RU2800253C1 - Method of complex rehabilitation of patients who have had covid-19 with lung damage at the second stage of medical rehabilitation - Google Patents

Abstract

FIELD: medicine, pulmonology and restorative medicine.

SUBSTANCE: invention can be used in the medical rehabilitation of patients after a new coronavirus infection at the second stage of medical rehabilitation. During the rehabilitation of patients with COVID-19, breathing exercises, mechanotherapy, physiotherapy, respiratory muscle training, and cognitive rehabilitation are carried out. Along with therapeutic exercises, the Threshold IMT respiratory muscle simulator is additionally used in therapy to achieve the following effects: an increase in VC, training of the respiratory muscles. The course of rehabilitation is at least 10 procedures. The complex is carried out during the period of convalescence, after normalization of temperature, completion of courses of antiviral and anti-inflammatory therapy. The course of rehabilitation procedures is carried out for an average of 17–21 days, depending on the severity of the infection. Under the guidance of an exercise therapy instructor, patients are taught diaphragmatic breathing, as well as a set of general strengthening exercises with elements of breathing exercises, including strength and aerobic exercises of increasing intensity. Classes are held every day. Also, in addition to physiotherapy exercises, mechanotherapy (motomed, stepper, VEM, treadmill), dosed walking, training of the respiratory muscles Threshold IMT and vibration-compression therapy are carried out.

EFFECT: method provides a reduction in the symptoms of a respiratory disease, an increase in exercise tolerance.

1 cl, 4 tbl, 1 ex

Description

The method relates to the field of medicine, namely to complex rehabilitation, and can be used in the medical rehabilitation of patients after suffering COVID-19 with lung damage at the second stage of medical rehabilitation, in order to restore and comprehensively improve the function of the respiratory and cardiovascular systems.

In some patients, COVID-19 is mild, but about 15% require hospitalization and 5% of them have a high risk of extremely severe course with the development of multiple organ failure. Health professionals face new challenges related not only to the diagnosis and treatment of patients with this infection, but also issues of rehabilitation at different times after the disease [Ministry of Health of the Russian Federation. Interim Guidance Note: Interim Guidance Note: Medical Rehabilitation for Novel Coronavirus Infection (COVID-19). Version 2 (07/31/2020)].

In most patients, after discharge from the infectious diseases hospital, there is a decrease in exercise tolerance, primarily due to respiratory failure and the syndrome of the consequences of intensive care, myopathy [Fesyun A.D., Lobanov A.A., Rachin A.P., Yakovlev M.Yu., Andronov S.V., Konchugova T.V., Gilmutdinova I.R., Barashkov G.N., Mitroshkina E.E., Bogdanova E.N., Lebedev Ya.O., Nikitina A.M. Challenges and approaches to the medical rehabilitation of patients who have undergone complications of Covid-19. Herald of Restorative Medicine . 2020; 97 (3): 3-13.]. The most common complaints are shortness of breath, cough, decreased muscle strength, anxiety, depression, decreased concentration, and difficulty in remembering. Shortness of breath is caused not only by direct damage to the lung tissue, but also by dysfunction of the respiratory muscles, as well as by taking certain medications. Cough occurs in half of the cases, most often it occurs in patients who were on respiratory support, with bronchial hyperreactivity and a tendency to superinfection [Zaitsev A.A. Cough: problems and solutions. Practical Pulmonology 2020;2:78-86). Belotserkovskaya Yu.G., Romanovskikh A.G., Smirnov I.P., Sinopalnikov A.I. Long COVID-19. Consilium Medicum . 2021; 23(3): 261–268].

According to the recommendations of the rehabilitation program, you need to start as early as possible, and the total duration should be from 6 to 12 weeks. Patients who have completed a rehabilitation program after discharge from the hospital are advised to continue their studies on their own.

An analysis of the medical literature showed a lack of research work on the complex use of exercise therapy, breathing exercises using breathing simulators, vibration-compression therapy and mechanotherapy.

After discharge, patients are recommended to continue the use of breathing exercises, physiotherapeutic methods of treatment, according to indications, taking into account indications and contraindications. It is recommended to organize the work of the psychological support service, to form the patient's motivation to continue independent studies and the formation of a healthy lifestyle.

