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Fixing Your Autonomic Function in Long Covid | With Dr Boon Lim (Film 1) — Transcript

by Gez Medinger · 4,668 words · 764 segments · language en · Watch on YouTube

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0:00sorry for the radio silence the last
0:02month or two i have been rather busy
0:04writing a book anyway uh last week i had
0:07the great fortune to have a long chat
0:09with consultant cardiologist and
0:11electrophysiologist dr boon lim who is
0:13clinical lead for the imperial syncope
0:15units at hammersmith hospital if you've
0:18got a question about dysautonomia and
0:20tilt tests you really couldn't find
0:22anyone better to ask there's absolutely
0:25loads to talk about on the subject so
0:26i'm going to break it up into a trilogy
0:28of three films uh in this first film
0:31we're going to talk about dysautonomia
0:33which long-covered symptoms it can be
0:34responsible for how dr lim treats it in
0:36his clinic and what the hell is going on
0:39when we wake up in the middle of the
0:40night with a racing heart in the next
0:42film we dive into the fascinating world
0:44of tilt tests and how they give us a
0:46window into the physiology of
0:48dysautonomia what's actually involved in
0:50having one what can you learn from the
0:52results and do you actually need one to
0:54be able to get a handle on dysautonomia
0:57in the third film we're going to talk
0:58about hrv
1:00why it's so relevant for long haulers
1:02what we can do to improve it and what it
1:04means in terms of managing our symptoms
1:06and possibly even aiding recovery so
1:09could we just start with something
1:11really simple
1:12and that is to describe what
1:14dysautonomia is in simple terms so
1:17dysautonomia is a term that
1:19describes
1:21a disorder or dysfunction of the
1:23autonomic nervous system and i guess the
1:25two ways of thinking about it your
1:26autonomic nervous system is that bit of
1:28the nervous system that controls all the
1:30activities we don't consciously think
1:32about subconscious or unconscious
1:34control things like heart rate
1:36peristalsis blood pressure regulation
1:39temperature regulation
1:41and these things are normally
1:43automatically regulated quite finely so
1:47it generally isn't much of an issue now
1:50any one of us including those who don't
1:51have long cobait can have a dysautonomic
1:55uh profile for example
1:57uh after you've had a lot of alcohol say
2:00on a night out for your birthday you
2:02wake up the next morning you haven't had
2:03covet you haven't had a virus and you
2:05can feel
2:06a little bit rough and this is where
2:08things like the the kind of aura ring or
2:10your apple watch might tell you your
2:12readiness score or whatever that score
2:15is is a bit low
2:16and and so the autonomic numb system i
2:19don't want to
2:21imbue too much uh if you like illness or
2:25a a
2:26feeling that this is something that is
2:28an all-or-nothing phenomena i.e
2:30long-covered dysautonomia screwed for
2:33life
2:34it is something that that
2:36on a daily basis and sometimes even on a
2:39minute by minute basis will fluctuate
2:41and sometimes when it fluctuates in an
2:43exaggerated manner you can call that
2:45transient dysautonomia so my view is
2:48that dysautonomia is a
2:50is a fairly normal process that can hit
2:53any one of us even in the absence of a
2:55viral illness
2:56for some amount of time when there is a
2:59particular trigger and a susceptibility
3:01and of course what
3:02the viral illness does whether it's long
3:04corbett or glandular fever is it can
3:06then provoke a worsening earnings or an
3:10exaggerated
3:11autonomic uh dysfunction or autonomic
3:15nervous system
3:17that activates in in a way that causes a
3:19whole consolidation of symptoms and i'm
3:21sure we'll expand on that shortly
3:23um
3:25so i mean this is interesting because my
3:27feeling is that
3:29dysautonomia is
3:31or dysautonomia as a consequence of long
3:33covid
3:34is not something that we're necessarily
3:36going to be stuck with forever because
3:37my own experience of it and other other
3:38people i've seen is that it does
3:40fluctuate and there may be days where
3:42actually i'm quite tolerant and i can do
3:44all sorts of things on other days i
3:45couldn't do one of the things that david
3:47petrino
3:48uh said on twitter recently which i
3:50agreed with because that's my experience
3:52too is
3:53that there's almost this clunking that
3:55happens between
3:57okay function and then suddenly bang
3:59sympathetic nervous system activation
4:01and then suddenly clunk and it can clunk
4:03back again i don't know if that's
4:05sort of
4:06rather than a smooth transition between
4:09parasympathetic and sympathetic there
4:10does seem to be this dial that kind of
4:14does that is that something you've
