Physiotherapists Role in ICU

Introduction

Critical care is the specialised care of patients whose conditions are life-threatening and who require comprehensive care and constant monitoring, usually in intensive care units (ICUs).

Critically ill patients frequently suffer long-term physical and psychological complications. They are on long-term mechanical ventilation and as a result, 25% display significant muscle weakness, and approximately 90% of long-term ICU survivors will have ongoing muscle weakness. Prolonged stays in the intensive care unit are also associated with impaired quality of life, functional decline and increased morbidity, mortality, cost of care and length of hospital stay.[1]

Therefore, they require a multidisciplinary team in critical care who are uniquely qualified with skills and expertise to work with the assessment and management of respiratory complications, physical deconditioning, and neuromuscular and musculoskeletal conditions.

Physiotherapy treatment as part of a multi-disciplinary approach to care is integral in promoting lung function, reducing the incidence of ventilator-associated pneumonia, facilitating weaning and promoting safe and early discharge from the intensive care unit.

Physiotherapy Rehabilitation in ICU

Physiotherapy is an important intervention that prevents and mitigates the adverse effects of prolonged bed rest and mechanical ventilation during critical illness. Rehabilitation delivered by the physiotherapist is tailored to patient needs and depends on the conscious state, psychological status and physical strength of the patient. It incorporates any active and passive therapy that promotes movement and includes mobilisation. Early progressive physiotherapy, with a focus on mobility and walking whilst ventilated, is essential in minimising functional decline.  

Adverse effects of ICU stay:

  • Physical Inactivity leading to muscular atrophy and generalized weakness
  • Diaphragmatic weakness due to prolonged mechanical ventilation
  • Pressure Ulcers
  • compromised cardiac and respiratory function
  • deep vein thrombosis
  • infections

Physiotherapist works to maintain and improve respiration and cardiac functions and later on aid in rehabilitation.

Short-term Goals:

  • Early activity - Both passive and active to maintain integrity of musculoskeletal system
  • Positioning patients: To allow gravity to help sputum drain from the lungs.
  • Manual techniques such as shaking and vibrations: These are applied to the ribs to try to loosen and clear the sputum.
  • Suction: By placing a small tube into the lungs to suck out the excess sputum.
  • They play a vital role in weaning a patient off ventilation.

Long-term Goals:

  • They plan an extensive rehabilitation programme to integrate and re-initiate the patient into society.
  • They set goals in conjunction with the medical team to rehabilitate the patient.

Rehabilitation goals are set in communication with the patient, patient's family and the medical team and are divided into short, medium or long term and change throughout the patient's recovery from critical illness. They can be physical as well as psychological but are concerned with the functional needs of the patient. Goals will need to be achievable and based on a regular patient assessment of physical and non-physical consequences of the critical illness throughout their recovery and change according to the progress.[2]

Physiotherapy Techniques in ICU

Respiratory Physiotherapy

The role of the respiratory physiotherapist is to assist in clearing the airways of the patients, and maintaining and improving the integrity of the respiratory system. Treatment interventions include:

  • Positioning,
  • Education,
  • Manual and ventilator hyperinflation,
  • Weaning from mechanical ventilation,
  • Non-invasive ventilation,
  • Percussion, vibration, suctioning,
  • Respiratory muscle strengthening,
  • Breathing exercises and mobilisation[3]

Rehabilitation

Early Mobilisation with a focus on returning to functional activities helps in reducing hospital stay and minimize functional decline. A survey [4]suggests positive outcomes with physiotherapy implementation in ICU and also discusses the barriers by the physiotherapists in ICU.  A pilot RCT suggests early in-bed cycling with mechanically ventilated (MV) patients has positive outcomes.[5] A systematic review and meta-analysis suggest early rehabilitation in the ICU reduces the incidence of developing Intensive Care Unit Acquired weakness (ICUAW)[6].

