COVID-19

PHYSIOTHERAPY MANAGEMENT
 MATERI
PENGENALAN COVID-19 DAN
PERMASALAHAN FISIOTERAPI

ASESMEN FISIOTERAPI

INTERVENSI FISIOTERAPI
PENGENALAN COVID-19 DAN
PERMASALAHAN FISIOTERAPI
DATA COVID-19 DUNIA
PATOFISIOLOGI

Fig 1 | Multi-organ complications of covid-19 and long

covid. The SARS-CoV-2 virus gains entry into the cells of
multiple organs via the ACE2 receptor. Once these cells
have been invaded, the virus can cause a multitude of
damage ultimately leading to numerous persistent
symptoms, some of which are outlined here (Crook, 2021)
 Decrease in surfactan

Decrease lung compliance

Alveolar collapse

Impaired gas exchange

hypoxemia

Increased work of breathing

Release inflammatory products

Increase capillary permeability

Interstitial edema

Impaired gas exchange

hypoxemia

Increased work of breathing

hypoxemia
MULTI ORGAN FAILURE
(Ali FE et al. , 2021)
PHYSIOTHERAPY PROBLEM
 Distal lung segmen Gejala COVID-19 akut
Post mechanical
mengalami kerusakan Peningkatan WOB yang berlangsung lama
ventilation
karena virus ( ≥ 3 minggu)

• Fibrosis paru → tigh • gangguan • endotracheal tube • Risiko ICUAW →

rib cage → gangguan keseimbangan dapat menyebabkan menurunkan
shoulder movement • Gangguan kekuatan kelemahan/gangguan kemampuan ADL
→ gangguan mobilitas distal pita suara • Kelemahan diafragma
trunk • Peningkatan risiko • Pita suara penting (Dress, 2020 dan
• Dyspnea → GERD untuk menghasilkan Tuinman, 2020)
overrecruitment (gastroesophageal tekanan core trunk
asesoris muscles → reflux disease (Massery, 2013)
pain, headache →
penurunan endurance
 sistem musculoskeletal
Muscle fatique
Joint swelling
Joint limitation
Tendon shorthening
Muscle weakness

Motaqi et al., 2021

ASESMEN FISIOTERAPI
EARLY WARNING SCORE
 GENERAL ASSESSMENT
- Kesadaran
ASESMEN SUBYEKTIF - Vital Sign
- Dyspnea NORMAL VALUE
• Keluhan utama
- Pain HR : 60-100x/menit
• Onset keluhan
• Topis keluhan Parameter Covid-19
RR : 12-20x/menit
• Etiologi Pulse Sinus tachycardia
• Riwayat pengobatan Frekuensi nafas Tachypnes (RR> 30 x/menit BP : 90/60-140/90 mmHg
• Faktor yang memperberat Temperatur Demam (89% kasus)
dan memperingan keluhan Saturasi Oksigen Happy hypoxia
SpO2 : 95-100%
Tekanan Darah Hipotensi (akibat dehiidrasi,
septic shock, heart failure)
suhu : 36,5-37,5 °C
Cardiovascular compensation for mild (85 to 90% Sao2), moderate (75 to 85% Sao2), severe (50 to 75% Sao2), and profound (<50% Sao2) hypoxemia. Increased cardiac output, mainly
mediated by increased heart rate, is the main cardiovascular response to hypoxemia, but is limited by age and cardiovascular disease. Mild to moderate hypoxemia causes increased
cellular glycolysis, which generates 2,3 diphosphoglycerate and increases the P50 of hemoglobin. Decreased tolerance of physical exertion or even normal activity is a sensitive
indicator of the adequacy of early cardiovascular response to hypoxemia. Loss of consciousness becomes likely at saturations less than 50%. Failure
of cardiovascular adaptation ultimately involves bradycardia, asystole, or pulseless electrical activity, with rapidly ensuing tissue injury and death. CO, cardiac output; HR, heart rate;
PVR, pulmonary vascular resistance; SVR, systemic vascular resistance.C
HEENT
Parameter Covid-19
Edema peri-
Head - Edeme peri-orbital & swelling of face and extremitass orbital
(fluid retention associated acute kidney injury)
- Cervical lymphadenopathy (Krajewska et al., 2020)
Eye - Conjunctivitis (Seah & Agrawal (2020)
- Epiphora (Wu et al., 2020)
Ear - Otitis media
- Bulging tympanic membrane (Fidan & Fural, 2020)
Nasal - Runny nose
- Nasal congestion Epiphora
Throat Throad congestion, tonsil edema (Krajewska et al., 2020)
 PERKUSI INSPEKSI
(sonor, redup, pekak) (STATIS, DINAMIS)

