Importance of Physical Therapy Interventions for Medically Complex Patient With Severe COVID-19: A Case Report : Cardiopulmonary Physical Therapy Journal

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Case Report

Importance of Physical Therapy Interventions for Medically Complex Patient With Severe COVID-19: A Case Report

Thomas, Bini PT, DPT, EdD1; Tabisz, Joanna PT, DPT2; Collins, Kelly PT, DPT1; Kim, Ok Kyung PT, DPT2; Gupte, Sharmila PT, DPT2

Author Information
Cardiopulmonary Physical Therapy Journal: October 2022 - Volume 33 - Issue 4 - p 151-156
doi: 10.1097/CPT.0000000000000201
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Abstract

INTRODUCTION

Coronavirus disease (COVID-19)1-4 has resulted in more than 47 million cases in the United States with a reported death toll of almost 760,000 as of November 20, 2021.5 Symptomatic patients with confirmed COVID-19 have reported severe pneumonia with acute respiratory distress syndrome (ARDS), hypoxemia, and death.2 Conventional oxygen therapy may be inadequate in patients with COVID-19 with acute hypoxemic respiratory failure and may require more invasive measures such as intubation and mechanical ventilation.2 At the time of this case report, there was very little known about COVID-19 and physical therapy (PT) management. The closest physiological condition to base therapeutic interventions on were studies on patients with ARDS.4 Although extracorporeal membrane oxygenation (ECMO) along with mechanical ventilation has been used for patients with severe ARDS4,6 to minimize barotrauma and oxygen toxicity,2,4 survivors often present with a longer recovery of functional abilities.4

Initiating PT interventions as soon as medically stable have been reported to prevent muscle weakness3 and increase physical function and outcomes in patients with ARDS.3 Mobility impairment is a predictor for discharge disposition; thus, limiting functional decline during hospitalization assists with discharge needs.3,6,7 Patients with obesity are at an increased risk for pulmonary complications from postoperative immobilization.8 Postoperative PT interventions are helpful to improve respiratory reserve in these patients.8 The combination of obesity, pregnancy, and COVID-19 in this case further stressed the need for a multidisciplinary approach to address the patient's complex medical presentation.

Owing to the acuity of patients with COVID-19, muscle weakness and functional decline may develop. Prolonged immobilization in patients with COVID-19 may cause detrimental effects, such as intensive care unit-acquired illnesses, neuromuscular weakness, deconditioning, and abnormal hemodynamic responses.2 This case outlines the importance of PT interventions in the functional recovery for a young female patient who had COVID-19 and was on ECMO at a level 1 trauma center.

CASE PRESENTATION

This case report discusses a 34-year-old female with morbid obesity (Body Mass Index 41), who was 35 weeks pregnant, and admitted to a community hospital with acute respiratory distress and tested positive for Severe Acute Respiratory Syndrome Coronavirus 2. Computerized tomography imaging was nondiagnostic for pulmonary embolism, consistent with pneumonia, and bilateral ground glass opacities in the lungs (Fig. 1). Pulmonary deterioration resulted in an intubation, an emergent caesarean section, sedation, and mechanical ventilation. The patient received broad-spectrum antibiotics, prophylactic heparin, and convalescent plasma therapy during the first week in the community hospital. Fiberoptic bronchoscopy was used to remove mucus plugs to help reduce plateau pressure, but the patient remained in hypoxemic respiratory failure with PaO2 at 39 and PaCo2 at 71, despite being on 100% FiO2. The patient was deemed to need ECMO support2 and was airlifted to the Level 1 trauma center for the higher level of care.

F1
Fig. 1.:
Computerized tomography scan comparison. Chest radiograph dated May 20, 2020.

During the first week of ICU admission, the patient had an elevated D-dimer, CPK, CRP, and LDH and was classified in the severe category of COVID-19. SOFA scores were obtained to predict ICU mortality based on laboratory results and clinical data.9 On admission, the patient's SOFA score was less than 9, which predicted mortality of 33%.1 Vasopressor support, continued mechanical ventilation, and ECMO support were required to keep the patient alive. The patient also had cardiac compromise including right ventricular strain as diagnosed by echocardiogram, prolonged QT interval, troponin elevation, nonocclusive and occlusive DVTs, and fluctuations in heart rate (HR), oxygen (O2) saturation, and respiratory rate (RR). She underwent tracheostomy for long-term ventilator support needs, and after 18 days on ECMO, the patient was weaned off the device but remained on mechanical ventilation.

