2. ICU UNIT
The physiotherapist was a most welcome
person, despite the discomfort endured to
have my secretion removed and
repositioned, this left me comfortable for
several more hours.'
2
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
3. What is CPPT?
• Cardio-pulmonary physical therapy CPPT refers to
prescription and delivery of non invasive
interventions in the comprehensive management
(diagnosis, assessment, treatment, and follow up)of
patients with primary or secondary cardio
pulmonary dysfunction.
3
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
4. WHY, WHEN, HOW-CPPT in ICU
• Cardiopulmonary physical therapy in the intensive
care unit (lCU) is a specialty by itself.
• Since 1980, reports on therapeutic interventions
that may reverse respiratory complications or
improve prognosis and reduce hospital stay for
patients with respiratory complications have
magnified.
• Evidence based practice in health care- major
implication of CPPT in ICUs.
4
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
5. CDM in ICU-Based on tripod approach
ICU
Knowledge of underlying
Patho-physiology
Tripod approach to patient management.
5
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
6. SPECIALISED EXPERTISE OF ICU PTs
• Knowledge of cardio-pulmonary and multisystem
physiology.
• First rate diagnostician
• Ability to identify impaired O₂ transport/pathway.
• Integration and interpretation of the vast amount
of multi-organ system data.
• Ability to identify indication, C-indication, timing
of treatment.
6
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
7. Patient effects on - ICU STAY
• Communication problems
• Sleep fragmentation
• Fear
• Sensory deprivation
• Sensory overload
• Discomfort
• Helplessness, dependency and depression
• Loss of privacy, dignity and identity
7
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
8. Who gets admitted in ICU?
LUNGS
• Type I & II respiratory
failure
• Severe COPD and RLD
and its complications
• Lung carcinoma
• Chest traumas
• Pul. Embolism/ARDS
• Status asthmaticus
NEUROMUSCULAR
DISORDERS
• CNS insults
• GuillaiIi-Barre syndrome
• Acute quadriplegia
• Acute head injury
• Myasthenia gravis
• Botulism
• Tetanus
• Critical illness neuropathy
8
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
9. POST-OP –Thoracic, Cardiac
SYSTEMS FAILURE
• Heart failure/MI/ CAD
• Disseminated intravascular coagulation
• Acute pancreatitis
• Collagen vascular disease
• Kidney failure
• Liver failure
MULTISYSTEM FAILURE
POISONING AND PARASUICIDE
SMOKE INHALATION/BURNS
Who gets admitted in ICU…..
9
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
10. Monitoring and Assessment in ICU
• Assessment
• Charts
• Patient
• Monitors
• Ventilator
• Imaging
10
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
11. ASSESMENT
• Vital parameters/signs(*wt gain)
• Differential diagnosis of Chest pain.
• Breathlessness/Dyspnoea
• Position of the patient and Posture
• Face & Cough
• Hands- cold, warm, wasted, stains, clubbing
• Oedema/Sputum/Cap-refill
• Configurations of chest wall-Shape, pattern, IC space
• Measure chest expansion.
• Chest auscultation- breath sounds/CTX C:UsersUserDownloadsDesktopN CTX.jpg
• Lines attached to the patient.
• Tactile/Vocal Fremitus & percussion 11
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
12. MONITORING -GENERAL GUIDELINES
• Rapid detection of changes in the clinical status.
• Complementary to clinical observation & not a
substitute.
• Accurate assessment of progress & response to PT
• Trends are generally more important than a single
reading
• Alarms are crucial for patient safety
12
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
13. MONITORS
PULSE OXIMETRY (SpO₂) < 90 % = 60 mm Hg
>95% Normal
91%-94% Acceptable O2, Suction
< 85% Critical Intubation
Arterial Blood Gases - ABG RESULTS
pH 7.35–7.45
PaO₂ 80 – 100 mmHg
PaCO₂ 35 – 45 mmHg
HCOз 22 to 26 mmol/L
CRITICALs
Resp Acidosis
Met Acidosis
Resp Alkalosis
Met Alkalosis
Excess base
Excess Lactate > 45 mg/dl
13
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
20. CLINICAL ASPECTS OF THE MANAGEMENT
OF THE ICU PATIENT
• Monitoring systems can be used to establish
A. Indications and contraindications for treatment
B. Parameters of the treatment prescription and
progression
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
20
Physical therapy treatment should be coordinated
with medication schedules.
Most medications have optimal dosages for any given
patient, optimal sensitivity, and peak-response time.
