Chest CT Findings at Six Months Following COVID-19 ARDS - Correlation With the mMRC Dyspnea Scale and Pulmonary Function Tests.

Background: Many survivors of severe COVID-19 pneumonia experience lingering respiratory issues. There is limited research on follow-up chest imaging findings in patients with COVID-19 ARDS, particularly in relation to their mMRC dyspnea scores and pulmonary function tests (PFTs). This study addresses this gap by investigating the clinical characteristics, mMRC dyspnea scores, PFTs, and chest CT findings of COVID-19 ARDS patients at the 6 months post-recovery. By analyzing these variables together, we aim to gain a better understanding of the long-term health consequences of COVID-19 ARDS. Methods: This prospective observational study included 56 subjects with COVID-19 ARDS with dyspnea at the six-month follow-up visits. These patients were evaluated by chest CT, mMRC dyspnea scale, and PFT. The CT severity score was calculated individually for each of the four major imaging findings - ground glass opacities (GGOs), parenchymal/atelectatic bands, reticulations/septal thickening, and consolidation - using a modified CT severity scoring system. Statistics were carried out to find any association between individual CT chest findings and the mMRC dyspnea scale and forced vital capacity (FVC). p values < 0.05 were considered statistically significant. Results: Our study population had a mean age of 55.86 ± 9.60 years, with 44 (78.6%) being men. Grades 1, 2, 3, and 4 on the mMRC dyspnea scale were seen in 57.1%, 30.4%, 10.7%, and 1.8% of patients respectively. Common CT findings observed were GGOs (94.6%), reticulations/septal thickening (96.4%), parenchymal/atelectatic bands (92.8%), and consolidation (14.3%). The mean modified CT severity scores for GGOs, reticulations/septal thickening, parenchymal/atelectatic bands, and consolidation were 10.32 ± 5.51 (range: 0-21), 7.66 ± 4.33 (range: 0-19), 4.77 ± 3.03 (range: 0-14) and 0.29 ± 0.91 (range 0-5) respectively. Reticulations/septal thickening (p = 0.0129) and parenchymal/atelectatic bands (p = 0.0453) were associated with an increased mMRC dyspnea scale. Parenchymal/atelectatic bands were also associated with abnormal FVC (<80%) (p = 0.0233). Conclusion: Six-month follow-up chest CTs of COVID-19 ARDS survivors with persistent respiratory problems showed a statistically significant relationship between increased mMRC dyspnea score and imaging patterns of reticulations/septal thickening and parenchymal/atelectatic bands; while parenchymal/atelectatic bands also showed a statistically significant correlation with reduced FVC.

Etapa subaguda de pos-COVID-19 grave o crítico. Rehabilitación musculoesquelética, respiratoria y uso de corticoides. Experiencia de la Unidad de Rehabilitación del Hospital del Banco de Seguros del Estado (URHBSE) / Subacute stage of severe or critical post-COVID-19. Musculoskeletal and respiratory rehabilitation, and use of corticosteroids. Experience of the rehabilitation Unit of the Banco de Seguros del Estado Hospital (URHBSE) / Estadio subagudo de pós-COVID-19 grave ou crítico. Reabilitação musculoesquelética e respiratória e uso de corticosteroides. Experiência da Unidade de Reabilitação do Hospital do Banco de Seguros do Estado (URHBSE)

