Respiratory Physiotherapy for ICU Patients

Original Editor - Merinda Rodseth

Top Contributors - Merinda Rodseth, Kim Jackson, Jess Bell, Stacy Schiurring, Tarina van der Stockt, Uchechukwu Chukwuemeka, Ewa Jaraczewska and Lucinda hampton  

The Respiratory System

Figure 1. Respiratory System

The respiratory system consists of the airways, lungs as well as musculoskeletal structures of the thoracic cage. A simple way of understanding the respiratory system is to split it into the musculoskeletal pump and the gas-exchanging organ. The musculoskeletal pump consists of the surrounding bony structures (rib cage, cervical and thoracic spine, upper pelvic area) as well as the muscles of respiration. The gas-exchanging organ refers to the airways which allow the movement of air from outside the body to the alveoli, and the alveolar-capillary membrane, which is the specialised interface between the inspired air and the circulation. Respiration involves the exchange of gas between the atmosphere and the lungs, lungs and the blood and the blood and body tissues. The function of this system is to maintain the supply of oxygen and the removal of carbon dioxide from the body. Failure in any of the components of the respiratory system can result in the need for mechanical ventilation.

Respiratory dysfunction is a common problem associated with the critically ill in the Intensive Care Unit (ICU). Critically ill patients in ICU are often confined to their beds. This results in general deconditioning, which impacts many systems of the body, including the respiratory system. Pulmonary complications, as the leading cause of hospital morbidity, is therefore of great concern in ICU patients. Common complications following bed rest include reduced lung volumes and expiratory airflow rate, decreased respiratory muscle strength, reduced compliance of the lungs and chest wall as well as impaired gas exchange. These factors all lead to an increase in the patient’s work of breathing and increases the risk for developing pneumonia and atelectasis. Weakness of the respiratory muscles together with the reduction in tidal volume can impair the cough mechanism which further increases the risk for pulmonary infections. ICU patients are always at risk of developing complications such as secretion retention, atelectasis, ventilator-associated pneumonia, decrease lung expansion, increased work of breathing, ventilation-perfusion mismatch, inspiratory muscle weakness and weaning failure.  

Aims of Physiotherapy

Respiratory physiotherapy is essential for patients in the Intensive Care Unit, playing a key role in preventing and mitigating functional complications. Timely respiratory physiotherapy aids in mucociliary clearance, maintains lung volume, improves oxygenation and ventilation, clears airway secretions, reduces the work of breathing, enhances inspiratory muscle and lung recruitment, while also preventing ventilator-induced lung injury (VILI), ICU-acquired weakness, and post-intensive care syndrome resulting from prolonged immobility. Using techniques like postural positioning and respiratory physiotherapy ensures safe care that actively prevents potential patient harm. Other aims include maximising musculoskeletal function, reducing the duration of mechanical ventilation, facilitating the return of independent function upon ICU discharge, improving long-term quality of life and reducing the length of stay in the ICU as well as the hospital in order to reduce the cost of care. The goals of respiratory physiotherapy are targeted towards four key categories:

1. Airway secretion clearance
2. Recruitment of lung volume or improvement of atelectasis
3. Maintenance/improvement of oxygenation
4. Maintenance/improvement inspiratory muscle strength

Physiotherapy Modalities for Respiratory Care

Physiotherapists, in an attempt to solve the respiratory challenges of ICU patients, utilise various modalities which will be discussed in brief. These modalities will be classified with respect to their uses.

