Long COVID Guidance Focuses on Breathing Discomfort, Cognitive Symptoms

A physiatry society published two more clinical guidance statements in its series on long COVID, this time focusing on breathing discomfort and cognitive symptoms.

The American Academy of Physical Medicine and Rehabilitation previously published guidance on fatigue. These latest consensus statements on post-acute sequelae of SARS-CoV-2 infection (PASC) were also published in its journal, PM&R.

The guidance statements originate from the PASC Collaborative, a network of 34 centers that focus on treating long COVID, which includes more than 50 experts spanning various disciplines, such as physical medicine and rehabilitation, primary care, pulmonology, cardiology, and critical care medicine.

Benjamin Abramoff, MD, of the University of Pennsylvania and a co-chair of the PASC Collaborative, said physical medicine and rehabilitation specialists are an ideal specialty to create such guidance since they “have a lot of experience taking care of complex patients with multi-organ-system issues.”

“We’re used to working with larger teams to treat these complex issues,” Abramoff told MedPage Today. “PASC patients have a lot of different system involvement and you need a multidisciplinary team to optimize outcomes.”

He acknowledged that PASC can manifest as a wide-ranging constellation of symptoms, and there will be overlap between the guidance statements.

“It’s really difficult to silo fatigue, cognitive dysfunction, breathing issues, and so on,” he said. “Even though we talk about them in separate guidance statements, we refer to the others. Sometimes treating fatigue, for example, can help with some cognitive dysfunction.”

He said the guidance statements are aimed at primary care physicians and other specialists who are interested in developing centers specialized in treating PASC. Both statements offer expert consensus on how to identify and diagnose these ailments, and make treatment recommendations.

Overall, about 10% to 30% of the general post-COVID population have some form of long COVID, Abramoff added.

Breathing Discomfort Guidance

Respiratory symptoms are among the most common symptoms reported by patients with long COVID. These symptoms include shortness of breath, impaired exercise tolerance, cough, and chest pain, the guidance noted.

Generally, the severity of ongoing lung disease appears to be associated with the severity of the initial episode, according to the guidance. Patients who had mild COVID are less likely to have pulmonary function test (PFT) abnormalities or imaging abnormalities. Yet shortness of breath and breathing discomfort “remain common aspects of PASC among patients with mild acute COVID-19 and warrant close evaluation,” the guidance stated.

The guidance recommends taking pulse oximetry at rest and during ambulation. Patients with more severe impairment who have abnormal PFTs or new oxygen desaturation with exertion should be referred to a pulmonologist.

“Does the initial workup demonstrate evidence of PFT abnormalities, or objective evidence of pulmonary dysfunction? That could be considered a red flag for an additional workup or referral to a pulmonologist,” Abramoff said.

The guidance also discusses options for rehabilitation and cases in which formal respiratory or pulmonary rehabilitation would be warranted.

“For those who don’t necessarily have objective findings or for those who are more subjective in their breathing issues,” he noted, “we have some resources in terms of breathing exercises that patients can do in their own homes and some self-guided programs that can help.”

Cognitive Symptoms Guidance

Common neurological and neuropsychiatric symptoms associated with long COVID include fatigue, myalgia, headaches, sleep disturbance, anxiety, depression, dizziness, anosmia, dysgeusia, and “brain fog,” according to the guidance. Primary cognitive symptoms include deficits in reasoning, problem solving, spatial planning, working memory, difficulty with word retrieval, and poor attention.

There’s no evidence that SARS-CoV-2 infects the central nervous system (CNS), but proposed mechanisms of CNS-related pathology include increased inflammation as a result of the activation of CNS immune mediators; excessive glutamate/NMDA excitotoxicity and neurotransmitter depletion; or an unmasking of previous subclinical neurologic and neuropsychiatric impairments.

Subjective measures such as patient self-reported decreases in cognitive symptoms can be supplemented with commonly used neurocognitive assessments, including the Mini-Mental Status Exam, Montreal Cognitive Assessment, Saint Louis University Mental Status Exam, Mini-Cog, and the Short Test of Mental Status, according to the guidance.

“We don’t prescribe one specific cognitive tool or test to use,” Abramoff said. “We give options for a few different ones that can be considered.”

“The other strong consideration is that it’s important to rule out other things that can contribute to cognitive dysfunction, whether that’s impaired sleep, anxiety, depression, or pain. All of these things, if left untreated, can cause people to have worsening cognitive function,” he added.

Recommended therapies — following an individualized treatment plan — include cognitive rehabilitation; sleep interventions to improve cognitive symptoms; watching for the potential impact of medications on cognitive function (including anticholinergics, antidepressants, antipsychotics, benzodiazepines, and skeletal muscle relaxants); and behavioral health interventions if needed.