Critically ill patients frequently suffer long-term physical and psychological complications.(1) For patients mechanically ventilated for more than 7 days, 25% display significant muscle weakness,(2) and approximately 90% of long-term ICU survivors will have ongoing muscle weakness.(3) Prolonged stays in the intensive care unit are also associated with impaired quality of life,(4) functional decline and increased morbidity, mortality, cost of care and length of hospital stay.(5)
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Physiotherapy is both safe(6) and effective.
Physiotherapists are an integral part of the multi-disciplinary team in critical care, and are uniquely qualified with skills and expertise to work with the assessment and management of respiratory complications, physical deconditioning, and neuromuscular and musculoskeletal conditions.
Respiratory physiotherapy interventions may include positioning, education, manual and ventilator hyperinflation, weaning from mechanical ventilation, non-invasive ventilation, percussion, vibration, suctioning, respiratory muscle strengthening, breathing exercises and mobilisation.(8)
Size of the problem
- For England the average cost of critical care beds is £1.3 billion annually(7)
- In 2010, almost 150,000 people in England were admitted to an intensive care bed, with a further 590,000 occupying a high dependency bed.(9)
- Approximately 110,000 people spend time in intensive care units after critical illness in England and Wales each year.(10)
There is substantial evidence that supports the role of physiotherapy for the respiratory management of critically ill patients,(8) which has been demonstrated to provide both short-term and medium-term benefits.(11-13) Physiotherapy treatment as part of a multi-disciplinary approach to care is integral in promoting lung function, reducing the incidence of ventilator-associated pneumonia, facilitating weaning and promoting safe and early discharge from the intensive care unit.(8, 12, 14-16)
Results of a cross-sectional study for patients who received intensive chest physiotherapy following pulmonary lobectomy estimated that reduced length of hospital stay (median hospital stay decreased from 8.3 to 5.7 days) was judged to be directly attributable to physiotherapy intervention. Further findings indicated a reduction in mortality rates, pneumonia rates and in lung collapse.(17)
Physiotherapy is an important intervention that prevents and mitigates adverse effects of prolonged bed rest and mechanical ventilation during critical illness. Rehabilitation delivered by the physiotherapist is tailored to patient needs and depends on conscious state, psychological status and physical strength. It incorporates any active and passive therapy that promotes movement and includes mobilisation. Early progressive physiotherapy, with a focus on mobility and walking whilst ventilated, is essential in minimising functional decline.(18) If this process does not occur within the critical care environment, there are increased costs of service provision to the health system, as these patients often require extensive periods of rehabilitation and follow-up to meet long-term disability needs as a result of critical illness.(19)
The National Institute for Health and Clinical Excellence (NICE)(10), The European Respiratory Society and the European Society of Intensive Care Medicine(14) recommend early assessment and management of physical morbidity (including mobilisation and muscle training) delivered by physiotherapists and other health professionals. They also recommend that the physiotherapist should be responsible for implementing mobilisation plans and exercise prescription in conjunction with other team members.
Early physiotherapy and occupational therapy of mechanically ventilated patients is safe, well-tolerated and has shown to result in more ventilator-free days compared with standard care, and a shorter duration of delirium.(20) Early rehabilitation of mechanically ventilated patients results in improved respiratory and limb muscle strength and better functional independence at hospital discharge, both in exercise capacity(21) and basic activities of daily living.(20)
Early mobilisation can reduce ICU and hospital length of stay.(21) A study that implemented a physiotherapy led early mobility protocol showed decreased intensive care unit and hospital length of stay (11.2 versus 14.5 days) and a potential cost saving of 7% of standard patient care costs.(22)
The potential savings from early physiotherapy for critically ill patients are significant for the UK health economy as demonstrated through evidence of impact on quality of life, functional independence and hospital length of stay.
More resources for GPs:
1. Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. New England Journal of Medicine. 2003;348(8):683-93.
2. de Jonghe B, Lacherade JC, Sharshar T, et al. Intensive care unit-acquired weakness: risk factors and prevention. Critical Care Medicine. 2009;37(10 Suppl):S309-15.
3. Fink H, Helming M, Unterbuchner C, et al. Systemic inflammatory response syn- drome increases immobility-induced neuromuscular weakness*. Critical Care Medicine. 2008;36(3):910.
4. Montuclard L, Garrouste-Orgeas M, Timsit JF, et al. Outcome, functional autonomy, and quality of life of elderly patients with a long-term intensive care unit stay. Critical Care Medicine. 2000;28(10):3389.
5. Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. American Journal of Critical Care. 2009;18(3):212.
6. Zeppos L, Patman S, Berney S, et al. Physiotherapy intervention in intensive care is safe: an observational study. Australian Journal of Physiotherapy. 2007;53(4):279. URL: http://ajp.physiotherapy.asn.au/AJP/vol_53/4/AustJPhysiotherv53i4Zeppos.pdf
7. Department of Health. NHS reference costs 2009-2010 London: Department of Health; 2011. URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
8. Denehy L, Berney S. Physiotherapy in the intensive care unit. Physical Therapy Reviews. 2006;11(1):49.
9. Department of Health. Critical care beds time series 1999-2011. London: Department of Health; 2011. URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performance...
10. National Institute for Health and Clinical Excellence. Rehabilitation after critical illness, CG83. London: National Institute for Health and Clinical Excellence; 2009. URL: http://www.nice.org.uk/CG83
11. Berney S, Denehy L. A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients. Physiotherapy Research International. 2002;7(2):100.
12. Ntoumenopoulos G, Presneill J, McElholum M, et al. Chest physiotherapy for the prevention of ventilator-associated pneumonia. Intensive Care Medicine. 2002;28(7):850-6.
13. Paratz J, Lipman J, McAuliffe M. Effect of manual hyperinflation on hemodynamics, gas ex- change, and respiratory mechanics in ventilated patients. Journal of Intensive Care Medicine. 2002;17(6):317.
14. Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Medicine. 2008;34(7):1188-99.
15. Choi J, Jones A. Effects of manual hyperinflation and suctioning in respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia. Australian Journal of Physiotherapy. 2005;51(1):25-30. URL: http://ajp.physiotherapy.asn.au/AJP/vol_51/1/AustJPhysiotherv51i1Choi.pdf
16. Malkoc M, Karadibak D, Yildirim Y. The effect of physiotherapy on ventilatory depend- ency and the length of stay in an intensive care unit. International Journal of Rehabilitation Research. 2009;32(1):85.
17. Varela G, Ballesteros E, Jimenez MF, et al. Cost-effectiveness analysis of prophylactic respiratory physiotherapy in pulmonary lobectomy. European Journal of Cardio-thoracic Surgery. 2006;29(2):216-20. URL: http://ejcts.ctsnetjournals.org/cgi/reprint/29/2/216.pdf
18. Perme C, Chandrashekar RK. Managing the patient on mechanical ventilation in ICU: early mobility and walking program. Acute Care Perspectives. 2008;17(1):10-5.
19. Ceriana P, Delmastro, M, Rampulla, C, Nava S. Demographics and clinical outcomes of patients admitted to a respiratory intensive care unit located in a rehabilitation center. Respi- ratory Care. 2003;48(7):670-6.
20. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874-82.
21. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short- term functional recovery. Critical Care Medicine. 2009;37(9):2499-505.
22. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine. 2008;36(8):2238-43.