Intensive Care Med (2008) 34:1188–1199DOI 10.1007/s00134-008-1026-7 ESICM STATEMENT

R. GosselinkJ. BottM. JohnsonE. DeanS. NavaM. NorrenbergB. SchönhoferK. StillerH. van de LeurJ. L. Vincent

Physiotherapy for adultpatients with critical illness:recommendationsof the European RespiratorySociety and European Societyof Intensive Care MedicineTask Force on Physiotherapyfor Critically Ill Patients

Received: 27 March 2007Accepted: 3 January 2008Published online: 19 February 2008© Springer-Verlag 2008

Electronic supplementary materialThe online version of this article(doi:10.1007/s00134-008-1026-7) containssupplementary material, which is availableto authorized users.

Abstract The Task Force reviewedand discussed the available lit-erature on the effectiveness ofphysiotherapy for acute and chroniccritically ill adult patients. Evi-dence from randomized controlledtrials or meta-analyses was limitedand most of the recommendationswere level C (evidence from un-controlled or nonrandomized trials,or from observational studies) andD (expert opinion). However, thefollowing evidence-based targetsfor physiotherapy were identified:deconditioning, impaired airwayclearance, atelectasis, intubationavoidance, and weaning failure.Discrepancies and lack of data onthe efficacy of physiotherapy in

clinical trials support the need toidentify guidelines for physiotherapyassessments, in particular to identifypatient characteristics that enabletreatments to be prescribed andmodified on an individual basis.There is a need to standardize path-ways for clinical decision-makingand education, to define the profes-sional profile of physiotherapists,and increase the awareness of thebenefits of prevention and treatmentof immobility and deconditioningfor critically ill adult patients.

Introduction

Critical illness can last from hours tomonths, depending on the underly-ing pathophysiology and response totreatment. It carries high morbidityand mortality rates, and the asso-ciated care is a major determinantof healthcare costs. The evolutionof intensive care medicine and inte-grated team management has greatlyimproved the survival of critically illpatients [26, 69]. In view of the highcosts associated with ICU, everyattempt should continue to be madeto prevent complications and appro-priately treat the primary underlyingpathophysiology to minimize lengthof stay in ICU. There are commoncomplications particularly associ-ated with a prolonged ICU stay,including deconditioning, muscleweakness, dyspnea, depression andanxiety, and reduced health-relatedquality of life [17, 41, 70]. Chroniccritical illness is associated withprolonged immobility and intensivecare unit (ICU) stay [29] and ac-counts for 5–10% of ICU stays,a proportion that appears to beincreasing [13]. Because of thesedetrimental sequelae of long-termbed rest, there is a need for re-habilitation throughout the criticalillness [16, 38, 66, 73, 114] andthereafter [49], to address theseeffects. The amount of rehabilita-

tion performed in ICUs is ofteninadequate [20] and, as a rule,is better organized in weaningcenters [66, 73].

Physiotherapy in the managementof patients with critical illness

Physiotherapists are involved in themanagement of patients with acute,subacute and chronic respiratoryconditions and in the prevention andtreatment of the sequelae of immobil-ity and recumbency [47, 77]. Theirrole varies across units, hospitals, andcountries [77], with respect to patientreferral, roles, treatment goals andselection of interventions [47, 77].Due to a lack of substantive evidence,an earlier review could not drawfirm conclusions on the effectivenessof physiotherapy for critically illpatients [98]. The purpose of thisdocument is to critically review theevidence currently available for theuse of physiotherapy in the adultcritically ill patient and to makerecommendations for assessment andmonitoring and best practice in threerelevant clinical areas:

• Deconditioning and relatedcomplications

• Respiratory conditions (retainedairway secretions, atelectasis,pneumonia, acute lung injury,inhalation injury, postoperativepulmonary complications, chesttrauma, intubation avoidance andweaning failure)

• Emotional problems andcommunication

The Task Force members mettwice face to face and agreed on theidentified areas and the working pro-cedures (see details in ESM). Detailsof the effectiveness of physiotherapyin specific pulmonary conditions, im-plications for staffing and suggestionsfor future research are discussed inthe ESM.

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Conditions and physiotherapyinterventions

Assessment and monitoring

Physiotherapy assessment of crit-ically ill patients is less driven bymedical diagnosis, instead focusingon deficiencies at a physiological andfunctional level [39]. This leads toidentification of problems and theprescription of one or more interven-tions. Physiotherapists should be ableto prioritize, and identify aims andparameters of treatments, ensuringthat these are both therapeutic andsafe by appropriate monitoring ofvital functions [22, 100]. Accurateand valid assessment of respiratoryconditions, and of deconditioning andrelated problems, is of paramountimportance for physiotherapists.While these areas should be assessedwith previously validated measures,such measures are often not availableor applicable in an ICU setting (e.g.,outcomes for functional performancesuch as the Functional IndependenceMeasure, the Berg Balance scale andSF-36 may be inapplicable for acutelyill ICU patients yet be successfullyused to monitor the progress ofpatients in long-term weaning facil-ities) [16]. In addition, physiothera-pists can contribute to the patient’s

Fig. 1 Model of respiratory insufficiency (adapted from [90])

overall well-being by providing emo-tional support and enhancing commu-nication. Fig. 1 outlines the etiologyof respiratory insufficiency and failure(see also ESM), and may serve asa framework for the respiratory as-sessment and treatment. Assessmentof muscle and neurological functionis difficult in the ICU [81], but phys-iotherapists can reveal undetectedinjuries [92]. Detailed descriptions ofassessment are given elsewhere [100].

Recommendations:

• Assessment prior to treatmentshould determine the underlyingproblem amenable to physio-therapy and which, if any,intervention(s) are appropriate(level D).

• Appropriate monitoring of vitalfunctions should be used andacted upon to help ensure thatphysiotherapy interventions areboth therapeutic and safe(level D).

Physical deconditioning and relatedcomplications

Due to the nature of critical illnessand the modalities used to manage it,prolonged bed rest, with well-knownadverse physiologic effects, seems

to be the rule in the ICU (see ESMfor details). Rehabilitation has thepotential to restore lost function but istraditionally not started until after ICUdischarge. Critically ill patients areoften viewed as ‘too sick’ to toleratephysical activity in the early phase oftheir illness and their immobilizationis frequently ‘inevitably’ prolonged.This will enhance deconditioningand might further complicate theclinical course [21]. Early mobi-lization was shown 30 years ago toreduce the time to wean from me-chanical ventilation and is the basisfor functional recovery [103, 104].Recently more attention has beengiven to (early) physical activityas a safe and feasible interventionafter the initial cardio-respiratory andneurological stabilization [6, 71]. Inthe ICU setting, the prescription ofexercise is mostly based on clinicalcondition and response to treatment.Reducing the active muscle mass(or even passive motion or electricalmuscle stimulation), the durationof the exercise and/or the numberof repetitions will result in lowermetabolic demands. Patients withhemodynamic instability, or thoseon high FiO2 and high levels ofventilatory support, are not candidatesfor aggressive mobilization. Therisk of moving a critically ill patientshould be weighed against the risksentailed by immobility and recum-bency [50, 108]. No adverse effectsof physical activity on the inflam-matory status of critically ill patientshave been demonstrated [109].Fig. 2 outlines the steps involvedin safe mobilization of criticallyill patients [100]. In the followingparagraphs several specific treatmentmodalities will be discussed.

