Physiotherapy for Critically ill patients

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Physiotherapy for Critically ill patients

  1. 1. MANAGING CRITICALLYMANAGING CRITICALLYILL PATIENTSILL PATIENTS–– A Physiotherapist’sA Physiotherapist’sperspectiveperspective
  2. 2. Chest Physiotherapy is…Chest Physiotherapy is…A treatment intervention employed for improvingA treatment intervention employed for improvingpulmonary hygiene including positioning, chestpulmonary hygiene including positioning, chestpercussion, vibration and manual hyperinflation topercussion, vibration and manual hyperinflation toassist in mobilizing secretions in the lungs from theassist in mobilizing secretions in the lungs from theperipheral airways into the more central airways soperipheral airways into the more central airways sothat they can be expectorated or suctioned.that they can be expectorated or suctioned.
  3. 3. Aims of this presentation…Aims of this presentation… To describe the individual physiotherapeuticTo describe the individual physiotherapeutictechniques.techniques. To provide a frame work for evidence basedTo provide a frame work for evidence basedpractice.practice.
  4. 4. IndicationsIndications PROPHYLACTICPROPHYLACTIC-- Pre-operative high risk surgical patientPre-operative high risk surgical patient- Post-operative patient who is unable to- Post-operative patient who is unable tomobilize secretionsmobilize secretions- Neurological patient who is unable to cough- Neurological patient who is unable to cougheffectivelyeffectively- Patient receiving mechanical ventilation who has a- Patient receiving mechanical ventilation who has atendency to retain secretionstendency to retain secretions- Patients with pulmonary disease,- Patients with pulmonary disease,who needs to improve bronchial hygienewho needs to improve bronchial hygiene
  5. 5. ……contdcontd THERAPEUTICTHERAPEUTIC-- Atelectasis due to secretionsAtelectasis due to secretions- Retained secretions- Retained secretions- abnormal breathing pattern due to primary or- abnormal breathing pattern due to primary orsecondary pulmonary dysfunctionsecondary pulmonary dysfunction- COPD and resultant decreased exercise- COPD and resultant decreased exercisetolerancetolerance- Musculoskeletal deformity that makes breathing- Musculoskeletal deformity that makes breathingpattern and cough ineffectivepattern and cough ineffective
  6. 6. AssessmentAssessmentGeneral ObservationGeneral Observation Patient PositionPatient PositionRespirationRespiration -- AirwayAirway ET/TracheostomyET/TracheostomyVentillatorVentillator ModeModeFiOFiO22VitalVital Signs – Temperature, BSigns – Temperature, BP,P, RR, HR SpORR, HR SpO2,2,GCS, ICPGCS, ICP Tubes - NG Tube, CV line, Peripheral line, Chest tubes,Tubes - NG Tube, CV line, Peripheral line, Chest tubes,CathetersCatheters DrugsDrugs
  7. 7. …… contdcontdExaminationExamination AuscultationsAuscultations Respiratory patternRespiratory pattern CyanosisCyanosis ClubbingClubbing RadiographRadiograph
  8. 8. GoalsGoals Prevent accumulation of secretionsPrevent accumulation of secretions Improve mobilization and drainage ofImprove mobilization and drainage ofsecretionssecretions Promote relaxation to improve breathingPromote relaxation to improve breathingpatternspatterns Promote improved respiratory functionPromote improved respiratory function Improve cardio-pulmonary exerciseImprove cardio-pulmonary exercisetolerancetolerance Teach bronchial hygiene programs toTeach bronchial hygiene programs topatients with chronic respiratory dysfunctionpatients with chronic respiratory dysfunction
  9. 9. PrecautionsPrecautionsUntreatedUntreated tension pneumothoraxtension pneumothorax Abnormal coagulation profileAbnormal coagulation profile Status epilepticus or status asthamaticusStatus epilepticus or status asthamaticus Immediately following intra cranial surgeryImmediately following intra cranial surgery Head injury with raised ICPHead injury with raised ICP Osteoporotic bonesOsteoporotic bones Recent acute myocardial infarction, unstable vitalsRecent acute myocardial infarction, unstable vitals Immediately after tube feedingsImmediately after tube feedings Sutures and ICD’sSutures and ICD’s
