Pt management in icu

1. JAMIA MILIA ISLAMIA
CENTRE FOR PHYSIOTHERAPY & REHABILITATION SCIENCES
PRESENTATION OF PHYSIOTHERAPY IN CARDIOPULMONARY
CONDITIONS(BPT-402)
TOPIC- PHYSIOTHERAPY MANAGEMENT FOR ICU PATIENTS
SUBMITTED TO- DR. JAMAL ALI MOIZ
SUBMITTED BY- TANVEER BHOLA
BPT 4TH YEAR
PRESENTATION DATE-19.01.2021

2. • Intensive care unit (ICU) is a special unit of a hospital or health care
facility that provides intensive treatment medicine.
• Intensive care unit provide care to the patients with severe and life
threatening diseases and injuries which require constant, close
monitoring and support from specialized equipment and medications in
order to ensure normal bodily functions.
• The most common techniques used by physiotherapists in the ICU are
positioning, mobilization, manual hyperinflation (MH), percussion,
vibrations, suction, cough, and various breathing exercises.

3. GOALS AND GENERAL BASIS FOR THE
MANAGEMENT IN ICU-
• To have the patient alert and oriented to person, time, and place
• To have the patient return to premorbid functional level to the greatest
extent possible
• To reduce morbidity, mortality, and length of hospital stay.
• As a precursor to achieving these three goals, the immediate goals
initially relate to the attainment of optimal oxygen transport and hence
cardiopulmonary function.

4. AIMS OF PHYSIOTHERAPY MANAGEMENT-
• To ensure adequate ventilation in lung fields and thereby optimize oxygen
transport overall
• Prolong spontaneous breathing (to the extent that is therapeutically
indicated) and thereby avoid, postpone, or minimize the need for
mechanical ventilation
• To assist in the removal of excess bronchial secretions.
• Minimize the work of breathing
• 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
• Optimize treatment outcome by interfacing physical therapy with the goals
and patient-related activities of other team members, coordinating
treatments with medication schedules and treating the patient specifically
based on results of objective monitoring available in the ICU.

5. CONTRAINDICATIONS TO CHEST
PHYSIOTHTERAPY IN ICU-
• ABSOLUTE CONTRAINDICATIONS-
• Recent myocardial ischaemia
• Heart rate <40 & >130 beats/min
• Mean arterial pressure (MAP) <60mmHg and >110mmHg
• Oxygen saturation <90%
• Fractional concentration of inspired oxygen (FiO2<0.6)
• PEEP>10cmH2o
• Respiratory rate> 40 breath/minute
• RELATIVE CONTRAINDICATIONS-
• Decreased level of awareness/consciousness
• Unstable fractures
• Sweating, pain
• Acute head injury or neurological instability: ICP>20cmH2O
• Undrained pneumothorax or emphysematous bullae
• Severe bronchospasm.

6. BODY POSITIONING-
• Positioning describes the use of body position as a specific treatment
technique.
• Positioning for ICU patients can be used with the physiologic aims of
optimizing oxygen transport through its effects of improving
ventilation/perfusion (V/Q) matching, augment alveolar volumes, reducing
the work of breathing, cough effectiveness, mucociliary transport, and
secretion clearance.
• Specific examples of positioning that may be used in the ICU setting
includes;
• upright positioning to improve lung volumes and decrease the work of
breathing in patients who are being weaned from mechanical
ventilation
• prone positioning to improve V/Q matching, and increase functional
residual capacity for patients with ARDS
• side lying with the affected lung uppermost to improve V/Q matching
for patients with unilateral lung disease, to improve ventilation and
clearance of airway secretions for patients with acute lobar atelectasis.

7. MOBILIZATION-
• Mobilization is defined as the therapeutic and prescriptive application of
low-intensity exercise in the management of cardiopulmonary dysfunction
usually in acutely ill patients.
• Primarily, the goal of mobilization is to exploit the acute effects of exercise
to optimize oxygen transport.
• Mobilization techniques that may be used for intubated patients receiving
mechanical ventilation in the ICU include active limb exercises, the patient
actively moving or turning in bed, getting out of bed via mechanical lifting
machines or slide board transfers, sitting on the edge of the bed, standing,
standing transfers from bed to chair, and walking.
• The physiologic rationale for mobilization is that it will optimize oxygen
transport by enhancing alveolar ventilation and V/Q matching.
• In addition, mobilization that involves being in the erect position will have
the beneficial effects associated with the erect position as previously
outlined. Mobilization can also provide a gravitational stimulus to maintain
or restore normal fluid distribution in the body and to reduce the effects of
immobility and bed rest.
• In the longer term, mobilization aims to optimize work capacity and
functional independence and to improve cardiopulmonary fitness.

