Respiratory Management of COVID 19
Please note: this is a rapidly developing topic and while we will try to keep this page up to date please let us know if you are aware of any new information or evidence that should be incorporated into this page. (6/06/2020)
Original Editor - Naomi O'ReillyTop Contributors - Naomi O'Reilly, Rachael Lowe, Kim Jackson, Laura Ritchie and Tarina van der Stockt
- 1 Introduction
- 2 Clinical Syndromes
- 3 Procedures at Risk of Contamination
- 4 Oxygen Therapy
- 5 Ventilatory Support
- 6 Specific Physiotherapy Techniques
- 7 Prevention of Complications
- 8 Indications for Physiotherapy Referral
- 9 On-Call Physiotherapy Considerations
- 10 Resources
- 11 References
IntroductionCoronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS-CoV-2), is a single-stranded ribonucleic acid (RNA) encapsulated corona virus and is highly contagious. Transmission is thought to be predominantly by droplet spread (i.e. relatively large particles that settle in the air), and direct contact with the patient, rather than ‘airborne spread’ (in which smaller particles remain in the air longer). There is still no specific antiviral treatment for COVID-19 infection, only supportive therapies including respiratory care for affected patients, especially in more severe cases. 
Approximately 15% of individuals with COVID-19 develop moderate to severe disease and require hospitalisation and oxygen support, with a further 5% who require admission to an Intensive Care Unit and supportive therapies including intubation and ventilation. The most common complication in severe COVID-19 patients is severe pneumonia, but other complications may include Acute Respiratory Distress Syndrome (ARDS), Sepsis and Septic Shock, Multiple Organ Failure, including Acute Kidney Injury and Cardiac Injury, which are more prevalent in at-risk groups including Older Age (> 70 years) and those with Co-morbid Diseases such as Cardiovascular Disease, Lung Disease, Diabetes and those who are Immunosuppressed. In a small proportion of these, the illness may be severe enough to lead to death. Data currently suggests that illness is less common and usually less severe in younger adults. 
Many patients presenting with COVID-19 will have no specific airway clearance needs. It is important that staff contact is kept to a minimum with positive patients to help reduce the risk of transmission therefore follow usual on-call policies and criteria. To date, COVID-19 patients who require hospitalisation are presenting with pneumonia features and bilateral patchy shadows or ground-glass opacity in the lungs. There have been no reports of COVID-19 positive patients having high secretion loads that would require intensive respiratory physiotherapy/airway clearance. This may change as the situation evolves and for that reason, all presenting patients should be discussed with Consultant Respiratory Clinicians/Critical Care Consultants before mechanical devices are used and guidance from a physiotherapist's specific Service Provider should be followed. It is important to note that some therapeutic interventions will be contraindicated for patients with COVID-19. There may be patients with existing respiratory conditions who require personalised physiotherapy treatments which may include mechanical airway clearance or oscillating devices. In this scenario, it is important that the risk and benefit of continuing with the regime are discussed with Consultant Respiratory Clinicians/Critical Care Consultants. 
The World Health Organisation outlines the following Clinical Syndromes associated with COVID-19: 
|Patients present with uncomplicated upper respiratory tract viral infection and may have non-specific symptoms such as fever, fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or headache. Rarely. patients may also present with diarrhoea, nausea, and vomiting.
The elderly and immunosuppressed may present with atypical symptoms. Symptoms due to physiologic adaptations of pregnancy or adverse pregnancy events, such as dyspnea, fever, GI-symptoms or fatigue, may overlap with COVID- 19 Symptoms.
|Pneumonia||Adult: with pneumonia but no signs of severe pneumonia and no need for supplemental oxygen.
Child: with non-severe pneumonia who has a cough or difficulty breathing + fast breathing: Fast Breathing (in breaths/min) .< 2 months old ≥ 60; 2-11 months old ≥ 50; and 1-5 years old ≥ 40, and no signs of severe pneumonia.
Patients may be productive, with an increased sputum load but this is a less common presentation in viral pneumonia.
|Severe Pneumonia||Adolescent or Adult: Fever or suspected respiratory infection, plus one of the following: High Respiratory Rate > 30 breaths/min; Severe Respiratory Distress; or SpO2 ≤ 93% on Room Air.
Child: with a cough or difficulty in breathing, plus at least one of the following: Central Cyanosis or SpO2 < 90%; Severe Respiratory Distress (e.g. Grunting, Very Severe Chest Indrawing); Signs of Pneumonia with a general danger sign: Inability to breastfeed or drink, Lethargy or Unconsciousness, or Convulsions.
