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ORIGINAL ARTICLE
EFFECT OF MULTIMODALITY CHEST PHYSIOTHERAPY ON THE RATE
OF RECOVERY AND PREVENTION OF COMPLICATIONS IN PATIENTS
WITH MECHANICAL VENTILATION: A PROSPECTIVE STUDY IN
MEDICAL AND SURGICAL INTENSIVE CARE UNITS
RENU B. PATTANSHETTY, GAJANAN S. GAUDE1

ABSTRACT
BACKGROUND: Mechanically ventilated patients have an increased risk of complications
leading to ventilation weaning more difficult resulting in excessive morbidity and
mortality. Chest physiotherapy plays an important role in management of ventilated
patients. However, these techniques have been studied on patients as a single entity
or with combination of two techniques. The present study was designed to evaluate
the effect of multimodality chest physiotherapy on the rate of recovery and prevention
of complications in adult ventilated patients. MATERIALS AND METHODS: Out of 173
patients who were randomly allocated to two groups, 86 patients received MH and
suctioning in control group and 87 patients were treated with multimodality chest
physiotherapy in the study group twice daily till they were extubated. All patients were
followed up for the global outcomes and complications during mechanical ventilation.
RESULTS: There were significant improvements in terms of rate of recovery in study
group compared to the control group (P = 0.000). Complication rates were higher
with 61.6% in the control group as compared to 26.4% in the study group. Duration
of hospitalization was longer in the study group (16 9.40 days) as compared to the
control group (12.8 6.12 days). Successful weaning from mechanical ventilation was
noted in 58 patients in the study group and 24 patients in the control group which was
statistically significant. CONCLUSIONS: Multi-modality chest physiotherapy protocol has
shown to prevent ventilator-associated pneumonia and enhance the clinical outcome in
ventilated patients and may be recommended as a treatment option in ICU. It has also
shown to enhance the weaning process and proved to be safe.
Key words: Chest vibrations, complications, ICU, mechanical ventilation, multimodality
chest physiotherapy, outcome, positioning, suctioning, manual hyperinflation
Department of Cardio-respiratory physiotherapy,
KLEU Institute of Physiotherapy, JN Medical College,
1
Department of Pulmonary Medicine, JN Medical College,
Nehru Nagar, Belgaum, Karnataka, India
Address for correspondence:
Dr. Renu B. Pattanshetty,
KLEU Institute of Physiotherapy, JN Medical College Campus,
Nehru Nagar, Belgaum- 590 010, Karnataka, India.
E-mail: renu_kori@rediffmail.com

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DOI:
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INTRODUCTION
Patients needing mechanical ventilation
represent an important subset of all individuals
admitted to an ICU due to the intensity of
medical treatment they receive and their
associated costs. Additionally, approximately
one third of all patients who enter an ICU
require mechanical ventilation for the
management of hypoxemia and hypercapnea,
making this one of the most common
indications for admission in ICU. These patients
may have an increased risk of ventilatorassociated pneumonia (VAP) and atelectasis,
besides an increased risk of sputum retentions
leading to ventilation weaning more difficult
and resulting in excess morbidity and mortality.
Thus, every effort should be made to determine
which patient can be rapidly extubated so as to
keep the weaning period minimum.[1]
Chest physiotherapy is an integral part of
the management of patients in ICUs. The
most common techniques used by chest
physiotherapists in the ICU are positioning,
mobilization, manual hyperinflation (MH),
percussion, chest vibrations, suction, cough
techniques, and various breathing exercises.[2-8]
A combination of these techniques is used by
some physiotherapists in ICU regardless of
the patients underlying patho-physiological
condition, with intention of preventing
complications, whereas other physiotherapists
use such techniques selectively when they
believe they are specifically indicated.
Chest physiotherapy has shown to reduce
the occurrence of VAP and atelectasis in
patients intubated for more than 7 days with
the APACHE score >15.[9] Manual hyperinflation
Indian Journal of Medical Sciences, Vol. 65, No. 5, May 2011

and suctioning techniques have been adopted

by physiotherapists in management of
mechanically ventilated patients which aim to
improve lung volume, promote ventilation, and
mobilize secretions.[10]
In spite of the short-term benefits of the chest
physiotherapy in ICUs, there has been hardly
any documentation regarding the effectiveness
of multimodality chest physiotherapy on the
rate of recovery prevention of complications
and length of stay in ICU. There are no data
concerning its effectiveness in preventing or
treating other pulmonary conditions common
to ICU patients.
Hence, the present study was done to evaluate
the role of multimodality chest physiotherapy
on the rate of recovery and prevention of
complications in patients with mechanical
ventilation. We have also tried to analyze the
role of manual hyperinflation and suctioning
in patients undergoing mechanical ventilation.

