Management of Post-COVID Breathlessness
For a post-COVID patient experiencing inability to take full deep breaths, initiate controlled breathing techniques including pursed-lip breathing, upright positioning with forward lean, and breathing retraining exercises as first-line management. 1
Initial Non-Pharmacological Interventions
The cornerstone of treatment for post-COVID dyspnea involves specific breathing techniques that have demonstrated effectiveness in managing breathlessness:
Positioning and Breathing Techniques
Implement pursed-lip breathing: Have the patient inhale through their nose for several seconds with mouth closed, then exhale slowly through pursed lips for 4-6 seconds, which relieves the perception of breathlessness. 1
Position the patient sitting upright: This increases peak ventilation and reduces airway obstruction. 1
Encourage forward-leaning posture: Have the patient lean forward with arms bracing a chair or knees and upper body supported, as this improves ventilatory capacity. 1
Teach shoulder relaxation: Instruct the patient to relax and drop their shoulders to reduce the hunched posture that accompanies anxiety and worsens breathlessness. 1
Breathing Retraining
Refer for breathing retraining: This helps patients regain a sense of control and improves respiratory muscle strength, ideally delivered by physiotherapists or clinical nurse specialists (can be done remotely). 1
Consider pulmonary rehabilitation: Patients with post-COVID dyspnea should participate in adapted pulmonary rehabilitation programs and physiotherapy techniques for breathing management. 2
Diagnostic Considerations
While implementing breathing techniques, assess for underlying pathology that may require specific treatment:
Rule Out Specific Pulmonary Complications
Evaluate for pulmonary fibrosis and thromboembolic disease: These specific sequelae need careful assessment and might require particular investigations and treatments. 2
Recognize that spirometry may be normal: Up to 90% of post-COVID patients with breathing difficulties have normal spirometry, yet 50% may have small airway dysfunction detectable only by specialized testing. 3
Consider chest imaging if symptoms persist: Chest x-ray or lung ultrasound may identify organizing pneumonia, fibrosis, or other structural abnormalities not apparent on physical examination. 4
Assess for Dysfunctional Breathing
Recognize dysfunctional breathing patterns: Many post-COVID patients have abnormal respiratory patterns with irregular and variable respiratory rates and/or tidal volumes, representing impaired control of breathing from CNS effects or acquired "memory" of respiratory symptoms. 5
Evaluate thoracic expansion and respiratory movements: Decreased thoracic expansion (62% of patients) and abnormal respiratory movements (58%) are common findings not detected by traditional pulmonary function tests. 6
When to Consider Pharmacological Management
Pharmacological interventions are reserved for specific situations:
For Severe, Distressing Breathlessness
Low-dose opioids may be considered: For patients with serious COVID-19 and distressing breathlessness despite optimal treatment of underlying causes, low-dose opioids (morphine sulfate immediate-release 2.5-5 mg every 2-4 hours as needed) can be used for palliative treatment. 1
Note the evidence limitation: This recommendation is based on palliative care experience rather than specific COVID-19 trials, and should be used cautiously with careful consideration of individual circumstances and risk of adverse effects. 1
Optimize Pre-existing Conditions
- Optimize COPD therapy if applicable: For patients with underlying COPD, early utilization of dual bronchodilators is appropriate, though inhaled corticosteroids should be used cautiously in the setting of recent pneumonia. 4
Common Pitfalls to Avoid
Don't dismiss normal spirometry: The absence of spirometry abnormalities does not exclude significant respiratory dysfunction in post-COVID patients. 3
Don't overlook anxiety: Severe breathlessness often causes anxiety, which then increases breathlessness further, creating a vicious cycle that breathing techniques specifically address. 1
Don't assume single etiology: Post-COVID breathlessness is highly heterogeneous—some patients have residual pulmonary disorders, others have extrapulmonary complications like reduced exercise tolerance, and many have dysfunctional breathing patterns. 2, 5
Don't delay rehabilitation: Breathing retraining and pulmonary rehabilitation should begin early rather than waiting for complete diagnostic workup, as these interventions are safe and beneficial regardless of underlying mechanism. 5
Follow-up Strategy
Close monitoring is essential: Patients should be followed to unmask interstitial lung disease that may have been present prior to COVID-19 and worsened post-infection. 4
Reassess at 3 months: Clinical symptoms often improve with radiological resolution of ground glass changes by 3 months post-infection. 4