ICU management

See the patient is well conscious or not

Read the case papers and daily orders. Note the temperature
Type of mode of ventilators

1. PHYSIOTHERAPY PHYSIOTHERAPY
MANAGEMENT IN ICU MANAGEMENT IN ICU
PATIENTSPATIENTS
Dr.Abhijit DiwateDr.Abhijit Diwate
Associate ProfessorAssociate Professor
Cardio-Vascular & Respiratory PTCardio-Vascular & Respiratory PT
DVVPF College of Physiotherapy,DVVPF College of Physiotherapy,
Ahmednagar 414111Ahmednagar 414111

2. Objectives Objectives

Assessment of patient Assessment of patient

Goals Goals

Treatment techniques used in ICU by Treatment techniques used in ICU by
physiotherapist physiotherapist

Chest physiotherapy for pediatrics Chest physiotherapy for pediatrics

3. ASSESSMENT OF PATIENTASSESSMENT OF PATIENT

See the patient is well conscious or notSee the patient is well conscious or not

Read the case papers and daily orders. Note Read the case papers and daily orders. Note
the temperaturethe temperature

Type of mode of ventilatorsType of mode of ventilators

4. Examination of the chest in Examination of the chest in
mechanically ventilated patientsmechanically ventilated patients
1) INSPECTION1) INSPECTION

Chest movementChest movement

ClubbingClubbing

CyanosisCyanosis

AP & Lateral chest diameterAP & Lateral chest diameter

KyphoscoliosisKyphoscoliosis

5. 2) PALPATION2) PALPATION

Confirm all inspectory findingsConfirm all inspectory findings

TendernessTenderness

Rib fractureRib fracture

CrepitusCrepitus

Tracheal deviationTracheal deviation

6. 3)PERCUSSION3)PERCUSSION

Dullness/ Normal/ HyperesonantDullness/ Normal/ Hyperesonant

Breath sounds-VesicularBreath sounds-Vesicular
BronchialBronchial
Added breath sounds-RhonchiAdded breath sounds-Rhonchi
WheezeWheeze
CracklesCrackles
4)AUSCULTATION4)AUSCULTATION

7. GOALSGOALS

Pain reliefPain relief

To prevent accumulation of secretionsTo prevent accumulation of secretions

To mobilize and remove secretions To mobilize and remove secretions

To teach proper method of breathing pattern and To teach proper method of breathing pattern and
effective coughing or huffingeffective coughing or huffing

To mobilize the thorax and shoulder girdle and To mobilize the thorax and shoulder girdle and
to teach the postural awarenessto teach the postural awareness

To teach relaxationTo teach relaxation

To improve functional capacity by exercise To improve functional capacity by exercise
training programme training programme

To advice the home programme To advice the home programme

8. OBJECTIVES OF CHEST OBJECTIVES OF CHEST
PHYSIOTHERAPYPHYSIOTHERAPY

Clearance of secretions from large and Clearance of secretions from large and
small airways and re-expansion of small airways and re-expansion of
nonventilated lungnonventilated lung

Improve ventilation to areas of local lung Improve ventilation to areas of local lung
obstructionobstruction

To reduce incidence of post operative To reduce incidence of post operative
respiratory infection, morbidity and respiratory infection, morbidity and
hospital stayhospital stay

9. Treatment techniques used in ICU by Treatment techniques used in ICU by
physiotherapist physiotherapist

PositioningPositioning

MobilizationMobilization

Manual HyperinflationManual Hyperinflation

Percussion, Vibration, ShakingPercussion, Vibration, Shaking

Cough/huffCough/huff

SuctionSuction

Breathing exercisesBreathing exercises

10. POSITIONINGPOSITIONING
AIMSAIMS

Optimizing O2 transport through its effect of Optimizing O2 transport through its effect of
improving ventilation/perfusion matching (V/Q)improving ventilation/perfusion matching (V/Q)

Increase lung volumesIncrease lung volumes

Reduce work of breathingReduce work of breathing

Minimize the work of heartMinimize the work of heart

Enhance mucociliary clearanceEnhance mucociliary clearance

11. HANDLING A CONSCIOUS PATIENTHANDLING A CONSCIOUS PATIENT

2-3 people are needed to turn a patient 2-3 people are needed to turn a patient

Ensure sufficient slack in lines and tubes Ensure sufficient slack in lines and tubes

Inform the patientInform the patient

If possible disconnect the patient from If possible disconnect the patient from
ventilator/tracheal manualyventilator/tracheal manualy

Turn the patient smoothly & check the lines, Turn the patient smoothly & check the lines,
patient comfort and observe monitorspatient comfort and observe monitors