Positioning can be used to increasegravitational stress and associatedfluid shifts, through head tilt andother positions that approximate theupright position. The upright posi-tion increases lung volumes and gasexchange [15], stimulates autonomicactivity, and can reduce cardiac stressfrom compression [57]. Mobilizationhas been part of the physiotherapy

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Fig. 2 Overview of safety issuesbefore mobilizing critically illpatients. (Reproduced from:Stiller K, Phillips A (2003)Safety aspects of mobilisingacutely ill inpatients. PhysiotherTheory Pract 19(4):239–257;with permission of Taylor &Francis Group, LLC,http://www.taylorandfrancis.com[100])

management of acutely ill patientsfor several decades [23]. Mobilizationrefers to physical activity sufficientto elicit acute physiological effectsthat enhance ventilation, central andperipheral perfusion, circulation,muscle metabolism and alertnessand are countermeasures for venousstasis and deep vein thrombosis [79].

Strategies – in approximate orderof intensity – include passive andactive turning and moving in bed,active-assisted and active exercise,use of cycling pedals in bed, sittingover the edge of the bed, standing,stepping in place, transferring fromthe bed or chair, chair exercises andwalking. These activities are safe

and feasible in the early phase ofICU admission [6]. Walking andstanding aids (e.g., modified walkingframes, tilt tables) are safe and fea-sible to facilitate the mobilization ofcritically ill patients [15, 112, 113].In patients with spinal cord injuryabdominal belts improve vital ca-pacity [34] and increase the exercise

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ability. Non-invasive ventilationduring mobilization may improveexercise tolerance for non-intubatedpatients, similar to that demonstratedin patients with severe COPD [106].

Aerobic training and musclestrengthening, in addition to routinemobilization, improved walking dis-tance more than mobilization alonein ventilated patients with chroniccritical illness [73]. A recent random-ized controlled trial (RCT) showedthat a 6-week upper and lower limbtraining program improved limb mus-cle strength, increased ventilator-freetime and improved functional out-comes in patients requiring long-termmechanical ventilation comparedto a control group [16]. These re-sults are in line with a retrospectiveanalysis of patients on long-termmechanical ventilation who partic-ipated in whole-body training andrespiratory muscle training [66].In patients recently weaned frommechanical ventilation, the additionof upper-limb exercise enhanced theeffects of chest physiotherapy onexercise endurance and dyspnea [82].Recent technological developmentshave resulted in equipment for activeor passive leg cycling during bedrest. This allows early application ofleg cycling in critically ill patients,potentially improving functionalstatus [11].

Low-resistance multiple repeti-tions of resistive muscle training canaugment muscle mass, force genera-tion and oxidative enzymes. This inturn can improve O2 extraction andefficiency of muscle O2 kinetics. Ap-plying these physiological responsesto the ICU scenario, ICU patientsshould be given sets of repetitions(3 sets of 8–10 repetitions at 50–70%of 1 repetition maximum, RM) [52] toperform daily within their tolerance,commensurate with their goals. Inpatients unable to perform voluntarymuscle contractions, neuromuscularelectrical stimulation (NMES) hasbeen used to prevent disuse muscleatrophy. In patients with lower limbfractures and cast immobilization for6 weeks, daily NMES for at least

1 h reduced the decrease in cross-sectional area of the quadriceps andenhanced normal muscle protein syn-thesis [33]. In ICU patients, NMES ofthe quadriceps, in addition to activelimb mobilization, enhanced musclestrength and hastened independenttransfer from bed to chair [114].

Passive stretching or range-of-motion exercise may have a particu-larly important role in the manage-ment of patients who are unable tomove spontaneously. Passive move-ment has been shown to enhanceventilation in neurological patients inhigh-dependency units [14]. Evidencefor using continuous dynamic stretch-ing is based on the observation, inother patient groups, that continuouspassive motion (CPM) prevents con-tractures and promotes function [91].CPM has been assessed in patientswith critical illness subjected to pro-longed inactivity [38]. Three hours ofCPM per day reduced fiber atrophyand protein loss, compared withpassive stretching for 5 min twicedaily [38].

For patients who cannot be ac-tively mobilized and are at highrisk for soft tissue contracture (e.g.,following severe burns or trauma,and in some neurological conditions),splinting may be indicated. In burnspatients, fixing the position of jointshas been shown to reduce muscle andskin contraction [55]. The ideal dura-tion of the intervention is unknown.Many facilities use a ‘2 h on, 2 h off’schedule, but this is not supported bydata [85]. In patients with neurologi-cal dysfunction, splinting may reducemuscle tone [42].

Recommendations:

• Active or passive mobilizationand muscle training should beinstituted early (level C).

• Positioning, splinting, passivemobilization and musclestretching should be used topreserve joint mobility andskeletal muscle length in patientsunable to move spontaneously(level C).

• NMES may be instituted, whereequipment is available, in patientswho are unable to move spon-taneously and at high risk ofmusculo-skeletal dysfunction(level C).

• Techniques, such as positioning,passive movement and transfers,should be administered jointlywith the nursing staff (level D).

• The physiotherapist should beresponsible for implementingmobilization plans and exerciseprescription, and make recom-mendations for progression ofthese in conjunction with otherteam members (level D).

Respiratory conditions

Respiratory dysfunction is one ofthe most common causes of criticalillness necessitating ICU admission.Failure of either of the two pri-mary components of the respiratorysystem (i.e., the gas-exchange mem-brane and the ventilatory pump.. [90](Fig. 2; see ESM, Table S2), canresult in a need for mechanicalventilation to maintain adequate gasexchange and to assume some, if notall, of the work of breathing. Theaims of physiotherapy in respiratorydysfunction are to improve globaland/or regional ventilation and lungcompliance, to reduce airway resis-tance and the work of breathing,and to clear airway secretions. Bodypositioning and mobilization arepotent options for treatment thatmay optimize oxygenation by im-proving ventilation, V/Q matching,using gravity dependency to aug-ment alveolar recruitment, and lungperfusion. Evidence for interventionsused to clear retained airway secre-tions will be discussed generally.The ESM describes the evidence forinterventions in specific pathophysi-ological problems and diagnoses, i.e.atelectasis, pneumonia, acute lunginjury, acute respiratory distresssyndrome, inhalation injury, postop-erative pulmonary complications andchest trauma.

