The purpose of respiratory rehabilitation for patients diagnosed with COVID-19 and hospitalized during isolation;

• Improve dyspnea symptoms.
  
• Reducing the risk of anxiety and depression in the patient during this process.
  
• Reduction of pulmonary and respiratory complications that will occur.
  
• Prevent lung dysfunction or improve the resulting dysfunction.
  
• Disability reduction.

It is to protect the lung function at the highest level and increase the respiratory capacity or to maintain the existing capacity and most importantly to improve the quality of life.

Early interventional respiratory rehabilitation is not recommended during unstable/progressive exacerbations and for patients with severe/critical illness. Respiratory rehabilitation interventions should not include contraindications to respiratory rehabilitation.

At a later stage, gradual respiratory rehabilitation measures can be taken for different clinical residual problems of discharged patients.

Regardless of the method of rehabilitation respiratory intervention, especially heavy/critical illness, advanced age, obesity, underlying diseases, and combined single-or multi-organ complications for patients with personalized principles should be followed.

APPLICATION OF RESPIRATORY REHABILITATION ACCORDING TO THE CLINICAL SYMPTOMS OF THE PATIENTS

1) APPLICATION OF RESPIRATORY REHABILITATION IN MILD PATIENTS

The symptoms of the patients are mild. They have one or more complaints such as fever, fatigue and cough. First of all, isolation is provided in these patients. During this period, the patient experiences anger, fear, anxiety, depression, insomnia, attacks and loneliness. The patient may not want to cooperate with healthcare professionals in the treatment due to fear of illness or may encounter psychological problems such as leaving the treatment in this process. With respiratory rehabilitation, the risk of anxiety and depression in the patient during isolation and treatment can be reduced.

Patients are told what they can do during the isolation process through videos or guides, so that the person will understand the disease information and treatment process and learn what they can do.

In order for the person to continue his routine;

• Getting enough sleep
  
• Getting enough rest
  
• Balanced nutrition in the process
  
• Quitting smoking is among the highly recommended recommendations for lung health, thus reducing the risk of respiratory distress.

Another important issue in the isolation process is that the patient maintains physical activity and exercises at regular intervals. The intensity of the exercise to be performed is adjusted, provided that the Borg Dyspnea score is below 3 points out of 10 and that the fatigue does not occur on the 2nd day. It is recommended to do the exercises 2 times a day for 15 – 45 minutes, 1 hour after the meal. Among the exercises, personalized breathing exercises have an important place. Psychological intervention can be given to patients by looking at the results of the self-assessment scale.

2) RESPIRATORY REHABILITATION IN THE HOSPITALIZATION OF ORDINARY PATIENTS

The most effective means to stop the transmission of the disease is isolation therapy, conditions such as fever, fatigue, muscle pain can be seen. In most patients, the sitting and lying time increases significantly, however, they can stay in bed for a long time. Decreased muscle strength, sputum, and deep venous thrombosis risk are significantly increased in patients. In this process, other psychological problems such as anxiety, depression, lack of motivation can also lead to exercise intolerance.

While applying respiratory rehabilitation for patients, the patient’s dyspnea duration and oxygen saturation are taken into account when deciding to start this exercise training. In severe and critically ill patients, the exercise intensity should not be too large to maintain current physical fitness. In severe or critically ill patients, it is recommended that the intensity of exercise activities not be too great to maintain existing physical fitness.

If patients;

• If the body temperature is higher than 38 degrees
  
• Lung image progression over 50% within 24 to 48 hours of imaging
  
• Blood-oxygen saturation is below 95%
  
• Patients can be excluded from respiratory rehabilitation if their blood pressure is below 90/60 mmHg or above 140/90 mmHg.

Criteria for stopping exercise in patients;

• If the Borg Dyspnea score is above 3 out of 10
• Chest tightness in the patient
• Dizziness
• Headache
• Blurred vision
• Palpitation
• Sweat
• If there are conditions such as inability to maintain balance, respiratory rehabilitation should be stopped and authorized medical personnel should be notified and asked for help.

The main interventions in respiratory rehabilitation are grouped under 3 headings;

1) In Airway Cleaning: The dilatation method during deep breathing can be used to help expel sputum when cleaning the airway; closed plastic bags are used to prevent the removed sputum from spreading the virus.

2) In Respiratory Control Training: Sitting position is generally used for body position (if the patient has shortness of breath, semi-recumbent position may also be used.) During pulmonary rehabilitation training, the auxiliary inspiratory muscles of the shoulder and neck should be relaxed, inhale slowly through the nose and exhale slowly. The patient observes that the lower chest is enlarged.

