What is the approach to managing long haul COVID symptoms?

Management of Long Haul COVID Symptoms

The management of long COVID requires a systematic, symptom-based approach focusing on ruling out other conditions first, followed by targeted interventions for specific persistent symptoms to improve morbidity, mortality, and quality of life. 1

Definition and Diagnosis

Long COVID (post-COVID-19 syndrome) is defined as:

• Symptoms persisting or relapsing for more than 12 weeks after acute COVID-19 infection
• Cannot be explained by an alternative diagnosis
• May affect patients regardless of initial disease severity 1

Diagnostic Approach

1. Rule out other conditions first - Long COVID is a diagnosis of exclusion 1
2. Confirm COVID-19 association - Document prior infection (though a positive test is not required) 1
3. Assess symptom duration - Symptoms lasting >12 weeks qualify as long COVID 1

Common Symptoms and Assessment

The most prevalent symptoms include:

• Fatigue (31-58%)
• Dyspnea (24-40%)
• Cognitive impairment/"brain fog" (12-35%)
• Sleep disturbances (11-44%)
• Musculoskeletal pain (9-19%)
• Anosmia/dysgeusia (10-22%)
• Cough (7-29%)
• Chest pain (6-17%) 1

Initial Assessment

• Blood tests: Complete blood count, kidney and liver function, C-reactive protein, ferritin, B-type natriuretic peptide, and thyroid function 1
• Chest imaging: For patients with respiratory symptoms 1
• Functional testing: Exercise capacity tests (e.g., 1-minute sit-to-stand test) 1
• Autonomic testing: For postural symptoms, perform lying and standing blood pressure/heart rate recordings (3-minute active stand test) 1

Management Approach by Symptom

1. Fatigue Management

• Energy conservation strategies - Pacing activities and setting realistic goals 1
• Avoid post-exertional malaise - Carefully tailor physical activity to current tolerance 2
• Gradual return to activities - Phased approach to work or education 1

2. Respiratory Symptoms

• Breathing techniques:
  • Pursed-lip breathing: Inhale through nose for several seconds, exhale slowly through pursed lips for 4-6 seconds
  • Upright sitting to increase ventilation
  • Leaning forward with arms bracing a chair to improve ventilatory capacity 1
• Respiratory rehabilitation - Consider referral to pulmonary rehabilitation 1
• For distressing cough: Consider codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 1

3. Cognitive Symptoms ("Brain Fog")

• Cognitive rehabilitation - Memory aids and cognitive exercises 1
• Structured daily routines - Maintain consistent schedules 2
• Avoid cognitive overexertion - Similar to physical pacing 2

4. Vertigo/Dizziness

• Vestibular rehabilitation therapy combined with symptomatic treatment using meclizine (25-100 mg daily in divided doses) 3
• For persistent vertigo: Consider short course of oral corticosteroids if vestibular neuritis is suspected 3

5. Fever Management

• Hydration - Regular fluid intake (no more than 2 liters per day)
• Antipyretics - Paracetamol preferred over NSAIDs for symptom relief 1

6. Psychological Support

• Validate patient experiences - Many patients report having symptoms dismissed 2
• Address anxiety and depression - These can worsen physical symptoms 1
• Social support - Connect with patient organizations and online support groups 1

Special Considerations

Risk Factors for Long COVID

• Female sex - Approximately two-fold increased risk
• Severe acute COVID-19 - Strongest association with fatigue
• Multiple early symptoms (>5) during acute infection 1

Return to Work/Activities

• Phased return - Gradual reintroduction to work or education
• Workplace accommodations - May be necessary as symptoms can fluctuate 2
• Disability considerations - Long COVID is recognized as a potential disability under the Americans with Disabilities Act 2

Red Flags Requiring Urgent Referral

• Severe hypoxemia or oxygen desaturation on exercise
• Signs of severe lung disease
• Cardiac chest pain
• Multisystem inflammatory syndrome 1

Pitfalls to Avoid

1. Overexertion - Pushing too hard can trigger symptom relapse; 85.9% of patients experience relapses triggered by physical or mental activity 4

2. Dismissing symptoms - Long COVID is a real condition with multisystem involvement; validate patient experiences 2

3. Missing alternative diagnoses - Always rule out other serious conditions that may mimic long COVID 1

4. One-size-fits-all approach - Symptoms vary widely between patients and require tailored management 1

5. Ignoring autonomic dysfunction - Postural symptoms are common and may require specific testing and management 1

By following this systematic approach to long COVID management, clinicians can help improve outcomes and quality of life for patients experiencing persistent symptoms after COVID-19 infection.