COVID-19: do I need to wash my shopping and groceries?
How physiotherapy is helping coronavirus patients
Alongside doctors and nurses, physiotherapists have played a key role in the care and treatment of COVID-19 patients in hospitals in the UK. But how do they help patients recover?
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David McWilliams is a consultant physiotherapist in critical care at the University Hospitals Birmingham NHS Foundation Trust. He has been working with COVID-19 patients since the start of the outbreak, specifically in critical care.
Outside of coronavirus care, physiotherapists are continuing to help other patients with their injuries and movement problems during the pandemic through video appointments. You can now book a private remote appointment with a physiotherapist via Patient Access. But what's happening on the hospital wards?
On admission to critical care, also called an intensive treatment unit (ITU) or intensive care unit (ICU), patients are sedated and intubated (a tube is inserted through the mouth and into the airway). On average, patients remain sedated for seven to 10 days; then they are slowly 'woken up' from sedation.
"The primary aim when people first arrive is to get enough oxygen into their blood," he explains. "They have a really stormy course, maybe the first seven to 10 days. After that point, when their condition starts to gradually improve, their lungs are improving and we'll start to slowly turn off the sedation."
As the patient is weaned off sedation, they might then be ventilated through a tracheostomy, a tube that runs through the windpipe. Although this ventilation is invasive, it is a little more comfortable for the patient than intubation through the mouth (endotracheal intubation).
"We get quite a high incidence of delirium and cognitive dysfunction, which is normal in critical care, and typical in this long a stay," he says.
During sedation, patients are in a low conscious awareness state, rather than sleep, which also contributes to disorientation. Patients also have to cope with receiving treatment from clinicians in full PPE, and cannot receive visitors.
"Sedation can also stop you laying down memories, so a lot of patients don't remember, particularly, the early stages of critical care," McWilliams adds. "It can be frustrating at times, because you do a lot of rehab with people then go see them on the ward and they're like, 'Who are you? Sorry. I don't remember you.'"
McWilliams is a leading researcher into the benefits of early rehabilitation in critical care. With COVID-19 patients, he and his team decided to start rehab as early as possible.
By beginning physiotherapy in the ICU, McWilliams and his team found that, with help, patients could manage to sit on the edge of the bed or even take a few steps while still on a ventilator, with the majority managing to at least stand before being discharged on to a ward.
COVID-19 is new to UK doctors, which makes treatment uncertain and challenges. Working in PPE has also been challenging. Another challenge was that many COVID-19 patients were larger than average.
The Intensive Care National Audit and Research Centre (ICNARC) reported on 22 May that 35% of critically ill COVID-19 patients had a BMI of 25-29.9, 31% had a BMI of 30-39.9 and 8% had a BMI of 40 or more - a total of 39% with a BMI over 30 (the obese category), compared to 27% of men and 30% of women nationally in England. Patients with higher BMIs often need more therapists per patient, especially where they feel weak or disorientated.
Weaning off the ventilator
Patients don't always necessarily need to be intubated after sedation. But clinicians need to keep these patients' blood full of oxygen. To help 'splint' or open tiny airways at the bottom of the lungs, patients receive non-invasive ventilation. Oxygen is delivered through a mask (often called CPAP or bi-PAP).
Once a patient can breathe without invasive ventilation and come off the blood pressure medication used in ICU, they are usually moved out of ICU on to a ward.
On 22 May, ICNARC had been been notified of 11,292 patients admitted to critical care with confirmed COVID-19 in England, Wales and Northern Ireland. Of that number, 1,839 were still receiving critical care. At the time, 9,307 people were in hospital with COVID-19 according to government data.
Moving patients on to wards
Ema Swingwood is a physiotherapist working at an acute trust in the South West of England. She also works as the chair of the Association of Chartered Physiotherapists in Respiratory Care.
Like McWilliams, she has been working with patients with COVID-19 since the start of the outbreak. At work she helps assess what kind of ventilation patients need, weans them off ventilation, and helps get them moving again. But Swingwood remarks that recovering from COVID-19 has so far been a slow process for many patients.
"On the wards when they're on CPAP, we're finding that they're on it for up to a couple of weeks," she reports. "But then weaning them off takes so long - almost another week or couple of weeks. In that time, they are displaying a lot of breathlessness and fatigue, which is impacting on their ability to participate in rehab."
For Swingwood's team, this means giving patients 'breaks' of just ten minutes when the ventilator is turned down slightly to deliver lower levels of oxygen. Patients start with one break a day then two breaks, or one longer break, the next day. But even during these, Swingwood adds, patients need a lot of oxygen.
Physiotherapists will help patients to the edge of a bed, sit in a chair and stand up from a seated position. Often they use tilting chairs or hoists to support movement. Simple exercises also force patients to breathe a little harder. This strengthens a patient's respiratory system, which prepares them for learning to dress, move and make cups of tea again.
Dry cough is one of the main symptoms of COVID-19. Swingwood says she can only think of a few cases where she and her colleagues have needed to use manual techniques to help people breathe.
"The patient would be side-lying or sitting up in a chair and we do gentle clapping on their chest," she explains, "Or we have our hands around their chest wall or rib cage and, as they breathe out, give them a gentle shake. We have sometimes used techniques like that, but the majority of patients have just got a dry cough."
Once patients on the wards are well enough to return home, they will be discharged with a treatment plan, including physio at home delivered via video. But Swingwood expects that recovery from COVID-19 will have long-term challenges, such as chronic cough or trouble breathing.
"We need to be mindful that once we've discharged the patient we need to think, 'What are this patient's long-term needs from us?' We need to make sure that there are the pathways for the patient to come back in to get that specialist care that they need."
The Chartered Society of Physiotherapy (CSP) warns that as well as breathlessness, fatigue and neurological issues, many COVID-19 survivors will be left with scarring on their lungs that needs respiratory rehabilitation.
Sue Hayward Giles, an assistant director at the CSP, explains, "Our concern is that there isn't any clear plan from the Government yet. Access to this lifeline is already patchy at best across the country, putting at risk the recoveries of a huge number of patients." COVID-19 patients' needs, and the needs of patients already receiving care from physios, call for a national plan.