The Corona Virus epidemic is a highly virulent respiratory infection that emerged from Wuhan, a city in China, in December 2019. The virus rapidly spread to other parts of the country and across the globe leading to high mortality and morbidity cases. Due to the mode through which Covid 19 is transmitted and the increasing mortalities, the World Health Organization (WHO) declared it a global pandemic in March 2020. The main modes through which Covid 19 is transmitted are through respiratory droplets and when a susceptible host comes in contact with an already colonized person who has the Corona Virus (World Health Organization, 2020). After coming in contact with the virus, an individual begins exhibiting a dry cough, mild febrile illness, and severe respiratory distress. Severe respiratory distress is one condition that leads to hospitalizations in the Intensive Care Unit (ICU) among most Covid 19 infected patients.
Purpose of the Study
What and So What
The Corona Virus has an impact on several body systems and not the respiratory system alone. Covid 19 can also prompt the decompensation of the circulatory system, particularly among patients with earlier underlying disorders, including congestive heart disease and coronary artery disease (Robba et al., 2020). Most Covid 19 patients are often hospitalized for a long since they undergo comprehensive medical management. Some medical management practices include extended protective lung aeration, sedation, and use of neuromuscular blockers. The prolonged hospitalization also puts the patient at risk of having ICU acquired weakness, an aspect that contributes to poor outcomes (Robba et al., 2020). Thus important that Covid 19 patients, specifically those in the ICU, should be initiated on early rehabilitation after the acute phase has elapsed (Robba et al., 2020). Based on the impact that Covid 19 has on the body systems, different patients need to be initiated on different ventilator strategies.
Now What
Different strategies can be used in enhancing the quality of life of all Covid 19 patients who have been hospitalized in ICU units. Since the seriously ill patients on ventilators are confined to beds for long periods, they may develop problems with their breathing and other physical challenges (Thomas et al., 2020). To help these patients recover effectively, a physiotherapist may come in handy in fulfilling different roles. Physiotherapy is a globally recognized profession, with most of its workers providing their services in acute hospital wards. Physiotherapists also focus on managing acute and chronic respiratory conditions to promote the general physical recovery of the patients (Thomas et al., 2020).
Physiotherapy is important among Covid 19 patients since they may develop copious secretions that they cannot clear without any form of assistance (Thomas et al., 2020). Physiotherapists practicing in the ICU may offer airway sanction practices and help position patients experiencing severe respiratory failure (Simonelli et al., 2020). Based on the roles that physiotherapists play, encouraging physiotherapy sessions on Covid 19 patients is vital since it will aid in offering exercise, mobilization, and rehabilitative interventions, which will assist the Covid 19 survivors in experiencing a normal functional return to their families and community at large (Simonelli et al., 2020). This paper, therefore, seeks to expound on the role of physiotherapy in providing exercise, mobilization, and rehabilitative interventions among Covid 19 patients in their acute and post-acute phases and the role of chest physiotherapy among adults and children hospitalized in the ICU.
Literature Review
Theme 1: Physiotherapy during the Acute and Post-Acute Phases
Physiotherapy has proven to successfully assist Covid 19 patients, especially those admitted in the ICU, regain back their physical and functional status a few days post-admission. According to a study conducted by Andrade et al. (2020), physiotherapy needs to be initiated for Covid 19 patients during the critical, acute, and post-acute phases. This study indicates that rehabilitative interventions in this phase have to be initiated once the patient is clinically stable (Andrade et al., 2020). Treatments should also be withdrawn when this patient starts exhibiting signs of dyspnea, respiratory distress, arterial hypertension, bradycardia, shock, and intense sedation. Although the patients may be dyspneic, physiotherapy procedures geared towards relieving the patients from dyspnea, tracheobronchial clearance, exercising of the skeletal muscles, and preservation of the activities of daily living are discouraged (Simonelli et al., 2020). Subsequently, airway clearance procedures are contraindicated during the acute phase, especially among patients who do not have significant challenges related to bronchial obstruction. During the acute phase, physiotherapists are encouraged to regularly change patients’ posture, passive movement, and neuromuscular electrical stimulation among the unconscious patients. The semi-orthopneic prone should also be adopted for this type of patient since it helps improve the perfusion ratio, aspects that prevent further damage as a result of immobilization.
