All Wales Guideline for the Management of Long COVID
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Coding Long COVID
STEP 1: Overview
Use the pathway below to structure your consultation with a patient presenting with neurological symptoms associated with Long COVID.
Presenting symptoms:
- Fatigue and lethargy
- Brain fog and cognitive impairment
- Headaches
- Loss of sense of taste or smell
- Myalgia and pain on eye movement
- Sleep disorders
- Guillain-Barré syndrome (very rare)
It is not clear why patients have persistent neurological symptoms associated with Long COVID. In common with other coronaviruses SARS-CoV-2 does exhibit some neurotropism but it is relatively rare for the central or peripheral nervous system to be severely and persistently affected.
STEP 2: History
3 questions to include in the history:
- How well were they before COVID and how does this compare to how they are now?
- How does the nature and severity of any longstanding symptoms compare with their current symptoms?
- How have the person’s employment and activities, mobility and independence been affected by Long COVID?
Red flags to look out for:
Patients who required a prolonged stay on an intensive care unit may experience significant deconditioning, and in some a neuromyopathy occurs which can hamper recovery, or in some be the main cause of impaired mobility.
The presence of one or more red flag features or symptoms may indicate a significant complication of Long COVID, or the emergence or worsening of a co-morbidity.
STEP 3: The neurological examination
Features of long-COVID
The standard neurological examination starts with higher function, cranial nerves, and examination of the limbs
In general, despite some patients reporting a marked reduction in stamina and exercise tolerance, it is unusual to detect neurological signs on examination.
- Patients who are non-specifically unwell should be assessed for anaemia, renal impairment, and raised inflammatory markers
- Watch the patient walk, breathe, swallow, and speak, in order to assess their overall function
- Some patients with focal dysfunction should have an examination of their limbs, to include inspection, strength, tone, reflexes, co-ordination and sensation
Need more information?
Step 4: Investigations
Routine blood tests
Routine blood tests including FBC, U&Es, glucose, calcium, thyroid function, LFT, vitamin D, B12 and folate, should be requested for any patient presenting with malaise and fatigue.
More detailed neurological tests
Patients referred to neurology clinics for unexplained, persistent symptoms, may go on to have more detailed neurological testing.
Need more information?
Step 5: Diagnosis
Highly likely to be explained by long-COVID:
- Predominantly symptoms of malaise, fatigue and brain fog
- No red flag features
- No abnormalities found on investigations
Need more information?
Patients with typical symptoms of Long COVID can be reassured that their journey of recovery is normal.
Proceed to step 6 to determine which patients might benefit from a referral to a Long COVID multidisciplinary rehabilitation service, and which can be managed at home with support of the COVID recovery app.
Step 6: Management
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
- Understanding the importance of good sleep quality
- Healthy diet and good hydration
- Pacing of activity levels and gentle return to exercise and activity
Referral to multidisciplinary rehabilitation services
Consider referral if:
- Neurological examination is normal
- Patient needs help to get into a cycle of recovery
- The individual is struggling with ‘boom and bust’ cycle of activity
Refer to specialist neurology clinic
Consider referral if:
- Unable to return to previous level of independence after 6 months
- Any red flag symptoms or abnormality on neurological examination
Need more information?
For most patients, the road to recovery begins by acknowledging how unwell they have been, validating their experience with a healthcare professional, and accepting that they have a post-viral syndrome. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
Armed with this knowledge, some patients will be happy to proceed with self-management, while others may need some further holistic support by the multidisciplinary rehabilitation services for long COVID. Details of this team in your area can be found below.
COVID Rehabilitation Service in your area:
In order to view the Long COVID services available in your area, please complete your profile here
Making a referral:
Healthboard not selected
Coding Long COVID
STEP 1: Overview
Use the pathway below to structure your consultation with a patient presenting with respiratory symptoms associated with Long COVID.
