What is the best approach to manage symptoms of long COVID (Coronavirus disease 2019)?

Managing Long COVID Symptoms: A Multidisciplinary Approach

The best approach to manage symptoms of long COVID requires a structured, multidisciplinary framework focused on symptom-specific interventions, energy management strategies, and rehabilitation tailored to avoid post-exertional malaise, as recommended by national guidelines. 1

Understanding Long COVID

Long COVID is defined in three distinct phases:

• Acute COVID-19: Signs and symptoms for up to 4 weeks
• Ongoing symptomatic COVID-19: Symptoms from 4 weeks up to 12 weeks
• Post-COVID-19 syndrome: Symptoms persisting beyond 12 weeks not attributable to alternative diagnoses 1

Approximately 20% of people with COVID-19 experience symptoms lasting 5+ weeks, with symptoms varying widely and often fluctuating unpredictably 1.

Step 1: Energy Management and Pacing

• Implement activity pacing to prevent post-exertional malaise (PEM), which affects 75% of long COVID patients 2
• Avoid exercise that worsens symptoms - standard exercise recommendations can trigger symptom exacerbation 2
• Use cognitive pacing strategies to prevent mental exhaustion 2
• Position management for breathlessness:
  • Controlled breathing techniques (pursed-lip breathing)
  • Sitting upright to increase ventilation
  • Leaning forward with arms bracing a chair to improve ventilatory capacity 1

Step 2: Symptom-Specific Management

For Fatigue

• Carefully graded physical activity that avoids triggering PEM 2
• Consider underlying anemia and provide appropriate supplementation if present 2
• For distressing fatigue, implement structured daily routines with planned rest periods 1

For Breathlessness

• Offer chest radiograph by 12 weeks if respiratory symptoms persist 1
• Use breathing retraining techniques with support from physiotherapists 1
• For severe distressing breathlessness, consider appropriate medications 1

For Orthostatic Symptoms

• Increase salt and fluid intake (up to 2 liters daily) 2
• Consider compression garments 2
• For POTS symptoms, β-blockers may be considered 2

For Cognitive Dysfunction ("Brain Fog")

• Implement cognitive pacing strategies 2
• Use memory aids and organizational tools 3
• Avoid cognitive overexertion 2

For Pain Management

• Standard headache protocols with analgesics 2
• For cough, consider honey (for patients over 1 year) 1
• For distressing cough, consider short-term use of codeine linctus or morphine sulfate oral solution 1

Step 3: Mental Health Support

• Provide psychological first aid and stress management 2
• Consider brief psychological interventions based on cognitive behavioral therapy 2
• Validate patient experiences - many have had symptoms dismissed by healthcare providers 3
• Non-drug interventions like breathing relaxation training and mindfulness 2

Step 4: Rehabilitation and Return to Function

• Deploy multidisciplinary rehabilitation services based on local resources 1
• Physical and respiratory rehabilitation as first-line approaches 2
• Occupational therapy for return-to-work planning and daily function 3
• Speech and language therapy for those with communication difficulties 3

Common Pitfalls to Avoid

1. Dismissing symptoms as psychological - Long COVID is a recognized medical condition with physiological basis 2
2. Recommending standard exercise programs - These can worsen symptoms and trigger PEM 2
3. Failing to provide adequate mental health support - This can worsen outcomes 2
4. Overlooking alternative diagnoses - Long COVID is a diagnosis of exclusion 2
5. Neglecting to monitor for thrombotic complications in high-risk patients 2

Monitoring Progress

• Track symptom severity using validated tools 2
• Assess improvement in key symptoms (fatigue, dyspnea, cognitive function) 2
• Document persistence, pattern, and progression of symptoms 2
• Evaluate impact on quality of life and daily functioning 2

The management of long COVID requires patience and recognition that symptoms may fluctuate and persist for months. A structured approach with clear communication, validation of patient experiences, and appropriate symptom management strategies offers the best chance for improved quality of life and functional recovery 1, 3.