Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019

Abstract

Introduction Since December 2019, the coronavirus disease 2019 (COVID-19) has become a public health emergency. COVID-19 has already been classified as a category B infectious disease according to the Law of the People's Republic of China on the Prevention and Treatment of Infectious Diseases, and control measures for category A infectious diseases have been adopted. The National Health Commission has also published diagnosis and treatment protocols to guide the clinical diagnosis and treatment. With the accumulating experience of treating COVID-19 patients, particularly severely and critically ill patients, in clinical practice, our understanding of COVID-19 has continuously deepened. With regard to varying degrees of respiratory, physical, and psychological dysfunction in patients,[1] it is vital to standardize respiratory rehabilitation techniques and procedures for respiratory rehabilitation in various regions. Hence, we combined the opinions of frontline epidemic control experts and reviewed the evidence in relevant literature. Based on the “Coronavirus Disease 2019 Respiratory Rehabilitation Guidelines (First Edition),”[2] we organized experts in evidence-based medicine, respiratory and critical care medicine, and rehabilitation medicine in China, and invited some experts at the frontline of epidemic control in Wuhan and other cities in Hubei province to jointly draft these recommendations. Methodology Registration These recommendations were registered at the International Practice Guidelines Registry Platform (http://www.guidelines-registry.org; registration number: IPGRP-2020CN016). Recommendation work group The recommendation work group was divided into the recommendation drafting group, evidence assessment group, and expert consensus group. The drafting group is responsible for determining the topic and scope of the recommendations, guiding the evidence assessment group in evidence summary, and drafting recommendations. The evidence assessment group is responsible for searching, assessing, and providing a summary of relevant evidence. The expert consensus group is responsible for achieving a consensus from the preliminary recommendations. Literature search Our recommendations included rehabilitation-related guidelines, systemic reviews, and randomized controlled trials with regard to three infectious diseases (COVID-19, severe acute respiratory syndrome [SARS], and Middle East respiratory syndrome [MERS]). Two members of the evidence assessment team performed independent computer searches of English databases (PubMed, Ovid, Embase), Chinese databases (Chinese Biological Medical Literature database, China National Knowledge Infrastructure, Chinese Medical Journal Database), and relevant online website bulletins on COVID-19 (the World Health Organization, Elsevier, the Lancet, the New England Journal of Medicine, and the Journal of the American Medical Association, 2019 Novel Coronavirus Resource (2019nCoVR), and the Chinese Medical Journal Network). The search period was from database construction to February 21, 2020. The search terms included the English terms and their Chinese equivalents: “novel coronavirus pneumonia,” “NCP,” “severe acute respiratory syndrome,” “SARS,” “Middle East Respiratory Syndrome,” “MERS,” “influenza,” “psychological therapy,” “guideline,” “statement,” “recommendation,” “randomized controlled trial,” and other rehabilitation-related English search terms and their Chinese equivalents included “respiratory rehabilitation,” “pulmonary rehabilitation,” “physiotherapy,” “physical therapy,” and “occupational therapy.” If the complete article was unavailable, we emailed the corresponding author to obtain it. Paper screening and evidence summary Two members of the evidence assessment group used the Endnote X9 literature management software to screen the literature independently according to the inclusion and exclusion criteria. Different rehabilitation topics were used for classification and to summarize the results of the included articles. Cross-verification was carried out by two staff members during screening and during the preparation of the summary. If there was any dispute, a third researcher intervened, discussed, and resolved the dispute. Quality assessment The evidence assessment group employed the Appraisal of Guidelines for Research & Evaluation II tool for methodological quality assessment of the included guidelines, the Assessment of Multiple Systematic Reviews tool for quality assessment of systematic reviews, and the Cochrane bias risk assessment tool for bias risk assessment of randomized controlled trials. Generation of recommendations and consensus Based on the evidence summary and quality assessment results, the recommendation drafting group combined all existing recommendations and drafted a preliminary version of rehabilitation recommendations. The recommendations were submitted to the expert consensus group, and a consensus was