Phys ther 1996-ciesla-609-25


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Phys ther 1996-ciesla-609-25

  1. 1. Chest Physical Therapy for Patients in the Intensive Care Unit Nancy D Ciesla PHYS THER. 1996; 76:609-625. The online version of this article, along with updated information and services, can be found online at: Collections This article, along with others on similar topics, appears in the following collection(s): Airway Clearance Pulmonary Conditions: Other e-Letters To submit an e-Letter on this article, click here or click on "Submit a response" in the right-hand menu under "Responses" in the online version of this article. E-mail alerts Sign up here to receive free e-mail alerts Downloaded from by guest on July 21, 2013
  2. 2. Chest Physical Therapy for Patients in the Intensive Care Unit Chest physical therapy is used in the intensive care unit (ICU) to minimize pulmonary secretion retention, to maximize oxygenation, and to reexpand atelectatic lung segments. This article reviews how chest physical therapy is used with patients who are critically ill. A brief historical review of the literature is presented. Chest physical therapy treatments applicable to patients in the ICU are discussed. Postural drainage, percussion, vibration, breathing exercises, cough stimulation techniques, and airway suctioning are described in detail, with current references. The importance of patient mobilization is emphasized. The advantages of chest physical therapy over therapeutic bronchoscopy also are discussed. Two patient examples are used to demonstrate the beneficial effects that may be obtained with chest physical therapy. Following the removal of retained secretions, arterial oxygenation and partial pressure of arterial oxygen/fraction of inspired oxygen concentration ratios improved, and atelectasis resolved without the negative hemodynamic side effects of therapeutic bronchoscopy. Physical therapists trained in the ICU can safely perform chest physical therapy with the majority of patients who are critically ill. [Ciesla ND. Chest physical therapy for patients in the intensive care unit. Phys Ther. 1996; 76:609- 625.1 Key Words: Airway suctioning, Breathing exercises, Bronchial hygiene, Cardiopulmonary, Chest physical therapy, Cough, Intensive care units, Postural drainage, Thorax. Nancy D Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013
  3. 3. he purpose of this article is to review the role of chest physical therapy in the intensive care unit (ICU). Treatments are described and critiqued for utility in the ICU. The ICU is a unique environment, and patients are frequently mechanically ventilated and have multiple invasive lines and drainage tubes that are needed to optimize hemodynamic status. Pulmonary artery, intracranial, and central venous pressures are routinely monitored. Chest physical therapy is often necessary due to retained secretions following intubation and immobility. Some physicians advocate volume-controlled mechanical ventilation or mandatory synchronized intermittent ventilation, whereas others recommend pressure support and pressure control modes.' In my experience, most critically ill patients in the ICU tolerate therapy when supplemental oxygen delivery and ventilator adjustments are permitted before or during chest physical therapy to enable them to tolerate turning and mobilization. Chest physical therapy usually consists of postural drainage, percussion, vibration, coughing and cough stimulation techniques, breathing exercises, suctioning, and patient mobilization. In my experience, mobilization that includes side-to-side turning, transfer training, and ambulation while ventilating the patient with a manual resuscitator bag (MRB) usually minimizes the need for postural drainage with manual techniques. The forcedexpiration technique, active cycle of breathing, positive expiratory pressure, autogenic drainage, and use of a flutter valve are newer airway clearance techniques that appear to be beneficial for cooperative patients with chronic sputum-producing diseases such as cystic fibrois.'-^ The focus of this article is the adult patient in the ICU who is frequently intubated, receiving supplemental oxygen, and unable to follow complex instructions. Breathing exercise techniques, therefore, for patients with less acute chronic sputum-producing disease are not discussed. Historical Review Studies of chest physical therapy did not occur until the 1950s when Palmer and Sellickhnd Thoren-tudied 352 patients following gastrectomy, hernia repair, and cholecystecomy. These authors demonstrated that postural drainage, percussion and vibration, breathing exercises, and coughing were more effective at reducing postoperative pulmonary complications including atelectasis and pneumonia than either no treatment or breathing exercises alone. The study of the effects of chest physical therapy on arterial oxygenation, oxygen consumption, total lung/ thorax compliance, cardiac output, and airway resistance was possible in the 1970s due to the routine use of mechanical ventilation and hemodynamic monitoring. Mackenzie et a17 demonstrated radiological improvement without hypoxemia in 47 patients with multiple trauma who received chest physical therapy and were mechanically ventilated with positive end-expiratory pressure (PEEP). The fraction of inspired oxygen conwas centration ( F I O ~ ) not altered during chest physical therapy for these patients. Chest physical therapy improved lung/thorax compliance in 42 patients with atelectasis, pneumonia, lung contusion, and adult respiratory distress syndrome (ARDS) who were mechanically resistance was ventilated following trauma."rway unchanged immediately following and for 2 hours after chest physical therapy.8 Mackenzie and c o l l e a g ~ e s ~ ~ ~ concluded, therefore, that chest physical therapy most likely affects the small airways rather than large airways in adult patients with traumatic injuries. Even in patients with unstable vital signs following severe multiple trauma, chest physical therapy has been shown to assist in the resolution of left lower-lobe atelectasis and to improve arterial o~ygenation.~ Investigatorsl0 also have noted that suctioning decreases the saturation of venous oxygen (SVO~) due to increased oxygen consumption when there is an inadequate increase in cardiac output. Klein et all] demonstrated an increase in cardiac output with chest physical therapy, which returned to baseline within 15 minutes of the procedure. Only two research g r o ~ p s ~ ~ . ~ " a v e examined the effect of chest physical therapy on the resolution of acute primary pneumonia. Outcome variables included duration of fever, radiographic clearing, hospital stay, and m~rtality.~z.'"raham and Bradley12 demonstrated no difference in the resolution of pneumonia for 27 patients treated with intermittent positive pressure breathing (IPPB) and chest physical therapy compared with a control group of 27 patients. Britton and colleagued3 studied 177 patients. Outcomes were the same for the control group, which received advice on deep breathing and coughing, and for the study group, in which postural drainage, manual techniques, and breathing exercises were used.lVn both studies, the majority of patients received antibiotics. Patients with nosocomial pneumonia, however, were not included in either study. Patients who were intubated, patients who had undergone thoracic or upper abdominal surgery, ND Ciesla, PT, is Clinical Instructor, Department of Physical Therapy, University of Maryland School of Medicine, Baltimore, MD 21201-1595 (USA) ( also was Director of Physical Therapy, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, at the time this article was written. 610 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013
