Discuss the role of physiotherapists in the management of patients in the ICU.

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College Answer

Physiotherapists are part of the multidisciplinary team providing care to patients in the ICU.

Physiotherapists perform an assessment that includes the respiratory, cardiovascular, neurological, and musculoskeletal systems to formulate treatment plans.

The traditional focus of treatment has been the respiratory management of both intubated and spontaneously breathing patients however emerging evidence of the longstanding physical impairment suffered by survivors of intensive care has resulted in physiotherapists re-evaluating treatment priorities to include exercise rehabilitation as a part of standard clinical practice.

The goals of respiratory physiotherapy management are to promote secretion clearance, and to maintain or recruit lung volume, in both the intubated and spontaneously breathing patient. In the intubated patient, physiotherapists commonly employ manual and ventilator hyperinflation and positioning as treatment techniques whilst in the spontaneously breathing patients there is an emphasis on mobilisation.

Physiotherapists have a role in maintaining joint and muscle function in those who are at risk of contractures, for example in neurological injuries and patients with prolonged paralysis. A trend toward an emphasis on exercise rehabilitation over respiratory management is increasingly evident as survivors of a prolonged ICU stay can suffer deconditioning, muscle atrophy, and weakness that may impact upon quality of life.

Additional roles include the fitting of cervical collars, spinal braces, slings etc. in trauma patients, setting up TENS machines and patient education (exercise, rehab etc.)

Discussion

This topic merited an entire chapter in Oh's Manual; and therefore we can expect that this question is the college's way of investigating whether or not anybody has read that chapter. Specifically, the chapter begins with a list of the main roles of the physiotherapist in the ICU.

Thus, it is the primary source for the answer below.

  • Optimisation of cardiopulmonary function
  • Assistance in the weaning process utilising ventilatory support and oxygen therapy
  • Instigation of an early rehabilitation/mobilisation program to assist in preventing the consequences of enforced immobility
  • Advise on positioning to protect joints and to mini-mise potential muscle, soft tissue shortening and nerve damage
  • Optimisation of body position to effect muscle tone in the brain-injured patient
  • Optimisation of voluntary movement to promote functional independence and improve exercise tolerance
  • Management of presenting musculoskeletal pathology
  • Advise and education of family and carers
  • Liaison with medical and nursing staff on the continuation and monitoring of ongoing physiotherapy-devised care plans.

A more structure list-like answer would resemble the following:

  • Respiratory optimisation
    • manual hyperinflation, suction, inspiratory muscle training, positioning, percussion/vibration
  • Musculoskeletal optimisation
    • Mobilisation, joint-protective positioning, tone-improving positioning
  • Orthopedic
    • Management of immobilisation devices, application and removal of plaster casts, fitting of collars, braces and slings
  • Rehabilitation
    • Exercise and education to improve function following a period of critical illness

At some point, the cynical candidate should use a key phrase such as "multidisciplinary team", "collaborative interdisciplinary care" or "shared therapeutic strategy". 

Potential risks of physiotherapy:

  • Airway trauma from suctioning
  • Deterioration in gas exchange
  • Barotrauma
  • Paradoxically, chest physiotherapy can actually increase the duration of ventilation (Maie et al, 2007)
  • Haemodynamic instability
  • Increased cardiac output requirements
  • Rise in ICP
  • Increased patient pain, stress and anxiety
  • Risk of falls
  • Pressure areas from splints
  • Wound dehiscence (eg. of laparotomy wounds)
 

References

Oh's Manual (7th ed) Chapter 5 (pp.38)  Physiotherapy  in  intensive  care   by Fiona  H  Moffatt  and  Mandy  O  Jones

Stiller, Kathy. "Physiotherapy in intensive care: towards an evidence-based practice." CHEST Journal 118.6 (2000): 1801-1813.