Respiratory Management of COVID 19

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Jess Bell, Rachael Lowe, Laura Ritchie, Stacy Schiurring, Lucinda hampton, Vidya Acharya, Admin, Tarina van der Stockt, Leana Louw, Khloud Shreif, Wendy Walker, Simisola Ajeyalemi, Tony Lowe, Wanda van Niekerk and Nicole Hills  

Introduction

This content has been generously supported by World Physiotherapy

Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS-CoV-2), is a highly contagious, single-stranded ribonucleic acid (RNA) encapsulated corona virus.

In the early pandemic period (pre-vaccination, original strain), approximately 80% of individuals had no or mild symptoms that were manageable at home, 15% developed moderate to severe disease requiring hospitalisation and oxygen support, and 5% required ICU admission and supportive therapies, including intubation and ventilation.

Transmission. SARS-CoV-2 is transmitted primarily via airborne aerosols, which can remain suspended in the air over distances greater than 2 metres and accumulate in poorly ventilated indoor spaces. Shorter-range droplet transmission and direct contact with contaminated surfaces (fomite transmission) also occur, though fomite transmission is now considered a minor route. This has significant implications for ventilation, room design, and personal protective equipment (PPE) requirements in clinical settings. Staff contact should be minimised with positive patients to reduce transmission risk, following usual on-call policies and criteria.

Treatment. Several pharmacological treatments are now recommended for hospitalised patients with COVID-19. Corticosteroids, particularly dexamethasone, are the standard of care for patients requiring supplemental oxygen or mechanical ventilation. Antiviral agents (including remdesivir and, for non-hospitalised high-risk patients, nirmatrelvir–ritonavir/Paxlovid) and immunomodulatory therapies (including IL-6 inhibitors such as tocilizumab) are used according to clinical severity. Physiotherapists should be familiar with these treatments and their potential implications for rehabilitation (e.g., steroid-related myopathy, osteonecrosis).

Complications. The most common complication in severe COVID-19 is severe pneumonia. Other complications include acute respiratory distress syndrome (ARDS), sepsis, septic shock and multiple organ failure (including acute kidney injury and cardiac injury). These are more prevalent in at-risk groups, including: older age (> 70 years); those with co-morbidities such as cardiovascular disease, lung disease, diabetes, or obesity, and those who are immunosuppressed. Data currently suggests that illness is less common and usually less severe in younger adults. Corticosteroid use in COVID-19 management carries a risk of steroid-induced osteonecrosis of the femoral head (ONFH). Physiotherapists should be aware of this complication in patients who received prolonged or high-dose corticosteroids.

Clinical Syndromes

The World Health Organization (WHO) outlines the following clinical syndromes associated with COVID-19. The WHO's clinical management guidance has been updated multiple times since 2020; the most current version should be consulted for definitive staging criteria.

