PULMONARY REHABILITATION IN INTENSIVE CARE UNIT

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PULMONARY REHABILITATION IN INTENSIVE CARE UNIT

• Prof. Dr. Sema Savci
• Hacettepe University Faculty of Health
  Sciences, Department of Physical Therapy and
  Rehabilitation

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Who admitted intensive care unit?

• Major surgery
• Severe head trauma
• Respiratory failure
• Coma

• Hemodynamic failure,
• Severe dehidratation,
• Multiple organ failure.

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Pulmonary Rehabilitation in ICUthe Team

• Co-ordinator
• RT
• Physical therapist
• Nurse
• Speech therapist
• Psycologist
• Dietician
• Family

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Team members in respiratory rehabilitation
TEAM MEMBERS in Respiratory Rehabilitation
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Physiotherapists in Turkey
Reason of physiotherapy ()

• 56 (n31)physiotherapy,
• 44 master of science (n24),
• 70.9 (n39) uni hospt,
• 92.7(n51) surgery,
• 74.5 (n41) internal medicine,
• 38.3 pediatric ICU
• Savci, Yogun Bakim Dergisi 2005

Interventions ()
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What is role of physiotherapy in ICU ?

• Optimize cardiopulmonary and neuromuscular
  function
• PHYSIOTHERAPYFUNCTION

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Evaluation in Intensive Care Unit

• It is not include SOAP parameters.
• BUT
• Physiologicol disorders
• Loss of functional level.

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Clinical decision making I

• Previous level of function,
• Mental status(unconscineuous /Sedation),
• Cardiac status (HR, BP, rhytm, EF, by-pass,
  stent, drugs),

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Clinical decision making II

• Pulmonary status (Ventilatory settings, FiO2,
  ABG, X-Ray, weaning process),
• Neurological status (CVA, head trauma, SCI),
• Musculo-skeletal status (Limitation in ROM, trunk
  and leg control, muscle strenght and endurance),

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Clinical decision making III

• Renal status(acute renal failure, dialysis),
• Multiorgan failure (prognosis, hemodynamic
  stability, sepsis, encepholopaty, neuropaty,
  gangrene, contractures).

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Clinical decision making IV

• Safety measures
• ET tube/tracheostomy,
• IV lines, nutrition tubes,
• Telemetry, BP,
• Pulse oxyimetre,
• Walking ability,
• Portabl O2 support.

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Clinical decision making V

• MV settings
• Mode of ventilation
• Oxygen (FiO2)
• PEEP
• Breathing frequency, Tidal Volüme
• Ventilatory alarms

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Remember

• It is always important to know few things before
  during and after the PT sessions
• Hemodynamic responses (HR,BF,SaO2,BP)
• ICP- CPP ??
• Hyperoxygenation
• Sedation status

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Remember

• Physical therapy programmes should be based on
  patients condition and goals, not on the ICU
  equipment

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Knowledge of underlying pathophysiology
Physiologic and scientific evidence for treatment
interventions
Clinical experience
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DECONDITIONING REDUCED MOBILITY and SELF CARE WEAKNESS MYOPATHIES AND NEUROPATHIES WEANING FAILURE QUALITY OF LIFE PROLONGED ICU AND HOSPITAL STAY
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The goal of physical therapy interventions

• Prevention and treatment of
• Cardiorespiratory deconditioning
• Muscle atrophy
• Joint contractures
• Activities of daily living
• Quality of life

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Physical therapy interventions

• Positioning, mobilisation
• Kinetic therapy
• Chest physiotherapy methods
• Manual hyperinflation
• Ventilatory hyperinflation

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Physical therapy interventions

• Exercise training
• Electrical stimulation
• Noninvasive MV
• Weaning process

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Positioning

• Acute respiratory failure
• ? PaO2 - prone position
  Jolliet, Crit care med 261998. Gattinoni
  , N Engl J Med 3452001.
• Unilateral lung disesases
• ?PaO2 good lung down Gillepsie, Chest 91
  1987.
• Gastroesophageal reflue !
• Brain surgery !

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25
1000
900
20
800
15
700
10
600
Supine
Standing
500
5
400
Tidal Volüme
0
Ventilation

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25
24
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20
breathing frequencyi
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Physical therapy interventions

• Postural Drainage,
• ? peripheral and central lung clearance, ? FRC
  Sutton, Resp Med 5 1985.
• Chest wall percussion Vibration, shaking,
  Wanner, ARRD 130 1984.

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Assistive devices
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Mechanical In-Exsufflator

• Applies positive pressure to the airways- rapidly
  shifts to the negative pressure
• Rapid shifts produces cough and high expiratory
  flow rates shearing secretions from bronchial
  walls
• Often called cough machine

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Physical therapy interventions

• Aspirations,
• removes secretions from central airways
• stimulates cough
• Cough, Ciesla, Phys Ther 1996.

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Physical therapy interventions

• Manual hyperinflation (MHI)
• To prevent pulmonary atelectasis
• To re-expand collapsed alveoli
• To improve oxygenation, lung compliance
• To increase mucociliary clearance towards the
  central airway
• Indicated for mechanically ventilated patients
  with significant atelectasis and impaired
  mucociliary clearance

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Physical therapy interventions

• Breathing exercices
• Not indicated during assist controlled mechanical
  ventilation
• May be used during weaning
• Sequence at various lung volumes to optimize
  airflow within multiple generations of
  bronchi. Ciesla, Phys Ther 1996.

