MANAGING CRITICALLY

ILL PATIENTS

A Physiotherapists perspective


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


To describe the individual physiotherapeutic
techniques.

To provide a frame work for evidence based
practice.

PROPHYLACTIC
- Pre-operative high risk surgical patient
- Post-operative patient who is unable to
mobilize secretions
- Neurological patient who is unable to cough
effectively
- Patient receiving mechanical ventilation who has a
tendency to retain secretions
- Patients with pulmonary disease,
who needs to improve bronchial hygiene


contd
THERAPEUTIC
- Atelectasis due to secretions
- Retained secretions
- abnormal breathing pattern due to primary or
secondary pulmonary dysfunction
- COPD and resultant decreased exercise
tolerance
- Musculoskeletal deformity that makes breathing
pattern and cough ineffective

General Observation
Patient Position
Respiration - Airway ET/Tracheostomy
Ventillator Mode
FiO
2
Vital Signs Temperature, BP, RR, HR SpO
2,
GCS, ICP
Tubes - NG Tube, CV line, Peripheral line, Chest tubes,
Catheters
Drugs
contd
Examination
Auscultations
Respiratory pattern
Cyanosis
Clubbing
Radiograph

Prevent accumulation of secretions
Improve mobilization and drainage of
secretions
Promote relaxation to improve breathing
patterns
Promote improved respiratory function
Improve cardio-pulmonary exercise
tolerance
Teach bronchial hygiene programs to
patients with chronic respiratory dysfunction

Untreated tension pneumothorax
Abnormal coagulation profile
Status epilepticus or status asthamaticus
Immediately following intra cranial surgery
Head injury with raised ICP
Osteoporotic bones
Recent acute myocardial infarction, unstable vitals
Immediately after tube feedings
Sutures and ICDs

Positioning
Chest tapotement techniques
Manual hyperinflation
Airway suctioning
Coughing techniques
Breathing exercises
Neuro physiological facilitation
Controlled mobilization
Patient education




Positioning



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

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

Physiological effects of
Positioning
Optimizes oxygen transport by improving
V/Q mismatch
Increases lung volumes
Reduces the work of breathing
Minimizes the work of heart
Enhances mucociliary clearance (postural
drainage)

isnt
a separate technique. Its just an example of
positioning which has the particular aim of clearing
airway secretions with the assistance of gravity.
Patients are positioned with the area to be drained
the upper most, but modifications should be done
wherever necessary.
Drainage times vary, but ideally each position
requires 10 minutes (gumery et al, 2001).


Positioning restores ventilation to dependent lung
regions more effectively than PEEP or large tidal
volumes (Froese & Bryan, 1974).
Positioning has a marked influence on gas
exchange because of unevenly damaged lungs
(Tobin, 1994).
Side lying reduces lung densities in the upper most
lung (Brismar, 1985).
Right side lying may be more beneficial for cardiac
output than left side lying (Wong, 1998).
Simply turning from supine to side lying can clear
atelectasis from dependent regions (Brismar, 1985).



contd
Positioning affects lung volume
Lung volume is related to the position of the
diaphragm
FRC decreases from standing to slumped sitting to
supine (Macnaughton, 1995)
contd
Positioning affects compliance (Wahba et al found that
work of breathing is 40% higher in supine than in sitting)

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

Which position to choose
1. lung volume by 57% (Rialp et al., 1997).

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

3. normal V/Q units by 12%

4. shunt by 11% (Wong 1999)

5. barotrauma (Du et al., 1997)

6. drainage of secretions (Kesecioglu, 1997)

7. length of ICU stay. (Gosheron, 1998)
Chest Vibrations
Rib Springing/Shaking
Chest Percussion/Clapping

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



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


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

Was originally defined as inflating the lungs with
oxygen and manual compression to a tidal volume
of 1 liter requiring a peak inspiratory pressure of
between 20 and 40 cm H2O (Med j Aust, 1972).
More recent definitions include providing a larger
tidal volume than base line tidal volume to the
patient (Aust j physiotherapy, 1996) and using a tidal
volume which is 50% greater than that delivered
the ventilator (chest, 1994).

Reverses atelectasis (Lumb 2000)
Improves oxygen saturation and lung compliance
(Patman et al.,1999)
Improves sputum clearance (Hodgson et al., 2000)
Haemodynamic and metabolic upset (Stone, 1991 &
Singer et al.,1994)
Risk of barotrauma
Discomfort and anxiety
Coughing: It is a forced expiratory technique
performed with a closed glottis.
Huffing: It is a forced expiratory technique
performed with a open glottis.
Sniffing: Its an respiratory maneuver performed
after a full inspiration or expiration.

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

Diaphragmatic breathing
- concentrates on epigastric and lower rib
movements( gaskell & webber, 1980).
- concentrates on allowing the whole abdomen
to swell as diaphragm descends (innocenti, 1966).


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

Glossopharyngeal
Pursed Lip



Suctioning is the mechanical aspiration of
pulmonary secretions from a patient with an
artificial airway in place.
cirteria for suctioning:
1) secretions are accessible to the catheter.
2) secretions are detrimental to the patient.
3) patient is unable to clear secretions by other
means.


Neuro Physiological Facilitation (NPF)
promoting or hastening the response of neuro
muscular mechanism through proprioceptors
(dorothy voss et al, 1985).
Cutaneous and proprioceptive stimulation reflexly
increases the depth of breathing (Jones, 1998).

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

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

Perioral technique

Intercostal stretch

Co- contraction of abdominal muscles

Vertebral pressure
(D.D .Bethune, 1975)
ICU rehabilitation has been shown to accelerate recovery
(oleary & coackley, 1996)

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

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

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

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

Graded ambulation can be started depending on patients
condition

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


Stable (Progressive tilting & Ambulation)
A hammer in a carpenters hand is not used
to pull out a nail