1MA
REVAKI
Cardiorespiratory Physiotherapy 3
PHYSIOTHERAPY IN INTENSIVE CARE
YORICK VAN HULST
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
1 INHOUDSOPGAVE
2 HC1 – Blood Gases ................................................................................................................ 5
2.1 Blood gases .............................................................................................................................. 5
2.1.1 Venous blood gas(es) ...................................................................................................... 5
2.1.2 Arterial blood gases : ABG ............................................................................................... 6
2.1.3 Blood gas analysis ............................................................................................................ 6
2.2 Interpretation arterial blood gases ......................................................................................... 7
2.3 Interpretation of partial pressure of carbon dioxide in arterial blood ................................... 9
2.3.1 Hypercapnia or CO2 retentie........................................................................................... 9
2.3.2 Hypocapnia .................................................................................................................... 11
2.4 Interpretation of partial pressure of oxygen in arterial blood .............................................. 12
2.4.1 Causes of hypoxemia ..................................................................................................... 13
2.4.2 Effect of oxygen therapy on hypoxemia........................................................................ 21
2.4.3 Effect van hypoxemia .................................................................................................... 22
2.5 Respiratory insufficiency ....................................................................................................... 23
2.5.1 Classification respiratory insufficiency .......................................................................... 23
2.5.2 Causes of RI ................................................................................................................... 24
2.5.3 Symptoms of RI.............................................................................................................. 24
2.6 Acid-base interpretation ....................................................................................................... 25
2.6.1 pH arterial blood............................................................................................................ 25
2.6.2 Alkalose & Acidose ........................................................................................................ 25
2.6.3 Source of bases in body ................................................................................................. 26
2.6.4 Source of acids in body .................................................................................................. 26
2.6.5 pH bloed en klinische symptomen ................................................................................ 26
2.6.6 Disturbance pH balance ................................................................................................ 27
2.6.7 Rol of Acid-Base balance ............................................................................................... 27
2.6.8 Acid-Base Disorders ....................................................................................................... 29
2.6.9 Voorbeeldopgaves primaire AB stoornissen ................................................................. 32
3 HC2 – Hemodynamics.......................................................................................................... 33
3.1 What is hemodynamica ......................................................................................................... 33
3.1.1 Hemodynamic system ................................................................................................... 33
3.2 The heart ............................................................................................................................... 34
3.2.1 Cardiac Cycle.................................................................................................................. 34
3.3 Hemodynamic parameters .................................................................................................... 35
3.3.1 Blood pressure............................................................................................................... 35
1
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
3.4 Measurement methods for hemodynamic parameters........................................................ 36
3.4.1 Non-invasive methods of measurement ....................................................................... 36
3.4.2 Invasive methods of measurement ............................................................................... 37
3.4.3 Measuring hemodynamics parameters, WHY? ............................................................. 45
3.5 Hemodynamic support .......................................................................................................... 45
4 HC3 – Neuromonitoring....................................................................................................... 46
4.1 Neuromonitoring ................................................................................................................... 46
4.2 Clinical neurological monitoring ............................................................................................ 46
4.2.1 Glascow Coma Scale ...................................................................................................... 47
4.2.2 Glascow-Liege Coma Scale ............................................................................................ 48
4.2.3 Pupils ............................................................................................................................. 49
4.3 Invasive neurological monitoring .......................................................................................... 50
4.3.1 IntraCranial Pressure (ICP)............................................................................................. 50
4.3.2 Intracranial pressure measurement .............................................................................. 50
4.3.3 IntraCranial Pressure (ICP) → Cerebral Perfusion Pressure (CPP) – Cerebral Blood Flow
(CBF) 52
4.4 Craniocerebral Trauma .......................................................................................................... 58
4.4.1 Epidemiologie TBI .......................................................................................................... 58
4.4.2 Severity TBI .................................................................................................................... 58
4.4.3 Causes of TBI ................................................................................................................. 58
4.4.4 Primary and secondary brain injury .............................................................................. 59
5 HC4 – Respiratory Support .................................................................................................. 61
5.1 Releasing or to keep free of the respiratory tract ................................................................. 61
5.1.1 Symptoms of total or partial airway obstruction .......................................................... 61
5.1.2 Causes obstructions airways ......................................................................................... 61
5.1.3 Management airway obstruction .................................................................................. 62
