Chest physiotherapy techniques in neurological intensive care units of India: A survey

Effects of proprioceptive neuromuscular facilitation combined with threshold inspiratory muscle training on respiratory function in neurocritical patients with weaning failure: a randomized controlled trial

The purpose of this study was to determine the effects of combining proprioceptive neuromuscular facilitation (PNF) with threshold inspiratory muscle training (TIMT), compared with TIMT alone, on respiratory function in neurocritical patients who experienced a weaning failure. Forty-seven participants (mostly after a stroke), were randomly divided into the experimental group ( n  = 24) and the control group ( n  = 23). The control group received usual care and TIMT, whereas the experimental group, in addition, underwent four 90-s periods of manual PNF. Both groups performed training in the ICU twice a day for 5 consecutive days. The main outcome measures included maximum inspiratory pressure, diaphragmatic excursions, diaphragm thickening fraction, oxygenation index, and forced expiratory volume in 1 s/forced vital capacity. The results showed a significant group-by-time interaction effect for maximum inspiratory pressure [ F (1, 45) = 17.84, η2  = 0.328, P  < 0.001] and oxygenation index [ F [1, 45) = 5.58, η2  = 0.11, P  = 0.023]. When compared with the control group, the experimental group showed overall significantly higher maximum inspiratory pressure [mean difference = 4.37 cm H 2 O, 95% confidence interval (CI) 0.25-8.50, P  = 0.038]. No other significant group differences were found. Combining PNF with TIMT may improve respiratory function in neurocritical patients with weaning failure. This combination approach may increase the likelihood of survival of neurocritical patients in the ICU.

[Update on manual bronchial clearance techniques (adults and adolescents)]

In adults and teenagers, airway clearance physiotherapy techniques (ACPT) are various and numerous. However, they for still awaiting scientific validation. Among ACPTs, Slow Expiration with the Glottis Opened in the Lateral Posture (ELTGOL), Autogenic Drainage (DA), and Active Cycling Breathing Technique (ACBT) present a Grade B level of evidence with weak recommendations. Even though these maneuvers are widely applied, precise description of chest physiotherapy (CP) is largely absent from the scientific literature; it is difficult to standardize its implementation and reproduce the results; scientific validation and faithful execution of the techniques are consequently problematic. In this paper, the authors aim to depict each of the three CP techniques as precisely as possible; with this in mind, graphic modeling of the different respiratory exercises is presented in such a way that they can be easily learned, applied and reproduced by physiotherapists.

What Interventions Do Physical Therapists Provide for Patients With Cardiorespiratory Conditions, Neurological Conditions, and Conditions Requiring Acute Hospital Care? A Systematic Review

OBJECTIVE

The aim of this systematic review was to determine what percentages of physical therapists provide interventions that are of high value, low value, or unknown value for cardiorespiratory conditions, neurological conditions, or conditions requiring acute hospital care. Whether an intervention was considered high or low value was determined by reference to guidelines or systematic reviews.

METHODS

Searches of numerous databases were performed by combining terms synonymous with "practice patterns" and "physical therapy" until April 2018. Studies that investigated what interventions physical therapists provide for any cardiorespiratory condition, neurological condition, or condition requiring acute hospital care through surveys and audits of clinical notes were included. Through the use of medians and interquartile ranges, the percentages of physical therapists who provided interventions that were of high value, low value, or unknown value were summarized.

RESULTS

Twenty-six studies were included. The median percentages of physical therapists who provided interventions of high, low, and unknown value for chronic obstructive pulmonary disease ranged from 78% to 96%, 67% to 100%, and 56% to 91%, respectively. These percentages ranged from 61% to 97%, 87% to 98%, and 83% to 98% for adults who were critically ill in intensive care units; 70% to 93%, 38% to 50%, and 8% to 95% before or after cardiac/thoracic surgery; 25% to 96%, 23% to 84%, and 96% for acute stroke; and 11% (high value) and 13% (unknown value) for Parkinson disease, respectively.

CONCLUSIONS

This review found patterns of physical therapist practice for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care that were both evidence based and not evidence based. A concern is that a substantial percentage of physical therapists provided interventions that were of low or unknown value despite the availability of high-value interventions.

IMPACT

This systematic review is the first, to our knowledge, to summarize the percentage of physical therapist treatment choices that were high versus low value for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care. The findings highlight areas of practice where low-value care could be replaced with high-value care-such as in the management of patients who have chronic obstructive pulmonary disease or who are in intensive care-and identify an urgent need to develop and test strategies to ensure that patients with these conditions receive the interventions most likely to improve their outcomes.

