Respiratory Physiotherapy for ICU Patients: Difference between revisions

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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.<ref name=":0">Malone DJ, Bishop KL. [https://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=2513712&site=ehost-live Acute Care Physical Therapy : A Clinician’s Guide], Second Edition [Internet]. Vol. Second edition. Thorofare, NJ: SLACK Incorporated; 2020 [cited 2021 Mar 5].  </ref> 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.<ref name=":0" /> 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.<ref name=":0" />  Failure in any of the components of the respiratory system can result in the need for mechanical ventilation.<ref name=":1">Gosselink R, Roeseler J. [https://www.researchgate.net/profile/Rik-Gosselink/publication/300609219_Chapter_32_Physiotherapy_in_critically_ill_patients/links/5b2aa631aca27209f379600f/Chapter-32-Physiotherapy-in-critically-ill-patients.pdf Physiotherapy in critically ill patients]. The ESC Textbook of Intensive and Acute Cardiovascular Care. 2015 Feb 26:284. </ref>
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.<ref name=":0">Malone DJ, Bishop KL. [https://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=2513712&site=ehost-live Acute Care Physical Therapy : A Clinician’s Guide], Second Edition [Internet]. Vol. Second edition. Thorofare, NJ: SLACK Incorporated; 2020 [cited 2021 Mar 5].  </ref> 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.<ref name=":0" /> 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.<ref name=":0" />  Failure in any of the components of the respiratory system can result in the need for mechanical ventilation.<ref name=":1">Gosselink R, Roeseler J. [https://www.researchgate.net/profile/Rik-Gosselink/publication/300609219_Chapter_32_Physiotherapy_in_critically_ill_patients/links/5b2aa631aca27209f379600f/Chapter-32-Physiotherapy-in-critically-ill-patients.pdf Physiotherapy in critically ill patients]. The ESC Textbook of Intensive and Acute Cardiovascular Care. 2015 Feb 26:284. </ref>


