Physiotherapy Guidelines in the Management of

Patients with SARS in hospital

Cardiopulmonary Specialty Group

Hong Kong Physiotherapy Association

May 2003

Introduction

Severe Acute Respiratory Syndrome (SARS), a newly emerging infectious disease, is highly
contagious and potentially lethal. By 23 May, 2003, 1724 cases had been reported in Hong Kong
with 260 deaths (Department of Health, Hong Kong Special Administrative Region). In an
epidemiological study on 1425 cases in Hong Kong (Donnelly et al 2003), the common clinical
symptoms at presentation include fever, influenza-like symptoms, chills, malaise, loss of
appetite, myalgia, cough and headache. Less common symptoms included rigor, dizziness,
shortness of breath and sputum production.

Physiotherapists are involved in the management of SARS. It has been shown that 15 to 25
percent of the cases required physiotherapy service for acute respiratory care and rehabilitation
(unpublished data). With more information available and clinical experience gained, individual
hospitals in the territory have compiled different hospital-based guidelines that are already
available on the Hong Kong Physiotherapy Association (HKPA) website. As these guidelines are
very much hospital-based, the Cardiopulmonary Specialty Group (CPSG) has taken the initiative
of producing consensus guidelines on management of SARS. The guidelines were based on the
documents developed by various hospitals (Queen Elizabeth Hospital, Princess Margaret
Hospital, Prince of Wales Hospital and United Christian Hospital), established evidence,
anecdotal experience and consensual view among members of the CPSG when current
information was inadequate. No attempt was made to give detailed description of individual
techniques as they could be referenced from the Service manual for physiotherapy in adult
ICU published by Coordinating Committee in Physiotherapy, Hospital Authority.

The guidelines are intended for use by clinicians involved in the care of patients with SARS, and
their main goals are to inform health professionals and to streamline the approach to the
management of the patients. The guidelines need to be revised regularly to adapt to the trend and
progress of our clinical experience.

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Common Clinical Presentation Relevant to Physiotherapy Practice

Non-intubated Cases

dyspnoea at rest
exertional dyspnoea especially in the standing or sitting position
irritable cough
easy desaturation on exertion and coughing

Intubated Cases

hypoxaemia
requires high ventilatory setting
scanty or no sputum
incidence of blockage of the endotracheal / tracheostomy tube due to restrictions in the use of
humidifiers
impaired airway clearance due to prolonged intubation
physical deconditioning due to lengthy intensive care

Disease Sequelae / Complications Relevant to Physiotherapy Practice

spontaneous pneumothorax or pneumomediastinum

acute respiratory distress syndrome
anaemia secondary to Ribavirin therapy
secondary chest infection
steroid-induced muscle atrophy / myopathy
activity intolerance
psychological incompetence

Indications for Physiotherapy

Chest physiotherapy

lung collapse
increased work of breathing
thick sputum plugs predisposing to ventilation difficulty, blood-gas abnormalities and altered
level of consciousness
evidence or suggestion of difficulty with secretion clearance, e.g. coughing impaired by
drowsiness or pain
sputum retention with or without superimposed chest infection
pneumonia complicating co-morbid chronic pulmonary diseases, e.g. COPD, bronchiectasis
and other cavitating lung disease

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Limb Physiotherapy

DVT prophylasis for high risk patients (e.g. Caucasian, history of DVT, deeply sedated
patients)
physical deconditioning
psychological incompetence

Goals of Physiotherapy

1. reinflate atelectatic lung areas; improve distribution of ventilation

2. improve oxygenation
3. decrease work of breathing
4. maintain airway clearance
5. minimize deconditioning; facilitate recovery
6. improve exercise tolerance
7. enhance self-confidence

Physiotherapy Management

Principles

Minimizing therapists risk of exposure video/pamphlet can be used to educate relatively

well patients, e.g. video for breathing exercise and breathing control; pamphlet for advice on
exercise.
Aerosol-generating procedures may increase the risk of disease transmission. Chest
physiotherapy maneuvers such as coughing and huffing exercise, tracheal tickling and airway
suctioning can increase the likelihood of droplet nuclei being expelled into the air. These
high-risk procedures should not be performed on patients with or suspected to have SARS
unless such procedures are deemed medically necessary.
Adequate control measures should be put in place if prevention of exposure to risk is not
possible.

