For the past couple of years, the world’s population has been dealing with a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The COVID-19 pandemic, which is related to high morbidity and mortality rates, started from the city of Wuhan, China, and has ever since spread rapidly worldwide through the air contaminated by minute airborne particles that contain the virus. This airborne infection showed a range of symptoms in patients, including severe hypoxemic respiratory failure requiring mechanical ventilation and possible multiorgan failure in most severe cases.
During this time, Respiratory Physiotherapy (RPT) was considered to be an essential part of patient management and rehabilitation. It has also been proven to be effective in improving long-term physical function among ICU survivors that have been tested positive. Physiotherapy in Whitby for critically ill patients with respiratory complications, in general, is based on a multisystem approach that focuses not only on chest physiotherapy but also on the entire musculoskeletal rehabilitation. These combined physiotherapy techniques are proven beneficial in reducing the incidence of complications, speeding up the process of weaning from mechanical ventilation, and facilitating recovery of functional autonomy.
The conventional chest physiotherapy maneuvers for respiratory complications in patients include techniques such as airway clearance, lung re-expansion through recruitment maneuvers (RMs), ventilator therapies, inhalation procedures, humidification, bronchial aspiration, and much more. Physiotherapists are also currently focussing on other equally effective methods, which can enhance these current techniques. Some of these new techniques are also being practiced in parallel with the old methods.
Since the critical pulmonary illness related to the coronavirus can lead to long-term mechanical ventilation with increased respiratory complications, early physiotherapy and mobilization may be imperative for improving patient care. The exercises prescribed by physiotherapists can play an integral role in the effective treatment of patients and can also help them improve respiration in the long run.
Physiotherapy-Led Respiratory Interventions For Patients With COVID-19 Infection
- Airway clearance physiotherapy
Airway clearance physiotherapy includes a number of methods to enhance the flow of air. It focuses mainly on positioning, active cycle of breathing, manual and/or ventilator hyperinflation, percussion and vibrations, positive expiratory pressure therapy (PEP), and mechanical insufflation-exsufflation.
There are mainly two types of airway clearance techniques listed below.
Normal Clearance
A normal clearance physiotherapy requires an open airway, a functional mucociliary escalator, and the patient must be able to perform an effective cough. The respiratory airways are normally kept open by the structural support mechanisms and kept clear by the effective functioning of their ciliated mucosa. The average human bronchial tree is lined by a light (5 micrometers) layer of mucus which is transferred over the airway surface by the mucociliary escalator. The ciliated epithelium which lines the airways is what causes the continuous flow of mucus over the airway surface to the upper respiratory tract. Mucus is pushed via a coordinated movement of ciliary motion toward the trachea and larynx, where excess secretions can be swallowed or expectorated.
An effective cough is the most common procedure for normal airway clearance. Respiratory physiotherapists can help patients through controlled coughs which are some of the most important protective reflexes in the human body. By liberating the larger airways of excessive mucus and foreign matter, the cough helps the normal mucociliary clearance and provides airway patency. There are mainly four distinct phases to a normal cough, they are irritation, inspiration, compression, and expulsion.
Abnormal Clearance
The flow of air through the tracheobronchial tree and its interaction with the mucus lining can be quite complicated due to several factors, such as:
- The branching geometry of the airways
- Collapsible airway walls
- Frequently varying velocity of the airflow
- Changing viscoelastic properties of mucus
For patients suffering from COVID-19 and other endobronchial diseases, the mucus layer may exceed 5 mm in thickness and ciliary clearance becomes unproductive. Two-phase discharge now becomes an essential method of clearance, and at a precise blend of airflow, mucus viscosity, and thickness there is a very strong gas-liquid interaction which first intensifies the pressure reduction and then detaches liquid from the airway wall.
One of the mechanisms by which cough concerns sputum clearance in endobronchial diseases is the two-phase gas-liquid flow: the transfer of momentum and energy from the high-speed flow of air to the mucus that lines the bronchi. The high transmural pressure produced during physiotherapy cough directs to dynamic compression of the airway inhibiting mucociliary clearances. Thus, helping the patients to clear the airways and take in more air which is absolutely imperative while suffering from the Coronavirus infection.
- Non-invasive ventilation and inspiratory positive pressure breathing
Physiotherapists tend to use inspiratory positive pressure breathing and non-invasive ventilation as a part of airway clearance strategies in the management of respiratory failure caused by the COVID-19 pandemic.
Non-invasive ventilation (NIV) is the delivery of oxygen with the help of a face mask and consequently eliminating the need for an endotracheal airway. Non-invasive ventilation achieves better physiological advantages when compared to conventional mechanical ventilation by decreasing the stress of breathing and enhancing gas exchange. This method is recognized as an effective treatment for not only patients with COVID-19 infection but can also be beneficial for chronic obstructive pulmonary disease, cardiogenic pulmonary edema, and other respiratory conditions.
Respiratory physiotherapy leverages NIV to create a positive airway pressure, which means that the pressure outside the lungs must be greater than the pressure inside of the lungs. This forces the air into the lungs, reducing the respiratory struggle and relieving the stress on breathing. It also enables patients to keep the chest and lungs expanded by raising the functional residual capacity, which is the amount of air remaining in the lungs after expiration.
- Techniques to facilitate secretion clearance
The respiratory physiotherapy techniques to facilitate secretion clearance in coronavirus infected patients include administered or prompted cough maneuvers and airway suctioning. Physiotherapy treatment to facilitate secretion clearance in people with COVID has included traditional chest physiotherapy techniques of manual percussion and vibrations as well as postural drainage. Moreover, other physiotherapy techniques that are leveraged to enhance forced expiration, including cough, have been successful during implementation, hence, improving inspiratory capacity and stability or increasing expiratory flow and strength.
During straight position, only the segments of the right upper lobe and the non-lingular portion of the left upper lobe receive gravitational assistance whereas the segment of the middle, lingular portion of the left upper lobe, and lower lobe segments of both lungs must drain against gravity. In a normal healthy state, the mucociliary mechanism clears off the bronchial secretions. But in the diseased state, they get compromised and secretions get accumulated especially in the smaller airways that cannot be emptied without gravity assistance which can further lead to inflammation and scarring. The physiotherapy methods of emptying the tracheobronchial tree of accumulated secretion are on the whole extremely efficient and are successful the majority of the time.
Conclusion
Respiratory physiotherapy can improve breathing functions and quality of life in patients with COVID-19, especially after discharge. But patients must not completely depend on physiotherapy for COVID-19 and must initially consult with their doctors before undergoing any procedures. Moreover, it should be noted that respiratory physiotherapy is an individualized treatment based on the patient’s interests and perspective.
If the patient has been relying on physiotherapy earlier for other health-related issues, then he/she will be more inclined to leverage physiotherapy for COVID treatment as well. In addition, when administering respiratory physiotherapy for patients in the acute stage, therapists must ensure that safety measures and proper distance are maintained in order to prevent cross-infection.