1189Conditions and physiotherapy overall well-being by providing emo- to be the rule in the ICU (see ESMinterventions tional support and enhancing commu- for details). Rehabilitation has the nication. Fig. 1 outlines the etiology potential to restore lost function but isAssessment and monitoring of respiratory insufﬁciency and failure traditionally not started until after ICU (see also ESM), and may serve as discharge. Critically ill patients arePhysiotherapy assessment of crit- a framework for the respiratory as- often viewed as ‘too sick’ to tolerateically ill patients is less driven by sessment and treatment. Assessment physical activity in the early phase ofmedical diagnosis, instead focusing of muscle and neurological function their illness and their immobilizationon deﬁciencies at a physiological and is difﬁcult in the ICU , but phys- is frequently ‘inevitably’ prolonged.functional level . This leads to iotherapists can reveal undetected This will enhance deconditioningidentiﬁcation of problems and the injuries . Detailed descriptions of and might further complicate theprescription of one or more interven- assessment are given elsewhere . clinical course . Early mobi-tions. Physiotherapists should be able lization was shown 30 years ago toto prioritize, and identify aims and Recommendations: reduce the time to wean from me-parameters of treatments, ensuring chanical ventilation and is the basisthat these are both therapeutic and • Assessment prior to treatment for functional recovery [103, 104].safe by appropriate monitoring of should determine the underlying Recently more attention has beenvital functions [22, 100]. Accurate problem amenable to physio- given to (early) physical activityand valid assessment of respiratory therapy and which, if any, as a safe and feasible interventionconditions, and of deconditioning and intervention(s) are appropriate after the initial cardio-respiratory andrelated problems, is of paramount (level D). neurological stabilization [6, 71]. Inimportance for physiotherapists. • Appropriate monitoring of vital the ICU setting, the prescription ofWhile these areas should be assessed functions should be used and exercise is mostly based on clinicalwith previously validated measures, acted upon to help ensure that condition and response to treatment.such measures are often not available physiotherapy interventions are Reducing the active muscle massor applicable in an ICU setting (e.g., both therapeutic and safe (or even passive motion or electricaloutcomes for functional performance (level D). muscle stimulation), the durationsuch as the Functional Independence of the exercise and/or the numberMeasure, the Berg Balance scale and Physical deconditioning and related of repetitions will result in lowerSF-36 may be inapplicable for acutely complications metabolic demands. Patients withill ICU patients yet be successfully hemodynamic instability, or thoseused to monitor the progress of Due to the nature of critical illness on high FiO2 and high levels ofpatients in long-term weaning facil- and the modalities used to manage it, ventilatory support, are not candidatesities) . In addition, physiothera- prolonged bed rest, with well-known for aggressive mobilization. Thepists can contribute to the patient’s adverse physiologic effects, seems risk of moving a critically ill patient should be weighed against the risks entailed by immobility and recum- bency [50, 108]. No adverse effects of physical activity on the inﬂam- matory status of critically ill patients have been demonstrated . Fig. 2 outlines the steps involved in safe mobilization of critically ill patients . In the following paragraphs several speciﬁc treatment modalities will be discussed. Positioning can be used to increase gravitational stress and associated ﬂuid shifts, through head tilt and other positions that approximate the upright position. The upright posi- tion increases lung volumes and gas exchange , stimulates autonomic activity, and can reduce cardiac stress from compression . MobilizationFig. 1 Model of respiratory insufﬁciency (adapted from ) has been part of the physiotherapy
