ROLES OF PHYSIOTHERAPY IN INTENSIVE CARE UNIT (ICU)

 BY

OBUNIKE, STEPHANIE CHINELO

CARDIO UNIT 

ON
1 17TH OF JULY, 2023.
2 INTRODUCTION
 The Intensive Care Unit (ICU) is an area within a medical
facility which is a specialized facility equipped with
advanced technologies designed for close monitoring,
rapid intervention and often extended treatment of patients
with acute organ failure.
 Intensive care aims to maintain vital functions, prevent
further physiological deterioration, reduce mortality and
prevent morbidity in critically ill patients (Marshall et al,
2017).
 The physiotherapeutic interventions in critical care units
(ICU) is to prevent pulmonary complications, ICU-
acquired weakness and delirium.
 Early physiotherapy ICU intervention reduces ICU-stay,
mechanical ventilation duration and enhances functional
capacity (Swaminathan et al, 2019).
3 EPIDEMIOLOGY
 There is evidence that the greatest proportion of admissions to ICUs are for medical
emergencies (41%), followed by planned admissions from elective surgery (25%) and
emergency surgical admissions (18%).
 In a randomized controlled trial conducted in 2 university hospital ICUs, 104
mechanically ventilated subjects randomized to early physical therapy and occupational
therapy interventions were more likely to return to independent physical functioning at
hospital discharge (59% vs 35%, P = .02), have shorter duration of mechanical
ventilation (3.4 d vs 6.1 d, P = .02), and have fewer days with delirium in the ICU (2 d
vs 4 d, P = .03) (Hashem et al, 2016).
 Physiotherapy intervention as a principal and consistent therapy services has been
shown to help reduce mortality rate by 25% (Swaminathan et al, 2019; Tomasi et al,
2010).
4 TYPES OF ICU

 ICU can be organized based on the pathologies/conditions treated

(e.g. neurological, trauma, burns, medical or surgical ICUs) or by
the age group of the patient admitted (adult or pediatric) (Nates et
al, 2016).
 It is grouped into 4 types (Schamelenberg and Kramer, 2007):
medical, including coronary care; surgical, including trauma and
cardiovascular; neonatal and pediatric;
5 CATEGORIES OF PATIENTS IN ICU

 According to the critical care modernization plan in 2000, the

categories of patient In the ICU are patients who are in Level-2 and
Level-3 of the adult critical care spectrum.
 Level 2 refers to patients who need more detailed observation or
intervention; e.g. patients with a single failing organ system, or
post-operative patients, or patients stepping down from higher
levels of care, while Level-3 refers to patients who require advanced
respiratory support alone, or basic respiratory support together with
support of at least two organ systems.
6 MANAGEMENT OF PATIENTS IN ICU

 According to the Society of Critical Care Medicine, patients in the

ICU are managed by a critical care team which is a group of specially
trained caregivers who work in the intensive care unit. These
specially trained caregivers come from many professions.
Members of the team usually include one or more of these caregivers:

 Intensivist physician, Critical care nurse, Pharmacist, Registered

dietician, Respiratory therapist, Physical therapist, Occupational
therapist,Child life specialist.
 PHYSIOTHERAPY ASSESSMENT IN INTENSIVE CARE UNIT
7

 The role of physiotherapy in the ICU has traditionally been respiratory management but in
current practices rehabilitation and mobilization has become a priority for patients in ICU
(Twose et al, 2021).
 Assessing a critically ill patient is a unique procedure considering the wide spectrum of patients
one may encounter in the ICU.
Assessment of the critically ill patient incorporates three major categories (Malone and Bishop,
2020):

 History
 System review
 Test and measures
8 ADVERSE EFFECT OF PROLONGED ICU
STAY
 The purpose of critical care is to support critically ill patients through their acute illness to allow
them to return to their pre-admission lifestyle.
Adverse effects of ICU stay:

