What I Learned As a Physiotherapist in the ICU?

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Physiotherapists are part of the multidisciplinary ICU team.

The traditional focus of treatment has been the respiratory management of both intubated and spontaneously breathing patients.

Emerging evidence of the longstanding physical impairment suffered by survivors of intensive care has resulted in physiotherapists re-evaluating treatment priorities to include exercise rehabilitation as a part of standard clinical practice.

Physiotherapists perform an assessment that includes the respiratory, cardiovascular, neurological, and musculoskeletal systems to formulate treatment plans.



The precise roles and indications for physiotherapy are uncertain as physiotherapy involvement is largely based on clinical reasoning and there is a lack of high quality evidence supporting physiotherapy in the ICU.

MOBILISATION, DECONDITIONING AND MUSCULOSKELETAL THERAPY

Physiotherapists have a role in maintaining joint and muscle function in those who are at risk of contractures, for example in neurological injuries and patients with prolonged paralysis.

There is increasing emphasis on exercise rehabilitation over respiratory management is increasingly evident as survivors of a prolonged ICU stay can suffer deconditioning, muscle atrophy, and weakness that may impact upon quality of life.


RESPIRATORY PHYSIOTHERAPY

Goals of respiratory physiotherapy: management

  • promote secretion clearance
  • maintain or recruit lung volume, in both the intubated and spontaneously breathing patient
  • Techniques for optimisation of cardiopulmonary function
  • Manual hyperinflation (MHI) (mechanical ventilation only)
  • Suction (mechanical ventilation only)
  • Manual techniques: chest shaking and vibration, chest wall compression, chest clapping/ percussion
  • Positioning, gravity-assisted positioning (GAP)
  • Mobilization/ rehabilitation
  • Active cycle of breathing technique (ACBT)
  • Intermittent positive-pressure breathing (IPPB)
  • Continuous positive airways pressure (CPAP)
  • Non-invasive ventilation (NIV)
  • Nasopharyngeal/oral suction
  • Positive expiratory pressure (PEP) mask, flutter valve

In the intubated patient, physiotherapists commonly employ manual and ventilator hyperinflation and positioning as treatment techniques whilst in the spontaneously breathing patients there is an emphasis on mobilisation.


Aims of chest physiotherapy inside I.C.U.

  • Assist in the removal of secretions.
  • Improve ventilation of all areas of the lungs.
  • Maintain mobility and good posture of the patients.
  • Decrease patient’s hospital stay.

The most common techniques used by physiotherapists in the intensive care unit are:

  • Postural drainage, percussion and vibrations.
  • Tracheal suctioning, Lavage and coughing.
  • Mobilization techniques.
  • Breathing exercises and incentive spirometer.


Methods of Airway Clearance

Methods of Cough Stimulation

  • Huffing
  • Vibration
  • Deep breathing exercise
  • External tracheal stimulation
  • Stimulation of oropharynx with a suction catheter
  • Suctioning.

Tracheal Suction

Suctioning is performed routinely on intubated patients to aid in secretion removal and cough stimulation. The frequency of suctioning is determined by the quantity of secretions.

  • Oropharyngeal airways
  • Nasopharyngeal airways
  • Endotracheal tubes
  • Tracheostomy tubes

Basic steps of the suctioning procedure

1. Provide the patient with supplemental oxygen before suctioning to increase arterial oxygenation - patient receiving mechanical ventilation may not require this step.

2. Check the amount of negative pressure produced by the suction apparatus and, if necessary, adjusts to 100 - 160 mmHg.

3. Put a sterile glove on the dominant hand. Gloves should be worn on both bands to protect the clinician from contamination.

4. Expose the vent end of the catheter and connect it to the suction tubing. Any part of the catheter that may contact the patent’s trachea must be kept sterile.

5. Slide the catheter out of its packaging, taking care not to cause contamination.

6. Disconnect the patient from the ventilator or oxygen source.

7. Gently insert the catheter into the tracheal tube. No suction is applied during insertion of the catheter.

8. If resistance to the catheter is present, pull the catheter back slightly and attempt to reinsert.

9. Apply suction by placing a finger over the vent. Turn the catheter slowly while withdrawing it, so that the side holes of the catheter are exposed to a greater surface area.

10. Reconnect the patient to the ventilator or oxygen source.

Difficulty cannulating the main stems bronchus

It is more difficult to pass a suction catheter into the left than the right main bronchus. In adults; the right main stem bronchus usually comes off at an angle of about 200 from a midline sagittal plane, whereas the left main stem bronchus has a more marked angle of about 35o (making the left more difficult to successfully cannulate) similar angles of bifurcation are noted in the neonate (24o for the right and 44o for the left). It is suggested that turning the head to the right or tilting the body to the left increases the chances of successful cannulation of the left bronchus. Curved tip (crude) catheters are thought to improve the chances of entering the left lung during suctioning.