  10. 10. TechniquesTechniques PositioningPositioning Chest tapotement techniquesChest tapotement techniques Manual hyperinflationManual hyperinflation Airway suctioningAirway suctioning Coughing techniquesCoughing techniques Breathing exercisesBreathing exercises Neuro physiological facilitationNeuro physiological facilitation Controlled mobilizationControlled mobilization Patient educationPatient education
  11. 11. PositioningPositioning POSITIONING is the use of body position as aPOSITIONING is the use of body position as aspecific treatment techniquespecific treatment technique ((it has a marked influence on gas exchangeit has a marked influence on gas exchangebecause of the unevenly damaged lungs- Tobin etbecause of the unevenly damaged lungs- Tobin etal, 1994)al, 1994)
  12. 12. Positioning…Positioning…Physiological effects ofPhysiological effects ofPositioningPositioning Optimizes oxygen transport by improvingOptimizes oxygen transport by improvingV/Q mismatchV/Q mismatch Increases lung volumesIncreases lung volumes Reduces the work of breathingReduces the work of breathing Minimizes the work of heartMinimizes the work of heart Enhances mucociliary clearance (posturalEnhances mucociliary clearance (posturaldrainage)drainage)
  13. 13. Postural DrainagePostural Drainage isn’t…isn’t… a separate technique. Its just an example ofa separate technique. Its just an example ofpositioning which has the particular aim of clearingpositioning which has the particular aim of clearingairway secretions with the assistance of gravity.airway secretions with the assistance of gravity.
  14. 14.  Patients are positioned with the area to be drainedPatients are positioned with the area to be drainedthe upper most, but modifications should be donethe upper most, but modifications should be donewherever necessary.wherever necessary. Drainage times vary, but ideally each positionDrainage times vary, but ideally each positionrequires 10 minutes (gumery et al, 2001).requires 10 minutes (gumery et al, 2001).
  15. 15. PositioningPositioning Positioning restores ventilation to dependent lungPositioning restores ventilation to dependent lungregions more effectively than PEEP or large tidalregions more effectively than PEEP or large tidalvolumesvolumes (Froese & Bryan, 1974).(Froese & Bryan, 1974). Positioning has a marked influence on gasPositioning has a marked influence on gasexchange because of unevenly damaged lungsexchange because of unevenly damaged lungs(Tobin, 1994).(Tobin, 1994). Side lying reduces lung densities in the upper mostSide lying reduces lung densities in the upper mostlunglung (Brismar, 1985).(Brismar, 1985). Right side lying may be more beneficial for cardiacRight side lying may be more beneficial for cardiacoutput than left side lyingoutput than left side lying (Wong, 1998).(Wong, 1998). Simply turning from supine to side lying can clearSimply turning from supine to side lying can clearatelectasis from dependent regionsatelectasis from dependent regions (Brismar, 1985).(Brismar, 1985).
  16. 16. ……contdcontd Positioning affects lung volumePositioning affects lung volume Lung volume is related to the position of theLung volume is related to the position of thediaphragmdiaphragm FRC decreases from standing to slumped sitting toFRC decreases from standing to slumped sitting tosupinesupine (Macnaughton, 1995)(Macnaughton, 1995)
  17. 17. ……contdcontd Positioning affects compliancePositioning affects compliance (Wahba et al found that(Wahba et al found thatwork of breathing is 40% higher in supine than in sitting)work of breathing is 40% higher in supine than in sitting) Positioning affects arterial oxygenation byPositioning affects arterial oxygenation byimproving V/Q mismatchimproving V/Q mismatch (V/Q is usually mismatched if(V/Q is usually mismatched ifthe affected lung is dependent- Gillespie et al)the affected lung is dependent- Gillespie et al)““Bad lung up” positionBad lung up” position
  18. 18. Positioning…Positioning… Which position to choose…Which position to choose…??
