MANAGING CRITICALLY MANAGING CRITICALLY ILL PATIENTSILL PATIENTS

– – A Physiotherapist’s A Physiotherapist’s perspectiveperspective

Leema, Jebaraj, DavidLeema, Jebaraj, David

PMR dept PMR dept

Chest Physiotherapy Chest Physiotherapy is…is…

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

Aims of this Aims of this presentation…presentation…

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

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

IndicationsIndications PROPHYLACTIC PROPHYLACTIC

- - Pre-operative high risk surgical patientPre-operative high risk surgical patient- Post-operative patient who is unable to- Post-operative patient who is unable to

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

effectively effectively - Patient receiving mechanical ventilation who has a- Patient 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 secretions- Retained secretions- abnormal breathing pattern due to primary or- abnormal breathing pattern due to primary or

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

tolerancetolerance- Musculoskeletal deformity that makes - Musculoskeletal deformity that makes breathingbreathing

pattern and cough ineffectivepattern and cough ineffective

AssessmentAssessment

General ObservationGeneral Observation Patient PositionPatient Position RespirationRespiration - - Airway Airway ET/TracheostomyET/Tracheostomy

Ventillator Ventillator ModeMode FiOFiO22

VitalVital Signs – Temperature, BSigns – Temperature, BP,P, RR, HR SpO RR, HR SpO2,2,GCS, ICPGCS, ICP Tubes - NG Tube, CV line, Peripheral line, Chest tubes, Tubes - NG Tube, CV line, Peripheral line, Chest tubes,

CathetersCatheters DrugsDrugs

… … contdcontd

ExaminationExamination AuscultationsAuscultations Respiratory patternRespiratory pattern Cyanosis Cyanosis ClubbingClubbing RadiographRadiograph

GoalsGoals Prevent accumulation of secretions Prevent accumulation of secretions Improve mobilization and drainage of Improve mobilization and drainage of

secretionssecretions Promote relaxation to improve breathing Promote relaxation to improve breathing

patternspatterns Promote improved respiratory functionPromote improved respiratory function Improve cardio-pulmonary exercise Improve cardio-pulmonary exercise

tolerancetolerance Teach bronchial hygiene programs to Teach bronchial hygiene programs to

patients with chronic respiratory patients with chronic respiratory dysfunctiondysfunction

PrecautionsPrecautions UntreatedUntreated tension pneumothoraxtension pneumothorax Abnormal coagulation profileAbnormal coagulation profile Status epilepticus or status asthamaticusStatus epilepticus or status asthamaticus Immediately following intra cranial surgeryImmediately following intra cranial surgery Head injury with raised ICPHead injury with raised ICP Osteoporotic bonesOsteoporotic bones Recent acute myocardial infarction, unstable Recent acute myocardial infarction, unstable

vitalsvitals Immediately after tube feedingsImmediately after tube feedings Sutures and ICD’sSutures and ICD’s

TechniquesTechniques PositioningPositioning Chest tapotement techniquesChest tapotement techniques Manual hyperinflationManual hyperinflation Airway suctioningAirway suctioning Coughing techniquesCoughing techniques Breathing exercisesBreathing exercises Neuro physiological facilitationNeuro physiological facilitation Controlled mobilizationControlled mobilization Patient 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 lungs- because of the unevenly damaged lungs- Tobin et al, 1994)Tobin et al, 1994)

Positioning…Positioning…Physiological effects ofPhysiological effects ofPositioningPositioning Optimizes oxygen transport by Optimizes oxygen transport by

improving V/Q mismatchimproving V/Q mismatch Increases lung volumesIncreases lung volumes Reduces the work of breathingReduces the work of breathing Minimizes the work of heartMinimizes the work of heart Enhances mucociliary clearance Enhances mucociliary clearance

(postural drainage)(postural drainage)

Postural Drainage Postural Drainage isn’t…isn’t… a separate technique. Its just an example of a separate technique. Its just an example of

positioning which has the particular aim of positioning which has the particular aim of clearing airway secretions with the clearing airway secretions with the assistance of gravity.assistance of gravity.

Patients are positioned with the area to be Patients are positioned with the area to be drained the upper most, but modifications drained the upper most, but modifications should be done wherever necessary.should be done wherever necessary.

Drainage times vary, but ideally each Drainage times vary, but ideally each position requires 10 minutes (gumery et al, position requires 10 minutes (gumery et al, 2001).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 (Froese & Bryan, 1974).(Froese & 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 Side lying reduces lung densities in the upper most lung most lung (Brismar, 1985).(Brismar, 1985).

Right side lying may be more beneficial for Right side lying may be more beneficial for cardiac output than left side lying cardiac 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 (Brismar, 1985).(Brismar, 1985).

……contdcontd

Positioning affects lung volumePositioning affects lung volume Lung volume is related to the position of the Lung volume is related to the position of the

diaphragmdiaphragm FRC decreases from standing to slumped FRC decreases from standing to slumped

sitting to supinesitting to supine (Macnaughton, 1995)(Macnaughton, 1995)

……contdcontd

Positioning affects compliance Positioning affects compliance (Wahba et al (Wahba et al found that work of breathing is 40% higher in supine found that work of breathing is 40% higher in supine than in sitting)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 (V/Q is usually mismatched if the affected lung is dependent- mismatched if the affected lung is dependent- Gillespie et al)Gillespie et al) ““Bad lung up” positionBad lung up” position

Positioning…Positioning… Which position to choose…Which position to choose…

??

