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Welcome to the Long COVID

– An Update Session.
Welcome
This session is due to commence at 6.30pm.

Long COVID – An Update

Title of Presentation goes here
Agenda
Time Session Presenter

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

• What is ”Long Covid” and who gets it

• Most common ongoing symptoms and how to
manage these:
• Respiratory
• Fatigue
• Persisting pain
• Psychological effects
• Role of primary and community care
• What resources are available and when to
refer
What is Long Covid?

The presentation and management of COVID-19 can be broken down

in to 3 main phases;
• Acute COVID-19: signs and symptoms of COVID-19 for up to 4
weeks.
• Ongoing symptomatic COVID-19: signs and symptoms of COVID-19
from 4 to 12 weeks.
• Post-COVID-19 syndrome: 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

“Long COVID” has been commonly used to describe signs and

symptoms that continue or develop after acute COVID-19. It includes
both ongoing symptomatic COVID-19 (from 4 to 12 weeks) and post-
COVID-19 syndrome (12 weeks or more).
Who gets Long Covid?
• Somewhere between 2.5 - 15% of people still symptomatic >12/52
• Factors that appear to be associated with a greater risk of suffering from
“Long COVID” appear to be:
• Increasing age
• Excess weight/ obesity
• Female gender
• Asthma
• Multiple symptoms at presentation
• BAME
• Patients may not have had a positive Covid test
• Children – approx. 750 children across GM to date
• 15% in 12-16 yr olds
• 13% in 2-11yr olds
 Symptoms can be multiple, varied and fluctuate over time

Most • Fatigue • general and post-

exertional fatigue (93%)
• Respiratory persistent SOB (81%),
Common
•
symptoms persistent cough(63%)

• Musculoskeletal • including pain & muscle

Symptoms • Neurological •
fatigue (72%)
Headaches (55%), neuro-
cognitive disorder (46%),
dizziness (46%)
• Cardiovascular • Palpitations/ arrhythmias
(42%), Postural tachycardia
• Gastrointestinal syndrome (25%)
• Nausea, bowel changes,
• General indigestion (41%)
• Persistent fever (38%),
chest pain (60%), rashes
• Metabolic (19%), anosmia (54%)
• Worsening of diabetes or
underlying metabolic
disease (20%)
• Psychiatric/
psychological • Sleep disorders and mood
changes (76%)
Role of Primary
Care
• Listen - “Finding the right GP”: shows the importance of patients being believed by their GP and shown empathy and understanding.
• Holistic, person-centred approach - perform a comprehensive clinical history and appropriate examination including:
• physical, cognitive, psychological and psychiatric symptoms, as well as functional abilities.
• Screening questionnaires such as Newcastle or Yorkshire screening questionnaires
• Exclude other pathology - eg cancer, PE, heart failure, anaemia, uncontrolled diabetes or active infection
• Signpost to appropriate resources
• online resources
• refer to specialist services
• Peer support group
• Health and wellbeing navigators
• Coding
• Acute COVID-19 infection (1325171000000109)
• Ongoing symptomatic COVID-19 (1325181000000106)
• Post-COVID-19 syndrome (1325161000000102)
Four-Tiered Approach
Fig. 2

