Role of physiotherapy in COVID 19 patients

1. IMPORTANCE OF
PHYSIOTHERAPY IN COVID 19
PATIENTS
Dr Hina Vaish ( PT)
BPT, MPT ( Cardiopulmonary), MIAP
Assistant Professor, MMIPR
Maharishi Markandeshwar (Deemed to be University),
Mullana, Ambala, Haryana, India

2. COVID-19
COVID-19 (previously called novel coronavirus) is a new strain of a
coronavirus that first emerged in Hubei province in China in late 2019
Predominant spread by respiratory droplets (e.g. someone coughing)
and contact (hands → surfaces → eyes and mouth)

4. Pulmonary manifestation of COVID 19

5. Happy hypoxemia

6. Extra pulmonary manifestations of COVID 19

7. COVID
19
Impaired
lung function
Physical
deconditioning,
muscle weakness
and
musculoskeletal
complications
Impaired cogntion
and mental health
and other
neurological
complications
Difficulty
managing
ADLs
Impaired
communication
and swallowing

8. Patient Classification
COVID 19
Patients
Symptomatic
Mild
pneumonia
Moderate
pneumonia
Severe Critical
Asymptomatic

9. Clinical classification of patients on disease severity
Mild disease
• Upper respiratory
tract symptoms (
&/or fever)
WITHOUT
shortness of
breath or hypoxia
• Home Isolation
Moderate Disease
• Respiratory rate >
24 min
• SpO2 < 94% on
room air
• Admit in ward
Severe Disease
• Respiratoty rate
> 30/min
• Spo2 < 90% on
room air
• Admit in ICU

10. Cont…
COVID 19 Patients
with symptoms
Mechanically
ventilated
Sedated/paralysed Minimally sedated
Non mechanically
ventilated
Patients with HFO
Patients with LFO
Patients on Room
Air

11. PT in
COVID
19
Improve
ventilation
Maintain
circulation
Helps to deal
with
complications
improving
strength
endurance ,
balance etc
Prevent
deconditioni
ng
Prevent
complications
of
immobilization
Reduce work of
breathing

12. Importance of PT in Asymptomatic patients
• Simple strategies may help
• Practicing simple diaphragmatic breathing with inspiratory hold
• Monitor saturation
• Monitor saturation with exertion. 6MWT can help to identify happy
hypoxemia at early stages
• Sitting is secondary smoking, every 30 minutes change position

13. Six minute walk test

14. Aims of PT management of COVID 19
mechanically ventilated patients
• Minimize complications of
immobility
• Chest clearance
Sedated/Paralysed
• Facilitate slow progressive
early mobilization
• Optimize oxygenation
Minimally sedated
patients

15. Aims of PT management of COVID 19
mechanically ventilated patients
• Enhance progressive
mobilization
• Optimize
oxygenation
Patients on
HFO
• Improve endurance
• Improve functional
independence
Patients
with LFO
Patients on
room air

16. Recommendations for Assessment and Screening
• All patients should be screened for presence of comorbidities
• Screening for hemodynamic stability
• Screening for respiratory distress

17. Cont…
• The sedation level and awakening should be evaluated for patients on
mechanical ventilation or noninvasive ventilation to assess readiness
for early mobilization. Safety parameters for mobilization should be
considered.

18. Cont…
• Screening for activity-induced desaturation
• Screening for readiness to mobilization

19. Assessing for mobility and function

20. Recommendations for Physiotherapeutic
Interventions
• Physiotherapeutic maneuvers
include body positioning to
improve ventilation-perfusion
ratio and oxygenation,
• It is recommended to encourage
awake active prone positioning
“COVID awake repositioning
proning protocol” called as
“CARP”

21. Dyspnoea relieving postures

22. Breathing exercises

23. Airway clearance techniques

24. Nebulization
• Dry inhalers or ultrasonic nebulizers connected to the mechanical
ventilator in a closed circuit

25. Early Mobilization
• It is recommended to begin with an early passive or active assisted
mobilization program based on patients level of cooperation/orientation,
oxygen saturation, and hemodynamic stability.
• Gradual progression with very low intensity depending on saturation,
symptoms, permissible level of oxygen therapy, and hemodynamic
response should be encouraged.
• Exercises to progress from assisted to active mobilization at the edge of
bed and out of bed. Progression of the exercise should depend on level of
cooperation, hemodynamic stability, exercise tolerance, and
neuromuscular parameters. Allow adequate rest during exercises till
discharge and stabilization

26. Graded Mobilization
• With very mild symptoms due to COVID-19, it is recommended to
consider limiting activity to light activity within functional
requirement of metabolic equivalents but limit sedentary periods. If
needed, oxygen therapy may be initiated in consultation with the
physician if patient desaturates.
• Increase rest periods if symptoms deteriorate. Prolonged exhaustive
or high-intensity training should be avoided

27. Cont..
• Asymptomatic patients may be encouraged to achieve at least 10
minutes of continuous physical activity or structured exercise without
fatigue or desaturation below 90% .
• Adequate rest periods should be encouraged to avoid undue fatigue.

28. Cont….
• Exercises may progress to 20 minutes applying principles of
frequency, intensity, time, and type after 3 weeks of acute episode
and once patient is asymptomatic to allow adequate recovery.
• Mobility aids used should be disinfected. Use of light thera-bands
depending on the muscle strength is recommended during the
predischarge phase provided there is no desaturation

29. Use of Respiratory Devices

30. Management of complication
• Different domains of physiotherapy has a role to play

31. Telerehabilitation

32. Summary
• Physiotherapy is essential both in acute respiratory phase and to
support rehabilitation of COVID 19 patients.
• Organisation and planning are key to success
• Significant ongoing rehabilitation is needed following hospital
discharge

33. Contact: hinavaish@mmumullana.org