chest physiotherapy in icu

CURRENT PRACTICES OF PHYSIOTHERAPY IN ICUs:

Saad SaleemB.S.(PT), M.Sc.(PT)

A treatment intervention employed for improving pulmonary hygiene including positioning, chest percussion, vibration and manual hyperinflation to assist in mobilizing secretions in the lungs from the peripheral airways into the more central airways so that they can be expectorated or suctioned out.

Chest Physiotherapy

is…

• Prophylactic - Pre-operative high risk surgical patient- Post-operative patient who is unable to

mobilize secretions- Neurological patient who is unable to cough

effectively - Patient receiving mechanical ventilation who has a

tendency to retain secretions- Patients with pulmonary disease,

who needs to improve bronchial hygiene

Indications

…cont.

• Therapeutic

- Atelectasis due to secretions

- Retained secretions

- Abnormal breathing pattern due to primary or

secondary pulmonary dysfunction

- COPD and resultant decreased exercise

tolerance

- Musculoskeletal deformity that makes breathing

pattern and cough ineffective

Indications

• Neurological system• Cardiovascular system• Respiratory system

Assessment

Neurological System

• Level of consciousness • Cerebral perfusion pressure (>70mmHg)– CPP = MAP- ICP

• Intracranial pressure (<10mmHg)

…cont.Assessment

• Heart rate and rhythm• Arterial BP• Central Venous pressure

…cont.Assessment

Cardiovascular System

Respiratory System

• Auscultation• Expansion• Chest X-ray • Mode of ventilation• Oxygen therapy• RR• Airway pressures• ABGs• Sputum

…cont.Assessment

General Observation• Patient Position

• Respiration - Airway (artificial airway) ET/Tracheostomy

Ventilator Mode, Ventilator Parameters

• Vital Signs –BP, RR, HR, SpO2,GCS, ICP• Tubes - NG Tube, CVP line, Peripheral line, Chest tubes,

Catheters• Drugs

…cont.Assessment

General Observation

• Auscultations

• Respiratory pattern

• Cyanosis

• Radiograph

…cont.Assessment

Goals

• Prevent accumulation of secretions

• Improve mobilization and drainage of secretions

• Promote relaxation to improve breathing patterns

• Improves respiratory function

• Improve cardio-pulmonary exercise tolerance

• Teach bronchial hygiene programs to patients with chronic

respiratory dysfunction

…cont.Goals

• Untreated tension pneumothorax

• Abnormal coagulation profile

• Status epilepticus or status asthamaticus

• Immediately following intra cranial surgery

Precautions

• Head injury with raised ICP

• Osteoporotic bones

• Recent acute myocardial infarction, unstable vitals

• Immediately after tube feedings

• Sutures and ICD’s

…cont.Precautions

PHYSIOTHERAPY TECHNIQUES

Physiotherapy Techniques

• Gravity-assisted Positioning• Manual techniques• Manual hyperinflation• Airway suctioning• Mobilization

Positioning

Physiological Effects of Positioning

• Optimizes oxygen transport by improving V/Q mismatch• Increases lung volumes• Reduces the work of breathing• Minimizes the work of heart• Enhances mucociliary clearance (postural drainage)

…cont.Positioning

Postural Drainage isn’t…

• A separate technique. Its just an example of positioning

which has the particular aim of clearing airway secretions

with the assistance of gravity.

…cont.Positioning

• Patients are positioned with the area to be drained the upper most, but modifications should be done wherever necessary.

• Drainage times vary, but ideally each position requires 10 minutes (gumery et al, 2001).

…cont.Postural Drainage

• Positioning restores ventilation to dependent lung regions more effectively than PEEP or large tidal volumes (Froese & Bryan, 1974).

• Positioning has a marked influence on gas exchange because of unevenly damaged lungs (Tobin, 1994).

• Side lying reduces lung densities in the upper most lung (Brismar, 1985).

…cont.Positioning

• Right side lying may be more beneficial for cardiac output than left side lying (Wong, 1998).

• Simply turning from supine to side lying can clear atelectasis from dependent regions (Brismar, 1985).

