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.