Airway clearance, exercise common physiotherapy practice in adult ICUs in Singapore

Conventional airway clearance is still the most used treatment among all the available physiotherapy management techniques for patients in the intensive care unit (ICU), according to a Singapore study.

Exercise is also routinely prescribed for both spontaneously breathing and mechanically ventilated patients, but no exercise protocol has been established yet.

“Presently, a combination of subjective and objective measures is being used to guide the prescription and progression of exercise, as well as for the monitoring of patients’ response to exercise,” said the researchers, led by Gabriel Wai Mun Ou of the Singapore Institute of Technology, Singapore.

Ou and colleagues mailed a 19-item questionnaire to 90 physiotherapists working in 15 adult ICUs across restructured and private hospitals in Singapore. They summarized data sets from the responses, which included identifying common physiotherapy techniques and exercise prescription protocols for both mechanically and nonmechanically ventilated patients in the ICU.

Of the 90 questionnaires sent, 63 (70 percent) were returned. Many physiotherapists reported using the following interventions: airway secretion clearance, techniques to improve lung ventilation, and mobilization out of bed. [Proc Singap Healthc 2022;doi:10.1177/20101058211068589]

The most used respiratory technique was positioning (60/61, 98 percent), while the most preferred physical activity for ICU patients was sitting on the edge of bed (43/44, 98 percent). Physiotherapists also routinely prescribed exercise (50/61, 83 percent), but only a few (8/50, 16 percent) have set protocols for exercise prescription.

For patients on mechanical ventilation, the most used intervention was active/active assisted exercises (40/44, 91 percent). Of note, 12 percent of ICU physiotherapists used either the Chelsea Critical Care Physical Assessment Tool or the Functional Status Score for the Intensive Care Unit as routine outcome measures.

“The present study revealed two key findings about respiratory management techniques employed by critical care physiotherapists,” according to the researchers.

“Firstly, positioning is the most used respiratory technique. Secondly, despite having good evidence supporting its efficacy in weaning, respiratory muscle training was not frequently used in Singapore ICUs,” they said. [Ann Am Thorac Society 2018;15:735-744; Thorax 2016;71:812-819; J Physiother 2015;61:125-134]

These findings were consistent to those of previous studies. Thus, the researchers suggested that local ICUs incorporate internal medicine training in their competency checklist. [Turk Thorac JPMCID 2020;21:139; Respir Care 2015;60:1476-1485]

Regarding the routine prescription of exercise among ICU patients, the most prescribed physical activities were sit on edge of bed, active exercises, and sit-to-stand, which were consistent with a prior survey study by Skinner and colleagues. [Physiotherapy 2008;94:220-229]

The factors considered by physiotherapists for prescribing exercises included objective measures such as heart rate, oxygen saturation, respiratory rate, and blood pressure, as well as subjective measures such as the pain and fatigue reported by patients.

“[T]he use of validated ICU outcome measures should be encouraged to allow for a more objective evaluation of patients in the ICU,” the researchers said.

“Finally, the formation of a mobility team for the early mobilization of mechanically ventilated patients, and the involvement of family members in the rehabilitation of patients in the ICU should be considered, to enhance the effects of exercise on patients,” they added.