Respiratory Medicine (2013) 107, 68e74

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/rmed

Chest physiotherapy effectiveness to

reduce hospitalization and mechanical
ventilation length of stay, pulmonary
infection rate and mortality in ICU patients
Antonio A.M. Castro a,b,c,d,*,e, Suleima Ramos Calil a,e, Susi Andrea Freitas a,e,
Alexandre B. Oliveira a,e, Elias Ferreira Porto a,b,e

a
Physical Therapy Department of the Adventist University (Unasp), Sao Paulo, Brazil
b
Respiratory Diseases of the Federal University of Sao Paulo (Unifesp), Sao Paulo, Brazil
c
Heart Institute, Sao Paulo Medical School, Sao Paulo, Brazil
d
Federal University of Pampa (Unipampa), Rio Grande do Sul, Brazil

Received 27 June 2012; accepted 25 September 2012

Available online 22 October 2012

KEYWORDS Summary
Chest physiotherapy; Introduction: Although physiotherapy is an integral part of the multiprofessional team in
Hospital stay; most ICUs there is only limited evidence concerning the effectiveness of its procedures.
Weaning; The objectives of this study were to verify if physiotherapy care provided within 24 h/day
Pulmonary infection; for hospitalized patients in the ICU reduce the length of stay, mechanical ventilation
Mortality; support, pulmonary infection and mortality compared to a physiotherapy care provided
Intensive care unit within 6 h/day.
patients Methods: A cohort study was designed to assess differences between one hospital where
patients were given physiotherapy care for 24 h/day and another hospital with only 6 h/
day. We considered the following as outcome measurements: clinical diagnosis, medication
in use, presence of associated diseases, APACHE II and SOFA scores, ICU and mechanical
ventilation length of stay, development of pulmonary infections and survival.
Results: One hundred and forty-six patients were enrolled. Patients admitted in the service
A presented a lower length of stay in mechanical ventilation (p < 0.0001), ICU stay
(p Z 0.0003), respiratory infections (p Z 0.0043) than patients admitted in service B. No
difference was found for APACHE II score (p Z 0.8) and SOFA scores (p Z 0.2) between
groups. The mortality risk was OR 1.3 (1.01e2.33) (p Z 0.04) for patients in the service B.

* Corresponding author. Rua Conego Eugenio Leite, 632 apt 132, Pinheiros, 05414000 Sao Paulo, SP, Brazil. Tel.: 55 11 30627606.
E-mail addresses: antonioamcastro@yahoo.com.br (A.A.M. Castro), suleimacalil@gmail.com (S.R. Calil), susifreitas@yahoo.com.br
(S.A. Freitas), alexandreoliveira@gmail.com (A.B. Oliveira), eliasfporto@gmail.com (E.F. Porto).
e
Present address: Estrada de Itapecerica, 5859 Jardim IAE, Sao Paulo/SP e 05858-001, Brazil.