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Muscle atrophy in ICU (critically ill) patients
Exercise
Nutritional status
Hormones (Drugs)
Innervation
INFLAMMATORY MEDIATORS
Muscle mass
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Critical Illness Neuromyopathy
High risks

• Sepsis
• Immobilisation
• Drugs
• Hiperglisemia
• Controlled MV
• Critical Care Med 2007.

Low risks
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Weaning

• Respiratory muscle training
• Respiratory muscle unloading

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Non-Invasive Ventilation

• time on MV ?
• nosocomial infections ?
• time in ICU ?

Nava et al. Ann Intern Med. 1998 128721-8.
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• ASTDNIMV, time on ventilation ? (1,7 day)
• Lenght of stay ICU ? (1,3 day)
• PaCO2 more stable and decrease
• Austr J Phys Ther 2004.

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• Training prog.
• 6-8 breath/set
• 4-6 sets/day
• Physical Therapy 2003 83171-176.

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Physical Therapy 2003 83171-176.
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• 24 patients (50 days ICU)
• Grup I mobilisation
• Grup II elektrical stimulation mobi.
• 4 weeks 20 sessions

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50
20
5
4
15
3
10
Transfer (days)
Muscle strenght
2
5
1
0
0
Active
Active el stim.
X SD plt0.05
Zanotti, Chest 2003.
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Admitted to RICU n80
Step 1 n60 PT, posture
Step 1 n20 PT, posture
Step 2 n50 Progressive Ambulation
Step 2 Progressive Ambulation
Step 3 n43 IMT LLMT
Usual Care
Step 4 n18 Exercise training
Usual Care
Arch. Phys. Med. Rehabil. 79 849-854, 1998.
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Pre
Post
? 6MWT (m)
Arch. Phys. Med. Rehabil. 79 849-854, 1998.
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• Resistance training during Acute Exacerbation
  COPD

Resistance training Usual care (n8)

• COPD patients
• acute exacerbation
• Age 67 years
• FEV1 44 pred
• QF 80 pred

Usual care (n9)
9 days - inpatient - 8 sessions
Probst, ERS 2005.
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Resistance training during AE
Probst, ERS 2005.
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Exercises

• to facilitate weaning process,
• ?oxygenation,
• ? muscle strenght and endurance,
• ? function .

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Ling-Ling Chiang, Physical Therapy . Volume 86 .
Number 9 . September 2006
METHODS 39 patients with PMV were assigned to
either a treatment group (n 20) or a control
group (n 19). Treatment group received physical
training 5 days a week for 6 weeks Upper-extremi
ty exercises included range-of-motion (ROM)
exercises (flexion and extension abduction,
adduction, and internal and external rotation,
with 10 repetitions of each motion per set for 2
sets) initially exercises against gravity in a
supine position, then in sitting position as
tolerated, then against resistance using
weights (0600 g) RESULTS Respiratory and
limb muscle strength, ADL improved significantly
only in the treatment group
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Upper limb exercises

• ? VO2 consump., VCO2 prod., HR, VE.
• inspiratory muscle predominance
• thoracoabdominal dyssynchrony, increase in
  hyperinflation
• ? Dyspnoea,

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Number of patients 8 Age,y 688 M, F, n
5/3 BMI 194 Days of tracheostomy,d
4555 Days of ICU stay,d 223 Days of MV, d
2410 APACHE II 131 FEV1 prd 4411 FVC
prd 5411 FEV1/FVC 4810 MIP, cmH20 653 pH
7.380.02 PaO2/FIO2
24015 PaCO2, mmHg 486
To evaluate effects of an incremental and an
endurance supported arm exercise tests In (COPD)
tracheostomised patients during Spontaneous
Breathing or Inspiratory Pressure Support
M. Vitacca Intensive Care Medicine 2006
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Max load IT (SB)
7.184.50 watt
3.533.25 dk
Max time ET (SB)
106.12 watt
Max load IT (MV)
4.783.68 dk
Max time ET (MV)
M. Vitacca Intensive Care Medicine 2006
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Breathing pattern
Tidal volüme breathing
frequency
MV SB
SB MV
M. Vitacca Intensive Care Medicine 2006
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Dyspnoea fatigue
SB MV
M. Vitacca Intensive Care Medicine 2006
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Safety recomendations assesment and monitoring of
exercise in ICU

• Resting HRlt 50 (age pred max HR)
• PaO2/FIO2 gt300
• SpO2 gt 90,
• lt 4 decrease
• BP lt 20
• Body temperature lt38C
• Breathing pattern

• EKG normal,
• No contraendications from neurological,
  orthopaedic systems or lines
• Safe environment
• Experience team
• Clinical decision of PT

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Evidence based results

• Acute lobar atelectasis
• Secretions clearance
• Alveoller recruitment
• Decrease in airway resistance
• Decrease in ventilatory associated pneumonia
• ? Time of NIMV NHMRC, Phys Ther Rev,
  2006.

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Evidence based results
Activity Modality Level of evidence Activity Modality Level of evidence Activity Modality Level of evidence
Weaning TDPs A
Mobilisation Postures Limb exercises CRT C D B-C
Chest PT MH Percussion /vibration B-C C
Muscle training Respiratory muscle Peripheral muscle ES C B-C B
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