Longing for homelikeness: A hermeneutic phenomenological analysis of patients' lived experiences in recovery from COVID-19-associated intensive care unit acquired weakness.

AIMS: To explore lived experiences of patients recovering from COVID-19-associated intensive care unit acquired weakness and to provide phenomenological descriptions of their recovery. DESIGN: A qualitative study following hermeneutic phenomenology. METHODS: Through purposeful sampling, 13 participants with COVID-19-associated intensive care unit acquired weakness were recruited with diversity in age, sex, duration of hospitalization and severity of muscle weakness. Semi-structured in-depth interviews were conducted from 4 to 8 months after hospital discharge, between July 2020 and January 2021. Interviews were transcribed verbatim and analysed using hermeneutic phenomenological analysis. RESULTS: The analysis yielded five themes: 'waking up in alienation', 'valuing human contact in isolation', 'making progress by being challenged', 'coming home but still recovering' and 'finding a new balance'. The phenomenological descriptions reflect a recovery process that does not follow a linear build-up, but comes with moments of success, setbacks, trying new steps and breakthrough moments of achieving mobilizing milestones. CONCLUSION: Recovery from COVID-19-associated intensive care unit acquired weakness starts from a situation of alienation. Patients long for familiarity, for security and for recognition. Patients want to return to the familiar situation, back to the old, balanced, bodily self. It seems possible for patients to feel homelike again, not only by changing their outer circumstances but also by changing the understanding of themselves and finding a new balance in the altered situation. IMPACT: Muscle weakness impacts many different aspects of ICU recovery in critically ill patients with COVID-19-associated intensive care unit acquired weakness. Their narratives can help nurses and other healthcare professionals, both inside and outside of the intensive care unit, to empathize with patient experiences. When healthcare professionals connect to the lifeworld of patients, they will start to act and communicate differently. These insights could lead to optimized care delivery and meeting patients' needs in this pandemic or a possible next.

A Sense of Being Needed: A Phenomenological Analysis of Hospital-Based Rehabilitation Professionals' Experiences During the COVID-19 Pandemic.

OBJECTIVE: The purpose of this study was to explore lived experiences of rehabilitation professionals working in hospitals during the COVID-19 pandemic, including the ethical issues and moral distress that these professionals might have encountered. METHODS: An interpretative phenomenological study was performed. First-person experiences of rehabilitation professionals (dieticians, occupational therapists, physical therapists, and speech-language therapists) were collected with semi-structured interviews and analyzed with interpretative phenomenological analysis. RESULTS: The data of 39 hospital-based rehabilitation professionals revealed 4 themes: a disease with great impact, personal health and safety, staying human in chaotic times, and solidarity and changing roles. Participant experiences show that the virus and COVID-19 measures had a significant impact on the in-hospital working environment due to the massive downscaling of regular care, due to infection prevention measures, and due to unknown risks to rehabilitation professionals' personal health. At the same time, participants experienced a certain freedom, which made room for authentic motives, connection, and solidarity. Participants felt welcomed and appreciated at the COVID-19 wards and intensive care units and were proud that they were able to fulfill their roles. The findings reflect a wide range of situations that were morally complex and led to moral distress. CONCLUSION: To diminish the long-lasting negative impact of the COVID-19 pandemic and moral distress, employers should empathize with the experiences of hospital-based rehabilitation professionals and create conditions for ethical reflection. Our data show that hospital-based rehabilitation professionals value professional autonomy. Creating room for professional autonomy helps them feel needed, connected, and energized. However, the needs of hospital-based rehabilitation professionals may conflict with organizational rules and structures. IMPACT: Hospital-based rehabilitation professionals were involved in situations they considered morally undesirable, and they inevitably faced moral distress during the COVID-19 crisis. This study offers rationale and guidance to employers regarding how to reduce the long-term negative impact of the COVID-19 pandemic on rehabilitation professionals.

Feasibility of critical care ergometry: Exercise data of patients on mechanical ventilation analyzed as nine-panel plots.