THERAPEUTIC FOCUS

Physical and occupational therapy (OT) evaluations were initiated the day after ECMO explantation. On transfer to the Level 1 trauma center, therapies were delayed because the patient was not medically stable nor cleared to participate by the critical care team. However, the patient was turned and repositioned by the nursing staff. The patient's ECMO cannulation site was through femoral access, and she presented with a Richmond Agitation and Sedation Score of −3 until decannulation, precluding mobility until patient sedation could be reduced. Once awake and PT consulted, the patient presented with ICU-acquired weakness (manual muscle test: 3-/5 in all extremities), confusion, impulsive behavior, and visual impairment. The patient required moderate assistance x 2 for bed mobility and maximal assistance × 2 for transfers. Initial interventions included dangling and sitting with support at the edge of bed.

Mobility sessions initially required the assistance of multiple disciplines including respiratory therapy (RT), OT, and nursing because of the patient's medical acuity. There were also safety concerns because of multiple lines including ventilatory support through tracheostomy, IV lines, Foley catheter, Flexi-Seal, and Dobhoff feeding tube. RT provided support for ventilator management, trach collar trials, adjustment of oxygen delivery settings, and suctioning. Nursing assisted with pain control and line management. During the initial sessions in the ICU, PT and OT cotreated because of patient's acuity, limited endurance, and weakness.

Because the patient medically progressed out of the ICU, PT efforts focused on improving the patient's respiratory effort, lower extremity strength, endurance, core, and postural control. Mobility devices were used to assist in advancing the patient's mobility to provide extra support and ensure safety because of severe deconditioning. Initially, a motorized sit-to-stand device (Encore) was used with a supportive sling to assist with trunk control and knee support to initiate ambulation. Mobility progression on transferring out of the ICU was based on ongoing monitoring of hemodynamic responses to activity and was coordinated with respiratory therapy to adjust ventilatory parameters. Patient’s arterial blood gas analysis and vitals are shown in Table 1. Because the patient increased tolerance to therapy, there was no longer a need for consistent cotreatment with OT Eliminate this please.

TABLE 1 - Arterial Blood Gas Analysis and Vitals
Date PH PO2 PCO2 HCO3 HR RR BP SPO2
May 1, 2020 7.5 39 71 44 101 10 110/58 87
May 2, 2020 7.49 63 56 43 101 10 110/58 87
May 8, 2020 7.37 54 82 48 98 10 125/71 94
May 11, 2020 7.41 62 42 27 80 10 145/79 91
May 15, 2020 7.42 85 54 35 94 21 93/39 97
May 17, 2020 7.43 74 46 31 112 38 151/79 91
May 18, 2020 7.46 136 46 33 91 14 133/53 93
May 19, 2020 7.46 90 38 27 92 14 133/53 94
May 20, 2020 7.48 111 41 31 125 21 113/60 98
May 22, 2020 7.46 122 38 27 96 25 122/65 100
May 25, 2020 84 24 113/52 100
May 26, 2020 87 30 100/85 100
May 30, 2020 110 21 125/64 100

The patient progressed to the use of a platform walker (Ro Walker), which also assisted with thoracic extension and improved posture to facilitate ventilation. This device was also used because it safely accommodated the patient's body habitus and included a seat feature to allow for rest breaks and energy conservation. Quick access and accommodation for a seated rest break was important with the patient's deconditioning, elevated HR of >140 bpm with ambulation, and general acuity. Although the patient was able to tolerate resting on a trach collar, physical therapy continued to be provided in conjunction with RT because a portable ventilator was used to facilitate patient progression during therapy sessions. Tracheostomy suctioning and ventilator management provided by RT during PT sessions were vital to the patient's improved tolerance to activity.

Education was a key intervention in the management and progression of this patient. A home exercise program (HEP) was introduced at the initial PT evaluation through printed handouts and demonstration. The patient performed the HEP diligently because she was motivated to return home to her children and family. The patient's spouse was routinely included by the therapy staff in patient/family education through video phone call because in-person hospital visitation was not allowed during this time in the pandemic. Additional therapy efforts included education on plan of care of all therapies and therapists' roles, mobility safety, therapy progression, breathing technique, energy conservation, and swallow strategies on the Passy Muir® valve. Therapy intensity was dictated by the patient's tolerance and vital signs, such as HR, RR, and O2 saturation. Frequent rest periods were encouraged to avoid reaching the anaerobic threshold during sessions. After 30 days of multidisciplinary aggressive treatment, the patient was successfully transferred back to the referring community hospital, where she was subsequently weaned off of mechanical ventilation followed by successful tracheostomy decannulation and was discharged home. A chronological outline of major events and PT interventions is shown in Table 2.

