Rehabilitation in times of COVID-19

Prof. Dr. R. Koczulla, Dr. Dr. Tobias Böselt and Dr. Inga Jarosch

Course of the disease

The COVID-19 disease, caused by the novel SARS-CoV-2 virus, originated in China and spread to Europe. Since early/mid-March, the pandemic has also been unfolding in Germany, with severe, sometimes unexpected, cases and fatalities.

Besides asymptomatic infections, mild to moderate cases are observed, but also very severe cases that lead to hospitalization and intensive care. Unfortunately, fatalities also occur.

In approximately 801 of the registered infections, the disease presents with fever or mild symptoms. In about 151 of the cases, it is more severe, and in 51 of the cases, it is so severe that intensive care is necessary because the condition is considered critical or life-threatening.

Bilateral pneumonia with respiratory failure is a key pathology in severe cases. To date, there are no data specifically describing the course of the disease in Alpha-1 patients.

Proof

Diagnosis is made via a deep nasal/pharyngeal swab. We assume an incubation period of 14 days. Typical symptoms are fever, cough, and shortness of breath. However, asymptomatic cases are also possible. Diarrhea may occur, as well as changes in the sense of smell and taste. Shortness of breath, fatigue, and muscle pain can be further typical symptoms. In addition to lung involvement, cardiovascular involvement has been described. Neurological changes have been reported, including ischemic stroke, thromboembolic events, meningitis, headaches, altered mental status, and critical illness polyneuropathy following a severe hospital stay.

prophylaxis

For preventative measures, the recommendations issued by the Robert Koch Institute apply. Maintaining distance, wearing a face mask, and regular hand disinfection are important and can be found in all recommendations.

Therapy in the acute phase

Currently, there is neither a specific treatment for COVID-19 nor a vaccine. Besides symptomatic treatment—that is, administering oxygen when oxygen saturation drops and blood oxygen levels are low—treatment options include mechanical ventilation and intensive care for severe cases. There are some studies on medications—such as the antiviral drug Remdesivir, which can shorten the course of the disease by a few days.

Post-acute phase

How should someone recovering from a COVID-19 infection be cared for afterward? A prompt follow-up appointment with a pulmonologist is certainly advisable, where lung function tests, blood gas analysis, and diffusion capacity measurements could be useful. If heart problems are present, a cardiac examination should also be performed. In cases of severe impairment, imaging in the form of a high-resolution CT scan may be beneficial. Further diagnostic procedures should be determined based on the CT findings.
According to current understanding, Alpha-1 ATG administration should not be interrupted if possible. The research group led by McElvaney was able to show (New England Journal 2020) that interrupting alpha-1 AT therapy leads to an increased exacerbation rate.
It is assumed that everyday physical activities such as walking and moderate physical training are beneficial in the post-acute phase.

Inpatient rehabilitation

Furthermore, the care provided after mild to severe cases of COVID-19 is certainly an important consideration. As a direct consequence of COVID-19, it is assumed that the number of patients with long-term health consequences related to COVID-19 will increase significantly. While patients with asymptomatic cases appear to recover completely and without long-term limitations, initial studies show that mild, severe, and critical cases of the disease have lasting effects in various areas (cognitive function, skeletal muscles, mental health, etc.). Clinical observations indicate that COVID-19 is primarily characterized by lung damage and can thus lead to persistent shortness of breath. Impairments in blood clotting are also observed, which can sometimes lead to the occlusion of smaller vessels or even to a pulmonary embolism. The specific consequences of COVID-19 in patients with a pre-existing lung condition such as alpha-1 antitrypsin deficiency are currently largely unknown. It is assumed that the long-term effects of the disease can be addressed and reduced through specialized rehabilitation. Data from the 2003 SARS-CoV-1 outbreak show that rehabilitation can positively influence the post-acute course of the disease. The content of pulmonary rehabilitation (PR) in the post-acute COVID-19 phase is based on established pulmonary rehabilitation programs for chronic lung diseases. In the international PR guidelines of the American Thoracic Society (ATS) and the European Respiratory Society (ERS), PR has become established as a core component of disease management for patients with chronic respiratory diseases. Studies demonstrate clear positive effects on physical performance, quality of life, and symptoms (shortness of breath, fatigue).

A Swiss group of authors proposed using the same rehabilitation treatments recommended for patients with pulmonary fibrosis, as the observed pulmonary and extrapulmonary symptoms are very similar (Carda 2020, Kenn 2013). This comprehensive, multimodal, and multidisciplinary therapeutic approach combines both pharmacological and non-pharmacological therapies. In addition to optimizing medical care, a targeted exercise program is a core component. Physical training in pulmonary rehabilitation (PR) consists of at least individually tailored endurance and strength training, which should be conducted with a mobile oxygen supply in cases of severely reduced blood oxygen saturation. Another component of PR is respiratory physiotherapy, which aims to restore respiratory function as much as possible and to teach symptom-reducing breathing techniques for both rest and exertion. Furthermore, psychological support and knowledge transfer are important components of PR. The extent to which these components are also optimal in patients who have experienced COVID-19, or whether they can be further improved, will be determined in clinical practice over the coming weeks and in further studies.
to reveal on this topic.

Naturally, the COVID-19 situation has significantly changed the procedures in our hospital. In the first weeks after the outbreak of the pandemic up to the present day, we have actively helped care for COVID-19 patients.
We resumed routine operations at the end of May, but we continue to keep rooms physically separate for COVID-19 patients. We have implemented special hygiene measures in our daily routines, as prescribed by the Robert Koch Institute (RKI). A dedicated team is available for COVID-19 patients.

We have also begun developing a concept for post-COVID-19 patients, which is intended to meet the needs of this specific patient group and is also being addressed within the framework of studies. In general, we have meticulously implemented the hygiene regulations of the Robert Koch Institute (RKI) throughout the hospital. With the easing of the corresponding social distancing measures across Germany, there is, of course, a general risk of reinfections occurring, which could lead to a renewed exacerbation of the COVID-19 situation in hospitals as well.