Managing Breathing Difficulties Associated With Long-COVID.
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A young woman, feeling ill, is sitting on her living room sofa and coughing.

Long-COVID (medically known as Post-Acute Sequelae of COVID-19 (PASC))— causes a variety of complex symptoms. Breathing discomfort, fatigue, and cognitive challenges are three of the most prevalent. In 2021, the American Academy of Physical Medicine & Rehabilitation (AAPM&R) developed a series of guidelines for diagnosing, assessing, and treating these conditions. This lays the groundwork for best-practices for managing the major manifestations of long-COVID. Today, we will highlight information particularly about the breathing discomfort and respiratory symptoms seen in long-COVID and discuss the main elements of their diagnosis and treatment.

Symptoms and manifestations.

While COVID-19 infections impact the entire body, it is largely a respiratory virus that affects cells in the lungs and airway causing characteristic symptoms such as cough and shortness of breath. After the initial COVID-19 infection has resolved, patients with long-COVID often continue to face respiratory symptoms for weeks to months following their acute illness. These symptoms often appear as:

  • Continuing shortness of breath either with activity or at rest 
  • Chest discomfort and chest pain
  • Chest congestion
  • Chest tightness, constriction, or pressure 
  • Inability to breathe deeply
  • Cough that is either new or continuing

Patients may experience one or many of these symptoms, and they can occur alone, in combination with other respiratory challenges, or alongside non-respiratory symptoms.

Unlike fatigue, brain fog, and some other long-COVID manifestations, the severity of respiratory symptoms do tend to correlate with the severity of the original infection. For example, patients hospitalized for a severe COVID infection that required mechanical ventilation are more likely to struggle with moving air through their lungs and thus getting oxygen into their bodies. These patients are also more at risk of developing pulmonary fibrosis, which is damage and stiffening of lung tissues. It is important to note however that patients can still experience a wide variety of lingering respiratory symptoms, even if they did not require hospitalization.

Diagnosis and assessment.

When breathing problems are evaluated during the diagnosis of long-COVID, physicians may turn to a variety of methods. These evaluations may initially be done by a primary care physician but might eventually be performed by a pulmonologist or rehabilitative specialist such as a physiatrist if more advanced care is needed. Sometimes, ENT specialists will also be involved, particularly if the breathing symptoms are caused by problems in the upper airway. 

Initial assessments of long-COVID breathing difficulties may include:

  • Chest imaging—such as X-rays or CT scans. 
  • “Pulmonary function tests,” which are breathing tests that measure the lungs’ ability to move air inwards and outwards and to exchange oxygen within the body. 
  • Lung capacity and exercise tolerance tests, such as 30-second sit-to-stand tests, 2 minute step-tests, and 6 minute walk-tests.
Other tests examine heart function alongside lung function and are used to perform more specific assessments on patients suffering from associated conditions along with long-COVID:

  • Echocardiogram, or ultrasound of the heart
  • Cardiac stress test, which measures the heart’s ability to work under exertion
  • Cardiopulmonary exercise testing, which measures the heart and lung’s response to exercise

If possible, it is especially helpful to have information on pre-COVID-19 respiratory status and medical history during your long-COVID evaluation, including descriptions of any previous breathing challenges or respiratory symptoms; baseline exercise capacity; results from any prior pulmonary testing; and copies of any prior chest imaging. This will allow for comparison of pre and post COVID-19 statuses and allows for easy progress-tracking.



Treatment for breathing challenges in long-COVID will depend on the severity of symptoms and rate of their improvement. For less severe symptoms, self-directed breathing exercises can be used to help return to baseline lung capacity and bring breathing mechanisms back to normal. 

Rehabilitative therapies are another vital element of treating breathing challenges. Physical therapy, occupational therapy, and speech and language pathology are all extremely effective programs commonly used for returning to normal breathing function. Each therapy works in unique ways to counter shortness-of-breath and associated fatigue, as well as increase pulmonary muscle strength and function.


While breathing exercises and rehabilitation are the focus of treatment, medications, such as inhalers, or even supplemental portable oxygen can sometimes be prescribed to treat breathing difficulties in long-COVID, especially if pulmonary function is severely impaired, or if there is an underlying history of respiratory disease. 

Just like with many other medical conditions, accessing and maintaining medical care for long-COVID can be challenging. If personal circumstances or other barriers make it difficult to attend office visits or maintain regular appointments, telehealth options can sometimes be used.  Many clinicians offer self-guided manuals for rehab instructions that allow exercises to be performed independently. Oftentimes, the final stage of rehabilitation for breathing challenges in long-COVID leads to maintenance of independent, at-home exercises as symptoms improve over time—regardless of how the symptoms were treated initially—as continuing self-guided breathing exercises over the long term can ensure sustained improvement and progress.

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