Chest Physiotherapy in Patients Admitted to the Intensive Care Unit With COVID-19: A Review

1. INTRODUCTION

Coronavirus is a single-stranded RNA virus that belongs to the Coronaviridae family of viruses [1]. Subjects affected with this coronavirus develop Coronavirus disease, also known as COVID-19 [2]. Presently, this is a pandemic disease as declared by the World Health Organisation (WHO) worldwide. Patients acquire this infection if they come in close contact with infected persons who are either asymptomatic or symptomatic with cough and sneeze symptoms [3]. The respiratory symptoms observed in such patients are sore throat, dry, and mostly non-productive cough. Sometimes the clinical presentation is of mild respiratory tract infection (Influenza-like illness (ILI)), or the patient will show pneumonia or Adult Respiratory Distress Syndrome (ARDS) or may even present with respiratory failure late in the disease course. The acute respiratory illness is managed in the Intensive Care Unit (ICU), and because of severe hypoxic respiratory failure, it may require oxygen therapy, Non-invasive Ventilator (NIV) support, or invasive ventilatory support along with other advanced care management [2]. The patient develops ventilatory limitation, dyspnea, and ventilation/perfusion ratio mismatch due to the respiratory system involvement [4].

Patients admitted to the ICU usually have dyspnea associated with decreased tidal volume, Ventilation-perfusion (V/Q) mismatch, and muscular dysfunction requiring chest physical therapy to optimize the body's oxygen transport system [5]. Evidence suggests that amongst COVID-19 patients, around 80% of patients are asymptomatic, 15% of patients present with mild symptoms requiring oxygen support, and 5% of patients are critically ill and may require intubation along with advanced airway management techniques [6]. The admission rate of COVID-19 patients is nearly 5% in ICU [7].

Chest physiotherapist provides airway clearance techniques, optimal patient positioning, and inspiratory muscle training that improve the ventilatory function in these patients. COVID-19 patients may present in two different manners, i.e., some patients show severe hypoxemia with normal lung compliance, wherein the cause of hypoxemia is impaired pulmonary blood flow. On the other hand, there is a different subset of COVID-19 patients who present with severe hypoxemia and decreased lung compliance like ARDS [8].

COVID-19 has affected the lives of not only common people but also of health care professionals. Today, many hospital wards are converted into semi ICU and ICU to manage critically ill and intubated COVID-19 patients. The physical therapist is one of the intensive care unit team members who can play an essential role in managing even COVID-19 patients. During patient management, they are in close contact with the patient, and many of the interventions done by chest physiotherapists are aerosol-generating, and thus the therapist's safety is of great concern in such situations. A patient admitted to the ICU can be either suspected or infected COVID-19 patient with normal underlying lung or diseased lung pathology.

The review article aims to find the role of chest physiotherapy in COVID-19 infected patients admitted to the ICU. Thus, admissions in ICU can be of patients suspected or infected with COVID-19, with or without underlying lung disease (Other than COVID-19).

2. BREATHING TECHNIQUES

Various breathing techniques that may be utilized are diaphragmatic breathing technique, pursed-lip breathing, segmental breathing exercise, and inspiratory muscle training technique [13]. These exercises may be utilized in non-ventilated patients who are not in respiratory distress.

Diaphragmatic breathing exercises increase diaphragm excursion. These exercises can be taught to the patients and practiced by them if they are not on a ventilator, irrespective of the presence of underlying respiratory disease. Also, in patients showing alveolitis and fibrosis, these breathing exercises can decrease the lung's atelectasis areas.⁹Pursed lip breathing exercises can be taught to conscious patients, and it may be beneficial, especially in patients with underlying obstructive lung disease like COPD [10, 13]. This technique helps in creating positive pressure and thus decreases dyspnea and work of breathing. Dyspnea relieving positions can be given in such patients, and pursed-lip breathing can be practiced [13]. Similarly, segmental breathing exercise also increases the lateral and coastal expansion of the lung. It also decreases the atelectasis areas so that it can be recommended in patients with evidence of alveolitis and fibrosis at the time of presentation [9, 13]. Inspiratory muscle training (IMT) is provided by IMT devices that are readily available and can be cost-effective for some patients, but a single device for a single patient and routine cleaning and disinfection of the devices is crucial [13]. Hemodynamic monitoring is also essential. The technique can be taught to a conscious patient with the help of the audio-visual aid method [10]. IMT improves respiratory muscle strength [13].

