Physiotherapy in Intensive Care: Towards an Evidence-Based Practice

Abstract

In most hospitals in developed countries, physiotherapy is seen as an integral part of the management of patients in ICUs. The precise role that physiotherapists play in the ICU varies considerably from one unit to the next, depending on factors such as the country in which the ICU is located, local tradition, staffing levels, training, and expertise. The referral process is one example of this variation, whereby in some ICUs, physiotherapists assess all patients, whereas in other ICUs, patients are seen only after referral from medical staff. 1 The most common techniques used by physiotherapists in the ICU are positioning, mobilization, manual hyperinflation (MH), percussion, vibrations, suction, cough, and various breathing exercises. 1‐7 Some physiotherapists routinely treat most, if not all, ICU patients with a combination of these techniques, 1 regardless of the patient’s underlying pathophysiologic condition, with the intention of preventing pulmonary complications, whereas other physiotherapists use such techniques selectively when they believe they are specifically indicated. As the cost associated with the management of ICU patients is very high, the requirement for all those who work in ICUs, including physiotherapists, to provide evidence-based practice is mandatory. The aim of this article is to review the evidence regarding the effectiveness of physiotherapy for patients in the ICU and thus provide a framework for evidence-based practice. Potential areas for future research are also discussed. This review is primarily concerned with the management of intubated, mechanically ventilated, adult patients. The role of physiotherapy for nonintubated patients, including those receiving noninvasive mechanical ventilation, and pediatric patients is beyond the scope of this review. Initially, a description of the individual physiotherapy treatment techniques and their physiologic rationale will be provided. The literature review of the effectiveness of physiotherapy for intubated patients receiving mechanical ventilation in the ICU will then be discussed under the following headings: pulmonary function; hemodynamic and metabolic factors; the incidence of pulmonary complications; the clinical course of pulmonary conditions; overall outcome; and the effectiveness of the individual components of physiotherapy. Evidence concerning the effectiveness of continuous rotational therapy, which can be considered a type of physical therapy, will be reviewed in the treatment technique research section. In view of the large number of studies identified in some of these areas, details of each study will not be provided. Instead, selected studies that are considered to be landmark studies or characteristic of those conducted in the area will be described. Subsequent to the literature review, recommendations for evidence-based practice for physiotherapy in the ICU are considered under the following headings: prevention of pulmonary complications; treatment of pulmonary conditions and complications; short-term benefits; selection of individual treatment techniques; and monitoring required during physiotherapy. To ensure that the major relevant articles were reviewed, literature searches were performed using a CD-ROM version of the databases MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature) with appropriate subject headings and keywords, including physical therapy, intensive