physiotherapy in intensive care: towards an evidence-based practice

DOI 10.1378/chest.118.6.1801 2000;118;1801-1813 Chest

Kathy Stiller

an Evidence-Based PracticePhysiotherapy in Intensive Care : Towards

http://chestjournal.organd services can be found online on the World Wide Web at: The online version of this article, along with updated information

). ISSN: 0012-3692. http://www.chestjournal.org/misc/reprints.shtml(of the copyright holder may be reproduced or distributed without the prior written permission Northbrook IL 60062. All rights reserved. No part of this article or PDFby the American College of Chest Physicians, 3300 Dundee Road,

2007Physicians. It has been published monthly since 1935. Copyright CHEST is the official journal of the American College of Chest

Copyright © 2000 by American College of Chest Physicians on April 18, 2008 chestjournal.orgDownloaded from

http://chestjournal.org

http://www.chestjournal.org

Usuario

Resaltado

Usuario

Resaltado

Physiotherapy in Intensive Care*Towards an Evidence-Based Practice

Kathy Stiller, PhD

(CHEST 2000; 118:1801–1813)

Key words: critical care; evidence-based medicine; intensivecare; physical therapy

Abbreviations: ABG 5 arterial blood gas; APACHE 5 acutephysiology and chronic health evaluation; CPP 5 cerebral perfu-sion pressure; Fio2 5 fraction of inspired oxygen; ICP 5 intracranialpressure; MH 5 manual hyperinflation; V̇/Q̇ 5 ventilation/perfusion;Vt 5 tidal volume

I n most hospitals in developed countries, physio-therapy is seen as an integral part of the manage-

ment of patients in ICUs. The precise role thatphysiotherapists play in the ICU varies considerablyfrom one unit to the next, depending on factors suchas the country in which the ICU is located, localtradition, staffing levels, training, and expertise. Thereferral process is one example of this variation,whereby in some ICUs, physiotherapists assess allpatients, whereas in other ICUs, patients are seenonly after referral from medical staff.1 The mostcommon techniques used by physiotherapists in theICU are positioning, mobilization, manual hyperin-flation (MH), percussion, vibrations, suction, cough,and various breathing exercises.1–7 Some physiother-apists routinely treat most, if not all, ICU patientswith a combination of these techniques,1 regardlessof the patient’s underlying pathophysiologic condi-tion, with the intention of preventing pulmonarycomplications, whereas other physiotherapists usesuch techniques selectively when they believe theyare specifically indicated.

As the cost associated with the management ofICU patients is very high, the requirement for allthose who work in ICUs, including physiotherapists,to provide evidence-based practice is mandatory.The aim of this article is to review the evidenceregarding the effectiveness of physiotherapy for pa-

tients in the ICU and thus provide a framework forevidence-based practice. Potential areas for futureresearch are also discussed. This review is primarilyconcerned with the management of intubated, me-chanically ventilated, adult patients. The role ofphysiotherapy for nonintubated patients, includingthose receiving noninvasive mechanical ventilation,and pediatric patients is beyond the scope of thisreview.

Initially, a description of the individual physiother-apy treatment techniques and their physiologic ra-tionale will be provided. The literature review of theeffectiveness of physiotherapy for intubated patientsreceiving mechanical ventilation in the ICU will thenbe discussed under the following headings: pulmo-nary function; hemodynamic and metabolic factors;the incidence of pulmonary complications; the clin-ical course of pulmonary conditions; overall out-come; and the effectiveness of the individual com-ponents of physiotherapy. Evidence concerning theeffectiveness of continuous rotational therapy, whichcan be considered a type of physical therapy, will bereviewed in the treatment technique research sec-tion. In view of the large number of studies identi-fied in some of these areas, details of each study willnot be provided. Instead, selected studies that areconsidered to be landmark studies or characteristicof those conducted in the area will be described.Subsequent to the literature review, recommenda-tions for evidence-based practice for physiotherapyin the ICU are considered under the followingheadings: prevention of pulmonary complications;treatment of pulmonary conditions and complica-tions; short-term benefits; selection of individualtreatment techniques; and monitoring required dur-ing physiotherapy.

To ensure that the major relevant articles werereviewed, literature searches were performed using aCD-ROM version of the databases MEDLINE andCINAHL (Cumulative Index to Nursing and AlliedHealth Literature) with appropriate subject headingsand keywords, including physical therapy, intensive

*From the Physiotherapy Department, Royal Adelaide Hospital,Adelaide, South Australia 5000, Australia.Manuscript received July 22, 1999; revision accepted May 17,2000.Correspondence to: Kathy Stiller, PhD, Physiotherapy Depart-ment, Royal Adelaide Hospital, North Terrace, Adelaide, SouthAustralia 5000, Australia; e-mail: [email protected]

critical care reviews

CHEST / 118 / 6 / DECEMBER, 2000 1801



care, rehabilitation, postural drainage, MH, andbreathing exercises. The reference lists of all articleswere reviewed to identify other potentially relevantarticles.

Treatment Techniques

Positioning

Positioning in this context describes the use of body position asa specific treatment technique. Positioning for ICU patients canbe used with the physiologic aims of optimizing oxygen transportthrough its effects of improving ventilation/perfusion (V̇/Q̇)matching, increasing lung volumes, reducing the work of breath-ing, minimizing the work of the heart, and enhancing mucociliaryclearance.8–10 Rather than considering postural drainage as aseparate technique, it is considered herein as one example ofpositioning which has the particular aim of increasing clearanceof airway secretions with the assistance of gravity.

Specific examples of positioning that may be used in the ICUsetting include upright positioning to improve lung volumes anddecrease the work of breathing in patients who are being weanedfrom mechanical ventilation; prone positioning to improve V̇/Q̇matching, redistribute edema, and increase functional residualcapacity for patients with ARDS; side lying with the affected lunguppermost to improve V̇/Q̇ matching for patients with unilaterallung disease; side lying with the affected lung uppermost toimprove ventilation (via distending forces on the uppermost lung)and clearance of airway secretions for patients with acute lobaratelectasis.5,11–22

Mobilization

Mobilization techniques that may be used for intubated pa-tients receiving mechanical ventilation in the ICU include activelimb exercises, the patient actively moving or turning in bed,getting out of bed via mechanical lifting machines or slide boardtransfers, sitting on the edge of the bed, standing, standingtransfers from bed to chair, and walking. The physiologic ratio-nale for mobilization is that it will optimize oxygen transport byenhancing, for example, alveolar ventilation and V̇/Q̇ match-ing.8,10 In addition, mobilization that involves being in the erectposition will have the beneficial effects associated with the erectposition as previously outlined. Mobilization can also provide agravitational stimulus to maintain or restore normal fluid distri-bution in the body and to reduce the effects of immobility andbed rest.8,10 In the longer term, mobilization aims to optimizework capacity and functional independence and to improvecardiopulmonary fitness.8,10

MH

MH involves disconnecting the patient from the ventilator andinflating the lungs with a large tidal volume (Vt) via a manualresuscitator bag. The technique is usually performed by deliver-ing a slow deep inspiration, an inspiratory hold, and a quickrelease of the inflation bag to enhance expiratory flowrate.4,7,9,23–25 MH is used with the aim of preventing pulmonarycollapse, reexpanding collapsed alveoli, improving oxygenationand lung compliance, and increasing movement of pulmonarysecretions toward the central airways.4,5,7,23–27 It is likely that theadditional Vt delivered with MH reaches the most compliantparts of the lungs and so expands normal rather than collapsedalveoli, although it may help reinflate collapsed alveoli by pro-moting airflow through collateral channels and the phenomenonof interdependence.9,24

It is important to differentiate between MH and manualhyperoxygenation, the latter being the delivery of high levels ofoxygen, using a manual resuscitator bag, but with no attempt toincrease Vt to the extent sought with MH. Manual hyperoxygen-ation is usually performed before and between suction passes, withthe specific intention of preventing suction-induced hypoxemia.