Modalities for Airway Secretion Clearance

Airway clearance techniques refer to the manual or mechanical processes utilised to facilitate the mobilisation and removal of secretions (mucociliary clearance) from the airway. The mucociliary clearance system is normally very efficient and effective, but following many respiratory diseases, pulmonary complications, anaesthesia and surgical procedures, excess sputum is often produced and the inherent mechanisms for secretion removal may become impaired. Airway clearance techniques include:

• Manual and Ventilator Hyperinflation (VHI)
• Positioning (Postural Drainage)
• Manual chest techniques (Percussion, Vibration, and Shaking)
• Airway Suctioning (open/closed)
• Insufflation and Exsufflation (positive pressure to negative pressure; device)
• Nebulisation
• Active Cycle of Breathing Technique (ACBT)
• Assisted Cough Techniques
• Forced expiratory maneuver (Coughing/Huffing)
• Positive Expiratory Pressure (PEP) Devices such as flutter, acapella

Please view the following optional 4:25 long video for an overview of various airway clearance techniques to include: huffing, active cycle of breathing, autogenic drainage, chest physical therapy, high-frequency chest wall oscillating vest, positive expiratory pressure (PEP) devices, airway oscillating device (AOD).

Modalities for Enhancing Lung Volume/Improvement of Atelectasis

Figure 2. Atelectasis

The following modalities can be used for enhancing lung volume or improve atelectasis (see figure 2):

• Positioning (side-lying with affected side uppermost)
• Manual and Ventilator Hyperinflation
• Deep Breathing Exercises (Segmental and resisted breathing)
• Incentive Spirometry (IS)
• Positive End-Expiratory Pressure (PEEP)
• Active Cycle of Breathing Technique
• Breath Stacking
• Thoracic Expansion Exercises (TEE)
• Rib springing
• Manual Chest Wall Shaking and Vibrations
• Intermittent Positive Pressure Breathing (IPPB)
• Non-Invasive Ventilation (NIV) and CPAP

Please view the following optional 4:34 long video for an overview of non-invasive ventilation and CPAP devices.

Modalities for Improvement of Oxygenation (Gas exchange)

• Positioning
• Non-Invasive Ventilation (Continuous Positive Airway Pressure (CPAP), Intermittent Positive Pressure Breathing (IPPB) devices, BiPAP, VPAP)
• Manual or ventilator hyperinflation
• Breath Stacking
• Deep Breathing Exercises
• Thoracic Expansion Exercises (TEE)

Modalities to Maintain or Improve Inspiratory Muscle Strength

• Inspiratory and expiratory muscle training
• Inspiratory Muscle Training Devices (spring-loaded Threshold® IMT or POWERbreathe® device)
• Incentive Spirometry
• Manual chest wall resistance

Conclusion

Continuous evaluation is essential during the treatment of critically ill patients in the ICU. The findings of the evaluation are also what will guide the physiotherapist as to the most appropriate treatment. Constant changes in the physiological, motivational and emotional condition of the patient in ICU also necessitates that the plan of care is flexible. Respiratory physiotherapy plays a big role in the ICU but it is important to remember that the role of the physiotherapist in the ICU is not limited only to respiratory management but also extends to mobilisation and rehabilitation which itself will have a direct impact on the respiratory system.

Resources

Optional Additional Reading:

• Olsén MF, Lannefors L, Westerdahl E. Positive expiratory pressure–common clinical applications and physiological effects. Respiratory medicine. 2015 Mar 1;109(3):297-307.

Clinical Resources:

• Contraindications to respiratory (chest) physiotherapy
• Example of a patient education sheet
• Here is a collection of various respiratory therapy treatment guidelines (by the American Association of Respiratory Care)

Optional Additional Videos:

Below is a collection of short respiratory physiotherapy technique videos to deepen your understanding of pontential treatment modalities and interventions useful for patient in the ICU. As with any advanced treatment technique, additional hands-on training and demonstration of competency is recommended before attempting these interventions on patients.

• This video demonstrates positioning options for drainage of the different lobes of the lungs.

• This video demonstrates cupping and percussive manual therapy techniques.

• This video demonstrates assisted cough techniques.

• This video demonstrates pursed-lip breathing techniques.

• This video demonstrates huffing and PEP use.

• The following two videos demonstrate active cycle of breathing techniques.

• The following 13:33 long video provides a more extensive explanation of lung volumes and capacities.