Chest Physiotherapy in Intensive Care Unit (ICU) PDF

Chest
Physiotherapy
in the Intensive
Care Unit
SECOND EDITION
Physiotherapy
in the Intensive
Care Unit
SECOND EDITION
Colin F. Mackenzie, M.B., Ch.B., Editor

Associate ProCessor
Department of Anesthesiology
University of Maryland School of Medicine
Baltimore, Maryland
P. Cristina Imle, M.S., P.T.

Physical Therapist
Maryland Institute for Emergency Medical Services Systems
Clinical Instructor. Department of Physical Therapy
University of Maryland School of Medicine
Baltimore. Maryland
Nancy Ciesla, B.S., P.T.

Chief Physical Therapist
Maryland Institute (or Emergency Medical Services Systems
and Montebello Rehabilitation Hospital
Clinical Instructor. Department of Physical Therapy
Universily of Maryland School of Medicine
Baltimore. Maryland
With a contribution in the 1st Edition to Chapters 5 and

6 from Nancy Klemic, B.S., P. T.
Formerly, Senior Physical Therapist
Maryland Institute for Emergency Medical Services Systems
Ballimore, Maryland
WILLIAMS & WILKINS

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Copyright 1989
Williams & Wilkins
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Printed in the United SIOles of America
First Edition 1981
Library of Congress Cataloging-in-Publication Data
Chest physiotherapy in the intensive care unit/Colin f'. Mackenzie.

editor: P. Cristina Imle. Nancy Ciesla. Nancy Klemic.-2nd ed.
p. em.
Includes bibliographies and index.
ISBN 0683053299
1. Lungs-Diseases-Physical therapy. 2. R espiratory therapy.
3. Critical care medicine. I. Mackenzie. Colin f'. II. Imle. P.
Christina. III. Ciesla. Nancy. IV. Klemic. Nancy.
(DNLM: 1. Intensive Care Units. 2. Lung Diseases-therapy.
3. Physical Therapy. WF 145 C526)
RC735.P58C48 1988
617'.5406-dc 19
DNLM/DLC
for Library of Congress 8837426
CIP
90 91 92
2 3 4 5 6 7 8 9 10
Preface to the Second Edition
The second edition of Chest Physiother change pulmonary pressures and assist
apy in the Intensive Care Unit follows 8 in the clearance of retained secretions.
years after the first. The object remains Chapter 2 provides new sections on res
to provide a comprehensive reference piratory physiology and respiratory
source for all professionals involved in mucus. Scientific data to justify postural
respiratory intensive care. Over 900 drainage, positioning and breathing ex
references are provided. A new section ercises, and percussion and vibration are
summarizes respiratory physiology and updated in Chapters 3 and 4. Chapter 5
there are comprehensive reviews of res compares the effects of coughing and
piratory mucus, cough, and suctioning forced expiration and reviews the cur
techniques. Every chapter is extensively rent techniques recommended for airway
updated. This new edition adds over 300 suctioning. Chapter 6 summarizes the
references from material published since important new aspects of patient mobili
1980. zation used to minimize the need for
The second edition addresses contro chest physiotherapy. Chapter 7 includes
versies about use of postural drainage, more information on collateral airways
percussion, vibration, breathing exer and synthesizes some postulated mecha
cises, cough, suctioning, and mobiliza nisms of action of chest physiotherapy.
tion. Current theories and conflicts about Treatment of patients with brain and
indications and contraindications for spine injuries is comprehensively up
chest physiotherapy are described and dated in Chapter 8. Chapter 9 covers
discussed. The authors' 15 years of ex some newer adjuncts to chest physio
perience of managing chest physiother therapy, most notably positive pressure
apy for critically ill patients is presented. techniques. Pain management tech
The format of the second edition remains niques in the ICU are expanded in the re
unchanged because the first edition had vised Chapter 10. Statistics of patients
three printings, was published in Spanish treated since 1974 are now consolidated
and Portuguese and was favorably re in Appendix I. Abbreviations and sym
viewed. bols are defined in Appendix II. An up
In Chapter 1 of the second edition, crit dated summary of chest physiotherapy
ical summaries of literature since 1981 treatment and evaluation is presented in
describe pathophysiology of respiratory Appendix 1II, and Appendix IV details
complications and techniques including the interventions in four critically ill pa
chest physiotherapy, bronchoscopy and tients. The index is now more com
positive pressure, all of which are used to prehensive.
v
Preface to the First Edition
It is quite apparent, from even a casual remarkable record of service. The three
conversation with physicians or other physical therapists who have contributed
personnel involved in respiratory care to this book have had betwee!l them 18
management, that there is a large spec years of work at M[EMSS since 1973. The
trum of differing treatments termed by therapy they have provided encompasses
their users as "chest physiotherapy." The five maneuvers: 1) postural drainage, 2)
literature is not helpful in specifying chest wall percussion and vibration, 3)
what chest physiotherapy is intended to coughing, 4) suctioning of the loosened
include. [s the inhalation of bronchodi secretions, and 5) breathing exercises in
lating or mucolytic agents part of chest the spontaneously breathing patient. [n
physiotherapy? In tracheally intubated addition, mobilization is used whenever
patients, is manual hyperinflation of the possible.
lung an inclusive part of chest physio Besides the similarities in patient pop
therapy? Many centers would use these ulation, personnel, and therapy, the me
therapies, others would not. All would chanical ventilatory support was stan
claim to be treating the patient with chest dardized at the Institute between 1973
physiotherapy. It is not surprising, there and 1978 with the use of only one type of
fore, that there are many contradictory volume-present ventilator. Controlled
opinions concerning the effects of chest mechanical ventilatory support was em
physiotherapy. Because of these varia ployed for resuscitation, for anesthesia
tions, if an improvement does occur, it is and throughout recovery, providing hu
likely to be difficult to determine the midification at all times. From October
beneficial component. 1978 on, intermittent mandatory ventila
A homogeneous patient population tion was occasionally used instead of
treated in a similar manner by the same controlled mechanical ventilation. No in
personnel over a number of years gives termittent positive pressure breathing
a useful clinical experience that fre (IPPB) machines were used to deliver
quently cannot be duplicated. At the bronchodilator or mucolytic agents. No
Maryland Institute for Emergency Medi inhaled drugs. other than water vapor,
cal Services Systems (MIEMSS) in Balti were given in the critical or intensive
more, Maryland, there is a unique and care units. Tracheal lavage was rarely
homogeneous population of traumatized employed. The "bag squeezing" tech
patients. Year after year, the admission nique of chest physiotherapy, in which
statistics confirm the similarities in the the lung is hyperinflated and the chest
patients, and their injuries, and in mor vibrated during expiration, was not used.
bidity and mortality. The population is No spontaneously breathing patients
unique because about 60% of the 1,200 or were treated with the aid of blow bottles
more patients admitted each year come or incentive inspiratory spirometers. Na
directly from the scene of their accident sotracheal suctioning was seldom used or
and about 75% of these patients come to attempted. Tracheal suctioning was only
the Institute by helicopter. carried out in intubated patients. Be
For the first 7 years, chest physiother cause these other respiratory maneuvers
apy has been used in the critical care and were excluded, the effect of chest phys
intensive care units to treat patients with iotherapy alone was determined.
lung secretion retention. The physical As with any book directed at diverse
therapists providing the therapy have a groups, such as critical care specialists,
vii
viii PREFACE TO THE FIRST EDITION
anesthesiologists, surgeons, internists, book presents our experience with chest

chest physiotherapists, nurse intensiv physiotherapy in the management of
ists, and respiratory therapists, some acute lung pathology in patients with
areas of the text are more relevant than previously normal and abnormal lungs,
others to each group, For the physician, Over the 7 years (1973-80), a homoge
the changes that take place with therapy neous patient population of over 3,000 in
and the aggressive approach taken at tensive care unit patients was treated.
MIEMSS are complemented by a consid The mechanical ventilation and physio
erable quantity of data and many case therapy techniques were standardized,
histories, To the physical therapist work and the medical and physical therapy
ing in the intensive care unit, this book personnel managing the respiratory care
provides complete coverage of the spe were constant. It is hoped that this book
cialty of chest physiotherapy, For the will provide others with a well-tested,
nurse intensivist and respiratory thera practical approach to chest physiother
pist, a practical approach to the respira apy for intensive care patients.
tory management of the multiply-moni
tored intensive care unit patient is C.F.M.
combined with a reference guide to the February 1981
literature on chest physiotherapy, This
Acknowledgments
First Edition. The majority of this book drafts, and to Sandy Bond-Lillicropp,
was written from knowledge acquired at who organized the typing of the earlier
the Maryland Institute for Emergency drafts.
Medicine under the direction of R. Finally, we thank experts in the field of
Adams Cowley, M.D. We are greatly in chest physiotherapy on both sides of the
debted to our mentors and colleagues, Atlantic who have read and criticized the
who have worked at the Institute with us manuscript at various stages. However,
during these years, for their teaching and the final result should not be blamed on
assistance. Particular acknowledgment them. Rather, the end product is the re
must be made to T. Crawford McAslan, sult of our determination to keep some
M.D., who was Clinical Associate Direc parts, such as the patient population data
tor of MIEMSS. Under his guidance, and the sections on special patients
chest physiotherapy was introduced to and mobilization which do not relate
MIEMSS in 1973. He and Baekhyo Shin, strictly to "chest therapy" or intensive
M.D., provided a stimulating intellectual care." The reviewers included Margaret
environment in which to study clinical Branthwaite, M.R.C.P., F.F.A.R.C.S., and
respiratory physiology and the effects of Barbara Webber of the Brompton Hospi
chest physiotherapy. Our debt to Drs. tal, London. England; Anthony Clement,
McAslan, Shin, and Cowley is very great. M.B .. B.S.. F.F.A.R.C.S., of St. Thomas'
We thank our colleagues, physicians and Hospital, London; John Hedley-Whyte,
nurses. for their help and cooperation M.D., and Cynthia Zadai of Beth Israel
with the production of this book, and Hospital and Harvard Medical School,
Gareth Green, M.D., Editor of the Amer Boston, Massachusetts; T. Crawford
ican Review of Respiratory Diseases, who McAslan, M.D., of Baltimore City Hospi
kindly supplied drafts of the November tals and The Johns Hopkins Medical
1980 supplement. We also owe thanks to School; lain L. Mackenzie, M.D., of York
Mark Moody, Ph.D.. Director of Clinic Hospital, York, Pennsylvania, and Bae
and Field Evaluation at MIEMSS, for data khyo Shin, M.D., Lucille Ann Mostello,
concerning admissions appearing in Ta M.D.. and Martin Helrich, M.D., all of the
bles 1.1-1.6, and to T. Crawford Mc University of Maryland Hospital and
Asian, M.D., for the traces appearing in Medical School, Baltimore. Particular
Figures 1.2-1.4. thanks are due Martin Helrich, M.D.,
For the photographs, we thank Colin Chairman, Department of Anesthesiol
Mackenzie, M.B., Ch.B., F.F.A.R.C.S., and ogy for his support and encouragement.
Dick Register for taking them; and Frank
Ciesla, MIEMSS and University of Mary
land Hospital Illustrative Services, for Second Edition. We gratefully ac
printing them. For illustrations, we thank knowledge help from John New, B.A.,
Chris McCullough-Green; and for proof with preparation of statistical data and
reading. Barbara Eerligh and Beverley we are grateful to Beverly Sopp and her
Sopp. Jeremy Hallisey, M.B., B.S., and staff (Lynn Kesselring and Eina Segal) for
David Clark helped with data analysis, editorial assistance. Marlene Wheeler
proofreading and reference checking. and Ruth Allan were unflagging typists.
Our thanks go to Marlene Wheeler and Justina Smith prepared the graphs in Ap
Kate McWilliams, who typed the final pendix I and Appendix IV and assisted in
ix
CONTENTS
many ways in the completion of this sec reviewed each chapter with thoughtful
ond edition. We are grateful to all of the criticism. In addition. George Barnas,
reviewers of the first edition and hope to Ph.D. provided excellent comments on
have answered their criticisms with the Chapter 7. Finally, we thank our editor at
second edition. We are especially thank Williams & Wilkins, Carol Eckhart, who
ful to Nancy Klemic who, while not in cajoled and persuaded us sufficiently fre
volved as an author in the second edition quently to get the revision finished.
because of other commitments, skillfully
Contents
Preface to the Second Edition . . . . ........ . ... . . . ..... . . ..... . v

Preface to the First Edition . ... . .. .. ........... . .. .. . . . ...... . vii
Acknowledgments ... .... . .. . . .... , , .. , .. . . .. ... . .... .... ix
Chapter 1 History and Literature Review of Chest Physiotherapy, ICU Chest

Physiotherapy, and Respiratory Care: Controversies and
Questions ................................................ . 1
Colin F. Mackenzie. M.B., Ch.B., F.F.A.R.C.S.
Chapter 2 Clinical Indications and Usage of Chest Physiotherapy: Anatomy,

Physiology, Physical Examination, and Radiology of the Airways
and Chest ................................................ . 53
Colin F. Mackenzie, M.B., Ch.B., F.F.A.R.C.S.
Chapter 3 Postural Drainage, Positioning, and Breathing Exercises 93

Chapter 4 Percussion and Vibration. . ....... . ......... . . ... . ...... . .... 134
P. Cristina 1m Ie, M.S., P.T.
Chapter 5 Methods of Airway Clearance: Coughing and Suctioning . . . . . . ... 153

Nancy Klemic, B.S.. P.T.
Chapter 6 Changes with Immobility and Methods of Mobilization 188

Nancy Klemic, B.S.. P.T.
Chapter 7 Physiological Changes Following Chest Physiotherapy. . ......... 215

Colin F. Mackenzie, M.B.. Ch.B.. F.F.A.R.C.S.
Chapter B Chest Physiotherapy for Special Patients 251

Chapler 9 Adjuncts to Chest Physiotherapy 281

P. Cristina 1m Ie, M.S., P.T.
Chapler 10 Undesirable Effects, Precautions, and Contraindications of Chest

Physiotherapy . . . ..... . .. . . . . . . . . . . . . . . . . . . . . ...... . ..... 321
xi
xii CONTENTS
AppendixI Chest Physiotherapy Statistics Showing Type and Number of

Patients Treated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 345
Appendix II Abbreviations and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Appendix III Summary of Chest Physiotherapy Treatment and Evaluation . . . 355
Appendix IV Duration, Type, and Frequency of Interventions in Four

Critically III Patients.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360
Index. . . . . . . . . . . . . . . . . . . . . . . . . . ... .. . . 367

CHAPTER 1
History and Literature Review of

Chest Physiotherapy, ICU Chest
Physiotherapy, and Respiratory
Care: Controversies and
Questions
Historical Summary and Literature Review

Update of Literature Since 1980
Pathophysiology and Risk Factors for Postoperative Respiratory Complications
Therapy for Respiratory Complications
Chest Physiotherapy
Techniques to Change Transpulmonary Pressures
Use of Bronchoscopy
Summary of Literature Update Since 1980
What Is Chest Physiotherapy?
What Are the Objectives of Chest Physiotherapy?
Chest Physiotherapy Organization
Respiratory Management
Indications for Intubation, Ventilation, Weaning, and PEEP
Alternative Modes of Mechanical Ventilation
Misconceptions About Effects of Chest Physiotherapy
Conflicting Data and Points of Contention
As an introduction to this book, Chap controversial aspects of respiratory care

ter 1 is intended to put chest physiother that relate to secretion clearance. Finally
apy into historical perspective and pro the chapter summarizes conflicting data
vide a review of the literature. A brief and points of contention concerning
description of the authors' understanding chest physiotherapy.
of chest physiotherapy and its objectives
is followed by some comments on the
variations found in the literature con
cerning indications, type, usage. and du HISTORICAL SUMMARY AND
ration of chest physiotherapy. A chest LITERATURE REVIEW
physiotherapy program and techniques 1901 Willi am Ewart described the beneficial
for respiratory management and assess effects of postural drainage in the
ment are discussed together with some treatment of bronchiectasis.
1
2 CHEST PHYSIOTHERAPY IN THE INTENSIVE CARE UNIT
1908 Pasteur delivered the Bradshaw Lec the Brompton Hospital, London, En
ture on massive collapse of the lung. gland, introduced "localized breathing
1910 Pasteur reported on the finding of exercises" for the thoracic surgical pa
acute lobar collapse as a complication tient (Gaskell and Webber, 1973).
of abdominal surgery. 1934 Nelson recommended bronchial drain
1915 MacMahon described the use of age for management of bronchiectasis
breathing and physical exercises in in children. He emphasized the use of
patients with lung, diaphragm, and physical and radiological examination
pleural injuries sustained in World War to locate the specific position of the
I. lung lesion and to determine patient
1918 Bushnell used postural drainage for positioning for drainage.
patients with pulmonary tuberculosis. 1938 Knies recommended bronchial drain
1919 MacMahon used breathing exercises age following thoracic surgery.
for patients recovering from gunshot 1950 Temple and Evans defined broncho
wounds of the chest. pulmonary segments to identify areas
1924 Featherstone described the causation of the lung needing resection.
of postoperative pneumonia, summa 1950 Felson and Felson used the silhouette
rized the pertinent literature since sign to localize intrathoracic lesions
1895, analyzed the results of 1000 radiographically.
consecutive medical and surgical au 1952- Kane described pulmonary segmental
topsies, compared the incidence of 1953 localization on posteroanterior chest
pneumonia after upper and lower ab x-rays. He also noted that the more ac
dominal surgery, and discussed his curately gravity was applied to the
observations as an anesthetist on the draining bronchus, the more effective
causes of postoperative pneumonia . was the postural drainage.
His pertinent findings are summarized
in Table 1.1. Many reports of symptomatic and
Dr. Featherstone's masterly work is physiological benefits from breathing ex
impressive because its conclusions
ercises and postural drainage appeared
are almost all still valid, and because of
the low incidence of pneumonia, which
up to 1945 (Heckscher). However, until
is little changed today from 1924. the 1 950s lhere was little change in the
1933 Jackson and Jackson wrote on the incidence of aleleclasis from that re
benefits of pulmonary drainage and ported by Pasteur and no change in lhe
coughing. incidence of pneumonia reported by
1934 Winifred Linton, a physiotherapist at Featherstone (1924), despite the ad-
Table 1 .1
Summary of the Causes of Postoperative Pneumonia
1. Postoperative pneumonia occurs with grave frequency (incidence in 1924 varied from 2.7 to
8.5%).
2. Often pneumonia is not recognized and figures that purport to give its incidence are
unreliable.
3. The anesthetic agent and the method of administration, except in special cases, are seldom
decisive factors.
4. Age and sex are not of importance.
5. General health and local disease of the lungs may play a considerable part.
6, At operation, every care should be taken to prevent loss of heat, of fluid, and of blood and
especially exhaustion from trauma to nerve tissue and to highly vascular parts.
7. Infection of the lung is often by means of aspiration in the presence of certain other factors.
8, Severe sepsis in the other regions affects the lung via the blood stream.
9. There is evidence that lymphatic infection through the right half of the diaphragm leads first
to pleurisy and then to pneumonia.
10. In the absence of severe sepsis, operations on the abdomen, and especially the upper
abdomen, provide the start of the chain of events which leads to pneumonia,
11. Pain in the abdomen from operative trauma, or from inflammation, gives rise to rigidity of the
anterior abdominal wall and to reflex inhibition of the diaphragm, together with some spasm
of the lower intercostal muscles. The lower lobes of the lungs, then, do not freely expand
and contract, so that congestion of the blood with edema sets in.
'From Featherstone (1924).
CHEST PHYSIOTHERAPY, ICU CHEST PHYSIOTHERAPY, ANO RESPIRATORY CARE 3
vances in surgery, anesthesia, and anti ventilation in 1 953 (Crampton Smith et

biotic usage. Pioneering work on the a\., 1 954) as a means of treating acute res
effects of chest physiotherapy was pub piratory insufficiency also gave rise to the
lished by Palmer and Sellick in 1953. realization that during artificial respira
They described the use of breathing ex tion there is a special liability to pulmo
ercises, postural drainage with vibratory nary complications. Opie and Spalding
and clapping percussion, and inhalation (1958) produced a review of some of the
of isoprenaline before and after surgery. physiological changes that occurred dur
This regime was significantly more effec ing chest physiotherapy and controlled
tive than breathing exercises alone in re mechanical ventilation, using intermit
ducing pulmonary atelectasis in 180 pa tent positive pressure with a negative ex
tients operated upon for hernia repair or piratory phase. The negative phase was
partial gastrectomy. They also found that then popular because this improved ve
isoprenaline combined with postural nous return to the heart. Advocates of in
drainage and vibratory and clapping per termittent mandatory ventilation make a
cussion prevented atelectasis, but that similar claim about the spontaneous
neither intervention alone prevented it. breath with this mode of ventilation.
These studies included controls but were Opie and Spalding noted that the rate
based on the somewhat subjective data of of air flow in and out of the lungs was de
atelectasis, as judged by clinical exami pendent upon the esophagotracheal pres
nation and chest x-ray. Thoren (1954), sure gradient, and that a rise in esopha
using diaphragmatic breathing and deep geal pressure with chest compression
breathing while side-lying, postural accelerated expiration (Fig. 1 . 1 ). Appli
drainage, and coughing, showed that cation of chest compression late in expi
without the use of inhalation therapy it ration caused only a very slight alteration
was also possible to produce a significant in air flow. Two mechanisms for the ac
reduction in pulmonary complications tion of chest physiotherapy were postu
after cholecystectomy. Atelectasis devel lated. ( 1 ) By raising intrathoracic pres
oped in 1 1 of 101 patients treated before sure as a whole, air was rapidly expelled
and after cholecystectomy, in 1 8 of 70 pa from the lungs, carrying secretions with
tients (25.7%) treated with chest physio it, as in a cough. The paper, however, ar
therapy only after cholecystectomy, and gues quite successfully against this
in 68 of the 1 72 patients (35.9%) who mechanism. (2) By local compression of
were not given chest physiotherapy after the lung underneath the physiothera
surgery. pist's hands, secretions were pushed
Therefore. over 25 years ago, there ap from the more peripheral airways into
peared to be a specific indication for the main bronchi. This has since been
chest physiotherapy in the prevention of disputed as the mode of action (Laws and
pulmonary complications after surgery. Mclntyre, 1 969).
Since then, there has been an explosion Wiklander and Norlin (1957) compared
in the apparent indications for chest 1 00 patients who, following laparotomy,
physiotherapy. It is the application of received chest physiotherapy, with 100
chest physiotherapy with lack of specific who did not. Chest physiotherapy was
indications that has rightly promoted ad given before and after surgery, for usu
verse commentary. The original popular ally 3 days, or as long as sputum was ob
ity of chest physiotherapy arose because tained. The incidence of atelectasis was
of the benefits produced in patients with 1 3% in those who received chest phys
retained lung secretions. However, to our iotherapy, and 24% in those who were
knowledge, no one has shown that treat asked to turn from side to side in bed and
ment with chest physiotherapy has al given instruction and help in coughing.
tered the morbidity or mortality of pa In a frequently quoted study on the
tients with chronic lung disease, whereas value of lung physiotherapy in treatment
chest physiotherapy for acute lung pa of acute exacerbations in chronic bron
thology in a previously normal lung may chitis, Anthonisen and his colleagues
produce a more favorable outcome. (1 964) compared conventional treatment
The advent of controlled mechanical and chest physiotherapy to conventional
TRACHEAL
020
'"
I
E
u
w
I sec.
Figure 1 . 1 . The effect of chest physiotherapy on tracheal and esophageal pressure in a patient
ventilated with intermittent positive/negative pressure ventilation. Hatched area. inspiratory period.
(A) Chest vibration during inspiration. (B) Chest vibration during the inspiratory-expiratory junction.
(C) Chest vibration during the middle of the expiratory period. Note the greatest trach eoesophageal
pressure differences occur with Band C which are normally used methods of applying chest vi
bration. (Tracing from Opie LH. Spalding JMK: Lancet 2.71-674. 1958.)
treatment alone. No differences in out as the cause for the fall in PaO, in the
come were found between the groups treated patients.
randomly treated with and without chest Further information about chest phys
physiotherapy. During an acute flare-up iotherapy was published in 1969 when
of chronic bronchitis, chest physiother Laws and Mcintyre described changes in
apy did not seem beneficial. but they did gas exchange and cardiac output associ
not exclude the possibility of benefit in ated with chest physiotherapy in six pa
lobar atelectasis. tients in respiratory failure. All were
In 1 966. Holloway and his colleagues ventilated with volume ventilators and a
reported that chest physiotherapy ap tidal volume (V,) of 10-13 mllkg. Cardiac
peared to cause a fall in arterial oxygen output was measured with the dye dilu
ation when applied to neonates with tet tion technique. Since this was before the
anus. This preliminary observation was era of flow-directed pulmonary artery
followed by the publication of a study on catheters, neither pulmonary artery pres
22 patients with tetanus who received sure nor mixed venous gases were mon
chest physiotherapy (Holloway et a!., itored. However, mixed expired and
1 969). These patients were compared to a inspired gases were analyzed. Alveolar
matched group of 14 spontaneously to-arterial tension gradients for both 0,
breathing patients and a group of 1 5 ne and CO, were derived and used to mea
onates receiving mechanical ventilation sure the efficiency of gas exchange be
but not chest therapy. Chest physiother fore, during, and after chest physiother
apy, which took the form of clapping and apy. The procedures performed included
compression. percussion and vibration, postural drainage with percussion, shak
was followed by suctioning. A fall in ing, and vibration. Artificial coughs were
PaO, occurred after chest physiotherapy, given in the supine position, and both lat
but it is doubtful if the changes of PaO, eral positions, and chest compression
50.6 6.4 to 47.0 6.4 mm Hg (mean was performed during expiration. These
SO) were clinically significant, although procedures were followed by lung hyper
it was apparently statistically so. The inflation (V" 20-25 mllkg). The patients
control group was ventilated but did not were then suctioned: none had large
receive chest physiotherapy and was not amounts of sputum. This factor appeared
turned to the same positions. Therefore. to be crucial, as these authors were un
simple V /0. changes cannot be excluded able to show any improvement in gas ex-
CHEST PHYSIOTHERAPY, ICU CHEST PHYSIOTHERAPY, AND RESPIRATORY CARE 5
change. They also cast doubt on the hy cantly greater than that of the control of
pothesis that external chest compression 1 . 6 ml (p < 0.0001).
squeezes secretions from completely oc Lord et aJ. (1972) showed anecdotal ev
cluded airways by direct lung compres idence for radiological and arterial blood
sion. They suggest that the amount of gas improvement after chest physiother
compression required to do this would apy in an infant and adults. Gormezano
produce areas of collapse. As an alterna and Branthwaite (1972a) reported the ef
tive hypothesis. they put forward the fects of chest physiotherapy on 43 adults
idea that airway clearance requires some receiving intermittent positive pressure
expansion of distal lung units. Indirect ventilation. The patients were consid
ventilation of these distal airways may be ered in three groups: Group I included 18
achieved by collateral channels. The patients with no cardiac disability; Group
more proximal airways are then cleared II. 1 3 patients with cardiovascular dis
by increased expiratory flows. generated ability; and Group III, 11 patients with
by the physiotherapists. from the dis respiratory failure. Chest therapy in
tal airways. Our explanation of the cluded hyperinflation to 20 cm H,O
mechanism of chest physiotherapy above previous ventilator settings. man
action is similar and is described in ual chest compression. and tracheal suc
Chapter 7. tioning. Duration of treatment was was
In the patients studied by Laws and from 7 to 20 min. depending on whether
McIntyre during physiotherapy. cardiac copious secretions were mobilized. Ar
output varied up to 50% from the levels terial blood gases were sampled before
obtained before physiotherapy. These and at 5. 15. and 30 min after cessation of
variations persisted for as long as 30 min. therapy. Patients in Groups I and III did
The greatest variation occurred during not show any change; Group II showed a
the artificial cough with inflation pres maximum fall in PaO, of 14.9 4.55 mm
sures of 60-100 cm H,O. In some patients. Hg (SE) 5 min after therapy. Within 30
cardiac output fell due to impaired ve min this had returned to the levels ob
nous return during this maneuver. In tained before therapy. Hyperinflation
those who were conscious, the procedure caused a rise in PaO, in all groups. PaCO,
was also found to be extremely unpleas i ncreased in all groups, but a rebreathing
ant. During resistance to lung hyperinfla circuit was used during manual chest
tion. and with patient apprehension, car compression. The authors postulated that
diac output rose. These hyperinflations. during chest physiotheraEY. ( 1 ) cardiac
although causing such changes in the output fell; therefore. PVO, fell; and.
cardiovascular system, were not able to therefore. PaO, fell; (2) there was an in
produce any lasting benefit to pulmonary crease in intrapulmonary shunt; and (3)
gas exchange. These are some of the rea there was increased oxygen consump
sons for our omission of lung hyperinfla tion. Because no indications for chest
tion from physiotherapy treatment (see p. physiotherapy were given. it is not
225). known whether treatmenl was per
Lorin and Denning (1971 ) found that formed prophylactically or for a specific
postural drainage produced more than indication. Since the patients were
twice the volume of sputum as an equal turned on both left and right sides but
period of cough alone in 1 7 patients with were not apparently posturally drained
cystic fibrosis. Postural drainage lasted with the affected lobe or segment upper
20 min and included positioning for the most, it is not certain whether chest
right middle lobe. lingula. and some bas physiotherapy produced these changes
ilar segments of the lower lobe. The pa or whether they were due to changes in
tients received percussion and vibration posture.
in each position. The volume of sputum Gormezano and Branthwaite (1972b)
produced when compared with the vol also studied patients treated with chest
ume produced by the same patient in the physiotherapy and intermittent positive
sitting position, coughing every 5 min for pressure breathing (IPPB). Thirty-two
20 min. averaged 3.4 ml and was signifi- chronic bronchitic patients with airway
obstruction and sputum production were appear to have normal mucus clearance.
divided into three groups: those with re The radioactive tracer clearance tech
versible airway obstruction (Group I), nique is now the accepted model for fur
those with profuse secretions (Group II), ther investigation. However, peripheral
and those with respiratory failure (Group deposition of radioaerosols is difficult in
Ill). Mean PaO, fell 4-6 mm Hg in all patients with chronic lung diseases be
groups, but the fall was greatest in Group cause they often have impaired inhala
II. The fall was thought to be due to in tion and they cough. Radioaerosols do
creased intrapulmonary shunt. However, not reach airways that are obstructed so
no specific cause of the increased shunt that although airway clearance may
was identified, although several were hy occur, this is not demonstrated by the ra
pothesized, such as decreased pulmonary dioaerosol clearance technique. In 1974,
artery pressure with rest after therapy, the National Heart and Lung Institute, as
increased pulmonary artery pressure due i t was then called, organized a confer
to i ncreased cardiac output, and abolition ence, frequently referred to as the Sugar
of hypoxic pulmonary vasoconstriction. loaf Conference, on the scientific basis
In 1 973, Clarke and his colleagues re of respiratory therapy. This conference
ported the effects of sputum on pulmo and a similar conference on in-hospital
nary function. Patients with copious spu respiratory therapy published in
tum production and airway obstruction 1 980 are summarized in Chapter 7, pp.
(forced expired volume in 1 sec (FEV,)! 245-248.
forced vital capacity (FVC) < 70% pre Campbell and his colleagues (1975) re
dicted) improved in all measured param ported that bronchoconstriction, as mea
eters, particulary specific airway conduc sured by a fall in FEV" occurred in seven
tance, following sputum removal. There patients with exacerbation of chronic
was, however, no relationship between bronchitis following chest percussion or
the volume of sputum produced and the vibration. They found that bronchocon
improvement of pulmonary function. striction was particularly noticeable in
They concluded that although sputum patients who did not have copious spu
volume production is important, its dis tum production. The fall in FE V, was not
tribution within the bronchial tree and confirmed by other studies of chest phys
its viscoelastic properties may be of iotherapy and chronic bronchitis (Coch
greater importance. rane et al.. 1977; Newton and Stephen
A report in which removal of inhaled son. 1 978; May and Munt. 1979).
radioactive tracers was used to measure Tecklin and Holsclaw (1975) found that
pulmonary mucociliary clearance in cys following postural drainage, percussion,
tic fibrosis appeared in 1 973 (Sanchis et vibration and coughing in 26 patients
al.). Despite previous beliefs, mucociliary with cystic fibrosis, significant increases
transport in 1 3 children with cystic fibro occurred in peak expiratory flow rate .
sis was found to take place at a similar FVC, expiratory reserve volume and in
rate to that found in normal adults. The spiratory reserve capacity. Larger air
theory that the viscid secretions found ways appeared to be the sites of this ben
in cystic fibrosis (or mucoviscidosis) were eficial action. There was no indication
inadequately cleared, resulting in that these benefits lasted beyond 5 min
blocked airways, stasis, and resultant in after treatment had ceased. Cystic fibro
fection, appeared to be considerably set sis is one of the few chronic lung diseases
back by this finding (Waring, 1 973). How for which the benefits of chest physio
ever, one problem with the technique therapy are documented. A conference in
used was that the particle size of 3 I'm Europe, published in 1 977. summarized
was perhaps too large and, therefore, the the state of the art (Baran and Van Bo
radioactive particles did not penetrate gaert, 1 977).
the lung effectively. More central pene Objective evidence of change in the
tration occurred in children than in lungs following sputum removal by chest
adults. Because mucociliary clearance is physiotherapy in mechanically venti
faster from larger airways than from lated patients was reported by Winning
smaller airways, the children may only and colleagues (1975). They estimated al-
CHEST PHYSIOTHERAPY, ICU CHEST PHYSIOTHERAPY, AND RESPI RATORY CARE 7
veolar pressure by means of a retard midexpiratory now rate worsened, show

mechanism applied to the lungs at end ing significant decrease with the inhala
expiration. A significant fall in "alveolar tion. This was thought to be due to renex
pressure" was noted to occur after chest small airway constriction and edema fol
physiotherapy in 1 7 patients. Unfortu lowing N-acetylcysteine or due to cough
nately the adjustment of the ventilator ing. Using technetium-99m, Pavia et al.
necessary to produce the "alveolar pres (1976) found that a mechanically vibrat
sure" alters the characteristics of the ing pad did not significantly alter clear
lung under study. Therefore, it is difficult ance of sputum when compared in 1 0
to determine whether the changes found patients who had histories o f productive
were due to chest physiotherapy or ven cough and difficulty expectorating
tilator manipulation. phlegm; however, postural drainage was
The additional effect of only a muco not used.
lytic agent, or a bronchodilator and a mu Martin et al. (1976) investigated the
colytic agent, on arterial oxygenation ability of unilateral breathing exercises
following chest physiotherapy was com to alter distribution of ventilation and
pared to the therapy alone. No differ blood now in patients u ndergoing bron
ences were found (Brock-Utne et al.. chospirometry. In no instance was the
1975). A similar finding was reported in distribution of ventilation or blood flow
which clearance of inhaled polystyrene altered to the side that was supposed to
particles tagged with technetium-99m be limited. However, although these pa
was used to assess removal of lung secre tients had active tuberculosis, there was
tions in a double-blind crossover trial in no indication that the pathological lung
16 patients with chronic bronchitis was the target of the therapy, since both
(Thomson et aI., 1975). There was no sig sides of the chest were treated. All pa
nificant difference in weight or radioac tients had less than 1 5% involvement of
tive content of sputum expectorated be the lung fields by chest x-ray. respiratory
tween the patients who were given function tests were all normal, and only
S-carboxymethylcysteine, a mucolytic one subject was thought to have moder
agent, and those who were not. Ventila ately advanced disease. Therefore, it is
tory capacity as assessed by dry spirom possible that in major lung pathology or
etry was not changed, nor was there sub in patients with chest splinting due to
jective improvement noted by the pain, breathing exercises may have a dif
patients. Roper and colleagues (1976) ferent effect, when large differences in
found right upper lobe atelectasis oc lung/thorax compliance occur.
curred after tracheal extubation in 18 of Removal of sputum by chest physio
188 newborn infants. This was thought to therapy produced an improvement in
result from the anatomical positions of specific airway conductance in 17 of 23
the right upper lobe bronchus and dam patients with chronic cough, airway ob
age from suction catheters. The atelecta struction. and at least a 30-ml sputum
sis could usually be expanded by chest production per day (Cochrane et aI.,
physiotherapy. If it was unresponsive. an 1 977). This improvement did not occur in
orotracheal tube was inserted, and the 4 normal subjects, nor in 8 of the study
lungs manually hyperinnated and suc patients who, on the following day, were
tioned until all secretions were mobi given 1 50 mg isoprenaline base by inha
lized. Following this the trachea was lation instead of physiotherapy. Coch
immediately extubated. This regime re rane and his colleagues reiterated their
sulted in the elimination of recurrent at belief that the distribution of sputum
electasis as a major problem after extu throughout the airways appeared to be
bation. Tecklin and Holsclaw (1976) more relevant than sputum volume, vis
found that N-acetylcysteine (Mucomyst) cosity. or character. No correlation was
and bronchial drainage and coughing found between changes in specific air
produced the same changes in respira way conductance and sputum volume
tory function in 20 patients with cystic fi produced by chest physiotherapy.
brosis, that occurred without the use of By using transcutaneous 0, monitor
the mucolytic agent. In fact, maximal ing, the effect of chest physiotherapy on
PaO, in 45 patients who had undergone 1 ). After a control period, 30 sec of ante
abdominal surgery was compared to rior chest wall vibration was performed
three deep breaths using incentive spi by using a mechanical vibrator. The in
rometry, a mechanical lung insufflator, fants were then suctioned and hyperven
and the blowing up of a paper coil (Hed tilated for ten breaths. Since neither pos
strand et al" 1 978). Chest physiotherapy tural drainage nor percussion was used.
produced a greater increase in PaO, than the treatment given was not strictly chest
did the other maneuvers, though it is physiotherapy. However, there was a
doubtful if a 7 mm Hg rise in PaO, is clin consistent trend in which compliance
ically any different from the 3 to 4.5 mm and functional residual capacity (FRC)
Hg obtained with the respiratory therapy increased in parallel throughout all the
devices. The reliability of transcutaneous periods of study. Inspiratory airway re
0, monitoring, when used in adults, is sistance was noted to fall significantly
also in question. This paper does not re following chest vibration and suctioning,
cord why the patients needed therapy. but this had returned to control levels
The respiratory therapy devices may within 2 hr. Arterial oxygenation fell sig
have been used in the recommended nificantly following suctioning. This was
manner; however, chest physiotherapy, reversed with hyperventilation. Two
which apparently consisted of ten deep hours following therapy, PaO, levels did
breaths and a minute of coughing fol not differ from control. The fall in PaO"
lowed by assisted costal breathing in the which was as high as 81 mm Hg in a pa
lateral position, at our institution would tient breathing 55% oxygen, was not
be considered inadequate to clear re thought to be due to atelectasis because
tained secretions. there was no change in FRC and no fall
Two abstracts (Finer et aI., 1 977; Fox et in lung compliance. It was, perhaps, due
aI., 1 977) that described chest physio to the rise in pleural pressure accompa
therapy for the neonate were published nying coughing and suctioning which
as papers the following year. Finer and may have increased a right-to-left shunt.
Boyd (1978) studied 20 neonates with a Mackenzie et al. (1978) studied 47 pa
mean weight of 2.07 kg. Seven neonates tients with a variety of chest x-ray
were mechanically ventilated; all had changes that included atelectasis, pneu
respiratory failure and were receiving monia, or lung contusion. Eight of the 47
supplemental 0,. Respiratory failure was patients were nontrauma and had multi
due to respiratory distress syndrome in ple pathology; the remainder were
14 neonates, tachypnea in 2, pneumonia trauma patients. All patients were me
in 3, and apnea in 1. Arterial blood gases chanically ventilated with positive end
were analyzed before, and 1 5 min after, expiratory pressure (PEEP) (5-10 cm
postural drainage and suction (10 infants) H,O). Changes in arterial oxygenation
or postural drainage, percussion and suc were prospectively studied before and
tion (10 infants). The neonates showed a for 2 hr after chest physiotherapy. No sig
rise in PaO, when postural drainage, per nificant changes in PaO, were found after
cussion and suction were used but no sig chest physiotherapy. There were no dif
nificant change with postural drainage ferences between patients with or with
and suction alone. The same findi ngs, in out trauma or between those treated with
a population of a different age and venti or without head-down postural drainage.
lated differently, were reported in the ab The falls in arterial oxygenation reported
stract. It is not clear why some patients, by others to occur after chest physiother
whose data appeared in the abstract, apy may be reversed by the use of PEEP.
were omitted from the paper. Unilobar lung pathology showed radio
Fox and his colleagues (1 978) studied logical improvement in 74% (20/27) and
1 3 newborns to "determine the benefit/ multilobar pathology improvement in
risk ratio of chest physiotherapy." All 60% (12/20). These radiological findings
were int ubated, breathing spontaneously are similar to those obtained by fiberoptic
with positive airway pressure, and were bronchoscopy in patients resistant to rou
recovering from respiratory disease (res tine respiratory therapy (Lindholm et al.
piratory distress, 1 0; aspiration, 2; apnea, 1 974).
Chest physiotherapy produced a differ to be a pneumonic process was cleared in

ent effect on pulmonary function in pa its early stages with treatment by chest
tients with acute exacerbations of physiotherapy (Case History 2 . 1 ). Restric
chronic bronchitis (Newton and Stephen tion of chest physiotherapy to a predeter
son) than in patients with bronchiectasis mined time of 20 min may not provide
and cystic fibrosis (Cochrane et al.). The sufficient duration to clear secretions, es
33 patients studied by Newton and Ste pecially when IPPB is also given during
phenson, within 4 days of admission for the same 20 min. The conclusion by Mur
acute exacerbation of chronic bronchitis, ray (1979), that the use of chest physio
had an FEV,/FVC ratio of <50%, indi therapy for patients with otherwise un
cating considerable respiratory impair complicated pneumonia should stop,
ment and airway obstruction. They had appears quite reasonable, especially if
less than 15% improvement after use of the patients are ambulatory or mobilized.
bronchodilators. Thoracic gas volumes For the mechanically ventilated patient
and airway resistance were measured in in the ICU this may not be valid, since it
a body plethysmograph, and specific con is difficult to arrive at the diagnosis of
ductance was derived. FEVt, vital capac pneumonia unless retained secretions
ity, and inspiratory capacity were also are not cleared or radiological improve
measured before chest physiotherapy. ment fails to occur following chest phys
All tests were repeated two times at half iotherapy. Recent data provide more
hourly intervals after 1 5 min of physio objective evidence for diagnosis of pneu
therapy. Positioning and chest physio monia (Salata et aI., 1987; Johanson et aI.,
therapy maneuvers were not adequately 1 988a) and make some management
described. No more than 5 ml of sputum suggestions for its prevention in the ICU
was produced in any patient. An acute (Driks et aI., 1 987; Johanson et aI., 1 988b).
rise in lung volume, FRC and conduc An editorial in the Loncel (1978) scru
tance occurred, but there was no change tinized the use of chest physiotherapy
in arterial blood gases. No deterioration and noted that surprisingly few studies
occurred in FEVt Most patients pro showing objective assessment were pub
duced 2 ml of sputum or less: it is not sur lished. Those that were published
prising that the authors concluded that seemed to have concentrated on areas
their patients did not show any obvious where physiotherapy is predictably inef
benefit from chest physiotherapy. fective. Chest physiotherapy was thought
Graham and Bradley (1978) compared a to be most useful when copious amounts
randomized group of 27 patients, treated of very sticky sputum were produced. It
with chest physiotherapy and IPPB for 20 was also emphasized that by talking to,
minutes, to a control group of 27 similar touching, and making the patient more
patients. Both groups had pneumonia, as comfortable, the physiotherapist pro
judged by a compatible clinical history of vides an important link between the pa
fever and increased cough, radiological tient and other members of staff.
confirmation, and a positive gram stain of Newton and Bevans (1978) treated 39
sputum and blood cultures (12% posi patients with acute exacerbations of
tive). They found no difference in dura chronic bronchitis with antibiotics, bron
tion of fever, extent of radiographic chodilators and diuretics (standard treat
clearing, duration of hospital stay, or ment). These patients were compared
mortality between the control and with 40 patients treated with IPPB (3
treated groups. As was pointed out in the times daily with nebulized saline) and
correspondence following this article, chest physiotherapy for 1 0-15 min, in ad
the authors excluded patients with bron dition to the standard treatment. Arterial
chiectasis, lung abscess and cystic fibro blood gases, sputum volume, FEVt and
sis who might have expected to benefit vital capacity were measured among
from chest physiotherapy. The establish other parameters. Only admission and
ment of a diagnosis of pneumonia in the discharge data were provided. Since dis
intensive care unit (ICU) is not as simple charge is frequently not a clinical but an
as was cited by Graham and Bradley. As administrative decision, it would be
mentioned in Chapter 2, what appeared helpful if some daily data were included.
10 CHEST PHYSIOTHERAPY I N THE INTENSIVE CARE UNIT
Chest physiotherapy was not adequately did not alter clearance. The differences
described and the results were at times in the findings of this study and that of
confusing. However. no differences were Bateman et al. may be a function of study
found in PaO,. PaCO,. FEV,. vital capac design and the properties of the radiola
ity. or duration of hospital stay between beled aerosols used (Rochester and Gold
the two groups. The only difference was berg. 1 980). The site of deposition of ra
that men who received chest physiother dioactive aerosol showed considerable
apy produced a greater sputum volume variation between the subjects in the
than those who did not. study by Oldenburg and colleagues.
The effects of chest percussion and Therefore. the conclusion that cough was
postural drainage on respiratory function effective in improving peripheral airway
in 35 patients with stable chronic bron clearance may not be valid. These find
chitis were compared to sham treatment ings need confirmation in a larger patient
with an infrared lamp. (May and Munt. population since they have not been con
1 979). The conclusions were similar to firmed by others (see Chapter 5). It is also
the study of Newton and Stephenson on doubtful if any clinician would use pos
patients with acute exacerbations of tural drainage and eliminate cough or
chronic bronchitis and suggested that huff. Bronchial clearance following pos
postural drainage and chest percussion tural drainage and coughing was not ex
did not benefit the patients. This study amined by these investigators. Camner et
showed that although chest physiother al. (1979) differentiated between healthy
apy improved FVC and FEV,. these also subjects and those with expectoration
improved following the use of the infra and lung disease on the basis of clearance
red lamp (sham treatment). Sputum pro of inhaled 6 I'm radioactively tagged Tef
duction was greater during percussion lon particles following coughing. Six of
and postural drainage than during the in eight patients with lung disease repro
frared warming (5.5 vs. 1 .4 ml average) or ducibly eliminated the tagged particles
during coughing (9.0 vs. 3.5 ml average). after 1 -2 min of voluntary coughing. The
Bateman and his colleagues (1979) did rapid clearance suggests the particles
not use a sham treament but used a were deposited in the central large
crossover control when they compared airways.
clearance of bronchial secretions labeled Fiberoptic bronchoscopy is frequently
with techneti um-99m from 1 0 patients used to clear acute lobar atelectasis (see
with stable chronic airway obstruction Chapter 9). Marini et al. (1979) compared
and regular sputum production. They bronchoscopy to incentive spirometry.
found that chest physiotherapy was coughing. and tracheal suctioning in non
highly effective in moving bronchial se intubated patients. If they were intu
cretions from peripheral to more central bated. they received IPPB with nebulized
lung regions and aided in expectoration. isoetharine (Bronkosol) and chest percus
Feldman et al. (1979) found that pos sion and postural drainage. Neither bron
tural drainage with chest percussion. vi choscopy. nor the regime of respiratory
bration and coughing resulted in signifi therapy produced differences in resolu
cant improvement in expiratory flow at tion of the atelectasis at 24 or 48 hr. Pa
50% and 25% of FVC. In the 1 9 patients tients who had air bronchograms seen on
studied who had chronic bronchitis or chest x-ray had slower resolution of the
cystic fibrosis. there was no correlation atelectasis. Marini et al. concluded that
between volume of sputum produced an air bronchogram is the result of satis
and changes in lung function. factory central clearance of secretions
Oldenburg et al. (1979) studied the ef and. therefore. contraindicates fiberoptic
fect of postural drainage. exercises and bronchoscopy. However. bronchoscopy
cough in 8 clinically stable patients with may be necessary when effective respi
chronic bronchitis. They found that ratory therapy cannot be accomplished
cough alone greatly accelerated bron or long-standing atelectasis and inspis
chial clearance of a radioactive tracer de sated secretions remain unresponsive to
posited in the tracheobronchial tree. Pos respiratory therapy.
tural drainage. with cough prohibited. Murray (1979) likened the removal of
secretions from the respiratory tract to that chest physiotherapy is not indicated
gelling ketchup out of a bottle. He sum in patients without sputum production.
marized the present debate about indi The ability to perform chest physio
cations for chest physiotherapy in pa therapy and produce a favorable radio
tients with chronic lung diseases. He did logical outcome, when bronchoscopy was
not discuss acute lung pathology in pa considered too hazardous, was reported
tients with otherwise normal lungs. What in a case study by Ciesla and colleagues
was considered of particular concern was (1981 ). Despite severe trauma involving
the unnecessary use and cost of chest multiple body systems, intrapulmonary
physiotherapy and other respiratory shunt was decreased and acute atelecta
therapy procedures for patients with sis reversed following chest physiother
chronic obstructive pulmonary disease apy. Hammond and Martin (1981 ) con
and other lung diseases in which no spu firmed that advantages of chest
tum was produced. The bottle must con physiotherapy over bronchoscopy and
tain some ketchup before it can be emp showed convincing radiological evidence
tied. No one would argue with this of improvement when chest physiother
generality. Murray advocates that if chest apy was used to treat acute atelectasis.
physiotherapy does not produce in ex
cess of 30 ml of sputum, it should be dis UPDATE OF LITERATURE SINCE
continued. This has not been found to be 1980
an appropriate guideline for patients
with acute lung disease in the ICU, nor In 1 980, the first edition of Chest Phys
has it been substantiated as a guideline iotherapy in the Intensive Care Unit was
for patients with chronic lung disease. completed and the most recent proceed
Mackenzie et al. (1980), using calcula ings of the NHLBI Conference on the Sci
tion of lung/thorax compliance (CT) de entific Basis of In-hospital Respiratory
scribed by Winning et al. (1975), but Therapy was published. For publications
avoiding their adjustments of the venti since 1980, added in this new edition,
lator that alter lung mechanics, found an headings of broad interest are used to
increase in the CT following chest phys group critical summaries of similar
iotherapy. Forty-two patients who suf topics.
fered trauma were studied. There ap
peared to be no difference in the CT Pathophysiology and Risk Factors for
increase whether the patient had atelec Postoperative Respiratory
tasis, lung contusion, pneumonia, or res Complications
piratory dist ress syndrome. Nor did
differences occur between patients ven Andersen and J espersen (1980) identi
tilated with or without PEEP or between fied communications between neighbor
those treated for more or less than 1 hr. ing lung segments in normal lungs using
The greatest CT increase occurred 2 hr resin casts. They found collateral air
after therapy had ceased, which sug ways with a diameter of 80-150 I'm
gested that changes continue to occur (when fixed at 1 0 cm H,O pressure) in all
even after the completion of therapy. lobes, but especially in the lower lobes
Connors et al. (1980) found that acutely (Fig. 1 .2A and B). These intersegmental
ill patients with lower lobe disease who respiratory bronchioles are probably of
produced little or no sputum showed a great importance in the reexpansion of
significant fall in PaO, during postural atelectatic lung by chest physiotherapy.
drainage and percussion. Those patients Macklem (1971 ) and Menkes and Trayst
that produced more than 2 ml of sputum man (1 977) have previously suggested
showed no change in PaO,. The spectrum these alternative pathways, particularly
of intensive care and ward patients, dis the largest, the interbronchiolar channels
eases treated, and methods of ventilation of Martin, as a means of prevention and
are large in the study population. There reexpansion of atelectasis beyond ob
are methodological variations in arterial structed subsegmental or more periph
blood gas sampling and oxygen delivery eral airways. Resistance in collateral air
that detract from the data. They conclude ways decreases with increased lung
Figure 1.2. (A) Corrosion cast of two adjacent bronchopulmonary segments distal to 3 mm air
ways. The left segment is cast with light resin, the right with dark resin. Note that the light resin
has crossed the segmental borders and occupies the distal part of the right segment. (6) A cast of
a large intersegmental bronchiole from the lower lobe with a diameter of 110 "m. (From Andersen
JB. Jespersen W: De monstration of inte rsegmental respiratory bronchioles in normal human lung.
EurJRespirOis61:337-341,1980.)
volume. The increased collateral venti tainly avoid narcotic-induced ventilatory

lation that occurs with increased lung depression (see Chapter 10).
volume supports the use of deep breath Vickers (1982) noted that the incidence
ing and positive airway pressure to re of chest complications after surgery has
verse atelectasis found postoperatively not changed appreciably in 30 years, sug
(Craig, 1981). gesting that the main determinants were
The pathophysiology and management largely unaffected by changes in medical
of atelectasis after anesthesia are dis and surgical practice. Although multiple
cussed by Rigg (1981). He identifies many etiologies are proposed for the cause of
risk factors likely to increase alveolar chest infection after surgery, none has
collapse including low lung volume, high produced unequivocally positive find
closing volume, oxygen therapy, rapid ings. Surveys of postoperative infections
shallow ventilation, chronic lung dis indicate upper abdominal or chest sur
ease, smoking, and obesity. Postoperative gery as the most important causal deter
pain following abdominal or thoracic sur minant. Chronic respiratory disease
gery and narcotic-induced ventilatory tripled postoperative respiratory compli
depression were additional factors to cations; obesity (over 120 kg), old age
gether with neurological, neuromus (above 70 years), and a history of smoking
cular, and musculosketetal diseases as were also associated with a greater prob
sociated with impaired respiration. Man ability of postoperative pneumonia.
agement to prevent atelectasis includes Vickers discussed perioperative chest
chest physiotherapy, or delay in elective physiotherapy, IPPB, incentive spirome
surgery. Improvement in respiratory try, and bronchodilators, but stated that
function may be achieved with antibiot none made a difference in the develop
ics, bronchodilators, and steroids, and by ment of pulmonary infection after upper
stopping smoking and weight loss. Elec abdominal surgery. Prophylactic antibi
tive postoperative ventilation may re otics were viewed with disdain because
duce atelectasis in selected patients. resistant strains develop, and up to 80%
Whereas elective surgery may be de of patients suffer no respiratory compli
layed, emergency procedures and many cations. Improvements in pain relief
of the identified risk factors are unavoid have not generally brought about a re
able or irreversible. Improvements in duction in respiratory infections, though
postoperative pain management can cer- they may yet do so. Doxapram, a respi-
ratory stimulant, may reduce the produc age Uones, 1982). Catley et al. (1982) com
tion of purulent sputum without influ pared regional nerve block and continu
ence on analgesia, However, when ous i.v. morphine infusion analgesia in
Doxapram was used in 20 postoperative patients following cholecystectomy and
patients greater than 126 kg in weight, hip replacement. Comprehensive contin
there was no difference in the degree of uous monitoring of electroencephalo
hypoxemia or incidence of chest infec gram (EEG), arterial 0, saturation (SaO,),
tions in the treated or untreated group ECG, and inductance pletysmography
(Holloway and Stanford, 1 982), Garibaldi identified abnormal periods of apnea and
et al. (1981 ) found an association between paradoxical movement between rib cage
obesity and postoperative pneumonia in and abdomen (Fig. 1 .3 ), especially during
patients weighing more than 100 kg. sleep. The site of surgery had no influ
They also note that surgery lasting more ence on the abnormal respiratory pat
than 4 hr, malnutrition (serum albumin terns, but they occurred more frequently
less than 30 g/liter), and a preoperative following morphine and with increased
stay of more than 7 days was associated age. Paradoxical movements due to par
with an increase in predisposition to pul tial upper airway obstruction caused the
monary infection. greatest desaturation, to levels of 72%, on
Natof (1980) described the postopera room air.
tive complications in 1 3,433 patients hav Whether respiratory infection in the
ingoutpatient surgery. Only four patients postoperative period can be prevented by
(0.03%) had postoperative pulmonary in pre- or intraoperative measures was an
fections, whereas Gracey at al. (1979) re swered by many past studies that showed
ported a 1 9% incidence of pulmonary reduced complications for COPD patients
complications after thoracic procedures with the preoperative use of bronchodi
and 25% after upper abdominal proce lators and chest physiotherapy. Gener
dures in patients with chronic obstruc ally, prophylactic antibiotics are not rec
tive pulmonary disease (COPD). Gari ommended. However, Morran and
baldi et al. found that the risk of McArdle ( 1 980) found that trimethoprim
developing postoperative pneumonia in and sulfamethoxazole (Bactrim) 1 hr be
patients with COPD is doubled by smok fore anesthesia reduced postoperative
ing. Bacterial filters on mechanical ven chest infections from 32% to 9% follow
tilators produced no reduction in the rate ing cholecystectomy. For major elective
of postoperative pulmonary infections procedures more likely to require post
(Garibaldi et al.; Feeley et aI., 1981 ). operative ICU management, prophylactic
The mechanism for postoperative hyp antibiotics should be avoided because
oxia is not well understood. The early they are likely to cause overgrowth and
phase of hypoxia lasts only about 2 hr. development of resistant gram-negative
The chest wall and diaphragm may be organisms (Mackowiack, 1 982). General
implicated (Craig, 1 981; Schmid and Reh anesthesia and surgery have an immu
der, 198 1 ) in addition to the ventilation/ nosuppressive effect (Serota et aI., 1 98 1 )
perfusion (V /Q) mismatch produced by and nitrous oxide decreases neu trophil
some anesthetics. Hypoxia reduced the motility (Nunn and O'Morain, 1 982),
duration of breathing against resistance which may also predispose patients to
before diaphragmatic fatigue occurs chest infection after surgery. Shennib et
(Macklem, 1 980). The later phase of hyp al. (1984) showed in piglets that atelecta
oxemia lasts up to a week after surgery, sis predisposes the lung to infection due
was more likely to occur after upper ab to impaired alveolar macrophage anti
dominal and thoracic surgery, and was bacterial function. There was progressive
characterized by a fall in FRC (Craig, depression of phagocytic activity against
1981 ) and expiratory reserve volume Pseudomonas aeruginosa for up to 24 hr
(ERV) Uones, 1982). The postoperative after atelectasis. Reexpansion of atelec
fall in lung volume was highly correlated tasis with mechanical ventilation and
with drop in PaO,. Elderly patients were 100% 0, restored the impaired alveolar
more likely to have low PaO, because of macrophage antibacterial activity.
increased closing volume with increased Ventilatory failure, inadequate lung
EEG
EOG
EOG
EEG
ab 3",=
OO m!!J1V----__--'-..r--,
.um 800m11
ECG
>-
_ ____ 30 cond. -----_
Figure 1 .3. The movements of the rib cage (rc) and abdomen (diaphragm ab) are shown together
with their sum, which is tidal volume. The trace shows obstructive apnea. rc and ab are first in
phase for three breaths and then opposite in phase as upper airway obstruction becomes com
plete. The sum falls to zero as apnea occurs. The 0, saturation (0, Sat) signal has a 1 O-sec delay
so appears to go on falling after the patient shows arousal at the end of the period of obstructive
apnea. EEG, electroencephalogram; EOG, electrooculogram; ECG, electrocardiogram. (From
Jones JG: Pulmonary complications following general anesthesia. In Anaesthesia Review, ed ited
by L Kaufman, 2nd Ed., Chapter 3, pp. 21 -38. Churchill Livingstone, Edinburgh, 1 984.)
expansion, and the postoperative fall in electasis on vascular pressure-flow rela