Other signs of pneumonia may be present: Chest Indrawing; Fast Breathing (in breaths/min): < 2 months: ≥ 60; 2 - 11 months: ≥ 50;1 - 5 years: ≥ 40.
While the diagnosis is made on clinical grounds, chest imaging may identify or exclude some pulmonary complications.
|Acute Respiratory Distress Syndrome||Onset: Within 5 - 7 days from the onset of initial respiratory symptoms
Diagnostic Tools (Radiograph, CT Scan, or Lung Ultrasound): Bilateral Opacities, not fully explained by volume overload, lobar or lung collapse, or nodules; Origin of Pulmonary Infiltrates: Respiratory failure not fully explained by cardiac failure or fluid overload; Need Objective Assessment (e.g. Echocardiography) to exclude Hydrostatic cause of infiltrates/oedema if no risk factor present.
Oxygenation Impairment in Adults: Based on PF Ratio, which is the ratio of arterial oxygen partial pressure to fractional inspired oxygen
Oxygenation Impairment in Children: Note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2. Use PaO2-based metric when available. If PaO2 not available, wean FiO2 to maintain SpO2 ≤ 97% to calculate OSI or SpO2/FiO2 ratio:
|Sepsis||Adults: Life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection. Signs of organ dysfunction include: Altered Mental Status; Difficult or Fast Breathing; Low Oxygen Saturation; Reduced Urine Output; Fast Heart Rate; Weak Pulse; Cold Extremities; Low blood Pressure; Skin Mottling; Laboratory Evidence of Coagulopathy, Thrombocytopenia, Acidosis, High Lactate, or Hyperbilirubinemia.
Children: Suspected or proven infection and ≥ 2 age-based systemic inflammatory response syndrome criteria, of which one must be abnormal temperature or white blood cell count.
|Septic Shock||Adults: Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP MAP ≥ 65 mmHg and serum lactate level > 2 mmol/L.
Children: Any hypotension (SBP < 5th centile or > 2 SD below normal for age) or two or three of the following: Altered Mental State; Tachycardia or Bradycardia - HR < 90 bpm or > 160 bpm in Infants or HR < 70 bpm or > 150 bpm in Children; Prolonged Capillary Refill (> 2 sec) or Feeble Pulse; Tachypnoea; Mottled or Cool Skin or Petechial or Purpuric Rash; Increased Lactate; Oliguria; Hyperthermia or Hypothermia
Patients with severe disease often need oxygenation support. High-flow oxygen and noninvasive positive pressure ventilation have been used, but the safety of these measures is uncertain, and they should be considered aerosol-generating procedures that warrant specific isolation precautions and PPE considerations. Some patients may develop acute respiratory distress syndrome and warrant intubation with mechanical ventilation; extracorporeal membrane oxygenation may be indicated in patients with refractory hypoxia.Physiotherapy may be beneficial in the respiratory treatment and physical rehabilitation of patients with COVID-19, although a productive cough is a less common symptom, physiotherapy may be indicated if patients with COVID-19 present with airway secretions that they are unable to independently clear. This may be evaluated on a case- by-case basis and interventions applied based on clinical indicators, and may also be utilised in high risk individuals e.g. patients with existing comorbidities that may be associated with hypersecretion or ineffective cough (e.g. neuromuscular disease, respiratory disease, cystic fibrosis etc). 
Guideline Recommendations: Senior physiotherapists should be involved in determining the appropriateness of physiotherapy interventions for patients with suspected and/or proven COVID-19 in consultation with senior medical staff and according to a referral guideline. Physiotherapy will have a strong role in providing exercise, mobilisation and rehabilitation interventions to survivors of critical illness myopathies associated with COVID-19 in order to enable a functional return to home. 
Procedures at Risk of Contamination
COVID-19 is spread by inhalation of infected matter containing live virus, which can travel up to 2m or by exposure from contaminated surfaces. SARS-CoV-2 remains viable for at least 24 hours on hard surfaces and up to eight hours on soft surfaces. Aerosol airborne infected particles created during a sneeze or cough remain viable in the air for at least three hours.  Aerosol-generating procedures create an increased risk of transmission of infection. Rachael Moses, a Consultant Physiotherapist at Lancashire Teaching Hospital, suggests that particular attention should be given during those interventions that place the health care staff at greater risk of contamination for aerial dispersion of droplets.
