J. Paediatr. Child Health (1 992) 28, 297-300
A review of chest physiotherapy in neonatal intensive care units in Australia J. A. LEWIS,' J. L. LACEY2and D. J. HENDERSON-SMART' 'Department of Perinatal Medicine, King George V Hospital, Sydney and 2Department of Physiotherapy, Royal Prince Alfred Hospital, Sydney, Australia
Abstract Clinical techniques and protocols for chest physiotherapy vary greatly from one Neonatal Intensive Care Unit to another. In 1988 a questionnaire designed to investigate differing techniques used was distributed to Neonatal Intensive Care Units (NICU) around Australia. Fourteen of the 15 questionnaires were completed and returned. The results revealed that the methods of chest treatment and the indicators for commencing chest treatment were similar throughout NICU. Both physiotherapists and nursing staff played a role in the performance of chest treatment in all but one unit where it was the responsibility of nursing staff. However, the area in which there was most variability between NICU was the individual treatment protocols emploved pre- and postextubation of the neonate. A review of literature over the past 10 years also demonstrates variability in chest physiotherapy. It was concluded that further well-controlled studies with larger sample sizes are needed to validate the use of chest physiotherapy for the neonate, especially in relation to the techniques and specific protocols employed. Key words:
chest physiotherapy: neonatal intensive care; newborn infant.
Chest physiotherapy is routinely used in Neonatal Intensive Care Units (NICU) throughout Australia as part of the overall care of respiratory conditions in the neonate.'S2 With the advances in medical management and technology of modern neonatal intensive care, there is an increase in the number of surviving infants of very low birthweight (VLBW: 51500 9). A study by Stewart et a13 examined the literature on the outcome of VLBW infants over a 32 year time period (1946-78). From 1960 onwards, there was a significantly larger proportion of VLBW infants surviving. Yu et a14 also found an improved survival rate in that 79% of 375 VLBW infants born between 1977 and 1980 survived their initial hospitalization. Of the survivors with prolonged hospitalization, 67% required oxygen therapy and 59% received assisted ventilation. With such a high proportion of these infants requiring prolonged ventilatory support, respiratory complications such as mucous plugging and lobar/lung collapse may be encountered suggesting an important management role for the physiotherapist in evaluating and providing chest physiotherapy for the neonate. In order to examine and evaluate the current clinical practices used in NICU. a literature review covering the past 10 years concerning chest physiotherapy for the neonate was undertaken. The studies were divided into three sections examining the effects of chest physiotherapy on the neonate, specific techniques utilized, and the effect of physiotherapy on postextubation atelectasis. A survey of Australian NICU was undertaken subsequently.
Correspondence: Ms J. A. Lewis, Departmentof Perinatal Medicine, King George V Hospital, Missenden Rd. Camperdown, NSW 2050, Australia. J. A. Lewis, BAppSc(Phty), Physiotherapist. J. L. Lacey, DipPhys, Physiotherapy Co-ordinator of Neurology and Perinatology. D. J. Henderson-Smart, FRACP, PhD, Professor of Perinatal Medicine. Accepted for publication 22 July 1991.
LITERATURE REVIEW The effects of chest physiotherapy on the neonate Etches and Scott' examined the amount of secretions removed by physiotherapy. They compared physiotherapy with postsuction only on a sample of six infants, of which two-thirds (4 of 6) were extubated and respiratory problems were varied. Treatment consisted of postural drainage, manual vibration and percussion administered 4-hourly. This was found to increase the weight and removal of secretions in neonates with a secretion problem. Fox et a16 measured the physiological alteration in respiratory function associated with chest physiotherapy in 13 neonates in order to determine the risk-benefit ratio. Physiological alterations were measured during the control period, after physiotherapy and suctioning, after hyperventilation. and 2 h after suctioning. The treatment consisted of positioning the neonate in supine, vibration of the chest wall with a mechanical vibrator for 30 s, and suction. Postsuction. there was a significant decrease in Paop. which increased significantly posthyperventilation. It was concluded that, due to potential hypoxaemia, physiotherapy with suctioning was not warranted in neonates recovering from respiratory problems. A major difficulty with this study was that it was not possible to distinguish separately the treatment effects of physiotherapy or suctioning. Finer and Boyd' studied the effect of postural drainage versus postural drainage with percussion in a sample of 20 neonates with respiratory distress of various aetiologies. Chest treatment consisted of postural drainage of the basal segments with contact-heel percussion or postural drainage alone, followed by suctioning. The results showed that there was a significant increase in Pao2 immediately following postural drainage with percussion but not with postural drainage alone. Despite the fact that these studies suggest that physiotherapy may be of benefit, the issue remains controversial. The com-
J. A. Lewis et a/.
298
parison of results from differing studies is difficult because of the varying physiotherapy regimens and differing samples utilized in each study.
