Clinical Review ABC of intensive care

Other supportive care

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7203.175 (Published 17 July 1999) Cite this as: BMJ 1999;319:175
  1. Sheila Adam,
  2. Sally Forrest

    As well as specific organ support techniques such as mechanical ventilation and renal replacement therapy, patients in intensive care require other interventions to maintain organ function and prevent further damage. These include nutritional support, preserving skin integrity, psychological support, and mobilisation. These interventions enable patients to recover their previous level of health, prevent intercurrent problems such as nosocomial infection and lung atelectasis, and support psychological and physical wellbeing.

    Intensive care is not just about organ support

    Chest physiotherapy

    Patients who are intubated or mechanically ventilated require chest physiotherapy to remove excess bronchial secretions, re-expand atelectatic areas, improve ventilation, decrease ventilation-perfusion mismatch, and mobilise the thoracic cage.

    Respiratory complications associated with tracheal intubation and mechanical ventilation

    • Inability to clear secretions

    • Trauma related to high inflation pressures, large tidal volumes, and shear stresses

    • Microatelectasis and consolidation

    • Alterations in ventilation-perfusion matching

    Bronchial secretions increase in intubated patients as the tracheal mucous membrane is irritated. These secretions may become tenacious as the patients' natural humidification has been bypassed. Expectoration may also be reduced by an ineffective cough, decreased ciliary action, and loss of sigh breaths.

    Secretion tenacity can be reduced by adequate humidification and systemic hydration. Clearance of secretions is achieved by chest physiotherapy, suctioning, and occasionally bronchial lavage.

    Manual hyperinflation improves lung compliance and arterial oxygenation

    Disadvantages of immobility

    Cardiovascular
    • Venous stasis

    • Increased risk of venous thrombosis and pulmonary embolism

    Respiratory
    • Decrease in functional residual capacity (when supine)

    • Decreased lung compliance

    • Retained secretions

    • Atelectasis

    Metabolic
    • Increased excretion of nitrogen, calcium, potassium, magnesium, and phosphorus

    • Osteoporosis

    • Kidney stones

    Musculoskeletal
    • Decrease in muscle bulk

    • Loss of bone density

    • Decreased range of joint movement

    • Pressure sores

    The primary aims of chest physiotherapy are to improve gas exchange and prevent atelectasis and consolidation, which occur as a result of mucus plugging or infection. Patients are assessed daily and will receive the following treatments as appropriate.

    Positioning—For postural drainage or to improve ventilation-perfusion matching.

    Manual …

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