Rehabilitation Respiratoire Post Covid 19 Def11

REABILITARE RESPIRATORIE POST-COVID-19
Dr. Fayssal EL HUSSEINI

Pneumologue
PARIS- 2021
SARS-Cov-2COVID-19
Introducere
•  Intre Decembrie 2019 si Mai 2021, incidenta infectiei cu

coronavirus (SARS-Cov-2 - COVID-19), a crescut intr-un fel
drastic:
–  157 000 000 persoane infectate in lume (11 mai 2021)
–  3 200 000 DC
•  70% din supravietuitorii Covidului-19, prezinta disfunctii in unu

sau mai multe organe , 4 luni dupa infectia initiala: Sindrom post-
COVID-19
•  OMS 2021
Nat. Med. 2021, 27, 626-631
02/10/21 2:52 PM Dr. Fayssal EL HUSSEINI 2
COVID-19: Formele clinice
The illness severity pattern so far observed is as
follows;
•  Asymptomatic infected patients.
•  Symptomatic patients isolating at home.
•  Symptomatic patients admitted to hospital
•  Symptomatic patients requiring ventilatory
support in critical care.
COVID-19: Fazele Bolii
Terminologie
The timeline of Post-acute COVID-19 syndrome is defined as 4 to
12 weeks between initial confirmation of SARS-CoV-2 infection,
while Post-COVID-19 syndrome is defined as 12 weeks after initial

infection.
. 2021 Aug 5;9(8):966. doi: 10.3390/biomedicines9080966.

Lancet 2020; 395: 1054-62
Summary of multi-system
clinical presentations of
Long COVID-19
Syndrome
Effect on Various Organ

Systems
Efectele asupra diferitelor

organe si sisteme
. 2021 Aug 5;9(8):966. doi: 10.3390/biomedicines9080966.

Presentations of Long COVID-19 Syndrome
•  DEFICIT FUNCTIONAL PULMONAR
•  PERSISTENTA LEZIUNILOR PULMONARE
•  TULBURARI TROMBOEMBOLICE
•  TULBURARI LA NIVELUL CELULELOR

ENDOTELIALE
•  MODIFICARI VASCULARITICE
•  HIPER COAGULABILITATE
•  MICRO ANGIOPATIE
•  TROMBO EMBOLISM
•  MIOCARDITA
•  PIERDERI DE MEMORIE
•  SCADEREA ATENTIEI
•  LENTOARE PSIHICA
•  TULBURARI COGNITIVE
•  LEZIUNI INTESTINALE DIFUZE
•  EDEMUL SI DESCUAMARE ENTEROCITELOR
•  LEJERA DILATARE A INTESTINULUI
•  INFILTRATIE LIMFOCITARA LA NIVELUL TUBULUI DIGESTIV
•  NODULE HEMORAGICE SI NECROZA ALE MEZENTERULUI

•  LEZIUNI RENALE ACUTE
•  INSUFICIENTA RENALA
•  SCADEREA FILTRARII GLOMERULARE

•  HIPERGLICEMIE FARA DIABET
•  ACIDICETOZA DIABETICA
•  EPUIZARE MUSCULARA DOBÂNDITA

'Long-COVID': a cross-sectional study of persisting symptoms,
biomarker and imaging abnormalities following hospitalisation
for COVID-19
Large numbers of people are being discharged from hospital following COVID-19 without assessment
of recovery.
•  In 384 patients (mean age 59.9 years; 62% male) followed a median 54 days post discharge,
–  53% reported persistent breathlessness,
–  34% cough and 69% fatigue.
–  14.6% had depression.
In those discharged with elevated biomarkers,

–  30.1% and 9.5% had persistently elevated d-dimer and C reactive protein, respectively.
–  38% of chest radiographs remained abnormal with 9% deteriorating.
•  Systematic follow-up after hospitalisation with COVID-19 identifies:

–  the trajectory of physical
and psychological symptom burden,
–  Recovery of blood biomarkers and
–  Imaging,
could be used to inform the need for rehabilitation
THORAX. 2021 Apr;76(4):396-398

COVID-19: Short and Long Term
Effects of Hospitalization on Muscular
Weakness in The Elderly
COVID-19: Efectele spitalizaii, ale

tratamentelor medicamentoase si ale
terapiei intensive pe termen scurt si pe
termen lung, si consecintele
Int. J. Environ Res. Public Health 2020, 8715

SARS-Cov-2 si SPITALIZAREA
pe termen scurt
•  Reducerea masei musculare
•  Scaderea fortei musculare
•  Alterarea fibrelor musculare
•  Modificarea tesutului muscular
•  Slabiciunea contractiei musculare
•  Epuizare
•  Inflamatie locala si sistemica
SARS-Cov-2 si TRAMAMENTUL
MEDICAMENTOS
pe termen scurt
•  Stimulare a Catabolismului
•  Miopatie
•  Desechilibru Proteic
•  Rezistenta La Insulina
•  Astenie Indusa De Terapia Intensiva
SARS-Cov-2
pe termen lung
•  Fragilitate Accelerata
•  Declinul Capacitatilor Functionale
•  Invaliditate Cronica
•  Dependenta
•  Ingrijiri La Domiciliu
•  Cresterea Nevoilor Sanitare
SARS-Cov-2 - COVID-19
•  70% din supravietuitorii Covidului-19, prezinta
disfunctii in unu sau mai multe organe , 4 luni
dupa infectia initiala: Sindrom post-COVID-19
Nat. Med. 2021, 27, 626-631.
•  Multi pacienti cu S. post-COVID-19 au nevoie

de reabilitare
•  Data privind eficacitatea si despre sucuritatea
reabilitarii, lipseste!
ATS-ERS Coordinated International Task Force - 2021
REABILITARE POST-COVID
3 TIPURI DE RECOMANDARI:
•  LOCALE -I- Universitatea din Hong Kong – China:

