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Completed COVID Treatment, What Next?

Post COVID Care by Prof Nibedita Pani

Dept Of Anasthesiology And Critical Care Sriram Chandra Bhanj Medical College, Cuttack

If you have just recovered from COVID-19 or returned home from the hospital, you have already won the war. Pat yourself and get ready for some smaller battles as you get back to your routine life.

Question Arises

How to manage the after effects of COVID-19?
What to do for post-COVID fatigue?
What to do if you have a cough and too much mucus?
What to do if you have chest congestion?
How to deal with anxiety in post-COVID-19 patients?
What to do if you are feeling breathless?
Post-COVID diet: what to eat after COVID-19?
How to resume normal physical activity and exercise after COVID-19?
When to see a doctor?

After COVID-19 treatment, you may still experience some symptoms such as:

Low energy levels and fatigue
Difficulty breathing, and becoming breathless with even a little bit of physical exertion
Chest congestion and a lot of phlegm
Cough with phlegm
Poor appetite and/or changed taste in the mouth
Headaches
Difficulty remembering things and poor concentration
Anxiety
Difficulty falling asleep
Fear of relapse or a family member contracting the illness
Nightmares or bad memories of your time in the hospital

Fatigue

Fatigue is a common sign of viral infection. This is because the body diverts a lot of energy from the normal body processes to the infection. Some patients with COVID-19, however, report feeling extremely fatigued—a symptom that can continue for a little while after they beat the disease.

What to do for post COVID fatigue?

You can try these six tips to deal with fatigue after COVID-19:

Make a new timetable with your current energy levels in mind. Plan meticulously
Reorganize your space/office/desk to reduce energy consumption.
Be honest about how much you can take, and the things that need your input. Assign a priority to the tasks you set for yourself.
Go slow: pace yourself
Don’t overlook how you are feeling
Eat energy-boosting foods like Bananas, apples, oranges (or freshly squeezed orange juice), goji berries and sweet potato are great for getting energy quickly. You can also add a little bit of honey to warm lemon water and drink that for a quick pick-me-up. When you are feeling really low energy, sipping on water can be surprisingly helpful. Try it.

Cough

What to do if you have a cough and too much mucus?

How to manage a dry cough?

1. Drink lots of fluids. This should include warm drinks like an infusion of Tulsi (Basil) leaves in boiled water or honey and lemon in warm water.

1. Try to avoid alcohol, sugary drinks and coffee for some time, as these can cause dehydration.
2. Sip on water throughout the day—don’t gulp several glasses at a time, sip slowly and frequently.
3. If you don’t have water or anything else to drink nearby, try swallowing your saliva a few times. This can help if you need cough or your throat is very dry.
4. Inhale steam for 10-15 minutes, two to three times a day. You can also keep a humidifier in your room if the weather is dry and/or cold.

How to manage a productive cough or cough with sputum?

1. Steam inhalation can loosen the phlegm and help it to come out. Take steam twice or thrice a day, for about 15 minutes each time.
2. Phlegm can cause congestion in the chest or nose. This may disrupt your sleep—which, in turn, could adversely affect you recovery.
3. Try sleeping on one side rather than flat on your back. You could also sleep in the high side-lying position (on one side, with your head raised on multiple pillows).
4. Drink lots of fluids, including high-protein and high-energy drinks like bone broth, and vegetables and lentil soup.
5. You can also drink kadha (Soup) made by boiling ginger, (Basil leaves) tulsi and black pepper in water for 5-7 minutes.

What to do if you have chest congestion?

Exercise to ease chest congestion

Active cycle of breathing: This is a multi-step breathing exercise that may help some former COVID-19 patients to expel phlegm and chest congestion. Here’s how to do it:
Sit comfortably in a chair. Relax your shoulder by pushing them down and away from your ears. Take two or three number breaths to get comfortable.
Now, take three or four belly breaths: place one hand on your chest and the other on your tummy. Breathe in through nose. Try to fill your stomach (rather than chest) with air.
Now expel your breath in two huffs: imagine you are trying to fog up a mirror to clean it. Use your chest and stomach muscles to breathe out slightly forcefully.