5.2 Medication ............................................................................................................................ 65
5.3 Oxygen therapy ..................................................................................................................... 65
5.3.1 Methods of oxygen administration ............................................................................... 65
5.3.2 Humidification of oxygen during oxygen therapy ......................................................... 70
5.3.3 Side effects of oxygen therapy ...................................................................................... 70
5.4 Chest drainage ....................................................................................................................... 70
5.4.1 Goals chest drainage ..................................................................................................... 71
5.4.2 Indication chest drainage .............................................................................................. 71
5.4.3 Thoraxdrainage.............................................................................................................. 73
5.4.4 Chest drainage system .................................................................................................. 73
2
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
5.4.5 1-Bottle drainage ........................................................................................................... 73
5.4.6 2-Bottle drainage ........................................................................................................... 74
5.4.7 3-Bottle drainage ........................................................................................................... 74
5.5 Bronchoscopy ........................................................................................................................ 75
6 HC5 – Physiotherapy in IC .................................................................................................... 76
6.1 Introduction ........................................................................................................................... 76
6.2 Mortality in ICU ..................................................................................................................... 76
6.2.1 Mortality in ICU and after discharge from intensive care ............................................. 76
6.3 Complications during stay on ICU ......................................................................................... 78
6.3.1 Muscle weakness in critical ill patient ........................................................................... 79
6.3.2 Weight loss and muscle weakness in critical ill patient ................................................ 83
6.3.3 Joint contracture in critical ill patient............................................................................ 84
6.3.4 Effects of muscular weakness in critical ill patient ........................................................ 85
6.3.5 Muscle weakness and Quality of Life in critical ill patients ........................................... 88
6.3.6 Pressure ulcers or decubitus ulcers in critical ill patients ............................................. 88
6.3.7 Pulmonary complication in critical ill patients .............................................................. 92
7 HC6 - Mobilization in ICU..................................................................................................... 94
7.1 Types of mobilization in ICU .................................................................................................. 94
7.2 Evidence of (early) mobilization ............................................................................................ 95
7.2.1 Cardiopulmonary system............................................................................................... 95
7.2.2 Muscle mass and muscle strength ................................................................................ 97
7.2.3 Endurance ...................................................................................................................... 97
7.2.4 Physical function............................................................................................................ 97
7.2.5 LOS ................................................................................................................................. 97
7.3 Evidence of electrical stimulation (ES) in critical ill patients ................................................. 97
7.3.1 Effect ES on muscle mass .............................................................................................. 98
7.3.2 Effect ES on muscle strength ......................................................................................... 98
7.3.3 Effect ES on physical function ....................................................................................... 98
7.3.4 Effect ES on LOS ............................................................................................................. 98
8 Mechanical ventilation ........................................................................................................ 99
8.1 Basic Physiology................................................................................................................... 101
8.1.1 Lung Physiology ........................................................................................................... 101
8.1.2 Mechanical Ventilatory Support.................................................................................. 102
8.2 Types of (invasive positive pressure) ventilation ................................................................ 103
8.2.1 Provide PEEP ................................................................................................................ 104
8.2.2 Deliver a (tidal) volume ............................................................................................... 104
3
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
8.3 Setting the ventilator........................................................................................................... 108
8.4 Loops & curves: the ventilator as a monitor ....................................................................... 110
8.4.1 Curves: Pressure, volume, flow ................................................................................... 110
8.4.2 Loops: Combination of curves ..................................................................................... 111
9 HC8 – Physiotherapy in the ICU – Resp. Phys.......................................................................114
9.1 Respiratory physiotherapy .................................................................................................. 115
9.1.1 Respiratory muscle function........................................................................................ 115
9.1.2 Recruitment of collapsed alveoli ................................................................................. 120
9.2 Active mobilization: limb muscle deconditioning ............................................................... 121
4
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
2 HC1 – BLOOD GASES
2.1 BLOOD GASES
= Blood sample to determine blood gases analysis (test)
- Arterial
- Venous
2.1.1 Venous blood gas(es)
- Peripheral venous sample
- Central venous sample
- Mixed venous sample
Peripheral venous sample
Zijn makkelijk uit te voeren door een venipuncture
Central venous sample
Central venous blood is venous bloed dat teruggaat naar de rechterkant van het hart in de vena cava
superior.
Mixed venous sample
Mixed venous bloed is venous bloed van de meest distale poort van de PA catheter, een mix van
inferior vena cava bloed, superior vena cava bloed, en de coronaire sinussen.
Het resultaat is een gemiddelde van venous bloed.
