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A Practical Physiotherapy Approach in Intensive Care Unit

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 International Journal of Health Sciences and Research
www.ijhsr.org ISSN: 2249-9571

Review Article

A Practical Physiotherapy Approach in Intensive Care Unit

Manivel Arumugam1, Murali Thangaraj2, Baskaran Chandrasekaran3, Ramanathan Palaniappan Ramanathan4,
Pauline Kiruba Priyadharshini5, Pitchaimani Govindharaj6
1
Senior Physiotherapist, 4Professor and Head,
Department of Pulmonary and Critical Care Medicine, PSG Hospitals, PSG Institute of Medical Sciences and
Research, Coimbatore, Tamil Nadu, India.
2
Associate Professor, Department of Critical Care Medicine, PSG Hospitals, PSG Institute of Medical Sciences
and Research, Coimbatore, Tamil Nadu, India.
3
Assistant Professor, Department of Exercise Physiology and Sports, School of Allied Health Sciences, Manipal
University, Manipal. Karnataka, India.
5
Senior Physiotherapist Department of Physical Medicine and Rehabilitation, PSG Hospitals, PSG Institute of
Medical Sciences and Research, Coimbatore, Tamil Nadu, India.
6
Lecturer, Department of Allied Health Sciences, Sri Ramachandra Institute of Higher Education and Research,
Porur, Chennai, Tamil Nadu, India.
Corresponding Author: Manivel Arumugam

ABSTRACT

Intensive care unit (ICU) is the most required area to treat patients who admitted for an unconscious,
cardiopulmonary arrest, drowning, poisoning, cerebrovascular accidents, acute post-operative surgery
patients etc. for improving their health with various treatment procedures. Physiotherapy is one of the
treatment procedures in inside the ICU to regain the patient’s mobility and stability with the use of
procedures such as chest physiotherapy, range of motion exercises and early mobilization activities to
be used to improve functional capacity, strengthening the muscles with continuous rehabilitation
would improve quality of life among patients admitted to respiratory and medical ICUs. In order to
practice in the ICU, this study aimed to review the planning and implementation methods of
physiotherapy in the area of critical care to suggest the physiotherapy protocol. Initiation of this
protocol based assessment and implementation of physiotherapy inside the ICU is safe and beneficial
while practiced with good team members. Our views may differ with other national practices, but it is
easier to practice with simplest ideas and planning which we currently practicing in our domain. It is
useful for the newcomer in ICU team for making effective treatment.

Key words: Physiotherapy, Early Mobilization, Airway clearance, Breathing exercise.

INTRODUCTION chest physiotherapy, range of motion

Intensive care unit (ICU) is the most exercises and early mobilization activities to
required area to treat patients who admitted be used to improve functional capacity,
for unconscious, cardio pulmonary arrest, strengthening the muscles with continuous
drowning, poisoning, cerebrovascular rehabilitation would improve quality of life
accidents, acute post-operative surgery among patients admitted to respiratory and
patients etc. for improving their health with medical ICUs. [1]
various treatment procedures. Physiotherapy In Indian scenario most of the ICUs
is one of the treatment procedures in inside doesn’t have physiotherapist team to give
the ICU to regain the patient’s mobility and treatments in critical care settings, and also
stability with the use of procedures such as if available, they weren’t practice regularly

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 Manivel Arumugam et.al. A Practical Physiotherapy Approach in Intensive Care Unit

in ICU for the whole day, not in a proper importance for physiotherapists. [3] In
planning in making decisions regarding addition, physiotherapists can contribute to
assessment and treatment and the patient’s overall well-being by providing
documentation. [2] In order to practice in the emotional support and enhancing
ICU, this study aimed to review about the communication. For better planning and
planning and implementation methods of implementation there is a need of good team
physiotherapy in the area of critical care for members like pulmonary physician,
to suggest the physiotherapy protocol. intensivist, physicians for specialized
Physiotherapy assessment of condition, surgeons, ICU physiotherapist.
critically ill patients is directed to These team member roles were explained in
deficiencies at a physiological and Figure.1. According to the need other team
functional level and less by the medical members of the ICU like Nurses,
diagnosis. Accurate and valid assessment of perfusionist, respiratory therapist can also
respiratory conditions, deconditioning and included in planning and implementation of
related problems is of paramount treatment in ICU.

