ABSTRACT
Introduction: The COVID -19 pandemic presented a new range of challenges to clinicians across the world in caring for patients affected by a virus with what at the time was an unknown pathophysiology.1 In meeting this challenge physiotherapists utilised their knowledge and experience in treating patients with acute respiratory distress syndrome (ARDS) to provide the best possible care. Objectives: The aim of this paper is to reviewand reflect on physiotherapy treatment for a patient with COVID - 19 who received ECMOsupport, from admission to discharge home. Methods: A case study design to provide a detailed review of the treatments used with the patient during their journey, including feedback from the patient. Figure 1 outlines a timeline of key events during their patient journey. Results: • Historically the Physiotherapy team within the ECMO centre have believed that chest physiotherapy would be mostly ineffective on patients with low lung volumes. However, in this case study it was shown that with tidal volumes of between 30 - 100mls, expiratory vibrations with saline instillation and suctioning cleared more secretions then suctioning alone. • Despite the use of foot splinting whilst sedated we still faced challenges with contractures in calves which subsequently limited standing. • Effective and safe use of SOEOB and tilt-table built up-to standing with support whilst having ECMO in situ. • The use of PMV whilst ventilated allowed the wider MDT to provide effective support for the patient's overall wellbeing. The use of PMV was timed with chaplaincy and psychology input, in addition to enabling twoway communication during video and phone calls with the patient's wife, who at the time was unable to visit due to restrictions. Patient feedback on the use of the PMVTo be able to communicate normally was wonderful, as you are locked into a world where no one understands you and it can be so frustrating to make people understand what you want. Conclusions: The patient was successfullyweaned fromthe ECMO, ventilator and tracheostomy was de-cannulated;they were transferred back to their local hospital for ongoing rehab and were eventually discharged home. This case study introduces a debate as to the effectiveness of manual techniques and suctioning with saline on patients with low lung volumes as it appeared to be beneficial compared to suctioning alone. The use of the PMV within the ventilator circuit enabled vocalisation much earlier during their admission which not only progressed their swallowing and cough strength rehabilitation but also significantly increased the amount of psychological support they were able to access. On reflection it seemed appropriate to utilise similar rehabilitation treatment options used in the management of ARDS patients on ECMO, despite the challenges associated with the complex logistical and safety factors when managing this patient group.
ABSTRACT
Introduction: Due to the COVID-19 pandemic there has been an unprecedented number of hospital and Intensive Care Unit (ICU) admissions for respiratory failure. This has required a significant and sudden increase in ICU capacity. 1,2 Due to severe pulmonary infection and inflammation, patients have presented with acute respiratory distress syndrome (ARDS) with an associated inability to ventilate lungs with poor compliance. This has led to an increased requirement for extra corporeal membrane oxygenation (ECMO) support. This is only available in six commissioned centres across the United Kingdom.3 Objectives: The objective of this is to present a case study of a long-term patient in ICU with a prolonged duration on ECMO. This highlights the complex, mutli-dimensional physiological and psychological impact of recovery and rehabilitation in patients following a severe physical illness. Methods: Figure 1 shows the timeline of significant events during the patient's hospitalisation and admission at the ECMO centre. Due to the nature of a long ICU admission, the patient's condition fluctuated throughout their stay. Rehabilitation was impacted physically by the patient's limited ventilatory reserve caused by lung damage due to COVID. A severe sacral moisture lesion also limited their ability to sit in a chair for longer than one hour and perform sustained sitting on the edge of the bed activities. Psychologically the patient was limited due to significant anxiety and agitation. There were a number of barriers and challenges to rehabilitation whilst the patient was on ECMO as well as post ECMO decannulation. These challenges are detailed in Figure 2. Results: Despite the challenges, the patient was able to participate in physical rehabilitation and was provided psychological support by the psychology team. At their peak ability, the patient was able to perform 12 steps with maximal assistance of three staff. The patient's Chelsea Critical Care Physical Assessment Tool (CPAx) scores can be seen in Figure 3. There was marked difference in the patient's ability to meet the physiological demand of rehabilitation with the ECMO support and without. Following ECMO decannulation the patient struggled with fatigue, hypercapnia and increasing dependency on the ventilator. These issues led to a decline in ability and longer periods of tachypnoea and recovery. Conclusion: Supporting patients after a critical illness requires physical and psychological rehabilitation from the whole MDT. This example of a patient's recovery both during and post ECMO support due to COVID-19 shows the complex relationships affecting the patient's ability to improve and progress.