SciELO - Scientific Electronic Library Online

vol.21 issue4Telerehabilitation in knee arthroplasty, therapeutic alternative and ethical challenge author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand




  • Have no cited articlesCited by SciELO

Related links

  • Have no similar articlesSimilars in SciELO


Revista de la Facultad de Medicina Humana

Print version ISSN 1814-5469On-line version ISSN 2308-0531

Rev. Fac. Med. Hum. vol.21 no.4 Lima Oct./Dec. 2021 


Timely and early respiratory rehabilitation in patients with Covid-19 pneumonia in a referral hospital.

Antonio O. Morales Avalos1 

Félix K. Llanos Tejada1  2 

Juan A. Salas Lopez1  3 

Aldo R. Casanova Mendoza1  3 

1Servicio de Neumología, Hospital Nacional Dos de Mayo, Lima, Perú

2Facultad de medicina Humana, Universidad Ricardo Palma, Lima, Perú

3Facultad de medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Perú

Mr. Editor

SARS-CoV-2 is a beta-coronavirus of the same subgenus as SARS and MERS viruses, they share the same gene binding receptor, angiotensin converting enzyme (ACE2).1The spectrum of disease severity is varied, with the mild form being the most frequent (81%), and severe disease present in 14% of cases, with critical presentation being present in 5%, with a mortality of 2.3%.2

The post-pneumonia respiratory sequela caused by beta-Coronaviruses is diffuse alveolar damage with fibrotic lesions; the pathophysiological mechanism is multifactorial, which involves activation of transforming growth factor beta (TGF-β)3, IL1, IL6, MCP1 and TNF-α secondary to epithelial injury and subsequent inflammation. In addition, exposure to high O2 concentrations and effects of barotrauma, caused by advanced oxygen/ventilatory support, activate the pro-fibrotic TGF-β pathway, resulting in aberrant repair characterized by exaggerated deposition of fibroblasts, myofibroblasts and collagen. Forty-seven percent and 25% of patients who survive moderate to severe COVID-19 pneumonia have decreased carbon monoxide diffusion and predicted total lung capacity, respectively.4

Respiratory rehabilitation is a tool used by the clinician to improve the physical and psychological condition and quality of life of people suffering from chronic respiratory disease. It is based on individualized management of the patient by applying muscle training, physiotherapy techniques, education, psychological and nutritional evaluation.5Respiratory rehabilitation applied in a timely and early manner reduces dyspnea, relieves anxiety and depression. In addition, it could reduce the occurrence of respiratory complications, improve pulmonary dysfunction and reduce the disability rate of hospitalized patients with a diagnosis of moderate to severe COVID-19 at the end of the acute phase.

For aerobic exercises, an extremity cycloergometer is used, with oxygen support to ensure an O2saturation (SatO2) greater than 95%, controlled according to the Borg scale and safety heart rate. In addition, it is suggested to use an incentive inspirometer, by flow or volume, considering that the pulmonary sequelae are of restrictive pattern. As for the initial and follow-up evaluation parameters, it is suggested to use the one-minute standing-sitting test or the desaturation test with walking.

Our pulmonology team of a referral hospital for COVID-19 management suggests starting the post-COVID-19 respiratory rehabilitation program as follows (Table 1).

Tabla 1.  Early Respiratory Rehabilitation of moderate to severe COVID-19 pneumonia. 

Criteria for initiation of early respiratory rehabilitation Prescription of early respiratory rehabilitation exercises COVID-19
Basal FiO2requirement ≤ 40% (binasal cannula). Respiratory rate < 25rpm Rhythmic heart rate < 100lpm Temperature < 38°C SatO2> 94%. Systolic blood pressure > 90mmHg Mean arterial blood pressure > 70mmHg Time to onset of illness 10 - 14 days Borg resting scale < 3 points Early sitting out of bed. 10 minutes warm-up with isotonic movements of limbs, torso and head; accompanied by diaphragmatic breathing and pursed lip. Start of limb ergometer, monitoring Borg scale (<7 points) and maintain target heart rate (64% - 76% of maximal HR value -defined as 220 - age of patient-).For 30 minutes, continuous or intermittent (progressive goals). *Oxygen support for SatO2> 94% (pre-during-post exercise). 10-minute cool-down and rest. Start of incentive inspirometer (contraindicated in obstructive pattern): 20 inspirations 1 minute apart (progressive targets). *PEP device, Threshold IMT as required. *Duration 1 week in-hospital (re-evaluation), complete two months at home. *Nutritional evaluation *Psychological evaluation
Criterios de finalización
Borg dyspnea scale > 7 (total score: 10 points). Anterior chest tightness, dizziness, headache, palpitations, diaphoresis, vertiginous syndrome. Sustained desaturation Decrease in SatO2> 4 points from basal for more than 1 minute. Decrease in O2< 88% for more than 1 minute.

FiO2: Inspired fraction of O2. SatO2: O2saturation. Maximum HR: Maximum heart rate. PEP: Positive expiratory pressure.


1. Ashish Chawla y cols. Computer Vision Syndrome: Darkness under the Shadow of Light. Canadian Association of Radiologists Journal 70 (2019) ]

2. Susan A. Randolph. Computer Vision Syndrome. Workplace Health Saf. 2017 Jul; 65(7):328. doi: 10.1177/2165079917712727. [ Links ]

3. Sheppard AL, Wolffsohn JS. Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophth 2018;3:e000146. doi:10.1136/bmjophth-2018-000146 [ Links ]

4. Eurofound. Sixth European Working Conditions Survey. 2017. ]

5. INEI. Estadísticas de las tecnologías de información y comunicación en los hogares. INFORME TÉCNICO N° 03 - septiembre 2020. Instituto Nacional de Estadística e Informática - INEI. ]

6. Vásquez García, Efecto del tiempo de exposición a pantallas de visualización de datos sobre la fatiga visual en digitadores del HNGAI -EsSALUD. UNIVERSIDAD NACIONAL MAYOR DE SAN MARCOS. FACULTAD DE MEDICINA. UNIDAD DE POST GRADO. ]

7. Fernández Villacorta, Prevalencia del síndrome visual informático en estudiantes universitarios de postgrado de una universidad privada Lima -2019. UNIVERSIDAD PERUANA UNION ]

Funding sources: Self-funded.

Received: May 04, 2021; Accepted: August 10, 2021

Correspondence: Antonio Omar Morales Avalos Address: Jr. Huiracocha 1852 Jesús María, Lima - Perú. Telephone: +51 989112109.

Authorship contributions: AMA, FLT, JSL y ACM have participated in the preparation of the letter to the editor and the approval of its final version.

Conflicts of Interests: The authors declare that there is no conflict of interest.

Creative Commons License Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons