Invited Topical Review
Physiotherapy management for
COVID-19 in the acute hospital setting: clinical practice recommendations
Peter Thomas a, Claire Baldwin b, Bernie Bissett c,d, Ianthe
Boden e, Rik Gosselink f,g, Catherine L Granger h, Carol Hodgson i, Alice YM Jones j,k, Michelle E Kho l,m,n, Rachael Moses o, George Ntoumenopoulos p, Selina M Parry q, Shane Patman r, Lisa van der Lee s
a Department of Physiotherapy, Royal Brisbane and
Women’s
Hospital, Brisbane, Australia; b Caring
Futures Institute, College of Nursing and Health Sciences, Flinders University,
Adelaide, Australia; c Physiotherapy, University of
Canberra, Australia; d Physiotherapy Department, Canberra Hospital, Canberra, Australia; e Physiotherapy Department,
Launceston General Hospital, Launceston, Australia; f Department of Rehabilitation
Sciences, KU Leuven, Belgium; g Department of Critical Care, University Hospitals Leuven, Leuven,
Belgium; h Department of Physiotherapy, The University of Melbourne, Australia; i Australian and New Zealand
Intensive Care Research Centre, Monash University, Melbourne, Australia; j School of Health and
Rehabilitation Sciences, The University of Queensland, Brisbane, Australia; k Discipline of Physiotherapy,
Faculty of Health Sciences, The University of Sydney, Sydney, Australia; l School of Rehabilitation
Science, McMaster University, Hamilton, Canada; m St Joseph’s Healthcare, Hamilton, Canada; n The Research Institute of St Joe’s, Hamilton, Canada; o Physiotherapy, Lancashire
Teaching Hospitals, Preston, United Kingdom; p Physiotherapy, St Vincent’s Hospital, Sydney, Australia; q Department of Physiotherapy, The University of Melbourne, Melbourne,
Australia; r School of Physiotherapy, The University of Notre Dame Australia, Perth,
Australia;
s Physiotherapy Department, Fiona
Stanley Hospital, Perth, Australia
KEY WORDS
Physical therapy
Coronavirus
COVID-19
ABSTRACT
This document outlines recommendations for physiotherapy management for
COVID-19 in the acute hospital setting. It includes: recommendations for
physiotherapy workforce planning and preparation; a screening tool for
determining requirement for physiotherapy; and recommendations for the
selection of physio-therapy treatments and personal protective equipment. It is
intended for use by physiotherapists and other relevant stakeholders in the
acute care setting caring for adult patients with confirmed or suspected COVID-19. [Thomas P, Baldwin C, Bissett B, Boden I,
Gosselink R, Granger CL, Hodgson C, Jones AYM, Kho ME, Moses R, Ntoumenopoulos
G, Parry SM, Patman S, van der Lee L (2020) Physiotherapy man-agement for
COVID-19 in the acute hospital setting: clinical practice recommendations. Journal
of Physiotherapy -:-–-]
© 2020 Australian Physiotherapy
Association. Published by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) is a new coronavirus that emerged in 2019 and causes coronavirus
disease 2019 (COVID-19).1,2 SARS-CoV-2 is highly contagious. It differs from other respiratory
viruses in that it appears that human-to-human transmission occurs
approximately 2 to 10 days prior to the individual becoming symptomatic.2–4 The virus is transmitted from
person to person through respiratory secretions. Large droplets from coughing,
sneezing or rhinorrhoea land on surfaces within 2 m of the infected person.
SARS-CoV-2 remains viable for at least 24 hours on hard surfaces and up to 8 hours
on soft surfaces.5 The virus is transferred to another person through hand contact on a
contami-nated surface followed by touching the mouth, nose or eyes. Aerosol
airborne infected particles created during a sneeze or cough remain viable in
the air for 3 hours.5 These airborne particles of SARS-CoV-2 can then be inhaled by another
person or land on the mucosal membranes of the eyes.
Individuals with COVID-19 can
present with an influenza-like illness and respiratory tract infection demonstrating fever
(89%),
cough (68%), fatigue (38%), sputum production (34%) and/or short-ness of
breath (19%).4 The spectrum of disease severity ranges from asymptomatic infection or
mild upper respiratory tract illness through to severe viral pneumonia with
respiratory failure and/or death. Current reports estimate that 80% of cases
are asymptomatic or mild; 15% of cases are severe (infection requiring oxygen);
and 5% are critical requiring ventilation and life support.2
Preliminary
reports indicate that chest radiographs may have diagnostic limitations in
COVID-19.6
Clinicians need to be aware that lung computed tomography (CT) scan findings often include multiple
mottling and ground-glass opacity.7 Lung
ultrasound is also being used at the bedside with findings of multi-lobar
distribution of B-lines and diffuse lung consolidation.8
The current mortality rate is 3 to 5%, with new
reports of up to 9%, which is in contrast to influenza at
around 0.1%.2 The rates of admission to an intensive care unit (ICU) are
approximately 5%.4 Around 42% of patients admitted to hospital will require oxygen
therapy.4 Based on emerging data, individuals at highest risk of developing
severe COVID-19 disease requiring hospitalisation and/or ICU support are those
who are older, male, have at least one
Box 1. Physiotherapy workforce planning and
preparation recommendations.
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1.1
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Plan
for an increase in the required physiotherapy workforce. For example:
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allow additional
shifts for part-time staff
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offer
staff the ability to electively cancel leave
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recruit
a pool of casual staff
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recruit
academic and research staff, staff who have recently retired or are currently
working in non-clinical roles
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work
different shift patterns (eg, 12-hour shifts, extended evening shifts)
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1.2
|
Identify
potential additional staff who could be deployed to areas of higher activity
associated with COVID-19 admissions (eg, infectious disease ward, ICU and/or
high
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dependency
unit and other acute areas). Prioritise staff for deployment who have
previous cardiorespiratory and critical care experience.
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1.3
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Physiotherapists
are required to have specialised knowledge, skills and decision-making to
work within ICU. Physiotherapists with previous ICU experience should be
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1.4
|
Physiotherapists
who do not have recent cardiorespiratory physiotherapy experience should be
identified by
hospitals and facilitated to return to support additional
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hospital
services. For example, staff without acute hospital or ICU training may
facilitate rehabilitation, discharge pathways or hospital avoidance for
patients without
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COVID-19.
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1.5
|
Staff
with advanced ICU physiotherapy skills should be supported to screen patients
with COVID-19 assigned to physiotherapy caseloads and provide junior ICU
staff
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with
appropriate supervision and support, particularly with decision-making for
complex patients with COVID-19. Hospitals should identify appropriate
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physiotherapy
clinical leaders to implement this recommendation.
