CPPT in The Icu

Cardiopulmonary
Physiotherapy (CPPT)
in the ICU
Dr. Dheeraj Lamba

Head & Associate Professor,
Depth. of Physiotherapy,
Jimma University
Email: [email protected]
Patients Interpretation:
A physiotherapist is a most
important person, despite the
discomfort endured to have my
secretion removed and
repositioned, but this left me
(patient) comfortable for
several more hours.
What is CPPT?
Cardio-pulmonary physical therapy CPPT
refers to prescription and delivery of non
invasive interventions in the
comprehensive management (diagnosis,
assessment, treatment, and follow up)of
patients with primary or secondary cardio
pulmonary dysfunction.
TYPES OF ICU UNITS
 Neonatal intensive care unit (NICU)
 Pediatric intensive care unit (PICU)
 Coronary care unit (CCU)
 Psychiatric intensive care unit (PICU)
 Neurological intensive care unit (Neuro ICU).
 Trauma intensive care unit (Trauma ICU).
 Post-anesthesia care unit (PACU): High dependency unit
(HDU)/ step down unit or progressive care unit )
 Surgical Intensive Care Unit (SICU)
 Mobile Intensive Care Unit (MICU)
WHY, WHEN, HOW-CPPT in
ICU
• Cardiopulmonary physical therapy in the
intensive care unit (lCU) is a specialty by itself.
• Since 1980, reports on therapeutic interventions
that may reverse respiratory complications or
improve prognosis and reduce hospital stay for
patients with respiratory complications have
magnified.
• Evidence based practice in health care is a major
implication of CPPT in ICUs.
Clinical Decision Making in
ICU-Based on tripod approach
Knowledge of underlying pathophysiology
ICU
EXPERTISE OF ICU PTs
• Knowledge of cardio-pulmonary and
multisystem human physiology.
• Ability to identify impaired O₂
transport/pathway.
• Integration and interpretation of the
vast amount of multi-organ system data.
• Ability to identify indication,
Contraindication, timing of treatment.
Patient effects on - ICU
STAY
• Communication problems
• Sleep fragmentation
• Fear
• Sensory deprivation
• Sensory overload
• Discomfort
• Helplessness, dependency and depression
• Loss of privacy, dignity and identity
Candidates in ICU?
Lungs/ Respiratory Problems
• Type I & II respiratory failure
• Severe COPD and RLD and its complications
• Lung carcinoma
• Chest traumas
• Pulmonary Embolism/ARDS
• Status asthmaticus
Cont.….
NEUROMUSCULAR DISORDERS
•CNS insults
• GuillaiIi-Barre syndrome
• Acute quadriplegia
• Acute head injury
• Myasthenia gravis
• Botulism
• Tetanus
• Critical illness neuropathy
Cont.…
• POST-OP –thoracic, cardiac
• Systems failure
• Heart failure/mi/ cad
• Disseminated intravascular coagulation
• Acute pancreatitis
• Collagen vascular disease
• Kidney failure
• Liver failure
• Multisystem failure
• Poisoning and parasuicide
• Smoke inhalation/burns
Monitoring and
Assessment in ICU
• Assessment
• Charts
• Patient
• Monitors
• Ventilator
• Imaging
ASSESMENT
• Vital parameters/signs(wt gain/loose)
• Differential diagnosis of Chest pain.
• Breathlessness/Dyspnoea
• Position of the patient and Posture
• Appearance Face & Cough
• Hands- cold, warm, wasted, stains, clubbing
• Edema/Sputum/Cap-refill
• Configurations of chest wall-Shape, pattern, IC space
• Measure chest expansion.
• Chest auscultation- breath sounds/CTX
• Lines attached to the patient.
• Tactile/Vocal Fremitus & percussion
MONITORING -GENERAL
GUIDELINES
• Rapid detection of changes in the clinical
status.
• Complementary to clinical observation & not a
substitute.
• Accurate assessment of progress & response
to PT
• Trends are generally more important than a
single reading
Monitor and Readings
PULSE OXIMETRY (SPO₂) < 90 % = 60 mm Hg
>95% Normal
90-94% Acceptable O2 therapy, may need Suction
Less than 85 critical may need intubation
Arterial Blood Gases - ABG RESULTS
pH 7.35–7.45
PaO₂ 80 – 100 mmHg
PaCO₂ 35 – 45 mmHg
HCOз 22 to 26 mmol/L
Cont.…
Systolic. . . . . . . . . . . . 100-140 mm Hg
Diastolic . . . . . . . . . . 60–80 mm Hg
Mean MAP . . . . . . . . 70–100 mm Hg
CVP ……….. ………………2 – 8 mmHg

PAP(MPAP). . . . . . . . . .10 – 15 mmHg
Systemic venous O₂ saturation (SvO₂) - 60%–80%
Cont..
Indications: SpO₂<90%, PaO₂ <70mmHg
Device: Nasal cannula (FiO₂ 25-45%)
Sometimes FiO₂ 100% (Danger-Absorbtive atelectasis)
Sedation Assessment Scales