Patients recovering from Covid 19, especially those in the post-acute phase, may exhibit signs of disability and functional impairments (Lazzeri et al., 2020). Some of these damages may consist of impaired respiratory function, myopathy, neuropathy, and deterioration in their general quality of life (Lazzeri et al., 2020). The required period for the recovery of these patients often varies based on the extent of normocapnic respiratory failure and physical and emotional failure. Most patients with different comorbidities will require more time to return to their normal status. Therefore, physiotherapists are encouraged to monitor clinical parameters, including temperature, difficulty in breathing, respiratory rate, and thoracoabdominal dynamics, on a routine basis (Lazzeri et al., 2020).
According to Kalirathinam et al. (2020), patients recovering from Covid 19 are required to be successfully weaned from oxygen therapy. Physiotherapists need to follow repeated and straightforward protocols during this stage. When evaluating peripheral muscle strength post-recovery, physiotherapists are encouraged to use the Medical Research Council scale (Kalirathinam et al., 2020). Findings from this study also indicate that patients who are experiencing prolonged weaning arising from mechanical and oxygen use need to get reconditioning intervention since it helps in enhancing their physical status as well as correcting the motor and intellectual effects of extended ambulation in the ICU (Kalirathinam et al., 2020). Battaglini et al. (2020) note that the impact of muscle activity in infectious associated viral agents is not known yet; however, physical activity geared at steady load increase centered on the subjective indications that every patient is experiencing is encouraged. Subsequently, low-intensity exercise, daily patient counseling, and education should be advocated. Adopting the outlined physiotherapy activities during the acute and post-acute phases is vital since it lays a foundation for the patients to attain their physical stability and functional status within a short period (Battaglini et al., 2020).
Theme 2: Role of Chest Physiotherapy and Neuromuscular for Covid 19 patients in the ICU
Physiotherapy has been demonstrated to be an outstanding procedure in enhancing the long-term physical function among ICU survivors (Kress & Hall, 2018). However, different studies have not yet established the true benefits of physiotherapy, especially among Covid 19 survivors who are already experiencing alveolar damage. A recent study published by Lazzeri et al. (2020) indicates that certain physiotherapy procedures should be limited among Covid 19 patients, including diaphragmatic breathing, bronchial hygiene, manual mobilization, respiratory muscle training, and lung re-expansion techniques. These physiotherapy procedures are contraindicated because they lead to massive changes in their respiratory, cardiovascular, and cerebral hemodynamic function, which contributes to potentially harmful effects. When providing physiotherapy to patients, it is important to not only focus on the chest but also focus on other systems, especially the musculoskeletal system.
A study conducted by Simonelli et al. (2020) indicates that chest physiotherapy for critically patients consists of maneuvers such as chest clearance techniques, recruitment maneuvers, inhalational therapies, tracheostomy, and bronchial aspiration. According to the World Health Organization (2020), although the existing literature is still scarce, early physiotherapy, especially at the start of mechanical ventilation, is important since it aids in enhancing the patient’s performance and quality of life. Before starting any chest physiotherapy session, it is crucial that physiotherapists dawn in the required personal protective equipment.
Covid 19 patients in the ICU may require intubations to help them breathe easily. During the intubation process, the tracheal tube often bypasses the larynx completely: an aspect that facilitates the passage of microbes into the lower respiratory tract (Battaglini et al., 2020). Additionally, bypassing the larynx during the intubation process may predispose the Covid 19 patients from acquiring nosocomial infections, including ventilator-associated pneumonia. Therefore, subglottic secretion drainage (SSD) is encouraged among the critically Covid 19 patients since it reduces the risk of developing Ventilator-Associated Pneumonia (VAP) during intubation and post-extubation (Battaglini et al., 2020). Since SSD is associated with numerous benefits, it is encouraged that it should be initiated early and should be conducted under a closed aspiration circuit since it aids in limiting droplet dispersion and loss of Positive End Expiratory Pressure (PEEP).
