PHYSIOTHERAPY

MANAGEMENT IN ICU
PATIENTS
 Objectives
 Assessment of patient
 Goals
 Treatment techniques used in ICU by
physiotherapist
 Chest physiotherapy for pediatrics
 ASSESSMENT OF PATIENT

 See the patient is well conscious or not

 Read the case papers and daily orders. Note

the temperature

 Type of mode of ventilators

 Examination of the chest in
mechanically ventilated patients

1) INSPECTION

 Chest movement
 Clubbing
 Cyanosis
 AP & Lateral chest diameter
 Kyphoscoliosis
 2) PALPATION

 Confirm all inspectory findings

 Tenderness
 Rib fracture
 Crepitus
 Tracheal deviation
3) PERCUSSION

Dullness/ Normal/ Hyperesonant

4) AUSCULTATION

Breath sounds-Vesicular
Bronchial
Added breath sounds-Rhonchi
Wheeze
Crackles
 GOALS
 Pain relief
 To prevent accumulation of secretions
 To mobilize and remove secretions
 To teach proper method of breathing pattern and
effective coughing or huffing
 To mobilize the thorax and shoulder girdle and
to teach the postural awareness
 To teach relaxation
 To improve functional capacity by exercise
training programme
 To advice the home programme
 OBJECTIVES OF CHEST
PHYSIOTHERAPY
 Clearance of secretions from large and
small airways and re-expansion of
nonventilated lung

 Improve ventilation to areas of local lung

obstruction

 To reduce incidence of post operative

respiratory infection, morbidity and
hospital stay
 Treatment techniques used in ICU by
physiotherapist

 Positioning
 Mobilization
 Manual Hyperinflation
 Percussion, Vibration, Shaking
 Cough/huff
 Suction
 Breathing exercises
 POSITIONING

AIMS

 Optimizing O2 transport through its effect of

improving ventilation/perfusion matching (V/Q)
 Increase lung volumes
 Reduce work of breathing
 Minimize the work of heart
 Enhance mucociliary clearance
 HANDLING A CONSCIOUS PATIENT

 2-3 people are needed to turn a patient

 Ensure sufficient slack in lines and tubes
 Inform the patient
 If possible disconnect the patient from
ventilator/tracheal manualy
 Turn the patient smoothly & check the lines,
patient comfort and observe monitors
TURNING PATIENT WITH CRANIOTOMY

 Position require
 To minimize pressure on the operated
side especially in bone flap is
 removed
500ml IV infusion bags above &below this
area support the head & prevent undue
pressure
 2] MOBILISATION
 This technique help to maintain or restore
normal fluid distribution in the body
 It reduces the effect of immobility & bed
rest

It Limb exercises, Neck exercise

 includes-
 Moving/Turning in bed
 Sitting in the edge of the bed
 Standing
 Standing transfer from chair,
 bed

Walking
 3]MANUAL HYPERINFLATION
 It is one of the technique where there is
involvement in disconnecting the patient
from ventilator &inflating the lungs with
a large tidal volume via a manual
resuscitator bag
 Bagging can be used as a technique to
hand ventilate a patient or during
physiotherapy
 MH can be given by using Ambu bag
 4] POSTURAL DRAINGE
POSITION
 Definition
 Goals
 To prevent accumulation of secretions in
patient at high risk for pulmonary
complication
 To remove secretions already
accumulated in the lungs
 Contraindications

 Haemoptysis
 Severe pulmonary edema
 CCF
 Large pleural effusion
 Pulmonary embolism
 Pneumothorax
 Cardiac arrhythmias
 Recent MI
 Recent neurosurgery
 5] PERCUSSION & VIBRATIONS
 Are manual technique used to increase
clearance of airway secretions

 PERCUSSION
 Medications to reduce pain is given prior to
treatment
 In pediatrics percussion is given by
using hand, fingers or facemask
 Force-58 & 65N on chest wall
 100-480time/min
 CONTRINDICATIONS

 Lung abcess
 Bronchopleural fistula
 Haemoptysis
 Rib Fractures
 Osteoporotic bone
 Tumour area
 Pulmonary embolism
 Low platelet count/ anticoagulation therapy
 Unstable angina
 Chest wall pain eg Thoracic surgery
 VIBRATIONS

 Are performed manually by

vibrating/compressing the chest wall

 Pressure is applied in the same direction

in which chest is moving

 The vibrating action is achieved by

therapist isometrically contracting the
muscle of upper extremity from shoulder
to hands
 SHAKING