21. THERAPEUTIC BODY POSITIONING
Identify most & least beneficial body positions thro
monitoring
1.Supine lying –
Non physiological, deleterious to O₂ transport,
↓ses FRC, ↓ses VC, central shift of blood
volume, ↑ses area of dependant lung
2.Up right/ 45˚ -
Max FRC, ↑ses airway dia.m (), Max VA/Q ratio ()
Compression of heart & lungs minimal
Favourable for diaphragmatic fibres
↓ses work of breathing
Hemodynamic and Fluid shift effects () 21
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
22. 3. Side-Lying Positions/High side lying
Most benefits are between supine and upright.
Unilateral pathology - “ Good lung down”
Bilateral pathology – “lie on the right side”
VA/Q matching occurs in upper ⅓ rd of both lungs
THERAPEUTIC BODY POSITIONING
4. Prone Position
Good rationale should be made for not incorporating
this position into the treatment prescription.
Enhances lung compliance, tidal volume, FRC and
diaphragmatic excursion.
i. Abdomen free prone ii. Abdomen contact prone iii. Semi prone
"stir-up“ regimen or positional perturbations - (Pyne 1999)
22
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
23. Mobilization and Exercise
• Application of low-intensity exercise.
• Combine M & E with positioning.
• In patients Rhythmic inflation and deflation of
the lungs associated with physical activity.
• Chest expansion exs, Breathing exs, Upper
extremity exs, ROM exs, Bed turning.
C
•In patients:
• Passive movt for UE & LE
• Manual hyper inflation
• NPF of respiration () () ()
• Tracheal tickles
UC
23
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
24. Mob & Ex’s – Clinical Implications
• Chairs should be available at the side of every ICU
bed.
• Bed mobility- Active, Assisted
• Bed side standing
• Active Ex;s of UE – Note PSCA of muscles
• Ambulation inside the unit with baseline monitors
• Relaxation Ex’s - to minimize O₂ demand.
• If pt is Unconscious – Passive interventions.
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
24
25. Thoracic Expansion Ex’s
• Breathing Ex’s
Apical
Upper costal
Lower costal
Diaphragmatic
Sniff Maneuvers
• SMI
• Wand Ex’s- Note incorporate inhalation/exhalation
• Inter costal and Accessory muscle stretch
• Thoracic spine mobilization
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
25
In corporate Neck, Eye ball
26. Airway Clearance Techniques
• Postural Drainage
• Percussion or Chest clapping
Mainstay of Rx in HDUs
• Vibration
• Shaking
26
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
27. • ACBT
Airway Clearance Techniques
27
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
29. • SUCTIONING
Inability to cough
Pre & Post O₂ safe
Hazards- arrythmias, hypoxia
• SALINE INSTILLATION
Normal saline
5 ml or even more
Thro Nebuliser
BRONCHO DILATORS & AEROSOL
Very effective direct administration
of drug enhance chest PT effects.
OTHER ACT & ADJUNCTS
ASSISSTED COUGHING () 29
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
30. Consideration for PTs – Critical care
• Fluctuating ICP (neurological instability) – PT
may magnify it.
• Atrial fibrillation, supraventricular, ventricular
tachycardias, arrythimias – PT is
Cont.indicated.
• Avoid Manual hyperinflation in high PAP and
low CO
• Sometimes PT can cause bronchospasm-
caution
• Cross infection is very common in ICU
30
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
31. Consideration for PTs – Critical care
• Treatment should be carried out at least 1 1/2 hrs
after feeding time.
• Avoid overfeeding in type II Resp Failure.
• Treat interstitial edema with full force
• Many PT ploys are contraindicated in
haemoptysis.
• In Pul embolism – PT is started only after anti
coagulant therapy. 31
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
37. CASE
A 70 yrs old man
admitted in ICU with
acute hypoxemic Resp
failure left lower
lobectomy.
Vital: BP 125/70 mm
Hg, Pulse 103/min, BR
18/min
Auscultation: no breath
sound Lf lower lung
field. Diffused crackle
on Lf upper lobe.
ABG: PaO2 65 mm Hg,
PaCo2 45 mm Hg ,
HCO3 24
Diffuse bilateral pulmonary
infiltrates consistent with
pulmonary edema
37
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
38. Hi PT’s- In ICU “its do or die
Thank you
38
J.Balamurugan, Dept of Physiotherapy, UOG
11 th Feb 2014
Editor's Notes
Frown felter pg 568
Inability to communicate has been found the most stressful experience in the ICU .
Sleep disruption is caused by noise, interruptions, anxiety, pain, reversal of the day-night cycle, difficulty in finding a comfortable position or
fear of falling asleep and not waking again.
Fear: Patients face previously unmet fears for
which they have not developed coping
strategies.
Fear is compounded by helplessness. Patients try to assess their progress by watching staff and family reactions and comparing themselves to others
on the unit. Agitation can lead to myocardial arrhythmias, ischaemia and sometimes infarction.
Sensory deprivation: Social isolation, loss of comforting touch, immobilization, certain drugs, a limited visual field and removal of hearing aid or glasses lead to a form of emotional solitary confinement that can leave patients felling intense loneliness despite constant attention.
