According to a recent Harvard Health Blog published on the Harvard University website, clinical studies and surveys conducted by patient groups suggest 50% to 80% of people who recover from a bout of COVID-19 will continue to have troublesome symptoms three months after the initial onset of the disease. Called “long-haulers” by many, these pandemic survivors complain of fatigue, body aches, difficulty concentrating, an inability to exercise, headache, difficulty sleeping, and — yes — shortness of breath.
It is the last symptom that is sending many of them to pulmonary rehabilitation (PR) programs. Respiratory therapists are now exploring their options for including them in programs typically set up to care for people with COPD and other chronic lung conditions.
Two distinct groups
Kimberly Hunchuk, MEd, RRT, RPSGT, CTTS, CPFT, works at Sharon Regional Medical Center in Sharon, PA, where they recently reopened their pulmonary rehabilitation program after being shut down for nearly a year due to the pandemic. So far, she has only worked with a handful of patients with what they are calling “Post-Covid Syndrome,” but several things stand out from the experience.
“We are seeing two distinct groups,” she said. “People who may have had some previously undiagnosed and/or under-treated pulmonary disease prior to contracting COVID, and the patients who were perfectly healthy pre-COVID and are now suffering a variety of symptoms, especially exertional dyspnea and tachycardia — POTS like — and subsequent fatigue.” Either way, she believes these patients are a good fit for pulmonary rehabilitation because the clinicians who work in these programs are well trained in helping patients manage their dyspnea. They understand the value of pacing and interval work/rest with exercise.
She also believes PR delivers the kind of softer support services these patients may need, again because what they need is similar to what patients with COPD need.
“Like our COPD patients who do not require continuous oxygen, the COVID survivors usually appear healthy and well while sitting and doing nothing,” Hunchuk said. Since they often don’t look sick and don’t require a visible sign of disability like a cane or a wheelchair, their conditions can be overlooked or misunderstood. “The emotional and psychological support provided in pulmonary rehab may be of even greater importance for our younger COVID survivors,” she said.
Despite the similarities she sees with other chronic respiratory disease patients, though, Hunchuk emphasizes long-haul COVID-19 patients have some unique characteristics. In particular, she notes a growing concern that patients who push too hard in their recovery may end up with a cytokine exacerbation that makes things worse.
“So I am trying to rest the patient an equal number of minutes as they work with each activity,” she said. She’s also seen some patients who improved dramatically after receiving a COVID-19 vaccination. That has made her wonder if the vaccine might be triggering their immune system to reorganize and work properly again.
Regardless, she firmly believes pulmonary rehabilitation will be vital in managing ongoing symptoms for many survivors.
“I have no doubt that we can help these patients, whether the damage is temporary or permanent,” she said.
Get the patient involved in his care
Laura Frantzen, RRT, is the lead pulmonary rehabilitation therapist at Mary Greeley Medical Center in Ames, IW. She has seen one patient so far who came to her program after spending several weeks on the hospital’s non-critical COVID-19 floor.
The man was discharged on oxygen and has gone through 12 sessions in the program.
“Although we have put him through the program in basically the same way as our other patients, I have focused discussions with him on his oxygen needs and whether he will be able to get off it,” Frantzen said. ”We also taught him PLB, and we encourage him daily to use it to help improve oxygenation.”
The patient feels stronger, but his oxygen needs still vary depending on what he is doing, such as trying to talk and walk on the treadmill at the same time while not concentrating on his PLB. She has had many discussions with him about whether or not his lungs will ever fully recover. She has suggested he try a smaller concentrator to resume his normal activities, including playing golf. When asked how best to handle these types of patients, Frantzen simply said, “The short answer is to discuss and brainstorm with each patient based on their individual needs.”
She believes RTs in her PR program are right for the job. Not only do they have a wealth of experience working with other chronic lung disease patients, but all three of them also work in critical care, so they know firsthand what kinds of treatments many of these patients have endured.
“We develop relationships with the patients and are eager to see them continue to get better,” she said.
Positioned for success
At Sanford Medical Center in Fargo, ND, respiratory care services include a section on disease management that covers hospital inpatient and outpatient services in diagnostics, rehabilitation, and patient education/navigation.
Becky Anderson, RRT, manager of disease management for the department, says that has positioned them well to get actively involved in the care of COVID-19 long-haulers. Their pulmonary diagnostics section has provided post-COVID testing for several months now, with many of those tests indicating a restrictive-type disease. Two months ago, the hospital implemented a pulmonary rehabilitation specialty program to provide rehabilitation for post-COVID patients.
“The target population is patients who were hospitalized for COVID-19, were discharged with and continue to need home oxygen, and/or who exhibit deconditioning that impacts ADLs,” Anderson said. Their primary care providers must clear patients before they can attend the program. The program supervisor, Val Tomhave, RRT, has visited with the hospital’s pulmonology, internal medicine, and family medicine providers to advise them of the service.
Anderson gives Tomhave much of the credit for getting the program up and running.
“She gained medical director support, reconfigured patient and staff scheduling to support COVID-19 sessions four days per week, and identified patient education materials,” she said. “She will continue to lead the way as we standardize these services across our organization.”
In addition to these efforts, Sanford pulmonologists are developing a COVID-19 service that will come under the ambulatory Coordinated Treatment Center. Anderson expects both pulmonary rehabilitation and pulmonary diagnostics to be a part of that care team as well.
She is not surprised by how quickly RTs have been pulled into these post-COVID initiatives.
“Respiratory therapists are the experts at providing care for people with acute and chronic pulmonary disease,” she said. “As the picture of post-COVID becomes clearer, we find that our past experiences give us an exceptional foundation from which to serve these patients.”
We have a plan
According to Teena Culhane, BHK, RRT, pulmonary rehabilitation program coordinator at Beaumont Health and Wellness Center in Royal Oak, MI, a handful of patients initially referred to the hospital’s outpatient neuro physical therapy (PT) program following a lengthy stay for COVID-19 have been transferred to pulmonary rehabilitation once PT deemed them strong enough to take part in the program.
“Unfortunately, during those few situations, we were not consulted until the patient was nearing the end of their therapy, and it was apparent that they still needed some form of therapy for residual shortness of breath/deconditioning,” she said. The two programs put their heads together and came up with a solution.
The team decided that if a patient is referred to PT and the diagnosis is post-COVID, a request will be made for a pulmonary rehabilitation consultation. Each consultation will include —
- A six-minute walk test. If the patient has a supplemental oxygen device, they are asked to bring their device with them when they come for the consult to determine if it meets their needs.
- A recommendation for a pulmonologist if needed to recommend/facilitate the ordering of PFTs if needed to determine eligibility for PR.
- An assessment for PR eligibility. The patient will need to ambulate independently to all machines, transfer on and off without assistance, and be independent with their ADLs.
Culhane and her colleagues believe this system will serve them well as more and more patients present with long-term needs following a bout of COVID-19.
Ready, willing, and able
Indeed, much work remains to determine how best to care for COVID-19 patients who continue to suffer from symptoms many weeks or even months after recovering from the illness’s acute phase. The medical community still isn’t even sure what to call these survivors, although the Harvard Health Blog notes the NIH has proposed an official name: post-acute sequelae of SARS-CoV-2 infection, or “PASC” for short. A formal definition is yet to come, but whatever the result is, it is clear that many of these patients will need some form of pulmonary rehabilitation to regain their quality of life. Respiratory therapists stand ready to do their part.