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Hello, everyone. My name is Rachel Malls is I'm a consultant. Respiratory physiotherapist by background. Currently working is associate director every other therapies at the right Brompton and hair field hospitals. But really, I speak today on behalf of all the amazing Allied health, professional and support staff that I've had the pleasure to work with. Durian this terrible cold in 19 pandemic. And that's in the Northwest and here in London and on the many intensive care and respiratory wards I've had the pleasure to work on, including any chest Nightingale London. Where was Chief HP? Um, I told today, is on challenges and strategies for rehabilitation during called in 19. 1st of all, I cannot emphasize as much the importance of an understanding the pathophysiology of sauce cough, too, when we think about how devastating this virus could be. Now we know the predominant mold of transmission first alcove to is from person to person by respiratory droplets, mainly by coughing, sneezing, talking with this high level viral shredding that takes place in the upper respiratory tract. Particular good, the nasal in the bronchial epithelial cells, and it's through this viral spike protein here on the top left hand picture with the S protein that binds to these two receptors, which allow the Corona virus and to the whole cell, as you can see here on the right hand side. And it's important to remember that the RV all I itself so looking down the middle of the picture here is a single cell membrane in chest tight one cells and type two cells that continues to fucked, and that helps maintain surface member intention. And you have. These are viola macrophages, which protect the loan, and when you have something that comes in like a foreign body or in this case, a virus, it in causes this pro inflammatory effect by causing and this pro inflammatory like a Demadex fluid to come in in. How bring all of the's really important antibodies that will help fight infection. And this causes a scientist kind storm. A pro inflammatory effect which will cause pulmonary Deemer to develop it, will cause an influx of monocytes and neutrophils help fight the virus. It will cause damage to the epithelial cell itself. On Dwork caused the activation of coagulation, which needs to these microthrombus formation and can cause pulmonary thrombosis. And it's it's proinflammatory effect, which was compatible with early stage acute respiratory distress syndrome. Now, when we think about the respiratory implications, there is overwhelming evidence to support and suggest the SARS cough two viruses complex with several clinical manifestations that involves the central on peripheral nervous system, particularly with patients hospitalized of corporate 19. And we do see these neurological consequences and other viruses, such as in the sauce and the mayor's epidemic. And we do also know the neurological manifestations of corporate. 19 are common in disabling enough to have both short and long term impact on population health. And it's what we're seeing in these patients with Long Corbett. And when we're thinking about how the possible neurological damage related and induced by SARS cough to can happen, it's important to understand the normal immune reactions to viral infection in the brain. And, for example, then you were invasive capacities and the new inflammatory events that may lead to the short, long term, your pathologies we see and I really like this paper, I'm highlighting it to. It shows that solves cop to is newer trophic, which causes the replication and new Ron's, and it has a potential probably toe enter the central nervous system through east to receptors in the olfactory bulb on also through the central nervous system itself in the cranial nerves. And it's this whole reaction here that causes the alterations in mental status of confusion, disorientation, agitation, comment of Philly fatigue, which we can collectively could define as and careful apathy Onda again. This is probably further implicated by the Hae poxy. Receive the hypertension on the renal failure and, of course, heavy doses of sedatives. And I just want to draw it to this paper just published last month in The Lancet that included two over 2000 adult patients from 69. I see use a cross 14 countries with severe audio secondary to corporate 19, and they looked at incidents of calmer related, obviously to requirements of respiratory support. On found that over 80% of patients how were in an induced calm it when they were having, um, significant respiratory support, which isn't surprising. But over 50% developed a Librium all the time, and this supported the Chinese data, where they found 45% of patients hospitalized recorded, 19 had nervous system symptoms, including delirium, saw regardless of the exact pathophysiology was seeing significant and couple oscopy in hospitalized over 19 patients, which significantly effects orientation awareness and engagement and rehabilitation. And that is further impacted by the environment that we see in a Corvette. 19 respiratory hike, a unit are intensive care unit. We've spent years humanizing the icy use and almost all the night they've become the most hospital hostile environment that many of us will ever work in. There's no personal items. There's no pictures, is no family visits. There's no interaction with the outside world of been staff dressed in enhanced PP. Many makeshift eyes he use don't have windows, they don't have curtains, they don't have screens. And for a week patient, this could be particularly traumatic. A swell a saying potentially multiple deaths on the intensive care respiratory I care unit every single day. And this, of course, infects and effects of engagement and rehab not just in critically ill patients, but those in the rehab boards and the respiratory wards. And this is where the therapist, for example, or teas in clinical psychologists really come into their own. So I want to just really back through some of the search short term complications that were saying that I could talk about this. Um, all day we're seeing airway. DMI was seen this in the first wave. We're seeing this, and continued waves were seeing pulmonary secretions that are a problem. Ongoing high oxygen requirements, rapid D saturation d recruitment, delirium