In the early days of this pandemic, every call seemed to be about fever, cough and breathlessness. Can you even remember back to when this kicked off 4 months ago and we were all gripped with the unknown and pervasive uncertainty?
But while for most of us around the UK new cases have waned, they have been replaced with another uncertainty – post-COVID syndrome. It is increasingly recognised that a subgroup of patients who survive COVID-19 have symptoms, some enduring, some intermittent, some which improve over weeks, some which still continue months after infection with no known timeframe for resolution.
In itself this is not a surprise or unique to SARS-CoV-2. The pattern of illness, recovery, then recurrence of certain features such as sweats and fatigue (often extreme) similar to experiences of patients post-Dengue fever. Persisting impact on lung function was seen with MERS and SARS – it remains unclear if the frequently seen fibrosis post-ventilation will improve in the longer term - as was post-infective fatigue.
We also should not be surprised that patients who were critically ill have long-lasting complications. Existing data shows that 10% of critically ill patients from any cause develop chronic fatigue – this could translate in to thousands of people from this pandemic.
And we shouldn’t focus solely on the physical – there is significant impact on mental health as well. Of critical care patients with ARDS at 2 years later 4 in 10 have anxiety, 3 in 10 depression and 2 in 10 PTSD. 70% in critical care have delirium in hospital, 1 in 5 still have some after 6 months, and studies have linked coronaviruses with the development of neurodegenerative disorders such as Alzheimer’s.
None of all this accounts for the elephant in the room – for all those diagnosed “clinically” in the community in the early days when there was no access to tests we simply have no idea if what we are dealing with was SARS-CoV-2. We all hoped antibody testing would provide clarity but instead it has proved another source of confusion. Post-COVID syndrome may not be covid at all in many.
So what can we do? There is no data to help us – there just hasn’t yet been enough time - thankfully first principles of good general practice can. So here’s some suggestions for managing patients with continuing symptoms:
- Keep an open mind
- Even with confirmed COVID cases, persisting or new symptoms could be something else. History remains key, examine where necessary. Target investigations based on your findings rather than testing everything – we will only dig ourselves a hole.
- NHS England/NHS Improvement have published a detailed document on how to manage hospital inpatients with their recovery after discharge, which is also applicable to community cases. This covers a wide range of physical and mental sequelae and unsurprisingly there is a strong emphasis on community care. There are some specific recommendations:
- Patients with radiological signs of COVID-19 should have a repeat CXR at 12 weeks (or 6 weeks if there’s any concern about possible lung cancer) to ensure there are not persistent changes.
- Persisting respiratory symptoms, physiological impairment or CXR abnormalities should be referred for lung function tests and CT.
- Refer for pulmonary rehab 6-8 weeks post-discharge for persistent breathlessness – there is a similar recommendation for cardiac rehab if myocardial injury.
- If a patient has persisting mental health issues signpost self-referral to IAPT services. Ideally, there should also be post-ICU-specific support from secondary care.
- Particularly for persistent breathlessness the Post-COVID Hub website, set up by Asthma UK and the British Lung Foundation, has practical tips to help patients manage and improve their symptoms.
- And for ongoing fatigue, while the debate about the best way to manage this will continue to rage, the Royal College of Occupational Therapists have published practical advice on how to manage post-COVID fatigue in a step-wise fashion.