What is the initial approach to managing symptoms in patients with Long Covid (Post-Acute Covid-19 Syndrome)?

Initial Management of Long COVID (Post-Acute COVID-19 Syndrome)

The initial approach to managing Long COVID symptoms should focus on a structured multidisciplinary assessment, symptom validation, and implementation of symptom-specific management strategies with energy conservation as a cornerstone of treatment. 1, 2

Assessment and Diagnosis

• Definition: Long COVID is defined as symptoms persisting beyond 12 weeks after COVID-19 infection not attributable to alternative diagnoses 2
• Common symptoms include:
  • Fatigue (31-58% of patients)
  • Breathlessness (25-37%)
  • Chest pain (6-17%)
  • Cognitive dysfunction ("brain fog")
  • Sleep disorders
  • Anosmia/dysgeusia (13-21%) 2

Initial Investigations

1. Blood tests:

   • Full blood count
   • Kidney and liver function
   • C-reactive protein
   • Ferritin
   • B-type natriuretic peptide
   • Thyroid function 1

2. Imaging:

   • Chest radiograph by 12 weeks for persistent respiratory symptoms 2
   • Note: A normal chest X-ray does not rule out lung disease 1

3. Functional testing:

   • Exercise capacity assessment (e.g., 1-minute sit-to-stand test)
   • Record breathlessness, heart rate, and oxygen saturation during testing 1
   • For postural symptoms: 3-minute active stand test (or 10 minutes if suspecting POTS) 1

Urgent Referral Indications

Refer urgently to acute services for:

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

Management Approach

1. Symptom Validation and Support

• Listen with empathy and acknowledge impact on daily life
• Validate patient experiences to avoid feelings of dismissal 1, 2, 3

2. Self-Management Support

• Provide information on:
  • Setting realistic goals
  • Symptom tracking (diaries/apps)
  • Support groups and online resources
  • Social prescribing
  • Information about financial support and employment advice 1

3. Energy Conservation and Pacing

• Implement structured daily routines with planned rest periods
• Avoid post-exertional malaise through careful activity pacing
• Start with very gentle exercise and gradually increase as tolerated 2

4. Symptom-Specific Management

Breathlessness:

• Position management: sitting upright, leaning forward with arms braced
• Breathing retraining techniques with physiotherapy support
• Consider medications for severe distressing breathlessness 2

Cough:

• Consider honey (for patients over 1 year)
• Short-term use of codeine linctus or morphine sulfate oral solution for distressing cough 2

Fatigue:

• Structured daily routines with planned rest periods
• Careful grading of physical activity to avoid symptom exacerbation 1, 2

Cognitive symptoms:

• Cognitive pacing strategies to avoid mental overexertion 2

5. Rehabilitation Planning

• Refer to multidisciplinary rehabilitation services based on local resources
• Include physical, psychological, and psychiatric aspects in rehabilitation plan
• Focus on management of fatigue as a key component 1

Follow-up and Monitoring

• Agree on frequency of follow-up based on symptom severity
• Consider remote or in-person monitoring based on patient preference and clinical suitability
• Monitor for symptom changes and adjust management accordingly 1

Common Pitfalls to Avoid

1. Dismissing symptoms as psychological or exaggerated - Long COVID is a recognized medical condition 2

2. Recommending excessive exercise - This can trigger post-exertional malaise and worsen symptoms 2, 3

3. Fragmented care - Ensure effective information sharing between services and provide continuity with the same healthcare team when possible 1

4. One-size-fits-all approach - Symptoms vary widely between patients and require individualized management 3

5. Overlooking mental health impacts - Address psychological aspects alongside physical symptoms 1, 3

The evidence for specific pharmacological interventions for Long COVID remains limited, with current management focusing primarily on symptom-based supportive care 1, 2, 3. A multidisciplinary rehabilitation approach remains the cornerstone of management, with careful attention to energy conservation and avoiding symptom exacerbation 2, 3.