Care Unit Chest Physical Therapy For Patients in The Intensive

Chest Physical Therapy for Patients in the Intensive
Care Unit
Nancy D Ciesla
PHYS THER. 1996; 76:609-625.
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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 concen-
tration ratios improved, and atelectasis resolved without the negative
hemodynamic side effects of therapeutic bronchoscopy. Physical ther-
apists 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

he purpose of this article is to review the role of The study of the effects of chest physical therapy on
chest physical therapy in the intensive care unit arterial oxygenation, oxygen consumption, total lung/
(ICU). Treatments are described and critiqued thorax compliance, cardiac output, and airway resistance
for utility in the ICU. The ICU is a unique was possible in the 1970s due to the routine use of
environment, and patients are frequently mechanically mechanical ventilation and hemodynamic monitoring.
ventilated and have multiple invasive lines and drainage Mackenzie et a17 demonstrated radiological improve-
tubes that are needed to optimize hemodynamic status. ment without hypoxemia in 47 patients with multiple
Pulmonary artery, intracranial, and central venous pres- trauma who received chest physical therapy and were
sures are routinely monitored. Chest physical therapy is mechanically ventilated with positive end-expiratory
often necessary due to retained secretions following pressure (PEEP). The fraction of inspired oxygen con-
intubation and immobility. Some physicians advocate centration ( F I O ~was
) not altered during chest physical
volume-controlled mechanical ventilation or mandatory therapy for these patients. Chest physical therapy
synchronized intermittent ventilation, whereas others improved lung/thorax compliance in 42 patients with
recommend pressure support and pressure control atelectasis, pneumonia, lung contusion, and adult respi-
modes.' In my experience, most critically ill patients in ratory distress syndrome (ARDS) who were mechanically
the ICU tolerate therapy when supplemental oxygen ventilated following trauma."rway resistance was
delivery and ventilator adjustments are permitted before unchanged immediately following and for 2 hours after
or during chest physical therapy to enable them to chest physical therapy.8 Mackenzie and c o l l e a g ~ e s ~ ~ ~
tolerate turning and mobilization. concluded, therefore, that chest physical therapy most
likely affects the small airways rather than large airways
Chest physical therapy usually consists of postural drain- in adult patients with traumatic injuries. Even in patients
age, percussion, vibration, coughing and cough stimula- with unstable vital signs following severe multiple
tion techniques, breathing exercises, suctioning, and trauma, chest physical therapy has been shown to assist
patient mobilization. In my experience, mobilization in the resolution of left lower-lobe atelectasis and to
that includes side-to-side turning, transfer training, and improve arterial o~ygenation.~ Investigatorsl0 also have
ambulation while ventilating the patient with a manual noted that suctioning decreases the saturation of venous
resuscitator bag (MRB) usually minimizes the need for oxygen (SVO~) due to increased oxygen consumption
postural drainage with manual techniques. The forced- when there is an inadequate increase in cardiac output.
expiration technique, active cycle of breathing, positive Klein et all] demonstrated an increase in cardiac output
expiratory pressure, autogenic drainage, and use of a with chest physical therapy, which returned to baseline
flutter valve are newer airway clearance techniques that within 15 minutes of the procedure.
appear to be beneficial for cooperative patients with
chronic sputum-producing diseases such as cystic fibro- Only two research g r o ~ p s ~ ~ . ~ " a vexamined
e the effect
is.'-^ The focus of this article is the adult patient in the of chest physical therapy on the resolution of acute
ICU who is frequently intubated, receiving supplemental primary pneumonia. Outcome variables included dura-
oxygen, and unable to follow complex instructions. tion of fever, radiographic clearing, hospital stay, and
Breathing exercise techniques, therefore, for patients m~rtality.~z.'"raham and Bradley12 demonstrated no
with less acute chronic sputum-producing disease are difference in the resolution of pneumonia for 27
not discussed. patients treated with intermittent positive pressure
breathing (IPPB) and chest physical therapy compared
Historical Review with a control group of 27 patients. Britton and col-
Studies of chest physical therapy did not occur until the leagued3 studied 177 patients. Outcomes were the same
1950s when Palmer and Sellickhnd Thoren-tudied for the control group, which received advice on deep
352 patients following gastrectomy, hernia repair, and breathing and coughing, and for the study group, in
cholecystecomy. These authors demonstrated that pos- which postural drainage, manual techniques, and
tural drainage, percussion and vibration, breathing exer- breathing exercises were used.lVn both studies, the
cises, and coughing were more effective at reducing majority of patients received antibiotics. Patients with
postoperative pulmonary complications including atel- nosocomial pneumonia, however, were not included in
ectasis and pneumonia than either no treatment or either study. Patients who were intubated, patients who
breathing exercises alone. 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) (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.
610 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996