Presenting symptoms:
- Breathlessness
- Dry cough
- Fatigue
The aetiology for these symptoms may simply be down to deconditioning or hyperventilation. However, there are a some organic illnesses that are recognised as a consequence of acute COVID infection, including chronic cough, bronchiectasis, pulmonary fibrosis, and pulmonary vascular disease.
STEP 2: History
3 questions to include in the history:
- Have you had a confirmed COVID infection, and how long ago was that?
- What is the nature and severity of breathlessness?
- Is the cough dry or productive, do you cough up any blood, is it worse at night time?
Red flags to look out for:
The presence of one or more red flag features or symptoms may indicate a significant complication of Long COVID, or the emergence or worsening of a co-morbidity.
STEP 3: The respiratory examination
Features of long-COVID
The standard respiratory examination should include oxygen saturations, checking for ankle swelling, finger clubbing, assessing JVP, tachycardia, and chest auscultation.
Typically, patients with Long COVID will have no remarkable findings on respiratory examination
- Assess pulse oximetry at rest and on mobilisation, using a simple exercise tolerance test to check for desaturations (>3%)
- Chest auscultation should be normal; any evidence of crackles (coarse or fine) would suggest a differential diagnosis
- Patients with persistent breathlessness and fatigue should be assessed for anaemia
Need more information?
Step 4: Investigations
Further investigations may be required, dictated by the deficits described by the patient.
Chest x-ray
Every patient with continuing respiratory symptoms after 12 weeks should have a chest x-ray (NICE).
Spirometry
To rule out any obstructive abnormalities (FEV1/FVC<0.7) or restrictive abnormalities (abnormally reduced FVC).
Pulse oximetry
If pulse oximetry at rest is normal, ask the patient to do a simple exercise tolerance test to monitor for desaturations.
Need more information?
Step 5: Diagnosis
Highly likely to be associated with long-COVID:
- Predominantly symptoms of breathlessness and dry cough
- No red flag features
- No abnormalities found on investigations
Need more information?
Patients with typical symptoms of Long COVID can be reassured that their journey of recovery is normal.
Proceed to step 6 to determine which patients might benefit from a referral to a Long COVID multidisciplinary rehabilitation service, and which can be managed at home with support of the COVID recovery app.
Step 6: Management
Self-management, with the support of the NHS Wales COVID recovery app
Patients are coping well and are happy to continue with some self-management advice.
The COVID recovery app supports the patient with:
- Controlled breathing exercises to manage panicky breathing
- Fan or flannel therapy to reduce the sensation of breathlessness
- Pacing of activity levels and gentle return to exercise and activity
Referral to multidisciplinary rehabilitation services
Consider referral if:
- Respiratory examination and further investigations are normal
- Patient needs help to get into a cycle of recovery
- The individual is struggling with ‘boom and bust’ cycle of activity
Refer to specialist respiratory clinic
Consider referral if:
- Any red flag symptoms or abnormality on respiratory examination
Need more information?
For most patients, the road to recovery begins by acknowledging how unwell they have been, validating their experience with a healthcare professional, and accepting that they have a post-viral syndrome. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
Armed with this knowledge, some patients will be happy to proceed with self-management, while others may need some further holistic support by the multidisciplinary rehabilitation services for long COVID. Details of this team in your area can be found below.
COVID Rehabilitation Service in your area:
In order to view the Long COVID services available in your area, please complete your profile here
Making a referral:
Healthboard not selected
Coding Long COVID
STEP 1: Overview
Use the pathway below to structure your consultation with a patient presenting with cardiac symptoms associated with Long COVID.
Presenting symptoms:
- Chest pain
- Breathlessness
- Dizziness
- Palpitations
- Postural orthostatic tachycardia syndrome
There are a some cardiac sequelae of acute COVID infection, including arterial and venous thrombosis, heart muscle inflammation and autonomic dysfunction.
STEP 2: History
3 questions to include in the history:
- Have you had a confirmed COVID infection, and how long ago was that?
