Rehabilitation

In
Covid Patients

Dr Subhasish Das CMS

 In order to understand the
Rehabilitation and its needs
in post Covid states
A few basics ..
What is the virus that causes
Covid-19?
The virus is a Coronavirus known
as SARS-C0V-2,
Containing a single stranded RNA
First emerged in Wuhan,China
in Dec 2019

Don’t forget that Coronaviruses

cause common cold
and some GIT disturbances in
humans before Covid -19
What are the variants
of SARS-CoV-2 ?
New WHO Code Found in Concern
Label
Alpha B.1.1.7 UK, Kent, Dec 2020 Rapid spread
Beta B.1.351 S.Africa, May 2020 Shows resistance
Gamma P.1 Brazil, Nov 2020 Resistance and infectivity
Delta/Delta B.1.617.2 India, Oct 2020 More transmission, loss of
plus lives
Epsilon B.1.427-9 California, Mar 2020 More transmission

Zeta P.2 Brazil,Apr 2020 More resistant

Eta B.1.525 Multiple countries, Dec More resistant to vaccines
2020
Kappa B.1.617.1 India, Oct 2020 More resistant with easy
spread
 What are the Upper
Respiratory Infections
• Normal human coronaviruses cause 5-10% of common
cold/URIs,
229E and NL63 (alpha coronaviruses)
OC43 and HKU1 (beta coronaviruses)
• These four predominately attach to receptors in UPPER
airway (receptors: aminopeptidase N, dipeptidyl peptidase 4)
• URI symptoms, croupy or dry cough, rarely pneumonia
(except sometimes NL63, but usually just causes croup); Mild
diarrhea in infants
• Don’t forget other URI viruses: Rhinovirus, Influenza A/B,
Adenovirus, Parainfluenza, Respiratory syncytial virus, Human
metapneumovirus
What is “Novel” Coronaviruses
• Novel coronaviruses predominantly in LOWER
respiratory tract
• SARS, MERS, SARS-CoV-2
• High healthcare worker infection and other
nosocomial spread
• Aerosolization during procedures (intubation, nebs,
BiPAP, suctioning)
What happens when
you have Covid?
Among those who develop symptoms, most (about 80%) recover
from the disease without needing hospital treatment.
About 15% become seriously ill and require oxygen
5% become critically ill and need intensive care.
Complications leading to death may include
respiratory failure,
acute respiratory distress syndrome (ARDS),
sepsis and septic shock,
thromboembolism,
and/or multiorgan failure,
injury of the heart, liver or kidneys.
In rare situations, children can develop a severe inflammatory
syndrome a few weeks after infection. 
 What are the Symptoms?
• Week 1: ( Day 1-5 of symptoms):
• Fever (77-98%) (intermittent or persistent), Fatigue/Malaise (11-
52%), Dry cough (46-82%), dyspnea (3-31%);
• Less common: Sputum (33%), Myalgia (15%), Headache (13%),
Sore throat (14%), Diarrhea (4%), Nausea/Vomiting (5%),
Nasal congestion (4%), Hemoptysis (1%)
• Week 2 (~ day 6-9 of symptoms): ~ 15-20% develop severe
dyspnea due to viral pneumonia
• Hospitalization, supportive care, oxygen
What are the dangers after
2 weeks of the disease?
• Week 2-3: Of hospitalized patients, 1/3 ultimately
need ICU care, with up to half needing intubation (i.e.
~5% of total diagnosed cases need ICU)
• Can rapidly decline (over 12-24 hrs) from mild
hypoxia to frank ARDS
• Cytokine Storm, Multi-organ failure
• Late stage sudden cardiomyopathy/viral
myocarditis, cardiac shock
How does Novel CoV cause
damage?
• ACE-2 Receptors
• Type 2 alveolar cells - highest
• Bronchial epithelia
• Tongue > buccal epithelia
• Upper Intestinal epithelia
• Myocardial cells
• Kidney proximal tubule cells
• Bladder urothelial cells
• SARS-CoV-2 binds to ACE-2 Receptor 10-20x more
strongly than SARS-CoV
Are there long term
effects of covid?
Some people who have had COVID-19, whether they
have needed hospitalization or not, continue to
experience symptoms, including fatigue, respiratory
and neurological symptoms.
What are the organs affected?
Severe COVID-19 patients
• The illness may be complicated by
respiratory failure and other forms of multi
organ failure, resulting in ICU admission
with likely invasive mechanical ventilation.
• Rehabilitation needs are typically related to
the consequences of ventilatory support,
and prolonged immobilization
What are the 3 POINTS to be
remembered?
• Not all people die from COVID-19 (majority
don’t)
• Patients have sequelae
• Respiratory but also NON-respiratory burden
= degree of rehab need
= learning from others
 Common country experiences