FRC and ERV may be due to respiratory tionships in pigs with closed chests. With
muscle fatigue (Macklem, 1 981; Craig, lobar atelectasis the atelectatic lobe be
1 981; Jones, 1 984). Fatigue of the dia haved as a vascular resistor in parallel
phragm was predicted by the fall in force with the surrounding lung. When normal
generated at low-frequency compared to l ung surrounding lobar atelectasis was
high-frequency stimulation (Moxham et inflated, its vascular resistance was in
aI., 1981 ). Respiratory muscle fatigue was creased and pulmonary blood flow was
relieved for long periods by a single un redistributed to the atelectatic lobe, caus
loaded breath (Lawler et aI., 1 979), and ing a significant increase in intrapulmo
this may be the physiological basis for nary shunt. However, with sublobar at
the beneficial effects sometime seen electasis, lung inflation did not cause
with intermittent mandatory ventilation redistribution of blood flow. The expla
(IMV). Phosphate depletion was associ nation of these differences was that re
ated with muscle weakness and hypo gional volume inhomogenicity occurs,
ventilation, and may particularly be a which distorted the sublobar vessels and
cause of respiratory complications in al prevented redistribution of pulmonary
coholics who receive dextrose intrave blood flow. Enjet et al. suggested that
nously and gastric antacids containing their findings supported the use of selec
aluminum or magnesium (Newman, tively applied PEEP to diseased lung
1 977). The mechanism determined by units in unilateral lung or lobar disease.
Aubier et al. (1985) was that hypophos There was, however, no discussion of the
phatemia impairs the contractile proper anatomic differences between pig and
ties of the diaphragm during acute respi human lung. Collateral airways provide a
ratory failure. means of ventilation to atelectatic sublo
Enjeti et al. (1982) compared the effects bar units in humans but collateral air
of lung inflation of lobar and sublobar at- ways are lacking in pigs.
Ford e t al. (1983) studied diaphrag to the site and magnitude of surgery and
matic function in 15 patients before and associated abnormalities such as pain
after cholecystectomy. Diaphragmatic and preoperative respiratory dysfunc
function was assessed by changes in tion.
transdiaphragmatic pressure swings dur The mechanism of reduced vital capac
ing quiel tidal breathing, the ratio of ity, hypoxemia and atelectasis that oc
changes in gastric to esophageal pressure curs after upper abdominal surgery re
swings, and the ratio of changes in ab mains unknown. However, Ford and
normal rib cage diameters. There were Guenter (1984) quote Pasteur (1908, 1 910)
significant falls in transdiaphragmatic that a defiCiency of inspiratory power is
and gastric-to-esophageal pressure important and suggest that respiratory
changes after surgery, which reverted to muscle activity may be reflexly modified
ward normal within 24 hr. Ford et al. sug by intraabdominal afferent nerves. Post
gest this reduction in diaphragm function operative diaphragm function is im
may be responsible for the atelectasis, re paired after cholecystectomy and breath
duced vital capacity, and hypoxemia ing is predominantly thoracic. The return
seen in patients after surgery. Different to normal thoracoabdominal breathing
anesthetic techniques were used but not takes 24-48 hr. Animal studies suggest
described. No assessment of neuromus that when diaphragm function is im
cular function was made to confirm that paired, expiratory muscles are activated
complete reversal of muscle relaxants and cause lung volumes to cycle below
was present. FRC. Therefore, despite loss of diaphrag
Because the role of pain in the etiology matic contractility, there is still passive
of postoperative respiratory dysfunction movement of the diaphragm. Expiratory
was still not fully established, Simon muscle activation may cause atelectasis
neau et al. (1983) examined diaphragm and hypoxemia because of small airway
function after upper abdominal surgery. closure. Ford and Guenter (1984) suggest
Opiate epidural analgesia on the first that the reduced tidal excursions of the
postoperative day did not modify dia lung adjacent to the diaphragm lead to
phragmatic dysfunction, and measures of the retained secretions, atelectasis, and
diaphragmatic function took until the infection seen in the lower lung fields.
seventh postoperative day to return to Intervention to block the reflex pathways
normal. They were able to demonstrate responsible for decreased diaphragm ac
that the postoperative dysfunction was tivity may be possible when the afferent
due to the upper abdominal surgery, not limb is established. Because diaphragm
general anesthesia. Simonneau and asso activity spontaneously reverts to normal,
ciates implicated neuromuscular dys this definitive therapy will probably only
function or impairment of diaphragmatic be required for 24-48 hr.
mechanics induced by surgery as a pos Fletcher and Larsson (1985), in an in
sible mechanism of diaphragm dysfunc teresting case report, monitored expired
tion. Pain relief alone did not result in re CO, curves and sulfahexafluoride SF6
covery of postoperative respiratory washout (used to measure FRC) in an 1 1 -
muscle abnormalities. Schur et al. (1984) month-old child who developed atelec
measured pulmonary function in chil tasis. They found that alveolar dead
dren before and after scoliosis surgery space and intrapulmonary shunt were in
and compared them to a similar group of creased, but the blood shunt through the
patients undergoing elective peripheral atelectatic lung was too small to account
surgery. The peripheral surgery group for the large increase in alveolar dead
had no postoperative change in lung vol space. They suggest that atelectasis in the
umes, whereas the scoliosis patients had infant is associated with a more wide
44% of their preoperative VC, 81% of spread disturbance in gas exchange due
FRC, 124% of preoperative residual vol to the effects of interdependence on ad
ume, and 61 % of total lung capacity. jacent lung regions.
Schur et al. concluded that postoperative Celli et al. (1986) found that in patients
lung volume abnormalities were related with severe airway obstruction, arm ex-
ercises increased dyspnea and lead to The difficulties in diagnosis of nosoco

dyssynchronous movements of the ab mial pneumonia in intubated intensive
domen and chest wall. Celli et al. and the care unit patients were addressed by Sal
editorial that accompanied their article, ata et al. (1987). They noted that patients
concluded that breathing and simultane with tracheal tubes were at particularly
ously exercising of the shoulder girdle high risk for colonization and subsequent
muscles, which are also accessory mus pneumonia because of disrupted local
cles of respiration, increased the de clearance mechanisms, underlying im
mands on the other respiratory muscles, munosuppression, frequency of invasive
resulting in an increased load on the di procedures, use of respiratory therapy
aphragm. The diaphragm works ineffi equipment, and location in an intensive
ciently in chronic lung diseases; hyper care environment where exposure to nu
inflation and loss of elastic recoil of the merous nosocomial pathogens was likely.
lungs cause diaphragm flattening. The Noninfectious pulmonary infiltrates may
dyssynchronous breathing noted in the occur in the presence of colonization and
study may be due to increased dia this condition is difficult to distinguish
phragm flattening, and diminished expi from nosocomial pneumonia. Salata et al.
ratory ability of the abdominal muscles studied 51 patients prospectively using
when the breathing rate increases and three times weekly tracheal aspirates ob
expiratory time decreases during ex tained by a sterile suction catheter. Suc
ercise. tion catheter sampling almost certainly
Ourenil et al. (1986), after excluding increases the false positives by contami
neuromuscular dysfunction, concluded nation from tracheal tube to t racheobron
that postoperative diaphragm dysfunc chial tree, yet such sampling is fre
tion was secondary to mechanisms such quently used in the ICU. Graded gram
as a decrease in central nervous output. stains, quantitative bacterial cultures,
There may be inhibited phrenic nerve and examination of aspirates for elastin
output due to reflexes from the chest or fibers were used together with clinical
peritoneum. Local anesthetic nerve and radiological observation. Grading of
blockage of the sympathetic splanchnic, the gram stain for neutrophils, bacteria,
vagal abdominal, or afferent pathways and intracellular organisms correlated
from the esophagus or gallbladder may with quantitative tracheal aspirate cul
be therapeutic and relieve inhibition of ture. The presence of elastin fibers pre
central neural drive to the diaphragm. ceded pulmonary infiltrates by a mean of
Craven et al. (1986) identified risk fac 1.8 1.3 (SO) days and had a sensitivity
tors for pneumonia and fatality i n me of 52% and predictive value of 100%. Ex
chanically ventilated patients as univar amination of serial tracheal aspirates for
iately associated with the presence of elastin fibers and by graded gram stain
intracranial pressure monitors (p < may improve differentiation of coloniza
0.002), cimetidine treatment (p < 0.001), tion from nosocomial pneumonia. Of the
fall-winter hospitalization (p < 0.04), 51 patients, 34 developed pulmonary in
and ventilator tubing changes every 24 h r filtrates on an average of 11 13 days
rather than 4 8 hr (p < 0.02). The overall (range 1-60 days) after study entry and 21
fatality rate for 49 of 233 patients who de of 34 were infected. Gram-negative ba
veloped pneumonia was 55%, confirming cilli were the most common isolates and
the severity of illness of these patients. were found most frequently in infected
The diagnostic criteria used for pneu patients. Faling (1988) questions how the
monia in this study are too nonspecific predictive value of elastin fibers might
and do not provide a certain diagnosis of change in patients with adult respiratory
pneumonia. However, this study shows distress syndrome (AROS). Elastin fibers
that there is a greater incidence of a are produced by lung necrosis and this
pneumonia-like disease in patients who also occurs in AROS, making differentia
receive steroids (as in head injury) tion from pneumonia difficult.
have increased gastric pH and get Oriks et al. (1987) hypothesized that
more frequent ventilator tubing mani gram-negative nosocomial pneumonia
pulation. may result from retrograde colonization
CHEST PHYSIOTHERAPY. ICU CHEST PHYSIOTHERAPY. AND RESPIRATORY CARE 17
of Ih e pharynx from the stomach. The in microbes with resistance to significant

cidence of pneumonia in 1 32 mechani numbers of antibiotics.
cally ventilated patients in an ICU was Lack of mucociliary clearance occurs
twice as high in Ihe patients given ant in subjects with Kartageners syndrome.
acids or histamine type 2 (H2) blockers Vevaina et al. (1987) examined radioiso
for slress ulcer prophylaxis compared to topic mucociliary clearance and the ul
sucralfate. Sucralfate produced signifi trastructure of respiratory cilia in such a
canlly lower gastric aspirate pH. Gram patient. They confirmed total absence of
negative bacilli were isolated more fre clearance of inhaled technetium-labeled
quently and mortality rates were 1.6 sulfur colloid after 1 hr. Transmission
times higher in the group of patients re electron microscopy of bronchial muco
ceiving antacids or H2 blockers. Driks et sal biopsy tissue showed that in virtually
aI. suggest that sucralfate may reduce the all cilia inner dynein arms were absent.
risk of nosocomial pneumonia in me The outer and inner dynein arms on the
chanically ventilated patients because it cilia are microtubule-associated proteins
preserves the natural gastric acid barrier that are thought to be the transducers of
againsl bacterial overgrowth and pre mechanical forces necessary for ciliary
vents gastric colonization of the airway. motion. Inner dynein arms are of high
Johanson and colleagues (1988a) exam molecular weight and have six electro
ined diagnostic accuracy of bronchoal phoretically distinct heavy chains. These
veolar lavage (BAL) in mechanically ven proteins have unique and high adenosine
tilated baboons compared to culture of triphosphatase activity in the presence of
tracheal secretions. protected specimen magnesium and calcium ions. Other
brush samples. and direct lung aspirates. causes for human ciliary immotility in
The cultures of the three specimens ob clude abnormalities of the length and
tained were compared with culture of basal apparatus of cilia. radial spoke de
lung homogenates. BAL produced the fects. outer or inner dynein arm defi
besl refleclion of lung infections both ciency. absence of microtubules within
qualitatively and quantitatively. BAL re the cilia. and ciliary immotility induced
covered 74% of all microbes isolated and by infection and injury (Eliasson et al..
there were 15% false-positive specimens. 1 977; Supp1 1 27. Eur / Resp Dis 1 983; Ve
Tracheal aspirates found 78% of the or vaina et al .. 1 987). All these recognized
ganisms in the lung tissue but 40% (14/ ultrastructural defects have the same
30) of bacterial species isolated were not clinical effect of causing impaired ciliary
presenl in lung tissue. In a second paper. clearance from the tracheobronchial tree.
Johanson et aI. (1988b) compared the oc Tokis et al. (1987) examined whether
currence of pneumonia after topical an spontaneous breathing. compared to con
tibiotics. applied to the oropharynx and trolled mechanical ventilation. muscle
Irachea. with and without the addition of paralysis. and PEEP. was an etiology i n
intravenous antibiotics. Thirty-five ba the development of atelectasis and im
boons were studied for 7-10 days. Thirty paired gas exchange during general an
animals had acute lung injury induced esthesia. They used computerized axial
by oleic acid or hyperoxia. In 12 animals. tomographic (CT) scans and the multiple
no antibiotics or topical or intravenous inert gas elimination technique (Wagner
antibiotics alone were given. Of the et al.. 1974) for assessment of the distri
postmortem lung lobes 81 % had severe bution of V /Q ratios in 13 supine adult
pneumonia and none was sterile. Com patients. Seven patients were smokers
binations of topical polymyxin and intra and two had obstructive airways disease.
venous penicillin and gentamycin were Ventilation of poorly perfused areas oc
efficacious in preventing pneumonia in curred in nine patients ranging from 9%
23 animals. Only 15% of lobes from these to 1 9% of total ventilation. CT scans after
animals contained moderate to severe 15 min of halothane anesthesia and me
pneumonia and 52% of the lobes were chanical ventilation showed densities in
sterile. Further studies are required in dependent lung regions in 11 of 19 pa
humans to assess the efficacy of these re tients (Figs. 1 .4 and 1 .5). There was close
gimens in human subjects who may have correlation (r= 0.84) between the area of
.7 Awake
.3
0 01 t n m
'" _ ZEEP
01 t n m
""
_ PEEP
p.o,
137 II'riig
/0
01 t n m
Figure 1 .4. Transverse computerized tomographic (CT) scans of the chest and alveolar ventila
tion (VJ/blood flow (0) distribution (0= VA = 0 liters/min), awake, during anesthesia, with con
ventional mechanical ventilation, and after the addition of 1 0 cm H 20 PEEP. There is a unimodal
V./O distribution awake with shunt (0,) of 0.8%. After induction of anesthesia, densities appear in
the dependent lung and 0, is 7.4%. PEEP reduces the densities but not the shunt and causes a
high V./O mode. PaD, is shown at each time. (From Tokis L, Hedenstierna G, Stranberg A, Brismar
B, Lundquist H: Lung collapse and gas exchange during general anesthesia: Effects of spontane
ous breathing, muscle paralysis and positive end-expiratory pressure. Anesthesiology 66:157 -167,
1987.)
atelectasis on CT scan and the magnitude taneous breathing, shunt and density
of shunt. Both CT density area and shunt area were decreased compared to pa
increased after muscle paralysis. PEEP tients managed with muscle paralysis
reduced the CT density area but did not and mechanical ventilation. Tokis et al.
consistently alter the shunt. During spon- suggested that anesthesia reduced or al-
CHEST PHYSIOTHERAPY, ICU CHEST PHYSIOTHERAPY, AND R ESPI RATORY CARE 19
.9 Awake
p.o,
158 rm'IHg
100
""".th. PEEP
p. o,
1 14 rm'IHg
.01 t '0. 100
Figure 1.5. Same as Figure 1 .4 except the patient is a smoker with mild airway obstruction. During
anesthesia (middle panel). the diaphragm moves cranially and appears as the white area, especially
in the left lung. There is, however, only a small atelectatic area and low shunt (3.4%) although there
are many low VJQ areas. PEEP reduced the atelectatic area but had minimal effects on VJQ.
(From Tokis L, Hedenstierna G, Stranberg A, Brismar B, Lundquist H: Lung collapse and gas ex
change during general anesthesia: Effects of spontaneous breathing, muscle paralysis and positive
end-expiratory pressure. Anesthesiology 66:1 57-167, 1 987.)
tered Ihe lone of the diaph ragm and lation, diaphragmatic movement occurs
caused development of atelectasis. The probably in a piston-like manner [K. Reh
reason atelectasis increased after muscle der, personal communication). Tokis et
paralysis was not explained. a!. found no further cranial movement of
FRC was reduced during anesthesia, the diaphragm [Fig. 1 .5) after muscle pa
and there was a cranial shift of the dia ralysis, compared to spontaneous breath
phragm. During positive pressure venti- ing during anesthesia. Because the CT
scans took 5 sec, there were differences levels, and collapse reoccurred, after
in the duration of the scan exposed dur each maneuver. Alternatively, either al
ing end expiration with spontaneous veolar collapse was not the cause of hyp
breathing (rate 20/min) and mechanical oxemia, or viscid secretions blocking the
ventilation (rate 1 2/min). Atelectasis is airway caused overexpansion of the ven
more apparent on chest x-ray at end ex tilated lung that further compressed the
piration, even in normal subjects. The collapsed segments. Segmental bronchi
changes in mechanically ventilated pa blockage could be the mechanism, as
tients compared to spontaneously breath blockage at a subsegmental or more pe
ing patients and unexplained differences ripheral airway would allow expansion
in CT density and diaphragm position through collateral airways and a cut off
could be related to lack of standardiza in the chest x-ray air bronchogram
tion of respiration and CT scans. In the should be clearly visible. Novak et al. do
experience of Tokis et aI., 73 of 78 pa not explain why the patients were turned
tients studied before and after anesthesia on both left and right sides. Respiratory
developed atelectasis. Clearly, anesthe mechanics and gas exchange for unilat
sia with halothane was associated with eral lung lesions may improve in one lat
intraoperative atelectasis. Other inhala eral position and deteriorate in the other.
tiona I agents or anesthetic techniques For either hyperinflation or bag-sigh suc
such as hypnotic or narcotic agents may tioning to be beneficial, secretions should
not produce the same incidence of be removed. The quantity of sputum re
atelectasis. moved was not described.
Novak et al. (1987) reexamined the Mankikian et al. (1988) measured the
benefits of periodic hyperinflation on gas effects of thoracic epidural block on dia
exchange for mechanically ventilated pa phragm function in 13 patients after
tients with hypoxemic respiratory fail upper abdominal surgery. Fourth tho
ure. They used periodic hyperinflations racic vertebral block with 0.5% plain bu
of 40 cm H20 lasting 15-30 sec as a pivacaine reversed diaphragm dysfunc
sustained, exaggerated, hyperinflation tion that occurred consistently after
rather than a sigh. To maximize trans upper abdominal surgery. They sug
pulmonary pressure during hyperinfla gested that inhibitory reflexes of phrenic
tion, the patients were turned with the motor activity arising from the abdomi
area to be expanded uppermost. Cough nal wall and viscera may be involved in
ing was encouraged during exhalation diaphragm dysfunction. They were un
from the hyperinflation, and expiratory able to discriminate between potential
flow was enhanced by manual external inhibitory afferents from intraabdominal
chest compression in uncooperative pa structure afferents and mechanical an
tients. The procedure was performed 1 0 tagonism between abdominal muscles
times a t 3D-sec intervals between hyper and the diaphragm. Using the same
inflations, five times with the patient in methodology as in this study. Simmo
each of the right and left lateral positions, neau et al. (1983) showed that postoper
and was compared to standard bag-sigh ative diaphragm dysfunction was un
suctioning. Neither technique, alone or changed with epidural opiates. Clergue
in sequence, resulted in changes in gas et al. (1984) showed that shallow and
exchange or lung/thorax compliance 5 rapid breathing that occurs after upper
or 30 min after treatment. abdominal surgery was not modified by
In view of the attempts made to in spinal morphine despite complete pain
crease transpulmonary pressures by use relief. It appears that pain is not the
of incentive spirometry and inspiratory mechanism underlying respiratory dys
resistive breathing devices these findings function after upper abdominal surgery.
are important. The reason that 40 cm H20 Epidural block with 0.5% bupivacaine is
was not able to recruit collapsed lung or the only technique to improve respira
improve oxygenation in patients with tory dysfunction after upper abdominal
hypoxemic respiratory failure of more surgery. Clearly, studies examining the
than 24 hr duration could be that end-ex effects of continuous epidural anesthesia
piratory pressure returned to baseline with lower concentration of bupivacaine
CHEST PHYSIOTHERAPY, ICU CHEST PHYSIOTHERAPY, AND R ESPIRATORY CARE 21
are warranted to determine whether Ihe lated, the authors suggested that vibra
incidence of posloperative respiratory tion therapy may be applied when pa
complications can be reduced, tients were intolerant of postural
drainage and percussion. There was no
Therapy for Respiratory Complications
indication of how much sputum was pro
duced with suctioning, no details of use
Since 1980, the reports on therapeutic of PEEP, and no information on the du
interventions that may reverse respira ration of improved PaO, beyond 1 hr. If
tory complications or improve prognosis the data from the three spontaneously
and reduce hospital stay for patients with breathing patients are extracted, there
respiratory complications have magni are probably no significant differences in
fied, In this section, papers on chest phys PaO,.
iotherapy and cough, techniques to No difference was found between
change pulmonary pressure, and use of chest physiotherapy and IPPB in prevent
bronchoscopy, are critically summarized, ing postoperative pulmonary complica
Papers published since 1980 are com tions among patients who underwent
pared to similar previous publications. upper abdominal surgery (Schuppisser et
aI., 1 980). Because of the potential haz
Chest Physiotherapy ards with IPBB of cross-infection. gastric
dilatation, ileus, tension pneumothorax,
Weller et al. (1980) found that chest decrease in FRC and PaO" and increased
physiotherapy resulted in significantly airway resistance, hypotension, and gas
improved peak now rates in 20 children trointestinal perforation, the authors rec
with cystic fibrosis. No patients received ommended chest physiotherapy (see
aerosol therapy. On average, about 8 ml Chapter 9). Kigin (198 1 ) published a com
of sputum was produced. In 1 2 patients prehensive review of chest physical ther
sputum grew Pseudomonas aeruginosa. apy for the postoperative or traumatic in
Pulmonary function was assessed for 24 jury patient. She suggests that controlled
hr and compared to no chest physiother studies of secretion removal techniques
apy. The authors suggest that central but are a priority for this group of patients.
not peripheral airway clearance occurred She identifies the lack of studies deter
with chest physiotherapy. Bronchodila mining the beneficial components of
tors had no added effects. Tecklin and chest physiotherapy and states that clar
Holsclaw (1975) also reported increased ification of contraindications and compli
peak now rates but did not follow up cations is required.
their 26 patients with cystic fibrosis and Kerrebijn et al. (1982) were unable to
had no control group. show clearance of mucus from peripheral
In a study designed to eliminate dis airways in 25 clinically quiescent, spu
crepancies in arterial blood gases due to tum-producing children with cystic fi
changes in position. Holody and Gold brosis. Chest physiotherapy or no ther
berg (1981 ) examined the effect of me apy with or without aerosolized N
chanical vibrations over the anatomic acetylcysteine was randomly compared
area of acute lung disease during therapy on consecutive days. No effects on respi
for atelectasis or pneumonia. Patients ratory nows (maxium expiratory, FEV"
were seated upright or in a high semi or VC) and volumes (total lung capacity)
Fowler position. Ten patients were stud were found. One of the points discussed
ied, at least nine of whom had lower lobe by these authors was that the optimum
lung pathology. Mechanical vibration frequency and strength of chest percus
lasted 30 min and the patients were suc sion were not the same at different ages
tioned only after completion of chest vi because of changes in chest wall compli
bration therapy. Blood gases at 30 min ance and amounts of lung tissue. Patients
and 1 hr after therapy showed average in with cystic fibrosis may respond differ
creases (p < 0.05) in PaO, of 10 and 1 5 ently to chest physiotherapy when in a
mm Hg, respectively. when compared to quiescent, compared to an active phase.
baseline. In these acutely ill patients, The papers in which beneficial effects oc
70% of whom were mechanically venti- curred in patients with cystic fibrosis
(Tecklin and Holsclaw; Weller et al.) do rheology. Newhouse suggested that

not identify whether their patients were cough is more effective in clearing bo
experiencing exacerbations at the time of luses of secretions rather than thin, wa
therapy. The differences in techniques tery. copious secretions. which were
(frequency of percussion and force and more likely to be cleared by PD. The con
frequency of chest vibration) may also in flicting results of Oldenberg et al. (1979).
fluence the response of individual pa Bateman et al. (1981 ), and Rossman et al.
tients to chest physiotherapy. These (1982) concerning the role of cough in
techniques are discussed in Chapter 4. dependent of the other maneuvers used
The conclusion of Kerrebijn et al. that no in chest physiotherapy stimulated De
clearance of mucus from peripheral air Boeck and Zinman (1984) to assess con
ways occurred in patients with cystic fi ventional pulmonary function tests after
brosis confirmed the findings of Weller et cough alone or chest physiot herapy for
al. patients with cystic fibrosis. Chest phys
Rossman and colleagues (1982) com iotherapy was standardized, consisting of
pared the effectiveness of spontaneous 2 min of percussion and vibration in 1 1
cough (control). postural drainage (PD) postural drainage positions that pro
with and without mechanical percus ceeded sequentially from lower to upper
sion. PD deep breathing with vibration lobes. The patient then performed three
and percussion administered by a phys slow vital capacity maneuvers, during
iotherapist. and directed vigorous cough. which exhalation was assisted by the
They found PD was not as effective as physiotherapist. This was compared with
physiotherapy or cough and frequent a directed vigorous cough session re
self-directed vigorous cough was most ef peated 1 1 times over 1 0 min in the seated
fective. This was in contrast to the find position. The amount of sputum pro
ings of Sutton et al. (1983) who report that duced and the pattern and magnitude of
the addition of PD nearly tripled the spu changes in PFTs 1 hr after treatment on
tum yield achieved by cough alone. Ross consecutive mornings were the same
man et al. did not differentiate between after cough or chest physiotherapy. De
the use of a forced expiratory technique Boeck and Zinman confirmed the lack of
(FET) and cough. Sutton et al. (1983) correlation between sputum produced
found that cough alone did not enhance and improvement in PFT. They sug
mucus clearance. but FET and PD did. gested that vigorous coughing and FET
The forced expiratory technique con should be further investigated for long
sisted of one or two forced expirations term effectiveness in cystic fibrosis.
from mid- to low-lung volume. followed The studies on patients with acute and
by a period of relaxation and diaphrag chronic lung diseases comparing the
matic breathing. No glottic closure oc effectiveness of the independent compo
curred and the airway compressive nents of chest physiotherapy are confus
phase that characterizes coughing was ing, because combinations of compo
avoided so that worsening of broncho nents may be more effective than a single
spasm may be prevented by this forced variable under study. The multitude of
expiratory maneuver (Sutton et al.. 1 983). possible permutations of chest vibration.
(See Chapter 3, p. 1 2 1 . ) In 1 0 patients percussion, cough. FET. PD, or tracheal
with copious sputum (mean 63 ml/24 hr) suctioning in patients with different
FET alone and with PD i ncreased the chronic or acute lung pathology makes
clearance of sputum compared to control. clinically relevant studies difficult to
Directed coughing without FET and PD find. The clinician wishes to know if lung
was not different from control. Sutton et reexpansion is achieved more efficiently
al. (1984) suggest that protracted cough when all the techniques are used or
ing was fruitless and exhausting. leading whether one or two of them may be omit
to poor compliance. ted without loss of effectiveness. To date,
Newhouse (1984) argued that the dif this dilemma is unresolved.
ferences between the findings of the two Zapletal et al. (1983) found that chest
studies investigating clearance of mucus physiotherapy that included manual
probably related to secretion volume and chest percussion and vibration in various
postural drainage positions and stimula fects of prolonged coughing. Narrowing

tion of cough produced adverse effects in of bronchi was demonstrated on contrast
24 patients with cystic fibrosis, Despite cinebronchiographic studies (Fig. 1.6A
production of 2-10 ml of sputum, flow at and B).
25% vital capacity decreased signifi For postoperative patients, Morran et
cantly. The authors suggest that the flow a!. (1983) showed in a prospective ran
limitation may result from adverse ef- domized controlled trial of 102 patients
Figure 1,6. (A) Contrast bronchograms ot the right lung of a 1 7-year-old female with cystic fibro
sis. Arrow denotes significant narrowing of the right medial basal bronchus. On left is anteropos
terior view and on right a lateral view during normal breathing. (6) Same as A during coughing.
Note that there is marked narrowing of the airways during coughing and a lack of evacuation of
the contrast material from peripheral airways. (From Zapletal A, Stefanova J, Horak J, Vavrova V,
Somanek M: Chest physiotherapy and airway obstruction in patients with cystic fibrosis-a neg
ative report. Eur JRespir Dis64:426-433, 1983.)
24 CH EST PHYSIOTHERAPY IN THE INTENSIVE CARE UNIT
that routine prophylactic chest physio manual vibration, percussion, shaking,

therapy significantly reduced the fre and cough. The use of chest physiother
quency of chest infection after elective apy in acute and chronically ill patients
cholecystectomy. The authors differenti was described. Carswell et aJ. (1 984) ex
ated between routine and intensive chest amined deoxyribonucleic acid (DNA)
physiotherapy. Postural drainage and output in the sputum of patients with
bronchodilator therapy was referred to cystic fibrosis to determine if it was a
as intensive chest physiotherapy and useful indicator of pulmonary cellular
breathing exercises, assisted coughing, damage. Aggressive therapeutic inter
and vibration of the chest wall were used vention may be more efficiently timed to
as routine prophylactic chest physiother coincide with increased rate of lung dam
apy. The control group in their study re age if DNA was such an indicator. How
ceived only encouragement to breathe ever, sputum DNA showed similar vari
deeply and cough from nursing and med ations to sputum weight and was not well
ical staff. The authors specifically distin correlated with lung damage. Sputum
guished bet ween atelectasis and infec was obtained by physiotherapy using
tion. Although 18 patients receiving percussion and postural drainage,
routine chest physiotherapy developed breathing exercises and chest shaking,
atelectasis, only 7 developed chest infec assisted panting, huffing, and coughing.
tion, whereas of patients not receiving Physiotherapy sessions lasted 25 min. Pa
chest physiotherapy, 1 1 had atelectasis tients carried out this therapy at home
and 1 9 developed chest infection (p < two times per day for 3 weeks, followed
0.02). There were weaknesses in this by 3 weeks parental use of a mechanical
clinical study because previous respira percussor. For the next 3 weeks a profes
tory disease was not adequately defined sional physiotherapist visited the home 5
and the means for confirming infection days a week and provided a third session
and use of antibiotics were vague. The in addition to parental chest physiother
authors suggested that routine chest apy. In two of the three subjects in which
physiotherapy prevented progression of data were gathered, the professional and
atelectasis to chest infection. parental regimen produced significantly
Flower et aJ. (1979) showed that maxi greater quantities of DNA than the per
mum peak vibration of the bronchial tree cussor or parental therapy alone. Sputum
in adults occurred at about 1 6 Hz using weight correlated well (p = 0.90) with
an external chest pressure of about 2.5 DNA (Fig. 1 .7). This suggests that the pro
kg. Hand clapping reaches only about 8 fessional physical therapists treatment
Hz. King et aJ. (1983), however, found was more effective than the parental or
that external chest wall compression at percussor therapy in removing secre
frequencies above 3 Hz and up to 17 Hz tions.
increased tracheal mucus clearance. Buscaglia and SI. Marie (1983) found no
Peak enhancement of clearance reached dangerous hypoxemia using continuous
340% of control at 1 3 Hz. King et aJ. sug oximetry monitoring of arterial 0, satu
gested that the high-frequency chest wall ration during chest percussion and vibra
compression may cause a reduction in tion with postural drainage. Ten sponta
cross-linking of mucus glycoproteins, re neously breathing patients with acute
sulting in improved mucus clearance. exacerbation of severe COPD were stud
They did not consider other factors be ied. Although most patients had elevated
sides frequency when comparing manual PCO, and required 0, to maintain PaO,
and mechanical techniques of chest above 60 mm Hg, the largest decrease in
physiotherapy. The clinical advantages saturation was 2%, and the lowest abso
of manual percussion over mechanical lute value was 91%. These findings are
devices are in our opinion, significant, surprising, considering the variability of
and are fully discussed in Chapter 4. FiO, in spontaneously breathing patients
Kigin (1984) comprehensively re receiving Oz' In addition, even in normal
viewed indications for chest physiother individuals, arterial saturation fre
apy and the effects of the individual com quently falls below 91% during coughing
ponents such as positioning, suctioning, and breathholding.
CHEST PHYSIOTHERAPY. ICU CHEST PHYSIOTHERAPY, AND RESPIRATORY CARE 25
Eb:tstgtbc[ag:iBgj[!]es
Parental + Percussor + Professional Parental

100 . SO
Sputum Weight (g/24 hrs)
o Sputum DNA Output
80
(mgl24 hours)
:
\
: <><>

40
.
/
!..
60
30
l! . .
40
20
20
H , t'
' vvJ \Nw : . '\.\0\ .\N
' .
: ". ., :
10

: . :
0
10 20 30 40 DAYS SO 60 70
Figure 1.7. Weight of sputum (solid circles) and DNA (open circles) is compared (p 0.9) in the =
course of parental chest physiotherapy twice a day (parental). mechanical percussor twice a day
(percussor). and parental and physiotherapist treatment for a total of three treatments per day
(professional) Sputum production was greater but peak ex piratory flow less with the profe ss iona l
.
than percussor regimen. (From Carswe ll F. Robi nson OW. Ward CCl, Waterfield M R : Deoxyribo
nucleic acid output in the sputum from cystic fibrosis palients. Eur J Respir Dis 65:53-57, 1984.)
Sutton et aJ. (1985) examined the value particle penetration of the peripheral air
of percussion. vibratory shaking, and ways. The techniques of labeling and
breathing exercises with and without scanning of the three regions are open to
postural drainage and FET in eight pa criticism because of the inability to ade
tients with copious sputum production. quately visualize the isotope in three di
Using inhaled aerosols, bronchial secre mensions. The requirement that the pa
tions were labeled and their clearance tients are in exactly the same position
monitored by gamma camera. Random with the same lung volume to make valid
ized treatments included vibratory shak comparisons before and after each of the
ing during relaxed expiration followed therapies that were as many as 1-4 days
by maximum inspiration. percussion apart is not addressed. Although the
during tidal breathing compared to a con eight patients did have copious sputum,
trol period of 30 min postural drainage, the range varied by over 100%. The eight
and voluntary cough. Vibration (12-16 patients had three different causative pa
Hz), shaking (2 Hz). and percussion (ap thologies, which suggests that they might
proximately 5 Hz) were used to enhance have responded differently to the thera
mucus clearance. No differences in clear pies under study. Some of the variations
ance of radioisotope were found between found in studies using radioisotopes may
any of the treatments. although the wet be due to different techniques for aero
weight of sputum was increased by vi sol deposition and measurement of
bration and percussion with deep breath clearance.
ing. Why radioisotope clearance was no Chest percussion was found to be of lit
different when sputum clearance was in tle value as an adjunct to postural drain
creased with vibration and percussion age and instructed coughing in the treat
was not explained. but may be due to ment of 10 patients with chronic
bronchitis (Wollmer et aI., 1 985). Percus above baseline values in two patients
sion was associated with a small decrease who did not receive fentanyl only pla
in FEV, after therapy; however, this was cebo infusion. Cardiac output was mea
not associated with any changes in 0, sured in 6/10 patients in the groups that
saturation. Radioisotope penetration was received 3.0 and 1 .5 IIg/kg fentanyl. Nei
higher following chest physiotherapy ther dose prevented elevation of baseline
with percussion. The two patients who cardiac output by about 20-25% during
produced 1 00 ml and 1 30 ml of sputum chest physiotherapy. In all instances
had substantially higher clearance of in within 1 5 min of the finish of chest phys
haled radioisotope particles when per iotherapy cardiac output was not differ
cussion was included, compared to when ent to baseline whether the patients
it was omitted. The findings were not, received fentanyl or placebo. The un
therefore, clear-cut. Mazzocco et al. changed cardiac output and PaO, imme
(1985) found that chest percussion and diately after therapy confirms the find
postural drainage were helpful, safe, and ings of Mackenzie et al. (1987b) and
effective in assisting 13 patients with sta Mackenzie and Shin (1985). The issue is
ble bronchiectasis to clear secretions. whether elevation of cardiac output and
There were no adverse effects on heart metabolic rate during chest physiother
rate or rhythm, pulmonary function or 0, apy is clinically significant. Is this a rea
saturation. son to withhold chest physiotherapy in
Mackenzie and Shin (1985) measured critically ill patients with cardiovascular
cardiorespiratory function before, imme dysfunction? These are the very patients
diately after, and 2 hr after chest physio who can least tolerate pulmonary deteri
therapy in 1 9 patients with posttraumatic oration. In our opinion chest physiother
respiratory failure. Cardiac index was apy should not be withheld because car
unchanged and intrapulmonary shunt diac output and metabolic rate increase.
fell, followed at 2 hr by an increase in Instead sedation and analgesia are used
lung/thorax compliance. The reduced before and during therapy.
cardiac output after chest physiotherapy Van der Schans et al. (1 986) examined
reported by Laws and Mcintyre (1969) percussion in nine patients with stable
was not found, but cardiac output was chronic airflow obstruction and exces
not measured during chest physiother sive tracheobronchial secretions. Manual
apy. In addition, the patient population percussion was no different when ap
was young and did not have preexisting plied in combination with PO coughing
cardiac disease. None of the detrimental and breathing exercises for 20 min. com
cardiopulmonary changes associated pared to the same regimen without per
with bronchoscopy occurred in these cussion. The addition of PO and coughing
critically il l patients, yet beneficial ef with or without percussion improved
fects on gas exchange and lung mechan mucociliary clearance. The authors sug
ics were documented. gested that because manual percussion
Klein et al. (1988) found that heart rate, as a single procedure was found to im
systolic and mean blood pressure, and prove tracheobronchial clearance. it may
cardiac output were increased during be useful when a patient was not able
chest physiotherapy. Metabolic rate de to cough or cannot tolerate postural
termined by measurement of 0, con drainage.
sumption and CO, production was in An editorial on management of acute
creased. In no patient was PaO, changed bronchiolitis in infancy (Milner and Mur
but in some groups PaCO, i ncreased with ray, 1 988) suggests that chest physiother
chest physiotherapy. The increases in apy, although a popular therapy, may not
blood pressure and heart rate were atten be beneficial. In a controlled study of 96
uated by continuous infusion of 3 IIg/kg children with bronchiolitis chest phys
fentanyl but not 1.5 IIg/kg fentanyl. Fen iotherapy was not found to be beneficial
tanyl did not alter the increased meta (Webb et aI., 1 985). The criteria for as
bolic response with chest physiotherapy. sessment of benefit were clinical and,
Cardiac output increased up to 50% therefore, subjective. The authors do not
CHEST PHYSIOTHERAPY, ICU CHEST PHYSIOTHERAPY, AND RESPI RATORY CARE 27
recommend chesl physiotherapy in the chanica I means that generate a subat

management of acute bronchiolitis as the mospheric pleural pressure greater than
babies require considerable disturbance the normal 5-10 cm H,O include inspi
and many children were noted to become ratory incentive spirometry, inspiratory
more distressed during and immediately resistive breathing, and, in patients with
after chest physiotherapy. Directed, su diaphragmatic paralysis, electrical pac
pervised coughing was found to be ing. Positive airway pressure is obtained
equally effective as chest physiotherapy by mechanical ventilation with or with
in management of 39 patients hositalized out PEEP, continuous positive airway
for treatment of an exacerbation of pul pressure (CPAP) during spontaneous res
monary symptoms from cystic fibrosis piration, or IPPB. Pressure support and
(Bain et aI., 1 988). Directed coughing con changing inspiratory/expiratory ratios
sisted of five quick small huffs or pants may alter the length of time during the
followed by expiratory huffs and cough respiratory cycle that transpulmonary
ing until all loosened sputum was cleared pressure is increased. Inspiratory resis
from the airways. The sequence was then tive breathing may also increase respira
repeated twice every 5 min for 35 min. tory muscle endurance and strength. Me
No differences were found in pulmonary chanical means of altering local lung
function tests and sputum charac expansion include selective positive
teristics. pressure inflation of an atelectatic lung
Cardiac output, oxygen consumption, segment, recruitment by collateral ven
and arterial and mixed venous saturation tilation, and interdependence.
(5VO,) were measured during suctioning Anderson et al. (1979) showed that at
in 10 acutely ill mechanically ventilated electatic lung can be recruited through
patients (Walsh et aI., 1989). 5uctioning collateral airways by positive pressure
produced significant decreases in 5V O, ventilatory techniques. They suggested
predominantly due to increased 0, con that time constants (product of compli
sumption but also due to an inadequate ance and resistance) for collateral air
rise or even a fall in cardiac output. Ar ways during exhalation were longer than
terial saturation was virtually unchanged during inspiration, so more air entered
partly because the patients were preox the lung at the periphery of an atelectatic
ygenated with 100% 0, before suction area than left during exhalation. As a re
ing. The authors comment that arterial sult, pressure rose distal to the obstruc
saturation was not a sensitive indicator tion and became greater than the pres
of changes in 5VO,. The mechanism pos sure in the surrounding lung. Collateral
tulated for fall in 5V O, was decreased airway reinflation, therefore, potentially
cardiac output occurring from decreased forced secretions centrally to larger bron
intrathoracic pressure with suctioning. If chi where they may be more easily re
this is indeed the mechanism, closed moved. Andersen et al. (1980) suggested
sheath suction catheters which prevent the use of periodic applications of contin
entrainment of atmospheric air during uous positive airway pressure (CPAP) by
suctioning may potentiate this effect. The face mask to increase collateral ventila
solution is to sedate agitated patients be tion of obstructed lung regions. Twenty
fore suctioning so that 0, consumption is four patients with postoperative atelec
reduced and to restrict suctioning if no tasis were studied in a prospective
secretions are obtained. randomized controlled clinical trial.
CPAP with 1 5 cm H,O once per hour and
Techniques to Change Transpulmonary conventional therapy was compared to
Pressures conventional therapy alone. Conven
tional therapy included humidification,
By producing either subatmospheric oxygen, intensive chest physical therapy
pleural pressure or positive airway pres with three times daily postural drainage,
sure, bilateral lung expansion is tracheal suctioning, and instruction in
achieved because both maneuvers in deep breathing. The comparison was
crease transpulmonary pressure. Me- made over 24 hr and successful therapy
was considered to be an increase in PaO, ance caused by quiet breathing. They

of at least 1 5% or decrease in area of ra suggest that when multiple measures in
diological atelectasis by 50%. Signifi addition to lung hyperinflation were
cantly more patients were treated suc used, encouraging results were obtained.
cessfully with the addition of CPAP. Lung hyperinflation affects the high com
Chest wall strapping, such as occurs pliance lung units and needs to be sup
with dressings around chest tubes or plemented with other measures that di
after thoracotomy, reduces respiratory rect ventilation to the low compliance
excursion and the ability to generate compartments in the lung, particularly in
subatmospheric intrapleural pressures the high-risk patients with obesity or ob
and increases the elastic work of breath structive lung disease.
ing. After strapping the chest of four Falk et al. (1984) suggest that periodic
healthy young men, OeTroyer (1980) application of face mask positive expira
found that both FRC and chest wall com tory pressure (PEP) with forced expira
pliance were decreased. FRC decreased tory technique (FET) improved sputum
about 1 liter and compliance of the chest production and was better tolerated by
wall fell from 22.9 to 1 0.6 mljcm H,O 74 patients with cystic fibrosis than pos
(Fig. 1.8). Whenever possible, chest wall tural drainage, percussion and chest vi
restriction should be minimized as it re bration, or PO and periodic application of
duces subatmospheric pleural pressure PEP or FET. They thought that PEP may
causing lung volume to fall below FRC. be beneficial to other patients with ex
Belman and Mittman, in an editorial cessive secretions.
( 198 1 ), raised the issue of the unproven Celli et al. (1984) showed that lPPB, in
efficacy and widespread use of incentive centive spirometry (IS), and deep breath
spirometry. They found the evidence ing exercises (OBE) were superior to no
against the efficacy of incentive spirom treatment at all in preventing pulmonary
etry convincing, yet they concede that complications in a controlled trial among
the theoretical basis for expecting this 1 72 patients after abdominal surgery.
approach to be effective was also con Hospital stay for 21 of 81 patients who
vincing. Lung hyperinflation by what underwent upper abdominal surgery and
ever means reverses low lung compli- received incentive spirometry was
': ]
Figure 1.8. Effects of chest strap
ping on the pressure-volume curve 2
of the relaxed chest wall in four
subjects. Control data are shown
as solid circles data after strapping 6
as open circles. Transthoracic
4

pressure shown on the abscissa is
the difference between esophageal
and barometric pressures. (From 2
DeTroyer A: Mechanics of the -
:>
chest wall during restrictive tho , , ,
racic strapping. Respiration g -20 -10 0 10 20 -20 -10 0 10 20