Aerosol Generating Procedures (AGP)
Aerosols generated by medical procedures are one route for the transmission of the COVID-19 virus. For patients with suspected/confirmed COVID-19, any of these potentially infectious AGPs should only be carried out when essential and minimised as much as possible. Where these procedures are indicated, they should be carried out in a single room with the doors shut but preferably should be completed in a Negative Pressure Side Room. Only those healthcare staff who are needed to undertake the procedure should be present. Full PPE Equipment including a disposable, Fluid Repellent Surgical Gown, Gloves, Eye Protection and an FFP3 Respirator Mask should be worn by those undertaking the procedure and those in the room and good hand hygiene following the procedure. Hair cover should also be considered. The following procedures are considered to be potentially infectious AGPs: 
- Intubation, Extubation and Related Procedures;
- Tracheotomy/Tracheostomy Procedures;
- Manual Ventilation;
- Open Suctioning;
- Non-Invasive Ventilation (NIV) e.g. Bi-level Positive Airway Pressure (BiPAP)and Continuous Positive Airway Pressure Ventilation (CPAP);
- Surgery and Post-Mortem Procedures in which high-speed devices are used;
- High-Frequency Oscillating Ventilation (HFOV);
- High-flow Nasal Oxygen (HFNO)
- Induction of Sputum; Note: Induction of sputum typically involves administration of nebulised saline to moisten and loosen respiratory secretions (this may be accompanied by chest physiotherapy such as percussion and vibration to induce forceful coughing). This may be required if lower respiratory tract samples are needed
Certain other procedures/equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk. Procedures in this category include: 
- Administration of Pressurised Humidified Oxygen;
- Administration of Medication via Nebulisation; Note: During nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces (combines) with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks.
Physiotherapy Specific Aerosol Generating Techniques 
- Manual Techniques (e.g. Percussion/Manual Assisted Cough) that may lead to coughing and expectoration of sputum
- Use of Positive Pressure Breathing Devices (e.g. IPPB), Mechanical Insufflation-Exsufflation (Cough Assist) Devices, Intra/Extra Pulmonary High Frequency Oscillation Devices (e.g. the Vest / MetaNeb / Percussionaire etc.)
- Any Mobilisation or Therapy that may result in Coughing and Expectoration of Mucus
- Any Diagnostic Interventions that involve use of Video Laryngoscopy that can result in Airway Irritation and Coughing (e.g. Direct Visualisation during airway clearance techniques or when assisting Speech and Language Therapists perform Fibreoptic Endoscopic Evaluation of Swallow)
Reusable (communal) non-invasive equipment must be decontaminated:
- between each patient and after patient use;
- after blood and body fluid contamination; and
- at regular intervals as part of equipment cleaning.
An increased frequency of decontamination should be considered for reusable non-invasive care equipment when used in isolation/cohort areas. 
- Reusable equipment should be avoided if possible; if used, it should be decontaminated according to the manufacturer’s instructions before removal from the room. If it is not possible to leave equipment inside a room then follow IPC Guidelines on Decontamination. This usually involves cleaning with neutral detergent, then a chlorine-based disinfectant, in the form of a solution at a minimum strength of 1,000ppm available chlorine (e.g. “Haz-Tab” or other brands).
- If possible use dedicated equipment in the isolation room. Avoid storing any extraneous equipment in the patient’s room
- Dispose of single-use equipment as per clinical waste policy inside a room
- Point of care tests, including blood gas analysis, should be avoided unless a local risk assessment has been completed and shows it can be undertaken safely
- Ventilators and mechanical devices (e.g. Cough Assist Machines) should be protected with a high-efficiency viral-bacterial filter such as BS EN 13328-1.
- When using mechanical airway clearance, filters should be placed at the machine end and the mask end before any expiratory or exhalation ports. Filters should be changed when visibly soiled or dependent on the filter used either after each use or every 24 hours. Complete circuit changes should be undertaken every 72 hours (please follow specific Service Provider guidance on this)
- Closed system suction should be used if patients are intubated or have tracheostomies
- Disconnecting a patient from mechanical ventilation should be avoided at all costs but if required the ventilator should be placed on standby
- Manual hyperinflation (bagging) should be avoided if possible and attempt ventilator recruitment manoeuvres where possible and required
- Water humidification should be avoided and a heat and moisture exchanger should be used in ventilator circuits
- Disposable crockery and cutlery may be used in the patient’s room as far as possible to minimise the numbers of items which need to be decontaminated
- Any additional items such as Stethoscopes, Pulse Oximeters or Ultrasound Probes that are taken into a room will also need to be disinfected, regardless of whether there has been direct contact with the patient or not. This is due to the risk of environmental contamination of the equipment within the isolation room. 
- If AGPs are undertaken in the patient’s own room, the room should be decontaminated 20 minutes after the procedure has ended (please follow specific Service Provider IPC guidance on this also).
- If a different room is used for a procedure it should be left for 20 minutes, then cleaned and disinfected before being put back into use.
