1

SYMPTOMATIC RESPIRATORY PHYSIOTHERAPY

MANAGEMENT STRATEGIES FOR COVID-19 PATIENTS
DATE OF WRITTEN- 28 April 2020

Total pages -21

ABSTRACT

The role of physiotherapy while dealing with the current pandemic of COVID 19 is by
using various methods included as an adjuvant therapy such as- Deep breathing exercises,
Bronchial hygiene techniques Permissive hypercapnia Iontophoresis with zinc ion (Zn 2+),
Diaphragmatic pacing, Active movement of extremities (lower and upper) Mechanical airway
clearance and oscillating devices such as positive pressure devices, high-frequency chest
oscillation, oral high-frequency chest oscillation, flutter device and Cornet devices along with
NIV, HNFC, and COT. The benefit of these techniques and devices is to loosen the adhesion
of mucus, reducing the load from mechanical ventilation and facilitate its transport
from smaller to higher airways respectively. So that the mucus gets easily removed,
improves in systemic & peripheral airflow, exchange in oxygen, and for maintaining lung
hygiene in mild, moderate, and severe complications.

KEYWORDS

respiratory symptoms; chest physiotherapy techniques; respiratory devices; physiotherapy interventions

1
Author’s - 1. Ms. SAKSHI ARORA ,ASSISTANT PROFESSOR ,GALGOTIAS UNIVERSITY, UTTAR PRADESH ,INDIA
(sakshi.arora@galgotiasuniversity.edu.in)

2. HARDIKA JAIN, RESEARCH STUDENT ,GALGOTIAS UNIVERSITY,UTTAR PRADESH, INDIA

(jainhardika19@gmail.com)

3. SHIVANK KHARE ,RESEARCH STUDENT ,GALGOTIAS UNIVERSITY,UTTAR PRADESH, INDIA

(khareshivank078@gmail.com)

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INTRODUCTION

source [1]

Coronavirus is a newly discovered virus from SARS-COV-2 (2) causing the infectious
respiratory disease in humans. People infected with COVID -19 viruses will experience
mild to moderate respiratory illness, while people with underlying medical problems like
cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely
to develop serious illness. [2] According to ongoing studies the virus affects the type 2
alveolar epithelial cells of respiratory airways causing excess production of mucus and
blockage of airways. The symptoms may appear after exposure and the Reports have
shown that clinical deterioration can occur rapidly, often during the second week of the
disease after intubation and recovery depending on the strength of the immune system.

The preliminary data from EU/EEA shows that around 20-30% of diagnosed COVID-19
cases are hospitalized and 4%have severe illness. Hospitalization rates are higher for
those aged 60 years and above, and for those with other underlying health conditions. [4]

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The physiotherapy has been used since a long time to optimize the functional capacity
and well being of patients dealing with various respiratory disorders in ICU, OPD, or
rehabilitation health centers to help integrate that patient return to their chosen lifestyle
early as possible. Physiotherapy is an effective model that can be used precisely to
provide symptomatic relief in various symptoms of COVID 19 targeting at all age groups.

BACKGROUND- The novel detected in Wuhan city, China in 2019 and is closely
related genetically to the SARS-CoV-1 virus. The SARS emerged at the end of 2002 in
China, and it caused more than 8000 cases in 33 countries over eight months. At the end
of 30 march 2020, the COVID-19 outbreak has caused over 7,00,000 cases worldwide [3]
the first case was reported in China in January 2020. Among these more than 30000 are
known to have died, while the virus that COVID-19 and seasonal influenza transmitted
from person-to-person and may cause similar symptoms. Around more than 16000
people died till March 25th across the world[3] So it is mandatory for specific detection of
symptoms and utilizing the health care workforce for providing symptomatic treatment to
the patients until an effective vaccine is available against the virus.

MODE OF TRANSMISSION -It spreads primarily through droplets of saliva or

discharges from the nose when an infected person coughs or sneezes. It lasts hours in
the form of aerosol and the soil for 4-5 hours. [ 3] These droplets can then be inhaled, or
they can land on surfaces that can come in contact with, one can get infected when they
touch their nose, mouth, or eyes. The virus can survive on different surfaces from several
hours (copper, cardboard), up to a few days (plastic and stainless steel). However, the
amount of viable virus declines over time in the absence of the host, and May is not
always present in sufficient numbers to cause infection.

