Pulmonary rehabilitation in COVID-19 pandemic era: The need for a revised approach
To the Editors:
The coronavirus disease 2019 (COVID-19) pandemic is affecting millions of people worldwide with no current signs of abatement; manifestation of illness in those infected with the virus varies widely, from asymptomatic requiring no treatment to very severe complications requiring mechanical ventilation support. Initially, the virus was thought to primarily effect the pulmonary system alone, but later it was recognized that the virus can impact multiple organ systems also. Nevertheless, those who are physically fit and possess a healthy living phenotype are less severely affected by the disease than those with pre-existing co-morbid conditions and hence having less morbidity and mortality. 1 The recovery rate of COVID-19 is improving with time due to better insight of the disease and available treatment options and hence, the number of survivors is increasing. During the recovery period, it has been reported that even patients with symptoms as a result of the viral infection continue to experience dyspnoea, chest pain and fatigue; these symptoms have been shown to persist for weeks following acute recovery. In patients recovering from a more severe manifestation of the viral infection, severe morbidity and low quality of life persist. 2 Pulmonary rehabilitation (PR) has the potential to play a vital role in the recovery of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, the traditional approach to PR is not conducive to the healthcare environment in the COVID-19 era. In this context, the approach must be modified from the perspective of both the rehabilitation programme employed as well as a focus on minimizing the possibility of viral spread by transferring the patients to the government or community-designated isolation centres. In this pandemic era, the multidisciplinary role by members is crucial with primary role of the members being to reenforce the PR plan for COVID-19 and provide awareness, education and support whenever required. 3 Telerehabilitation is an important component of PR in this environment as it allows access to patients who would benefit while minimizing human-to-human contact. During face-to-face treatment, healthcare professionals should employ techniques that require minimal manual handling of patients, such as remote-controlled mechanical tilting beds, mechanical assisted limb exercisers and closed-circuit suctioning. In the immediate post-recovery period, patients must remain in isolation for at least 2 weeks before enrolling for supervised PR programme. During this isolation phase, patients should be advised to perform low-to-moderate intensity exercises as per individual capabilities or using self-perceived exertion scales which can be easily administered from remote centres. Following the self-isolation phase, exercise testing and prescription need to be assessed under strict protocols to minimize viral spread; properly ventilated rooms and sanitization of rehabilitation settings are essential components. Proper nutritional counselling and psychological rehabilitation are also important components of PR that should be included. 4 Table 1 lists a proposed modified approach to PR for the COVID-19 era. The authors of this correspondence hope that readers will find this proposed approach to be of value when considering how to alter the approach to PR. Table 1 Proposed phase wise PR protocol depending on the severity of symptoms (1) Asymptomatic patients (no or minimal V/Q mismatch)-Telerehabilitation Goal: Prevention of developing comorbidities and early recovery Improvement of immunity Aerobic exercises, yoga and nutritional care Improve lung compliance Deep breathing, intercostal expansion and yoga Respiratory muscle conditioning IMT at moderate to high intensity using MIP to set intensity Skeletal muscle conditioning Aerobic and resistance training targeting larger muscles group. Train at moderate to high intensity using RPE and 10 RM for setting intensity Oxygen supplementation will not be required and need for telemonitoring (vitals) will be minimal unless other pre-existing comorbid conditions Activities log and telemonitoring can be done for improving compliance Aerobic and resistance training at moderate intensity targeting larger muscle group Oxygen supplementation may be required during exercise training and need for telemonitoring (SpO 2 by pulse oximetry) will be mandatory whether other pre-existing co-morbid conditions are present Activities pacing training and self-symptoms monitoring must be incorporated Caution: No active exercise if fever and weakness are worsening (3) Symptomatic patients requiring mechanical ventilation (moderate to severe V/Q mismatch)-ICU rehabilitation protocols Goal: Improve pulmonary ventilation and prevent deconditioning Improvement of alveolar ventilation/oxygenation Pneumonia: Airway clearance techniques-modified postural drainage regimen, suctioning-closed loop suctioning will be better than open suctioning ARDS: Prone positioning and frequent change in positions and appropriate mechanical ventilation strategies Improvement of immunity Nutritional care (protein-rich diet, zinc and vitamins)-enteral/parenteral route Improve lung compliance Ventilatory setting with appropriate PEEP adjusted Weaning from mechanical ventilation T-piece trials IMT (moderate intensity) through endotracheal /tracheostomy tube as tolerable Skeletal muscle conditioning Active/active assisted/passive exercises, cycle ergometry and electric muscle stimulation at the bedside may be considered approaches Early ambulation strategies as tolerated once vital signs stabilize Neuromuscular electrical stimulation Need for telemonitoring (SpO 2 by pulse oximetry) will be mandatory during all the ICU rehabilitation phase whether other preexisting co-morbid conditions are present If pulmonary fibrosis is present, perform training with oxygen supplementation as needed If secretions are present, perform airway clearance techniques Improvement of immunity Aerobic exercises, yoga and nutritional care Improve lung compliance Deep breathing, intercostal expansion and yoga Respiratory muscle conditioning IMT at moderate to high intensity, using MIP to set intensity Skeletal muscle conditioning Aerobic and resistance training targeting larger muscles group at moderate to high intensity, using RPE and 10 RM for setting intensity N.B. As patients will be non-contagious, rehabilitation still requires separate settings than the other patients. Proper precautionary and safety measures must be followed at rehabilitation settings as prescribed by regulatory bodies for prevention of COVID-19 spread. Make patients learn rehabilitation exercises and self-monitoring of vitals (B) Home/self-monitored training Goals and means are same as of supervised training Telerehabilitation can be used to improve compliance of the PR General: For non-infected people in the community Goal: Staying fit and prevention of comorbidities due to long-term home stay Interventions: Aerobics, resistance and flexibility exercises such as meditation and yoga Emphasize on activities easily done at home-aerobic dancing, leisure activities-skipping, cycling, stepping, stair climbing, etc. if treadmill is not available COVID-19, coronavirus disease 2019; ICU, intensive care unit; IMT, inspiratory muscle training; MIP, maximal inspiratory pressure; PEEP, positive end-expiratory pressure; PR, pulmonary rehabilitation; RM, repetition maximum; RPE, rate of perceived exertion; V/Q, ventilation/perfusion.