Physiotherapy in the ICU: assessment, safety, equipment and ventilated cases

1ICU assessment

Write this first in any ICU answer. It shows the examiner you check before you treat.

From the chart and the monitors

• Diagnosis and course: reason for admission, surgery, days on the ventilator, trend (better or worse since yesterday).
• Ventilator: mode, FiO₂, PEEP, rate, tidal volume, pressures (see the ventilation card).
• Vital signs: heart rate and rhythm, BP and mean arterial pressure (MAP), SpO₂, respiratory rate, temperature; intracranial pressure if monitored.
• ABG and chest X-ray: oxygenation, CO₂ and pH; collapse, consolidation, effusion, pneumothorax, tube position.
• Drugs: sedation, pain relief, drugs supporting BP, paralysing agents.
• Blood tests: haemoglobin, platelets and clotting (bleeding risk), lactate, electrolytes, sugar.
• Lines and drains: what is attached and where (femoral lines limit hip bending).

At the bedside

• Conscious level: Glasgow Coma Scale; sedation score (Richmond Agitation–Sedation Scale, RASS, −5 to +4); delirium screen (CAM-ICU).
• Chest: breathing pattern, synchrony with the ventilator, chest movement, auscultation, secretions (amount, colour, thickness), cough on suction.
• Limbs: range of motion, tone, early contractures, skin and pressure areas, oedema.
• Strength and function (when awake): MRC sum score of 12 muscle groups (0–60; below 48 = ICU-acquired weakness); bed mobility, sitting balance; ICU Mobility Scale (0 = lying in bed, 10 = walking independently).
• Pain: self-report if possible, or a behavioural pain scale.

2Principles of ICU monitoring

3Safety before mobilising a ventilated patient

An international consensus (Hodgson, 2014) uses traffic lights: green = low risk, go ahead; yellow = possible risk, discuss with the team; red = high risk, do not mobilise actively without senior agreement.

If a patient is near the limit in several areas at once (for example FiO₂ 0.6, PEEP 10 and SpO₂ 90%, like the W24 case), decide with an experienced ICU doctor before mobilising.

4ICU equipment (7 marks in W24)

5Physiotherapy for the ventilated patient (S17, S21, S26; goals W17)

Short-term goals for a patient on a ventilator (W17)

• Keep the airways clear and the lungs expanded; improve oxygenation.
• Prevent ventilator-associated pneumonia, collapse and aspiration.
• Keep joint range; prevent contractures, pressure injuries and DVT.
• Limit muscle wasting; start active exercise as soon as safe.
• Support weaning; keep the patient oriented and able to communicate.

Chest physiotherapy on SIMV (7 marks in S26)

1. Check: settings, vital signs, ABG, X-ray, sedation and safety criteria; time the session with pain relief and away from feeds.
2. Positioning: head of bed 30–45°; side-lying with the affected area uppermost for drainage; turns every 2–4 hours; upright sitting as soon as possible.
3. Manual techniques on expiration: chest shaking, vibrations, percussion where secretions are retained (avoid with fractures, low platelets, unstable patients).
4. Hyperinflation by bag (manual) or by the ventilator to re-open collapsed areas and move secretions, then suction (see the suction card).
5. Breathing exercises when awake on SIMV: deep breaths with a hold on the patient's own breaths; inspiratory muscle training during weaning.
6. Limbs: passive ROM of all joints when sedated; active-assisted and active exercise when awake; splints for ankles and hands where needed.
7. Mobilisation ladder: rolling → sitting up in bed → sitting over the edge → standing → marching on the spot → transfer to a chair → walking with the ventilator, as safety criteria allow.
8. Reassess: breath sounds, SpO₂, secretions, ventilator pressures; record.

6Worked cases from the papers

GBS on SIMV (S23 Q4(b), 15 marks)

Read the case: Guillain–Barré syndrome is an immune attack on peripheral nerves causing rapidly rising, symmetrical flaccid weakness. He needs a ventilator because his breathing muscles are weak, not because his lungs are diseased, so his FiO₂ and PEEP are modest.

Activity and participation: fully dependent for bed mobility, self-care and communication; off work as a teacher.

Ventilator management, physiotherapy part:

• Lungs: 2–4-hourly turns, head up 30–45°, manual or ventilator hyperinflation with vibrations, suction when secretions are present (watch the heart rate; pre-oxygenate).
• Track strength: vital capacity and inspiratory pressure trends tell when weaning can start; a tracheostomy is common because recovery takes weeks.
• Weaning: as strength returns, gradually more spontaneous breathing (lower SIMV rate, pressure support, breathing trials); inspiratory muscle training in short, non-fatiguing sets; upright sitting for trials.
• Limbs: gentle passive ROM within pain, ankles at 90° with splints or pillows, hands in a functional position; then active-assisted and active exercise, avoiding fatigue (recovering muscles weaken further if overworked).
• Other: pressure care, DVT prevention, tilt table for low BP on sitting up, a communication board, reassurance (most patients recover over months).

