventilator support for
abnormalities that can be present in Sinusitis,lack of adequate breathing. This is reported in patients
stroke.Stroke can also manifest as oxygen(hypoxia),use of Personal who have taken covid vaccine also. It
sudden onset of visual protection equipment (PPE) are other can be effectively treated with IVIG-
symptoms(hemianopia),swallowing causes. It can also be due to meningi- (immunoglobulin) or plasma
problems,inability to walk tis , encephalitis,stroke, blood clotting exchange-a procedure which removes
steadily(ataxia) or pins and needle in brain or bleeding in the brain. plasma from body and replaces with
sensation of one side of body Loss of smell and taste fresh frozen plasma(FFP).It gives
including face. A complete or partial loss of smell complete recovery. So early
sensation (anosmia) and taste identification is very important. .
Seizures sensation (ageusia) are the most
frequent neurological manifestation of Miller Fisher syndrome is a variant of
Seizures are due to either infection of COVID-19. Lack of smell is due to Guillain-Barré syndrome and is
brain or due to blood clotting in the affection of olfactory nerve-the characterized by weakness of muscles
venous system of brain.Seizures can cranial nerve that controls the smell which moves the eye leading to double
be generalized or focal onset.In sensation.It is present in olfactory vision and unsteadiness of gait.
generalised seizures,there will be epithelium of nose.Virus can spread
uprolling of eyes,tonic posturing and to brain via this nerve. Muscles
clonic movement of all Guillain-Barré syndrome General muscle pain or myalgia and
fourlimbs,involuntary passage of fatigue are common symptoms of
urine,froathig from mouth and Guillain-Barré syndrome is a disease COVID-19. Rhabdomyolysis is a
injuries to tongue due to biting. In affecting the peripheral nerves of serious condition can lead on to acute
focal seizures,there can be deviation body,producing weakness of renal failure.
of head to one side and posturing of muscles.Weakness usuall starts in
one side of body.If seizures are Treatment
prolonged beyond 30 minutes,it can Patients with mild disease are usually
produce irreversible damage to treated at home.
brain.It can also produce cardiac and Meningitis,encephalitis,seizures
respiratory arrest ,stroke,Guillain Barre syndrome –all
requires hospital care and ICU
care.CT scan,MRI scan and MR
Venogram are essential to diagnose
the neurological diseased.Stroke due
to blood clotting can be treated with
injections that dissolves clot if
brought to hospital within 4.5
hours.Seizures requires hospital care
as early as possible.Severe and
critically ill patients require intensive
care treatment and mechanical
ventilation.

24|CARING HEARTS|JULY-SEPTEMBER, 2021

JULY-SEPTEMBER, 2021|CARING HEARTS|25

immune system to respond in the same
way as it would have on its first
reaction to the actual pathogen. It is
enough that our body can learn to
build the specific antibody. Then if
the body encounters the real antigen
later, as part of the real organism, it
already knows how to defeat it. Some
vaccines require multiple doses, given
weeks or months apart. This is needed
to allow for the production of long-
lived antibodies. It also helps the
development of memory cells. The
body is trained to fight the specific
disease-causing organism. It builds up
memory of the pathogen. The body
rapidly fights it if and when exposed
in the future.

Dr.Geetha Philips, MD, FRCP Vaccines contain weakened or Most vaccines have been in use for
inactive parts of a particular decades. Millions of people have been
Lead Senior Consultant organism (antigen). It receiving them safely every year. As
- Internal Medicine triggers an immune response within with all medicines, every vaccine must
Director of Academic Affairs the body. Newer vaccines contain the go through extensive and rigorous
- Aster Medcity, Kochi blueprint for producing the antigens. testing to ensure it is safe before it can
Training Programme Director They do not contain the antigen itself. be introduced in a country’s vaccine
- Internal Medicine (UK) They also contain other ingredients to programme. Once a vaccine is in use,
International Adviser, India, Kerala keep the vaccine safe and effective. it must be continuously monitored to
- RCP Global These latter ingredients are included make sure it continues to be safe.
in most vaccines and have been used
for decades in billions of doses of Each vaccine under development must
vaccine. The weakened or inactivated first undergo screenings and
version of antigens or blueprint for evaluations to determine which
producing antigens will not cause the antigen should be used to invoke an
disease in the person receiving the immune response. This preclinical
vaccine, but it will prompt their phase is done without testing on
humans. An experimental vaccine is
first tested in animals to evaluate its
safety and potential to prevent
disease. If the vaccine triggers an
immune response, it is then tested in

26|CARING HEARTS|JULY-SEPTEMBER, 2021

human clinical trials in three phases. remains protective. with pre-existing conditions of any
kind, including auto-immune
Manufacturing, safety and quality COVID 19 vaccine disorders. These conditions include:
control of vaccines hypertension, diabetes, asthma,
There are several safe and effective pulmonary, liver and kidney disease,
A vaccine has to reach pre-approved vaccines that prevent people from as well as chronic infections that are
stage following clinical trials. Then it getting seriously ill or dying from stable and controlled. Pregnant
is assessed by the relevant regulatory COVID-19. This is one part of women who develop COVID-19 are
body for compliance with quality, managing COVID-19, in addition to more likely to require intensive care
safety and efficacy criteria. Following the main preventive measures of than their non-pregnant counterparts.
regulatory approval, manufacturers staying at least 1 meter away from COVID-19 infection during
can submit a vaccine to WHO for others, covering a cough or sneeze in pregnancy may result in rapid
prequalification (PQ). This assessment your elbow, frequently cleaning your deterioration of health of pregnant
process ensures quality, safety and hands, wearing a mask and avoiding women and might affect the fetus
efficacy of the vaccine. It helps the poorly ventilated rooms. also. In the context of current
UN and other international situation of the SARS-CoV-2
procurement organizations determine As of 3 June 2021, the following pandemic, experts have suggested
the programmatic suitability of a vaccines against COVID-19 have that the COVID-19 vaccine may be
vaccine. met the necessary criteria for safety offered to the pregnant women if no
and efficacy: contraindications exist. A pregnant
Once vaccines start being woman can take an informed
administered, national authorities and AstraZeneca/Oxford vaccine decision. This decision is based on
WHO constantly monitor for – and the woman’s understanding that the
establish the severity of – any possible Johnson and Johnson risk of infection and/or morbidity
adverse side effects and responses from COVID-19 outweighs the
from people who have received the Moderna undescribed risk of being vaccinated
vaccine. The safety of the vaccine is during pregnancy.
paramount, with regular assessments Pfizer/BionTech
and post-approval clinical studies to Types of Vaccines
report on its safety and effectiveness. Sinopharm
Inactivated vaccine
Studies are often conducted to Sinovac
determine how long a given vaccine The first way to make a vaccine is to
The COVID-19 vaccines are safe for take the disease-carrying virus or
most people 18 years and older bacterium, or one very similar to it,
(making more than 69% of and inactivate or kill it using
population eligible) including those chemicals, heat or radiation. This
approach uses technology that’s been
The COVID-19 vaccines are safe for most proven to work in people – this is the
people 18 years and older (making more than way the flu and polio vaccines are
69% of population eligible) including those with made – and vaccines can be
pre-existing conditions of any kind, including manufactured on a reasonable scale.
auto-immune disorders.
Live-attenuated vaccine

A live-attenuated vaccine uses a
living but weakened version of the
virus or one that’s very similar. The

>>>

JULY-SEPTEMBER, 2021|CARING HEARTS|27

measles, mumps and rubella (MMR) subunits) of a virus or bacterium that them to make the specific protein that
we want our immune system to
vaccine and the chickenpox and the immune system needs to recognize and respond to.