1190Fig. 2 Overview of safety issuesbefore mobilizing critically illpatients. (Reproduced from:Stiller K, Phillips A (2003)Safety aspects of mobilisingacutely ill inpatients. PhysiotherTheory Pract 19(4):239–257;with permission of Taylor &Francis Group, LLC,http://www.taylorandfrancis.com)management of acutely ill patients Strategies – in approximate order and feasible in the early phase offor several decades . Mobilization of intensity – include passive and ICU admission . Walking andrefers to physical activity sufﬁcient active turning and moving in bed, standing aids (e.g., modiﬁed walkingto elicit acute physiological effects active-assisted and active exercise, frames, tilt tables) are safe and fea-that enhance ventilation, central and use of cycling pedals in bed, sitting sible to facilitate the mobilization ofperipheral perfusion, circulation, over the edge of the bed, standing, critically ill patients [15, 112, 113].muscle metabolism and alertness stepping in place, transferring from In patients with spinal cord injuryand are countermeasures for venous the bed or chair, chair exercises and abdominal belts improve vital ca-stasis and deep vein thrombosis . walking. These activities are safe pacity  and increase the exercise
1191ability. Non-invasive ventilation 1 h reduced the decrease in cross- • NMES may be instituted, whereduring mobilization may improve sectional area of the quadriceps and equipment is available, in patientsexercise tolerance for non-intubated enhanced normal muscle protein syn- who are unable to move spon-patients, similar to that demonstrated thesis . In ICU patients, NMES of taneously and at high risk ofin patients with severe COPD . the quadriceps, in addition to active musculo-skeletal dysfunction Aerobic training and muscle limb mobilization, enhanced muscle (level C).strengthening, in addition to routine strength and hastened independent • Techniques, such as positioning,mobilization, improved walking dis- transfer from bed to chair . passive movement and transfers,tance more than mobilization alone Passive stretching or range-of- should be administered jointlyin ventilated patients with chronic motion exercise may have a particu- with the nursing staff (level D).critical illness . A recent random- larly important role in the manage- • The physiotherapist should beized controlled trial (RCT) showed ment of patients who are unable to responsible for implementingthat a 6-week upper and lower limb move spontaneously. Passive move- mobilization plans and exercisetraining program improved limb mus- ment has been shown to enhance prescription, and make recom-cle strength, increased ventilator-free ventilation in neurological patients in mendations for progression oftime and improved functional out- high-dependency units . Evidence these in conjunction with othercomes in patients requiring long-term for using continuous dynamic stretch- team members (level D).mechanical ventilation compared ing is based on the observation, into a control group . These re- other patient groups, that continuoussults are in line with a retrospective passive motion (CPM) prevents con- Respiratory conditionsanalysis of patients on long-term tractures and promotes function .mechanical ventilation who partic- CPM has been assessed in patients Respiratory dysfunction is one ofipated in whole-body training and with critical illness subjected to pro- the most common causes of criticalrespiratory muscle training . longed inactivity . Three hours of illness necessitating ICU admission.In patients recently weaned from CPM per day reduced ﬁber atrophy Failure of either of the two pri-mechanical ventilation, the addition and protein loss, compared with mary components of the respiratoryof upper-limb exercise enhanced the passive stretching for 5 min twice system (i.e., the gas-exchange mem-effects of chest physiotherapy on daily . brane and the ventilatory pump.. exercise endurance and dyspnea . For patients who cannot be ac- (Fig. 2; see ESM, Table S2), canRecent technological developments tively mobilized and are at high result in a need for mechanicalhave resulted in equipment for active risk for soft tissue contracture (e.g., ventilation to maintain adequate gasor passive leg cycling during bed following severe burns or trauma, exchange and to assume some, if notrest. This allows early application of and in some neurological conditions), all, of the work of breathing. Theleg cycling in critically ill patients, splinting may be indicated. In burns aims of physiotherapy in respiratorypotentially improving functional patients, ﬁxing the position of joints dysfunction are to improve globalstatus . has been shown to reduce muscle and and/or regional ventilation and lung Low-resistance multiple repeti- skin contraction . The ideal dura- compliance, to reduce airway resis-tions of resistive muscle training can tion of the intervention is unknown. tance and the work of breathing,augment muscle mass, force genera- Many facilities use a ‘2 h on, 2 h off’ and to clear airway secretions. Bodytion and oxidative enzymes. This in schedule, but this is not