37
illness . However , increasing age , obesity , female sex and the need for intubation all appear to be risk factors . 5
The causes of long Covid remain unclear but current theories include an overactive immune response to the virus , ‘ pockets ’ of coronavirus that linger in the body , fluctuations in blood sugar levels and inflammation of small blood vessels in the body along with abnormal clotting events .
The symptoms vary enormously . Some studies have characterised long Covid as a fluctuating illness associated with a cough and fever , whereas others highlight chronic chest discomfort , breathlessness and neuro-cognitive difficulties . Most sufferers typically have one or more of the ‘ big four ’ symptoms of fatigue ( often severe ), breathlessness on even mild exertion , joint and chest pains , and a persistent cough . Others experience a persisting loss of taste or smell , headaches , a constantly running nose and red eyes . People also report insomnia , low mood , depression and anxiety ( including post-traumatic stress disorder symptoms , particularly in healthcare workers and carers ). 6 , 7
Clinical assessment should always start with a full history from the date of the first symptoms , along with the nature and severity of the current symptoms . Clinical testing is often not indicated ; for many patients , their blood tests and oxygen levels are normal and few , if any , abnormalities are found on
Around
15 %
progress to severe disease requiring hospital treatment , and approximately 5 % become critically ill
body scans . However , clinical tests may on occasion help to pinpoint possible causes of ongoing symptoms , and can help to exclude related conditions such as myocarditis or pulmonary embolism , as well as unrelated pathology that might otherwise be assumed to be linked to long Covid , such as diabetes , hypothyroidism , anaemia , the menopause and lung cancer . Blood tests to consider include a full blood count , kidney and liver function , C-reactive protein test , ferritin , B-type natriuretic peptide ( BNP ) and thyroid function . 8
Patients should be advised to seek medical advice if they experience worsening breathlessness , confusion , chest pains , oxygen saturation below 95 %, or unexplained focal weakness . Referral to secondary care may be indicated , depending on the clinical findings . For example , consider referral to cardiology for suspected new heart failure or myocardial infarction , and myocarditis or pericarditis ; respiratory referral for significant pneumonia or pulmonary embolism ; and neurology referral for any acute neurological event . Persisting dyspnoea or cardiac symptoms may warrant referral to pulmonary or cardiac rehabilitation clinics .
Medical management Definitive , evidence-based guidelines for the management of long Covid are still being established but most authorities currently agree on a combination of medical and selfmanagement principles .
In those with long Covid who need assessment , include a comprehensive clinical history and appropriate examination to assess physical , cognitive , psychiatric and psychological symptoms , as well as functional ability . The current NICE long Covid guidelines include the following : 2
Offer a chest X-ray by 12 weeks after acute Covid-19 if the person has not already had one and has continuing respiratory symptoms . Chest X-ray findings alone should not determine the need for onward referral , and be aware that a plain chest X-ray may not rule out lung disease . In the case of mental health concerns with post-Covid-19 syndrome , refer urgently for psychiatric assessment if they have severe psychiatric symptoms or are at risk of self-harm or suicide . Referral to an integrated multidisciplinary assessment service ( if available ) can occur at any time from four weeks after the start of acute Covid-19 , and referral should not be excluded on the absence of a positive Covid-19 test . Such ‘ long Covid clinics ’ should now be available in all Clinical Commissioning Group areas in England . NHS
England is currently setting these up for the assessment of physical and mental health symptoms and for further tests and investigations , led by a doctor . In April , NHS England chief executive Simon Stevens said there would be 83 long Covid clinics in place by the end of that month . Self-management tips include : Ask the patient to consider using a pulse oximeter daily and to seek medical advice if their oxygen saturation falls below 96 %.
Emphasise the importance of rest and relaxation , and the fluctuating nature of the condition .
Offer general health advice about the importance of a healthy balanced diet , adequate sleep , having little or no caffeine , and the avoidance of alcohol and tobacco .
Self-pacing and a gradual increase in exercise if tolerated can be advised but it should be remembered that some people with a chronic postviral condition can find this has a negative rather than a positive effect . Signpost patients to the website yourcovidrecovery . nhs . uk
Dr Roger Henderson is a GP in Dumfries and Galloway , Scotland
References
1 Zhe Xu et al . Pathological findings of Covid-19 associated with ARDS . Lancet Respir Med 2020 ; 8 ( 4 ): 420 – 422 . bit . ly / 2QWH89M 2 NICE : Covid-19 rapid guideline : managing the long-term effects of Covid-19 . London : NICE , December 2020 . nice . org . uk / ng188 3 NIHR : Living with Covid19 – Second review . March , 2021 . bit . ly / 3fj4jV4 4 ONS : Prevalence of ongoing symptoms following coronavirus ( Covid-19 ) infection in the UK : 1 April , 2021 . bit . ly / 3yyHdBv 5 Sudre C et al . Attributes and predictors of long Covid . Nat Med 2021 ; 27 ( 4 ): 626-631 . go . nature . com / 3wy9Ixh 6 Editorial . Facing up to long Covid . Lancet 2020 ; 396:1026:186 . bit . ly / 3vt4Fhu 7 Covid Symptom Study . How long does Covid-19 last ? Kings College London , 2020 . bit . ly / 3wCPDFV 8 Greenhalgh T et al . Management of post-acute Covid-19 in primary care . BMJ 2020 ; 370 : m3026 doi : bit . ly / 3hXQVay
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