1. Rachael Evans, consultant respiratory physician1,
  2. Anton Pick, consultant in rehabilitation medicine2,
  3. Rachel Lardner, respiratory physiotherapist2,
  4. Vicki Masey, respiratory physiotherapist2,
  5. Nikki Smith, lived experience expert3,
  6. Trisha Greenhalgh, professor of primary care health sciences4
  1. 1National Institute for Health Research Biomedical Research Centre – Respiratory, Department of Respiratory Sciences, University of Leicester, Leicester, UK
  2. 2Long Covid Clinic, Churchill Hospital, Oxford OX3 7LE, UK
  3. 3Person with long covid, Windsor, Berkshire, UK
  4. 4Nuffield Department of Primary Care Health Sciences, University of Oxford
  1. Correspondence to: R Evans re66{at}leicester.ac.uk

What you need to know

  • Breathing difficulties are common sequelae of covid-19

  • Typically there are multiple contributing factors to breathing difficulties within an individual

  • Breathing pattern disorder can be positively diagnosed from the history and clinical examination, but parallel investigations to rule out other causes may be necessary

  • Self management support tools may help some patients regain a normal breathing pattern

  • Further investigation and specialist respiratory physiotherapy should be considered when symptoms are not improving

Around one in four adults who were hospitalised with covid-19 and one in six who were not hospitalised experience persistent breathing difficulties beyond four weeks after SARS-CoV-2 infection,12 and a cohort study in China demonstrated that breathlessness can persist beyond two years.3 In long covid (defined as symptoms beyond four weeks4) breathing difficulties can be the predominant feature or be part of a multisystem presentation.5 Cardiorespiratory complications after covid-19 include thromboembolic disease, interstitial lung disease, and heart failure and need to be excluded. This article predominantly focuses on other, more common causes of post-covid breathing difficulties that can be treated but are often less well understood.6

Definitive, evidence based protocols and treatment for persistent breathlessness after covid-19 are currently lacking. Until they exist, the pragmatic approach outlined here, including a careful history and examination and appropriate use of investigations, should help identify treatable conditions and improve symptoms. In particular, a positive diagnosis of breathing pattern disorder (box 2) can often be made in general practice. Self management resources (box 3) should be offered early. Timely referral to specialist services is needed for patients whose symptoms are severe or progressive.

Presentation of breathing difficulties

Breathing difficulties can present in several ways, including breathlessness or pressure, tightness, soreness, and pain or burning in the chest. These symptoms can be associated with considerable distress. The general multisystem approach and investigation of …

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