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A Case in the Intensive Care Unit: A Physiotherapy Perspective
Chris Farley, BHSc, MScPT
The Intensive Care Unit (ICU) is a fast-paced environment with a diverse team of staff. Physicians, nurses, respiratory therapists, physiotherapists, dietitians and pharmacists, among others, each with their own scope of practice to care for patients with critical illnesses.
It is an unfortunate reality in health care, particularly in intensive care, that there are sad and unsuccessful stories. To maintain a good outlook, it is important to remember the positive impact we, as health professionals, have and recall our success stories.
One of my favourite success stories involved a former patient who we will call Jennifer. She presented to the emergency department with progressive weakness, longstanding difficulty swallowing and overall fatigue. Jenn developed respiratory failure which required intubation and was then transferred to ICU.
Upon Jennifer’s arrival to the ICU on day one, physicians, nurses and respiratory therapists worked to monitor and stabilize her using various intravenous medications and cardiac monitoring. After a brief discussion with the medical team, it seemed they were unsure of what was causing her progressive weakness and respiratory failure.
On day two, we received an order for physiotherapy to assess Jenn. Upon reviewing the patient’s chart, it seemed the medical team was considering her illness to be neurological, with Guillain Barre syndrome and myasthenia gravis being two potential diagnoses among other neurological conditions.
We arrived to assess Jenn and found her husband, Jim at her side. With Jim present and able to communicate for the patient, we were able to get a sense of what Jenn’s life looked like before she ended up with us. She was an active 68-year-old lady with two adult children, both of whom lived outside of the province. She had enjoyed gardening, traveling and exercising at the gym.
At this time, Jenn was intubated, rousing minimally and not following commands. Our treatment mainly focused on maintaining her joint range of motion, monitoring her respiratory status to ensure she wasn’t retaining secretions and repositioning to maintain skin integrity.
The next day, Jenn was starting to rouse more but wasn’t able to consistently follow commands. Our treatment continued to focus on maintaining her respiratory status and skin integrity with repositioning. She was able to participate with her bed exercises with active assisted range of motion to initiate muscle activation.
By day four, Jenn was fully roused. She was assisting nursing staff with turning and consistently participating actively with bed exercises. Her treatment needed to be progressed. I had been in to speak with Jenn and Jim earlier in the day and mentioned that today may be the day we try sitting on the side of the bed and perhaps even stand.
Later that day, the nurse and I arrived to find Jennifer poised to carry out our plan. With the intravenous lines, drains and the ventilator tubing being organized and managed by myself and the nurse, Jenn was able to make her way towards the side of the bed. Today, she needed assistance from both of us to move her legs and torso to sit at the edge. Fortunately, once she was settled at the edge, Jenn was able to maintain her sitting balance by herself while her feet were firmly on the floor. Jenn tolerated the session well, with her vital signs remaining stable throughout.
Jenn remained mechanically ventilated through the endotracheal tube for the next several days. We continued to challenge her endurance and strength by asking her to sit for longer periods and by progressing to standing with assistance. She had also started and was able to complete more repetitions of basic lower and upper extremity exercises.
By day 15, Jenn was still ventilator dependent. The team had opted to insert a PEG tube to feed her and perform a tracheostomy to continue to mechanically ventilate her. Jenn was left to rest on the day her PEG and tracheostomy were inserted.
On day 20, Jenn had progressed well with her sitting and standing tolerance. Her standing tolerance had improved so well with the walker that she was able to side step up the bed and towards her chair at the bedside. By this time, she was sitting up in the chair for up to an hour, twice a day. We had reached a plateau. Jenn’s balance and strength had improved, but her endurance during transitional movements and stepping was still poor.
Over the three weeks we had been seeing her, we had learned more about her. Not only did she enjoy exercising, more specifically she was an avid cycler years ago. At this time, our hospital was involved in a study looking at the feasibility of in-bed cycling for mechanically ventilated patients. Although Jenn didn’t meet the inclusion criteria for the study, she was a perfect candidate for us to try the cycle. For the next two weeks, we set up an alternating program of in-bed cycling and functional mobility. Two days per week Jenn would complete fifteen to thirty minutes of in-bed cycling. The mechanics of the bike allowed for patients to cycle actively as much as they could, while allowing for passive movement for recovery periods. Jenn had already been one of the most motivated patients I had ever treated, but using the bike got her more focused on her recovery than ever.
The focus of the other three days of the week was functional mobility. We had started marching on the spot with a walker and taking short walks away from and back towards her bed. Jenn’s bed to chair transfers had improved to a level that nursing staff were able to transfer her to the chair three times per day in addition to her physiotherapy treatment sessions.
By day 30, Jenn was walking short distances with her rollator walker. She had begun weaning off the ventilator with tracheostomy mask trials; however she still required the added support from the ventilator to ambulate. Setup for Jenn to walk on the ventilator required the most collaboration with the team. The respiratory therapist would transfer her from the ventilator in the room to the portable ventilator and then monitor the ventilator throughout the treatment. The nurse would ensure that all her lines were secured and locked off. The nurse would also be secondary support for the patient during the actual ambulation task, in case she lost her balance or needed hands on assistance of two people. I would provide primary support for Jenn as she ambulated around our unit with her walker while closely monitoring her oxygen saturation and heart rate. The final member of our mobility team was Jenn’s husband. Jim’s main responsibility involved managing the wheelchair that would allow her to take her sitting rests.
With the combined cycling and ambulation training, Jenn’s endurance improved very rapidly. Our unit is a large square of approximately 100 metres around. In the next two weeks, Jenn was able to walk between six and ten laps per physiotherapy session with a sitting rest between each lap.
Soon cycling no longer posed a challenge to Jenn. Her weaning continued to improve such that she didn’t need to be on the ventilator during her physiotherapy treatment anymore. To continue to improve her functional strength, we continued to progress her ambulation distance with fewer rests. We started to alternate between ambulation training one day and stair training the next. Within the next few weeks, Jenn was completing two to three laps of the unit between each rest. Her endurance had improved such that she was ascending and descending our eight-stair flight twice between each rest.
Although she continued to have fairly steady improvements with her progress with physiotherapy, Jenn did experience medical setbacks every few weeks. Along with her functional mobility training, we would intermittently need to use manual secretion mobilization techniques like percussion, vibrations and facilitated deep breathing to promote secretion clearance. Urinary tract infections and new pneumonia symptoms at times dictated her ability to participate. Luckily, her participation would only be limited for one or two days, and she would quickly return to the functional mobility level she had achieved days earlier.
Finally, after four months, Jenn was consistently remaining off the ventilator during the night. Her tracheostomy had been corked and she was consistently on room air. She had reached her goals for discharge from the ICU and she was nearing her physiotherapy goals for discharge from the hospital.
Jenn was signed out to medicine and she left our ICU. Often when someone has had a four month stay in the ICU they require some sort of rehabilitation program prior to discharge back to independent living. Having been able to participate in and tolerate such a high level of functional training supported by the ICU interdisciplinary team, Jenn was discharged back home with Jim just 10 days after her transfer to the medical floor.