- Are your symptoms worse on exertion, and what makes them better or worse?
- Any comorbidities or risk factors, such as angina, high blood pressure, diabetes, family history of ischaemic heart disease, smoking?
Red flags to look out for:
The presence of one or more red flag features or symptoms, may indicate a significant complication of Long COVID, or the emergence of a co-morbidity.
STEP 3: The cardiac examination
Features of long-COVID
The standard cardiac examination should include blood pressure, pulse, and perfusion status.
Typically, patients with Long COVID will have no remarkable findings on cardiac examination
- Assess the patient’s fluid status; ankle swelling, bibasal crepitations, raised JVP
- In patients with palpitations and dizziness, measure their lying and standing blood pressure
Need more information?
Step 4: Investigations
Further investigations may be required, dictated by the deficits described by the patient.
12-lead ECG
A resting 12-lead ECG is useful to identify abnormality.
Blood tests
Blood tests including full blood count, electrolytes, and BNP.
Chest x-ray
Looking for signs of fluid congestion.
Need more information?
Step 5: Diagnosis
Highly likely to be explained by long-COVID:
- Predominantly symptoms of breathlessness, palpitations and fatigue
- No red flag features
- No abnormalities found on baseline investigations
Need more information?
Patients with typical symptoms of Long COVID can be reassured that their journey of recovery is normal.
Proceed to step 6 to determine which patients might benefit from a referral to a Long COVID multidisciplinary rehabilitation service, and which can be managed at home with support of the COVID recovery app.
Step 6: Management
Self-management, with the support of the NHS Wales COVID recovery app
Patients are coping well and are happy to continue with some self-management advice.
The COVID recovery app supports the patient with:
- Controlled breathing exercises and mindfulness
- Fan or flannel therapy to reduce the sensation of breathlessness
- Pacing of activity levels and gentle return to exercise and activity
Referral to multidisciplinary rehabilitation services
Consider referral if:
- Cardiac examination and further investigations are normal
- Patient needs help to get into a cycle of recovery
- The individual is struggling with ‘boom and bust’ cycle of activity
Refer to specialist cardiology clinic
Consider referral if:
- Any red flag symptoms or abnormality on examination
Need more information?
For most patients, the road to recovery begins by acknowledging how unwell they have been, validating their experience with a healthcare professional, and accepting that they have a post-viral syndrome. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
Armed with this knowledge, some patients will be happy to proceed with self-management, while others may need some further holistic support by the multidisciplinary rehabilitation services for long COVID. Details of this team in your area can be found below.
COVID Rehabilitation Service in your area:
In order to view the Long COVID services available in your area, please complete your profile here
Making a referral::
Healthboard not selected
Coding Long COVID
STEP 1: Overview
Use the pathway below to structure your consultation with a patient presenting with psychological symptoms associated with Long COVID.
Presenting symptoms:
- Anxiety
- Depression
- Trauma-related symptoms
- Problems with memory
- Problems with concentration
There are little data on long term psychological sequelae in COVID-19, especially in those with Long COVID. Adults are more likely to be diagnosed with psychiatric conditions including anxiety and depression, and this is often associated with persistent physical symptoms such as breathlessness and myalgia.
STEP 2: History
3 questions to include in the history:
- Have you had a confirmed COVID infection, and if not, what makes you think you have had a COVID-19 infection?
- What is the nature and severity of your psychological symptoms?
- How do your physical symptoms impact your psychological symptoms?
Red flags to look out for:
The presence of one or more red flag features or symptoms may indicate a significant complication of Long COVID, or the emergence or worsening of a co-morbidity.
Step 3: Investigations
GAD-7 scoring system
A tool for assessing anxiety in practice.
PHQ-9 scoring system
A tool for assessing depression in practice.
Impact of events scale for assessing trauma
Assessing Psychological Trauma and PTSD.
Need more information?
