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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: http://ptjournal.apta.org/content/76/6/609
Key Words: Airway suctioning, Breathing exercises, Bronchial hygiene, Cardiopulmonary, Chest physical
therapy, Cough, Intensive care units, Postural drainage, Thorax.
Nancy D Ciesla
ND Ciesla, PT, is Clinical Instructor, Department of Physical Therapy, University of Maryland School of Medicine,
Baltimore, MD 21201-1595 (USA) (nciesla@erols.com).She also was Director of Physical Therapy, R Adams Cowley
Shock Trauma Center, University of Maryland Medical Center, at the time this article was written.
Clinical examination and data gained from ventilation- Evidence of retained secretions (blood or sputum) not removed by
suctioning, coughing, and turning
perfusion scans, computerized tomography, magnetic
Radiological evidence of acute atelectasis or infiltrate
resonance imaging, and portable radiographs are used
to determine an indication for chest physical therapy. Decrease in Pao2 or Spo2 as a result of secretion retention
Monitoring in the ICU and pulse oximetry allow contin- Prophylactic Use
uous assessment of patients' vital signs and oxygen Acute neurolo ical diseases affectin the innervation of the
saturation before, during, and after treatrnent.14 Unfor- intercostal, !iaphragmmatic, or aidominal muscles
Smoke inhalation
tunately, because studies evaluating treatment tech- Acute moderate to severe brain iniury
niques are limited, clinicians have frequently extrapo- - - -
lated the outcomes from studies of patients with chronic "Pao,=partial pressure of oxygen, arterial: Spo,=oxygen
.. ~aturationmeasured
by pulse oximet~y.Adapted from Ciesla ND. Chest physical therapy for the
disease or patients who are mobile to patients in the ICU adult intensive care unit trauma patient. Pt~y\i(alThmnIrj I%/~r.ticr.1994;3:99.
who are immobilized and mechanically ventilated.I5-l7
For example, Sutton and colleague^'^ studied eight
patients with copious sputum production (five patients distinct organism, and a new pulmonary infiltrate on
with br13nchiectasis,two patients with chronic bronchitis, chest radi~graph.~"-' Patients in the ICU meeting these
and one patient with cystic fibrosis) who were not in the criteria may respond to chest physical therapy without
ICU and concluded that tracheobronchial clearance is antimicrobial therapy.'"oshi and colleagues2%tudied
unaffected by adding vibration shaking or percussion to 39 patients with trauma (32 patients were intubated)
postural drainage with the forced-expiration technique. who met the criteria for diagnosis of pneumonia, at
Early ambulation following gallbladder and cardiac sur- which time chest physical therapy was initiated. Within 3
gery has almost eliminated the need for chest physical days of chest physical therapy, 31 of the 39 patients
therapy in these patients unless comorbidities are showed complete or partial clearing of pulmonary infil-
p r e ~ e n t . ' ~Whether
-~~ the positioning therapy recom- trates and did not require antimicrobial therapy. Over-
mended by Dean and colleagues'2-a contributes to the use of antibiotics can result in toxicity, emergence of
resolution of acute atelectasis is unknown. The resolu- resistant strains of bacteria, superinfections, and
tion of acute atelectasis (37%-83%) demonstrated with increased hospital cost^.^^^ For some patients in the
postural drainage and manual techniques, however, has ICU, the response to chest physical therapy can differ-
been shown to be equally as effective as therapeutic entiate the diagnosis of atelectasis from pneumonia and
bronct~oscopyfor the treatment of acute lobar atelectasis can be used to determine which patients require anti-
and has been studied in the ICU.738.'" The use of chest microbial therapy.26
physical therapy without regard to the patient popula-
tion or condition for which it is prescribed, and with n o Although activities in the ICU, including chest physical
standard definition of treatment components, has led, in therapy, have been reported to increase metabolic rate
my opinion, to numerous negative reports on the up to 35%, the use of short-acting narcotics usually
efficacy. diminishes any associated hemodynamic
The importance of an increase in oxygen consumption
Efficacy of Chest Physical Therapy in the and carbon dioxide production, which return to base-
Intensive Care Unit line within 15 minutes, is questionable. Therefore, most
The efficacy of chest physical therapy can be determined patients in the ICU who tolerate turning will tolerate the
by a reduction in the incidence of pulmonary infection positioning necessary for chest physical therapy.
