Respiratory Physiotherapy for ICU Patients

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

The Respiratory System

The respiratory system consists of the airways, lungs as well as the 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 to 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) (Gosselink 2015, Connolly 2020). Critically ill patients in ICU are often confined to their beds, resulting in general deconditioning impacting 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-acquired pneumonia, decrease lung expansion, increased work of breathing, ventilation-perfusion mismatch, inspiratory muscle weakness and weaning failure.  

Aims of Physiotherapy

The aim of physiotherapy for respiratory dysfunction in the ICU is to maintain lung volume, improve oxygenation and ventilation, clear airway secretions, reduce the work of breathing, enhance inspiratory muscle function in order to prevent respiratory complications in both intubated and spontaneously breathing patients (Main 2016 chap 9, Gosselink 2011, 2015, Swaminathan 2019, Denehy 2018, Spapen 2017). Other aims include maximizing 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 (Main 2016, Cakmak 2019, Vincent 2017 chap 45). The goal of physiotherapy is targeted towards four key categories: (Main 2016 chap9, Denehy 2018, Troosten in Palanga 2019, Malone 2020, Gupta 2018)

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 clearance (Main 2016, Cakmak 2019, Gupta 2018, Connolly 2020, Malone 2020 chap 1, Swaminathan 2019, Troosters 2019in Palange)

Airway clearance techniques refer to the manual or mechanical processes utilised to facilitate the mobilisation and removal of secretions (mucociliary clearance) from the airway (Ahmad 2018, Main 2016). 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. (Main 2016) Airway clearance techniques include:(Main 2016, Cakmak 2019, Gupta 2018, Connolly 2020, Malone 2020 chap 1, Swaminathan 2019, Troosters 2019in Palange)

• 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 End Pressure (PEP) Devices such as flutter, acapella

Modalities for Enhancing Lung Volume/Improvement of Atelectasis (Main 2016, Swaminathan 2019, Malone 2020, Troosters 2019)

• 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)
• ACBT
• 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

Modalities for Improvement of Oxygenation (Gas exchange) (Main 2016, Swaminathan 2019, Malone 2020, Troosters 2019)

• 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
• TEE

Modalities to Maintain or Improve Inspiratory Muscle Strength (Main 2016, Malone 2020, Ahmad 2018)

• Breathing exercises
• 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 be flexible (Malone 2020). 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.

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