Post Covid-19 Pulmonary Rehabilitation

New Vision University
Post- Covid
Pulmonary
Rehabilitation
This paper provides a collective data from prior studies to bring a pulmonary
Rehabilitation perspective and intervention to the multidisciplinary
treatment of COVID-19.
Zuber Irfan Chauhan
7/30/2021
STUDENT NAME: ZUBER IRFAN CHAUHAN
"COVID-19 POST PULMONARY
REHABILITATION"
PROFESSOR NAME: DAVID KERESELIDZE.
DATE:30/JULY/2021.

Post- COVID Pulmonary Rehabilitation
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Table of Contents
1. Abstract

1.1 Background

1.2 Aim

1.3 Problem Description

1.4 Preliminary Thesis

1.5 Materials used

1.6 Study Methodology

1.7 Result

2. Introduction

Current knowledge

2.1 What is Pulmonary Rehabilitation?

2.2 Triad of Practice: Structure, Adherence & Maintenance

3. Considerations and Contraindications

4. General Intervention with Specific Exercise Recommendations for Inpatient

4.1 For Mild Disease
4.2 For Moderate Disease
4.3 For Severe Disease
5. Acute Inpatient Management

6. Outpatient Management Criteria

7. Discussion: Post- Acute Rehabilitation

8. Conclusion

9. References

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1. Abstract
1.1 Background
The global pandemic caused by SARS-CoV-2 started in Wuhan, China, which has since spread around
the world affecting millions of people. After the COVID-19 outbreak, a growing number of patients
worldwide who have survived the disease are still suffering from its sequelae. Despite testing
clinically negative, patients have been suffering from COVID-19 complications such as ARDS,
pneumonia, lung fibrosis, and pulmonary embolism. Hence, legitimizing the need for pulmonary
rehabilitation as a post- COVID management.
This paper provides a collective data from prior studies to bring a pulmonary Rehabilitation
perspective and intervention to the multidisciplinary treatment of COVID-19. The aim of pulmonary
rehabilitation in COVID-19 patients is to enhance and preserve function ad improve quality of life by
minimizing disability and reducing complications and anxiety. Pulmonary rehabilitation should be
considered during acute management of COVID-19 when possible and safe and should include
nutrition, airway, posture, clearing technique, oxygen supplementation, breathing exercises,
stretching, manual therapy and physical activity. Given the likelihood of long- term disability,
outpatient post- hospitalization pulmonary rehabilitation could also be considered altogether via
tele-medicine& tele-rehabilitation. Pulmonary Rehabilitation is a core aspect of medical
rehabilitation and the basic tools and interventions of pulmonary rehabilitation are extremely
important traditional interventions that have a particular important new role within the treatment
of COVID-19.

1.2 Aim
The aim of this paper is to review the published data and provide preliminary analysis, composed of
post Covid-19 pulmonary rehabilitation and its benefits
1.3 Problem Description

Pulmonary rehabilitation provides medical teams with unique tools to combat diseases for which
there is currently no clear cure other than supportive care. These recommendations are based on
research and knowledge of COVID19 patients, pulmonary rehabilitation patients without COVID19,
and previous SARS/MERS epidemics. The flexibility and integration of heterogeneous and
multidisciplinary data and knowledge among majors is very important to face the new and unique
rehabilitation challenges brought by this epidemic.

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1.4 Preliminary Thesis

This review serves as a guide to understand the need for the continuous management of functional
and co-morbid rehabilitation issues related to COVID19. The definition of pulmonary rehabilitation,
as adapted from the American Thoracic Society/European Respiratory Society, is a comprehensive
intervention based on a comprehensive evaluation of the patient, followed by treatment tailored to
the patient, including but not limited to exercise training, education and behavior. Changes aimed at
improving the physical condition of patients with respiratory diseases. And with the same ideology,
pulmonary rehabilitation should be tailored for each patient.

