Notice to navigators: I'm going to extend a lot… If you just want to know what physiotherapy can do for the patients infected with sars-cov2 read, go to the last point of the article 😉
(I've been locked up for so long that you can see I needed to express myself.)
Introduction
It's Friday, March 27th. I've been with the closed respiratory physiotherapy center for over two weeks. When the first two cases of Covid-19 appeared less than 100 kilometers from my center, I decided to close the doors. I was going to close on Monday the 16th, but the information rushed and, to protect my patients and my family, to help contain the curve, to avoid being a vector of contagion the Sars-Cov2 virus,… I decided to close on Thursday, March 12, when it might still seem like it was an exaggerated measure. I have to thank Tania (a fellow physio respi very consciously) for our conversations. They helped me a lot to make the decision at the right time.
And here I am, writing from home this post, wishing I could contribute something else to society, knowing that there are many toilets at the foot of the canyon and wanting to be useful in some way. I try to help my patients by doing telework, reading, study… besides taking care of my three children, the dog, the cat and trying to maintain harmony with my husband.
I think now, what I can help with right now is sharing the information and reflections I've been collecting these days. And at this point I am very grateful for the professional WhatsApp groups to which I belong and who have brought me ideas, light and information.
Sars-Cov2 virus effects
Now we know a little more about Sars-Cov2 and the disease it produces, Covid-19. When we are infected, we spend a time 5 to 14 days, in most cases, without having symptoms (but being contagious!!!), and then experimenting:
- Dry cough (without moving secretions in 66% of the cases evaluated, but producing contagious microdropths)
- Muscle aches (often due to fever)
- Headaches
- Fever (to fight infection)
- Dyspnoea, or feeling short of breath (due to thickening of the alveoal walls, which decreases its stretching potential to allow good ventilation and causes problems in the effective breathing of the lungs)
- Loss of smell and taste (due to olfactory nerve involvement, which also helps regulate the sense of taste to a large extent)
The most severe cases should go to the hospital for help. Currently, mild cases should be left at home self-ingesting to avoid infecting more people, having alerted health authorities. The lines are very saturated, but in many autonomous communities Apps have appeared to be able to warn if you have symptoms.
Very often the symptomatology of this disease is mild. It could even be that the symptomatology is so slight that we pass it without realizing it.
When the disease progresses and the body does not have enough defenses to stop it, pneumonia often bilaterally appears. In this case, the pneumonia that appears is interstitial, causing a kind of alveolar inflammation. The consequence turns out to be that the wall of the sockets (it would become the leafs of the bronchial tree) becomes fatter, decreasing the elasticity of the lung and making it harder for oxygen to pass into the blood.
Covid-19 treatment
When symptoms are mild, it's often enough to allow time to act on the body's natural defenses and doses of acetaminophen if the fever goes up.
They have been trying different medications to help you get through the disease better and faster. They're doing studies to find the one that works best.
They are also working on the development of a vaccine. The intended loop to get it ready ranges from one year to 18 months.
When symptoms get worse, it's when we need a fan to help us pass oxygen into the blood.
If the disease is mild we heal in about two weeks and if we are unlucky and have a serious time, we will need 3 to 4 weeks.
Respiratory physiotherapy
My work as a physiotherapist in the field of breathing is based on improving the passage of air through the airways, helping to remove mucus, improving the function of the respiratory muscles, improving the arrival of oxygenated air, opening potentially collapsed regions and helping people with lung diseases continue to move or restart their physical activity by finding mechanisms to manage dyspnoea (or feeling short of breath).
We help manage many acute respiratory diseases, even more chronic respiratory diseases, and hospital spending has been shown to decrease if we do prevention and follow-up work on chronic patients.
Respiratory physiotherapy at UCIs until the onset of Covid-19
Physical therapists have very useful tools and techniques. And more and more physiotherapists who are currently in hospitals enter UCIs, participating in the management of respirators, in the management of bronchial secretions, in the mojora of ventilation and oxygenation of the patient, preventing and working in the early mobilization of patients to prevent their muscles from losing strength too quickly, favoring a faster recovery once the respirator can be removed.
