To the Editor:
Survivors of critical illness have long-term morbidity resulting in physical, emotional, and cognitive dysfunction.1,2 Early mobilization improves functional outcomes and is essential to quality critical care.3, 4, 5, 6 Early mobilization is feasible and safe for critically ill patients, including those receiving mechanical ventilation and extracorporeal membranous oxygenation (ECMO).3,4,7 Early rehabilitation may be deferred in the critically ill because of a variety of barriers that are magnified by the staffing shortages, overwhelmed hospital capacity, and severity of respiratory failure seen with the COVID-19 pandemic. Patients recovering from COVID-19 have been shown to benefit from inpatient rehabilitation after ICU admission, which suggests that disability after acute illness is common, and shifting rehabilitation earlier may have merit.8 We present a single academic center’s experience providing rehabilitation to critically ill patients infected with SARS-CoV-2.
Methods
In this retrospective chart review, patients admitted to the ICU with SARS-CoV-2 infection confirmed by reverse transcriptase-polymerase chain reaction of nasal pharyngeal swabs from March 1 to July 31, 2020 were identified. Patients for whom a physical or occupational therapy consult was ordered, an impairment in baseline mobility was observed, and at least one treatment session was provided were included. Rehabilitation teams included one physical therapist and one occupational therapist and were available 7 days per week. Therapy sessions were conducted jointly by physical and occupational therapy. Patients underwent a daily safety screen followed by a standardized progressive early mobility protocol.4,5 The clinical outcomes collected were the number of rehabilitation sessions, session length, activities completed, support needed, presence of delirium, and serious adverse events. Statistical analysis was performed with Stata 16.1 (StataCorp LP). The study was approved by the institutional review board (IRB20-1292).
Results
Two hundred ninety patients were admitted to the COVID-19 ICU during the study period. One hundred eighty-five received a consult for rehabilitation services, and 116 participated in at least one therapy session. The most common reasons patients received consults but did not participate were hemodynamic instability, evaluation without impairment of baseline mobility, and ICU discharge within 24 hours of rehabilitation order. Patient characteristics are summarized in Table 1. Most (85%) were admitted to the ICU for hypoxemic respiratory failure. Forty-seven (40%) patients were intubated, with median duration of mechanical ventilation of 11 days (IQR, 4-16 days). Three patients participated in therapy while receiving ECMO. Nine patients (8%) had received neuromuscular blockade for severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia. Patients frequently received targeted therapies against COVID-19: remdesivir (42%), hydroxychloroquine (28%), tocilizumab (32%), corticosteroids (7%), and convalescent plasma (1%). The ICU and hospital mortality rates of this cohort were 17% and 19%, respectively.
Table 1.
Patients Characteristics
| Characteristics | Total (N = 116) |
|---|---|
| Age, y | 63 (54-74) |
| Sex, male | 67 (58%) |
| BMI | 31 (26-34) |
| Medical history: | |
| Hypertension | 79 (68%) |
| Diabetes | 38 (33%) |
| Hyperlipidemia | 28 (24%) |
| Chronic kidney disease | 18 (16%) |
| Coronary artery disease | 14 (12%) |
| Chronic heart failure | 16 (14%) |
| Ethnicity | |
| African American | 89 (77%) |
| White | 11 (9%) |
| Hispanic | 13 (11%) |
| Asian | 3 (3%) |
| APACHE II | 17 (11-21) |
| SOFA at time of first PT session | 4 (3-5) |
| FSS-ICU | 17 (9-23) |
| Pao2: Fio2 | 145 (105-217) |
| Outcomes | |
| ICU length of stay, days | 7 (3.5-15) |
| Hospital length of stay, days | 16 (10-28.5) |
| Presence of intubation | 47 (40%) |
| Duration of mechanical ventilation, days | 6 (4-16) |
| Hospital mortality | 22 (19%) |
| ICU mortality | 20 (17%) |
| Discharge destination | n = 94 |
| Home | 57 (61%) |
| Acute rehabilitation | 16 (17%) |
| Long-term acute care facility | 9 (10%) |
| Sub-acute rehabilitation | 8 (8%) |
| Skilled nursing facility | 4 (4%) |
Data presented as median (interquartile range) for continuous variables and absolute value (%) for categorical variables. APACHE = Acute Physiology and Chronic Health Evaluation; FSS-ICU = functional status score for the ICU; Pao2: Fio2 = ratio of Pao2 to fractional inspired oxygen; SOFA = Sequential Organ Failure Assessment.
