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Persistent COVID Symptoms: Resources for Primary Care

Dr Dee Mangin

David Braley Chair in Family Medicine

@DeeMangin

mangind@mcmaster.ca

@McMasterFamMed

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Key Messages: the State of Knowledge

  • Management of post COVID is currently based on limited evidence
  • The cause is unclear
  • Up to 10% of people experience prolonged illness after covid-19
  • Many such patients recover spontaneously (slowly) with holistic support, rest, symptomatic treatment, and gradual increase in activity

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Risk Factors

  • The presence of comorbidities (e.g. obesity asthma)
  • Increased disease severity during acute infection*
  • Female sex

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*Does not mean that people without severe disease do not experience

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Acute covid-19 infection: up to 4 weeks

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Ongoing symptomatic covid-19: 4-12 weeks

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Post-covid-19 syndrome: >12 weeks (and not attributable to alternative diagnoses)

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  • Over 200 symptoms (persistent or new) see hfam.ca
  • Neuropsychiatric/cognitive symptoms
  • Physical symptoms
  • Respiratory symptoms
  • Cardiovascular/Cerebral
  • Persistent organ dysfunction
  • “Other”

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“Other” �

Most commonly reported

  • Joint and/or muscle pain 19–44%
  • Fever/chills/sweats 12–24%
  • GI symptoms (Diarrhoea, Nausea/vomiting, ↓ Appetite) 12–21%
  • Autonomic dysregulation disorder eg: POTS also noted
  • Worsening of pre-existing chronic conditions

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Into the Weeds…..

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Support

  • Recognize and validate the impact of illness on QoL
  • Peer support resources

Local patient support groups, online forums

https://www.covidlonghaulcanada.com

  • Continuity of care and a single co-ordinator
  • Longitudinal care (active follow up)

Ladd E et al Developing services for long COVID: lessons from a study of wounded healers Clin Med J Jan 2021

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  • Certainly how we think about and perceive our situation will undoubtably impact recovery
  • Calibrate expectations so they can be met (SMART)
  • Living in spite of symptoms rather than with them

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Investigations

  • Choose Wisely! Important to avoid over investigation – patients report this as a burden.

“Will this change my management / referral?”

  • Blood tests guided by symptoms (CBC, kidney and liver function tests, C‑reactive protein, and TFTs)
  • Chest imaging: In the UK NICE suggests offering a chest X-ray by 12 weeks after acute COVID-19 if the person has not already had one and they have continuing respiratory symptoms.

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Physical Symptoms / Fatigue

  • Resist pushing through fatigue.
  • Over-vigorous exercise can set back recovery.
  • Activity in manageable amounts: pacing important (Stop before overly tired)
  • Space activities through day, rest before and after
  • Consider energy “budget” idea
  • Meaningful rest

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Patient Resource CANCOV “Take Control of Fatigue” video

CANCOV “Controlling COVID Symptoms with Pacing” (written advice)

https://cancov.net/controlling-long-covid-symptoms-with-pacing/

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  • When returning to work, consider a ‘phased return to work’ to help build up slowly. Assessment may help with RTW plan

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Persistent COVID-19 olfactory disorder�

  • Maintain smoke and natural gas detectors
  • Monitor food expiration dates and nutritional intake.
  • Olfactory training (RCT):
    • Deliberately smelling rose, lemon, cloves and eucalyptus for 20 seconds each twice a day, for at least 3 months.
  • A comparative study showed no evidence of additional benefit from intranasal steroids. (Whitcroft et al JAMA 2020) 

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Respiratory Rehabilitation

  • Increasing ventilation
    • Active Cycle of Breathing techniques: Exercises that increase breathing control and support deep breathing with thoracic expansion to improve ventilation of the lower lung area. Square breathing (4-4-4-4)
    • Pursed Lip Breathing

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Education for breathlessness patient resource https://www.youtube.com/watch?v=5ux5rwDQT8U

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    • Positioning
    • Calming techniques

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Respiratory Rehabilitation

  • Returning to everyday activities - help patients to reduce avoidance as this will increase weakness
  • Physical exercise and fitness - help clients to reduce avoidance as this will increase weakness
    • Use a pulse oximeter to monitor oxygen saturation.
    • Stop physical activity /exercise when sat drops > 5-10% during exercise.
    • Start with less exercise and increase slowly (e.g. 30 seconds -1 min each time)

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Cognitive dysfunction

  • Think of it as a brain insult
  • Head injury approach of cognitive rest and pacing
  • If significant – consider driving ability

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When more is needed

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Monitoring

  • FU Minimum 2-3 monthly
  • Specific and general assessment tools

in OH guidance document (use judiciously)

  • Includes link to PCFS
  • Pulse oximetry: can be helpful in monitoring breathlessness

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Key messages

  • Most may be managed by Primary Care physicians and guided self-management
  • Little concrete or predictive data on how long it takes: most recover (slowly) not clear if all will
  • Pacing and setting “slow and low” goals initially
  • Some require multidisciplinary rehabilitation approach.

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© Mangeshig Pawis-Steckley (Woodland artist Ojibwe, Barrie, ON)

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Useful resources

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Excellent primary care doesn’t have to be elaborate

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