ARTICULO REVISIÓNREVISTA DE LA FACULTAD DE MEDICINA HUMANA 2021 - Universidad Ricardo Palma
1Departamento de Medicina Física y Rehabilitación. Hospital Nacional Edgardo Rebagliati Martins.
aResident Physician in Physical and Rehabilitation Medicine
Introduction: The SARS-CoV-2 coronavirus is a new pathogen causing COVID-19 disease, ranging from an asymptomatic infection to a critical condition dependent on mechanical ventilation. Rehabilitation interventions contribute for the prevention and treatment of related complications and associated disability. Objective: Describe rehabilitation recommendations for adult patients with COVID-19. Methods: A literature search was carried out. Databases and portals were consulted using the following terms and their equivalents: SARS-CoV2, COVID-19, rehabilitation, physiotherapy. The search was carried out in Spanish, English, Chinese and Italian languages, with a time window between January 2010 and April 2020. Results: 23 publications met the predetermined inclusion and exclusion criteria. Based on the information obtained, recommendations and tables were prepared regarding the clinical classification of COVID-19, medical behavior to be followed according to severity, general care and rehabilitation interventions in adult patients with COVID-19. Conclusions: Rehabilitation interventions are essential and indispensable resources for the multidisciplinary treatment of patients with COVID-19, despite of the low quality of the available evidence.
Keywords: COVID-19; SARS-CoV-2; physical medicine and rehabilitation; respiratory rehabilitation; respiratory physiotherapy. (Source: MeSH NLM).
Introducción: El coronavirus SARS-CoV-2 es un nuevo patógeno causante de la enfermedad COVID-19, que varía desde una infección asintomática hasta un cuadro crítico dependiente de ventilación mecánica. Las intervenciones de rehabilitación contribuyen a la prevención y tratamiento de las complicaciones relacionadas y la discapacidad asociada. Objetivo: Describir las recomendaciones para la rehabilitación de pacientes adultos con COVID-19. Métodos: Se realizó una búsqueda en la literatura. Se consultó en bases de datos y portales utilizando los siguientes términos y sus equivalentes: SARS-CoV2, COVID-19, rehabilitación, fisioterapia. La búsqueda se realizó en idiomas castellano, inglés, chino e italiano, con una ventana de tiempo entre enero del 2010 y abril del 2020. Resultados: 23 publicaciones cumplieron con los criterios de inclusión y exclusión predeterminados. A partir de la información obtenida se elaboraron recomendaciones y tablas sobre la clasificación clínica de la COVID-19, conducta médica a seguir según gravedad, atención general e intervenciones de rehabilitación en pacientes adultos con COVID-19. Conclusiones: Las intervenciones de rehabilitación son recursos esenciales e indispensables para el tratamiento multidisciplinario de pacientes adultos con COVID-19, a pesar de la baja calidad de la evidencia disponible.
Palabras Clave: COVID-19; SARS-CoV-2; medicina física y rehabilitación; rehabilitación respiratoria; fisioterapia respiratoria. (fuente: DeCS BIREME).
SARS-CoV-2 coronavirus is a new pathogen that emerged in 2019 and caused the COVID-19 disease,
which has extended rapidly throughout the world and has become an international public health emergency.