PATIENTS AND METHODS

Based on the results of the previous studies,
assuming complications, and decreased rate of
recovery proportion of 40% in the control group,
to detect the 20% absolute reduction (40% to
20%) in complications, and enhanced rate of
recovery in the study group, the sample size was
derived 100 in each group with type I error (a)
P= 0.05, power of 80% and dropout rate of 20%.
The study was undertaken in a tertiary care
referral hospital over a period extending from
March 2008 to November 2010. All adult patients
who were mechanically ventilated in MICUs and
SICUs, referred by the concerned physician,

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MULTIMODALITY CHEST PHYSIOTHERAPY IN ADULT VENTILATED PATIENTS IN INTENSIVE CARE UNITS 177
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surgeon, or the intensivists, and age above

18 years were included in the study. Patients
with hemodynamic instability, CABG patients,
bed-side dialysis, untreated pneumothorax,
conditions where head of bed end elevation was
contraindicated, and any clinical condition where
chest physiotherapy was contraindicated were
excluded from the study. Ethical approval was
obtained from the Ethics Review Committee of
the KLE University before the commencement of
the study. All patients enrolled in the study were
ventilated by Servo 900C or Servo-Ventilator
300. Baseline data including age, gender,
admission diagnosis, ventilatory mode, type of
intubation(s), radiological features suggesting
pneumonia, staging of atelectasis and other
conditions, and clinical parameters (CPIS score
and GCS score) of all the patients prior to the
chest physiotherapy was noted. After obtaining
the baseline data, the patients were categorized
in either of two groups, i.e. the study group or
the control group by the concealed envelope
method.
Patients in the study group were given
multimodality chest physiotherapy protocol of
suctioning[1] + chest vibrations[11] + suctioning
+ manual hyperinflation [9] + suctioning +
positioning[12] (head of bed elevation 3045).
Patients in the control group were treated with
manual hyperinflation (MH) and suctioning.
Standard care in the form of pharmacological
therapy, inhalation (aerosol) therapy, and
the routine nursing care was administered
throughout the intervention period. The
changes in ventilatory parameters were
adjusted by the intensivist.
All the patients in both the groups were
treated by chest physiotherapist twice a day till

patients were weaned off from the ventilator.

All patients were followed up for the global
outcomes in terms of successful weaning,
recovery and discharge from hospital,
death, total length of stay on ventilation,
discharge against medical advice, or any other
complications.
Statistical analysis
Statistical analysis of the data was done
using SPSS windows version 13.0. Student
paired and unpaired t tests were used to
compare the results within and between the
groups, respectively. The Wilcoxon test was
used depending on the nature of the data.
Acomparison of the results was done using the
Student unpaired t test or the MannWhitney
U test depending on the normal distribution
of the data. The chi-square test was used in
finding the independence (association) of the
qualitative variables. Logistic regression was
used to analyze risk factors for mortality and
VAP.

RESULTS
A total of 220 intubated and mechanically
ventilated patients were referred for chest
physiotherapy out of whom 20 were excluded
as ineligible. Finally, data consisting of all
primary and the secondary variables of 87
patients in the study group and 86 patients in
the control group were successfully subjected
to statistical analysis [Figure 1].
The results of the present clinical trial
demonstrated significant improvements with
multimodality chest physiotherapy treatment
in terms of rate of recovery with 58 (66.7%)
patients in the study group compared to
28 patients (32.6%) in the control group
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which was statistically significant (P =

0.000) [Table 1]. The physiotherapist-based
protocol was helpful in significant reduction
of complications. Only 23 (26.4%) patients
suffered from complications in the study group
as compared to 53 (61.6%) in the control
group which was statistically significant (P
= 0.000) [Table 2]. VAP emerged as the
largest complication in both the groups
with no statistical significance. Duration
of hospitalization was longer in the study
group (16 9.40 days) as compared to
the control group (12.8 6.12 days) which
was statistically significant (P = 0.000)
[Table 1 and Table 3]. Multimodality chest
physiotherapy also demonstrated significant
improvements in the oxygenation status
Indian Journal of Medical Sciences, Vol. 65, No. 5, May 2011

(P=0.000) and ventilator parameters

(P=0.000) [Table 4] between both the groups.
The protocol has also been demonstrated to
be safe irrespective of the clinical condition
with no significant adverse events.