4:16witnessed too is does that sort of ring
4:18a bell for you
4:19so i've witnessed on um
4:21both both states really and there are
4:24some patients who recognize to the hour
4:26or to the day that the symptoms started
4:29and started to get worse and oftentimes
4:32it is on the background of a significant
4:36stressful event and now when i say
4:38stress i don't mean mental stress it
4:40could be any challenge so for example if
4:43you think you're recovering from kobe
4:44three weeks have passed and you think
4:45you've got over it you go for a 5k run
4:49that could be the tipping point
4:51following which you trigger some kind of
4:53clunking as you say or a transition step
4:56which is quite a large step in your
4:58autonomic state and thereafter you find
5:00it very difficult to recover for a week
5:02or two after that 5k run and if you try
5:04another 5k run after two weeks you step
5:07down even
5:08greater so i think a lot of what you've
5:10discussed in your previous webinars jess
5:13including the pacing the recovery taking
5:15it nice and slow
5:16is part of
5:17um an intuitive body listening exercise
5:21that we need to learn and i think this
5:22is one aspect that we
5:25um don't do very well or people with
5:27long covered don't don't tend to have
5:30that intraceptive ability to recognize
5:33when they're at the incipient or
5:36threshold stage of clunking because the
5:38clunking doesn't happen just like that
5:41you need a few risk factors and
5:44certain preconditions to push you to the
5:46state at which you can clunk
5:49and then it happens you do something
5:51which it may not seem stupid at the time
5:53like going for a 5k run when you are
5:55typically going for 10k runs prior to
5:58corbett may not seem like such a big
6:00deal especially if you wake up fresh and
6:02alert good night sleep sunday morning
6:04well hydrated you do it and then you and
6:07then you you step down
6:09and then you kick yourself so
6:11uh so yeah yes is the answer but i also
6:13want to qualify that by saying
6:15that the other option is also possible
6:17that some people
6:19have a gradual deterioration in the
6:22autonomic nervous system function and i
6:24i particularly
6:26like what you've done previously in your
6:28previous webinars when you talked about
6:30the impact of previous trauma or
6:32the kind of personalities that may be
6:34susceptible to
6:35uh having a relapsing remitting long
6:38corvette experience because in my own
6:41view and experience this is something
6:42that comes across time and time again
6:44the likes of you jess who wants to push
6:46it skiing whilst recovering from long
6:49coven and seeing how far you can push it
6:51uh and i think he got away with it uh
6:53quite nicely but other people may not
6:56yes yeah and for me i wouldn't have got
6:58away with it had i not added a set of
7:00other behaviors to compensate
7:02for the activity i was doing and
7:04modifying the activity the way i was
7:05doing it so short you know 20 seconds
7:08skiing stop breathe ski a little bit
7:10further stop breathe and even only an
7:13hour in total in the day as opposed to
7:15what i would normally have done is just
7:16cane it from the top of the mountains to
7:18both the mountains that needs to be that
7:20needs to be repeated jess you need to
7:22tell people that you're not skiing eight
7:25hours like you used to yeah your skin
7:27for 20 seconds and just tell me about
7:29the breath again because that's
7:30phenomenally interesting
7:33so
7:34so basically what i try and do is i i
7:36mean skiing naturally for skiing with
7:38the group you would tend to ski
7:40a distance and then stop and wait ski
7:41distance top and weights and i was
7:43simply shortening those distances and in
7:45the points of time when i wasn't skiing
7:47i would very consciously slow my breath
7:49down and do coherence breathing you know
7:51five seconds in five seconds out
7:54and make sure i was doing that in every
7:56one two three four minute period i was
7:58waiting between each skiing segment and
7:59on every lift i was getting on suddenly
8:02now you're sitting down for five ten
8:04fifteen minutes on my entire lift i
8:06would just sit there and just focus on
8:07my breathing and try to not get sucked
8:09into the conversation that was happening
8:11around me but just focus on the
8:12breathing so again i was just calming
8:14things down
8:16in compensation for the fact that what i
8:17was doing was
8:19very stimulatory otherwise
8:21yeah so i i fully fully agree that this
8:24is the way that people should pace when
8:25they get back to exercise and
8:28um to your point earlier on when you ask
8:30me about clunking you don't always have
8:32to clunk in the wrong way in terms of
8:34sympathetic activation what you've
8:35demonstrated there is you can clunk the
8:38other way so you can you can you can
