ICU AND PHYSIOTHERAPY

GUIDED BY:- Ms. QUINETTE

PRESENTED BY:- SAMEEKSHA SIDHPURIA
 INTRODUCTION
• Intensive care, also known as critical care, is a
multidisciplinary and inter-professional specialty
dedicated to the comprehensive management
of patients having, or at risk of developing acute,
life-threatening organ dysfunction.

• The primary goal of intensive care is to prevent

further physiologic deterioration while the
underlying disease is treated and resolves.
• Intensive care is not just a clinical specialty,
but a system of care delivered by a skilled
interprofessional team that includes
physicians, nurses, respiratory therapists,
physiotherapists, pharmacists, microbiologists,
social workers, ethicists, spiritual care, and
many others.
 DEFINITION OF ICU
• An intensive care unit (ICU) is an organized
system for the provision of care to critically ill
patients that provides intensive and specialized
medical and nursing care, an enhanced capacity
for monitoring, and multiple modalities of
physiologic organ support to sustain life during a
period of acute organ system insufficiency.
 TYPES OF ICU UNITS
• Neonatal intensive care unit (NICU)
• Pediatric intensive care unit (PICU)
• Coronary care unit (CCU)
• Neurological intensive care unit (NeuroICU).
• Trauma intensive care unit (Trauma ICU)
• Post-anesthesia care unit (PACU)
• High dependency unit (HDU)
• Surgical Intensive Care Unit (SICU)
• Medical Intensive Care Unit (MICU)
• Post Operative Care Unit
 MONITORING
• Non-invasive monitoring:-
1. Temperature
2. Heart rate
3. Respiratory rate
4. Blood pressure
5. Oxygen saturation
6. End-tidal CO2
• Invasive monitoring
1. Arterial blood pressure
2. Central venous pressure (CVP)
3. Pulmonary
4. Capillary wedge pressure (PCWP)
• ECG monitoring
ASSESSMENT
 ADVERSE EFFECTS OF ICU STAY
• Bed rest and immobility during critical illness
result in profound physical deconditioning.
• Skeletal muscle weakness in the intensive care
unit
• Development of neuropathy or myopathy
contributes to weaning failure
• Respiratory dysfunction
• Prolonged ventilator dependence
 PROBLEMS IN ICU
• Decreased lung volumes/ compliance
• Decreased gas exchange
• Decreased mucociliary clearance
• Weakness of peripheral and respiratory
muscles
• Increased work of breathing
 PHYSIOTHERAPY IN ICU
• Physical therapy in the intensive care unit
(lCU) is a specialty in itself.

• Clinical decision making in the lCU and rational

management of patients is based on a tripod
approach.
• General information required before treating the ICU
patient:-
1. Medical and surgical histories
2. Gender and age
3. Premorbid status (e.g., life style. ethnicity. culture,
work situation. stress, cardiopulmonary conditioning,
and oxygen transport reserve capacity)
4. Smoking history
5. Hydration and nutritional status: deficiencies.
obesity, or asthenia
6. Recency of onset and course of present condition
7. Existing or potential medical instability
8. Indications or necessity for intubation and
mechanical ventilation
9. Invasive monitoring, lines, leads, and catheters
10.Existing or potential for complications and
multiorgan system failure
11.Coma
12.Elevated intracranial pressure (lCP) and the need
for ICP monitoring
13.Risk or presence and site(s) of infection
14.Quality of sleep and rest periods
15.Nutritional support during ICU stay
16.Pain control regimen
 GOALS IN THE ICU PATIENT
• Maintain or restore adequate alveolar ventilation and
perfusion and their matching in nonaffected and affected
lung fields and thereby optimize oxygen transport overall

• Prolong spontaneous breathing (to the extent that is

therapeutically indicated) and thereby avoid, postpone, or
minimize need for mechanical ventilation

• Minimize the work of breathing

• Minimize the work of the heart

• Design a positioning schedule to maintain comfort and postural
alignment (distinct from therapeutic body positioning to optimize
oxygen transport)

• Maintain or restore general mobility, strength. endurance, and

coordination, within the limitations of the patient's condition and
consistent with the patient's anticipated rehabilitation prognosis.

• Maximally involve the patient in a daily routine including self-care,

changing body position, standing, transferring, sitting in a chair,
and ambulating in patients for whom these activities are indicated

• Optimize treatment outcome by interfacing physical therapy with

the goals and patient-related activities of other team members,
coordinating treatments with medication schedules.
 PHYSIOTHERAPY TECHNIQUES
• Once a thorough assessment has been
completed, the findings must be analysed to
identify relevant physiotherapeutic problems.

