The Egyptian Journal of Critical Care Medicine 6 (2018) 147–149

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The Egyptian Journal of Critical Care Medicine

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Original article

Physiotherapy for ECMO patients

Marlice van Dyk 1
Netcare Unitas Hospital, Cnr Clifton Avenue and Cantonments Road, Centurion, Pretoria, South Africa

a r t i c l e i n f o a b s t r a c t

Article history: Physiotherapy is part of the overall care in an interdisciplinary intensive care unit. Patients on extracor-
Received 3 December 2018 poreal membrane oxygenation (ECMO) were previously deemed to be too unstable to mobilise. Safety is
Revised 13 December 2018 of paramount importance as these patients often have multiple large cannulas, monitoring and lines.
Accepted 13 December 2018
Mobilisation protocols should be in place, and each team member must be aware of their role. Contra-
Available online 21 December 2018
indications for mobilisation should be adhered to, and patients should be monitored before, during
and after mobilisation. Secretion and respiratory management should be performed daily to address
Keywords:
the reason why the patient was placed on ECMO.
Physiotherapy
Extracorporeal membrane oxygenation
Ó 2018 The Egyptian College of Critical Care Physicians. Production and hosting by Elsevier B.V. This is an
Intensive care open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Mobilisation

1. Introduction Physiotherapy in ICU involves mobilisation activities, functional

Physiotherapy in the intensive care unit (ICU) is an important
part of the interdisciplinary team for critically ill patients espe-
cially those who are on organ support such as ventilation and
extracorporeal membrane oxygenation (ECMO). Multiple studies
have shown that not only do patients who receive physiotherapy
in ICU recover faster but the long-term outcome, regarding muscu-
lar weakness and quality of life, is better. The benefits of early
mobilisation in ICU include decreased delirium, weakness, dura-
tion of mechanical ventilation, length of ICU and hospital stay,
mortality, also improving cognitive function and functional ability
[1].
Physiotherapy plays a vital role to promote lung function and
manage secretions. There are more ventilator-free days for patients
who receive early physiotherapy compared to standard care [2].
There are some physical limitations for active physiotherapy in
ICU. Patients are attached to monitors, ventilators, ECMO circuits
and even dialysis circuits. They are often on inotropes and multiple
infusions that influence their capacity to increase their cardiac out-
put in response to movement and exercise.
1
Research Assistant: Sarah MacDonald.
E-mail address: dr.marlice@icudoctor.co.za
Peer review under responsibility of The Egyptian College of Critical Care Physicians.
Production and hosting by Elsevier
positioning, passive- and active-assisted movements of extremi-
ties, sitting, bedside standing, walking with support, early mobili-
sation, postural drainage, clear airway secretions, percussion and
vibration, as well as assisted and resisted exercise.
The rationale for mobilisation in ICU includes prevention of bed
rest-related problems, optimisation for early recovery, improving
functional ability as quickly as possible and improving mood and
psychology with engagement in goal setting and attainment [3].
2. Safety
Safety is of paramount concern for patients on ECMO that
require mobilisation. Dislodgement or even kinking of the cannulas
will lead to immediate desaturation (VV-ECMO) or a precipitous
drop in blood pressure and cardiac output (VA-ECMO). Placement
of the cannula can facilitate or hinder mobilisation. Double lumen
cannula placed in the internal jugular vein allows better mobility
than two separate cannulas or insertion in the femoral veins. It is
important that the cannulae are well secured with sutures to pre-
vent tugging, twisting, kinking or decannulation [3].
International consensus recommendations for exercising
mechanically ventilated patients in the ICU were developed in
2014 by a group of ICU experts. The recommendations comprise
four considerations: respiratory, cardiovascular, neurological and
other. Boyd et al. represent these considerations as indicated in
Table 1 below. The recommendations employ a ‘traffic-light’ colour
coding system (green, yellow, red) and classify each parameter into
a corresponding colour when considering exercise rehabilitation
[4,5].

https://doi.org/10.1016/j.ejccm.2018.12.013
2090-7303/Ó 2018 The Egyptian College of Critical Care Physicians. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
148 M. van Dyk / The Egyptian Journal of Critical Care Medicine 6 (2018) 147–149

Table 1
Traffic light recommendation and summary of parameters for consideration outlined in the consensus document [4,5].