Patients completed a total of 379 rehabilitation sessions. The median number of treatment sessions during ICU admission per patient was 2 (interquartile range [IQR], 1-4). Therapy sessions were deferred most often for mean arterial pressure <65 mm Hg, hypoxemia (pulse oximetry <88%), and severe tachypnea (respiratory rate, >40 breaths/min). The median time from ICU admission to first session was 4 days (IQR, 3-5). The median Sequential Organ Failure Assessment score on first day of therapy was 4 (IQR, 3-5). The median percentage of ICU days with physical and occupational therapy treatment was 33% (IQR, 21%-50%). The median session length was 25 minutes (IQR, 25-30 min). Maximum activity level achieved in each session included walking in 186 instances (49%), sitting in the bedside chair in 26 sessions (7%), standing in 55 sessions (15%), sitting at the edge of the bed in 88 instances (23%), and in-bed passive/active range of motion exercises in 24 sessions (6%).
Therapy sessions were provided to patients with respiratory failure treated with invasive mechanical ventilation (21% of sessions), high-flow nasal cannula (45% of sessions), noninvasive positive-pressure ventilation by helmet or facemask (7% of sessions), and ECMO (12% of sessions). Patients requiring vasoactive medications (4% of sessions) and continuous renal replacement (6% of sessions) therapy were also treated by physical and occupational therapy. Delirium, determined by confusion assessment method, was encountered frequently (32% of sessions) and was not an absolute barrier to therapy (Table 2).
Table 2.
Activity Levels Achieved during Therapy
| Possible Barrier to Physical Therapy | Total No. of Sessions (N = 379) | Presence on First Session | Sit in Bed (% Total Sessions) | Stand (% Total Sessions) | Walk (% Total Sessions) | Chair (% Total Sessions) |
|---|---|---|---|---|---|---|
| ECMO | 46 (12%) | 1% | 43 (11%) | 28 (7%) | 9 (2%) | 12 (3%) |
| Invasive mechanical ventilation | 78 (21%) | 9% | 68 (18%) | 34 (9%) | 20 (5%) | 15(4%) |
| NIPPV | 11 (3%) | 3% | 11 (3%) | 10 (3%) | 6 (2%) | 1 (<1%) |
| Helmet | 14 (4%) | 7% | 13 (3%) | 11(3%) | 8 (2%) | 3 (1%) |
| HFNC | 177 (45%) | 45% | 170 (45%) | 144 (38%) | 99(26%) | 62 (16%) |
| Vasoactive drugs | 17 (4%) | 3% | 13 (3%) | 4 (1%) | 1 (<1%) | 3 (1%) |
| CRRT | 22 (6%) | 3% | 19 (5%) | 4 (1%) | 3 (1%) | 3 (1%) |
| Delirium | 121 (32%) | 30% | 32 (8%) | 57 (15%) | 32 (8%) | 18 (5%) |
Total number of sessions are presented as an absolute value (%), presence on first session is presented as a percentage, activities accomplished (sit, stand, walk, chair) are presented as absolute numbers with percentage of total sessions. CRRT = continuous renal replacement therapy; ECMO = extracorporeal membranous oxygenation; HFNC = high-flow nasal cannula; NIPPV = noninvasive positive-pressure ventilation
Serious adverse events occurred in 62 patients. Desaturation <80% occurred during 129 (34%) sessions, but all recovered with rest. Hypotension systolic BP < 90 mm Hg occurred in seven sessions (2%). One patient had persistent supraventricular tachycardia after cessation of activity. Notable patient agitation took place four times (1%). There were no instances of device removal during therapy.
Ninety-four patients survived; discharge location was home (n = 57, 61%), acute rehabilitation units (n = 16, 17%), long-term acute care hospitals (n = 9, 10%), subacute care centers (n = 8, 8%), and skilled nursing facilities (n = 4, 4%). Therapy recommendation for discharge location occurred in 82% of cases. In 17 instances, patients who were recommended for acute or subacute rehabilitation were discharged home. ICU-acquired weakness was diagnosed in 110 (95%) of patients. Additionally, no members of the therapy team noted that they were diagnosed with SARS-CoV-2 during the study period.