(1) It is highly contagious, and it differentiates itself from other
respiratory viruses in that it can present possible transmission events two to three days after onset of
It is transmitted through respiratory secretions: rhinorrhea, sneezing and cough droplets that land on surfaces, disseminating in a space of approximately one to two meters distance from the infected person. (3) SARS-CoV2 survives at least one day in hard surfaces and up to eight hours in soft surfaces. The virus is transferred through manual contact over a contaminated surface and after a person touches their mouth, nose or eyes. The infected air particles created while sneezing or coughing remain in the air during at least three hours. (4) These air particles can be inhaled by another person and deposited in the ocular mucous membranes. (3)
People with COVID-19 may present a clinical presentation similar to the flu, with fever (89%), cough (68%), fatigue (38%), sputum production (34%) and/or dyspnea (19%). (5) The severity spectrum of this disease varies from an asymptomatic or mild acute respiratory infection to severe or critical with shock and hypoxic respiratory insufficiency, which could lead to death. The current reports approximate that 80 % of cases are asymptomatic or mild, 15% are severe which require oxygen therapy, and 5% are critical cases that require mechanical ventilation and vital support. (6)
Currently, the mortality rate is 3 to 5%. The admission rate into an intensive care unit (ICU) is approximately 5%. (5). A little less than half of hospitalized patients (42%) require oxygen therapy.(5) According to the emerging data, individuals with greater risk of developing severe or critical COVID-19 clinical presentations, that require hospitalization and/or support in ICU, are mostly depending on a variant, elderly, of masculine sex, with at least one coexisting comorbidity, with more elevated disease severity indices, high levels of D Dimer and/or lymphocytopenia.(5-7)
An important percentage of the population seen in the Physical and Rehabilitation Medicine specialty has COVID-19 risk factors. Many of them receive rehabilitation therapy in the emergency department, critical area or hospitalization floors, finding themselves with greater exposure to infection in the COVID-19 pandemic frame. It is therefore urgent that assistant personnel in charge know the main characteristics of this disease, preventive measures, and risk control. The planning and preparation strategies for assistant resources, and the recommendations for COVID-19 patient care.
A literature review was conducted which provided recommendations for rehabilitation of adult
patients with COVID-19. Scientific data bases and portals were consulted, such as PubMed, sCielo,
Elsevier, Lilacs, Medigraphic, Informed, and portals from public and private associations and
foundations, using the following terms and its equivalents: SARS-CoV2, COVID-19, rehabilitation,
physiotherapy. The search was done in Spanish, English, Chinese and Italian, with a window of time
between January 2010 and April 2020.
The inclusion criteria were thematic review publications, systematic reviews, meta-analyses, clinical practice guidelines and subject matter experts’ comments (in this case, it was required that the document or article have the endorsement of an institution with national or international recognition, as well as the author’s employment and academic credentials). We excluded articles with duplicate information, the endorsement of an institution in more extensive studies or those that consisted in case reports or letters to the editor. Articles that contained incomplete or imprecise information were also excluded.
Additional information searches were performed in the bibliographic reference lists of the articles included in the study in order to avoid the loss of relevant information. We also obtained information from the web portals from the World Health Organization (http://www.who.int), and the Centers for Disease Control and Prevention (http://www.cdc.gov).
In the course of the initial search, 56 publications were identified in different data bases. After reading the title and summary, 20 of these publications were eliminated due to duplication in different data bases. Once the complete publications were evaluated, 13 were excluded for containing information that did not correspond with the study objectives. Finally, 23 publications (8-20,22-26,28,-30,33,35) met the predetermined inclusion and exclusion criteria, although in some of these all the required information is not reported. 47.9% corresponded to publications in English (11), 43.5% (10) in Spanish, 4.3% (1) in Italian and 4.3% (1) in Chinese. The most important publications are summarized in Table 1. Recommendations and tables about COVID-19 clinical classification, medical care that should be followed according to disease severity, general attention and rehabilitation interventions of adult patients with COVID-19 are elaborated from the information obtained.
Table 1. Most important identified publications.
