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van der Lee L.1,2, Hill A.-M.3, Patman S.1
1University of Notre Dame Australia, School of Physiotherapy, Perth, Australia, 2Fiona Stanley Hospital, Department of Health, Perth, Australia, 3Curtin University, School of Physiotherapy and Exercise Science, Perth, Australia
Background: Severe community acquired pneumonia is a common reason for ICU admission for intubation and mechanical ventilation, resulting in high morbidity and mortality. Physiotherapy is commonly provided to such patients in the ICU, however there is a lack of evidence to guide best practice for physiotherapy with those with pneumonia.
Purpose: To explore current physiotherapy practice and factors which influence treatment duration, frequency, and utilization of after-hours physiotherapy for this patient cohort within Australia.
Methods: A cross-sectional, mixed methods survey was conducted. Senior intensive care physiotherapists, with a minimum one-years experience in the position and a minimum of five years physiotherapy experience, were recruited from 88 Australian public and private hospitals. An online questionnaire was developed and piloted to explore current clinical practice, clinical reasoning, and service provision based on common aspects of physiotherapy assessment, rationale and intervention options for intubated and mechanically ventilated adults. Factors which influenced the delivery of respiratory physiotherapy intervention during the acute intubated period, including after-hours, were explored.
Results: There were 75 respondents (72% response rate). The main rationale for intervention reported were improved airway clearance (98%), alveolar recruitment (75%) and gas exchange (32%). Intervention included positioning alternate side lying (81%) or affected lung uppermost (83%), hyperinflation techniques (60%), chest-wall vibrations (53%), and airway suction (92%). Vibrations were used for excessive sputum (20%). Manual hyperinflation was chosen for high sputum load (30%) due to specific aspects of the technique (21%). Ventilator hyperinflation was selected if there were concerns about ventilator disconnection (30%), loss of high positive end-expiratory pressure (64%) or risk of airborne pathogen transmission (18%).
The average intervention lasted 16 to 30 minutes (70% of respondents, n = 41) and was delivered once (44%, n = 26) or twice (44%, n = 26) daily. Duration of intervention was most affected by sputum volume (95%, n = 54), viscosity (93%, n = 53) and purulence (88%, n = 50), cough effectiveness (95%, n = 52), chest-xray (87%, n = 40) and auscultation (84%, n = 42). Sixty percent of respondents (n = 34) reported that workload and staffing levels affected intervention duration and frequency. Intervention time was more likely to be increased when staffing levels were greater (p=0.03).
An after-hours physiotherapy service was not universally available (54%, n = 37). Treatment response (83%, n = 41) was the biggest factor including patients for after-hours intervention when the service was available.
Conclusion(s): Senior physiotherapists rationalise that a significant physiotherapy role does exist during the acute intubated period for community acquired pneumonia. Duration and frequency of intervention is determined by ongoing assessment of patient-centred variables, but tempered by service provision and workforce factors. Wide variability in clinical practice exists and the optimal dosage and frequency to impact patient outcomes is unknown.
Implications: This study provides a snapshot of current physiotherapy practice and after-hours respiratory management for an acute and potentially curable respiratory condition common to ICU. Further research is necessary to determine what constitutes best physiotherapy practice for these critically ill patients, to optimize outcomes.
Funding acknowledgements: No funding sources to report
Topic: Critical care
Ethics approval: Ethics approval was granted by the Human Research and Ethics Committee of The University of Notre Dame Australia (Ref: 014130F).
All authors, affiliations and abstracts have been published as submitted.