ASESMEN
OBYEKTIF
PALPASI AUSKULTASI
(ekspansiThorax, trachea,
(suara nafas normal
Focal fremitus,
Spasmeototbantu nafas) dan suara tambahan)
Auskultasi Perkusi

Pasien COVID-19 → dull sounds

pada area konsolidasi

Shifting range of
bottom of lung
 PEMERIKSAAN KHUSUS
Sesak nafas: VAS, Borg Fatique/kelelahan: Borg
Kekuatan otot: MMT
scale scale RPE

Pemeriksaan fungsional: 30-second chair sit and

rise, isometric grip strength, one-leg stance TUG test, 6MWT
(untuk pasien dengan gejala ringan–sedang dan (sebelumdischarge)
sebelum discharge)
 MRC DYSPNEA SCALE

GRADE RELATED TO ACTIVITY

1 Not troubled by breathless except on strenuous exercise

2 Short of breath when hurrying on a level or when walking up

a slight hill
3 Walks slower than most people on the level, stops after a
mile or so, or stops after 15 minutes walking at own pace

4 Stops for breath after walking 100 yards, or after a few

minutes on level ground
5 Too breathless to leave the house, or breathless when
dressing/undressing
Adapted from Fletcher CM. The clinical diagnosis of pulmonary
emphysema—an experimental study. Proc R Soc Med 1952;45:577–584.

GOLD, 2013
Modified Borg Dyspnea Scale
Sesak Nafas Keterangan
0 Tidak ada
0,5 sangat sangat ringan
1 Sangat ringan
2 Ringan
3 Sedang
4 Sedikit berat
5 Berat
6
7 Sangat berat
8
9 Sangat-sangat berat
10 maksimal
Dyspnea Scale
 Roth score (cocok untuk pasien hipoksia) (Chorin et al.,
2016)

- Tarik nafas dalam dengan

menghitung keras dari 1 sd 30 dalam
Bahasa ibu
- Hitung jumlah detik sebelum
mengambil nafas lagi
- Jika waktu penghitungan 8 detik
atau kurang → SaO2 < 95%
(sensitifitas 78% dan spesifisitas 71%)
- Jika waktu penghitungan adalah 5
detik atau kurang → sensitivitasnya
91%
 Resting and Dynamic Breathing Pattern

• Inspirasi : ekspirasi
• Gerakan dinding dada
• Rekruitmen otot :
• Inspirasi
• Ekspirasi tenang
• Ekspirasi paksa
• Pola nafas abnormal

Pasien COVID-19 biasanya mengalami tachypnea

 LUNG EXAMINATION FINDING IN COVID-19

LUNG EXAMINATION FINDING IN COVID-19

Physical exam Mild-moderate infection Severe infection (ARDS) (Gibson et al., 2020)
(Pneumonia)[ (DE Jongh & Thiadens, 2011)
Inspection Tachypnea Dyspnea
Maybe normal respiratory rate Tachypnea [Respiratory rate (≥ 30 breaths/min)
indicates severe disease]
Increased work of breathing using accessory muscles
lethargic and dehydrated patient
Palpation Increased vocal fremitus Decreased vocal fremitus
(accompanying pneumothorax)
Diminished chest expansion at the
Diminished chest movements at the affected side
affected side
Percussion Dull percussion note Tympanic note if pneumothorax accompanies
Auscultation Decreased breath sounds if pleural Decreased breath sounds over a lung may indicate a
effusion accompanies pneumothorax or endotracheal tube down the right
Bronchial breath main bronchus
Rhonchi
Rhonchi
Rales may or may not be present
Rales and Crackles
 HEART
Parameter Covid-19

Pulse pressure - PP yang sempit (mengindikasikan shock hipovolemik)

