Author: G.Guido Rodriguez PT, RT with the participation of Calvin Weaver PTA and the collaboration of George A. Purcelley PT, DPT, GCS, WCC, CEEAA
We are living in unprecedented times pulling through a pandemic.
Even more, the role of physical and occupational therapy has been conflicted regarding the treatment of elderly patients with COVID 19.
Ever changing regulations, as well as the overall lack of medical guidance, leaves us with an unclear treatment plan of COVID19 patients.
COVID-19 has affected the global population at every level of healthcare. It has saturated our hospitals, urgent cares, canceled nonessential surgeries, and more.
However, one of the most vulnerable populations we serve in this country, which frequently housed skilled nursing facilities, assisted living facilities, and senior living communities have been greatly struck by this virus.
Unfortunately, COVID-19 has demonstrated a high rate spread and is easily transferred in these settings. The death rate and outbreaks at these facilities will continue to grow as this virus spreads across our country.
Over the past three weeks, I have been involved in the direct care of patients in isolation with active COVID-19 symptoms in the skilled nursing setting.
I would like to share some insights and strategies about providing physical therapy care to these patients.
Unfortunately, at this time, there are minimal guidelines for providing direct rehabilitation services to COVID patients. The main focus has been preventing propagation, and there has been minimal to and, in some facilities, no therapy involvement.
Among the common symptoms of COVD-19, dry cough is frequent. However, in patients with underlying respiratory conditions, acute exacerbation of symptoms with increased mucus production in the lungs was observed.
Prior consultation with Drs and nurses and after establishing clinical priorities, only those patients presenting with rapid physical decline and/or with exudative consolidation, mucous hypersecretion, and/or difficulty clearing secretions were assessed to determine whether therapy, in general, will help facilitate better fighting changes against this disease.
What have I seen?
After screening multiple patients in their late 70s and 80s with severe respiratory compromise, I noticed various clinical and general aspects where these patients will benefit from therapy services.
All patients seen were in isolation. (Isolation precautions, Droplet isolation precautions, including Standard PPE, gown, gloves, N95 mask, face shield, hair cover and shoes impermeable to liquids used)
- Increased general weakness with decreased general mobility and poor repositioning abilities.
- Fluctuating level of alertness and confusion.
- Fluctuating fever
- Multiple clinical presentations, with typical mild to severe respiratory insufficiency.
- Increased sputum production with decreased efficiency to expectorate, particularly, those patients with comorbidities and/or prior underlying respiratory conditions (COPD, Asthma, etc.)
- Fluctuating alertness, preventing patients from drinking water, or asking for care services.
- High volumes of supplemental O2 via nasal cannula with inadequate humidification.
- Lack of respiratory therapists due to ancillary staff not being able to enter the facility and that the overfilled hospitals are utilizing them.
What can be done?
Screening and assessments were performed on multiple patients. Each patient presented with varying severity of symptoms from COVID-19. However, the need for skilled therapy services was significant. Below is a list of typical assessments and treatments I performed during my evaluations.
- Assess functional mobility, strength, and level of alertness in order to anticipate the feasibility of CPT (Chest physical therapy)
- Assess respiratory function, via auscultation identity Phlegms (rhonchi/rales) as well as location.
If secretions are found, have the patient wear a mask as much as possible and start working on bronchial hygiene using CPT, including postural drainage with clapping, percussion, and vibration, as well as assisted expiration and forced coughing to facilitate expectoration of sputum.
- Focus on treating severe deconditioning, if the patient does not present increased lung secretion production. Use incentive spirometry to improve inspiratory volume.
- Use pulse oximetry and lung auscultation through the session
- Aerosol generating procedures (AGPs) are believed to create an airborne risk of transmission of COVID-19, consult with the physicians to assess risk/benefit regarding the use of nebulization with saline solution, since this would be an optimal intervention to significantly improve moisturization of phlegms before CPT in patients with increased sputum production.
- The utilization of a PARI Filter/Valve or the Aeroeclipse Breath Actuater Nebulizer is strongly recommended to minimize the amount of aerosol that would otherwise enter the environment.
- Current APTA recommendations in this regard are based in Australian-based guidelines that state; “If aerosol-generating procedures (AGPs) are required, they should be conducted in a negative-pressure room, or at least in a single room with the door closed, with a minimum number of staff, all wearing PPE.
