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1. Definition: An Intensive care unit is an area set aside
for the care of patients who are chronically ill or who
are in danger of becoming so if deprived of continuous
care and attention. Patients are admitted to an icu for
intensive therapy, intensive monitoring or intensive
support. They are at risk of failure of one or more
organs. Intensive care unit-acquired muscle weakness is
a frequently observed complication of critical illness,
occurring in approximately 50% of intensive care
patients.They are referred to rehab for following
purposes:
• Impaired mobility, continuing pain, post
traumatic stress disorder
• Compression neuropathies
• Prolonged weakness, fear of falls, panic attacks
• Significant anxiety and depression
Indications:
Basic respiratory monitoring and support
• Need more than 50% O2

2. • Possibility of progressive deterioration to need
advanced respiratory support
• Need physiotherapy to clear secretions atlas 2hrs
• Patients recently extubated after
prolonged intubation and ventilation
• Patients who are intubated to protect the airway
but require no ventilation
• Need for mask CPAP or NIV
Circulatory support
• Need for vasoactive drugs to support BP and
cardiac output
• Support for circulatory instability due to
hypovolemia
• Patients resuscitated after cardiac arrest
• Intra aortic ballon pumping
Neurological monitoring and support

3. • Central nervous system depression
• Invasive neurological monitoring
Renal support
• Need for acute renal transplantation therapy
Criteria for calling ICU staff
• Threatened airway
• All respiratory arrests
• RR >=40 or <=8 breaths/min
• Oxygen saturation <90% on 50% oxygen
• All cardiac arrests
• PR<40 or >140 beats/min
• Systolic BP <90 mm hg
• Sudden fall in level of consciousness
• Repeated or prolonged seizures

4. • Rising arterial carbon di oxide tension with
respiratory acidosis
Types of ICU
• Neonatal intensive care unit
• Pediatric intensive care unit
• Psychiatric intensive care unit
• Coronary care unit
• Neurological intensive care unit
• Trauma intensive care unit
• Post anesthesia care unit
• High dependency unit
• Surgical intensive care unit
• Out of hospital ICU- mobile intensive care unit

5. Equipment used in adult and pediatric ICU
Electronic measurements
Invasive and as a risk of mortality
It has a powerful micro processor that can store data
for future recall and examination.
ECG: it is used to generate rate & rhythm disturbance
rather than fine recordings.
Pressure: arterial pressure automatic stethoscope it is
directly to a cannula placed in the artery.
Central venous pressure by transducer or by simple
manometer. Catheter is placed in or close to
right atrium, usually by percutaneous puncture of
median basilic vein of arm or internal jugular vein. It
allows the administration of potent drugs.
Pulmonary artery pressure and pulmonary wedge
pressure it can be measured by balloon
catheter. Wedge pressure reflects functions of left
atrium.
Intra cranial pressure it can be measured by means of
transducer connected to either the extra dural space
or to the ventricles.
Temperature fever is found in sepsis and
subnormal temperature is found in brain damage.

6. Electroencephalogram it is cheap and can provide
information about cerebral function. It is also used in
assessment of coma.
Other measurements: fluid balance, weight, to monitor
respiration respirometer is used, gas analysis
Laboratory investigations: hematological, biochemical
Radiology chest x ray, CT scan
Airway
If a patient cannot maintain his own airway
endotracheal tube or tracheostomy is used. Oral
intubation is easy to perform but it is least
comfortable. It is performed for 7days. The patient is
much more comfortable than either oral or nasal tube,
mouth hygiene is much simpler.
Functions of ET tube or tracheostomy tube:
• To access pulmonary secretions
• To prevent substances from the mouth entering the
lungs.
• To maintain positive pressure ventilation
• To bypass an obstruction preventing ventilation.
Disadvantages of tracheostomy