1.5 Materials used

This paper is composed of data derived from peer-reviewed published papers and pre-print
manuscripts on post COVID19 pulmonary rehabilitation and its benefits.

1.6 Study Methodology

we utilized distinctive clinical sites joined the content words for "SARS-CoV-2", and
"Coronavirus", pulmonary recovery and their rehabilitation". References of audit articles were
additionally looked to fuse quickly advancing information regarding the matter. I utilize a quest
for Covid affiliation clinical articles accessible in (ScieneDirect.com) despite the fact that there
isn't a lot of data yet, also (PubMed, NCBI). I pick cautiously the specific data I need to
remember for the exploration. Articles from Cochrane library, Taylor & Francis Journal, BMJ,
Chinese Journal, European Journal of Respiratory Disease were also used.
Keywords: Pulmonary Rehabilitation, Inpatient, Outpatient, Rehabilitation, COVID-19.

1.7 Result

The retrospective review analyzes the 2019 novel corona virus outbreak (COVID-19) to assist
provide direction for additional studies which will facilitate the way we perceive COVID-19
rehabilitation and its requirement, with an emphasis on Rehabilitation medicine.

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2. Introduction
Pulmonary rehabilitation is a complete intervention that begins with a thorough assessment of the
patient, followed by individualized treatment that includes exercise training, education, and lifestyle
changes. Its goal, as described by the American Thoracic Society and the European Respiratory
Society in 2013, is to "improve the physical and psychological condition of patients with chronic
respiratory disorders, as well as to promote long-term adherence to health-improving
activities."(1)Pulmonary Rehabilitation is suitable for individuals who have recently deteriorated.
The purpose is to optimize their respiratory function, thereby optimizing their QoL and help them
participate in their daily lives. Compared with conventional care, pulmonary rehabilitation has been
shown to significantly improve the QoL and exercise capacity of patients with COPD. (2)
In the view of the COVID pandemic, there has been a shortage in staff, medical equipment e.g., PPE
and the basic medical amenities everyone should receive and the high risk of in-hospital
transmission, rehabilitation has been carried out through telemedicine with minimal exposure. Self-
supervised rehabilitation is initiated through telemedicine. Previous data indicated that o
telemedicine programs and home pulmonary rehabilitation have shown that the results are the same
when compared to center-based programs. If direct supervision is required, full PPE, including
gloves, masks, and gowns, should be used for all-person interaction. In addition, if there is a risk of
infection with aerosol droplets, it is also recommended to wear a facemask and/or goggles. The
current non-invasive ventilation technology has a high risk of SARS CoV2.10,11virus atomization.
The rate of in-hospital transmission among medical staff is extremely high (approximately 35% of
contact medical staff will develop the disease) and the disease has a more serious clinical course
among medical staff.

Current knowledge

COVID-19 is caused by a virus, the extreme acute respiratory syndrome coronavirus 2.
(SARS-CoV-2). The global pandemic began in Wuhan, China, in December 2019 and has since became
global pandemic, with COVID-19 infection cases continuing to increase. As till of July 30, 2021, In
Georgia there are 416,388 COVID-19 patients, 5793 deaths, 381,246 recovered, and 197,703,056
COVID-19 infection cases worldwide. [34]

Discussion:

2.1 What is Pulmonary Rehabilitation?

Pulmonary Rehabilitation plans vary, depending on patient presentation and available resources, but
usually include: -
• Multidisciplinary advisory
• Exercise
• Diet counseling
• Disease education
1
Spruit et al., “An Official American Thoracic Society/European Respiratory Society Statement.”
2
Lee et al., “The Impact of Pulmonary Rehabilitation on Chronic Pain in People with COPD.”