Introducción: en los pacientes que cursaron COVID-19 grave o crítico se ha descripto el uso de prednisona y rehabilitación musculoesquelética y respiratoria. No está claramente establecido el rol de estas intervenciones, ni el momento óptimo para su inicio. En este trabajo se muestran los resultados de la Unidad de Rehabilitación del Hospital del Banco de Seguros del Estado (URHBSE) que implementó un programa de rehabilitación integral y uso de corticoides en la etapa subaguda de pacientes pos-COVID-19 grave o crítico, con un enfoque sistematizado, trabajando desde la interdisciplina y centrado en la persona atendida. Se reportan hallazgos al ingreso, requerimiento de oxígeno, escala de Barthel, patrones tomográficos, uso de corticoides, su respuesta y complicaciones. Se describen los resultados de este enfoque sobre variables clínicas, respiratorias y funcionales. Material y método: estudio descriptivo, retrospectivo, de pacientes pos-COVID-19 que completaron la rehabilitación en la URHBSE, en el período comprendido entre abril y agosto de 2021. Datos obtenidos de revisión de historias clínicas. Análisis estadístico con PRISM (v8.2.1). Resultados: completaron el programa de rehabilitación 84 pacientes. Al ingreso a la URHBSE, 55% tenía dependencia total o grave en la escala de Barthel. No lograba marcha el 48%. Requería oxígeno el 89,2% de los pacientes con una media de saturación de 90,3 ± 4,8. El 25% ingresó requiriendo máscara con reservorio. Todos los pacientes que comenzaron el programa se encontraban en fase subaguda de la enfermedad (4 a 12 semanas), y recibieron un plan de rehabilitación integral e individualizado. El objetivo era alcanzar una situación funcional similar a la que presentaban previo al COVID-19. La duración de la internación en la URHBSE fue de 23,5 ± 13,8 días. A 76 pacientes (90,5%) se les realizó tomografía de alta resolución de tórax (TACAR), resultando patológica en 96,1%. Predominaba el vidrio deslustrado (49,3%), la consolidación en 8,23% y un patrón de tipo fibrosis like en 30,13%. Se detectaron alteraciones tomográficas "no típicas" de daño pos-COVID (derrame pleural, nódulos cavitados, cavidades apicales, etc.) en 11,8% de las tomografías. En dos pacientes (2,6%) se halló una aspergilosis pulmonar y en 6,6% tromboembolismo pulmonar. Recibieron prednisona 44 pacientes (52,3%). En 63,4% se suspendió el aporte de oxígeno en los primeros 15 días desde el inicio de prednisona. Encontramos asociación entre el patrón tomográfico con vidrio deslustrado y la suspensión precoz del aporte de oxígeno desde el inicio de prednisona (p = 0,047). A pesar del alto grado de colonización, incluso en aquellos casos en que utilizamos prednisona, no observamos infecciones por microorganismos colonizantes. Comparando ingreso y egreso se hallaron diferencias estadísticamente significativas en los siguientes parámetros: el grado de disnea, el requerimiento de oxígeno (un solo paciente fue dado de alta con oxígeno), la saturación, el grado de instrumentación (traqueostomía, sonda nasogástrica, etc.), y la escala de dependencia de Barthel. En cuanto a las variables respiratorias solo contamos con el dato de la presencia de disnea de los primeros 35 pacientes, de éstos, 83% presentaba disnea al ingreso, mientras que solo 17% la presentaba al egreso (p < 0,0001). Hubo, asimismo, diferencias significativas en el requerimiento de oxígeno entre el ingreso y el egreso (p < 0,0001) y en el grado de dependencia medido en la escala de Barthel, teniendo dependencia total o grave al ingreso 55% de los pacientes y solo 3,4% al alta. Conclusiones: las intervenciones realizadas en la etapa subaguda de la enfermedad se asociaron con mejoras significativas en variables de interés clínico. Faltan más estudios para definir el rol y el momento exacto del inicio de los corticoides y la rehabilitación en este grupo de pacientes. (AU)

