1981; 61:1724-1736. PHYS THER.

Colleen M Kigin
Traumatic Injury Patient
Chest Physical Therapy for the Postoperative or
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Chest Physical Therapy for the Postoperative
or Traumatic Injury Patient
COLLEEN M. KIGIN, MS
Techniques of chest physical therapy have been used since the early 1900s to
decrease postoperative pulmonary complications. Through investigations since
the 1950s, documentation as to the efficacy of chest physical therapy in actually
reducing postoperative pulmonary complications has been published. However,
the careful documentation of techniques employed (such as full Trendelenburg's
position versus a modified position and vibration of particular force and fre-
quency) has not been done. Also, because of an inability to specify the risk
factors of postoperative pulmonary complications occurring in particular pa-
tients or to qualitate the occurrence of these complications, it is difficult to
establish what treatment is most efficacious. This article is a critical review of
investigations to date with recommendations for further research stemming from
this review.
Key Words: Respiratory dysfunction, Treatment techniques, Physical therapy.
Operative procedures and the care of trauma vic-
tims have been recorded for centuries, with open
chest surgery performed in Galen's time.
1
As a result
of advances over the past two centuries in mechanical
ventilation, anesthesia, and infection control the es-
timated number of surgical procedures in the United
States in 1979 was 23,858,000. Included in this num-
ber were 445,000 cholecystectomies, 166,000 open
heart operations, and 813,000 respiratory procedures.
2
The incidence of trauma has also been increasing in
the United States and, in 1979, accounted for 65,000
hospital beds, and 22,000,000 bed days.
3
Although operative procedures are vast in number,
sophisticated in techniques, and remarkable in results,
they continue to harbor significant risks. Respiratory
failure is either a major cause or a major contributing
factor in 50 percent of postoperative deaths.
1
Treat-
ment to prevent or modify respiratory complications
has been a major focus of care for the operative
patient. Since 1915, physical therapy has been widely
used to prevent or reverse respiratory complications
of surgery and trauma.
4-9
The purpose of this paper is to review physical
therapy used for postoperative or traumatic injury
patients. This review will define and critically review
postoperative pulmonary complications (PPC), and
evaluative and therapeutic procedures used for the
above types of patients. Needed investigations in
chest physical therapy (CPT) will be proposed.
POSTOPERATIVE PULMONARY
COMPLICATIONS
Anesthesia and medication result in some degree
of respiratory depression in postoperative patients.
10
Transient hypoxemia, first noted by Overholt in the
1930s, is a common finding in the early postoperative
hours.
11, 12
Supplemental oxygen, deep breathing, and
coughing are routinely used to prevent PPC. Despite
these preventive efforts, patients develop PPC (in-
cluding atelectasis, which makes up 90 percent of
PPC).
1
Pasteur, in 1908, was the first to recognize atelec-
tasis in the postoperative patient.
13
Atelectasis, of
Greek derivation meaning lack of expansion, is syn-
onomous with alveolar collapse. Palmer stated, in
1952, that atelectasis was the most common PPC and
it remains so today.
14, 15
The primary causes of atelectasis include hypoven-
tilation caused by obstruction of airways by secre-
tions, decreased activity of the respiratory muscles,
and decreased expiratory reserve volume.
15
Preoper-
ative medications, anesthetic agents, and drugs given
in the intraoperative period decrease lung compli-
ance, which contributes to diminished lung volume
and atelectasis.
16
Because surgery of the extremities
results in fewer PPC than do abdominal and thoracic
procedures, it appears that anesthesia is not the pri-
mary cause of postoperative atelectasis.
17
Other fac-
tors that may contribute to atelectasis include supple-
mental oxygen delivered to a patient at low lung
volumes,
18
increased abdominal girth that restricts
lung expansion,
17, 19
and changes in negative pressure
in the thorax.
20
Miss Kigin is Director, Chest Physical Therapy andCo-Director,
Respiratory Care, Department of Anesthesia, Massachusetts General
Hospital, Boston, MA 02114 (USA).
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Physiologic changes resulting from atelectasis in-
clude increased alveolar surface tension caused by
deficient amounts of surfactant in the atelectatic
area.
20, 21
Surfactant, produced by type II pneumo-
cytes, improves lung compliance, which decreases the
need for high inspiratory pressures.
22
With persistent
atelectasis and the subsequent decrease in surfactant,
increased inspiratory pressures are needed to reinflate
the atelectatic area.
23
Although atelectasis is not an
infective process, prolonged atelectasis and decreased
mucociliary transport can result in bacterial infection,
or pneumonia.
17, 21
A summary of postoperative
pathophysiologic changes outlined by Tisi is found in
Table l.
15
Other PPC, less common than atelectasis, are pneu-
monia, aspiration, adult respiratory distress syn-
drome, and pulmonary embolus.
19
FACTORS CONTRIBUTING TO PPC
Tisi, in 1979, divided into four groups the factors
contributing to PPC (Fig. 1).
15
A patient with one or
more of these factors is considered at high risk for
developing PPC. Although the figure offers predis-
posing characteristics, no criterion has 100 percent
sensitivity. Peters noted, in 1980, that the diversity of
criteria for high risk classification adds to the variety
of conclusions from studies of PPC.
