Slide 1
'Physiotherapy in ICU'
Rachel Crawford
Senior Lecturer
Physiotherapy
Physiotherapy in ICU. Presented by Rachel Crawford, senior lecturer in Physiotherapy at
Sheffield Hallam University.
Slide 2
Aim of the session
• To review the key contemporary issues around
practice in ICU by exploring the rationale for
intervention from its origins to the present day
The aim of this session is to review the key contemporary issues around practice in ICU by
exploring the rationale for intervention from its origins to the present day
Slide 3
Where have we come from?
So where have we come from? I’m talking specifically now about intensive care therapy, so
that’s the only environment we’re really focusing on.
Slide 4
'Traditional physiotherapy'
• Sections on the respiratory system exist in the
earliest British manuals of massage and remedial
gymnastics as well as medical texts
• 1846 – Hutchinson presented his work to the Royal
Medical and Chirurgical Society on lung volumes and
recorded that VC was affected by age, height, weight
and disease. He exhibited the first spirometer
So where have we come from and traditional physiotherapy, I’m talking about the
positioning, breathing exercises, manual therapy, bagging, suction, where has all that come
from? Well, we’ve got a lot to thank the society of trained masseuses for because it was in
the early texts of massage and remedial therapy that respiratory movements were
mentioned in the context of rehabilitation. And certainly the remedial gymnastics did a lot
of rib cage expansion work but didn’t necessarily call them breathing exercises or didn’t
necessarily use the language that we are so familiar with today. And this guy in 1846, Dr
Hutchinson, he was really the first person to record any changes in lung volume as a result of
position change, weight, height and he was the first person to actually refer to vital capacity
so the definitions of lung volumes are fairly well established now in medical texts, and he
also exhibited the first spirometer.
Slide 5
continued....
1894-1934
• 1894 - Society of Trained Masseuses established
• Arthur Tanner, a member of Swedish Gymnastics Association
(living in Fulham) described 'respiratory movements' to be
done 'to promote a more rapid oxygenation of the blood,
rendered venous by the muscular exertion';
• method: 'taking a deep breath with a fully expanded chest'.
But still no mention of physiotherapy at this point, until we get to the establishment of the
society of masseuses in 1894. Arthur Tanner, who was actually Swedish but lived in Fulham,
he was the first person to describe respiratory movements that should be done to promote a
more rapid oxygenation of the blood, rendered venous by muscular exertion. And the
method he described is perhaps one that we would recognise in the context of our current
practice, taking a deep breath with a fully expanded chest, but he didn’t at that stage call it a
breathing exercise he called it a respiratory movement in the context of remedial
gymnastics.
Slide 6
continued......
• 1898 - 'percussion' documented as a massage
technique, as well as general breathing exercises for
asthma and emphysema
• Placing of the hands on the ribcage
• Postural drainage (intermittent and continuous)
documented as early as the 2nd half of 19th century
in treatment of TB cavities
And then it was in 1898 that respiratory movements were perhaps defined in the way that
we would recognise with our own language as percussion and the placing of hands on the
rib cage and postural drainage, it’s quite a well established technique. And that’s
documented as early as the early 1800’s in response to people who were diagnosed with TB.
Slide 7
continued.....
• Same techniques continued to be documented in the
early part of the 20th century
• 1934 – Nelson published the first paper on postural
drainage which took the anatomy of the bronchial
tree into account (the same positions that are
recognised today); postural drainage bed was
invented
So, we’ve got placing of the hands, palpation, postural drainage and breathing exercises
specifically for asthma and emphysema pretty well established by 1900. And obviously we
all know that those same techniques are now well documented and established in
physiotherapy literature in the 20th century. But it was 1934 that postural drainage actually
was associated with pure anatomy as well. This guy Nelson took the anatomy of the
bronchial tree into account and that was the first recordings of the postural drainage
techniques that we are familiar with today and in association with that the first postural
drainage bed was invented. Can you imagine what that was like in 1934? So I guess you
could say that, bearing in mind I’ve already mentioned the 1800’s it wasn’t until 1934 that
some of these anatomical and physiological elements to respiratory practice were being
introduced. It was all a bit more external at that point where as maybe people started to
think well what is actually going on internally? But interestingly before the pure respiratory
physiotherapy techniques were established and developed we’ve got that element of
rehabilitation so the gymnasts, remedial gymnasts, were doing something that had a
respiratory connotation that the end point being for rehabilitation, it wasn’t associated with
secretion clearance so much at that point it was more to do with overall rehab, maybe from
opening of the airways but it wasn’t documented as being that at the time.
