Happy Rosyalynda1, Adhrie Sugiarto2, Sidharta Kusuma Manggala3
Author affiliation:
Patients admitted to the intensive care unit (ICU) with severe COVID-19, are at high risk of developing ICU acquired weakness and deconditioning syndrome. Early rehabilitation is a critical therapeutic intervention to reduce the complications of immobilization. We present the case of a 51-year-old woman with acute respiratory distress syndrome (ARDS) due to COVID-19. The patient underwent early rehabilitation program, starting from her fourth day after ICU admission. The rehabilitation program included: (1) prone and semi- prone positioning; (2) respiratory exercises, such as diaphragmatic deep breathing, chest stretch, and effective coughing; (3) other exercises which included mobilization, range of motion exercises, and joint relaxation. The patient’s respiratory function eventually improved (as indicated by improved SpO2. Her ability to perform activities of daily living also improved so that she was able to walk independently to the toilet without respiratory distress. Although further research is required, this report suggests that patients with severe COVID-19 admitted to the ICU will benefit from early rehabilitation program.
Key words: SARS CoV-2; COVID-19; Early Rehabilitation; Mobilization; Breathing Exercises
Citation: Rosyalynda H. The role of early rehabilitation in the ICU management of a severe COVID-19 patient: a case report. Anaesth. pain intensive care 2023;27(6):783−785; DOI: 10.35975/apic.v27i6.2092
Received: September 03, 2023; Reviewed: September 16, 2023; Accepted: September 16, 2023
Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has become a major public health issue since the end of 2019. The highly transmissible SARS-CoV-2 has put a huge burden on the healthcare systems. A systematic review by Rodriguez-Morales et al. found that 20.3% of patients with COVID-19 require intensive care unit (ICU) admission and almost 75% of patients with COVID-19 admitted to the ICU need invasive mechanical ventilation (IMV).1
Patients with severe COVID-19 admitted to the ICU are at high risk of developing ICU-acquired weakness (ICU-AW), as well as disuse syndrome. ICU-AW occurs as a consequence of prolonged immobilization which leads to myopathy, neuropathy, and ventilator dependency.2 A previous cohort study by Di Pietro et al. reported that patients with generalized muscle weakness after COVID-19 were more likely to have axonal and asymmetric polyneuropathy.3 Rehabilitation program plays an important role in reducing the risk of ICU-AW. A study by Kader et al. (2022) indicated that breathing exercise, even for a short period, effectively improve specific respiratory parameters in moderate to severe COVID-19 patient.4 The ICU Liberation: ABCDEF Bundle (where E stands for Early Mobility and Exercises) showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.5
Although ICU-AW is an increasingly recognized problem, research or data related to the incidence and prevalence of ICU-AW, especially in COVID-19 patients remains limited. In this case report, we emphasize the important role of early rehabilitation for COVID-19 patient, who developed acute respiratory distress syndrome (ARDS).
A 51-year-old woman with a history of diabetes mellitus type II, hypertension stage II, and obesity grade II, was diagnosed with SARS-CoV-2 infection at the end of June 2021 based on positive nasopharyngeal swab polymerase chain reaction (PCR) test. She was immediately admitted to the isolation ward. Her body temperature was 39.4○C, respiratory rate 28-32/min, pulse rate 112 bpm, and blood pressure 140/80 mmHg. Her SpO2 was 90-92%.
We found rhonchi on both sides of her chest. Laboratory findings showed that she had leukocytosis (13,500/mm3). Other laboratory findings, e.g., hemoglobin, platelets, bilirubin, urea and creatinine, were normal. Her blood glucose was also normal (controlled using metformin). Her chest x-ray showed non-homogeneous ground-glass opacity appearance at subpleural zone on her right lung which indicated signs of pneumonia suspected due to COVID-19. The patient was initially put on non-face-breathing facemask (NRM), and her SpO2 was 94-95% with 10 L of oxygen. Antivirus (favipiravir) and fluoroquinolones were initiated. Treatment for diabetes mellitus (metformin and insulin intramuscular) was continued.