  4. 4. and patients with cystic fibrosis, lung abscess, lung contusion, and bronchiectasis were also excluded. Clinical examination and data gained from ventilationperfusion scans, computerized tomography, magnetic resonance imaging, and portable radiographs are used to determine an indication for chest physical therapy. Monitoring in the ICU and pulse oximetry allow continuous assessment of patients' vital signs and oxygen saturation before, during, and after treatrnent.14 Unfortunately, because studies evaluating treatment techniques are limited, clinicians have frequently extrapolated the outcomes from studies of patients with chronic disease or patients who are mobile to patients in the ICU who are immobilized and mechanically ventilated.I5-l7 For example, Sutton and colleague^'^ studied eight patients with copious sputum production (five patients with br13nchiectasis,two patients with chronic bronchitis, and one patient with cystic fibrosis) who were not in the ICU and concluded that tracheobronchial clearance is unaffected by adding vibration shaking or percussion to postural drainage with the forced-expiration technique. Early ambulation following gallbladder and cardiac surgery has almost eliminated the need for chest physical therapy in these patients unless comorbidities are p r e ~ e n t . ' ~Whether the positioning therapy recom-~~ mended by Dean and colleagues'2-a contributes to the resolution of acute atelectasis is unknown. The resolution of acute atelectasis (37%-83%) demonstrated with postural drainage and manual techniques, however, has been shown to be equally as effective as therapeutic bronct~oscopy the treatment of acute lobar atelectasis for and has been studied in the ICU.738.'" The use of chest physical therapy without regard to the patient population or condition for which it is prescribed, and with n o standard definition of treatment components, has led, in my opinion, to numerous negative reports on the efficacy. Efficacy of Chest Physical Therapy in the Intensive Care Unit The efficacy of chest physical therapy can be determined by a reduction in the incidence of pulmonary infection or an improvement in pulmonary function. The mortality rate from nosocon~ialpneumonia remains high and ranges from 30% to 60%.26327 Other benefits of chest physical therapy may include decreased duration of mechanical ventilation and prevention of tracheostomies--benefits that reduce cost and shorten hospital stays. The diagnosis of pneumonia in the critical care setting is difficult. The clinical criteria used to diagnose pneumonia include the presence of fever, purulent sputum expec~:oration, leukocytosis, a Gram stain showing many polymorphonuclear cells and a single morphologically Physical Therapy . Volume 76 Table 1. Indications for Chest Physical Therapya Evidence of retained secretions (blood or sputum) not removed by suctioning, coughing, and turning Radiological evidence of acute atelectasis or infiltrate Decrease in Pao2 or Spo2 as a result of secretion retention Prophylactic Use Acute neurolo ical diseases affectin the innervation of the intercostal, !iaphragmmatic, or aidominal muscles Smoke inhalation Acute moderate to severe brain iniury - - - Pao,=partial pressure of oxygen, arterial: Spo,=oxygen ~aturation measured .. by pulse oximet~y. Adapted from Ciesla ND. Chest physical therapy for the adult intensive care unit trauma patient. Pt~yi(al ThmnIrj I%/~r.ticr. 1994;3:99. " distinct organism, and a new pulmonary infiltrate on chest radi~graph.~"-' Patients in the ICU meeting these criteria may respond to chest physical therapy without antimicrobial therapy.'"oshi and colleagues2%tudied 39 patients with trauma (32 patients were intubated) who met the criteria for diagnosis of pneumonia, at which time chest physical therapy was initiated. Within 3 days of chest physical therapy, 31 of the 39 patients showed complete or partial clearing of pulmonary infiltrates and did not require antimicrobial therapy. Overuse of antibiotics can result in toxicity, emergence of resistant strains of bacteria, superinfections, and increased hospital cost^.^^^ For some patients in the ICU, the response to chest physical therapy can differentiate the diagnosis of atelectasis from pneumonia and can be used to determine which patients require antimicrobial therapy.26 Although activities in the ICU, including chest physical therapy, have been reported to increase metabolic rate up to 35%, the use of short-acting narcotics usually diminishes any associated hemodynamic The importance of an increase in oxygen consumption and carbon dioxide production, which return to baseline within 15 minutes, is questionable. Therefore, most patients in the ICU who tolerate turning will tolerate the positioning necessary for chest physical therapy. Indications for Treatment Many authors have described the inappropriate use of chest physical therapy. For example, the American Association of Respiratory Care's clinical practice guideline for postural drainagegQonsiders recent spinal surgery, rib fractures, and bronchopleural fistulas to be contraindications for postural drainage. This approach may be a result of prescribing therapy without a clear-cut indication for treatment (Tab. 1) or of the health care provider not having the training to position the patient with neurologic and orthopedic injuries o r the skills to assess the patient's breath sounds, vital signs, and ability to cough. I believe that the patient's level of mobility is . Number 6 . June 1996 Downloaded from by guest on July 21, 2013 Ciesla . 61 1
  5. 5. often not considered in the initial patient assessment by non-physical therapists. I have found that patients who adequately clear srcretions with side-to-side turning, mobilization, and suctioning d o not need postural drainage with manual techniques. In my experience, chest physical therapy is frequently administered to both lungs without directing therapy to the anatomic area of lung involvement, is not continued until secretions reach the upper airway, or is not terminated when the patient stops producing secretions. The presence of chronic sputum-producing lung diseases, with the exception of cystic fibrosis, does rlot warrant chest physical therapy unless another indication for treatment (Tab. 1) o r recurrent pneumonia is present. Chest Physical Therapy Components Mucociliary activity and an effective cough are needed ~.~" for normal airway c l e a r a n ~ e . ~Viscous secretions, the presence of a cuffed tracheal tube, dehydration, hypoxemia, immobility, and poor humidification of gases impede mucociliary clearance, causing secretion retentiotls3(i-v Neurologic conditions and phar~nacologically induced paralysis affecting the innervation of the glottis or intercostal and abdominal muscles may diminish airflow, resulting in a n ineffective cough.:'Vatients in the ICU usually have one or more of these conditions. The treatment techniques used in the ICU are similar to those advocated by ThorenQmore than 40 years ago. Postural drainage, percussion, vibration, coughing, suctioning, breathing exercises, patient mobilization, and sometimes manual lung inflation are the usual treatments used to renlove secretions. T h e effectiveness of positioning alol~e to remove retained secretions is unknown. Most patients in the ICU cannot tolerate strenuous exercise programs. However, turning, suctioning, transfer training, and ambulation (with a n MRB, if' necessary) are integral parts of'the chest physical therapy assessment and treatment and may minimize the need for postural drainage using manual t e c h n i q ~ e s . ~ ~ ' Positioning Postural Drainage Postural drainage refers to placing the body in a position that allows gravity to assist drainage of mucus from the lung periphery to the segmental bror~chusand upper airway."" Eleven positions are commonly used to drain 14 lung segments. A detailed description of positioning the patient in the ICU is published elsewhere." Postural drainage enhances peripheral lung clearance, increases functional residual capacity, and accelerates mucus clearanCe.~~).~?.m Postural drainage in conjunction with mechanical ventilation and PEEP is thought to increase transpulmonary pressure, irllprove ventilation-perfusion ratios, increase lung/thorax compliance of the nondependent hemithorax, and reduce collateral airway re~istance.5~ Atelectasis may resolve more quickly when the patient is turned with the affected lung ~ipperrnost.~:' Obese patients placed in the 19degree Trendelenburg position after abdominal surgery fbr postural drainage of the lower lobes rarely demonstrate clinically significant oxygen desaturation."" Transient decreases in oxygen saturation measured by pulse oximetry (Spo,) that occur with postural drainage positioning return to baseline within a few minutes. Therefore, most spontaneously breathing and mechanically ventilated patients tolerate positional changes necessary for segmental postural drainage. Infrequently, an increase in metabolic demand o r worsening ventilation-perfusion ratios result in a decrease in oxygenation, insufficient gas flow, o r low ~'.