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
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/Ál 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
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.