Specific physiotherapy techniques used Tudehope and Bagley’ conducted a study to compare three physiotherapy techniques: contact-heel percussion, cupping with the Bennett face mask and electric toothbrush vibration. The sample of 15 neonates all required mechanical ventilation because of respiratory distress syndrome (RDS).The three techniques were studied 2 h apart on each neonate, each being performed in four drainage positions, followed by suctioning. Percussion was tolerated best with vibration being tolerated least. Problems in maintaining the Pao2postsuctioning were encountered. Curran and KachoyeanosQ compared the effects of two methods of chest physiotherapy on a small sample of six neonates with RDS. One group was treated with an electric toothbrush for 1 min, the second group with a padded nipple for 1 min, and the control group had no physiotherapy at all, only suctioning. The results revealed that the neonates treated with clearer the electric toothbrush had a significantly higher fao2, breath sounds and better tissue perfusion. There was a significant increase in heart rate, respiratory rate and activity levels post-treatment in all three groups, suggesting that this deterioration may have been associated with the suctioning. Peters’O compared the two physiotherapy techniques of cupping with the Bennett face mask versus contact-heel percussion using a sample of 30 neonates with RDS. The treatment regimen was postural drainage of the upper and lower lobes with percussion/cupping for 5 min in each position, followed by suctioning. Results indicated there was an increase in heart rate, mean arterial pressure and intracranial pressure, increased oxygen requirements and longer periods of hypoxia and hyperoxia postsuctioning with both physiotherapy techniques, but these effects were greater with cupping. There was an improvement in the A-aO;! gradient after percussion. A recent study by Duara ef a/.’’ compares percussion time intervals of 0.5, 1.5 and 2.5 min. The sample consisted of six neonates with RDS involved in a regimen of six postural drainage positions per session, at 2-hourly intervals, for three sessions. Findings demonstrated that in all three intervals there was a decrease in transcutaneous oximetry ( Tcfo2) but the group with the 2.5 min percussion interval produced the greatest improvement without any greater decrease in Tcfo2. These studies suggest that physiotherapy was associated with a deterioration in physiological parameters of the neonate, but it is difficult to ascertain how much of this deterioration was related to the physiotherapy and how much to the suctioning. It is also not possible to compare physiotherapy techniques accurately because of the varying treatment regimens, but the studies suggest that percussion may be more effective.
The etfect that chest physiotherapy has on postextubation atelectasis (PEA) Finer et a/.’2conducted a retrospective review and a prospective controlled study involving 85 neonates to determine the role of chest physiotherapy in the prevention of PEA. An intensive physiotherapy routine consisting of hourly and 2-hourly treat-
ment for the first 24 h, and 3-hourly treatment for a further 24 h was performed.A significant decrease in the occurrence of PEA was demonstrated following physiotherapy. It was concluded that infants extubated after more than 24 h of intubation benefited significantly from chest physiotherapy. Vivian-Beresford ef a/.’3 investigated the effect that different time intervals between physiotherapy may have on PEA. The sample consisted of 32 neonates with respiratory distress, randomly assigned to one of four groups with varying frequency of treatment: hourly, 2-, 4-hourly and no treatment. A specific physiotherapy regimen of postural drainage and percussion was performed 1 h prior to extubation and at postextubation, with the frequency depending upon the assigned group. Due to the small sample size, the sample was divided into two rather than four groups for data analysis: (group 1) hourly physiotherapy and the no treatment control group, and (group 2) combined 2- and 4-hourly treatment group. The authors found a significant decrease in poor outcome of infants in group 2, thereby supporting the use of 2-4-hourly postextubation treatment as a more effective regimen. In summary, these studies suggest that chest physiotherapy may have a role in the prevention of postextubation complications, but further research is needed to confirm the type of physiotherapy routine required. In reviewing the literature of the past 10 years, it is difficult to draw firm conclusions regarding chest physiotherapy in the management of the neonate. Few comparisons between studies can be made because of the varying physiotherapy treatments, the small sample sizes and the differing respiratory conditions of the neonate in each study.