Traffic light Respiratory Cardiovascular Neurological Other

Endotracheal tube or Mean arterial Level of Other (ICU-acquired
tracheostomy pressure (MAP) consciousness weakness
Within target range RASS 1 to +1 CRRT Venous and
with low level arterial femoral
Low risk of an adverse event. support catheters
Proceed as usual according to each ICU’s protocols and protocols FiO2 < 0.6 Cardiac devices: Delirium Able to Other drains and
SpO2 > 90% Ventricular assist follow attachments
RR < 30/min device (VAD) commands
Positive end-expiratory Arrhythmias Stable
pressure (PEEP) < 10 rhythm
cmH2O
Ventilator dysynchrony Pulmonary Craniotomy
hypertension Acute spinal
High-frequency oscillating Arrhythmias cord injury
ventilation (HFOV) mode Unstable rhythm SAB
Potential risk and consequences of an adverse event are higher Shock with lactate Vasospasm
than green, but may be outweighed by the potential benefits of >4 mmo/L
mobilisation. Acute DVT/PE
Precautions should be clarified before mobilisation. Severe aortic
Mobilisation should be gradual and cautious stenosis
Cardiac devices:
ECMO
Rescue therapies (NO, Blood pressure-on iv Raised Surgical
prostacyclin and prone antihypertensives Intracranial (fracture/wound)
positioning) Pressure
Cardiac ischemia Open lumbar Medical (bleeding/
The significant potential risk of an adverse event. drain febrile/active
Active mobilisation should not occur unless specifically requested cooling)
by the Intensivist Cardiac devices: Uncontrolled Femoral sheaths
Intra-aortic balloon seizures
pump (IABP)