7. • Increased danger of infection
• Loss of humidification
Humidification it is the moistening of the air or gases
we breathe. It is normally one of the functions of
URT.
Artificial humidification is necessary for patients who
breathe through ET tube or tracheostomy,
when breathing air to which gases have been added, or
when secretions is abnormally thick.
Ventilation and oxygenation
Analgesia routes- systemic analgesia(fast, profound and
short acting), inhalation(e.g. nitrous oxide, short term
pain relief for PT conditions), regional local analgesia or
extradural and intrathecal injections( effective and
pain relief is for more than 4days).
Assessment
Neurological system:
Sedation score(0-6) addenbrooke’s sedation score
Level of consciousness by Glasgow coma scale
Pupils size (graded either numerically or by description
ranging from pinprick to dilated), reactivity to
light(optic and oculomotor), equality

8. Cerebral perfusion pressure=mean arterial pressure-
intracranial pressure(normal >70mm Hg, critical <25mm
Hg)
Intracranial pressure (normal <10mm Hg, critical
>25mm Hg)
Cardiovascular system
Heart rate and rhythm (normal 50-100bpm,
bradycardia <50bpm, tachycardia >100bpm)
Arterial blood pressure (mean bp=systemic vascular
resistance*stroke volume*heart rate){mean arterial
pressure=diastolic+1/3(pulse pressure)}
Central venous pressure is measured by placing a
central venous catheter situated in a central
vein(normal 3-15 cm H2O
Pulmonary arterial pressure 10-20mm Hg and pulmonary
capillary wedge pressure 6-15mm Hg
Respiratory system
Mode of ventilation/PEEP/CPAP
Humidification
Oxygen therapy(FiO2 0.21-1.0)
Intercostal drains in case of pneumothorax
Respiratory rate
Airway pressure should be monitored as it may cause
barotrauma
Auscultation- breath sounds is harsh

9. Percussion note helps to differentiate between pleural
effusions, atelectasis or consolidation
Expansion indicates secretions, bronchospasm or
surgical emphysema
Chest radiograph- important in conditions like
pneumonia
Arterial blood gas- says patients respiratory and
metabolic functions and acid base balances (pH =7.35-
7.45, PaCO2 =35-45 mm Hg,PaO2 =80-100 mm Hg,
HCO3 =22-26mmol/l, BE
Sputum/hemoptysis - contraindicated for
physiotherapy
Drugs
Renal system
Measures of intravascular volume- HR/MAP/CVP/PCWP
Urine output
Assessment of peripheral perfusion and tissue turgor
Daily weight
Serum and urinary electrolytes
Arterial blood gas
Daily chest x ray
Net fluid balance
Hematological/immunological system
Sepsis is complicated by abnormal coagulation
Prolonged clotting time, low platelet- causes bleeding

10. Gastrointestinal system
Metabolic acidosis- seen in ABG
Nutritional support
Routes of administration-enteral(directly feeds
gastrointestinal tract), parental(intravenous feeding
via central or peripheral line) or oral
Musculoskeletal system
Positioning to aid pressure relief , drain secretions,
improving ventilation, increase functional residual
capacity
Beds to assist in turning and position the critically ill
patient
Objective assessment
On observation
Appearance: color-normal/blue/yellow
Expansion of chest
External appliances: lines/tubes
Clubbing
Jugular venous pressure
Chest shape
Edema
On palpation
Abdominal distension
Chest expansion
Capillary refill:<3s for reduced CO

11. Tactile fremitus
Trachea
On percussion
Vocal fremitus
On auscultation
Breath sounds
Added sounds
Voice sounds
Drains
If drains in chest-type,side
Site of insertion-color,volume,amount,clamping
Drainage tube in abdomen-peritoneal dialysis
Physiotherapy techniques
Aim of treatment
• Short term
• To assist bronchial secretions
• To ensure adequate ventilation
• To promote collateral ventilation
• To maintain ROM and muscle length by passive
movements