Position for congestion

You could try one of these positions for draining the lungs:
Lie down on your right side with one or two pillows under your hip s. You can also increase the number of pillows to three, drain the lower lobes (sections) of the lungs.
Lie down on your right side with two or three pillows under your head. Cross your left arm over your chest if this feels comfortable.

When you should not assume these positions:

You are feeling nauseous
There’s blood in your phlegm
You feel dizzy
You have acid reflux or heartburn
The position makes you breathless

How to deal with anxiety in post-COVID-19 patients?

Stop watching the news about the pandemic if it makes you unhappy or anxious in any way.
If this is not possible, limit your exposure to news to only a few minutes a day and only reliable channels, newspapers or news sites.
Take up meditation or yoga to de-stress and jumpstart your physical recovery.
Practise relaxation techniques such as: Visualisation: Imagine you are in a place you really like. It could your mom’s kitchen, a favourite holiday spot, your favourite library. Really think about the details of this place: what does it smell like, what can you see, is it cosy here breezy.
Ground yourself: Engage all five senses, to really become present in the moment. List five things you can see, four you can hear, three you can touch, two you can feel and one you can taste.
Stay connected with friends and family over the phone and video calls.

What to do if you are feeling breathless?

Shortness of breath is one of the more serious symptoms of COVID- 19—the infection can reach the air sacs (alveoli) and cause inflammation and fluid build-up in the lungs (pneumonia).
Some of the breathing difficulties may persist in the post-treatment recovery phase of COVID-19 as well. The reason: COVID-may cause a pulmonary embolism (blockage in the tiny blood vessels of the lungs, by blood clots and debris that is left behind a hyperactive immune response) and/or post-COVID lung fibrosis (scarring of lung tissue) in some patients.

There are at least two ways you can manage breathlessness after COVID-19:

By assuming breathing positions
By doing some breathing exercises

Let’s look at them one by one.

1) Breathing Problem

These aren’t difficult or even challenging positions. The point is to make you comfortable, and help you get as much air into your lungs as possible. Try one of these positions anytime you feel breathless:

Seated upright:

Sit comfortably but upright in a chair or sofa.
Relax your shoulder by lifting and dropping them once or twice —or simply try to increase the distance between your ears and shoulders.
Place your hands in your lap.
Keep your eyes op gaze soft and look forward.
Try to breathe slowly.
Sitting straight helps to remove obstructions in the airways. Relaxing the shoulders can reduce anxiety and improve breathing.

Seated, bent forward:

Sit comfortably in a chair.
You can put your forearms on the arm rests of the chair or your thighs an lean slightly forward.
Don’t do this if you feel dizzy, though.
Leaning forward improves “ventilatory capacity” or the ability your lungs to take in more air.

Seated with head laid down:

If you are sitting in front of a desk, make a pillow with your arms
and lay your head down.
Look to one side—rest one of your cheeks on the arms rather than the forehead.
You can also keep a chair cushion or pillow under your cheek.

Standing with back support:

Lean your back against a wall.
Bring your feet slightly forward, away from the wall.
Focus relaxing your shoulders.

Standing, forward bend:

Face a wall or window sill.
Lean forward slightly and rest your palms on the wall or your elbow the window sill (make sure the window is secure and there is no risk of you falling out).

High side-lying:

Place four or five soft pillows on your bed and lay down on one side with your head resting on the pillow
This position is also good to sleep if nasal congestion (blocked nose) is giving you sleepless nights.

2) Breathing Exercises:

It can be quite scary when you can’t breathe properly. It is also completely understandable if this brings up bad memories of you stay in the hospital or the sickbed at home. However, your immediate goal when you are out of breath should be to regularize your breathing. Try not to panic and focus on doing one of these exercises:

Belly breathing:

Sit comfortably in a chair. You back should be upright but supported.
Now place one hand on your chest the other on your tummy.
As you breathe in through the nose, feel the hand on your tummy rising.
Breathe out through your mouth and observe the hand on your tummy returning to its original spot.
Breathe comfortably.
Research has shown that when we breathe in through the nose, there’s a natural injection of nitric oxide into the body. This helps the lungs to take up more oxygen with each breath.

