The long COVID problem
A recent Australian National University study (.pdf) showed that long COVID – wherein symptoms persist beyond 12 weeks from infection – is currently occurring in around 5 per cent of all Australian COVID-19 patients. Given the high infection rate in Victoria over the past 12 months, there is likely a huge burden of illness in the community.
There is no correlation between the severity of primary infection and the likelihood of developing long COVID. Reports in The Age on 10 November 2022 and 24 November 2022 reveal hospital-based long COVID clinics are either overwhelmed or shutting down.
Long COVID is clinically no different to other post-viral syndromes with which we are familiar, and general practice is well placed to provide and coordinate clinical care for most patients.
Note: It is beyond the scope of this article to cover the pathophysiology of long COVID. Refer to articles published by the Virology Journal, Nature Immunology and the US National Library of Medicine for information on this topic.
Definitions and time frames
Here are definitions from the UK’s National Institute for Health and Care Excellence (NICE).
Acute COVID-19: signs and symptoms of COVID‑19 for up to 4 weeks. Most patients with COVID-19 recover in this time frame.
Ongoing symptomatic COVID-19: signs and symptoms of COVID‑19 from 4 weeks up to 12 weeks.
Post-COVID-19 syndrome (also known as “long COVID”): signs and symptoms that develop during or after an infection consistent with COVID‑19, continue for more than 12 weeks and are not explained by an alternative diagnosis.
Recovery time is different for everyone, but in most people symptoms resolve by 12 weeks. For those with long COVID, research published in the European Respiratory Journal finds that regardless of severity, about 75 per cent of people will recover from long COVID within 12 months. In other research, the average duration was 9 and 4 months respectively in hospitalised and non-hospitalised individuals.
Which long COVID symptoms are most common?
COVID-19 causes multisystem infection. According to the UK’s Office of National Statistics, at July 2022 the most commonly reported long-COVID symptoms were:
- fatigue (54 per cent)
- shortness of breath (31 per cent)
- loss of smell (23 per cent)
- muscle aches (22 per cent).
Other common symptoms include palpitations, chest pain, brain fog, tinnitus, headache, gastrointestinal upset, dizziness, cough, and psychological symptoms such as anxiety.
Symptoms can change over time and often fluctuate.
Simplifying the general practice approach to long COVID
General practice is well placed to manage long COVID. We are experts in multisystem care, are care coordinators, and provide holistic support and education to our patients. We have access to most of the same diagnostic services as hospitals and can mobilise a multidisciplinary team.
Here’s a simplified approach:
Make the diagnosis/exclude serious complications
While long COVID is a clinical diagnosis, we may need to rule out other pathologies. These may include complications from the primary COVID-19 infection, such as venous thromboembolism or myocarditis, exacerbations of underlying illnesses; conditions triggered by COVID-19, such as cardiac dysautonomia; or unrelated conditions. Investigate according to symptoms, if necessary (see below).
Be mindful of red flags
As is usual in clinical practice, red flags require further evaluation and referral – potentially urgently. Red flag symptoms with COVID-19 include:
- severe, new onset, or worsening breathlessness or hypoxia
- unexplained chest pain, palpitations or arrhythmias
- focal neurological signs or symptoms
- severe psychiatric symptoms including risk of self-harm or suicide
Optimise management of underlying medical conditions
For example, this may include optimising asthma or diabetes management.
Manage specific symptoms
Guidelines suggest taking a symptoms-based approach to managing specific symptoms. See the investigation framework below.
Provide education and support
This may include psychological support. A long COVID diagnosis is difficult for patients, and we are well placed to raise awareness of, and referrals to, the right education and support.
Commence rehabilitation early
This may include making a management plan with your patient and an action plan for symptom exacerbations. We can commence education about self-management, including discussing fatigue management.
Most long COVID patients benefit from allied health intervention, often through exercise physiologists, physiotherapists or psychologists. We may also need to make referrals to other medical specialists depending on symptoms and severity.
Simplified symptom-based investigation framework
After a thorough history and physical examination consider the investigations listed below.
Depending on symptoms and severity consider as basic investigations O2 saturation, FBE, UEC, LFTs, CRP, Fe, BSL, HBA1c% and TSH.
Then, consider investigations for the following symptoms:
Shortness of breath
Consider BNP, troponin, d-dimer (+/- CTPA) if concerned about myocarditis or VTE. Consider chest x-ray if symptoms persist. Spirometry is recommended in those with persisting symptoms.