Palpation - Impuls apical bergeser ke lateral (pelebaran ventrikel kiri pada

myocarditis/gagal jantung akibat covid-19)
Auscultasi - Tachycardia atau aritmia
- S3 atau gallops terutama pada disfungsi biventrikel, gagal
jantung atau shock kardiogenik
- Murmur mitral atau tricuspid dengan pelebaran ventrikel
- Pericardial friction rub dan suara jantung intensitas rendah
(pericarditis dan efusi) (Siripanthong et al., 2020)
 NEUROMUSKULAR
Parameter Covid-19
Mental status - Penurunan kesadaran (akibat dehidrasi berat, acute kidney injury, ensefalitis,
meningitis)
Cranial nerve - N I olfactory ➔ anosmia (membantu diagnosis covid-19 tahap awal (Lee et la.,
2020; Menni et al., 2020)
- N III : opthalmoparesis
- N VII : kelemahan sering ditemukan pada GBS
- N III, V, VI, IX, X, XII → ptosis, facial drop, disfagia, disartria, dan diplopia
sensory - Absent withdrawal to painful stimuli (padaencephalitis (Benameur et al., 2020)
- Hypesthesia (Sedaghat & Karimi, 2020; Gupta et al., 2020)
Motor system - Paresis dan atonia (Sheraton et al., 2020)
- Bilateral ascending flaccid paralisis atau quadriparesis (ditemukan pada GBS
akibat covid-19) (Sedaghat & Karimi, 2020)
- Ataxia gait (jarang)
Refleks - Deep tendon areflexia or hyporeflexia (pada GBS akibat covid-19)
- absent corneal reflex, gag reflexes, oculocephalic refle, penurunan deep
tendon reflex, myoclonus (pada encephalitis) (Benameur et al., 2020)
 EKSTREMITAS

- Edema pedal (pada pasien covid yang mengalami cedera ginjal akut, gagal
jantung, miokarditis, atau kerusakan hati
- Jari kaki COVID-19: pola pseudo-chilblain dapat muncul di jari kaki yang secara
luas dikenal sebagai jari kaki COVID. (Galvan et al., 2020)

Chilblains in a COVID-19 patient commonly known

as COVID toes- By Sapp - Own work, Public
Domain, https://commons.wikimedia.org/w/index.php?cu
rid=3297622
 PEMERIKSAAN PENUNJANG

- Pulse oximetry
- SpO2 < 90%
- Waspadai “silent hypoxia” - CRP
- ABG - Biasanya meningkat
- Gejala berat → hypercarbia atau acidosis
- Biasanya menunjukkan hasil penurunan tekanan parsial - Serum lactate dehydrogenase
O2 - Meningkat
- Direkomendasikan pada pasien dengan gangguan - Serum kreatinin kinase
pernafasan dan sianosis dengan SpO2 < 90% - Pada pasisen dengan gejala yang parah terjadi
- FBC peningkatan
- Leukopenia - Indikasi → injuuri myocardium
- Limfopenia - Serum troponin level
- Leukositosis, trombositopenia, penurunan Hb - Meningkat pada pasien dengan cardiac injury
- Limfopenia dan trombositopenia → indicator klinis utk
memantau perkembangan penyakit
- Rasio neutrophil-limfosit yang tinggi → indicator utk
risiko penyakit parah dan prognosis yang buruk
 LAB VALUE COVID-19

• Peningkatan CRP • Peningkatan Il-6

• Penurunan limfosit • Peningkatan Feritin
• Penurunan platelet • Penurunan Procalcitonin
• Peningkatan BUN/Cr • CBC : leukopenia & Lymphopenis
• Peningkatan LFTs (AST/ALT/Total bili
• ARDS → peningkatan PCT dan lactat
• Peningkatan ESR (>50%)
- Kultur darah dan sputum
- infeksi bakteri negative PEMERIKSAAN
- RT-PCR
- Swap nasofaring dan orofaring
- Dahak/aspirasi endotrakeal (172)
- Saliva (239)
- Chest X ray
- Unilateral lung infiltrate (25%) /bilateral infiltrate (75%) (24,25,178)
- CT SCAN
- - ground-glass opacity atau konsolidasi pada beberapa lobus bilateral atau subsegmental)
- Biasanya perifer atau posterior terutama di lobus bawah, jarang di lobus kanan bawah
- Penebalan interlobular atau septum (halus dan tidak teratur)
- Penebalan pleura
- dll
 Komorbiditas(obesit
as, DM, hipertensi,
disfungsitiroid,
stroke,
gangguanginjal, dll)
SCREENING
Desaturasi yang
diinduksi aktivitas.
Stabilitashemodina
Pasien dengan
mik: nyeridada,
penurunan saturasi
takikardi, aritmia,
> 3% atau saturasi <
edema kaki,
96% saat istirahat
sesaknafas, dll
harus diobservasi
degan cermat
SCREENING

Gangguan
pernafasan:
takipnea
Kesiapan mobilisasi
(>30x/menit),
(tingkat kesadaran,
perubahan pola
risiko jatuh, dll).
nafas, penggunaan
otot asesoris saat
istirahat
SAFETY
 Rekomendasi Keselamatan Bagi Fisioterapis (Aleksandra et
al., 2020)

Apa yang harus

Apa yang paling penting ? dipertimbangkan ?
Apa yang harus dikenakan?