0954-6111/$ - see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.rmed.2012.09.016
Chest physiotherapy and weaning
Conclusion: The presence of a physiotherapist in the intensive care unit contributes deci-
sively to the early recovery of the patient, reducing mechanical ventilation support need,
number of hospitalization days, incidence of respiratory infection and risk of mortality.
2012 Elsevier Ltd. All rights reserved.
Introduction
Advances in the management of intensive care unit (ICU)
patients have improved outcomes and survival rates for this
population. However, as patients survive acute illness,
long-term complications are more apparent.1 A feasible
approach to obtain complications decrease is the use of
physical therapy techniques in these critically ill patients.2
Physiotherapists in an ICU setting have focused to treat
functional impairment especially in the patient on
mechanical ventilation support. The physiotherapeutic
care begins with a detailed assessment and scheduling goals
of treatment. This care involves the use of techniques such
as endotracheal suction of bronquial secretions, mobiliza-
tion and positioning of the patient. The physiotherapy
treatment is addressed to prevent and reduce potential
pulmonary complications such as hypoventilation, hypox-
emia and infection in order to restore muscular and
pulmonary function as fast as possible.2,3
Stiller et al. showed that although physiotherapy is seen
as an integral part of the multidisciplinary team in most
ICUs, there is only limited evidence concerning the effec-
tiveness of physiotherapy mainly due to the variability of
data reported in preceding studies.4 On the other hand,
Burtin et al.3 showed that physiotherapy care for ICU
patients promotes early recovery, reduction of hospitali-
zation length and costs.
However, the occurrence of complications can be influ-
enced by the quality of care provided as well as to the amount
of care given for ICU patients.4,5 In a study conducted in 460
ICUs from 17 countries of the developed Europe, Norremberg
and Vincent5 found considerable variation in the role phys-
iotherapist played in the ICU. The authors showed that only
35% of services had physiotherapists working 24 h per day in
ICU. Chaboyer et al.6 studied 77 public hospitals of Australia.
They showed that 90% of institutions maintain physiothera-
pists in their ICU from Monday to Friday, only 25% remains
rounding in weekend and 10% every day of the week. Prob-
ably, the lack of techniques standardization as well as the
amount of the care provided are possibly the main factors for
the negative outcome reported in most systematic reviews
related to this topic.4,7
We hypothesized that 24 h/day of physiotherapy care
provided for ICU admitted patients is associated to
a reduced length of hospitalization and required mechan-
ical ventilation support as well as to a lower incidence of
pulmonary infection and mortality. We aimed to assess if
a 24 h/day physiotherapy care provided for ICU admitted
patients would reduce the length of hospitalization and the
required mechanical ventilation support, as well as to
pulmonary infection and mortality, as compared to a 6 h/
day physiotherapy care service.
69
Materials and methods
Study subjects
This was a cohort study which evaluated all hospitalized
patients admitted to ICUs of two public hospitals in the city
of Sao Paulo, Brazil. The protocol was sent to the research
committee of the Adventist University and data assessment
and analysis only begun after its approval (Adventist
University ethics institutional research committee;
approval number: 407). All family members agreed and
signed an informed consent.
Study design
In one hospital, physiotherapy care was given in a 24 h/day
basis while in the other hospital the care was provided for
only 6 h/day. The enrolled patients were divided into two
groups according their hospitalization admittance (service
A e 24 h/day; service B e 6 h/day). The physical therapy
care protocol was similar for both services prioritizing the
motor and respiratory therapy to each ICU admitted
patient. Physical therapy treatment protocol in both
hospitals consisted in mucus removal techniques (endotra-
cheal suctioning and manual thorax percussion) and general
mobilization (upper and lower limbs). Number of repeti-
tions and time spent for each technique as well as the time
spent for each visit were similar in both hospitals. In order
to assure that the same physical therapy techniques were
being used in both hospitals we have observed each service
for a week prior to the initiation of the study protocol.
Twenty-four hour/day physical therapy treatment was
related to the period hospital had available the physical
therapy assistance. Usually, a 24-hour/day care consisted
of at least four visits (morning, afternoon, evening and
night) of the physical therapist for patients treatment.
However, if any additional visit was to be necessary
a physical therapist was available (24 h/day) to provide the
needed care. On the other hand, the 6 h/day physical
therapy consisted in only one visit regardless of the
patients individual need for this care.
The reason why the service B provided less physio-
therapy care was due to the limited number of physio-
therapists hired in. Unfortunately, that scenario is still
common in the public health system in our country. No
intervention was accomplished by the authors that could
interfere with the hospital physical therapy routine. We
included patients who were admitted into the general ICU
of two public hospitals enrolled and patients eligible to
physical therapy after the initial assessment of the refer-
ring doctor and the unit physical therapist. We excluded
70 A.A.M. Castro et al.