Percussion and Vibrations

Percussion and vibrations are techniques that are believed toincrease clearance of airway secretions by the transmission of anenergy wave through the chest wall.28 Percussion may be per-formed manually by clapping the chest wall over the affected areaof the lung, using cupped hands.28 Vibrations may be appliedmanually by vibrating, shaking, or compressing the chest wallduring expiration. Both percussion and vibrations can also beperformed using mechanical devices.28

Suction

Suction via an endotracheal tube or tracheostomy is used withthe aim of removing secretions from the central airways andstimulating a cough.2,3,5

Limb Exercises

Limb exercises (passive, active assisted, or active resisted) maybe performed with ICU patients with the aim of maintaining orimproving joint range of motion, soft-tissue length, musclestrength, and function, and of decreasing the risk of thromboem-bolism.2,9,29

Continuous Rotational Therapy

Continuous rotational therapy refers to the use of specializedbeds that continuously and slowly turn a patient along thelongitudinal axis, up to an angle of 60° onto each side, with thedegree and speed of rotation preprogrammed.30,31 The therapy isachieved by the entire platform of the bed rotating (also knownas kinetic therapy) or by the inflation and deflation of compart-ments in the mattress (also known as oscillating beds).30,31 Therationale for the use of continuous rotational therapy is that it willprevent dependent airway closure, decreased compliance, atel-ectasis, pooling and stagnation of pulmonary secretions, andsubsequent infection that are believed to result from prolongedimmobility.31

Evidence Regarding Effectiveness ofPhysiotherapy in the ICU

The Effect of Physiotherapy on PulmonaryFunction

Many studies have investigated the short-termeffect of multimodality respiratory physiotherapy(eg, positioning, percussion, vibrations, MH, andsuction) on the pulmonary function of intubatedICU patients receiving mechanical ventilation.17,32–37

Mackenzie and Shin,32 in a study typical of thoseconducted in this area, examined the effect of aphysiotherapy treatment (consisting of posturaldrainage, percussion, vibrations, and suction) admin-istered to each of 19 patients receiving mechanicalventilation (12 men, 7 women; mean age, 32.4 years).All patients had respiratory failure after trauma thathad occurred a mean of 4.4 days before the study.

1802 Reviews



Various respiratory variables were measured beforeand up to 2 h after treatment. It was not noted whorecorded these measurements. No significantchanges were found in arterial blood gas (ABG)measurements, but intrapulmonary shunt signifi-cantly decreased by a mean of 20% immediatelyafter physiotherapy (from a mean of 16.4 to 13.2%),and there was a significant increase in total lungcompliance of 14% 2 h after physiotherapy (from amean of 29 to 33 mL/cm H2O).

Other studies have also demonstrated significantimprovements after physiotherapy in lung compli-ance, ABG values, and intrapulmonary shunt.17,35,37

These improvements were usually of short duration,but improvement lasting up to 2 h after treatmenthas been reported.35 However, other studies havereported no significant changes in pulmonary func-tion after multimodality physiotherapy.33,34,36 In vir-tually all of these studies, measurements were takenbefore and after physiotherapy, without the inclusionof a control group that received no intervention oranother treatment group to enable comparison ofoutcomes. This may be an important omission, asSasse et al,38 who measured ABGs for a 1-h period in28 ICU patients, with all facets of management beingheld constant during this period, found that themean intraindividual variation was 6% for the Pao2and 5% for the Paco2. Thus, there is a substantialspontaneous variability for ABG values, whichshould be taken into account when interpreting suchdata.

The Effect of Physiotherapy on Hemodynamic andMetabolic Factors

The hemodynamic and metabolic effects of mul-timodality respiratory physiotherapy for intubatedICU patients receiving mechanical ventilation havebeen extensively investigated.4,39–48 The hemody-namic effects associated with physiotherapy werecomprehensively reviewed by Paratz.9

In an example of the studies conducted in thisarea, Cohen et al47 evaluated the hemodynamic andmetabolic effects of respiratory physiotherapy for 32patients receiving mechanical ventilation (18 men,14 women; mean age, 62.0 years). All but twopatients were studied in the postoperative period,and all patients were hemodynamically stable andreceiving ventilation using the synchronized inter-mittent mandatory ventilation mode. Patients weredivided into two groups, each containing 16 patients.All patients, who were receiving physiotherapy treat-ment as part of their routine care, received twophysiotherapy treatments in randomized order—onetreatment was preceded by administration of propo-fol and the other treatment was preceded by admin-istration of a placebo drug. The dosage of propofol

administered before treatment varied between thetwo groups—one group received 0.75 mg/kg, andthe other group, 0.35 mg/kg. The physiotherapytreatment consisted of percussion in alternate side-lying positions, followed by suction in the supineposition. Hemodynamic and metabolic variableswere recorded during an initial baseline rest period,immediately after the physiotherapy treatment, andduring a rest period after treatment. It was not notedwho collected these data or whether they wereblinded to the study. Significant and at times dra-matic increases in heart rate, systolic and mean BP,cardiac output, oxygen consumption, carbon dioxideproduction, and Paco2 were found during the phys-iotherapy treatment. The administration of propofolbefore the treatment decreased or prevented thesehemodynamic and metabolic responses. As an exam-ple of the metabolic effects seen, oxygen consump-tion increased by approximately 70% over baselinevalues during the physiotherapy treatments pre-ceded by the placebo drug (from a mean of 236 to404 mL/min), compared with an increase of 19% forpatients given the higher dose of propofol (from amean of 233 to 277 mL/min) and 43% for patientsgiven the lower dose of propofol before treatment(from a mean of 243 to 348 mL/min).

Other authors have documented similar significantdetrimental hemodynamic and metabolic responsesto multimodality physiotherapy.4,39–46,48 In general,these detrimental effects were noted during physio-therapy and up to half an hour after treatment, andwere reduced or prevented by the prior administra-tion of sedative medications, such as propofol orfentanyl.41,44,47

Horiuchi et al48 further investigated the cause forthe increased metabolic and hemodynamic re-sponses during physiotherapy by studying sevenpatients receiving mechanical ventilation after majorvascular or abdominal surgery (no other patientdetails were provided). These patients all receivedtwo standardized physiotherapy treatments (consist-ing of percussion in alternate side-lying positions,followed by suction in the supine position), with thefirst treatment preceded by midazolam and thesecond treatment preceded by vecuronium. Theyfound that the administration of vecuronium sup-pressed the increased metabolic demands that wereseen during the physiotherapy treatment precededby midazolam, whereas the hemodynamic responseswere not altered by the administration of vecuro-nium. Thus, they hypothesized that the increasedmetabolic demand during multimodality physiother-apy is an exercise-like response resulting from in-creased muscular activity, whereas the increased

CHEST / 118 / 6 / DECEMBER, 2000 1803



hemodynamic responses are most likely caused by astresslike response associated with an increased sym-pathetic output.

Cardiac arrhythmias have been documented dur-ing respiratory physiotherapy in a study involving 72critically ill ICU patients (42 men, 30 women; meanage, 58.6 years).42 Patients included in this study hada variety of medical conditions, including pneumonia(44 patients), abdominal surgery (19 patients), andacute cardiac conditions (20 patients). Although itwould seem that not all patients were intubated, theexact number of patients intubated and receivingmechanical ventilation, and their mode of ventila-tion, were not reported. A standardized physiother-apy treatment comprising postural drainage andpercussion was performed on all patients. All pa-tients had been referred for physiotherapy by aphysician, but the specific indications for this treat-ment were not described. No cardiac arrhythmiaswere seen for 46 patients (63.9%), minor arrhyth-mias were seen for 18 patients (25.0%), and majorarrhythmias were seen for 8 patients (11.1%). Mostpatients with minor arrhythmias had an increasedfrequency of premature atrial contractions (eightpatients) or less than six premature ventricular con-tractions per minute (six patients). The most com-mon major arrhythmia reported was the occurrenceof more than six premature ventricular contractionsper minute (six patients). None of the cardiac ar-rhythmias seen were life threatening, and in all cases,the arrhythmia resolved spontaneously or on re-sumption of the upright position or cessation oftreatment. It was noted that cardiac arrhythmias weremore common in older patients and those with acutecardiac disorders.

