|Year : 2022 | Volume
| Issue : 2 | Page : 75-80
Postintensive care syndrome after severe COVID-19 respiratory illness and functional outcomes: Experience from the rehabilitation hospital in Qatar
Krishnaprasad Ittilavalappil Narayanankutty, Sami Ullah, Saquib Hanif, Mohamed Lamine Missaoui, Rafat Mohmamed Abdullah Saad
Department of Physical Medicine and Rehabilitation, Qatar Rehabilitation Institute, Hamad Medical Corporation, Doha, Qatar
|Date of Submission||17-Jan-2022|
|Date of Decision||20-Jan-2022|
|Date of Acceptance||25-Jan-2022|
|Date of Web Publication||15-Apr-2022|
Dr. Sami Ullah
MBBS, FCPS (PMR), Department of Physical Medicine & Rehabilitation, Qatar Rehabilitation Institute, Hamad Medical Corporation Doha
Source of Support: None, Conflict of Interest: None
Objective: This study aimed to observe functional outcomes post coronavirus disease (COVID) rehabilitation in COVID-19 patients with postintensive care syndrome (PICS). Methods: We present 13 cases of severe COVID-19 pneumonia who required prolonged intensive care unit (ICU) stay, and were later admitted to our rehabilitation institute with features of PICS and functional disability, during the months of July and August 2020. All these patients underwent a multidisciplinary rehabilitation program and are the first group of patients successfully discharged to the community. Results: Among 13 patients presented, 11 were male patients and 2 were female, in the age range 34–64 years. Ten out of 13 patients had at least one chronic illness such as diabetes mellitus, systemic hypertension, dyslipidemia, obstructive airway disease, and coronary artery disease, and seven among them had more than one illness. None of them had any known neuropsychiatric illnesses. All of them had severe pneumonia which required mechanical ventilation from 12 to 30 days and an average length of ICU stay of 36 days (Range 21–54 days). The most common impairments on rehabilitation admission were impaired exercise tolerance with poor scores in Modified Medical Research Council (mMRC) dyspnea scale and desaturation on 40-step walking test, as well as significant ICU acquired weakness with a Medical Research Council (MRC) sum score in the range of 30–46 out of 60. Eight out of 13 patients had critical illness myopathy and/or neuropathy diagnosed with neuro-electrodiagnostic testing. The average length of stay for the patients in rehabilitation was 36 days, with a range of 18–65 days. Conclusion: Early multidisciplinary rehabilitation has got a potential benefit in the functional outcome of COVID-19 survivors. More studies are required in this area to further evaluate the benefits of different rehabilitation interventions, their intensity, duration, long-term benefits, and to create guidelines for addressing similar situations in the future.
Keywords: Coronavirus disease-2019, postintensive care syndrome, rehabilitation
|How to cite this article:|
Narayanankutty KI, Ullah S, Hanif S, Missaoui ML, Saad RM. Postintensive care syndrome after severe COVID-19 respiratory illness and functional outcomes: Experience from the rehabilitation hospital in Qatar. J Int Soc Phys Rehabil Med 2022;5:75-80
|How to cite this URL:|
Narayanankutty KI, Ullah S, Hanif S, Missaoui ML, Saad RM. Postintensive care syndrome after severe COVID-19 respiratory illness and functional outcomes: Experience from the rehabilitation hospital in Qatar. J Int Soc Phys Rehabil Med [serial online] 2022 [cited 2022 Dec 5];5:75-80. Available from: https://www.jisprm.org/text.asp?2022/5/2/75/343326
| Introduction|| |
The coronavirus disease-2019 (COVID-19) originated in Wuhan in the Hubei Province of China in December 2019 has spread out to be a worldwide pandemic. As of November 30, 2020, the total number of COVID-19 cases in the world has reached 62,195,274 with 1,453,355 confirmed deaths. Our understanding about the disease has evolved over the last 2 years.
