Case Physiotherapy management of COVID-19 patients in acute set up of government tertiary care hospital: A case series

The entire world is in the grip of COVID-19. India is under lockdown since our Institute, a Tertiary Care Hospital, was declared as COVID-19 dedicated Hospital by the Corporation Greater Mumbai.13th onwards, Physiotherapy School & Centre, an integral part of the above mentioned institute, was called upon to offer their services to the COVID-19 patients. This paper aims to share our physiotherapy professional experiences and challenges faced as front liners in treating critically ill patients with COVID-19 admitted in Intensive Care Unit through case series of 4 patients.


Introduction
COVID-19 is a highly communicable disease caused by SARS-CoV-2 transmitted by direct contact with infected people (droplet transmission within 1 m distance) and indirect contact with surfaces or with objects used by the infected person in the same environment. Airborne transmission may be possible during aerosol-generating procedures like endotracheal intubation, bronchoscopy, open suctioning, nebulization, prone positioning, weaning the patient from the ventilator, NIV, tracheostomy, and CPR. 1 The clinical presentation begins within 14 days of exposure, however in most cases symptoms present after about 5 days and symptom onset is within 11.5 days in 97.5% of individuals. 2,3 (Table 1) Hypoxaemia without the perception of dyspnoea ('silent hypoxaemia') is a hallmark of the disease. Hypoxaemia is usually associated with an increase in alveolar to arterial oxygen gradient signifying either a ventilation perfusion mismatch or an intrapulmonary shunting. 4 Adverse outcomes are associated consolidation particularly on the peripheral and the lower lobes of the lungs. 8 The mainstay of clinical treatment consists of symptomatic management and oxygen therapy, with mechanical ventilation for patients with respiratory failure. COVID-19 is a novel disease, the pathophysiology of which is still not very clear. Role of Physiotherapeutic intervention is well established in Intensive care and is effective in treating respiratory disorders such as ventilatory dysfunction, dyspnea by reducing work of breathing, improving ventilation and quality of life. 9 The aim of this article is to share the Physiotherapy interventions and its benefits in the management of critical patients with severe disease of Covid-19 in the Intensive Care Unit of a government tertiary care hospital. The patients in this case series have a diverse presentation and response to physiotherapeutic interventions.

Case study 1
A 29-year-old male, gym trainer by occupation was admitted to ICU on the 5th day of onset of symptoms. His saturation was maintained on 14 litres oxygen with bag and mask ventilation. His CRP was 79.10 mg/dl, D-Dimer was 1.2 ng/dl, ferritin was 716 ng/ml, PO2-76.5. HRCT showed COVID pneumonia grade 3 with multiple confluent ill-defined patchy attenuation in the bilateral Lung parenchyma. The first session of Physiotherapy began with patient education followed by breathing control and thoracic expansion exercises in supine as well as in sitting and ended with prone positioning which patient maintained for 2 hours. Exercises of the upper and lower limb were included as the patient's condition stabilized. The patient showed good recovery and was further progressed to exercises in standing. Spot Marching was given before progressing to walking around the bed and later to walking in ICU. As the patient was young he could tolerate the exercises well and made a quick recovery. Sessions were concluded with prone positioning (Table 2). Table 2 -Table 5 Details of hemodynamic parameters with Physiotherapy management of cases from day of admission to day of discharge in intensive care unit

Case study 2
A 30-year-old male with recently diagnosed diabetes mellitus was admitted to ICU on 7th day of onset of symptoms. He was on BIPAP, Fio2 100%. His IL6 was 9.47, ferritin was 386, D-Dimer was 4779 ng/dl, CRP was 60 mg/dl and PO2-60. HRCT showed ground-glass opacities and ill-defined consolidation patch in the bilateral middle and lower lobe. Xray showed bilateral fluffy shadows in middle and lower lobes. Initially, positioning in prone was difficult because of the risk of detachment of BIPAP mask hence high side-lying and quarter prone positions were used. In bed mobility and breathing exercises were given. As his condition improved, he was shifted from BIPAP to bag and mask ventilation. Prone positioning was now included along with exercises in sitting, standing and walking. Sessions were concluded with prone positioning (Table 3).