The incubation period of coronavirus is currently estimated in between 1 to 14 days. [2]

PATHOPHYSIOLOGY- COVID-19 name given by WHO as Beta- Cov of group 2B. The
genetic sequential study shows more than 80% SARS -cov & 50% to MERS-CoV, both
originating in bats. So the phylogenetic statically data indicates that COVID-19 belongs
to genus *beta-coronavirus*, which SARS-Cov, that infects human, bat & wild animals.
COVID-19 represents the 7th member of the coronavirus family that infects humans & is
classified under ortho-coronavirus sub-family. Some underlying genetic factors are also
enlisted -

1. High level of cytokines & chemokines:-

IL1-β, IL1RA, IL7, IL8, IL9, IL10, basic FGF2, GCSF, GMCSF, IFNγ, IP10,MCP1,
MIP1α, MIP1β, PDGFB, TNFα, and VEGFA

2. High level of pro-inflammatory cytokines: - IL2, IL7, IL10, GCSF, IP10,MCP1, MIP1α,
and TNFα

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General symptoms – ranges from asymptomatic to mild fever, tiredness, and a dry
cough, muscular pain. [2]

✧ Running nose, sore throat, nasal congestion, body aches/pain or diarrhea

✧ Loss their senses of taste and/or smell.

About 80% COVID -19 mild case – experience as a regular cold & recover without
needing any special treatment. According to the National, Health Science has identified
the specific symptoms

- High temperature –you feel hot to touch on your Cloister back

Continuous cough –coughing repeatedly
- viral pneumonia

Emergency symptoms

● Trouble breathing
● Persistent pain or pressure in the chest

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● Mild Mental confusion or inability to arouse

● Bluish lips or face

COMPLICATIONS
o Severe pneumonia
o Acute respiratory distress syndrome
o Sepsis
o Septic shock
o Multiple organ failure
o Acute kidney injury
o Cardiac injury

METHOD AND REVIEW OF LITERATURE

The underlining articles are based on respiratory symptoms similar as observed in

COVID patients and the previously used physiotherapy management strategies are
mentioned below in the table-

AUTHOR TOPIC TECHNIQUE/DEVICES ARTICLE REVIEW

Conduct a cohort study on the

Antonio et Effectiveness of 24 hour/day and 6 efficiency of chest physiotherapy
al.[5] chest hours/day chest among two groups of patients 'A' and
'B' in which group 'A' was provided
physiotherapy in physiotherapy given to with 24 hr/day chest physiotherapy in
ICU patients ICU patients. 4 shifts (morning, afternoon, evening,
night) and the other group 'B' with
based on Common techniques 6hr/day PT in one shift in two different
hospitals of Brazil. The chest
duration. applied to both groups therapeutically cares given with the
are- detailed assessment of 143 patients
in ICU and scheduled goals with
● the mucus removal given protocol included the mucus
removal techniques (endotracheal
techniques suctioning and manual thorax
(endotracheal percussion) and general mobilization
(upper and lower limbs). The
suctioning and manual physiotherapy treatment is addressed
to prevent and reduce potential
thorax percussion) pulmonary complications such as
hypoventilation, hypoxemia, and
infection to restore muscular and
● general mobilization pulmonary functions as fast as
possible. The analysis was done once
(upper and lower a week & measures outcomes such
limb) as- clinical diagnosis, medications in
use, APACHE II and SOFA scores,

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ICU and mechanical ventilation

length of stay, and development of
pulmonary infection and survival.
Hence study found that the recovery
of group 'A' was fast at low
mechanical ventilator length of stay
and low development of complication
as compared with group 'B'.

Jones A Y M Chest Various chest Concluded that physiotherapy

[6] techniques reduce intra-pulmonary
et al. physiotherapy in physiotherapy techniques shunt and hence increases
ICU patients manually in mechanical compliance of the respiratory
system. The patient has high carbon
ventilated and respiratory dioxide, increased heart rate, and
disorder disease. systolic blood pressure, and
increased oxygen consumption.