Table 1. Clinical syndromes associated with COVID-19

Mild Illness	Patients present with uncomplicated upper respiratory tract viral infection and may have non-specific symptoms, such as fever, fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnoea, nasal congestion, or headache. Rarely, patients may also present with diarrhoea, nausea, and vomiting. Older adults and immunosuppressed patients may present atypically.
Pneumonia	Adult: with pneumonia but no signs of severe pneumonia and no need for supplemental oxygen. Child: with non-severe pneumonia who has a cough or difficulty breathing + fast breathing: Fast Breathing (in breaths/min): < 2 months old ≥ 60; 2-11 months old ≥ 50; and 1-5 years old ≥ 40, and no signs of severe pneumonia. Patients may be productive, with an increased sputum load but this is a less common presentation in viral pneumonia.
Severe Pneumonia	Adolescent or Adult: Fever or suspected respiratory infection, plus one of the following: high respiratory rate > 30 breaths/min; severe respiratory distress; or SpO2 ≤ 93% on room air. Child: Cough or difficulty breathing, plus at least one of the following: central cyanosis or SpO2 < 90%; severe respiratory distress (e.g. grunting, very severe chest indrawing). While the diagnosis is made on clinical grounds, chest imaging may identify or exclude some pulmonary complications.
Acute Respiratory Distress Syndrome (ARDS)	Onset: Within 5-7 days from the onset of initial respiratory symptoms. Oxygenation impairment is classified by PaO₂/FiO₂ (mmHg) ratio: Mild ARDS: 200-300mmHg with PEEP or CPAP ≥5 cmH₂O, or non-ventilated Moderate ARDS: 100-200 mmHg with PEEP ≥5 cmH₂O, or non-ventilated Severe ARDS: ≤100 mmHg with PEEP ≥5 cmH₂O, or non-ventilated When PaO₂ unavailable: SpO₂/FiO₂ ≤315 mmHg suggests ARDS (including non-ventilated patients)
Sepsis	Adults: Life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection. Signs of organ dysfunction include: altered mental status; difficult or fast breathing; low oxygen saturation; reduced urine output; bradycardia; weak pulse; cold extremities; hypotension; skin mottling; laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate, or hyperbilirubinemia. Children: Suspected or proven infection and ≥ 2 age-based systemic inflammatory response syndrome (SIRS) criteria, of which one must be abnormal temperature or white blood cell count.
Septic Shock	Adults: Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥ 65 mmHg and serum lactate level > 2 mmol/L. Children: Hypotension (SBP < 5th percentile or > 2 SD below normal for age) or two or three of the following: altered mental state; tachycardia or bradycardia (HR < 90 bpm or > 160 bpm in infants or HR < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or feeble pulse; tachypnoea; mottled or cool skin, petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia.

Aerosol Generating Procedures and Infection Control

For patients with suspected/confirmed COVID-19, aerosol generating procedures (AGPs) should only be carried out when essential and in a single room with the door shut (preferably a negative pressure room). Full PPE, including a fluid-repellent surgical gown, gloves, eye protection, and an FFP3 respirator mask (N95 equivalent in North America; P2 in Australia/New Zealand) must be worn by all staff present.

Common AGPs

• Intubation, extubation and related procedures
• Tracheotomy/tracheostomy procedures
• Manual ventilation
• Open suctioning
• Bronchoscopy
• Non-invasive ventilation (NIV) e.g., bi-level positive airway pressure (BiPAP) and continuous positive airway pressure ventilation (CPAP)
• Surgery and post-mortem procedures in which high-speed devices are used
• High-frequency oscillating ventilation (HFOV)
• High-flow nasal oxygen (HFNO)
• Induction of sputum: this typically involves administration of nebulised saline to moisten and loosen respiratory secretions (and may be accompanied by chest physiotherapy techniques, such as percussion and vibration to induce forceful coughing). This may be required if lower respiratory tract samples are needed

Note: HFNO and NIV have historically been classified as AGPs, but this is now contested. A 2022 NHS England rapid review recommended removing both from the UK AGP list, and a 2023 systematic review and meta-analysis found that neither HFNO nor NIV significantly increased aerosol generation compared with unsupported breathing.

Physiotherapy Specific AGPs

• Manual techniques (e.g., percussion, manual assisted cough) that may lead to coughing and expectoration of sputum
• Use of positive pressure breathing devices (e.g., IPPB), mechanical insufflation-exsufflation (cough assist) devices, intra/extra pulmonary high frequency oscillation devices (e.g., the Vest, MetaNeb, Percussionaire, etc.)
• Any mobilisation or therapy that may result in coughing and expectoration of mucus
• Any diagnostic interventions involving video laryngoscopy leading to airway irritation and coughing (e.g., direct visualisation during airway clearance techniques or when assisting speech and language therapists perform fibreoptic endoscopic evaluation of swallow)

Oxygen Therapy

In mild to moderate disease, standard oxygen support (face mask oxygen) may be sufficient. The WHO recommends supplemental oxygen therapy immediately for patients with respiratory distress, hypoxaemia, or shock. Patients may continue to have increased work of breathing even when oxygen is delivered via a face mask with a reservoir bag (flow rates 10–15 L/min; FiO₂ 0.60–0.95).

Oxygen therapy targets vary depending on the patient population.

