Case Report
C.H. Gaspari, PT, DPT, Department of
Physical Therapy, Instituto Estadual do The First 60 Days: Physical
Cérebro Paulo Niemeyer, Rua do
Resende, 156, Rio de Janeiro, RJ
20231-092, Brazil. Address all
Therapy in a Neurosurgical
correspondence to Dr Gaspari at:
cgaspari@gmail.com. Center Converted Into a COVID-19
I. Assumpção, PT, Department of
Physical Therapy, Instituto Estadual do
Cérebro Paulo Niemeyer.
Center in Brazil
R. Freire, Department of Physical Clara H. Gaspari, Iana Assumpção, Renata Freire, Ariane Silva, Cintia Santiso,
Therapy, Instituto Estadual do Cérebro Anna Carolina Jaccoud
Paulo Niemeyer.
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A. Silva, PT, Department of Physical
Therapy, Instituto Estadual do Cérebro Objective. The purpose of this case report was to describe the role of physical therapists
Paulo Niemeyer. in a neurosurgical center that was converted into a COVID-19 center for critically ill
C. Santiso, PT, Department of Physical
patients.
Therapy, Instituto Estadual do Cérebro
Paulo Niemeyer. Methods (Case Description). On March 16, 2020, the state government of Rio
A.C. Jaccoud, PT Department of de Janeiro, Brazil, determined that a neurosurgical center with 44 ICU beds equipped
Physical Therapy, Instituto Estadual do with mechanical ventilators should immediately transfer all patients with neurological
Cérebro Paulo Niemeyer. conditions to other institutions and prepare for patients who were critically ill with COVID-
[Gaspari CH, Assumpção I, Freire R, 19. The staff, including physical therapists, were trained to handle patients with COVID-
Silva A, Santiso C, Jaccoud AC. The 19, many of whom were developing acute respiratory distress syndrome (ARDS) with
first 60 days: physical therapy in a complex and multifactorial ventilatory support needs. Adjustments were made to the
neurosurgical center converted into a physical therapy routine and protocols. Following the stabilization of patients’ respiratory
COVID-19 center in Brazil. Phys Ther. condition, physical therapist interventions focused on restoring physical function.
2020;100:2120–2126.]
© The Author(s) 2020. Published by Results. A total of 116 confirmed COVID-19 cases were treated from March 17 to
Oxford University Press on behalf of May 17, 2020. Sixty percent were men (70) and 40% were women (46), with a median
the American Physical Therapy age of 59 years. Eighty-nine percent (103) underwent mechanical ventilation during
Association. All rights reserved. For hospitalization, of which 11% (11) were successfully extubated. Thirty percent (31) of
permissions, please e-mail: patients underwent tracheostomy, and 26% of those (8) were successfully decannulated.
journals.permissions@oup.com
Of the total patients, 57 patients died (mortality rate of 49%), 4 (3%) were transferred
Published Ahead of Print: to another institution, 23 (20%) were discharged home, and 32 (28%) continued to be
September 17, 2020 hospitalized.
Accepted: September 13, 2020
Submitted: May 22, 2020
Conclusion. Physical therapists in the ICU can facilitate care for critical events such
as intubation, patient positioning, ventilatory adjustments, extubation, and functional
training.
Impact. The coronavirus pandemic has highlighted the importance of physical therapists,
specifically in the care of patients who are critically ill with COVID-19. The availability
and expertise of physical therapists in the ICU are important for managing critical events
such as intubation, patient positioning, ventilatory adjustments, extubation, and functional
training.
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2120 Physical Therapy Volume 100 Number 12 2020
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P
hysical therapists are part of the professional teams IECPN had to write its own unprecedented conversion
involved in the management and care of patients roadmap. After suspending scheduled
infected with coronavirus disease (COVID-19).1,2 neurosurgeries and transferring all patients, the hospital
Their specific role varies widely in different parts of the equipped all 44 ICU beds with mechanical ventilators and
world. In several countries, the emphasis of physical began training the staff for their new role. Our team of
therapy is on restoring physical function and physical therapists, until then proficient in treating
rehabilitation3 ; in others, the focus rests predominantly patients after neurological surgery, started to handle
on ventilatory care.4 In Brazil, where respiratory patients critically ill with COVID-19, many of whom were
therapy is not viewed as a separate field, the patient’s developing acute respiratory distress syndrome (ARDS)
ventilatory management is performed by physicians with complex and multifactorial ventilatory support
and physical therapists in the intensive care unit needs.