patients diagnosed with terminal phase cancer and patients between the baseline data obtained by the patients
with clinically proven brain death on the first day of medical records, laboratory tests, APACHE II, SOFA, Glas-
hospitalization. gow and Ramsay scores. The proportion of individuals with
The technological devices such as mechanical ventila- different ages, length of hospitalization and mechanical
tion and monitoring equipment, patients exams, drugs use, ventilation time and survival was analyzed by the Kaplan
number of doctors and nurses per bed were similar in both Mayer method. We used a regression model and the odds
hospitals. All patients were evaluated by a medical ratio analysis to assess the chance of mortality in both
specialist according to each diagnosis, however, the refer- services. Statistical significance was set at p < 0.05. We
ring doctor responsible for the treatment during the ICU used the SigmaStat software in order to analyze our data.
stay was an intensive care specialist in both hospitals. The A minimum sample of 64 patients per group was calculated
only end-point that differed between one hospital to by the formula E/S (the expected effect/standard devia-
another was the physiotherapy care given into two tion of the sample) as necessary for an a Z 0.05 and
manners: 24 h per day in the first hospital (service A) and a b Z 0.80, as the minimal clinical difference.4,7 There-
6 h per day in the second hospital (service B). fore, to ensure the statistical power we analyzed 73
patients in each group.
Protocol
Results
Patients were evaluated on the first day of his/her ICU
admittance and daily during their stay. We considered the Seventy-three out of 146 patients were selected from the
following evaluation parameters: clinical diagnosis, time of hospital which had 24 h/day of physiotherapy care (service
diagnosis, medication in use and current drug introduced in A), and the remaining 73 patients from the hospital which
the ICU period, presence of associated diseases, need of had 6 h/day of physiotherapy care (service B). In both
mechanical ventilation support, previous surgeries, duration services the male gender was prevalent and patients mean
of antibiotics use, severity of disease analysis of patients by age was 54.51  18.4 and 50.25  18.9 for service A and B,
means of the APACHE II score, incidence and severity of organ respectively (Table 1).
dysfunction analysis by means of the SOFA score (Sequential Patients heart rate (88.85  18.7 vs. 89.03  24.3 bpm;
Evaluation of failure of organs), the Glasgow coma scale (for p Z 0.78), respiratory rate (18.34  5.1 vs.
patients without sedation) and sedation scale of Ramsay (for 16.48  7.2 rpm; p Z 0.08), leukocytes count (13.84  6.4
sedated patients). Data were collected daily through the vs. 12.37  5.2 mm3; p Z 0.09), plasmatic sodium
patients medical records and the laboratory tests taken. (137.70  6.3 vs. 136.37  11.4 mEq/L; p Z 0.08), plas-
The mechanical ventilation (MV) time which the patient matic potassium (4.42  0.6 vs. 4.22  0.8 mEq/L;
was submitted to was measured in days and it was considered p Z 0.72), creatinine (1.74  0.7 vs. 1.04  0.5 mg/dL;
from the moment of the tracheal intubation to the moment p Z 0.41), initial and 48 h after admission C-reactive
of extubation. Noninvasive ventilation period was not protein (70.18  10.6 vs. 65.71  12.1 mg/L; p Z 0.40), pH
considered mechanical ventilation length of stay. Respira- (7.36  0.1 vs. 7.37  0.1; p Z 0.91), SpO2 (93.14  10.9 vs.
tory infection occurred after patients were admitted into 95.01  12.8%; p Z 0.10), FiO2 (0.47  0.2 vs. 0.48  0.2%;
each hospital. Therefore, ventilator-associated pneumonia p Z 0.53) and alveolar arterial oxygen (305.57  105.1 vs.
(VAP) was characterized by the definitions as follows: 1) 312.99  121.5; p Z 0.53) were similar between service A
Pneumonia occurring >48 h after endotracheal intubation; 2) and B, respectively. In addition, the Glasgow score, number
Risk factors for multidrug-resistant (MDR) bacteria causing of organs with dysfunction, APACHE II score and SOFA score
VAP. Additionally, nosocomial pneumonia was also assessed were also similar in both hospitals (Table 1).
by the worsening of the patients radiological pattern on
a chest radiogram prior to ICU hospitalization as well as to the
increase in the white blood cells count. Table 1 Baseline characteristic of the 146 studied
Survival and mortality were considered to be major patients in both services.
outcome variables. Patients who were discharged from the Variables Service A Service B p
ICU to another clinical ward of the hospital, to an outpa- (24 h) (6 h)
tient or home-care system were considered to have Sex (Female/Male) 27/46 25/48 e
survived the ICU period. Mortality was considered in those Age (years) 54.51  18.4 50.25  18.9 0.16
cases where death occurred within the ICU hospitalization Ramsay score 4.66  0.7 5.48  0.6 0.01
period. The duration of ICU stay was measured in days. Glasgow score 13.05  3.1 11.19  4.1 0.08
The instruments used for assessing the patient were: APACHE II score 19.90  12.2 20.40  7.7 0.76
APACHE II and SOFA score to assess the severity of the SOFA score 7.97  0.8 8.37  0.9 0.76
disease8,9; the Glasgow coma scale, which assesses the Number of 1.61  0.7 1.87  0.8 0.05
level of consciousness and neurological status10; and the dysfunctional
Ramsay scale, which assesses the level of sedation.11 organs
Overall time of 52.8  2 21.6  1.5 0.001
Statistical analysis chest physical
therapy (h)
Data are expressed in mean and standard deviation. Man- Data expressed as mean  standard deviation.
neWhitney U test was used to determine differences
Chest physiotherapy and weaning 71

We found that the body temperature (36.45  0.7 vs.