• Severe distress, hypoxaemia or shock: SpO₂ >94%
• Stable non-pregnant adults: SpO₂ >90%
• Stable pregnant adults: SpO₂ 92–95%
• Acute hypoxaemic respiratory failure: SpO₂ ≤96%

Ventilatory Support

Early recognition of worsening respiratory function (e.g., hypercapnia, acidaemia, respiratory fatigue, haemodynamic instability, or altered mental status) and referral of patients on conventional oxygen therapies is important to ensure timely escalation to invasive mechanical ventilation. Early ICU involvement is recommended. Acute or chronic hypoxaemia is a common reason for admission to intensive care and for the provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes.

Non-Invasive Respiratory Support (CPAP/NIV/HFNO)

Non-invasive respiratory support encompasses high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP), and bilevel non-invasive ventilation (NIV). These modalities deliver oxygen and/or positive pressure via nasal cannulae, face masks, or helmet/hood interfaces, without an artificial airway.

High Flow Nasal Oxygen (HFNO)

Early COVID-19 evidence suggested that HFNO was beneficial in a select cohort of patients with hypoxaemic respiratory failure and no evidence of hypercapnia, preventing intubation in some patients. HFNO devices deliver flow rates up to 60 L/min with FiO₂ titrated up to 1.0 (100%). However, the 2022 RECOVERY-RS trial found CPAP superior to conventional oxygen in reducing intubation or death, while there was no significant difference between HFNO as an initial strategy and conventional oxygen therapy.

Where HFNO is treated as an AGP under infection control policy, a negative pressure room is preferable. Staff should wear appropriate airborne PPE, including an FFP3 (or equivalent) respirator mask, fluid-repellent gown, gloves, and eye protection.

Continuous Positive Airway Pressure (CPAP) and Non-invasive Ventilation (NIV)

The WHO conditionally recommends CPAP and NIV (in addition to HFNO) over standard oxygen therapy for hospitalised patients with severe or critical COVID-19 and acute hypoxaemic respiratory failure who do not require emergent intubation.

Due to uncertain data, the WHO guidelines do not make a recommendation on HFNO versus CPAP versus NIV. Clinical decisions should be guided by device availability, oxygen supply, clinician experience, and patient-specific factors such as claustrophobia or nasal discomfort.

Where CPAP or NIV are used, the clinical distinction between CPAP and bilevel NIV is important: CPAP has stronger evidence in hypoxaemic COVID-19. The 2022 RECOVERY-RS trial found that CPAP reduced intubation and death compared with conventional oxygen. Bilevel NIV is primarily indicated for hypercapnic respiratory failure.

A trial of CPAP or NIV should be time-limited (approximately one hour initially) and closely monitored. If substantial improvement does not occur, early intubation should follow in a controlled environment with adequate infection prevention and control measures.

Where CPAP or NIV are treated as aerosol-generating procedures under local infection control policy, they should be delivered in negative pressure single rooms using a dual-limb system with a separate expiratory port, or a double-port filter system with a viral filter between the mask and the expiratory port.

Invasive Ventilation

Lung-protective mechanical ventilation is the recommended strategy, using a low tidal volume (4–8 mL/kg predicted body weight) and limiting plateau pressures to less than 30 cmH₂O. The WHO living guidelines recommend an initial target tidal volume of 6 mL/kg PBW, but a tidal volume of up to 8 mL/kg PBW is allowed if undesirable side-effects occur, such as dyssynchrony or pH < 7.15. Permissive hypercapnia is usually well-tolerated.

PEEP should be individualised based on lung recruitability, haemodynamic status, and oxygenation response, rather than set at a blanket high level. A trial of higher PEEP is suggested in patients with moderate or severe ARDS. However, higher PEEP is not universally beneficial — it may worsen outcomes in patients with low lung recruitability, and its effects should be monitored closely using oxygenation response, driving pressure, and haemodynamic status. Bedside tools such as lung ultrasound and driving pressure titration can assist in guiding PEEP individualisation. Driving pressure is the difference between plateau pressure and PEEP. Titration involves adjusting PEEP and tidal volume to minimise driving pressure (ideally below 15 cmH₂O), reducing ventilator-induced lung injury risk.

Patients are generally sedated to allow adequate ventilation control. Daily sedation holds are good practice, though deeper sedation may be required until oxygenation improves. Prolonged deep sedation increases the risk of delirium, ICU-acquired weakness, and long-term cognitive impairment. It should, therefore, be titrated to the minimum required. Neuromuscular blockade agents are not generally recommended unless significant dyssynchrony, hypoxia or hypercapnia cannot be managed with sedation alone.

