A 66-year-old male started to present symptoms of fever, dyspnea, coughing, asthenia, lack of appetite, nausea, and vomiting. He was admitted to the acute care unit for observation and oxygen therapy, but his oxygen requirements constantly increased due to moderate ARDS. After 12 days of deep sedation, neuromuscular blocking agents, and proning with daily passive range of motion, the patient finally started to initiate active movements and was passively transferred to a chair. However, due to a persisting difficult weaning status, probably related to respiratory muscle weakness, tracheostomy was performed [ventilator settings: pressure support 10 cmH2O, positive end-expiratory pressure (PEEP) 8 cmH2O]. Subsequently, the patient showed significant improvement in his physical functions with active SOEB, chair-transfer with the help of 2 physical therapists, and active in-bed cycling against resistance for 20 minutes (). The strategy was to increase pressure support (by 5 cmH2O) during efforts to reinforce exercise training effects, unloading respiratory muscles. This strategy along with a highly collaborative patient culminated in his rapid improvement in physical function (MRC-SS 58/60, physical function ICU test score 10/12, walking distance 10 m), although he was still experiencing fatigue, inspiratory muscle weakness (maximal inspiratory pressure of −45 cmH2O) and dysphagia upon his transfer to a step-down unit.
This 66-year-old male patient was admitted to the hospital due to an ischemic left-hemispheric stroke in addition to a dry cough and fever. He tested positive for SARS-CoV-2 the following day but continued to deteriorate resulting in severe ARDS, intubation, and ICU admission. Despite repeated proning, gas exchange did not improve sufficiently and the patient was placed on veno-venous extracorporeal membrane oxygenation for 7 days. After sedation was stopped, the patient continued to be somnolent and unable to communicate or to follow commands. Physical therapy therefore focused on perception training, movement exercises, airway-clearing techniques, dysphagia therapy, and mobilization. A first SOEB trial had to be discontinued due to hemodynamic instability. Instead, the patient was positioned in a side-edge position (), which he tolerated better and where an intensive exercise training including trunk and head control was conducted. Nevertheless, muscle tone and strength remained severely reduced, particularly on his hemiplegic side, and a second SOEB trial failed again. Physical therapy was also limited because of reduced self-activity and suspected impaired perception and visual acuity. Consequently, occupational therapy was involved to create a basis of communication, to support functional initiation of upper limb movements, and to integrate perception-training into activities of daily living. Currently, the patient tolerates spontaneous breathing trials, shows signs of being alert during therapy, but cannot communicate. He is hemodynamically stable, even in an SOEB position, but remains functionally dependent (CPAx 6/50).