2. INTRODUCTION
Physiotherapy is an essential component in the management of
patients admitted to the intensive care unit (ICU). Traditionally,
the role of physiotherapy in the ICU was limited to respiratory
management, but over the last decade rehabilitation
and mobilization have become the priority for patients admitted to
the ICU.
Physiotherapists are, therefore, responsible for the prevention and
treatment of deconditioning musculoskeletal function, as well as
management of the respiratory system maintain lung volume, improve
oxygenation and ventilation, optimize clearance of secretions) in
critically ill patients.
3. ASSESSMENT OF THE CRITICALLY ILL PATIENT
INCORPORATES THREE MAJOR CATEGORIES:
1- History (including investigation of symptoms and review of systems)
Systematically gathering past and present data related to why the patient
needs physiotherapy should be incorporated in history taking along with the
patient’s primary reason for hospitalization and admission to the ICU. History
taking should include:
General demographics (including religious and cultural beliefs, as well as any
language barriers)
General health status
Presenting condition
Previous medical and surgical history.
4. CONTD…
list of patient’s current medications
family history
social history
By inquiring about the patient’s history, the physiotherapist also becomes
aware of the cognitive status of the patient (alert, unconscious, confused)
which leads into the next category.
5. CONTD…
2- Systems Review (multisystem assessment) refers to the assessment of:
The anatomical and physiological status of
the cardiovascular, respiratory, neurological,
musculoskeletal, integumentary and renal systems
The communication ability, language, cognition and learning style of the
individual. The assessment of communication ability includes the level of
consciousness and the orientation (i.e. person, place and time) of the patient
as this will impact the physiotherapy intervention.
6. CONTD…
3- Tests and measures
The physiotherapist will select specific tests and measures based on the
information gathered from the history and systems review. In the ICU, tests
and measures are limited to those necessary for establishing the patient’s
level of functioning and those impacting the physiotherapist’s judgment of
the diagnosis or treatment plan.
These are often incorporated when assessing the multiple body systems and
can include spirometery radiological examinations, sputum
analysis, aerobic capacity and endurance, muscle performance (including grip
strength, manual muscle testing), etc.
7. MULTI-SYSTEMS APPROACH TO ASSESSMENT:
Cardiovascular system
Assessment of the cardiovascular system should include heart/pulse rate,
heart rhythm (as evident on the electrocardiogram [ECG]) and quality, blood
pressure, peripheral oedema and perceived level of exertion at rest and with
activity. It is important to also review the cardiac trends over the 12-24 hours
preceding the physiotherapy assessment in order to establish a true picture of
the patient.
Circulation, ventilation and respiration are often assessed concurrently as
cardiovascular and respiratory conditions present with similar signs and
symptoms.
8. RESPIRATORY SYSTEM
Bed rest, immobility and inflammation in critically ill patients lead to
impaired ventilation, increased resistance of the airways and decreased
compliance of the lungs, resulting in dysfunction of the respiratory system.
These complications are even more pronounced in mechanically ventilated
patients. The functioning of the respiratory system is best assessed by
analyzing measures of oxygenation and ventilation, including oxygen
saturation and arterial blood gases.
Evaluation of the respiratory system starts with simply observing how the
patient breathes - expansion of the thorax, effort of breathing, breathing
pattern and the symmetry of breathing. It is also important to note if the
patient requires ventilator support and the level of support needed full or
assisted and support.
9. NEUROLOGICAL SYSTEM
ASSESSMENT of the neurological system includes various factors such as the
level of consciousness generally measured using the Glasgow Coma Scale,
pupils size, reactivity, and equality, tendon reflexes, muscle tone any
spasticity or rigidity, skin sensation, cerebral perfusion pressure (CPP),
intracranial pressure (ICP), and a review of any radiological imaging cranial
computed tomography scan (CT) or magnetic resonance imaging [MRI]. A
unilateral fixed dilated pupil is indicative of pressure on the oculomotor nerve
and must be investigated urgently.