Slide 8
continued....
1935-1960
1935 - Breathing control for asthma
1938 – Chest clapping and shaking
1943 – Localised breathing exercises
and postural control for thoracoplasty
and empyema
So it wasn’t until the mid 1930’s up until about 1960 that we started getting some clarity
around the respiratory techniques that we have all been trained with. So breathing control,
chest clapping and shaking and certainly localised breathing exercises particularly for those
who had undergone major thoracic surgery, thoracoplasty and empyema. So you’re looking
at the industrial type of diseases there. Your asbestos induced lung disease, nasty
empyemas needing huge lung resections and those horrible sort of massive thoracoplasties
that were done back in the 40’s and 50’s, which fortunately have gone out of practice now.
Slide 9
Respiratory physio' progresses
• During 1940s and 1950s techniques developed in
response to advancing surgical techniques –
particularly advancing lung, heart and oesophageal
surgery
• Use of inhalers
• 1951 – Cash's 1st textbook 'Medical Conditions for
Physiotherapists'
• 1955 – Cash's 'Physiotherapy in Some Surgical
Conditions'
And in the 50’s we had Miss Cash, as she is referred to in the literature. Miss Cash’s first
textbook was the ‘medical conditions for physiotherapists’, it was quite a thick blue book and
then the surgical one she brought out in 1959 which was the big green one, but these were
really the bibles for what you did with these conditions. And it was very much condition
based physiotherapy as opposed to what we would like to think is our problem based
physiotherapy that we all engage in now, in current times. So it was what do you do with
the asthmatic, what do you do with the COPD, what do you do with the surgical patient, and
that was really the way Cash went. But, she was a pioneer, she was the first one of the first
physiotherapists to start to document some of the interventions that at the time were
deemed to be hugely significant and vital for these patients for reasons that we’ll elaborate
on in a moment. I guess that did come with this lung, heart and oesophageal surgery that
was developed in the 50’s and that surgery could really only be developed and pioneered
once they had mastered how to manage the airway and ventilation for that major surgery.
So we’ll come onto that in a moment. But carrying on with physiotherapy well, names like
Cash, Innocenti, Webber and Pryor all sort of found their niche really in the period of the
70’s to 80’s. I mean Webber and Pryor, well Jennifer Pryor came over, she started writing in
New Zealand in the late 70’s and most of her literature, most of her recognised early
literature was of the 80’s when she had actually moved to the UK on FET and the ACBT
technique. But certainly Dianna Innocenti, she worked at the Brompton pre- Webber and
Pryor era and she was also a huge influence on respiratory physiotherapy.
Slide 10
continued....
• Innovative physiotherapy practice e.g. 'Chest
physiotherapy by the 'bag squeezing' method'
Clement (1968) in Physiotherapy
• Blending of traditional physiotherapy practices
into the exciting and dynamic realms of care for
the post-operative and intensive care patient
• Published work from the pioneers – Cash,
Innocenti, Webber and Pryor
So by the late 60’s in response to some of these advancing surgical techniques and the way
that patients were managed in those days physiotherapy was deemed to be innovative bag
squeezing to improve lung volume and to move secretions. And then you’ve got a blending
of what was considered to be traditional physiotherapy within this dynamic environment,
because at the time it was very pioneering, postoperative patients were difficult to manage
in those days and the intensive care patient was becoming a new sort of patient in the late
50’s and 60’s. That was a whole new area that physiotherapy could develop into. So these
were exciting times and I guess this was where the sort of bread and butter physiotherapy
techniques that we were all trained with and perhaps are now struggling to let go of, this is
where they came from, and this is why as a profession we probably struggle to let go of
them because we associate them with the icons of respiratory literature. Cash, Innocent,
and certainly in later years, Webber and Pryor. So, although we’re probably going to be
contentious and a little bit controversial as the morning goes on, I don’t think we can let go
of, or indeed undermine, the enormity of what these women were doing at the time, and
that I think is very exciting for the profession, but it’s about accepting that the environment
that they worked in no longer exists really, and we’ll be able to highlight that in a moment.