Figure.1: Organogram

AIMS AND GOALS OF INTENSIVE  To decrease symptoms such as pain,

CARE PHYSIOTHERAPY breathlessness and make mobility in
Aims and goals of intensive care ease.
physiotherapy are;  To decrease anxiety, depression
 To aid in airway clearance on need and associated with ICU monitors, tubes,
on – call. isolation and related delirium, to
 To decrease complications of increase chances of early liberation from
immobility (DVT, pressure sore).

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 Manivel Arumugam et.al. A Practical Physiotherapy Approach in Intensive Care Unit

mechanical ventilation through early ASSESSMENT PEARLS

mobilization, exercise, etc. [4] Initial assessment shall be based on
 To facilitate early out of bed (pertained medical records and history from the patient
to primary ailment) and promote if conscious or attender if patient in
functional independence, to monitor for ventilator or unconscious. The ICU
foreign tubes (Endotracheal, Foley’s and physiotherapy record sheet was showed in
ICD) during techniques, to maintain Table.1 and therapeutic assessment and
good rapport with ICU team members outcome measures are described in
for effective therapeutic care.

Table.1: ICU Physiotherapy Record Sheet

Name: Age: IP No: Date of admission Date of assessment:
Bio hazard: Y Isolation: Y N Diagnosis: Present complaints:
N
History: ECMO: Y N
Monitor: RR: T: BP: HR: SpO2: (FiO2 Mode: V RA NC FM NIV ) ECG:
Examination:
Observation Palpation Percussion (*) Auscultation
Built? Bony contour? *Creps
Distress? Tracheal deviation? ∆ Wheeze
Tubes? ICD, Diaphragm
tracheostomy
Mobility × Rales

Higher functions: GCS Muscle Power Others

Mobility functions Independency? Walking aids? Transfers Bathing /Toilet
Musculoskeletal problems: Urinary problem:
Mechanically Y /No If yes, Ventilatory Mode FIO2 PEEP PS
ventilated parameters:
Drugs Vasopressors Anticoagulants Bronchodilator Mucolytes:
Problem List Airway clearance Breathlessness Functional incapacity Poor MICU coping/
(ventilator weaning) Ventilation liberation
Physiotherapy  Postural drainage and  Positioning  Inbed  Diet – normal, tube
management plan suctioning  Relaxation techniques strengthening  Inbed strengthening
 ET/Tracheostomy  Purse lip breathing  Oxygen titration and early mobilisation
tube care  Aerobic/ resistance for during activities  Rapport with
 Ventilation quadriceps and  Chair sitting attenders during
humidification scapulothoracic muscles  High sitting in physio session
 Steam inhalation  Passive techniques bed  Social activities
 ACBT (trigger, myofascial)  Standing with /  Oxygen titration
 Discuss regarding  Breathing exercises without walker  Humidification
mucolytics  Walking
prescription
 Pressure sore
and DVT

System wise assessment shall be carried (for e.g., if neurologically impaired, reflexes, higher
functions and functional independence, if cardiac, murmurs and functional ability), If patient
in invasive ventilation, the ventilator modes, pressures pertained to the primary pathology,
mobilization criteria, termination of mobilization (after discussion with ICU intensivist’s
team), the weaning ability and contraindications to physiotherapy as decided by senior
physiotherapist. Assessment of RT feeding tube, Foley’s catheter, PEG feeding tube,
Vasopressors support, Infusion pump tubing, real time monitor (ECG, Pulse Oximeter)
chords, CUP monitor tubes shall be done prior to mobilization. Mobilization criteria shall be
strictly followed based on scale, Chest physiotherapy on need and on call.