5
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
Application venous blood samples
Peripheral venous blood sample → normale bloedtest, meeste bloedtests worden zo uitgevoerd.
Central venous – mixed venous blood sample → Central venous en mixed venous blood kan
genomen worden om zuurstofconsumptie te meten. Door central venous en mixed venous bloed te
nemen kunnen we de zuurstofopname en levering meten
2.1.2 Arterial blood gases : ABG
How to take an arterialblood sample
- Puncture van een arterie
- Meest gebruikte arteriele puncture plaatsen:
o Arteria radialis
o Arteria femoralis
o Arteria dorsalis pedis
Andere manier om af te nemen is door een indwelling catheter. Meeste hebben een arteriele
catheter. Machine zal alle bloedgassen analyseren en naar computer sturen.
2.1.3 Blood gas analysis
Een bloedgas analyse meet:
- PaO2 = Partieeldruk van zuurstof in bloed
- SaO2 = O2 saturatie
- PaCO2 = Partieel druk van CO2 in bloed
- pH = maat voor zuurgraad
- HCO3 = Waterstofcarbonaat
Normal blood gas values
6
, Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
Pulse Oximetry (SaO2)
Meet de zuurstof saturatie, gemeten met een pulse oximeter.
Zie normaalwaardes arteriele bloedgassen
Normaal waardes op zee niveau en FiO2 = 20,96%.
BELANGRIJK: WAARDES KENNEN!
PaO2 = partiele druk O2 = 85-100 mmhg
SaO2 = saturatie = 95-100%
PaCO2 = partiele druk CO2 = 35-45 mmhg
pH = 7.36-7.45
HCO3 = 23-25 mmol/l
2.2 INTERPRETATION ARTERIAL BLOOD GASES
- Interpretatie PaCO2
- Interpretatie PaO2
- Respiratory insufficiency
- Acid-Base interpretatie
How do we come to this normal values of PaO2 en PaCO2?
- FiO2 = fraction van zuurstof in ingeademde lucht
- FiCO2 = fraction van koolstofdioxide in ingeademde lucht
- PiO2 = partiele druk van zuurstof in ingeademde lucht
- PiCO2 = partiele druk van koolstofdioxide in ingeademde lucht
7
REVAKI
Cardiorespiratory Physiotherapy 3
PHYSIOTHERAPY IN INTENSIVE CARE
YORICK VAN HULST
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
1 INHOUDSOPGAVE
2 HC1 – Blood Gases ................................................................................................................ 5
2.1 Blood gases .............................................................................................................................. 5
2.1.1 Venous blood gas(es) ...................................................................................................... 5
2.1.2 Arterial blood gases : ABG ............................................................................................... 6
2.1.3 Blood gas analysis ............................................................................................................ 6
2.2 Interpretation arterial blood gases ......................................................................................... 7
2.3 Interpretation of partial pressure of carbon dioxide in arterial blood ................................... 9
2.3.1 Hypercapnia or CO2 retentie........................................................................................... 9
2.3.2 Hypocapnia .................................................................................................................... 11
2.4 Interpretation of partial pressure of oxygen in arterial blood .............................................. 12
2.4.1 Causes of hypoxemia ..................................................................................................... 13
2.4.2 Effect of oxygen therapy on hypoxemia........................................................................ 21
2.4.3 Effect van hypoxemia .................................................................................................... 22
2.5 Respiratory insufficiency ....................................................................................................... 23
2.5.1 Classification respiratory insufficiency .......................................................................... 23
2.5.2 Causes of RI ................................................................................................................... 24
2.5.3 Symptoms of RI.............................................................................................................. 24
2.6 Acid-base interpretation ....................................................................................................... 25
2.6.1 pH arterial blood............................................................................................................ 25
2.6.2 Alkalose & Acidose ........................................................................................................ 25
2.6.3 Source of bases in body ................................................................................................. 26
2.6.4 Source of acids in body .................................................................................................. 26
2.6.5 pH bloed en klinische symptomen ................................................................................ 26
2.6.6 Disturbance pH balance ................................................................................................ 27
2.6.7 Rol of Acid-Base balance ............................................................................................... 27
2.6.8 Acid-Base Disorders ....................................................................................................... 29
2.6.9 Voorbeeldopgaves primaire AB stoornissen ................................................................. 32
3 HC2 – Hemodynamics.......................................................................................................... 33
3.1 What is hemodynamica ......................................................................................................... 33
3.1.1 Hemodynamic system ................................................................................................... 33
3.2 The heart ............................................................................................................................... 34
3.2.1 Cardiac Cycle.................................................................................................................. 34
3.3 Hemodynamic parameters .................................................................................................... 35
3.3.1 Blood pressure............................................................................................................... 35
1
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
