Study Assessing Vagus Nerve Stimulation in CoViD-19 Respiratory Symptoms

Vagus nerve stimulation (VNS) has an established history of reducing airway distress. VNS has
at least two mechanisms of action that may profoundly affect respiratory function in patients
with respiratory distress due to CoViD-19.

First, vagus nerve stimulation modulates bronchoconstriction, acute stimulation has
demonstrated a marked improvement in Work of Breathing (WOB) as well as Forced Expiratory
Volume (FEV1) in patients with severe respiratory distress due to airway reactivity. This
effect appears to occur via an afferent response to stimulation of the vagus nerve.

Second, and perhaps more importantly, VNS has been shown to be a potent moderator of
pathologic immune reactions, specifically suppressing pro-inflammatory cytokine levels via
activation of the Cholinergic Anti-inflammatory Pathway (CAP). VNS is currently being studied
to modulate pro-inflammatory cytokines patterns and concentrations in a variety of acute and
progressive inflammatory conditions, ranging from septic shock and asthma to stroke,
rheumatoid arthritis and Inflammatory Bowel Disease. VNS has been studied in animal models of
acute septic shock, consistently demonstrating life-saving potential. In one such study,
cecal ligation and puncture was used to induce a septic state in an animal model. VNS reduced
the expression of cytokines which was tightly associated with survival. Specifically, in
animal and human models, this neuromodulatory therapy has the capacity to reduce the
expression of inflammatory mediators, including TNF-α, IL-6 and IL-1β. These are precisely
the same cytokines which are elevated in ARDS and other inflammatory disorders. In all cases,
the therapy has shown considerable promise as a potential alternative to steroids (having
potent anti-inflammatory activity but without the adverse side effects of steroids) and
biologic therapies targeting pro-inflammatory cytokines (broadly - e.g., tofacitinib, or
specifically - e.g., adalimumab, etanercept, and infliximab).

Viral-induced acute respiratory distress syndrome (ARDS), including those caused by SARS
CoV-1 and MERS are characterized by a massive systemic pro-inflammatory state. Although a
pro-inflammatory environment is required to control the rate of infection as well as the
eradication of infected and compromised cells, the massive response to these viruses,
primarily due to leukocytes of the innate arm of the immune system, is part of the problem as
a significant number of tissues are damaged and lost secondary to the infected tissues in a
by-stander and collateral manner. A simple, drug-free approach to attenuate this systemic
inflammation would be of significant benefit to the progression of the syndrome and
potentially improve the overall recovery of the patients.

For these reasons, the investigators propose that VNS may ameliorate the over-activity of the
pro-inflammatory immune condition in CoViD-19 patients, thus conferring a superior
therapeutic option especially for elderly patients and those presenting with respiratory
illness in setting of co-morbid conditions who experience severe symptoms. These groups are
at particularly high risk of requiring mechanical ventilation, developing ARDS, experiencing
severe cytokine storm and have a higher mortality rate.

Non-Invasive Vagus Nerve Stimulation (nVNS) - Historically, VNS was delivered using implanted
signal generators coupled to leads having electrodes that wrap around the vagus nerve. The
vagus nerve is located within the carotid sheath, and thus the implantation surgery is
complicated with inherent risks, particularly in the critically ill. More recently, a
non-invasive approach to vagus nerve stimulation (nVNS) was cleared by the FDA for the acute
treatment of pain associated episodic cluster and migraine headaches and the prevention of
cluster headaches and migraine headaches. This device, gammaCore (electroCore, Inc., Basking
Ridge, NJ) is handheld and requires no surgery or implants. The device is applied by
healthcare providers or patients to the skin at the neck over the vagus nerve to deliver
periodic doses of VNS non-invasively.

With respect to bronchoconstriction, early studies demonstrated modulation of airway
reactivity in hospitalized asthmatic patients, improving various measures of airway patency.

Non-invasive VNS (nVNS) is a safe method of stimulating the vagus nerve, with minimal side
effects. It does not require surgery or an invasive procedure that would otherwise limit its
utility in the critically ill. The stimulation can be either self-administered or
administered by a health care practitioner. There are numerous studies with both implanted
and nVNS in multiple animal models and humans that have demonstrated a modulation of the
inflammatory cascade with an improvement in survival.

gammaCore® (nVNS) has been studied in approximately 2,000 patients as part of clinical trials
with an excellent safety profile. It is available through commercial insurers and the private
pay market, and is listed on the federal supply schedule available for purchase by the VA and
Department of Defense and also carries a CE mark for distribution abroad. More than ten
thousand patients have been successfully treated in the United States and abroad.