Recruitment manoeuvres — delivered as episodic high CPAP, incremental PEEP increases, or high driving pressure — were previously conditionally recommended in ARDS, but subsequent trial evidence of high-PEEP/prolonged-RM protocols demonstrated harm.

Cuffs must be inflated at all times. If tracheostomy is indicated, a subglottic approach should be considered to allow above-cuff vocalisation, improving communication and swallow rehabilitation. Delayed tracheostomy (generally after 10–14 days) is recommended due to infection risk and the prolonged recovery typical of COVID-19 ARDS.

Patients with worsening hypoxia, hypercapnia, acidaemia, respiratory fatigue, haemodynamic instability, or altered mental status should be considered for early invasive mechanical ventilation. The risk of aerosol transmission is reduced once a patient is intubated with a closed ventilator circuit.

Positioning

Positioning is a vital component of care for mechanically ventilated patients with COVID-19. Regular turning is recommended to prevent atelectasis, optimise ventilation, and prevent pressure injuries.

Prone ventilation (mechanically ventilated patients). Prone ventilation improves oxygenation in most patients with ARDS. Care should always be taken to minimise adverse events (e.g. accidental extubation). In adult patients, prone positioning is recommended for at least 16 hours per day.

Awake prone positioning (non-intubated patients). Awake prone positioning should be considered for non-intubated patients with moderate-to-severe hypoxaemia (SpO₂ <93% on supplemental oxygen), including those receiving HFNO or CPAP. Contraindications include: an inability to get into prone independently, haemodynamic instability, altered consciousness, facial/spinal injuries, and pregnancy beyond the first trimester. Monitoring during awake prone positioning is essential.

Suctioning

Suctioning should be performed as clinically required, not routinely. Closed inline suction catheters are recommended. Any disconnection from the ventilator should be avoided to prevent lung derecruitment and aerosolisation. If necessary, the endotracheal tube should be clamped and the ventilator paused.

Nebulisation

Metered-dose inhalers are preferred over nebulisers for non-intubated patients with COVID-19, where clinically appropriate. There is conflicting guidance on whether nebulisation is an aerosol generating procedure. Where a nebuliser is clinically indicated, local infection control policy should be followed, including the use of inline viral filters and appropriate PPE.

Humidification

In mechanically ventilated patients with COVID-19, heat and moisture exchanger (HME) filters are recommended in preference to heated humidification systems. HME filters serve the dual purpose of providing humidification and acting as a viral/bacterial barrier, thereby reducing circuit contamination and the risk of nosocomial transmission. Active heated humidification is not recommended in this context, as it requires circuit disconnection for maintenance, increasing the risk of aerosolisation and derecruitment.

HME filters should be changed when they malfunction, become soiled or blocked, or after 5–7 days, whichever occurs first. They should not be used in conjunction with heated humidification simultaneously, as this renders the filter ineffective.

HME filters are contraindicated or may be less appropriate in specific clinical circumstances, including:

• Copious or thick secretions that may block the filter
• Large air leaks (e.g., bronchopleural fistula)
• Hypothermic patients
• High minute ventilation requirements (>10 L/min), where increased dead space from the HME may become clinically significant

In these circumstances, active heated humidification may be required, with appropriate infection control precautions taken during any circuit handling.

Weaning and Liberation from Mechanical Ventilation

Standard weaning protocols should be followed. HFNO and/or NIV with a well-fitted facemask (with separate inspiratory and expiratory limbs) can be considered as bridging therapy post-extubation, with strict use of staff PPE.

Specific Physiotherapy Techniques

Physiotherapy helps prevent and mitigate the adverse effects of prolonged bed rest and mechanical ventilation. Rehabilitation is tailored to patient needs and depends on conscious state, psychological status, and physical strength. Full PPE is required throughout, in line with local infection control policy.

Acute Phase

In the acute phase of severe COVID-19 — particularly in patients with respiratory distress, hypoxaemia, or haemodynamic instability — care is needed when planning physiotherapy interventions. Modalities that increase the work of breathing, generate aerosols, or destabilise an acutely unwell patient are generally avoided.

