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.