PHYSIOTHERAPY

in
ICU
PT Modalities in Critically ill Patients
 Physiotherapists work in ICU and are part of the Multidisciplinary ICU team
Some people find this surprising as Physiotherapy is often associated mainly with sports
injuries.
However, Physiotherapists work within many areas in healthcare, so do not be alarmed if
they come to assess you or your relative as early as the acute stage of recovery
Physiotherapist perform a comprehensive multi system assessment that includes
Musculoskeletal, Neurological, Cardiovascular and Respiratory systems to formulate
treatment plans
Physiotherapists will visit patients in ICU at least once a day and more if needed
The traditional focus of treatment has been the Rehabilitation and Chest Physiotherapy
of both intubated and spontaneously breathing patients
Advances in the management of ICU patients have improved outcomes and survival
rates. However, as patients survive acute illnesses, long term complications are more
apparent.
DELETERIOUS EFFECTS OF IMMOBILIZATION:
1. Muscle Wasting,Atrophy and Weakness
2. Muscle Tightness and Joint Contractures
3. Decubitus Ulcer
4. Edema
5. Cardiovascular Deconditioning
6. Decreased Ventilatory Exchange,Venous Stasis,DVT and
Pulmonary Embolism

1. Muscle wasting, Atrophy and Weakness

 Patients in ICU can become weak very quickly, losing up to 2% of muscle daily
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
ICU acquired weakness is observed in a substantial proportion of patients receiving MV
for more than one week in the ICU due to deconditioning and disuse atrophy after
prolonged bed rest, immobility and critical illness Neuromyopathy
Studies have shown that after four hours of bed rest, muscle starts to deteriorate

PT Modalities and Intervention:

a.) Therapeutic Exercises (PROME-A-AROME-AROME-RROME)

b.) Electrical Stimulation (ES)

2. Muscle tightness and Joint contractures

 Physiotherapist maintain joint and muscle function in those who are at risk of tightness
and contractures for example in Neurological cases and patients with prolonged
paralysis

PT Modalities and Intervention:

a.) Range of Motion Exercises

b.) Stretching
c.) Therapeutic Ultrasound
d.) Orthotics

3. Decubitus Ulcer
 Pressure sore is a common clinical problem.
Massive tissue necrosis follows when there is interference with the local circulation of
sufficient degree and for a sufficiently prolonged time for extensive irreversible tissue
changes to take place
This results from compression of the skin and subcutaneous tissues between unyielding
bone on one side and a firm mattress on the other
In the presence of normal tissue sensibility, such compression after a time produces
discomfort, whereupon the conscious patient shifts his position or asked to be moved.
Even during sleep, sensations from the skin cause slight changes in position. But for
patients with sensory deficits as in Paraplegia and CVA and those unconscious patients,
they feel no irritation and pain therefore they are more prone to developing ulcers
Other contributing factors of Pressure Ulcers are shear forces. Friction, repetitive stress,
nutritional deficiency and Maceration (softening associated with excessive moisture)
Common sites of Pressure Sores are over bony prominences such as Sacrum, Heels,
Trochanters, Lateral Malleoli, Ischial areas and elbows

PT Modalities and Intervention:

a.) Range of Motion Exercises

b.) Every two hours turning

4. Edema
 Excessive tissue accumulation water, either localized or generalized due to poor venous
drainage, lymphatic obstruction, increase venous pressure or increase water retention

PT Modalities and Intervention:

a.) Range of Motion Exercises

b.) Ankle Pumping
c.) Elevation
d.) Elastic Stockings
e.) Intermittent Pneumatic Compression
f.) Massage

5. Cardiovascular Deconditioning, Venous Stasis, DVT and Pulmonary

Embolism
 Prolonged bed rest and immobility can cause Venous Stasis (stagnation of blood within
vein) then can lead to DVT (Deep Vein Thrombophlebitis) which usually occurs in the
lower extremities and if left untreated may precipitate Pulmonary Embolism. This is a
condition which occurs abruptly associated with chest pain, dyspnea, diaphoresis, cough
and apprehension. This is life threatening and requires emergency treatment.
Medical Management will be anticoagulation therapy such as Heparin and Thrombolytic
agents (streptokinase)

PT Modalities and Intervention:

a.) Range of Motion Exercises
b.) Ankle pumping
c.) Elevation
d.) Elastic Stockings
e.) Intermittent Pneumatic Compression
f.) Ambulation
 6. Decreased Ventilatory Exchange and Pulmonary Complications

Everyday our Lungs produce 100 ml of fluid called sputum

Sputum traps the dirt particles that we breathe in. This is normally coughed and
cleared during the day to clean the lungs
Patients in ICU may require MV to help their breathing. This is necessary to allow
the body to heal. However, it stops patients from coughing and clearing the daily
sputum load. This is made worse if the patient has Pneumonia or chest infection,
as more sputum is produced.
Physiotherapists help patients to clear this excess sputum, reducing the chance
of chest infection

PT Modalities and Intervention:

a.) Chest Physiotherapy

a1.) Postural Drainage
a2.) Percussion
a3.) Vibration
a4.) Turning
a5.) Breathing Exercises
a6.) Coughing and Huffing Techniques
a7.) Abdominal Strengthening Exercises
a8.) Incentive Spirometry
Chest Physiotherapy (CPT) is the term for a group of treatments designed
to improve respiratory efficiency, promote expansion of the lungs, strengthen
respiratory muscles and eliminate secretions from the respiratory system.

