Physiotherapy in ICU

OVERVIEW

  • Physiotherapists are part of the multidisciplinary ICU team
  • The traditional focus of treatment has been the respiratory management of both intubated and spontaneously breathing patients
  • Emerging evidence of the longstanding physical impairment suffered by survivors of intensive care has resulted in physiotherapists re-evaluating treatment priorities to include exercise rehabilitation as a part of standard clinical practice
  • Physiotherapists perform an assessment that includes the respiratory, cardiovascular, neurological, and musculoskeletal systems to formulate treatment plans
  • The precise roles and indications for physiotherapy are uncertain as physiotherapy involvement is largely based on clinical reasoning and there is a lack of high quality evidence supporting physiotherapy in the ICU

ROLES

Physiotherapist roles include:

  • involvement in physiotherapy devised care plans
  • optimisation of cardiopulmonary function
  • weaning from the ventilator
  • early rehabilitation/mobilisation programme
  • positioning to protect joints, prevent contractures and improve muscle tone
  • promote functional independence and improve exercise tolerance
  • management of musculoskeletal pathology
  • assisting with orthotics and equipment (e.g.fitting of cervical collars, spinal braces, slings etc. in trauma patients; setting up TENS machines)
  • patient education (exercise, rehab etc.)

MOBILISATION, DECONDITIONING AND MUSCULOSKELETAL THERAPY

  • Physiotherapists have a role in maintaining joint and muscle function in those who are at risk of contractures, for example in neurological injuries and patients with prolonged paralysis
  • There is increasing emphasis on exercise rehabilitation over respiratory management is increasingly evident as survivors of a prolonged ICU stay can suffer deconditioning, muscle atrophy, and weakness that may impact upon quality of life
  • See mobilisation of the critically ill

RESPIRATORY PHYSIOTHERAPY

Goals of respiratory physiotherapy management

  • promote secretion clearance
  • maintain or recruit lung volume, in both the intubated and spontaneously breathing patient

Techniques for optimisation of cardiopulmonary function

  • Manual hyperinflation (MHI) (mechanical ventilation only)
  • Suction (mechanical ventilation only)
  • Manual techniques: chest shaking and vibration, chest wall compression, chest clapping/ percussion
  • Positioning, gravity-assisted positioning (GAP)
  • Mobilization/ rehabilitation
  • Active cycle of breathing technique (ACBT)
  • Intermittent positive-pressure breathing (IPPB)
  • Continuous positive airways pressure (CPAP)
  • Non-invasive ventilation (NIV)
  • Nasopharyngeal/oral suction
  • Positive expiratory pressure (PEP) mask, flutter valve

In the intubated patient, physiotherapists commonly employ manual and ventilator hyperinflation and positioning as treatment techniques whilst in the spontaneously breathing patients there is an emphasis on mobilisation.

MANUAL HYPERINFLATION

  •  a self-inflating circuit is used to deliver a volume of gas 50% greater than tidal volume (VT) via an endotracheal or tracheostomy tube

Potential advantages

  • Reversal of acute lobar atelectasis
  • Alveolar recruitment via channels of collateral ventilation
  • Improvement in PaO2
  • Mobilisation of secretions and contents of aspiration
  • Improved static lung compliance
  • Effectiveness may be increased when combined with appropriate positioning and manual techniques

Disadvantages

  • Absolute contraindications: undrained pneumothorax, unexplained haemoptysis
  • haemodynamic instability
  • Loss of PEEP, inducing hypoxia and potential lung damage (minimised by incorporating a PEEP valve into the circuit)
  • Risk of volutrauma, barotrauma and pneumothorax (reduced by including a manometer in the circuit)
  • Risk of increased ICP
  • Increased patient stress and anxiety

ACTIVE CYCLE OF BREATHING TECHNIQUE

ACBT is a cycle of breathing exercises used to remove excess bronchial secretions with these potential benefits:

  • Mobilises and clears excess bronchial secretions
  • Improves lung function
  • Minimises the work of breathing
  • Individual components of the cycle can be utilised/emphasised
  • to target specific problems
  • Can be used in combination with other manual techniques,
  • gravity-assisted positioning, V/Q matching, positioning to reduce breathlessness and during activities such
  • as walking
  • Self-treatment can be included in a home programme

Potential complications

  • Without adequate periods of breathing control, bronchospasm and desaturation can occur
  • Poor technique can lead to ineffective treatment and unnecessary energy expenditure

SUCTION

EVIDENCE

Some evidence for physiotherapy in critically patients from a systematic review of 10 RCTs (Kayambu et al ,2013):

  • No evidence for a mortality benefit for physiotherapy in ICU
  • improved quality of life, physical function, peripheral and respiratory muscle strength
  • increased ventilator-free days
  • decreased hospital and ICU LOS

The evidence for early mobilisation in ICU is reviewed in Mobilisation in the ICU

There is a lack of high level evidence and a need for high quality trials

  • the appropriate timing, nature of interventions and intensity (“dose”) of physiotherapy remains unproven

References and Links

LITFL

Journal articles

  • Ambrosino N, Venturelli E, Vagheggini G, Clini E. Rehabilitation, weaning and physical therapy strategies in chronic critically ill patients. Eur Respir J. 2012 Feb;39(2):487-92. doi: 10.1183/09031936.00094411. Epub 2011 Dec 1. Review. PubMed PMID: 22135278. [Free Full Text]
  • Fan E. Critical illness neuromyopathy and the role of physical therapy and rehabilitation in critically ill patients. Respir Care. 2012 Jun;57(6):933-44; discussion 944-6. doi: 10.4187/respcare.01634. Review. PubMed PMID: 22663968. [Free Full Text]
  • Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, Schönhofer B, Stiller K, van de Leur H, Vincent JL. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008 Jul;34(7):1188-99. doi: 10.1007/s00134-008-1026-7. Epub 2008 Feb 19. Review. PubMed PMID: 18283429.
  • Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013 Jun;41(6):1543-54. doi: 10.1097/CCM.0b013e31827ca637. Review. PubMed PMID: 23528802.
  • Strickland et al. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients. Respir Care 2013;58:2187-2193 [Free Full Text]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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