COVID-19 is a highly infectious respiratory virus that can lead to severe pneumonia, acute respiratory distress syndrome, and multi-organ dysfunction. In majority (81%), COVID-19 infection causes only mild disease with fever (88.7%), cough (57.6%), and dyspnea (45.6%). However, for a significant number of patients, especially the elderly with comorbidities, the infection can have very serious sequelae. Among hospitalized patients, a relatively high percentage (20.3%) require management in the intensive care unit (ICU), often for acute respiratory distress syndrome and multi-organ failure. Among hospitalized patients, a case fatality rate of 13.9% has been reported, the leading cause of death being an acute respiratory failure.
Patients admitted in the ICU can have several complications due to extended immobilization and many hours in the prone position as part of treatment. These complications can include severe muscle weakness due to neuro-myopathy, joint stiffness, pain, dysphagia, psychological problems, cognitive problems, reduced mobility, impaired balance and gait, frequent falls, limitations in activities of daily living, and severely impaired quality of life. The longer a patient remains in the ICU, the greater the risk of long-term physical, cognitive, and emotional complications, which are collectively known as postintensive care syndrome (PICS).
Older COVID-19 patients with increased frailty or underlying diseases such as diabetes, hypertension, and other chronic disorders are at higher risk of ICU admission and subsequently at higher risk of developing PICS.
Functional limitations and decreased quality of life were reported in adults and children recovering from COVID-19. Word Health Organization (WHO) also recommended rehabilitation in the acute phase of care for COVID-19 patients presenting with respiratory failure. A pilot randomized controlled trial conducted by Wu et al. in 2019 in critical care survivors concluded the importance of intensive early rehabilitation. The role of rehabilitation for survived critically ill COVID-19 patients recognizes in preliminary research.,
Multidisciplinary rehabilitation services have shown to play an important role in minimizing residual impairments after a prolonged ICU stay. Multidisciplinary rehabilitation is a complex multidisciplinary intervention focused on minimizing the disabling effect of an individual's impairments and promoting and optimizing independence in activities of daily living and maximizing opportunities to participate meaningfully in society with a new functional baseline. WHO emergency medical team minimum standards recommend rehabilitation as a core component of patient-centered care in response to disasters, and have suggested minimum standards regarding staffing, equipment, and space.
Qatar rehabilitation institute is the main rehabilitation services provider in Qatar with 159 inpatient beds and outpatient rehabilitation services. QRI also provides day care and community rehabilitation services being led by a physiatrist. Rehabilitation services are also being provided in primary health-care centers and other inpatient hospitals.
At the time this study was conceived, there were no studies available in the region about post-COVID rehabilitation of critically ill patients. This study therefore aimed to explore the efficiency and effectiveness of an inpatient early rehabilitation program for patients with PICS after severe COVID-19 respiratory illness. This study will help to understand impairment, rehabilitation needs, and functional outcomes of patients with PICS after severe COVID-19 respiratory illness, as well as serve as pilot data for future studies.
| Methods and Results|| |
We present 13 cases of severe COVID-19 pneumonia who required prolonged ICU stay and were later admitted to our rehabilitation institute with features of PICS and functional disability, during the months of July and August 2020. All these patients underwent an interdisciplinary rehabilitation program and are the first group of patients successfully discharged to the community.
Among 13 patients presented, 11 were male patients and 2 were female, in the age range 34–64 years. Ten out of 13 patients had at least one chronic illness such as diabetes mellitus, systemic hypertension, dyslipidemia, obstructive airway disease, and coronary artery disease, and seven among them had more than one illness. None of them had any known neuropsychiatric illnesses. All of them had severe pneumonia which required mechanical ventilation from 12 to 30 days and an average length of ICU stay of 36 days (range: 21–54 days).
