Updated consensus statement for pulmonary rehabilitation of patients with coronavirus disease 2019 (2023)

The global outbreak of coronavirus disease 2019 (COVID-19) began toward the end of 2019 and persists as of 2024.[1] Patients infected with COVID-19 may show multiple organ involvement, and body systems can be affected with varying degrees of severity. After acute infection, many patients have physical and psychological symptoms that involve multiple systems and persist for a long time.[2] Pulmonary rehabilitation is a crucial issue in the management of COVID-19. Early recommendations for respiratory rehabilitation in adults with COVID-19[3] were based on the studies and knowledge of severe acute respiratory syndrome and Middle East respiratory syndrome, combined with knowledge of COVID-19 accrued during the initial stage of the pandemic. However, the recommendations lacked clinical evidence. Therefore, an updated, evidence-based guideline is needed, given the further investigation of COVID-19 that has occurred during the past 3 years. This updated guideline is based on the systematic evaluation of a series of guidelines for pulmonary rehabilitation in cases of COVID-19 and related evidence-based medical research published in China and elsewhere in recent years [Supplementary Material, https://links.lww.com/CM9/C146]. The aim is to provide guidance for standardized COVID-19 pulmonary rehabilitation programs to Chinese medical workers. Our updated guideline was designed and developed with reference to the World Health Organization handbook for guideline development, published in 2014,[4] and the Guiding Principles for the Development/Revision of Clinical Guidelines in China (2022 Edition) published by the Chinese Medical Association. For reporting and writing, the Reporting Items for Practice Guidelines in Healthcare (RIGHT) were used as a reference.[5] We convened a multidisciplinary expert working group that developed key questions regarding pulmonary rehabilitation in cases of COVID-19 using the population, intervention, comparison, outcome (PICO) format. The Medline, Embase, Cochrane Library, Epistemonikos, Chinese Biomedical Database, Wanfang, and China National Knowledge Infrastructure databases were searched for relevant literature by the literature search team of the Institute of Medical Informatics of the Chinese Academy of Medical Sciences. The 2009 version of the Oxford Center for Evidence-Based Medicine’s Grading of Evidence and Strength of Recommendation Criteria was used to grade the level of evidence and strength of the recommendations. To achieve consensus, graded recommendations and ungraded consensus-based statements were drafted and voted on using the Delphi technique. Sixteen evidence-based, graded recommendations were formulated; these are detailed in Table 1. Table 1 - Summary of recommendations for pulmonary rehabilitation of patients with COVID-19 (2023). Recommendations Level of evidence Strength of recommendation 1. Pulmonary rehabilitation is recommended for eligible patients with COVID-19. 2b B 2. Early initiation of pulmonary rehabilitation is recommended for patients with COVID-19. 2b B 3. Rehabilitation assessment is recommended for patients with COVID-19. 1a A 4. Screening for a risk of aspiration is recommended for older (age ≥ 65 years) patients with COVID-19 and those at a high risk of comorbid swallowing disorders. Individualized assessments of and interventions for aspiration in patients identified by screening as being at a high risk of aspiration are recommended. 2b B 5. Dynamic assessment of the risk of VTE and bleeding in patients hospitalized with COVID-19 is recommended. 2b B 6. Airway clearance techniques are recommended for patients with COVID-19 who have impaired airway clearance or are at high risk of impaired airway clearance. 2b B 7. Postural management is recommended for patients with COVID-19. 5 D 8. Inspiratory muscle training is recommended for patients with COVID-19 with long-term symptoms. 2b B 9. Energy-sparing techniques are recommended for patients with COVID-19 to alleviate fatigue in response to debilitation. 2b B 10. Early physical activity to improve physical mobility is recommended for patients with COVID-19. 3a B 11. Occupational therapy (OT) is recommended in patients with cognitive impairment due to COVID-19 to improve cognitive function. 4 C 12. For COVID-19 patients with resting or exertional hypoxemia (SpO2 ≤89%), home oxygen therapy with maintenance of SpO2 >90% is recommended. 1a A 13. Self-management of symptoms is recommended in older (age ≥ 65 years) patients with COVID-19 to improve their health-related quality of life. 1a A 14. Rehabilitation therapy that includes PT and OT is recommended to improve the mental health of patients with COVID-19. 2a B 15. Telerehabilitation is recommended as an alternative or a supplement to in-hospital rehabilitation for patients with mild to moderate COVID-19. 2b B 16. Early enteral nutrition tube feeding is recommended for patients with severe COVID-19 who are receiving mechanical ventilation and are unable to eat by themselves. 