COVID Reflections/moving forwards @TheACPRC course
My learning points https://abs.twimg.com/emoji/v2/... draggable="false" alt="🤓" title="Nerd-Gesicht" aria-label="Emoji: Nerd-Gesicht">
THREAD (long)https://abs.twimg.com/emoji/v2/... draggable="false" alt="⤵️" title="Nach rechts zeigender Pfeil mit Krümmung nach unten" aria-label="Emoji: Nach rechts zeigender Pfeil mit Krümmung nach unten">
Huge thank you to all the speakers and for putting on a great webinar https://abs.twimg.com/emoji/v2/... draggable="false" alt="🙏🏼" title="Folded hands (mittelheller Hautton)" aria-label="Emoji: Folded hands (mittelheller Hautton)">
Looking forward to putting into practice with @RBH_ICU_Physio & @GoPerformUK
Intubation & Ventilation https://abs.twimg.com/emoji/v2/... draggable="false" alt="🖥" title="Desktop-Computer" aria-label="Emoji: Desktop-Computer">
- Different phenotypes = different results
- Tracheostomy in 14 days decreased ICU stay
- Physio important in ICU Mx - sputum/trache’s https://abs.twimg.com/emoji/v2/... draggable="false" alt="💦" title="Schweißtropfen" aria-label="Emoji: Schweißtropfen">
- 2nd wave showing reduced I&V patients https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌊" title="Wasserwelle" aria-label="Emoji: Wasserwelle">
NHF
- reduces WOB, bronchospasm, helps AWC https://abs.twimg.com/emoji/v2/... draggable="false" alt="💦" title="Schweißtropfen" aria-label="Emoji: Schweißtropfen">
- Flow is key https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔑" title="Schlüssel" aria-label="Emoji: Schlüssel"> 10L/min = 1cm PEEP
- Prescribe FiO2 & Flow ranges https://abs.twimg.com/emoji/v2/... draggable="false" alt="📈" title="Tabelle mit Aufwärtstrend" aria-label="Emoji: Tabelle mit Aufwärtstrend">
- Start at 40% : 40L/ min
- Combo with proning
- AGP issues ? face mask https://abs.twimg.com/emoji/v2/... draggable="false" alt="😷" title="Gesicht mit Mundschutz" aria-label="Emoji: Gesicht mit Mundschutz"> with NHF but tolerance issues
- 5% wean at a time
CPAP
- early response & break behaviour can be key predictors
- Don’t rush weans
- Careful monitoring https://abs.twimg.com/emoji/v2/... draggable="false" alt="📊" title="Balkendiagramm" aria-label="Emoji: Balkendiagramm">
- MDT approach: all onboard to help patient compliance https://abs.twimg.com/emoji/v2/... draggable="false" alt="👩🏼‍⚕️" title="Woman health worker (mittelheller Hautton)" aria-label="Emoji: Woman health worker (mittelheller Hautton)">https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧑🏾‍⚕️" title="Health worker (durchschnittlich dunkler Hautton)" aria-label="Emoji: Health worker (durchschnittlich dunkler Hautton)">https://abs.twimg.com/emoji/v2/... draggable="false" alt="👩🏿‍⚕️" title="Woman health worker (dunkler Hautton)" aria-label="Emoji: Woman health worker (dunkler Hautton)">https://abs.twimg.com/emoji/v2/... draggable="false" alt="👨🏻‍⚕️" title="Man health worker (heller Hautton)" aria-label="Emoji: Man health worker (heller Hautton)">
- Bridge to I&V in severe ARDS
Conscious proning https://abs.twimg.com/emoji/v2/... draggable="false" alt="🛌" title="Übernachtungsmöglichkeit" aria-label="Emoji: Übernachtungsmöglichkeit">
- encourage long durations
- Improvements in VQ https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧽" title="Sponge" aria-label="Emoji: Sponge">
- Reduction in regional HI lung injury
- Semi prone can still be beneficial https://abs.twimg.com/emoji/v2/... draggable="false" alt="🙇‍♂️" title="Mann verbeugt sich tief" aria-label="Emoji: Mann verbeugt sich tief">
Cognition https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧠" title="Gehirn" aria-label="Emoji: Gehirn"> 1/3
- symptoms include brain fog https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌫" title="Nebel" aria-label="Emoji: Nebel">, attention issues, memory & planning issues
Why?