supported by positioning and mobilization areturn can improve O2 extraction and data . In patients with neurologi- potent options for treatment thatefﬁciency of muscle O2 kinetics. Ap- cal dysfunction, splinting may reduce may optimize oxygenation by im-plying these physiological responses muscle tone . proving ventilation, V/Q matching,to the ICU scenario, ICU patients using gravity dependency to aug-should be given sets of repetitions Recommendations: ment alveolar recruitment, and lung(3 sets of 8–10 repetitions at 50–70% perfusion. Evidence for interventionsof 1 repetition maximum, RM)  to • Active or passive mobilization used to clear retained airway secre-perform daily within their tolerance, and muscle training should be tions will be discussed generally.commensurate with their goals. In instituted early (level C). The ESM describes the evidence forpatients unable to perform voluntary • Positioning, splinting, passive interventions in speciﬁc pathophysi-muscle contractions, neuromuscular mobilization and muscle ological problems and diagnoses, i.e.electrical stimulation (NMES) has stretching should be used to atelectasis, pneumonia, acute lungbeen used to prevent disuse muscle preserve joint mobility and injury, acute respiratory distressatrophy. In patients with lower limb skeletal muscle length in patients syndrome, inhalation injury, postop-fractures and cast immobilization for unable to move spontaneously erative pulmonary complications and6 weeks, daily NMES for at least (level C). chest trauma.
1192Fig. 3 Pathways and treatmentmodalities for increasing airwayclearance (PEP, positiveexpiratory pressure; CPAP,continuous positive airwaypressure; HFO, high-frequencyoscillation; IPV, intrapulmonarypercussive ventilation; NIV,non-invasive ventilation; IPPB,intermittent positive pressurebreathing)Retained airway secretions expiratory force, via a mouthpiece expiratory force is contributing to or facemask. This increases tidal ineffective forced expirationAs different mechanisms can be volume and augments expiratory (level B).responsible for reducing airway clear- ﬂow and thus is indicated when the • Manually assisted coughance, it is important ﬁrstly to identify patient is unable to clear secretions. techniques and/or in-exsufﬂationthe problem and then to select the in- Although not widely used, it has should be applied in the man-tervention(s) that may be appropriate been successfully applied in the man- agement of non-intubated patients(Fig. 3). agement of non-intubated patients with retained secretions Non-intubated patient: Interven- with retained secretions secondary secondary to respiratory muscletions aimed at increasing inspiratory to respiratory muscle weakness (e.g., weakness (level B).volume (see Fig. 3) affect lung muscular dystrophy) . Airway • Oro-nasal suctioning should beexpansion, regional ventilation, suctioning is, dependent on local used only when other methods failairway resistance and pulmonary agreements, practiced by doctors, to clear secretions (level D).compliance. Interventions aimed at nurses and physiotherapists and is • Nasal suctioning should be usedincreasing expiratory ﬂow include used solely to clear central secretions with extreme caution in patientsforced expirations (both active and that are considered a primary problem with anticoagulation, bony or softpassive). Actively, these can be with when other techniques are ineffec- tissue injuries or after recentan open glottis (a huff), or with tive. Detailed descriptions of airway surgery of the upper airwaysa closed glottis (a cough). Manually suctioning techniques and the risks (level D).assisted cough, using thoracic or associated with these techniques areabdominal compression, may be given elsewhere . Intubated and ventilated patients:indicated for patients with expiratory Body positioning and mobilizationmuscle weakness or fatigue (e.g., Recommendations for the may optimize airway secretion clear-neuromuscular conditions) . All non-intubated patient: ance and oxygenation by improvingforced expiratory techniques rely ventilation, alveolar recruitment andon an adequate inspiratory volume • Interventions for increasing V/Q matching. Manual hyperinﬂationand may need to be accompanied by inspiratory volume should be used (MHI) or ventilator hyperinﬂation,interventions to increase inspiratory if reduced inspiratory volume is positive end-expiratory pressurevolume, if reduced inspiratory vol- contributing to ineffective forced (PEEP) ventilation and airwayume is contributing to an ineffective expiration (level B). suctioning may assist in secretioncough. The mechanical in-exsufﬂator • Interventions for increasing clearance . The aims of MHI arecan be used to deliver an inspiratory expiratory ﬂow should be used to to prevent pulmonary atelectasis,pressure followed by a high negative assist airway clearance if reduced re-expand collapsed alveoli, im-
