A Case Report on Pulmonary Rehabilitation for Post COVID-19 Patient with Pulmonary Fibrosis

Ershad Ali^1*, Forhad Hossain², Ehsanur Rahman¹ and Shofiqul Islam^1
*Correspondence: Ershad Ali, Department of Physiotherapy, Bangladesh Health Professions Institute, Tangail, Bangladesh, Tel: 8801689290303, Email:

Keywords

Coronavirus disease 2019 • Pulmonary fibrosis • Pulmonary rehabilitation

Introduction

Pulmonary fibrosis is the lung compliance characterized by a dry cough, weariness, dyspnea and in extreme cases the requirement for oxygen supplementation [1]. For patients with pulmonary fibrosis, lung auscultation may be normal or patchy with diffuse crackles [2].

The likelihood of spontaneous remission and the requirement for medication therapy of chronic fibrotic lung damage in post-COVID patients are currently being debated. Studies on a variety of respiratory illnesses, including influenza and atypical pneumonia show a strong correlation between viral damage to lung tissues, abnormal inflammatory response, the establishment of persistent lesions and the development of fibrosis [3].

It's also possible that the prolonged inflammatory response damages the vascular endothelium and epithelium of the respiratory tract, leading to tissue damage caused by cytokines. As a result, the restoration of normal breathing and lung tissue regeneration may be hampered [4]. TGF-1 and other growth factors (FGF, EGF) are upregulated followed by activation of pro-fibrotic pathways and an imbalance in the rennin-angiotensin system, all of which may contribute to the development of post-COVID lung fibrosis [5].

Pulmonary fibrosis is a medical disorder in which the lungs scar and breathing becomes more difficult as a result of different respiratory complications [6]. For the treatment of post-inflammatory COVID-19 lung fibrosis, there is currently no fully established rehabilitation strategy available. But the rehabilitation is important at the acute and especially recovery stage. It helps with breathing, exercise endurance, self-care in daily activities and psychological support. So, the aim of this study is to evaluate the effect of Pulmonary Rehabilitation on a single case of post-COVID-19 pulmonary fibrosis.

Case Presentation

Mr. X, a 70-year-old smoker male businessman lived in a village with his family members. He was admitted to Z.H Sikder’s Medical College and Hospital with symptomatic COVID-19 for 5 days. The diagnosis was based on a nasopharyngeal swab using the Reverse Transcription Polymerase Chain Reaction (RT-PCR) test for SARSCoV- 2 RNA and chest computed tomography (CT scan) (Figure 1).

Two days after admission, that is, 7 days after symptom onset, his dyspnea worsened and he required endotracheal intubation. He was subsequently placed on mechanical ventilation for 10 days and supervised physiotherapy care. On the 15^th hospital day his nasopharyngeal swab PCR test result turned negative and he was transferred from the intensive care unit to the general ward. The antibiotics and corticosteroids were stopped as the general condition improved. However, he required oxygen supplementation via nasal cannula with a flow of 22 L per minute of oxygen. The CT scan was advised by pulmonologist and diagnosed the patient with pulmonary fibrosis as subsequent complication of COVID-19 and advised him to continue the rehabilitation treatment. At the start point of rehabilitation clinician reassess on the basis of rehabilitation and functional status through developed assessment form and valid questionnaire (Figures 1 and 2, Tables 1-4).

Disability assessment: An interviewer administered questionnaire using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) (Table 5 and Figure 3).

I am now going to ask you about difficulties in taking care of yourself.

The answer and the scoring are as follows:

None=1, Mild=2, Moderate=3, severe=4, Extreme or cannot do=5

Domain 1: Cognition.

International classification of functioning, disability and health health condition

Intervention: The clinician decided to provide a conventional pulmonary rehabilitation program for post COVID-19 pulmonary fibrosis according to “evidence-based consensus statement on the role of physiotherapy in pulmonary rehabilitation in the indian context” [7].

