List Care Protocol

Physiotherapy Care Protocol : Critically Ill Adult
Contents Page
1. DEFINITION 2
2. OVERVIEW 3
3. PART 1 : CRITICALLY ILL ADULT WITH MECHANICAL VENTILATION 4
GOALS OF TREATMENT 5
ASSESSMENT 6-12
INTERVENTION 13-19
4 PART 2 : CRITICALLY ILL ADULT WITHOUT MECHANICAL VENTILATION 20

GOALS OF TREATMENT 21-22
ASSESSMENT 22-28
INTERVENTION 29-36
5. REFERENCES 37
6. GLOSSARY 38-39
7. ALGORITHM 1 - MANAGEMENT OF CRITICALLY ILL ADULT WITH 40
MECHANICAL VENTILATORY SUPPORT
2 - MANAGEMENT OF CRITICALLY ILL ADULT WITHOUT 41
MECHANICAL VENTILATORY SUPPORT
8. APPENDIX 1 – UNIVERSAL PRECAUTION 43-44
2 – GLASGOW COMA SCORE 45
3 – ACTIVE CYCLE OF BREATHING TECHNIQUE 46
4 – ARTERIAL BLOOD GASES 47
5 – DRUGS FOR THE NEUROLOGICAL SYSTEM 48-49
6 – DRUGS FOR THE CARDIOVASCULAR SYSTEM 50-51
7 – DRUGS FOR THE RESPIRATORY SYSTEM 52
8 – POSTURAL DRAINAGE POSITIONS 53-54
9 – MODIFIED POSTURAL DRAINAGE POSITIONS 55
Technical Committee, Physiotherapy Profession, July 2003 1

1. DEFINITION
DEFINITION OF CRITICALLY ILL ADULTS
Critically ill adults (CIA) are defined as those patients who have a critical illness or injury
which acutely impairs one or more vital organs systems such that the patient’s survival is
jeopardized. (http:// www. chestnet.org)
DEFINITION OF CRITICAL CARE
Critical care is care for patients who have potentially recoverable conditions and who can
benefit from more detailed observation (with or without invasive treatment) in the intensive
and high-dependency unit than can be provided safely in a general ward.
(http:// www. chestnet.org)

2. OVERVIEW
Critical care services include decision making of high complexity but are not limited to the
treatment or prevention of or further deterioration of central nervous failure, circulatory
failure, shock –like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative
complications, or overwhelming infection.
Critical care is usually, but not always, given in a critical care area, such as the coronary
care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.
The critical unit has an emphasis on early mobilisation and exercise as an integral part of
the patient’s care, to counteract the deleterious effects of bed rest.
Physiotherapy is regarded as an integral part to the daily management of adult patients in
the critical care settings. Therefore the critical care unit will require the physiotherapist to
have a broad general experience, as patient management will call upon all fields of
physiotherapy.
The implication of protocol for improving the care of critically ill patients appear substancial:
- Reduced duration for mechanical ventilation and increased rate of
successful extubation.
- Shorter length of stay in intensive care unit and hospital.
- Lower rate of nosocomial infection.
• Evidence showed that the cost of ICU care was reduced by more than
USD5000 (RM 18,500) per patient among those treated with a weaning
protocol compared with those weaned without a protocol.

PART 1
CRITICALLY ILL ADULT WITH
MECHANICAL VENTILATORY
SUPPORT
3. CRITICALLY ILL ADULT WITH MECHANICAL VENTILATORY

SUPPORT
This Care Protocol will be initiated for a patient :

- Through a blanket referral unless advised otherwise by doctor in-charge.
- Through a referral depending on the policy of the hospital.
GOALS OF TREATMENT
A. Attainment of optimal cardiopulmonary function

• Maintain / improve airway clearance.
• Improve gas exchange and prevent atelectasis and consolidation.
• Decrease ventilation / perfusion mismatch.
• Improve lung volumes.
• Improve in functional residual capacity.
• Reeducate work of breathing
• Mobilise the thoracic cage.
B. Attainment of optimal musculo-skeletal function

• Preserve skin integrity.
• Stimulate circulation to prevent post-operative thromboemboli and reduce oedema.
• Maintain / improve normal joint range and extensibility of muscles.
C. Attainment of optimal neurological function

• Improve mental status
• Relieve pain.
• Reduce abnormal muscle tone.
A. ASSESSMENT
• Assessment is carried out using the Cardiorespiratory Form :
Physio./ Ax. 11 / 2000, Kementerian Kesihatan Malaysia.
Examination particulars Parameters / Impact on Physiotherapy

Intervention
Initiate contact with patient. Personal data

Review medical records in bed head ticket History – current, past, family & social
Diagnosis
Subsequent contact with patient. Temperature :

Vital signs 36.5 – 37.5 C (Normal)
Sepsis : >38 C or < 36 C
Review medical records in observation chart /
information from monitoring Blood Pressure :
device : 120/80 mmHg (Normal)
Hypertension : > 145/95mm Hg
Hyportension : < 90/60mm Hg
Septic Shock : Systolic BP < 90mm Hg
Heart Rate :
70-100 bpm (Normal)
Tachycardia : > 100bpm
Bradycardia : < 60bpm
Sepsis : > 90bpm
Respiratory Rate :
12 – 16 breaths/m (Normal)
Tachypnoea : > 20breaths/min
Bradypnoea : < 10 breaths/min
Difficulty in weaning : > 25breaths/min
Sepsis : > 20breaths/min

Intervention
General observation of patient : (Refer Appendix 2)
Mental status (Glasgow Coma Score) GCS 3/15 : Minimal physiotherapy intervention
(Refer glossary)
Colour
Pink (Normal)
Cyanosis - central / peripheral
(Refer glossary)
Ventilatory Settings Invasive ventilation

- CMV, SIMV, CPAP
(Refer Glossary)
Tidal volume
- 6–10ml/kg of body weight or >300ml (Normal)
- <300ml / >700ml (difficulty in weaning)
PEEP
- < 5cm H2O (criteria for weaning)
- >10cm H2O ( no manual hyperinflation and
close system suctioning is indicated )
(Refer Glossary)


Intervention
Oxygen Therapy Devices & oxygen flow rate / min :

