Healthcare e-Compendium
A joint initiative of DPSRU & DRSC
Healthcare e-Compendium
A joint initiative of DPSRU & DRSC
Author: Dr. Arvind Gupta
MBBS, M.D. General Medicine, D.M. Nephrology, Professor, MLN Medical College, Allahabad.
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Abstract
The novel Coronavirus disease 2019 (COVID-19) is a disease caused by severe intense respiratory condition COVID (SARS-CoV-2). The World Health Organization (WHO) has declared this outbreak a global health emergency on April 24, 2020. It has spread to 213 countries, with 109M confirmed cases, and 61.1M cases have been recovered from COVID-19. In the present circumstance, it is imperative to understand the possible outcome of COVID-19 recovered patients and determine if they have any other detrimental illnesses by longitudinal analysis to safeguard their life in the future. It is essential to follow-up these recuperated patients and performs detailed appraisals for discovery and proper administration towards their mental, physical, and social domain. This urges us to suggest that it's essential to provide physical and emotional counseling, mental support, and a couple of recommended guidelines to recover patients and society to restore to normalcy. Epidemiological, clinical, and immunological investigations from COVID-19 recuperated patients are incredibly essential to comprehend the illness and plan better for possible episodes.
Keywords: COVID-19, SARS-CoV-2, Rehabilitation
Introduction
The novel coronavirus 2019 (COVID-19), the unprecedented pandemic, has caused severe panic among individuals worldwide. It is a severe illness with a high attack rate on the respiratory system followed by a high fatality rate worldwide. According to a report, active alveolitis that is active during the host immune system response to the SARS-CoV antigen might lead to pulmonary fibrosis in certain patients after recovery [1]. Fifty-five patients who recovered from Middle East Respiratory Syndrome (MERS) were found to have lesions present in the periphery of the lungs. Even with such a high mortality rate, there is hope that the COVID-19 patients will recuperate from this unexpected situation [2]. In this situation, researchers should take responsibility for regular follow-up surveys of COVID-19 recovered patients during the convalescent phase. It would help evaluate any changes in the acquired immune function, blood parameters, psychological factors, biochemical factors, and organ functions. Reports have proposed that the SARS-CoV-2 predominantly influences individuals who have had any past ailments identified with lungs, kidney, heart, and the GI tract [3,4].
Lungs: The virus-mediated cytokine activation in the alveolar macrophages results in lung fibrosis and damage.
Kidney: Activated nucleotide-binding domain (NOD)-like receptor protein-3 (NLRP3) signaling can cause pyroptosis and cell death.
Heart: This viral infection can rupture the necrotic lipid core and form blood clots resulting in myocardial infarction.
Brain: If the neural structure gets infected by SARS-CoV-2, it results in the lack of smell and, in some cases, may additionally trigger neurodegenerative diseases within the COVID-19 recovered patients.
Eyes: The tears act as the route of transmission to other organs of the human system through the nasolacrimal system [4,5].
Also, the COVID-19 recovered patients may have psychological stress due to their infection and may be skeptical about their acceptance in society post-COVID-19. Hence, it is crucial to conduct follow-up studies in recovered patients to determine if they might have any other detrimental illnesses. According to World Health Organization (WHO), the death rate of COVID-19 patients will be around 3 to 5%, and the remaining patients affected by COVID-19 will mostly recover. More research is required on the diagnostic and therapeutic approaches for patients' wellbeing after recovering [5,6]. Hence this review emphasizes focusing the research on various multi-organ damages which could occur because of SARS-CoV-2 infection. Further, we propose the possible complications faced by the COVID-19 recovered patients and suggest handling the aftermath by providing counseling on overcoming psychological stress and ensuring patients' physical and mental wellbeing.
Understanding Post-COVID Long Term Symptoms
While the lungs are the primary organs suffering from COVID-19, there are many organs other than lungs that are affected. This increases the danger of long-term health problems that individuals may still face months after the initial infection. Healthcare providers are reporting long-term impacts which will affect the guts, kidneys, skin, and brain.
Older adults and other people with underlying medical conditions are more likely to possess lingering COVID-19 symptoms. However, even people that weren't hospitalized and who had mild illness can experience persistent or late symptoms long after a few weeks. Most commonly, these longer-term symptoms include:
Some individuals may also experience:
COVID-19 Repercussions and Challenges
The COVID-19 affected patients have symptoms like fever, mild respiratory symptoms after infection of 5–6 days, and most of them with mild disease will recover. After the recovery, those patients should take care of their health status and follow-up. Additionally, to lungs, other organs, including kidney, heart, liver, gastrointestinal tract, and eye, are possible infection sites (fig. 1). A recent study reported that the human kidney might be a specific target for SARS-CoV-2 infection [6]. During follow-up of SARS recovered patients, the infection has been reported in other organs, including the kidney and gut, along with alveolar cells within the lungs [7]. People who have recovered from COVID-19 should focus on maintaining and monitoring their health status. They need to be in regular monitoring for their future complications that might occur after their recovery. Hence, the recovered patients are recommended to finish a master health check-up to check for risks for other diseases.
