Physiotherapy Management for COVID-19 in the Acute Hospital Setting: Recommendations to guide clinical practice

Endorsed by:
World Confederation for Physical Therapy, International Confederation of Cardiorespiratory Physical Therapists, Australian Physiotherapy Association, Canadian Physiotherapy Association, Associazione Riabiliatory dell’ Insufficieza, Respiratoria, Association of Chartered Society of Physiotherapist in Respiratory Care UK (ACPRC)

The full article is published on Journal of Physiotherapy, April 2020;66(2):73-82, https://doi.org/10.1016/j.jphys.2020.03.011


Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a highly contagious new coronavirus that emerged in 2019 and causes Coronavirus Disease 2019 (COVID-19). The Section of Cardiovascular and Respiratory Physiotherapy - Rehabilitation (CRPR) of the Panhellenic Physiotherapists’ Association in Greek language after permission the “Physiotherapy Management for COVID-19 in the Acute Hospital Setting: Recommendations to guide clinical practice” (Thomas et al., 2020) (http://www.tkafa.gr/img/enimerosi_files/0659202001586446489100000.pdf) (March, 2020). These recommendations inform physiotherapists and the rest of the hospital's healthcare staff about the role of physiotherapy in the acute phase of hospitalization in the management of patients with confirmed and / or suspected COVID-19 and the individual protective equipment (GDP) required duration of physiotherapy.

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, physiotherapists may provide airway clearance techniques for ventilated patients who show signs of inadequate airway clearance and they can assist in positioning patients with severe respiratory failure associated with COVID-19, including the use of prone position to optimise oxygenation. First of all, it is necessary to record the equipment of respiratory physiotherapy, mobilization and exercise, in order to prevent the movement of the equipment between infectious and non-infectious areas of the hospital. Avoid sharing equipment. Physiotherapists are required to have specialised knowledge, skills and decision making to work within the ICU. It is necessary to increase the required physiotherapy workforce by allowing additional shifts for part-time staff, or recruit a pool of casual staff. Physiotherapy interventions should only be provided when there are clinical indicators, so that staff exposure to patients with COVID-19 is minimised and PPE supplies may be reduced. Physiotherapists should meet regularly with senior medical staff to determine indications for physiotherapy review in patients with confirmed or suspected COVID-19 and screen according to set/agreed guidelines (if they have pneumonia, mild symptoms or severe symptoms, lower respiratory tract infection). Physiotherapy may be indicated, particularly if weak cough, productive and/or evidence of pneumonia on imaging and/or secretion retention. Patients should wear a surgical mask during any intervention. Staff uses airborne precautions. Patients will be provided treatment in isolation rooms. A Senior PT will screen patients with COVID-19 in consultation with an ICU medical Consultant before the physiotherapy program. 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. In adult patients with COVID-19 and severe ARDS, prone ventilation for 12–16 hours per day is recommended. Closed inline suction catheters are recommended. Physiotherapy respiratory interventions (or chest physiotherapy) include: Airway clearance techniques, positioning, active cycle of breathing, manual and/or ventilator hyperinflation, percussion and vibrations, positive expiratory pressure therapy, mechanical insufflation-exsufflation (MI-E). Techniques to facilitate secretion clearance should be followed i.e., assisted or stimulated cough manoeuvres, and airway suctioning. BubblePEP is not recommended for patients with COVID-19. There is no evidence for incentive spirometry in patients with COVID-19. Physiotherapists also play an integral role in the management of patients with a tracheostomy.

Physiotherapists are responsible for the early mobilization of the patients including passive, active assisted, active, or resisted joint range of motion exercises to maintain or improve joint integrity and range of motion and muscle strength, bed mobility, sitting out of bed, sitting balance, sit to stand, walking, tilt table, standing hoists, upper limb or lower limb ergometry. Only where there are significant functional limitations (e.g. (risk for) ICU-acquired weakness, frailty, multiple comorbidities, advanced age) should the requirement for direct physiotherapy interventions is considered. It is recommended COVID-19 patient’s, ideally, be treated in a Class N negative pressure single room. Airborne precautions are followed including: an N95/P2 mask, fluid resistant long-sleeved gown, goggles/face shield, gloves, hair cover for AGPs, shoes that are impermeable to liquids and can be wiped down.