or an improvement in pulmonary function. The mortal-
ity rate from nosocon~ialpneumonia remains high and Indications for Treatment
ranges from 30% to 60%.26327Other benefits of chest Many authors have described the inappropriate use of
physical therapy may include decreased duration of chest physical therapy. For example, the American Asso-
mechanical ventilation and prevention of tracheosto- ciation of Respiratory Care's clinical practice guideline
mies--benefits that reduce cost and shorten hospital for postural drainagegQonsiders recent spinal surgery,
stays. rib fractures, and bronchopleural fistulas to be contra-
indications for postural drainage. This approach may be
The diagnosis of pneumonia in the critical care setting is a result of prescribing therapy without a clear-cut indi-
difficult. The clinical criteria used to diagnose pneumo- cation for treatment (Tab. 1) or of the health care
nia include the presence of fever, purulent sputum provider not having the training to position the patient
expec~:oration,leukocytosis, a Gram stain showing many with neurologic and orthopedic injuries o r the skills to
polymorphonuclear cells and a single morphologically assess the patient's breath sounds, vital signs, and ability
to cough. I believe that the patient's level of mobility is
Figure 2.
Computerized tomography scans showing (A) bilateral lower-lobe atelectasis and right pleural effusion and (B) improvement in bilateral lower-lobe
atelectasis.
Z l r 2 2 2 8 u
7
I Complication Recommended Intervention I Size less than one half the Usually 12-14 French for adults
diameter of the airway with a 7- to 9-mm endotracheal
II
tubeo; reduces airwa occlusion
Hypoxemia, death Adequate oxygenation prior to and and suction-inducediypoxemia
following the procedure
Limit suctioning to 15-20 so Material PolPinylchlorideb
Bacterial contamination
Mechanical trauma
Sterile technique, changing the
suction catheter every 2-4 passes
Polyvinyl chloride catheters with
I Tip design Straight-for routine use
Coude-when it is necessary to
intubate the leh main-stem
bronch~s~,~
multiple side holes and an end Side holes Two or more to minimize tracheal
holeb; minimize the number of mucosal damage and optimize
times the catheter is inserted into secretion removale
the airway; use continuous
" DePew CL, Noll ML. In-line closed-system suctioning: a research analysis.
suctionC Dimensions of Critical Care Nuwing. 1993;13:73-83.
Flow rate of 16 L/mind "ubota Y, Magaribuchi T, Ohara M, et al. Evaluation of selective bronchial
Negative pressure < 160 mm Hg suctioning in the adult. CKL Care Med. 1980;8:748-749.
Atelectasis Lung inflation prior to and following "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
the procedure
Med. 1989;8:748-749.
Minimize use of 100% oxygen "Hart TP, Mahutte CK. Evaluation of a closed-system, directional-tip suction
catheter. Respir Care. 1992;37:1260-1265.
" Boutros AR. Arterial blood oxygenation
.- during and after endotracheal
'Jung RE, Gottlieb LS. Comparison of tracheobronchial suction catheters in
suctioning in the apneic patient. Awsthesiolo~.1970;32:114-118.
humans: visualization by fiberoptic bronchoscopy. Chest. 1976;69:179-181.
"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. ulation techniques, and suctioning of the oropharynx, is
Dimmsionc (ff;ri/irrrl Care Nursing 1993;13:73-83. ineffective and the medical team does not plan to
intubate the patient.
Precautions and contraindications. Suctioning through Systems. Suctioning can be performed using either an
an artificial airway of a patient with adequate oxygen- open or closed system. When using an open system, the
ation and stable vital signs has relatively few contraindi- patient is disconnected from the mechanical ventilator
cations. Prior to suctioning the patient with unstable and suctioned using a conventional catheter. The
vital signs or a low Spo, , the benefit of suctioning versus patient remains on the mechanical ventilator for closed-
the risk of causing additional arrhythmias or desatura- system suctioning. Closed-system suctioning is accom-
tion should be weighed in consultation with medical and plished by using either a "port adapter" or the more
nursing staff. When coughing results from mechanical recently introduced in-line s u c t i ~ n i n g . ~ The
~~~~~
stimulation of the trachea caused by heavy ventilator recommended features of suction catheters are listed
tubing or a malpositioned tracheal tube, suctioning is in Table 4.