 More vigorous form of vibrations

 Applied during exhalation using an intermittent

bouncing maneuver coupled with wide
movement of therapist hands
 6]SUCTION
 In unconscious patient & in patients with depressed
cough
 Should not done routinely but only on demand
 Every 2hrly suctioning
 Ideally catheter diameter should be half of the
size of the tracheal tube/ETT
 Adults- 10,12,14,16 FG & Pediatrics - 6,8 FG
 Monitor vacuum pressure 150-200mmHg for adults
&
<100mmHg for children
 Kink one end of catheter while inserting into the
tube ,move in a circular manner in downward
direction &release the kink when you feel resistance
to pass the catheter further
 Never prolong the procedures
 COMLICATIONS

 Infection
 Bronchospasm
 Tracheaobroncheal trauma
 Hypoxia
 Atelectasis
 Cardiac arrest/arrhythmia
 7] COUGH/HUFF
 COUGHING
 To keep the lungs clear

Procedure
 Evaluate the patient Place the patient in relaxed
forward bending neck slightly flexed
 Teach controlled diaphragmatic breathing
 Demonstrate sharp double cough
 Ask the patient to repeat

Precautions
 Never allow the patient to suck air in by gasping
 HUFFING
 Huff is a rapid forced exhalation without
maximum effort
 Glottis remains open
 Required less effort than coughing
 9] BREATHING EXERCISES
 Goals
 Assist removal of secretions
 Improve respiratory muscle strength &
endurance
 Increase thoracic mobility and tidal
volume
 Promote relaxation
 Teach the patient how to deal with shortness of
breath attack
 Improve patients overall functional capacity
 TYPES

1] Diaphragmatic Breathing
2] Ventilatory Muscle Training
i] Diaphragmatic breathing
ii] Inspiratory resistance training
iii] Incentive respiratory spirometry
3] Segmental breathing
i] Lateral costal
ii] Posterior Basal
Expansion iii] Apical
Expansion
4] Glossopharyngeal Breathing
 Indications-Severe inspiratory muscle weakness

postpolio
Spinal cord injury
 Contraindication-COPD

5] Pursed lip Breathing

It increases tidal volume, improve
exercise tolerance
Decrease respiratory rates
Breathing Exercises In Obstructive Airway
Disease

1] Breathing Control
 Treatment should start with breathing control

 It is a normal tidal breathing to promote relaxation &

prevent hyperventilation
 While teaching Breathing Control avoid full

expiration should be controlled but not forceful

 Position- Side lying, head elevated, leaning

forward
 EFFECT- Relief of dysponea, improve vital capacity,

improve V/Q
2] Diaphragmatic Breathing
 For relaxation & coordinated breathing pattern
 It is often used with pursed lip breathing
 Greater tidal volume is achieved with Diaphragmatic
breathing improve overall ventilation

3] Pursed Lip Breathing

 Benefits- increase tidal volume, decrease RR,

decrease PaCO2 level, increase PaO2

 PLB may improve patients confidence and decrease

anxiety by providing some temporary control over

oxygenation
4] Ventilatory Muscle Training
i] Diaphragmatic training with
weights ii] Inspiratory resistance
training
iii] Incentive respiratory training

 BE After Surgery
i] Diaphragmatic
breathing ii] Lateral costal
breathing iii] Incentive
spirometry
 9] PASSIVE EXERCISES AND
ACTIVE EXERCISES
 Limb exercise like
PROM, AAROM/ARROM
are performed in
ICU patients
 It helps to improve joint
ROM, function, muscle
strength, soft tissue
length
 It decreases the risk of
thromboembolism
 IRR, TENS can be given
for relief of pain
 10] IMPROVEMENT IN
FUNCTIONAL
CAPACITY
 Based on walk test the dyspnoea is noted
& also performance of the patient is
noted
 According to this the goals are set
 CHEST PHYSIOTHERAPY FOR
PAEDIATRIC PATIENTS
Indications
 Neurological impairment
 Asthma
 Cystic fibrosis
 Secretion retention after surgery
 Immobility
 Decrease collateral ventilation

CPT should not performed more frequently more

than 3 hr & includes 3min chest percussion in 5
PD position followed by assisted
coughing/suctioning
 Handling/ positioning

 Excessive handling of low birth weight infant

causes hypoxemia
 Supine - compromise lung functional
 Side lying-Releases diaphragm from pressure of
abdominal viscera allowing more effective basal
expansion
 Facilitate drainage of secretions from the
uppermost part of lung
Prone-Better compared to supine position
-Improve gas exchange
-Reduce gastro-esophageal reflux
-It increases tidal volume, minute ventilation &
decreases period of apnea &25% increase in PaO2

 Placing preterm baby in prone position may

significantly reduce morbidity & mortality

 It may stabilize the compliant chest wall of the infant

& improve co-ordination between rib cage,
diaphragm & abdominal movement