April 30, 2021 9:49:47 pm
Written by Saima Zaki
The rapid surge of COVID-19 has covered the entire nation. Usually, COVID symptoms resolve overtime. However, in some critical cases, it has led to development of ARDS (Acute Respiratory Distress Syndrome), septic shock, hypovolaemia (low fluid in body), multiple organ failures, and congestive heart failure. These complications are seen predominately in older adults and individuals with cardiorespiratory, endocrine, or gestational co-morbidities.
I am a cardiopulmonary physiotherapist professional. I finished my post-graduation in July 2019, and was excited to give my inputs on research in my field. I got admission in a Ph.D programme in October 2019. But the coronavirus has shredded all my enthusiasm.
This pandemic has not allowed me to start my work as the university is usually closed, as well as because I have proposed to study the effect of a novel exercise regime on a human population which is susceptible to get the coronavirus infection. This article is about public awareness on the role of pulmonary rehabilitation (PR) in COVID-19.
The chest computer tomography (CT) is a highly sensitive tool for the diagnoses of COVID-19, but due to cost and availability, it is less commonly performed. The abnormality in the lungs can be seen by a chest CT, which commonly demonstrates fluid retention, fibrosis, and scarring due to injury in the lung tissue in COVID-19 patients.
A lung is like a balloon: as we inhale, it inflates as air goes inside and during exhalation it deflates as air goes outside. Suppose I constrict some part of the balloon, and then try to inflate it. Will it will have the capacity of the same amount of air before constriction? No. The same happens after pulmonary (lung) fibrosis or scarring as seen in patients with COVID-19.
In normal lungs, the branches of the lungs called alveoli diffuse with blood capillaries for the transfer of oxygen to the body, and carbon dioxide is excreted during exhalation. Our body organs require oxygen for their functions and energy production. Since COVID patients have low oxygen consumption, they complain of breathlessness, fatigue and inability to perform daily activities thus impacting their quality of life.
Based on the length of hospital stay and COVID impact after recovery, we have seen patients complaining of musculoskeletal (muscles and bone) symptoms like muscle cramps, joint stiffness, and muscle weakness on clinical examination. Many patients have developed muscle atrophy (decrease in muscle girth), low muscle strength and power.
In addition, treatments for COVID such as corticosteroids and immunosuppressive therapy may lead to drug-induced myopathy (muscle dysfunction), as it increases oxidative stress and mitochondrial dysfunction that may cause physiological hypercortisolemia, excess proteolysis which is directly related to cachexia (muscle weakness), and muscle atrophy.
Before understanding the role of PR in COVID, it is necessary to understand what it actually is. According to the American Thoracic Society and European Respiratory Society, “pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behaviour change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviours.”
Cardiopulmonary physiotherapists are a key provider in delivering PR, in collaboration with other healthcare professionals. The best interventions are provided in patient’s care through them.
In people with COVID-19, the PR programme starts from day one in the hospital or in-home quarantine to the recovery stage. In the acute phases of COVID, patients demonstrate low oxygen saturation (SPO2). The standard guidelines recommend providing supplementary as the SPO2 drops below 90 per cent.
With and without supplementary oxygen in PR, exercises are provided to increase lung function as per the patient’s SPO2 level. Supplementary oxygen, making the patient lie on the stomach (prone position) also promotes even distribution of gases of the lung, increases the chest wall elasticity, oxygenation, and promotes ventilation-perfusion matching.
According to the guidelines, the prone position should be sustained for at least 12 hours per day in severe ARDS. However, when employing the prone position for a longer duration, the chances of pressure ulcers are increased on the bony prominences such as earlobes, heels, back of elbow, etc. It is essential to provide cushioning on these regions that could be performed with cotton or towel underneath.
Patients with prolonged bed rest are susceptible to cardiovascular complications also, like increase sympathetic tone, decrease cardiac reserve, orthostatic hypotension, and venous thromboembolism. For the prevention of these complications, early mobilisation and physical activity are emphasised in PR, which is a safe and cost-effective approach as well.
Mobilisation includes passive range of motion and passive turning and rolling on bed when the patient is unconscious, and not following commands. Active mobilisation is recommended which consists of semi-recumbent position, sitting, and ambulation, according to the patient’s recovery and hemodynamic stability. The evidence suggests that once the patient is stable, these manoeuvres can be performed whenever required, at any stage of COVID, with adequate precautions.
Despite the availability of high-grade research on PR, on the beneficial effects of improvements in lung function, oxygenation, functional capacity, and a person’s quality of life in lung diseases, people lack the appropriate knowledge about it. The reasons are many. Most common among them is the fewer numbers of cardiorespiratory specialised physiotherapists.
In most of the scenarios, surgeons, and physicians try to take on the role of physio by prescribing therapy. It is time the government set up a department for PR in hospitals and appoint cardiopulmonary physiotherapists as early as possible.
The writer is a research scholar, MPT (Cardiopulmonary), Jamia Millia Islamia
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