Role of physiotherapy in ICU

Physiotherapy assessment in ICU

MEDICAL CHART READING:
Name, Age, Sex
H\O Present Illness
Past Medical History
Past Surgical History
Drug History
Social/Occupational History
Investigation




BED CHART READING /BEDSIDE MONITORING
Temperature
PR
BP
SpO
2
Hb
Platelets count/INR



CPP
ICP
CVP
PAP/PCWP

Neurological Assessment
Level of consciousness
GCS
Pupil
Size
Reactivity
Equality
CPP(Cerebral Perfusion pressure)
Normal value >70mmHg
Critical value<50 mm Hg
ICP(Intra cranial pressure)
Normal <10mm Hg
Critical >25mm Hg

Physiotherapy with PROM can be used safely
in patients with acute neurological diseases,
even if ICP is elevated before therapy.[1]
1.Roth, C., et al., Effect of early physiotherapy on intracranial pressure and cerebral
perfusion pressure. Neurocrit Care, 2013. 18(1): p. 33-8.
Evidence is compelling that a randomized-
controlled trial is indicated to test the
hypothesis that chest physiotherapy may
actually result in short-term resolution of high
intracranial pressure, and thus provide one
more clinical tool in the management of
elevated intracranial pressure.[2]

2Olson, D.M., et al., Changes in intracranial pressure associated with chest
physiotherapy. Neurocrit Care, 2007. 6(2): p. 100-3
The supine position and Valsalva maneuvers,
however, should be avoided, and ICP should
be monitored closely in patients with severe
intracranial hypertension.[3]

3.Serge Brimioulle, J.-J.M., Danielle,Norrenberg and Robert J Kahn, Effects of Positioning and Exercise on
Intracranial Pressure in a Neurosurgical Intensive Care Unit. Journals of American physical therapy association,
1997. 77: p. 1682-1689.

In situation of high ICP or unstable ICP use
inotropic to maintain MAP
HR(Heart rate and rhythm)
Normal value 50-100bpm
Bradycardia <50
Tachycardia >100

Assess heart rate and basic rhythm by looking
at ECG reading or taking a pulse manually
Sinus bradycardia (< 60 bpm) care should be
taken. Patient should be pre-oxygenated prior
to suction.

Suctioning can cause vagal stimulation and
decrease HR further. Pre-oxygenation helps to
lessen effects of SB and vagal stimulation
Sinus tachycardia (>100bpm) care should be
taken with manual techniques and exercise.

Increased HR may be due to pain/anxiety or
sepsis in response to decreased BP.

Full explanation of treatment and adequate
analgesia should be given
Slow AF is essentially stable fast AF (> 120 bpm)
may contraindicate treatment.

If patient is in SVT or VT treatment is
contraindicated

If the patient is being externally paced, care must
be taken to observe the insertion point of the
wires
Blood Pressure
Assess BP using arterial line (use the recent trend
in BP recordings) or NIBP reading. If BP < 90/60 or
patient is hypotensive in relation to normal BP,
care is required with treatment.

Patient may be hypovolaemic, septic sedated or
have insufficient cardiac function

Treatment techniques could cause BP to decrease
further

Manual hyperinflation can restrict venous
return - reducing cardiac output and can
decrease BP further
Care with suction should be taken hypotensive
patients should be preoxygenated prior to
suction.

Suction can simulate a vaso-vagal response
further reducing BP
If BP is >145/90 or patient is hypertensive in
relation to normal care with treatment is
required.

Patients may be in pain, have anxiety or have
cardiac dysfunction. They may not be
adequately sedated.
If BP suddenly increases or decreases
significantly during treatment stop and
inform nursing staff if they do not settle within
a few minutes and/or intervention is needed
e.g. increase in inotropes
To Treat or not to Treat on Critical Care, Guidelines for Practice 2012---Nottingham University Hospitals

CVP
Circulating blood flows into the right atrium
via the inferior and superior vena cava. The
pressure in the right atrium is known as
central venous pressure (CVP).
Normal value is 3-15cmH
2
0


http://docsm14.webs.com/CVP.pdf
PAP & PCWP

It gives indirect measurement of left atrial
pressure
PAP-10-22mm Hg
PCWP-Normally 8-10 mmHg
High PAP, high pulmonary vascular resistance
and may exacerbated during MHI
INR-international normalized ratio
The prothrombin time (PT) and its derived
measures of prothrombin ratio (PR) and
international normalized ratio (INR) are
measures of the extrinsic pathway of
coagulation
This test is also called "ProTime INR" and
"PT/INR

http://en.wikipedia.org/wiki/Prothrombin_time
Normal range INR in absence of
anticoagulation therapy is 0.8-1.2

If INR is > 1.5 caution with treatment is
required

Check with patients consultant prior to
insertion of NPA,OA
Respiratory support/Mode of
ventialtion
Oxygen therapy
Oxygen is given to treat hypoxaemia. Patients
should initially be given a high concentration.
The amount can then be adjusted according to
the results of pulse oximetry and arterial
blood gas analysis.
Oxygen range vary from21%(FiO
2
0.21)to
100%(FiO
2
1.0)*





HELLY, M. P. & NIGHTINGALE, P. 1999. ABC of intensive care Respiratory support. British Medical Journals, 319, 16741677.



