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Long Covid An Update Full Presentation Final Version
Long Covid An Update Full Presentation Final Version
6.30 – 6.45pm Welcome & Introduction - The Dr Karen McEwan, Planned Care GP
Management of Long COVID Lead, Stockport CCG
6.45 – 7pm COVID Recovery; a Respiratory Dr Vandana Gupta, Consultant Chest
Perspective Physician, Stockport FT
7pm – 7.15pm Managing Post COVID Marie Gregory, Clinical Lead
Breathlessness Physiotherapist, Stockport
Pulmonary & HF Rehabilitation
Service
7.15 – 7.30 Long COVID -19 and Fatigue Tina Betts CFS/ME Physiotherapist,
Stockport CFS/ME Service
7.30 – 7.45 Psychological Care - Recovery from Dr Paul Hood, Clinical Psychologist,
COVID-19 & Long-COVID Stockport FT
7.45 – 8pm Q&A and Close Whole Panel
Management of Long
Covid
Dr Karen McEwan
Aims and Objectives
Useful Resources
Radiological follow-up will not change management for some patients (e.g.
with severe cognitive impairment, limited life expectancy <6 months, unlikely
to be troubled with breathlessness due to severely limited mobility). These
patients should be assessed on a case-by-case basis using a patient-centred
approach focusing on symptom review and management.
PATHWAY
*Patients with COVID-19 may be at risk of
developing ILD and/or pulmonary HTN. Radiological evidence of COVID-19?
Radiological follow-up will not change CXR or CT shows classical/probable changes consistent with Patients with lobar
NO
outcomes in some, and treatment options COVID-19 AND confirmed/presumed COVID-19 consolidation on CXR should
may be limited for some patients (e.g. be followed-up with 6/52 CXR
patients with severe cognitive impairment, as per usual pathways.
patients with limited life expectancy <6 YES
months, patients unlikely to be troubled with
breathlessness due to severely limited Give safety netting advice and PIL
mobility). These patients should be assessed See GP if persistent >6 weeks, worsening, or new onset respiratory
on a case-by-case basis using a patient- symptoms (cough, breathlessness, chest pain, haemoptysis).
centred approach focusing on symptom Patient-centred symptom
review and management. review. Consider symptomatic
NO treatment. Consider referral to
Would the patient benefit from radiological follow-up?* rehabilitation.
YES
AMBER (mild/moderate COVID RED (severe COVID pneumonitis)
AMBER AND
pneumonitis)
Confirmed PE
6/52 virtual FU with respiratory. If ICU/HDU
Primary care phone call at 6 weeks admission will also have ICU FU clinic to assess
psychosocial needs and multisystem review
3/12 repeat CXR (requested on
discharge by ward team)
COVID clinic review 3/12 with repeat
CXR report reviewed by referring CXR
Consultant
NORMAL/
IMPROVED NORMAL/
PERSISTENT SIGNIFICANT PERSISTENT
IMPROVED SYMPTOMS/CXR CHANGE
ILD/PH?
