1. MANAGING CRITICALLYMANAGING CRITICALLY
ILL PATIENTSILL PATIENTS
–– A Physiotherapist’sA Physiotherapist’s
perspectiveperspective

2. Chest Physiotherapy is…Chest Physiotherapy is…
A treatment intervention employed for improvingA treatment intervention employed for improving
pulmonary hygiene including positioning, chestpulmonary hygiene including positioning, chest
percussion, vibration and manual hyperinflation topercussion, vibration and manual hyperinflation to
assist in mobilizing secretions in the lungs from theassist in mobilizing secretions in the lungs from the
peripheral airways into the more central airways soperipheral airways into the more central airways so
that they can be expectorated or suctioned.that they can be expectorated or suctioned.

3. Aims of this presentation…Aims of this presentation…
 To describe the individual physiotherapeuticTo describe the individual physiotherapeutic
techniques.techniques.
 To provide a frame work for evidence basedTo provide a frame work for evidence based
practice.practice.

4. IndicationsIndications
 PROPHYLACTICPROPHYLACTIC
-- Pre-operative high risk surgical patientPre-operative high risk surgical patient
- Post-operative patient who is unable to- Post-operative patient who is unable to
mobilize secretionsmobilize secretions
- Neurological patient who is unable to cough- Neurological patient who is unable to cough
effectivelyeffectively
- Patient receiving mechanical ventilation who has a- Patient receiving mechanical ventilation who has a
tendency to retain secretionstendency to retain secretions
- Patients with pulmonary disease,- Patients with pulmonary disease,
who needs to improve bronchial hygienewho needs to improve bronchial hygiene

5. ……contdcontd
 THERAPEUTICTHERAPEUTIC
-- Atelectasis due to secretionsAtelectasis due to secretions
- Retained secretions- Retained secretions
- abnormal breathing pattern due to primary or- abnormal breathing pattern due to primary or
secondary pulmonary dysfunctionsecondary pulmonary dysfunction
- COPD and resultant decreased exercise- COPD and resultant decreased exercise
tolerancetolerance
- Musculoskeletal deformity that makes breathing- Musculoskeletal deformity that makes breathing
pattern and cough ineffectivepattern and cough ineffective

6. AssessmentAssessment
General ObservationGeneral Observation
 Patient PositionPatient Position

RespirationRespiration -- AirwayAirway ET/TracheostomyET/Tracheostomy
VentillatorVentillator ModeMode
FiOFiO22

VitalVital Signs – Temperature, BSigns – Temperature, BP,P, RR, HR SpORR, HR SpO2,2,GCS, ICPGCS, ICP
 Tubes - NG Tube, CV line, Peripheral line, Chest tubes,Tubes - NG Tube, CV line, Peripheral line, Chest tubes,
CathetersCatheters
 DrugsDrugs

7. …… contdcontd
ExaminationExamination
 AuscultationsAuscultations
 Respiratory patternRespiratory pattern
 CyanosisCyanosis
 ClubbingClubbing
 RadiographRadiograph

8. GoalsGoals
 Prevent accumulation of secretionsPrevent accumulation of secretions
 Improve mobilization and drainage ofImprove mobilization and drainage of
secretionssecretions
 Promote relaxation to improve breathingPromote relaxation to improve breathing
patternspatterns
 Promote improved respiratory functionPromote improved respiratory function
 Improve cardio-pulmonary exerciseImprove cardio-pulmonary exercise
tolerancetolerance
 Teach bronchial hygiene programs toTeach bronchial hygiene programs to
patients with chronic respiratory dysfunctionpatients with chronic respiratory dysfunction

9. PrecautionsPrecautions

UntreatedUntreated tension pneumothoraxtension pneumothorax
 Abnormal coagulation profileAbnormal coagulation profile
 Status epilepticus or status asthamaticusStatus epilepticus or status asthamaticus
 Immediately following intra cranial surgeryImmediately following intra cranial surgery
 Head injury with raised ICPHead injury with raised ICP
 Osteoporotic bonesOsteoporotic bones
 Recent acute myocardial infarction, unstable vitalsRecent acute myocardial infarction, unstable vitals
 Immediately after tube feedingsImmediately after tube feedings
 Sutures and ICD’sSutures and ICD’s

