General

Protocol
of ICU
Physical
Therapy

2nd Edition
Date: 28 June 2020
 General protocol of ICU physical therapy
Assessment, possible interventions and
infection control considerations

2nd Edition
Date: 28 June 2020

Prepared by
1- Dr. Mohamed Ababa
PT, PhD. Beni Suef University hospital Egypt

2- Dr. Abd El Rahman Abo Zaid

Gerontological Physiotherapist, working in Orange, NSW, Australia

3- Dr. Fatma Hassan

ICU & Cardiopulmonary rehabilitation PT Chest Diseases hospital, Kuwait.

4- Nourhan Tarek
Tutor of Cardiorespiratory physiotherapy, Otago University in New Zealand.
With a contribution of
-Dr. Mostafa El Naggar. Lecturer of physical therapy Horas University. Egypt
-Dr. Mohammed Ali. Physical therapist. Egypt

Supervised by
Dr. Hamdy Radwan.
PT, MS, PhD, CMP
Professor of Physical Therapy
Director of the Transitional DPT program
Winston-Salem State University

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

‫ھﺬا اﻟﻌﻤﻞ ھﻮ اھﺪاء ﻟﻜﻞ دﻛﺎﺗﺮة اﻟﻌﻼج اﻟﻄﺒﯿﻌﻲ ﻓﻲ ﻣﺼﺮ ﺿﻤﻦ ﺣﻤﻠﺔ‬
‫‪#‬اﻟﻌﻼج ـ اﻟﻄﺒﯿﻌﻲ ـ ﺣﯿﺎه اﻟﺘﻲ ﯾﺮﻋﺎھﺎ أﻋﻀﺎء ﺟﺮوب ﺻﺒﺎﺣﻚ طﺒﯿﻌﻲ ﻋﻠﻰ‬
‫اﻟﻔﯿﺲ ﺑﻮك‪ .‬ﺳﻮف ﯾﺘﻢ ﺗﺤﺪﯾﺚ ھﺬا اﻟﻤﻠﻒ ﺑﺼﻔﮫ دورﯾﮫ ﻣﻦ ﻧﺨﺒﮫ ﻣﻦ‬
‫اﺳﺘﺸﺎري واﺧﺼﺎﺋﻲ اﻟﻌﻼج اﻟﻄﺒﯿﻌﻲ ﻓﻲ ﻣﺼﺮ واﻟﻌﺎﻟﻢ طﺒﻘﺎ ﻷﺣﺪث اﻷﺑﺤﺎث‬
‫واﻟﺪورﯾﺎت اﻟﻌﻠﻤﯿﺔ اﻣﻼ ﻓﻲ اﻟﻮﺻﻮل اﻟﻲ أﻓﻀﻞ ﺧﺪﻣﮫ ﺻﺤﯿﺔ ﻣﻘﺪﻣﮫ‬
‫ﻟﻠﻤﺮﺿﻲ ﻓﻲ وطﻨﻨﺎ اﻟﺤﺒﯿﺐ ﻣﺼﺮ‪.‬‬

‫‪General Protocol of ICU Physical Therapy‬‬ ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

 ICU physical therapy Protocol
Introduction:

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new

coronavirus that emerged in 2019 and causes Coronavirus Disease 2019
(COVID-19).1 SARS-CoV-2 is highly contagious. It varies from other
respiratory viruses in that it appears that human to human transmission
occurs approximately 2 to 10 days prior to the individual becoming
symptomatic .2

Individuals with COVID-19 can present with influenza like illness and
respiratory tract infection demonstrating fever (89%), cough (68%),
fatigue (38%), sputum production (34%) and/or shortness of breath
(19%). The spectrum of disease severity ranges from an asymptomatic
infection, mild upper respiratory tract illness, severe viral pneumonia
with respiratory failure and/or death. Current reports estimate that 80%
of cases are asymptomatic or mild; 15% of cases are severe (infection
requiring oxygen); and 5% are critical requiring ventilation and life
support.3
Preliminary reports indicate that chest radiographs may have diagnostic
limitations in COVID-19. Clinicians need to be aware of lung CT scan
findings that often include multiple mottling and ground-glass opacity.4
Lung ultrasound is also being utilised at the bedside with findings of
multi-lobar distribution of B-lines and diffuse lung consolidation.5 At
present, the mortality rate is 3 to 5%, with new reports of up to 9%, in
contrast to influenza, which is around 0.1% .6

