Physical therapy (PT) in Intensive care unit (ICU)

Physical therapy in ICU

Rationale for PT in ICU - increase mucus production and decrease mucociliary activity due to artificial airway and inadequate humidifiation - increase risk of nosocomial infection atelectasis

- mechanical ventilated patients may lead to decrease FRC and CL , V /Q mismatching

- immobilized critically ill patients suffer muscle deconditioning, increased risk of DVT, pressure sore

Goals of PT treatment in ICU

kimprove / maintain cardiopulmonary function promoting mucociliary clearance , sputum expectoration , alveolar expansion kmaximize musculoskeletal function performance physical

joint movement , muscle

strength , ADL , ambulation

PT. assessment of the critically ill patients in ICU

 concerned with the patients respiratory system  analytical assessment must be conducted on the other related system to allow a full overview of the patients medical stability and suitability for Rx

Cycle of PT program
Assessment / reassessment Analysis of findings Problems identification Implementation of treatment Planning of treatment

Complication of retained secretion

 atelectasis  hypoxemia

Retained secretions Partially occlude Uneven distribution of ventilation Vr/Qr mismatching Hypoxe mia Complete occlude Shunting blood Vr/Qr mismatching

Airway clearance techniques

 Postural drainage position  Percussion  Vibration  FET  ACBT etc.

Postural drainage position (PD)

position that aligns the segmental bronchi with gravity , so the accumulated secretions in a bronchopulmonary segment move toward centrally and removed by coughing , then easily expectorated.

Percussion and vibration = external

manipulation of thorax, assist secretion mobilization percussion : rapid clapping , cupping or striking of external thorax directly over the lung segment being drained , with cupped hands or mechanical percussor : the mechanical wave of energy produced are believed to be transmitted through the chest wall to loosen airway mucous

vibration : fine tremorous action or fine shaking, manually performed by pressing in the direction that the ribs and soft fissure of chest normally move during exhalation

Combination of physical therapy treatments

: PD with percussion and vibration facilitate removal of secretions : Percussion by itself may cause : FEV1 : induced hypoxemia but the adversed effects can be prevented if breathing exercises are incorporated into Rx program

During percussion and vibration : PT must observed patient s facial expression because of pain or uncomfortable
The consequences of pain are - muscle splinting - increase work of breath - increase O2 consumption - breath holding - bronchospasm etc.

Secretion removal techniques

- Coughing - suction - huffing. etc.

Breathing exercises (BE)

- Muscles of ventilation consist of diaphragmatic muscle and intercostal muscle, act as pump muscles to move bony thorax,causing intrathoracic pressure changes that, in turn, produce airflow into the lungs. - Muscles of the larynx and pharynx act as valves that help regulate airflow and maintain airway patency.

Active inspiration
 Lung expansion in 3 directions - antero posterior - transverse - longitudinal  Pump handle movement occurs at upper ribs  Bucket handle movement occurs at lower ribs  abdominal contents move downward

Patterns of BE
- Diaphragmatic BE - Costal BE (thoracic expansion exercise) - Pursed lips breathing (PLB) - Sustained maximal inspiration (SMI) - Deep BE etc.

Collateral ventilation
- Channels of Martin (interbronchiolar channel) - Channels of Lambert (bronchiole-alveolar channel) - Pore of Kohn (interalveolar channel)

Considerations for PT. in ICU Closed observation and continuously monitoring

- patient s ability to tolerate PT Rx - ventilated patient / reduced level of consciousness / poor gag reflex aspiration minimize cross-infection

- appropiate care

- raised airway pressure - high PAP - arrhythmia - vital sign - level of ICP - level of consciousness , sedation etc.

Complexity of patients problems in ICU

PT must remember the possible feelings and fears that patients may have in their unnatural surrounding - inability to speak - loss of perception of time - suffer from chronic sleep deprivation

Summary
At the ICU bedside
- VS and ventilation parameters should be checked before Rx - Proper physical therapy techniques application - Closed observation and continuously monitored during Rx - Reassessed at the end of Rx - Before leaving a patient , PT must ensure that all alarms are reactivated, VS are stable, patient feels comfortable and secure.

Thank you For Your attention