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Fig. 3 Pathways and treatmentmodalities for increasing airwayclearance (PEP, positiveexpiratory pressure; CPAP,continuous positive airwaypressure; HFO, high-frequencyoscillation; IPV, intrapulmonarypercussive ventilation; NIV,non-invasive ventilation; IPPB,intermittent positive pressurebreathing)

Retained airway secretions

As different mechanisms can beresponsible for reducing airway clear-ance, it is important firstly to identifythe problem and then to select the in-tervention(s) that may be appropriate(Fig. 3).

Non-intubated patient: Interven-tions aimed at increasing inspiratoryvolume (see Fig. 3) affect lungexpansion, regional ventilation,airway resistance and pulmonarycompliance. Interventions aimed atincreasing expiratory flow includeforced expirations (both active andpassive). Actively, these can be withan open glottis (a huff), or witha closed glottis (a cough). Manuallyassisted cough, using thoracic orabdominal compression, may beindicated for patients with expiratorymuscle weakness or fatigue (e.g.,neuromuscular conditions) [96]. Allforced expiratory techniques relyon an adequate inspiratory volumeand may need to be accompanied byinterventions to increase inspiratoryvolume, if reduced inspiratory vol-ume is contributing to an ineffectivecough. The mechanical in-exsufflatorcan be used to deliver an inspiratorypressure followed by a high negative

expiratory force, via a mouthpieceor facemask. This increases tidalvolume and augments expiratoryflow and thus is indicated when thepatient is unable to clear secretions.Although not widely used, it hasbeen successfully applied in the man-agement of non-intubated patientswith retained secretions secondaryto respiratory muscle weakness (e.g.,muscular dystrophy) [35]. Airwaysuctioning is, dependent on localagreements, practiced by doctors,nurses and physiotherapists and isused solely to clear central secretionsthat are considered a primary problemwhen other techniques are ineffec-tive. Detailed descriptions of airwaysuctioning techniques and the risksassociated with these techniques aregiven elsewhere [4].

Recommendations for thenon-intubated patient:

• Interventions for increasinginspiratory volume should be usedif reduced inspiratory volume iscontributing to ineffective forcedexpiration (level B).

• Interventions for increasingexpiratory flow should be used toassist airway clearance if reduced

expiratory force is contributing toineffective forced expiration(level B).

• Manually assisted coughtechniques and/or in-exsufflationshould be applied in the man-agement of non-intubated patientswith retained secretionssecondary to respiratory muscleweakness (level B).

• Oro-nasal suctioning should beused only when other methods failto clear secretions (level D).

• Nasal suctioning should be usedwith extreme caution in patientswith anticoagulation, bony or softtissue injuries or after recentsurgery of the upper airways(level D).

Intubated and ventilated patients:Body positioning and mobilizationmay optimize airway secretion clear-ance and oxygenation by improvingventilation, alveolar recruitment andV/Q matching. Manual hyperinflation(MHI) or ventilator hyperinflation,positive end-expiratory pressure(PEEP) ventilation and airwaysuctioning may assist in secretionclearance [7]. The aims of MHI areto prevent pulmonary atelectasis,re-expand collapsed alveoli, im-

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prove oxygenation, improve lungcompliance, and facilitate move-ment of airway secretions towardsthe central airways [43, 68]. Thehead-down position may enhance theeffects of MHI on sputum volumeand compliance [8]. MHI involvesa slow deep inspiration with man-ual resuscitator bag, an inspiratoryhold, and then a quick release of thebag to enhance expiratory flow andmimic a forced expiration. MHI canprecipitate marked hemodynamicchanges associated with a decreasedcardiac output, which result fromlarge fluctuations in intra-thoracicpressure [95]. As with other forms ofventilatory assistance, damage to thelung can occur if inflation is forcedor PEEP is lost during the technique.A pressure of 40 cmH2O has beenrecommended as an upper limit [84].Similarly, there is a risk of hypo- aswell as hyperventilation. MHI canalso increase intracranial pressure(ICP) and mean arterial pressure,which has implications for patientswith brain injury. These increases areusually limited, however, such thatcerebral perfusion pressure remainsstable [78]. Airway suctioning mayhave detrimental side effects [110]although reassurance, sedation, andpre-oxygenation of the patient mayminimize these effects [61]. Suctioncan be performed via an in-lineclosed suctioning system or an opensystem. The in-line system does notappear to decrease the incidenceof ventilator-associated pneumonia(VAP) [25, 59] or the duration ofmechanical ventilation, length of ICUstay or mortality [59], but it doesincrease costs. Closed suctioning maybe less effective than open suction-ing for secretion clearance duringpressure-support ventilation [58].The routine instillation of normalsaline during airway suctioning haspotential adverse effects on oxygensaturation and cardiovascular stabil-ity, and variable results in terms ofincreasing sputum yield [1, 9]. Chestwall compression prior to endotra-cheal suctioning did not improveairway secretion removal, oxygena-

tion, or ventilation after endotrachealsuctioning in an unselected popu-lation of mechanically ventilatedpatients [105].

Recommendations for the intubatedpatient:

• Body positioning andmobilization can be used toenhance airway secretionclearance (level C).

• Manual or ventilatorhyperinflation and suctioning areindicated for airway secretionclearance (level B).

• MHI should be used judiciouslyin patients at risk of barotraumaand volutrauma or who arehemodynamically unstable(level B).

• Care must be taken to ensure thatover- or under-ventilation doesnot occur with MHI (level B).

• Airway pressures must bemaintained within safe limits(e.g., by incorporating a pressuremanometer into the MHI circuit)(level D).

• Reassurance, sedation, andpre-oxygenation should be used tominimize detrimental effects ofairway suctioning (level D).

• Open system suctioning can beused for most ventilated patients(level B).

Fig. 4 Factors contributing to respiratory insufficiency, failure and ventilator dependence

• Neither suctioning nor instillationof normal saline should beperformed routinely (level C).

Respiratory insufficiency – intubationavoidance

Complications of endotracheal in-tubation and mechanical ventilationare common, and weaning frommechanical ventilation can be chal-lenging, so where appropriate andpossible, physiotherapy is aimed atavoiding intubation. Of paramountimportance is whether the respira-tory failure is due to lung failure,pump failure, or both (Fig. 2; seeESM Table S2), as the problems andstrategies will vary accordingly. Im-balance between respiratory muscle(pump) workload and muscle (pump)capacity can result in respiratoryinsufficiency (Fig. 4) and is a majorcause of need for ventilatory support.Physiotherapy may help decreaseventilatory load, e.g., by reducingatelectasis [62, 99] or removingairway secretions [60, 99]. Condi-tions contributing to the need forventilatory support or weaning failureare described in the ESM (TableS3).

