When COVID Comes Home

• What We Don’t Know
• What We Do Know
• Assessment
• Education
• Treatment
• Discharge Planning
• Considerations
• References

Updated:
February 21, 2022

Putting Our Skills to Work

What We Don’t Know

We don’t know yet what makes the difference as to who experiences Long-COVID symptoms and who doesn’t. It seems that even those who had a relatively mild course of the disease can end up with Long-COVID symptoms. Ultimately, we don’t know what causes Long-COVID, but many people have an idea of what contributes to it including diffuse vascular damage, one of the factors that also leads to hypercoagulability.

There are special considerations for therapists treating in the home in times of pandemic. If you are feeling the strain of this, you are not alone.

What We Do Know

Known effects of COVID-19 so far:

• Sepsis
• ARDS/ARF
• Renal Failure
• Bilateral reticular nodular opacities 
• Ground glass opacities (may or may not be permanent – see more here)
• Low white blood cell count (higher white blood cell count in those with PNA comorbid).
• Hypercoagulation
• Impaired Oxygen Diffusion
• Consolidation – Less common
• Increased risk for strokes
• Myalgias
• GI symptoms
• Runny nose
• Anosmia
• This presents as a RESTRICTIVE disease state
• Can result in Long-COVID

Many patients who have COVID-19 do not have excess secretion production, therefore, minimal consolidation. That means that airway clearance techniques are not typically required. However, for patients with comorbidities like COPD, they may still be necessary. But that doesn’t mean that “chest physiotherapy” is needed. There is more to “chest physiotherapy” than airway clearance!

Patients coming home after hospitalization who require home care services will likely have comorbidities. Treatment will most likely be focused on the COPD, Heart Failure, PNA, organ failure, CVAs, Guillian-Barre Syndrome, or PICS, all of this in the presence of severe damage to several organ systems that are still trying to heal.

We also know that those who are more significantly compromised may not be able to recover and may have lasting impairments to their pulmonary function. This virus may be mutating and we are finding new possible representations of its symptoms:

• Encephalitis
• Meningitis
• Sores on the Feet
• Clotting disorders which increase the risk of developing Pulmonary Embolisms and increase in Ischemic CVAs
• Dizziness
• Confusion/Delirium
• Increased risk of Guillain Barre Syndrome
• Diffuse vascular damage which could possibly result in clotting much later after the disease process clears the body.

You may even have transitioned to a telehealth based platform for your treatments during the height of the pandemic, as insurers have allowed for this service for most patients at this time. Some insurers are making telehealth changes permanent so continuing to provide this more efficient method of care may be part of the future of PT!

Record Review

• How long did this patient spend in ICU?
• Did this patient require mechanical ventilation?
• Did this patient require ECMO?
• Was this patients on a proning/positioning program?
• Has this patient tested negative yet?
• Where else has this patient received care?
• What was this patient doing before COVID-19?
• Did this patient have complications such as ICUAW or GBS?
• Does this patient have ongoing increased risk of clotting?

Assessment

• Full set of vitals (HR/PR, BP, RR, O2)
• Persisting symptoms
• Lung auscultation
• Diaphragmatic expansion and activation
• Vitals at rest and with activity
• Aerobic Capacity (Vital capacity is reduced in patients after discharge from ICU)
• Is consolidation present?
• Cough (strength, effectiveness)
• Energy expenditure with ADL
• Pain/soreness (from coughing, sepsis, lines/leads or positioning)
  • Thoracic spine mobility and positioning
  • Cervical musculature
  • Subcranial musculature
  • Cervical Spine mobility and positioning
  • Rib mobility
  • Posture/Positioning
• Functional difficulties resulting from illness/hospitalization (per typical PT assessment)
• Environment accessibility with or without a device
• Skin integrity due to long term positioning in ICU/proning or wounds due to lines/leads/ECMO
• Neurological Baseline Assessment
  • Peripheral Nerve Injury Assessment if proned while in ICU
  • Persistent symptoms of delirium (especially if on mechanical ventilation in ICU as 60-80% will have delirium and incidence rises with age and comorbidities)
  • Long-COVID neurological symptoms including “foggyness” or “Cognitive fatigue”