Slide 11
Advancement:
1960 – 1980
• Developing technology in monitoring and
support systems
• Advancing, pioneering surgery
• Increased understanding of physiological
principles
• Dialogue and research across the professions
So towards the 1980’s we’ve got a massive change in IC practice. We’ve got a development
in ventilation, a development in the way that patients were cared for, no longer were they
bed bound for x number of days. My dad tells me, my mum and dad met in the hospital
ward because my mum was a nurse and dad was a patient, shock horror, but dad says those
were the days when they got to know the nurses because they were in hospital for weeks, I
mean he just had an ear operation and he was in hospital for 10 weeks and ended up getting
married to his nurse who is now my mum. But those days were left behind in the 70’s and
80’s, there is a great change in practice, people were encouraged to get out of bed much
sooner. Technology and monitoring developed so that there weren’t the fears associated
with moving somebody were perhaps alleviated by the fact that they could be monitored
more closely. And indeed with that there was better knowledge of physiological principles,
particularly for the physiotherapists as well, and I think you’ve only got to look at the
literature as we’ve moved through the 80’s and 90’s to see that physiotherapists are actually
very knowledgeable and clearly understand certainly respiratory physiology and some of the
rationale behind the interventions. So that really came about in the period, probably the
late 60’s to the 80’s. And there was much more inter-professional dialogue, so physios were
starting to talk to doctors to liaise with them, to say what about this, what about that. And
we know from the research that there was much more collaboration, research was coming
out of units as opposed to one person trying to establish a change in practice. And I think
The Brompton did set the scene really didn’t it, that was a respiratory unit that said well this
is how we do things, what are you doing?
Slide 12
Ventilation
• Dates from Vesalius (1555) and Hooke (1667)
• 1896 – 1st successful laryngeal intubation
• 1910 – Dorrance evolved the prototype of modern,
cuffed ET tube
• 1929 – Drinker of Harvard developed tank respirator
aka 'Iron Lung' - commercially available (described as
early as 1838)
So, that’s the sort of grass roots of traditional respiratory techniques. So let’s just hold those
thoughts for a moment and move to ventilation, and then we’ll draw the two together.
Because I think in the context of intensive care we have to understand how ventilation has
changed really over the years. And in ventilation this idea of forcing air into the lungs isn’t a
new technique. There were awful texts around the intubation of dogs and things in the 16 th
and 17th century so Versalius and Hooke there are texts associated with them. But the first
successful laryngeal intubation which was done by fingers, so fingers were inserted into the
larynx to open up the larynx and the airway, was done in 1896 but fortunately things
changed soon after that. And it wasn’t until 1910 that this chap Dorrance, I can’t remember
if he’s UK or US, he evolved the prototype of what we now consider to be the modern cuffed
endotracheal tube. But I’m sure even in the time you’ve been practicing, you’ve seen a huge
change in airway management, not just in terms of what they look like but also what they
are made of and we know that there are some high tech materials now involved in airway
management. But I guess the biggest influence on ventilation as we know it today was the
commercial availability of what’s called the Iron Lung or the tank respirator as it was known.
That was first developed by this guy Drinker in Harvard University. Although the concept of
ventilation predates that so intermittent positive pressure ventilation had been around even
before the first laryngeal intubation.
Slide 13
http://www.johnpowell.net/pages/clevedon.htm
- accessed on 28/09/05
And if you haven’t recently seen a picture of the Iron Lung, here it is. It’s a pretty hideous
thing isn’t it? You can sort of imagine why it was called the Iron Lung or the tank ventilator.
Now, are you understanding what they key difference is between this and modern day
ventilation? These are negative pressure ventilators so the ventilation today, apart from your
modern Hiac Oscilator or Hiac Jacket or whatever, is positive pressure where as this is
negative pressure. So, the patient was laid on the plinth sort of part component of the
ventilator and the tank was closed over them, so the only exposed part of the body was the
head, which stuck out of this end here. And you can see just on the top left of the picture
you can see that’s actually a mirror that’s sticking out diagonally. Can you make that out?