Problems related to the work ofbreathing and efficiency of ventila-tion, along with progressive debility,are the primary focuses of physiother-apy in the management of respiratoryinsufficiency and the avoidance of

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intubation. Positioning can reduce thework of breathing and improve theefficiency of ventilation. Improve-ments have been documented (seeESM) for patients with unilaterallung disease when they are positionedon their side with the affected lunguppermost [45]. For those with, or atrisk of, reduced FRC, supported up-right sitting, with the help of pillowsif necessary, may be beneficial [46].In lung failure, CPAP has producedfavorable outcomes in adults withARDS [36] and in patients with Pneu-mocystis carinii pneumonia [37],and may prevent re-intubation [24].NIV has been used for postoperativesupport [2] and for COPD patientswith CAP [18], as well as in somepatients with acute lung injury [89],to avoid intubation When pump dys-function is present, NIV can reducebreathlessness [10], reduce rates ofintubation [83], reduce mortality fromexacerbations of COPD [83], and iscost effective [80]. Both CPAP andNIV can reduce the need for intuba-tion in acute cardiogenic pulmonaryedema [67].

Recommendations:

• Body positioning should be usedto optimize ventilatory pumpmechanics in patients withrespiratory insufficiency (level C).

• CPAP and NIV should beconsidered for the management ofacute cardiogenic pulmonaryedema (level A).

• NIV should be used as the firstline of treatment in pump failuredue to exacerbations of COPD,providing immediate intubation isnot warranted (level A).

• NIV may be used in selectedpatients with pump failure due toacute respiratory complicationsfrom musculo-skeletal chest walldysfunction or neuromuscularweakness (level A).

• NIV/CPAP can be used inselected patients with type 1 acuterespiratory failure, e.g., inhalationinjury, trauma and somepneumonias (level C).

Weaning failure

Only a small proportion of pa-tients fail to wean from mechanicalventilation, but they require a dis-proportionate amount of resources.Therapist-driven protocol (TDP)was shown to reduce the durationof mechanical ventilation and ICUcost [27, 51]. However, a recentstudy showed that protocol-directedweaning may be unnecessary in anICU with generous physician staffingand structured rounds [54]. A spon-taneous breathing trial (SBT) can beused to assess readiness for extuba-tion with the performance of serialmeasurements, such as tidal volume,respiratory rate, maximal inspira-tory airway pressure, and the rapidshallow breathing index [63, 111].Early detection of worsening clinicalsigns such as distress, airway ob-struction and paradoxical chest wallmotion ensures that serious problemsare prevented. Airway patency andprotection (i.e., an effective coughmechanism) should be assessed priorto commencement of weaning. Peakcough flow is a useful parameter topredict successful weaning in patientswith neuromuscular disease or spinalcord injury when extubation is antici-pated [5]. An “airway care score” hasbeen developed based on the qualityof the patient’s cough during airwaysuctioning, the absence of ‘exces-sive’ secretions and the frequency ofairway suctioning [12, 27].

NIV can facilitate weaning [74]and reduce ICU costs [102], andphysiotherapists can play a major rolein its application [53, 77]. NIV is ef-fective in preventing post-extubationfailure in patients at risk [75, 97].Respiratory muscle weakness is oftenobserved in patients with wean-ing failure [56]. Since inactivity(‘ventilator-induced diaphragm dys-function’, VDI) is suggested as animportant cause of respiratory musclefailure [31], and intermittent loadingof the respiratory muscles has beenshown to attenuate respiratory mus-cle deconditioning [32], inspiratorymuscle training might be beneficial

in patients with weaning failure.Uncontrolled trials [3, 64] and oneRCT [65] observed an improvementin inspiratory muscle function anda reduction in duration of mechan-ical ventilation and weaning timewith intermittent inspiratory muscletraining. Finally, biofeedback to dis-play the breathing pattern has beenshown to enhance weaning [44].Voice and touch may be used toaugment weaning success either bystimulation to improve ventilatorydrive or by reducing anxiety [40].Environmental influences, such asambulating with a portable venti-lator, have been shown to benefitattitudes and outlooks in long-termventilator-dependent patients [28].

Recommendations:

• Therapist-driven weaningprotocols and SBTs can beimplemented dependent onphysician staffing in the ICU(level A).

• Therapist-driven protocols forweaning should be adhered to ifin existence (level A).

• In patients with respiratorymuscle weakness and weaningfailure respiratory muscle trainingshould be considered (level C).

• NIV may be used as a weaningstrategy in a selected populationof hypercapnic patients (level A).

• Patients at risk of post-extubationventilatory failure should beidentified and considered for NIV(level B).

• During the early post-extubationphase, assisted coughingmaneuvers or nasal endotrachealsuctioning should be performed asnecessary (level C).

• Physiotherapists can assist inpatient managementpost-decannulation (level D).

Emotional problems andcommunication

Critically ill patients may experiencefeelings of anxiety, alienation and

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panic, particularly if nursed in an ICUor high-dependency unit [76, 101].Those on mechanical ventilation mayexperience additional distress fromthe endotracheal tube [30]. Theseemotions may lead to post-traumaticstress disorder in some patientsafter discharge [48]. Anxiety alsoadversely affects recovery if notassessed and treated [72]. Promotinga restful environment conduciveto relaxation and sleep is a dailychallenge in critical care [87].Physiotherapists can make a valuablecontribution to the psychologicalwell-being and education of thecritically ill patient [94]. Relaxationinterventions can reduce anxietyand panic, promote sleep, and, inturn, reduce the severity of painand dyspnea. Body positioning andrepositioning are useful means ofachieving relaxation and reducesymptoms. Breathlessness canrespond favorably to positioning [93].Therapeutic touch has been reportedto promote relaxation and comfortin critically ill patients, whichin turn may enhance sleep [86].Physiotherapists, by virtue of theirhands-on treatment provided toICU patients, have an opportunityto provide such therapeutic touch.Massage may be useful in enhancingrelaxation and reducing anxietyand pain in acute and criticalcare [88]. Communication is centralto patient satisfaction and physicaland emotional well-being [94].The development of post-traumaticstress disorder has been associatedwith the inability to communicateeffectively. Informed consent isa means of empowering the patientwhen highly vulnerable [19].Education is designed to help the

patient understand their condition andcare and appreciate their own role inpain control, e.g., patient-controlledanalgesia, wound support duringmovement or airway clearance, andstrategies such as body positioningfor comfort [107].

Recommendations:

• Physiotherapists should ensuretreatment sessions addressdiscomfort and anxiety as well asphysiological problems (level D).

• Physiotherapists should ensurepatient education is included intreatment sessions (level D).

• Physiotherapists can considermassage as an intervention foranxiety management and sleeppromotion (level C).

• Physiotherapists should includeappropriate use of therapeutictouch in all treatments theyprovide (level D).

