MANAGING CRITICALLY MANAGING CRITICALLY ILL PATIENTSILL PATIENTS

–– A PhysiotherapistA Physiotherapist’’s perspectives perspective

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Chest Physiotherapy isChest Physiotherapy is……

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

Aims of this presentationAims of this presentation……

To describe the individual physiotherapeutic To describe the individual physiotherapeutic techniques.techniques.

To provide a frame work for evidence based To provide a frame work for evidence based practice.practice.

IndicationsIndications

PROPHYLACTIC PROPHYLACTIC -- PrePre--operative high risk surgical patientoperative high risk surgical patient-- PostPost--operative patient who is unable tooperative patient who is unable to

mobilize secretionsmobilize secretions-- Neurological patient who is unable to coughNeurological patient who is unable to cough

effectively effectively -- Patient receiving mechanical ventilation who has aPatient receiving mechanical ventilation who has a

tendency to retain secretionstendency to retain secretions-- Patients with pulmonary disease, Patients with pulmonary disease,

who needs to improve bronchial hygienewho needs to improve bronchial hygiene

……contdcontd

THERAPEUTIC THERAPEUTIC -- Atelectasis due to secretionsAtelectasis due to secretions-- Retained secretionsRetained secretions-- abnormal breathing pattern due to primary orabnormal breathing pattern due to primary or

secondary pulmonary dysfunctionsecondary pulmonary dysfunction-- COPD and resultant decreased exerciseCOPD and resultant decreased exercise

tolerancetolerance-- Musculoskeletal deformity that makes breathingMusculoskeletal deformity that makes breathing

pattern and cough ineffectivepattern and cough ineffective

AssessmentAssessment

General ObservationGeneral ObservationPatient PositionPatient Position

RespirationRespiration -- AirwayAirway ET/ET/TracheostomyTracheostomy

VentillatorVentillator ModeMode

FiOFiO22

VitalVital Signs Signs –– Temperature, BTemperature, BP,P, RR, HR SpORR, HR SpO2,2,GCS, ICPGCS, ICP

Tubes Tubes -- NG Tube, CV line, Peripheral line, Chest tubes, NG Tube, CV line, Peripheral line, Chest tubes, CathetersCathetersDrugsDrugs

…… contdcontd

ExaminationExaminationAuscultationsAuscultationsRespiratory patternRespiratory patternCyanosis Cyanosis ClubbingClubbingRadiographRadiograph

GoalsGoals

Prevent accumulation of secretions Prevent accumulation of secretions Improve mobilization and drainage of Improve mobilization and drainage of secretionssecretionsPromote relaxation to improve breathing Promote relaxation to improve breathing patternspatternsPromote improved respiratory functionPromote improved respiratory functionImprove cardioImprove cardio--pulmonary exercise pulmonary exercise tolerancetoleranceTeach bronchial hygiene programs to Teach bronchial hygiene programs to patients with chronic respiratory dysfunctionpatients with chronic respiratory dysfunction

PrecautionsPrecautions

UntreatedUntreated tension pneumothoraxtension pneumothoraxAbnormal coagulation profileAbnormal coagulation profileStatus Status epilepticusepilepticus or status or status asthamaticusasthamaticusImmediately following intra cranial surgeryImmediately following intra cranial surgeryHead injury with raised ICPHead injury with raised ICPOsteoporoticOsteoporotic bonesbonesRecent acute myocardial infarction, unstable vitalsRecent acute myocardial infarction, unstable vitalsImmediately after tube feedingsImmediately after tube feedingsSutures and Sutures and ICDICD’’ss

TechniquesTechniques

PositioningPositioningChest Chest tapotementtapotement techniquestechniquesManual hyperinflationManual hyperinflationAirway suctioningAirway suctioningCoughing techniquesCoughing techniquesBreathing exercisesBreathing exercisesNeuro physiological facilitationNeuro physiological facilitationControlled mobilizationControlled mobilizationPatient educationPatient education

PositioningPositioning

POSITIONING is the use of body position as a POSITIONING is the use of body position as a specific treatment technique specific treatment technique

((it has a marked influence on gas exchange it has a marked influence on gas exchange because of the unevenly damaged lungsbecause of the unevenly damaged lungs-- Tobin et Tobin et al, 1994)al, 1994)

PositioningPositioning……

Physiological effects ofPhysiological effects ofPositioningPositioning

Optimizes oxygen transport by improving Optimizes oxygen transport by improving V/Q mismatchV/Q mismatchIncreases lung volumesIncreases lung volumesReduces the work of breathingReduces the work of breathingMinimizes the work of heartMinimizes the work of heartEnhances Enhances mucociliarymucociliary clearance (postural clearance (postural drainage)drainage)

Postural Drainage Postural Drainage isnisn’’tt……

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

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

PositioningPositioning

Positioning restores ventilation to dependent lung Positioning restores ventilation to dependent lung regions more effectively than PEEP or large tidal regions more effectively than PEEP or large tidal volumes volumes ((FroeseFroese & Bryan, 1974).& Bryan, 1974).Positioning has a marked influence on gas Positioning has a marked influence on gas exchange because of unevenly damaged lungs exchange because of unevenly damaged lungs (Tobin, 1994).(Tobin, 1994).