So when the patient was lying in this monstrosity all that they could see was their own face
but it meant that they could just see, it gave them a little bit of peripheral vision, but not a
huge amount. So, a pretty hideous thing. Now at the end of that tank, you can’t see it in
this picture, would be a huge sort of bellows effect suction creation piece of equipment. So
this was a sealed unit apart from the head and around the head would have been a bit like a
space suit, you know they have a sort of extra bit of material that closes the circuit around
the neck. So when the tank was closed what the suction unit did was sucked air out of the
tank, so it became almost a vacuum so that created a negative pressure, in other words
there was nothing in there. So as that negative pressure was created and there was no air
left to suck out the suction unit continued to suck and what actually happened was that the
chest wall was sucked outwards, so that created volume changes and therefore because of
the pressure difference between atmospheric pressure and intra-lung pressure air was
sucked in just as we breath today. But obviously this was used on patients who couldn’t
create enough volume and we’ll talk about the type of patient that went in these in a
moment. The suction unit was then set to cut out, so there was a slight increase or a
decrease in negative pressure if you like, it never went to positive, a slight change in
pressure, the rib cage was then allowed to go back to its resting position and the patient
would breathe out. So the modern ventilation as we know it today is fairly young really and
that is why it’s developed so massively over the last 10-20 years because it was essentially a
fairly new concept even in the 70’s really. So that’s the good old tank ventilation, now that
was the prototype that was situated in the USA.
Slide 14
http://www.johnpowell.net/pages/clevedon.htm - accessed
on 28/09/05
And this is what it looked like when a patient was in it. So you can just see the head sticking
out and then they had this, there could be an enclosing of the head as well which would
have been hideous, and obviously the nurse would lift that up to talk to the patient and do
mouth care and to allow the patient to eat and drink if indeed they could do that. So a far
cry from where we’re at now, don’t you agree? And usually with the undergraduates when I
talk to them about ventilation I show them like a montage of some of the modern
ventilators, you know the nice slim line, on a pedestal, electronic, small, it’s just a massive
difference isn’t it in terms of what we’re faced with today.
Slide 15
continued....
• 1938, Lord Nuffield gave tank respirators to
any British hospital that asked for them
• 1947 – polio epidemic
• Pandemic of polio resulted in global use of
such equipment and by default the 1st
'intensive care units' evolved
So this tank ventilator, how did it come across the water to us? Well Lord Nuffield, who is
William Morris, the designer of the Morris car, he was a very rich man based in Oxford, he
decided to offer one tank ventilator to every hospital that asked him for one in the UK. And
that was a really good thing to have done, not that they would have known it at the time
because what actually happened in the post war years was the polio epidemic swept across
the world and indeed Europe. And the tank ventilator, or the Iron Lung, came into its own at
that time. And by default really, the first intensive care unit were evolved as a direct result
of the polio epidemic.
Slide 16
http://www.johnpowell.net/pages/
clevedon.htm – accessed on
28/09/05
So here we have however many, you imagine, that’s just one ward in one hospital, so you
imagine across the world where iron lungs were available, these were polio patients, polio
patients were the ones that needed it. Now why did polio patients need ventilation? What
is it about polio that affects the respiratory system? Think of Guillain Barre and Myasthenia
Gravis as well, what happens to those patients when they come onto intensive care?
Basically, polio affects the anterior horn cell of the spinal segment, Guillain Barre affects the
sheath, Myasthenia Gravis affects the neuromuscular junction. So any of those three
peripheral neuromuscular diseases or disorders will wipe out the respiratory muscles, if
indeed it affects that spinal level. The problem with Guillan Barre is that it ascends as we
know from the lower peripheries and it comes up through the thoracic and cervical regions
quite quickly and therefore can wipe out the respiratory nerves. The other problem is if it
affects high enough it will affect the cranial nerves which hopefully you realise they are
peripheral nerves, they are not actually central nerves, they are peripheral nerves, so cranial
nerve function can be wiped out by these and that will affect swallow, cough, ability to
manage saliva, all of those things, and that’s why these patients had such a high, this polio
epidemic had such a high mortality rate, because even in the presence of ventilation they
were often overwhelmed by upper airway occlusions due to secretion retention purely
because their cranial nerve function had been wiped out by the polio. So this was the first
intensive care, so with these polio patients, they had to care for them in a fairly isolated
place in the same way, so the best plan was to bring them all into one room, so this would
be like a Florence nightingale ward in the old style wards, and put in lots of nurses and care
for them that way. So it was pretty horrific really.