Multimodality physiotherapy has also been shownto increase intracranial pressure (ICP) significantly,although cerebral perfusion pressure (CPP) is usu-ally maintained at adequate levels.43,49–52 The mag-nitude of the mean increase in ICP seen in thesestudies was , 10 mm Hg, with the exception of thestudy by Ersson et al52 in which mean ICP increasedby . 30 mm Hg during suction and manual “bagsqueezing.” In those studies in which BP, ICP, andCPP were measured, the increases in ICP wereaccompanied by increases in BP, therefore resultingin , 10 mm Hg mean change in CPP.43,52

As the physiotherapy treatments applied in themajority of the studies investigating the effect ofphysiotherapy on hemodynamic and metabolic vari-ables used combinations of techniques, such aspositioning, percussion, vibrations, MH, and suction,it is not possible to attribute any decrements infunction to a particular technique. There were alsomethodologic concerns with most studies. The ma-jority studied patients with heterogeneous respira-

tory problems, comparative treatment or controlgroups were not used in most studies, patient num-bers were generally small, and the rationale forphysiotherapy intervention and treatment selectionwas often not provided or questionable.

The Effect of Physiotherapy on the Incidence ofPulmonary Complications

In some hospitals, physiotherapy is performedroutinely on all intubated ICU patients receivingmechanical ventilation, with the aim of decreasingthe incidence of pulmonary complications (eg, nos-ocomial pneumonia, bronchopulmonary infection,atelectasis). To my knowledge, the only publishedreport investigating the effectiveness of physiother-apy in preventing pulmonary complications for intu-bated patients receiving mechanical ventilation is byNtoumenopoulos et al.53 In this key study, 46 pa-tients who were receiving mechanical ventilationafter trauma were randomly allocated to a group thatreceived standard nursing care (which comprised atleast two hourly turns and suction) plus physiother-apy, or standard nursing care alone. The physiother-apy consisted of twice-daily postural drainage, MH,and suction. Outcome measurements included ABGanalyses, the incidence of nosocomial pneumonia,days receiving mechanical ventilation, and length ofstay in the ICU. Nosocomial pneumonia was diag-nosed by consultant or registrar medical staff whowere blind to the patients’ groups, and defined as thepresence of a new pulmonary infiltrate on chestradiograph, together with at least three of the fol-lowing: temperature . 38°C, WBC count . 11,000cells/mL, purulent sputum with bacteria on Gram’sstain, and positive sputum culture. The reliability ofmedical staff involved in the diagnosis of pneumoniawas not investigated. If patients developed nosoco-mial pneumonia, they were withdrawn from thestudy and provided with appropriate physiotherapy.Because of a delay in the final diagnosis of nosoco-mial pneumonia (while awaiting Gram’s stain orsputum cultures), some patients were withdrawnfrom the study owing to the clinical suspicion ofpneumonia.

The profiles of the two groups on entry into thestudy were similar and not significantly differentwith respect to data such as age (mean, 40.1 years),APACHE (acute physiology and chronic health eval-uation) II score (mean, 13.2), and injury severityscore (mean, 26.6). Of the 22 patients in the groupthat received physiotherapy and standard nursingcare, 4 patients (18.2%) were withdrawn because ofa suspicion of nosocomial pneumonia, with 3 of thesepatients (13.6%) subsequently receiving a diagnosisof nosocomial pneumonia. For the 24 patients in thegroup who received standard nursing care alone, 8

1804 Reviews



patients (33.3%) were withdrawn because of a sus-picion of nosocomial pneumonia, with the diagnosisof nosocomial pneumonia confirmed for 4 of thesepatients (16.7%). There were no statistically signifi-cant differences between the two groups in eitherthe number of patients withdrawn from the study onthe suspicion of nosocomial pneumonia or the num-ber of patients with a final diagnosis of pneumonia.Similarly, no significant differences were seen be-tween groups in ABG values, the length of timereceiving mechanical ventilation (mean, 6.1 daysphysiotherapy group; 5.2 days control group), lengthof ICU stay (mean, 7.4 days physiotherapy group; 6.8days control group), or mortality rate in the ICU (0for both groups). As identified by the authors, thesmall sample size was a limitation of the study thatmay have led to a type II error.

The Effect of Physiotherapy on the Clinical Courseof Pulmonary Conditions

The management of pulmonary conditions com-monly found in intubated ICU patients receivingmechanical ventilation (eg, pneumonia, bronchopul-monary infection, atelectasis, acute exacerbation ofchronic pulmonary disease, ARDS) often includesphysiotherapy. However, the effect of physiotherapyon the clinical course of such conditions has beenstudied only for acute lobar atelectasis.17,54–57

Marini et al,54 in a landmark study, investigated 31patients (23 men, 8 women; mean age, 50.5 years)with acute lobar atelectasis diagnosed by chest ra-diograph. There were a variety of primary diagnoses,with postoperative conditions and neurologic prob-lems the most common. Patients were intubated andreceived mechanical ventilation for 43% and 36% oftreatments, respectively. Patients were randomly al-located to a group that received initial fiberopticbronchoscopy followed by physiotherapy or a groupthat received physiotherapy alone. Physiotherapyconsisted of postural drainage, percussion, vibra-tions, MH or deep breathing, suction, or coughing,and was given at 4-h intervals for 48 h. Two exam-iners blinded to the patients’ treatment groups as-sessed the percentage resolution of atelectasis asseen on chest radiograph after the first treatmentand at 24 h and 48 h. Intraexaminer and interexam-iner reliability was not assessed. No significant dif-ference was seen between the two groups in the rateof resolution of atelectasis at any stage, nor werethere significant differences between the groups inABG values.

Fourrier et al57 investigated 26 patients with acutelobar atelectasis (no other patient details were pro-vided) who were randomly allocated to receive eithera single episode of bronchoscopy or a single treatmentof physiotherapy (positioning in side lying, vibrations,

and suction). Chest radiographs were taken initially andat 1 h, 6 h, and 24 h after treatment, and reviewed bytwo examiners who were blind to the patients’ allocatedgroups. It was not noted whether intraexaminer orinterexaminer reliability was assessed. During the 24-hfollow-up period, they found that complete resolutionof atelectasis was seen on chest radiograph for 67% ofpatients who received physiotherapy compared with29% of patients who received bronchoscopy (p 5 0.05).

Other studies have also shown that physiotherapy,incorporating techniques such as positioning, MH,and suction, is an effective treatment for acute lobaratelectasis.17,55,56

The Effect of Physiotherapy on Overall Outcome

With the exception of the study by Ntoumenopou-los et al,53 as outlined previously, the ability ofphysiotherapy to facilitate weaning, shorten thelength of stay in the ICU or hospital, or decreasemorbidity and mortality has not been reported.

The Effectiveness of the Individual Components ofPhysiotherapy

Positioning: Although the physiologic rationale forthe use of positioning with critically ill patients issound, there are limited published data to support itsefficacy in the clinical setting. Prone positioning hasbeen shown to result in short-term improvements inoxygenation for 57 to 92% of patients with severeacute respiratory failure or ARDS.15,16,18–21 As anexample of the improvements seen, Chatte et al,18

investigating 32 patients receiving mechanical venti-lation (24 men, 8 women; mean age, 55.9 years) withsevere acute respiratory failure (Pao2 to fraction ofinspired oxygen [Fio2] ratio , 150) that was notcaused by left ventricular failure or atelectasis, foundthat the mean Pao2/Fio2 ratio significantly increasedfrom a baseline value (supine) of 103 to 158 after 1 hin the prone position and to 159 after 4 h prone.Improvements in lung function have also been

documented for patients with unilateral lung diseasewhen they are positioned in side lying with theaffected lung uppermost.11–14 Ibanez et al11 studied10 patients (7 men, 3 women; mean age, 33.5 years)who were receiving mechanical ventilation becauseof acute respiratory failure and whose chest radio-graph findings predominantly showed unilateral dis-ease. They found that the Pao2/Fio2 ratio signifi-cantly increased from 112 when patients werepositioned in side lying with the affected lung de-pendent, to 189 when in side lying with the affectedlung uppermost.

It is not known whether these improvements inpulmonary function result in faster recovery or im-proved outcome for patients with severe acute respi-ratory failure, ARDS, or unilateral lung disease.

