The document discusses physiotherapy techniques used in the intensive care unit (ICU). It begins by defining ICU and describing the types of ICU units. It then discusses the goals of physiotherapy in the ICU which include improving ventilation, gas exchange, secretion clearance, and mobility. The document proceeds to describe various physiotherapy techniques used to achieve these goals, including lung expansion techniques like incentive spirometry, manual hyperinflation, and positive pressure devices. It also discusses airway clearance techniques, positioning, suctioning, and active cycle of breathing.

1. ICU AND PHYSIOTHERAPY
GUIDED BY:- Ms. QUINETTE
PRESENTED BY:- SAMEEKSHA SIDHPURIA

2. INTRODUCTION
• Intensive care, also known as critical care, is a
multidisciplinary and inter-professional specialty
dedicated to the comprehensive management of
patients having, or at risk of developing acute,
life-threatening organ dysfunction.
• The primary goal of intensive care is to prevent
further physiologic deterioration while the
underlying disease is treated and resolves.

3. • Intensive care is not just a clinical specialty,
but a system of care delivered by a skilled
interprofessional team that includes
physicians, nurses, respiratory therapists,
physiotherapists, pharmacists, microbiologists,
social workers, ethicists, spiritual care, and
many others.

4. DEFINITION OF ICU
• An intensive care unit (ICU) is an organized
system for the provision of care to critically ill
patients that provides intensive and specialized
medical and nursing care, an enhanced capacity
for monitoring, and multiple modalities of
physiologic organ support to sustain life during a
period of acute organ system insufficiency.

5. TYPES OF ICU UNITS
• Neonatal intensive care unit (NICU)
• Pediatric intensive care unit (PICU)
• Coronary care unit (CCU)
• Neurological intensive care unit (NeuroICU).
• Trauma intensive care unit (Trauma ICU)
• Post-anesthesia care unit (PACU)
• High dependency unit (HDU)
• Surgical Intensive Care Unit (SICU)
• Medical Intensive Care Unit (MICU)
• Post Operative Care Unit

6. MONITORING
• Non-invasive monitoring:-
1. Temperature
2. Heart rate
3. Respiratory rate
4. Blood pressure
5. Oxygen saturation
6. End-tidal CO2

7. • Invasive monitoring
1. Arterial blood pressure
2. Central venous pressure (CVP)
3. Pulmonary
4. Capillary wedge pressure (PCWP)

8. • ECG monitoring

9. ASSESSMENT

11. ADVERSE EFFECTS OF ICU STAY
• Bed rest and immobility during critical illness
result in profound physical deconditioning.
• Skeletal muscle weakness in the intensive care
unit
• Development of neuropathy or myopathy
contributes to weaning failure
• Respiratory dysfunction
• Prolonged ventilator dependence

12. PROBLEMS IN ICU
• Decreased lung volumes/ compliance
• Decreased gas exchange
• Decreased mucociliary clearance
• Weakness of peripheral and respiratory
muscles
• Increased work of breathing

13. PHYSIOTHERAPY IN ICU
• Physical therapy in the intensive care unit
(lCU) is a specialty in itself.
• Clinical decision making in the lCU and
rational management of patients is based on a
tripod approach.

14. • General information required before treating the ICU
patient:-
1. Medical and surgical histories
2. Gender and age
3. Premorbid status (e.g., life style. ethnicity. culture,
work situation. stress, cardiopulmonary conditioning,
and oxygen transport reserve capacity)
4. Smoking history
5. Hydration and nutritional status: deficiencies.
obesity, or asthenia
6. Recency of onset and course of present condition
7. Existing or potential medical instability

15. 8. Indications or necessity for intubation and
mechanical ventilation
9. Invasive monitoring, lines, leads, and catheters
10.Existing or potential for complications and
multiorgan system failure
11.Coma
12.Elevated intracranial pressure (lCP) and the need
for ICP monitoring
13.Risk or presence and site(s) of infection
14.Quality of sleep and rest periods
15.Nutritional support during ICU stay
16.Pain control regimen