and patients with cystic fibrosis, lung abscess, lung Table 1.
Indications for Chest Physical Therapya
contusion, and bronchiectasis were also excluded.
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
Physical Therapy . Volume 76 . Number 6 . June 1996 Ciesla . 61 1

often not considered in the initial patient assessment by Postural Drainage
non-physical therapists. I have found that patients who Postural drainage refers to placing the body in a position
adequately clear srcretions with side-to-side turning, that allows gravity to assist drainage of mucus from the
mobilization, and suctioning d o not need postural drain- lung periphery to the segmental bror~chusand upper
age with manual techniques. In my experience, chest airway."" Eleven positions are commonly used to drain
physical therapy is frequently administered to both lungs 14 lung segments. A detailed description of positioning
without directing therapy to the anatomic area of lung the patient in the ICU is published elsewhere." Postural
involvement, is not continued until secretions reach the drainage enhances peripheral lung clearance, increases
upper airway, or is not terminated when the patient functional residual capacity, and accelerates mucus
stops producing secretions. The presence of chronic clearanCe.~~).~?.mPostural drainage in conjunction with
sputum-producing lung diseases, with the exception of mechanical ventilation and PEEP is thought to increase
cystic fibrosis, does rlot warrant chest physical therapy transpulmonary pressure, irllprove ventilation-perfusion
unless another indication for treatment (Tab. 1) o r ratios, increase lung/thorax compliance of the non-
recurrent pneumonia is present. dependent hemithorax, and reduce collateral airway
re~istance.5~ Atelectasis may resolve more quickly when
Chest Physical Therapy Components the patient is turned with the affected lung ~ipperrnost.~:'
Mucociliary activity and an effective cough are needed Obese patients placed in the 19degree Trendelenburg
for normal airway c l e a r a n ~ e . ~Viscous
~ . ~ " secretions, the position after abdominal surgery fbr postural drainage
presence of a cuffed tracheal tube, dehydration, hypox- of the lower lobes rarely demonstrate clinically signifi-
emia, immobility, and poor humidification of gases cant oxygen desaturation."" Transient decreases in oxy-
impede mucociliary clearance, causing secretion reten- gen saturation measured by pulse oximetry (Spo,) that
tiotls3(i-v Neurologic conditions and phar~nacologically occur with postural drainage positioning return to base-
induced paralysis affecting the innervation of the glottis line within a few minutes. Therefore, most spontane-
or intercostal and abdominal muscles may diminish ously breathing and mechanically ventilated patients
airflow, resulting in a n ineffective cough.:'Vatients in tolerate positional changes necessary for segmental pos-
the ICU usually have one or more of these conditions. tural drainage. Infrequently, an increase in metabolic
The treatment techniques used in the ICU are similar to demand o r worsening ventilation-perfusion ratios result
those advocated by ThorenQmore than 40 years ago. in a decrease in oxygenation, insufficient gas flow, o r low
Postural drainage, percussion, vibration, coughing, suc- lung v o l u ~ n e s . ~ Increasing
~'.~~ the patient's Fro, or addi-
tioning, breathing exercises, patient mobilization, and tional ventilator adjustments are therefore required
sometimes manual lung inflation are the usual treat- prior to or during therapy. Positioning for postural
ments used to renlove secretions. T h e effectiveness of drainage is usually continued once the patient has
positioning alol~e to remove retained secretions is responded fivorably to changes in ventilator settings.
unknown. Most patients in the ICU cannot tolerate The duration of postural drainage may range from 1 5 to
strenuous exercise programs. However, turning, suction- 60 minutes, depending on the patient's tolerance to
ing, transfer training, and ambulation (with a n MRB, if' c:hanges in position and the amount of sputum
necessary) are integral parts of'the chest physical therapy production.
assessment and treatment and may minimize the need
for postural drainage using manual t e c h n i q ~ e s . ~ ~ ' Cooperative, spontaneously breathing patients who can
cough effectively may not need postural drainage. John-
Positioning son et a157 found no difference in the resolution of'
The benefits of positioning versus postural drainage is atelectasis when postural drainage and percussion were
often difficult to discern. Changes in ventilation- added to deep breathing exercises in patients with acute
perfusion relationships with positional changes have lobar atelectasis, although the diagnoses and mobility
been d o c ~ r n e n t e d . Side-to-side
~~,~~ turning decreases level of the patients studied were not addressed.
postoperative fever and improves o ~ y g e n a t i o n .Im-
~~
provements in arterial oxygenation after patient posi-
tioning, including in patients with adult respiratory Patient Example # 7
distress syndrome (ARDS), have been s h o ~ n . ~ Posi-~-~' The following example demonstrates improvement in
tioning patients for chest physical therapy with the both atelectasis and oxygenation after prone positioning
"good lung down" is associated with improved and chest physical therapy. The patient was discharged 8
ventilation-perfusion ratios and oxygenation.U4* days after treatment was initiated. Although it was ini-
Patients with pathology in the superior, and frequently tially felt that this patient would require extracorporeal
the atelectatic posterior, segments of the lower lobes lung assistance to sustain life, after positioning and chest
may have better oxygenation with prone positioning physical therapy this was not necessary.
than with supine po~itioning.4"~"
6 12 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996