12. TURNING PATIENT WITH CRANIOTOMYTURNING PATIENT WITH CRANIOTOMY

Position requirePosition require

To minimize pressure on the operated To minimize pressure on the operated
side especially in bone flap is removedside especially in bone flap is removed

500ml IV infusion bags above &below this 500ml IV infusion bags above &below this
area support the head & prevent undue area support the head & prevent undue
pressurepressure

13. 2] MOBILISATION2] MOBILISATION

This technique help to maintain or restore This technique help to maintain or restore
normal fluid distribution in the bodynormal fluid distribution in the body

It reduces the effect of immobility & bed restIt reduces the effect of immobility & bed rest
It includes-It includes-

Limb exercises, Neck exerciseLimb exercises, Neck exercise

Moving/Turning in bedMoving/Turning in bed

Sitting in the edge of the bedSitting in the edge of the bed

StandingStanding

Standing transfer from chair, bed Standing transfer from chair, bed

WalkingWalking

15. 3]MANUAL HYPERINFLATION3]MANUAL HYPERINFLATION

It is one of the technique where there is It is one of the technique where there is
involvement in disconnecting the patient involvement in disconnecting the patient
from ventilator &inflating the lungs with a from ventilator &inflating the lungs with a
large tidal volume via a manual large tidal volume via a manual
resuscitator bagresuscitator bag

Bagging can be used as a technique to Bagging can be used as a technique to
hand ventilate a patient or during hand ventilate a patient or during
physiotherapyphysiotherapy

MH can be given by using Ambu bagMH can be given by using Ambu bag

17. 4] POSTURAL DRAINGE 4] POSTURAL DRAINGE
POSITIONPOSITION

DefinitionDefinition

GoalsGoals

To prevent accumulation of secretions in To prevent accumulation of secretions in
patient at high risk for pulmonary patient at high risk for pulmonary
complicationcomplication

To remove secretions already To remove secretions already
accumulated in the lungsaccumulated in the lungs

18. ContraindicationsContraindications

HaemoptysisHaemoptysis

Severe pulmonary edemaSevere pulmonary edema

CCFCCF

Large pleural effusionLarge pleural effusion

Pulmonary embolismPulmonary embolism

PneumothoraxPneumothorax

Cardiac arrhythmiasCardiac arrhythmias

Recent MIRecent MI

Recent neurosurgeryRecent neurosurgery

19. 5] PERCUSSION & VIBRATIONS5] PERCUSSION & VIBRATIONS

Are manual technique used to increase Are manual technique used to increase
clearance of airway secretionsclearance of airway secretions

PERCUSSIONPERCUSSION

Medications to reduce pain is given prior to Medications to reduce pain is given prior to
treatmenttreatment

In pediatrics percussion is given by using In pediatrics percussion is given by using
hand, fingers or facemaskhand, fingers or facemask

Force-58 & 65N on chest wallForce-58 & 65N on chest wall

100-480time/min100-480time/min

20. CONTRINDICATIONSCONTRINDICATIONS

Lung abcessLung abcess

Bronchopleural fistulaBronchopleural fistula

HaemoptysisHaemoptysis

Rib FracturesRib Fractures

Osteoporotic boneOsteoporotic bone

Tumour areaTumour area

Pulmonary embolismPulmonary embolism

Low platelet count/ anticoagulation therapyLow platelet count/ anticoagulation therapy

Unstable anginaUnstable angina

Chest wall pain eg Thoracic surgeryChest wall pain eg Thoracic surgery

21. 
VIBRATIONSVIBRATIONS

Are performed manually by Are performed manually by
vibrating/compressing the chest wallvibrating/compressing the chest wall

Pressure is applied in the same direction Pressure is applied in the same direction
in which chest is movingin which chest is moving

The vibrating action is achieved by The vibrating action is achieved by
therapist isometrically contracting the therapist isometrically contracting the
muscle of upper extremity from shoulder muscle of upper extremity from shoulder
to handsto hands

22. 
SHAKINGSHAKING

More vigorous form of vibrationsMore vigorous form of vibrations

Applied during exhalation using an intermittent Applied during exhalation using an intermittent
bouncing maneuver coupled with wide bouncing maneuver coupled with wide
movement of therapist handsmovement of therapist hands

23. 6]SUCTION6]SUCTION

In unconscious patient & in patients with depressed In unconscious patient & in patients with depressed
coughcough

Should not done routinely but only on demandShould not done routinely but only on demand

Every 2hrly suctioning Every 2hrly suctioning

Ideally catheter diameter should be half of the size Ideally catheter diameter should be half of the size
of the tracheal tube/ETTof the tracheal tube/ETT

