Recommendations for Respiratory Rehabilitation in Adults with Coronavirus Disease 2019
The coronavirus disease 2019 (COVID-19) has emerged as a significant public health emergency since December 2019. In response, the Chinese government classified COVID-19 as a category B infectious disease, implementing control measures typically reserved for category A diseases. The National Health Commission of China has published protocols to guide clinical diagnosis and treatment. As clinical experience with COVID-19, particularly in severe and critically ill patients, has accumulated, the understanding of the disease has deepened. Respiratory, physical, and psychological dysfunctions are common among COVID-19 patients, necessitating standardized respiratory rehabilitation techniques and procedures across various regions. This article provides comprehensive recommendations for respiratory rehabilitation in adults with COVID-19, based on evidence and expert consensus.
Methodology
The recommendations were developed through a structured process. The work group was divided into three subgroups: the recommendation drafting group, the evidence assessment group, and the expert consensus group. The drafting group determined the topic and scope of the recommendations, guided the evidence assessment group in summarizing evidence, and drafted the recommendations. The evidence assessment group conducted literature searches, assessed evidence, and provided summaries. The expert consensus group achieved consensus on the preliminary recommendations.
Literature searches included rehabilitation-related guidelines, systematic reviews, and randomized controlled trials on COVID-19, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS). Searches were performed in English databases (PubMed, Ovid, Embase) and Chinese databases (Chinese Biological Medical Literature database, China National Knowledge Infrastructure). The search period extended from database construction to February 21, 2020. Search terms included “novel coronavirus pneumonia,” “NCP,” “SARS,” “MERS,” “respiratory rehabilitation,” and others.
The evidence assessment group used the Appraisal of Guidelines for Research & Evaluation II tool for methodological quality assessment, the Assessment of Multiple Systematic Reviews tool for systematic reviews, and the Cochrane bias risk assessment tool for randomized controlled trials. Recommendations were generated based on evidence summaries and quality assessments, with consensus achieved through panel discussions.
Basic Principles of Respiratory Rehabilitation
Respiratory rehabilitation for COVID-19 patients must adhere to the “Guidelines for COVID-19 Prevention and Control in Medical Institutions (1st Edition).” Staff involved in respiratory rehabilitation must pass infection control training and examinations. The aim of respiratory rehabilitation is to alleviate dyspnea, reduce anxiety and depression, prevent complications, improve dysfunction, and enhance quality of life.
Early respiratory rehabilitation is not recommended for severely and critically ill patients whose conditions are unstable or deteriorating. Rehabilitation should be initiated when contraindications are excluded and infection prevention burdens are not aggravated. Staged rehabilitation measures can be employed for discharged patients with sequelae.
For patients in isolation wards, educational videos, self-management booklets, and remote consultations are recommended to reduce protective equipment usage and avoid cross-infection. Integrated rehabilitation using multiple methods is suitable for patients who meet recovery criteria and are no longer under quarantine observation.
Personalization is crucial in respiratory rehabilitation, especially for severe/critical patients, older adults, obese patients, those with multiple comorbidities, and patients with organ failure. Rehabilitation plans should be customized based on individual patient needs. Evaluation and monitoring must be conducted throughout the rehabilitation process.
Respiratory Rehabilitation Recommendations for Mildly Ill Patients During Hospitalization
Mildly ill COVID-19 patients may experience fever, fatigue, coughing, and physical dysfunctions. Psychological issues such as anger, fear, anxiety, depression, insomnia, and loneliness are common. Respiratory rehabilitation can alleviate anxiety and depression.
Patient Education
Patient education includes advocacy, videos, and booklets to help patients understand the disease and treatment process. Patients are encouraged to take regular rest, get sufficient sleep, eat a balanced diet, and stop smoking.
Activity Recommendations
Exercise intensity should be based on a Borg dyspnea score of 3 or less, with no fatigue on the following day. Exercise frequency is twice daily, lasting 15 to 45 minutes per session, one hour after meals. Recommended exercises include breathing exercises, Tai chi, and square dancing.
Psychological Intervention
Self-assessment scales are used to identify psychological dysfunction. Patients should consult psychologists or use mental health hotlines if necessary.
Respiratory Rehabilitation Recommendations for Moderately Ill Patients During Hospitalization
Moderately ill patients experience fever, fatigue, muscle ache, and prolonged bed rest, leading to decreased muscle strength, poor sputum expulsion, and increased risk of deep vein thrombosis. Anxiety, depression, and fatigue contribute to exercise intolerance.
Intervention Timing
Due to the limited understanding of COVID-19 pathophysiology, around 3% to 5% of moderately ill patients develop severe or critical disease after 7 to 14 days of infection. Exercise intensity should be low, aiming to maintain physical status. Initial consultation time, duration from disease onset to dyspnea, and blood oxygen saturation (SpO2) are assessed to determine rehabilitation initiation.
Exclusion Criteria
Patients with a temperature above 38.0°C, initial consultation time less than 7 days, duration from disease onset to dyspnea less than 3 days, chest radiological scans showing over 50% progression within 24 to 48 hours, SpO2 levels below 95%, and resting blood pressure outside the range of 90/60 to 140/90 mmHg are excluded.
Exercise Termination Criteria
Rehabilitation is discontinued if the Borg dyspnea score exceeds 3, or if patients experience chest tightness, shortness of breath, dizziness, headache, blurred vision, heart palpitations, profuse sweating, or balance disorders. Assistance from physicians and nurses is sought in such cases.
