Introduction
The importance of a respiratory physiotherapy in intensive care units The physiotherapy science that study objective is the human movement goes to collaborate, launching hand of physiotherapy knowledge and resources, with the goal of better understanding the factors that can let to loss or diminishment of the quality of life and of the well-being of the people. The intensivist physiotherapist is that has it total dedication turned on the critic patient, realizing functional diagnostics and deciding the intervention by using kinesiologic and instrumental procedures, with the objective of amelioratingthe patient, discussing with the multidisciplinary team of coherent way to the patient's permanence in the intensive therapy. For that, is important to realizea specific training in former centers to form professionals to actuate on secure and adequate way on the Intensive Care Unit. The Intensive Care Unit The idea of to have specific locals to the more critical patients. Initiated in Denmark on the poliomyelitis epidemic in the 1950s due to the need of ventilatory support to the patients [1]. After, it was initiated, a movement to make the profession- als that act in this area with determinate specific knowledge, it will be the first one the intensivist physician. Today, these units correspond to about of 5 to 10% of the beds of a hospital. An intensive care unit (ICU) is a local destination for grave or potential grave patients that need of continuous treatment during 24 hours by a multidisciplinary team formed by physician, physiotherapists, nurses, and others not less important, such as sectors of clean, maintenance, pharmacy, and laboratory [2]. All trained and turned on to the treatment of critical patients would be assistants or environmentalists. These places have been for a while, considerably cold and closed; there aren’t contact with relatives. Today, much ICUs are open to visit diary and some open during any hour of the day or night to the relatives. There is a discrete confusion between nomenclature, ICU and ITC (Intensive Therapy Centre); the second is the result of the presence of more of a sector of intensive treatment. After the recover and high of ICU, the patients could be forwarded to the intermediate care units before known as semi-intensive units [3]. Each ICU bed must have the presence of fowler bed, multiparametric monitor, continuous infusion bomb, AMBU and gas networks with exits to compress air and oxygen, aspirator, and a microprocessor mechanical ventilator, in addition of the possibility of special mattresses that objectively help in the prevention of pressure ulcers. Patients will be admitted to ICU it they require intensive care therapy and/or intensive monitoring [4]. The physiotherapy approaches inside the ICU include assistance in the removal of secretions, improve ventilation of all areas of the lungs, maintained mobility and good posture of the patients, and decreased patient hospital stay [5-6]. In the ICU the most common techniques used by physiotherapists are postural drainage, percussion and vibrations, tracheal suctioning, lavage and coughing, mobilization techniques, breathing exercises, and incentive spirometry [7].
Methods of Airway Clearance
The first method is the Ciliary action that causes the mucus blanket that covers the tracheobronchial tree epithelium to be mobilized in a continuous motion toward the hilum of the lung, and to the Larynx where the mucus is moved into the pharynx and may be coughed up or swallowed. The mucous blanket moves at a reasonably rapid rate of 16 mm/min and can completely clean the normal adult lung in less Than 20 minutes. Ciliary activity may be impaired by a history of smoking, surgery, anesthesia, trauma, or pre-existing lung disease; pain and mobility accompany recovery and further impede secretion clearance and reduce lung volumes—consequently, secondary techniques for airway clearance, such as coughing and suctioning, become increasingly important in the prevention of atelectasis and pulmonary infection [8]. The second method, Coughing is considered an extremely important mechanism for the removal of lung secretions. In addition, Coughing is a major defence against retained secretions. The cough mechanism involves some phases, initiating with an adequate inspiration followed by an inspiratory pause, and then the glottis must close tightly. With the glottis closed, the prime mechanism for increasing intrathoracic pressures is to increase intra-abdominal pressure, which will push the diaphragm upward, decreasing the volume of the thoracic cavity. After that the glottis suddenly opens and allows high-velocity airflow from the lungs. Peak flow rates may be as high as 300 litre/minute [9]. But it could occur through the suppression of the cough by involuntary or voluntary suppression. The causes of involuntary cough suppression are: the decreased inspiratory effect, as in patients with quadriplegia; inability to close and then open the glottis, as in patients with recurrent laryngeal palsy; and the diminished expiratory effect as in patients with quadriplegia and paraplegia. So, the causes of voluntary cough suppression are the result of fear or pain. Fear can be minimized by preoperative instruction. The pain after surgery cannot be eliminated but can be alleviated with analgesics, and instruct the patients to compress or support the operated part [10]. The cough could be stimulated by some methods [11-12] as huffing, vibration, deep breathing exercises, external tracheal stimulation, stimulation of the oropharynx with a suction catheter, and suctioning. Huffing is a forced expiratory effort is made, but the glottis remains open, and the intrathoracic pressure does not rise to such high levels as in a cough, causing rapid changes in airflow that may oscillate the secretions and hence mechanically stimulate a normal cough. Vibration over the chest during expiration causes increased expiratory force and may increase cough effectiveness. The increased lung volume achieved by accumulating inspiratory effect may make for a more effective cough. The external tracheal stimulation is achieved by applying manual pressure to the trachea above the manubrial notch. This creates partial tracheal compression, which often causes mechanical stimulation to the cough mechanism. The use of the suction by catheter to do the stimulation of the oropharynx must occur when none of the above methods of cough stimulation were successful. Some complications of cough there are, as bronchoconstriction trauma [13] to airways and larynx, barotrauma, pneumothorax, interstitial emphysema, decreased venous return, arrythmia, transient systemic hypertension and hypotension, syncope, rib fractures, urinary incontinence, ruptured rectus abdominus muscles, and pulmonary emboli.