24
A variety of signs and symptoms can identify PPC.
Some authors choose only one criterion (radiogra-
phy),
6, 14
others choose a combination of factors (ra-
diography, temperature changes, breath sound
changes, and pulmonary function changes).
5, 8, 25-32
These variable criteria for PPC result in widely dif-
fering complication rates for similar patients. Table
2 summarizes the criteria and incidence of PPC.
33
TREATMENT OF PPC
A variety of treatments has developed through the
years, but as recently as 1980 there was no consensus
of the superiority of any procedure for the nonintu-
bated patient.
24, 33
The literature offers no more defin-
itive information for the intubated patient group than
it does for the nonintubated. This article will provided
discussion about investigations in both groups.
PREOPERATIVE EVALUATION
Advances in preoperative evaluation have helped
decrease the incidence of PPC.
15, 34-37
In addition to
identifying high risk factors, the information from the
patient history and preoperative testing may indicate
either that surgery may proceed or that further pre-
operative evaluation and treatment are necessary.
Advances in preoperative evaluation have been es-
pecially effective in recognizing and decreasing po-
TABLE 1
Postoperative Pathophysiologic Changes in the Lung
Factors Mea-
sured
Lung Volume
Type sur-
gery
Thoracic
Abdomi-
nal
upper
lower
Extrem-
ity
Ventilatory
Pattern
Gas Ex-
change
TLC



no
TV

Po
2

Change
a
VC

(50-70%)
(5-40%)
no
RR

A-aPo
2

ERV

( 60%)
( 25%)
no
Compli-
ance

RV

Sigh
Mecha-
nism

a
TLC =total lung capacity.
VC =vital capacity.
ERV =expiratory reserve volume.
RV =residual volume.
TV =tidal volume.
RR =respiratory rate.
Po
2
=partial pressure of arterial oxygen.
A-aPo
2
=alveolar to arterial oxygen gradient.
=increase.
=decrease,
no =no change.
tential respiratory complications in the patient with
chronic lung disease and the patient undergoing tho-
racic surgery.
Weighting of high risk factors has been attempted
to identify preoperatively the patient likely to develop
PPC.
17
The results, however, were not conclusive.
L General Factors
smoking history
obesity
age (>50)
II. Disease Related Factors
history COPD including
emphysema and bronchitis
history restrictive lung disease
including neuromuscular disease
HI. Type Anesthesia (listed least risk to greatest)
general anesthesia
spinal anesthesia
IV. Type Surgery (listed least risk to greatest)
nonabdominal, nonthoraeic (<1%)
lower abdominal
thoracic
upper abdominal (6-70%)
Fig. 1. Factors contributing to postoperative pulmonary
complications.
Volume 61 / Number 12, December 1981
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TABLE 2
a
Selected Studies on Frequency of Postoperative Pulmonary Complications
Investigator
King (25)
Dripps and Dem-
ing (26)
Palmer and Sel -
lick (14)
CPT only group
Thoren (5)
Control group
Anscombe (27)
Browne and
Rockford
(28)
Latimer et al (29)
Bartlett et al (30)
Control group
Craven et al (31)
Hansen et al (32)
Lyager et al (8)
Study
Type
Pro-
s pe c -
tive
Study
+
+
+
+
+
0
+
+
+
+
+
Total
No. Pa-
tients
7,065
1,240
90
172
300
226
46
75
70
40
94
Patients
b
No. with
Thoracic
Surgery
(...)
(...)
(...)
226
(...)
(...)
(...)
(...)
(...)
No. with
Upper
Abdomi-
nal Sur-
gery
759
1,240
66
172
46
75
70
40
94
Therapy
c
Preop
CPT or
Other
RT
0
+
0
?
?
?
?
+
+
+
Preven-
tive
Postop
CPT or
Other RT
0
"Stir-up"
0
?
?
?
"Stir-up"
+
+
+
Diagnostic Criteria
d
Clinical
Si gns,
Symp-
toms
+
+
+
+
+
+
+
+
+
(+)
Radi-
ogra-
phy
+
+
+ R
+ R
+ R
+ R
+ R
+ R
+ R
+ R
+ R
ABG
0
0
0
0
0
0
+
(+)
Inci-
de nc e
of PPC
(%)
9 (total)
27 (UAS)
6
43
42
49
51
76
25
60
75
47
a
Reprinted by permission of American Review of Respiratory Disease.
33
b
No study excluded patients with preoperative pulmonary disease.
c
Preoppreoperative; CPTchest physical therapy; RTrespiratory therapy; Postoppostoperative; +yes;
0no.
d
ABGarterial blood gases; PPCpostoperative pulmonary complications; UASupper abdominal surgery; R
routine test in all patients, performed at least once; (+)reported, but not used to calculate incidence; based on
positive radiograph only.
Pulmonary function tests are often cited as an iden-
tifying factor for potential PPC. Stein and associates,
in 1962, found maximal expiratory flow rates to be
the best correlate with respiratory complications.
34
Levy and associates found that spirometry results
were no more successful than a chest radiograph for
predicting PPC.
38
Levy's group also found that pul-
monary function testing, routine physical examina-
tion, and chest radiograph results, when used to-
gether, identified preoperatively 80 percent of the
patients at risk for PPC. Gracey, too, supported mul-
tifactored evaluations that included pulmonary func-
tion tests.