SummaryPhysiotherapists are members of theinterdisciplinary healthcare teamfor the management of criticallyill patients. For the purpose ofthis review, several importantareas for physiotherapy in criticalillness were identified: physicaldeconditioning, neuromuscular andmusculoskeletal complications;prevention and treatment ofrespiratory conditions; and emotionalproblems and communication.The following problems wereidentified as evidence-based targetsfor physiotherapy: deconditioning,muscle weakness, joint stiffness,

retained airway secretions, atelec-tasis and avoidance of intubationand weaning failure. Appropriatelyprescribed physiotherapy may im-prove outcomes and reduce the risksassociated with intensive care, as wellas minimize costs.

The lack of systematic reviewsand RCTs to support or reject physio-therapy interventions was recognizedby the Task Force, as most recom-mendations were level C and D.However, evidence-based medicinein the ICU is not restricted to RCTsand meta-analyses. Other forms ofevidence, including expert opinion andphysiologic evidence, are also valid interms of providing a basis for practiceand identifying areas where furtherresearch is needed to strengthen andadvance this evidence base.

Discrepancies regarding the effi-cacy of physiotherapy in clinical trialssupport the need to identify indica-tions for interventions based on anindividual’s needs, rather than beingcondition dependent, and to establishsound principles for the prescriptionof specific interventions to achievethe desired outcome. However, thereis a need to standardize pathwaysfor clinical decision-making andeducation, and define the professionalprofile of ICU physiotherapists inmore detail. Patients in the ICU havemultiple problems that change rapidlyin response to the course of illness andto medical management. Rather thanstandardized treatment approachesfor various conditions, the goal isto extract principles of practice thatcan guide the physiotherapist’s as-sessment, evaluation and prescriptionof interventions and their frequentmodification for each patient in theICU.

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References1. Ackerman MH, Mick DJ (1998)

Instillation of normal saline beforesuctioning in patients with pulmonaryinfections: a prospective random-ized controlled trial. Am J Crit Care7:261–266

2. Aguilo R, Togores B, Salvador P,Rubi M, Barbe F, Agust A (1997) Non-invasive ventilatory support after lungresectional surgery. Chest 112:117–121

3. Aldrich TK, Karpel JP, Uhrlass RM,Sparapani MA, Eramo D, Ferranti R(1989) Weaning from mechanical ven-tilation: adjunctive use of inspiratorymuscle resistive training. Crit Care Med17:143–147

4. Anonymous (1992) AARC clinicalpractice guideline. Nasotracheal suc-tioning. American Association forRespiratory Care (update 2004). RespirCare 37:1176–1179

5. Bach JR, Saporito LR (1996) Criteriafor extubation and tracheostomy tuberemoval for patients with ventila-tory failure. A different approach toweaning. Chest 110:1566–1571

6. Bailey P, Thomsen GE, Spuhler VJ,Blair R, Jewkes J, Bezdjian L, Veale K,Rodriquez L, Hopkins RO (2007)Early activity is feasible and safe inrespiratory failure patients. Crit CareMed 35:139–145

7. Berney S, Denehy L (2002) A com-parison of the effects of manual andventilator hyperinflation on static lungcompliance and sputum production inintubated and ventilated intensive carepatients. Physiother Res Int 7:100–108

8. Berney S, Denehy L, Pretto J (2004)Head-down tilt and manual hyper-inflation enhance sputum clearancein patients who are intubated andventilated. Aust J Physiother 50:9–14

9. Blackwood B (1999) Normal saline in-stillation with endotracheal suctioning:primum non nocere (first do no harm).J Adv Nurs 29:928–934

10. Bott J, Carroll MP, Conway JH,Keilty SE, Ward EM, Brown AM,Paul EA, Elliot MW, Godfrey RC,Wedzicha JA, Moxham J (1993)Randomised controlled trial of nasalventilation in acute ventilatory failuredue to chronic obstructive airwaysdisease. Lancet 341:1555–1557

11. Burtin C, Clerckx B, Robbeets C,Gall S, Pillen R, Leclercq H, Caluwé K,Lommers B, Wilmer A, Troosters T,Ferdinande P, Gosselink R (2006)Effectiveness of early exercise in crit-ically ill patients: preliminary results.Intensive Care Med 32:109

12. Capdevila XJ, Perrigault PF, Perey PJ,Roustan JP, d’Athis F (1995) Occlusionpressure and its ratio to maximum inspi-ratory pressure are useful predictors forsuccessful extubation following T-pieceweaning trial. Chest 108:482–489

13. Carson SS, Bach PB (2002) The epi-demiology and costs of chronic criticalillness. Crit Care Clin 18:461–476

14. Chang A, Paratz J, Rollston J (2002)Ventilatory effects of neurophysiologi-cal facilitation and passive movement inpatients with neurological injury. AustJ Physiother 48:305–310

15. Chang AT, Boots R, Hodges PW,Paratz J (2004) Standing with assis-tance of a tilt table in intensive care:a survey of Australian physiotherapypractice. Aust J Physiother 50:51–54

16. Chiang LL, Wang LY, Wu CP, Wu HD,Wu YT (2006) Effects of physicaltraining on functional status in patientswith prolonged mechanical ventilation.Phys Ther 86:1271–1281

17. Combes A, Costa MA, Trouillet JL,Baudot J, Mokhtari M, Gibert C,Chastre J (2003) Morbidity, mortal-ity, and quality-of-life outcomes ofpatients requiring > or = 14 days ofmechanical ventilation. Crit Care Med31:1373–1381

18. Confalonieri M, Potena A, Carbone G,Porta RD, Tolley EA, Umberto MG(1999) Acute respiratory failure inpatients with severe community-acquired pneumonia. A prospectiverandomized evaluation of noninvasiveventilation. Am J Respir Crit Care Med160:1585–1591

19. Copnell B, Fergusson D (1995) Endo-tracheal suctioning: time-worn ritualor timely intervention? Am J Crit Care4:100–105

20. Corrado A, Roussos C, Ambrosino N,Confalonieri M, Cuvelier A, Elliott M,Ferrer M, Gorini M, Gurkan O, Muir JF,Quareni L, Robert D, Rodenstein D,Rossi A, Schoenhofer B, Simonds AK,Strom K, Torres A, Zakynthinos S(2002) Respiratory intermediate careunits: a European survey. Eur RespirJ 20:1343–1350

21. De Jonghe B, Bastuji-Garin S, Shar-shar T, Outin H, Brochard L (2004)Does ICU-acquired paresis lengthenweaning from mechanical ventilation?Intensive Care Med 30:1117–1121

22. Dean E (1997) Oxygen transportdeficits in systemic disease and impli-cations for physical therapy. Phys Ther77:187–202

23. Dean E, Ross J (1992) Discordancebetween cardiopulmonary physiologyand physical therapy. Toward a rationalbasis for practice. Chest 101:1694–1698

24. Dehaven CB Jr., Hurst JM, Branson RD(1985) Postextubation hypoxemiatreated with a continuous positiveairway pressure mask. Crit Care Med13:46–48

