Dr. Abhijit Diwate discusses physiotherapy management of ICU patients. Key points include:
1) Physiotherapists assess patients, set goals like pain relief and secretion clearance, and use techniques like positioning, manual hyperinflation, percussion and breathing exercises.
2) Assessment involves examining the chest and determining ventilator settings. Goals are to prevent complications and improve function.
3) Common techniques are positioning, mobilization, manual hyperinflation, percussion, coughing/huffing, and breathing exercises to clear secretions and strengthen respiratory muscles.
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ICU management
1. PHYSIOTHERAPYPHYSIOTHERAPY
MANAGEMENT IN ICUMANAGEMENT IN ICU
PATIENTSPATIENTS
Dr.Abhijit DiwateDr.Abhijit Diwate
Associate ProfessorAssociate Professor
Cardio-Vascular & Respiratory PTCardio-Vascular & Respiratory PT
DVVPF College of Physiotherapy,DVVPF College of Physiotherapy,
Ahmednagar 414111Ahmednagar 414111
2. ObjectivesObjectives
Assessment of patientAssessment of patient
GoalsGoals
Treatment techniques used in ICU byTreatment techniques used in ICU by
physiotherapistphysiotherapist
Chest physiotherapy for pediatricsChest physiotherapy for pediatrics
3. ASSESSMENT OF PATIENTASSESSMENT OF PATIENT
See the patient is well conscious or notSee the patient is well conscious or not
Read the case papers and daily orders. NoteRead the case papers and daily orders. Note
the temperaturethe temperature
Type of mode of ventilatorsType of mode of ventilators
4. Examination of the chest inExamination of the chest in
mechanically ventilated patientsmechanically ventilated patients
1) INSPECTION1) INSPECTION
Chest movementChest movement
ClubbingClubbing
CyanosisCyanosis
AP & Lateral chest diameterAP & Lateral chest diameter
KyphoscoliosisKyphoscoliosis
7. GOALSGOALS
Pain reliefPain relief
To prevent accumulation of secretionsTo prevent accumulation of secretions
To mobilize and remove secretionsTo mobilize and remove secretions
To teach proper method of breathing pattern andTo teach proper method of breathing pattern and
effective coughing or huffingeffective coughing or huffing
To mobilize the thorax and shoulder girdle andTo mobilize the thorax and shoulder girdle and
to teach the postural awarenessto teach the postural awareness
To teach relaxationTo teach relaxation
To improve functional capacity by exerciseTo improve functional capacity by exercise
training programmetraining programme
To advice the home programmeTo advice the home programme
8. OBJECTIVES OF CHESTOBJECTIVES OF CHEST
PHYSIOTHERAPYPHYSIOTHERAPY
Clearance of secretions from large andClearance of secretions from large and
small airways and re-expansion ofsmall airways and re-expansion of
nonventilated lungnonventilated lung
Improve ventilation to areas of local lungImprove ventilation to areas of local lung
obstructionobstruction
To reduce incidence of post operativeTo reduce incidence of post operative
respiratory infection, morbidity andrespiratory infection, morbidity and
hospital stayhospital stay
9. Treatment techniques used in ICU byTreatment techniques used in ICU by
physiotherapistphysiotherapist
PositioningPositioning
MobilizationMobilization
Manual HyperinflationManual Hyperinflation
Percussion, Vibration, ShakingPercussion, Vibration, Shaking
Cough/huffCough/huff
SuctionSuction
Breathing exercisesBreathing exercises
10. POSITIONINGPOSITIONING
AIMSAIMS
Optimizing O2 transport through its effect ofOptimizing O2 transport through its effect of
improving ventilation/perfusion matching (V/Q)improving ventilation/perfusion matching (V/Q)
Increase lung volumesIncrease lung volumes
Reduce work of breathingReduce work of breathing
Minimize the work of heartMinimize the work of heart
Enhance mucociliary clearanceEnhance mucociliary clearance
11. HANDLING A CONSCIOUS PATIENTHANDLING A CONSCIOUS PATIENT