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-~nedwith 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 increas-
ing 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, comput-
erized tomography and chest radiography demonstrated
bilateral lower-lobe atelectasis and consolidation,with right
pleura~leffiision 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 Figure 1.
Chest radiograph demonstrating bilateral lower-lobe atelectasis. Note
prone positioning and chest physical therapy. Twenty-four +hat the diaphragmatic
bordersare obscured,
hours following admission to the second trauma center, the
patient was evaluated for chest physical therapy while phar-
macologically paralyzed with metabine and mechanically
ventilated via an endotracheal tube. Coarse rales were noted appear to be indicated u~ltilfurther research demon-
over the posterior lung zones. The initial treatment con- strates that positioning alone can be equally effective.
sisted 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 Percussjon and Vibration
sputum was obtained with suctioning. Following treatment, percussion and vibration are the techniques ]nost fie-
improved air ent~ywas noted by auscultation. quently recommended for the patient who is intubated
and mechanically ventilated and for patients with
After 5 days of treatnlent, the patient was placed on a
impaired cognition or poor coughing Percus-
regular bed due to the marked improvement in his respi-
sion and vibration are used to enhance m~icociliary
ratory status. Chest physical therapy was administered for 7
days and consisted of postl~raldrainage, percussion, and clearance fi-om both central and peripheral
vibration to the lower lobes (Tab, 2). Sputllm The exact niechanism of action of chest percussion is
incre:ased, with a gradual improvement in breath sounds unknown, bur there is some evidellce froln animal
and chest radiograph findings and marked in~provement models that physical stimulation alters airflow and is
shown in computerized tomography scan (Fig. 3). The associated with the release of pulmonary chemical medi-
patient was extubated on day 8. Following extubation, the ators, mediators that may improve ciliary trallsport speed
patient ambulated with assistance and had a good prodl~c- by as much as 340%,") Mllcociliary flow is dependent o n
tive cough. Within 24 hours, the patient was discharged the viscoelastic property of the geometry of the
back to the original hospital, alert and oriented while airnay, and the speed o f a i r f l o w . ~ oLuterations
,~ in aiMiay
following three-step commands.
diameter and airflow may decrease the viscosity of
mucus, making percussion more effective in mobilizing
Chest physical therapy and prone positioning were most
secretions that are adherent to the bronchial walls.
likely responsible for reexpansion of this patient's col-
lapsed lower lobes and for improved oxygenation, which
Percussion with postiiral drainage has been used to
in turn led to successful weaning from ~nechanical
remove mucus and aspirated teeth from patients who are
ventilalion. The physicians and physical therapists
medically too iinstable to undergo bronchoscopy. This
involved with this patient did not know which interven-
suggests that manual techniques can assist in clearing
tion was primarily responsible for the patient's improve-
secretions from both the central and peripheral air-
ment. However, when faced with a patient with
way~."~z Because of differences in aerosol deposition in
increasing airway pressures and secretion retention who
the airways a n d no standardization of manual versus
is difficult to ventilate on 100% of Fro,, simultan-
mechanical technique, controversy exists as to whether
eous treatment using gravity to maximize
the radionuclide clearance noted with percussion and
ventilation-perfusion ratios and postural drainage with
vibration indicates peripheral o r central ainvay clear-
manual techniques to mobilize retained secretions
ance. Manual percussion and vibration, when performed
Physical Therapy. Volume 76 . Number 6 . June 1996 Ciesla . 61 3