 Physical Inactivity leading to muscular atrophy and generalized weakness, Diaphragmatic

weakness due to prolonged mechanical ventilation ,Pressure Ulcers, compromised cardiac
function, deep vein thrombosis, Infections, Joint stiffness, Contracture, Impaired exercise
tolerance, respiratory conditions- atelectasis, secretion retention, and respiratory muscle weakness
(Camak et al, 2019), Skin diseases, Post-intensive care Syndrome (Morgan, 2021).
9 GOALS OF PHYSIOTHERAPY

 According to the Chartered Society of physiotherapy in 2011, Physiotherapy

is an important intervention that prevents and mitigates adverse effects of
prolonged bed rest and mechanical ventilation during critical illness.
 Rehabilitation delivered by the physiotherapist is tailored to patient needs
and depends on conscious state, psychological status and physical strength.
 Early progressive physiotherapy, with a focus on mobility and walking
whilst ventilated, is essential in minimizing functional decline
10
GOALS OF PHYSIOTHERAPY IN ICU CONT’D
The goals of a physiotherapist in the ICU can be divided into Short term goals and Long term goals.

 Short Term Goals

 To improve lung expansion/ lung volume

 To clear mucus secretion in the lungs

 To ensure patent airway

 To wean patients off mechanical ventilator

 To prevent pressure sores

 To prevent neuromusculoskeletal complications such as contractures, muscle atrophy, hypotonia, ICU-

acquired weakness, amongst others.

 Long Term Goals

 To rehabilitate patient back into the society.

11
PHYSIOTHERAPY INTERVENTIONS

 National guidelines state personal rehabilitation programmes involving a

multidisciplinary team should be commenced within 4 days of admission
and continued after discharge to the ward (Morgan, 2021).
 For clinical practice, the recommended physiotherapy interventions are
divided into interventions for patients who are able to follow instructions
(active interventions) and who are not able to follow instructions (passive
interventions), determined primarily by the level of consciousness
(Sommer et al, 2015).
 For unconscious patients the range of motion for joint, contractures and
muscle tone are maintained using passive joint movements WHILE For
patients who are conscious and able to follow instructions, active therapy
modalities in a functional context are recommended (Sommer et al,
2015)
12 PHYSIOTHERAPY INTERVENTIONS
 Physiotherapist employ techniques such as
 Body positioning
 Postural drainage
 Manual chest physiotherapy
 suctioning
 Manual hyperinflation
 Active cycle of breathing
 Incentive spirometry
 Therapeutic exercise
 Early mobilization
 PHYSIOTHERAPY INTERVENTIONS
13
 PHYSIOTHERAPY INTERVENTIONS
14
 CRITERIA FOR TREATMENT
15

 monitoring patients’ safety before and during  RED FLAGS

mobilization and activation is of vital importance as  Oxygen Saturation ≤ 90%
their medical situation can rapidly change owing to
them being critically ill.  Respiratory Frequency > 40 breath/min
 As part of the clinical reasoning process, every
patient should be screened for the presence of red  Temperature ≥ 38.5°C ≤ 36°C
flags (contra-indications) and relative contra-
indications to consider (potential) risks and benefits  Recent myocardial ischemia
before and during every physiotherapy treatment
session.
 Heart rate 130 beats/min
16 Yellow Flag

 Abnormal face color

 Pain

 Fatigue

 Unstable fractures

 Presence of lines that make mobilization

unsafe.

 Neurological instability: Intra Cranial

Pressure (ICP) ≥ 20 cmH2 O
 NATIONAL EARLY WARNING SCORE 2

17

 Early warning scores (EWS) are forms of track and trigger scoring systems. These
involve checking basic physiological signs at intervals – tracking and responding to
abnormal physiological parameters – triggers
 NEWS is a tool which improves the identification and response to acutely unwell and
deteriorating adult patients.
 It measures 6 physiological parameters which form the basis of the scoring system.
They include; respiration rate, oxygen saturation, systolic blood pressure, pulse rate,
level of consciousness or new confusion, temperature.
 NATIONAL EARLY WARNING SCORE 2
18

