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Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) is a single-stranded ribonucleic acid (RNA) coronavirus and is highly infectious.
- Transmission is thought to be primarily via droplet transmission (ie, relatively large particles settling in the air) and direct contact with patients, rather than “airborne transmission” (where smaller particles remain in the air for a longer period of time).
- There is still no specific antiviral treatment for COVID-19 infection, only supportive care, including respiratory care for affected patients, especially in more severe cases.  A literature review (June 2020) investigates and discusses unclear issues related to disease transmission and disease Pathogenesis and accuracy of diagnostic tests and treatment modalities .
- 15% of COVID-19 patients develop moderate to severe disease requiring hospitalization and oxygen support
- Another 5% required admission to an intensive care unit and received supportive care, including intubation and ventilation. 
- Severe pneumonia is the most common complication in severe COVID-19 patients
- Other complications may include acute respiratory distress syndrome (ARDS), sepsis and septic shock, and multiorgan failure (including acute kidney injury and heart injury)
- It is more prevalent in high-risk groups, including: older age (>70 years); those with comorbidities such as cardiovascular disease, pulmonary disease, diabetes, and immunosuppression . In a small percentage of them, the disease may be severe enough to cause death.
- Current data suggest that the disease is less common in younger people and usually less severe. 
Many COVID-19 patients do not have specific airway clearance needs. It is important that staff minimize contact with positive patients to help reduce the risk of transmission, so follow usual on-call policies and standards.
- To date, COVID-19 patients requiring hospitalization have presented with features of pneumonia and bilateral patchy or ground-glass opacities in the lungs.
- There were no reports of high secretory burden requiring intensive respiratory physiotherapy/airway clearance in COVID-19 positive patients. This may change as the situation develops, so all patient visits should be discussed with a respiratory consultant Clinicians/intensive care consultants should follow specific service provider guidance for physical therapists before using mechanical devices.
- It is important to note that certain therapeutic interventions are contraindicated in patients with COVID-19. There may be patients with respiratory disease who will require individualized physical therapy, which may include mechanical airway clearance or an oscillating device. at this In such cases, it is important to discuss the risks and benefits of continuing the regime with the consultant respiratory clinician/intensive care consultant. 
The World Health Organization outlines the following clinical syndromes associated with COVID-19:
Uncomplicated upper respiratory viral infection in mildly ill patients who may have nonspecific symptoms such as fever, fatigue, cough (with or without sputum), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion or headache. rare. patients may also present Accompanied by diarrhea, nausea and vomiting. Elderly and immunosuppressed patients may present with atypical symptoms. Symptoms due to physiological adaptations to pregnancy or adverse pregnancy events such as dyspnea, fever, gastrointestinal symptoms, or fatigue may overlap with COVID-19 symptoms. Pneumonia in adults: with pneumonia However, there were no signs of severe pneumonia and no need for oxygen inhalation. Children: non-severe pneumonia with cough or dyspnea + shortness of breath: shortness of breath (in breaths/min). <2 months ≥60; 2-11 months ≥50; and 1-5 years ≥40 with no signs of severity pneumonia. Patients may be productive due to increased sputum production, but this is less common in viral pneumonia. Adolescent or adult with severe pneumonia: Fever or suspected respiratory infection plus one of the following: high respiratory rate > 90%; severe respiratory distress (eg grunting very severe chest constriction); signs of pneumonia with general danger signs: inability to breastfeed or drink drowsiness or loss of consciousness or convulsions. Other signs of possible pneumonia: chest depression; rapid breathing (breaths/min): < 2 months: ≥ 60; 2 – 11 months: ≥ 50; 1 – 5 years: ≥ 40. Although diagnosis is made on clinical grounds, chest imaging may identify or rule out some pulmonary complications. Onset of Acute Respiratory Distress Syndrome (ARDS): Within 5 – 7 days of onset of initial respiratory symptoms Diagnostic tools (radiographic CT scan or lung Ultrasound): bilateral opacities not fully explained by volume overloaded lobes or lung collapse or nodules; origin of pulmonary infiltrates: respiratory failure not fully explained by heart failure or fluid overload; objective assessment (e.g., echocardiography) required to rule out Cause of hydrostatic pressure Infiltration/edema if risk factors are not present. Impaired Oxygenation in Adults: Based on the PF ratio, which is the ratio of partial pressure of arterial oxygen to partial pressure of inspired oxygen Mild ARDS: 200 mmHg < PaO2/FiO2a ≤ 300 mmHg (PEEP or CPAP ≥ 5 cmH2O or no ventilation) Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤ 200 mmHg (PEEP ≥ 5 cmH2O or not ventilated) Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (PEEP ≥ 5 cmH2O or not ventilated) SpO2/FiO2 ≤ 315 when PaO2 is absent patient). Oxygenation disorders in children: note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2. Use PaO2-based metrics when available. If PaO2 is not available, wean FiO2 to maintain SpO2 ≤ 97% to calculate OSI or SpO2/FiO2 ratio: Bilevel (NIV or CPAP) ≥ 5 cmH2O Through full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤ 264 Mild Degree ARDS (invasive ventilation): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5 