Early Intervention of Physiotherapy in the ICU
For mechanically ventilated patients, early physiotherapy has been shown to improve quality of life and to prevent ICU-associated complications like deconditioning, ventilator dependency, and respiratory conditions.
Despite recent progress in medical treatment and mechanical ventilation (MV), critical illness in the intensive care unit (ICU) is still associated with high mortality rates. Furthermore, ICU survivors may suffer from muscle weakness, physical disability, and cognitive problems lasting up to 5 years. These critically ill patients may show muscle wasting in the very first week of illness, with more severity in patients with multi organ failure compared with those with a single organ failure.
Physiotherapy has been recommended by scientific societies as a main component in the management of patients with critical illness. Proposed strategies include patient mobilization based on a progressive sequence of activities like decubitus change and functional positioning; passive, supported-active, and active mobilization; cycling and sitting in the bed; and standing, static walking, transferring from bed to chair, and walking. Early physiotherapy is aimed at improving a patient’s quality of life and preventing ICU-associated complications like deconditioning, ventilator dependency, and respiratory conditions
Intensive care unit-acquired weakness (ICUAW) is observed in a substantial proportion of patients receiving MV for more than 1 week in the ICU. The etiology includes deconditioning and disuse atrophy due to prolonged bed rest and immobility, and critical illness polyneuropathy and or myopathy, known as critical illness neuromyopathy. Other risk factors for ICUAW include the systemic inflammatory response syndrome, sepsis, and multiple organ dysfunction syndrome; hyperglycemia; and medications, such as use of corticosteroids and neuromuscular blocking agents. As a consequence, recommendations to avoid these risk factors have been suggested.
Implementation of an early mobilization program is feasible in most ICUs and provides benefits if started no later than 1 or 2 days after MV initiation. Such programs must be delivered after cardiorespiratory and neurological stabilization. This approach, together with specific muscle training, can improve functional outcomes and cognitive and respiratory conditions (See Table 1).
Continuous rotational therapy uses special beds to turn patients along the longitudinal axis up to 60° on each side, with preset degree and speed of rotation. It has been hypothesized that this modality can reduce the risk of sequential airway closure and pulmonary atelectasis, resulting in reduction of the incidence rate of lower respiratory tract infection and pneumonia, and the duration of endotracheal intubation and length of hospital stay.
Figure 1: Early Mobilization
Early mobilization can be performed also in unconscious or sedated patients. Protocols include semirecumbent positioning with the bed head positioned at 45°, frequent changes in postures, daily sessions of joint passive movement, and passive bed cycling and electrical stimulation. (See Figure 1.)
ICU early rehabilitation program can generate net financial savings for hospitals and even more clinical improvements for patients.
Management of Airway Secretions
Mechanically ventilated patients in the ICU may suffer from retained secretions due to many causes. The mucociliary system may be disturbed by endotracheal intubation, with increased infection susceptibility and mucus volume and tenacity.
Furthermore, immobilized patients may suffer from atelectasis, impaired cough mechanism, and related inability to expel secretions. Associated expiratory muscle weakness decreases cough strength; in addition, fluid restriction contributes to secretion retention. Helping airway clearance in patients under MV includes different techniques.
Postural drainage- Postural drainage traditionally includes gravity-assisted positions, deep breathing exercises, chest clapping, shaking or vibration, and incentivized cough to move airway secretions toward the upper airways.
Intrapulmonary percussive ventilation- Intrapulmonary percussive ventilation (IPV) is a high-frequency ventilation modality that can be superimposed on spontaneous breathing. Intrapulmonary percussive ventilation may reduce respiratory muscle load and help to move airway secretions. This tool creates a percussive effect in the airways, thus enhancing mucus clearance through direct high-frequency oscillatory ventilation able to help the alveolar recruitment. Positive effects from this technique have been shown in patients with respiratory distress, neuromuscular diseases, and pulmonary atelectasis.
Positive expiratory pressure- Positive expiratory pressure (PEP), first introduced in the 1970s, consists of a one-way valve through a mask or a mouthpiece connected to one or more small-exit orifices and adjustable expiratory resistor to enhance and promote secretion removal by stenting airways, increasing intrathoracic pressure, or increasing functional residual capacity.
A new modality to deliver a low level PEP at the mouth during spontaneous breathing is called temporary PEP, which has been recently proposed to treat patients with chronic mucus hypersecretion. This modality produces a 1 cm H2O increase in airway pressure along the respiratory cycle until immediately before the end of expiration.
Manual hyperinflation- Manual hyperinflation (MH) is commonly applied in patients under MV. It may stimulate cough and move the airway secretions toward the larger airways, from where they can be easily suctioned. Manual hyperinflation can prevent airway plugging and pulmonary collapse, and improve oxygenation and lung compliance.
Insufflation-exsufflation– Methods to improve cough are important in critically ill patients because cough effectiveness is a determinant in weaning success and patient outcomes. Cough assist such as a mechanical insufflator/exsufflator clears secretions by gradually applying a positive pressure to the airway then rapidly shifts to negative pressure, producing a high expiratory flow.
By contrast, direct tracheal suction applies negative pressure to a small, localized area
Physiotherapy should be considered a cornerstone in the comprehensive management of critical ill patients and, when applied early, may benefit patients and prevent some ICU complications. Modalities and devices for each patient depend on disease severity, comorbidities, and patient cooperation.
Dr. MOHAMMED SHADAB KHAN(PT)
BPT,MPT(CARDIO),MIAP,HAAD LICENSE,AFAQ MEDICAL CARE CENTRE