SURVEY OF AUSTRALIAN NlCU Method A questionnaire consisting of 10 items regarding chest physiotherapy in the neonate was developed (see Appendix 1). Most questions requested the respondent to select the appropriate answer from given alternatives and asked for comment where necessary. Pre- and postextubation protocols had to be described specifically by respondents because of the variability involved. The questionnaire was distributed by mail to 15 level 3 NlCU around Australia: three in Victoria, seven in New South Wales, two in Western Australia and one in Queensland.
Results Of the 15 questionnaires distributed, 14 were returned. In eight NlCU (57%) the questionnaire was completed by the neonatologist, in four units (29%) by the physiotherapist: in one unit (7%) by the neonatologistand nursing staff combined and in one unit (7%) by the neonatologist and physiotherapist. Chest treatments were performed by nursing staff and physiotherapists in 11 NlCU (79%). In two units, treatments were performed by nursing staff with occasional input from the physiotherapist and in one unit all treatments were performed by nursing staff only. All units provided a 24 h service for chest treatments but only two NlCU (14%) provided an on-call physiotherapist who was available overnight.
Chest physiotherapy in neonatal ICU
Criteria for initiation and cessation of treatment The criteria for initiation of chest treatment in 12 NlCU (86%) were a combination of chest X-ray changes and endotracheal tube (ETT)/oropharyngeal (OP) aspirate changes. Aspirate changes included an increase in volume and/or viscosity of secretions, and/or mucous plugging. The remaining two units used the criteria of aspirate or chest X-ray changes separately. Some factors delaying the commencement of chest treatment included low gestational age (two units: 14Oh) and/ortime on the ventilator before the infant was considered stable (five units: 36%). The criteria for cessation of chest treatment in seven NlCU (50%) were a combination of improved chest X-ray and a decrease in viscosity and/or volume of ETT/OP aspirate; two units combined chest X-ray changes, aspirates and/or extubation; three units used ETT/OP aspirate changes only; and the remaining two units considered chest X-ray changes and the neonate’s clinical condition as criteria for cessation of chest treatment. A specific pre-extubation chest treatment protocol for every ventilated baby was followed in nine NlCU (64%), while 10 NlCU (71%) followed a specific postextubation protocol. Of the remaining four units, two had no routine physiotherapy protocol postextubation, and two continued with the infant’s previously prescribed treatment.The intensity of the postextubation protocol varied widely, ranging from nasal suctions every 15 min for the first hour followed by 2-hourly treatment at one unit, to 4-6 hourly treatment for 24 h commencing 2 h postextubation at another unit. Because of the great contrasts seen in postextubation protocols, it was inappropriate to list each unit’s response separately, but this information is available upon request. Chest treatments in all units combined postural drainage with percussion and/or vibration; six (43%) of these used appliances as an adjunct to treatment but manual techniques were preferred. The appliances used were the Bennett face mask in four units, the Laerdel bag mask in one unit and the electric toothbrush in two units. Similarly, both percussion and/or vibration with postural drainage were utilized in the treatment of lung collapse. With regard to changes in the frequency of chest treatments over the last 5 years, five units (36%) stated that there was no change, four units (28%) experienced a decrease and five units an increase in the frequency of chest treatments. On considering the number of babies treated over this time frame, six units (43%) stated that there was no change, one unit had a decrease and the remaining seven units (50%) had an increase in the number of babies treated.
Discussion This report was designed to investigate the variability in published research and in the practical application of chest physiotherapy techniques and regimens in neonates. There is great variability in clinical practice in management and in treatment protocols, in particular that of pre- and postextubation. The range of postextubation treatment protocols used in NlCU was remarkable, ranging from no treatment at all to half-hourly treatment over a 24-48 h time period. Preextubation protocols are less varied in the clinical setting, but in some units the neonate is treated up to three times prior to extubation whereas in others there is no treatment at all. On review of the literature, two articles examined PEA but only one compared the frequency of treatments in terms of its
299
benefits. Unfortunately the sample size was too small to be able to draw any conclusions. Some specific physiotherapy techniques have been compared empirically. In most studies the sample size was small and the respiratory status of the neonate was variable, there was no consistency in treatment protocols therefore precluding comparisons between studies, and longterm effects such as length of time on the ventilator and total days in oxygen were not considered. Studies using Pao2 as a dependent variable to assess the influence of chest physiotherapy did not consider the behavioural state of the neonate. A study by Martin et found that the Pao2was significantly lower and more variable during active sleep than quiet sleep, thus emphasizing the need to control for the behavioural state of the infant. Despite the increasing rate of survival of the critically ill neonate, including those of VLBW who may require prolonged ventilatory upp port,^^^ few controlled studies have been attempted to evaluate objectively the risk-benefit ratio of chest physiotherapy for the critically ill neonate, let alone the large variety of techniques, treatment times and protocols being utilized in Australia. It is generally accepted that chest physiotherapy can be of benefit to neonates with a respiratory secretion problem such as increased volume of secretions, mucous plugging and lobar/ lung collapse. However, the potential complications of hypoxaemia and deterioration in other physiological parameters should not be ignored. In the studies reviewed, this deterioration could be the effect of suctioning rather than individual physiotherapy techniques alone, as most studies did not separate these procedures. There does not appear to be any supporting evidence for the use of prophylactic chest physiotherapy for the neonate whose clinical course is not complicated by adherent or plugging secretions. Our review of the literature and the results of this study lead us to conclude that there is a need for further research in this area to compare the benefits of the various methods of chest physiotherapy in the neonate.