• For each problem a suitable treatment plan

must be formulated taking into consideration
any potential influencing factors.
 LUNG EXPANSION THERAPY
• All modes of lung expansion therapy increase
lung volume by increasing the transpulmonary
pressure (PTP) gradient.

• The PTP gradient can be increased by either

1. Decreasing the surrounding Ppl
2. Increasing the Palv
GOAL:-
• To implement a plan that provides an effective
strategy in the most efficient manner.
 INCENTIVE SPIROMETRY
• The purpose of IS is to coach the patient to take
a sustained maximal inspiratory (SMI) effort
resulting in a decrease in Ppl and maintaining
the patency of airways at risk for closure.
Physiologic Basis:-
• An SMI is functionally equivalent to performing
a functional residual capacity (FRC) to
inspiratory capacity (IC) maneuver, followed by a
breath hold.
 Indications
1. Presence of pulmonary
atelectasis
2. Presence of conditions
predisposing to atelectasis
• Upper abdominal surgery
• Thoracic surgery
• Surgery in patients with COPD
3. Presence of a restrictive lung
defect associated with
quadriplegia or
dysfunctional diaphragm
Contraindications
1. Patient cannot be instructed
or supervised to ensure
appropriate use of device
2. Patient cooperation is
absent, or patient is unable
to understand or
demonstrate proper use of
device
3. Patients unable to deep
breathe effectively (VC <10
ml/kg or IC <1 3 predicted)
Hazards and Complications:-
1. Hyperventilation and respiratory alkalosis
2. Discomfort secondary to inadequate pain
control
3. Pulmonary barotrauma
4. Exacerbation of bronchospasm
5. Fatigue
Potential Outcomes:-
1. Absence of or improvement in signs of atelectasis
2. Decreased respiratory rate
3. Normal pulse rate
4. Resolution of abnormal breath sounds
5. Normal or improved chest radiograph
6. Improved PaO2 and decreased PaCO2
7. Increased SpO2
8. Increased VC and peak expiratory flows
9. Restoration of preoperative FRC or VC
10.Improved inspiratory muscle performance and cough
11.Attainment of preoperative flow and volume levels
12.Increased FVC
 Noninvasive Ventilation
• Noninvasive ventilation (NIV) provides breathing
support to patients with inadequate ability to
ventilate.
• Variations of NIV, including IPPB and PEP therapy,
are the potentially valuable lung expansion tools.
 Intermittent Positive Airway
Pressure Breathing
Physiologic Basis:-
• IPPB is a specialized form of NIV used for relatively short
treatment periods (approximately 15 minutes per
treatment).

• The intent of IPPB, to provide machine-assisted deep breaths

assisting the patient to deep breathe and stimulate a cough.

• IPPB has historically consisted of providing an aerosol under

positive pressure, augmenting the patient’s own inspiratory
efforts and thus resulting in a larger tidal volume (VT) than
could be spontaneously generated.
Indication Contraindication
1. Need to improve lung expansion 1. Tension pneumothorax
2. Presence of clinically significant 2. ICP >15 mm Hg
pulmonary atelectasis 3. Hemodynamic instability
3. Inability to clear secretions
4. Active hemoptysis
4. Need for short-term noninvasive
ventilatory support for
5. Tracheoesophageal fistula
hypercapnic patients 6. Recent esophageal surgery
5. Need to deliver aerosol 7. Active, untreated tuberculosis
medication 8. Radiographic evidence of blebs
6. IPPB may be used to deliver 9. Recent facial, oral, or skull
aerosol medications to patients surgery
with ventilatory muscle weakness
10. Singultus (hiccups)
or fatigue or chronic conditions in
which intermittent noninvasive 11. Air swallowing
ventilatory support is indicated. 12. Nausea
Hazards and Complications:-
1. Increased airway resistance and work of breathing
2. Barotrauma, pneumothorax
3. Nosocomial infection
4. Hypocarbia
5. Hemoptysis
6. Gastric distention
7. Impaction of secretions (associated with inadequately
humidified gas mixture)
8. Psychologic dependence
9. Impedance of venous return
10.Exacerbation of hypoxemia
11.Hypoventilation or hyperventilation
12.Increased mismatch of ventilation and perfusion
13.Air trapping, auto-PEEP, overdistention
Potential Outcomes:-
1. Improved VC
2. Increased FEV1 or peak flow
3. Enhanced cough and secretion clearance
4. Improved chest radiograph
5. Improved breath sounds
6. Improved oxygenation
7. Favorable patient subjective response
 Positive Airway Pressure Therapy
Physiologic Basis
• There are three current approaches to PAP therapy: PEP, flutter, and CPAP.