–  Recommendation on rehabilitation plans for « Long COVID
Syndrome »
•  TEMPORARE- II- ERS/ATS – Europa + USA:
–  Interim Guidance on Rehabilitation for Covid-19 or Post-
Covid-19 syndrome
•  GLOBALE - III- STANFORD HALL Consensus – UK:
–  Consensus statement for Post-COVID-19 rehabilitation
RECUPERARE POST-COVID
RECOMANDARI
•  I- Universitatea din Hong Kong – China:

–  Recommendation on rehabilitation plans for « Long COVID Syndrome »
Recommended
rehabilitation model
for patients with
Long COVID-19
Syndrome.
. 2021 Aug 5;9(8):966. doi: 10.3390/

biomedicines9080966.
RECOMANDARI
•  II- ERS/ATS – Europa + USA:

–  Interim Guidance on Rehabilitation for Covid-19 or Post-Covid-19 syndrome
COVID-19: Interim Guidance on Rehabilitation in the Hospital
and Post-Hospital Phase
European Respiratory Society and American Thoracic Society
•  Pacientii cu COVID-19 sau POST-COVID-19, deseori
au nevoie de reabilitare in timpul spitalizarii sau imediat
dupa iesirea lor;
•  Data (informatii) privind eficacitatea si despre

sucuritatea, lipsesc;
•  93 experti au fost solicitati sa raspunda la 13 intrebari
•  Principiu: Cel putin 70% de consens pentru a adopta

raspunsul respectiv.
European Respiratory Society and American Thoracic Society-coordinated
Q1 :
Reabilitare In Timpul Spitalizarii ?
•  Pacientii COVID-19,
aflati in spital (in camera
obisnuita sau in terapie
DA!
intensiva) n-ar trebui sa
primeasca reabilitare
pâna la iesire din spital?
Q2:
Sa fie evaluata nevoia de oxigen inaintea iesirii?
•  Inaintea iesirii din spital,

nu ar trebui sa fie
masurata nevoia de
oxigen, in repaus si la DA!
efort?
Q3:
Pacientul sa fie încurajat sa aiba activitate zilnica?
•  Dupa iesire din spital,

nu ar trebui ca
pacientul sa fie DA!
încurajat sa aiba
zilnic activitate, in
primele 6-8 saptamâni
de la iesire?
Q4:
Pacientul care nu a avut un control oximetric inaite de iesire,
trebuie încurajat sa faca exercitiu fizic lejer/
moderat la domiciliu?
•  Fara control oximetric,
la iesire din spital,
pacientul trebuie
DA!
încurajat sa faca
exercitiu fizic lejer/
moderat la domiciliu in
primele 6-8 saptamâni?
Q5:
Trebuie Sa fie evaluat din punct de vedere fizic
si psihic la 6-8 saptamâni de la iesire?
•  La pacientii COVID-19
trebuie sa fie evaluati din
punct de vedere fizic si
psihic la 6-8 saptamâni de DA!
la iesire din spital, in
vederea evaluarii nevoilor
lor in materie de
reabilitare?
Q6:
Starea psihica si mentala sa fie evaluata cu chestionare
de tip « EQ-5D, Hospital Anxiety si Depression Scale »?
•  În cazul pacientilor COVID-19, care
au trecut prin Insuficienta
Respiratorie Acuta si care au
supravietuit, n-ar trebui ca statutul
psihic, mental si anxios sa fie
evaluat cu chestionarele de tip « DA!
EQ-5D, Hospital Anxiety si
Depression Scale », la 6-8
saptamâni de la iesire din spital?
Q7:
Sa fie realizate Explorari Functionale Respiratorii, la
6-8 saptamâni?
•  Supravegherea pacientilor
spitalizati pentru
COVID-19, nu ar trebui
sa contina si explorari DA!
functionale respiratorii, la
6-8 saptamâni de la iesire
din spital?
Q8:
Sa fie realizate Explorari ale Capacitatii Fizice, la 6-8
saptamâni?
•  Supravegherea pacientilor
spitalizati pentru
COVID-19, nu ar trebui
sa contina si explorari ale DA!
capacitatii la exercitiu, la
din spital?
Q9:
Pacientul Sa primeasca un program clar de
reabilitare?
•  P a c i e n t i c a r e a u
supravietuit COVID-19,
care au nevoie de
reabilitare, la 6-8 DA!
saptamâni de la iesire din
spital, nu ar fi preferabil
sa primeasca un program
clar de reabilitare?
Q10:
Acest program trebuie sa fie conform standardului
international?
•  Pacienti care au supravietuit

COVID-19, mai ales cei care
au invaliditati functionale
respiratorii , la 6-8 saptamâni DA!
de la iesire din spital, nu ar fi
preferabil sa primeasca un
program clar si conform
standardul international, de
reabilitare?
Q11:
Si un program de reîntarire musculara?
care au nevoie de
reîntarire musculara, la DA!
din spital, nu ar fi
preferabil sa primeasca un
program de reîntarire
musculara?
Q12:
Si un program de suport nutritiv?
care au nevoie de un
suport nutritiv, la 6-8 DA!
sa primeasca un program
de suport nutritiv?
Q13:
Si sa primeasca o asistenta psihologica?
•  Pacienti care au
care au simptome de stres
psihologic, la 6-8 DA!
sa primeasca o asistenta
psihologica?
RASPUNSURILE LA CELE 13 ÎNTREBARI
COVID-19: Interim Guidance on Rehabilitation in the
Hospital and Post-Hospital Phase
from a European Respiratory Society and American Thoracic
Society-coordinated International Task Force
•  76 experti (82%) a fost de acord cu reabilitare in timpul

spitalizarii, la iesire din spital si la 6-8 saptamâni dupa.
•  Au fost toti de acord asupra continutului programului de reabilitare
–  Toti au preconizat prescriptie de Oxygen la domiciliu, la iesire din spital
–  Toti au preconizat reabiliratre fizica si mentala , 6-8 saptamâni dupa iesire
din spital.
–  Toti au preconizat ca reabilitarea sa fie multidisciplinara cu attentie
crescuta la recuperarea musculara, functionala si mintala.
•  Grupul « International Task Force » a recomandat sa se ia
Rehabilitarea Respiratorie ca un model mai ales la pacienti cu
sechele respiratorii din cauza bolii COVID-19.

