PHYSICAL THERAPY

MANAGEMENT

OF PATIENTS IN THE ICU

This protocol is prepared by the Committee of Physical Therapy protocols, Office of Physical Therapy Affairs, Ministry

of Health, Kuwait. With cooperation of

Physical Therapy Department, Kuwait University. (2003)

Patient Referral: All patients should be referred by the attending physician before assessment and treatment. The physical therapist is responsible to see the patient upon receiving the physical therapy referral request or according to standard order (appendix A).

Patient Assessment: Patient must be assessed within 3 days of referral or admission (appendix B).

Primary Cardiopulmonary Dysfunction in the ICU: 1.Respiratory failure 2.Heart Failure 3.Cardiac Surgeries 4.Thoracic Surgeries

Secondary Cardiopulmonary Dysfunction in the ICU:

1. Burns 2. Head Injuries 3. Musculoskeletal Trauma 4. Neuromuscular Dysfunction 5. Acute Spinal Cord Injury 6. Renal Failure 7. Complicated General Surgeries

PHYSICAL THERAPY GOALS FOR PATIENTS IN THE ICU:

1) Improve / Maintain Normal or Baseline Ventilation and Oxygenation.

a) Clearance of Airways b) Improve Chest Expansion c) Improve Breath Sound d) Improve Cough Effectiveness e) Improve Breathing Pattern

2) Improve / Maintain Musculoskeletal System within Functional Limit.

a) Improve ROM b) Improve Muscle Strength and Endurance c) Prevent Joint Deformities and Contractures

3) Improve Circulatory System Function a) Prevent DVT b) Prevent Swelling

4) Improve / Maintain Neurological System and Cognitive Status within Functional Limits.

5) Improve / Maintain Level of Functional Status within Patient's Tolerance.

ICU Patient

(A) Intubated

(B) Extubated / Non-Intubated

Unconscious

Conscious

Unconscious

Conscious

Points to remember

1. Monitor physiological responses such as heart rate, blood pressure, respiratory rate and oxygen saturation at all times. (appendix C)

2. The physical therapist should be aware of effects of positioning and mobility of the patient on the various monitoring devices and their readings.

3. The physical therapist should always deal with the patient as if he/she were conscious and awake even if the patient appears not to be (talk to him and explain all procedures he is going through, and do not talk about his condition within his hearing). This may help to relax the patient and decrease patient anxiety and possible subsequent increase in muscle tone.

4. Frequency and intensity of treatment sessions will be determined by patient condition, but should generally be at least twice a day.

5. Treatment should be carried out at least 1 1/2 hrs after feeding time.

6. The physical therapist must be aware of patient's medication (appendix D), pertinent laboratory test result (appendix E), patient's management by other health care team, and patient's / family concerns.

7. The physical therapist should be familiar with all ICU equipment.

Pulmonary System

(A) INTUBATED PATIENTS: (endotracheal tube or tracheostomy)

Unconscious 1. Pre-treat with bronchodilator if the patient presents with severe bronchospasm (20 min. before treatment). 2. Modified postural drainage positions, usually with the head of the bed flat unless patient has an increase in intercranial pressure above 30 mmHg, then the head of the bed should be elevated to 30 degrees.

If there are no other contraindications (appendix F), then the following should be done by two therapists: a) Turn patient to both sides and manually hyperventilate the patient using the ambu bag" and hyperoxygenate using 10-15 L O2; if the patient who can't be taken off ventilator, set the ventilator FIO2 200% b) Use pulmonary hygiene techniques to mobilize secretions such as vibration, percussion, rib springs and shaking. c) Endotracheal suctioning to clear retained secretions using sterile techniques. 3. The best position for relaxation, decreased dyspnea and improved ventilation and oxygenation are with the head of the bed elevated to 30 degrees and lying on well aerated lung. The prone lying position is also proven to be beneficial.

Conscious Proceed with the same procedures done with the unconscious patient, and then encourage the following:

1. Independent efforts of inspiration and coughing 2. Coordinate upper extremities mobility with

inspiration and expiration to improve lung expansion

(B) EXTUBATED OR NON-INTUBATED PATIENTS Unconscious

Modified postural drainage position, usually with the head of the bed elevated to 30 degrees, and then performs the following: 1. If no contraindications, then use pulmonary hygiene

techniques to mobilize secretions. 2. Use neurophysiological facilitation of respiration to

facilitate deep breathing, increase lung volume and increase thoracic expansion. (appendix G)

3. Use tracheal tickle technique to elicit a cough, if not successful, then use nasopharyngeal suctioning to clear the retained secretions. It is very important to hyperoxygenate the patient with 10-15 L O2 prior to suctioning to avoid complications.

4. If the patient has a tracheostomy, then manually hyperventilate and hyperoxygenate the patient before suctioning.

5. Side lying and/or the prone positions are the best positions to improve oxygenation and ventilation.

Conscious Modified postural drainage position, usually with head of the bed elevated to 30 degrees, and then encourages the following: 1. Teach patient effective coughing and huffing to clear

retained secretions.* 2. If cough is non-effective and productive, then

nasopharyngeal suctioning should be performed using sterile techniques and hyperoxygenating the patient with 10-15 L O2 to avoid complications

3. If patient has restrictive lung disease, then teach patient segmental, sustained maximal inspiration, diaphragmatic breathing exercises and use of incentive spirometer 10 X hour to increase lung volume.*

4. Teach patients with COPD pursed lip breathing exercises to decrease dyspnea and prolong exhalation phase.*

* could be done in upright position as patient tolerates

Musculoskeletal System

Unconscious To avoid contractures and deformities, concentrate on the following:

1. Passive ROM of upper and lower extremities including prolonged stretching.

2. Use of splints (by keeping most joints in the neutral or functional position). Inhibitive casting or patients shoes can also be used.