39:241 -250, 1 980.) 1O
:>
-'
i i
-20 -10 0 10 20 -10 0 10 20 30
!'6-p. , em 11:10
shorter than the control group who re ties suggest CPAP is superior to achieve
ceived no therapy. The authors acknowl the increase. The rapid reversal of bene
edge that the optimal treatment schedule fit on cessation suggests that CPAP
for these techniques remains unknown should be used continuously for the ther
and they recommend further study of IS apy to alter outcome and reduce postop
and DBE in patients at high risk of pul erative complications.
monary complications. Many of the ar Incentive spirometry was not found to
guments they use to support DBE would be beneficial in producing differences in
equally apply to chest physiotherapy. chest x-ray, PaO" spirometric evalua
This was not considered. An editorial tion, or clinical evaluation 2 and 4 days
(Ford and Guenter) referring to Celli's after elective cholecystectomy, com
paper stressed that the most important pared to a group of similar patients who
factor predicting the development of had no specialized respiratory care
postoperative pulmonary complications (Schweiger et aI., 1 986). Both groups of 20
was the upper abdominal site of surgery. patients had 1 2-16% pulmonary compli
It may also be important to know which cations. The low-risk patients with sub
organs were involved in the upper ab costal cholecystectomy incisions did not
dominal surgery. benefit from incentive spirometry. IPPB
Dull and Dull (1983) found that 49 is reported to improve lung compliance
adult patients who underwent cardiopul in subjects with kyphoscoliosis (Sinha
monary bypass and were assigned to ei and Begofsky, 1 972). IPPB was examined
ther mobilization, incentive spirometry, to see if it conferred benefit on patients
or maximal inspiratory breathing exer with respiratory muscle weakness. How
cises all experienced decreases in lung ever, in 14 subjects with either quadri
volume. No advantage was shown with plegia or muscular dystrophy, no imme
incentive spirometry or breathing exer diate improvements were derived in
cises in addition to mobilization, com ventilatory mechanics (McCool et al..
pared to mobilization alone. Stock et al. 1 986).
(1985) demonstrated that the use of in The study by Zibrak et al. ( 1 986)
centive spirometry with documented strongly suggested that a concerted effort
maximal volume inhalations was not su to set priorities for the use of respiratory
perior to deep breathing exercises in pre therapy techniques (bronchodilator aer
venting postoperative pulmonary com osols, ultrasonic mist aerosols, IPPB, in
plications after upper abdominal surgery. centive spirometry, and oxygen therapy)
Respiratory function tests including FRC, for patients in at least seven common di
FeV" and FVC were not different. CPAP agnostic categories can be successful . Im
produced a more rapid increase in FRC plementation of these priorities did not
than incentive spirometry or deep change overall mortality, although pa
breathing. tients stayed a shorter time in the hospi
The effect of continuous positive air tal after coronary artery bypass surgery
way pressure (CPAP) and blow bOllles on and the staffing of respiratory therapists
FRC was examined by Heitz et al. (1985) was reduced. In an editorial commenting
in two groups of comparable patients un on rational respiratory therapy stimu
dergoing elective abdominal su rgery. lated by the study of Zibrak et aI., Pelly
Both blow bOllles and CPAP increased (1986) identified the core of a major prob
FRC by 50% both preoperatively and lem. He states that the prescribing phy
postoperatively. The significant reduc sician's lack of firm grounding in the ra
tion in FRC seen postoperatively re tional ordering of respiratory therapy is
turned within 10 min of stopping either one of the factors that created the uncon
therapy. CPAP had a lower resistive trolled and excessive use of respiratory
work of breathing and was beller toler therapy. A large difference in usage of IS
ated by patients. The average postopera and chest physiotherapy after coronary
tive reduction in FRC in the 20 patients artery surgery exists in the United States
who underwent upper abdominal sur and Great Britain. Only 44% of 39 hospi
gery was 20-30%. Both CPAP and blow tals used IS in Britain, whereas O'Dono
bollles increased FRC, but most authori- hue ( 1 985) reported 95% used IS in the
United States. Chest physiotherapy was cruitment of respiratory muscles, or the

only used in 41% of U.S. hospitals after intrinsic properties of the inspiratory
cardiac surgery, whereas in Britian all muscles at shorter length (Collett and
hospitals surveyed used CPT Uenkins Engel, 1986).
and Soutar, 1 986). High-frequency ventilation produces
Strohl et al. (1984) reported on the ef positive airway pressure and changes
fects of bilateral phrenic nerve pacing in transpulmonary pressures like PEEP.
a C, quadriplegic. The results are sum George et al. (1985) found that high-fre
marized in Figure 1 .9. Both upper and quency oscillation (HFO) at 8-12 Hz by
lower rib cage showed paradoxical mo means of a bass loudspeaker applied
tion during paced breaths in the supine through a mouthpiece in seven normal
and 85' upright position. Abdominal subjects increased clearance of radioiso
compression decreased supine tidal vol tope compared to a control group with no
ume 1 0-20%, whereas in the upright pos HFO. HFO may alter the viscoelastic
ture it i ncreased tidal volume 200%. Ab properties of the mucus either by in
dominal compression changed only the creased vagal discharge or an effect on
movement of the lower ribs. These ob the cross-linking altering mucociliary
servations suggested that the diaphragm coupling and viscoelasticity. Further
can move the lower ribs independently studies are clearly required to confirm
of the upper ribs. Tidal volume during these findi ngs and examine the effects on
diaphragmatic pacing is determined both patients with excessive sputum produc
by the resting length and diaphragm load. tion and purulent sputum because there
Lisboa et al. (1986) showed that unilateral is conflicting evidence of the benefits of
diaphragm paralysis resulted in use of in HFO on mucus clearance. Purulent spu
tercostal and accessory inspiratory mus tum contains copious white blood cells,
cle or compensatory use of abdominal bacteria, and their products. Neutrophil
expiratory muscles. Vital capacity was elastase and bacterial products damage
reduced in all cases of unilateral dia human ciliated epithelium and reduce
phragmatic paralysis. There is a decrease ciliary beat frequency in vilro (Wilson el
in inspiratory muscle efficiency that may aI., 1 985, 1 986).
contribute to regional V /Q mismatch, di Ricksten et al. (1986) st udied 43 con
minished lung volumes, and decreased secutively randomized patients who had
endurance during inspiratory resistive elective upper abdominal surgery. They
loading at lung volumes higher than FRC compared CPAP, PEP, and a control
(such as occur in emphysema). The group using a deep breathing device (Tri
mechanisms for the increase in 0, cost of flo). One of the three therapies was ad
breathing that results include changes in ministered for 30 consecutive breaths
mechanical coupling, the pattern of re- every waking hour for 3 days postopera-
Figure 1.9. Upper and lower rib I'tf'IENIC PACED BREATHS

cage motion and tidal volume are
shown during a postural shift from SlftIE -----.. UPRIGHT------_
full recumbency to 85 upright pos
ture and subsequent application of we !
a: :!! , [ABDOMINAL COMPRESSION
45 5"
abdominal compression. The dia "0 I
.. ..
phragm is paced by phrenic nerve "' 0:
stimulation. (From Strohl KP, Mead
JM, Banzett RB, Lehr J, Loring SH,
O'Cain CF: Effect of posture on
upper and lower rib cage motion
and tidal volume during diaphragm
pacing. Am Rev Respir Dis
130.20-321, 1984.)
tively. Postoperative pain was controlled than PEP therapy in the silting position.
using lumbar epidural morphine for at Sputum clearance was less effective
least 2 days postoperatively. Pulmonary when PEP was included in the treatment
function tests and chest x-ray were mea regimen.
sured regularly before and after surgery. Albert et al. (1987) examined the ef
Alveolar arterial PO, difference in fects of the prone position in oleic acid
creased in all groups but was signifi induced acute lung injury in dogs. The
cantly lower in the PEP group after 2 prone position produced an immediate
days and after 3 days with CPAP and PEP and persistent increase in PaD, and de
compared to control. Peak expiratory crease in Q,/ Q " which was reversed on
flow was not different, but FRC was turning the animals supine (Fig. 1 . 10).
higher in the PEP and CPAP groups by The improvement in gas exchange was
the third day after su rgery. Atelectasis not related to changes in FRC, regional
occurred in 6 of 15 control patients, no diaphragmalic molion, cardiac output. or
PEP, and 1 of 1 3 CPAP palients. Ricksten pulmonary vascular pressures. The au
et al. concluded that the simple PEP thors were unable to explain the mecha
mask was equally effeclive as the CPAP nism. The prone position is also benefi
system in preservalion of lung volumes cial in improving oxygenalion in patients
and prevention of atelectasis after upper with acute respiratory failure (Douglas et
abdominal surgery. aI., 1977). Jones et al. (1986), however,
Hofmeyer et al. (1986) compared three using two gases of markedly different dif
treatment regimens for assisting clear fusivilies in nine normal subjects, found
ance of secretions in palients with cystic that the effect of posture on gas mixing
fibrosis to determine if PEP with or with represents a conveclive and diffusive-de
out postural drainage increased sputum pendent change in the distribution of
yield. Postural drainage without PEP pro ventilation. The effect of posture was not
duced more sputum than PEP and pos solely due to lung volume changes. How
tural drainage. Both the postural drain ever, this report and the two previously
age regimens produced more sputum published human studies suggest that pa-
'"
:J:
E
E
..
o
to
Q.
Time (min)
Figure 1.10. Effect on PaO, of changing from the prone to supine position in dogs with oleic acid
induced acute lung injury. Animals were kept prone for 1 5-45 min after oleic acid injection before
the first measurement. (From Albert RK, Leasa D, Sanderson M, Robertson HT, Hlastala MP: The
prone position improves arterial oxygenation and reduces shunt in oleic-acid-induced acute lung
injury. Am Rev Respir Dis 135.28-633. 1987.)
tient positioning should be used as a sive to respiratory therapy, or when pa

means of reducing the requirements for tients do not show improvemenl after 24
oxygen and PEEP during mechanical hr of respiratory therapy (Marini et a!.,
ventilation. The prone position is the 1 982). Selective positive pressure venti
postural drainage postion for drainage of lation through the suction port of a cuffed
the superior segments of the lower lobes. fiberoptic bronchoscope was found effec
Quadriplegic patients nursed on Stryker tive in the expansion of refractory atel
frames may spend considerable time ectasis (Harada et a!., 1 983). Fourteen of
prone. The lack of information provided 1 5 palienls wre successfully managed;
about positioning of palients during chesl however, in six patients atelectasis re
physiotherapy, in many publications, curred.
makes interpretation of pulmonary func Bronchoscopy produces marked he
tion changes due to the therapy alone modynamic changes when performed
difficull. under topical aneslhesia. Lundgren et a!.
(1982) found mean arterial pressure in
Use of Bronchoscopy
creased by 30%, heart rate by 43%. car
diac index by 28%. and pulmonary
Perruchoud et a!. (1980) found thai wedge pressure by 86% compared to pre
bronchoscopic lavage and aspiration with bronchoscopic control values in 10 pa
saline and acetylcysteine, followed by tients. The patienls were premedicated
positive pressure inflation of the atelec with morphine and scopolamine and the
tatic lung through the bronchoscope, was pharynx, larynx, Irachea, and bronchi
successful in reexpanding atelectasis in were aneslhetized with 250 mg of lido
37 of 51 patients. Rigid bronchoscopy was caine. Flexible fiberoptic bronchoscopy
used in the 1 1 spontaneously breathing was performed without supplemental ox
patients and fiberoptic bronchoscopy in ygen and PaO, decreased significantly
Ihe 40 mechanically ventilated patients. from 75 3 mm Hg before bronchoscopy
Eleven patients had partial reexpansion 10 67 3 mm Hg during bronchoscopy.
of the atelectasis and Ihree showed no Jaworski et a!. (1988) found that fiber
change. Atelectasis recurred in three pa optic bronchoscopy was no better than
tients on the first day and five on Ihe sec routine physical therapy in prevention of
ond, and seven patients developed pneu ateleclasis after lobectomy for lung
monia. Lobar atelectasis was more tumor. Twenty postoperative patients
successfully cleared (85%) than segmen were studied. Five of six patienls who
tal atelectasis (47%) using these tech produced more than 30 ml spulum per
niques. Segmental atelectasis also oc day developed atelectasis. One patient
curred more frequently. All Ihe patients who received only physiotherapy re
described had recent radiological evi q uired Iherapeutic bronchoscopy. In the
dence of mucoid impaction. Some of the group who received routine bronchos
patients were apparently given physio copy in the postanesthesia recovery
therapy, but no information is provided room, one patienl also required repeated
about the success rate of reexpansion bronchoscopy. There was no difference
with physiotherapy alone. Bronchoscopy in lCU or hospital stay or duration of
may be indicated if chest physiolherapy chest tube placement posloperatively.
fails to reexpand an atelectasis. These findings make fiberoptic bronchos
Bronchoscopy may be more efficacious copy undesirable in most critically ill pa
in the non intubated patient with atelec tients. The majority of critically ill lCU
tasis than in the intubated patient (Fried patients can tolerate the position changes
man, 1 982). There are a few indications necessary for chest physiotherapy (see
for fiberoptic bronchoscopy after an ini Chapter 3). In our experience (Mackenzie
tial aggressive regimen of respiralory et a!., 1980; Mackenzie and Shin, 1 986)
therapy. Bronschoscopy may be neces and olhers (Friedman, 1 982; Marini et a!.,
sary when a symptomatic patient is un 1 979, 1 982) bronchoscopy is only used
able to tolerate vigorous respiratory ther when atelectasis persists longer than 48
apy, an important diagnostic question hr or a realistic diagnostic dilemma
coexists, massive collapse is u nrespon- exists.
CHEST PHYSIOTHERAPY. ICU CHEST PHYSIOTHERAPY. AND R ESPIRATORY CARE 33
Summary of Literature Update Since ically ill patient and requires physician
1 980 participation. Bronchoscopy is more
costly and no more effective than chest
The importance of diaph ragmatic mal physiotherapy maneuvers for secretion
function as an etiology in development of removal.
respiratory complications has been estab
lished since 1 980. The interaction of the WHAT IS CHEST PHYSIO THERAPY?
chest wall and abdomen in the relation
ship that leads to reduced lung volume Encompassed i n the use of the term
and atelectasis has nol been as well in chest physiotherapy are five maneuvers:
vestigated. Pain is now considered less of (1 )postural drainage. (2) chest wall per
a causative factor in the postoperative cussion and vibration. (3) coughing. (4)
fall in FRC than was thought before 1 980. suctioning, and (5) breathing exercises in
Certainly epidural and intrathecal opi the spontaneously breathing patient.
ates have revolutionized pain relief after Breathing exercises include the forced
surgery so that in many studies this is no expiration technique or huffing. dia
longer a confounding variable (Ricks ten phragmatic costal excursion. and lateral
et al.). However. epidural and intrathecal costal excursion exercises. In addition,
opiates have not reduced the incidence patient mobilization is used whenever
of postoperative respiratory complica possible. These maneuvers are discussed
tions or resulted in improved diaphragm in detail in subsequent chapters. Postural
function. Epidural bupivacaine does im drainage, manual percussion. and chest
prove diaphragmatic function after upper vibration are applied until specific end
abdominal surgery (Mankikian et al.. points indicate therapy should cease.
1 988) but as yet has not been shown to The end-points include increased air
reduce respiratory complications. entry, reduced adventitial breath sounds.
A major confusion that has developed increased lung/thorax compliance, ces
since 1 980 is in the effects of posture on sation of sputum production. or patient
gas exchange in patients with unilateral intolerance. Duration of therapy may.
lung disease. Prone positioning. depen t herefore. vary from 15 to 90 min and re
dent positioning of the good lung, and the flects the extent of pulmonary dysfunc
effects of chest wall compliance are fac tion. Chest physiotherapy, including in
tors that may improve gas exchange ir structions on turning. frequency of
respective of the therapeutic modality application, methods of performance.
under study. The effects of increases in things to avoid. and evaluation of effec
transpulmonary pressures on lung and tiveness. is described in abbreviated
cardiac function are numerous. The data form in Appendix II\,
are confusing in many of the reported
studies that employ small numbers of pa WHAT ARE THE OBJECTIVES O F
tients. It seems physiologically unlikely CHEST PHYSIO THERAPY
that PEP is greatly different from CPAP
or PEEP if they are all applied intermit The objectives of chest physiotherapy
tently. None of these means of increasing include clearance of secretions from
transpulmonary pressure may be differ large and small airways and reexpansion
ent from deep breathing. As shown so of nonventilated lung. The goal of chest
dramatically by Driks et al.. PEEP may physiotherapy is to obtain this favorable
reduce atelectasis but increase VA/Q outcome equally or more effectively than
mismatch. The mechanics of what occurs bronchoscopy without the invasiveness,
during surgery requires more investiga trauma, risk of hypoxemia. complica
tion to find the causes of loss of lung vol tions. physician involvement, and cost
ume and impaired diaphragmatic func that bronchoscopy requires (Mackenzie
tion after surgery. All the relatively and Shin, 1986). A further objective of
noninvasive techniques for removal of chest physiotherapy is to specifically im
secretions are genera l ly preferred over prove ventilation to areas of local lung
bronchoscopy, which produces major obstruction. In this respect it differs from
cardiorespiratory disturbance in the crit- blow bOllles, incentive spirometry. bron-
chodilators, mucolytic agents, IPPB, pres fore. supplements chest physiotherapy

sure support, or application of positive treatments on evening and night shifls.
pressure (CPAP) that are applied to both Nurses can also help by providing a
lungs indiscriminately. Chest physio backup when the case load becomes too
therapy aims to aIter local lung expan great for the number of physical
sion and is physically directed at the therapists.
local lesion. Postural drainage places the The essence of application of chest
local lesion in the ideal position for grav physiotherapy to these patients with
ity to promote drainage of secretions. acute lung problems lies in a cooperative
Percussion and vibration over the skin approach that includes the critical care
surface area of the local lesion assist pos physician, radiologist, physical therapist,
tural drainage and are also directed at the and nurse. Patienls receive a daily por
lung wilh the local lesion. In addition. table anteroposterior chest x-ray that is
one of the objects of chest physiotherapy reviewed in the morning critical care
is to produce benefit when infiltrates are conference by the radiologist, following
generalized. the palient case presenlation. At least
If the objectives of the chest physio one physical therapist attends the daily
therapy are achieved, an increase in local morning rounds. An attempt is made by
lung expansion should occur and a par the radiologisl to identify not jusl lobar
allel increase in perfusion to the affected involvement but, more particularly, seg
area would result . If secretions are ments within a lobe. This approach, even
cleared from larger airways, airway re with potential sources of error, has a rel
sistance and now obstruction should de atively high success rate (Ayella, 1978).
crease. Clearance of secretions and im The chest physical therapist. therefore,
proved ventilation of small airways approaches the patient wilh knowledge
should increase lung compliance. If of the early morning chest x-ray and a
clearance of secretions from both large verbal reporl that enables the patient to
and small airways occurs, it is reasonable be positioned with the affected segmenl
to assume that the work of breathing and uppermost. After chest physiotherapy, a
oxygen consumption should decrease, follow-up chest x-ray is requested on a
and gas exchange improve. Furthermore, patient with a complete lobar atelectasis.
if these objectives are achieved, the in Treatment is given unlil clinical signs of
cidence of postoperative respiratory in improvement are noted and as long as
fection, morbidity, and hospital stay for sputum is obtained. Details of the exact
those with acute and chronic lung dis procedures and Ihe outcome are dis
eases should be reduced. The mecha cussed in laler chapters and are summa
nisms by which chest physiotherapy at rized in Appendix Ill.
tempts to achieve these objectives are
discussed in Chapter 7, pp. 237-242. RESPIRATORY MANAGEMENT
CHEST PHYSIOTHERAPY Physiolherapy should not be consid

ORGANIZATION ered in isolalion from overall respiratory
care managemenl. All the data in me
The number of palients treated with chanically ventilated palients presented
chest physiotherapy at our institution in this book before October 1978 refer to
has risen annually. The statislics for Ihe ventilation Ihat was completely con
types and numbers of patients treated trolled by means of a time-cycled vol
with chest physiolherapy appear in Ap ume-preset mechanical ventilator, the
pendix I. The patient population is sum Engslrllm 300. Since 1978, intermittent
marized in Appendix I. There are 16 full mandatory ventilation, high-frequency
time physical therapists who provide not ventilation. CPAP, pressure supporl ven
only chest, but also rehabilitation care. tilation, independent lung ventilation.
The physicial Iherapists train the nurses continuous now ventilation, and combi
by means of in-service tutorials. Audio nations of high-frequency and continu
visual aids assist in this process (Macken ous now ventilation and conventional
zie el al .. 1978). The nursing staff, Ihere- positive pressure ventilation were used.
CHEST PHYSIOTHERAPY. ICU CHEST PHYSIOTHERAPY. AND RESPIRATORY CARE 35
Indications for Intubation, Ventilation, chanica I ventilation are no longer

Weaning, and PEEP required in a patient with a tracheos
tomy. the patient is extubated. Use of
To prevent unnecessary complications. fenestrated tracheostomy tubes and pro
minimize confusion resulting from dif gressive reduction in tracheostomy tube
ferent techniques and ideas used by size needlessly prolong tracheal intuba
other training centers, and aid in collec tion and efforts to decannulate. Both the
tion of meaningful data, respiratory care fenestrated and small tracheostomy tube
may be standardized. The following increase airway resistance and the work
suggestions for respiratory care are. of breathing and decrease cough effec
therefore, dogmatic and certainly are not tiveness and secretion clearance (Criner
necessarily applicable in all sit uations. et aI., 1 987).
Intubation Mechanical Ventilation

The indications for intubation include Mechanical ventilation is used during
1. Airway obstruction that cannot be tracheal intubation unless the patient is
simply relieved about to be extubated or spontaneous
2. PaO, of less than 80 mm Hg on supple respiration with PEEP is employed. For
mental 0, or of less than 60 mm Hg on completely controlled mechanical venti
room air lation minute ventilation of the ventila
3. Patient in shock with a systolic blood tor is adjusted to satisfy respiratory drive.
pressure of less than 80 mm Hg so that the patient is kept in phase. This
4. Severe head injury or unconscious commonly means hyperventilation to a
ness PaCO, of 30-35 mm Hg. Ventilation is
5. Anticipated surgery. most frequently kept at a rate of 1 2-20
breaths/min. and a tidal volume in the
In an emergency patients are preoxy range of 10-15 mljkg is used. Many cen
genated, and cricoid pressure (Sellick, ters use a high tidal volume and low res
1961 ) is applied to prevent regurgitation piratory rate (Bendixen et al.. 1 963). The
of gastric contents during rapid sequence patient with a head injury is routinely
intubation. with thiopental (when indi hyperventilated to a PaCO, of 25-30 mm
cated) and succinylcholine. Intubation is Hg as one part of the therapeutic maneu
initially carried out by the orotracheal vers to reduce intracranial pressure.
route. Other maneuvers for this purpose may
If the patients are incapable of protect include steroids, di uretics, barbiturates.
ing their own airway due to unconscious and monitoring of intracranial pressure.
ness. incompetent laryngeal reflexes. or
upper airway obstruction. then. after If the patient is out of phase with the
about 1 0-14 days a tracheostomy is usu ventilator. pneumothorax. inadequate
ally performed, and a cuffed tracheos minute ventilation, retained secretions
tomy tube is placed. Patients with severe and inadequate sedation should be con
head injury and spasticity may have a sidered. investigated. and if present. cor
tracheostomy much earlier. within 1 -3 rected. Narcotics and benzodiazepines or
days of ICU admission. Since tracheal both are used for sedation and pain relief.
tubes promote secretion production and Muscle relaxants. such as vecuronium or
reduce the effectiveness of coughing, ex pancuronium. are used only if the cause
tubation is carried out once the tube is no of asynchrony cannot be found and cor
longer indicated to protect the airway. rected. The two groups of patients in
and the patient meets weaning criteria. whom muscle relaxants are used most
Therefore, patients would not normally frequently are decorticate or decerebrate
breathe spontaneously for prolonged per patients with head injury and those who
iods through orotracheal or nasotracheal develop generalized sepsis. Patients with
tubes; instead. a tracheostomy is per severe head injury and elevated intracra
formed or the patient is extubated. Simi nial pressure may also receive high doses
larly when airway protection and me- of barbiturates.
Weaning from Mechanical Ventilation PaO,/FIO, is still not in excess of 200.

chest physiotherapy may be indicated if
The weaning criteria that are used there is retention of lung secretions. If,
include following chest physiotherapy, the ratio
1. Partial pressure of arterial oxygen/ is still not in excess of 200, further incre
fractional inspired oxygen (PaO,/ ments of PEEP are added to a maximum
FlO,) greater than 250 of 10 cm H,O. If, with 10 cm H,O. PEEP,
2. Vd/V, less than 0.55 (by nomogram or and chest physiotherapy, the PaO,/FIO,
direct measurement) is still not greater than 200, a Swan-Ganz
3. Maximum inspiratory force greater flow-directed, thermistor-tipped, pulmo
than -20 cm H,O nary artery catheter is inserted. Further
4. Vital capacity 1 5 ml/kg body weight increases of PEEP above 10 cm H,O may
or greater than 1 000 ml be detrimental to cardiorespiratory func
5. Total lung/thorax compliance greater tion and should be monitored with arte
than 30 ml/cm H,O rial, mixed venous gas, and cardiac out
6. No muscular fatigue, neurological or put determinations.
nutritional indication for continued Normally PaO, is maintained at about
mechanical ventilation. 100 mm Hg by adjustment of FlO, and
PEEP. FlO, is not normally increased
If all the weaning criteria are met, the above 0.6. Exceptions may occur with
patient may be placed on a T-piece or tra carbon monoxide poisoning. chest phys
cheostomy collar. A T-piece is normally iotherapy in an extremely unstable pa
used when the patient has an orotracheal tient, hyperbaric oxygen therapy, and dif
or nasotracheal lube. Arterial blood gases fusion problems in the lung.
are measured after 30 min and 1 hr of
spontaneous breathing. If the patients
maintain adequate arterial blood gases, Alternative Modes 01 Mechanical
extubation is indicated. Gradual weaning Ventilation
is not used. As an alternative to the T
piece, gradually decreasing rates of IMV, Intermittent Mandatory Mechanical
CPAP, and pressure support may be em Ventilation
ployed. This approach considerably in Intermittent mandatory ventilation
creases the duration of weaning but has (IMV) was introduced in 1 973 by Downs
many advocates. et a!. Compared to conventional inter
The indications for reinstitution of me mittent positive pressure ventilation, the
chanical ventilation include essential difference is provision of a par
1. Fall in PaO, below 60 mm Hg when allel inspiratory gas circuit that allows
breathing 10 liters/min of 40% 0, by the patient to breathe spontaneously be
an aerosol humidifier tween mechanical breaths. The advan
2. Increase in PaCO, of 10 mm Hg/hr, or tages and disadvantages of intermittent
5 mm Hg/hr for 3 consecutive hours mandatory ventilation are summarized
3. Respiratory rate consistently exceed by Benzer (1982) and Willatts (1985a,b).
ing 50/min The advantages claimed for IMV include
4. Sudden deterioration of conscious reduced sedation requirements, sponta
ness. neous breathing that may prevent respi
ratory muscle atrophy, improved auto
PEEP
regulation of acid-base balance, reduced
mean intrathoracic pressure, reduced
PEEP may be applied if PaO,/FIO, is risk of barotrauma, and an improvement
less than 200. However, there are many in renal excretory function. The claimed
critical care physicians who advocate use benefits of earlier weaning are not sub
of PEEP of at least 5 cm H,O in all me stantiated by clinical trials (Weisman et
chanically ventilated patients. Initially, 5 a!., 1983). Modification of simple IMV cir
cm H,O is applied. and arterial blood gas cuits is necessary to reduce the work of
analysis is repeated after about 1 5 min. If breathing and respiratory muscle fatigue.
.Airway pressures during IMV may be AO and TRIO require a, and do not ex
equally high as with conventional me crete adequate amounts of CO, for pro
chanical ventilation. longed use without development of res
High-Frequency Ventilation. Highfre piratory acidosis. CFV techniques may be
quency ventilation (HFV) utilizing low used as adjuncts to conventional and
tracheal pressures can maintain gas ex DLV techniques. The main clinical use of
change while reducing the effects of CFV occurs during extracorporeal mem
pressure on the lung and circulation. brane CO, removal. CFV may be a useful
HFV is indicated in bronchopleural fis adjunct to augment oxygenation (Gatti
tula and necrotizing pneumonia. HFV noni et aI., 1 980).
may be beneficial in respiratory failure
unresponsive to conventional tech Inverse Ratio Ventilation
niques, although there is little agreement
in the literature on benefits of HFV com This technique aims to increase the
pared to conventional mechanical venti relative duration of inspiration but may
lation. High frequency jet ventilation at cause gas trapping and elevated intratho
60-300 breaths/min (bpm) produces gas racic pressure. Depending on the respi
exchange by modifications in gas mixing ratory pathology. reversal of the normal
and streaming. Air trapping occurs at I : E ratio of 1 : 2 to 3 : 1 may decrease intra
higher frequencies. High-frequency os pulmonary shunt, dead space, and PaCO,
cillation has the advantage of an active (Perez-Chada et aI., 1 983). If decreased
expiratory phase that prevents gas trap lung compliance occurs with normal air
ping and allows frequencies of 1000-3000 way resistance, time constants for inspi
bpm to be achieved using small tidal vol ration are reduced. In those patients, pro
umes. It may be clinically valuable to longation of inspiration by inverse ratio
combine HFV with conventional me ventilation may improve gas exchange by
chanical ventilation (Nunn, 1 987). increasing the lime that otherwise closed
Differential Lung Ventilation (DLV). In alveoli are held open (Willatts, 1985b).
circumstances where disease or surgery
result in pathological changes in one lung Exclusions in Respiratory Care
not found in the other, DLV may be ben
eficial. Use of two synchronized ventila No assist modes or sigh mechanisms
tors enables ventilation and PEEP to be were used during mechanical ventilation
adjusted independently. A double-lumen of any of the patients treated at our insti
cuffed tube is used to separate ventila tution. No IPPB machines were used for
tion to the right and left lung. DLV has delivery of bronchodilators or mucolytic
limited long-term use because double agents to assist secretion clearance and
lumen tubes are large and traumatize the no inhaled drugs, other than water vapor,
larynx, trachea, and particularly the were used in any of the patients treated
mainstem bronchi. before 1 980. All patients received humid
ification from the moment of intubation,
Continuous Flow Ventilation (CFV) through anesthesia, and during any sub
sequent mechanical ventilation. No
Apneic oxygenation (AO) and tracheal spontaneously breathing patients were
insufflation of oxygen (TRIO) were de treated with blow bottles. Tracheal la
scribed by Hirsch (1905) and Meltzer and vage was rarely part of routine patient
Auer (1909). More recently Lenhert et al. care.
(1982) described a technique of endo Secretions were removed in intubated
bronchial insufflation (EI) of flows of 1 patients by means of postural drainage,
liter/kg/min. AO, TRIO, and EI are all percussion, vibration or shaking therapy,
CFV techniques and they produce gas ex and tracheal suctioning. Mobilization
change without any chest movements. EI was encouraged in all patients, and
differs from the others in producing nor coughing, in those who were spontane
mal oxygenation and CO, excretion for ously breathing. Lung hyperinflation or
up to 5 hr with room air insufflation. Both "bagging" was not employed when chest
physiotherapy was given to mechanically lowing chest physiotherapy in these pa

ventilated patients. Breathing exercises tients to those who have acute lung dis
were used in spontaneously breathing ease in otherwise normal l ungs.
patients. Rarely was bronchoscopy used. The patient population studied also in
Chest physiotherapy replaced bronchos fluences the likely outcome of maneu
copy as the first treatment of choice for vers designed to remove retained lung
removal of retained secretions at our in secretions. For example, the response fol
stitution in 1 974. The number of thera lowing chest physiotherapy of a patient
peutic bronchoscopies between 1 972 and with atelectasis secondary to pain from a
1979 is shown in Table 1 .2. Bronchoscopy stab wound in the chest is more likely to
is not used when an air bronchogram is be favorable than is the response to chest
visible on chest x-ray to peripheral lung. physiotherapy of a patient with adult res
Bronchoscopy is employed for therapeu piratory distress syndrome and multisys
tic effect when 24 hr of chest physiother tem blunt trauma. When comparisons are
apy has failed to reexpand atelectatic made between two forms of therapy de
lung and a diagnostic dilemma exists. De signed to remove secretions from the tra
tails of procedures followed in applica cheobronchial tree, a single use of the
tion of chest physiotherapy are discussed therapy should be compared on similar
in subsequent chapters and summarized patient populations with similar lung pa
in Appendix III. thology. Confounding variables such as
differences in position during therapy
MISCONCEPTI ONS ABOUT may produce changes in oxygenation
EFFECTS OF CHEST that are unrelated to the therapy. Apples
PHYSIOTHERAPY must not be compared to oranges. When
chest physiotherapy is compared to any
Misconceptions exist about the use of other therapy, both therapies must be
chest physiotherapy in patients with performed on a similar patient popula
acute lung pathology. Many reports in tion. This is not always done. Therefore,
the literature discuss the use of chest confusion may exist concerning effec
physiotherapy in patients with chronic tiveness of the therapy in improving the
lung diseases, such as bronchiectasis, patient. This, of course, brings up a most
cystic fibrosis. or bronchitis. These pa important point. What is meant by
tients may not be hospitalized and often improvement?
receive treatment at a clinic or on an out There is difficulty in adequately quan
patient basis. They have chronically ab titating the effectiveness of chest phys
normal lungs. Therefore, it may not be iotherapy. Subjective claims that the pa
justified to extrapolate what occurs fol- tient feels better. that clinical signs
Table 1.2
The Number of Patients Receiving Therapeutic Bronchoscopy for Retention of Lung
Secretions for 1 972-1980 Is Compared to the Total Number of Admissions'
Number of Number of Patients
Year Total Admissions Comments
Bronchoscopies Requiring Bronchoscopy
1 972 61 5 31 19 One patient had 7
Six patients had 2
1 973 982 21 17 Four patie nts had 2
1 974 872 7 7
1 975 920 9 9
1 976 1 , 1 05 14 12 Two patients had 2
1977 1 ,023 9 I Two patients had 2
1 978 1 ,053 8 6 Two patients had 2
1 979 1 ,249 18 14 One patient had 3
Two patients had 2
'The data for 1 972-1975 were kindly supplied by J. Hankins, M.D., Thoracic Surgical Consultant
to MIEMSS.
improve, or that the chest x-ray appear lungs are hyperinflated), and vibration or
ance is more favorable are very difficuli chest shaking is applied during expira
to interpret. Objective evidence is sparse, tion (Gormezano and Branthwaite,
and it was agreed, in the excellent con 1 972a), The duration of therapy also
ferences sponsored by the American shows an amazingly wide variation, This
Thoracic Society in 1974 (National Heart reasonably may be expected to produce
and Lung Institute) (NHLI) and in the different resulis, In some centers, ther
similar conference (National Heart, Lung apy lasts only a few minutes (Hedstrand
and Blood Institute) (NHLBI) in 1 979 (see et al.), In other centers, it may be applied
pp, 245-248 for summary), that there are for 7-20 min (Gormezano and Branth
very few, adequate, and acceptable ways waite, 1 972a), or in others the therapy is
reported that provide evidence of the ef restricted to a predetermined duration of
fectiveness of chest physiotherapy in 1 0- 1 5 min (Newton and Bevans, 1 978),
chronic lung diseases, Lung function Some reports also include the adminis
tests would appear to be the best param tration of nebulized solutions by IPPB as
eter for comparison, However, even they part of chest physiotherapy (Graham and
may be prejudiced either by requiring in Bradley, 1978), Therefore, a reported 20
vasive and sophisticated techniques for min of chest physiotherapy may actually
measurements, such as xenon inhalation, consist of 1 5 min of IPPB and only a short
or by the tests themselves allering the pa period of postural drainage percussion
rameter that they purport to measure, and coughing, All these variables must
For example, the maneuver of forced ex be appreciated before drawing conclu
piration is known to cause small airway sions from the literature,
closure and may induce bronchospasm in I I seems reasonable to assume that un
some patients (Nunn et aI., 1 965), FEV, less sputum is produced by chest phys
measurement may, therefore, not accu iotherapy, the treatment is not likely to
rately reflect the effect of chest physio be beneficial. II is, however, doubtful
therapy, as some authors have suggested that the more sputum produced, the
(Campbell et al.), Another important rea greater the benefit. Sputum removal may
son why confusion may exist about the cause a fall in PaO, and an increase in in
use of chest physiotherapy is the wide trapulmonary shunt because of alleration
range of therapies that are described, in ventilation perfusion relationships,
Claims that chest vibration did not pro This was suggested as the probable cause
duce a statistically significant difference for the falls in PaO, noted by Gormezano
in clearance of sputum when compared and Branthwaite ( 1972b) following chest
to coughing alone must be questioned physiotherapy in chronic lung disease
when it is learned that the therapy was patients, Partial reexpansion of a lobar
performed in the silting position with a atelectasis may reverse the vascular
mechanical vibrating pad (Pavia et al.), In compensating mechanisms that previ
our experience, upper lobe secretion re ously reduced intrapu lmonary shunt.
tention is uncommon (see Appendix I), Most clinicians agree with Murray that
Far more frequently, lower lobe collapse sputum production is essential if chest
is seen, especially left lower lobe col physiotherapy is to be effective for the
lapse, Therefore, the silling position is treatment of chronic lung disease, How
inappropriate for drainage of lower lobe ever, the removal of 30 ml. that he states
secretions, If chest vibration was per as the minimum necessary to produce
formed by a physiotherapist, with the pa benefit, is excessive in the patient with
tient in the appropriate postural drai nage normal lungs and acute secretion reten
position, until there was clinical evi tion, If sputum is removed from the
dence of secretion clearance, the out smallest airways. less should produce
come may be different. beneficial effects (see p, 220),
In other reports, "chest physiotherapy" Sputum volume measurement is noto
includes suctioning but no percussion, riously unreliable (Bateman et al.), The
manual vibration or postural drainage expectorated measurement has consid
(Fox et al" 1 978), Some physiotherapy erable sources of error, as the patient can
techniques include bagging (where the swallow sputum. so reducing the volume
collected, and equally, the patient can tions studied are variable, sometimes
add saliva apparently increasing the inappropriately excluding those patients
quantity. The effectiveness of humidifi likely to or including those least likely to
cation and patient hydration may also af benefit.
fect sputum volume. Except for our data Chest physiotherapy is used frequently
presented in Chapter 7, few studies mea in pediatric ICUs, surgical ICUs for res
sure volume of sputum production in tra piratory problems occurring after sur
cheally intubated patients. The cuffed gery, and for treatment of chronic lung
tracheal tube removes two of the major disease. In the acute selling. physiother
sources of error in sputum collection apy appears equally as good as bronchos
mentioned above. Volume of sputum copy for reexpansion of atelectasis. For
may not be the primary consideration for patients with chronic lung disease it
assessing chest physiotherapy effective seems effective when production of se
ness for the ICU patient. In our experi cretions is great.
ence treating acute lung pathology, there Some common misconceptions about
is lillie relationship between the volume chest physiotherapy that occur because
of sputum produced in excess of 5 ml and of the lack of standardization were em
the benefits in terms of improved physi phasized. Chest physiotherapy tech
ological parameters. In acute processes, niques were briefly described.
as in chronic lung disease, different lung Controlled mechanical ventilation was
problems produce different volumes and considered the treatment of choice for
types of sputum. The lung contusion pro the acute management of the severely in
duces mostly blood, not sputum, yet jured and pathological lung. Removal
chest physiotherapy may improve venti from mechanical ventilatory support
lation/perfusion relationships (Macken does not need to be gradual in patients
zie and Shin, 1 979a). Lobar and segmen recovering from acute lung pathology.
tal atelectasis may clear when only a Changes in lung/thorax compliance
small volume of sputum is removed, yet were thought to be a good indicator of the
dramatic improvement in intrapulmo benefits and end point of chest phys
nary shunt and total lung/thorax compli iotherapy.
ance may occur on reexpansion. In pa Assist modes of ventilation, sighs and
tients with established pneumonia, lillie hyperinflation, bronchodilator and mu
improvement may be apparent whether a colytic agent inhalations, and use of blow
large or a negligible amount of sputum is bottles and incentive spirometers have
produced. The long-term benefits of re clouded the interpretation of the results
moval of retained sputum are unknown. of chest physiotherapy. Therapeutic
It is thought that it does not alter the bronchoscopy is rarely required for spu
course of chronic lung diseases (NHLI, tum removal when chest physiotherapy
1974), but in acute lung diseases, espe is employed. It is clear from the literature
cially in an ICU environment, it seems since 1980 that posoperative pain is not
likely that it would reduce the incidence the major factor in development of res
of respiratory tract infection and, there piratory complications. Diaphragmatic
fore, morbidity (and possibily mortality). dysfunction after upper abdominal sur
Areas of dispute concerning the compo gery appears to be an important etiology
nents, alternatives and disease processes for respiratory complications that is re
treated by chest physiotherapy are sum versed by epidural bupivacaine but not
marized in Table 1 .3. This table also pro by spinal or epidural opiates. Despite a
vides our opinion on some controversial multitude of mechanical aids to lung ex
points. pansion such as PEEP. CPAP, PEP, pres
sure support, and inverse ratio ventila
SUMMARY tion none is convincingly superior to
chest physiotherapy, deep breathing, and
Objective studies of chest physio position changes in prevention of respi
therapy are few and the techniques em ratory complications in the ICU. For me
ployed are not standardized or ade chanically ventilated patients, the re
quately described. The patient popula- cently described techniques to improve
()
::t
Table 1 .3 m
Conflicting Data and Points 01 Contention Concerning Chest Physiotherapy
."
For Against Authors Opinion and Practice ::t
-<
(J)
Component
Percussion and Assists secretion clearancel-3 May not add to the effect of cough Assists secretion clearance;
::t
vibration and suction"' mode of action postulated in m
Chapter 4 and on p. 240-242 :D

Postural drainage Peripheral clearance of secretions is Both cough and exercise are superior Identification of the involved lung ."
(PD) enhanced with PD.' Significantly to PO at clearance of secretions.'O segment is essential to .-<
more sputum is produced with Sputum production is reduced with determine which of 1 1 o
c
PD and the forced expiratory CPT including PD compared to different positions is correct
()
technique.' PD without positive FET or PEP without PD." PD is no for gravity assisted segmental ::t
expiratory pressure (PEP) better than cough alone' 2.13 drainage,'" PO has an additive m
(J)
produced more sputum than PEP effect to percussion, vibration, .....
therapy in the sitting position.' coughing, and FET. PD ."
::t
The addition of PD and coughing improves central airway -<
improves mucociliary clearance9 clearance when cough is (J)
Cough CPT does not add benefits to cough CPT but not cough produces
impaired
It is inappropriate to separate

::t
m
alone,I2 80th clear central and peripheral clearance of secretions.' cough from other CPT :D
peripheral airways' Cough effects are limited to the techniques. Cough occurs
."
central airways, proximal to the spontaneously and :<
fifth generation.ls Repetitive concurrently when secretions
z
coughing may cause fatiguel6 and are loosened or suctioned. o
bronchospasml1 Cough is important for :D
removal of secretions m
(J)
advanced to the central 31
airways. Protracted coughing :D
Forced expiratory FET is more effective than cough Sputum clearance was less effective
should be avoided
FET is not shown to improve
:D
technique (FET) alone. FET with PD produced when PEP is included in treatment. mucus clearance in peripheral -<
and PEP more sputum than CPT.' PEP PEP clears less secretions than PD airways. May be helpful to ()

prevents atelectasis after upper alonee clear central airways. :D
abdominal surgery." FET is better Physiological basis m
tolerated than CPT" unknown.19 PEP produces
only short-lived benefits
..

t
Table 1.3
Conflicting Data and Points 01 Contention Concerning Chest Physiotherapy-Continued
For Against Authors Opinion and Practice
Component
Tracheal suctioning Is safe since it is widely used and Is dangerous and may cause cardiac It is dangerous; if the patient
in nonintubated advocated dysrhythmia" or arrest" ; it may cannot cough up secretions
patients stimulate vomiting and cause by using other techniques to
aspiration (p. 1 79-180) stimulate cough, tracheal
intubation with a cuffed tube
is required
Mechanical chest Manulacturers claim that they Manufacturers claims not No mechanical devices used;
vibratorsl provide percussive directional substantiated in clinical practice?4 hands on care provides
percussors stroking lor postural drainage." Percussion frequencies of 3-17 Hz better, safer, more adaptable,
o
Hand clapping Irequency of up to is adequate for secretion and cheaper therapy. Manual I
8 Hz is too low for sputum clearance. 26 techniques can be varied to m
Ul
clearance23 suit patient tolerance -i
Sputum volume If less than 30 ml is produced, chest Sputum measurement is not Sputum must be obtained, but 'U
I
physiotherapy should be accurate; importance is not the removal of 5 ml may -<
Ul
discontinued26 volume, but where it comes from frequently result in impressive
physiological and radiological
changes

I
m
Short duration of Widely practiced; it ranges from a Treatment times less than 20 min Treatment may last 1 hr; if there JJ
>
therapy few rninutes,27 7-20 min,28 or is have not been sufficient to clear is improvement in lunglthorax 'U
restricted to predetermined time29 atelectasis or produce radiographic compliance and clinical signs, -<
or physiological improvement it may be stopped earlier Z
-i
Adjuncts I
Mucolytic agents Reduced sputum viscosity, Using radioactive tracer techniques Not used m
increased pourability, subjective has not been shown to increase Z
-i
and objective clinical sputum clearance31 m
z
improvement following use30 Ul
Bronchodilators Improvement in arterial 0, following Not better than placebo when given If patient is a known asthmatic <:
m
chest physiotherapy may be more by IPPB33 taking regular bronchodilator
o
obvious if therapeutic levels of therapy, drugs by continuous >
aminophylline are obtained32 Lv. infusion are appropriate JJ
m
during mechanical ventilation; c
otherwise, they are not z
routinely used =i
Tracheobronchial Promotes cough and helps humidify No amount of lavage will loosen Provided there is adequate o
lavage or and loosen secretions; lavage viscid tenacious sputum from small systemic and local hydration I
volume of up to 200 ml is used airways; large volumes may cause m
instillation (humidity), bronchial lavage is U>
with bronchoscopy34 deterioration of chest x-ray and not used -i
accumulate in the lungs3S "
I
Alternatives -<
U>

Bronchoscopy Highly successful at clearing Traumatic, expensive, and not more If an atelectasis cannot be
atelectasis; performed under effective at secretion clearance38; it cleared after 36 hr of
visual control; can identify cannot reach peripheral airways; physiotherapy, bronchoscopy m
JJ
obstruction if present.3f1 Selective fiberoptic bronchoscopy cannot is appropriate to exclude >
positive pressure ventilation suction large quantities of other pathology; "
-<
.
through suction port may expand tenancious secretions39; needs a bronchoscopy is not the first
refractory atelectasis37 physician's participation, causes treatment for lobar segmental o
c
rises in systemic and pulmonary collapse o
artery pressure in the critically ill I
m
patient"
Incentive Cheap, prevents atelectasis, and Did not increase PaD, as significantly Incentive spirometry may be
"
spirometry (IS) reduces hospital stay compared as physiotherapy" and has not used; mobilization and verbal I
to IPPB, and patients like i1.'41,..2 been shown to be better than deep encouragement to cough are -<
U>
Superior to no treatment at all" breathing." No benefit compared
to specialized respiratory care"5
cheaper and probably equally
effective I
IPPB IPPB modifies lung compliance"6 In controlled studies in postoperative IPPB is not used and is not m
patients, IPPB did not reduce the thought to help clearance of JJ
and lung mechanics..7; maximum >
volume IPPB treats atelectasis" incidence of pulmonary retained secretions; IPPB has "
complications"9 51; it may harm the no ability to alter local lung .-<
>
patient." It does not help patients expansion; chest z
with quadriplegia" physiotherapy increases lung o
compliance and may alter JJ
m
local lung expansion Ul
CPAP Increases Pa02 and reduces No advantage over mobilization. S6 CPAP is useful during :!1
JJ
radiological density when used Increases in FRC found with CPAP spontaneous respiration in
with CPT." Increases FRC more
rapidly than IS or breathing
ceases within 10 min of stopping
therapy." PEP mask is equally
the intubated patient. Mask
CPAP is not practical in the
JJ
-<
exercises5S effective and simpler18 critically ill. CPAP lacks the o
regional specificity necessary >
for effective expansion of JJ
m
segmental or lobar collapse
...
'"
...
...
Table 1 .3
Conflicting Data and Points of Contention Concerning Chest Physiotherapy-Continued
For Against Authors Opinion and Practice
()
I
Transtracheal Lavage fluid instillation precipitates May cause death, uncontrollable Transtracheal catheters are m
catheters and coughing in the otherwise tracheal hemorrhage, dangerous. Alternative
minitracheostomy uncooperative patient; this may pneumomediastinum, local techniques to stimulate cough ..,
I
clear secretions; apparently infection, etc.59 Catheter may be and clear secretions are -<
frequently used in the ICU" aspirated" clearly preferable U>
(5
Disease Processes Treated by Chest Physiotherapy ....
I
Pneumonia Pneumonia may be aborted by Chest physiotherapy and IPPB do not The diagnosis of pneumonia in m
chest physiotherapy preventing hasten the resolution of the ICU is very subjective; JJ

retention of secretions. pneumonia29 more recent diagnostic aids ..,
Pneumonia in the ICU is difficult are helpful61 63; reversal of a -<
to distinguish from atelectasis or pneumonia-like process is z
ARDS" possible with chest ....
I
physiotherapy (see Case m
History 2 . 1 ) z
....
Chronic bronchitis Subjective improvement in dyspnea Chest physiotherapy had no effect on In the ICU, infection is present; it m
and reduced obstruction and acute exacerbations of the is, therefore, mandatory that z
U>
increased clearance of sputum disease&4&5 all patients with preexisting <'
after chest physiotherapy chronic sputum producing m
respiratory disease should ()

obtain prophylactic therapy to JJ
reduce the retention of m
c
secretions. until the patient is z
mobilized =i
Cystic fibrosis (CF) CPT improves mucous clearance CPT does not clear peripheral CPT is beneficial. Efficacy may ()
I
and pulmonary function66,87 secretions in patients with CF.68.69 vary when disease is m
Vital capacity decreases70 quiescent and active
Acute atelectasis Radiological and clinical benefit No better than encouragement of See Chapters 2-5 "
from CPT,87,lI,12 Oxygenation27 deep breathing and mobilization.'3 I
-<
and lung/thorax compliance 14 CPT is not effective and causes a (f)
Lung contusion
increased
CPT decreases intrapulmonary
fall in PaO/
May cause transbronchial aspiration See Chapters 2 and 1 0
I
shunt7S and increases lung! of blood. CPT is contraindicated'S m
JJ
thorax compliance1
"
' Bateman et aI., 1 979. "Shim et aI., 1 969. "Feldman and Huber, 1 976. "Matthews and Hopkinson, 1 984. :<
'Cochrane et aI., 1 977. " Welply et aI., 1975. "Lundgren et aI., 1 982. "Schmerber and Deltenre, 1 978. o
'Opie and Spalding, 1 958. "General Physiotherapy, 1 979. " McConnell et aI., 1 974. c
"Charnley and Verma, 1 986.
()
'Murray, 1 979b. "Flower et aI., 1 979. ". Dohi and Gold, 1 978. " Faling, 1 988. I
'Mellins, 1 974. " Pavia et aI., 1 976. "Celli et aI., 1 984. "Salata et aI., 1987. m
'Bateman et aI., 1 98 1 . "King et aI., 1 983. I ngram, 1 980. "Johanson et aI., 1 988a.
'Sutton e t aI., 1983. "Murray, 1 979a. "Schweiger et aI., 1 986. " Newton and Stephenson, 1 978. "
I
'Hofmeyer, 1 986. " Hedstrand et aI., 1 978. "Murray, 1980. "May and Munt, 1 979. -<
'Van der Schans et aI., 1 986 "Gormenzano and Branthwaite, 1 972a. "Sinha and Bergofsky, 1 972. "Tecklin and Holsclaw, 1 975. (f)
" Oldenberg et aI., 1979. "Graham and Bradley, 1 978. "O' Donohue, 1 979. "Kirilloff et aI., 1 985. 6
-i
" Falk et aI., 1 984. '"Aylward, 1 973. "Sands et aI., 1 96 1 . "Weller et aI., 1 980. I
m
"Rossman et aI., 1 982. " Thomson et aI., 1 975. "Barach and Segal, 1 975. "Kerrebijn et aI., 1 982. JJ
"DeBoek and Zinman, 1 984. "Menkes and Britt, 1 980. " Petty, 1 974a. "Zapletal et aI., 1 983.
"
"Mackenzie et aI., 1 980. "Shim et aI., 1 978. "Gold, 1 976. " Hammond and Martin, 1981 . -<
.
"Smaldone and Smith, 1 985. "Barrett, 1 978. "McCool et aI., 1 986. "Mackenzie et aI., 1 978.
"Sutton et aI., 1 984. "Sackner et aI., 1 972. S' Andersen et aI., 1 986. "Fairley, 1 980. z
a
"Zapletal et aI., 1 983. "Sackner, 1 975. "Stock et aI., 1 985. "Connors et aI., 1 980. JJ
"Ricksten et aI., 1 986. "Harada et aI., 1 983. "Dull and Dull, 1 983. "Mackenzie and Shin, 1 979a. m
(f)
"Pryor and Webber, 1 979. "Mackenzie and Shin, 1 986. "Heitz et ai, 1 983. "Tyler, 1982. J1
JJ

o
JJ
-<
()

JJ
m

diagnosis. prevention. and management anesthesia with controlled ventilation. N Eng/ J