TABLE 2 - Timeline of Events and PT Interventions
Date Event Action/Intervention
April 22, 2020 Presented to ER with hypoxic respiratory failure, 35 weeks IUP SARS-CoV-2+, 15 LPM O2 through nonrebreather, emergent caesarian section, and intubated
April 23, 2020 Elevated D-dimer  CTA nondiagnostic of PE, moderate bilateral ground glass opacities. Heparin started
April 27, 2020 Cytokine release syndrome (CRS) Grade 4 Convalescent plasma treatment
April 30, 2020 ARDS (acute respiratory distress syndrome) Flolan started, proned all night
May 1, 2020 Ongoing respiratory distress, need for pressor support, ARDS, CRS Grade 4 Multiple bronchoscopy procedures for mucus plug removal. Transferred to level 1 trauma center for ECMO support.
May 4, 2020 Ongoing need for mechanical ventilation  Tracheostomy
May 13, 2020 Ongoing bronchopneumonia, remains sedated on paralytics Bronchoscopy
May 17, 2020 Patient more alert, responding inconsistently, and improved urine output Patient off pressors and nitric oxide, weaning of ECMO support
May 19, 2020 ECMO decannulated, patient started following simple commands. Pt with severe deconditioning. PT/OT eval/treatment initiated. Transfer training, sitting balance with mod to max Ax2
May 20, 2020 Febrile, tachycardia  Bed exercises, patient education for home exercise program
May 22, 2020 Remained febrile but stable enough to participate in PT PT initiated sit–stand with encore. Ongoing therapeutic exercises, standing balance, and core engagement.
May 25, 2020 Transfer from ICU to cardiac tele floor, tracheostomy and on vent support Initiated ambulation (125 feet) with encore on vent support, coordinated with RT for vent and oxygen management
May 26, 2020 Improved sitting balance, endurance  Started seated ADLs with OT Unsupported sitting, core strengthening, and ambulation (20 feet) with RO Walker and MinAx1+1
May 30, 2020 Improved standing balance, endurance  Progressive ambulation with RO Walker and MinAx1+1 for 290 feet. Transferred back to community hospital.
PT, physical therapy; SAR-Cov-2, Severe Acute Respiratory Syndrome Coronavirus 2.

PATIENT OUTCOMES

The AM-PAC outcome measure is a standardized assessment of patients' function and an accepted tool for discharge recommendations.10 On initial evaluation, the patient's AM-PAC score was 6 and had increased to 17 on day of discharge from the level 1 trauma center. This upward trend is significant because the score at the time of evaluation indicated that the discharge recommendation for this patient should be a rehabilitation institution. However, within 8 PT visits, remarkable physical improvement increased the patient's AM-PAC score to predict discharge home after completing the remainder of her inpatient stay back at the community hospital.

Other outcomes measured included patient tolerance to activity and ability to participate in therapy. Within 11 days, the patient had progressed bed mobility from moderate assistance × 2 to supervision. After 3 therapy sessions, the patient was able to initiate standing activity with moderate assistance × 2, progressing to minimal assistance × 1 on the sixth therapy treatment session. Interval gait had been initiated on the fourth session with intervals of 25 feet, 50 feet, and 50 feet with seated rest breaks. Five days later on the eighth and final session, the patient was able to walk 290 feet with only 1 standing rest break for ventilator oxygen tank exchange.

DISCUSSION

This case highlights a patient with complex medical issues, including morbid obesity, recently postpartum, and severe COVID-19, requiring mechanical ventilation and ECMO. During this encounter, the patient was ventilator dependent and had exhausted all life-saving measures yet was able to recover quickly partly because of the contribution of PT. Despite a high mortality prediction as per the initial SOFA9 scores, the patient was in stable condition on final discharge. She did not require any assistive device, was able to negotiate stairs, and no longer required supplemental oxygen. These quick gains are more salient when one takes note that the patient had been sedated and on ECMO for 18 days before initiating PT. In addition, before cannulation, the patient had been intubated on ventilator support for 5 days, resulting in 23 days of bedrest before the initiation of mobility in the ICU.

This case report demonstrates that mobilization of complex patients in the ICU and physical therapy interventions can contribute to the recovery of patients with COVID-19. Foundational research demonstrates that early mobilization has a significant impact on length of stay, progression of mobility, improving functional outcomes, and discharge disposition.3,11 Individual components of the ABCDEF bundle12 including spontaneous awakening trials, early mobility and exercise, and family engagement were implemented and aided in the care of this patient. Given the complex medical management for patients with COVID-19, it may be important to initiate physical therapy as soon as the patient is medically appropriate. In this particular case, this time frame was marked by the removal of bilateral femoral ECMO cannulation allowing for patient mobility and the decrease in sedative medical management by the medical team. Patient mobility was initiated the next day after decannulation.

