This 52-year-old male tested COVID-19 positive 4 days after the beginning of a dry cough, fever, and head and limb pain. One day later, he was hospitalized with exertional dyspnea. He was diagnosed with pneumonia that developed into moderate ARDS needing mechanical ventilation and intermittent dialysis. After extubation, oxygenation was stable with 2 to 3 L/min of oxygen. However, the patient was disoriented and could not communicate verbally. His global weakness (CPAx 11/50) was accompanied by oral and pharyngeal weakness and paresthesia. Spontaneous swallowing frequency and tongue control were severely reduced, and the patient showed insufficient protection from aspiration. This was confirmed by a specialized physical therapist with the Gugging Swallowing Screen, which confirmed severe dysphagia with 2/20 points. He was treated nil by mouth and received dysphagia therapy such as intensive oral stimulation, facilitation of swallowing, and training of protection mechanisms. After initial agitation and disorientation, the patient started to communicate in single-word phrases, but dysphagia continued to be severe with massive oral and pharyngeal dry saliva residuals that compromised his paresthesia and required regular mouth care. Over the next days, the patient managed to swallow pureéd food and mildly thick fluids under supervision, although cough strength was still weak (Gugging Swallowing Screen 13/20, CPAx 30/50). Nevertheless, he continued to progress and became capable of independent food ingestion (Gugging Swallowing Screen 20/20, CPAx 39/50) before his discharge to a rehabilitation clinic 25 days after admission.
One week after a positive COVID-19 result this 57-year-old male was admitted to the ICU because of oxygen desaturation (70%) with worsening tachypnea and dyspnea. Physical therapy started immediately after ICU admission. We found a highly dyspneic patient with a high breathing frequency and significant symptom exacerbation from the slightest effort. With hands-on physical therapy guidance, the patient managed to achieve a 135° prone position and to perform deep-breathing exercises resulting in an increase in oxygen saturation from 88% to 96%. Intensive physical therapy and positioning was continued along with 6 to 12 L/min of oxygen therapy over the next days and intubation was avoided. The major challenges in achieving a prone position were the patient’s profoundly reduced respiratory capacity and the high risk of exacerbating his symptoms. However, standard ICU monitoring enabled safe implementation at an individually adapted pace to allow sufficient time for convalescence. After 3 days with this regime, he could be transferred to the normal ward, where physical therapists carried on his rehabilitation with walking and strength training. The patient’s severe instability remained a challenge. Nevertheless, 9 days after ICU admission, the patient was able to leave the hospital as a pedestrian.