moderate ARDS (invasive ventilation): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3 severe ARDS (invasive ventilation): OI ≥ 16 or OSI ≥ 12.3.SepsisAdults : Life-threatening organ dysfunction caused by a dysregulated host response to a suspected virus or confirmed infection. Signs of organ dysfunction include: altered mental status; difficulty or shortness of breath; low oxygen saturation; decreased urine output; fast heart rate; weak pulse; cold extremities; low blood pressure; mottled skin; laboratory evidence of clotting disorders thrombocytopenia poisoned Hyperlactate or hyperbilirubinemia. Children: Suspected or confirmed infection and ≥ 2 age-based systemic inflammatory response syndrome criteria, one of which must be abnormal temperature or abnormal white blood cell count. Adults in septic shock: persistent hypotension despite need for volume resuscitation Vasopressors to maintain MAP MAP ≥ 65 mmHg and serum lactate levels > < 5th percentile or > 2 standard deviations below normal for age) or two or three of the following: altered mental status; Tachycardia or bradycardia – HR < 90 bpm or > 160 bpm in infant or HR < 70 bpm or > 150 bpm in child; extended capillary Refill (>2 seconds) or weak pulse; rapid breathing; mottled or cool skin or ecchymotic or purpuric rash; increased lactic acid; oliguria; hyperthermia or hypothermia
Patients with severe disease often require oxygenation support. High-flow oxygen and non-invasive positive pressure ventilation have been used, but the safety of these measures is uncertain and should be considered an aerosol-generating procedure requiring specific isolation precautions and PPE considerations. Some patients may develop acute respiratory distress syndrome and require intubation for mechanical ventilation; patients with refractory hypoxia may require extracorporeal membrane oxygenation.
Physiotherapy may be:
- Benefits respiratory therapy and physical recovery in COVID-19 patients, although expectoration is a less common symptom
- Indicated if a patient with COVID-19 has airway secretions that cannot be cleared independently. This can be assessed on a case-by-case basis and interventions applied based on clinical indicators, and can also be used in high-risk individuals such as existing patients Comorbidities that may be associated with hypersecretory or ineffective cough (e.g. neuromuscular disease, respiratory disease, cystic fibrosis, etc.). 
Guideline recommendation: Senior physical therapists should be involved in determining the appropriateness of physical therapy interventions for patients with suspected and/or confirmed COVID-19, in consultation with senior medical staff and in accordance with referral guidelines. 
Physiotherapy will play an important role in providing athletic mobilization and rehabilitation interventions for survivors of critical illness myopathy associated with COVID-19 to be able to return home functionally. 
Procedures at Risk of Contamination
COVID-19 is spread by inhaling infected material containing live virus, which can travel up to 2 meters, or by touching contaminated surfaces. SARS-CoV-2 can survive for at least 24 hours on hard surfaces and up to 8 hours on soft surfaces. Aerosol infection particles produced in the air Sneezes or coughs survive in the air for at least three hours. 
- Aerosol-generating procedures increase the risk of infection transmission.
Rachael Moses, consultant physiotherapist at Lancashire Teaching Hospitals, advises that particular attention should be paid to interventions that put healthcare workers at greater risk of droplet airborne contamination.  This article describes the guidelines for Specific aspects of physical therapy for COVID-19 patients to limit the spread of the disease and ensure the safety of healthcare workers .
Aerosol Generating Procedures (AGP)
Aerosols from medical procedures are one way the COVID-19 virus is transmitted. For patients with suspected/confirmed COVID-19, any of these potentially infectious AGPs should be performed only when necessary and minimized as much as possible. where these procedures are indicated It should be done in a single room behind closed doors, but is best done in a negative pressure side room. Only those health care workers who need to perform surgery will be present. Full PPE equipment including disposable fluid protective gown Personnel performing the procedure and those in the room should wear gloves, eye protection, and an FFP3 respirator mask and practice good hand hygiene after the procedure. Hair coverage should also be considered. The following procedures are considered potentially infectious AGP:
- Intubation and extubation and related procedures;
- Tracheotomy/Tracheostomy Procedures;
- Manual Ventilation;
- Open Suctioning;
- Non-invasive ventilation (NIV) such as bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP);
- Surgical and autopsy procedures using high-speed equipment;
- High-frequency oscillatory ventilation (HFOV);
- High-flow Nasal Oxygen (HFNO)
- Sputum induction; Note: Sputum induction usually involves the administration of nebulized saline to moisten and loosen airway secretions (this may be accompanied by chest physical therapy, such as tapping and vibration to induce forced coughing). This may be required if the lower respiratory tract Need a sample
Certain other procedures/devices may generate aerosols from materials other than patient secretions but are not considered to present a significant risk of infection. Such procedures include:
- Management of pressurized and humidified oxygen;
- Administered by nebulization; Note: During nebulization, the aerosol is from a non-patient source (fluid in the nebulizer chamber) and does not carry patient-derived viral particles. If particles in the aerosol coalesce (bond) with contaminated mucous membranes, it will no longer be airborne and therefore will not be part of the aerosol. Staff should practice proper hand hygiene when helping patients remove nebulizers and oxygen masks.
