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\begin{document}

\title{The clinical impact and benefits of a simultaneous cardiopulmonary
rehabilitation in a COVID-19 infected patient following cardiac arrest:
A Case Report}



\author[1]{Jun Young  Ko, MD}%
\author[1]{Jeong Jae Lee, MS, PT}%
\author[1]{Mi rim  Lee, MD}%
\author[1]{Yong Kyun Kim, MD, PhD}%
\author[1]{Seungbok Lee, MD, MPH}%
\affil[1]{Myongji Hospital}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
The decline in cardio-respiratory function is rising among COVID-19
survivors amid the pandemic. Cardiopulmonary rehabilitation is known to
be clinically effective but no studies show data to substantiate its
application. The simultaneous treatment improved cardiopulmonary
clinical indicators in our patient yielding enhanced functional
restoration to enable independent community participation.%
\end{abstract}%



\sloppy


Title Page:

\textbf{The clinical impact and benefits of a simultaneous
cardio-pulmonary rehabilitation in a COVID-19 infected patient following
cardiac arrest: A Case Report}

Jun Young Ko\textsuperscript{a}, Jeong Jae Lee\textsuperscript{b, c}, Mi
rim Lee\textsuperscript{a}\emph{,} Yong Kyun Kim\textsuperscript{a},
Seungbok Lee, MD, MPH\textsuperscript{a,d}

\textsuperscript{a}Department of Physical Medicine and Rehabilitation,
Myongji Hospital. Hanyang University College of Medicine. Goyang,
Republic of Korea.

\textsuperscript{b}MJ Cardiac Rehabilitation Center of Myongji Hospital.
Goyang, Republic of Korea.

\textsuperscript{c}Department of Physical Therapy. College of Health
Sciences, Yonsei University. Wonju, Republic of Korea.

\textsuperscript{d}Yonsei Enabling Science and Technology Research
Clinic. College of Health Sciences, Yonsei University. Wonju, Republic
of Korea.

Corresponding author:

Seungbok Lee, MD, MPH

MJ Cardiac Rehabilitation Center, Myongji Hospital.

55 Hwasu-ro 14-gil, Deogyang-gu, Goyang-si, Gyeonggi-do, 412-270
Republic of Korea.

Tel.: +82-31-810-6450 Fax: +82-504-444-6061

ORCID: \#0000-0001-9437-1352

Email: supermandrlee@gmail.com

First author:

Jun Young Ko, MD

ORCID: \#0000-0002-3351-7247

Email: kobari12@naver.com

Co-author:

Jeong Jae Lee, MS, PT

ORCID: \#0000-0003-2241-4178

Email: ptljj@naver.com

Co-author:

Mi rim Lee, MD

ORCID: \#0000-0001-5957-4517

Email: flagus2@naver.com

Co-author:

Yong Kyun Kim, MD, PHD

ORCID: \#0000-0002-12254-8965

Email: yacha@hanmail.net

\textbf{Competing interests}

The authors declare that they have no competing interests.

\textbf{Funding}

This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.

\textbf{Key Clinical Messaage}

As COVID-19 cases rise the application of rehabilitation following acute
treatment is increasing. This case emphasizes the critical need for
cardiopulmonary rehabilitation for functional restoration after cardiac
arrest and COVID-19 treatment.

\textbf{Abstract\_Unstructured} :

Since the advent of the pandemic, cardiopulmonary rehabilitation (CR)
has been shown to be an effective treatment. However, there are no
studies showing data to substantiate its simultaneous application. A
62-year-old man was resuscitated for asystole during the work-up after
presenting with two-day history of difficulty breathing. PCR test was
positive for COVID-19. He was intubated and admitted to a negative
pressure zone. Symptoms improved in response to acute treatment.
Following extubation, respiratory distress persisted, and CR was
implemented. Clinical indicators of cardiopulmonary function improved
resulting in a successful return to community participation. The decline
in cardiopulmonary function has been on the rise among COVID-19
survivors. The simultaneous application of CR treatment in our patient
resulted in improved clinical indicators of cardiopulmonary function.
The patient regained full function for independent community
participation.