Tracheal Suction
Suctioning is performed routinely on intubated patients to aid in secretion removal and cough stimulation. The fre- quency of suctioning is determined by the quantity of se- cretions. Oropharyngeal airways are used in unconscious patients who are unable to maintain a patent airway. These airways should not be used in conscious and semiconscious patients in whom they may induce vomiting and subsequent aspiration. The proper size of an oropharyngeal airway is estimated by placing it along the cheek and measuring the distance from the corner of the mouth to the ear. Nasopharyngeal airways are used to maintain a potent airway and for frequent naso- tracheal suctioning [14]. The advantage of the nasal airway over the oral airway is that the conscious and semiconscious patient better tolerates it. The proper distance for insertion of the nasopharyngeal airway is estimated by measuring from the tip of the nose to the ear and adding 1 inch. Before insertion, the airway should be lubricated with water -solu- ble lubricant. The endotracheal tube is used to prevent air- way obstruction, to facilitate suctioning, to provide mechanical ventilation, and to protect the lower airway from foreign objects. The endotracheal tubes are usually constructed of- polyvinyl chloride (PVC) or silicone. PVC is rigid to facilitate insertion of the tube becomes softer at body temperature. PVC does not react with tissues and is smooth to facilitate passage of suction catheters. The tube contains marking for inside diameter (ID) and outside diameter (OD) in millimeters. The cuff present in the endotracheal tube can be inflated with air using a syringe. The cuff provided fixation of the endotracheal tube prevents air leak from the trachea and produces minimal pressure on the tracheal mucosa and thus minimal ischemic injury to the tracheal wall [15]. A tracheostomy tube has several advantages over oral or nasal endotracheal tubes. Suctioning is facilitated, it is better tolerated by the conscious patient, fixation of the tube is easier, eating and even speaking is possible, and changing the tube is easier. A tracheostomy is also used when a long-term airway is needed and it is usually considered after 10 to 14 days of intubation [16]. The basic steps of the suctioning procedure are Provide the patient with supplemental oxygen before suctioning to increase arterial oxygenation—a patient receiving mechanical ventilation may not require this step; Check the amount of negative pressure produced by the suction apparatus and, if necessary, adjusts to 100 - 160 mmHg. Put a sterile glove on the dominant hand. Gloves should be worn on both hands to protect the clinician from contamination. Expose the vent end of the catheter and connect it to the suction tubing. Any part of the catheter that may contact the patent’s trachea must be kept sterile; Slide the catheter out of its packaging, taking care not to cause contamination; Disconnect the pa- tient from the ventilator or oxygen source; Gently insert the catheter into the tracheal tube. No suction is applied during insertion of the catheter; If resistance to the catheter is pres- ent, pull the catheter back slightly and attempt to reinsert; Apply suction by placing a finger over the vent. Turn the cath- eter slowly while withdrawing it, so that the side holes of the catheter are exposed to a greater surface area; Reconnect the patient to the ventilator or oxygen source [14-15]. Difficulty cannulating the main stems bronchus It is more difficult to pass a suction catheter into the left than the right main bronchus. In adults; the right main stem bron- chus usually comes off at an angle of about 200 from a midline sagittal plane, whereas the left main stem bron- chus has a more marked angle of about 35° (making the left more difficult to successfully cannulate). similar angles of bifurcation are noted in the neonate (24o for the right and 44o for the left). It is suggested that turning the head to the right or tilting the body to the left increas- es the chances of successful cannulation of the left bronchus. Curved-tip (crude) catheters are thought to improve the chances of entering the left lung during suctioning. Catheters are typically made of polyvinyl chloride or rubber, polyvinyl chloride catheters are preferred as: they are less likely to cause irritation, allow visualization of suctioned secretion because they are clear; easier in insertion and can be directed more easily. Some complications of tracheal suctioning [17] are hypoxemia during suctioning, and each suctioning procedure is lim- ited to a total of 15 seconds; arrhythmia that may occur during suctioning process from two sources, arterial hypoxemia and vagal stimulation; hypotension occur from either of two cir- cumstances, the profound bradycardia resulting from vagal stimulation or the prolonged coughing maneuvers during the suctioning process. The hypoxemia, the arrhythmia and the hypotension are bet avoided by suctioning technique by pre and intermittent oxygenation with high inspired oxygen con- centrations, or by limitation of the suctioning process