~~ lung v o l u ~ n e s . ~ Increasing the patient's Fro, or additional ventilator adjustments are therefore required prior to or during therapy. Positioning for postural drainage is usually continued once the patient has responded fivorably to changes in ventilator settings. The duration of postural drainage may range from 1 5 to 60 minutes, depending on the patient's tolerance to c:hanges in position and the amount of sputum production. Cooperative, spontaneously breathing patients who can cough effectively may not need postural drainage. Johnson et a157 found no difference in the resolution of' atelectasis when postural drainage and percussion were added to deep breathing exercises in patients with acute lobar atelectasis, although the diagnoses and mobility level of the patients studied were not addressed. The benefits of positioning versus postural drainage is often difficult to discern. Changes in ventilationperfusion relationships with positional changes have been d o c ~ r n e n t e d . Side-to-side turning decreases ~~,~~ ~~ postoperative fever and improves o ~ y g e n a t i o n .Improvements in arterial oxygenation after patient posiPatient Example # 7 tioning, including in patients with adult respiratory The following example demonstrates improvement in ~-~ distress syndrome (ARDS), have been s h o ~ n . ~ Posi- ' both atelectasis and oxygenation after prone positioning tioning patients for chest physical therapy with the and chest physical therapy. The patient was discharged 8 "good lung down" is associated with improved days after treatment was initiated. Although it was inioxygenation.U4* ventilation-perfusion ratios and tially felt that this patient would require extracorporeal Patients with pathology in the superior, and frequently lung assistance to sustain life, after positioning and chest the atelectatic posterior, segments of the lower lobes physical therapy this was not necessary. may have better oxygenation with prone positioning than with supine po~itioning.4"~" 6 12 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013
  6. 6. A 33-year-old white man was admitted to a trauma center following a near-drowning accident. He had been s u b 1nergec-lfor approximately 'LO minutes and had hypother~nic cardiac arrest with 30 rninutes of cardiac asystole. His admitting Glasgow Coma Scak was 3. The patient had a core temperature of 80°F. On admission to the hospital, he was rewal-~ned with gastric pelitoneal lavage. During the initial hospitalization, the patient developed progressive I-espiratory failure requiring pressure-control ventilation with 36 cln of water pressure, 18 cm of water pressure of PEEP, and 100% of Flo,. Due to severe ARDS and increasing ailway pressures, the patient was transferred to a trauma center with expertise in extracorporal lung assistance. Five <baysfollowing the accident, the patient was t~ansferredto the second trauma center. At this trauma center, computerized tomography and chest radiography demonstrated bilateral lower-lobe atelectasis and consolidation,with right pleura~l effiision without evidence of ARDS (Figs. 1 , 2A). To optimize ventilation and treat the bilateral lower-lobe consolidation,the patient was placed on a turning frame for prone positioning and chest physical therapy. Twenty-four hours following admission to the second trauma center, the patient was evaluated for chest physical therapy while pharmacologically paralyzed with metabine and mechanically ventilated via an endotracheal tube. Coarse rales were noted over the posterior lung zones. The initial treatment consisted of postural drainage and percussion to the posterior basal segments of both lower lobes for 45 rninutes with the patient in the prone head-down position. Less than 10 cc of sputum was obtained with suctioning. Following treatment, improved air ent~y noted b auscultation. was y After 5 days of treatnlent, the patient was placed on a regular bed due to the marked improvement in his respiratory status. Chest physical therapy was administered for 7 days and consisted of postl~raldrainage, percussion, and vibration to the lower lobes (Tab, 2). Sputllm incre:ased, with a gradual improvement in breath sounds and chest radiograph findings and marked in~provement shown in computerized tomography scan (Fig. 3). The patient was extubated on day 8. Following extubation, the patient ambulated with assistance and had a good prodl~ctive cough. Within 24 hours, the patient was discharged back to the original hospital, alert and oriented while following three-step commands. Chest physical therapy and prone positioning were most likely responsible for reexpansion of this patient's collapsed lower lobes and for improved oxygenation, which in turn led to successful weaning from ~nechanical ventilalion. The physicians and physical therapists involved with this patient did not know which intervention was primarily responsible for the patient's improvement. However, when faced with a patient with increasing airway pressures and secretion retention who is difficult to ventilate on 100% of Fro,, simultaneous treatment using gravity to maximize ventilation-perfusion ratios and postural drainage with manual techniques to mobilize retained secretions Figure 1. Chest radiograph demonstrating bilateral lower-lobe atelectasis. Note +hat the diaphragmatic bordersare obscured, appear to be indicated u~ltilfurther research demonstrates that positioning alone can be equally effective. Percussjon and Vibration percussion and vibration are the techniques ]nost fiequently recommended for the patient who is intubated and mechanically ventilated and for patients with impaired cognition or poor coughing Percussion and vibration are used to enhance m~icociliary clearance fi-om both central and peripheral The exact niechanism of action of chest percussion is unknown, bur there is some evidellce froln animal models that physical stimulation alters airflow and is associated with the release of pulmonary chemical mediators, mediators that may improve ciliary trallsport speed by as much as 340%,") Mllcociliary flow is dependent o n the geometry of the the viscoelastic property of airnay, and the speed o f a i r f l o w . ~ o , ~ Luterations in aiMiay diameter and airflow may decrease the viscosity of mucus, making percussion more effective in mobilizing secretions that are adherent to the bronchial walls. Percussion with postiiral drainage has been used to remove mucus and aspirated teeth from patients who are medically too iinstable to undergo bronchoscopy. This suggests that manual techniques can assist in clearing secretions from both the central and peripheral airway~."~z Because of differences in aerosol deposition in the airways a n d no standardization of manual versus mechanical technique, controversy exists as to whether the radionuclide clearance noted with percussion and vibration indicates peripheral o r central ainvay clearance. Manual percussion and vibration, when performed Physical Therapy. Volume 76 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013 Ciesla . 61 3
  7. 7. with postural drainage, are thought to expedite drainage of secretions from the central and peripheral airways, which may reduce treatment This is particularly important for patients in the ICU who have periods of hernodynamic instability and require multiple diagnostic and therapeutic procedures. Both techniques are used with postural drainage. Redness or petechiae are usually a result of improper technique. For patients with thoracic abrasions or burns needing manual techniques, a sterile drape should be placed over the chest wall. When treating a patient with spinal injuries who is stabilized in either a halo vest or thoracic corset, the therapist opens the vest after the patient is placed in the appropriate postural drainage position. Opening the vest in this manner allows access Manual techniques should be applied only over the lung to the thorax without disrupting spinal stabilization. For that approximates the chest wall with full i n ~ p i r a t i o n . ~ ~ the patient with severe brain injury requiring intracraCornmonly accepted anatomic landmarks for percussion nial pressure (ICP) monitoring, manual techniques are and vibration include the level of the 10th thoracic not contraindicated because they do not increase vertebra posteriorly and the xiphoid process anteriorly ICP.(j"b7 The force and frequency of manual percussion with normal respiration. Posteriorly, the lower borders and vibration vary depending on the therapist's experiof the lung descend to T-12 with deep inspiration and ence; whether a one- or two-handed technique is used; and the patient's pain tolerance, especially when rib rise to T-9 with forced e x ~ i r a t i o n . ~ ~ fractures are present. The lower lung borders may be two to three levels higher in patients with abdominal distention and in patients Percussion. Percussion is used during both the inspirawith liver or kidney disease. Lower lung borders can be tory and expiratory phases of respiration. The therapist's assessed with auscultation and mediate percussion (perhand should create an air cushion, and the energy wave cussion as part of the physical examination to determine created by that hand is transmitted through the chest the density of underlying structures). One lung segment, wall and is thought to dislodge secretions from the the medial segment of the right lower lobe, is not bronchial ~ a l l s . ~ ~ ~ ~ r o n c h o sis a s m most frep the accessible to manual techniques because of its anatomic quently discussed adverse effect of percussion in patients location. Percussion and vibration should be applied with chronic bronchi ti^.