       
Useful Resources

Patient Resources Clinician Resources

• https://www.yourcovidrecover • NICE guidance for the management of
y.nhs.uk Post COVID syndrome
• NG188
• www.longcovidkids.org
• RCGP elearning module – Post Covid
• www.longcovid.org
Syndrome
• See links on CCG website and • Ons.gov.uk - The prevalence of long
Covid Recovery template COVID symptoms and COVID-19
• Fatigue complications
• Breathing
• Exercise • Stockport CCG website – Covid
• Mental health recovery resources
• Diabetes • https://www.e-lfh.org.uk/programme
s/covid-19-recovery-and-rehabilitatio
n/
• Covid Recovery template on Emis
Covid Recovery; a Respiratory
perspective
Dr Vandana Gupta
Consultant Chest Physician
Stockport NHS Foundation Trust
 Outline
• Admissions and outcomes
• Respiratory features
• BTS guidelines
• Covid clinics
• Long term respiratory complications
• Clinical assessment
Admissions and outcomes
 Respiratory features
• Fever (83-99%)
• Cough (59-82%)
• Fatigue (44-70%)
• Anorexia (20-84%)
• SOB (31-40%)
• Myalgia (11-35%)
• Others: ansomia, loss of taste, GI, headache
https://www.who.int/publications/i/item/clinical-management-of-covid-19
• May 2020
• 20-60% SARS/MERS survivors had ILD
• May take 12 weeks for symptoms and radiology to resolve
• Increasing evidence VTE/PH with Covid-19
• Divided patients into mild-moderate and severe
• Risk of deconditioning and development of other co-morbidity eg
obesity, DM, psychological
• RAG system for triaging discharges: BTS, NHSE
• https://brit-thoracic.org.uk/about-us/covid-19-information-for-the-resp
iratory-community
/
• https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52
/2020/06/C0388-after-care-needs-of-inpatients-recovering-from-covid-
19-5-june-2020-1.pdf
Follow Up for confirmed/presumed Covid-19 patients: TRIAGE

RED patients (severe COVID

GREEN patients:
• Asymptomatic, COVID PCR
positive
• Mild symptoms, no radiological
change.
Give PIL and safety netting advice:
See GP if persistent (>6 weeks) or
progressive symptoms of cough,
breathlessness, chest pain, or
haemoptysis, or development of new
respiratory symptoms.  change/symptoms/concern.
Primary care virtual clinic 6/52
(mental health, rehab, fatigue,
nutrition, respiratory symptoms).
If PE needs 3/12 FU chest clinic.
AMBER patients (mild/moderate
COVID pneumonitis):
• Radiological evidence of COVID
infection.
• AND absence of severe features.
Give PIL and safety netting advice.
Primary care virtual clinic 6/52.
CXR 3/12 from discharge (requested
on discharge by hospital team).
Referral into Secondary Care Chest
Clinic if persistent radiological
If CXR normalised/significant
improvement discharge back to GP.
If PE needs 3/12 FU chest clinic.
pneumonitis):
• Critical Care admission.
• Required CPAP/NIV
• Required ≥ 35% oxygen (6L/min).
• Discharged with new oxygen
prescription.
• Probable/definite COVID ILD on
CT.
• Other clinical concern (referring
consultant’s discretion).
Give PIL and safety netting advice.
Referral to respiratory medicine.
6/52 telephone FU from chest clinic
3/12 clinical review in chest clinic
with CXR. ).

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

Discharge to GP PERSISTENT Refer to chest (COVID) clinic for Referral to tertiary

Discharge from Keep under
with safety SYMPTOMS clinical assessment/pulmonary services i.e.
clinic. clinical review.
netting advice function/imaging. ILD/PH
 Covid clinics….
• 117 patient episodes in Covid clinics (severe
patients, non resolving CXRs, GP referrals)
• 6 chest consultants
• 6/52 TA for severe patients with holistic
assessment (in collaboration with post ICU
clinic)
 Covid clinics…
• If the CXR has not cleared and/or the patient has ongoing
respiratory symptoms at 12 weeks we consider:
- Full pulmonary function testing
- Walk test with assessment of oxygen saturation
- Echocardiogram
- Sputum sample if expectorating for microbiological
analysis
- Assess need for referral to rehabilitation services if not
already done
- HRCT/CTPA
Male 56 : Intubated within 8 hours of Resolution at 12 weeks
admission
Clinic outcomes: severe patients
59 severe patients completed 3/12 FU

38 no symptoms

33 CXR/CT resolution

2 resolving changes

1 mild fibrosis

2 Awaiting HRCT

19 SOB

10 CXR/CT resolution

5 resolving changes

1 severe fibrosis

3 awaiting HRCT

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)

