Management of Patients with COVID-19 Infection in Acute Settings: A Position Paper for Cardiopulmonary Physiotherapists by the Association of Clinical and Academic Physiotherapists of Nigeria ()
1. Introduction
The Nigeria Centre for Disease Control (NCDC) reported that as at July 24 2020, over 251,000+ individuals have been tested among which 38,000+ cases were confirmed to be positive. Out of these, 16,000+ have been successfully managed and discharged while 833 deaths have been recorded [5]. It is important to note that ever since COVID-19 was first detected in Nigeria, there has been a steady increase in the prevalence of the disease, which has necessitated shutting down many cities and states in the country. Other measures taken by the Nigerian government included suspension of international and local air travel to and from the country, banning of inter-state travels across several states, and directing citizens (with the exception of essential service providers) have been directed to “stay-at-home” (with the exception of essential service providers) or possibly work from home, as measures to combat the spread of the disease [6].
Nevertheless, several analysts have expressed concern about the “true” state of the COVID-19 data presented by the NCDC in Nigeria in view of the limited testing capacity across the country. Moreover, only a small fraction of the population has been tested. States such as Kano in recent times have recorded unprecedented surge in deaths of individuals fitting the mortality pattern from COVID-19 [7]. Furthermore, widespread community transmission of the disease has been suspected even before the Nigerian Government declared lockdown and movement restrictions. Therefore, there is a high possibility that COVID-19 is underdiagnosed and underestimated in Nigeria.
Susceptibility to COVID-19 is associated with age, sex and other health conditions or comorbidities [8]. COVID-19 reported to be prevalent among the elderly and male sex. Despite the fact that most infected individuals may be asymptomatic, symptoms experienced by patients with COVID-19 who are indicated for treatment span across multiple systems; respiratory (cough, short of breath, sore throat, rhinorrhoea, haemoptysis, and chest pain), gastrointestinal (diarrhoea, nausea, and vomiting), musculoskeletal (muscle ache), and neurologic (headache or confusion) [8]. Of note, patients affected by COVID-19 who need hospitalisation often present with viral pneumonia, that is often complicated by an acute respiratory failure, which may eventually evolve to acute respiratory distress syndrome [9].
Considering that pneumonia and Acute Respiratory Distress Syndrome (ARDS) are the commonest associated complications of COVID-19. There may be a resultant alteration of the ventilation-perfusion ratio with possible shunt [10]. Moreover, acute hypoxemic patients may experience dyspnoea which may persist despite the administration of oxygen flows (of >10 - 15 L/min) using a reservoir mask [11]. However, some devices, such as High-Flow Nasal Oxygen (HFNO), Continuous Positive Airways Pressure (CPAP) or Non-Invasive Ventilation (NIV) have been found to be useful [12].
In the presence of acute respiratory failure, there is a reduction of lung compliance, increased respiratory work of breathing and alteration of blood oxygenation, leading to a rapid and shallow respiratory pattern [13]. Usually, this pattern is spontaneously adopted by the subject as a strategy to minimize inspiratory effort and maximize mechanical efficiency of breathing. Additionally, in such clinical conditions, the strength of the respiratory muscles can be reduced. It is important that treatments and procedures used by physiotherapists do not cause a further burden on the work of breathing, exposing the patient to an increased risk of respiratory distress. Consequently, experts have cautioned against the use of diaphragmatic breathing—pursed lips breathing—bronchial hygiene/lung re-expansion techniques (PEP Bottle, EzPAP®, cough machines, incentive spirometer—manual mobilization/stretching of the rib cage in the presence of acute respiratory failure that determines a reduction of lung compliance, because the increase in the respiratory work of breathing and alteration of blood oxygenation may lead to rapid and shallow respiratory pattern, while treating patients with COVID-19 [14].
Some form of respiratory or general physiotherapy may be indicated in such patients on a case by case basis. Cardiopulmonary physiotherapists are involved in the management and care of patients with COVID-19 in the acute hospital setting, and play a key role in non-invasive support management, postural changes, mobilisation and during weaning from invasive mechanical ventilator support. Physiotherapists are also involved in the rehabilitation period following recovery from the disease. A number of reputable international organisations such as the World Confederation of Physical Therapists and the European Respiratory Society have published international guidelines for physiotherapy management of COVID-19 on their websites. Most of the published guidelines have been either adopted, adapted or endorsed by national or specialized associations, notably: Australian Physiotherapy Association, Canadian Physiotherapy Association, International Confederation of Cardiorespiratory Physical Therapists, Italian Association of Respiratory Physiotherapists [9] [15].