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• Psychological intervention
• Behavioral intervention
e.g., A group of COPD patients, take classes together in a gym or community room, where they
participate in supervised exercises with a physical therapist, and then conduct educational
sessions with nurses or educators on topics such as bronchodilator techniques, nutrition, and
COPD management. (3)

2.2 Triad of Practice: Structure, Adherence & Maintenance

(i) Structure

The duration of the pulmonary rehabilitation plan can vary, from 68 weeks to 1 year. BTS guidelines
recommend 6-12 weeks, with 2 supervised exercises per week (the third unsupervised) and at least
12 supervised exercises. It can be hospital-based, community-based, or both. Previous data has
shown that compared to community-based pulmonary rehabilitation, inpatient-based pulmonary
rehabilitation has better outcomes, as measured by chronic respiratory questionnaires measuring
dyspnea, fatigue, emotional function, and proficiency. The guide also recommends providing people
with some kind of exercise plan after completing the pulmonary rehabilitation.

(ii) Adherence
NICE guidelines recommend an emphasis on adherence to Pulmonary Rehabilitation to
individuals post COVID so that a desired quality of life and improved respiratory function can be
achieved. Some specific ways to improve the state of adherence under optimizing access to
pulmonary rehabilitation are as follows: -
• Suitable time for classes
• Clear access to facilities
• Timely referrals to pulmonary rehabilitation centers

(iii) Maintenance
Since, the guidelines recommend exercise post COVID pulmonary rehabilitation to sustain the
desired respiratory function, exercise tolerance and improved quality of life, its recommended
that an8-week outpatient pulmonary rehabilitation to be maintained at a 2 year follow up plan
for patients with moderate to severe obstructive pulmonary diseases. Also, better scores for a
6min walk distance and BMI, airflow obstruction, BORG score for dyspnea and exercise tolerance.
Adherence to the maintenance programme should be based on the exercise and cycle ergometers
at home and primary health care centers with a supervised session every other week. (4)
3. *Considerations and Contraindications
3
McCarthy et al., “Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease.”
4
“Pulmonary Rehabilitation.”

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NICE guidelines for people who should not undergo Pulmonary Rehabilitation are:-
(i) Patients who are unable to walk
(ii) Patients who suffer from unstable angina
(iii) Patients with recent history of MI
BTS guideline recommends those with MRC: - A dyspnea score of 3-5, for patients who are
functionally limited due to breathlessness should not be referred for pulmonary
rehabilitation.
Specific Consideration should be given to patients: -
(i) Unstable Cardiac disorders
(ii) Physical Disability
(iii) Difficulty in following instructions due to cognitive or psychiatric
impairments
(iv) Presence of a support person to enable and encourage adherence
(5)
4. General Intervention with Specific Exercise Recommendations for Inpatient
management: -
Rehabilitation plays an important role in measuring beneficial outcomes in COVID patients. Since,
there was not enough time to establish a COVID specific rehabilitation service, existing models
of guideline-based exercise have been prescribed and supervised by physiotherapists, often
including the Frequency, Intensity, Time and Type (FITT) methodology. Practically, both
functional and maximal exercise has shown significant improvement post- pulmonary
rehabilitation.
Types of rehabilitation:
(i) Pulmonary Rehabilitation focuses on positioning, and necessary exercises with the
use of bronchodilators.
(ii) Functional training: used for patients with end stage diseases or extreme weakness
post COVID. Major Focus: -
5
Bolton et al., “British Thoracic Society Guideline on Pulmonary Rehabilitation in Adults.”

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(6)
Specific Exercise Recommendations-

4.1 For Mild Lung Disease:

4.2 For Moderate Lung Disease:
Symptom: Patient experience shortness of breath, performing daily activities. * Pulmonary
Rehabilitation has good prognosis for those patients that have had acute pneumonia
post- surgery.

