ROLE OF PT IN ICU

Goals of PT in ICU 1.Improve / maintain normal or baseline ventilation and oxygenation 2.Improve / maintain musculoskeletal system within functional limit - Improve range of motion - Improve muscle strength and endurance - Prevent joint deformities and contractures

Goals-contd Improve circulatory system function 4. Improve / maintain neurological system and cognitive status within the functional limits. 5. Improve / maintain level of functional status within patient tolerance

Assessment Cardiovascular system Respiratory system Neurological system Renal system Hematological system Gastrointestinal system

Cardiovascular system Heart rate and rhythm Arterial BP Central Venous pressure Pulmonary Artery pressure (PAP) and pulmonary artery wedge pressure (PCWP)

Neurological system Level of consciousness (Glascow coma scale) Pupils – Size – Reactivity – Equality Cerebral perfusion pressure (>70mmHg) CPP = MAP- ICP (Mean arterial pressure-Intra cranial pressure) Intracranial pressure (<10mmHg)

Intracranial pressure measurement

Renal system Assessment of fluid balance – Measure of Intravascular volumes – Urine output – Serum electrolytes – ABG

Gastrointestinal system Nutritional support – Routes of administration – Enteral ( Ryles tube) – Parentral ( Venous line) – Oral

CARDIO PULMONARY DYSFUNCTION 1. PRIMARY - Respiratory failure - Heart failure - Cardiac surgeries - Thoracic surgeries 2. SECONDARY - Burns - Head injuries - Musculoskeletal trauma - Neuro muscular dysfunctions - Acute spinal cord injuries - Renal failure - Complicated general surgeries

Respiratory system Auscultation Percussion Expansion Chest X-ray Mode of ventilation Humidification Oxygen therapy Respiratory rate Airway pressures ABG Sputum

Assessment General Observation  Patient Position  Respiration - Airway Endo Tracheal / Tracheostomy Ventillator Mode & FiO 2  Vital Signs – Temperature, BP, RR, HR SpO 2, GCS, ICP  Tubes - CV line, Peripheral line, Chest tubes, Catheters  Drugs

Examination  Auscultations  Respiratory pattern  Cyanosis  Clubbing  Radiograph

Goals Prevent accumulation of secretions Improve mobilization and drainage of secretions Promote relaxation to improve breathing patterns Promote improved respiratory function Improve cardio-pulmonary exercise tolerance

Precautions Untreated tension pneumothorax Status asthmaticus Immediately following intra cranial surgery Head injury with raised ICP Osteoporotic bones Recent acute myocardial infarction, unstable vitals Sutures and Intercostal drainage

Physiotherapy Techniques Gravity-assisted Positioning Manual techniques Manual hyperinflation Airway suctioning Chest Mobilization

Physiological effects of Positioning Optimizes oxygen transport by improving V/Q mismatch Increases lung volumes Reduces the work of breathing Minimizes the work of heart Enhances mucociliary clearance (postural drainage)

Chest Mobilization Chest Vibrations Chest Percussion/Clapping Postural drainage

Chest Percussion / Vibration PERCUSSION consists of rhythmic clapping on the chest with loose wrist & cupped hand. Effect : Dislodges & loosens secretions from the lung VIBRATIONS consists of a fine oscillation of the hands directed inwards against the chest, performed on exhalation after deep inhalation. Effects: Helpful in moving loosened mucous plugs towards larger airway

Manual Hyperinflation (MH) This is inflating the lungs with oxygen and manual compression to a tidal volume. Indications To aid removal of secretions To aid reinflation of atelectatic segments To assess lung compliance To improve lung compliance

Hazards of Manual Hyperinflation Reduction in blood pressure Reduced saturation Raised intracranial pressure Reduced respiratory drive Hemodynamic and metabolic upset Risk of barotrauma Discomfort and anxiety

Contraindications Undrained Pneumothorax Severe bronchospasm Cardiac arrhythmias Unexplained Hemoptysis Patient on High PEEP (Positive end expiratory pressure)

Advantages of MH Reverses atelectasis Improves oxygen saturation and lung compliance Improves sputum clearance

Suctioning Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place. Indications – Inability to cough effectively – Sputum plugging – To assess tube patency

Contraindication Frank hemoptysis Severe brochospasm Undrained pneumothorax

The suction catheter used must be less than half the diameter of endotracheal tube. The vacuum pressure should be as low as possible. (60-150mmHg) Suction should never be routine, only when there is an indication

Hazards of suctioning Mucosal trauma Cardiac arrhythmias Hypoxia Raised intracranial pressure

ROUTE OF SUCTION Nasal and oral suction Endotracheal suction Tracheostomy suction

Mobilisation Critically ill (Frequent Position changes, Kinetic & Kinematic Therapy) Stable (Progressive tilting & Ambulation)

Mobilization ICU rehabilitation has been shown to accelerate recovery Early mobilization for unconscious patients starts right from turning the patient every two hours. Graded exercises can be started as soon as the patient regains consciousness.

Activity is required to maintain sensory input, comfort, joint mobility and healing ability. Activity minimizes the weakness caused by loss of muscle mass Graded ambulation can be started depending on patients condition