Muscle strength and functional outcome after prone positioning in COVID-19 ICU survivors

Upper limb peripheral nerve injuries in patients with ARDS requiring prone positioning: A systematic review with proportion meta-analysis

OBJECTIVE

To investigate the prevalence of upper limb peripheral nerve injuries (PNI) in adult patients admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) undergoing prone positioning.

METHODS

This systematic review with meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Four electronic databases including PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, and EMBASE were searched from inception to January 2024. The quality of the included studies was evaluated according to the Joanna Briggs Institute Critical Appraisal Tools. A proportion meta-analysis was conducted to examine the combined prevalence of upper limb PNI among patients requiring prone positioning.

RESULTS

A total of 8 studies (511 patients) were pooled in the quantitative analysis. All studies had a low or moderate risk of bias in methodological quality. The overall proportion of patients with upper limb PNI was 13% (95%CI: 5% to 29%), with large between-study heterogeneity (I2 = 84.6%, P<0.001). Both ulnar neuropathy and brachial plexopathy were described in 4 studies.

CONCLUSION

During the COVID-19 pandemic, prone positioning has been used extensively. Different approaches among ICU teams and selective reporting by untrained staff may be a factor in interpreting the large variability between studies and the 13% proportion of patients with upper limb PNI found in the present meta-analysis. Therefore, it is paramount to stress the importance of patient assessment both after discharge from the ICU and during subsequent follow-up evaluations.

IMPLICATIONS FOR CLINICAL PRACTICE

Specialized training is essential to ensure safe prone positioning, with careful consideration given to arms and head placement to mitigate potential nerve injuries. Therefore, healthcare protocols should incorporate preventive strategies, with patient assessments conducted by expert multidisciplinary teams.

Functional status and quality of life after ICU discharge in severe COVID-19 patients

PURPOSE

To assess the health status of individuals affected by COVID-19 after discharge from the ICU.

METHOD

Cross-sectional study, with patients discharged from the ICU due to severe COVID-19, in which Quality of Life (QoL) was assessed using the 12-Item SFHF, functionality using the Post-COVID-19 FSS, and the level of physical activity using the IPAQ.

RESULTS

Of the sixty patients, 51.7 % were male, with a mean age of 58 years. The physical component of QoL scored worse than the mental component and older patients had worse QoL in the physical component. These patients were shown to have low functionality scores and an irregularly active level of physical activity B. A lower level of physical activity was associated with individuals who remained in the prone position during hospitalization, while worse functionality was associated with the 70+ age group, although all age groups had functional losses. There was no association between QoL, functionality and level of physical activity and the clinical characteristics of the patients during hospitalization or the time they were discharged.

CONCLUSION

The majority of patients discharged from the ICU after severe COVID-19 have altered functional capacity, QoL and physical activity levels, which is not associated with the clinical characteristics during hospitalization.

Effectiveness of Rehabilitation Interventions in Individuals With Emerging Virtual Respiratory Tract Infectious Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Assessing rehabilitation effectiveness for persistent symptoms post-infection with emerging viral respiratory diseases.

DATA SOURCES

Systematic review of seven databases (MEDLINE, EMBASE, Cochrane Library, PEDro, MedRxiv, CNKI, Wanfang) until 30 December 2023.

REVIEW METHODS

Evaluated 101 studies (9593 participants) on respiratory function, exercise capacity, and quality of life. Methodological quality was assessed using the Cochrane Collaboration's Risk of Bias tool for randomized controlled trials (RCTs), the Newcastle-Ottawa Scale (NOS) for observational studies and non-RCTs, and the NIH Quality Assessment Tools for before-after studies.

RESULTS

The most common rehabilitation program combined breathing exercises with aerobic exercise or strength training. Rehabilitation interventions significantly enhanced respiratory function, as evidenced by improvements on the Borg Scale (MD, -1.85; 95% CI, -3.00 to -0.70, low certainty), the mMRC Dyspnea Scale (MD, -0.45; 95% CI, -0.72 to -0.18, low certainty), and the Multidimensional Dyspnoea-12 Scale (MD, -4.64; 95% CI, -6.54 to -2.74, moderate certainty). Exercise capacity also improved, demonstrated by results from the Six-Minute Walk Test (MD, 38.18; 95% CI, 25.33-51.03, moderate certainty) and the Sit-to-Stand Test (MD, 3.04; 95% CI, 1.07-5.01, low certainty).

