The prevalence of Corona Virus Disease (COVID-19) is gradually reducing. However, its aftermath, the post COVID syndrome is being increasingly reported and gains the attention of clinicians in recent times. Severe acute respiratory syndrome caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) had given utmost burden to health care system worldwide [1]. With improvements in diagnostic approaches and also alongside development of conventional and alternative therapy, COVID-19 prevalence has significantly reduced [2]. When physicians and other health care workers were taking a sigh of relief, there was an increase in the visits of patients with post-COVID syndrome visiting our outpatient department (OPD). Long COVID or post COVID whose illness, clinical picture and precise definition was still lacking, known to affect the COVID survivors irrespective of age, co-morbidities and status of hospitalization. Post COVID syndrome refers to any of the persistent symptoms or complications that follows the attack of COVID-19, which usually lasts for more than 4 weeks [3]. Prevalence of long COVID was 10%-30% in patients with recent history of SARS-CoV-2 infection [4]. Studies report that most of the symptoms of post-COVID syndrome, such as fibromyalgia, fatigue, subjective fevers, headache, dyspnea, cognitive slowing, and autonomic impairment, are related to microangiopathy and endothelial injury [5]. Among these symptoms, dyspnea is the most common, with 40% of post-COVID patients experiencing it [6]. A recent meta-analysis has reported that patients experiencing post-COVID dyspnea have impaired pulmonary functions [7]. To manage post-COVID syndromes, including dyspnea requires multidimensional approach including careful history taking, symptom-oriented treatment, treatment of underlying problem and most importantly, provide with the much-needed psychological support [8]. Yoga and Naturopathy helps provide holistic care to the patients by delivering symptomatic relief, treating the root cause of the diseases (cytokine storm), and promote psychological wellbeing through yogic techniques which is also helps to manage post-COVID syndromes including dyspnea [9,10]. In Naturopathy, hydrotherapy is a treatment modality that utilizes water in its various forms, at various temperature, applied either internally or externally to provide desired physiological benefits [11,12]. Hydrotherapy interventions such as hot arm and foot bath, hot fomentation have been documented to improve pulmonary functions in patients with asthma and chronic obstructive pulmonary disease [13,14]. Hence, no studies have explored the effects of hot fomentation in patients with post-COVID dyspnea. In this case report, our aim is to investigate the immediate effects of hot fomentation on pulmonary function tests (PFT) in a patient experiencing post-COVID dyspnea.

On 13th February 2022, a 35-year-old married female patient approached the OPD with the presenting complaint of shortness of breath and tiredness over the past 3 months. She had a past history of SARS-CoV-2 infection and tested positive on May 2021. Since her prime symptom was only mild fever, headache, myalgia, and shivering, she was advised to stay in home quarantine with appropriate medications. She took medicine for a period of 7 days- Azithromycin (500 mg), Paracetamol (650 mg), and Pantoprazole. Breathlessness worsened with climbing stairs and walking over the period of last 1 month. She had no past previous history of surgery, not known case of allergy, bronchial asthma, cardiovascular diseases, diabetes mellitus-II and tuberculosis. Her appetite was good, sleep was undisturbed, diet was mixed, had normal frequency of micturition with absence of irritation and dribbling. Menstruation was normal, 4 days of bleeding in 30 days of menstrual cycle, had lower backache, pain and cramping sensation on inner thigh during menstruation. Her blood pressure was 120/80 mmHg. Pulse was 72 beats per minute, height 150 cm, weight 54 kg, and Body Mass Index 24 kg/m². She had not visited any of the physician for her post COVID dyspnea and not under any medication. After complete history taking, her final diagnosis was derived to be post-COVID breathlessness. The procedure of fomentation was informed to the patient and the intervention was delivered at the OPD of the hospital. In order to know the immediate effect of fomentation, we took PFT at baseline and immediately after the intervention.

The intervention procedure was explained to the patient and written informed consent was obtained prior to intervention. The patient was made to lie on a couch in the prone position, with the head rested on the arms. Hot water of temperature 110°F ± 2°F was filled in a rubber bag and the mouth of the bag was closed with a suitable lid and was placed directly over the interscapular region for a period of 20 minutes. The fomentation bag was covered with a woolen cloth. After 20 minutes, the hot fomentation bag was removed and a PFT was taken immediately after the removal of the application in a sitting position [15]. PFT was performed using RMS Helios 401. A spirometry was performed in a sitting position without clipping the nose. A minimum of three sessions were performed and the best of the three readings was considered for analysis. Forced vital capacity (FVC), forced expired volume in 1 second (FEV1), FEV1 to FEC ratio (FEV1/FEC), peak expiratory flow rate (PEFR), and mean forced expiratory flow during the middle half of FVC (FEF 25%-75%) were assessed using Spirometry.

Improvement in most of the assessed parameters of PFT such as FVC, FEV₁, FEF (25%-75%), and PEFR was observed after application of hot fomentation. Only FEV₁/FVC% remained unchanged after the intervention (Table 1 and Fig. 1). Though the inspiratory curve in the PFT was flat, the patient did not have any extrapulmonary issues. Qualitatively, the patient herself reported that the feeling of tightness in the chest was reduced, and she could breathe easily. This is the first-ever report on the immediate effect of hot fomentation on PFT in patient with post-COVID dyspnea is one of the uniqueness of this current case report. The available literature on appropriate management of post-COVID breathlessness is limited and physicians are looking for effective treatment modalities to improve clinical outcomes in the management of post-COVID breathlessness [16]. Hot fomentation was selected as the intervention for the ease of application and its previous documented evidence on improving pulmonary function. The possible physiological effects could be similar to that of broncho-dilator drugs, wherein hot fomentation reduces mucus accumulation and alleviate bronchospasm [17]. Stimulation of the hypothalamus through the neuronal pathway would result in increased lung activity [14,18]. Patient not reported any adverse effect during and after intervention. However, this report presented with following limitations single case report, assessed only immediate effect, and also severity of the dyspnea was not assessed by any validated tool. This particular case report would contribute to the available literature on the effective management of post-COVID dyspnea. Future randomized controlled trials with follow-up would help substantiate our observation.

Hot fomentation could be an effective complementary therapy in improving pulmonary function in patients with post-COVID dyspnea. Future experimental studies with adequate sample sizes would help substantiate our findings.

COPD, Chronic obstructive pulmonary disease; FEF, Forced expiratory flow; FEV₁, Forced expired volume in 1 second; FVC, Forced vital capacity; PEFR, Peak expiratory flow rate; PFT, Pulmonary function test; SARS-CoV-2, Severe acute respiratory syndrome coronavirus 2.

Nil.

The authors declare that they have no competing interests.

Nil.

Written informed consent was obtained from the patient for the publication of this case report.

Not applicable.

The data that support the findings of this case report is available from the corresponding author, [MK], upon reasonable request.

YC and AA gave intervention and collected data. PR wrote the original draft which was reviewed and edited by VV and MK. DB and AA carried out the clinical work and diagnostics. All authors read and approved the final manuscript.