10. TechniquesTechniques
 PositioningPositioning
 Chest tapotement techniquesChest tapotement techniques
 Manual hyperinflationManual hyperinflation
 Airway suctioningAirway suctioning
 Coughing techniquesCoughing techniques
 Breathing exercisesBreathing exercises
 Neuro physiological facilitationNeuro physiological facilitation
 Controlled mobilizationControlled mobilization
 Patient educationPatient education

11. PositioningPositioning
 POSITIONING is the use of body position as aPOSITIONING is the use of body position as a
specific treatment techniquespecific treatment technique
 ((it has a marked influence on gas exchangeit has a marked influence on gas exchange
because of the unevenly damaged lungs- Tobin etbecause of the unevenly damaged lungs- Tobin et
al, 1994)al, 1994)

12. Positioning…Positioning…
Physiological effects ofPhysiological effects of
PositioningPositioning
 Optimizes oxygen transport by improvingOptimizes oxygen transport by improving
V/Q mismatchV/Q mismatch
 Increases lung volumesIncreases lung volumes
 Reduces the work of breathingReduces the work of breathing
 Minimizes the work of heartMinimizes the work of heart
 Enhances mucociliary clearance (posturalEnhances mucociliary clearance (postural
drainage)drainage)

13. Postural DrainagePostural Drainage isn’t…isn’t…
 a separate technique. Its just an example ofa separate technique. Its just an example of
positioning which has the particular aim of clearingpositioning which has the particular aim of clearing
airway secretions with the assistance of gravity.airway secretions with the assistance of gravity.

14.  Patients are positioned with the area to be drainedPatients are positioned with the area to be drained
the upper most, but modifications should be donethe upper most, but modifications should be done
wherever necessary.wherever necessary.
 Drainage times vary, but ideally each positionDrainage times vary, but ideally each position
requires 10 minutes (gumery et al, 2001).requires 10 minutes (gumery et al, 2001).

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

16. ……contdcontd
 Positioning affects lung volumePositioning affects lung volume
 Lung volume is related to the position of theLung volume is related to the position of the
diaphragmdiaphragm
 FRC decreases from standing to slumped sitting toFRC decreases from standing to slumped sitting to
supinesupine (Macnaughton, 1995)(Macnaughton, 1995)

17. ……contdcontd
 Positioning affects compliancePositioning affects compliance (Wahba et al found that(Wahba et al found that
work of breathing is 40% higher in supine than in sitting)work of breathing is 40% higher in supine than in sitting)
 Positioning affects arterial oxygenation byPositioning affects arterial oxygenation by
improving V/Q mismatchimproving V/Q mismatch (V/Q is usually mismatched if(V/Q is usually mismatched if
the affected lung is dependent- Gillespie et al)the affected lung is dependent- Gillespie et al)
““Bad lung up” positionBad lung up” position

18. Positioning…Positioning…
 Which position to choose…Which position to choose…
??

19. What does evidence say…What does evidence say…
1. lung volume by 57% (Rialp et al., 1997).1. lung volume by 57% (Rialp et al., 1997).
2. need for PEEP (Lim et al., 1999).2. need for PEEP (Lim et al., 1999).
3. normal V/Q units by 12%3. normal V/Q units by 12%
4. shunt by 11% (Wong 1999)4. shunt by 11% (Wong 1999)
5. barotrauma (Du et al., 1997)5. barotrauma (Du et al., 1997)
6. drainage of secretions (Kesecioglu, 1997)6. drainage of secretions (Kesecioglu, 1997)
7. length of ICU stay. (Gosheron, 1998)7. length of ICU stay. (Gosheron, 1998)