8. MANUAL HYPERINFLATION-
• Manual ventilation, or ‘bagging’, is the use of a manual resuscitator bag (MRB)
for the ventilation of a patient via either a facemask or an endotracheal tube.
• The technique of manual hyperinflation is used in patients with an artificial
airway, who are mechanically ventilated or who have a tracheostomy.
• MH is used with the aim of preventing pulmonary collapse, re-expanding
collapsed alveoli, improving oxygenation and lung compliance, and increasing
movement of pulmonary secretions toward the central airway.
• The most common technique used is a slow inspiration, and inspiratory hold
followed by quick expiratory release (Clement & Hubsch 1968).
• Slow deep inspiration:
• Recruits collateral ventilation thus promoting mobilization of secretions
• Improves gaseous exchange
• Inspiratory hold (at full inspiration):
• Further utilizes collateral ventilation and
• Fast expiratory release:
• Mimics a forced expiration (huff or cough)
• Stimulates a cough.

9. • Contraindications-
• Undrained pneumothorax
• Severe bronchospasm
• Head injury with ICP > 25mmHg
• Severe arterial hypotension
• Risk-
• It can cause barotraumas.

10. SUCTIONING-
• suctioning refers to the method of clearing secretions from the airways of
patients who can not mobilize and expectorate them without assistance.
• it is given in-
• patients incapable of coughing at voluntary or reflex level.
• ineffective coughing due to weakness and exhaustion in very sick
patients.
• patients who are breathing spontaneously but are unwilling or unable
to cough effectively due to confusion, pain or fear
• deeply unconscious or, patients with respiratory muscle paralysis
• all intubated patients
• Contraindications to suctioning the intubated patient-
• Frank haemoptysis
• Severe bronchospasm
• Undrained pneumothorax

11. CONTINUOUS ROTATIONAL THERAPY-
• Continuous rotational therapy refers to the use of specialized beds that
continuously and slowly turn a patient along the longitudinal axis, up to
an angle of 60° onto each side, with the degree and speed of rotation
preprogrammed.
• The therapy is achieved by the entire platform of the bed rotating (also
known as kinetic therapy) or by the inflation and deflation of
compartments in the mattress (also known as oscillating beds).
• The rationale for the use of continuous rotational therapy is that it will
prevent dependent airway closure, decreased compliance, atelectasis,
pooling and stagnation of pulmonary secretions, and subsequent infection
that are believed to result from prolonged immobility.
LIMB EXERCISES-
• Limb exercises (passive, active assisted, or active resisted) may be
performed with ICU patients with the aim of maintaining or improving
joint range of motion, soft-tissue length, muscle strength, and function,
and of decreasing the risk of thromboembolism.

12. PERCUSSION AND VIBRATIONS-
• Percussion and vibrations are techniques that are believed to loosen the
tenacious secretions and increase clearance of airway secretions by the
transmission of an energy wave through the chest wall.
• Percussion is performed manually by clapping the chest wall over the affected
area of the lung, using cupped hands in both inspiratory and expiration phases of
breathing.
• Vibration and shaking are performed during expiration phase of breathing.
Vibration is performed by co-contracting all muscles in therapist’s upper
extremity and shaking is a strong bouncing maneuver that also applies a
concurrent compressive force to chest wall.
BREATHING AND COUGHING MANEUVERS-
• If the patient is non ventilated or recently extubated, body positioning and
breathing and coughing maneuvers are emphasized to promote mucociliary
transport and secretion clearance, decrease minute ventilation and respiratory
rate, increase tidal volume, and improve arterial blood gases.
• Breathing exercises are believed to be most effective if pursed-lips breathing is
performed in conjunction with mechanical pressure applied over the abdomen.
To derive the maximal benefits, breathing and coughing maneuvers should be
performed in body positions that are most mechanically and physiologically
optimal.