REFERENCES 1 Crane L. Physical therapy for neonates with respiratory dysfunction. Phys. Ther. 1981; 61: 1764-73. 2 Bertone N. The role of physiotherapy in a neonatal intensive care unit. Aust. J. Physiother. 1988; 34: 27-34.
3 Stewart A.. Reynolds E., Lipscomb A. Outcome for infants of very low birthweight: survey of world literature. Lancet 1981; i:1038-41. 4 Yu V., Kinlay S.. Orgill A,, Bajuk B., Astbury J. Outcome of very low birthweight infants who required prolonged hospitalization. Aust. Paediatr. J. 1984; 20: 293-6. 5 Etches P., Scotl 6. Chest physiotherapy in the newborn: Effect on secretions removed. Pediatrics 1978; 62: 713-1 5. 6 Fox W., Schwartz J., Shaffer T. Pulmonary physiotherapy in neonates: Physiologicalchanges and respiratory management.J. Pediatr.1978; 92: 977-81. 7 Finer N.. Boyd J. Chest physiotherapy in the neonate: A controlled study. Pediatrics1978; 61: 282-5. 8 Tudehope D.. Bagley C. Techniques of physiotherapy in intubated babies with the respiratory distress syndrome. Aust. Paediatr. J. 1980; 16: 226-8. 9 Curran C., Kachoyeanous M. The effects on neonates on 2 methods of chest physical therapy. Matern. Child Nurs. 1979;4: 309-13. 10 Peters K. The physiological responses of the respiratory distressed neonates to 2 forms of chest physiotherapy. Unpublished thesis, Edmonton, Canada 1983.
300
11 Duara
S..Bessard K., Keszler L., Artes D.. Batzer K. Evaluation of different percussion time intervalsof chest physiotherapy on neonatal pulmonary function parameters. Pediatr. Res. 1983; 17: 310A (Abstr.). 12 Finer N.. Moriartey R.. Boyd J., Phillips H., Stewart A,, Ulan 0. Postextubation atelectasis: A retrospective review and a prospective controlled study. J. Pediatr. 1979; 94: 110-13. 13 Vivian-Beresford A,. King C.. Macauley H. Neonatal postextubation complications:The preventive role of physiotherapy. Physiother. Can. 1987; 39:184-90. 14 Martin R., Okken A,. Rubin D. Arterial oxygen tension during active and quiet sleep in the normal neonate. J. Pediatr. 1979;94: 271 -4.
APPENDIX 1 . QUESTIONNAIRE ON NEONATAL CHEST TREATMENT Please circle the appropriate answer /s and comment where applicable: 1 Person completing this questionnaire a Neonatalogist b Physiotherapist c Nurse d Other. Please state 2 Staff members performing chest treatments on the babies are a Nursing staff b Physiotherapists c Physiotherapist assesses but treatment is by other staff. Please state