The disadvantages of this technical solution include that the recommended methods of rehabilitation include mainly methods of physiotherapy and do not contain detailed information about mechanotherapy and methods of training the respiratory muscles using a breathing simulator and vibration-compression therapy. This reduces the effectiveness of the treatment and can subsequently lengthen the recovery period, which is costly.

A known method of rehabilitation of patients with bronchopulmonary pathology of infectious origin (Patent RU No. 2745697, IPC - A61N 1/00, G01N 33/00 - 30.03.2021, Bull. No. 10), which includes daily exercise therapy and vibration-compression exposure apparatus VKV-01. The procedures are carried out after stabilization of the general condition, the absence of desaturation during exercise therapy, characterized in that as exercise therapy, patients perform static breathing exercises in the mode of consciously controlled localized breathing with dosed resistance, the course of respiratory rehabilitation using the VKV-01 device consists of 10 procedures.

The disadvantage of this method lies in the fact that this technique does not use in the complex rehabilitation training of the respiratory muscles with the help of respiratory simulators, as well as classes in the form of mechanotherapy, with the aim of a comprehensive restoration of body systems.

There is also known a method of hardware compression-vibration exposure using a physiotherapy apparatus VKV-01 for the treatment of patients with impaired bronchial patency and patients with COPD [T.A. Turusina, AV Averyanov, AG Sotnikova. The method of vibration-compression effect on the chest in the complex therapy of exacerbation of chronic obstructive pulmonary disease. - Moscow 2012].

The disadvantage of this method lies in the fact that an integrated approach is not used in the recovery of patients with damage to the respiratory system, with an impact not only directly on the muscle group of the chest, but also on other groups of skeletal muscles.

The objective of the claimed invention is development of a method for therapeutically effective medical rehabilitation of patients with viral pneumonia associated with COVID-19 at the second stage of medical rehabilitation, including exercise therapy techniques, mechanotherapy and vibration-compression therapy, respiratory muscle training using the Threshold IMT breathing simulator.

The technical result of the claimed invention is to increase the effectiveness of the treatment of patients after suffering COVID-19 with impaired oxygen-metabolic balance and the restoration of adequate gas exchange of tissues and organs.

The technical result of the claimed invention is achieved due to the fact that after achieving stabilization of the general condition and stable saturation indicators above 92%, patients are prescribed exercise therapy complexes, respiratory muscle training with the Threshold IMT respiratory simulator, walking at a certain pace of steps, calculated individually, using the formulas presented below. Vibration-compression therapy for at least 14 days. Mechanotherapy on Motomed with saturation rates of more than 95% at rest and desaturation on load up to 92%. With an increase in the functional class, an increase in the intensity of loads, transfer to the next stage of VEM, treadmill, with ECG control, indicators of blood pressure, heart rate, SpO2. Complex treatment is carried out daily.

Implementation of the invention.

Medical rehabilitation using these methods was carried out within the framework of the Territorial programs of state guarantees of free provision of medical care to citizens at the second stage of rehabilitation on the basis of the medical rehabilitation department of the State Budgetary Institution of the RME Medical Unit No. 1.

Thus, we have developed and scientifically substantiated a differentiated rehabilitation program for the second stage of medical rehabilitation of patients who have undergone COVID-19, which together significantly (p<0.05) contributes to the optimization of rehabilitation programs.

Data were obtained on the effect of exercise therapy, mechanotherapy, respiratory muscle training, dosed walking on increasing tolerance to physical exertion, restoring impaired breathing properties, and improving the quality of life.

Detailed description of the method and examples of its clinical implementation .

Patients aged 56.54 ± 11.73 years old who had viral pneumonia associated with COVID-19 with a clinical variant of lung tissue damage received rehabilitation at the medical rehabilitation department of the State Budgetary Institution of the RME of the Medical Unit No. 1. All patients had informed voluntary consent to undergo medical rehabilitation in a hospital. According to the severity of the disease, patients of moderate severity (40.4%) of the course of COVID-19 with lung damage prevailed. According to the Rehabilitation Routing Scale (RRS), patients with RMS 4 prevailed - 63.3%.

At the time of hospitalization, patients had a negative PCR test for SARS-Cov2, positive dynamics of the clinical and radiological picture of the course of the disease.

