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expert comment on treatment and recovery post-COVID infection

There have been questions from journalists on how patients recover from COVID-19 and what support and treatment they will need during this phase of the illness.

 

Dr James Gill, Locum GP & Honorary Clinical Lecturer, Warwick Medical School, said:

 “At the front end of the health care service we continue to struggle with increasing numbers of COVID-19 infections and the sad loss of life which is associated with an alarming proportion of those infections. But there is a growing need for information on the longer-term care for patients who have contracted the coronavirus and thankfully recovered.

“As SARS-CoV-2 is a novel infectious agent our understanding of the infectious stages of the COVID-19 disease has had to rapidly evolve. We also have a steep learning curve to follow with regard to caring for patients who have survived the COVID19 infection, as patients continue to experience feelings of fatigue, shortness of breath and reduced exercise tolerance.

“It is absolutely correct that vast amounts of resources are being poured into treating new patients and attempting to control the current pandemic course.  But we also need to cast an eye to the future with consideration on how best to care for patients, both in the post-acute stages of COVID-19 and on leaving the hospital or recovering at home. What is needed for the successful rehabilitation after a post COVID-19 infection – if anything?

“To put things into perspective, undergoing a hip replacement operation is certainly a physical challenge for a patient’s body, but it is the post-surgery care – recognising and responding to post-operative complications, such as wound infections or blood clots, in a timely manner, along with the patient’s rehabilitation at home – which results in the operation’s success.

“We understand post-operative surgical care in terms of pain management, physiotherapy input and nutritional advice, all of which combine to make the recovery a success. There are few problems in medicine where the best management plan is ‘take a pill now go away’; and that is likely to be just as true with COVID19. The medical community currently has limited information regarding the best route to full recovery for post coronavirus infection patients, but it is highly likely after a hospital admission that an integrated care pathway will be required, looking at the patient as a whole person, not just a biological organism that experienced a respiratory problem.

“Thus, there will be patients in need of step-down care whether in the hospital before discharge home, or after a recovery in the community with primary care support. That additional input will likely be multidisciplinary in nature, recomposing respiratory review, physiotherapy and nutritional team advice, and likely psychiatric support as they regain their health.

“The current assumptions around COVID-19 planning in the UK – and as we’ve seen, such assumptions are highly likely to change – are that 50% of patients admitted to hospital will require no further input on discharge.  45% will need some form of low level medical or social input for recovery, and a predicted 5% of patients will require more focused, ongoing intense rehabilitation. 

“We may be able to draw guidance from similar infections, whether that be annual influenza case recoveries, or the closely virologically related SARS and MERS when it comes to long-term case outcomes. 

“Let’s take a look at the SARS cases recovery.  One year after recovery, two thirds of patients had some evidence of mental health impact, including depression, anxiety and post-traumatic stress1.  From this we can extrapolate that patients recovering from COVID-19 should be advised to actively engage with mental health services, whether directly or via home-based approaches. Two effective online resources that COVID-19 patients may be directed to are www.headspace.com – currently free for NHS workers, but also for parents and patients experiencing increased health anxiety post infection it may be reassuring to access www.whenshouldiworry.com.

“From the physical side of things, again looking at SARS cases, 27.8% of patients demonstrated persistent changes on chest X-rays 12 months after their recovery. Whilst post-infection lung function was within normal range for those patients, they also demonstrated reduced exercise tolerances2.  That finding of normal lung function testing post SARS recovery is important, as it has not been possible to draw a convincing connection between pulmonary function and post infection reduced exercise capacity3.

“The lack of correlation between normal lung function and post-infection reduced exercise tolerance suggests that there may be more subtle changes underlying the functional impairment some patients have experienced, possibly suggesting a facet of post viral fatigue affecting patients. In such cases a combination of physical interventions such as physiotherapy and graded exercise programmes may provide benefits. Additionally providing clinically validated mental health interventions such as CBT, good nutrition and possibly antidepressants may be an active part of recovery4.  Graded exercise tolerance and mental health support interventions and could likely be extended to patients who are recovering from COVID-19.

“Breathing exercises are actively encouraged post operatively and could probably be advised to recovering COVID-19 patients as well.  If we look at the types of breathing exercises that have been used after major surgeries, no difference in benefit has been found when using an incentive spirometer – essentially a game-like device to blow a ball a round – or simple deep breathing exercises5  with either approach giving a benefit to the patient in recovery.  Thus, it would be quite reasonable for similar advice to be extended to the post coronavirus patients, in the hope of producing a short term benefit in improvement of their breathing.  Many surgical departments have freely available breathing exercises on their patient pages which can easily be accessed by patients6

“As for nutritional support in recovery, simple advice ensuring consumption of five fruits and veg a day should be advised, along with increased intake of high quality protein to provide resources for the repair of muscles which will have been taxed considerably during the course of the COVID19 symptoms.  As the focus in the post-acute phase is going to be on the recovery of a patient’s respiratory function, cessation of smoking should be encouraged along with avoidance of ibuprofen where possible.”

 1 https://journals.sagepub.com/doi/abs/10.1177/070674370705200405

2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7127710/ 

3 https://www.karger.com/Article/Abstract/95673.

4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7127710/ 

5 https://www.sciencedirect.com/science/article/abs/pii/S0012369215501839

6 https://www.uhs.nhs.uk/Media/UHS-website-2019/Patientinformation/Respiratory/Tips-on-a-speedier-recovery-after-surgery-patient-information.pdf 

 

All our previous output on this subject can be seen at this weblink: www.sciencemediacentre.org/tag/covid-19

 

Declared interests

None received.

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