DISCUSSION
Overall, 200 patients fulfilled all the inclusion
criteria and were randomly allocated to either of
the two groups with 100 patients in each group.
Thirteen patients from the study group and 14
patients from the control group withdrew during
the study period. Finally, a total of 87 patients
in the study group and 86 patients in the control
group were successfully subjected for statistical
analysis.

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Table 1: Baseline characteristics of patients in both the groups
Variables

Study Group (n = 87)

Control Group (n = 86)

Statistical test used

DF

P Value

Endotracheal

85 (97.7%)

84 (97.7%)

2 test = 0

Tracheostomy

2 (2.3%)

2 (2.3%)

Volume control

38 (43.7%)

49 (56.3%)

2 test = 10.909

0.001

SIMV + PS

59 (68.6%)

27 (31.4%)

RR/Vt

75.6 4.49

76.4 3.22

t test = 0.784

80

0.099

RR

32.9 1.30

33.2 1.64

t test = 0.982

80

0.329

Spontaneous Vt score

0.43 0.02

0.43 0.02

t test = 0.845

80

0.921

3.8 1.16

3.6 0.65

Mann Whitney U
test, z = 1.666

171

0.09

6.8 1.70

4.76 1.76

Mann Whitney U
test, z = 6.765

171

0.000

Duration of intubation (days)

7.6 3.97

6.8 4.46

t test = 1.274

171

0.201

Duration in ICU (days)

11.4 9.75

9.3 5.92

t test = 1.699

171

0.091

16 9.40

12.8 6.12

t test = 2.685

171

0.008

n = 58

n = 24

1.98 0.73

2.10 0.78

t test = 0.632

80

0.529

PaO2

60.6 6.95

68.7 7.86

t test = 7.22

171

0.000

PaCO2

51.6 3.41

50.8 3.66

t test = 1.388

171

0.167

PaO2/FiO2

94.8 25.44

99.6 28.88

t test = 1.149

171

0.252

Vt

3.5 29.44

320.1 87.44

t test = 31.887

171

0.000

PAP

33.9 5.65

25.3 3.79

t test = 11.760

171

0.000

PEEP

9.4 3.91

9.7 2.68

t test = 0.714

171

0.476

Vt/ PAP PEEP

13.9 4.76

21.7 7.78

t test = 8.001

171

.000

21.65 2.907

21.652 2.104

t test = 0.005

171

0.99

0.67 0.15

0.72 0.14

t test = 2.272

171

0.024

Mode of intubation

Initial ventilatory mode

RSBI

CPIS
GCS

Hospital stay (days)

Duration of weaning
Oxygenation status
parameters

Ventilatory parameters

MAWP
FiO2
Vital signs
PR

108 13.74

120.9 11.87

t test = 6.372

171

0.000

SBP

117.9 18.04

107.3 9.90

t test = 4.720

171

0.000

DBP

60 10.58

64.9 6.27

t test = 3.720

171

0.000

Successful outcome

58 (66.7%)

28 (32.6%)

2 = 22.577

Death

24 (27.6%)

39 (45.3%)

5 (5.7%)

17 (19.8%)

02 (2.3%)

Global outcome

D/C AMA
Discontinued

2 = 22.198

SIMV + PS = Synchronized intermittent mandatory ventilation plus pressure support; RSBI = Rapid shallow breathing index;
RR/Vt= Ratio of respiratory rate by tidal volume; RR = Respiratory rate; CPIS = Clinical pulmonary infection score; GCS = Glasgow
coma score; PaO2 = Partial pressure of arterial oxygen; PaCO2 = Partial pressure of arterial carbon dioxide; PaO2/FiO2 = Ratio of
partial pressure of arterial oxygen to fraction of inspired oxygen; Vt = Tidal volume; PAP = Peak airway pressure; PEEP = Positive
end expiratory pressure; Vt/PAP-PEEP = Dynamic compliance; MAWP = Mean airway pressure; FiO2 = Fraction of inspired oxygen;
PR = Pulse rate; SBP = Systolic blood pressure; DBP = Diastolic blood pressure; D/C AMA = Discharge against medical advice