Airway clearance techniques and use of mucoactive agents for adult critically ill patients with acute respiratory failure: a qualitative study exploring UK physiotherapy practice

OBJECTIVES

To explore and describe current UK physiotherapy practice relating to airway clearance techniques and mucoactive agents in critically ill adult patients with acute respiratory failure in the intensive care unit.

DESIGN

A descriptive, qualitative study using focus group interviews. Focus groups were audio-recorded, independently transcribed, and data analysed thematically. Participants Senior, experienced physiotherapists, clinically active in critical care.

RESULTS

Fifteen physiotherapists participated in four interview sessions. Five themes emerged describing airway clearance techniques: 'Repertoire of airway clearance techniques', 'Staffing and skillset', 'Commencing respiratory physiotherapy', 'Technique selection', and 'Determining effectiveness' were themes related to airway clearance techniques. Five themes were also identified in relation to mucoactive agents: 'Use in clinical practice', 'Decision to commence', 'Selection of agent', 'Stopping mucoactive agents', and 'Determining effectiveness'. A summary of key features of standard practice was developed.

CONCLUSIONS

Standard UK physiotherapy practice of airway clearance techniques is variable, but patient-centred and targeted to individual need, with adjunctive use of mucoactive agents to enhance and optimise patient management if required. Based on this study, key features of airway clearance techniques have been summarised to help capture standard care, which could be used in future trials involving ACT as part of usual care.

[Physiotherapy interventions in the ICU : Outcome-relevant measurement parameters]

BACKGROUND

Guidelines cannot provide differentiated recommendations for physiotherapy (PT) in intensive care medicine. Scientific publications for PT in the intensive care unit (ICU) usually only have low levels of evidence and often express safety and feasibility of PT in the ICU.

OBJECTIVE

Which measurement parameters are relevant for defining outcome and what interventions should one take into consideration?

MATERIALS AND METHODS

A literature review was conducted. This was based on a PubMed search with full text access, as well as specific definitions for physical therapy, intensive care and four out of seven conditions from the manual "Physiotherapy in intensive care".

RESULTS

The availability of 172 studies clearly shows that there is certainly PT research concerning the critical environment of the ICU. However, parameters for quantitative and qualitative detection of vigilance and state of consciousness as well as assessments to evaluate the mobility and the ability to help themselves are important for everyday use.

CONCLUSIONS

The difficulties of using PT in the ICU are not useful in ensuring the safety of the patient or performing a PT treatment. The conditions of the intensive care environment are not an obstacle. It is of immanent importance to use the limited resources of PT in an optimal and targeted manner in the ICU environment. The determination of ICU-adapted goals plays a crucial role.

The scope of physiotherapy services provided in public ICUs in Greece: A pilot study

The aim of the present study was to determine the scope of physiotherapy services provided in Greek ICUs in Athens. A cross-sectional study was conducted with two postal questionnaires administered separately, one for ICU directors and one for ICU physiotherapists. Responses were received from 19 ICU directors and 103 physiotherapists employed in all the adult public mixed medical and surgical ICUs across Athens. The response rate for the survey completion was 100% for ICU directors and 68.7% for physiotherapists. The results showed a 1:50 to 1:12 range in the ratio of physiotherapists to ICU beds. Among the 19 ICUs, 15 (78.9%) employed physiotherapists on a rotational basis, while four (21.0%) retained them exclusively. On weekdays, all surveyed ICUs were covered by physiotherapists in the morning and 10/19 (52.6%) during the afternoon. On weekends, 12/19 (63.2%) of the surveyed ICUs reported physiotherapy care during the morning and 4/19 (21.0%) during both morning and afternoon. All 103 physiotherapists conducted airway clearance techniques and progressive mobilization, 92/103 (89.3%) were involved in extubating patients, 102/103 (99.0%) in passive and active range of motion exercises, and 61/103 (59.2%) in walking. In conclusion, all Greek ICUs in Athens surveyed had physiotherapy cover. The physiotherapists working in these ICUs in Athens were involved in respiratory care and mobilization.