8:41automatically reset or actually
8:43recalibrate your parasympathetic nervous
8:45system and increase the expression of
8:47the vagus nerve
8:48by doing exactly what you've done a five
8:50second breath in and then a five second
8:53breath out um and on a continuous basis
8:55if you can breathe like this
8:56particularly through your nose and into
8:58your belly
8:59so this is belly breathing or
9:01diaphragmatic breathing i think it's a
9:03particularly
9:05useful way to activate the biggest and
9:07dial down the sympathetic nerve system
9:08so don't ever underestimate in fact it
9:11is crucial to the recovery of patients
9:13with long coverage to really focus on
9:15breath particularly nasal belly
9:17breathing and i think that's why some
9:19long covert recovery groups or exercises
9:22with either respiratory physio
9:24or even say
9:26the english national opera program ian
9:28o'brief have had some success
9:31some yoga
9:33some yoga studios have opened up rest
9:35recovery
9:36programs such as susie bowl and there
9:38are several other yoga programs and the
9:41focus for all these programs
9:43is centered around breath work i mean
9:46there are other things including pacing
9:48and important holistic strategies which
9:50i fully believe in but breath work is
9:52the central tenet by which you can
9:54reduce the expression of the
9:55parasympathetic surface nervous system
9:58so so another example of pacing where i
10:00do try and activate a clunk in the other
10:02direction is even sitting at home and
10:04working at my desk i'll do
10:07perhaps 40 minutes if i'm really lucky i
10:09might manage to stretch for about 40
10:10minutes at my desk and i notice at that
10:13point that my cognitive is weird i start
10:15to feel that my ability to process
10:17information becomes compromised i can go
10:19and lie down i put on my alpha stim so
10:21electrical stimulation
10:22um theory of a you know slows that long
10:25wave stimulation something like that and
10:27i'll lie down on the sofa i'll close my
10:29eyes trying to remove as much as
10:30possible do the coherence breathing and
10:32what i find often happens really quickly
10:34is i will trigger
10:36a series of very strong aggressive yawns
10:39that come through and after that
10:4110 minute period my eyes are watering
10:43the horns are attacking and that feels
10:45like it's a clunk back in the other
10:47direction back towards a parasympathetic
10:49once i've done that the heart rate's
10:51about 10 15 bpm lower
10:54and my head is clear and i can think
10:55again and i've got another 40 minutes
10:57clear and that's how i manage my working
10:59days so so can can can i can i share
11:02that um one of the things that i've
11:04always wanted to study in greater detail
11:07is the physiology of yawning
11:09because oh my goodness do we see people
11:11gone a lot during tilt particularly i
11:13mean if we have time we can talk about
11:15the tilt data which i can demonstrate
11:17your own data but
11:18the yawning that occurs in people who
11:21are not otherwise sleepy but the
11:23opposite people who are adrenergically
11:25driven or sympathetic nerve system
11:27overdrive
11:28is so marked sometimes
11:30and in the context of that of that
11:32sympathetic overdrive they start yawning
11:34and i think yawning is a very very
11:37complex physiological process
11:39and um
11:41you know the dr seuss sleep book if
11:43you've ever come across it is a great
11:45way to get your kids to sleep because i
11:47guarantee you by the time you're halfway
11:48through the book both you and your kid
11:51will have yawn at least five or
11:53a dozen times
11:55because it is that kind of looking at
11:57somebody else's yawn can trigger yawning
12:00you but in this particular case on the
12:02tilt lab and certainly what you've just
12:04described i think yawning triggers a
12:06physiological reset if you like i can't
12:09really uh prove it yet but it's
12:12something it's one of the things that i
12:13have observed as an interesting thing
12:16that's seen during tilt during synthetic
12:18there's an argument i read somewhere
12:20about how actually the process of
12:21yawning creates pressure on the vagus
12:23nerve so it's a
12:25it's a sort of an action that the body
12:26takes to try and push the body back into
12:29a parasympathetic state that was what i
12:31read and it seems to make some sort of
12:33sense right yeah so it makes sense but
12:35you know if you think about respiratory
12:37sinus arrhythmia
12:39the maximum variability in in the heart
12:42rate profile which is your respiratory
12:44sinus erythema and that's what hrv is
12:46heart rate variability
12:47is the extent that your heart rate
12:49varies between the nader the trough and
12:51the peak over a respiratory cycle so if
12:54you take a deep breath in
12:56and you take a deep breath out and you
