Psychological Intervention with COVID-19 Patients
The psychological stress and symptoms of COVID-19 patients
Confirmed COVID-19 patients often have symptoms such as regret and resentment,
loneliness and helplessness, depression, anxiety and phobia, irritation and sleep
deprivation. Some patients may have panic attacks. Psychological evaluations in the
isolated wards demonstrated that, about 48% of confirmed COVID-19 patients
manifested psychological stress during early admission, most of which were from their
emotional response to stress. The percentage of delirium is high among the critically ill
patients. There is even a report of encephalitis induced by the SARS-CoV-2 leading to
psychological symptoms such as unconsciousness and irritability.
f) Establishing a dynamic mechanism for evaluation and warning of
psychological crisis
Patients' mental states (individual psychological stress, mood, sleep quality, and
pressure) should be monitored every week after admission and before discharge. The
self-rating tools include: Self-Reporting Questionnaire 20 {SRQ-20), Patient Health
Questionnaire 9 {PHQ-9) and Generalized Anxiety Disorder 7 {GAD-7). The peer-rating
tools include: Hamilton Depression Rating Scale {HAMD), Hamilton Anxiety Rating Scale
{HAMA), Positive and Negative Syndrome Scale (PANSS). In such a special environment
as the isolated wards, we suggest that patients should be guided to complete the
questionnaires through their cell phones. The doctors can interview and perform scale
assessing through face-to-face or online discussion.
C)
Intervention and treatment based on the assessment
3.1 Principles of intervention and treatment
For mild patients, psychological intervention is suggested. Psychological
self-adjustment includes breathing relaxation training and mindfulness training. For
moderate to severe patients, intervention and treatment by combining medication and
psychotherapy are suggested. New antidepressants, anxiolytics, and benzodiazepines
can be prescribed to improve the patients' mood and sleep quality. The second
generation antipsychotics such as olanzapine and quetiapine can be used to improve
psychotic symptoms such as illusion and delusion.
3.2 The recommendation of psychotropic medications in elderly patients
Middle-aged or elderly COVID-19 patients' medical situations are often complicated by
physical diseases such as hypertension and diabetes. Therefore, when selecting
psychotropic medications, the drug interactions and their effects on respiration must be
fully considered. We recommend using citalopram, escitalopram, etc. to improve
depression and anxiety symptoms; benzodiazepines such as estazolam, alprazolam,
etc. to improve anxiety and sleep quality; olanzapine, quetiapine, etc. to improve
psychotic symptoms.
XV. Rehabilitation Therapy for COVID-19 Patients
Severe and critically ill patients suffer from different degrees of dysfunction, especially
respiratory insufficiency, dyskinesia and cognitive impairment, during both acute and
recovery stages.
Rehabilitation therapy for severe and critically ill patients
The goal of early rehabilitation intervention is to reduce breathing difficulties, relieve
symptoms, ease anxiety and depression and lower the incidence of complications. The
process of early rehabilitation intervention is: rehabilitation assessment - therapy -
reassessment.
1.1 Rehabilitation assessment
Based on general clinical assessment, especially functional evaluation, including
respiration, cardiac status, motion and AOL should be emphasized. Focus on respiratory
rehabilitation assessment, which includes the evaluation of thoracic activity,
diaphragm activity amplitude, respiratory pattern and frequency, etc.
1.2 Rehabilitation therapy
The rehabilitation therapy of severe or critically ill COVID-19 patients mainly includes
position management, respiratory training, and physical therapy.
(1) Position management. Postural drainage may reduce the influence of sputum on the
respiratory tract, which is especially important to improve the patient's V/Q. Patients
must learn to tip themselves into a position which allows gravity to assist in draining
excretion from lung lobes or lung segments. For patients using sedatives and suffering
from consciousness disturbance, a standing-up bed or the bed head elevation
(30°-45°-60°) may be applied if the patient's condition permits. Standing is the best
body position for breathing in a resting state, which can effectively increase the
patient's respiratory efficiency and maintain lung volume. As long as the patient feels
good, let the patient take a standing position and gradually increase the time standing.
(2) Respiratory exercise. Exercise can fully expand the lungs, help the excretions from
pulmonary alveoli and airway expel into the large airway so that sputum would not
accumulate at the bottom of the lungs. It increases the vital capacity and enhances lung
function. Deep-slow breathing and chest expansion breathing combined with shoulder
expansion are the two major techniques of respiratory exercises.
G) Deep-slow breathing: while inhaling, the patient should try his/her best to move the
diaphragm actively. The breathing should be as deep and slow as possible to avoid the
reduction of respiratory efficiency caused by fast-shallow breathing. Compared with
thoracic breathing, this kind of breathing needs less muscle strength but has better tidal
volume and V/Q value, which can be used to adjust breathing when experiencing short
of breath.