37
He also recognized that despite categori-
zation as high risk, individuals within that group
would vary greatly.
CHEST PHYSICAL THERAPY
History
Chest physical therapy was first described by
MacMahon in a 1915 article that described treatment
of the postoperative and trauma patient.
4
Mac-
Mahon's techniques have been supplemented by new
approaches and devices, but the stated goals remain
largely unchanged. Those goals were 1) enabling the
collapsed lung to regain normal condition, 2) restor-
ing the normal shape of the chest wall, 3) assisting
the discharge of pus through lung inflation, and 4)
improving general conditioning by exercise.
Chest physical therapy originated in Great Britain
and is currently universally used. For example, arti-
cles about CPT have been published in Germany,
39, 40
France,
41, 42
Russia,
43
Japan,
44
South Africa,
45
and the
Scandinavian countries.
5, 6, 8, 9
This review of CPT for postoperative or traumatic
injury patients will discuss breathing exercises, posi-
tioning and bronchial drainage, manual techniques,
coughing, suctioning, transcutaneous electrical nerve
stimulation (TENS), and upper extremity mobility
exercises and ambulation. For each topic, a brief
rationale will precede the major discussion regarding
efficacy of the treatment.
Breathing Exe r c i s e s
Rationale
In 1908, Pasteur recognized lobar collapse follow-
ing paralysis or temporary inhibition of muscular
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PHYSICAL THERAPY
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activity.
13
The exercises used by MacMahon in an
attempt to reverse atelectasis included movement of
the upper extremities, lateral costal expansion, and
thoracic expansion in the area of collapse.
4
Efficacy
MacMahon promoted maximal inspiration with
placement of the therapist's hands on the area of
collapse.
4
This technique continues to be used. The
therapist provides stimulus to the area through tactile
input, as well as stretch and resistance provided to the
muscles of inspiration. This is done in conjunction
with verbal commands to the patient to inspire to the
fullest. Though this has been a long standing method
of treatment, there is lack of standardization as to
how much pressure or stretch; in what position one
should offer this pressure or stretch; and also how
much resistance to provide to the diaphragm or inter-
costals once movement has been initiated. In review-
ing literature on CPT for the postoperative patient, it
is not even clear whether instructions to a patient are
done with the use of manual assistance of the hands,
or only through verbal encouragement or simple tac-
tile proprioception of hand placement.
Neuromuscular facilitation of respiration for the
postoperative patient has been rarely discussed since
1915.
4
Bethune, in 1975, outlined an approach to
facilitate respiration in the unconscious adult, using
principles suggested by Rood.
46
Using cocontraction
of the abdominal muscles, pressure on the upper
thoracic vertebrae, and stretch of the intercostal mus-
cles, Bethune visibly noted in her patients deeper
respiration, change in respiratory pattern, and an
apparent increase in consciousness. I have observed
similar findings when using these techniques for the
postoperative patient. Further study is needed in this
area of care.
More definitive studies of CPT began in 1954 when
Thoren examined the incidence of PPC in 343 pa-
tients who had cholecystectomies.
5
Patients were as-
signed to one of three groups: 1) preoperative and
postoperative CPT, 2) postoperative CPT, and 3) no
CPT. The CPT included breathing exercises with the
patient sitting and sidelying and encouragement to
cough, as described by Ingvarsson.
9
The 12 percent
PPC incidence in group 1 was lowest. Groups 2 and
3 had complication rates of 27.1 percent and 41.9
percent, respectively.
5
These findings were confirmed
by a similar study in 1956 by Wiklander and Norlin.
6
Both studies used radiographic evidence of atelectasis
as the criterion for PPC. Although the treatment is
described for each study, it is difficult to ascertain
whether percussion and vibration were used also.
In 1977, Vraciu and Vraciu studied the effects of
breathing exercises taught by physical therapists to 40
postoperative cardiac surgery patients.
7
The experi-
mental group received the breathing exercises in ad-
dition to the incentive spirometry, ultrasonic nebuli-
zation, and routine instructions by nurses in deep
breathing and coughing provided for the control
groups A 38 percent PPC rate was found for the
control group. The experimental group, whose sub-
jects were instructed and monitored by physical ther-
apists, had only a 16 percent complication rate. The
PPC were defined as temperature higher than
38.5 C, radiographic changes, or abnormal breath
sounds. This study indicates a need to standardize the
method of deep breathing in a manner different from
that routinely taught by nurses.
Adjuncts to Breathing Exercises
Blow bottles, intermittent positive pressure breathing
(IPPB), and incentive spirometry (IS) have been used
in an effort to decrease PPC.
33, 47-50
Blow bottles and
IPPB have not been upheld as efficacious treat-
ments.
33
Incentive spirometry currently is being in-
vestigated heavily. The efficacy of IS to date has
varied when compared to other techniques including
CPT
8, 5 1 - 5 3
In 1966, Ward supported the necessity of hourly
deep breathing to prevent or reverse atelectasis.
54
Pontoppidan, in 1980, speculated that this hourly
requirement for deep breaths might account for the
ineffectiveness of IPPB in preventing atelectasis when
delivered every 4 hours.