6
Lee et al., “The Impact of Pulmonary Rehabilitation on Chronic Pain in People with COPD.”
Alternating performance
task
•Slow pace
•Minimize body
movements
•Plan the task with
enough break and rest
Methods to relieve symptoms
•maintaineance of non- interruptive
breathing pattern
•Avoid talking in between tasks
•For COPD patients:- pace during lifting
tasks & lean forward (Increases IAP which
allows the accessory muscles to iniitiate
inspiration)
•For RLD patients:- rapid shallow breaths
are easier (prevents elastic resistance)
•Reduce anxiety related to dyspnea
secondary to biofeedback of non-
respiratory muscles
Enviornmental Adaptation for ease
•Table to slide heavy objects
•Chairs near stairs and in washroom
•Use of adaptive equipment and assistive
technology
•Use of good ventilation
Specific Exercise Recommendations (variable management for)
Mild Lung Disease Moderate Lung Disease Severe Lung Disease
Criteria: -
• Symptoms with effort e.g. cough, sputum
• Spirometry: FEV1 < 70-80%, VC prediction
• ABG: normal or hypoxemia
• Individual Exercise prescribed, patient does not require rehab, focused testing &
training
Criteria: -
• VC &FEV1 55-70% (3-4 MET)
• ET: Progressive, start at 1.5 MET, and increment of 0.5 MET at each stage. Monitor: ECG, BP,
HR or perform 12min walk test
• Exercise potential: - HR monitoring with Borg Scale: 2-3 dyspnea
- Frequency: 5-7times/ week
- For symptomatic patient: Use O2

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4.3 For Severe Lung Disease

Criteria: -
• VC & FEV1 <50%
• SoB on daily activities
• ECG: R ventricular dysfunction
• Exercise potential: - Steady endurance of 2-3 MET
- prescribe interval training, in short bouts (frequent rests)
- Frequency: 5 times/week
- Monitor SpO2 with every drop in 3% and start O2 therapy if
SpO2<88%
- Use BORG scale for chest pain and shortness of breath

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5. Acute Inpatient Management
General Considerations: -
• Early pulmonary rehabilitation and ICU activities may require careful consideration.
• SARSCoV2 will be atomized during surgery and in the ICU setting.
• Should not recommend additional rehabilitation staff for early activities, full-time ICU staff
may consider this.
• During the weaning test, inspiratory muscle training can be performed by a qualified
respiratory therapist as after
prolonged mechanical ventilation,
respiratory muscle weakness caused
by diaphragmatic proteolysis may
occur.
• Safety regulations should be
observed when initiating pulmonary
rehabilitation.
• Intensity of the initial exercise
should be carefully controlled and
change in level of consciousness.
(7)(8)(9)
Physical exercise is a central
component of pulmonary
rehabilitation and can start from
bedridden activities for patients
with extremely weak bodies to
patients who can move. The goal of rehabilitation intervention should be SpO2>90%, while
supplemental oxygen is titrated to maintain target saturation. (10) If SpO2 is less than the
target value or the dyspnea score on the Borg scales>3, activity should be suspended and
breathing technique should be considered, such as resuming labial breathing for exercise
intervention after SpO2 reaches target. (11)
Lip-tightening breathing is carried out through the nasal cavity during training and then exhales
against pursed lips to reduce airway collapse, reduce respiratory rate and dynamic hyperinflation,
with the goal of increasing overall stamina. Supplemental oxygen during physical training has also
7
Lin and Li, “[Interpretation of ‘Guidelines for the Diagnosis and Treatment of Novel Coronavirus (2019-nCoV)
Infection by the National Health Commission (Trial Version 5)’].”
8
Jones et al., “Pulmonary Rehabilitation in Patients with an Acute Exacerbation of Chronic Obstructive Pulmonary
Disease.”
9
Yang et al., “[Pulmonary rehabilitation guidelines in the principle of 4S for patients infected with 2019 novel
coronavirus (2019-nCoV)].”
10
Liu et al., “Effects of Comprehensive Pulmonary Rehabilitation Therapy on Pulmonary Functions and Blood Gas
Indexes of Patients with Severe Pneumonia.”
11
Rodriguez-Morales et al., “Clinical, Laboratory and Imaging Features of COVID-19.”
Exclusion criteria: - Body temperature> 38.0 ℃
- Time from initial
diagnosis or onset of
symptoms ≤ 3 days
- Difficulty of breathingfor
the first time ≤ 3 days
- Disease progression
>50% within 24 to 48 hours
- SpO2 ≤ 90%
- BP 180/90 mmHg
- RR>40 breaths/minute
- HR 120 bpm 9.
- New onset arrhythmia
and MI

