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Edit Comment Close By: ASHEL (40 month(s) ago) very good presentation please let me know some research projects on cardio pt Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript ICU management – A Physiotherapist’s perspective : ICU management – A Physiotherapist’s perspective Chest Physiotherapy is… : Chest Physiotherapy is… A treatment intervention employed for improving pulmonary hygiene including positioning, chest percussion, vibration and manual hyperinflation to assist in mobilizing secretions in the lungs from the peripheral airways into the more central airways so that they can be expectorated or suctioned. Indications : Indications Prophylactic - Pre-operative high risk surgical patient - Post-operative patient who is unable to mobilize secretions - Neurological patient who is unable to cough effectively - Patient receiving mechanical ventilation who has a tendency to retain secretions - Patients with pulmonary disease, who needs to improve bronchial hygiene …contd : …contd Therapeutic - Atelectasis due to secretions - Retained secretions - Abnormal breathing pattern due to primary or secondary pulmonary dysfunction - COPD and resultant decreased exercise tolerance - Musculoskeletal deformity that makes breathing pattern and cough ineffective Assessment : Assessment Neurological system Cardiovascular system Respiratory system Renal system Hematological system Gastrointestinal system Neurological system : Neurological system Level of consciousness Pupils Size Reactivity Equality Cerebral perfusion pressure (>70mmHg) CPP = MAP- ICP Intracranial pressure (<10mmHg) Intracranial pressure measurement : Intracranial pressure measurement Cardiovascular system : Cardiovascular system Heart rate and rhythm Arterial BP Central Venous pressure Pulmonary Artery pressure (PAP) and pulmonary artery wedge pressure (PCWP) Respiratory system : Respiratory system Auscultation Percussion Expansion Chest X-ray Mode of ventilation Humidification Oxygen therapy RR Airway pressures ABG Sputum Renal system : Renal system Assessment of fluid balance Measure of Intravascular volumes Urine output Serum electrolytes ABG Gastrointestinal system : Gastrointestinal system Nutritional support Routes of administration Enteral Parentral Oral Assessment : Assessment General Observation Patient Position Respiration - Airway ET/Tracheostomy Ventillator Mode FiO2 Vital Signs – Temperature, BP, RR, HR SpO2,GCS, ICP Tubes - NG Tube, CV line, Peripheral line, Chest tubes, Catheters Drugs … contd : … contd Examination Auscultations Respiratory pattern Cyanosis Clubbing Radiograph Goals : Goals Prevent accumulation of secretions Improve mobilization and drainage of secretions Promote relaxation to improve breathing patterns Slide 19: Promote improved respiratory function Improve cardio-pulmonary exercise tolerance Teach bronchial hygiene programs to patients with chronic respiratory dysfunction Precautions : Precautions Untreated tension pneumothorax Abnormal coagulation profile Status epilepticus or status asthamaticus Immediately following intra cranial surgery Slide 21: Head injury with raised ICP Osteoporotic bones Recent acute myocardial infarction, unstable vitals Immediately after tube feedings Sutures and ICD’s Physiotherapy Techniques : Physiotherapy Techniques Physiotherapy Techniques : Physiotherapy Techniques Gravity-assisted Positioning Manual techniques Manual hyperinflation Airway suctioning Mobilisation Positioning : Positioning Physiological effects ofPositioning : Physiological effects ofPositioning Optimizes oxygen transport by improving V/Q mismatch Increases lung volumes Reduces the work of breathing Minimizes the work of heart Enhances mucociliary clearance (postural drainage) Postural Drainage isn’t… : Postural Drainage isn’t… a separate technique. Its just an example of positioning which has the particular aim of clearing airway secretions with the assistance of gravity. Slide 27: Patients are positioned with the area to be drained the upper most, but modifications should be done wherever necessary. Drainage times vary, but ideally each position requires 10 minutes (gumery et al, 2001). Positioning : Positioning Positioning restores ventilation to dependent lung regions more effectively than PEEP or large tidal volumes (Froese & Bryan, 1974). Positioning has a marked influence on gas exchange because of unevenly damaged lungs (Tobin, 1994). Side lying reduces