-CONDUCTED BY RUDRA NARAYANRAY, BPT, FOR, FSR (SENIORPHYSIOTHERAPIST, ASANSOL DISTRICT HOSPITAL, WB
ABSTRACT Physiotherapists who work in primary healthcare facilities are likely to have a role inthe management of patients admittedto hospital with confirmed and/or suspected COVID-19.[1] Physiotherapy is an established profession throughout the world. In India & overseas, physiotherapists often work in acute hospitalwards and ICUs. In particular, cardio- respiratory physiotherapy focuses on the management of acute and chronic respiratory conditions and aims to improvephysical recovery following an acute illness.Physiotherapy may be beneficial in the respiratory treatment and physicalrehabilitation of patientswith COVID-19. Althougha productive coughis a less common symptom(34%), physiotherapy may be indicatedif patients with COVID-19 presentwith copious airway secretions that they are unable to independently clear.This may be evaluated on a case-by-case basis and interventions applied based on clinical indicators. High-risk patients may also benefit,for example: patientswith existing co-morbidities that may be associated with hyper-secretion or ineffective cough (eg, neuromuscular disease, respiratory diseaseand cystic fibrosis).[1] The purposeof this case study is to outlinethe Physiotherapy interventions to treat such patients with COVID19 by taking adequatesafety measures as per WHO guidelines of Infection Prevention& Control for healthcare workers. REVIEW & RESEARCHOF LITERATURE A detailed review & research of literature was done for making this case study as I was dealing with a completely new disease condition. A lot of articles on the specific topics were used to draw references for evidence mostly from Physiopedia, WHO and WCPT websites as well as from other resources, with the following search terms- 1. Physiotherapy management in COVID19 patients 2. Physiotherapy guidelines in COVID19 patients 3. Respiratory therapy in COVID19 patientsin ICU settings 4. WHO guidelines in COVID19 patients 5. Infection Prevention & Control in COVID19 patients
The details of which are enlisted in the References section of this article. The basic criterion used for research of literature was to identify any such similar case study or any given guidelines for Physiotherapy management and respiratory intervention for patients with COVID19. Please note that the name of the patient is changed to protect the confidentiality of the patient. Additionally every effort was made to follow standard guidelines to write a Case Studyas per given recommendations. [12] [13] [14] INTRODUCTION Severe acute respiratory syndromecoronavirus 2 (SARS-CoV-2) is a new coronavirus that emerged in 2019 and causes Coronavirus Disease 2019 (COVID-19). SARS-CoV-2 is highly contagious. It differs from other respiratory viruses in that it appearsthat human-to-human transmission occurs approximately 2 to 10 days priorto the individual becoming symptomatic. The virus is transmitted from person to person through respiratory secretions. Large droplets from coughing, sneezing or rhinorrhoea land on surfaceswithin 2 m of the infectedperson. SARS-CoV-2 remains viablefor at least 24 hours on hard surfacesand up to 8 hours on soft surfaces. The virus is transferred to another personthrough hand contacton a contaminated surface followedby touching the mouth, nose or eyes.Aerosol airborne infectedparticles created during a sneeze or cough remain viable in the air for ≤ 3 hours. These airborne particles of SARS-CoV-2 can then be inhaled by another person or land on the mucosal membranes of the eyes. Individuals with COVID-19 can present with an influenza-like illness and respiratory tract infection demonstrating fever (89%), cough (68%), fatigue (38%), sputum production (34%) and/or shortness of breath (19%). The spectrum of disease severity ranges from asymptomatic infection or mild upper respiratory tract illness through to severe viral. [1] Current reports estimate that 80% of cases are asymptomatic or mild; 15% of cases are severe (infection requiringoxygen); and 5% are criticalrequiring ventilation and life support.Preliminary reports indicatethat chest radiographs may have diagnostic limitations in COVID-19.Clinicians need to be aware that lung computed tomography (CT) scan findingsoften include multiplemottling and ground-glass opacity. Lung ultrasound is