reached through panel discussions, which was then determined to be the final draft of the recommendations. Basic Principles of Respiratory Rehabilitation Prerequisite First, the requirements of the “Guidelines for COVID-19 Prevention and Control in Medical Institutions (1st Edition)”[3] printed by the National Health Commission should be strictly complied with. All staffs who had a close contact with patients for respiratory rehabilitation assessment and treatment must pass the infection control training and examination in the local hospital before they can start to work. Aim For COVID-19 inpatients, the aim of respiratory rehabilitation is to ameliorate dyspnea, alleviate anxiety and depression, reduce complications, prevent and improve dysfunction, reduce morbidity, preserve functions, and improve quality of life as much as possible. Timing Early respiratory rehabilitation is not recommended for severely and critically ill patients if their condition remains unstabilized or progressively deteriorates. The timing of respiratory rehabilitation intervention should exclude contraindications for respiratory rehabilitation and should not aggravate the burdens of infection prevention. The staged respiratory rehabilitation measures can be employed at the later stages for discharged patients with different sequelae. Methods For patients in isolation ward, educational videos, self-management booklet, and remote consultation are recommended during respiratory rehabilitation to reduce the usage of protective equipment and avoid cross-infection. Integrated rehabilitation using multiple methods can be employed in patients who meet the recovery criteria and are no longer under quarantine observation based on their indications and conditions. Personalization The principle of personalization must be adhered to regardless of the type of respiratory rehabilitation intervention. In particular, for patients with severe/critical condition, older adults, obesity patients, patients with multiple comorbidities, and patients with one or more organ failure, the respiratory rehabilitation team should customize a respiratory rehabilitation plan based on the unique problems of each patient. Evaluation Evaluation and monitoring must be conducted from the initiation until the completion of respiratory rehabilitation. Protection [Table 1] The staff must refer to the requirements indicated in the “Recommendations for Airway Management in Adult Severe Coronavirus Disease 2019 Patients (Interim)” and determine the appropriate protective measures according to the type of task.[4]Table 1: Protection categories when performing respiratory rehabilitation for COVID-19 patients.Respiratory Rehabilitation Recommendations for Mildly ill Patients During Hospitalization (Only for Cabin Hospitals) The clinical symptoms of the patient are mild and may include fever, fatigue, coughing, and one or more physical dysfunctions.[5,6] During quarantine, patients with confirmed disease may show anger, fear, anxiety, depression, insomnia or aggression, and loneliness, or will be uncooperative due to fear of the disease. The patients will tend to give up treatment or develop other psychological problems.[7] Respiratory rehabilitation can ameliorate anxiety and depression in patients.[8] Recommendations Patient education (1) Advocacy, videos, and booklet are used to help patients understand the disease and treatment process; (2) the patients are required to take regular rest and have sufficient sleep; (3) they are encouraged to eat a balanced diet; (4) they are advised to stop smoking. Activity recommendations (1) Exercise intensity: Borg dyspnea score ≤3 points (total score: 10 points), fatigue should be absent on Day 2 preferably; (2) Exercise frequency: twice a day, duration 15 to 45 min/session, 1 h after meals; and (3) type of exercise: breathing exercise, Tai chi, or square dancing. Psychological intervention (1) Self-assessment scales are used to rapidly identify the type of psychological dysfunction. (2) If necessary, the patients should visit the psychologists or ask for help through mental health hotline. Respiratory Rehabilitation Recommendations for Moderately ill Patients During Hospitalization (Only for Cabin Hospitals) Isolation is an effective method for reducing the transmission of disease. However, isolation causes patients to have limited exercise space. In addition, patients experience fever, fatigue, muscle ache, and so on,[6] and the duration of sitting and lying down is significantly increased for most patients. Prolong bed rest will decrease muscle strength, result in poor expulsion of sputum,[9] and significantly increase the risk of deep vein thrombosis.[10] Moreover, anxiety, depression, and fatigue will result in exercise intolerance.