Due to the intensive medical management of Covid 19, most patients stay in the ICU for prolonged periods hence developing ICU acquired weakness: a condition affecting approximately 50 percent of patients on mechanical ventilation for more than 48 hours. The risk factors of developing ICU acquired weakness include multiorgan failure, bed rest, use of corticosteroids, and neuromuscular blockers (Thomas et al., 2020). Therefore, it is important to start early planning of protocols that will be followed for the mobilization of these patients. The mobilization strategies should also be rational in assisting the patients to recover rapidly. A metaanalysis by Meng et al. (2020) indicates that inspiratory muscle training plays an influential role in enhancing maximal inspiratory pressure and successful weaning (Meng et al., 2020). Based on these findings, it is evident that early ambulation of critically ill patients is practical and harmless since it aids in reducing the number of days that patients spend in the ICU; further studies need to be conducted to prove the effectiveness of these strategies.
Theme 3: Inconsistencies in the findings on Physiotherapy among Critically Ill Patients in the ICU
Although physiotherapy plays an integral role among critical patients in the ICU, Lazzeri et al. (2020) note that certain procedures should not be conducted during the acute phase. Covid 19 patients in the ICU may experience acute respiratory failure, which reduces lung compliance and elevated respiratory work. In the long run, these changes alter blood oxygenation and shallow respiratory pattern (Lazzeri et al., 2020). Due to such changes, physiotherapists are contraindicated from engaging in procedures that may cause further burden to the patient’s respiratory system. Engaging in pursed-lip breathing, lung re-expansion techniques, incentive spirometer, and manual mobilization should not be practiced. A similar study by Abdullahi (2020) also provides similar findings on why physiotherapy is not encouraged during the acute period on Covid 19 infection. According to the author, most patients during the acute phase do not exhibit any signs of exudation; hence there would be no need to engage in any form of physiotherapy procedures. In the acute phase, the priority given to patients is to be placed on mechanical ventilators to support their breathing. Patients exhibiting mild symptoms of dyspnea and depression anxiety can, however, be placed on chest physiotherapy, although up to date, there are no studies indicating that chest physiotherapy should be used during the acute stage. The existing recommendation is only based on subjective evidence (Abdullahi, 2020).
Discussion
The role of Chest physiotherapy on mechanically ventilated Covid 19 patients during the acute and chronic phase is a subject of discussion in different studies. Approximately 41 percent of patients hospitalized in critical care units are mechanically ventilated, necessitating their close observation (Andrade et al., 2020). Covid 19 patients with multiple comorbidities such as obstructive pulmonary disorders may develop exudation consolidation and mucous hyper secretions, which they cannot effectively clear on their own. Since chest physiotherapy has proven to be effective in relieving patients from distress, it may also be beneficial to mechanically ventilated patients exhibiting the same symptoms (Andrade et al., 2020). Chest physiotherapy is effective and feasible since it helps in enhancing gaseous exchange, reverses pathological progression, and reduces the need for providing mechanical ventilation.
Covid 19 is a respiratory infection that can rapidly spread from one person to another. As a result, there have been concerns regarding the use of chest physiotherapy in such infectious diseases since it may contribute to increased aerosolization. However, during the influenza pandemic, chest physiotherapy produced droplets less than 10 millimeters. This size of droplets is very small and not easily respirable. However, the risk of acquiring Covid 19 from droplets during chest physiotherapy can be mitigated by following the universally recognized infection prevention measures (Abdullahi, 2020). Some of these precautions consist of disinfecting the surroundings and dawning in the required personal protective equipment (PPEs). Additionally, if surgical masks are available, patients putting them on can help prevent the dispersion of these aerosols to the environment. The primary aim of chest physiotherapy is to assist in alleviating dyspnea, anxiety, and depression within the shortest time possible. Doing so helps improve the patient’s general quality in the long run and helps them integrate successfully into society post-discharge (Abdullahi, 2020).