Scores represent:
- 0-5 mild
- 6-10 moderate
- 11-15 moderately severe anxiety
- 15-21 severe anxiety
Scores represent:
- 0-5 = mild
- 6-10 = moderate
- 11-15 = moderately severe
- 16-20 = severe depression
Step 4: Management
Self-management, with the support of the NHS Wales COVID recovery app
Patients are coping well and are happy to continue with some self-management advice.
The COVID recovery app supports the patient with:
- Mindfulness and breathing control exercises
- Talking to friends, family and employers about how you are feeling
- Distancing yourself from unhelpful thoughts
Referral to multidisciplinary rehabilitation services
Consider referral if:
- Person is not continuing to recover
- Person needs help to get into a cycle of recovery
- There are no red flag symptoms
Refer to specialist psychology clinic
Consider referral if:
- Unable to return to previous level of independence after 6 months
- Any red flag symptoms after 12 weeks of initial infection
Need more information?
For most patients, the road to recovery begins by acknowledging how unwell they have been, validating their experience with a healthcare professional, and accepting that they have a post-viral syndrome. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
Armed with this knowledge, some patients will be happy to proceed with self-management, while others may need some further holistic support by the multidisciplinary rehabilitation services for long COVID. Details of this team in your area can be found below.
COVID Rehabilitation Service in your area:
In order to view the Long COVID services available in your area, please complete your profile here
Making a referral:
Healthboard not selected
Coding Long COVID
STEP 1: Overview
Use the pathway below to structure your consultation with a patient presenting with dermatological symptoms associated with Long COVID.
Presenting symptoms:
- Chilblain-like eruptions, commonly on the toes
- Skin rashes
- Itchy skin
- Urticaria
Since the start of the COVID-19 pandemic, the dermatological manifestations of Long COVID have been reported, however, data on duration of signs and symptoms are lacking.
Most rashes associated with COVID-19 do not require treatment and will resolve within a few days/ weeks.
Video 1: Overview of psychological symptoms
Video 2: Management and referral
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STEP 2: History
3 questions to include in the history:
- Have you ever had symptoms like this in the past?
- How does the nature and severity of any longstanding symptoms compare with their current symptoms?
- How has the rash changed over time?
Red flags to look out for:
STEP 3: The dermatological examination
Features of long-COVID
- Urticarial and morbilliform eruptions were relatively short-lived
- Papulosquamous eruptions and particularly chilblain-like eruptions on the feet (known as “COVID toes”) are generally longer-lasting
Need more information?
Step 4: Management
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
- Healthy diet and good hydration
- Tips for coping with chillblain-like eruptions (coming soon)
- When to consult with your GP if your symptoms persist
Referral to multidisciplinary rehabilitation services
Consider referral if:
- Patient needs general recovery advice
- The individual is struggling with ‘boom and bust’ cycle of activity
Refer to specialist dermatology clinic
Consider referral if:
- Unable to return to previous level of independence after 6 months
- Any red flag symptoms or abnormality on dermatological examination
Need more information?
For most patients, the road to recovery begins by acknowledging that they have a post-viral syndrome and that recovery can take time. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
COVID Rehabilitation Service in your area:
In order to view the Long COVID services available in your area, please complete your profile here
Making a referral:
Healthboard not selected
Coding Long COVID
STEP 1: Overview
Use the pathway below to structure your consultation with a patient presenting with ENT symptoms associated with Long COVID.
Presenting symptoms:
- Loss of taste and/or smell
- Difficulty swallowing
- Sore throat
- Ear ache
- Tinnitus
- Dizziness
It is not clear why patients have persistent ear, nose and throat symptoms following infection with COVID-19, but the upper airway is one of the main sources of transmission of infection.
STEP 2: History
3 questions to include in the history:
- Have you ever had symptoms like this in the past?
- How have your symptoms changed over time? Are your symptoms getting worse?
- Are there any other symptoms that seem associated with the ENT symptoms?
