Intensive Care Med (2004) 30:1014–1016
DOI 10.1007/s00134-004-2216-6 EDITORIAL
Andrew C. Argent
Brenda M. Morrow
What does chest physiotherapy
do to sick infants and children?
Accepted: 28 January 2004
Published online: 5 March 2004

Springer-Verlag 2004
A. C. Argent ()) · B. M. Morrow
Division of Paediatric Critical Care and Children’s Heart Disease,
School of Child and Adolescent Health,
University of Cape Town, Cape Town, South Africa
e-mail: aargent@ich.uct.ac.za
A. C. Argent · B. M. Morrow
Department of Paediatric Intensive Care,
Red Cross War Memorial Children’s Hospital,
Cape Town, South Africa
Endotracheal suctioning (ET) and chest physiotherapy
(CP) are part of the accepted care of intubated children in
many paediatric intensive care units in spite of a limited
evidence-base [1, 2], largely because of the risks of
endotracheal tube obstruction. A wide variety of delete-
rious effects of ET on children and infants have been
reported including bacteraemia [3], lobar atelectasis [4,
5], hypoxia [6], decreased cerebral oxygenation [7, 8],
hypertension and raised intracranial pressure [9, 10],
pneumothoraces [11] and death. Some of the side effects
may be minimised by reduction of suction pressure and
limitation of the depth of insertion of the suction catheter
[5], appropriate pre-oxygenation [12, 13], adequate seda-
tion and analgesia [14] and muscle paralysis [9].
Chest physiotherapy has been associated with the
development of severe brain damage in very low birth
weight infants [15] and potentially severe hypoxaemia
in neonates [16]. Following paediatric cardiac surgery,
routine 4-hourly CP was related to the development of
atelectasis and prolonged hospital stay [17], while another
study showed that pre-extubation CP did not decrease the
incidence of post-extubation atelectasis [18].
In this context Main et al. [19, 20] have accurately and
reproducibly studied the effects of ET or CP on paralysed,
sedated, mechanically ventilated children who had been
“deemed on assessment by the physiotherapist to require
respiratory physiotherapy”, in a randomised cross-over
trial. Fifteen minutes after CP there was a statistically
significant drop in base excess (BE), bicarbonate and
oxygen saturation, and a trend to a drop in respiratory
resistance (Rrs). Thirty minutes after CP there was an
increase in physiological deadspace (VDphys). Fifteen
minutes after ET alone there was no change in expired
tidal volume (VTE), compliance (Crs), Rrs blood gas
parameters or physiological deadspace. When CP and ET
were compared, at 15 min BE was higher in the CP group
and, 30 min after intervention, VTE, VDphys, alveolar
deadspace (VDalv) and Crs were higher in the CP group.
There were no significant differences in pCO2, pO2 or pH.
At an individual level, an apparent improvement in
VTE, Crs and Rrs (exceeding the 95% limits of agreement)
was observed in about twice as many subjects following
CP as following ET. This reached statistical significance
in VTE only. Improvements in VTE, Crs and Rrs were
possibly offset by increases in dead space, although this
specific data is not provided in the two papers.
In up to a third of the patients, respiratory function
deteriorated following both physiotherapy and suction
procedures. Even in retrospect the authors were not able
to identify groups of patients who were more or less likely
to respond positively or negatively to therapy. As the
authors suggest, more work is required to identify
adequately the children who may benefit from or dete-
riorate following the procedure.
These results were obtained following CP that took
8.5 minutes on average (range 1–33 min), used tracheal
saline instillation in 98% of cases and consisted typical-
ly of pre-oxygenation, saline instillation, hyperinflation
breaths with chest wall vibrations during expiration,
tracheal suction and several re-inflation breaths. ET con-
sisted of pre-oxygenation, saline instillation, manual
hyperinflation breaths, suction and then manual re-infla-
tion breaths, and took 5.6 min on average (range 1–
20 min). No details are given of the pre-oxygenation
 1015

technique, pressures generated or rate during hyperinfla-
tion or re-inflation breaths. More than 1.5 ml/kg of saline
was instilled in 20% of CP procedures and recommen-
dations were made that suction pressure should not
exceed 18–20 kpA, and the external diameter of suction
catheters should approximate half the internal diameter of
the tracheal tube during suctioning unless secretions were
particularly tenacious.
Chest physiotherapy and ET were “flexibly defined” in
order to approximate clinical reality. Unfortunately this
does undermine the generalizability and reproducibility of
the study, as there appears to be considerable variation in
the way in which these procedures are performed in
different units [18].
The authors suggest that the greater drop in Rrs in the
CP group could be explained by more effective removal
of secretions. The suggestion that the increase in phys-
iological deadspace could be attributed to the opening of
poorly perfused alveoli to ventilation seems plausible.
Both observations raise interesting questions about clin-
ical relevance and show that careful monitoring of re-
sponses over time are required before we will begin to
understand the processes set in motion by CP.
The changes in BE, bicarbonate and oxygen saturation
in the CP group were not clinically significant at 15 min.
However they suggest that metabolic acidosis may have
developed in the CP group during the procedure. Patients
were monitored throughout the procedures, but haemo-
dynamics and other changes may be difficult to assess
when patients are moved.
One would expect different responses to these proce-
dures depending on: the age and size of the patient;
underlying respiratory system and cardiovascular pathol-
ogy; nature of the ventilatory strategy that is employed;
details of sedation and analgesia; nature of percussion
and/or vibration used; pre- and post-oxygenation proce-
dures (duration, FiO2 used); details of the hyperinflation
and re-inflation procedures (pressures, duration, wave-
forms, pressures generated during expiratory vibration);
use of saline installation; details of suctioning (duration,
depth of insertion, size of suction catheters, relationship
of endotracheal tube and suction catheter sizes, suction
pressure) etc. Responses may affect the respiratory system
[7, 8], cardiovascular system, metabolic demand and
central nervous system [9, 11, 13]. Future studies will
have to focus on the details of the procedures and their
effects on organ systems. They must also be aimed at
specific patient groups where clinical significance of
changes may be more easily defined.
Finally, the underlying issue is really: what effect do
these procedures have on the clinical outcomes of in-
dividual patients? Any benefits must be balanced against
the costs of the procedure: costs to the patient of un-
dergoing potentially distressing procedures of significant
duration and with well-documented side effects and costs
of staff spending up to 33 min per patient performing the
procedures.