But to what extent can respiratory physiotherapy help or hinder if affected by Covid-19?
According to the recommendations of SEPAR (Spanish Society of Pneumology and Chest Surgery) and the A.R.I.R (Associazione Riabilitatori dell'Insufficienza Respiratoria, Italy). It is not recommended to apply techniques that help to wait if you do not have complete isolation. They also ask to avoid mists and replace the inhaled medication application (if needed) with spacer chambers and test. Aerosol particles that form during respiratory physiotherapy techniques that target bronchial drainage, as well as nebulizers, produce microdropsts that help deposit the virus one meter away from the emitting person.
So in hospitals, physio respi si at UCIs, as long as the protection recommendations are followed:
- Protection of the professional with adequate clothing.
- Turn off fans before removing endotracheal tubes or masks to prevent microdroplet formations
- Avoid techniques with clear bronchial drainage targets
- Avoid the application of mists.
Respiratory physiotherapy in Covid-19 in mild cases (in confinement)
As an expert physiotherapist in the respiratory system, I wish my discipline could help patients who have become ill with this new virus, but I was slow to write something linking physio respi and this new disease because it was unclear to what extent we could be useful. It seemed that the risks of respiratory physiotherapy (due to the generation of infectious aeorosoles, these microdropths we talked about earlier) with these patients were greater than the advantages.
The first information that came from scientific societies such as SEPAR basically spoke of the physiotherapy that is performed in the ICU, since the most responsible given the situation is that any non-urgent physiotherapy procedure was avoided until we knew more. As the days go by, the physiotherapists in the rear have understood the disease more and can already venture into giving recommendations based on evidence learned from other similar diseases, adding the precautions that sars-cov2 requires.
The area of respiratory physiotherapy of SEPAR, based on scientific evidence criteria recommend:
– Avoid long periods of seating or immobility
– Perform physical exercise daily (intensity and volume will depend on the feeling of dyspnoea, and will be contraindicated if the patient has a fever)
– Coordinate breathing with exercises performed
– Promote good hydration
All this while maintaining the most careful hygiene and disinfection guidelines possible.
In addition, taking into account clinical experience in pathologies that would have consequences similar to Covid-19, if you have MILD symptoms, I suggest that the following can be tested:
- Deep nose inspiring inspirations with inspirational pauses of 3 to 5 seconds.
Inspirations will be made in a seated position or lying in the most comfortable position.
As the problem can get deep in the lung, it can help inspire deeply, to help swell all the sockets well and favor the passage of oxygen in the blood.
We'll add pauses after each inspiration to help activate what we call "collateral ventilation" and help open the closed sockets even more.
After inspiring, we will stop breathing for a lapse of time that will go from 3 to 5 seconds.
The ehalation should not be profound. A normal amount of air is simply exhaled, without completely emptying the lungs. Better with pinched lips, like your blowing a candle.
5 cycles of 5 breaths can be done, for example. And repeat the cycles throughout the day.
If at any time the patient notices fatigue or increased dry cough, we recommend that you stop exercising. You might try Exercise B:
- Stepped inspirations
If it costs, deep inspirations cause pain or increase coughing, you can make inspirations as long as you can, without causing pain, taking out little air and catching some air again, swelling each cycle a little more.
If we introduce the staggering of inspiration and remain unsused, and either the dry cough increases, we will stop doing the exercises.
If productive coughing appears during the inspirational exercises, it would be best to contact your head respiratory physiotherapist to assess, telematically, the steps to follow.
- Anti-resistance inspirations
To help your lungs swell further, strangely, inspiring against resistance helps stretch the sockets. On the market there are specific utensils to do this function, but since it is not time to go out on the street or place orders online, putting a straw between the lips and inspiring through it to do exercise A or B can be a good idea.
Use a new straw every time (nowadays, to protect the environment disposable straws should be deprecated, but if you still have them at home, you can take advantage of them).
If the person gets tired or appears more dry cough, let them leave it.
