Physiotherapy in Intensive Care

Historically, respiratory physiotherapy has been considered as an integral part of the daily rehabilitation of the intensive care unit (ICU) patient. However, not since 2000 has there been a specific evaluation of the various physiotherapy modalities available. Kathy Stiller, PhD, conducted a systematic review to evaluate evidence appearing over the last 13 years either supporting or refuting the role of physiotherapy in the care of the adult, intubated ICU patient.

The review is deliberately broad, encompassing clinical studies as well as expert opinion pieces and surveys. A literature review focused on papers published between 1999 and 2012 and accessible through PubMed, MEDLINE, CINAHL, Embase, the Physiotherapy Evidence Database and the Cochrane Library databases. The broad criteria naturally resulted in culling studies with variable study designs and outcomes, hence precluding a meta-analysis. Eighty-five new studies were identified including 12 focused systematic literature reviews. The identified trials evaluated several physiotherapy interventions including multimodality respiratory physiotherapy (an umbrella term encompassing diverse interventions such as manual or ventilator hyperinflation, positioning, chest wall vibrations, and rib-cage compression), mobilization, inspiratory muscle training and neuromuscular electrical stimulation.

Twenty-six new randomized controlled trials were identified. Overall, these studies, analyzed through a narrative review, demonstrated that early mobilization is feasible and safe, and results in significant functional benefits at hospital discharge, shorter duration of delirium and mechanical ventilation, and reduced ICU and hospital lengths of stay. The evidence behind multimodality respiratory physiotherapy, though of equally high quality, was more conflicted. Trials demonstrated both positive and neutral effects on duration of intubation and ICU length of stay. Expiratory rib-cage compression was found to be ineffective, while manual hyperinflation may provide short-term improvements to respiratory compliance, oxygenation and airway clearance but no lasting effects on the duration of mechanical ventilation or incidence of ventilator-associated pneumonia. The evidence behind neuromuscular electrical stimulation remained lacking, and no specific recommendation could be made.

The mixed conclusions elicited in this review reflect the broad inclusion criteria. Studies of various methodological quality and sample diversity were collected, and the effects of any specific interventions, whether positive or negative, were difficult to elucidate. This was compounded by the fact that many papers published data on multiple simultaneous interventions. These factors also disallowed any statistical pooling or a meta-analysis of any intervention. Nonetheless, the wide range of studies highlights the consistency in the benefit of early and progressive mobilization in the ICU. The Stiller review can be used to reinforce the role of the physiotherapist as an integral part of intensive care, though additional trials targeting specific aspects of the therapy are required.

This Concise Critical Appraisal was authored by Uzer Khan, MD, a fellow in surgical critical care at the University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center.

Samuel M. Galvagno Jr., DO, PhD, is editor of Concise Critical Care Appraisal. An assistant professor at the University of Maryland, R Adams Cowley Shock Trauma Center, he is board certified in anesthesiology, critical care medicine, and public health.

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