References
1. Krause MF, Hoehn T (2000) Chest
physiotherapy in mechanically venti-
lated children: a review. Crit Care Med
28:1648–1651
2. Stiller K (2000) Physiotherapy in in-
tensive care. Towards an evidence-
based practice. Chest 118:1801–1813
3. Storm W (1980) Transient bacteremia
following endotracheal suctioning in
ventilated newborns. Pediatrics 65:487–
490
4. Brandstater B, Muallem M (1969) At-
electasis following tracheal suction in
infants. Anesthesiology 31:468–473
5. Boothroyd AE, Murthy BVS,
Darbyshire A, Petros AJ (1996) Endo-
tracheal suctioning causes right upper
lobe collapse in intubated children.
Acta Paediatr 85:1422–1425
6. Simbruner G, Coradello, Fodor M,
Havelec L, Lubec G, Pollak A (1981)
Effect of tracheal suction on oxygen-
ation, circulation and lung mechanics in
newborn infants. Arch Dis Child
56:326–330
7. Shah AR, Kurth CD, Gwiazdowski SG,
Chance B, Delivoria-Papadopoulos M
(1992) Fluctuations in cerebral oxy-
genation and blood volume during en-
dotracheal suctioning in premature in-
fants. J Pediatr 120:769-774
8. Kohlhauser C, Bernert G, Hermon M,
Popow C, Seidl R, Pollak A (2000)
Effects of endotracheal suctioning in
high-frequency oscillatory and conven-
tionally ventilated low birth weight
neonates on cerebral haemodynamics
observed by near infrared spectroscopy
(NIRS). Pediatr Pulmonol 29:270–275
9. Fanconi S, Duc G (1987) Intratracheal
suctioning in sick preterm infants: pre-
vention of intracranial hypertension and
cerebral hypoperfusion by muscle pa-
ralysis. Pediatrics 79:538–543
10. Durand M, Sangha B, Cabal LA,
Hoppenbrouwers T, Hodgman JE
(1989) Cardiopulmonary and intracra-
nial pressure changes related to endo-
tracheal suctioning in preterm infants.
Crit Care Med 17:506–510
11. Anderson K, Chandra K (1976) Pneu-
mothorax secondary to perforation of
sequential bronchi by suction catheters.
J Pediatr Surg 11:687–693
12. Walsh C, Bada A, Korones S, Carter M,
Wong S, Arheart K (1987) Controlled
supplemental oxygenation during tra-
cheobronchial hygiene. Nurs Res
36:211–215
13. Kerem E, Yatsiv I, Goitein KJ (1990)
Effect of endotracheal suctioning on
arterial blood gases in children. Inten-
sive Care Med 16:95–99
14. Hickey PR, Hansen DD, Wessel DL,
Lang P, Jonas RA, Elixson EM (1985)
Blunting of stress responses in the
pulmonary circulation of infants by
fentanyl. Anesth Analg 64:1137–1142
15. Harding JE, Miles FKI, Becroft DMA,
Allen BC, Knight DB (1998) Chest
physiotherapy may be associated with
brain damage in extremely premature
infants. J Pediatr 132:440–444
1016
16. Fox WW, Schwartz JG, Shaffer TH
(1978) Pulmonary physiotherapy in
neonates: physiologic changes and res-
piratory management. J Pediatr 92:977–
981
17. Reines HD, Sade RM, Bradford BF,
Marshall J (1982) Chest physiotherapy
fails to prevent postoperative atelectasis
in children after cardiac surgery. Ann
Surg 195:451–455
18. Bloomfield FH, Teele RL, Voss M, 20. Main E, Stocks J (2004) The influence
Knight DB, Harding JE (1998) The role of physiotherapy and suction on respi-
of neonatal chest physiotherapy in pre- ratory deadspace in ventilated children.
venting postextubation atelectasis. Intensive Care Med (http://dx.doi.org/
J Pediatr 133:269–271 10.1007/s00134-004-2261-1)
19. Main E, Castle R, Newham D, Stocks J
(2004) Respiratory physiotherapy ver-
sus suction: the effects on respiratory
function in ventilated infants and chil-
dren. Intensive Care Med (http://
dx.doi.org/10.1007/s00134-004-2262-
0)