Chest physiotherapy in ICU

Chest physiotherapy in ICU

1. CURRENT PRACTICES OF PHYSIOTHERAPY IN ICUs: Saad Saleem B.S.(PT), M.Sc.(PT )

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

3. Prophylactic - Pre-operative high risk surgical patient - Post-operative patient who is unable to mobilize secretions - Neurological patient who is unable to cough effectively - Patient receiving mechanical ventilation who has a tendency to retain secretions - Patients with pulmonary disease , who needs to improve bronchial hygiene Indications

4. …cont. Therapeutic - Atelectasis due to secretions - Retained secretions - Abnormal breathing pattern due to primary or secondary pulmonary dysfunction - COPD and resultant decreased exercise tolerance - Musculoskeletal deformity that makes breathing pattern and cough ineffective Indications

5. Neurological system Cardiovascular system Respiratory system Assessment

6. Neurological System Level of consciousness Cerebral perfusion pressure ( >70mmHg ) CPP = MAP- ICP Intracranial pressure ( <10mmHg ) …cont. Assessment

7. Heart rate and rhythm Arterial BP Central Venous pressure …cont. Assessment Cardiovascular System

8. Respiratory System Auscultation Expansion Chest X-ray Mode of ventilation Oxygen therapy RR Airway pressures ABGs Sputum …cont. Assessment

9. General Observation Patient Position Respiration - Airway (artificial airway) ET/ Tracheostomy Ventilator Mode, Ventilator Parameters Vital Signs –BP , RR, HR, SpO 2, GCS, ICP Tubes - NG Tube, CVP line, Peripheral line, Chest tubes, Catheters Drugs …cont. Assessment

10. General Observation Auscultations Respiratory pattern Cyanosis Radiograph …cont. Assessment

11. Goals Prevent accumulation of secretions Improve mobilization and drainage of secretions Promote relaxation to improve breathing patterns

12. Improves respiratory function Improve cardio-pulmonary exercise tolerance Teach bronchial hygiene programs to patients with chronic respiratory dysfunction …cont. Goals

13. Untreated tension pneumothorax Abnormal coagulation profile Status epilepticus or status asthamaticus Immediately following intra cranial surgery Precautions

14. Head injury with raised ICP Osteoporotic bones Recent acute myocardial infarction, unstable vitals Immediately after tube feedings Sutures and ICD’s …cont. Precautions

15. PHYSIOTHERAPY TECHNIQUES

16. Physiotherapy Techniques Gravity-assisted Positioning Manual techniques Manual hyperinflation Airway suctioning Mobilization School of Physiotherapy School of Physiotherapy

17. Positioning

18. Physiological Effects of Positioning Optimizes oxygen transport by improving V/Q mismatch Increases lung volumes Reduces the work of breathing Minimizes the work of heart Enhances mucociliary clearance (postural drainage) …cont. Positioning

19. Postural Drainage isn’t… A separate technique. Its just an example of positioning which has the particular aim of clearing airway secretions with the assistance of gravity . …cont. Positioning

20. Patients are positioned with the area to be drained the upper most , but modifications should be done wherever necessary. Drainage times vary, but ideally each position requires 10 minutes ( gumery et al, 2001). …cont. Postural Drainage

21. Positioning restores ventilation to dependent lung regions more effectively than PEEP or large tidal volumes ( Froese & Bryan, 1974). Positioning has a marked influence on gas exchange because of unevenly damaged lungs (Tobin, 1994). Side lying reduces lung densities in the upper most lung ( Brismar , 1985). …cont. Positioning

22. Right side lying may be more beneficial for cardiac output than left side lying (Wong, 1998). Simply turning from supine to side lying can clear atelectasis from dependent regions ( Brismar , 1985). Positioning affects lung volume Lung volume is related to the position of the diaphragm FRC decreases from standing to slumped sitting to supine ( Macnaughton , 1995) …cont. Positioning

23. Positioning affects compliance ( Wahba et al found that work of breathing is 40% higher in supine than in sitting) Positioning affects arterial oxygenation by improving V/Q mismatch (V/Q is usually mismatched if the affected lung is dependent- Gillespie et al) “ Bad lung up ” position …cont. Positioning

