Corona Virus/ COVID- 19

We all are very well aware of the important and critical role of Chest/Cardiorespiratory Physiotherapy, in treating various Acute and Chronic Cardiorespiratory ailments in Acute Hospital as well as Clinical settings and how we, being Cardiorespiratory/Cardiopulmonary  Physiotherapists, are an integral part of the Healthcare System when it comes to such Global issues like the COVID-19 pandemic.

So here I am, sharing my inputs on the same, as we are hit by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) /COVID-19/Coronavirus Pandemic, that affects primarily the Respiratory system¹.

Severe Pneumonia being the most common of all the complications in the highly contagious  COVID-19  patients, other complications may include Acute Respiratory Distress Syndrome (ARDS), Sepsis and Septic Shock, Multiple Organ Failure, including Acute Kidney or Cardiac Injury, which are more prevalent in at-risk groups including Older Age (> 60 years). Also, those with underlying co-morbid diseases such as Cardiovascular Disease, Diabetes, Hypertension, Lung Diseases and those who are Immunosuppressed are at high risk.(as quoted by World Health Organization/WHO)^1,2,3.

 Individuals with COVID-19 can present with an Influenza like illness and Respiratory tract infection demonstrating most common symptoms of fever, dry cough, fatigue, shortness of breath and sputum production (less common)⁴. The disease severity ranges from an Asymptomatic infection, Mild upper respiratory tract illness, Moderate disease, Severe viral pneumonia leading to Acute Respiratory failure or death⁴. As per the current report of World Health Organization, 80% of cases are estimated to be asymptomatic or mild, 15% of cases are severe (requiring oxygen) and 5% are critical requiring ventilation and life support.^1,2,5,6

Being a recent pandemic, we don't have enough evidences on the exact line of medical treatment and also the vaccinations are under trial now, so enlisting any FIXED protocol of Physiotherapy treatment won't be advisable for now.

 But for now, from the available data and references produced till date by the World Health Organization and Research Authorities of the various countries who are already adversely hit by this pandemic, it is seen that depending on the severity of the cases and the underlying co-morbidities, Cardiopulmonary Physiotherapy can be of great help in the treatment for COVID-19 suspected or confirmed cases. 

I would like to enlighten the quotation by WHO before briefing about the role of Physiotherapists in this pandemic situation which has led to social distancing and lockdown in most of the nations Globally, which states that

'Acutely unwell confirmed or suspected COVID-19 patients should NOT be routinely referred to physiotherapy. There are currently no reports that suggest COVID-19 patients have high secretion loads requiring intensive respiratory physiotherapy/airway clearance. Physiotherapy intervention is likely to be of limited benefit in the acute stages and most beneficial use of physiotherapy resources will be to facilitate the treatment and discharge of non-infected patients as well as training and supporting our colleagues in managing the acutely unwell. Physiotherapists will have a role in the rehabilitation of COVID-19 patients who have not returned to their functional baseline once they are no longer acutely unwell.⁷

So from the database available till now for this newly hit Pandemic COVID-19/Coronavirus Disease, mild symptoms where no significant respiratory compromise is observed like for e.g. fever, dry cough, no changes in chest X-ray, pneumonia requiring low-level oxygen and presenting the features of non-productive cough, Physiotherapy interventions are not required.

Any intervention that can lead to the increased risk or work of breathing should be avoided in Acute cases of confirmed COVID-19 patients. In the cases of Acute Respiratory Distress, most of the physiotherapy interventions are contraindicated as it can further compromise the increased work of breathing⁷.

1. Positioning

Positioning or Postural drainage positions are advisable in cases of secretions, to assist the clearance of airways or to promote ventilation.