- Clearance of any aerosols is dependent on the ventilation of the room. In hospitals, rooms commonly have 12 to 15 air changes per hour, and so after about 20 minutes, there would be less than 1 per cent of the starting level (assuming cessation of aerosol generation).
- If it is known locally that the design or construction of a room may not be typical for a clinical space, or that there are fewer air changes per hour, then the local IPCT would advise on how long to leave a room before decontamination. 
In the mild and moderate stages of disease, normal oxygen supportive measures (facemask oxygen) may be advantageous. WHO  recommends supplemental oxygen therapy immediately for patients with respiratory distress, hypoxaemia or shock with a target SpO2 > 94%. Patients may continue to have increased work of breathing or hypoxemia even when oxygen is delivered via a face mask with reservoir bag (flow rates of 10 - 15 L/min, which is typically the minimum flow required to maintain bag inflation; FiO2 0.60 - 0.95).  Nasal cannulas are not recommended as they may cause a higher spread of droplets.
Early recognition and referral of patients with worsening respiratory function while on conventional oxygen therapies, such as simple face masks or masks with reservoir bags, are important to ensure the timely and safe escalation of respiratory support. Early optimisation of care and involvement of Intensive Care Unit is recommended. In patients with COVID-19 there is the potential for a worsening of hypoxia and an increased need for intubation and invasive mechanical ventilation so close monitoring is advised.
Oxygen therapy targets may vary depending on the presentation of the patient.
For patients with presenting with severe respiratory distress, hypoxaemia or shock
- SpO2 > 94% is targeted 
Once a patient is stable
In adults with COVID-19 and Acute Hypoxaemic Respiratory Failure
- SpO2 target should not be maintained higher than 96% 
High Flow Nasal Oxygen (HFNO)
There have been some differing opinions on the use of HFNO due as an aerosol generating procedure but based on the Italian experience, HFNO has been found to be beneficial at the early stage, with a select cohort of patients who present with hypoxemic respiratory failure with no evidence of hypercapnia and can prevent intubation in some patients.  Given that HFNO is an aerosol generating procedure negative pressure rooms are preferable for patients receiving HFNO therapy and all staff entering the room should wear optimal PPE Equipment including a disposable, fluid repellent surgical gown, gloves, eye protection and an FFP3 respirator mask to ensure a low risk of airborne transmission. Flow rates of up to 60% and 100% oxygen are possible with HFNO. Early recognition and referral of patients with worsening respiratory function (hypercapnia, acidaemia, respiratory fatigue), haemodynamic instability or those with altered mental status are important to ensure the timely and safe escalation of respiratory support, with consideration for early invasive mechanical ventilation if appropriate.
Guideline Recommendations: While HFNO does carry a small risk of aerosol generation, it is considered a recommended therapy for hypoxia associated with COVID-19, as long as staff are wearing optimal airborne PPE. The risk of airborne transmission to staff is low when optimal PPE and other infection control precautions are being used. Negative pressure rooms are preferable for patients receiving HFNO. 
Acute or chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes.
Non-Invasive Ventilation (CPAP/NIV)
Routine use of non-invasive ventilation is not recommended.
Non-invasive ventilation, an aerosol generating procedure, is when oxygen is given as breathing support by using a face mask or nasal mask under positive pressure, and is a recognised evidence-based intervention utilised for the treatment of hypercapnic respiratory failure. The amount of pressure generally alternates depending on inhalation or exhalation. Although non-invasive ventilation may temporarily improve oxygenation and reduce the work of breathing in patients with viral infections complicated by pneumonia, this method does not necessarily change the natural disease course and as such non-invasive ventilation is not routinely recommended and has no role in severe hypoxemic respiratory failure. Where non-invasive ventilation is utilised, a clear plan for treatment failure and escalation of care should be in place. 
Current experience suggests that non-invasive ventilation for COVID-19 can be associated with a high failure rate, delayed intubation and possibly increased risk of aerosolisation with poor mask fit. It seems clear from the available evidence that non-invasive ventilation should not be routinely used when the patient has severe respiratory failure or a trajectory that suggests that invasive ventilation is inevitable. In such circumstances, deteriorating patients should be considered for early endotracheal intubation and transitioned from oxygen therapy via a simple facemask to invasive ventilation without delay.  Negative prognostic factors for non-invasive ventilation success are overall severity, renal failure and hemodynamic instability.Non-invasive ventilation has been considered an effective strategy with a specific cohort of patients in the early presentation of COVID-19, in particular with presentations of COVID-19 with hypercapnic respiratory failure, such as those with concomitant respiratory conditions e.g. COPD. In Italy, where non-invasive ventilation has been utilised with this cohort group, they recommend to perform a single attempt of up to 1 hour. If substantial improvement does not occur, the medical team must be alerted because the patient should be considered for early endotracheal intubation and invasive ventilation within a controlled environment with adequate infection prevention and control measures taken. 