• PPE for rehabilitation personnel is essential but concerns

repeatedly raised about limited access. Unmet rehabilitation
needs & lack of resources reported to ministries of health,
advocacy by professionals essential, value of involving
rehabilitation workforce in service decisions highlighted
• Telehealth (primarily phone calls) being utilised for service
delivery for patients - important way forward
• Online videos for patient rehabilitation and pre-developed
pamphlets used for COVID-19 clients
• Supply chains for assistive products interrupted
• Greater task-sharing, upskilling and transdisciplinary
teamwork occurring – but must be within scope of practice.
• Rehabilitation professionals undertaking online training
Rehabilitation along the continuum of care
in COVID-19

Post-acute
Acute Long-term
Objectives
Objectives Objectives
- Identify and manage
- Optimize impairments for - Optimize
oxygenation affected functioning functioning/ minimize
- Manage secretions domains impact of
- Prevent - Facilitate safe impairments on
complications discharge and independence and
onward referral quality of life
Input:
Specialist Respiratory Input: Input:
physiotherapist Multidisciplinary Multidisciplinary
/therapist and/or Setting:
rehabilitation staff Setting: Home,
Rehabilitation outpatient facility,
experienced with ward/unit, stepdown
ICU/HDU setting clinic
facility, home
Setting: ICU/HDU
Challenges of Rehabilitation

• Difficult in full PPE

• Double bed spaces mean very little space
• High BMI (39% overweight, 50%
obese/morbid obese)
• Prolonged periods of sedation / paralysis
• High incidence of delirium
• Stretched staffing models / non ICU staff
What are targeted in Rehabilitation?
• Impairments most likely to encounter:
• Physical deconditioning and muscle weakness, fatigue
• Impaired lung function
Delirium and other cognitive impairments
Impaired swallow and communication
Mental health disorders and psychosocial support needs.
Multi-disciplinary team approach is key
Still many unknowns related to the pathophysiology of
COVID-19 and the long-term complications, many
organs can be affected
What are the Common
Post Covid Symptoms?
Weakness
Deconditioning
Shoulder dysfunction
Pain
Cognitive disturbances
Breathlessness
Fatigue
What are the measures for Voice disorders ?

 Risk assessment
 Regular review/outcome measurement
If a patient has not had
laryngoscopy …..route for referral back to Tertiary
centre
 Telehealth - Guidance
What is Pulmonary Rehab?
• A multidisciplinary, long-term program based on
targeted exercise and education for patients with
chronic respiratory illnesses
– COPD, ILD
• Improves HRQOL, mortality, exercise tolerance
• Decreased exacerbations
– Aimed at improving physical, mental and
emotional
health
– 6 weeks, 2x/wk
– Physical: Endurance, Resistance, Flexibility
– Education: Diet, anxiety, disease-specific
Is Pulmonary Rehab
beneficial?
• Evidence is SPARSE prior to COVID
• One small observational study (Taiwan,
n=9)
• H1N1 ARDS survivors
• PFT measures, 6MWT improved within 3
months
• HRQOL improved in 6 months
So what do we do?
• Majority of evidence suggests that there are
long term deficits in pulmonary function and
HRQOL after ARDS
• PR is designed to address these, but data is
sparse
– One recent RCT supporting PR
• How to implement?
– Timing?
– In person vs. virtual sessions?
What are the problems of
Respiratory Treatment
Often requires 2 people – factor into staff planning
Positioning may be difficult
There may be CVS instability
Difficult in prone
Manual techniques may be difficult
Saline – secretions are often thick
Desaturation is VERY common, does recover but
takes time
What are the advantages
of Rehabilitation ?
•Reduces disability
•Quicker resumption of normal work and duty
• Social reintegration
• Prevents congestion in medical and acute facilities

• Pulmonary rehab includes interval, strength,

flexibility and respiratory training
• Initiated early reduces subsequent hospital
admissions
• Function and QOL
Why rehabilitation
is important during
the second wave?
The second wave saw:
~6.9% death rate world wide
~20-30% hospitalized
~5-10% ICU admission
~ large burden of surviving group
Sequelae of Covid-19
– Pulmonary – 3-67% ARDs*, milder resp symptoms majority,
Lung fibrosis, reduced lung function, laryngeal
stenosis/injury, tracheomalacia
– Neurological – 30-84% admitted, weakness and chr fatigue
• CNS – strokes ischemic + hemorrhagic – 5%-23%
• PNS - Loss of smell and taste - 40-70%
• Neuromuscular – myalgia 40%
– Fatigue – 44%+
– Neurocognitive – 36-80%
– Hyper-coagulation – 30-80%
– Cardio, vascular inflammation –MI, CHF, m.carditis – 8-33%
– Psychiatric –depression anxiety, PTSD - 48%+
– Renal – catabolic, AKI, dialysis – unknown
– ICU related – PICS, weakness – 70-80%+
– prolonged admission (±21 days)
 Registration

Covid Vaccination Status

Date of Covid (+) Report If Hospitalized
If ICU Stay

Tachycardia and BP Total Leucocyte Count

Resp Rate and SPO2 ESR
Chest X Ray/CT Fasting Sugar
Spirometry Renal Func Tests
6 Min Walk Test CRP, D-Dimer, Ferritin
ECG Liver Func Tests

Advice on Medicines
Psychiatric Counseling
Lung Exercises
Physiotherapy and Rehabilitation Programmes
What is the effect on Heart?