The goals are mapped out based on patient's physical, psychological status. During his critical care unit stay, physiotherapists should perform a short clinical assessment

  • to determine the patient's risk of developing physical and non-physical morbidity.
  • to identify their current rehabilitation needs
  • For patients at risk, start rehabilitation as early as clinically possible which should include:
  1. Measures to prevent avoidable physical and non-physical morbidity,
  2. Nutrition support
  3. An individualised, structured rehabilitation programme with frequent follow-up reviews. The details of the structured rehabilitation programme and the reviews should be collated and documented in the patient's clinical records.[7]

Impact of Physiotherapy

Early intervention by physiotherapists in the ICU helps

  • Reduce the patient's stay in the ICU and overall hospital stay.
  • Prevent ICU related complications
  • To improve function and quality of life in the long term[8]

Studies have shown that physiotherapy intervention in critical care has helped reduce the mortality rate by 25%.[9] Randomised clinical trial suggested no effect of visits to ICU before admission on anxiety or depression. It also had a negative effect on the patient's satisfaction level[10]. A retrospective cohort study on 285 survivors of prolonged ICU-stay suggested that the ability to ambulate was associated with a higher possibility of being discharged, emphasizing the importance of mobility training in long-term acute care hospitals[11].

Resources

Physical Therapy Intervention in ICU

Physiotherapy in Intensive Care Unit

Exercise in Critical care

References

  1. Chartered Society of Physiotherapy, Physiotherapy works: critical care. Accessed on 2/6/19 http://www.csp.org.uk/publications/physiotherapy-works-critical-care
  2. Rahimi RA, Skrzat J, Reddy DR, Zanni JM, Fan E, Stephens RS, Needham DM. Physical rehabilitation of patients in the intensive care unit requiring extracorporeal membrane oxygenation: a small case series. Physical therapy. 2013 Feb 1;93(2):248-55.
  3. Denehy L, Berney S. Physiotherapy in the intensive care unit. Physical Therapy Reviews. 2006;11(1):49.
  4. Çakmak A, İnce Dİ, Sağlam M, Savcı S, Yağlı NV, Kütükcü EÇ, Özel CB, Ulu HS, Arıkan H. Physiotherapy and Rehabilitation Implementation in Intensive Care Units: A Survey Study. Turkish thoracic journal. 2019 Apr;20(2):114.
  5. Kho ME, Molloy AJ, Clarke FJ, Ajami D, McCaughan M, Obrovac K, Murphy C, Camposilvan L, Herridge MS, Koo KK, Rudkowski J. TryCYCLE: a prospective study of the safety and feasibility of early in-bed cycling in mechanically ventilated patients. PloS one. 2016 Dec 28;11(12):e0167561.
  6. Anekwe DE, Biswas S, Bussières A, Spahija J. Early Rehabilitation Reduces the Likelihood of Developing Intensive Care Unit-Acquired Weakness: A Systematic Review and Meta-Analysis. Physiotherapy. 2019 Dec 19.
  7. NICE clinical guideline 83 Developed by the Centre for Clinical Practice at NICE Rehabilitation after critical illness in adults Published date:  
  8. https://physiotherapy.ca/sites/default/files/valuePT/cpa_valuept_icu-en.pdf
  9. Tomasi CD, Figueiredo F, Constantino L, Grandi R, Topanotti MFL, Giombelli V, Dal-Pizzol F, Ritter C. Beneficial effect of respiratory physiotherapy in critically ill patients ventilated for more than 48 hours: A randomized controlled trial. Intensive Care Medicine. Conference 23rd Annual Congress of the European Society of Intensive Care Medicine, ESICM Barcelona Spain. Date of publication: September 2010.
  10. González-Martín S, Becerro-de-Bengoa-Vallejo R, Angulo-Carrere MT, Iglesias ME, Martínez-Jiménez EM, Casado-Hernández I, López-López D, Calvo-Lobo C, Rodríguez-Sanz D. Effects of a visit prior to hospital admission on anxiety, depression and satisfaction of patients in an intensive care unit. Intensive and Critical Care Nursing. 2019 Oct 1;54:46-53.
  11. Tran DH, Maheshwari P, Nagaria Z, Patel HY, Verceles AC. Ambulatory Status Is Associated With Successful Discharge Home in Survivors of Critical Illness. Respiratory Care. 2020 Mar 31.