J. A. Lewis e l a/.
3 Is physiotherapy treatment available as a 24-h service? a Yes b No 4 Decision to commence chest treatment is based on a Chest X-ray b ETT aspirate c Period of time on the ventilator. Please state d Gestational age. Please state e Regimen for a specific condition. Please state f Other. Please state 5 Treatment regimen prior to extubation. Please state 6 Treatment regimen postextubation. Please state 7 The following procedures used for chest treatments a Postural drainage b Percussions and vibrations c Appliances. Please state 8 Collapse on chest X-ray is treated by a Posturally draining the area of collapse only b Using physiotherapy techniques with postural drainage 9 Cessation of chest treatment is based on a Chest X-ray b ETT aspirate or oropharyngeal aspirate if extubated c Extubation d Other. Please state 10 Any changes in a the frequency of chest treatments over the last 5 years increased, decreased, unchanged b the number of babies treated over the last 5 years increased, decreased, unchanged
A review of chest physiotherapy in neonatal intensive care units in Australia J. A. LEWIS,' J. L. LACEY2and D. J. HENDERSON-SMART' 'Department of Perinatal Medicine, King George V Hospital, Sydney and 2Department of Physiotherapy, Royal Prince Alfred Hospital, Sydney, Australia
Abstract Clinical techniques and protocols for chest physiotherapy vary greatly from one Neonatal Intensive Care Unit to another. In 1988 a questionnaire designed to investigate differing techniques used was distributed to Neonatal Intensive Care Units (NICU) around Australia. Fourteen of the 15 questionnaires were completed and returned. The results revealed that the methods of chest treatment and the indicators for commencing chest treatment were similar throughout NICU. Both physiotherapists and nursing staff played a role in the performance of chest treatment in all but one unit where it was the responsibility of nursing staff. However, the area in which there was most variability between NICU was the individual treatment protocols emploved pre- and postextubation of the neonate. A review of literature over the past 10 years also demonstrates variability in chest physiotherapy. It was concluded that further well-controlled studies with larger sample sizes are needed to validate the use of chest physiotherapy for the neonate, especially in relation to the techniques and specific protocols employed. Key words:
chest physiotherapy: neonatal intensive care; newborn infant.
Chest physiotherapy is routinely used in Neonatal Intensive Care Units (NICU) throughout Australia as part of the overall care of respiratory conditions in the neonate.'S2 With the advances in medical management and technology of modern neonatal intensive care, there is an increase in the number of surviving infants of very low birthweight (VLBW: 51500 9). A study by Stewart et a13 examined the literature on the outcome of VLBW infants over a 32 year time period (1946-78). From 1960 onwards, there was a significantly larger proportion of VLBW infants surviving. Yu et a14 also found an improved survival rate in that 79% of 375 VLBW infants born between 1977 and 1980 survived their initial hospitalization. Of the survivors with prolonged hospitalization, 67% required oxygen therapy and 59% received assisted ventilation. With such a high proportion of these infants requiring prolonged ventilatory support, respiratory complications such as mucous plugging and lobar/lung collapse may be encountered suggesting an important management role for the physiotherapist in evaluating and providing chest physiotherapy for the neonate. In order to examine and evaluate the current clinical practices used in NICU. a literature review covering the past 10 years concerning chest physiotherapy for the neonate was undertaken. The studies were divided into three sections examining the effects of chest physiotherapy on the neonate, specific techniques utilized, and the effect of physiotherapy on postextubation atelectasis. A survey of Australian NICU was undertaken subsequently.
Correspondence: Ms J. A. Lewis, Departmentof Perinatal Medicine, King George V Hospital, Missenden Rd. Camperdown, NSW 2050, Australia. J. A. Lewis, BAppSc(Phty), Physiotherapist. J. L. Lacey, DipPhys, Physiotherapy Co-ordinator of Neurology and Perinatology. D. J. Henderson-Smart, FRACP, PhD, Professor of Perinatal Medicine. Accepted for publication 22 July 1991.
LITERATURE REVIEW The effects of chest physiotherapy on the neonate Etches and Scott' examined the amount of secretions removed by physiotherapy. They compared physiotherapy with postsuction only on a sample of six infants, of which two-thirds (4 of 6) were extubated and respiratory problems were varied. Treatment consisted of postural drainage, manual vibration and percussion administered 4-hourly. This was found to increase the weight and removal of secretions in neonates with a secretion problem. Fox et a16 measured the physiological alteration in respiratory function associated with chest physiotherapy in 13 neonates in order to determine the risk-benefit ratio. Physiological alterations were measured during the control period, after physiotherapy and suctioning, after hyperventilation. and 2 h after suctioning. The treatment consisted of positioning the neonate in supine, vibration of the chest wall with a mechanical vibrator for 30 s, and suction. Postsuction. there was a significant decrease in Paop. which increased significantly posthyperventilation. It was concluded that, due to potential hypoxaemia, physiotherapy with suctioning was not warranted in neonates recovering from respiratory problems. A major difficulty with this study was that it was not possible to distinguish separately the treatment effects of physiotherapy or suctioning. Finer and Boyd' studied the effect of postural drainage versus postural drainage with percussion in a sample of 20 neonates with respiratory distress of various aetiologies. Chest treatment consisted of postural drainage of the basal segments with contact-heel percussion or postural drainage alone, followed by suctioning. The results showed that there was a significant increase in Pao2 immediately following postural drainage with percussion but not with postural drainage alone. Despite the fact that these studies suggest that physiotherapy may be of benefit, the issue remains controversial. The com-
J. A. Lewis et a/.
298
parison of results from differing studies is difficult because of the varying physiotherapy regimens and differing samples utilized in each study.