Bilaterally fixed and dilated pupils point towards severe neurological
impairment sustained severe ICP and cerebral oedema which is sensitive to
hypoxia and often a sign of brainstem death. Any of these signs signal the
urgent referral for a CT or MRI scan.
10. MUSCULOSKELETAL SYSTEM
Prolonged bed rest leads to decreased skeletal muscle strength including
diaphragm strength and poor endurance of patients. When combined with
critical illness, it results in ICU-acquired weakness which has long-term
repercussions for patients beyond discharge from the ICU. Assessment of the
musculoskeletal system should, therefore, include the evaluation of a
patient’s skeletal muscle properties muscle tone, active and passive
joint range of motion.
Assessment of functional tasks includes bed mobility rolling, supine to sit,
sitting over the edge of the bed and out-of-bed mobility sitting-to-standing
transfers, transfers from bed to chair, wheelchair transfers, commode
transfers and ambulation on level surfaces and stairs.
11. INTEGUMENTARY SYSTEM
Reviewing the integumentary system should incorporate the assessment of
pliability i.e. texture, skin color, presence of scar tissue and skin integrity.
Many factors such as medications for example corticosteroids, poor nutrition,
prolonged bed rest and general age-related changes can lead to more fragile
skin which is also more prone to breakdown. It is, therefore, essential to look
for areas of skin breakdown, ecchymosis and pressure injuries as these can be
potential sites for infection, causing poor patient outcomes and prolonged
length of stay. Skin lesions can be prevented by frequently changing the
position of the patient, especially with activities out of the bed.
12. RENAL SYSTEM
Measurement of fluid balance including urine output is important as it affects
the consistency of the patient’s secretions, as well as cardiac output.
Dehydration can cause constant mucous plugging which in return can block
the airway and result in patient distress. Fluid retention can be a sign of
acute kidney injury which may require urgent medical attention. The
physiotherapist may be the person to identify this sudden change and may
need to call the attention of the ICU physician or the nurse. In assessing the
renal system, it is important to note if the patient is catheterized or not, the
type of catheter used and the length of catheterization, as this could
potentially be a route of infection.
13. OTHER SYSTEMS TO CONSIDER INCLUDE
THE:
Gastro-intestinal system to ensure adequate nutritional support for optimal
energy and prevention of muscle wasting protein supplements.
Hematological and immunological systems - awareness of infection, the
organism responsible for the infection and the risk of cross-infection between
patients and to the ICU team.
14. ACUTE RESPIRATORY DISTRESS
SYNDROME
Acute respiratory distress syndrome
(ARDS) occurs when fluid builds up
in the tiny, elastic air sacs (alveoli)
in your lungs. The fluid keeps your
lungs from filling with enough air,
which means less oxygen reaches
your bloodstream. This deprives your
organs of the oxygen they need to
function.
15. SYMPTOMS
Severe shortness of breath
Labored and unusually rapid breathing
Low blood pressure
Confusion and extreme tiredness
17. RISK FACTORS
Inhaling vomit, smoke, chemical fumes, or water during a near
drowning
Injury from a blow, burn, or broken bone can lead to ARDS. A broken
bone, for example, can lead to a fat embolism, a clot of fat that
blocks an artery.
Lung or heart surgery or being placed on a heart-lung bypass machine
or ventilator
Pancreatitis
Reaction to medicines.
18. DIAGNOSIS
Chest X-ray:
A chest X-ray can reveal which parts of your lungs and how much of
the lungs have fluid in them and whether your heart is enlarged.
Computerized tomography (CT):
A CT scan combines X-ray images taken from many different directions
into cross-sectional views of internal organs.
19.
20. TREATMENT
OXYGEN
Supplemental oxygen. For milder symptoms or as a temporary measure,
oxygen may be delivered through a mask that fits tightly over your nose and
mouth.