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been used successfully to help reduce the load on the respiratory muscles. (12)If SpO must be
interrupted for pulmonary rehabilitation or respiratory exercise, level 2 patients cannot recover and
cannot maintain Borg scale dyspnea score <4 points under conditions of rest and supplemental
oxygen. Rehabilitation exercises should also be interrupted for chest pain, palpation, and dizziness.
The Borg scale is a proven and easy-to-use tool that allows patients to self-monitor their breathing
effort. There is a close correlation between the size of the breathing effort and the intensity of the
dyspnea. The active circulation of breathing technique uses a combination of circulatory airway
clearance technique to ventilate the obstructed lung segment. (13)(14)
Airway clearances a common technique via active cycle of breathing, uses a combination of
techniques to mobilize the secretions. In the peripheral airway, it is followed by normal breathing to
collect the secretions of the middle airway, and deep breathing and coughing to discharge the
secretions. (15) The application of airway clearance technology can significantly reduce the need for
ventilator support, mechanical ventilation and hospital stays. Airway clearance technology aims to
help clear the airway by moving cephalic mucus from the periphery to the upper respiratory tract,
promoting lung capacitance, and clearing mucus through coughing or sputum production. Physical
exercise is the cornerstone of pulmonary rehabilitation and has been shown to help clear mucus. (16)
Lung volume recruitment techniques include air stacking and glottis holding. Air accumulation
involves conveying air through Ambu bags. (17) Glossopharyngeal breathing is a positive pressure
breathing technique that can be used to support defective respiratory muscles and increase tidal
volume. It involves continuously inhaling large amounts of air and pushing it into the lungs. (18) The
3-secondbreath-hold is a way to ventilate the blocked lung segment. The3-second pause allows
Pendelluft to flow, and air moves from the unobstructed area to the blocked area in the lungs. (19)
Forced exhalation can be used, such as sneezing to push secretions. The cough is performed under
the open glottis, where the dynamic compression of the isobaric points of the airway increases the
linear velocity of the expiratory air flow and pushes the secretions. The initiation of forced exhalation
with low lung volumes will displace the isobaric points toward the periphery and the small airways.
Forced exhalation with a high lung volume will move the isobaric point into the large central airway.
Posture plays an important role in respiratory function, which may encourage patients to perform
upright head and neck postures during respiratory therapy whenever possible. (20)If available, an
oscillation frequency of less than 17 Hz can be used to apply external vibration to improve
mucociliary clearance.
12
Wax and Christian, “Practical Recommendations for Critical Care and Anesthesiology Teams Caring for Novel
Coronavirus (2019-NCoV) Patients.”
13
Bissett, Gosselink, and van Haren, “Respiratory Muscle Rehabilitation in Patients with Prolonged Mechanical
Ventilation.”
14
Chinese Association of Rehabilitation Medicine, Respiratory Rehabilitation Committee of Chinese Association of
Rehabilitation Medicine, and Cardiopulmonary Rehabilitation Group of Chinese Society of Physical Medicine and
Rehabilitation, “[Recommendations for respiratory rehabilitation of coronavirus disease 2019 in adult].”
15
Lim, Ng, and Tay, “Impact of a Viral Respiratory Epidemic on the Practice of Medicine and Rehabilitation.”
16
Mayer et al., “Effects of Acute Use of Pursed-Lips Breathing during Exercise in Patients with COPD.”
17
Kang and Bach, “Maximum Insufflation Capacity.”
18
Maltais, “Glossopharyngeal Breathing.”
19
Crawford et al., “Effect of Airway Closure on Ventilation Distribution.”
20
McIlwaine et al., “PersonalisingAirway Clearance in Chronic Lung Disease.”