with postural drainage, are thought to expedite drainage Redness or petechiae are usually a result of improper
of secretions from the central and peripheral airways, technique. For patients with thoracic abrasions or burns
which may reduce treatment This is particu- needing manual techniques, a sterile drape should be
larly important for patients in the ICU who have periods placed over the chest wall. When treating a patient with
of hernodynamic instability and require multiple diag- spinal injuries who is stabilized in either a halo vest or
nostic and therapeutic procedures. Both techniques are thoracic corset, the therapist opens the vest after the
used with postural drainage. 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 intracra-
Cornmonly 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 experi-
of the lung descend to T-12 with deep inspiration and ence; whether a one- or two-handed technique is used;
rise to T-9 with forced e x ~ i r a t i o n . ~ ~ and the patient's pain tolerance, especially when rib
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 inspira-
with liver or kidney disease. Lower lung borders can be
tory and expiratory phases of respiration. The therapist's
assessed with auscultation and mediate percussion (per-
hand 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 sisp athe
s m most fre-
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 bron-
directly 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 incorpo-
as 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 tis-
surgery. More often, particularly in patients with quad-
sue). The presence of, and any increases in, subcutane-
riplegia, 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 phy-
require inhaled bronchodilators prior to or following
sician or nurse should also be notified when subcutane-
treat~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.

percussion, appropriate intervention should be
-Y
implemented.
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 h
L
V I S
force 011 the chest wall have been reported.58 There is
some evidence that both fast and slow percussion N m+
increase sputum production in patients with bronchiec-
tasis and alveolar proteinosis. Gallon7l and Hammon * a
(WE Hammon, PT, Chief of Rehabilitative Services,
Oklahoma Memorial Hospital, Oklahoma City, Okla;
personal communication) report that fast percussion 0-
m *
(240 cycles per minute) demonstrated the greatest spu- C
tum production, although slow percussion (6-12 cycles s. o-e& Z

2
per minute) was more effective than no percussion. m m o

7-1 0 "
0
Hammon reported that when large amounts of protein- N =
aceous material are present in the alveoli, percussion is
more effective than vibration (WE Hammon, personal * 0
communication). In patients in the ICU, the quantity of
m
sputum produced has not been shown to correlate with
improvements in pulmonary function.54 Differences in
technique may account for discrepancies in therapy ") 0
0
advocated in different parts of the United state^.^^^^^

- m
The use of percussion over rib fractures remains contro-

0
versial. Extrapleural pathology, pneumothorax, and 0
hemothorax that develop as a result of the initial injury
m
should not be considered a contraindication to percus
sion. I11 a retrospective study of 252 patients with rib -k 2
fractures who received chest physical therapy (including
manual percussion), 24 patients developed extrapleural
Z'I'E&! 7.E
2 E
0
k+
-E x z
pathology.75Ten of these patients developed extrapleu- -UPS A
m
ral pathology before chest physical therapy was started, r

N
and 14 patients developed extrapleural pathology after ~ C " O " 2 I \ b .
chest physical therapy was started. There was no differ- 8 2 2 I\ I\
ence in the development of extrapleural hematomas

C 0
between the patients who received manual percussion .2 E
and those who did not receive manual percu~sion.~"
Followng treatment of more than 500 patients with rib
121
* L C
N
N O " b w w
3 a 9
fractures, physical therapists at the R Adams Cowley 426 2 2
Shock Trauma Center (Baltimore, Md) have noted that
patients who are intubated and who are being mechan-
ically kentilated usually tolerate percussion in conjunc-
.-
C
0
H
H
tion with analgesics and sedation. Greater alterations in -i
intrathoracic pressure occur with coughing than with
properly performed percussion." For patients with rib 2 0
and sternal fractures, controlled mechanical ventilation
may even stabilize the fracture site by minimizing nega- 2
tive intrathoracic pressure^.^^ The force and frequency 5 e
.-
*
0 f
of percussion can be modified to patient tolerance. -
.-0 P
?!
.=
,o .g
-
6
c
Percussion is not indicated for the spontaneously breath- ?! f ~2
g 0 ,
ing patient with rib fractures who is responding to
breathing exercises and assistive coughing techniques. : >*
s" " s o p .-
L L a
Z l r 2 2 2 8 u
7