1193prove oxygenation, improve lung tion, or ventilation after endotracheal • Neither suctioning nor instillationcompliance, and facilitate move- suctioning in an unselected popu- of normal saline should bement of airway secretions towards lation of mechanically ventilated performed routinely (level C).the central airways [43, 68]. The patients .head-down position may enhance the Respiratory insufﬁciency – intubationeffects of MHI on sputum volume avoidanceand compliance . MHI involves Recommendations for the intubateda slow deep inspiration with man- patient: Complications of endotracheal in-ual resuscitator bag, an inspiratory tubation and mechanical ventilationhold, and then a quick release of the are common, and weaning frombag to enhance expiratory ﬂow and • Body positioning and mechanical ventilation can be chal-mimic a forced expiration. MHI can mobilization can be used to lenging, so where appropriate andprecipitate marked hemodynamic enhance airway secretion possible, physiotherapy is aimed atchanges associated with a decreased clearance (level C). avoiding intubation. Of paramountcardiac output, which result from • Manual or ventilator importance is whether the respira-large ﬂuctuations in intra-thoracic hyperinﬂation and suctioning are tory failure is due to lung failure,pressure . As with other forms of indicated for airway secretion pump failure, or both (Fig. 2; seeventilatory assistance, damage to the clearance (level B). ESM Table S2), as the problems andlung can occur if inﬂation is forced • MHI should be used judiciously strategies will vary accordingly. Im-or PEEP is lost during the technique. in patients at risk of barotrauma balance between respiratory muscleA pressure of 40 cmH2 O has been and volutrauma or who are (pump) workload and muscle (pump)recommended as an upper limit . hemodynamically unstable capacity can result in respiratorySimilarly, there is a risk of hypo- as (level B). insufﬁciency (Fig. 4) and is a majorwell as hyperventilation. MHI can • Care must be taken to ensure that cause of need for ventilatory support.also increase intracranial pressure over- or under-ventilation does Physiotherapy may help decrease(ICP) and mean arterial pressure, not occur with MHI (level B). ventilatory load, e.g., by reducingwhich has implications for patients • Airway pressures must be atelectasis [62, 99] or removingwith brain injury. These increases are maintained within safe limits airway secretions [60, 99]. Condi-usually limited, however, such that (e.g., by incorporating a pressure tions contributing to the need forcerebral perfusion pressure remains manometer into the MHI circuit) ventilatory support or weaning failurestable . Airway suctioning may (level D). are described in the ESM (Tablehave detrimental side effects  • Reassurance, sedation, and S3).although reassurance, sedation, and pre-oxygenation should be used to Problems related to the work ofpre-oxygenation of the patient may minimize detrimental effects of breathing and efﬁciency of ventila-minimize these effects . Suction airway suctioning (level D). tion, along with progressive debility,can be performed via an in-line • Open system suctioning can be are the primary focuses of physiother-closed suctioning system or an open used for most ventilated patients apy in the management of respiratorysystem. The in-line system does not (level B). insufﬁciency and the avoidance ofappear to decrease the incidenceof ventilator-associated pneumonia(VAP) [25, 59] or the duration ofmechanical ventilation, length of ICUstay or mortality , but it doesincrease costs. Closed suctioning maybe less effective than open suction-ing for secretion clearance duringpressure-support ventilation .The routine instillation of normalsaline during airway suctioning haspotential adverse effects on oxygensaturation and cardiovascular stabil-ity, and variable results in terms ofincreasing sputum yield [1, 9]. Chestwall compression prior to endotra-cheal suctioning did not improveairway secretion removal, oxygena- Fig. 4 Factors contributing to respiratory insufﬁciency, failure and ventilator dependence