All patients were examined by a multidisciplinary team upon admission: a pulmonologist, a psychiatrist, a doctor of physical and rehabilitation medicine, a physiotherapist, an exercise therapy methodologist, who compiled individual rehabilitation programs. The goal and tasks of the rehabilitation process were determined, the effectiveness of the measures taken was evaluated. Before carrying out rehabilitation measures, patients were assessed according to the Rehabilitation Routing Scale (RRS). The degree of disability, the need for outside help, the clinical picture of the disease, and functional indicators were taken into account.

Patients were assigned a rehabilitation complex according to the claimed method:

Stage 1 - dosed walking. With saturation indicators of 89-92%, motor activity was determined by activity within the ward, with additional oxygen support, under the control of SpO2 indicators. With saturation indicators of 92-95%, motor activity was determined in the form of walking and activity within the ward. After stabilization of indicators (saturation ≥95%), patients were transferred to the next stage of physical activity (corridor mode). At this stage of motor activity, the patient was allowed complete freedom of movement around the ward, access to the corridor. At the first or second exit to the corridor, walking up to 50–60 meters was allowed, accompanied by an exercise therapy instructor, under the control of SpO2. In the following days, the walking distance increased by 200–500 meters in several steps.

Stair walking in patients who had a severe and extremely severe course of COVID-19 began with a descent to the 1st floor and an ascent to the previous floor by elevator (2–3 times per session). On the 2-3rd day, patients carefully climbed 1 flight, then - 1 floor up the stairs in the presence of an instructor (methodologist) of exercise therapy. Patients with a moderate course of COVID-19, in the absence of desaturation, immediately began going up and down stairs controlled by an exercise therapy instructor (without using an elevator). The control of exercise tolerance and effectiveness was assessed by the patient's clinical condition, heart rate, SpO2, and the results of repeated exercise tests.

When dosed walking is used as a training load, heart rate and blood oxygen saturation remain the main method for controlling the correct dosing of the load and selecting the pace of walking in patients before transferring to the next step. The required rate of dosed walking for each patient was calculated according to the formula of D.M. Aronov:

TX \u003d 0.042 × M + 0.15 × HR + 65.5,

where TX is the desired pace of walking (steps per 1 minute),

M is the maximum load during the VEM test in kgm / min (we multiply the load in W by 6),

Heart rate - heart rate at maximum load during the VEM test.

Stage 2 - exercise therapy. Thanks to respiratory gymnastics, the respiratory muscles are strengthened, the activity of the diaphragm is stimulated. With saturation indicators of less than 95%, an individual exercise therapy methodologist performs an initial exercise therapy complex with the patient, consisting of breathing exercises, exercises for small muscle groups (arms, legs). In the future, with the expansion of the motor regimen and with stable SpO2≥95%, the patient is transferred to group classes, where heart rate, SpO2, RR are monitored, both before the start of exercise, in the middle, and after.

Stage 3 - mechanotherapy. The physical activity program consisted of several stages. Initial - preparatory stage: 5-10 lessons. Training loads with the help of simulators (motomed) begin in a low intensity mode, especially with saturation indicators of 92-95%, with a desaturation of less than 92%, additional oxygen therapy is performed during the load. In the future, after increasing tolerance to physical activity and the absence of desaturation on the load, there is an increase in the level of physical activity. The load level increases to a mode of moderate intensity (at the rate of 50-60% of the maximum), 10-12 lessons. In addition to saturation indicators, patient complaints, heart rate is an indicator of controlling the level of training load. Maximum heart rate is the highest heart rate during an exercise test. Normally, it depends on gender and age. Heart rate at different percentages of oxygen consumption during exercise depending on age and gender (according to R. Andersen et al.)