(ICU).1,5
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The work dynamic of ICU-based physical therapy in Brazil Team Resizing and Restructuring
is different when compared with settings in which The department, originally staffed with 37 physical
respiratory therapists perform respiratory and ventilatory therapists, was increased by an additional 18 hires to meet
care. According to Brazilian National Health Surveillance the influx of patients requiring constant mechanical
Agency regulations, a certified ICU must have at least 1 ventilation adjustments and complex care. Reports of
physical therapist for every 10 ICU beds.6 Brazilian increased contamination among health care workers
physical therapists are part of the decision-making team abroad17,18 were also contemplated for possible future sick
for invasive and noninvasive ventilatory management.7 leave.
In times of COVID-19, this means being at high risk
for contamination and aerosol-generating Other disciplines also quickly adapted to the new
procedures—intubation, extubation, and noninvasive demands. Anesthesiologists, who normally assisted in
ventilation procedures—placing physical therapists in neurosurgeries, became part of the team of intensivists
direct contact with SARS-CoV-2 (the virus causing caring for patients with COVID-19. Their expertise in
COVID-19).2 difficult intubations and other invasive procedures were of
immense benefit. Outside physicians joined the inhouse
intensivist staff, and neurointensive care pediatricians
Becoming a COVID-19 Center for People began caring for adult patients. Adaptability became the
Who Are Critically Ill greatest challenge for each member of every team.
The first reported case in China occurred on December 1,
20198 ; the first death in Wuhan province was reported on On March 17, the first patient with COVID-19 arrived,
January 11, 20209 ; and, on March 13, the United States had 1 day after receiving the state guidelines to convert. All 44
already declared a national health emergency.10 The first beds were occupied in the succeeding weeks and have
confirmed case in Brazil was on February 26,11 and the since been fully occupied with patients with COVID-19.
first death was registered on March 17.12 By that date,
Brazil was far behind in preparations for COVID-19:
hospitals were already reporting personal protective
equipment (PPE) shortages13 ; viral testing was being
Planning and Training
As the staff began receiving specific PPE (protective
conducted only in patients who were critically ill,14
glasses, N95/PPF2 masks, rubber-soled shoes, face shields,
contradicting recommendations by the World Health
and impermeable gowns), the infectious disease (ID)
Organization15 ; and public hospitals in the country
control team created training protocols on the proper use
already were reporting 95% occupancy of ICU
of each PPE. Knowing that most health care professional
beds.16
contamination occurs during the doffing of PPE, special
care was given to the proper sequence of doffing and
Instituto Estadual do Cérebro Paulo Niemeyer (IECPN) is a
discarding each item.19 The training sessions were led by
public neurosurgical center of excellence with 44 ICU
the ID physician and nurses, who ensured that every
beds in Rio de Janeiro, Brazil. Until early March 2020, it
professional correctly demonstrated the donning/doffing
handled a vast range of neurosurgical procedures, from
sequencing. All staff practiced 2 to 3 times in group
aneurysmal repairs to complex tumor resections. The
sessions that lasted 30 to 40 minutes.
emergency conversion of IECPN into a COVID-19 center
for people who were critically ill occurred on March 16.
On that date, the state government of Rio de Janeiro Another cause for concern was the continuous reports of
determined the hospital should immediately transfer all worldwide PPE unavailability and the ongoing perception
patients with neurological conditions to other institutions that IECPN could also run short of such crucial
and get ready for patients who were critically ill with equipment. As suppliers struggled to provide the items
COVID-19. and keep up with the hospital’s demands, the infection
2020 Volume 100 Number 12 Physical Therapy 2121
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Figure 1. Figure 2.
“Bed sheet envelope technique”: Five team members wrap the Maintaining a tight grip on the edges of the bed sheets, the patient
patient using 2 bed sheets (one under and one over the patient) is horizontally moved towards the side of the bed opposite of the
leaving the head/neck exposed. The edges are tightly rolled to mechanical ventilator.
maintain the patient swaddled during the maneuver. The team
member at the headboard commands each step and protects the
artificial airway.
hospital-wide effort, led by the physical therapy
department, to develop and implement a protocol for
control team implemented extended-use and limited-reuse prone positioning in patients who are mechanically
guidelines to prevent PPE shortage during times of peak ventilated. Although the procedure was uncommon in our
demand. The N95/PFF2 masks, which were discarded pre-coronavirus routine for neurosurgical patients, we
following each use prior to the COVID-19 outbreak, had provided training in proning to all health care
to be reused for 30 consecutive days. The once disposable professionals handling patients with COVID-19.
