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
- Neurological patient who is unable to cough
- 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
- Musculoskeletal deformity that makes breathing
pattern and cough ineffective Assessment : Assessment Neurological system
Gastrointestinal system Neurological system : Neurological system Level of consciousness
Cerebral perfusion pressure (>70mmHg)
CPP = MAP- ICP
Intracranial pressure (<10mmHg) Intracranial pressure measurement : Intracranial pressure measurement Cardiovascular system : Cardiovascular system Heart rate and rhythm
Central Venous pressure
Pulmonary Artery pressure (PAP) and pulmonary artery wedge pressure (PCWP) Respiratory system : Respiratory system Auscultation
Mode of ventilation
Sputum Renal system : Renal system Assessment of fluid balance
Measure of Intravascular volumes
ABG Gastrointestinal system : Gastrointestinal system Nutritional support
Routes of administration
Oral Assessment : Assessment General Observation
Respiration - Airway ET/Tracheostomy Ventillator Mode
Vital Signs – Temperature, BP, RR, HR SpO2,GCS, ICP
Tubes - NG Tube, CV line, Peripheral line, Chest tubes, Catheters
Drugs … contd : … contd Examination
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
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
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
Raised intracranial pressure
Reduced respiratory drive Contraindications : Contraindications Undrained Pnuemothorax
Gross cardiovascular instability inducing arrhythmias and hypovolaemia
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.
Inability to cough effectively
To assess tube patency Contraindication : Contraindication Frank haemoptysis
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
Raised intracranial pressure Slide 53: Nasal and oral suction
Closed-circuit suction Closed-circuit suction : Closed-circuit suction Mobilisation : Mobilisation Mobilisation : Mobilisation Critically Ill
(Frequent Position changes, Kinetic & Kinematic Therapy)
(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