Recommendations For Respiratory Rehabilitation In.99313 PDF
Recommendations For Respiratory Rehabilitation In.99313 PDF
Recommendations For Respiratory Rehabilitation In.99313 PDF
DOI: 10.1097/CM9.0000000000000848
COVID-19
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Wang Chen, Chinese Academy of Medical Sciences & Peking Union Medical
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[Abstract] Coronavirus disease-2019 (COVID-19) is a highly infectious
adults with COVID-19 based on the opinions of frontline clinical experts involved in
the management of this epidemic and a review of the relevant literature and evidence.
rehabilitation would relieve the symptoms of dyspnea, anxiety, and depression and
eventually improve physical functions and the quality of life; 2. for severe/critical
can guide clinical practice and form the basis for respiratory rehabilitation in COVID-
19 patients.
Since December 2019, the coronavirus disease 2019 (COVID-19) that originated
from Wuhan in Hubei province has become a public health emergency and has spread
to various provinces in China and many other countries. COVID-19 has already been
control measures for category A infectious diseases have been adopted. The National
Health Commission has also published diagnosis and treatment protocols to guide the
COVID-19 patients, particularly severe and critical patients, in clinical practice, our
epidemic control experts and reviewed the evidence in relevant literature. Based on
rehabilitation medicine experts 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.
I. Methodology
into the recommendation drafting group, evidence assessment group, and expert
consensus group. The drafting group is responsible for determining the topic and
The expert consensus group is responsible for achieving a consensus from the
preliminary recommendations.
3. Literature search: Our recommendations included three infectious diseases
reviews, and randomized controlled trials. Two members of the evidence assessment
Elsevier, the Lancet, the New England Journal of Medicine, and the Journal of the
Medical Journal Network). The search period was from database construction to
February 21, 2020. The search terms included the English terms and their Chinese
and other rehabilitation-related English search terms and their Chinese equivalents
assessment group used the Endnote X9 literature management software to screen the
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
tool for methodological quality assessment of the included guidelines, the AMSTAR
tool for quality assessment of systematic reviews, and the Cochrane bias risk
consensus group, and a consensus was reached through panel discussions, which was
prevention and control in medical institutions (1st edition)”[3] printed by the National
Health Commission should be strictly complied. 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 resume
work.
for respiratory rehabilitation and should not worsen clinical infection prevention
rehabilitation using multiple methods can be employed in patients who meet the
recovery criteria and are no longer under quarantine observation based on their
patients with severe/critical condition, older adults, obesity patients, patients with
multiple comorbidity, and patients with one or more organ failure, the respiratory
7. Protection (Table 1): The staff must refer to the requirements indicated in the
2019 Patients (Interim)” and select the type of task to determine the appropriate
protective measures[4]:
III. Respiratory rehabilitation recommendations in mild patients during
The clinical symptoms of the patient are mild and may include fever, fatigue,
[5-6]
coughing, and one or more physical dysfunctions . During quarantine, patients
with confirmed disease will show anger, fear, anxiety, depression, insomnia or
aggression, and loneliness, or will be uncooperative due to fear of the disease. The
[Recommendations]
1. 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,
points (total score: 10 points), fatigue should be absent on Day 2 preferably; (2)
and (3) type of exercise: breathing exercise, Tai chi, or square dancing.
However, Isolated causes patients to have limited exercise space. In addition, patients
experience fever, fatigue, muscle ache, etc.,[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]
current clinical observations found that around 3%–5% of ordinary patients develop
severe or even critical disease after 7 d–14 d 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
initiated.
2. Exclusion criteria: Patients (1) with a temperature >38.0°C, (2) with an initial
consultation time ≤7 d, (3) in whom the duration from disease onset to dyspnea was
≤3 d, (4) whose chest radiological scans showed >50% progression within 24–48 h,
(5) with a blood oxygen saturation level of ≤95%, and (6) with a resting blood
discontinued when one of the following conditions develop during rehabilitation: (1)
dyspnea index: Borg dyspnea score >3 (total score: 10 points); (2) chest tightness,
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.
