Ventilated COVID Patients May Experience Nerve Damage, Prompting New Protocols

Severely ill patients on ventilators are often placed in a prone, or face down, position to help improve oxygenation and reduce chances of death related to respiratory distress syndrome (ARDS). But in cases of COVID-19, this life-saving technique may cause permanent nerve damage, according to a new study from Northwestern University.

“Ordinarily when people are critically ill, they can tolerate these protocols for keeping them safe without too many complications,” lead investigator of the study Colin Franz, MD, PhD, an assistant professor of physical medicine, rehabilitation, and neurology at Northwestern’s Feinberg School of Medicine in Illinois, tells Verywell. “But what we’ve noticed in people with COVID-19 is that the susceptibility to acquiring injuries is much greater.”

For the study, Franz and his colleagues reviewed the medical information of 85 patients admitted to the Shirley Ryan AbilityLab, a rehabilitation hospital in Chicago where Franz works, between late April and late June. The patients recovered after developing ARDS as a result of COVID-19 and were discharged into the care of AbilityLab from six different hospitals. 

All 85 patients received mechanical ventilation during their treatment and had been placed in the prone position. Of these patients, 11 were diagnosed with peripheral nerve damage. The September study, accepted by the British Journal of Anesthesia, has not yet been peer-reviewed.

Since the study, Franz says he’s seen additional patients with the same injuries. “We’ve never seen a patient group that comes in and just had this high rate of nerve damage like this,” he says.

Nerve Damage and Recovery 

Most patients experienced injuries around the neck—specifically to two nerves (ulnar and radial) that travel from the neck to the hand, according to the study.

Franz says the nerve injuries from placing COVID-19 patients in the prone position may take one to two years to heal and many individuals won’t regain full function and mobility of affected areas. 

“The recovery of peripheral nerves is really slow,” Franz says. “If you damage the axons, which are like wires that connect to our body, muscles, and skin, they only grow about an inch a month. And they’re not particularly good at it.” Underlying conditions such as diabetes mellitus, which can impact nerves, may also impede the healing process, according to the research.

Most patients won’t require surgery for nerve repair, Franz says, because the nerves aren’t being severed as a result of being in the prone position. Instead, patients may undergo physical or occupational therapy to keep tissue healthy and mobile and prevent joints from becoming fixed while nerves regenerate. Nerve stimulation may also be a part of the recovery process. In addition to a paralyzed joint or a loss of strength, some patients experience intense pain as a result of nerve injury, which Franz says can be tough to treat.

The researchers don’t yet know why COVID-19 patients are more susceptible to nerve damage from proning than recovered patients placed in the same position to treat another condition. 

But Franz says COVID-19 involves a systemic inflammatory response that impacts multiple systems of the body. “I think these injuries are probably related to the nerves being more vulnerable, probably due to inflammation, poor circulation—combined with these positions," he says.

Changes to Prone Position

Even with the study’s findings, ICU physicians treating patients who are severely ill with COVID-19 will still need to place some patients in the prone position. “This maneuver is saving lives of patients with COVID-19,” Franz says. “That shouldn’t be lost sight of here.”

But now that researchers and physicians at Northwestern have a map of where patient's nerves are frequently damaged, they’re making adjustments, Franz says. For example, they’re using padding and changing the way they position a patient’s neck in relation to their arm to avoid extra traction on the nerves. Franz says they’re working with engineers to develop wearable wireless pressure sensors. “You have to be even more vigilant with COVID patients,” he says.

Additional Rehabilitation Needs

COVID-19 patients who aren’t on mechanical ventilation are also sometimes placed in the prone position at intervals to improve oxygenation, based on research in JAMA Internal Medicine. But Franz says he hasn’t seen those patients reporting the same injuries. 

Many COVID-19 patients—even those who don’t have injuries related to prone positioning—have required rehabilitation in some capacity, Mahesh Ramachandran, MD, chief medical officer at Marianjoy Rehabilitation Hospital in Illinois, tells Verywell. 

“The majority of patients who require inpatient rehabilitation—they’ve been on the vent for a while,” Ramachandran says. “They have a hard time walking and doing basic things.” After their stay, many patients will transition to an outpatient program to continue any needed therapies.

But COVID-19-positive individuals who weren’t on ventilators, and in some cases weren’t even hospitalized, have also developed neurological and cognitive symptoms when they’re nearly fully recovered, Ramachandran adds. “Unfortunately we’re realizing that even some of the patients that were having milder illnesses are having other manifestations that crop up later,” he says. 

The need for rehabilitation after a prolonged respiratory illness isn’t a new phenomenon. But Ramachandran says, in his experience, patients who are recovering from COVID-19 have needed rehab to a greater extent and frequency than with other respiratory viruses. The bottom line, he adds, is that researchers are still learning about all of the different manifestations of COVID-19.

"I can’t think of another infection that impacts the nerves this way in critically ill patients," Franz says. "This is just a very unique situation.”

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