shingles vaccine are examples of this recognize. Most of the vaccines on The nucleic acid approach is a new
way of developing vaccines. Before
type of vaccine. However, vaccines the childhood schedule are subunit the COVID-19 pandemic, none had
yet been through the full approvals
like this may not be suitable for vaccines, protecting people from process for use in humans, though
some DNA vaccines, including for
people with compromised immune diseases such as whooping cough, particular cancers, were undergoing
human trials. Because of the
systems. tetanus, diphtheria and pandemic, research in this area has
progressed very fast and some mRNA
Viral vector vaccine meningococcal meningitis. vaccines for COVID-19 are getting

This type of vaccine uses a safe virus The genetic approach (nucleic
to deliver specific sub-parts – called acid vaccine)

proteins – of the germ of interest so Unlike vaccine approaches that use

that it can trigger an immune response either a weakened or dead whole

without causing disease. Particular microbe or parts of one, a nucleic

parts of the pathogen of interest are acid vaccine just uses a section of

inserted into a safe virus. The safe genetic material that provides the emergency use authorization, which
virus then serves as a platform or instructions for specific proteins, not means they can now be given to
vector to deliver the protein into the the whole microbe. DNA and RNA people beyond using them only in
body. The protein triggers the are the instructions our cells use to clinical trials.
immune response. The Ebola vaccine make proteins. In our cells, DNA is
is a viral vector vaccine and this type first turned into messenger RNA, In India, at present three vaccines
can be developed rapidly. which is then used as the blueprint to have received approval for restricted
make specific proteins. use in emergency situation. One of
The subunit approach them is an inactivated vaccine
A nucleic acid vaccine delivers a (Covaxin) and other two are based on
A subunit vaccine is one that only specific set of instructions to our nonreplicating viral vector platform
uses the very specific parts (the cells, either as DNA or mRNA, for (Covishield and Sputnik V).

28|CARING HEARTS|JULY-SEPTEMBER, 2021

What should you do and expect
after getting vaccinated

Stay at the place where you get
vaccinated for at least 30 minutes
afterwards, just in case you have an
unusual reaction, so health workers
can help you.

Check when you should come in for a While a COVID-19 vaccine will prevent
second dose – if needed. Most of the serious illness and death, we still do not
vaccines available are two-dose know to what extent it keeps us from being
vaccines. Check with your care infected. We do not know whether we can
provider whether you need to get a pass the virus on to others
second dose and when you should get
it. Second doses help boost the vaccine works. However, you may your bent elbow
immune response and strengthen take paracetamol or other painkillers
immunity. if you do develop side effects such as When indoors with others,
pain, fever, headache or muscle ensure good ventilation, such as
In most cases, minor side effects are aches after vaccination. by opening a window.
normal. Common side effects after
vaccination, which indicate that a Even after you’re vaccinated, keep Effectiveness against Delta
person’s body is building protection to taking precautions. Variant
COVID-19 infection include:
While a COVID-19 vaccine will Only modest differences in vaccine
Arm soreness prevent serious illness and death, we effectiveness were noted with the
still do not know to what extent it delta variant as compared with the
Mild fever keeps us from being infected. We do alpha variant after the receipt of two
Tiredness not know whether we can pass the vaccine doses. Data show that
Headaches virus on to others. The more we both doses of a vaccine offer good
Muscle or joint aches allow the virus to spread, the more protection against getting infected.
opportunity the virus has to change. However, there is still a risk of
Contact your care provider if there is infection as no vaccine is 100%
redness or tenderness (pain) where Continue to take actions to slow and effective.
you got the shot that increases after 24 eventually stop the spread of the
hours, or if side effects do not go virus: Vaccination after COVID 19
away after a few days. Infection
Keep at least 1 meter from
If you experience an immediate severe others As per the guidelines of the Ministry
allergic reaction to a first dose of the of Health and Family Welfare
COVID-19 vaccine, you should not Wear a mask, especially in (MOHWF), Covid-19 vaccine can be
receive additional doses of the crowded, closed and poorly deferred by 3 months after recovery
vaccine. It’s extremely rare for severe ventilated settings. in individuals having lab test proven
health reactions to be directly caused SARS-2 COVID-19 illness.
by vaccines. Clean your hands frequently

Taking painkillers such as Cover any cough or sneeze in (Courtesy: WHO)
paracetamol before receiving the
COVID-19 vaccine to prevent side
effects is not recommended. This is
because it is not known how
painkillers may affect how well the

JULY-SEPTEMBER, 2021|CARING HEARTS|29

A report on

the Cardio Pulmonary
Resuscitation (CPR)-
Basic life support
Awareness Session on
Heart Care Foundation
for NCPL on Zoom
platform

11.30 am Sunday
September 12, 2021
The Session with Novelty Clothing P.
Ltd went off very well. The meeting
started with welcome address by Mr.
Nishil HR Manager NCPL, The
meeting was inaugurated by Mr.
George E P MD, NCPL. This was
followed by a brief presentation by
Chairman Dr. Jose Chacko
Periappuram on HCF activities. Dr
Jacob Abraham (Trustee, HCF) then
made a detailed presentation in his
usual inimitable style with facts and
figures. After the presentation the
floor was open for Q&A. The
Session was concluded with a vote of
thanks by Mr. Dileesh Operation
Head NCPL.

30|CARING HEARTS|JULY-SEPTEMBER, 2021

Dr.Thomas Kurian Unlike during the onset of the Listed below are few questionswhich
pandemic, most of us have are asked in my clinic most often.
MBBS, MD, DNB, EDIC, IDCCM now contracted the virus or However, if you had moderate or
at least have relativesand severe COVID, you should follow up
Consultant Pulmonologist acquaintances who have contracted it with the doctor who treated you.
Lisie Hospital over the past year. Unfortunately,
most of the information available on I was tested positive for COVID
post COVID symptoms are unverified and had an uneventful course.
reports that circulates through social What are the things to care, once
media. I have personally seen many tested negative for COVID?
who had a battery of tests done or
made a cocktail juice which they had Do not venture out and meet people as
to consume to purge outthe virus or soon as you test negative. There is a
remnants of the virus because it was chance that you could still infect
advertised by some laboratory or others in the initial days. It is best to
shared on social media. assess how you feel. The symptoms
which I believe require most attention
Post-COVID syndrome or Long are breathlessness that occurs after
COVID is anew terminology and walking small distances(which you
surely something I say today, might haven’t experienced previously),
turn irrelevant few weeks from now. confusion, bluish colour over lips and

>>>

JULY-SEPTEMBER, 2021|CARING HEARTS|31

palm and chest pain. These should Do not venture out and meet people
prompt you to visit your doctor. Mild as soon as you test negative. There is
cough and fatigue are common for a a chance that you could still infect
few days to few weeks post COVID. If others in the initial days. It is best to
they are mild, these are expected after assess how you feel.
COVID and you could wait for around
8 weeks for it to pass. If these
symptoms bother you, you should visit
a Pulmonologist and at least get a
Chest X-ray done.