not indicated. Appropriate treatment is to remove the
stimulus triggering the coughing. For patients who have Prior to suctioning a patient who is mechanically venti-
retained secretions, are unable to cough effectively, and lated, the therapist should be aware of the washout time
have difficulty tolerating suctioning, suctioning should (the time necessary for the gas volume in the ventilator
be timed with chest physical therapy to minimize the risk circuit to be replaced with gases at the higher FIO,) of
of hypoxemia. the ventilator in use.'Ol With current technology, the
washout time may be as little as three to five breaths for
Nasotracheal suctioning (suctioning through the nose ventilators such as the SERVO 900C.'02
into the trachea without an artificial airway in place) is
contraindicated in the presence of stridor because of the Interventions fbr minimizing hypoxemia. The harmful
increased risk of mechanical trauma to an edematous effects of tracheal suctioning include hypoxia, cardiac
airway." Because the catheter may enter the brain, arrhythmias, and death." Accepted methods for mini-
nasotracheal suctioning with basilar skull fracture, facial mizing suction-induced oxygen desaturation include use
fractures, and known or suspected cerebrospinal fluid of a port adapter, lung hyperinflation, preoxygenation,
leaks is also contraindicated." Nasotracheal suctioning and in-line suctioning. Placing a valve or port adapter
may result in apnea, laryngospasm, bronchospasm, and over the end of the endotracheal or tracheal tube allows
severe cardiac arrythmia~.~7 Nasotracheal suctioning is ventilation during the procedure, maintains PEEP, and
recommended only when vigorous chest physical ther- preserves functional residual capacity. The result is
apy, including prolonged postural drainage, cough stim- improved oxygenation during s u c t i ~ n i n g . ~ ~ ~ ~ the
~Wsing
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 5:20 PM, LLL,
copious secretions prior to chest radiograph atelectasis
Day 4, 12: 15 PM Turned into the right sidelying head-down position for segmental Leh lung collapse
postural drainage of the posterior and loterol segments of the LLL; (see Fig. 4)
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
" S a o , = o x v g r ~ ~ a t u ~ a r i ornc;~cured
Iohc.
n
Leh lung reexpanded
(see Fig. 5)
99%
by pulsr oxinretry; Pat,,=partial pressure of oxygcrl, arterial; F~o,=fractiotr 01' inspirrcl oxygen concentration;
420/100
420
LL.L=leftlowel-
I
Patient Mobilization ical therapy can be performed regardless of tracheal
Mobilizirig the patient in the ICU is important, but the tube size, as long as the appropriate-size suctio~lcatheter
patient's medical condition usually prohibits indepen- is used, and does not require physician participation.
dent ambulation and vigorous activity. The severity of Chest physical therapy is directed to the area of periph-
injury or disease and life-sustaining paraphernalia also eral lung pathology; during bronchoscopy, secretion
usually lirnit n~obilizationof patients who are mechani- removal is limited to the level of the segmental bron-
cally ventilated to dependent o r stand-pivot transfers and chus. Cardiac arrhythmias are reported with both pro-
active- and passive-range-of-motion exercises. Upright cedures, although fatal dysrhythrnias were noted only
positioning of patients is encouraged to improve cough- with bron~hoscopy.'"~~27 The major fall in Pao, associ-
ing and lung volumes, including functional residual ated with bronchoscopy has riot been seen with chest
capacity, and lung compliance. Patients who are difficult physical therapy. l f l , " H
to wean fi-om the ventilator frequently benefit from
transfer training and ambulation with portable ventila- Several 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 unsuc-
details 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 cath-
of chest physical therapy versus therapeutic bronchos- eter in expansion of collapsed lobes in patients with
copy for treatment of' atelectasis and foreign-body aspi- atelectasis who were unresponsive to chest physical ther-
ration. Both treatments are indicated for aspiration of apy, but the treatment regimen was not
blood, gastric contents, and foreign bodies. Lung con- Haenel and c o l l e a g ~ e s ' : ~
advocate
~ use of a kinetic
tusion, lung abscess, smoke inhalation, and pneumonia (rotating) bed that in itself prohibits postural drainage
also are indications for chest physical therapy or bron- of the most frequently affected lower-lobe segments
choscopy. 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 anti-
biotics (M Joshi, personal communication). Chest phys-
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 positive-
pressure 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 Therapy is withheld until medical intervention
Continuous arterial-venous hemodialysis 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 intra-
abdominal 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 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.
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