On the fourth day of treatment, her SpO2 dropped to 84-88% with non-rebreathing mask. Arterial blood analysis revealed that her PF ratio (arterial PO2 divided by the FiO2) dropped to 53.8, thus a diagnosis of severe acute respiratory distress syndrome (ARDS) was established. The patient was transferred to the ICU and received oxygenation with high flow nasal cannula (HFNC) at 60 L/min, FiO2 100%, so that her SpO2 increased to 85-90%.
As soon as the patient was transferred, the patient underwent the following rehabilitation interventions:
(1) respiratory exercises twice a day to increase breathing function, which included diaphragmatic deep breathing, chest stretch, and breath counting test; (2) in-bed positioning every 2 h to prevent decubitus ulcer formation, which included prone positioning for 6 h a day and semi-prone positioning every 2 h; (3) other exercises to prevent contractures due to immobilization, which included mobilization, range of motion exercises, and joint relaxation.
After the rehabilitation program in the ICU was completed, she was able to be transferred to the ward. Her SpO2 was above 95% with non-rebreathing mask, which indicated improvement of respiratory function. Her muscle strength now ranged between 4 and 5 based on the Manual Muscle Testing Scale and she was able to independently walk to the toilet without experiencing any respiratory distress (Table 1).
In addition to disuse syndrome, patients with COVID-19 are at higher risk of developing ICU-AW. For patients managed in the ICU, rehabilitation should be provided as early as possible. A systematic review by Goodwin et al. reported that exercise, early mobilization, and multicomponent programs may improve recovery after ICU admission for severe respiratory illness.6 Another systematic review by Bernal-Utrera et al. concluded that physical therapy for patients with COVID-19 admitted to the ICU is a necessary strategy to prevent complications and contribute to the stabilization of patients in critical periods, facilitating their recovery.7
This patient was in ARDS when she was admitted to the ICU, and after early rehabilitation program, her respiratory and physical function improved. This showed the need for early mobilization and exercises for COVID-19 inpatients in order to improve patient’s recovery and prevent ICU-AW.
To date no validated guideline of interventions has been established, especially in terms of rehabilitation for severe COVID-19 in the ICU. However, there is a consensus of recommendations for severe to critical COVID-19 rehabilitation, such as the adoption of breathing training in prone or semi-recumbent bed position, moderate head elevation, limb mobilization, as well as sitting and standing at bedside.8 Early pulmonary rehabilitation including controlled respiration, airway clearance techniques, and strengthening of inspiratory muscles are important to maintain and improve lung capacity. Appropriate positioning in bed prevents long-term contractures and pressure injuries.9
Early rehabilitation program improves respiratory and physical functions in patient with severe COVID-19. Although further research is needed, our results suggest that early exercises and mobilization program may be beneficial for patient with severe COVID-19 admitted to the ICU, as it improves their recovery.
5. Competing Interests
The authors have full access to all the data, take full responsibility for the accuracy of the data.
6. Authors contribution
All authors contributed equally in this case report.
Author affiliation:
- Happy Rosyalynda, RSU Negara, Jembrana, Bali, Indonesia; E-mail: bu_oteng@yahoo.com; Phone: (+62) 81351248162
- Adhrie Sugiarto, Department of Anesthesiology, RSCM - FKUI, Jakarta, Indonesia; E-mail: adrie@gmail.com; Phone:(+62) 81510368016
- Sidharta Kusuma Manggala. Department of Anesthesiology, RSCM - FKUI, Jakarta, Indonesia; E-mail: sidharta.k.manggala@gmail.com; Phone: (+62) 81281772295
ABSTRACT
Patients admitted to the intensive care unit (ICU) with severe COVID-19, are at high risk of developing ICU acquired weakness and deconditioning syndrome. Early rehabilitation is a critical therapeutic intervention to reduce the complications of immobilization. We present the case of a 51-year-old woman with acute respiratory distress syndrome (ARDS) due to COVID-19. The patient underwent early rehabilitation program, starting from her fourth day after ICU admission. The rehabilitation program included: (1) prone and semi- prone positioning; (2) respiratory exercises, such as diaphragmatic deep breathing, chest stretch, and effective coughing; (3) other exercises which included mobilization, range of motion exercises, and joint relaxation. The patient’s respiratory function eventually improved (as indicated by improved SpO2. Her ability to perform activities of daily living also improved so that she was able to walk independently to the toilet without respiratory distress. Although further research is required, this report suggests that patients with severe COVID-19 admitted to the ICU will benefit from early rehabilitation program.