Heart rate at different percentages of oxygen consumption during exercise depending on age and gender (according to R. Andersen et al.) Percentage of oxygen consumption Age, years 20-29 30-39 40-49 50-59 60-69 M AND M AND M AND M AND M AND Heart rate, beats/min 75 161 167 156 160 152 154 145 145 140 142 100 195 198 187 189 178 179 170 172 162 163

Monitoring the condition of patients before and during physical therapy is the first and indispensable condition that ensures their safety. In the presence of fixed deviations in the clinical condition, the intensity of training is reduced for the patient (returns to the previous stage), or is suspended until the condition stabilizes. Physical activity assigned to patients should be adequate to their functional state and not cause any pain and discomfort. In the first weeks of training, heart rate at the height of physical activity and in the first 3 minutes after it should not exceed the initial one by more than 20 beats / min, and breathing - by no more than 6 per minute. An increase (from baseline) in systolic blood pressure by 20–40 mm Hg is allowed. Art. and diastolic blood pressure - by 10-12 mm Hg. Art.

Mechanotherapy was carried out using the MOTOmed viva2 device, initial loads at a slow pace (30-40 rpm) with a power of up to 5 W - 5-10 minutes, then increasing the load to 10 W, were carried out in steps, under the control of heart rate, SpO2.

- training of the respiratory muscles was carried out using the Threshold IMT respiratory simulator. Inspiratory training was carried out in order to reduce the impact of ventilation-perfusion disorders. Threshold PEP was used less frequently, only for comorbidities. Trainings were carried out daily during the entire course of rehabilitation, 3 times a day, starting from 5 minutes. The pressure was selected individually, depending on the patient's sensations (inspiratory resistance), further adjustment was made with an increase in resistance.

- vibration-compression therapy. Due to chest compression, irritation of the mechanoreceptors occurs and the tension of the respiratory muscles decreases, the passage of the contents of the respiratory tract improves.

Vibration-compression therapy was carried out using the apparatus of the airway clearance system “The Vest Airvay Clearance System, model 105 (registration certificate No. ФСЗ 2009/03829).

Before the procedure, the clinical picture and the extent of lung damage were assessed. The level of compression and vibration increased consistently with each treatment.

procedure Compression level Vibration, hertz 1 4 7 2 4 7 3 4 8 4 5 8 5 5 8 6 6 8 7 6 9 8 6 9 9 7 9 10 7 9

The procedures were carried out daily. With an interval from eating at least 40 minutes. The course consists of at least 10 procedures

Based on the results of the rehabilitation program, the following indicators were achieved.

Table. Dynamics of oxygenation parameters and exercise tolerance tests in patients with different CRM parameters

Parameters in dynamics ShRM33 SHRM4 SHRM5 p*, p**, p*** SpO ₂ at admission, %
Me [Q ₁ -Q ₃ ] 98
[95 - 98] 96
[95 - 98] 94
[92 - 96] р**= 0.001р***= 0.017 SpO ₂ at discharge %
Me [Q ₁ -Q ₃ ] 98
[98 - 98] 98
[98 - 98] 98
[96 - 98] р**= 0.002р***< 0.001 T6X at admission, m
Me [Q ₁ -Q ₃ ] 400
[360 - 431] 300
[240 - 350] 110
[40 - 248] p*< 0.001r**< 0.001r***< 0.001 T6X at discharge, m
Me [Q ₁ -Q ₃ ] 480
[475 - 510] 420
[360 - 480] 335
[270 - 365] p*= 0.001r**< 0.001r***< 0.001

Note: significance of differences between the groups p* _{RB3 and RB4} , p** _{RB3 and RB5} , p*** _{RB 4 and RB5}

Patients with high SPM5 at admission had a lower 6-minute walk test (T6X) of 110 m (40-248 m) and _an SpO2 of 94%. At ShRM4 - T6X 300 m (240-350m) and SpO ₂ 96%. With ShRM3 - T6X 400 m (360-431 m) and SpO ₂ 98%. By the time the rehabilitation programs were completed (on average, 21 days after the start of classes), the increase in T6X was 90 m in the group with SPM5, SPM 4 - 120 m, SPM 3 - 90 m. SpO ₂ in room air exceeded 95% in all patients. An increase in T6X in meters, maximum in terms of the distance traveled, was observed in patients with SPM4 - 120 m (60–180m) and 90 m each in patients with SPM3 and SPM 4, p>0.05. But in terms of the percentage increase from baseline to discharge on T6X, the maximum percentage increase was observed in patients with SPM5, amounting to 75% (19–21%), 40% (20–75%) in patients with SPM4, and 22% (15–3%) in patients with SPM3. Significance of differences between the groups SHRM3 and SHRM4 was p=0.036, between the groups SHRM3 and SHRM5 - p=0.007.