^,^^^ Gallon71 noted that brondirectly over the skin to allow the therapist to observe chospasm can be prevented when a forced-expiration anatomic landmarks, skin redness, or petechiae, as well technique or the active cycle of breathing is incorpoas chest tube and line insertion sites, and to detect rated into chest physical therapy. Bronchospasm is rare undiagnosed rib and sternal fractures or the presence of in patients in the ICU who have undergone trauma or subcutaneous emphysema (air in the subcutaneous tissurgery. More often, particularly in patients with quadsue). The presence of, and any increases in, subcutaneriplegia, wheezes are noted as secretions are mobilized ous ernphysema may be associated with a life-threatening from the lung ~ e r i p h e r y . ~Once the secretions are ' pneumothorax. This condition should therefore be removed by coughing or suctioning, breath sounds monitored closely, and the physician or nurse should be improve.7' Patients with reactive airway disease may notified when airway pressures are increasing. The phyrequire inhaled bronchodilators prior to or following sician or nurse should also be notified when subcutanetreat~nent.~%en bronchospasm persists as a result of ous emphysema is increasing, as noted with palpation. Figure 2. Computerized tomography scans showing (A) bilateral lower-lobe atelectasis and right pleural effusion and (B) improvement in bilateral lower-lobe atelectasis. 6 14 . Ciesla Physical Therapy Downloaded from by guest on July 21, 2013 . Volume 76 . Number 6 . June 1996
  8. 8. percussion, appropriate implemented. intervention should be -Y a The optimal frequency and force of chest percussion are not known. Frequencies of 100 to 480 cycles per minute, producing 2 to 4 ft-lb (2.7-5.4 Nsm) and 58 to 65 N of force 011 the chest wall have been reported.58 There is some evidence that both fast and slow percussion increase sputum production in patients with bronchiectasis and alveolar proteinosis. Gallon7l and Hammon (WE Hammon, PT, Chief of Rehabilitative Services, Oklahoma Memorial Hospital, Oklahoma City, Okla; personal communication) report that fast percussion (240 cycles per minute) demonstrated the greatest sputum production, although slow percussion (6-12 cycles per minute) was more effective than no percussion. Hammon reported that when large amounts of proteinaceous material are present in the alveoli, percussion is more effective than vibration (WE Hammon, personal communication). In patients in the ICU, the quantity of sputum produced has not been shown to correlate with improvements in pulmonary function.54 Differences in technique may account for discrepancies in therapy advocated in different parts of the United state^.^^^^^ The use of percussion over rib fractures remains controversial. Extrapleural pathology, pneumothorax, and hemothorax that develop as a result of the initial injury should not be considered a contraindication to percus sion. I11 a retrospective study of 252 patients with rib fractures who received chest physical therapy (including manual percussion), 24 patients developed extrapleural pathology.75Ten of these patients developed extrapleural pathology before chest physical therapy was started, and 14 patients developed extrapleural pathology after chest physical therapy was started. There was no difference in the development of extrapleural hematomas between the patients who received manual percussion and those who did not receive manual percu~sion.~" Followng treatment of more than 500 patients with rib fractures, physical therapists at the R Adams Cowley Shock Trauma Center (Baltimore, Md) have noted that patients who are intubated and who are being mechanically kentilated usually tolerate percussion in conjunction with analgesics and sedation. Greater alterations in intrathoracic pressure occur with coughing than with properly performed percussion." For patients with rib and sternal fractures, controlled mechanical ventilation may even stabilize the fracture site by minimizing negative intrathoracic pressure^.^^ The force and frequency of percussion can be modified to patient tolerance. Percussion is not indicated for the spontaneously breathing patient with rib fractures who is responding to breathing exercises and assistive coughing techniques. $ L h V I S m+ N * a 0 - * m C s. o-e Z & 2 m m o 7-1 N * 0 0 " = 0 m 0 0 " ) - m 0 0 m -k 2 Z'I'E&! 7.E 2 E A -E x z -UPS 0 k+ m r N ~ C " O " 2 I b . I I 8 2 2 C 0 .2 E 121 * 3 L N N C O " b w a 426 2 2 w 9 .C 0 H H -i 2 0 2 5 .* 0 .c 6 ?! P ? ! f g e 0 .= f ,o .g ~2 0 , >* :sr"2 "2 s2 o8 pu Z l .- L L a 7 Physical Therapy . Volume 76 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013 Ciesla . 6 15
  9. 9. Figure 3. Chest radiograph showing improvement in right lower-lobe atelectosis. Vibration. Vibration is a more forceful technique than percussion. At 12 to 20 HZ, vibration is similar to the normal beat frequencies of human ciliaa7"he rib cage is "shaken" during the expiratory phase of respiration. Some clinicians define vigorous vibration as "rib shaking" or "rib springing."I7 Vibration is used with both patients who are spontaneously breathing and patients who are mechanically ventilated. Secretions move into the upper aimaJ's when vibration is performed during b r o n c h o ~ c o p yForceful vibration is not recommended .~~ over rib fractures, which may perforate the pleura and cause a pneumothorax, intrapleural bleeding, or an extrapleural hematoma. Some clinicians use a mild vibration of light, fast oscillations over rib fractures and report no adverse effects. Vibration in patients with thoracic spinal fractures should be mild and performed by clinicians trained in chest physical therapy techniques. S~ontaneously breathing patients who are difficult to arollse (such as those with acute brain injury) may benefit from vibration to erlcourage deep inspiration and stimulate a cough. In my clirlical experience, dysrhythmias are more likely to occur as a result of hemodynamic instability associated with positiorlal change than as a result of the actual manual technique. Percussion and vibration adjacent to a cardiac electrode may produce artifacts. After consultation with nurses and physicians, electrodes can usually be repositioned or, in rare cases, temporarily disconnected. The therapist should then closely monitor the clinical status of the patient and any alterations in blood pressure or heart rate. Mechanical devices. Mechanical percussors and vibra- tors were introduced in the late 1960s to permit patients with cystic fibrosis more independence with therapy. For 6 16 . Ciesla adult patients in the ICU, use of these devices increases cost, does not reduce staffing requirements, and introduces the risk of cross-infection, without documented benefit over manual techniques. Although Radford and colleagues77 advocate mechanical percussion at 25 to 35 Hz, their research using an animal model has not been extended to human subjects. Mechanical devices, used with patients who have chronic pulmonary disease, offer no benefit over forced-expiration techniques combined with postural drainage.7R-H0In patients with pulmonary alveolar proteinosis, manual percussion (180270 cycles per minute) was almost twice as effective as mechanical percussion (36 Hz) in removing proteinaceous material from the a l ~ e o l i . ~ ' Recently, Hammon and McCaffree" studied the effects of manual percussion, saline alone, and a commercially available pneumatic percussor on the removal of alveolar material in three patients with pulmonary alveolar proteinosis. Measurements of optical density were better with manual percussion than with saline alone or the pneumatic per cuss or.^ Although these results cannot be extrapolated directly to non-saline-filled lungs, they suggest that manual percussion is capable of removing secretions from the most distal airnays and alveoli and is more effective than mechanical percussors, vibrators, or saline alone. High-frequency chest compression (HFCC) has recently gained popularity as a means of enhancing mucus clearance in patients with cystic fibrosis.60 The patient wears an inflatable vest that covers any lung lobes affected with pathology. Frequencies are adjusted to airflow and to maximize mucus optimize clearance. Whitman and colleagues," however, found no increase in mucus clearance over traditional techniques in six patients who had been mechanically ventilated for 90 to 1,203 days. Percussion was applied for 2 minutes to five lung regions with postural drainage. No indications for treatment were stated other than that the patients were mechanically ventilated. The practicality of using HFCC with mechanical ventilation in the JCU is questionable when patients are at high risk for crosscontamination and access to the thorax is required for cardiorascular monitoring. Further study is needed to determine whether HFCC and use of a flutter valve facilitate mucus clearance from central and peripheral for patients who are critically ill and immobile. Manuallung /nflation Manual lung inflation, which involves disconnecting the patient from the mechanical ventilator and inflating the lungs with a large tidal volume via an MRB, is a common practice in Great Britain, Canada, and A u ~ t r a l i aAfter .~~ the lungs are hyperinflated, the bag is quickly released, producing a high expiratory flow. ~l~~ rates range from 123 to 340 L/rnin, depending on the type of bag used Physical Therapy . Volume 7 6 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013