Mobilization of patients in neurological Intensive Care Units of India: A survey

Context:

The rehabilitation needs of the patients in neurological Intensive Care Units (ICUs) vary from that of a medical ICU patient. Early mobilization is known to improve the various neurological outcomes in patients admitted to neurological ICUs, although little is known about the practice pattern among physiotherapists. The mobilization practice pattern may vary significantly than that of developed countries due to the reasons of differences in training of professionals, availability of equipment, and financial assistance by health insurance.

Aim of the Study:

To study the current mobilization practices by the physiotherapists in neurological ICUs of India.

Subjects and Methods:

A cross-sectional survey was conducted with a content validated questionnaire about the mobilization practices. Online questionnaire was distributed to physiotherapists working in neurological ICUs of India. Descriptive statistics were used.

Results:

Out of 185 e-mails sent, 82 physiotherapists completed the survey (survey response rate = 44%). Eighty participants (97.6%) mentioned that the patients received some form of mobilization during the day. The majority of the physiotherapists (58.5%), “always” provided bed mobility exercises to their patients when it was found appropriate for the patients. Many physiotherapists (41.5%) used tilt table “sometimes” to introduce orthostatism for their patients.

Conclusion:

Mobilization in various forms is being practiced in the neurological ICUs of India. However, fewer mobilization sessions are conducted on weekends and night hours in Indian Neurological ICUs.

Physiotherapy practice patterns in Intensive Care Units of Nepal: A multicenter survey

Context:

As physiotherapy (PT) is a young profession in Nepal, there is a dearth of insight into the common practices of physiotherapists in critical care.

Aims:

To identify the availability of PT services in Intensive Care Units (ICUs) and articulate the common practices by physiotherapists in ICUs of Nepal.

Settings and Design:

All tertiary care hospitals across Nepal with ICU facility via an exploratory cross-sectional survey.

Subjects and Methods:

An existing questionnaire was distributed to all the physiotherapists currently working in ICUs of Nepal with 2 years of experience. The survey was sent via E-mail or given in person to 86 physiotherapists.

Statistical Analysis Used:

Descriptive and inferential statistics according to nature of data.

Results:

The response rate was 60% (n = 52). In the majority of hospitals (68%), PT service was provided only after a physician consultation, and few hospitals (13%) had established hospital criteria for PT in ICUs. Private hospitals (57.1%) were providing PT service in weekends compared to government hospitals (32.1%) (P = 0.17). The likelihood of routine PT involvement varied significantly with the clinical scenarios (highest 71.2% status cerebrovascular accident, lowest 3.8% myocardial infarction, P < 0.001). The most preferred PT treatment was chest PT (53.8%) and positioning (21.2%) while least preferred was therapeutic exercise (3.8%) irrespective of clinical scenarios.

Conclusions:

There is a lack of regular PT service during weekends in ICUs of Nepal. Most of the cases are treated by physiotherapists only after physician's referral. The preferred intervention seems to be limited only to chest PT and physiotherapists are not practicing therapeutic exercise and functional mobility training to a great extent.

Physiotherapy practices in Intensive Care Units across Maharashtra

Purpose:

To find out the current physiotherapy practices in Intensive Care Unit (ICU) across Maharashtra.

Materials and Methods:

Study design was exploratory cross-sectional survey. Questionnaires were sent to the physiotherapists working in hospitals across Maharashtra state, India. Four weeks for completion of questionnaire was given in an attempt to ensure good response rates.

Result:

Of 200, 73 questionnaires were received representing a 36% response rate. The study revealed that 76% of the respondents were bachelors qualified, 15% were masters in physiotherapy with only 4% specialized in cardio-respiratory physiotherapy; 82% had <5 years experience in ICU. Almost 19% had not at all attended any seminars/workshops related to ICU management while 61% attended up to three within last 2 years. The availability of a physiotherapist during the night was affirmed by 63%, 58% responded initiation of physiotherapy to be “always physician referred” and 39% mentioned “physiotherapist initiated.” Almost 80% performed chest wall techniques, 86% positioning, 27% postural drainage, 5% manual hyperinflation, 12% application of nebulizer, and 56% bedsores management. Only 5% reported involvement in ventilator setting, 11% had their opinion sought before weaning from ventilator, 29% practiced noninvasive ventilation, 11% were involved in decision-making for extubation and 44% reported involvement in patient family education.

Conclusion:

The study showed that physiotherapists among the responding ICUs surveyed lack in experience and updated knowledge. Physician reference is necessary to initiate physiotherapy and there exists no established criteria for physiotherapy treatment in ICU. All physiotherapists were routinely involved in chest physiotherapy, mobilization, and positioning.