Side lying reduces lung densities in the upper most Side lying reduces lung densities in the upper most lung lung ((BrismarBrismar, 1985)., 1985).

Right side lying may be more beneficial for cardiac Right side lying may be more beneficial for cardiac output than left side lying output than left side lying (Wong, 1998).(Wong, 1998).Simply turning from supine to side lying can clear Simply turning from supine to side lying can clear atelectasis from dependent regions atelectasis from dependent regions ((BrismarBrismar, 1985)., 1985).

……contdcontd

Positioning affects lung volumePositioning affects lung volumeLung volume is related to the position of the Lung volume is related to the position of the diaphragmdiaphragmFRC decreases from standing to slumped sitting to FRC decreases from standing to slumped sitting to

supinesupine ((MacnaughtonMacnaughton, 1995), 1995)

……contdcontd

Positioning affects compliance Positioning affects compliance ((WahbaWahba et al found that et al found that work of breathing is 40% higher in supine than in sitting)work of breathing is 40% higher in supine than in sitting)

Positioning affects arterial oxygenation by Positioning affects arterial oxygenation by improving V/Q mismatch improving V/Q mismatch (V/Q is usually mismatched if (V/Q is usually mismatched if the affected lung is dependentthe affected lung is dependent-- Gillespie et al)Gillespie et al)

““Bad lung upBad lung up”” positionposition

PositioningPositioning……

Which position to chooseWhich position to choose……

What does evidence sayWhat does evidence say……

1. lung volume by 57% (1. lung volume by 57% (RialpRialp et al., 1997).et al., 1997).

2. need for PEEP (Lim et al., 1999).2. need for PEEP (Lim et al., 1999).

3. normal V/Q units by 12%3. normal V/Q units by 12%

4. shunt by 11% (Wong 1999)4. shunt by 11% (Wong 1999)

5. 5. barotraumabarotrauma ((DuDu et al., 1997)et al., 1997)

6. drainage of secretions (6. drainage of secretions (KeseciogluKesecioglu, 1997), 1997)

7. length of ICU stay. (7. length of ICU stay. (GosheronGosheron, 1998), 1998)

Chest Chest TapotementTapotement

Chest VibrationsChest VibrationsRib Springing/ShakingRib Springing/ShakingChest Percussion/ClappingChest Percussion/Clapping

Clapping/Chest PercussionClapping/Chest Percussion

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

Chest VibrationChest Vibration

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

Rib Springing/ShakingRib Springing/Shaking

Shaking is a coarser movement in which the chest Shaking is a coarser movement in which the chest wall is rhythmically compressed.wall is rhythmically compressed.Effects : Direct secretions towards larger airways & Effects : Direct secretions towards larger airways & Stimulates cough.Stimulates cough.

Manual HyperinflationManual Hyperinflation

Was originally defined as inflating the lungs with Was originally defined as inflating the lungs with oxygen and manual compression to a tidal volume oxygen and manual compression to a tidal volume of 1 liter requiring a peak inspiratory pressure of of 1 liter requiring a peak inspiratory pressure of between 20 and 40 cm H2O between 20 and 40 cm H2O (Med j (Med j AustAust, 1972)., 1972).

More recent definitions include providing a larger More recent definitions include providing a larger tidal volume than base line tidal volume to the tidal volume than base line tidal volume to the patient patient ((AustAust j physiotherapy, 1996)j physiotherapy, 1996) and using a tidal and using a tidal volume which is 50% greater than that delivered volume which is 50% greater than that delivered the ventilator the ventilator (chest, 1994).(chest, 1994).

Advantages of MHAdvantages of MH

Reverses atelectasisReverses atelectasis ((LumbLumb 2000)2000)

Improves oxygen saturation and lung compliance Improves oxygen saturation and lung compliance ((PatmanPatman et al.,1999)et al.,1999)

Improves sputum clearance Improves sputum clearance (Hodgson et al., 2000)(Hodgson et al., 2000)

Disadvantages of MHDisadvantages of MH

Haemodynamic and metabolic upsetHaemodynamic and metabolic upset (Stone, 1991 & (Stone, 1991 & Singer et al.,1994)Singer et al.,1994)

Risk of Risk of barotraumabarotraumaDiscomfort and anxiety Discomfort and anxiety

Coughing TechniquesCoughing Techniques

Coughing:Coughing: It is a forced expiratory technique It is a forced expiratory technique performed with a closed glottis.performed with a closed glottis.Huffing:Huffing: It is a forced expiratory technique It is a forced expiratory technique performed with a open glottis.performed with a open glottis.Sniffing:Sniffing: Its an respiratory maneuver performed Its an respiratory maneuver performed after a full inspiration or expiration.after a full inspiration or expiration.