12. • Long term
• To maintain mobility and blood circulation
• To ensure maintenance of good posture
• To prevent atelectasis
• To rehabilitate the patient to full and independent
life
Handling patients who are critically ill:
1. Minimizing O2 consumption- increase FiO2 before
treatment if necessary
2.Therapeutic touch- assists relaxation and sleep and
foot massage is accessible for ICU patients, reduce
muscle tension and lower respiratory rate
3.Turning- 1)inform the patient 2)turn off continuous
tube feedings 3)ensure sufficient slack in lines and
tubes
4.Clear ventilatory tubing

13. 5.Ensure that glide sheets are in place
6.Ensure the care of skin and joints
7.Support tracheal tube
8.Turn smoothly
Check lines, patient comfort and monitors
Pressure area care:
• Adequate nutrition especially vitamin-C and protein
• Frequent turning and judicious positioning
• Pressure reducing cushions on chairs and specialized
beds
• Proper monitoring via wound assessment scale
Techniques to increase lung volume:
For spontaneously breathing patients;
1. Controlled mobilization- to increase lung volume
is exercise

14. - identifying the feeling of
breathlessness and getting their breath back
2.Positioning- for immobile patients with potential
atelectasis- side lying, well forward so that the
diaphragm is free from abdominal pressure.
- A 2 hourly positional change
3.Breathing exercises- atleast 10 deep breaths every
waking hours.
- if side lying is impossible,
upright sitting is next option.
- long sitting allows limited
expansion only
4.End expiratory hold- inspiratory pressure of 30-
50cm H2O should be held for 5s at 2-6times tidal
volume
5.Breathing control/abdominal breathing
6.Sniff at the end of inspiration
7. Neurophysiological facilitation- for non-alert
patients,partially breathing on ventilator i.e., peri

15. oral technique, intercostal stretch, vertebral
pressure, co-contraction of abdominal muscles
8.Rib springing-mechanical aids to increase lung
volume
-incentive spirometry
-CPAP
-Intermittent positive pressure breathing
Manual hyperinflation for deep breathing on the
ventilator -it delivers extra volume & O2 to the lungs
via a rebreathing bag
-preventive care
(if causes no change stop
after 6-8breaths for re-assessment)
Patient education-educate the patient about basics
of anatomy and physiology of heart and
lungs,nutriton,physical activity and exercise, analysis of
lab tests, effects of smoking, effects of medications
and so on. Patient is made empowered and motivated
and lifestyle recommendations. Smoking cessation is
the most important intervention.
DVT prophylaxis-intermittent pneumatic compression
devices, elastic stockings

16. Positioning(monitor vitals, tubes,lines,cords,ventilator)
Indications
• Weak diaphragm
• Unable to use diaphragm in inspiration
• Inhibition of diaphragm muscles due to pain
ROM in ICU includes- breath in during shoulder flexion
abduction, external rotation with upward gaze, opposite
for expiration
-posterior pelvic tilt encourage
diaphragmatic breathing
Bed mobility -breath out during rolling, inhale when
patient the trunk to sit
-inspiration with trunk flexion, expiration
with trunk extension
Dyspnea relieving positions (increases intra abdominal
pressure, diaphragm lengthens, improved length tension
relationship, diaphragm strength of contraction)
Airway clearance techniques
• Functional mobility training
Goals-patient perform as much as
activity for as long as possible

17. Progression- based on patient’s
performance
1.bed mobility exercises-bridging(helps with
placement removal of bed pan, linen changes,
positioning), rolling with airway clearance techniques,
sitting at the edge of the bed, dangling. Assistance is
required to prevent forward flexed position.
2. Transfers and ambulation-Patient do not
require extubation to start ambulation.
lower extremity ergometry, four wheeled walker, gait
belt is required.
After extubation-patient progress to standard walker.
Goals - increase ambulation distance, decrease
assistance
Contraindications- untreated DVT,
unstable vitals, patient not able to follow commands,
high ventilatory support, other ortho,neuro,vascular
injury
• Postural drainage:
Precautions Relative contra indications
Pulmonary edema Inc. intracranial pressure
Hemoptysis Hemodynamically unstable
Massive obesity Recent esophageal anastomosis
Large pleural effusion Recent spinal fusion/injury
Massive ascites Recent head trauma