3) In Activities and Exercises: It is recommended that the intensity be less than 1.0 MET at rest and 3.0 MET at light physical activity. Exercises in respiratory rehabilitation are performed 2 times a day, 1 hour after a meal. Depending on the physical condition of the patient, the duration of the exercise varies between 15-45 minutes. Patients prone to fatigue can do exercises at intervals.

3) RESPIRATORY REHABILITATION IN PATIENT INDIVIDUALS WITH SEVERE AND CRITICAL DISEASE

Severe and critically ill patients account for approximately 15.7% of patients diagnosed with COVID-19. Many COVID-19 patients receiving mechanical ventilation completely lose spontaneous breathing under deep sedative analgesics. Patients have weak or no reflexes to stimuli and have a high incidence of delirium.

Starting the respiratory rehabilitation intervention at the right time is very important for delirium and mechanical ventilation to be able to significantly reduce its duration, which can improve the functional state of patients.

Before the rehabilitation intervention of severe and critical patients, a comprehensive assessment should be made of the patient’s general functional status (especially the state of consciousness), respiratory and cardiovascular system, musculoskeletal system. In patients for whom respiratory rehabilitation is indicated, a treatment program should be initiated as soon as possible.

Respiratory rehabilitation interventions cover 3 areas:

1) Posture Management
2) Early Activities
3) Breathing Method

Depending on the patient’s consciousness and functional status, the therapeutic intervention techniques chosen should be different.

1) Posture Management: In respiratory rehabilitation intervention; If physiological conditions allow, the simulated anti-gravity position is gradually increased so that the patient maintains an upright position, such as 60 degrees bedside elevation. One of the pillows to be used as an aid in positioning in severely ill patients is placed with the lower edge on the scapula to prevent excessive stretching of the head, and the other is placed under the popliteal fossa to loosen the abdomen. Patients with severe acute respiratory distress syndrome (ARDS) are recommended to be in the prone position for more than 12 hours. In respiratory rehabilitation, orthostatic treatments are applied 3 times a day for 30 minutes.

2) Early Treatment:

• Regular Rollovers and Activities
• Get Out of Bed
• Bed-Chair Transfer
• Sitting on a Chair
• Standing and Stepping on the Spot progress step by step in this order in the following stages;
• Depending on the patient’s condition, active or passive full joint range (ROM) exercises can be applied.

3) Respiratory Management: The main goal is to expand the lung capacity and eliminate sputum discharge. The respiratory therapist does not need to come into contact with the patient for a long time and endanger himself from the point of view of contracting the virus. Attention should be paid to the fact that the patient has a severe irritating cough and does not cause an increase in respiratory work in terms of further worsening of the symptoms and condition. High-frequency chest wall oscillation(HFCWO) may be recommended.

RESPIRATORY REHABILITATION TREATMENT IN DISCHARGED PATIENTS

1) PATIENTS WITH MILD AND GENERAL DISCHARGE

The rehabilitation of mild and ordinary patients after discharge is mainly to achieve physical fitness and psychological adjustment. Step-by-step aerobic exercise can be chosen to gradually restore the ability to move before the onset of the disease and return to society as soon as possible.

2) PATIENTS DISCHARGED IN SERIOUS CRITICAL CONDITION

Respiratory rehabilitation should be offered to severely or critically ill COVID-19 patients who, after discharge, still have respiratory or limb dysfunction. Based on the current findings of patients discharged from SARS and Middle East Respiratory Syndrome (MERS) and clinical experience of discharged and recovered ARDS patients, the performance of COVID-19 patients may be dyspnea and muscle atrophy after exercise (including respiratory muscles and trunk muscles).

Before starting respiratory rehabilitation, patients with one of the following conditions should consult with specialists;

• Psychological disorders such as post-traumatic stress syndrome
• Pulmonary hypertension
• Myocarditis
• Congestive heart failure
• Deep vein thrombosis
• Patients with unstable fractures and other diseases

In the Evaluation of Rehabilitation;

a) Clinical Evaluation: Physical examination, imaging examination, laboratory examination, lung function examination, nutritional screening, ultrasound examination, etc.

b) Evaluation of Exercise and Respiratory Function:

1) Respiratory Muscle Strength: Maximum inspiratory pressure/maximum expiratory pressure (MIP/MEP)
2) Muscle Strength: Sixth class muscle strength assessment (UK Medical Research Council (MRC), Manual Muscle Test (MMT), Isokinetin Muscle Test (IMT))
3) Measurement of joint range of motion (ROM)
4) Balance Function Evaluation: Berg balance scale (Berg Balance Scale, BBS)
5) Aerobic Exercise Capacity: 6-minute walking test (6MWT), cardiopulmonary exercise test (CPET)
6) Physical Activity Evaluation: International physical activity level table (International physical activity questionnaire, IPAQ), physical activity scale for the elderly (PASE), etc. scales can be used.

c) Evaluation of Daily Living Ability: Evaluation of activities of daily living (ADL) (Barthel Index.)