Sensory overload: Patients find themselves lost in a sea of electronic wizardry, bombarded by unfamiliar beeping, overhead lights, telephones, confining
equipment, painful procedures (sometimes without warning), tubes in various orifices and incomprehensible conversation over their heads.
Discomfort: Patients experience immobility, gagging on the endotracheal tube, dribbling, sweating, a dry mouth, distended abdomen, unscratchable itches and lack of synchrony with the ventilator. Discomfort is increased with paralysis or other form of restraint. Physical restraints have been found to increase rather than decrease the risk of selfextubation.
One patient commented that 'it is the helplessness of illness that is humiliating' (Moore, 1991, p. 12).Depression is particularly apparent in the
recovery period and can hinder rehabilitation.
Loss of privacy, dignity and identity: It is easy for us to forget how people feel when they lose their autonomy, clothes, teeth,personal space and surname. Patients who are elderly or from a different culture are particularly vulnerable to this form of depersonalization.
“he will get a dozen people around the clock, all busily preoccupied with his heart rate, pulse, secretions or
excretions, but not with him as a human being”
Accurate assessment is the linchpin of physiotherapy
Weight gain in ICU could be due to Hypervolemia
Physiotherapy can upset gas exchange, and if desaturation occurs, treatment should normally stop and the '100% oxygen' knob on the ventilator activated if appropriate.
BP can be measured by an automated cuff that intermittently compresses the limb and senses arterial pulsations. Continuous monitoring of BP by an indwelling catheter gives a beat-to-beat waveform display and provides more accurate and instant feedback than cuff pressure.
The CVP (indicates circulating bld vol)provides early warning of cardiac tamponade, which causes a sudden rise in CVP, or haemorrhage, which causes a sudden drop. CVP is more sensitive to haemorrhage than BP, because BP is maintained for longer by vasoconstriction.
A raised PAP indicates pulmonary hypertension, pulmonary embolism or fluid overload.
MAP, or mean arterial pressure, is defined as the average pressure in a patient's arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure (SBP)
*Note that the FiO
2
is the abbreviation for the fractional concentration of inspired oxygen. It is a
measure of the proportion of inspired oxygen. For example, an FiO2 of 21% or 0.21 means that 21% of the inspired air is oxygen. The precise FiO2
delivered via a particular delivery system depends on
the breathing pattern and the fit of the mask on the patient.
CPP-Cerebral perfusion pressure
Certain medications, such as bronchodilators, sedatives, mucolytic agents, antianginal medications, and analgesics, help the patient to be able to cooperate during treatments.
beta-blocking agents, for example, will not show the normal changes in heart rate and blood pressure in response to exercise.
beta-blockers contribute to fatigue.
vasopressor agents help regulate blood pressure and heart rate. Patients on these agents may also exhibit abnormal exercise responses.
Despite their benefi cial effects on pain relief, narcotics prohibit PT mgmt.
Because of its potent and direct effect on oxygen transport, therapeutic body positioning is a primary non-invasive physical therapy intervention that can augment arterial oxygenation so that invasive, mechanical, and pharmacological forms of respiratory support can be postponed,reduced, or avoided the single most important objective of cardiopulmonary physical therapy.
Identify most and least beneficial body positions thro monitoring, 360 degrees in the horizontal plane and 180 degrees in the vertical plane.
Frequent changes in body position and avoidance of prolonged periods in any single position will minimize the risk of diminishing returns, which are inevitable.
Duration a patient assumes a body position should be primarily response-dependent rather than time-dependent.
The position of the diaphragm and its function is dependent on body position.
Patients lose optimal positions in bed very quickly and thus need to be monitored to ensure the specific positions are maintained.
Mechanical turning beds such as the Rotobed have significant benefits On oxygen transport in severely ill patient.
Peripheral vascular resistance increases and blood flow decreases, with the assumption of the upright position greater than 45 degrees to off
set dependent fluid shifts and potential blood pressure drop
Even though a position (particularly an upright position) may only be tolerated for a short period of time, the physiological benefits are considerable.
The semiprone position may be more conservative, safer, and comfortable for the patient who is severely ill, potentially hemodynamically unstable, older, or who has a protruding abdomen.
Prescriptive positioning is based on clear indications and well-defined parameters; it is not to be confused with 'routine' positioning.
Prescriptive parameters of body positioning and body position changes include the positions selected, the duration spent in each position, the sequence of position changes, the cycle of all positions, and position changes overall.
Even a relatively low-intensity mobilization stimulus can impose considerable metabolic demand on the patient with cardiopulmonary compromise.
NPF –Intercostal stretch, Vertebral compression, Perioral stimulation, Abdominal cocontraction, Rib springing