Slide 17
continued.....
• 1940s – evolution of cuffed ET tube
• 1949 – IPPV successfully used
• 1952 – massive epidemic of Polio in Copenhagen.
Between August and December of that year 3000
cases admitted to hospital
• Massive mortality due to airway incompetence and
fatal secretion retention
Now at the same time as all this was happening somebody in the world was developing the
cuffed ET tube and in 1945 back over in the USA caring for these polio patients they actually
tried intermittent positive pressure ventilation via a Bennett positive pressure valve and a
waters bag and when they were changing patients from tank to tank or when there was an
emergency or when they just wanted to supplement the patients volume changes, even
though they were in these tank ventilators, they added in this intermittent positive pressure
ventilation. And word about that came across the water to Europe and what happened was
in Copenhagen where they were absolutely wiped out by the polio epidemic an anaesthetist
decided to try and combat this massive mortality rate that they were experiencing due to
airway incompetence and what was fatal secretion retention because the ventilation alone
wasn’t actually dealing with what these patients needed.
Slide 18
continued....
On August 27th, 1952 Dr Ibsen called for new
treatment:
• cuffed tracheostomy
• suction
• repeated bronchoscopy
• postural drainage
• manual PPV
So he decided for a new radical treatment for all of these patients and that involved using a
waters bag with a cuff tracheostomy, suctioning the patient , repeat the bronchoscopy to
make sure the lungs fields were clear, keep turning the patient and the manual positive
pressure ventilation will maintain their lung volumes.
Slide 19
http://www.johnpowell.net/pages/clevedon.htm
- accessed on 28/09/05
And here we see, this was 1952, perhaps what we could consider to be the start, the
evolution, of traditional physiotherapy in addition to those other techniques that we talked
about.
Slide 20
continued.....
• By the end of that year mortality had fallen
from 87% to 26%
• 1953 – the Clevedon ventilator piloted on a
21yr old male – Max died in 1998!
• Positive pressure ventilators became the
treatment of choice
So, as a result of that treatment mortality rate in Copenhagen from polio fell from 87% to
26%. And in 1953 here in the UK, the Clevedon ventilator was piloted on a twenty year old
male called max and he died in 1998. So it was obviously a successful venture. And so, after
1953, positive pressure ventilators became the treatment of choice.
Slide 21
http://www.johnpowell.net/pages/clevedon.htm
- accessed on 28/09/05
And here it is, that’s the Clevedon ventilator. And again if you think about the sort of
ventilator we might come across in our career we’d probably think of the nice slim line
Servos, the Puriton Bennetts, lovely electronic things, all singing all dancing bright lights,
pedestal ,wheels, small, and there you have something that is essentially mechanical, there
were no electronics involved in this it was pure mechanics. So engineers developed these as
opposed to very clever software program developers now who are probably involve in
ventilator design. So this was good old fashioned engineering, mechanical engineering and
quite remarkable when you think about the challenge of the day.
Slide 22
continued....
Copenhagen polio life-saving programme was
to be the foundation of modern intensive
respiratory care:
intubation and positive pressure
ventilation
humidification
regular airway suction
changes of position
So, by default really the Copenhagen polio epidemic and the life saving program that was
introduced was really the foundation of what we would consider as physiotherapists to be
traditional, intensive respiratory care, and that would be intubation and positive pressure
ventilation, humidification, regular airway suction and position change. Interesting that
there is no mention it the literature talking about the Copenhagen program, there is no
mention of additional breathing exercises or additional manual therapy or anything like that.
Slide 23
Changing environment......... 1980s to date
Merging of ICU & traditional
physiotherapy
So, let’s bring the two together then. So we’ve talked about the history of ventilation and
some of the more traditional manual therapies, so let’s talk about the merging of ICU and
traditional physiotherapy.