33
Bartlett and associates, in 1971, had patients per-
form a yawn maneuver postoperatively using the
incentive spirometer.
55
The group of patients using
the yawn had an increase in mean arterial partial
pressure of oxygen (Pao
2
) when compared to a control
group. The incentive spirometer is a device that pro-
vides visual feedback in terms of volumetric success
as a patient performs a deep breath. The value of a
sustained maximal inspiration is also brought to the
forefront through work by Bartlett. This very princi-
ple was in fact mentioned by MacMahon in 1915.
Craven and colleagues subsequently compared IS
and CPT in 70 subjects who had upper abdominal
surgery.
51
Both the IS and CPT groups received train-
ing before and after surgery. The IS group was en-
couraged to use the device 10 times each hour for the
first 5 postoperative days. The CPT group was treated
at least twice each day. The IS group had a PPC rate
of 37 percent and the CPT group had a rate of 63
percent. Craven stated that the CPT regimen failed
to emphasize deep breathing as had been suggested
by Thoren.
5
In 1978, Hedstrand and associates compared ver-
bally and manually assisted breathing exercises to
three breathing devicesIS, IPPB, and paper coil
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Fig. 2. Example of modified drainage position for right
middle lobe. Patient receiving hyperinflation on 100 per-
cent oxygen and vibration.
rebreathing tube.
52
In the groups using the devices, a
mean increase in transcutaneous Pao
2
(Tcpo
2
) of 3.0
to 3.5 mmHg was noted, with no difference among
the devices. The group receiving breathing exercises
had a mean increase in Tcpo
2
of 7.0 mmHg. This
study showed the importance of manually facilitated
deep breathing. I suggest that manual assistance fa-
cilitates inspiration by initiation of a stretch reflex
within the diaphragm or intercostal muscles.
Lyager and colleagues, in 1979, studied IS as an
adjunct to CPT for upper abdominal surgery pa-
tients.
8
They found no change in the PPC rate with
the addition of IS and attributed the results to an
aggressive physical therapy program similar to that
of Thoren.
5
In 1979, Heisterberg and co-workers compared
blow bottles to CPT in 98 patients who had abdomi-
nal surgery. Although they found no difference be-
tween the treatments, the rate of PPC was 30 percent
for each. Others have questioned the efficacy and
safety of blow bottles and suggested that they not be
used.
33
Other recognized aids to ventilation for the post-
operative patient that will not be discussed in detail
are appropriate pain medication and nerve blocks.
56, 57
Conclusions
There is a need for studies that carefully define
breathing exercises and their benefits to postoperative
patients. Previous studies are difficult to compare, but
those emphasizing specific breathing exercises result
in a low PPC rate. Changes in ventilation resulting
from manual stretch, resistance, and other techniques
of neuromuscular facilitation have yet to be docu-
mented. The addition to a CPT regimen of adjunctive
devices including IS, IPPB, and blow bottles adds
little to further decrease the PPC rate.
Positioning, Bronchial Drainage, and Manual
Techniques
Little research has been done to study the efficacy or
adverse reactions of either bronchial drainage or man-
ual techniques. However, clinically it is observed day
after day that using a full Trendelenburg's position
may cause a transient drop in blood pressure in a
patient, but using a modified position allows the
treatment to proceed. A situation that also can be
reversed easily is one of a patient showing transient
arrhythmias with the use of percussion that do not
appear when the therapist switches to vibration. Even
though research is scanty as to the actual positive or
adverse effects of each of these techniques, this article
will differentiate, when possible, between position
change, bronchial drainage, and manual techniques.
Positioning and Bronchial Drainage
Rationale
Many authors have stated that position change for
bronchial drainage facilitates mucus flow through the
effects of gravity.
58-62
When patients cannot tolerate
the full Trendelenburg's position, modified drainage
positions have been suggested (Fig. 2).
7, 63-65
Frequently changing the position of the postoper-
ative or traumatic injury patient has been advised to
decrease the risk of atelectasis. Because most air flow
goes to the most dependent lung region,
66
sitting
upright improves flow to the lung bases and side lying
increases airflow to the dependent lung. Also, im-
proved and more efficient diaphragmatic excursion
occurs on the side of the dependent lung.
67
With time,
the pressure of the bed against the chest wall begins
to restrict movement of the dependent portion of the
thorax. Additionally, the bedridden patient does not
change his ventilatory pattern as frequently as the
alert, ambulatory patient. These physical factors plus
the detrimental effects on mucociliary transport of
general anesthesia will combine to cause atelectasis
in the dependent lung area.
Efficacy
Research to verify mucus flow with the patient in
full or modified positions has been scanty. Sackner,
in 1978, reported that abnormal mucus moved cau-
dally through the trachea with the patient upright,
and cranially with the patient's head down.
68
Other
attempts to document the efficacy of positioning have
been made, usually by recording Pao
2
changes.
69-74
Studies of physiologic changes concomitant with
position change have concentrated on side lying and
prone positions. These studies found an increase in
Pao
2
with the healthy lung dependent in patients with
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unilateral lung disease.
69, 70
Patients with acute respi-
ratory disease had an increase in Pao
2
when moved
from supine to prone.
73
These findings should be
reviewed in relation to full positioning and modified
positioning when treating the postoperative or trau-
matic injury patient.
