L. van der Lee1, A.-M. Hill2, S. Patman1
1The University of Notre Dame Australia, School of Physiotherapy, Fremantle, Australia, 2Curtin University, School of Physiotherapy and Exercise Science, Perth, Australia

Background: Community-acquired pneumonia is a common cause for ICU admission requiring invasive mechanical ventilation. Physiotherapists working in ICU are involved in the respiratory care of these patients during the intubated period, however there is clinical variability regarding respiratory physiotherapy intervention, and limited evidence exists to guide best clinical practice for this ICU cohort. Guidelines to support complex clinical decision-making have shown to optimise patient outcomes by promoting translation of best evidence into practice.

Purpose: To establish and synthesise evidence to develop a clinical practice guideline regarding respiratory physiotherapy for adults invasively ventilated with community-acquired pneumonia.

Methods: A five-phase program of mixed-methods research was conducted. A systematic literature review and meta-analysis, to evaluate the best available evidence of efficacy, and a national survey to determine current clinical practice of Australian senior intensive care physiotherapists, were used to inform the development of international expert consensus statements using an e-Delphi method. These expert consensus statements, which established a minimum standard for physiotherapy practice, were then peer-reviewed by intensivists, senior nurses and senior physiotherapists working in Australian ICUs to determine clinical validity and applicability. Consensus statements were modified where necessary according to clinical stakeholder feedback to facilitate translation into clinical practice. The final stage of guideline development involved evaluation of each consensus statement according to the best level and certainty of the available evidence according to the GRADE approach. The strength and wording of recommendations were determined using the criteria feasibility, appropriateness, meaningfulness and effectiveness according to the Grading of Recommendations approach from the Joanna Briggs Institute.  

Results: This program of research resulted in the development of 26 guideline recommendations. Strong recommendations (n=17, 65%) were made for the domains of physiotherapy assessment (n=4), patient selection and prioritisation (n=3), humidification (n=1), patient positioning (n=2), hyperinflation techniques (n=3), normal saline instillation (n=1) and active treatment and mobilisation (n=3). Nine conditional recommendations (35%) were made across the domains of physiotherapy assessment (n=2), patient positioning (n=2), manual chest wall techniques (n=4), and normal saline instillation (n=1). Conditional recommendations were reached where evidence was low, conflicting, and/or local cultural influences guided clinical practice.

Conclusion(s): A guideline was developed for trial in Australian ICUs for physiotherapy management of adults invasively ventilated with commuinty-acquired pneumonia. Further research is now required to evaluate the guideline in the clinical setting, and to incorporate the values and preferences of patients and their families.

Implications: This clinical practice guideline incorporates both new and existing evidence and provides a minimum standard to facilitate best physiotherapy practice for adults invasively ventilated with community-acquired pneumonia. Further research is required to evaluate this guideline in clinical practice.

Funding, acknowledgements: No funding was obtained to conduct this research

Keywords: pneumonia, intensive care, physiotherapy

Topic: Cardiorespiratory

Did this work require ethics approval? Yes
Institution: The University of Notre Dame Australia
Committee: Human Research and Ethics Committee
Ethics number: 014130F

All authors, affiliations and abstracts have been published as submitted.

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