Proposing an #EASIER cardiopulmonary rehabilitation protocol for coronavirus disease 2019 survivors

The economic and social impact that coronavirus disease 2019 (COVID-19) can bring is undeniable since high numbers of active workers in production and service provision are being contaminated. In addition, those infected may have long-term sequelae, impairing their functional capacity, and consequently, their work activities. It considers that intervention in cardiopulmonary rehabilitation is of great importance, especially in the recovery stage, and should be carried out mainly with the aim of improving dyspnea, severe muscle weakness, and fatigue, to promote functional independence, and increase quality of life. Based on the limitations demonstrated in COVID-19 survivors, we developed a protocol based on the acronym #EASIER, which is divided into six phases. Such a study will be able to early identify the impact of COVID-19 in different severities as well as provide subsidies to guide physiotherapists early, through the correct prescription of rehabilitative interventional measures. © 2023 Heart and Mind ;Published by Wolters Kluwer - Medknow.

CRRT impact on outcomes of patients treated with ECMO and fluid overload: a case report

Background: ECMO is an extracorporeal circulation used as a short-term life-saving support in patients with refractory cardiac and respiratory failure. Fluid overload (FO) in patient with this support, sometimes due to the onset of AKI, is associated with an increased morbidity and mortality rate and with prolonged duration of mechanical ventilation and ECMO. It also alters the volume of distribution of most drugs and can even mask the presence of AKI. Mantaining a negative fluid balance is an essential goal to improve gas exchanges in patients with respiratory failure who have undergone ECMO support. So, fluid overload removal has a significant prognostic value. Diuretic therapy, at the maximal dosage, can be insufficient to reach a negative water balance and it can also lead to metabolic disorders. Initiating RRT may help to obtain this goal. Method(s): A 32-years-old man, without any comorbidity, was admitted to the intensive care unite (ICU) with severe acute respiratory distress syndrome (ARDS) due to SARS Cov-2 infection and refractory hypoxemia. After intubation and mechanical ventilation, he was treated with VV-ECMO. In order to maintain a negative fluid balance, diuretic therapy at maximum dosage was started. Despite this therapy, the patient continued to show fluid overload clinical and its radiological signs, with a little improvement in gas exchanges. For that reason and in order to avoid metabolic alterations due to the diuretic therapy, it was decided to start CVVHF treatment. Thus, the patient was submitted to 3 sessions of CVVHF with a total ultrafiltration of 12 liters. He never lost spontaneous diuresis (his hourly dieresis was about of 150 ml). Diuretic therapy was restarted at the end of the CRRT sessions. Result(s): There was an improvement in patient's gas exchanges already during the first treatment which led to the stop of ECMO after 14 days. FGF (fresh gas flow) had been progressively decreased to the oxygenator. At the same time, lung ventilation has been increased to maintain an adequate CO2 clearance. The patient remained stable at a FGF of 0 L/min for a period of 24 hours;thus only mechanical ventilation was kept. A negative fluid balance has led to a significant patient's clinical conditions improvement to permit VV-ECMO weaning. Conclusion(s): Fluid overload removal is an essential goal to improve gas exchanges and, consequently, outcomes in patients treated with ECMO and its duration can both improve. This goal requires continuous renal replacement therapy (CRRT) because of patient's hemodynamic instability. However, the approach combining CRRT and ECMO is facilitated by several ways to link the different circuits without the necessity of positioning a bilumen CVC and, also, by using the same anticoagulation regimen.

Reduced respiratory muscle strength, lung function, and functional status and symptomology in patients referred to Long COVID clinics, an observational cohort analysis