36.82  0.6  C; p Z 0.01), mean arterial pressure
(90.84  20.1 vs. 99.86  22.6 mmHg; p Z 0.03), bicar-
bonate (18.80  5.1 vs. 21.48  5.3 mEq/L; p Z 0.04),
Ramsay score (4.66  0.7 vs. 5.48  0.6; p Z 0.01), arterial
oxygen pressure (110.96  34.1 vs. 95.12  32.3 mmHg;
p Z 0.02), and hematocrit (32.95  5.7 vs. 29.96  5.1%;
p Z 0.01), were different for patients hospitalized in the
service A (24 h/day) as compared to service B (6 h/day),
respectively. As expected, the physical therapy treatment
overall time given throughout patients ICU stay was higher
in the service A as compared to B (p Z 0.001) (Table 1).
Among 73 patients hospitalized in the service A, 52 had
two or more associated diseases while in the service B 43
individuals presented associated conditions. The most Figure 1 Days patients remained on mechanical ventilation
frequent diagnoses for both groups are listed in Table 2. support in services A (24 h/day of physiotherapy care) and B
The number of patients on mechanical ventilation was (6 h/day of physiotherapy care). OR Z odds ratio;
57 in the service A and 59 in service B. Twenty patients CI Z confidence interval.
admitted in service A died while 26 patients died in service
B. We found that patients in the service A presented lower The index of respiratory system infection was calculated
length of stay in mechanical ventilation than patients in the by the number of patients who presented respiratory
service B (10  20 and 15  12 days, A and B service, infection divided by the total number of admitted patients.
respectively, p < 0.0001). Fig. 1 show that this difference We found the respiratory infection index to be 0.356 and
occurred from the 5th day on, which represented 80% and 0.616 in service A and B, respectively (p Z 0.0043) (Fig. 3).
95% of patients on mechanical ventilation in the service A Mortality was found to be 15% lower in service A than B.
and B, respectively. After 31 days of mechanical ventilation Also, the regression analysis showed a likely mortality
the service A had no patients in mechanical ventilatory probability for service B (OR 1.3 95%, IC 1.08e2.33,
support while 22% of patients in the service B still required p Z 0.04) (Fig. 4). Twenty patients died in service A (27.3%)
mechanical ventilation (p < 0.0001). The regression anal- and 26 in service B (35.5%). This specific group of patients
ysis showed a longer mechanical ventilation length of stay showed no difference in the APACHE II score for service A
probability for service B (OR Z 3.8, 95% CI, 1.65 to 9.12, and B (26.0  16.1 and 25.3  6.6, respectively, p Z 0.8),
p Z 0.0001) (Fig. 1). There were no significant difference and in the SOFA score for service A and B (8.1  2.6 and
for APACHE II (p Z 0.8) and SOFA (p Z 0.2) scores for both 10.0  2.2, respectively, p Z 0.180).
groups.
The ICU length of stay was 13.2  12.6 and 21.6  17.8 in
the service A and B, respectively (p Z 0.0003). This
Discussion
difference was first found from the 13th day of ICU hospi-
talization and on. At the end of 30 days the service A had
The novel finding of this study is that full-time 24 h/day
already discharged all patients while 40% of patients in the
physiotherapy care is associated with reduction of hospi-
service B remained hospitalized in the ICU (p Z 0.0003)
talization and mechanical ventilation length of stay, and
(Fig. 2). Also, the regression analysis showed a longer ICU
lower incidence of respiratory infection and mortality in
length of stay probability for service B (OR Z 3.1, 95% CI,
general ICU admitted patients.
1.45e6.88, p Z 0.0003) (Fig. 2).
We showed that the groups were similar among most
variables (Table 1). However, the service B (6 h/day)