At the time of this case, the hospital protocols for medical treatment and physical therapy interventions specific to patients with COVID-19 were just beginning to be established globally. The progression of this patient was based on the current medical guidelines and the expertise of experienced PTs. The Journal of Physiotherapy had issued Clinical Practice Recommendations13 in March 2020 to further streamline the appropriate interventions, screening, and personal protective equipment needed for physical therapists providing care to patients with COVID-19. Further establishment of physical therapy–specific treatment protocols, prescribed frequency, and outcome measures through clinical research will aid in providing robust evidence for functional recovery post–COVID-19.

Proning had been completed at the community hospital before ECMO implantation which has also been documented as an effective intervention to oxygenate the lungs.14,15 The proning guidelines for patients with COVID-19 were based on the treatment recommendations published on patients with ARDS with documented results in increased lung volume, perfusion, and even ventilation distribution.15

Owing to the medical complexity and limited activity tolerance of most patients with COVID-19, an interdisciplinary treatment approach may be beneficial to maximize gains. Based on the patient's presentation, her mobility sessions were often completed with a combined team approach from nursing, physical therapy, occupational therapy, and respiratory therapy. This collaboration did not always transpire because of scheduling conflicts, which limited the activities that required significant hands-on assistance that could be executed at each session. Further interdisciplinary collaboration and research will provide additional evidence to substantiate the positive effects of interdisciplinary interventions in the recovery from COVID-19.

On the first PT session, the patient was educated on plan of care, PT role, HEP, mobility safety, assistive devices, activity pacing, and optimal breathing techniques. Education helps the patient and family to improve their knowledge of the condition, care, expected length of stay, and sources of support during recovery.16 It also reduces anxiety and ultimately improves health outcomes.16 In addition, self-exercise programs show significant improvement in maximum oxygen consumption and in submaximal rate pressure product.16 Self-exercise programs and education are effective in improving clinical and health-related quality of life in cardiac patients.16

Obesity is associated with increased mortality and increased LOS.8 Obesity is also a barrier for mobility training. This was overcome by cotreating with the other disciplines and using mobility aids such as the Encore and Ro Walker. Appropriate planning, coordination, equipment access, and teamwork were crucial facilitators in the mobilization of this patient. Therapy intensity was determined by vital signs, including HR, RR, and O2 saturation. Frequent resting periods were encouraged to avoid reaching the anaerobic threshold during training and possible adverse events during therapy sessions.

Limitations identified in this case include the fact that physical therapy interventions were not initiated until after ECMO explantation because the patient was not medically stable and was too lethargic for active participation before explantation. The patient was transferred to several units within the hospital, thereby affecting the consistency of mobility progression with 1 primary therapist. Fluctuations in physiological presentation and response to mobility also limited safe advancement of the patient toward the established therapy plan of care.

The patient's primary language was Creole. This language barrier and limited ability to phonate with tracheostomy posed problems in adept communication for the patient, however, was overcome by the assignment of a Creole-speaking occupational therapist. Patient access to health care providers and lack of health insurance were limiting factors for this patient and are factors that must be taken into consideration during a pandemic.

CONCLUSIONS

Efforts led by physical therapists for this patient with COVID-19, including initiating mobilization and interventions as early as safe and medically appropriate, were beneficial for her functional recovery.2 Interventions such as positioning to optimize ventilation, airway clearance, instruction on breathing techniques, and strengthening exercise may have contributed to the functional gains in this patient. Staff availability, access to specialized mobility equipment, the capability to mobilize the patient on a mobile ventilator, and the patient's motivation to get back to her newborn were contributing factors to the recovery of this patient. Although this case report provides some insight into addressing some of the significant challenges in managing 1 complex patient with COVID-19, further research is recommended to establish treatment parameters and protocols in this population.

REFERENCES

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3. Zhang L, Hu W, Cai Z, et al. Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PLoS One. 2019;14(10):e0223185.
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13. Thomas P, Baldwin C, Bissett B, et al. Physiotherapy management for COVID-19 in the acute hospital setting: Clinical practice recommendations. J Physiother. 2020;66(2):73-82.
14. Chilkoti GT, Mohta M, Saxena AK, Ahmad Z, Sharma CS. Awake prone positioning in the management of COVID-19 pneumonia: A systematic review. Indian J Crit Care Med. 2021;25(8):896-905.
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Keywords:

COVID-19; complex; physical therapy

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