1194intubation. Positioning can reduce the Weaning failure in patients with weaning failure.work of breathing and improve the Uncontrolled trials [3, 64] and oneefﬁciency of ventilation. Improve- Only a small proportion of pa- RCT  observed an improvementments have been documented (see tients fail to wean from mechanical in inspiratory muscle function andESM) for patients with unilateral ventilation, but they require a dis- a reduction in duration of mechan-lung disease when they are positioned proportionate amount of resources. ical ventilation and weaning timeon their side with the affected lung Therapist-driven protocol (TDP) with intermittent inspiratory muscleuppermost . For those with, or at was shown to reduce the duration training. Finally, biofeedback to dis-risk of, reduced FRC, supported up- of mechanical ventilation and ICU play the breathing pattern has beenright sitting, with the help of pillows cost [27, 51]. However, a recent shown to enhance weaning .if necessary, may be beneﬁcial . study showed that protocol-directed Voice and touch may be used toIn lung failure, CPAP has produced weaning may be unnecessary in an augment weaning success either byfavorable outcomes in adults with ICU with generous physician stafﬁng stimulation to improve ventilatoryARDS  and in patients with Pneu- and structured rounds . A spon- drive or by reducing anxiety .mocystis carinii pneumonia , taneous breathing trial (SBT) can be Environmental inﬂuences, such asand may prevent re-intubation . used to assess readiness for extuba- ambulating with a portable venti-NIV has been used for postoperative tion with the performance of serial lator, have been shown to beneﬁtsupport  and for COPD patients measurements, such as tidal volume, attitudes and outlooks in long-termwith CAP , as well as in some respiratory rate, maximal inspira- ventilator-dependent patients .patients with acute lung injury , tory airway pressure, and the rapidto avoid intubation When pump dys- shallow breathing index [63, 111]. Recommendations:function is present, NIV can reduce Early detection of worsening clinicalbreathlessness , reduce rates of signs such as distress, airway ob- • Therapist-driven weaningintubation , reduce mortality from struction and paradoxical chest wall protocols and SBTs can beexacerbations of COPD , and is motion ensures that serious problems implemented dependent oncost effective . Both CPAP and are prevented. Airway patency and physician stafﬁng in the ICUNIV can reduce the need for intuba- protection (i.e., an effective cough (level A).tion in acute cardiogenic pulmonary mechanism) should be assessed prior • Therapist-driven protocols foredema . to commencement of weaning. Peak weaning should be adhered to if cough ﬂow is a useful parameter to in existence (level A).Recommendations: predict successful weaning in patients • In patients with respiratory with neuromuscular disease or spinal muscle weakness and weaning • Body positioning should be used cord injury when extubation is antici- failure respiratory muscle training to optimize ventilatory pump pated . An “airway care score” has should be considered (level C). mechanics in patients with been developed based on the quality • NIV may be used as a weaning respiratory insufﬁciency (level C). of the patient’s cough during airway strategy in a selected population • CPAP and NIV should be suctioning, the absence of ‘exces- of hypercapnic patients (level A). considered for the management of sive’ secretions and the frequency of • Patients at risk of post-extubation acute cardiogenic pulmonary airway suctioning [12, 27]. ventilatory failure should be edema (level A). NIV can facilitate weaning  identiﬁed and considered for NIV • NIV should be used as the ﬁrst and reduce ICU costs , and (level B). line of treatment in pump failure physiotherapists can play a major role • During the early post-extubation due to exacerbations of COPD, in its application [53, 77]. NIV is ef- phase, assisted coughing providing immediate intubation is fective in preventing post-extubation maneuvers or nasal endotracheal not warranted (level A). failure in patients at risk [75, 97]. suctioning should be performed as • NIV may be used in selected Respiratory muscle weakness is often necessary (level C). patients with pump failure due to observed in patients with wean- • Physiotherapists can assist in acute respiratory complications ing failure . Since inactivity patient management from musculo-skeletal chest wall (‘ventilator-induced diaphragm dys- post-decannulation (level D). dysfunction or neuromuscular function’, VDI) is suggested as an weakness (level A). important cause of respiratory muscle • NIV/CPAP can be used in failure , and intermittent loading Emotional problems and selected patients with type 1 acute of the respiratory muscles has been communication respiratory failure, e.g., inhalation shown to attenuate respiratory mus- injury, trauma and some cle deconditioning , inspiratory Critically ill patients may experience pneumonias (level C). muscle training might be beneﬁcial feelings of anxiety, alienation and