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Positioning is efficient, simple and easy to implement. Given the pathophysiology of COVID19 and
other techniques such as postural drainage, localization may be preferable. A V / Q mismatch is
observed. Sitting and standing are the preferred postures for patients who are not critically ill to
maximize lung function, including FVC, increase lung compliance and elastic retraction, move
mediastinal structures and provide mechanical benefits during forced exhalation. Targeted
positioning can be used to improve ventilation, perfusion, oxygenation, and mobilization of
secretions in specific areas of lung consolidation through gravity. Perfusion of the dependent
pulmonary segments is greater in all positions. Priority Ventilation Changes Based on Location. When
performing breathing exercises, two minutes in each position may be sufficient to ventilate / perfuse
the target lung segment.(21)(22)
Anecdotal evidence from the hospital suggests that the prone position is beneficial during the acute
care of patients with COVID19. If possible, we recommend time in all positions, including lying on
your side, upright, supine. The target position can be determined by the consolidation position seen
on the image or found during inspection.
In the upright position, ventilation occurs preferentially in the middle and lower lobe, with the most
perfusion in the lower lobe. The patient can lie supine in a resting position. Assist DLCO occasionally.
The DLCO of healthy subjects increased in the supine position. The supine position also preferentially
ventilates the upper lobes During the administration of inhaled drugs, the lateral position may be a
good position, with a better13% deposition on the drooping upper lobe.
Prone position for 2 minutes can help back lung ventilation by reducing the compression of the heart
on the lungs in the semi-prone position. Due to the ventral displacement of the heart and the increase
in expiratory trans- pulmonary pressure and expiratory reserve, lung expansion from the dorsal to
ventral side is more uniform and oxygenation is improved. PaO2/ FiO2 are used in mechanically
ventilated patients and reduces cardiovascular complications.
The patient can be encouraged to perform routine stretches3 times a day. Stretching has been shown
to increase compliance by upto 50 ml. Stretching exercises should include neck, upper chest,
pectoralis major, lateral chest extension and flexion and extension to mobilize the small joints. It has
been shown that the dorsal chest wall has poor compatibility with ARDS patients.
Osteopathic therapy may help if appropriate, and should address autonomy, lymphatic drainage, and
chest mobility. Patients can also participate in modified segmented breathing. The patient puts
pressure on his chest cavity to resist respiratory deviation in a certain area of the chest cavity and
promote the expansion of adjacent areas of the chest cavity that may reduce ventilation and mobility.
(23)
Education and adequate nutrition are particularly important in COVID19, because studies in Western
countries have shown that obesity is an important risk factor for disease severity, and at least 1/3 of
ICU patients have BMI overweight. In obesity, lung function is also affected.
The same strategy applies to patients recovering from ICU care. In these patients, taking into account
the adaptation that occurs in the ICU, attention to breathing exercises and bed activities may be the
initial intervention. Flexibility exercises on the bed include ankle pump, sliding leg flexion/extension,
head arm extension, sitting by the bed and standing by the bed. In addition, patients with prolonged
21
Manning et al., “Effects of Side Lying on Lung Function in Older Individuals.”
22
Gattinoni et al., “COVID-19 Does Not Lead to a ‘Typical’ Acute Respiratory Distress Syndrome.”
23
Harmony, “Segmental Breathing.”

