Routine neonatal postextubation chest physiotherapy: a randomized controlled trial

[Respiratory physiotherapy in pediatric practice]

Congestion of the upper (URT) and lower respiratory tracts (LRT) is a common symptom in several acute and chronic respiratory diseases that occur in childhood. To eliminate these secretions, airway clearance techniques (ACT) directed to the URT and LRT are frequently prescribed. The rationale for the application of these techniques is the same as in adults, but they need to be adapted to be transposed to children. The physiotherapist will be able to choose among a wide range of techniques, of which the most adequate will depend not only on the age of the child and the indication, but also on the basis of his preferences or habits, as well as those of the child. Upper airway clearance, including nasal irrigation, is now recommended for acute and chronic rhinosinusitis in children. It is also one of the symptomatic treatments recommended for infants with acute bronchiolitis. For LRT clearance, several indications, such as cystic fibrosis, primary ciliary dyskinesia and neuromuscular disease, are now widely advocated. Conversely, other indications, such as for infants with acute viral bronchiolitis, are highly controversial. Thoughtful application of these techniques is lacking in robust and precise tools to objectively assess the presence of bronchial congestion, and to treat it accordingly. Similarly, no precise and reliable evaluation of the effectiveness of these ACTs is available to date. This review is designed to explore the ACTs used by physiotherapists, to provide an overview of their current indications, and to consider complementary approaches.

Positive versus negative pressure during removal of endotracheal-tube on prevention of post-extubation atelectasis in ventilated neonates: A randomized controlled trial

Background

Post-extubation-atelectasis (PEA) is a common problem after the removal of an endotracheal tube in neonates which increases the rate of extubation failure. Different techniques have been introduced for the prevention of PEA. One technique is the removal of the endotracheal tube by negative or positive gradients of pressure. No RCT has yet been done to compare the use of these two methods in neonates. So this study aimed to compare the role of positive and negative pressure during extubation of neonates on the prevention of PEA.

Materials and methods

We enrolled 100 newborns in this RCT that required at least 24 h of mechanical ventilation. The endotracheal tube in one group was removed by a T-Piece resuscitator at a PEEP level of 5 CmH2o while in another group extubation was done applying suction pressure of 100 mmHg by random selection. Prevalence of PEA in CXRs after extubation was compared between the two groups.

Results

The prevalence of PEA in the extubation of the positive pressure group (24%) was significantly lower than that of the negative pressure group (46%) (p = 0.024). Extubation failure was found to be lower in the positive pressure group (6% versus 20% P = 0.037). No significant difference was observed between the two groups in the prevalence of apnea, pneumothorax, and death at 3 days after extubation.

Conclusion

The use of positive pressure during removal of the endotracheal tube in newborn infants reduced the rate of PEA compared with the negative pressure so extubation by a positive pressure is recommended in neonates.

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Post extubation atelectasis (PEA) is a common problem after the removal of an endotracheal tube in neonates.

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This study compares two different extubation methods for the prevention of PEA in neonates.

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The prevalence of PEA in the extubation with positive pressure method was significantly lower than the negative pressure.

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Extubation by a positive pressure method is recommended in neonates.

Atelectasis and lung changes in preterm neonates in the neonatal period: a blind radiological report and clinical findings

OBJECTIVE

To determine the occurrence and characteristics of atelectasis, opacities, hypolucency and pulmonary infiltrates observed on chest X-rays of preterm infants in a neonatal intensive care unit.

METHODS

This was a cross-sectional observational study. From August to December 2017, all chest radiographs of newborn infants were analyzed. The study included the chest radiographs of preterm neonates with gestational ages up to 36 weeks in the neonatal period that showed clear changes or suspected changes, which were confirmed after a radiologist's report. Radiological changes were associated with possible predisposing factors.

RESULTS

During the study period, 450 radiographs were performed on preterm neonates, and 37 lung changes were identified and classified into 4 types: 12 (2.66%) changes were described as opacities, 11 (2.44%) were described as atelectasis, 10 (2.22%) were described as pulmonary infiltrate, and 4 (0.88%) were described as hypolucency. A higher occurrence of atelectasis was noted in the right lung (81.8%). Among the abnormal radiographs, 25 (67.6%) newborn infants were receiving invasive mechanical ventilation.

CONCLUSION

Considering the radiological report, no significance was found for the observed changes. Atelectasis was not the most frequently observed change. The predisposing factors for these changes were extreme prematurity, low weight, male sex, a poorly positioned endotracheal tube and the use of invasive mechanical ventilation.

Acute Lobar Atelectasis

Lobar atelectasis (or collapse) is an exceedingly common, rather predictable, and potentially pathogenic companion to many forms of acute illness, postoperative care, and chronic debility. Readily diagnosed by using routine chest imaging and bedside ultrasound, the consequences from lobar collapse may be minor or serious, depending on extent, mechanism, patient vulnerability, abruptness of onset, effectiveness of hypoxic vasoconstriction, and compensatory reserves. Measures taken to reduce secretion burden, assure adequate secretion clearance, maintain upright positioning, reverse lung compression, and sustain lung expansion accord with a logical physiologic rationale. Both classification and logical approaches to prophylaxis and treatment of lobar atelectasis derive from a sound mechanistic knowledge of its causation.

Continuing to challenge practice to be evidence based

Practice habits continue in clinical practice despite the availability of research and other forms of evidence that should be used to guide critical care practice interventions. This article is based on a presentation at the 2014 National Teaching Institute of the American Association of Critical-Care Nurses. The article is part of a series of articles that challenge critical care nurses to examine the evidence guiding nursing practice interventions. Four common practice interventions are reviewed: (1) weight-based medication administration, (2) chest tube patency maintenance, (3) daily interruption of sedation, and (4) use of chest physiotherapy in children. For weight-based administration of medication, the patient's actual weight should be measured, rather than using an estimate. The therapeutic effectiveness and dosages of medications used in obese patients must be critically evaluated. Maintaining patency of chest tubes does not require stripping and milking, which probably do more harm than good. Daily interruption of sedation and judicious use of sedatives are appropriate in most patients receiving mechanical ventilation. Traditional chest physiotherapy does not help children with pneumonia, bronchiolitis, or asthma and does not prevent atelectasis after extubation. Critical care nurses are challenged to evaluate their individual practice and to adopt current evidence-based practice interventions into their daily practice.

Post-extubation atelectasis in newborns with surgical diseases: a report of two cases involving the use of a high-flow nasal cannula

Atelectasis is a pulmonary disorder that lengthens the hospitalization time of newborns in intensive care units, resulting in increased morbidity among these infants. High-flow nasal cannulae have been used in newborns to prevent atelectasis and/or expand pulmonary regions affected by atelectasis; however, to date, no evidence-based data regarding this approach have been reported. In this paper, we report on the cases of two male newborn patients. The first and second patients described in this report were hospitalized for a neurosurgical procedure and the treatment of abdominal disease, respectively, and were subjected to invasive mechanical ventilation for 4 and 36 days, respectively. After extubation, these patients continued receiving oxygen therapy but experienced clinical and radiological worsening typical of atelectasis. In both cases, by 24 hours after the implantation of an high-flow nasal cannulae to provide noninvasive support, radiological examinations revealed the complete resolution of atelectasis. In these cases, the use of an high-flow nasal cannulae was effective in reversing atelectasis. Thus, this approach may be utilized as a supplemental noninvasive ventilatory therapy to avoid unnecessary intubation.

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.

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.