2b B COVID-19: Coronavirus disease 2019; OT: Occupational therapy; PT: Physical therapy; SpO2: Percutaneous arterial oxygen saturation; VTE: Venous thromboembolism. The previous recommendations for respiratory rehabilitation in adults with COVID-19[3] are only advisory; they do not constitute evidence-based recommendations for pulmonary rehabilitation in COVID-19 cases of varying severity. On the basis of the evidence regarding pulmonary rehabilitation in COVID-19, we proposed the Updated Consensus Statement for Pulmonary Rehabilitation of COVID-19 (2023) and formulated 16 evidence-based, graded recommendations. In comparison with the previous recommendations for respiratory rehabilitation in adults with COVID-19,[3] we updated the recommendations as follows. Indications Indications do not vary by disease stage. Pulmonary rehabilitation should be considered throughout the entire disease course. On the basis of new clinical evidence, we recommend early initiation of pulmonary rehabilitation for eligible patients with COVID-19. Isolation and protection strategies In accordance with the recent approach to infectious disease management, isolation, protection strategies, and treatment location during pulmonary rehabilitation are not covered by the updated guideline. Rehabilitation assessment The time point (the entire course of the rehabilitation therapy) and patient status (acute and recovery phases, follow-up after discharge, presence of sequelae/symptoms) should be defined for rehabilitation assessment. The target of rehabilitation assessment should also be defined (dyspnea; health-related quality of life; somatic, pulmonary, and respiratory muscle functions; fatigue; ability to perform activities of daily living; comorbidities). Pulmonary rehabilitation risk screening This is a category in the updated guideline absent from the previous recommendations for pulmonary rehabilitation in adults with COVID-19. The updated guideline recommends dynamic assessment and screening for risk of aspiration, venous thromboembolism, and bleeding during pulmonary rehabilitation, anticoagulant intervention, and the application of mechanical prophylaxis. Pulmonary rehabilitation therapy techniques Airway clearance techniques: This guideline updates the indications (for patients with COVID-19 who currently have or are at a high risk of having impaired airway clearance) and clinical evidence for airway clearance techniques, which were not included in the previous guideline. Postural management: (1) This guideline determines the optimal time of initiation and the goal of simulated antigravity positions. A management strategy that progressively increases simulated antigravity positions within physiological limits until patients can remain in an upright position is recommended for those with severe COVID-19, instead of the three 30-min sessions per day recommended in the previous guideline. (2) This guideline updates the recommendations for the duration of prone ventilation. We recommend daily prolonged prone ventilation to improve the prognosis of patients with COVID-19 who develop severe acute respiratory distress syndrome, instead of ≥12 h for the prone position ventilation duration recommended in the previous guideline. (3) This guideline provides education on awake-prone ventilation and postural management, which was not included in the previous guideline. Inspiratory muscle training: This guideline clarifies the indications for inspiratory muscle training in patients with COVID-19, which were not included in the previous guideline. Energy-sparing techniques: This guideline provides evidence-based recommendations for the application of energy-sparing techniques to alleviate fatigue in patients with debilitating COVID-19, which were not included in the previous guideline. Early physical activity: This guideline provides evidence-based recommendations for early physical activity in patients with COVID-19. Occupational therapy (OT): This guideline provides evidence-based recommendations for OT targeting cognitive impairment caused by COVID-19, which were not included in the previous guideline. Home oxygen therapy: This guideline provides evidence-based recommendations for home oxygen therapy, which were not included in the previous guideline. Self-management This guideline provides evidence-based recommendations for self-management of symptoms in older (aged ≥65 years) patients with COVID-19, which were not included in the previous guideline. Mental health This guideline provides evidence-based recommendations for rehabilitation therapy, including physical therapy and OT, to improve the mental health of patients with COVID-19; these were not included in the previous guideline. Telerehabilitation This guideline provides evidence-based recommendations for telerehabilitation as an alternative or a supplement to in-hospital rehabilitation for patients with mild-to-moderate COVID-19, which were not included in the previous guideline. Nutrition management This guideline provides evidence-based recommendations for early enteral nutrition through tube feeding via the nasojejunal route and permissive short-term low-energy feeds in patients with COVID-19, which were not included in the previous guideline. Traditional Chinese medicine pulmonary rehabilitation Recommendations for traditional Chinese medicine pulmonary rehabilitation are not covered by the updated guideline. Comprehensive pulmonary rehabilitation is recommended for patients with COVID-19 for alleviating their symptoms and improving their health-related quality of life. A pulmonary rehabilitation program that includes the medications and devices mentioned above can be tailored to the patient’s specific situation using caring, encouraging, and enlightening language along with suggestions regarding adjustments to the home environment and diet. In this manner, a systematic, comprehensive, and effective rehabilitation program could be realized for patients complaining of fatigue, tiredness, or weakness. Funding This work was supported by the Chinese Academy of Medical Sciences (CAMS) Innovation Fund for Medical Sciences (CIFMS) (No. 2021-I2M-1–056) and National High Level Hospital Clinical Research Funding (No. 2022-NHLHCRF-LX-01). Conflicts of interest None.