Case study 3
A 34-year-old male, fruit seller by occupation, was hospitalized on the 12th day of onset of symptoms and transferred to ICU the next day. He was on 8 litres oxygen bag and mask ventilation. CRP was 65 mg/dl, ferritin was 1144 ng/ml and PO2-67.9. HRCT showed multiple large ground-glass opacities with consolidation patch involving 70% of lung parenchyma. As 70% of lung parenchyma was involved, this patient desaturated considerably with exercise. Patient's oxygen level was increased before starting the exercises as he used to desaturate (up to 85%). He benefited from prone positioning and breathing control. Exercises were gradually progressed from in bed mobility exercises to exercise in standing keeping in consideration the hemodynamic stability of the patient. Sessions were concluded with prone positioning (Table 4).

Case study 4
A 59-year-old male, with diabetes and hypertension, was admitted in the hospital on the 5th day after the onset of symptoms and was transferred to ICU on the same day. His oxygen saturation was maintained on bag and mask Ventilation with 8 litres oxygen. D-Dimer was 11.3ng/dl; CRP was 77 mg/dl and ferritin was 1315 ng/ml and SPO2 level was 63.3. Chest Xray showed bilateral fluffy shadows indicating ARDS. The first session of Physiotherapy began with patient education followed by breathing control  Pre  88  92  81  89  92  88  88  Post  92  96  100  96  88  96  91   RR bpm  Pre  24  22  25  23  20  26  25  Post  22  21  22  20  21  22  23   SPO2 %  Pre  100  99  98  100  100  100  100  Post  97  97  98  97  99  100 100 exercises in sitting. Exercises were progressed at a slower rate as the patient complained of easy fatigability. Adequate rest-pause was included between all exercises. Exercises began with lower repetition and then were progressed according to patient perception of fatigue. The exercise was terminated whenever he complained of severe fatigue and pain in calf muscles. Sessions were concluded with prone positioning (Table 5).

Discussion
COVID-19 is a highly communicable viral infection associated with overactive host immune response resulting in pneumonia and ARDS. The duration of symptoms is approximately 4 to 19 days with complications setting in between 7 to 19 days 9 to 14% of patients have severe disease while 5% of patients are critical. 10 As can be seen from the above cases, even young patients (29 years, 30 years and 34 years) with comorbidities had severe to critical COVID -19 disease. On account of the increased risk of exposure to infection, Personal Protective Equipment (PPE kit) was used while treating these patients. Assessment by Physiotherapist was limited to observing breathing pattern and respiratory rate, use of finger pulse oximeter which displays oxygen  saturation and pulse rate, and cardioscope which displays heart rate and BP. Furthermore, patient assessment and Physiotherapy management should not exceed 10-15 minutes to reduce risk of exposure. Being a 1000 bedded dedicated COVID-19 hospital, the number of patients referred daily meant treating patients in PPE for 4-5 hours which was a big challenge. [11][12][13][14] Patients with COVID-19 pneumonia and ARDS are admitted to ICU with Type 1 respiratory failure. They are unable to maintain the oxygen saturation in the blood and hence are put on oxygen therapy. During the natural course of the disease, the primary goal of a Physiotherapist in ICU is to prevent the accumulation of or to clear bronchopulmonary secretions and to prevent ICU acquired muscle weakness. As all the above patients had dry cough with no secretions, interventions were directed to reduce hypoxemia with positioning, to relieve dyspnea with a diaphragmatic breathing exercise and general exercises to prevent muscle weakness.
Physiotherapy management was started with patient education which helped in reducing anxiety and fear about the COVID 19. Patients were given position changes every Graded exercises were given to prevent complications of bed rest and deconditioning. Patients were given exercises of the upper and lower extremity in supine and progressed to sitting at the edge of the bed, standing, spot marching and walking in ICU with adequate rest-pause. Exercises helped to optimize oxygen transport by improving alveolar ventilation and V/Q matching and also in maintaining normal fluid distribution in the body and also helped in reducing the fear of activity. 16 Post-exercise, the elderly patient required longer recovery time and reported a higher level of fatigue as compared to the younger patients owing to the progressive decline in innate immune response observed with increasing age, and comorbidities. 17 The above COVID-19 patients were attended on one to one basis by a Physiotherapist for 15 minutes daily. The breathing exercises and general mobility exercises performed in the presence of Physiotherapist probably reduced their anxiety and improved their confidence to perform basic activities with less breathlessness. Positive outcomes were obtained with physiotherapy interventions in all the four patients' despite their diverse characteristics.

Conclusion
Thus we conclude that Physiotherapy intervention was well tolerated by the patients and hence can be administered safely in COVID 19. It helped in reducing their anxiety and fear which had a positive effect on the level of oxygen saturation and level of breathlessness. All the above patients showed early recovery which helped them to go back to the community with good functional capacity.

Source of Funding
None.

Conflict of Interest
None.