( depending on ABG results)
- High flow mask > 15 l/min

- Venturi mask
60% oxygen (15 l/min)
40% oxygen (10l/min)
35% oxygen ( 8 l/min )
28% oxygen ( 6l/min)
- Nasal prong < 6l/min
Arterial Blood Gases Normal Values :

pH 7.35 – 7.45
PaCo2 35 – 45mmHg ( 4.7 – 6.0 kPa )
PaO2 80 –100 mmHg (10.7 – 7.45 kPa )
HCO2 22 – 26 mmol
BXS -2 to + 2 mmol
SaO2 > 95%
(Refer Appendix 4)
Pulse Oximetry Reading Arterial oxygen saturation :

> 95% (Normal)
< 95% (Stop physiotherapy intervention till
oxygen saturation picks up)

Intervention
Cerebral status ICP :

< 10 mmHg (Normal)
> 25 mmHg (Critical level, stop intervention)
CPP :
> 70mm Hg (Normal)
< 50mm Hg (Stop intervention)
Fluid Balance Normal :

+/- daily balance : 700 –1000ml
Implications :
If < 700ml (will cause dehydra tion)
If > 1000ml (may lead to Acute Pulmonary
Oedema)
Medication (Refer Appendix 5, 6 & 7 )

Examination Particulars Parameters / Impact on Physiotherapy
Intervention
Respiratory assessment : Normal :
Chest x-ray Clear lung field

Abnormal :
• Lobar collapse – shift of trachea, raised
hemi-diaphragm and fissures may be
obviously displaced.
(Positioning is important)
• Consolidation – patchy opacity; localized
to lobe or segment
• Cavitation lesion – round dense area in
the lung field
(No clapping to be doned)
• Pleural effusion – loss of costophrenic
angles and seen as dense opacity
(Precaution during phyysiotherapy
intervention)
Pneumothorax – no lung markings
(No physiotherapy intervention if
chest tube is not inserted)
Shape of chest Deformities – barrel chest, pigeon chest

Intervention
Chest expansion Symmetrical / Asymmetrical

Normal :
• Thumb displacement of 3cm-5cm
Abnormal :
• Localized or unilateral diminished
movement due to consolidation, collapse,
fibrosis of lung
(Positioning is important.
If patient on CPAP mode emphasis on
breathing exercises on affected side)
Breathing pattern Abnormal :

• Prolonged expiration, I:E ratio 1:3 / 1:4
• Apnoea (absence of breathing > 15 sec)
• Hypopnoea (When patient on CPAP
mode,take precaution during intervention)
Percussion note Hyperresonant

Indicates :
• Pneumothorax, emphysema
Hyporesonant
Indicates :
• Pleural effusion, lung collapse,
consolidation, localized fibrosis

Interervention
Ascultation Abnormal breath sound :

• Crepitations
- inspiratory, expiratory, fine
coarse, localized or wide spread
(Ensure airway clearance)
• Rhonchi
- inspiratory and expiratory, localized
• Pleural rub
- localized, loud and generalized
• Stridor
- upper airway obstruction following
prolong intubation.
( No aggresive suctioning )
Sputum Quantity of sputum

Normal : < 100ml / 24 hours
Abnormal : > 100ml / 24hours
Colour
• Mucoid (clear or grey)
• Purrulent (yellow or green) - infection
• Frothy (white and bubbly)
• Red or black - haemoptysis
• Pink and frothy – acute pulmonary
oedema

ANALYSIS OF FINDINGS
Cardiopulmonary Status
- Level of cardiovascular and respiratory impairment
Musculo-skeletal status
- Level of impairment / disability
- Level of functional ability
Neurological status
- Level of neurological impairment
B. INTERVENTION
Chest physiotherapy
• Postural drainage
- enhance mucociliary clearance by use of gravitational effects to assist in movement
of bronchial secretions from peripheral to proximal central airways of a specific
bronchopulmonary segments
• Modified postural drainage

- may be indicated for patients with cardiovascular instability
to obtain an optimum position for effectiveness of removal of secretions
.
• Manual techniques
- shakings, vibrations & clapping
• Suctioning
- suctioning is carried out by use of a suction catheter (size of 12-14Fg Y) which must be
half the diameter of the endotrachael tube
- suctioning is done by applying 80-120 mm Hg / 25-30 kPa of suction pressure through
a catheter which is passed down the endotracheal tube to the level of the carina.
- there may be an increase of bronchial secretion in intubated patients as trachael
mucous membrane is irritated
- commence nebulisers half an hour prior to chest physiotherapy (if required)

Bronchial lavage
• 0.9% normal saline can be instilled into the endotrachael tube before the breath with
manual hyperinflation when necessary.
Humidification
• Ensure adequate humidification and systemic hydration to reduce secretion tenacity
because natural humidification has been bypassed for the intubated patient.
Manual hyperinflation ( MHI )

• MHI is indicated for :
- reexpansion of collapsed segments of the lungs
- promoting mobilization of pulmonary secretions toword the central airways
- improving oxygenation and lung compliance.
• Technique of MIH :
- involves disconnecting the patient from the ventilator and inflating the lungs with a
large tidal volume via a manual resuscitator bag.
- is usually performed by delivering a slow deep inspiration, an inspiratory hold, and a
quick release of the inflation bag to enhance expiratory flow rate
- do not carry out this procedure if PEEP is > 10cm H2O unless a hand-held PEEP is
available. ( Refer glossary )
. - a prolonged inspiratory hold is contraindicated in a patient who is already hyperinflated
e.g emphysema.
Positioning
• Aims of positioning :
To optimize oxygen transport through its effects of :-
- improving ventilation / perfusion matching
- increasing lung volumes
- reducing the work of breathing
- minimising the work of the heart

• Frequent turning and careful positioning

- includes upright , prone or side lying positioning
- side lying with affected lung uppermost to improve ventilation perfusion matching for
unilateral lung disease
- side lying to reduce extensor tone
- footboards to prevent plantar-flexion contractures
- ankle / arm splint if necessary
Mobilisation
• Aims:
- To improve carrdiopulmonary function and oxyen transport.
- To provide gravitational stimulus for maintaining / restore normal fluid distribution in
the body
• Mobilisation comprises of :
- Passive movements
This is carried out when patient is unable to actively participate in the exercises.
- Active exercises
This is carried out for patient who is able to participate actively in the exercises with /
without assistance
Functional activities
• Sitting is encouraged to :
- increase funtional residual capacity.
- reduce hypotension, wrap lower extremities with elastic bandages from toe to groin
- improve trunk and abdominal support with appropriate braces / corsets.
• Encouraged patient to :
- shift from side to side & chair push ups to reduce ischial pressure weight
- assume sitting posture either independently or with assistance

Psychological support or patient / carer education

• When handling these patients, the physiotherapist should be compassionate,
understanding and show respect for the patient and his family.
Points to Note:
Do not discuss patient’s conditions while carrying out procedures.