2-3 people are needed to turn a patient2-3 people are needed to turn a patient
Ensure sufficient slack in lines and tubesEnsure sufficient slack in lines and tubes
Inform the patientInform the patient
If possible disconnect the patient fromIf possible disconnect the patient from
ventilator/tracheal manualyventilator/tracheal manualy
Turn the patient smoothly & check the lines,Turn the patient smoothly & check the lines,
patient comfort and observe monitorspatient comfort and observe monitors
12. TURNING PATIENT WITH CRANIOTOMYTURNING PATIENT WITH CRANIOTOMY
Position requirePosition require
To minimize pressure on the operatedTo minimize pressure on the operated
side especially in bone flap is removedside especially in bone flap is removed
500ml IV infusion bags above &below this500ml IV infusion bags above &below this
area support the head & prevent unduearea support the head & prevent undue
pressurepressure
13. 2] MOBILISATION2] MOBILISATION
This technique help to maintain or restoreThis technique help to maintain or restore
normal fluid distribution in the bodynormal fluid distribution in the body
It reduces the effect of immobility & bed restIt reduces the effect of immobility & bed rest
It includes-It includes-
Limb exercises, Neck exerciseLimb exercises, Neck exercise
Moving/Turning in bedMoving/Turning in bed
Sitting in the edge of the bedSitting in the edge of the bed
StandingStanding
Standing transfer from chair, bedStanding transfer from chair, bed
WalkingWalking
14.
15. 3]MANUAL HYPERINFLATION3]MANUAL HYPERINFLATION
It is one of the technique where there isIt is one of the technique where there is
involvement in disconnecting the patientinvolvement in disconnecting the patient
from ventilator &inflating the lungs with afrom ventilator &inflating the lungs with a
large tidal volume via a manuallarge tidal volume via a manual
resuscitator bagresuscitator bag
Bagging can be used as a technique toBagging can be used as a technique to
hand ventilate a patient or duringhand ventilate a patient or during
physiotherapyphysiotherapy
MH can be given by using Ambu bagMH can be given by using Ambu bag
16.
17. 4] POSTURAL DRAINGE4] POSTURAL DRAINGE
POSITIONPOSITION
DefinitionDefinition
GoalsGoals
To prevent accumulation of secretions inTo prevent accumulation of secretions in
patient at high risk for pulmonarypatient at high risk for pulmonary
complicationcomplication
To remove secretions alreadyTo remove secretions already
accumulated in the lungsaccumulated in the lungs
19. 5] PERCUSSION & VIBRATIONS5] PERCUSSION & VIBRATIONS
Are manual technique used to increaseAre manual technique used to increase
clearance of airway secretionsclearance of airway secretions
PERCUSSIONPERCUSSION
Medications to reduce pain is given prior toMedications to reduce pain is given prior to
treatmenttreatment
In pediatrics percussion is given by usingIn pediatrics percussion is given by using
hand, fingers or facemaskhand, fingers or facemask
Force-58 & 65N on chest wallForce-58 & 65N on chest wall
100-480time/min100-480time/min
21. VIBRATIONSVIBRATIONS
Are performed manually byAre performed manually by
vibrating/compressing the chest wallvibrating/compressing the chest wall
Pressure is applied in the same directionPressure is applied in the same direction
in which chest is movingin which chest is moving
The vibrating action is achieved byThe vibrating action is achieved by
therapist isometrically contracting thetherapist isometrically contracting the
muscle of upper extremity from shouldermuscle of upper extremity from shoulder
to handsto hands
22. SHAKINGSHAKING
More vigorous form of vibrationsMore vigorous form of vibrations
Applied during exhalation using an intermittentApplied during exhalation using an intermittent
bouncing maneuver coupled with widebouncing maneuver coupled with wide
movement of therapist handsmovement of therapist hands
23. 6]SUCTION6]SUCTION