Adults- 10,12,14,16 FG & Pediatrics - 6,8 FGAdults- 10,12,14,16 FG & Pediatrics - 6,8 FG

Monitor vacuum pressure 150-200mmHg for adults & Monitor vacuum pressure 150-200mmHg for adults &
<100mmHg for children<100mmHg for children

Kink one end of catheter while inserting into the Kink one end of catheter while inserting into the
tube ,move in a circular manner in downward tube ,move in a circular manner in downward
direction &release the kink when you feel resistance direction &release the kink when you feel resistance
to pass the catheter furtherto pass the catheter further

Never prolong the proceduresNever prolong the procedures

DurationDuration

25. COMLICATIONSCOMLICATIONS
InfectionInfection
BronchospasmBronchospasm
Tracheaobroncheal traumaTracheaobroncheal trauma
HypoxiaHypoxia
AtelectasisAtelectasis
Cardiac arrest/arrhythmiaCardiac arrest/arrhythmia

26. 7] COUGH/HUFF7] COUGH/HUFF

COUGHINGCOUGHING

To keep the lungs clearTo keep the lungs clear
Procedure Procedure

Evaluate the patient Place the patient in relaxed Evaluate the patient Place the patient in relaxed
forward bending neck slightly flexedforward bending neck slightly flexed

Teach controlled diaphragmatic breathingTeach controlled diaphragmatic breathing

Demonstrate sharp double coughDemonstrate sharp double cough

Ask the patient to repeat Ask the patient to repeat
PrecautionsPrecautions

Never allow the patient to suck air in by gaspingNever allow the patient to suck air in by gasping

27. 
HUFFINGHUFFING

Huff is a rapid forced exhalation without Huff is a rapid forced exhalation without
maximum effortmaximum effort

Glottis remains openGlottis remains open

Required less effort than coughingRequired less effort than coughing

28. 9] BREATHING EXERCISES9] BREATHING EXERCISES

GoalsGoals

Assist removal of secretionsAssist removal of secretions

Improve respiratory muscle strength & Improve respiratory muscle strength &
enduranceendurance

Increase thoracic mobility and tidal volumeIncrease thoracic mobility and tidal volume

Promote relaxationPromote relaxation

Teach the patient how to deal with shortness of Teach the patient how to deal with shortness of
breath attackbreath attack

Improve patients overall functional capacityImprove patients overall functional capacity

29. 
TYPESTYPES
1] Diaphragmatic Breathing1] Diaphragmatic Breathing
2] Ventilatory Muscle Training2] Ventilatory Muscle Training
i] Diaphragmatic breathing using weighti] Diaphragmatic breathing using weight
ii] Inspiratory resistance trainingii] Inspiratory resistance training
iii] Incentive respiratory spirometryiii] Incentive respiratory spirometry
3] Segmental breathing3] Segmental breathing
i] Lateral costal i] Lateral costal
ii] Posterior Basal Expansionii] Posterior Basal Expansion
iii] Apical Expansioniii] Apical Expansion
iv] Rt middle/Lingula expansioniv] Rt middle/Lingula expansion

30. 4] Glossopharyngeal Breathing4] Glossopharyngeal Breathing

Indications-Severe inspiratory muscle weaknessIndications-Severe inspiratory muscle weakness
postpoliopostpolio
Spinal cord injurySpinal cord injury

Contraindication-COPDContraindication-COPD
5] Pursed lip Breathing5] Pursed lip Breathing
It increases tidal volume, improve exercise It increases tidal volume, improve exercise
tolerancetolerance
Decrease respiratory ratesDecrease respiratory rates

31. Breathing Exercises In Obstructive Airway Breathing Exercises In Obstructive Airway
DiseaseDisease
1] Breathing Control1] Breathing Control

Treatment should start with breathing control Treatment should start with breathing control

It is a normal tidal breathing to promote relaxation & It is a normal tidal breathing to promote relaxation &
prevent hyperventilationprevent hyperventilation

While teaching BC avoid full expiration should be While teaching BC avoid full expiration should be
controlled but not forcefulcontrolled but not forceful

Position- Side lying, head elevated, leaning forward Position- Side lying, head elevated, leaning forward

EFFECT- Relief of dysponea, improve vital capacity, EFFECT- Relief of dysponea, improve vital capacity,
improve V/Q improve V/Q

32. 2] 2] Diaphragmatic BreathingDiaphragmatic Breathing

For relaxation & coordinated breathing patternFor relaxation & coordinated breathing pattern

It is often used with pursed lip breathingIt is often used with pursed lip breathing