12:58monitor your pulse either in your neck
13:00or your
13:01wrist then your audience can do that now
13:03particularly if you follow a slow
13:05cadence which is said to be a coherent
13:07breathing pattern the ideal breath as
13:09james nestor says in his book breath
13:12which is there which is there
13:15is is a phenomenal
13:18way to activate your maximum hrv
13:21training and this this we can show very
13:23clearly on tools like heart math and so
13:26this is something that
13:28actually with the bio feedback that you
13:30get and your regulation of your heart
13:32rate variability
13:33can help to activate the parasympathetic
13:35nervous system but it's often thought
13:37that it's due to the mechanisms not only
13:39pressure in the vegas but
13:41intrathoracic pressure expansion and
13:44contraction lung volume expansion and
13:46contraction
13:47and therefore the volume of blood in
13:50your heart expanding and contracting and
13:53they are very sensitive both
13:54chemoreceptors and baroreceptors but i
13:56think for yawning
13:58it's not mainly the chemoreceptor
14:00because it would take too quick for for
14:02you to change your co2 levels or oxygen
14:04levels
14:05but more like immediate stretch because
14:08the stretch receptor is quick
14:10and the stretch receptors are available
14:12for action and reaction in the lung
14:15in the aortic arch and in the bare
14:17reflex which are here and that can
14:19can be activated just like that so
14:21yawning resets those stretch receptors
14:24that then give a very complex feedback
14:26loop into the primitive brain
14:28which then alters the outputs which are
14:30vagus
14:32and sympathetic chain and depending on
14:34how much your vegas is pulsing up
14:37and down together with the sympathetic
14:39chain that dictates your hrv
14:43so it's it's complex it's wonderfully
14:46complex and i would say it's so so uh
14:49nice to see this physiology every day in
14:51in in the tilt lab uh it's just that um
14:55the too many variables
14:58when your sympathetic nervous system is
14:59yo-yoing and activating the yawn doesn't
15:01really touch it all that much so trying
15:03to demonstrate a clear delta is a bit
15:06more difficult so we need i guess more
15:08controlled conditions and it's always
15:10been one of my dreams to do a doctor
15:13sleep book tilt table
15:14test control in a normal subject to see
15:17what the physiological impact of the ion
15:19is
15:21absolutely fascinating let's say you've
15:23got two types of patients who present to
15:24you one like me who presents with this
15:27automobile but not necessarily pots and
15:29another who presents like one of those
15:31other tilt um
15:33tests you showed which have definite
15:36pots as well as dysautonomia how do you
15:38go about treating them what are the
15:40first things that you advise in terms of
15:42behavior and what do you
15:44is there anything that you go down in
15:46terms of medication
15:47so i i would suggest that
15:50there
15:51is the
15:52ability to
15:54deploy a whole lot of conservative
15:56strategies so this is my kind of website
15:58which is a moment charitably run and
16:01kind of created on a sunday morning with
16:03my co-conspirators
16:06pro bono um but uh there's one
16:09particular autonomic dysfunction sheet
16:11that you could you could download freely
16:14from from the website
16:15and um
16:17it really
16:18talks about top tips for improving
16:20autonomic dysfunction in long covet
16:22so
16:23i i don't like to start off with drugs
16:25and that much i will say i like to start
16:27off with a very clear diagnosis and
16:31i don't want to pretend that there
16:33aren't other multiple diagnosis or
16:36mechanisms for long covet that you've
16:39covered very much and very well in your
16:41other talks
16:43but if
16:45if the patient has got worsening
16:46symptoms on standing and improving on
16:49sitting
16:50and
16:51and that is a prevailing feature the
16:54palpitations and everything else we
16:55talked about
16:56then i'm going to for a moment forget
16:58about mast cell immune activation viral
17:01debris
17:02uh platelets and all this other stuff
17:04i'm gonna forget about it because if
17:06those were true
17:08then when you stand up or you sit down
17:10those mechanisms would still be at play
17:12so this is specific for the patient
17:14cohort that i'm talking about autonomic
17:16dysfunction and i recognize that this is
17:18a
17:19cohort that obviously i'm biased in my
17:21experience because when they are
17:22referred for people are suspecting it so
17:26it tends to be
17:27manifested in the tilt data
17:29but that being said
17:31that caveat being said i would say that
17:34fluid increase
17:35because most of these people have got
17:37low or low normal blood pressures
17:40uh but
17:41with the exception of the the tilts that