3. Contra-indications 5. Team roles

All ECMO patients should be included in a mobilisation protocol
unless there are contraindications, which include hypoxia, hemo-
dynamic instability, unstable cardiac rhythm, intracranial pressure
monitoring, lose or unstable cannula sites, desaturation episodes
with minimal movements, escalation of vasopressors in the last
12 h, and chugging of the ECMO circuit. Mobilisation can be
achieved even on low dose vasopressor and/or inotropic support
[6].
4. Mobilisation
A scale of safe activities for ECMO patients has been developed
by the University of Michigan (Table 2). Initially, passive move-
ments and the use of a mechanical lift for positional changes will
be used. As the patient progresses sitting in bed, sitting on the edge
of the bed, sitting in a chair and standing can be achieved. The first
step towards mobility is for all members of the ECMO team to be
available. The ECMO cannula must be securely sutured in place
and secured to the patient’s head with elastic tape, crepe bandage
or indwelling catheter leg strap [6].
Table 2
Scale of Activity for ECMO patients [6,7].
Phase 0– No mobilisation or passive range of motion – 4 h re-assessment
1 [6].
Turning in bed (including passive and active range of motion)
Sitting in bed – elevated head of the bed
Sitting on the edge of the bed, feet on the floor
Sitting in a chair
Standing
Phase 2 Marching in place
Ambulation with assistance
Phase 3 Ambulation independently (ECMO patients will not achieve
phase 3)
For safety reasons, each team member is assigned specific
responsibilities during mobilisation. The ECMO specialist has pri-
mary responsibility for all aspects of the ECMO circuit and directs
the movements of the patient and the team. Care should be taken
to ensure that the lines and cannulas do not get kinked, twisted or
dislodged during movement of the patient. The patient must be
able to follow commands and assist staff.
The physiotherapist is responsible for maintaining the airway
and ventilator. While the bedside nurses are responsible for all
lines and monitoring the patient’s response to treatment and
activity. Finally, the Intensivist is responsible for the overall reac-
tion to the activity and must oversee the team [6].
6. Monitoring
Comprehensive monitoring of the patient’s baseline, observa-
tions of their response and circuit integrity should be documented
before, during, and after all episodes of patient mobility. With con-
tinuous monitoring of all vital signs. The ECMO flow and SVO2 are
continuously monitored via the ECMO circuit. The mobilisation of
the patient results in an increase in cardiac output, oxygen con-
sumption, and carbon dioxide production, these factors may lead
to an increased requirement for ECMO support during mobilisation
7. Respiratory and secretion management
The rationale for respiratory treatment in ICU includes the
optimisation of secretion clearance from airways and the improve-
ment in ventilation-perfusion mismatch along with improvement
in atelectasis and lung collapse. Respiratory treatments include
 M. van Dyk / The Egyptian Journal of Critical Care Medicine 6 (2018) 147–149
in-bed positioning and postural exercises to promote ventilation
and removal of secretions [3].
A full respiratory assessment should be done prior to respira-
tory treatment. This assessment should comprise of a review of
CXR and/or CT scan(s), observation and palpation of the chest wall
movement and fremitus, the ECMO settings, ventilation mode, flow
curves and compliance, arterial blood gases, oxygenation satura-
tion, auscultation. Consideration of the level of sedation should
be part of the assessment [3].
The delivery of sub-dead space tidal ventilation head up posi-
tioning and deep sedation may lead to mucus stasis. By positioning
the patient supine, head down, increasing tidal volume with venti-
lator hyperinflation to a pressure of 30 cmH2O and augmenting
expiratory flow by providing chest wall compression during expi-
ration, an expiratory airflow bias moves the mucus cranially via a
2-phase gas-liquid flow and can be removed by suction [8].
The positioning of patients for postural drainage depends on the
lung lobes from which secretions need to be drained. It includes
different techniques such as percussion, shaking, or vibration
coughing to move secretions toward upper airway from where
they can be suctioned. Also breathing exercises such as forced
expiration, deep breathing, and incentive spirometry can be used
to increase chest expansion. It also helps to strengthen respiratory
muscles [9]. The use of automated rotational percussion beds also
aids in improving respiratory mechanics [10].
Respiratory treatment options include positioning and postural
drainage, installation of saline via a closed suction port and suc-
tioning, manual or ventilator hyperinflation techniques, nebulisers,
physiotherapy-assisted flexible bronchoscopy, intermittent posi-
tive pressure breathing, and high-frequency chest wall oscillation.
The positioning of the patient for postural drainage can compro-
mise the ECMO flow and must be discussed with the Intensivist
beforehand. Suctioning on ECMO always carries the risk of airway
bleeding as these patients are heparinised [3].
8. Conclusion
Critically ill patients with respiratory failure on ECMO can be
safely mobilised if there are no contra-indications and if there is
adherence to protocols. Respiratory management plays a signifi-
cant role in treating the underlying lung pathology. The aim of
physiotherapy in our institution is to be able to discharge patients
149
from the hospital that can perform all activities of daily living by
themselves. Unfortunately, there is only level IV evidence for early
physiotherapy in ICU [1]. More prospective randomized trails are
necessary to proof that early physiotherapy does make a difference
to these very ill patients. Early physiotherapy for ECMO patients
might well reduce ICU and hospital length of stay and reduce cost.
In most cases, the long-term quality of life is better compared to
cases that have weakness after being critically ill.
References
[1] Adler J, Malone D. Early mobilization in the intensive care unit: a systematic
review Available from. Cardiopulm Phys Ther J 2012;23(1):5–13. https://
www.ncbi.nlm.nih.gov/pubmed/22807649.
[2] Ntoumenopoulos G, Presneill J, McElholum M, Cade J. Chest physiotherapy for
the prevention of ventilator-associated pneumonia. Intensive Care Med
2002;28(7):850–6. doi: https://doi.org/10.1007/s00134-002-1342-2.
[3] Eden A, Purkiss C, Cork G, Baddeley A, Morris K, Carey L, et al. In-patient
physiotherapy for adults on veno-venous extracorporeal membrane
oxygenation – United Kingdom ECMO Physiotherapy Network: a consensus
agreement for best practice. J Intensive Care Soc 2017;18(3):212–20. Available
from: https://www.ncbi.nlm.nih.gov/pubmed/29118833.
[4] Hodgson CL, Stiller K, Needham DM, Tipping CJ, Harrold M, Baldwin CE, et al.
Expert consensus and recommendations on safety criteria for active
mobilization of mechanically ventilated critically ill adults. Crit Care 2014;18
(6):658. doi: https://doi.org/10.1186/s13054-014-0658-y.
[5] Boyd J, Paratz J, Tronstad O, Caruana L, McCormack P, Walsh J. When is it safe
to exercise mechanically ventilated patients in the intensive care unit? an
evaluation of consensus recommendations in a cardiothoracic setting. Hear
Lung 2018.
[6] Rickelmann C, Knoblauch DJ. Incorporating safe patient-handling techniques
to mobilize our most complex patients on extra corporeal membrane
oxygenation. Crit Care Nurs Q 2018;41(3). Available from: https://journals.
lww.com/ccnq/Fulltext/2018/07000/
Incorporating_Safe_Patient_Handling_Techniques_to.6.aspx.
[7] Hodgson C, Needham D, Haines K, Bailey M, Ward A, Harrold M, et al.
Feasibility and inter-rater reliability of the ICU Mobility Scale. Hear Lung J
Acute Crit Care 2014;43(1):19–24. doi: https://doi.org/10.1016/j.
hrtlng.2013.11.003.
[8] Cork G, Barrett N, Ntoumenopoulos G. Justification for chest physiotherapy
during ultra-protective lung ventilation and extra-corporeal membrane
oxygenation: a case study. Physiother Res Int 2013;19(2):126. doi: https://
doi.org/10.1002/pri.1563.
[9] Jyoti Meenu. Role of physiotherapist in critical care situations: recent
perspective. J Card Crit Care 2018;02(01):14–8.
[10] Sharma NS, Wille KM, Bellot SC, Diaz-Guzman E. Automated rotational
percussion bed and bronchoscopy improves respiratory mechanics and
oxygenation in ARDS patients supported with extracorporeal membrane
oxygenation. ASAIO J 2016;62(3). Available from: https://journals.lww.com/
asaiojournal/Fulltext/2016/05000/
Automated_Rotational_Percussion_Bed_and.25.aspx.