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Long COVID

April 18, 2022  /  Victoria Roman

Dr. Matt Taylor

Long COVID is a constellation of symptoms due to the involvement of various body symptoms in COVID patients after the acute phase. This develops after COVID pneumonia and continues for greater than 12 weeks. ​Similar symptoms have been seen with Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and Influenza (H1N1 and H7N9). Symptoms can occur in hospitalized and non-hospitalized patients.

Risk factors for persistent symptoms include comorbidities (ex. essential hypertension, diabetes, cardiovascular disease …), age > 40 years old, hospital or intensive care admission, and underlying anxiety and depression. Symptoms can involve the upper respiratory tract, cardiopulmonary, neurological and neuromuscular, musculoskeletal, gastrointestinal, neurocognitive, and psychological with fatigue being one of the most commonly reported symptoms. These symptoms are variable when initially present, the duration of symptoms, or the presence of a quiescence period. Pulmonary symptoms include cough, cardiac disease, venous thromboembolism, dyspnea, and COVID interstitial lung disease (ILD).

The mechanism of the cough is thought to be due to activation of the vagal sensory nerves which leads to a cough hypersensitivity state and neuroinflammatory events in the brain. Long-term cough occurs in 33-43% of cases at 4 weeks, 5-46% of cases at 8 weeks, and 2-17% of cases at 12 weeks. ​History and workup include any invasive maneuvers (intubation, tracheostomy) and spirometry as well as ruling out other etiologies of chronic cough. There is no specific treatment specific for COVID-associated cough but suggested remedies include honey, opioid-derived products, gabapentin, and ant muscarinic inhalers.

In a patient with sudden onset dyspnea, suggest evaluating for respiratory super-infection, VTE, and post-COVID heart failure. From a cardiovascular standpoint, left or right ventricular systolic dysfunction can occur due to myocarditis, stress-induced cardiomyopathy, or myocardial infarction. If suspecting, workup includes troponin and echocardiogram. Long-term consequences and improvement of heart failure are not well defined. Patients can also present with pericarditis which may or may not be diagnosed with an echocardiogram. One can consider MRI if the initial workup is negative and still has high suspicion.

The incidence of VTE is ~15 % of hospitalized patients, especially if either prolonged hospital stay or the ICU. Given the high incidence of PE in the hospital, these patients may be at risk of developing chronic thromboembolic pulmonary hypertension (CTEPH), but data is not currently available on the incidence of CTEPH after COVID. Development of a thrombus outside of the hospital and in follow-up is rare (0.5-2.5%).

Many patients present with unexplained dyspnea and reduced physical functioning. The severity of the illness can be measured with the post-COVID 19 functional status scale (PCFSS) or COPD assessment tools (CAT). History and workup include mMRC dyspnea scales, Nijmegen questionnaire, history of invasive maneuvers (discussed above), and fevers. Respiratory function abnormalities on pulmonary function testing most often include a reduced DLCO and reduced Maximum Inspiratory and Expiratory Pressure (MIP/MEP). Spirometry is often normal but when abnormal can present with either a restrictive (more common) or elevated TLC/FVC ratio (second most common). Arterial blood gas is often normal. Patients often have a reduced 6-minute walk test (6MWT) distance compared to healthy controls. Cardiopulmonary exercise testing data is limited but small reports suggest a decreased peak VO2, low anaerobic threshold, and a normal respiratory reserve more likely due to decreased exercise tolerance rather than underlying pulmonary disease. These patients benefit from rehabilitation, exercise, and breathing exercises with a physiotherapist.

Approximately 5% of patients with COVID are left with persistent radiographic changes. Fibrotic changes include ground-glass opacities, interstitial thickening, and traction bronchiectasis. Risk factors include male gender, age > 50 years old, the extent of damage on the initial radiographic image, and severity of the disease.

Workup includes the severity of the disease. In mild disease, consider initial outpatient evaluation within 12 weeks of discharge. Recommend a chest X-RAY. If normal, then no further workup is necessary. If abnormal chest X-RAY, then order full pulmonary function tests (PFTs) and consider CT angiography. If there are any abnormalities on the PFTs then recommend a high-resolution CT scan and consider a 6MWT test and echocardiogram with concern for interstitial lung disease or pulmonary hypertension likely due to Group 3 pulmonary hypertension or CTEPH. If patients had severe disease (ICU or medical-surgical with severe pneumonia) then consider initial outpatient evaluation within 4-6 weeks for dedicated ICU follow-up (if applicable). At 12 weeks, then order chest X-RAY and consider full PFTs, walk test, sputum sampling, and echocardiogram. If any of these are abnormal, then continue the follow-up plan stated above.

Treatment options are currently limited for COVID ILDs. In a non-fibrotic state with concern for organizing pneumonia in patients with persistent ground-glass opacities, consider steroid treatment. Data is limited to small randomized controlled trials but suggests that 10 mg of prednisone is equivalent to 40 mg for a treatment duration of 6 weeks. Treatment with steroids showed improvement in symptoms, PFTs, and 6MWT distance. Data for the use of fibrotic disease with antifibrotics in the acute and chronic phases is still pending (NCT04653831, NCT04282902, ​NT04541680, NCT04607928).

Matthew J Taylor, D.O.

Dr. Matt Taylor is a Third-Year year Fellow in the Division of Pulmonary, Critical Care, and Sleep Disorders Medicine at the University of Louisville

Medical School: Des Moines University College of Osteopathic Medicine, Des Moines, IA

Residency: University of Iowa-Des Moines/UnityPoint Health Affiliated Hospitals, Des Moines, IA

Research interests: High flow nasal cannula and infectious disease in the ICU

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categories / LL Blog Internal Medicine
tags / Long COVID