  10. 10. and the amount of pressure g e n e r a t e d . H V h i s technique, often referred to as the "bag-squeezing method," was introduced in the 1960s to prevent pulmonary segmental collapse, reexpand collapsed alveoli, minimize the risk of hypoxemia, and stimulate a cough in the patient who is i n t ~ b a t e d Vibration is sometimes .~~~~ performed during the expiratory phase to enhance mobilization of secretions from the central airways.5H The additional tidal volume delivered, however, most likely reaches the most compliant lung zones and therefore expands normal rather than collapsed alveoli. Because the patient is removed from the ventilator, lung volumes., PEEP, flow rates, and FIO, are not controlled. Novak and colleaguesHH studied 16 patients with hypoxemic relspiratory failure in a surgical ICU and were unable to demonstrate any improvement (<5 minutes) in gas exchange or pulmonary compliance with hyperinflations of 40 cm H,O of pressure for 15 to 30 seconds. Flow rates were not documented. Although Jones and colleaguesw found an increase in lung compliance for up to 2 hours in patients without pulmonary disease with bagging and percussion, the same results have been demonstrated with postural drainage, percussion, and vibration in patients with pulmonary p a t h o l ~ g y . ~ Hyperinflation may be hazardous in patients with severe ARDS, because high airway pressures and overdistension of normal alveoli may damage normal lung parenchyma and increase the quantity of lung tissue contributing to the respiratory distress syndrome.'") The effect of hyperinflation on cerebral perfusion pressure in patients with brain injury who are not medically paralyzed is unknown. Garrard and BullockY1 used ICP monitoring to study 20 patients with brain injuries. Prolonged manual hyperinflation with a 2-L rebreathing bag caused a 5-mm Hg increase in ICP in patients who were medically paralyzed and in patients who were not paralyzed. Because cerebral perfusion pressures were not reported, the clinical significance is unknown. Hyperinflation, with a plateau pressure of 80 cm H,O of pressure for 2 to 3 seconds, of 13 patients with severe brain injuries who were paralyzed and well-sedated did not decrease cerebral perfusion p r e s ~ u r e . ~ ~ o r patients who are mechar~ically ventilated, lung hyperinflation with vibration is associated with large fluctuations in cardiothoracic pressure, and the physiologic benefit is therefore questi~nable.~? Coughing Coughing removes secretions from the trachea, mainstem bronchi, and up to the fourth generation of segmental bronchi." Many patients spontaneously breathing in the ICU are unable to cough effectively because of respiratory muscle weakness, pain, o r a decreased level of consciousness. Therapists working in the ICIJ, therefore, should be familiar with cough stim- ulating and assistance techniques. Compressing the trachea just above the sternal notch or huffing (after a maximal inspiration, the patient exhales several times quickly) is indicated when the patient has sufficient neuromuscular function of the respiratory and abdominal muscles. While huffing, the glottis remains open and intrathoracic pressure is lower than with c ~ u g h i n g . ~ ~ When incisional pain is the limiting factor, support of thoracic and abdominal incisions and huffing are indicated. Upright positioning also improves cough pressures." Coughing is also enhanced by early tracheostomy removal, placing an airtight dressing over the tracheostomy stoma, and supporting the stoma site during expiration. Loss of innervation of the intercostal and abdominal muscles decreases airflow in individuals with quadriplegia.g"upport and compression of the upper abdomen during expiration facilitates an effective, productive cough. Abdominal support and pressure during exhalation are necessary with injuries or diseases that result in abdominal muscle weakness that prohibits effective coughing. Tracheal Suctioning Tracheal suctioning is an integral component of chest physical therapy for the patient who is intubated. Deep suctioning is necessary for patients who cannot mobilize secretions to the proximal portion of the tracheal tube by coughing o r huffing. Withholding suctioning may ~ result in airway occlusion and h y p ~ x e m i a . "Because upper-airway secretions are most prevalent before and after a change in patient position and during or following chest physical therapy, the suctioning procedure should be timed with these interventions, particularly in patients who have difficulty tolerating the procedure. Suctioning is a sterile procedure. Occupational Safety and Health Administration guidelinesYH for exposure to blood and body fluids, therefore, must be followed. Eye protection, a mask for protection from bloody o r mucus secretions, and sterile gloves should be worn. As part of the initial assessment, the therapist should evaluate the patient's need for and response to suctioning. Airway suctioning frequently improves breath sounds and may lower airway pressures. When no segmental or lobar pathology is present, suctioning may be adequate and postural drainage with manual techniques may not be indicated. Patients who are intubated and who have a poor cough usually require tracheal suctioning. As with all physical therapy in the ICU, the patient's vital signs should be assessed before, during, and after the procedure. Table 3 lists the most frequently cited complications associated with tracheal suctioning and the recommended interventions to minimize side effects. Physical Therapy . Volume 7 6 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013 Ciesla . 6 1 7
  11. 11. Table 3. Table 4. Complications of Endotracheal Suctioning Recommended Features of Suction Catheters I Complication II Hypoxemia, death Recommended Intervention Adequate oxygenation prior to and following the procedure Limit suctioning to 15-20 so Bacterial contamination Sterile technique, changing the suction catheter every 2-4 passes Mechanical trauma I Polyvinyl chloride catheters with multiple side holes and an end holeb; minimize the number of times the catheter is inserted into the airway; use continuous suctionC Flow rate of 16 L/mind Negative pressure < 160 mm Hg Atelectasis Lung inflation prior to and following the procedure Minimize use of 100% oxygen " Boutros AR. Arterial blood oxygenation during and after endotracheal .suctioning in the apneic patient. Awsthesiolo~.1970;32:114-118. "Jung RE. Gottlieb LS. Comparison of tracheobronchial suction catheters in humans: visualization by fiberoptic bronchoscopy. Chest. 1976;69:179-181. ' Czarnik RE, Stone KS, Everhart C, et al. Differential effects of continuous versus intermittent suction on tracheal tissue. Heart Lung. 1991;20:144-151. "DePew C L , Noll ML. In-line closedaystem suctioning: a research analysis. Dimmsionc (ff;ri/irrrl Care Nursing 1993;13:73-83. Precautions and contraindications. Suctioning through an artificial airway of a patient with adequate oxygenation and stable vital signs has relatively few contraindications. Prior to suctioning the patient with unstable vital signs or a low Spo, , the benefit of suctioning versus the risk of causing additional arrhythmias or desaturation should be weighed in consultation with medical and nursing staff. When coughing results from mechanical stimulation of the trachea caused by heavy ventilator tubing or a malpositioned tracheal tube, suctioning is not indicated. Appropriate treatment is to remove the stimulus triggering the coughing. For patients who have retained secretions, are unable to cough effectively, and have difficulty tolerating suctioning, suctioning should be timed with chest physical therapy to minimize the risk of hypoxemia. Nasotracheal suctioning (suctioning through the nose into the trachea without an artificial airway in place) is contraindicated in the presence of stridor because of the increased risk of mechanical trauma to an edematous airway." Because the catheter may enter the brain, nasotracheal suctioning with basilar skull fracture, facial fractures, and known or suspected cerebrospinal fluid leaks is also contraindicated." Nasotracheal suctioning may result in apnea, laryngospasm, bronchospasm, and severe cardiac arrythmia~.