Infection Control
Controlling exposure to COVID-19 is the fundamental method of
protecting health care workers. This can be represented by a hierarchy
of controls. Engineering controls are designed to remove the hazard at
the source, before it comes in contact with the worker. Administrative
controls and Personal Protection Equipment (PPE) are frequently used
with existing processes where hazards are not particularly well
controlled.7

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

 Fig. (1): Hierarchy of controls
Engineering Controls

Engineering Controls are designed to remove the hazard at the source,

before it comes in contact with the worker. Patients are placed in higher
order engineering control areas before using lower order areas. Patient
care areas include:

Class N rooms: are negative pressure isolation rooms used to isolate

patients capable of transmitting airborne infection.

Class S rooms: are standard rooms which can be used for isolating
patients capable of transmitting infection by droplet or contact routes.
Class S rooms have no negative pressure capability and therefore no
engineering controls.

Open Cohort: Areas have no negative pressure and no engineering

controls.

We recommend COVID-19 patient’s, ideally, be treated in a Class N

negative pressure single room. If Class N rooms are not available then
the preference should be Class S single rooms with clear areas
demarcated for donning and doffing of PPE. Once all Class N and Class S

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

single rooms are exhausted, patients will need to be cohered in areas
that are physically separate to areas containing non-COVID-19 patients.
In an open ICU cohered area with one or more COVID-19 patients, the
whole area is recommended to require airborne PPE precautions.

We recommended that all hospitals should keep a record of staff

training in PPE compliance and competency; only staff who have been
trained in PPE usage should care for patients with COVID-19.

Staff Care and Well Being

We recommend that hospitals have the following available for all staff in
intensive care:
● Clean scrubs available to change into before each shift
● Showering facilities at the end of each shift.
● Provision of meals and drinks for frontline staff
● Staff temperature reporting and temperature checks at the start of
each shift.
We recommend cancelling face-to-face meetings as much as possible.
For meetings with operational, clinical or education value we
recommend that secure videoconferencing applications are provided
and utilised. We recommend the use of interdisciplinary small group
simulation to practice and improve clinical processes and staff training in
PPE.

Staff Illness

Staff who are ill should follow national guidelines in regard to self-
isolation and testing for COVID-19. We recommend prioritising the
testing for COVID-19 in health care workers to minimise the time away
from the workforce.

For either staff illness or post exposure management we recommend the

provision of adequate psychosocial support for the staff member during
quarantine or for the duration of their illness. On return to work a
refresher infection control and prevention training should be offered for
the staff member.
The international experience is that mortality is higher in older patients,
particularly with comorbidities related to cardiovascular disease,

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

 diabetes mellitus, chronic respiratory diseases, hypertension and
malignancy. We recommend that these staff would be reallocated to
other roles and not enter COVID-19 areas and also staff who are
pregnant.

PPE Recommendations for physiotherapists and health workers:

1- All Staff will be trained in correct donning and doffing of PPE.For all
suspected and confirmed cases, at a minimum droplet precautions are
implemented. Staff will wear the following items:
• Surgical mask
• Fluid resistant long-sleeved gown
• Goggles/face shield
• Gloves.
• Hair cover for AGPs
• Shoes that are impermeable to liquids and can be wiped down.
• Wear an additional apron if high volumes of fluid exposure is expected.
• If reusable PPE items are used, e.g. goggles – these must be cleaned and
disinfected prior to re-use.
2- Use a step-by-step process for don/doff PPE as per local guidelines.
3- Check local guidelines for information on laundering uniforms and/or
wearing uniforms outside of work if exposed to COVID-19. For example,
changing into scrubs may be recommended in local guidelines and/or
staff may be encouraged to get changed out of their uniform before
leaving work and to transport worn uniforms home in a plastic bag for
washing at home.
4- All personal items should be removed before entering clinical areas and
donning PPE. This includes ear rings, watches, lanyards, mobile phones,
pagers, pens etc.and hair should be tied back out of the face and eyes.
5- Stethoscope use should be minimised. If required, use dedicated
stethoscopes within isolation areas.
6- Avoid sharing equipment. Preferentially use only single use equipment.8

