6 Major role of Physiotherapist in Intensive Care Unit (ICU) during treating pandemic nCOVID-19

What is Intensive Care Unit (ICU)?

ICU is as area set aside for care of patients who are either clinically ill or who are in danger of becoming so if deprived of continuous care and attention.

Primary purpose of ICU is to provide a complete setup up of space with personnel (medical staff’s) & equipment’s in which highly care can be taken.

In COVID-19 infected people develop Pneumonia and fill one or both lungs with sputum/secretions. As a result, Hypoxia (low level of oxygen) develop and result into breathing difficulty.

When patient admitted in hospital with moderate symptoms, main focus is to try that patient do not come on a ventilator. If patient comes on ventilator then it will be more complicated as it will be bedridden for long time as per severity.

SPECIFIC GOALS OF PHYSIOTHERAPY :

1.    Postural Drainage Technique, Mucus mobilizing & Secretion removal  technique, aerosol therapy in case of productive cough

2.    Develop the breathing skills

3.    Reduction of Dyspnea (difficulty in breathing)

4.    Relaxation Technique

5.    Involvement of Musculoskeletal muscle training

6.    Re-education & Reassurance

1.    Postural Drainage Technique, Mucus mobilizing & secretion removal technique, aerosol therapy in case of productive cough

a.    POSTURAL DRAINAGE TECHNIQUE –

It is technique for mobilizing secretion from one or more lung segments to the central airways by placing the patients in various gravity assistance position. Once secretion are mobilized to the larger airways they can be cleared by coughing or by suctioning. 

    

b.    MUCUS MOBILIZING & SECRETION REMOVAL TECHNIQUES –

Percussion,

Vibration,

Effective Coughing :

Huffing

Forced Expiratory technique (FET)

Suctioning

   This will improve ventilation perfusion ratio.

In Percussion hands are slightly cupped, wrist are quickly flexed and extended. Percussion is thought to send sound waves through chest wall, causing compression & rarefaction of air within the airways, thus setting up vibration and loosening the secretions.

Vibration chest shaking technique. – Performed only in expiratory phase of breathing. It can be given unilateral & bilateral to chest.

Effective Coughing : Take deep breath with more volume of air, tighten the abdominal muscle and cough. Expired forceful air clear the secretions from trachea and main bronchus.

Huffing : Take medium size breath with mid-lung volume air, tighten the abdominal wall and do huff. Moves the secretions up from lobar & segmental bronchi.

Difference between coughing and huffing?

Coughing we do with closed epiglottis while in huffing its open.

Forced Expiratory Technique (FET)

One or two huffs followed by relaxed breathing and finally 2-3 coughs.

Thus patient is performing from mid lung to low lung volume which moves secretions from peripheral airways to central.

Finally , coughing will aid in removing secretions from central airways as it is high lung volume.

Suctioning : One end of catheter is pass inside through nose or oral while other is connected with suction pump which helps in sucked out the secretions. It is mechanical technique use when coughing is not possible.

c.  AEROSOL THERAPY-

Mucolytic , Bronchodilators & Humidification use in ICU for thinning the sputum & easing their removal through coughing & reduce the load of breathing. It can be given for 20-30 mins before postural drainage.

Pressurized aerosol, Rota halers, Nebulizers can also used.

 

2.   Develop the Diaphragmatic + lateral costal breathing skills

Diaphragm is main muscle of respiration. Helps in forward, movement of whole abdominal wall.We have to promote greater use of Diaphragm muscle and decrease the use of other accessory muscle.

Patient Position- Half Lying or sitting position with head and back fully supported.

Technique-Physiotherapist place hand on anterior costal margin (front of chest) and upper abdomen to feel the movement. In this upper abdomen will bulge forward and anterior costal margin moves up and out.

In Lateral costal, there will be chest expansion laterally along with forward movement.

These will reduce the dyspnea level and load of breathing.

3. Reduction of Dyspnea (difficulty in breathing)

Dyspnea – difficulty in breathing

Breathing control is most important when patient is in chronic respiratory disease because respiratory muscle uses more effort as compared to normal person.First give relaxed position and then taught the breathing pattern

for example : One out and one in slowly according the patient breathing rate or Tummy out/tummy in

Gradually patient will slow down & come to normal breathing pattern.

Progression :

One out and one in
one, two out, one in
one, two three out, one two in.
Then in sitting, standing, walking,
going up and downstairs with breathing control.
Leaning forward.

4.  Relaxation Techniques used for breathlessness:

It is most important to relax the patient in frightening dyspnoeic patient.

  Various position are given to change frequently .

High side lying

Forearm support on table with leaning forward

Forearm support on thighs with leaning forward

Sitting on chair with leaning position

Forward leaning while standing

Back support against wall/ relaxed standing position.

 5.  Involvement of Musculoskeletal Muscle training .

It is necessary to maintain the muscle property as prolong bedridden develops muscle weakness. Priority is to maintain respiratory and shoulder muscles.

Start with warm up 10-15 mins. of all joints.

  In sitting position : Trunk mobility

Trunk rotation

Trunk bending forward

Trunk bending sideways

Shoulder mobility

Elevate arm up and down front in full range

Elevate arm side ways up and down in full range

Elevate arm sideways upto half range and slowly do circles movement.

  Exercise prescription & free active exercise can be given as per patient condition. 

Intensity  : It should be based on Target Heart Rate (THR) to Maximum heart rate (MHR) – 60% of MHR

Formula how to calculate

MHR = 220 - age

Target HR = 0.6 x MHR

Duration    : Upto THR for atleast 15-20 mins.

Frequency : 3-5 times workout/week.

An aerobic exercise involve large muscle group is also appropriate for respiratory rehabilitation.

Might include Walking, Cycling , Jogging , rowing etc can given as post discharge from hospital

   6.  Re-education & Reassurance.

            Patient is explained in detail to care of health & proper hygiene.

Advice regarding use of bronchiodilators , mucolytics its long term use , effects and side effects.Regularly follow the exercise regimen and take consultation for further progression. Advice to take care for prevention of relapse condition

 

SUMMARY :

Aerosol therapy use for thinning the secretion.
Postural Drainage is gravity assisting technique to move secretions to main bronchus
Remove the secretions from to main bronchus with help of Coughing , Huffing & FET
Breathing patterns are should be in control manner
Diaphragm is main respiration muscle
Check the regular progression
Maintain Shoulder Arm mobility
Do exercise as per Target Heart Rate (THR)
Do regular follow up Physiotherapy Consultation.
Keep Patience without any panic
Most Important Prevention is better than cure

OVERALL MANAGEMENT : It involves many specialist doctors apart from Physiotherapy, including Doctors, nurses, radiographers, technician etc. Patient treatment in ICU is incomplete without any one of it.

Thank you for reading my blog.

Take care. Have a Pain Free Life.

If any query, Please feel free to contact. We are here to help you . . .

Regards,

Dr Amita Agrawal,

(BPT, PGDEMS, D.Acu., MIAP, MBA)

Consultant Physiotherapist.