They conducted a study based on

Isabella Naira Bronchial hygiene Techniques such as - analysis describing why & what are the
et al[7] technique in vibrocompressor, bronchial hygiene techniques used in
patients of mechanical ventilation by a
mechanically hyperinflation, postural group of a physiotherapist from five
ventilated drainage, percussion & different hospitals (3private, 1 teaching
& 1 public).In round 185 questionnaires
patients motor mobilization of filled by professionally trained physical
mucus. therapists & experience in the various
clinical setup of ICU management give
their static review on no. Of patient
handling along with their experiences
over different bronchial hygiene
techniques:-
PT graduation year Total population
1.6to10 yr. 2. Before the study 43.2%,
More than 10 yr. Before 31.9%
Now the patients handling details:-
Number Of patients seen per shift
1. 41.1% handles around 4to6 patients
per 6 hours of the shift.
2. 31.9% handles around 9to10
patients during a duty shift.
The clinicians use different categories of
techniques on mechanical ventilation to
maintain bronchial hygiene, some of the
underlying techniques are:-
Percussion, Vibro-compressor, tracheal
suction, hyperinflation, postural
drainage & motor mobilization.

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Give their literature review on

O' Cronin. Effectiveness of Permissive hypercapnia permissive hypercapnia related to its
& Catarina non-invasive effectiveness & adverse side effects,
both the articles have a common
Silvestre et hypercapnia to approach as a ventilation strategy in
[8,9]
al. fulfill the oxygen which high level of CO2 are tolerated
as to avoid high tidal volume, lung
requirements in overdistension & ventilator-induced
lung injury, so to fulfill the sufficiency
patients with of O2 into the lungs at low inspiratory
ARDS, pressure & volume use of this non-
invasive technique is taken
mechanical place. The main underlying
indications regarding permissive
ventilated, hypercapnia are ARDS, mechanical
acute lung ventilation, acute lung injury, etc.
Used in critical care for adult,
injury. pediatric & neonatal patients
requiring mechanical ventilation

Airway clearance ● Controlled breathing 1. Controlled breathing

techniques for- -Deep coughing It is a therapeutic technique which

includes chest and stomach muscles
-mild to moderate -huff coughing for improving cough clearance
respiratory ● Deep breathing among which there are further two
methods such as
symptoms A) Deep coughing – the patient
position is sitting or straight in
patients. supine lying, wrapping his/her
arms around the stomach and
inhales deeply keeping lips
pursed, emits a forceful cough
while compressing arms firmly
against stomach muscles.
This technique will force the
diaphragm to do more work.
B) Huff coughing –taking slow,
deep breaths in to fill lungs with
air. Then tensing the stomach
muscles, make three rapid
exhalations with your mouth
open with the sound of “ha” on
expiring air. Continue repeating
until the patient feels the mucus
breaking up, then take a deep
cough out to clear the lungs.

2. Deep breathing

It involves taking pro long breaths to

expand the lungs (breath in mode)
during inhalation and push out excess
air (breath out) as u can during
exhalation.
These techniques are helpful mostly
for active patients having mild
symptoms to prevent further spread.

Excess use of mechanical ventilator

on lung disorder patient leads to
impairment of mucociliary clearance

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lesions caused by inadequate

humidification, suctioning,
administration of paralytic agents &
drug which reduces the chest wall
tone, so ultimately there is an
increase in chances of complications
results into infection & damage to
airways.[15]

Ka Man Fong Providing oxygen The Meta-analysis summarizes the

Preoxygenation using efficiency of giving the pre-oxygenation
et al. [10] before intubation NIV, conventional oxygen using NIV, COT (conventional oxygen
therapy) via nasal prong, cannula mask
among acute therapy, high flow nasal or bag-valve-mask, HFNC before
respiratory failure cannula(HFNC)method. intubation in among 956 patients while
performing RTC.
Pre-oxygenation helps in delivering
oxygen during the period before the
induction of anesthesia.
◆ The primary outcome was the
patient's pre -oxygenated using NIV
having less desaturation that is minimum
spO2 low than using HFNC, COT methods.
◆ The secondary outcome was
intubation related complication was
negligible using NIV, HFNC as compared
to COT among acute respiratory failure
patients.