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

 Fig (2): Donning of PPE

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

 Fig (3): Doffing of PPE

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

 ICU Physiotherapy assessment

Initial impression:

a- Check patient sheet.

b- Stand back to see monitor parameters.
c- Fully expose the patient for examination.
d- Maintain patient privacy.

Patient sheet:

Personal data:
Name: Age: Date of admission Date of assessment:
Hosp. No: Sex:
Diagnosis: Bio hazard: Isolation: Present complaints:
Y N Y N
Examination:
History: Muscle tone: Muscle Power
Monitor HR: RR: SpO2: BP: T: GCS:
Observation Body built: Distress: tracheostomy Tubes: ICD
Palpation Bony contour: Tracheal deviation Diaphragm
Mobility functions Independency Transfers Bathing /Toilet Walking aids
Urinary problem : Smoke: Y N Percussion: Auscultation:
Posture: Normal Scoliosis Kyphosis Rounded shoulder
Cough Dry Productive CXR:
ABGs: PH PaO2 PaCo2 HCO3 SpO2
Mechanically Ventilated: Y N
Ventilatory FIO2: VS: PEEP:
parameters: Mode: PS:
Drugs: Vasopressors: Anticoagulants: Bronchodilator:
Mucolytes:
Problem list: Treatment Plan:

• Goals of ICU physical therapy:

1- Prevent ICU related complications.
2- Reduce incidence of developing intensive care unit acquired weakness
(ICUAW).
3- Reduce hospital stay.
4- Return to functional activities.9

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

• Protocol for conscious patients need O2 support:

A- Improve ventilation:
1- Breathing exercises: deep breathing exercise.12
Frequency: 3 breaths / 3 sets / 5 times daily.
2- Strength abdominal muscles with graduation.
Frequency: 5 repetitions / 3 sets / twice daily.
3- Relaxed positions of breathing: leaning forward from sitting or standing
on table or wall.
Frequency: 5 minutes / twice daily.
4- Stretching exercises for accessory muscles of respiration as sternocledo
mastoid, scaleni, upper trapezius.10
Frequency: 20 seconds / 3 repetitions / twice daily.
5- Massage for chest muscles and neck muscles.
Frequency: 5 minutes / twice daily.

B- Improve clearance of secretions:

1- Postural drainage.11
Frequency: 5: 10 minutes for each position / twice daily.
2- Percussion and vibration.
Frequency: 3 : 5 minutes after postural drainage / twice daily.
3- Active cycle of breathing technique.
Frequency: 3 breaths / 3 sets / according to presence of secretions.
4- Autogenic breathing exercise.12
Frequency: 3 breaths / 3 sets / according to presence of secretions.
5- Huffing and coughing exercise.
Frequency: 3 repetitions / 3 sets / according to presence of secretions.

C- Improve mobility of patient:

1- Active assistive ROM (AAROM) or active ROM (AROM).13
Frequency: 5 repetitions / 3 sets / twice daily.
2- Circulatory exercises.
Frequency: 8 repetitions / 3 sets / twice daily.
3- Mobility of the patient: (e.g. bed mobility, high sitting position, sitting
out of bed, sitting balance, sit to stand, walking, tilt table, standing hoists,
upper limb or lower limb ergometry, exercise programs).14
Frequency: twice daily.