All these patients developed at least two medical complications while at ICU, which included electrolyte dysfunctions, secondary bacterial infection, sepsis, acute kidney injury, thrombotic events, and delirium. All those complications were managed successfully with appropriate interventions which included supportive care, antibiotics, anticoagulation, and hemodialysis, whenever appropriate. Medical management of COVID-19 infection was provided according to the then existing guidelines, which consisted of hydroxychloroquine, antiviral agents (ritonavir, lopinavir, oseltamivir, and ribavirin), and immunomodulatory therapies (steroids, tocilizumab, and interferon-alpha). Most of them received convalescent plasma therapy and two were treated with intravenous immunoglobulin.
The most common impairments of on rehabilitation admission were impaired exercise tolerance with poor scores in Modified Medical Research Council (mMRC) dyspnea scale [Table 1] and desaturation on 40-step walking test, as well as significant ICU acquired weakness with a Medical Research Council (MRC) sum score [Table 1] in the range of 30–46 out of 60. Eight out of 13 patients had critical illness myopathy and/or neuropathy (CRIMYNE) diagnosed with neuro-electrodiagnostic testing. Berg balance test and Dynamic Gait Index scored poorly on admission and four patients demonstrated significant dysphagia. Depression screening showed minimal depression in three patients, mild depression in four patients, and moderate depression in six patients. Seven out of 13 patients showed varying levels of cognitive impairments on admission. Functional independence measure scores on admission were in the range of 49–102 out of 126 [Table 2].
|Table 2: Length of stay in intensive care unit, inpatient rehabilitation, and rehabilitation outcomes|
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The average length of stay for the patients in rehabilitation was 36 days, with a range of 18–65 days. During this period, all of them received customized patient-centered multidisciplinary rehabilitation interventions, which included medication and dietary optimization, training to improve endurance, respiratory dynamics, muscle strength and swallowing function, cognitive retraining, psychological support, and training in ADL to return to premorbid functional baseline. Endpoints of rehabilitation were improved exercise tolerance and muscle strength, which enabled them to perform their basic activities of daily living and to live independently in the community. Exercise tolerance showed improvement in most patients with a significant reduction in oxygen requirements during exercise and rest. Two patients with significant lung damage required home oxygen therapy and were discharged on the same. MRC sum score was more than 48 in all patients at the time of discharge, and Berg balance score, Dynamic Gait Index score, and dyspnea score showed good improvement [Figure 1]. Those patients who were screened positive for depression were assessed by a psychiatrist and were started on appropriate therapy. Those patients who had significant cognitive impairments on admission showed some improvement during admission, while those who had mild impairment remained stable in their cognitive faculties. Functional independence measure scores improved in all patients, those who had low scores on admission showed more improvement than those who had high scores.
|Figure 1: Improvement in muscle strength, balance, gait, and ADL after rehabilitation|
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| Discussion|| |
Our result suggests that multidisciplinary rehabilitation intervention in COVID-19 patients with PICS results in improved muscle strength, balance gait, and activity of daily living. Majority of these patients had chronic illnesses. All these patients had severe pneumonia requiring mechanical ventilation and an average length of ICU stay of 36 days. Most of the patients on inpatient rehabilitation admission had poor scores in MMRC dyspnea scores and impaired exercise tolerance. More than half of the patients (8 out of 13 patients) had CRIMYNE diagnosed with neuro-electrodiagnostic testing.
The average length of stay for the patients in rehabilitation was 36 days, with a range of 18–65 days. In our study, the average length of stay in rehabilitation matches with an average length of stay in ICU for these patients. This finding highlights the importance of multidisciplinary inpatient rehabilitation in these COVID-19 patients with PICS. Multiple studies have demonstrated the benefit of rehabilitation interventions in the short- and long-term outcomes of patients with PICS, across different settings.
A randomized trial of 21 general medical/surgical ICU survivors (8 controls and 13 intervention patients), in the RETURN study by Jackson et al., demonstrated significantly improved cognitive executive functioning and better performance on the Functional Activities Questionnaire. In another prospective double-blinded randomized controlled trial investigating early physical rehabilitation, involving fifty critically ill adults admitted to a general ICU with sepsis syndromes, Kayambu et al. demonstrated a significant increase in patient self-reported physical function (P = 0.04) and physical role for the SF-36 (P = 0.005) at 6 months in the exercise group compared to control.