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1.6 Identify
existing learning resources for staff who could be deployed to ICU. For
example:
eLearning packages (eg, Clinical Skills Development Service for
Physiotherapy and Critical Care Management)18 local physiotherapy staff ICU orientation
PPE training
1.7 Keep
staff informed of plans. Communication is crucial to the successful delivery of
safe and effective clinical services.
1.8 Staff who are judged to be at high risk should not enter the COVID-19
isolation area. When planning staffing and
rosters, the following people may be at higher risk of developing more serious
illness from COVID-19 and should avoid exposure to patients with COVID-19. This
includes staff who:
are
pregnant
have significant chronic respiratory illnesses are immunosuppressed
are older (eg, . 60 years)
have severe chronic health conditions such as heart disease, lung
disease, diabetes
have immune deficiencies, such as neutropenia,
disseminated malignancy and conditions or treatments that produce immunodeficiency12
It is recommended that staff who are pregnant avoid exposure to
COVID-19. It is known that pregnant women are potentially at increased risk of
complications from any respiratory disease due to the physiological changes
that occur in pregnancy. There is not enough currently available information on
the impact of COVID-19 on a pregnant woman or her baby.
1.9 Workforce planning should include consideration for pandemic-specific requirements such as additional workload from donning and doffing PPE, and the need to allocate staff to key non-clinical duties such
as enforcing infection control procedures.12
1.10 Consider organising the workforce
into teams that will manage COVID-19 versus non-infectious patients. Minimise
or prevent movement of staff between teams.
Liaise
with local infection control services for recommendations.
1.11 Be aware of and comply with relevant international, national, state
and/or hospital guidelines for infection control in healthcare facilities. For
example, World Health Organization ‘Guidelines for infection
prevention and control during health care when novel coronavirus infection is
suspected’.19
1.12 Senior physiotherapists should be involved in determining the
appropriateness of physiotherapy interventions for patients with confirmed or suspected COVID-19 in consultation with senior medical staff and
according to a referral guideline.
1.13 Identify hospital-wide plans for allocation/cohorting patients with
COVID-19. Utilise these plans to prepare resource plans that may be required.
For example, Table 2 below is
an example of a resource plan for ICU physiotherapy.
1.14 Identify additional physical resources that may be required for
physiotherapy interventions and how the risk of cross-infection can be
minimised (eg, respiratory equipment; mobilisation, exercise and rehabilitation
equipment; and equipment storage).
1.15 Identify and develop a facility inventory of respiratory, mobilisation,
exercise and rehabilitation equipment and determine the process of equipment
allocation as pandemic levels increase (ie, to prevent movement of equipment
between infectious and non-infectious areas).
1.16 It should be recognised that staff will likely have an increased
workload with a heightened risk of anxiety both at work and home.12 Staff should be supported during and beyond the active treatment phases
(eg, via access to employee assistance programs, counselling and facilitated
debriefing sessions).
1.17 Consider and/or promote debriefing and
psychological support; staff morale may be adversely affected due to the
increased workload, anxiety over personal safety and the health of family
members.12
COVID-19 = coronavirus disease
2019, ICU = intensive care unit, PPE = personal protective equipment.
co-existing comorbidity, higher severity of illness scores
Purpose
This document has been prepared to provide
information to physiotherapists and acute care healthcare facilities about the
po-tential role of physiotherapy in the management of hospital-admitted
patients with confirmed or suspected COVID-19.
Physiotherapists who work in primary healthcare
facilities are likely to have a role in the management of patients admitted to
hospital with confirmed or suspected COVID-19. Physiotherapy is an established profession
throughout the world. Globally,
physiotherapists often work in acute hospital wards and ICUs. In
particular, cardiorespiratory physiotherapy focuses on the manage-ment of acute
and chronic respiratory conditions and aims to improve physical recovery
following an acute illness. Physiotherapy may be beneficial in the respiratory treatment and physical rehabilitation of
patients with COVID-19. Although a productive cough is a less com-mon symptom
(34%),4 physiotherapy may be indicated if patients with COVID-19 present with
copious airway secretions that they are unable to clear independently. This may
be evaluated on a case-by-case basis and interventions applied based on
clinical indicators. High-risk patients may also benefit, for example: patients with existing comorbidities that may be
associated with hypersecretion or ineffective cough (eg, neuromuscular disease,
respiratory disease and cystic fibrosis). Physiotherapists who
practise in the ICU environment may also provide airway clearance techniques
for ventilated patients
|
3
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Box 2. Whom should physiotherapists treat?
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2.1
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The
respiratory infection associated with COVID-19 is mostly associated with a
dry and non-productive cough; lower respiratory tract involvement usually
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involves
pneumonitis rather than exudative consolidation.20 In these cases, respiratory physiotherapy
interventions are not indicated.
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2.2
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Respiratory
physiotherapy interventions in hospital wards or ICU may be indicated for
patients who have confirmed or
suspected COVID-19 and concurrently
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or
subsequently develop exudative consolidation, mucous hypersecretion and/or
difficulty
clearing secretions.
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2.3
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Physiotherapists
will have an ongoing role in providing interventions for mobilisation,
exercise and rehabilitation (eg, in patients with comorbidities creating
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significant functional decline and/or
(at risk of) ICU-acquired weakness).
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2.4
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Physiotherapy
interventions should only be provided when there are clinical indicators, so
that staff exposure to patients with COVID-19 is minimised.
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Unnecessary
review of patients with COVID-19 within their isolation room/areas will also
have a negative impact on PPE supplies.
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2.5
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Physiotherapists
should meet regularly with senior medical staff to determine indications for
physiotherapy review in patients with confirmed or suspected
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2.6
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Physiotherapy
staff should not be routinely entering isolation rooms, where patients with
confirmed or
suspected COVID-19 are isolated or cohorted, just to
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screen
for referrals.
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2.7
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Options
for screening patients via subjective review and basic assessment whilst not
being in direct contact with the patient should be trialled first whenever
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possible
(eg, calling the patient’s
isolation room telephone and conducting a subjective assessment for mobility
information and/or providing education on
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airway
clearance techniques).
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|
COVID-19 = coronavirus disease
2019, ICU = intensive care unit, PPE = personal protective equipment.
who show signs of inadequate airway clearance and they can assist in
positioning patients with severe respiratory failure associated with COVID-19,
including the use of prone position to optimise oxygenation.12
Table 1
Screening guidelines for
physiotherapy involvement with COVID-19.