Discussion
This report demonstrates the feasibility of conducting physical and occupational therapy in COVID-19-specific ICUs. Providing therapy services appeared to be safe for patients and members of the therapy team, because adverse events were rare, and no therapist was diagnosed with COVID-19. Patients tolerated therapy in spite of receiving advanced respiratory support. The discharge location of the patients was notably different from that of other COVID-19 cohorts, with more patients discharged to acute rehabilitation and home,9,10 suggesting that shifting rehabilitation efforts earlier in acute illness can improve functional outcomes.
This study has several limitations. First, because of its retrospective nature, there was no control group, limiting our ability to assess rehabilitation effect on clinical outcomes. Second, no long-term functional data were collected to assess the impact of early rehabilitation on recovery.
Our report highlights the feasibility of early rehabilitation for critically ill patients with COVID-19. Furthermore, given the known effectiveness of rehabilitation in the post-acute setting, research is needed to highlight the clinical implications of early initiation of therapy services.8 This report emphasizes the feasibility and importance of continuing interventions known to be essential to high-quality critical care.
Acknowledgments
Author Contributions: M. R. S., P. L.-O., S. D. P., K. S. W., A. S. P., J. P. K., and B. K. P. collected and interpreted data, wrote manuscript. C. M. W. collected and interpreted data, conducted physical therapy, assisted writing manuscript. P. R. H. conducted physical therapy, assisted writing manuscript.
Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.
Footnotes
FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.
FUNDING/SUPPORT: NIH/NHLBI K23 HL148387 (B. K. P.); NIH/NHLBI T32 HL007605 (M. R. S. and S. D. P.)
References
- 1.Pandharipande P.P., Girard T.D., Jackson J.C., et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306–1316. doi: 10.1056/NEJMoa1301372. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hill A.D., Fowler R.A., Pinto R., Herridge M.S., Cuthbertson B.H., Scales D.C. Long-term outcomes and healthcare utilization following critical illness: a population-based study. Crit Care. 2016;20:76. doi: 10.1186/s13054-016-1248-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Fan E., Cheek F., Chlan L., et al. An official American Thoracic Society Clinical Practice guideline: the diagnosis of intensive care unit-acquired weakness in adults. Am J Respir Crit Care Med. 2014;190(12):1437–1446. doi: 10.1164/rccm.201411-2011ST. [DOI] [PubMed] [Google Scholar]
- 4.Pohlman M.C., Schweickert W.D., Pohlman, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010;38(11):2089–2094. doi: 10.1097/CCM.0b013e3181f270c3. [DOI] [PubMed] [Google Scholar]
- 5.Schweickert W.D., Pohlman M.C., Pohlman A.S., et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874–1882. doi: 10.1016/S0140-6736(09)60658-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Schaller S.J., Anstey M., Blobner M., et al. Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet. 2016;388(10052):1377–1388. doi: 10.1016/S0140-6736(16)31637-3. [DOI] [PubMed] [Google Scholar]
- 7.Wells C.L., Forrester J., Vogel J., Rector R., Tabatabai A., Herr D. Safety and feasibility of early physical therapy for patients on extracorporeal membrane oxygenator: University of Maryland Medical Center experience. Crit Care Med. 2018;46(1):53–59. doi: 10.1097/CCM.0000000000002770. [DOI] [PubMed] [Google Scholar]
- 8.Curci C., Negrini F., Ferrillo M., et al. Functional outcome after inpatient rehabilitation in post-intensive care unit COVID-19 patients: findings and clinical implications from a real-practice retrospective study. Eur J Phys Rehabil Med. 2021;57(3):443–450. doi: 10.23736/S1973-9087.20.06660-5. [DOI] [PubMed] [Google Scholar]
- 9.Larsson E., Brattstrom O., Agvald-Ohman C., et al. Characteristics and outcomes of patients with COVID-19 admitted to ICU in a tertiary hospital in Stockholm, Sweden. Acta Anaesthesiol Scand. 2021;65(1):76–81. doi: 10.1111/aas.13694. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.McWilliams D., Weblin J., Hodson J., et al. Rehabilitation levels in COVID-19 patients admitted to intensive care requiring invasive ventilation: an observational study. Ann Am Thorac Soc. 2021;18(1):122–129. doi: 10.1513/AnnalsATS.202005-560OC. [DOI] [PMC free article] [PubMed] [Google Scholar]