The program consisted of 10 supervised physical therapy sessions according to frequency, intensity, time, and type principles: 5 days a week of frequency, 09 to 14 on borg Rating of Perceived Exertion (RPE) of intensity, 60 minutes per day of time, stretching, strengthening and aerobic exercises of type (Table 6).

^*For upper extremity strengthening, dumbbells were used. For lower extremity strengthening, Noland and Kuckhoff table with weights. SpO₂ was detected via pulse oximeter.

Discussion

Many pharmacological treatments have been challenged for postacute COVID-19 pulmonary fibrosis with confined evidence. Several narrative critiques are counseled on pulmonary rehabilitation program primarily based at the management guidelines of chronic obstructive pulmonary disease or different chronic pulmonary [8]. Thus, rehabilitation is gaining more importance. So far, no guidelines or systematic reviews of pulmonary rehabilitation for post COVID-19 pulmonary fibrosis. The authors found some case study but didn’t offer the details information of the rehabilitation program. In this case, we provided a preferred and structured exercising program with monitoring followed by “evidence-based consensus statement on the role of physiotherapy in pulmonary rehabilitation in the indian context”. In general, pulmonary rehabilitation for lung fibrosis decreases dyspnea and improves exercising ability and quality of life [9,10].

In addition to active drug treatment, it is equally important to minimize the respiratory symptoms and associated complications to improve the quality of life of patients and such patients should actively carry out rehabilitation interventions to reduce morbidity and mortality. To the point of explicit and tacit knowledge this is the report of a successful attempt at the rehabilitation of post COVID-19 Pulmonary fibrosis. The steady but progressive response of the patient to treatment was novel in the authors opinion. The unique presentation makes this case noteworthy with respect to detailed timing of the events.

As the patient, initially present with depressed level of cognition and additional symptoms onset of dyspnea, chest tightness, respiratory distress, and fatigue, and impaired mobility, difficulty with coordinated and balanced posture. He was treated under the supervision of a physiotherapist with an exercise program with stretching, strengthening, breathing and aerobic exercise with cardiorespiratory care according to FITT and the intensity measured by Borg Rating of Perceived Exertion (RPE). Physiologically, breathing exercises lift the abdomen and chest cavity and cause an increase in intra-thoracal pressure. Deep and long inspiration will induce surfactant secretion produced by alveolar type II and increase chest expansion 10. Following the initial path-gnomonic symptoms described, he gradually displayed improvement and ultimately making a remarkable symptomatic and functional recovery by one and half months with rehabilitation management.

From the point of patient and his career, he is now much better than previous. Now he is happy to share his feeling to walk independently and performing Activity of Daily Living (ADL) without minimal support or supervision. According to the patient’s career opinion they are very much thankful to the clinician who were involve in the management of such critical case with care and professionalism. Author could conclude that the report had a favorable outcome following the management of post COVID-19 pulmonary fibrosis through gradual physiotherapy treatment.

Conclusion

This case reported post COVID-19 pulmonary fibrosis with severity of symptoms and the evidence encouraged the medical management as well as early care of physical therapy and the optimal nutritious support. The incremental advancements in the mental and the functional capacity may take months to be noticed from the various evidence and from the case. Chest therapy, breathing exercise, aerobic exercise and specific rehabilitation for patients with post COVID-19 pulmonary fibrosis may improve the dyspnoea, chest discomfort, fatigue, poor transitional mobility, uncoordinated movement and gross motor function of patients and significantly restore activities of daily living. The expert practioner explosively suggested that early care and physiotherapy treatment with proper medication are the possible standard for the management and improvement of such respiratory disorder. Future studies in the form of well-designed, randomized clinical trials should be performed to evaluate the effectiveness of physiotherapy and rehabilitation management for patients withpost COVID-19 pulmonary fibrosis. This is critical information for rehabilitation practitioner that has been determined to be successful in patients with post COVID-19 pulmonary fibrosis.

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