Goal Setting

• Set measurable goals
  • Increase duration of activity tolerance
  • Decrease dependence on oxygen
  • Wean from oxygen if they didn’t have it before COVID-19 (need a “titrate to” order)
  • Minimize reliance on physical assistance from family members (Family members can get PICS, too!)
  • Fewer rest breaks in the same activity in the same amount of time
• Consider cognitive changes from PICS and ICUAW
• Decreased effort of breathing/Inefficient breathing pattern which feeds in to energy conservation at the most physiological level
• What are the patient-specific functional needs?
  • Stairs?
  • Community distances?
  • Squats?

Education

Hand hygiene:

• Especially after using the bathroom and performing pulmonary hygiene activities as viral RNA was found in stool samples 15 days post symptom-onset (now maybe up to 37 days??) and it is yet to be determined how long this will continue.
• Caregiver hand hygiene and proper PPE use, donning, doffing, surface cleaning
• Community transmission reduction including wearing a mask whenever leaving the home.

New to Supplemental Oxygen

• Tubing Safety
• Tubing and canula replacement schedule
• How to transition to and from mobile tanks without desaturation
• Emergency back-up plan and kilo tank supply
• Regulator management
• Using oxygen equipment with an assistive device
• Oximeter Use

Are “titrate to…” orders needed?
Are altered oxygen parameters needed for CO2 retainer?

Cough Etiquette and Efficiency – More than just COVER YOUR COUGH!

Coughing is exhausting and can be dangerous for patients who are more fragile, like those with osteoporosis. Extraneous coughing can result in sore muscles, fatigue, sore throat/chest, and less rehabilitative activity.

Patients should be educated on making their coughing as efficient as possible if they are utilizing coughing to mobilize and express secretions. Implementing ACBT is useful for this, or just FET techniques generally. Timing performance of these activities when secretions are thickest or interfere most with breathing is useful. This can help the patient conserve energy for other rehabilitative interventions.

Self Monitoring

Educate patient on importance of self-monitoring of symptoms, maybe keeping journals to enhance memory and focus on progression.

Educate patients on the importance of self-monitoring of pulse oximetry at rest and with activity. They will likely need to know how to trouble shoot this device and how to know when readings don’t make sense. Especially if the patient has a “titrate to” order, they will need to know when to increase and decrease their supplemental O2.

As we ask our patients to increase the duration and/or intensity of their exercise, we need to educate them on how to monitor their symptoms when we are not present to help them do so safely. This also includes having reasonable expectations of progression, which we know will be slow, as it relies on the natural phases and timelines of healing. This may be a very big adjustment for patients who were completely independent prior to COVID-19. These patients are already at a higher risk of depression and anxiety due to ARDS and PICS, so providing education regarding expectations will be crucial to their successful recovery.

Self-monitoring for clotting issues is going to become a long-term need as we don’t know how long this increased risk persists. Educate your patients on the signs and symptoms of DVT and PE so they can know when to seek help. We know now that the risk for hypercoagulability persists long after typical COVID symptoms are gone. Read more on that HERE!

Treatment Options

Pulmonary Function Support

• Support V/Q Matching
• Positioning in prone, changing positions (sidelying, hookyling, etc)
• Segmental breathing to increase alveolar recruitment
• Diaphragmatic Breathing
• Positive Expiratory Pressure (PEP) or Hyperinflation techniques to reinflate alveoli
• Aerobic Activity

Pulmonary Hygiene

• Active Cycle of Breathing/Airway Clearance maneuvers
• Cough Stimulation or Support (FET)
• Diaphragmatic Breathing
• Huffing
• PEP devices
• Postural Drainage/Positioning Interventions
• Secretion-thinning dietary modifications
• Increase fluid intake (consider restrictions, if any)
• Mucolytics
• Vibration or percussion (if not contraindicated)
• Nebulizers are not recommended due to aerosolization of the virus. Inhalers are recommended with or without a spacer instead.