In order for non-invasive ventilation to be delivered in a safe manner and minimise the risk of aerosolisation, negative pressure single rooms should be used, using a dual link system with separate expiatory port or use of a double port filter system with a viral filter placed between the mask and the respiratory port.
Recommendations in terms of non-invasive ventilation preferences are;
- First Choice: CPAP without humidification and with Hood / Helmet PEEP between 10 - 12 cmH20 and up to 15-20 cmH2O according to patient’s needs, tolerance and any side-effects.
- Second Choice: CPAP with mask
- Third Choice: NIV with face mask (total full face mask / oronasal face mask with filter between mask respiratory port)
Guideline Recommendation: Routine use of NIV is not recommended. as current experience with COVID-19 hypoxic respiratory failure reflects a high associate failure rate. If utilised e.g. with a patient with COPD or post-extubation it must be provided with strict airborne PPE. 
Lung protective mechanical ventilation (MV) is the recommended strategy for the management of acute respiratory failure, which aims to protect the lung. This is when mechanical ventilation is employed with the use of a low tidal volume strategy (4-8ml/kg predicted body weight) and limiting plateau pressures to less than 30 cmH2O. Permissive hypercapnia is usually well-tolerated and may reduce volutrauma, local over distention of normal alveoli as achievement of adequate oxygenation is key. Higher levels of PEEP, greater than 15 cmH2O, are recommended. 
Alternate modes of ventilation such as APRV may be considered based on clinician preference and local experience. Viral (rather than HME) filters should be utilised and circuits should be maintained for as long as allowable, as opposed to routine changes. 
Generally patients are sedated to allow adequate control of ventilation. While good practice to perform daily sedation holds, patients with COVID-19 may be kept under deeper sedation until adequate oxygenation levels are achieved to reduce the risk of ventilator dyssynchrony and control respiratory drive (which is important to achieve adequate target tidal volumes). Use of neuromuscular blockade agents are not generally recommended, unless the patient has significant worsening hypoxia or hypercapnia and in situations where the patient's respiratory drive cannot be managed with sedation alone resulting in ventilator dyssynchrony and lung decruitment. 
Use of recruitment measures are not recommended in severe ARDS but may be considered during the weaning phase but in the case of COVID-19 patients, manual recruitment methods such as manual hyperinflation which involve a break in the circuit are not recommended due to increased risk of droplet spread.In the majority of patients with COVID-19, endotrachael tubes are used, with very few requiring tracheostomy. It is vital that cuffs are inflated at all times and never deflated during any treatments. If tracheostomy is indicated subglotic tracheotomy should be utilised so above cuff vocalisation can be achieved without needing to deflate the cuff to improve communication and swallow.
Guideline Recommendation: Patients with worsening hypoxia, hypercapnia, acidaemia, respiratory fatigue, haemodynamic instability or those with altered mental status should be considered for early invasive mechanical ventilation if appropriate. The risk of aerosol transmission is reduced once a patient is intubated with a closed ventilator circuit. 
Positioning is a vital component of management for the mechanically ventilated COVID-19 patient, with regular turning recommended to prevent atelectasis, optimise ventilation and prevent pressure sores. Positioning can include lateral (side lying) positioning but may also include prone positioning, which is well recognised to treat hypoxemic respiratory failure. Prone ventilation is ventilation that is delivered with the patient lying in the prone position. Prone ventilation may improve lung mechanics and gas exchange, thus improving oxygenation in the majority of patients with ARDS, and could improve outcomes. Current reports suggest prone ventilation is effective in improving hypoxia associated with COVID-19 and should be completed in the context of a hospital guideline that includes appropriate PPE for staff and that minimise the risk of any adverse events, e.g. accidental extubation and breaking of the circuit.  With adult patients, prone positioning is recommended for at least 16 hours per day.
Closed inline suction catheters are recommended and imperative. Any disconnection of the patient from the ventilator should be avoided to prevent lung decruitment and aerosolisation. If necessary, the endotracheal tube should be clamped and the ventilator disabled (to prevent aerosolisation).  Suctioning is not required routinely but should be used as required.
The use of nebulised agents (e.g. salbutamol, saline) for the treatment of non-intubated patients with COVID-19 is not recommended as it increases the risk of aerosolization and transmission of infection to health care workers in the immediate vicinity. The use of metered-dose inhalers are preferred where possible. 