Given the intensive medical
management for some COVID-19 patients – including prolonged protective
lung ventilation, sedation and use of neuromuscular blocking agents – those who are admitted to ICU may be at high risk of developing
ICU-acquired weakness;13
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Physiotherapy
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COVID-19
patient presentation (confirmed or
suspected)
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Physiotherapy
referral
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intervention
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Respiratory
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Mild
symptoms without significant
respiratory compromise (eg,
|
Physiotherapy
interventions are not indicated for airway
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fever,
dry cough, no chest x-ray changes)
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clearance
or sputum samples20
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No
physiotherapy contact with patient
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Pneumonia
presenting with features:
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Physiotherapy
interventions are not indicated for airway
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a
low-level oxygen requirement (eg, oxygen flow 5
l/min for
|
clearance
or sputum samples
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SpO2 90%)
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No
physiotherapy contact with patient
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non-productive
cough
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or
patient coughing and able to clear secretions independently
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Mild
symptoms and/or pneumonia
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Physiotherapy
referral for airway clearance
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AND
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co-existing
respiratory or neuromuscular comorbidity (eg, cystic
|
Staff
use airborne precautions
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fibrosis, neuromuscular disease,
spinal cord injury, bronchiectasis,
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||
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chronic
obstructive pulmonary disease)
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If not
ventilated, where possible, the patient should wear
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AND
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a
surgical mask during any physiotherapy
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current
or anticipated difficulties
with secretion clearance
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Mild
symptoms and/or pneumonia
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Physiotherapy
referral for airway clearance
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AND
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evidence
of exudative consolidation with difficulty clearing or
|
Staff
use airborne precautions
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inability
to clear secretions independently (eg, weak, ineffective and
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moist
sounding cough, tactile fremitus on chest wall, wet sounding
|
If not
ventilated, where possible, the patient should wear
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voice,
audible transmitted sounds)
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a
surgical mask during any physiotherapy
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Severe
symptoms suggestive of pneumonia/lower respiratory tract
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Consider
physiotherapy referral for airway clearance
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infection
(eg, increasing oxygen requirements; fever; difficulty
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breathing;
frequent, severe or productive coughing episodes; chest
|
Physiotherapy
may be indicated, particularly if weak
|
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x-ray,
CT or lung ultrasound changes consistent with
|
cough,
productive, evidence of pneumonia on imaging
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consolidation)
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and/or
secretion retention
|
|||
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Staff
use airborne precautions
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If not
ventilated, where possible, the patient should wear
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a
surgical mask during any physiotherapy
|
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Early
optimisation of care and involvement of ICU is
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recommended
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Mobilisation,
exercise and rehabilitation
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Any
patient at significant
risk of developing or with evidence of
|
Physiotherapy
referral
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significant functional limitations
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eg,
patients who are frail or have multiple comorbidities
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Use
droplet precautions
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impacting
their independence
|
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eg,
mobilisation, exercise and rehabilitation in ICU patients
|
Use
airborne precautions if close contact required or
|
||
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with
significant
functional decline and/or (at risk of) ICU-acquired
|
possible
aerosol generating procedures
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weakness
|
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If not
ventilated, where possible, the patient should wear
|
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a
surgical mask during any physiotherapy
|
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COVID-19 = coronavirus disease
2019, CT = computed tomography, ICU = intensive care unit, SpO2 =
oxyhaemoglobin saturation.
Table 2
Example of an ICU physiotherapy
resource plan.
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Phase
|
Bed
capacity
|
Description
and location of patients
|
Physiotherapy
staffing
|
Equipment
for respiratory
|
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care,
mobilisation, exercise
|
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and
rehabilitation
|
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Business
as usual
|
22 ICU
beds and six HDU
|
All
patients within existing ICU and
|
Four
FTE
|
six
stretcher chairs
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beds
|
HDU
physical resources
|
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10
high-back sitting chairs
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three
rollators
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one
tilt table
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two
cycle ergometers
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steps/blocks
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bariatric
equipment
|
|
4
|
|
Tier 1
|
Expansion
with additional
|
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|
number
of ICU beds
|
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|
provided
(eg, opening
|
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previously
non-
|
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|
commissioned
beds)
|
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|
Fewer than four patients with
COVID-19
Patients with COVID-19 only
allocated to beds with reverse flow
isolation rooms
There is limited availability of
reverse flow rooms within most
hospitals
Additional one FTE per four
One senior physiotherapist
will screen patients with
COVID-19 in consultation
with an ICU medical
consultant
Patients will be provided
treatment in isolation rooms
If needed, one stretcher chair
allocated and quarantined for
use
One tilt table quarantined for
use with COVID patients.
Quarantined in room, or
cleaned and located for
storage in isolation
Additional respiratory
equipment
|
Thomas
et
|
|
Tier 2
|
Further
expansion to
|
The
number of patients with COVID-19
|
Calculation
for additional
|
Additional
chair resources
|
||
|
|
|
maximum
ICU capacity
|
exceeds
the availability of
|
FTE as
above
|
may be
required
|
|
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|
isolation
rooms, necessitating the
|
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care of
infectious patients outside the
|
Infections
ICU Pod
|
Keep
separate sets of chairs,
|
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|
confines of a negative pressure room
|
physiotherapists
allocated,
|
tilt
tables, etc, for infectious
|
|
|
|
|
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|
including
one senior
|
and
non-infectious patients
|
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Infectious
patients will be cohorted
|
physiotherapist
|
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on the
open ward of the ICU
|
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Non-infections
ICU Pod
|
|
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Normal
ICU admission/non-
|
physiotherapists
allocated,
|
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|
|
|
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infectious
patients located in a
|
including
one senior
|
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|
|
|
|
separate
part of ICU
|
physiotherapist
|
|
|
|
|
|
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Infectious
and non-infectious
|
|
|
|
|
|
|
|
staff
allocated, including
|
|
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|
|
|
|
|
weekends
|
|
|
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|
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|
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|
|
|
Tier 3
|
Additional
ICU beds
|
Surge
in patients with COVID-19 exceeds the
|
Calculation
for additional FTE as above
|
Additional
chair resources may be required
|
|
|
|
|
created
outside of ICU
|
capacity
of the allocated infectious area
|
|
|
|
|
|
|
(eg, in
anaesthetic areas)
|
|
|
Keep
separate sets of chairs, tilt tables, etc,
|
|
|
|
|
|
Bed
allocation for patients with COVID-19
|
|
for
infectious and non-infectious patients
|
|
|
|
|
|
allocated
across the entire ICU
|
|
|
|
|
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|
Non-infectious
satellite ICU will be
|
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|
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|
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|
|
established
in a separate location
|
|
|
|
|
|
Tier 4
|
Additional
beds created
|
Large-scale
emergency
|
Calculation
for additional
|
Additional
chair resources
|
|
|
|
|
across
clinical areas in
|
|
FTE as
above
|
may be
required
|
|
|
|
|
other
parts of the hospital
|
|
|
|
|
|
|
|
(eg,
cardiology, operating
|
|
|
Keep
separate sets of chairs,
|
|
|
|
|
theatres)
|
|
|
tilt
tables, etc, for infectious
|
|
|
|
|
|
|
|
and non-infectious patients
|
|
|
|
|
|
|
|
|
|
COVID-19 = coronavirus disease
2019, FTE = full-time equivalent, HDU = high dependency unit, ICU = intensive
care unit.
|
al: Physiotherapy
and COVID-19
|
|
5
|
Table 3
Specific respiratory interventions.
