Hold the ET tube securely. Implementation continued...  Apply suction by occluding the suction control port with finger and withdraw catheter slowly while applying suction.  Suction for no more than 10 seconds each pass.  Repeat suctioning until secretions are cleared.

1. ICU PROTOCOL

2. INTRODUCTION
 An ICU, is a specialized section of
a hospital that provides
comprehensive and continuous
care for persons who are critically
ill and who can benefit from
treatment.

3.  An ICU is a specially staffed and
equipped area of a hospital
dedicated to the management of
patients with life threatening
illness , injuries or complications.

4. SPECIALIZED ICUs
• Coronary Care Unit
(CCU)
• Medical Intensive
Care Unit (MICU)
• Surgical Intensive
Care Unit
• Neonatal Intensive
Care Unit (NICU)
• Burn Wounds
Intensive Care
Unit (BWICU)
• Neurological
Critical Care Unit
(NCCU),

5. CLASSIFICATION OF ICU
 Level I: Close monitoring,
resuscitation, and short term
ventilation <24hrs has to be
performed.
 Level II : Undertake more prolonged
ventilation.
 Level III: Provides all aspects of
intensive care required and all
complex procedures undertaken.

6. SEVERITY SCORING SYSTEM
 Glasgow Coma Scale
 APACHE II
 PIM 2
 SAPS II
 SAPS III
 SOFA

7. DESIGN OF ICU
 Single entry and exit
 Adequate and appropriate lighting for
clinical observation
 Sited in close proximity to relevant
acute areas
 Doors should be spacious enough to
allow easy passage of beds and
equipment

8.  All central staff and patient areas must
have large clean windows
 Air conditioning and heating with an
emphasis on patient comfort
 Utility rooms must be clean and separate
each with its own access
 A good communication network of
phones/intercom .

10. STAFFING IN ICU
1. Medical staff
Medical director
Junior doctor (anes, med, sur)
2. Nursing staff (1:1)
3. Allied health
Physiotherapist
Dietician
Pharmacist
Respiratory therapist
Pathologist & Radiologist

11. EQUIPMENTS IN ICU
 A mobile bed
 Central O2 and Suction lines
 Defibrillator
 Infusion Pump
 Mechanical Ventilator
 Pulse Oximeter
 Nebulizer
 Equipment for ETT

12.  Humidifiers
 Cardiac Emergency Trolley
 Spirometer
 IV fluids
 Drugs
 Crash cart

13. MONITORING IN ICU
 PURPOSE
◦ To measure in “real time” physiologic values
that can change rapidly
◦ The best monitor is patients care giver,
nurse and physician
• Monitors are used for
1.Continuous monitoring
2.Measurement of values that care givers
cannot detect – e.g. airway pressure

14. Monitoring is divided into
 Respiratory monitoring
 Cardiac and cardiovascular monitoring
 Neurological monitoring
 Renal, Liver monitoring
 Nutritional monitoring
 Global indices monitoring

15.  Respiratory monitoring
-ABG
-Pulse oximetry
-O2 consumption
-Alveolar Arterial O2 tension

16.  Cardiovascular monitoring
-HR
-Arterial BP
-ECG
-CVP
-Mean pulmonary arterial pressure
-Pulmonary capillary wedge pressure
-Cardiac output
-Cardiac index
-Systemic vascular resistance
-Pulmonary vascular resistance

17.  Neurologic monitoring
-Mental status
-Pupillary response
-Eye movement assessment
-Corneal response
-Gag reflex
-Respiratory rate/pattern
-General motor and sensory evaluation

18.  Monitoring renal function
-Urine volume
-Electrolyte composition of body fluids
 Monitoring liver function
-Liver function test
 Nutritional monitoring
 Global monitoring indices
-APACHE(Acute Physiology And Chronic
Health Evaluation)

19. VENTILATORY
MONITORING
Parameters thus evaluated are :
- Ventilation
- Airway pressure
- Respiratory quotient (Vco2 / Vo2=0.8
normally)
- Respiratory rate

20. - I:E ratio
- FiO2
- Dynamic pulmonary compliance
curves : derived from continuous
measurements of airway pressure and
volume curves
- Maximal inspiratory strength
- PEEP and CPAP