Specific physiotherapy techniques used Tudehope and Bagley’ conducted a study to compare three physiotherapy techniques: contact-heel percussion, cupping with the Bennett face mask and electric toothbrush vibration. The sample of 15 neonates all required mechanical ventilation because of respiratory distress syndrome (RDS).The three techniques were studied 2 h apart on each neonate, each being performed in four drainage positions, followed by suctioning. Percussion was tolerated best with vibration being tolerated least. Problems in maintaining the Pao2postsuctioning were encountered. Curran and KachoyeanosQ compared the effects of two methods of chest physiotherapy on a small sample of six neonates with RDS. One group was treated with an electric toothbrush for 1 min, the second group with a padded nipple for 1 min, and the control group had no physiotherapy at all, only suctioning. The results revealed that the neonates treated with clearer the electric toothbrush had a significantly higher fao2, breath sounds and better tissue perfusion. There was a significant increase in heart rate, respiratory rate and activity levels post-treatment in all three groups, suggesting that this deterioration may have been associated with the suctioning. Peters’O compared the two physiotherapy techniques of cupping with the Bennett face mask versus contact-heel percussion using a sample of 30 neonates with RDS. The treatment regimen was postural drainage of the upper and lower lobes with percussion/cupping for 5 min in each position, followed by suctioning. Results indicated there was an increase in heart rate, mean arterial pressure and intracranial pressure, increased oxygen requirements and longer periods of hypoxia and hyperoxia postsuctioning with both physiotherapy techniques, but these effects were greater with cupping. There was an improvement in the A-aO;! gradient after percussion. A recent study by Duara ef a/.’’ compares percussion time intervals of 0.5, 1.5 and 2.5 min. The sample consisted of six neonates with RDS involved in a regimen of six postural drainage positions per session, at 2-hourly intervals, for three sessions. Findings demonstrated that in all three intervals there was a decrease in transcutaneous oximetry ( Tcfo2) but the group with the 2.5 min percussion interval produced the greatest improvement without any greater decrease in Tcfo2. These studies suggest that physiotherapy was associated with a deterioration in physiological parameters of the neonate, but it is difficult to ascertain how much of this deterioration was related to the physiotherapy and how much to the suctioning. It is also not possible to compare physiotherapy techniques accurately because of the varying treatment regimens, but the studies suggest that percussion may be more effective.
The etfect that chest physiotherapy has on postextubation atelectasis (PEA) Finer et a/.’2conducted a retrospective review and a prospective controlled study involving 85 neonates to determine the role of chest physiotherapy in the prevention of PEA. An intensive physiotherapy routine consisting of hourly and 2-hourly treat-
ment for the first 24 h, and 3-hourly treatment for a further 24 h was performed.A significant decrease in the occurrence of PEA was demonstrated following physiotherapy. It was concluded that infants extubated after more than 24 h of intubation benefited significantly from chest physiotherapy. Vivian-Beresford ef a/.’3 investigated the effect that different time intervals between physiotherapy may have on PEA. The sample consisted of 32 neonates with respiratory distress, randomly assigned to one of four groups with varying frequency of treatment: hourly, 2-, 4-hourly and no treatment. A specific physiotherapy regimen of postural drainage and percussion was performed 1 h prior to extubation and at postextubation, with the frequency depending upon the assigned group. Due to the small sample size, the sample was divided into two rather than four groups for data analysis: (group 1) hourly physiotherapy and the no treatment control group, and (group 2) combined 2- and 4-hourly treatment group. The authors found a significant decrease in poor outcome of infants in group 2, thereby supporting the use of 2-4-hourly postextubation treatment as a more effective regimen. In summary, these studies suggest that chest physiotherapy may have a role in the prevention of postextubation complications, but further research is needed to confirm the type of physiotherapy routine required. In reviewing the literature of the past 10 years, it is difficult to draw firm conclusions regarding chest physiotherapy in the management of the neonate. Few comparisons between studies can be made because of the varying physiotherapy treatments, the small sample sizes and the differing respiratory conditions of the neonate in each study.
SURVEY OF AUSTRALIAN NlCU Method A questionnaire consisting of 10 items regarding chest physiotherapy in the neonate was developed (see Appendix 1). Most questions requested the respondent to select the appropriate answer from given alternatives and asked for comment where necessary. Pre- and postextubation protocols had to be described specifically by respondents because of the variability involved. The questionnaire was distributed by mail to 15 level 3 NlCU around Australia: three in Victoria, seven in New South Wales, two in Western Australia and one in Queensland.