1. Postural Drainage
2. Percussion
3. Vibration
4. Turning
5. Breathing Exercises
6. Airway Clearance Techniques
7. Abdominal Strengthening
8. Incentive Spirometry

1. Postural Drainage
 Uses the force of gravity to assist in effectively draining secretions from the
smaller airways into the central airway where they can either be coughed up or
suctioned out.
The patient is placed in a head-or-chest down positions and is kept in this
position for up to 15-20 minutes
To obtain the head-down position, the use of pillow, beanbag chair or couch
cushions can be helpful.
Observe for sign of intolerance
Precautions and Considerations:
a. Pulmonary Edema
b. Congestive Heart Failure
c. Hypertension
d. Obesity
e. Ascites
f. Pregnancy
g. Hiatal Hernia
h. Nausea and vomiting
i. Recent food consumption
j. Recent Neurosurgery
k. Increase ICP
l. Aneurysm
m. SOB
Considerations in side lying position:
a. Axillo-Femoral Bypass graft
b. Humeral Fracture
c. Need for Hip Abduction Brace
d. Arthritis
e. Shoulder Bursitis

2. Percussion
 Cover the area with a light weight cloth to avoid erythema
Involves rhythmically striking the chest wall with cupped hands
Break up thick secretions in the lungs so they can more easily removed
Performed on each lung segment for one to two minutes at a time and moved
over one lobe of the lung for approximately five minutes, while the patient is
encouraged to performing coughing and deep breathing techniques
Observe for signs of intolerance
Precautions and Considerations:
a. Pain made worse by the technique
b. Aneurysm precautions
c. Hemoptysis
d. Increase Partial Thromboplastin Time (PTT)
e. Increase Prothrombin Time (PT)
f. Decreased Platelet count (below 50,000)
g. Medications that interfere coagulation
h. Rib fractures
i. Flail Chest
j. Degenerative Bone Disease
k. Bone Metastases

3. Vibration

As with Percussion its purpose is to break up lung secretions

It is either mechanical or manual
 Performed at 5 to 10 deep inhalations
When done manually, the Physiotherapist places his or her hands so that fingers
are parallel to the ribs and creates a jarring bouncing motions by quickly
contracting and relaxing arm and shoulder muscles while the patient exhales
Observe for signs of intolerance
Precautions and Considerations is same as for Percussion

4. Turning

This is usually done by the nurses with a scheduled time of every two hours
Turning the patient from side to side permits lung expansion
 Done at a minimum of every two hours for bedridden patients
Head of the bed can also be elevated in order to promote drainage

5. Breathing Exercises

Deep breathing helps expand the lungs and forces an improved distribution of
the air into all sections of the lungs
 Patient either sits on a chair or sits upright on bed and inhales the pushes the
abdomen out to force maximum amount of air into the lung
The abdomen is the contracted, and the patient exhales
Done several times each day for short periods
Other breathing exercises are Pursed lip breathing, Diaphragmatic and
Segmental breathing exercises

6. Airway Clearance Techniques

 Coughing helps to break up secretions in the lungs so that the mucus can be
expectorated or suctioned out if necessary
Patient sit upright and inhale deeply through the nose then exhale in short puffs
or coughs
In Huffing the procedure is same with coughing except that during the exhalation
the patient has to say the words ha ha
Done several times each day for short periods
Assisted Cough is done with patient upright sitting or Fowlers position and the
procedure is like the Heimlich maneuver
Tracheal Stimulation is performed for patients who are unable to cough. The
therapists finger/thumb placed above the suprasternal notch and gives a quick
inward and downward pressure on Trachea
 7. Abdominal Strengthening

Critically ill patients during prolonged bed rest experience general body
weakness without the exception of the Abdominal muscles
These patients find it difficult to get rid of the secretions through huffing and
coughing
making the abdominal muscles strong through Abdominal Isometrics and
Abdominal curls aid into easier coughing and huffing techniques to expectorate
the sputum out from the lungs

8. Incentive Spirometry

An Incentive Spirometer is a device that measures how deeply you can inhale
It helps you to take slow, deep breaths to expand and fill your lungs with air
 Helps to prevent lung problems like Pneumonia
It is made up of a breathing tube, an air chamber and an indicator
Breathing tube is connected to the air chamber and has a mouthpiece at the end
The indicator is found inside the device
It is most commonly used after surgery and patients who are at risk of airway or
breathing problems like those who are smoker and have lung diseases and
bedridden patients
Procedure: Sit upright as possible do not bend your head forward or backward
holing the device in an upright position. Place the target pointer to the level that
you need to reach. Exhale normally then do the following

a. Put the mouthpiece in your mouth and close your lips tightly around it. Do not
block the mouthpiece with your tongue
b. Inhale slowly and deeply through the mouthpiece to raise the indicator. Try to
make the indicator rise up to the level of the goal marker
c. When you cannot inhale any longer, remove the mouthpiece and hold your
breath for at least 3 seconds
d. Exhale normally
e. Repeat this steps 10-12 times every hour when you are awake, or as often as
directed
f. Clean the mouthpiece with soap and water after each use. Do not use a
disposable mouthpiece for longer than 24 hours
g. Keep a log of the highest you are able to reach each time. This will help nurse
and Physiotherapists see if you lung function improves