- Coming and going should be minimized during the AGP”. PTs should not implement AGPs, including humidification or noninvasive ventilation, without first obtaining agreement with a “senior doctor”.
Practice Guidelines Emerge for Physical Therapy and COVID….https://www.apta.org/PTinMotion/News/2020/03/26/AcuteHospitalCOVIDGuidelines/?blogid=10737418615
- If CPT is not possible, consider the use of oscillatory PEP, such as a Blue/Green Acapella device; it can be paired inline with a viral-bacterial filter if such filter is not available wrap a standard surgical mask at the end of the device to minimize exposure.
- If possible, have the patient in a sitting position and work with incentive spirometry in order to improve lung capacity. Keep in mind that deep breathing and intermittent positive-pressure breathing exercises could be equally effective “but not measurable.” making it difficult to assess progress.
- Provide therapeutic exercises and activities as needed to decrease the risk of developing or progression of significant functional limitations and weakness, particularly patients with multiple comorbidities.
- Educate patients about disease process, therapy interventions, and goals.
- Coordinate services: this health crisis has provoked a shortage in medical personnel available with an increasing number of rotating agency medical staffing; this presents an alteration in the coordination of services, and therapists may contribute significantly to facilitate proper care. (e.g., facilitate hydration, repositioning, nutrition, check equipment, etc.)
- Establish a repositioning frequency schedule, to preserve skin integrity as well as prevent positioning lung mucus condensation, educate nursing. When the patient is in supine, thorax angulation is recommended to be >30°, this is associated with improvement of functional residual capacity (FRC), better oxygenation and reduction of work of breathing.
Identify increase risk for skin integrity issues and fall prevention, assess the need for devices (e.g., air mattress, positional bolsters, crash mats)
Documentation for these services needs to include the following:
Regular rehab documentation does not typically address cardiorespiratory components. I have attached basic examples below to demonstrate documentation while following insurance guidelines with skilled and measurable comments and goals.
The evaluation should be completed as you usually would. However, you need to add more detailed information on the cardiopulmonary assessment section or the clinical impressions section of most evaluation templates in Rehab Optima
(e.g., The patient is in isolation with COVID-19. He presents with increased fatigue, decreased strength, decreased functional mobility, intermittent somnolence, decreased endurance, and balance.
Upon lung auscultation, he presents disseminated rhonchi, wheezing sounds, and decreased ability to expectorate.
Pulmonary physical therapy and breathing training recommended being the primary interventions, in order to improve mucociliary clearance and ventilatory efficiency to minimize the effects of COVID).
Since respiratory goals notes are not common in physical therapy documentation, I again have provided some samples below on how to create standard and measurable goals, which are often required by insurances.
When addressing functional mobility and strength goals, those goals should remain the same as you have written them before.
However, goals related to respiratory rehab may emphasize pulmonary capacities as well as clinical findings with auscultation.
You can utilize the predictive nomogram of inspiratory capacity chart that comes with each incentive spirometry unit to familiarize yourself with standard values.
Added respiratory goals for physical therapy should be STGs and predict improvement in an increment of 25-30% from baseline incentive spirometry and auscultation results if phlegms are present.
- Patient to improve inspiratory capacity by achieving 750ml with an incentive spirometer in order to improve pulmonary function after a debilitating pulmonary disease.
- Patient to demonstrate diminished to no acute pathological breath sounds with minimal to no productive cough.
I have added an example of a daily note which is required by most facilities to maintain compliance for insurances. When billing the respiratory component of your treatment can be billed under Therapeutic Activities.
- (e.g., patient continues in isolation with COVID-19 she is up in her W/C upon therapist arrival to her room. Initial O2 sat was 92% on % liters of supplemental O2, HR 92bpm, and 20 RR.
Scattered Rhonchi and rales found upon chest auscultation mostly noticed on expiration.
Patient transferred to bed with FWW/Mod A, undergoing postural drainage in multiple positions, along with percussion and vibration with forced expiration techniques.
Patient assisted to sit at EOB to perform forced expiration followed by forced coughing, facilitating moderate expectoration of sputum.
Patient performed incentive spirometry, obtaining up to 850ml of inspiratory volume. Final auscultation completed finding only rales sound at the base of the lungs. O2 sat 97%, HR 88bpm, and RR 18. Patient educated regarding the use of her Acapella OPEP device and instructed to use it for 15 minutes up to 4 times daily.)