CoViD-19 Respiratory Issues Involve Virally-triggered Severe (Lethal) Cytokine Expression -
CoViD-19 (coronavirus disease 2019) is caused by SARS CoV-2 (severe acute respiratory
syndrome coronavirus 2) and is related to the coronavirus which caused SARS in 2003 (SARS
CoV-1). The virus is transmitted either through airborne droplets (e.g. coughing or sneezing)
or direct contact (e.g. through a surface containing the virus), with a mean incubation
period between 4 and 7 days (range 2 days to > 2 weeks). As of April 3, 2020, there are over
a million confirmed cases and rising with 55,000 individuals deceased to date. This gives a
current mortality rate of 5.3 %, although the base case of confirmed cases may be markedly
underestimated. Elderly and those with co-morbid conditions including heart disease,
diabetes, and asthma seem to have a higher mortality rate.

Many CoViD-19 patients experience moderate to severe respiratory symptoms, including
shortness of breath and impaired oxygen saturation. Eighty-eight percent (88%) of patients
present with respiratory symptoms. A significant and increasing number of CoViD-19 patients
require hospitalization, and progress to being intubated and/or ventilator dependent. Given
the rapid spread of this contagion, concern exists that the international healthcare systems
do not have the number of ventilators and/or ICU beds to meet the expected demand in the
coming months.

The most critically afflicted can experience pneumonia and/or ARDS. Accumulating evidence
suggests that this subgroup with severe CoViD-19 likely have a cytokine storm syndrome, a
hallmark of ARDS that includes dramatic increase in the expression of pro-inflammatory
cytokines, mainly TNF-α, IL-6 and IL-1β among others. Elevations in IL-6 seem to be a
particularly poor outcome indicator of respiratory compromise. It is believed that the
mortality of ARDS is at least partially the result of an over activity of the patient's
immune system.30 Predictors of fatality from a recent retrospective, multi-center study of
150 confirmed CoViD-19 cases in Wuhan, China, included elevated ferritin (mean 1297•6 ng/ml
in non-survivors vs 614•0 ng/ml in survivors; p<0•001) and IL-6 (p<0•0001)31, suggesting that
mortality and respiratory decompensation may be due to virally-driven hyperinflammation.

Therapies that could block the cytokine storm may help improve survival and decrease the need
for ventilator use and prolonged respiratory support. Other companies are in fact developing
pharmaceutical approaches for the treatment of cytokine storm, or plasma infusions from those
who have recovered from the virus. At this point there is no cure or vaccine for the virus
and neither is there a treatment approach to dampen the systemic inflammation.

Given the CE mark and excellent safety profile, including the twenty year history of the use
of VNS to block the over production of pro-inflammatory mediators via the CAP (cholinergic
anti-inflammatory pathway), and the lack of other effective or reasonable options during this
pandemic the investigators propose deploying gammaCore® (nVNS) devices for prophylactic use
to those who have been diagnosed as infected with the virus, but before the cytokine storm
begins to cause and/or exacerbate the severe respiratory distress syndrome. The hypothesis is
that the administration of non-invasive VNS using gammaCore®, during and following severe
infection with CoViD-19 may prevent the worsening inflammatory response and acute injury
associated, thus decreasing ventilator dependence and mortality of the virus. If utilized
early enough in the course of disease the investigators hope to reduce ventilator dependence
and improve survival with a scientifically driven safe and cost-effective approach.
Furthermore, through additional acute utility of gammaCore® (nVNS) in cases of ARDS and
cytokine storm the investigators can effectively blunt the pro inflammatory response, reduce
mortality and liberate patients from mechanical ventilation earlier which will assist in
deploying the ventilator to other patients in need during the CoViD-19 pandemic.

electroCore has designed a non-invasive vagus nerve stimulation (nVNS) device called
gammaCore®. The gammaCore® (nVNS) device is a handheld, battery-powered unit that produces a
proprietary electrical waveform in the vicinity of the vagus nerve in the neck. Each
treatment, or dose, is relatively brief (120 seconds) and the user maintains control over the
stimulation intensity.

gammaCore® is currently commercially available for the treatment of cluster and migraine
headaches, and broad safety data with thousands of patients treated in the US Europe and the
UK in both clinical trials and routine clinical care.