as I've mentioned persistent cough in patients, breathlessness on rest and exertion, dysfunctional breathing patterns related to anxiety, fatigue, ongoing joint pain and neuropathy and weakness related to you. Urological insults have just explained, but really one of the most important challenges is that these patients are sore, predictable. From the moment the end to the ambulance off the end of the emergency department, we don't know how quickly they're going to deteriorate the some. We sometimes have this false sense of security that the stabilize, particularly if they are on high fluoxetine, the CPAP. But it's really important. We rely on a multi system assessments, continuous monitoring, early interventions, decisions and escalation plans. Now airway management. It's pop is problematic. In a percentage of these patients, we know that laryngeal edema is reported not to 55% of all patients requiring and following trick you trivial extra vacation and the icing you. Sometimes it's apparent immediately on extra vacation. Sometimes it develops over 24 48 hours and we're probably saying an increase in this patient population because the length of time they are into a tid, particularly with trivial intubation, is longer. You know well over 28 days. We also know that the Corona viruses caused laryngitis, inflammation of voice box in the larynx on again, this confer cyst post extrication as well. On when we do extra beat a decannulate these patients, we all seeing an incident stride all communication, difficulty, swallow difficulties. And, as I said, this ongoing airway edema on speech and language therapist, of course, come into their own year is the experts of a reassessment in lots of collaboration with our ENT colleagues and for patients that are integrated with endotracheal tube undergoing an extra vacation, conflict tests have become the norm. The standard of it is usually practice to perform a conflict test just because of the incidents of lowering the gym, and Strider was saying, and for those patients being decannulated with the track your ostomy, we are advocating these of sporadic suction tubes to allows the blood of drainage but also dream and of soup. Um, Subglottic air flow to help with three sensitization of desensitization is part of the weaning process, and it's important to anticipate airway edema for extra patient decannulation to these patients do to the complications and addition challenges that exist with having relevant stuff around. If patients do require intubation equipment and obviously juice do the airborne nature of intubation, um, itself And I really wanted just highlight this brilliant paper from Dr Sally are two incredible consultant XL tea from GI STT. Her team reviewed 100 and 64 patients, and they looked at those of that truck us to me. Is it being intubated on the amount of SLT input required urine in Patients Day and those that required community follow? A particularly for dysplasia, which was just in the 8% of all their patients. We massively under estimated the nutritional complications of these patients in the first wave. We know how important are dietetic colleagues are in managing the nutritional challenges of the critically on, well patient on the risperidone, or e and well, patient. But for these patients, that Dean on well, sometimes up to 10 days before they were admitted. The first wave was an older population patients well into the sixties. This is a slightly younger generation of patients were saying and this wave, but they made it being on welfare days before admission they were. They're probably malnourished when they come in. At least 25 to 40% of all patients have a least one more bang call mobility. We're seeing diabetes in this patient population, approximately 75% of all corporate 19. I see you patients are classified. Are all the weight all or BCE, according to the economic data, was saying my nutrition with scaly or muscle mass loss with functional impairment difficulties with supplemental feeding, long periods of sedation and paralysis and prone positioning, the laid gastric mt and high protein the crime. Is this cat a polyp state? I mean, I could go on if patients on fed and they don't get their calorific intake with good nutritive sources. Then that's a problem, because we can't rehabilitate the memory complex additional energy demands on them because they're in this metabolic state. So a really challenging a shoutout are dietetic colleagues. Now all teas bring a completely unique perspective to acute rehab, be mental and physical, health trained. And they really focus on a person's ability to participate not only in daily life but the environment that they're in in the relate all of this, the occupation. Where know that people waking up on a critical care unit being told got Corvette? Maybe being surrounded on a completely alien traumatic environment has a deep impact on someone psychological, physical and cognitive ability to engage on Teo to communicate. So the authorities will consider the environment there work of humanizing the environment there in the critical care of the respiratory ward important with barrier such as ppd and social family isolation, there's a focus on interventions that are meaningful that I felt functional, that a vocational, what he's have a real force under leery and management and cognitive deficits which were seeing so frequently in these patients. The have a lot of sleep disturbances and nightmares and daughters can really encourage asleep. I gene strategies pervade management strategies for anxiety long mood which, of course, things into breathing pattern, breathlessness and overall engagement with, um with rehabilitation. And at this point, I really want to give a shoutout to the Christian role of psychological services that the health nurses, clinical health consul and psychologists in the role in recovery for all patients but particularly called 19 patients now physiotherapists, physiotherapists, our standard in common place and most intensive cane. It's a respiratory words at least I hope so. Um, huge role in positioning and limb care for these patients on a specific chest visual therapy now for think back to the first wave. I mean, we didn't anticipate the amount of chest physiotherapy these patients would need, and certainly the 2nd and 3rd wave we have