16. GOALS IN THE ICU PATIENT
• Maintain or restore adequate alveolar ventilation and
perfusion and their matching in nonaffected and
affected lung fields and thereby optimize oxygen
transport overall
• Prolong spontaneous breathing (to the extent that is
therapeutically indicated) and thereby avoid, postpone,
or minimize need for mechanical ventilation
• Minimize the work of breathing
• Minimize the work of the heart

17. • 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.
• Maximally involve the patient in a daily routine including self-
care, changing body position, standing, transferring, sitting in a
chair, and ambulating in patients for whom these activities are
indicated
• Optimize treatment outcome by interfacing physical therapy
with the goals and patient-related activities of other team
members, coordinating treatments with medication schedules.

18. PHYSIOTHERAPY TECHNIQUES
• Once a thorough assessment has been
completed, the findings must be analysed to
identify relevant physiotherapeutic problems.
• For each problem a suitable treatment plan
must be formulated taking into consideration
any potential influencing factors.

19. LUNG EXPANSION THERAPY
• All modes of lung expansion therapy increase
lung volume by increasing the transpulmonary
pressure (PTP) gradient.
• The PTP gradient can be increased by either
1. Decreasing the surrounding Ppl
2. Increasing the Palv

20. GOAL:-
• To implement a plan that provides an effective
strategy in the most efficient manner.

21. INCENTIVE SPIROMETRY
• The purpose of IS is to coach the patient to
take a sustained maximal inspiratory (SMI)
effort resulting in a decrease in Ppl and
maintaining the patency of airways at risk for
closure.
Physiologic Basis:-
• An SMI is functionally equivalent to
performing a functional residual capacity
(FRC) to inspiratory capacity (IC) maneuver,
followed by a breath hold.

22. Indications
1. Presence of pulmonary
atelectasis
2. Presence of conditions
predisposing to atelectasis
• Upper abdominal surgery
• Thoracic surgery
• Surgery in patients with COPD
3. Presence of a restrictive lung
defect associated with
quadriplegia or
dysfunctional diaphragm
Contraindications
1. Patient cannot be instructed
or supervised to ensure
appropriate use of device
2. Patient cooperation is
absent, or patient is unable
to understand or
demonstrate proper use of
device
3. Patients unable to deep
breathe effectively (VC <10
ml/kg or IC <1 3 predicted)

23. Hazards and Complications:-
1. Hyperventilation and respiratory alkalosis
2. Discomfort secondary to inadequate pain
control
3. Pulmonary barotrauma
4. Exacerbation of bronchospasm
5. Fatigue

24. Potential Outcomes:-
1. Absence of or improvement in signs of atelectasis
2. Decreased respiratory rate
3. Normal pulse rate
4. Resolution of abnormal breath sounds
5. Normal or improved chest radiograph
6. Improved PaO2 and decreased PaCO2
7. Increased SpO2
8. Increased VC and peak expiratory flows
9. Restoration of preoperative FRC or VC
10. Improved inspiratory muscle performance and cough
11. Attainment of preoperative flow and volume levels
12. Increased FVC

25. Noninvasive Ventilation
• Noninvasive ventilation (NIV) provides breathing
support to patients with inadequate ability to
ventilate.
• Variations of NIV, including IPPB and PEP therapy,
are the potentially valuable lung expansion tools.

27. Intermittent Positive Airway
Pressure Breathing
Physiologic Basis:-
• IPPB is a specialized form of NIV used for relatively
short treatment periods (approximately 15 minutes per
treatment).
• The intent of IPPB, to provide machine-assisted deep
breaths assisting the patient to deep breathe and
stimulate a cough.
• IPPB has historically consisted of providing an aerosol
under positive pressure, augmenting the patient’s own
inspiratory efforts and thus resulting in a larger tidal
volume (VT) than could be spontaneously generated.

