Lecture 4

Question 1

what are the possible problems that are relevant to ICU patients?

Answer 1

impaired airway clearance 
Impaired gas exchange 
impaired lung volume/compliance 
increased work of breathing 
weakness of peripheral and respiratory muscles

Question 2

what are the respiratory goals?

Answer 2

Promote secretion clearance
improve lung volume/compliance
optimise gas exchange
prevent/treat respiratory complications (decrease incidence of ventilator acquired pneumonia)

Question 3

What are the general goals?

Answer 3

Prevent deconditioning

increase mobility

Question 4

possible interventions for intubated patients

Answer 4

positioning (GAD) 
manual techniques (P&V) 
manual hyperinflation 
suction 
mobilisation and exercise

Question 5

when is GAD contraindicated

Answer 5

1. hypertension and heart failure - HDT increases preload
2. patients with neurological issues/on ICP monitoring - 30deg HDT increases ICP
3. resistive lung disease - 15 deg HDT increases lung elastance and resistance

Question 6

Pros of semi-recumbent

Cons of semi-recumbent

Answer 6

pros: protective against pulmonary aspiration and decrease gastroesophageal reflux

Cons: may further decrease systemic blood pressure in patients with sepsis where systemic vascular resistance is already low
decreased respiratory compliance

Question 7

cons of upright sitting

Answer 7

Cons: patient’s who are hemodynamically unstable may not be able to tolerate upright sitting

Question 8

effects of lateral decubitus (side lying)

Answer 8

1. lying on right side may decrease preload and MAP by 15%
2. lying on left side may increase CO by 30%
3. act pf turning: increases HR by 9%, SBP by 11%, CO by 33%, CVP by 22% and PAP by 20%

Question 9

Pros of prone positioning

Answer 9

improve oxygenation in patients with extrapulmonary acute lung injury

Question 10

Pros of MHI

Answer 10

1. facilitate secretion clearance - enhance secretion yield via the two-phase flow mechanism
2. reverse and prevent atelectasis - improve respiratory system compliance
3. optimise ventilation and oxygenation - effect from MHI or effect from FiO2 1.0

Question 11

recommended application of MHI

Answer 11

1000ml, 20-40cmh2o
FiO2 = 1.0
Slow inflation of at least 3sec to pressure of 40cmh2o
2-3 second inspiratory pause
rapid release for exhalation (to enhance PEFR)
6set of 5 -8 hyperinflations
can be done with adjuncts: positioning, expiratory chest wall vibration, endotracheal suctioning PRM

Question 12

What are the physiological mechanism for secretion clearance

Answer 12

1. increase in expiratory flow via the two-phase gas-liquid flow
2. oscillation of airflow (cough and FET, percussion and vibration)
3. increasing lung volume - increase in positive back pressure within the airway to maintain patency, increase FRC to greater than closing capacity

Question 13

Advantages of VHI

Answer 13

control and more flexible 
maintain PEEP 
less manipulation of the airway 
may be better tolerated by more alert patients 
relies less on the therapist expertise

Question 14

Indications to wean off MV

Answer 14

assessed the reasons for MV
evidence for reversal of underlying cause
adequate oxygenation
hemodynamically stable
ability to initiate an inspiratory effort
pass spontaneous breathing trial

Question 15

physiotherapists role in MV weaning

Answer 15

early assessment of patient's rehab potential 
assistance with secretion clearance 
respiratory muscle training 
ambulatory ventilation 
identify readiness for extubation 
facilitate early extubation 
assisting with tracheostomy weaning 
recognising patients at risk of difficulties with weaning