\textbf{Keywords} : cardiopulmonary rehabilitation, COVID-19, cardiac
arrest

\textbf{INTRODUCTION}

The application of cardiopulmonary rehabilitation (CR) has dramatically
increased in many areas globally. Studies have reported that CR
treatment has significantly decreased mortality rates, reduced
re-admissions, and improved quality of life among patients with heart
and respiratory diseases {[}1,2{]}. On the other end of the spectrum,
the current public health crisis stemming from the coronavirus
(COVID-19) outbreak has taken many lives primarily owing to severely
compromised respiratory status. Since the first human-infected case was
reported in late 2019, followed by rapid transmission and its global
spread, the state of a pandemic was declared by the World Health
Organization in early 2020.

In response to the pandemic, various acute care and treatment methods
for COVID-19 infection have been proposed based on limited research
data. The recent and notable preventive measure in response to the
crisis has been developing vaccines to achieve herd immunity. However,
there is still insufficient research evidence for the treatment of
conventional acute cardiopulmonary failure, which is accompanied by
deterioration of physical condition, postural instability, muscle
shortening, and contracture that may occur after COVID-19 infection.
{[}3,4{]}.

Our patient with cardiac arrest, presumably associated with recent
COVID-19 infection, showed improvement in cardiopulmonary function after
undergoing a simultaneously combined pulmonary and cardiac
rehabilitation. The resultant effect was a rapid return to daily life
activities and vital community participation.

\textbf{CLINICAL CASE}

1. \emph{HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE}

A 62-year-old man with chronic hypertension and no other significant
medical history presented to the emergency department (ED) with
complaints of severe dyspnea. He reported the onset of breathing
difficulties two days prior to presentation. The patient's wife was
undergoing mandatory self-isolation at home, where they reside together,
due to a recent COVID-19 infection positive test result. In the ED, the
patient required 15L of O2 by mask and reported SpO2 of 60\% on
saturation monitoring.

During the work-up in the ED, an onset of asystole required
cardiopulmonary resuscitation for approximately 2 minutes. The efforts
resulted in the return of spontaneous circulation (ROSC). PCR test
result was positive for COVID-19. He was intubated and admitted to the
Infectious Disease service for the acute treatment of COVID-19 in a
negative pressure isolation room in a separate wing of the hospital. The
patient was extubated on hospital day 10 with significantly improved
clinical symptoms by hospital day 28. He was released from the
quarantine zone following a confirmed resolution of COVID-19, and
gradual improvement of pneumonia was observed via serial radiography
(Figure 1).

Medical management was discontinued at this juncture of the hospital
course, and discharge planning was initiated. However, as a former
COVID-19 patient with a recent cardiac event, residual respiratory
distress and symptoms were noted when engaging in any activity with the
slightest movement. Upon returning home, he could not perform basic
daily life activities independently and was prompted to undergo CR.

2. \emph{EVALUATION TOOLS}

Pre-requisite evaluation (hospital day 38, T1) before CR involved the
following areas of assessment: pulmonary function test (PFT),
cardiopulmonary exercise (CPX) test, 6-minute walk test (6MWT), and Berg
balance test (BBS). The patient was reassessed after seven days of CR
(hospital day 48, T2).

Pulmonary function was based on PFT evaluation (Pony FX MIP/MEP, Cosmed
Srl, Italy) which included measurements of Functional Vital Capacity
(FVC\%), FEV1(\%), FEV1/FVC(\%) with Peak Cough Flow (PCF), Vital
Capacity (VC), Maximal Insufflation Capacity (MIC), Maximal Inspiratory
Pressure (MIP), Maximal Expiratory Pressure (MEP). CPX test was
conducted using American College/American Heart Association guidelines
using Peak Oxygen uptake per Kilogram (VO2/Kg), Peak Oxygen uptake per
Heart Rate (VO2/HR), and Oxygen Uptake Efficiency Slope (OUES) as
clinical indicators.

3. \emph{CLINICAL INTERVENTION}

The rehabilitation course required a combined program consisting of 1)
60 minutes of pulmonary rehabilitation, 2) 60 minutes of cardiac
rehabilitation, and 3) 30 minutes of strengthening exercise with balance
training. The regimen was applied once daily for a total of seven days.

