Remember me
CASE REPORT
Year : 2021 | Volume
: 10
| Issue : 3 | Page : 242-244
Impact of physical activity levels on length of hospital stay in patients with severe COVID ARDS
Hetal Manoj Mistry, Akhila Natesan
Physiotherapy School and Centre, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
Correspondence Address:
Dr. Akhila Natesan
Physiotherapy School and Centre, Topiwala National Medical College and BYL Nair Charitable Hospital, Dr. AL Nair Road, Mumbai Central, Mumbai - 400 008, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijhas.IJHAS_271_20
SARS-CoV2 is a lethal virus that primarily affects the respiratory system causing severe pneumonia leading to ARDS. This case series describes the cases of two middle-aged men suffering from severe coronavirus disease-19 ARDS presenting to hospital with similar clinical signs who were given similar treatments. Pre infection activity levels of both patients were assessed using Global Physical Activity Questionnaire and length of hospital stay was observed for both patients. Patient with sedentary lifestyle prior to infection had a longer length of hospital stay of 25 days whereas the second patient who had an active lifestyle had a shorter length of hospital stay of 11 days. Based on our observations, we conclude that pre infection physical activity levels positively influences the severity of disease and helps to reduce length of hospital stay. With lockdown being declared in many parts of the world on account of the second wave of infection, it is important to encourage people to adopt a healthy lifestyle while adhering to the norms of lockdown.
Keywords: COVID-ARDS, length of hospital stay, physical activity
The coronavirus disease (COVID-19) predominantly affects the respiratory system, the clinical manifestations range from a mild disease with common cold to more severe form that manifest as viral pneumonia leading to acute respiratory distress syndrome (ARDS), multiorgan failure and death.[1] The virus has caused about million deaths worldwide since December 2019 when it was first reported. Due to its high transmission and mortality rate, COVID-19 was declared as a pandemic in March 2020.[2] In the absence of a cure for this deadly virus, attempts were made to contain its spread worldwide. Especially in the months of April and May 2020, a stringent lockdown was declared in India. Since then, routine everyday activities have been disrupted due to travel restrictions, closure of academic institutions and “work from home” regulations imposed on all offices.
Staying indoors has promoted a sedentary lifestyle, as people spend large amounts of time lying down or reclining, restriction of outdoor activities and disruption of normal routine has detrimental effects on physical condition of people. Although majority of people engage in some form of exercise at home, the activity levels are less than the levels of physical activity recommended by the WHO.[3]
Regular exercise increases immunosurveillance against infectious pathogens including viruses. Evidence shows that physical inactivity negatively impacts the immune system and downregulates the ability to resist viral infection and increases the risk of damage to immune, respiratory, cardiovascular and musculoskeletal system.[4] Numbers of factors such as age, comorbidities, time of hospitalization, time of physiotherapy referral influence the progression of disease, and length of hospital stay of COVID cases.[5],[6] The length of hospital stay is directly related to cost of care and utilization of healthcare resources and is an important outcome for both patient and the healthcare provider.[7]
Research articles on whether physical activity levels prior to SARS-CoV2 infection effects the disease outcomes of are scarce.[4]
We assessed the physical activities performed during a typical week prior to the development of symptoms of two patients with moderate-severe COVID ARDS using Global Physical Activity Questionnaire (GPAQ) – English Version. Both patients had a fairly regular daily routine. GPAQ is a free, valid, and reliable physical activity surveillance questionnaire developed by the WHO. It is a 16-item questionnaire that assesses the intensity, duration, and frequency of physical activity in three domains – occupational, transport related and recreational domains.[8]
The main purpose of this double case study was to report our clinical experience of how pre COVID physical activity level affects disease progression and in turn influences length of hospital stay.
Case ReportBoth cases are middle-aged men (40 years and 54 years). Case 1 was admitted to the hospital on day 5 postfirst symptom and Case 2 on day 4 since first symptom. Both cases presented with similar clinical manifestations (cough, tachypnea, shortness of breath, tachycardia, low spo2 <90%).
Radiological investigation of both cases showed that, Case 1 had diffused patchy airspace consolidation in bilateral lungs and absence of consolidation in Case 2.
Based on arterial blood gas reports, both cases showed moderate – severe ARDS. (PaO2/FiO2 ratio - 83.4 and 151 for Case 1 and Case 2, respectively).
