COMMENTARY

Treating Post-COVID Fatigue and Dyspnea -- Deep Breaths and Plenty of Rest

Aaron B. Holley, MD

Disclosures

February 19, 2021

Post-COVID syndrome is here. It's been reported by the lay press and by multiple non-peer-reviewed medical sites, including Medscape. People with persistent symptoms have been called "long-haulers," and the lingering COVID-19 effects described thus far have involved almost every organ system. Because COVID-19 is so new, a coherent picture of "post-COVID syndrome" does not yet exist. In this article, however, we're going to focus on dyspnea and fatigue.

As a pulmonologist and a sleep medicine doctor, patients with these specific complaints already are presenting to my clinic. Persistent dyspnea and fatigue are the most common symptoms reported following hospitalization for COVID-19. This shouldn't necessarily be surprising, as the virus primarily involves the lungs, and non-COVID post-viral fatigue syndromes have been well described.

When evaluating persistent symptoms, it's important to separate the acute from the recovery phase of disease. No specific time threshold or biomarker exists to delineate one phase of disease from another. For the purposes of this article, my focus is on those patients who are no longer hospitalized, are afebrile, and have achieved some degree of symptomatic improvement. They've reached a plateau but have enough residual dyspnea or fatigue to affect their quality of life.

It's also useful to consider the initial severity of illness when discussing residual symptoms during recovery. Patients with COVID-19 who are hospitalized and have an extended stay are expected to have a long road to recovery. This is particularly true for patients who required prolonged ICU care. Fatigue and dyspnea following discharge will be affected by the nature of the initial lung injury, hospital-associated complications, duration of immobility, and individual patient comorbidities. In patients with severe illness, it can be difficult to separate COVID-19–specific fatigue or dyspnea from what might be expected following any severe illness requiring a prolonged hospitalization.

Two reports noted dyspnea and exercise intolerance in more than 40% of patients 60-90 days after acute infection with COVID-19. Another study found dyspnea in 30% of patients 60 days after acute illness. Unfortunately, we know next to nothing about the etiology of these symptoms. One study found diffusion abnormalities (47.2%) and a restrictive pattern on spirometry (25%) to be the most common lung testing abnormalities approximately 1 month after discharge among patients hospitalized for COVID-19. The likelihood of diffusion abnormality was related to the severity of illness. Beyond this, I've seen little in the way of objective evaluation.

The story with post-COVID fatigue isn't much different. It's certainly common, experienced by more than 50% of those surveyed across several studies. One survey found that fatigue was common in university students, none of whom had been hospitalized. Another found that fatigue symptoms were not related to the initial severity of illness. These reports raise concerns that post-COVID fatigue is not confined to those who have been hospitalized or have moderate to severe disease.

Like most things with COVID, we have no idea what we're dealing with. Most of the papers I've cited here are preprints or letters and rely mainly on survey responses. This isn't high-quality data. Furthermore, without cardiopulmonary exercise and objective sleep testing, it's very difficult to characterize the symptoms of dyspnea and fatigue. Are we dealing with physiologic changes caused by direct effects of the virus, or the normal recovery phase one might expect after having a long-term serious infection?

To answer this question, we'll need larger case series with more objective testing. Until we have that data, we're left with speculation. So, here's mine. Aside from patients admitted with documented gas exchange abnormalities during the acute phase, most dyspnea and exercise intolerance will be related to a combination of deconditioning and dysfunctional breathing. My anecdotal experience thus far confirms this. We've seen a similar phenomenon with post–pulmonary embolism syndrome.

I'd recommend keeping it simple with fatigue too. Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) was reported following SARS, and neurologic effects have been reported with COVID-19. Still, it takes 6 months of chronic symptoms that do not improve with rest before one considers a diagnosis like CFS/ME. It's too early to say whether we're going to see this with COVID-19.

For now, clinicians would be wise to start their evaluation with a good sleep history and a sleep apnea risk assessment. And, above all, take a deep breath, get some sleep, and have patience.

Aaron B. Holley, MD, is an associate professor of medicine at Uniformed Services University and program director of pulmonary and critical care medicine at Walter Reed National Military Medical Center. He covers a wide range of topics in pulmonary, critical care, and sleep medicine.

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