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Figure.2: Therapeutic assessment and outcome measures.

TREATMENT MEASURES IN ICU

Early mobilization and physical activity
This is the prime and foremost goal of the ICU therapeutic team. Evidence claims the
early mobilization shall decrease mortality, economic cost, [5,6] incidence of delirium, length
of stay in ICU, reduction in impact of primary illness and increase sense of wellbeing,
functional independence, early return to social activities and quality of life. [7-11] Mobilization
plan is explained in Figure.3.

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Figure.3: Mobilization plan tree.

The 2nd hourly position: This is in liaison and promote good cardio respiratory
with nursing staff, the 2nd Hourly position parameters.
chart shall be maintain to combat the risk High sitting (dangling): This is done
of pressure sore and DVT incidences. [12] in conscious patients whose ventilation
The contraindications to frequent turning impaired due to recent pulmonary, cardiac
(such as ARDS, severe trauma, or neuromuscular (stroke) pathology.
vasopressors support, and immediate Evidence claim that high sitting promotes
resuscitation) shall be opined from the increased basal ventilation, improved trunk
concerned unit physician or senior support and reduces cardiac overload, and
Intensivist. The 2nd hourly position which also to improve equilibrium and balance, to
includes long sitting within bed, high promote sitting ADL activities.
sitting, chair sitting and standing with or Chair sitting: Shall be practiced in
without support. stroke, surgical, stabilized sub-acute cardio
Long sitting within bed: This is pulmonary patients to gain confidence in
done for almost all the patient in ICU patients who is recovering from ICU,
except comatose (semi-reclined), high nor- improves patients communication ability,
adrenalin support. This is done to avoid promotes further ADL activities, and to
aspiration, facilitating ventilatory pattern, initiate further mobilization programmed
to decrease muscle works for respiration, to like standing, walking with appropriate
improve alertness or sensorium, to maintain parameters.
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 Manivel Arumugam et.al. A Practical Physiotherapy Approach in Intensive Care Unit

Standing with or without support: tolerated assess for weaning process or

This is done in liaison with nursing staff. train the patients through ventilator modes
Care shall be taken for dislodgement of and making the patient to breath easily with
tubes, cardiac compromise, imbalance and ventilator through proper positioning,
neuromuscular compromise. High standing breathing retraining and adequate T-piece
shall not be executed in recent CPR. If the spontaneous breath trail before weaning.
patients not supported adequately can use Weaning failure patient is treated
rollater walker, high standing frame or adequately with ICU team members
table, with help of other healthcare workers according to the results weaning process
can initiate further mobilization like should be carried. Functional independency
walking around the cot or room. Walking: achieved with good counseling,
This may be done in the presence of mobile communication among with family
ventilator, oxygen support and walker members, motivating the patients to do
assistance. The walking intensity shall be ADLs in the bed side with or without
decide on higher functions (GCS > 8/15, assistance.
well oriented obeying commands),muscle
power (MRC > V4/5), patient comfort, a. Airway clearance
vital stability [SpO2> 90%, Heart rate rest It is the prime motto of the MICU
< 100/min, walk heart rate rise < 20 BPM, respiratory physical therapy team. The
not on any ionotropes, MABP > 70 mmHg, pulmonary disabled, drowning, sepsis,
no drop in post walk BP < 10 mmHg, FiO2 poisoning, traumatic and neurologically
< 0.4, pyretic (T > 99*F)], berg balance impaired, expiratory muscle weakness
score ( > 3) and Borg’s exertion (<5/10). patients shall be the target patients for the
[10]
airway clearance. The bulbar palsied,
Supplemental oxygen assistance: bronchiectasis, comatose, ventilator
This is based on exertional desaturation. initiated individuals shall require airway
Non desaturations if breathlessness with no clearance at a higher frequency. [1] Protocol
obvious saturation decrease also shall be on for airway clearance strategies in MICU is
supplemental oxygen if the clients are explained in Figure.4.
feeling comfortable with minimal level of
FiO2. Nasal cannula or facemask with Indications:
venture shall be decided on the flow basis  Excessive secretion production:
or the minimal oxygen requirement as bronchiectasis, foreign tubes – ET,
advised by the pulmonary care physician. tracheostomy, RT, airway tubes, lung
During inbed exercises or any transfers, a abscess, comatose, epilepsy, endocrine
flow of extra 2 L/ min than the baseline if dysfunction, and upper airway trauma.
the patient shall complaints of fatigue,  Failure in secretion clearance:
breathlessness, desaturation or discomfort Comatose, sedated, paralyzed, stroke,
during exertion. GBS, poisoning, higher level spinal
Ventilatory independence cord injury, ET and tracheostomy tubes,
Ventilatory independence can be post abdominal surgery, and thoracic
achieved through airway clearance, surgery.
breathing exercises, and mechanical  Secretions thickening: Increased
ventilation liberation. Patients who have chloride electrolyte, Noninvasive
ventilated through intubation or non ventilation, no humidified connected,
invasive ventilation needs to improve with excessive breathlessness, and
airway clearance techniques and correct neurologically impaired
breathing control exercises, if the patients