 Each scores 0–3 and individual scores are added together for an overall score. An additional two points are
added if the patient is receiving oxygen therapy. The total possible score ranges from 0 to 20. The higher the
score the greater the clinical risk. Higher scores indicate the need for escalation, medical review and possible
clinical intervention and more intensive monitoring.
19
IMPACT OF PHYSIOTHERAPY

 According to the National Institute of Health and Clinical excellence (NICE), European
Respiratory Society, and ICU medicine, there are more ventilator-free days for patients with
early physiotherapy in ICU compared with standard care.
 A retrospective cohort study on 285 survivors of prolonged ICU-stay suggested that the
ability to ambulate was associated with a higher possibility of being discharged,
emphasizing the importance of mobility training in long-term acute care hospitals (Tran et
al, 2020).
 Early intervention by physiotherapists in the ICU helps;

 Reduce the patient's stay in the ICU and overall hospital stay.

 Prevent ICU related complications

 To improve function and quality of life in the long term

20 OUTCOME MEASURES

 Glasgow coma scale

 Richmond Agitation-Sedation Scale (RASS)
 Critical Care Pain Observation Tool (CPOT)
21 CASE REPORT

I present to you a case of a 9year old school girl, who was unconscious and all information was gotten
from her folder as documented

HISTORY; patient was in her usual state of health until 3months prior to presentation when she was
trying to cross a major road on her way to church and was hit by a school bus. Details surrounding the
accident could not be gotten as her mother could not give account of the incident. Patient was
transferred from a private facility to this facility in an unconscious state the following day where she
was admitted into the ICU. Patient was assessed by the physiotherapist team 10days following her
admission into the ICU.
22 CASE REPORT

OBSERVATION: patient was met in supine lying, febrile and was on oxygen mask. Patient has injury
scars on her face, arms bilaterally and right knee.

VITALS: Pulse rate; 145b/m

Blood pressure; 113/69mmHg

Temp; 39.5C

ASSESSMENT

CNS: GCS; eye opening -1, MR-3, VR-2: - 6/15

23 CASE REPORT

THORAX AND ABDOMEN; Musculoskeletal

 breath sounds- coarse transmitted sounds Muscle bulk – normal

respiratory rate – 40c/m Muscle power – not assessed

SPO2 -95% in room air Tone- normal

CVS;

HR – 130bpm
 CASE REPORT
24

REVIEW AFTER 10 SESSIONS UPPER LIMB

GCS is 8/15  Tone; Hypertonic

HEAD AND NECK;  Muscle bulk; atrophied.

 Muscle power; not assessed
 Pressure sores at the right ear, and occiput
 PROM;- Limited at the shoulder joints
 PROM of the neck limited in left and right rotation,
bilaterally, elbow joints, interphalangeal joints
left and right lateral flexion and flexion and extension.
bilaterally.
25 CASE REPORT

THORAX AND ABDOMEN  Observation and examination;

Patient was met in a decerebrate
 Scoliosis
posture with the plinth in semi-
 Muscle atrophy fowler’s position with
LOWER LIMB nasogastric tube, catheter, blood
pressure cuffs, pulse oximeter in
 Tone- Spastic
situ. Patient has pressure sores on
 Muscle bulk – atrophied her right ear, bilateral popliteal
 Muscle power – not assessed fossa, left part of her back.
 PROM- limited at the hip joints bilaterally, and
ankle joints
 Knee fused bilaterally
26 CONCLUSION

Physiotherapy in the ICU play a significant role. The choice of technique and protocol is
individually tailored and multidimensional, but the effects of early physiotherapeutic interventions
are effective in ensuring speedy and maximal possible recovery for critically ill patients.

There is evidence to support the benefit of physiotherapy in the ICU which is not just respiratory
advantage. The role of the physiotherapist in the ICU according to the recent research shows that
early mobilization decreases the length of ICU stay and overall hospital stay, prevents ICU related
complications, improve function and quality of life in the long term.
27 REFERENCE

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Benjamin Stretch, Stephen J. Shepherd; Criteria for intensive care unit admission and severity of illness Surgery (Oxford); Volume 39,
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28 REFERENCES

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