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.

Chest physiotherapy

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.

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 hyperinflation--A 2 litre manual inflation bag is used to deliver up to 1.5 times the patient's tidal volume. An inspired breath is delivered at a slow rate and held for a short period before releasing rapidly. Normal saline can be instilled before the breath. This technique reinflates atelectatic areas of lung and loosens secretions by improving collateral ventilation. This improves arterial oxygenation and lung compliance.

Manual techniques--Shaking and vibrations applied to the chest wall may loosen secretions in the airways.

Suction--Secretions are removed by applying 25-30 kPa of negative pressure through a catheter passed down the endotracheal tube to the level of the carina.

Some of these techniques may then be done by nursing staff to maintain the condition of the chest.

Products

Aqua Plus Flex Humdfr Resp, Tracheal Humidification, Hudson RCI, Thermovent 600 HME, Thermovent O2 Oxygen Adapter

Mobilisation

The musculoskeletal system is designed to keep moving; it takes only seven days of bed rest to reduce muscle bulk by up to 30%. Immobility and muscle wasting in intensive care patients must be attended to after an initial assesment. Immobility may be caused by administration of sedative mad neuromuscular blocking agents, neurological deficit, mad general debilitation and weakness. Patients with cardiorespiratory instability may need to be immobilised for long periods. The use of restricting support technology--for example, haemofiltration or intra-aortic balloon counterpulsation--may also limit movement.

Some patients develop critical illness polyneuropathy or myopathy after the acute phase of multiple organ dysfunction. This results in muscle wasting and often profound weakness. Affected patients exhibit flaccidity and a reduction or loss of deep tendon reflexes. Function is usually recovered, although it may take several months of rehabilitation.

Some patients may be able to undertake a partial active exercise regimen but most will require either active assisted or passive movements. These movements maintain full joint range, maintain full muscle length and extensibility, assist venous return, and maintain the sensation of normal movement.

Shoulders, hands, hips, and ankles are at particular risk of contractures. Resting splints for the hands and feet can be made or bought to maintain and protect these joints in a neutral position.

Early mobilisation out of bed is crucial even when the patient is intubated and ventilated. Hoists, tilt tables, and walking aids can be used to promote early physical rehabilitation.