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BEST PRACTICES

Physiotherapy in the ICUPublished on July 25, 2014

For mechanically ventilated patients, early physiotherapy has been shown to improve quality of life andto prevent ICU-associated complications like deconditioning, ventilator dependency, and respiratoryconditions.

By Nicolino Ambrosino, MD, and Dewi N. Makhabah, MD

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.1 Furthermore, ICU survivors may suffer from muscle

weakness, physical disability, and cognitive problems lasting up to 5 years.2-5 These critically ill patients may showmuscle wasting in the very first week of illness, with more severity in patients with multiorgan failure compared

with those with a single organ failure.6

Physiotherapy has been recommended by scientific societies as a main component in the management of

patients with critical illness.7,8 Proposed strategies include patient mobilization based on a progressive sequenceof activities like decubitus change and functional positioning; passive, supported-active, and active mobilization;

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cycling and sitting in the bed; and standing, static walking, transferring from bed to chair, and walking. Earlyphysiotherapy is aimed at improving a patient’s quality of life and preventing ICU-associated complications likedeconditioning, ventilator dependency, and respiratory conditions. It has been demonstrated that it is feasible and

useful, even in patients needing extracorporeal membrane oxygenation (ECMO).7-12 In addition, a pilot study

demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy.13

ICU-Acquired Weakness

Intensive care unit-acquired weakness (ICUAW) is observedin a substantial proportion of patients receiving MV for more

than 1 week in the ICU.6,14-16 The etiology includesdeconditioning and disuse atrophy due to prolonged bed restand immobility, and critical illness polyneuropathy and/or

myopathy, known as critical illness neuromyopathy.17 Otherrisk factors for ICUAW include the systemic inflammatoryresponse syndrome, sepsis, and multiple organ dysfunctionsyndrome; hyperglycemia; and medications, such as use of

corticosteroids and neuromuscular blocking agents.18 As aconsequence, recommendations to avoid these risk factors

have been suggested.19

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.9-11,15,20 Such programs must be delivered after cardiorespiratory and

neurological stabilization.20-23 This approach, together with specific muscle training, can improve functional

outcomes and cognitive and respiratory conditions (See Table 1).22

Rotational Therapy

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 ofsequential airway closure and pulmonary atelectasis, resulting in reduction of the incidence rate of lowerrespiratory tract infection and pneumonia, and the duration of endotracheal intubation and length of hospital

stay.10,24

Early Mobilization

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Early mobilization can be performed also in unconscious or sedated

patients.11 Protocols include semirecumbent positioning with the bedhead positioned at 45°, frequent changes in postures, daily sessionsof joint passive movement, and passive bed cycling and electrical

stimulation.10,25 (See Figure 1.)

Many studies conclude that early mobilization of critically ill patientscan be done with low risk to the patient. Algorithms have beenproposed as a guide in selecting suitable patients for mobilization andproviding appropriate treatment strategies tailored to each individual

patient.8,11 Although the short-term effectiveness of early physiotherapy has been shown, more studies areneeded to confirm the long-term responsiveness of ICU survivors to physiotherapy. Furthermore, despiterecognized benefits of early mobilization, only a small proportion of ICUs are able to deliver full-time physiotherapyto these patients. As a consequence, we need to improve ICU organization and teams to deliver early

physiotherapy.26-29 Indeed, a financial model, based on actual experience and published data, projects thatinvestment in an ICU early rehabilitation program can generate net financial savings for US hospitals and even

more clinical improvements for patients.30

Management of Airway Secretions

Mechanically ventilated patients in the ICU may suffer from retained secretions due to many causes. Themucociliary system may be disturbed by endotracheal intubation, with increased infection susceptibility andmucus volume and tenacity.

Furthermore, immobilized patients may suffer from atelectasis, impaired cough mechanism, and related inabilityto expel secretions. Associated expiratory muscle weakness decreases cough strength; in addition, fluid restriction

contributes to secretion retention.31,32 Helping airway clearance in patients under MV includes different

techniques.33,34 (See Table 1.)

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.34,35

Chen et al36 performed a randomized study in mechanically ventilated patients in the ICU. Their results suggest

that percussion and postural drainage may improve lung collapse. Ntoumenopoulos et al37 suggested that chest

physiotherapy may be useful in prevention of ventilator-associated pneumonia. Lemyze et al38 suggested that incritically ill obese patients under MV, sitting position constantly and significantly relieved expiratory flow limitationand intrinsic-positive end-expiratory pressure (PEEPi) resulting in a dramatic drop in alveolar pressures. Combining

sitting position and applied PEEP may be the best strategy in these patients.38

Intrapulmonary percussive ventilation. Intrapulmonary percussive ventilation (IPV) is a high-frequency ventilationmodality that can be superimposed on spontaneous breathing. Intrapulmonary percussive ventilation may reducerespiratory 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 alveolarrecruitment. Positive effects from this technique have been shown in patients with respiratory distress,

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neuromuscular diseases, and pulmonary atelectasis.39-41

Physiologic effects of IPV were studied by Vargas et al42 in intubated COPD patients. Intrapulmonary percussive

ventilation improved the reduction of expiratory limitation flow and gas exchange. Dimassi et al43 performed aprospective study to assess the short-term effects of IPV in patients at high risk for extubation failure who werereceiving noninvasive ventilation after being extubated. This study concluded that both noninvasive ventilation and

IPV reduced the respiratory rate and work of breathing. Clini et al44 performed a randomized multicenter trialconcluding that the addition of IPV improves gas exchange and expiratory muscle performance and reduces theincidence of pneumonia.