Table 2 Diagnosis number of the admitted ICU patients in

both services.
Variables Service A Service B
(24 h/day) (6 h/day)
Cerebral infarction 8 11
Brain trauma 4 24
Diabetes 7 11
Tumor of any kind 7 3
Renal failure 16 8
Respiratory failure 10 13
Systemic arterial 20 20
hipertension
Chronic heart failure 9 6
Pneumonia 13 21 Figure 2 Days patients remained hospitalized in services A
COPD exacerbations 4 5 (24 h/day of physiotherapy care) and B (6 h/day of physio-
therapy care). OR Z odds ratio; CI Z confidence interval.
72
Figure 3 Respiratory infection index of intensive care unit
patients in services A (24 h/day of physiotherapy care) and B
(6 h/day of physiotherapy care).
showed that the body temperature, mean arterial pressure,
bicarbonate, and Ramsay were higher than service A (24 h/
day). While in service A (24 h/day) the arterial oxygen
pressure and hematocrit were higher. These findings were
considered irrelevant due to the common variability these
variables present while a physiotherapy procedure is per-
formed as reported previously.12 Jones et al.13 showed that
physiotherapy techniques reduces intrapulmonary shunt
and increases compliance of the respiratory system. That
mechanism is the main responsible for the increased heart
rate, systolic blood pressure, mean blood pressure, oxygen
consumption and production of carbon dioxide most
patients present in a physiotherapy treatment session.
Nevertheless, the baseline of the APACHE II and SOFA scores
were similar between patients in both hospitals.
Additionally, we have reported that the rate of neuro-
logical patients and pneumonia is more frequent in the low
physiotherapy group (29% and 17%, respectively). Despite
the differences found in the diseases etiology between the
two hospitals our results were not influenced by any of
these confounding factors. One reason for this is that early
and adequate mobilization and weaning were accomplished
in both hospitals however with less (6 h/day) or more (24 h/
day) intensity. We have controlled the techniques used by
physiotherapists in both hospitals, as well as the medical
and nurse treatment, leaving only the amount of physical
therapy given for each patient as the outcome variable. As
expected, we could not control the amount of specific
diseases enrolled in the protocol since we meant to
Figure 4 Survival rate of hospitalized patients in services A
(24 h/day of physiotherapy care) and B (6 h/day of physio-
therapy care). OR Z odds ratio; CI Z confidence interval.
A.A.M. Castro et al.
simulate the characteristics of a general ICU unit. Also, we
intently choose a convenience sample recruiting model
once selected the hospitals to perform the protocol.
Nevertheless, we can assure that despite the differences
found it did not influence the main outcome due to the fact
that Glasgow coma scale, APACHE II and SOFA scores were
the same for both hospitals.
Ventilator-associated pneumonia (VAP) diagnosis was
characterized by its recognized definitions which was: 1)
Pneumonia occurring >48 h after endotracheal intubation;
2) Risk factors for multidrug-resistant (MDR) bacteria
causing VAP.28 We found that pneumonia rate was higher in
the low physical therapy group than in the 24 h group.
However, this difference did not alter the final outcome
since the severity of diseases (APACHE II and SOFA scores)
and treatment used (medical, physical therapy and nursing)
were the same within both group. Also, we had only few
patients that developed the critical illness polineuropathy
for service A and B (3% and 5%, respectively) accounting no
additional confounding factor to our study outcome.
Some authors have shown the effectiveness of physio-
therapy for patients undergoing mechanical ventilation in
ICU, especially concerning the improvement of pulmonary
function and hemodynamic, reducing the incidence of
pulmonary complications.14,15 But still randomized studies
to evidence the reduction of hospitalization and mechan-
ical ventilation length of stay are required.16e18
Our study showed that the service A had 57 patients in
mechanical ventilation and the service B had 59 patients.
We found that the mechanical ventilation length of stay in
service A was significantly lower than in the service B
(Fig. 1). As in our study, others authors19,20 showed
a reduction of mechanical ventilation length of stay with
chest physiotherapy care. Many studies reports that
weaning and early mobilization are priority outcomes to be