Mechanical ventilation. Most people with (ARDS) will need the help of a
machine to breathe. A mechanical ventilator pushes air into your lungs and
forces some of the fluid out of the air sacs.
21. Medication
Prevent and treat infections
Relieve pain and discomfort
Prevent blood clots in the legs and lungs
Minimize gastric reflux
Sedate
22. LIFESTYLE AND HOME REMEDIES:
Quit smoking. If you smoke, seek help to quit, and avoid secondhand smoke
whenever possible.
Get vaccinated. The yearly flu (influenza) shot, as well as the pneumonia
vaccine every five years, can reduce your risk of lung infections.
23. DISSEMINATED INTRAVASCULAR
COAGULATION
Disseminated intravascular coagulation (DIC) is
a rare but serious condition that causes
abnormal blood clotting throughout the body’s
blood vessels. You may develop DIC if you have
an infection or injury that affects the body’s
normal blood clotting process.
24. DIC PROGRESSES THROUGH TWO
STAGES:
In stage one, overactive clotting leads to blood clots throughout the blood
vessels. The clots can reduce or block blood flow, which can damage organs.
In stage two, as DIC progresses, the overactive clotting uses up platelets and
clotting factors that help the blood to clot and clotting factors, DIC leads to
bleeding just beneath the skin, in the nose or mouth, or deep inside the body.
25. SYMPTOMS:
Bleeding at wound sites or from the nose, gums, or mouth
Blood in the stool or urine
Bruising in small dots or larger patches on the body
Chest pain
Pain, redness, warmth, and swelling of the leg
26. CAUSES
Sepsis: This is a body-wide response to infection that causes inflammation.
Sepsis is the most common risk factor for DIC.
Major damage to organs or tissues: This may be caused by of the liver,
pancreatitis, severe injury, burns, or major surgery.
Severe immune reactions: Your body may overreact because of a failed
blood transfusion, rejection of an organ transplant, or a toxin such as snake
venom.
Serious pregnancy-related problems: These include the separating from the
uterus before delivery, amniotic fluid entering the bloodstream, or serious
bleeding during or after delivery.
27. TREATMENT
Treatment for DIC depends on your symptoms and how serious they are. The
main goals of treatment for DIC are to control clotting and bleeding and to
treat the underlying cause. DIC may go away once the underlying cause is
treated. In the meantime, your doctor may use medicines or procedures to
help stop the bleeding.
MEDICINE
You may be given them as a pill, as an injection, or through an IV. Possible
side effects include bleeding, especially if you are taking other medicines
that also thin your blood, such as aspirin.
28. PHYSIOTHERAPY TECHNIQUES IN ICU
The role of the respiratory physiotherapist is to assist in clearing the airways
of the patients, and maintaining and improving the integrity of the
respiratory system. Treatment interventions include:
Positioning,
Education,
Manual and ventilator hyperinflation,
Weaning from mechanical ventilation,
Non-invasive ventilation,
Percussion, vibration, suctioning,
Respiratory muscle strengthening,
Breathing exercises and mobilization.
29. REHABILITATION
Early Mobilization with a focus on returning to functional activities helps in
reducing hospital stay and minimize functional decline. A survey. suggests
positive outcomes with physiotherapy implementation in ICU and also
discusses the barriers by the physiotherapists in ICU. A pilot RCT suggests
early in-bed cycling with mechanically ventilated (MV) patients has positive
outcomes.
For patients at risk, start rehabilitation as early as clinically possible which
should include:
Measures to prevent avoidable physical and non-physical morbidity,
Nutrition support
An individualized, structured rehabilitation program with frequent follow-up
reviews. The details of the structured rehabilitation program and the reviews
should be collated and documented in the patient's clinical records.
30. IMPACT OF PHYSIOTHERAPY
Early intervention by physiotherapists in the ICU helps:
Reduce the patient's stay in the ICU and overall hospital stay.
Prevent ICU related complications
To improve function and quality of life in the long term