RECOMANDARI
•  III- STANFORD HALL Consensus – UK:

–  Consensus statement for Post-COVID-19 rehabilitation
The Stanford Hall Consensus Statement for Post-
COVID-19 Rehabilitation
Observatii Introductive
1.  COVID-19 is a multisystem disease, which in certain cases will

require full multidisciplinary team (MDT) rehabilitation to
enable recovery.
2.  Whenever possible rehabilitation should commence in the

critical care setting.
3.  The National Institute for Health and Care Excellence (NICE)
recommends progressive rehabilitation programmes are best
initiated within the first 30 days (post-acute phase) to have
greatest impact on recovery.
The Stanford Hall Consensus Statement
for Post-COVID-19 Rehabilitation
1.  General recommendations
Pentru toate cazurile de reabilitare Post-COVID 19
2.  Pulmonary recommendations

In caz de sechele pulmonare post-COVID 19
3.  Cardiac recommendations

In caz de sechele cardiovasculare post-COVID 19
4.  Exercise recommendations

In caz de reabilitare la exercitiu post-COVID 19
5.  Psychological recommendations

In caz de sechele psihologice post-COVID 19
•  Barker-Davis RM, 6.  Musculoskeletal recommendations
O’Sullivan O, Senaratne In caz de sechele musculo-scheletice post-COVID 19
KPP, et al. Br J ports
Med, 2020, 54: 7.  Neurological recommendations
949-959. In caz de sechele neurologice post-COVID 19
•  (DMRC) Defence 8.  Medical recommendations
Medical Rehabilitation
Centre In caz de alte sechele post-COVID 19 ( GI, Hepatice, Renale, Dermatologice, Reumatologice,
Hematologice sau Endocrine)
RECOMANDARI / Tip de Sechele
COVID-19
Nr RECOMANDARILOR 1.General
rehabilitation
2.Pulmonary
4 rehabilitation
5
3.Cardiac
rehabilitation
5 3 4.Exercise
rehabilitation
5.Psychological
rehabilitation
6.Musculoskeletal
4 6 rehabilitation
•  Barker-Davis RM,
7.Neurological O’Sullivan O, Senaratne
KPP, et al. Br J ports
rehabilitation Med, 2020, 54:
4 5 8.Medical
949-959.
•  (DMRC) Defence
rehabilitation Medical Rehabilitation
Centre
The Stanford Hall consensus for post-COVID-19
rehabilitation
Oxford Evidence Levels
Barker-Davies RM, O’Sullivan, Senaratne KPP, et al. Br J Sports Med 2020; 54: 949-959
General rehabilitation recommendations
I
•  Clinicianul trebuie :
–  sa respecte masurile preventive, anti COVID-19
–  Se foloseasca echipamente de protectie conform policitii locale
–  Sa ia masuri in scopul de a evita sau de a reduce riscul
aerosolizarii in timpul interventiilor si al activitatilor.
•  Clinicians should
–  follow preventive measures,
–  wear appropriate personal protective equipment according to local policy
–  and measures should be taken to avoid or reduce, the risk of aerosol generation during interventions and
activities.
–  Level of evidence: Level 5.

–  Level of agreement: mean score 9.23 (95% CI 8.66 to 9.91).
II
•  Programul reabilitarii trebuie:
–  Sa fie individualizat pentru fiecare pacient tinând cont de
comorbiditatile acestuia
•  Rehabilitation treatment plans should be

individualised according to the patient’s needs, taking into consideration their comorbidities.
•  Level of evidence: Level 5.

•  Level of agreement: mean score 9.70 (95% CI 9.46 to 9.97).
III
•  Scopurile reabilitarii post-covid trebuie sa fie:
–  Usurarea simptomelor de dispnee si stresul psihic
–  Ameliorarea participarii in reabilitare
–  Ameliorarea functilor fizice (musculare)
–  Inbunatatirea calitatii vientii
•  For patients with COVID-19, rehabilitation should be aimed at
–  relieving symptoms of dyspnoea, psychological distress and
–  improving participation in rehabilitation,
–  physical function and
–  quality of life.

IV
•  Pacientul trebuie sa fie:
–  Revazut prin prisma procesului de reabilitare
•  Patients should be reviewed through the rehabilitation process.

V
•  Pacientul trebuie sa primeasca:
– Educatie asupra strategiei reabilitarii si conditiilor de
recuperare.
•  Patients should receive education about their condition and given strategies on how to manage recovery.

Pulmonary rehabilitation
recommendations
I
•  Complicatiile respiratorii trebuie sa fie luate in vedere la patients
post-COVID-19 având in vedere ca acesti pacients pot prezinta
invaliditati si limitari functionale, incluziv respiratorii.
•  Respiratory complications should be considered in post-COVID-19 patients as they may present with some degree
of
–  impairment and
–  functional limitation, including but not exclusively, due to decreased respiratory function.
•  Level of evidence: Level 2b.

recommendations
II
•  Momentul consultatie de includere in programul de
reabilitare, depinde de gradul de disfunctie sau de
insuficienta respiratorie si de statutul fizic si psihic al
pacientului.
•  Initial assessment is recommended in a timely manner when safe to do so, depending on
–  the degree of dysfunction, normocapnic respiratory failure and patient’s physical and mental status.
•  Level of evidence: Level 2b.

recommendations
III
•  Nivelul initial de efort trebuie sa fie sub controlul FC,
SpO2 , TA :
–  < 3 METS (1 MET = 3,5 ml O2/min/Kgc)
–  Sa creasca progresiv bazindu-se pe evolutia simptomelor
•  Low intensity exercise (≤3 METs or equivalent) should be considered initially particularly for patients who
required oxygen therapy, while concurrently monitoring vital signs (heart rate, pulse oximetry and blood pressure).
Gradual increase in exercise should be based on their symptoms.
•  Level of evidence: Level 5