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Young Zhu et Providing oxygen High flow nasal cannula, They Conducted a study on extubation
al.[11] therapy to avoid Conventional oxygen which removes endotracheal tubes in
mechanically ventilated patients. Due to
post complication therapy the increased duration of using
mechanical ventilators, there are
of extubation in increased chances of hypoxemia,
extubation failure and reduces the function
mechanically mechanical capacity of lungs. It is found
that the conventional oxygen therapy is
ventilated supportive treatment with maximal flow
rate 15L/min, which is far lower than the
patients. demand of post-extubation patients with
acute respiratory failure. While high flow
nasal cannula can supply a mixture of air
and oxygen via a heated and humidified
circuit at very high flow, it can provide
maximum pure oxygen with more than
60L/min flow rate.

al. [12] In vitro study of Iontophoresis using They conducted an independent in-
zinc ion, use of pyrithione in combination vitro study in 2010 which
demonstrated the combination of zn2+
low concentration with zinc ions. and PT at low concentration
(2Umzn2+ and 2umM PT) inhibits the
zinc ion in replication of (SARS CoV) and equine
iontophoresis. arteritis virus (EAV) in cell culture.
They utilize additionally provided
information for the use of zinc ion in
iontophoresis as antiviral therapy.
Zn +2 ions are the commonest ion
in various cellular processes to serve
the role of an enzyme, transcription
factors & co-factor for numerous viral
proteins as well. The intracellular low
level of zn2+ ions affects a common
step in the replication cycle of these
viruses. The effect of zn2+ ion on
positive-strand RNA virus includes
major pathogens found in humans
and livestock which mainly focuses
on SARS-Cov causing severe acute
respiratory syndrome, respiratory
syndrome virus (PRRSV). The zn2+
concentration in PT inhibits certain
proteolysis cleavages in the process
of replication of the coronavirus
replicas’ protein in the infected cell
and cell-free system.
In this study, they reported that the
iontophoresis with pyrithione & zn2+
potentially inhibits the replication of
SARS-coronavirus (SARS CoV) and
equine arterivirus by increasing Zn
ion concentration in cell culture. But
the data on the procedure of using
iontophoresis with Zn2+ is still
inadequate.

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Iris A. Perez Study to increase Diaphragmatic pacingThey ca. In this literature review about
diaphragmatic pacing author suggested
et al[13] the breathing rate to increase the breathing rate by
stimulating the phrenic nerve at the place
by using a of a mechanical ventilator in various
spinal cord injuries & congenital
diaphragmatic hypoventilation syndromes (CCHS) by
using mainstream criteria of application in
pacing technique. patient's, A person is to be considered for
diaphragmatic pacing one must be sure
that:- 1. There is normal diaphragm
muscle functioning, 2. The phrenic nerves
are intact & able to send a signal when
stimulated, 3. The person has some
relatively mild or no lung disease. [The
system doesn't work well if the lungs
functioning is not proper.]

for

Early mobilization Early and post ventilated

The early mobilization before using
and recovery in Mobilization of the upper mechanical ventilator in ill patients, with
postural drainage or endotracheal
mechanically and lower limb. suctioning procedure and post ventilation
ventilated mobilization of the patient in bed, while
standing during changing posture and
patients[14] position from bed to chair then to standing
proved to be beneficial in the cohort study
conducted by twelve ICU’s in Australia[21]
that -
● Reduce the duration of ventilation
● Decrease ICU length of stay
● Decrease hospital length of stay

Conducted a study on patients over

Priya Sharma ACAPELLA mechanical ventilator on more than 48
et al.[15] hours with and Canada ay showing
bilateral infiltration in lungs, falling
between the age of 27-71 years with
ARDs.
They used ACAPELLA which was
connected to the expiratory part of the
mechanical ventilator with frequency dial
set at the minimum for 15 min. further
ACAPELLA is attached and pass through
a pivoting cone and generate airflow
vibration between 0-30 Hz .later suctioning
is done and amount of sputum is
measured along with SpO2.