[11] Recommendations Intervention timing for respiratory rehabilitation in moderately ill patients Due to the limited understanding of the pathophysiological mechanisms of COVID-19, current clinical observations found that around 3% to 5% of moderately ill patients develop severe or even critical disease after 7 to 14 days of infection. Therefore, the exercise intensity should not be too high as its objective is to maintain the existing physical status. After the patient is admitted to the cabin hospital, data on the patient's initial consultation time, duration from disease onset to dyspnea, and blood oxygen saturation (SpO2)[12,13] should be assessed to determine if the respiratory rehabilitation can be initiated. Exclusion criteria Patients (1) with a temperature >38.0°C, (2) with an initial consultation time ≤7 days, (3) in whom the duration from disease onset to dyspnea is ≤3 days, (4) whose chest radiological scans show >50% progression within 24 to 48 h, (5) with an SpO2 level of ≤95%, and (6) with a resting blood pressure of <90/60 (1 mmHg = 0.133 kPa) or >140/90 mmHg. Exercise termination criteria Respiratory rehabilitation is immediately discontinued when one of the following conditions develops during rehabilitation: (1) dyspnea index: Borg dyspnea score >3 (total score: 10 points); (2) chest tightness, shortness of breath, dizziness, headache, blurred vision, heart palpitations, profuse sweating, and balance disorder; and (3) other conditions that the clinician determines to be unsuitable for exercise. Assistance should be sought from physicians and nurses. Primary intervention measures for respiratory rehabilitation include airway clearance, breathing control, physical activity, and exercise (1) Airway clearance: (i) dilation during deep breathing exercise can be used to help sputum expectoration and (ii) a sealed plastic bag should be used when coughing to avoid virus transmission. (2) Breathing control: (i) positioning: An upright sitting position is usually adopted. Patients with shortness of breath should adopt a semi-sitting position or a leaning forward position; (ii) maneuvers: During training, the accessory muscles of the shoulders and neck are relaxed, and the patient slowly inhales through the nose and slowly exhales through the mouth. Attention is paid to the expansion of the lower chest. (3) Physical activity and exercise recommendations: (i) intensity: The recommended exercise intensity is between rest (1.0 metabolic equivalents [METs]) and light exercise (<3.0 METs); (ii) frequency: Exercise is performed twice a day, 1 h after meal; (iii) duration: The exercise duration is based on the patient's physical status, and each session lasts 15 to 45 min. Patients who are prone to fatigue or are physically weak should perform intermittent exercise; (iv) type of exercise: breathing exercises, stepping, Tai chi, and exercises that are recommended to prevent thrombosis; and (v) the management of patients with limited locomotor activity is the same as that for severely ill patients. Respiratory Rehabilitation Treatment for Severely and Critically Ill Patients Severely and critically ill patients account for 15.7% of the number of confirmed cases.[6] The latest pathology results show that early-[14] and late-stage pulmonary lesions are mainly due to diffuse alveolar injury, significant fibrosis did not occur, and diffuse lymphocyte infiltration is present between myocardial fibers, and the possibility of comorbid viral myocarditis cannot be excluded.[15] Many COVID-19 patients who are given mechanical ventilation under deep sedation and receiving analgesia completely lose spontaneous breathing and have no or weak response to stimuli, and the incidence of delirium in patients is high.[16] Respiratory rehabilitation can be initiated at a suitable time and can significantly reduce delirium and mechanical ventilation duration, and eventually improve the patient's functional status.[17] Before performing the rehabilitation intervention in severely and critically ill patients, a comprehensive evaluation of the patient's systemic function is required, particularly in terms of cognitive status, respiratory function, cardiovascular function, and musculoskeletal function. Treatment should be initiated as soon as possible in patients who are eligible for respiratory rehabilitation. Before initiating treatment, a consensus from the medical team must be obtained, and sufficient preparations should be made. Reassessment should be carried out in patients who do not fulfill the criteria for respiratory rehabilitation, and respiratory rehabilitation can only be performed once they satisfy the criteria. If adverse events occur during rehabilitation, rehabilitation should be discontinued immediately, and the chief physician must be informed. The cause should be determined, and safety should be re-evaluated. Due to safety and human resource concerns, only the recommended bed and bedside activities are carried out during rehabilitation in severely and critically ill patients. Rehabilitation intervention measures must cover three major areas: (1) positioning management, (2) early mobilization, and (3) respiratory management. The therapeutic interventions should be based on the patient's cognitive