Figure 1: Effect of SARS-CoV-2 infection on organs in different parts of the body. (Clockwise)
Most of the COVID-19 recovered patients experience stress for several weeks, which usually disappears within a brief period. Still, the psychophysical symptoms, including depression, fear, and anxiety, may persist for an extended time. The recovery time depends on an individual's age and pre-existing conditions before the onset of the infection. According to WHO, people of 10–50 years of age are likely to recover from the disease since the death rate for this age category is well below 1%. The COVID-19 patients who were hospitalized resume their everyday lives after spending weeks breathing with mechanical ventilators' assistance. A number of the recovered patients will still have some lingering effects of the virus and the hospital environment. Such situations would make the recovered patients feel paranoid, and therefore the aftermath of the disease would be persistent within the back of their minds. During the quarantine period, the infected, also as few recovered patients, are devoid of human contact, which could increase the probabilities of psychological symptoms. Hence, we propose providing counseling, moral support, also like a couple of recommended guidelines to the COVID-19 recovered patients returning to normalcy [8].
Rehabilitation and Interventions
Patients who were seriously ill with COVID-19 and have passed the critical phase of lung infection and are discharged but have pulmonary dysfunction symptoms should be prescribed a rehabilitation program to restore wellness and reduce anxiety and depression [9, 10].
Rehabilitation is like medical aid to ensure that patients do not deteriorate after discharge and need readmission. It begins with an assessment aiming to discover the patient's primary problems and concerns and understand how they arise and can be alleviated. Effective rehabilitation interventions fall into five categories that are the same across all conditions [11]:
Physiotherapy and Post-Acute COVID-19 Rehabilitation Phase
Physiotherapists are instrumental in rehabilitating patients as they transition from the acute phase to the post-acute phase [12]. The outcomes of COVID-19 will be narrowed down in each individual, and their rehabilitation needs will be specific to these consequences, such as:
COVID-19 patients will often present with pre-existing comorbidities, which must be considered within the patient's rehabilitation plan.
Rehabilitation for Patients with Mild and Moderate COVID-19
Most patients with COVID-19 present with mild influenza-like symptoms and may encounter fever, fatigue, cough, muscle pain, and other indications. The principal respiratory rehabilitation interventions include airway clearance, respiratory control, posture management, active work, and exercise [13, 14]. A diagnosis of COVID-19 may build a feeling of fear in patients [15], and psychological counseling is especially significant. Besides, these patients should zero in on making sure to do regular work and rest, have a balanced diet, and stop smoking [13]. For patients with mild and moderate signs and symptoms of COVID-19, Traditional Chinese Medicine (TCM) and adjuvant therapy involving acupuncture, cupping, moxibustion, massage, acupoint application, and aromatherapy are reported [16].
Rehabilitation for Severe and Critically Ill COVID-19 Patients with Underlying Comorbidities or who are Elderly
Severe and critically ill patients with COVID-19 often develop respiratory distress and/or hypoxemia one week after onset, progressing to ARDS, septic shock, metabolic acidosis, and even death [12, 15, 16]. For severe and critically ill patients, specialists from different nations have proposed that respiratory rehabilitation should be undertaken once a patient's condition is steady, but not start too early, to abstain from intensifying respiratory failure or unnecessary spreading of the virus through droplets [12, 16]. Therefore, determining an exact recovery time is significant. Timely rehabilitation can reduce or even eliminate these complications and the adverse effects on patients' everyday life [17,18].
Early rehabilitation should be performed within a patient's resilience level, including posture management, rollover, active/passive joint activity, respiratory muscle training, sputum training, basic exercises for patients confined to their beds, mobility training, stand on support, standing independently, and ADL training [12, 19-22]. For patients with ventilator dependence, progressive resistance training of inspiratory muscles has been observed as a feasible and viable treatment to improve inspiratory muscle strength and improve quality of life (QoL) after weaning [9, 19]. In the early stage of severe illness, aerobic exercise should be avoided as it may cause respiratory failure in some patients [21].
