ICU Instrumentation and Physical Therapy

ICU Environment and the Role of Physical Therapy

  • ICU rooms can be overwhelming due to numerous lines, tubes, and monitors.
  • Nursing staff are the primary experts and are available for questions and concerns.
  • Experienced therapists are also available for support.

What PTs Do in the ICU

  • Patients are often perceived as too sick for PT, but this is not true.
  • Activities are modified based on the patient's acuity level.
  • Interventions can include range of motion exercises, bed exercises, and supported sitting.
  • ICU therapists do more than just range of motion and isometric exercises.
  • Mobilization is possible, starting in bed and progressing to out-of-bed activities.
  • Edge-of-bed exercises are performed as tolerated.
  • Ventilated patients can be mobilized if medically stable.
  • Early mobility programs prioritize movement over long-term sedation, reducing the adverse effects of prolonged sedation.

Timing of Therapy

  • Therapy begins once the patient is medically stable.
  • Early interventions may include passive range of motion, positioning, and family education.
  • Early start to therapy helps maintain range of motion and prevent pressure sores.

Complications of Prolonged ICU Stay

  • Muscle weakness and atrophy, especially in anti-gravity muscles.
  • Loss of range of motion and development of contractures.
  • Functional decline.
  • Delirium (ICU psychosis) due to prolonged sedation, leading to mental instabilities that can take weeks or months to resolve.
  • Neuropathy.
  • Pressure sores.
  • Sepsis.
  • Detrimental effects on all body systems, including slowed gut function.
  • Early mobilization is essential for lung, gut, and heart function, as well as general strength and endurance.

PT's Role in the ICU

  • Positioning to prevent loss of range of motion and pressure sores.
  • Maintaining range of motion.
  • Strengthening exercises in various positions.
  • Early mobilization when medically stable.
  • General mobility, even for non-ventilated patients who may be in the ICU for minor complications.

Essential Knowledge for Working in the ICU

  • Comprehensive understanding of general PT practices is crucial.
  • Familiarity with specific equipment types is necessary. This includes:
    • Beds
    • Monitors
    • Lines
    • Catheters
    • Tubes
    • Ventilators
    • Dialysis equipment
    • Mechanical circulatory devices

Types of Beds

Standard Adjustable Bed
  • Similar to beds in PT labs.
  • Adjustable head and leg positions.
  • Semi-Fowler's position (head elevated).
  • Fowler's position (head and knees elevated).
  • May include buttons for height adjustment or manual cranks.
Total Care Bed
  • Advanced features, like newer PT lab beds.
  • Adjustable height, length, and position.
  • Chair position is frequently used for early mobilization.
  • Uses a standard foam mattress.
Low Air Loss Therapy Beds
  • Similar bed frame to Total Care beds.
  • Mattress differences are key.
  • Air cylinders that can be adjusted for hardness or softness.
  • Can make therapy more challenging due to movement on air bladders.
Mattress Variations
  • Standard foam mattress
  • General air mattress
  • First Step Mattress:
    • Air cylinders over a standard mattress; good for pressure relief.
    • Air can be removed, allowing the patient to sink onto a regular mattress.
  • Big Boy Mattress:
    • Designed for bariatric patients, supporting up to 1,000 pounds.
  • Standard Air Mattress:
    • Air mattress over a metal frame, which can be uncomfortable if air is removed.
Clinitron (Air Fluidized Support Bed)
  • Specialized bed for pressure relief.
  • Used in burn units and for patients with grafts.
  • Contains millions of silicon glass beads in a bladder, creating a floating effect.
  • Patients are typically lifted in and out using lifts.
Roto Rest
  • Common in ICUs, especially for trauma patients.
  • Slowly and continuously turns the patient from side to side.
  • Prevents pressure sores and improves lung function.
  • Has a trap door for sanitary cleaning.
Stryker Frame
  • Old school turning frame with anterior and posterior canvas.
  • Rotates patients from supine to prone.
  • Rare in modern hospitals but may be seen in older or rural facilities.
  • Used for patients with spinal cord injuries or significant injuries.
Roto Prone
  • Newer version of the Stryker frame with improved technology.
  • Turns patient from supine to prone for extended periods.

Physical Therapy's Role as Bed Experts

  • PTs should know the basic operations of ICU beds and not have to be computerized experts.
  • Understanding various buttons and positions such as head up/down and leg up/down etc.
  • Familiarity with chair position, Trendelenburg, reverse Trendelenburg, brakes, and side rails.
  • Always ensure lines and tubes are clear when manipulating beds to prevent dislodgement.
  • Avoid placing objects under the bed to prevent crushing when lowering the bed.

Other Equipment Associated with the Bed

  • Lower extremity traction with weights.
  • Trapeze for patient-assisted bed mobility.
  • Traction splints.
  • Cervical traction.
  • Multiple lines of traction - know what can be done, with what is available and safe.

Vital Sign Values and Monitoring

  • Familiarize yourself with normal and critical vital sign values.
  • APTA provides excellent guidelines on critical lab values and safe exercise limits.