There seems to be a lot of talk immediately after testing negative difficulty, and confusion. But, this is
regarding lab panel tests that can unless you have received a a very rare complication in someone
be done post-COVID. Should I do monoclonal antibody(which you with mild COVID.
them? might have received if you were
admitted with severe COVID). But, Should I take lime juice or garlic
Laboratory tests may be done if you at present, our national guidelines or pepper to prevent COVID?
have post COVID symptoms. If you recommend waiting for 3 months
are asymptomatic, no testing is before vaccination. So, until that While lime juice is rich in vitamin C
required. The laboratory tests which recommendation changes, it is and garlic and pepper in
are recommended by the CDC if you prudent to follow that. antioxidants, they do not help to
have post COVID symptoms are: prevent COVID. So, while you may
Blood count, S. Electrolytes, Renal Should I avoid sports/ running take these,remember to use your
and Liver function tests, Thyroid post COVID? masks and maintain social
function, Vitamin D, Vitamin B12, distancing.
CRP & Ferritin. I personally don’t
recommend these. In a country like You should start slow and see if you How long am I protected from
ours, where finding a doctor is much have any breathing difficulty. It’s COVID after an infection?
easier than in the West, it is always better to start at a lower threshold
better to consult a doctor and tailor and gradually increase your activity. If you have had very mild symptoms,
the tests needed for you. The pulse oximeter is a wonderful there is a chance that you have not
tool and I highly recommend that produced enough antibodies that can
Is there anything I should avoid you buy one.Check if there is a fallin help you from getting COVID again.
taking? the oxygen saturation aftersome mild So, always get your vaccine shot at
exercise. Your normal saturation your first chance, if you weren’t
Although not born out of firm would be around 97-99%. If there is already vaccinated. Data suggest that
evidence, I advise my patients to a fall in saturation of more than 4%, antibodies last for 6-9 months and
avoid spicy and sour food. This is do stop the exercise and consult your possibly much longer if you have had
based on the finding that few patients, doctor. moderate to severe COVID.
who had mild COVID, have mild
fibrosis of the lungs and having spicy Is there a risk of “clotting in the Lastly, please remember to always
or sour food are known to aggravate blood vessels” after I had COVID? double check the facts you read on
lung fibrosis. social media about the disease. I
COVID has been shown to increase truly hope that the day is not far off
When can I get vaccinated after the risk of clotting of blood. This is when I can go on a long-awaited road
being COVID positive? more common in those who have trip, without wearing a mask and
severe COVID. The symptoms which without fear.
Most international guidelines should alert you regarding the same
recommend getting vaccinated are chest tightness/pain, breathing

32|CARING HEARTS|JULY-SEPTEMBER, 2021

some people’s immune systems go into
overdrive, attacking not just the virus
but their own tissues. That can happen
in people who have very strong
immune responses.

The virus itself getting into and
damaging our cells might explain some
symptoms like brain fog and a loss of
smell and taste, while damage to blood
vessels in particular could lead to
heart, lung and brain problems.

Most people who catch joint pain Another theory is that fragments of the
Covid-19 won’t become virus could remain in the body,
severely ill and get better Surveys have identified tens and possibly lying dormant and then
relatively quickly. even hundreds of other complaints. becoming reactivated.This happens
A large study by University College with some other viruses, like herpes
But significant numbers have had London (UCL), identified 200 and the Epstein Barr virus which
long-term problems after recovering symptoms affecting 10 organ causes glandular fever.However, there
from the original infection - even if systems in people with long Covid, isn’t much evidence for this happening
they weren’t very ill in the first at higher levels than in those who with Covid at the moment.It’s likely
place.However, new research suggests had fully recovered. there are several different things going
fewer children are experiencing “long on in different people, to cause such a
Covid” than previously feared. These include hallucinations, wide range of problems.
insomnia, hearing and vision
What are long Covid symptoms? changes, short-term memory loss Can the vaccine help?
and speech and language issues.
Symptoms continuing for more than Others have reported gastro- Roughly half of people with long
12 weeks after an infection - severe or intestinal and bladder problems, Covid reported an improvement in
mild - which can’t be explained by changes to periods and skin their symptoms after being jabbed -
another cause. conditions. possibly by resetting their immune
response or helping the body attack
symptoms include: The severity of symptoms varies, any remaining fragments of the virus,
but many have been left unable to say experts.Vaccination can also help
extreme tiredness perform tasks like showering, prevent people contracting the virus
grocery shopping and remembering and developing long Covid in the first
shortness of breath, heart words. place.
palpitations, chest pain or
tightness What causes long Covid? What treatments are available?

problems with memory and We don’t yet know for sure.One At the moment there are no proven
concentration (“brain fog”) possibility is the infection makes drug treatments and the main focus is
on managing symptoms and gradually
changes to taste and smell increasing activity.A formal clinical
trial into drug treatments is expected to
launch soon.

(Courtesy BBC News )

JULY-SEPTEMBER, 2021|CARING HEARTS|33

Dr Nisha Vikraman Optimal intake of all nutrients, mainly to the relationship of this
those playing crucial roles in immune macronutrient with immune system. In
Assistant Professor system, should be assured through a this line, it has been highlighted that
Department Of Home Science diverse and well-balanced diet. including proteins of high biological
St. Theresa’s College Ernakulum Nevertheless, in order to reduce the value (those present in eggs, lean
risk and consequences of infections, meat, fish, and dairy) containing all
Nutrition management/ the intakes for some micronutrients the essential amino acids may exert an
treatment is very important may exceed the recommended dietary anti-inflammatory effect. In addition,
to enhance immune response allowances since infections and other some amino acids, such as arginine
for an infected person against RNA stressors can reduce micronutrient and glutamine are well known for
viral infection. There is sufficient status. their ability to modulate the immune
evidence to demonstrate that immune system .
response can be weakened by Role of nutrients in fighting Covid -19
inadequate nutrition. Among lipids, the omega-3 fatty acids
Protein deficiency is linked to eicosapentaenoic acid (EPA) and
impaired immune system function, docosahexaenoic acid (DHA) can
mainly due to its negative effects on inactivate enveloped viruses by
both, the amount of functional modulating the optimal host lipid
immunoglobulins and gut-associated conditions for viral replication. The
lymphoid tissue (GALT). Besides supplementation with DHA and EPA
quantity, the quality of proteins is may be useful to reduce the severity
also an important factor with regard

Protein deficiency is linked to impaired immune system function,
mainly due to its negative effects on both, the amount of functional
immunoglobulins and gut-associated lymphoid tissue (GALT)