Interventions that remain contraindicated in the acute phase of severe COVID-19:

• Bronchial hygiene/lung re-expansion techniques (PEP Bottle, EzPAP®, cough machines, etc.)
• Incentive spirometry
• Diaphragmatic breathing
• Pursed lip breathing
• Manual mobilisation techniques or stretching of the rib cage
• Nasal washings (aerosol generating)
• Exercise training and active mobilisation during clinical instability
• Breathing techniques that increase the work of breathing in patients with marked respiratory distress (e.g., resisted respiratory exercises)

Weaning Phase

Where the patient is awake, cooperative, and in the weaning stage, the Active Cycle of Breathing Technique (ACBT) and lung volume recruitment procedures (e.g., breath stacking) can be combined with positioning to actively engage the patient in their respiratory care.

Lung Ultrasound

Diagnostic lung ultrasound is a valuable tool in the assessment and management of COVID-19, as it can identify characteristic findings, such as multi-lobar B-lines and diffuse lung consolidation, with higher accuracy than bedside chest radiograph. It can be used to track disease evolution, monitor lung recruitment manoeuvres, and assist decision-making in weaning and liberation from mechanical ventilation.

For a practical guideline on lung ultrasound within an acute hospital setting, see: Physiotherapists use of Lung Ultrasound during the COVID-19 Pandemic - A Practical Guideline on Supporting Acute Hospital Colleagues.

Manual Techniques

Evidence for chest percussion in acute respiratory care is limited. There is some evidence for expiratory vibrations to mobilise secretions and manual assisted cough to improve cough effectiveness. These treatments may be considered as adjuncts in both mechanically ventilated and extubated patients, in line with local infection control policy.

Rehabilitation Phase

This is where the main role of the physiotherapist in COVID-19 management lies. Strong evidence supports early mobilisation with a focus on returning to functional activities to reduce the length of hospital stay and minimise functional decline. This phase requires a multi-disciplinary approach including measures to prevent avoidable physical and non-physical morbidity, support adequate nutrition (particularly following prone ventilation), and an individualised, structured rehabilitation programme. Such a programme should include passive, active-assisted, active, or resisted joint range of motion (ROM) exercises to maintain joint integrity and muscle strength, alongside mobilisation activities (e.g. bed mobility, sitting out of bed, sitting balance, sit-to-stand transfers, walking, tilt table, standing hoists, and upper or lower limb ergometry).

Prevention of Complications

Physiotherapists can play a key role in the prevention of a range of complications, including ventilator-associated pneumonias, secondary infections, contractures or pressure areas/sores.

Reduced Days of Mechanical Ventilation

•  Use weaning protocols or develop individual weaning plans
•  Assessment of spontaneous breathing capacity and readiness for extubation, including involvement in daily sedation holds and spontaneous breathing trials.

Reducing Ventilator-Associated Pneumonia (VAP)

• Keep the patient in a semi-sitting position (30 - 45 degrees)
• Regular 2-hourly turning to minimise the risk of atelectasis and consolidation
• Prone ventilation where indicated and appropriate
• Use a closed suction system; periodically drain and discard condensate in tubing
• Use a new ventilation circuit for each patient; change only if damaged or soiled, not routinely
• Change the heat moisture exchanger when it malfunctions, when soiled, or every 5-7 days

Reduce the Incidence of Pressure Injuries

• Turn the patient every 2 hours
• Pressure care positioning / protection of pressure areas

Reducing ICU-Acquired Weakness (ICUAW)

Early mobilisation is encouraged. Actively mobilise the patient as soon as their condition allows and when safe to do so.

ICUAW encompasses ICU-acquired myopathy and critical illness polyneuropathy. Assessment tools, including the MRC Sum Score (MRC-SS) and handgrip dynamometry, are recommended for monitoring muscle strength. ICUAW is a significant contributor to long-term functional impairment after critical illness and warrants structured rehabilitation both in ICU and post-discharge.

