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What to do if patient has chronic respiratory symptoms after COVID infection

November 1, 2023

Despite initial reports that children largely were spared from severe manifestations of COVID-19, long-term complaints that range in severity have been identified following acute infection.

Symptoms reported most frequently include respiratory symptoms, nasal congestion, fatigue, muscle and joint pain, and concentration difficulties (Buonsenso D, et al. Acta Paediatr. 2021;110:2208-2211).

This phenomenon has been referred to by many names in the literature, including long COVID and more accurately, post-acute sequelae of SARS-CoV-2 (PASC).

To date, no clear definition has been established for PASC, but it has been determined to be a multiorgan illness with over 200 reported symptoms. Many of these symptoms are nonspecific for any one disease.

This chronic health condition commonly is diagnosed when patients describe signs and symptoms that continue or develop following an acute COVID-19 infection and cannot be explained by an alternative diagnosis.

Recent data show 23% of children who had COVID-19 experience PASC (Zheng YB, et al. J Infect Public Health. 2023;16:660-672).

Respiratory post-infectious sequelae

There are well-documented data in adults regarding chronic pulmonary symptoms, such as cough and trouble breathing, after SARS-CoV-2 infection. In addition, changes have been noted in pulmonary function with decreased diffusing capacity of the lungs for carbon monoxide and radiologic abnormalities found in high resolution computed tomography (Logue JK, et al. JAMA Netw Open. 2021;4:e210830). A similar presentation was reported following SARS-CoV-2 infection in children and adolescents (Fainardi V, et al. Life. 2022;12:285).

The study by Buonsenso and colleagues showed at least 14.7% of 129 pediatric patients reported chest pain and/or chest tightness, and 12.4% reported nasal congestion 60 or more days after initial diagnosis of COVID-19. Other studies reported symptoms such as cough and exercise-induced dyspnea.

A prospective study in China revealed 45% of adults who underwent pulmonary function testing had abnormal results, demonstrating predominantly mild obstructive patterns with half of cases showing reversibility with bronchodilators (Zhao YM, et al. EClinicalMedicine. 2020;25:100463).

Therefore, pulmonary function testing in children with previous SARS-CoV-2 infection is recommended (Ashkenazi-Hoffnung L, et al. Pediatr Infect Dis J. 2021;40:e509-e511).

In addition to the standard radiologic imaging and spirometry, a 6-minute walk test is a useful clinical modality to assess autonomic dysfunction, as observed by variable heart rates or significant tachycardia (Palacios S, et al. Pediatr Pulmonol. 2022;57:2455-2463).

Management plans

Although dyspnea is an infrequent symptom in children with PASC compared to other major complaints (Funk AL, et al. JAMA Netw Open. 2022;5:e2223253), its presence requires close observation and workup. Treatment guidelines are based largely on adult data due to the limited research in the pediatric population. Chest X-rays may be beneficial to rule out any structural disease in persistent dyspneic patients (Greenhalg T, et al. BMJ. 2020;370:m3026).

Conservative management with the use of breathing exercises has shown some promise (Saha S, Sharma K. J Lifestyle Med. 2022;12:113-118). Reactive airway disease medications, such as inhaled corticosteroids and bronchodilators, also have shown some benefit in reducing dyspnea (Rabinovitch N, et al. J Allergy Clin Immunol Pract. 2022;10:2748-2749).

In patients presenting with symptoms of vocal cord dysfunction, a referral to an ear, nose and throat specialist may be warranted for consideration of direct laryngoscopy (Aviv JE, et al. Int J Pul & Res Sci. 2020;4:555641).

If patients do not respond to conservative therapy, pediatricians may consider referral to an appropriate pediatric subspecialist for further evaluation. Subspecialist care may involve further testing, such as cardiopulmonary exercise testing to determine the necessity for pulmonary rehabilitation (Naeije R, Caravita S. JACC Heart Fail. 2022;10:214-215).

It is important to continue offering COVID-19 vaccinations to those who have not completed their series not only to reduce the severity of acute disease and its chance for recurrence, but also to facilitate reduction in severity and duration of respiratory symptoms associated with PASC (Taylor L. BMJ. 2023;380:491). 


Although the long-term prognosis and recovery of respiratory symptoms associated with PASC are uncertain, studies from Denmark and the United Kingdom have found most children with PASC recover within five months of symptom onset without any significant issues (Berg SK, et al. Lancet Child Adolesc Health. 2022;6:240-248; Molteni E, et al. Lancet Child Adolesc Health. 2021;5:708-718).

Despite these findings, further research is needed to fully understand the long-term effects of COVID-19 on respiratory health and determine the most effective treatment approach for pediatric patients.

Dr. Mull is a member of the AAP Section on Pediatric Pulmonology and Sleep Medicine. Dr. Lowe is a member of the AAP Section on Pediatric Trainees. 

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