Cardiac rehabilitation recommendations
I
•  Existenta unor sequele cardiace la un Post-COVID, trebuie sa fie
considerata indiferent de severitatea boli:
–  Semnele clinice cardiace trebuie cautate sistematic
–  Examene de laborator necesare trebuie cerute
–  EKG, Ecocardiografie, Test de efort cardiac sau IRM cardiac deasemenea.
•  Cardiac sequelae should be considered in all patients post-COVID-19, regardless of severity, and all patients
should have an assessment of their cardiac symptoms, recovery, function and potential impairments. Depending on
the patient’s initial assessment and symptoms, specialist advice should be sought, and further investigations may
include a specialist blood panel, ECG, 24-hour ECG, echocardiogram, cardiopulmonary exercise testing and/or
cardiac MRI.

II
•  O perioada de repaus post-infectios in COVID-19, reduce
riscul de insuficienta cardiaca secundara miocarditei, in
perioada reabilitarii.
•  A period of rest postinfection, depending on symptoms and complications, will reduce risk of
postinfection cardiac failure secondary to myocarditis.

III
•  Daca se constata o patologie cardiaca post-COVID, cu
ocazia cs de includere in programul de reabilitare:
–  Programul trebuie sa fie
•  De reabilitare cardiaca specifica cazului respectiv
•  Bazat pe complicatiile, limitarile si pe nevoile de reabilitare constatate.
•  If cardiac pathology is present,

–  specific cardiac rehabilitation programmes should be provided tailored to the individual
–  based on their cardiac complications, impairments and rehabilitation needs assessment.

IV
•  Pacientul care a avut miocardita confirmata, si care are
nevoie de reabilitare la un nivel ridicat:
–  Inainte, are nevoie, de repaus complet timp de 3-6 luni
•  Patients returning to high-level sport or physically demanding occupation following confirmed myocarditis
–  require a 3–6 months period of complete rest.
–  The period of rest is dependent on
•  the clinical severity and
•  duration of illness,
•  left ventricular function at onset and
•  extent of inflammation on CMR.
–  Level of evidence: Level 2b
V
•  Antranamentul la nivel înalt poate urma miocardita daca:
–  Functia sistolica a ventricolului stâng este normala
–  Biomarkeri cardiaci sunt normali in sânge
–  Monitoring EKG /24 ore si Testul de efort cardiac nu arata nici o aritmie
•  Training and high-level sport may resume following myocarditis, if

–  left ventricular systolic function is normal,
–  serum biomarkers of myocardial injury are normal and if
–  relevant arrhythmias are ruled out on 24-hour ECG monitoring and exercise testing.
•  Level of evidence: Level 2a

VI
•  Daca reintoarcerea la nivel înalt in sport sau in munca
dupa miocardita (covid-19)
–  Un control medical periodic este de prevazut in special in
primii doi ani.
•  If returning to high-level sport or physically demanding occupation following myocarditis, patients are required to
–  undergo periodic reassessment, in particular during the first 2 years.
•  Level of evidence: Level 2a

Exercise rehabilitation recommendations
I
•  Pacientii care au necesitat oxigenoterapie sau au prezentat o
limfopenie trebuie:
–  Identificati de urgenta
–  Sa beneficieze de o radiologie pulmonara
–  Cautate anomaliile in Explorari Functionale Respiratorii
•  Patients with COVID-19 who required oxygen therapy or exhibited lymphopenia

–  acutely should be identified and tested for radiological pulmonary changes and pulmonary
function test abnormalities.

II
•  Pacientii cu COVID-19 si care au urmatoarele simptome:
–  Iritatie traheala severa
–  Dureri la nivelul corpului
–  Dispnee
–  Astenie
–  Dureri toracice
–  Tuse
–  Febra
•  Trebuie sa evite orice efort > 3METS timp de 2-3 saptamâni dupa disparitia simptomelor
•  Patients with COVID-19 who experience the following symptoms: severe sore throat, body aches, shortness of
breath, general fatigue, chest pain, cough or fever should avoid exercise (>3 METs or equivalent) for between 2
weeks and 3 weeks after the cessation of those symptoms.

III
•  Pacientii cu simptome usoare, care pot sa nu fie legate de COVID-19:
–  Pot sa se limiteze la eforturi usoare < 3METs dar
–  sa limiteze perioadele sedentare si
–  Sa creasca perioadele de repause daca simptomele se deterioreaza
–  Eforturile intense sau prelungite trebuie evitate
•  With very mild symptoms which may or may not be due to COVID-19, consider limiting activity to light activity
(≤3 METs or equivalent) but limit sedentary periods. Increase rest periods if symptoms deteriorate. Prolonged
exhaustive or high intensity training should be avoided.

IV
•  Persoanele asimptomatice , « contact COVID-19 pozitiv»
trebuie:
–  Continue activitatea obisnuita in limita restrictiilor date de
autoritatile sanitare
•  Asymptomatic contacts of positive COVID-19 cases should continue to exercise as they would do
normally within current government restrictions.

V
•  In cazurile de lejer/moderat COVID-19:
–  1 saptamâna de exercitiu de întideri si lejer exercitiu de re-întarire musculara,
inainte de a trece la exercitiu clasic
•  In cazurile de sever COVID-19:
–  Nivelul initial de efort trebuie sa fie sub controlul FC, SpO2 , TA :
–  < 3 METS (1 MET = 3,5 l O2/min/Kgc)
–  Sa creasca progresiv bazindu-se pe evolutia simptomelor
•  On return from mild/moderate COVID-19 illness to exercise, 1 week of low-level stretching and light muscle
strengthening activity should be trialled prior to targeted cardiovascular sessions. Patients in the severe category
should be identified as per recommendation 15 above with exercise progression following a pulmonary
rehabilitation approach (defined further in the pulmonary section of the main text).

