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.1 Furthermore, ICU survivors may suffer from muscle weakness, physical disability, and cognitive problems lasting up to 5 years.2-5 These critically ill patients may show muscle wasting in the very first week of illness, with more severity in patients with multiorgan failure compared with those with a single organ failure.6

Physiotherapy has been recommended by scientific societies as a main component in the management of patients with critical illness.7,8 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).7-12 In addition, a pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy.13

ICU-Acquired Weakness

Ambrosino-table1 Intensive care unit-acquired weakness (ICUAW) is observed in a substantial proportion of patients receiving MV for more than 1 week in the ICU.6,14-16 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.17 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.18 As a consequence, recommendations to avoid these risk factors have been suggested.19

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.9-11,15,20 Such programs must be delivered after cardiorespiratory and neurological stabilization.20-23 This approach, together with specific muscle training, can improve functional outcomes and cognitive and respiratory conditions (See Table 1).22

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.10,24

Early Mobilization

Ambrosino_Figure1Early mobilization can be performed also in unconscious or sedated patients.11 Protocols include semirecumbent 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.10,25 (See Figure 1.)

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.8,11 Although the short-term effectiveness of early physiotherapy has been shown, more studies are needed to confirm the long-term responsiveness of ICU survivors to physiotherapy. 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.26-29 Indeed, a financial model, based on actual experience and published data, projects that investment in an ICU early rehabilitation program can generate net financial savings for US hospitals and even more clinical improvements for patients.30

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.31,32 Helping airway clearance in patients under MV includes different techniques.33,34 (See Table 1.)

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.34,35

Chen et al36 performed a randomized study in mechanically ventilated patients in the ICU. Their results suggest that percussion and postural drainage may improve lung collapse. Ntoumenopoulos et al37 suggested that chest physiotherapy may be useful in prevention of ventilator-associated pneumonia. Lemyze et al38 suggested that in critically ill obese patients under MV, sitting position constantly and significantly relieved expiratory flow limitation and intrinsic-positive end-expiratory pressure (PEEPi) resulting in a dramatic drop in alveolar pressures. Combining sitting position and applied PEEP may be the best strategy in these patients.38

Intrapulmonary percussive ventilation. Intrapulmonary percussive ventilation (IPV) is a high-frequency ventilation modality that can be superimposed on spontaneous breathing. Intrapulmonary percussive ventilation may reduce respiratory muscle load and help to move airway secretions. This tool creates a percussive effect in the airways, thus enhancing mucus clearance through direct high-frequency oscillatory ventilation able to help the alveolar recruitment. Positive effects from this technique have been shown in patients with respiratory distress, neuromuscular diseases, and pulmonary atelectasis.39-41

Physiologic effects of IPV were studied by Vargas et al42 in intubated COPD patients. Intrapulmonary percussive ventilation improved the reduction of expiratory limitation flow and gas exchange. Dimassi et al43 performed a prospective study to assess the short-term effects of IPV in patients at high risk for extubation failure who were receiving noninvasive ventilation after being extubated. This study concluded that both noninvasive ventilation and IPV reduced the respiratory rate and work of breathing. Clini et al44 performed a randomized multicenter trial concluding that the addition of IPV improves gas exchange and expiratory muscle performance and reduces the incidence of pneumonia.

Positive expiratory pressure. Positive expiratory pressure (PEP), first introduced in the 1970s, consists of a one-way valve through a mask or a mouthpiece connected to one or more small-exit orifices and adjustable expiratory resistor to enhance and promote secretion removal by stenting airways, increasing intrathoracic pressure, or increasing functional residual capacity.45 The benefit of PEP is still under investigation. A systematic review assessed the effectiveness of PEP in patients after thoracoabdominal surgery. Six randomized controlled trials were included comparing PEP with other breathing techniques or in addition to routine chest physiotherapy treatment. Only 1 of the 6 trials showed positive effects of PEP compared with other physiotherapy techniques.46

Ambrosino_Figure2A new modality to deliver a low level PEP at the mouth during spontaneous breathing is called temporary PEP, which has been recently proposed to treat patients with chronic mucus hypersecretion. This modality produces a 1 cm H2O increase in airway pressure along the respiratory cycle until immediately before the end of expiration. (See Figure 2.)

The level of applied pressure is several times lower than that (5 to 15 cm H2O) commonly used and considered effective with other PEP and/or oscillatory-PEP devices. Preliminary results show that an expiratory pressure less than or equal to 1 cm H2O applied for a fraction of the expiratory phase may improve the distribution of alveolar ventilation and prevent mechanical stress injury, which is expected to occur in the bronchial tree or lung parenchyma at a higher pressure.34 Whether this suggested technique may be applied to ICU patients is still to be studied.

Manual hyperinflation. Manual hyperinflation (MH) is commonly applied in patients under MV. It may stimulate cough and move the airway secretions toward the larger airways, from where they can be easily suctioned. Manual hyperinflation can prevent airway plugging and pulmonary collapse, and improve oxygenation and lung compliance.47 This technique is widely used, though the practice varies across different ICUs.48 The possible physiological side effects of delivered air volume, flow rates, and airway pressure must be carefully considered—especially in patients under MV.49 When performed by experienced and trained physiotherapists in stable, critically ill patients, MH is associated with short-term and probably nonrelevant side effects like reduction in cardiac output, alterations in heart rate, and increased central venous pressure. Nevertheless, other studies failed to show MH benefits in intubated and mechanically ventilated patients.50

Ambrosino_Figure3Insufflation-exsufflation. Methods to improve cough are important in critically ill patients because cough effectiveness is a determinant in weaning success and patient outcomes. Cough assist such as a mechanical insufflator/exsufflator clears secretions by gradually applying a positive pressure to the airway then rapidly shifts to negative pressure, producing a high expiratory flow. (See Figure 3.)

By contrast, direct tracheal suction applies negative pressure to a small, localized area. Goncalves et al studied the efficacy of mechanical insufflation-exsufflation as part of an extubation protocol, which suggested that this technique may reduce reintubation rates and ICU length of stay.51 Guerin et al assessed the impact of cough-assist insufflation-exsufflation on peak expiratory flow, and results showed it was significantly reduced.52 Chatwin et al compared conventional physiotherapy with physiotherapy plus in-exsufflation in noninvasively ventilated patients. Their results indicated that in-exsufflation shortens the treatment time in the ICU without any difference in secretion clearance.53


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, comorbidities, and patient cooperation. RT

Nicolino Ambrosino, MD, is a physician in the Pulmonary Rehabilitation and Weaning Unit at Auxilium Vitae (Volterra, Italy) and Dewi N. Makhabah, MD, is a physician in the Pulmonology Department of the University of Sebelas Maret (Surakarta, Indonesia). For more information, contact [email protected].


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