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 expiratoryresistor to enhance and promote secretion removal by stenting airways, increasing intrathoracic pressure, or

increasing functional residual capacity.45 The benefit of PEP is still under investigation. A systematic reviewassessed the effectiveness of PEP in patients after thoracoabdominal surgery. Six randomized controlled trialswere included comparing PEP with other breathing techniques or in addition to routine chest physiotherapy

treatment. Only 1 of the 6 trials showed positive effects of PEP compared with other physiotherapy techniques.46

A new modality to deliver a low level PEP at the mouth duringspontaneous breathing is called temporary PEP, which has beenrecently proposed to treat patients with chronic mucushypersecretion. This modality produces a 1 cm H2O increase inairway pressure along the respiratory cycle until immediately beforethe end of expiration. (See Figure 2.)

The level of applied pressure is several times lower than that (5 to 15cm H2O) commonly used and considered effective with other PEPand/or oscillatory-PEP devices. Preliminary results show that anexpiratory pressure less than or equal to 1 cm H2O applied for a fraction of the expiratory phase may improve thedistribution of alveolar ventilation and prevent mechanical stress injury, which is expected to occur in the bronchial

tree or lung parenchyma at a higher pressure.34 Whether this suggested technique may be applied to ICU patientsis still to be studied.

Manual hyperinflation. Manual hyperinflation (MH) is commonly applied in patients under MV. It may stimulatecough and move the airway secretions toward the larger airways, from where they can be easily suctioned. Manualhyperinflation can prevent airway plugging and pulmonary collapse, and improve oxygenation and lung

compliance.47 This technique is widely used, though the practice varies across different ICUs.48 The possiblephysiological side effects of delivered air volume, flow rates, and airway pressure must be carefully considered—

especially in patients under MV.49 When performed by experienced and trained physiotherapists in stable, criticallyill patients, MH is associated with short-term and probably nonrelevant side effects like reduction in cardiac output,alterations in heart rate, and increased central venous pressure. Nevertheless, other studies failed to show MH

benefits in intubated and mechanically ventilated patients.50

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Insufflation-exsufflation. Methods to improve cough are important incritically ill patients because cough effectiveness is a determinant inweaning success and patient outcomes. Cough assist such as amechanical insufflator/exsufflator clears secretions by graduallyapplying a positive pressure to the airway then rapidly shifts tonegative pressure, producing a high expiratory flow. (See Figure 3.)

By contrast, direct tracheal suction applies negative pressure to asmall, localized area. Goncalves et al studied the efficacy ofmechanical insufflation-exsufflation as part of an extubation protocol,which suggested that this technique may reduce reintubation rates

and ICU length of stay.51 Guerin et al assessed the impact of cough-assist insufflation-exsufflation on peak

expiratory flow, and results showed it was significantly reduced.52 Chatwin et al compared conventionalphysiotherapy with physiotherapy plus in-exsufflation in noninvasively ventilated patients. Their results indicated

that in-exsufflation shortens the treatment time in the ICU without any difference in secretion clearance.53

Conclusion

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 eachpatient depend on disease severity, comorbidities, and patient cooperation. RT

Nicolino Ambrosino, MD, is a physician in the Pulmonary Rehabilitation and Weaning Unit at Auxilium Vitae (Volterra, Italy) and DewiN. Makhabah, MD, is a physician in the Pulmonology Department of the University of Sebelas Maret (Surakarta, Indonesia). For moreinformation, contact RTmagazine@allied360.com.

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50. Paulus F, Binnekade JM, Vermeulen M, Vroom MB, Schultz MJ. Manual hyperinflation is associated with a low rate ofadverse events when performed by experienced and trained nurses in stable critically ill patients: a prospectiveobservational study. Minerva Anestesiol 2010;76 (12):1036-1042.

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52. Guérin C, Bourdin G, Leray V, Delannoy B, Bayle F, Germain M, Richard JC. Performance of the cough assist insufflation-exsufflation device in the presence of an endotracheal tube or tracheostomy tube: a bench study. Respir Care 2011; 56(8):1108-1114.

53. Chatwin M, Simonds AK. The addition of mechanical insufflation/exsufflation shortens airway-clearance sessions inneuromuscular patients with chest infection. Respir Care 2009; 54 (11): 1473-14

 

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