key: cord-0897719-c2btn52t authors: Denehy, Linda; Puthucheary, Zudin title: Surviving COVID-19: a familiar road to recovery? date: 2021-10-07 journal: Lancet Respir Med DOI: 10.1016/s2213-2600(21)00447-1 sha: 9389be291343994d53ce1b1085a59be1c1b9a5db doc_id: 897719 cord_uid: c2btn52t nan As health care improves, the concept of surviving well has become increasingly important. This is certainly the case in critical care, in which survivorship has been coined the defining challenge of the 21st century. Within this setting, the field now grapples with the onslaught of the COVID-19 pandemic. The initial objective globally was to manage system strain to enhance equity of provision of care. Acute services expanded care provision by increasing acute care bed numbers and stretching existing resources. For a brief period of time, the world focused only on patient survival. Consistent with the additional survivorship focus in critical care over the past 20 years, the recognition of prolonged disability in survivors of COVID-19 has stimulated a drive to understand the nature of impairments and their effects on mental and physical health, as well as return to societal roles. In The Lancet Respiratory Medicine, Rachael Evans and colleagues of the PHOSP-COVID Collaborative Group present the first analyses of a UK multicentre cohort study of survivorship of hospitalised patients with COVID-19. 1 Of the 1077 patients assessed at a median of 5·9 months (IQR 4·9-6·5) after hospitalisation with COVID-19, 20% developed a new disability, 19% experienced a health-related change in occupation, and 71% described themselves as not having fully recovered. Patients described a median of nine different symptoms covering physical and mental domains, which were mirrored in both patient-reported outcome measures and in objective physical assessments. Of note, the PHOSP-COVID group reports an inconsistent relationship between illness severity and impairments for ward-based versus intensive care-based patients with COVID-19. The four recovery phenotype clusters identified in a post-hoc clustering analysis were similarly not closely related to illness severity. The authors hypothesise that mechanisms other than index severity could be responsible for persistent symptoms. Why might patients who were not admitted to the intensive care unit (ICU) develop symptoms consistent with post-intensive care syndrome in this study? Perhaps one answer is that critically ill patients have long been managed outside the physical constraints of the ICU. During data collection, in the setting of almost overwhelmed services in the UK, the criteria for ICU admission (a threshold that has substantial international and intranational variability) would have been unusually strict. 2 In a large cohort study such as PHOSP-COVID, it is not possible to drill down to the level of detail required to substantiate this hypothesis. The fact that the recovery of non-hospitalised patients with COVID-19 follows a faster trajectory is, in some respects, supportive of a role for disease severity. 3 The extraordinary social rules of the pandemic-with numerous restrictions on mobility and lifestyle that would not normally affect discharged hospitalised patients in their recovery-might have affected mental health sequelae. Women are more likely than men to live alone in high-income countries, and are therefore less able to function without support once disabled by acute illness, which would perhaps explain the reported sexual dimorphism. In another large cohort study published in 2021, social isolation before ICU hospitalisation was associated with a greater disability burden in the year after critical illness, suggesting the need for social isolation screening and intervention frameworks. 4 Additionally, socioeconomic position might affect health outcomes, particularly mental health, after critical illness. 5 These previously published data illustrate the important impacts of the social determinants of health. Further reported data of particular interest in the PHOSP-COVID study are those related to comorbidities. These are identified in each of the four clusters. A unifying thread in acute illnesses is the modifying effect of pre-morbid comorbidities and baseline functional states, which are greater discriminators of long-term physical and mental health outcomes than the severity of acute illness or cardiorespiratory physiology. 6 Similarly, cognitive outcomes are highly prevalent after acute illness and in older people during hospitalisation, related to the development of in-hospital delirium. The incidence of delirium in patients was not reported by the PHOSP-COVID group, but it would be interesting to investigate whether this is associated with poor cognitive outcomes. Pre-hospitalisation alcohol intake could also affect cognitive outcomes. 7 Patients who survive a critical illness suffer from physical disability as a result of loss of skeletal muscle mass, affecting physical functional capacity. This can be due to general immobility or associated with time in the ICU (so-called ICU-acquired weakness), which is reported Science Photo Library in patients with COVID-19. 8 There are no data provided on in-hospital or outpatient rehabilitation treatments that might have attenuated subsequent functional recovery. Furthermore, anxiety, depression, and posttraumatic stress disorder are common and often coexist, and patients can have multiple symptoms across these domains. Return-to-work rates are low among survivors of critical illness, and this alone could affect health-related quality of life and psychological function, and many of these symptoms can persist for years. 9 Indeed, the PHOSP-COVID group offers convincing evidence that there are minimal phenotypic differences after hospitalisation for COVID-19 versus critical illness. The findings from these high-quality data are a cause for concern. A substantial proportion of the working-age population is likely to have longterm, life-changing sequelae after COVID-19, with physical, mental, social, and fiscal effects. The good news is that the PHOSP-COVID data confirm that we have an existing prism through which to view this public health issue, with mature domains to guide research and policy: that of post-intensive care syndrome. We can view acquired disability in domains (rather than symptoms), each of which can be screened for (eg, using the Post-ICU Presentation Screen) at hospital discharge. 10 Moving forward, it will be important to use such a framework not only to capture symptomatology, but also to map symptoms to domains that could guide holistic rehabilitation and recovery interventions. Using these systematic approaches will ensure that no domains that might be affected are missed; for example, poor nutrition, dysphonia, and dysphagia are all reported in survivors of COVID-19 but are not reported by the PHOSP-COVID group. The long-term sequelae of COVID-19-similar to the persistent effects of critical illness-are unrelated to the acute diagnosis per se. Instead of developing new interventions, translation of interventions from other disease modalities offers hope for future patients, if resources are appropriately allocated. We urgently need to build on the plethora of descriptive cohort studies examining COVID-19 sequelae with large, powered trials that examine the efficacy of individualised management options, such as pharmacological interventions, multidisciplinary inpatient and outpatient rehabilitation, or the role of targeted follow-up clinics. As with the trajectory of research over the past two decades in critical care, we need to identify responders to specific interventions, map impairments across time, and involve patients and caregivers in the process of recovery. Physical, cognitive, and mental health impacts of COVID-19 after hospitalisation (PHOSP-COVID): a UK multicentre, prospective cohort study If not now, when? A clinical perspective on the unprecedented challenges facing ICUs during the COVID-19 pandemic Attributes and predictors of long COVID Association of social isolation with disability burden and 1-year mortality among older adults with critical illness Socioeconomic position and health outcomes following critical illness: a systematic review Functional trajectories among older persons before and after critical illness Long-term cognitive impairment after critical illness Intensive care unit acquired muscle weakness in COVID-19 patients Return to employment after critical illness and its association with psychosocial outcomes. A systematic review and meta-analysis The post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part I: development and preliminary clinimetric evaluation We declare no competing interests.