Effects of CoughingEffects of Coughing

Cough removes secretions from the larger airwaysCough removes secretions from the larger airwaysHuff mobilizes the secretions from the distal Huff mobilizes the secretions from the distal airways.airways.During a huff the pleural pressure becomes positive During a huff the pleural pressure becomes positive and equals the alveolar pressure and so it opens and equals the alveolar pressure and so it opens up the distal collapsed airway.up the distal collapsed airway.Sniff augments collateral ventilation thereby Sniff augments collateral ventilation thereby preventing distal airway collapse.preventing distal airway collapse.

Breathing ExercisesBreathing Exercises

Diaphragmatic breathingDiaphragmatic breathing

-- concentrates on concentrates on epigastricepigastric and lower rib and lower rib movements( movements( gaskellgaskell & & webberwebber, 1980)., 1980).

-- concentrates on allowing the whole abdomen concentrates on allowing the whole abdomen to swell as diaphragm descends (to swell as diaphragm descends (innocentiinnocenti, 1966)., 1966).

Breathing TechniquesBreathing Techniques

Costal breathingCostal breathing-- Is a technique which concentrates on Is a technique which concentrates on ventilation to specific areas of lungs. ventilation to specific areas of lungs. -- In this technique during inspiration the chest In this technique during inspiration the chest wall moves up and out.wall moves up and out.-- This technique can be localized to any This technique can be localized to any involved segments of the lung.involved segments of the lung.

GlossopharyngealGlossopharyngealPursed LipPursed Lip

SuctioningSuctioning

Suctioning is the mechanical aspiration of Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an pulmonary secretions from a patient with an artificial airway in place. artificial airway in place. cirteriacirteria for suctioning:for suctioning:

1) secretions are accessible to the catheter.1) secretions are accessible to the catheter.2) secretions are detrimental to the patient.2) secretions are detrimental to the patient.3) patient is unable to clear secretions by other 3) patient is unable to clear secretions by other means.means.

NeuroNeuro Physiological FacilitationPhysiological Facilitation (NPF)(NPF)

promoting or hastening the response of promoting or hastening the response of neuroneuromuscular mechanism through muscular mechanism through proprioceptorsproprioceptors((dorothydorothy vossvoss et al, 1985).et al, 1985).CutaneousCutaneous and and proprioceptiveproprioceptive stimulation stimulation reflexlyreflexlyincreases the depth of breathing increases the depth of breathing (Jones, 1998).(Jones, 1998).

INDICATIONS: INDICATIONS: Non alert patients such as those who are drowsy Non alert patients such as those who are drowsy postoperatively.postoperatively.Those with neurological conditions.Those with neurological conditions.Partially breathing patient on ventilator, especially if Partially breathing patient on ventilator, especially if they are unable to turn.they are unable to turn.

Techniques of NPFTechniques of NPF

Stimulation of diaphragm Stimulation of diaphragm (Dorothy (Dorothy vossvoss et al, 1985).et al, 1985).

PerioralPerioral techniquetechnique

IntercostalIntercostal stretchstretch

CoCo-- contraction of abdominal musclescontraction of abdominal muscles

Vertebral pressureVertebral pressure(D.D .Bethune,(D.D .Bethune, 1975)1975)

MobilisationMobilisation

ICU rehabilitation has been shown to accelerate recovery ICU rehabilitation has been shown to accelerate recovery ((oo’’learyleary & & coackleycoackley, 1996), 1996)

Early mobilization for unconscious patients starts right from Early mobilization for unconscious patients starts right from turning the patient every two hours. ( Brooksturning the patient every two hours. ( Brooks-- brunnbrunn, 1995)., 1995).

Graded exercises can be started as soon as the patient Graded exercises can be started as soon as the patient regains consciousness.regains consciousness.

Activity is required to maintain sensory input, comfort, joint Activity is required to maintain sensory input, comfort, joint mobility and healing ability (Frank et al, 1994).mobility and healing ability (Frank et al, 1994).

Activity minimizes the weakness caused by loss of Activity minimizes the weakness caused by loss of uptoupto half half the patients muscle mass (Griffiths & Jones, 1999).the patients muscle mass (Griffiths & Jones, 1999).

Graded ambulation can be started depending on patients Graded ambulation can be started depending on patients conditioncondition

MobilisationMobilisation

Critically Ill Critically Ill (Frequent Position changes, Kinetic (Frequent Position changes, Kinetic & & KinematicKinematic Therapy)Therapy)

Stable Stable (Progressive tilting(Progressive tilting && Ambulation)Ambulation)