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MANAGING CRITICALLY ILL PATIENTS – A Physiotherapist’s perspective

MANAGING CRITICALLY ILL PATIENTS – A Physiotherapist’s perspective. Leema, Jebaraj, David PMR dept . Chest Physiotherapy is….

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MANAGING CRITICALLY ILL PATIENTS – A Physiotherapist’s perspective

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  1. MANAGING CRITICALLY ILL PATIENTS– A Physiotherapist’s perspective Leema, Jebaraj, David PMR dept

  2. Chest Physiotherapy is… 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.

  3. Aims of this presentation… • To describe the individual physiotherapeutic techniques. • To provide a frame work for evidence based practice.

  4. Indications • 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. …contd • 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. Assessment General Observation • Patient Position • Respiration - AirwayET/Tracheostomy VentillatorMode FiO2 • VitalSigns – Temperature, BP, RR, HR SpO2,GCS, ICP • Tubes - NG Tube, CV line, Peripheral line, Chest tubes, Catheters • Drugs

  7. … contd Examination • Auscultations • Respiratory pattern • Cyanosis • Clubbing • Radiograph

  8. Goals • Prevent accumulation of secretions • Improve mobilization and drainage of secretions • Promote relaxation to improve breathing patterns • Promote improved respiratory function • Improve cardio-pulmonary exercise tolerance • Teach bronchial hygiene programs to patients with chronic respiratory dysfunction

  9. Precautions • Untreatedtension pneumothorax • Abnormal coagulation profile • Status epilepticus or status asthamaticus • Immediately following intra cranial surgery • Head injury with raised ICP • Osteoporotic bones • Recent acute myocardial infarction, unstable vitals • Immediately after tube feedings • Sutures and ICD’s

  10. Techniques • Positioning • Chest tapotement techniques • Manual hyperinflation • Airway suctioning • Coughing techniques • Breathing exercises • Neuro physiological facilitation • Controlled mobilization • Patient education

  11. Positioning • POSITIONING is the use of body position as a specific treatment technique • (it has a marked influence on gas exchange because of the unevenly damaged lungs- Tobin et al, 1994)

  12. Positioning… 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)

  13. Postural Drainage isn’t… • a separate technique. Its just an example of positioning which has the particular aim of clearing airway secretions with the assistance of gravity.

  14. 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).

  15. Positioning • 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). • 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).

  16. …contd • 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)

  17. …contd • 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

  18. Which position to choose… ? Positioning…

  19. What does evidence say… 1. lung volume by 57% (Rialp et al., 1997). 2. need for PEEP (Lim et al., 1999). 3. normal V/Q units by 12% 4. shunt by 11% (Wong 1999) 5. barotrauma (Du et al., 1997) 6. drainage of secretions (Kesecioglu, 1997) 7. length of ICU stay. (Gosheron, 1998)

  20. Chest Tapotement • Chest Vibrations • Rib Springing/Shaking • Chest Percussion/Clapping

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

  22. 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

  23. Rib Springing/Shaking • Shaking is a coarser movement in which the chest wall is rhythmically compressed. • Effects : Direct secretions towards larger airways & Stimulates cough.

  24. Manual Hyperinflation • 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 the ventilator (chest, 1994).

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

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

  27. Coughing Techniques • Coughing: It is a forced expiratory technique performed with a closed glottis. • Huffing: It is a forced expiratory technique performed with a open glottis. • Sniffing: Its an respiratory maneuver performed after a full inspiration or expiration.

  28. Effects of Coughing • Cough removes secretions from the larger airways • Huff mobilizes the secretions from the distal airways. • During a huff the pleural pressure becomes positive and equals the alveolar pressure and so it opens up the distal collapsed airway. • Sniff augments collateral ventilation thereby preventing distal airway collapse.

  29. Breathing Exercises • Diaphragmatic breathing - concentrates on epigastric and lower rib movements( gaskell & webber, 1980). - concentrates on allowing the whole abdomen to swell as diaphragm descends (innocenti, 1966).

  30. Breathing Techniques • Costal breathing - Is a technique which concentrates on ventilation to specific areas of lungs. - In this technique during inspiration the chest wall moves up and out. - This technique can be localized to any involved segments of the lung. • Glossopharyngeal • Pursed Lip

  31. Suctioning • Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place. • cirteria for suctioning: 1) secretions are accessible to the catheter. 2) secretions are detrimental to the patient. 3) patient is unable to clear secretions by other means.

  32. Neuro Physiological Facilitation(NPF) • promoting or hastening the response of neuro muscular mechanism through proprioceptors (dorothy voss et al, 1985). • Cutaneous and proprioceptive stimulation reflexly increases the depth of breathing (Jones, 1998). INDICATIONS: • Non alert patients such as those who are drowsy postoperatively. • Those with neurological conditions. • Partially breathing patient on ventilator, especially if they are unable to turn.

  33. Techniques of NPF • Stimulation of diaphragm (Dorothy voss et al, 1985). • Perioral technique • Intercostal stretch • Co- contraction of abdominal muscles • Vertebral pressure (D.D .Bethune, 1975)

  34. Mobilisation • 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. • 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 upto half the patients muscle mass (Griffiths & Jones, 1999). • Graded ambulation can be started depending on patients condition

  35. Mobilisation • Critically Ill (Frequent Position changes, Kinetic & Kinematic Therapy) • Stable (Progressive tilting&Ambulation)

  36. Conclusion A hammer in a carpenter’s hand is not used to pull out a nail…

  37. Thankyou

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