impermeable gowns were now used for extended periods
(2 gowns per 12-hour shift). The “bed sheet envelope-technique”23 was adopted based
on the experience of senior physical therapists and in
As of mid-June, 8 of the 55 physical therapists (15%) at conjunction with colleagues from other hospitals in Rio de
IECPN have tested positive for SARS-CoV-2. All of these Janeiro. Essentially, this technique uses 2 bedsheets to
infected professionals also worked extra shifts at different wrap the patient and allows the patient to be swaddled for
institutions. a 3-point turn to be performed in sequential movements:
first, the patient is moved to the side of the bed opposite
of the mechanical ventilator; next, the patient is placed in
Proning Protocol side-lying, and then turned to the prone position.23 Mock
From the early months of the pandemic, articles in bedside training stations were set up for practice sessions.
medical journals suggested that the prone position, widely Figures 1 through 6 show the sequence of the maneuver
used since the 1990s to increase oxygenation in patients during practice sessions. (Consent forms were obtained
with ARDS,20 could be effective for appropriately selected from all team members who participated in the training,
patients with COVID-19.21,22 This information led to a of which photographs were taken.) The maneuver
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Figure 3. Figure 4.
Sustaining the tight grip at the edges of the bed sheet, the patient The patient is then turned to the prone position while the person at
is placed in side-lying. the head ensures the patient’s proper head and neck support.
requires a team of 5 professionals: 1 physician, 1 nurse, 1 therapy protocols were developed or adjusted, according
physical therapist, and 2 nursing technicians (or another to the current patients’ clinical needs.
physical therapist, if possible). It is a high-risk procedure
because accidental extubation can lead to the patient’s The weaning protocol was adapted to the new patient
death24 and environment contamination.25 Relying on their profile and consisted of a 3-step assessment:
expertise in airway management, anesthesiologists were
designated to be stationed at the headboard to reintubate (1) Evaluation of the patient’s readiness to undergo the
promptly if needed. Rigorous team synchronization and spontaneous breathing trial (SBT) checklist:
effective communication were essential. Each nurse, resolution of the cause that led to intubation,
nurse’s aide, physician, and physical therapist was trained absence of fever, partial pressure of arterial
at least once for the specific sequence of events by oxygen/fraction of inspired oxygen (PaO2 /FiO2 )
performing a simulation of the maneuver using one of the ≥200 mm Hg, positive end-expiratory pressure
staff members as a mock patient. This preparation led to (PEEP) ≤ 8 cm H2 0, pressure support (PS) ≤ 10 cm
increased staff confidence for the arrival of the first H2 0, and FiO2 ≤ 40%.
patient. As of June, no adverse event has been registered (2) If approved on all items, the patient would undergo
in over 72 proning maneuvers. the SBT in a closed system with PS of 5 cm H2 0 and
PEEP of 0 cm H2 0 for 60 minutes.
(3) If approved on step 2, the patient’s ability to protect
the airway was assessed prior to artificial airway
Adjustments to the Physical Therapy removal: the patient was asked to follow 4 simple
Routine and Protocols commands, and coughing was assessed using
The regular monthly journal clubs and weekly inservice closed-system tracheal aspiration. The institutional
discussions related to our usual neurosurgical patient extubation protocol was also adjusted to include the
population were temporarily suspended. New physical use of an acrylic box and the administration of
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Figure 5. Figure 6.
The patient is appropriately positioned with rolls and pillows, Proper position is verified. Check that lines and tubes are not
according to body shape to ensure appropriate thoracic expansion pressing against skin and catheters and mechanical ventilator tubing
during ventilation and to decrease pressure areas. The patient is is not kinked.
positioned in the alternate “swimmer position”—raising one arm
overhead while placing the other arm at the patient’s side. The neck
is rotated towards the side of the ventilator.
Snapshot
A total of 116 confirmed COVID-19 cases were treated
from March 17 to May 17, 2020. Sixty percent were men
intravenous lidocaine (by the medical team or (70) and 40% were women (46), with a median age of
nursing) to decrease coughing, 2 techniques meant 59 years. Eighty-nine percent (103) of these patients
to reduce droplet spread during the procedure.25 ,26 underwent mechanical ventilation during hospitalization,
of which 11% (11) were successfully extubated. Thirty
A specific protocol for the application and management of percent (31) of patients underwent tracheostomy, and
noninvasive ventilation took into account the high 26% of those (8) were successfully decannulated. Of the
transmissibility of the virus and ways to minimize staff total patients, 57 patients died (mortality rate of 49%),
contamination during this procedure.27 Specific measures 4 (3%) were transferred to another institution, 23 (20%)
included using double-limb breathing circuit, full face were discharged home, and 32 (28%) continue
masks, high-efficiency particulate air (HEPA) filter, and, hospitalized.
when available, an isolation room.27
Following the stabilization of the patient’s respiratory Conclusion
condition, the physical therapist interventions focused on The day our institution opened its doors for the first
restoring physical function. When the patient lacked trunk patient with COVID-19, there were 291 confirmed cases in
control, physical therapists regularly used the tilt-table, Brazil. As of the date this report was revised, the country
and, prior to discharge, all patients sat at the edge of the holds third place in global ranking on number of
bed, stood, and walked during the physical therapy confirmed cases, tallying 4,330,455 cases and 131,625
session. deaths.28 The role that physical therapists played in the
2124 Physical Therapy Volume 100 Number 12 2020
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treatment of the patients with COVID-19 thus far has been 7 COFFITO CFdFeTO. Resoluão N◦ 402 de 03 de Agosto de
fundamental throughout the entire hospitalization period. 2011: Disciplina a Especialidade Profissional Fisioterapia em
Terapia Intensiva e dá outras providências. In.