Adhere strictly to the universal safety precautions on infection control
(Refer Appendix 1)
Treat all infectious cases last (MRSA, HIV, etc).
Do not carry out any chest physiotherapy on patient immediately after insertion of
neck line until a chest X-Ray rules out pneumothorax.
Always observe for any changes aggravating patient’s stability (vital signs).
Re-assess and modify treatment techniques if patient’s condition does not
improve.
Take necessary precautions for patients with fragile skin, osteoporosis,
bronchospasm, recent thoracic surgery, subacute emphysema.
Take appropriate precautions for patients with various monitoring/ treatment
devices e.g. arterial lines, catheter etc.
Ensure sedatives are given according to doctor’s instructions (when necessary)
prior to physiotherapy intervention.
FREQUENCY OF TREATMENT
• Physiotherapy intervention and frequency in critical care settings depends on :

- Specific treatment goals.
- Aggresiveness of treatment indicated.
- Impact of related problems on physiotherapy.
- Co-operation of patient.

CONTRAINDICATIONS
Note contraindications to certain treatment techniques, as follows :-
• Positioning should not be done in the following situations :

- Unstabilized head & neck injuries / trauma
- Recent spinal injury / surgery
- Acute haemorrhage and haemodynamic instability
- Pulmonary embolism
• Trendelenburg Position should be avoided when there is :

- Increased ICP > 20mmHg
- Aneurysm
• Reverse Trendelenburg should be avoided when patient is :

- Hypotensive
• Chest percussion should be avoided when patient has :

- Active Pulmonary Tuberculosis
- Dysarrhythmias
- Osteoporosis of thoraco-lumbar spine
- Acute bronchospasm
- Untreated tension pneumothorax
- Lung contusion
N.B.
The following cases are not indicated for physiotherapy intervention unless
requested by the doctor :
• The unstable patient
• Patients on cerebral resuscitation
• Patients having :
- Tetanus
- Pulmonary oedema

DOCUMENTATION
• Each patient encounter must be documented and signed legibly.
RE-EVALUATION
Re-assess treatment plan at each visit (patient encounter) or at a pre-established
frequency based on patient equity (needs/ condition).
Modify treatment interventions based on patient’s progress or specific physician’s
order.
COMMUNICATION
• Effective communication and teamwork among health care providers in the critical
unit Is important.
• Communicate with other health care professionals in-charge regarding modification
of physiotherapy intervention.

CRITERIA FOR DISCONTINUATION OF PHYSIOTHERAPY TREATMENT

Discuss with other health care professionals in-charge prior to discontinuation of
physiotherapy intervention.
Outcome Assessment Description
1 Change in sputum production. Sputum less 25 ml / day
2 Change in breath sounds. Normal breath sounds
3 Subjective change reported by How patient feels before, during and after therapy.
patient. Effective coughing.
4 Improved in vital signs. Improved in quality of sleep.
5 Change in chest radiograph. Resolution.
6 Change in improved gas exchange. Improved ABG.
7 Change in lung mechanics. Reduced resistance / increased compliance.

Changes consistent with resolution of atelectasis
and mucous plugging.

PART 2
CRITICALLY ILL ADULT WITHOUT
MECHANICAL VENTILATORY
SUPPORT
3. CRITICALLY ILL ADULT WITHOUT MECHANICAL

VENTILATORY SUPPORT
This Care Protocol will be initiated for a patient :

- Through a blanket referral unless advised otherwise by doctor in-charge.
- Through a referral depending on the policy of the hospital.
GOALS OF TREATMENT
A. Attainment of optimal cardiopulmonary function

• Maintain / improve airway clearance.
• Improve gas exchange and prevent atelectasis and consolidation.
• Decrease ventilation / perfusion mismatch.
• Improve lung volumes.
• Increase effectiveness of cough.
• Improve in functional residual capacity.
• Reeducate work of breathing
• Mobilise the thoracic cage.
B. Attainment of optimal musculo-skeletal function

• Preserve skin integrity.
• Stimulate circulation to prevent post-operative thromboemboli and reduce oedema.
• Maintain / improve normal joint range and extensibility of muscles.
C. Attainment of optimal neurological function

• Improve mental status
• Relieve pain.
• Reduce abnormal muscle tone.
D. Prevent the multitude of side effects of immobility and confinement to bed

• Increase muscle strength and endurance.
• Improve functional activities.
E. Support psychological and physical wellbeing

• Improve patient / family awareness and co-operation
A. ASSESSMENT
• Assessment is carried out using the Cardiorespiratory Form :
Physio./ Ax. 11 / 2000, Kementerian Kesihatan Malaysia.

Intervention
Initiate contact with patient. Personal data

Review medical records in bed head ticket History – current, past, family & social
Diagnosis
Subsequent contact with patient. Temperature :

Vital signs 36.5 – 37.5 C (Normal)
Sepsis : >38 C or < 36 C
Review medical records in observation chart /
information from monitoring Blood Pressure :
device : 120/80 mmHg (Normal)
Hypertension : > 145/95mm Hg
Hyportension : < 90/60mm Hg
Septic Shock : Systolic BP < 90mm Hg
Heart Rate :
70-100 bpm (Normal)
Tachycardia : > 100bpm
Bradycardia : < 60bpm
Sepsis : > 90bpm
Respiratory Rate :
12 – 16 breaths/m (Normal)
Tachypnoea : > 20breaths/min
Bradypnoea : < 10 breaths/min
Difficulty in weaning : > 25breaths/min
Sepsis : > 20breaths/min

Intervention
General observation of patient : (Refer Appendix 2)
Mental status (Glasgow Coma Score) GCS 3/15 : Minimal physiotherapy intervention
(Refer glossary)
Colour
Pink (Normal)
Cyanosis - central / peripheral
(Refer glossary)
Ventilatory Settings Non-Invasive ventilation

- BiPAP
(Refer Glossary)
Oxygen Therapy Devices & oxygen flow rate / min :