3.4 Measurement methods for hemodynamic parameters........................................................ 36
3.4.1 Non-invasive methods of measurement ....................................................................... 36
3.4.2 Invasive methods of measurement ............................................................................... 37
3.4.3 Measuring hemodynamics parameters, WHY? ............................................................. 45
3.5 Hemodynamic support .......................................................................................................... 45
4 HC3 – Neuromonitoring....................................................................................................... 46
4.1 Neuromonitoring ................................................................................................................... 46
4.2 Clinical neurological monitoring ............................................................................................ 46
4.2.1 Glascow Coma Scale ...................................................................................................... 47
4.2.2 Glascow-Liege Coma Scale ............................................................................................ 48
4.2.3 Pupils ............................................................................................................................. 49
4.3 Invasive neurological monitoring .......................................................................................... 50
4.3.1 IntraCranial Pressure (ICP)............................................................................................. 50
4.3.2 Intracranial pressure measurement .............................................................................. 50
4.3.3 IntraCranial Pressure (ICP) → Cerebral Perfusion Pressure (CPP) – Cerebral Blood Flow
(CBF) 52
4.4 Craniocerebral Trauma .......................................................................................................... 58
4.4.1 Epidemiologie TBI .......................................................................................................... 58
4.4.2 Severity TBI .................................................................................................................... 58
4.4.3 Causes of TBI ................................................................................................................. 58
4.4.4 Primary and secondary brain injury .............................................................................. 59
5 HC4 – Respiratory Support .................................................................................................. 61
5.1 Releasing or to keep free of the respiratory tract ................................................................. 61
5.1.1 Symptoms of total or partial airway obstruction .......................................................... 61
5.1.2 Causes obstructions airways ......................................................................................... 61
5.1.3 Management airway obstruction .................................................................................. 62
5.2 Medication ............................................................................................................................ 65
5.3 Oxygen therapy ..................................................................................................................... 65
5.3.1 Methods of oxygen administration ............................................................................... 65
5.3.2 Humidification of oxygen during oxygen therapy ......................................................... 70
5.3.3 Side effects of oxygen therapy ...................................................................................... 70
5.4 Chest drainage ....................................................................................................................... 70
5.4.1 Goals chest drainage ..................................................................................................... 71
5.4.2 Indication chest drainage .............................................................................................. 71
5.4.3 Thoraxdrainage.............................................................................................................. 73
5.4.4 Chest drainage system .................................................................................................. 73
2
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
5.4.5 1-Bottle drainage ........................................................................................................... 73
5.4.6 2-Bottle drainage ........................................................................................................... 74
5.4.7 3-Bottle drainage ........................................................................................................... 74
5.5 Bronchoscopy ........................................................................................................................ 75
6 HC5 – Physiotherapy in IC .................................................................................................... 76
6.1 Introduction ........................................................................................................................... 76
6.2 Mortality in ICU ..................................................................................................................... 76
6.2.1 Mortality in ICU and after discharge from intensive care ............................................. 76
6.3 Complications during stay on ICU ......................................................................................... 78
6.3.1 Muscle weakness in critical ill patient ........................................................................... 79
6.3.2 Weight loss and muscle weakness in critical ill patient ................................................ 83
6.3.3 Joint contracture in critical ill patient............................................................................ 84
6.3.4 Effects of muscular weakness in critical ill patient ........................................................ 85
6.3.5 Muscle weakness and Quality of Life in critical ill patients ........................................... 88
6.3.6 Pressure ulcers or decubitus ulcers in critical ill patients ............................................. 88