Aerosol-generating procedures The following procedures create
an airborne risk of transmission of COVID-19:
intubation/extubation bronchoscopy
high-flow nasal oxygen use non-invasive ventilation
tracheostomy
cardiopulmonary resuscitation prior to intubation12,22
High-flow nasal
oxygen This is a
recommended therapy for hypoxia associated with COVID-19, as long as staff are
wearing optimal airborne PPE.12
At flow rates 40 to 60 l/min, high-flow nasal
oxygen does carry a small risk of aerosol generation. The risk of airborne
transmission to staff is low when optimal PPE and other infection control
precautions are being used.23 Negative pressure rooms are preferable for patients receiving high-flow nasal oxygen.12
Respiratory support via high-flow nasal
oxygen should be restricted to patients in airborne isolation rooms only.
Limiting the flow rate to no more than 30 l/min might reduce potential viral
transmission.
|
Non-invasive
ventilation
|
Routine
use is not recommended12 because
current experience with COVID-19 hypoxic respiratory failure has a high
associated failure rate.
|
|||||
|
|
If used
(eg, with a patient with chronic obstructive pulmonary disease or
post-extubation), it must be provided with strict airborne PPE.12
|
|||||
|
Oxygen
therapy
|
Treatment
targets may vary depending on the presentation of the patient.
|
|
|
. 94% is targeted.23
|
|
|
|
|
shock, SpO
|
|
|
|
||
|
|
For patients presenting with severe respiratory
distress, hypoxaemia or 24
|
|
2
|
|
23
|
|
|
|
Once a patient is stable, the SpO2 target
is . 90% in
non-pregnant adults
|
and 92
to 95% in pregnant patients.
|
|
22
|
||
|
|
In adults with COVID-19 and acute hypoxaemic
respiratory failure, the SpO2 target
should not be maintained . 96%.
|
|
||||
|
Nebulisation
|
The use
of nebulised agents (eg, salbutamol, saline) for the treatment of non-intubated
patients with COVID-19 is not recommended
|
|||||
|
|
because
it increases the risk of aerosolisation and transmission of infection to
healthcare workers in the immediate vicinity.
|
|||||
Use of metered-dose inhalers or spacers is preferred where possible.12 If a nebuliser is required,
liaise with local guidelines for directions to minimise aerosolisation (eg, use
of a Pari Sprint with inline viral filter).
Use of nebulisers, non-invasive ventilation, high-flow nasal oxygen and spirometry should be avoided and agreement to their
use sought from senior medical staff.20 If deemed essential, airborne
precautions should be used.
COVID-19 = coronavirus disease 2019, FTE = full-time equivalent, HDU =
high dependency unit, ICU = intensive care unit, PPE = personal protective
equipment, SpO2 = oxyhaemoglobin saturation.
this may worsen their morbidity and mortality.14 It is therefore essential to initiate early rehabilitation after the
acute phase of res-piratory distress in order to limit the severity of
ICU-acquired weakness and promote rapid functional recovery. Physiotherapy will
have a role in providing exercise, mobilisation and rehabilitation
interventions to survivors of critical illness associated with COVID-19 in
order to enable a functional return to home.
Scope
This document focuses on the
adult acute hospital setting. The rec-ommendations for physiotherapists are
outlined below in two sections: workforce planning and preparation, including
screening to determine indications for physiotherapy; and delivery of
physiotherapy in-terventions, including both respiratory and
mobilisation/rehabilitation as well as personal protective equipment (PPE)
requirements.
It is recognised that
physiotherapy practices vary across the world. When using these
recommendations, the scope of practice within the local context should be
considered.a
Methods
Consensus
approach
A group of international experts
in cardiorespiratory physio-therapy came together to rapidly prepare clinical
recommendations for physiotherapy management of COVID-19. The author group
initially convened on 20 March 2020 to discuss the urgent need for worldwide
acute care physiotherapy guidance in relation to COVID-
19. Efforts were quickly prioritised
to develop specific guidance for physiotherapists in the acute care settings.
The AGREE II framework15 was used to guide development,
and recognising the expediency of this work required pragmatic and transparent
reporting. Conduct was modelled after the GRADE Adolopment Process16 and Evidence to Decision
framework17 for recommendations and decision-making. Expertise includes ICU and
acute inpatient physiotherapy (all), rehabilitation interventions in the
ICU (all), physiotherapy administration (PT, IB, RG, AJ, RM, ShP), sys-tematic
reviews (PT, CB, CG, RG, CH, MK, SP, ShP, LV), guideline methodology (PT, IB,
RG, CH, MK, RM, ShP, LV), and epidemiology (CH, MK).
Through a web search and personal files, recently developed guidelines for COVID-19 management of critically
ill patients were identified from international agencies
(eg, World Health Organiza-tion), critical care professional societies or
groups (eg, Australia and New Zealand Intensive Care Society, Society of
Critical Care Medicine/ European Society of Intensive Care Medicine), or
physiotherapy pro-fessional societies up to 21 March 2020. These guidelines
were used to inform the consensus recommendations developed in conjunction with
expert opinion of the authorship group.
A priori it was decided to develop consensus recommendations,
given the time-sensitive nature of the guidance. It was agreed that a 70%
agreement was required for a recommendation. On Friday 20 March 2020 the lead
author (PT) circulated draft recommendations to all authors. All authors
independently returned comments to the lead author. The lead author (PT)
collated all comments for further discus-sion. All recommendations were
discussed in a teleconference on 22 March 2020. Fourteen people participated in
the development process and 66 recommendations were developed. A consensus of . 70% was achieved for all items. Further discussion was focused on
greater clarity in wording and/or reduction of items where overlap occurred.