What does evidence What does evidence say…say…

1. lung volume by 57% (Rialp et al., 1997).1. lung volume by 57% (Rialp 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. barotrauma (Du et al., 1997)5. barotrauma (Du et al., 1997)

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

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

Chest TapotementChest Tapotement Chest VibrationsChest Vibrations Rib Springing/ShakingRib Springing/Shaking Chest Percussion/ClappingChest Percussion/Clapping

Clapping/Chest Clapping/Chest PercussionPercussion Percussion consists of rhythmic clapping on Percussion consists of rhythmic clapping on

the chest with loose wrist & cupped hand.the chest with loose wrist & cupped hand. Effect : Dislodges & loosens secretions from Effect : Dislodges & loosens secretions from

the lungthe lung

Chest VibrationChest Vibration Vibrations consists of a fine oscillation of the Vibrations consists of a fine oscillation of the

hands directed inwards against the chest, hands directed inwards against the chest, performed on exhalation after deep performed on exhalation after deep inhalation.inhalation.

Effects: Helpful in moving loosened mucous Effects: Helpful in moving loosened mucous plugs towards larger airwayplugs towards larger airway

Rib Springing/ShakingRib Springing/Shaking Shaking is a coarser movement in which the Shaking is a coarser movement in which the

chest wall is rhythmically compressed.chest wall is rhythmically compressed. Effects : Direct secretions towards larger Effects : Direct secretions towards larger

airways & Stimulates cough.airways & Stimulates cough.

Manual HyperinflationManual Hyperinflation Was originally defined as inflating the lungs Was originally defined as inflating the lungs

with oxygen and manual compression to a with oxygen and manual compression to a tidal volume of 1 liter requiring a peak tidal volume of 1 liter requiring a peak inspiratory pressure of between 20 and 40 cm inspiratory pressure of between 20 and 40 cm H2O H2O (Med j Aust, 1972).(Med j Aust, 1972).

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

Advantages of MHAdvantages of MH Reverses atelectasisReverses atelectasis (Lumb 2000)(Lumb 2000) Improves oxygen saturation and lung Improves oxygen saturation and lung

compliance compliance (Patman et al.,1999)(Patman et al.,1999) Improves sputum clearance Improves sputum clearance (Hodgson et al., (Hodgson et al.,

2000)2000)

Disadvantages of MHDisadvantages of MH Haemodynamic and metabolic upsetHaemodynamic and metabolic upset (Stone, (Stone,

1991 & Singer et al.,1994)1991 & Singer et al.,1994) Risk of barotraumaRisk of barotrauma Discomfort 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 Its an respiratory maneuver

performed after a full inspiration or performed after a full inspiration or expiration.expiration.

Effects of CoughingEffects of Coughing Cough removes secretions from the larger Cough removes secretions from the larger

airwaysairways Huff mobilizes the secretions from the distal Huff mobilizes the secretions from the distal

airways.airways. During a huff the pleural pressure becomes During a huff the pleural pressure becomes

positive and equals the alveolar pressure positive and equals the alveolar pressure and so it opens up the distal collapsed and so it opens up the distal collapsed airway.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 epigastric and lower - concentrates on epigastric and lower

rib movements( gaskell & webber, 1980).rib movements( gaskell & webber, 1980).- concentrates on allowing the whole - concentrates on allowing the whole

abdomen to swell as diaphragm descends abdomen to swell as diaphragm descends (innocenti, 1966).(innocenti, 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.

GlossopharyngealGlossopharyngeal Pursed 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.

cirteria for suctioning:cirteria 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.

Neuro Physiological Neuro Physiological FacilitationFacilitation (NPF)(NPF) promoting or hastening the response of promoting or hastening the response of

neuro muscular mechanism through neuro muscular mechanism through proprioceptors proprioceptors (dorothy voss et al, 1985).(dorothy voss et al, 1985).

Cutaneous and proprioceptive stimulation Cutaneous and proprioceptive stimulation reflexly increases the depth of breathing reflexly increases the depth of breathing (Jones, 1998).(Jones, 1998).

INDICATIONS: INDICATIONS: Non alert patients such as those who are Non alert patients such as those who are

drowsy postoperatively.drowsy postoperatively. Those with neurological conditions.Those with neurological conditions. Partially breathing patient on ventilator, Partially breathing patient on ventilator,

especially if they are unable to turn.especially if they are unable to turn.

Techniques of NPFTechniques of NPF

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

Perioral techniquePerioral technique

Intercostal stretchIntercostal stretch

Co- contraction of abdominal musclesCo- contraction of abdominal muscles

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

MobilisationMobilisation ICU rehabilitation has been shown to accelerate ICU rehabilitation has been shown to accelerate

recovery (o’leary & coackley, 1996)recovery (o’leary & coackley, 1996)

Early mobilization for unconscious patients starts right Early mobilization for unconscious patients starts right from turning the patient every two hours. ( Brooks- from turning the patient every two hours. ( Brooks- brunn, 1995).brunn, 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, Activity is required to maintain sensory input, comfort, joint mobility and healing ability (Frank et al, 1994).joint mobility and healing ability (Frank et al, 1994).

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

Graded ambulation can be started depending on Graded ambulation can be started depending on patients conditionpatients condition

MobilisationMobilisation Critically Ill Critically Ill (Frequent Position changes, (Frequent Position changes,

Kinetic Kinetic & Kinematic & Kinematic Therapy)Therapy)

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

ConclusionConclusion

A hammer in a A hammer in a carpenter’s hand is not carpenter’s hand is not used to pull out a nail…used to pull out a nail…

ThankThank youyou