28. Indication
1. Need to improve lung expansion
2. Presence of clinically significant
pulmonary atelectasis
3. Inability to clear secretions
4. Need for short-term noninvasive
ventilatory support for
hypercapnic patients
5. Need to deliver aerosol
medication
6. IPPB may be used to deliver
aerosol medications to patients
with ventilatory muscle
weakness or fatigue or chronic
conditions in which intermittent
noninvasive ventilatory support
is indicated.
Contraindication
1. Tension pneumothorax
2. ICP >15 mm Hg
3. Hemodynamic instability
4. Active hemoptysis
5. Tracheoesophageal fistula
6. Recent esophageal surgery
7. Active, untreated tuberculosis
8. Radiographic evidence of
blebs
9. Recent facial, oral, or skull
surgery
10. Singultus (hiccups)
11. Air swallowing
12. Nausea

29. Hazards and Complications:-
1. Increased airway resistance and work of breathing
2. Barotrauma, pneumothorax
3. Nosocomial infection
4. Hypocarbia
5. Hemoptysis
6. Gastric distention
7. Impaction of secretions (associated with inadequately
humidified gas mixture)
8. Psychologic dependence
9. Impedance of venous return
10. Exacerbation of hypoxemia
11. Hypoventilation or hyperventilation
12. Increased mismatch of ventilation and perfusion
13. Air trapping, auto-PEEP, overdistention

30. Potential Outcomes:-
1. Improved VC
2. Increased FEV1 or peak flow
3. Enhanced cough and secretion clearance
4. Improved chest radiograph
5. Improved breath sounds
6. Improved oxygenation
7. Favorable patient subjective response

31. Positive Airway Pressure Therapy
Physiologic Basis
• There are three current approaches to PAP therapy: PEP, flutter, and
CPAP.
• PEP and flutter valves create expiratory positive pressure only, whereas
CPAP maintains a positive airway pressure throughout both inspiration
and expiration.
• CPAP elevates and maintains high alveolar and airway pressures
throughout the full breathing cycle, this increases PTP gradient
throughout both inspiration and expiration.
• Typically, a patient on CPAP breathes through a pressurized circuit
against a threshold resistor, with pressures maintained between 5 cm
H2O and 20 cm H2O.

32. Indications
• Postoperative atelectasis
• Cardiogenic pulmonary
edema
• Pulmonary vascular
congestion.
• Lung compliance is
improved
Contraindications
• Hypoventilation
• Hemodynamically unstable
• Nausea
• Facial trauma
• Untreated pneumothorax
• Elevated intracranial
pressure (ICP).

33. MANUAL HYPERINFLATION
• Manual hyperinflation delivers extra volume and
oxygen to the lungs via a bag such as a rebreathing
bag.
• Manual ventilation means squeezing gas into the
patient's lungs at tidal volume, e.g. when changing
ventilator tubing.
• Manual hyperventilation delivers rapid breaths, e.g. if
the patient is breathless, hypoxaernic or hypercapnic.
• It provides deep breaths in order to increase lung
volume.

35. Beneficial effects:
1. Reversal of atelectasis
2. Sustained improvement in lung compliance and oxygen
saturation
3. Improved sputum clearance
Disadvantages:-
1. Haemodynamic and metabolic upset
2. Risk of barotrauma for certain patients
3. Discomfort and anxiety if done incorrectly.
Contraindications:-
1. Extra-alveolar air, e.g. undrained pneumothorax, bullae,
surgical emphysema.
2. Bronchospasm causing peak airway pressure above 40
cmH20.

36. POSITIONING
• Positioning is the main physiotherapy treatment for
patients in intensive care, and may be the only
intervention for some patients.
• Positioning can be used to:
1. Optimize relaxation
2. Provide pain relief
3. Improve ventilation, ventilation-perfusion matching,
and gas exchange
4. Minimize dyspnea
5. Minimize the work of breathing—i.e promote efficient
diaphragm and accessory muscle function
6. Promote airway clearance

37. Cardiovascular and Pulmonary Effects
of Different Positions:-
Upright
1. Increases FRC
2. Increases FVC
3. Decreases closing volume
4. Increases chest wall anterior-
posterior diameter
5. Decreases venous return and
cardiac output
6. Increases pooling of secretions in
the bases of the lung
7. Better basal expansion with large
inspiration
8. Decreases curvature of diaphragm
at end-expiration—especially in
those patients with weak
abdominals

