Reassuring patients they’re not going to be “permanently damaged” is a key part of managing long-COVID, the Australian respiratory physician leading a specialised clinic for the condition says.
Associate Professor Lou Irving was the driving force behind the Royal Melbourne Hospital’s Post-Covid Clinic when it opened a little over two years ago, as a major wave of infections surged across the state.
Since then, hundreds of patients have been through the clinic’s doors – many who had found themselves completely incapacitated even months after contracting the virus.
One of the first patients, and the most severe, was a young mother. She had been working as a medical scientist and leading an incredibly busy life, but had become wheelchair- and bed-bound by her first visit.
Two years on, she is “completely back to normal”, one of many patients who have got better over time, Professor Irving says.
With the last vestiges of pandemic restrictions easing around the country, the plight of patients experiencing ongoing symptoms is now the subject of a Federal Parliamentary inquiry.
But the topic remains a controversial one, with little clarity on the true number of patients impacted or any established model of care.
In evidence to the inquiry last week, the respiratory physician said about 15% of those infected with SARS-CoV-2 were experiencing ongoing symptoms at 12 weeks.
Just over a third of those had severe symptoms, or about 6% of the total number of people who contracted COVID-19, he said.
He told MPs research pointed to risk factors being older as well as pre-existing physical or mental health issues, although his own clinic had seen numerous patients from another group: high achievers – particularly among the hospital’s own staff.
In fact, 40% of the clinic’s patients were health workers themselves, he said.
“We unfortunately had a large outbreak of COVID with the second wave, and 250 of our own staff were infected,” Professor Irving told the inquiry.
“Some of them have got persistent symptoms. Healthcare workers are particularly at risk, in my experience.”
Professor Irving said patients fell into three main categories.
The first group, comprising about a third of all patients at the clinic, were people who had been in hospital with acute COVID-19. These had often desperately ill but had survived.
“They had ongoing lung inflammation and fibrosis, resolving into acute lung injury, ARDS,” he said.
The patients were often deconditioned because they had spent a significant amount of time in hospital receiving acute care.
However, all improved over time, Professor Irving said, with the standard support of cardiopulmonary rehabilitation, of nutritional support and of supplemental oxygen when required.
“There’s a second group, who were a small number of people presenting with a nuance of breathlessness or palpitations,” he added.
“When we did some screening tests, we discovered that they actually had underlying asthma or potentially PEs or potentially myocarditis. They’re a small group; but they’re important, because they’re eminently treatable, providing they’re accurately diagnosed.”
“So it’s important to have careful assessment when people present with persisting symptoms after COVID.”
Majority of patients had mild initial disease
The other type of patients, and the majority of those using the clinic, were people who had mild initial disease, but developed progressive symptoms over time.
These typically included some combination of progressive fatigue, breathlessness, palpitations and sometimes brain fog, Professor Irving said.
“If a solution wasn’t provided for their symptoms, they became increasingly frustrated, anxious, hypervigilant and depressed,” he said, adding that psychological support was often a feature of their care.
“Over time, we’ve learnt to not over-investigate and to just do some focused tests depending on their symptoms,” he said.
“We tend to use a six-minute walk for people who say they can’t walk or that they’re too breathless to move. Interestingly, the six-minute walk is usually a minimum. If a patient has a lot of palpitations, we might do an echo or a Holter monitor, but we don’t use a wide battery of tests on everyone.”
Instead, he said the clinic would validate their symptoms and we refer them to a 12-week allied health-led service. Called ReCOV, this offered services including clinical and neurology, psychology, social work, nutrition, occupational therapy, music therapy, physiotherapy, exercise physiology and rehabilitation medicine.
“The last point I’d make is that a lot of patients get better over time, and our most severe patient—in fact, she was the stimulus for setting up this clinic—a young mother working as a medical scientist and leading an incredibly busy life and who was wheelchair- and bed-bound when we first saw her, is completely back to normal after two years.”
“But it has been a long road, and it’s required very careful ongoing treatment.”
“Being able to reassure people that they’re not going to be permanently damaged is part of the management.”