also being used at the bedside with findings of multi-lobar distribution of B-lines and diffuse lung consolidation. The current mortality rate is 3 to 5%, with new reportsof up to 9%, which is in contrast to influenza at around 0.1%. The rates of admissionto an intensive care unit (ICU) are approximately 5%. Around 42% of patientsadmitted to hospitalwill require oxygen therapy. Based on emergingdata, individuals at highest risk of developing severe COVID-19 diseaserequiring hospitalization and/or ICU support are those who are older, male, have at least one co- existingco-morbidity, higher severityof illness scores (measured via SOFA scores), elevated d-dimer levels and/orlymphocytopaenia. [1] PATIENT CHARACTERISTICS Mr Rakesh Shaw (name changed) a 49-year-old obese gentle-man with a historyof hypertension, Type 2 DiabetesMellitus and COPD, reported in the Triage area of our Hospital(Asansol District Hospital,West Bengal) with fever, dry cough and breathing
difficulty. He had a positive history of cigarette smoking for the past 20 years which he reduced considerably in the past 2 years. He worked as a technician in a Steel Plant for eight hours per day. He remembered to have come in contactwith a suspected person who was tested positive that very day.He was escorted by his wife andelder son who were immediately asked to self quarantine after visiting the Fever Clinic. He had just completed a medical check-up and the report showed body height of 173cm and body weight of 88kg, and random glucoseof 160mg/dL and body temperature of 101 degree Fahrenheit. He was immediately admitted to isolationward and samplesof Nasopharyngeal and Oro-pharyngeal swabs were collected and sent to the DistrictNodal centers for RT-PCR testing.
RISK FACTORS & CO-MORBIDITIES
Mr Shaw had many risk factors-
Cigarette smoking for over 20 years
Hypertension (even though his blood pressure was under controlwith medication)
ype 2 DiabetesMellitus for 11 years and was on oral Hypotensives
COPD for the past 8 years
Obesity
Positive family historyof Cardio-respiratory diseases
CLINICAL EXAMINATION & INVESTIGATIONS At the time of admission the respiratory rate was around 35/min, Pulse rate was 110/min, BP was 145/90 & Oxygen saturation was 85. Later Chest X-raywas done which showed signs of mild to moderatebilateral Pneumonia. Urea,Creatinine levels were normal. Samplesof Nasopharyngeal and Oro-pharyngeal swabs were collected and sent to the DistrictNodal centers for RT-PCR testingwhich on the following day PCR tests came to be positive. MANAGEMENT Mr Shaw was immediately put on Oxygen Therapyvia nasal cannula with amoderate flow of 12-15Ltrs/min and FIO2 of 50% with an SPO2 targetof 94%. IV fluids were also started and Urinary catheterization was done to monitor urinaryoutput. Pharmacological therapyincluded Antipyretics, Hypotensives, Loop diuretics, Hypoglysemics, Antibiotics to controlPneumonia, Antivirals like Lopinavir/Ritonavir combination along with Hydroxychloroquine. [3] On the following night his condition deteriorated, (Saturation fell below 70% and FIO2 was 60%) and he was shifted to ICU following signs of early Acute Respiratory Distress Syndrome (ARDS). He was immediately intubated and put on Invasive Ventilator in Assist-Control mode. Tidal Volume was set in 500ml/min, PEEP was set
at 15cms of H2O with a plateau pressureat 30cms of H2O. Sedativeswere also given to achieveadequate oxygen levels. [3]
PHYSIOTHERAPY REFERRAL AND INTERVENTION
On the very followingmorning the patientwas referred to our Physiotherapy Unit for an active intervention on the basis of mainly the followingreasons- [3]
Moderate symptoms of Pneumonia and coexisting COPD
Avoid functional limitations and furthercomplications The patient was attended after taking adequate safety precautions & measures like PPE suits, Masks, Glassesand Gloves worn in proper order as recommended by WHO. N- 95 respirators were also worn in additionto normal Medicalmasks as there were multipleAerosol generating procedures taking place in ICU.Hand Hygiene was also maintained repeatedly by alcohol based hand-rubs as per IPC guidelines laid down by WHO. [1] [3] [4] [5] [6] [7] The patient was duly assessed and evaluated and an objectivespecific, goal orientedtreatment program was planned. [3] The goal specific aims and objectives were-
A] Short-termgoals-
Airway clearance