achieved in order to promote mechanical ventilation and
hospitalization length of stay reduction.21e24
On the other hand, there are several studies that shows
the benefits of chest physiotherapy in ICU patients,25e28
however, none of them regards the prevention of pulmo-
nary complications with the use of chest physiotherapy. In
our study we found significant reduction of time ICU length
of stay in the service A as to the service B (Fig. 2). We
believe that this was related to the intensity of the given
physiotherapy care offered for the patient. Safety and
intensive physiotherapy care29 promotes not only reduction
of costs but also a reduction in the incidence of respiratory
infection (Fig. 3).
We found that mortality was 15% higher in the service B
that provided less physiotherapy care than in the service A
that provided full-time physiotherapy. Most studies do not
show that association. Ali et al.30 showed that patients with
acquired muscle weakness are more likely of death,
however, no study ever pointed out if any physiotherapy
techniques are effective to recover such patient.31
Stiller4 stated that the physiotherapy effects are exclu-
sively short-term and therefore there is no evidence that
chest physiotherapy reduce complications and mortality in
an ICU setting. However, it can not be assumed that phys-
iotherapy techniques in the ICU are ineffective as the
literature presents not enough evidence regarding that
matter. We are the first to show that patients with a full-
Chest physiotherapy and weaning
time physiotherapy care are less likely of death. We found
that patients with less physiotherapy care present at least
30% more chance of death than patients with full-time
physiotherapy care (Fig. 4).
The limitation of this study was the fact that the service
B presented more patients diagnosed with brain trauma
than in the service A (Table 2). Since we designed our study
as a cohort we did not control the recruitment in order to
avoid a bias. However, this does not invalidate our results
since the severity of the disease was similar between
patients of both services.
Conclusions
We conclude that the presence of the chest physiotherapist
in the intensive care unit contributes to the early recovery
of the patient, reducing length of stay on mechanical
ventilation and hospitalization as well as the incidence of
respiratory infection and mortality.
Key message
Chest physical therapy care given in a 24 h basis can reduce
mechanical ventilation and hospitalization length of stay as
well as the incidence of respiratory infections and
mortality.
Acknowledgments
The authors would like to acknowledge the partnership we
had with both hospitals while in subject enrollment.
Authors contributions
Antonio A.M. Castro; Suleima Ramos Calil; Susi Andrea
Freitas; Alexandre B. Oliveira, Elias Ferreira Porto: for
assistance in subject recruitment, data collection, data
analysis and manuscript preparation.
Antonio A.M. Castro and Elias Ferreira Porto: Statistical
analysis and guidance.
Conflict of interest statement
The protocol was submitted and approved by the Ethics
Committee of our University and all family members gave
written signed consent. This material has not been entirely
or in part published and it is not being considered for
publication elsewhere. All authors wish to state that no
company has provided grants, gifts, equipments and or any
drugs to this study or any participant. Also, any tobacco
company has not funded any part of this manuscript. Any
unexpected adverse effects or changes in protocols have
been disclosed. All authors have made significant contri-
butions to the study and have read and approved the
manuscript. All authors agreed with the statements above
and gave away the editorial rights of this manuscript. Also,
as the main author I had access to the entire manuscript
73
and by that means I take responsibility for the integrity and
accuracy of the data.
References
1. Schweickert W, Pohlman M, Pohlman A, et al. Early physical
and occupational therapy in mechanically ventilated, critically
ill patients: a randomised controlled trial. The Lancet 2009;
373:1874e82.
2. Bailey P, George T, Vick S, et al. Early activity is feasible and
safe in respiratory failure patients. Crit Care Med 2007;35:
139e45.
3. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in criti-
cally ill patients enhances short-term functional recovery. Crit
Care Med 2009;37(9):2499e505.
4. Stiller K. Physiotherapy in intensive care: towards an evidence-