Some patients may require an echocardiogram, if there are signs and symptoms of an underlying cardiac disorder such as orthopnea, elevated jugular venous pressure, peripheral oedema, inspiratory crackles, new murmurs, rubs or gallops.
A sit-to-stand test is an easy clinical test which will identify any concerning oxygen desaturation and may guide on-referral. This fact sheet (.pdf) explains how to perform a one-minute sit-to-stand test, and this video demonstration includes an interpretation guide. A sit-to-stand test is positive if O2 levels drop by 3 per cent or more.
Chest pain is a common after the acute phase of COVID-19 infection and may be either due to myalgia or non-specific inflammation. The purpose of evaluation is to rule out a cardiac cause. Investigate as for ‘shortness of breath’.
Palpitations are common after COVID-19, with as many as 10 per cent of patients experiencing palpitations. Consider ECG and Holter monitoring if clinically indicated.
Orthostatic intolerance and fatigue post COVID-19 may indicate a post viral postural orthostatic tachycardia syndrome (POTS), which may occur in up to 15 per cent of patients. This is defined as a sustained increase in heart rate of greater than 30 beats per minute within 10 minutes of standing.
You can carry out lying and standing blood pressure and heart rate recordings +/- 3-minute active stand test for orthostatic hypotension, or 10 minutes if you suspect postural tachycardia syndrome, or other forms of orthostatic intolerance. Here is a video of how to do an active stand test.
Consider other causes of fatigue such as medications, poor sleep, mood disorders, cardiopulmonary, autoimmune or endocrine causes. Basic evaluation (as above) then additional investigations as directed by symptoms. This consensus guideline may assist in directing investigations of fatigue post COVID.
Again, the guidelines suggest taking a symptom-based approach to managing symptoms. Develop a management plan with your patient and provide referrals as necessary, such as to specific medical disciplines, or allied health such as exercise physiology for exercise rehabilitation, physiotherapy, occupational therapy, dietician or psychology.
Review patients regularly to monitor new or changing symptoms. Provide a safe, patient-centred space to debrief and listen to concerns.
Most guidelines recommend referring for rehabilitation as early as possible. The guide below will help you.
Shortness of breath
Address the underlying cause, and consider physiotherapy for breathing management strategies. If severe desaturation, refer to specialist clinic. Manage persisting cough as per post-viral cough.
If chest pain is cardiac, refer. After ruling out serious cause, manage symptomatically — such as NSAIDS for musculoskeletal pain, or a bronchodilator if tightness is caused by bronchospasm.
Most can be managed conservatively, for instance with compression stockings, hydration, physiotherapy or exercise physiology. Some may require referral to specialist clinics to consider medication.
Educating about specific fatigue management strategies such as the “4P” approach (.pdf) to energy conservation – that is, planning, pacing, prioritising, and positioning – can be extremely helpful. There is currently no evidence for the use of specific pharmacologic agents in the treatment of fatigue related to COVID-19 infection. Consider referral to exercise physiology.
Support lifestyle modifications such as encouraging adequate rest, good sleep hygiene, reducing alcohol consumption, and good nutrition. Use strategies such as writing a list or plan for the day.
GPs play a key role in providing psychosocial support for patients to counter the emotional impact of long COVID. Consider referral to a psychologist or psychiatrist as needed. Be optimistic but acknowledge uncertainty.
North Western Melbourne Primary Health Network’s free CAREinMIND™ services are available for people who cannot afford (or are ineligible for) other local services and are experiencing mental health stress from mild to severe.
You (or your patient) can also contact NWMPHN’s Head to Health Victoria intake team on 1800 595 212. A trained mental health professional will help direct your patient to the best available support.
- Australian Clinical Evidence Taskforce – flowchart, care of people after COVID
- UpToDate – COVID evaluation and management of persistent symptoms after COVID
- NICE – managing the long-term effects of COVID
- Investigating fatigue – consensus guideline
- ANU – The experience of COVID-19 in Australia
- Centre for Evidence Based Medicine – the efficiency and safety of rapid exercise tests for exertional desaturation in COVID-19
- The sit stand test
- NWMPHN GP update – long-COVID management (a GP perspective)
- NWMPHN webinar (June 2022): a multidisciplinary approach to long COVID
- NWMPHN quality improvement activity: identify and manage patients with long COVID
- Post-COVID-19 – Long COVID: for the latest clinical information and local referral pathways
Information for patients
- RACGP – managing long COVID
- British Heart Foundation – long COVID
- NHS – post COVID patient information pack
Thanks to Dr Elizabeth Williams from PVH Medical for providing input to this article.