to 10- 15 seconds or less, or by close cardiac monitoring. The insertion of large suction catheter into a small diameter artificial airway result in inadequate space for air to present around the catheter. Thus, when a vacuum is applied the lung may collapse. This is avoided by using a catheter whose diameter is smaller than one-half the internal diameter of the tube being suctioned. The nasotracheal suctioning complications include oxygen desaturation, hypoxia, severe cardiac arrhythmias, and laryngeal spasm or bronchospasm [18]. Other adjuncts made to coughing and suctioning are: lung wash that infusion of sterile saline into the lungs with the intent of washing out secretions or mucus plugs, it will be the use of small amount lavage (<10>The role of bronchoalveo- lar lavage remains experimental in most diseases and plays a more important role in diagnosis than in the therapeutic management of lung pathology [19]. Bagging is a means of providing artificial ventilation by use a manual resuscitator bag, which is usually connected to an oxygen supply. If the patient is not intubated a mask may be attached to the bag and placed over the patient’s face, covering the nose and mouth. For the intubated patient, the mask is removed and the bag is connected directly to the tracheal tube. Bagging [20] is performed by squeezing the bag rhythmically, to deliver a volume of gas to the patient. Expiration is passive. Bagging is most frequently used for resuscitation, transportation of a patient requiring mechanical ventilation and conjunction with suctioning of spontaneously breathing patients. The postural drainage is a procedure where there are positions that promote gravity-assisted drainage of secretions in lung segments that are positioned uppermost [21]. The majority of ICU treatment is for lower lobes. Some problems associated with obtaining the ideal postural drainage inside de ICU are: turning the patient with multiple injuries; turning the patient into the prone position; turning the patient with intravenous lines; turning the patient with chest tube or tra- cheal tube or feeding tube or sump drains; turning patients with a urinary catheter [22]. Percussion and vibration The use of percussion and vibration in the patients require that the maneuvers used in combination with postural drain- age and the facilitation large and small airway clearance by advancing secretions centrally so that it can be expectorated or suctioned. The percussion is a rhythmic clapping with cupped hands over the involved lung segment. It aids in separation of se- cretions form the wall of airways [22-23]. It is applied during inspiration and expiration, not should cause pain to the pa- tient. It is applied over the bare area of the thorax. It was notice that obesity and bulky dressing decrease percussion effects. In children percussion [24] must be applicated with bell end of the stethoscope, 30 mL medicine cup with pad- ded rim, rubber nipple, and tenting hand (overlapping of the 2nd finger on 1st and 3rd fingers).Vibration is intermittent chest wall compression applied during expiration over the affected area of the lung, in the direction of the chest motion, and used in combination with postural drainage [22-25]. Separate secretions from the walls of large and small airways are obtained using a frequency of vibration about 12-20 Hz, gentle shaking form of vibration. Manual vibration and percussion have the following advan- tages over mechanical devices as: it can be modified for cas- es with rib fractures not detected with x-ray; therapist can monitor patient responses by manual palpation and visual inspection; it can be adjusted to suit patient needs; many benefits can be obtained from manual techniques; there is no advantage for mechanical devices over manual techniques [26]. Methods of improving ventilation The breathing exercises assist in removal of secretions, improve respiratory muscle strength and endurance, increase thoracic cage mobility and expansion, and promote relaxation. They include diaphragmatic breathing exercises, pursed-lips breathing and nose exercise, upper costal breathing, lower costal breathing, apical breathing and sternal breathing exercise, exercise connected with breathing, and belt exercise. Incentive spirometer (IS) It is a therapeutic modality that relies on the patient own effort to perform a hyperinflation manoeuvre and provides biofeedback to the patient [27]. When the patient observes his/her inspired volume, he/she can be encouraged to work by inhaling more and more. It is an effective method in prevention and reversal of lung collapse, and the promotion of cough is postoperative cases. There are three types of IS: volume-oriented incentive spirometers (Voldyne, Volurex) [28], flow-oriented incentive spirometers (Triflow) [29], and photoelectric-oriented incentive spirometers (Spirocare) [30]. The clinical application of incentive spirometers is evaluation and diagnosis of respiratory disorders, prevention and treatment of atelectasis and promotion of cough in postoperative cases, and improvement of patient exercise performance.