21. Chest TapotementChest Tapotement
 Chest VibrationsChest Vibrations
 Rib Springing/ShakingRib Springing/Shaking
 Chest Percussion/ClappingChest Percussion/Clapping

22. Clapping/Chest PercussionClapping/Chest Percussion
 Percussion consists of rhythmic clapping on thePercussion consists of rhythmic clapping on the
chest with loose wrist & cupped hand.chest with loose wrist & cupped hand.
 Effect : Dislodges & loosens secretions from theEffect : Dislodges & loosens secretions from the
lunglung

24. Chest VibrationChest Vibration
 Vibrations consists of a fine oscillation of the handsVibrations consists of a fine oscillation of the hands
directed inwards against the chest, performed ondirected inwards against the chest, performed on
exhalation after deep inhalation.exhalation after deep inhalation.
 Effects: Helpful in moving loosened mucous plugsEffects: Helpful in moving loosened mucous plugs
towards larger airwaytowards larger airway

26. Rib Springing/ShakingRib Springing/Shaking
 Shaking is a coarser movement in which the chestShaking is a coarser movement in which the chest
wall is rhythmically compressed.wall is rhythmically compressed.
 Effects : Direct secretions towards larger airways &Effects : Direct secretions towards larger airways &
Stimulates cough.Stimulates cough.

27. Manual HyperinflationManual Hyperinflation
 Was originally defined as inflating the lungs withWas originally defined as inflating the lungs with
oxygen and manual compression to a tidal volumeoxygen and manual compression to a tidal volume
of 1 liter requiring a peak inspiratory pressure ofof 1 liter requiring a peak inspiratory pressure of
between 20 and 40 cm H2Obetween 20 and 40 cm H2O (Med j Aust, 1972).(Med j Aust, 1972).
 More recent definitions include providing a largerMore recent definitions include providing a larger
tidal volume than base line tidal volume to thetidal volume than base line tidal volume to the
patientpatient (Aust j physiotherapy, 1996)(Aust j physiotherapy, 1996) and using a tidaland using a tidal
volume which is 50% greater than that delivered thevolume which is 50% greater than that delivered the
ventilatorventilator (chest, 1994).(chest, 1994).

28. Advantages of MHAdvantages of MH

Reverses atelectasisReverses atelectasis (Lumb 2000)(Lumb 2000)
 Improves oxygen saturation and lung complianceImproves oxygen saturation and lung compliance
(Patman et al.,1999)(Patman et al.,1999)
 Improves sputum clearanceImproves sputum clearance (Hodgson et al., 2000)(Hodgson et al., 2000)

29. Disadvantages of MHDisadvantages of MH

Haemodynamic and metabolic upsetHaemodynamic and metabolic upset (Stone, 1991 &(Stone, 1991 &
Singer et al.,1994)Singer et al.,1994)
 Risk of barotraumaRisk of barotrauma
 Discomfort and anxietyDiscomfort and anxiety

30. Coughing TechniquesCoughing Techniques
 Coughing:Coughing: It is a forced expiratory techniqueIt is a forced expiratory technique
performed with a closed glottis.performed with a closed glottis.
 Huffing:Huffing: It is a forced expiratory techniqueIt is a forced expiratory technique
performed with a open glottis.performed with a open glottis.
 Sniffing:Sniffing: Its an respiratory maneuver performedIts an respiratory maneuver performed
after a full inspiration or expiration.after a full inspiration or expiration.

31. Effects of CoughingEffects of Coughing
 Cough removes secretions from the larger airwaysCough removes secretions from the larger airways
 Huff mobilizes the secretions from the distalHuff mobilizes the secretions from the distal
airways.airways.
 During a huff the pleural pressure becomes positiveDuring a huff the pleural pressure becomes positive
and equals the alveolar pressure and so it opensand equals the alveolar pressure and so it opens
up the distal collapsed airway.up the distal collapsed airway.
 Sniff augments collateral ventilation therebySniff augments collateral ventilation thereby
preventing distal airway collapse.preventing distal airway collapse.