(Prone positioning: As per the reports from the International Centers till date, who are dealing with large numbers of critically ill patients with COVID-19 related ARDS, prone ventilation is suggested to be an effective strategy in mechanically ventilated patients. Adult patients with COVID-19 and prone ventilation for 12–16 hours per day is recommended in severe ARDS with sufficient human resources and expertise to be performed safely.^8,9)    

2. Bronchial hygiene which includes techniques to keep the airways clear by maneuvers like Chest Vibrations or Shaking, along with postural drainage, to assist drainage of secretions  (limited data is found in support of percussion which should be probably avoided unless we get enough evidence about the disease, due to the mutating nature of virus), respiratory facilitation, Forced Expiratory Techniques like Huffing and Coughing, Active Cycle of Breathing or Autogenic Drainage, as per the status, underlying co-morbidities and requirement of the patient. Aerosol generating procedures should be avoided. Closed Suctioning is preferred^10,11

4. Breathing exercises to improve lung volumes, depending upon the underlying respiratory comorbidities, which may include Inspiratory or Expiratory exercises for e.g. Diaphragmatic breathing, Thoracic expansion exercises, Pursed lip breathing, Breath stacking exercises etc.

(Active Cycle of Breathing as well as techniques which helps in recruiting lung volumes combined with positioning can be helpful in weaning stages when the patient is co-operative and involved in the treatment)

*All of the above interventions, except for positioning, should not be used in Acute cases of Respiratory distress as it can lead to an increased work of breathing*.

5. Early Mobilisation is highly recommended in critical care settings and recovering cases. Improving Strength, Endurance, Cognitive functions and Quality of life of the patients recovered from ICU / on supplemental oxygen / suffering from Post ICU syndrome also marks the crucial role of Physiotherapists in Covid-19 disease.

So the above mentioned physiotherapy treatment can be performed depending on the need, stage, severity, underlying comorbidities of the cases and where they are appropriate and safe to perform, abiding by the protective guidelines of the health authorities and maintaining the highest level of Infection Prevention Control.^12,13

The World Health Organization also recommends limiting the number of Health Care Workers who are in contact with the suspected and confirmed COVID-19 patients and to limit the number of persons present in the room to the absolute minimum required for the patient’s care and support.⁷

So a Physiotherapist will have to be calculative and judgemental about how and where to provide the treatment by considering and practicing the strict Infection prevention and control guidelines and with proper Personal Protective Equipments (PPE) to reduce the risk of transmission.¹³

 

When not working in Acute Hospital Settings,  

THIS IS THE NEED OF THE HOUR WHICH IS EXPECTED FROM ALL THE PHYSIOTHERAPISTS.

• Primarily, Physiotherapists, especially Cardiorespiratory Physiotherapists, may find themselves in a position of contributing in reducing the workload in emergency departments as well as diverting the staff to contribute in the care and the management of hospitalized COVID-19 cases.
• Educate and spread the awareness about the condition and the symptoms by spreading all that is valid by WHO or local/ National Health authorities.
• Practice, Promote and Teach Infection control
• Promote the Importance and techniques of Breathing Exercises in healthy and most importantly elderly individuals, to keep their lungs healthy and to improve their aerobic capacity as well. A healthy, expanded lung keeps the entire body well oxygenated which in turn removes toxins from the body and improves our immunity and this is what we need to educate people for, at this hour.
• Give Home Exercise Programs, including breathing and chest expansion exercises, to the people who are quarantined or isolated. Now here it is very important to understand first that what kind of breathing exercises are needed for a particular patient. As we all know, that breathing exercises differ according to a person's co-morbidities. So diagnose, differentiate and design your treatment protocol as per the need of the patient. Start consulting online for such patients.
• Dealing with Quarantine or Isolation can lead to multiple other health issues so educate and counsel your patients about how to deal with it physically and mentally.
• Tele Rehabilitation is something that needs to be strongly promoted and recommended at this situation so that we don't deprive our patients from any necessary Physiotherapy consultation.

             Concluding this, I would like to mention that as and how we see the cases of this new pandemic, we will getter a better idea of the sequelae and in the near future, with more evidence based researches and studies, we can definitely come up with something more precise, in terms of Physiotherapy treatment protocol, and work accordingly as we have been doing for H1N1 and other infectious diseases in the past as a Cardiopulmonary Physiotherapist.

  Chest Physiotherapists have always worked at risk and at the frontline with other medical professionals in treating multiple ailments including highly infectious diseases, so even now, when and where needed, we will deliver our best to the society.