Prevent Ventilator associated complications like Ventilator AssociatedPneumonia (VAP)
Prevent general complications like Pressure sores,DVTs and PulmonaryEmbolism
Early weaning off from InvasiveMechanical Ventilation B] Mid-term goals-
Prevent ICU related myopathy
Prevent functional decline Physiotherapy interventions included positioning, chest percussions, vibrations, clapping along with closed suctioning without disconnecting the ventilator circuitto clear lung fields. Positionshifts, DVT stockings, Active-Assisted foot-ankle exercises were implemented to avoid generalcomplications. [2] [3] Post weaning off Active Cycle of Breathing Techniques, Breath stacking activities combined with Deep Breathing Exerciseswith maintaining PositiveExpiratory Pressure (PEP) via pursed lip exhalationto increase Lung Compliance and increase
lung volumes.Incentive spirometers were also used to improve powerof the respiratory muscle groups. Early mobilization was conducted as soon as it was safe to prevent myopathies and functional limitations. [2] [3] OUTCOME After ten days of the aboveexercise program combinedwith the Pharmamanagement & ventilator support Mr Shaw showed significant improvement in his respiratory functions. His fever was gone. Both his Blood pressure and Blood sugarwas under controlthrough supportive treatment. He was successfully weaned off from Invasive ventilation and extubation done. Then he was temporarily put on Non-Invasive Ventilation for 36 hours intermittently. He was fully awake and cooperative during the process. Active Cycle of Breathing Techniques, Breath stacking activities & Incentive Spirometry was implemented during this phase.He was later transferred to the isolation ward with Oxygen therapy being still continued. During his stay in the ICU henever showed any deterioration in his Cardiacor Renal functions. He was also additionally monitoredfor any neural deficits as SARS COV1 had a history of neural infiltration. After about 20 days from his date of admission PCR tests were performed and found to be negative. After 48 hours PCR tests were again repeated which again came negative. He was discharged thereafter and asked to continuethe oral Hypotensives, Hypoglycemics along with Multi-vitamins, Multi-minerals and Anti-oxidants. Home exercise programsmainly included Deep Breathing Exercisesmaintaining Positive Expiratory Pressure (PEP) along with Incentive spirometery to maintain lung compliance. He was encouraged to quit smoking and also asked to self quarantine for another two weeks. DISCUSSION Sincethe first outbreakof corona virus (COVID-19) in Wuhan, China, the diseaseis spreading worldwide. We are currentlyliving through an unprecedented global health crisisresulting from a pandemic caused by a novel Corona virus. Individuals at the extremeof ages and those that are immune-compromised are at the most significant risk. Approximately 15% of individuals with COVID-19 develop moderateto severe diseaseand require hospitalization and oxygen support,with a further 5% who require admission to an Intensive Care Unit and supportive therapies including intubation andventilation. The most common complication in severe COVID-19patients is severe pneumonia, but other complications may include Acute Respiratory Distress
Syndrome (ARDS), Sepsis and Septic Shock, Multiple Organ Failure, including Acute Kidney Injury and Cardiac Injury. [3] Physiotherapist has an importantrole to play as an essential member of a Multi- Disciplinary team in the management of patients with COVID-19 in the acute hospital settingand also in the rehabilitation following recovery from the disease.Furthermore, as a frontline health professional Physiotherapist should be aware of the precautions necessary to avoid the contraction and spread of the disease. Patients and families shouldreceive instruction to: [8]
Avoid close contact with subjects sufferingfrom acute respiratory infections.
Wash their hands frequently, especiallyafter contact with sick people or their environment.
Avoid unprotected contact with farm or wild animals.
People with symptomsof acute airway infection shouldkeep their distance,cover coughs or sneezes with disposable tissuesor clothes and washtheir hands.
Immuno-compromised patientsshould avoid publicexposure and publicgatherings.
Strict personal hygienemeasures are necessaryfor the prevention and control of this infection.