~7 Nasotracheal suctioning is recommended only when vigorous chest physical therapy, including prolonged postural drainage, cough stim6 18 . Ciesla Usually 12-14 French for adults with a 7- to 9-mm endotracheal tubeo; reduces airwa occlusion and suction-inducediypoxemia Material I Size less than one half the diameter of the airway PolPinylchlorideb Tip design Straight-for routine use Coude-when it is necessary to intubate the leh main-stem bronch~s~,~ Side holes Two or more to minimize tracheal mucosal damage and optimize secretion removale " DePew CL, Noll ML. In-line closed-system suctioning: a research analysis. Dimensions of Critical Care Nuwing. 1993;13:73-83. "ubota Y, Magaribuchi T, Ohara M, et al. Evaluation of selective bronchial suctioning in the adult. CKL Care Med. 1980;8:748-749. "Panacek E . Albertson TE, Rutherford WF, et al. Selective bronchial suctioning in the adult using a curved-tip catheter with a guide mark. Cnt Care Med. 1989;8:748-749. "Hart TP, Mahutte CK. Evaluation of a closed-system, directional-tip suction catheter. Respir Care. 1992;37:1260-1265. 'Jung RE, Gottlieb LS. Comparison of tracheobronchial suction catheters in humans: visualization by fiberoptic bronchoscopy. Chest. 1976;69:179-181. ulation techniques, and suctioning of the oropharynx, is ineffective and the medical team does not plan to intubate the patient. Systems. Suctioning can be performed using either an open or closed system. When using an open system, the patient is disconnected from the mechanical ventilator and suctioned using a conventional catheter. The patient remains on the mechanical ventilator for closedsystem suctioning. Closed-system suctioning is accomplished by using either a "port adapter" or the more The recently introduced in-line s u c t i ~ n i n g . ~ ~ ~ ~ ~ ~ recommended features of suction catheters are listed in Table 4. Prior to suctioning a patient who is mechanically ventilated, the therapist should be aware of the washout time (the time necessary for the gas volume in the ventilator circuit to be replaced with gases at the higher FIO,) of the ventilator in use.'Ol With current technology, the washout time may be as little as three to five breaths for ventilators such as the SERVO 900C.'02 Interventions fbr minimizing hypoxemia. The harmful effects of tracheal suctioning include hypoxia, cardiac arrhythmias, and death." Accepted methods for minimizing suction-induced oxygen desaturation include use of a port adapter, lung hyperinflation, preoxygenation, and in-line suctioning. Placing a valve or port adapter over the end of the endotracheal or tracheal tube allows ventilation during the procedure, maintains PEEP, and preserves functional residual capacity. The result is ~W improved oxygenation during s u c t i ~ n i n g . ~ ~ ~ ~ the s i n g Physical Therapy . Volume 76 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013
  12. 12. adapter may minimize the need for preoxygenation, therefore eliminating the potential hazards of exposure to 100% oxygen."J4A port adapter is recommended for patients who are mechanically ventilated patients and require a PEEP of >10 cm H 2 0 and for patients who are at high risk for suction-induced arrhythmias and hypo~ernia.~~*~')" Proponents of in-line suctioning report less oxygen desaturation than with an open system; however, the same results have been achieved by using a port adaptClinical impressions of in-line suctioning er.9!',100,104.106 that need to be substantiated with further research include the following: (1) The catheter is more difficult to maneuver, (2) the additional weight of the catheter may increase tracheal damage, (3) higher inspiratory flow rates may be required, and (4) airway pressure may drop as a result with suctioning and intermittent mandatory ventilation (IMV).100.104,106 to baseline within 10 to 15 seconds and when the resting Pao, is below 85 mm Hg. Saline installation. Saline instillation is commonly used before and during tracheal suctioning to "loosen" secretions.ll"aline instilled through a tracheal or endotracheal tube is not likely to reach the peripheral airways, where secretions are most prevalent."s To be effective, the saline must pass through several generations of segmental bronchi and reach the terminal bronchioles and alveoli. Patients should, however, receive adequate systemic hydration and airway humidification rather ~~,ll~ than saline i n ~ t i l l a t i o n . ~ Patients with copious purulent secretions (eg, bronchiectasis) may require saline installation to remove viscid secretions from the upper airways and tracheal tube. Breathing Exercises Once extubated, alert, and cooperative, the patient in the ICU may benefit from breathing exercises to increase tidal volume, improve thoracic-cage mobility, Preoxygenation is the most commonly used method for increase inspiratory capacity, enhance cough efficacy, mechanical preventing oxygen d e ~ a t u r a t i o n . ~ ~ ~ . ~ ~ Y h e ventilator or an MRB is used to inflate the lungs and and assist in removal of ~ecretions.5~ Breathing exercises increase the inspired oxygen concentration prior to are indicated in the ICU setting for patients with neurosuctioni~ng. patients who are mechanically ventilated, For muscular disease or injury affecting the respiratory musthe ventilator is preferred over the MRB. Minute venticles. Breathing exercises also are used when thoracic lation, PEEP, and FIO, are all controlled, and there are excursion is decreased as a result of retained secretions no ~ari~ations lung volume, flow rates, and pressure in or pain or when a patient is immobile following surgery. ~~~ based on the clinician's bagging t e ~ h n i q u e . lWhen ~ l ~ Breathing exercises are not indicated during mechanical using tlhe ventilator, the second clinician who may be ventilation but may be used during weaning from mechanical ventilation. required when using an MRB is not needed. When using an MRB, the FIO, varies from 33% to loo%, depending on flow rate, minute ventilation, and whether the bag There are several types of breathing exercises. Diaphragmatic breathing and lateral costal and segmental costal has a r e ~ e r v o i r . l l l . ~ ~ ~ expansion exercises are used most often postoperativeThe miajority of studies evaluating tracheal suctioning ly?l Use of a flutter valve, the forced-expiration techhave compared the effects in patients who had cardiac nique-more recently referred to as the active cycle of surgery.10i.10"111~113 Although hyperoxygenation is combreathing (huffing at various lung volumes interspersed mon practice, it may not be necessary for all patients. with diaphragmatic breathing)-and autogenic drainBased on my clinical experience, I believe that suctionage (using a sequence of breathing maneuvers at various induced hypoxemia may not be as significant in patients lung volumes to optimize airflow within multiple genersuch as8 young patients with traumatic injuries but withations of bronchi) are beneficial in patients with cystic out cardiac disease. A suctioning protocol that encourfibrosis, although the efficacy of these procedures after ages clinical judgment is recommended.l14 When surgery has not been determined.5"11i Inspiratory muspatients are hyperoxygenated prior to or during chest cle training and resistive diaphragmatic breathing exerphysical therapy, the effect of chest physical therapy on cises may be beneficial while weaning the patient with quadriplegia or chronic obstructive pulmonary disease Sao,, Spo,, or partial pressure of arterial oxygen (Pao,) may be masked. from the ~ e n t i l a t o r . ~ ~ - ~ 2 ~ spirometry is comIncentive monly used postoperatively, although it is no more The most important indicators as to whether a patient advantageous or costeffective than instruction in deep breathing and coughing.I2l Following coronary artery will desaturate with suctioning are the resting Spo, and the resting Pao,. Depending on the patient being sucbypass or gall-bladder surgely, breathing exercises offer no advantage over early patient m0bilization.~*-21 tioned, hyperoxygenation is recommended when the Spo, is less than 90% (95% for high-risk patients). Hyperoxygenation also is recommended when the Spo, drops below 85% during suctioning and does not return Physical Therapy. Volume 76 . Number 6 .June 1996 Downloaded from by guest on July 21, 2013 Ciesla . 6 19