Trace a rectangle:

This exercise can help you regularise your breathing by getting into an easy rhythm.
Start by finding a small rectangle in your room: a computer monitor, television screen or window frame will do.
Breathe in as you move you gaze from one end of the shorter side of the rectangle to the other end.
Breathe out as you look down the long side of the rectangle.
Do this for one or two minutes or until your breathing becomes more rhythmic.

Paced breathing:

Climbing stairs and walking longer distances may leave some recovered patients winded.
Rest assured it will get better little by little.
You can gradually increase the distances you walk and stairs you climb by following this rhythm of breathing:
Breathe in before you take a step up.
Breathe out as you step up one stair.
Rest and breathe in before climbing again.
Pulmonologists warn that supplemental oxygen will not ease breathlessness in these circumstances. It is much better to focus your attention on one of the exercises described above. Feeling breathless can also cause anxiety, which can make breathing even more difficult. It’s not easy, but it is important to try and stay calm.

Post-COVID diet: what to eat after COVID-19

During this time, it is important to eat foods that help you rebuild muscle, immunity and energy levels.
Your diet should be rich proteins, vitamins and minerals, but you should eat something from all food groups.
Whole grains like wheat, ragi and oats are a storehouse of healthy carbohydrates—the body’s main source of energy. Meat, fish, eggs are great sources of protein. Drinking bone broth or chicken soup is also a good idea. If you are a vegetarian you could eat lentils, beans, soybeans, nuts and seeds.
You should consume healthy fats found in nuts like walnuts and almonds. Cashews are a good source of zinc, which boost your immunity and eases some flu-like symptoms
Dairy products: You can have turmeric milk once a day to
boost your immunity and build up strength again.
Soymilk, tofu cottage cheese are also good vegetarian sources of protein.
For adequate vitamins and mineral, eat at least five servings each of vegetables and fruits in a day.
Fruits contain a natural sugar known as fructose which is easily absorbed in the body—that’s why eating fruits gives you energy quite quickly.
You should, as they say, “Eat with the rainbow”. This
means, try to include different colors on your plate.
Purple from berries, from carrots, yellow from yellow bell
peppers, green from peas, and so on.
Eat foods that lift your mood and boost your immunity,
like dark chocolate (at least 70% cocoa).
Add plenty of fiber and water in your diet to improve gut health.
Some of you may experience loss of sense of taste
(ageusia). Or difficulty swallowing may kill your appetite.
It is important eat at regular intervals despite these problems.
If you don’t find the food palatable, try adding pickles and
jams to make the taste sharper.
If you are having difficulty swallowing, try blending your food into a smooth paste or cutting it up into very tiny pieces.

How to resume normal physical activity and exercise after COVID-19

If you’ve spent many days or weeks convalescing in bed, then you might have also had some “physical deconditioning” meaning your muscles aren’t used to some movements now.

Devoting 20-30 minutes a day, five days a week to the exercises you can do will help you regain your strength and improving breathing faster.
You can do some of the exercises standing up or sitting down, whichever is possible for you in your current stage of recovery.
Spend five minutes doing warmup. Sit on a chair. Shrug your shoulders up and down, lift each knee by turn, rotate the ankle and the wrists and if possible, bend from side to side.
For the main workout, you can do cardio exercises like marching on the spot, climbing up and down on one step in your staircase (you can hold the handrail for support), or walking outdoors.
Strength exercises like wall pushups (doing standing pushups by placing your hands on the wall instead of the floor).
Supported squats (with you back against the wall),
Bicep curls can help you build up strength in the muscles again and heel raises (you can stand behind a chair or take support from a wall as you come on your toes).
Try to do some strength exercise thrice a week. You can start with three sets of 10 repetitions and gradually increase the weights, repetitions and difficulty level.
Always end a workout with stretching exercises. For example, you could extend your arms to the sides (at shoulder level) turn your palms up and down, bend slowly from side to side, give a gentle stretch to your hamstrings by sitting on a chair a leaning forward slightly
These are just some suggestions to get you started. You can do a host of other things.
Take up morning walks when you feel you walk for a few minutes without getting severely out of breath or tired.
Remember also that it is normal to become slightly out-of- breath while working out.
If you can talk with a little bit of difficulty between sets, there’s nothing to worry about.
But if you can’t get two words out without huffing for
breathing, slow down.