Key words: SARS CoV-2; COVID-19; Early Rehabilitation; Mobilization; Breathing Exercises
Citation: Rosyalynda H. The role of early rehabilitation in the ICU management of a severe COVID-19 patient: a case report. Anaesth. pain intensive care 2023;27(6):783−785; DOI: 10.35975/apic.v27i6.2092
Received: September 03, 2023; Reviewed: September 16, 2023; Accepted: September 16, 2023
1. INTRODUCTION
Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has become a major public health issue since the end of 2019. The highly transmissible SARS-CoV-2 has put a huge burden on the healthcare systems. A systematic review by Rodriguez-Morales et al. found that 20.3% of patients with COVID-19 require intensive care unit (ICU) admission and almost 75% of patients with COVID-19 admitted to the ICU need invasive mechanical ventilation (IMV).1
Patients with severe COVID-19 admitted to the ICU are at high risk of developing ICU-acquired weakness (ICU-AW), as well as disuse syndrome. ICU-AW occurs as a consequence of prolonged immobilization which leads to myopathy, neuropathy, and ventilator dependency.2 A previous cohort study by Di Pietro et al. reported that patients with generalized muscle weakness after COVID-19 were more likely to have axonal and asymmetric polyneuropathy.3 Rehabilitation program plays an important role in reducing the risk of ICU-AW. A study by Kader et al. (2022) indicated that breathing exercise, even for a short period, effectively improve specific respiratory parameters in moderate to severe COVID-19 patient.4 The ICU Liberation: ABCDEF Bundle (where E stands for Early Mobility and Exercises) showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.5
Although ICU-AW is an increasingly recognized problem, research or data related to the incidence and prevalence of ICU-AW, especially in COVID-19 patients remains limited. In this case report, we emphasize the important role of early rehabilitation for COVID-19 patient, who developed acute respiratory distress syndrome (ARDS).
2. CASE REPORT
A 51-year-old woman with a history of diabetes mellitus type II, hypertension stage II, and obesity grade II, was diagnosed with SARS-CoV-2 infection at the end of June 2021 based on positive nasopharyngeal swab polymerase chain reaction (PCR) test. She was immediately admitted to the isolation ward. Her body temperature was 39.4○C, respiratory rate 28-32/min, pulse rate 112 bpm, and blood pressure 140/80 mmHg. Her SpO2 was 90-92%.
We found rhonchi on both sides of her chest. Laboratory findings showed that she had leukocytosis (13,500/mm3). Other laboratory findings, e.g., hemoglobin, platelets, bilirubin, urea and creatinine, were normal. Her blood glucose was also normal (controlled using metformin). Her chest x-ray showed non-homogeneous ground-glass opacity appearance at subpleural zone on her right lung which indicated signs of pneumonia suspected due to COVID-19. The patient was initially put on non-face-breathing facemask (NRM), and her SpO2 was 94-95% with 10 L of oxygen. Antivirus (favipiravir) and fluoroquinolones were initiated. Treatment for diabetes mellitus (metformin and insulin intramuscular) was continued.
On the fourth day of treatment, her SpO2 dropped to 84-88% with non-rebreathing mask. Arterial blood analysis revealed that her PF ratio (arterial PO2 divided by the FiO2) dropped to 53.8, thus a diagnosis of severe acute respiratory distress syndrome (ARDS) was established. The patient was transferred to the ICU and received oxygenation with high flow nasal cannula (HFNC) at 60 L/min, FiO2 100%, so that her SpO2 increased to 85-90%.
As soon as the patient was transferred, the patient underwent the following rehabilitation interventions:
(1) respiratory exercises twice a day to increase breathing function, which included diaphragmatic deep breathing, chest stretch, and breath counting test; (2) in-bed positioning every 2 h to prevent decubitus ulcer formation, which included prone positioning for 6 h a day and semi-prone positioning every 2 h; (3) other exercises to prevent contractures due to immobilization, which included mobilization, range of motion exercises, and joint relaxation.
After the rehabilitation program in the ICU was completed, she was able to be transferred to the ward. Her SpO2 was above 95% with non-rebreathing mask, which indicated improvement of respiratory function. Her muscle strength now ranged between 4 and 5 based on the Manual Muscle Testing Scale and she was able to independently walk to the toilet without experiencing any respiratory distress (Table 1).
