ICU conditions: pulmonary oedema, shock, multiple organ failure, poisoning, aspiration and near drowning

1Pulmonary oedema

What it is

Fluid in the lung tissue and alveoli, so gas exchange fails.

• Cardiogenic: a failing left ventricle (heart attack, heart failure, valve disease, arrhythmia) or fluid overload raises the pressure in the lung capillaries and pushes fluid out.
• Non-cardiogenic: leaky capillaries with normal pressure: ARDS, near drowning, smoke inhalation, high altitude, after severe head injury (neurogenic).

What you see

• Severe breathlessness, worse lying flat (orthopnoea), waking breathless at night; anxiety, sweating.
• Frothy, pink sputum; fine crackles at both bases, sometimes wheeze; low SpO₂.
• X-ray: haziness spreading from both hila ("bat's wing"), Kerley B lines at the edges, a large heart and pleural effusions in cardiogenic oedema.

Medical point that matters for physio

Sit upright, oxygen to target, diuretics, nitrates, treatment of the cause. CPAP or bilevel NIV by mask relieves breathlessness and acidosis quickly and reduces the need for intubation in cardiogenic pulmonary oedema (Cochrane, 2013).

Physiotherapy by problem

• Breathlessness: high sitting with the legs down (less venous return), breathing control, reassurance; help apply and tolerate the CPAP mask.
• Sputum: the frothy fluid is oedema, not secretions, so airway clearance does not help and only tires the patient. Treat secretions only if there is also a chest infection.
• After it settles: early mobilisation, then heart failure rehabilitation (see the heart failure page).

Precautions

• Never lie the patient flat or head-down; watch BP (diuretics and nitrates lower it) and fluid balance; do not exercise until breathing and oxygen are stable at rest.

Exam points

• Cardiogenic vs non-cardiogenic; pink frothy sputum; bat's wing and Kerley B lines; sit up with legs down; CPAP; no airway clearance for oedema fluid.

2Shock

What it is

Circulatory failure: the tissues do not get enough oxygen. Signs: fast pulse, low BP (systolic below about 90 or MAP below 65 mmHg), cold clammy skin (warm in early septic shock), urine below 0.5 mL/kg/hour, confusion, raised blood lactate (above 2 mmol/L).

Sepsis (Sepsis-3, 2016): life-threatening organ dysfunction caused by a dysregulated response to infection. Septic shock: sepsis needing drugs to keep MAP at 65 mmHg or more, with lactate above 2 mmol/L despite adequate fluids.

Medical point that matters for physio

Fluids, drugs that raise BP (for example noradrenaline), antibiotics within an hour in sepsis, treatment of the cause; MAP usually kept at 65 mmHg or more (Surviving Sepsis Campaign, 2021).

Physiotherapy by problem

• While unstable: no active mobilisation; positioning, pressure care and gentle passive movement only if BP allows; chest physiotherapy only for a clear need (retained secretions, collapse), kept short.
• As support is weaned: follow the safety criteria (MAP above target on no or low support is green; high support or rising doses is a reason to wait) and start the mobilisation ladder (see the ICU safety table).
• Recovery: survivors of sepsis are often very weak and tired for months; progressive strength and endurance training and follow-up.

Precautions

• Turning and sitting up can drop BP sharply: monitor MAP during and after; stop if it falls below target, the pulse races or the patient becomes confused or clammy.

Exam points

• Four types with examples; MAP 65; lactate above 2; sepsis and septic shock definitions; no active mobilisation while unstable.

3Multiple organ failure (MODS)

What it is

Multiple organ dysfunction syndrome: progressive failure of two or more organ systems in an acutely ill patient, so that normal balance cannot be kept without support. Common causes: sepsis, major trauma, burns, pancreatitis, major surgery, shock of any cause.

Severity is tracked with the SOFA score, which scores six systems: breathing (PaO₂/FiO₂), clotting (platelets), liver (bilirubin), circulation (MAP and BP-support drugs), brain (GCS) and kidneys (creatinine or urine output).

What you see

A ventilated, sedated patient on BP-support drugs, often on dialysis, with jaundice, bleeding tendency, swelling, confusion or coma. Long stays lead to ICU-acquired weakness.

