Patients admitted to the Pediatric Intensive Care Unit (PICU) or Neonatal Intensive Care Unit (NICU) often suffer respiratory complications1 and could benefit from respiratory physiotherapy (RP) techniques that can shorten hospital stay.2 While the international literature has addressed the role of physiotherapy in PICUs/NICUs,3,4 no such studies have been published in Spain to date. The present study analyzes the situation of RP in Spanish PICUs/NICUs.

An internal validation was carried out involving 6 experts in RP and with training in Intensive Care and Pediatrics, in order to assess the suitability of form and contents. Following due approval from the Teaching and Research Ethics Committee of the University of A Coruña (CEID-UDC-2018-0019), in September 2019 an electronic survey was sent to the 45 Spanish PICUs/NICUs of the registry of the Spanish Society of Pediatric Intensive Care (Sociedad Española de Cuidados Intensivos Pediátricos),5 addressed to the Physiotherapy coordinator at each center. A period of 6 months was allowed for receiving the reply, with a total of three reminders if needed.

A total of 24 hospitals answered the survey (53.3%): 22 public centers (91.7%) and two private centers (8.3%), with 26.1 ± 17.4 staff physiotherapists, of which two (1–3) were in charge of the service in the PICU/NICU (Table 1). The mean number of beds was 19.3 ± 12.9 (range 5–50), with a physiotherapist / bed ratio of 1/8. The implementation of physiotherapy was dependent upon referral by the Department of Rehabilitation or the specialist in Intensive Care in 16 (66.7%) and four (16.7%) hospitals, respectively. In another four centers (16.7%), RP consultation was directly requested from any specialized physician or – in the case of consultation for motor physiotherapy – from the Department of Rehabilitation. Twenty answers were obtained regarding the percentage of children that received physiotherapy; specifically, 37.1 ± 32.1% of the patients received treatment both in the PICU and in the NICU in 15 Units (75%). In three Units (15%), estimates were made for PICU (17.1 ± 4% of the patients) and NICU (14.5 ± 16.3% of the admitted patients). The remaining two Units (10%) considered the seasonal factor: children treated in summer (18.4 ± 2.3%) and in winter (90 ± 14.1%). In one of the NICUs, physiotherapy was provided for all infants with a gestational age of under 28 weeks. The duration of the sessions ranged from 10−35 min, with an average of 22.5 ± 7.7 min. The service was available only in the mornings in 19 of the Units (79.2%), and only on working days in 19 Units (79.2%). On the other hand, 70.8% of those surveyed considered that the number of physiotherapists associated to the service was insufficient to cover the care needs. In 22 of the Units (91.7%), the physiotherapists were not exclusively dedicated to work in the Unit; 14 (63.6%) also offered RP to patients in the ward and 9 (19.8%) to ambulatory patients. In addition, 18 (81.8%) performed physiotherapy in patients admitted to the ward and 14 (63.6%) in outpatient clinics.

Academically, the participants had 20.3 ± 5.1 years of general working experience, and 11 (45.8%) had between 3–10 years of experience in the PICU/NICU. For 19 of the participants (79.2%), having specific training in RP in critical pediatric patients was not a requirement for their job position. At present, 19 (79.2%) have training in RP, and of these, 15 (62.5%) have training in pediatric RP; 14 (58.3%) have training in RP in Intensive Care; and 10 (41.7%) have training in RP and in the management of mechanical ventilation. Only 8 participants (33.3%) had training in all three areas. Lastly, 16 of the Units (66.7%) provided clinical practice training at grade or master level (Table 2).

Our results evidence low commitment of the physiotherapist to the PICU/NICU. This is in contrast to the situation found in Brazil, for example, where 21.2% of the staff physiotherapists are exclusively related to the PICU/NICU.3 Nevertheless, the physiotherapist / bed ratio is better than in the PICUs in Brazil (1:9.3), in the PICUs/NICUs in Korea (1:20),3,4 and in Spain referred to adult Intensive Care (1:13).6 In any case, the situation falls short of the recommendations of the European Society of Intensive Care Medicine (ESICM),7 which advises a ratio of 1:5.

With regard to the patient referral system, our findings are consistent with those corresponding to adult Intensive Care in Spain, with a Department of Rehabilitation referral rate of 65.1%.8 Likewise, in terms of the mean duration of each session, our data coincide with those recorded in Korea,4 where 36.2% of the participants reported a duration per session of under 10 min and 29.3% less than 30 min. The same situation was found in adult Intensive Care in Spain, where the mean duration of the rehabilitation sessions was 16−30 min.6 Thus, the characteristics identified in our study do not comply with the standards and recommendations referred to the quality of Intensive Care published by the Spanish Ministry of Health,9 which estimate that each patient requires at least 30 min a day of physiotherapy.

On the other hand, the ESICM7 recommends that physiotherapists who work in the Intensive Care Unit (ICU) should do so full time, with a coverage of 7 days a week. While this objective is not met by the analyzed Spanish PICUs/NICUs, at European level 75% of the adult ICUs have at least one or two physiotherapists with full time dedication.10 In relation to weekly coverage of the service, our results fall short of those recorded by the hospitals in Barcelona, where the percentage reaches 47%,6 and of those published in Europe, with a percentage of 83%.10 Lastly, nocturnal service was inexistent in the Units participating in our study, and very low in the Spanish adult ICUs8 — while the figure reaches 34% in the European general ICUs.10

As limitations of the present study, replies were not obtained from all the hospitals with PICU/NICU, despite the long time allowed for them to reply. In turn, most of the centers belonged to the Spanish public healthcare system, which might not be representative of the situation of RP in the PICUs/NICUs of private centers.

The present study underscores the need to integrate physiotherapists within the interdisciplinary teams of the Spanish PICUs/NICUs, facilitating direct patient referral to physiotherapy on the part of the specialist in Intensive Care, and with exclusive and full-time dedication.