Post-Ventilator (Extubation) Diaphragm Weakness

• Inspiratory Muscle Trainer (IMT) PREs
• Diaphragmatic Breathing
• Manual diaphragm facilitation/PNF techniques
• Positioning for resistance against gravity
• Aerobic activity
• Cough Stimulation or Support
• Hyperinflation techniques
• Use of an incentive spirometer is not supported by evidence and is not recommended

Pain

• Manual Interventions (STM, muscle lengthening, OA release, METs, mobilization)
• Positioning for comfort
• Diaphragmatic Breathing
• Medication for pain management

PICS

• See PICS post for details
• Aerobic Reconditioning focusing on alternating interval training.
• Lower level intensities for up to 6-8 weeks simply due to physiological damage that takes time to heal.
• Resistance training for core and smaller muscle groups.
• Screening for delirium and referral as needed

Exercise

• Don’t forget the number one intervention! Many patients who were discharged from the hospital will have significant deconditioning of their entire body, all systems included. This will require extensive rehabilitation.
  • Exercise considerations for these folks will include full body functional recovery, transfers, ambulation, progressive devices, progressive resistive exercises, and most importantly: aerobic reconditioning.
• Some patients, even not having been hospitalized, will continue to experience difficulty returning to their PLOF.
  • These patients will benefit most from aerobic reconditioning. Consider High-intensity interval training programs as these are shown to be most effective at reducing breathlessness, increasing tolerance to exercise, and can include the patient’s most meaningful activities.
• Some patients will experieince post-exertional malaise, a symptom that presents after viral infections in some people as part of the cluster of symptoms now known as Long-COVID.
  • For these patients, best evidence show sus that low and slow is the tempo. We do not want to push them to post-exertional malaise. The WCPT and JOSPT have posted guidelines on providing activity prescriptions for patients with post-exertional malaise. Take a read here.

Discharge Disposition

Continued Isolation

• Until cleared by physician or 2 negative tests 2 days apart
• Will require referrals for social and community resources for food and other needs

If underlying COPD

• Recommend pulmonary rehab after isolation if possible

If the patient has tested positive but remains asymptomatic

• May discontinue home isolation when at least 7 days have passed since the date of their first positive COVID-19 diagnostic test and have no subsequent illness

Utilize technology to support practice

• Consider telephone/telehealth monitoring to ensure recovery beyond final face-to-face visit.

Considerations

1. ALL respiratory PT procedures should be considered aerosol-generating, require airborne precautions and PPE, and should be performed in a single room with the door closed to others.
   – Please consider the risk/benefit analysis of providing these interventions to patients as it places you and others in the home at significant risk, especially if you do not have proper PPE.
   – ALL EXERCISE IS AEROSOL-GENERATING.
2. Throat soreness post-ventilation when accompanied by hoarseness or difficulty swallowing warrants an SLP referral
3. Patients with concurrent bacterial pneumonia will have decreased functional capacity due to antibiotic therapies in addition to antivirals.
4. Assess general strength for reconditioning (Post-Acute Care Syndrome/Post Intensive Care Syndrome)
5. Contagious phase lasts up to 14 days after initial exposure. That’s right. You can spread COVID-19 the day you contract it.
6. Anyone with long-term steroid dosing or who is immunocompromised may have difficulty with recovery
   1. Rheumatological Conditions
   2. Transplants (including optical lens)
   3. Cancer/Chemo/Radiation
   4. Pregnant Women
   5. List is not all-inclusive
7. If hospitals become overwhelmed, patients may be coming home on ventilator or hemodialysis
   1. Review FiO2, PEEP, pressures, vent functions and settings
   2. Prone ventilation improves outcomes
   3. Familiarize yourself with the side effects of hemodialysis and intervention parameters (FYI, this includes intradialytic exercise programs!)
8. Screen for side effects of ARDS
9. Review all recent blood work and monitor patient for hemodynamic stability.