CHEST / 118 / 6 / DECEMBER, 2000 1805



Stiller et al,17 in a study that compared variouscombinations of physiotherapy techniques for 35patients with acute lobar atelectasis, found thatpositioning patients in side lying with the affectedlung uppermost and the head of the bed flat en-hanced the resolution of acute lobar atelectasis, asseen on chest radiograph, when added to a treatmentof MH and suction. The use of traditional posturaldrainage positions did not further add to the efficacyof this treatment.

An additional consideration regarding the use ofpositioning is its effect on gastroesophageal refluxand subsequent pulmonary aspiration and nosoco-mial pneumonia. Torres et al58 investigated 19 pa-tients (13 men, 6 women; mean age, 60 years) whowere receiving mechanical ventilation for acute re-spiratory failure. They showed that the supine posi-tion (compared with the 45° head-up position), andthe length of time in the supine position, are poten-tial risk factors for the pulmonary aspiration ofgastric contents for patients receiving mechanicalventilation. Similar findings were reported in studiesby Ibanez et al59 and Orozco-Levi et al,60 in which, incomparison with the supine position, the semirecum-bent position (45° head up) essentially preventedpulmonary aspiration60 while decreasing (but notpreventing) gastroesophageal reflux for patients re-ceiving mechanical ventilation who have a nasogas-tric tube.59,60

Mobilization: Dean and Ross8 and Dean10 pro-posed that mobilization should be used as a primarymeans of enhancing oxygen transport in patients withacute pulmonary disease, including patients in theICU. Although there is unequivocal evidence thatprolonged bed rest results in deconditioning, to myknowledge, there are no published data involvingintubated patients receiving mechanical ventilationthat investigate the effect of mobilization on pulmo-nary function, the resolution of pulmonary disease,weaning from mechanical ventilation, or the lengthof ICU stay.

MH: Despite the many theoretical aims of MH,there are few definitive studies to support its routineuse. Furthermore, the published research is oftendifficult to interpret, as various combinations ofmachine hyperinflation and MH, with and withoutchanges in the Fio2, have been compared. However,improvements in lung compliance and oxygenationfor up to 2 h after treatment have been noted afterMH.35,37,61 Jones et al,35 for example, found that totalstatic compliance significantly increased by 16%immediately after MH (from a mean of approxi-mately 34 to 40 mL/cm H2O) for 20 patients (15men, 5 women; mean age, 48.7 years) who were

receiving mechanical ventilation for respiratory fail-ure. Other authors, however, have reported no sig-nificant change in oxygenation or compliance withMH.33,36 The effect of MH on longer-term out-comes, such as the resolution of pulmonary diseaseand the prevention of pulmonary complications, hasnot been studied (to my knowledge).

It is known that MH has the potential to resultin high airway pressures and overdistension ofnormal alveoli and may also cause significanthemodynamic changes (eg, decrease in cardiacoutput), partially as a result of the large fluctua-tions in intrathoracic pressure it may cause.4,5,9,61

MH has also been shown to increase ICP andmean arterial pressure significantly for neurosur-gical patients.43 The mean increases seen in ICPand mean arterial pressure were , 5 mm Hg, andCPP was not altered significantly.43 The actualapplication of the technique of MH by bothphysiotherapists and nursing staff, in terms of theVt delivered, airway pressure, amount of positiveend-expiratory pressure applied, flow rates, andFio2, may be quite variable.23,25,26,62,63

Percussion and Vibrations: Although the effective-ness of percussion in enhancing sputum clearancehas been extensively studied in stable, nonintubatedpatients with chronic pulmonary disease, no pub-lished data were found regarding its effectiveness forICU patients. Percussion has been associated withdetrimental effects, such as cardiac arrhythmias anda fall in pulmonary compliance in critically ill pa-tients.35,42

The effectiveness of vibrations for ICU patientshas been evaluated in two studies.17,36 Eales et al,36

investigating 37 patients receiving mechanical venti-lation after cardiac surgery, found that ABG valuesand lung compliance did not significantly changeduring a treatment of MH and suction, with orwithout the addition of vibrations. Stiller et al17

found that the addition of vibrations to a treatmentof positioning, MH, and suction failed to significantlyalter the rate of chest radiograph resolution of theatelectasis.

Suction: Although it is clear in the clinical settingthat suction does achieve its aim of removing secre-tions from the central airways, to my knowledge, nostudies have specifically investigated this. It has beenshown that suction can be associated with manydetrimental effects, such as hypoxemia and hemody-namic instability, as summarized by Paratz,9 andtracheobronchial erosion and hemorrhage.3 How-ever, the use of sedation, reassurance, preoxygen-ation, and optimal technique minimizes the occur-rence of these side effects.9,64–66

1806 Reviews



Usuario

Resaltado

Usuario

Resaltado

Continuous Rotational Therapy: In one of thelargest studies to date investigating the use of con-tinuous rotational therapy in the management ofICU patients, deBoisblanc et al67 studied 120 criti-cally ill patients (age and sex not noted) admitted toa medical ICU. From their clinical presentations, themajority of patients received a diagnosis of sepsis (61patients) or obstructive airways disease (37 patients),and approximately 80% were receiving mechanicalventilation. Patients were randomly allocated to agroup that was nursed on conventional beds andreceived standard 2-h turning by nursing staff or to agroup that was nursed on oscillating beds that ro-tated through an arc of approximately 90° every 7min. The treatment period lasted 5 days. Outcomemeasures included the incidence of pneumonia dur-ing the first 5 days of admission to the ICU, length ofmechanical ventilation, length of ICU and hospitalstay, and hospital mortality. Specific criteria wereused to define pneumonia (a new chest radiographinfiltrate that persisted $ 3 days, temperature of. 38.3°C, purulent sputum, and the growth of oneor more respiratory pathogens). Although it is notedthat the chest radiographs were interpreted by apulmonologist who was blinded to the treatmentgroup, it is not stated whether the person making theoverall diagnosis of pneumonia was also blinded tothe patients’ treatment groups, nor was examinerreliability assessed. The groups were comparable onadmission into the study for perceived risk factors forthe development of pneumonia. For example, therewas no significant difference between groups in theirmean APACHE II scores (mean, 16.8 control group;18.5 oscillating bed group). Overall, a significantlylower incidence of pneumonia was seen in the groupthat was nursed on the oscillating beds (8.7%)compared with those patients nursed on conven-tional beds (21.6%). This effect was most noticeablefor those patients with a diagnosis of sepsis (inci-dence of pneumonia, 23.1% control group; 2.9%oscillating bed group). However, no significant dif-ference was found between groups in the duration ofmechanical ventilation (mean, 9.9 days controlgroup; 6.1 days oscillating bed group), length of ICUstay (mean, 10.8 days control group; 7.8 days oscil-lating bed group), length of hospital stay (mean, 18.5days control group; 17.0 days oscillating bed group),or hospital mortality (27.5% control group; 39.1%oscillating bed group).

Similar significant reductions in the incidence oflower respiratory tract infection, pneumonia, andatelectasis were found by Gentilello et al68 (com-bined incidence of atelectasis and pneumonia, 65.8%control group; 33.3% kinetic therapy group) andFink et al69 (incidence of lower respiratory tractinfection, 58.3% control group; 25.5% oscillating bed

group; incidence of pneumonia, 39.6% controlgroup; 13.7% oscillating bed group) for patientstreated with continuous rotational therapy comparedwith conventional beds. Additionally, Fink et al69

found, for survivors, a significantly lower duration ofintubation (median, 7 days control group; 4 daysoscillating bed group) and length of stay in hospital(median, 44.5 days control group; 20 days oscillatingbed group) for patients nursed on the oscillatingbeds. In a crude cost-benefit analysis, Fink et al69

noted that average costs per day of care in the ICUwere not significantly different for patients treatedwith continuous rotational therapy compared withconventional beds. Significant improvements in ABGvalues and intrapulmonary shunt have also beennoted during short periods on kinetic therapy bedsfor patients with mild to moderate acute lung inju-ry.70 It has been noted, however, that continuousrotational therapy may not be well tolerated by somepatients, who may become agitated during treat-ment.67,69

Limb Exercises: To my knowledge, there are nopublished data regarding the ability of limb exercisesto maintain joint range of motion and soft-tissuelength, improve strength and function, or decreasecirculatory risks for patients in the ICU. Limbmovements, performed passively by a physiothera-pist, have been shown to result in significant in-creases in metabolic and hemodynamic variables forcritically ill patients, with, for example, approxi-mately 15% increase in oxygen consumption demon-strated.40,71 It has also been demonstrated that al-though passive and active limb movements throughrange do not significantly alter ICP or CPP,29,72

exercises involving isometric contraction do have thepotential to increase ICP and CPP significantly(mean increases of 4 mm Hg and 7 mm Hg,respectively, seen for patients with normal ICP).72

As well as performing passive limb exercises withICU patients who are incapable of movement, somephysiotherapists routinely provide resting splints,particularly for the hands and feet, with the aim ofpreventing contractures. There do not appear to beany published data regarding the effectiveness ofsplinting for this patient group.