1195panic, particularly if nursed in an ICU patient understand their condition andretained airway secretions, atelec-or high-dependency unit [76, 101]. care and appreciate their own role in tasis and avoidance of intubationThose on mechanical ventilation may pain control, e.g., patient-controlledand weaning failure. Appropriatelyexperience additional distress from analgesia, wound support during prescribed physiotherapy may im-the endotracheal tube . These movement or airway clearance, and prove outcomes and reduce the risksemotions may lead to post-traumatic strategies such as body positioning associated with intensive care, as wellstress disorder in some patients for comfort . as minimize costs.after discharge . Anxiety also The lack of systematic reviewsadversely affects recovery if not and RCTs to support or reject physio-assessed and treated . Promoting Recommendations: therapy interventions was recognizeda restful environment conducive by the Task Force, as most recom-to relaxation and sleep is a daily • Physiotherapists should ensure mendations were level C and D.challenge in critical care . treatment sessions address However, evidence-based medicinePhysiotherapists can make a valuable discomfort and anxiety as well as in the ICU is not restricted to RCTscontribution to the psychological physiological problems (level D). and meta-analyses. Other forms ofwell-being and education of the • Physiotherapists should ensure evidence, including expert opinion andcritically ill patient . Relaxation patient education is included in physiologic evidence, are also valid ininterventions can reduce anxiety treatment sessions (level D). terms of providing a basis for practiceand panic, promote sleep, and, in • Physiotherapists can consider and identifying areas where furtherturn, reduce the severity of pain massage as an intervention for research is needed to strengthen andand dyspnea. Body positioning and anxiety management and sleep advance this evidence base.repositioning are useful means of promotion (level C). Discrepancies regarding the efﬁ-achieving relaxation and reduce • Physiotherapists should include cacy of physiotherapy in clinical trialssymptoms. Breathlessness can appropriate use of therapeutic support the need to identify indica-respond favorably to positioning . touch in all treatments they tions for interventions based on anTherapeutic touch has been reported provide (level D). individual’s needs, rather than beingto promote relaxation and comfort condition dependent, and to establishin critically ill patients, which sound principles for the prescriptionin turn may enhance sleep . of speciﬁc interventions to achievePhysiotherapists, by virtue of their Summary the desired outcome. However, therehands-on treatment provided to Physiotherapists are members of the is a need to standardize pathwaysICU patients, have an opportunity interdisciplinary healthcare team for clinical decision-making andto provide such therapeutic touch. for the management of critically education, and deﬁne the professionalMassage may be useful in enhancing ill patients. For the purpose of proﬁle of ICU physiotherapists inrelaxation and reducing anxiety this review, several important more detail. Patients in the ICU haveand pain in acute and critical areas for physiotherapy in critical multiple problems that change rapidlycare . Communication is central illness were identiﬁed: physical in response to the course of illness andto patient satisfaction and physical deconditioning, neuromuscular and to medical management. Rather thanand emotional well-being . musculoskeletal complications; standardized treatment approachesThe development of post-traumatic prevention and treatment of for various conditions, the goal isstress disorder has been associated respiratory conditions; and emotional to extract principles of practice thatwith the inability to communicate problems and communication. can guide the physiotherapist’s as-effectively. Informed consent is The following problems were sessment, evaluation and prescriptiona means of empowering the patient identiﬁed as evidence-based targets of interventions and their frequentwhen highly vulnerable . for physiotherapy: deconditioning, modiﬁcation for each patient in theEducation is designed to help the muscle weakness, joint stiffness, ICU.
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