Early Rehabilitation For Critically Ill Patients.98018 PDF
Early Rehabilitation For Critically Ill Patients.98018 PDF
Early Rehabilitation For Critically Ill Patients.98018 PDF
DOI: 10.1097/PHM.0000000000001445
Pengming Yu, MS1,2; Quan Wei, MD, PhD1,2; Chengqi He, MD, PhD1,2
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Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University,
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Chengdu, Sichuan, PR China.
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Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, PR China.
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Pengming Yu and Quan Wei contributed equally to this work.
Medicine Center, West China Hospital, No.37 Guoxue Alley, Chengdu ,610041, Sichuan Province,
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PR China
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This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses
in any form or by any means with acknowledgement of the original source. These permissions are
granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing.
Upon expiration of these permissions, PMC is granted a perpetual license to make this article
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Keywords: COVID-19, Pneumonia, Early Rehabilitation, Intensive Care Unit
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INTRODUCTION
As of April 4, 2020, a novel coronavirus disease (COVID-19) has spread to 181 countries
or regions. An epidemiological analysis of 72,314 confirmed cases in China shows that while the
proportion of critically ill is low, the actual number is large.1 One recent study reported that of the
52 COVID-19 patients who were critically ill, 61.5% died within 28 days, and 71% required
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mechanical ventilation.2 Apart from treating a large number of critically ill people, impairment of
body function in survivors has also posed a big challenge to the clinicians, the patient’s families,
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and the society.
In recent years, the concept of early rehabilitation has been widely accepted by clinicians
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in critical care around the world. It is recognized that early rehabilitation in the critically ill patients,
including those requiring extracorporeal membrane oxygenation, is feasible, safe, effective and
promotes weaning from mechanical ventilation, maintains and improves system function,
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improves prognosis, quality of life and facilitates the return to daily activities and work.4 Therefore,
Coronavirus disease (COVID-19) is spreading rapidly across the globe. Since COVID-19
is a new disease, scientists are racing to determine the nature of the virus and how it affects the
human body. Two recent reports reveal the pathological characteristics of patients with COVID-
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19.5,6 The pathology suggests that a patient suffering COVIOD-19 may benefit from early
intervention by a multidisciplinary rehabilitation team. The first pathology report on the novel
coronavirus disease (COVID-19), analyzing its impact on a patient's lungs, liver and heart by
studying the autopsy samples.5 The samples were taken from lung, liver and heart tissue of the
body of a 50-year-old man, who was hospitalized on Jan 21 and died 14 days later, according to a
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case report published by the Lancet. The patient was admitted to a fever clinic with symptoms of
fever, chills, cough, fatigue and shortness of breath, and received supplemental oxygen therapy as
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well as antiviral therapy with interferon alfa-2b and lopinavir plus ritonavir. Lung samples showed
that the patient had suffered from the acute respiratory distress syndrome (ARDS), with the
pathological features greatly resembling those in SARS and MERS coronavirus infection, the
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report said. The liver tissue showed moderate microvascular steatosis and mild lobular activity,
but no evidence indicated that the injury in the liver was caused by the COVID-19 infection or by
the drugs. There were no obvious histological changes in the heart tissue, showing that the disease
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might not directly impair the heart of patients infected with the COVID-19. The report agreed that
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lymphopenia, as a common feature in the COVID-19 patients, might be a critical factor associated
with disease severity and mortality. The report describes COVID-19 being associated with bilateral
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diffuse alveolar damage with cellular fibromyxoid exudates.5 These findings can provided new
insights into the pathogenesis of the COVID-19, which may contribute to improve the early
rehabilitation strategies for similar severe patients and reduce mortality. The other study compared
the central nervous system, peripheral nervous system and skeletal muscular system symptoms
exhibited in patients with severe and moderate COVID-19 disease.6 The finding suggests that
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COVID-19 patients commonly had neurological symptoms manifested as acute stroke (6%),
consciousness impairment (15%), and skeletal muscle injury (19%) . Elderly patients with chronic
conditions are at an increased risk of altered mental status in the setting of acute infections. Also,
a staging system based on the severity and organ involvement is needed in COVID-19 in order to
rank the patients for aggressive or conventional treatment modalities. It is important to mention
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here that although the cerebral damage may complicate a COVID-19 infection, it appears that it is
the widespread dysregulation of homeostasis caused by pulmonary, renal, cardiac, and circulatory
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damage that proves fatal in COIVD-19 patients. With the recent COVID-19 outbreak, there is an
urgent need to understand the neurotropic potential of the COVID-19 virus in order to prioritize
and individualize the treatment protocols based on the severity of the disease and predominant
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organ involvement.