Preventing Osteonecrosis of the Femoral Head (ONFH)

Corticosteroids, particularly dexamethasone, reduce mortality and are standard of care for hospitalised patients with COVID-19 who require oxygen. However, prolonged or high-dose courses are associated with an increased risk of steroid-induced osteonecrosis of the femoral head (ONFH). Follow-up MRI may be considered for at-risk patients after discharge, with physiotherapy and pharmacotherapy indicated for early-stage disease.

Post-Acute Sequelae of COVID-19 (Long COVID)

The persistence of disabling symptoms beyond four weeks following acute COVID-19 illness is referred to as Post-Acute Sequelae of SARS-CoV-2 (PASC), or Long COVID. It is a multisystemic condition affecting at least 10% of SARS-CoV-2 infections, with more than 200 symptoms identified across multiple organ systems. A meta-analysis of 144 studies published from 2021 to 2024 estimated an overall global prevalence of 36% among those with a confirmed COVID-19 diagnosis, with a cumulative global incidence estimated at around 400 million people. Long COVID affects individuals across all severity spectra of acute illness, including those who experienced mild initial infection.

The 2024 National Academies of Sciences, Engineering, and Medicine (NASEM) describes long COVID as "an infection-associated chronic condition that occurs after SARS-CoV-2 infection and is present for at least 3 months as a continuous, relapsing and remitting, or progressive disease state that affects one or more organ systems." The WHO uses the term post-COVID condition for symptoms persisting beyond 12 weeks. NICE (NG188) defines it as signs and symptoms that continue or develop for more than four weeks after acute infection. Clinicians should be aware that multiple definitions are in use internationally.

Respiratory Manifestations of Long COVID:

• Persistent breathlessness and reduced exercise tolerance
• Persistent cough
• Dysfunctional breathing and breathing pattern disorder: increasingly recognised as an important and likely under-recognised driver of dyspnoea in long COVID, occurring even in patients with no significant organic cardiopulmonary damage
• Reduced diffusion capacity (DLCO impairment)
• Pulmonary fibrosis (in a subset of patients following severe disease)
• Fatigue disproportionate to physiological impairment
• Autonomic dysfunction, including postural orthostatic tachycardia syndrome (POTS), which may manifest with breathlessness and exercise intolerance

Physiotherapy Role in Long COVID. Physiotherapists have a central role in the assessment and rehabilitation of patients with Long COVID. Key interventions include:

• Breathing retraining for dysfunctional breathing and breathing pattern disorder, including breathing control techniques and paced breathing strategies, and the use of validated assessment tools such as the Breathing Pattern Assessment Tool (BPAT)
• Pulmonary rehabilitation. Evidence now supports pulmonary rehabilitation for Long COVID, with demonstrated improvements in dyspnoea, physical function, and quality of life. Face-to-face and tele-rehabilitation approaches have shown similar effects, with the exception of physical domain quality of life outcomes favouring face-to-face delivery.
• Exercise training. Individually tailored to account for post-exertional symptom exacerbation risk. Respiratory muscle training, aerobic training, and strength training have all been used within structured programmes.
• Pacing strategies and energy conservation for fatigue management, including structured activity diaries and heart rate monitoring
• Collaborative multidisciplinary team management, including occupational therapy, psychology, and speech and language therapy

Important caution: Post-Exertional Symptom Exacerbation (PESE), the worsening of symptoms following physical or cognitive exertion, is estimated to affect around one-third of people living with Long COVID. It is a characteristic and defining feature that distinguishes Long COVID management from standard pulmonary or musculoskeletal rehabilitation. Physiological evidence from two-day cardiopulmonary exercise testing demonstrates measurable reductions in exercise capacity on day two compared to day one, confirming an objective basis for this phenomenon. Standard graded exercise therapy must not be applied without first assessing for PESE. Exercise prescription should be preceded by a thorough baseline assessment, commence well below the symptomatic threshold, and progress very gradually with close symptom monitoring. Structured pacing protocols have demonstrated improvements in PESE episodes and health status in Long COVID cohorts. Immediate referral criteria and escalation pathways should be in place.

Indications for Physiotherapy Referral

The following guidelines outline the relevant indications for physiotherapy in the presence of a suspected or confirmed case of COVID-19.