24. Life’s most urgent question is: What are you doing for others?

25. Chest Maneuver

26. Chest Maneuver Chest Vibrations Chest Percussion/Clapping

27. Chest Clapping/Chest Percussion Percussion consists of rhythmic clapping on the chest with loose wrist & cupped hand. Effect: Dislodges & loosens secretions from the lung …cont. Chest Maneuver

28. Chest Vibration Vibrations consists of a fine oscillation of the hands directed inwards against the chest, performed on exhalation after deep inhalation. Effects : Helpful in moving loosened mucous plugs towards larger airway …cont. Chest Maneuver

29. Manual Hyperinflation

30. 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 H 2 O (Med j Aust , 1972). More recent definitions include providing a larger tidal volume than base line tidal volume to the patient ( Aust j physiotherapy, 1996) and using a tidal volume which is 50% greater than that delivered via the ventilator (chest, 1994). …cont. Manual Hyperinflation School of Physiotherapy School of Physiotherapy

31. Indications To aid removal of secretions To aid reinflation of atelectatic segments To assess lung compliance To improve lung compliance …cont. Manual Hyperinflation School of Physiotherapy School of Physiotherapy

32. Technique Slow deep inspiration Inspiratory hold (at full inspiration) Fast expiratory release Hand-held Pressure Support …cont. Manual Hyperinflation School of Physiotherapy School of Physiotherapy

33. Hazards of MHI Reduction in blood pressure Reduced saturation Raised intracranial pressure Reduced respiratory drive …cont. Manual Hyperinflation School of Physiotherapy School of Physiotherapy

34. Contraindications Undrained Pnuemothorax Potential bronchospasm Severe bronchospasm Gross cardiovascular instability inducing arrhythmias and hypovolaemia Unexplained Haemoptysis Patient on High PEEP …cont. Manual Hyperinflation School of Physiotherapy School of Physiotherapy

35. Advantages of MH Reverses atelectasis ( Lumb 2000) Improves oxygen saturation and lung compliance ( Patman et al.,1999) Improves sputum clearance (Hodgson et al., 2000) …cont. Manual Hyperinflation School of Physiotherapy School of Physiotherapy

36. Disadvantages of MH Haemodynamic and metabolic upset (Stone, 1991 & Singer et al.,1994) Risk of barotrauma Discomfort and anxiety …cont. Manual Hyperinflation School of Physiotherapy School of Physiotherapy

37. Suctioning

38. Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place . Indications Inability to cough effectively Sputum plugging To assess tube patency …cont. Suctioning School of Physiotherapy School of Physiotherapy

39. Contraindication Frank haemoptysis Severe brochospasm Undrained pneumothorax Compromised cardiovascular system …cont. Suctioning School of Physiotherapy School of Physiotherapy

40. The suction catheter used must be less than half the diameter of endotracheal tube. The vacuum pressure should be as low as possible. ( 60-150mmHg ) Suction should never be routine , only when there is an indication …cont. Suctioning School of Physiotherapy School of Physiotherapy

41. Hazards of Suctioning Mucosal trauma Cardiac arrhythmias Hypoxia Raised intracranial pressure …cont. Suctioning School of Physiotherapy School of Physiotherapy

42. Routes Nasal and oral suction Endotracheal suction Tracheostomy suction Suctioning …cont. School of Physiotherapy School of Physiotherapy

43. Mobilization

44. Critically ill (Frequent Position changes , Active and Passive Exercises ) Stable ( Progressive tilting & Ambulation ) Mobilization …cont. School of Physiotherapy School of Physiotherapy

45. ICU rehabilitation has been shown to accelerate recovery ( o’leary & coackley , 1996) Early mobilization for unconscious patients starts right from turning the patient every two hours . ( Brooks- brunn , 1995). Graded exercises can be started as soon as the patient regains consciousness . Mobilization …cont. School of Physiotherapy School of Physiotherapy

46. 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 Mobilization …cont. School of Physiotherapy School of Physiotherapy

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