Special aerosol generation technology for physiotherapy 
- Manual techniques that may result in coughing and expectoration (e.g. tapping/manual assisted coughing)
- Use positive pressure breathing device (eg IPPB) Mechanical insufflation-exhalation (cough assist) device Intrapulmonary/external high frequency oscillation device (eg vest / MetaNeb / Percussionaire etc.)
- Any mobilization or treatment that may result in coughing and expectoration of mucus
- Any diagnostic intervention involving the use of a videolaryngoscope that may result in airway irritation and coughing (eg, direct visualization during airway clearing techniques or when assisting a speech and language therapist with fiberoptic endoscopic assessment of swallowing)
Reusable (public) non-invasive devices must be decontaminated:
- Between each patient and after patient use;
- After contamination with blood and body fluids; and
- Periodically as part of equipment cleaning.
Increased frequency of decontamination should be considered when using reusable non-invasive care devices in isolation/cohort areas. 
- Reusable equipment should be avoided if possible; if used, it should be decontaminated according to the manufacturer’s instructions before being removed from the room. If it is not possible to leave the device in the room, follow the IPC decontamination guidelines. This usually involves cleaning Use a mild cleaner followed by a chlorine disinfectant with a minimum of 1000 ppm available chlorine in solution (such as “Haz-Tab” or other brands).
- If possible, use specialized equipment in an isolation room. Avoid storing any extraneous equipment in the patient room
- Dispose of single-use equipment according to the room’s medical waste policy
- Point-of-care testing, including blood gas analysis, should be avoided unless a local risk assessment has been completed and shown to be performed safely
- Ventilators and mechanical equipment (e.g. cough suppressants) should be protected with high efficiency virus-bacteria filters (e.g. BS EN 13328-1).
- When using a mechanical airway clearance filter, it should be placed at or before any exhalation port on the machine end and mask end. The filter should be replaced when it becomes visibly dirty or depending on the filter being used after each use or every 24 hours. The complete circuit change should be Every 72 hours (follow specific service provider guidance)
- Closed system suction should be used if the patient is intubated or has a tracheostomy
- Disconnecting the patient from mechanical ventilation should be avoided at all costs, but the ventilator should be placed on standby if required
- Manual overinflation (bagging) should be avoided if possible and ventilator recruitment maneuvers should be attempted when possible and needed
- Humidified water should be avoided and a HME should be used in the ventilator circuit
- Use single-use crockery and cutlery in patient rooms wherever possible to minimize the number of items that need to be sanitized
- Any other items brought into the room, such as stethoscopes, pulse oximeters, or ultrasound probes, whether or not they came into direct contact with the patient, will need to be disinfected. This is due to the risk of environmental contamination within the device isolation room. 
- If AGP is performed in the patient’s own room, the room should be decontaminated 20 minutes after the procedure (also follow specific provider IPC guidelines).
- If a different room is used for the procedure, it should be left for 20 minutes before being cleaned and disinfected before being reused.
- The removal of any aerosols depends on the ventilation of the room. In a hospital room, there are typically 12 to 15 air changes per hour, so after about 20 minutes the air change will be less than 1% of the starting level (assuming aerosol production stops).
- If there is local knowledge that the design or construction of the room may not be a typical clinical space, or that the air changes per hour are low, then the local IPCT will advise how long to leave the room before decontamination. 
In mild and moderate stages of the disease, normal measures of oxygen support (mask oxygen) may be beneficial. WHO  recommends immediate supplemental oxygen therapy for patients with respiratory distress hypoxemia or shock, with a target SpO2 > 94%. patients may continue to increase Work of breathing or hypoxemia occurs even when oxygen is delivered by face mask with reservoir bag (flow rate 10 – 15 L/min, usually the minimum flow required to maintain cuff inflation; FiO2 0.60 – 0.95).  Nasal cannulae are not recommended as they may result in higher transmission water drop
Early identification and referral of patients with deteriorating respiratory function while receiving conventional oxygen therapy (e.g. simple facemask or facemask with reservoir bag) is important to ensure timely and safe escalation of respiratory support. Optimizing Care and Engagement Early Intensive care unit recommended. In patients with COVID-19, hypoxia may worsen, increasing the need for intubation and invasive mechanical ventilation, so close monitoring is recommended. 
Oxygen therapy goals may vary based on patient performance. 
For patients with severe respiratory distress hypoxemia or shock
- SpO2 > 94% is targeted 
Once a patient is stable
- SpO2 > 90%  in non-pregnant adults and 92-95%  in pregnant adults is the target.