22. HUMIDIFICATION
 Humidity therapy involves adding water
vapor and (sometimes) heat to the
inspired gas.
 TYPES :
◦ Bubble humidifiers
◦ Passover humidifiers
◦ Heat and moisture exchangers

23. Indications of Humidifier
 Primary
◦ Humidifying dry medical gases
◦ To overcome humidity deficit when upper
airway is bypassed
 Secondary
◦ Managing hypothermia
◦ Treating bronchospasm caused by cold
air

24. COMPLICATIONS OF
HUMIDIFICATION
 Rise in core temperature and airway burns
 Imposed work of breathing
 Nosocomial respiratory tract infection
 Electrical hazard

26. OXYGEN THERAPY
 It is the administration of oxygen as a
therapeutic modality.
 Benefits the patient by increasing the
supply of oxygen to the lungs and thereby
increasing the availability of oxygen to the
body tissues.

27. INDICATIONS OF O2
THERAPY:
 Documented hypoxemia
 Severe respiratory distress
 Severe trauma
 COPD
 Pulmonary hypertension
 Acute myocardial infarction
 Short-term therapy- post-anesthesia
recovery

28. HAZARDS OF OXYGEN
THERAPY
 Respiratory depression
 Oxygen toxicity
 Absorption atelectasis
 Ciliary or leukocyte depression
 Bacterial contamination

29. Oxygen delivery system
Three basic designs
-Low flow systems
 Nasal cannula , Nasal catheter ,Tran tracheal
catheter
-Reservoir systems
 Reservoir cannulas , Masks and
nonrebreathing circuits
-High flow systems
 Air entrainment masks and nebulizers

30. Venturi mask
Is a medical device to deliver a known O2
concentration to patient on controlled O2
therapy.
Blue-24%
White-28%
Orange-31%
Yellow-35%
Red-40%
Green-60%

31. MECHANICAL VENTILATION
 The use of a machine to take over
active breathing for a patient.
 It is used when a patient can no
longer breath on his own due to
injury, illness, or general
anesthesia during surgery .

32. Indications of Mechanical
Ventilation
1) CNS disorders
-Depressant drugs e.g. barbiturates
-Brain or brainstem lesion
2) Neuromuscular function disorders
-Paralytic disorders e.g. poliomyelitis
3) Increased work of breathing
-Increased airway resistance e.g.
asthma

33. CLASSIFICATION OF
VENTILATORS
 Time cycled ventilator: - Time
delivery of gas flow
- Delivers relatively constant Tidal
Volume;
- Allows precise control of gas delivery

34. Volume Cycled Ventilator
- Inspiratory gas flow terminated after
preselected volume delivery .
- Pressure in circuit determined by tidal
volume and Compliance
- Delivered Tidal volume changes with
changes in Compliance

35. Pressure cycled
ventilators:
- Gas flow continues until preset pressure
develops
- Tidal volume = Flow rate x Time until
pressure is reached
- Variable volume if circuit pressure varies
(change in Compliance)

36. High Frequency
Ventilators:
3 types:
1) Positive pressure ventilation
2) Jet ventilation
3) Oscillation ventilation
- Advantages: -
Lower Mean airway
pressure
Lung volume is increased

37. MODES OF VENTILATION
 Control Mode (CMV)
 The Ventilator is responsible for the
initiation and delivery of each tidal
volume
 The Ventilator sets both rate and
volume no spontaneous breaths
delivered . Ventilator does all the work
of breathing for patient

38. Assist mode
 The patient is totally responsible for
initiation of the inspiratory phase, but
the ventilator delivers the volume
 Patient totally sets rate

39. Assist/Control ventilation
 Ventilator functions in the assist mode
unless the patient’s rate falls below a
preset rate, at which time the
ventilator converts to the control mode
 All volumes are ventilator delivered,
patient sets rate

40. IMV (Intermittent Mandatory
Ventilation)
 Periodic ventilation with positive pressure,
with the patient breathing spontaneously
between breaths
 Periodic breaths are time triggered

41. SIMV (Synchronized Intermittent
Mandatory Ventilation)
 Here patient is guaranteed a preset
number of breaths of a preset
VT .
 Between mandatory breaths patient
initiates spontaneous breaths.
 Periodic breaths are patient triggered

42. COMPLICATIONS OF
MECHANICAL VENTILATION
- Ventilator associated pneumonia
- Atelectasis
- Barotrauma
- Tracheal stenosis
- O2 toxicity
- Ongoing ventilation - pneumothorax ,