Both patients received the same medical management (oxygen therapy, IL6 blocker [tocilizumab], antibiotics, corticosteroids, low molecular weight heparin, hydroxychloroquine).
Physiotherapy management was begun for both patients on their 3rd day postadmission.
Case 2 comparatively had a more active lifestyle than Case 1 as he did moderate intensity physical activity for 180 min/week.
Case 1 did absolutely no moderate or vigorous activities in his day to day life.
At the time of discharge, Case 1 walked 30 meters without desaturating, whereas, Case 2 completed 350 meters. Thus showing that, Case 1 had a lower functional capacity. Case 1 also had a longer duration of hospital stay than Case 2 (25 days and 11 days respectively). Case 1 also was dependent on oxygen support for greater number of days than Case 2 (11 days and 9 days, respectively.
DiscussionWritten informed consent was obtained from both participants.
Length of hospital stay is influenced by age, day of hospitalization post presentation of first symptom, and day of physiotherapy referral. Older patients have a longer recovery time; although Case 2 was older than Case 1 he had a shorter span of hospital stay. Case 1 got admitted and received physiotherapy intervention 1 day later than Case 2 and this may have contributed to delay in recovery of Case 1.
The beneficial effects of exercise conditioning on all body systems helps to combat infections.[4] Guidelines for Ppysical activity for Indians recommend a total 60 min physical activity every day which includes at least 30 min moderate intensity aerobic activity, 15 min work related activity, and 15 min muscle strengthening activity (3–4 times a week).[9]
Although Case 2 had physical activity levels less than the recommended value, he was more active than Case 1. Case 2 performed moderate intensity exercises 6 days a week for 30 min. Case 2 was also continuing his work post lockdown as a pharmacist, whereas Case 1 had discontinued his job temporarily and spent majority of his time sitting or reclining.
Moderate intensity exercises performed daily reduces susceptibility, morbidity and mortality to respiratory viral infections by increasing salivary lactoferrin and leukocytes and other immunoprotective agents.[4]
Isolation and confinement causes glucocorticoids levels to be raised, which inhibit critical functions of our immune system. Reduced skeletal muscle activity increases peripheral insulin resistance and disrupts mitochondrial homeostasis. This leads to organic and systemic inflammation and increased levels of cytokines.[4] As observed from investigations, Case 1 had more severe manifestations than Case 2. The sedentary lifestyle and physical inactivity of Case 1 influenced the severity of illness thus prolonging his recovery time.
Decreased lung compliance is a feature of ARDS – a higher than normal pressure is required to inflate the lung, thus imposing great demands on the respiratory muscles. Aerobic training promotes biochemical alterations in diaphragm muscle phenotype.[4] Adaptations as a result of endurance training help in combating the stress on respiratory system. The total days of oxygen dependency of Case 2 is less than that of Case 1 as good respiratory muscle function due to his active lifestyle helped in early weaning.
Higher physical activity levels played a major role in early recovery of Case 2. He had a higher functional capacity at the time of discharge. There was a reduction in the length of hospital stay without any unfavorable effects on patient outcomes.
Our findings are consistent with the recommendations stated by division of Preventive and Sports medicine, Germany (Eszter Fuzeki et al.). It states the harmful effects of limited activity due to social distancing and quarantine on physical and mental health. They recommend that physical activity counseling to society and community must be provided by health care professionals.[10] Individualized exercise programs compliant to local and national regulations targeting “at risk” population will help to minimize the deleterious effects of virus, ameliorate the symptoms, and shorten the recovery time.
ConclusionBased on our experience, we conclude that, pre infection activity levels positively influence the recovery time of COVID patients. Adaptations from an active lifestyle help in combating the infection thereby shortening the length of hospital stay in COVID patients.
Acknowledgement
The authors acknowledge Dr. Ramesh Bharmal (Dean) and Dr. Chhaya V Verma (Head of Physiotherapy School and Centre) for allowing us to carry out this study. Dr. Rosemarie Desouza and Dr. Mala V. Kaneria from the Department of Medicine of Topiwala National Medical College and BYL Nair Hospital, Mumbai, whose patient information was used. Postgraduate students, faculty and staff members of Physiotherapy School and Centre, Topiwala National Medical College and BYL Nair Hospital.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
Comments (0)