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Physiotherapy in the ICU

Published on July 25, 2014

For mechanically ventilated patients, early physiotherapy has been shown to improve quality of life and
to prevent ICU-associated complications like deconditioning, ventilator dependency, and respiratory
conditions.
By Nicolino Ambrosino, MD, and Dewi N. Makhabah, MD

Despite recent progress in medical treatment and mechanical ventilation (MV), critical illness in the intensive care
unit (ICU) is still associated with high mortality rates.1 Furthermore, ICU survivors may suffer from muscle
weakness, physical disability, and cognitive problems lasting up to 5 years.2-5 These critically ill patients may show
muscle wasting in the very first week of illness, with more severity in patients with multiorgan failure compared
with those with a single organ failure.6
Physiotherapy has been recommended by scientific societies as a main component in the management of
patients with critical illness.7,8 Proposed strategies include patient mobilization based on a progressive sequence
of activities like decubitus change and functional positioning; passive, supported-active, and active mobilization;
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cycling and sitting in the bed; and standing, static walking, transferring from bed to chair, and walking. Early
physiotherapy is aimed at improving a patients quality of life and preventing ICU-associated complications like
deconditioning, ventilator dependency, and respiratory conditions. It has been demonstrated that it is feasible and
useful, even in patients needing extracorporeal membrane oxygenation (ECMO).7-12 In addition, a pilot study
demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy.13

ICU-Acquired Weakness
Intensive care unit-acquired weakness (ICUAW) is observed
in a substantial proportion of patients receiving MV for more
than 1 week in the ICU.6,14-16 The etiology includes
deconditioning and disuse atrophy due to prolonged bed rest
and immobility, and critical illness polyneuropathy and/or
myopathy, known as critical illness neuromyopathy.17 Other
risk factors for ICUAW include the systemic inflammatory
response syndrome, sepsis, and multiple organ dysfunction
syndrome; hyperglycemia; and medications, such as use of
corticosteroids and neuromuscular blocking agents.18 As a
consequence, recommendations to avoid these risk factors
have been suggested.19
Implementation of an early mobilization program is feasible in most ICUs and provides benefits if started no later
than 1 or 2 days after MV initiation.9-11,15,20 Such programs must be delivered after cardiorespiratory and
neurological stabilization.20-23 This approach, together with specific muscle training, can improve functional
outcomes and cognitive and respiratory conditions (See Table 1).22

Rotational Therapy
Continuous rotational therapy uses special beds to turn patients along the longitudinal axis up to 60 on each side,
with preset degree and speed of rotation. It has been hypothesized that this modality can reduce the risk of
sequential airway closure and pulmonary atelectasis, resulting in reduction of the incidence rate of lower
respiratory tract infection and pneumonia, and the duration of endotracheal intubation and length of hospital
stay.10,24

Early Mobilization

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Early mobilization can be performed also in unconscious or sedated

patients.11 Protocols include semirecumbent positioning with the bed
head positioned at 45, frequent changes in postures, daily sessions
of joint passive movement, and passive bed cycling and electrical
stimulation.10,25 (See Figure 1.)
Many studies conclude that early mobilization of critically ill patients
can be done with low risk to the patient. Algorithms have been
proposed as a guide in selecting suitable patients for mobilization and
providing appropriate treatment strategies tailored to each individual
patient.8,11 Although the short-term effectiveness of early physiotherapy has been shown, more studies are
needed to confirm the long-term responsiveness of ICU survivors to physiotherapy. Furthermore, despite
recognized benefits of early mobilization, only a small proportion of ICUs are able to deliver full-time physiotherapy
to these patients. As a consequence, we need to improve ICU organization and teams to deliver early
physiotherapy.26-29 Indeed, a financial model, based on actual experience and published data, projects that
investment in an ICU early rehabilitation program can generate net financial savings for US hospitals and even
more clinical improvements for patients.30

Management of Airway Secretions

Mechanically ventilated patients in the ICU may suffer from retained secretions due to many causes. The
mucociliary system may be disturbed by endotracheal intubation, with increased infection susceptibility and
mucus volume and tenacity.
Furthermore, immobilized patients may suffer from atelectasis, impaired cough mechanism, and related inability
to expel secretions. Associated expiratory muscle weakness decreases cough strength; in addition, fluid restriction
contributes to secretion retention.31,32 Helping airway clearance in patients under MV includes different
techniques.33,34 (See Table 1.)
Postural drainage. Postural drainage traditionally includes gravity-assisted positions, deep breathing exercises,
chest clapping, shaking or vibration, and incentivized cough to move airway secretions toward the upper
airways.34,35
Chen et al36 performed a randomized study in mechanically ventilated patients in the ICU. Their results suggest
that percussion and postural drainage may improve lung collapse. Ntoumenopoulos et al37 suggested that chest
physiotherapy may be useful in prevention of ventilator-associated pneumonia. Lemyze et al38 suggested that in
critically ill obese patients under MV, sitting position constantly and significantly relieved expiratory flow limitation
and intrinsic-positive end-expiratory pressure (PEEPi) resulting in a dramatic drop in alveolar pressures. Combining
sitting position and applied PEEP may be the best strategy in these patients.38
Intrapulmonary percussive ventilation. Intrapulmonary percussive ventilation (IPV) is a high-frequency ventilation
modality that can be superimposed on spontaneous breathing. Intrapulmonary percussive ventilation may reduce
respiratory muscle load and help to move airway secretions. This tool creates a percussive effect in the airways,
thus enhancing mucus clearance through direct high-frequency oscillatory ventilation able to help the alveolar
recruitment. Positive effects from this technique have been shown in patients with respiratory distress,
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neuromuscular diseases, and pulmonary atelectasis.39-41