Summary of Evidence

Table 1 summarizes the evidence concerningphysiotherapy for intubated ICU patients receivingmechanical ventilation. There are data demonstrat-ing that multimodality physiotherapy may result inshort-term improvements in the pulmonary functionof ICU patients. However, it has also been shown

CHEST / 118 / 6 / DECEMBER, 2000 1807



that these techniques may have deleterious effectson hemodynamic and metabolic variables, particu-larly if used inappropriately. There is evidence fromone study that twice-daily physiotherapy, in additionto routine nursing procedures, does not reduce theincidence of nosocomial pneumonia.53 To my knowl-edge, no other studies have investigated the ability ofphysiotherapy to prevent pulmonary complicationsfor intubated ICU patients receiving mechanicalventilation. Physiotherapy has been shown to be aneffective treatment for acute lobar atelectasis, but, tomy knowledge, no studies have attempted to estab-lish whether physiotherapy results in a speedierresolution of other pulmonary diseases, overall re-duction in length of stay, or improved outcomes forICU patients. There is little research into the effec-tiveness of the individual components of physiother-apy, although positioning has been shown to improvepulmonary function in the presence of some disease

processes, and vibrations have not been shown to beof additional benefit. Overall, it is clear that despitethe widespread use of physiotherapy for intubatedICU patients receiving mechanical ventilation, thereis perilously little research to support its role.

Recommendations for Evidence-BasedPractice

Based on the research available, what recommen-dations can be made regarding evidence-based prac-tice for physiotherapy in the ICU (Table 1)?

Prevention of Pulmonary Complications

Is there sufficient evidence to dictate whetherphysiotherapists should routinely use respiratorytechniques with all intubated patients receiving me-chanical ventilation with the intention of preventingcomplications? An intubated patient in the ICU hasmany factors that may adversely affect airway clear-ance, including the presence of an artificial airway,inadequate humidification, medications, underlyingpulmonary disease, and mucosal damage as a resultof suction.3,73 Thus, there are theoretical reasonswhy physiotherapy may be routinely required. How-ever, the expectation that physiotherapy provided afew times a day (in addition to routine nursing care)will decrease the incidence of pulmonary complica-tions may be unrealistic, given that many of the majorcausative factors responsible for the high incidence ofcomplications are not addressed (eg, prolonged immo-bility, microaspiration, reduced host defenses, poornutritional status, colonization of ventilator circuits, andantibiotic treatment leading to lower-airway coloniza-tion and superinfection).74–79

Given the overall limited evidence regarding theeffectiveness of physiotherapy in the ICU, and theresults of one study in which twice-daily physiother-apy did not reduce the incidence of nosocomialpneumonia,53 it could be argued that the routine useof respiratory physiotherapy for all patients is notevidence-based and is therefore unsupportable.

Most authors who have discussed the role of phys-iotherapy in the ICU propose that it should be atherapy that is given for specific indications rather thanroutinely.2,3,5 For example, Ciesla5(p609) described theaim of physiotherapy as being to “. . . minimize pulmo-nary secretion retention, to maximize oxygenation,and to reexpand atelectatic lung segments.” Judsonand Sahn3(p222) concluded that “Chest physiotherapyis clearly effective in intubated patients with acutelobar collapse; however, the routine use of chestphysiotherapy in intubated patients has not beenshown to be of value and cannot be recommended.”Although it is easy to sympathize with these com-

Table 1—Summary of Evidence and Evidence-BasedRecommendations for Physiotherapy in the ICU

Strong evidence that:Physiotherapy is the treatment of choice for patients with acute

lobar atelectasisProne positioning improves oxygenation for some patients with

severe acute respiratory failure or ARDSPositioning in side lying (affected lung uppermost) improves

oxygenation for some patients with unilateral lung diseaseHemodynamic status should be monitored during physiotherapy

to detect any deleterious side effects of treatmentSedation before physiotherapy will decrease or prevent adverse

hemodynamic or metabolic responsesPreoxygenation, sedation, and reassurance are necessary before

suction to avoid suction-induced hypoxemiaContinuous rotational therapy decreases the incidence of

pulmonary complicationsModerate evidence that:

Multimodality physiotherapy has a short-lived beneficial effecton respiratory function

MH may have a short-lived beneficial effect on respiratoryfunction, but hemodynamic status, airway pressure, or Vtshould be monitored to detect any deleterious side effects oftreatment

ICP and CPP should be monitored on appropriate patientsduring physiotherapy to detect any deleterious side effects oftreatment

Very limited or no evidence that:Routine physiotherapy in addition to nursing care prevents

pulmonary complications commonly found in ICU patientsPhysiotherapy is effective in the treatment of pulmonary

conditions commonly found in ICU patients (with theexception of acute lobar atelectasis)

Physiotherapy facilitates weaning, decreases length of stay in theICU or hospital, and reduces mortality or morbidity

Positioning (with the exception of examples cited above),percussion, vibrations, suction, or mobilization are effectivecomponents of physiotherapy for ICU patients

Limb exercises prevent loss of joint range or soft-tissue length,or improve muscle strength and function, for ICU patients

1808 Reviews



ments, it must be acknowledged that the current lackof evidence does not allow a firm directive to bemade regarding the benefits, risks, and costs associ-ated with the provision of routine multimodalityrespiratory physiotherapy to all intubated ICU pa-tients receiving mechanical ventilation. Thus, thedecision as to whether respiratory physiotherapyshould be provided routinely or selectively in addi-tion to routine nursing care can, at this time, only bemade by consultation between physiotherapists andother ICU staff in individual units.

Treatment of Pulmonary Conditions andComplications

There is comparatively strong evidence to indicatethat physiotherapy is the treatment of choice, at leastinitially, for patients with acute lobar atelectasis, with-out the need for additional fiberoptic bronchoscopy.

As there is no evidence concerning the ability ofphysiotherapy to improve the clinical course of otherpulmonary conditions commonly found in ICU pa-tients, no other recommendations can be made. Itmay be unrealistic to expect that physiotherapy willspeed the overall recovery of patients with thepulmonary conditions common to the ICU as, inmost instances, the physical techniques that consti-tute physiotherapy would not seem likely to reversethe underlying pathophysiologic conditions. How-ever, clearly some pulmonary conditions, such asacute lobar atelectasis, do respond favorably to phys-iotherapy.

Short-term Benefits of Physiotherapy

As the available evidence shows that respiratoryphysiotherapy has, at best, a short-lived beneficialeffect on pulmonary function, this should be consid-ered when identifying patients who require respira-tory physiotherapy and making decisions about treat-ment frequency. If a patient has a pulmonarycondition that is likely to resolve quickly, a singlesession of physiotherapy or a number of treatmentsover a few hours may be an effective means ofmanagement. Alternatively, respiratory physiother-apy may be indicated when short-term improve-ments in pulmonary function are desired, whilewaiting for other treatments to take effect or spon-taneous recovery to occur. However, if the underly-ing condition that is adversely affecting pulmonaryfunction is unlikely to resolve quickly, as is the casefor many intubated ICU patients receiving mechan-ical ventilation, any beneficial effect from physio-therapy is likely to wear off within a short time oftreatment cessation. To compensate for this, physio-therapy techniques could be applied at more fre-quent intervals. Alternatively, rather than relying on

possible short-term beneficial effects from physio-therapy intervention, it may be more effective toalter background ventilatory variables (eg, by in-creasing the Vt, level of pressure support, oramount of positive end-expiratory pressure) toachieve beneficial effects that are likely to be oflonger duration.