Two studies of critically-ill patients showed:

23% cardiac injury and
33% developed cardiomyopathy
• Troponin rise
• Cardiorespiratory rehab program up to 50%
lower mortality long-term
hat are the Psychiatric changes?

China - 48% of COVID-19 patients manifested

psychological distress during early admission
• Social stigma, “labeled”
• Survivors of critical illness
>30% depression,
>32% anxiety, and
>20% PTSD 1 year follow up
• Family, community distress + support
What is PICS
(post-intensive care syndrome) ?
• “new or worsening impairments in physical,
cognitive, or mental health status after critical
illness” – 70-80%
• Persistent Impairments at 1 + 5 year f/u
• 1/3+ don’t return to work
• 2 years - 80% required further inpatient
admission
• Outpatient support
What is ICUAW
(ICU Acquired Weakness)?
Can exceed 10% loss of muscle mass 1 week of ICU
• CIM (myopathy) and CIN (neuropathy) complicate
• Weakness impairments persist >2 years despite
recovery of pulmonary function long-term ARDs
• Diaphragmatic weakness
• Post-intubation dysphagia 30%
• Sores, contractures
What are the Neurocognitive
defects after Covid?
• Longer duration hypoxemia association
with
worse cognitive impairment*
– Full sequelae unknown, mild-moderate
patients captured?
• “dysexecutive syndrome” 36%
• ARDs critical illness survivors @ 2 years
=
56% deficiencies in short-term memory,
29% executive function
What is the role of respiratory
rehabilitation in the COVID crisis ?:
• Acute Critical Phase (ICU)
• Ventilation support/ weaning
• Reduction of dyspnea, airway clearance*
• Positional therapy
• WHO advises early activation, fatigue level
• OT – delirium, early ADLs, seating
• SLP – dysphagia, communication
What is the role of respiratory
rehabilitation in the COVID-crisis ?:
Acute Ward (out of ICU or not needing it)
• Mobilize (get out of bed)
• Therapeutic postures
• Limb exercises
• Neuromuscular electrical stim*
• Respiratory muscle training
• Bronchial clearance closed circuits
• OT – ADLS, cognitive, coping, mobilize
• SLP – dysphagia, cognitive
• RT – trach, respiratory
• Discharge planning team
What is the role of respiratory
rehabilitation in the COVID crisis ?:
• Post-Acute (Intermediate rehab location)
Depends on degree of pre- and post-
comorbidities,
recovery sequence
- Trach weaning + phonation, secretions
- Mobilize muscle strength
- Specific mobility aides
- Respiratory muscle training
- PT, OT, SLP, RT, discharge team
- Tele-follow ups
- Community* and home program
What is ARDS in Covid patients?
ARDS is Acute Respiratory Distress Syndrome when these is
severe breathing problems and oxygenation goes down due
to viral pneumonia and or diffuse microvascular pulmonary
thrombosis.
DIAGNOSTIC CRITERIA OF ARDS:
1. Acute hypoxemic respiratory failure
2. Presentation within 1 week of worsening respiratory
symptoms
3. Bilateral airspace disease on Chest X –Ray or CT or USG
not explained by other causes
4. Cardiac failure is NOT the cause of acute hypoxemic
respiratory failure
Respiratory rate >30/min
SPO2 <= 92%
PaO2/FiO2<= 300 mmHg
What are the Lung/Pulmonary
complications of ARDS?
• Objective
– 80% have decreased DLCO
– 20% have airways obstruction
– 20% have restrictive lung disease
– Some will recover over time
– INCONSISTENT data about whether or not PFTs
correlated with HRQOL/functional
• Long term impairments in HRQOL, exercise
tolerance, ability to return to work, mental health,
social health
– Includes date from recent viral pandemics
– Younger patients (<40) tend to do better
– Some conflicting data
Mobility levels

• 43% of patients step transferring or walking at ICU d/c

Tele-health experiences
• Shorter sessions to maximise attention
• Integrated ‘end2end’ encrypted video conferencing
• Using a combination of physical objects such as books
and toys and interactive resources like Symplify and
Boom Cards
• Creating activities within PowerPoint that can be used
interactively in sessions and for home practice
 What are the limitations
of Rehabilitation?
• Extremely high acuity of illness

• Transient hypoxia on movement or intervention

• High sedation requirements – significant agitation and

asynchrony

BUT……
• Instability on de proning with thick secretions++
 WORKSHOP HOSPITAL
EASTERN RAILWAY
KANCHARAPARA
HAS
STARTED
COVID REHABILITATION
CLINICS
Thank You