Physiotherapy in the ICU Flashcards
Goals
Early mobilization
Optimize ventilation/perfusion matching.
Early Mobilization
Right at the beginning after admission.
Feasible and safe even with various monitors attached to the patient.
No red flags, incite to minimal sedation. If sedated can do passive mobilization.
Some techniques (transfers, verticalization etc.) require several people from ICU team to avoid complications and correct execution.
Monitoring Vital Signs
Careful with invasive and non-invasive devices before intervention.
Continuous monitoring!
Stop if:
35> HR >130
MAP < 65mmHg
RR > 35
SaO2 < 88%
Pain (VAS) > 5
Must consider patient and pathology specifically to see if patient can be mobilized.
Conscience Level Monitoring
Glasgow Coma Scale:
Eye opening, verbal response and motor response.
Richmond Agitation Sedation Scale: level of anxiety of patient. Touch, talk and look.
Delirium screening: patients ability to communicate with you, organized thoughts.
Clinical Indications for Resp. Failure type I and II - Mechanical Ventilation
PaO2 <60
PaCO2 >50
SpO2 <88%
RR > 30-35
PaO2/FiO2 (%) < 150-200
Lung Failure vs Pump Failure
Lung Failure: white lung, pulmonary lung edema, pneumonia, acute respiratory distress syndrome.
Pump Failure: black lung, COPD, asthma, neuromuscular disease.
Indications for Ventilatory Failure - Mechanical Ventilation
Apnea / resp. arrest
Inadequate ventilation
Inadequate oxygenation
Chronic respiratory insufficiency with FTT
Protect upper airways
Indications for Cardiac Insufficiency and Neurological Dysfunction
Cardiac insufficiency:
- Eliminate work of breathing
- Reduce oxygen consumption
Neuro: central hypoventilation/frequent apnea
Patient comatose
Inability to protect airway
Comfort/sedation
Invasive Mechanical Ventilation - 3 Types
Controlled: sedated + neuromuscular problem. Diaphragm not working, controlling everything (RR and VT).
Assisted/controlled: Sets the RR but lets the patient breathe, f.ex. 5 and machine does 5. IMV & SIMV.
Assisted: Patient breathes how many times he wants. Patients VT: 350ml, machine adds 150ml.
Spontaneous Breathing vs Mechanical Ventilation
Spontaneous: Negative pressure ventilation, ventilates the dependant zone.
Mechanical: Positive pressure ventilation. Ventilating non-dependent zone first, over extending alveoli, compressing capillaries, ↓ venous return, preload problem for L heart, afterload problem for R heart.
Mechanical Ventilation - What we can manipulate
Minute Ventilation (↑RR, VT)
Pressure Gradient (↑ atmospheric pressure, FiO2, ventilation, change RQ (CO2eliminated/O2consumed)
Surface Area (↑ volume by ↑ airway pressure)
If the volume is set, pressure varies and vice versa according to the compliance (Δvolume/Δpressure)
PEEP
Positive end expiratory pressure.
Greater than atmospheric pressure in mechanically ventilated patients to keep the lungs always inflated.
Prevents alveolar collapse.
Complications of Increasing PEEP
can ↑ dead space, ↓ cardiac output, ↑ V/Q mismatch.
This ↑ R atrial pressure and ↓ venous return (↓ preload). → less blood reaching LV, less blood pumped out. Work of heart less efficient.
Result is drop in mean arterial pressure (MAP).
Weaning from Mechanical Ventilation
Reducing ventilatory support, ultimately resulting in patient breathing spontaneously and being extubated (patient does deep inspiration). When the original cause of the resp. failure has improved.
Non-Invasive Ventilation
Patients without sedation and neuromuscular block. Assisted ventilation.
Positive pressure NIV: CPAP, BIPAP
- COPD exacerbations
- Acute cardiogenic pulmonary edema
- Immunocompromised patients
Goals of Non-Invasive Ventilation (6)
Provide time for the cause of resp. failure to resolve and improve gas exchange.
Overcome auto-PEEP
Unload resp. muscles
Decrease dyspnea
Avoid endotracheal intubation
Avoid complications
How does Non-Invasive Ventilation work?
Assistance of resp. muscles and avoidance of fatigue.
Augments tidal volume
Improves compliance by reversing micro atelectasis.
Overcomes intrinsic PEEP
Enhanced cardiovascular function
Sent the airway
Reduce CO2 production
Contraindications of Mechanical Ventilation
Cardiopulmonary arrest
hemodynamic instability
Recent trauma
Inability to protect airway
Nonresp. multiorgan failure
Suctioning
IMV and sedated
Weak coughing
Tracheostomized
Saw pattern on flow volume curve.
Open or closed circuit.
Vasodilatory Shock
excessive vasodilation, hypotension, inadequate perfusion. Inappropriate vascular smooth muscle relaxation despite hypotension.
Cause of septic shock.
Neuromuscular Electrical Stimulation
Intubated patients, mechanical ventilation, sedated or not, can’t stand. Loss of muscle mass, ICU acquired weakness.
Clinical Goal of O2 Therapy
Treat hypoxemia
Decrease work of breathing
Decrease myocardial work
Different Types of Hypoxemia (4)
Hypoxic (O2 poor air, hypoxic gas mixture, high altitude)
Anemic (O2 carrying capacity of blood decreased)
Stagnant (Inadequate tissue perfusion, ↓ cardiac oitput)
Histotoxic (cells cannot utilize oxygen)
Indications for O2 therapy
Hypoxemia PaO2 <60mmHg
Normoxic hypoxemia (low cardiac output, anemia, CO poisoning)
Trapped gases (obstruction)
Anesthesia
