This 60-year-old male was hospitalized due to moderate ARDS from COVID-19 with symptoms of fever, dry cough, and dyspnea. We encountered several difficulties during physical therapy on the acute ward. First, any change of position or deep breathing triggered coughing attacks that induced oxygen desaturation and dyspnea. To avoid rapid deterioration and respiratory failure, we instructed and performed position changes very slowly and step-by-step. In this way, a position change to the 135° prone position () took around 30 minutes. This approach was well tolerated and increased oxygen saturation, for example, on day 5 with 6 L/min of oxygen from 93% to 97%. Second, we had to adapt the breathing exercises to avoid prolonged coughing and oxygen desaturation. Accordingly, we instructed the patient to stop every deep breath before the need to cough and to hold inspiration for better air distribution. In this manner, the patient performed the breathing exercises well and managed to increase his oxygen saturation. Third, the patient had difficulty maintaining sufficient oxygen saturation during physical activity. However, with close monitoring and frequent breaks, he managed to perform strength and walking exercises at a low level without any significant deoxygenation. Exercise progression was low on days 1 to 5, but then increased daily until hospital discharge to a rehabilitation clinic on day 10.
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.