34|CARING HEARTS|JULY-SEPTEMBER, 2021

and/or improve the recovery of mitochondrial overload and Recommendations
patients with COVID-19. subsequent free radical synthesis.
Indeed, increased circulating levels • Ensure intake of adequate fluids; at
The polar lipids, such as of inflammatory cytokines such as C
phospholipids, glycolipids or reactive protein (CRP), tumor least two liters of water per day or
sphingolipids (also present in food necrosis factor alpha (TNF-á), and more if there is fever.
sources of omega 3 fatty acids, such interleukin-6 (IL-6) have been
as fish and fish oils) have the ability to reported with the consumption of • Fever increases the need for more
block platelet-activating factor (PAF) these kind of carbohydrates . Due to
as well as its receptor, exerting anti- the aforementioned inflammatory calories: Increase the amount of
inflammatory effects that may be status that usually occurs in nutritious food by increasing the
beneficial in COVID-19. Moreover, it respiratory infections such as number of times you eat. The food
has also been described that these COVID-19, limiting the consumption should include a variety of foods
lipid species can also down-regulate of foods rich in these carbohydrates including energy-rich foods, meat,
the enzymes involved in PAF may be advisable. milk, legumes and pulses, fruits
biosynthesis, as well as up-regulate and vegetables.
those involved on its degradation . With regard to fiber, its importance
The blockage of platelet activation for a correct metabolic functioning • Consider supplementation with
may also be useful to prevent the has been widely reported. Several
thrombotic complications associated studies have revealed that an Vitamin C, zinc, Vitamin A, B6, D,
to COVID. adequate fiber intake (25–35 g/day) E, iron, Folate and fiber if not
may help reducing both, systemic getting enough from the diet.
Carbohydrates and dietary fiber have and gut inflammation.
also been reported to be related to • Ensure enough sleep, reduced
immune system function. As far as Vitamins A, C, D, E, B6, B12, and
carbohydrates are concerned, the folate, iron, magnesium and trace stress, exercise, avoid intake of
consumption of those with higher elements including zinc, selenium alcohol and tobacco products.
glycemic indexes (highly processed and copper play a pivotal role in
carbohydrates) can result in disease susceptibility and the • Coughs can be relieved by use of
maintenance of immune function.
Deficiencies and/or inadequate status honey, pineapple and chicken
in these nutrients may negatively soup, gargling and hand washing.
affect immune system, resulting in
decreased resistance against • Sore throat can be relieved by
infections.
taking tea, honey, ginger, turmeric,
COVID-19 presents with symptoms sage.
that require different types of
nutrition management. The • The use of culinary herbs like
recommended Nutrition management
below is based on symptoms that oregano, sage and cinnamon as
come with the COVID-19. well as increased consumption of
fruits and vegetables is encouraged
A. NUTRITION MANAGEMENT to improve antioxidant levels in the
FOR MILD SYMPTOMS body.

The symptoms include runny • Limit intake of refined carbohy-
nose, fever, cough, headache and
sore throat. drates such as sugar, sweets, cake,
soft drinks and sugar sweetened
beverages.

• Limit intake of foods containing

trans-fats and saturated fats e.g. fat
and skin from meat, hydrogenated
vegetable oils, shortening, fried
foods, cookies, and pastries.

• Fluid intake should be based on

weight, on average 40kg-60kg

>>>

JULY-SEPTEMBER, 2021|CARING HEARTS|35

1.5L- 2.0L, 60-80kg 2.0L-2.5L,
above 80kg 2.5L-3.0L or 30-35mL/
kg with allowances for extra losses
via drains.

Note: some caution should be used
with elderly patients or other patients
who may have reduced cardiac/renal
function (20-25mL/kg33 suggested
starting point for IV fluids). AI 2.1-
2.6L of fluid per day for adults.

B. NUTRITION MANAGEMENT
FOR PULMONARY DISEASE

Pulmonary disease includes Mild

pneumonia, severe pneumonia, and

acute respiratory distress Nutrition

relevant signs and symptoms in diet. Provide adequate but not Some foods may cause increased
pulmonary disease. excessive nutrients. Avoid mucus production if you are allergic
or intolerant to them. Common food
Cough : Use honey and lemon, warm overfeeding. If need be, reduce the allergens include eggs, fish, milk,
water/fluids. Continue taking feeds to 50% of required intake and nuts, peanuts, shellfish, wheat, soy.
prescribed medication. increase the amount slowly as the Avoid any of these foods if they
patient stabilizes. cause allergic reaction.
Early satiety: Eat small frequent
Fatigue : Include a source of • Some foods naturally contain
nutrient dense meals. histamine and their consumption
protein at every meal to sustain may increase histamine production.
Anorexia : Eat preferred nutritious energy released from food. Limit Enhanced histamine levels in the
meals or snacks. Increase intake of sweets and sugary food. Avoid body can cause increased
fruits. Vitamins and mineral production of mucus.
alcohol and caffeine. Eat small
supplements may improve on appetite frequent meals .Exercise with caution • Foods with histamine include
and food intake. processed meats like hot dogs and
while considering degree of illness. bacon, vinegar, dried fruits,
avocados, tomatoes, spinach,
Patients with Weight loss : Ensure • A multiple micronutrient mushrooms, eggplant, cheese,
adequate intake of food from all food supplement may be considered for yogurt, sour cream, buttermilk,
groups. patients at risk of vitamin and smoked fish, sardines, alcoholic
beverages.
• Adequate protein intake is key to minerals deficiency or whose intake
Vomiting : Eat small frequent
prevent muscle wasting. is inadequate. As pulmonary nutritious meals. Consider intake of
dry foods and snacks .Do not take
• Protein 1.2-1.7gms/kg/day disease progresses, other related food together with fluids. Take fluids
conditions may interfere with food separately. Eat while seated at 45
• Energy 30-35gms/Kg/day Dyspnea intake or overall nutrition status. degrees to 90 degrees and take some
(shortness of breath) : Eat a diet time before lying down again.
with fewer carbohydrates and These include: Abnormal
healthy fat e.g. canola, sunflower, production of sputum : Increase Anemia : Increase intake of iron
avocado, corn oil (liquid at room intake of Fruits and Vegetables like
temperature) to meet energy including citrus fruits and leafy
requirements for the period when vegetables .Increase intake of warm
breathing is difficult. Eat proteins drinks including clear broth soups,
from a good source like eggs and meaning soups without cream or
lean meat in addition to a healthy dairy, and warm decaffeinated tea.

36|CARING HEARTS|JULY-SEPTEMBER, 2021

A multiple micronutrient supplement may be
considered for patients at risk of vitamin and minerals
deficiency or whose intake is inadequate. As
pulmonary disease progresses, other related
conditions may interfere with food intake or overall
nutrition status

outcomes. The gastrointestinal route Enteral Nutrition should be
is preferred, although aspiration and replaced by progressive Parenteral
bacterial overgrowth are concerns. Nutrition.

rich foods including green leafy • Feeding procedures that minimize D. KIDNEY FAILURE
vegetables, meat and vitamin c rich aspiration include the use of a
foods such as citrus fruits. Consider continuous method of feeding rather • May be acute kidney Injury(AKI)
supplementation depending on than large bolus feedings, tube also known as Acute Kidney failure
severity and cause of anemia. placement in the duodenum rather or chronic kidney failure
than the stomach, the use of
Fluid retention : Some patients smallbore nasogastric feeding tubes, • Nutritional therapy in these
with fluid retention require sodium chest elevation to at least 45 degrees, patients should be based on severity
and fluid restriction. Depending on the frequent evaluation for gastric of multiple organ failure (MOF) and
diuretics, prescribed, increased dietary residuals, and endotracheal tube cuff not on the impairment of renal
intake of potassium may be required. inflation. function

• The use of parenteral lipids or C. SEPSIS • Essential dietary modifications
calorically dense enteral feedings include energy, protein, potassium,
may help the meet energy needs. • Minimize catabolism by ensuring sodium, phosphorus and fluid based
adequate intake of nutrients on disease stage1. Patients with renal
Other Comorbidities : Consider through normal diet, parenteral or disease should undergo formal
presence of other disease such as enteral nutrition depending on nutrition assessment, including
cardiovascular or renal disease, severity of illness. evaluation of inflammation, with
cancer, or diabetes mellitus and their development of a nutrition care plan.
specific nutrient requirement during • Meet energy requirements, but do 2. Standard amino acid parenteral
management not overfeed. For patients with nutrition formulations should be used
normal body weight, provide 30-35 in acute kidney injury. 3.
Enteral feeding : Patients kcal/kg/day. 0bese: 18-20 kcal/kg/ Intradialytic parenteral nutrition (a
receiving inadequate oxygen may day. Meet protein, vitamin, and form of parenteral nutrition
complain of anorexia, early satiety, mineral needs. Establish need and administered during regular
malaise, bloating, and constipation or maintain fluid /electrolyte balance. scheduled dialysis sessions) should
diarrhea. Intubated patients usually Plan nutrition therapy (oral, not be used as a nutritional
require enteral tube feeding or enteral, and/or parental nutrition) supplement in malnourished chronic
parenteral feeding. Decreased duration kidney disease V hemodialysis
of mechanical ventilation increases the • In patients with mild and severe patients. 4. Patients with renal failure
likelihood of appropriate enteral sepsis, immune modulating who require nutrition support
feeding, thus leading to better clinical formulae may be harmful and therapy should receive enteral
therefore are not recommended. nutrition if intestinal function
Early and progressive Enteral permits. 5. Individualized assessment
Nutrition should be used in septic of energy intake goals, and provision
patients after hemodynamic of adequate calories, as with other
stabilization. If contraindicated,
>>>