adult patients in the ICU, use of these devices increases
cost, does not reduce staffing requirements, and intro-
duces 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 com-
bined with postural drainage.7R-H0In patients with pul-
monary alveolar proteinosis, manual percussion (180-
270 cycles per minute) was almost twice as effective as
mechanical percussion (36 Hz) in removing protein-
aceous material from the a l ~ e o l i . ~
Recently,
' Hammon
and McCaffree" studied the effects of manual percus-
sion, saline alone, and a commercially available pneu-
Figure 3. matic percussor on the removal of alveolar material in
Chest radiograph showing improvement in right lower-lobe atelectosis. three patients with pulmonary alveolar proteinosis. Mea-
surements of optical density were better with manual
percussion than with saline alone or the pneumatic
per cuss or.^ Although these results cannot be extrapo-
Vibration. Vibration is a more forceful technique than lated directly to non-saline-filled lungs, they suggest that
percussion. At 12 to 20 HZ, vibration is similar to the manual percussion is capable of removing secretions
normal beat frequencies of human ciliaa7"he rib cage is from the most distal airnays and alveoli and is more
"shaken" during the expiratory phase of respiration. effective than mechanical percussors, vibrators, or saline
Some clinicians define vigorous vibration as "rib shak- alone.
ing" or "rib springing."I7 Vibration is used with both
patients who are spontaneously breathing and patients High-frequency chest compression (HFCC) has recently
who are mechanically ventilated. Secretions move into gained popularity as a means of enhancing mucus
the upper aimaJ's when vibration is performed during clearance in patients with cystic fibrosis.60 The patient
b r o n c h o ~ c o p yForceful
.~~ vibration is not recommended wears an inflatable vest that covers any lung lobes
over rib fractures, which may perforate the pleura and affected with pathology. Frequencies are adjusted to
cause a pneumothorax, intrapleural bleeding, or an optimize airflow and to maximize mucus
extrapleural hematoma. Some clinicians use a mild clearance. Whitman and colleagues," however, found
vibration of light, fast oscillations over rib fractures and no increase in mucus clearance over traditional tech-
report no adverse effects. Vibration in patients with niques in six patients who had been mechanically venti-
thoracic spinal fractures should be mild and performed lated for 90 to 1,203 days. Percussion was applied for 2
by clinicians trained in chest physical therapy tech- minutes to five lung regions with postural drainage. No
niques. S~ontaneouslybreathing patients who are diffi- indications for treatment were stated other than that the
cult to arollse (such as those with acute brain injury) may patients were mechanically ventilated. The practicality of
benefit from vibration to erlcourage deep inspiration using HFCC with mechanical ventilation in the JCU is
and stimulate a cough. questionable when patients are at high risk for cross-
contamination and access to the thorax is required for
In my clirlical experience, dysrhythmias are more likely cardio\rascular monitoring. Further study is needed to
to occur as a result of hemodynamic instability associated determine whether HFCC and use of a flutter valve
with positiorlal change than as a result of the actual facilitate mucus clearance from central and peripheral
manual technique. Percussion and vibration adjacent to for patients who are critically ill and immobile.
a cardiac electrode may produce artifacts. After consul-
tation with nurses and physicians, electrodes can usually Manuallung/nflation
be repositioned or, in rare cases, temporarily discon- Manual lung inflation, which involves disconnecting the
nected. The therapist should then closely monitor the patient from the mechanical ventilator and inflating the
clinical status of the patient and any alterations in blood lungs with a large tidal volume via an MRB, is a common
pressure or heart rate. practice in Great Britain, Canada, and A u ~ t r a l i aAfter
.~~
the lungs are hyperinflated, the bag is quickly released,
Mechanical devices. Mechanical percussors and vibra- producing a high expiratory flow. ~l~~ rates range from
tors were introduced in the late 1960s to permit patients 123 to 340 L/rnin, depending on the type of bag used
with cystic fibrosis more independence with therapy. For
6 16 . Ciesla Physical Therapy . Volume 7 6 . Number 6 . June 1996

