The role of neonatal chest physiotherapy in preventing postextubation atelectasis

Thoracoabdominal rebalancing is not superior to manual hyperinflation to increase the amount of pulmonary secretion removed in preterm newborns: A randomized crossover trial

Background and Aims

Respiratory physical therapy is recommended to prevent complications of accumulated secretion in mechanical ventilated infants, but no consensus about the best technique is available.

Aims

To evaluate the effects of manual hyperinflation maneuver (MHM) and thoracoabdominal rebalancing method (TRM) in preterm newborns (PTNB) for bronchial hygiene.

Methods

Single-blind randomized crossover trial with intention-to-treat analysis was carried out with 24 PTNB (<37 weeks of gestation) under invasive ventilatory support via orotracheal cannula received both interventions (MHM and TRM) with an interval of 4 h, followed by tracheal suctioning. The primary outcome was the amount of pulmonary secretion, while secondary outcomes were the response of the autonomous (heart rate, respiratory rate [RR], tidal volume [TV], and oxygen saturation [SpO2]), motor (classification of general movements), and regulatory (pain and respiratory discomfort) systems pre and postintervention.

Results

Although the amount of secretion was not different after the MHM and TRM interventions (0.10 and 0.09 g, respectively, p = 0.47), a difference was observed in the increase of SpO2 (p ≤ 0.001), and in the decrease of RR (p ≤ 0.001) for TRM. The poor repertoire pattern was predominant (23 PTNB), and it did not alter after interventions. Pain was not observed during interventions, the respiratory discomfort decreased after both interventions (p = 0.50).

Conclusion

The amount of secretion removed was similar after MHM and TRM and both maneuvers did not negatively alter the response of the autonomous, motor, and regulatory systems.

Chest physiotherapy in preterm infants with lung diseases

BACKGROUND

In neonatology the role of chest physiotherapy is still uncertain because of the controversial outcomes.

METHODS

The aim of this study was to test the applicability in preterm infants of 'reflex rolling', from the Vojta method, in preterm neonates with lung pathology, with particular attention to the effects on blood gases and oxygen saturation, on the spontaneous breathing, on the onset of stress or pain. The study included 34 preterm newborns with mean gestational age of 30.5 (1.6) weeks - mean (DS) - and birth weight of 1430 (423) g - mean (DS) -, who suffered from hyaline membrane disease, under treatment with nasal CPAP (continuous positive airways pressure), or from pneumonia, under treatment with oxygen-therapy. The neonates underwent phase 1 of 'reflex rolling' according to Vojta method three times daily. Respiratory rate, SatO2, transcutaneous PtcCO2 e PtcO2 were monitored; in order to evaluate the onset of stress or pain following the stimulations, the NIPS score and the PIPP score were recorded; cerebral ultrasound scans were performed on postnatal days 1-3-5-7, and then weekly.

RESULTS

In this population the first phase of Vojta's 'reflex rolling' caused an increase of PtcO2 and SatO2 values. No negative effects on PtcCO2 and respiratory rate were observed, NIPS and PIPP stress scores remained unmodified during the treatment; in no patient the intraventricular haemorrhage worsened in time and none of the infants developed periventricular leucomalacia.

CONCLUSIONS

Our experience, using the Vojta method, allows to affirm that this method is safe for preterm neonates, but further investigations are necessary to confirm its positive effects and to evaluate long-term respiratory outcomes.

Influência da fisioterapia respiratória sobre a função cardiopulmonar em recém-nascidos de muito baixo peso

OBJETIVO: Avaliar as repercussões da fisioterapia respiratória sobre a função cardiopulmonar em recém-nascidos pré-termo (RNPT) submetidos à ventilação mecânica. MÉTODOS: Estudo prospectivo de RNPT com peso de nascimento menor que 1500g, sendo verificados os valores de frequência cardíaca (FC), saturação de oxigênio (SatO2), frequência respiratória (FR) e pressão arterial sistêmica (PA) antes e após a fisioterapia respiratória e a aspiração endotraqueal. Os RNPT incluídos foram avaliados em sessões sequenciais entre o 3º-7º dias de vida por dois fisioterapeutas da unidade neonatal. Os valores de FC, SatO2 e PA foram coletados por monitorização eletrônica e a FR, por cronômetro. Na análise estatística, foi utilizado o teste de ANOVA para medidas repetidas, sendo significante p<0,05. RESULTADOS: Foram estudados 42 recém-nascidos, 57% do sexo feminino, com peso de nascimento médio de 1024g e idade gestacional média de 29,5 semanas. Somente 3 RNPT apresentaram Apgar de 5º minuto menor que 5 e a Doença das Membranas Hialinas foi o principal diagnóstico respiratório (88%). Foram realizadas 252 sessões de fisioterapia. A FC, FR, SatO2 e PA atingiram valores considerados fisiológicos após os procedimentos fisioterapêuticos e a aspiração endotraqueal. CONCLUSÕES: Os procedimentos de fisioterapia respiratória e de aspiração endotraqueal não apresentaram influências significativas na função cardiopulmonar, sugerindo que, quando bem indicados e realizados, não comprometem a estabilidade clínica de RNPT.