In adults with COVID-19 and acute hypoxemic respiratory failure
- SpO2 goals should not be maintained above 96% 
High Flow Nasal Oxygen (HFNO)
There are some differences of opinion regarding the use of HFNO as an aerosol-generating procedure, but based on the Italian experience, HFNO has been found to be beneficial in the early stages of a selected group presenting with hypoxic respiratory failure but no evidence Hypercapnia, and can prevent intubation in some patients.  Given that HFNO is an aerosol-generating procedure, negative pressure rooms are more appropriate for patients receiving HFNO, and all staff entering the room should wear optimal PPE equipment, including disposable liquid repellent Surgical gown gloves goggles and FFP3 breathing mask to ensure a low risk of airborne transmission. Oxygen flow rates as high as 60% and 100% can be achieved with HFNO. 
Early identification and referral of patients with deteriorating respiratory function (hypercapnia, respiratory fatigue), hemodynamic instability, or altered mental status is important to ensure timely and safe escalation of respiratory support and consideration of early invasive therapy Provide mechanical ventilation where appropriate.  
Guideline Recommendation: While HFNO does present a small risk of aerosol generation, it is considered the recommended therapy for hypoxia associated with COVID-19 as long as staff wear optimal airborne PPE. Low risk of airborne transmission to staff with optimal PPE and other infections Control precautions are being used. Negative pressure rooms are more suitable for patients receiving HFNO. 
Acute or chronic hypoxemia is a common reason for admission to intensive care and provision of mechanical ventilation. Various improvements in mechanical ventilation or assistive devices are used to improve patient outcomes.
Non-Invasive Ventilation (CPAP/NIV)
Routine use of non-invasive ventilation is not recommended.
Noninvasive ventilation, an aerosol-generating procedure that uses a face or nasal mask to provide oxygen as respiratory support under positive pressure, is a well-established evidence-based intervention for the treatment of hypercapnic respiratory failure. amount of pressure Usually alternate according to inhalation or exhalation. Although noninvasive ventilation may temporarily improve oxygenation and reduce work of breathing in patients with viral infection and pneumonia, this approach does not necessarily alter the natural history of the disease, and This type of noninvasive ventilation is not routinely recommended and has no role in severe hypoxic respiratory failure. Where non-invasive ventilation is used, there should be a clear plan for treatment failure and escalation of care. 
Current experience suggests that non-invasive ventilation for COVID-19 may be associated with a high failure rate of delayed intubation and may increase the risk of aerosolization due to improper mask fit.  It is clear from the available evidence that non-invasive ventilation should not Routinely used when patients have severe respiratory failure or when trajectories indicate that invasive ventilation is unavoidable. In such cases, consideration should be given to early intubation in deteriorating patients and transition from oxygen therapy via simple masks to Invasive ventilation is urgent.  Negative prognostic factors for success with noninvasive ventilation are overall severity of renal failure and hemodynamic instability. 
Non-invasive ventilation is considered to be an effective strategy for specific patient populations with early onset of COVID-19, especially those with hypercapnic respiratory failure, such as those with associated respiratory disease. COPD in Italy Where non-invasive ventilation was used in this cohort, they suggested single attempts of up to 1 hour. If substantial improvement does not occur, the medical team must be alerted as early intubation and invasive procedures should be considered for the patient Ventilate in a controlled environment with appropriate infection prevention and control measures in place.  In order to provide non-invasive ventilation in a safe manner and minimize the risk of nebulized negative pressure, a single chamber should be used with a dual link system A separate exhalation port or use a dual-port filter system with a virus filter placed between the mask and the exhalation port.
Suggestions on non -invasive ventilation preferences are;
- First choice: CPAP without humidification and with Hood / Helmet PEEP between 10 – 12 cmH20 and 15-20 cmH2O according to patient tolerance needs and any side effects.
- Second Choice: CPAP with mask
- Third: NIV with face mask (full face mask / oronasal face mask with filter between mask breathing port)
Non-invasive ventilation can be effectively used to prevent ventilation and can be used to assist ventilation in the intensive care unit. The following Standard Operating Protocol for the preparation and use of Non-Invasive Ventilation or HiFlow Oxygen (AirVo) for suspected or confirmed Patients Coronavirus Version 1.7 – March 17th 2020 provides detailed explanation of HFNO & NIV functionality.  .
Guidance Recommendation: Routine use of NIV is not recommended. as current experience with COVID-19 hypoxic respiratory failure reveals high rates of associate failure. When used e.g. in a patient with COPD or after discharge, strict ventilated PPE should be provided.  .
Lung protective mechanical ventilation (MV) is the recommended method for managing respiratory failure aimed at lung protection. This is the era of mechanical ventilation using a low tidal regimen (4-8ml/kg body weight predicted) and a limiting plateau pressure below 30 cmH2O. Permissive hypercapnia is generally better tolerated and may reduce local volutrauma than distention of normal alveoli because adequate oxygenation is key. A high PEEP level of more than 15 cmH2O is recommended.  .