25. Dodek P, Keenan S, Cook D, Hey-land D, Jacka M, Hand L, Muscedere J,Foster D, Mehta N, Hall R, Brun-Buisson C (2004) Evidence-based clini-cal practice guideline for the preventionof ventilator-associated pneumonia.Ann Intern Med 141:305–313

26. Eisner MD, Thompson T, Hudson LD,Luce JM, Hayden D, Schoenfeld D,Matthay MA (2001) Efficacy of lowtidal volume ventilation in patients withdifferent clinical risk factors for acutelung injury and the acute respiratorydistress syndrome. Am J Respir CritCare Med 164:231–236

27. Ely EW, Baker AM, Dunagan DP,Burke HL, Smith AC, Kelly PT, John-son MM, Browder RW, Bowton DL,Haponik EF (1996) Effect on theduration of mechanical ventilationof identifying patients capable ofbreathing spontaneously. N Engl J Med335:1864–1869

28. Esteban A, Alia I, Ibanez J, Benito S,Tobin MJ (1994) Modes of mechanicalventilation and weaning. A nationalsurvey of Spanish hospitals. The Span-ish Lung Failure Collaborative Group.Chest 106:1188–1193

29. Fletcher SN, Kennedy DD, Ghosh IR,Misra VP, Kiff K, Coakley JH, Hinds CJ(2003) Persistent neuromuscular andneurophysiologic abnormalities in long-term survivors of prolonged criticalillness. Crit Care Med 31:1012–1016

30. Fontaine DK (1994) Nonpharmacologicmanagement of patient distress duringmechanical ventilation. Crit Care Clin10:695–708

31. Gayan-Ramirez G, Decramer M (2002)Effects of mechanical ventilation ondiaphragm function and biology. EurRespir J 20:1579–1586

32. Gayan-Ramirez G, Testelmans D,Maes K, Racz GZ, Cadot P, Zador E,Wuytack F, Decramer M (2005) Inter-mittent spontaneous breathing protectsthe rat diaphragm from mechanicalventilation effects. Crit Care Med33:2804–2809

33. Gibson JNA, Smith K, Rennie MJ(1988) Prevention of disuse muscleatrophy by means of electrical stimula-tion: maintenance of protein synthesis.Lancet 2(8614):767–769

34. Goldman JM, Rose LS, Williams SJ,Silver JR, Denison DM (1986) Effectof abdominal binders on breathing intetraplegic patients. Thorax 41:940–945

1197

35. Gomez-Merino E, Sancho J, Marin J,Servera E, Blasco ML, Belda FJ,Castro C, Bach JR (2002) Mechanicalinsufflation-exsufflation: pressure,volume, and flow relationships andthe adequacy of the manufacturer’sguidelines. Am J Phys Med Rehabil81:579–583

36. Greenbaum DM, Millen JE, Eross B,Snyder JV, Grenvik A, Safar P (1976)Continuous positive airway pressurewithout tracheal intubation in spon-taneously breathing patients. Chest69:615–620

37. Gregg RW, Friedman BC, Williams JF,McGrath BJ, Zimmerman JE (1990)Continuous positive airway pressureby face mask in Pneumocystis cariniipneumonia. Crit Care Med 18:21–24

38. Griffiths RD, Palmer A, Helliwell T,Maclennan P, Macmillan RR (1995)Effect of passive stretching on thewasting of muscle in the critically ill.Nutrition 11:428–432

39. Grill E, Quittan M, Huber EO, Boldt C,Stucki G (2005) Identification ofrelevant ICF categories by health pro-fessionals in the acute hospital. DisabilRehabil 27:437–445

40. Hall JB, Wood LD (1987) Liberation ofthe patient from mechanical ventilation.JAMA 257:1621–1628

41. Herridge MS, Cheung AM, Tansey CM,Matte-Martyn A, Diaz-Granados N,Al Saidi F, Cooper AB, Guest CB,Mazer CD, Mehta S, Stewart TE,Barr A, Cook D, Slutsky AS (2003)One-year outcomes in survivors of theacute respiratory distress syndrome.N Engl J Med 348:683–693

42. Hinderer SR, Dixon K (2001) Physio-logic and clinical monitoring of spastichypertonia. Phys Med Rehabil Clin NAm 12:733–746

43. Hodgson C, Ntoumenopoulos G, Daw-son H, Paratz J (2007) The MaplesonC circuit clears more secretions thanthe Laerdal circuit during manual hy-perinflation in mechanically-ventilatedpatients: a randomised cross-over trial.Aust J Physiother 53:33–38

44. Holliday JE, Hyers TM (1990) Thereduction of weaning time from me-chanical ventilation using tidal volumeand relaxation biofeedback. Am RevRespir Dis 141:1214–1220

45. Ibanez J, Raurich JM, Abizanda R,Claramonte R, Ibanez P, Bergada J(1981) The effect of lateral positionson gas exchange in patients withunilateral lung disease during mechan-ical ventilation. Intensive Care Med7:231–234

46. Jenkins SC, Soutar SA, Moxham J(1988) The effects of posture on lungvolumes in normal subjects and inpatients pre- and post-coronary arterysurgery. Physiotherapy 74:492–496

47. Jones AYM, Hutchinson RC, Oh TE(1992) Chest physiotherapy practicein intensive care units in Australia, theUK and Hong Kong. Physiother TheoryPract 8:39–47

48. Jones C, Macmillan RR, Griffiths RD(1994) Providing psychological supportfor patients after critical illness. ClinIntensive Care 5:176–179

49. Jones C, Skirrow P, Griffiths RD,Humphris GH, Ingleby S, Eddle-ston J, Waldmann C, Gager M (2003)Rehabilitation after critical illness:a randomized, controlled trial. Crit CareMed 31:2456–2461

50. King J, Crowe J (1998) Mobilizationpractices in Canadian critical care units.Physiother Can 50:206–211

51. Kollef MH, Shapiro SD, Silver P,St.John RE, Prentice D, Sauer S,Ahrens TS, Shannon W, Baker-Clinkscale D (1997) A randomized,controled trial of protocol-directedversus physician-directed weaning frommechanical ventilation. Crit Care Med25:567–574

52. Kraemer WJ, Adams K, Cafarelli E,Dudley GA, Dooly C, Feigenbaum MS,Fleck SJ, Franklin B, Fry AC, Hoff-man JR, Newton RU, Potteiger J,Stone MH, Ratamess NA, Triplett-McBride T (2002) American Collegeof Sports Medicine position stand.Progression models in resistance train-ing for healthy adults. Med Sci SportsExerc 34:364–380

53. Kramer N, Meyer TJ, Meharg J,Cece RD, Hill NS (1995) Randomized,prospective trial of noninvasive positivepressure ventilation in acute respiratoryfailure. Am J Respir Crit Care Med151:1799–1806