Respiratory dysfunction is a common problem associated with the critically ill in the Intensive Care Unit (ICU) (Gosselink 2015, Connolly 2020).<ref name=":1" /><ref name=":2">Connolly B, Barclay M, Blackwood B, Bradley J, Anand R, Borthwick M, Chikhani M, Dark P, Shyamsundar M, Warburton J, McAuley DF. [https://sci-hub.se/https://www.sciencedirect.com/science/article/abs/pii/S0031940620303862 Airway clearance techniques and use of mucoactive agents for adult critically ill patients with acute respiratory failure: a qualitative study exploring UK physiotherapy practice]. Physiotherapy. 2020 Sep 1;108:78-87. DOI:10.1016/j.physio.2020.06.003.</ref> 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.<ref name=":0" /> Pulmonary complications, as the leading cause of hospital morbidity, is therefore of great concern in ICU patients.<ref name=":0" /> 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.<ref name=":0" /> 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.<ref name=":0" /> 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.<ref name=":0" /><ref name=":2" /><ref>Main E, Denehy L, editors. Cardiorespiratory Physiotherapy: Adults and Paediatrics E-Book: formerly Physiotherapy for Respiratory and Cardiac Problems. 5th ed. Elsevier Health Sciences; 2016 Jun 7.</ref><ref>Çakmak A, İnce Dİ, Sağlam M, Savcı S, Yağlı NV, Kütükcü EÇ, Özel CB, Ulu HS, Arıkan H. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453635/pdf/ttj-20-2-114.pdf Physiotherapy and Rehabilitation Implementation in Intensive Care Units: A Survey Study]. Turkish thoracic journal. 2019 Apr;20(2):114. DOI:10.5152/TurkThoracJ.2018.18107   </ref><ref>Spapen HD, De Regt J, Honoré PM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5303101/pdf/jtd-09-01-E44.pdf Chest physiotherapy in mechanically ventilated patients without pneumonia—a narrative review.] Journal of thoracic disease. 2017 Jan;9(1): E44. DOI: 10.21037/jtd.2017.01.32  </ref>  
Respiratory dysfunction is a common problem associated with the critically ill in the Intensive Care Unit (ICU) (Gosselink 2015, Connolly 2020).<ref name=":1" /><ref name=":2">Connolly B, Barclay M, Blackwood B, Bradley J, Anand R, Borthwick M, Chikhani M, Dark P, Shyamsundar M, Warburton J, McAuley DF. [https://sci-hub.se/https://www.sciencedirect.com/science/article/abs/pii/S0031940620303862 Airway clearance techniques and use of mucoactive agents for adult critically ill patients with acute respiratory failure: a qualitative study exploring UK physiotherapy practice]. Physiotherapy. 2020 Sep 1;108:78-87. DOI:10.1016/j.physio.2020.06.003.</ref> 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.<ref name=":0" /> Pulmonary complications, as the leading cause of hospital morbidity, is therefore of great concern in ICU patients.<ref name=":0" /> 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.<ref name=":0" /> 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.<ref name=":0" /> 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.<ref name=":0" /><ref name=":2" /><ref name=":3">Main E, Denehy L, editors. Cardiorespiratory Physiotherapy: Adults and Paediatrics E-Book: formerly Physiotherapy for Respiratory and Cardiac Problems. 5th ed. Elsevier Health Sciences; 2016 Jun 7.</ref><ref name=":4">Çakmak A, İnce Dİ, Sağlam M, Savcı S, Yağlı NV, Kütükcü EÇ, Özel CB, Ulu HS, Arıkan H. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453635/pdf/ttj-20-2-114.pdf Physiotherapy and Rehabilitation Implementation in Intensive Care Units: A Survey Study]. Turkish thoracic journal. 2019 Apr;20(2):114. DOI:10.5152/TurkThoracJ.2018.18107   </ref><ref name=":5">Spapen HD, De Regt J, Honoré PM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5303101/pdf/jtd-09-01-E44.pdf Chest physiotherapy in mechanically ventilated patients without pneumonia—a narrative review.] Journal of thoracic disease. 2017 Jan;9(1): E44. DOI: 10.21037/jtd.2017.01.32  </ref>  


== Aims of Physiotherapy ==
== 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)
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.<ref name=":1" /><ref name=":3" /><ref name=":5" /><ref>Gosselink R, Clerckx B, Robbeets C, Vanhullebusch T, Vanpee G, Segers J. [https://www.njcc.nl/sites/nvic.nl/files/NJCC%2002%20review-Gosselink.pdf Physiotherapy in the intensive care unit]. Neth J Crit Care. 2011 Apr 1;15(2):66-75. </ref><ref name=":6">Swaminathan N, Praveen R, Surendran P. [https://pdfs.semanticscholar.org/f87d/85ed9f7b860bd47e2666c118c223ce873480.pdf The role of physiotherapy in intensive care units: a critical review]. Physiotherapy Quarterly. 2019;27(4):1-5. DOI:10.5114/pq.2019.87739 </ref><ref name=":7">Denehy L, Granger CL, El-Ansary D, Parry SM. [https://www.tandfonline.com/doi/full/10.1080/17476348.2018.1433034 Advances in cardiorespiratory physiotherapy and their clinical impact]. Expert review of respiratory medicine. 2018 Mar 4;12(3):203-15. DOI:10.1080/17476348.2018.1433034 </ref> 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.<ref name=":3" /><ref name=":4" /><ref>Lipshutz AKM, Gropper MA. [https://1lib.us/book/2858938/c10165 Early Ambulation in the ICU]. In: Vincent JL, Abraham E, Kochanek P, Moore FA, Fink MP. Textbook of Critical Care. 7th ed. Philadelphia: Elsevier; 2017. </ref> The goal of physiotherapy is targeted towards four key categories:<ref name=":0" /><ref name=":3" /><ref name=":7" /><ref name=":8">Troosters T, Bott J. [https://1lib.us/book/5279599/b02250 Respiratory physiotherapy]. IN: Palange P, Rohde G. (eds.) ERS Handbook of Respiratory Medicine. 3rd ed. European Respiratory Society; 2019. p.232-238. </ref><ref name=":9">Gupta L, Gupta H. [https://www.researchgate.net/profile/Lalit-Gupta-6/publication/327919926_Physiotherapy_for_Respiratory_conditions/links/5bad25f245851574f7ea95e7/Physiotherapy-for-Respiratory-conditions.pdf Physiotherapy for Respiratory Conditions]. Advanced nursing & patient care international journal. 2018;1(1):180003. </ref>