In view of the rising cases of patients with COVID-19 in Nigeria, there is a very high possibility, in the nearest future, for the need for more specialized care such as respiratory physiotherapy, to manage patients with indications for physiotherapy. Moreover, most hospitals in Nigeria have limited capacity in terms of number of bed spaces, especially in the intensive care units (ICU). There is already severe shortage of personal protective equipment (gears) for use by healthcare practitioners. It is also possible that physiotherapists could be exposed to other asymptomatic patients who may not have been tested for COVID-19, but potentially infectious. Therefore, this document is prepared to provide guidelines for Nigerian physiotherapists who may be called upon in the management of patients with confirmed COVID-19.
2. Overview of Assessment
Relevant relevant assessment should be done by a respiratory physiotherapist prior to treatment as indicated in the subject headings below:
Signs of respiratory abnormalities
A respiratory assessment is an external assessment of ventilation that includes observations of the rate, depth and pattern of respirations. While assessing for signs and symptoms of respiratory changes, emphasis should be placed on the following:
1) Complaints of shortness of breath (dyspnea);
2) Bluish or cyanotic appearance of the nail beds lips, mucous membranes;
3) Restlessness, irritability, confusion, decreased level of consciousness;
4) Pain on inspiration and expiration;
5) Laboured or difficult breathing;
6) Orthopnea;
7) Use of accessory respiratory muscles;
8) Abnormal breath sounds such as wheezes, rhonchi or rales;
9) Inability to breathe spontaneously;
10) Thick, frothy, blood-tinged or copious sputum production;
11) Paradoxical chest wall movement.
Assessment of breath sounds
Normal breath sounds or vesicular sound: these are low-pitched, soft blowing sounds heard throughout the lung fields that occur throughout inspiration.
Abnormal breath sounds: 1) tracheal-high-pitched, harsh tubular sounds heard over the trachea and throat; 2) bronchial-high-pitched tubular sounds over the large airways of the chest; 3) bronchovesicular-tubular sounds, best heard posteriorly between the scapulae; 4) crackles-popping or bubbling sounds that occur when air is forced through fluid-filled airways; and 5) plural-fiction rub: A cracking sound caused by the moves quickly through mucus-filled, narrowed airways [16] [17] [18] [19] [20].
3. Significance of This Paper
The recommendation in this paper follows international standards as they were drawn from web search and international guidelines for COVID-19 management of critically ill patients with COVID-19. (Thomas et al. [21]; World Health Organization, professional bodies such as Italian Association of Respiratory Physiotherapists, World Confederation of Physical Therapy). The guidelines were modified to conform with the specific peculiarity of the Nigerian context. The initial draft was made by experts in the field of cardiopulmonary physiotherapy and was later reviewed by senior Physiotherapy academics. Thomas et al. [21] previously presented a list in a comprehensive document for use by physiotherapists in the management of COVID-19. This list has been adapted to the Nigerian context and presented in Tables 1-5 below.
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Table 1. Physiotherapy workforce planning and preparation recommendations.
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Table 2. COVID-19 indications for physiotherapy.
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Table 3. Recommendations for physiotherapy respiratory interventions.
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Table 4. Recommendations for Physiotherapy Mobilisation, Exercise and Rehabilitation Interventions.
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Table 5. Recommendations regarding personal protective equipment for physiotherapists.
4. Conclusion
Due to the peculiarity of COVID-19 as a highly communicable/infectious disease with attendant respiratory and other physical complications, training and utilization of specialized physiotherapy services has become very important for the purpose of providing effective and qualitative services. This position paper is expected to serve as the minimum requirement for participation of physiotherapists as frontline healthcare workers in the battle against COVID-19, with minimal or no risk to both staff and patients. Since training materials are highly essential to guide effective treatment procedures, our aim is to also compile the assessments and treatment guidelines available worldwide to guide Nigerian physiotherapists. These guidelines could be adjusted or modified to fit specific clinical settings across the nation.