Treatment paradigms have been developed and tested in clinical trials to support FDA
clearance for the acute treatment of pain associated with episodic cluster and migraine
headaches, and the prevention of cluster and migraine headache. This experience demonstrates
that nVNS may be administered safely in up to 24 two-minute doses per day. The investigators
thus have data to draw on as to how to effectively stimulate the vagus nerve. Given the
multiple modes of action with blocking the CAP, and acute bronchodilatation, using a similar
treatment paradigm for a trial to evaluate nVNS treatment of ARDS is reasonable. The device
should be used both prophylactically and acutely early in the course of the disease prior to
mechanical ventilation, and once trained, treatment can be fully managed by either a
healthcare professional or the patient. If one waits until mechanical ventilation has
started, it is less likely that a therapy will be able to block the cytokine storm and
outcomes will be less profound.

With respect to the theoretical cardiac and respiratory side effects of non-invasive
treatment, historically, stimulation of the vagus nerve is associated with adverse side
effects, including bradycardia and bronchoconstriction. These effects were shown to be the
result of in discriminant stimulation of all fibers in the vagal bundle (the vagus nerve is
primarily comprised of A and C fibers), which could be avoided by specifically tuning the
electrical signals to selectively stimulate only the A fibers. This is possible because of
the difference in electric field strengths necessary to activate the different fiber types.

The intensity, pulse duration and frequency of gammaCore® (nVNS) stimulation parameters have
been optimized to induce signals in the large, myelinated Aβ fibers of the cervical branch of
the vagus nerve. Since gammaCore® activates only the low threshold afferent Aβ fibers, versus
the high threshold efferent C-fibers that innervate the heart, there is no known risk for
adverse cardiac or other systemic parasympathetic effects.

electroCore has conducted pre-clinical studies to assess the potential risk of vagus nerve
over-stimulation on the heart and airways. Several studies were conducted in beagle dogs with
hypersensitized airways (worst case for airway reactivity) at maximum stimulation output for
2 minutes. Review of heart rate and airway resistance before, during and after stimulation
indicated that there were no significant adverse changes associated with stimulation. These
results are consistent with the human clinical experience with the gammaCore® device.

Regarding the theorized mechanism of action, afferent fibers from the vagus nerve enter the
brain and synapse onto the nucleus tractus solitarius (NTS) in the brain stem , making
connections with many structures in the brain including the locus coeruleus (LC), the
periaqueductal gray (PAG) and the raphe nucleus (RN). These structures are known to control
the release of key inhibitory neurotransmitters. Numerous animal and clinical studies over
the last 25 years have implicated the activity of these structures, in particular the LC, in
the mechanism of action of VNS to inhibit seizures.

Clinical Use for Clinical Care - Given the lack of other effective and/or reasonable options
for a patient with CoViD-19 respiratory distress and the anticipated demands on our
healthcare system, considering gammaCore® (nVNS) therapy, the investigators propose, is a
reasonable approach. To achieve goal of decreasing health care burden with patient benefit of
decreasing ventilator dependency, inflammatory response and mortality, plan to use it early
in course of disease i.e. prior to severe respiratory distress and the need for mechanical
ventilation.

The presumptive mechanisms of bronchodilatation and modulation of the cytokine storm would
suggest that early intervention is ideal in improving pulmonary function and avoiding
respiratory depression.

1. Prevention. Mitigation of pro-inflammatory immunokine release would be best achieved
with two doses, consisting of a two-minute stimulation, on each side of the neck three
times a day (am, afternoon and an hour before bed). This would be a total of 6
treatments (2 stimulations x 3 times per day) of stimulation as a
prophylactic/preventive measure. This dosage is well below the known safety dosage
threshold

2. In addition, patients may receive additional treatments when experiencing acute
respiratory distress. Similarly, one treatment is two doses. Each treatment (a
two-minute stimulation on each side of the neck) is performed on the neck. If shortness
of breath (SOB) persists 20 minutes after start of first treatment, administer a second
treatment. Maximum number of treatments per day is 9. This is symptomatic control and
can be used to improve FEV1, Work of Breathing or dyspnea.