Dr. Bijoy Das. PT
For mechanically ventilated patients, early physiotherapy has been shown to improve quality of life and to prevent ICU-associated complications like deconditioning, ventilator dependency, and respiratory conditions.

Despite recent progress in medical treatment and mechanical ventilation (MV), critical illness in the intensive care unit (ICU) is still associated with high mortality rates. Furthermore, ICU survivors may suffer from muscle weakness, physical disability, and cognitive problems lasting up to 5 years. These critically ill patients may show muscle wasting in the very first week of illness, with more severity in patients with multi organ failure compared with those with a single organ failure.

Physiotherapy has been recommended by scientific societies as a main component in the management of patients with critical illness. Proposed strategies include patient mobilization based on a progressive sequence of activities like decubitus change and functional positioning; passive, supported-active, and active mobilization; cycling and sitting in the bed; and standing, static walking, transferring from bed to chair, and walking. Early physiotherapy is aimed at improving a patient’s quality of life and preventing ICU-associated complications like deconditioning, ventilator dependency, and respiratory conditions. It has been demonstrated that it is feasible and useful, even in patients needing extracorporeal membrane oxygenation (ECMO).In addition; a pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy.

ICU-Acquired Weakness
Intensive care unit-acquired weakness (ICUAW) is observed in a substantial proportion of patients receiving MV for more than 1 week in the ICU.

The etiology includes deconditioning and disuse atrophy due to prolonged bed rest and immobility, and critical illness polyneuropathy and/or myopathy, known as critical illness neuromyopathy. Other risk factors for ICUAW include the systemic inflammatory response syndrome, sepsis, and multiple organ dysfunction syndrome; hyperglycemia; and medications, such as use of corticosteroids and neuromuscular blocking agents. As a consequence, recommendations to avoid these risk factors have been suggested.

Implementation of an early mobilization program is feasible in most ICUs and provides benefits if started no later than 1 or 2 days after MV initiation. Such programs must be delivered after cardio respiratory and neurological stabilization. This approach, together with specific muscle training, can improve functional outcomes and cognitive and respiratory conditions.

Rotational Therapy
Continuous rotational therapy uses special beds to turn patients along the longitudinal axis up to 60° on each side, with preset degree and speed of rotation. It has been hypothesized that this modality can reduce the risk of sequential airway closure and pulmonary atelectasis, resulting in reduction of the incidence rate of lower respiratory tract infection and pneumonia, and the duration of endotracheal intubation and length of hospital stay.

Early Mobilization
 
Early mobilization can be performed also in unconscious or sedated patients. Protocols include semi recumbent positioning with the bed head positioned at 45°, frequent changes in postures, daily sessions of joint passive movement, and passive bed cycling and electrical stimulation.

Many studies conclude that early mobilization of critically ill patients can be done with low risk to the patient. Algorithms have been proposed as a guide in selecting suitable patients for mobilization and providing appropriate treatment strategies tailored to each individual patient.

Furthermore, despite recognized benefits of early mobilization, only a small proportion of ICUs are able to deliver full-time physiotherapy to these patients. As a consequence, we need to improve ICU organization and teams to deliver early physiotherapy.

Management of Airway Secretions
Mechanically ventilated patients in the ICU may suffer from retained secretions due to many causes. The mucociliary system may be disturbed by endotracheal intubation, with increased infection susceptibility and mucus volume and tenacity.

Furthermore, immobilized patients may suffer from atelectasis, impaired cough mechanism, and related inability to expel secretions.
Associated expiratory muscle weakness decreases cough strength; in addition, fluid restriction contributes to secretion retention. Helping airway clearance in patients under MV includes different techniques.

Postural drainage: Postural drainage traditionally includes gravity-assisted positions, deep breathing exercises, chest clapping, shaking or vibration, and incentivized cough to move airway secretions toward the upper airways.

Conclusion
Physiotherapy should be considered a cornerstone in the comprehensive management of critical ill patients and, when applied early, may benefit patients and prevent some ICU complications. Modalities and devices for each patient depend on disease severity, co morbidities, and patient cooperation.