Endorsement for the recommendations was sought from
phys-iotherapy societies, physiotherapy professional groups and the World
Confederation for Physical Therapy. The recommendations were circulated to
these groups on 23 March 2020, requesting endorsement; endorsements will be
updated as they are confirmed.
Strengths and limitations
This document has several strengths. It responds to
an urgent need for clinical guidance for acute care physiotherapists worldwide.
|
|
Thomas
et al: Physiotherapy and COVID-19
|
||
|
Table 4
|
|
|
|
|
Additional
respiratory interventions in the ICU.
|
|
|
|
|
|
|
|
|
|
|
Intubation
and mechanical ventilation
|
Patients
with worsening hypoxia, hypercapnia, acidaemia, respiratory fatigue,
haemodynamic instability or those with
|
|
|
|
|
altered
mental status should be considered for early invasive mechanical ventilation
if appropriate.12
|
|
|
|
|
The
risk of aerosol transmission is reduced once a patient is intubated with a
closed ventilator circuit.12
|
|
|
|
Recruitment
manoeuvres
|
Although
current evidence does not support the routine use of recruitment manoeuvres
in non-COVID-19 ARDS, they
|
|
|
|
|
could
be considered in patients with COVID-19 on a case-by-case basis.12
|
|
|
|
Prone
positioning
|
Anecdotal
reports from international centres dealing with large numbers of critically
ill patients with COVID-19-related
|
|
|
|
|
ARDS
suggest that prone ventilation is an effective strategy in mechanically
ventilated patients.12
|
|
|
|
|
||
|
|
|
requires
sufficient
human resources and expertise to be safely performed, to prevent known
complications including
|
|
|
|
|
pressure
areas and airway complications.
|
|
|
|
|
|
|
|
Bronchoscopy
|
Bronchoscopy
carries a significant
risk of aerosol generation and transmission of infection. The clinical yield
is thought to
|
||
|
|
|
be low
in COVID-19 and unless there are other indications (such as suspected
atypical/opportunistic superinfection or
|
|
|
|
|
|
|
|
|
Suctioning
|
Closed
inline suction catheters are recommended.12
|
|
|
|
Sputum
samples
|
In a
ventilated patient, tracheal aspirate samples for diagnosis of COVID-19 are
sufficient
and bronchoalveolar lavage is
|
|
|
|
|
not
usually necessary.12
|
|
|
|
|
Any
disconnection of the patient from the ventilator should be avoided to prevent
lung decruitment and aerosolisation.
|
|
|
|
|
If
necessary, the endotracheal tube should be clamped and the ventilator
disabled (to prevent aerosolisation).12
|
|
|
|
Tracheostomy
|
Tracheostomy
could be considered in suitable patients to facilitate nursing care and
expedite ventilator weaning, but is
|
|
|
|
|
an
aerosolising procedure and this must be considered in clinical decision
making.12
|
|
ARDS = acute respiratory distress
syndrome, COVID-19 = coronavirus disease 2019, ICU = intensive care unit.
Guidance was based on the most recent and relevant COVID-19 clinical
practice guidelines from highly-respected organisations, national physiotherapy
organisations and peer-reviewed studies; these sources were transparently
reported. The authors represent an international group of physiotherapists,
with extensive clinical experience in the ICU and on the wards. They are also
academic physiotherapists with experience in the leadership, conduct and
execution of rigorous sys-tematic reviews, clinical studies (including
prospective cohort studies and international multi-centre trials), and clinical
practice guidelines. The recommendations have been endorsed by international
physio-therapy organisations.b Translations of the recommendations are available in Appendix 1 on the
eAddenda.
There are also some limitations. Given the recent
presentation of COVID-19, clinical guidance may change as more is learnt about
the natural history of this disease. Recommendations were extrapolated based on
best evidence for current management of critically ill pa-tients and long-term
outcomes in critical illness survivors. No patient was included in the author
group. While the recommendations apply to physiotherapy interventions in the
acute-care setting, longer-term follow-up of survivors is needed.
Recommendations for physiotherapy workforce planning and preparation
COVID-19 is placing significant demands on healthcare resources throughout the world. Box 1 outlines recommendations to
assist the physiotherapy workforce to plan and respond to this demand. Box 2 and Table 1 provide recommendations for determining whom phys-iotherapists should
treat when patients have confirmed or suspected COVID-19. Table 2 provides an example of a resource plan for ICU physiotherapy from Tier 0
(business as usual) through to Tier 4 (large-scale emergency). Local context,
resources and expertise should be considered when utilising this example
resource plan.
Medical management of COVID-19
It is important for physiotherapists to be aware of
the medical management for patients with COVID-19. Table 3 summarises some of the recommendations available from medical guidelines
developed by professional societies (as listed in Appendix 2 on the eAddenda).
For patients admitted to ICU, additional strategies
may be used; these are summarised in Table 4. With increasing acuity, there is an increased risk of dispersion of
aerosolised virus into the healthcare environment due to the nature of critical
illness, higher viral load and the performance of aerosol-generating
procedures. It is recom-mended that airborne PPE precautions should be used to
care for all patients with COVID-19 in ICU.12
Recommendations for the delivery of physiotherapy interventions,
including personal protective equipment requirements
Physiotherapy management
principles –
respiratory care
Examples of physiotherapy-led respiratory
interventions (or chest physiotherapy) are provided below.
Airway clearance techniques
Airway clearance techniques include positioning,
active cycle of breathing, manual and/or ventilator hyperinflation, percussion and vibrations, positive expiratory pressure therapy
(PEP) and mechanical insufflation-exsufflation.
Non-invasive ventilation and
inspiratory positive pressure breathing Physiotherapists may use inspiratory
positive pressure breathing
(eg, for patients with rib fractures). Non-invasive ventilation may be
applied as part of airway clearance strategies in the management of respiratory
failure or during exercise.
Techniques to facilitate
secretion clearance
Techniques to facilitate secretion clearance
include assisted or stimulated cough manoeuvres and airway suctioning.
Other
Physiotherapists prescribe exercise and assist
patients to mobilise. Physiotherapists also play an integral role in the management
of patients with a tracheostomy.
COVID-19 poses significant
considerations for respiratory physio-therapy interventions due to their
aerosol-generating procedures. Box 3 outlines recommendations for providing respiratory care to patients with
COVID-19.
|
7
|
Box 3. Recommendations for physiotherapy
respiratory interventions.