54. Krishnan JA, Moore D, Robeson C,Rand CS, Fessler HE (2004) A prospec-tive, controlled trial of a protocol-basedstrategy to discontinue mechanicalventilation. Am J Respir Crit Care Med169:673–678

55. Kwan MW, Ha KW (2002) Splintingprogramme for patients with burnthand. Hand Surg 7:231–241

56. Laghi F, Cattapan SE, Jubran A,Parthasarathy S, Warshawsky P,Choi YS, Tobin MJ (2003) Is weaningfailure caused by low-frequency fatigueof the diaphragm? Am J Respir CritCare Med 167:120–127

57. Langou RA, Wolfson S, Olson EG,Cohen LS (1977) Effects of orthostaticpostural changes on myocardial oxygendemands. Am J Cardiol 39:418–421

58. Lindgren S, Almgren B, Hogman M,Lethvall S, Houltz E, Lundin S, Sten-qvist O (2004) Effectiveness and sideeffects of closed and open suctioning:an experimental evaluation. IntensiveCare Med 30:1630–1637

59. Lorente L, Lecuona M, Martin MM,Garcia C, Mora ML, Sierra A (2005)Ventilator-associated pneumonia usinga closed versus an open tracheal suctionsystem. Crit Care Med 33:115–119

60. Mackenzie CF, Shin B (1985) Car-diorespiratory function before and afterchest physiotherapy in mechanicallyventilated patients with post-traumaticrespiratory failure. Crit Care Med13:483–486

61. Mancinelli-Van Atta J, Beck SL(1992) Preventing hypoxemia andhemodynamic compromise related toendotracheal suctioning. Am J Crit Care1:62–79

62. Marini JJ, Pierson DJ, Hudson LD(1979) Acute lobar atelectasis:a prospective comparison of fiberopticbronchoscopy and respiratory therapy.Am Rev Respir Dis 119:971–978

63. Marini JJ, Smith TC, Lamb V (1986)Estimation of inspiratory musclestrength in mechanically ventilatedpatients: the measurement of maxi-mal inspiratory pressure. J Crit Care1:32–38

64. Martin AD, Davenport PD,Franceschi AC, Harman E (2002) Useof inspiratory muscle strength trainingto facilitate ventilator weaning: a seriesof 10 consecutive patients. Chest122:192–196

65. Martin D, Davenport PW, Gonzalez-Rothi J, Baz M, Banner J, Caruso L,Layon J, Gabrielli A (2006) Inspiratorymuscle strength training improvesoutcome in failure to wean patients.p 369s

66. Martin UJ, Hincapie L, Nimchuk M,Gaughan J, Criner GJ (2005) Impact ofwhole-body rehabilitation in patients re-ceiving chronic mechanical ventilation.Crit Care Med 33:2259–2265

67. Masip J, Roque M, Sanchez B, Fer-nandez R, Subirana M, Exposito JA(2005) Noninvasive ventilation inacute cardiogenic pulmonary edema:systematic review and meta-analysis.JAMA 294:3124–3130

68. Maxwell L, Ellis E (1998) Secretionclearance by manual hyperinflation:possible mechanisms. PhysiotherTheory Pract 14:189–197

69. Milberg JA, Davis DR, Steinberg KP,Hudson LD (1995) Improved survivalof patients with acute respiratory dis-tress syndrome (ARDS): 1983–1993.JAMA 273:306–309

70. Montuclard L, Garrouste-Org, Tim-sit JF, Misset B, De Jonghe B, Carlet J(2000) Outcome, functional autonomy,and quality of life of elderly patientswith a long-term intensive care unitstay. Crit Care Med 28:3389–3395

71. Morris PE (2007) Early mobility of theICU patient. Crit Care Clin 23:1–116

1198

72. Moser DK, Chung ML, McKinley S,Riegel B, An K, Cherrington CC,Blakely W, Biddle M, Frazier SK,Garvin BJ (2003) Critical care nursingpractice regarding patient anxietyassessment and management. IntensiveCrit Care Nurs 19:276–288

73. Nava S (1998) Rehabilitation of pa-tients admitted to a respiratory intensivecare unit. Arch Phys Med Rehabil79:849–854

74. Nava S, Ambrosino N, Clini E, Prato M,Orlando G, Vitacca M, Brigada P, Frac-chia C, Rubini F (1998) Noninvasivemechanical ventilation in the weaningof patients with respiratory failuredue to chronic obstructive pulmonarydisease. A randomized, controlled trial.Ann Intern Med 128:721–728

75. Nava S, Gregoretti C, Fanfulla F,Squadrone E, Grassi M, Carlucci A,Beltrame F, Navalesi P (2005) Nonin-vasive ventilation to prevent respiratoryfailure after extubation in high-riskpatients. Crit Care Med 33:2465–2470

76. Nelson BJ, Weinert CR, Bury CL,Marinelli WA, Gross CR (2000) Inten-sive care unit drug use and subsequentquality of life in acute lung injurypatients. Crit Care Med 28:3626–3630

77. Norrenberg M, Vincent JL (2000)A profile of European intensive careunit physiotherapists. European Societyof Intensive Care Medicine. IntensiveCare Med 26:988–994

78. Paratz J, Burns Y (1993) The effect ofrespiratory physiotherapy on intracra-nial pressure, mean arterial pressure,cerebral perfusion pressure and endtidal carbon dioxide in ventilated neu-rosurgical patients. Physiother TheoryPract 9:3–11

79. Partsch H (2002) Bed rest versus ambu-lation in the initial treatment of patientswith proximal deep vein thrombosis.Curr Opin Pulm Med 8:389–393

80. Plant PK, Owen JL, Parrott S, El-liott MW (2003) Cost effectiveness ofward based non-invasive ventilationfor acute exacerbations of chronic ob-structive pulmonary disease: economicanalysis of randomised controlled trial.BMJ 326:956

81. Polkey MI, Moxham J (2001) Clin-ical aspects of respiratory muscledysfunction in the critically ill. Chest119:926–939

82. Porta R, Vitacca M, Gile LS, Clini E,Bianchi L, Zanotti E, Ambrosino N(2005) Supported arm training in pa-tients recently weaned from mechanicalventilation. Chest 128:2511–2520

83. Ram FS, Lightowler JV, Wedzicha JA(2003) Non-invasive positive pressureventilation for treatment of respira-tory failure due to exacerbations ofchronic obstructive pulmonary dis-ease. Cochrane Database Syst RevCD004104

84. Redfern J, Ellis E, Holmes W (2001)The use of a pressure manometerenhances student physiotherapists’ per-formance during manual hyperinflation.Aust J Physiother 47:121–131

85. Richard R, Ward RS (2005) Splintingstrategies and controversies. J BurnCare Rehabil 26:392–396

86. Richards K, Nagel C, Markie M,Elwell J, Barone C (2003) Use ofcomplementary and alternative thera-pies to promote sleep in critically illpatients. Crit Care Nurs Clin North Am15:329–340