PRYOR, J. A. & PRASAD, A. S. 2008. Physiotherapy for Respiratory and Cardiac Problems: Adults and Paediatrics, Elsevier
Sp0
2
normal 94%-100%

http://www.amperordirect.com/pc/help-pulse-oximeter/z-interpreting-
results.html
Oxygen is usually given
1. Fixed performance device-Venturi Mask
2. Variable performance device-face mask,
nasal prongs or cannulas
http://www.ccmtutorials.com/rs/oxygen/page13.htm
Fi0
2
: Fraction of Inspired Oxygen
Nasal canula

O2 Flow rate (l/min) FiO2
1 24%
2 28%
3 32%
4 36%
5 40%
6 44%
Over 4 l/min cause mucosal drying and nasal bleeding
Oxygen face mask
simple oxygen mask has open side ports that
allow room air to enter the mask and dilute
the oxygen, as well as allowing exhaled carbon
dioxide to leave the containment space
Mary Elizabeth Martelli R.N., B.S.The Gale Group Inc., Gale. Gale Encyclopedia of
Nursing and Allied Health, 2002
Oxygen face mask -cntd
partial rebreather oxygen mask
similar to a simple face mask, however, the
side ports are covered with one-way discs to
prevent room air from entering the mask.
Mary Elizabeth Martelli R.N., B.S.The Gale Group Inc., Gale. Gale Encyclopedia of
Nursing and Allied Health, 2002
Oxygen face mask -cntd
This mask is called a rebreather because it has
a soft plastic reservoir bag connected to the
mask that conserves the first third of the
patient's exhaled air while the rest escapes
through the side ports.

Mary Elizabeth Martelli R.N., B.S.The Gale Group Inc., Gale. Gale Encyclopedia of
Nursing and Allied Health, 2002
Oxygen face mask -cntd
Non-rebreather oxygen mask
similar to a simple face mask but has multiple
one-way valves in the side ports. These valves
prevent room air from entering the mask but
allow exhaled air to leave the mask.
Mary Elizabeth Martelli R.N., B.S.The Gale Group Inc., Gale. Gale Encyclopedia of
Nursing and Allied Health, 2002
Oxygen face mask -cntd
It has a reservoir bag like a partial rebreather
mask but the reservoir bag has a one-way
valve that prevents exhaled air from entering
the reservoir.
Mary Elizabeth Martelli R.N., B.S.The Gale Group Inc., Gale. Gale Encyclopedia of
Nursing and Allied Health, 2002
Oxygen face mask -cntd
This allows larger concentrations of oxygen to
collect in the reservoir bag for the patient to
inhale.
Mary Elizabeth Martelli R.N., B.S.The Gale Group Inc., Gale. Gale Encyclopedia of
Nursing and Allied Health, 2002
CPAP/Bi PAP
Continuous positive airway pressure (CPAP) is
the use of continuous positive pressure to
maintain a continuous level of positive airway
pressure. It is functionally similar to positive
end-expiratory pressure (PEEP),

CPAP also may be used to treat preterm
infants whose lungs have not yet fully
developed.
Eg-segmental lung collapse, ARDS, Pneumonia

CPAP is used when lung volumes are reduced
specially FRC

It will improve the lung compliance and
reduce the work of breathing

Conventional mechanical ventilation
Continuous mandatory ventilation
Assist-control ventilation
Intermittent mandatory ventilation
Synchronous intermittent mandatory
ventilation
Pressure support ventilation


CMV
Breaths are delivered at preset intervals,
regardless of patient effort.

This mode is used most often in the paralyzed
or apneic patient because it can increase the
work of breathing if respiratory effort is
present.
The hallmark of CMV is that the ventilator
makes no effort to sense patient effort
Assist-control ventilation

The ventilator delivers preset breaths in
coordination with the respiratory effort of the
patient.
With each inspiratory effort, the ventilator
delivers a full assisted tidal volume.
Spontaneous breathing independent of the
ventilator between A/C breaths is not allowed
http://www.lakesidepress.com/pulmonary/books/physiology/chap10b.
htm
IMV
With intermittent mandatory ventilation
(IMV), breaths are delivered at a preset
interval
Spontaneous breathing is allowed between
ventilator-administered breaths.
Spontaneous breathing occurs against the
resistance of the airway tubing and ventilator
valves, which may be formidable.
http://www.lakesidepress.com/pulmonary/books/physiology/chap10b.htm
SIMV
The ventilator delivers preset breaths in
coordination with the respiratory effort of the
patient.
Spontaneous breathing is allowed between
breaths.
Synchronization attempts to limit barotrauma
that may occur with IMV when a preset breath is
delivered to a patient who is already maximally
inhaled (breath stacking) or is forcefully exhaling.
Positive end-expiratory pressure
(PEEP)

PEEP can be used to increase oxygenation in
either AC or SIMV mode. The effect of PEEP on
the lungs is similar to blowing up a balloon
and not letting it completely deflate before.




http://www.modernmedicine.com/modern-medicine/news/quick-guide-vent-
essentials#sthash.7ljg63Wo.dpuf

Pressure support
For the spontaneously breathing patient, pressure
support ventilation (PSV) has been advocated to limit
barotrauma and to decrease the work of breathing.