Immobilization and methods of mobilization in- side ICU
Factors lead to immobilization inside ICU The administration of anaesthesia, sedation, and neuromuscular cular blockers; A skeletal traction, casting, and splinting; A neurological disorder such as paralysis Pain; General weakness and malnutrition; Use of monitoring equipment. There are existing factors to indicate immobilization inside de ICU [31].
Effects of immobilization
In the Cardiovascular system: Decrease of blood volume, plasma volume and Hb concentration; The physical deconditioning as decreasing aerobic work capacity and endurance; Postural hypotension; Venous thrombosis and pulmonary emboli. They are factors that affect the cardiovascular system [32-33]. In the Respiratory system: Decrease of vital capacity and total lung capacity, anteroposterior diameter and lateral diameter of the chest; secretion retention produces small airway closure, leads to atelectasis (collapse) [33]. In the Metabolic system: Producing Osteoporosis, formation of kidneys and urethral stones [34]. In the Musculoskeletal system: Provokes muscle weak- ness, atrophy, joint contractures, and pressure ulcers [35]. In the Central nervous system: Exacerbate emotional and behavioral changes (childlike behavior), anxiety, and depression [36].
Methods of Mobilization inside ICU
The patient's mobility should be initiated in the the ICU in order to prevent complications of bed rest and immobilization. As the patient progresses, activities can be modified accordingly. The passive movement is always possible in spite of numerous intravascularlines and life- sustaining and monitoring equipment.
Bedridden patient
The passive movement should be done for bedridden patients [37]. Once there is active participation in the desired motions, active exercises become possible. Continuous passive motion (CPM): can be used in the ICU to improve range of motion and tissue healing as well as decrease pain and edema following joint surgery. Adding resistance to movement may improve strength by the effect of gravity, manual resistance, weights, and pulleys. Endurance can be improved by increasing the number of repetitions of any given exercise.
Standing and ambulation
Sitting balance is a prerequisite for standing. Standing balance is a prerequisite for walking. Walker and crutches may be used during walking. During ambulation, intravenous lines may be attached to a rolling IV pole. ECG, arterial, central venous pressure lines, chest tubes, and abdominal sump can be disconnected temporarily with permission. The collection bag of the urinary catheter may be fixed to the base of the rolling pole during ambulation. An oxygen tank with added humidification can be secured to a standard walker or IV pole. Early mobilization often diminishes the need for long and vigorous chest physical therapy [38].
Equipment used for Mobilization
A pulley system with overhead traction units, ropes, weights, and pulleys. The use of a safety belt for patient transferring. Adjusting the the walker and crutches. An IV rolling pole and a source of supplemental oxygen can be adjusted [39].
Conclusion
This work pretends to present the utilization of physiotherapist methods and its consequences in develop better condi- tions through the patients in intensive care units. Presenting this revision guide to give a north to all physiotherapists and health professionals.
Summary
This work tries to present physiotherapy as the simplest way of treatment used in the intensive care unit. The physiotherapy techniques involved are used to improve the patients’ condition and quality of life. The utilization of physiotherapist methods and its consequences in developing better conditions through the patients presenting on this revision guide to give a way of treatment to cardiopulmonary physiotherapists and their patients that still in intensive care units.
Declarations
Ethical approval: not applicable.
Competing interest: The authors declare that they have no competing interests in this work.
Author's contribution: all authors have the same contribution in this article.
Funding: not applicable.
Available data: not applicable.