In unconscious patient & in patients with depressedIn unconscious patient & in patients with depressed
coughcough
Should not done routinely but only on demandShould not done routinely but only on demand
Every 2hrly suctioningEvery 2hrly suctioning
Ideally catheter diameter should be half of the sizeIdeally catheter diameter should be half of the size
of the tracheal tube/ETTof the tracheal tube/ETT
Adults- 10,12,14,16 FG & Pediatrics - 6,8 FGAdults- 10,12,14,16 FG & Pediatrics - 6,8 FG
Monitor vacuum pressure 150-200mmHg for adults &Monitor vacuum pressure 150-200mmHg for adults &
<100mmHg for children<100mmHg for children
Kink one end of catheter while inserting into theKink one end of catheter while inserting into the
tube ,move in a circular manner in downwardtube ,move in a circular manner in downward
direction &release the kink when you feel resistancedirection &release the kink when you feel resistance
to pass the catheter furtherto pass the catheter further
Never prolong the proceduresNever prolong the procedures
DurationDuration
26. 7] COUGH/HUFF7] COUGH/HUFF
COUGHINGCOUGHING
To keep the lungs clearTo keep the lungs clear
ProcedureProcedure
Evaluate the patient Place the patient in relaxedEvaluate the patient Place the patient in relaxed
forward bending neck slightly flexedforward bending neck slightly flexed
Teach controlled diaphragmatic breathingTeach controlled diaphragmatic breathing
Demonstrate sharp double coughDemonstrate sharp double cough
Ask the patient to repeatAsk the patient to repeat
PrecautionsPrecautions
Never allow the patient to suck air in by gaspingNever allow the patient to suck air in by gasping
27. HUFFINGHUFFING
Huff is a rapid forced exhalation withoutHuff is a rapid forced exhalation without
maximum effortmaximum effort
Glottis remains openGlottis remains open
Required less effort than coughingRequired less effort than coughing
28. 9] BREATHING EXERCISES9] BREATHING EXERCISES
GoalsGoals
Assist removal of secretionsAssist removal of secretions
Improve respiratory muscle strength &Improve respiratory muscle strength &
enduranceendurance
Increase thoracic mobility and tidal volumeIncrease thoracic mobility and tidal volume
Promote relaxationPromote relaxation
Teach the patient how to deal with shortness ofTeach the patient how to deal with shortness of
breath attackbreath attack
Improve patients overall functional capacityImprove patients overall functional capacity
31. Breathing Exercises In Obstructive AirwayBreathing Exercises In Obstructive Airway
DiseaseDisease
1] Breathing Control1] Breathing Control
Treatment should start with breathing controlTreatment should start with breathing control
It is a normal tidal breathing to promote relaxation &It is a normal tidal breathing to promote relaxation &
prevent hyperventilationprevent hyperventilation
While teaching BC avoid full expiration should beWhile teaching BC avoid full expiration should be
controlled but not forcefulcontrolled but not forceful
Position- Side lying, head elevated, leaning forwardPosition- Side lying, head elevated, leaning forward
EFFECT- Relief of dysponea, improve vital capacity,EFFECT- Relief of dysponea, improve vital capacity,
improve V/Qimprove V/Q
32. 2]2] Diaphragmatic BreathingDiaphragmatic Breathing
For relaxation & coordinated breathing patternFor relaxation & coordinated breathing pattern
It is often used with pursed lip breathingIt is often used with pursed lip breathing
Greater tidal volume is achieved with DiaphragmaticGreater tidal volume is achieved with Diaphragmatic
breathing improve overall ventilationbreathing improve overall ventilation
3] Pursed Lip Breathing3] Pursed Lip Breathing
Benefits- increase tidal volume, decrease RR,Benefits- increase tidal volume, decrease RR,
decrease PaCO2 level, increase PaO2decrease PaCO2 level, increase PaO2
PLB may improve patients confidence and decreasePLB may improve patients confidence and decrease
