This 57-year-old male was admitted to the ICU with dyspnea, heavy dry cough, and fever 6 days after testing positive for COVID-19. Initially, he was able to exercise and sit in a chair with a physical therapist, but progressive respiratory failure necessitated intubation and proning. The patient had large amounts of bronchial mucus and required regular suctioning along with respiratory therapy. Secretions were assessed with pulmonary auscultation (presence of crackles) and by analyzing expiratory flow on the ventilator (sawtooth pattern). When suctioning failed to improve these clinical signs, 1 to 2 physical therapists used manual airway clearance techniques. The goal of these techniques was to sufficiently increase expiratory flow for effective airway clearance while avoiding alveolar collapse. To achieve this, manual compressions on the chest and abdomen were performed with just enough intensity to modify expiratory flow. After extubation, the patient was still unable to effectively clear his mucus due to weak cough. He continued to need intensive manual airway clearance techniques, nasal rinsing to induce cough and to help expectoration as well as upper and lower airway suctioning. To this end, the patient was treated up to 6 times per day/night. Additional physical therapist interventions included passive range of motion, assisted exercising, and mobilization. At the time of writing, the patient was still in the ICU without ventilatory support.
This 69-year-old male was admitted to the ICU after a dry cough for 2 weeks, oxygenation was poor and computer tomographic imaging showed typical COVID-19 pneumonia. Initially the patient received lung-protective ventilation and targeted sedation, but was otherwise stable. Treatment interventions included passive range of motion and positioning including passive mobilization into a side-edge position (). Over the next days, the patient deteriorated with hemodynamic instability and severe ARDS leading to intermittent prone positioning and continuous renal replacement therapy. The role of physical therapists during proning was to ensure correct joint positioning and pressure prophylaxis to prevent secondary complications such as nerve lesions, contractures, or pressure ulcers. Nevertheless, the long duration and repeated positioning resulted in a small pressure ulcer on the patient’s forehead. After tracheostomy, passive range-of-motion exercises, and passive side-edge mobilization were slowly resumed, whereby asynchronous ventilation and hemodynamic instability remained 2 major problems leading to further sedation and relaxation, thus inhibiting any active participation. After 24 days in the ICU, the patient scored 1/50 points on the Chelsea Critical Care Physical Assessment Tool (CPAx) and showed severe signs of muscle loss. The patient died soon after withdrawal of life support.