Physiotherapy by problem

After the ICU: many survivors have post-intensive care syndrome: weakness, fatigue, breathlessness, memory and concentration problems, anxiety, depression and nightmares. Plan follow-up rehabilitation.

Exam points

• Definition; causes; SOFA systems; organ-by-organ precautions; prevent ICU-acquired weakness; post-ICU follow-up.

4Poisoning

In India the commonest ICU poisonings are pesticides (organophosphates, often deliberate self-poisoning), snakebite, and drug overdose. Every self-poisoning patient needs a mental health assessment before discharge.

Organophosphate poisoning

Organophosphates block acetylcholinesterase, so acetylcholine builds up at every cholinergic junction.

• Medical point: decontamination, oxygen, intubation if needed, and atropine given until the chest is clear and dry, the heart rate is above 80, the systolic BP above 80, the pupils no longer pinpoint and the armpits dry; oximes in some centres; ventilation for weakness.
• Physiotherapy: early on, frequent suction and positioning for the bronchorrhoea and aspiration (pneumonia is common), head up; ventilator care. Each day, test neck flexion (can the patient lift the head off the pillow?): new neck weakness is an early warning of the intermediate syndrome. Then mobilise and rebuild strength.

Other poisonings

Exam points

• Muscarinic, nicotinic and brain effects; bronchorrhoea needs suction; intermediate syndrome at 24–96 hours with neck flexor weakness; mental health assessment.

5Aspiration and near drowning

Aspiration

• Aspiration pneumonitis: chemical injury from inhaled stomach contents (Mendelson's syndrome), causing sudden breathlessness and low oxygen within hours.
• Aspiration pneumonia: infection from inhaled mouth bacteria, developing over days.
• Who: reduced consciousness (head injury, overdose, alcohol, seizures), stroke and other swallowing problems, vomiting, tube feeding while flat, poor oral hygiene.
• Where it goes: usually the right lung (the right main bronchus is wider and more vertical): the lower lobe basal segments when upright, the posterior segment of the upper lobe and the superior segment of the lower lobe when lying supine.
• Physiotherapy: head up 30–45° and side-lying for at-risk patients; suction and airway clearance for the affected segments; mobilise; refer for a swallowing assessment; good oral care.

Drowning and near drowning

• Drowning (WHO, 2002) is "the process of experiencing respiratory impairment from submersion or immersion in liquid"; the outcome may be death, survival with damage, or survival without damage. "Near drowning" is the older term for survivors.
• Problems: severe hypoxaemia; aspirated water washes out surfactant, causing collapse and pulmonary oedema that can progress to ARDS; aspiration pneumonia; brain damage from lack of oxygen; hypothermia; neck injury in diving accidents.
• Physiotherapy: as for ARDS and aspiration in the ventilated stage (positioning, careful airway clearance, no high pressures); spinal precautions until the neck is cleared; then neurological rehabilitation if the brain was injured.

6Smoke inhalation

• Heat injures the upper airway (swelling can close it within hours, so early intubation is common); smoke particles and chemicals injure the lower airways (bronchospasm, sloughing, casts, pneumonia, ARDS).
• Carbon monoxide: binds haemoglobin; the pulse oximeter reads falsely normal, so a blood carboxyhaemoglobin level is needed; give high-flow oxygen through a reservoir mask. Cyanide from burning plastics also blocks oxygen use.
• Physiotherapy: upright positioning, humidified oxygen, deep breathing, ACBT, suction and early mobilisation; details and precautions on the burns page (inhalation burns, 7 marks in W22).

7Other acute respiratory disorders

8Exam corner

None of these conditions was asked on its own in the 20 papers from 2016 to 2026; inhalation burns (W22, 7 marks) and ventilated pneumonia and ARDS cases (W24, S24) come closest. The paper says any syllabus topic can be asked.

Practice questions (not from a paper)

• 7 marks: physiotherapy in organophosphate poisoning on a ventilator.
• 7 marks: types of shock, and physiotherapy precautions in a patient in shock.
• 3 marks: three X-ray features of cardiogenic pulmonary oedema.
• 3 marks: define multiple organ dysfunction syndrome and name the six SOFA systems.