Psychological rehabilitation
recommendations
I
•  in faza acuta, comunicarea efectiva si contactul social cu
pacientul si completarea unei fise de informatii, pot fi
utile in privinta sechelelor psihosociale
•  In the acute phase, effective communication, social contact (although remotely) and an information
sheet for people admitted to acute National Health Service care regarding the psychological sequelae
of COVID-19 could help.

recommendations
II
•  In faza de recuperare din COVID-19:
–  Pacientul trebuie revazut in scopul de a identifica pe cei care au
reactii psihosociale adverse, fata de boala.
–  Aceasta cs trebuie sa fie orientata catre dispozitia si bunastare
ale pacientului.
•  Individuals should be reviewed in the recovery phase to identify those who may have adverse psychological
outcomes as a result of their COVID-19 experiences. Healthcare workers who contracted COVID-19 should be
considered a high-risk group. This review should focus on mood and well-being.
•  Level of evidence:
–  Level 5.
recommendations
III
•  Monitorizarea activa trebuie sa fie realizata la cei are au
simptome psihologice sub-liminare
•  Active monitoring (ongoing review) should be undertaken for those with subthreshold psychological
symptoms.
–  Level of evidence: Level 1a.

recommendations
IV
•  Pentru pacientii care au tulburari acute de stres, sunt
adaptate situatiei:
–  Terapie Comportamentala
–  Terapie cognitiva
•  Referral to psychological services and consideration of trauma focused cognitive behavioural therapy, cognitive
processing therapy or eye movement desensitisation and reprocessing is appropriate for those with moderate to
severe symptoms of acute stress disorder.
–  Level of evidence: Level 1a.

Musculoskeletal rehabilitation
recommendations
I
•  La toti pacientii care au nevoie de reabilitare post-COVID
–  Trebuie evaluat nivelul de deficienta musculara
–  Pentru a determina reabilitarea fizica corespunzatoare
•  All patients requiring rehabilitation following COVID-19 should have a functional assessment to
determine residual musculoskeletal impairments in order to determine appropriate rehabilitation.

recommendations
II
•  Pacientii care trecusera prin Terapie Intensiva trebuie sa
fie luati in sarcina de catre echipe multidisciplinare
pentru reabilitarea lor.
•  Patients that have had an ICU admission should have a multidisciplinary team approach for
rehabilitation.

recommendations
III
•  Pacientii care prezinta un sindrom post-reanimare trebuie luate in
sarcina cele 3 tipuri de invaliditati:
–  Psihologice
–  Fizice
–  Cognitive
•  Patients presenting with postintensive care syndrome should include rehabilitation efforts focusing
on all three domains of impairments: psychological, physical and cognitive.

recommendations
IV
•  Reabilitarea fizica post-COVID-19, poate fi realizata:
–  In spital
–  In abbulatoriu
–  La domiciliu
•  In direct sau prin telemedicina
•  Physical rehabilitation following COVID-19 can be delivered in a series of settings including

inpatient, outpatient, in-home telehealth or patient-directed exercises determined according to patient
needs.

Neurological rehabilitation
recommendations
I
•  Toti pacientii COVID-19 trebuie revazuti pentru oricare
simptom neurologic:
–  Imediat: In perioada infectiei active
–  Mai târziu : in perioada Post-COVID
•  All patients with COVID-19 should be reviewed for any neurological symptoms, as symptoms can be immediate
(at time of active infection) or delayed (in the weeks following COVID-19). Consider a cognitive screen for those
at risk (postcritical care or with residual cognitive impairment).
–  Level of evidence: Level 2b.

recommendations
II
•  Trebuie informat pacientul care prezinta simptome neurologice usoare, ca
–  cefalee,
–  ameteala,
–  anosmie,
–  ageusie,
au ameliorare dupa interventii minime.
•  Reassurance should be given that milder neurological symptoms like headache, dizziness, loss of
smell or taste, and sensory changes are likely to improve with minimal intervention.

recommendations
III
•  Educatia trebuie sa fie data in asa fel incât:
–  pacientul cu simptome neurologice lejere sau moderate sa
recupereze complet.
•  Education should be provided that mild-to-moderate neurological symptoms are likely to have a full
recovery.
–  Level 3b.
recommendations
IV
•  Simptomele severe pot rezulta potential de la o problema
legate de o schimbare in stilul de viata;
•  de aceea avest tip de pacient trebuie luat in sarcina de
catre o echipa multi disciplinara
•  Severe symptoms potentially may result in significant or life-changing impairment, therefore inpatient
multidisciplinary rehabilitation is recommended for patients with moderate-to-severe neurological symptoms to
maximise recovery.

recommendations
V
•  Asistenta fizica, cognitiva si functionala trebuie
considerata ca ajutor pentru a se intoarce la munca
corespunzatoare
•  Physical, cognitive and functional assessments should be considered to support return to work
according to occupational setting.

Medical rehabilitation recommendations
I
•  Sechelele post-covid 19, trebuie luate in vedere:
–  In perioada post-acuta trebuie sa se constitue un dosar medical
complet cu istoria bolii, biomarkerii, etc
–  Imagistica radiologica.
•  Post COVID-19 medical sequelae should be considered in all patients. Postacute assessment should include a full
medical history and if indicated, an examination and panel of blood markers. Dual energy X-ray absorptiometry
should be considered in cases of prolonged immobilisation.
–  Level of evidence: Level 3b.

II
•  In prezenta unor patologii multiple, un consultant in Reabilitare
este recomandat, cu o echipa multidisciplinara ca sa poata lua in
sarcina eventuala gama larga de sechele; si include un dietetician
cu suplimente nutritive la nevoie
•  In the presence of multiple pathologies or specialist issues, a rehabilitation consultant assessment is recommended
with a multidisciplinary approach to rehabilitation, to manage the wide range of potential sequelae including a
dietician (with supplements and micronutrient blood panel if required).
•  Level of evidence: Level 1a.

