COVID-19 is a systemic disease, but the lungs are the most commonly affected organs. The types and severity of respiratory and functional symptoms in COVID-19 long-haulers, however, are unknown. In addition, the functional impairment associated with COVID-19 may also be associated with adverse psychological outcomes. Using a multidisciplinary approach, a January 2021 study in Italy explored the functional and psychological factors associated with long COVID-19.*

What they did

The prospective cohort study was conducted at Azienda Ospedaliero–Universitaria Maggiore della Carità university hospital in Novara, Italy, from March 1-June 29, 2020. It involved 238 patients, with an average age of 61 years old, who had received a confirmed diagnosis of acute respiratory coronavirus infection severe enough to require hospital admission. 

The primary outcome of the study was to identify and describe the proportion of patients with a diffusing lung capacity for carbon monoxide (DLCO) of less than 80% of the expected value, given their age and sex. 

Secondary outcomes included:

• Patients with severe lung function impairment (defined as DLCO of less than 60% expected value)
• Patients with functional impairment
• Patients with post-traumatic stress symptoms (PTS)
• Factors associated with DLCO reduction and psychological or functional symptoms

All patients were given:

• Standard pulmonary function testing (PFT), regarding:
  • Forced expiratory volume
  • Vital capacity
  • Forced vital capacity (FVC) 
  • DLCO
  • DLCO constant
  • Total lung capacity
• Short Physical Performance Battery (SPPB) testing, which includes:
  • Balance assessment in a standing position 
  • Walking speed for four minutes
  • Standing up from a chair with five repetitions 
• Impact of Event Scale-Revised (IES-R) survey, a 15-item self-rated four-point scale based on how often an event has occurred in the past seven (7) days to assess the presence of PTS symptoms, such as:
  • Nightmares
  • Intrusive thoughts

An SPPB score over 10 is the expected value for healthy individuals. To improve functional impairment detection, patients with SPPB scores over 10 were tested with the two-minute walk test. That score was compared with reference data for an age- and sex-matched population.

What they found

The study results showed that more than half of the participants had a significant reduction of DLCO or measurable functional impairment, and approximately one-fifth (⅕) of patients had symptoms of PTS four months after hospital discharge.

• Of the 238 participants, 219 were able to complete both pulmonary function tests and DLCO measurement. DLCO was reduced to:
  • Less than 80% in 113 patients (51.6%)
  • Less than 60% in 34 patients (15.5%)
• The SPPB score suggested limited mobility in 53 patients (22.3%). Of the patients with SPPB scores over 10 who underwent the two-minute walk test:
  • 75 of the patients (40.5%) showed limited mobility, making the total number of participants with motor impairment 128 (53.8%).
• Results of the IES-R questionnaire for PTS symptoms included:
  • 61 patients (25.6%) with mild symptoms
  • 27 patients (11.3%) with moderate symptoms
  • 14 patients (5.9%) with severe symptoms 

Male sex was the only factor independently associated with moderate to severe PTS symptoms.

What it means

These findings suggest that, despite recovery from the virus, a sizable proportion of patients who had been hospitalized with COVID-19 experienced respiratory, functional, or psychological symptoms at least four months after their hospital discharge. In addition, ongoing respiratory and physical functional impairment may impact psychological health.

Risk factors associated with DLCO of less than 80% at follow-up included:

• Female sex
• Chronic kidney disease (CKD)
• Modality of oxygen delivery during hospital stay (nasal cannulae/Venturi masks, 

noninvasive ventilation, or mechanical ventilation) 

Risk factors associated with DLCO of less than 60% at follow-up were:

• Female sex
• Chronic obstructive pulmonary disease (COPD)
• ICU admission during a hospital stay

Though older age is associated with a higher fatality rate, it was not associated with reduced DLCO or impaired motor function—confirming that older people who survive COVID-19 may have the same chance as younger survivors to return to their previous state of physical health. 

*Bellan, M., Soddu, D., Balbo, P. E., Baricich, A., et al. (2021, Jan. 27). Respiratory and Psychophysical Sequelae Among Patients With COVID-19 Four Months After Hospital Discharge. JAMA Network Open. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775643 

Much about the novel coronavirus, i.e., COVID-19, is still not fully understood. As research progresses and our knowledge of the virus increases, information can change rapidly. We strive to update all of our articles as quickly as possible, but there may occasionally be some lag between scientific developments and our revisions.