Chest physiotherapy for the medical patient--are current practices effective?

Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours

OBJECTIVE

This study aimed to determine the impact of providing chest physiotherapy after routine clinical assessment on the duration of mechanical ventilation, outcome and intensive care length of stay.

DESIGN AND SETTING

Single-centre, single-blind, prospective, randomised, controlled trial in a university hospital general intensive care unit.

PATIENTS AND PARTICIPANTS

180 patients requiring mechanical ventilation for more than 48 h.

INTERVENTIONS

Patients randomly allocated, one group receiving physiotherapy as deemed appropriate by physiotherapists after routine daily assessments and another group acting as controls were limited to receiving decubitus care and tracheal suctioning.

MEASUREMENTS AND RESULTS

Primary endpoints were initial time to become ventilator-free, secondary endpoints included intensive care unit (ICU) and hospital mortality and ICU length of stay. Kaplan-Meier analysis censored for death revealed a significant prolongation of median time to become ventilator-free among patients receiving physiotherapy (p=0.047). The time taken for 50% of patients (median time) to become ventilator-free was 15 and 11 days, respectively, for physiotherapy and control groups. There were no differences between groups in ICU or hospital mortality rates, or length of ICU stay. The number of patients needing re-ventilation for respiratory reasons was similar in both groups.

Rate and force of application of manual chest percussion by physiotherapists

The rate and force of manual chest percussion as applied by 35 physiotherapists was investigated. The influence of gender, body weight, body mass index (BMI), rate and frequency of usage on force were examined. Percussion was applied to a healthy male for 35 seconds and the rate and force were measured using a force platform. The rate and force varied among subjects. The mean (SD) rate and force of percussion were 6.60 (1.00) Hertz and 58.10 (15.32) Newtons respectively. There was no relationship between force and 1) gender, 2) body weight, 3) BMI or 4) frequency of usage of percussion. A weak relationship was found between rate and force (r = -0.358, p = 0.034). Thirty-two subjects demonstrated a hand dominance.

The effect of breathing exercises with body positioning on regional lung ventilation

This review discusses the distribution of ventilation in the normal adult lung and includes the influence of quiet and deep breathing on regional ventilation. The effects of breathing at low lung volumes; inspiratory flow rate; posture; age; and body weight on ventilation are also described. A selection of breathing exercises are examined with regard to their ability to influence regional ventilation. There is no evidence that breathing control (diaphragmatic breathing exercises) improves regional ventilation to the dependent zones of the lungs. Limited evidence does suggest that thoracic expansion exercises, whereby respiratory muscles are voluntarily contracted to alter regional chest wall expansion, can improve underlying ventilation. However, there remains a paucity of evidence regarding the effects of breathing exercises on regional ventilation.

A comparison of bronchial drainage treatments in cystic fibrosis

We compared standard chest physical therapy and postural drainage (CPT/PD) with a new airway clearance therapy called high-frequency chest wall oscillation (HFCWO) in a group of stable cystic fibrosis (CF) patients. In this crossover trial, 29 CF patients (15 males, 14 females), aged 7-47 years that met the inclusion criteria were randomly assigned to alternate CPT/PD and HFCWO, on a daily basis, over a 4 day period. Each patient received 2 days of each form of therapy; treatment frequency and the length of treatment were the same for both techniques. Expectorated secretions were collected during each 30 minute therapy session and for 15 minutes following treatment. The wet and dry weights of collected secretions were determined gravimetrically, and the therapy methods were compared. Significantly more sputum was expectorated during HFCWO than during CPT/PD as determined by both the wet (P < 0.001) and the dry (P < 0.01) measurements. This study suggests that HFCWO is at least as effective as manual CPT/PD in clearing secretions from the airways in patients with cystic fibrosis.

Fibreoptic bronchoscopy in the critically ill: a prospective study of its diagnostic and therapeutic value

AIM

A prospective study was undertaken to assess the diagnostic value and therapeutic usefulness of fibreoptic bronchoscopy in the critically ill.

METHOD

Fifty-six bronchoscopies were performed in fifty patients. Biochemical, radiological, microbiological and clinical assessments were made before and after each procedure.

RESULTS

Eighteen fibreoptic bronchoscopies were performed for therapeutic indications (32.1%) of which ten (55.6%) yielded a useful outcome. Thirty-eight bronchoscopies were for diagnostic purposes (67.8%) of which 22 (57.9%) were clinically useful. Broncho-alveolar lavage was performed in twenty-eight cases (50%) and it led to a clinically useful diagnosis in 17 (60.7%). There was no major complication. A subgroup of patients was defined (persistent left lower lobe collapse or consolidation following thoracic or abdominal surgery) in whom fibreoptic bronchoscopy usually did not yield a useful outcome.

CONCLUSION

The use of fibreoptic bronchoscopy in the Intensive Care Unit, in combination with the technique of broncho-alveolar lavage, results in a clinically useful outcome in the majority of cases. Fibreoptic bronchoscopy is an effective and safe diagnostic and therapeutic tool in critically ill patients.

Chest physiotherapy for the surgical patient

This article reviews the evidence that chest physiotherapy is effective in the prevention and treatment of pulmonary complications after major abdominal and thoracic surgery. There is some evidence that regular chest physiotherapy significantly decreases the incidence of pulmonary complications, although the mechanism of this effect is uncertain. It is not known whether chest physiotherapy is effective in the treatment of postoperative pulmonary complications after they have developed.