Measuring arterial blood gases postoperatively in
obese patients, Vaughan and Wise found a statisti-
cally significant increase in Pao
2
when the supine
patient was repositioned semirecumbent.
71
This
change occurred because vital capacity is less in the
supine position than when upright. This finding sup-
ports moving patients not only from side to side, but
to an upright position as soon after surgery as is
feasible.
Connors and associates, in 1980, studied 22 acutely
ill nonsurgical patients using a full Trendelenburg's
side lying position.
75
The patients also received per-
cussion. Connors' group recorded heart rate, respira-
tory rate, blood pressure, and arterial blood gases
after the patient reclined in a 30 degree head up
position for 10 minutes. Measurements were repeated
after the patient had been side lying with the foot of
the bed raised 12 inches and the diseased lung supe-
rior for at least 5 minutes. These two measurements
were followed by a third set taken after percussion
and vibration. Although not the primary purpose of
this study, the results showed that most patients had
little change in Pao
2
after position change. However,
two mechanically ventilated patients had a significant
drop in Pao
2
after either the position change or the
position change followed by percussion and vibration.
This decrease in Pao
2
was reversed with a fraction of
inspired oxygen (Fro
2
) of 100 percent.
In 1978, Mackenzie and associates studied 47
trauma victims with respiratory failure.
76
Twenty-six
were treated while side lying in full Trendelenburg's
position, and 16 were treated in one of three modified
positionssupine, upright, or side lying. Treatment
included percussion and vibration without hyperin-
flation. Gormezano and Brainthwaite had previously
advocated hyperinflation with manual chest compres-
sion.
64
Mackenzie and associates found no significant
change in Pao
2
in patients treated in either Trende-
lenburg's or modified positions. The mean treatment
time for each patient was 51 minutes. The mean Fro
2
was 42 percent. Mackenzie speculated that differences
in techniques in their study prevented the fall in Pao
2
reported in other studies.
76
However, in our clinic,
bag squeezing is used routinely without apparent
adverse effects while permitting efficient secretion
removal.
Changes in both cardiac output and intracranial
pressure have been measured during CPT.
63, 77, 78
The
two measurements noted above have been determined
during a regimen of CPT that includes positioning
and manual techniques. No definitive studies have
attempted to differentiate the various techniques and
their effect on cardiac output or intracranial pressure.
Clinical observation or monitoring of these physio-
logic factors allows treatment for patients with cardiac
or neurologic disease to be done by modifying the
position or technique as necessary.
Conclusions
The gravity dependent portion of the lung receives
the greatest airflow except when long periods are
spent in one position and during mechanical venti-
lation. Placing the acutely ill patient prone may in-
crease the Pao
2
without changing the Fio
2
. Cardiac
output and intracranial pressure may also vary with
position changes. These measurements must be
closely monitored. Modified positions are often tol-
erated by patients with adverse reactions to full po-
sitioning.
Position change to facilitate mucus flow is unnec-
essary for patients with normal mucociliary functions.
Patients may lose their mucociliary clearance post-
operatively or during mechanical ventilation. Chang-
ing position in these situations will facilitate secretion
removal and decrease secretion pooling.
Arterial Pao
2
may vary with position changes. The
findings have been neither consistent nor definitive
for postoperative patients and further study is needed.
Manual Techniques
Rationale
Although manual techniques are universally em-
ployed, their historical development is unclear. Man-
ual percussion or clapping on the chest is thought to
loosen secretions. Frownfelter states that this loosen-
ing is achieved by mechanical waves produced by the
percussing hand.
60
Vibration may be used alone or in
conjunction with percussion. Ingwersen states that
vibration, used with a forced expiratory maneuver
called "huffing," moves secretions toward the tra-
chea.
61
Vibration is reportedly a more comfortable
alternative to percussion for use on the patient with
pain. Shaking is a more vigorous form of vibration
used when secretions are thick and tenacious.
Efficacy
Research to document the specific effects on the
postoperative patient of percussion, vibration, and
shaking of the chest wall has not been reported.
Studies have included the combined effects of manual
techniques with bronchial drainage and breathing
exercises. There was no agreement regarding the du-
ration and frequency of manual techniquesreported
durations ranged from 7
64
to 110
76
minutes and one
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frequency for vibration was 20 cycles a second.
64
Nor
was there consensus of the force or rapidity with
which each technique should be applied to the thorax.
Studies using manual techniques for medical pa-
tients showed the techniques successful in removing
secretions.
79-81
Success was defined as sputum pro-
duction and improvement of regional ventilation.
Success of the manual techniques for the postopera-
tive patient can be only inferred from studies of
PPC rates, denoted in the postoperative groups by
temperature change, radiographic improvement,
breath sound increases, and blood gas enhance-
ment.
5-8, 26, 31, 32
Clinically, investigators have seen through a bron-
choscope rapid clearance of secretions during manual
percussion and vibration to the thorax (personal com-
munication, D. Kanarek, MD, May 1981). In our
institution it is common practice for chest physical
therapists to provide positioning, percussion, vibra-
tion, and shaking to facilitate secretion removal dur-
ing bronchoscopies. I have observed through a bron-
choscope secretion flow during percussion and vibra-
tion to dogs (unpublished research). Percussion on
each dog's thorax resulted in a splattering of plugs of
propyliodone previously instilled into the trachea.