4. The 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 mobilization
sputum and (ii) a sealed plastic bag should be used when coughing to avoid virus
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
and light exercise (<3.0 METs); (ii) frequency: Exercise is performed twice a day, 1
hour after meal; (iii) duration: The exercise duration is based on the patient’s physical
status, and each session lasts for 15–45 minutes. Patients who are prone to fatigue or
are physically weak should perform intermittent exercise; (iv) type of exercise:
breathing exercise, stepping, Tai chi, and ankle pump exercises are recommended to
prevent thrombosis; and (v) the management of patients with limited locomotor
Severe and critical patients account for 15.7% of the number of confirmed
lesions are mainly due to diffuse alveolar injury, significant fibrosis did not occur, and
patients who are given mechanical ventilation completely lose spontaneous breathing
and have no or weak response to stimuli, and the incidence of delirium in patients
under deep sedation and receiving analgesia is high.[16] Respiratory rehabilitation can
be initiated at a suitable time and can significantly reduce delirium and mechanical
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
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 reevaluated. Due to safety and human
resource concerns, only the recommended bed and bedside activities are carried out
measures must cover three major areas: (1) positioning management, (2) early
Recommendations
the following criteria are met[18]: (1) respiratory system: (i) fraction of inspired
oxygen (FiO2) ≤0.6, (ii) blood oxygen saturation (SpO2) ≥90%, (iii) respiratory rate
≤40 breaths/min, (iv) positive end expiratory pressure (PEEP) ≤10 cmH2O, (v)
absence of ventilator resistance, and (vi) absence of unsafe hidden airway problems;
(2) cardiovascular system: (i) systolic blood pressure ≥90 mmHg or ≤180 mmHg, (ii)
mean arterial pressure (MAP) ≥65 mmHg or ≤110 mmHg, (iii) heart rate ≥40 bpm or
120 bpm, (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;
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
occur[18]: (1) respiratory system: (i) blood oxygen saturation <90% or decrease
of >4% from baseline, (ii) respiratory rate >40 breaths/min, (iii) ventilator resistance,
and (iv) artificial airway dislodgement or migration; (2) cardiovascular system: (i)
systolic blood pressure <90 mmHg or >180 mmHg, (ii) MAP <65 mmHg or >110
mmHg or >20% change compared with baseline, (iii) heart rate <40 bpm or >120
bpm, and (iv) new arrhythmia and myocardial ischemia; (3) nervous system: (i) loss
of consciousness and (ii) irritability; and (4) others: (i) discontinuation of any
below the axilla to relax the lower limbs and abdomen. positioning management is
[19]
carried out in 30-minute sessions and 3 sessions are conducted each day . Prone
position is carried out in acute respiratory distress syndrome (ARDS) patients for 12
[20]
hrs and above. (2) Early mobilization: Attention should be paid during the entire
activity to prevent tubing detachment, and vital signs should be monitored during the
entire process. (i) Intensity: Lower strength, duration, or activity scope can be used in
patients with poor physical fitness, and patients only need to complete the
movements; (ii) Duration: The total training duration for a single session should not
exceed 30 minutes nor exacerbate fatigue; (iii) Type of exercise: Firstly, periodic
flipping and activities on the bed should be carried out, such as sitting up on bed,
movingout of the bed to chair, sitting on the chair, standing up, and stepping. This
performed within the full range of motion (ROM).[21] Thirdly, for patients receiving
bicycle, passive joint movement and stretch exercise, and neuromuscular electrical
and sputum expulsion and does not require therapist to have long periods of patient
contact. The management should not trigger severe cough and increase the respiratory
techniques and oscillatory positive expiratory pressure (OPEP) are among the
exercises can be selected so that patients can gradually recover the level of activity
rehabilitation in ARDS patients, COVID-19 patients may have poor physical fitness,
[Recommendations]
1. Exclusion criteria: Patients with (1) a heart rate of >100 bpm, (2) a blood
pressure of <90/60 mmHg or >140/90 mmHg, (3) a blood oxygen saturation of ≤95%,
and (4) other diseases that are not suitable for exercise are excluded from the study.
fluctuation (>37.2°C) (2) exacerbation of respiratory symptoms and fatigue that are
not alleviated with rest should discontinue exercises immediately. The physician
should be consulted if the following symptoms occur: chest tightness, chest pain,
dyspnea, severe cough, dizziness, headache, blurred vision, heart palpitations, profuse
imaging tests, laboratory tests, lung function test, nutrition screening, and
(MIP/MEP); (ii) muscle strength: Medical Research Council (MRC) , manual muscle
test (MMT), and other inspiratory muscle tests (IMT); (iii) joint ROM test; (iv)
balance functional evaluation: Berg balance scale (BBS); (v) aerobic exercise
capacity: 6-minute walk test (6MWT) and cardiopulmonary exercise testing (CPET);
(IPAQ) and physical activity scale for the elderly (PASE). (3) Evaluation of activities
education; (iii) encouraging patients to participate in family and social activities. (2)
are customized according to the patient’s underlying disease and residual dysfunction.