Airway Clearance

COVID-19 Patient Presentation (Confirmed or Suspected)	Physiotherapy Referral
Mild symptoms without significant respiratory compromise  (e.g. fevers, dry cough, no chest x-ray changes)	No — physiotherapy not indicated. No physiotherapy contact with patient.
Pneumonia presenting with features: Low-level oxygen requirement (e.g. oxygen flow ≤5L/min for SpO2 ≥ 90%). Non-productive cough Patient coughing and able to clear secretions independently	No — physiotherapy not indicated. No physiotherapy contact with patient.
Mild symptoms and/or pneumonia AND co-existing respiratory or neuromuscular comorbidity, e.g., Cystic Fibrosis, neuromuscular disease, spinal cord injury, bronchiectasis, COPD, AND current or anticipated difficulties with secretion clearance	Yes — Physiotherapy referral for airway clearance. Staff use airborne precautions. Patient should wear surgical mask where possible.
Mild symptoms and/or pneumonia AND evidence of exudative consolidation with difficulty clearing or inability to clear secretions independently  (e.g., weak, ineffective and moist-sounding cough, tactile fremitus on chest wall, moist/wet-sounding voice, audible transmitted sounds)	Yes — Physiotherapy referral for airway clearance. Staff use airborne precautions. Patient should wear surgical mask where possible.
Severe symptoms suggestive of pneumonia / lower respiratory tract infection  (e.g., increasing oxygen requirements, fever, difficulty breathing, frequent, severe or productive coughing episodes, chest X-ray / CT / lung ultrasound changes consistent with consolidation)	Consider — Physiotherapy may be indicated if weak cough, productive cough, and/or imaging evidence of consolidation. Staff use airborne precautions. Early ICU involvement recommended.

Mobilisation, Exercise & Rehabilitation

COVID-19 Patient Presentation (Confirmed or Suspected)	Physiotherapy Referral
Any patient at significant risk of developing or with evidence of significant functional limitations (e.g., frailty, multiple comorbidities, ICU-acquired weakness)	Yes — Physiotherapy referral. Use droplet precautions; airborne precautions if close contact or AGPs likely. Patient should wear surgical mask if not ventilated.

Clinical Criteria for Acute Physiotherapy Referral

On-call physiotherapy referral for patients with COVID-19 should be guided by specific clinical criteria rather than acuity alone, with input from the multidisciplinary team and in accordance with local departmental policy..

On-call physiotherapy referral should be considered when the following clinical criteria are met:

Inclusion Criteria:

• Increasing oxygen requirement (FiO₂ >60%)
• Evidence of retained pulmonary secretions with difficulty expectorating
• Ineffective cough or impaired airway clearance

Exclusion Criteria:

• Viral pneumonia without the above inclusion criteria
• ARDS
• Haemodynamic instability
• Uncooperative or agitated patient
• Unstable intracranial pressure
• Uncontrolled bronchospasm

Patients who are not generally appropriate for emergency physiotherapy referral include those with a dry, non-productive cough, those with severe hypoxaemia requiring immediate intubation, and routine respiratory patients unless the inclusion criteria above are met. If suction is the only requirement, this should be considered a nursing intervention.

Early mobilisation remains the most clinically effective intervention for patients who are haemodynamically stable, and should be prioritised where safe to do so.

Local referral criteria should be developed in accordance with departmental policy and current national guidance. Clinicians are directed to Thomas et al. (2022) for a validated physiotherapy screening tool applicable across the continuum of acute hospital care, from ICU admission through to discharge planning.

Resources

Clinical Guidelines

• WHO COVID-19 Clinical Management: Living Guidance (2023)
• NICE Managing the Long-Term Effects of COVID-19 (updated January 2024)

Physiotherapy-Specific Resources

• Safe Rehabilitation Approaches for People Living with Long COVID: Physical Activity and Exercise (2021, World Physiotherapy)
• Thomas P, Baldwin C, Beach L, Bissett B, Boden I, Cruz SM, Gosselink R, Granger CL, Hodgson C, Holland AE, Jones AY. Physiotherapy management for COVID-19 in the acute hospital setting and beyond: an update to clinical practice recommendations. Journal of physiotherapy. 2022 Jan 1;68(1):8-25.
• Long COVID Physio