If a nebulizer is required and deemed essential, liaise with local guidelines for directions to minimise aerosolization e.g. use of a Pari sprint with inline viral filter with use of adequate airborne precautions and PPE. 
Weaning and Liberation from Mechanical Ventilation
Standard weaning protocols should be followed. HFNO and/or NIV with well-fitted facemask with separate inspiratory and expiratory can be considered as bridging therapy post-extubation but must be provided with strict use of staff PPE. 
Specific Physiotherapy Techniques
Physiotherapy is an important intervention that prevents and mitigates the adverse effects of prolonged bed rest and mechanical ventilation during critical illness. Rehabilitation delivered by the physiotherapist is tailored to patient needs and depends on the conscious state, psychological status and physical strength of the patient. It incorporates any active and passive therapy that promotes movement and includes mobilisation. Much of the role of the ICU physiotherapist will continue during the COVID-19 pandemic, with the main change in practice being the routine use of full PPE while working within the ICU environment.
In the early stages of COVID-19 and respiratory distress, care is advised when planning a treatment programme. Common modalities often used by respiratory physiotherapists may be contraindicated in the acute phase as they may further compromise the increased work of breathing.
Contraindicated interventions include:
- Diaphragmatic breathing
- Pursed lips breathing
- Bronchial hygiene/lung re-expansion techniques (PEP Bottle, EzPAP®, cough machines, etc.)
- Incentive spirometry
- Manual mobilisation techniques or stretching of the rib cage
- Nasal washings
- Respiratory muscle training
- Exercise training
- Patient mobilisation during clinical instability
Physiotherapists should continue to actively screen and/or accept referrals for mobilisation, exercise and rehabilitation. When screening, discussion with nursing staff, the patient (e.g. via phone) or family is recommended before deciding to enter the patient’s isolation room. For example,to try to minimise staff who come in to contact with patients with COVID-19, physiotherapists may screen to determine an appropriate aid to trial. A trial of the aid may then be performed by the nursing staff already in an isolation room, with guidance provided if needed by the physiotherapist who is outside the room.
Where the patient is awake, cooperative and in the weaning stage, consider the use of the active cycle of breathing technique as well as lung volume recruitment procedures (e.g. breath stacking) combined with positioning to ensure the patient is involved in his/her treatment.
Anything in relation to ventilator disconnection should not be utilised e.g. manual hyper inflation / bagging.
Mechanical Insufflation-Exsufflation (Cough Assist) Devices
Generally, cough assist devices are not indicated or required in viral pneumonia, as they do not tend to have productive chests, retained secretions or problems with secretion retention or mucus plugging. If it was felt that such a device was indicated, the issue must be discussed with the medical team considering the physiological impact of Insufflation-Exsufflation in someone who may already have an acute lung injury, which may be counterproductive to the lung protection strategy utilised. The use of this type of device may be considered in patients with co-morbid conditions where these techniques were part of their normal airway clearance strategies, but benefit versus risk would need to be discussed with the team. This is not recommended and would not be considered first line intervention. Because it is an AGP, full PPE would be required and in order to protect the machine and the patient, a double viral filter system should be in place at the mask and device expiratory port.
Diagnostic lung ultrasound has been identified as a potential diagnostic tool in the assessment and management of COVID-19. It shows similar findings to radiological cases and has a higher degree of accuracy than the bedside chest radiograph, with findings of multi-lobar distribution of B-lines and diffuse lung consolidation. It approaches the level of accuracy seen with computed tomography (CT) for many pathologies that reach the pleura. Lung ultrasound can be used throughout the course of the treatment process to track the evolution of the disease, to monitor lung recruitment manoeuvres, to provide feedback in relation to the success of interventions and to assist decision-making in relation to weaning and liberation from mechanical ventilation. The following provides a practical guideline for the use of lung ultrasound during the COVID-19 Pandemic within an acute hospital setting:
- Physiotherapists use of Lung Ultrasound during the COVID-19 Pandemic - A Practical Guideline on Supporting Acute Hospital Colleagues.
There is controversy about the effectiveness of manual techniques in general. There is minimal evidence for percussion. There is some evidence for expiratory vibrations to mobilise secretions and manual assisted cough to improve cough effectiveness and aid mucocillary clearance if required. This could be an adjunct and safe to use with patients who are both mechanically ventilated and extubated provided adequate PPE is used.