and the amount of pressure g e n e r a t e d . H V h i s tech- ulating and assistance techniques. Compressing the tra-
nique, often referred to as the "bag-squeezing method," chea just above the sternal notch or huffing (after a
was introduced in the 1960s to prevent pulmonary maximal inspiration, the patient exhales several times
segmental collapse, reexpand collapsed alveoli, mini- quickly) is indicated when the patient has sufficient
mize the risk of hypoxemia, and stimulate a cough in the neuromuscular function of the respiratory and abdomi-
patient who is i n t ~ b a t e d Vibration
. ~ ~ ~ ~ is sometimes nal muscles. While huffing, the glottis remains open and
performed during the expiratory phase to enhance intrathoracic pressure is lower than with c ~ u g h i n g . ~ ~
mobilization of secretions from the central airways.5H When incisional pain is the limiting factor, support of
The additional tidal volume delivered, however, most thoracic and abdominal incisions and huffing are indi-
likely reaches the most compliant lung zones and there- cated. Upright positioning also improves cough pres-
fore expands normal rather than collapsed alveoli. sures." Coughing is also enhanced by early tracheos-
Because the patient is removed from the ventilator, lung tomy removal, placing an airtight dressing over the
volumes., PEEP, flow rates, and FIO, are not controlled. tracheostomy stoma, and supporting the stoma site
Novak and colleaguesHHstudied 16 patients with hypox- during expiration.
emic relspiratory failure in a surgical ICU and were
unable to demonstrate any improvement (<5 minutes) Loss of innervation of the intercostal and abdominal
in gas exchange or pulmonary compliance with hyper- muscles decreases airflow in individuals with quadriple-
inflations of 40 cm H,O of pressure for 15 to 30 seconds. gia.g"upport and compression of the upper abdomen
Flow rates were not documented. Although Jones and during expiration facilitates an effective, productive
colleaguesw found an increase in lung compliance for cough. Abdominal support and pressure during exhala-
up to 2 hours in patients without pulmonary disease with tion are necessary with injuries or diseases that result in
bagging and percussion, the same results have been abdominal muscle weakness that prohibits effective
demonstrated with postural drainage, percussion, and coughing.
vibration in patients with pulmonary p a t h o l ~ g y . ~
Tracheal Suctioning
Hyperinflation may be hazardous in patients with severe Tracheal suctioning is an integral component of chest
ARDS, because high airway pressures and overdistension physical therapy for the patient who is intubated. Deep
of normal alveoli may damage normal lung parenchyma suctioning is necessary for patients who cannot mobilize
and increase the quantity of lung tissue contributing to secretions to the proximal portion of the tracheal tube
the respiratory distress syndrome.'") The effect of hyper- by coughing o r huffing. Withholding suctioning may
inflation on cerebral perfusion pressure in patients with result in airway occlusion and h y p ~ x e m i a . "Because
~
brain injury who are not medically paralyzed is upper-airway secretions are most prevalent before and
unknown. Garrard and BullockY1used ICP monitoring after a change in patient position and during or follow-
to study 20 patients with brain injuries. Prolonged man- ing chest physical therapy, the suctioning procedure
ual hyperinflation with a 2-L rebreathing bag caused a should be timed with these interventions, particularly in
5-mm Hg increase in ICP in patients who were medically patients who have difficulty tolerating the procedure.
paralyzed and in patients who were not paralyzed.
Because cerebral perfusion pressures were not reported, Suctioning is a sterile procedure. Occupational Safety
the clinical significance is unknown. Hyperinflation, and Health Administration guidelinesYH for exposure to
with a plateau pressure of 80 cm H,O of pressure for 2 blood and body fluids, therefore, must be followed. Eye
to 3 seconds, of 13 patients with severe brain injuries protection, a mask for protection from bloody o r mucus
who were paralyzed and well-sedated did not decrease secretions, and sterile gloves should be worn. As part of
cerebral perfusion p r e s ~ u r e . ~ ~patients
or who are the initial assessment, the therapist should evaluate the
mechar~icallyventilated, lung hyperinflation with vibra- patient's need for and response to suctioning. Airway
tion is associated with large fluctuations in cardiotho- suctioning frequently improves breath sounds and may
racic pressure, and the physiologic benefit is therefore lower airway pressures. When no segmental or lobar
questi~nable.~? pathology is present, suctioning may be adequate and
postural drainage with manual techniques may not be
Coughing indicated. Patients who are intubated and who have a
Coughing removes secretions from the trachea, main- poor cough usually require tracheal suctioning. As with
stem bronchi, and up to the fourth generation of all physical therapy in the ICU, the patient's vital signs
segmental bronchi." Many patients spontaneously should be assessed before, during, and after the proce-
breathing in the ICU are unable to cough effectively dure. Table 3 lists the most frequently cited complica-
because of respiratory muscle weakness, pain, o r a tions associated with tracheal suctioning and the recom-
decreased level of consciousness. Therapists working in mended interventions to minimize side effects.
the ICIJ, therefore, should be familiar with cough stim-
Physical Therapy . Volume 7 6 . Number 6 . June 1996 Ciesla . 6 1 7