Respiratory Rehabilitation Interventions

a) Recommendations for Respiratory Rehabilitation:

1) Aerobic Exercise: Formulate aerobic exercise prescriptions for patients with basic ailments and residual dysfunction such as walking, brisk walking, jogging, swimming, etc., starting with low intensity, the intensity can be increased. Its duration can be adjusted 3 to 5 times a week, 20 to 30 minutes each time. Intermittent exercise can be used for patients prone to fatigue.

2) Strength Training: For Strength Training, progressive resistance training is recommended. Training load for each target muscle group is 8~12 RM (Repetition maximum, so repeat each group 8 to 12 action loads), 1 to 3 groups/times each group with a training interval of 2 minutes, 2 to 3 times a week, every 6 weeks has training time and a weekly increase of 5% to 10%. Patients with balance dysfunction should be included in balance training, including free hand balance training and balance training equipment, under the guidance of a rehabilitation therapist.

3) Respiratory Training: Symptoms such as shortness of breath, wheezing, difficulty in sputum discharge, etc., after the patient’s discharge should be combined with the results of the assessment targeting respiratory pattern education and expectoration education.

4) Breathing Mode Training: It should mobilize body management, adjustment of respiratory rhythm, training of chest activity and participation in respiratory muscle group.

5) Sputum Education: First, patients with original chronic airway disease can use the breath while clearing the airway in the hospital. The techniques help reduce sputum and reduce energy expenditure in coughing. Secondly, it assists positive expiratory pressure(PEP) / (OPEP) and other equipment.

b) ADL Guidance

Basic Activities of Daily Living (BADL): Assess the patient’s ability to perform daily activities such as educational transfer, toilet and bathing, and provide rehabilitation guidance for these daily living disabilities.

Activities of Daily Living (IADL): Assess the ability to perform instrumental daily activities, find barriers to engagement, and perform targeted intervention under the guidance of occupational therapists.

HOW SHOULD HEALTH WORKERS PROTECT THEMSELVES FROM SARSCO1 VIRUS INFECTION IN THE TREATMENT OF A PATIENT -SUSPECTED CASE?

Tips for the prevention of New Corona Virus infection by Medical Institutions;
1) Wear your mask or other protective equipment when dealing with a patient with respiratory distress.
2) Inquire the International travel history of your patients. Especially for those countries where an epidemic of the Corona Virus appears!
3) Report your patient with suspected Corona Virus to medical institutions.

Tips to prevent the spread of COVID-19 among the Public;
1) Wash your hands with soap and water for at least 30 seconds. If you cannot find soap and water, use an alcohol-based disinfectant.
2) If you don’t have a mask, please use the inside of your elbow to cough. If you have coughed by covering your mouth with a tissue, throw the tissue away.
3) Do not touch your eyes, nose and mouth with your hands.
4) Wear a mask when visiting medical facilities.
5) Do not be in crowded places.
6) Do not come into close contact with people who have symptoms of Fever and Cough.

THINGS THAT HEALTHCARE PROFESSIONALS NEED TO CONSIDER WHEN USING PROTECTIVE EQUIPMENT

1) Hair should be collected with care, personnel should not wear any jewelry to avoid contamination.
2) Health personnel should drink water before putting on the protective equipment to prevent thirst, and then they should meet their toilet needs.
3) If any contamination or damage is detected after wearing the protective equipment, the equipment should be replaced.
4) Health personnel whose gloves get wet should change their gloves.
5) Healthcare workers should wear protective masks, safety glasses and face shields, disposable long-sleeved waterproof gloves or normal medical gloves.
6) It is mandatory to wear all protective clothing when performing trecheal intubation, laryngoscopy or cardiopulmonary resuscitation.
7) If possible, it is recommended that at least 1 doctor and 1 assistant nurse use a compressed air cleaner device.
8) 2 pairs of gloves should be worn against the risk of tearing the gloves.
9) Considering that healthcare professionals working during the pandemic stay in the hospital in order not to infect their families, and cope with heavy patient burden during long working hours, they should receive psychological support. It is beneficial for them to eat regularly and do stretching exercises as much as they can.

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