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Figure.4: Airway clearance assessment.

Contraindications: antiarrhythmics, vasopressors and high

 Uncontrolled acute hemoptysis (If FiO2 - minimal handling of patients and
physician opinion regarding stability and minimize open suction frequency.
patient breathlessness, cough, fever and 
radiological collapse probably due to b. Breathing exercises
underlying clots in alveoli, then gentle It shall be administered in the view of
airway clearance to be carried out), increasing ventilation, pulmonary expansion
 Rib fracture, nasal bone fracture, thereby increasing tissue ventilation
immediate post operative thoracic perfusion perfect, reducing tissue
surgery and head injury with risk of hypoventilation and hypoxic injury.
increasing intracranial pressure - no Breathing exercises are proved to have
percussion, shaking or head down, positive effects on length of ICU stay,
 Recent liver failure, severe GERD, increase pulmonary efficiency and breathing
aspiration – no head down position reserve, early ward activities in spite of
unless physician presence, High PEEP, primary pathology for admission to
Pressure support, medications like intensive care. [13]
sedatives and paralytics,

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Manual techniques: lung expansion and airway clearance by

 Diaphragmatic breathing exercises: This providing biofeedback or visual incentive
type of breathing relaxes the diaphragm for the lung expansion and airway clearance
and abdominal muscles there by through intraoral oscillations. [14,15] Some
increases the vertical vital capacity of manual techniques may be combined with
lung. This type of breathing said to be nebulizer and humidification as an adjunct
effective during anxious hospital stay, to airway clearance and lung expansion.
ICD or rhyles tube, thoracic abdominal
surgery and COPD. It should be Mechanical Ventilation liberation
emphasized that overtraining may cause Weaning from mechanical
the risk of hyperventilation and ventilation and early return to the step down
barotraumas. wards and home shall be the prime
 Purse lip breathing exercises: These component of respiratory physical therapy
types of exercises shall be effective in in ICU. Researches states the complications
COPD and small airway diseases where such as critical illness, delirium, increasing
backpressure said to regulate the hospital and ICU stay, ventilator associated
collapsibility of the airways. Usually in pneumonias, increased mortality, increasing
acute hospitalization patient adapts to healthcare cost, increased drug dependence,
prevent the bronchospasm himself. If the increased chronicity of the prime pathology
patient has not adapted, the technique shall be combated by early liberation from
shall be taught as a protocol. ventilator and returning stability of the
 Glossopharyngeal breathing: This type patient to at most stability.
of exercises shall be employed in higher
spinal cord injuries where only facial Weaning assessment and therapy:
and neck muscles are working with no The weaning assessment is described
activity from intercostals and in Figure.5. The therapist shall coordinate
diaphragm. Lumps of air shall be with the Intensivist or the concerned unit
engulfed and ingested by the tongue into physician in planning for early weaning
the trachea. Ingestion into esophagus assessment and liberation from mechanical
and air swallowing is common. ventilation as early as possible. The
 Chest expansion exercises: This shall be weaning from mechanical ventilation
executed in case of COPD, atelectasis, (change in mode or trigger) shall be
neuromuscular patients (Stroke, GBS, exercised in the presence or in the
poisoning) and post ventilated critical knowledge of Intensivist or pulmonologist
illness polyneuropathy patients who may concerned. The senior therapist shall review
be at the risk of shortening of chest the everyday investigation and progress
muscles and poor lung expansion cards, real time and PACS, HIS
thereby increasing length tension investigation e-copies for following up the
relationship and hence ventilation prime pathology reduction, changes in the
perfusion matching. arterial blood gases (metabolic stability),
cardiopulmonary stability, fluid and energy
Mechanical techniques: balance as a part of activity monitor in ICU.
[16-18]
This shall be executed in forms of
incentive spirometer, inspiratory muscle
training devices, [13] EzPAP (positive airway
pressure device) and Acapella, lung flute for