JULY-SEPTEMBER, 2021|CARING HEARTS|37

nutrition support patients, is Isocaloric diet is an
recommended. 6. For patients with energy administration
acute kidney injury protein intake of around the defined
should be adjusted according to target. Hypocaloric or
catabolic rate, renal function, and underfeeding is an
dialysis losses. 7. Electrolyte intake energy administration
in patients should be adjusted by below 70% of the
monitoring serum concentrations of defined target
potassium, Magnesium, Phosphorous,
and Calcium. edema or 300mls if there is edema. taken with meals and snacks to help
control the amount of phosphorus
Energy: Acute Kidney Injury and Sodium: is restricted, depending absorbed in the body. Minimize
sepsis increase energy needs by upto on the level of urinary excretion. intake of high phosphorus foods meat,
30%.For enteral nutrition provide 20- 2400mg per day (one leveled dairy and offals to one serving per
30kcal/kg/day adopted to teaspoon) unless in situation of day. Have a moderate intake of
individualized needs in case of hyponatremia which should be legumes ad cereals of 2-3 servings a
underweight or obesity. identified and corrected. day. Soak legumes overnight and
discard the water to reduce
For parenteral nutrition provide 30 Potassium: Potassium intake phosphorous content. Avoid cola
to 35 kcal/kg/days should be needs to be individualized according beverages, processed meats and
administered as carbohydrate and to serum levels. Restricted in patients cheese.
lipid solutions, and the serum with serum potassium >5.5 mmol/L
concentration of glucose and and on dialysis. Low potassium foods E. NUTRITION MANAGEMENT
triglycerides controlled. include mangoes, pineapple, IN CRITICALLY ILL PATIENTS
tangerines, apples, pears and lemons.
Protein: Acute Kidney Injury Take maximum 3 servings a day. Commonly used terms:
(Acute kidney failure) :Consider high High potassium fruits include passion
catabolic state. For patients on fruit guava, banana, avocado and Isocaloric diet is an energy
continuous renal replacement therapy jackfruit. Limit to one serving a day. administration of around the defined
(CRRT) 1.8-2.5gms/kg body weight Approaches for in food preparation target. Hypocaloric or underfeeding is
is recommended. For patients on methods for potassium reduction an energy administration below 70%
hemodialysis provide 1.5gms/kg/day required cutting vegetables, boil in of the defined target. Trophic feeding
and can be increased to 2.5gms/kg plenty of water for 5 minutes in is a minimal administration of
per day based on need. moderate heat, drain immediately and fry. nutrients having beneficial effects,
such as preserving intestinal
Chronic Kidney disease (CKD): Phosphorous : A normal epithelium, stimulating secretion of
(No renal function)Maintenance phosphorus level is 2.5 to 4.5 mg/dl brush border enzymes, enhancing
haemodialysis-1.2gms/kg/day should be maintained. Phosphorous immune function, preserving
Continuous ambulatory peritoneal restriction is advised when GFR is epithelial tight cell junctions, and
dialysis-1.3gms /kg/day .Stage III or less than 29ml/min and patients on preventing bacterial translocation.
IV CKD(partial renal function)- dialysis. Adopt measures of food
0.3gms-0.6gms/kg/day . preparation methods targeting
reduction of dietary phosphorus load.
Fluid: Balance fluid and Phosphate binders are prescribed and
electrolyte intake to output. Ideally,
fluid and electrolyte intake should
balance the net output. Fluid
monitoring to facilitate feeding: last
24 hr fluid output + 500ml if no

38|CARING HEARTS|JULY-SEPTEMBER, 2021

Overfeeding is energy administration seven days. Use Continuous rather reaching the energy target with an
of 110% above the defined target. than bolus Enteral Nutrition oral diet, oral nutritional
Low protein diet is protein supplements should be considered
administration below 0.5 g/kg/day . • Gastric access should be used as first and then Enteral Nutrition. In
the standard approach to initiate non-intubated patients with
General Recommendations Enteral Nutrition unless there is dysphagia, texture-adapted food
gastric feeding intolerance then can be considered. If swallowing is
• Consider medical nutrition therapy Consider post pyloric or jejunal proven unsafe, Enteral Nutrition
for all patients staying in the ICU, feeding. should be administered.
mainly for more than 48 h10
.General clinical assessment could • Hypocaloric nutrition (not Energy : Critically ill adult patients
include report of unintentional exceeding 70% of Estimated should receive feedings at rates of 25
weight loss or decrease in physical Energy) should be administered in to 30 kcal/kg. The amount of glucose
performance before ICU admission, the early phase of acute illness and (PN) or carbohydrates (EN)
body composition, muscle mass and increased from day 3 to day 7 to administered to ICU patients should
strength, 80-100% based on stability and not exceed 5 mg/kg/min. For
tolerance of the patient. Nutrition intravenous lipids the upper
• Oral diet shall be preferred over support should begin as soon as the recommendation is 1 g/kg body
patient is hemodynamically stable. weight/day with a tolerance up to 1.5
Enteral Nutrition or Parenteral g/kg/day. Do not overfeed the
• Critically ill patients who are patient. Once stable, energy
Nutrition in critically ill patients injured, septic, or bedridden may requirements may be estimated at
not gain weight, lean body mass, or >30 kcal/kg. Parenteral nutrition
who are able to eat, and if not strength as expected until the should be initiated with a low
source of hyper metabolism is dextrose infusion rate. Insulin should
possible, initiate early enteral treated or corrected and physical be administered to maintain blood
therapy or exercise is begun. glucose levels at desirable levels. In
nutrition and if possible within 48 some cases, continuous insulin
• In unstable and complex ICU infusion may be useful.
hours. • In case of patients, particularly in those
suffering from liver and renal Protein : For the unstressed adult
contraindications to oral and Enteral failure, parenteral glutamine – patient with adequate organ function
dipeptide(GNL) shall not be requiring nutrition support, 1.3 g/kg/
Nutrition, Parenteral Nutrition administered .Antioxidants as high day-1.5g/kg/day may be adequate.
dose monotherapy should not be Requirements may rise with
should be initiated within three to administered without proven metabolic demands to levels of about
deficiency. To enable substrate 2 g/kg/day.
seven days .To avoid overfeeding, metabolism, micronutrients (i.e.
trace elements and vitamins) Micronutrients : Micronutrient
early full Enteral Nutrition and should be provided daily with needs are elevated during acute
Parenteral Nutrition. illness .Mineral and electrolyte
Parenteral Nutrition shall not be requirements are determined and
• Enteral Nutrition should be delayed adjusted individually.
used in critically ill patients but if there is uncontrolled shock,
hypoxemia, hypercapnia or Fluids : Fluid and electrolytes
shall be prescribed within three to acidosis upper GI bleeding, high- should be provided to maintain
output intestinal fistula or gastric adequate urine output and normal
residual volume is above 500 ml. serum electrolytes. Adjust based on