Med 260:991-996. 1 963
of pneumonia may reduce the incidence Benzer 1-1: The value or intermittent mandatory
and fatality of nosocomial pneumonia. ventilation. Editorial. Intensive Care Med 8:267-
There are many conflicting opinions that 266. 1962
confuse the interpretation of the effects Bergman NA: Effects or varying respiratory wave
of chest physiotherapy. Particularly the rorms on gas exchange. Aneslhesiology 28:390-
395. 1967
different combinations of chest physio Bone RC: Compliance and dynamic characteristic
therapy maneuvers used by different in curves in acute respi ratory railure. Cril Core Med
vestigators creates difficulty in determin 4 : 1 73-179, 1976
ing efficacy. Brock-Utne IG. Winning TI. BOLha E, Goodwin NM:
Chest physiotherapy during mechanical ventila
References tion. Anaeslh In fensive Care 3:234-236, 1975
Buscaglia AI, 51. Marie M: Oxygen saturation dur
Albert RK, Leasa D. Sanderson M. Robertson HT. ing chest physiotherapy ror acute exacerbation of
Hlaslala MP: The prone position i mproves arte severe chronic obstructive pulmonary disease.
rial oxygenation and reduces shunt in oleic acid Resp Core 28:1009-1013, 1983
induced acule lung injury. Am Rev Respir Dis Bushnell GE: The treatment or tuberculosis. Am
135:626-633. 1967 Rev Tuberc 2:259-275, 1918
Andersen lB. Jespersen W: Demonstration of inler Campbell AH, O'Connell 1M, Wilson F: The effect
segmental respiratory bronchioles in normal or chest physiot herapy upon the FEV. in chronic
human l u ng. Eur J Respir Dis 61:337-341. 1980 bronchitis. Med I Aust 1 :33-35, 1975
Andersen lB. Qvist J, Kahn T: Recruiting collapsed Canner P. Mossberg B. Philipson K, Strandberg K:
lung through collateral channels with positive Elimination of test particles rrom the human tra
end-expiratory pressure. Scand I of Ilesp Dis cheobronchial tract by voluntary coughing.
60:260-266. 1979 Scand J /lesp Dis 60:52-62, 1979
Andersen lB. Olesen KP. Eikard S. Jansen E. Qvist Carswell F, Robinson OW. Ward CCL, Waterfield
J: Periodic continuous positive airway pressure. MR: Deoxyribonucleic acid output in the sputum
CPAP. by mask in the treatment of atelectasis. rrom cystic fibrosis patients. Eur J Respir Dis
Eur J Respir Dis 61 :20-25. 1 980 65:53-57. 1 964
Ant honisen P. Riis P. Sogaard-Andersen T: The Casaburi p, Wasserman K: Exercise training in pul
value of lung physiotherapy in the treatment of monary rehabilitation, Editorial. N Eng I Med
acute exacerbations in chronic bronchitis. Acla 314:1 509-1 5 1 1 . 1 966
Med Scand 175:715-719. 1 964 Cat ley OM, Thornton C, Jordan C, Royston D, Le
Aubier M. M u rciano D. LeCocgnic Y. Viires N. lac hane JR. lonos IG: Postoperative respiratory de
quens Y. Squara P. Parienote R: Effect of hypo pression associated with continuous morphine
phosphatemia on diaphragmatic contractility in inrusion. Sr J Anaeslh 54:235. 1 982
patients with acute respiratory failure. N Eng J Celli BR, Rodriguez KS, Snider GL: A controlled
Med 3 1 3:420-424. 1965 trial or intermittent positive pressure breathing,
Ayella RI: Radiologic Management fo Ihe Massively incentive spirometry and deep breathing exer
Traumali7.ed Palient. pp 93-97. Williams & Wil cises in preventing pulmonary complications
kins . Balti more. 1978 after abdominal su rgery. Am Rev /lpspir Dis
Bain I . Bishop J, Olinsky A: Evaluation or directed 130:12- 1 5 , 1 984
coughing in cystic fibrosis, Br I Dis Chest 82:138- Celli BR. Rassulo I , Make 81: Dyssynchronous
148, 1 988 breathing during a rlll but not leg exercise in pa
Baran 0, Van Bogaert E (eds): Chest Physical Ther tients with chronic ai rflow obstruction. N Eng! 1
a py in Cyslic Fibrosis and Chronic Obslructive Med 314:1465-1490. 1966
Pulmonary Disease. European Press. Ghenl. Bel Cherniack RM: Physical therapy. Am Rev Rf'spir Dis
gium, 1977 1 22(2):25-27. 1 960
Bateman IRM. Newman SP, Daunt KM, Pavia O. Ciesla N, Klemic N, Imle PC: Chest physical therapy
Clarke SW: Regional lung clearance or excessive to the palient with multiple trauma. Two case
bronchial secretions during chest physiotherapy studies. Phys Ther 61:202-205, 1981
in patients with stable chronic airways obstruc Clarke SW, Cochrane GM, Webber SA Effects of
tion. l.onceI 1 :294-297. 1979 sputum on pulmonary runction (abstract). Thoro:<
Bateman IRM. Newman Sp, Daniel KM, Sheahan 26:262. 1973
NF, Pavia 0, Clarke SW: Is cough as effective as Clergue F. Montcmbauh C, Oespierre 0, Ghes
chest physiotherapy in removal or excessive tra q u iere F, lIarari A, Viars P: Respiratory effects of
cheobronchial secretions? Thora x 36:683-687, intrathecal morphine after upper abdominal sur
1981 gery. Anesthpsio!ogy 61:677-685, 1984
Beecher HK, Todd DP: A study or the deaths asso Cochrane GM, Webber BA, Clarke SW: Effects or
ciated with anesthesia and s u rgery. Ann Surg sputum on pulmonary function Sr Med 1 2: 1 181-
140:2-34, 1954 1 1 63. 1977
Belman M , Miltman C: Incentive spirometry, The Collett PW, Engel LA Influence or lung volume on
answer is blowing in the wind. Chesl 79:254-255. oxygen cost of resistive breathing. J App! Physio/
1961 61 : 1 6-24, 1 986
Bendixen HH, Hedley-Whyte I, Laver MB: Impaired Connors AF, Hammon WE, ?>.fartin RI. Rogers RM:
oxygenation in surgical patients during general Chest physical therapy: The immediate effect on
oxygenation in acutely ill patients. Chest 78:559- chronic bronchial affections by posture and res
564, 1 980 piratory exercises. Lancel 2:70-72. 1 901
Craig DB: Postoperative recovery of pulmonary Fairley HB: Oxygen therapy ror s u rgical patients.
function, Anesfh Anolg 60:46-52. 1981 Am Rev Respir Dis 122(2):37-44, 1 980
Crampton Smith A. Spalding JMK. Russell WR: Ar Faling LI. Editorial. New advances in diagnosing
tificial respiration. by intermittent positive pres nosocomial pneumonia in intubated patients.
sure in poliomyelilis and other diseases. Lonce! Part 1 . Am Rev Respir Dis 1 3 7:253-255. 1 988
1 :939-945. 1 954 Falk M. Kelslrup M. Andersen IB, Kinoshita T, Falk
Craven DE. Kunches LM. Kilinsky V. Lichtenberg P. Staving S. Cothgen I: Improving the ketchup
OA. Make BI. McCabe WR: Risk faclors for pneu bottle method with positive expiratory pressure.
monia and fatality in patients receiving continu PEP. in cystic fibrosis. Eur J Resp Dis 65:423-432.
ous mechanical ventilation. Am Rev Respir Dis 1 984
133:792-796. 1986 Featherstone H: An inquiry into the causation or
Criner C. Make B, Celli B: Respiratory muscle dys postoperative pneumonia. Br I Surg 1 2:482-523,
function secondary to chronic tracheostomy lube 1924
placemenl. Chest 91:139-141. 1987 Feeley TW. Hamilton WK, Xavier B. Moyers J. Egar
Dammann IF, MeAslan TC: Optimal flow pattern for EI: Sterile anesthesia breathing circuits do not
mechanical ventilation of the l u ngs: Evaluation prevent postoperative pulmonary inrection. An
wilh a model lung. Cdl Care Med 5:128-136. eSlhesiology 54:369-372. 1981
1977 Feldman J . Traver CA. Taussig LM: Maximal expi
Darrow C. Anthonisen NR: Physiot herapy in hos ratory nows after postural drainage. Am Rev Res
pitalized medical patients. Am Rev Respir Dis pir Dis 1 1 9:239-245, 1979
122(2):155-158. 1980 Feldman NT. Huber GL: Fiberoptic bronchoscopy
DeBoed. C. Zinman R; Cough versus chest physio in the intensive care unit. lnt Anesthesial elin
therapy. A comparison or the acute effects on pul 14:31-42, 1976
monary runction in patients with cystic fibrosis. Felson B, Felson F: Localization or lesions by means
Am Rev Respir Dis 1 29:182-184. 1984 or the postero-anterior roentgenogram. Radiology
DeTroyer A: Mechanics or the chest wall during re 55:363-373 . 1 950
strictive thoracic strapping. Respira/ion 39:241- Finer NN, Boyd J: Chest physiotherapy in the neo
250. 1 980 nate. A controlled study. Pediatrics 61:282-285,
Dohi S, Cold MI: Comparison or two methods or 1978
postoperative respiratory care. Chest 73:592-595. Finer NN. Grace MG, Boyd I: Chest physiotherapy
1978 in the neonate with respiratory dist ress (abstract
Douglas WW. Rehder K. Beynell FM, Sessler AD. 1 1 89). Pediolr Res 1 1 :570, 1977
Marsh HM: Improved oxygenation in patients Fletcher R , Larsson A: Cas exchange in the partially
with acute respiratory failure: the prone posi lion. atelectatic lung. Anat!slhesio 40:1186-1188, 1 985
Am Hev R('spir Dis 1 1 5:559-566, 1977 Flower KA, Eden RI. Mann NM, Burges I: New me
Downs lB. Klein ER. Desautels D. Modell IH. Kirby chanical aid to physiotherapy in cystic fibrosis. Sr
RR: Intermittent mandatory ventilation: new ap Med / 110630-631. 1979
proach to weaning patients from mechanical ven Ford GT. Whitelaw WA. Rosenal TW. Cruse PI.
tilators. Chesl 64:331-335, 1973 Cuenter CA: Diaphragm runction aner upper ab
Driks MR. Craven DE, Celli BR, Manning M . Burke dominal surgery in h u mans. Am Rev Respir Dis
RA, Garvin CM, Kunches t. Farber HW. Wedel 127:431-436, 1 983
SA, McCabe WR: Nosocomial pneumonia in in Ford CT. Guenter CA: Toward prevention or post
tubated patients given SucraIrate as compared operative pulmonary complications (editorial).
with antacids or histamine Type 2 blockers. N Am Rev Respir Dis 1 30:4-5. 1984
Engl / Med 317:1 376-1382. 1987 Fox W\\'. Schwartz IG, Shaffer TH: Alterations in
Dull IL. Dull WL: Arc ma'Cimal inspiratory breath neonatal respiratory runction rollowing chest
ing exercises or incentive spirometry beLler than physiotherapy (abstract 1 1 92). Pedialr Res 1 1 :570,
early mobilization aner cardiopulmonary bypass? 1977
Phl's Ther 63:655-659. 1983 Fox WW. Schwartz IG. Shaffer TH: Pulmonary
Durenil B. Viires N. Cantineau JP. Aubier M, Des physiotherapy in neonates: PhysiologiC changes
monts 1M: Diaphragma tic contracLility aner and respiratory management. I Pedialr 92:977-
upper abdominal surgery. J Appl Physiol 61: 1775- 981. 1978
1 780. 1986 Friedman SA (let ter), Marini Jj, Pierson 01, Hudson
Eliasson R. Mossberg B. Camner P. Arzeliu5 BA: LD (replyt. Comparison or fiberoplic bronchos
The immobile cilia syndrome. A congenital cili copy and respiratory therapy. Am Rev Respir Dis
ary abnormality as an etiologic ractor in chronic 1 26:367-368. 1 984
airway inrections and male sterility. N Engl J Med Fuleihan SF. Wilson RS. Pontoppidan H: Effect or
297:1-6. 1977 mechanical ventilation with end-inspiratory
cngslrOm Respiralon' Sl'slem EA 300 Instruction pause on blood gas exchange. Aneslh Analg
Manual VI. Lk':B Medical. Stockholm. Arne Tryck (Cleve) 55:122-130. 1976
are, 1974 Garibaldi RA. Britt MR. Coleman ML. Reading IC.
Enjeti S, O'Neill IT, Terry PB. Menkes HA. Trayst Pace NL: Risk ractors for postoperative pneumo
man RJ: Effects or positive and expiratory pres nia. Am J Med 70:677-680. 1981
sure on shunt now in atelectasis. Respir Physial Gaskell DV. Webber BA: The Bromplon Hospital
48:243-254. 1 982 Guide fo Chesl Physiolheropy (prerace). 2nd ed.
Ewart W: The treatment or bronchiectasis and or Blackwell Scientific Publications. London. 1973
Catlinoni L. Pesenti A. Rossi GP et 81: Treatment of neonates treated by intermittent positive pres
acute respiratory failure by low freq uency posi sure respiration. Thorax 24:421-426. 1 969
tive pressure ventilation and extracorporeai re Holloway TE. Sta nrord BI: Effect of doxopram on
moval of CO:/:. Lancel 2:292-294. 1 980 postoperative oxygenation i n obese palients. An
General Physiot herapy: GS Massage Apparatus. aesthesia 37:718-721. 1982
General Physiotherapy. St. Louis. 1 979 Holody B. Goldberg I-IS: The effect of mechanical vi
George RJD. Johnson MA. Pavia D. Agnew JL. Clark bration physiotherapy on arterial oxygenation in
SW. Geddes OM: Increase i n mucociliary clear acutely ill patients with atelectasis or pneumonia.
ance in normal man induced by oral high fre Am Rev Raspir Dis 1 26:372-375. 1981
Quency oscillation. Thorax 40:433-437. 1985 Ingram RH: Mechanical aids to lung expansion. Am
Gold MI: Is intermittent positive-pressure breathing Rev Respir Dis 122(2):23-24. 1980
therapy (IPPS Rx) treatment necessary in the sur Jackson C . Jackson Cl: Peroral pul monar}' drainage:
stieal palient? Ann SUTg 184:122-123. 1976 Natural and therapeutic with special reference to
Gormezano J. Branthwaite MA: Effects of physio the tussive squeeze. Am J Med Sci 1 86:849-854.
therapy during intermittent positive pressure 1933
ventilation. Anaesthesia 27:258-263. 1 972a Jaworski A. Goldberg SK. Walkenstein MD. Wilson
Gormezano J. Branthwaite MA: Pulmonary physio B. Lippmann Ml: Utility of immediate pastlobec
therapy with assisted ventilation. Anaesthesia lomy fiberoptic bronchoscopy in preventing atel
21,249-251, 1912b ectasis. Chest 94:38-43. 1 988
Gracey DR, Divertic MB. Didier EP: Preoperative Jenkins SC. Soutar SA: A survey ' into the use or in
pulmonary preparation of patients with chronic centive spirometry following coronary artery by
obstructive pulmonary disease. Chest 76:123-129. pass graft su rgery. Physiofherapy 72:492-493.
1919 1 986
Graham WG. Bradley DA: Efficacy of chest physio Johanson WG. Seidenfeld I I . Gomez P. De Los San
therapy and intermittent positi ve-pressure tos R. Coalson II: Bacteriologic diagnosis of noso
breathing in the resolution of pneumonia. N Eng! comial pneumonia following prolonged mechan
J Med 299,624-621, 1918 ical ventilation. Am Rev Respir Dis 1 37:259-264.
Grimby G: Aspects of lung expansion in relation to 1 988a
pulmonary physiotherapy. Am Rev Aespir Dis Johanson WG. Seidenfeld JJ. Dc los Santos R. Coal
1 1 0(2), 145-1 53, 1 914 son If. Gomez P: Prevention of nosocomial pneu
Hammond WE. Martin RJ: Chest physical therapy monia using topical and parenteral antimicrobial
for acute atelectasis. Phys Ther 61:217-220, 1981 agents. Am Rev R('spir Dis 1 37:265-272. 1988b
Harada K. Mutsuda T. Saoyama N. Tainki T. Ki Jones itA. Davies EE. Hughes 1MB: Modification of
mura H: Reexpansion of refractory atelectasis pulmonary gas mixing by postural changes. J
using a bronchofiberscope with a balloon cuff. Appl PhysioI 61:15-80, 1986
Chesl 84'125-128, 1 983 Jones JG: Pulmonary complications following gen
Heckscher H: The emphysema of the l u ngs. its eral anesthesia. Chapter 3 in Anesthesia Review 2.
symptoms and relations 10 other diseases. Acta edited by L Kaurman. pp 21-37. Churchill living
Med Scond 1 20,349-383, 1 945 stone. Edinburgh. 1984
Hedstrand U. Liw M. Rooth G. Ogren CH: Effect of Jones JG. Minty BO, Royston D: The physiology of
respiratory physiotherapy on arterial oxygen ten leaky l ungs. Sr J Anoesth 54:705-721. 1982
sion. Acto Anaesthesial Scand 22:349-352. 1 978 Jones NL: Physical therapy-present state of the art.
Heitz M. Holzach P. Dillman M: Comparison of the I\m Rev Respir Dis 1 1 0(2):132-136. 1974
effects of continuous positive airway pressure Kane IJ: Segmental localization of pulmonary dis
and blowing bottles on functional residual capac ease on the pastero-anterior chest roentgeno
i t y after abdominal su rgery. Respiration 48:277- gram. Radiology 59:229-237. 1952
284, 1985 Kane I I : Segmental pastural drainage in pulmonary
Herzog P: Advice and practical i nstruction for the diseases. Dis Ghest 23:418-427. 1953
use of the EngstrOm respirator. Opusc Med Sd Kerrebijn KF, Veentzer R. Bonzet E. Water VD: The
9(8), , 1 , , 964 immediate effect of physiotherapy and aerosol
Herzog P . Norlander DO: Distribution of alveolar treatment on pulmonary function in children
volumes into different types of positive pressure with cystic fibrosis. cur J Hesp Dis 63:35-42, 1982
gas flow patterns. Opusc Med Bd 1 3(1 1 J:1-45. 1968 Kigin CM: Chest physical therapy for the postoper
H i rsch M: Uber Kunstliche Hemung durch ventila ative or traumatic injury patient. Phys Ther
tion der trachea. Dissertation Gressen. 1905. 61:1 724-1736. 1981
Hofmeyer Jl, Webber BA. Hodson ME: Evaluation Kigin eM: Advances i n chest physical therapy. In
of positive expiratory pressure as an adjunct to Current Advances in Respiratory Core. edited by
chest physiotherapy in the treatment of cystic fi WJ O'Oonohue, pp 37-71. American Call. Chest
brosis. Thorax 41 :951 -954. 1986 Physicians. Park R idge. IL. 1984
lIolioway R, DeSai SO, Kelly SO, Thambiran AK, King M. Phillips OM. Gross D. Vartian V. Chang HK.
Strydom SE. Adams EB: The effect of chest phys Zidulka A: Enhanced tracheal mucus clearance
iotherapy on the arterial oxygenation of neonates with high freq uency chest wall compression. Am
during treatment of tetanus by intermittent posi Rev Respir Dis 128:511-515, 1983
tive pressure respiration. S AIr Med } 40:445-447, Kirilloff lH, Owens HR. Rogers RM, Mazzocco MC:
1 966 Does chest physical therapy work? Chest 88:436-
Holloway R. Adams EB. Desai SO, Thambiran AK: 444. 1985
Effect of chest physiotherapy on blood gases of Klein P. Kemper M. Weissman C , Rosenbaum SH.
Askanazi 1 . Hyman AI: Attenuation of the hemo Mackenzie CF. Shin B. Hadi F, Imle PC: Changes in
dynamic responses to chest physical therapy. total l u ng/thorax compliance following chest
Che" 93,36-42, 1966 physiotherapy. Anesth Analg 59:207-210. 1 960
Knies PT: Physical therapy in thoracic diseases. Mackenzie CF. Shin B: Cardiorespiratory function
Phys Ther Rev 1 8:239-243. 1938 before and after chest physiotherapy in mechan
Lambert MW: Accessory bronchiole-alveolar ically ventilated patients with post-traumalic
communications. / Palhol Bacteriol 70:31 1 -314, respiratory failure. Crit Core Med 1 3:483-486.
1955 1965
Lancet Editorial: Chest physiotherapy under scru Mackenzie CF. Shin B: Chest physiotherapy vs
tiny. Lancel 2:1241. 1978 bronchoscopy, Crit Care Med 1 4:76-79. 1 986
Lawler P. lones IG, Loh L. Lonn M: Inability 10 Macklem PT: Airway obstruction and collateral
maintain ventilation against large inspi ratory ventilation. Physio/ Rev 5 1 : 368-436. 1971
threshold loads: muscle fatigue or progressive Macklem PT: Respiratory muscles: The vital pump.
failure of coordination. Br / A no eslh 5 1 :994P, 1979 Chesf 76,753-756. 1 960
Laws AK. Mcintyre RW: Chesl physiothe rapy: A Macklem PT: Normal and abnormal function of the
physiological assessment during intermittent pos diaph ragm. Thorax 36:161-163. 1981
itive pressure ventilation in respiratory failure. Mackowiack PA: The normal microbial flora. N
Can Anaesth Soc J 1 6:487-493. 1969 Engl l Med 307,63-93. 1 962
Lenhert BE. Oberdorster G. Slutsky AS: Continuous MacMahon C: Breathing and physical exercises for
flow ventilation of apneic dogs. J App/ Physiol use in cases of wounds in the pleura and lung and
53:483-489. 1982 diaphragm, Lancel 2:769-770. 1 9 1 5
Lillehei RC: Surgery. Med World News 10:102. 1969 MacMahon C: Some cases o f gunshot wounds and
Lindholm CEo Oilman B. Snyder J. Mullen E. Gren other affectations of the chest treated by breath.
vik A: Flexible fiberoptic bronchoscopy in critical ing and physical exercises. Lancet 1 :697-699,
car medicine. Crit Care Med 2:250-261. 1 974 1919
Lisboa C. Pare PD. Pertuze J. Contreras G. Moreno Mankikian B . Cantineau JP. Bertrand M , Kieffer E,
R. Guillemi S. Cruz E: Inspiratory muscle func Sartene R. Viars P: Improvement of diaphrag
tion in unilateral diaphragmatic paralysis. Am matic function by a thoracic extradural block
Rev Respir Dis 1 34:488-492. 1986 after upper abdominal su rgery. Anesthesiology
Lord GP. Herbert CA. Francis DT: A clinical. ra 66,379-366. 1 966
diologic and physiologic evaluation of chest phys Marini 1 1 . Pierson DJ. Hudson LD: Acute lobar atel
iotherapy. } Maine Med Assoc 63:142-150, 1972 ectasis: A prospective comparison of fiberoptic
Lorin MI. Denning CR: Evaluation of postural drain bronchoscopy and respiratory therapy. Am Rev
age by measurement of sputum volume and con Respir Dis 1 1 9:971-976. 1979
sistency. Am J Phys Med 50:215-219, 1971 Marini 11, Pierson OJ. Hudson LD: Comparison of fl
Lundgren R , Haggmark S. Reiz S: Hemodynamic ef beroptic bronchoscopy and respiratory therapy
fects of flexible fiberoptic bronchoscopy per (leller). Am Rev Respir Dis 126:368, 1 982
formed under topical anesthesia. Chest 62:295- Martin CJ. Ripley H. Reynolds J. Best F: Chest phys
299. 1962 iotherapy and the distribution of ventilation,
Lyager S. Wernberg M. Rajani N. Boggi ld-Madsen B. Chesl 69:174-178, 1976
Nielsen L. Nielsen HC. Andersen M. Moller I. SiI Martin HB: Respiratory bronchioles as the pathway
berschmid M: Can postoperative pulmonary con for collateral ventilalion. J App/ Physio/ 2 1 : 1 443-
ditions be improved by Ireatment with the Bart 1447. 1 966
lell-Edwards Incentive Spirometer after upper May DB. Munt PW: Physiologic effects of chest per
abdominal su rgery? Acla Anaesthesiol Scand cussion and postural drai nage in patients with
23,312-319, 1 979 stable chronic bronchitis. Chest 75:29-32. 1979
Mackenzie cr. Ayella RI. 1m Ie pc: Chest PhysiO Mazzocco MC,Owens CR. Kirilloff LH. Rogers RM:
therapy-A n Alternative 10 Bronchoscopy. De Chest percussion and postural drainage i n pa
partment of Physical Therapy. Un iversity of tients with bronchiectasis, Chest 88:360-363, 1985
Maryland Hospital. Audiovisual Services. 1976a McAslan TC: Automated respiratory gas monitoring
Mackenzie cr. Shin S. McAslan TC: Chest physio of critically ill patients. Crit Gare Med 4:255-260.
therapy: The effect on arterial oxygenation. 1976
Anes!h Analg 57:28-30, 1978b McConnell DH. Maloney IV. Buckberg CD: Postop
Mackenzie CF, Shin B: Evaluation of respiratory erative intermittent positive-pressure breathing
physical therapy (letter). N Engl } Med 301 :665- treatments. } Thoroc Cardiovosc Surg 68:944-952,
666. 1 979a 1974
Mackenzie cr. Shin B, Fisher R. Cowley RA: Two McCool FD. Mayewski RF. Shayne DS, Cibson Cj.
year mortality in 760 patients transported by heli G riggs Re. Hyde RW; Intermittent positive pres
copter direct from the road accident scene. Am sure breathing in patients with respiratory mus
Surg 45:101-108, 1 979b cle weakness,Chest 90:546-552. 1986
Mackenzie CF, Shin B. McAslan Te, Blanchard CL. Mcintyre RW, Laws AK. Ramanchandran PR: Posi
Cowley RA: Severe stridor after prolonged endo tive expiratory pressure plateau: Improved gas
tracheal intubation using high volume cufTs. An exchange during mechanical ventilation. Can An
es/hesi% gy 50:235-239, 1 979c aesth Soc J 1 6:477-486, 1969
Mackenzie CF. Shin B. Friedman S, Wai M: Evalu Mellins RB: Pulmonary physiotherapy in Ihe pedi
ation of total lung/thorax vs static lung compli atric age group. Am Rev Respir Dis 1 1 0(2):137-
ance. Aneslhesi% g}' 51 :S381, 1979d 142. 1 974
Meltzer Sf, Auer J: Continuous respiration without tility of human neutrophils in vitro. Anesthesiol
respiratory movements. J Exp Med 1 1 :622-625. ogy 56:45-48. 1982
1909 O'Donohue WJ: Maximum volume IPPB for the
Menkes HA, Traystman RI: SLate of the art: collat management of pulmonary atelectasis. Chest
eral ventilation, Am Rev Respir Dis 1 1 6:287-309, 76:683-687. 1 979
1977 O'Donohue WJ: National survey of the usage of lung
Milner AD, Murray M: Acute bronchiolitis in in expansion modalities for the prevention and
fancy: Treatment and prognosis. Editorial. Tho treatment of postoperative atelectasis follOWing
rax 44:1-5, 1989 abdominal and thoracic surgery. Chest 87:76-80.
Morran C. McArdle CS: The reduction of postoper 1985
ative chest infection by prophylactic co-trimoxa Oldenburg FA. Dolovich MS. Montgomery 1M.
zole. Br I Surg 67:464. 1 980 Newhouse MT: Effect of postural drainage. exer
Morran CG, Finlay IG. Matheson M, McKay AI. Wil cise and cough on mucus clearance in chronic
son N. McArdle CS: Randomized controlled Irial bronchitis. Am Rev Respir Dis 120:739-745. 1979
of physiotherapy for postoperative pulmonary Opie LH. Spalding IMK: Chest physiotherapy dur
complications. Br J Anoesfh 55: 1 1 1 3 - 1 1 16, 1983 ing intermittent positive pressure respiration.
Mossberg B. Canmer P: M ucociliary transport and Lancel 2:671-674, 1958
cough as tracheobronchial clearance mechanims Pardy RL. Rivington RN. Despas PI. Macklem PT:
in pathological conditions. Eur J Respir Dis Inspiratory muscle training compared with phys
61:SuppI 1 10. 47-55. 1 980 iotherapy in patients with chronic airflow Iimi
Moxham I. Morris AIR. Spiro SG. Edwards RHT. tation, Am Rev Respir Dis 123:421-425, 1981
Green M: Contractile properties and fatigue of the Palmer KNV. Sellick SA: The prevention of post
diaph ragm in man. Thorax 36:164-168. 1981 operative pulmonary atelectasis. La ncet 1 : 164-
Murray IF: Editorial: The ketchupbottle method. N 168. 1953
Engl l Med 300: 1 1 55-1157. 1 9790 Pasteur W: The Bradshaw Lecture on massive col
Murray IF: Reply to correspondence on evaluation lapse of the lung. Loncel 2:1351-1 355. 1908
of respiratory physical therapy. N Eng J Med Pasteur W: Active lobar collapse of the lung after
301 :666. 1979b abdominal operations. A contribution to the
Murray IF: Indication for mechanical aids to assist study of post operative lung complications. Lon
lung inflation in medical patients. Am Rev Respir cel 2: 1080-1083. 1910
Dis 122(2): 1 2 1 -125. 1980 Pavia D. Thomson ML. Phillipakos 0: A preliminary
National Heart. Lung and Blood Institute (NHLBI): study of the effect of a vibrating pad on bronchial
Proceedings of the 1979 conference on the scien clearance. Am Rev Resp;r Dis 1 1 3;92-96. 1976
tific basis of i n hospi t a l respiratory therapy. Am
. PerezChada RD. Gardez JP. Madgewick P. Sykes
Rev Respir Dis 122{2): 1 6 1 , 1 980 MK: Cardiorespiratory effects of an inspiratory
National Heart and Lung Institute (NHLI): Proceed hold and continuous positive pressure ventilation
ings of the conference on the scientific basis of in goats. Intensive Core Med 9:263-269. 1983
respiratory therapy. Am Rev Respir Dis 1 1 0(2):1- Perruchoud A. Ehrsam R . Heitz M. Kopp C. Tschan
204, 1 974 M. Herzog H: Atelectasis of the lung: Broncho
Natof HE: Complications associated with ambula scopic lavage with acetylcysteine. Experience in
tory surgery. lAMA 244: 1 1 1 6- 1 1 1 8, 1980 51 patients. Eur J Resp Ois 61 :Suppl lll, 163-168.
Nelson P: Postural drainage of the lu ngs. Br 1\lled J 1980
20251-255. 1932 Peters RM, Turnier E: Physical therapy: Indications
Newhouse MT. Rossman CM: Response to Sutton for and effects in surgical patients. Am Rev Respir
PP et al. 1984 lelter. Am Rev Respir Dis 127:391. Dis 122(2):147-154. 1980
1 984 Pelly TL: A crit ical look at IPPS (editorial). Chest
Newman I H , Neff TA. Ziporin P: Acute respiratory 66: 1-3. 1 974a
failure associated with hypophosphatemia. N Pelly TL: Physical therapy. Am Rev Respir Dis
Engl l Med 296: 1 1 0 1 - 1 103. 1977 1 1 0(2)o129-1 30. 1 974b
Newton DAG, Bevans HG: Physiotherapy and inter Pelty TL: Rational respiratory therapy. Editorial. N
millent positivepressure ventilation of chronic cngl l Med 3150317-318. 1986
bronchitis. Sr Med J 2 : 1 525-1528. 1978 Piehl MA. Brown RS: Use of extreme position
Newton DAC, Stephenson A: Effect of physiother changes in acute respiratory failure. Cri t Core
apy on pulmonary function. Lance! 2:228-230. Med 4:13-14. 1976
1978 Pontoppidan H: Mechanical aids to lung expansion
Novak RA. Shumaker L. Snyder IV. Pinsky MR: Do in nonintubated surgical patients. Am Rev Respir
periodic hyperinflations improve gas exchange in Dis 122(22):109- 1 1 9. 1 980
patients with hypoxemic respiratory fa ilure? Cril Pryor IA. Webber BA: An evaluation of the forced
Care Med 1 5 : 1 08 1 -1085. 1987 expiratory technique as an adjunct to postural
Nunn IF, Coleman AI. Sachithanandan I . Bergman drainage. Physiotherapy 65:304-307. 1979
NA. Laws JW: Hypoxaemia and atelectasis pro Ricker lB. Haberman B: Expired gas monitoring by
duced by forced expiration. Br I Anoes!h 37:3-1 1 . mass spectrometry in a respiratory intensive care
1965 unit. Cril Core Med 4:223-229. 1976
Nunn IF: Artificial ventilation. Chapter 21 In Ap Ricksten SE. Benglsson A, Soderberg C. Thordeu M.
plied Respiratory PhYSiology. 3rd ed .. pp 392-422. Kwist H: Effects of periodic positive airway pres
Butterworth, London. 1987 sure by mask on postopera tive pulmonary func
N u n n IF, O'Morain C: Nitrous oxide decreases mo tion. Chest 89:774-78 1 . 1986
Rigg IRA: Pulmonary atelectasis after anaesthesia: Sania K. Novlant Y. Duroux P: Diaphragm dys
Pathophysiology and management. Con Anaeslh function induced by upper abdominal surgery.
Soc 1 28,305-313. 1981 Role of postoperative pain. Am Rev Respir Dis
Rochester OF, Goldberg SK: Techniques of respira 1 28,899-903. 1983
tory physical therapy. Am Hev Respir Dis Sinha R . Bergofsky EH: Prolonged alteration of lung
1 22(2P 33-146. 1980 mechanics in kyphoscoliosis b y positive pressure
Roper PC, Vonwiller lB. Fisk ce. Gupta 1M: Lobar hyperinflation. Am Rev Respir Dis 1 06:47-57.
atelectasis after nasotracheal intubation in new 1972
born infants. Ausl Poedial 1 t 2:272-275. 1976 Stock CM. Downs JB. Ganer PK. Alsler JM. Purrey
Rossman eM. Waldes R. Sampson D, Newhouse PB: Pre .... ention of postoperative pulmonary com
MT: Effect of chest physiotherapy on the removal plications with CPAP incentive spirometry and
of mucus in patients with cystic fibrosis. Am Rev conservative therapy. Chesl 67:151-157. 1985
Respir Dis 126:131-135. 1982 Strohl KP, Mead J , Banzel! RB. Lehr J . Loring SH,
Rubi JAG. Sanartin A. Diaz CG. Apezteguia C. Mar O'Cain CF: Effect of posture on upper and lower
tinez CT. Rubi leM: Assessment of total pulmo rib cage motion and tidal volume during dia
nary airway resistance under mechanical venti phragm pacing. Am Rev Respir Dis 1 30:320-321 .
lation. Gril Care Med 8:633-636. 1 980 1 984
Sackner MA: State of the art bronchofiberscopy. Am Sulton PP. Parker RA. Webber BA. Newman sr.
Rev Respir Dis 1 1 1 :62-88. 1975 Garland N. Lopez-Vidriero MT. Pavia D. Clarke
Sackner MA: State of the art bronchofiberoscopy. SW: Assessment of the forced expiration tech
Am Rev Respir Dis 1 1 1 :62-88. 1975 nique. postural drainage and directed coughing in
Salata RA. Lederman MM, Shlaes OM. Jacobs MR. chest physiotherapy. Eur / Resp Dis 64:62-68.
Eckstein E. Tweardy D. Toossi Z. Chmielewski R. 1983
Mnrino I. King CK. Graham RC. Ellner 11: Diag Sutton PP. Lopez-Vidriero MT, Pavia O. Newman
nosis of noso"omial pneumonia in int ubated in SP. Clarke SW: Effect of chest physiotherapy on
tensive care unit patients. Am Rev Respir Dis the removal of mucus in patients with cystic fl
1 35A2&--437. 1 987 brosis (letter). Am Rev Respir Dis 1 27:390-39 1 .
Sanchis J. Oolovich M, Rossman C. Wilson \V. New 1 984
house M: Pulmonary mucociliary clearance i n Sulton PP. Lopez-Vidriero MT. Pavia D, Newman
cystic fibrosis. N Eng' / Med 288:651-654. 1973 SP. Clay MM. Webber B. Parker RA. Clarke SW,
Sands 11'1. Cypert C. Armstrong R . Ching S. Trainer Assessment of percussion vibratory-sha king and
D. Quinn W. Stewart 0: A controlled study using breathing exercises in chest physiotherapy. Eur /
routine intermittent positivepressure breathing Respir Dis 66:147-152. 1 965
in the post.surgical patient. Dis Chest 40: 126-133. Tecklin IS. Holsclaw DS: Evaluation of bronchial
1961 drainage in patients with cystic fibrosis. Phys
Schmerber J, Oeltenre M: A new fatal complication Ther 55:1081-1064, 1975
of transtracheal aspiration. Scand / Resp Dis Tecklin IS, Holsclaw OS: Bronchial drai nage with
59,232-235. 1978 aerosol medication in cystic fibrosis. Phys Ther
Schmid ER.Rehder K: General anesthesia and the 56:999-to03, 1976
chest wall. Anesthesiology 55:668-675. 1981 Temple HL. Evans IA: The bronchopulmonary seg
Schuppisser JP. Brandi O. Meili U: Postoperative in ments. Am / Roenlgenol Rod Ther 63:26-46. 1 950
termittent positive pressure breathing vp.rsus Terry PB. Traystman R f , Newball HH. Batra C.
physiotherapy. Am / Surg 140:682-686. 1980 Menkes HA: Collateral ventilation in man. N Eng
Schur MS. Brown IT, Kafer ER, Strope CL. Creene I Med 298,10-15. 1978
WB, Mandell J: Postoperative pulmonary function Thomson ML, Pavia O. Jones Cf, McQuiston TAC:
in children. Am Rev Respir Dis 1 30:46-51 . 1 984 No demonstrable effect of S-carboxymethyl
Schweiger 1. Garnlin Z. Foster A. Meyer p, Gem cysteine on clearance of secretions from the
perle \l1 . Suter PM: Absence of benefit of incen human l u ng. Thorax 30:669-673. 1975
tive spirometry in low risk patients undergoing Thoren L.: Postoperative pulmonary complications.
elective cholecystectomy. Chest 89:652-656. 1986 Observations on their prevention by means of
Sellick BA: Cricoid pressure to control regurgitation physiotherapy. Acto Chir Scond 107:1 93-204.
of stomach contents during induction of anaes 1954
thesia. Lancet 2:404-406. 1961 Tokis L. Hedenstierna C. Stranberg A. Brismar B.
Serota AI. Meyer RD, Wilson SE, Edcstein PH, Fi Lundquist 1'1: Lung collapse and gas exchange
negold SM: Legionnaire's disease in the postop during general anesthesia: effects of spontaneous
erative patient. / Surg Res 30:417-427. 1981 breathing. muscle paralysis and positive end-ex
Shennib II. Mulder OS. Chiu RCI: The effects of piratory pressure. AnestheSiology 66: 1 57-167,
pulmonary atelectasis and re-expansion on lung 1987
cellular immune defenses. Arch Surg 1 1 9:274- Tyler t\IL: Complications of positioning and chest
277. 1984 physiotherapy. Resp Care 21:456-466. 1982
Shim C. Fine N. Fernandez R. Williams MH: Car Van der Schans CPo Piers PA. Postma OS: Effect of
diac arrhythmias resulting from tracheal suction manual percussion on tracheobronchial clear
ing. Ann Inlern Med 7 1 : 1 1 49-1153. 1969 ance in patients with chronic ai rflow obstruction
Shim C. Bajwa S. Williams MH: Tho effect of inha and excessive tracheobronchial secretion. Thorax
lation therapy on ventilatory function and expec 41 :448-452. 1 986
toration. Chest 73:798-801. 1978 Veviana I R . Teichberg S. Buschman O. Kirapalrick
Simonneau G. Vivien A. Sartene R. Kunstlinger F. CH: Correlation of absent inner dynein arms and
mucociliary clearance in a patient with Karlage and general anaesthesia. Paraplegia 13:172-182.
ners syndrome. Chest 91:91 -95. 1987 1975
Vickers MD: Postoperative pneumonias. Editorial. Wiklander 0, Norlin U: Effect of physiotherapy on
Br Med J 284:292-293, 1982 post operative pulmonary complications. A clini
Vraciu JK. Vraciu RA: Effectiveness of breathing ex cal and roentgenographic study of 200 cases. Acla
ercises in preventing pulmonary complications Chir Scand 1 1 2:246-254, 1 957
following open heart surgery. Phys TheT 57:1 367- Willals SM: Alternative modes of ventilation. Part I.
1 37 1 , 1977 Disadvantages of controlled mechanical ventila
Wagner PD. Naumann PF, Laravuso RB: Simulta tion: intermittent mandatory ventilation. Inten
neous measurement of eight foreign gases in sive Core Med 1 1 :51-55, 1985a
blood by gas chromatography. J Appl PhysioJ Willats SM: Alternative modes of ventilation. Part
36:600-605, 1 974 I I . High and low frequency positive pressure ven
Wahba WB: Influence of aging on lung function tilation, PEEP. CPAP. reversed ratio ventilation.
Clinical significance of changes from age twenty. Inlensive Core Med 1 1 : 1 1 5-122. 1985b
Anesth Anolg 62:764-776, 1 983 Wilson R. Roherts D. Cole P: Effects of bacterial
Walker J. Cooney M: Improved respiratory function products on human Ciliary function in vitro. Tho
in quadri plegics after pulmonary therapy and ra x 40:1 25- 1 3 1 . 1985
arm ergometry (letter). N Eng/ J Mad 3 1 6:486-487. Wilson R. Sykes D, Currie DC. Cole PI: Beat fre
1987 quency of cilia from sites of purulent infection.
Waring WW: Editorial. Cilia and cystic fibrosis. N Thorax 41 :453-458. 1 986
Engl J Med 288:681-682, 1973 Winning TJ, Brock-Utne IG. Goodwin NM: A simple
Webb MSC, Martin lA, Cartlidge PHT, Ng YK, clinical method of quantitating the effects of
Wright NA: Chest physiotheapy in acute bronchi chest physiotherapy in mechanically ventilated
olitis. Arch Dis Child 60:1078-1079. 1 985 patients. Anaeslh Intensive Care 3:237-238.
Weil MH. Shubin H: The "VIP" approach to the 1975
bedside management of shock. lAMA 207:337- Wollmer p, Ursing K. Midgren B. Eriksson L: Ineffi
340. 1 969 ciency of chest percussion in the physical therapy
Weisman 1M. Rinaldo jE. Rogers RM, Sanders MH: of chronic bronchitis. Eur J Respir Dis 66:233-239,
Intermittent mandatory ventilation. Am Rev Res 1985
pir Dis 127:641-647. 1983 Zapletal A. SteCanova J. Horak J. Vavrova V. Sama
Weller PH. Bush E. Preece MA. Mathew OJ: Short nek M: Chest physiotherapy and airway obstruc
term effects of chest physiotherapy on pulmonary tion in patients with cystic fibrosis-a negative
function in children with cystic fibrosis. Respi report. Eur J Respir Dis 64:426-433, 1983
rolion 40:53-56. 1980 Zibrak 10. Dosetti p, Wood E: Effect of reductions in
Welply NC. Mathias Cj. Frankel HL: Circulatory re respiratory therapy on patient outcome. N Eng J
flexes in letraplegics during artificial ventilation Med 315:292-295, 1986
CHAPTER 2
Clinical Indications and Usage of

Chest Physiotherapy: Anatomy,
Physiology, Physical Examination,
and Radiology of the Airways and
Chest
Anatomy of the Airway and Lung Segments and Lobes

Surface Anatomy of the Lung Lobes
Upper AirwllY
Trllchea
Bronchi to Alveoli
Physiology of Respiration
Respiratory Mechllnics
AirwllYs lind Lung Volumes
Respirlltory Pressures lind Flow
Respiretory Muscles and Rib Cage
Gas Exchange
Gss Mixing
Pulmonary Blood Flow
Delld Space and the Intrapulmonary Shunt
Gas Transport
Oxyhemoglobin Dissociation
CO, Dissocilltion Curve
O,-CO, Dlagrllms
Human Respiratory Mucus
Examination of the Che.t in Mechanically Ventilsted Pstients
Inspection
Palpation
Percussion
Auscultlltion
Pitflllls of CliniclIl Examination in the Mechanically Ventilated Patient
Rsdiologiclll lndiclltions for Chest Physiotherapy
Localization of Lung Segment.
Silhouene Sign
Air Bronchogrllm
Acute Indiclltions for Chest Physiotherapy
Blood Gas Changes
Pneumonia
Lung Contusion
53
Prophylactic Use of Chest Physiothe",py

Chronic Sputum-Producing Lung Oisellse
Acute Quadriplegill
Smoke Inhalation and Aspirlltion
Oep",s.ed Level of Consciousness
Obesity
The intention of this chapter is primar upper and lower lobes are found poste
ily to assist the clinician in determining riorly. Both oblique fissures (separating
the need for chest physiotherapy. A brief upper and middle from lower lobes) run
review of airway and lung anatomy is in from the spine of the third thoracic ver
cluded so that clinical examination and tebra to the sixth costochondral junction.
the chest x-ray may be most usefully in The horizontal fissure (found only on the
terpreted. Respiratory physiology is re right and separating the upper from the
viewed with the purpose of assisting un middle lobe) runs from the oblique fis
derstanding of the research reported in sure in the midaxillary line to the level
the literature and the objectives of chest of the fourth costal cartilage anteriorly.
physiotherapy. Research on human res Consequently, both upper lobes (exclud
piratory mucus and mucus properties is ing the lingula) are located above the spi
described. A section covers examination nous process of T3 or the spine of the
of the chest in mechanically ventilated scapula posteriorly and above the fourth
patients together with a summary of and the sixth costal cartilage anteriorly.
some commonly found acute lung le The lingula and right middle lobe are
sions. An approach to chest x-ray inter predominantly anterior to the midaxil
pretation is described, and finally, the lary line and are found between the
acute and prophylactic uses of chest fourth costal cartilages. The lower lobes
physiotherapy are discussed. of the lungs are located between the lev
Initially, the indication for chest phys els of thoracic vertebra 3 and 10 posteri
iotherapy for the intensive care unit orly (or as low as 1 hand breadth below
(ICU) patient with acute lung disease is the inferior angle of the scapula posteri
based on bedside examination. the chest orly in the adult) and lateral to the xiphi
x-ray, and blood gas analysis. A knowl sternum anteriorly. lt should be noted
edge of the anatomy of the tracheobron that these surface markings are described
chial tree and lung lobes and segments is in reference to a full inspiration. Breath
essential to allow the maximum amount ing, however, is not static; therefore,
of information to be obtained from clini landmarks may vary with the phases of
cal and radiological examination of the ventilation, lung disease, surgical inter
chest, since this enables correct patient vention, and changes in ventilatory pat
positioning for postural drainage. terns (Lockhart et aI., 1959; Downie,
1 979). There are 11 segmental postural
drainage positions used when performing
ANATOMY OF THE AIRWAY AND
chest physiotherapy (see Fig. 3.1 A-T).
LUNG SEGMENTS AND LOBES
The corresponding surface markings of
these lung segments and the overlying
Surface Anatomy of the Lung Lobes
anatomic landmarks are shown in Figure
The lungs rise cranially to above the 2.1 A-C.
first rib. During full inspiration the lower
lobes descend to the tenth thoracic ver Upper Airway
tebra posteriorly and to the xiphoid pro
cess anteriorly. Parts of all lung lobes The pharynx extends from the base of
(right upper, middle, and lower; left the skull to the esophagus and commu
upper and lower) are adjacent to the an nicates with the nose, mouth, and larynx
terior chest wall, while only parts of the (Fig. 2.2). The pharynx serves as a com-
CLINICAL INDICATIONS AND USAGE OF CHEST PHYSIOTHERAPY 55
\--."""V'
-t-
bronchus
lett
lobe
Anterior
...... ri;r
Rig t nd;;::+1 ----.::.
Posterior Anterior
middlehI Medial a
lateral
Superior and
inferior
outline
Anterior Anterior
lett
lobe
upper lobe
Posterior
Superior
.
:
Medial an d
lateral segment
g Posterior
R,,;i
IiI'--- I" ; hlobe
Anterior
"""
::f t Lateral
lett Apical
upper lobe "'---IVJ;;,6 Anterior
posterior
Superior
Superior and
inferior
Posterior
Lateral
Anterior
Superior
.. --1 -',
=t];:)!n
left Superior
lower lobe Ri ght
J l i
Anterior
Diaphragm
lower lobe Anterior
\ .
outline
---....
/... lateral
Lateral
c
Posterior
Figure 2.1. (A) Anterior view of the chest and lungs showing lobar distribution on the left and
bronchopulmonary segments on the right. (B) Lateral views of the right chest and lungs (upper)
and left chest and lungs (lower). The lobar distribution is shown on the left and the bronchopul
monary segments are shown on the right. (C) Posterior view of the chest and lungs showing lobar
distribution on the left and bronchopulmonary segments on the right.
Figure 2.2. Xeroradiograph of a normal lateral cervical spine showing the pharynx and its com
munications. (Kindly supplied by E. McCrea, M.D., Department of Radiology, University of Maryland
Hospital, Baltimore, MD.)
mon passage for air and food; breathing ing the laryngeal prominence or Adam's
and swallowing cannot take place simul apple. This is greater in the male (where
taneously in the adult. the apple is said to have stuck). The
Phonation and prevention of aspiration upper border of the thyroid cartilage is
into the tracheobronchial tree are the im attached to the hyoid bone by the thyro
portant functions of the larynx. Aspira hyoid membrane (Fig. 2.3). The angle of
tion protection is achieved by the sphinc
teric action of the aryepiglottic and
vestibular folds. The infant larynx is fun
nel-shaped, with its narrowest point 1 cm Grt.r horn -ir;;;;::
below the vocal cords, and is situated UpPer horn .
higher in the neck than is the adult lar
ynx. A neonate can elevate the larynx so
that the epiglottis touches the soft palate.
Arytenoid cart. ..
LarynV 1 promlnenc:.
lamina of thyroid eart.
Breathing can, therefore, continue even Lower horn

when liquids are swallowed. This ability --Cricoid
is lost after 6 months. The larynx con
"". ., {
tains the vocal cords which vibrate to
produce phonation on expiration. The cartllage.--
larynx is composed mostly of the thyroid

and cricoid cartilages and the hyoid
bone. The thyroid is made up of two Figure 2.3. The laryngeal cartilages viewed
plates of cartilage joined anteriorly, form- from the anterolateral aspect.
the thyroid laminae within the larynx is may have six cross-sectional shapes: C,
the attachment for the epiglottic carti U, D, elliptical, triangular, and circular
lage. The epiglottis projects up behind (Fig. 2.6). The shape varies throughout
the tongue as a flap and fuses with the the length of the trachea and changes
aryepiglottic folds that are the bounda with inspiration, expiration, coughing,
ries of the laryngeal inlet. The cricoid mechanical ventilation, and posture. The
cartilage is attached to the lower border trachea enlarges with inspiration and
of the thyroid cartilage by the cricothy contracts with expiration. The most com
roid membrane which can be palpated mon cross-sectional autopsy tracheal
anteriorly as the notch just beneath the shapes are C and U (Mackenzie et aI.,
Adam's apple. Two arytenoid cartilages 1978a). There is no correlation between
articulate with the upper body of the cri adult tracheal shape, size, or circumfer
coid cartilage. The arytenoid cartilages ence and height, or weight (Mackenzie et
have two processes at their bases. Ante aI., 1979. 1 980b). Because the posterior
riorly, the vocal process gives attachment membranous portion has a higher com
to the vocal cords; laterally, the muscular pliance than the anterior cartilage, it is
process is the insertion site for the pos more readily deformed during changes in
terior and lateral cricoarytenoid muscles. intratracheal pressure. Tracheal compli
These muscles abduct and adduct the ance decreases progressively with age,
vocal cords. The pair of vocal cords and and calcification of the cartilages may be
the arytenoid elevations comprise the seen after age 35 years and is almost al
glottis. The intervening sagittal slit, ways seen to some degree in those pa
known as the rima glottidis, is the nar tients older than 60 years of age. The in
rowest part of the larynx at rest (Lockhart fant trachea differs from the adult
et al. (Fig. 2.4). The width of the rima trachea in several respects; these are
glottidis is altered by the cricoarytenoid summarized in Table 2.1.
muscles, and air flow is controlled.
Bronchi t o Alveoli
Trachea
At the carina the trachea bifurcates
The adult trachea extends from the into right and left main stem bronchi
lower border of the cricoid cartilage (Fig. 2.5). The right main stem bronchus
(which lies opposite the sixth cervical differs in several ways from the left. The
vertebra) to the carina. This is found over right is usually shorter and wider and
the fifth thoracic vertebra and under the comes off the trachea at an angle of about
sternal angle of Louis. The trachea is 1 5', whereas the left branches at about
composed of many flexible interlacing 35' to a midline sagittal plane. This does
cartilages with a posterior membrane not necessarily always occur, however
(Fig. 2.5A-C). The unstretched adult au (Fig. 2.5A). Also, the right main bronchus
topsy specimen varies in length from 8 to branches into three lobar bronchi; the
12 cm. Stretching the trachea with a 500- left, only two. Lobar bronchi supply dif
gm weight increases the length approxi ferent lobes of the lung, and they branch
mately 30%. During extension of the within the lung to give rise to the seg
neck and inspiration the trachea is mental bronchi. The segmental or third
stretched. The cartilage of the trachea generation bronchi supply a portion of
Figure 2.4. The glottis-on the

left shown at rest; on the right
shown during forced expiration.
The lateral cricoarytenoid muscle
and the arytenoideus adduct. The
poste rior cricoarytenoid muscle is
the only abductor of the vocal
cords and is, therefore, vital for
respiration.
Thyroid
cartilage
membrane sinus
ring
Posterior
Tracheal
Righi
upper
lobe
Figure 2.5. (A) Anterior view of a normal larynx and trachea. The trachea is shown as interlacing
cartilages. In this specimen the right main stem bronchus is shorter and wider than the left and
makes a 45 angle with the sagittal plane; the left main stem bronchus makes a 28 angle. These
anatomical differences from the normal may account for some success in cannulation of the left
bronchus with a straight catheter. (8) Right lateral view of a normal larynx and trachea. The right
upper lobe bronchus is seen coming off the right main stem bronchus 3 mm below the tracheal
bifurcation. Compare the laryngeal structures shown in this photograph with those in Figure 2.3.
The hyoid bone has been removed in the photographs. (C) Posterior view of the normal larynx
showing the compliant posterior membrane. the epiglottis. and other laryngeal structures.
Figure 2.6. Autopsy cross-sectional tracheal shapes. Specimens taken from between the fourth
and seventh tracheal cartilages. From top left, clockwise, these are circular D-Shaped, U-shaped,
elliptical, C-shaped, and triangular. C and U shapes are the most common. (From Mackenzie CF,
et al: The shape of the human adult trachea. Anesthesiology 49:48-50, 1978a.)
58
Table 2.1
Major Anatomical Dillerence. Between the Adult and Infant Trachea'
Number Narrowest
of Cross- Lumen Posterior Portion of
Unstretched Tracheal sectional Circumference Membrane Level of Upper
Length lem) Cartilages Shape lem) Length lem) Carina Airway
Adu" 8-12 12-19 See FIg. 2.6 6.0-7.6 0.7-2.3 T5 Vocal cords
Infant (birth Same but
106 closer
months) 3.5-4.5 together Nearly circular 1.4_1.7 0.0S-0.1 T3-T4 Cricoid
Oata are from Mackenzie at al. (19788. 1979, and 198Ob; and Unpublished data).
Specimens preserved In a dilute formalin solution.
lung known as the bronchopulmonary scribed by Martin (1966). and bronchio

segment. The distribution of these bron lar-alveolar communications were re
chopulmonary segments is shown in Fig ported by Lambert (1955) (Fig. 2.8). The
ure 2.7. The main. lobar and segmental communicating lobules are sometimes
bronchi normally remain patent during bifid and connected with the adjacent al
inspiration and expiration and coughing. veoli. When found in generations 12-14.
but they are susceptible to collapse with they may connect with their own subdi
changes in intrathoracic pressure. When vided alveoli. but in generations 14-16
intrathoracic pressure exceeds intralu (terminal bronchioles) they may connect
minal pressure by about 50 cm H20. as with other alveoli (interacinar connec
may occur during forced expiration. the tions). These connections are much big
larger bronchi collapse and limit peak ger (about 30 I'm in diameter) than the
expiratory flow (Nunn. 1977). pores of Kohn and can remain open de
Small bronchi branch from the seg spite bronchiolar smooth muscle contrac
mental bronchi. and their diameters. pro tion (Krahl. 1964). They are. therefore.
gressively decrease from 3.5 to 1 mm important avenues of collateral ventila
until. at the twelfth generation. the air tion and may be highly significant in the
way divisions cease to have cartilage in reexpansion of collapsed airways by such
their walls and become known as bron maneuvers as deep inspiration and chest
chioles. The caliber of the bronchioles is physiotherapy (see p. 237-242).
influenced by lung volume. Each bron
chiole enters a lobule of the lung and PHYSIOLOGY OF RESPIRATION
gives off five to seven terminal bronchi
oles (generations 12-16). The lung lobule Respiratory Mechanics
served by terminal bronchioles is termed
an acinus. The terminal bronchioles are Airways and Lung Volumes
the last of the conducting air passages
and derive blood supply from the bron The conducting airways include the
chial circulation. Distal to this. the air trachea and all branches of the airway
passages take on the function of gas ex down to the terminal bronchioles that are
change and are supplied by the pulmo supplied with blood from the bronchial
nary circulation. artery. The conducting airways contain
Beyond the terminal bronchioles (gen no alveoli. do not take part in gas ex
erations 17-23) the acinus is composed of change. and. therefore. constitute what is
respiratory bronchioles. alveolar ducts. known as the anatomic dead space (often
alveolar sacs. and alveoli. As many as 20 referred to as the Fowler dead space).
alveoli communicate with the central Distal to the terminal bronchioles. the
chamber of the alveolar sac. Small open respiratory bronchioles. which contain
ings (5-10 I'm in diameter) found in the alveoli. take on the function of gas ex
alveoli. termed pores of Kohn. permit air change and derive their blood supply
to pass from one alveolus to another from the pulmonary artery. There is so
(Menkes and Traystman. 1977). much branching of the airways in the
Interbronchiolar channels were de- respiratory gas exchange zone that the
2
.Q
j
o
-'
lateral View Lateral View
[
J
Apical Posterior
Apical
Upper Upper
Pos t . A nterior
Lobe
Ant. --tij,....--, Lobe
Superior
Superior
Inferior
} lingula
f Lateral
l
Middle
l Medial
Right Left
lobe
lower
J
Lobe
Posterior
Medial and Basal View Medial and Basal View
Figure 2.7. The distribution of the bronchopulmonary segments. (Redrawn from Krahl V: The
anatomy of the mammalian lung. In Handbook of Physiology, vol 1 , Respiration, p 248, Fig. 23,
American Physiological Society, Washington, DC, 1964.)
sum of the cross-sectional area of the air pressure gradients between the blood
ways increases (Fig. 2.9). As a result, res and the respiratory zone airways.
piratory gas flow over the last 5 mm be The volume of gas in the lung at the
fore reaching the alveolus is slowed end of a quiet exhalation is the func
markedly. Oxygen diffusion occurs into tional residual capacity (FRC). The nor
the adjacent pulmonary capillaries, and mal values for subjects in different posi
CO, diffuses out of the blood along partial tions are shown in Table 2.2. FRC is a
Int.rbfoochlolar
chonn.1 01 Mortin
Broochiol.olvoolar
channolof Lambert
Interolveolor
par. of Kahn
Figure 2.8. Potential pathways for collateral flow. (From Menkes HA, Traystman RJ, Terry P: Col
lateral ventilation. Fed Proc 38:22-26, 1979.)
Figure 2.9. A comparison of human airway

I generation [according to Weibel's (1963)
I idealization] airway resistance and cross-sec
I tional area (from West, 1985), showing the ex
Eu
N
I
I
tremely rapid increase in total cross-sectional
I area of the airways in the respiratory zone and
'"
a:
"' I the location of the chief site of airway resist
'"
I ance in the intermediate-sized bronchi. Little
z w ., resistance is located in the very small airways
0 u
z'
;:::
U
-' I where cross-:::.ectional area is greatest and air
1- ' I flow low. L, liter(s); transit and resp. z., transi
",
III ON
I
"'
Vir
III
tional and respiratory zones; BR, bronchus;
III
III wE I BL, bronchiole; TBl, terminal bronchiole; RBl,
0 a: I
a:
u I
respiratory bronchiole; AD, alveolar duct; and
I AS, alveolar sac. (Adapted from Weibel ER:
..J Morphometry of the Human Lung, p ",,
0
I-
Springer-Verlag, Berlin, 1963; and West JB:
Respiratory Physiology- The Essentials, ed 3,
pp 7 and 104. Williams & Wilkins, Baltimore,
1985.)
Table 2.2
Physical Characteristics and FRC Measurements in 100 Subjects Sitting and Supine'
FRC
Age Height Weight Sitting Supine
Sex (yr) (m) (kg) (liters) (liters)
Women
Mean 33 1.6 56 2.45 1.80
SD 12.6 0.07 48 0.43 0.34
Range 20-63 1.45-1.77 48-83 1.52-3.49 1.08-2.43
Men
Mean 36 1.69 71 2.99 0.61
SD 13.3 0.06 9 0.66
Range 22-65 1.57-1.81 52-101 1.72-4.54 1.27-2.63
'FRC was measured by the helium dilution closed circuit method. Twenty-five women and 30 men
were smokers. but no differences were found in FRC between smokers and nonsmokers. FRC
always decreased when the subject changed from sitting to supine. Correlation coefficients
between FRC and height were significant for both sexes. Age and weight had negligible effect on
FRC. (From Ibanez J, Raurich JM: Normal values of functional residual capacity in sitting and
supine positions. Intensive Care Med 8:173-177, 1982.)
commonly used starting point for consid take place during the expiratory pause.
ering lung volumes, as it is the resting Other lung volumes of clinical impor
place of normal lung for the majority of tance are vital capacity and residual vol
its working life. FRC is the volume of gas ume (RV). All lung volumes except FRC
left in the lungs after passive exhalation and RV are measured by spirometry (Fig.
and allows gas mixing and exchange to 2.10). FRC is determined by washout of
Inspiratory Inspiratory Reserve Volume
-1 -
-
Capacity
-- __
",\
Tidal Volume
u
(any level of
,., 0.
activity)
U
JV-
u

0.