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

33. Breathing TechniquesBreathing Techniques

Costal breathingCostal breathing
- Is a technique which concentrates on- Is a technique which concentrates on
ventilation to specific areas of lungs.ventilation to specific areas of lungs.
- In this technique during inspiration the chest- In this technique during inspiration the chest
wall moves up and out.wall moves up and out.
- This technique can be localized to any- This technique can be localized to any
involved segments of the lung.involved segments of the lung.
 GlossopharyngealGlossopharyngeal
 Pursed LipPursed Lip

34. SuctioningSuctioning
 Suctioning is the mechanical aspiration ofSuctioning is the mechanical aspiration of
pulmonary secretions from a patient with an artificialpulmonary secretions from a patient with an artificial
airway in place.airway in place.
 cirteria for suctioning:cirteria for suctioning:
1) secretions are accessible to the catheter.1) secretions are accessible to the catheter.
2) secretions are detrimental to the patient.2) secretions are detrimental to the patient.
3) patient is unable to clear secretions by other3) patient is unable to clear secretions by other
means.means.

36. Neuro Physiological FacilitationNeuro Physiological Facilitation
(NPF)(NPF)
 promoting or hastening the response of neuropromoting or hastening the response of neuro
muscular mechanism through proprioceptorsmuscular mechanism through proprioceptors
(dorothy voss et al, 1985).(dorothy voss et al, 1985).
 Cutaneous and proprioceptive stimulation reflexlyCutaneous and proprioceptive stimulation reflexly
increases the depth of breathingincreases the depth of breathing (Jones, 1998).(Jones, 1998).
INDICATIONS:INDICATIONS:
 Non alert patients such as those who are drowsyNon alert patients such as those who are drowsy
postoperatively.postoperatively.
 Those with neurological conditions.Those with neurological conditions.
 Partially breathing patient on ventilator, especially ifPartially breathing patient on ventilator, especially if
they are unable to turn.they are unable to turn.

37. Techniques of NPFTechniques of NPF
 Stimulation of diaphragmStimulation of diaphragm
(Dorothy voss et al, 1985).(Dorothy voss et al, 1985).
 Perioral techniquePerioral technique
 Intercostal stretchIntercostal stretch
 Co- contraction of abdominal musclesCo- contraction of abdominal muscles
 Vertebral pressureVertebral pressure
(D.D .Bethune,(D.D .Bethune, 1975)1975)

38. MobilisationMobilisation
 ICU rehabilitation has been shown to accelerate recoveryICU rehabilitation has been shown to accelerate recovery
(o’leary & coackley, 1996)(o’leary & coackley, 1996)
 Early mobilization for unconscious patients starts right fromEarly mobilization for unconscious patients starts right from
turning the patient every two hours. ( Brooks- brunn, 1995).turning the patient every two hours. ( Brooks- brunn, 1995).
 Graded exercises can be started as soon as the patientGraded exercises can be started as soon as the patient
regains consciousness.regains consciousness.
 Activity is required to maintain sensory input, comfort, jointActivity is required to maintain sensory input, comfort, joint
mobility and healing ability (Frank et al, 1994).mobility and healing ability (Frank et al, 1994).
 Activity minimizes the weakness caused by loss of upto halfActivity minimizes the weakness caused by loss of upto half
the patients muscle mass (Griffiths & Jones, 1999).the patients muscle mass (Griffiths & Jones, 1999).
 Graded ambulation can be started depending on patientsGraded ambulation can be started depending on patients
conditioncondition

39. MobilisationMobilisation
 Critically IllCritically Ill (Frequent Position changes, Kinetic(Frequent Position changes, Kinetic
& Kinematic Therapy)& Kinematic Therapy)
 StableStable (Progressive tilting(Progressive tilting && Ambulation)Ambulation)

40. ConclusionConclusion
A hammer in a carpenter’sA hammer in a carpenter’s
hand is not used to pull outhand is not used to pull out
a nail…a nail…

41. ThankThank
youyou