6.3.7 Pulmonary complication in critical ill patients .............................................................. 92
7 HC6 - Mobilization in ICU..................................................................................................... 94
7.1 Types of mobilization in ICU .................................................................................................. 94
7.2 Evidence of (early) mobilization ............................................................................................ 95
7.2.1 Cardiopulmonary system............................................................................................... 95
7.2.2 Muscle mass and muscle strength ................................................................................ 97
7.2.3 Endurance ...................................................................................................................... 97
7.2.4 Physical function............................................................................................................ 97
7.2.5 LOS ................................................................................................................................. 97
7.3 Evidence of electrical stimulation (ES) in critical ill patients ................................................. 97
7.3.1 Effect ES on muscle mass .............................................................................................. 98
7.3.2 Effect ES on muscle strength ......................................................................................... 98
7.3.3 Effect ES on physical function ....................................................................................... 98
7.3.4 Effect ES on LOS ............................................................................................................. 98
8 Mechanical ventilation ........................................................................................................ 99
8.1 Basic Physiology................................................................................................................... 101
8.1.1 Lung Physiology ........................................................................................................... 101
8.1.2 Mechanical Ventilatory Support.................................................................................. 102
8.2 Types of (invasive positive pressure) ventilation ................................................................ 103
8.2.1 Provide PEEP ................................................................................................................ 104
8.2.2 Deliver a (tidal) volume ............................................................................................... 104
3
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
8.3 Setting the ventilator........................................................................................................... 108
8.4 Loops & curves: the ventilator as a monitor ....................................................................... 110
8.4.1 Curves: Pressure, volume, flow ................................................................................... 110
8.4.2 Loops: Combination of curves ..................................................................................... 111
9 HC8 – Physiotherapy in the ICU – Resp. Phys.......................................................................114
9.1 Respiratory physiotherapy .................................................................................................. 115
9.1.1 Respiratory muscle function........................................................................................ 115
9.1.2 Recruitment of collapsed alveoli ................................................................................. 120
9.2 Active mobilization: limb muscle deconditioning ............................................................... 121
4
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
2 HC1 – BLOOD GASES
2.1 BLOOD GASES
= Blood sample to determine blood gases analysis (test)
- Arterial
- Venous
2.1.1 Venous blood gas(es)
- Peripheral venous sample
- Central venous sample
- Mixed venous sample
Peripheral venous sample
Zijn makkelijk uit te voeren door een venipuncture
Central venous sample
Central venous blood is venous bloed dat teruggaat naar de rechterkant van het hart in de vena cava
superior.
Mixed venous sample
Mixed venous bloed is venous bloed van de meest distale poort van de PA catheter, een mix van
inferior vena cava bloed, superior vena cava bloed, en de coronaire sinussen.
Het resultaat is een gemiddelde van venous bloed.
5
,Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
Application venous blood samples
Peripheral venous blood sample → normale bloedtest, meeste bloedtests worden zo uitgevoerd.
Central venous – mixed venous blood sample → Central venous en mixed venous blood kan
genomen worden om zuurstofconsumptie te meten. Door central venous en mixed venous bloed te
nemen kunnen we de zuurstofopname en levering meten
2.1.2 Arterial blood gases : ABG
How to take an arterialblood sample
- Puncture van een arterie
- Meest gebruikte arteriele puncture plaatsen:
o Arteria radialis
o Arteria femoralis
o Arteria dorsalis pedis
Andere manier om af te nemen is door een indwelling catheter. Meeste hebben een arteriele
catheter. Machine zal alle bloedgassen analyseren en naar computer sturen.
2.1.3 Blood gas analysis
Een bloedgas analyse meet:
- PaO2 = Partieeldruk van zuurstof in bloed
- SaO2 = O2 saturatie
- PaCO2 = Partieel druk van CO2 in bloed
- pH = maat voor zuurgraad
- HCO3 = Waterstofcarbonaat
Normal blood gas values
6
, Cardiorespiratory Physiotherapy 3 1e master jaar Revaki UA
Pulse Oximetry (SaO2)
Meet de zuurstof saturatie, gemeten met een pulse oximeter.
Zie normaalwaardes arteriele bloedgassen
Normaal waardes op zee niveau en FiO2 = 20,96%.
BELANGRIJK: WAARDES KENNEN!
PaO2 = partiele druk O2 = 85-100 mmhg
SaO2 = saturatie = 95-100%
PaCO2 = partiele druk CO2 = 35-45 mmhg
pH = 7.36-7.45
HCO3 = 23-25 mmol/l
2.2 INTERPRETATION ARTERIAL BLOOD GASES
- Interpretatie PaCO2
- Interpretatie PaO2
- Respiratory insufficiency
- Acid-Base interpretatie
How do we come to this normal values of PaO2 en PaCO2?
- FiO2 = fraction van zuurstof in ingeademde lucht
- FiCO2 = fraction van koolstofdioxide in ingeademde lucht
- PiO2 = partiele druk van zuurstof in ingeademde lucht
- PiCO2 = partiele druk van koolstofdioxide in ingeademde lucht
7