CONCLUSION

Rehabilitation interventions are promising for survivors of viral respiratory diseases, yet gaps in research remain. Future investigations should focus on personalizing rehabilitation efforts, utilizing remote technology-assisted programs, improving research quality, and identifying specific subgroups for customized rehabilitation strategies to achieve the best outcomes for survivors.

Getting Back on Track: Meanings of Recovery After Critical Illness Caused by COVID-19

Introduction

Being critically ill in need of intensive care, lead to a challenging way back after survival, so also for survivors of COVID-19. The process to recovery can be long.

Objectives

The aim of our qualitative study was to elucidate meanings of recovery for people who were once critically ill with COVID-19.

Method

We conducted qualitative individual interviews with 13 individuals who had been critically ill with COVID-19, following a narrative approach. The data collected from the interviews, were analyzed according to phenomenological hermeneutic interpretation.

Results

The participants, although feeling alone in the process of recovery, had willpower to return to normal life but struggled to keep pace with others. They strived for balance in everyday life and to regain strength despite being exhausted after having COVID-19. The participants were grateful for their survival but displayed a need to understand what had happened. They longed for social contact, expressed feelings of abandonment, and wished for follow-up dialogues with healthcare professionals to better understand their situation. However, because support from healthcare was insufficient, the participants ultimately needed to develop their own strategies to cope with their questions, fears, and weakness.

Conclusion

Meanings of recovery for people once critically ill with COVID-19, is to strive for balance in everyday life. In their recovery process, healthcare professionals should seek to understand what the illness means for the ill person, and in mutual understanding support them based on their needs.

Effectiveness of Rehabilitation Interventions on Adults With COVID-19 and Post-COVID-19 Condition. A Systematic Review With Meta-analysis

OBJECTIVE

To evaluate the effectiveness of rehabilitation interventions for adults with COVID-19 and post COVID-19 condition (PCC) in all settings.

DATA SOURCES

PubMed, EMBASE, CINAHL, Scopus, Web of Science, and Physiotherapy Evidence Database were searched from inception to December 31st, 2021. PROSPERO registration number: CRD42021258553.

STUDY SELECTION

We included randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) according to the University of Alberta Evidence-based Practice Center.

DATA EXTRACTION

One author extracted data using a predetermined Excel form.

DATA SYNTHESIS

The meta-analysis indicates uncertain evidence about the effect of pulmonary rehabilitation and self-activities on exercise capacity (MD 65.06, 95% CI 42.87 to 87.25), respiratory function (forced expiratory volume in the first second [FEV1]: MD 0.16, 95% CI 0.05 to 0.28; FEV1/forced vital capacity [FVC]: MD 0.05, 95% CI 0.01 to 0.09; FVC: MD 0.19, 95% CI -0.03 to 0.42) and anxiety (MD -12.03, 95% CI -21.16 to -2.90) in mild COVID-19 and PCC patients. According to the narrative synthesis, including RCTs and NRSI, prone positioning seems to show improvements in vital parameters in severe COVID-19 post intensive care unit (ICU) discharge, pulmonary rehabilitation in activities of daily living, and qigong exercise and acupressure rehabilitation program, and "twist and raise" walking technique in reducing dyspnea and weakness in any degree of severity of COVID-19 and PCC. Functional electrical stimulation-cycling or early rehabilitation programs seem to support a faster recovery in patients with moderate COVID-19 after ICU discharge. Yoga and naturopathy, Mandala coloring, and respiratory exercise seem to reduce anxiety and depression in patients with moderate and mild COVID-19. Cognitive motor training seems to improve cognitive function in PCC patients.

CONCLUSIONS

There is very uncertain evidence about the effect of pulmonary rehabilitation on exercise capacity and respiratory function in patients with mild COVID-19 and PCC. Further high-quality research is required to improve the certainty of evidence available to support rehabilitation's crucial role in managing COVID-19.

Short-Term Outcomes of the First-Session Prone Position in Patients With Severe Coronavirus Disease 2019: A Retrospective Chart Review

Introduction Prone positioning during ventilation is recommended for patients with severe coronavirus disease 2019 (COVID-19). However, the efficacy of first-session prone positioning in improving short-term outcomes remains unclear. Therefore, we aimed to investigate the impact of the rate of change in partial pressure of oxygen/fraction of inspired oxygen (P/F) ratio before and after initial prone positioning on activities of daily living (ADL) and outcomes at discharge. Methods In this retrospective chart review, 22 patients with severe COVID-19 who required ventilator management between April and September 2021 were analyzed. Patients with an improvement in the P/F ratio (after initial prone positioning, compared to that before the session) by > 16mHg and < 16mmHg were defined as responders and non-responders, respectively. Results Compared with non-responders, responders had a significantly shorter ventilator duration, a higher Barthel Index at discharge, and a higher proportion of discharged patients. There was a significant between-group difference in chronic respiratory comorbidities, with one case (7.7%) among responders and six cases (66.7%) among non-responders. Conclusions This study is the first of its kind to investigate short-term outcomes in patients with COVID-19 requiring ventilator management after initial prone positioning. After initial prone positioning, responders had higher P/F ratios as well as improved ADLs and outcomes at discharge.

