Physiotherapy over the last decade has evolved considerably in the areas of critical care, cardiac and thoracic surgery. This chapter will review the changes in these areas supported by research, in particular, postoperative critical care based rehabilitation, respiratory physiotherapy and physiotherapy practice in relation to cardiothoracic surgery.
At some stage during the majority of critical care admissions, many patients will require sedation to maintain physiological stability during an acute period of illness and will be unable to mobilise out of bed. In addition to sedation and immobility, the use of neuromuscular blockades and the presence of sepsis lead to intensive care acquired weakness and a reduction in functional ability.
Physical and non-physical changes present in critical care patients. Below are a number of negative changes associated with sedation and bed rest, however, this is not an exhaustive list.
Pressure sores/tissue viability
Reduced bone density
Early rehabilitation is essential to limit the impact of changes associated with prolonged critical care stay and should be started as soon as appropriate. Providing treatment to improve the patient’s overall physical ability is not just the role of the physiotherapist, but requires effective multidisciplinary team (MDT) working, involving medical and nursing staff, other therapists, the patient’s family, friends and the patient. The setting of goals should be discussed and agreed with the whole team, including the patient. Those involved in rehabilitation can support the patient to achieve their goals by providing a stimulating environment that encourages independence and maintains focus and orientation for the patient.
The physiotherapist’s role is to coordinate the rehabilitation pathway to enable the patient to achieve their goals, and to act as a lead in the provision of physical rehabilitative treatment. However, other members of the MDT are crucial in the delivery of rehabilitation, for example, regular functional activities such as brushing hair, cleaning teeth, assisting with eating, performance of prescribed exercise programmes and practising of bed mobility for personal care. Additional benefits of rehabilitation include a reduction in delirium, reduced time weaning from mechanical ventilation, reduced length of stay in critical care and overall hospital admission, reduction in long-term disability and a faster return to normal functional ability.
A large number of research studies on rehabilitation in critical care focus on ‘early’ rehabilitation. Many studies involve services that require referral for physical therapeutic intervention, therefore the intervention group receives expedited referrals for rehabilitation. The UK model of healthcare provides the opportunity for early rehabilitation as physiotherapists assess respiratory and physical needs at the first assessment. The research on early rehabilitation supports and recommends that rehabilitation should commence as soon as it is safe to do so. This may be passive treatment during times of sedation, or becoming more active and participative from the commencement of sedation breaks. Physiotherapy can be provided for patients on mechanical lung ventilation. This can be in the form of stationary bicycles especially adapted to lie on the bed to early ambulation using a portable ventilator, and can also be applied to patients on ECMO.
The NICE guidance for ‘Rehabilitation after Critical Illness’ advises that a short clinical assessment is required to identify patients at risk of physical or non-physical morbidity whilst in critical care. Patients deemed ‘at risk’ should receive comprehensive clinical assessments throughout their hospital admission and multitherapeutic input.
In collaboration with the patient, rehabilitation should start as early as possible, based on agreed physical and non-physical rehabilitation goals. These goals should be short, medium and long term. Review of the assessment should be performed before discharge from critical care, during ward base care, before discharge from hospital and 2–3 months after critical care discharge. In addition to supportive rehabilitative in-patient care and community care, follow-up clinics provide an environment to identify on-going physical and non-physical issues that require referral to other healthcare providers. The provision of critical care diaries to patients and their families at follow-up clinics supports patients with memory loss and adjusting to their period of critical illness.
A standard pattern of exercise progression can be seen in Figure 20.1.
Figure 20.1 Pattern of exercise progression.
