Physiotherapy guide in management of COVID 19 patients

Physiotherapy is a core component of multidisciplinary care in patients with COVID-19, particularly in hospitalized and critically ill individuals. The objectives are to:

• Improve ventilation and oxygenation

• Facilitate secretion clearance

• Prevent complications of immobility

• Restore functional independence

• Reduce ICU and hospital length of stay

COVID-19 frequently produces viral pneumonitis progressing to Acute Respiratory Distress Syndrome, characterized by decreased lung compliance, impaired gas exchange, and severe fatigue after recovery. Early and targeted physiotherapy therefore significantly improves outcomes.

A. Purpose of Physiotherapy in COVID-19 Care

Physiotherapy aims to address four domains:

Indications occur in:

• Pneumonia with retained secretions

• ICU mechanical ventilation

• Prolonged immobilization

• Neuromuscular weakness

• Post-COVID functional limitation

B. Clinical Practice Guidelines

1. Indications for Respiratory Physiotherapy

Respiratory physiotherapy should ONLY be provided when clinically necessary to reduce staff exposure.

Appropriate indications

• Exudative consolidation

• Mucus hypersecretion

• Ineffective cough

• Difficulty clearing sputum

• Neuromuscular weakness

• Co-existing lung disease (COPD, bronchiectasis)

NOT indicated

• Dry non-productive cough

• Mild pneumonitis without secretion retention

• Stable mild disease

2. Infection Prevention & Control

COVID physiotherapy involves aerosol-generating procedures (AGPs). Strict precautions are mandatory.

High-risk staff (pregnant, immunocompromised) must not be assigned.

3. Service Organization

• Dedicated COVID physiotherapy team

• Staff rotation schedule

• Recommended ratio: 1 physiotherapist : 5 patients / shift

• Continuous multidisciplinary consultation

C. Physiotherapy Equipment

Mobility & Rehabilitation Equipment

• Tilt table

• Oxford chairs

• Walking rollators

• Cycle ergometer

• Step blocks

• Treadmill

Respiratory Equipment

• Incentive breathing devices

• Positioning supports

• Airway clearance devices

Mandatory PPE

• Face shield

• Gloves

• Long-sleeve gowns

• Hair cover

• N95 respirator

D. Respiratory Physiotherapy Interventions

1. Airway Clearance Techniques (ACT)

Indicated when secretions are present and patient cannot clear independently.

Active Cycle of Breathing Technique (ACBT)

Three phases:

Oscillatory Positive Expiratory Pressure (OPEP)

• Improves mucus mobilization

• Enhances expiratory airflow

• Reduces airway collapse

Forced Expiratory Technique

• Huff coughing rather than forceful cough

• Prevents airway collapse

• Reduces fatigue

Postural Drainage

Uses gravity to drain lung segments.

Key Principles

• Maintain position 5–10 minutes

• Combine with breathing exercises

• Monitor oxygen saturation

2. Prone Positioning (Awake Proning)

A highly effective non-invasive oxygenation strategy.

Physiological Effects

• Improves ventilation-perfusion matching

• Recruits posterior lung segments

• Reduces shunt

• May prevent intubation

Suggested Rotation

1. Prone

2. Left lateral

3. Sitting upright

4. Right lateral

Each position: 30–120 minutes depending tolerance.

E. Respiratory Functional Training

Breathing Exercises

• Diaphragmatic breathing

• Segmental expansion

• Controlled breathing

Respiratory Endurance Training

Not first-line during acute infection but useful in recovery phase.

F. Physical Rehabilitation Program

COVID patients rapidly develop ICU-acquired weakness and sarcopenia. Early mobilization is essential.

1. Aerobic Exercise Prescription

Start once clinically stable.

Prescription

• 20–30 minutes/session

• 3–5 sessions/week

• Start low → gradual progression

• Avoid next-day exhaustion

2. Strength Training

Progressive resistance training:

• Sandbags

• Resistance bands

• Water bottles

Protocol

• 15–20 repetitions

• 1–2 sets/day

• 3–5 days/week

Targets:

• Quadriceps

• Gluteal muscles

• Shoulder girdle

• Respiratory accessory muscles

G. Mobilization Strategy (Hospital → Recovery)

H. Special Situations

Mechanically Ventilated Patients

Physiotherapy focuses on:

• Positioning

• Passive movements

• Secretion clearance

• Weaning facilitation

Severe Fatigue Patients

Use interval training:

• Short activity bursts

• Long rest periods

I. Expected Benefits of Physiotherapy

Key Clinical Principle

Physiotherapy in COVID-19 is not routine treatment — it is an indication-based intervention aimed at maximizing recovery while minimizing infection risk.

Early, safe, and progressive rehabilitation significantly reduces complications and long-term disability after severe infection.