Chest physiotherapy in ICU

3. A treatment intervention employed for improving
pulmonary hygiene including positioning, chest
percussion, vibration and manual hyperinflation to
assist in mobilizing secretions in the lungs from the
peripheral airways into the more central airways so
that they can be expectorated or suctioned out.

4. • Prophylactic
- Pre-operative high risk surgical patient
- Post-operative patient who is unable to
mobilize secretions
- Neurological patient who is unable to cough
effectively
- Patient receiving mechanical ventilation who has a
tendency to retain secretions
- Patients with pulmonary disease,
who needs to improve bronchial hygiene

5. …cont.
• Therapeutic
- Atelectasis due to secretions
- Retained secretions
- Abnormal breathing pattern due to primary or
secondary pulmonary dysfunction
- COPD and resultant decreased exercise
tolerance
- Musculoskeletal deformity that makes breathing
pattern and cough ineffective

6. • Neurological system
• Cardiovascular system
• Respiratory system

7. Neurological System
• Level of consciousness
• Cerebral perfusion pressure (>70mmHg)
– CPP = MAP- ICP
• Intracranial pressure (<10mmHg)
…cont.

8. • Heart rate and rhythm
• Arterial BP
• Central Venous pressure
…cont.
Cardiovascular System

9. Respiratory System
• Auscultation
• Expansion
• Chest X-ray
• Mode of ventilation
• Oxygen therapy
• RR
• Airway pressures
• ABGs
• Sputum
…cont.

11. General Observation
• Patient Position
• Respiration -Airway (artificial airway) ET/Tracheostomy
Ventilator Mode, Ventilator Parameters
• Vital Signs –BP, RR, HR, SpO2,GCS, ICP
• Tubes - NG Tube, CVP line, Peripheral line, Chest tubes,
Catheters
• Drugs
…cont.

12. General Observation
• Auscultations
• Respiratory pattern
• Cyanosis
• Radiograph
…cont.

13. • Prevent accumulation of secretions
• Improve mobilization and drainage of secretions
• Promote relaxation to improve breathing patterns

14. • Improves respiratory function
• Improve cardio-pulmonary exercise tolerance
• Teach bronchial hygiene programs to patients with chronic
respiratory dysfunction
…cont.

15. • Untreated tension pneumothorax
• Abnormal coagulation profile
• Status epilepticus or status asthamaticus
• Immediately following intra cranial surgery

16. • Head injury with raised ICP
• Osteoporotic bones
• Recent acute myocardial infarction, unstable vitals
• Immediately after tube feedings
• Sutures and ICD’s
…cont.

17. PHYSIOTHERAPY
TECHNIQUES

18. • Gravity-assisted Positioning
• Manual techniques
• Manual hyperinflation
• Airway suctioning
• Mobilization

20. Physiological Effects of Positioning
• Optimizes oxygen transport by improving V/Q mismatch
• Increases lung volumes
• Reduces the work of breathing
• Minimizes the work of heart
• Enhances mucociliary clearance (postural drainage)
…cont.

21. • A separate technique. Its just an example of positioning
which has the particular aim of clearing airway secretions
with the assistance of gravity.
…cont.

23. • Patients are positioned with the area to be drained the
upper most, but modifications should be done wherever
necessary.
• Drainage times vary, but ideally each position requires 10
minutes (gumery et al, 2001).
…cont.

24. • Positioning restores ventilation to dependent lung regions
more effectively than PEEP or large tidal volumes (Froese &
Bryan, 1974).
• Positioning has a marked influence on gas exchange
because of unevenly damaged lungs (Tobin, 1994).
• Side lying reduces lung densities in the upper most lung
(Brismar, 1985).
…cont.

25. • Right side lying may be more beneficial for cardiac output
than left side lying (Wong, 1998).
• Simply turning from supine to side lying can clear
atelectasis from dependent regions (Brismar, 1985).
• Positioning affects lung volume
• Lung volume is related to the position of the diaphragm
• FRC decreases from standing to slumped sitting to supine
(Macnaughton, 1995)
…cont.