- Nasal cleansing
Even if the disease does not occur with nasal mucus, if some mucus we have in the nose, it can favor the appearance of coughing. Instillating 2.5 ml of serum by nasal cavity, swallowing it and making forced inspirations, such as sipping in mucus can be a good idea.
- Physical activity
When we are inactive, the muscles lose strength very quickly.
If there is a fever: you have to rest, but when the fever drops you can do simple exercises with your legs and arms. Above the bed or sitting in a chair. We can walk around the room, get up and sit repetitively
If the clinic is very, very mild and the patient is well, he can adapt the efforts to his condition: squats, abs… zumba classes on youtube…. Whatever we can think of. It's not a matter of getting too tired, it's about staying active during isolation, so that when you can leave your body isn't deconditioned.
We recommend doing the exercises when alone in the room. However, if we are positive for SARS-Cov-2, the main recommendation is to isolate ourselves from the rest of the family to avoid contagion.
Respiratory physiotherapy with COVID19 and other associated respiratory diseases
If in addition to having COVID-19 a previous respiratory disease, you will have to go more carefully when assessing symptomatology, being a group of greater risk. If your condition is good you will be able to stay at home and follow the recommendations explained so far.
At the home level, if sars-cov2 infection is suspected, to prevent the spread of microdropths, especially if isolation is not 100% effective, it is NOT recommended to:
- The use of risk nebulizers to propagate microdropths.
- Applying bronchial drainage techniques if they are not essential
In case of prior respiratory pathology, the risks of not applying such techniques should be assessed. I recommend talking to your therapists to value it. If there is another previous pathology that you have with abundant bronchial hypersecretion, it may be better to continue with bronchial hygiene techniques to avoid older bad ones. In case of diseases with cystic fibrosis or chronic bronchitis with recurrent pneumonia, to give two examples, it may be more sensible to continue with bronchial drainage techniques extreme precautions. For example, draining the lung with masks and being even more rigorous ventilating the room and disinfecting surfaces.
Post-Covid-19 respiratory physiotherapy
Currently, the functional and anatomical sequelae that SARS-COV-2 infection can cause are unknown. But it is clear that these new patients who are currently attending to their aguo process, like patients who have had other respiratory diseases, may need pulmonary rehabilitation. In these contexts, respiratory physiotherapy is based on: patient education, aerobic exercise, strength and training exercises, secretion drainage techniques and ventilatory, if clinical manifestations of the patient require it.
In short, and answering the question of the title of this letter: COVID-19. With or without physical therapy?:
According to everything spoken, my answer is YES, without a doubt:
- Respiratory physiotherapists in ICU YES, helping with respirators, managing hypersecretion if appropriate and with the early mobilization of patients as long as the protection of sanitary and other patients can be guaranteed.
- Respiratory physiotherapy in mild yes cases, without the need for the physical therapist to be present, in order to limit the possibility that the physical therapist is a vector of contagion of others. Basically working inspiration and therapeutic physical activity. Avoiding bronchial drainage techniques, when not strictly necessary.
- Respiratory physiotherapy when patients overcome the disease and are no longer infectious YES, to assess possible sequelae and help patients avoid complications. Rating your status on a case-by-case basis.
This post is very aimed at adults and I do not talk about the little ones at home because luckily, the involvement in boys and girls has been almost anecdotal so far. While it is true that children are wonderful vectors of contagion, they do not tend to get sick ostentatiously. Now it's more time to take care of the elders.
I hope I've been of help to you. I send you a hug full of positive energy so that you can hold the confinement in the best possible way. And, in any case, moving is health, so, even if it's at home, move it!!
Arillaga A, Pards M, Escudero R, Rodríguez R, Alcaraz V, Llanes S, et al. Respiratory physiotherapy in the management of the patient with COVID-19: general recommendations. SEPAR 2020 Mar 26
Ministry of Health. Clinical management of COVID-19: intensive care units. Published 19 March 2020
Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, et al. Physiotherapy management for COVID-19 in the acute hospital setting. Recommendations to guide clinical practice. Version 1.0, published 23 March 2020.