Key Vital Signs

  • Heart Rate:
    • Normal range: 60-100 beats per minute.
    • Below 60 or above 100 (resting) is concerning.
  • Intracranial Pressure (ICP):
    • Normal range: 5-15 mmHg.
  • Oxygen Saturation:
    • Below 88% may indicate need for supplemental oxygen during functional tasks.

ICU Monitor Interpretation

  • Green: Heart rate and EKG rhythm.
  • Blue: Oxygen saturation.
  • Respiration rate.
  • Temperature.
  • Red blood pressure indicates arterial line measurement; purple indicates peripheral blood pressure.

Sources of Monitor Data

  • Oximeters (pulse oximeters)
  • Pulmonary artery catheters (Swan-Ganz catheters)
  • Arterial lines (A-lines)
  • Central venous pressure catheters
Oximeters
  • Measure oxygen saturation through the skin.
  • Placed on fingers, toes, or ear clips.
  • Tabs can also be placed on the forehead.
Swan-Ganz Catheter (Pulmonary Artery Catheter)
  • Measures pressure in the pulmonary artery in real-time.
  • Evaluates pulmonary hypertension and right-sided heart failure.
Arterial Line (A-Line)
  • Used for arterial blood gas (ABG) analysis.
  • Measures blood pressure in real-time (indicated in red on the monitor).
  • Used to draw blood.
  • Placement sites vary (femoral, upper extremity).
  • Femoral A-lines may contraindicate hip movement.
  • Dislodgement requires immediate pressure and notification of the nurse.
Central Venous Pressure Catheters (CVCs)
  • Hickman Catheter:
    • Threaded through a vein (upper extremity or thorax) into the subclavian vein.
    • Administers medication (chemotherapy, antibiotics).
    • Measures central venous pressure (CVP).
  • Quinton Catheter:
    • Placed in the neck or groin.
    • Can be hard or soft; hard catheters may limit mobilization.
    • Femoral placement may contraindicate hip flexion.
  • Peripherally Inserted Central Catheter (PICC Line):
    • Threaded through a peripheral vein into the superior vena cava (typically in the upper extremity).
    • Administers antibiotics or chemo; can also be used to draw blood.
IV Bags and Peripheral Inserted Lines
  • Managed by nursing staff.
  • Regulate flow rate and timing.
  • Travel with IV poles.
  • PTs ensure the devices are not kinked or alarms are going off, defer to the nurse for maintanence.
  • Patient-Controlled Analgesia (PCA):
    • Allows patients to self-administer small, predetermined doses of medication.
    • Limits are set by the nurse and physician.

General PT Considerations for Lines and Tubes

  • Do not dislodge, disconnect, or overstretch tubing.
  • Be aware of all lines and tubes attached to the patient during environmental assessments.
  • Exercise caution when lines are in the elbow region due to range of motion restrictions and avoid bending too far.
  • Depending on their insertion, periphal lines in wrist regions may impact ambulation with an assistive device.
  • Avoid holding an extremity in a dependent position for too long to prevent blood backup in the tube.
  • Be aware of signs of infection (redness, swelling) at tube placement sites.
  • Be aware of signs of thrombosis.
  • Avoid ambulating patients with femoral or saphenous catheters and be aware of movement limitations.
  • Address alarms and involve IV poles appropriately.
  • Avoid taking blood pressure on an extremity with an IV line.

Draining Devices

Catheters and Rectal Tubes

  • Foley Catheter:
    • Drains to gravity; bag should be below the bladder to prevent backflow.
    • A balloon inflated with saline holds the tube in place.
    • Be careful not to pull tubing, make sure it follows along with movement.
  • Rectal Tube:
    • Used when patients have difficulty eliminating (liquid stool).
    • A balloon helps hold it in place, but it can be messy.
    • Use caution to avoid dislodging during mobility.
  • Condom Catheter:
    • External catheter for male patients that does not enter the urethra (difficult to keep steady).
  • Sponge Catheter:
    • Newer version for females that uses a sponge with suction but are known to leak.

Chest Tubes

  • Surgically inserted into the lungs to evacuate fluid.
  • Critical to avoid pulling out the tube, as it can cause a pneumothorax and may be a medical emergency.
  • The lower half of the chest tube connects to a Pleurovac, which may be hooked up to suction.
  • Patients can be mobilized with chest tubes and Pleurovacs with nursing or physician permission.
  • Plurovacs can be hooked to ambulation devices or IVs.
  • Fluid levels in the Pleurovac are carefully monitored; avoid tipping it over to prevent inaccurate readings.

JP Drain (Jackson-Pratt Drain)

  • Squeeze bulbs that provide constant pressure to remove fluid from a cavity or wound.
  • Common post-op device.
  • Can be safety-pinned to the patient's gown during mobility.

Hemovac

  • Accordion-style pressurized drain used post-op to remove fluid from surgical sites.
  • Also safety-pinned to the gown.

Wound Vac

  • Used in wound care for advanced fluid drainage.
  • Involves placing a sponge inside an open wound covered with airtight plastic film, which is hooked up for suction.