38. Supine
1. Decreases chest wall AP
diameter
2. Reduces FRC
3. Pooling of secretions to the
posterior (dependent) lung
zone
4. Increases central blood volume
5. Increases airway closure
6. Increases curvature of
diaphragm at end-expiration—
especially in those with weak
abdominals

39. Side-Lying
1. Increases chest wall AP
diameter of the
dependent region
2. Increases ventilation to
the dependent region
but decreases tidal
volume and FRC
3. Theoretically speaking,
positioning the good
lung lowermost should
improve oxygenation
•

40. Prone
• Improves oxygenation in
patients with ARDS or acute
lung injury
• improved lung compliance
secondary to stabilization of
anterior chest wall,
• Improved tidal ventilation,
diphragmatic excrusion and
functional residual capacity
• Reduced airway closure

41. AIRWAY CLEARANCE THERAPY (ACT)
• Airway clearance therapy uses noninvasive techniques
designed to assist in mobilizing and removing
secretions to improve gas exchange.
• Five general approaches to ACT, which can be used
alone or in combination, include
1. CPT
2. Coughing and related expulsion techniques (including
manual insufflation-exsufflation
3. Positive expiratory pressure [PEP] devices)
4. Active cycle of breathing technique
5. mobilization and physical activity.

42. CHEST PHYSIOTHERAPY
• This therapy includes postural drainage (PD) and
percussion or vibration.
Postural drainage:-
• Postural drainage (PD) has been shown to increase
mucociliary clearance in patients by means of
measuring sputum collection dry weight, volume, or
radionuclide particles clearance rate.
• The classic postural drainage positions are designed
to drain individual segments of the lungs

45. Cough and Huff:-
• Coughing clears the larger airways of excessive
mucus and foreign matter, assists normal
mucociliary clearance, and helps ensure airway
patency.

46. • Staccato-like bursts of air against an open
glottis are referred to as huffing.
• With this technique the patient is instructed
to make the sound “huff, huff, huff” rapidly
with the mouth and glottis open.

47. ACTIVE CYCLE OF BREATHING TECHNIQUE

48. SUCTIONING
• Suctioning is the application of negative pressure
(vacuum) to the airways through a collecting tube
(flexible catheter or suction tip).
• Suctioning can be performed by way of either the
upper airway (oropharynx) or the lower airway
(trachea and bronchi).
• Secretions or fluids also can be removed from the
oropharynx by using a rigid tonsillar or Yankauer
suction tip.

49. • Access to the lower airway is by introduction
of a flexible suction catheter through the nose
(nasotracheal suctioning) or artificial airway
(endotracheal suctioning).
• Tracheal suctioning through the mouth should
be avoided because it causes gagging.

50. • Endotracheal Suctioning

51. • Closed suctioning:-
Mechanically ventilated patients,
especially neonates and patients
with:
1. Positive end expiratory pressure
≥10 cm H2O
2. Mean airway pressure ≥20 cm
H2O
3. Inspiratory time ≥1.5 seconds
4. FiO2 ≥0.60
5. Frequent suctioning (≥6
times/day)
6. Hemodynamic instability
associated with ventilator
disconnection
7. Respiratory infections requiring
airborne or droplet precautions
8. Inhaled agents that cannot be
interrupted by ventilator
disconnection (e.g., nitric oxide,
helium/oxygen mixture)

52. • Nasotracheal Suctioning

54. POSITIVE EXPIRATORY PRESSURE
• Positive expiratory pressure includes one way
breathing valve and an adjustable level of
expiratory resistance that create back pressure to
stent the airways opening during exhalation.
• PEP therapy involves active expiration against a
fixed orifice flow resistor or variable orifice
threshold resistor capable of developing pressure
of 10-20cm H2O

55. • PEP breathing reinflates collapsed alveoli by
allowing air to be redistributed through
collateral channels- the pores of Kohn, and the
Lambert canals- allowing pressure to build up
distal to the obstruction and promoting the
movement of secretion toward the larger
airways.
• Low pressure PEP resistance is regulated to
achieve 10-20cm H2O during slightly active
expiration.