17:43i showed you okay yeah yeah
17:45if if you are going to be doing an
17:47activity as particularly exercising
17:49consider salt intake or consider an
17:52isotonic effervescent tablet
17:54which is the isotonic isotabs that you
17:58can put and it fizzes like a baroque
17:59dust not broken something like noon
18:01precision 1500 ors these kind of tablets
18:05consider wearing compression stockings
18:07which should be lower limb compression
18:08to the thigh or to the waist or abdomen
18:12and
18:12if you like there are consumer grade
18:14stockings sporting stockings that are
18:17pretty compressive such as skins
18:19uh but then there are
18:21there are other stockings which are
18:22medical grades such as bauerfeind
18:24sigvaris garment and these are stockings
18:27that you could wear
18:28because if you think about the
18:30physiology you're pooling blood right in
18:32your lower limbs and what you'd like to
18:33do is squeeze externally so the
18:35stockings give you some external squeeze
18:38and then the internal compression is
18:40quite helpful where
18:43you learn to perform isometric counter
18:45pressure exercises i don't know if
18:46you've ever done this js but just
18:48squeezing your glutes your quadriceps
18:50and your calves can immediately give you
18:53that boost so if you're if you're
18:54flagging a bit now jazz try and just
18:56squeeze your buttocks squeeze your
18:59halves and your and your quads you see
19:01i'm bouncing in my chair yeah and just
19:03by squeezing sometimes you see a
19:05sharpening because what you're doing is
19:07you're returning the blood
19:09parked away in the huge reservoirs which
19:11are your lower limbs
19:12back into the heart so that could work
19:15and then
19:16this is the bit that you already talked
19:18about and i'm glad you you you raised
19:20this not me slowing your breath down to
19:22five or six seconds
19:24uh in a sinusoidal pattern because then
19:26you activate or you clunk into vegas
19:29yeah um and then
19:31my view is there are two
19:33approaches one is the bottom-up approach
19:36where you engage and entrain physiology
19:38in my mind the autonomic nervous system
19:40facets
19:41of which there we said peristalsis blood
19:44pressure breathing rate temperature
19:46sweating
19:47capillary dilatation
19:49a lot of that is not under your control
19:51apart from one which is your breath
19:54so the breath i think is a very very
19:57nice shortcut or the only way in roads
20:00into the autonomic nervous system
20:03to which we can apply our own effort so
20:06physiologically we take control of our
20:08breath and we train it to the perfect
20:10breath
20:11which is five or six seconds for most
20:13people
20:14and that gives you more vagal expression
20:16but the other component that expresses
20:19higher
20:20positive autonomic balance and in
20:23particular more vegas less sympathetic
20:25is actually coupling that breath with a
20:27positive emotion or thought
20:29and the easiest to elicit would be
20:32something like gratitude but compassion
20:34love forgiveness these are also other
20:37emotions that you could you could bring
20:39into play as you're focusing on the
20:40breath
20:41and the focus on the breath without
20:44ideally any distracting thoughts about
20:46what's happening in the future or how
20:48the day is going to be or
20:50the past thoughts of anxiety is the way
20:54i think the best way to try and recenter
20:57your autonomic nervous system by
20:59yourself and this means living in the
21:01present moment and what better way as
21:03you know
21:04to be in the present moment than to just
21:06focus on the air the healing
21:08kind of nurturing air
21:11uh coming in through your nose into the
21:13deep recesses of the lungs in a six
21:15second breath and coming out
21:17so
21:18so that is my bias
21:20in terms of treatment um
21:23which is a more conservative
21:25step-wise not step-wise but a
21:27conservative
21:28lot of treatment
21:30uh there are pharmacological agents that
21:33i will use in some patients and in new
21:35jersey you hadn't
21:37if you were my patient i guess you came
21:39for a tilt but you weren't referred to
21:40me but if you were my patient i would
21:42ask you
21:43how you're getting along in day to day
21:44life
21:45and i would see you are you as a highly
21:48functioning patient when you want to be
21:50or when you're not misbehaving like
21:51going to thor park all day
21:53or skiing without a break yeah and this
21:56kind of behaviors that are necessary for
21:59enjoyment of life
22:00sometimes
22:02uh are should be forgiven by yourself
22:05yeah yeah so you you've gone to thought
22:07part don't regret a crash that you're
22:09experiencing now
22:10in fact embrace the fact that you
22:12enjoyed top part yesterday and today
22:14you'll sleep it off or rest or recover