Patients with a lower rehabilitation score (SRM4) in 54% of cases were engaged in motomed, but later, due to a higher rehabilitation potential, they were transferred to more intense types of loads, taking into account the regression of clinical symptoms, cardiological and psychological disorders. Dynamic physical activity programs for patients were adapted from traditional cardiac rehabilitation programs, taking into account the individual characteristics of the patient (for example, the volume of lung damage, complications of COVID-19). The use of this methodological approach has demonstrated its effectiveness, which was reflected in the dynamics of T6X growth, especially in the group of the most severe multimorbid patients with SPM5.

Inspiratory training was used in all hospitalized patients, regardless of RD, since the incidence of dyspnea and a decrease in muscle strength were noted in more than half of the examined population. At discharge, patients showed an improvement in respiratory status: SpO ₂ increased in the most severe patients (SPM5) from 94% [92–96] at admission to 98% [96–98] by discharge. Due to the restoration of the correct breathing pattern, static breathing exercises with the participation of the main respiratory muscles, breathing simulators, there was a decrease in shortness of breath, improved exercise tolerance, and, as a result, improved ventilation and gas exchange.

The method has been tested on a large clinical material and can be recommended for widespread use in rehabilitation centers licensed to carry out medical activities for medical rehabilitation at the second stage.

Clinical example.

Patient Ch , 69 years old, was hospitalized in the medical rehabilitation department of the State Budgetary Institution of the Republic of Russia, Medical Unit No. 1 in January 2023. Complaints of general weakness, fatigue, weakness in the legs. Shortness of breath with minimal movements (within the ward), dry cough is rare. Rapid heartbeat, taste distortion. Dispersed within the ward. At night he uses oxygen support (2 liters per minute).

Anamnesis of the disease: she fell ill acutely on December 7, 22 - febrile temperature, shortness of breath, weakness. Outpatient treatment without effect. Inpatient treatment in the infectious diseases hospital of the Yoshkar-Ola city hospital from 12/14/22-01/16/23 with a diagnosis: “Coronavirus infection caused by COVID-19 (confirmed), extremely severe form, convalescent. Bilateral polysegmental pneumonia in the stage of incomplete resorption. ODN III. NIV. Hypertension II stage, controlled, risk 2. Obesity I degree. Target BP < 130-139/80 mmHg CHF IIa. FC III. Violation of the rhythm by the type of extrasystole. (in history). Peptic ulcer of the duodenum, remission.

According to X-ray examination - CT4 (lung tissue damage is about 75%).

Condition: relatively satisfactory. Consciousness: clear. Position: active. Nutrition: increased. Height = 154 cm, weight = 76 kg. BMI \u003d 32 Skin: physiological color. cyanosis of the lips: no. Sclera icterus: no. The mucosa of the mouth and throat: physiological color. Lymph nodes: no features. Mammary glands without features. Edema: pastosity of the legs Respiratory system: Chest: regular shape. Percussion of the lungs: percussion over the lungs, the sound is pulmonary, on both sides. Respiration: respiratory movements are symmetrical, on both sides, vesicular breathing. Wheezes: not heard. Pleural friction rub: no. NPV: 20 per min. SpO2: 90% at rest when breathing free air. Cardiovascular system: The area of the heart and large vessels: not changed. Apex beat: not palpable. Pulsation of the vessels of the neck: no. The boundaries of the heart: within the normal range / expanded, the right border of the relative dullness of the heart along the right edge of the sternum, the left border of the relative dullness of the heart along the left midclavicular line, the upper border of the relative dullness of the heart along the 2nd rib. Heart sounds: muffled, rhythmic. Heart murmurs: absent. BP (l) 120/80 mm[Hg], BP (pr) 140/90 mm[Hg]. Pulse: 100 per minute, heart rate 100 per minute, rhythmic. Digestive system: Tongue: clean, moist. Abdomen: soft, symmetrical, painless on palpation. Symptoms of peritoneal irritation: negative. Peristalsis: active, pathological masses in the abdominal cavity are not palpable. Liver: not enlarged. Gallbladder: Palpation of the projection of the gallbladder is painless. Spleen: not palpable. bowel function is not impaired. Urinary system: Kidneys: not palpable, Pasternatsky's symptom is negative on both sides. Urination: free, painless. Bladder: The area of the bladder is painless on palpation. Endocrine system: Thyroid gland: elastic, mobile, painless. regional nodes: not enlarged Osteo-articular system: no features

Upon admission, a diagnosis was made according to the International Classification of Functioning (ICF):

Rehabilitation diagnosis: presented in the table below with a reflection of the dynamics.