  13. 13. Table 5. Patient Example 2: Improved Oxygenation and Chest Radiograph 1 Hour Following Chest Physical Therapya - - Day/Time - - - - - - - Positioning/Chest Physical Therapy - - Chest Radiograph Results Sao, - - Pao, /FIo, Ratio - - - Admission Positioned supine on turning frame Clear Days 1-2 Positioned prone four times and suctioned for copious secretions Clear Day 3 Positioned prone 7 % hours, supine 9'12 hours, suctioned for copious secretions prior to chest radiograph 5:20 PM, LLL, atelectasis Day 4, 12: 15 PM I - Turned into the right sidelying head-down position for segmental postural drainage of the posterior and loterol segments of the LLL; percussion and vibration over appropriate segments while in the drainage position; copious viscid blood-tinged secretions suctioned; following a 45-minute treatment, auscultation revealed improved air entry over the LLL and lingula with expiratory wheezes Leh lung collapse (see Fig. 4) Day 4, 2:00 PM Repeat chest radiograph Leh lung reexpanded (see Fig. 5) 99% "Sao,=oxvgr~~ a t u ~ a r i o n rnc;~curedby pulsr oxinretry; Pat,,=partial pressure of oxygcrl, arterial; F~o,=fractiotr 01' inspirrcl oxygen concentration; 420/100 420 I LL.L=leftlowel- Iohc. ical therapy can be performed regardless of tracheal Patient Mobilization Mobilizirig the patient in the ICU is important, but the tube size, as long as the appropriate-size suctio~l catheter patient's medical condition usually prohibits indepenis used, and does not require physician participation. dent ambulation and vigorous activity. The severity of Chest physical therapy is directed to the area of peripheral lung pathology; during bronchoscopy, secretion injury or disease and life-sustaining paraphernalia also of removal is limited to the level of the segmental bronusually lirnit n~obilization patients who are mechanically ventilated to dependent o r stand-pivot transfers and chus. Cardiac arrhythmias are reported with both proactive- and passive-range-of-motion exercises. Upright cedures, although fatal dysrhythrnias were noted only with bron~hoscopy.'"~~27 major fall in Pao, associThe positioning of patients is encouraged to improve coughated with bronchoscopy has riot been seen with chest ing and lung volumes, including functional residual physical therapy. l f l , " H capacity, and lung compliance. Patients who are difficult to wean fi-om the ventilator frequently benefit from transfer training and ambulation with portable ventilaSeveral case studie~'"~-':'l have demonstrated a favorable tor. Rehabilitative techniques are used while monitoring response to chest physical therapy for lobar collapse vital signs to note any alterations from baseline. The when bronchoscopy was either too high-risk or unsucdetails of n~obilizingthe patient in the ICU are beyond cessful. Raghu and Piersoliw reported successful the scope of this article but are described el~ewhere.~~',]2' removal, with chest physical therapy, of a tooth aspirated during intubation. Due to the patient's life-threatening Chest Physical Therapy Versus Therapeutic myocardial infarction, bronchoscopy was considered too Bronchoscopy invasive. There are two reports of the effectiveness of Several inve~tigators~'.""-'2(~ have compared the efficacy selective lung insufflation through a balloon-tipped cathof chest physical therapy versus therapeutic bronchoseter in expansion of collapsed lobes in patients with copy for treatment of' atelectasis and foreign-body aspiatelectasis who were unresponsive to chest physical therration. Both treatments are indicated for aspiration of apy, but the treatment regimen was not Haenel and c o l l e a g ~ e s ' : ~ ~ advocate use of a kinetic blood, gastric contents, and foreign bodies. Lung con(rotating) bed that in itself prohibits postural drainage tusion, lung abscess, smoke inhalation, and pneumonia of the most frequently affected lower-lobe segments also are indications for chest physical therapy or bronchoscopy. In the surgical ICU, chest physical therapy is (posterior, superior, and lateral) and of the posterior recommended because it is less costly and less invasive segments of both upper lobes. for treatment of an atelectasis or infiltrate for 24 to 48 hours before therapeutic bronchoscopy o r starting antibiotics (M Joshi, personal communication). Chest phys620 . Ciesla Physical Therapy . Volume 7 6 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013
  14. 14. Figure 4. Complete collapse of the left lung prior to chest physical therapy Patient Example Figure 5. Reexpansion of the left lung 1 hour following one chest physical therapy treatment. #2 The following example demonstrates the development of a left :lung collapse (Fig. 4) despite prone positioning and tracheal suctioning. Chest physical therapy that includedl postural drainage with percussion and vibration was necessary t o reexpand the patient's left lung. Chest pllysical therapy eliminated the need for therapeutic bronchoscopy, a more costly procedure with risks of hypoxemia and life-threatening cardiac arrhythmias. A 22-year-old white man was admitted to the trauma center fbllowing a diving injury with a C-4 teardrop compression ti-acturr. Neut-ologicalexamination following American Spinal Injury Association Standards revealed incomplete sensory deficit (impaired sensation at C-6, C-7, T-3 to T-5, L-3, and a111sacral segments). Motor level was C-4. The patient required mechanical ventilation for respiratory support. 'Table 5 describes the sequence of therapeutic positioning, airway siictioning, and the need for chest physical therapy due to an increasing left-lung atelectasis. Following chest physical therapy, the patient's Sao, increased from 87% to 99% and his Pao,/Flo, ratio increased from 53 to 420. The patient's FIO, was lowered from 100% to 40% within 24 hours of treatment. I n addition, the left-lung atelectasis resolved immediately following 45 minutes of chest physical therapy, as noted in Figure 5. Prone positioning and suctioni~~g not prevent did the secretion retention that resulted in collapse of the patient's left lung. Special Conditions Table 6 summarizes the medical conditions commorilv found in patients in the ICU, indications for chest physical therapy, and treatment guidelines. Summary This article provides a discussion of the literature relating to chest physical therapy, indications for treatment, and the rationale for its use in the ICU. Comparisons are made with therapeutic bronchoscopy and therapeutic positioning. The complications of tracheal suctioning are discussed as well as methods for minimizing hypoxemia, and the necessary features of suction catheters are described. Although patient mobilization and deepbreathing exercises with coughing can often replace postural drainage, percussion, and vibration, many patients in the ICU cannot be mobilized sufficiently to eliminate the sequelae of secretion retention due to the severity of injury or illness and the paraphernalia necessary to sustain life. I believe that when a clear indication for chest physical therapy is present, it can be performed safely and effectively by clinicians who have received training in the ICU. I contend that the recommended treatment of lobar and segmental atelectasis is postural drainage with percussion and vibration in conju~lctionwith airway suctioning for patients who are intubated. Further research is needed to assess the efficacy of manual hyperinflation i11 patients who are mechanically ventilated and the efficacy of therapeutic positioning without postural drainage and manual techniques. Physical Therapy . Volume 76 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013 Ciesla . 62 1