lung densities in the upper most lung (Brismar, 1985). …contd : …contd Right side lying may be more beneficial for cardiac output than left side lying (Wong, 1998). Simply turning from supine to side lying can clear atelectasis from dependent regions (Brismar, 1985). Positioning affects lung volume Lung volume is related to the position of the diaphragm FRC decreases from standing to slumped sitting to supine (Macnaughton, 1995) …contd : …contd Positioning affects compliance (Wahba et al found that work of breathing is 40% higher in supine than in sitting) Positioning affects arterial oxygenation by improving V/Q mismatch (V/Q is usually mismatched if the affected lung is dependent- Gillespie et al) “Bad lung up” position Positioning… : Positioning… Which position to choose… ? Chest Maneuver : Chest Maneuver Chest Maneuver : Chest Maneuver Chest Vibrations Chest Percussion/Clapping Clapping/Chest Percussion : Clapping/Chest Percussion Percussion consists of rhythmic clapping on the chest with loose wrist & cupped hand. Effect : Dislodges & loosens secretions from the lung Chest Vibration : Chest Vibration Vibrations consists of a fine oscillation of the hands directed inwards against the chest, performed on exhalation after deep inhalation. Effects: Helpful in moving loosened mucous plugs towards larger airway Manual Hyperinflation : Manual Hyperinflation Manual Hyperinflation : Manual Hyperinflation Was originally defined as inflating the lungs with oxygen and manual compression to a tidal volume of 1 liter requiring a peak inspiratory pressure of between 20 and 40 cm H2O (Med j Aust, 1972). More recent definitions include providing a larger tidal volume than base line tidal volume to the patient (Aust j physiotherapy, 1996) and using a tidal volume which is 50% greater than that delivered the ventilator (chest, 1994). Indications : Indications To aid removal of secretions To aid reinflation of atelectatic segments To assess lung compliance To improve lung compliance Technique : Technique Slow deep inspiration Inspiratory hold (at full inspiration) Fast expiratory release Hand-held PEEP Hazards of MHI : Hazards of MHI Reduction in blood pressure Reduced saturation Raised intracranial pressure Reduced respiratory drive Contraindications : Contraindications Undrained Pnuemothorax Potential bronchospasm Severe bronchospasm Gross cardiovascular instability inducing arrhythmias and hypovolaemia Unexplained Haemoptysis Patient on High PEEP Advantages of MH : Advantages of MH Reverses atelectasis (Lumb 2000) Improves oxygen saturation and lung compliance (Patman et al.,1999) Improves sputum clearance (Hodgson et al., 2000) Disadvantages of MH : Disadvantages of MH Haemodynamic and metabolic upset (Stone, 1991 & Singer et al.,1994) Risk of barotrauma Discomfort and anxiety Suctioning : Suctioning Suctioning : Suctioning Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place. Indications Inability to cough effectively Sputum plugging To assess tube patency Contraindication : Contraindication Frank haemoptysis Severe brochospasm Undrained pneumothorax Compromised cardiovascular system Slide 51: The suction catheter used must be less than half the diameter of endotracheal tube. The vacuum pressure should be as low as possible. (60-150mmHg) Suction should never be routine, only when there is an indication Hazards of suctioning : Hazards of suctioning Mucosal trauma Cardiac arrhythmias Hypoxia Raised intracranial pressure Slide 53: Nasal and oral suction Endotracheal suction Tracheostomy suction Closed-circuit suction Closed-circuit suction : Closed-circuit suction Mobilisation : Mobilisation Mobilisation : Mobilisation Critically Ill (Frequent Position changes, Kinetic & Kinematic Therapy) Stable (Progressive tilting & Ambulation) Mobilisation : Mobilisation ICU rehabilitation has been shown to accelerate recovery (o’leary & coackley, 1996) Early mobilization for unconscious patients starts right from turning the patient every two hours. ( Brooks- brunn, 1995). Graded exercises can be started as soon as the patient regains consciousness. Slide 58: Activity is required to maintain sensory input, comfort, joint mobility and healing ability (Frank et al, 1994). Activity minimizes the weakness caused by loss of up to half the patients muscle mass (Griffiths & Jones, 1999). Graded ambulation can be started depending on patients condition Slide 60: Thank you You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.