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Figure.5: Weaning assessment.

Caution: Never change mode / trigger portal hypertension and ascites and with
setting by therapist himself/ herself. pleural disorders where negative pressure
Increasing oxygenation (FiO2) other than may be contraindicated.
suctioning (During mobilization) shall be Functional independence:
discussed with Intensivist or pulmonologist. During the mechanical ventilation,
If PEEP > 8 cmH2O, never disconnect for the patient restrains to the bed clinically due
suctioning or mobilization without consent to the prime pathology, tubes (ventilator, RT
of the Intensivist. Checking for mode, FIO2, aspiration, Foley’s, Monitor, ICD, CVP,
PEEP, Paw, dynamic compliance and infusion), sedation, paralytic agents,
resistance, flow volume loops, 24 hrs trends neuromuscular inability, breathlessness and
in FiO2 requirement, Volume, pressure restraints. Respiratory physical therapist
change shall be exercised strictly for the 24 shall administer his/ her therapeutic skills to
hrs physiotherapy plan in MICU. attain at most functional independence such
During mobilization or suctioning, as passive (unconscious sedated) and active
accompanying staff nurse or physician is a mobilization (conscious, oriented) ranging
must. Follow universal precautions (Glove, from in bed, standing to walking with
goggles, apron, and masks) for contagious mobile ventilator.
person or immunocompromised patients. Pre mobilization check list such as
Mechanical adjuncts such as threshold oxygenation index, mechanical ventilation
inspiratory muscle trainer and other status such as high PEEP, high FiO2
resistance training modalities shall be added requirements, high Paw, volume or NAVA
for early respiratory strength training modes, acute respiratory distress in spite of
without Valsalva maneuver. Care shall be adequate pharmacological management
exercised in case of persons with subdural monitors such as SpO2, cardiac rate and
hemorrhage, bleeding diathesis, COPD, rhythm, no arrhythmias, no sedatives and
recent trauma to oral cavity, blunt abdomen, ionotropes, physician’s opine regarding

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 Manivel Arumugam et.al. A Practical Physiotherapy Approach in Intensive Care Unit

mobilization, prime pathology hindering national practices but it is easier to practice

mobilization, early use of walking aids, with simplest ideas and planning which we
recent surgeries such as valve, knee currently practicing in our domain. It is
replacements, spinal pathologies, higher useful for the new comer in ICU team for
mental functions and motor power, balance making effective treatment. Involving a
deficits such as retinopathies, Vertigo, multidisciplinary team, with a recognized
cochlear implants, ear surgeries, leader, can be effective in changing ICU
neuromuscular dysfunctions such as stroke, culture and practice to effectively deliver
GBS, Parkinson’s shall be considered. early mobilization and rehabilitation.
The mobilization aids such as
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How to cite this article: Arumugam M, Thangaraj M, Chandrasekaran B et.al. A practical

physiotherapy approach in intensive care unit. Int J Health Sci Res. 2019; 9(4):311-321.

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