PASC Pulmonary Symptoms: Approach to Dyspnea and Cough

Please Note: The information below is intended for healthcare professionals, specifically primary care providers. These are not meant to be guidelines or supplant individual provider discretion in the management of PASC, as evidence-based consensus guidelines for the diagnosis of management of this new disease do not exist currently. The following represents the expert opinions of an interprofessional group that is appraising emerging evidence and should be interpreted as recommendations and clinical guidance rather than the standard of care.

PASC Pulmonary Symptoms: Approach to Dyspnea and Cough

Written May 12, 2021 by: W. Michael Brode, MD, Faith Noah, MS3, Matthew Seghers, MS3, and Michael Shapiro, MD

Dyspnea Workup PASC

Cough (50%) and shortness of breath (29%) are predominant symptoms of acute COVID-19, with a persistent cough lasting 2-3 weeks after the initial illness in many cases.1,2 These symptoms resolve slowly in the majority of patients by 3 months without specific treatment,2,3 but for patients with mild disease approximately 10% can still experience these symptoms at 6 months.4

For patients who were hospitalized with COVID-19 pneumonia or ARDS, reduction in diffusion capacity of the lungs (DLCO) is closely related to disease severity. Reduced DLCO at 6 months has been found in 29% of patients who required oxygen by nasal cannula, and 59% of patients who required high-flow nasal cannula (HFNC) or mechanical ventilation.5

Dyspnea and persistent cough have also been commonly described in 41% of patients 3 months after hospital discharge in the absence of PFT or other objective exam/radiographic abnormalities.6

Evaluation should focus on the history/severity of the acute COVID-19 illness and underlying comorbidities. Hospitalized patients with COVID-19 are at risk of pulmonary fibrosis, bronchiectasis, restrictive lung disease on pulmonary function tests (PFTs), or neuromuscular weakness from post-ICU syndrome. Development of organizing pneumonia has also been described, as either sequelae of the initial COVID-19 infection or late phase complication, especially in those with underlying autoimmunity.7–9

Chest x-ray (CXR) is the initial screening test of choice for patients with persistent respiratory symptoms. We recommend waiting 3 months from the initial illness to get a CXR, as the bilateral diffuse ground glass opacities of initial illness usually resolve at 4 weeks but may take up to 12 weeks.5,7

  • If a new or persistent abnormality is noted on CXR, we recommend obtaining a high-resolution CT (HR-CT) of the chest without contrast to further evaluate.
  • The radiographic pattern of infiltrates on HR-CT can occasionally be diagnostic, but if it’s not it should prompt further evaluation with PFTs and referral to a pulmonologist.

If CXR is normal, we recommend ruling out other systemic or thromboembolic disease with baseline labs and obtaining PFTs.

  • Elevated d-dimer should prompt CT chest angiography to rule out pulmonary embolism or chronic thromboembolic pulmonary hypertension.

PFTs should include spirometry, lung volumes, and diffusion capacity. If PFTs are abnormal but non-diagnostic, obtaining a HR-CT and referral to a pulmonologist is recommended.

If CXR, PFTs, and initial labs are all normal, obtaining a transthoracic echocardiogram (TTE) to rule out structural heart disease or pulmonary hypertension is reasonable (see section on PASC Cardiology and Dyspnea for further info). Patients should also do an ambulatory walk test that measures their SpO2 with a pulse oximeter while walking (either in clinic or patient can complete at home). Desaturations < 88% should be investigated by a pulmonologist.

Pulmonary abnormalities on PFTs or HR-CT chest are clear indications for referral to a pulmonologist for consideration of further testing such as bronchoscopy or lung biopsy. Organizing pneumonia responds well to corticosteroid treatment, and there are newer agents such as pirfenidone available for pulmonary fibrosis, but these are best administered by a specialist and their use for PASC specifically is still be investigated.

Patients with neuromuscular weakness from prolonged ventilation are best treated in a dedicated interdisciplinary post-ICU clinic, or other clinic that can meet these complex rehabilitation needs.

  • A significant portion of patients can have dyspnea with a negative workup outlined above.
    • Patients without objective abnormalities or ambulatory desaturations have no contraindications to start a trial of graduated exercise, either independently or under the direction of a physical therapist. Patients should be counseled to start slowly as post-exertional malaise has been widely reported, with gradual increase in intensity as tolerated.
      • Patients who cannot tolerate a graduated exercise plan due to dyspnea (not fatigue or myalgia) should be referred to pulmonology or cardiology for consideration of cardiopulmonary exercise testing (CPET)

Chronic cough without abnormalities should be treated similarly to a post-viral chronic cough. Evaluation should rule out other causes of chronic cough (e.g. cough variant asthma, upper airway cough syndrome, GERD). Treatment is supportive including benzonatate capsules (Tessalon Perles) or over the counter cough medications (e.g. guaifenesin, dextromethorphan).7,10

  • The use of albuterol inhalers or corticosteroids is not recommended without PFT evidence of bronchospasm.

1. Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance - United States, January 22-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(24):759-765. doi:10.15585/mmwr.mm6924e2

2. Xiong Q, Xu M, Li J, et al. Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal study. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2021;27(1):89-95. doi:10.1016/j.cmi.2020.09.023

3. Garrigues E, Janvier P, Kherabi Y, et al. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. J Infect. 2020;81(6):e4-e6. doi:10.1016/j.jinf.2020.08.029

4. Logue JK, Franko NM, McCulloch DJ, et al. Sequelae in Adults at 6 Months After COVID-19 Infection. JAMA Netw Open. 2021;4(2):e210830. doi:10.1001/jamanetworkopen.2021.0830

5. Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. The Lancet. 2021;0(0). doi:10.1016/S0140-6736(20)32656-8

6. Carfì A, Bernabei R, Landi F, for the Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020;324(6):603. doi:10.1001/jama.2020.12603

7. George PM, Barratt SL, Condliffe R, et al. Respiratory follow-up of patients with COVID-19 pneumonia. Thorax. 2020;75(11):1009-1016. doi:10.1136/thoraxjnl-2020-215314

8. Lu J, Yin Q, Zha Y, et al. Acute fibrinous and organizing pneumonia: two case reports and literature review. BMC Pulm Med. 2019;19(1):141. doi:10.1186/s12890-019-0861-3

9. Wang Y, Jin C, Wu CC, et al. Organizing pneumonia of COVID-19: Time-dependent evolution and outcome in CT findings. PLoS ONE. 2020;15(11). doi:10.1371/journal.pone.0240347

10. COVID-19: Evaluation and management of adults following acute viral illness - UpToDate. Accessed April 18, 2021.…