|Year : 2021 | Volume
| Issue : 1 | Page : 50-54
Pathway to discharge following COVID-19 in an obese female with multiple comorbidities: Does physiotherapy play a pivotal role?
Shivam N Chopra1, Mariya P Jiandani1, Smrati Tiwari2
1 Physiotherapy School and Centre, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
2 Department of Medicine, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
|Date of Submission||21-Aug-2020|
|Date of Decision||02-Mar-2021|
|Date of Acceptance||26-Mar-2021|
|Date of Web Publication||19-Aug-2021|
Dr. Shivam N Chopra
Physiotherapy School and Centre, Seth G.S. Medical College and KEM Hospital, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
From Wuhan to India, the severe acute respiratory syndrome coronavirus-2 or COVID-19 presentations ranged from completely asymptomatic to severe respiratory failure requiring intensive care. Patients with associated morbidities such as obesity, hypertension, and diabetes were known to have high mortality. We present the case of a 28-year-old obese female with type-II diabetes, hypertension, and pulmonary Koch admitted for moderate pulmonary impairment with hypoxia and altered metabolic dysfunctions in COVID-intensive care unit, facilitated to discharge with support of physiotherapy (PT). In spite of maximal standard medical management as per the COVID guidelines and oxygen support on nonrebreather bag at 15 L/min, she failed to show improvement in symptoms. PT interventions in the form of education and counseling, positioning, breathing exercises, and gradual peripheral conditioning were carried out to prevent complications and deterioration in view of associated comorbidities. This resulted in successful weaning-off oxygen, improved breath-holding time from 3s on PT day 3 to 11 s on PT day 15 and improved 6-min-walk distance from 165 m on PT day 7 to 215 m with no desaturation on PT day 15, reflecting improved respiratory and functional capacity. Timely intervention with respiratory PT and early out-of-bed mobility along with positive communication facilitated the path for discharge and independence in self-care.
Keywords: COVID-19, mobilization, obesity, physiotherapy, rehabilitation
|How to cite this article:|
Chopra SN, Jiandani MP, Tiwari S. Pathway to discharge following COVID-19 in an obese female with multiple comorbidities: Does physiotherapy play a pivotal role?. Physiother - J Indian Assoc Physiother 2021;15:50-4
|How to cite this URL:|
Chopra SN, Jiandani MP, Tiwari S. Pathway to discharge following COVID-19 in an obese female with multiple comorbidities: Does physiotherapy play a pivotal role?. Physiother - J Indian Assoc Physiother [serial online] 2021 [cited 2021 Dec 3];15:50-4. Available from: https://www.pjiap.org/text.asp?2021/15/1/50/324128
| Introduction|| |
Early mobilization and respiratory physiotherapy (PT) are integral in management of patients with respiratory illness. As COVID-19 infection is dynamic with systemic inflammatory response, the course is often unpredictable. Patients with associated morbidities such as obesity, hypertension, and diabetes are known to have high mortality. With no proven and completely successful treatment yet available, existing medical modalities are under evaluation in view of cytokine storm, thromboembolism, and systemic inflammation.
There are guidelines emphasizing the role of PT in preventing complications in acute care., However, an actual change in parameters with PT in morbidly obese patients with COVID-19 with comorbidities is yet to be documented. This study highlights the course of successful improvement in respiratory and functional capacity with feasibility of facilitating discharge with dedicated PT interventions along with medical management.
| Case Report|| |
A 28-year-old female was admitted in COVID intensive care unit with positive reverse transcriptase–polymerase chain reaction (RT-PCR) and chief complaints of breathlessness, dry cough, fever, and generalized weakness for 6 days. She was febrile (102° F) and dyspneic (mMRC Grade-4) with associated tachycardia (127 beats/min) on admission. Her oxygen saturation was 87% on room air. She was morbidly obese (body mass index: 35 kg/m2) with a history of type II diabetes and hypertension for 1 year and pulmonary Koch 2 years ago. She was classified as COVID Stage IIB (moderate pulmonary involvement with hypoxia).
Her hemoglobin A1c was 7.6%, with Hemoglucotest (HGT) of 376 mg/dL on admission indicating deranged metabolic parameters. High-resolution computed tomography of the chest showed CO-RADS-6 with ground-glass densities and interlobular septal thickening with 70%–80% lung involvement and few reticulations predominantly in lower lobes suggestive of atypical pneumonia. Although her blood urea nitrogen showed mild derangement, other blood investigations pertaining to electrolytes and creatinine levels were normal. Arterial Blood Gas analysis (ABG) revealed partially compensated respiratory acidosis with severe hypoxemia. She was treated with oxygen therapy with a non-rebreathing mask at 15 L O2/min to maintain a saturation of >97%.
Medications included antibiotics (piperacillin-tazobactam, azithromycin), corticosteroids (methylprednisolone), nonsteroidal anti-inflammatory drug (paracetamol), antivirals, (hydroxychloroquine, Tamiflu), antihypertensives (Nicardia, Lasix), statins (atorva), anticoagulants (low molecular-weight heparin), antacid (PAN 40), and vitamin and mineral supplements (Vitamin A, C, D, zinc).