(depending on ABG results)
- High flow mask > 15 l/min

- Venturi mask
60% oxygen (15 l/min)
40% oxygen (10l/min)
35% oxygen ( 8 l/min )
28% oxygen ( 6l/min)
- Nasal prong < 6l/min

Intervention
Arterial Blood Gases Normal Values :

pH 7.35 – 7.45
PaCo2 35 – 45mmHg ( 4.7 – 6.0 kPa )
PaO2 80 –100 mmHg (10.7 – 7.45 kPa )
HCO2 22 – 26 mmol
BXS -2 to + 2 mmol
SaO2 > 95%
(Refer Appendix 4)
Pulse Oximetry Reading Arterial oxygen saturation :

> 95% (Normal)
< 95% (Stop physiotherapy intervention till
oxygen saturation picks up)
Cerebral status ICP :

< 10 mmHg (Normal)
> 25 mmHg (Critical level, stop intervention)
CPP :
> 70mm Hg (Normal)
< 50mm Hg (Stop intervention)

Intervention
Fluid Balance Normal :

+/- daily balance : 700 –1000ml
Implications :
If < 700ml (will cause dehydra tion)
If > 1000ml (may lead to Acute Pulmonary
Oedema)
Medication (Refer Appendix 5, 6 & 7)
Respiratory assessment : Normal :
Chest x-ray Clear lung field

Abnormal :
• Lobar collapse – shift of trachea, raised
hemi-diaphragm and fissures may be
obviously displaced.
• Consolidation – patchy opacity; localized
to lobe or segment
• Cavitation lesion – round dense area in
the lung field
(No clapping to be doned)
• Pleural effusion – loss of costophrenic
angles and seen as dense opacity
(Precaution during phyysiotherapy
intervention)
Pneumothorax – no lung markings
(No physiotherapy intervention if
chest tube is not inserted)

Intervention
Shape of chest Deformities – barrel chest, pigeon chest
Chest expansion Symmetrical / Asymmetrical

Normal :
• Thumb displacement of 3cm-5cm
Abnormal :
• Localized or unilateral diminished
movement due to consolidation, collapse,
fibrosis of lung
(Positioning is important.
If patient on CPAP mode emphasis on
breathing exercises on affected side)
Breathing pattern Abnormal :

• Prolonged expiration, I:E ratio 1:3 / 1:4
• Apnoea (absence of breathing > 15 sec)
• Hypopnoea
• Pursed lip breathing
Percussion note Hyperresonant

Indicates :
• Pneumothorax, emphysema
Hyporesonant
Indicates :
• Pleural effusion, lung collapse,
consolidation, localized fibrosis


Interervention
Ascultation Abnormal breath sound :

• Crepitations
- inspiratory, expiratory, fine
coarse, localized or wide spread
• Rhonchi
- inspiratory and expiratory, localized
• Pleural rub
- localized, loud and generalized
• Stridor
- upper airway obstruction following
prolong intubation.
(No aggressive suctioning)
Sputum Quantity of sputum

Normal : < 100ml / 24 hours
Abnormal : > 100ml / 24hours
Colour
• Mucoid (clear or grey)
• Purrulent (yellow or green) - infection
• Frothy (white and bubbly)
• Red or black - haemoptysis
• Pink and frothy – acute pulmonary
oedema


Interervention
Respiratory function test Peak expiratory flow rate (PEFR)

Female : 300-500l/min (Normal)
Male : 450-700l/min (Normal)
Incentive Spirometry Value according to sex and height of patient

(Refer to equipment catalogue)

ANALYSIS OF FINDINGS
Cardiopulmonary Status
- Level of cardiovascular and respiratory impairment
Musculo-skeletal status
- Level of impairment / disability
- Level of functional ability
Neurological status
- Level of neurological impairment
B. INTERVENTION
Chest physiotherapy
• Postural drainage
- enhance mucociliary clearance by use of gravitational effects to assist in movement
of bronchial secretions from peripheral to proximal central airways of a specific
bronchopulmonary segments
• Modified postural drainage

- may be indicated for patients with cardiovascular instability
to obtain an optimum position for effectiveness of removal of secretions
.
• Manual techniques
- shakings, vibrations & clapping
• Suctioning
- suctioning is carried out by use of a suction catheter (size of 12-14Fg Y)
- suctioning is done by applying 80-120 mm Hg / 25-30 kPa of suction pressure through
a catheter which is passed down the oral cavity to the level of the carina.
- commence nebulisers half an hour prior to chest physiotherapy (if required)

Humidification
• Ensure adequate humidification and systemic hydration to reduce secretion tenacity
Active cycle of breathing technique (ACBT)

• ACBT is carried out if patient has ineffective cough, decreased ciliary action, loss of sigh
breaths in patient associated with tracheal intubation
(Refer Appendix 3)
Incentive Spirometry
• To improve lung volume
• Encourage patient to hold his breath 1-3 seconds at full inspiration
Positioning
• Aims of positioning :
To optimize oxygen transport through its effects of :-
- improving ventilation / perfusion matching
- increasing lung volumes
- reducing the work of breathing
- minimising the work of the heart
• Frequent turning and careful positioning

- includes upright , prone or side lying positioning
- side lying with affected lung uppermost to improve ventilation perfusion matching for
unilateral lung disease
- side lying to reduce extensor tone.
- footboards to prevent plantar-flexion contractures.
- ankle / arm splint if necessary.

Mobilisation
• Aims:
- To improve carrdiopulmonary function and oxyen transport..
- To provide gravitational stimulus for maintaining / restore normal fluid distribution in
the body.
• Mobilisation comprises of :
- Passive movements
This is carried out when patient is unable to actively participate in the exercises.
- Active exercises
This is carried out for patient who is able to participate activiely in the exercises with /
without assistance.
- Repetitive / resisted excersises

Manual / mechanical exercises is carried out to improve strength and endurance.
- Continous passive motion ( C.P.M. )

This is carried out to improve range of motion and tissue healing, decreased pain and
oedema following joint replacement or repair.
• Sitting
Sitting is encouraged to :
- increase funtional residual capacity.
- reduce hypotension, wrap lower extremities with elastic bandages from toe to groin
- improve trunk and abdominal support with appropriate braces / corsets.
Encourage patient to :
- shift from side to side & chair push ups to reduce ischial pressure weight
- assume sitting posture either independently or with assistance
• Standing
- tilt table ( if available ) can be used for re-orientating patients to weight bearing and
the upright position particularly following extensive periods of immobilization.
• Ambulation with / without aids

- is encouraged as this diminishes the need for vigorous chest physiotherapy due to
spontaneous coughing achieved following exertion. This thereby improves the breath
sounds.
• Transcutaneous Nerve Stimulator ( Tens )

- may be used for pain relief.
Psychological support or patient / carer education

• When handling these patients, the physiotherapist should be compassionate,
understanding and show respect for the patient and his family.