based practice. Chest 2000;118:1801e13.
5. Norrenberg M, Vincent JL. A profile of European intensive care
unit physiotherapists. European Society of Intensive Care
Medicine. Intensive Care Med 2000;26:988e94.
6. Chaboyer W, Gass E, Foster M. Patterns of chest physiotherapy
in Australian intensive care units. J Crit Care 2004;19:145e51.
7. Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult
patients with critical illness: recommendations of the Euro-
pean Respiratory Society and European Society of Intensive
Care Medicine Task Force on physiotherapy for critically ill
patients. Intensive Care Med 2008;34(7):1188e99.
8. Knaus WA, Zimmerman JE, Wagner DP, et al. APACHE e acute
physiology and chronic health evaluation: a physiologically
based classification system. Crit Care Med 1981;9(8):591e7.
9. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related
Organ Failure Assessment) score to describe organ dysfunc-
tion/failure. Intensive Care Med 1996;22:707e10.
10. Teasdale G, Jennet B. Assessment of coma and impaired
consciousness, a practical scale. Lancet 1974;78(2):81e4.
11. Ramsay MA, Savege TM, Simpson BR, et al. Controlled sedation
with alphaxaloneealphadolone. Br Med J 1974;2:656e9.
12. Horiuchi K, Jordan D, Cohen D, et al. Insights into the increased
oxygen demand during chest physiotherapy. Crit Care Med
1997;25:1347e51.
13. Jones AYM, Hutchinson RC, Oh TE. Effects of bagging and
percussion on total static compliance of the respiratory
system. Physiotherapy 1992;78:661e6.
14. Mackenzie CF, Shin B. Cardiorespiratory function before and
after chest physiotherapy in mechanically ventilated patients
with post-traumatic respiratory failure. Crit Care Med 1985;
13:483e6.
15. Novak RA, Shumaker L, Snyder JV, et al. Do periodic hyperin-
flations improve gas exchange in patients with hypoxemic
respiratory failure? Crit Care Med 1987;15:1081e5.
16. Jones AYM, Hutchinson RC, Oh T. Chest physiotherapy practice
in intensive care units in Australia, the UK and Hong Kong.
Physiother Theory Pract 1992;8:39e47.
17. Daber SE, Jackson SE. Role of the physiotherapist in the
intensive care unit. Intensive Care Nurs 1987;3:165e71.
18. Ciesla ND. Chest physical therapy for patients in the intensive
care unit. Phys Ther 1996;76:609e25.
19. Hedstrand U, Liw M, Rooth G, et al. Effect of respiratory
physiotherapy on arterial oxygen tension. Acta Anaesthesiol
Scand 1978;22(4):349e52.
20. Patrick P, Martin RT, Bernhard W. Prophylactic respiratory
physiotherapy after cardiac surgery: systematic review. BMJ
Publishing Group Ltd 2003;13:327e35.
21. Morris P, Goad A, Thompson C, et al. Early intensive care unit
mobility therapy in the treatment of acute respiratory failure.
Crit Care Med 2008;36(8):2238e43.
74
22. Thomsen GE, Snow GL, Rodriguez L, et al. Patients with
respiratory failure increase ambulation after transfer to an
intensive care unit where early activity is a priority. Crit Care
Med 2008;36(4):1119e24.
23. Clini E, Ambrosino N. Early physiotherapy in the respiratory
intensive care unit. Respir Med 2005;99:1096e104.
24. Chiang LL, Wang LY, Wu CP, et al. Effects of physical training on
functional status in patients with prolonged mechanical
ventilation. Phys Ther 2006;86:1271e81.
25. Natasha K Brusco, Jennifer Paratz. The effect of additional
physiotherapy to hospital inpatients outside of regular business
hours: a systematic review. Phys Theory Pract 2006;22(6):
291e307.
26. Berney S, Denehy L. A comparison of the effects of manual and
ventilator hyperinflation on static lung compliance and sputum
A.A.M. Castro et al.
production in intubated and ventilated intensive care patients.
Physiother Res Int 2002;7:100e8.
27. Berney S, Denehy L, Pretto J. Head-down tilt and manual
hyperinflation enhance sputum clearance in patients who are
intubated and ventilated. Aust J Physiother 2004;50:9e14.
28. Kollef MH. What is ventilator-associated pneumonia and why is
it important? Respir Care 2005;50(6):714e21.
29. Stiller Kathy. Safety issues that should be considered when
mobilizing critically ill patients. Crit Care Clin 2007;23:35e53.
30. Ali NA, OBrien JM, Hoffmann SP, et al. Acquired weakness,
handgrip strength, and mortality in critically ill patients. Am J
Respir Crit Care Med 2008;178:261e8.
31. Hodgin KE, Nordon-Craft A, McFann KK, et al. Physical therapy
utilization in intensive care units: results from a national
survey. Crit Care Med 2009;37(2):561e8.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.