Results Of the 15 questionnaires distributed, 14 were returned. In eight NlCU (57%) the questionnaire was completed by the neonatologist, in four units (29%) by the physiotherapist: in one unit (7%) by the neonatologistand nursing staff combined and in one unit (7%) by the neonatologist and physiotherapist. Chest treatments were performed by nursing staff and physiotherapists in 11 NlCU (79%). In two units, treatments were performed by nursing staff with occasional input from the physiotherapist and in one unit all treatments were performed by nursing staff only. All units provided a 24 h service for chest treatments but only two NlCU (14%) provided an on-call physiotherapist who was available overnight.
Chest physiotherapy in neonatal ICU
Criteria for initiation and cessation of treatment The criteria for initiation of chest treatment in 12 NlCU (86%) were a combination of chest X-ray changes and endotracheal tube (ETT)/oropharyngeal (OP) aspirate changes. Aspirate changes included an increase in volume and/or viscosity of secretions, and/or mucous plugging. The remaining two units used the criteria of aspirate or chest X-ray changes separately. Some factors delaying the commencement of chest treatment included low gestational age (two units: 14Oh) and/ortime on the ventilator before the infant was considered stable (five units: 36%). The criteria for cessation of chest treatment in seven NlCU (50%) were a combination of improved chest X-ray and a decrease in viscosity and/or volume of ETT/OP aspirate; two units combined chest X-ray changes, aspirates and/or extubation; three units used ETT/OP aspirate changes only; and the remaining two units considered chest X-ray changes and the neonate’s clinical condition as criteria for cessation of chest treatment. A specific pre-extubation chest treatment protocol for every ventilated baby was followed in nine NlCU (64%), while 10 NlCU (71%) followed a specific postextubation protocol. Of the remaining four units, two had no routine physiotherapy protocol postextubation, and two continued with the infant’s previously prescribed treatment.The intensity of the postextubation protocol varied widely, ranging from nasal suctions every 15 min for the first hour followed by 2-hourly treatment at one unit, to 4-6 hourly treatment for 24 h commencing 2 h postextubation at another unit. Because of the great contrasts seen in postextubation protocols, it was inappropriate to list each unit’s response separately, but this information is available upon request. Chest treatments in all units combined postural drainage with percussion and/or vibration; six (43%) of these used appliances as an adjunct to treatment but manual techniques were preferred. The appliances used were the Bennett face mask in four units, the Laerdel bag mask in one unit and the electric toothbrush in two units. Similarly, both percussion and/or vibration with postural drainage were utilized in the treatment of lung collapse. With regard to changes in the frequency of chest treatments over the last 5 years, five units (36%) stated that there was no change, four units (28%) experienced a decrease and five units an increase in the frequency of chest treatments. On considering the number of babies treated over this time frame, six units (43%) stated that there was no change, one unit had a decrease and the remaining seven units (50%) had an increase in the number of babies treated.
Discussion This report was designed to investigate the variability in published research and in the practical application of chest physiotherapy techniques and regimens in neonates. There is great variability in clinical practice in management and in treatment protocols, in particular that of pre- and postextubation. The range of postextubation treatment protocols used in NlCU was remarkable, ranging from no treatment at all to half-hourly treatment over a 24-48 h time period. Preextubation protocols are less varied in the clinical setting, but in some units the neonate is treated up to three times prior to extubation whereas in others there is no treatment at all. On review of the literature, two articles examined PEA but only one compared the frequency of treatments in terms of its
299
benefits. Unfortunately the sample size was too small to be able to draw any conclusions. Some specific physiotherapy techniques have been compared empirically. In most studies the sample size was small and the respiratory status of the neonate was variable, there was no consistency in treatment protocols therefore precluding comparisons between studies, and longterm effects such as length of time on the ventilator and total days in oxygen were not considered. Studies using Pao2 as a dependent variable to assess the influence of chest physiotherapy did not consider the behavioural state of the neonate. A study by Martin et found that the Pao2was significantly lower and more variable during active sleep than quiet sleep, thus emphasizing the need to control for the behavioural state of the infant. Despite the increasing rate of survival of the critically ill neonate, including those of VLBW who may require prolonged ventilatory upp port,^^^ few controlled studies have been attempted to evaluate objectively the risk-benefit ratio of chest physiotherapy for the critically ill neonate, let alone the large variety of techniques, treatment times and protocols being utilized in Australia. It is generally accepted that chest physiotherapy can be of benefit to neonates with a respiratory secretion problem such as increased volume of secretions, mucous plugging and lobar/ lung collapse. However, the potential complications of hypoxaemia and deterioration in other physiological parameters should not be ignored. In the studies reviewed, this deterioration could be the effect of suctioning rather than individual physiotherapy techniques alone, as most studies did not separate these procedures. There does not appear to be any supporting evidence for the use of prophylactic chest physiotherapy for the neonate whose clinical course is not complicated by adherent or plugging secretions. Our review of the literature and the results of this study lead us to conclude that there is a need for further research in this area to compare the benefits of the various methods of chest physiotherapy in the neonate.