Vibration resulted in a more directional flow of the
propyliodone without a breaking apart of the bolus.
These findings warrant further study.
There have been no studies to evaluate or compare
mechanical vibrators or percussors with manual tech-
niques in the postoperative patient.
Other variables studied during bronchial drainage,
percussion, and vibration have included cardiac out-
put,
63, 77
cardiac arrhythmias,
82
intracranial pressure,
78
gas distribution,
79
and lung compliance.
83
There is no
current consensus regarding physiologic changes ac-
companying individual techniques including full or
modified positioning, percussion, vibration, and shak-
ing.
Bronchial Drainage with
Manual Techniques
Efficacy
Many investigators have found CPT successful in
reversing lobar atelectasis in postoperative, traumatic
injury, and nonsurgical patients.
76, 82-85
Marinni and
associates, in 1979, compared bronchoscopy to a reg-
imen including several respiratory techniques.
84
This
regimen included deep breathing with IS every four
hours, cough or suction, bronchodilator administra-
tion, and bronchial drainage with chest percussion.
This well-designed study found no difference between
the two therapeutic approaches in restoring lung vol-
ume lost to atelectasis. The mean volume restoration
was 38 percent. Mackenzie and associates also found
significant mean resolution in atelectasis of 68 percent
following CPT.
76
Marinni and associates used percussion and drain-
age for five minutes to each area of atelectasis.
84
Mackenzie and associates
76
and Ciesla and col-
leagues,
85
in separate studies, used full positioning
and vigorously applied manual techniques. Ciesla's
group found dramatic increases in Pao
2
ranging
from 61 to 150 mmHgin patients with hypotension
who were also receiving mechanical ventilation with
high levels of positive end expiratory pressure
(PEEP). Hypotension and PEEP are often considered
as contraindications for CPT by other investigators.
In 1969, Laws and co-workers studied six patients
receiving CPT in right and left side lying positions.
77
Treatment included vibration and an artificial cough
produced by a deep breath with maximum vibratory
compression during exhalation. They found no
change in arterial blood gases or alveolar-arterial
oxygen difference, but cardiac output varied by 50
percent in either direction in several patients.
Lord and associates studied patients who received
CPT in the recovery room following cholycystec-
tomy.
86
Patients were treated in full Trendelenburg's
position with percussion and vibration. An abrupt
rise in Pao
2
was noted in the CPT group when
compared with a control group. F
I
o
2
was not recorded
in the study.
Gormezano and Brainthwaite, in 1972, studied 42
mechanically ventilated patients following cardiac
surgery or respiratory failure.
64
The CPT included
hyperinflation, manual chest compression, and suc-
tioning. The patients were treated in either supine or
side-to-side positions. The authors found no signifi-
cant change in Pao
2
except in patients with cardio-
vascular complications. The drop in Pao
2
in this
group with complications occurred at 5 and 15 min-
utes after treatment, but Pao
2
had returned to pre-
treatment values by 30 minutes after treatment. These
authors were among the few who clearly defined
duration of treatment (7 to 20 minutes) and frequency
of chest compression (20 Hz).
Tyler and associates reported on the effects upon
Pao
2
of CPT for critically ill patients.
87
Although they
noted a mean decrease in Pao
2
during CPT, a regres-
sion analysis found that patients with low initial Pao
2
had little or no further decrease during treatment.
Hence, Tyler's group concluded that CPT should not
be denied patients with low Pao
2
.
Conclusions
The above data strongly support using CPT for
patients with segmental or lobar atelectasis and large
amounts of retained secretion. The Pao
2
can be main-
tained during treatment and will improve following
treatment even in acutely ill patients. The preventive
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value of percussion, vibration, and shaking is un-
known for the patient with small amounts of sputum.
Air flow alterations resulting from position change,
deep breathing, sighing, and manual techniques must
be clarified. By carefully recording specific techniques
and their effects on specific types of patients, inves-
tigators can fully verify the indications and contrain-
dications for the techniques. The optimal frequency,
force, and duration of manual techniques also must
be ascertained for specific types of patients.
Adjuncts to Bronchial Drainage and Manual
Techniques
Mechanical aids to inspiration and the importance
of adequate oxygenation have been discussed previ-
ously. Administration of bland aerosols and proper
humidification to aid secretion clearance have re-
cently been reviewed.
88
Winning and associates studied bronchodilators
used in conjunction with CPT.
89
This study is of
interest in that the effects of physical therapy plus
bronchodilators were studied in conjunction with the
patient receiving an F
I
O
2
of 100 percent for five
minutes before, during, and after treatment. In a
previous paper
90
the authors noted that they were
unable to document a deterioration in arterial oxy-
genation after physical therapy as found by previous
investigators. In this study they found that there were
no significant changes in arterial oxygen tension after
treatment, but that alveolar pressure fell significantly
indicating a definite improvement in pulmonary com-
pliance.
Cough
Rationale
A cough is a rapid expulsion of air from the lungs
elicited either reflexly or voluntarily. For an effective
cough, the lungs must be inflated well and the vocal
cords must close. These two events are quickly fol-
lowed by strong contraction of the abdominal muscles
which, in conjunction with elastic recoil of the lung
tissue, results in a rapid expulsion of air through the
suddenly reopened vocal cords.