Pulmonary rehabilitation comprised pursed-lip breathing exercises, deep
breathing exercises (secretion mobilization and diaphragmatic
breathing), rib cage expansion exercises, and controlled coughing
exercises. The patient was also educated on self-management practices,
emphasizing coping skills, dietary intake, self-medication, and
performance in activities of daily living.

Cardiac rehabilitation involved the use of a hand-bike ergometer system
based on CPX results of the initial evaluation. Our patient was
supervised by a therapist using a pulse oximeter during the exercise
period. The intensity of the activity was adjusted based on the
patient's heart rate (HR). The criteria for discontinuing or reducing
the exercise intensity was determined by using oxygen saturation of SpO2
\textless{} 85\%, symptom-limited by the subjective rating of perceived
exertion (RPE \textgreater{}14).

The regimen also required 30 minutes of strengthening exercise and
balance training, as aforementioned. A strengthening exercise was
performed in 3 sets of 12-15 repetitions with the 30-40\% of 1
repetition maximum (RM) {[}5{]}. When oxygen saturation fell below 85\%,
supplemental oxygen was added with 2 liters via nasal cannula to
maintain oxygen saturation greater than 90\%.

Despite the patient's confirmed resolution of the infection,
precautionary measures were strictly enforced during the rehabilitation
treatment phase. Protective equipment, including gowns, face shields,
and masks, were required for patients and clinical staff in the rehab
center to minimize potential risks of new infection and re-infection.

\textbf{DISCUSSION}

The sequela of COVID-19 infection primarily cause a decrease in
diffusion capacity and compromised function via obstructive respiratory
patterns and weaknesses of accessory muscles {[}6{]}. In addition,
impairment of cardiac function due to complex mechanisms, an
inflammatory immune response from infection, virus invasion of
cardiomyocytes, and hypoxic myocardial injury can all occur as
complications {[}7{]}. A similar pathophysiologic mechanism presumably
manifested in this patient.

Many experts in the field believe that it is indispensable to perform
respiratory and cardiac rehabilitation treatment simultaneously.
However, cardio-pulmonary rehabilitation's implementation and clinical
practice are insufficient and sparse due to the lack of hospital
resources and the heightened risks of contagion {[}3{]}, especially
during the current global public health crisis. Moreover, the decline in
cardiopulmonary function is a clinical sequela observed as an increasing
trend among COVID-19 survivors {[}9{]}.

The effects of respiratory and cardiac rehabilitation therapies have
been proven through various studies to date {[}8-10{]}. A recent
systematic review showed that respiratory rehabilitation treatment after
COVID-19 infection improves respiratory function and quality of life
{[}10{]}. Since the advent of the current pandemic, CR has been combined
with respiratory rehabilitation treatment across centers in many
geographic areas. However, no studies show data to confirm its
generalizability and substantiate its clinical application as a reliable
treatment. The observed clinical result shown in our case study is
consistent with the improved effects of CR when combined with
respiratory rehabilitation in patients with severe COVID-19 infection
following cardiac arrest. Symptoms improved, and bilateral patchy
opacity was reduced on chest X-ray findings after acute pharmacologic
treatment at 38 days of hospital admission. At this juncture, CR was
implemented without concomitant antibiotic therapy. Subsequently,
symptoms and radiographic findings were further diminished, and although
unaffected by antibiotic treatment, the patient's decline in function
improved following CR application. Nevertheless, the residual symptoms
and radiographic opacity persisted.

Hermann et al. (2020) demonstrated in their study of 28 participants
following 2-4 weeks of CR in which the group requiring mechanical
breathing (n=12) compared to the group without (n=16) showed a
significant increase in the measured outcome on 6MWT evaluation {[}9{]}.
The improvement was shown in VO2/kg, VO2/HR, OUES, and 6MWT, all of
which served as indicators of cardiovascular function. In addition, the
BBS index by functional balance test also showed improvement.

Aytur, Y et al. (2020) proposed a theory and produced guidelines of
respiratory rehabilitation for COVID-19-infected patients through a
multi-center trial in Turkey {[}10{]}. We followed this model in our
study and applied the proposed treatment model in pulmonary
rehabilitation. Upon completing the week-long CR treatment, the
following respiratory function indicators improved: PFT, FVC, FEV1, PCF,
VC, MIC, and MIP/MEP, as shown in Table 1. Simultaneously,
cardiovascular function improved which enabled the patient to ambulate
independently without difficulty in respiratory function.