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

• Protocol for unconscious patients on O2 support or on mechanical
ventilation:

A- Improve ventilation:
1- Breathing exercises:12
Frequency: 3 breaths / 3 sets / 5 times daily.
2- Massage for chest muscles and neck muscles.
Frequency: 5 minutes / twice daily.
3- Facilitatory techniques for abdominal muscles as squeezing, massage.
Frequency: 3 minutes / twice daily.
4- Positioning: supine, semi supine, side lying, prone, semi fowler
position.16
Frequency: each 2 hours.

B- Improve clearance of secretions:

1- Postural drainage.11
Frequency: 5: 10 minutes for each position / twice daily.
2- Percussion and vibration.
Frequency: 3: 5 minutes after postural drainage / twice daily.
3- Stimulation of cough reflex by pressure on trachea, on mid rectus
abdominus muscle after end of inspiration, along lower costal borders
during expiration.

C- Improve mobility of patient:

1- Passive ROM (PROM).13
Frequency: 10 repetitions / 3 sets / twice daily.
2- Turning of patient.16
Frequency: each 2 hours.

v Process of weaning from mechanical ventilation:

1- Weaning criteria.
2- Spontaneous breathing trail.
3- T – tube.
4- Extubation and O2 mask.

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

v Guidelines for physical therapy:
1- Use of nebulizers, NIV, HFNO and spirometry should be avoided and
agreement to their use sought from senior medical staff. If deemed
essential, airborne precautions should be used.
2- Bronchoscopy carries a significant risk of aerosol generation and
transmission of infection. It is strongly advised to avoid the procedure.
3- Suctioning: closed inline suction catheters are recommended.
4- Sputum samples: in a ventilated patient, tracheal aspirate samples for
diagnosis of COVID-19 are sufficient.
5- Cough etiquette: Both patients and staff should practice cough etiquette
and hygiene. During techniques which may provoke a cough, education
should be provided to enhance cough etiquette and hygiene:
a- Ask patient to turn head away during cough and expectoration
b- Patients who are able should “catch their cough” with a tissue, dispose
of tissue and perform hand hygiene. If patients are unable to do this
independently then staff should assist.
c- In addition, if possible, Physiotherapist should position themselves ≥
2m from the patient and out of the “blast zone” or line of cough.
6- Bubble PEP is not recommended for patients with COVID-19.
7- There is no evidence for incentive spirometry in patients with COVID-19.
8- Avoid the use of MI-E or IPPB devices. However, if clinically indicated
and alternative options have not been effective, consult with both senior
medical staff and Infection Prevention and Monitoring Services within
local facilities prior to use. If used, ensure machines can be
decontaminated after use.
9- Manual hyperinflation: As it involves disconnection / opening of a
ventilator circuit, avoid MHI and utilize ventilator hyperinflation (VHI) if
indicated.
10- Positioning including gravity assisted drainage: In adult patients with
COVID-19 and severe ARDS, prone ventilation for 12–16 hours per day
is recommended. It requires sufficient human resources and expertise to
be performed safely to prevent known complications including pressure
areas and airway complications.
11- The use of inspiratory muscle training, speaking valves and leak speech
should not be attempted until patients are over acute infection and the risk
of transmission is reduced.

General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬

12- If the physical therapist mobilizes the patient outside of the isolation
room, ensure the patient is wearing a surgical mask.
13- Early mobilization is encouraged. Patients should be encouraged to
maintain function as able within their rooms as sit out of bed, perform
simple exercises and activities of daily living.
14- Mobilization and exercise prescription should involve careful
consideration of the patients’ state (e.g. stable clinical presentation with
stable respiratory and hemodynamic function).15,17

Reference

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10. Griffiths RD, Palmer A, Helliwell T, Maclennan P, Macmillan RR. Effect of passive
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AYM, Kho ME, Moses R, Ntoumenopoulos G, Parry SM, Patman S, van der Lee L
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General Protocol of ICU Physical Therapy ‫ﺻﺑﺎﺣك طﺑﯾﻌﻲ‬