Coronavirus recovery doesn’t stop when the patient leaves the intensive care unit. Doctors in post-ICU clinics are trying to treat the lasting health effects they recognize from treating ordinary viral pneumonia patients but must also be ready to adapt to the effects from the new coronavirus.
“The lungs are the problem when you’re in the hospital, but it’s the muscles and your other health problems and your brain that are the problem afterward,” said Dr. Jack Iwashyna, a professor in the Division of Pulmonary and Critical Care Medicine at the University of Michigan.
After leaving the hospital, patients must contend with muscle weakness, cognitive deficits, and other health problems. Critical care doctors have constructed post-ICU rehabilitation centers to work specifically with patients who have been discharged from hospital ICUs and must work to regain their physical strength after days or weeks of immobility on breathing machines.
“We’ve realized that the patients who make it out of the ICU oftentimes are not the same patients they were when they went in,” said Dr. Jake McSparron, critical care pulmonologist at the Michigan Medicine Pulmonary Clinic. “It may have been that the acute problem has improved if they were in respiratory failure with some kind of pneumonia, but they had major deficits in physical function, cognitive function, or psychiatric function.”
With the onset of the coronavirus pandemic and acute respiratory distress syndrome, the lung disease caused by the coronavirus, came a wave of uncertainties about the kinds of long-term health effects of the disease after patients leave the hospital.
Patients recovering from acute respiratory distress syndrome, whether caused by the flu or COVID-19, may have some difficulty breathing even after leaving the hospital. They may also have scarring on their lungs from being placed on a ventilator. Most physicians in post-ICU and post-COVID clinics focus more closely on other debilitating side effects, such as muscle weakness and atrophy, that can persist for months.
A 2013 report on muscle shrinkage in intensive care patients still holds up, Iwashyna said. University College London researchers found that patients in critical care for organ failure saw roughly 18% muscle shrinkage in their quadriceps by day 10 in the ICU. At just seven days in the ICU, patients with a failing organ saw their muscles shrink by about 10%.
“Think about the kid who breaks their arm. That bone heals, and when you take the cast off, the kid can’t lift up their arm,” said Dr. Ashley Montgomery, founder of the University of Kentucky post-ICU recovery clinic. “The lack of movement that occurs in a hospital stay, you get a lot of muscle atrophy, a lot of weakness. People can’t walk, and they can’t feed themselves.”
More often than not, Montgomery said, physical therapy will take place remotely due to the necessity of social distancing that has never been more crucial than in the coronavirus pandemic. Patients recovered from COVID-19 will use remote heart and oxygen monitors in their homes that physicians in the Lexington, Kentucky, clinic can watch while the patient does exercises.
“There’s a physical therapist and a respiratory therapist there to say, ‘Your oxygen is OK. I know your heart’s beating a little fast, but it’s not dangerous.’ Or they say, ‘This muscle group looks really weak. Let’s work on this exercise to help.’ We’ve traditionally done that in a hospital environment, but we figured out that those sorts of things can be done in the home,” Montgomery said.
In addition to muscle weakness, people will likely also experience cognitive impairment for months or several years after recovering from the coronavirus disease. Muscular and neurological damage after being discharged from the ICU is not unusual. Physicians have studied the long-term effects for years, which means they can rely to some extent on treatments developed for people recovering from pneumonia or multiple organ failure. Still, because COVID-19 has never been seen before, doctors are learning about some long-term impairments as they treat them.
“You see these videos of people leaving the hospital after surviving the coronavirus, and everyone’s clapping and happy, but that is not the end of the story,” said Dr. Carla Sevin, critical care pulmonologist at Vanderbilt University Medical Center. “Depending on their severity of illness, some of those patients will have six, nine, 12 months of hard recovery, and some will never return to baseline.”
Many patients recovering from COVID-19 experience cognitive damage similar to that experienced by someone with a traumatic brain injury. Vanderbilt University physicians found in 2013 that three months after discharge from the intensive care unit, 40% of patients hospitalized for respiratory failure showed cognitive impairment similar to that of someone who experienced moderate brain trauma. About 34% of patients still showed the same cognitive impairment 12 months after discharge from the hospital.
Doctors in post-COVID rehabilitation centers are also discovering that young, previously healthy people are not immune to lasting debilitation. Sevin told the Washington Examiner that a 19-year-old patient at the Vanderbilt post-COVID clinic had severe cognitive impairment and such severe muscle weakness that he was unable to return to work.
Though physicians can begin to expect what sort of long-term impairments COVID-19 patients will experience, they have to be ready to alter the ways in which they administer treatment as they learn more about the new virus.
“We need to admit we don’t know, and we need to work with these patients to adapt to what happens to them,” Iwashyna said. “We just assume it’s only going to be X, and we only look for X. We’re going to get it wrong because I think coronavirus has clearly told us it’s going to do unpredictable things.”
The United States has surpassed 2 million cases of the coronavirus since the pandemic began in March. While the rate of new daily cases has slowed, new cases have emerged in states that had been relatively spared by the pandemic, such as Arizona and Texas, sparking worry among public health officials.
