Interview with Jordi Vilaró on the role of the respiratory physiotherapist in the ICU
At Lovexair we have had the pleasure of being able to interview Jordi Vilaró, a member of our Advisory Council. Vilaró is a specialist in Respiratory Diseases, Dr. in Health Sciences and Research
At Lovexair we have had the pleasure of being able to interview Jordi Vilaró, a member of our Advisory Council. Vilaró is a specialist in Respiratory Diseases, Dr. in Health Sciences and Researcher in Physiotherapy and Pulmonary and Cardiac Rehabilitation.
Respiratory physiotherapy is still largely unknown to the general public. What is the role of respiratory physiotherapy in the Intensive Care Unit during the COVID-19 crisis?
At the time when the first cases began, the importance of respiratory physiotherapy was somewhat in doubt due to the lack of knowledge of the disease. One of the objectives of physiotherapy is to achieve the elimination of secretions within the lungs, but it must be taken into account that secretions are a considerable source of infection transmission and therefore the entry of respiratory physiotherapists was stopped.
Once this week passed and greater knowledge began to be obtained, it was confirmed that there were fewer secretions in the lungs than expected in an infection that generates viral pneumonia, and also that this infection causes significant fibrosis in the alveoli.
When the alveoli are affected, which is where gas exchange takes place during breathing, how does respiratory physiotherapy help in these cases?
While the person is in this phase of the infection, it can be a great help in improving the ventilation of the lungs, but above all in maintaining the elasticity and distensibility of the alveoli. We know that if the alveoli are more distensible, there will be less fibrosis and thus recovery will be facilitated, hence the importance of respiratory physiotherapy in intensive care units.
Due to this affectation, people need a mechanical ventilator to be able to breathe, and it has been proven that the figure of the respiratory physiotherapist reduces the days of connection to a respirator. It must be taken into account that one of the great complications before COVID -19 is the general affectation at the muscular level. That is, someone who is in intensive care with the support of a mechanical ventilator is someone who is in bed without moving 24 hours a day, in a pro decubitus position. As the days go by, a significant alteration of the muscles begins to take place and from the first week, once you have been in bed for 7 days, you lose 10% of muscle mass per day.
People who spend more than 15 days in the ICU will have lost a lot of muscle mass when they leave, considerably complicating their recovery.
But it is not all, in addition, what is called myopathy is generated, an alteration due to inflammation of the muscle fibers, that is, the muscle deteriorates and loses the ability to perform contractions. One of the functions of respiratory physiotherapy in the ICU is to maintain the mobility of these people, perform actions to activate the muscles, even though they cannot move, for example with electrostimulation.
Considering these circumstances, what is the rehabilitation process like for people who have overcome COVID-19?
Intensive care is the most critical moment, despite the fact that it was questioned and staff have been increased, the presence of respiratory physiotherapists in the ICU is still very limited in Spain and now it has been seen as in other countries in Europe and Latin America there are professionals in intensive care units at all times.
After the actions in the ICU, the patient goes to the floor and there the rehabilitation continues where a reactivation work is carried out, to start up all the muscles.
What we have detected is that aerobic work is less tolerated due to the lack of ventilation and breathing. On the other hand, strength training is well tolerated and helps to recover the muscles without compromising the lungs. Patients get tired very quickly, and therefore, the programs must be soft, slow and progressive, compared to other pathologies.
Once out of the hospital, how does rehabilitation continue?
The problem that we have detected is that those sick with COVID-19 are often alone, they have no one nearby, the environment is afraid, and they suffer from panic and post-traumatic stress due to the situation they are experiencing. This means that they are less and less active and at home they end up losing what they have gained through rehabilitation in the hospital and their situation is further complicated.
Do we know today the scope of the possible sequels?
We still do not know with certainty what the sequelae will be in the medium term, but if we compare them with other pathologies that require mechanical ventilation, we know that myopathy, atrophy, pulmonary involvement, a feeling of suffocation, in addition to joint problems, occur. We also know that, due to lack of oxygen, brain damage occurs with memory loss, such as forgetting how to perform an action or how to structure a conversation.
These would be some examples of the most serious cases, but between 25-30% of people will have difficulty returning to their daily routines. Some people may take 6 months to a year to return to work or be able to drive. This is where respiratory physiotherapy plays a key role, in the post-hospital phase. Specialist professionals in the field of psychology, nutrition and occupational therapists will also be needed.
Considering the pathologies of similar evolution, what we know is that if it is not treated, the number of relapses is higher. If good rehabilitation is not provided to all people, relapses will be important and will result in hospital admissions, use of health resources, visits to the psychologist, psychiatrist, etc. In other words, either we design a good system, or in the long run the burden on the health system will be greater. If not enough resources are allocated, it can end up generating greater spending and wear and tear on the health system.
In groups at risk, this is even more sensitive, because the deterioration of their basic pulmonary system is already serious, so when leaving the ICU a very severe and difficult to recover affectation, with many limitations, such as being permanently with oxygen or with a permanent ventilator at night.
But this phenomenon goes further, according to some cardiologists such as Ramón Brugada. Until now we have focused on treating people in the ICU, but the challenge will be to treat all the sequelae that remain in the affected people and at the same time care for people who have not been infected by COVID-19 but who already had one. respiratory or cardiac pathology and those that have been totally neglected.
Faced with this situation, it can generate concern in people with respiratory diseases, can we send them a positive message?
Yes, there is a positive message to give and to reinforce. This situation should help us to see the importance of the affected people being informed, taking care of themselves and knowing how to see in which situations it is not necessary to go to the health professional and being able to resolve them autonomously, if possible.
For example, in the case of asthma, there is a lot of concern in this regard. If we detect that we are about to enter a bronchospasm crisis, we can act individually. We know that it can be controlled by training self-control, reducing anxiety, taking the prescribed medication prescribed by the doctor and strictly following his recommendations.
In respiratory pathology, there is a series of tips on breathing that can be done independently and that can help mitigate these effects. It is usually done in person guided by a professional, but if you learn to do it autonomously, the professional can help you remotely. This is the great advantage of respiratory physiotherapy.
It is a change and we must learn because this model is here to stay and in the future face-to-face and non-face-to-face assistance will be combined because it can be done perfectly, exercises can be guided from a distance and it is easy to see if they are done well or not. We must take this possibility into account, in this way the management of the disease would be facilitated for people who live with worry and anxiety; being able to contact the professional remotely. Physiotherapist colleges are already considering these possibilities and are making themselves available to those in need shortly.
Thank you very much Jordi for your time, it is a pleasure to talk with you.
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