1) no clear evidence on direct affect on brain cells https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧠" title="Gehirn" aria-label="Emoji: Gehirn">
2) Impact of pandemic https://abs.twimg.com/emoji/v2/... draggable="false" alt="🦠" title="Microbe" aria-label="Emoji: Microbe"> - social/physical isolation, reduced stimulation, stress/anxiety/depression, post viral fatigue
3) Critical care - PICS, linked to longer periods of ICU delirium, 1/3 are similar impact as mod TBI, effected long after d/c
- Management - recognition, fatigue Mx, pacing, sleep https://abs.twimg.com/emoji/v2/... draggable="false" alt="💤" title="Schlafsymbol" aria-label="Emoji: Schlafsymbol">hygiene, relaxation https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧘🏼‍♀️" title="Frau im Lotossitz (mittelheller Hautton)" aria-label="Emoji: Frau im Lotossitz (mittelheller Hautton)">, reassurance of improvement, Neuropsych input?
2/3
- OT importance in MDT https://abs.twimg.com/emoji/v2/... draggable="false" alt="❗️" title="Rotes Ausrufezeichen" aria-label="Emoji: Rotes Ausrufezeichen">
- COVID PR ? Have cognition education session?
http://www.yourcovidrecovery.nhs.uk"> http://www.yourcovidrecovery.nhs.uk 
3/3
Your COVID Recovery

An NHS resource to support your recovery after COVID-19.

http://www.yourcovidrecovery.nhs.uk
Brachial Plexus Injuries 1/3 @PhysioPhil2
- Neuropathic pain is key indicator https://abs.twimg.com/emoji/v2/... draggable="false" alt="💥" title="Symbol für eine Kollision" aria-label="Emoji: Symbol für eine Kollision">
- Supra clavicular injuries from neck SF & shoulder depression
- Infra clavicular from GHJ Abduction
- Mechanism from squashing & traction over 10% (fibula head area compression - drop foot - common peroneal nerve) https://abs.twimg.com/emoji/v2/... draggable="false" alt="🦶" title="Foot" aria-label="Emoji: Foot">
- Evidence of GHJ dislocation on CXR
- Brachial plexus more common with triple threat co-morbidity (T2DM, HTN, Obesity) 2/3
- Prone positioning - use guidance for handling & GHJ alinement e.g support chest, rotate head towards abducted arm https://abs.twimg.com/emoji/v2/... draggable="false" alt="🏊🏼‍♀️" title="Schwimmerin (mittelheller Hautton)" aria-label="Emoji: Schwimmerin (mittelheller Hautton)">
- Referral to PNI unit with neuropathic pain or local ortho unit https://abs.twimg.com/emoji/v2/... draggable="false" alt="🦴" title="Bone" aria-label="Emoji: Bone"> 3/3
Psychology https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧠" title="Gehirn" aria-label="Emoji: Gehirn"> 1/3
- PICS - 50% PTSD/Anxiety/Depression (pre C-19) & 25% cognitive impairment
- -“waking to an alien world”https://abs.twimg.com/emoji/v2/... draggable="false" alt="👽" title="Außerirdischer" aria-label="Emoji: Außerirdischer"> - PPE https://abs.twimg.com/emoji/v2/... draggable="false" alt="😷" title="Gesicht mit Mundschutz" aria-label="Emoji: Gesicht mit Mundschutz">, lack of family input & dehumanisation of ICU
- Prolonged sedation & delirium https://abs.twimg.com/emoji/v2/... draggable="false" alt="💊" title="Tablette" aria-label="Emoji: Tablette">
- Media coverage https://abs.twimg.com/emoji/v2/... draggable="false" alt="🎥" title="Filmkamera" aria-label="Emoji: Filmkamera"> increased fear but better understanding of critical care
- Fatigue & physical limitations impacting mood https://abs.twimg.com/emoji/v2/... draggable="false" alt="😓" title="Gesicht mit kaltem Schweiß" aria-label="Emoji: Gesicht mit kaltem Schweiß">
- Fear & uncertainty https://abs.twimg.com/emoji/v2/... draggable="false" alt="😖" title="Verblüfftes Gesicht" aria-label="Emoji: Verblüfftes Gesicht">
- PTSD - HPA axis -flight or flight on overdrive https://abs.twimg.com/emoji/v2/... draggable="false" alt="😱" title="Vor Angst schreiendes Gesicht" aria-label="Emoji: Vor Angst schreiendes Gesicht">