56. • High pressure PEP use the same principle but at
much higher levels of pressure (50-120cm H2O).

57. • Oscillating PEP provide positive expiratory
pressure, oscillation of the airway and
accelerated expiratory flow rate to loose
secretion and move secretion centrally.

59. MOBILIZATION
• Reductions in functional performance, exercise
capacity, and quality of life in ICU survivors indicate
the need for rehabilitation following ICU stay.
• It is important to prevent or attenuate muscle
deconditioning as early as possible in patients with
an expected prolonged bed rest.
• Intensive care unit-acquired weakness (ICUAW) is
observed in a substantial proportion of patients
receiving MV for more than 1 week in the ICU.

61. Indications:-
1. Atelectasis
2. Pulmonary consolidation
3. Pulmonary intiltrates
4. Bronchopulmonary and lobar pneumonias
5. Bronchiolitis
6. Alveolitis
7. Pleural effusions
8. Acute lung injury and pulmonary edema
9. Hemothorax
10. Pneumothorax
11. Cardiopulmonary insufficiency
12. Cardiopulmonary sequelae of surgery
13. Cardiopulmonary sequelae of immobility

62. Contraindications:-
1. Terminal diseases
2. Systolic hypertension > 170mmhg
3. Spo2 < 90%
4. Intracranial hypertension
5. Unstable fractures
6. Recent acute myocardial infarction
7. Open abdominal wounds
8. Heart rate reduction of 20% or more during early
mobilization activities.
9. Deep cognitive and neurological deficits

63. • The etiology includes deconditioning and disuse
atrophy due to prolonged bed rest and
immobility, and critical illness polyneuropathy
and/or myopathy, known as critical illness
neuromyopathy.
• Other risk factors for ICUAW include the
systemic inflammatory response syndrome,
sepsis, and multiple organ dysfunction
syndrome; hyperglycemia; and medications,
such as use of corticosteroids and
neuromuscular blocking agents

66. Passive mobilization:-
• Patient unable to follow commands and actively
participate in mobilization are suitable for passive
mobilization (ie, hoist transfer to sit-out-of-bed).
• Patients who are sedated and unresponsive may
benefit from the high sitting position in an
appropriate chair to potentially minimize
orthostatic intolerance
• A portable sling lifter for mobilization is feasible

67. Active mobilization:-
• Phase 1 can involve sitting balance retraining (eg,
reaching and returning to midline from the bed
or chair), strength training including the use of
weights or slings, and/ or treatment on the tilt
table.
• A patient will remain in this phase until they
achieve adequate sitting balance and lower limb
strength to progress to “phase 2 mobilization”.
• If patient is not able to stand with the assistance
the “supported weight-bearing” phase, which
involves the use of a gait harness to facilitate
mobilization.

69. • If the patient is able to stand with the
assistance the “active weight-bearing phase”
facilitated

71. • Early mobilization can be performed also in
unconscious or sedated patients.
Acutely ill, uncooperative patients
• Treated with modalities such as
1. Passive range of motion,
2. Muscle stretching,
3. Splinting,
4. Body positioning,
5. Passive cycling with a bed cycle,
6. Electrical muscle stimulation

72. The stable cooperative patient (on mechanical
ventilation)
1. Mobilized on the edge of the bed,
2. Transfer to a chair,
3. Perform resistance muscle training
4. Active cycling with a bed cycle or chair cycle
5. Walk with or without assistance.
The uncooperative critically ill patient
1. Needs to be positioned upright (well supported),
and rotated when recumbent.
2. Passive stretching or range of motion exercise

73. The cooperative critically ill patient
1. Mobilization strategies –in order of intensity-
include:-
• Transferring in bed
• Sitting over the edge of the bed
• Moving from bed to chair,
• Standing,
• Stepping in place
• Walking with or without support.
2. standing aids, and tilt tables, enhance physiological
responses

76. MOBILIZING AN INVASIVELY
MECHANICALLY VENTILATED PATIENT

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81. THANK YOU