Routine neonatal postextubation chest physiotherapy: a randomized controlled trial

OBJECTIVE

To test the effects of a neonatal postextubation programme on the incidence of postextubation collapse and adverse outcomes.

METHODS

A randomized controlled trial was carried out at the Mater Mothers' Hospital, Brisbane. Mechanically ventilated infants were randomized into one of two groups, physiotherapy group--which involved a regimen of chest wall percussion and oropharyngeal suctioning and control group - which involved suctioning without the percussion unless indicated. Chest X-rays were taken at 6 h and at 24 h postextubation. The primary outcome measure was postextubation collapse as determined by a paediatric radiologist blinded to the group allocation.

RESULTS

One hundred and seventy-seven neonates were enrolled in the trial between 1997 and 1999. After an interim analysis, the trial was stopped early. No statistically significant difference was shown in the rate of postextubation collapse (15 of 87 (17.2%) physiotherapy group and 17 of 86 (19.8%) control group (P = 0.85)). No differences were shown between the groups in the number of apnoeic or bradycardic events, duration of requirement for supplemental oxygen or the need for re-intubation within 24 h postextubation.

CONCLUSION

The results of this trial suggest that a routine neonatal postextubation chest physiotherapy programme for all infants is not indicated. There was no evidence that chest physiotherapy is associated with any adverse outcomes.

Bronchoscopic surfactant administration in pediatric patients with persistent lobar atelectasis

Persistent lobar atelectasis in pediatric patients on mechanical ventilation results in impaired gas exchange and lung mechanics and contributes to a further need for mechanical ventilation. The most common types of atelectasis in children are resorption atelectasis following airway obstruction, and atelectasis due to surfactant deficiency or dysfunction. We aimed to determine whether bronchoscopic suctioning and surfactant application to atelectatic lung segments would result in improved oxygenation, ventilation, chest X-ray scoring, and early extubation. Five children with heterogeneous lung diseases (aged between 7 months and 15 years) were treated with a diluted surfactant preparation (Curosurf) in a concentration of 5-10 mg/ml (total dose 120-240 mg) which was instilled into the affected segments. Outcome parameters were gas exchange, radiographic resolution of atelectasis and extubation. All mechanically ventilated patients could be extubated within 24 h following the intervention. Bronchoscopic surfactant application could be carried out without adverse effects and brought improvements in oxygenation, respiratory rate, and partial or complete resolution of atelectases without recurrence.

Airway lavage with exogenous surfactant in an animal model of meconium aspiration syndrome

BACKGROUND

Meconium aspiration syndrome (MAS) is a major cause of respiratory morbidity and mortality in term infants, and occasionally causes serious respiratory disturbance. Viscous meconium debris in the trachea interferes with ventilation, and chest physiotherapy (CPT) is effective for removing secretions from the trachea. The effects of conventional exogenous diluted surfactant lavage combined with CPT were evaluated in a MAS animal model in a randomized controlled study.

METHODS

Twenty-three MAS model adult Japanese rabbits were randomized into three groups and artificially ventilated for 3 h with the following treatments: group 1, suction only (n = 7); group 2, surfactant lavage (n = 7); group 3, surfactant lavage with CPT (n = 7). Surfactant lavage was performed by infusing 2 mL/kg of diluted Surfactant TA (Surfacten; 6 mg/mL) into the trachea over approximately 5 s, then performing gentle manual bagging six times, and aspirating the tracheal contents using a suction catheter. This procedure was performed four times in four different positions (total, 8 mL/kg). In group 3, CPT (squeezing) was performed during expiration of manual bagging in surfactant lavage.

RESULTS

In group 3, PaO(2) improved significantly (P < 0.05) at all time points compared with those in the other groups. Oxygenation index (OI) in group 3 improved significantly (P < 0.05) at all time points except after 0.5 h compared with that in group 1, and at 2, 2.5, and 3 h compared with that in group 2.

CONCLUSIONS

A combination of exogenous surfactant lavage and CPT (squeezing) improves respiratory disturbance in MAS.

Neonatal respiratory therapy in the new millennium: Does clinical practice reflect scientific evidence?

Respiratory therapy has historically been considered the primary role of the physiotherapist in neonatal intensive care in Australia. In 2001 a survey was undertaken of all level three neonatal intensive care units in Australia to determine the role of the physiotherapist and of respiratory therapy in clinical practice. It appears that respiratory therapy is provided infrequently, with the number of infants treated per month ranging from 0 to 10 in 15 of the 20 units who provide respiratory therapy, regardless of therapist availability. The median number of respiratory treatments per month during the week was three, and on weekends it was one. Respiratory therapy was carried out by physiotherapists and nurses in 54.6% of units, by physiotherapists only in 36.4% of units, and by nurses only in the remaining 9% of units surveyed. There was also a diminution of the role of respiratory therapy in the extubation of premature infants. A review of the literature shows that overall the use of respiratory therapy reflects current evidence. The question remains whether it is possible to maintain the competency of staff and justify the cost of training in the current healthcare economic climate. It seems probable that the future role of physiotherapists in neonatal intensive care unit may be in the facilitation of optimal neurological development of surviving very low birth weight infants.