These exercises include walking, brisk walking, slow jogging, and swimming, and
total of 3–5 sessions are carried out per week, and each session lasts for 20–30
minutes. Patients who are prone to fatigue should perform intermittent exercises. (ii)
[25, 29]
Strength training: progressive resistance training is recommended for strength
training. The training load for each target muscle group is 8–12 repetitions maximum
(RM); i.e., each group will repeat 8–12 movements, 1–3 sets/time, with 2-minute rest
should be carried out in patients with comorbid balance disorders, including hands-
free balance training under the guidance of the rehabilitation therapist and balance
expelling sputum occur in patients after discharge, the evaluation results should be
used to arrange the targeted deep breathing exercise[30–31] and airway clearance
[32]
techniques . Breathing exercise: this includes posture management, adjustment of
groups, etc.; airway clearance techniques: firstly, forced expiratory techniques can be
used at the early stages of airway clearance after discharge in chronic airway disease
patients to expel sputum and reduce coughing and energy consumption. Secondly,
positive expiratory pressure (PEP)/OPEP can be used as aids. (3) ADL guidance: (i)
basic ADLs (BADLs): the patient’s ability in transferring, getting dressed, toileting,
and bathing are assessed, and rehabilitation guidance is provided for these
activities[33]; (ii) instrumental ADLs (IADLs): the IADL of the patient is assessed to
identify any disorders in tasks. Targeted intervention is carried out under the guidance
carried out after assessment by specialists. One or two of these exercises can be used.
be progressive. All eight moves are performed 6–8 times, with a total duration of 30
(https://mp.weixin.qq.com/s/NYY5Ts4N09zzZCpiL8nAvg).
3. Guided breathing exercises: This includes six stages of relaxed standing, two
tian-accupoint breathing, lung and kidney conditioning, body turning, kidney region
massage, and qi cultivation and training. Each set requires around 30 minutes. One set
sounds (xi, he, hu, xu, chui, and xi) to regulate qi and blood flow through the organs
and meridians. Every character is recited six times for each set. Each set requires
(https://mp.weixin.qq.com/s/ibsxWq5cDo40Jxz8mZzv-Q).
VIII. Conclusion
cautiously added the timing for respiratory rehabilitation and revised the respiratory
first edition. We hope that this can aid in frontline clinical diagnosis and treatment to
discharged patients, the updated third edition will provide more detailed guidelines
Finally, we would like to express our respect to all frontline epidemic control
staff.
Main reviewing expert: Chinese Academy of Sciences and Peking Union Medical
(Guoen Fang)
China–Japan Friendship Hospital (Yixiao Xie, Yajing Duan, Siyuan Wang, and
Liberation Army No. 304 Hospital (Shan Jiang); and Henan University of Traditional
Fang, Enxi Niu, and Tiebin Yan); Chinese Academy of Sciences and Peking Union
China–Japan Friendship Hospital (Jun Duan, Yajing Duan, Peng Feng, Gang Li,
Xuanming Situ, Siyuan Wang, Yuxiao Xie, Ting Yang, Hongmei Zhao, and Qing
Zhao); Peking University Third Hospital (Xiaobian Liu and Mowang Zhou); Beijing
Song); Tongji Hospital (Xiaolin Huang and Jianping Zhao); Henan University of
Traditional Chinese Medicine (Jiansheng Li and Hailong Zhang); 2nd Affiliated
Hospital of Harbin Medical University (Hong Chen); 301 Hospital (Lixin Jie);
People’s Liberation Army No. 304 Hospital (Shan Jiang); Evidence-Based Medicine
(Yaolong Chen); Xinqiao Hospital (Qi Li); Binzhou People’s Hospital (Mengmeng
Wu); West China Hospital (Zongan Liang, Pengming Yu); Shanghai Ninth People’s
Shanghai Institute of Health Sciences (Qi Guo); First Affiliated Hospital of Xi’an Jiao
Tong University (Zhihong Shi); Sir Run Run Shaw Hospital (Huiqing Ge); First
Xiangya Hospital of Central South University (Pinhua Pan); Third Affiliated Hospital
Li).
Nan Yang) and China–Japan Friendship Hospital (Xuan He, Qian Lu, Mingzhen Li,
External review expert group: Peking University First Hospital (Chunhua Chi and
Hainan Branch of the General Hospital of Chinese People’s Liberation Army (Yuzhu
Li); Second Hospital of Jilin University (Jie Zhang); Southwest Hospital (Hongliang
Liu), Inner Mongolia People’s Hospital (Dejun Sun); Qingdao Municipal Hospital
(Wei Han and Huaping Tang); Ruijin Hospital (Qing Xie); Second People’s Hospital
Friendship Hospital (Hongchun Zhang and Qing Zhao); Xiangya Hospital of Central
South University (Chengping Hu); and Second Xiangya Hospital of Central South
Wuhan frontline epidemic control experts: Hong Chen, Fan Dong, Jun Duan,
Huiqing Ge, Xiaolin Huang, Gang Li, Qi Li, Pinhua Pan, Yuanlin Song, Zhihong Shi,
Mengmeng Wu, Weining Xiong, Jianping Zhao, Haiqing Zheng, Guan W, Ni Z, and
Hu Y.
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