key: cord-0975362-6n2yyfpx
authors: Dr, Yichun Jiang; Dr, Jun Chen; Dr, Fulan Cen; Dr, Xu Li; Dr, Zhi Song; Dr, Mian Peng; Dr, Xueyan Liu
title: Importance of respiratory airway management as well as psychological and rehabilitative treatments to COVID-19 patients
date: 2020-04-30
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2020.04.055
sha: 757fd484ea052638ffc6f0a89e52f4487634e5e0
doc_id: 975362
cord_uid: 6n2yyfpx

Abstract The clinical therapy for severe 2019 coronavirus disease (i.e., COVID-19) sufferers is relatively challenging. Herein, the processes involving salvage of a critical COVID-19 patient were retrospectively analyzed. The condition of an obese female critical COVID-19 sufferer progressively worsened in the initial period after admission. According to her symptoms and examination reports, endotracheal intubation and mechanical ventilation were timely conducted and meanwhile high-dose sedatives and analgesics were administrated. In the later therapeutic phase, however, sedative and analgesic dosages were gradually reduced, and psychological and rehabilitative therapies were conducted, concomitantly with enhancement of airway care to facilitate sputum expectoration. Eventually, the endotracheal tube was feasibly removed after intubation for 18 days and subsequently replaced with noninvasive ventilation and a high-flow nasal cannula oxygen therapy. Intensive airway care alongside psychological and rehabilitative therapies can shorten the mechanical ventilation time and improve the prognosis of COVID-19 sufferers.

J o u r n a l P r e -p r o o f Therapies for COVID-19 patients considerably improve the critical patients' respiratory efficiency, becomes an imperative means in the therapy. In addition, the critical patients are generally anxious and fearful [5, 6] and thus large-dose sedatives, analgesics and even muscle relaxants are requisite. Hence, both assisted ventilation and proper psychological therapy are essential for these patients. In this report, a case of a critical COVID-19 patient who was initially subjected to mechanical ventilation and then to psychological and rehabilitative treatments and was finally ventilator-weaned is elaborated as follows.

A 36-year-old woman got a fever on January 25th, 2020, without obvious inducements, and the highest body temperature reached 37.7 °C. Her clinical syndromes include cough, expectoration with a small amount of sticky sputum, and slight nasal congestion and rhinorrhea, but without fatigue, headache, nausea, vomiting, celialgia, diarrhea or muscle soreness. Two days later, she was admitted to ××× Hospital, and the chest tests suggest a pulmonary infection; thus, a nucleic acid test of the pharynx swab for coronavirus 2019-nCoV was subsequently conducted in the centers for disease control (CDC). The positive result prompts the transfer to ××× Hospital on January 28 for further treatments. Although there is nothing special in her past history, one noteworthy event in the epidemiology is that the couple on January 18 picked up their mother and child, who both had got a fever.

Due to the positive nucleic acid test result, a further physical examination was conducted in ××× Hospital on admission. The results were as follows: height 160 cm, weight 80 kg, body mass index (BMI) 31.25, body temperature 37.7 °C, pulse 110 J o u r n a l P r e -p r o o f Therapies for COVID-19 patients sedatives (i.e., propofol and midazolam), analgesics (i.e., remifentanil and dexmedetomidine) and muscle relaxant (i.e., rocuronium bromide), lung protective ventilation as well as a prone-position therapy were comprehensively conducted.

On February 8, she still had a high fever and was then subjected to blood routine examination. Considering the results (white blood cell count 2.82 × 10 9 /L, auxiliary T lymphocyte absolute count 256/µL), piperacillin-tazobactam was immediately replaced with meropenem to improve the anti-infection effect.

On February 11, the blood culture results verified the emergence of gram-positive streptococci, and thus the anti-bacterial drug Linezolid was added.

On February 17 the chest CT (not shown) showed that the distribution of lesions scattered on the right lung was marginally sparser than before and the oxygenation index increased, and hence we attempted reduction of the sedative dosages. In addition, she was given alprazolam for relieving the anxiety.

On February 19 (day 24 since admission), the chest CT ( and substituted with noninvasive ventilation, which was further replaced by a high-flow nasal cannula oxygen therapy after two days. The patient was discharged from ICU when her condition became steady.

The clinical therapy for severe COVID-19 patients is comparatively difficult and the salvage is somewhat strenuous and low-efficient. For example, the mortality rate of the 99 COVID-19 patients admitted to Wuhan Jinyintan Hospital in the early period is 11% [3] , and the national mortality rate of COVID-19 patients is as high as The chest CT pictures obtained on the 5th day after admission show lesions in the pulmonary lower parts that are close to the pleura. The CT on the 9th day after admission indicates that pulmonary lesions increased further and that fusion and consolidation of lesions occurred in the pulmonary lower parts. As the patient's condition was getting worse, on the 14th day after admission intubation and mechanical ventilation were conducted, a large dose of sedation, analgesics and muscle medicine was given, the ARDS's lung protective ventilation strategy (including ventilation in prone position) was performed, and anti-viral and anti-infection therapies were executed. On the 23th day after admission, the patient's oxygenation index increased to 228 (see Table S1 in Supplementary information for more details), indicating that the patient was getting better, and thus we gradually reduced the amount of sedative drugs and lowered the parameters of the ventilator. On the 25th day after admission, she exhibited anxiety, fear and serious human-machine confrontation. On the 27th day after admission, the chest CT results indicate that the pulmonary lesions were more sprawling than ever since the admission and even consolidated considerably and that an air bronchogram could be observed in the pulmonary middle area. Therefore, it is infeasible yet to wean the ventilator right then.

Nevertheless, allowing for the above problems, we actively tried discharging J o u r n a l P r e -p r o o f Therapies for COVID-19 patients sputum aided with mechanical vibration and percussion on back; physically rehabilitative treatments were also entrusted; furthermore, the anti-anxiety medicine (i.e., flupentixol and melitracen tablets) was administrated, and psychological counseling was made concurrently. Consequently and expectedly, the patient's condition gradually improved; and on the 33th day after admission the ventilator was successfully withdrawn.

The experience of successfully rescuing this patient suggests two additional vital elements expect the common anti-virus and immune-enhancing therapies. (1) Respiratory airway care should be intensified. This patient is obese, and her thorax activities are thus restricted; more importantly, the chest CT on February 17 shows consolidation in the pulmonary lower parts but an obvious air bronchogram, suggesting that the respiratory airway might be blocked; furthermore, this hypothesis is consistent with the autopsy report [8] that a plethora of sticky secretions overflows from the alveoli in the pulmonary transection and some fibrous stripes are visible; in addition, the radiographically ground-glass opacity is compatible with the anatomically pulmonary gray-white lesions [8], implying that COVID-19 causes the inflammatory reactions featured mainly by damage in the deep airway and pulmonary alveoli. Hence, it is exceedingly critical to widen the congested respiratory airway in the later therapeutic processes to promote the expectoration of mucus. (2) Attention to the patient's psychological and physical rehabilitation in the later phase should also be paid. The COVID-19 patients are per se scared of the disease, and moreover, long-term high-dose use of sedative and analgesic medicine readily leads to delirium and restlessness once discontinuation; therefore, psychotropic drugs (e.g., alprazolam, flupentixol and melitracen tablets) should also be administrated besides bolstering psychological comfort. Additionally, the muscle disuse atrophy syndrome will readily appear if patients are bedridden for a long time, and thus timely rehabilitations, 

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We are grateful to the physicians and nurses at the ××× Hospital who participated in clinical examinations and sample collection.

The authors declare that they have no competing interests.