91, 92
Coughing effec-
tiveness may be impaired postoperatively because of
decreased inspiratory volume caused by poor dia-
phragmatic excursion and weak contraction of the
abdominal muscles.
19
Byrd and Burns studied cough
dynamics in 24 adult males.
93
Immediately following
thoracotomy the subjects could develop a cough with
a mean force of only 29 percent of the preoperative
value. A 50 percent diminution in force remained one
week after surgery. The authors stated that pain was
probably the primary factor causing the changes in
cough.
The patient with an endotracheal intubation will
also experience submaximal airflows during coughing
because of the increased resistance to airflow resulting
from the endotracheal tube.
94
It is important, there-
fore, to inflate adequately the intubated patient's
lungs by using a ventilator or by bag squeezing before
expecting him to cough.
Efficacy
Yamazaki and colleagues, in 1980, determined
cough strength in thoracotomy patients by using a
balloon catheter to measure intrapleural pressure dur-
ing coughing.
95
They found higher cough pressures
with the patient sitting than with the patient supine.
They also found significant increases in cough pres-
sures when a therapist or nurse provided manual
compression during the patient's cough. Compression
of the chest wall with the patient sitting was the most
effective method, but compression of the abdominal
wall with the patient supine also was effective.
Others have studied the effects of position on
coughing. Curry and Van Eeden studied air flow
during coughing in nine normal subjects in positions
ranging from semiprone to upright.
96
They found the
highest flow rates with the patient upright. In 1980,
Starr studied 20 subjects who had undergone choly-
cystectomy.
97
Included in the preoperative CPT was
cough instruction. Four standard positions for cough-
ing were taught and their effectiveness evaluated. The
order of positions was randomized and included right
and left side lying, semi-Fowler's, and upright. Be-
tween 4 and 6 hours postoperatively, and again after
24 hours, flow rates were measured in each position
while the patients coughed. The upright position re-
sulted in the patient achieving a greater flow rate than
any other position. There were no differences among
the side lying and semi-Fowler's positions.
Huffingthe expulsion of air through an open
glottishas been advocated as a less painful and less
stressful method of clearing the airways of secretions.
This technique has been studied in subjects with
asthma, chronic obstructive lung disease, and cystic
fibrosis.
98
"
100
These three studies have concluded that
huffing is an effective means of mobilizing secretions
and may provide better stabilization of the airways
than does coughing. I have found huffing beneficial
for the surgical patient having difficulty in coughing,
but no published data support its use following sur-
gery.
Conclusions
The effectiveness of a cough at removing secretions
has been documented. Adequate inspiratory volume
and forceful contraction of the abdominal muscles
are necessary for effective coughing. The upright
position permits a stronger cough than side lying or
supine positions. Support and compression of the
patient's thorax or abdomen may enhance the cough-
Volume 61 / Number 12, December 1981
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Fig. 3. Optimum position for coughing, with option of
therapist using chest compression or vibration to facilitate
secretion removal.
ing effort (Fig. 3). Huffing may be a good alternative
to coughing but its effectiveness for the surgical pa-
tient needs further study.
Tracheobronchial Suctioning
Rationale
Tracheobronchial suctioning uses a catheter at-
tached to a vacuum source to aspirate secretions from
the airways of a patient unable to cough. Suctioning
is widely discussed in the CPT and surgical literature
and is an important alternative to coughing during
CPT.
Efficacy and Complications
The effectiveness of tracheobronchial suctioning
appears to have face validity; secretions that cannot
be cleared voluntarily are obtained easily through the
aspirating catheter. The irritative effect on the tra-
cheal mucosa from a suction catheter may stimulate
an effective cough without vacuum aspiration. During
suctioning, a patient with thick tenacious secretions
and a cough that cannot be stimulated even with the
catheter in the trachea may benefit from vibration,
which moves the secretions toward the trachea (Fig.
4).
Many studies have examined the possible compli-
cations of suctioning the airway.
101-107
The most com-
mon problems are damage to the tracheal mucosa
and abrupt drops in Pao
2
. The drop in Pao
2
occurs
during both nasotracheal suctioning and aspiration
through an endotracheal tube or tracheostomy.
Adlkofer and Powaser studied the effects on arterial
blood gases of nasotracheal suctioning after cardiac
surgery in 64 subjects.
106
Patients who received sup-
plemental oxygen before suctioning had no signifi-
cant fall in Pao
2
. Patients suctioned without supple-
mental oxygen experienced a decrease in Pao
2
. Hence,
adequate oxygenation is recommended before and
after suctioning the airway. In addition to supple-
menting the F
I
o
2
, proper vacuum levels and sterile
technique will minimize complications from suction-
ing.
Conclusions
Adequate preoxygenation and postoxygenation,
minimal duration of suctioning, and proper vacuum
levels are important elements of proper suctioning.
Patients who receive supplemental oxygen before suc-
tioning do not experience the dramatic fall in Po
2
levels that occurs without this supplement. Many
clinicians use a suction catheter to stimulate a cough
in the nonintubated patient who is unable to clear
secretions spontaneously.