Primary Intervention Measures
Airway clearance techniques include deep breathing exercises and coughing into a sealed plastic bag. Breathing control involves upright sitting or semi-sitting positions, with slow inhalation through the nose and exhalation through the mouth. Physical activity and exercise recommendations include light exercise (less than 3.0 metabolic equivalents [METs]), performed twice daily, one hour after meals, for 15 to 45 minutes per session. Recommended exercises include breathing exercises, stepping, Tai chi, and exercises to prevent thrombosis.
Respiratory Rehabilitation Treatment for Severely and Critically Ill Patients
Severely and critically ill patients account for 15.7% of confirmed COVID-19 cases. Early-stage pulmonary lesions involve diffuse alveolar injury, with diffuse lymphocyte infiltration between myocardial fibers, suggesting possible viral myocarditis. Respiratory rehabilitation can reduce delirium, mechanical ventilation duration, and improve functional status.
Timing of Intervention
Rehabilitation is initiated when the fraction of inspired oxygen is 0.6 or less, SpO2 is 90% or higher, respiratory rate is 40 breaths per minute or less, positive end-expiratory pressure is 10 cmH2O or less, and there are no unsafe airway problems. Cardiovascular and nervous system criteria must also be met.
Early Rehabilitation Discontinuation
Rehabilitation is discontinued if SpO2 drops below 90%, respiratory rate exceeds 40 breaths per minute, ventilator resistance occurs, or artificial airway dislodgment or migration happens. Cardiovascular and nervous system criteria must also be monitored.
Respiratory Rehabilitation Intervention Measures
Positioning management includes raising the head of the bed by 60°, with pillows placed to prevent head hyperextension and relax lower limbs and abdomen. Prone position ventilation is recommended for acute respiratory distress syndrome (ARDS) patients for 12 hours or more. Early mobilization involves regular turnover and movement on the bed, sitting up, moving from bed to chair, standing, and stepping. Respiratory management includes lung recruitment and sputum expulsion, with methods such as high-frequency chest wall oscillation and oscillatory positive expiratory pressure.
Respiratory Rehabilitation Treatment for Discharged Patients
Mildly and moderately ill patients focus on improving physical fitness and psychological adjustment. Severely and critically ill patients with respiratory and/or limb dysfunction undergo respiratory rehabilitation. Post-discharge rehabilitation may address poor physical fitness, post-exertion shortness of breath, muscle atrophy, and post-traumatic stress disorder.
Exclusion Criteria
Patients with a heart rate above 100 beats per minute, blood pressure outside the range of 90/60 to 140/90 mmHg, SpO2 below 95%, or other diseases unsuitable for exercise are excluded.
Exercise Termination Criteria
Exercises are discontinued if patients experience temperature fluctuation above 37.2°C, exacerbation of respiratory symptoms, or fatigue not alleviated after rest. Symptoms such as chest tightness, chest pain, dyspnea, severe cough, dizziness, headache, blurred vision, heart palpitations, profuse sweating, and unstable gait require physician consultation.
Rehabilitation Evaluation
Clinical evaluation includes physical examination, imaging tests, laboratory tests, lung function tests, nutrition screening, and ultrasonography. Exercise and respiratory function evaluation includes respiratory muscle strength, muscle strength, joint range of motion, balance function, aerobic exercise capacity, and physical activity assessment. Activities of daily living (ADL) are evaluated using the Barthel index.
Respiratory Rehabilitation Intervention
Patient education includes booklets and videos explaining the importance, specifics, and precautions of respiratory rehabilitation. Respiratory rehabilitation recommendations include aerobic exercises, strength training, balance training, and breathing exercises. ADL guidance includes basic ADLs and instrumental ADLs (IADLs).
Traditional Chinese Medicine Respiratory Rehabilitation
Traditional Chinese medicine respiratory rehabilitation is suitable for mildly and moderately ill patients and discharged patients. Recommended exercises include Baduanjin qigong, 24-form Tai chi chuan, guided breathing exercises, and the six-character mnemonic.
Baduanjin Qigong
Baduanjin qigong involves relaxed, natural, and flexible movements, combining training and support. All eight moves are performed 6 to 8 times, lasting 30 minutes per session, once daily.
Twenty-Four-Form Tai Chi Chuan
Twenty-four-form Tai chi chuan emphasizes gentle movements and conscious breathing in coordination with systemic movements. Each set lasts 50 minutes, performed once daily.
Guided Breathing Exercises
Guided breathing exercises include standing in a relaxed pose, breathing in qi to Dantian, recuperating the lung and kidney, twisting the body and moving the hands, kneading the Shenshu point, and drawing in exercises with cultivating qi. Each set lasts 30 minutes, performed once daily.
Qigong Rehabilitation Method
The six-character mnemonic uses different sounds to regulate qi and blood flow through organs and meridians. Each character is recited six times per set, lasting 30 minutes, performed once daily.
Conclusions
These recommendations provide a comprehensive guide for respiratory rehabilitation in adults with COVID-19, based on the latest research and clinical experience. The recommendations aim to maintain physical function, promote psychological reconstruction, and enhance the capacity for remodeling activity. As understanding of COVID-19 deepens and the number of cured patients increases, updated guidelines will provide more detailed recommendations for home respiratory rehabilitation.
doi.org/10.1097/CM9.0000000000000848
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