3. AIRWAY CLEARANCE TECHNIQUE

Various physiotherapy techniques generally used for airway clearance routinely are positioning, cough and huff techniques, various bronchial hygiene techniques (e.g., modified postural drainage technique, positive expiratory pressure device, cough assist devices, high-frequency chest wall oscillator, and active cycle of breathing technique), suctioning procedures (open suction via endotracheal and tracheostomy pathway, saline installation, and manual hyperinflation via AMBU bag), any other maneuver that requires disconnection from the ventilator and results in secretion removal and any mobilization technique that assists in the removal of secretions [10, 13].

All of these procedures are potentially aerosol-generating procedures [6]. Therefore, physiotherapists should decide whether to provide a particular technique by assessing risk: benefit ratio and, if beneficial, they should follow the following recommendations and guidelines to minimize the exposure.

Before the airway clearance technique, nebulization is generally recommended in normal patients. However, it is contraindicated in COVID 19 patients [6]. Risk: benefit ratio should be assessed before conducting airway clearance techniques, and also experienced clinicians in the team should be contacted and consent must be taken before conducting these techniques in an environment wherein airborne infection guidelines are strictly implemented.

Inhalation and humidification therapy is not recommended in COVID-19 patients. Inhalers (metered-dose inhalers) should be used [14]. The spacer should be used with inhalers, and it should be single-patient used. In ventilated patients, the ultrasonic nebulizer may be used in a closed circuit without removing the anti-microbial filter [2, 6]. Generally, the aerosol-generating technique is relatively contraindicated in COVID-19 patients.

Active Cycle of Breathing Technique (ACBT) and autogenic drainage technique can be taught to non-ventilated patients with underlying lung pathology, but with airborne precaution.

Positive Expiratory Pressure (PEP) using an oscillatory PEP device can be used. If required, a single patient device can be used.

Postural drainage positions can be given, but after consulting senior clinicians and with all the precautions [6]. Postural drainage techniques such as percussion, vibrations, and shaking are absolutely contraindicated in all the COVID-19 patients due to aerosol generation risk.

Suctioning should be done with precautions in suspect or confirmed COVID-19 patients. Open suctioning should be avoided, and close suctioning should be the mode of treatment [2, 6].

The following essential precautions should be strictly followed during physiotherapy management of suspect/ confirmed COVID-19 patients:

• (1) Proper hand hygiene.
• (2) Use of PPE. Face shield, hair cover, N95 mask, and full-sleeved gowns should be worn [6].
• (3) Proper disposal of patient secretions [6, 13]
  • (1) Proper disinfecting and cleaning instruments and equipment used by the patient for his/her benefit [2, 6].
  • (2) Maintaining a safe distance from the patient, i.e., at least >2 m and therapist position, should be preferably at the patient's backside [6].
  • (3) Physiotherapy technique must be carried out either in a negative pressure room or single room with a single patient and minimum staff, and it is pertinent to avoid visitor's entry during an intervention [6].
  • (4) The patient should wear a surgical mask and preferably, should be appropriately placed and use disposable equipment to reduce the patient's movement to minimize the spread of infection [6].

4. MOBILIZATION

Active mobilization is essential to prevent deconditioning and maintain the range of motion and muscle strength [9, 10, 13]. Strength training using therabands of a different colour can be given. Every patient should have their own theraband to prevent cross-infection [13]. Charts and audio-visual aids can help mobilize conscious patients, and in an unconscious patient, passive mobilization is given to prevent deep vein thrombosis (DVT) and other complications due to prolonged bed rest [11, 13]. Sitting on the bed edge or near the bedside is essential for early recovery. Similarly, if the patient has sufficient strength, walking should also be encouraged as early as possible for a speedy recovery.

Precaution: Hemodynamic monitoring in ICU is essential during mobilization [10].

The therapist should be aware of the happy hypoxia observed in COVID 19 patients to prevent any complications due to physiotherapy in non-ventilated patients. So, it is essential for the physiotherapist to monitor and assess vital parameters, including oxygen saturation at room air, before, during, and after the intervention [15].

CONCLUSION

The physiotherapist's role in treating COVID-19 patients in ICU is essential for early recovery and decreasing the morbidity associated with the disease, thus improving the quality of life. However, at the same time, strict adherence to precaution is a must to prevent infection transmission.

REFERENCES