Jul 30, 2014 - deconditioning related to critical illness. A variety of modalities ... macological agents such as corticosteroids, neuromuscular blockers, and antibiotics. Skeletal ... The aims of physiotherapy in respiratory dysfunction are to im-.
Customer OUP
Book Title The ESC Textbook of Intensive and Acute Cardiac Care 2e
Stage First Proof
Supplier Thomson Digital
Date 30 July 2014
Chapter 33
Physiotherapy in critically ill patients R Gosselink and J Roeseler
Contents Summary 285 Introduction 285 Respiratory conditions 286 Prevention of post-operative pulmonary complications (abdominal and thoracic surgery) 286 Retained airway secretions and atelectasis 286 Mechanically ventilated patients 287 Weaning failure 288
Early mobility and physical activity 288 The uncooperative critically ill patient 289 The cooperative critically ill patient 291
Personal perspective 292 Further reading 292
Summary Physiotherapists are involved in the management of patients with critical illness. Physiotherapy assessment of critically ill patients is less driven by medical diagnosis; instead, there is a strong focus on deficiencies at a pathophysiological and functional level. An accurate and valid assessment of respiratory conditions (retained airway secretions, atelectasis, and respiratory muscle weakness), physical deconditioning, and related problems (muscle weakness, joint stiffness, impaired functional exercise capacity, physical inactivity, and emotional function) allows the identifying of targets for physiotherapy. Evidence-based targets for physiotherapy are deconditioning, impaired airway clearance, atelectasis, (re-)intubation avoidance, and weaning failure. Early physical activity and mobility are key in the prevention, attenuation, or reversion of physical deconditioning related to critical illness. A variety of modalities for exercise training and early mobility are evidence-based and are implemented, depending on the stage of critical illness, comorbid conditions, and cooperation of the patient. The physiotherapist should be responsible for implementing mobilization plans and exercise prescription and make recommendations for their progression, jointly with medical and nursing staff.
Introduction The progress of intensive care medicine has dramatically improved the survival of critically ill patients, especially patients with ARDS [1]. This improved survival is, however, oftentimes associated with general deconditioning, muscle weakness, dyspnoea, depression and anxiety, and reduced health-related quality of life after ICCU discharge [2, 3]. Deconditioning, and specifically muscle weakness, but not pulmonary function, is suggested to have a key role in impaired functional status after ICCU stay [2]. Optimal physiologic functioning depends on an upright position [4], so bed rest and limited mobility during critical illness result in profound physical deconditioning and dysfunction of the respiratory, cardiovascular, musculoskeletal, neurological, renal, and endocrine systems. These effects can be exacerbated by inflammation and pharmacological agents such as corticosteroids, neuromuscular blockers, and antibiotics. Skeletal muscle weakness in the ICU is observed in 25% of patients that were ventilated * This work is partially funded by Research Foundation—Flanders grant G0523.06.
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Customer OUP
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Book Title The ESC Textbook of Intensive and Acute Cardiac Care 2e
chapter 33
Supplier Thomson Digital
Date 30 July 2014
physiotherapy in critically ill patients
Prevention of post-operative pulmonary complications (abdominal and thoracic surgery)
Respiratory insufficiency
Lung failure
Pump failure
Hypoxaemia
Hypercapnia Hypoxaemia
Reduced regional ventilation
Altered respiratory drive
Reduced airway clearance/cough
Mechanical defect
Impaired diffusion capacity
Neuromuscular dysfunction
V/Q mismatch
Figure 33.1 Model of causes and consequences of respiratory insufficiency.
for >7 days [5]. The development of neuropathy or myopathy also contributes to weaning failure [6]. Finally, muscle weakness has been linked with increased mortality [7]. Respiratory dysfunction is one of the most common causes of critical illness, necessitating ICCU admission. Failure of either of the two primary components of the respiratory system (i.e. the gas exchange membrane and the ventilatory pump) (see Figure 33.1) can result in a need for mechanical ventilation. Respiratory dysfunction includes impaired global and/or regional ventilation and lung compliance, and an increased airway resistance and work of breathing. Although, most patients under mechanical ventilation are extubated in 20 cmH2O Minute ventilation