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Various oscillating ● Positive expiratory Positive Expiratory Pressure devices–

it helps in allowing more air to enter in
devices pressure devices[15] peripheral airways through collateral
channels in alveoli, the pressure air to go
● High-frequency chest behind secretion, and move them from
smaller airways to larger airways.
oscillation It had been reported that significant central
clearance, easy for the patient to handle
● Oral high-frequency and comfortable, reduce chances of
pulmonary infections and reduce the
oscillation devices requirement of antibiotics, prevent

●
atelectasis, reduce the need for intubation
Flutter devices in respiratory ill patients.
●
.
Cornet devices High-Frequency Chest Oscillation
device:- it is performed with a mechanical
device that consists of the inflatable vest
around the chest and an air pulse
generator which produces positive
pressure air pulses to the chest wall. It,
therefore,e, produces pressure of about
50cm H2O at a frequency of around 525
Hz delivered via a pneumatic vest which
surrounds the thorax. The vibration
causes flow increase in the airways,
loosening mucus, an increase in low lung
volume, and hence, provide
stabilization\improvement of respiratory
function.
According to the study, then these devices
have thannthannandard CPT in small
clinical trials12.
Oral High-Frequency Oscillation
device: - within the lungs produce high-
frequency sine wave oscillations that are
associated with an increased clearance of
CO2 are produced by an eccentric cam
piston superimposed on normal tidal
breathing. The low volume of
approximately 48ml and pressure
approximately 0.2cm – 2.0cm H2O with a
mean pressure of zero provides
supplement breathing to the patient
spontaneously. It applies to the
management of a patient with acute and
chronic respiratory failure.

Flutter devices: - it is a controlled

vibration system that produces positive
expiratory pressure and cyclic oscillations
of the airways during expiration. It consists
of a tube-based on oscillations of a steel
ball during expiration through a pipe.
Facilitating in loosening mucus, decrease
the lung collapse, and accelerate airflow.
It is followed by huffing and coughing
maneuver actively by the patient.

Cornet device: - it consists of a semi-

circular tube that was ita h a flexible latex-
free hose. Expiration through the cornet
causes the hoes to flex, buckle, unbuckle,
causing oscillating positive pressure in the
airways which fluctuate many times per
second. It has only a short term effect for
clearing mucus from the airways 10.

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DETAIL of INTERVENTIONS AND TECHNIQUES FOR RESPIRATORY SYMPTOMS:-

TECHNIQUES SUB - TECHNIQUES BENEFITS/USES

1. Mucus clearance Endo-tracheal suctioning, • Removes mucus
techniques. manual thorax percussion & from trachea &
general mobilization. upper respiratory
segments.
• Allows better
breathing cycles by
maintaining proper
oxygenation &
ventilation

2. Bronchial hygiene Vibro-compressor • Clearing

techniques. hyperinflation, percussion, respiratory
postural drainage & motor secretions.
mobilization. • Decrease airway
obstructions.
Improves
ventilation quality.
•Activates
respiratory muscles
for their effective
working.
3. Airways clearance A. Controlled breathing • Releases mucus
techniques. ● Deep coughing • Allows effective
● Huff coughing gaseous (O2 & Co2)
B. Deep breathing exchange with the
environment.
•Breathing improves
the saturation
quality in alveoli &
allows a max.
Ventilation
4. Oxygenating • Extends the safe
techniques. apnoea time

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● Pre-oxygenation using NIV • By using the NIV

technique it
provides effective
oxygenation &
prevents
desaturation of
● Conventional O2 arterial
therapy(COT) oxyhemoglobin.
• Use of COT
enhances the level
of o2 in lungs &
blood in low oxygen
patients which
ultimately improves
various physiological
processes such as -
sleep, mental
●High flow nasal cannula alertness, stamina,
(HFNC) etc.
• HFNC reduces
patient breathing
load, allows proper
O2 flow into the
lungs & serves as an
alternative
mechanical
ventilation device.
5. Oscillatory devices ● Positive expiratory pressure • PEP moves the
device (PEP) mucus in from
smaller to larger
airways & allows the
airway to clear and
open from
● High-frequency chest wall obstructions.
oscillations (HFCWO) • Loosen thick
mucus & improves
lung functioning by

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reducing the load of

lung infections,
antibiotics &
● Oral high-frequency hospital-acquired
oscillation device. pneumonia.
• Act as ann internal
percussor & provide
ventilatory support
respectively.