U
..
c

oJ
Functional Expiratory Reserve Volume
o
f-
Residual
Capacity
j ------j ------
Residual
Volume
o -- -- ! ---- o
Special Divisions for Primary Subdivisions
Pulmonary Function Tests of Lung Volume
Figure 2.10. Spirometric subdivision of the lung showing four volumes and four capacities. Each
capacity is made up of the combination of two or more volumes. (From Pappenheimer JR. Comroe
JH, Cournand A, Ferguson JWK, Filley GF, Fowler WS, Gray JS, Helmholz HF, Obis AB, Rahn H,
Riley RL: Standardization of definitions and symbols in respiratory physiology. Fed Proc 9:602-
615,1950.)
N2 or other tracer gas or by measurement crease in size, the diameter and length of
of volume changes in a body box. the airways increase proportionately
(Fig. 2.1 1 ).
Respiratory Pressures and Flow
Respiratory Muscles and Rib Cage
At FRC the elastic recoil forces of the
chest wall tending to expand outward are Because of the shape of the ribs and the
exactly matched by the elastic recoil way in which the intercostal muscles are
forces of the lung collapsing inward. The attached in parallel to the chest circum
traction between the two pleural sur ference, anteroposterior and lateral ex
faces covering the lung and lining the pansion of the chest takes place by con
chest wall generates a subatmospheric traction of intercostal muscles. During
pleural pressure of 5 cm H20 at FRC. Be inspiration the anteroposterior and [at
cause there is no airflow at FRC, alveolar eral diameters increase, and the ribs are
pressure is atmospheric. The pressure dif raised. The movement of the ribs about
ference between the pleura and alveolus their axis of rotation is analogous to the
at FRC, of 5 cm H20, is known as the arc described by a bucket handle. The
transpulmonary pressure. With inspira point at which the radial distance from
tion of a tidal volume breath (usually 8- the axis of rotation is greatest (where a
10 ml/kg), a greater subatmospheric bucket handle would be held) is anterior
pressure is generated. The amount of in in the upper chest and more lateral in the
creased subatmospheric pressure that is lower ribs. The movement of the ster
generated to produce a tidal volume num during inspiration has the action of
change is a measure of compliance. a pump handle moving up and out.
Compliance is defined as volume The diaphragm is the most important
change per unit pressure change. Pleural muscle of inspiration. [n quiet breathing
pressure may be estimated from an it normally contributes 70-80% of the
esophageal balloon placed in the lower tidal volume. Contraction of the dia
third of the esophagus. If pressure is mea phragm causes descent of its dome, ex
sured during inspiration of the tidal vol pansion of the base of the thorax, in
ume, a subatmospheric alveolar pressure crease in intraabdominal pressure, and
develops. [f inspiratory flow is also deter decrease in intrathoracic pressure. [n
mined, airway resistance may be calcu normal tidal breathing the diaphragm
lated by dividing alveolar pressure by moves about 1 cm; with exercise and
flow. Normal values for airway resistance forced inspiration and expiration it may
and compliance as well as causes of ab move 1 0 times that amount. The dia
normality are shown in Table 2.3. Air phragm is not essential for respiration, as
way conductance is the reciprocal of air there are other accessory muscles of res
way resistance. There is a linear piration. When the diaphragm is para
relationship between airway conduc lyzed, it moves up rather than down with
tance and lung volume: as the lungs in- inspiration, because the intrathoracic
Table 2.3
Definitions, Measurement Requirements, Typical Values, and Causes of Abnormality for
Compliance and Resistance
Definition Measurement Typical Values
Compliance' Volume change produced Static pressure Lung/thorax =
by a unit of pressure and volume 50-100 ml/

change cm H,O
Resistanceb Pressure difference required Dynamic pressure 0.5-1.5 cm H20
for a unit flow change and flow (liters/sec)
'Low compliance occurs with pulmonary edema, pneumonia, lung contusion, interstitial fibrosis,
and respiratory distress syndrome.
'High resistance occurs with asthma, emphysema, bronchitis, bronchospasm, sputum retention in
large airways, airway compreSSion, and narrowing or stenosis.
.05
alae nasi nare the nostrils. and the supra
5 hyoid elevates and stabilizes the larynx.
il
::J .04
NQ 4 Gas Exchange
, :I:
0 E
0
:x:
N

The major mechanism by which gas
.03
:I:
E 3 passes through the conducting airways

....
u
, , during spontaneous respiration or con
...J
U
z E ventional mechanical ventilation is bulk
.02 ,W
2 l'J convection. Bulk convection is the phys
'" ,
Vi z
u
ical mass transport of gas from one part

....
:::;
, <l
.01 '
') .' of the airway to another. Once in the res
:I; z
' a.
,
- 0
piratory zone airways. gas exchange
;0
<l
, - 0 0
0: U u takes place by passive diffusion. first in
<i the gaseous medium of the alveolus and
0 2 4 6 8 then across the blood-gas barrier be
LUNG VOLUME III
tween the alveoli and pulmonary
-. -'-' AIRWAY RESISTANCE capillaries.
- - - - AIRWAY CONDUCTANCE The relative rates of diffusion of gases
in a gaseous medium are inversely pro
---- LUNG COMPLIANCE
portional to the square root of their den
Figure 2.1 1 . Airway resistance. airway con sities. Because 0, has a smaller molecu
ductance. and specific lung compliance are lar weight than CO, (0, 32. CO, 44).
= =
plotted against lung volume in liters (L). Airway 0, diffuses more rapidly in alveolar gas
resistance falls in an exponential manner with than does CO,. A normal human alveolus
increasing lung volume. while airway conduc
tance increases linearly. Compliance is at its
is 100 I'm in diameter; diffusion of gas is
greatest at about a FRC of 2.5-3 liters and then 80% complete in 0.002 sec if the diffusion
falls progressively as lung volume rises above distance is 0.5 mm. In emphysema.
FRC. groups of alveoli may become one air sac.
however. the distances for diffusion are
much greater. If the diffusion distance in
pressure falls. The most important mus an air sac is 7 mm. 0.38 sec would be re
cles of expiration are the abdominal quired for 80% completion. The area of
muscles. The external. internal oblique. the blood-gas barrier is 50-100 m'. and
and transversus abdominis muscles com the alveolar-mixed venous partial pres
press the abdomen. The rectus abdom sure difference for 0, is 100 - 40 = 60
inis muscle draws the anterior ribs to the mm Hg (breathing room air) and is 46 -
symphysis pubis and compresses the ab 40 (alveolar CO,) = 6 mm Hg for CO,.
domen during expiration. Expiratory The alveolar-capillary membrane is nor
muscles are active at high rates of venti mally less than 0.5 I'm thick. The amount
lation when movement of air out of the of gas t ransferred across the alveolar-cap
lungs is impeded, such as in respiratory illary membrane is proportional to the
failure. The expiratory muscles also reg area. a diffusion constant. and the differ
ulate breathing, as is required during ence in partial pressure and is inversely
talking. singing. coughing, defecation. proportional to the thickness of the mem
and parturition. In addition to the three brane. The diffusion constant is propor
major muscles of respiration. the dia tional to gas solubility and inversely pro
phragm. the intercostals. and the abdom portional to molecular weight.
inal muscles. there are secondary mus Cas diffusion occurs between a gaseous
cles. The scaleni muscles elevate and fix phase (the alveolus) and a liquid phase
ribs 1 and 2; the sternocleidomastoids el (the pulmonary capillary blood). Because
evate the sternum and may be an impor CO, is 24 times more soluble than 0, in
tant means of ventilation for quadriplegic water at atmospheric pressure. there is
patients. as they are innervated by the far more rapid diffusion of CO, from the
spinal accessory nerve and Cl-C3. The capillary blood than entry of 0,. even
though a, has a more rapid diffusion in fro motion between adjacent areas. This
the gas phase of the alveolus. phenomena is often called pendelluft. In
In disease states. the path for diffusion complete alveolar gas mixing constitutes
may become longer. The alveolar wall a measurable limitation to gas exchange
may be thickened as in fibrosis or edema. in the normal lung.
the capillary membrane may be thick The major gas transport mechanisms
ened or the capillaries may be dilated. during spontaneous respiration and con
and edema may occur between the alve ventional positive pressure mechanical
oli or in the alveolus. These causes of al ventilation are bulk convection and mo
veolar capillary block all result in a de lecular diffusion. Bulk convection occurs
creased pulmonary diffusing capacity. To when lung expansion increases the total
test the ability of alveolar capillary mem number of gas molecules in the lung.
branes to transfer or conduct gases. the There is a random dispersion of these
diffusing capacity for carbon monoxide molecules. so that differences in gas con
(DCa) is frequently employed. DCa is centrations are evened out. Mixing by
specific for impaired diffusion. Decreased molecular diffusion is enhanced by oscil
DCa occurs in pulmonary edema. fibro lations in acinar gas (cardiogenic oscilla
sis. and emphysema. DCa is decreased in tions) produced by cardiac activity. Dur
pulmonary embolus or when blood flow ing high-frequency oscillation. bulk
to the lung is decreased as in shock. DCa convection becomes a less important
may be normal in uncomplicated bron means of gas exchange than during con
chial asthma but may be increased in ventional mechanical ventilation. High
high blood flow or pressure states such as frequency jet ventilation or high.fre
pulmonary hypertension. DCa is mea quency flow interrupter techniques.
sured because CO has an affinity for he however. still rely heavily on bulk con
moglobin (Hb) 210 times that of a,. So vection for gas transport. Cardiogenic os
very low CO concentrations suffice to cillations and to-and-fro gas mixing be
saturate Hb. The diffusion capacity for a, come more important mechanisms of gas
can be obtained by multiplying DCa by mixing in peripheral airways during
1 .23 (Comroe. 1975). high-frequency oscillation and continu
ous-flow ventilation techniques of gas
Gas Mixing
exchange.
The majority of gas volume in the Pulmonary Blood Flow

lungs is contained within the acini in air
ways and air spaces distal to terminal The lungs and heart are the only two
bronchioles. Most gas mixing takes place organs in the body through which the en
in acinar units with volumes less than 0.2 tire circulation flows. Normal blood flow
ml. An airway 2-3 mm in diameter may measured as cardiac output per minute
subtend about 35 terminal bronchioles ranges from 5 to 15 liters/min at rest and
and their acini. During inspiration of during exercise. respectively. The right
fresh gas the separation of fresh from "al heart moves venous blood and pumps it
veolar" gas occurs within the acinus. into the pulmonary artery (Pa). The Pa
where the magnitude of bulk convection progressively branches into successively
and diffusion gas transport mechanisms smaller vessels adjacent to the branching
are similar. The volume contained in the airways. Beyond the terminal bronchi
airways more central to the point of sep oles the capillary branches of the Pa con
aration of alveolar and fresh gas defines tain mixed venous blood. The pulmonary
the Fowler (anatomical) dead space. Be capillaries form an almost continuous
cause of the asymmetrical branching of thin sheet of blood flowing in the alveolar
airways within the acinus. there are in walls of the airways in the respiratory
equalities of gas concentrations within zone. The pulmonary vein leaves the
alveolar gas despite equal volume expan capillary bed and is composed by addi
sion. Mixing between lung units with dif tion of all the oxygenated blood flowing
ferent time constants results in a to-and- in progressively larger vessels. which
empty into the left heart. A diagrammatic airways and increase their dimensions
representation of partial pressures of 0, with increasing lung volume. Due to ra
and CO, and of the intravascular pres dial traction of elastic lung parenchyma,
sures is shown in Figure 2.12. pressure in these extraalveolar vessels is
Resistance in the pulmonary circula reduced as lung volume increases. The
tion is normally about one tenth of the major vessels around the mediastinum
systemic vascular resistance (normal pul respond to intrapleural pressure. Intra
monary = 50-150 dynes/sec/cm-'; nor pleural pressure may be less subatmos
mal systemic = 900-1500 dynes/sec/ pheric than extraalveolar vessel pres
cm-'). The entire circulation flows sures because of dynamic forces within
through the pulmonary vasculature. lung parenchyma. The pulmonary vas
Functionally, this requires less blood culature is able to reduce acute rises in
flow regulatory capability than the sys vascular resistance that might normally
temic circulation, which distributes por occur during the increased blood flow,
tions of the circulation to organs and tis e.g., during exercise. The two mechan
sues above or distant from the heart. isms that prevent marked rises in pul
There are three major types of pulmo monary pressures are the opening of pre
nary vessels: the pulmonary capillaries, viously closed vessels (recruitment) and
the alveolar vessels, and the major ves the increase in caliber of already-open
sels around the mediastinum. The pul vessels (distension).
monary capillaries are unusual in that If the pressure difference between the
they are surrounded by gas in the alveo alveolus and the pulmonary capillaries
lus. When alveolar pressure rises above falls because of either an elevation in al
pulmonary capillary pressure, the capil veolar pressure or a fall in pulmonary
lary collapses and blood flow ceases. Ex capillary pressure, the resistance in pul
traalveolar vessels within the lung pa monary capillaries rises because of com
renchyma respond in the same way as pression of the thin capillary walls. Re-
AIR
P02 ( mm HgI
A
RA PV
0 40 50 100 150
<
2
PA ATMOSPHERE
2"'."
RV
25/0 > L A

UNGS
AIR
PCAP
LV ALVEOLAR
120/ 0 PA GAS
OIFFUSION
120/80100
T
I
S
S
MITOCHONDRIA U
TI SSUE
MITOCHONDRIA VENOUS ARTERIAL AIR
46
Pe02
40
(mm HgI
Figure 2.12. On the right the PO, (upper) and PCO, (lower) changes from air to mitochondria are
0
shown. The depression in PO, caused by diffusion and shunt is illustrated. On the left,pressures
(in mm Hg) in the pulmonary and systemic circulation including capillaries are compared. RA, right
atrium; PA, pulmonary artery; RV, right ventricle: PV, pulmonary vein; LA, left atrium; LV, left ven
tricle. (Modified from West JB: Respiratory Physiology-The Essentials, ed 3, pp 32 and 53. Wil
liams & Wilkins, Baltimore, 1985.)
sistance continues to rise as the tween PA and pleural pressure (known

transmural gradient between the alveo as transpulmonary pressure) becomes
lar and capillary pressure falls. At the less from the apex to the base of the lung.
point the alveolar pressure exceeds cap The greater t ranspulmonary pressure at
illary pressure, transl)1ural pressure be the apex of the lung results in open pe
comes positive, pulmonary capillaries ripheral airways and alveoli, whereas at
close, and blood now through them the bases, airways and alveoli are closed
ceases. There is an increase in pulmo at low lung volumes. Normally, the api
nary vascular pressures from apex to cal alveoli remain open and have vol
base. As a result of gradients in vascular ume. They are higher up the pressure/
transmural pressures, there are regional volume curve of the lung at end expira
differences in perfusion (0). A model of tion. Apical alveoli, therefore, have less
distribution of (0) is shown in Figure 2.13 potential for further volume increase
(West, 1964). In zone 1, alveolar pressure with inspiration. The alveoli at the base
(PA) is greater than either pulmonary ar of the lung are emptied at end expiration,
tery (Pa) or pulmonary vein (Pv) pres and they are at the bottom of the pressure
sures. The pulmonary capillary is com volume curve. With a tidal volume inspi
pressed, and no blood now (shown on the ration, the apical alveoli are ventilated
right side of the diagram) occurs. In zone initially because they are open. As lung
2, Pa is greater than PA, but PA is greater volume increases, basal alveoli open and
than Pv. Blood now in zone 2 is deter receive the majority of the tidal volume
mined by the difference Pa - PA. Blood increase. Therefore, ventilation is greater
now through the pulmonary capillaries in the base than in the apex. As was
progressively increases down zone 2 as shown above, there is no perfusion of
Pa hydrostatic pressure increases and apical alveoli: the apical alveoli however,
transpulmonary pressure falls. In zone 3, are open and do have some ventilation so
vascular pressures are greater than PA, that, relative to 0; there is a large excess
and Pa is greater than Pv. Blood now in of V. The V /0 relationship is greater
zone 3 is determined by the usual arte than 1 and tending toward infinity, since
riovenous pressure differences. there is no blood now in zone 1 . In zone
Regional differences also occur in ven 2, there is better matching of V and 0,
tilation (V). At the base of the lungs. and V /0 is more nearly equal to 1. In
when a person is sitting or standing, zone 3, because blood now (0) increases
pleural pressure becomes less subatmos more than ventilation from the apex to
pheriC because of the weight of the lungs. the base. of the lunS' there is an excess of
At FRC, PA is atmospheric throughout o over V. The V /Q relationship in zone
the lung. Therefore, the difference be- 3 is, therefore, less than 1.
Figure 2.13. Model showing

West's three zones and the uneven
distribution of blood flow in the lung
based on pressures affecting the
capillaries. (From West JB, Colley
CT, Naimak A: Distribution of blood
flow in isolated lung: relation to
vascular and alveolar pressures. J
Appl Physio/19:713, 1964.)
__ --- PZONE
>P >P3
--
-l , V " BLOOD FlOW-
Dead Space and the Intrapulmonary of hypoxemia while breathing room air,
Shunt when low inspired 0, mixtures are
breathed (such as occurs at high alti
Considering the state in the zone 1 tude), the alveolar end capillary blood 0,
regions of the lung, there is an excess of content differences can become quite
ventilation over perfusion. The excess large.
ventilation does not take part in gas ex By far, the most common and impor
change and is termed dead space. High tant cause of hypoxemia is ventilation/
V /0 causes alveolar dead space. The perfusion mismatch. When V/0. is
combination of anatomical dead space greater than 1, there is excess ventilated
and dead space occurring due to excess dead space. When V/0 is less than 1,
of ventilation over perfusion in the res there is venous admixture. The possible
piratory zone is called the physiological relationships of V/0. are summarized
or Bohr dead space. Physiological dead succinctly in the O,-CO, diagram in Fig
space is always greater than anatomical ure 2.14. In the extreme case where the
dead space, since it is a combination of airway is obstructed (V = 0) but blood
anatomical and alveolar dead space. flow (0) persists, there is intrapulmonary
When there is an excess of perfusion shunt (left side of diagram). The alveolar
over ventilation, as in zone 3. some of the gas trapped behind the occluded airway
blood in the pulmonary capillaries is not would have the composition of mixed ve
in contact with alveolar gas across the nous blood, namely. PO, 40 mm Hg
=
alveolar-capillary membrane, and gas ex and PCO, = 46 mm Hg. In the opposite

change does not take place. The nonox extreme, ventilation occurs and there is
ygenated blood is referred to as intrapul no blood flow (right side of diagram); the
monary shunt or venous admixture. Both composition of alveolar gas would be the
names are synonymous with blood that same as the inspired gas, namely, PO, =
passes through the lungs and does not be 1 50 mm Hg and PCO, =0 mm Hg. Be
come oxygenated or remove CO,. Ana tween these two extremes are gradations
tomical intrapulmonary shunt is due to of V/0. mismatch which are described by
the bronchial blood supply that empties the solid line. Figure 2.13 shows how V/
into the pulmonary vein and the thebe o decreases down the upright lung. Note
sian veins that drain from the coronary that both blood flow and ventilation in
sinus into the left ventricle. In congenital crease from the apex to the base of the
cardiac diseases such as atrial or ventric lung, but blood flow increases more than
ular septal defects, much greater anatom ventilation. Opposite the third rib, ven
ical right-to-left shunts may cause severe tilation and perfusion are matched and
arterial hypoxemia. Hypoventilation V/0 = 1 (West's zone 2). As a result of
causes hypoxemia if the rate of supply of these regional differences in V/0, 0, is
0, to the alveolus is less than the rate of higher and CO, lower at the apex, and
removal of 0, by the blood. Although de the reverse is true at the base of the up
creased diffusion of 0, is a minor cause right lungs.
Figure 2.14. O,-CO, diagram in

which a single 'iJ'A ratio line is
shown, representing the extremes
of dead space and intrapulmonary
0
shunt, with the PO, and PCO, at !f ,
various 'iJ/0 ratios. A, alveolar gas E
(PO, 1 00, PCO, 40); V, mixed EN
0
= =
venous point (PO, 40, PCO,

&
= =
45); I, inspired point (PO, = 150,

PCO, = 0= room air). (From West
JB: Ventilation/Blood Flow and
Gas Exchange, ed 3. Bl ackwell Sci- a ,0 '00 "0
entific Publications, Oxford, 1 977.) POl mmHg
v/Q mismatching occurs if a patient diverts blood to low V/Q units, and 100%
breathes at low lung volume because air 0, causes absorption atelectasis once ni
ways close. At low lung volumes, some trogen (from air) is washed out.
airways are closed for part of each
breath, and V/Q is, therefore, reduced.
With age, airways close at progressively Gas Transport
larger lung volumes and gas exchange Oxygen is carried attached to Hb and
deteriorates. In pathological states such in solution. The oxygen capacity of arte
as atelectasis, lung contusion, or infec rial blood is determined by the product of
tion, a reduction in lung volume in Hb content, arterial saturation, and 1 .39
creases the amount of airway closure ml/100 ml (the amount of 0, carried by
during tidal volume breathing, and gas 1 gm of Hb; some authorities use 1 .34 or
exchange is impaired. Multiple inert gas even 1 .36 ml/100 ml). Normal arterial
tracer techniques are used to distinguish oxygen content (CaO,) is approximately
between intrapulmonary shunt and low 20 ml/100 ml of blood. Delivery of oxy
V/Q without altering their values (Wag gen to the tissues is determined by the
ner et aI., 1974). product of CaO, and cardiac output (Q,).
What are the clinical implications of Since Q, at rest is approximately 5 liters/
V/Q and shunt? Increasing the inspired min, 0, delivery is 5 X 20 X 1 0 (to con
oxygen concentration cannot directly in vert to ml/100 ml ) or about 1000 ml/min.
crease the oxygenation of shunted blood The only three variables that may be ma
but can improve 0, content in the blood nipulated to improve 0, delivery in a sit
passing through low V/Q units. In a pa uation where there is evidence of inade
tient with an early pneumonia, there is quate tissue perfusion (evidence
hypoxemia during room air breathing. includes metabolic acidosis, low mixed
V/Q mismatch occurs as more lung venous 0, tension, oliguria) are Hb, Q"
regions become zone 3 (low V/Q). If ox and arterial 0, saturation. Cardiac failure
ygen is given, this compensates for V/Q in an anemic patient would require man
mismatch and allows more of the exces agement to ensure that arterial desatu
sive blood perfusion to be oxygenated. As ration was prevented. Chest physiother
the pneumonia progresses and the in apy, by removal of secretions, and
spired 0, concentration is raised, more mechanical ventilation, by decreasing
airways become obstructed and absorp 0, consumption, may improve arterial
tion atelectasis occurs. When atelectasis saturation and 0, delivery to the
occurs V/Q mismatch becomes intrapul tissues.
monary shunt. There is no gas exchange
if blood flows past a collapsed alveolus.
Increasing inspired oxygen does not im Oxyhemoglobin Dissociation
prove arterial oxygenation if the cause of
hypoxemia is intrapulmonary shunt. The shape of the oxyhemoglobin
Raising the fraction of inspired 0, (FlO,) (HbO,) dissociation curve favors HbO,
becomes progressively less and less effec dissociation in capillary blood supplying
tive as V/Q mismatch converts to intra metabolically active cells, and Hb gives
pulmonary shunt. Distinction between up 0, especially easily in the PO, range
V/Q mismatch and intrapulmonary of 20-40 mm Hg where the curve is so
shunt used to be made on the basis of steep (Fig. 2.15). The HbO, curve shifts to
measuring the partial pressure of oxygen the right with decreasing pH, increasing
(paO,) on 100% 0,. Hypoxemia due to the PCO" increasing temperature, 2. 3-DPG
intrapulmonary shunt cannot be im and anemia. In low tissue perfusion
proved by increasing FiO" and PaO, re states when acidosis occurs, the curve
mains low, whereas hypoxemia due to shifts to the right, and 0, unloading at the
V/Q mismatch can be improved. Two tissues is facilitated, because at the same
major errors, however, result from this PO, the blood is less saturated. The dif
technique: breathing 100% 0, reverses ference between the amount of 0, satu
hypoxic pulmonary vasoconstriction and ration at different pH and PCO, levels is

}tJ' 1
.
100 J':J" '0 '- '- '-'-'
- '-' 1
70 " HbO, I
!IIo 10D [L
I'O J
SAT
100 \ I
o
100
PO,
80 " 0 4lJ
SAT
60
o
'ore
40 ,:{ '0_
.
-

SAT
"
...
-
20
o
o
co, C O N r C N r or
100
u
'0
:: r
: PC02
WHOt: BLOOD
...11",., 0, $1I1",,,,,on
O L--J-J
IS
20 40 60 80 tOO 9 7 , ,,
.. " .

o
Q
'" '"
PO, lmmHgl " '" '" '"
.. , ." ."

o "
.. ...

Figure Oxyhemoglobin d issociation
2.15. H ,0>

curve showing the right shift with changes in u '" '" '"
pH, PCO" temperature (TEMP.), and 2,3-di .. ... ".f m
' : L, , , ,,,
phosphoglycerate (DPG). Anemia also shifts
the curve to the right. (From West JB: Respi
ratory Physiology-The Essentials, ed 3, p 71 .
Williams and Wilkins, Baltimore, 1985.)
,
__ __ __
10 20 J 0 40 '0 "0 1 0 80
co, P R e S S U R C (n",)
known as the Bohr effect and results in
extra 0, availability for the tissues when Figure 2.16. CO, dissociation curve. The re
pH falls and PCO, rises. lationship of CO, content of whole blood and
PCO, varies with changes in saturation of Hb
with 0, (box insert). PCO, of the blood. there
CO, Dissociation Curve fore, infiuences 0, saturation (Bohr effect), and
0, saturation of the blood influences CO, con
0, saturation of the blood also influ tent (Haldane effect). Note the CO, d issociation
ences CO, carriage. Desaturated blood curve is almost linear between 40 and 60 mm
can carry more CO, than oxygenated Hg. (From Comroe JH: Physiology of Respira
blood. This effect of additional CO, car tions, 2 ed, p 165. Year Book Medical Publish
riage is called the Haldane effect. The ers, Chicago , 1 965.)
CO, dissociation curve differs from the
HbO, dissociation curve because in the O,-CO, Diagrams
physiological range it is essentially linear
(Fig. 2.16). If alveolar ventilation is dou 0, and CO, dissocialion curves may be
bled, alveolar CO, is halved, and if alve ploUed together to show Ihe 0, satura
olar ventilation is halved, alveolar CO, is tion at any given PO, and PCO, (Fig.
doubled. This means that if atelectasis or 2.17). The diagram allows arterial satu
other pulmonary pathology in one lung ration to be determined when PCO, is ei
prevents adequate CO, removal in the ther greater than or less than 40 mm Hg.
diseased lung, hyperventilation of the A low arterial saturation may occur be
good lung can compensate and prevent cause of the effect of increased PCO,.
rises in arterial CO, above a normal value Figure 2.14 shows another application
of 40 mm Hg. The end capi11ary CO" of the information that can be obtained
even in a totally nonventilated lung, does from the O,-CO, diagram in which a sin
not exceed mixed venous CO" which is gle line represents the entire spectrum of
normally aboul 46 mm Hg. possible 'if/0. ratios. The result of analy-
PC02. , , O,-CO, diagram of

Figure 2.17.
(tor'r ml CO2
% 02 Rahn and Fenn. PO, is plotted
) ;;;5 8T r /l
SAT Hb
70 IOOml W.B against PCO,. There are seven
58
lines of % saturation of Hb02 called
975
60
1 1/
isopleths that represent equal vol
50 ! 54
71 I I / /
umes of 0, combined with Hb at
50 saturation between 70% and 1 00%.
40
,/1 1 / / / -
46 There are nine lines that are iso
30
TI / / // 42 pleths of CO, in vol %. The HbO,
-I /' 100 38 dissociation curve can be recon
20
177 34
30
structed from the HbO, saturation
10 26 shown at each PO, when following
the 40 mm Hg PCO, line from left to
o .., , I ,
40 50 60 70 80 90 100 110 120 130 140 right. More specifically, this 0,
P 02 ( tor,. ) CO, diagram shows that with CO,
retention, 0, saturation falls, e.g., if
PO, is 93 mm Hg and PCO, is 70 mm Hg, HbO, saturation is only 95% (when if PCO, was 40 mm
Hg, HbO, saturation would be 97%). The lower saturation is not a function of diffusion impairment
or other pulmonary disease. (From Comroe JH: Physiology of Respiration, 2 ed, p 1 66. Year Book
Medical Publishers, Chicago, 1965.)
sis of alveolar PO, and PCO, at any point 21 -25, 1980). The following information
on the curve is obtained from the axis. At is mostly abstracted from these sou rces.
the extreme of dead space shown at pain/ The normal volume of tracheobron
I (inspired point), alveolar gas is room air, chial secretions is estimaled to range
contains no CO" and has a PO, of 150 mm from 10 to 100 mil day. Mucus coats the
Hg. This is quantitatively similar to the airway from alveoli to the trachea and is
apex of the lung or West's zone 1 . At Ihe 2-5 11m thick. The secretion is a heterog
other end of the curve, which shows enous mixture derived from several
"true" intrapulmonary shunt. the alveo sources. The four major conslituenls are
lar gas tensions are the same as those mucus glycoprotein (MGP). lipids, pro
found in mixed venous blood, namely, teins, and water. The cells producing the
PO, 40 mm Hg and PCO, 46 mm Hg.
= = secretion include alveolar type II cells.
The spectrum of increasing and decreas Clara cells. goblet cells, and mucous and
ing V/0. on either side of point A repre serous glandular cells of the su rface epi
sents V10. mismatching, the most com thelium. Duct cells from the submucous
mon cause of hypoxia. Painl A (alveolar glands line the cartilage containing air
gas) describes the ideal alveolus where ways. Goblet cells occur throughout the
ventilation and perfusion are equal (V = respiratory tract down to the alveolar
Q = 1 ). This is similar 10 West's zone 2. duct, where Clara cells are found.
Respiratory mucus has protective
functions, which include lubrication, hu
Human Respiratory Mucus
midification. waterproofing, insulation,
and provision of the environment for cil
In a National Institutes of Health con iary action (Kaliner et aI., 1984). Mucus
ference on human respiratory mucus also acts as a selective macromolecular
published in the American Review of Res sieve to trap microorganisms and as an
pira / o ry Diseases ( 1 34:61 2-62 1 , 1986) are exlracellular su rface for immunoglobu
summarized the present state of knowl lin and enzyme action. Mucus neutral
edge and approaches to management of izes toxic gases, as in smoke inhalation.
bronchorrhea in adults. There was also a and, together with cilia, has a transport
workshop to eluciclate mechanisms of function in disposal of trapped materials.
cough and the nature of bronchial expec The defense mechanisms of mucus may
toration which was published as a sup be overwhelmed by excessive secretions
plement to the E uro pea n Jo u r n al of Res or an increase in the proteins or cells.
piralory Disease (61 (Supplement 1 1 0): Noninfected tracheobronchial secretions
are composed of 95% water, 0.5-1 % pro of neuropeptides may regulate mucus se
tein, 0.5-0.8% lipid and 1-3% Mep (Pot cretion. Because there appears to be no
ter et aI., 1 963, Lopez-Vidriero and Reid, motor nerve supply to surface submuco
1 980). With infection, more protein gly sal glands and there is no response to
coprotein or deoxyribonucleic acid cholinergic or adrenergic antagonists, se
(DNA) from dead neutrophils is present cretory stimulation of surface cells is
in secretions. Increases in DNA decrease probably by neural mechanisms (Borson
the flow of mucus. The viscosity and the and Nadel, 1986). The effects of a-, fl-,
elasticity of tracheobronchial secretions and muscarinic agonists on Iracheal se
are due to the Mep. Patients with viral cretions i n animals are shown in Table
i nfections have impaired mucociliary 2.4.
clearance (Camner et aI., 1973). Myco Using techniques to distinguish sur
plasma pneumoniae infection causes se face cells secrelions from those of sub
verely impaired mucociliary transport mucous glands, Varsano et al. (1 986) have
(jarstand et aI., 1 974). Infections of the suggesled that the macromolecules re
airway are probably unlikely unless mu leased by surface cells contribute to the
cociliary transport is depressed. Congen viscoelastic properties of the mucous gel.
ital nonfunctioning cilia cause chronic Because of their location, surface cells
bronchitis, rhinitis, and sinusitis in early probably play a role in airway inflam
childhood (Camner et aI., 1975; Eliasson, mation (bacterial infections, bronchitis,
1977; Mossberg and Camner, 1980). asthma, cystic fibrosis). Surface cells also
Cholinergic nerves innervate and af release arachidonic acid metabolites. In
fect secretions from the airways; there asthma, mucociliary clearance is de
fore, vagal stimulation and muscarinic layed, and Iipoxygenase products of ara
agonists such as neostigmine cause in chidonic acid metabolism released from
creased secretion, and atropine, a mus mast cells (located immediately outside
carinic antagonist, reduces secretion. Ad vascular capillaries) appear to be the ac
renergic (a-agonist) drugs such as tive mediators (Wanner et aI., 1975). In
phenylephrine selectively stimulate se flammatory changes in asthma are re
cretion of lysozyme from serous cells of sponsible for many of the mucociliary
submucosal glands. Secretions after a changes in the disease, including stalus
stimulation are of low viscosity and low asthmaticus (Borson and Nadel. 1986).
elasticity. These sympathetically pro Mast cell degradation results from anti
duced secretions could assist airway de gen i nteraclion with immunoglobulin E
fenses, e.g., by diluting inhaled irritant and release of anaphylaxis mediators in
materials. Circulating catecholamines, cluding prostaglandins, leukotrienes, li
particularly epinephrine, with more ad poxygenase products, and bradykinin
renergic effects, however, produce more (Wasserman, 1 983).
viscous secretions. Both a - and fl-adren Products of the cyclooxygenase palh
ergic mechanisms regulate the produc way of arachidonic acid melabolism
tion of macromolecular secretions. Neu (namely, prostaglandins A" 0" E" and
ropeptides, such as substance P, and F",) stimulate Mep secretion (Patow,
vasoactive intestinal peptides may also 1986), as does histamine (Shelhamer el
cause mucus secretion. The degradation aI., 1 980). Cyclooxygenase inhibition,
Table 2.4
Effects 01 Adrenergic and Cholinergic Agonists on Properties 01 Tracheal Secretions on
Animal Models'
Effect a-Adrenergic Agonist ii-Adrenergic Agonist Muscarinic Agonist
Fluid secretion from glands 1tt 1 ttl
Macromolecular secretion 111 11 111
Protein concentration I 1
Mucus viscosity I 1
Mucus elasticity I
' 1 , increase; I . decrease; -, no change.
however, causes even greater secretion ticosteroids (Kaliner, 1986). As a clinical

of MGP, implying that the lipoxygenase example of therapeutic application for
pathway is important in the regulation of asthmatic patients, systemic corticoste
MGP production. Leukotriene C. and D. roids in bursts, inhaled corticosteroids
are potent stimulants of MGP secretion and then atropine may be given when
(Marom, 1986). systemic steroids are tapered. Mucolytic
The pulmonary macrophage functions agents and potassium iodide are not gen
as the first line of defense against inhaled erally helpful. A single daily dose of tet
particles, recruits other cell types to the racycline and inhaled {:I,-adrenergic ago
inflamed lung, and participates in the nists, followed by postural drainage with
mucous secretion process (Marom et aI., chest percussion and vibration, may be a
1984). Human macrophages and mono useful approach to mucous hypersecre
cytes release a potent mucus secreta tion in the asthmatic (Kaliner, 1986).
gogue on surface activation. The secre
tagogue increases MGP secretion in EXAMINATION OF THE CHEST IN
pulmonary inflammatory states and in MECHANICALLY VENTILATED
fections and in smoking-related bronchi PATIENTS
tis. Complement may also be associated
with increased mucous production. Examination of the chest in mechani
There is substantial data that CSa is gen cally ventilated patients is such a fre
erated during adult respiratory distress quent necessity in the ICU that it is sur
syndrome and that CSa is a potent mucus prising how little is written about it. It
secretagogue (Marom, 1986). differs from examination of the chest in
Several therapies may reduce exces nonintubated cooperative patients in
sive mucus secretion: prostaglandin E" several important respects. With con
eicosatetraynoic acid and other lipoxy trolled mechanical ventilation, there is
genase inhibitors (Table 2.5), atropine, loss of the patient's respiratory pattern
cimetidine inhibition of histamine, vaso and rate as indicators of disease. These
active intestinal peptides, and glucocor- may, however, still be usefully noted
Table 2.5
Human Respiratory Mucus Secretory Responses
Airway Nasal Turbinate
Agent Mucus Mucus
Methacholine , ,
Atropine NE NE
Methacholine + atropine NE NE
a-Adrenergic agonists , ,
jS-Adrenergic agonists NE NE
Cyclic guanosine monophosphate ,
Cyclic adenosine monophosphate NE
Arachidonic acid , NE
Prostaglandins E" F"" 0" I" A, , NE
Prostaglandin E, j
Aspirin , NE
Indomethacin , NE
Eicosatetraynoic acid j
5-, 8-, 9-, 1 1 -, or 1 5-Hydroxyeicosatetraenoic acid , NE
5- and 9-Hydroperoxyeicosatetraenoic acid , NE
Leukotriene C, or 0, , NE
Anaphylaxis , t
Histamine , ,
Prostaglandin-generating factor ,
Macrophage or monocyte mucus secretagogue ,
C3a ,
" , increased: NE, no net effect on mucus secretion: -, not studied.
when assisted or intermittent mandatory cies between movement of the two sides
ventilation is used. The ventilated pa of the chest are easy to observe. The
tient is unable to cooperate in such ma lungs are inflated with the same volume
neuvers as are required to elicit tactile of gas at each breath. and the usual in
vocal fremitus and vocal resonance be spired volume variation seen in a spon
cause of tracheal intubation. There may taneously breathing patient is avoided.
be difficulties with percussion when Diminished movement indicates disease
dressings over chest tubes. incisions. or of the lung. pleura. or chest wall of that
intravenous sites cover the chest. Fre side. The only exception to this may be
quently the patient cannot be positioned caused by external restrictions. In the
favorably for examination and is unable ICU. these include chest tubes and intra
to clear adventitial sounds by coughing. venous line dressings. arm slings. figure
Auscultatory sounds may. therefore. of-eight bandages for clavicle fractures.
need interpretation in the light of me and high abdominal binders. These all
chanical ventilation and these possible may cause diminished chest movement
restrictions. and almost certainly give rise to atelec
Mechanical ventilation may. in some tasis if left in position (Fig. 2.18). The halo
respects. make assessment of the respi vest used in the management of cervical
ratory system easier. but it requires adap spine injuries may also prevent adequate
tion of other parts of the physical exam inspection of the chest. If it is applied too
ination. Many of these problems have tightly. it restricts chest movement. caus
been overcome in the intensive care pa ing atelectasis in this particularly vulner
tient. and some of the compromises used able patient population. Compared to the
are discussed. Examination. as is tradi body cast. however. the halo vest has ad
tional. should be divided into inspection. vantages. in that it may be loosened. al
palpation. percussion and auscultation. lowing inspection. palpation. percussion.
and auscultation. There is also less radi
Inspection
ological interference from the vest than
from the body cast. Unilateral applica
During controlled mechanical ventila tion of external restrictions to the chest
tion with the patient supine. discrepan- should. therefore. be considered as an
Figure 2.18 (A) A portable anteroposterior chest x-ray taken 36 hr after admission and application
of a figure-of-eight bandage for the right fractured clavicle. (8) The right lower lobe atelectasis
cleared completely after chest physiotherapy and removal of the bandage. as shown on the chest
film taken 8 hr later.
imporlant cause of diminished move airway rupture. Air can be identified in

ment apart from disease of the underly the mediastinum on chest x-ray and may
ing lung, pleura. or chest walL give rise to pneumothoraces (Macklin
The first observation, therefore, is the and Macklin, 1 944). If coughing occurs
equality of movement of either side of and a pneumothorax is present, it may be
the chest. Notice should be taken of ex further aggravated, giving rise to a ten
ternal evidence of trauma or previous op sion pneumothorax. Observation of ven
eration. If chest tubes are present, these tilator airway pressure may be diagnos
can be very helpful in determining the tic. A sudden rise in peak and end
likely diagnosis on completion of the ex inspiratory pressures is indicative of a
amination. Blood in a chest tube suggests rise in intrathoracic pressure that accom
a different respiratory problem from pus panies pneumothorax.
or serosanguineous drainage. The hourly Tactile vocal fremitus may not be elic
rate of production of the drainage should ited in mechanically ventilated patients
also be noted. A chest tube may enable unless there are rhonchi present. Rhon
the diagnosis of bronchopleural fistula to chi are low pitched and usually associ
be made, when air is seen bubbling ated with large airway pathology. They
through the water seal drainage bollle may, therefore, be palpable. Crackles are
with inspiration of the ventilator. This is not palpable. Tracheal deviation may
most easily observed when there is no normally be a useful sign of upper lobe
suction applied to the water seaL Mea pathology or pneumothorax. In the intu
surement of inspired and expired vol bated patient, this happens less fre
ume, which are separated by placing a quently because the tracheal tube tends
shunt valve in the Y-piece of the venti to prevent it. Despite the presence of a
lator tubing, enables this leak to be tracheal tube, deviation away from the
quantitated. side of a tension pneumothorax may
Lastly. the ventilator airway pressure commonly occur and should always be
gauge can give useful information con looked for when a pneumothorax is
cerning total lung/thorax compliance suspected.
(C,) and airway resistance. Details of the
calculations are given in Chapter 7. Ex Percussion
amination for cyanosis and finger club
bing, the observation of the anteroposte Percussion is useful in the diagnosis of
rior (AP) diameter of the chest, and note pneumothorax. Besides the reduction in
of any kyphoscoliosis may provide addi chest movement, a pneumothorax is hy
tional information about a previous his perresonant to percussion and is, there
tory of respiratory disease. fore, immediately differentiated from
fluid, which gives a stony dullness to per
Palpation
cussion. In a patient with fluid in the
chest, turning may elicit a shift in
Palpation may be restricted because of the dullness to the dependent part of the
dressings covering incisions, chest tubes. lung. This does not occur if the fluid is
and intravenous in fusion sites, particu loculated. Shifting dullness should dif
larly those in the subclavian area. Rib ferentiate free fluid from consolidation.
fractures may be felt as crepitus during collapse or fibrosis which also elicit dull
inspiration, expiration, and coughing. If ness and cause diminished chest move
the patient is conscious, tenderness may ment. Clinical examination of the patient
be elicited. The clinical diagnosis of rib who cannot sit up may be obtained by
fractures is helpful, since this finding percussion bilaterally over the anterior
may be missed on the initial chest radio chest. This should be followed by per
graph of a patient with multiple trauma, cussion in both midaxillary lines before
if specific rib films are not taken. Subcu turning the patient laterally for posterior
taneous emphysema may also be present chest examination. Examination of the
and palpable, initially over the neck and chest by percussion in the lateral posi
chest wall. In mechanically ventilated tion of a multiply monitored patient may
patients this is frequently due to small cause more problems than there is addi-
tiona I information gained. This is a use making the distinction between vesicular
ful way to confirm fluid. however. if and bronchial breath sounds (Fig. 2.19).
there is more resonance in the axilla Bronchial breathing occurs when there
after turning. Percussion. palpation. and is loss of the normal air/alveolus inter
auscultation should be performed in re face. In other words. when the lung be
lation to the underlying lung lobes. The comes solid due to consolidation. fluid. fi
surface anatomy of these is shown in Fig brosis. or collapse of peripheral bronchi.
ure 2.1 A-C. the sounds that are normally heard in the
central region of the tracheobronchial
Auscultation
tree are now transmitted peripherally by
the physical means of the solid lung.
The firsl questions the examiner Bronchial breathing is. therefore. likely
should ask on placing a stethoscope on to be heard in pneumonia. lung contu
the chest of a mechanically ventilated sion. or segmental collapse. It is abnor
patient are: "Do I hear breath sounds?"; mal when heard in areas of the lungs
and if so. "Are the breath sounds vesic where vesicular breathing occurs nor
ular or bronchial?" A vesicular breath mally. The bronchial breath sounds are
sound is louder during inspiration and heard over the area where the disease
has a longer expiration. and there is no process is taking place. The surface anat
pause between inspiration and expira omy should. therefore. be noted and re
tion. It is normally heard over all periph lated to the underlying lung lobes and
eral lung fields. Bronchial breathing is segments (Fig. 2.1A-C). In lung contu
louder than vesicular breathing and has sion. one of the characteristic clinical
a pause between inspiration and expira and radiological findings is that the con
tion. Expiration is louder and longer than tused area does not conform to. and is not
inspiration. Bronchial breath sounds are restricted by. normal anatomical lung
harsh and abnormal except when heard segmental distribution. as would be ex
over the trachea anteriorly and between pected in other pathology. Maximum ra
the scapulae posteriorly. The usual plots diological change is commonly seen 12 or
of normal breath sounds are helpful in more hours after injury. and clinical and
BRONCHIAL VESICULAR
Inspiration
Io\.., III ,... ,t','lAw..,.J.
.... ... " ,.

