Chest physiotherapy in the management of ICU patients

immediately after extubationSahar Elkaradawy

Assistant Professor in Anaesthesia and Intensive Care Unite .

Weaning from ventilation Weaning process is a

liberation of patient from ventilator, after resolution of illness.

Role of physiotherapist after extubationPhysiotherapists are often involved in the

weaning from ventilation to:assist patients to maintain a good respiratory

function prevent re-intubation.

Standardized weaning protocolMechanical ventilation should be

discontinued under the direction of one of three board,

certified critical care physicians respiratory therapists nursing staff.

Criteria for weaning from ventilationCooperative and pain freeGood cough reflex to tracheal suctioningMinimal secretionPaO2to FIO2 ratio >24 kPa > 300 , minute ventilation

≤12 lPEEP <5 cm H2OHb >7 g dl±1Axillary temperature between 36 and 38.5°CPlasma K+ concentration >3.0 and <5.0 mmol litre±1Plasma Na+ concentration >128 and <150 mmol litre±1Inotropes reduced or unchanged over previous 24 hSpontaneous ventilatory frequency >6 min

Evaluation of the cough strengthThe cough strength on command (0 to 5) and

amount of endotracheal secretions (none to abundant). Patients are asked to cough onto a white card through the endotracheal tube. If secretions were propelled onto the card, it is termed a positive white card test (WCT). Patients with weak (grade 0 to 2) coughs and abundant secretions were more likely to fail extubation.

Extubation failureExtubation failure-need for reintubation

within 72 h of extubation, is common in intensive care unit (ICU).

The impact of extubation faliure :increased morbidity, higher costs, higher ICU

and hospital length of stay (LOS) and mortality.

Risk factors for re-intubationPatients with advanced age. High severity of illness at ICU admission and

extubation. ICU factors:o Deconditioned muscles, poor nutrition, upper

airway edema due to prolonged translaryngeal intubation, inability to clear secretions, decreased level of consciousness due to persistent effects of sedative and analgesics and polyneuropathy

Physiotherapy after extubationUpper and lower limb active exercises Deep breathing exercises Chest percussion and vibrations Huffing and assisted cough

The Effect on respiratory mechanicsImprovement of vital capacity maximum

inspiratory pressure immediately after exercise in ICU in extubated patients.

Management of failed extubationA strategy to prevent failed extubation, if

anticipated,: Treatment of causes of muscle weakness and

excessive secretions and daily assessment for readiness to extubate, until predictors become more favorable.

If there is no hope for extubation, non- invasive ventilation and prophylactic steriods are alternative option.

Thank you