key: cord-275838-un11s2mr
authors: Levy, Jonathan; Léotard, Antoine; Lawrence, Christine; Paquereau, Julie; Bensmail, Djamel; Annane, Djillali; Delord, Vincent; Lofaso, Frédéric; Bessis, Simon; Prigent, Hélène
title: A model for a ventilator-weaning and early rehabilitation unit to deal with post-ICU impairments with severe COVID-19
date: 2020-04-18
journal: Ann Phys Rehabil Med
DOI: 10.1016/j.rehab.2020.04.002
sha: 
doc_id: 275838
cord_uid: un11s2mr

nan

J o u r n a l P r e -p r o o f Dear Editor. The unprecedented outbreak of the novel coronavirus (nCoV-19 or SARS-CoV-2) that emerged in Wuhan, China, in 2019 and spread all over Europe and the world has forced French hospitals to reorganize and admit a large number of critically ill patients in a short period of time. Data from China reported up to 6% of patients overall (1) and 71% with severe COVID-19 (2) requiring mechanical ventilation. Median length of hospital stay was 12 days (1), but patients with severe disease may remain in intensive care units (ICUs) for 2 to 3 weeks, and survival time for non-survivors has been reported to be 1 to 2 weeks (2).

On March 23, 2020 in France, 2,082 of 19,856 confirmed cases of COVID-19 needed intensive care (3) . Reports from Italy warned of the risk of ICU bed shortage (4). New cases and especially severe ones are increasing exponentially following a similar evolution in Italy (5) , with a risk of ICU saturation in many French regions. There is a growing need for ventilator weaning units that could help ICUs discharge ventilator-dependent patients with stable disease and no other organ failure but respiratory or neurological features. According to other physical medicine and rehabilitation societies worldwide, early evaluation and rehabilitation for these patients is mandatory (6, 7) .

Here we describe our organization of this type of unit and our first feedback from its functioning, based on the experience in a French tertiary care university hospital. This weaning unit was set ex nihilo within 7 days and was ready for the first 4 patients by March 26, 2020.

The pavilion architecture of our hospital allowed us to secure 2 buildings for COVID-19-free patients (from the conventional ICU and infectious diseases and neurorehabilitation units) and isolate one building for COVID-19 patients ( 

Each bed is equipped with a level-3 life support ventilator Astral 150® (ResMed, San Diego, CA, USA) and non-invasive continuous monitoring (oxygen saturation, heart rate, noninvasive blood pressure). Each ventilator has flow meters for perfusion and a nutrition pump for enteral feeding. We could not implement a full monitoring system in the nurses' office, but ventilator alarms are repeated by using "babyphones" or with an independent remote alarm system. Finally, each room is equipped with a lift and harness for transfers (Fig. 2) . Mean ICU length of stay before admission in the weaning unit was 11 (4.0) days (vs 3 weeks in the Chinese series (2)). Mean length of stay in our unit was 6 (4.6) days. For successfully weaned patients, mean total duration of mechanical ventilation was 13 (6.3) days (range 8 to 22 days). Six patients had a history of hypertension and none were active or previous smokers.

Three patients had post-ICU-acquired weakness, progressively regressive, and 1 had initial and transient brachiofacial paresis (intracerebral hemorrhage ruled out, but to date, MRI could not be performed). All had moderate to severely low serum albumin levels (< 25 g/L). All had mild to moderate post-ICU delirium, and 5 had persistent anxiety or post-traumatic stress.

By the date of final acceptance of this article (April 11), we counted 86,740 active cases of COVID-19 in France; 7,004 patients were considered to have serious or critical disease and were in an ICU. This indicates an exponential increase of severe cases and confirms the past hypotheses of ICU-bed saturation (< 6,000 before the epidemic). The survivors (approximately 60%) will need invasive ventilation for 3 weeks and early rehabilitation support. Our preliminary feedback on our set-up attests to the appropriateness of our approach.

The goal of the specific organization we describe is to allow for early patient discharge from the ICU and increase ICU admission capacity over time during the COVID-19 crisis. It also allows for a physical medicine and rehabilitation holistic evaluation of post-critical COVID-19 patients. Hence, our first feedback strengthens the idea that our unit constitutes a possible intermediary stage between ICU and either home discharge or inward rehabilitation for patients with pulmonary, nutritional, neurological and psychological COVID-19-related and/or post-ICU impairments. 

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study

Avis relatif aux recommandations thérapeutiques dans la prise en charge du COVID-19

COVID-19 and Italy: what next? The Lancet 2020

European Centre for Disease Prevention and Control (ECDC) Public Health Emergency Team. Rapidly increasing cumulative incidence of coronavirus disease (COVID-19) in the European Union/European Economic Area and the United Kingdom

Impact of COVID-19 outbreak on rehabilitation services and Physical and Rehabilitation Medicine (PRM) physicians' activities in Italy. An official document of the Italian PRM Society (SIMFER)

Facing in real tim the challenge of the COVID-19 epidemic for rehabilitation