13. INSPIRATORY MUSCLE TRAINING-
• More recently, it is increasingly apparent that diaphragm dysfunction is
present in a high percentage of critically ill patients and is associated
with increased morbidity and mortality. Mechanically ventilated patients,
diaphragm weakness is thought to develop from disuse secondary to
ventilator-induced diaphragm in activity and as a consequence of the
effects of systemic inflammation
• This form of critical illness acquired diaphragm dysfunction impairs the
ability of the respiratory pump to compensate for an increased respiratory
work load due to lung injury and fluid overload, leading to sustained
respiratory failure and death.
• Inspiratory muscle training applies a load to the diaphragm and accessory
inspiratory muscles to increase their strength and endurance. Trials of
inspiratory muscle training in the ICU have typically applied this load via
devices that impose resistive or threshold loads ,or via adjustment of the
ventilator sensitivity so that patients can only initiate inspiratory flow by
generating more negative intrathoracic pressure.
• The benefits include an improved breathing pattern, more successful
weaning, potential reductions in length of stay. These benefits are
achieved safely when the training is applied to appropriate patients under
constant supervision and with other safe guards in place.

14. COUGH AUGMENTATION-
• Cough augmentation techniques comprise:
1.Lung volume recruitment (also termed air-stacking or breath-stacking)
2.Manually assisted cough
3.Insufflation-exsufflation (MI-E) device.
Lung volume recruitment (air-stacking or breath-stacking)-
• During lung volume recruitment, the patient inhales a volume of gas via
the ventilator, or self inflating resuscitation bag adapted with a one-way
valve to facilitate gas holding. The patient retains the inhaled volume by
closing the glottis, inhales another volume of gas and then again closes the
glottis; this process is repeated until maximumin insufflation capacity is
reached. Lung volume recruitment can be performed in isolation or in
combination with manually assisted cough.
Manually assisted cough-
• Costophrenic assist
• Heimlich type assist
• Anterior chest compression

15. Figure 2- Hand position for Heimlich type or
abdominal thrust assistance
Figure 1- Hand position for costophrenic assistance
Figure 3- hand position for the anterior chest compression assistance

16. Insufflation-exsufflation (MI-E) device-
• A mechanical insufflator–exsufflator uses positive pressure to deliver
a maximal lung inhalation, followed by an abrupt switch to negative
pressure to the upper airway.
• The rapid change from positive to negative pressure is aimed at
simulating the airflow changes that occur during a cough, thereby
assisting sputum clearance.
• Alternation of pressure may be manually or automatically cycled. MI-
E comprises a deep, pressure targeted lung insufflation aimed at
expanding the lungs to approximately 90% of capacity. Insufflation is
followed by vacuum exsufflation enabling lung emptying and
increasing peak cough flow. Pressures of 40mmHg(insufflation) to-
40mmHg(exsufflation) (54cmH2O) are usually most effective and
best tolerated by the patient.

17. SUMMARY-
• Introduction to ICU
• General basic goals of management in ICU
• Aims of physiotherapy management in ICU
• Various physiotherapeutic techniques used in ICU are body
positioning, mobilizations, manual hyperinflation, suctioning,
continuous rotational therapy, limb exercises, percussion, vibration,
shaking, breathing and coughing maneuvers, inspiratory muscle
training.
• Cough augmentation techniques like,
1. Lung volume recruitment (also termed air-stacking or breath-stacking)
2. Manually assisted cough
3. Insufflation-exsufflation (MI-E) device are used in ICU patients.

18. REFERENCES-
• Stiller K. (2000). Physiotherapy in intensive care: towards an evidence-
based practice. Chest, 118(6), 1801–1813.
https://doi.org/10.1378/chest.118.6.1801
• Physiotherapy for Respiratory and Cardiac Problems Edited by Jennifer
A Pryor MBA MSc FNZSP MCSP and Barbara A Webber FCSP
DSc(Hon),SECOND EDITION.
• PRINCIPLES AND PRACTICE OF CARDIOPULMONARY
PHYSICAL THERAPY, THIRD EDITION , Edited by: Donna
Frownfelter, MA, PT, CCS, RRT and Elizabeth Dean, PhD, PT, Associate
Professor,University of British Columbia.
• Ambrosino, N., Janah, N., & Vagheggini, G. (2011). Physiotherapy in
critically ill patients. Revista Portuguesa de Pneumologia (English
Edition), 17(6), 283-288.