4(a) Physiotherapy Techniques in Intensive Care

Question 1

What are the physiotherapy treatment aims in ICU?

Answer 1

Maintenance of function
Prevention of complications
Treatment of acute problems
Rehabilitation & recovery

Question 2

What are the treatment techniques for non-intuibated patients?

Answer 2

All techniques you learnt last year

• Oro/nasopharyngeal suction
• Mask CPAP/NIV

Question 3

What are the treatment techniques for intubated patients?

Answer 3

Manual/ventilator hyperinflation

Endotracheal suction

Question 4

What are the effects of positioning on patients in ICU?

Answer 4

Alters distribution of ventilation/gas movment
Increases compliance
Decrease complications (other systems)

Question 5

What are the precautions for positioning a patient in ICU?

Answer 5

Conditions requiring caution:

Spinal cord injury
Skeletal traction
Acute brain injury
Craniotomy without bone flap
#ribs/flail
Chest drains
Sengstaken-blakemore/minnesota tube

Question 6

What is manual inflation?

Answer 6

Lung inflation by means of a resuscitation bag; does not imply an increase in percentage of oxygen and/or pressure

Question 7

What is preoxygenation?

Answer 7

Administration of oxygen before suctioning; does not imply an increase in percentage of oxygenation and/or pressure

Question 8

What is hyperoxygenation”?

Answer 8

Administration of oxygen at a FI02 greater than the patient is receiving or usually required; may be performed before, during and after suctioning

Question 9

What is hhyperinflation?

Answer 9

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

Question 10

What is hyperventilation?

Answer 10

An increase in the rate of ventilation; does not imply an increase in volume or oxygenation concentration

Question 11

What is manual hyperinflation?

Answer 11

Application of a larger than tidal volume breath with an anaesthetic or resuscitation circut

Slow, deep inspiration with inspiratory hold
Rapid release for expiration

Question 12

During manual hyperinflation, why is an inspiratory hold used?

Answer 12

Collateral ventilation and interdependence

Question 13

During manual hyperinflation, why is a rapid release used for expiration?

Answer 13

Mucocilliary clearance - simulates cough

Question 14

Why is a slow breath in used for manual hyperinflation?

Answer 14

Reduce the effect of airway resistance on distribution of ventilation

Question 15

Why is a deep breath used when doing manual hyperinflation?

Answer 15

Stretch promoting surfactant production

Question 16

What are the detrimental effects of manual hyperinflation?

Answer 16

-Positive intrathoracic pressure
-disconnection causing de-recruitment
- 100% O2
Poor patient tolerance

Question 17

Why is positive intrathroracic pressure a detrimental effect of manual hyperinflation?

Answer 17

Decrease venous return to the heart (CO)
Decrease venous drainage from the head (increase ICP)
Risk of barotrauma

Question 18

Why is 100% oxygen detrimental?

Answer 18

Absorption atelectasis - won’t have nitrogen in airways to splint them open

Reduced respiratory drive

Question 19

What are the types of circuits for manual hyperinflation?

Answer 19

self inflating (resuscitation)
anaesthetic

Question 20

What are the advantages of self inflating/resuscitation circuit?

Answer 20

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

Question 21

What are the limitations of self inflating/resuscitation circuits?

Answer 21

Reduced expiratory flow rates, therefore reduced sputum clearance
Unable to do inspiratory holds
Poor tactile feedback so difficult to feel changes in compliance.

Question 22

What is a PEEP, when and how is it used

Answer 22

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

Question 23

What can happen with high PEEP from MHI PEEP valve?

Answer 23

> 10 cmH20 they can actually slow expiratory flow, thus reduce airway clearance
(the higher the PEEP, the lower the respiratory flow)

Question 24

What are the advantages of an anaesthetic circuit?

Answer 24

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)

Question 25

What are the limitations of an anaesthetic circuit?

Answer 25

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

Question 26

Precautions/contraindications to MHI

Answer 26

• 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

Question 27

What is ventilator hyperinflation?

Answer 27

• 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

Question 28

What are recruitment maneouvres

Answer 28

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.

Question 29

Techniques in ICU for reduced lung volumes

Answer 29

• Positioning
• “Deep breathing”
– Manual hyperinflation
– Ventilator hyperinflation
– Recruitment manoeuvres

Question 30

Techniques in ICU for reduced secretion clearance?

Answer 30

• Facilitate secretion movement
– Drainage
– Manual/ventilator hyperinflation
• Manual techniques
– Percussion
– Vibration
• Additional humidification
– Saline instillation
• Clearance
– Endotracheal suction

Question 31

What is saline instillation

Answer 31

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

Question 32

What are the reported benefits of saline instillation?

Answer 32

• Reported Benefits
– Improved oxygenation
– Increased secretion yield
– Maintain tube patency
– Prevention of VAP

Question 33

What are the anecdotal effects of saline instillation?

Answer 33

• Anecdotal Effects
– Hypoxaemia
– Bronchospasm
– Increased intracranial pressure
– Cardiac arrest
– Respiratory arrest
– Infection
– Patient anxiety, fear
– Pain with no improvement in oxygenation or sputum yield.

Question 34

Indications for suction

Answer 34

• Indications
– Ineffective cough (after trying other techniques)
– Retained secretions
– Artificial airway patency (ETT/trache)

Question 35

Detrimental effects of suction

Answer 35

• Detrimental effects
– Hypoxaemia
– Arrhythmias/hypotension
– Increased ICP
– Mucosal trauma
– Bronchospasm

Question 36

Precautions suction for all patients

Answer 36

– Severe hypoxaemia
– Unstable cardiovascular system
– Coagulopathies/low platelets
– Pulmonary resection (bronchial stump)

Question 37

Contra-indications to non-intubated suction

Answer 37

• 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.