Red flags to look out for:
Symptoms persist for longer than 3 months.
Problematic, persistent globus or throat sensitivity.
Difficulty with chewing and swallowing, choking episodes, persistent coughing and throat clearing.
Signs and symptoms of sinonasal malignancy include loss of sense of smell, unilateral nasal obstruction, visible unilateral mass, unilateral bloody nasal discharge, facial paraesthesia and facial swelling, and diplopia.
USC referral to ENT for endoscopy and investigation.
Signs of Upper Aerodigestive Tract Cancer include difficulty swallowing, sore throat, dysphonia, voice change, progressive difficulty swallowing, neck mass, weight loss, particularly if the symptoms are progressive and continuing for more than 3 weeks.
USC referral to ENT for nasal endoscopy and further investigation.
Signs of sudden onset sensorineural hearing loss include sudden reduction/loss of hearing with no clinical cause identified. Tuning fork: Webers test to contralateral side, and Rinne positive on contralateral (beware false negative ipsilateral).
Commence oral steroids as soon as possible (40mg Prednisolone OD 1/52). Refer to ENT on-call for expedited investigation and ongoing management.
Signs and symptoms of Vestibular Schwannoma (Acoustic Neuroma) include generally gradual progressive unilateral hearing loss (can present with sudden onset in 10%), unilateral tinnitus, but examination of the ears is normal.
Refer to ENT for assessment of ears/hearing and further investigation as appropriate (can be triaged routine).
STEP 3: The ENT examination
Features of long-COVID
- Despite some patients reporting distressing symptoms, it is unusual to detect abnormal signs on ENT examination.
COVID-related ENT conditions:
- COVID-specific diagnoses include sudden onset sensorineural hearing loss, vestibular hypofunction, sensorineural anosmia (post-URTI), chronic rhinosinusitis (triggered by COVID), and laryngeal trauma/inflammation, sudden onset sensorineural hearing loss and vestibular hypofunction.
- Be mindful that a number of ENT conditions have psychological components and can be exacerbated by periods of psychological stress, including tinnitus and dizziness, laryngopharyngeal reflux/globus, temporomandibular joint dysfunction.
Need more information?
Sensorineural Anosmia – loss or change to sense of smell without signs or symptoms of sinonasal pathology or other identifiable cause. Reassure patient that post-URTI anosmia can take up to two years to settle, and a trial of prednisolone for 2-3/52 can be considered. Refer to ENT for further investigation (routine) or more urgently if other clinical features are present.
Chronic Rhinosinusitis – nasal obstruction/congestion or nasal discharge, facial pain/pressure, hyposmia/anosmia, discharge anteriorly/tracking to oropharynx, inflamed congested mucosa, nasal polyps. Consider nasal douching/Sterimar and Nasal steroid inhaler, and consider course of antibiotics. Refer to ENT if no improvement.
Laryngeal trauma/inflammation – dysphonia, clear history of onset as result of URTI/ repeated coughing, no other features of UAT malignancy. Commence Gaviscon Advance 10ml QDS plus PPI. Refer to ENT if no improvement, but refer as USC straightaway if malignancy is suspected.
Vestibular Hypofuction – imbalance or unsteadiness on feet, caused by poor compensation post vestibular insult (post-labyrinthitis; URTI). Refute neurological cause (confirm peripheral deficit), Cooksey-Cawthorne exercises, refer to ENT.
Step 4: Management
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
- Healthy diet and good hydration
- Tips for eating and drinking if you have swallowing difficulties
- When to consult with your GP if your symptoms persist
Referral to multidisciplinary rehabilitation services
Consider referral if:
- Patient needs general recovery advice
- The individual is struggling with ‘boom and bust’ cycle of activity
- The individual needs support from a dietitian
Refer to specialist ENT clinic
Consider referral if:
- Unable to return to previous level of independence
- Any red flag symptoms or abnormality on investigations
Need more information?