Points to Note:
Do not discuss patient’s conditions while carrying out procedures.

Adhere strictly to the universal safety precautions on infection control
(Refer Appendix 1)
Treat all infectious cases last (MRSA, HIV, etc).
Do not carry out any chest physiotherapy on patient immediately after insertion of
neck line until a chest X-Ray rules out pneumothorax.
Always observe for any changes aggravating patient’s stability (vital signs).
Re-assess and modify treatment techniques if patient’s condition does not
improve.
Take necessary precautions for patients with fragile skin, osteoporosis,
bronchospasm, recent thoracic surgery, subacute emphysema.
Take appropriate precautions for patients with various monitoring/ treatment
devices e.g. arterial lines, catheter etc.
Ensure sedatives are given according to doctor’s instructions (when necessary)
prior to physiotherapy intervention.
FREQUENCY OF TREATMENT
• Physiotherapy intervention and frequency in critical care settings depends on :

- Specific treatment goals.
- Aggresiveness of treatment indicated.
- Impact of related problems on physiotherapy.
- Co-operation of patient.

CONTRAINDICATIONS
Note contraindications to certain treatment techniques, as follows :-
• Positioning should not be done in the following situations :

- Unstabilized head & neck injuries / trauma
- Recent spinal injury / surgery
- Acute haemorrhage and haemodynamic instability
- Pulmonary embolism
• Trendelenburg Position should be avoided when there is :

- Increased ICP > 20mmHg
- Aneurysm
• Reverse Trendelenburg should be avoided when patient is :

- Hypotensive
• Chest percussion should be avoided when patient has :

- Active Pulmonary Tuberculosis
- Dysarrhythmias
- Osteoporosis of thoraco-lumbar spine
- Acute bronchospasm
- Untreated tension pneumothorax
- Lung contusion
N.B.
The following cases are not indicated for physiotherapy intervention unless
requested by the doctor :
• The unstable patient
• Patients on cerebral resuscitation
• Patients having :

- Tetanus
- Pulmonary oedema
DOCUMENTATION
• Each patient encounter must be documented and signed legibly.
RE-EVALUATION
Re-assess treatment plan at each visit (patient encounter) or at a pre-established
frequency based on patient equity (needs / condition).
Modify treatment interventions based on patient’s progress or specific physician’s
order.
COMMUNICATION
• Effective communication and teamwork among health care providers in the critical
unit Is important.
• Communicate with other health care professionals in-charge regarding modification
of physiotherapy intervention.

CRITERIA FOR DISCONTINUATION OF PHYSIOTHERAPY TREATMENT

Discuss with other health care professionals in-charge prior to discontinuation of
physiotherapy intervention.
Outcome Assessment Description
1 Change in sputum production. Sputum less 25 ml / day
2 Change in breath sounds. Normal breath sounds
3 Subjective change reported by How patient feels before, during and after therapy.
patient. Effective coughing.
4 Improved in vital signs. Improved in quality of sleep.
5 Change in chest radiograph. Resolution.
6 Change in improved gas exchange. Improved ABG.
7 Change in lung mechanics. Reduced resistance / increased compliance.

Changes consistent with resolution of atelectasis
and mucous plugging.

References
American Association of Critical - Care Nurses (AACN) (2003).
APTA (1997) Physical Therapy Guideline to Physical Therapy Practice
Chaitow L, Bradley D, Gilbert C ( 2002 ) Multidisciplinary Approaches to Breathing

Pattern Disorders, Churchill Livingstone.
file://J:\Jabatan%20Sokongan\Fisioterapi\Rx%20Protocol%20&%20resource\Cardiore
Hough A. (1998) Physiotherapy in Respiratory Care: A Problem – Solving Approach.

Chapman & Hall.
http://planetaterra.combr
http://www.aarc.org
http://www.chestnet.org
http://www.thoracic.org
Meade MO & Ely EW (2002) Protocol to Improve the Care of Critically ill Pediatric and
Adult patient, JAMA, Vol. 288(20.Nov 27,2601-2603.
Prasad SA, Pryor JA (2002) Physiotherapy for Respiratory and Cardiac Problems:
Adults and Peadiatrics. 3rd. edition, Churchill Livingstone.
Schunk C & Reed K (2000 ) Clinical Practice Guideline: Examination and Intervention
for Rehabilitation .Aspen Publication, Maryland.
Webber BA & Pryor JA (2000 ) Physiotherapy for Respiratory and Cardiac Problems
2nd. Edition, Churchill Livingstone.
WHO ( 2000) Fact Sheets on HIV/AIDS for Nurses and Midwives. WHO/EIP/OSD/
2000.5
WHO ( 2001) Best Infection Control Practices for Intradermal, Subcutaneous and
Intramuscular Injections. WHO/BCT/DCT 01.03
WHO (1993) HIV Prevention and Care: Teaching Modules for Nurses and Midwives.
WHO/GPA/CNP/TMD/93.3
Wilkins RL, Olfert M, McCarty KD ( 1994) Quick Reference Guide To Clinical

Assessment In Respiratory Care. Mosby – Year Book USA.
World Health Organization Global Programme on AIDS (1995) A Guide to Preventing HIV Transmission in Health
Facilities. GPA/TCO/HCS/95.1
GLOSSARY
• Cyanosis
Is the blue colour of the skin and mucous membranes.
Peripheral cyanosis is due to reduced blood flow through the peripheries and is
associated with cold extremities.
Central cyanosis is due to reduced oxygen saturation of arterial blood and is
noticed in the tongue, lips, ear lobes and is associated with warm extremities.
• Active cycle of breathing technique (ACBT)

It is a cycle of breathing control, thoracic expansion exercises and the forced
expiration technique.
• Breathing control
Is a normal tidal breathing using the lower chest with relaxation of the upper
chest and shoulders.
• Thoracic expansion exercises (TEE)