status and functional status. Recommendations Timing of intervention Respiratory rehabilitation can be initiated once all of the following criteria are met[18]: (1) respiratory system: (i) fraction of inspired oxygen ≤0.6, (ii) SpO2 ≥90%, (iii) respiratory rate ≤40 breaths/min (bpm), (iv) positive end expiratory pressure ≤10 cmH2O (1 cmH2O = 0.098 kPa), (v) absence of ventilator resistance, and (vi) absence of unsafe hidden airway problems; (2) cardiovascular system: (i) systolic blood pressure ≥90 and ≤180 mmHg, (ii) mean arterial pressure (MAP) ≥65 and ≤110 mmHg, (iii) heart rate ≥40 and ≤120 beats/min, (iv) absence of new arrhythmia or myocardial ischemia, (v) absence of shock with lactic acid level ≥4 mmol/L, (vi) absence of new unstable deep vein thrombosis and pulmonary embolism, and (vii) absence of suspected aortic stenosis; (3) nervous system: (i) Richmond Agitation-Sedation Scale score: −2 to +2 and (ii) intracranial pressure <20 cmH2O; and (4) others: (i) absence of unstable limb and spinal fractures, (ii) absence of severe underlying hepatic/renal disease or new progressively worsening hepatic/renal impairment, (iii) absence of active hemorrhage, and (iv) temperature ≤38.5°C. Early rehabilitation is discontinued immediately if the following conditions occur[18] (1) Respiratory system: (i) SpO2 <90% or decrease by >4% from baseline, (ii) respiratory rate >40 bpm, (iii) ventilator resistance, and (iv) airway or (2) cardiovascular system: (i) systolic blood pressure or mmHg, (ii) or mmHg, or with baseline, (iii) heart rate or beats/min, and (iv) new arrhythmia and myocardial (3) nervous system: (i) of and (ii) and (4) others: (i) of any treatment or of monitoring to the (ii) heart palpitations, of dyspnea or shortness of breath, and and (iii) in patient. Respiratory rehabilitation intervention measures (1) In that status is increased until the patient can maintain an upright as the of the bed by the lower of the is on of the to prevent A is the to the lower and management is carried out in and three are conducted each position ventilation is carried out in acute respiratory syndrome patients for h and (2) Early Attention should be paid during the activity to prevent and vital should be during the (i) strength, duration, or activity scope can be used in patients with poor physical status, and patients only to complete the (ii) duration: The training duration for a session should not (iii) type of exercise: First, regular and on the sitting up on from the bed to sitting on the and should be carried out by exercise training is performed within the of for patients receiving or patients with of cognitive dysfunction, or with limited include bedside lower limb exercise and exercise, and (3) Respiratory mainly and sputum expulsion and not to have of patient The management should not severe and increase the work of chest and positive expiratory pressure are the recommended treatment Respiratory Rehabilitation Treatment for Patients Mildly and moderately ill patients after rehabilitation of and moderately ill patients mainly of physical and psychological exercises can be so that patients can the level of activity before disease onset and eventually to ill patients after ill COVID-19 patients with respiratory limb dysfunction after should respiratory rehabilitation. Based on the in discharged and and clinical experience on rehabilitation in patients, COVID-19 patients may have poor physical shortness of breath, muscle respiratory muscles and and limb and The should be on if the patients have as pulmonary heart failure, deep vein and unstable before respiratory rehabilitation treatment. Recommendations Exclusion criteria (1) A heart rate of beats/min, (2) a blood pressure of <90/60 or >140/90 mmHg, (3) an SpO2 of ≤95%, and (4) other diseases that are not suitable for exercise. Exercise termination criteria Patients who experience (1) temperature (2) of respiratory symptoms and fatigue that are not after rest should exercises The physician should be if the following symptoms chest tightness, chest dyspnea, severe dizziness, headache, blurred vision, heart palpitations, profuse sweating, and unstable Rehabilitation evaluation (1) physical function and (2) Exercise and respiratory function (i) respiratory muscle expiratory (ii) muscle the Medical Research muscle and muscle (iii) (iv) balance function balance (v) exercise and exercise and (vi) physical activity International Physical Activity and Physical Activity Scale for the (3) Evaluation of activities of The is used to Respiratory rehabilitation intervention (1) Patient (i) booklet and should be to the and of respiratory rehabilitation to increase patient (ii) (iii) patients to in and (2) Respiratory rehabilitation recommendations: (i) exercises are according to the patient's underlying disease and dysfunction. These exercises include and and at a intensity before progressively in intensity and A of to are carried out and each session lasts to min. 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