Low death rates were observed in the study

group suggesting usefulness of multimodality
chest physiotherapy. In one of the first studies

that examined the initial results and outcomes

following the introduction of mechanical
ventilation reported high mortality rate of
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Table 2: Incidence of VAP among both the groups
Variables

Study Group (n=87)

Control Group (n=86)

No VAP

55(63.2%)

48(55.8%)

VAP 5 days

23 (26.4%)

29 (33.7%)

VAP5 days

9(10.3%)

09(10.5%)

Statistical test used

DF

P Value

2= 1.162

0.559

VAP = Ventilator-associated pneumonia

Table 3: Complications other than VAP in both the groups

Variables

Study Group (n=87)

Control Group (n=86)

Statistical test used

DF

P Value

----

12 (14%)

2=9.108

0.011

15(17.2%)

18 (20.9%)

Septicemia
UTI
Hypokalemia

-----

6 (7%)

Hyperkalemia

------

---------

Hyponatremia

02(2.3%)

01(1.2%)

Hypernatremia

-------

01(1.2%)

Renal failure

01(1.1%)

07(8.1%)

Seizures

02(2.3%)

05(5.8%)

Paralytic Ileus

- -----

03(3.57%)

Cardiac arrest

03(3.4%)

------

UTI = Urinary tract infection

Table 4: Mean differences between oxygenation status, ventilator parameters, and vital signs before and
after chest physiotherapy among both the groups
Study Group

Control Group

DF

P Value

PaO2

20.38.01

10.28.93

7.837

171

0.000

PaCO2

6.8 5.13

3.74.06

4.403

171

0.000

109.269.42

52.570.30

5.331

171

0.000

Oxygenation parameters

PaO2/FiO2
Ventilator parameters
Vt

317.456.74

2.511.61

50.442

171

0.000

PAP

0.33.70

0.52.61

1.847

171

0.066

PEEP

0.22.82

0.61.88

2.495

171

0.014

Vt/ PAP PEEP

0.063.72

1.74.44

2.817

171

0.005

MAWP

0.20 .20

0.1 0.23

3.456

171

0.001

FiO2
Vital parameters
PR

1.810.47

0.32.92

1.760

171

0.80

SBP

0.1.410.84

0.33.56

1.411

171

0.160

DBP

0.46.49

0.810.24

0.985

171

0.326

63%.[13] Another study[14] suggested the best

predictors of outcome were the number of
associated complications, degree of severity of
the disease, degree of hypoxemia, and age of
the patients.
Age >40 years for both the sexes was
identified as one of the risk factors for
Indian Journal of Medical Sciences, Vol. 65, No. 5, May 2011

mortality in present study. According to one

study, [15] previous medical history did not
influence the final outcome predictor, but
co-existing chronic diseases, the functional
status, and the severity of the acute illness
may play an important role in predicting
the mortality in mechanically ventilated
patients. Besides age, ventilatory parameters

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like PEEP >10 cm H 2 O, increased FiO 2

values, and low GCS scores have also
demonstrated to be the risk factors for in
hospital mortality in ventilated patients
receiving either conventional or multimodality
chest physiotherapy in the study.
In a cohort study,[16] it has been observed that
patients with very long stays in ICU (at least 30
days) appear to have a reasonable chance of
survival. In the present study, the duration of
ICU stay (days) and hospital stay (days) was
comparable to the control group. However, this
may explain the long-term survival in the study
group. Another study[17] suggested malignant
tumor disease and exacerbations of chronic
cardio-vascular disease as the most frequent
causes of death in the hospital adult patients
admitted to ICU irrespective of whether they
were ventilated or non-ventilated.
Ventilated patients prefer larger tidal volume
(Vt). Breath sizes as large as 1.0L often with
PEEP levels of 5 cm of H 2O are common
and do not cause ventilator-associated lung
damage in the absence of acute lung injury
from other causes.[18] However, in the present
study, PEEP >10 cm of H 2 O was one of
the risk factors for mortality and death may
have been due to ventilator-associated lung
damage. Studies have shown that diabetes
mellitus, heart disease, cigarette smoking,
and percentage of predictive FEV1 to be the
independent predictors of all cause mortality.
They also suggested airway clearance
techniques including chest physiotherapy which
may help in reducing the mortality.[19]
In one of the international studies,[20] the median
duration of mechanical ventilation was 3 days
and only 3% were ventilated for longer than