Table 3. Table 4.
Complications of Endotracheal Suctioning Recommended Features of Suction Catheters
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

adapter may minimize the need for preoxygenation, to baseline within 10 to 15 seconds and when the resting
therefore eliminating the potential hazards of exposure Pao, is below 85 mm Hg.
to 100% oxygen."J4A port adapter is recommended for
patients who are mechanically ventilated patients and Saline installation. Saline instillation is commonly used
require a PEEP of >10 cm H 2 0 and for patients who are before and during tracheal suctioning to "loosen" secre-
at high risk for suction-induced arrhythmias and tions.ll"aline instilled through a tracheal or endotra-
hypo~ernia.~~*~')" cheal tube is not likely to reach the peripheral airways,
where secretions are most prevalent."s To be effective,
Proponents of in-line suctioning report less oxygen the saline must pass through several generations of
desaturation than with an open system; however, the segmental bronchi and reach the terminal bronchioles
same results have been achieved by using a port adapt- and alveoli. Patients should, however, receive adequate
Clinical impressions of in-line suctioning
er.9!',100,104.106 systemic hydration and airway humidification rather
that need to be substantiated with further research than saline i n ~ t i l l a t i o n . ~ Patients
~ ~ , l l ~ with copious puru-
include the following: (1) The catheter is more difficult lent secretions (eg, bronchiectasis) may require saline
to maneuver, (2) the additional weight of the catheter installation to remove viscid secretions from the upper
may increase tracheal damage, (3) higher inspiratory airways and tracheal tube.
flow rates may be required, and (4) airway pressure may
drop as a result with suctioning and intermittent man- Breathing Exercises
datory ventilation (IMV).100.104,106 Once extubated, alert, and cooperative, the patient in
the ICU may benefit from breathing exercises to
Preoxygenation is the most commonly used method for increase tidal volume, improve thoracic-cage mobility,
preventing oxygen d e ~ a t u r a t i o n . ~ ~ ~ .mechanical
~~Yhe increase inspiratory capacity, enhance cough efficacy,
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 neuro-
suctioni~ng.For patients who are mechanically ventilated, muscular disease or injury affecting the respiratory mus-
the ventilator is preferred over the MRB. Minute venti- cles. 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 in lung volume, flow rates, and pressure 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
required when using an MRB is not needed. When using mechanical ventilation.
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. Diaphrag-
has a r e ~ e r v o i r . l l l . ~ ~ ~ matic breathing and lateral costal and segmental costal
expansion exercises are used most often postoperative-
The miajority of studies evaluating tracheal suctioning ly?l Use of a flutter valve, the forced-expiration tech-
have 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 com- breathing (huffing at various lung volumes interspersed
mon practice, it may not be necessary for all patients. with diaphragmatic breathing)-and autogenic drain-
Based on my clinical experience, I believe that suction- age (using a sequence of breathing maneuvers at various
induced hypoxemia may not be as significant in patients lung volumes to optimize airflow within multiple gener-
such as8young patients with traumatic injuries but with- ations of bronchi) are beneficial in patients with cystic
out cardiac disease. A suctioning protocol that encour- fibrosis, although the efficacy of these procedures after
ages clinical judgment is recommended.l14 When surgery has not been determined.5"11i Inspiratory mus-
patients are hyperoxygenated prior to or during chest cle training and resistive diaphragmatic breathing exer-
physical therapy, the effect of chest physical therapy on cises may be beneficial while weaning the patient with
Sao,, Spo,, or partial pressure of arterial oxygen (Pao,) quadriplegia or chronic obstructive pulmonary disease
may be masked. from the ~ e n t i l a t o r . ~ ~Incentive
- ~ 2 ~ spirometry is com-
monly used postoperatively, although it is no more
The most important indicators as to whether a patient advantageous or costeffective than instruction in deep
will desaturate with suctioning are the resting Spo, and breathing and coughing.I2l Following coronary artery
the resting Pao,. Depending on the patient being suc- bypass or gall-bladder surgely, breathing exercises offer
tioned, hyperoxygenation is recommended when the no advantage over early patient m0bilization.~*-21
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 Ciesla . 6 19

Table 5.
Patient Example 2: Improved Oxygenation and Chest Radiograph 1 Hour Following Chest Physical Therapya
- - - - - - - - - - - - --
Chest Radiograph Pao, /FIo,

Day/Time Positioning/Chest Physical Therapy Results Sao, 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 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
I Day 4, 2:00 PM Repeat chest radiograph
" 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-
620 . Ciesla Physical Therapy . Volume 7 6 . Number 6 . June 1996

