Chest Physiotherapy in ICU Settings
Chest Physiotherapy (CPT) is acclaimed as an important constituent of respiratory care in all mechanically ventilated (MV) critically ill patients, even in the absence of primary or significant lung disease. Tracheal intubation indeed seriously impairs cough reflex and mucociliary escalator function leading to sequestration and impaction of secretions in the lower airways. This exposes MV patients to severe lung complications [i.e. ventilator-associated tracheobronchitis, ventilator-associated pneumonia (VAP) and lung atelectasis] prolongs the weaning process, and may increase mortality .
What are the principles, expected benefits, risks, and points for attention of the different CPT techniques used in MV patients?
In clinical studies, Chest Physiotherapy (CPT) included a combination of body positioning, chest wall vibration or compression, and manual lung hyperinflation. In one study, IPV-ADD was used as a CPT method. Control patients received standard nursing care and airway suctioning.
Chest Physiotherapy (CPT)
- All CPT techniques aim to loosen airway secretions and help remove them from the lungs. Therapists use body positioning and chest mobilization to improve secretion clearance. This includes frequent posture changes, maintaining a 30° upright position, in-bed rotations, proper chest alignment, and passive limb movements.
- Another key goal of CPT is to improve oxygenation. It enhances alveolar ventilation and improves ventilation-perfusion matching. It also helps redistribute body fluids using gravity. At present, no single standardized protocol exists for chest mobilization in ICU care.
- Manual lung hyperinflation, also known as bagging, delivers larger tidal volumes than normal breathing. This improves lung compliance and gas exchange. It also mimics a cough, helping secretions move toward larger airways for suctioning. This technique is commonly used in cardiorespiratory physiotherapy in ICU settings.
Intrapulmonary Percussive Ventilation (IPV) Intrapulmonary Percussive Ventilation (IPV) delivers rapid, small bursts of air at high frequencies. These bursts help open distal airways and mobilize mucus. Expiratory airflow exceeds inspiratory flow, pushing secretions upward. When combined with aerosol drug delivery (ADD), IPV further loosens mucus and improves clearance.
- Studies show IPV is as effective as standard CPT in improving lung function and sputum clearance. ICU patients with recurrent atelectasis, excessive secretions, or inhalation injuries benefit the most from this technique.
CPT is safe when the patient’s respiratory and hemodynamic status is stable. However, intensive chest mobilization may cause complications. These include tube dislodgement, blood pressure changes, raised intracranial pressure, or cardiac rhythm disturbances.
Manual hyperinflation and IPV require temporary ventilator disconnection. These techniques may interfere with sedation protocols and lung-protective ventilation strategies. Delivered pressure, volume, and flow must be carefully monitored to prevent complications.
IPV requires advanced equipment and skilled handling. The therapist must understand respiratory physiology and adjust pressures based on chest movement. Continuous monitoring of heart rate, oxygen saturation, blood pressure, respiratory rate, and end-tidal CO₂ is essential. Supplemental oxygen should be given when required. Pressure safety valves help reduce the risk of barotrauma.
Providing IPV therapy around the clock is resource-intensive. It requires a trained physiotherapy team working closely with ICU physicians. This level of care reflects the expertise involved in advanced cardiorespiratory physiotherapy and rehabilitation services.
Any change in the patient’s condition during CPT must be reported immediately. CPT is contraindicated in patients with undrained pneumothorax, severe instability, recent lung surgery, active bleeding, unstable chest wall injuries, acute bronchospasm, or raised intracranial pressure.