• In non-intubated patients not >>>

JULY-SEPTEMBER, 2021|CARING HEARTS|39

individual needs. Closely monitor o When using canned or dried oil, soy, canola, sunflower and corn
blood glucose and electrolytes vegetables and fruit, choose oils) rather than saturated fats (e.g.
especially the first week. varieties without added salt or found in fatty meat, butter, coconut
sugar. oil, cream, cheese, ghee and lard).
WHO Recommendation for Drink enough water every day o Choose white meat (e.g. poultry)
prevention of Covid 19 and fish, which are generally low in
o Water is essential for life. It fat, rather than red meat.
Eat fresh and unprocessed transports nutrients and compounds o Avoid processed meats because
foods every day in blood, regulates your body they are high in fat and salt.
Eat fruits, vegetables, legumes (e.g. temperature, gets rid of waste, and o Where possible, opt for low-fat or
lentils, beans), nuts and whole lubricates and cushions joints. reduced-fat versions of milk and
grains (e.g. unprocessed maize, dairy products.
millet, oats, wheat, brown rice or o Drink 8–10 cups of water every
starchy tubers or roots such as day.
potato, yam, taro or cassava), and
o Water is the best choice, but you
can also consume other drinks,

foods from animal sources (e.g. fruits and vegetables that contain o Avoid industrially produced trans
meat, fish, eggs and milk). water, for example lemon juice fats. These are often found in
o Daily, eat: 2 cups of fruit (4 (diluted in water and unsweetened), processed food, fast food, snack
servings), 2.5 cups of vegetables (5 tea and coffee. But be careful not food, fried food, frozen pizza,
servings), 180 g of grains, and 160 to consume too much caffeine, and pies, cookies, margarines and
g of meat and beans (red meat can avoid sweetened fruit juices, spreads.
be eaten 1"2 times per week, and syrups, fruit juice concentrates, Eat less salt and sugar
poultry 2"3 times per week). fizzy and still drinks as they all
o For snacks, choose raw vegetables contain sugar. o When cooking and preparing
and fresh fruit rather than foods Eat moderate amounts of fat and food, limit the amount of salt and
that are high in sugar, fat or salt. oil high-sodium condiments (e.g. soy
o Do not overcook vegetables and o Consume unsaturated fats (e.g. sauce and fish sauce).
fruit as this can lead to the loss of found in fish, avocado, nuts, olive
important vitamins. o Limit your daily salt intake to less
than 5 g (approximately 1
teaspoon), and use iodized salt.

40|CARING HEARTS|JULY-SEPTEMBER, 2021

COVID-19 may need support with
their mental health and diet to ensure
they keep in good health. Seek
counseling and psychosocial support
from appropriately trained health
care professionals and also
community-based lay and peer
counselors.

o Avoid foods (e.g. snacks) that are People living with chronic illnesses Will COVID
high in salt and sugar. who have suspected or confirmed vaccines
COVID-19 may need support with provide
o Limit your intake of soft drinks or their mental health and diet to ensure long-term
sodas and other drinks that are high they keep in good health. Seek protection?
in sugar (e.g. fruit juices, fruit juice counseling and psychosocial support
concentrates and syrups, flavoured from appropriately trained health Because COVID vaccines
milks and yogurt drinks). care professionals and also have only been developed in
community-based lay and peer the past months, it’s too early
o Choose fresh fruits instead of sweet counselors. to know the duration of
snacks such as cookies, cakes and protection of COVID-19
chocolate. The influence of nutrition in the vaccines. Research is ongoing
Avoid eating out immune system has been widely to answer this question.
Eat at home to reduce your rate of reported. In addition, recent studies However, it’s encouraging that
have also highlighted the influence of available data suggest that
contact with other people and lower both, an adequate nutritional status most people who recover from
your chance of being exposed to and the appropriate intake of specific COVID-19 develop an
COVID-19. We recommend nutrients in COVID-19.Proper immune response that provides
maintaining a distance of at least 1 nutrition and hydration are vital. at least some period of
metre between yourself and anyone People who eat a well-balanced diet protection against reinfection
who is coughing or sneezing. That is tend to be healthier with stronger – although we’re still learning
not always possible in crowded social immune systems and lower risk of how strong this protection is,
settings like restaurants and cafes. chronic illnesses and infectious and how long it lasts. (WHO)
Droplets from infected people may diseases. So you should eat a variety
land on surfaces and people’s hands of fresh and unprocessed foods every
(e.g. customers and staff), and with day to get the vitamins, minerals,
lots of people coming and going, you dietary fiber, protein and
cannot tell if hands are being washed antioxidants your body needs .Drink
regularly enough, and surfaces are enough water. Avoid sugar, fat and
being cleaned and disinfected fast salt to significantly lower your risk of
enough. overweight, obesity, heart disease,
stroke, diabetes and certain types of
Counseling and psychosocial cancer.
support

While proper nutrition and
hydration improve health and
immunity, they are not magic bullets.

JULY-SEPTEMBER, 2021|CARING HEARTS|41

If you are home quarantined, stay in a well- Using disposable utensils is also a good idea. Just
ventilated room with an attached toilet make sure that the used utensils are stored
properly so that rodents don’t get to it
Listen to good music or some entertainment
activity that lifts your spirits The family member attending the person in
quarantine must wear disposable gloves and
Stay away from the rest of the family members, double masks when delivering food
especially children and elderly people
Clean your own plates and vessels
Strict hygiene measures must be followed
including wearing masks, hand sanitization and Utensils, such as spoons, plates, glasses, cups,
maintaining safe distance etc, must be washed separately with a good
washing soap
If you don’t have fever or any other illness, take
a bath every day and dress clean Drink at least 8 to 10 glasses of water every day

Must have a nutritious, balanced diet every day Drink healthy drinks especially citrus fruit juices,
such as orange or lime juice
Have foods rich in vitamin C, proteins, and
other essential nutrients Do mild exercises regularly without exerting
yourself
Make a meal schedule and stick to it
Yoga is good for your body and meditation is
One selected family member only should take good for your mind
care of the individual under home quarantine
Lie down comfortably and sleep well and long
Make sure that the family member just transfers
the food to your plate or vessels with minimal Talk to your spouse, friends and relatives
contact with either the vessels or the surfaces normally and generally, video calls are even
that you have touched better

42|CARING HEARTS|JULY-SEPTEMBER, 2021

Disinfect surfaces you touched frequently Resuming physical
and often. They include doorknobs, toilet activities after
surfaces, bed-frames, and such COVID-19 infection

If possible, start a few indoor plants or an Post COVID-19 you may feel fatigued for a few
aquarium. Both will help improve your weeks longer even after other symptoms resolve and
mental health this can make physical activity difficult.

Replace your mask with a new one every 6 At the beginning, you will only be able to do less
to 8 hours and dispose the used mask in a physical activity than before, but gradually you can
closed bin. Please make sure you cut the ear build up to do what you were doing beforehand.
handles off
You should start with low intensity activity and
Clothes must be washed separately using a gradually move towards more intense activities.
good detergent and should be sun-dried Athletes should hold off on resuming regular
training for at least 10 days from symptom onset and
If you experience any discomforting seven days from symptom resolution.
symptoms, such as cough, fever, fatigue,
dehydration, or difficulty in breathing, If you are just feeling a little more short of breath
contact your nearest healthcare centre than usual, getting tired more quickly, or cough a
immediately little, you should focus on gradually increasing the
duration of your physical activity as you get
Don’ts stronger.