Other ventilation techniques such as APRV may be considered based on physician preference and local experience. Virus (rather than HME) filters should be used and circuits should be maintained for as long as allowed as opposed to routine adjustments.  .
Patients are usually sedated to improve ventilatory control. While good practice for daily sedation holds, patients with COVID-19 may be placed under deep sedation until adequate levels of oxygen are achieved for risk that ventilatory inefficiency is reduced and respiration is controlled drive (necessary to achieve proper target tidal volumes). Generally, neuromuscular blockers are not used unless the patient has severely worsening hypoxia or hypercapnia and in situations where the patient’s respiration cannot be managed with sedation only leading to ventilation dysfunction and lung decruitment.    .
Movement techniques are not recommended for use in severe ARDS but may be considered at the time of weaning but for COVID-19 patients, manual techniques such as manual hyperinflation of fractures at the circuit are not recommended due to the increased risk of leakage spread.
In most patients with COVID-19, endotrachael tubes are used with only a few requiring a tracheostomy. It is important to always inflate the gloves and never deflate them during any treatment. If a tracheostomy is indicated a subglotic tracheotomy should be used so that above cuff vocalisation is possible can be achieved without the need to deflate the cuff to improve communication and swallowing.
Guideline Recommendation: Patients with hypoxia hypercapnia acidaemia worsening respiratory fatigue haemodynamic instability or those with altered mental status should be considered for early mechanical implantation if appropriate. The risk of aerosol exposure decreases once the patient is exposed a closed ventilation system is installed.  .
Positioning is an important aspect of management for the COVID-19 patient with routine mechanical ventilation recommended to prevent atelectasis to improve ventilation and prevent pressure ulcers. Positioning can be lateral (side lying) positioning but it can also be prone positioning which is well recognized for treating hypoxemic respiratory failure. Prone ventilation is ventilation with the patient lying on the floor in a prone position. Facilitated ventilation can and can improve lung mechanics and gas exchange and therefore improve oxygenation in most patients with ARDS the results are effective. Current reports suggest that soft ventilation is effective in improving hypoxia associated with COVID-19 and should be completed within clinical guidelines that include appropriate PPE for personnel and reduce the risk as adverse events any outcome e.g. accidental discharge and breaking the circuit.  For adult patients, a minimum of 16 hours per day is recommended in a weak posture.
See practical proning guidelines from the American Journal of Respiratory and Critical Care Medicine.
Closed inline suction catheters are recommended and necessary. Any disconnection between the patient and the ventilator should be avoided to limit lung tissue damage and aerosolisation. If necessary the endotracheal tube should be clamped and ventilation activated (to prevent aerosolisation).  . Regular absorption is not required but should be used as needed.
The use of nebulised agents (e.g. salbutamol saline) is not recommended for the treatment of unmedicated patients with COVID-19 because it increases the risk of aerosolization and transmission of infection to immediate health care providers in the snow is great. Metered inhalers are preferred where possible.  .
If a nebulizer is required and deemed necessary, contact local guidelines for guidelines to minimize aerosolization e.g. Pari sprint using an inline viral filter with proper airborne precautions and PPE.  .
Both cold and hot water supply systems are not recommended for cold water use and HME Filters should be used.  .
Weaning and Independence from Mechanical Ventilation
A standard weaning schedule should be followed. HFNO and/or NIV with properly fitted face masks with separate inspiratory and expiratory may be considered bridging therapy post-extubation but strict use of staff PPE should be provided.  .
Specific Physiotherapy Techniques
Physical activity is an important intervention that prevents and reduces the adverse effects of prolonged bed rest and mechanical ventilation during critical illness. The preparation provided by the physiotherapist is tailored to a patient’s needs and depends on the psychological state of the conscious state and physical fitness of the patient. It incorporates every type of active and passive therapy that promotes movement and includes movements. Much of the role of the ICU physical therapist will continue during the COVID-19 pandemic with the main change in practice being the routine use of full PPE when working in the ICU setting. Although there is no evidence that chest exercises are effective in the specific setting of COPD, a recent study suggests that several exercise techniques can be used established have been used safely in these patients to reduce and improve atelectasis consequences.
In the early stages of COVID-19 and respiratory distress, it is recommended that they be monitored while planning a treatment plan. Conventional techniques commonly used by respiratory physiotherapists may be contraindicated in the acute phase as they may further compromise upper respiratory function.
Prohibited interventions include:
- Diaphragmatic breathing
- Pursed lips breathing
- Pulmonary hygiene/rediffusive lung hygiene techniques (PEP Bottle EzPAP® cough machines etc.) .
- Incentive spirometry
- Manual gathering or stretching of the ribs
- Nasal washings
- Respiratory muscle training
- Exercise training
- Patient mobilization during clinical instability
Physical therapists should continue to actively seek and/or accept clients for mobilization and rehabilitation exercises. When exploring discussions with nursing staff, the patient (e.g. by telephone) or family is recommended before a decision is made to enter the patient’s isolation unit. For example, to try so that staff who come in contact with patients with COVID-19 exercises can search to determine the appropriate testing aids. The animals can then be tested by the nursing staff already in the isolated room with guidance from the on-site physiotherapist if necessary outside the room.
