ICU management

A Physiotherapists perspective

Chest Physiotherapy is
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.

Indications
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

contd

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

Assessment

Neurological system Cardiovascular system Respiratory system Renal system Hematological system Gastrointestinal system

Neurological system

Level of consciousness Pupils

Size Reactivity Equality CPP = MAP- ICP

Cerebral perfusion pressure (>70mmHg)

Intracranial pressure (<10mmHg)

Intracranial pressure measurement

Cardiovascular system

Heart rate and rhythm Arterial BP Central Venous pressure Pulmonary Artery pressure (PAP) and pulmonary artery wedge pressure (PCWP)

Respiratory system

Auscultation Percussion Expansion Chest X-ray Mode of ventilation Humidification Oxygen therapy RR Airway pressures ABG Sputum

Renal system

Assessment of fluid balance

Measure of Intravascular volumes Urine output Serum electrolytes ABG

Gastrointestinal system

Nutritional support

Routes of administration Enteral Parentral Oral

Assessment
General Observation Patient Position

Respiration

- Airway ET/Tracheostomy
Ventillator Mode FiO2

Vital Signs Temperature, BP, RR, HR SpO2,GCS, ICP

Tubes - NG Tube, CV line, Peripheral line, Chest tubes, Catheters Drugs

 contd

Examination

Auscultations Respiratory pattern Cyanosis Clubbing Radiograph

Goals

Prevent accumulation of secretions Improve mobilization and drainage of

secretions

Promote relaxation to improve breathing

patterns

Promote improved respiratory function

Improve cardio-pulmonary exercise tolerance

Teach bronchial hygiene programs to

patients with chronic respiratory dysfunction

Precautions

Untreated tension pneumothorax

Abnormal coagulation profile

Status epilepticus or status asthamaticus Immediately following intra cranial surgery

Head injury with raised ICP Osteoporotic bones Recent acute myocardial infarction, unstable vitals

Immediately after tube feedings

Sutures and ICDs

Physiotherapy Techniques

Physiotherapy Techniques

Gravity-assisted Positioning Manual techniques Manual hyperinflation Airway suctioning Mobilisation

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)

Postural Drainage isnt

a separate technique. Its just an example of positioning which has the particular aim of clearing airway secretions with the assistance of gravity.

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).

Positioning

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).

contd

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)

contd

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

Positioning

Which position to choose

Chest Maneuver

Chest Maneuver

Chest Vibrations

Chest Percussion/Clapping

Clapping/Chest Percussion

Percussion consists of rhythmic clapping on the chest with loose wrist & cupped hand. Effect : Dislodges & loosens secretions from the lung

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

Manual Hyperinflation

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 the ventilator (chest, 1994).

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 PEEP

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

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

Contraindication

Frank haemoptysis Severe brochospasm Undrained pneumothorax Compromised cardiovascular system

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

Hazards of suctioning

Mucosal trauma Cardiac arrhythmias Hypoxia Raised intracranial pressure

Nasal and oral suction Endotracheal suction Tracheostomy suction Closed-circuit suction

Closed-circuit suction

Mobilisation

Mobilisation

Critically Ill

(Frequent Position changes, Kinetic & Kinematic Therapy)

Stable

(Progressive tilting & Ambulation)

Mobilisation

ICU rehabilitation has been shown to accelerate recovery (oleary & 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