CXR CHANGE
38 no
symptoms
19 SOB 2 DNA
Clinic outcomes: Long covid patients
• GP referrals
• Ongoing SOB, cough, chest pain
• Covid clinic/ Breathlessness clinic
• 10-15 patients
• PFTs normal
• CT normal so far
Long term respiratory symptoms
• ONS figures 21% symptomatic at 5 weeks and 9.9% at 12
weeks (ons.gov.uk)
• Covid symptom study app data: 4200 cases, 13.3% had
symptoms >4 weeks, 4.5% >8 weeks, 2.3% >12 weeks
(Sudre et al 2020)
• 3700 patients, international patient led study (Davis et al
2020, may have had negative test);at 7 months
- SOB 37.9%
- Cough 20.1%
- Chest pain 23.1%
NICE guidance
PFT and CT abnormalities
n Time Country Severity Findings Reference
(months)
55 3 China Mod-severe 25% PFT and Zhao et al
71% HRCT 2020
abnormality
60 3 Canada Mod-severe 58% PFT and Shah et al
55% HRCT 2020
abnormality
125 3 Netherlands 79% mod- 99% resolving Van den
severe CT changes, Borst et al
16% desaturate 2021
on 6MWT
350 6 China 75% severe 22% PFT and Huang et al
50% HRCT 2021
abnormality
• Increased coagulopathy in hospitalised
patients
• Increased arterial and venous thrombosis in
severe and non severe disease
• Microthrombi seen in lungs, heart, liver and
kidney
• CTPA can miss small vessel/subsegmental PE
• Recommend perfusion imaging (V:Q, dual
energy CT)
MR abnormalities
• Unpublished data (COVERSCAN, Dennis et al
2021)
-201 patients (Oxford/London)
- 18% hospitalised
- 3 months, 87% SOB
- MR scan used to diagnose organ
impairment: lungs (33%), heart (32%), pancreas
(17%), kidney (12%), liver (10%)
Xenon scans
• 40 patients
• Sheffield/Oxford
• PHOSPH-COVID (national covid follow up
study)
• Hyperpolarised xenon with MRI to identify
oxygen diffusion in alveoli
• Full results awaited
Mast cell activation syndrome (MCAS)
History ●
●
Refer on emergency basis if life threatening diagnosis considered eg acute PE/MI/arrythmia
Consider other causes eg fatigue, deconditioning, breathing pattern disorder/hyperventilation
●
Bibasal creps, wheeze, red flags eg clubbing, lymphadenopathy
Exam ●
●
Murmurs, oedema
Sats at rest and after exercise (if desaturates more suggestive of respiratory disease)
Investigations ECG
●
Sputum MC+S
●
●
Bloods FBC, UE, LFT, CRP, TFT, BNP, Ferritin
●
If concerns re patient can be anytime post acute illness
Clinical assessment: covid clinic
• Clinic • Differential
– - PE
History/examination
- ILD
– CXR
- Fatigue/deconditioning
– PFTS - Breathing pattern disorder
– 6MWT
– CTPA/HRCT • If investigations normal
– CPEX - Discharge and signpost
– ECHO - Refer for rehab/PARIS
- Chest physiotherapy
- Other services eg fatigue,
psychology, cardiology etc
Summary
• Radiology improves even in severe patients
• High number of patients have ongoing
respiratory symptoms
• Exclude PE/ILD
• Consider other causes and investigate as per
NICE/BTS guidance
• More research needed
Questions…….
Welcome
Patient Presentation
• Variable from person to person:
General health, hospitalised with Covid infection, pathological changes to
lung tissue, deconditioning, raised BMI
• By 6 weeks post infection, most show substantial improvement, but can take 3-
6 months to fully resolve. Beyond this: Long Covid
Post Covid breathlessness
• 14 patient referrals – direct from ITU follow up or Chest Clinic. 9 patients seen
• Required high level of input: cardiology, pain management, CFS /ME service, psychology,
GP
Pre-covid baseline
compared to post covid – No change /slight Severe
Slight /moderate decline Moderate decline
physical ability & decline decline
breathlessness.
Breathing control
• Comfortable position, relaxed shoulders.
• Hand on tummy & chest
• Steady breaths in through the nose, feel tummy rise
• Relaxed out breath out through the mouth.
Blow as you go/ Purse lip breathing – Breath out on the main effort
Pacing – Slow down, break tasks down, regular short breaks as opposed to fewer
prolonged breaks.
Other Hints and tips - cool wet flannel on cheeks and nose, fresh air,
relaxation/mindfulness, encourage staying calm/controlling anxiety
(fan therapy not recommended)
Breathlessness management
Online resources
13% of people with COVID may go on to experience symptoms 28 days post infection
Symptoms:
• Fatigue
• Neurological: Headache, brain fog, neuropathy
• CV: Shortness of breath, chest pain/ palpations / tachycardia/bradycardia
• Fever
• GI
• MSK, pain, weakness deconditioning
• ENT: Loss of smell, tinnitus,
• Psychiatric, primary? secondary? adjustment?
https://www.kcl.ac.uk/news/study-identifies-those-most-risk-long-covid
and
https://
www.nice.org.uk/guidance/ng188/resources/covid19-rapid-guideline-managing-the-longterm-effects-of-covid1
9-pdf-66142028400325
Presentation
• Expected Recovery
• Risk Factors
• Symptoms
– Fatigue
– Breathlessness and cough
– Deconditioning
• What is the CFS/ME service doing?