43. WEANING FROM
VENTILATOR
Weaning: Gradual reduction in the level
of ventilatory support
Ventilator discontinuation: Process of
disconnecting the patient from
mechanical ventilatory support

44. Benefits
- Minimizing iatrogenic complications.
- Minimizing the duration of ICU stay
- Preventing atrophy of inspiratory
muscles

45. CRITERIA FOR WEANING
 Underlying disease process that
necessitated ventilation has resolved
or improved.
 Afebrile, conscious and coherent.
 Stable Cardiovascular Function:
a) HR <140/min
b) Absence of myocardial
ischaemia
c) Absence of vasopressors
 Hb>8 g%

46. -PaO2 >60 mm Hg or more
-FiO2 0.40 to 0.50 or less
-PEEP 5 to 8 cm H2O or less
-PaO2/FiO2 ratio > 200
-pH of 7.25 or greater
-Absence of clinical signs of respiratory distress
-Cardio logical and neurological status should be
stable

47. ROLE OF
PHYSIOTHERAPY
IN ICU

48.  Optimization of cardiopulmonary function
 Early rehabilitation / mobilization - preventing
the consequences of immobility
 Positioning to protect joints, minimise potentia
muscle, soft tissue shortening and nerve
damage
 Voluntary movement to promote functional
independence and improve exercise tolerance

49. Airway Clearance
Technique
o It is defined as manual or mechanical
procedures that facilitate clearance of
secretions from the airways
Techniques :
Postural drainage
Percussion and Vibration
Cough techniques
 Manual hyperinflation
Airway suctioning

50. Goals of airway clearance
technique:
-To optimize airway patency
-Increase ventilation and perfusion
matching
-Promote alveolar expansion and
ventilation
-Increase gas exchange

51. POSTURAL DRAINAGE
Means of mobilizing secretions in one
or more lung segments to the central
airways by placing the patient in
various positions so that gravity
assists in the drainage process.

53. Goals of Postural Drainage
1) Prevent Accumulation of secretions in:
 Prolonged bed rest.
 Pulmonary diseases - chronic bronchitis and
cystic fibrosis.
 Pt’s on ventilator ( stable enough to tolerate
the treatment).
 After receiving GA.

54. 2 ) Remove Accumulated secretions:
 Generally very weak or elderly.
Acute or chronic lung diseases –
• Pneumonia
• Atelectasis
• Acute lung infections
• COPD.

55. INDICATIONS :
 Difficulty clearing secretions,
increased sputum production
 Retained secretions - artificial airway
 Atelectasis caused by mucus plugging
 Diseases - cystic fibrosis,
bronchiectasis .

56. Contraindications to
Postural Drainage:
 Severe hemoptysis.
 Untreated Acute conditions.
◦ Severe pulmonary edema.
◦ CHF.
◦ Large pleural Effusion.
◦ Pneumothorax.
◦ Pulmonary Embolism .

57. Contraindications to PD…
 Cardiovascular Instability.
◦ Cardiac arrhythmia.
◦ Severe hypertension or hypotension.
◦ Recent MI.
◦ Unstable Angina.
 Recent Neurosurgery .
◦ Head down positioning - increased intracranial
pressure .

58. COMPLICATIONS OF PD
- Hypoxemia
- Increased ICP
- Hypotension
- Pulmonary hemorrhage
- Pain or injury to muscles, ribs, spine
- Vomiting or aspiration
- Bronchospasm
- Arrhythmia

59. PERCUSSION
 It is used to further mobilize
secretions by mechanically dislodging
viscous or adherent mucus from the
lungs.
 Manual percussion consists of a
rhythmical clapping with cupped
hands over the affected lung segment.

61. Contraindications to
percussion
◦ Tumor area.
◦ Fracture, spinal fusion or osteoporotic bone.
◦ Unstable angina.
◦ Hemorrhage could easily occur ex: low platelet
count, Pt receiving anticoagulation therapy.
◦ Chest wall pain ex: after thoracic surgery or trauma

62. VIBRATION
 Vibration can be performed mechanically or
manually.
 At the end of a deep inspiration, the clinicia
exerts pressure on the patient’s chest wall an
gentle oscillates it through the end of expiratio

65. COUGHING
 An effective cough is necessary to eliminate
respiratory obstructions and keep the lungs
clear.
The cough mechanism-
 Deep inspiration .
 Glottis closes n vocal cords tighten.
 Abdominal muscles contract and the diaphragm
elevates
 Sudden opening of glottis n forceful expulsion.