Mechanical ventilation is used to sustain Covid 19 patients experiencing severe respiratory distress. However, they may lose spontaneous breathing during the process, hence predisposing the patients to develop lung collapse and ventilator-associated pneumonia. Therefore, chest physiotherapy is encouraged in this scenario since it aids in reducing the length of stay on mechanical ventilation and in the ICU. Using chest physiotherapy, especially chest wall oscillation, on intubated patients can also help increase dry sputum weight, reduce lung prolapse, improve arterial oxygen levels, and reduce culture positivity. Therefore, it is evident that chest physiotherapy is key in reversing the pathological progression and improving impaired gaseous exchange.
Intubated patients also need to undergo physiotherapy before and after their extubation. The extubation process is equally an uphill task, thus the need to take the relevant preventive measures to prevent the aerosols from spreading to the surrounding environment. Before starting the extubation process, endotracheal suctioning must be performed. Alveolar recruitment maneuvers can also be practiced before extubation since it helps in reducing alveolar derecruitment. Spontaneous Breathing Trial should also be practiced on critically ill patients since it helps in improving the outcomes of critically ill Covid 19 patients on mechanical ventilation. Spontaneous breathing trials are often used to evaluate whether a patient can breathe independently while receiving little or no mechanical ventilation support. Covid 19 patients often present with respiratory distress, which makes them dyspneic. The formation of hypersecretions may also prevent these patients from breathing effectively. Thus, physiotherapists need to ensure that the underlying cause of respiratory distress has been resolved before starting the chest physiotherapy pre extubation.
Chest physiotherapy has proven to be effective in improving gaseous exchange among critically ill patients immediately after they have undergone the extubation process. Therefore, chest physiotherapy should also be considered among all the Covid 19 patients who require mechanical ventilation. A wide range of techniques can be adopted post-extubation, including active cycle breathing techniques, neuromuscular electrical stimulation, airway suctioning, manual hyperinflation, and positive expiratory pressure (Kalirathinam et al., 2020). With regard to active cycle breathing techniques, it should be embraced since it helps in promoting airway clearance hence minimizing the retention of sputum and inflammation. Manual hyperinflation is also vital since it helps in delivering a high tidal volume of oxygen to the lungs. Neuromuscular mobilization is key post-extubation since it promotes fast recovery. Based on my findings, the literature review supports my research questions since it reveals vital information concerning the role of physiotherapy in helping patients on mechanical ventilation regain their physical and functional state within a short period.
According to the findings from my research, physiotherapy among Covid 19 should not be taken for granted. One of the strengths of this research is that it has included findings from peer-reviewed articles published within the last two years. It has provided a rich analysis of the role of physiotherapy, especially chest physiotherapy among Covid 19 patients on mechanical ventilation. Most of my findings were also consistent with findings from other studies.
The role of physiotherapy has not been well elucidated in most studies. However, findings from my study can be used as a guide for proving physiotherapy procedures to critically ill Covid 19 patients in their acute, chronic, pre-extubation, and post-extubation phases. Since Covid 19 is a highly infectious respiratory infection, it is recommended that physiotherapists maintain high levels of infection prevention measures. Most studies mainly focus on analyzing the impact of physiotherapy in critically ill Covid 19 patients leaving out those who are discharged and are in the community. Further studies need to be conducted on physiotherapy to Covid 19 survivors at the community level.
Conclusion
Covid 19 is a new condition with limited information concerning the effective ways through which it can be managed. However, physiotherapy has proven to be successful in helping Covid 19 patients return to their functional status. There is also scanty evidence concerning whether physiotherapy should be provided to Covid 19 patients during their acute phase. Regardless of the situation, every patient is unique; thus, the type of physiotherapy procedure to be provided to a Covid 19 patients should be based on individual needs.
References
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