• Cough, wheeze, SOB and multisystem disease

• 17% population (undiagnosed)
• May cause severe acute Covid-19 and chronic
disease (Afrin et al 2020)
• ?role for histamine receptor antagonists/ low
histamine diet
• More research needed
Clinical assessment: primary care
History
•Exclude other causes eg asthma, CCF, malignancy, reflux, sinonasal disease, arrythmias, OSA
•Refer on emergency basis if life threatening diagnosis considered eg acute PE/MI/arrythmia
•Consider other causes eg fatigue, deconditioning, breathing pattern disorder/hyperventilation

Exam
•Bibasal creps, wheeze, red flags eg clubbing, lymphadenopathy
•Murmurs, oedema
•Sats at rest and after exercise (if desaturates more suggestive of respiratory disease)

Investigations
•CXR (doesn’t exclude lung disease if normal)
•ECG
•Sputum MC+S
• Bloods FBC, UE, LFT, CRP, TFT, BNP, Ferritin

Refer •Refer to Covid clinic at SHH if other causes excluded

•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

Managing Post Covid Breathlessness

Title of Presentation goes here
Marie Gregory
Clinical Lead Physiotherapist, Pulmonary Rehabilitation Service
Post Covid breathlessness

Patient Presentation
• Variable from person to person:
General health, hospitalised with Covid infection, pathological changes to
lung tissue, deconditioning, raised BMI

• Consider patient baseline MRC score

• Secretions /need for chest clearance: not highlighted as a significant problem

• Oxygen saturations: Desaturation on exertion not always synonymous with SOB

• 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

Post Covid Pulmonary Rehabilitation Pilot

• Band 7 Respiratory Physiotherapist, 9 hours per week (0.24 WTE)

• 14 patient referrals – direct from ITU follow up or Chest Clinic. 9 patients seen

• 40 contacts: 28 home visits – all exceeded 1hr , 12 phone calls

• Complex: pain, arthralgia, SOB, fatigue, weakness, cardiac concerns

• Required high level of input: cardiology, pain management, CFS /ME service, psychology,
GP

• Treatment offered: Up to 8 weeks of support. Exercise prescription and monitoring plus

advice and education primarily managing breathlessness and pacing. Onward referral.

Outcome/conclusion: Due to the complexity of the patients it is not possible to run

Post Covid Rehabilitation as a bolt on with ‘standard’ Pulmonary Rehabilitation.
Breathlessness management
Treatment stratification

• Focus on advice, education and self-management

• 1:1 treatment, Identified gap in primary care services

MRC 1-2 3 3-4 5

Pre-covid baseline
compared to post covid – No change /slight Severe
Slight /moderate decline Moderate decline
physical ability & decline decline
breathlessness.

Targetted information provision:

Positions of ease
General online Breathing Control
resources & self Purse lipped breathing
1:1 rehab through
Offer help: Plan pace and prioritise existing channels
My COVID recovery / Stay active - appropriate intensity
direct to PARiS
My COVID recovery
LTH covid recovery videos
WHO, ACPRC & BLF resources
Breathlessness management
Principles of Treatment

Positioning – reduces the work of breathing

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.

Rectangular breathing - Focus on extending the out breath.

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

NHS: Your Covid Recovery

https://www.yourcovidrecovery.nhs.uk/
Breathlessness management Online
resources

Lancashire Teaching Hospitals Videos:

https://covidpatientsupport.lthtr.nhs.uk/#/

British Lung Foundation:

• How to manage breathlessness
• Post Covid breathlessness helpline 0300 222 5942

Royal College of Occupational Therapists

• Energy conservation
https://www.rcot.co.uk/conserving-energy
Breathlessness Management
Printable Resources

World Health Organisation

• Support for Rehabilitation Self-management after COVID-19 Related illness
Breathlessness Management
Printable Resources

Association of Chartered Physiotherapists in Respiratory Care (ACPRC)

• How to cope with being short of breath – positions & breathing exercise
Summary plus Q&A

• Advice, education and self help

• Reassurance, realistic goals & encouraging patience
• Liaise with chest medicine if ongoing concerns/ specialist advice needed
 Welcome

Long COVID -19 Fatigue

Title of Presentation goes
Tina Betts CFS/ME Physiotherapist
here
March-April 2020

CFS/ME service: commissioned to provide fatigue management to

patients diagnosed with CFS/ME, which may include:
– Energy management -3 P’s
– Physical activity advice
– Anxiety
– Sleep
– Pain