66. COMPLICATIONS
 Respiratory- bronchoconstriction,
barotraumas, trauma to airways and
larynx
 Hemodynamic- Decreased venous
return
 Cerebral- syncope, raised ICP
 Chest wall - rib #, rupture rectus ab.
 Miscellaneous - urinary incontinence,
pulmonary embolism .

68. BREATHING EXERCISES
 Breathing exercises are
fundamental interventions for the
prevention or comprehensive
management of acute or chronic
pulmonary disorders.

69. Breathing exercise
indications
Obstructive lung disease
-Diaphragmatic
-Pursed lip
-Breathing control
After surgery
-Diaphragmatic
-Costal excursion exercises

70. Goals of Breathing
Exercises
 Improve or redistribute ventilation.
 Prevent postoperative pulmonary
complications.
 Relaxation and relieve stress.
 Deal with episodes of dyspnea.
 Correct inefficient or abnormal
breathing patterns, decrease the WOB
etc…

71. SUCTIONING
 Suctioning involves application of
negative pressure (vacuum) to the
airways through a collecting tube.
 Suction Pressure:
Adults .......... - 120 to -100 mm of Hg.
Pediatrics….. - 80 to - 60 mm of Hg.

72. Purpose of suctioning
To assist in the removal of bronchial
secretions that cannot be expectorated by
the patient spontaneously.
INDICATIONS:
 Visible presence of secretions in tube orifice
 Coarse tubular breath sounds on auscultation -
unable to cough or without artificial airway
 Patient with an artificial airway.

73. Equipments required
• Sub-micron mask
• Suction Equipment
• Connective tubing
• 02 flow meter
• Resuscitation bag
• Sterile suction
catheter
• Sterile gloves
• Sterile cup (if
needed)
• Sterile H20
• Stethoscope
• Normal saline

74. PROCEDURE:
Preparation:
 Review patients chart for physicians order
 Identify the patient by comparing hospital
number
 Examine and auscultate patient
 Assemble equipments
 Identify yourself and your department
 Inform the patient/ family of procedure and
purpose

75. IMPLEMENTATION:
 Wash hands and apply personal
protective equipments.
 Adjust vacuum.
 Position the patient.
 Open suction catheter, attach to
connective tubing.
 Check heart rate before, during and
after procedure.

76. Implementation continued …
 Place sterile gloves on both hands.
 Remove suction catheter from
envelope.
 Hyper oxygenate with a AMBU bag or
mechanical ventilation.
 Insert catheter to the point of
restriction without applying suction.

77. Implementation continued …
 Once catheter has been placed in
trachea, slowly withdraw while
applying suction and rotating catheter
(not > 10 to 15 seconds).
 Hyper oxygenate patient.
 Auscultate pt’s chest , if secretions
heard repeat procedure.
 Before resuctioning clean catheter
with sterile water.

78. FOLLOW UP:
 Discard gloves and catheter in an
aseptic manner.
 Clear connective tubing with
remaining sterile water and turn off
suction.
 Return patient to comfortable position.
 Discard personal protective
equipments, wash hands.
 Document procedure.

79. Precautions/Complications
- Hypoxia
- Vagal
stimulation:
Cardiac
arrhythmia
- Tracheitis
- Bleeding
disorders
- Damage to
mucus
membrane
- Airway
occlusions
- Sudden death

80. LUNG EXPANSION THERAPY
 Includes a variety of respiratory care
modalities designed to prevent or
correct atelectasis .
 It includes
-IPPB
-IS
-CPAP
-PEP

81. Lung expansion therapy increases lung
volume by increasing the transpulmonary
pressure gradient .
Atelectasis :- Abnormal collapse of distal
lung parenchyma.
2 types –1)Resorption atelectasis
2)Passive atelectasis

82. INCENTIVE SPIROMETRY
 Designed to mimic natural sighing
 encouraging patient to take long, slow,
deep breaths
 Performed using devices that provide
visual cues to patients when the
desired inspiratory flow or volume has
been achieved