6. Mobilization A. Upper limb mobilization • For activation of

B. Lower limb mobilization body soft tissue
structure, improving
blood circulations,
facilitating
lymphatic drainage,
and for better
functioning of vital
functioning of
organs like - lungs,
heart, brain, etc.
7. Permissive •Acceptance of
hypercapnia higher carbon
dioxide (CO2) levels
than normal
___ facilitated the use of
lower ventilator
settings and smaller
tidal volumes which
result in decreased
lung injury & other
respiratory trauma.
8. Acapella • Remove mucus
adhesion
___ • Clears air-ways
•for better
effectiveness they

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are used after

bronchodilators
9. Iontophoresis with an Inhibit growth and
ion ___ replication of the
virus inside the host
cell
Further data is
inadequate.
10. Diaphragmatic pacing a) Uses in people
___ having breathing
difficulty.
b) It lowers the
breathing rate &
reduces chest
wall tone
overtime in
respiratory
disorders.
c) Use in place of
mechanical
ventilators at
times.

DISCUSSION
Currently provided treatment according to the protocol [1, 7]
o 14%-severe ill required oxygen therapy
o 5%-require ICU treatment
o Critically ill-due to severe viral pneumonia require mechanical ventilation.
● The situation arises in front of healthcare professionals, it is high time to update the
multidisciplinary approach for providing the treatment available to the able workforce and
equipment. So a large number of patients get good medical facilities and recovery
becomes speedy.
On the other hand, by providing adequate and available Physiotherapy techniques to
keep the airways open so that the medication will get ample time to act properly.

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● As a physiotherapist using various physical therapy interventions and devices which can
help in reducing the load on the use of mechanical ventilators because of its high
requirements & low availability.
● An increase in mucus production is a major issue seen in COVID 19
patients and the secretions can block airways
(narrowed air passages, difficult to breathe air, and hence reducing
respiratory rate ), the accumulated mucus also becomes the cause
of breeding growth in any other pathogens. So the counter treatment
in certain chest physiotherapy interventions and exercises can be
used to maintain pulmonary hygiene.
● For the patient, those who are unable to have any active methods
can be treated with intrapulmonary percussion, ventilator, PVPD,
suctioning.
● Musculoskeletal abnormalities, muscle dystrophies or other similar
disease requires stabilization of functions, optimizing ventilation in such
patient may require positive pressure ventilation during sleep or
continuously, externally applied pressure, within insufflator or the
cyclically inflated pneumatic belts can provide patient self-assistance
while doing work.[16]
● The manual or mechanical chest physiotherapy helps in enhancing

mucociliary clearance. Along with ch provide intra-thoracic oscillation that

creates variable resistance within the airways, generating positive
pressure with control oscillation helping in reducing mucus adhesion
inside the lungs and alveoli.

LIMITATIONS

Though there is a lack of proper treatment approach to completely get cured of

COVID-19 respiratory disease.

Many techniques have only a systematic review of the literature and are lacking in
practical applications.

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The data was collected based on similar symptoms which are identical to
respiratory distress caused by the COVID-19 virus.

There is no such evidence for iontophoresis & diaphragmatic pacing but if using
them with proper application method and ruling out contraindication then reviving
effective breathing rate can be done in mild to moderate symptoms of COVID-19.

The facts one goes with new non-evidence based strategies but as a pre -
prevention point of view the future upcoming medical health sector loads can be
reduced & prevent further pandemic by using some of the above-mentioned
interventions or techniques.

ROLE OF PHYSIOTHERAPY

GOAL OF REHABILITATIONS
● To maintain bronchial hygiene and airway clearance.
● To decrease phases of shortness of breath.
● To reduce the complication of a mechanical ventilator.
● To maintain active physiological movements in ventilated patients.
● To reduce the spread of infection.
● To maintain chest wall mobility.
● To reduce the dependency on a mechanical ventilator.
● Using other techniques & devices manually to restore muscular and
pulmonary function.