When to see a doctor

If all goes well, you should feel a little bit stronger and a little bit happier every day. That said, there are some things you should look out for during this period. The following could indicate the need for medical attention:
A little bit of breathlessness is to be expected, especially during exercise or strenuous physical activity.
However, if your breathing difficulties increase in frequency and/or intensity while you’re resting and the breathing positions and exercises , you should call your doctor.
If you become breathless after even a little bit of activity and this does not improve over the next few days, call your doctor
If you develop fever again, or if your body temperature keeps rising and coming back to normal, call your doctor.
Call your doctor if you have chest pain or a feeling of pressure in your chest.
If your memory and focus don’t improve, check in with your doctor.
If you experience new confusion—that is, you develop confusion as a symptom now—see your doctor immediately.
If you are finding it difficult to do your daily chores despite trying for a few days, ask your doctor to recommend an occupational therapist.
If your anxiety and mood become worse rather than improving over the next few days, call your doctor or the government helpline.
If you are still experiencing any of these symptoms six to eight weeks after being declared COVID-free, visit your doctor.
If the recovered patient is a child up to19 years, see a doctor if he or she gets a fever for 24 hours along with any of these symptoms
Breathing difficulty
Confusion
Bluish lips and face
Diarrhea
Vomiting
Rashes
Red eyes
Swollen hands or feet

Takeaways

The really hard part is over. Now you just need to be patient with yourself and
keep trying to increase your strength and stamina through a healthy diet, exercise
and self-care routine.
Try to push yourself to do a little more every day. Managing your symptoms like fatigue, cough, breathlessness and anxiety is important in this phase of convalescence. So, listen to your body.
If your symptoms don’t get better within six to eight weeks, if they become worse or if you develop new symptoms like chest pain or confusion, visit your doctor.
Consider donating plasma 28 days after your doctor declares you COVID -free if you are between 18 and 55 years old. Doing this could bring you a sense of purpose
and happiness—research shows that the act of giving brings us much more pleasure than we give it credit for. Do make it a point to check who can give blood plasma before going to a donation centre.

The recovery period is likely to be longer for patients who suffered from more severe form of the disease and those with pre-existing illness.

Post-COVID Follow Up Protocol

I. At individual level

Continue COVID appropriate behavior (use of mask,
hand & respiratory hygiene, physical distancing).
Drink adequate amount of warm water (if not contra- indicated.
If health permits, regular household work to be done.
Professional work to be resumed in graded manner
Mild/ moderate exercise
Daily practice of Yoga or Meditation, as much as health permits or as prescribed.
Breathing exercises as prescribed by treating physician.
Daily morning or evening walk at a comfortable pace as tolerated.
Balanced nutritious diet, preferably easy to digest freshly cooked soft diet.
Have adequate sleep and rest.
Avoid smoking and consumption of alcohol.
Take regular medications as advised for COVID and also for managing comorbidities, if any. Doctor to be always informed about all medicines that the individual is taking so as to avoid prescription interaction.
Self-health monitoring at home – temperature, blood pressure, blood sugar (especially, if diabetic), pulse oximetry etc. (if medically advised)
If there is persistent dry cough / sore throat, do saline gargles and take steam inhalation.
Cough medications, should be taken on advice of medical doctor.
Look for early warning signs like high grade fever, breathlessness, Sp02 < 95%, unexplained chest pain, new onset of confusion, focal weakness

II. At the level of community

Recovered individuals to share their positive experiences with their friends and relatives using social media, community leaders, opinion leaders, religious leaders for creating awareness, dispelling myths and stigma.
Take support of community-based self-help groups, civil society organizations, and qualified professionals for recovery and rehabilitation process (medical, social, occupational, livelihood).
Seek psycho-social support from peers, community health
workers, counsellor. If required seek mental health support service.
Participate in group sessions of Yoga, Meditation etc. while taking all due precautions like physical distancing.

