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In addition, any adjustments to the treatment technique can be made e. Factors that may indicate caution during the assessment before performing hyperinflation.
Manual hyperinflation MHI involves the delivery of larger than baseline tidal volumes to a peak pressure of 40 cm H 2 O. Technique: delivery of a slow inspiration, a 2—3 s inspiratory hold, and a fast uninterrupted expiratory flow that mimics a forced expiration. This is particularly useful in patients who are PEEP-dependent.
If there are concerns regarding the risk of barotrauma, a manometer can be put into the MHI circuit and the MHI breaths can be limited to a set pressure. The main advantage of using MHI over ventilator hyperinflation VHI is that the physiotherapist can gain proprioceptive feedback from the bag, which can allow for assessment of lung compliance to take place.
As the name would suggest, these hyperinflation breaths are performed while the patient remains on the ventilator. Technique: in the spontaneously breathing patient, VHI is achieved by making incremental increases in pressure support.
When a patient is on controlled modes, it is done by either altering pressure or volume limits to reach a predetermined target volume or pressure. The patient's tidal volume is increased by ml increments until a peak pressure of 40 cm H 2 O is achieved. Six breaths are delivered and then ventilation is returned to the original parameters and the patient is allowed to rest for 30 s and repeat as required.
The use of a high PEEP is currently thought to be part of an optimal ventilatory strategy for acute lung injury and the maintenance of the PEEP is beneficial in those patients who are at potential risk of ventilator-associated lung injury. However, recruitment manoeuvres which are similar in principle to VHI are used more frequently by medical staff.
Continuous lateral rotational therapy involves the use of specialized beds that rotate along the longitudinal axis with a pre-set speed and degree of rotation. The aim is to reduce atelectasis and improve drainage of secretions, although this therapy is not commonplace in the UK mainly due to a lack of evidence of cost-effectiveness.
It has been found that when comparing supine with standing values, rib cage displacement increased by Adverse effects to positioning patients with their heads down include arrhythmias and raised intracranial pressure.
The most common arrhythmia is bradycardia; this is likely to be secondary to stimulation of sino-aortic baroreceptors, leading to a reflex sympathetic withdrawal or parasympathetic increase in nervous input to the heart. It is best being selective with positioning based on individual need and response to the process rather than it being routine. Different mechanisms can be responsible for why patients are unable to clear secretions independently; therefore, it is important that the physiotherapist correctly identifies the problem and selects the correct intervention to facilitate sputum clearance.
Percussions are performed using cupped hands to clap over the affected part of the lung and can be added to postural drainage. The theory is that percussion generates flow transients in airways beneath a percussed segment.
Vibrations can be performed manually or using mechanical devices to compress the chest wall during the expiratory phase. The application of the aforementioned techniques mobilize secretions in the more peripheral airways centrally, so they can be removed via suction. Secretions in the more peripheral airways should not be removed by airway suction. The recommended suction pressure is 11—16 kPa this can be increased to 20 kPa if the secretions are very thick.
The catheter diameter should be no greater than half the internal diameter of the tracheal tube TT or the tracheostomy. The length of time for suction should be no greater than 15 s. The correct sizing, timing, and suction pressure are essential to reduce the risk of trauma, atelectasis, and hypoxia. Most contraindications to suction are relative to the patient's risk of developing adverse reactions or worsening clinical conditions as a result of the procedure.
When indicated, there is no absolute contraindication. Table 4 identifies the potential adverse effects of suction. These adverse effects need to be taken into account before carrying out each suction and attempts made to ensure the potential for the adverse effects to occur are minimized. Suction can be performed via an open or a closed technique.
The circuit is not broken using closed suction and disruption is minimized during the suction process, this being especially important if the patient has high oxygen or ventilatory requirements. There is also less chance of cross-infection, especially if secretions contain blood. With TTs in situ , 0. It is suggested that between 2 and 5 ml is used pre-suction if deemed necessary.
It is thought instillation works by a combination of loosening any secretions present and by increasing spontaneous cough strength in adults. There is insufficient evidence to support the use of sodium chloride instillation and it should not be routinely performed when performing tracheal suction. Mobilization refers to any activity sufficiently performed to produce physiological effects on the body that enhance ventilation, perfusion, circulation, and muscle metabolism.
It may involve any of the following: passive and active turning and moving in bed, active-assisted and active exercises, pedal cycles in bed, tilt table, sitting at the edge of the bed, standing with the assistance of the physiotherapist and with or without the help of standing or walking aids , transfers from bed to chair, chair-based exercises, and walking. Bed rest and deconditioning are major problems associated with prolonged mechanical ventilation.
The patient will usually remain in bed, which can lead to muscle weakness, including the muscles used for breathing. Muscle wasting, skin sores, joint pain and stiffness caused by lack of movement are risks facing patients as they recover from a critical illness. Physiotherapists will assess patients in critical care for breathing difficulties or coughing, using techniques to help bring up phlegm or to make breathing easier.
Physios will assist patients in breathing independently, and help keep their chests clear of mucus to prevent lung infections. Physios also aid physical recovery, encouraging patients to sit, stand with support and walk as early as possible.
In addition, physios will teach specific exercises to be done at different times of the day. Some hospitals offer follow-up physiotherapy after a period of critical illness, to help people regain full fitness. If this is not available, your GP or hospital consultant may be able to refer you to your local physiotherapy service for ongoing rehabilitation. If you have been critically ill, you were most likely asleep or sedated when the physiotherapist first assessed you. Usually the physio will have listened to your breathing and moved your limbs to assess the impact of your illness or injuries.
And please circulate as widely as you can via all local and national networks, forums and social media Involves creating a UK critical care physiotherapy database for research purposes.
This database would be for contact purposes only to facilitate access for conduct of various research studies; inclusion of contact details on this database would not commit any individual clinician from participation in any study. If you are the senior critical care physio within your team, please get in touch on my email below and I will send you a specific information sheet regarding this.
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