Pulmonary rehabilitation in COVID-19 pandemic era: The need for a revised approach.

The coronavirus disease 2019 (COVID‐19) pandemic is affecting millions of people worldwide with no current signs of abatement; manifestation of illness in those infected with the virus varies widely, from asymptomatic requiring no treatment to very severe complications requiring mechanical ventilation support. Initially, the virus was thought to primarily effect the pulmonary system alone, but later it was recognized that the virus can impact multiple organ systems also. Nevertheless, those who are physically fit and possess a healthy living phenotype are less severely affected by the disease than those with pre‐existing co‐morbid conditions and hence having less morbidity and mortality. The recovery rate of COVID‐19 is improving with time due to better insight of the disease and available treatment options and hence, the number of survivors is increasing. During the recovery period, it has been reported that even patients with symptoms as a result of the viral infection continue to experience dyspnoea, chest pain and fatigue; these symptoms have been shown to persist for weeks following acute recovery. In patients recovering from a more severe manifestation of the viral infection, severe morbidity and low quality of life persist.

Pulmonary rehabilitation (PR) has the potential to play a vital role in the recovery of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). However, the traditional approach to PR is not conducive to the healthcare environment in the COVID‐19 era. In this context, the approach must be modified from the perspective of both the rehabilitation programme employed as well as a focus on minimizing the possibility of viral spread by transferring the patients to the government or community‐designated isolation centres. In this pandemic era, the multidisciplinary role by members is crucial with primary role of the members being to re‐enforce the PR plan for COVID‐19 and provide awareness, education and support whenever required. Telerehabilitation is an important component of PR in this environment as it allows access to patients who would benefit while minimizing human‐to‐human contact. During face‐to‐face treatment, healthcare professionals should employ techniques that require minimal manual handling of patients, such as remote‐controlled mechanical tilting beds, mechanical assisted limb exercisers and closed‐circuit suctioning. In the immediate post‐recovery period, patients must remain in isolation for at least 2 weeks before enrolling for supervised PR programme. During this isolation phase, patients should be advised to perform low‐to‐moderate intensity exercises as per individual capabilities or using self‐perceived exertion scales which can be easily administered from remote centres. Following the self‐isolation phase, exercise testing and prescription need to be assessed under strict protocols to minimize viral spread; properly ventilated rooms and sanitization of rehabilitation settings are essential components. Proper nutritional counselling and psychological rehabilitation are also important components of PR that should be included. Table 1 lists a proposed modified approach to PR for the COVID‐19 era. The authors of this correspondence hope that readers will find this proposed approach to be of value when considering how to alter the approach to PR.

Table 1

Proposed phase wise PR protocol depending on the severity of symptoms

(1) Asymptomatic patients (no or minimal V/Q mismatch)—Telerehabilitation
Goal: Prevention of developing comorbidities and early recovery
Improvement of immunity	Aerobic exercises, yoga and nutritional care
Improve lung compliance	Deep breathing, intercostal expansion and yoga
Respiratory muscle conditioning	IMT at moderate to high intensity using MIP to set intensity
Skeletal muscle conditioning	Aerobic and resistance training targeting larger muscles group. Train at moderate to high intensity using RPE and 10 RM for setting intensity
Oxygen supplementation will not be required and need for telemonitoring (vitals) will be minimal unless other pre‐existing co‐morbid conditions
Activities log and telemonitoring can be done for improving compliance
(2) Symptomatic patients not requiring mechanical ventilation (minimal to moderate V/Q mismatch)—Telerehabilitation
Goal: Prevention of comorbidities and early recovery
Improvement of immunity	Aerobic exercises, yoga and nutritional care
Improve lung compliance	Deep breathing and yoga
Improvement of alveolar ventilation/oxygenation	Postural drainage and autogenic drainage/active cycle of breathing techniques
Respiratory muscle conditioning	IMT at moderate intensity
Skeletal muscle conditioning	Aerobic and resistance training at moderate intensity targeting larger muscle group
Oxygen supplementation may be required during exercise training and need for telemonitoring (SpO2 by pulse oximetry) will be mandatory whether other pre‐existing co‐morbid conditions are present
Activities pacing training and self‐symptoms monitoring must be incorporated
Caution: No active exercise if fever and weakness are worsening
(3) Symptomatic patients requiring mechanical ventilation (moderate to severe V/Q mismatch)—ICU rehabilitation protocols
Goal: Improve pulmonary ventilation and prevent deconditioning
Improvement of alveolar ventilation/oxygenation	Pneumonia: Airway clearance techniques—modified postural drainage regimen, suctioning—closed loop suctioning will be better than open suctioning ARDS: Prone positioning and frequent change in positions and appropriate mechanical ventilation strategies
Improvement of immunity	Nutritional care (protein‐rich diet, zinc and vitamins)—enteral/parenteral route
Improve lung compliance	Ventilatory setting with appropriate PEEP adjusted
Weaning from mechanical ventilation	T‐piece trials IMT (moderate intensity) through endotracheal /tracheostomy tube as tolerable
Skeletal muscle conditioning	Active/active assisted/passive exercises, cycle ergometry and electric muscle stimulation at the bedside may be considered approaches Early ambulation strategies as tolerated once vital signs stabilize Neuromuscular electrical stimulation
Need for telemonitoring (SpO2 by pulse oximetry) will be mandatory during all the ICU rehabilitation phase whether other pre‐existing co‐morbid conditions are present
N.B. (1) In addition, regular psychological counselling and rehabilitation should also go side by side in each phase of rehabilitation in all the affected patients (2) Special precautions must also be taken if pre‐existing co‐morbid conditions are also present
(4) Post recovery period—(A) Supervised training, (B) Home/self‐monitored training
(A) Supervised training—Individualized exercise testing and prescription
Goal: Improve cardiopulmonary and physical conditioning
Improvement of alveolar ventilation/oxygenation	If pulmonary fibrosis is present, perform training with oxygen supplementation as needed If secretions are present, perform airway clearance techniques
Improvement of immunity	Aerobic exercises, yoga and nutritional care
Improve lung compliance	Deep breathing, intercostal expansion and yoga
Respiratory muscle conditioning	IMT at moderate to high intensity, using MIP to set intensity
Skeletal muscle conditioning	Aerobic and resistance training targeting larger muscles group at moderate to high intensity, using RPE and 10 RM for setting intensity
N.B. As patients will be non‐contagious, rehabilitation still requires separate settings than the other patients. Proper precautionary and safety measures must be followed at rehabilitation settings as prescribed by regulatory bodies for prevention of COVID‐19 spread. Make patients learn rehabilitation exercises and self‐monitoring of vitals
(B) Home/self‐monitored training
Goals and means are same as of supervised training
Telerehabilitation can be used to improve compliance of the PR
General: For non‐infected people in the community
Goal: Staying fit and prevention of comorbidities due to long‐term home stay
Interventions: Aerobics, resistance and flexibility exercises such as meditation and yoga
Emphasize on activities easily done at home—aerobic dancing, leisure activities—skipping, cycling, stepping, stair climbing, etc. if treadmill is not available

COVID‐19, coronavirus disease 2019; ICU, intensive care unit; IMT, inspiratory muscle training; MIP, maximal inspiratory pressure; PEEP, positive end‐expiratory pressure; PR, pulmonary rehabilitation; RM, repetition maximum; RPE, rate of perceived exertion; V/Q, ventilation/perfusion.