  19. 19. What does evidence say…What does evidence say…1. lung volume by 57% (Rialp et al., 1997).1. lung volume by 57% (Rialp et al., 1997).2. need for PEEP (Lim et al., 1999).2. need for PEEP (Lim et al., 1999).3. normal V/Q units by 12%3. normal V/Q units by 12%4. shunt by 11% (Wong 1999)4. shunt by 11% (Wong 1999)5. barotrauma (Du et al., 1997)5. barotrauma (Du et al., 1997)6. drainage of secretions (Kesecioglu, 1997)6. drainage of secretions (Kesecioglu, 1997)7. length of ICU stay. (Gosheron, 1998)7. length of ICU stay. (Gosheron, 1998)
  20. 20. Chest TapotementChest Tapotement Chest VibrationsChest Vibrations Rib Springing/ShakingRib Springing/Shaking Chest Percussion/ClappingChest Percussion/Clapping
  21. 21. Clapping/Chest PercussionClapping/Chest Percussion Percussion consists of rhythmic clapping on thePercussion consists of rhythmic clapping on thechest with loose wrist & cupped hand.chest with loose wrist & cupped hand. Effect : Dislodges & loosens secretions from theEffect : Dislodges & loosens secretions from thelunglung
  22. 22. Chest VibrationChest Vibration Vibrations consists of a fine oscillation of the handsVibrations consists of a fine oscillation of the handsdirected inwards against the chest, performed ondirected inwards against the chest, performed onexhalation after deep inhalation.exhalation after deep inhalation. Effects: Helpful in moving loosened mucous plugsEffects: Helpful in moving loosened mucous plugstowards larger airwaytowards larger airway
  23. 23. Rib Springing/ShakingRib Springing/Shaking Shaking is a coarser movement in which the chestShaking is a coarser movement in which the chestwall is rhythmically compressed.wall is rhythmically compressed. Effects : Direct secretions towards larger airways &Effects : Direct secretions towards larger airways &Stimulates cough.Stimulates cough.
  24. 24. Manual HyperinflationManual Hyperinflation Was originally defined as inflating the lungs withWas originally defined as inflating the lungs withoxygen and manual compression to a tidal volumeoxygen and manual compression to a tidal volumeof 1 liter requiring a peak inspiratory pressure ofof 1 liter requiring a peak inspiratory pressure ofbetween 20 and 40 cm H2Obetween 20 and 40 cm H2O (Med j Aust, 1972).(Med j Aust, 1972). More recent definitions include providing a largerMore recent definitions include providing a largertidal volume than base line tidal volume to thetidal volume than base line tidal volume to thepatientpatient (Aust j physiotherapy, 1996)(Aust j physiotherapy, 1996) and using a tidaland using a tidalvolume which is 50% greater than that delivered thevolume which is 50% greater than that delivered theventilatorventilator (chest, 1994).(chest, 1994).
  25. 25. Advantages of MHAdvantages of MHReverses atelectasisReverses atelectasis (Lumb 2000)(Lumb 2000) Improves oxygen saturation and lung complianceImproves oxygen saturation and lung compliance(Patman et al.,1999)(Patman et al.,1999) Improves sputum clearanceImproves sputum clearance (Hodgson et al., 2000)(Hodgson et al., 2000)
  26. 26. Disadvantages of MHDisadvantages of MHHaemodynamic and metabolic upsetHaemodynamic and metabolic upset (Stone, 1991 &(Stone, 1991 &Singer et al.,1994)Singer et al.,1994) Risk of barotraumaRisk of barotrauma Discomfort and anxietyDiscomfort and anxiety
  27. 27. Coughing TechniquesCoughing Techniques Coughing:Coughing: It is a forced expiratory techniqueIt is a forced expiratory techniqueperformed with a closed glottis.performed with a closed glottis. Huffing:Huffing: It is a forced expiratory techniqueIt is a forced expiratory techniqueperformed with a open glottis.performed with a open glottis. Sniffing:Sniffing: Its an respiratory maneuver performedIts an respiratory maneuver performedafter a full inspiration or expiration.after a full inspiration or expiration.
  28. 28. Effects of CoughingEffects of Coughing Cough removes secretions from the larger airwaysCough removes secretions from the larger airways Huff mobilizes the secretions from the distalHuff mobilizes the secretions from the distalairways.airways. During a huff the pleural pressure becomes positiveDuring a huff the pleural pressure becomes positiveand equals the alveolar pressure and so it opensand equals the alveolar pressure and so it opensup the distal collapsed airway.up the distal collapsed airway. Sniff augments collateral ventilation therebySniff augments collateral ventilation therebypreventing distal airway collapse.preventing distal airway collapse.