‘mothballed’ - Team re-deployed:

– D2A
– Swabbing with DN
– COVID Hub Patient Liaison
Long COVID

Long COVID-19 as defined:

‘’Signs and symptoms that develop during or following an

infection consistent with COVID 19 which continue for more
than 12 weeks and are not explained by an alternative
diagnosis’’
‘’it usually presents with clusters of symptoms, often
overlapping, which can fluctuate and change over time and
can affect any system of the body’’
NICE/SIGN/RCGP
Post Intensive Care
Syndrome
Post Intensive Care Syndrome.
Long COVID is not PICS:
• ICU aquired weakness (ICUAW)
• Cognitive dysfunction: memory and
concentration
• Psychological problems: trauma
• Other: post intubation and catheterisation
problems, sleep disruption
Specialist rehabilitation required.
Symptoms
Results from The Kings College: COVID Symptoms Study App:

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

• 4 weeks: reduction in muscle aches, chest pain, and

sputum production
• 6 weeks: cough and breathlessness substantially reduced
• 3 months: most symptoms resolved – fatigue may persist
• 3 months + Unresolved S&S consistent with COVID: post-
COVID syndrome (LONG COVID -19)
• 6 months: resolution of symptoms – unless complications
of ITU admission
Ref: RCGP Recovery from COVID 19
Risk Factors

• Increase with age

• Slight increased risk females to males; and
• Multisystem involvement in the first week of the illness
• BMI
Summary: looking at the age of an individual and the
number of symptoms experienced in the first week can
be a reliable predictor of who might go on to develop
Long COVID -19
Interventions
Symptoms of:
• Fatigue
• Breathlessness
• Cough
• Deconditioning

One-Stop place for sign-posting patients Your COVID Recovery Self-Help:

https://www.yourcovidrecovery.nhs.uk/

E-learning Professional Education:

https://
portal.e-lfh.org.uk/myElearning/Catalogue/Index?HierarchyId=0_45016&program
meId=45016
COVID 19 Recovery and Rehabilitation modules can be accessed without enrolment
Fatigue

Fatigue is reported to be one of the most consistent and

persistent symptoms people experience following COVID
infection, implications of unresolved fatigue:
• Physical: reduction in physical activity
• Sensory: experiencing aches/pains and hypersensitivity
• Function: reduction in function capabilities, may delay or
prevent return to work, or normal functional activities
• Psychological: frustration-worry-anxiety-depression
• Cognitive function: memory/ concentration
• Social and personal relations
Causes of Fatigue

Exact causes are unclear, contributing factors:

• Muscle weakness/deconditioning following period of illness
• Routine disruption: sleep, diet, work
• Worry-fear-anxiety-stress-depression
• Immune system: cytokines/mast cell activation syndrome
• Co-existing health problems
• High expectations

Persistent fatigue continuing past the ‘infective’ period is a

feature of COVID
Fatigue progression

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:

 Post exertional malaise (PEM)

 Fatigue that substantially reduces normal activity levels
 Muscle weakness
 Feeling dizzy or light headed, needing to sit or lie down more frequently
 Needing to rest or sleep more – unrefreshed sleep
 Altered mood: low mood and motivation
 Cognitive disturbances: brain fog, poor memory and poor information processing
Other unexplained symptoms
Management

 Re-assure – normal for fatigue after viral infection

 Routine
 Gentle activity within self assessed limitation
 Rest and Sleep
 Hydration and nutrition
Adobe Acrobat

 Patient Information Leaflet Fatigue Document

 Referral to CFS/ME single session of fatigue management

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:

– Physical activity through ADL

– Exercise: Is the individual safe and ready for exercise? Exclude significant
conditions that would contraindicate exercise
NHS website 
https://www.nhs.uk/live-well/exercise/flexibility-exercises/ OR
Referral to Life Leisure: https://www.lifeleisure.net/
– Nutrition
https://www.nhs.uk/live-well/eat-well/