Chest physiotherapy in mechanically ventilated children: a review

OBJECTIVE

Many physicians, nurses, and respiratory care practitioners consider chest physiotherapy (CP) a standard therapy in mechanically ventilated children beyond the newborn period. CP includes percussion, vibration, postural drainage, assisted coughing, and suctioning via the endotracheal tube.

DATA SOURCES

We searched the medical literature by using the key words "chest physiotherapy" and "chest physical therapy" (among others) by means of the MEDLINE and Current Contents databases.

STUDY SELECTION

Because of the paucity of objective data, we examined all reports dealing with this topic, including studies on adult patients. For data extraction, not enough material existed to perform a meta-analysis.

DATA SYNTHESIS

Despite its widespread use, almost no literature dealing with this treatment modality in pediatric patients exists. Studies with mechanically ventilated pediatric and adult patients have shown that CP is the most irritating routine intensive care procedure to patients. An increase in oxygen consumption often occurs when a patient receives CP accompanied by an elevation in heart rate, blood pressure, and intracranial pressure. CP leads to short-term decreases in oxygen, partial pressure in the blood, and major fluctuations in cardiac output. Changes in these vital signs and other variables may be even more pronounced in pediatric patients because the lung of a child is characterized by a higher closing capacity and the chest walls are characterized by a much higher compliance, thus predisposing the child to the development of atelectasis secondary to percussion and vibration.

CONCLUSION

CP in mechanically ventilated children may not be considered a standard therapy. Controlled studies examining the impact of CP on the duration of mechanical ventilatory support, critical illness, and hospital stay are needed.

Computer assisted analysis of the chest radiograph lung area and prediction of failure of extubation from mechanical ventilation in preterm neonates

Post-extubation chest radiographs (CXRs) are frequently requested on the neonatal intensive care unit, but it is controversial whether they generate useful information. A low lung volume assessed by measurement of functional residual capacity (FRC) post extubation has been demonstrated to predict extubation failure, which is a subsequent requirement for increased respiratory support. We have previously shown that the CXR lung area obtained by computer assisted analysis significantly correlated with FRC and, therefore, speculated that a low CXR lung area post extubation would reliably predict extubation failure. The aim of this study was to test the hypothesis by analysing CXRs from 20 infants, with median gestational age of 28 weeks (range 25-33 weeks) and postnatal age 4 days (range 1-11 days). CXRs were obtained within 4 h of extubation and were scanned and analysed using a Power Macintosh computer with a Wacom A5 Ultra pad and NIH image software. The cardiac, mediastinal and thymic shadows, and areas of perihilar and lobar consolidation were subtracted from the thoracic area to give the lung area. Seven infants failed extubation and differed significantly from the rest of the cohort only with regard to their CXR lung area, median gestational age, birth weight and postnatal age. Receiver operator characteristic (ROC) curves were constructed and the areas under each ROC curve were compared. Analysis demonstrated that a low CXR lung area and an older postnatal age were the best predictors of extubation failure. A post-extubation CXR lung area of < 8.5 cm2 had the highest specificity (100%) in predicting extubation failure. We conclude that routine post-extubation CXRs can have a useful role.

Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation

BACKGROUND

This section is under preparation and will be included in the next issue.

OBJECTIVES

To assess the effects of active chest physiotherapy on babies being extubated from mechanical ventilation for neonatal respiratory failure.

SEARCH STRATEGY

The standard search strategy for the Neonatal Review Group was used as outlined in the Cochrane Handbook in the Cochrane Library.

SELECTION CRITERIA

All trials utilising random or quasi-random patient allocation, in which active chest physiotherapy was compared with non-active techniques (eg positioning and suction alone) or no intervention in the periextubation period. The methodological quality of each trial was assessed by two independent authors.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors. The data were analysed from 3 trials. Subgroup analysis was performed on different treatment frequencies.

MAIN RESULTS

In this review of 3 small trials, 2 of which were carried out 10 & 20 years ago, no clear benefit of periextubation active chest physiotherapy can be seen. Active chest physiotherapy did not significantly reduce the rate of postextubation lobar collapse (RR 0.69;0.33,1.45), though a reduction in the use of reintubation was shown in the overall analysis (RR 0.24;0.08,0.75). Subgroup analysis of different treatment frequencies showed the same effect with more frequent treatment (1 & 2 hourly) but showed a trend to increased lobar collapse, and no reduction in the use of reintubation, with less frequent treatment (4 hourly). There is insufficient information to assess other important short and long term outcomes, including adverse effects.

REVIEWER'S CONCLUSIONS

The results of this review do not allow development of clear guidelines for clinical practice. Caution is required when interpreting the possible positive effects of chest physiotherapy of a reduction in the use of reintubation and the trend for decreased post-extubation atelectasis as the numbers of babies studied are small, the results are not consistent across trials, data on safety are insufficient, and applicability to current practice may be limited.