The availability and expertise of physical therapists in our
8 Huang C, Wang Y, Li X, et al. Clinical features of patients
ICU has facilitated care for critical events such as infected with 2019 novel coronavirus in Wuhan, China.
intubation, patient positioning, ventilatory adjustments, Lancet. 2020;395:497–506.
extubation, and functional training. 9 World Health Organization. Novel Coronavirus – China.
Accessed May 21, 2020. https://www.who.int/csr/don/12-ja
nuary-2020-novel-coronavirus-china/en/
10 The White House. Donald J Trump Proclamation on Declaring
a National Emergency Concerning the Novel Coronavirus
Disease (COVID-19) Outbreak [press release]. March 13, 2020.
Author Contributions
11 Prefeitura da Cidade do Rio de Janeiro. Coronavírus
(Covid-19): perguntas e respostas. Prefeitura Rio de Janeiro.
Concept/idea/research design: C.H. Gaspari, A.C. Jaccoud. Accessed May 20, 2020. http://prefeitura.rio/saude/novo-coro
Downloaded from https://academic.oup.com/ptj/article/100/12/2120/5907857 by guest on 09 May 2024
Writing: C.H. Gaspari, I. Assumpção, R. Freire, A. Silva, C. Santiso, navirus-perguntas-e-respostas/
A.C. Jaccoud. 12 Ministério da Saúde do Brasil. Painel de casos de doença pelo
Data collection: I. Assumpção, R. Freire, A. Silva, C. Santiso. coronavírus 2019 (COVID-19) no Brasil Ministério da Saúde
Data analysis: C.H. Gaspari, I. Assumpção, R. Freire, A. Silva, do Brasil. Accessed May 20, 2020. https://covid.saude.gov.br/
C. Santiso. 13 Bergamo M. Hospitais alertam Paulo Guedes que estoques de
Project management: C.H. Gaspari. máscaras e luvas podem acabar em dois meses. Folha de São
Providing facilities: C.H. Gaspari. Paulo. Accessed March 19, 2020. https://www1.folha.uol.com.
br/colunas/monicabergamo/2020/03/estoques-de-mascaras-e-
Providing institutional liaisons: C.H. Gaspari. luvas-de-hospitais-privados-podem-acabar-em-menos-de-doi
Clerical/secretarial support: C.H. Gaspari. s-meses.shtml
Consultation (including review of manuscript before submitting): 14 Passos L. Após apelo da OMS para testes em massa, Brasil
C.H. Gaspari, I. Assumpção, R. Freire, A. Silva, C. Santiso, mantém foco nos casos graves e diz estudar importação de
A.C. Jaccoud. kits rápidos. G1 March 16; 2020. https://g1.globo.com/beme
star/coronavirus/noticia/2020/03/16/apos-apelo-da-oms-pa
ra-testes-em-massa-brasil-mantem-foco-nos-casos-graves-e-di
z-estudar-importacao-de-kits-rapidos.ghtml
Funding
15 World Health Organization. Laboratory testing for coronavirus
disease (COVID-19) in suspected human cases: interim
There are no funders to report. guidance. Accessed June 7, 2020. https://www.who.int/dg/
speeches/detail/who-director-general-s-opening-remarks-at-
the-media-briefing-on-covid-19---16-march-2020
Disclosures 16 Brasil AdMI. Comunicado da AMIB sobre o Avanço do
COVID-19 e a Necessidade de Leitos em UTIS no Futuro.
The authors completed the ICMJE Form for Disclosure of Potential AMIB. Accessed March 16, 2020. http://www.somiti.org.br/vi
Conflicts of Interest and reported no conflicts of interest. sualizacao-de-noticias/ler/700/amib-emite-comunicado-so
bre-a-necessidade-de-leitos-em-utis-para-enfrentar-a-covid-19
https://doi.org/10.1093/ptj/pzaa175 17 Ferioli M, Cisternino C, Leo V, Pisani L, Palange P, Nava S.
Protecting healthcare workers from SARS-CoV-2 infection:
Practical indications. Eur Respir Rev. 2020;29:200068.
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