. ,.
v
...'
Start or Expiration
- ,-
.\'iItI/..try<IrIirl,'4I/;1l\Yl1
.....
ijIr",\,w-I.t,..f+t.',
J.,I '..\'
..' , .. " ,"
---tIl If- 6 msec t+ 6 msec
Figure 2.19. On the left is shown a time intensity plot of a normal bronchial breath sound. Inspi
ration is shorter than expiration. There is a well-marked pause between inspiration and expiration.
Expiration is louder and longer than inspiration. On the right is shown a time intensity plot of a
normal vesicular breath sound. The trace begins at inspiration. Inspiration is louder than expiration.
There is no clear demarcation between inspiration and expiration. (From Murphy RLH: A Simplified
Introduction to Lung Sounds.)
radiological examinations frequently un nally affected by the contusion. Rhonchi

derestimate the extent of the contusion may clear after coughing or tracheal suc
(Shin et aI., 1979). tioning. Wheezes are found with airway
If no breath sounds are heard when lis narrowing and obstruction. If the cause
tening over the chest, this is indicative of wheezing is bronchoconstriction, this
that there is no air entry to the underly may be aggravated by coughing and suc
ing lung or that something is preventing tioning. Wheezing due to retained secre
the transmission of the breath sounds. A tions, however, may diminish after their
comparison should be made with the removal. Some of these clinical signs may
same area of lung on the other side of the now be associated with commonly occur
chest. Absence of breath sounds indi ring acute lung pathology. This is con
cates lung pathology. Diminution of veniently done in Table 2.6.
breath sounds may be present in obesity
or increased muscle mass but may also Pitfalls of Clinical Examination in the
indicate underlying lung pathology. Mechanically Ventilated Patient
Breath sounds may be absent in the pres
ence of a pneumothorax, pleural fluid, or There are several pitfalls in clinical ex
a major lobar collapse. Atelectasis or fi amination of the chest of intubated and
brosis cause diminished breath sounds. mechanically ventilated patients. These
Next, the presence of any adventitial may be deceptive to even a most experi
sounds should be noted. An adventitial enced clinician. For example. a right en
sound is any sound not normally occur dobronchial intubation may give rise to
ring. These can be described in many signs resembling an atelectasis of the left
ways. Various names have been attached lung. If allowed to persit, it commonly
to adventitial sounds. A low-pitched produces both left lung and right upper
sound may be referred to as a rhonchus lobe atelectasis. Because the right upper
(or a low-pitched wheeze), and a high lobe bonchus branches off the main stem
pitched sound, as a wheeze, rale, crackle, bronchus about 2-3 mm below the ca
or crepitation. Since the latter sound may rina, it is very susceptible to occlusion
frequently be divided into fine or coarse, with endobronchial intubation (Fig.
which may be synonymous with a partic 2.SC). U nlike atelectasis, signs of de
ular lung pathology, considerable confu creased movement, dullness to percus
sion exists as to their precise meaning. sion, and decreased air entry completely
Therefore, only three terms are used: disappear on extubation of the right
crackle, rhonchus, and wheeze. The bronchus if this is recognized soon
crackle is high pitched, the rhonchus is enough. A deceptive adventitial sound
low pitched, and the wheeze is high may be heard if air leaks around the cuff
pitched and most common and loud in of a tracheal tube. Since airway pressure
expiration which is also prolonged. Mur of mechanical ventilators is highest on
phy et aI., (1977), by means of time-ex inspiration, the leak is likely to be heard
panded wave-form analysis, showed that and felt at this time; if only slight, it can
crackles are discontinuous sounds and mimic a wheeze. If this is thought to be
wheezes are continuous sounds. Visual the cause, brief compression of the pilot
ization of these lung sounds by electronic balloon of the tracheal tube should raise
means is extremely helpful and is shown cuff pressure suffiCiently to occlude the
in Figure 2.20 together with nomencla trachea and prevent the air leak around
ture. Crackles are associated with pul the cuff. Auscultation over the neck
monary edema, interstitial fibrosis, or should verify this finding.
pneumonia. Rhonchi are found with ex Obstruction of the tracheal tube by in
cess sputum production, in bronchitis, spissated secretions or partial kinking
and in association with absorption atel may produce elevated airway pressures,
ectasis. They are produced by narrowing and the resulting turbulence may alter
of the bronchial lumen due to spasm, the character of the breath sounds. Water
swelling, or secretions. Bleeding from a in the ventilator tubing that has spilled
severe lung contusion may give rise to over from a humidifier or kinking of
rhonchi in other areas of lung not origi- compliant ventilator tubing can give a se-
....
CD
lung Sounds' Classifications and Nomenclature
Acoustic
Characteristics
nme-Expanded
Waveform
Recommended
Term English French German Japanese Portuguese I Spanish
Some Common
Clinical
Associations
IBnl'
Discontinuous, interrupted, Coarse Coarse RaJes bulleux Grobes Estertores Estertores Pulmonary edema
explosive sounds---loud, -'I<I'- crackle crackles ou Rassein grosses gruesos resolving
duration 01 about 10 ms: Sous-crepitants pneumonia
low in pitch: initial denae-
lion, width averaging 1.5
ms. I
;j(.iH
Discontinuous, interrupted, Fine Fine Ra.les Feines Eslertores Eslertores Interstitial fibrosis ()
explosive sounds-less crackle crackles crepltanls Rassein finos finos (eg, asbestosis) ::r
loud and of shorter dura- m
tion; they average less than
5 ms in duration and are

, ."
lower In pitch: initial denec-
1100 width averages about t I ::r
-<
0.7 ms
en
Continuous soundnger Wheeze Wheezes Ra.les Pfeilen Sibilos SibHancias Airway narrowing

::r
than 250 ms, high-pitched
dominant frequency of 400
WiftM sibilants
j. ( IR )
..
..
(eg, asthma) m
Jl

Hz or more: a hissing sound ."
-<
Continuous sounds .. k
.... ... mger Rhonchus Rhonchus Aa.les Brummen Aoneas Roncus Spulum production
. (f Z
than 250 ms, low-pitched,
dominanl frequency about A/\NWJWVV ronnanls
( n: ) ll'
(eg, bronchitiS)
-i
::r
200 Hz or less; a snoring m
sound
Z
-i
m
Figure 2.20. Time-expanded wave forms of crackles, rhonchi, and wheezes together with Inter z
national nomenclature. (From Andrews JL Jr, Badges IL: Lung sounds through the ages. JAMA en
<:
241 :2629, 1979, and Cugell OW: Lung sound nomenclature. Am Rev Respir Dis 136:1016, 1987.) m
()

Jl
m
c
z
=<
Table 2.6
Clinical Signs Associated with Commonly Occurring Acute Lung Pathology"
Pathological ()
Process Inspection Palpation Percussion Auscultation c::
z
Pneumothorax " or I movement; Possible subcutaneous Hyperresonance over Breath sounds I 0
C, I , P_, f ,
emphysema; pneumothorax or absent r
POE f if tension; tracheal deviation z
otherwise may away from pneumo- 0
be N thorax if tension 0

Pulmonary Movement N ; I f florid, palpable fluid Dullness Crackles and
edema frothy sputum i n in airways wheezes 5
tracheal tube; z
(J)
CT ! ' PfnI;.. N or
?, POE f z
0
c
Atelectasis I movement; C, Tracheal deviation Dullness over area of Breath sounds I
I ; P_, N or ?; towards lesion if collapse or absent with (J)

PEE f complete upper lobe major collapse; Gl
atelectasis maybe bronchial m
breathing and 0
"
crackles ()
Contusion Bruising may be May be tenderness Dullness over Bronchial breathing; I
present; and crepitus over contusion wheezes and m
(J)
movement N or fractured ribs rhonchi if
"
I ; C, I ; P_, N excessive I
-<
(J)
or ?; P" 1 bleeding
Aspiration Movement N or I ; Rhonchi may be Dullness may be Vesicular breathing; 5
CT N or ! ; p"",.. palpable present rhonchi
I
N or .1'; Pie N or m
? :D

Pleural fluid Movement I ; C, No breath sounds Stony dullness may Breath sounds "
-<
N or I ; P, N palpable; tracheal clear on turning absent; may be
or T ; POE N or f deviation away from patient if fluid not bronchial
depending on fluid if voluminous loculated breathing about
quantity fluid
Pneumonia Movement I ; C, Pleural rub may be Dullness over Early breath sounds
I ; P_, ?; POE ? palpable consolidation I ; bronchial
breathing
crackles and
pleural rub
Fibrosis Movement I ; C, Tracheal deviation Dullness over fibrosis Breath sounds ,,;
I ; P_, T ; POE toward fibrosis bronchial
..,.
'"
T breathing and
crackles
.'. slightly decreased; ! . decreased; 1 , increased; ?, slightly increased; P",.u maximum airway pressure; Pie, endinspiratory pressure; N,
normal.
ries of apparently unexplainable sounds association of ventilator airway pressure

that may, at times, resemble mucus se and full inspiration for mechanically
cretions in the larger airways. Sump ventilated patients.
drains in the subhepatic or splenic bed
areas may considerably confuse auscul Localization of Lung Segments
tation of the chest when they are con
nected to vacuum suction. Equally, na Based on anatomical bronchial seg
sogastric tubes on continuous low ments, specific areas of the lung corre
suction drainage may cause additional spond to individual bronchi on a straight
sounds. The loudest and most easily rec AP chest x-ray. There is, however, some
ognizable additional sound occurs with overlapping of areas due to superimposi
chest tubes connected through drains to tion of the lobes in the AP projection. The
vacuum suction. This abruptly termi localization of these segments is some
nates if the chest tube is briefly clamped. what different from many other similar
diagrams, but the designations shown in
RADIOLOGICAL INDICATIONS FOR Figure 2.21A-C are based on the anat
CHEST PHYSIOTHERAPY omy of the bronchial tree segments on
bronchography and on nuclear scanning
Almost without exception in a critical (Ayella, 1 978a). The silhouette sign and
care unit, the patient has a daily portable air bronchogram together with the seg
chest x-ray. The practice of clinical ex mental anatomy are used to localize lung
amination backed up by radiological con pathology, so that chest physiotherapy is
firmation ensures a high degree of directed at specific lung segments.
success in establishing the area of pul
monary infiltrates. Although clinical ex Silhouette Sign
amination is often correct, the chest x
ray offers an additional dimension that is The silhouette sign occurs when two
frequently not possible with clinical ex separate structures adjacent to each
amination alone. The additional dimen other have the same densities. The bor
sion is the ability to pinpoint the lung in der between the two is not identifiable on
fi ltrate not just to a lobar distribution but x-ray because of the lack of contrast in
to a specific segment within the lobe. densities. In normal circumstances on
This is of utmost importance to the chest chest x-ray the heart, diaphragm, and
physical therapist in determining the mediastinum have contrasting densities
correct postural drainage position. to the aerated lung. The borders of the
Patients in the ICU are unable to be heart, diaphragm, and upper mediasti
transported to the radiology department num are, therefore, clearly visible on
for a chest x-ray if they are critically ill. chest x-ray. When lung pathology occurs
Routinely, therefore, portable AP chest in segments adjacent to these structures
x-rays are taken of these patients. If these and the lung becomes consolidated, atel
are taken with the patient in the erect po ectatic, edematous, or fibrotic, however,
sition, there are several advantages. The its density i ncreases, and the contrast
erect chest x-ray allows better visualiza with the cardiac, mediastinal. and dia
tion of the superior mediastinum (Ayella, phragmatic borders is lost. The lung seg
1977) and comparative assessment of ments adjacent to various structures
heart size on a daily basis if the film is within the chest are shown in Figures
exposed with the same degree of inspi 2.22, 2.24, 2.26, and 2.30. Loss of the def
ration. The erect position accentuates the inition of these borders infers pathologi
presence of free pleural fluid which grav cal involvement of the adjacent lung seg
itates, giving a characteristic blunting of ment. It appears to be quite specific.
the costophrenic angle seen with pleural Figure 2.23A shows atelectasis of the
effusion. In patients with spinal and pel right upper lobe which responded to a
vic injuries, the x-ray is normally taken single treatment with chest physiother
with the patient in the supine position. apy (Fig. 2.238). Silhouette of the left and
The radiograph should be exposed on right heart borders is shown diagrammat
full inspiration: therefore, the radiology ically in Figure 2.24 and in clinical prac
technician should be familiar with the tice in Figure 2.25A. The atelectasis of
c
Figure 2.21. (A) Bronchopulmonary segments of the right upper lobe and basal segments of both
lower lobes as seen on a straight AP chest x-ray. The mediastinum and diaphragm are outlined in
this and in 8 and C. Note contact of lower lobes with diaphragm and right upper lobes with superior
mediastinum. (8) Bronchopulmonary segments of the right middle and left upper lobe. Note contact
with right heart border, left heart border, and superior mediastinum. (C) Superior segments of both
lower lobes are large but make no contact with mediastinum or diaphragm. Compare the radiolog
ical bronchopulmonary segmental distribution shown here with the surface anatomy shown in Fig
ure 2 . 1 . (From Ayella RJ: Radiologic Management of the Massively Traumatized Patient, p 95, Figs.
8.25-8.27. (Williams & Wilkins, Baltimore, 1 978.)
the lingula is successfully cleared by

physiotherapy, and the left heart border
becomes visible (Fig. 2.25B). The silhou
I
ette sign of lower lobe atelectasis is
shown in Figure 2.26. The diaphragm
from Ihe outer third, medially, silhou
/!f ettes the anterior lateral and posterior
segments of the lower lobe, respectively.
The diaphragm appears to be "lost" op
posite the anterior (Fig. 2.27) and the pos
terior segments (Fig. 2.28) in these AP
erect portable chest x-rays. A complete
atelectasis of the left lower lobe (Fig.
Figure 2.22. Silhouette sign showing " Ioss"
2.29A) partially reexpands with chest
of the superior mediastinum bilaterally. This in physiotherapay [Fig. 2.29B). To com
dicates right posterior and left apical posterior pletely clear this atelectasis of the poste
segmental atelectasis of the upper lobes. rior basal segment of the left lower lobe,
(From Ayella RJ: Radiologic Management of the patient required the coryect, specific,
the Massively Traumatized Patient, p 96, Wil postural drainage position. Each segment
liams & Wilkins, Baltimore, 1 978a.) of the lower lobe has a different postural
, 't E 1 E" f ,/.-

A B Pon (It s 1'" P/r
Figure 2.23. (A) Note " loss" of the right supenor mediastinum and atelectasis of the right upper
lobe. Also, there IS " Ioss" of the right hemidiaphragm, indicating atelectasIs of the nght lower lobe.
(B) After a single treatment with chest physiotherapy the nght upper lobe IS now reexpanded. and
the right superior mediastinum outline is clearly visible. The nght lower lobe atelectasIs has also
reexpanded, and the diaphragm outline is now visible.
drainage position. so that identification The importance of identification of seg

before therapy is of the utmost impor mental involvement to the chest physical
tance. I n order to clear a total lower lobe therapist is. therefore. immense. If the in
atelectasis completely, five different pos volved segment can be identified, the
tural drainage positions may be required. patient can be positioned in the ideal
drainage position, and percussion and vi
bration therapy can be carried out in this
position. In our opinion this approach
greatly i ncreases the likelihood of clear
ance of the area of lung involvement. A
complete atelectasis of the left upper lobe
(including lingula) silhouettes the left
heart and the superior mediastinum (Fig.
2.30). The chest x-ray shows haziness of
the left heart border and superior medi
astinum (Fig. 2.31A) which cleared with
chest physiotherapy (Fig. 2.31 8).
Air Bronchogram
The air bronchogram is the reverse of

Figure 2.24. Silhouette sign showing "loss"
the phenomenon that causes the silhou
of the right and left heart borders. This Indi ette sign. Since air is less dense than con
cates middle lobe and lingula involvement. solidated, edematous, conlused, or fi
(From Ayella RJ: Radiologic Management of brosed lung. the differing densities resull
the Acutely Traumatized Patient. p 96, Fig in a line of demarcation visible on chest
8.286. Williams & Wilkins, Baltimore, 1978a.) x-ray. In normal circumstances there is
A
Figure 2.25 (A) Note loss of the left heart border in this chest x-ray showing atelectasis of the
lingula. The diaphragm IS vIsible. (8) After chest physiotherapy the heart has now moved to the
right. and the lingula IS reexpanded. The left heart border IS now clearly visible.
no demarcation because the lungs. and air bronchogram. If an air bronchogram is

Ihe bronchi are bolh well aerated. With visible to the peripheral lung fields. the
loss of air in the lung the densily contrast lesion is unlikelv to be due to a mucus
is apparent between Ihe air in the bron plug. Bronchoscopy is usually not helpful
chi and the more dense lung. If a mucus in patients who have an air bronchogram
plug is thought to be the cause of the at that can be traced to the peripheral lung
electasis, this may be apparent, on the field. This is because most fiberoptic
straight AP film. as a sharp cutoff of the
Figure 2.26. Silhouette sign shOWing "loss"

of diaphragms. If the outer one third IS missing,
the anterior segment IS Indicated; If the middle
one third IS missing. the lateral segment is in
dicated; and if the inner one third is missing, Figure 2.27. Atelectasis of the anterior basal
the posterior segment of the lower lobes is In segment of the left lower lobe. The lateral third
dicated. (From Ayella RJ: Radiologic Manage of the diaphragm is "lost." (From Ayella RJ:
ment of the MassIVely Traumatized Patient, p Radiologic Management of the Massively Trau
96. Fig 8.28C. Williams & Wilkins, Baltimore. matized Patient. p 1 2 1 . Fig 8.90. Williams & Wil
1 978a.) kins. Baltimore. 1 978a.)
bronchoscopes are too large to be passed

beyond the third generation of bronchial
divisions and the secretion retention in
volves the 16-23 generations much more
peripherally (see p. 308).
ACUTE IN DICATIONS FOR CHEST

PHYSIOTHERAPY
Blood Gas Changes
If a patient requires mechanical venti

lation, a controlled readily determined
FlO, is administered, and arterial blood
gas analyses are necessary. Critically ill
patients may have three arterial blood
gas analyses during a 24-hr period. Other
Figure 2.28. Atelectasis of the posterior basal
analyses are done if the clinical situation
segment of the left lower lobe. The medial third is believed to justify the requirement or
of the diaphragm, from the arrow, i s missing. afler ventilator adjustment. With use of
(From Ayella RJ: Radiologic Management of the pulse oximeter and the on-line end
the Massively Traumatized Patient, p 1 20, Fig tidal CO, monitor, blood gases may be
8.89. Williams & Wilkins, Baltimore, 1 978a.) less frequently analyzed.
Figure 2.29. (A) Silhouette sign showing absence of left hemidiaphragm. (B) After chest physio-
therapy the outer two thirds of the left hemidiaphragm is clearly visible. There is still an infiltrate in
the posterior segment of the left lower lobe which silhouettes with the medial third of the
diaphragm.
(Aye et a!.. 1978). If PaO,/FIO, is less

than 200. the patient. the ventilator. and
the current chest x-ray should be exam
ined to determine any clinical. mechani
cal. or radiological reason for the in
creased shunt. If there was clinical or
radiological evidence of retained secre
tions. the most involved lung segments
are identified. and chest physiotherapy is
performed with the patient in the pos
tural drainage position for the affected
segments. After repeating the blood gas
analysis. if PaO,/FIO, is not greater than
200. positive end-expiratory pressure
Figure 2.30. Complete loss of the left heart (PEEP) is added in increments to a max
border and superior mediastinum indicates a imum of 10 cm H,O so that functional re
complete left upper lobe atelectasis. (From Ay sidual capacity may be increased and in
ella RJ: Radiologic Management of the Mas trapulmonary shunt improved (McIntyre
sively Traumatized Patient. p 96. Fig. 8.280. and Laws. 1969). Further increases in
Williams & Wilkins. Baltimore. 1978a )
.
PEEP beyond 10 cm H,O are monitored
with a pulmonary artery catheter in
order to exclude a cardiac cause of in
creased shunt. Patients with high shunts
Accurate knowledge of the PaO, and may benefit from chest physiotherapy
FlO, enables calculation of the PaO,/ alone. without the addition of further in
FlO, ratio to approximate the degree of crements of PEEP. Causes of V/0. mis
blood shunting occurring in the lungs. match that may be improved by chest
PaO,/FIO, is a good approximation of in physiotherapy include atelectasis and se
trapulmonary shunt (Q./Q,) up to 20% cretion retention.
B
Figure 2.31. A. Left upper lobe atelectasis showing haziness of left heart border and left superior
mediastinum. B. After physiotherapy and reexpansion of the atelectasis these borders become
clearly visible. (From Ayella RJ: Radiologic Management of the Massively Traumatized Patient. p
1 1 9. Fig. 8.8SA and B. Williams & Wilkins. Baltimore. 1 978a .)
Pneumonia sure monitor (intracranial pressure. 9 mm Hg)

and for laparotomy. which revealed a ruptured
Pneumonia may be improved by chest spleen and renal contusion.
physiotherapy. but this is controverisal The patient remained unconscious due to
and hinges on the definition of pneumo cerebral contusion for t 7 days. Starting 9 days
nia. Graham and Bradley (1978) could after admission, Pseudomonas aeruginosa
show no improvement. using intermit was grown for 3 successive days from tracheal
cultures. Maximum daily temperature (T_.) .
tent positive-pressure breathing and 20
white blood cell count. and chest x-ray findings
min of chest physiotherapy. in the reso from the time of positive tracheal cultures are
lution of pneumonia. They have how shown in Table 2.7.
ever. excluded many of the diseases as Eleven days after admission. there was no
sociated with pneumonia. such as lung obvious source found for the leukocytosis and
abscess. bronchitis. and bronchiectasis. pyrexia. and the chest x-ray was not thought to
that are thought to benefit from therapy. be sufficient to account for these changes de
They also used the therapy for o nly 20 spite the positive tracheal cultures. On the
min at each treatment session. In our ex twelfth day after admission. the morning chest
perience this duration may not be suffi x-ray showed development of fluffy infiltrates in
the left lower lobe and right middle and lower
cient to clear retained secretions (Mac
lobes (Fig. 2.32). These. and clinical examina
kenzie et al.. 1980a). The concept of a tion. were thought to be compatible with a left
predetermined length of therapy is un lower lobe pneumonia. Tobramycin and ticar
acceptable; rather. the chest physical cillin were suggested but not given. because.
therapist should continue unlil there is following 45 min of chest physiotherapy. arte
clinical evidence of improvemenl in the rial oxygenation (PaO,). CT. and temperature all
area being treated or sputum production improved significantly. A repeat chest x-ray
ceases. Evidence for the benefit of chest also showed improvement. The PaO,. CT and
physiotherapy in a patient with pneu temperature changes before and after chest
monia is presented in the case history physiotherapy are shown in Table 2.8.
The leukocytosis and pyrexia decreased
below.
(Table 2.7). and the chest x-ray showed
Case History 2. 1 . A 1 9-year old male was marked improvement by the following day (Fig.
admitted by helicopter directly from the scene 2.33). The patient had two further chest phys
of an automobile accident. The patient was a iotherapy treatments. on days 1 4 (Fig. 2.34)
passenger in a truck hit by a train. He arrived and 1 5 (Fig. 2.35). Chest x-ray confirmed com
unconscious, with a right tension pneumotho plete resolution. and he was extubated on the
rax, absent bowel sounds, and hematuria. seventeenth day after admission. The labora
Chest x-ray showed fracture of the first right tory. chest x-ray. and clinical data strongly sug
and second left ribs. Minilaparotomy was pos gested that chest physiotherapy had played a
itive. and the patient went to the operating significant role in reversal of the patient's
room for placement of an intracranial press- pneumonia.
Table 2.7
T .. White Blood Cell Count (WBC). and Chest X-ray Findings of Patient in Case History 2.1
_
for 1 Week after P. aeruginosa Cultures Showing Pyrexia, Leukocytosis, and Development of
Pneumonia (Chest Physiotherapy Given on Days 12-(5)
Day from
Admission T_. (OF) WBC Chest X-ray
9 1 0 1 .6 24.600 Clear
10 1 01 .8 33.800 Clear
11 1 02.6 37.400 Slight infiltrate in left lower and right middle lobes
12 1 03 36.100 Fig. 2.31
First Chest Physiotherapy Given

13 1 00.4 27.600 Fig. 2.32
14 1 0 1 .8 22.500 Fig. 2.33
15 1 00.8 24.200 Fig. 2.34
Figure 2.32. Fluffy infiltrates in the left lower lobe and lin
gula and right lower lobe developed on the twelfth day after
admission.
Figure 2.34. Morning chest x-ray on the four

teenth day after admission.
JA/
Figure 2.35. Complete resolution of pneu
monia on the fifteenth day after admission.
Figure 2.33. Marked clearing of pneumonitis the day after

chest physiotherapy was given.
In the ICU, pneumonia commonly oc lar lavage and a combination of topical

curs as the end product of secretion re and intravenous antibiotics improve the
tention behind blocked airways. It is an diagnosis and prevent development of
extremely difficult diagnosis to make. nosocomial pneumonia in animals (Jo
Positive bacteriological cultures from the hanson et aI., 1 988a,b).
airway of tracheally intubated patients In practice, if lung infiltrates that can
are commonplace. The difficulty occurs not be cleared within 36 hours of their
in identifying whether these are patho appearance and the other criteria exist, a
logical. A method of increasing the diagnosis of pneumonia is made. At this
likelihood of obtaining cultures of a point Graham and Bradley's conclusions
pathological organism from tracheally in that pneumonia does not benefit from
tubated patients by peripheral sampling chest physiotherapy may be true. The
has been described. By using this method treatment now includes appropriate an
the pathological organism was success tibiotics. Until this point, the removal of
fully cultured at a peripheral airway de retained secretions and the opening up of
spite polymicrobial colonization of the blocked airways may prevent the propa
upper airways (Matthew et aI., 1977). gation of pneumonia.
This method, however, has been dis
puted as an effective diagnostic aid (Boy Lung Contusion
sen et aI., 1980). Also, the ICU patient
commonly has a temperature elevation Lung contusion may also be improved
and leukocytosis that may be related to a after chest physiotherapy. Lung contu
pneumonic process. Lastly, the presence sion is commonly the result of a high
of infiltrates within the lung does not speed automobile accident. In the early
necessarily signify pneumonia. Radiolog stages there may be no radiological evi
ical infiltrates in 70% of cases that are dence of lung damage (Ayella, 1978b),
unilateral and 60% that are bilateral may particularly when rapid evacuation from
be improved by one treatment of chest the scene of the accident by helicopter
physiotherapy (Mackenzie et al. 1 978b). occurs. If increasing intrapulmonary
These are, therefore, unlikely to be shunt, a confirmed history of blunt
pneumonia. The cardinal signs of pneu trauma, bloody tracheal secretions, and
monia, positive sputum culture, temper crackles on auscultation of the chest are
ature with a leukocytosis, and compati present, however, chest physiotherapy is
ble radiological infiltrate have little indicated. When the contusion is caused
meaning as criteria for making the diag by rapid deceleration creating an implo
nosis in the ICU. Were these circum sion effect within the lung (Zuckerman,
stances allowed to persist without at 1 940), there may be no fractured ribs or
tempts at removal of the retained any external signs of injury. Improve
secretions, however, the accumulation ment in intrapulmonary shunt after chest
would certainly give rise to pneumonia. physiotherapy may be obtained by re
More recent data (Salata et aI., 1987) in moval of bloody secretions from the areas
dicate that examination of serial tracheal of normal lung around the contused area
aspirates for elastin fibers and by graded into which bleeding has occurred. Im
gram's strain may enable differentiation provement is not always seen, however.
of colonization from nosocomial pneu If the lung is severely contused and lac
monia. The presence of elastin fibers in erated as a result of the injury, there may
sterile suction catheter aspirations oc be copious bleeding. Deterioration after
curred about 2 days before radiological chest physiotherapy in this set of circum
pulmonary infiltrates. Sucralfate for stances may be noted (see p. 222, Case
stress ulcer prophylaxis rather than ant History 7.1 ). Nevertheless, morbidity, as
acids or histamine type 2 blockers pre measured in terms of duration of me
vents gastric colonization of the airway chanical ventilation, was reduced in our
and reduces the risk of nosocomial pneu institution as a result of managing lung
monia in mechanically ventilated pa contusion with a combination of early in
tients (Driks et aI., 1987) Bronchioalveo- itiation of mechanical ventilation, chest
CLINICAL IN DICATIONS AND USAGE OF CHEST PHYSIOTHERAPY 89
physiotherapy, and PEEP where indi cause of the loss of motor function below
cated (Shin et aI., 1979; Mackenzie and the spinal cord transection. The amount
Shin, 1981). The reported mortality of of respiratory impairment is generally re
lung contusion has varied between 20% lated to the level of transection; CB-C8
and 50% (Roscher et al.. 1974). By using function ensures competent diaphrag
the early approach to intubation outlined matic innervation and often allows pa
in Chapter 1 and the support of con tient involvement in secretion clearance.
trolled mechanical ventilation and chest In the acutely quadriplegic patient, how
physiotherapy, this has been reduced to ever, pulmonary complications are fre
mortality of 10% in 132 patients (Shin et quently fatal (McMichan et aI., 1980). Ag
al.). If the bloody secretions occuring in gressive tracheobronchial toilet on a
lung contusion are allowed to remain prospective basis, in an attempt to pre
within the lung, they act as a perfect cul vent secretion retention, is indicated in
ture medium. Therefore, infection may this group of patients. It is reported to be
be a common sequela of lung contusion. highly successful in reducing mortality
Similarly, traumatic lung cysts at the (McMichan et al.). The approach to chest
focus of the contusion can also become physiotherapy for the quadriplegic pa
infected, giving rise to lung abscesses if tient is described further in Chapter
the area is not adequately drained (Ay 8.
ella, 1978b). Chest physiotherapy may be
highly successful at draining a lung ab Smoke Inhalation and Aspiration
scess that communicates with the tra
cheobronchial tree. Secretion and particulate matter reten
tion should be prevented in the patient
suffering from inhalation of smoke or
PROPHYLACTIC USE OF CHEST
gastric contents. Lung parenchymal dam
PHYSIOTHERAPY
age may develop from inhaled irritants,
such as soot and cyanide from burning
Chronic Sputum-Producing lung
plastics, or from acid aspiration. Smoke
Disease
inhalation victims may also suffer from
the effects of carbon monoxide inhala
In circumstances in which there are tion, causing a reduced level of con
excessive secretions or the ability to sciousness. The damaged lung, after
clear secretions is impaired, the use of smoke inhalation injury or aspiration,
prophylactic chest physiotherapy may be may become infected. To reduce this
indicated. Smokers who produce morn likelihood, drainage of lung secretions
ing phlegm or patients with chronic lung and particulate matter should be assisted
disease and copious sputum production by chest physiotherapy.
probably benefit from chest physiother
apy, especially after major surgical pro
cedures or during prolonged tracheal Depressed level 01 Consciousness
intubation, ventilation, and immobiliza
tion. In an ideal situation, breathing ex The unconscious or semiconscious pa
ercises should be practiced by the patient tient who breathes spontaneously re
before operation. When acute circum quires prophylactic chest physiotherapy
stances precipitate admission, this is not because coughing and deep breathing are
possible. Patients with normal lungs may depressed. The unconscious patient with
also benefit from preventive measures head injury may frequently breathe
aimed at reducing pulmonary complica spontaneously with spastic respiration,
tions when they are immobilized. using an active expiration. The combi
nation of low tidal volume (300 ml or
Acute Quadriplegia
less) and high frequency (30-50 breaths/
min) is another variant of abnormal res
The acutely quadriplegic patient is un piration found with depressed levels of
able to clear secretions effectively be- consciouness. Both may cause small air-
way closure and secretion retention. The tioning for postural drainage and ensures
chest physical therapist may alter these application of chest physiotherapy to the
respiratory patterns and induce deeper involved areas of lung.
breathing and generate coughs in other Deterioration of arterial blood gas due
wise-unresponsive patients. The tech to increased intrapulmonary shunt is an
niques employed are described in Chap indication for chest physiotherapy when
ters 3 and 5. the cause of the shunt is acute atelecta
sis. secretion retention. or lung contu
sion. Pneumonia may be difficult to di
Obesity agnose and may in the early stages
respond favorably to chest physiother
The obese patient is well recognized as apy. Patients with chronic sputum-pro
having a higher incidence of pul monary ducing lung disease. acute quadriplegia.
complications after surgery than normal
smoke inhalation. aspiration. depressed
subjects. Obesity and immobilization in levels of consciousness. and obesity who
the supine position predispose to inade
are admitted to the ICU. especially if they
quate lung expansion and. therefore.
require tracheal intubation and mechan
small airway closure and secretion reten ical ventilation. benefit from prophylac
tion (Cherniack et al.. 1 986). In our ex tic chest physiotherapy.
perience the best chest therapy for the
obese patient is deep breathing and
coughing that can be induced with early References
and aggressive attention to mobilization.
Aye S. Shin B, Mackenzie CI", Milholland AV. Hel
The sooner the patient is moved out of rich M: Tracking of respiratory function: Evalua
bed and is walking. the more quickly the tion of respiratory index and Pa01/FI02 ratio (ab
respiratory problems resolve. In obese stract). Am Soc Aneslh 391-392. 1978
patients with a tracheostomy. early tube AyelJa RJ: Ra diologic Managemenl of Ihe Massivdy
Troumalized PC/ l ie nl , pp 93-96. W i ll iams & Wil
removal appears to greatly assist the pro
kins. Balti more. 1976a
cess of lung reexpansion and secretion AyclJa RI: Radiologic Managemenl of Ihe MassiveI},
clearance. Mobilization is. therefore. Traumali7.ed Polient. pp 1 29-140. Williams & Wil
used prophylactically for the obese kins. Balti m ore. 1978b
patient. Ayella RI, Hankins JR. Turney SZ. Cowley RA.
R upt u red thoracic aorla due 10 b l u n t trauma. J
Trauma 1 7 : 1 99-205, 1977
Dorson 13. Nadel J: Neurophysiologic control of air
SUMMARY way secretions i n experimental animals. Kaliner
M, Moderator: lIuman respiratory mucus. Am
A knowledge of the anatomy of the air R ev flcspir Dis 134:614-617. 1 966
ways. lung segments. and lobes is essen Boysen PC. Jenkins R B. M u rphy EJ: Prospective
tial for clinical and radiological exami comparison of cultures of proximal and periph
eral endotracheal aspirates in intubated patients
nation of the chest and the performance (abstract). Grit Care Med 6:236. 1 980
of effective chest physiotherapy. An out Camner p, Jarstrand C, Philipson K: Tracheobron
line of pulmonary physiology is useful. chial clearance in patients with influenza. Am
especially the concepts of dead space. Hev Respir Dis 108:131-135. 1973
Canmer P. Mossberg B. Afzelius SA: Evidence for
shunt. and 'iI/Q mismatch. to understand congenitally non-funclioning cilia in Ihe tracheo
how they may be changed by chest phys bronchial tract in two s ub jects Am Hev H('spir Dis
.
iotherapy. Details of the production. 1 1 2:607-609, 1975
function. and biochemistry of sputum Cherniack RM. Zwillich CWo Maclem PT, Kryger
may provide therapeutic strategies for in .
M H , Olson GH: Obesi t y Am Rev ncspir Dis
1 34,827-828. 1986
creasing its removal. Some pitfalls of Com roe 11-1: P hysiology of respiro lion. cd 2. p 165.
chest examination in mechanically ven Yearbook Medical Publishers. Chicago. 1975
tilated patients were described. Identifi Downie PA: Cash's Texlbook of Chest. lIeorl and
cation of atelectatic lung segments or Vascu la r Disorders for Physiotherapists. pp 1 7-34.
Faber & Faber. London. 1979
lobes on chest x-ray by means of the sil Driks MR. Craven DE. Celli BR. Manning M. Burke
houette sign is the major radiological in RA. Garvin GM. Kunches L. Farber HW. Wedel
dication for chest physiotherapy. This SA. McCabe WR: Nosocom ial pneumonia in in
technique enables correct patient posi- tubated patients given slicralfale as compared
with antacids or histamine Iype 2 blockers. N tory diseases and other condi l i ons: An interpre
EngJ J Med 3 1 7: 1 376-1382. 1987 tation of the ciinical liLerature in the light of lab
Eliasson R. Mossberg B. Canmer P. Afzelius BA: oratory experiment. Medicine 23:2Bl358, 1 944.
The immobile cilia syndrome. A congen ital cili Marom Z: The effects of macrophage (monocyte)
ary abnormality as an etiologic factor in chronic products on respiratory mucus secretion. In. Kal
airway infections and male sterility. N EngJ J Med iner M. Moderator: Human respiratory mucus,
297:1-6, 1977 Am Rev Respir Dis 134:618. 1 986
Fowler WS. Gray IS. I-Ielmholz HF' Jr. Otis AB. Rahn Maram Z. Shelhamer JH, Kaliner M: Human pul
1-1. Riley RL: Standardization of definitions and monary macrophage derived mucus secrela
symbols in respiratory physiology. Ff'd Pror. gogue. I Exp Med 1 59:844-860. ) 984
9:602615, 1 950 Martin HB: Respiratory bronchioles as the pathway
Graham WGB, Bradley DA: Efficacy of chest phys for collateral venlilal ioll. ) Appl PhysioI 2 1 : 1443-
iotherapy and intermittent positive-pressure 1447, 1966
breathing in the resol ution of pneumonia. N Engl Mallhew EB. l Io l mstrom FMG. Kasper RL: A simple
J Med 299:624-627, 1978 method for diagnosing pneumonia in intubated or
Jarstrano C, Canmer P. Philipson K: Mycoplasma Iracheostomized patients. Crif Care Med 5:76-6 1 .
pneu ll10niae and tracheobronchial clearance. Am 1977
Rpv Respir Dis 1 1 0:415-419, 1974 Mcintyre RW. Laws AK. Ramanchandran PR: Posi
Johanson WG. Seidenfeld JJ. Gomoz P. De Los San tive expiratory pressure plateau: im proved gas
tos R. Coalson II: Bacteriologic diagnosis of noso exchange during mechanical ventilation. Cun An
comial pneumonia following prolonged mechan aeslh Soc 1 16:477-486. 1 969
ical ventilation. Am Bev Respir Dis 1 37:259-264. McMichan JC. Michel L. Weslbrook PR: Pul monary
1988a dysfunction follOWing traumatic quadriplegia.
Johanson we, Seidenfeld JI. De Los Santos R. Coal JAMA 243:528-531 . 1 980
son IL Gomez P: Prevention of nosocom ial pneu Menkes HA, Traystman R J : Collateral ventilation.
monia using topical and parenteral antimicrobiaj Am Rev Respir Dis 1 1 6:287-309, 1977
agents. Am Hev Respir Dis 1 37:265-272. 1 988b Menkes HA. Traystman RI. Terry P: Collateral ven
Kalincr M: Pharmacologic approach Lo the treat tilation. red Pror: 38:22-26. 1979
ment of mucus hypersecretion. Kaliner M. mod Mossberg S, Camner P; Mucociliary transport and
erator: Human respiralory mucus. Am Rev Rcspir cough as tracheobronch ial clearance mechanisms
Dis 134:618-619, 1 986 i n pathological conditions. Eur I Respir Dis 61
Kaliner M. Maroon J. Patow C. Shelhauser I: Human (Suppl l l 0):47-55. 1 980
respiratory mucus. ) A1Jprg Clil1 hnmtlr'IVJ 73:31B- M u rphy RUl. Holford SK. Knowler WC: Visual
323, 1984 lung-sound characterization by l i me-expanded
..... rahl V: Anatomy of the mammalian lung In Hond waveform analysis. N Engl J Med 296:968-971 ,
book of Physiology. vol 1 . Respiration, edited by 1977
wa Fenn and I I Rahn. American Physiological Nunn JF: Applied Respiratory Physiology. ed 2. p 9.
Society. Washington DC, 1 964 BuUerworth. London. '1977
Lambert MW: Accessory bronchiole-alveolar com Patow C: Studies on control of mucus secretion in
munications . 1 Palho/ Bacterio/ 70:3 1 1 -314. 1955 human airways. Kaliner M , moderator: Human
Lockhart RD, Hamilton CF. Fyfe FW: Analolll}' of respiratory mucus. Am Rev Respir Dis 134:617-
the Iluman Body. pp 535-548. Faber & Faber, Lon 618, 1 986
don. 1 959 Poller II.. Matthm... s LW, Lemm J . Spector S: l Iuman
Lopez-Vidriem MI. Reic! L: Respiratory tracl Ouid pulmonary secretions i n health and disease. Ann
chemical and physical properties of airway NY Acou Sci 106:692-697. 1963
mucus. cur J R(spir Dis61 (Suppl l 1 0):2'1-25. 1 980 Roscher R . Bittner R , Stockmann U: Pulmonary
Mackenzie cr, Shin B: Sequential respiratory func contusion. Arch Surg 1 09:508-510, 1974
tion following human lung contusion (abstract). Salala RA. Lederman MM. Shloes DM, Jacobs M R .
Crit Core Med 9:205. 1981 Eckstein E . Tweardy D . Toossi Z , Chmielewski R .
Mackenzie CF. McAslan TC. Shin B. Schellinger D, Marino J . King C K . Graham R e . Ellner J I : Diag
lIelrich M: Tho shape of thE! human adult trachea. nosis of nosocomial pneumonia i n intubated in
Anesthesi% gy 49:48-50, 1!.17an tensive care unit patients. Am He\' Ilespir Dis
Mackenzie Cr:, Shin 13. McAslan TC: Chest physio 1 35:426-432, 1987
therapy: the effect all arterial oxygenation. Shelhamer JH. Marvin Z. Kaliner M: Immu nologiC
Anes!h Anols 57:28-30. 1978b and neuropharmacologic s t i m u lation of mucus
Mackenzie CF, Shin B. Whitley N. Schellinger D: glycoproleins release from human airways. I Clin
The relationship of human tracheal size to body lnves! 66:1400-1 408, 1980
habitus. AnestheSiology 51 :$376, 1979 Shin B. McAslan TC, Hankins J R . Ayella R J . Cowley
r..lackenzie CF. Shin B. Hadi F. Il11le PC: Changes in RA: Management of lung contusion. Am Surg
total lung/thorax compliance following chest 45:168-175. 1979
physiotherapy. Aneslh Annlg 59:207-210, '1 980a Varsano $, norson DB. Gold M. Forsberg LS, Bas
Mackenzie CF, Shin e, Whilley N, Helrich M : baum C. Nadel JA: Proleinases release JS04-la
I luman I racheal Circumference a s an indicator of beled macromolecules from cult ured airway epi
correct cuff size. A neslhesiology 53:S414. 1 980b thelial cells. red Proc 43:786. 1 986
Mack lin MT, Macklin CC: Malignant interstitial Wagner PD. Saltzman HA. West JS: Measurement of
emphysema of the lungs and mediast inum as an continuous distribut ion of ventilation perfusion
important occult compliclltion i n many respira- ratios: Theory. ) Appl Physiol 36:588-599, 1974
Wanner A , Zarzecki S. H i rsch 1. Epstein S: Tracheal West IS: Respiratory Physiology-The Essenlials. ed
mucus transport in experimental canine asthma. 3, pp 7 and 104. Williams & Wilkins, Baltimore,
J Appl PhysioI 39:950-957. 1975 1985
Wasserman 51: Mediators of immediate hypersen West lB. Dolley CT, Naimak A: Distribution of
sitivity. } Allerg Clio Immunol 7 2 : 1 0 1 - 1 1 5 , blood flow i n isolated lung: Relation to vascular
1983 and alveolar pressures. J App/ Physio/ 19:71 3-724.
Weibel ER: Morphometry of the Human Lung. 1 1 1 . 1 964
Springer-Verlag. Berlin, 1963 Zuckerman S: Experimental study of blast inju ries
to the lungs. Lancet 2:21 9-224, 1940
CHAPTER 3
Postural Drainage, Positioning, and

Breathing Exercises
Postural Drainage
Problems Associated with Obtaining Ideal Postural Drainage Positions in the Intensive
Care Unit
Turning the Patient with Multiple Injuries
Turning the Patient into the Prone Position
Turning the Patient with Intravascular Lines
Turning the Patient with Chest, Tracheal, Feeding, and Sump Tubes
Turning the Patient with a Urinary Catheter
Patients with Head Injury
Turning the Patient with Head Injury
Obtaining the Head-Down Position
Orthopedic Injuries
Positioning the Patient with Long-Bone Injury
Positioning the Patient with Spinal Fracture
Beds
Modifications for Postural Drainage
Breathing Exercises
Breathing Exercises for the Patient with Obstructive Airway Disease
Forced Expiration Technique
Ventilatory Muscle Training
Breathing Exercises for the Patient after Surgery
Methods of Teaching Breathing Exercises
Chest physiotherapy consists of (1 ) pos The lung segments receIVing drainage

tural drainage, (2) percussion and vibra are positioned uppermost. Patients are
tion, (3) coughing, (4) suctioning, (5) t herefore placed i n the sitting, side-lying,
breathing exercises if the patient is not supine, prone, and head-down positions.
mechanically ventilated, and (6) optimal The side-lying head-down position is
patient mobilization as the medical con used most frequently. The majority of in
dition allows. This chapter discusses po tensive care unit (ICU) treatments are
sitioning the patient for optimal postural given to the lower lobes (see Appendix
drainage and the use of breathing A 1 .3 ).
exercises. Studies evaluating the efficacy of pos
tural drainage as a single component of
chest physiotherapy are limited, al
POSTURAL DRAINAGE
though this is an accepted treatment
Postural drainage, often referred to as component. The addition of postural
bronchial drainage, is achieved by posi drainage to cough instruction was shown
tioning the patient to promote gravity-as by Bateman et al. ( 1 981 ) to enhance pe
sisted drainage of retained secretions. ripheral lung clearance in patients with
93
chronic obstructive pulmonary disease Ventilation and perfusion are primar

(COPD). Marini et al. (1984) documented i l y gravity dependent (West. 1962; Glais
that lung volumes and oxygenation were ter, 1 967: Nye, 1 968). Lung ventilation
not significantly changed by using the varies according to the amount of active
head down position in 25 COPD patients, diaphragmatic contraction. Froese and
although 8 patients demonstrated an in Bryan (1 974) and Bryan (1974) found that
creased functional residual capacity the dependent lung volume was de
(FRC). In a similar patient population, creased with mechanical ventilation. Re
Buscaglia and St. Marie ( 1 983) docu cent studies suggest the diaphragm
mented no change in oxygen saturation moves with a piston-like motion with
with the prone and supine head-down mechanical ventilation (Rheder, 1987.
positions. Radioaerosol clearance of cen personal communication). Kaneko et al.
tral lung regions, increased sputum ex (1 966) noted that, in spontaneously
pectoration (Sulton et aI., 1 983; Maloney breathing normal subjects, ventilation
et aI., 1 98 1 ), and accelerated mucus was greater i n dependent lung zones at
clearance (Wong, 1 977) were also noted low lung volumes.
with postural drainage. Cardiorespira Studies evaluating the respiratory ef
tory function was studied by Mackenzie fects of changes in body position are not
and Shin ( 1 98 5) in 1 9 trauma patients re as conclusive in infants and patients with
quiring controlled mechanical ventila stable chronic lung disease. Wagamen et
tion and positive end expiratory pressure al. ( 1 979) noted that lung compliance.
(PEEP). Intrapulmonary shunt and lung tidal volume, and PaO, improved when
thorax compliance were significantly im changing the position of 14 mechanically
proved without a decrease in arterial ox ventilated infants from supine to prone,
ygenation during chest physical therapy although Heaf et al. ( 1 983) noted trans
that included postural drainage. cutaneous oxygen measurements to be
The effects of position changes in belter with the "good lung up." Improved
acutely ill patients following thoracic distribution of ventilation was noted in
and abdominal surgery, or in patients the uppermost lung in four subjects with
with acute unilateral lung disease have asymptomatic and stable COPD (Chang
been studied by several authors. Patients et aI., 1 986).
turned every 2 hr immediately after cor Available literature supports position
onary artery bypass surgery had a de ing adults with the "good lung down."
creased stay in the surgical ICU and a This is the usual position for delivering
lower postoperative fever compared with chest physiotherapy to patients with uni
a control group (Chulay et al" 1 982). lateral lung disease. The positions into
Clauss et al. (1 968) and Douglas et al . which clinicians are often reluctant to
(1 977) also demonstrated improved oxy place critically ill patients (right or left
genation with the simple maneuver of lateral, prone, and one-quarter turn from
turning side to side or prone. Spontane prone) appear optimal for maximum
ously breathing patients with pneumo matching of ventilation and perfusion. In
nia. lung contusion. and pleural effusion these positions improved oxygenation
and those mechanically ventilated with may occur.
PEEP demonstrated improved arterial Patients with bilateral lung disease are
oxygenation when positioned laterally assessed individually. In some patients it
with the "good lung down" (Zack et al.. may be difficult to determine the most in
1 974: Seaton. 1979: Dhainaut et aI., 1 980: volved lung by clinical examination and
Ibanez et a I . , 1981; Remolina et aI., 1 98 1 : chest x-ray. These patients should be
Sonnenblick e t aI., 1 983; R ivara e t aI., closely monitored while turning. a
1 984). Piehl and Brown ( 1 976) compared marked deterioration in oxygenation
PaO, in adults with acute respiratory fail may occur (Fig. 3 . 1 ). The side-lying posi
ure positioned prone and supine. Oxy tion may provide belter oxygenation than
genation was improved by prone posi the silting position (Table 3 . 1 ). Monitor
tioning. Improved perfusion of the ing vital signs. lung volumes, and oxygen
dependent lung is also noted with posi saturation may promote safe and effec
tioning the "good lung down" (Arbore tive treatment.
lius et al .. 1 974). Response to chest physiotherapy treat-
POSTURAL DRAINAGE, POSITIONING, AND BREATHING EXERCISES 95
120 ................ . . 60 ................... .. 120
1
---.:--..-----.----.--.-.
--_. . ._
- -
--_."
-0.____----
60 ...... ..... .............. .... 30 ....... ..... .. . . .. .. 60 .... .. ........ ......30

......-::
.- CP02
_I'_--::
-
rc; J:,
- I - ----'
'" 'J . (J)
w - w
(J)
j2"W' ....
.. .. 00 ..
CPC02
SITTING
RIGHT SIDE
SI ";;:;NG RIGHT SIDE
60 DOWN DOWN
LEFT SIDE SUCTIONING
DOWN
Figure 3.1. Transcutaneous oxygen (CPO,) and carbon dioxide (CPCO,) measurements for a pa
tient with closed head injury, pulmonary contusion, and a fractured left femur. The patient was
turned with the better lung (right) down after developing pneumonia and an ARDS patte rn on chest
x-ray. Data provided by Joan Stoklosa, B.S.
ment varies depending on the type of The findings of Oldenburg et al. ( 1 979J
mechanical ventilation or whether the that intermittent postural drainage is less
patient is spontaneously breathing. Pro effective without cough than with exer
kocimer and associates ( 1 983) found that cise or cough and Zinman's ( 1 984J eval
the head-down position improved oxy uation of stable cystic fibrosis children
genation in patients with bilateral lower demonstrating cough to be equally as ef
lobe lung disease receiving mechanical fective as postural drainage do not seem
ventilation with PEEP. Patients with se clinically relevant for the intensive care
vere posttraumatic ARDS unresponsive patient who cannot be mobilized. New
to conventional mechanical ventilation house ( 1 984) states that postural drainage
and therapeutic position change may re is likely to be most effective when secre
quire simultaneous independent lung tions are thin and copious. Postural
ventilation (SILV) (Siegel. 1988). Chest drainage may be especially beneficial in
physiotherapy may be performed, if in acutely ill patients who are often intu
dicated, for patients receiving (SILV) (Fig. bated, i n pain, or have a decreased level
3.2). The tidal volume delivered to each of consciousness, because, spontaneous
lung may be increased when necessary cough is less effective.
with changes in position. The following section discusses meth-
Table 3.1
Respiratory Effects of Changing Position for Patient in Figure
3.1'
Position
SIT 60 RT LAT SIT 60 RT LAT
Time 1 7:45 1 9:00 21:10 22:20

FlO, .65
PEEP 20
PaO, (mm Hg) 70 85 63 84
PaCO, (mm Hg) 34 29 41 37
0./0, 29% 24%
CO (liters/min) 9.1 7.4
'Data provided by Joan Stoklosa, B.S.

Figure 3.2. Patient receiving SILV

and chest physiotherapy to the left
upper lobe, posterior segment.
Therapist should closely monitor
changes in respiratory parameters
of each lung.
ods of achieving optimum segmental iary action and consequently the move
bronchial drainage for the ICU patient. ment of copious and viscous mucus to
Clinicians ordering or performing chest ward the major bronchi are influenced by
physiotherapy should encourage use of forces of gravity. By utilizing the follow
the optimum postural drainage positions ing methods to turn critical multiply in
to remove retained secretions and im jured patients, improved ventilation and
prove matching of ventilation and perfu perfusion relationships and secretion re
sion. This is most important for patients moval may be obtained.
immobilized or with poor cough ability.
Both lungs should be drained in patients
with lung contusion or lung abscess PROBLEMS ASSOCIATED WITH
when adventitial breath sounds occur OBTAINING IDEAL POSTURAL
during treatment and denote spillage of DRAINAGE POSITIONS IN THE
secretions to the dependenl lung. Treat INTENSIVE CARE UNIT
ment of all involved lung segments min
imizes spillage of secretions and bacterial Discussion and observation of treat
contamination of Ihe "good lung." The ment given by other physical therapists,
therapist should closely monitor the pa n u rses, and respiratory therapists con
tient's vital signs during treatment. Ar firm that chest physiotherapy is often not
terial blood gas, SaO" and chest x-ray re performed in the optimal bronchial
sults allow the clinician to tailor drainage positions. This may be due to
treatment to the needs of the individual the apparent difficulty of positioning a
patient. Monitoring is particularly impor patient who has multiple injuries or
tant following cardiac surgery, when car monitoring devices. Methods of obtain
ing optimum bronchial drainage by turn
diac output and mixed venous saturation
may be decreased during treatment (Bar ing patients despite the presence of mul
tiple injuries, lines, catheters, tubes and
rell and Abbas, 1978). It is important to
monitoring equipment are discussed in
note that a single measurement of arte
rial oxygenation is only temporal for a the following section.
specific body position and may change
dramatically with time and treatment. Turning the Patient with Multiple Injuries
Some patients may have a decrease in
The following guidelines are helpful
PaD, during treatment that increases
for turning the patient with multiple
once secretions are removed from Ihe pe
injuries:
ripheral airways. In the author's experi
ence the majority of ICU patients lolerate 1. Obtain the patient's history and
position changes necessary for postural diagnosis.
drainage quite well. 2. Observe the patient supine and iden
Illustrations showing the position and tify Ihe presence of fractures and soft
angle of tilt necessary to drain each seg tissue injuries or placement of lines,
ment (colored black) appear i n Figure tubes, catheters, and monitoring
3.3A-T. Zausmer (1968) suggests that cil- equipment.
POSTURAL DRAINAGE. POSITIONING. AND BREATHING EXERCISES 97
Figure 3.3. (A) The apical segments of both upper lobes are drained with the patient sitting up
right. (8) This spontaneously breathing patient is receiving postural drainage of the apical seg
ments of both upper lobes. (C) The anterior segments of both upper lobes are drained with the
patient supine. (0) This patient. positioned for drainage of the anterior upper lobe segments. had
a closed head injury and was unconscious. He also had multiple orthopedic injuries. (E) The left
upper lobe apical posterior segment is drained with the thorax elevated approximately 30. This
can be achieved by raising the head of the bed or by placing the whole bed 30 up from horizontal.
The patient is also positioned one-quarter turn from prone. (F) After a left thoracotomy and ex
ploratory laparotomy. this patient received postural drainage to the apical posterior segment of the
left upper lobe.
?11oi1111""'"'
is=;;>?ww)
K
Figure 3.3. (Continued) (G) The posterior segment of the right upper lobe is drained with the
patient positioned one-quarter turn from prone. The bed remains flat. (H) Postural drainage of the
right upper lobe posterior segment in a patient with a head injury, left pulmonary contusion. frac
tured ribs, left pneumothorax, and pelvic and limb fractures. He received physiotherapy following
splenorrhaphy and internal fixation of bilateral femur fractures. (I) Upper: right middle lobe position;
lower: lingula position. The right middle lobe and lingula are drained with the patient onequarter
turn from supine. A 12-inch bed elevation is recommended. (J) A patient receiving postural drainage
of the lingula. (K) The bed is flat and the patient is prone to drain the superior segments of both
lower lobes. (L) A patient with mUltiple-system involvement, including cervical spinal cord, chest
and abdominal injuries.
POSTURAL DRAINAGE. POSITIONING, AND BREATHING EXERCISES 99
Figure 3.3. (Continued) (M) The lateral segment of the right lower lobe is drained with the patient
lying on the left side. The foot of the bed is elevated. (N) Postural drainage of the lateral segment
of the right lower lobe is shown in a patient who sustained a head injury. a fractured left femur.
fractured right lateral malleolus and fibula. ruptured spleen. and liver lacerations. Pancuronium. a
neuromuscular blocking agent, was used because the patient was agitated and out of phase with
the ventilator. The patient has resting hand splints to preserve functional range of motion. Neufeld
traction permits turning to the left side. (0) The right side-lying head-down position is used for
postural drainage of the lateral segment of the left lower lobe and the medial segment of the right
lower lobe. (P) The lateral segment of the left lower lobe is posturally drained in a patient with
bilateral femoral fractures, a fractured left tibia, left lung contusion. and a chest tube draining a left
hemothorax. Neufeld traction and exoskeletal fixation devices allow the patient to be turned. A
Philadelphia collar IS being worn Since the seventh cervical vertebra could not be visualized on
lateral cervical spine x-ray. (a) The posterior segments of both lower lobes are drained in the prone
head-down position. (R) This patient had a right pneumothorax, lung contusion and soft-tissue lac
erations around the right elbow. He also had a laparotomy for repair of liver lacerations and mes
enteric tears. (S) The supine head-down poSitIOn is used to drain the ante nor segments of both
lower lobes. (T) This patient with multiple extremity fractures receives postural drainage of the
anterior segments of the lower lobes.
Figure 3.6. A roll made from sheets (arrow) is

Figure 3.4. Two people are required to pull a very practical and can be used to maintain the
patient with multiple injuries to the side of the patient in a side-lying position.
bed.
Turning the Patient into the Prone

3. Move the patient to the side of the bed Position
before turning (Fig. 3.4). If the patient
cannot assist, two people slide the pa The following guidelines have been
tient to the side of the bed. One person found useful for turning the patient into
lifts the thorax while the second the prone position:
moves the hips. 1 . Flex the dependent shoulder 1 80' or
4. Move lines and electrocardiogram position the dependent arm so that the
wires away from the side onto which patient can be rolled over it. One ther
the patient is turning. apist raises the trunk while the second
5. While facing the patient, place one moves the arm and shoulder from
hand over the shoulder and the other under the patient. Patients with oro
over the hip to rotate the patient onto tracheal or nasa tracheal tubes can
the side. A second person may be re maintain the prone position as long as
quired to move the hip and shoulder cervical rotation is not restricted (Fig.
back so that the patient remains cor 3 . 7 ). Sometimes it may be necessary to
rectly positioned (Fig. 3.5) . A roll may prop the patient's head on a pillow or
be used to prevent the patient from rolled towel to prevent kinking of the
rolling supine. Rolls, which can be tracheal and/or ventilator tubes.
made from folded sheets or blankets,
are better than pillows because they
are less easily compressed (Fig. 3.6).
Figure 3.7. Three people are required to turn

a patient with a tracheal tube prone. The de
pendent arm is moved under the patient's tho
Figure 3.5. On e therapist places a hand over rax and positioned comfortably. A roll is then
the shoulder and hip; a second pulls the hips placed under the chest to prevent the tracheal
back to position the patient on his side. tube from becoming occluded.
5. Once the patient is turned into the ap

propriate position, the ventilator tub
ing and monitoring equipment are
checked and readjusted as necessary.
Turning the Patient with Intravascular