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mechanical ventilation may suspect respiratory muscle weakness caused by diaphragmatic
proteolysis. These patients can start by
stimulating the spirometer for
inhalation and exhalation muscle
training, and then gradually use the
muscle training equipment. (24)(25)

6. Outpatient Management
Criteria

Mild disease is associated without
imaging manifestations of pneumonia.
Rehabilitation of mild illnesses can be
managed in outpatient clinics using
telemedicine. (26)
In mild illness, pulmonary rehabilitation
can be considered, including education,
techniques to clear the airways, physical
exercises, breathing exercises, activity
guidance and anxiety management. In
particular, body fluids should be properly managed and handled during home pulmonary
rehabilitation. Patients should be instructed to cover their mouth and nose with a tissue when
coughing or sneezing, and to remove the tissue immediately. Expectorant hygiene should be
strengthened in airtight containers to avoid atomization of sputum. (27)After contact with respiratory
secretions and contaminated objects/materials, hand washing should be emphasized. Patients
should be educated about the clinical process of COVID19, and individualized education should be
conducted according to the patient’s comorbidities. Patients, including asymptomatic relatives, may
be advised to wear masks; SarsCoV2 has a high transmission rate and the asymptomatic prodromal
period is 214 days, with an average of 37 days. Mathematical models show that the use of masks with
50% compliance during a virus outbreak can slow the spread, increasing the prevalence rate by 50 °
and the cumulative incidence rate by 20 °. At this stage, breathing exercises can be used. Diaphragm
breathing involves instructing the patient to primarily contact the diaphragm while minimizing the
activity of the auxiliary muscles. Nasal inhalation should be stimulated to promote recruitment of the
diaphragm and improve humidification. (28)The abdominal muscles should be actively contracted at
the end of exhalation to increase abdominal pressure Yoga, especially Viniyoga, during inhalation or
24
Katz et al., “The Effect of Body Position on Pulmonary Function.”
25
Bailey, Farrow, and Lau, “V/Q SPECT-Normal Values for Lobar Function and Comparison With CT Volumes.”
26
Rodriguez-Morales et al., “Clinical, Laboratory and Imaging Features of COVID-19.”
27
Guo et al., “The Origin, Transmission and Clinical Therapies on Coronavirus Disease 2019 (COVID-19) Outbreak -
an Update on the Status.”
28
Elad, Wolf, and Keck, “Air-Conditioning in the Human Nasal Cavity.”

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exhalation phase Coordinate breathing with arm lift or body posture. Pranayama, Tai Chi, (29) and
singing also use timed breathing techniques.

7. Post- Acute Rehabilitation
The suitability of acute inpatient rehabilitation should be individualized according to the patient and
institution, and should be carried out in accordance with the ongoing Rehabilitation guidelines. (30)
Patient selection criteria should be developed in the coming months for the pandemic. For patients
with residual functional defects due to prolonged hospitalization, occupational and physical therapy
may also be considered. The use of chest radiographs and PFT may be considered for routine
monitoring in an outpatient setting, especially within 6 months of infection and in critically ill
patients. Pulmonary fibrosis can occur in COVID19.
In the 2003 SARS-CoV-2, 45% of patients (diagnosed by X-ray and CT scan) had pulmonary fibrosis
1 month after infection, 36% at 36 months after infection, 46 and 28% 1 year after the infection. The
improvement of lung function in patients with SARS-CoV-2 stabilized at 6 months, especially with
persistent disability in DLCO 2 years after infection. (31)(32) Pulmonary rehabilitation after the acute
phase can help improve exercise capacity. In patients with interstitial lung disease, stress
desaturation is a key feature and is often more severe than other lung diseases. Interstitial lung
disease is associated with discomfort / fatigue during submaximal exercise with reduced ventilation
and tissue oxygenation, as well as metabolic acidosis, dyspnea, and premature onset of the lower
extremities. There is also pulmonary hypertension and reduced exercise capacity. Supplemental
oxygen may be necessary to promote tissue oxygenation and improve exercise capacity. Target SpO2
ranges from85- 90% (33)

