Combating a Case of COVID Pneumonia with ARDS – a Physiotherapist’s Standpoint

Introduction: Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV2 virus, affecting multiple organ systems. The disease usually presents as mild to moderate respiratory illness but in many cases has progressed to development of pneumonia and ARDS ultimately requiring ventilatory support and prolonged ICU stay. Prolonged immobilization itself is a harbinger of various complications drastically altering a patient’s functional status. Physiotherapy plays a vital role in the management of COVID-19 symptoms as well as in the prevention of complications. Case Study: This case report describes the progress of a 44-year old female patient diagnosed with COVID-19 presenting with subsequent pneumonia and ARDS. The patient was started with medical management and supplemental oxygen therapy. In combination to the above-mentioned protocols, physiotherapy treatment was also initiated. After 2 weeks of rehabilitation and drug therapy, the patient displayed improved respiratory function at room air and was able to independently ambulate with minimal breathing difficulty. Discussion: This case report aims to highlight the importance of early intervention of physiotherapy in COVID-19 patients. The scope of physiotherapy treatment in patients with COVID19 pneumonia is vast. The treatment protocol adapted for this patient are in tune with the various research articles analysed to ensure evidence-based care. This will enable the healthcare Case Study Ratheesh and Nair; JPRI, 33(57B): 412-417, 2021; Article no.JPRI.79978 413 professionals to ensure timely referral and early initiation of Physiotherapy treatment. Conclusion: As per the findings and results of this case report, it is evident that the patient benefited from the timely advent of physiotherapy intervention. The key factor was the correct identification of the problematic areas and accurate prioritization based on the clinical presentation and investigation findings


INTRODUCTION
Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus, that affects various organs containing the Angiotensin-converting enzyme 2 (ACE-2) receptors, similar to the ones present in the pulmonary system. This leads to a multiorgan inflammation, creating a cascade of events worsening the patient's condition [1]. In moderate to severe cases, COVID-19 can cause pneumonia that progresses to acute respiratory distress syndrome (ARDS), which may require hospital stay, ventilatory support and Intensive Care Unit (ICU) admission [2]. The patient discussed in this case report met the ARDS criteria established in the Berlin consensus, including acute onset, abnormal radiological findings in the lung and abnormal oxygenation values [3]. A cardio-respiratory physiotherapist plays an invaluable role in the rehabilitation of critically ill patients by delivering evidence-based therapy to improve the patient's pulmonary, cardiac and overall function as well as preventing further complications and co-morbidities. Physiotherapy treatment varies for patients with mild, moderate and severe COVID-19 symptoms. The treatment ranges from airway clearance and lung expansion to long term exercise training [4]. This case report discusses about the progress of a patient diagnosed with COVID-19 pneumonia associated with ARDS admitted to a tertiary care hospital in Karnataka, who underwent physiotherapy rehabilitation with details on assessment findings, rehabilitation plan and execution.

CASE PRESENTATION
A 44-year-old female patient with a known history of Type 2 Diabetes Mellitus presented with remittent hyperpyrexia and progressive breathlessness associated with intermittent expectorating cough and scanty purulent sputum. In addition, the patient also had a possibility of COVID-19 exposure. The vitals on the day of admission were as follows: SPO2: 90% on 6 liters of Oxygen, Heart Rate: 82 beats/minute, Chest X-ray showed heterogenous infiltrates over bilateral lung fields (left > right) and reduced lung expansion, indicating features of COVID pneumonia with ARDS ( Fig. 1). Her ABG values revealed uncompensated respiratory alkalosis and hypoxemia with Partial pressure of Oxygen (PaO2) value of 66 mmHg.
In conjunction with the medical management, the patient was also referred for Physiotherapy. After collecting extensive details of history of presenting illness and progress of the disease, a thorough bedside assessment was done which displayed the following findings: significant use of accessory muscles with supra-clavicular indrawing, labored breathing pattern with abnormal inspiratory-expiratory ratio, dull percussive note over bilateral lung fields (left > right and lower lobe > middle lobe > upper lobe), and audible polyphonic wheeze. The New York Heart Association classification of breathlessness, Fatigue Severity Score and Cough Symptom score were administered for an objective analysis of the patient's condition which reported Grade 4, Score 5.2 and Grade 2 respectively.
The clinical signs and symptoms presented by the patient were meticulously formatted into the International Classification of Functioning, Disability and Health (ICF) for organized analysis of the patient's condition (Table 1). This step helps in the structured planning of the patient's Rehabilitation Goals, focusing on symptoms-wise therapy and overall improvement in function. The following aspects in the ICF checklist were relevant for this patient: Having charted out the clinical presentation of the patient, a detailed rehabilitation protocol was planned ( Table 2). The following were the Goals planned for this patient: The treatment was divided as immediate intervention and long-term intervention for achieving and maintaining sustained improvement in the patient's condition ( Table  3). The treatment sessions were administered by a qualified physiotherapist trained in COVID-19 protocols and measures. Facilitate airway clearance and decrease the work of breathing 2.