anxiety by providing some temporary control overanxiety by providing some temporary control over
oxygenationoxygenation
33. 4] Ventilatory Muscle Training4] Ventilatory Muscle Training
i] Diaphragmatic training with weightsi] Diaphragmatic training with weights
ii] Inspiratory resistance trainingii] Inspiratory resistance training
iii] Incentive respiratory trainingiii] Incentive respiratory training
BE After SurgeryBE After Surgery
i] Diaphragmatic breathingi] Diaphragmatic breathing
ii] Lateral costal breathingii] Lateral costal breathing
iii] Incentive spirometryiii] Incentive spirometry
34. 9] PASSIVE EXERCISES AND9] PASSIVE EXERCISES AND
ACTIVE EXERCISESACTIVE EXERCISES
Limb exercise likeLimb exercise like
PROM, AAROM/ARROMPROM, AAROM/ARROM
are performed in ICUare performed in ICU
patientspatients
It helps to improve jointIt helps to improve joint
ROM, function, muscleROM, function, muscle
strength, soft tissuestrength, soft tissue
lengthlength
It decreases the risk ofIt decreases the risk of
thromboembolismthromboembolism
IRR, TENS can be givenIRR, TENS can be given
for relief of painfor relief of pain
35. 10]10] IMPROVEMENT INIMPROVEMENT IN
FUNCTIONAL CAPACITYFUNCTIONAL CAPACITY
Based on walk test the dyspnoea is notedBased on walk test the dyspnoea is noted
& also performance of the patient is noted& also performance of the patient is noted
According to this the goals are setAccording to this the goals are set
36. CHEST PHYSIOTHERAPY FORCHEST PHYSIOTHERAPY FOR
PAEDIATRIC PATIENTSPAEDIATRIC PATIENTS
IndicationsIndications
Neurological impairmentNeurological impairment
AsthmaAsthma
Cystic fibrosisCystic fibrosis
Secretion retention after surgerySecretion retention after surgery
ImmobilityImmobility
Decrease collateral ventilationDecrease collateral ventilation
CPT should not performed more frequently moreCPT should not performed more frequently more
than 3 hr & includes 3min chest percussion in 5than 3 hr & includes 3min chest percussion in 5
PD position followed by assistedPD position followed by assisted
coughing/suctioningcoughing/suctioning
37. Handling/ positioningHandling/ positioning
Excessive handling of low birth weight infantExcessive handling of low birth weight infant
causes hypoxemiacauses hypoxemia
Supine - compromise lung functionalSupine - compromise lung functional
Side lying-Releases diaphragm from pressure ofSide lying-Releases diaphragm from pressure of
abdominal viscera allowing more effective basalabdominal viscera allowing more effective basal
expansionexpansion
Facilitate drainage of secretions from theFacilitate drainage of secretions from the
uppermost part of lunguppermost part of lung
38. Prone-Better compared to supine positionProne-Better compared to supine position
-Improve gas exchange-Improve gas exchange
-Reduce gastro-esophageal reflux-Reduce gastro-esophageal reflux
-It increases tidal volume, minute ventilation &-It increases tidal volume, minute ventilation &
decreases period of apnea &25% increase in PaO2decreases period of apnea &25% increase in PaO2
Placing preterm baby in prone position mayPlacing preterm baby in prone position may
significantly reduce morbidity & mortalitysignificantly reduce morbidity & mortality
It may stabilize the compliant chest wall of the infantIt may stabilize the compliant chest wall of the infant
& improve co-ordination between rib cage,& improve co-ordination between rib cage,
diaphragm & abdominal movementdiaphragm & abdominal movement
39. SummarySummary
Assessment of patientAssessment of patient
GoalsGoals
Treatment techniques used in ICU byTreatment techniques used in ICU by
physiotherapistphysiotherapist
Chest physiotherapy for pediatricsChest physiotherapy for pediatrics
40. QUESTIONSQUESTIONS
1.1. WRITE THE AIMS OF POSITIONING.WRITE THE AIMS OF POSITIONING.
3MARKS3MARKS
2.2. WRITE ABOUT POSTURAL DRAINAGE.WRITE ABOUT POSTURAL DRAINAGE.
3MARKS3MARKS