Selection of Treatment Techniques

Limited recommendations for evidence-basedpractice can be made about which treatment tech-niques physiotherapists should use.

When considering the management of intubatedpatients receiving mechanical ventilation with spe-cific pulmonary conditions and complications, posi-tioning to improve oxygenation has been shown to beof short-term value for some patients with conditionssuch as ARDS and unilateral lung disease. There isalso limited evidence available to assist therapists inthe selection of the most effective techniques to usein the treatment of acute lobar atelectasis. Apartfrom these specific examples, there are insufficientdata to enable physiotherapists to select treatmenttechniques using evidence-based practice for pa-tients with specific pulmonary conditions.

As far as the routine management of intubatedICU patients receiving mechanical ventilation isconcerned, it is likely, despite the lack of evidenceconcerning suction, that the majority of intubatedpatients will require regular suction to maintain apatent endotracheal or tracheostomy tube, and toclear the central airways of secretions, regardless ofthe patient’s underlying disease. There is evidence toshow that preoxygenation, sedation, good technique,and reassurance are mandatory to avoid suction-induced hypoxemia. However, the necessity for anyother routine treatment beyond this (eg, positioning,MH, vibrations, percussion) cannot currently besupported or refuted on the basis of the availableevidence. The effect of mobilization on pulmonaryfunction, weaning from mechanical ventilation, im-proving muscle strength and function, and prevent-ing contractures has not been investigated (to myknowledge), so it is not certain whether mobilizationshould be seen as a respiratory physiotherapy tech-nique or as the start of the rehabilitation process forICU patients.

There is research showing that the use of contin-uous rotational therapy decreases the incidence ofpulmonary complications (such as nosocomial pneu-monia) for critically ill patients. However, given theconsiderable expense of purchasing or renting thesebeds and the lack of definitive cost-benefit analyses,further studies are needed before a firm recommen-dation regarding their widespread use can be made.

CHEST / 118 / 6 / DECEMBER, 2000 1809



Monitoring During Physiotherapy

A clear recommendation for evidence-based prac-tice that can be made from a review of the literatureis that hemodynamic status should always be care-fully monitored to ensure there are no detrimentaleffects as a result of any physiotherapy intervention.Similarly, when appropriate, ICP and CPP should bemonitored during physiotherapy intervention. To erron the side of caution, it is recommended that duringMH, airway pressure and/or Vt be monitored inaddition to hemodynamic status to minimize the riskof hemodynamic instability, volutrauma, and baro-trauma. Although monitoring of metabolic status isnot routinely used for ICU patients, physiotherapistsshould carefully consider each patient’s reserve be-fore any intervention in view of the evidence thatphysiotherapy may increase metabolic demand sig-nificantly.

Professional Roles

An area of considerable controversy that, at times,engenders professional jealousy concerns the delin-eation of the various roles of ICU staff, in particularbetween physiotherapists and nursing staff. Althoughthere are comparatively clear delineations for sometasks (eg, delivery of medications and general patientcare are usually seen as the sole responsibility ofnursing staff, and physiotherapists are usually re-sponsible for providing patients with rehabilitationregimens), many tasks do not fall solely into the lapof either profession. In particular, respiratory tech-niques may be performed only by physiotherapists,only by nursing staff, or by a combination of physio-therapists and nursing staff, depending on factorssuch as the time of day, the patient’s condition, andstaffing levels and expertise. Similar conflicts mayarise in ICUs in which both physiotherapists andrespiratory therapists work. As no research has beendone (to my knowledge) comparing the ability ofvarious professional groups to perform selectedtasks, it is not possible to use evidence-based practiceto decide which professional group should performwhich task. Given this lack of evidence, a balanced,unemotional decision based on factors specific toeach individual ICU and including a consideration ofeconomic implications is all that can be recom-mended at this time.

Additional Role of Physiotherapists in the ICU

It has been my observation that in many ICUs,physiotherapists tend to restrict their role to onepredominantly involving respiratory assessment andtreatment. An additional role that physiotherapistsmay have in the ICU is the assessment and manage-

ment of neurologic and musculoskeletal complica-tions. Although this additional role has been previ-ously acknowledged,2,80 to my knowledge, there areno published data to support it. Nevertheless, regu-lar neurologic assessment enables the early detectionof neurologic deficits, particularly the neuromyopa-thies often found in critically ill patients,81,82 and,less frequently, other lesions involving the peripheraland central nervous systems, all of which may signif-icantly affect the management and outcome of pa-tients. Thorough musculoskeletal assessment en-sures that fractures or soft-tissue injuries have notbeen overlooked (particularly relevant for traumapatients) and enables early detection of the onset ofjoint stiffness or soft-tissue tightness. Physiothera-pists, with their broad knowledge of neurologic andmusculoskeletal conditions, would seem particularlywell placed to provide such holistic assessment andthe appropriate treatment required.

Areas for Future Research

It is clear that virtually every aspect of the phys-iotherapy management of intubated ICU patientsreceiving mechanical ventilation requires validation.Further study to investigate the short-term effect ofphysiotherapy treatments on pulmonary and hemo-dynamic variables, preferably with the inclusion ofcontrol groups, will be of value. However, the role ofphysiotherapy in the ICU will continue to be ques-tioned until it has been shown to have a favorableimpact on broader outcomes of ICU patients. There-fore, randomized, controlled trials evaluating theeffect of multimodality physiotherapy on the inci-dence of nosocomial pneumonia, bronchopulmonaryinfection, and atelectasis, similar to that performedby Ntoumenopoulos et al,53 will be particularlyuseful as they would help establish the necessity forroutine physiotherapy beyond regular positionchange, preoxygenation, and suction. Similarly, theeffect of physiotherapy on the rate of recovery (eg,rate of resolution of abnormalities seen on chestradiograph, duration of mechanical ventilation, du-ration of antibiotic medication, length of ICU andhospital stay) for patients with pulmonary conditionscommonly found in ICU (eg, pneumonia, exacerba-tion of chronic airflow limitation, ARDS) could beinvestigated in randomized, controlled studies. Theeffect that aggressive mobilization has on pulmonaryand hemodynamic variables and broader outcomes,such as those previously mentioned, may help estab-lish whether these techniques are therapeutic to thepatient’s underlying respiratory dysfunction orshould be seen as the initial phase of rehabilitation.Research could also be undertaken to evaluate the

1810 Reviews



necessity for performing limb movements or splint-ing to prevent loss of joint range and soft-tissuelength for unconscious ICU patients. Similarly, theability of exercise programs to achieve a sufficienttraining intensity to maintain or increase strengthand endurance, improve function, and facilitate re-covery could be evaluated on a sample of consciousICU patients. Further study is also required on theability of continuous rotational therapy to preventpulmonary complications, reduce the duration ofmechanical ventilation and intubation, and decreasethe length and costs of ICU and hospital stay.

Conclusion

Although physiotherapy is seen as an integral partof the multidisciplinary team in most ICUs, there isonly limited evidence concerning the effectiveness ofphysiotherapy in this setting. Physiotherapy mayhave short-term beneficial effects on pulmonaryfunction, but it may also adversely affect the hemo-dynamic and metabolic status of intubated patientsreceiving mechanical ventilation. Physiotherapy hasbeen shown to be effective in the treatment of acutelobar atelectasis but, in one study, did not decreasethe incidence of nosocomial pneumonia. To myknowledge, there are no data concerning its effec-tiveness in preventing or treating other pulmonaryconditions common to ICU patients, and there isonly limited evidence concerning which individualphysiotherapy techniques are effective. The ability ofphysiotherapy to facilitate weaning and to improvefunction and outcomes of intubated ICU patientsreceiving mechanical ventilation is unknown. Al-though recommendations can be made concerningevidence-based practice for physiotherapy in theICU, these are limited because of the lack of dataevaluating the effectiveness of physiotherapy in thissetting. There is an urgent need for further researchto be conducted to justify the role of physiotherapyin the ICU.

ACKNOWLEDGMENT: The author thanks Allan Garland (Ed-itor, CHEST); Matthew McInnes and Naomi Haensel, Physio-therapy; Robert Young, ICU, Royal Adelaide Hospital; and SueJenkins, School of Physiotherapy, Curtin University for theirhelpful comments regarding this article.