|Author||Country||Study objetive||Methodology||Relevant results||Conclusions|
|Thomas, et al.||Australia.||Describe physiotherapy recommendations for COVID-19 patients in the hospital setting.||Clinical practice guide.||
||These recommendations were developed by an international team of experts in intensive care and acute cardiorespiratory care. They have been designed for adult patient exclusive use.|
|McNeary L, et al.||United States.||Help specialists in Physical Medicine and Rehabilitation in hospital rehabilitation centers in oatient care during this public health emergency.||Review.||
||Hospital emergency preparedness frequently do not take into account specific matters in hospital rehabilitation. The CAN model may be used to prepare in case of natural disasters, including COVID-19. Patient and personnel safety must be prioritized with regard to the provision of rehabilitation services in our communities.|
|SEPAR Respiratory Physiotherapy Area||Spain.||Update SARS-CoV2 physiopathology information and elaborate on the respiratory physiotherapy interventions, especially in three assistance scenarios which have greater relevance: hospitalization admission, ICU admission, and posterior phase after hospital discharge.||Clinical practice guide.||
||The general objectives of the respiratory physiotherapy interventions in COVID-19 patients are: preserve and improve respiratory function, improve associated symptomatology (dyspnea and muscular fatigue), favor drainage of secretions, improve functional capacity, prevent and reduce complications. Improve adaptation to daily activities and improve quality of life.|
|Chinese Association of Rehabilitation Medicine.||China||Combine expert opinions in the front-line fight against the COVID-9 pandemic to guide pulmonary rehabilitation.||Clinical practice guide.||
||Combining the latest research results and accumulated clinical experience on respiratory rehabilitation and COVID-19 from China and other countries, the respiratory rehabilitation time was added with caution and the respiratory rehabilitation protocol directed at clinical issues in different stages was reviewed, with respect to the first edition.|
|Lazzeri, et al.||Italy.||To share information worldwide with physiotherapists involved in the care of patients affected by COVID-19. Taking into account the complexity and frailty of COVID-19 patients, we recommend, when possible, to have as a work group, physiotherapists with experience and/or specialized training in respiratory physiotherapy.||Clinical practice guide||ARIR, in collaboration with AIFI, issued this document to provide a quick reference guide for respiratory physiotherapy to structure treatments in the management of acute stages in patients suffering from severe COVID-19. The main goal of these treatments is to reduce secondary effects in this patient population while maximizing healthcare professional protection.|
It is important to know the disease clinical classification in order to determine the level of severity of suspected, probable and confirmed COVID-19 cases, as well as the recommended clinical behavior according to the table Table 2. (8,9)
Table 2. COVID-19 clinical classification and recommended behavior according to severity.
|Definition||Mild clinical presentation||Moderate clinical presentation||Severe clinical presentation|
|Symptoms||Everyone with acute respiratory infection and two or more of the following
||Everyone with acute respiratory infection with at least one of the following
||Everyone with acute respiratory infection with two or more of the following
|Recommended behavior||No hospitalization required. Home confinement no less than 14 days and medical follow-up. require hospitalization.||Requires hospitalization.||Requires hospitalization in the intensive care unit (ICU) due to respiratory failure or signs of sepsis.|
GENERAL RECOMMNEDATIONS FOR COVID-19 ADULT PATIENT CARE
REHABILITATION INTERVENTIONS FOR ADULT PATIENTS WITH COVID-19
Table 3. Safety criteria for the start of rehabilitation interventions.
Table 4. Safety criteria for the suspension of rehabilitation interventions.
Table 5. Rehabilitation interventions with high viral transmission risk.
REHABILITATION OF ADULT PATIENTS WITH COVID-19 IN ICU
Approximately 20-25% of hospitalized patients with COVID-19 require ICU care, generally for a
long period of time. (28) The main reasons are respiratory insufficiency and
shock due to vasopressors. (28) The majority are admitted with multiorgan
dysfunction syndrome, including acute respiratory distress syndrome (67%), acute renal failure (29%),
hepatic insufficiency (29%), and cardiac insufficiency (23%).(30) The
prognosis is poor and half pass
The stage and prolonged mechanical ventilation in ICU contribute in generating complications in the critical COVID-19 patient, such as the post-intensive care syndrome (PICS) with an impact in the physical, cognitive and mental function, polyneuropathy and/or associated myopathy, intensive care unit acquired weakness (ICU-AW), etc.(14,31)
Positioning and postural changes
REHABILITATION OF HOSPITALIZED ADULT PATIENTS WITH COVID-19
Authorship contributions: The authors participated in the idea
genesis, project design, data collection and interpretation, result analysis and manuscript
preparation of the current research work.
Funding sources: Self-financed
Declaration of conflicts of interest: The authors declare they did not sign any agreement to receive benefits or honorariums and no commercial entity paid foundations, education institutions or other non-profit organizations they are affiliated with.
Received: April 23, 2020
Approved: May 20, 2021
Correspondence: Roger Christian De la Cerna Luna
Address: Hospital Edgardo Rebagliati Martins, Av. Edgardo Rebagliati 490, Jesús María, Lima
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