The patient was referred for PT on day 3 of admission for respiratory care and mobilization with an objective of preventing deterioration, as she had multiple comorbidities and there was no change in her symptoms since admission in spite of maximal care. She had additional complaints of fatigue, distress, and emotional outburst of crying.
PT assessment and treatment was carried out using complete protection and prevention equipment (PPE). On assessment, she was unable to move out of bed independently and needed assistance. Her breath-holding time was only 3 s, indicating poor pulmonary function. She complained of fear and had emotional liability where she went into bouts of crying on talking, indicating emotional distress. It was not possible to auscultate through PPE; however, there were no obvious secretions on palpation of posterior chest wall while breathing. She desaturated by more than 3% in simple assisted bed movements. Her resting heart rate (HR) was 120 beats/min; hence, 6-min-walk-test (6MWT) was deferred till stabilization. Physiotherapeutic strategies were designed in a stepladder approach [Figure 1] with continuous monitoring of HR, saturation, and fatigue (rate of perceived exertion [RPE]) with an aim of:
- Preventing complications associated with immobility
- Improving oxygenation with positioning and breathing exercises to assist weaning oxygen support
- Counseling for alleviating fear and motivating her for out-of-bed mobility
- Achieving functional independence.
PT sessions included strategies to improve ventilation, positioning to improve ventilation/perfusion ratio, mobility, and endurance training. Education and counseling was needed to motivate the patient to follow PT regime.
It was difficult to position the patient in prone in-view-of obesity. Hence, side-lying position was adopted with advice to frequently change positions. Besides COVID-related lung changes, her basal ventilation was also affected because of obesity. Hence, thoracic expansion and deep breathing co-ordinated with limb movements was encouraged. Out-of-bed exercises and exercises in standing were added with oxygen titration to prevent desaturation below 90%. After 3 days of PT, the patient was more co-operative, could adopt semi-prone position, and was able to move out of bed with minimal assistance. The oxygen requirement at rest was reduced to 7 l/min from 15 l/min. However, oxygen titration to 10 l/min was needed during PT. [Table 1] shows day-wise PT protocol.
By day 10 of admission, the patient was able to walk independently and carry out basic activities of daily living, and it was feasible to do 6MWT on oxygen. As seen in [Table 2], she could walk 165 m with 10 pauses and desaturation up to 89%. A positive change seen was that she could help others in the ward, took lead in reminding others for position change and exercises. She performed her exercises at least 3 times/day.
With gradual progression, her 6MWD improved to 210 m with 6 pauses at 97% saturation. Her oxygen requirement at rest had reduced to 2 l/min and she did not desaturate with basic bedside activities and exercises. Oxygen titration was no more necessary. Her breath-holding time improved to 11 s at the end of day 17 of admission showing a 266% increment from the baseline value.
| Discussion|| |
COVID-19 has a varied course; with associated co-morbidities patients are also prone to develop coagulation-dysfunction Supervised physiotherapy-interventions and parallel medical management can make a difference in clinical & functional outcomes, by improving oxygenation and preventing complications. Physical therapy sessions began with communication, education, and counseling regarding the disease. Strategies such as semi-prone positioning (as it was difficult to position prone in view of obesity) and CARP (Covid-Awake-Repositioning/Proning) Protocol), were used to improve preferential ventilation, as well as reduce hypoxaemia and shunting Deep & segmental breathing exercises with proprioceptive feedback was used to direct attention over specific areas to inflate; this helped to improve the basal ventilation & open-up closed alveoli and hypo-ventilated segments of the lung associated with obesity reducing patient symptoms. Subsequently, the addition of incentive spirometer focusing on sustained maximal inspiration provided the patient with a real-time feedback of her performance.
Inpatient pulmonary rehabilitation with conditioning and strengthening exercises with monitoring of HR and saturation was of utmost importance. Gradual progression of exercises from in-bed to bedside sitting followed by limb mobility in standing, spot marching, and gradual ambulation with breathing control allowed the progression of walking for toilet activities up to 50 m. Body movements coordinated with breathing probably improved overall efficiency and reduced the work of breathing associated with movement. Out-of-bed mobility and ambulation with oxygen titration not only improved walking capacity but also improved her psychological status, ability to carry out basic activities independently and get discharged with no emotional liability.
To have sustained benefits of exercise and encourage physical activity, it was imperative to practice the regime 2–3 times a day. Emphasis on improvements motivated her to gain respiratory capacity as measured on breath-holding time (improved by 8 s) and overall functional capacity on 6MWD improved by 45 m over 7 days without oxygen supplementation and a reduced RPE to 9 on BORG 6–20 scale (very-light exertion). Following 20 days of regular physiotherapy along with medical management, the patient's discharge was planned on grounds of resolution of symptoms, negative RT-PCR, improved clinical outcomes, and functional independence.
The case study shows that timely intervention using an appropriate PT approach helps to prevent complications associated with multiple comorbidities and facilitates pathway for discharge. The improvements in 6MWD, breath-holding time, and complete independence on functional independence measures highlight the importance of physiotherapy intervention in recovery.
Written informed consent was obtained from the patient for her anonymized information to be published in this article.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
We would like to acknowledge Dr. Hemant Deshmukh (Dean), Dr. Milind Nadkar (Academic Dean,)and Dr. Saraswati Iyer (HOD, Physiotherapy School and Centre), for allowing us to carry out this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]