ARDS on SIMV (S24 Q3(b), 15 marks; acute phase, S25 Q2(c), 7 marks)

ARDS (Berlin definition, 2012): within 1 week of a known insult (pneumonia, sepsis, trauma, aspiration); white shadows in both lungs on X-ray; not fully explained by heart failure or fluid overload; PaO₂/FiO₂ on a PEEP of 5 or more: mild 201–300, moderate 101–200, severe 100 or less (mmHg). A 2024 global definition also includes patients on high-flow oxygen and allows SpO₂/FiO₂ when blood gases are not available.

• Impairments (S24): poor oxygenation; stiff, low-volume lungs; possible secretions; inactive breathing muscles; reduced consciousness from sedation; limb stiffness and weakness; anxiety.
• Likely complications: lung injury from the ventilator, pneumothorax, ventilator-associated pneumonia, ICU-acquired weakness, contractures, pressure injuries (especially if nursed prone), DVT and pulmonary embolism, delirium, and later reduced exercise capacity, anxiety and memory problems (post-intensive care syndrome).
• Medical point: lung-protective ventilation (tidal volume 6 mL/kg predicted body weight, plateau pressure 30 or less), PEEP, careful fluids, and prone positioning for 16 hours or more a day when PaO₂/FiO₂ is below 150 (this lowered deaths in the PROSEVA trial).

Acute-phase physiotherapy (S25):

• Minimal, clustered handling while oxygenation is poor; agree the plan with the ICU team.
• No disconnection: closed suction only when secretions are present; ventilator hyperinflation rather than bagging; avoid high pressures (the lungs tear easily).
• Positioning: head up 30–45°; regular turns; help the team with safe prone turning (protect eyes, face, shoulders, knees and lines).
• Limbs: passive ROM and positioning against contractures and pressure injury.
• As she improves (S24 settings, FiO₂ 0.4 and PEEP 5, are within the green zone): active exercise, sitting over the edge of the bed, standing and walking with the ventilator; inspiratory muscle training during weaning; after extubation, breathing exercises and a graded exercise programme, with follow-up rehabilitation.

Other ventilated cases

• W24: atypical pneumonia of both lungs on CMV, FiO₂ 0.6, PEEP 10: worked plan on the pneumonia page.
• S20: COPD exacerbation with right lower lobe pneumonia on SIMV: COPD page.
• W17: electrician with burns and 3 rib fractures on a ventilator: burns page and chest-wall page.

The other ICU conditions in the syllabus are on two pages: head injury, tetanus, spinal cord injury and neuromuscular disease, and pulmonary oedema, shock, multiple organ failure, poisoning, aspiration and near drowning.

7Early mobilisation: what the evidence says

Mobilisation is one part of the ICU ABCDEF bundle: Assess and manage pain; Both spontaneous awakening and breathing trials; Choice of sedation; Delirium care; Early mobility and exercise; Family involvement.

8Exam corner

Past questions (MUHS, 2016–2026)

• S20 Q3(b), 5 + 3 + 7 marks60-year-old farmer with a COPD exacerbation and respiratory failure, in ICU on SIMV, with right lower lobe pneumonia. Impairments, activity and participation; short- and long-term management.
• S23 Q4(b), 15 marks45-year-old teacher with GBS on SIMV, PEEP 6, FiO₂ 0.4. Impairments and ventilator management (section 6).
• S24 Q3(b), 15 marks30-year-old housewife with ARDS, ventilated for 2 days: SIMV, PEEP 5, FiO₂ 0.4. Impairments; likely complications; physiotherapy (section 6).
• W24 Q4(a), 15 marks35-year-old man with atypical pneumonia of both lungs on CMV, FiO₂ 0.6, PEEP 10 for 3 days. Functional diagnosis and physiotherapy.
• 7-mark questionsModes of ventilation and the role of physiotherapy in ICU (S17). Short-term goals for a patient on a ventilator (W17). Physiotherapy on a ventilator (S21). Equipment used in ICU (W24). Acute-phase physiotherapy in mechanically ventilated ARDS (S25). Chest physiotherapy for a patient on SIMV (S26).

Answer skeleton: any ventilated long case

1. [Read the case, 1–2] Diagnosis, why ventilated, what the settings mean (low, moderate or high support).
2. [Impairments or ICF, 4–5] Chest (gas exchange, secretions, lung volume), muscles and joints, circulation and skin, consciousness and communication; activity; participation; context.
3. [Complications, if asked, 3] Lung injury, VAP, ICU-acquired weakness, contractures, pressure injuries, DVT, delirium.
4. [Physiotherapy, 7–8] Assessment and safety check → positioning → airway clearance (manual techniques, hyperinflation, suction) → limbs → mobilisation ladder → weaning support → after extubation → precautions and stop criteria.