  15. 15. Table 6. Chest Physical Therapy With Special Conditions" Condition Treatment Increased intracranial pressure Maintain cerebral perfusion pressure >50 mm Hg and ICP <25 mm Hg in the headdown positionb; routine headdown positioning is limited to 15 min; headdown positioning should be restricted when it exacerbates an increase in a cerebrospinal fluid leak Coagulopathy Determine cause; when copious bleeding occurs in the tracheobronchial tree, risk/benefit must be weighed; treatment is coordinated with other nursing interventions; suction carefully Bronchopleural fistula Chest physical therapy is continued to decrease incidence of infection and enhance healing; avoid prolonged periods of time with affected lung uppermost with positivepressure ventilation and PEEP, which may increase leakage through the fistula Spinal fracture Vest may be opened after patient positioning; after stabilization, use headdown positioning as indicated by the patient's clinical condition Rib fractures Avoid vigorous vibration Pulmonary embolus Avoid line occlusion; bed may need to be elevated to maximize flow Continuous venovenous hemodialysis Avoid line occlusion Peritoneal dialysis Treatment is given while the dialysate is draining from the abdomen to minimize intraabdominal pressure Extracorporeal lung assistance Avoid line occlusion; ensure that flow i s within preset guidelines Adult respiratory distress syndrome [ARDS) Prone positioning may optimize oxygenation; may require evaluative treatment to determine whether the patient is productive of secretions or whether lung volumes and Spa, improve with manual techniques and postural drainage Extrapleural hematoma Therapy may be restricted when the hematoma is expanding or the patient has a coagulopathy Pnemothorax, hemothorax Treatment is initiated after chest tube placement has been confirmed radiologically Lung abscess, lung contusion " Therapy is withheld until medical intervention Continuous arterial-venous hemodialysis Follow treatment of involved lung lobe or segment with treatment of dependent area to minimize tronsbronchial aspiration ICP=intr-acraoial pressure; PEEP=positivr el~dexpiratorypressure; Spo,=oxygen saturation measured by pulse oximetry. " Ciesla N . Chest physical therapy for the adult intensive care unit trauma patient. Physiral 7'hmapy Practice. 1994;3:92-108. Acknowledgments I acknowledge Bill Hammon, PT, Alex Sciaky, PT, CCS, and Susan Ludwick-Mihans, PT, for their critical review of the manuscript as it pertains to patients in the ICU. I thank Marianne Mars, PT, Jill Kuramoto, PT, and Faith Kousalis, PT, for their critique of the manuscript and for providing data for the case studies. References 1 Shapiro BA, Peruzzi WT. Changing practices in ventilator management: a review of the literature and suggested clinical correlations. Su~gay.1995;117:121-133. 2 Hardy KA. A review of airway clearance: new techniques, indications, and recommendations. Retpiratoly Care. 1994;39:440-452. 3 Pryor .]A, Webber B. Physiotherapy for cystic fibrosis: which trchnique? Physiothmapy. 1992;78:105-I 08. 4 Mortenson J, Falk M, Groth S, et al. The effects of postural drainage and positive expiratory pressure physiotherapy on tracheohronchial clearance in cystic fibrosis. Chest. 1991;100:1350-1357. 5 Palmer KNV, Sellick BA. The prevention of post operative pulmonary atelectasis. Lancet. 1953;1:164-1 68. 622 . Ciesla 6 Thoren L. Postoperative pulmonary complications: obselvations of their prevention by means of physiotherapy. Acta Chir Srand. 1954;107: 193-204. 7 Mackenzie CF, Shin B, McAslan TC. Chest physiotherapy: the effect on arterial oxygenation. Anesth Analg. 1978;57:28-30. 8 Mackenzie CF, Shin B, Hadi F, lmle PC. Changes in total lung/ thorax compliance following chest physiotherapy. Anesth Analg. 1980; 59:207-210. 9 Ciesla ND, Iilemic N, lmle PC. Chest physical therapy for the patient with multiple trauma. Phys Thm. 1981;61:202-205. 10 Walsh J, Vanderwarf D, Hoscheit C, et al. Unsuspected hernodynamic alterations during endotracheal suctioning. Chest. 1989;95:162165. 11 Klein P, Kemper M, Weissman C, et al. Attenuation of the hemodynamic responses to chest physical therapy. Chest. 1988;93:38-42. 12 Graham M'G, Bradley DA. Efficacy of chest physiotherapy and intermittent positive pressure breathing in the resolution of pneumonia. N Engl J Med. 1978;299:624-627. 13Britton S, Bejstedt M, Vedin L. Chest physiotherapy in primary pneumonia. BMJ. 1985;290: 1703-1704. 14 Severinghaus JW, Kelleher JF. Recent developments in p ~ ~ l oximse etry. Anstthesiology. 1992;76:1019. Physical Therapy . Volume 76 . Number 6 . June 1996 Downloaded from by guest on July 21, 2013
  16. 16. 15 Sutton I'P. Chest physiotherapy: time for reappraisal. BrJDis Chest. 1988;82:127-137. 38 Newhouse MT. Factors affecting sputum clearance. Thurax. 1973; 28:267. Abstract. 16 Pavia D. The role of chest physiotherapy in mucus hypersecretion. Lung. 1990;168(suppI):614-621. 39 Siebens AA, Kirby NA, Poulos DA. Cough following transection of the spinal cord at C-6. Arch Phys Med Rehabil. 1964;45:1-8. 17 Sutton I'P, Lopez-Vidriero MT, Pavia D, et al. Assessment of percussion, vibratory shaking and breathing exercises in chest physiotherapy. EurJRespir Dis. 1985;66:147-152. 40 Imle PC, Klemic N. Changes with immobility and methods of mobilization. In: Mackenzie CF, ed. Chest Physiotherapy in the Intensive Care Unit. 2nd ed. Baltimore, Md: Williams & Wilkins; 1989:188-214. 18Jenkins S, Soutar SA, Loukota JM, et al. Physiotherapy after coronary artery surgery: Are breathing exercises necessary? Thorax. 1989; 44:634-639. 41 Clauss RH,Scalabrini BY, Ray JF, et al. Effects of changing body position upon improved ventilation-perfusion relationships. Circulation. 1968;37(suppl 2):214-217. 19 Dull JI, Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiac surgery? Phys Ther. 1983;63:655-659. 42 Douglas WW, Rehder K, Beynen EM, et al, Improved oxygenation in patients with acute respiratory failure: the prone position. Am Rm Respir Dis. 1977;115:559-566. 20 Hallbook T, Lindbald B, Lindroth B, et al. Prophylaxis against pulmonary complications in patients undergoing gallbladder surgery: a comparison between early mobilization, physiotherapy with and k without bronchodilation. ~ n Chir Gynaecol. i984;73:55-58. 43 Chulay M, Brown J, Summer W. Effect of post-operative immobilization after coronary artery bypass. Crit Care Med. 1982;10:176-179. 21 Stiller R, Montarello J, Wallace M, et al. Efficacy of breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery. Chest. 1994;105:741-747. 22 Dean E, Ross J. Oxygen transport: the basis for contemporary cardiopulmonary physical therapy and its optimization with body positioning and mobilization. Physical Therapr Practice. 1992;1:34-44. 23 Dean E, Ross J. Discordance between cardiopulmonary physiology and physical therapy. Chest. 1992;101:1694-1698. 24 Dean E. Oxygen transport: a physiologically based conceptual framework; for the practice of cardiopulmonary physiotherapy. Physie therapy. 1994;80:347-355. 44 Remolina C, Khan AU, Santiago TV, et al. Positional hypoxemia in unilateral lung disease. N Engl J Med. 1981;304:523-525. 45 Langer M, Mascheroni D, Marcolin R, et al. The prone position in ARDS patients. Chest. 1988;94:103-107. 46 Arborelius M, Granqvist U, Lija B, et al. Regional lung function and central hemodynamics in the right lateral body position during hypoxia and hyperoxia. Respiration. 1974;31:193-200. 47 Pappert D, Rossaint R, Klaus S, et al. Influence of positioning on ventilation-perfusion relationships in severe adult respiratory distress syndrome. Chest. 1994;106:1511-1516. 48 Zack MB, Pontoppidan H, Kazemi H. The effect of lateral positions on gas exchange in pulmonary disease. Am Reu Respir Dis. 1974;llO: 49-55. 25 MariniJ, Pierson DJ, Dudson L. Acute lobar atelectasis: a prospective comparison of fiberoptic bronchoscopy and respiratory therapy. Am Rm Respir Dis. 1979;119:971-978. 49 Piehl MA, Brown MS. Use of extreme position changes in acute respiratory failure. Crit Care Med. 1976;4:13-15. 26 Light KB. Pneumonia. In: Hall JB, Schmidt GA, Wood LD, eds. Pn'ncipb rf Critical Care. New York, NY McGraw-Hill; 1992:1249. 50 Wong JW, Keens TG, Wannamaker EM, et al. 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Am Reu Respir Dis SuppL 1985;141:s39-s42. 35 Mossberg B, Cramer P. Mucociliary transport and cough as tracheobronchial clearance mechanisms in pathological conditions. Eur J Respir Dis Suppl. 1980;61:47-55. 36 King h4. Rheological requirements for optimal clearance of secretions: cili.ary transport versus cough. Eur J Respir Dis. 1980;61(suppl): 39-42. 51 Ciesla N. Postural drainage, positioning, breathing exercises. In: Mackenzie CF, ed. Chest Physiotherapy in the Intensive Care Unit. Baltimore, Md: Williams & Wilkins; 1989:97-99. 52 Bateman J, Newman S, Daunt K, et al. Is cough as effective as chest physiotherapy in the removal of excessive tracheobronchial secretion? Thurax. 1981;36:683-687. 53 Sutton PP, Parker RA, Webber BA. Assessment of the forced expiration technique, postural drainage and directed coughing in chest physiotherapy. Eur J Respir Dis. 1983;64:62-68. 54 Mackenzie CF. Physiological changes following chest physiotherapy. Mackenzie CF, ed. 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  19. 19. Chest Physical Therapy for Patients in the Intensive Care Unit Nancy D Ciesla PHYS THER. 1996; 76:609-625. This article has been cited by 1 HighWire-hosted articles: Cited by Subscription Information Permissions and Reprints Information for Authors Downloaded from by guest on July 21, 2013