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COVID - 19:Physiotherapy in the ICU

Alya Bartlett, MScPT Physiotherapist, Foothills Medical Centre

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Physiotherapy in the FMC ICU: Some Context

• ARDS is not a new phenomenon in ICU, it can occur from many different sources (e.g. sepsis, trauma) [1] • However, COVID-19 poses unique challenges related to anticipated number

of ARDS patients and transmissibility • Currently ~30 ICU beds, preparing for surge capacity of ~150 beds • Modelling suggests probable scenario of 232 AB COVID-19 cases

needing ICU care in late May-June [2]• Patients who survive ARDS at high risk for impaired physical

function, PTSD and depression [3]• Major focus on early progressive mobility to improve patient

outcomes [4]

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Case Study: Initial Stage

• Patient in their 40s, admitted with severe respiratory failure (ARDS) secondary to COVID-19

• Total of 22 days spent in ICU • During initial stage of ICU stay, patient was consistently:

• Intubated and fully dependent on ventilator • Sedated • Chemically paralyzed on neuromuscular blockers

• Proned 5 times to improve ventilation (16 hours prone/8 hours supine)

• Developed an acute kidney injury, requiring continuous dialysis

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PT Involvement: Initial Stage ● Evidence for chest PT in ARDS sparse

● Ineffective cough (due to paralytics) may benefit from PT involvement to facilitate secretion clearance

● Primarily an issue of inflammation and pulmonary edema rather than secretion production

● Main role is related to preventing secondary complications ● Maintaining ROM ● Positioning ● Monitoring for appropriateness for mobilization

● Heavily reliant on input and collaboration with interprofessional team (RNs, RTs, MDs) at this stage

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Case Study: Gradual Improvements

• After approximately 10 days intubated, ventilated, sedated and chemically paralyzed, patient began gradually showing signs of improvement, including: • No longer requiring proning • Decreased O2 requirements, improvement seen on blood gasses and chest

x-rays • Improved tolerance for neuromuscular blockade and sedation weaning • Improved global organ function, no longer requiring continuous dialysis

• Not linear, days of slow improvement with episodes of decline

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PT Involvement: Initiating Early Mobility

• Mobility is the primary treatment approach to address deconditioning and optimize respiratory status

• Monitoring patient status from beginning allowed for identification of improvements to help make informed decision about mobility

• Decision to initiate early mobility required extensive discussion with team to confirm that we were pursuing the same goals

• Consistently evaluating the risks vs. benefits of pushing patient

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PT Involvement: Mobility ProgressionFirst session: positioned patient upright in bed

• Done to assess tolerance for upright positioning • Increased respiratory rate, brief desaturation

Second session: positioned in bed-chair, sat forward to dangle with 2 person max assist

• Improved tolerance, still too sedated to progress

Third session: transferred to sitting at edge of bed with 2 person assist • Tolerated approximately 10 minute dangle, helped make a case for extubation

Fourth session (after extubation): patient stood, transferred to/from chair with 1-2 person assist

• Tolerated well!

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Guiding Principles Constantly evaluate risks vs. benefits

• ARDS patients are very fragile; however, not mobilizing has risks too!

Be more conservative • In an effort to conserve PPE and limit contact unless absolutely necessary

Collaborate, collaborate, collaborate! • Share assessment findings, work with other HCPs to plan care

Be flexible • May involve completing tasks outside of typical role to optimize efficiency

Caseload management: Don’t forget about non-COVID patients• Plan to see COVID-positive patients at the end of the day

Focus on the patient, not just the COVID status • While considerations around COVID are pertinent, important to maintain a high standard of care to

optimize outcomes for these patients

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Citations1. Griffiths MJD, McAuley DF, Perkins GD, et alGuidelines on the management of acute respiratory distress

syndromeBMJ Open Respiratory Research 2019;6:e000420. doi: 10.1136/bmjresp-2019-0004202. https://www.alberta.ca/assets/documents/covid-19-case-modelling-projection.pdf3. Bein T, Weber-Carstens S, Apfelbacher C. Long-term outcome after the acute respiratory distress

syndrome: different from general critical illness?. Curr Opin Crit Care. 2018;24(1):35–40. doi:10.1097/MCC.0000000000000476

4. Hodgson, C.L., Capell, E. & Tipping, C.J. Early Mobilization of Patients in Intensive Care: Organization, Communication and Safety Factors that Influence Translation into Clinical Practice. Crit Care 22, 77 (2018). https://doi.org/10.1186/s13054-018-1998-9

5. Kenny J-E. Predicting the Haemodynamic Response to Prone Positioning: A Novel and Simultaneous Analysis of the Guyton and Rahn Diagrams. Critical Care Horizons 2017:1-7.

6. https://physiotherapy.ca/physiotherapy-management-coivd-19-acute-hospital-setting-recommendations-guide-clinical-practice

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