26. • Positioning affects compliance (Wahba et al found that
work of breathing is 40% higher in supine than in sitting)
• Positioning affects arterial oxygenation by improving V/Q
mismatch (V/Q is usually mismatched if the affected lung is
dependent- Gillespie et al)
• “Bad lung up” position
…cont.

29. • Chest Vibrations
• Chest Percussion/Clapping

30. Chest Clapping/Chest Percussion
• Percussion consists of rhythmic clapping on the chest with
loose wrist & cupped hand.
• Effect: Dislodges & loosens secretions from the lung
…cont.

32. Chest Vibration
• Vibrations consists of a fine oscillation of the hands directed
inwards against the chest, performed on exhalation after
deep inhalation.
• Effects: Helpful in moving loosened mucous plugs towards
larger airway
…cont.

34. Manual Hyperinflation

35. • Was originally defined as inflating the lungs with oxygen and
manual compression to a tidal volume of 1 liter requiring a
peak inspiratory pressure of between 20 and 40 cm H2O (Med
j Aust, 1972).
• More recent definitions include providing a larger tidal
volume than base line tidal volume to the patient (Aust j
physiotherapy, 1996) and using a tidal volume which is 50%
greater than that delivered via the ventilator (chest, 1994).
…cont.

36. Indications
• To aid removal of secretions
• To aid reinflation of atelectatic segments
• To assess lung compliance
• To improve lung compliance
…cont.

37. Technique
• Slow deep inspiration
• Inspiratory hold (at full inspiration)
• Fast expiratory release
• Hand-held Pressure Support
…cont.

39. Hazards of MHI
• Reduction in blood pressure
• Reduced saturation
• Raised intracranial pressure
• Reduced respiratory drive
…cont.

40. Contraindications
• Undrained Pnuemothorax
• Potential bronchospasm
• Severe bronchospasm
• Gross cardiovascular instability inducing arrhythmias and
hypovolaemia
• Unexplained Haemoptysis
• Patient on High PEEP
…cont.

41. Advantages of MH
• Reverses atelectasis (Lumb 2000)
• Improves oxygen saturation and lung compliance (Patman
et al.,1999)
• Improves sputum clearance (Hodgson et al., 2000)
…cont.

42. Disadvantages of MH
• Haemodynamic and metabolic upset (Stone, 1991 & Singer
et al.,1994)
• Risk of barotrauma
• Discomfort and anxiety
…cont.

44. Suctioning

45. • Suctioning is the mechanical aspiration of pulmonary
secretions from a patient with an artificial airway in place.
• Indications
– Inability to cough effectively
– Sputum plugging
– To assess tube patency
…cont.

47. Contraindication
• Frank haemoptysis
• Severe brochospasm
• Undrained pneumothorax
• Compromised cardiovascular system
…cont.

48. • The suction catheter used must be less than half the
diameter of endotracheal tube.
• The vacuum pressure should be as low as possible. (60-
150mmHg)
• Suction should never be routine, only when there is an
indication
…cont.

49. Hazards of Suctioning
• Mucosal trauma
• Cardiac arrhythmias
• Hypoxia
• Raised intracranial pressure
…cont.

50. Routes
• Nasal and oral suction
• Endotracheal suction
• Tracheostomy suction
…cont.

52. Mobilization

53. • Critically ill
(Frequent Position changes, Active and Passive Exercises)
• Stable
(Progressive tilting & Ambulation)
…cont.

54. • ICU rehabilitation has been shown to accelerate
recovery (o’leary & coackley, 1996)
• Early mobilization for unconscious patients starts right
from turning the patient every two hours. ( Brooks-
brunn, 1995).
• Graded exercises can be started as soon as the patient
regains consciousness.
…cont.

56. • Activity is required to maintain sensory input, comfort, joint
mobility and healing ability (Frank et al, 1994).
• Activity minimizes the weakness caused by loss of up to
half the patients muscle mass (Griffiths & Jones, 1999).
• Graded ambulation can be started depending on patients
condition
…cont.