In situations where the patient is awake and in the weaning phase, consider the use of active cycle-breathing techniques along with lung volume recruitment procedures (eg, breath stacking) combined with positioning to ensure the patient is engaged in his/her care.
Anything related to ventilator disconnection, such as manual overinflation/bagging, should not be used.
Mechanical insufflation-exhaust (cough assist) devices
Usually, viral pneumonia does not require or require cough aids as they do not cause productive pleural effusions or problems with retained secretions or mucus plugging. If it is believed that such a device is indicated, the issue must be discussed with the medical team Given the physiological impact of inflation-deflation on persons who may already have acute lung injury, this may be counterproductive to the lung protection strategies used. This type of device may be considered in patients with comorbidities Technique is part of their normal airway clearance strategy, but benefits and risks need to be discussed with the team. This is not recommended and would not be considered a first-line intervention. Because it is AGP, full PPE is required in order to protect the machine and The patient should have a dual viral filtration system on the mask and at the exhalation port of the device.
Diagnostic lung ultrasound has been identified as a potential diagnostic tool in the assessment and management of COVID-19. It showed similar findings to radiology cases and was more accurate than bedside chest radiographs, with B-line multilobar findings and Diffuse pulmonary consolidation.  For many lesions reaching the pleura, it approaches the level of accuracy seen with computed tomography (CT).  Lung ultrasound can be used throughout treatment to track the evolution of the disease to monitor lung Lung recruitment maneuvers to provide feedback related to the success of the intervention and to assist in decisions related to weaning and release from mechanical ventilation.  The following provides practical guidance on the use of lung ultrasound during the COVID-19 pandemic Acute hospital setting:
- Physiotherapists using lung ultrasound during the COVID-19 pandemic – a practical guide to supporting acute hospital colleagues.
In general, the effectiveness of manual techniques is debated. Evidence for percussion is scant. There is some evidence that expiratory vibrations can mobilize secretions, and manual cough assistance can improve cough effectiveness and help clear mucocilia when needed. this It can be used as an aid and can be used safely in mechanically ventilated and extubated patients if adequate personal protective equipment is used.
Here we will look at the primary role of physiotherapists in the management of COVID-19 patients. There is strong evidence that early mobilization focused on restoring functional activity helps shorten hospital stay and minimize functional activity Therefore, the sooner patients begin to mobilize, the sooner they can leave the ICU and potentially have better long-term outcomes. Management at this stage should use a multidisciplinary approach, including measures to prevent avoidable physical and non-physical disorders Adequate support Nutrition (especially after the effects of ventilation in the prone position) and an individualized structured rehabilitation program. This phase should follow the typical approach of rehabilitation and exercise in the intensive care unit, followed by transfer to the ward for rehabilitation.
- Passive-active assisted active or resistance joint range-of-motion exercises to maintain or improve joint integrity and range of motion and muscle strength;
- Mobilization and rehabilitation (eg, under-bed mobility sitting sitting balance sitting standing walking incline table standing lifts upper or lower body ergometry exercise program). 
Prevention of Complications
Physiotherapists can play a key role in preventing a range of complications, including contractures or pressure areas/ulcers secondary to infection in ventilator-associated pneumonia.
Reduced Days of Mechanical Ventilation
- Use offline scenarios or create a personal offline plan
- Assess spontaneous breathing capacity and readiness for extubation, including participation in daily sedation maintenance and spontaneous breathing trials .
Reduce the incidence of ventilator-associated pneumonia
Reducing this risk is important because any secondary infection increases the number of days patients are intubated and ventilated, thereby increasing their overall time in the ICU, occupying beds longer than they should, and reducing hospital flow.
- Hold the patient in a semi-seated position (30 – 45 degrees)
- Regular 2-hour turning to minimize the risk of atelectasis and consolidation
- Ventilate in prone position when indicated and appropriate. In China and Italy, multiple patients are often prone in the ICU
- Use a closed suction system; periodically drain and discard condensate
- Once the patient is ventilated, use a new ventilation circuit for each patient, replacing the circuit only if it is damaged or dirty, not routinely
- Replace the HME when it is dirty or fails every 5-7 days
- Assists in extubation phase and weaning of invasive ventilation possible.
Reduce the Incidence of Pressure Ulcers
- Turn the patient every 2 hours 
- Pressure Care Positioning / Pressure Area Protection
Reduced incidence of intensive care-associated myopathy
- Encourage early mobilization. Actively mobilize the patient as soon as the patient’s condition allows and it is safe to do so. 
Preventing Osteonecrosis of Femoral Head
There is a high risk of steroid-induced osteoporosis in the femoral head (ONFH). Research suggests follow-up of MRI after hospital discharge for the diagnosis of ONFH and the initial prescription of chemotherapy in patients with steroid-induced ONFH.