Fig. 1. Chest X-ray (Bedside AP view) of the patient on the day of admission shows heterogenous infiltrates over bilateral lung fields (yellow arrows) and reduced lung expansion (red arrows)
Improve tidal volume, alveolar ventilation and lung compliance.

3.
Prevent multisystem complications that will lead to limited movement, recumbency, and potential deconditioning 1.
Enhance the overall efficiency of the cardiopulmonary system.

2.
Educate the patient on maintenance of attained health.

3.
Prevention of disease recurrence -Progression to walking with supplemental oxygen. Weaning from supplemental oxygen initiated when SpO2 value was consistent within 98%-100% range. Two-minute walk test (2MWT) was administered to accurately calculate the exercise intensity for the patient which was derived as 30-40% of Maximum Heart Rate (MHR) Based on the calculation, the patient was started with monitored walking and stair climbing. The patient was further advised to gradually increase the intensity by 5% MHR every week.

Fig. 2. Chest X-ray (Bedside AP view) on the day of discharge shows significant improvement in aeration and lung expansion with reduced infiltrates and opacities bilaterally
After 2 weeks of regular physiotherapy intervention, the patient was able maintain saturation of oxygen on room air. She was independently able to sit, stand and walk with minimal difficulty in breathing. She required significantly shorter rest intervals during exercises and could perform them for more repetitions and duration. Stair climbing was still a difficult task (ascending stairs > descending stairs) although the same was achieved in milder intensities and lesser frequencies on room air with no exacerbations. The patient's cough had improved, airway was clear and breath sounds were clear and equal bilaterally. The patient also reported lower levels of fatigue as compared to the time of admission. On the day of discharge, her vitals were as follows: SPO2: 99% on room air, Heart Rate: 84 beats/minute, Respiratory Rate: 17 breaths/minute, Blood Pressure: 135/80 mmHg, Temperature: 98.4⁰F. Chest X-ray showed significant improvement in aeration and lung expansion with reduced infiltrates and opacities bilaterally (Fig. 2). The New York Heart Association classification of breathlessness, Fatigue Severity Score and Cough Symptom score were administered post physiotherapy treatment at the time of discharge which reported a significant improvement in score. At the time of discharge, the patient was advised to continue and maintain the airway clearance, lung expansion and exercise training as per the parameters mentioned in Table 3.

DISCUSSION
This case report aims to highlight the importance of early intervention of physiotherapy in COVID-19 patients. In COVID-19, the viral replication affects both the pulmonary vasculature as well as the endothelium. The release of inflammatory markers adds further damage to the microvasculature. The disease process also renders a state of hypercoagulability that shifts the physiological dynamics of the pulmonary system. This cascade keeps recurring in a loop causing repeated injury to the alveoli and the airway, which is responsible for the clinical presentation of the patient [3]. The scope of physiotherapy treatment in patients with COVID-19 pneumonia is vast. Multiple focal points are addressed such as reduced ventilation-perfusion matching, impaired airway clearance, pathomechanical movement of the thorax, reduced lung expansion, and reduced mobility [4][5].
The treatment protocol adapted for this patient are in tune with the various research articles analysed to ensure evidence-based care [4,[6][7]. Several studies have shown the positive impact of exercises by directly enhancing the immune system, regulating the release of supportive defence mechanism i.e. immunoglobulins, macrophages etc. against the virulent material; by synchronising the release of C-reactive proteins that significantly aids the pulmonary defence mechanism [8-9]. In a study conducted by Scheiber B et.al., a vast majority of physiotherapists favoured an individually tailored rehabilitation program for the maximum benefit of the patient. This enables the physiotherapist to accurately assess the patient, analyse the findings and prioritise the treatment based on severity and urgency [10]. An awareness of the available literature for physiotherapy rehabilitation amongst the healthcare professionals is of utmost importance for the timely referral and initiation of treatment for the benefit of the patient.

CONCLUSION
As per the findings and results of this case report, it is evident that the patient benefited from the timely advent of physiotherapy intervention.
The key factor was the correct identification of the problematic areas and accurate prioritization based on the clinical presentation and investigation findings. The long-term goal will guide the patient to achieve her functional status prior to COVID-19 exposure. Further studies are needed to accurately identify the effects of early intervention in critically ill patients during the acute phase and the importance of clinical reasoning in the healthcare community.

CONSENT AND ETHICAL APPROVAL
As per university standard guideline, participant consent and ethical approval have been collected and preserved by the authors.