• Positioning affects lung volume• Lung volume is related to the position of the diaphragm• FRC decreases from standing to slumped sitting to supine

(Macnaughton, 1995)

…cont.Positioning

• Positioning affects compliance (Wahba et al found that work of breathing is 40% higher in supine than in sitting)

• Positioning affects arterial oxygenation by improving V/Q mismatch (V/Q is usually mismatched if the affected lung is dependent- Gillespie et al)

• “Bad lung up” position

…cont.Positioning

Life’s most urgent question is:

What are you doing for others?

Chest Maneuver

Chest Maneuver

• Chest Vibrations

• Chest Percussion/Clapping

Chest Clapping/Chest Percussion

• Percussion consists of rhythmic clapping on the chest with loose wrist & cupped hand.

• Effect: Dislodges & loosens secretions from the lung

…cont.Chest Maneuver

Chest Vibration• Vibrations consists of a fine oscillation of the hands directed

inwards against the chest, performed on exhalation after deep inhalation.

• Effects: Helpful in moving loosened mucous plugs towards larger airway

…cont.Chest Maneuver

Manual Hyperinflation

• Was originally defined as inflating the lungs with oxygen and manual compression to a tidal volume of 1 liter requiring a peak inspiratory pressure of between 20 and 40 cm H2O (Med j Aust, 1972).

• More recent definitions include providing a larger tidal volume than base line tidal volume to the patient (Aust j physiotherapy, 1996) and using a tidal volume which is 50% greater than that delivered via the ventilator (chest, 1994).

…cont.Manual Hyperinflation

Indications• To aid removal of secretions• To aid reinflation of atelectatic segments• To assess lung compliance• To improve lung compliance


Technique • Slow deep inspiration• Inspiratory hold (at full inspiration)• Fast expiratory release• Hand-held Pressure Support


Hazards of MHI

• Reduction in blood pressure• Reduced saturation• Raised intracranial pressure• Reduced respiratory drive


Contraindications

• Undrained Pnuemothorax• Potential bronchospasm• Severe bronchospasm• Gross cardiovascular instability inducing arrhythmias and

hypovolaemia• Unexplained Haemoptysis• Patient on High PEEP


Advantages of MH

• Reverses atelectasis (Lumb 2000)

• Improves oxygen saturation and lung compliance (Patman

et al.,1999)

• Improves sputum clearance (Hodgson et al., 2000)


Disadvantages of MH

• Haemodynamic and metabolic upset (Stone, 1991 & Singer

et al.,1994)

• Risk of barotrauma

• Discomfort and anxiety


Suctioning

• Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place.

• Indications– Inability to cough effectively– Sputum plugging– To assess tube patency

…cont.Suctioning

Contraindication

• Frank haemoptysis• Severe brochospasm• Undrained pneumothorax• Compromised cardiovascular system

…cont.Suctioning

• The suction catheter used must be less than half the diameter of endotracheal tube.

• The vacuum pressure should be as low as possible. (60-150mmHg)

• Suction should never be routine, only when there is an indication

…cont.Suctioning

Hazards of Suctioning• Mucosal trauma• Cardiac arrhythmias• Hypoxia• Raised intracranial pressure

…cont.Suctioning

Routes

• Nasal and oral suction• Endotracheal suction• Tracheostomy suction

Suctioning …cont.

Mobilization

• Critically ill (Frequent Position changes, Active and Passive Exercises)

• Stable (Progressive tilting & Ambulation)

Mobilization …cont.

• ICU rehabilitation has been shown to accelerate recovery (o’leary & coackley, 1996)

• Early mobilization for unconscious patients starts right from turning the patient every two hours. ( Brooks- brunn, 1995).

• Graded exercises can be started as soon as the patient regains consciousness.


• Activity is required to maintain sensory input, comfort, joint mobility and healing ability (Frank et al, 1994).

• Activity minimizes the weakness caused by loss of up to half the patients muscle mass (Griffiths & Jones, 1999).

• Graded ambulation can be started depending on patients condition


THANK YOU

chest physiotherapy in icu

Health & Medicine