Indications for Physiotherapy Referral
The following guidelines outline the appropriate indications for physical therapy in a suspected or confirmed case of COVID-19.  .
COVID-19 Patient Presentation(Confirmed or Suspected)Physiotherapy Referral ?Mild symptoms without major respiratory distress e.g. fevers dry cough no chest x-ray changes.Exercise intervention is not indicated for airway clearance or lung specimenNo physiotherapy contact with patient.Pneumonia presenting with features:Low-level oxygen requirement (e.g. oxygen flow ≤5L/min for SpO2 ≥ 90%).Non-productive cough;Patient coughing and able to clear secretions.Intravenous is not indicated treatment is not valid for excluded airway or sputum samples.No physiotherapy contact with patient.Mild symptoms and/or pneumonia ANDco-existing Respiratory or Neuromuscular Comorbidity e.g. Cystic Fibrosis vascular disease spinal cord injury bronchiectasis COPD ANDcurrent or anticipated problems with secretion clearancePhysiotherapy referral for airway clearance.Staff use airborne precautions.Where possible patients should wear a surgical mask during any exercise.Mild symptoms and/or pneumonia ANDevidence of exudative consolidation with difficulty clearing or inability to clear secretions independently e.g. weak dysfunction and cold sounding cough tactile fremitus on chest wall moist/wet sounding voice audible transmitted sounds.Physiotherapy referral for airway clearance.Staff use airway precautions.Where possible patients should wear a surgical mask during exercise- . any tears.Severe symptoms suggestive of pneumonia / lower respiratory disease e.g. increased oxygen requirement fever dyspnea Frequent severe or productive cough Chest X-ray / CT / Lung Ultrasound changes consistent with Consolidation.Consider physiotherapy referral for airway clearance.Physiotherapy may be indicated. mu-teacher especially if there is a mild productive cough and/or evidence of pneumonia on imaging and/or retention.Staff use airborne precautions.Where possible, patients should wear them surgical mask during any exercise.Early optimization of care and ICU intervention is recommended.
Mobilisation, Exercise & Rehabilitation
COVID-19 Patient Presentation(Confirmed or Suspected)Physiotherapy Referral ?Any patient at high risk of progression or with evidence of significant functional limitation se.g. frail patients or with multiple comorbidities affecting their independence.g. mobilization exercises and preparation in ICU patients with significant functional decline and/or (at risk for) weakness acquired from ICUNmedical referral.Use drip precautions.Use airborne precautions if close contact is necessary or possible AGPs.If not ventilated patients should wear a surgical mask at all times physical therapy whenever possible.
On-Call Physiotherapy Considerations
Very low-risk patients with confirmed or suspected COVID-19 should NOT be routinely referred to the gym. There are currently no reports of COVID-19 patients having sufficient evacuation burden to require intensive respiratory physiotherapy/airway management. Exercising will likely do that there will be little benefit in the acute stages and the greatest use of physiotherapy resources will be to facilitate treatment and discharge of patients who are not infected and to train and support our colleagues to deal with the less vulnerable. Physiotherapists will play a role in. Rehabilitation of COVID-19 patients who have not returned to baseline activities when they are no longer significantly ill.  .
WHO recommends limiting the number of Health Professionals who have contact with a suspected and confirmed case of COVID-19 and limiting the number of people in the room to the minimum required for the patient look at his animals.  .
Physiotherapy referrals should be offered to patients who meet the On-Call Physiotherapy Criteria which typically include;  .
Additional Resources: Patients likely to benefit from on-call therapeutic exercise:
- Oxygen therapy up to FiO2 >60% .
- Evidence of persistent pulmonary circulation with difficulty in pulmonary aspiration
- Ineffective cough/airway clearance
Exclusion Criteria Patient: Unlikely to benefit from on-call exercises:
- Viral Pneumonia
- Cardiovascular Instability
- Uncooperative Patient
- Unstable Intracranial Pressure
- Uncontrolled Bronchospasm
- Pulmonary Embolism
- Non-acute COPD
Unqualified criteria for an emergency call:
- Patients diagnosed with COVID-19 with a nonproductive dry cough
- Patients diagnosed with COVID-19 with severe hypoxaemia requiring intubation
- Patients with regular breathing e.g. postoperatively unless the above criteria are met
- Patients who only need breastfeeding – If the patient needs ONLY breastfeeding, consider it as a nursing option. Motivate any patient who is well enough as this is the most natural way to promote optimal lung function. Such a patient is unlikely to require emergency physiotherapy
- The Italian Thoracic Society (AIPO – ITS) and Italian Respirarory Society (SIP/IRS). Managing the Respiratory Care of Patients with COVID-19. Version – March 08, 2020 [Available from: https://www.acprc.org.uk/Data/Resource_Downloads/ManagingtheRespiratorycareofpatientswithCOVID-19(1).pdf?date=18/03/2020%2020:14:01]
- Yuksel A, Karadogan D, Gurkan CG, Akyil FT, Toreyin ZN, Marim F, Arikan H, Eyuboglu TS, Emiralioglu N, Serifoglu I, Develi E. Unclear Issues Regarding COVID-19. The Eurasian Journal of Medicine. 2020 Jun;52(2):191.