8. Conclusion

Rehabilitation professionals (physical therapists, respiratory therapists, speech, language and
swallowing therapists, occupational and physical therapists) participate in the clinical care of
COVID19 patients admitted to the ICU to reduce pulmonary complications and improve functional
recovery. Rehabilitation teams involved in COVID19 care must consult existing medical guidelines
and related literature to obtain the best evidence, but at the same time, equipment strategies and
protocols must take into account their own resources and patient information. Consider the
community pulmonary rehabilitation of COVID19, and family members in the process that produces
positive results.
More research is needed to generate evidence-based methods for effective public relations; focusing
on the optimal dose, duration, intensity, and frequency, designed specifically for COVID19 patients.
In short, there is increasing evidence that pulmonary rehabilitation is helpful for survivors of
COVID19. A pulmonary rehabilitation plan that has already started in the hospital can reduce hospital
29
Ngai, Jones, and Tam, “Tai Chi for Chronic Obstructive Pulmonary Disease (COPD).”
30
Hui et al., “Impact of Severe Acute Respiratory Syndrome (SARS) on Pulmonary Function, Functional Capacity and
Quality of Life in a Cohort of Survivors.”
31
Xie et al., “Follow-up Study on Pulmonary Function and Lung Radiographic Changes in Rehabilitating Severe
Acute Respiratory Syndrome Patients after Discharge.”
32
Venkataraman and Frieman, “The Role of Epidermal Growth Factor Receptor (EGFR) Signaling in SARS
Coronavirus-Induced Pulmonary Fibrosis.”
33
Dowman, Hill, and Holland, “Pulmonary Rehabilitation for Interstitial Lung Disease.”

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stays and improve overall respiratory function. Experts from different countries such as China, Italy,
UK have proposed guiding principles, which can be adjusted according to local needs, in this regard,
global rehabilitation associations such as the ISPM can play an active role. More prospective clinical
trials are needed to determine which pulmonary rehabilitation strategies are safe and successful for
COVID19 survivors, with the objective of enhancing their quality of life after they leave emergency
rooms. Early Intervention and pulmonary rehabilitation provide us with additional tools to fight
COVID19, which may include nutrition, airway, posture, cleansing techniques, oxygen
supplementation, breathing exercises, stretching exercises, manual therapy, and physical activities.

*In the months or years following this pandemic, the burden of disease may be significant, and
both pulmonary medicine and rehabilitation will play a key role in the recovery of patients with
disabilities associated with COVID19.

9. References

1. Spruit, Martijn A., Sally J. Singh, Chris Garvey, Richard ZuWallack, Linda Nici, Carolyn
Rochester, Kylie Hill, et al. “An Official American Thoracic Society/European Respiratory
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Journal of Respiratory and Critical Care Medicine 188, no. 8 (October 15, 2013): e13-64.
https://doi.org/10.1164/rccm.201309-1634ST.
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Impact of Pulmonary Rehabilitation on Chronic Pain in People with COPD.” COPD 17, no. 2
(April 2020): 165–74. https://doi.org/10.1080/15412555.2020.1733952.
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Lacasse. “Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease.” Cochrane
Database of Systematic Reviews, no. 2 (2015).
https://doi.org/10.1002/14651858.CD003793.pub3.
4. Physiopedia. “Pulmonary Rehabilitation.” Accessed July 28, 2021. https://www.physio-
pedia.com/Pulmonary_Rehabilitation.
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ii1–30. https://doi.org/10.1136/thoraxjnl-2013-203808.
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Impact of Pulmonary Rehabilitation on Chronic Pain in People with COPD.” COPD 17, no. 2
(April 2020): 165–74. https://doi.org/10.1080/15412555.2020.1733952.
7. Lin, L., and T. S. Li. “[Interpretation of ‘Guidelines for the Diagnosis and Treatment of Novel
Coronavirus (2019-nCoV) Infection by the National Health Commission (Trial Version 5)’].”
Zhonghua Yi Xue Za Zhi 100, no. 0 (February 7, 2020): E001.
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