Rehabilitation potential: average Rehabilitation prognosis: favorable. Score on the Rehabilitation Routing Scale-5.

The function of external respiration from 01/17/2023. Investigation: VC: 41% FVC: 55% FEV1: 56% IndTif: 103% FEV: 106% MOS25: 109% MOS50:52%, MOS75:39%, SOS2575:60%, Conclusion on respiratory function: Moderate violations of a mixed type. Significant decrease in VC.

6 minute walk test 10 meters.

During the 18 days of stay in the rehabilitation department, rehabilitation activities were carried out according to the above scheme.

In dynamics against the background of treatment, tolerance to physical activity increased, the patient walked up to 1.5 km per day. Self care without shortness of breath.

Objective status: Respiratory system: Chest: correct shape. Percussion of the lungs: percussion over the lungs, the sound is pulmonary, on both sides. Respiration: respiratory movements are symmetrical, on both sides, vesicular breathing. Wheezes: not heard. Pleural friction rub: no. NPV: 18 per min. SpO2: 94% at rest when breathing free air

According to computed tomagrophy, there is a positive trend.

The function of external respiration from 03.02.2023. Investigation: VC: 61% FVC: 55% FEV1:60% IndTif: 103% FEV: 106% MOS25: 109% MOS50:52%, MOS75:39%, SOS2575:60%, Conclusion on respiratory function: Moderate disturbances of a mixed type. Decreased VC

6 minute walk test 150 meters.

At discharge, a diagnosis was made according to the International Classification of Functioning (ICF):

Rehabilitation diagnosis in dynamics: according to the ICF

domain On admission At discharge s 410 Structure of the cardiovascular system 1 1 s 430 Structure of the respiratory system 4 3 b 440 Breathing functions (breath rate, inspiratory depth) 3 2 b 450 Additional respiratory functions (cough) 2 1 b 455 Functions of exercise tolerance 3 2 b 460 Sensations associated with the functioning of the cardiovascular and respiratory systems (feelings of heaviness in the chest, irregular heartbeat, dyspnea, shortness of breath, suffocation, lump in the throat, spasm and wheezing) 3 2 d 450 Walking 4 2

Rehabilitation potential: average Rehabilitation prognosis: favorable. Assessment according to the Scale of rehabilitation routing in dynamics 4.

Claims (6)

A method for complex rehabilitation of patients after suffering COVID-19 with lung damage at the second stage of medical rehabilitation, including exercise therapy, vibration-compression therapy, respiratory muscle training, characterized in that the procedures are carried out for 17-21 days when the saturation index is more than 92%, and the following is carried out: dosed walking with the speed of steps, calculated individually according to the formula of D.M. Aronov; as exercise therapy, patients perform breathing exercises, exercises for small muscle groups under the control of heart rate, SpO2, respiratory rate, before the start of exercise, in the middle and after, with a course of at least 10 procedures; mechanotherapy using the MOTOmed viva2 device, where the initial - preparatory stage: 5-10 sessions at a pace of 30-40 rpm, with a power of up to 5 W, 5-10 minutes, then increase the load level to the intensity mode at the rate of 50-60% of the maximum - 10-12 sessions, with an increase in the number of revolutions up to 50-60 per minute and a power of 10 W until the heart rate increases in the first 3 minutes after mechanotherapy by no more than 2 0 beats / min, and breathing - no more than 6 per minute from the original; respiratory muscle training using the Threshold IMT breathing simulator - training is carried out daily during the entire rehabilitation course, 3 times a day, starting from 5 minutes, with a gradual increase to 15 minutes; daily vibration-compression therapy using The Vest Airvay Clearance System, with an interval from meals of at least 40 minutes, a course of at least 10 procedures.