3 weeks. Although the present study did not

consider the reason for mechanical ventilation
since the patients were referred, however,
the results of mean duration of mechanical
ventilation in the present study were almost
similar to the results of the above-mentioned
study. There have been various studies that
have compared the duration of mechanical
ventilation for different indications to find out
if duration of mechanical ventilation could be
predictable.[21,22]
Although VAP emerged as the major
complication in both the groups in the present
study, a majority of the patients did not suffer
from VAP. Needless to say that probably
multimodality may have helped in prevention
of VAP and may have also played a role in
decreasing mortality. Various studies [22,23]
have shown efficacy of chest physiotherapy
on arterial oxygenation, hemodynamic and
ventilatory effects, changes in total lung/thorax
compliance. There is only one documented
evidence[24] to suggest that multimodality chest
physiotherapy was independently associated
with a reduction of VAP similar to the finding
of the present study. However, the clinical
effectiveness of chest physiotherapy for
pneumonia is controversial. According to
Kirilloff etal,[25] chest physiotherapy does not
seem to play a role in resolution of pneumonia
while in one of the recent studies, multimodality
chest physiotherapy has shown to decrease the
occurrence of VAP and reduce the mortality
rates in adult ventilated patients.[26] The use of
semi-recent positioning has shown to reduce
the occurrence of VAP since it decreases
the risk of aspiration of both gastric contents
and secretions from the upper aero- digestive
tract.[27]
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Weaning criteria in the present study included

both oxygenation and ventilator criteria
which were more objective in nature marking
as better markers of recovery. Among the
weaning indices developed, rapid shallow
breathing index (RSBI) is one which is simple
to use and calculate and highly predictable
in weaning success. The absence of rapid
shallow breathing as the f/Vt ratio less than
100 cycles/L is very accurate predictor of
weaning success.[28] Studies[29] have suggested
RSBI as an accurate predictor of weaning in
elderly mechanically ventilated patients. What
contributed to successful weaning in the present
study is difficult question to answer but may
be attributed to the initial mode of ventilation
in the study group which was SIMV + PS.
However, this reason may need confirmation
with further future trials using multimodality
chest physiotherapy as a treatment option.
In the present study, high levels of PEEP (>10
cm of H2O) have been shown to be a risk factor
for VAP. Although there are no studies to show
that high levels of PEEP is a risk factor for VAP,
but a study by Cereda etal[30] has demonstrated
that higher levels of PEEP (15 cm of H2O) have
been shown to prevent the respiratory system
compliance. Some authors[21] have reported

that higher levels of PEEP may decrease the

lung compliance during mechanical ventilation
that may allow the development of atelectasis.
Mercat etal[31] demonstrated that increasing
levels of PEEP did not improve mortality in
adults ventilated patients. A study by Grasso
etal[32] suggested that higher level of PEEP may
critically affect the venous return. PEEP levels
>10 cm H2O may increase the risk of mortality
and morbidity in critically ill patients with a
significant increase in the intra-abdominal
pressure. [33] High levels of PEEP may be
necessary to maintain or restore oxygenation,
despite the fact that aggressive mechanical
ventilation can markedly affect cardiac
function in a complex and often unpredictable
fashion.[34] As the heart rate usually doesnt
change with PEEP, the entire fall in the cardiac
output is a consequence of a reduction in left
ventricular stroke volume. Since the present
study comprised of heterogeneous population
suffering from various disorders [Table 5 and
Table 6], admitted to the different ICUs, it was
difficult to set the same levels of PEEP for all
patients.
High FiO 2 values has also been found to
be a risk factor for mortality in the present
study [Table 7], results of which are similar

Table 5: Age, gender, and admission to ICU in both the groups

Variables

Study Group (N=87)

Control Group (N=86)