References1 Jones AYM, Hutchinson RC, Oh TE. Chest physiotherapy

practice in intensive care units in Australia, the UK and HongKong. Physiother Theory Pract 1992; 8:39–47

2 Daber SE, Jackson SE. Role of the physiotherapist in theintensive care unit. Intensive Care Nurs 1987; 3:165–171

3 Judson MA, Sahn SA. Mobilization of secretions in ICUpatients. Respir Care 1994; 39:213–226

4 Singer M, Vermaat J, Hall G, et al. Hemodynamic effects ofmanual hyperinflation in critically ill mechanically ventilatedpatients. Chest 1994; 106:1182–1187

5 Ciesla ND. Chest physical therapy for patients in the inten-sive care unit. Phys Ther 1996; 76:609–625

6 King J, Crowe J. Mobilization practices in Canadian criticalcare units. Physiother Can 1998; 50:206–211

7 Hodgson C, Carroll S, Denehy L. A survey of manualhyperinflation in Australian hospitals. Aust J Physiother 1999;45:185–193

8 Dean E, Ross J. Discordance between cardiopulmonaryphysiology and physical therapy: toward a rational basis forpractice. Chest 1992; 101:1694–1698

9 Paratz J. Haemodynamic stability of the ventilated intensivecare patient: a review. Aust J Physiother 1992; 38:167–172

10 Dean E. Oxygen transport: a physiologically-based conceptualframework for the practice of cardiopulmonary physiother-apy. Physiotherapy 1994; 80:347–355

11 Ibanez J, Raurich JM, Abizanda R, et al. The effect of lateralpositions on gas exchange in patients with unilateral lungdisease during mechanical ventilation. Intensive Care Med1981; 7:231–234

12 Prokocimer P, Garbino J, Wolff M, et al. Influence of postureon gas exchange in artificially ventilated patients with focallung disease. Intensive Care Med 1983; 9:69–72

13 Rivara D, Artucio H, Arcos J, et al. Positional hypoxemiaduring artificial ventilation. Crit Care Med 1984; 12:436–438

14 Gillespie DJ, Rehder K. Body position and ventilation-perfusion relationships in unilateral pulmonary disease. Chest1987; 91:75–79

15 Langer M, Mascheroni D, Marcolin R, et al. The proneposition in ARDS patients. Chest 1988; 94:103–107

16 Pappert D, Rossaint R, Slama K, et al. Influence of position-ing on ventilation-perfusion relationships in severe adultrespiratory distress syndrome. Chest 1994; 106:1511–1516

17 Stiller K, Jenkins S, Grant R, et al. Acute lobar atelectasis: acomparison of five physiotherapy regimens. Physiother The-ory Pract 1996; 12:197–209

18 Chatte G, Sab J-M, Dubois J-M, et al. Prone positioning inmechanically ventilated patients with severe acute respiratoryfailure. Am J Respir Crit Care Med 1997; 155:473–478

19 Mure M, Martling C-R, Lindahl SGE. Dramatic effect onoxygenation in patients with severe acute lung insufficiencytreated in the prone position. Crit Care Med 1997; 25:1539–1544

20 Jolliet P, Bulpa P, Chevrolet J-C. Effects of the prone positionon gas exchange and hemodynamics in severe acute respira-tory distress syndrome. Crit Care Med 1998; 26:1977–1985

21 Trottier SJ. Prone position in acute respiratory distress syn-drome: turning over an old idea. Crit Care Med 1998;26:1934–1935

22 Wong WP. Use of body positioning in the mechanicallyventilated patient with acute respiratory failure: application ofSackett’s rules of evidence. Physiother Theory Pract 1999;15:25–41

23 Jones A, Hutchinson R, Lin E, et al. Peak expiratory flowrates produced with the Laerdal and Mapleson-C baggingcircuits. Aust J Physiother 1992; 38:211–215

24 King D, Morrell A. A survey on manual hyperinflation as aphysiotherapy technique in intensive care units. Physiother-apy 1992; 78:747–750

25 Denehy L. The use of manual hyperinflation in airwayclearance. Eur Respir J 1999; 14:958–965

26 McCarren B, Chow CM. Description of manual hyperinfla-tion in intubated patients with atelectasis. Physiother TheoryPract 1998; 14:199–210

27 Maxwell L, Ellis E. Secretion clearance by manual hyperin-

CHEST / 118 / 6 / DECEMBER, 2000 1811



Usuario

Resaltado

flation: possible mechanisms. Physiother Theory Pract 1998;14:189–197

28 Pryor J. Mucociliary clearance. In: Ellis E, Alison J, eds. Keyissues in cardiorespiratory physiotherapy. Oxford, UK: But-terworth-Heinemann, 1992; 105–130

29 Koch SM, Fogarty S, Signorino C, et al. Effect of passiverange of motion on intracranial pressure in neurosurgicalpatients. J Crit Care 1996; 11:176–179

30 Traver GA, Tyler ML, Hudson LD, et al. Continuous oscil-lation: outcome in critically ill patients. J Crit Care 1995;10:97–103

31 Raoof S, Chowdhrey N, Raoof S, et al. Effect of combinedkinetic therapy and percussion therapy on the resolution ofatelectasis in critically ill patients. Chest 1999; 115:1658–1666

32 Mackenzie CF, Shin B. Cardiorespiratory function before andafter chest physiotherapy in mechanically ventilated patientswith post-traumatic respiratory failure. Crit Care Med 1985;13:483–486

33 Novak RA, Shumaker L, Snyder JV, et al. Do periodichyperinflations improve gas exchange in patients with hypox-emic respiratory failure? Crit Care Med 1987; 15:1081–1085

34 Poelaert J, Lannoy B, Vogelaers D, et al. Influence of chestphysiotherapy on arterial oxygen saturation. Acta AnaesthesiolBelg 1991; 42:165–170

35 Jones AYM, Hutchinson RC, Oh TE. Effects of bagging andpercussion on total static compliance of the respiratorysystem. Physiotherapy 1992; 78:661–666

36 Eales CJ, Barker M, Cubberley NJ. Evaluation of a singlechest physiotherapy treatment to post-operative, mechani-cally ventilated cardiac surgery patients. Physiother TheoryPract 1995; 11:23–28

37 Hodgson C, Denehy L, Ntoumenopoulos G, et al. The acutecardiorespiratory effect of manual lung hyperinflation onventilated patients [abstract]. Eur Respir J 1996; 23(suppl):37s

38 Sasse SA, Chen PA, Mahutte CK. Variability of arterial bloodgas values over time in stable medical ICU patients. Chest1994; 106:187–193

39 Aitkenhead AR, Taylor S, Hunt PCW, et al. Effects ofrespiratory therapy on plasma catecholamines [abstract]. An-esthesiology 1984; 61:A44

40 Weissman C, Kemper M, Damask MC, et al. Effect of routineintensive care interactions on metabolic rate. Chest 1984;86:815–818

41 Klein P, Kemper M, Weissman C, et al. Attenuation of thehemodynamic responses to chest physical therapy. Chest1988; 93:38–42

42 Hammon WE, Connors AF, McCaffree DR. Cardiac arrhyth-mias during postural drainage and chest percussion of criti-cally ill patients. Chest 1992; 102:1836–1841

43 Paratz J, Burns Y. The effect of respiratory physiotherapy onintracranial pressure, mean arterial pressure, cerebral perfu-sion pressure and end tidal carbon dioxide in ventilatedneurosurgical patients. Physiother Theory Pract 1993; 9:3–11

44 Harding J, Kemper M, Weissman C. Midazolam attenuatesthe metabolic and cardiopulmonary responses to an acuteincrease in oxygen demand. Chest 1994; 106:194–200

45 Weissman C, Kemper M, Harding J. Response of critically illpatients to increased oxygen demand: hemodynamic subsets.Crit Care Med 1994; 22:1809–1816

46 Harding J, Kemper M, Weissman C. Pressure support venti-lation attenuates the cardiopulmonary response to an acuteincrease in oxygen demand. Chest 1995; 107:1665–1672

47 Cohen D, Horiuchi K, Kemper M, et al. Modulating effectsof propofol on metabolic and cardiopulmonary responses tostressful intensive care unit procedures. Crit Care Med 1996;24:612–617