horned in on our manual chest. Physiotherapy techniques. So using percussion expertise vibrations there manually Sister cough. Combining this with ventilator optimization. The use of combined saline and suction with manual techniques. Problem positioning toe help airway clearance but also ventilation on doing significant chest physiotherapy with some patients. Before we we deprogram patients. This all contributes to reading from mechanical ventilation and, as I said we've seen must've delayed weaning in these patient populations, needing much longer periods of sedation and paralysis, which in turn leads to increased challenges and rehabilitation, which I took China bit more on a second but one of the main reasons, I think in one of the impacts of challenges and rehabilitation. Now is there a consequence of national and local lockdowns for which are coming up to 12 months now? On Dwell, seeing poor nutritional habits in the public was seeing a younger population of patients are saying maybe less exercise significant deconditioning and I honestly believe that's what's impacting on rehabilitation. At this stage in the pandemic, secretion management is complex. It's mixed pictures. It's impossible to predict with relied on mucolytic some units starting them from the admission of the patient, including car. The Sistine use of hypotonic saline nebulizer is to help the juice we sputum viscosity and these a recurrence, particularly when combined with just physiotherapy prone positioning of, I said, Really effective for secretion management in the you much itching and also three quarter side lying three quarter prone and, of course conscious are a week prone ing and our patients on the respiratory ward. And as much as we shied away from mechanical airway clearance devices in the first wave were definitely using them in this second wave and third wave, just with additional precautions. Of course, I mentioned several times these patients day sedate and per eyes for longer. This causes increased joint pain. Were saying really strange neuropathies that are just not related to prodding but probably related to you if you think back to the passage physiology in the new Americanisms on the second slide. But passive movements have been really important. Actually, this this's something anyone can perform the patient here in the pictures on ECMO. So we do have limitations in terms of joint movements, but just anything to keep the patient regular position regular turned to prevent pressure sores, too, at routine in um on the use of hell. Protectors and floor transact sector are really important now. What are the rehabilitation challenges? Well, there are many, So we're working an environment that's hostile where it's part to communicate where we've lost that humanization. We're working with stuff we've never worked with before. We have redeployed stuff. We have one critical care nurse to three or four patients in in parts of the surge one critical kernels to six patients. We relied on bedside support and redeployed work as that may have not worked in intensive care unit before. Therefore, we have to plan and prepare rehabilitation really carefully. We have to make sure there's enough skill people around, even from a therapy perspective. One. Where is surging 234 times are critical. Can response unit capacity. We need to make sure we've got enough hands on deck to help rehabilitate the patient. It has to be mean and fill. It has to be functional. We're seeing short, sharp sessions with these patients because of fatigue because of cognitive impairments because of their engagement of rehabilitation. The rapid d saturations the the recruitment on, of course, some of the red flags we're picking up on. So we proceed with caution. We normally preoxygenated patients on oxygen therapy on ventilation. That's just something between that become a standard. And we know what our rescue techniques are but is, well, one of the things were very main, full of assist trauma that people feel and this survivor guilt and this fear that they're going to get on well, if the participate in rehab, I just want to touch on this paper, please take the reference down and take a picture. Great people. What I love about it is it relates the acute Corbett 19 symptoms to those seen and the pores Corvin 19, follow up. So what we're doing in this way this We're really educating the patients to say this is why you're breathless. This is why your fatigue looking out for cardiopulmonary and the additional thromboembolic disease were saying in patients and the cute stage and also when they discharged in this neurological so quietly, including this brain fog in this cognitive impairment. So really trying to educate from the very start about why they're feeling this, And I just want to pause for a second so you can take my details down in terms of my email address and also my twitter handle. If you want to ask any questions before, I sure I'm sure you're very short video now This is Sam in San was transferred to the right Brompton Hospital from North Week Park on the 22nd of March with severe covered 19 related lung disease. Northwest part is an incredible hospital. I've been fortunate enough to be there, see the team, see how the work and they're one of the first hospitals, the first in London to crack declare a major incidents secondary to the huge demand on their critical current respiratory services On the 29th of May, Sound was discharged 72 years young and type of celebrating son's birthday. And this is his story. It's been a journey for me. Rough one. One night. I had a bad experience, all kind of nightmare. It was scary. I drive. My son died a sin. No, I didn't leave one. Let me die. I did not sleep for the whole night. Following that, they sent me a nurse. I said, You're like my mom. She said, I'm not really enough to me to be a month. I said, There is a touch, Very hearing. So every step of the way I felt I was getting stronger. I began to feel the change. Gradual. I begin to use my legs and my hands on in the past two weeks. Hey, folks, that talking about home, I want a home. It was like a I know the infusion off energy, those folks who touch me really touching my life. Okay, I'm so glad I'm going home with all the images. I wouldn't be here today and I'm truly grateful. Yeah, thank you very much for listening