Jones et al., in a randomized controlled trial of 93 intensive care patients aged 45 years or older also demonstrate promising results of rehabilitation intervention.
Similarly, the RECOVER Trial (2015) by Walsh et al., at two hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU supports rehabilitation intervention.
Rehabilitation interventions may include resumption of activities; exercise therapy; breathing techniques; rehabilitation for communication and swallowing difficulties; occupational rehabilitation; psychological interventions; and cognitive training;,
At our rehabilitation center, prior to COVID-19 pandemic, we had limited experience dealing with PICS as inpatients, as days spent in ICU for most patients admitted for inpatient rehabilitation were quite low to develop PICS. However, COVID-19 respiratory illness demanded more ICU days for the patients and has created a group of patients with features of PICS, who required inpatient rehabilitation. These patients had functional impairments across multiple domains, which we tried to address by applying the fundamental principles of rehabilitation medicine. Through this case series, we tried to present the clinical outcomes we observed after a course of multidisciplinary rehabilitation; in the first batch of patients, we were able to discharge successfully. Among the key domains of physical, psychological, and cognitive impairments, we observed a good improvement in the physical domain at the end of our rehabilitation program. The other two domains will require long-term interventions to show significant improvement, which will be assessed through a series of follow-ups.
A primary concern is regarding the timing of when to start a rehabilitation protocol in the face of the COVID-19 spread and the chance of clinical worsening and cross infection. The role of an early multidisciplinary rehabilitation including respiratory rehabilitation during the acute phase has been controversial as some early reports indicate poor tolerance and rapid desaturation. However, once patients have recovered and are vitally stable, they can undergo multidisciplinary rehabilitation, according to their clinical condition [Table 3].
|Table 3: Suggested admission criteria for physical medicine and rehabilitation for coronavirus disease-2019 patients|
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During COVID rehabilitation, the respiratory therapist role become more inclusive than before as almost all COVID-19 patients required respiratory therapist initial evaluation and continuation of respiratory therapy program. Our dedicated team of respiratory therapists joins hands with other rehabilitation team members to achieve common goals of restoration of functional ability and improve quality of life.
The aim of respiratory rehabilitation is to improve symptoms of dyspnea, relieve anxiety and depression, reduce complications, prevent, and improve dysfunction, reduce disability, preserve function to the maximum extent, and improve quality of life.
Physical therapy should be started in the acute inpatient setting and continued to inpatient rehabilitation. Early active mobilization is important to improve muscle strength and promote better mobility and better quality of life. Aerobic reconditioning kept to <3 metabolic equivalents of task initially and later progressed to 20–30 min, 3–5 times a week as well as balance and gait training also should be incorporated in the exercise plan. Occupational therapy focuses on basic and instrumental ADL guidance as well as targeted interventions to facilitate functional independence and address cognitive changes. Speech–language pathologists assess and treat dysphagia and voice impairments resulting from prolonged intubation, address respiratory strength and coordination, and address issues with communication. Psychological interventions may be required for patients with depression, anxiety, or PTSD. Education on the importance of a healthy lifestyle and participation in family and social activities are also incorporated in rehabilitation programs.
Multidisciplinary rehabilitation should be started as early as possible, when the medical condition permits, in the ICU itself. After discharge from the ICU, its intensity can be increased and can be delivered over multiple settings as per the functional status of the patient.
This study is limited to one center and a few patients as case series. More studies with bigger data are required in this area to further evaluate the benefits of different rehabilitation interventions, their intensity, duration, long-term benefits, and to create guidelines for addressing similar situations in the future.
| Conclusion|| |
Multidisciplinary rehabilitation is a key component in the management of PICS to minimize the disability and optimize the function.
Initial findings show good promise that early multidisciplinary rehabilitation has got a potential benefit in the functional outcome of COVID-19 survivors.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]