A case study reflecting on the physiotherapy input with a patient who received extracorporeal membrane oxygenation (ECMO) support following COVID-19

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.