Physical Therapy Practice for Critically Ill Patients With COVID-19 in the Intensive Care Unit

Reevaluating Rehabilitation Practice for Patients Who Were Critically Ill After COVID-19 Infection: An Administrative Case Report

OBJECTIVE

The goal of this case report is to describe the process, challenges, and opportunities of implementing rehabilitation for individuals who were critically ill and required both mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO) support following a coronavirus 2019 (COVID-19) infection in an academic medical center.

METHODS

This administrative case report is set in a heart and vascular intensive care unit, a 35-bed critical care unit that provides services for patients with various complex cardiovascular surgical interventions, including transplantation. Patients were admitted to the heart and vascular intensive care unit with either COVID-19 acute respiratory distress syndrome or pulmonary fibrosis for consideration of bilateral orthotropic lung transplantation. The authors describe the process of establishing rehabilitation criteria for patients who, by previously established guidelines, would be considered too ill to engage in rehabilitation.

RESULTS

The rehabilitation team, in coordination with an interprofessional team of critical care providers including physicians, respiratory care providers, perfusionists, and registered nurses, collaborated to implement a rehabilitation program for patients with critical COVID-19 being considered for bilateral orthotropic lung transplantation. This was accomplished by (1) reviewing previously published guidelines and practices; (2) developing an interdisciplinary framework for the consideration of rehabilitation treatment; and (3) implementing the framework for patients in our heart and vascular intensive care unit.

CONCLUSION

In response to the growing volume of patients admitted with critical COVID-19, the team initiated and developed an interprofessional framework and successfully provided rehabilitation services to patients who were critically ill. While resource-intensive, the process demonstrates that rehabilitation can be implemented on a case-by-case basis for select patients receiving extracorporeal membrane oxygenation and MV, who would previously have been considered too critically ill for rehabilitation services.

IMPACT

Rehabilitating patients with end-stage pulmonary disease on extracorporeal membrane oxygenation and MV support is challenging but feasible with appropriate interprofessional collaboration and knowledge sharing.

Implementation of Early Rehabilitation in Severe COVID-19 Respiratory Failure

The purpose of this scoping review is to describe current clinical practice guidelines (CPGs) for early rehabilitation for individuals hospitalized in an intensive care unit with COVID-19 and examine practice patterns for implementation of mobility-related interventions.

Methods

PubMed, EMBASE, and CINAHL databases were searched from January 1, 2020, through April 1, 2022. Selected studies included individuals hospitalized with severe COVID-19 and provided objective criteria for clinical decision making for mobility interventions. A total of 1464 publications were assessed for eligibility and data extraction. The PRISMA-ScR Checklist and established guidelines for reporting for scoping reviews were followed.

Results

Twelve articles met inclusion criteria: 5 CPGs and 7 implementation articles. Objective clinical criteria and guidelines for implementation of early rehabilitation demonstrated variable agreement across systems. No significant adverse events were reported.

Conclusions

Sixty percent (3/5) of CPGs restrict mobility for individuals requiring ventilatory support of more than 60% Fio₂ (fraction of inspired oxygen) and/or positive end-expiratory pressure (PEEP) greater than 10-cm H₂O (positive end-expiratory pressure). Preliminary evidence from implementation studies may suggest that some individuals with COVID-19 requiring enhanced ventilatory support outside of established parameters may be able to safely participate in mobility-related interventions, though further research is needed to determine safety and feasibility to guide clinical decision making.