Dangerous agitation
Ve r y A g i t a t e d
Agitated
Calm and Cooperative
Sedated
Ve r y S e d a t e d
Unarousable
Cont.…
Intracranial Pressure
• Normal ICP is 1–15 mm Hg.
• CPP should be maintained at 70–80 mm Hg
• CPP = MAP - ICP
Fluid and Electrolyte Balance
Urine output Normal: 1200 ml/day (minimum- 12ml/hr.)
• Serum Na+ (135-148 mmol/L)
• Hyponaetremia indicates- excess fluid or ADH
• Hypernatremia indicates – dehydration
• K+ (3.5 - 5 mmol/L) – hypokalaemia predispose
arrhythmias, Hyperkalaemia indicates renal failure.
PSYCHOSOCIAL ISSUES IN
CRITICAL CARE
Confusion, Hallucinations, Lethargy, Disorientation,
Anxiety, Withdrawal
NEAR-DEATH EXPERIENCE (NDE)

• Seeing an intense light
• Seeing angels or departed loved ones
• Travelling through a tunnel
ICU PT Management
Goals of CPPT
• Maximize alveolar ventilation (minimize airflow resistance)
• Maximize VA/Q matching, Optimize diffusion
• Reduce work of breathing
• Reduce work of the heart
• Minimize electrocardiogram (ECG) irregularities
• Optimize blood flow distribution
• Optimize oxygen extraction ratio
• Reduce excessive or unnecessary energy expenditure
• Optimize carbon dioxide (C02) removal
• Optimize hydration
CLINICAL ASPECTS OF THE
MANAGEMENT
OF THE ICU PATIENT
Monitoring systems can be used to
establish
A. Indications and contraindications for
treatment
B. Parameters of the treatment prescription and
progression
Cont.…
• Physical therapy treatment should be
coordinated with medication schedules.
• Most medications have optimal dosages for

any given patient, optimal sensitivity, and
peak-response time.
BODY POSITIONING
Identify most & least beneficial body positions
thro monitoring
Supine lying –
Non physiological, deleterious to O₂
transport, ↓ses FRC, ↓ses VC, central shift
of blood volume, ↑ses area of dependent
lung
Cont.…
Up right/ 45˚ -
Max FRC, ↑ses airway diameter , Max VA/Q

ratio
Compression of heart & lungs minimal
Favorable for diaphragmatic fibers
↓ses work of breathing
Hemodynamic and Fluid shift effects
Cont.….
Side-Lying Positions/High side
lying
Most benefits are between supine and

upright.
Unilateral pathology - “ Good lung down”
Bilateral pathology – “lie on the right side”
VA/Q matching occurs in upper ⅓ rd of both
lungs
Cont.…
Prone Position
Good rationale should be made for not
incorporating this position into the treatment
prescription.
Enhances lung compliance, tidal volume, FRC
and diaphragmatic excursion
Mobilization and
Exercises
• Application of low-intensity exercise.
• Combine M & E with positioning.
In Conscious patients
• Rhythmic inflation and deflation of the lungs
associated with physical activity.
• Chest expansion exs, Breathing exs, Upper
extremity exs, ROM exs, Bed turning.
Cont.…
In Un conscious patients:
• Passive movts for UE & LE
• Manual hyper inflation
• Neuro Physiological Facilitation of respiration
• Tracheal tickles
Mob & Ex’s – Clinical
Implications
Thoracic Expansion Ex’s
• Breathing Ex’s
 Apical
 Upper costal
 Lower costal
 Diaphragmatic
 Sniff Maneuvers
• SMI
• Wand Ex’s- Note incorporate inhalation/exhalation
• Inter costal and Accessory muscle stretch
• Thoracic spine mobilization
Airway Clearance
Techniques
• Postural Drainage
• Percussion or Chest clapping

• Vibration
• Shaking
• ACBT
Cont.…
ACT (Manual hyperinflation
technique)
OTHER
SUCTIONING
• Inability to cough
• Pre & Post O₂ safe
• Hazards- arrythmias, hypoxia
SALINE INSTILLATION
• Normal saline
• 5 ml or even more
• Thro Nebuliser
Cont.….
BRONCHO DILATORS & AEROSOL
• Very effective direct administration of drug
enhance chest PT effects.
ASSISSTED COUGHING
Considerations for PTs –
Critical care
• Fluctuating ICP (neurological instability) – PT may
magnify/ Increase it.
• Atrial fibrillation, supraventricular, ventricular
tachycardias, arrythimias – PT is Cont.indicated.
• Avoid Manual hyperinflation in high PAP and low
Cardiac Output
• Sometimes PT can cause bronchospasm- caution
• Cross infection is very common in ICU
Cont.….
• Treatment should be carried out at least 1 1/2 hrs
after feeding time.
• Avoid overfeeding in type II Respiratory Failure.
• Treat interstitial edema with full force
• Many PT ploys are contraindicated in hemoptysis.
• In Pulmonary embolism – PT is started only after
anti coagulant therapy.
Thanks

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Cardiopulmonary

Dr. Dheeraj Lamba

Knowledge of underlying pathophysiology

PaO₂ 80 – 100 mmHg

CVP ……….. ………………2 – 8 mmHg

Indications: SpO₂<90%, PaO₂ <70mmHg

Device: Nasal cannula (FiO₂ 25-45%)

Sometimes FiO₂ 100% (Danger-Absorbtive atelectasis)

Sedation Assessment Scales

NEAR-DEATH EXPERIENCE (NDE)

• Most medications have optimal dosages for

Max FRC, ↑ses airway diameter , Max VA/Q

Most benefits are between supine and

• Percussion or Chest clapping

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