Personal
protective equipment
|
3.1
|
It is
strongly recommended that airborne precautions are utilised during respiratory
physiotherapy interventions.
|
|
|
|
|
|
|
|
Cough
etiquette
|
|
|
|
|
|
|
3.2
|
Both
patients and staff should practise cough etiquette and hygiene.
|
|
During
techniques that may provoke a cough, education should be provided to enhance
cough etiquette and hygiene:
Ask the patient to cover their cough by coughing into their elbow or
sleeve or into a tissue. Tissues should then be disposed and hand hygiene
performed. In addition, if possible, physiotherapists should position
themselves 2 m from the patient and out of the likely path of dispersion.
Aerosol-generating
procedures
|
3.3
|
Many
respiratory physiotherapy interventions are potentially aerosol-generating
procedures. While there are insufficient investigations confirming the
|
|
|
aerosol-generating potential of various
physiotherapy interventions,25 the
combination with cough for airway clearance makes all techniques potentially
|
|
|
aerosol-generating
procedures.
|
These
include:
cough-generating
procedures (eg, cough or huff during treatment)
positioning or gravity-assisted drainage techniques and manual
techniques (eg, expiratory vibrations, percussion and manually assisted cough)
that may trigger a cough and sputum expectoration
use of positive pressure breathing devices (eg, inspiratory positive
pressure breathing), mechanical insufflation-exsufflation devices, intra/extra pulmonary high-frequency oscillation devices
(eg, The Vest, MetaNeb, Percussionaire)
PEP and oscillating PEP devices bubble PEP
nasopharyngeal or oropharyngeal suctioning manual hyperinflation
open suction
saline instillation via an open-circuit endotracheal tube
inspiratory muscle training, particularly if used with patients who are
ventilated and disconnection from a breathing circuit is required sputum
inductions
any mobilisation or therapy that may result in coughing and
expectoration of mucus
|
|
Therefore,
there is a risk of creating an airborne transmission of COVID-19 during
treatments. Physiotherapists should weigh up the risk versus benefit in
|
|
|
|
completing
these interventions and use airborne precautions.
|
|
|
|
|
|
|
3.4
|
Where
aerosol-generating procedures are indicated and considered essential they
should be undertaken in a negative-pressure room, if available, or in a
|
|
|
|
single
room with the door closed. Only the minimum number of required staff should
be present and they must all wear PPE, as described. Entry and exit from
|
|
|
|
the
room should be minimised during the procedure.12
|
|
|
|
This
may not be able to be maintained when cohorting is required because of the volume
of patients presenting with COVID-19.
|
|
|
|
|
|
|
3.5
|
BubblePEP
is not recommended for patients with COVID-19 because of uncertainty around
the potential for aerosolisation, which is similar to the caution the
|
|
|
|
WHO
places on bubble CPAP.23
|
|
|
3.6
|
There is
no evidence for incentive spirometry in patients with COVID-19.
|
|
|
3.7
|
Avoid
the use of mechanical insufflation/exsufflation, non-invasive
ventilation, inspiratory positive pressure breathing devices or high-flow nasal oxygen
|
|
|
|
devices.
However, if clinically indicated and alternative options have been
ineffective, consult with both senior medical staff and infection prevention
and
|
|
|
|
monitoring
services within local facilities prior to use.
|
|
|
|
If
used, ensure that machines can be decontaminated after use and protect
machine with viral filters
over machine and patient ends of circuits:
|
|
|
|
Use
disposable circuits for these devices.
|
|
|
|
Maintain
a log of devices that includes patient details for tracking and infection
monitoring (if required).
|
|
|
|
Use
airborne precautions.
|
|
|
3.8
|
Where
respiratory equipment is used, whenever possible, use single-patient-use
disposable options (eg, single-patient-use PEP devices).
|
|
|
|
Re-usable
respiratory equipment should be avoided where possible.
|
|
|
|
|
|
|
3.9
|
Physiotherapists
should not implement humidification,
non-invasive ventilation or other aerosol-generating procedures without
consultation and agreement
|
|
|
|
with a
senior doctor (eg, medical consultant).
|
|
|
Sputum
inductions
|
|
|
|
|
|
|
|
3.10
|
Sputum
inductions should not be performed.
|
|
|
|
|
|
|
Requests
for sputum samples
|
|
|
|
|
|
|
|
3.11
|
In the first instance, ascertain whether
the patient is productive of sputum and able to clear sputum independently.
If so, physiotherapy is not required for a
|
|
|
|
sputum
sample.
|
|
If physiotherapy interventions are required to facilitate a sputum
sample, full airborne PPE should be worn. The handling of sputum samples should
adhere to local policies. Generally, once a sputum sample has been obtained the
following points should be followed:
All
sputum specimens and request forms should be marked with a biohazard label.
The specimen should be
double-bagged. The specimen should be placed in the first bag in the isolation room by a staff member wearing recommended PPE.
Specimens should be hand-delivered to the laboratory by someone who understands
the nature of the specimens. Pneumatic tube systems must not be
used to transport specimens.
Saline
nebulisation
|
3.12
|
Do not
use saline nebulisation. It should be noted that some UK guidelines allow use
of nebulisers, but this is currently not recommended in Australia.
|
|
|
|
|
|
|
Manual
hyperinflation
|
||
|
|
|
|
|
3.13
|
As it
involves disconnection/opening of a ventilator circuit, avoid manual hyperinflation and utilise ventilator
hyperinflation
if indicated (eg, for suppurative
|
|
|
|
presentations
in ICU and if local procedures are in place).
|
|
|
|
|
|
(Continued on next page)
Box 3. Continued
Positioning,
including gravity-assisted drainage
|
|
|
|
|
3.14
|
|
Physiotherapists
can continue to advise on positioning requirements for patients.
|
|
Prone
positioning
|
|
|
|
|
|
|
|
3.15
|
|
Physiotherapists
may have a role in the implementation of prone positioning in the ICU. This
may include leadership within ICU ‘prone teams’, providing staff
|
|
|
|
education
on prone positioning (eg, simulation-based education sessions) or assisting
in turns as part of the ICU team.
|
|
Tracheostomy
management
|
||
|
|
|
|
|
3.16
|
|
The
presence of a tracheostomy and related procedures are potentially aerosol
generating:
|
|
|
|
Cuff deflation trials and inner tube
changes/cleaning can be aerosol generating.
|
|
|
|
Closed,
in-line suction is recommended.
|
|
|
|
Inspiratory
muscle training, speaking valves and leak speech should not be attempted
until patients are over the acute infection and the risk of transmission
|
|
|
|
is
reduced.
|
|
|
|
Airborne
precautions are recommended with infectious patients with COVID-19 with a
tracheostomy.
|
COVID-19 = coronavirus disease 2019, CPAP = continuous positive airway
pressure, ICU = intensive care unit, PEP = positive expiratory pressure, PPE =
personal protective equipment, WHO = World Health Organization.
