7 rehabilitation techniques to improve outcomes in critical care patients
Critical care patients usually are not thought of as good candidates for physical rehabilitation. However, when rehabilitation techniques are incorporated into a treatment plan, outcomes can improve significantly. Such techniques can be used to control pain, promote healing and manage—and even prevent—complications from pneumonia, atelectasis, embolisms and pressure wounds.
Critically ill patients are often laterally recumbent for extended periods. In these cases, pneumonia, whether it is the primary disease process or secondary to aspiration, can be a fatal complication. These patients are also at risk for atelectasis, particularly if they have been physically restricted or unable to ventilate properly.
In critical care patients, breathing can also be compromised by trauma, pain, abdominal distention, pnuemothorax or hemothorax, pulmonary contusions, sedation from analgesia and severe metabolic derangements. Tidal volume, functional residual capacity and lung compliance may be reduced, causing decreased oxygen saturation and a slowdown of the healing process. Fortunately, patients at risk for these potentially life-threatening respiratory complications can be helped by rehabilitative chest physiotherapy techniques. Here are several effective physical rehabilitation techniques for use in critically ill patients.1. Encourage movement
Increasing the depth of breathing and stimulating a cough are the best ways to encourage clearing of thick mucoid secretions from the smaller airways. You can't ask an animal to do this, but you can encourage activities that require deeper and more frequent breathing. Both walking and standing exercises can strengthen the thoracic muscles and stimulate sympathetic activity, increasing ciliary motility and decreasing mucous viscosity.
Standing or walking can be beneficial even for patients unable to do so without assistance. Use slings or harnesses that allow for mobility in a safe environment. This activity should mobilize the secretions, stimulating a cough that moves the mucus from the smaller to the larger airways where it can be coughed out or swallowed.
2. Perform chest percussion or coupage
This is an extremely effective technique for stimulating a cough response. Use the percussive force of your hands, cupping and placing them on one side of the patient's chest. Begin at the caudal aspect of the lung fields and move cranially, gently striking the chest wall in a rhythmic fashion. Proper technique is much more important than force, which should be done based on the patient's comfort level. After standing or walking exercises, percussion or coupage generally is most productive.
3. Use vibration
Vibration can help patients mobilize secretions into the larger airways. To perform this technique, lock your arms, and use your hands to vibrate the chest wall as the patient is lying down and exhaling. Perform vibration during four to six consecutive breaths.
Note that both percussion or coupage and vibration are contraindicated in patients with rib fractures, chest tubes, severe chest pain, arrhythmias or platelet counts of < 30,000/µl and should not be done over open wounds. In cases in which you are unsuccessful at stimulating a cough through patient movement, percussion or coupage techniques or vibration, try applying gentle pressure to the area of the third tracheal ring.
4. Position the patient appropriately
Proper positioning of critical care patients is important to optimize oxygen exchange. Alternating right lateral, left lateral and sternal recumbency at least every four hours can decrease both the secretion buildup in the dependent lung field and the possibility of atelectasis. Consistent rotation of the lung fields also decreases the mismatch between the alveolar ventilation and pulmonary blood flow that can occur when the amount of blood in the dependent lung field increases but the lung can't expand enough to deliver well-oxygenated blood to the body.
Note, patients with severely compromised lung fields may be unable to tolerate a specific recumbent position for an extended period. Monitor them closely for increased respiratory rate and effort, and turn them to a position that allows for optimal gas exchange.
Animals that have experienced trauma to the musculoskeletal system from an accident or surgery also can benefit from rehabilitation techniques. Maintain the limbs and joints of these patients in a neutral position to avoid the muscle fiber loss that occurs faster if the muscles are shortened. Provide padding under and in between joints to maintain air circulation and prevent moisture buildup and pressure sores. Turn the patient every four hours, and place padded doughnuts around joints if the skin looks irritated. Employ standing or assisted-standing exercises to improve circulation, neuromuscular strength and proprioception.