The symptoms in the cases reported above were often managed by early intervention of an
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experienced rehabilitation team. The main goal of early rehabilitation is minimizing the adverse
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effects of critically ill with COVID-19 on the respiratory system, restoring respiratory and physical
independence, preventing the need for subsequent dependence on mechanical ventilation and
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subsequent hospitalizations and improving patient’s quality of life. First of all, this is achieved by
the reduction of patient’s dependency on the ventilator, reduction of secretion retention, atelectasis
resistance and work of breathing, and optimization of oxygenation. Not of less importance are the
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preservation and improvement of respiratory and peripheral muscle strength. In clinic setting,
auscultation cannot be used due to the PPE, and patients may report only dry cough, but we still
recommend early use of airway clearance techniques to help patients promote lung ventilation and
mobilization peripheral sputum, so as to avoid the formation of sputum thrombus. At the same
time, we should not only focus on the problems of the lungs, but also consider whether patients
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will have neuromuscular injury, and adopt early activities to prevent them the occurrence of
DISCUSSION
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Whether early rehabilitative interventions for COVID-19 patients should commence in the
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intensive care unit (ICU) is controversial, and many physicians, both medical as well as clinicians
in rehabilitation, hold a conservative attitude. Medical clinicians are particularly cautious about
risks associated with early intervention of rehabilitative techniques. The reason may come from
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the general lack of understanding of existing research on COVID-19 and a consequently over
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The rehabilitation clinicians are concerned that there is no precedent for early rehabilitation
treatment of COVID-19, a lack of experience in acute management of COVID-19 patients, and the
Some are of the view that the current treatment plan should not allow physical therapists to provide
treatment to COVID-19 patients in ICU, as this may increase the risk of cross infection, and that
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management of these patients should focus on life support, antiviral therapy and hormone therapy.
Some physicians are of the view that early rehabilitation will interfere with clinical treatment,
increase patient oxygen consumption and may not cause any benefit.
The above opinions have led to the current situation where most critically ill patients are
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not offered the opportunity of early rehabilitative intervention. As of April 4, there is no report on
early rehabilitation of critically ill patients with covid-19 in the world. We retrieved on the website
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of Baidu and WeChat in China, also reviewed all of the Epidemic Bulletin from Chinese
physiotherapists entering ICU to carry out early rehabilitation. However, we are of the view that
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early rehabilitation interventions delivered by a multidisciplinary team, following comprehensive
assessment and treatment, is safe when conducted in the critical care environment. We hold this
view because the rehabilitation team adopts an evidence-practice approach to the management of
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patients with acute respiratory distress syndrome, sepsis, acute respiratory failure, acute heart
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failure, acute renal failure, mechanical ventilation and extracorporeal membrane oxygenation.
Secondly our experience at West-China Hospital, where early rehabilitation intervention was
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introduced for critically ill patients with COVID-9, has been very positive. Our hospital sent a
multidisciplinary medical team including 2 physiotherapists to take over Chengdu Public Health
Center ICU, which is a designated treatment center for all COVID-19 patients in Sichuan province.
Our physiotherapists carried out early rehabilitation for more than dozen of critically ill patients
with COVID-9 from February 16th till all of them have been discharge or transferred to general
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ward. Before performing the early rehabilitation intervention, we have done a comprehensive
evaluation of the patient’s systemic function, particularly in terms of cognitive status, respiratory
consensus from the medical team must be obtained, and sufficient preparations should be made.
The cause should be determined, and safety should be reevaluated. Due to safety and human
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resource concerns, we covered three major areas: positioning management, early mobilization, and
respiratory management. From our clinic evidence, we found the early rehabilitation interventions
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has a positive effect on patients’ prognosis, as assessed by improvements in functional status such
as exercise capacity, muscle strength, and walking ability at discharge, as well as reductions in the
duration of mechanical ventilation, length of the ICU stay, and length of hospital stay. We will
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publish our observations soon.
CONCLUSION
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We believe that it is safe and effective to carry out early rehabilitation intervention for
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critical ill patients of COVID-19 with the cooperation of multidisciplinary teams. Early
rehabilitation for critically ill patients with COVID-2019:More benefits than risks.
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CONFLICTS OF INTEREST
This work did not receive any grant from funding agencies in the public, commercial, or not-for-
profit sectors.
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REFERENCES
Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From
the Chinese Center for Disease Control and Prevention. JAMA 2020
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CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study.
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3. Ferreira DDC, Marcolino MAZ, Macagnan FE, Plentz RDM, Kessler A: Safety and
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