Detailed information on current recommendations on infection control can be found at the

websites of Hospital Authority, Hong Kong Special Administrative Region and Centres for
Disease Control and Prevention.

Chest Physiotherapy Techniques

techniques for reducing the work of breathing

body positioning
relaxation technique
breathing control
pursed-lip breathing
adjuncts, e.g. positive expiratory pressure (PEP) therapy

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 techniques for improving ventilation

localized thoracic expansion exercise

adjuncts, e.g. PEP therapy, incentive spirometry (Low flow device)

sputum-mobilization techniques

postural drainage
deep breathing exercise
percussion, vibration and shaking
adjuncts, e.g. PEP therapy

sputum-removal techniques (to be performed only if deemed medically necessary)

coughing and huffing exercises

tracheal tickling
airway suctioning

Special points to note

1. To protect yourself

a) All staff should apply standard, (e.g. hand hygiene), airborne (e.g. respiratory
protective devices with a filter efficiency of greater than or equal to 95%), and
contact (e.g. gloves and gown) precautions when aerosol-generating procedures are
being performed (Centers for Disease Control and Prevention). Additional
precaution measures should be considered, e.g. tight-fitting goggles, full-face shield
and water repellent gowns (Hospital Authority, Hong Kong Special Administrative
Region).
b) When performing aerosol-generating procedures, avoid facing the patient directly
(e.g. turn the patients face away from the therapist; stand behind the patient) and
keep as far away from the patient as possible (6 feet is recommended).
c) Pay attention to the direction of airflow in relation to persons: must be from lower
risk to higher risk (the therapist should try not to stand between the patient and the
extractor if the direction of airflow is from the former to the latter).
d) Keep your hands together or find a way to avoid unnecessary touching of face, hair,
etc.

2. To protect the environment, every attempt should be made to avoid the SARS droplet
nuclei being expelled into the air:

a) Make sure that the patient is wearing a surgical mask.

b) Avoid both involuntary/voluntary cough high flow incentive spirometry is not
recommended as it easily triggers irritable cough; deep breathing exercise has to be
done in a slow and controlled manner; voluntary coughing is discouraged.

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 c) For intubated patients, the use of closed suction system is recommended. It is
essential to ensure there is no air leak from the system. Kink the inlet tubing before
attaching the normal saline syringe to it. A separate suction circuit for oral/nasal
suction is recommended.
d) For spontaneously breathing patients requiring naso / oro-pharyngeal aspiration
and/or airway suctioning, additional precautions using a form of barrier should be
considered, e.g. plastic curtains or tents.
e) Bagging is not recommended as the disconnection of the ventilatory circuit and the
high expiratory flow rate generated may release aerosol into the environment.
f) Extra precaution should be taken to avoid disconnection of the ventilatory circuits in
intubated cases before changing patient position in bed.

3. Sputum sampling

Physiotherapists can facilitate the diagnostic procedure by collecting a good quality

sputum sample for culture. When sampling endotracheal aspirate for investigation,
change to a new closed suction catheter and attach the sputum trap to the distal end of
the new closed suction catheter before obtaining the endotracheal aspirate.
4. Subcutaneous emphysema and pneumothorax are not uncommon in patients requiring
intensive care, therefore a modification of techniques may need to be considered.

5. In neonates nursed in incubators, ensure that the scavenging and the negative ventilatory
system inside the incubator is functioning well before opening the doors. Never open all
the 4 doors simultaneously.