Proper room cleaning with antiseptic agentsshould be undertaken and performed. HOW THE CORONA VIRUS DISEASE PROGRAM FROM PHYSIOPLUS HELPED ? The course on Corona Virus Disease Program from Physio-plus that I enrolled recently helped me in multiple ways. There were a lot of new things I was introduced to enlisted below- 1. Firstly it helped me understand the origin of the SARS CoV-2, its clinical presentations and its progression and why it is declared as pandemic. It also helpedme identify the methods of transmission, which are the maximum risk population and how the transmission can be prevented to some extent. [9] [10] 2. Secondly it also helped me understand Infection Prevention & Control methods &guidelines to be applied during patient treatment. I learnt about hand hygiene, cough etiquette and social distancing. I also learnt about Personal Protective Equipment (PPE), its correct sequence of donning and doffing. I have followed these guidelines sincerely while working in my Hospitalsetting and also encouraged others to do the same for protecting myself and other healthcare workers as well aspreventing the spread of the disease. [4] [5] [6][7]
3. Thirdly it helped me learn the role of a Physiotherapist both in a Community health as well as in a Hospital care settings. As I personally work in an Hospital care setting these guidelines were as boon to me. It also helped me identify the indications and criteria behind the referral of a confirmed COVID19patient to Physiotherapy Department. Later I took this up with my hospital authorities and management team who later agreed to follow the given guidelines and directives. In the above case it can be clearlyseen that those guidelines were followed prior to referringthis patient to our Physiotherapy Department. [1] [2] [3] 4. Fourthly and most importantly this course finally helped me set specific treatmentgoals and objectives both short and mid-term as discussed in the Physiotherapy Referral and Intervention sectionand helped us achieve a superior outcome.[1] [3] Without hesitation or doubt I can confidently say that this course has imparted so much knowledge and expertise in me that now I feel lot more preparedequipped and empowered to deal with similar such outbreaks (GOD forbid !!) in future. The guidelines and directive given will surely reflect in my future practice both in Community or Hospital care settings. REFERENCES [1] Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations by Peter Thomas, Claire Baldwin, Bernie Bissett, Ianthe Boden, Rik Gosselink. Link- https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/images/FINAL%20Physiothe rapy_Guideline_COVID-19_V1_Dated16April2020_endorsed.pdf [2]WHO- Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Link- https://www.who.int/docs/default- source/coronaviruse/clinical-management-of-novel- cov.pdf?sfvrsn=bc7da517_10&download=true [3] Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Link- https://www.acprc.org.uk/Data/Resource_Downloads/ARIRStatementonRespiratoryPhysiotherapyinpatientswithCOVID-19inacutesettings.pdf?date=03/04/2020%2019:59:27
[4] Infection Prevention and Control- Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
Link- https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control- recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus
[5] When and How to Wash Your Hands. Link- https://www.cdc.gov/handwashing/when- how-handwashing.html
[6] Personal Protective Equipment for Infection Control. Link- https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/personal-protective-equipment-infection-control
[7] Coronavirus disease (COVID-19) technical guidance: Infection prevention and control / WASH, WHO. Link-https://www.who.int/emergencies/diseases/novel-coronavirus- 2019/technical-guidance/infection-prevention-and-control
[8] Features, Evaluation and Treatment Coronavirus (COVID-19). Link- https://www.ncbi.nlm.nih.gov/books/NBK554776/
[9] Introduction to COVID-19, Physiopedia article. Link- https://www.physio- pedia.com/Coronavirus_Disease_(COVID-19)
[10] Difference Between an Epidemic and a Pandemic. Link- https://www.verywellhealth.com/difference-between-epidemic-and-pandemic-2615168
11] Information and resources about COVID-19. Link- https://www.wcpt.org/news/Novel- Coronavirus-2019-nCoV
12] Assignment Guidelines, Physiopedia article. Link https://www.physio- pedia.com/Assignment_Guidelines#ppm29765
13] Guidelines to the writing of case studies by Dr. Brian Budgell, DC, PhD. Link- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
14] Introduction to literature searching. Link- https://www.keele.ac.uk/hltutorials/informationskills/introtolitsearch/story_html5.html