Nine-panel plots are standard displays of cardiopulmonary exercise data, used in cardiac and pulmonary medicine to investigate the nature of exercise limitation. We explored whether this approach could be used to analyze the data of critically ill patients on mechanical ventilation, capable of exercising actively. Patients followed an incremental exercise protocol using a bedside cycle ergometer. Respiratory gases were analyzed using indirect calorimetry, and blood gases were sampled from arterial catheters. Data of seven patients were combined into nine-panel plots. Systematic analysis clarified the nature of exercise limitation in six cases. Resting metabolic rate was increased in all patients, with a median oxygen uptake ( V˙O2 ) of 5.52 (IQR 4.29-6.31) ml/kg/min. Unloaded cycling increased the V˙O2 by 19.8% to 6.61 (IQR 5.99-7.08) ml/kg/min. Adding load to the ergometer increased the V˙O2 by another 20.0% to reach V˙O2peak at a median of 7.14 (IQR 6.67-10.75) ml/kg/min, corresponding to a median extrinsic workload of 7 W. This was accompanied by increased CO2 production, respiratory minute volume, heart rate, and oxygen pulse. Three patients increased their V˙O2 to >40% of predicted V˙O2max , two patients passed the anaerobic threshold. Dead space ventilation was 44%, decreasing to 42% and accompanied by lower ventilatory equivalents during exercise. Exercise produced no net change in alveolo-arterial PO2 difference. We concluded that diagnostic ergometry in mechanically ventilated patients was feasible. Analysis of the data as nine-panel plots provided insight into individual limitations to exercise.

Recommendations for Hospital-Based Physical Therapists Managing Patients With COVID-19.

OBJECTIVE: The COVID-19 pandemic is rapidly evolving and has led to increased numbers of hospitalizations worldwide. Hospitalized patients with COVID-19 experience a variety of symptoms, including fever, muscle pain, tiredness, cough, and difficulty breathing. Elderly people and those with underlying health conditions are considered to be more at risk of developing severe symptoms and have a higher risk of physical deconditioning during their hospital stay. Physical therapists have an important role in supporting hospitalized patients with COVID-19 but also need to be aware of challenges when treating these patients. In line with international initiatives, this article aims to provide guidance and detailed recommendations for hospital-based physical therapists managing patients hospitalized with COVID-19 through a national approach in the Netherlands. METHODS: A pragmatic approach was used. A working group conducted a purposive scan of the literature and drafted initial recommendations based on the knowledge of symptoms in patients with COVID-19 and current practice for physical therapist management for patients hospitalized with lung disease and patients admitted to the intensive care unit. An expert group of hospital-based physical therapists in the Netherlands provided feedback on the recommendations, which were finalized when consensus was reached among the members of the working group. RESULTS: The recommendations include safety recommendations, treatment recommendations, discharge recommendations, and staffing recommendations. Treatment recommendations address 2 phases of hospitalization: when patients are critically ill and admitted to the intensive care unit, and when patients are severely ill and admitted to the COVID ward. Physical therapist management for patients hospitalized with COVID-19 comprises elements of respiratory support and active mobilization. Respiratory support includes breathing control, thoracic expansion exercises, airway clearance techniques, and respiratory muscle strength training. Recommendations toward active mobilization include bed mobility activities, active range-of-motion exercises, active (assisted) limb exercises, activities-of-daily-living training, transfer training, cycle ergometer, pre-gait exercises, and ambulation.

Feasibility of Exercise Testing in Patients Who Are Critically Ill: A Prospective, Observational Multicenter Study.

OBJECTIVE: To evaluate the feasibility and safety of exercise testing and to describe the physiological response to exercise of patients in the Intensive Care Unit (ICU). DESIGN: A prospective observational multicenter study. SETTING: Two mixed medical-surgical ICUs. PARTICIPANTS: Patients (N=37; with no primary neurological disorders, 59% men; median age 50y; ICU length of stay 14.5d; Acute Physiology and Chronic Health Evaluation IV 73.0) who had been mechanically ventilated for more than 48 hours and were hemodynamically stable enough to perform physical exercise. INTERVENTIONS: A passive or active incremental exercise test, depending on muscle strength, on a bed-based cycle ergometer. MAIN OUTCOME MEASURES: Feasibility and safety were evaluated based on protocol adherence and adverse events. Physiological responses to exercise quantified as changes in respiratory frequency (RF), oxygen uptake (Vo2), carbon dioxide output (Vco2), respiratory exchange ratio (RER), and blood lactate. RESULTS: Thirty-seven patients of whom 18 were mechanically ventilated underwent the exercise test. The active incremental test was performed by 28, and the passive test by 9 participants. Thirty-three (89%) accomplished the test according to the protocol and 1 moderate severe adverse event (bradycardia; heart rate 44) occurred shortly after the test. RF, Vo2, Vco2, and lactate increased significantly, whereas RER did not change during the active incremental exercise test. No changes were observed during the passive exercise test. CONCLUSIONS: It is safe and feasible to perform exercise testing on a bed-based cycle ergometer in patients who are critically ill and a physiological response could be measured. Future research should investigate the clinical value of exercise testing in daily ICU practice and whether exercise capacity and its limiting factors could be determined by incremental exercise testing.