• PEP and flutter valves create expiratory positive pressure only, whereas CPAP
maintains a positive airway pressure throughout both inspiration and
expiration.

• CPAP elevates and maintains high alveolar and airway pressures throughout
the full breathing cycle, this increases PTP gradient throughout both
inspiration and expiration.

• Typically, a patient on CPAP breathes through a pressurized circuit against a

threshold resistor, with pressures maintained between 5 cm H2O and 20 cm
H2O.
Indications
• Postoperative atelectasis
• Cardiogenic pulmonary
edema
• Pulmonary vascular
congestion.
• Lung compliance is
improved
Contraindications
• Hypoventilation
• Hemodynamically unstable
• Nausea
• Facial trauma
• Untreated pneumothorax
• Elevated intracranial
pressure (ICP).
 MANUAL HYPERINFLATION
• Manual hyperinflation delivers extra volume and oxygen to
the lungs via a bag such as a rebreathing bag.

• Manual ventilation means squeezing gas into the patient's

lungs at tidal volume, e.g. when changing ventilator
tubing.

• Manual hyperventilation delivers rapid breaths, e.g. if the

patient is breathless, hypoxaernic or hypercapnic.

• It provides deep breaths in order to increase lung volume.

Beneficial effects:
1. Reversal of atelectasis
2. Sustained improvement in lung compliance and oxygen
saturation
3. Improved sputum clearance

Disadvantages:-
4. Haemodynamic and metabolic upset
5. Risk of barotrauma for certain patients
6. Discomfort and anxiety if done incorrectly.

Contraindications:-
7. Extra-alveolar air, e.g. undrained pneumothorax, bullae, surgical
emphysema.
8. Bronchospasm causing peak airway pressure above 40 cmH20.
 POSITIONING
• Positioning is the main physiotherapy treatment for patients in
intensive care, and may be the only intervention for some
patients.

• Positioning can be used to:

1. Optimize relaxation
2. Provide pain relief
3. Improve ventilation, ventilation-perfusion matching, and gas
exchange
4. Minimize dyspnea
5. Minimize the work of breathing—i.e promote efficient
diaphragm and accessory muscle function
6. Promote airway clearance
 Cardiovascular and Pulmonary Effects of Different Positions:-

Upright
1. Increases FRC
2. Increases FVC
3. Decreases closing volume
4. Increases chest wall anterior-posterior
diameter
5. Decreases venous return and cardiac
output
6. Increases pooling of secretions in the
bases of the lung
7. Better basal expansion with large
inspiration
8. Decreases curvature of diaphragm at
end-expiration—especially in those
patients with weak abdominals
 Supine
1. Decreases chest wall AP
diameter
2. Reduces FRC
3. Pooling of secretions to the
posterior (dependent) lung
zone
4. Increases central blood volume
5. Increases airway closure
6. Increases curvature of
diaphragm at end-expiration—
especially in those with weak
abdominals
 Side-Lying
1. Increases chest wall AP
diameter of the
dependent region
2. Increases ventilation to •
the dependent region
but decreases tidal
volume and FRC
3. Theoretically speaking,
positioning the good
lung lowermost should
improve oxygenation
 Prone
• Improves oxygenation in
patients with ARDS or acute
lung injury
• improved lung compliance
secondary to stabilization of
anterior chest wall,
• Improved tidal ventilation,
diphragmatic excrusion and
functional residual capacity
• Reduced airway closure
 AIRWAY CLEARANCE THERAPY (ACT)
• Airway clearance therapy uses noninvasive techniques
designed to assist in mobilizing and removing secretions to
improve gas exchange.

• Five general approaches to ACT, which can be used alone or in

combination, include
1. CPT
2. Coughing and related expulsion techniques (including manual
insufflation-exsufflation
3. Positive expiratory pressure [PEP] devices)
4. Active cycle of breathing technique
5. mobilization and physical activity.
 CHEST PHYSIOTHERAPY
• This therapy includes postural drainage (PD) and
percussion or vibration.
Postural drainage:-
• Postural drainage (PD) has been shown to increase
mucociliary clearance in patients by means of
measuring sputum collection dry weight, volume, or
radionuclide particles clearance rate.