Greater tidal volume is achieved with Diaphragmatic Greater tidal volume is achieved with Diaphragmatic
breathing improve overall ventilationbreathing improve overall ventilation
3] Pursed Lip Breathing3] Pursed Lip Breathing

Benefits- increase tidal volume, decrease RR, Benefits- increase tidal volume, decrease RR,
decrease PaCO2 level, increase PaO2decrease PaCO2 level, increase PaO2

PLB may improve patients confidence and decrease PLB may improve patients confidence and decrease
anxiety by providing some temporary control over anxiety by providing some temporary control over
oxygenation oxygenation

33. 4] Ventilatory Muscle Training4] Ventilatory Muscle Training
i] Diaphragmatic training with weightsi] Diaphragmatic training with weights
ii] Inspiratory resistance trainingii] Inspiratory resistance training
iii] Incentive respiratory trainingiii] Incentive respiratory training

BE After SurgeryBE After Surgery
i] Diaphragmatic breathingi] Diaphragmatic breathing
ii] Lateral costal breathingii] Lateral costal breathing
iii] Incentive spirometry iii] Incentive spirometry

34. 9] PASSIVE EXERCISES AND 9] PASSIVE EXERCISES AND
ACTIVE EXERCISESACTIVE EXERCISES

Limb exercise like Limb exercise like
PROM, AAROM/ARROM PROM, AAROM/ARROM
are performed in ICU are performed in ICU
patientspatients

It helps to improve joint It helps to improve joint
ROM, function, muscle ROM, function, muscle
strength, soft tissue strength, soft tissue
lengthlength

It decreases the risk of It decreases the risk of
thromboembolismthromboembolism

IRR, TENS can be given IRR, TENS can be given
for relief of pain for relief of pain

35. 10] 10] IMPROVEMENT IN IMPROVEMENT IN
FUNCTIONAL CAPACITYFUNCTIONAL CAPACITY

Based on walk test the dyspnoea is noted Based on walk test the dyspnoea is noted
& also performance of the patient is noted& also performance of the patient is noted

According to this the goals are setAccording to this the goals are set

36. CHEST PHYSIOTHERAPY FOR CHEST PHYSIOTHERAPY FOR
PAEDIATRIC PATIENTSPAEDIATRIC PATIENTS
IndicationsIndications

Neurological impairmentNeurological impairment

AsthmaAsthma

Cystic fibrosisCystic fibrosis

Secretion retention after surgerySecretion retention after surgery

ImmobilityImmobility

Decrease collateral ventilationDecrease collateral ventilation
CPT should not performed more frequently more CPT should not performed more frequently more
than 3 hr & includes 3min chest percussion in 5 than 3 hr & includes 3min chest percussion in 5
PD position followed by assisted PD position followed by assisted
coughing/suctioningcoughing/suctioning

37. Handling/ positioningHandling/ positioning

Excessive handling of low birth weight infant Excessive handling of low birth weight infant
causes hypoxemiacauses hypoxemia

Supine - compromise lung functionalSupine - compromise lung functional

Side lying-Releases diaphragm from pressure of Side lying-Releases diaphragm from pressure of
abdominal viscera allowing more effective basal abdominal viscera allowing more effective basal
expansionexpansion

Facilitate drainage of secretions from the Facilitate drainage of secretions from the
uppermost part of lunguppermost part of lung

38. Prone-Better compared to supine positionProne-Better compared to supine position
-Improve gas exchange-Improve gas exchange
-Reduce gastro-esophageal reflux-Reduce gastro-esophageal reflux
-It increases tidal volume, minute ventilation & -It increases tidal volume, minute ventilation &
decreases period of apnea &25% increase in PaO2decreases period of apnea &25% increase in PaO2

Placing preterm baby in prone position may Placing preterm baby in prone position may
significantly reduce morbidity & mortalitysignificantly reduce morbidity & mortality

It may stabilize the compliant chest wall of the infant It may stabilize the compliant chest wall of the infant
& improve co-ordination between rib cage, & improve co-ordination between rib cage,
diaphragm & abdominal movementdiaphragm & abdominal movement

39. Summary Summary

Assessment of patient Assessment of patient

Goals Goals

Treatment techniques used in ICU by Treatment techniques used in ICU by
physiotherapist physiotherapist

Chest physiotherapy for pediatrics Chest physiotherapy for pediatrics

40. QUESTIONSQUESTIONS
1.1.WRITE THE AIMS OF POSITIONING. WRITE THE AIMS OF POSITIONING.
3MARKS3MARKS
2.2.WRITE ABOUT POSTURAL DRAINAGE. WRITE ABOUT POSTURAL DRAINAGE.
3MARKS3MARKS