III
•  In caz de probleme medicale identificate , se recomanda
ca pacientul sa fie adresat intr’un serviciu medical
competent in specialitatea respectiva
•  If ongoing medical problems are identified, patients should be referred on to the appropriate medical
specialty for further management.
•  Level 5.
IV
•  In POST-COVID-19, reaparitia dispnei sau a unor dureri
toracice, cazul trebuie considerat ca o urgenta vitala.
•  In post-COVID-19 patients with new-onset shortness of breath or chest pain, life-threatening

medical complications should be considered.

COVID-19: Interim Guidance on Rehabilitation in the
Hospital and Post-Hospital Phase
from a European Respiratory Society and American Thoracic Society-
coordinated International Task Force
•  76 experti (82%) a fost de acord cu reabilitare in timpul

spitalizarii, la iesire din spital si la 6-8 saptamâni dupa.
•  Au fost toti de acord asupra continutului programului de reabilitare
–  Toti au preconizat prescriptie de Oxygen la domiciliu, la iesire din spital
–  Toti au preconizat reabiliratre fizica si mentala , 6-8 saptamâni dupa iesire
din spital.
–  Toti au preconizat ca reabilitarea sa fie multidisciplinara cu attentie
crescuta la recuperarea musculara, functionala si mintala.
•  Grupul « International Task Force » a recomandat sa se ia
Rehabilitarea Respiratorie ca un model mai ales la pacienti cu
sechele respiratori din cauza bolii COVID-19.

REABILITAREA RESPIRATORIE
DEFINITIE
REABILITAREA RESPIRATORIE ESTE O INTERVENTIE
–  MULTIDISCIPLINARA
–  INTEGRATA IN TRATAMENTUL PACIENTULUI PENTRU PACIENTII CU:
•  BOLI RESPIRATORII CRONICE
•  CARE SUNT SIMPTOMATICI SI
•  CARE DESEORI AU DIMINUAT ACTIVITATEA LOR ZILNICA.
REABILITAREA RESPIRATORIE ARE CA SCOP
•  SA REDUCA SIMPTOMELE,
•  SA OPTIMIZEZE STAREA FUNCTIONALA,
•  SA CREASCA PARTICIPAREA
•  SA REDUCA COSTURILE INGRIJIRILOR PACIENTILOR
PRIN INTERMEDIUL STABILIZARII SAU REDUCERII MANIFESTARILE BOLII.
PROGRAMUL REABILITARII RESPIRATORII INCLUDE:

•  REANTRENARE LA EXERCITIU ,
•  EDUCATIE TERAPEUTICA,
•  SI ASISTENTA PSIHO SOCIALA.
ERS -Pulmonary Rehabilitation, Monograph 13; March 2000

ECHIPA REABILITARII RESPIRATORII
IN JURUL PACIENTULUI
•  MD : Medic Specialist
•  MSW: Asistent Social
•  Psych: Psiholog
•  PT: Fizioterapeut
•  RD: Dietetician
•  OT: Medicina Muncii
•  RT: Tehnician
•  RN: Asistent Medical
CASABURI / PETTY, priciples and practice of pulmonary rehabilitation
Reabilitarea in Centrul CARDIF din PARIS
•  Patient BPCO
•  Stable, sans affection intercurrente évolutive
•  Dyspnée à l’exercice malgré un traitement bien suivi
•  VEMS < 80%
•  Déconditionné
•  Compliant
•  Ne présentant pas de C.I. absolue
EVALUATION DE BASE
•  EFR, GDS
•  VO2max
•  T6M
•  DYSPNEE
•  BODE
•  IMC
•  FORCE MUSCULAIRE
CONTENU DU PROGRAMME DE
REHABILITATION
1.  INCLUSION
2.  BILAN PRE-STAGE
3.  STAGE DE 6 SEMAINES:
–  REENTRAINEMENT A L’EFFORT: 4 fois/Sem.
–  EDUCATION THERAPEUTIQUE
–  PRISE EN CHARGE NUTRITIONNELLE
–  PRISE EN CHARGE PSYCHOLOGIQUE
–  KINESITHERAPIE
–  PRISE EN CHARGE SOCIALE
4.  BILAN POST-STAGE
5.  FIN DE STAGE
6.  PROGRAMME DE MAINTIEN DES ACQUIS
REHABILITATION
•  INCLUSION:
–  INDICATIONS ET CONTREINDICATIONS
–  CONSTITUTION D’UN DOSSIER MEDICAL DE
REHABILITATION
–  ORIENTATION DU BILAN ET DE LA PRISE EN CHARGE
–  PRESENTATION DU PROCESSUS AU PATIENT
–  ETABLISSEMENT D’UN ACCORD D’OBJECTIFS AVEC LE
PATIENT
REHABILITATION
•  BILAN PRE-STAGE:
–  Planification +++
–  Cs antitabac (si besoin)
–  Avis cardiologique (ECG, Echo cardiaque, etc..)
–  Bilan fonctionnel respiratoire: EFR, DLCO et GDS
–  Epreuves d’effort: VO2max et T6M
–  Evaluation musculaire
–  Bilan nutritionnel
–  Entretien avec le psychologue
–  Diagnostic éducatif
–  Prise en charge sociale (si besoin)
REHABILITATION
•  STAFF TRANSDISCIPLINAIRE
–  PARTICIPANTS:
•  Coordinateur de stages: Pneumologue
•  Responsable de la nutrition: Médecin
•  Psychologue
•  Educateur thérapeutique
•  Secrétaire de planification
•  Kinésithérapeute
•  Infirmière
–  CONSTITUTION DES GROUPES
•  Discussion des dossiers et prescription individualisée
•  Un groupe = 5 patients
•  Homogénéité des groupes +++
•  Désigner le soignant responsable du groupe
–  INDIVIDUALISATION DES PROGRAMMES
•  RECOMMANDATIONS SPECIFIQUES
•  GESTION DES RISQUES:
–  CONSIGNES DE SURVEILLANCE INDIVIDUELLE
REHABILITATION RESPIRATOIRE EN AMBULATOIRE
AU CTAR
TEL-EREHABILITATION A L’EXERCICE
REHABILITATION
•  STAGE DE 6 SEMAINES:
–  REENTRAINEMENT A L’EFFORT:
•  4 séances/sem.
•  45-60 minutes/ séance
•  30-45 minutes / membres inférieurs / vélo-ergomètre
•  10-15 minutes / membres supérieurs
SEANCE DE REENTRAINEMENT A L'EFFORT
DES MEMBRES INFERIEURS
1
0.9
0.8
PUISSANCE(% du VO2max)
0.7
0.6
0.5 % de VO2max
0.4
0.3
0.2
0.1
0
0 1 2 3 4 5 6 7 8 9 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 32 33 34 35 36 37 38 39 40
TEMPS (min)
SEANCE POUR CHAQUE MEMBRE SUPERIEUR
1
0,9
0,8
0,7
POIDS(% de la FMV)
0,6 FMV > 80 W

