06/12/2022
Persistent symptoms — Persistent physical symptoms following acute COVID-19 are common and typically include fatigue, dyspnea, chest pain, and cough. Patients recovering from COVID-19 may also have additional psychological (eg, anxiety, depression, posttraumatic stress disorder [PTSD]) and cognitive (eg, poor memory and concentration) symptoms, similar to the syndrome experienced by patients recovering from other critical illnesses known as post-intensive care syndrome (PICS).
Prolonged symptoms can follow mild or severe illness and include:
Physical symptoms –persistent symptoms in patients following acute COVID-19 with one-third or more experiencing more than one symptom. Common persistent physical symptoms include:
•Fatigue (13-87%)
•Dyspnea (10-71%)
•Chest pain or tightness (12-44%)
•Cough (17-34%)
Less common persistent physical symptoms include anosmia, joint pain, headache, sicca syndrome, rhinitis, dysgeusia, poor appetite, dizziness (from orthostasis, postural tachycardia, or vertigo), myalgias, insomnia, alopecia, sweating, and diarrhea.
●Psychological or cognitive – In one study of 100 patients with acute COVID-19 who were discharged from the hospital, 24 percent reported PTSD, 18 percent had new or worsened problems with memory, and 16 percent had new or worsened problems with concentration; numbers were higher among patients admitted to the intensive care unit (ICU). In other studies, almost one-half of COVID-19 survivors reported a worsened quality of life, 22 percent had anxiety/depression, and 23 percent of patients were found to have persistent psychological symptoms at three months. Among ICU survivors, another study reported anxiety in 23 percent, depression in 18 percent, and posttraumatic symptoms in 7 percent. In a prospective cohort study of nonhospitalized Ecuadorian patients with COVID-19, most of whom had mild disease, 21 percent had memory impairment as evidenced by a four-point decrease in their Montreal Cognitive Assessment (MoCA) scores.
Psychological complaints may be seen more commonly than in those recovering from similar illnesses. As an example, a retrospective examination of electronic health records in the United States reported that the risk of developing a new psychiatric illness following COVID-19 was higher compared with those recovering from other medical illnesses such as influenza.
PICS – Among ICU survivors, one single center analysis reported that over 90 percent of individuals with COVID-19 suffered from at least one component of PICS. Another prospective observational study found that 9.9 percent of individuals who were discharged from the ICU with COVID-19 developed critical illness polyneuropathy or myopathy versus 3.4 percent of other patients discharged from the ICU.
Hospitalized patients (moderate to severe COVID-19) – Data suggest that a significant proportion of patients who are admitted with acute COVID-19 experience symptoms for at least two months and even longer (eg, up to 12 months) following discharge (52 to 87 percent).
Outpatients (mild COVID-19) – Data also suggest that a significant proportion of patients with mild disease may experience symptoms for up to several months, if not longer, following acute illness.
●Fatigue, weakness, and poor endurance – Fatigue is by far the most common symptom experienced by patients regardless of the need for hospitalization. Although the fatigue resolves in most patients, it can be profound and may last for three months or longer, particularly among ICU survivors.
●Dyspnea – In patients with COVID-19 and dyspnea, the shortness of breath may persist, resolving slowly in most patients over two to three months, sometimes longer (eg, up to 12 months).
Chronic cough – In several studies, many patients experienced persistent cough at two to three weeks following initial symptoms. Cough resolved in the majority of patients by 3 months and rarely persisted by 12 months.
●Chest discomfort – Among patients with COVID-19, chest discomfort is common and may resolve slowly. Chest discomfort persists in 12 to 22 percent of patients approximately two to three months after acute COVID-19 infection, rarely longer.
Altered taste and smell –The majority have complete or near-complete recovery at one month following acute illness, although in some studies these symptoms persisted longer. Patients with hyposmia and male patients may recover more rapidly compared with those who have anosmia or are female.
Neurocognitive symptoms- concentration and memory problems persist for six weeks or more in COVID-19 patients after discharge from the hospital.