Are deep breathing exercises emphasing inspiration which is active and may be
combined with a second hold before passive relaxed expiration.
• Incentive Spirometry
A mechanical aid which encourages deep breathing and gives visual feedback
on performance.
• Forced expiration technique (FET)

Is a combination of 1 or 2 forced expirations / huffs and periods of breathing
control.
• Trendelenburg Position
Any recumbent position (supine / prone) in which table is tilted so that head is
lower than pelvis. Angle of tilt is usually specified. Full trendelenburg position is at
45 degrees angle.
• Reverse Trendelenburg
Any recumbent position (supine / prone) in which table is tilted so that pelvis is
lower than head.
• Intracranial pressure (ICP)

The components influencing ICP is the blood, brain and cerebrospinal fluid within
the rigid skull. Tthe blood components cam be influenced by changes in PaCO2
and drainage. Rises in ICP from normal levels correlate with a worseoutcome.
ICP measurement is used as a diagnostic tool to guide and assess the
effectiveness of medical treatment.

• Cerebral perfusion pressure (CPP)

This is a critical pressure required to ensure adequate blood supply to the brain
and prevent acidotic hypoxia and damage.
.CPP = mean arterial pressure (MAP) minus intracranial pressure (ICP)
• Ventilation-perfusion (V/Q)
Ventilation is the movement of air into and out of the alveoli.
Perfusion relates to the flow of blood through the pulmonary capillary network.
• Functional Residual Capacity (FRC)

Is the volume of air remaining in the lungs at the end of quiet respiration.
• Controlled mandatory ventilation (CMV)

Patient has no control over ventilation.
Breath are delivered at a rate and volume that are determined by adjusting the
ventilation control.
• Synchronized intermittent mandatory ventilation (SIMV)

The mandatory are delivered in synchrony with patient breathing.
• Continuous positive airway pressure (CPAP)

Oxygen is delivered by a system that maintain a positive pressure to the circuitry
and airway throughout inspiration and expiration.
• Bi-level positive airway pressure (BiPAP)

Non-invasive ventilation either pressure controlled or volume controlled.
• Close system suctioning

Is a method of removing secretions from the tracheobronchial tree of patients
who are being mechanically ventilated without disconnecting the ventilator with a
specific in-line catheter systems. The benefits of using these systems are the
ability to maintain positive pressure ventilation, positive end-expiratory pressure
and oxygen supply which in turn should result in minimising hypoxaemia during
suctioning
• Hand – held PEEP

A semi-filled bag with a opening at the end. Done by grasping and holding the
bag through inspiration and expiration in order to maintain a low level of PEEP.

Algorithm 1 Management of Critically Ill Adult

With Mechanical Ventilatory Support
Table of Red Flags
Critically Ill Adult o Avoid Positioning in the
Patients with a critical illness/injury acutely followings:
impairs one or more vital organs systems such Unstabilized head & neck
that the patients survival is jeopardized : injuriesTrauma
1. With Mechanical Ventilatory Support Recent spinal injuries / surgeries
Acute haemorrhage and
haemodynamic instability
Pulmonary embolism
Perform focused history
and physical examination o Avoid Trendelenburg Position
Refer Page 5-10 in the followings :
Increased ICP > 20mmHg
Aneurysm
ANY RED YES Take precaution. o Avoid Reverse Trendelenburg

FLAG ? Discuss with doctors when :
in-charge Hypotensive
NO o Avoid Chest percussion in the

followings :
Carry out appropriate Active PTB
physiotherapy intervention Dysarrhythmias
Refer Table 1 Osteoporosis thoraco-lumbar
Acute bronchospasm
Untreated tension pneumothorax
Lung contusion
Reevaluation of
outcome
Table 1
Psychological support
Continue with & patient / carer
YES education
physiotherapy
Improvement? intervention until Postural drainage
patient recover Manual techniques
Suctioning
NO Bronchial lavage
Manual hyperinflation
Positioning
Discuss with doctor incharge
Patient extubated Mobilisation
Modify physiotherapy
intervention
Refer Page 12 &13
Continue with physiotherapy Table 2

intervention until patient transfer Add
out from ICU ACBT
Refer Table 2 Incentive spirometry
CPM
TNS
Ambulation
Refer page 25-27

Algorithm 2 Management of Critically Ill Adult

Without Mechanical Ventilatory Support
Critically Ill Adult

Patients with a critical illness/injury acutely
impairs one or more vital organs systems such
that the patients survival is jeopardized : Table of Red Flags
2. Without Mechanical Ventilatory Support o Avoid Positioning in the followings:
Unstabilized head & neck
injuriesTrauma
Recent spinal injuries / surgeries
Perform focused history and Acute haemorrhage and
physical examination haemodynamic instability
Refer Page 18-23 Pulmonary embolism
o Avoid Trendelenburg Position

in the followings :
Yes Increased ICP > 20mmHg
Take precaution.
ANY RED Discuss with doctors in- Aneurysm
FLAG ? charge
o Avoid Reverse Trendelenburg when :
Hypotensive
No
o Avoid Chest percussion in the
followings :
Carry out appropriate Active PTB
physiotherapy Dysarrhythmias
intervention Osteoporosis thoraco-lumbar
Refer Table 1 Acute bronchospasm
Untreated tension pneumothorax
Lung contusion
Reevaluation of
outcome
Yes Continue with physiotherapy intervention until

Improvement
? patient recover and transfer out from ICU
Refer Table 2
Table 2
No Table 1 Add
Psychological ACBT
support Incentive
Discuss with doctor incharge & patient/carer spirometry
Modify physiotherapy intervention education CPM
Postural drainage TNS
Manual techniques Functional
Suctioning activities
Positioning Ambulation
Mobilisation Refer Page 25-27
Refer Page 25-27