Figure 4.
Complete collapse of the left lung prior to chest physical therapy
Figure 5.
Reexpansion of the left lung 1 hour following one chest physical therapy
treatment.
Patient Example #2
The following example demonstrates the development
of a left :lung collapse (Fig. 4) despite prone positioning
and tracheal suctioning. Chest physical therapy that Special Conditions
includedl postural drainage with percussion and vibra- Table 6 summarizes the medical conditions commorilv
tion was necessary t o reexpand the patient's left lung. found in patients in the ICU, indications for chest
Chest pllysical therapy eliminated the need for thera- physical therapy, and treatment guidelines.
peutic bronchoscopy, a more costly procedure with risks
of hypoxemia and life-threatening cardiac arrhythmias. Summary
This article provides a discussion of the literature relat-
A 22-year-old white man was admitted to the trauma center ing to chest physical therapy, indications for treatment,
fbllowing a diving injury with a C-4 teardrop compression and the rationale for its use in the ICU. Comparisons are
ti-acturr. Neut-ologicalexamination following American Spi- made with therapeutic bronchoscopy and therapeutic
nal Injury Association Standards revealed incomplete sen- positioning. The complications of tracheal suctioning
sory deficit (impaired sensation at C-6, C-7, T-3 to T-5, L-3, are discussed as well as methods for minimizing hypox-
and a111sacral segments). Motor level was C-4. The patient emia, and the necessary features of suction catheters are
required mechanical ventilation for respiratory support. described. Although patient mobilization and deep-
'Table 5 describes the sequence of therapeutic positioning,
breathing exercises with coughing can often replace
airway siictioning, and the need for chest physical therapy
due to an increasing left-lung atelectasis. postural drainage, percussion, and vibration, many
patients in the ICU cannot be mobilized sufficiently to
Following chest physical therapy, the patient's Sao, eliminate the sequelae of secretion retention due to the
increased from 87% to 99% and his Pao,/Flo, ratio severity of injury or illness and the paraphernalia neces-
increased from 53 to 420. The patient's FIO, was lowered sary to sustain life.
from 100% to 40% within 24 hours of treatment. I n
addition, the left-lung atelectasis resolved immediately fol- I believe that when a clear indication for chest physical
lowing 45 minutes of chest physical therapy, as noted in therapy is present, it can be performed safely and
Figure 5. Prone positioning and suctioni~~g did not prevent effectively by clinicians who have received training in the
the secretion retention that resulted in collapse of the ICU. I contend that the recommended treatment of
patient's left lung. 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 venti-
lated and the efficacy of therapeutic positioning without
postural drainage and manual techniques.

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 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.
Acknowledgments 6 Thoren L. Postoperative pulmonary complications: obselvations of

I acknowledge Bill Hammon, PT, Alex Sciaky, PT, CCS, their prevention by means of physiotherapy. Acta Chir Srand. 1954;107:
and Susan Ludwick-Mihans, PT, for their critical review 193-204.
of the manuscript as it pertains to patients in the ICU. 7 Mackenzie CF, Shin B, McAslan TC. Chest physiotherapy: the effect
I thank Marianne Mars, PT, Jill Kuramoto, PT, and Faith on arterial oxygenation. Anesth Analg. 1978;57:28-30.
Kousalis, PT, for their critique of the manuscript and for 8 Mackenzie CF, Shin B, Hadi F, lmle PC. Changes in total lung/
providing data for the case studies. thorax compliance following chest physiotherapy. Anesth Analg. 1980;
59:207-210.
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Physical Therapy. Volume 76 . Number 6 . June 1996 Ciesla . 625

Chest Physical Therapy for Patients in the Intensive
Care Unit
Nancy D Ciesla
PHYS THER. 1996; 76:609-625.
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Physical Therapy . Volume 76 . Number 6 . June 1996

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610 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996

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To optimize ventilation and treat the bilateral lower-lobe

Physical Therapy. Volume 76 . Number 6 . June 1996 Ciesla . 61 3

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tum production, although slow percussion (6-12 cycles s. o-e& Z

per minute) was more effective than no percussion. m m o

advocated in different parts of the United state^.^^^^^

The use of percussion over rib fractures remains contro-

ral pathology before chest physical therapy was started, r

ence in the development of extrapleural hematomas

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Chest Radiograph Pao, /FIo,

Admission Positioned supine on turning frame Clear

I Day 4, 2:00 PM Repeat chest radiograph

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Acknowledgments 6 Thoren L. Postoperative pulmonary complications: obselvations of

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