48 Horiuchi K, Jordan D, Cohen D, et al. Insights into theincreased oxygen demand during chest physiotherapy. CritCare Med 1997; 25:1347–1351

49 Parsons LC, Ouzts Shogan JS. The effects of the endotrachealtube suctioning/manual hyperventilation procedure on pa-tients with severe closed head injuries. Heart Lung 1984;13:372–380

50 Garradd J, Bullock M. The effect of respiratory therapy onintracranial pressure in ventilated neurosurgical patients.Aust J Physiother 1986; 32:107–111

51 Imle PC, Mars MP, Eppinghaus CE, et al. Effect of chestphysiotherapy (CPT) positioning on intracranial (ICP) andcerebral perfusion pressure (CPP) [abstract]. Crit Care Med1988; 16:382

52 Ersson U, Carlson H, Mellstrom A, et al. Observations onintracranial dynamics during respiratory physiotherapy inunconscious neurosurgical patients. Acta Anaesthesiol Scand1990; 34:99–103

53 Ntoumenopoulos G, Gild A, Cooper DJ. The effect of manuallung hyperinflation and postural drainage on pulmonarycomplications in mechanically ventilated trauma patients.Anaesth Intensive Care 1998; 26:492–496

54 Marini JJ, Pierson DJ, Hudson LD. Acute lobar atelectasis: aprospective comparison of fiberoptic bronchoscopy and re-spiratory therapy. Am Rev Respir Dis 1979; 119:971–978

55 Hammon WE, Martin RJ. Chest physical therapy for acuteatelectasis. Phys Ther 1981; 61:217–220

56 Stiller K, Geake T, Taylor J, et al. Acute lobar atelectasis: acomparison of two chest physiotherapy regimens. Chest 1990;98:1336–1340

57 Fourrier F, Fourrier L, Lestavel P, et al. Acute lobaratelectasis in ICU patients: comparative randomized study offiberoptic bronchoscopy versus respiratory therapy [abstract].Intensive Care Med 1994; 20:S40

58 Torres A, Serra-Batlles J, Ros E, et al. Pulmonary aspirationof gastric contents in patients receiving mechanical ventila-tion: the effect of body position. Ann Intern Med 1992;116:540–543

59 Ibanez J, Penafiel A, Raurich JM, et al. Gastroesophagealreflux in intubated patients receiving enteral nutrition: effectof supine and semirecumbent positions. J Parenter EnteralNutr 1992; 16:419–422

60 Orozco-Levi M, Torres A, Ferrer M, et al. Semirecumbentposition protects from pulmonary aspiration but not com-pletely from gastroesophageal reflux in mechanically venti-lated patients. Am J Respir Crit Care Med 1995; 152:1387–1390

61 Clarke RCN, Kelly BE, Convery PN, et al. Ventilatorycharacteristics in mechanically ventilated patients duringmanual hyperventilation for chest physiotherapy. Anesthesia1999; 54:936–940

62 Glass C, Grap MJ, Corley MC, et al. Nurses’ ability to achievehyperinflation and hyperoxygenation with a manual resusci-tation bag during endotracheal suctioning. Heart Lung 1993;22:158–165

63 McCarren B, Chow CM. Manual hyperinflation: a descriptionof the technique. Aust J Physiother 1996; 42:203–208

64 Chulay M. Arterial blood gas changes with a hyperinflationand hyperoxygenation suctioning intervention in critically illpatients. Heart Lung 1988; 17:654–661

65 Walsh JM, Vanderwarf C, Hoscheit D, et al. Unsuspectedhemodynamic alterations during endotracheal suctioning.Chest 1989; 95:162–165

66 Mancinelli-Van Atta J, Beck SL. Preventing hypoxemia andhemodynamic compromise related to endotracheal suction-ing. Am J Crit Care 1992; 1:62–79

67 deBoisblanc BP, Castro M, Everret B, et al. Effect of

1812 Reviews



air-supported, continuous, postural oscillation on the risk ofearly ICU pneumonia in nontraumatic critical illness. Chest1993; 103:1543–1547

68 Gentilello L, Thompson DA, Tonnesen AS, et al. Effect of arotating bed on the incidence of pulmonary complications incritically ill patients. Crit Care Med 1988; 16:783–786

69 Fink MP, Helsmoortel CM, Stein KL, et al. The efficacy of anoscillating bed in the prevention of lower respiratory tractinfection in critically ill victims of blunt trauma. Chest 1990;97:132–137

70 Bein T, Reber A, Metz C, et al. Acute effects of continuousrotational therapy on ventilation-perfusion inequality in lunginjury. Intensive Care Med 1998; 24:132–137

71 Norrenberg M, De Backer D, Moraine JJ, et al. Oxygenconsumption can increase during passive leg mobilization[abstract]. Intensive Care Med 1995; 21:S177

72 Brimioulle S, Moraine J-J, Norrenberg D, et al. Effects ofpositioning and exercise on intracranial pressure in a neuro-surgical intensive care unit. Phys Ther 1997; 77:1682–1689

73 Konrad F, Schreiber T, Brecht-Kraus D, et al. Mucociliarytransport in ICU patients. Chest 1994; 105:237–241

74 Sinclair DG, Evans TW. Nosocomial pneumonia in theintensive care unit. Br J Hosp Med 1994; 51:177–180

75 Meduri GU, Estes RJ. The pathogenesis of ventilator-associ-ated pneumonia: II. The lower respiratory tract. IntensiveCare Med 1995; 21:452–461

76 George DL, Falk PS, Wunderink RG, et al. Epidemiology ofventilator-acquired pneumonia based on protected broncho-scopic sampling. Am J Respir Crit Care Med 1998; 158:1839–1847

77 Bowton DL. Nosocomial pneumonia in the ICU: year 2000and beyond. Chest 1999; 115(suppl):28S–33S

78 Kollef MH. The prevention of ventilator-associated pneumo-nia. N Engl J Med 1999; 340:627–634

79 Vincent J-L. Prevention of nosocomial bacterial pneumonia.Thorax 1999; 54:544–549

80 Bishop KL. Pulmonary rehabilitation in the intensive careunit. In: Fishman AP, ed. Pulmonary rehabilitation. NewYork, NY: Marcel Dekker, 1996; 725–738

81 Nates JL, Cooper DJ, Day B, et al. Acute weakness syn-dromes in critically ill patients: a reappraisal. Anaesth Inten-sive Care 1997; 25:502–513

82 De Jonghe B, Cook D, Sharshar T, et al. Acquired neuro-muscular disorders in critically ill patients: a systematicreview. Intensive Care Med 1998; 24:1242–1250

CHEST / 118 / 6 / DECEMBER, 2000 1813



DOI 10.1378/chest.118.6.1801 2000;118;1801-1813 Chest

Kathy Stiller

Physiotherapy in Intensive Care : Towards an Evidence-Based Practice

This information is current as of April 18, 2008

& ServicesUpdated Information

http://chestjournal.org/cgi/content/full/118/6/1801high-resolution figures, can be found at: Updated information and services, including

References

http://chestjournal.org/cgi/content/full/118/6/1801#BIBLfor free at: This article cites 70 articles, 27 of which you can access

Citations

http://chestjournal.org/cgi/content/full/118/6/1801articles: This article has been cited by 3 HighWire-hosted

Permissions & Licensing

http://chestjournal.org/misc/reprints.shtml(figures, tables) or in its entirety can be found online at: Information about reproducing this article in parts

Reprints http://chestjournal.org/misc/reprints.shtml

Information about ordering reprints can be found online:

Email alerting service

online article. article sign up in the box at the top right corner of the Receive free email alerts when new articles cite this

Images in PowerPoint format

format. See any online article figure for directions. downloaded for teaching purposes in PowerPoint slide Figures that appear in CHEST articles can be


http://chestjournal.org/cgi/content/full/118/6/1801

http://chestjournal.org/cgi/content/full/118/6/1801#BIBL

http://chestjournal.org/cgi/content/full/118/6/1801

http://chestjournal.org/misc/reprints.shtml

http://chestjournal.org/misc/reprints.shtml


physiotherapy in intensive care: towards an evidence-based practice

Documents