- World Health Organisation. Clinical Management of Severe Acute Respiratory Infection (SARI) when COVID-19 Disease is Suspected – Interim Guidance. WHO, 13 March 2020
- Rachael Moses, Consultant Respiratory Physiotherapist. COVID-19 Respiratory Physiotherapy On Call Information and Guidance.Lancashire Teaching Hospitals. Version 2 Dated 14th March 2020
- Rachael Moses, Consultant Respiratory Physiotherapist. COVID 19 and Respiratory Physiotherapy Referral Guideline. Lancashire Teaching Hospitals. Version 1 Dated 17th March 2020
- Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, Hodgson CL, Jones AYM, Kho ME, Moses R, Ntoumenopoulos G, Parry SM, Patman S, van der Lee L (2020): Physiotherapy management for COVID-19 in the acute hospital setting. Recommendations to guide clinical practice. Version 1.0, published 23 March 2020. Journal of Physiotherapy.
- Review . 2020 Jun 22;75:e2017. doi: 10.6061/clinics/2020/e2017. eCollection 2020. Physiotherapy Care of Patients with Coronavirus Disease 2019 (COVID-19) – A Brazilian Experience. Clinics (Sao Paulo)
- Lazzeri M, Lanza A, Bellini R, Bellofiore A, Cecchetto S, Colombo A et al. Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Monaldi Archives for Chest Disease. 2020;90(1).
- Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, Deshpande R, Zhang L, Meng J, Tong C, Liu H. Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan’s Experience. Anesthesiology. 2020 Mar 19.
- Metro North, Interim infection prevention and control guidelines for the management of COVID-19 in healthcare settings, 2020: https://www.health.qld.gov.au/__data/assets/pdf_file/0038/939656/qh-covid-19-Infection- control-guidelines.pdf.
- Alhazzani, W., M. Moller, Y. Arabi, M. Loeb, M. Gong, E. Fan, S. Oczkowski, M. Levy, L. Derde, A. Dzierba, B. Du, M. Aboodi, H. Wunsch, M. Cecconi, Y. Koh, D. Chertow, K. Maitland, F. Alshamsi, E. Belley-Cote, M. Greco, M. Laundy, J. Morgan, J. Kesecioglu, A. McGeer, L. Mermel, M. Mammen, P. Alexander, A. Arrington, J. Centofanti, G. Citerio, B. Baw, Z. Memish, N. Hammond, F. Hayden, L. Evans, and A. Rhodes, Surviving sepsis campaign: Guidelines of the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Critical Care Medicine, 2020. EPub Ahead of Print.
- Associazione Riabiliatori Dell’Insufficienza Respiratoria. Indicazioni Per La Fisioterapia Respiratoria In Pazienti Con Infezione Da COVID-19. Updated 16/03/2020
- Australian and New Zealand Intensive Care Society. ANZICS COVID-19 Guidelines. Melbourne: ANZICS 2020
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- David J Brewster, Nicholas C Chrimes, Thy BT Do, Kirstin Fraser, Chris J Groombridge, Andy Higgs, Matthew J Humar, Timothy J Leeuwenburg, Steven McGloughlin, Fiona G Newman, Chris P Nickson, Adam Rehak, David Vokes and Jonathan J Gatward. Consensus Statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 Adult Patient Group. Medical Journal of Australia. Updated 17 March 2020
- Adam Rochester, NIV Lead for Respiratory Support Services. Standard Operating Protocol for the setup and Use of Non-Invasive Ventilation or HiFlow Oxygen (AirVo) for Patients with Suspected or Confirmed Coronavirus. Royal Brompton and Harefield NHS Trust. Version 1.7 – March 17th, 2020
- Messerole E, Peine P, Wittkopp S, Marini JJ, Albert RK. The pragmatics of prone positioning. American journal of respiratory and critical care medicine. 2002 May 15;165(10):1359-63.
- Jonathan Downham. Proning the ARDS Patient- Why do we do it?. Available from: http://www.youtube.com/watch?v=FS4t5w1eCYw[last accessed 17/03/2020]
- Critical Care & Major Trauma Network. Prone Position 1. Available from: http://www.youtube.com/watch?v=bE4mmGdjA5I[last accessed 17/03/2020]
- Rachael Moses. Physiotherapy Interventions for COVID-19.March 2020. https://vimeo.com/398333258 Accessed 18 March 2020
- D Battaglini, C Robba, S Caiffa, L Ball, I Brunetti.Chest physiotherapy: An important adjuvant in critically ill mechanically ventilated patients with COVID-19.Respir Physiol Neurobiol2020 Aug 17
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- Simon Hayward and Dr Chris Duncan. Physiotherapists use of Lung Ultrasound during the COVID-19 Pandemic – A Practical Guideline on supporting Acute Hospital Colleagues. 2020
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