3. DISCUSSION
In addition to disuse syndrome, patients with COVID-19 are at higher risk of developing ICU-AW. For patients managed in the ICU, rehabilitation should be provided as early as possible. A systematic review by Goodwin et al. reported that exercise, early mobilization, and multicomponent programs may improve recovery after ICU admission for severe respiratory illness.6 Another systematic review by Bernal-Utrera et al. concluded that physical therapy for patients with COVID-19 admitted to the ICU is a necessary strategy to prevent complications and contribute to the stabilization of patients in critical periods, facilitating their recovery.7
This patient was in ARDS when she was admitted to the ICU, and after early rehabilitation program, her respiratory and physical function improved. This showed the need for early mobilization and exercises for COVID-19 inpatients in order to improve patient’s recovery and prevent ICU-AW.
To date no validated guideline of interventions has been established, especially in terms of rehabilitation for severe COVID-19 in the ICU. However, there is a consensus of recommendations for severe to critical COVID-19 rehabilitation, such as the adoption of breathing training in prone or semi-recumbent bed position, moderate head elevation, limb mobilization, as well as sitting and standing at bedside.8 Early pulmonary rehabilitation including controlled respiration, airway clearance techniques, and strengthening of inspiratory muscles are important to maintain and improve lung capacity. Appropriate positioning in bed prevents long-term contractures and pressure injuries.9
4. CONCLUSION
Early rehabilitation program improves respiratory and physical functions in patient with severe COVID-19. Although further research is needed, our results suggest that early exercises and mobilization program may be beneficial for patient with severe COVID-19 admitted to the ICU, as it improves their recovery.
5. Competing Interests
The authors have full access to all the data, take full responsibility for the accuracy of the data.
6. Authors contribution
All authors contributed equally in this case report.
7. REFERENCES
- Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez- Ocampo E, Villamizar-Peña R, Holguin-Rivera Y, Escalera- Antezana JP, et al. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Med Infect 2020;34:101623. [PubMed] DOI: 10.1016/j.tmaid.2020.101623
- Vanhorebeek I, Latronico N, Van den Berghe G. ICU- acquired weakness. Intensive Care Med 2020;46:637-53. [PubMed] DOI: 23736/S1973-9087.20.06582-X
- Vanhorebeek I, Latronico N, Van den Berghe G. ICU-acquired weakness. Intensive Care Med. 2020 Apr;46(4):637-653. [PubMed] DOI: DOI: 1007/s00134-020-05944-4
- Kader M, Hossain MA, Reddy V, Perera NKP, Rashid M. Effects of short-term breathing exercises on respiratory recovery in patients with COVID-19: a quasi-experimental study. BMC Sports Sci Med Rehabil. 2022 Apr 5;14(1):60. [PubMed] DOI: 1186/s13102-022-00451-z
- Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J, et al. Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Crit Care 2019;47(1):3-14. [PubMed] DOI: 10.1097/CCM.0000000000003482
- Goodwin VA, Allan L, Bethel A, Cowley A, Cross JL, Day J, et al. Rehabilitation to enable recovery from COVID-19: a rapid systematic review. Physiotherapy. 2021 Jun;111:4-22. [PubMed] DOI: 1016/j.physio.2021.01.007
- Bernal-Utrera C, Anarte-Lazo E, Gonzalez-Gerez JJ, De-La-Barrera-Aranda E, Saavedra-Hernandez M, Rodriguez-Blanco C. Could Physical Therapy Interventions Be Adopted in the Management of Critically Ill Patients with COVID-19? A Scoping Review. Int J Environ Res Public Health. 2021 Feb 8;18(4):1627. [PubMed] DOI: 3390/ijerph18041627
- Li J. Rehabilitation management of patients with COVID-19: lessons learned from the first experience in China. Eur J Phys Rehabil Med. 2020 Jun;56(3):335-338. [PubMed] DOI: 23736/S1973-9087.20.06292-9
- Hashem MD, Nelliot A, Needham DM. Early Mobilization and Rehabilitation in the ICU: Moving Back to the Future. Respir Care. 2016 Jul;61(7):971-9. [PubMed] DOI: 4187/respcare.04741