Some patients require no additional therapeutic intervention other than exercise and movement facilitation. However, patients who have received high levels of sedation, paralysing agents and steroids often develop intensive care acquired weakness characterised by very poor global muscle power. These patients require increased input to progress. Physiotherapists have a repertoire of equipment that can be used within the critical care environment to aid physical recovery and functional ability. Manual handling equipment such as handling belts, frames, turn aids, standing hoist, tilt table and parallel bars could be used to aid the physical facilitation of patients. However, caution should be applied in view of recent surgical wounds, i.e. sternotomy and thoracotomy, as it is advised that patients should not weight bear through their upper limbs during the acute postoperative stage, and thoracic belts used with some manual handling equipment may be uncomfortable on wounds and drain sites. Pedals that can be used in bed or the chair in passive, active assisted or resistive mode have been shown to increase quadriceps strength and functional ability at hospital discharge.
There is emerging evidence that transcutaneous neuromuscular electrical stimulation may be beneficial in preserving muscle strength, specifically in patients who are critically unwell for longer periods, and therefore more likely to develop intensive care acquired weakness. The use of interactive video games within critical care can be used to improve muscle strength, balance, coordination and cognitive state.
To be able to conduct rehabilitation in critical care safely, a number of factors must be considered:
Assessment of patient’s psychological state, ability to follow commands and risk/benefit analysis if patient is or becomes delirious during treatment.
Does the patient require glasses or hearing aids to be able to participate adequately during the session?
Is the patient receiving or has recently discontinued an infusion of inotropes; is the cardiovascular system stable?
What indwelling cannula, attachments and monitoring does the patient require? What are the risks if these are disconnected/dislodged during treatment?
What is the patient’s weaning plan? Do they need more ventilator support during rehabilitation and therefore a plan for treatment before reduction of support is commenced?
If the patient is physically able, it is possible to progress rehabilitation to walking whilst on the ventilator (this can be achieved with a tracheostomy or endotracheal tube in situ, if the patient is tube tolerant).
If the patient is moving outside of the critical care environment, i.e. to a gym, for rehabilitation, ensure there are hospital guidelines to ensure this is undertaken safely.
The key to a successful rehabilitation session is the correct staff numbers and skill mix. It is common to require at least two members of physiotherapy staff (at least one registered physiotherapist) and the nurse. Additional support from healthcare support workers may be required if moving attachments or a wheelchair is needed.
Obtaining enough staff to provide rehabilitation throughout the day can be difficult. The use of physiotherapy assistant practitioners to provide some aspects of treatment is a growing practice within critical care and ward environments.
To assess a patient’s progression throughout their critical care admission, the regular use of outcome measures is strongly recommended. Outcome measures can be used to assess level of impairment, physical functional status, mental functional status and neuropsychological functioning. The use of outcome measures should improve MDT communication, provide increased direction for treatment planning and help motivate patients. Physiotherapists mainly use measures to evaluate physical changes. There are a multitude of outcome measures available, however, many do not have adequate sensitivity to detect small physical changes found within debilitated critical care patients.
A basic test is the Medical Research Council scale of muscle strength. This is a validated and reliable scoring system from 0 (no movement) to 5 (normal power). However, this test is not linked to functional ability, and therefore its application for a patient’s physical capability is limited.
There are many outcome measures such as Katz’s Index of Independence in Activities of Daily Living, the Barthel Index, the Rivermead Motor Index and Functional Independence Measure and Functional Assessment Measure (known as FIM and FAM) which rank the patient’s ability on functional tasks. However, these tools lack sufficient sensitivity to recognise small changes in critical care patients’ ability.
Recently developed critical care outcome measures are Physical Functional Intensive Care test (PFIT) and the Chelsea Critical Care Physical Assessment tool (CPAx). PFIT assesses endurance, strength, cardiovascular capacity and functional level. The assessment components are: level of assistance required for sit to stand, steps per minute whilst marching on the spot, muscle strength of shoulder flexion and knee extension. This tool has proven reliability, validity and responsiveness. Patients need to be awake and cooperative to complete the PFIT, which is not representative of many critical care patients. The volitional aspects of testing will be dependent on patient effort, which may be poorly performed in critical care.
CPAx is a critical care specific tool that is sensitive enough to recognise small changes in ability in patients. It covers 10 dimensions involving respiratory function, bed and transfer ability and grip strength. These are graded 0–5 depending on the level of assistance required. It is validated for the general adult critical care population, but not for specialist conditions.