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

• Fatigue: Energy management, 3 P’s: plan, prioritise and pace,

rest and more….
• Breathlessness: anxiety, dysfunctional breathing pattern and
muscle weakness, (excluding complications related to cardiac,
respiratory, renal and skeletal muscle), relaxed breathing
techniques, positions for breath control, diaphragmatic
breathing, teach nose breathing and pursed-lip breath control
• Physical activity: ADL or exercise prescription
• Other: diet, mental health, sleep
Intervention

Early days Active Intervention 6 weeks + PVFS? 3-6 Months

Advice on self help 6 weeks + Chronic fatigue?
Advice: Advice: Advice: Advice:
 Re-assure  Re-assure,  Energy  Rest
 Routine acceptance of good Conservation –  Routine
 Gentle activity and bad days Plan, Prioritise and  Encourage
 Rest and Sleep  Rest and Sleep Pace -Pleasure functional physical
 Hydration and  Routine  Rest activity, avoid
nutrition  Activity  Routine exercise
 Hydration and  Gentle activity  Avoid stressful
https://www.yourcovidr nutrition within self- situations
ecovery.nhs.uk/   assessed  meassociation.org.uk/
Single fatigue limitations  
PIL COVID Fatigue management  Delay return to Refer to CFS/ME Service
consultation –CFS/ME work?  
  Service Single fatigue
management
consultation
Adobe Acrobat
Document
Discharge

In practice this is communication back to GP:

• Communicate assessment completed and the advice or
intervention given see EMIS
• Report on identified symptoms such as deconditioning,
breathlessness or mental health
• Suggestions for further investigation if concerns are
raised
Referral to: Life Leisure, Healthy Minds, or
Signposting to self-help supports such a Your Covid
Recovery
Useful things
• COVID related fatigue - validate the
symptoms, re-assurances, normalisation -
fatigue is normal following viral illness.
Encourage routine, rest, nutrition and
convalescence – not so fashionable these days
• Signpost – Your COVID Recovery and PIL
Fatigue
https://www.yourcovidrecovery.nhs.uk/
To conclude: Advice
• Self help: https://www.yourcovidrecovery.nhs.uk/
• Re-assurance, Energy Conservation, nutrition and sleep:
https://www.actionforme.org.uk/uploads/pdfs/Pacing-for-people-with-me-booklet-Fe
b-2020.pdf
• Address anxieties and provide re-assurances regarding some of the physical
symptoms of anxiety: palpitations, feeling SOB, poor sleep, delayed return to normal
function
https://
www.penninecare.nhs.uk/about-us/latest-news/new-mindfulness-courses-across-grea
ter-manchester
• Patience and convalescence: re-assure, give an individual permission to convalesce
• Sleep: https://www.nhs.uk/oneyou/every-mind-matters/sleep/
• Diet: https://www.nhs.uk/live-well/eat-well/
• Pleasure and rewards
Activity – avoid encouraging physical activity as a remedy, in the early months activity
should be limited to normal activities of daily living, greater emphasis on function,
rest and diet
Learning

Professional Learning: Health education

England
https://
portal.e-lfh.org.uk/myelearning/catalogue/
Index
Search the Full Catalogue(left side of
screen). Scroll down to COVID 19 Recovery
and Rehabilitation Programme
Psychological Care
Recovery fromWelcome
COVID-19 & Long-covid

Dr Paul Hood
Title of Presentation goes here
Clinical Psychologist
Stockport NHS Foundation Trust
Objectives

• Prevalence of psychological difficulties

• Causal & maintaining factors
• Vulnerable groups
• Good practice guidelines
• Resources
• Service outcomes
• Going forward
Symptom Distress
Large variances in
prevalence.

Array of physical health

changes 3-6 months after
symptomatic COVID-19

Big 3 physical symptoms

- 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%

Anxiety 50-80% Insomnia 40%

PTSD Stress &

Symptoms
20-50% Burnout
50-70%

Fear of
COVID
50-80%
Factors

For people severely affected by Covid 19 requiring hospital care

• Frightening and invasive nature of critical care experience
• High risk of death or long term complications
• Isolation from loved ones
• Stigma
• Uncertainty about recovery
• Risk development of PTSD, anxiety and/or depression
• Relatives may also be at risk

For many who did not require hospital care

• Additional uncertainly about diagnosis
Good Practice

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.