APPENDIX

Appendix 1
UNIVERSAL PRECAUTION
Definition:
Simple infection control measures that reduce the risk of transmission of blood-borne
pathogens through exposure to blood or body fluids among patients and health care
workers. Under the “universal precaution” principle, blood and body fluids from all persons
should be considered as infected with HIV, regardless of the known or supposed status of
the person. Improving the safety of injections is an important component of universal
precautions.
Methods:
1. Ensure Universal Precautions
• Use of new, single-use disposable injection equipment for all injections is highly
recommended. Sterilizable injection should only be considered if single use
equipment is not available and if the sterility can be documented with Time, Steam
and Temperature indicators.
• Discard contaminated sharps immediately and without recapping in puncture and
liquid proof containers that are closed, sealed and destroyed before completely full.
• Document the quality of the sterilization for all medical equipment used for
percutaneous procedures.
• Wash hands with soap and water before and after procedures; use of protective
barriers such as gloves, gowns aprons, masks, goggles for direct contact with blood
and other body fluids.
• Disinfect instruments and other contaminated equipment.
• Handle properly soiled linen. (Soiled linen should be handled as little as possible.
Gloves and leakproof bags should be used if necessary. Cleaning should occur
outside patient areas, using detergent and hot water.)
2. Ensure Adherence to Universal Precautions
• Staff understanding of universal precautions
Health care workers should be educated about occupational risks and should
understand the need to use universal precautions with all patients, at all times,
regardless of diagnosis. Regular in-service training should be provided for all
medical and non-medical personnel in health care settings. In addition, pre-service
training for all health care workers should address universal precautions.

• Reduce unnecessary procedures
Reduce the supply of unnecessary procedures: Health care workers need to be

trained to avoid unnecessary blood transfusions (e.g., using volume replacement
solutions), injections (e.g., prescribing oral equivalents), suturing (e.g. episiotomies)
and other invasive procedures. Standard treatment guidelines should include the use
of oral medications whenever possible. Inject able medications should be removed
from the national Essential Drug List where there is an appropriate oral alternative.
Reduce the demand for unnecessary procedures: Create consumer demand for
new, disposable, single-use injection equipment as well as increased demand for
oral medications.
• Make adequate supplies available
Adequate supplies should be made available to comply with basic infection control
standards, even in resource constrained settings. Provision of single use, disposable
injection equipment matching deliveries of injectable substances, disinfectants and
“sharps” containers should be the norm in all health care settings. Attention should
also be paid to protective equipment and water supplies. (While running water may
not be universally available, access to sufficient water supplies should be ensured.)
• Adopt locally appropriate policies and guidelines
Use of sterilizable injection equipment should be discouraged, as evidence shows

that the adequacy of the sterilization is difficult to ensure. National health care waste
management plans should be developed. The proper use of supplies, staff education
and supervision needs should be outlined clearly in institutional policies and
guidelines. Regular supervision in health care settings can help to deter or reduce
risk of occupational hazards in the workplace. If injury or contamination result in
exposure to HIV infected material, post exposure counselling, treatment, follow-up
and care should be provided.

Appendix 2
THE GLASGOW COMA SCORE (GCS)
Eye opening Spontaneous 4

To speech 3
To pain 2
None 1
Best verbal response Oriented 5

Confused speech 4
Inappropriate words 3
Incomprehensive sounds 2
None 1
Best motor response Obey commands 6

Localizes to pain 5
Withdraws ( generalized ) 4
Flexion 3
Extension 2
No response 1
Best Score 15 points
Worst Score 3 points
Uses :
• Prognostic indicator
• Therapeutic indicator

Appendix 3
ACTIVE CYCLE OF BREATHING TECHNIQUE
This technique can be carried out 1 to 3 cycles per session.

It consist of the followings :
• 3 or 4 thoracic expansion exercise ( 3 second hold, chest percussion )
• 3 or 4 thoracic expansion exercise ( 3 second hold, chest percussion )
• Forced Expiratory Technique ( 1 -2 huffs combined with breathing control )

Appendix 4
Table : Arterial Blood Gases Imbalance and Compensatory Mechanism
Imbalance Indicator Clinical Situation Compensatory

Mechanism
Respiratory Reduced pH Sputum retention Increased HCO3 –

acidosis Increased PaCO2 Atelectasis Increased H+ ions
Hypoventilation excreted
V/Q inequalities
Respiratory Increased pH Hyperventilation, Reduced HCO3-

alkalosis Reduced PaCO2 e.g. pain, anxiety via excretion
Mechanical
ventilation
Neurogenic
Metabolic acidosis Reduced pH Myocardial Increased RR –

Reduced HCO3 Infarction reduced PaCO2
Sepsis
Gastrointestinal
bleed
Overaggressive
diuretic therapy
Metabolic Increased pH Profuse vomiting Reduced RR –

alkalosis Increased HCO3 Profuse diarrhoea increased PaCO2

Appendix 5
Table : Drugs in the ICU - Tthe Neurological System and consideration for
physiotherapy
Drug Action Consideration for

Physiotherapy
Hypnovel – midazolam May need to be

Versed increased prior to
physiotherapy
Chloractil - chlorpromazine Sedatives intervention to prevent
Ormazine acute rises in ICP or BP.
Diprivan profol Care with manual

hyperinflation as sedation
can cause a drop in BP.
Cause impairment of
cough reflex, therefore
difficulty in clearing
secretion
Ketalar ketamine May need to be

Durogenic fentanyl increased prior to
physiotherapy
Rapifen alfentanil Sedatives and intervention to prevent
Affenta analgesic acute rises in ICP or BP.
MST morphine Care with manual

Astramorph hyperinflation as sedation
can cause a drop in BP.
Cause impairment of
cough reflex, therefore
difficulty in clearing
secretion


Physiotherapy
Pavulon pancuronium Muscle relaxant Used by continuous

infusion usually reflect
Tracrium atracurium either severe respiratory
failure with difficulty in
Norcuron vecuronium ventilation or neurological
instability.
Care with manual

hyperinflation as it may
not be tolerated
Absence of cough reflex
Care with positioning as

reduced muscle tone
leads to joint vulnerability
Nimitop nimodipine Specific cerebral Usually used inpatients

artery vasodilator whose ICP is raised and
or unstable.
Osmitrol mannitol Osmotic diuretic
If physiotherapy is
Decadron dexamethasone Corticosteriod – absolutely essential,
Aerosels - Dex reduced cerebral monitor parameter
edema carefully throughout
treatment.
Epanutin phenytoin Anticonvulsant If fitting is well control

Dilantin there is no contra-
indication for treatment

Appendix 6
Table : Drugs In the ICU - The Cardiovascular System and consideration for
physiotherapy

physiotherapy
Adrenaline Increased heart rate Iontropes are used to

Increased cardiac output support blood pressure.
Noradrenaline Peripheral Evaluation of

vasoconstriction cardiovascular stability
Increased systematic and effect of inotropic
vascular resistance support must be noted.
Isoprenaline Increased heart rate Care with hyperinflation

