Physiotherapy Care of Patients with Coronavirus Disease 2019 (COVID-19) - A Brazilian Experience

Abstract

Some patients with coronavirus disease (COVID-19) present with severe acute respiratory syndrome, which causes multiple organ dysfunction, besides dysfunction of the respiratory system, that requires invasive procedures. On the basis of the opinions of front-line experts and a review of the relevant literature on several topics, we proposed clinical practice recommendations on the following aspects for physiotherapists facing challenges in treating patients and containing virus spread: 1. personal protective equipment, 2. conventional chest physiotherapy, 3. exercise and early mobilization, 4. oxygen therapy, 5. nebulizer treatment, 6. noninvasive ventilation and high-flow nasal oxygen, 7. endotracheal intubation, 8. protective mechanical ventilation, 9. management of mechanical ventilation in severe and refractory cases of hypoxemia, 10. prone positioning, 11. cuff pressure, 12. tube and nasotracheal suction, 13. humidifier use for ventilated patients, 14. methods of weaning ventilated patients and extubation, and 15. equipment and hand hygiene. These recommendations can serve as clinical practice guidelines for physiotherapists. This article details the development of guidelines on these aspects for physiotherapy of patients with COVID-19.

Early mobilization and physical exercise in patients with COVID-19: A narrative literature review

“…And this need has been pointed out by recent guidelines [ 11 , 16 , 42 , 48 , 49 ] recommending early mobilization and exercises for COVID-19 patients to prevent and/or minimize these complications and to rehabilitate them. Besides the guidelines [ 11 , 16 , 42 , 48 , 49 ], all the other studies included in this review did also mention the importance of exercises for COVID-19 patients [ 35 , 40 , 46 , [50] , [51] , [52] ].

Figure 2 Signs and symptoms of coronavirus disease 2019 (COVID-19) and possible acute and chronic complications associated with COVID-19 in different body systems.

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“…As can been seen in table 4 , exercise intensity for mild COVID-19 patients should be limited to moderate. In fact, most of the studies recommended low-intensity exercise for these patients [ 16 , 35 , 51 ], represented by Borg category ratio (CR) 10 < 3 or MET values < 3. A single study advised low to moderate intensities (Borg CR 10 score ≤ 3) to mild COVID-19 patients [ 40 ], since the value 3 in the Borg CR 10 scale corresponds to moderate intensity.…”

“…Trying to better understand what “when possible” means, Kurtais et al [ 48 ] recommended that only passive range of motion exercises and secretion management should be done in COVID-19 patients presenting acute respiratory distress syndrome (ARDS). However, Righetti et al [ 51 ] strongly recommended 12 to 16 hours/day of prone ventilation for severe ARDS patients and related that this maneuver can be repeated when the PaO 2 /FiO 2 ratio of 150 mmHg is observed after 6 hours in the supine position, and must be interrupted if the patient presents hemodynamic instability. According to Lazzeri et al [ 42 ], as soon as clinical stability is reached, decubitus change, semi-prone, prone, semi-sitting and sitting position are recommended for severe patients spontaneously breathing or using non-invasive ventilatory support, and Kurtais et al [ 48 ] postulated that active exercises and electrical muscle stimulation (EMS) should be considered for those recovering from ARDS.…”

“…Among the various EMS modes, belt-type is suggested as more effective for critical care, because it can induce whole lower extremity exercise through whole muscle contraction between wrapped belts, and 50 min bouts, three bouts per day have presented good results in ventilated COVID-19 patients [ 59 ]. Righetti et al [ 51 ] recommended that the EMS be associated with early verticalization and exercises in severe COVID-19 patients.…”

Fisioterapia e COVID-19: das repercussões sistêmicas aos desafios para oferta de reabilitação

“…(BOLES et al, 2007) O modo de Ventilação com Pressão de Suporte (PSV) é recomendado, inclusive para a realização do TRE. (RIGHETTI et al, 2020) Após o TRE bem-sucedido, o fisioterapeuta deverá considerar o reflexo de tosse como indicador da capacidade de proteção da via aérea e não realizar teste de escape do cuff antes da extubação, devido à disseminação de gotículas. Recomenda-se que os pacientes sejam extubados, preferencialmente, em ambiente com pressão negativa ou em isolamento respiratório, com atenção às precauções de isolamento, incluindo a manutenção de um filtro trocador de calor e umidade conhecido como Heat and moisture Exchanger Filter (HMEF) e o sistema fechado de aspiração conectado ao tubo no momento da desinsuflação do cuff.…”