Ostomy Devices

  • Colostomy:
    • Drains fluid from the large intestine.
  • Ileostomy.
    • Drains fluid into the small intestine.
  • Urostomy.
    • Drains fluid from the urinary bladder.
  • Stomas are surgically opened.
  • Ensure proper management and ask the nurse before, requesting an empty or new bag before ambulation.
  • Place gait belt over the bag, not underneath, during ambulation.

Feeding Tubes and Devices

  • Used when patients cannot feed themselves normally or have swallowing issues.

Types of Feeding Tubes

  • Nasogastric Tube (NG Tube):
    • Tube inserted through the nose, down the esophagus, and into the stomach.
    • Can be used for feeding or suctioning stomach contents.
  • Dobhoff Tube:
    • Smaller tube specifically for feeding is less evasive.
    • Passes through the nose and cannot be used for suction.
  • Gastric Tube:
    • Inserted into the stomach through an incision.
  • Percutaneous Endoscopic Gastrostomy (PEG) Tube:
    • Inserted into the stomach through the abdominal wall.
  • Total Parenteral Nutrition (TPN).
    • Liquid nutrition delivered intravenously.

Complications and Precautions

  • When a patient is on active feeding, the head of the bed should be at or above 30 degrees.
  • Avoid removing or crimping the feeding line.
  • Gravity can work against NG tubes, tape to hold is key to mobility.
  • If disconnected, have the tube flushed to prevent blockages and notify nursing staff to do so.

Intracranial Pressure (ICP) Monitoring

  • A ventriculostomy can measure cerebral spinal fluid and any fluids from the head.
  • A catheter is placed in the cranium to monitor ICP and drain CSF in subdural spaces.
  • The ICP bolt is a common method where the catheter is inserted into a ventricle through drilled hole in the skull.

PT Considerations

  • Maintain head of bed angle elevated (as specified).
  • Limit bed mobility activities.
  • Avoid significant out-of-bed mobilization.
  • Collaborate with the nurse to ensure patient safety.

Oxygen Therapy

  • Hypoxemia is defined as oxygen saturation levels below 85%.
  • The goal is to maintain levels above 85% with supplemental oxygen.

Oxygen Delivery Methods

  • Nasal Cannula:
    • Low flow, delivering 25-45% oxygen.
    • Common device, but oxygen is considered medication, so do not remove without consent.
  • Face Mask:
    • Delivers higher percentage of oxygen (35-60%).
    • Mask has perforations to allow CO2 to escape.
  • Venti Mask:
    • Delivers 24-60% oxygen.
    • Allows respiratory therapists to precisely titrate oxygen delivery.
  • Non-Rebreather Mask:
    • Up to 100% oxygen delivery.
    • Used for patients with severe respiratory compromise; maintain mask throughout the session.
  • CPAP and BiPAP:
    • Used for sleep apnea and COPD patients.
    • Provide constant air pressure into the lungs.
    • BiPAP provides lower pressure during expiration.

Artificial Airways

  • Endotracheal Tube:
    • Inserted through the nose or mouth into the lungs for short-term. A first step intubation.
    • Patients can be awoken and mobilized with an endotracheal tube; but is usually a quick procedure.
  • Tracheostomy:
    • Long-term intubation option where a tube goes directly into the trachea.
    • Ventilator attaches directly to the trach.
    • Patients can be mobilized but be careful in the long term.
  • Passy Muir:
    • Valve that can be placed over a trach to allow the patient to speak.
    • Speech therapist will specialize and work with you!

Ventilators

  • Depend on nurse or respiratory therapist for detailed knowledge and management.

Basic Terminology

  • Assist Control (AC)
  • Synchronized Intermittent Mandatory Ventilation (SIMV)
  • Positive End Expiration Pressure (PEEP)
  • Fraction of Inspired Oxygen (FiO2)
  • Ventilators monitor lung function, including inspiratory and expiratory tidal volume.
  • Parameters are typically ordered by the physician.

Complications

  • Inadvertent extubations.
  • Delirium (ICU psychosis).
  • Self-extubation.
  • Disconnection of vent tubing.
  • Mucus plug causing airway loss.
  • Patient breathing over the ventilator.
  • Agitation and inadvertent or self-extubation.

Dialysis

  • Used in renal failure where arterial blood is filtered through a dialyzer, and the clean blood is returned to the patient via venous access.
  • Coordinate therapy sessions around dialysis schedules; ask the nurse or the caregiver.

Sequential Compression Device (SCD)

  • Prevents DVTs (deep vein thrombosis). A device connected to a pump.
  • Inflates air into the cuffs to provide slow compression to the calves.
  • Can typically be removed for therapy and reapplied after.

Final Thoughts

  • ICU can be daunting, but familiarity and teamwork can help.
  • Coordinate with nursing staff for line management and mobilization protocols.
  • Some equipment is only used in specialty areas.
  • Equipment and lines can provide insight into the patient's condition.
  • Start with bed exercises and progress as tolerated.
  • Advocate for early mobilization by collaborating with staff and seeking additional training.