Cuci tangan dengan seksama Gunakan pakaian bedah sekali

sebelum dan sesudah bekerja Tanyakan apakah pasien
diduga covid-19 pakai saat bekerja dengan
dengan setiap pasien pasien /lepaskan baju terinfeksi
– Ganti /lepas baju saat bekerja
di zona risiko
Alat pelindung diri Apakah pasien memerlukan
fisioterapi ?
Sepatu menutupi seluruh kaki,
Masker pelindung mudah dilap-tinggalkan di
tempat kerja
Biasakan diiri kita denga
Hindari prosedur yang
pedoman local untuk
menghasilkan aerosol jika tidak Jangan bawa pakaian anda ke
prosedur menejemen
perlu rumah
INTERVENSI PHASE AKUT DI ICU
 Dispnea

TUJUAN
PROBLEM Gangguan pembersihan jalan nafas Mengurangi sesak nafas
Penurunan volume dan kapasitas Meningkatkan kapasitas paru
paru Mencegah Komplikasi paru
Penurunan oksigenasi Mencegah Komplikasi akibat
Gangguan ventilasi dan perfusi immobilisasi
Mengurangi kecemasan dan
Peningkatan kerja pernafasan
depresi
Potensi terjadi komplikasi tirah
baring Cieloszczyk A, et al., 2020
Potensi terjadi kelemahan otot
akibat perawatan di ICU
Potensi terjadi komplikasi paru
(atelektasis,fibrosis DLL)
Olezene et al., 2021
The treatment strategies included the following
(Yuethong, 2020)
Treatment:.
(1) Position change:
(2) Prone position.
(3) Respiratory control: .
(4) Passive joint motion.
(5) Muscle stretching.
(6) Neuromuscular electrical stimulation.
(7) Bedside standing training
(8) Walking exercises (standing up independently with less help).
(9) Maintaining physical strength and exercise endurance.
 PASIEN TIDAK SADAR DAN MENGGUNAKAN VENTILATOR

• Posisioning : Prone position minimal 12 jam/hari

• Change position secara teratur
• Passive movement exercise (kerjasama tim)
• Monitoring respon hemodinamik pasien
• Jika kondisi hemodinamik tidak stabil, fisioterapi
harus ditunda
PPK PERFI, 2021
 Pasien sadar dan kooperatif
• Change position (half=seated 30-60 derajad) 3x/hari @ 20 menit
• Prone Positioning (bila PaO2/FiO2 < 150 mmHg)
• Prone position 30 menit, 3-4 kali sehari, atau
• CARP (COVID awake repositioning/prone protocol)
• Control breathing
• Asisted active exercise , stretching
• Bed mobility exercise (assisted bridging, rolling, transferring from
supine to sitting)
• NMES

✓ 30 menit sd 2 jam posisi prone

✓ 30 menit sd 2 jam berbaring ke sisi kanan
✓ 30 menit sd 2 jam duduk bersandar
✓ 30 menit sd 3 jam berbaring ke sisi kiri
✓ 30 menit sd 2 jam posisi prone PPK PERFI, 2021
POSITIONING
Tujuan :
- Memperbaiki oksigenasi
- Meningkatkan rasio vernilasi.perfusi
- Menurunkan respiratory rate