Lines
Central Intravenous Subclavian Lines
Suturing of central intravenous subcla

vian lines so that the external tubing
runs parallel to the patient's thorax al
Figure 3.B. A massively fractured extremity lows full shoulder movement. The 90"
requires careful positioning with turning. side-lying position, the prone position,
and full shoulder horizontal adduction
can then be obtained without the line
2. Patients who have orthopedic injuries being pulled out or kinked (Fig. 3.1 0).
or pain that inhibits turning onto the
dependent shoulder may be turned
Peripheral Intravenous Lines
prone over the noninvolved upper
extremity. Peripheral intravenous lines usually
3. Patients with skeletal traction or ex do not i nterfer with turning. Preferably,
ternal skeletal fixation on the lower in order to allow beller mobilization,
extremity require a third person for they should not cross a joint.
prone positioning. The extra person is
required to position the involved ex
tremity carefully, avoiding motion
that is detrimental to the injury (Fig.
3.8).
4. Mechanically ventilated patients with
tracheostomies also require the assis
tance of three people for turning into
the prone position. Two are required
to raise the patient's upper thorax,
while one places a roll under the chest
to prevent occlusion or pressure on
the tracheostomy tube (Fig. 3.9).
Figure 3,10. (A) Tubing of a subclavian line

may become kinked when the patient lies on
Figure 3.9. Placing a roll under the chest al the same side. (8) Suturing subclavian lines
lows a patient with a tracheal tube to be turned parallel to the patient's chest allows adequate
three-quarters prone. There is then adequate side-to-side turning and proper positioning for
space for the tracheal and ventilator tubes. postural drainage.
Arterial Lines lem, a large roll is placed under the upper

thorax. This allows adequate space for
Radial lines are maintained in good po the tracheostomy tube and ventilator
sition with a secure dressing. In addition, tubing (Fig. 3.7). In order to minimize tra
an armboard or splint may help avoid cheal trauma, the patient may be discon
displacement. Femoral lines function in nected from the ventilator while being
all the required positions for postural turned. Patients with large intrapulmo
drainage, including sitting. Occasionally, nary shunts that require high fractional
hip flexion affects line function. The hip inspired oxygen concentration (FlO,) and
is then further extended until the proper positive end-expiratory pressure to
wave form is again observed on the mon maintain adequate arterial oxygenation
itor. The prone and supine positions are are an exception to this general rule. In
ideal for maintaining a good femoral ar these patients, instead of disconnection,
terial line wave form. The presence of an additional person assists with turning
umbilical catheters in neonates should b y manipulating the ventilator tubing.
not be a contraindication to prone This regimen of turning the intubated
positioning. and mechanically ventilated patient has
been found most satisfactory. Patients
Turning the Patient with Chest, with tracheal tubes may be positioned
Tracheal, Feeding, and Sump Tubes prone routinely when this position is
clinically indicated for chest phYSIOther
Chest Tubes apy. To prevent agitated patients from re
moving their tracheal tube, hand re
Chest tubes are placed for treatment of
straints or sedation are used before
hemopneumothorax and to adeqately
treatment and the tracheal tube is well
drain the pleural cavity in cases of pa secured.
tients with empyema. They are routinely
connected to an underwater seal. Suction
is often added for adequate expansion of Feeding Tubes
pneumothorax or to increase drainage of Patients in the ICU may receive nutri
the pleural cavity. Kinks or compresson tional support intravenously or through
of the tubes are avoided during turning orogastric. nasogastric, or gastrostomy
by careful patient positioning (Fig. 3 . 1 1 ). feeding tubes. It is important for the cli
Turning and positioning the patient may nician altering a patient's position to be
increase pleural drainage from depen aware of the type of feeding an individ
dent lung regions. ual patient is receiving. Bolus feedings
usually require coordination of physio
Tracheal Tubes therapy treatment with the feeding
schedule. Chest physiotherapy is given
Tracheal tubes may obstruct with before or 30 min after a feeding. Contin
prone patient positioning for postural uous feedings can be stopped for physio
drainage. I n order to prevent this prob- therapy treatment and resumed when
the patient is no longer positioned head
down.
Gastroesophageal reflux, a malfunction
of the distal esophagus causing regurgi
tation of stomach contents into the
esophagus, may be associated with aspi
ration of gastric contents into the lungs.
This condition is seen in infants and chil
dren and presents a dilemma to the ther
apist performing chest physiotherapy.
Nutritional support must be coordinated
with prevention and treatment of aspira
Figure 3.1 1. A patient with chest tubes may tion. The recommended medical treat
be positioned prone. The tubes are carefully ment is the semi erect position (head ele
positioned without ten s ion or kinking. vated 30-60) (Herbst and Myers, 1981;
Ocha. 1981 ). especially 30-45 min after clamp the tubing between the collection
feedings. Chest physiotherapy is indi bag and patient before turning patients.
cated to areas of suspected or confirmed This prevents drainage of stagnant urine
aspiration. Treatment should be coordi into the bladder. which may lead to uri
nated with feedings and administered ei nary tract infection. The collection bag is
ther before meals or no sooner than 1 hr moved to the side of the bed that the pa
after meals. to minimize chances of re tient faces after turning. To promote
gurgitation [De Ceasare. 1985). Position urine drainage the collection bag should
ing should be done judiciously and the be kept i n the dependent position. moved
patient's response to position changes to the head or foot of the bed. depending
should be closely monitored. If increased on the patient's head-up or head-down
vomiting is noted after treatment. thera position.
peutic positioning to minimize reflux. or
a modified postural drainage position
may be required. Therapeutic position PATIENTS WITH HEAD INJURY
ing for children with recurrent reflux is
described in the literature. The prone up The two major problems of performing
right position with partial neck flexion chest physiotherapy in patients with
[Hewitt. 1976: Zimmerman and Oder. head injury are turning and obtaining the
1981 ) is thought to promote drainage of head-down position.
regurgitated secretions from the mouth
and eliminate aspiration into the lungs. Turning the Patient with Head Injury
The right side-lying position may be ben
eficial to increase gastric emptying Use of Intracranial Pressure (ICP)
[Wood. 1979). A prone Iyer may be used Monitoring
successfully in i nfants with severe cen
tral nervous system dysfunction associ ICP measurement by a subarachnoid
ated with gastroesophageal reflu x and as screw or intraventricular catheter is ex
piration. The infant is placed in the prone tremely helpful to enable administration
Iyer head up 30-45 min prior to feedings. of chest physiotherapy to the patient
Tracheal aspiration and the need for rou with head injury. Intracranial pressure
tine chest physiotherapy treatment may and cerebral perfusion pressure [CPP)
be eliminated [1m Ie. 1983). The goal of limits are set, and when these are not ex
treatment for patients with gastroesoph ceeded. treatment is administered to ap
ageal refl ux is to provide adequate nutri propriate lung lobes or segments. Moni
tional support and pulmonary hygiene. toring of ICP and CPP. therefore. may
Each patient should be individually as allow chest physiotherapy to be per
sessed to determine if therapeutic posi formed; without it there could be no cer
tioning is adequate. If adventitial breath tainty that it was not detrimental to ce
sounds and clinical signs of chest infec rebral perfusion. Postural drai nage and
tion persist chest physiotherapy is routine nursing procedures. such as turn
indicated. ing and suctioning. may cause marked
increases in ICP [See pp. 363-366). Once
Sump Drains
noxious stimulation has ceased. ICP re
turns to baseline. provided the patient
Intraabdominal sump drains do not in has a high cerebral compliance. There
terfere with patient pOSitioning. Care fore. after turning a patient. the therapist
should be taken not to pull or disconnect should wait a few minutes for the ICP to
intraabdominal tubes when moving the decrease spontaneously. rather than im
patient. Dislodging the sump may lead to mediately returning the patient to the
hemorrhage or peritonitis. baseline position if increased pressures
occur. Once the patient is turned and po
Turning the Patient with a Urinary
s itioned. the head may need to be
Catheter
propped on a roll or intravenous bag to
avoid pressure on the ICP monitoring de
Urinary catheters do not interfere with vice and to decrease ICP. Percussion and
patient positioning. It is important to vibration do not increase ICP [see Chap-
ter 8 and Appendix for details of patients extensive physiotherapy is initiated. and
with head injury treated with chest this may reduce spasticity.
physiotherapy).
Turning the Patient with Abnormal Turning Patients with a Craniotomy

Muscle Tone After a craniotomy. patients require
Decerebration or decortication may proper head positioning to minimize
make turning the patient with head in pressure on the operative side. especially
jury difficult. Change of body position to if a bone flap was removed. Placement of
minimize abnormal muscle tone allows 500-ml intravenous infusion bags above
both increased joint range of motion and and below this area support the head and
improved positioning for chest physio prevent undue pressure (Fig. 3.13).
therapy (Bobath. 1974). Spasticity is often
affected by the position of the neck. Al Obtaining the Head-Down Position
though full cervical flexion may be lim
ited for example. b y a tracheostomy tube. After turning the patient. the therapist
even a small amount of flexion may min should wait a few minutes for the ICP to
imize extensor spasticity. The uppermost return to resting level. If this is below the
shoulder. hip. and knee may then be set limit (usually 25 torr). the patient is
flexed and restrained. Flexing the hip lowered into the head-down position
and knee may allow patients with in while the ICP and CPP are observed on
creased lower extremity extensor muscle the bedside monitor. Often the ICP is
tone to assume the lateral position. greater during positioning than when the
Restraints are often required to keep the patient is relaxed in the head-down po
patient optimally positioned (Figs. 3.6 sition. CPP is usually> 50 mm Hg with
and 3 . 1 2 ). Once the patient with a head these transient increases in ICP.
injury is breathing spontaneously. more If the ICP or CPP exceeds the accepta
ble limits elevation of the head on a roll
may result in a decreased ICP and in
creased CPP. The thorax may then be
lowered. Once the secretions reach the
upper airway. they may be suctioned
even with the head elevated. If increased
ICP is a major problem. patients can be
sedated before treatment in an attempt to
keep the pressure as low as possible. Bar
biturates and lidocaine may be used (see
Chapter 8).
Figure 3.13. Following craniotomy the pa

Figure 3.1 2. A sheet tied around the thigh and tient's head may be supported on two intrave
a wrist restraint (arrows) allow this patient to be nous infusion bags (arrows) to prevent pres
m aintained lying sideway s. Neufeld traction is sure on the operative site when the patient is
used to permit turning. turned or placed i n a head-down position.
Case History 3.1. An 18-year-old male was ible traction system that allows patients
admitted following a motor vehicle accident. He to be turned equally to the right and left.
was unconscious and had a parietotemporal Appropriate traction is still maintained at
and basilar skull fracture, fractured mandible, the fracture site (Fig. 3.1 4). Neufeld trac
multiple facial lacerations, a ruptured spleen
tion therefore enables nearl y all the cor
and a lacerated liver.
An ICP monitor was inserted on admission.
rect postural drainage positions to be ob
His chest X-ray remained clear throughout the tained. The patient may be moved out of
first week of hospitalization. Because the intra bed and seated i n a chair. Ambulation
cranial pressures were greater than 15 torr training, usually non-weight-bearing,
when sitting up, and greater than 25 torr with can also begin. Since turning is restricted
turning and positioning, chest physiotherapy with bilateral Neufeld traction (Browner
was not administered for 48 hr. Arterial blood et aI. , 1981), on admission. patients with
gases at 8 A.M. on 60% FlO, by mechanical ven bilateral closed femur fractures require
tilation with 10 cm H,O of PEEP were as fol
internal or external fixation of at least
lows: PaO" 73: pH, 7.45: and PaCO" 24. Total
one of the fractures.
lung/thorax compliance (C,) before therapy
was 32 ml/cm H,O. It was decided that aggres
Tibial fractures, some humeral and
sive chest physiotherapy should be given be pelvic fractures, and an occasional open
cause of deteriorating clinical signs, including femur fracture may be managed with
rhonchi and decreased air entry over the right exoskeletal fixation. With the exception
middle and lower lobes. The chest x-ray re of the pelvic fixater these devices allow
mained clear, although arterial oxygenation turning i n all positions (Fig. 3.1 5 ). Pelvic
had worsened. One hour of chest physiother fixation permits turning 90" to either side
apy was given to the right middle and lower (Fig. 3.1 6). Alternately, a turning frme
lobes, during which ICP varied between 25 and may be used for severe pelvic fractures
35 torr. Treatment produced copious amounts
with or without external fixation and al
of viscid secretions. Air entry improved over
the right base and right middle lobe: rhonchi di
lows chest physiotherapy (see Case His
minished. Repeat arterial blood gases with the tory 8 . 1 ) (Fig. 3.1 7). External fixation of
same ventilator settings were as follows: PaO" fractures allows frequent dressing
304: pH, 7.65: PaCO" 24. Inspired oxygen was changes, whirlpool cleansing, and de
decreased to 43%, and shorter daily routine bridement in patients with massive soft
treatments were given, provided the patient tissue injuries. It also allows patients
was productive of secretions. C, at 2 P.M. fol with pelvic, femoral, tibial, and fibular
lowing chest physiotherapy was 46 ml/cm H,O. fractures to begin early sitting and am
This case history demonstrates that marked bulation training (Hoffmann, 1954: Fel
decreases in arterial oxygenation may occur
lander, 1 963: Karlstrom and Olerud,
and C, may worsen due to retained lung secre
1975: Edwards et aI., 1979: Brumback et
tions despite repeatedly clear chest x-rays. Ox
ygenation and C, may be increased with chest aI., 1986; Burgess and Mandelbaum,
physiotherapy. 1987). Patients with a fractured acetabu
lum or h i p dislocation are commonly
placed i n Bucks traction (Shands and
ORTHOPEDIC INJURIES
Positioning the Patient with Long-Bone

Injury
Some patients may be difficult to posi

tion because of traction and splinting de
vices or specific injuries. The therapist
must be familiar with the several differ
ent types of fixation before turning a pa
tient with these devices. Devices that
allow full patient turning and mobiliza
tion are preferred.
Closed femoral fractures that cannot
be fixed by interal fixation within the Figure 3.14. Neufeld traction (arrow) allows
first several hours of injury may be the patient with a fractured femur to be turned
placed in Neufeld traction. This is a nex- 90 to either side.
Figure 3.15. Exoskeletal fixation

for a fractured left femur and right
tibia allows prone positioning.
Raney, 1967). This form of skin traction hip flexion and adduction are avoided.
need not i nterfere with patient position Anterior shoulder dislocations require
ing for postural drainage when there is minimizing shoulder external rotation
close communication between the ortho and abduction. Patients with subluxa
pedic and therapy staff. For acetabular tion, dislocation, and ligamentous injury
fractures, a small roll may be placed are therefore moved with caution to
under the iliac crest, and a second roll avoid motion similar to that causing the
below the greater trochanter, to avoid original injury.
pressure on the acetabulum. With severe The following case study demonstrates
fractures the patient may be turned the need for flexible orthopedic traction
prone by turning over the opposite hip to devices that allow the patient to be
avoid pressure on the involved hip. The mobilized.
Bucks traction is adjusted during turning
to pull parallel to the patient's hip. Case History 3.2. A 24-year-old male was
Splints applied for preserving range of admitted following an auto accident in which he
motion or immobilization of minor frac sustained a fractured first left rib, liver lacera
tures do not interfere with patient po tions, a retroperitoneal hematoma, an oblique
sitioning. Extremities with fractures fracture of the left acetabulum, and a commi
nuted subtrochanteric fracture. Initially, for
treated with plaster casts are easily ma
management of the pelvic and proximal femo
neuvered once the plaster has dried.
ral fractures, the p atient was placed in 90-90
Soft-tissue injury alone does not inter traction (hip flexion, 90; knee flexion, 90).
fere with positioning the multiple Maximum turning was 70 to the right. and it
trauma patient. Dislocations, for exam was impossible to turn the patient onto the left
ple, are commonly seen following Side. The admission chest x-ray was clear.
trauma. With posterior hip dislocation, Four days later, repeat chest x-ray showed
Figure 3.16. External fixation al

lows patients with severe pelvic
fractures to be turned 90 to either
side.
right upper lobe atelectasis that persisted

throughout the following day (Fig. 3.1 BA). On
the sixth morning the patient also developed a
left lung infiltrate (Fig. 3.1 BB). At this time it was
decided that a more flexible traction system
was necessary to assist management of the
patient's pulmonary pathology. The patient
was started on antibiotics, and the traction was
lowered to allow turning (Fig. 3.1 BG). Chest
physiotherapy was given to the right upper and
lower lobes as well as the left lower lobe. Co
pious amounts of viscid brownish secretions
were suctioned from the patient's tracheos
tomy tube. There was clearing of the radiolog
ical lung infiltrates (Fig. 3.1BD).
Figure 3,17, This patient following thoracic This case history demonstrates that, in the
spine and pelvic injuries was managed on a trauma patient, priorities need to be estab
turning frame to facilitate skin care and chest lished in patient management. The traction that
physiotherapy treatment. allowed turning was not ideal, but the patient's
Figure 3.18. (A) Chest x-ray 4 days after admission shows a right upper lobe atelectasis. (B) On
the sixth day after admission a left lung infiltrate had developed in addition to the persistent right
lung infiltrate. (C) The traction was lowered to permit turning and chest physiotherapy. (0) Following
chest physiotherapy treatment, the lung infiltrates have cleared.
pulmonary status improved and the patient side turning and upright positioning (Fig.
survived. 3.20). A turning frame may be used prior
One inflexible traction system is the to surgical spinal stabilization for pa
Thomas splint and Steinmann pin. This tients with major neurological deficit (see
was traditionally used to manage femoral p. 268). Patients who cannot be turned
shaft fractures prior to the routine use of fully on an orthodox bed can assume the
internal and external fixation devices. prone and supine head-up and head
down positions on a turning frame (Table
The pin provided a point for skeletal
3 . 2 ). Halo vests and body casts are used
traction. This skeletal t raction makes
for stable fractures or after surgical fixa
turning a patient greater than 45' to ei
tion. Halo vests are preferred to body
ther side almost impossible (Fig. 3 . 1 9 ). If
casts because they do not restrict costal
turning is restricted to 45', this prevents
or diaphragmatic excursion, radiological
bronchial and segmental drainage of the
interpretation, silting to 90', or skin in
posterior segment of the right upper lobe,
spection. Chest physiotherapy can be ad
the apical posterior segment of the left
equately performed on patients with a
upper lobe, and the superior and poste
Halo vest by opening the jacket. Percus
rior segments of both lower lobes. This is
sion and vibration may be given to the
a serious restriction as, in OUf experi
nondependent lung in the lateral position
ence, the posterior segments of the lower
lobes are the most commonly atelectatic or to both lungs posteriorly when the pa
lung segments (Appendix). More flexible tient is in the prone position. The vest
traction systems are preferred for pa should be opened only after the patient is
appropriately positioned. Taping the
tients with femoral fractures and multi
opened vest to the bedrails improves tho
ple trauma.
racic expansion and permits percussion
and vibration to most lung segments (Fig.
Positioning the Patient with Spinal
3 . 2 1 ). Patients with poly trauma and com
Fracture
plete neurological deficit may develop
pulmonary problems if placed in a vest
Patients with cervical fractures requir too early. R espiratory complications may
ing traction can be managed routinely occur due to inadequate chest expansion
with a special board that allows side to as noted in the following case history.
Figure. 3: 19. This patient with multiple injuries, including a pneumothorax, extensive liver and
bowel Inlunes, and a fractured nght femur and left tibial plateau, can only be turned 45 to either
Side due to the Thomas splint (arrow), with traction applied to the femur by a Steinmann pin.
Figure 3.20. This quadriplegic pa

tient following subluxation and an
open-book pelvic fracture was
managed in a regular bed and
turned 90 to either side prior to re
ceiving a halo vest. (Note special
board and traction (arrow), which
allow side-to-side turning and up
right positioning.)
Case History 3,3, After being hit by a truck, patient remained on the turning frame for sev
a 45-year-old male was admitted with the fol eral months due to his respiratory dependency
lowing diagnoses: C3-C7 spinous process secondary to lack of diaphragmatic function.
fractures with neurological deficit at C4, Le The patient was later transferred to a rehabili
Forte I fracture, and chest injury with seventh tation center.
to ninth right rib fractures. The patient was
placed on a turning frame for 8 days, and he
received chest physiotherapy; his chest x-ray BEDS
remained clear (Fig. 3.22A). On the eighth day
after admission, it was decided to place the pa Modifications for Postural Drainage
tient in a halo vest. His pulmonary status had
stabilized, although he continued to need me The high incidence of respiratory com
chanical ventilation due to phrenic nerve paral plications in the leu makes pulmonary
ysis. Chest x-ray the following morning showed care a major patient management prior
infiltrates in both lower lobes, which became ity. The type of bed has a significant im
progressively worse (Fig. 3.22B). Three days
pact on the ability to perform adequate
after the patient was placed in a halo vest, he
chest physiotherapy. Beds that achieve a
was returned to the turning frame and contin '
ued on aggressive chest physiotherapy (which 30 or greater head-down postural drain
may not have been adequate while in the halo age position are preferred (Fig. 3.23). Gas
vest). Repeat chest x-ray the following morning kell and Webber (1973) advocate an 18-
showed some improvement, which continued inch elevation of the foot of the bed for
throughout the following day (Fig. 3.22C). This drainage of the anterior, lateral, poste-
Figure 3.21. The halo jacket can

be easily opened to permit percus
sion and vibration over appropriate
lung segments. Skin integrity can
also be evaluated.
Figure 3.22. (A) Clear chest x-ray following B

days of chest physiotherapy given to the pati ent
on a lurning frame. (8) Bilateral lower lobe infil
trates developed within 24 hr of placement in the
halo jacket. (e) The lower lobe infiltrates have
cleared since the patient was placed back on the
turning frame and received vigorous chest
physiotherapy.
rior, and medial segments of the lower ing beds, and beds specifically designed
lobes, and an elevation of 14 inches for for the obese patient. The need for spe
Ihe right middle lobe and lingula. The cialty beds is primarily dependent on the
length of the bed and patient's position nurse to patient ratio, training of the
should be taken inlo consideration be nursing staff regarding turning and posi
cause they alter the tilt of the bronchial tioning difficult patients, patient skin in
tree. Most standard beds can be placed in tegrity, and size of the patient. Turning
a 1 5 head-down position as a unit. Beds frames and kinetic beds are often rec
in which the head can be lowered to ob ommended for the spinal injury patient
tain an additional tilt of Ihe bronchial requiring traction, although a standard
tree are preferred. Shock blocks may be bed can be adapted to provide cervical
used with beds that do not provide an ad traction that allows the patient to be
equate head-down tilt (Fig. 3.24). During turned 90 to either side and sit up in bed
the past 10 years there has been a marked for pulmonary care (see Fig. 3.20). With
increase in the usage of specialty beds this system spinal stabilization is ade
with minimal evidence to substantiate q uate for management of cervical flexion
their usage. Frequently used specialty injuries (Frederick Geisler MD, personal
beds include turning frames, low air loss communication). It is the author's opin
beds. air fluidized beds. kinelic turn- ion that the turning frame allows beller
POSTURAL ORAINAGE, POSITIONING, AND BREATHING EXERCISES 111
skin inspection, chest physiotherapy

treatment, and early rehabilitation than a
kinetic bed. Proponents of all specialty
beds claim improved skin condition com
pared to a standard bed, although studies
evaluating turning frequency and body
position on standard versus specialty
beds are minimal. I t has been the au
thor's personal observation that low air
loss beds and flotation beds are often util
ized to replace side to side turning. Turn
ing affects all body systems, not just skin
pressure. Air fluidized beds offer contact
pressures lower than capillary closing
pressures. Decreased capillary pressure
is thought to lower the incidence of tis
sue breakdown and aid healing. Hargest
[1977) states that pneumonia has not de
veloped in patients on air fluidized beds
whose primary problem is lack of move
ment. lt is our experience and that of oth
ers [Smoot, 1986) that retained secretions
and pneumonia do develop in trauma pa
tients while on an air fluidized bed. Sit
ting upright and performing postural
drainage are extremely difficult on this
Figure 3,23. Hydraulic beds are easily placed bed [Fig. 3.25).
in the head-down position.
The continuous movement of kinetic
beds is thought to minimize tissue break
down and secretion retention. Schimmel
et al. [1977) demonstrated use of the ki
netic bed to change ventilation-perfu
sion relationships. In a patient with a
gunshot wound to the chest, a right lung
contusion cleared, but a left lower lobe
atelectasis was apparent on the chest x
ray taken within 8 hr of admission. At
tempts to perform chest physiotherapy
on patients i n this bed demonstrate that
adequate treatment can be given only for
four lung segments: the anterior seg
ments of both upper lobes, the right mid
dle lobe, lingula, and anterior segments
of both lower lobes. Seven postural
drainage positions for the other lung seg
ments therefore cannot be obtained. as
the bed limits turning. In practice. the pa
tient cannot be positioned with the af
fected lung uppermost for the most com
monly atelectatic lung segments. The
manufacturer advocates removal of the
posterior chest portion of the bed to allow
chest physiotherapy treatment. However.
Figure 3.24. This electric bed is placed on percussion and vibration without the use
shock blocks to promote more adequate pos of segmental postural drainage is likely
tural drainage. to be ineffective [see Chapter 4). Patients
Figure 3.25. The height and depth

of the low air loss bed make mobi
lizing patients in and out of bed
very difficult. Five staff members
are required to lift this mechanically
ventilated multiple trauma patient
from the low air loss bed to a chair.
who do not tolerate positioning and turn The kinetic bed was unable to prevent the
ing on a turning frame because of in development of complete right lung atelectasis
creased ICP or agitation also do not tol in this patient with chest trauma. Chest phys
erate treatment on the kinetic bed. For iotherapy performed with the patient turned
patients with increased ICP. a 45' head into the postural drainage positions described
in this chapter may have prevented some of the
elevated position is difficult to achieve.
aspiration of blood and secretion retention.
Table 3.2 compares standard and spe Once complete atelectasis and hypoxemia de
cialty beds. The following case history veloped, they were irreversible.
demonstrates the disadvantages of the ki
netic bed for a patient with severe chest This bed did not result in a favorable
trauma. outcome with this patient. It may be ad
vantageous for quadriplegic patients in a
Case History 3.4. A 1 9-year-old female was
chronic facility, who have recurrent
admitted to the trauma center following a mo
torcycle accident. She had a right pneumotho
chest infections and decubitus ulcers.
rax, lung contusion, rib and clavicular frac Often at home or in these facilities there
tures, and a torn right main stem bronchus. is insufficient help for adequate patient
She was taken to the operating room for rean turning. Bedridden quadriplegic patients
astomosis of the torn bronchus and a laparot who experience severe shoulder pain
omy. liver lacerations were found and with side-to-side turning may prefer the
repaired. kinetic bed. Results similar to the man
After surgery the patient was placed on a ki ufacturer's claims of treating acute atel
netic bed. Repeat chest x-ray 8 hrs after ad ectasis are obtained with chest physio
mission showed the bilateral alveolar-intersti
therapy (see Case History 6.1 ).
tial infiltrates of respiratory distress syndrome
(Fig. 3.26). This pattern persisted during the When working in a critical care unit it
patient's hospital stay. The kinetic bed was must be realized that any time a thera
used according to manufacturer's instructions peutic intervention interferes with the
when the patient was stable hemodynamically. operation of a specialty bed the cited
No chest physiotherapy was given because of benefits are eliminated. Many patients
inability to achieve proper bronchial drainage require bedside medical therapy, special
positions. Chest x-ray 4 days after admission studies, and transportation from the ICU
showed complete right lung atelectasis (Fig. for special procedures. Proponents of the
3.27). The patient's PaO, was 45 on an FlO, of rotating bed claim that the hazards of im
1 .00. Bronchoscopy was performed; copious
mobility are minimized and eliminated,
amounts of retained secretions were noted.
The anastomosis in the right main stem bron although the bed is often immobile
chus remained intact. Cardiopulmonary arrest (Trammel et aI., 1985), particularly when
developed following bronchoscopy secondary used for critically injured trauma pa
to hypoxemia. The patient expired after numer tients (see Appendix, pp. 361-362). Initial
ous attempts at resuscitation, including open claims by the manufacturer that kinetic
cardiac massage. therapy eliminates the hazards of immo-
Table 3.2 'U
0
Comparison 01 Standard and Specialty Beds (J)
-<
Criteria Standard Bed Large Person Turning Frame Low Air Loss Air Fluidized Kinetic C
JJ
l>
Recommended All When body weight Spinal injury or Immobilized patients, Burns, severe skin lesions. Spinal injury requiring r
patient exceeds patients except spinal immobilized patient up traction, immobilized 0
population standard bed requiring injury, tissue 10 260 lb. Nol patients, skin pressure JJ
weight inspection and breakdown, burns recommended with sores, questionable for
requirements, treatment cardiac disease, patients with elevated ICP.
Z

700 tb limit posteriorly. 250 reduced lung function, Patient must be able to Q
Ib limit or disoriented patients tolerate rotation 1 8 hr/day !"
(Kalaja. ( 984) 'U
Patient evaluation All body surfaces are Same Same Same Same Only anterior body surface is 0
(J)
and inspection exposed with side exposed. Pad placement =i
to side turning restricts inspection 0
Bedside diagnostic Allows 90 upright Same. 90 upright Cannot obtain true Same Cannot obtain true upright Cannot obtain true upright; Z
tests and lateral easier to obtain upright position position. difficult for abdominal and chest films Z
positioning for placing cassettes to are more difficult to obtain .P
bedside xrays take bedside xrays. and interpret. Cassette rack
and special more difficult to interpret placement is not ideal due Z
0
procedures xrays to varying patient size
III
Turning ease and Dictated by the Same. 3-4 Manufacturers Same Manufacturers claim these 1 24 every 3.5 min while JJ
frequency patient's medical persons may suggest 1 beds eliminate the need rotating. One person m
status, usually be required person, in leu for patient turning required to operate bed

-<
every 2-3 hrs, 1 -2 2 persons every although turning is I
persons for 2 hrs, prone necessary for most Z
routine turning. 3 and supine body systems (see Q
for obese patients poSitions Chapter 6); nursing staff m
x
or prone often neglects m
positioning JJ
necessary turning
()
(Smoot. ( 986) Ui
Patient comfort Subjective, normal Subjective Subjective, some Subjective Subjective, disorientation Subjective, manufacturers and m
environmental patients do not has been reported Keane (1977) claim better
(J)
stimulation like prone (Smoot. 1 986; Lucke than the Stryker frame; 4
position and Jarlsberg, 1 985; stroke patients found
Rath and Berger 1 982). confinement intolerable
Patients have requested (Kelley el al.. ( 987);
to be removed from bed increased agitation has
(Bolyard el aI., 1987) been noted in head injured
and complained of patients; 30% patients on
weightlessness, inability bed requested it be
to move freely. and stopped (Trammell et aL,
elevate head of bed ( 985)
(Nirmille and Storm
...
( 984)

...
Table 3.2 (Continued)

Comparison of Standard and Specialty Beds
Criteria Standard Bed Large Person Turning Frame Low Air Loss Air Fluidized Kinetic
Pulmonary care Suctioning: no Suctioning: same Suctioning: same, Suctioning: same Suctioning: same Suctioning: manufacturers
interference prone position claim the body position
assists changes improve
oropharyngeal cannulation of the left
drainage mainstem bronchus. This is
not substantiated in the
literature (Kirimli at aI.,
1970; Kubola el al.. 1 980)
Postural drainage: all Postural drainage: Postural drainage: Postural drainage: Postural drainage: More Postural drainage: allows
postural drainage 5/11 drainage 7 of 1 1 postural same difficult to obtain the 1 1 1 2 head-down position; 4/
()
positions positions drainage positions; headdown and 1 1 positions can be I
obtained. Does positions, prone sitting positions are not obtained. Results same as m
(f)
not go into position assists optimal. Atelectasis and documented by Mackenzie -i
headdown drainage of decreased lung function el aI., (1 985). Pulmonary "
position posterior and documented (Smoot, 1 987: complications may be I
-<
most frequently Kalaja, 1 984) reduced in spinal injury (f)
involved lung patients not easily turned 6
segments (Reines and Harris, 1 987) -i
I
Decreased atelectasis, m
pneumonia, in trauma :D
patients although frequency

"
of turning on a conventional -<
bed is not documented Z
(Genlilello el al., 1 988) -i
Spinal alignment Maintained through Same Adequate for most Not recommended Not recommended for Proponents claim better than I
m
standard traction spinal injuries for spinal spinal stabilization turning frame, not
or special board, stabilization documented by controlled Z
-i
(see Fig. 3.20) studies m
Intracranial Head may be raised Same Head can be Same Difficult to maintain upright Kelley el 01., (1 987) found Z
(f)
pressure as necessary to elevated to position; when patient is increased transtentorial <:
lower ICP reduce ICP upright, posterior thorax herniation compared to m
does not receive benefit standard bed, ICP not ()
of bed significantly altered by

:D
stationary bed positions m
(GonzalezArias et aI., C
1 983). Affect while rotating Z
unkown =i
Pressure sores Minimal with good Unknown Decreased Decreased, reported Fluidized pressure 1 5-30 Manufacturers and some -u
nursing care although bed compared to to increase mm Hg (Lucke and authors claim decreased o
has a very firm kinetic bed healing, contact Jarlsberg. 1985). sores compared to
mattress which (Trammell et ai., pressure less than Manufacturers and standard bed (Green, 1 9BO). C
JJ
may lead to 1 985) 27 mm Hg al any Micheels and Sorensen Authors have noted heel
increased point. lower than (1 987) claim pressure and decubitus ulcers. Firm r
pressure sores standard bed relief and bactericidal bed surface may lead to o
JJ
(Beaver, 1986; effects prevent ulcers pressure sores when bed is

Redfern et aI., and promote healing. not rotating Z
1 973) particularly with skin
gratts and burns; heel
.m
and occipital ulcers
reported (Parish and
-U
o
Witowski, 1 980; Smoot, en
1 986) =l
Mobility and Normal Upright position is Allows self- ADL easier than Upright positioning, bed to Spinal injury patients with 6
easily obtained feeding while kinetic and air chair transfers, and upper extremity function z
functional
activities for self-care, prone; not fluidized beds. ambulation require are limited in ADL. Z
G)
bed can be appropriate for Manufacturers additional personnel, 3 Positioning to prevent
adapted for patients who claim shearing or more personnel to lift shoulder and elbow
z
easier transfer can be forces minimized patient out of bed (Fig. contractu res is difficult. o
to the standing mobilized out of when moving 3.25) Normal progression of CD
position bed patient in bed mobilizing the ICU patient JJ
m
out of bed is cumbersome
unless a special kinetic bed
I
is used
Z
Range of motion Access to all joints Same Same; allows Same More difficult to maintain Many pads must be removed G)
(ROM) exercises for necessary positioning of and perform therapy for for range of motion m
exercises and bed SCI patients to shoulders, elbows, and exercises, full hip and x
m
positioning prevent hips. Appear to develop shoulder extension cannot JJ
shoulder. more shoulder be obtained. Active ()
elbow, ankle contractu res (Smoot, exercise of all dorsal u;
contractu res 1986). Positioning is muscles is difficult
m
en
more problematic, when
splinting is required to
maintain joint ROM the
effect of the bed is
eliminated under splints.
Shoulders cannot be
appropriately positioned
for burn victims (Lucke
and Jarlsberg, 1 985)

'"

en
Table 3.2 (Continued)

Comparison of Standard and Specialty Beds
Criteria Standard Bed Large Person Turning Frame Low Air Loss Air Fluidized Kinetic
Deep vein Variable in the Unknown in the Unknown Unknown Unknown Proponents of the bed claim
thrombosis literature obese decreased venous stasis,
thrombophlebitis population in decreased with heparin and
this bed; support stockings (Kelley at
improved ability aI., 1 987). Emhoff et al.
to ambulate ( 1 987) documented deep
and mobilize vein thrombosis in a patient
the obese on a kinetic bed
patient is
()
thought to have I
a beneficial m
Ul
effect -I
Infection Not specifically Unknown Unknown Unknown Controversial; Scheidt and Decreased in stroke victims ."
influenced by bed Drusin (1 983) report using bed (Kelley et al., I
-<
contamination of sheets 1 987). Bed has many parts Ul
in heavily infected burn to be cleaned between
is
patients; Bolyard et al. patients -I
I
(1987) noted negligible
m
difference to standard :D
bed of air contamination
."
in ulcer and pain -<
patients Z
Safety/resuscitation Board required Same Patients Rapid deflation of Can be rapidly defluidized One person can stop bed for -I
positioned the sacs provide a for a firm surface resuscitation, firm surface I
permits resuscitation m
prone must be Hat. firm base for
turned supine resuscitation z
-I
for resuscitation m
Mortality Effect of bed Unknown Inconclusive: Unknown effect Decreased mortality Inconclusive: increased when z
Ul
unknown reported by reported in burn victims compared to standard bed
Brackett and (Scheurer and Munster, i n controlled study of stroke
<:
m
Condon (1 984) 1 983) victims. (Kelley et aI., 1 987). ()
in a Brackett and Condon
:D
retrospective ( 1 984) reported decreased m
study to be mortality over the turning c
increased for frame in a retrospective z
=<
Ease of Easier to move for Patient must be Easier to move for Some air loss beds Patient must be Very bulky. difficult to "U
o
transportation special studies or transferred to a special studies have several bulky transferred to a transport for special Ul
transfer to the stretcher for than other control units. stretcher for procedures -;
C
operating room transport speciality beds Transportation transportation :JJ
than speciality more difficult than
r
beds other than standard bed
o
the turning frame :JJ
Expense No additional patient $8000, $90/day $SO-SO/day $SS-$80/day. Purchase $1 3S/day
(approximate) charge not recommended by Z
manufacturer because

Gl
of comprehensive .m
infection control "U
guidelines; $39.20 per o
day over standard bed Ul
and decreased nursing =i
care reported i5
z
Hazards Dehydration. increased Lines and nasogastric tubes
Z
insensible water loss. may be pulled out by Gl
hypernatremia (McNabb rotating bed. Documented

and Hyatt, 1 987; mechanical failure z
Micheels and Sorensen (Trammell et aI., 1 985) o
1 987; Rath and Berger IJ)
:JJ
1 982). Malfunction of m
thermal control, leaky
nylon sheets, corneal

I
abrasions. Ceramic Z
beads may need to be Gl
changed more m
frequently than
x
m
recommended by :JJ
company. (Nirmille and o
Slorm, 1 984). en
m
Other Thought to conserve body Ul
nitrogen through
reducing body protein
breakdown (Jones et
aI., 1985; Ryan, 1 983)
-
-
....
118 CHEST PHYSIOTHERAPY IN T H E INTENSIVE CARE UNIT
Figure 3.26. Chest x-ray taken

within 8 hrs of admission, showing
bilateral alveolar-interstitial infil
trates and a right lung contusion.
most patient populations have not been and pulmonary care to standard beds or
documented. Proponents of the bed now a turning frame. Table 3.2 demonstrates
claim it does not replace routine nursing documented advantages and disadvan
care (Green et al.. 1983). C u rrent litera tages of specific beds. Specific criteria
ture, except for the studies by Kelley et based on the results of well-designed
al. (1987) and Gentilello et al. (1988) do studies need to be developed to justify
not, in a controlled and detailed fashion, the cost of specialty beds compared to
compare patient turning, mobilization, traditional ones. The bed chosen for an
Figure 3.27. Complete right lung

atelectasis developed after 4 days
of treatment on a kinetic bed.
individual patient should include the 3. Increase thoracic cage mobility and
ability to provide adequate pulmonary tidal volume
hygiene, splinting and range of motion 4. Promote relaxation.
exercises, normal environmental stimu
lation, and allow easy access for diagnos Studies evaluating lung ventilation
tic tests and transfers to a bedside chair. with diaphragmatic and lateral costal ex
In our opinion the low air loss beds are cursion exercises show little or no
the most practical of the specialty beds change in the distribution of ventilation.
for the patient at high risk for tissue It was found that ventilation is deter
breakdown. Adequate patient mobility, mined by body position and is greatest i n
comfort, orientation, and positioning can dependent lung zones (Shearer et al.,
all be obtained. The exception is spinal 1972; Bake et aI., 1 972; Sackner et aI.,
injury patients who are managed quite 1974; Grimby et aI ., 1 975; Martin et
well on a turning frame. The large person aI., 1 976; and Brach et aI., 1977). This was
bed is very practical for the obese pa true in normal subjects with unilateral
tient, although the major limitation is the lung disease (see pp. 93-94), and patients
inability to achieve the head-down posi with chronic lung pathology. However, at
tion. Future clinical studies may deter high flow rates at functional residual ca
mine the efficacy of the low air loss ver pacity Roussos et al. (1977) and Fixley et
sus air fluidized beds. al. (1978) found that in normal subjects
abdominal inspiration increased gas dis
tribution to the dependent lung, while
BREATHING EXERCISES intercostal inspiration gave a mOfe even
distribution of ventilation, preferentially
Breathing exercises have been used
to the nondependent lung zones. Hughes
since the 1 890s to improve respiratory
(1979) suggested that changes i n thora
function (Nicholson, 1980). They are
coabdominal shape could influence re
commonly taught to patients with
gional blood flow after measuring
chronic lung disease and neuromuscular
changes in segmental oxygen and carbon
disease, as well as to patients after sur
dioxide concentrations through a
gery. The patient with chronic lung dis
bronchoscope.
ease is often taught "breathing control"
Recent studies continue to question
or "breathing retraini ng" exercises. Ex
the benefit of diaphragmatic breathing
ercises used clinically include diaph rag
exercises for the patient with chronic
matic and costal excursion exercises, the
lung disease. Williams et al. (1982) and
forced expiration technique, pursed lip
Willeput et al. (1983) were unable to doc
breathing, and, more recently, the intro
ument a beneficial effect from thoraco
duction of inspiratory muscle training
abdominal breathing that was used to de
(Leith and Bradley. 1976). In addition,
crease paradoxical chest movements and
segmental breathing exercises are fre
improve exercise performance.
quently described in standard texts
When studying the surgical patient.
(Irwin and Tecklin, 1985; Frownfelter,
decreased postoperative pulmonary com
1987). Research has not documented
plications and hospital stay have been
these exercises to provide additional
documented with chest physiotherapy
benefit over costal excursion exercises.
treatment that included breathing exer
As it is unlikely that a specific "segmen
cises (Warren and Grimwood, 1 980;
tal" breathing exercise can direct re
Thoren, 1954; Morran et aI., 1983; Wilk
gional ventilation to a specific lung lobe
lander and Norlin, 1957). Data are still in
or segment, these exercises are, there
conclusive regarding the use of breathing
fore, not advocated.
exercises compared to other chest phys
The main goals of breathing exercises
iotherapy treatment components. It is dif
are to
ficult to separate the effects of coughing,
1. Assist removal of secretions position change, manual techniques, and
2. Improve respiratory muscle strength breathing exercises because of the lack of
and endurance standardization of chest physiotherapy
treatment among acute care centers. the underlying physiological mechanism

Breathing exercise techniques used in is not known. pursed lip breathing ap
patients who are hypoventilating due to pears to be a beneficial noninvasive ma
intercostal muscle weakness or inci neuver for some patients with chronic
sional pain after surgery require further pulmonary disease. It can be taught i n
investigation. th e hospital an d th e response o f th e pa
tient monitored with ear oximetry. Tem
porary improvement in oxygen satura
Breathing Exercises for the Patient with tion is noted when pursed lip breathing
Obstructive Airway Disease is compared to relaxation. Tiep et al.
(1 986) believe pursed lip breathing may
Diaphragmatic improve patient confidence and decrease
anxiety by providing some temporary
For the patient with obstructive airway control over oxygenation.
disease, diaphragmatic "breathing con
trol" is advocated as a means of achiev
ing relaxation and coordinated breathing Breathing Control
patterns. It is often used with pursed
lip breathing. Greater tidal volumes Breathing control is taught to asthmat
achieved with diaphragmatic breathing ics and patients with chronic lung dis
may improve overall ventilation (Brach ease for use when i n mild to moderate
et a I . , 1977). Use of an electronic respira distress. These patients may require the
tion stimulator (Motley, 1963), a mechan side-lying, head-elevated. or forward
ical vibrator (Barach and Dulfano, 1968), leaning posture to achieve relaxation
and mechanical chest and abdominal instruction.
compression (Petty and Guthrie. 1971 ) Changes i n posture alter respiratory
also demonstrated increased tidal vol function more dramatically than breath
ume and decreased respiratory rate in ing retraining. Leaning forward posture.
patients with chronic airway obstruction. and. less frequently, the supine or head
Although an immediate decrease in res down positions alter minute ventilation,
piratory rate and increased tidal volume expiratory reserve volume. mi nimize ac
are demonstrated, long-term beneficial ef cessory muscle activity. relieve dyspnea.
fects are not substantiated (see pp. 1 1 9 ) and correct paradoxical abdominal mo
(Miller, 1954; Becklake et a I . , 1954; tion (Delgado et al .. 1982; Sharp et al..
McNeill and McKenzie, 1955; Campbell, 1980; Barach. 1 974). The leaning forward
1955; Emirgil et aI., 1 969; Petty and Guth posture is also adopted by long distance
rie, 1 97 1 , Willeput et aI., 1 983; Williams runners (Haas et aI., 1982). In these
et aI., 1982). healthy individuals who are stressing the
respiratory system and in patients with
Pursed Lip Breathing
chronic pulmonary disease, diaphrag
matic function is thought to be improved
Pursed lip breathing. used in conjunc by altering the muscle length-tension re
tion with breathing retraining and dia lationship when leaning forward. When
phragmatic breathing, is often taught to teaching breathing retraining it may be
the patient with chronic obslructive pul necessary to utilize the optimum position
monary disease. Temporary benefits in for an individual patient (leaning for
clude increased tidal volume, decreased ward, supine, or head down) and provide
respiratory rate, reduction in PaCO, lev a manual stretch to the diaphragm. This
els, and improved PaD,. Subjective ben would place the diaphragm in a position
efit is reported by many patients (Tho to facilitate optimum length-tension re
man et aI., 1966; Mueller et al .. 1 970; lationship. Kigen (1984) reports dramatic
Barach. 1973; Motley. 1 963; Tiep et al.. relief of dyspnea, improved walking abil
1 986). Ingram (1967) demonstrated that ity, and minimal use of accessory mus
symptomatic relief may occur before al cles with a manual stretch applied to the
veolar ventilation is altered. Although diaphragm. In one recent study exercise
POSTURAL DRAINAGE. POSITIONING, AND BREATHING EXERCISES 121
reconditioning and breathing retraining tion. It is our opinion that a controlled

led to significantly greater exercise tol expiration, at times through pursed lips,
erance. decreased respiratory rate. in followed by maximal inspiration is most
creased tidal volume. and improved PaO, beneficial.
when compared to exercise alone (Cas
ciari et aI . , 1 98 1 ). E lectromyogram and
biofeedback were used to monitor relax Forced Expiration Technique
ation of the accessory muscles. Magne
tometry and biofeedback were utilized to The forced expiration technique is de
synchronize movement of the abdomen scribed i n the E uropean and Australian
and thorax. One difference in this study literature as a breathing exercise that
and previous studies not substantiating a may minimize or eliminate the need for
benefit of breathing retraining (Williams manual or mechanical techniques when
et aI., 1 982: Booker, 1984) is that objective used in conjunction with postural drain
measurements were taken and utilized age. This breathing exercise is used most
in conjunction with the breathing exer often with stable cystic fibrosis, although
cises. For some patients biofeedback and it may be employed with chronic lung
magnetometry may be necessary to disease, and possibly after surgery. The
achieve the desired effects of breathing forced expiration technique consists of
retraining i n conjunction with a change controlled diaphragmatic breathing ex
in posture. Improved throacoabdominal ercises interspersed with " h uffing"
motion noted clinically may actually in (forced expirations from mid-lung to low
duce paradoxical chest motion and in lung volume) (see pp. 162). Currie e.I al.
duce hypoventilation during breathing ( 1 986) believe the forced expiration tech
exercise training (Willeput et aI., 1 983). nique (four deep breaths with relaxed
Paradoxical chest motion may therefore expiration followed by diaphragmatic
appear abnormal but actually be benefi breathing and forced expirations, dia
cial for some patients. Asynchronous phragmatic breathing, and one to two
chest motion detected t hrough magneto coughs) performed i n appropriate pos
meters may be an indicator of exercise tural drainage positions replaces the
tolerance (Delgado et al" 1 982). This may manual techniques of percussion and vi
have clinical significance in the ICU bration. Sutton and colleagues ( 1 983,
when breathing exercises are used in 1 984) found the forced expiration tech
conjunction with weaning the chronic nique was more effective than directed
lung disease patient from mechanical coughing with the most sputum obtained
ventilation. when it was used in conjunction with
While teaching breathing control In postural drainage. In a later study Sutton
nocenti (1 966) advocated avoiding full et al. ( 1 985) documented this exercise
expiration and beginning inspiration was more effective than manual tech
sooner than usual. In theory, prolonged niques that were used with postural
expiration does not achieve significant drai nage to the affected l ung. Faulk and
emptying of emphysematous bullae but colleagues ( 1 984) found greater sputum
does compress and hamper ventilation of production i n cystic fibrosis patients
normal lung, Gandevia (1 960), Miller using a face mask to deliver positive ex
( 1967), Gaskell and Webber (1975), and piratory pressure in conjunction with
Cash (1975) state that expiration should postural drainage when compared to
be controlled. but not forceful, to avoid chest physiotherapy that included the
increased airway resistance caused by forced expiration technique.
premature airway closure and progres Documented benefits of the forced ex
sive air trapping. Webber (personal com piration technique include decreased
munication) believes avoiding full expi time required for postural drainage and
ration and controlled expiration are increased patient independence (Pryor et
essentially the same. Becklake et al. aI., 1 979a,b; Murphy et aI., 1 983; Webber
(1 954). Dorinson (1 955), and Campbell et et al" 1 985). This may be a very cost-ef
a l. (1 986) emphasize prolonged expira- fective maneuver for patients with lung
disease requiring life-long assistance to 10 min, or the lime a patient could sus
remove excessive tracheobronchial tain a critical level of resistance. Cur
secretions. rently the inspiratory muscle training de
vices are more practical than isocapnic
Ventilatory Muscle Training exercise for clinical and home use.
Training benefits occur after 15-30 min
Since the initial work of Leith and of exercise daily for four to eight weeks.
Bradley in 1976 that demonstrated an in As noted in Table 3.3, research is incon
crease of inspiratory muscle strength and clusive as to whether these breathing ex
endurance in normal subjects with train ercises consistently improve respiratory
ing, breathing with inspiratory resistance muscle strength and endurance (Pardy et
is used in COPD, muscular dystrophy, se a \ . , 1988). Controlled studies where a
vere kyphoscoliosis, acid maltase defi training stimulus is chosen to achieve a
ciency, following spinal cord injury, and desired response with larger patient pop
with cystic fibrosis (Fig. 3.28). The major ulations are needed to determine the
ity of research includes subjects with worth of inspiratory muscle training.
chronic lung disease and cystic fibrosis Specific patient populations to be studied
and results are variable (Table 3.3). include cystic fibrosis, chronic lung dis
Training is prescribed for improving ven ease, muscular dystrophy, and quadri
tilatory muscle strength, endurance. or plegia comparing the response of training
both. Strength training is accomplished to diaphragmatic breathing and general
by subjects breathing through a narrow conditioning exercises. The advantage of
tube that offers inspiratory resistance. this type of training compared to other
The size of the tube orifice is determined approaches is the ability to exercise reg
by the patients tolerance, usually for 5- ularly at home with minimal equipment
1 5 min (Kim 1984: Jederlinic et a\., 1 984; that is inexpensive.
Dimarco et a\., 1985; Belman et a\., 1 986;
Hornstein and Ledsome, 1986). Endur Breathing Exercises for the Patient after
ance training is usually thought to be ac Surgery
complished through isocapnic exercise
that affects both the inspiratory and ex The incidence of postoperative pul
piratory muscles. In this type of training monary complications remains at 1 2-
subjects train for up to 1 5 min while the 22% despite advances in postoperative
maximum sustained ventilatory capacity pulmonary care (Ford and Guenter,
is measured under isocapnic conditions. 1 984). The majority of complications
Pardy et a\. ( 1 98 1 b ) and Sonne and Davis occur following thoracic or upper abdom
(1 982) documented endurance with in inal surgery. Chest physiotherapy is rou
spiratory muscle training as the amount tinely prescribed following surgery and
of resistance that could be tolerated for at times preoperatively. Tarhan and col
leagues (1973) documented that preoper
ative pulmonary preparation decreased
postoperative pulmonary complications
without altering mortality in 1 90 men
and 37 women requiring thoracic and ab
dominal surgery. Recently Castillo and
Haas (1985) studied preoperative chest
physiotherapy that included breathing
exercises and documented a decrease in
overall complications and atelectasis.
This patient population included 200
upper abdominal and thoracic surgical
patients over age 65. Respiratory therapy
that includes breathing exercises has sig
Figure 3.28. This quadriplegic patient uses nificantly decreased the incidence of
inspiratory muscle training during acute pneumonia and atelectasis following sur
hospita lizati on
. gery (Campbell et al.. 1986; Morran et a\.,
Table 3.3
."
Studies Evaluating Ventilatory Muscle Training 0
U>
Reference Population Studied Training Results -i
c
:D
Smith et al. 8 Ouchenne muscular 2 X /day-tolerable load for 1 0- No 1 vc or M I max
dystrophy r
(1 988) 1 5 min; 5 weeks-blinded;
0
crossover method :D
Abelson and 1 COPO, 3 quadriplegic bid. 1 5 min at initial tidal volume; 1 VC; t Plmax; 1 endurance
Brewer (1 987) who failed weaning 21-71 days z

from mechanical Gl
ventilation !"
Clanton ( 1 987) 1 6 swimmers 8 controls, 8 IMT; 50-60% PI max No additional benefit of IMT over ."
0
'" 1 0 min, 3 X week, 1 0 weeks a conditioning program U>
Hornstein ( 1 987) 2 severe bid, 1 5 min when tolerated I functional ability I PI max, 1 :::;
kyphoscoliosis subject I endurance (5
z
McKeon et al. 1 8 severe COPO after 1 0 subjects; orifice sizes 5- No t in inspiratory muscle z
(1 986) optimum 2.5mm ; three 1 5 min sessions/ strength (PI max); 1 tolerance Gl
conventional therapy day, 6 weeks; 8 trained with of resistance; no f mean
placebo exercise capacity z
0
Belman et al. 10 COPO One orifice smaller than orifice No change spirometric, pulmonary '"
(1 986) patient could sustain for 1 5 volumes, P I max, MEP, :D
min, 1 5 min bid, 6 weeks m
maximum sustained ventilatory
capacity -i
I
Hornstein and 20 acute quadriplegics Resistance tolerated for 1 5 min, 1 Plmax 10 subjects, safe for z
Ledsome 1 5 min bid acute stage quadriplegia Gl
(1 986) m
x
Larson et al. 22 COPD Threshold breathing device 30 1 endurance; 1 inspiratory m
:D
(1 986) min/day, 2 mos; 1 2-15% muscle strength; 1 12 min walk ()
Plmax; 1 0-30% Plmax test; group exercising at 30% iii
Plmax m
U>
Aldrich and 4 chronic respiratory Max tidal airway pressure 1 5- 1 PNIP in 3 patients, successful
Karpel ( 1 985) failure patients who 20% PNIP, 5-30 min, 1 0-24 weaning
failed weaning days
Clanton et al. 8 normal females Resistance adjusted to maintain 1 Plmax, t endurance time
(1 985) adequate tidal volume, 1 0
weeks, 25 min/week
Dimarco at al. 1 1 muscular dystrophy As tolerated for 5- 1 5 min, 1 5 min t VC, 1 PI max, 1 FEV" 1
(1 985) bid, 6 weeks duration of hyperpnea
Ambrosino et al. 1 6 stable COPO Breathing exercises, 3-1 0 min No added benefit measured in
(1 984) sessions daily of inspiratory pulmonary function tests, blood -
...
training; compared to medical gases, or exercise tolerance '"
treatment alone; fatigue

measured clinically and by
EMG

.,
...
Table 3.3 (Continued) ()

