4(a) Physiotherapy Techniques in Intensive Care Flashcards
What are the physiotherapy treatment aims in ICU?
Maintenance of function
Prevention of complications
Treatment of acute problems
Rehabilitation & recovery
What are the treatment techniques for non-intuibated patients?
All techniques you learnt last year
- Oro/nasopharyngeal suction
- Mask CPAP/NIV
What are the treatment techniques for intubated patients?
Manual/ventilator hyperinflation
Endotracheal suction
What are the effects of positioning on patients in ICU?
Alters distribution of ventilation/gas movment
Increases compliance
Decrease complications (other systems)
What are the precautions for positioning a patient in ICU?
Conditions requiring caution:
Spinal cord injury Skeletal traction Acute brain injury Craniotomy without bone flap #ribs/flail Chest drains Sengstaken-blakemore/minnesota tube
What is manual inflation?
Lung inflation by means of a resuscitation bag; does not imply an increase in percentage of oxygen and/or pressure
What is preoxygenation?
Administration of oxygen before suctioning; does not imply an increase in percentage of oxygenation and/or pressure
What is hyperoxygenation”?
Administration of oxygen at a FI02 greater than the patient is receiving or usually required; may be performed before, during and after suctioning
What is hhyperinflation?
Lung inflation by means of a resuscitation bag or ventilater; can be at a volume greater than the ventilator setting; does not imply a change in oxygen concentration
What is hyperventilation?
An increase in the rate of ventilation; does not imply an increase in volume or oxygenation concentration
What is manual hyperinflation?
Application of a larger than tidal volume breath with an anaesthetic or resuscitation circut
Slow, deep inspiration with inspiratory hold
Rapid release for expiration
During manual hyperinflation, why is an inspiratory hold used?
Collateral ventilation and interdependence
During manual hyperinflation, why is a rapid release used for expiration?
Mucocilliary clearance - simulates cough
Why is a slow breath in used for manual hyperinflation?
Reduce the effect of airway resistance on distribution of ventilation
Why is a deep breath used when doing manual hyperinflation?
Stretch promoting surfactant production
What are the detrimental effects of manual hyperinflation?
-Positive intrathoracic pressure
-disconnection causing de-recruitment
- 100% O2
Poor patient tolerance
Why is positive intrathroracic pressure a detrimental effect of manual hyperinflation?
Decrease venous return to the heart (CO)
Decrease venous drainage from the head (increase ICP)
Risk of barotrauma
Why is 100% oxygen detrimental?
Absorption atelectasis - won’t have nitrogen in airways to splint them open
Reduced respiratory drive
What are the types of circuits for manual hyperinflation?
self inflating (resuscitation) anaesthetic
What are the advantages of self inflating/resuscitation circuit?
Commonly used and available Easy technique for novices to learn Can be done with one hand Reduced risk of volu/barotrauma as respiratory valve opens automatically under excess pressure Able to attach PEEP valve
What are the limitations of self inflating/resuscitation circuits?
Reduced expiratory flow rates, therefore reduced sputum clearance
Unable to do inspiratory holds
Poor tactile feedback so difficult to feel changes in compliance.
What is a PEEP, when and how is it used
Can be added to some MHI circuits
Maintains PEEP in circuit
Screw down or fixed 5-15 cmH20 PEEP
Different types variable in their performance
What can happen with high PEEP from MHI PEEP valve?
> 10 cmH20 they can actually slow expiratory flow, thus reduce airway clearance
(the higher the PEEP, the lower the respiratory flow)
What are the advantages of an anaesthetic circuit?
Can do inspiratory hold
Can deliver larger volume
“Quick release” expiration to simulate cough
More tactile feedback
Research suggests generates higher PEFR (peak exp flow rate)
What are the limitations of an anaesthetic circuit?
Difficult technique for novices
Requires two hands
C02 re-breathing potential with incorrect use
Potential to cause barotrauma with incorrect technique
No built in attachment for PEEP valve
Precautions/contraindications to MHI
• Undrained pneumothorax ‐ must have ICC in‐situ
• Surgical emphysema may be increased
• Acute pulmonary oedema may be increased if cardiac output (CO) drops
(due to increased intrathoracic pressure) resulting in increased back
pressure into the pulmonary system
• Patients with low CO or who are cardiovascularly unstable
– Arrhythmias
– Hypovolaemia
• Patients with hyperinflated lungs, eg severe emphysema
• Acute severe bronchospasm, or airway pressures persistently > 40 cmH2O
• High or uncontrolled ICP
• PEEP > 10 cmH2O FiO2 > 0.6 (check hospital protocol)
• Nitric oxide treatment
What is ventilator hyperinflation?
• Deep breaths delivered by altering the settings on
the ventilator
• Do not need to disconnect patient from ventilator
thereby decreasing risk of de‐recruitment
• Alter volume, pressure or flow/time parameters
• Do not need FIO2 1.0
What are recruitment maneouvres
Any technique that transiently increases the alveolar
pressure above normal tidal ventilation (which may
have included an increase in any pressure, such as
plateau, peak, or end‐expiratory pressure) and
sustained that pressure beyond the normal time.
Techniques in ICU for reduced lung volumes
• Positioning • “Deep breathing” – Manual hyperinflation – Ventilator hyperinflation – Recruitment manoeuvres
Techniques in ICU for reduced secretion clearance?
• Facilitate secretion movement – Drainage – Manual/ventilator hyperinflation • Manual techniques – Percussion – Vibration • Additional humidification – Saline instillation • Clearance – Endotracheal suction
What is saline instillation
Assist in the removal of thick tenacious secretions
during physiotherapy
• Administered just prior to treatment or suction to
stimulate a cough and maximise secretion clearance
• Consider humidification and adequate hydration
What are the reported benefits of saline instillation?
• Reported Benefits – Improved oxygenation – Increased secretion yield – Maintain tube patency – Prevention of VAP
What are the anecdotal effects of saline instillation?
• Anecdotal Effects – Hypoxaemia – Bronchospasm – Increased intracranial pressure – Cardiac arrest – Respiratory arrest – Infection – Patient anxiety, fear – Pain with no improvement in oxygenation or sputum yield.
Indications for suction
• Indications
– Ineffective cough (after trying other techniques)
– Retained secretions
– Artificial airway patency (ETT/trache)
Detrimental effects of suction
• Detrimental effects – Hypoxaemia – Arrhythmias/hypotension – Increased ICP – Mucosal trauma – Bronchospasm
Precautions suction for all patients
– Severe hypoxaemia
– Unstable cardiovascular system
– Coagulopathies/low platelets
– Pulmonary resection (bronchial stump)
Contra-indications to non-intubated suction
• Contraindications to non‐intubated suction:
– # sphenoid or #’s in nasopharynx
– CSF leak into nasal passages
– Base of skull #
– Oropharyngeal/oesophageal surgery
– Platelet count < 50
– Do not suction immediately following a meal.
