COVID Reflections/moving forwards @TheACPRC course
My learning points
THREAD (long)
Huge thank you to all the speakers and for putting on a great webinar
Looking forward to putting into practice with @RBH_ICU_Physio & @GoPerformUK

Intubation & Ventilation
- Different phenotypes = different results
- Tracheostomy in 14 days decreased ICU stay
- Physio important in ICU Mx - sputum/trache’s
- 2nd wave showing reduced I&V patients

NHF
- reduces WOB, bronchospasm, helps AWC
- Flow is key 10L/min = 1cm PEEP
- Prescribe FiO2 & Flow ranges
- Start at 40% : 40L/ min
- Combo with proning
- AGP issues ? face mask with NHF but tolerance issues
- 5% wean at a time

CPAP
- early response & break behaviour can be key predictors
- Don’t rush weans
- Careful monitoring
- MDT approach: all onboard to help patient compliance
- Bridge to I&V in severe ARDS

Conscious proning
- encourage long durations
- Improvements in VQ
- Reduction in regional HI lung injury
- Semi prone can still be beneficial

Cognition 1/3
- symptoms include brain fog , attention issues, memory & planning issues
Why?
1) no clear evidence on direct affect on brain cells
2) Impact of pandemic - social/physical isolation, reduced stimulation, stress/anxiety/depression, post viral fatigue

3) Critical care - PICS, linked to longer periods of ICU delirium, 1/3 are similar impact as mod TBI, effected long after d/c
- Management - recognition, fatigue Mx, pacing, sleep hygiene, relaxation , reassurance of improvement, Neuropsych input?
2/3

- OT importance in MDT
- COVID PR ? Have cognition education session?
http://www.yourcovidrecovery.nhs.uk 
3/3

Brachial Plexus Injuries 1/3 @PhysioPhil2
- Neuropathic pain is key indicator
- Supra clavicular injuries from neck SF & shoulder depression
- Infra clavicular from GHJ Abduction

- Mechanism from squashing & traction over 10% (fibula head area compression - drop foot - common peroneal nerve)
- Evidence of GHJ dislocation on CXR
- Brachial plexus more common with triple threat co-morbidity (T2DM, HTN, Obesity) 2/3

- Prone positioning - use guidance for handling & GHJ alinement e.g support chest, rotate head towards abducted arm
- Referral to PNI unit with neuropathic pain or local ortho unit 3/3

Psychology 1/3
- PICS - 50% PTSD/Anxiety/Depression (pre C-19) & 25% cognitive impairment
- -“waking to an alien world” - PPE , lack of family input & dehumanisation of ICU
- Prolonged sedation & delirium

- Media coverage increased fear but better understanding of critical care
- Fatigue & physical limitations impacting mood
- Fear & uncertainty
- PTSD - HPA axis -flight or flight on overdrive
- Humanise at any opportunity - rehab consistency/focus & f/u 2/3

- Staff impact - PPE big predictor of stress, HPA axis & lack of social interaction. Mental health issues mirrors pt’s with PTSD, anxiety & depression
- Help! - focus on what’s within your control, self care, mini debriefs - acknowledge we are only human 3/3

UHS reflections 1/3
- SLACK channel to share info
- Chest Physio - positioning, VHI (slow ins), ins holds, Manual Techs (inc cough)
- Proning teams - who in the MDT?
- Tracheostomy - mixed duration

- Rehab - delayed, but stable enough. Reduced endurance & needing highest level of their current vent support
- Delirium increased - issues with double bed space, difficult to vent & needing Midaz sedation, family video calls, about me forms, rehab diaries 2/3

- Ward follow ups and virtual/phone call follow ups
- Team debriefs, team working 3/3

#LongCovid 1/4
- 10% post COVID
- Can Overlap into CFS & ME
- 80% non hospital admissions, typical age 30-50 years old & moderate - highly physically active
- Post COVID vital main symptoms: SOB, chest tightness, fatigue

- Infection cytokine storm
- Respiratory disease - O2, WOB, deconditioning, side effects of meds & cardiac disease - HRV, plts , , mental health issues - exercise could help here (in post viral fatigue <3 months 2/4

- ME/PVFS- CNS / neuroendocrine involvement (e.g altered state in brain, impact to mitochondria, HPA axis / cortisol, dopamine, anaerobic metabolism ATP) therefore graded exercise is NOT recommend
- Orthostatic/ANS symptoms 3/4

- Mx: 3 P’s (pace, prioritise, plan), , nutrition, relaxation, activity mx & HR monitoring (e.g keeping < aerobic threshold, HRV tracking )
- Medical Ix to exclude other causes
- Important to differentiate between PVF & PFVS/ME - different exercise mx @PhysiosForME 4/4

Breathlessness & BPD 1/3
- Post Covid can show abnormal pulmonary function - diffusion impairment & restrictive lung disease, CXR changes
- V/Q mismatch = breathlessness
- Acute symptoms chronic
- Load (WOB, compliance, sputum) vs. Capacity (altered respiratory mechanics)

- Complex neurophysiology - biochemical (pCO2 excess metabolic needs) biomechanical (length tension relationship of diaphragm, dynamic hyperinflation), psych-physiological (emotions impacting behaviours vent drive) threat to homeostasis - unhelpful
2/3

- Treatment options BPD - breathing retraining (nose breathing), fan therapy, AWC , singing , IMT, CBT, relaxation, PR , walking aids etc
- Different approaches- Papworth, Bradcliffe, Buytakeo, Breath Freely
- CPET could be utilised for differential dx for SOB 3/3

Continued in replies...

Upper airway issues / Laryngeal issues (can’t wait to ask @CharlieMacSALT lots of questions!)
- Laryngeal issues common following intubation
- Symptoms: dysphoria, pain, horse voice, dysphagia, laryngeal dyspnea, stridor
- COVID ? laryngeal oedema

- Larynx involved in multiple functions - swallow, cough, speech, breathing
- Issues can result in globus, throat clearing, ILO (difficulty breathing in), ongoing dry cough
- Ongoing dysphagia - aspiration risk & impact to meeting nutritional requirements

C-19 & Critical Care MDT follow up
- patient ID - triaged to appropriate MDT members
- 6/52 post d/c clinic f/u
- Outcome measures before clinic (CORE 34, SF 36, Nijmengen, Pittsburgh Sleep index, Nottingham Extended ADL score)

- Outcome measure in clinic- TUG, Quads/grip strength testing, voice handicap index & eating Ax tool, 6MWT to estb exercise desaturation
- MSK issues common requiring onward Rx (lateral thigh numbness, shoulder issues, back pain, big toe extension - EHL), hand issues

- Reduced exercise tolerance & issues with plateauing ? Fibrosis on lung CT
- BPD common

That's it!
Mind is blown from all the learning
Thanks again to all the speakers