Rehabilitation Treatment for Severe/Critically Severe Patients

Severe/critically severe patients meet the diagnostic criteria for suspected/ confirmed cases of Notice on Issuance of COVID-19 Diagnosis and Treatment Protocol (7th Trial Edition).

Severe types are adult patients who have any one of the following:

• 1) Respiratory distress, RR > 30 times/min
• 2) At rest oxygen saturation < 93%
• 3) Partial pressure of blood oxygen (Pa0₂)/fraction of inspiring oxygen (FiO₂) < 300 mmHg (1 mmHg = 0.133 kPa)
• 4) Lesions with significant progression within 24-48 hours in pulmonary imaging examination are treated as severe

Critically severe types are patients with any one of the following:

• 1) Respiratory failure and mechanical ventilation is required
• 2) Shock
• 3) Patients with other organ failure should be monitored in ICU
• 9.3.1.2.1 Objectives of Rehabilitation Treatment

The objectives are to promote the discharge of respiratory secretions; improve alveolar ventilation, improve respiratory function, prevent complications, such as muscle atrophy, joint contracture, decreased cardiopulmonary function, and deep vein thrombosis.

Exercise should not be too intense during rehabilitation treatment, and the rehabilitation physician should prescribe the time of intervention and withdrawal. If the patient has anemia or abnormal blood clotting function, check hemoglobin and blood clotting function indicators before respiratory rehabilitation treatment to avoid tissue hypoxia and bleeding caused by activities. For bedridden patients, guide them to exercise ankle pump or use elastic stockings to prevent the occurrence of deep vein thrombosis of the lower limbs.

• 9.3.1.2.2 Rehabilitation Treatment Methods
• 1) Position management: Patients undergoing respiratory rehabilitation therapy should be guided to change position after discussion by the clinical treatment team. By raising the bed head to the half-lying position, gradually transition to the sitting position. Position therapy lasts for 30 minutes, three times a day. Patients with acute respiratory distress syndrome (ARDS) can use prone position > 12 hours a day to improve ventilation blood flow ratio, reduce pulmonary edema, increase functional residual volume, and reduce the possibility of intubation. Consider extracorporeal membrane oxygenation (ECMO) for poor prone ventilation. Turn over regularly, once every 1-2 hours. Lung recruitment is recommended for patients with severe ARDS.
• 2) Airway cleaning: The “ha” coughing technique and deep inhalation stage expansion are adopted, and personnel should take care not to cause severe irritating and increased breathing work in patients. It is also possible to use positive pressure expiratory therapy/oscillatory positive pressure expiratory therapy, high-frequency chest wall vibration, and other methods, making it easier for patients to discharge airway secretions and improve lung function and prevent pulmonary complications. Pay attention to avoid causing or exacerbating bronchospasm. Patients with impaired consciousness or sedation are usually treated with three different frequencies of 10 Hz, 12 Hz, and 14 Hz for 10 minutes each. After treatment, the nurse should suck sputum.
• 3) Respiratory control training: Ensure adequate oxygen supply. Apply rehabilitation treatment techniques that avoid disconnecting patients from the ventilator. Patients with clear consciousness can also be under chest expansion breathing training. If necessary, terminally ill patients should receive palliative medication to relieve dyspnea.
• 4) Early activity: Ensure patients are given sufficient oxygen during activities. Prevent the pipeline connecting the patients from detaching and monitor vital signs throughout the process. If SpO₂ <88%, terminate the rehabilitation treatment. Bedridden patients can perform progressive active limb movements or passive instrumental movement on the bed, turn over and regularly move on the bed, and receive active/passive whole-joint exercise training. With the help of breathing control technology, patients who can get out of bed can sit up from bed, move from bed to chair, sit on a chair, stand up and march on the spot. Perform these exercises one to two times per day without increasing fatigue. All activities should not cause oxygen saturation or blood pressure to drop. For those with transfer disorders, this can be done with a walker, a sturdy chair or a bed file, or a therapist’s assistance. Patients with sedative use or cognitive impairment or physical limitations, choose passive power for lower limbs by the bedside, passive joint movement and stretching, and neuromuscular electrical stimulation. The total training time should not exceed 30 minutes at a time, so as not to cause aggravation of fatigue.

• 5) Exercise therapy: Patients can proceed with active body movement step by step when they are conscious. According to patients’ specific conditions, progressive strength training, and endurance training of upper and lower limbs can be carried out in the choice of exercise therapy without causing fatigue.
• 6) Lung recruitment therapy: This therapy refers to ventilator hyperinflation (VHI) technique, recruitment maneuver (RM), and intense breathing training. It can effectively increase lung volume, improve lung compliance, optimize ventilation and blood flow ratio, and reduce pulmonary edema by recruiting collapsed alveoli to correct hypoxemia and ensure the positive end-expiratory pressure (PEEP) effect. It is particularly essential for patients with ARDS.
• 7) Muscle strength training: This method adopts the bedside passive power cycling training for upper and lower limbs.
• 8) Patient education: Continue to educate and comfort patients so they understand the outcome of disease development, maximize their compliance, and reduce their mental burden.