CLINICAL CASE
1. 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. 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. 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
< 85%, symptom-limited by the subjective rating of perceived
exertion (RPE >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.