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.
This 77-year-old male patient was transferred to our ICU 1 week after his COVID-19 diagnosis due to continuing respiratory decompensation requiring intubation. Following the acute phase, with intermittent proning, the patient continued to be hemodynamically unstable and was difficult to wean. Rehabilitation proved challenging under these conditions, and physical therapists had to reevaluate and adapt their interventions daily according to his condition. After 2 weeks, he was tracheotomized and started to improve very slowly. One week after tracheostomy, the patient was able to speak for the first time after a cuff-down trial and with the help of a speaking valve. But the patient spoke only a few words with us and it was often difficult to involve him in exercises. Two days later, he was able to communicate with his relatives via video telephony. This was a very emotional moment for everyone involved, but it improved his communication and he was able to express to his wife that he had no strength left to continue. However, through the family’s active participation in his early rehabilitation process, they were able to reinforce his confidence and motivation. He was discharged to a rehabilitation clinic severely weak (MRC-SS 40/60) and functionally impaired (CPAx 22/50), but continued to progress in slow steps.