• Summary
Expected Recovery
Fatigue
Chronic
Fatigue
CFS
Fatigue
Fatigue-Safety Valve?
• An acute experience of exhaustion, it is a protective
response to physical and or psychological stress, and
illness.
• Resolved by rest and recovery.
• Managed by switching between activities physical
and mental
• Fatigue experience fluctuates from hour to hour, day
to day
Chronic Fatigue
Emerging Presentation
• Physical:
– Loss of muscle mass through illness,
– Deconditioning: illness behaviour/ lock-down restrictions
– Ongoing symptoms: breathlessness, cardiac….
• Cognitive:
– Cognitive processing of completing a task, e.g. going shopping, home schooling, returning to work
feels too much
– Memory and concentration
• Psychological and Emotional:
– Frustration: what is wrong with me? What have the Drs missed?
– Fear, anxiety, low mood
– Depressive symptoms
CFS
Once alternative fatigue causing COVID complications have been considered and
eliminated consider a diagnosis of Chronic Fatigue (Syndrome?)
Symptoms of CFS:
https://www.yourcovidrecovery.nhs.uk/
Breathing Problems
Once significant lung disease/damage has been excluded as causative – management can follow:
Breathlessness:
–Breathing and resting recovery positions to ease effort of breathing
–Nose and diaphragmatic breathing – breathing rhythm
–Breathing rectangle
–Relaxation
–Blow-as-you-go, pacing your breathing with activity
Cough:
may persist due to increased sensitivity throat and upper airways, remove triggers:
–Nose breath, to moisten and filter the air
–Sip water
–Suck sweets
–Relaxed breathing postures: such as forward lean sitting
–Relaxation
–Rhythmic cycles of breathing
https://www.yourcovidrecovery.nhs.uk/
Deconditioning
Deconditioned weak muscles compromise recovery, maintain breathlessness and
prevent return to normal function - encourage:
Bmj: Returning to physical activity after COVID –exercise should be undertaken with caution
https://www.bmj.com/content/372/bmj.m4721.full?ijkey=zg3oXn8zXc3doU1&keytype=ref
Service action
• Identify the need for fatigue management in an effort to minimise the
risk of developing CFS
• Service review of activity to identify if there was capacity and capability
to provide single session fatigue management /assessment and advice
• Patient information leaflet on fatigue using best available evidence,
based on PVFS
• EMIS template – ensure we captured the assessment data relevant to
the input we could deliver
• Mail shot GP to inform them of service availability
• Triage referrals – patients to be allocated to most appropriate MDT
clinician
• Single session Covid Fatigue Management
Service impact
• Evaluation of skills within the team, and understand
what skills were transferable to manage COVID fatigue;
L&D to understand Long COVID-19 and management
interventions from sources such as
– Health Education England e-learning
– RCGP Learning,
– IAPT, webinars
– BTS
• Referrals to date 26 – single session fatigue
management consultation
Findings
• Approximately 2.5 hours per patient (excluding
clinician learning)
• 4 Long COVID -19 patients diagnosed with CFS??