Introduction: In patients with severe or critical COVID-19, the use of prednisone and musculoskeletal and respiratory rehabilitation has been described. The role of these interventions and the optimal time for their initiation are not clearly established. This study presents the results of the Rehabilitation Unit of the Banco de Seguro del Estado Hospital, which implemented a comprehensive rehabilitation program and the use of corticosteroids in the subacute stage of patients with severe or critical post-COVID-19, with a systematic approach, working interdisciplinary and centered on the person being treated. Findings at admission, oxygen requirement, Barthel scale, tomographic patterns, use of corticosteroids, their response, and complications are reported. The results of this approach on clinical, respiratory, and functional variables are described. Method: Descriptive, retrospective study of post-COVID-19 patients who completed rehabilitation at the Rehabilitation Unit of the Banco de Seguros del Estado Hospital (URHBSE) in the period April-August 2021. Data obtained from review of medical records, statistical analysis with PRISM (v8.2.1). Results: Eighty-four patients completed the rehabilitation program. Upon admission to the URHBSE, 55% had total or severe dependence on the Barthel scale. Forty-eight percent were unable to walk. Eighty-nine-point two percent required oxygen, with a mean saturation of 90.3 ± 4.8. Twenty-five percent of patients were admitted requiring a reservoir mask. All patients who entered the program were in the subacute phase of the disease (4 to 12 weeks) and received a comprehensive and individualized rehabilitation plan. The objective was to achieve a functional situation similar to what they had before COVID-19. The length of stay at the URHBSE was 23.5 ± 13.8 days. A total of 76 patients (90.5%) underwent high-resolution chest tomography (HRCT), which was pathological in 96.1% of cases. The predominant findings were ground-glass opacity in 49.3% of cases, consolidation in 8.23%, and a fibrosis-like pattern in 30.13%. "Non-typical" post-COVID damage tomographic alterations were detected (pleural effusion, cavitary nodules, apical cavities, etc.) in 11.8% of the tomographies. In 2 patients (2.6%), pulmonary aspergillosis was found, and in 6.6%, pulmonary thromboembolism. Forty-four patients (52.3%) received prednisone. In 63.4% of cases, oxygen supplementation was discontinued within the first 15 days from the start of prednisone. We found an association between the ground-glass opacity tomographic pattern and early discontinuation of oxygen supplementation from the start of prednisone (p = 0.047). Despite the high degree of colonization, we did not observe infections by colonizing microorganisms, even in those who used prednisone. Comparing admission and discharge, statistically significant differences were found in the following parameters: degree of dyspnea, oxygen requirement (only one patient was discharged with oxygen), saturation, degree of instrumentation (tracheostomy, nasogastric tube, etc.), and the Barthel dependency scale. Regarding respiratory variables, we only have data on the presence of dyspnea in the first 35 patients. Of these, 83% had dyspnea at admission, while only 17% had it at discharge (p < 0.0001). There were also significant differences in the oxygen requirement between admission and discharge (p < 0.0001) and in the degree of dependency measured on the Barthel scale. Fifty-five percent of patients had total or severe dependence at admission, compared to only 3.4% at discharge. Conclusions: The interventions carried out in the subacute stage of the disease were associated with significant improvements in clinical variables of interest. More studies are needed to define the role and the exact timing of the initiation of corticosteroids and rehabilitation in this group of patients.

Introdução: O uso de prednisona e reabilitação musculoesquelética e respiratória foi descrito no tratamento de pacientes com COVID-19 grave ou crítico. O papel destas intervenções e o momento ideal para o seu início não estão claramente estabelecidos. Este trabalho mostra os resultados da Unidade de Reabilitação Hospitalar do Banco de Seguro del Estado que implementou um programa abrangente de reabilitação e uso de corticosteroides na fase subaguda de pacientes graves ou críticos pós-COVID-19, com uma abordagem sistematizada, trabalhando de forma interdisciplinar e centrada no paciente. São relatados os achados na admissão, a necessidade de oxigênio, a escala de Barthel, os padrões tomográficos, o uso de corticosteroides, a resposta ao tratamento e as complicações. Os resultados desta abordagem sobre variáveis clínicas, respiratórias e funcionais são descritos. Material e métodos: Estudo descritivo e retrospectivo de pacientes pós-COVID-19 que completaram reabilitação na Unidade de Reabilitação do Hospital Banco de Seguros del Estado (URHBSE) no período de abril a agosto de 2021. Os dados foram obtidos dos prontuários de pacientes com posterior análise estatísticas usando PRISM (v8.2.1). Resultados: 84 pacientes completaram o programa de reabilitação. No momento da admissão na URHBSE, 55% apresentavam dependência total ou grave da escala de Barthel. 48% não conseguiam se mover. 89,2% necessitaram oxigênio com saturação média de 90,3 ± 4,8. 25% dos pacientes foram internados necessitando máscara com reservatório. Todos os pacientes que ingressaram no programa estavam na fase subaguda da doença (4 a 12 semanas) e receberam um plano de reabilitação abrangente e individualizado. O objetivo era alcançar uma situação funcional semelhante à que apresentavam antes da COVID-19. O tempo de permanência na URHBSE foi de 23,5±13,8 dias. A tomografia de tórax de alta resolução (TCAR) foi realizada em 76 pacientes (90,5%); os resultados foram patológicos em 96,1%. O vidro fosco predominou em 49,3% deles, a consolidação em 8,23% e o padrão fibroso em 30,13%. Alterações tomográficas "atípicas" de danos pós-COVID (derrame pleural, nódulos cavitados, cavidades apicais, etc.) foram detectadas em 11,8% dos exames tomográficos. Aspergilose pulmonar foi encontrada em 2,6% dos pacientes e tromboembolismo pulmonar em 6,6%. 44 pacientes (52,3%) receberam prednisona. Em 63,4% a oferta de oxigênio foi suspensa nos primeiros 15 dias após o início da mesma. Encontramos associação entre o padrão tomográfico em vidro fosco e a suspensão precoce da oferta de oxigênio desde o início da administração da prednisona (p = 0,047). Apesar do alto grau de colonização, mesmo naqueles que usaram prednisona, não observamos infecções. Em relação às variáveis respiratórias, só temos dados sobre a presença de dispneia nos primeiros 35 pacientes; destes, 83% apresentavam dispneia na admissão, enquanto apenas 17% a apresentavam na alta (p< 0,0001). Observou-se também diferenças significativas na necessidade de O2 entre a admissão e a alta (p< 0,0001) e no grau de dependência medido pela escala de Barthel, com 55% dos pacientes apresentando dependência total ou grave na admissão e apenas 3,4% na alta. Conclusões: As intervenções realizadas na fase subaguda da doença foram associadas a melhorias significativas nas variáveis de interesse clínico. São necessários mais estudos para definir o papel e o momento exato do início dos corticosteroides e da reabilitação neste grupo de pacientes.