Increased cardiac output as blood pressure may
be labile.
Dobutamine Increased myocardial
contractility
Increased heart rate
Dopamine Low doses < 5u/kg/min

Increased myocardial
contractility
Higher doses > 5ukg/min

Increased vascular
resistance
Increased renal perfusion
Increased splanchnic
perfusion
Dopexamine Increased myocardial

contractility
Increased peripheral
dilation
Reduced systematic
vascular resistance


physiotherapy
Enoximone Potent voso-constriction Used in some centre in

the severely unstable
Milrinone patient
Angiotension
Other relevant cardiac

drug
Nifidipine Vascular smooth muscle Used primaryly in control

relaxant of hypertenion wspecially
Coronory and peripheral those at risk of
artery dilator myocardial ischemic.
Antihypertensive Monitor BP and EEG
during treatment
GTN –glyceryl trinitrate Vasodilator
ISMN-isosorbid Control of
supraventricular
Mononitrate tachycardiac, artrial
fibrillation or flutter
Digoxin Control of Stable arrhythmias are

supraventricular not a direct
tachycardiac, artrial contraindication to
fibrillation or flutter treatment. Monitor
rhythm throughout
Amiodrone Anti-arrhythmic intervention
Adenosine
Verapamil
Lignocaine
Heparin
Warfarin Anticoagulant If over-anticoagulated,
bleeding is at risk. Care
during suction.

Appendix 7
Table : Drugs in the ICU – The Respiratory System and consideration for
physiotherapy

physiotherapy
B-adrenoceptor agonist Assess the degree of

bronchospasm by
salbutamol (ventolin/ Bronchodilation auscultation and airway
aerolin) pressure.
terbutamine
May be beneficial to use
brochodilatation therapy
Anticholinergics pr-and post
physiotherapy
Iarotropium intervention
Bromide
( atrovent )
Smooth muscle relaxant High dose can lead to

arrhythmias
Theophylline Bronchodilation
Aminophylline
Corticosteroids Anti-inflammatory Increased risk of

infection.
Hyrocortisone
Used in patients with
irritable airways.
Respiratory Central respiratory Can be used in patients

Stimulus stimulant with rising PaCO2.
Daxapram Can produce fatigue

such that physiotherapy
is not tolerated.
Patient may become

agitated and
uncooperative during
treatment.

Appendix 8
POSTURAL DRAINAGE POSITION
This comprises positioning the patient so that gravity helps drain a lobe or
bronchopulmonary segment.
Positions used are as follows :
One-quarter turn from prone, right side up Left side up with head and trunk raised

One quarter turn to right from supine, foot of bed One quarter turn to left from supine, foot of bed
raised 35cm. raised 35 cm
Left side lying, foot end raised 45 cm Right side lying, foot of bed raised 45cm.
Prone lying, pillow under waist Supine lying, foot end raised 45cm
Pillows under hips and knees, none

under head. Foot of bed raised 45cm.

Appendix 9
MODIFIED POSTURAL DRAINAGE POSITION
The deep-tipped positions should be avoided if there is a precaution or relative
contraindication to the ideal position.
Left side up with head and trunk raised

One-quarter turn from prone, right side up

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Physiotherapy Care Protocol : Critically Ill Adult

4 PART 2 : CRITICALLY ILL ADULT WITHOUT MECHANICAL VENTILATION 20

Technical Committee, Physiotherapy Profession, July 2003 1

DEFINITION OF CRITICALLY ILL ADULTS

DEFINITION OF CRITICAL CARE

Technical Committee, Physiotherapy Profession, July 2003 2

Technical Committee, Physiotherapy Profession, July 2003 3

CRITICALLY ILL ADULT WITH

3. CRITICALLY ILL ADULT WITH MECHANICAL VENTILATORY

This Care Protocol will be initiated for a patient :

A. Attainment of optimal cardiopulmonary function

B. Attainment of optimal musculo-skeletal function

C. Attainment of optimal neurological function

Examination particulars Parameters / Impact on Physiotherapy

Initiate contact with patient. Personal data

Subsequent contact with patient. Temperature :

Technical Committee, Physiotherapy Profession, July 2003 6

General observation of patient : (Refer Appendix 2)

Ventilatory Settings Invasive ventilation

Technical Committee, Physiotherapy Profession, July 2003 7

Examination particulars Parameters / Impact on Physiotherapy

Oxygen Therapy Devices & oxygen flow rate / min :

- High flow mask > 15 l/min

Arterial Blood Gases Normal Values :

Pulse Oximetry Reading Arterial oxygen saturation :

Technical Committee, Physiotherapy Profession, July 2003 8

Cerebral status ICP :

Fluid Balance Normal :

Medication (Refer Appendix 5, 6 & 7 )

Technical Committee, Physiotherapy Profession, July 2003 9

Respiratory assessment : Normal :

Chest x-ray Clear lung field

Shape of chest Deformities – barrel chest, pigeon chest

Technical Committee, Physiotherapy Profession, July 2003 10

Chest expansion Symmetrical / Asymmetrical

Breathing pattern Abnormal :

Percussion note Hyperresonant

Examination Particulars Parameters / Impact on Physiotherapy

Technical Committee, Physiotherapy Profession, July 2003 11

Ascultation Abnormal breath sound :

Sputum Quantity of sputum

Technical Committee, Physiotherapy Profession, July 2003 12

• Modified postural drainage

Technical Committee, Physiotherapy Profession, July 2003 13

Manual hyperinflation ( MHI )

Technical Committee, Physiotherapy Profession, July 2003 14

• Frequent turning and careful positioning

Technical Committee, Physiotherapy Profession, July 2003 15

Psychological support or patient / carer education

Do not discuss patient’s conditions while carrying out procedures.

• Physiotherapy intervention and frequency in critical care settings depends on :

Technical Committee, Physiotherapy Profession, July 2003 16

• Positioning should not be done in the following situations :

• Trendelenburg Position should be avoided when there is :

• Reverse Trendelenburg should be avoided when patient is :

• Chest percussion should be avoided when patient has :

Technical Committee, Physiotherapy Profession, July 2003 17

Technical Committee, Physiotherapy Profession, July 2003 18