IntroductionOne in ten people will develop Long COVID (LC) following infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite broad-ranging and episodic symptomology, there are no data that demonstrate changes in functional status (FS), respiratory muscle strength and lung function over time. We conducted a sixteen-week cohort observation of LC patients to determine changes in FS, respiratory muscle strength and lung function.MethodSixty-six patients (n=48 females, mean age 51 ± 10 years, n=8 hospitalised, mean time post-infection 6.2 ± 1.8 months) were recruited from LC clinics in the United Kingdom (CPMS ID: 52331). Patients completed five face-to-face visits (day 0, 28, 56, 84 and 110 ± 3 days) and bi-weekly telephone consultations (day 14, 42, 70 and 98 ± 3 days). FS was assessed via the post-COVID functional status scale (PCFS) and the six-minute walk test (6MWT). Maximum inspiratory (MIP) and expiratory (MEP) respiratory muscle pressure and lung function (forced vital capacity (FVC) and forced expired volume in one second (FEV1) were assessed during face-to-face visits according to published standards.ResultsPCFS was 2.7 ± 0.4 AU, P=0.02 at baseline and improved at 16-weeks (2.1 ±1.1 AU) and still highlighted impaired FS. 6MWT was 322 ± 133 meters at baseline and improved at 16 weeks (430 ± 150 meters, P<0.01) but remained lower than normative values for healthy age-matched controls. MIP was 77 ± 21 cmH2O at baseline (86% predicted) and was unchanged post 16 weeks (88 ± 25 cmH2O, 92% predicted, P>0.05). Baseline MEP was 115 ± 41 cmH2O (96% and was unchanged post-16-weeks (119 ± 48 cmH2O, 92% predicted, P>0.05). Lung function data were below predicted values and unchanged over 16 weeks (baseline FVC: 3.10 ± 0.53 L.s-1, 72% predicted, post 16 weeks: 3.16 ± 0.34 L.s-1, 73% predicted, P>0.05 and baseline FEV1: 2.68 ± 0.39 L.s-1, 85% predicted, post 16 weeks: 2.75 ± 0.36 L.s-1, 85% predicted).ConclusionLC patients demonstrate reduced respiratory muscle strength and lung function which could be associated with reduced FS and should be addressed via specific rehabilitation approaches.Please refer to page A216 for declarations of interest related to this .

Mild-to-moderate COVID-19 impact on the cardiorespiratory fitness in young and middle-aged populations.

The goal of the present study was to compare pulmonary function test (PFT) and cardiopulmonary exercise test (CPET) performance in COVID-19 survivors with a control group (CG). This was a cross-sectional study. Patients diagnosed with COVID-19, without severe signs and symptoms, were evaluated one month after the infection. Healthy volunteers matched for sex and age constituted the control group. All volunteers underwent the following assessments: i) clinical evaluation, ii) PTF; and iii) CPET on a cycle ergometer. Metabolic variables were measured by the CareFusion Oxycon Mobile device. In addition, heart rate responses, peak systolic and diastolic blood pressure, and perceived exertion were recorded. Twenty-nine patients with COVID-19 and 18 healthy control subjects were evaluated. Surviving patients of COVID-19 had a mean age of 40 years and had higher body mass index and persistent symptoms compared to the CG (P<0.05), but patients with COVID-19 had more comorbidities, number of medications, and greater impairment of lung function (P<0.05). Regarding CPET, patients surviving COVID-19 had reduced peak workload, oxygen uptake (V̇O2), carbon dioxide output (V̇CO2), circulatory power (CP), and end-tidal pressure for carbon dioxide (PETCO2) (P<0.05). Additionally, survivors had depressed chronotropic and ventilatory responses, low peak oxygen saturation, and greater muscle fatigue (P<0.05) compared to CG. Despite not showing signs and symptoms of severe disease during infection, adult survivors had losses of lung function and cardiorespiratory capacity one month after recovery from COVID-19. In addition, cardiovascular, ventilatory, and lower limb fatigue responses were the main exercise limitations.

Targeting Sedentary Behavior in Minority Populations as a Feasible Health Strategy during and beyond COVID-19: On Behalf of ACSM-EIM and HL-PIVOT

Increased sedentary behavior has been an unintended consequence of social and physical distancing restrictions needed to limit transmission of SARS-CoV-2, the novel coronavirus that causes COVID-19. Sedentary behavior is defined as any waking behavior characterized by an energy expenditure <= 1.5 METs while in a sitting, reclining, or lying posture. These restrictions negatively affect peoples' cardiometabolic and mental health and disproportionately affect certain sectors of the population, including racial/ethnic minorities. In part, the higher risk for complications of COVID-19 could be the result of an increased prevalence of comorbid diseases. Further, regular participation and adherence to current physical activity guidelines, defined as at least 150 min.wk(-1) of moderate-intensity physical activity or muscle strengthening activities on 2 or more days a week, is challenging for many and may be especially difficult to achieve during the COVID-19 pandemic. A practical strategy to promote health and well-being during COVID-19 is reducing sedentary behavior. Reducing sedentary behaviors (e.g., breaking up periods of prolonged sitting with light-intensity physical activity) may be more easily achieved than physical activity for all individuals, including individuals of racial/ethnic decent, as it does not require purchasing equipment nor require compromising the physical restrictions necessary to slow the spread of COVID-19. The purpose of this commentary is to argue that sedentary behavior is a feasible, independent target to modify during COVID-19, particularly in minority populations, and to address this behavior we need to consider individual, environmental, and policy-level factors.