60W <FMV< 80W
0,5
40W <FMV< 60W
0,4 FMV <40W
0,3
0,2
0,1
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65
TEMPS(secondes)
REHABILITATION
–  REENTRAINEMENT A L’EFFORT
6 séances de 45 minutes
1.  Anatomie et physiologie de l’appareil respiratoire
2.  Les traitements inhalés
3.  Les techniques de respiration
4.  Les techniques de toux.
5.  La conservation de l’énergie dans les activités quotidiennes.
6.  Le cycle anxiété-essoufflement et les exercices de relaxation
REHABILITATION
–  PRISE EN CHARGE NUTRITIONNELLE:
•  Médecin Endocrino-Nutritioniste
•  Infirmière
•  6 séances d’éducation nutritionnelle/ stage
•  60 min par séances
REHABILITATION
–  PRISE EN CHARGE PSYCHOLOGIQUE:
•  Psychologue clinicien
•  Entretien individuel au début du stage
•  Groupe de parole 1 fois / semaine
•  Entretien individuel à la fin du stage
REHABILITATION
–  KINESITHERAPIE:
•  Evaluation musculaire
•  Drainage bronchique si besoin
•  Aérosolthérapie si besoin
REHABILITATION
–  REENTRAINEMENT A L’EFFORT: 3 fois/Sem.
–  KINESITHERAPIE
–  PRISE EN CHARGE SOCIALE:
•  En collaboration avec le Comité de Paris (CNMR) si besoin:
aide financière, démarches, etc..
REHABILITATION
•  BILAN POST-STAGE:
–  Planification +++
–  Bilan fonctionnel respiratoire: EFR, DLCO et GDS
–  Epreuves d’effort: VO2max et T6M
–  Evaluation musculaire
–  Bilan nutritionnel
–  Entretien avec le psychologue
–  Bilan éducatif
REHABILITATION
•  FIN DE STAGE:
–  Pneumologue
–  Bilan général
–  Synthèse et conclusions
–  Constat partagé avec le patient:
•  Réalisation des objectifs du stage
•  Préparer le programme pour la suite
REHABILITATION
•  PROGRAMME DE MAINTIEN DES ACQUIS:

–  En collaboration avec CARDIF-ASSISTANCE
–  Recommandation de faire des exercices à domicile
–  Visite de l’infirmière du CARDIF /15 J
–  Temps de 3 mois
–  Bilan après 6 mois et 12 mois
–  + inclusion dans un nouveau stage
META ANALIZA
– 11 STUDII – 637 PACIENTI
Effectiveness of Pulmonary Rehabilitation in Interstitial
Lung Disease, Including Coronavirus Diseases
•  This meta-analysis revealed a positive association

between:
–  pulmonary rehabilitation and
–  lung function,
–  exercise capacity, and
–  quality of life
in patients with ILD, including severely affected patients with
CoV.
•  Specific evidence of the effect of

–  pulmonary rehabilitation in patients who have survived the
severe acute respiratory syndrome coronavirus 2 infection
appears contradictory!
CONCLUZII
•  REABILITAREA POST-COVID-19
–  NU SE LIMITEAZA LA O REABILITARE PULMONARA
–  RECOMANDARILE INTERNATIONALE SUNT VARIABILE SI
TEMPORARE
•  PENTRU REABILITAREA RESPIRATORII IN POST-

COVID-19 , UNELE REZULTATE SUNT CONTRADICTORII
•  ESTE NEVOIE DE MAI MULTA EXPERIENTA SI MAI ALES

DE RECOMMANDARI CONSENSUALE, PRIVIND
REABILITAREA POST-COVID-19.

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REABILITARE RESPIRATORIE POST-COVID-19

Dr. Fayssal EL HUSSEINI

• Intre Decembrie 2019 si Mai 2021, incidenta infectiei cu

• 70% din supravietuitorii Covidului-19, prezinta disfunctii in unu

while Post-COVID-19 syndrome is defined as 12 weeks after initial

. 2021 Aug 5;9(8):966. doi: 10.3390/biomedicines9080966.

Effect on Various Organ

Efectele asupra diferitelor

. 2021 Aug 5;9(8):966. doi: 10.3390/biomedicines9080966.