Physiologic effects of IPV were studied by Vargas et al42 in intubated COPD patients. Intrapulmonary percussive
ventilation improved the reduction of expiratory limitation flow and gas exchange. Dimassi et al43 performed a
prospective study to assess the short-term effects of IPV in patients at high risk for extubation failure who were
receiving noninvasive ventilation after being extubated. This study concluded that both noninvasive ventilation and
IPV reduced the respiratory rate and work of breathing. Clini et al44 performed a randomized multicenter trial
concluding that the addition of IPV improves gas exchange and expiratory muscle performance and reduces the
incidence of pneumonia.
Positive expiratory pressure. Positive expiratory pressure (PEP), first introduced in the 1970s, consists of a oneway valve through a mask or a mouthpiece connected to one or more small-exit orifices and adjustable expiratory
resistor to enhance and promote secretion removal by stenting airways, increasing intrathoracic pressure, or
increasing functional residual capacity.45 The benefit of PEP is still under investigation. A systematic review
assessed the effectiveness of PEP in patients after thoracoabdominal surgery. Six randomized controlled trials
were included comparing PEP with other breathing techniques or in addition to routine chest physiotherapy
treatment. Only 1 of the 6 trials showed positive effects of PEP compared with other physiotherapy techniques.46
A new modality to deliver a low level PEP at the mouth during
spontaneous breathing is called temporary PEP, which has been
recently proposed to treat patients with chronic mucus
hypersecretion. This modality produces a 1 cm H2O increase in
airway pressure along the respiratory cycle until immediately before
the end of expiration. (See Figure 2.)
The level of applied pressure is several times lower than that (5 to 15
cm H2O) commonly used and considered effective with other PEP
and/or oscillatory-PEP devices. Preliminary results show that an
expiratory pressure less than or equal to 1 cm H2O applied for a fraction of the expiratory phase may improve the
distribution of alveolar ventilation and prevent mechanical stress injury, which is expected to occur in the bronchial
tree or lung parenchyma at a higher pressure.34 Whether this suggested technique may be applied to ICU patients
is still to be studied.
Manual hyperinflation. Manual hyperinflation (MH) is commonly applied in patients under MV. It may stimulate
cough and move the airway secretions toward the larger airways, from where they can be easily suctioned. Manual
hyperinflation can prevent airway plugging and pulmonary collapse, and improve oxygenation and lung
compliance.47 This technique is widely used, though the practice varies across different ICUs.48 The possible
physiological side effects of delivered air volume, flow rates, and airway pressure must be carefully considered
especially in patients under MV.49 When performed by experienced and trained physiotherapists in stable, critically
ill patients, MH is associated with short-term and probably nonrelevant side effects like reduction in cardiac output,
alterations in heart rate, and increased central venous pressure. Nevertheless, other studies failed to show MH
benefits in intubated and mechanically ventilated patients.50

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Insufflation-exsufflation. Methods to improve cough are important in

critically ill patients because cough effectiveness is a determinant in
weaning success and patient outcomes. Cough assist such as a
mechanical insufflator/exsufflator clears secretions by gradually
applying a positive pressure to the airway then rapidly shifts to
negative pressure, producing a high expiratory flow. (See Figure 3.)
By contrast, direct tracheal suction applies negative pressure to a
small, localized area. Goncalves et al studied the efficacy of
mechanical insufflation-exsufflation as part of an extubation protocol,
which suggested that this technique may reduce reintubation rates
and ICU length of stay.51 Guerin et al assessed the impact of cough-assist insufflation-exsufflation on peak
expiratory flow, and results showed it was significantly reduced.52 Chatwin et al compared conventional
physiotherapy with physiotherapy plus in-exsufflation in noninvasively ventilated patients. Their results indicated
that in-exsufflation shortens the treatment time in the ICU without any difference in secretion clearance.53

Conclusion
Physiotherapy should be considered a cornerstone in the comprehensive management of critical ill patients and,
when applied early, may benefit patients and prevent some ICU complications. Modalities and devices for each
patient depend on disease severity, comorbidities, and patient cooperation. RT
Nicolino Ambrosino, MD,isaphysicianinthePulmonaryRehabilitationandWeaningUnitatAuxiliumVitae(Volterra,Italy)andDewi
N. Makhabah, MD,isaphysicianinthePulmonologyDepartmentoftheUniversityofSebelasMaret(Surakarta,Indonesia).Formore
information,contactRTmagazine@allied360.com.

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the muscle mass of critically ill patients: a randomized study. Crit Care 2009; 13 (5): R161.

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50. Paulus F, Binnekade JM, Vermeulen M, Vroom MB, Schultz MJ. Manual hyperinflation is associated with a low rate of
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neuromuscular patients with chest infection. Respir Care 2009; 54 (11): 1473-14

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