• The classic postural drainage positions are designed to

drain individual segments of the lungs
Cough and Huff:-
• Coughing clears the larger airways of excessive
mucus and foreign matter, assists normal
mucociliary clearance, and helps ensure airway
patency.
• Staccato-like bursts of air against an open
glottis are referred to as huffing.

• With this technique the patient is instructed

to make the sound “huff, huff, huff” rapidly
with the mouth and glottis open.
ACTIVE CYCLE OF BREATHING TECHNIQUE
 SUCTIONING
• Suctioning is the application of negative pressure (vacuum)
to the airways through a collecting tube (flexible catheter or
suction tip).

• Suctioning can be performed by way of either the upper

airway (oropharynx) or the lower airway (trachea and
bronchi).

• Secretions or fluids also can be removed from the

oropharynx by using a rigid tonsillar or Yankauer suction tip.
• Access to the lower airway is by introduction
of a flexible suction catheter through the nose
(nasotracheal suctioning) or artificial airway
(endotracheal suctioning).

• Tracheal suctioning through the mouth should

be avoided because it causes gagging.
• Endotracheal Suctioning
• Closed suctioning:-
Mechanically ventilated patients,
especially neonates and patients
with:
1. Positive end expiratory pressure
≥10 cm H2O
2. Mean airway pressure ≥20 cm H2O
3. Inspiratory time ≥1.5 seconds
4. FiO2 ≥0.60
5. Frequent suctioning (≥6 times/day)
6. Hemodynamic instability associated
with ventilator disconnection
7. Respiratory infections requiring
airborne or droplet precautions
8. Inhaled agents that cannot be
interrupted by ventilator
disconnection (e.g., nitric oxide,
helium/oxygen mixture)
• Nasotracheal Suctioning
 POSITIVE EXPIRATORY PRESSURE
• Positive expiratory pressure includes one way
breathing valve and an adjustable level of
expiratory resistance that create back pressure
to stent the airways opening during exhalation.

• PEP therapy involves active expiration against a

fixed orifice flow resistor or variable orifice
threshold resistor capable of developing
pressure of 10-20cm H2O
• PEP breathing reinflates collapsed alveoli by
allowing air to be redistributed through
collateral channels- the pores of Kohn, and the
Lambert canals- allowing pressure to build up
distal to the obstruction and promoting the
movement of secretion toward the larger
airways.

• Low pressure PEP resistance is regulated to

achieve 10-20cm H2O during slightly active
expiration.
• High pressure PEP use the same principle but at
much higher levels of pressure (50-120cm H2O).
• Oscillating PEP provide positive expiratory
pressure, oscillation of the airway and
accelerated expiratory flow rate to loose
secretion and move secretion centrally.
 MOBILIZATION
• Reductions in functional performance, exercise capacity,
and quality of life in ICU survivors indicate the need for
rehabilitation following ICU stay.

• It is important to prevent or attenuate muscle

deconditioning as early as possible in patients with an
expected prolonged bed rest.

• Intensive care unit-acquired weakness (ICUAW) is observed

in a substantial proportion of patients receiving MV for
more than 1 week in the ICU.
Indications:-
1. Atelectasis
2. Pulmonary consolidation
3. Pulmonary intiltrates
4. Bronchopulmonary and lobar pneumonias
5. Bronchiolitis
6. Alveolitis
7. Pleural effusions
8. Acute lung injury and pulmonary edema
9. Hemothorax
10.Pneumothorax
11.Cardiopulmonary insufficiency
12.Cardiopulmonary sequelae of surgery
13.Cardiopulmonary sequelae of immobility
Contraindications:-
1. Terminal diseases
2. Systolic hypertension > 170mmhg
3. Spo2 < 90%
4. Intracranial hypertension
5. Unstable fractures
6. Recent acute myocardial infarction
7. Open abdominal wounds
8. Heart rate reduction of 20% or more during early
mobilization activities.
9. Deep cognitive and neurological deficits
• The etiology includes deconditioning and disuse
atrophy due to prolonged bed rest and
immobility, and critical illness polyneuropathy
and/or myopathy, known as critical illness
neuromyopathy.

• Other risk factors for ICUAW include the

systemic inflammatory response syndrome,
sepsis, and multiple organ dysfunction
syndrome; hyperglycemia; and medications,
such as use of corticosteroids and
neuromuscular blocking agents
Passive mobilization:-
• Patient unable to follow commands and actively
participate in mobilization are suitable for passive
mobilization (ie, hoist transfer to sit-out-of-bed).