Do not take any medicines without Following simple rules will help you exercise
consulting a qualified doctor. Medicines safely:
prescribed to your friend or family member
is not for you a. Always warm-up before exercising, and cool
down after exercising
Do not share your personal items, such as
drinking glasses, spoons, teacups, bedding, b. Wear loose, comfortable clothing and supportive
towels, and other items, with the rest of the shoes
family members
c. Wait at least an hour after a meal before
If you need to visit a doctor or hospital, do exercising
not use any public transport. Call a private
vehicle or an ambulance d. Drink plenty of water

Do not allow visitors to meet the home e. Avoid exercising in very hot weather
quarantined person
f. If you feel any of the following symptoms, do
Do not skip meals not exercise, or stop exercising, and contact your
healthcare professional:
Avoid frequent snacking • Nausea or feeling sick
• Dizziness or light headedness
Do not exercise if you are feeling • Severe shortness of breath
uncomfortable or experience any pain • Clamminess or sweating
• Chest tightness
Avoid eating outdoor or junk foods • Increased pain

Do not watch disturbing news on TV or JULY-SEPTEMBER, 2021|CARING HEARTS|43
social media

Do not sit and brood

Do not consume alcohol

Do not use tobacco or any intoxicants

Nutritional lentils and beans, fruit and vegetables and some foods from
Recomendations animal sources (e.g. meat, fish, eggs and milk). Drink plenty
While of water.
Recovering
From Covid 3. Eat plenty of fresh fruit and vegetables that are in season.
There is no specific fruit that has got a distinct advantage
1. Proper nutrition and hydration over the other.:
are vital. People who eat a
well-balanced diet tend to be 4. Keep salt intake to less than 5 g per day (approximately 1
healthier with stronger teaspoon):
immune systems and lower
risk of chronic illnesses and Use less salt during cooking and preparing food and use
infectious diseases. iodized salt.

2. Every day, eat a combination Check the labels on food and choose products with lower
of different foods including sodium content.
whole grains such as wheat,
maize and rice, legumes like Limit processed and prepackaged foods, which can be full
of hidden sodium

5. Those with preexisting or new onset diabetes should strictly
follow a diet recommended by the health professionals
without compromising on nutritive value.

Recommended Assessment & Testing
after Covid-19 Recovery

1. Routine laboratory testing Is not recommended for individuals who have fully recovered from a mild
COVID infection and are currently asymptomatic.

2. However, those who were admitted to hospital with moderate to severe infection and since recovered as
well as those having preexisting medical conditions, should follow their doctor’s advice regarding
further testing.

3. Laboratory tests including complete blood count, fasting blood glucose, postprandial blood glucose and
HbA1c ( in patients with diabetes ), renal and liver function tests, inflammatory markers such as CRP
and ESR, Thyroid function tests, Vitamin D , Vitamin B12 are usually performed when patients are
symptomatic after COVID. It is best to perform these tests after consulting with your doctor.

4. As COVID infection as well as some medications that are used to treat COVID can worsen preexisting
diabetes, one should carefully check their glucose values at various times of the day and manage their
glucose readings accordingly.

5. Those previously on thyroid medications also should consult their doctor and perform their thyroid
function blood tests to make sure the levels are controlled.

44|CARING HEARTS|JULY-SEPTEMBER, 2021

severe cases discharged from
hospital,” panel report explained.

Most of the post-Covid Those who are facing severe
symptoms are related to pulmonary problems such as
residual lung disorders like pneumonia, pulmonary fibrosis,
pulmonary fibrosis. Sometimes pneumothorax (air accumulates in
they may not be curable leading lung cavity), need hospitalisation,
to chronic lung diseases while others can be treated as
outpatients. If there is prolonged
diarrhoea and fever, the patients
should be hospitalised, they said.

“It was observed that three to four
weeks after recovery from Covid,
these problems, including
mucormycosis or black fungus are
occurring. At this point, we do not
know how long these post-Covid
problems will sustain,” report finds

Panel views that psychological
behaviour will impact on recovery
time. Some of them suffer from brain
fog as they cannot think logically and
they will be anxious and depressed.
According to experts, lung infections
normally lead to right heart failure
symptoms.

About 30% of people who among post-Covid cases, report says,. There are patients who are suffering
recovered from coronavirus are from post-Covid complications, but
facing post- Covid complications and Most of the post-Covid symptoms are are not seeking medical help.
most of them are those who were related to residual lung disorders like Psychological problems such as brain
severely affected and on oxygen pulmonary fibrosis. Sometimes they fog is because of long periods of
support, says an expert panel report may not be curable leading to chronic isolation during treatment and the loss
published in a National daily. lung diseases. These problems are of taste and smell for prolonged
mostly related to severe Covid cases period are also impacting their health,
Those who are coming with post- and those who were put on oxygen report added.
Covid complications are from all age support and the lung infections
groups and the problems they are normally lead to right heart failure There are chances of blood clotting
facing are related to head to toe, symptoms. (thrombosis) are also more among
including hair fall, occasional those recovered from Covid. In mild
nausea, reflux, diarrhoea and We are getting people who recovered and moderate cases as there was no
irregular heartbeat. Most important from Covid a few months ago in drop in oxygen saturation levels, post-
are psychological problems due to outpatient ward, complaining of Covid complications are very less,
hospitalisation for a long period. problems in breathing and chest pain. report observed.
Depression and anxiety are also seen Irrespective of age of patients, these
symptoms are being reported in

JULY-SEPTEMBER, 2021|CARING HEARTS|45

Dr.Danny Jose (PT) The Active Cycle of BreathingTechniques Breathe in and out gently through
Physical Therapist your nose if you can. If you cannot,
(ACBT) breathe through your mouth instead

People with a lung problems often cough and If you breathe out through your
produce more phlegm (sputum) than is usual. It mouth, purse your lips like you are
is important to remove sputum from your lungs blowing out a candle
to help you breathe more easily, prevent chest
infections and reduce bouts of coughing. Try to let go of any tension in your
Leaving sputum in your chest can make your body with each breath out
condition worse.
Gradually try to make the breaths
The Active Cycle of Breathing Techniques slower Try closing your eyes to help
(ACBT) is one way to help you to clear your you to focus on your breathing and to
sputum from your chest. ACBT is a set of relax
breathing exercises that loosens and moves the
sputum from your airways. It is very important to do breathing
control in between the more active
The ACBT exercises are breathing control, deep exercises of
breathing and huffing which are performed in a
cycle until your chest feels clear. ACBT as it allows your airway to
relax. Breathing control can also help
Breathing control you when you are short of breath or
feeling fearful, anxious or in a panic.
Breathing control is breathing gently, using as
little effort as possible. Deep breathing exercises

Take a long, slow, deep breath in,
through your nose if you can. Try to
keep your chest and shoulders
relaxed. Breathe out gently and
relaxed, like a sigh. You should do
three-five deep breaths. Some people
find it helpful to hold their breath for
about two-three seconds at the end of
the breath in, before breathing out.
Try the deep breathing exercises both
with and without holding your breath
and see which works best for you.

Huffing

A huff is exhaling through an open
mouth and throat instead of coughing.
It helps move sputum up your airways
so that you can clear it in a controlled
way.