This is where we will see the main role of the physiotherapist in the management of the patient with COVID-19. There is strong evidence to suggest that early mobilisation with a focus on returning to functional activities helps in reducing the length of hospital stay and minimising functional decline, thus the sooner patients start mobilising, the sooner they can leave the ICU, and potentially have better long-term outcomes. This phase of management should incorporate a multi-disciplinary approach including measures to prevent avoidable physical and non-physical morbidity, support adequate nutrition (particularly following the effects of prone ventilation) and an individualised, structured rehabilitation programme. This phase should follow the typical approach for rehabilitation and exercise within the Intensive Care Unit, followed by transfer to ward-based rehabilitation.
- Passive, Active Assisted, Active, or Resisted Joint Range of Motion Exercises to maintain or improve joint integrity and range of motion and muscle strength; 
- Mobilisation and Rehabilitation (e.g. bed mobility, sitting out of bed, sitting balance, sit to stand, walking, tilt table, standing hoists, upper limb or lower limb ergometry, exercise programs). 
Prevention of Complications
Physiotherapists can play a key role in the prevention of a range of complications including ventilator-associated pneumonias, secondary infections, contractures or pressure areas/sores.
Reduced Days of Mechanical Ventilation
- Use weaning protocols or development of individual weaning plans
- Assessment of spontaneous breathing capacity and readiness for extubation, including involvement in daily sedation holds and spontaneous breathing trials.
Reduce the Incidence of Ventilator-Associated Pneumonia
It is really important to reduce this risk because any secondary infection will increase the number of days the patient is intubated and ventilated and thus their overall time in the ICU, taking up bed space for longer than should be required and reduce flow through the hospital.
- Keep the patient in a semi-sitting position (30 - 45 Degrees)
- Regular 2 hourly turning to minimise the risk of atelectasis and consolidation
- Prone ventilation where indicated and appropriate. In China & Italy they often had multiple patients proned within the ICU
- Use a closed suction system; periodically drain and discard condensate intubing
- Use a new ventilation circuit for each patient, once the patient is ventilated change the circuit only if it is damaged or soiled, not routinely
- Change heat moisture exchanger when it malfunctions, when soiled, or every 5-7 days
- Assist in the extubuation phase, and weaning potential from invasive ventilation.
Reduce the Incidence of Pressure Ulcers
- Turn the patient every 2 hours 
- Pressure care positioning / protection of pressure areas
Reduce the Incidence of Intensive Care-Related Myopathy
- Early mobilisation is encouraged. Actively mobilise the patient as soon as their condition allows and when safe to do so. 
Indications for Physiotherapy Referral
The following guidelines outline the relevant indications for physiotherapy in the presence of a suspected or confirmed case of COVID-19. 
|COVID-19 Patient Presentation
(Confirmed or Suspected)
|Physiotherapy Referral ?|
|Mild symptoms without significant respiratory compromise
e.g. fevers, dry cough, no chest x-ray changes.
|Physiotherapy interventions are not indicated for airway clearance or sputum samples
No physiotherapy contact with patient.
|Pneumonia presenting with features:
||Physiotherapy interventions are not indicated for airway clearance or sputum samples.
No physiotherapy contact with patient.
|Mild symptoms and/or pneumonia AND
co-existing Respiratory or Neuromuscular Comorbidity e.g. Cystic Fibrosis, neuromuscular disease, spinal cord injury, bronchiectasis, COPD, AND
current or anticipated difficulties with secretion clearance
|Physiotherapy referral for airway clearance.
Staff use airborne precautions.
Where possible, patients should wear a surgical mask during any physiotherapy.
|Mild symptoms and/or pneumonia AND
evidence of exudative consolidation with difficulty clearing or inability to clear secretions independently e.g. weak, ineffective and moist sounding cough, tactile fremitus on chest wall, moist/wet sounding voice, audible transmitted sounds.
|Physiotherapy referral for airway clearance.
Staff use airborne precautions.
Where possible, patients should wear a surgical mask during any physiotherapy.
|Severe symptoms suggestive of pneumonia / lower respiratory tract infection e.g. increasing oxygen requirements, fever, difficulty breathing, frequent, severe or productive coughing episodes, Chest X-ray / CT / Lung Ultrasound changes consistent with Consolidation.||Consider physiotherapy referral for airway clearance.
Physiotherapy may be indicated, particularly if weak cough, productive and/or evidence of pneumonia on imaging and/or secretion retention.
Staff use airborne precautions.
Where possible, patients should wear a surgical mask during any physiotherapy.
Early optimisation of care and involvement of ICU is recommended.
Mobilisation, Exercise & Rehabilitation
|COVID-19 Patient Presentation
(Confirmed or Suspected)
|Physiotherapy Referral ?|
|Any patient at significant risk of developing or with evidence of significant functional limitations
Use droplet precautions.
Use airborne precautions if close contact required or possible AGPs.
If not ventilated, patients should wear a surgical mask during any physiotherapy whenever possible.