British Medical Association (2020). The impact of COVID-19 on mental health in

England; Supporting services to go beyond parity of esteem

British Psychological Society guidance: Meeting the needs of people recovering

from Covid, April 2020
Challenges
• New disease with emerging evidence

• Uncertainty in healthcare and society

• Services across the country are patchy

• Stepped vs. Matched psychological care?

• Uni-disciplinary pathways vs. COVID-19 MDTs?

• 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

Listening, advice and support

Guided Self-Care Social support groups

Qualified psychological therapies

Specialist Interventions Multidisciplinary support

Multi-service collaboration
Complex Cases Bespoke intensive / longer term care
planning
Resources (T1)

https://www.yourcovidrecovery.nhs.uk/

Self-guided help for:

• Understanding the recovery journey
• Coping with physical symptoms
• Managing mild-end psychological difficulties
• When and how to seek help

Other NHS websites (e.g. www.nhs.uk/live-well; www.nhs.uk/conditions/coronavirus-covid-19)

 https://www.stockport.gov.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

Guided 1-2-1 help for people struggling with:

• Long term conditions including long COVID
• Advice with common symptoms
• Social adversities (e.g. isolation & loneliness)
• Managing mild-end psychological difficulties
• Long COVID support group
Resources (T2)

www.iaptportal.co.uk/ServiceUser/SelfReferralForm.aspx

Self/Guided digital therapy courses of C-CBT:

• Managing mild-to-moderate psychological difficulties
• ~30 online courses
• Options to work with a mental health worker from
Healthy Minds
Resources (T3)

www.penninecare.nhs.uk/healthymindsstockport
Tel. 0161 204 4675 or Self referrer on website

1-2-1 therapies for psychological disorders.

• Psychologically trained and qualified professionals
• Moderate-to-severe mental health difficulties
• Psychological sequelae of long-COVID
Resources (T3)

www.stockport.nhs.uk
Tel. 0161 419 5015 SPMS@Stockport.nhs.uk

1-2-1 specialist MDT for persistent pain management.

• Consultants, Clinical Psychologist, OT, Physio, Nurses
• Holistic management of Covid-19 pain
• Specialist medical investigations and treatments
• Therapies, online course, PMP, webinars etc.
Resources (T3)

www.stockport.nhs.uk
ICU@stockport.nhs.uk Follow-up & networked service

1-2-1 specialist MDT for COVID-19 survivors after ICU care.

• Consultants, Clinical Psychologist, Nurses
• Holistic management of post-ICU and long COVID
• Follow-up assessments, medical, psychological &
neuropsychological interventions, online support group
Resources (T4)

www.penninecare.nhs.uk/stockportaccessteam
Tel. 0161 419 4678 or Referral via GP/health professionals

Single access point for triaging, assessing and sign posting

referrals into mental health services.
• Psychologists, Psychiatrists & Social Workers
• Managing psychological risk, complexity & emergencies
• Can provide home-based or inpatient assessment and
treatment
Going Forward

Stockport NHS COVID-19 Recovery Working Group

Long COVID Complex Cases MDT group

• Complex and treatment resistant long COVID presentations
• Multidisciplinary approach from diverse specialisms
• Holistic formulation and management planning
• Bespoke collaboration to overcome barriers to change.
 Case Study
ICU-FU, Pain & Fatigue Service Collaboration*
• 58-year-old John
• Admitted to ICU with COVID-19 pneumonitis
• Hx. Type-1 diabetes, polyneuropathy, chronic pain and
tachycardia.

• ICU-FU Nurse: depression, PTSD, pain, fatigue, cog. problems

• Risks: Suicidal thoughts, isolation, memory

• ICU-FU Clinical Psychologist

• Joint work with:
• ICU Consultant
• Pain Management Service
• Fatigue Service
• Social services  Housing association
*Patient consented with some details changed to maintain patient anonymity
Thank you for
all you do!

Any Questions?
Questions & Close