- Facilities will benefit from organizing separate teams for COVID-19/ recovered COVE versus noninfectious patients.
- Establish early rehabilitation interventions strategies
- Organize meetings/inservices with the therapy team, determine clinical weaknesses/strengths to treat COVID patients.
- Refresh cardiopulmonary knowledge for therapists, including familiarization with auscultation techniques, findings and CPT.
- Identify or consult with therapists with advanced cardiopulmonary skills to determine an approach to screen/treat patients with COVID-19.
- Prepare for recovered COVID patients addressing residual decreased pulmonary function, as well as general functional mobility issues.
- Prepare for the possibility of a second wave of infection.
- Obtain grief counseling services to therapists to address grieving multiple deaths.
Keep in mind that due to the COVID crisis, many devices are in high demand.
- A good stethoscope. Many therapists are not familiar with the use of such a device; a cheap one will not provide the sound quality needed for a proper assessment, “particularly if you are new to it.” I have two favorites for affordability and quality; one is the 3M Littman Classic III 5803, and the MDF Acustica dual-head, all black. You can get more expensive ones but it is not necessary.
- A suitable pulse oximeter, I prefer one with a hospital-grade quality provides SpO2 level, pulse rate, and perfusion index with a plethysmograph on a customizable LED display.
- Scrubs are absolutely necessary, they are manufactured in such a way that they do not collect much dirt, easy to wash to promote good hygiene. I would recommend to also wear a moisture-wicking tee, keep in mind that with all the PPE in an isolated room with an O2 concentrator, you will sweat. Here are some ideas; Scrubs for women, Scrubs for men.
- Water-resistant closed in shoes. You will need something comfortable, that you can sanitize at the end of the day. Here are some ideas: Medical shoes for women, Medical shoes for men.
- PARI Filter/Valve , the Aeroeclipse II Breath Actuater Nebulizer or Teleflex Medical Inc ISO-NEB Filtered Nebulizer System. If nebulization is going to be provided, these devices will minimize the risk of propagation via aerosol.
- Oscillating PEP devices. There are multiple options. The one that I have used the most is the Acapella Green for adults or the Acapella Blue, which is more for pediatric or for those with lower expiratory flows, age, or size. Another good one is the Aerobika; this one can be paired inline with the AeroEclipse Breath Actuated Nebulizer, make sure the canister is in breath-actuated mode to minimize aerosolization of the environment.
- Incentive spirometer: any 2500ml incentive spirometer will suffice.
Working in healthcare and following the news you know it is only a matter of time before you come into contact with a COVID positive patient.
Despite doing all the right things to prevent the virus from entering your facility, such as the screenings, cutting off visitors, canceling activities, keeping residents isolated in rooms, it can still get in.
From the moment you get your first positive test, you will have a rush of emotions. As therapists, you first think to yourself why are we still here, we are not “essential”, we have nothing to offer these patients.
As a human, one of your first reactions would be to you think about, your family, and your wellbeing, and THAT’S OK! It’s a natural human instinct to protect yourself and loved ones first.
Then COVID strikes hard, with multiple people getting infected quickly with many of them losing the battle against it.
Having witnessed the devastation, this virus can have first hand, that feeling will only last so long.
You see, patients that you consider to be your friends through years of working together succumb to the virus; you see the grief of family members, staff, and most of all, you feel the toll this virus has had on you emotionally and physically.
You are unable to truly grieve as you have to continue to work and help the patients that remain in your care. When you reach that point, you want to help. You want to do everything in your power to help these people that we took an oath to serve.
Because of my background in respiratory, I switched gear and started looking at this from a different angle, processing the critical situation differently than most therapists would.
So, part of the intention of writing this article was motivated by saving you, processing time, provide you with some clinical views and treatment insights, and assure you, that elderly patients with COVID-19, really need your clinical skills to increased survival rate.
Utilize your skills and the skills of those therapists around you to form a plan and act quickly, don’t hesitate. Use the information and knowledge that I have laid out for you to help your building stand a better chance against this virus.
Keep in mind that if you face a significant outbreak, you won’t be able to help everyone, so…, take a moment, think about your purpose helping these patients, regroup, gear up and continue your fight!!
Thanks for taking the time and read this article about Physical Therapy to elderly patients with COVID-19, please leave a comment below and share this with a physical therapist who may need this information.