83. INCENTIVE SPIROMETER

84. INDICATIONS
 Conditions predisposing - pulmonary
atelectasis
 Upper-abdominal surgery
 Thoracic surgery in COPD
 Restrictive lung defect associated with
quadriplegia, dysfunctional diaphragm

85. CONTRAINDICATIONS
 Unconscious / Uncooperative pt
 Patients who cant use it properly
 Patient unable to deep breathe
effectively
VC<10ml/Kg or
IC< 1/3 of predicted normal

86. HAZARDS AND COMPLICATIONS
 Ineffective unless closely supervised .
 Hyperventilation
 Exacerbation of bronchospasm
 Fatigue
 Discomfort secondary to inadequate pain
control
 Barotrauma (emphysematous lungs)

87. IPPB (intermittent Positive
Pressure Breathing)
Application of inspiratory positive
pressure to a spontaneously breathing
patient as an intermittent or short term
therapeutic modality .
15 – 20 minutes treatment.

89. INDICATIONS OF IPPB
 Improve lung expansion - pulmonary
atelectasis, when other forms of
therapy are unsuccessful.
 Inability to clear secretions leading to
inability to ventilate and cough
effectively
 Deliver aerosol medications in cases
of ventilatory muscle weakness.

90. CONTRAINDICATIONS
 Tension pneumothorax (absolute CI)
 ICP > 15 mm Hg
 Hemodynamic instability
 Recent esophageal surgery
 Nausea
 Active hemoptysis
 Recent facial , oral or skull surgery

91. HAZARDS AND
COMPLICATIONS
 Increases work of breathing
 Barotrauma and pneumothorax
 Nosocomial infections
 Hyperventilation / hypocapnia
 Hemoptysis

92.  Gastric distention
 Secretion impaction
 Psychological dependence
 Impedance of venous return

93. POSITIVE AIRWAY
PRESSURE THERAPY
 It uses positive pressure to increase
the PL gradient and enhance lung
expansion .
 PL = Palv – Ppl
 3 approaches
PEP
EPAP
CPAP

94. POSITIONING IN ICU
Use of body position as a specific
treatment technique .
AIMS:
-Optimizing O2 transport through its
effects of improving V/Q matching
-Increasing lung volumes
-Reducing the WOB
-Minimizing the WO heart
-Enhancing mucociliary clearance

96. Specific examples of
positioning:
Upright positioning:-
• Improves lung volume
• Reduces WOB in pt’s being weaned from
MV
Prone positioning:-
• Improves V/Q matching
• Redistribute edema
• Increases FRC for pt’s with ARDS

97.  Side lying with affected lung uppermost:-
• Improves V/Q matching for pt’s with
unilateral lung diseases
• Improve ventilation(via distending forces on
the uppermost lung)
• Clearance of secretions(acute lobar
atelectasis)

98. MOBILIZATION:
Active limb exercises
Pt actively moving or turning in bed
Getting out of bed via slide board
transfer
Sitting on edge of the bed
Standing
Standing transfer from bed to chair
Walking

99. Physiological rationale for
mobilization:
Optimize O2 transfer by enhancing-
 Alveolar ventilation
 V/Q matching
 Gravitational stimulus to maintain or
restore normal fluid distribution in the
body

100.  Reduce the effects of immobility and bed
rest
 Long term –
 Optimize work capacity
 Functional independence and
 Improve cardiopulmonary fitness

101. MANUAL
HYPERINFLATION:
Inflating the lungs with a large tidal
volume via a manual resuscitator bag .
Technique – Slow deep inspiration,
Inspiratory hold , quick release of
inflation bag to enhance expiration
flow rate

103. AIMS:
 Preventing pulmonary collapse
 Re expanding collapsed alveoli
 Improving oxygenation and lung
compliance
 Increasing movement of pulmonary
secretions towards the central airways

104. BASIC LIFE SUPPORT
Emergency treatment consisting
of cardiopulmonary resuscitation
(CPR) or emergency cardiac care
(ECC) that is provided until more
precise medical treatment can
begin.

107. Bibliography
 The ICU book . Paul . L . Marino
 Mechanical ventilation, Physiological
and clinical application . Susan . P .
Pilbeam , J.M. cairo
 EGAN’S , Fundamentals of respiratory
care
 Andrew D Bersten , Neil soni . Oh’s
Intensive Care Manual