PRONE POSITION

47
 Latihan harus dihentikan apabila:
• HR < 40 x/menit dan > 130 x/menit
• MAP < 65 mmHg dan > 110 mmHg
• RR > 40 x/menit
• SaO2 < 85%
• Aritmia jantung
• Penurunan kesadaran
• Pucat
• Nyeri
• Fatique
• Pasien tidak nyaman
• Suhu kaki dan tangan dingin
• Pusing
 Pasien dengan terapi oksigen via HFNO
INDIKASI INTERVENSI
✓ Pasien dengan pneumonia dengan kebutuhan oksigen ➢ Positioning untuk meningkatkan satirasi
tingkat rendah (oxygen flow 5l/min untuk SpO2 90%) oksigen
✓ Batuk non produktif ➢ Prone position 30 menit, 3-4 kali sehari,
✓ Batuk dan mampu mengeluarkan sekret secara mendiri atau CARP
➢ Deep breathing exercise
➢ ACBT (Active Cycle of Breathing Technique)
TUJUAN ➢ Bed Mobilisasi dan latihan di tepi bed
• Mempertahankan oksigenasi ➢ Ankle and toe exercise
• Menjaga ventilasi ➢ Active exercise extremitas
• Membersihkan jalan nafas
• Menurunkan kerja pernafasan (work of breathing) MONITORING
• Mencegah Komplikasi tirah baring - Respon Hemodinamik
- Saturasi Oksigen
- Respiratory distress
Pasien dengan defisiensi oksigen berat, dengan NIV atau HFNO
INTERVENSI
INDIKASI ➢ Positioning untuk meningkatkan satirasi
✓ Pasien dengan pneumonia dan oksigen
mempunyai komorbid respirasi ➢ Prone position 30 menit, 3-4 kali sehari,
✓ dan neuromuskuler atau CARP
✓ RR > 30x/menit ➢ Deep breathing exercise
✓ SpO2 < 94% ➢ ACBT (Active Cycle of Breathing Technique)
➢ Bed exercise dan out bed exercise
TUJUAN ➢ Ankle and toe exercise
• Mempertahankan oksigenasi ➢ Active exercise extremitas
• Membersihkan jalan nafas
• Mencegah Komplikasi tirah baring MONITORING
• Meningkatkan kemampuan - Respon Hemodinamik
fungsional - Saturasi Oksigen
- Respiratory distress
INTERVENSI FISIOTERAPI POST ACUT
TUJUAN : PENTINGNYA FUNCTIONAL TEST
– Meningkatkan endurance • Sit to stand test → 30 detik sit to
• Akibat perawatan RS yang stand test
lama (± 28 hari) → ICUAW • Mobility assessment → jarak
– Meningkatkan kekuatan otot ambulasi, status transfer
– Meningkatkan kemandirian • 2 MWT
– Safety • 6 MWT
Short-Term Effects of a Respiratory Telerehabilitation Program
in Confined COVID-19 Patients in the Acute Phase: A Pilot
Study (Gonzalez-Gerez et al., 2021
 STEP 1
• Positioning untuk meningkatkan saturasi oksigen
• Prone position 30 menit, 3-4 kali sehari, atau
• CARP (COVID awake repositioning/prone protocol)
• Breathing control
• Slow deep breathing exercise
• Thoracic expansion exercise
• Active cycle of breathing technique (ACBT)
• Assisted Active exercise, dimulai dari 5 kali ulangan dalam 1
set dan ditingkatkan bertahap sampai 10-15 ulangan dalam 3
set (3-4 skala Borg RPE, 3 – 4 METs)
• Bed mobility exercise (assisted bridging, rolling, transferring
from supine to sitting)
 STEP 2

❖ Assisted exercise saat duduk (

shoulder exercise, fleksi hip, ekstensi
❖ knee, ankle pump) mulai dari 5 kali
ulangan dalam 1 set dan
❖ ditingkatkan secara bertahap hingga
8-10 ulangan dalam 3 set. (3-4
❖ skala Borg RPE, 3-6 METs)
❖ Latihan berdiri
 STEP 3
EXERCISE
- Frekuensi → bervariasi tergantung
❖ Exercise pada posisi berdiri (shoulder exercise, fleksi
kondisi pasien, idealnya 4-6 kali
hip, fleksi knee,
seminggu
❖ jalan di tempat. Mulai dari 5 kali ulangan dalam 1 set
- Intensitas → mulai intensitas rendah 6-8
dan ditingkatkan secara bertahap hingga 8-10
minggu pertama dengan 0-10 Borg scale
ulangan dalam 3 set. (3-4 skala Borg RPE, 3-6 METs)
(Spruit et al., 2020)
❖ ADL training
- Durasi → mulai dari durasi pendek,
❖ Cycle ergometer
misalnya ambulasi 2 menit, rest 1 menit,
❖ Ambulasi, jalan sekitar bangsal (mulai 10-15 menit)
diulang 4 – 6 kali untuk total ambulasi 8
– 12 menit
- Type → walking, jogging, bike
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TERIMAKASIH