87. Richards KC (1994) Sleep promotion inthe critical care unit. AACN Clin IssuesCrit Care Nurs 5:152–158

88. Richards KC, Gibson R, Overton-McCoy AL (2000) Effects of massagein acute and critical care. AACN ClinIssues 11:77–96

89. Rocker GM, Mackenzie MG,Williams B, Logan PM (1999)Noninvasive positive pressure venti-lation: successful outcome in patientswith acute lung injury/ARDS. Chest115:173–177

90. Roussos C (1985) Function and fa-tigue of respiratory muscles. Chest88:124S–132S

91. Salter RB (1989) The biologic conceptof continuous passive motion of syn-ovial joints. The first 18 years of basicresearch and its clinical application.Clin Orthop Relat Res 242:12–25

92. Schwartz Cowley R, Swanson B, Chap-man P, Mackay LE (1994) The role ofrehabilitation in the intensive care unit.J Head Trauma Rehabil 9:32–42

93. Sharp JT, Druz WS, Moisan T, Foster J,Machnach W (1980) Postural relief ofdyspnea in severe chronic obstructivepulmonary disease. Am Rev Respir Dis122:201–211

94. Sim J (1998) Interpersonal aspectsof care: communication, counsellingand health education. In: Pryor JA,Webber BA (eds) Physiotherapy forrespiratory and cardiac problems.Churchill Livingstone, Edinburgh,pp 211–226

95. Singer M, Vermaat J, Hall G, Latter G,Patel M (1994) Hemodynamic effectsof manual hyperinflation in critically illmechanically ventilated patients. Chest106:1182–1187

96. Sivasothy P, Brown L, Smith IE,Shneerson JM (2001) Effect of man-ually assisted cough and mechanicalinsufflation on cough flow of normalsubjects, patients with chronic ob-structive pulmonary disease (COPD),and patients with respiratory muscleweakness. Thorax 56:438–444

97. Squadrone V, Coha M, Cerutti E,Schellino MM, Biolino P, Occella P,Belloni G, Vilianis G, Fiore G, Cav-allo F, Ranieri VM (2005) Continuouspositive airway pressure for treatment ofpostoperative hypoxemia: a randomizedcontrolled trial. JAMA 293:589–595

98. Stiller K (2000) Physiotherapy inintensive care. Towards an evidencebased practice. Chest 118:1801–1813

99. Stiller K, Jenkins S, Grant R, Geake T,Taylor J, Hall B (1996) Acute lobaratelectasis: a comparisosn of five phys-iotherapy regimens. Physiother TheoryPract 12:197–209

100.Stiller K, Philips A (2003) Safety as-pects of mobilising acutely ill patients.Physiother Theory Pract 19:239–257

101.Stoll C, Schelling G, Goetz AE, Kil-ger E, Bayer A, Kapfhammer HP,Rothenhausler HB, Kreuzer E, Reich-art B, Peter K (2000) Health-relatedquality of life and post-traumatic stressdisorder in patients after cardiac surgeryand intensive care treatment. J ThoracCardiovasc Surg 120:505–512

102.Stoller JK, Mascha EJ, Kester L,Haney D (1998) Randomized con-trolled trial of physician-directedversus respiratory therapy consultservice-directed respiratory care toadult non-ICU inpatients. Am J RespirCrit Care Med 158:1068–1075

103.Thomas DC, Kreizman IJ, Melchiorre P,Ragnarsson KT (2002) Rehabilitationof the patient with chronic criticalillness. Crit Care Clin 18:695–715

104.Topp R, Ditmyer M, King K, Do-herty K, Hornyak J III (2002) The effectof bed rest and potential of prehabili-tation on patients in the intensive careunit. AACN Clin Issues 13:263–276

105.Unoki T, Kawasaki Y, Mizutani T,Fujino Y, Yanagisawa Y, Ishimatsu S,Tamura F, Toyooka H (2005) Effectsof expiratory rib-cage compression onoxygenation, ventilation, and airway-secretion removal in patients receivingmechanical ventilation. Respir Care50:1430–1437

106.Van ’t Hul A, Gosselink R, Hollander P,Postmus P, Kwakkel G (2006) Trainingwith inspiratory pressure support inpatients with severe COPD. Eur RespirJ 27:65–72

1199

107.Walsh D (1991) Nocioceptive pathways– relevance to the physiotherapist.Physiotherapy 77:317–321

108.Wenger NK (1982) Early ambulation:the physiologic basis revisited. AdvCardio 31:138–141

109.Winkelman C, Higgins PA, Chen YJ,Levine AD (2007) Cytokines in chroni-cally critically ill patients after activityand rest. Biol Res Nurs 8:261–271

110.Wood CJ (1998) Endotracheal suction-ing: a literature review. Intensive CritCare Nurs 14:124–136

111.Yang KL, Tobin MJ (1991) A prospec-tive study of indexes predicting theoutcome of trials of weaning frommechanical ventilation. N Engl J Med234:1445–1450

112.Yohannes AM, Connolly MJ (2003)Early mobilization with walking aidsfollowing hospital admission withacute exacerbation of chronic obstruc-tive pulmonary disease. Clin Rehabil17:465–471

113.Zafiropoulos B, Alison JA, McCarren B(2004) Physiological responses to theearly mobilisation of the intubated,ventilated abdominal surgery patient.Aust J Physiother 50:95–100

114.Zanotti E, Felicetti G, Maini M,Fracchia C (2003) Peripheral musclestrength training in bed-bound patientswith COPD receiving mechanicalventilation. Effect of electricalstimulation. Chest 124:292–296

R. Gosselink (�)Katholieke Universiteit Leuven, RespiratoryRehabilitation, Faculty of Kinesiology andRehabilitation Sciences,Tervuursevest 101, 3000 Leuven, Belgiume-mail: rik.gosselink@uz.kuleuven.ac.be

J. BottSurrey Primary Care Trust, RespiratoryCare Team,Chertsey, UK

M. JohnsonMeath and National Children’s Hospital,Physiotherapy Department,Dublin, Ireland

E. DeanUniversity of British Columbia, Schoolof Rehabilitation Sciences,Vancouver, Canada

S. NavaFondazione S. Maugeri Istituto Scientificodi Pavia, Respiratory Intensive Care Unit,I.R.C.C.S. Pavia, Italy

M. Norrenberg · J. L. VincentErasme Hospital (Free University ofBrussels), Department of Intensive Care,Brussels, Belgium

B. SchönhoferKlinikum Region Hannover, KrankenhausOststadt-Heidehaus, AbteilungPneumologie und InternistischeIntensivmedizin,Hannover, Germany

K. StillerRoyal Adelaide Hospital, PhysiotherapyDepartment,Adelaide, South Australia, Australia

H. van de LeurHanze University Groningen, Faculty forHealth Studies, School of Physiotherapy,Groningen, The Netherlands