On-Call Physiotherapy Considerations
Acutely unwell confirmed or suspected COVID-19 patients should NOT be routinely referred to physiotherapy. There are currently no reports that suggest COVID-19 patients have high secretion loads requiring intensive respiratory physiotherapy/airway clearance. Physiotherapy intervention is likely to be of limited benefit in the acute stages and most beneficial use of physiotherapy resources will be to facilitate the treatment and discharge of non-infected patients as well as training and supporting our colleagues in managing the acutely unwell. Physiotherapists will have a role in the rehabilitation of COVID-19 patients who have not returned to their functional baseline once they are no longer acutely unwell. 
The WHO recommends limiting the number of Health Care Workers who are in contact with a suspected and confirmed COVID-19 patients and to limit the number of persons present in the room to the absolute minimum required for the patient’s care and support. 
Physiotherapy referrals should only be made for patients that meet the On-Call Physiotherapy Criteria, which normally would include; 
Inclusion Criteria: Patients likely to benefit from on-call physiotherapy:
- An increase in oxygen therapy to FiO2 >60%
- Evidence of retained pulmonary secretions with difficulty expectorating
- Ineffective cough/airway clearance
Exclusion Criteria: Patient unlikely to benefit from on-call physiotherapy:
- Viral Pneumonia
- Cardiovascular Instability
- Uncooperative Patient
- Unstable Intracranial Pressure
- Uncontrolled Bronchospasm
- Pulmonary Embolism
- Non-acute COPD
Criteria not appropriate for emergency call-out:
- Patients with a diagnosis of COVID-19 with a dry unproductive cough
- Patients with a diagnosis of COVID-19 with severe hypoxaemia requiring intubation
- Routine respiratory patients e.g. post-operatively, unless the criteria above are met
- Patients who are requiring suction only - If the patient requires suction ONLY, consider as a nursing technique. Mobilise any patient who is well enough as this is the most natural way of encouraging optimal pulmonary function. Such a patient is unlikely to require emergency physiotherapy.
- Physiotherapy Specific Guidelines for the Acute Hospital Setting
- Rachael Moses, Consultant Respiratory Physiotherapist at Lancashire Teaching Hospitals.
- COVID-19: Respiratory Physiotherapy Management Information and Guidance. Version 1 Dated 15th March 2020
- COVID-19 Respiratory Physiotherapy On Call Information and Guidance. Version 2 Dated 14th March 2020
- COVID 19 and Respiratory Physiotherapy Referral Guideline. Version 1 Dated 18th March 2020
- Adam Rochester, NIV Lead for Respiratory Support Services. Royal Brompton and Harefield NHS Trust.
- Italian Association of Respiratory Physiotherapists (ARIR)
- David McWilliams, Consultant Physiotherapist, University Hospitals Birmingham NHS Foundation Trust
- Kelly Morris, Isobel Hinton, Laura Mylott, Rachel Farley, Hannah Mitchell & Hannah Cumming, Physiotherapy Team, Guy’s and St.Thomas’ NHS Foundation Trust
- British Thoracic Society
- BTS Advice for Community Respiratory Services in Relation to COVID19 Version 1 Dated 16th March 2020
Airway Management Guideline
- World Health Organisation
- Clinical Management of Severe Acute Respiratory Infection when Novel Coronavirus (nCoV) Infection is Suspected Interim Guidance Dated 28th January 2020
- Australian and New Zealand Intensive Care Society
- The Australian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines Version 1 Dated 16th March 2020
- Italian Thoracic Society (AIPO - ITS) and Italian Respiratory Society (SIP/IRS)
- Managing the Respiratory Care of patients with COVID-19 Version 1 Dated 8th March 2020
- British Thoracic Society
- Use of Acute NIV in Patients Hospitalised with Suspected or Confirmed COVID-19 Infection Version 1 Dated 16th March 2020
- The Faculty of Intensive Care Medicine
Evidence Based Resources
- The First A�liated Hospital, Zhejiang University School of Medicine
- Cochrane Special Collections
- British Medical Journal
- 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]
- 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.
- 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
- Ñamendys-Silva SA. Respiratory support for patients with COVID-19 infection. The Lancet Respiratory Medicine. 2020 Mar 5.
- 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
- Lazzeri M, Lanza A, Bellini R, Bellofiore A, Cecchetto S, Colombo A, D'Abrosca F, Del Monaco C, Gaudellio G, Paneroni M, Privitera E. 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 Mar 26;90(1).
- 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
- Peng, Q.Y., X.T. Wang, L.N. Zhang, and G. Chinese Critical Care Ultrasound Study, Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med, 2020.