●Psychological – psychological symptoms (eg, anxiety, depression, PTSD) are common after acute COVID-19 infection, with anxiety being the most common. In general, psychological symptoms improve over time but may persist for more than six months for a subset of survivors. Those hospitalized are likely at greater risk for persistent psychological symptoms.
A 36 years old male presented with overwhelming fatigue, reduced range of movement, breathlessness and dysfunctional breathing pattern. He was a known case of severe COVID-19 infection and needed Intensive care unit (ICU) during his infective episode 5 months back. He was managed conservatively and kept on 15-Liters per minute (LPM) of oxygen through non-breather for 27 days as he refused mechanical ventilation. The patient was assessed by the Speech Language Pathologist (SLP) on the day of admission in our center. The patient was on 2 LPM Oxygen via nasal cannula, with resting SpO2 of 93% and respiratory rate of 22-25 breaths per minute. He had a clavicular breathing pattern with little diaphragm movement appreciated. When the patient completed any activities, such as serial swallows, sustained vocalization or conversational tasks, his SpO2 dropped below 90% and he required 30 seconds to 2 minutes of recovery breathing. His sustained vocalization was 3 seconds. The patient was also diagnosed with steroid stress hyperglycemia which was managed clinically. His Fasting Blood Sugar(FBS) was 230mg/dl, Post Prandial Blood Sugar(PPBS) 290mg/dl but Glycated Hemoglobin(HBA1C) was 5.6%. He was given metformin in divided doses and on discharge date; his FBS was 162mg/dl and PPBS was 260mg/dl. We continued his metformin and counseled about diabetic diet(Healthy food habit and lifestyle modification). At the end of 6-weeks therapy along with metformin, his sugar levels returned to baseline. The medical team also performed HRCT of the chest which revealed extensive fibrosis of the bilateral lungs.
After his initial assessment, the SLP provided the patient with a hospital made RMST. This device was calibrated 0-40cmH2O displaced by the hospital’s biomedical engineering department using water manometry in 10 cmH2O displaced ranges. The patient's initial maximum expiratory pressure was less than 10 cmH2O. Using standard practice of exercise completion at 75% of maximum effort, the RMST device was set to 10 cm H2O displaced. The patient was taught to complete ten short forced exhalations per cycle with a total of five cycles, then five long forced exhalations holding for five seconds. He was taught to complete these cycles hourly and as needed. The SLP also taught the patient lower abdominal (diaphragmatic breathing) and box breathing techniques to slow the respiratory rate. By the end of the SLP evaluation, the patient’s respiratory rate had slowed to 15-17 breaths per minute and SpO2 had increased to 96% while using the RMSTD.
Over the 6 next days of hospital admission, the patient presented with rapid and remarkable improvement. During admission the patient was unable to perform a 6-minutes walk test(6MWT). Within 24 hrs of admission, the patient was able to use the RMST device without supplemental oxygen and maintain SpO2 of 90%. Supplemental oxygen was completely weaned on day 5 of admission. By discharge on day 7, the patient was independently using thoracic and diaphragmatic breathing techniques while at rest, able to complete RMST device exercise regime at 40 cmH2O displaced with twenty repetitions per cycle and had sustained of 15 seconds still below normal but much improved. During discharge the patient was able to achieve 290m of 6MWT within Borg scale of 13-15 while maintaining all the vitals within normal limits except for SpO2 which was lowest recorded 83% with Borg scale of 15 at the end of 6MWT. The patient quickly recovered with 2-minutes of rest with SpO2 maintaining greater than 93%.
When the patient returned as an outpatient, he completed two additional speech therapy sessions while exercising in the wellness gym. He was taught to self-monitor for diaphragmatic breathing and pursed lip exhalation during times of fatigue and drops of SpO2. He reported continued home use of the RMSTD. And after six weeks of outpatient therapy, he could use RMSTD at 80 cmH2O. During follow up he could perform 390m of 6MWT with Borg scale maximum of 11 while maintaining all the vitals within normal limits.
Lets hear what he has to say about his experience after full rehabilitation program.