Slide 24
Physiological rationale
the presence of enforced bedrest & +/- ventilation and the
inevitable adverse sequelae
TRADITIONAL PHYSIOTHERAPY

• Prevent pulmonary complications by  lung volume, 
alveolar ventilation, facilitating secretion clearance
• To alter the clinical course of pulmonary conditions
• Improve lung function
So back in the 50’s when the Clevedon ventilator was introduced when physiotherapists
were being recognised as having a very clear role in the management of some of these very
unwell patients. The physiological rationale was pretty sound really, these were patients
who were on enforced bed rest, couldn’t move, there was no way they could get out of the
Iron Lung, your post surgical patients were bed bound for weeks, I mean my dad’s surgery
was pretty minor but if his experience is anything to go by I mean they really were you know,
the emphasis was on no movement rather than movement. So clearly there was inevitable
adverse sequale as a direct result of that. So traditional physiotherapy at that time was to
prevent pulmonary complications by increasing lung volume, alveolar ventilation and of
course facilitating secretion clearance, with the hope that that would change the clinical
course of pulmonary condition and improve lung function. And I suspect at the time that
this is where the belief that physiotherapy solved respiratory problems came from, because
these patients were really poorly, they had gallons of secretions. So you can imagine that
just by changing their position and getting them to cough might actually make a huge
difference so you can see why physiotherapy was so significant in the care of these patients.
Slide 25
Techniques used
•
•
•
•
•
Positioning
Manual therapies
Manual hyperinflation
Suction +/- saline
Passive movements
• Not as much emphasis on mobility/rehabilitation
And the techniques used were the ones that we would recognise today, and we know are
still being used today in various places routinely, that’s our tool bag of treatments really
aside from rehabilitation. And clearly in the early days there wasn’t as much emphasis on
mobility or rehabilitation.
Slide 26
continued....
•
•
•
•
•
 size and case mix of ICUs
Development of cardiac intensive care units
Pioneering surgery of the '60s & '70s becomes routine
Hospital stay reduces
Day surgery
Physiotherapy
• ACBT fully established
•  use of IPPB/CPAP
• Intervention across the respiratory and surgical/ICU
spectrum – 'routine physiotherapy'
• Increased staffing levels on ICU
But at the same time that physiotherapy was becoming established in its traditional way and
was deemed to be very significant in the management of these patients other things started
to happen outside of the physiotherapy context. So the environment started to change very
quickly so going from the big Iron Lung, the Iron Lungs all lined up in their great numbers in
those one rooms, things started to change, intensive care started to develop so we had
specific sort of self contained rooms that were deemed to be intensive care units. And
different types of patients were being ventilated so we’ve moved away from just the polio
patients and ventilation was deemed to be something that other patients required, so that
medical management could be offered. Cardiac intensive care units came into being so they
were separate from the general intensive care unit. And pioneering surgery of the 60’s and
70’s, so the big abdominal surgery, the thoracoplasties, the big lung resections, that all
became a bit sort of routine really, and hospital stays started to come down, so the 10 week
stay for ear surgery would have gone to day surgery and rightly so, obviously. But
physiotherapy was on the up, if you like, it was really selling itself even though the
environment was changing. And I think that’s where perhaps there was a separation of
traditional physiotherapy from actually what was needed. So ACBT, thanks to Jennifer Pryor,
was fully established, we know that that happened in the late 70’s early 80’s really. There
was an increased use of physios using Bird and CPAP, so the sort of development of
ventilation and in fact a lot of the early use of positive pressure for obstructive sleep apnoea
is as a result of work done by physiotherapists. But things change so quickly that other
people started to take on some of those things. And intervention across the respiratory and
surgical ITUs spectrum developed such that we’d deem it routine physiotherapy, or we
certainly did back then. And physiotherapy staffing levels increased on ICU so there was a
great emphasis on chest physiotherapy, we need to do that, that’s what the last 10-15 years
has told us we need to do, we’re going to do it, regardless of what was happening above.
Slide 27
Also – a change in approach
• Therapy becomes more proactive and dynamic,
patients move from a dependent state to one of
independence as soon as possible; prolonged and
enforced bedrest no longer exists – patients are
more mobile, earlier in their care.
• In many cases risk is much reduced purely on the
basis of  mobility e.g. surgical patients
So therapy becomes more proactive with a whole change in approach, patients become
independent much sooner so they go from a state of dependence to independence probably
within days rather than weeks or months. Patients are more mobile earlier in their care and
in fact a lot of the high risk that was associated with these patients back in the50’s and 60’s
was eliminated purely on the basis that they got up and walked, and that makes perfect
sense doesn’t it from what we all know and what we would all indeed encourage now. And
that obviously is very typical of our surgical patients, we’ve seen cardiac surgery become
fairly routine now, patients are fast-tracked and they’re out of bed within the first 24 hours
sometimes and therefore the risk goes down.