Clinical condition, Resuscitation and Medical-Psychological Care of Severe COVID-19 patients (part 2).

Respiratory rehabilitation is the penultimate step in the medical management of patients with severe COPD-19. It is an essential step before patients' returning home, and is usually carried out in specialised Follow-up and Rehabilitation Clinics. When discharged from hospital, patients with post-severe COVID-19 usually progress in their medical condition. However, they may remain frail and have a constant fear of possible deterioration leading to (re)hospitalisation and a return to baseline. Psychological support in this phase can reduce patients' anxiety and increase their motivation to carry out daily rehabilitation activities. This support provides a stable and consistent basis for patients to focus on their progress, leaving the difficulties behind. Being aware of the improvements in their physical condition allows them to maintain their motivation to continue to be physically active. Psychological support during respiratory rehabilitation aims at preparing patients to return to the normal life they had before the disease. It is usually based on brief psychotherapies that focus on strengthening the patient's abilities through behavioural changes and through reducing risk behaviours. Only after this phase is it sometimes possible to deal with complex issues and to cope with personality mechanisms and maladaptive behaviour patterns.

La réadaptation respiratoire constitue l'avant-dernier étage dans la prise en charge des patients COVID-19 sévère, une étape essentielle avant de retrouver leur vie quotidienne. L'accompagnement psychologique occupe une place importante dans cette étape. Cette réadaptation s'effectue habituellement dans une clinique de Soins de Suite et de Réadaptation (SSR) spécialisée. On peut généralement affirmer que les patients post-COVID-19 sévère sortis de danger vont progresser. Cette progression peut se décrire à travers le modèle de la spirale ascendante. Ce sont, néanmoins, des patients fragiles, pour lesquels on craint perpétuellement une dégradation rapide des paramètres physiologiques qui risque de les ramener vers une (ré)hospitalisation d'urgence et un retour vers la case de départ. L'accompagnement psychologique empêche les sensations négatives d'occuper le devant de la scène et d'aspirer le patient vers le bas. Il permet de baisser les angoisses et d'augmenter les motivations pour effectuer des activités de réadaptation quotidiennes. De cette manière, cet accompagnement a des retentissements physiologiques importants, permettant aux patients de progresser en voie de guérison, malgré certaines séquelles occasionnées par la maladie. Cet accompagnement psychologique permet, également, de préparer les patients à leur retour à la vie d'avant et d'adoucir l'impact traumatisant des souvenirs douloureux. Le patient peut les regarder de nouveau et leur redonner un sens moins troublant. Le travail psychologique vise à rassurer ces personnes qui ont perdu confiance en leur corps. On tend à favoriser des thérapies brèves qui mettent l'accent sur les renforcements des capacités, sur les changements comportementaux et le sevrage des produits, avant d'agir sur les mécanismes de coping et sur les schémas inadaptés plus profonds.