REFERENCES 1 Crane L. Physical therapy for neonates with respiratory dysfunction. Phys. Ther. 1981; 61: 1764-73. 2 Bertone N. The role of physiotherapy in a neonatal intensive care unit. Aust. J. Physiother. 1988; 34: 27-34.
3 Stewart A.. Reynolds E., Lipscomb A. Outcome for infants of very low birthweight: survey of world literature. Lancet 1981; i:1038-41. 4 Yu V., Kinlay S.. Orgill A,, Bajuk B., Astbury J. Outcome of very low birthweight infants who required prolonged hospitalization. Aust. Paediatr. J. 1984; 20: 293-6. 5 Etches P., Scotl 6. Chest physiotherapy in the newborn: Effect on secretions removed. Pediatrics 1978; 62: 713-1 5. 6 Fox W., Schwartz J., Shaffer T. Pulmonary physiotherapy in neonates: Physiologicalchanges and respiratory management.J. Pediatr.1978; 92: 977-81. 7 Finer N.. Boyd J. Chest physiotherapy in the neonate: A controlled study. Pediatrics1978; 61: 282-5. 8 Tudehope D.. Bagley C. Techniques of physiotherapy in intubated babies with the respiratory distress syndrome. Aust. Paediatr. J. 1980; 16: 226-8. 9 Curran C., Kachoyeanous M. The effects on neonates on 2 methods of chest physical therapy. Matern. Child Nurs. 1979;4: 309-13. 10 Peters K. The physiological responses of the respiratory distressed neonates to 2 forms of chest physiotherapy. Unpublished thesis, Edmonton, Canada 1983.
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S..Bessard K., Keszler L., Artes D.. Batzer K. Evaluation of different percussion time intervalsof chest physiotherapy on neonatal pulmonary function parameters. Pediatr. Res. 1983; 17: 310A (Abstr.). 12 Finer N.. Moriartey R.. Boyd J., Phillips H., Stewart A,, Ulan 0. Postextubation atelectasis: A retrospective review and a prospective controlled study. J. Pediatr. 1979; 94: 110-13. 13 Vivian-Beresford A,. King C.. Macauley H. Neonatal postextubation complications:The preventive role of physiotherapy. Physiother. Can. 1987; 39:184-90. 14 Martin R., Okken A,. Rubin D. Arterial oxygen tension during active and quiet sleep in the normal neonate. J. Pediatr. 1979;94: 271 -4.
APPENDIX 1 . QUESTIONNAIRE ON NEONATAL CHEST TREATMENT Please circle the appropriate answer /s and comment where applicable: 1 Person completing this questionnaire a Neonatalogist b Physiotherapist c Nurse d Other. Please state 2 Staff members performing chest treatments on the babies are a Nursing staff b Physiotherapists c Physiotherapist assesses but treatment is by other staff. Please state
J. A. Lewis e l a/.
3 Is physiotherapy treatment available as a 24-h service? a Yes b No 4 Decision to commence chest treatment is based on a Chest X-ray b ETT aspirate c Period of time on the ventilator. Please state d Gestational age. Please state e Regimen for a specific condition. Please state f Other. Please state 5 Treatment regimen prior to extubation. Please state 6 Treatment regimen postextubation. Please state 7 The following procedures used for chest treatments a Postural drainage b Percussions and vibrations c Appliances. Please state 8 Collapse on chest X-ray is treated by a Posturally draining the area of collapse only b Using physiotherapy techniques with postural drainage 9 Cessation of chest treatment is based on a Chest X-ray b ETT aspirate or oropharyngeal aspirate if extubated c Extubation d Other. Please state 10 Any changes in a the frequency of chest treatments over the last 5 years increased, decreased, unchanged b the number of babies treated over the last 5 years increased, decreased, unchanged