- Humanise at any opportunity - rehab consistency/focus & f/u 2/3
- Staff impact - PPE https://abs.twimg.com/emoji/v2/... draggable="false" alt="🥽" title="Goggles" aria-label="Emoji: Goggles"> big predictor of stress, HPA axis & lack of social interaction. Mental health issues mirrors pt’s with PTSD, anxiety & depression https://abs.twimg.com/emoji/v2/... draggable="false" alt="👩‍🚀" title="Woman astronaut" aria-label="Emoji: Woman astronaut">
- Help! - focus on what’s within your control, self care, mini debriefs - acknowledge we are only human https://abs.twimg.com/emoji/v2/... draggable="false" alt="👼🏻" title="Babyengel (heller Hautton)" aria-label="Emoji: Babyengel (heller Hautton)"> 3/3
UHS reflections https://abs.twimg.com/emoji/v2/... draggable="false" alt="🏥" title="Krankenhaus" aria-label="Emoji: Krankenhaus"> 1/3
- SLACK channel to share info
- Chest Physio - positioning, VHI (slow ins), ins holds, Manual Techs (inc cough) https://abs.twimg.com/emoji/v2/... draggable="false" alt="💦" title="Schweißtropfen" aria-label="Emoji: Schweißtropfen">
- Proning teams - who in the MDT?
- Tracheostomy - mixed duration
- Rehab - delayed, but stable enough. Reduced endurance & needing highest level of their current vent support https://abs.twimg.com/emoji/v2/... draggable="false" alt="😓" title="Gesicht mit kaltem Schweiß" aria-label="Emoji: Gesicht mit kaltem Schweiß">
- Delirium increased - issues with double bed space, difficult to vent & needing Midaz sedation, family video calls, about me forms, rehab diaries https://abs.twimg.com/emoji/v2/... draggable="false" alt="📱" title="Mobiltelefon" aria-label="Emoji: Mobiltelefon"> 2/3
- Ward follow ups and virtual/phone call follow ups
- Team debriefs, team working 3/3
#LongCovid https://abs.twimg.com/emoji/v2/... draggable="false" alt="🔋" title="Batterie" aria-label="Emoji: Batterie"> 1/4
- 10% post COVID
- Can Overlap into CFS & ME
- 80% non hospital admissions, typical age 30-50 years old & moderate - highly physically active https://abs.twimg.com/emoji/v2/... draggable="false" alt="🏃🏼‍♀️" title="Läuferin (mittelheller Hautton)" aria-label="Emoji: Läuferin (mittelheller Hautton)">
- Post COVID vital main symptoms: SOB, chest tightness, fatigue
- Infection https://abs.twimg.com/emoji/v2/... draggable="false" alt="🦠" title="Microbe" aria-label="Emoji: Microbe"> https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> cytokine storm https://abs.twimg.com/emoji/v2/... draggable="false" alt="⛈" title="Gewitter-Wolke und Regen" aria-label="Emoji: Gewitter-Wolke und Regen">
- Respiratory disease - https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">O2, https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">WOB, deconditioning, side effects of meds & cardiac disease - https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">HRV, plts https://abs.twimg.com/emoji/v2/... draggable="false" alt="🩸" title="Tropfen Blut" aria-label="Emoji: Tropfen Blut">, https://abs.twimg.com/emoji/v2/... draggable="false" alt="💊" title="Tablette" aria-label="Emoji: Tablette">, mental health issues - exercise could help here (in post viral fatigue <3 months 2/4
- ME/PVFS- CNS https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧠" title="Gehirn" aria-label="Emoji: Gehirn">/ neuroendocrine involvement (e.g altered state in brain, impact to mitochondria, HPA axis / https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> cortisol, https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">dopamine, https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> anaerobic metabolism https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">ATP) therefore graded exercise is NOT recommend
- Orthostatic/ANS symptoms 3/4