Rehabilitation of Patients with COVID-19 who Encounter Psychological Disorders
Patients diagnosed with COVID-19 may experience outrage, fear, nervousness, depression, insomnia, or hostility during the isolation treatment period, as well as psychological problems such as depression, loneliness, lack of cooperation, or abandonment of treatment due to fear of the disease, which all negatively affect patient treatment and rehabilitation [21, 24]. Patients in ICU have been found to have differing levels of nervousness, depression, and post-traumatic stress disorder (PTSD). These conditions can prompt dyspnea, tachycardia, raised blood glucose levels, hyperlacticacidemia, and low blood pressure, thus influencing treatment adequacy [23, 27].
Prevention or treatment of these clinical symptoms is likely to be of considerable benefit to ADL and patient recovery. Two studies detailed that clinical psychologists may assist patients to recover from their intense and unpleasant encounters. Clinical psychologists provide patients with stress management, interactive communication, and personalized care. The findings of both studies showed that patient's vital signs improved, and pain scores decreased, and that complication rates, anxiety, and sleep patterns all improved. Notwithstanding, barely any examinations have straightforwardly measured the impacts of early mediations by clinical therapists for patients who are severely or critically ill [28, 29]. Each patient's degree of capacity to convey may vary; therefore, they should personalize psychological treatment. Patient education can improve understanding and reduce anxiety levels. This methodology has been shown to improve recuperation times and reduce pain, psychological stress, and length of hospital stay [29].
Relaxation exercises (e.g., progressive muscle relaxation, breathing exercises and meditation) have been reported to improve vital signs and patient mood. Moreover, these exercises have been found to reduce the incidence of complications, fatigue, fear, pain levels, length of hospital stay and use of sedatives, and improve sleep quality [16]. Distraction methods (such as reading, listening to music, and engaging in dialogue) have been found to improve patients' pain symptoms [16]. Similarly, hypnotic interventions can effectively reduce the use of analgesics and relieve pain [29]. One study demonstrated that acupuncture, massage, and other TCM treatments could also reduce patient stress [30]. Music therapy is a widely used non-pharmaceutical intervention, which has been accounted to reduce stress, depression, anxiety, pain, and feelings of isolation for patients [27, 29].
Even though drug therapy is currently the central intervention to alleviate patients' anxiety and psychological distress, non-pharmacological interventions have gradually become widely acknowledged and implemented, benefiting many patients and reducing the risk of drug-related adverse reactions [27, 31].
Mental health
A topical study published in the Lancet reviewed many previous studies and reported the effect of quarantine on patients' mental health. Many studies reported adverse psychological effects, including post-traumatic stress symptoms, confusion, and anger. Stress factors included longer quarantine duration, fears of infection, helplessness, frustration, boredom, inadequate supplies, inadequate information, and stigma. Long-lasting psychosocial impacts were also reported. Such unprecedented reporting of mental health sufferings during COVID-19 calls for a full mental health policy and program to minimize psychological and emotional issues during the COVID-19 outbreak [32]. The WHO (2020) too has shared strategies to enable the global populace to remain mentally healthy during this unprecedented global health crisis [33]. In summary, it implores people to engage in routine activities, stay calm, indulge in hobbies, stay connected through social media, talking to friends or counselors in case of unmanaged anxiety or fear, doing physical exercises, and not resorting to alcohol or drug to deal with emotional problems [34].
Recommendations
The COVID-19 symptoms range from various organ dysfunction like the lungs, heart, eyes, brain, and gastrointestinal tract. Although the SARS-CoV-2 infected persons recover from the preliminary effects, there might be some aftermaths that the recovered patients may have to face. Many recovered patients still may need paranoid feelings about the COVID-19 disease. Therefore, through this review, we offer a couple of recommendations to safeguard the COVID-19 recovered patients and their families from the repercussion of this disease. The recommendations are:
Figure 2: Recommendations for SARS-CoV-2 recovered patients.
Conclusion
COVID-19 has known to be a deadly disease affecting people worldwide. It has tested all medical services, including rehabilitation, and will continue to do so for the next coming years. It has recently uncovered a multifaceted condition known to affect various other organs and not just our lungs. Rehabilitation intervention (including positioning and respiratory management, physiotherapy, traditional herbal medicine, and psychological support) should be given along with routine treatment, which can decrease hospital length of stay and improve patient status and quality of life. Ideal arrangement and insightful planning can assist with restricting any effect that emerges from this pandemic. Individuals who have recovered from the condition may be stressed, contributing to psychological issues like depression and anxiety. As the world recuperates from COVID-19, it is essential to move forward with all the necessary measures for the physical and mental wellbeing of recovered patients. It is essential to conduct follow-up studies in the COVID-19 recovered patients and provide the appropriate management of this dreadful disease in terms of psychological, physical, and social aspects.
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