Slide 28
But.......late 80s into 90s
but the evidence starts to emerge.....
• Questioning of rationale of physiotherapeutic techniques in
surgery and ICU – Stiller, Jenkins, Dean & Pong Wong
• RCTs
• problem-based management needs to replace conditionbased management
and at the same time ICU continues to evolve....
But, in the late 80’s and into the 90’s at the same time that Webber and Pryor were really
establishing ACBT and at the same time that physiotherapy was really quite prolific on
intensive care units and surgery, what people around the world who were starting to say,
well that’s all very well but, and they’re pretty familiar names to us now, that started to
write quite controversial things. Elizabeth Dean in the 80’s started to tell us about the
oxygen transport pathway and said well maybe instead of looking at sputum clearance just
in isolation, we should be looking at the whole body and doing whole body rehabilitation to
promote oxygen transport. We had Kathy Stiller doing extremely controversial work in
cardiac surgical patients because she produced a control group that didn’t even meet a
physiotherapist. Ok, how she got that through ethics I still don’t know, but she did and the
result of her RCT was that actually pulmonary complications didn’t change according to
whether the physiotherapist had seen the patient or not. Sue Jenkins had done some earlier
work on cardiac surgery and continued to work certainly in the UK, on RCT’s looking at
whether breathing exercises or incentive spirometry alone affected cardiac surgical patients,
and she started to raise the question in the UK, do we need to see these patients? And Pong
Wong over in Asia, we’ve got Dean in Canada, we’ve got Pong Wong in Asia, we’ve got
Jenkins in the UK, Stiller in Australia, so all corners of the world were starting to say, hang on
a minute, and Pong Wong was the first one really, she talked about this whole paradigm shift
from condition based physiotherapy. So instead of saying that patient has sputum therefore
I need to do that, she started saying well let’s look at Elizabeth Deans work and let’s say, well
maybe the sputum is just a symptom of something else and the sputum isn’t such a major
problem as we think it is, in other words physiotherapists were being encouraged not to
focus on the sputum, and I’m sure all of us have moved on from those early days where
sputum was the thing that we treated. And randomised controlled trials were starting to
become more significant, we’ve seen a lot more in the 90’s and in the early 2000’s
particularly out of Australia, they seem to do much more than we do over here. And there is
a real emphasis now on problem based management and certainly we are being encouraged
to do problem based management instead of condition based. But at the same time we’ve
always got this thing going on in the background, ICU continues to evolve.
Slide 29
Now, in the 21st century....
And now in the 21st century we’ve got ICU’s that are nothing like, they’re unrecognisable
from those early pictures of the iron lungs being lined up in the Florence Nightingale ward.
Slide 30
Changing environment....
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Evolution of units
Sophisticated & portable ventilators/Cough-Assist/NIV
Sedation choice and manipulation
Drug advancement
Weaning strategies
Rotation beds and use of prone
Early tracheostomy and weaning
Early discharge
Outreach teams
So we’ve got an evolution of units, we’ve had an evolution of technology and ventilation, so
we’ve got nice easy to use portable ventilators now, we’ve got the cough assist. So positive
pressure ventilation has been taken and adapted to certain environments and to fit certain
patients, both in terms of the acute setting and the more rehab type community setting as
well. So, oo that’s a bit scary suddenly it’s be taken out of our control by a machine, that’s
something we need to face. Sedation choice and manipulation have now become a key
factor in how quickly we can intervene with these patients. Drug advancement, weaning
strategies have all changed. Rotation beds, the all singing all dancing, do whatever you want
it to rotating bed. I remember a rep once telling me, I don’t know if he hadn’t read my
badge or whether he’d misheard me when I introduced myself but he said to my face, well of
course you don’t need physiotherapists now that we have a bed like this. But certainly
prone positioning has really come into its own hasn’t it and it’s where do physiotherapist
stand with all of that. Early tracheostomy and weaning had a massive impact on, certainly
not just the care of patients in the ICU but how quickly they are discharged from ICU and
that ‘s had huge implications for ward management as well. And Outreach teams have
obviously come on board, many of them without physiotherapists and its how we deal with
those as well.