Clinical condition, resuscitation and medical-psychological care of severe COVID-19 patients (part 1).

This interview covers the clinical and psychological condition of patients afflicted with severe COVID-19 and their pulmonary rehabilitation process. For these patients, symptoms are medically urgent and life-threatening. The sequelae of this viral attack and immune response to it are significant, and often persist for months after discharge from intensive care. To understand the medical and psychological state of these patients, a description is given of the organs affected, the oxygen cycle in the body and the medical care procedures that are used to help patients with dysfunctional respiratory systems. The link between physical and psychological progress is described. Physical weakness results from pulmonary sequelae and deconditioning, and is often experienced by patients as mental fatigue similar to psychological depression. This may draw the patient into a downward spiral, with multiple health aspects deteriorating, independently of the resolution of initial problems. Conversely, a positive physical or psychological evolution may lead to the evolution of the other. Thus, reversing the negative trend for just one system component can delay, completely arrest the spiralling down, or transform it into an upward spiral, improving the patient's condition. In addition, for people undergoing severe COVID-19, the return to normal life could be destabilizing and memories that arise from their crisis state may trigger Post-Traumatic Stress Disorder (PTSD). Health and psychosocial professionals hold an important role both in post-hospital care and in secondary prevention, i.e. prevention of relapse and re-hospitalization. Physical rehabilitation work must take these psychological factors into account, in the same way that any psychological follow-up is supposed to consider physiological factors.

Cet entretien porte sur l'état clinique médicopsychologique des patients atteints de COVID-19 sévère et sur leur réadaptation respiratoire. Pour ces patients, les séquelles de l'attaque virale et de la réaction immunitaire sont importantes et apparentes dans les tests fonctionnels et les imageries médicales. Elles persistent souvent quelques mois après la sortie des soins intensifs. Le virus SARS-CoV-2 provoque des atteintes des muqueuses bronchiques et alvéolaires. Le circuit de l'oxygène dans le corps peut être découpé en trois maillons imbriqués: l'ensemble de l'appareil respiratoire, le système cardiovasculaire, les muscles et le métabolisme énergétique. Ces systèmes fonctionnent en interdépendance. Lorsqu'il y a une défaillance de l'un des éléments, les autres sont touchés, pouvant amener l'ensemble à une décompensation. La décompensation respiratoire désigne la défaillance ou l'incapacité du système à fonctionner. Les patients sont hospitalisés en réanimation et bénéficient d'une supplémentation en oxygène, d'un support ventilatoire pour compenser la fatigue des muscles respiratoires et d'un traitement médicamenteux visant à réduire les symptômes et à lutter contre les infections acquises. À la sortie de l'hospitalisation, les patients post-COVID-19 sévère se trouvent dans un état physique et psychologique fébrile. La sensation vécue par ces personnes est celle d'une fatigue physique et mentale ; autrement dit, l'incapacité de trouver des ressources suffisantes pour effectuer des activités simples. Cette fatigue est vécue comme une dépression, une sensation qui elle seule risque d'aspirer le patient dans une spirale descendante : soit d'une fatigue en une absence de motivation, puis de sédentarité en déconditionnement musculaire. Ainsi, il y a un lien étroit qui existe entre progrès physique et renforcement psychologique, les deux sont interdépendants, un déclin dans l'un risque d'entraîner l'autre, mais, à l'inverse, une évolution positive dans l'un fait évoluer l'autre. Se rendre compte de l'amélioration de l'état physique permet de nourrir sa motivation et de trouver de l'énergie permettant de continuer à être physiquement actif. Le travail de réadaptation physique doit tenir compte de ces facteurs psychologiques, de la même manière que tout suivi psychologique doit tenir compte des facteurs physiologiques. Pour les personnes subissant un COVID-19 sévère, le retour à la vie normale peut être déstabilisant et les souvenirs de leur état de crise peuvent déclencher un syndrome de stress post-traumatique (SSPT). Les professionnels de la santé et les psychologues jouent un rôle important dans les soins post-hospitaliers et dans la prévention secondaire, c'est-à-dire la prévention des rechutes et des ré-hospitalisations.