Used alone or added to SIMV, this provides a small
amount of pressure during inspiration to help the
patient draw in a spontaneous breath.


http://www.modernmedicine.com/modern-medicine/news/quick-guide-vent-
essentials#sthash.7ljg63Wo.dpuf

auscultation
If patient is ventilated normal breath sounds
tend to be harsh
Percussion note
Plural effusion-stony dull
Atelectasis- consolidation dull
Pneumothorax - Hyperresonant
Chest expansion
Middle lobe & lingula motion
Upper lobe motion
Lower lobe motion
(>5cm)
Position of trachea
Vocal Fremitus(tactile)

Hand placement same as chest excursion.
Compare bilaterally
Ask pt to say k or 99
Note sound transmission under palm
Decrease transmission = air/emphysema
Increase transmission = consolidation, fluid

ABG-arterial blood gas
It is a blood test that is performed using blood
from an artery.

An ABG is a test that measures the arterial
oxygen tension (PaO
2
), carbon dioxide tension
(PaCO
2
), and acidity (pH).
http://en.wikipedia.org/wiki/Arterial_blood_gas
Sputum analysis
Bloody
inflammation of throat, bronchi; lung cancer;
sputum evenly mixed with blood, from alveoli, small
bronchi;
massive blood tuberculosis of lung, lung abscess,
bronchiectasis ,infarction, embolism.
Rusty colored - usually caused by
pneumococcal bacteria (in pneumonia)

Purulent - containing pus.

Foamy white - may come from obstruction or
even edema.

Frothy pink - pulmonary edema

MHI-Manual Hyper Ventilation
MHI sometimes known as "bagging" is a
technique that can be used as part of the
management of mechanically ventilated and
tracheostomy patients.

The physiotherapeutic technique involves the use
of a 2 liter, single patient use resuscitation bag
that is squeezed with a series of larger than
baseline peak airway pressures and tidal volume
at a slow inflation rate, with the addition of a
pause




A bag valve mask, abbreviated to BVM and
sometimes known by the proprietary name
Ambu bag or generically as a manual
resuscitator or self-inflating bag

Absolute Contraindications

1. Extra-alveolar air e.g. Bullae or Undrained
Pneumothorax
2. Subcutaneous emphysema of unknown
cause
3. Severe/widespread bronchospasm
Precautions
Pneumothorax, with a bubbling chest drain
Low, high or labile blood pressure
Labile ICP
Some lung diseases, especially emphysema/
hyperinflated lungs
Cardiac arrhythmias
Post Lung surgery
High PEEP requirements combined with high Fi02
requirement
PEEP > 10cmH20 on mechanical ventilation
Effects
Optimise alveolar ventilation. By reducing
atelectasis, this reduces ventilation perfusion
mismatch and improves gas exchange (Rothen et
al., 1993 and 1995)

Mobilise pulmonary secretions (Jones et al.,
1992)

Improve lung compliance (Hodgson et al., 1996)
A PEEP valve may be used when the patient is
on a PEEP > 10cmH2O and shows clinical signs
of desaturation.
Disconnect patient from the ventilator, attach
the bagging circuit to the catheter mount,
attach the reservoir bag to the ventilator
tubing and mute the alarm or switch the
ventilator to standby as per local policy in the
Unit
Using 1 or 2 hands, co-ordinate the delivery of
the breaths with any respiratory efforts of the
patient. Allow the patient to acclimatise by
using small TVs initially

Care should be taken to minimise movement
of the endotracheal or tracheostomy tube
during MHI
Use 10-15l of O
2

Common technique is slow inspiration and
inspiratory hold followed by quick expiratory
release.

Long inspiratory hold is contraindicated in a
patient who is already hyperinflated
If indicated apply manual techniques such as
shaking or vibration at the end of expiration
and during expiration

Repeat the procedure several times as
indicated(6-8 times)
Suctioning

Limb physiotherapy
Passive/Active movement

Positioning
Positioning for physiotherapy with the good
lung down is associated with improved
ventilation perfusion ratios and oxygenation

Side to side turning improves oxygenation

Prone positioning improves oxygenation in
patients with atelectatic superior and
posterior lower lobe segments

Ventilation/perfusion ratio

It is defined as: the ratio of the amount of air
reaching the alveoli to the amount of blood
reaching the alveoli.

"V" ventilation the air that reaches the alveoli

"Q" perfusion the blood that reaches the
alveoli

http://en.wikipedia.org/wiki/Ventilation/perfusion_ratio

1 liter of blood can hold about 200 mL of oxygen;
1 liter of dry air has about 210 mL of oxygen.
Therefore, under these conditions, the ideal
ventilation perfusion ratio would be about 1.05.

V/Q ratio-1.05

The actual values in the lung vary depending on
the position within the lung. If taken as a whole,
the typical value is approximately 0.8