@ Chest expansion breathing combined with shoulder expansion: Increase pulmonary
ventilation. When taking a deep-slow breath, one expands his/her chest and shoulders
while inhaling; and moves back his/her chest and shoulders while exhaling. Due to the
special pathological factors of viral pneumonia, suspending breathing for a long time
should be avoided in order not to increase the burden of respiratory function, and the
heart, as well as oxygen consumption. Meanwhile, avoid moving too fast. Adjust the
respiratory rate at 12-15 times/min.
(3) Active cycle of breathing techniques. It can effectively remove bronchus excretion
and improve lung function without exacerbation of hypoxemia and airflow obstruction.
It consists of three stages (breathing control, thoracic expansion and exhalation). How
to form a cycle of breathing should be developed according to the patient's condition.
(4) Positive expiratory pressure trainer. The pulmonary interstitium of COVID-19 patients
has been severely damaged. In mechanical ventilation, low pressure and low tidal
volume are required to avoid damages to the pulmonary interstitium. Therefore, after
the removal of mechanical ventilation, positive expiratory pressure trainer can be used
to help the movement of excretions from the low volume lung segments to the
high-volume segments, lowering the difficulty of expectoration. Expiratory positive
pressure can be generated through air flow vibration, which vibrates the airway to
achieve airway supporting. The excretions can then be removed as the high-speed
expiratory flow moves the excretions.
(5) Physical therapy. This includes ultrashort wave, oscillators, external diaphragm
pacemaker, electrical muscle stimulation, etc.
XVI. Lung Transplantation in Patients with COVID-19
Lung transplantation is an effective treatment approach for final-stage chronic lung diseases.
However, it is rarely reported that lung transplantation has been performed to treating acute
infectious lung diseases. Based on current clinical practice and results, FAHZU summarized
this chapter as a reference for medical workers. In general, following the principles of
exploration, doing the best to save life, highly selective and high protection, if lung lesions
are not significantly improved after adequate and reasonable medical treatment, and the
patient is in critical condition, lung transplantation could be considered with other
evaluations.
0
Pre-transplantation assessment
(1) Age: It is recommended that the recipients are not older than 70. Patients over 70
years old are subject to careful evaluation of other organ functions and postoperative
recovery capability.
(2) The course of the disease: There is no direct correlation between the length of the
disease course and the severity of the disease. However, for patients with short disease
courses (fewer than 4-6 weeks), a full medical assessment is recommended to evaluate
whether adequate medication, ventilator assistance, and ECMO support have been
provided.
(3) Lung function status: Based on the parameters collected from lung CT, ventilator,
and ECMO, it is necessary to evaluate whether there is any chance of recovery.
(4) Functional assessment of other major organs: a. Evaluation of the consciousness
status of patients in critical condition using brain CT scan and electroencephalography
is crucial, as most of them would have been sedated for an extended period; b. Cardiac
assessments, including electrocardiogram and echocardiography that focus on right
heart size, pulmonary artery pressure and left heart function, are highly
recommended; c. The levels of serum creatinine and bilirubin should also be
monitored; for patients with liver failure and renal failure, they should not be subjected
to lung transplantation until the functions of the liver and kidney are recovered.
(5) The nucleic acid test of COVID-19: The patient should be tested negative for at least
two consecutive nucleic acid tests with a time interval longer than 24 hours. Given the
increased incidents of COVID-19 test result returning from negative to positive after
treatment, it is recommended to revise the standard to three consecutive negative
results. Ideally, negative results should be observed in all body fluid samples, including
blood, sputum, nasopharynx, broncho-alveolar lavage, urine, and feces. Considering
the difficulty in operation, however, at least the testing of sputum and broncho-alveolar
lavage samples should be negative.
(6) Assessment of infection status: With the extended in-patient treatment, some
COVID-19 patients may have multiple bacterial infections, and thus a full medical
assessment is recommended to evaluate the situation of infection control, especially
for multidrug-resistant bacterial infection. Moreover, post-procedure antibacterial
treatment plans should be formed to estimate the risk of post-procedure infections.
(7) The preoperative medical assessment process for lung transplantation in COVID-19
patients: a treatment plan proposed by the ICU team • multidisciplinary discussion •
comprehensive medical evaluation •
analysis and treatment of relative
contraindications • pre-habilitation before lung transplantation
Contraindications
Please refer to The 2014 ISHLT Consensus: A consensus document for the selection of
lung transplantation candidates issued by the International Society for Heart and Lung
Transplantation (updated in 2014).
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