Most people who contract coronavirvus (COVID-19) recover. But about 14% will have a severe infection, and a further 6% will become critically ill. Research shows 16% of those hospitalised need an intensive care bed – often for prolonged periods of time. Some will need to be placed in a medical coma on a ventilator.
During this critical period, specialist physiotherapists will remotely monitor patients and decide if they’re needed to help a patient’s respiratory function and physical recovery by looking at factors such as a person’s oxygen levels, blood test results, lung scans, and following discussion with their colleagues.
Here are some of the problems that physiotherapists can assist with when people are in hospital with COVID-19.
Low blood oxygen
People with severe COVID-19 infections suffer from low blood oxygen. Patients with difficulty breathing because of the virus will have worsening lung function and won’t be able to circulate oxygen properly to the body’s essential organs.
In moderate to severe cases of COVID-19, prone positioning (lying face down) is recommended. Lying face down for hours at a time can increase oxygen levels in the blood. This is because it helps match air to blood supply in the lungs, and also opens up areas of lung tissue to allow more gas exchange.
Often, this treatment is used when patients are still critically unwell due to COVID-19. Moving the patient in and out of prone positioning requires a large team of specialist staff which can include physiotherapists. Physiotherapists may also recommend other positions, such as side lying, to assist lung function depending on the patient’s condition.
Non-invasive ventilation is a form of breathing support that doesn’t involve inserting a tube into the airways. This is usually done through a face mask, or a “helmet”, which can limit droplet spread of the virus.
However, the use of non-invasive ventilation in treating COVID-19 is still being debated. Research indicates that non-invasive ventilation did not work well for people with other types of viral illnesses such as the Middle East respiratory syndrome (MERS), which might mean there may be a high failure rate in COVID-19. Early intubation (placing a tube in the airways) and ventilation is often preferred for severe COVID-19.
Non-invasive ventilation can work for some patients with a less severe infection, especially if they’re not considered suitable for more intensive forms of treatment, or if ventilators are in low supply.
Mucus in the lungs and difficulty breathing
While many people with COVID-19 have a dry cough and don’t have problems with excess mucus build up data from one Chinese study reported that 34% of patients with severe COVID-19 had excess mucus. This build up may happen after being admitted to critical care.
For some people very unwell with COVID-19, physiotherapists might deliver ventilator hyperinflation to mimic larger breaths, or use a flexible catheter to suction mucus out without the need to disconnect the person from the ventilator.
Patients can also be taught breathing exercises to help them cough up mucus on their own. Those experiencing breathlessness or difficulty breathing can be advised about positioning, relaxed breathing techniques, and about modifying their daily activities.
However, some breathing techniques used to clear mucus will result in coughing. This may spread coronavirus, so physiotherapists will need full personal protective equipment. A negative pressure room (where air can’t be circulated outside the room) is also useful for preventing further virus spread.
This can start with simply getting patients to move their arms, legs and body in the bed. Physiotherapists will closely manage vital signs such as oxygen levels, respiratory rate and blood pressure to ensure movements are safely tolerated.
Rehabilitation will also vary depending on the patient’s condition. Tiredness or fatigue is reported in about 40% of patients, so physiotherapists will pace activity and potentially see patients more often for shorter treatment sessions. It can be hard sometimes for people to comply with treatment due to factors such as delirium causing confusion and anxiety, so remembering and building on prior sessions may be affected.
For those with severe infections, even the smallest movements can be exhausting and cause rapid drops in oxygen levels. Rehabilitation will be carefully planned and progress gradually to the patient sitting on the edge of their bed, standing, marching on spot, and walking, depending on how well each is tolerated.
Patients hospitalised with COVID-19 are more commonly people who are older and have underlying conditions, such as kidney problems, high blood pressure, diabetes, coronary heart disease and obesity. Some patients can also develop lung and kidney, cardiac and liver damage while in critical recovery. All of these factors influence their ability to recover and physiotherapists must carefully judge their rehabilitation.
People may also develop post-intensive care syndrome, which can develop after a critical illness. People commonly experience problems with their physical function, mental health, or cognitive ability. Where possible, physiotherapists will help patients make a full physical recovery so they can return home. Physiotherapists will work alongside a team to help patients during rehabilitation.
Since recovery and rehabilitation take some time, using technologies such as “tele-rehabilitation” or other forms of remote physiotherapy can help patients return to good health even after they’ve left the hospital.