3. Proper positioning for all joints of the body.

Conscious Proceed with the same procedures done with the unconscious patient, in addition to the following: 1. Active, active assistive ROM of upper and lower

extremities. 2. Strengthening exercises of upper and lower extremities.

Circulatory System

Unconscious To prevent DVT and swelling, concentrate on the following: PROM, elastic crepe bandage, compression unit, and limb elevation.

Conscious Proceed with the same procedures done with the unconscious patient in addition to the following: 1. Use ice pack to decrease swelling. 2. Encourage active exercise of all extremities and trunk.

Neurological System, Cognitive and Functional Status

Unconscious

(Glasgow coma scale below 9 + Rancho los Amigos cognitive scale below level 4) (appendix H) 1. Work with the patient to reach the next higher cognitive

level and increase level of arousal and response using different familiar auditory, visual, tactile, olfactory and proprioceptive stimuli. (For this purpose, ask the family to identify what patient likes and dislikes). Only one sensory system should be stimulated at a time, with intervals to prevent patients accommodation to the stimulus. Also, ensure giving the patient adequate time to respond.

2. The carryover of a structured program of sensory stimulation throughout the day requires the involvement of the family as well as all members of the medical team. Careful documentation should be kept on any response observed and type of stimuli used as well as their frequency, duration and intensity.

3. The patient must be oriented to place, person and time by health care team and family members.

4. To decrease limb spasticity keep hips flexed and abducted, or position patient in side lying. For decerebrate posture, use asymmetric tonic reflex on affected side to decrease upper limb extended tone. Symmetric neck reflex is used for decorticate posture to decrease flexor tone in the upper limbs and extensor tone in the lower limbs. Using ice pack can also decrease limb spasticity.

5. Activities in the upright and bed mobility can be used to improve muscles tone and facilitate active movement which will provide vestibular and tactile stimulation and improve lung function.

6. Patient should be in the upright position as soon as possible (by gradually raising the head, using the tilt table or transferring patient to the chair) to prevent osteoporosis, to improve lung function, to increase the environmental interaction, and to provide stress on the cardiovascular system.

7. Work on head and trunk control and use weight-bearing activities for the upper limbs while patient is at the edge of the bed to promote equilibrium reactions and to improve muscles tone. The therapist can move the patient passively in this position to give him feeling of weight shifting. When the patient is sitting at the edge of the bed, ensure that his feet are well supported to provide stimulation and feedback and to encourage some weight bearing through the lower limbs.

Conscious (or Patient regaining consciousness) 1. Patient will need to be reoriented several times during

each treatment session as the state of partial consciousness may trigger confusion, disorientation and consequently aggressive behavior. To prevent this from occurring, use large and prominent bulletin boards, calendars and clocks, and keep the routine and sequence of activities known to the patient.

2. Treatment activities should be kept simple and automatic using simple explanations that allow the patient to succeed with most tasks.

3. Work according to the patients attention span during all sessions. Each session will concentrate on automatic righting, equilibrium and reinforce normal movement patterns which can easily be achieved by the use of a task-oriented approach. Rest periods must be provided frequently for the patient during the treatment session.

4. The use of a task-oriented approach will encourage the patient to perform his own, active ROM of upper and

lower extremities and consequently, promote motor control. If indicated use visual demonstration, visual feedback, tactile and proprioceptive methods to improve patient's sensory awareness.

5. Increase patients functional activity by encouraging independent transfers in and out of bed, standing, marching in place and ambulation.

6. The therapist can use active assisted exercise for patient with functional limitation (severe to moderate physical impairment) to stimulate active participation.

Appendices

Appendix A Standard order for main ICU Physiotherapy Referral Form

Appendix B Cardiopulmonary Assessment

Appendix C Vital Signs

Appendix D Drugs used in the ICU Neurological System Cardiovascular System Respiratory System Renal System

Appendix E Pertinent Laboratory Test Results Arterial and Venous Blood Gases Pressures Admission Profile: Biochemistry and Liver

Profile Hematology CBC Sputum Culture Serum Chemistry Values in Acute Myocardial

Infarction

Appendix F Contraindications and Precautions for Postural Drainage Contraindications and Precautions for Vibration,

Percussion, Shaking and Rib Spring

Appendix G Neurophysiological Facilitation for the Chest

Appendix H Glasgow Coma Scale Rancho Los Amigos Cognitive Scale

Physical Therapy Protocol Committee:-

Ali Al-Mohanna (Al-Farwaniya Hospital) Khadijah Al-Ramezi (Ibn Sina Hospital) Dr.Sabriyah Al-Mazeedi (Kuwait University) Saud Mohammad (Al-Amiri Hospital) Tamadur Al-Said (Allergy Center) Noura Al-Jwear (Al-Farwaniya Hospital) Maali Al-Ajmi (Maternity Hospital) Mariam Al-Otabi (Mubarak Hospital)

This Protocol is a guideline only and may vary from patient to patient