• DEFICIT FUNCTIONAL PULMONAR

• PERSISTENTA LEZIUNILOR PULMONARE

• TULBURARI LA NIVELUL CELULELOR

• LEZIUNI INTESTINALE DIFUZE

• EDEMUL SI DESCUAMARE ENTEROCITELOR

• LEJERA DILATARE A INTESTINULUI

• INFILTRATIE LIMFOCITARA LA NIVELUL TUBULUI DIGESTIV

• NODULE HEMORAGICE SI NECROZA ALE MEZENTERULUI

• LEZIUNI RENALE ACUTE

• SCADEREA FILTRARII GLOMERULARE

• HIPERGLICEMIE FARA DIABET

• EPUIZARE MUSCULARA DOBÂNDITA

In those discharged with elevated biomarkers,

• Systematic follow-up after hospitalisation with COVID-19 identifies:

THORAX. 2021 Apr;76(4):396-398

COVID-19: Efectele spitalizaii, ale

Int. J. Environ Res. Public Health 2020, 8715

• Multi pacienti cu S. post-COVID-19 au nevoie

• LOCALE -I- Universitatea din Hong Kong – China:

• I- Universitatea din Hong Kong – China:

. 2021 Aug 5;9(8):966. doi: 10.3390/

• II- ERS/ATS – Europa + USA:

• Data (informatii) privind eficacitatea si despre

• 93 experti au fost solicitati sa raspunda la 13 intrebari

• Principiu: Cel putin 70% de consens pentru a adopta

• Inaintea iesirii din spital,

• Dupa iesire din spital,

• Pacienti care au supravietuit

• 76 experti (82%) a fost de acord cu reabilitare in timpul

European Respiratory Society and American Thoracic Society-coordinated

• III- STANFORD HALL Consensus – UK:

1. COVID-19 is a multisystem disease, which in certain cases will

2. Whenever possible rehabilitation should commence in the

2. Pulmonary recommendations

3. Cardiac recommendations

4. Exercise recommendations

5. Psychological recommendations

– Level of evidence: Level 5.

• Rehabilitation treatment plans should be

• Level of evidence: Level 5.

• Level of evidence: Level 5.

• Patients should be reviewed through the rehabilitation process.

• Level of evidence: Level 5.

• Level of evidence: Level 5.

• Level of evidence: Level 2b.

• Level of evidence: Level 2b.

• Level of evidence: Level 5

• Level of evidence: Level 5

• Level of evidence: Level 5

• If cardiac pathology is present,

• Level of evidence: Level 5

•  Intre Decembrie 2019 si Mai 2021, incidenta infectiei cu

•  70% din supravietuitorii Covidului-19, prezinta disfunctii in unu

•  DEFICIT FUNCTIONAL PULMONAR

•  PERSISTENTA LEZIUNILOR PULMONARE

•  TULBURARI LA NIVELUL CELULELOR

•  LEZIUNI INTESTINALE DIFUZE

•  EDEMUL SI DESCUAMARE ENTEROCITELOR

•  LEJERA DILATARE A INTESTINULUI

•  INFILTRATIE LIMFOCITARA LA NIVELUL TUBULUI DIGESTIV

•  NODULE HEMORAGICE SI NECROZA ALE MEZENTERULUI

•  LEZIUNI RENALE ACUTE

•  SCADEREA FILTRARII GLOMERULARE

•  HIPERGLICEMIE FARA DIABET

•  EPUIZARE MUSCULARA DOBÂNDITA

•  Systematic follow-up after hospitalisation with COVID-19 identifies:

•  Multi pacienti cu S. post-COVID-19 au nevoie

•  LOCALE -I- Universitatea din Hong Kong – China:

•  I- Universitatea din Hong Kong – China:

•  II- ERS/ATS – Europa + USA:

•  Data (informatii) privind eficacitatea si despre

•  93 experti au fost solicitati sa raspunda la 13 intrebari

•  Principiu: Cel putin 70% de consens pentru a adopta

•  Inaintea iesirii din spital,

•  Dupa iesire din spital,

•  Pacienti care au supravietuit

•  76 experti (82%) a fost de acord cu reabilitare in timpul

•  III- STANFORD HALL Consensus – UK:

1.  COVID-19 is a multisystem disease, which in certain cases will

2.  Whenever possible rehabilitation should commence in the

2.  Pulmonary recommendations

3.  Cardiac recommendations

4.  Exercise recommendations

5.  Psychological recommendations

–  Level of evidence: Level 5.

•  Rehabilitation treatment plans should be

•  Level of evidence: Level 5.

•  Level of evidence: Level 5.

•  Patients should be reviewed through the rehabilitation process.

•  Level of evidence: Level 5.

•  Level of evidence: Level 5.

•  Level of evidence: Level 2b.

•  Level of evidence: Level 2b.

•  Level of evidence: Level 5

•  Level of evidence: Level 5

•  Level of evidence: Level 5

•  If cardiac pathology is present,

•  Level of evidence: Level 5

•  Training and high-level sport may resume following myocarditis, if

•  Level of evidence: Level 2a

•  Level of evidence: Level 2a

•  Patients with COVID-19 who required oxygen therapy or exhibited lymphopenia

•  Level of evidence: Level 4.

–  Level of evidence: Level 5.

–  Level of evidence: Level 5.

–  Level of evidence: Level 5.

–  Level of evidence: Level 5.

–  Level of evidence: Level 5.

–  Level of evidence: Level 1a.

–  Level of evidence: Level 1a.

–  Level of evidence: Level 5.

–  Level of evidence: Level 5.

–  Level of evidence: Level 5.

•  Physical rehabilitation following COVID-19 can be delivered in a series of settings including

–  Level of evidence: Level 5.

–  Level of evidence: Level 2b.

–  Level of evidence: Level 4.

–  Level of evidence: Level 5.

–  Level of evidence: Level 5.

–  Level of evidence: Level 3b.

•  Level of evidence: Level 1a.

•  In post-COVID-19 patients with new-onset shortness of breath or chest pain, life-threatening

–  Level of evidence: Level 5.

•  76 experti (82%) a fost de acord cu reabilitare in timpul

•  PROGRAMME DE MAINTIEN DES ACQUIS:

•  This meta-analysis revealed a positive association

•  Specific evidence of the effect of

•  PENTRU REABILITAREA RESPIRATORII IN POST-

•  ESTE NEVOIE DE MAI MULTA EXPERIENTA SI MAI ALES