# Airway secretion clearance  
# Airway secretion clearance  
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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.
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) ===
=== Modalities for Airway clearance<ref name=":0" /><ref name=":2" /><ref name=":3" /><ref name=":4" /><ref name=":6" /><ref name=":8" /><ref name=":9" /> ===
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)
Airway clearance techniques refer to the manual or mechanical processes utilised to facilitate the mobilisation and removal of secretions (mucociliary clearance) from the airway.<ref name=":3" /><ref name=":10">Ahmad AM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200172/pdf/kjtcv-51-293.pdf Essentials of physiotherapy after thoracic surgery: What physiotherapists need to know. A narrative review.] The Korean Journal of thoracic and cardiovascular surgery. 2018 Oct;51(5):293. DOI:10.5090/kjtcs.2018.51.5.293 </ref> 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.<ref name=":3" /> Airway clearance techniques include:<ref name=":0" /><ref name=":2" /><ref name=":3" /><ref name=":4" /><ref name=":6" /><ref name=":8" /><ref name=":9" />


* Manual and Ventilator Hyperinflation (VHI)  
* Manual and Ventilator Hyperinflation (VHI)  
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* Positive End Pressure (PEP) Devices such as flutter, acapella  
* 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) ===
=== Modalities for Enhancing Lung Volume/Improvement of Atelectasis<ref name=":0" /><ref name=":3" /><ref name=":6" /><ref name=":8" />  ===


* Positioning (side-lying with affected side uppermost)
* Positioning (side-lying with affected side uppermost)
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* Non-Invasive Ventilation (NIV) and CPAP  
* Non-Invasive Ventilation (NIV) and CPAP  


=== Modalities for Improvement of Oxygenation (Gas exchange) (Main 2016, Swaminathan 2019, Malone 2020, Troosters 2019) ===
=== Modalities for Improvement of Oxygenation (Gas exchange)<ref name=":0" /><ref name=":3" /><ref name=":6" /><ref name=":8" /> ===


* Positioning  
* Positioning  
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* TEE
* TEE


=== Modalities to Maintain or Improve Inspiratory Muscle Strength (Main 2016, Malone 2020, Ahmad 2018) ===
=== Modalities to Maintain or Improve Inspiratory Muscle Strength <ref name=":0" /><ref name=":3" /><ref name=":10" /> ===


* Breathing exercises
* Breathing exercises
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== Conclusion ==
== 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.
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.<ref name=":0" /> 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  ==
== Resources  ==

Revision as of 22:40, 23 April 2021

Original Editor - User Name

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

The Respiratory System[edit | edit source]

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.[1] 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.[1] 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.[1]  Failure in any of the components of the respiratory system can result in the need for mechanical ventilation.[2]

Respiratory dysfunction is a common problem associated with the critically ill in the Intensive Care Unit (ICU) (Gosselink 2015, Connolly 2020).[2][3] 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.[1] Pulmonary complications, as the leading cause of hospital morbidity, is therefore of great concern in ICU patients.[1] 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.[1] 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.[1] 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.[1][3][4][5][6]  

Aims of Physiotherapy[edit | edit source]

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.[2][4][6][7][8][9] 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.[4][5][10] The goal of physiotherapy is targeted towards four key categories:[1][4][9][11][12]

  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[edit | edit source]

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[1][3][4][5][8][11][12][edit | edit source]

Airway clearance techniques refer to the manual or mechanical processes utilised to facilitate the mobilisation and removal of secretions (mucociliary clearance) from the airway.[4][13] 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.[4] Airway clearance techniques include:[1][3][4][5][8][11][12]

