Physiotherapy

Roles of physiotherapy in the ICU:

• Respiratory physiotherapy
  • Therapeutic hyperinflation
    Aims to ↑ recruitment and ↓ airway resistance. Can be:
    • Manual
      Use self-inflating circuit to deliver >150% of Vt.
    • Ventilator-assisted
      Use ventilator to ↑ V_T by 200mL increments until Pip of 40cmH₂O.
  • Active Cycle of Breathing Technique
    Controlled breathing to ↑ secretion clearance in spontaneously ventilating patients.
  • Suction
    Remove secretions via ETT.
  • Chest shaking
    Oscillatory movement during expiration ↑ mucociliary clearance.
  • Positioning
    
    • Sitting up to optimise V/Q matching
    • Gravity-assisted positioning
      Adjust patient to position bronchopulmonary segment perpendicular to gravity to ↑ secretion drainage.
    • Side-to-side turning
      ↓ VAP.
    • Proning
      ↑ Oxygenation and ↓ mortality in ARDS.
• Early rehabilitation
  Aims to ↑ independence and ↓ severity of ICU-acquired weakness. Techniques exist for:
  • Bed
    Cycle ergometry, passive movements, electrical stimulation, hoisting.
  • Chair
    Postural exercises, balance and proprioception, core stability.
  • Standing
    Marching, stairs, walking.
• Positioning aids
  ↓ Contracture formation.

Key Studies

• TEAM (2022)
  • 750 adult ventilated ICU patients
  • Early mobilisation vs. usual care
    • Early mobilisation: highest level of activity for the longest time on the lowest amount of sedation
    • Usual care still included reasonably early mobilisation
  • No significant mortality difference
  • Standing and walking occurred 1-2 days earlier in the early mobilisation group
  • More adverse events in the early mobilisation group

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References

1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.
2. Early Active Mobilization during Mechanical Ventilation in the ICU. New England Journal of Medicine. 2022;387(19):1747-1758.