Statistical test used

DF

P Value

Males

64 (73.6%)

67 (77.9%)

c2 test

0.505

Females

23(26.4%)

19 (22.1%)

Age

49.416.13

49.716.21

Student t test

171

0.949

NSICU

13(14.9%)

24(27.9%)

c2test=9.528

MICU

48 (55.2%)

43 (50%)

SICU

9 (10.3%)

13 (15.1%)

03

0.023

ICCU

17 (19.5%)

06(7%)

Sex distribution

Admission to ICU

ICU = Intensive care unit; NSICU = Neuro-surgical intensive care unit; MICU = Medical intensive care unit; SICU = Surgical
intensive care unit; ICCU = Intensive coronary care unit

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Table 6: Underlying predisposing conditions of patients
Condition

Study Group

Control Group

Total

Respiratory diseases

17

16

33 (19.07%)

Neurological diseases

28

38

66 (38.15%)

Musculoskeletal/trauma

00

04

04 (2.31%)

Cardiac diseases

16

06

22 (12.71%)

Other medical conditions

17

15

32 (18.49%)

Surgical conditions

09

07

16 (9.24%)

Total

87

86

173

Table 7: Risk factors for mortality in both the groups

Risk factors

Unadjusted OR (Univariate Analysis)

Adjusted OR (Multivariate Analysis)

OR

95% CI

P Value

OR

95% CI

P Value

Age > 40 years

0.37

0.150.92

0.032

0.39

0.160.94

0.035

PEEP > 10 cm H2O

3.10

1.098.83

0.034

4.29

1.889.79

0.001

FiO2

0.02

0.0020.29

0.004

0.04

0.0040.42

0.007

GCS

1.58

1.242.03

0.000

1.47

1.181.83

0.001

CPIS

0.80

0.561.16

0.242

GCS = Glasgow coma score

Table 8: Risk factors for ventilator-associated pneumonia in both the groups

Risk factors

Unadjusted OR

Adjusted OR

OR

95% CI

P Value

OR

95% CI

P Value

Age > 40 years

4.09

1.0216.38

0.047

3.99

1.0315.55

0.046

Vt

.97

.95.99

0.007

.97

.95.99

0.008

PAP

1.35

1.031.77

0.028

1.33

1.021.73

0.034

PEEP> 10 cm H2O

6.24

1.2331.55

0.027

6.24

1.2531.07

0.025

Vt /PAP-PEEP

1.65

1.172.32

0.004

1.59

1.162.18

0.004

CPIS

.009

.002.049

0.000

.01

.002.049

0.000

CPIS = Clinical pulmonary infection score

to the other studies.[35,36] However, research

suggests that FiO2 60% is without major
adverse effects and that an individual at risk
of developing arterial hypoxemia can be
protected by administering high FiO 2 and
routine administration of supplementary oxygen
is useful, harmless, and clinically indicated.
There are hardly any studies to suggest
that CLdyn is a risk factor for VAP and this
variable may be considered as an additional
risk factor for VAP as per the results of
present study [Table 8]. When an abnormally
low or high compliance is uncorrected, this
may lead to the development of ventilatory

and oxygenation failure.[37] Studies[38,39] have

suggested that increased chest wall elastance
is important in pathogenesis of ventilatory
induced lung injury.
To conclude, the results of the present
study suggest that multimodality chest
physiotherapy may be used as treatment
option in ICUs. It has also demonstrated to
be safe irrespective of the clinical conditions.
Similar clinical trials may be conducted in
single ICU set up with a single condition like
GBS, ARDS, SCI, etc. Prevention of other
ICU related complications like Critical illness
myopathy and critically illness polyneuropathy
Indian Journal of Medical Sciences, Vol. 65, No. 5, May 2011

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INDIAN JOURNAL OF MEDICAL SCIENCES
184
journal

may be also studied from physiotherapy

perspectives.

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How to cite this article: Pattanshetty RB, Gaude GS. Effect
of multimodality chest physiotherapy on the rate of recovery
and prevention of complications in patients with mechanical
ventilation: A prospective study in medical and surgical intensive
care units. Indian J Med Sci 2011;65:175-85.
Source of Support: Nil. Conflict of Interest: None.

Indian Journal of Medical Sciences, Vol. 65, No. 5, May 2011