CPX results showed improvement in VO2/Kg, VO2/HR, oxygen uptake
efficiency slope (OUES), 6MWT, and BBS, as summarized in Table 2. The
patient showed functional improvement after a short period of CR by
independent ambulation and performance in daily life movements at home
without dyspnea and other related respiratory signs and symptoms. As a
result, the clinically improved patient successfully returned to
community participation.

\textbf{SUMMARY AND CLINICAL APPLICATION}

The presented case in this report substantiates the critical need for
cardiopulmonary rehabilitation following the onset of a cardiac event
preceded by the resolution of a recent COVID-19 infection. Under the
usual protocol, following the resolution of COVID-19, individuals are
immediately discharged to home regardless of overt residual symptoms. It
is recommended that patients undergo cardiopulmonary rehabilitation
directly following treatment of a COVID-19 infection, given its
effectiveness and benefits for improved clinical status following a
short treatment period.

\textbf{Authors' Contributions:}

First author:

Jun Young Ko, MD

Initial investigation with clinical care and work-up; writing original
draft and preparation; data acquisition and analysis.

Second author:

Jeong Jae Lee, MS, PT

Investigation; clinical evaluation and work-up; acquisition and
interpretation of data; reviewing of final manuscript.

Co-author:

Mi rim Lee, MD

Clinical care and work-up; drafting original write-up; administration;
proofreading.

Co-author:

Yong Kyun Kim, MD, PhD

Project administration and support with supervision of the clinical
aspects; reviewing and editing.

Senior and Corresponding author:

Seungbok Lee, MD, MPH

Conceptualization and design; supervision with provision of resources;
manuscript drafting, reviewing and final editing with technical
language, proofreading.

All aforementioned authors participated sufficiently in the presented
work; the authors have read and agreed to the final approval of the
manuscript to be published.

\textbf{REFERENCE}

1. Mador, M.J., A.N. Patel, and J. Nadler, \emph{Effects of pulmonary
rehabilitation on activity levels in patients with chronic obstructive
pulmonary disease.} J Cardiopulm Rehabil Prev, 2011. 31(1): p. 52-9.

2. O'Connor, C.M., et al., \emph{Efficacy and safety of exercise
training in patients with chronic heart failure: HF-ACTION randomized
controlled trial.} JAMA, 2009. 301(14): p. 1439-50.

3. Andrenelli, E., et al.,\emph{Rehabilitation and COVID-19: a rapid
living systematic review 2020 by Cochrane Rehabilitation Field. Update
as of September 30th, 2020.}Eur J Phys Rehabil Med, 2020. 56(6): p.
846-852.

4. Piquet, V., et al., \emph{Do Patients with Covid-19 Benefit from
Rehabilitation? Functional outcomes of the first 100 patients in a
Covid-19 rehabilitation unit.} Archives of Physical Medicine and
Rehabilitation, 2021.

5. Sparling, P., et al., Strength training in a cardiac rehabilitation
program: a six-month follow-up. Archives of physical medicine and
rehabilitation, 1990. 71(2): p. 148-152.

6. Torres-Castro, R., et al.,\emph{Respiratory function in patients
post-infection by COVID-19: a systematic review and meta-analysis.}
Pulmonology, 2020.

7. Tan, W. and J. Aboulhosn, \emph{The cardiovascular burden of
coronavirus disease 2019 (COVID-19) with a focus on congenital heart
disease.} Int J Cardiol, 2020. 309: p. 70-77.

8. Wang, F., R.M. Kream, and G.B. Stefano, \emph{Long-Term Respiratory
and Neurological Sequelae of COVID-19.} Med Sci Monit, 2020. 26: p.
e928996.

9. Hermann, M., et al.,\emph{Feasibility and Efficacy of Cardiopulmonary
Rehabilitation After COVID-19.} Am J Phys Med Rehabil, 2020. 99(10): p.
865-869.

10. Kurtais Aytur, Y., et al.,\emph{Pulmonary rehabilitation principles
in SARS-COV-2 infection (COVID-19): A guideline for the acute and
subacute rehabilitation.} Turk J Phys Med Rehabil, 2020. 66(2): p.
104-120.

\textbf{Hosted file}

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