Transcutaneous Electrical
Nerve Stimulation
Rationale
Transcutaneous electrical nerve stimulation
(TENS) is a frequently used modality to treat chronic
pain. It was first developed in response to the gate-
control theory of pain proposed by Melzak and Wall
in 1965.
108
Efficacy
Hymes and associates, in 1974, used TENS for
postoperative pain in 213 patients.
109
Pain relief was
evaluated by examining the frequency with which
analgesics were used, length of stay in the intensive
care unit, incidence of atelectasis and ileus, and shoul-
der mobility. The authors found a significant reduc-
tion in atelectasis and an increase in the mean eleva-
tion of the humerus from 90 degrees to 154 degrees
following 15 minutes of TENS.
VanderArk and McGrath, in 1975, studied TENS
in 100 patients who had abdominal or thoracic op-
erations.
110
Patients were randomly assigned to a con-
trol or treatment group. Thirty-two of 39 subjects in
the control group had no pain relief. In the treatment
group, 47 of 61 patients reported relief, with maxi-
mum improvement noted after the initial treatment.
No difference in the incidence of atelectasis or ileus
was reported.
Cooperman and colleagues, in 1977, randomly as-
signed to a control group or treatment group 50
patients scheduled for major abdominal surgery.
111
Pain relief was recorded as excellent, good, or poor.
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In the control group, 12 percent had excellent relief,
21 percent had good relief, and 67 percent had poor
relief. In the treatment group 35 percent had excellent
results, 42 percent had good results, and 23 percent
had poor results. There was no difference between
the control and treatment groups in the incidence of
atelectasis, pneumonia, or ileus.
Stratton and Smith, in 1980, postoperatively mea-
sured forced vital capacity on the premise that mea-
surement of pain was too subjective.
112
After thora-
cotomy, 21 patients were randomly assigned to a
control group or TENS treatment group. Forced vital
capacity was significantly greater for subjects in the
TENS group. No incidence of complications was
recorded, and no other data were provided.
Conclusions
Transcutaneous electrical nerve stimulation ap-
pears to be an effective method to decrease symptoms
of postoperative pain. It is unclear if a concomitant
decrease in PPC rate accompanies the pain relief.
Mobility and Ambulation
Rationale
Early postoperative mobility and ambulation have
become routine. This activity helps decrease PPC rate
and lowers the incidence of pulmonary embo-
lism.
19, 113
The CPT literature describes the necessity
of range-of-motion exercises for extremities near the
incision site.
4, 59, 60, 62
Range-of-motion exercises will
prevent or retard loss of musculoskeletal function in
joints affected by incisional pain or splinting.
Efficacy
Studies to date have documented a decrease in the
incidence of pulmonary embolism in patients who are
ambulated early as well as in those who receive
passive and active lower extremity exercises.
113, 114
Physical therapists have proposed exercises to
maintain or restore motion to the upper extremity on
the side of a thoracotomy site.
4, 51, 62, 64, 111
Patients
without this exercise program often lose motion in
the shoulder and may develop a "frozen" shoulder. I
have noted this problem particularly in children.
Immediate postoperative range-of-motion exercises,
posture correction, and use of TENS can prevent
musculoskeletal dysfunction following thoracotomy.
Conclusions
Early mobility decreases pulmonary embolism
when used in conjunction with other prophylactic
treatments. Early range of motion, when indicated
for an extremity near an incision site, decreases mus-
culoskeletal changes resulting from immobilization.
PROPOSED AREAS FOR INVESTIGATION
Although the value of CPT for the postoperative
patient has been demonstrated by several well-de-
signed studies, including those by Thoren, Wiklander
and Norlin, and Lyager and associates, further re-
search is needed.
5, 6, 8
The benefits and complications caused by position
change should be determined for each major type of
patient. The addition to a physical therapy regimen
of mechanical devices, such as IS and IPPB, should
be studied. Will these costly devices add to the bene-
fits of an aggressive CPT regimen?
Controlled studies of secretion removal techniques
for the postoperative and traumatic injury patients
should be a priority. Determination of the separate
and combined benefits of positioning for bronchial
drainage, manual techniques, coughing, and huffing
is needed. New studies should measure the force,
frequency, and duration of both percussion and vi-
bration and determine their effects upon each type of
PPC. Also, clarifying the contraindications for and
complications of these techniques would be valuable.
Although individual techniques may be contraindi-
cated in certain instances, surely a modification of
that technique or substitution of another modality
can offer therapeutic benefit.
Investigation of the efficacy of TENS for decreas-
ing PPC rates should continue. The type and fre-
quency of upper extremity mobility exercises also
warrant documentation. And simple lower extremity
mobility exercises need to receive further study.
Fig. 4. Patient being suctioned (sterile technique) as
therapist continues to vibrate left lingula.
Volume 61 / Number 12, December 1981
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Postoperative pulmonary complications remain the
most prevalent problem for the surgical patient. The
number of operative procedures continues to increase
annually, as does the cost of hospital care. By inves-
tigators determining optimal treatment and preven-
tive measures for PPC, including the efficacy of CPT,
the surgical patient can be more effectively and more
economically treated by the practitioners.
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1736 PHYSICAL THERAPY
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1981; 61:1724-1736. PHYS THER.
Colleen M Kigin
Traumatic Injury Patient
Chest Physical Therapy for the Postoperative or
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