Despite overwhelming positive evidence in support of rehabilitation in critical care, treatment is delayed or limited. The Intensive Care Society recommends rehabilitation assessment within 24 hours and 45 minutes of rehabilitation per day, 5 days per week by each therapy. In practice, it is difficult to achieve this for various reasons:
Staff availability within physiotherapy and nursing;
Respiratory treatments take priority;
Rehabilitation is often time consuming and requires higher staff numbers to complete, and therefore is not undertaken in times of reduced staffing;
Critical care patients are often too fatigued or are having other procedures throughout the day, which means they are unable to participate in more than one session per day.
However, rehabilitation should take place at times that are best for the patient. Patients also tend to have low motivation to participate in treatment, as there is little short-term gain, and it is sometimes difficult to appreciate how the current treatment leads to discharge.
To overcome barriers, good communication and the setting of daily plans will aid a united approach to rehabilitation. Providing clear explanation of roles, treatment options, anticipated progression and plans will clarify expectations and improve compliance with patients, their families and staff. Having a clear, documented plan for weaning, treatment and rest times ensures patients receive optimal care and achieve their goals in a timely manner.
One of the common barriers to recovery following cardiothoracic surgery is postoperative pulmonary complications (PPCs) which are defined as ‘an identifiable disease or dysfunction that is clinically relevant and adversely affects the clinical course’. For patients this can lead to an increased length of stay, increased morbidity and mortality. The primary role of the physiotherapist is to aid in preventing PPCs and to provide effective treatment to enable a quicker resolution when they occur.
Examples of common respiratory complications are:
Atelectasis or lobar collapse;
Poor cough function due to pain or altered respiratory mechanics;
Respiratory Physiotherapy – What can it Treat?
Respiratory Physiotherapy Techniques
Mobilisation is an important treatment for all postsurgical patients and should be performed as early as possible, ideally the first morning after surgery or even on the day of surgery. In the early stages, mobilisation may entail sitting out of bed and/or marching on the spot, with this being progressed to ambulating as soon as is safe for the patient. However, static cycling is equally as effective. The aim of mobilisation is to increase the tidal volume and minute volume, therefore aiding expansion of atelectatic regions of lung. By improving lung volumes and therefore increasing airflow, secretions are mobilised enabling the patient to expectorate more easily. Patients should mobilise at a pace that equates to 3–4 on the Borg scale, or 11–14 on the modified Borg scale and on an appropriate level of supplementary oxygen if required. Patients being ventilated, on inotropes, on extracorporeal membrane oxygenation (ECMO) or ventricular assist devices (VAD) are not contraindicated to mobilising. Each patient should be assessed individually for their clinical need and safety.
Positioning is often used in conjunction with other treatments to help maximise their effectiveness, for example side lying whilst ventilator hyperinflation is performed. It is also an important aspect of patient care in preventing PPCs by positioning patients optimally in bed or out of bed so as to reduce the time spent in recumbent postures such as supine and slumped sitting where lung volumes (in particular functional residual capacity) are naturally reduced.
An important aspect of positioning is to optimise the patient’s ventilation/perfusion (V/Q) matching to improve oxygenation and ventilation. V/Q matching varies depending on whether the patient is ventilated or breathing spontaneously; this should be considered when positioning the patient. Ventilated patients will always have an element of V/Q mismatch due to the mechanics of positive pressure ventilation with the lung tissue and the effects of gravity on the pulmonary vasculature. In extreme cases of V/Q mismatch causing severe hypoxia, prone positioning has proven to be beneficial, but is a complicated procedure that requires an MDT approach.
Positioning can also be used to reduce WOB; for example, forward lean sitting or high side lying. These positions can be used with breathing control techniques for optimal effect.
Postural drainage uses gravity in specific positions to accurately drain certain lobes and segments of the lungs. These positions can be modified if the patient is unable to tolerate them, for example head-down tilt.