Box 4. Recommendations for physiotherapy
mobilisation, exercise and rehabilitation interventions.
Personal
protective equipment
|
|
|
|
4.1
|
Droplet
precautions should be appropriate for the provision of mobilisation, exercise
and rehabilitation in most circumstances. However, physiotherapists are
|
|
|
likely
to be in close contact with the patient (eg, for mobilisation, exercise or
rehabilitation interventions that require assistance). In these cases,
consider use
|
|
|
of a
high filtration
mask (eg, P2/N95). Mobilisation and exercise may also result in the patient
coughing or expectorating mucus, and there may be circuit
|
|
|
disconnections
with ventilated patients.
|
|
|
Refer
to local guidelines regarding ability to mobilise patients outside of their
isolation room. If mobilising outside of the isolation room, ensure that the
|
|
|
patient
is wearing a surgical mask.
|
|
Screening
|
|
|
|
|
4.2
4.3
Physiotherapists will actively screen
and/or accept referrals for mobilisation, exercise and rehabilitation.
When screening, discussion with nursing staff, the
patient (eg, via phone) or family is recommended before deciding to enter the
patient’s isolation room. For example, to try to minimise staff who come in to
contact with patients with COVID-19, physiotherapists may screen to determine
an appropriate aid to trial. A trial of the aid may then be performed by the
nursing staff already in an isolation room, with guidance provided, if needed,
by the physiotherapist who is outside the room.
Direct physiotherapy interventions should only be considered when there
are significant functional limitations, such as (risk of) ICU-acquired weakness,
frailty, multiple comorbidities and advanced age.
Early
mobilisation
|
4.4
|
Early
mobilisation is encouraged. Actively mobilise the patient early in the course
of illness when safe to do so.23
|
|
4.5
|
Patients
should be encouraged to maintain function as able within their rooms:
|
|
|
Sit out
of bed.
|
|
|
Perform
simple exercises and activities of daily living.
|
Mobilisation
and exercise prescription
|
|
|
|
4.6
|
Mobilisation
and exercise prescription should involve careful consideration of the patient’s state (eg, stable clinical
presentation with stable respiratory and
|
|
|
haemodynamic
function).26,27
|
Mobility
and exercise equipment
4.7
4.8
4.9
4.10
4.11
The use of equipment should be carefully considered and discussed with
local infection monitoring and prevention service staff before being used with
patients with COVID-19 to ensure that it can be properly decontaminated.
Use equipment that can be single
patient use. For example, use elastic resistance bands rather than distributing
hand weights.
Larger equipment (eg, mobility aids, ergometers,
chairs and tilt tables) must be easily decontaminated. Avoid use of specialised
equipment, unless necessary, for basic functional tasks. For example, stretcher
chairs or tilt tables may be deemed appropriate if they can be decontaminated
with appropriate cleaning and are indicated for progression of
sitting/standing.
When mobilisation, exercise or
rehabilitation interventions are indicated:
Plan well.
Identify/use the minimum number of staff required to safely perform the
activity.26 Ensure that all equipment is available and working before entering
rooms.
Ensure
that all equipment is appropriately cleaned or decontaminated.
If equipment needs to be shared among patients, clean and disinfect
between each patient use.23 Specific staff training for cleaning of equipment within isolation rooms may be
required.
Whenever
possible, prevent the movement of equipment between infectious and
non-infectious areas.
Whenever
possible, keep dedicated equipment within the isolation zones, but avoid
storing extraneous equipment within the patient’s room.
When performing activities with ventilated patients or patients with a
tracheostomy, ensure that airway security is considered and maintained (eg, a
dedicated airway person to prevent inadvertent disconnection of ventilator
connections/tubing).
COVID-19 = coronavirus disease
2019, ICU = intensive care unit.
|
9
|
Box 5. Recommendations regarding personal
protective equipment for physiotherapists.
|
|
5.1
|
All
staff must be trained in correct donning and doffing of PPE, including N95 ‘fit-checking’. A registry of staff who have
completed PPE education and fit
|
|
||
|
|
|
checking
should be maintained.
|
|
||
|
|
|
|
|
||
|
|
5.2
|
‘Fit testing’ is recommended when available,
but the evidence for fit
testing effectiveness is limited and the variation in supply of N95 mask
types may make
|
|
||
|
|
|
|
|||
|
|
5.3
|
|
|||
|
|
5.4
|
For all
confirmed or
suspected cases, droplet precautions should be implemented, at a minimum.
Staff must wear the following items:
|
|
||
|
|
|
surgical
mask
|
|
||
|
|
|
fluid-resistant long-sleeved gown
|
|
||
|
|
|
|
goggles or face shield
|
|
|
|
|
|
|
|
||
|
|
|
gloves
|
|
|
|
|
|
5.5
|
Recommended
PPE for staff caring for COVID-19-infected patients includes added
precautions for patients with significant respiratory illness, when aerosol-
|
|
||
|
|
|
generating
procedures are likely and/or prolonged or very close contact with the patient
is likely. In these cases, airborne precautions are followed,
|
|
||
|
|
|
including:
|
|
||
|
|
|
an
N95/P2 mask
|
|
||
|
|
|
fluid-resistant long-sleeved gown
|
|
||
|
|
|
|
goggles or face shield
|
|
|
|
|
|
|
|
||
|
|
|
gloves
|
|
|
|
|
|
5.6
|
In
addition, the following can be considered:
|
|
||
|
|
|
hair
cover for aerosol-generating procedures
|
|
||
|
|
|
shoes
that are impermeable to liquids and can be wiped down
|
|
||
|
|
|
Recurrent
use of shoe covers is not recommended, as repeated removal is likely to
increase the risk of staff contamination.12
|
|
||
|
|
5.7
|
PPE
must remain in place and be worn correctly for the duration of exposure to
potentially contaminated areas. PPE (particularly masks) should not be
|
|
||
|
|
|
adjusted
during patient care.24
|
|
||
|
|
5.8
|
|
|||
|
|
5.9
|
Check
local guidelines for information on laundering uniforms and/or wearing
uniforms outside of work if exposed to COVID-19. For example, changing into
|
|
||
|
|
|
scrubs may be recommended in local guidelines12 and/or staff may be encouraged to get changed out
of their uniform before leaving work and to transport
|
|
||
|
|
|
worn
uniforms home in a plastic bag for washing at home.
|
|
||
|
|
5.10
|
Minimise
personal effects in the workplace. All personal items should be removed
before entering clinical areas and donning PPE. This includes earrings,
|
|
||
|
|
|
watches,
lanyards, mobile phones, pagers, pens, etc.
|
|
||
|
|
|
Stethoscope
use should be minimised.12 If
required, use dedicated stethoscopes within isolation areas.19,23
|
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||
|
|
|
|
|||
|
|
5.11
|
Staff
caring for infectious patients must apply correct PPE, irrespective of
physical isolation. For example, in ICU, if patients are cohorted into a Pod
with open
|
|
||
|
|
|
rooms,
staff working within the confines of
the ICU Pod but not directly involved in patient care should also wear PPE.