18. Diaphragmatic hernia
Recent eye surgery
•
• Manual techniques: percussion, vibrations
Precautions Relative contra indications
Uncontrolled bronchospasm Hemoptysis
Osteoporosis Untreated tension pneumothorax
Rib # Unstable hemodynamic status
Metastatic cancer to ribs Open wounds, burns
Tumor obstruction of airway Pulmonary embolism
Anxiety Subcutaneous emphysema
Coagulopathy Recent skin grafts
Seizures Platelet count <20,000 per mm3
Recent pacemakers
shaking, rib springing, neurophysiological facilitation,
manual hyperinflation
• Cough techniques and assist/huff: to clear
secretions
• ACBT. Precautions-splinting for post op
incisions (hyperactive airways may get irritated
with deep breathing and huffing)

19. • Breathing exercises -ventilatory muscle training,
incentive spirometry
-inspiratory muscle training
-chest wall stretching
• Manual hyperinflation
• Suction
• Oxygen therapy
• Saline instillation: normal saline is instilled into the
lungs with the intention of mobilizing thick
secretions(volume=5-10ml or more)
• Intermittent positive airway pressure
• CPAP
• Weaning from ventilator
Exercise and rehab:
Ankle toe movements
Activity is required to maintain sensory input, comfort,
joint mobility& healing

20. Thoracic mobility exercises
Mobilization
A rebreathing bag provides ventilatory support if
patients walks more than a few steps from ventilator.
Walking should be brief to prevent fatigue
If unable to stand, sitting in a chair redistribute skin
pressure, change resting length
Tipping chairs, a tilt table may be useful
Discharge planning

21. Physiological Consequences of Bed Rest
↓Plasma and blood volume
Total heart and left LV volumes
↑ HR at rest and all levels of activity
↓Resting and maximum SV ,↓ maximum CO

22. ↑ Risk of of venous thrombosis and thromboembolism
Orthostatic tolerance ↓
↓Aerobic conditioning
↓VO2
↓Muscle mass, ↓ muscle strengh, ↓ muscle endurance
↓ diameter of vessels
↑ Insulin resistance
Catabolism
Paralytic ileus
↑Anxiety, depression,psychosis
Acute Physiological Effects of Mobilization and Exercise -
Pulmonary System
↑Regional ventillation
↑Regional perfusion
↑Regional diffusion
↑Zone 2 V/Q ratio
↑TV
Altered breathing frequency
↑Minute ventillation
↑Efficiency of respiratory mechanism
↓Airflow resistance
↑Flow rates
↑Strengh and quality of a cought
↑Mucociliary transport and airway clearence
↑Distribution and function of pulmonary immune factors

23. Acute Physiological Effects of Mobilization and Exercise
Cardiovascular System
↑Venous return
↑SV, HR, CO
↑Myocardial contractility
↑Coronary perfusion
↑Circultaing blood volume
↑Chest tube drainage
↓Peripherial vascular resistance
Neuromuscular system
↑cerebral elektrical aktivity
↑Symphatetic stimulation
↑Postural reflexes
Level of mobilisation during invasive ventillation
Turning in bed passive/active
Sitting over the edge of the bed
Transfering from the bedpassive/active
Standing up passive/active
Walking with mobile ventilator
walking with or without modifided walking frames or walker
References
Cash’s textbook of chest, heart and vascular disorders for physiotherapists 4th
edition pg;208-293
Cardiopulmonary and pulmonary physical therapy evidence and practice by Donna
frownfelter 4th edition pg:597-637
Physiotherapy for respiratory and cardiac problems adults and pediatrics
by Jennifer A Pryor, S Ammani Prasad
Essentials of cardiopulmonary physical therapy by Ellen A hillegass

24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607892/