Slide 31
Challenges to and influences on physiotherapy
practice
CHALLENGE
• Size of units/staffing
• Ventilation
• Improved anaesthesia, surgical
technique & pain mx
• Rotation beds & prone
• Drugs e.g.mucolytics
• Early discharge
• MRSA/Acintobacter
• Heavier patients
• Outreach
• Demand for EBP & outcome
measures
INFLUENCE
• Sedation
• Cough-Assist
• Early tracheostomy
• Weaning strategies
• Critical care neuropathy
• Seating/hoists
• Opportunities for rehabilitation
• Outreach
So just to finish off then, let’s think about the challenges to and the influences on, so having
come through those 50 years of massive change, and we know that things are continuing to
change, we are still challenged. Physiotherapy practice on ICU is still being challenged, in
other words the routineness, the traditionalness for want of a better phrase for what we
used to do, is being hugely challenged by the size of units and staffing. On the base of that
alone, you cannot treat every patient twice a day, because of the demand on you to be
either in another place or to treat another 18 patients, so you can’t do that. The nature of
ventilation has changed so it’s now much more sophisticated, it suits the patient much
more, it copes with their volume changes and their pressure changes, they are no longer
dependent on twice daily manual hyperinflation to increase their tidal volumes and alveolar
recruitment because the ventilator does it and their position is changed more frequently.
We know that we’ve got improved anaesthesia, surgical technique and improved post-op
pain management. So these patients do get up and walk pretty early, much earlier than they
used to so the physiotherapist is sort of, a little bit redundant, probably. The rotation beds,
the drugs such as mucolytics are a challenge to us because you know, you could argue that
that was something that wasn’t around 20-30 years ago. Early discharge, we’re also
challenged by the hospital bugs, the superbugs and that affects our accessibility to patients
and also how quickly they move. Heavier patients, we know that’s a huge problem now and
what are we going to do about that in terms of how we manage patients. Outreach, how
can we get involved with that, sometimes it’s done without physios and therefore there is
seen to be this tension on the ward against the outreach team and the physio. And
obviously that ongoing underlying, undercurrent of how do you know that your practice is
effective. So there is this pressure to keep producing evidence based practice, or to at least
say well, something is being done or this is my outcome measure and that’s the best thing
I’ve got at the moment. There is that pressure all the time to be saying that. But the
influences that are moving us perhaps towards early rehabilitation are helping us to manage
these patients much more easily are the sedation holidays, the sedation manipulation,
things like cough assist, early tracheostomy, weaning strategies so the patient can be woken
up and weaned more easily with a better understanding of what’s going on, critical care
neuropathy, obviously is perhaps more prevalent now, or it’s certainly recognised now more
than it was 10-15 years ago. The development of seating, high tech hoists for heavy
patients, you know this is all helping us do our job more effectively and there is greater
opportunities for rehab, and to infiltrate, if I dare you with that word, or certainly be part of
the outreach team.
Slide 32
Where are we now?
What of traditional physiotherapy?
So, the question I leave you with just at the minute is where are we now and what of that
traditional physiotherapy? Because, the face of health care is changing dramatically, we can
do research, we have the facility, we often have the funding, do we have the time, are we
choosing to ignore quality evidence, are we still sticking our heads in the sand, and we know
that that is still a problem, that physios choose, they actually make a choice to not read the
literature, they make a choice to do that and isn’t it an interesting concept that the public
will run with a piece of research that the news has announced one day, say of a particular
drug or there are all sorts of things about the contraceptive pill or what you do when you’re
pregnant and the public will suddenly be, and MMR is a classic example of how the public
have been influenced by perhaps poor research, and yet you could argue that in the
respiratory field we have actually got some fairly decent research and that in certain areas
but people choose to ignore it when it’s like well hang on a minute, you know, what’s going
on here. But the pressure is ever present to show that our interventions are effective. Does
anecdotal evidence hold water, how much longer can we as a profession say well I think it
works, in my experience, you know regardless of any literature that’s always worked for me.
Use of saline is a classic example of that. And if the evidence isn’t there what are we going
to do about it?