Post-Intensive Care Syndrome and COVID-19: Crisis After a Crisis?

Dear Editor,

We have read the paper “Post-intensive care syndrome and COVID-19: crisis after a crisis” by Jaffri and Jaffri with interest [1]. It highlights a largely neglected but important issue in the wake of the COVID-19 pandemic.

They bring to our attention the importance of identifying post-intensive care syndrome (PICS) as one of the long-term complications in COVID-19 patients admitted to the intensive care unit (ICU) and the urgent need for early mobilisation and integration of multidisciplinary rehabilitation teams for the prevention of PICS-associated complications. We would like to further expand upon this and highlight the issues with the non-availability of a dedicated ICU rehabilitation team for respiratory rehabilitation in developing countries such as Pakistan. We share our experience and suggest measures to improve the rehabilitation response to COVID-19.

Respiratory rehabilitation is defined as “a multidisciplinary intervention based on personalised evaluation and treatment, which includes, but is not limited to, exercise training, education, and behavioral modification designed to improve the physical and psychological condition of people with respiratory disease” [2,3].

Jaffri and Jaffri [1] mention the need for rehabilitation team members such as a rehabilitation physician (physiatrist), physiotherapist, occupational therapist, psychologist, and a nutritionist to help prevent and manage PICS in patients who have recovered from COVID-19. However, we feel that for such patients, respiratory therapists can also play an important role in the optimal management, recovery, and rehabilitation of COVID-19 patients admitted to the ICU. This is particularly relevant for those patients who need mechanical ventilation. In low-resource countries, particularly in Pakistan, respiratory therapists are very few in number and available only in a small number of large hospitals in major cities.

In developing countries like Pakistan, multidisciplinary rehabilitation services are either underdeveloped or not available to the majority of the patients in need of such services [4]. An additional challenge is the lack of understanding of multidisciplinary rehabilitation, both by physicians and the public. Most of them still equate it to “physiotherapy alone or some form of exercise” [5]. It is further complicated by the lack of coordination between different team members, who mostly work in isolation rather than as a team [6]. The October 2005 earthquake provided a boost to rehabilitation services in Pakistan by increasing resource allocation and awareness of the value of providing early coordinated rehabilitation to persons with disabilities (particularly those with spinal cord injuries and amputations). The COVID-19 pandemic can be an opportunity to develop ICU-related rehabilitation services by working with patients at risk of developing PICS.

The strong family and social support systems in Pakistan can be mobilised for patient rehabilitation after discharge from hospital. This was exemplified by the 2005 Pakistan earthquake, which resulted in a large number of major disabilities (e.g., spinal cord injury, long bone fractures, and amputations). The underdeveloped health system of the country was overwhelmed by the large number of patients. However, the availability of a large number of attendants and strong family networks made it possible to provide long-term home-based rehabilitation in a resource-constrained environment. However, we would also like to emphasise the importance of a supervised comprehensive program. Unsupervised exercise does not significantly improve the functional outcome compared with a comprehensive supervised program [7,8]. Therefore, a compromise can be reached where the patient’s attendants and caregivers learn the exercise protocol during the hospital stay and continue it at home after discharge with a regular rehabilitation follow-up.

Considering the possibility of PICS in many COVID-19 patients admitted to the ICU, there is a need to develop comprehensive ICU and respiratory rehabilitation services. The current emphasis is on the acute treatment of complications and in-hospital management. Health care professionals involved in the care of COVID-19 patients in the ICU should be educated about the role of multidisciplinary rehabilitation in preventing complications and reducing long- and short-term PICS-related disabilities. This is the right time to establish respiratory and ICU rehabilitation services in each tertiary care hospital managing COVID-19 to integrate an early rehabilitation response in mechanically ventilated patients with COVID-19. This will hopefully prevent PICS-related complications, reduce the financial burden, decrease the length of stay, and improve the functional outcomes and quality of life of these patients.