BASED ON EVIDENCE PHYSIOTHERAPY MANAGEMENT

● Providing 24hour/day physiotherapy to the ICU patients with mucus removal
techniques (endotracheal suctioning and manual thorax percussions) and
general mobilization (upper and lower limbs) is proved in terms of reducing
potential pulmonary and systemic complications, ventilator dependence,
hospital stay, restoring early muscular functions and early health
restoration.[5]

● Chest physiotherapy involving percussion, vibration, postural drainage for

bedridden, active breathing exercises, and oscillatory devices in mildly

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symptomatic patients shows better effects as to increase lung compliance

and chest tone ultimately results in the effective chest and diaphragmatic
movement.[6]

● Controlled breathing with deep coughing and huffing removes adhesion of

mucus from the lower airways to facilitate active efforts & for reducing
dependence on drugs in mild to moderate symptom patients.

● Permissive hypercapnia is one of the effective ways for fulfilling the O2

sufficiency into low inspiratory volume & pressure for reducing the
mechanical ventilation load, for better recovery of ARDS symptoms &
prevention from acute lung injuries in critical care.[8,9]

● Using oxygen therapy before intubation and after extubation using a non-
invasive ventilator, High flow nasal cannula(HFNC)reduces the damage to
respiratory airways and improves peripheral oxygen supply(HFNC shows
more beneficial effects).[10]

● Movement of the upper and lower limb is essential to

maintainlarontotonneognitive functions under general mobilization &
positioning technique.[14]

● By bronchial hygiene techniques (like – Vibro-compressor, postural

drainage, mobilization, hyperinflation & tracheal suctioning) are the
appropriate maneuvers’ in ICU & clinical hospital settings for dealing with
various symptoms of sputum release, cough removal airway clearance,
respiratory functional relaxation, etc.[7]

● Increasing the availability of various oscillating devices ( such as ACAPELLA,

HIGH-FREQUENCY CHEST OSCILLATION DEVICES, ORAL HIGH-FREQUENCY
OSCILLATION DEVICES, FLUTTER DEVICES, and CORNET DEVICE) for reducing

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dependency from mechanical ventilator demand, can be used in acute and

chronic respiratory failure, effectively prevent lung collapse.[15]

CONCLUSION

● Using chest PT techniques are beneficial in COVID 19 ICU patients with 24hr/day
sessions helps to control symptoms earlier along with medications and leads to a
low chance of developing hospital infection.

● After systemic review, the most often used techniques by the PT's in their
different hospital setting & ICU care management are – Vibro-compressor,
hyper-inflation, postural drainage, tracheal suction & motor mobilization. They
found all of them are most efficient bronchial hygiene maneuvers during clinical
practices but furthermore, nation-based literature reviews are required for
better confirmation

● Collectively if the use of the permissive hypercapnia technique is taken place

then there is a reduction in the number of ARDS symptoms & other systemic
symptoms from different parts of the body.

● The pre-oxygenation maintains oxygen saturation level by administrative use of

many techniques like- NIV, NHFNC, COT to prevent further complications of
intubation in respiratory pathways.

● Using HFNC over COT is more beneficial as it provides:- high oxygen rate of
flow, positive airway pressure, reduces dyspnoea, lowering the excessive
work while breathing, and ultimately gives comfort to respiratory patients.

● During mild symptoms of COVID-19 diaphragmatic pacing is might be an effective

tool for medical health professionals for better breathing patterns, there is no such
evidence regarding the use of phrenic nerve stimulation for general respiratory
distress but if we follow the criteria of the application then probably many cases of
COVID-19 can be treated properly.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3601818
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● Active movement of the upper and lower limb in patients during ICU on a
mechanical ventilator can reduce the complication and helps to keep
peripheral oxygen distribution along with inactive blood supply for better
health.

● The use of ACAPELLA or other oscillatory devices based on patients'

functional levels can help in increasing dynamic lung compliance
immediately on mechanical ventilator patients. The device lowers mucus
adhesion and reduces the collapsibility of the airway for improving overall
pulmonary function.

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8. https://ccforum.biomedcentral.com/articles/10.1186/cc2918
9. Silvestre C, Vyas H, Is permissive hypercapnia helpful or harmful?,
Paediatrics and

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3601818
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ChildHealth(2014).[http://dx.doi.org/10.1016/j.paed.2014.10.014]
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3601818