• Recurrent symptom presentations: chronic fatigue,
physical deconditioning, breathlessness/cough
• Complexity of symptoms - patients requiring further
support
• Service impact/data collection – supported by CFS/ME
administrator
Referral Data 28/01/21
Male: 10
Female: 15
16
14
12
10
8
Male
6 Female
0
Gender
Referral Data 28/01/21 Age
0-20: 1
21-30: 2
8 31-40: 4
41-50: 5
7
51-60: 7
6
61-70: 4
71-80: 2
5
4
0-20
3 21-30
31-40
2
41-50
51-60
1
61-70
0 71-80
Age
Referral Data 28/01/21 Referral Received
July 2020 - 1
August 2020 - 2
September 2020 - 0
12
October 2020 - 6
November 2020 - 2
10
December 2020 - 4
January 2021 - 10
8
6
Jul-20
Aug-20
4 Sep-20
Oct-20
2 Nov-20
Dec-20
Jan-21
0
Referral Received
Referral Data 28/01/21 Covid Infection
Unknown - 1
March 2020 - 6
7 April 2020 - 6
May 2020 - 4
6 June 2020 - 1
July 2020 - 0
5 August 2020 - 4
September 2020 - 1
4 October 2020 - 2
Unknown
3
Mar-20
Apr-20
2 May-20
Jun-20
Jul-20
1
Aug-20
Sep-20
0 Oct-20
COVID Infection
CFS Interventions
Summary
Dr Paul Hood
Title of Presentation goes here
Clinical Psychologist
Stockport NHS Foundation Trust
Objectives
- Fatigue
- Joint & chest pain
- Breathlessness
Community post-COVID
Relationship
Depression 20-40% Difficulties 15-25%
Sleep
Anxiety 30-50% Problems 40-60%
Adjustment
PTSD 2-5% Disorder
30-40%
Memory &
Fear of
20% 15-25%
Concentration
COVID
Hospital Discharged Pts
Interpersonal
Depression 40% Difficulties ?%
Sleep
Anxiety 33% Problems ?%
Adjustment
PTSD 20% Disorder
?%
Memory &
Fear of
30% 20-50%
Concentration
COVID
ICU-FU Pts ~3mths
Relationship
Depression 40% Difficulties 30-50%
Sleep
Anxiety 33% Problems 50-70%
PTSD Adjustment
Symptoms
15-30% Disorder
20-40%
Memory &
Fear of
30-60% Concentration
50%
COVID
Healthcare Frontline Staff
Relationship
Depression 30-50% Difficulties 29%
Fear of
COVID
50-80%
Factors
NICE guideline [NG188] COVID-19 rapid guideline: managing the long-term effects
of COVID-19. Published date: 18 December 2020
UK Government (2020). COVID-19: guidance for the public on mental health and
wellbeing.
• Bio-psycho-social approach
GP Appointments
• Open questions
• Attempt to establish rapport
• Active listening and positive regard
• Explore problems (panic, poor sleep, flashbacks, frightened to go out)
• Explore ICE (Ideas, Concerns, Expectations)
• Does patient have access to post-ICU clinic?
• Assess severity of symptoms (PHQ9 and GAD7)
• Consider physical health (e.g. diabetes control)
• Assess risk
• Reflection and summarise (e.g. memory and concentration)
• Discuss options – e.g. antidepressants and referral to psychosocial servivr
• Safety plan if required
• Book follow-up appointment if required
Service Options
Educational resources
Self-Care Signposting to activities / wellbeing
Multi-service collaboration
Complex Cases Bespoke intensive / longer term care
planning
Resources (T1)
https://www.yourcovidrecovery.nhs.uk/
SERVICE
DIRECTORY
QUICK GUIDE TO THE LOCAL SERVICE OFFER FOR
NEIGHBOURHOOD TEAMS
Resources (T2)
https://www.viaductcare.org.uk
Tel. 0161 204 4675 or Self referrer on website
www.iaptportal.co.uk/ServiceUser/SelfReferralForm.aspx
www.penninecare.nhs.uk/healthymindsstockport
Tel. 0161 204 4675 or Self referrer on website
www.stockport.nhs.uk
Tel. 0161 419 5015 SPMS@Stockport.nhs.uk
www.stockport.nhs.uk
ICU@stockport.nhs.uk Follow-up & networked service
www.penninecare.nhs.uk/stockportaccessteam
Tel. 0161 419 4678 or Referral via GP/health professionals
Any Questions?
Questions & Close