22:17drink lots of fluids and you know what
22:19you'll be better tomorrow yeah but you
22:21have to forgive yourself and this is
22:23also part of that state that we talked
22:25about the psychological state that oh
22:27damn it i did too much and now i'm back
22:29on
22:30that is also a very autonomically
22:32uh unhelpful state of mind to be in
22:36completely agreed
22:37yeah the mindset actually affects the
22:39autonomic a lot more than we think
22:41so um
22:43that that being said jess for for you if
22:46you had done your fluid to salt your
22:48compression your mindset you didn't go
22:50to the top part every other day
22:52and you were still symptomatic then i
22:53would give you a drug to augment your
22:55blood pressure something like mediadrin
22:57which is an alpha blocker which is um
23:00something that vasoconstricts
23:02your splenic or the
23:04blood vessels in your gut or the
23:06peripheral vascular system which is your
23:09lower limbs it would constrict that
23:11return blood to your heart and improve
23:12blood volume improve blood pressure or
23:15fluid your cortisone which is a
23:17mineralocorticoid which serves to
23:19reabsorb more salt at the level of your
23:20kidney and again expanding your plasma
23:23volume and not allowing this push or
23:25this pull gravitational pull to occur
23:28so that that is what i would i would
23:30suggest um in terms of the guidance from
23:34tilt testing because the tilt testing
23:36will give me an idea whether you're low
23:38or high blood pressure if you're high
23:39blood pressure i wouldn't give you
23:40midogram if your high blood pressure is
23:43the dominant symptom and
23:45not dominant symptom but the dominant
23:47physiology together with palpitations as
23:49your dominant symptom or maybe chest
23:51pain i might give you something to slow
23:53your heart rate down
23:55so this is then guided by the tilt
23:57because i don't want to give you
23:58mediadrin your blood pressure's already
24:00high i give you propranolol which is a
24:02non-selective beta blocker in the
24:04loadout something like 10 to 20
24:05milligrams twice a day
24:07or i give you evaporating
24:09if i'm concerned that i don't want to
24:11push your blood pressure down because
24:13propane oil can reduce your blood
24:14pressure a bit but generally propanol
24:16and ivabridine
24:19and vapordine by the way is 2.5
24:21milligrams twice a day
24:22these are the drugs that we would give
24:24for patients predominantly suffering
24:26with tachycardia on standing
24:28but it can also have a very calming
24:31effect and then very interestingly uh
24:34well interesting for me is that those
24:35patients who have palpitations at night
24:38and i'm seeing quite a lot of them who
24:40describe pop stations in a day
24:42but also palpitations at night you might
24:44ask me why
24:46when you're lying flat do you activate
24:48the autonomic nervous system there's no
24:50reason for it right because you're not
24:51being tilted and you're not sleepwalking
24:54and the answer is
24:55not the answer but in my anecdotal
24:58experience i think there is a degree of
25:01overlap between the mast cell story so
25:04as i said i'm open to other theories
25:06yeah
25:07and in in the in the realm of mass cell
25:11degranulation or histamine intolerance
25:14what we get is a spontaneous
25:17release of histamines at night
25:20which may be triggered by a dream or may
25:22be triggered by just
25:25the ongoing insensible losses at night
25:27in sensible losses means when you
25:28produce urine you sweat under the sheets
25:30you're breathing you're not drinking
25:32anymore at night and so the blood
25:33pressure tends to fall triggers an
25:35autonomic nervous system surge whilst
25:38getting dehydrated mast cells suddenly
25:40degranulate because it's reached a
25:42critical point because one of the
25:43sensitizes of mast cells is a heightened
25:46sympathetic nervous system
25:48then
25:49you suddenly get a pooling like this is
25:51a clunk occurrence because it's not like
25:54gradually getting tax cut you wake up
25:57and your heart is racing those patients
25:59can do very well with a nocturnal
26:01antihistamine or even bd antihistamines
26:04and i don't mind a h1 in h2 blocker and
26:07i do prescribe that this in my practice
26:09as well with that specific syndrome
26:11profile but also if you get a rash and
26:13hives and all these other more typical
26:15features of mast cells i hope you found
26:17that discussion as enlightening and
26:19fascinating as i did
26:21next up is going to be the film on tilt
26:23tests where we go through my results as
26:26well as
26:27a healthy control and two other long
26:29haulers and see exactly what's going on
26:31in terms of malfunctioning physiology
26:34until next time
26:44you

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