Vibrotherapy in COVID-19. Respiratory physiotherapy with the use of vibration in critically ill covid patients.

The scientific literature describes many techniques of manual respiratory physiotherapy that can be used for a variety of respiratory disorders. Manual respiratory physiotherapy is also proposed for respiratory problems in COVID-19. However, in the COVID-19 pandemic, the risk of exposure to SARS-CoV-2 during manual physiotherapy stimulates consideration of automated techniques to be used (to prevent the spread of the virus). Also, the number of people caring for the patient on the covid ward should be kept to an absolute minimum. Therefore, researchers from the Infanta Leonor University Hospital (Madrid, Spain) studied 10 critically ill mechanically ventilated covid patients with pneumonia. The secretions remaining in the respiratory tract were mobilized using vibrations delivered to the lower and posterior regions of the lungs in the prone position. The influence of vibrotherapy on the partial pressure of oxygen present in the arteries related to the oxygen concentration from the inhaled breathing mixture delivered by the ventilator (paO2/FiO2) was analyzed. The higher the paO2/FiO2, the greater improvement in respiratory function.

• The mean level of paO2/FiO2 in the supine position without vibration was 114.86;
• in the prone position without vibration: 144.7;
• in the prone position with additionally activated vibrotherapy: 162.7.

Prepared on the basis of:

Respiratory physiotherapy with Vibration belts in the critical patient Covid-19 in the prone position. Sancho PT, Gandarias PA, González RS, Gurumeta AA. Rev Esp Anestesiol Reanim. 2020 Oct;67(8):481-482.

Study population

Ten COVID-19 critically ill (mechanically ventilated) patients with pneumonia were studied.

Test procedure

PaO2/FiO2 measurements were performed in three stages:

• in the supine position without vibrations,
• in the prone position without vibrations (after 2 hours),
• in the prone position, additionally using respiratory physiotherapy with the use of vibrations (after 6 hours, i.e. firstly, patients were prone positioned for 2 hours without vibration + secondly, they were further prone positioned for 4 hours with intermittently – look underneath for details – delivered vibration).

In order to promote the mobilization of secretions from areas where they accumulate because of placing the patient in bed, a vibrating physiotherapeutic belt was placed on the back and lower part of the chest. (The belt had two side material tabs that allowed it to be permanently fastened so that it would not move during use and at the same time did not put pressure on the patient).

After 2 hours of prone positioning, three 15-minute sessions of pulmonary vibrotherapy were performed, still in the prone position. Between vibration sessions patients rested 1 hour {authors don’t precise the way of resting – more details in Comment; editorial note}. After the completion of three vibrotherapy sessions, i.e. 4 hours from the start of intermittent vibrotherapy and 6 hours from placing the patients in the prone position, the paO2/FiO2 measurement was performed.

Use of vibration in the study

A standard vibrating belt was used (Inno-vagoods, Sauna effect model, 2019, Valencia, Spain), frequency 8 Hz, without the optional heating “on”. This frequency of vibrations is similar to that used for many years in the case of other devices that use mechanical vibrations for respiratory tract secretion clearance.

Results

The average level of paO2/FiO2 in the supine position without vibrations was 114.86 (17.25*), in the prone position without vibrations: 144.73 (36.04), and in the prone position plus vibrotherapy: 162.66 (35.57). *{The values in parentheses are probably the standard deviation or standard error, but the authors do not specify it. Editorial note.}

Comment

The current pandemic situation has significantly increased the need for mechanical ventilation in patients with COVID-19. SARS-CoV-2 infection, causing a cytokine storm and excessive immune response, damages the lung epithelium and alveoli by increasing their secretory functions, what disturbs proper gas exchange in intact alveoli. This increases the risk of severe atelectasis due to the formation of mucus plugs which completely occlude the bronchial lumen. {Atelectasis is common in mechanically ventilated patients. It is associated with the state of incomplete filling of the alveoli with respiratory gases, leading to lung collapse [Wadełek et al., 2017]. Editorial note.}

Changing from supine to prone position can improve paO2/FiO2 improving pulmonary ventilation and perfusion, and mobilization of secretions. Additionally, by mobilizing the excretion of residual airway secretions by means of vibrating mechanical systems, the effect of positioning on the abdomen can be enhanced. This prevents the formation of bronchiolar obstruction by the mucus plugs and improves the paO2/FiO2.

{The study described here was published in the form of the letter in the Spanish Journal of Anesthesiology and Resuscitation. Although showing promising results, has some limitations. The most important seems to be the performance of the study protocol on patients in whom the influence of the prone positioning on paO2/FiO2 was examined directly before the influence of the prone positioning and vibrations. It is therefore difficult to discuss the pure effect of the vibrations themselves. Nevertheless, earlier studies clearly indicate that vibrations facilitate the removal of residual secretions in the respiratory tract (in various pulmonary diseases) by means of palpation vibrations or devices using therapeutic mechanical vibrations – vibrotherapy. That’s why the presented issue requires further research and brings hope for an improvement in physiotherapy of covid wards, as well as postcovid rehabilitation. Editorial note.}

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