For most patients, the road to recovery begins by acknowledging that they have a post-viral syndrome and that recovery can take time. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
COVID Rehabilitation Service in your area:
In order to view the Long COVID services available in your area, please complete your profile here
Making a referral:
Healthboard not selected
Coding Long COVID
STEP 1: Overview
Use the pathway below to structure your consultation with a patient presenting with musculoskeletal symptoms associated with Long COVID.
Presenting symptoms:
- Joint pain
- Muscle aches
- Muscle wasting
An abnormal, exaggerated inflammatory response, as well as periods of inactivity, appears to be the key mechanism for the variety of musculoskeletal features of Long COVID.
STEP 2: History
3 questions to include in the history:
- What is the onset of the symptoms (when did it start, how long have you had the symptoms, was it a gradual or sudden onset)?
- How have your symptoms changed over time? Does anything make the pain better?
- Are there any other symptoms that seem associated with the pain?
Red flags to look out for:
STEP 3: The Musculoskeletal examination
Features of long-COVID
- In general, despite some patients reporting distressing symptoms, it is unusual to detect abnormal signs on musculoskeletal examination.
- Blood tests, including ESR and CRP, should be organised for patients presenting with persistent musculoskeletal symptoms of Long COVID.
Need more information?
Step 4: Management
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
- Seated exercise programme
- Tips for managing post-exertional malaise
- When to consult with your GP if your symptoms persist
Referral to multidisciplinary rehabilitation services
Consider referral if:
- Patient needs general recovery advice
- The individual is struggling with ‘boom and bust’ cycle of activity
- The individual needs support from a physiotherapist
Refer to specialist rheumatology clinic
Consider referral if:
- Any red flag symptoms or abnormality on examination
Need more information?
For most patients, the road to recovery begins by acknowledging that they have a post-viral syndrome and that recovery can take time. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
COVID Rehabilitation Service in your area:
In order to view the Long COVID services available in your area, please complete your profile here
Making a referral:
Healthboard not selected
Coding Long COVID
STEP 1: Overview
Use the pathway below to structure your consultation with a patient presenting with gastrointestinal symptoms associated with Long COVID.
Presenting symptoms:
- Diarrhoea
- Nausea
- Vomiting
- Abdominal pain
- Weight loss
- Anorexia and reduced appetite
Emerging data suggest that the GI tract and liver might be affected by SARS-CoV-2, on the basis that epithelial cells and liver cells express ACE2, the major receptor of SARS-CoV-2.
STEP 2: History
3 questions to include in the history:
- Have you had a confirmed COVID infection, and if not, what makes you think you have had a COVID-19 infection?
- Do any of your current symptoms pre-date your COVID-19 infection?
- Are there any other symptoms that seem associated with the gastrointestinal symptoms?
Red flags to look out for:
The presence of red flag features or symptoms may indicate a significant complication of Long COVID, or the emergence or worsening of a co-morbidity.
Step 3: Investigations
Routine blood tests
Routine blood tests including FBC, U&Es, glucose, calcium, thyroid function, LFT, ferritin, B12 and folate, should be requested for any patient presenting with Long COVID and GI symptoms.
Need more information?
Step 4: Management
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
- Healthy diet and good hydration
- Tips for increasing your calorie intake if you have lost your appetite
- When to consult with your GP if your symptoms persist
Referral to multidisciplinary rehabilitation services
Consider referral if:
- Patient needs general recovery advice
- The individual is struggling with ‘boom and bust’ cycle of activity
- The individual needs support from a dietitian
Refer to specialist secondary care
Consider referral if:
- Unable to return to previous level of independence after 6 months
- Any red flag symptoms
Need more information?
For most patients, the road to recovery begins by acknowledging that they have a post-viral syndrome and that recovery can take time. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
COVID Rehabilitation Service in your area:
In order to view the Long COVID services available in your area, please complete your profile here
Making a referral:
Healthboard not selected