To “huff” you squeeze air quickly
from your lungs, out through your
open mouth and throat, as if you were
trying to mist up a mirror or your
glasses. Use your tummy muscles to

46|CARING HEARTS|JULY-SEPTEMBER, 2021

help you squeeze the air out, but do 1-2 HUFF BREATHING CONTROL
not force it so much that you cause
wheezing or tightness in your chest. BREATHING 3-4 THORACIS EXPANSION
Huffing should always be followed CONTROL EXCERCISE
by breathing control.
BREATHING
There are two types of huff, which CONTROL
help to move sputum from different
parts of the lungs.

The small-long huff

This will move sputum from low 3-4 THORACIS EXPANSION
down in your chest. Take a small to EXCERCISE
medium breath in and then huff
(squeeze) the air out until your lungs and it should then clear easily. When should I do my breathing
feel quite empty.
If you are wheezing with each huff exercises?
The big-short huff
you may be huffing too hard or for too You should do your exercises when
This moves sputum from higher up in
your chest, so use this huff when it long. Make sure you do not huff too it is easiest for you to move the
feels ready to come out, but not
before. Take a deep breath in and hard and always do some breathing sputum from your chest, or if you
then huff the air out quickly. This
should clear your sputum without control after each two huffs. If you feel sputum has built up in your
coughing.
find it hard to keep your mouth and lungs. The first sign may be that you
How do I know I am huffing
correctly? throat open when huffing, you may feel more breathless or that you are

Your huff should move the sputum in find it useful to use a small tube (e.g. coughing more. It is also important
your chest by making it “rumble” or
“rattle”. This will mean you are the mouthpiece for a peak flow meter) to try and fit your breathing exercises
moving the sputum up the airways,
when practising. around your life and your daily
The Active Cycle of
Breathing When should I cough? routine, so that you are able to do
Techniques
(ACBT) is one way If huffing clears your sputum you them regularly.
to help you to clear
your sputum from should not need to cough. However if Try to avoid doing ACBT straight
your chest. ACBT it does not clear your sputum, then you after a meal.
is a set of
breathing exercises may need to. You should only cough if How long should I do ACBT for?
that loosens and
moves the sputum the sputum can be cleared easily. It is You should aim to continue your
from your airways.
very important to avoid long bouts of exercises for about 10 minutes and

coughing as these can be very tiring ideally until your chest feels clear of

and may make you feel breathless, or sputum.

make your throat or chest sore or tight. What position should I do ACBT in?

How often do I need to do ACBT? The best position for you to do the

Clearing your chest should be done ACBT in will depend on your
often enough to keep it reasonably medical condition and how well it
clear between doing the exercises. works for you. It can be done in a
sitting or a postural drainage
When you are well you may need to position, as advised by your
do ACBT only once or twice a day. physiotherapist. Whatever position
When you have more sputum, you you use, make sure you are
may need to do it more often. When comfortable, well supported and
you are unwell or have more sputum, relaxed.
you may need to do shorter and/or

more frequent sessions.

JULY-SEPTEMBER, 2021|CARING HEARTS|47

Dear Friend, since you are reading this I selected by an expert panel, is awarded the Heart
presume that you either are a Heart Care Care Foundation’s Lifetime Achievement Award.
Foundation member or a member friend has Another very important activity,
given this to you. Either way, you are very important to ‘Hrudayasangamam’ happens twice a year and its
this humble movement called Heart Care Foundation primary objective is the rehabilitation of patients
and we all are thankful for whatever help your who underwent heart surgery during the period.
valuable association can bring to the Foundation. Through general Q&A with senior doctors,
physiotherapists and dietitians, the patients are
Let me briefly explain to you the activities of the encouraged back in to normal life stream. Family
Foundation. Founded on the World Heart Day, members of the patients form an integral part of this
September 29, 2005 and inaugurated by the then get-together and the experience sharing as well as
Governor Sri. R.L Bhatia, HCF was able to the general Q&A with the experts helps them realize
successfully complete several projects related to heart that their loved one is no longer an invalid. Adding
care in Kerala. Our first project ‘Save 1000 hearts, charm to this social gathering is our ‘Social
1000 lives, 1000 families’ provided financial Excellence Award’ constituted in memory of our
assistance to over 1500 needy patients from all over founder member Mr. C V Shanmugam. Selected by
the state, without any discrimination in cast or creed. another expert panel, the awardeeis an eminent
The next program ‘Save a Life, Save a Lifetime’ personality that exceled in their respective field of
launched in 2007 has been a big hit among the activity.
corporate houses, schools and colleges and we have
conducted over 200 training sessions on Basic Life Yet another project is ongoing and is unique as well
Support–CPR and was instrumental in the installation as ambitious and will help a much larger populace,
of AED’s (Automated External Defibrillator) at many hopefully covering the entire state. Recently
prominent public centers. launched by Sri P.Sreeramakrishnan,Honorable
Speaker, Kerala Legislative Assembly,
Every World Heart Day is celebrated as the inception ‘Hridayapoorvam’, is aimed at making the general
day of Heart Care Foundation and during the very public ‘Heart care literate’, panchayath by
elegant official function each year, an eminent doctor,

48|CARING HEARTS|JULY-SEPTEMBER, 2021

panchayath. In a three phased There are many ways to actively associate
program, people of age group 30 to with Heart Care Foundation. Being a
60 will be given tests at the local labs member is the first step. Please get in
and the results will be fed in to a touch with any member or directly with
software program developed under the HCF office and they will guide you
the guidance of the HCF. The
program will analyze the cardiac risk
factor of each result and an
awareness session conducted by an
eminent cardiologist will make sure
that everyone understands their
cardiac health. Those with risks will
be advised to consult their local
physician and others will be given
general tips to keep up a healthy,
heart friendly life style. We have
selected Alangad Grama
Panchayath as the first locality for
the project and response from the
people as well as the government
agencies has been very heartening.
Hopefully, entire Kerala will soon be
Heart Care literate in a short while.

There are many ways to actively
associate with Heart Care
Foundation. Being a member is the
first step. Please get in touch with
any member or directly with the HCF
office and they will guide you.

We need your help. Let us help those
in need together.

Looking forward to your
association,

Dr. Jose Chacko Periappuram
Chairman, Heart Care Foundation

JULY-SEPTEMBER, 2021|CARING HEARTS|49

Name:................................................................................................................................................
Address: ............................................................................................................................................
Tel.No.:................................... Mobile No:............................. E-mail: .................................................

Category Of Membership: Individual Institutional Organization

Name of the institution /Organization :..................................................................................................

Address :............................................................................................................................................

.........................................................................................................................................................

Tel. No: .................................. Mobile No: ...................................... E-mail:.........................................

I Want to sponsor a poor heart patient and enclose herewith a sum of Rs. 25,000/part
thereof; and become a member of the Foundation.

I Want to be a subscriber of the quarterly health magazine ‘Caring Hearts' for 3 years
And become a member of the Foundation, by paying Rs. 1250/-

I Want to become a member of the Foundation (by donating any amount as affordable)

Please wherever applicable. cut here

Details Of payment favouring Heart Care Foundation, Kochi:
Amount (Rs) : .................................................... DD/Cheque No:........................................................
Dated: ......................................... Drawn on Bank:................................... Branch:..............................
Place & Date:................................................................. Signature: ....................................................

For Office Use only:
Membership No:

Receipt No:
Fill this coupon and post with your payment to:

Heart Care Foundation, 36/117 A 1, Second floor, Lisie Hospital Road, Kottecanal Junction, Kochi, Kerala - 682018
E-mail:[email protected], Web:www.heartcarefoundation.com
Tel: 0484-2406393, Mob: 9847006000

50|CARING HEARTS|JULY-SEPTEMBER, 2021