Suction catheters:

  1. Tip design: Straight or curved.
  2. Material: Polyvinyl chloride (PVC) or rubber.
  3. Number of side holes: one or more.
  4. Size.
  5. Length.
  6. Packaging: straight or coiled.

Complications of tracheal suctioning

  • Hypoxemia
  • Arrhythmia
  • Hypotension
  • Lung collapse
  • Bacterial contamination
  • Nasotracheal suctioning complications

Postural drainage

  • They are positions that promote gravity-assisted drainage of secretions.
  • Lung segments receiving drainage are positioned uppermost.
  • The majority of I.C.U. treatment is for lower lobes.

Breathing exercises

Goals

  • Assist in removal of secretions.
  • Improve respiratory muscles strength and endurance.
  • Increase thoracic cage mobility and expansion.
  • Promote relaxation.

Types:

  1. Deep breathing includes diaphragmatic breathing exercise, pursed lips breathingand nose exercise.
  2. Segmental (localized) breathing exercise includes upper costal breathing, lowercostal breathing, apical breathing and sternal breathing exercise.

Equipment used for mobilization

  • Pulley system with overhead traction units, ropes, weights and pulleys.
  • Safety belt for patient transferring.
  • Adjustable walker and crutches.
  • I.V. rolling pole and a source of supplemental oxygen.



References and Links


Journal articles

  • Ambrosino N, Venturelli E, Vagheggini G, Clini E. Rehabilitation, weaning and physical therapy strategies in chronic critically ill patients. Eur Respir J. 2012 Feb;39(2):487-92. doi: 10.1183/09031936.00094411. Epub 2011 Dec 1. Review. PubMed PMID: 22135278. [Free Full Text]

  • Fan E. Critical illness neuromyopathy and the role of physical therapy and rehabilitation in critically ill patients. Respir Care. 2012 Jun;57(6):933-44; discussion 944-6. doi: 10.4187/respcare.01634. Review. PubMed PMID: 22663968. [Free Full Text]

  • Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, Schönhofer B, Stiller K, van de Leur H, Vincent JL. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients.

  •  Intensive Care Med. 2008 Jul;34(7):1188-99. doi: 10.1007/s00134-008-1026-7. Epub 2008 Feb 19. Review. PubMed PMID: 18283429.
  • Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013 Jun;41(6):1543-54. doi: 10.1097/CCM.0b013e31827ca637. Review. PubMed PMID: 23528802.

  • Strickland et al. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients. Respir Care 2013;58:2187-2193 [Free Full Text]

My Mentor's During My Clinical Posting ICU Journey 

  • Dr. Akhilesh Rajput, JR Medicine MICU
  • Dr. Maulik Singh, JR Medicine MICU
  • Dr. Pramod Kumar, JR Medicine MICU
  • Dr. Ajay, SR Medicine MICU
  • Mr. Vijay Kumar Yadav, SR Staff Nurse
  • Mr. Saurabh, SR Staff Nurse MICU
  • Dr. Kriti Mishra, SR Anesthesiology HICU
  • Mr. Vijay, Staff Nurse HICU
  • Mr. Amit, Staff Nurse HICU
  • Dr. Abhigyan Gupta, Anesthesiology SICU
  • Dr. Alankrita, SR Anesthesiology SICU
  • Mrs. Nalini, Staff Nurse SICU
  • Mrs. Ramvati, Nursing In Charge SICU
  • Mr. Lekhraj, Satff Nurse SICU
  • Mr. Deepak, Staff Nurse SICU Et al.

My Colleagues During ICU Journey 

  • Dr. Sandeep Raj, Physiotherapist 
  • Dr. Nitin Kumar, Physiotherapist 
  • Dr. Dwijendra, MBBS
  • Dr. Vinod, MBBS
  • Dr. Yash, MBBS
  • Dr. Aman, MBBS
  • Dr. Akanksha, MBBS
  • Dr. Shivangi, Physiotherapist
  • Dr. Riya, Physiotherapist
  • Dr. Kamal, Physiotherapist
  • Dr. Krati, Physiotherapist
  • Dr. Rakhi, Physiotherapist
  • Dr. Bandana, Physiotherapist
  • Dr. Zeenat, Physiotherapist
  • Dr. Suryabhan, Physiotherapist Et al. 
Share your ICU story in Discussion box.

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