Prone Chest Radiographs: Distinguishing Features and Identification of Support Devices

Purpose

Prone position is known to improve acute lung injury, and chest radiographs are often necessary to monitor disease and confirm support device placement. However, there is a paucity of literature regarding radiographs obtained in this position. We evaluated prone radiographs for distinguishing features and ability to identify support devices.

Methods

Pairs of prone and supine radiographs obtained during the COVID-19 pandemic were assessed retrospectively. IRB approval and waiver of informed consent were obtained. Radiographs were assessed for imaging adequacy, distinguishing features, and support device identification (endotracheal tube, enteric tube, or central line). Radiographs were reviewed by ≥ 2 cardiothoracic radiologists.

Results

Radiographs from 81 patients (63yo ± 13, 30% women) were reviewed. Prone and supine radiographs were comparable for imaging the lung bases (81% vs. 90%, p = 0.35) and apices (93% vs. 94%, p = 1); prone radiographs more frequently had significant rotation (36% vs. 19%, p = 0.021). To identify prone technique, scapula tip located beyond the rib border was 89% sensitive (95%CI 80–95%) and 85% specific (76–92%), and a fundal stomach bubble was 44% sensitive (33–56%) and 90% specific (81–96%). For women, displaced breast shadow was 46% sensitive (26–67%) and 92% specific (73–99%). Prone and supine radiographs each identified > 99% of support devices. Prone exams trended toward increased rate of malpositioned device (12% vs. 6%, p = 0.07).

Conclusion

Scapula position reliably distinguishes prone from supine position; fundal stomach bubble or displaced breast shadow is specific for prone position. Prone radiographs reliably identify line and tube position, which is particularly important as prone patients appear at increased risk for malpositioned devices.

Time to active sitting position: One-year findings from a temporary COVID-19 intensive care unit

Objective

To investigate the association between time to active sitting position and clinical features in people with COVID-19 admitted to intensive care unit (ICU) and referred to physiotherapists.

Method

Prospective study conducted in the largest temporary ICU in Lombardy (Italy) between April 2020 and June 2021. All individuals with COVID-19 who received physiotherapy were included. Multivariable Cox proportional hazard model was fitted to explore the statistical association between active sitting position and characteristics of patients referred to physiotherapists, also accounting for the different multidisciplinary teams responsible for patients.

Results

284 individuals over 478 (59.4%) had access to physiotherapy, which was performed for a median of 8 days, without difference between multidisciplinary teams (P = 0.446). The active sitting position was reached after a median of 18 (IQR: 10.0–32.0) days. Sex was the only characteristic associated with the time to active sitting position, with males showing a reduced hazard by a factor of 0.65 (95% CI: 0.48–0.87; P = 0.0042) compared to females. At ICU discharge, nearly 50% individuals increased Manchester Mobility Score by 3 points. During physiotherapy no major adverse event was recorded.

Conclusion

Individuals with COVID-19 take long time to reach active sitting position in ICU, with males requiring longer rehabilitation than females.

Factors affecting the emotional reactions of patient relatives who receive news of death: a prospective observational study

Background

Reporting the death of relatives to a family member is a very stressful task for physicians. Grief reactions differ from person to person.

Methods

Demographic data of 100 patients who died after staying in ICU for more than three days were recorded. For each patient, one of the family members filled a form which contained their own age, gender, education level, marital status, number of children, degree of relationship, psychiatric treatment status, living in the same house as the patient, and whether they had ever visited the ICU before. Grief reactions were evaluated in five different categories: normal grief response, initial shock reaction, denial, feeling guilty and anger.

Results

When the death was reported, 55.0% of the relatives accepted this situation as normal, 19.0% felt guilty and 14.0% showed an initial shock reaction. The results showed that for a one-unit increase in the patient's age, the probability of the denial reaction among relatives was reduced by 746 times and the probability of feeling guilty was reduced by 698 times.

Conclusion

The rate of denial and guilt in the grief reactions among patient relatives when given news of death in the intensive care unit increases with the decrease in patient age.