III. In healthcare facility setting

The first follow-up visit (physical/telephonic) should be within 7 days after discharge, preferably at the hospital where he/she underwent treatment.
Poly-therapy is to be avoided due to potential for unknown drug- drug interaction, which may lead to Serious Adverse Events (SAE) or Adverse Effects (AE).
The patients who had undergone home isolation, if they complain of persisting symptoms, will visit the nearest health facility.
Severe cases requiring critical care support will require more stringent follow up.

According to the American Psychological Association (APA), a study published in The Lancet Neurology in July 2020 and another published in The Lancet Psychiatry in June 2020, even patients who’ve had mild to moderate symptoms of COVID-19 are likely to grapple with cognitive changes in the aftermath.

The WHO recommends that you and your family recognize these difficulties related to attention, memory and thinking clearly, and adopt the following strategies to manage them.

Adjust expectations: It’s quite natural for memory and concentration issues to come up after being unwell, so don’t beat yourself up about not being able to get back to your old life and abilities immediately. Take your time, give your mind and body a chance to recuperate.
Brain exercises: Start new activities or hobbies that stimulate the brain, like puzzles, word games, number games, memory exercises and reading. Start with exercises which are achievable, and gradually challenge yourself to increase acuity.
Prompt yourself: Lists, notes, alarms and reminders can prompt you to get back to activities which you might be missing out on due to brain fog. These can also help you create a routine, which is one of the best ways to feel in control and get back to normal life.
Physical exercise: Exercising may be difficult if you’re also dealing with fatigue and breathlessness, but gently and gradually introducing them back into your daily life will make you both physically and cognitively stronger.
Break it down: Remembering or concentrating on all the steps of a complicated action might be difficult, so break down the steps and take them one at a time. The prompts mentioned above can come in handy here too.
Pace yourself: Slow down. Restlessness in times like these is understandable but you can’t rush your mind and body back into order, especially in the aftermath of a disease like COVID-19. Get into your old activities gradually, and if it feels too overwhelming, then take time off to recover or talk to a specialist.
Let others help: Accepting help from those you share your life with won’t harm you. Instead, it can make the recovery process easier and the cognitive difficulties less frustrating if you have company. Let your family and friends help you. In fact, ask them to join you in creating memory and concentration games. This will not only help you overcome your issues but also help those around you deal with stress.

WHO guidelines:

Dizziness, headaches, diminished cognitive abilities like lack of concentration, memory recall and recognition and brain fog (thinking clearly) are likely to show up.
The World Health Organization (WHO) says these difficulties may go away within weeks or months of you starting your recovery but for some people, they can last for a longer time.
These difficulties can have an impact on your relationships, daily activities and your professional life as you get back to it, so you and your loved ones should take them seriously.

Building Positive Mental Health in Nine Simple Steps

Effective habits for a healthy life, take simple steps every day to improve mental health and enhance well-being:

Get Good Sleep
Practice Meditation
Exercise Regularly
Connect Socially
Learn New Skills
Eat Healthy
Avoid Alcohol and Drugs
Reduce Screen Time / Media Exposure
Connect with Nature

Do not neglect your mental health

Everyone experiences mental health issues in life. Taking individual steps to build mental health resilience, and seeking external support when necessary, makes it easier to cope with such issues.

Positive mental health enables people to realize their potential, cope with the normal stresses of life, work productively, and contribute to their communities.

Help someone going through mental health issues

LISTEN: Listen to the person closely, with empathy, and without judging.
INQUIRE ABOUT NEEDS AND CONCERNS: Assess and respond to various needs and concerns — emotional, physical, social and practical. (e.g. childcare)
VALIDATE: Show that you understand and believe the person. Assure the person that he/she is not to blame.
ENHANCE SAFETY: Discuss a plan to protect the person from harm.
SUPPORT: Support the person by providing access to information, services and social support.

Do not discriminate against those undergoing mental health issues!

The needless stigma and shame associated with mental health prevents people from issues, asking for help. If you know someone who may be experiencing such issues, encourage them to take steps towards building positive mental health.

Remember It is normal to experience mental health issues. You can take control of your mental health by taking small conscious steps every day for prevention and treatment.