• Patients who are sedated and unresponsive may

benefit from the high sitting position in an
appropriate chair to potentially minimize
orthostatic intolerance

• A portable sling lifter for mobilization is feasible

Active mobilization:-
• Phase 1 can involve sitting balance retraining (eg,
reaching and returning to midline from the bed or
chair), strength training including the use of weights
or slings, and/ or treatment on the tilt table.

• A patient will remain in this phase until they achieve

adequate sitting balance and lower limb strength to
progress to “phase 2 mobilization”.

• If patient is not able to stand with the assistance the

“supported weight-bearing” phase, which involves
the use of a gait harness to facilitate mobilization.
• If the patient is able to stand with the
assistance the “active weight-bearing phase”
facilitated
• Early mobilization can be performed also in
unconscious or sedated patients.

Acutely ill, uncooperative patients

• Treated with modalities such as
1. Passive range of motion,
2. Muscle stretching,
3. Splinting,
4. Body positioning,
5. Passive cycling with a bed cycle,
6. Electrical muscle stimulation
The stable cooperative patient (on mechanical
ventilation)
1. Mobilized on the edge of the bed,
2. Transfer to a chair,
3. Perform resistance muscle training
4. Active cycling with a bed cycle or chair cycle
5. Walk with or without assistance.

The uncooperative critically ill patient

6. Needs to be positioned upright (well supported),
and rotated when recumbent.
7. Passive stretching or range of motion exercise
The cooperative critically ill patient
1. Mobilization strategies –in order of intensity-
include:-
• Transferring in bed
• Sitting over the edge of the bed
• Moving from bed to chair,
• Standing,
• Stepping in place
• Walking with or without support.
2. standing aids, and tilt tables, enhance physiological
responses
MOBILIZING AN INVASIVELY MECHANICALLY
VENTILATED PATIENT
 REFERENCES
• Marshall JC, Bosco L, Adhikari NK, Connolly B,
Diaz JV, Dorman T, Fowler RA, Meyfroidt G,
Nakagawa S, Pelosi P, Vincent JL. What is an
intensive care unit? A report of the task force of
the World Federation of Societies of Intensive
and Critical Care Medicine. Journal of critical
care. 2017 Feb 1;37:270-6.
• Pryor JA, Prasad AS. Physiotherapy for respiratory
and cardiac problems: adults and paediatrics.
Elsevier Health Sciences; 2008 Mar 6.
• Reid WD, Chung F, Hill K. Cardiopulmonary
physical therapy: management and case studies.
Slack Incorporated; 2014.
• Kacmarek RM, Stoller JK, Heuer A. Egan's
Fundamentals of Respiratory Care-E-Book.
Elsevier Health Sciences; 2016 Feb 5.
• Hough A. Physiotherapy in respiratory care: an
evidence-based approach to respiratory and
cardiac management. Nelson Thornes; 2001.
• Frownfelter DL, Dean EW, editors. Principles and
practice of cardiopulmonary physical therapy.
Mosby Incorporated; 1996.
• Puthucheary ZA, Rawal J, McPhail M, Connolly B,
Ratnayake G, Chan P. Acute skeletal muscle wasting
in critical illness. JAMA. 2013;310 (15):1591-1600.
• Stevens RD, Marshall SA, Cornblath DR, Hoke A,
Needham DM, de Jonghe B, et al. A framework for
diagnosing and classifying intensive care unit-
acquired weakness. Crit Care Med 2009;37(10
suppl):S299-S308.
• Gosselink R, Clerckx B, Robbeets C, Vanhullebusch
T, Vanpee G, Segers J. Physiotherapy in the
intensive care unit. Neth J Crit Care. 2011 Apr
1;15(2):66-75.
• Al AM. Outcome of Early Mobilization of Critically Ill
Patients: A Propensity Score Matching Trial. Journal
of Intensive and Critical Care. 2018;4(3):13.
• Aquim EE, Bernardo WM, Buzzini RF, de Azeredo NS,
da Cunha LS, Damasceno MC, de Oliveira Deucher
RA, Duarte AC, Librelato JT, Melo-Silva CA, Nemer SN.
Brazilian Guidelines for Early Mobilization in
Intensive Care Unit. Revista Brasileira de Terapia
Intensiva. 2019 Oct;31(4):434.
• Green M, Marzano V, Leditschke IA, Mitchell I, Bissett
B. Mobilization of intensive care patients: a
multidisciplinary practical guide for clinicians. Journal
of multidisciplinary healthcare. 2016;9:247.
THANK YOU