6. Use the patients designated stethoscope (clean the ear pieces with alcohol prep before
use).

7. Use stationery provided in the unit.

Limb Physiotherapy Techniques

prescription of anti-thrombotic stockings for high risk patients

positioning, e.g. Anti-contracture positioning, lower limb elevation
limb mobilization exercises
graded functional training, e.g. transfer, sitting out of bed, standing and walking exercises,
aerobic exercise
neuromuscular electrical stimulation to improve muscle mass and control

Special points to note

1. In patients recovering from critical illness, it is essential to watch out for any dizziness
during transfer activities and when in upright positions.

2. Early ambulation may not be encouraged as most patients require a period of physical
reconditioning to prepare for ambulation.
Outcome Evaluation

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 rate of perceived dyspnoea
respiratory rate
breathing pattern
sputum quantity
auscultation
cough sound
oxygen requirement
SpO2
ABGs
chest x-ray changes
muscle strength
functional performance (e.g. activity level, 6-minute walk distance)

Recommendations

As the disease is highly contagious, a good balance between the benefit of treatment and the
risk of cross infection has to be seriously considered.
The clinical presentation varies in different phases and the disease severity also varies among
patients, rational judgment of physiotherapy involvement is essential.
Dyspnoea both at rest and during exertion, irritable cough and desaturation are common
characteristics in patients with SARS requiring physiotherapy. Close monitoring of rate of
perceived dyspnoea (keep 3), SpO2 (> 90%) and heart rate (< 140/min) during exercise is
essential. The progression of exercise must be gradual, frequent rest may be needed.
The effectiveness of positioning has been explored. Side-lying and high side lying with bad
side up incorporated with breathing control have been found to improve the SpO2 and work
of breathing in most patients. However, the best position for each patient must be
individually assessed.
Due to the restriction of use of non-invasive positive pressure ventilation (NIPPV) in the
management of this disease, PEP has been used as an adjunct. However, its use has been
empirical. Some patients respond favorably to PEP therapy but some do not. It has been
shown to produce a dramatic response in reversing atelectasis, decreasing FiO2 requirement
and delaying intubation. However, there is yet no clear evidence proving its effect. Therefore,
the efficacy of the therapy needs to be further explored.
The decision for extubation has to be made in a timely manner, as no NIPPV can be used if
extubation fails. The physiotherapists opinion as to whether the patient is ready for
extubation with regard to respiratory function and airway patency is useful to facilitate an
uncomplicated process.
Although positive results were gained in our management of patients with SARS, the disease
progression can be very abrupt and patients response towards medical management could be
very unpredictable. A good understanding of patients condition and progress is essential to
guide our management.

References

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Centers for Disease Control and Prevention (CDCP). Interim domestic infection control
precautions for aerosol-generating procedures on patients with Severe Acute Respiratory
Syndrome (SARS). http://www.cdc.gov/ncidod/sars/aerosolinfectioncontrol.htm (updated May
20 2003).

Coordinating Committee in Physiotherapy, Hospital Authority. Service manual for

physiotherapy in adult ICU.

Department of Health, Hong Kong Special Administrative Region.

http://www.info.gov.hk/dh/ap.htm.

Donnelly CA, Ghani AC, Leung GM, Hedley AJ, Fraser C, Riley S, Abu-Raddad LJ, Ho L-
M, Thach T-Q, Chau P, Chan K-P, Lam T-H, Tse L-Y, Tsang T, Liu S-H, Kong JHB, Lau
EMC, Ferguson NM, Anderson RM. Epidemiological determinants of spread of casual agent
of severe acute respiratory syndrome in Hong Kong.
http://image.thelancet.com/extras/03art4453web.pdf (accessed May 7 2003).

Hospital Authority, Hong Kong Special Administrative Region. HA information on

management of SARS. http://www.ha.org.hk/sars/ps/guidelines/index.html (accessed May 7
2003).