  • 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[1][4][8][11][edit | edit source]

  • 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)[1][4][8][11][edit | edit source]

  • 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 [1][4][13][edit | edit source]

  • Breathing exercises
  • Inspiratory Muscle Training Devices (spring-loaded Threshold® IMT or POWERbreathe® device)
  • Incentive Spirometry
  • Manual chest wall resistance

Conclusion[edit | edit source]

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.[1] 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[edit | edit source]

  • bulleted list
  • x

or

  1. numbered list
  2. x

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 Malone DJ, Bishop KL. Acute Care Physical Therapy : A Clinician’s Guide, Second Edition [Internet]. Vol. Second edition. Thorofare, NJ: SLACK Incorporated; 2020 [cited 2021 Mar 5].
  2. ↑ 2.0 2.1 2.2 Gosselink R, Roeseler J. Physiotherapy in critically ill patients. The ESC Textbook of Intensive and Acute Cardiovascular Care. 2015 Feb 26:284.
  3. ↑ 3.0 3.1 3.2 3.3 Connolly B, Barclay M, Blackwood B, Bradley J, Anand R, Borthwick M, Chikhani M, Dark P, Shyamsundar M, Warburton J, McAuley DF. Airway clearance techniques and use of mucoactive agents for adult critically ill patients with acute respiratory failure: a qualitative study exploring UK physiotherapy practice. Physiotherapy. 2020 Sep 1;108:78-87. DOI:10.1016/j.physio.2020.06.003.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Main E, Denehy L, editors. Cardiorespiratory Physiotherapy: Adults and Paediatrics E-Book: formerly Physiotherapy for Respiratory and Cardiac Problems. 5th ed. Elsevier Health Sciences; 2016 Jun 7.
  5. ↑ 5.0 5.1 5.2 5.3 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. DOI:10.5152/TurkThoracJ.2018.18107  
  6. ↑ 6.0 6.1 Spapen HD, De Regt J, Honoré PM. Chest physiotherapy in mechanically ventilated patients without pneumonia—a narrative review. Journal of thoracic disease. 2017 Jan;9(1): E44. DOI: 10.21037/jtd.2017.01.32  
  7. ↑ Gosselink R, Clerckx B, Robbeets C, Vanhullebusch T, Vanpee G, Segers J. Physiotherapy in the intensive care unit. Neth J Crit Care. 2011 Apr 1;15(2):66-75.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Swaminathan N, Praveen R, Surendran P. The role of physiotherapy in intensive care units: a critical review. Physiotherapy Quarterly. 2019;27(4):1-5. DOI:10.5114/pq.2019.87739
  9. ↑ 9.0 9.1 Denehy L, Granger CL, El-Ansary D, Parry SM. Advances in cardiorespiratory physiotherapy and their clinical impact. Expert review of respiratory medicine. 2018 Mar 4;12(3):203-15. DOI:10.1080/17476348.2018.1433034
  10. ↑ Lipshutz AKM, Gropper MA. Early Ambulation in the ICU. In: Vincent JL, Abraham E, Kochanek P, Moore FA, Fink MP. Textbook of Critical Care. 7th ed. Philadelphia: Elsevier; 2017.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Troosters T, Bott J. Respiratory physiotherapy. IN: Palange P, Rohde G. (eds.) ERS Handbook of Respiratory Medicine. 3rd ed. European Respiratory Society; 2019. p.232-238.
  12. ↑ 12.0 12.1 12.2 Gupta L, Gupta H. Physiotherapy for Respiratory Conditions. Advanced nursing & patient care international journal. 2018;1(1):180003.
  13. ↑ 13.0 13.1 Ahmad AM. Essentials of physiotherapy after thoracic surgery: What physiotherapists need to know. A narrative review. The Korean Journal of thoracic and cardiovascular surgery. 2018 Oct;51(5):293. DOI:10.5090/kjtcs.2018.51.5.293
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