- Mx: 3 P’s (pace, prioritise, plan), https://abs.twimg.com/emoji/v2/... draggable="false" alt="💤" title="Schlafsymbol" aria-label="Emoji: Schlafsymbol">, nutrition, relaxation, activity mx & HR monitoring (e.g keeping < aerobic threshold, HRV tracking https://abs.twimg.com/emoji/v2/... draggable="false" alt="❤️" title="Rotes Herz" aria-label="Emoji: Rotes Herz">)
- Medical Ix to exclude other causes https://abs.twimg.com/emoji/v2/... draggable="false" alt="🧪" title="Test tube" aria-label="Emoji: Test tube">
- Important to differentiate between PVF & PFVS/ME - different exercise mx @PhysiosForME 4/4
Breathlessness & BPD https://abs.twimg.com/emoji/v2/... draggable="false" alt="🌬" title="Wind blasendes Gesicht" aria-label="Emoji: Wind blasendes Gesicht"> 1/3
- Post Covid can show abnormal pulmonary function - diffusion impairment & restrictive lung disease, CXR changes
- V/Q mismatch = breathlessness
- Acute symptoms https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts">chronic
- Load (WOB, compliance, sputum) vs. Capacity (altered respiratory mechanics)
- Complex neurophysiology - biochemical (https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">pCO2 https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pfeil nach rechts" aria-label="Emoji: Pfeil nach rechts"> excess metabolic needs) biomechanical (length tension relationship of diaphragm, dynamic hyperinflation), psych-physiological (emotions impacting behaviours https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> vent drive) threat to homeostasis - unhelpful
2/3
- Treatment options BPD - breathing retraining (nose breathing), fan therapy, AWC https://abs.twimg.com/emoji/v2/... draggable="false" alt="💦" title="Schweißtropfen" aria-label="Emoji: Schweißtropfen">, singing https://abs.twimg.com/emoji/v2/... draggable="false" alt="🎤" title="Mikrofon" aria-label="Emoji: Mikrofon">, IMT, CBT, relaxation, PR https://abs.twimg.com/emoji/v2/... draggable="false" alt="🏋️" title="Person lifting weights" aria-label="Emoji: Person lifting weights">, walking aids etc
- Different approaches- Papworth, Bradcliffe, Buytakeo, Breath Freely
- CPET could be utilised for differential dx for SOB 3/3
Continued in replies...
Upper airway issues / Laryngeal issues https://abs.twimg.com/emoji/v2/... draggable="false" alt="🗣" title="Silhouette eines sprechenden Kopfes" aria-label="Emoji: Silhouette eines sprechenden Kopfes">(can’t wait to ask @CharlieMacSALT lots of questions!)
- Laryngeal issues common following intubation
- Symptoms: dysphoria, pain, horse voice, dysphagia, laryngeal dyspnea, stridor
- COVID https://abs.twimg.com/emoji/v2/... draggable="false" alt="🦠" title="Microbe" aria-label="Emoji: Microbe">? https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> laryngeal oedema
- Larynx involved in multiple functions - swallow, cough, speech, breathing
- Issues can result in globus, throat clearing, ILO (difficulty breathing in), ongoing dry cough
- Ongoing dysphagia - aspiration risk & impact to meeting nutritional requirements
C-19 & Critical Care MDT follow up
- patient ID - triaged to appropriate MDT members
- 6/52 post d/c clinic f/u
- Outcome measures before clinic (CORE 34, SF 36, Nijmengen, Pittsburgh Sleep index, Nottingham Extended ADL score)
- Outcome measure in clinic- TUG, Quads/grip strength testing, voice handicap index & eating Ax tool, 6MWT to estb exercise desaturation
- MSK issues common requiring onward Rx (lateral thigh numbness, shoulder issues, back pain, big toe extension - EHL), hand issues
- Reduced exercise tolerance & issues with plateauing ? Fibrosis on lung CT
- BPD common
That& #39;s it!
Mind is blown from all the learning
Thanks again to all the speakers
You can follow @AnnaBoniface.
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