  29. 29. Breathing ExercisesBreathing Exercises Diaphragmatic breathingDiaphragmatic breathing- concentrates on epigastric and lower rib- concentrates on epigastric and lower ribmovements( gaskell & webber, 1980).movements( gaskell & webber, 1980).- concentrates on allowing the whole abdomen- concentrates on allowing the whole abdomento swell as diaphragm descends (innocenti, 1966).to swell as diaphragm descends (innocenti, 1966).
  30. 30. Breathing TechniquesBreathing TechniquesCostal breathingCostal breathing- Is a technique which concentrates on- Is a technique which concentrates onventilation to specific areas of lungs.ventilation to specific areas of lungs.- In this technique during inspiration the chest- In this technique during inspiration the chestwall moves up and out.wall moves up and out.- This technique can be localized to any- This technique can be localized to anyinvolved segments of the lung.involved segments of the lung. GlossopharyngealGlossopharyngeal Pursed LipPursed Lip
  31. 31. SuctioningSuctioning Suctioning is the mechanical aspiration ofSuctioning is the mechanical aspiration ofpulmonary secretions from a patient with an artificialpulmonary secretions from a patient with an artificialairway in place.airway in place. cirteria for suctioning:cirteria for suctioning:1) secretions are accessible to the catheter.1) secretions are accessible to the catheter.2) secretions are detrimental to the patient.2) secretions are detrimental to the patient.3) patient is unable to clear secretions by other3) patient is unable to clear secretions by othermeans.means.
  32. 32. Neuro Physiological FacilitationNeuro Physiological Facilitation(NPF)(NPF) promoting or hastening the response of neuropromoting or hastening the response of neuromuscular mechanism through proprioceptorsmuscular mechanism through proprioceptors(dorothy voss et al, 1985).(dorothy voss et al, 1985). Cutaneous and proprioceptive stimulation reflexlyCutaneous and proprioceptive stimulation reflexlyincreases the depth of breathingincreases the depth of breathing (Jones, 1998).(Jones, 1998).INDICATIONS:INDICATIONS: Non alert patients such as those who are drowsyNon alert patients such as those who are drowsypostoperatively.postoperatively. Those with neurological conditions.Those with neurological conditions. Partially breathing patient on ventilator, especially ifPartially breathing patient on ventilator, especially ifthey are unable to turn.they are unable to turn.
  33. 33. Techniques of NPFTechniques of NPF Stimulation of diaphragmStimulation of diaphragm(Dorothy voss et al, 1985).(Dorothy voss et al, 1985). Perioral techniquePerioral technique Intercostal stretchIntercostal stretch Co- contraction of abdominal musclesCo- contraction of abdominal muscles Vertebral pressureVertebral pressure(D.D .Bethune,(D.D .Bethune, 1975)1975)
  34. 34. MobilisationMobilisation ICU rehabilitation has been shown to accelerate recoveryICU rehabilitation has been shown to accelerate recovery(o’leary & coackley, 1996)(o’leary & coackley, 1996) Early mobilization for unconscious patients starts right fromEarly mobilization for unconscious patients starts right fromturning the patient every two hours. ( Brooks- brunn, 1995).turning the patient every two hours. ( Brooks- brunn, 1995). Graded exercises can be started as soon as the patientGraded exercises can be started as soon as the patientregains consciousness.regains consciousness. Activity is required to maintain sensory input, comfort, jointActivity is required to maintain sensory input, comfort, jointmobility and healing ability (Frank et al, 1994).mobility and healing ability (Frank et al, 1994). Activity minimizes the weakness caused by loss of upto halfActivity minimizes the weakness caused by loss of upto halfthe patients muscle mass (Griffiths & Jones, 1999).the patients muscle mass (Griffiths & Jones, 1999). Graded ambulation can be started depending on patientsGraded ambulation can be started depending on patientsconditioncondition
  35. 35. MobilisationMobilisation Critically IllCritically Ill (Frequent Position changes, Kinetic(Frequent Position changes, Kinetic& Kinematic Therapy)& Kinematic Therapy) StableStable (Progressive tilting(Progressive tilting && Ambulation)Ambulation)
  36. 36. ConclusionConclusionA hammer in a carpenter’sA hammer in a carpenter’shand is not used to pull outhand is not used to pull outa nail…a nail…
  37. 37. ThankThankyouyou

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