The same applies once infectious
|
|
||
|
|
|
patients
are nursed on an open ward. Staff then use plastic aprons, a change of gloves
and hand hygiene when moving between patients in open areas.
|
|
||
|
|
5.12
|
When a
unit is caring for a patient with confirmed or suspected COVID-19, it is recommended
that all donning and doffing are
supervised by an additional
|
|
||
|
|
|
appropriately
trained staff member.12
|
|
||
|
|
5.13
|
Avoid
sharing equipment. Preferably only use single-use equipment.
|
|
||
|
|
5.14
|
|
|||
|
|
5.15
|
If
reusable PPE items are used (eg, goggles), these must be cleaned and
disinfected prior to re-use.24
|
|
||
COVID-19
= coronavirus disease 2019, ICU = intensive care unit, PPE = personal
protective equipment.
Physiotherapy management principles – mobilisation, exercise and
rehabilitation interventions
Physiotherapists are responsible
for providing musculoskeletal, neurological and cardiopulmonary rehabilitation
tasks, as outlined below.
Range of
motion exercises
Passive, active-assisted, active
or resisted joint range of motion exercises may be performed to maintain or
improve joint integrity, range of motion and muscle strength.
Mobilisation
and rehabilitation
Examples of mobilisation and
rehabilitation include bed mobility, sitting out of bed, sitting balance, sit
to stand, walking, tilt table, standing hoists, upper/lower limb ergometry and
exercise programs.
Personal
protective equipment considerations
It is imperative that
physiotherapists understand the measures in place to prevent transmission of
COVID-19. Box 5 provides
recommendations for this. Patients with confirmed or suspected COVID-19 will be managed with either droplet or
airborne pre-cautions.12 Additionally, they will be placed in isolation. Hospitals are often
able to contain patients with droplet or airborne spread within dedicated
isolation rooms. However, there are a limited number of negative pressure bays
and pods and/or rooms across Australia and New Zealand,12 so isolation within dedicated
rooms may not be possible with COVID-19 because of the large volume of patient
admissions.
It is important for
physiotherapists to understand the different types of isolation rooms that
exist in hospitals. Class S rooms (standard single rooms, no negative pressure
capability), which can be used for isolating patients capable of transmitting
infec-tion by droplet or contact routes12 and Class N rooms (single negative pressure isolation rooms), which are
beneficial in isolating patients with transmissible airborne infections.12 The preference would be for patients with confirmed or suspected COVID-19 to be isolated in Class N rooms.12 If this is not possible, Class S
single rooms with clearly designated areas for donning and doffing PPE are recommended.12 In the event of all single Class
N and S rooms being fully occupied, the recom-mendation is for patients with
COVID-19 to be separately
cohorted to patients without COVID-19 within the hospital.12 In an open ICU or ward-cohorted
areas with one or more patients with COVID-19, it is recommended that staff
members in the whole area are required to use airborne PPE precautions.12 Box 5 describes how the movement from dedicated isolation rooms to open
cohorting might evolve within an ICU.
Footnotes: a An international team of expert researchers and cli-nicians within the
intensive care and acute cardiorespiratory fields have
developed these recommendations. The recommendations are intended for use in
adults only. This document has been constructed using existing medical
guidelines, relevant literature and expert opinion. The authors have made
considerable effort to ensure that the information contained with the
recommendation is accurate at time of publication. Further iterations of these
recommendations will be published as new information arises. The information
pro-vided in this document is not designed to replace local institutional
policies and should not replace clinical reasoning for individual patient
management. The authors are not liable for the accuracy, information that may
be perceived as misleading, or completeness of information in this document.
The author group will review and update this guidance within 6 months, or if
important new evi-dence emerges that changes the recommendations herein. b These recommendations have been
endorsed by: Australian Physio-therapy Association, Canadian Physiotherapy
Association, Associa-tion of Chartered Society of Physiotherapists in
Respiratory Care UK, Associazione Riabilitatori dell’ Insufficienza Respiratoria, Koninklijk Nederlands Genootschap voor
Fysiotherapie, Interna-tional Confederation of Cardiorespiratory Physical
Therapists, World Confederation for Physical Therapy, AXXON Physical Therapy in
Belgium, and Société de Kinésithérapie de Réanimation.
Ethics
approval: Not applicable.
Competing interest: All authors completed a World
Health Or-ganization conflict of interest form. Direct financial and industry-related conflicts of
interest were not permitted and were consid-ered to be disqualifying. The
development of these recommenda-tions did not include any industry input,
funding, or financial or non-financial contribution. No author
received honoraria or remuneration for any role in the development process. We
explicitly discussed conflicts of interest, including those
who held grants related to intensive care unit rehabilitation (CH, MK, SMP) or
received industry funding for high-flow nasal
cannula research (IB); because none of these projects specifically involved COVID-19, the group agreed that there were no relevant
conflicts of interest.
Sources
of support: Nil.
Acknowledgements: This work was adapted from a
guideline originally prepared by Dr Peter Thomas and endorsed by the Queensland
Cardiorespiratory Physiotherapy Network (QCRPN). The QCRPN was involved in the
design of the work and development of statements. Representatives included:
Alison Blunt, Princess Alexan-dra Hospital, Australia; Jemima Boyd, Cairns Base
Hospital, Australia; Tony Cassar, Princess Alexandra Hospital, Australia;
Claire Hackett, Princess Alexandra Hospital, Australia; Kate McCleary, Sunshine
Coast University Hospital, Australia; Lauren O’Connor, Gold Coast University
Hospital, Australia; Helen Seale, Prince Charles Hospital, Australia; Peter
Thomas, Royal Brisbane and Women’s Hospital, Australia; Oystein
Tronstad, Prince Charles Hospital, Australia; and Sarah Wright, Queensland
Children’s Hospital, Australia.
Provenance:
Invited. Peer reviewed.
Correspondence: Peter Thomas, Department of
Physiotherapy, Royal Brisbane and Women’s Hospital, Australia. Email: PeterJ.Thomas@health.qld.gov.au
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