Studies Evaluating Ventilatory Muscle Training' :r
m
(IJ
Reference Populalion Studied Training Results -i
."
Jederlinic (1 984) 6 normals. 1 9 COPD 4 weeks, resistor at 1 setting I SaO" no training ellect :r
-<
below max, 30 min daily (IJ
Larson and Kim. 9 stable COPD 1 5 min bid, 1 month 1 Plmax, 1 sputum is
(1 984) expectoration, no change 1 2 -i
:r
min walk test m
:D
Martin (1 983) 1 acid maltase bid, 15 min; 6, 2 1 , 46, cm H,O/ 1 SaO,; I 0, during sleep; 1
deficiency patient liter/sec endurance ."
-<
Asher et al. 1 1 cystic fibrosis, Max resistance tolerated for 1 0 1 Plmax and endurance, little
(1 982) moderately severe min, 4 weeks bid ellect on exercise performance
Z
-i
airflow limitation :r
Sonne and 6 severe COPD Resistance tolerated 1 0 min, 30 1 endurance (amount inspiratory m
Davis (1 982) min daily, 6 weeks resistance tolerated for 1 0 min). Z
-i
f max respiratory exercise m
z
capability (IJ
Pardy et al. 1 7 patients with chronic Compared IMT 30 min daily to IMT showed 1 endurance time in <:
(1981a) airflow limitation exercises 3 X /week, 2 months distance walked in 1 2 min m
()
Pardy et al. 12 moderate to severe Resistance adjusted to minimal f inspiratory muscle endurance
(1981 b) COPD resistance with a sustained documented by EMG and 1 2 :D
m
decrease H/L ratio noted in 2 min walk test. n o change c:
of 3 respiratory muscles, 1 5 strength z
min bid, 2 months =i
Belman (1981) 2 COPD with acute 1 5 min hyperpnea 3-6 X daily T MSVC: T ventilatory muscle ."
respiratory failure during weaning endurance
o
(j)
8elman and 10 stable COPD 1 5 min MSVC, 6 weeks Significant T in MSVC, T arm --i
C
Mittman and leg exercise tolerance :D
(1 980)
r
Gross et ai. 6 chronic quadriplegics Resistance determined by EMG T PI Max and PmCrit, strength o
(1 980) signs of fatigue, 30 min daily, and endurance :D
8-16 weeks
Z
Bradley and 1 2 normals (4 strength, Measured O2 consumption during T aerobic endurance of
4 endurance, 4 respiratory muscles with
(;)
Leith (1 978) sustained voluntary .m
control) normocapneic hyperpnea endurance training ."
Keens et ai. 4 normals, 4 cystic Maximal sustainable ventilatory Upper body endurance exercise is o
capacity 25 min/day, 5 days/ as effective at increasing
(j)
(1 977) fibrosis patients =<
week: normocapnic hyperpnea ventilatory muscle endurance 5
4 weeks: 1 .5 hr/day physical as specific training z
training z
1 2 normals 4 trained 30 min daily, 5 days T VC, T TLC in strength training, (;)
Leith and
Bradley week, 5 weeks, strength t maximal voluntary ventilation
z
(1 976) training at 20% intervals of VC, in endurance training o
4 trained for endurance III
through "ventilatory sprints"
:D

'H/L ratio, electromyogram ratiO, amplitudes of high and low frequency: PNIP, peak negative inspiratory pressure: EMG, electromyogram: --i
I
PmCrit, critical mouth pressure; MSVC, maximum sustained ventilatory capacity: M I N , minutes: MEP, maximum expiratory pressure; MAX, Z
maximum: IMT, inspiratory muscle training: VC, vital capacity: TLC, total lung capacity: FEV" forced expiratory volume in 1 sec and: SaO" (;)
arterial oxygen saturation; PI max, maximum inspiratory pressure. m
x
m
:D
Q
(j)
m
(j)

'"
'"
1 983; Celli et al .. 1984; Castillo and Haas, ing exercises and chest physiotherapy
1 985). Diaphragmatic and lateral costal after upper abdominal or thoracic surgi
breathing exercises with vibration were cal procedures except when there is a
shown to decrease chest infeclion when specific clinical indication for chest phys
studying 102 patients following cholecys iotherapy (see Chapter 6). Breathing ex
tectomy (Morran et aI., 1983). Campbell ercises and postural drainage with man
et a l. (1 986) demonstrated that hand-de ual techniques are necessary for the
livered positive expiratory pressure more acutely i l l patient who cannot be
(PEP) and breathing exercises delivered optimally mobilized or who does not
to 71 abdominal surgery patients de deep breathe and cough spontaneously.
creased respiratory complications. Smok The effects of deep breathing on arte
ing appeared to increase the incidence of rial oxygenation were studied by Ward et
respiratory complications: due 10 a larger al. (1 966) and Hedstrand et al. (1978).
number of smokers in the control group Ward et al. studied ten normal subjects
it is not known if PEP is of additional breathing 100% oxygen. Maximal inspi
benefit compared to breathing exercises ration. with and without a 5 sec hold. and
alone. Celli and colleagues (1 984) found 12 successive deep breaths were evalu
deep breathing exercises to be as effec ated by arterial blood gas analysis. The
tive as incentive spirometry and inter greatest increase in arterial oxygenation
mittent positive pressure breathing was found with maximal inspiration and
(IPPB) in 172 patients who had abdomi a 5-sec hold. There is controversy sur
nal surgery. rounding whether breathing 100% oxy
Following pedialric surgery the insti gen increases intrapulmonary shunt
tution of brealhing exercises and pos (McAslan et aI., 1973), but it is a fre
tural drai nage demonstrated a significanl quently stated opinion that it causes mi
decrease in the incidence of atelectasis croatelectasis due to denitrogenation.
(Strandberg, 1956). Poslural drainage was These conclusions, therefore, may not be
not differenlialed from Ihe use of breath justified. Breath holding, which causes
ing exercises in this study. Breathing ex positive pressure in the l ungs, is presum
ercises for patients following cardiotho ably the most effective of the three meth
racic procedures were sludied by Vraciu ods studied in reversing this process.
and Vraciu (1977). In high-risk patients, Hedstrand et al. (1978) investigated 45
breathing exercises resulted in a signifi patients with several types of deep
cant decrease in pulmonary complica breathing devices. which included in
lions, suggesling thai they were more ef centive spirometry, the Bird asthmatic
fective than poslural drainage wilh insufflator. and a paper coil. All produced
percussion. However, palients intubated essentially the same improvement in ar
for greater than 48 hrs and those in terial oxygenation. Deep breathing with
whom additional chest physiotherapy instruction by a physical therapist gave
was ordered were excluded. The group of the same improvement in PaO, without
patients in whom postural drainage and the use of any mechanical devices.
percussion may be of greatest benefit was Maneuvers designed to decrease pul
therefore eliminated. monary complications after surgery are
After coronary artery by-pass proce unable to completely eliminate atelecta
d u res Dull and Dull (1983) measured pul sis and pneumonia. This may be due to a
monary function in 49 adults randomly reduction of diaphragmatic function after
assigned to a breathing exercise, incen thoracic or upper abdominal surgery
tive spirometry, or early mobilization (Ford et al.. 1983: Simonneau; et aI.,
group. Neither form of breathing exercise 1983). It remains unclear whether
showed benefit over early patient mobi breathing exercises can alter diaphrag
lization. Hallbook and colleagues ( 1 984) matic dysfunction that is thought to
also documented patient mobilization to cause the adjacent lung to retain secte
be as effective as chest physiotherapy in tions (Ford and Guenter, 1984). Current
1 54 patients after gallbladder surgery. studies suggest that diaphragmatic con
Based on our clinical experience patient tractility is not altered after surgery but
mobilization may replace routine breath- diaphragmatic dysfunction is secondary
to decreased afferent input of the phenic with the back of the head supported.
nerve. Diaphragm activity spontaneously The COPD patient may lean forward
returns 24 to 48 hr after operation (Du or assume a position to enhance res
reuil et at., 1986), Ford and Guenter, piratory function.
1984). Block of this afferent stimulation 2. The therapist should oberve the pa
may be used i n conjunction with dia tient's breathing pattern and note
phragmatic breathing exercises. Pain and whether it is primarily abdominal,
anaesthesia may not contribute as greatly upper chest, or lateral costal.
to postoperative pulmonary complica 3. The therapist's hand should be placed
tions as previously thought (Craig, 1981). either just below the xiphoid process
Benefits gained from breathing exer or over the costal cartilages of the
cises such as diaphragmatic, and lateral lower ribs (Fig. 3.29).
costal exercises, which are traditionally 4. The patient is encouraged to exhale
taught by physiotherapists, may be the and then " fi l l out your waist," or to
same as the benefits gained from deep "push the therapist's hand up" during
breathing alone. Improvement in pain inspiration. Simple commands and
limited chest wall mobility is thought to demonstration are usually most effec
be seen following breathing exercises tive. Relaxation of the upper chest and
when they are given to the patient after shoulders is encouraged.
surgery (Grimby, 1974). Whether im 5. This maneuver is carried out with the
proved chest wall movement necessarily patient's hand placed over the upper
has any long-term benefit to ventilation abdomen (Fig. 3.30).
of the underlying lung is not determined. 6. It is repeated until adequate expan
It is our opinion that breathing exer sion is achieved.
cises are beneficial when used for spon
taneously breathing patients to assist in Costal Excursion Exercises
removal of secretions. They are used in
dependently or in conjunction with other Costal excursion exercises are used to
chest physiotherapy techniques. The ad mobilize the thoracic cage, especially in
dition of chest percussion and postural patients with intercostal weakness. They
drai nage depends on evaluation of the re may also relieve splinting from incisional
sults of the breathing exercises for spon or abdominal pain and may promote deep
taneously breathing patients. If de breathing in al l postural drainage pos
creased or adventitial breath sounds do tions. The hands are placed over the area
not improve with deep breathing and
coughing, chest physiotherapy is carried
out to the clinical and radiological area of
involvement.
Methods of Teaching Breathing

Exercises
Diaphragmatic Breathing
The techniques of teaching breathing

exercises are well described by Gaskell
and Webber (1973), Cash (1975), Irwin
and Tecklin (1985), and Frownfelter
(1 987). Diaphragmatic breathing exer
cises are used primarily to increase tidal
volume, to assist i n the removal of secre
tions, and for relaxation.
The following technique is used to
teach diaphragmatic breathing:
1. The postoperative patient is posi Figure 3.29. A patient receives instruction in
tioned relaxed in the sitting position diaphragmatic breathing exercises.
Figure 3.30. The patient performs diaphrag

matic breathing independently after instruction.
of the lung being treated. Lateral costal Figure 3.32. After thoracotomy this patient is
excursion and diaphragmatic breathing performing active shoulder range of motion
exercises are the most frequently used exercises.
breathing exercises.
The following technique is used to
teach lateral costal excursion exericses: coordinated with shoulder adduction
and extension exercises. Incisiona} or re
1 . The palm of the therapist's hand is ferred pleuritic pain from chest tubes
placed over the seventh to tenth ribs often limits shoulder motion. In these pa
laterally. tients, active range of motion exercises
2. The patient is encouraged to take an may be administered within the limits of
active deep inspiration, pushing the pain (Fig. 3.32). This maintains scapular
lower ribs outward against the ther mobility and reduces the chances of ad
apist's hands. hesions forming in the joint capsule. No
3. The therapist gradually increases re problems with dislodgment of the chest
sistance to this movement, as much as tube have been noted during range of
can be tolerated by the patient (Fig. motion exercises. However, al l chest
3.31 ). tubes are sutured into place. Trunk flex
4. The patient exhales, and the maneu ion, extension and rotation exercises
ver is repeated. may also be added depending upon the
Once the patient has mastered chest individual patient's limitation of motion
wall movement, inspiration may be co (Fig. 3.33).
ordinated with shoulder flexion and ab
duction exercises and expiration may be
Figure 3.31. A patient receiving lateral costal Figure 3.33. Lateral trunk flexion exercises
excursion exercises i n conjunction with pos are incorporated with breathing exercises to
tural drainage of the right lower lobe. improve thoracic cage mobility.
POSTURAL DRAINAGE, POSITIONING, A N D BREATHING EXERCISES 129
SUMMARY Bake B. Fugl-Meyer AR. Crimby G: Breathing pat

terns and regional ventilation distribution in te
Chesl physiotherapy is best performed Iraplegic patients and in normal subjects. Clin Sci
in optimum bronchial drainage positions, 42:1 1 7-128. 1 972
Barach AL. Dulfano MJ: Effect of chest vibration in
even when positioning is difficult. The pulmonary emphysema: A Preliminary report.
type of bed will influence the ability to Ann Allergy 26:10-17. 1 968
properly position patients for postural Barach AL: Physiologic advantages of grunting.
drainage. Standard beds that achieve a groaning. and pursed-lip breathing: Adaptive
symptoms related to the development of contin
15' or greater head-down position are
uous positive pressure breathi ng. Bull NY Acod
preferred. A turning frame and low air Med 49(8):666-673. 1973
loss bed allow better positioning than ki Barach AL: Chronic obstructive lung disease: Pos
netic and air fluidized beds. In sponta tural relief of dyspnea. Arch Phys Med Rehabil
neously breathing patients, breathing ex 55:494-504. 1974
Barrell SE. Abbas HM: Monitoring during physio
ercises are used to increase tidal volume therapy after open heart surgery. Physiotherapy
and aid removal of secretions. Chest wall 64:272-273. 1978
movement is encouraged by use of costal Bateman J. Newman 5, Daunt K. Sheahan N, Pavia
excursion exercises in patients who have P. Clarke 5; Is cough as effective as chest physio
therapy in the removal of excessive tracheobron
incisional pain, intercostal muscle weak
chial secretions? Thorax 36:683-687, 1981
ness, or poor inspiratory force. Diaphrag Beaver M : Mediscus low air loss beds and the pre
matic breathing, lateral costal excursion vention of decubutus ulcers. Cril Care Nurse
exercises, or encouragement to breathe 6:32-39. 1986
deeply and cough precede chest physio Becklake M . McGregor M . Goldman HI, Braudo JL:
A study of the effects of physiotherapy in chronic
therapy in spontaneously breathing pa hypertrophic emphysema using lung fu nction
tients. The forced expiration technique tests. Dis Chest 26:180- 1 9 1 . 1 954
may replace manual techniques in cystic Belman MJ: Respiratory failure treated by ventila
fibrosis and COPD. For spontaneously tory muscle training. Eur J Respir Dis 62:391-395,
1981
breathing patients without clinical or ra Belman MI. Mittman C; Venti latory muscle training
diological evidence of retention of secre improves exercise capacity in chronic obstructive
tion, diaphragmatic breathing exercises pulmonary disease patients. Am Rev Respir Dis
the forced expiration technique, or in 121 :273-280. 1980
spiratory muscle training may be all that Belman MJ. Thomas SG. Lewis M : Resistive breath
ing training in patients with chronic obstructive
is required for prophylaxis. The COPD pulmonary disease. Chest 90:662-669. 1986
patient may benefit from breathing exer Bobath B: Adult Hemiplegia. Evaluation and Treat
cises in the leaning forward or head men!, p 79. William Heinemann Medical Books.
down position. Early patient mobiliza London. 1974
Bolyard EA, Townsend TR. Horan T: Airborne con
tion after minor surgical procedures may
tamination associated with in-use air-fluidized
replace the need for chest physio beds: A descriptive study. Am J Infect Control
therapy. 1 5(2):75-78. 1 987
Booker HA; Exercise training and breathing control
in patients with chronic airflow limitation. Phys
References
iotherapy 70(7):258-260. 1984
Abelson H. Brewer K: Inspiratory muscle training in Brach BB. Chao RP. Sgroi VL. Minh VD, Ashburn
the mechanically ventilated patient. Physiolher WL. Moser KM: Xenon washout patterns during
Can 39(5):305-307. 1987 diaphragmatic breathi ng. Chesl 71:735-739. 1977
Aldrich TK. Karpel JP: inspiratory muscle resistive Brackett TO. Condon N: Comparison of the wedge
training in respiratory failure. Am Rev Respir Dis turning frame and kinetic treatment table in the
1 3 1 :461-462. 1985 acute care of spinal cord injury patients. Surg
Ambrosino N. Paggiaro PL. Roselli MG. Contini V: Neural. 22:53-56. 1 984
Failure of resistive breathing training to improve Bradley ME. Leith DE: Ventilatory muscle training
pulmonary function tests in patients with chronic and the oxygen cost of sustained hyperpnea. J
obstructive pul monary disease. Respiralion Appl Physiol: Respir Environ Exercise Physiol
45:455-459. 1 984 45(6):885-892. 1 978
Asher MI. Pardy RL, Coates AL. Thomas E. Mack Browner BO. Kaneja S. Edwards CC: The use of
lem P: The effects of inspiratory muscle training modified Neufeld traction in the management of
in patients with cystic fibrosis. Am Rev Respir Dis femoral fractures in polytrauma. J Trauma
126:855-859. 1982 21 :778-786. 1981
Arborelius M. Granqvist U. Uja B. Zanner CW: Re Brumback KI, Bosse MI, Poka A. Bu rgess AK: Intra
gional lung function and central haemodynamics medullary stabilization of h umeral shaft frac
in the right lateral body position during hypoxia t u res i n patients with multiple trauma: J Bone
and hyperoxia. Respiration 3 1 : 1 93-200. 1974 Joint Surg 68(1 ):960-969. 1 986
Bryan AC: Comments of a devil's advocate. Am Rev unilateral pneumonia using the lateral decubitus
Hespir Dis 1 1 0(2):143-144. 1974 position. Thorax 35:792-793. 1980
B u rgess AR, Mandelbaum B R : Acute orthopedic in Dimarco A. Dimarco M . Jacobs I, Shields R, Altose
juries. ln Trauma Emergency Surgery and Crilicol M: The effects of inspiratory resistive training on
Core. edited by I Siegel. p 1062. Churchill Living respiratory muscle function in patients with
ston. 1987 muscular dystrophy. Muscle Nerve 8:284-290,
Buscaglia AI. 51 Marie MS: Oxygen saturation dur 1985
ing chest physiotherapy for acute exacerbation of Dorinson SM: Breathing exercises for bronchial
severe chronic obstructive pulmonary disease. asthma and pulmonary emphysema. lAMA
Resp ir Core 28:1009-1013, 1983 156:931-933 . 1 955
Campbell ElM. Friend J: Action of breathing exer Douglas WW, Rehder K. Beynen FM. Sessler AD,
cises in pulmonary emphysema. 1 :325-329. 1955 Marsh HM: Improved oxygenation in patients
Campbell T. Ferguson N. McKinlay RGC: The use with acute respiratory failure: The prone posi
of a simple self-administered method of positive tion. Am Rev Respir Dis 1 1 5:559-566, 1977
expiratory pressure (PEP) in chest physiother Dull fL. Dull WL: Are maximal inspiratory breath
apy after abdominal su rgery. Physiolnerapy ing exercises or incentive spirometry better than
7211 0):498-500. 1 986 early mobilization after cardiopulmonary bypass?
Casciari R I . Pairshter RD. Ha rrison A. Morrison IT. Phys Ther 63(5):655-659. 1983
Dlackburn C. Wilson AF: Effects of breathing re Dureuil B. Viires N, Cantineau JP. Aubier M. Des
training in patients with chronic obstructive pul monls 'I: Diaphragmatic contractility afler
monary disease. Chest 79:393-398. 1981 upper abdominal surgery. l App/ Physio/
Cash IE: Chest. Heart and Vascular Disorders for 61(5):1775-1780. 1 986
Physiotherapists. pp 121-127. I B Lippincott. New Edwards CC. laworski MF, Solana I. Aronson B:
York. 1975 Management of compound tibial fractu res by ox
Castillo R . Haas A: Chest physical therapy: Com ternal fixation. Am Surg 45:190-203, 1979
parative efficacy of preoperative and postopera EmhoffT, Wedel S. Geisler FH. Gens D. The occur
tive in the elderly. Arch Phys Med Rehobil rence and detection of deep venous thrombosis
66:376-379. 1985 and pulmonary embolism in the spinal cord in
Celli OR. Rodriquez KS. Snider G: A controlled trail jured patienl. (abstract) Crit Care Med 1 5(4):428.
of intermittent positive pressure breathing. in 1987
centive spirometry. and deep breathing exercises Emirgil C, Sobol BI. Norman H, Moskowitze: A
in preventing pulmonary complications after ab study of the lon8 term effect of therapy in chronic
dominal surgery. Am Rev Respir Dis 130:12-15. obstructive pulmonary disease. Am J Med 47:367-
1984 376. 1 969
Chang S. KWflng IC. Chun I. Williams MH. Blaufos Faulk M, Kelstrup lB. Anderson 18. Kinoshita T,
0: Positional effects on distribution of ventilation Fnlk P. Slovring S. Gothgen I: Improving the
in chronic obstructive pulmonary disease. Ann ketchup bottle method with positive expiratory
l n fern Med 105(3 ):346-350. 1 986 pressure. PEP. in cystic fibrosis. Eur J Raspir Dis
Chulay M. Drown I. Summer W: Effect of postoper 65:423-432. 1984
ative immobilization after coronary artery by Fellander M: Treatment of fractures and pseudoar
pass. Cril Core Med 10:1 76-179, 1 982 throsis of the long bones by Hoffmann's transfix
Clanton TL. Dixon GF. Drake I. Cadek IE: Effects of alion method. Ac to Drthop Scand 33:132-143.
swim training 011 lung volumes and inspiratory 1 963
muscle conditioning. I Appl Physio! 62(1):39-46. Fixley MS. Roussos CS. Murphy B. Martin RR.
1987 Engel LA: Flow dependence of gas distribution
Clanton TL. Dixon G. Drake J . Gadek J : Inspiratory and the pallern of inspiratory muscle contraction.
muscle conditioning using a threshold device. I Appl Physio/ 45:733-741. 1 978
Chest 87:62-66. 1985 Ford CT. Whitelaw WA. Rosenal TW. Cruse PI.
Clauss RH, Scalabrini BY. Ray IF. Reed GE: Effects Cuenter CA: Diaph ragm function after upper ab
of changing body posi tion upon improved venti dominal surgery in humans. Am /lev Respir Dis
lat ion-perfusion relationships. Ci rcu io tion (Suppl 127:431-436. 1983
2)37:214-21 7. 1 968 Ford CT, Cuenter CA: Toward prevention of post
Craig DB: Postoperative recovery of pulmonary operative pulmonary complications. Am Rev Res
function. Aneslh Anaig 60:46-52. 1981 pir Dis 1 30:4-5. 1 984
Currie DC. to.funro C. Gaskell D. Cole PI: Practice. Froese A. Bryan AC: Effects of anesthesia and pa
problems and compliance with postural drainage. ralysis on diaphragmatic mechanics in man. An
A survey of chronic sputum producers. Br 1 Dis es thesi% g)' 41 :242-255. 1974
Chest 80:249-253. 1986 Frownfelter D: Ghesl Physico I Therapy and Pulmo
DeCesare I: PhYSical therapy for the child with res nor)' Rehabililalion, an In terdisCiplinary Ap
piratory dysfunction. In Cardiopulmonary Physi proach. pp 239-259. Year Book. Chicago, 1987.
cal Th erapy, edited by S Irwin and I Tecklin. p Gandcvia B: The treatment of chronic bronchitis
336. Mosby, SI. Louis. 1985 and bronchiectasis. Med J Ausl 47:700-703. 1960
Delgado t l R. Braun SR. Skatrud lB. Reddan WC. Gaskell DV. \Vebber BA: The Brompton Hospital
Peglow DF: Chest wall and abdominal motion Guide to Chest Physiolherop}', 2nd ed.. pp 5-9, 13-
during exercise in patients with chronic obstruc 15. 22-23. Blackwell Scientific Publications. Lon
tive pul monary disease. Am Rev Respir Dis don. 1973
126:200-205. 1982 Gcntilello L. Thompson P. Tonnesen A. Hernandez
Dhainaut IF. Bons I. Bricard C. Monsallier IF: Im D, Kapadia A. Allen S, Houteher SB. Miner M: Ef
proved oxygenation in patients with extensive fect of a rotating bed on the incidence of pulmo-
nary complications in erHically ill patients. Cri t Ingram RH. Schilder DP: Effect of pursed lips expi
Core Med 16:183-186. 1988 ration on the pulmonary pressureflow relation
Glaister DH: The effect of posture on the distribu ship in obstructive lung disease. Am Rev Respir
tion of ventilation and blood flow in the normal Dis 95:381-388, 1967
lu ng. Clio Sci 33:391-398, 1 967 Innocenti PM: Breathing exercises in the treatment
Gonzalez-Arias SM. Goldberg l\II L. Baumgartner R. of emphysema. Physiotherapy 52:437-44 1 . 1966
Hoopes D. Ruben B: Analysis of the effect of k i Irwin S, Tecklin J: Cardiopulmonary Physical Ther
netic therapy o n intracranial pressure i n coma apy. pp 205. 316-317. 263. 231-235. 295-298.
tose neurosurgical patients. Neurosurgery 1 3:654- Mosby, SI. Louis. 1985
656. 1983 lederlinic p, Muspralt IA. Miller M: Inspiratory
Green BA. Creen KL. Klose KJ: Kinetic nursing (or muscle training in clinical practice. Physiologic
acute spinal cord injury patients. Paraplegia conditioning of habituation to suffocation? Chesl
18:181-186. 1 980 86(6):810-813. 1 984
Green SA. Green KL. Klose K: Kinetic therapy for Jones GA. Clague MB. Ryan OW, lohnston 10: Dem
spinal cord injury. Spi ne 8(7): 722-728. 1 983 onstration of a reduction in postoperative body
Crimby G: Aspects of lung expansion in relation to protein breakdown using the Clinitron nuidized
pulmonary physiotherapy. Am Rev Respir Dis bed with an ambient temperature of 32 degrees C.
1 1 0:145-153, 1 974 Br I Surg 12(1):514-518. 1985
Crimby C. Oxhoj H. Bake B: Effects of abdominal Kalaja E: Clinical results of treatment of patients i n
breathing on distribution of ventilation i n ob the airnuidized bed during a one-year period.
structive lung disease. Clin Sci Mol Med 48:193- Scond J Plasl Reconstr Surg 1 8( 1 ): 1 53-154. 1 984
199. 1915 Kane II: Segmental postural drainage in pulmonary
Gross D. Ladd HW. Riley EJ. Macklem PT. Grassino disease. Dis Chest 23:41 8-427. 1953
A: The effect of training on strength and enduro Kaneko K . MilicEmili I . Dolovitch MB, Dawson A.
ance of the diaphragm in quadriplegia. Am J Med Bates DV: Regional distribution of ventilation and
68:21-35. 1980 perfusion as a function of body position. l App/
Haas F, Simnowita M. Axen K. Gaudino O. lIaas A: Physio/ 21 :767-777. 1 966
Effect of upper body posture on forced inspiration Karlstrom G. Olerud 5: Percutaneous pin fixation of
and expiration. J Appl Physiol 52(4):879-886. 1982 open tibial fractures. I Bone 10inl Surg 57:915-
Hal lbook T. Lindbald B. Lindrolh B. Wolff T: Pro 924. 1915
phylaxis against pulmonary complications in pa Keane r'X: Pain and cervical traction variation duro
tients undergoing gallbladder surgery: A compar ing manual turning. Paraplegia 1 5:343-348. 1 977-
ison between early mobilization. physiotherapy 18
with and without bronchodilation. Ann Chir Gy Keens TG. Krastins IRB. Wannamaker EM. Livison
noreol 73:55-58. 1 984 H. Crozier ON. Bryan AC: Ventilatory muscle en
Hargesl TS: Buoyant support systems: Their effect durance training in normal subjects and patients
on cardiovascular and pulmonary function. CVP with cystic fibrosis. Am Rev Respir Dis 1 1 6:853-
May/lune. 1911 860. 1911
Heaf DP. Helms P. Gordon I. Turner HM: Postural Kelley RE. Vibulsresth S. Bell L. Duncan RC: Eval
effects of gas exchange in infants. N Engl I Mad uation of k.inetic therapy i n the prevention of
308: I 505-I 508. 1 983 complications of prolonged bed rest secondary to
Hedstrand U. Liw M. Roath C. Ogren Cft: Effect of slroke. Sl roke 18(3 ):638-642. 1 981
respiratory physiotherapy on artf'Tial oxygen ten I<igin Cr-.I: Advances in chest physical therapy. In
sian. Acla Anaeslhesiol Stand 22:349-352. 1 978 Currenl Advances in Respirolon' Core, edited by
Herbst II. Myers WF: Gast roesophageal renux in a W ODonohue. pp 37-71. American Col lege of
child. Peclio/r Case nep Gaslroinlesfinal Dis Chest Physicians. Park Ridge I I I . 1 984
1(3):1-4. 1 981 I<im. ""11: Respiratory muscle training: Implications
Hewitt VM: Effect of posture on the presence of fat for patient care. Hearl tung 1 3(4}:333-339. 1984
in tracheal aspirate in neonates. Aus Poed ialr I l\irimli B. King IE. Pfaeffle HH: Evaluation of
1 2:267-271 . 1976 tracheo bronchial suction techniques. J Thoroe
Hoffmann R: Ostcotaxis. osteosynthese externe par Cordiovosc Surg ..59:340-344, 1970
fiches at rolules. :\clu Chir Scond 107;72-8 1 . 1954 .... ubota Y. Margaribuchi T. Ohara M . Fujita M. Toy
Hornstein S. Inman S. Ledsome JC: Ventilatory ada Y. Asada A. Harioka T: Evaluation of selec
muscle training in kyphoscoliosis. Spine tive bronchial suctioning in the adult. Cril Core
12(9)809-863. 1981 Med 8:148-149. 1 980
Hornstein S. Ledsome J; Ventilatory muscle training l..arson IL. Kim ,..,I J: Respiratory muscle training
i n acute quadriplegia. Ph\'siolht'r Can 38{3}:145- with the incentive spirometer resistive breathing
149. 1986 device. Hearl Lung 13:341 -345. 1 984
Hughes RL: Does abdominal breathing affect reo Larson IL, Kim MI: Sharp IT: Inspiratory muscle
gional gas excha nge? Chl'sl 76(3):288-293. 1979 training with a threshold resistive breathing de
Ibanez I. Raurich M. Abizanda R. et a!.: The effect vice in patients with chronic obstructive pulmo
of lateral positions on gas exchange in patients nary disease. A m Rev Respir Dis 1 33 : 1 00-103,
with unila teral lung disease during mechanical 1986
ventilation. Inlensivf> Core Med 7:321-324, 1981 I.eith DE. Bradley I: Ventilatory muscle strength
Imle PC: The physical therapy management of gas and endurance training. I Appl PhysioI 41(4 ):508-
troesophageal reflux and its pulmonary sequelae 516. 1 916
in a child with central nervous system dysfunc. Lucke D. larlsberg C: How is the air nuidized bed
tion. Masters Thesis. Johns Hopkins University. best used? Am J Nurs 85{l2}:1 338-1 340. 1 985
April 1983 Mackenzie CF. Shin B: Cardiorespiratory function
before and after chest physiotherapy i n mechan a i r-fluidized bed in the care of burned patients.
ically ventilated patients with post-traumatic res Scond J Plasl Reconslr Surg 1 8(1 ):149- 1 5 1 . 1984
piratory failure. Grit Care Med 13(6):483-486. Nye RE: The control and distribution of ventilation.
1985 Phys Ther 48:431-438. 1968
Maloney FP, Fernandez E, Hudgel OW: Postural Ochoa IB: Diagnosis and management of gastro
drainage effect after bronchial obstruction. Arch esophageal reflux in children. Surg Annu 3 1 : 1 23-
Phys Med Rehab 62:452-455. 1981 1 37. 1981
Marini JJ. Tyler ML, H udson LO. Davis OS, Huseby Oldenburg FA. Oolovich MB. Montgomery 1M.
IS: Influence of head dependent positions on lung Newhouse MT: Effects of postural drainage, ex
volume and oxygen saluration i n chronic air-flow ercise and cough on mucus clearance in chronic
obstruction. Am Rev Respir Dis 129:101-105. 1984 bronchitis, Am Rev Respir Dis 1 20:739-745. 1979
Marlin R I . Sufit RL. R i ngel SP. Hudgel OW. Hill PL: Pardy RL. Rivington RN. Despas PI, Macklem PT:
Respiratory improvement by muscle training i n Inspiratory muscle training compared with phys
adult-onset acid maltase defiCiency. Muscle Nerve iotherapy in patients with chronic airnow limi
6:201-203. 1983 tation. Am Rev Respir Dis 123:421-425. 1981a
Martin CJ, Ripley 1-1. Reynolds J . Best F; Chest phys Pardy RL. Rivi ngton RN, Despas PI. Macklem PT:
iotherapy and the distribution of ventilation. The effects or inspiratory muscle training on ex
Chest 69:174-178. 1976 ercise performance in chronic airflow limitation.
McAslan Te. Matjasko-Chiu I . Turney SZ. Cowley Am Rev Respir Dis 1 23:426-433. 1981b
R A : Influence of inhalation of 1 00% oxygen on in Pardy RL. Reid WOo Belman MI: Respiratory muscle
trapulmonary shunt in severely traumatized pa training. Clin Chest Med 9(2 1:287-296. 1988
tients. J Trauma 1 3:81 1 -821. 1973 Parish LC. Witowski JA: Clinitron therapy and the
McKeon IL. Turner I . Kelly C. Dent A. Zimmerman decubitus ulcer: Preliminary dermatologic stud
PV: The effect of inspiratory resistive training on ies. lnl l Dermolo! 19(9):517-518. 1980
exercise capacity i n optimally treated patients Petty TL. Cuthrie A: The effects of augmented
with severe chronic airflow I imiation, Ausl NZ J breathing maneuvers on ventilation in severe
Med 16:648-652. 1986 chronic airway obstruction. Respir Care 16:104-
McNabb LI. Hyatt I: Effect of an a i r-fluidized bed on 1 1 3. 1971
insensible water loss, Cri! Care Med 15(2):161- Pierce AK. Robertson I : Pulmonary complications of
162. 1 987 general surgery. Annu Rev Med 28:2 1 l . 1977
McNeill RS. McKenzie 1M: An assessment of the Piehl MA. Brown MS: Use of extreme position
value of breathing exercises i n chronic bronchitis cha nges in acute respiratory failure. Crit Care
and asthma, Thorax 10:250-252. 1955 Med 4:13-15. 1976
Menkes H . Brilt I: Physical therapy. rationale for Prokocimer P. Carbino J. Wolff M. Regnier B: Influ
physical therapy. Am Rev Respir Dis 122(2):127- ence of posture on gas exchange in arlifically ven
1 3 1 . 1 980 tilated patients with focal lung disease. fnlensive
Micheels I. Sorensen B: The physiology of a healthy Care Med 9:69-72, 1983
normal person in the air-fluidized bed, Burns Pryor IA. Webber BA: An evaluation of the forced
9:158-168. 1987 expiration technique as an adjunct to postural
Miller W: Rehabilitation of patients with chronic drainage. Physiotherapy 65:304-307. 1979a
obstructive lung disease, Med Clin North Am Pryor IA. Webber BA. Hodson ME. Batlen Ie: Eval
5:349-361. 1967 uation of the forced expiration technique as an
Miller WF: A physiologic evaluation of the effects adjunct to postural drainage in treatment of cystic
of diaphragmatic breathing training in patients fibrosis. Br Med 1 2:417-418. 1979b
with chronic pulmonary emphysema. Am J Med Rath T. Berger A: Treatment of severe burn cases i n
17:471-473. 1954 t h e air fluidized bed. Burns 9 : 1 1 5 - 1 17. 1982
Morran CC. Finlay IC. Mathieson M . McKay AI. Redfern 51. leneid PA. Gillingham ME: Local pres
Wilson N. McArdle CS: Randomized controlled sures with ten types of patient-support system.
trial of physiotherapy for postoperative pulmo Lancet 1 1 :277-280. 1973
nary complications, Br J Anaesth 5 5: 1 1 1 3- 1 1 16. Reines DH. Harris RC: Pulmonary complications
1 983 of acute spinal cord injuries. Neurosurgery
Motley HL: The effects of slow deep breathing on 21(21: 1 93-196. 1 987
the blood gas exchange i n emphysema. Am Rev Remolina C. Khan AU_ Santiago TV. Edelman NH:
Respir Dis 88:484-491. 1 963 Poslional hypoxemia in unilateral lung disease. N
Mueller RE. Petty TL. Filley GF: Ventilation and ar El1gl I Med 304(9):523-525. 1981
terial blood gas changes ind uced by pursed lips Rivara D. Arlucio H, Arcos I . Hiriarl C: Positional
breathi ng. J Appl PhysioI 28:784-789. 1970 hypoxemia during artificial ventilation. Grit Core
Murphy MB. Concannon D. Fitzgerald MX: Chest Med 12(51:436-438. 1 984
percussion: Help or hi ndrance to postural drain Roussos CS. Fixley M. Genest I . Cosio M. Kelly S.
age? Irish Med I 76(41:189-190. 1 983 Martin R R . Engel LA: Voluntary factors influenc
Newhouse MT. Rossman CM: Effect of chest phys ing the distribution of inspired gas. Am Rev Res
iotherapy on the removal of mucus in patients pir Dis 1 1 6:457-466. 1977
with cystic fibrosis. (letter) Am Rev Respir Dis Ryan OW: The i n fluence of environmental temper
127:391. 1 984 ature (32C) on catabolism using the clinitron flu
Nicholson I: A course of lessons on the art of deep id ized bed. lnlensive COfe Med 9:279-281. 1983
breathing giving physiolcgical exercises to 5ackner MA. Silva G. Banks JM. Watson O. Smoak
strengthen the ches!. lungs. stomach. back. etc. WM: Distribution of ventilation during diaphrag
Health Culture Co.. London. 1890 matic breathing in obstructive lung disease. Am
Nirmille E, Storm H: Five years experience with the Hev Hespir Dis 109:331-337. 1974
Scheidt A, Orusin LM: Bacteriologic contamination pursed lips breathing in patients with chronic ob
in an air-flu idized bed. J Trauma 23(3 ):241-242. structive pulmonary disease. Am Rev Resp;r Dis
1983 93,100-106. 1 966
Scheuler IA. Munster A: Clinitron air fluidized sup Thoren L: Postoperative pulmonary complications.
porI! An adjunct to burn care. I Burn Core Rehab Observations of their prevention by means of
4(4):10-12. 1 983 physiotherapy. Acla Chir Scond 107:1 93-204.
Schimmel L. Civelta 1M. Kirby RR: A new mechan 1954
ical method to influence pulmonary perfusion in Trammel TR. Reed DB. Goodwin CB: Controlled
critically ill patients. Crit Care Med 5:277-279, mobilization of patients undergoing reconstruc
1977 tion spinal su rgery: Preliminary comparison of
Seaton 0; Effect of body position on gas exchange the kinetic therapy vs the Foster frame. Ortho
after thoracotomy. Thorax 34:518-522. 1979 pedics 8(12):1489-1491. 1985
Shands AR. Raney R8: Handbook of Orthopaedic Vraciu J . Vraciu R : Effectiveness of breathing axer
Surgery. p 464. Mosby. Sl. Louis. 1 967 cises i n preventing pulmonary complications fol
Sharp IT. Drutz WS. Moisan T. Fosler I. Machnach lowing open heart surgery. Phys Ther 57:1 367-
W: Postural relief of dyspnea in severe chronic 1370. 1977
obstructive pulmonary disease. Am Rrv Respir Wagamen MI. Shu tack IG. Moomjian AS et al.: Im
Dis 1 22:201 -2 1 1 . 1 980 proved oxygenation and lung compliance with
Shearer MO, Banks 1M. Silva C . Sackner MA: Lung prone positioning of neonates. I Pediotr 94:787-
ventilation during diaphragmatic breathing. Phys 791. 1979
Ther 52:139-147. 1972 Ward RJ. Danziger F. Bonica JI: An evaluation of
Siegel I: Trauma: Emergency Surgery and Critical postoperative respiratory maneuvers. Surg Gyne
Care. p 629. Churchill. Livingston. New York. col ObsteI 123:51-54. 1 966
1988 Warren CPW, Grimwood M: Pulmonary disorders
Simonneau G. Vivien A. Sarlene R, Kunstlinger F. and physiotherapy in patients who undergo cho
Samii K, Noviant U, Duroux P: Diaphragm dys. lecystectomy. Can 1 Surg 23:384-386, 1980
function ind uced by upper abdominal su rgery. Webber B. Parker R. !-tofmeyr J, Hodson M: Evalu
Am Rev Respir Dis 128:899-903, 1983 ation of self-percussion during postural drainage
Smith P. Coakley I , Edwards R : Respiratory muscle using the forced expiration technique. Physiother
training in duchenne muscular dystrophy. Muscle Practice 42-45, 1985
Nerve 784-785. 1 988 West JB: Regional differences in gas exchange in the
Smoot EC: Clinitron bed therapy hazards (Ieller). lung of erect man. J App/ PhysioI 1 7:893-898, 1 962
Plosl Reconslr Surg 77(1):165, 1986 Wilklander 0, Norlin U: Effect of physiotherapy on
Sonne LJ. Davis JA: Increased exercise performance postoperative pulmonary complications: A clini
in patients with severe COPD following inspira cal and roentgenographic sludy of 200 cases. Acla
tory resistive training. Chesl 81 (4):436-439. 1982 Chir Scond 1 1 2:246-250. 1957
Sonnenblick M . Melzer E. Rosin AI: Body positional \Villepul R . Vachaudez JP. Lenders 0, Nys A.
effect on gas exchange in unilateral pleural effu Knoops T. Sergysp,ls R : Thoracoabdominal mol ion
sion. Chest 83(5):784-786. 1983 during chest physiotherapy in patients affected
Strandberg B: The incidence of atelectasis afler by chronic obstructive lung disease. Respirolion
heart operations with and without breathing ex 44;204-2 14. 1983
ercises. Ann Phys Med 3:1 8-20. 1956 Williams IP, Smith CM. McGavin CR: Diaphrag
Sullon PP. Parker RA. Webber DA: Assessment of matic breathing training and walking perfor.
the forced expiration technique. postural drain mance in chronic airways obstruction. Br J Dis
age and directed coughing in chest physiother Chesl 76:164-166. 1 982
apy. Eur J Respir Dis 64:62-68. 1983 Wong JW. Keens TG. Wannamaker EM. Douglas PT.
Sutton PP. LopezVidriero MT. Newman SP. Clarke Levinson H. Aspin N: Effects of gravity in tracheal
SW: Effect of chest physiotherapy on the removal transport rales in normal subjects and in pa
of mucus in patients with cystic fibrosis (letter). tients with cystic fibrosis. Pediatrics 60:146-- 1 52.
Am Rev Respir Dis 1 27:390-39 1 . 1 984 1977
Sullon pp, Lopez-Vidriero MT. Pavia D. Newman Wood LA: Nursing Skills for Allied Heallh Services.
SP. Clay MM. Webber B. Parker A, Clarke SW: Vol 3. p 315, 319. Saunders. Philadelphia. 1979
Assessment of percussion vibratory shaking and Zack MS. Pontoppidan H. Kazemi 1-1: The effect of
breathing exercises in chest physiotherapy. Eur } lateral positions on gas exchange in pulmonary
Respir Dis 66:147-152. 1985 disease. Am Rev Respir Dis 1 1 0:49-55. 1974
Tarhan S, Moffill EA. Sessler AD. Douglas WW, Zausmer E: Bronchial drainage. evidence support
Taylor WF: Risk of anesthesia and surgery in pa ing the procedures. Phys Ther 48:586-591. 1 968
tients with chronic bronchitis and chronic ob Zimmerman IE. Oder LA: Swallowing dysfunction
structive pulmonary disease. Surgery 74(5):720- in acutely i l l patients. Phys Ther 61(1 2}:1755-
726. 1973 1763. 1981
Ticp BL. Burns M , Kae D, Madison R . Herrera J: Zinman R: Cough versus chest physiotherapy, A
Pursed lips breathing training using ear oximetry. comparison of the acute effects on pulmonary
CheSf 90(2):218-221. 1 986 function in patients with cystic fibrosis. Am Rev
Thoman RL. Stoker GL. Ross Ie: The efficacy of Respir Dis 129:182-184. 1984
CHAPTER 4
Percussion and Vibration

Literature Review
Percussion
Vibration
Mechanical Vibrators and Percussors
Percussion and vibration are specific et al.. 1976; Ayel1a. 1078; Mackenzie et
maneuvers developed for use in conjunc al.. 1978; Finer et al.. 1979; Marini et al..
tion with postural drainage. They are 1979; Ciesla et al.. 1981; Hammon and
thought to facilitate both large and smal1 Martin. 1981). These chest x-ray changes
airway clearance by advancing secre provide some evidence of improved
tions centrally so they can be expecto clearance of both peripheral and central
rated or suctioned. It is theorized that secretions when manual techniques are
manual percussion and vibration de used on patients with acute lung
crease overall treatment time by enhanc pathology.
ing the gravitational effects of bronchial The successful removal of radioac
drainage (Petty. 1974). lillIe research has tively labeled secretions from central. in
been done on the mechanism of action or termediate. and peripheral airways fol
optimal methods of performing these lowing chest physiotherapy maneuvers
manual techniques. The literature on on patients with chronic lung disease has
percussion and vibration. though scarce been reported by Bateman et al. (1979.
and conflicting. is addressed in this chap 1981). In 1981. they found peripheral se
ter. An explanation of the various meth cretion removal to be beller enhanced by
ods of performing these manual tech physiotherapy techniques of postural
niques is reviewed. along with the drainage. percussion. vibration. and
associated indications and precautions. cough compared with cough alone. This
Information is presented on the use of contrasts with Rossman et al. (1982). who
mechanical vibrators and percussors as also measured radioaerosol clearance.
aids to chest physiotherapy treatment. These investigators found both di rected
cough and chest physiotherapy (consist
LITERATURE REVIEW ing of drainage. percussion. vibration.
and cough) to be more effective than a
It is widely accepted that percussion control period. postural drainage alone.
and vibration. when used with postural or in combination with mechanical per
drainage. assist secretion removal from cussion. Chest physiotherapy also re
the large airways. The effect of these sulted in the largest volume of sputum.
techniques on the smaller airways is Postural drainage with coughing was
more controversial. Radiological clearing evaluated with and without the use of
of segmental. lobar. and multi lobar atel deep breathing. vibration. and percus
ectasis following postural drainage. per sion by Sullon et al. (1985). No difference
cussion. vibration. and coughing or suc was found in radioaerosol clearance from
tioning is well documented in both the central. intermediate. or peripheral
pediatric and adult patients (Roper lung zones with any treatment. However.
134
PERCUSSION AND VIBRATION 135
the wet and dry weights of sputum were tests (PFT). They noted that some pa
increased significantly by the addition of tients responded beller to cough and oth
deep breathing with percussion or vibra ers to physiotherapy. No correlation was
tion. phcussion with tidal breathing sig found between the volume of sputum ex
nificantly increased the dry sputum pectorated and i mproved flow rates.
weight. These findings are similar to those of
There are some important similarities DeCesare and co-workers (1982), who
between the studies by Rossman et a!. used krypton scintigraphy on nine cystic
(1982) and Sullon and co-worker (1985). fibrosis patients to measure the efficacy
Both used subjects with chronic lung dis of drainage with cough, percussion, and
ease and in both investigations only 10% vibration on peripheral ventilation. Per
of the inhaled particles were deposited in cussion was again limited to 2 min and
the peripheral lung zones (Sullon et a!., vibration to five exhalations i n each pos
1984). It is difficult to show clearance of tural drai nage position. No significant
radioaerosols from the lung periphery if changes were noted i n PFT or peripheral
only a small fraction is deposited there. It ventilation. This is not surprising as the
seems logical that the aerosols that were subjects varied widely in the amount of
deposited in the peripheral zones would sputum produced, severity of disease
be deposited preferentially in the patent (mild to severe), and phase of disease
airways. Removal of secretions from the (acute exacerbation to routine outpatient
obstructed airways, perhaps with percus visit). Also treatment time to each lung
sion and vibration, could explain the sig segment was short and not directed to
nificant increase in sputum production ward areas of specific pathology. which
but not aerosol clearance found in both may have been evident from pretreat
studies. This theory is supported by the ment scintigraphy.
findings of Wollmer et a!. (1985), which In 16 cystic fibrosis patients during
are discussed on p. 136. Van der Schans acute exacerbation of pulmonary infec
et a!. (1986) neither confirmed nor ne tion, Webber and co-workers (1985)
gated this possibility in their study of ra looked at the effect of self-percussion
dioaerosol clearance in nine patients when added to a regimen of breathing
with stable chronic ai rflow obstruction. exercises, forced expiratory technique
No significant difference in central or pe (FET), and postural drainage. Self chest
ripheral aerosol clearance was found compression (vibration) was combined
when percussion was added to a regimen with FET in both groups if found helpful.
of postural drainage, coughing, and They found no significant difference i n
breathing exercises. There was no infor forced expiratory volume i n 1 sec (FEV,)
mation on sputum production or the pro or forced vital capacity (FVC) between
portion of tracer deposition in the periph the two groups concluding that self-per
eral or central lung zones. Only the cussion may not provide added benefit to
supine, head-down position was used in a treatment including drainage and FET.
this study compared to the others (Ross Zapletal and associates (1983) also stud
man et al" 1982; Sullon et al" 1985; Woll ied the effects of chest physiotherapy
mer et a!., 1985). (drainage, percussion, vibration. and
As in the preceding group of studies. cough stimulation) on 24 cystic fibrosis
most investigations on the efficacy of per patients with a mean age of 12. There was
cussion and vibration have been carried no improvement in PFT following 30 min
out on patients with chronic lung dis of treatment where only 2-10 m l of spu
ease. De Boeck and Zinman (1984) stud tum was produced. Similar findings were
ied nine subjects with stable cystic fibro reported by Kerrebijn et al. (1982) when
sis. They compared vigorous cough to 25 chest physiotherapy (drainage with per
min of chest physiotherapy, which in cussion, virbration, and coughing) was
cluded 2 min of percussion and vibration compared with no treatment or was pre
in 11 postural drai nage positions. They ceded by N-acetylcysteine aerosol. Spu
found chest physiotherapy to be of lim tum volume was not measured in this
ited significant benefit over cough in study.
terms of altering pulmonary function In 1984, Falk et al. reported a decrease
in FVC and skin oxygen tension (PsO,) three different positions both with and
when postural drainage (for 4-5 min in without percussion. A small but statisti
seven different positions) with percus cally Significant decrease in FEV, was
sion and vibration was performed on 14 noted when percussion was added, al
patients with cystic fibrosis. When face though there was no difference in VC or
mask positive expiratory pressure (PEP) oxygen saturation. Scintigraphic meas
was applied either with or without drain urements showed a better penetration of
age, these findings were reversed and inhaled aerosol after percussion and
sputum production was also better using drainage than with drainage alone. Sim
PEP than with FET or drainage, percus ilarly, peripheral clearance of the tracer
sion. and vibration. No patients had was higher when percussion was used.
acute pathological findings on chest x-ray These findings did not reach statistical
and no radiographical changes were Significance, perhaps because of the large
noted with any t herapy. This article is in particle size and the relatively poor pe
teresting, in part, because of its apparent ripheral deposition. I nterestingly, the
bias. The investigators slated Ihat "per two patients with high sputum produc
cussion should be stopped in patients tion (100-130 ml) had substantially
who beforehand are close to the knee of higher isotope clearance when percus
the oxygen dissociation curve." This sion was included. As noted by others.
comment is opinion at best, since Falk et sputum volume did not correlate with
al. did not specifically look at percussion particle clearance.
efficacy. It is also in conflict with others Another study of 10 patients during an
reporting on percussion in patients with acute exacerbation of severe chronic
chronic lung disease (Buscaglia and St. lung disease (bronchitis/emphysema)
Marie 1983: Mazzocco et aI., 1985; Woll was done by Bascaglia and St. Marie.
mer et al.) FET is also described in this They found no significant changes in ox
study as unacceptable and exhausting to ygen saturation during 12' head-down
cystic fibrosis patients, which is in direct positioning, while supine and prone, or
opposition to the findings of others (Pryor before and after 12 min of percussion and
et aI., 1979; Sutton et aI., 1983; Hofmeyer vibration in these two position. All sub
et aI., 1986). However, these reports by jects were spontaneously breathing and
Kerrebijn, Zapletal, and Falk et al. cast six required nasal oxygen prior to the
some doubt on the benefits of chest study to maintain baseline oxygen ten
phsiotherapy, including manual percus sions >60 mm Hg. Sputum production
sion and vibration, to improve PFT in pa was not addressed. and none of the sub
tients with stable cystic fibrosis. jects had radiographic evidence of atel
Mazzocco and associates (1985) studied ectasis or pneumonia. so it is unclear
13 subjects with stable chronic bronchi what the indications for treatment were.
tis. They failed to find either improve The authors conclude that Trendelen
ment or deterioration in FVC, FEV" or b urg, prone, and supine positioning with
peak expiratory flow (PEF) following 10 percussion and vibration does not pro
min of postural drainage alone and then duce hypoxemia in acutely ill patients
10 m i n of drainage with percussion. No with capo.
significant decrease in arterial oxygen Few studies are available on the effect
ation or heart rate was reported for pa of percussion or vibration on the postop
tients whose sputum production ranged erative or posttraumatic patient. Case re
from 0 to 110 ml during this treatment. ports on such patients with a variety of
The authors concluded that drainage and diagnoses showed marked improvement
percussion were both safe and helpful in in chest radiograph appearance, breath
mobiliZing secretions in persons with sounds, and arterial blood gases after
bronchiectasis. These findings conflict chest physiotherapy that included lobar
with those of Wollmer and associates and segmental drainage, percussion, vi
who studied patients with chronic bron bration, and cough or suctioning (Ciesla
chitis during acute exacerbation. The 10 et al.; Hammond and Martin, 1981). The
subjects served as their own control: re specific contributions of percussion or vi
ceiving postural drainage for 5 min in bration were not addressed. Retained se-
tions, atelectasis, and pneumonia were not clear if any attempt was made to di
indications for treatment in the seven pa rect the CPT toward the area of lung pa
tients presented, thology. The investigators reported no
Three recent studies evaluated the differences in PaO" FVC, sputum pro
routine use of chest physiotherapy to duction, chest x-ray findings, or hospital
prevent postoperative pulmonary com stay between the two groups; only a
plications. Morran and associates (1983) small but statistically significant differ
studied 102 patients for up to 4 days after ence in mean postoperative temperature
elective cholecystectomy. In addition to (OA-0.6"F) was found. The researchers
encouragement to cough and breathe report that CPT caused patient discom
deeply by the nursing and medical staff, fort. However, if CPT was more painful
51 of the patients were given 15 min of than the vigorous control treatment, this
breathing exercises, assisted cough, and suggests that it was improperly per
chest wall vibration (CPT). The fre formed and/or not coordinated with ap
quency of postoperative pulmonary com propriate postoperative analgesia. Pain
plications (atelectasis) was similar in with chest physiotherapy was not re
both groups and was attributed t o t he ef ported by Morran et a!., (1983), who had
fects of anesthesia and pain. However, a large number of obese patients (37) in
the incidence of chest infection was sig their study but did not include postural
nificantly less in the group receiving drainage. Although Torrington and co
CPT, suggesting that breathing exercises, workers reported an average hospital
cough, and vibration prevent or reverse stay of nearly 7 days, they did not moni
the progression of atelectasis to infection. tor signs of pulmonary pathology beyond
Hallbook et a !. (1984) also studied pa 48 hr after surgery. Therefore, no infor
tients undergoing elective cholecystec mation was available on the differences
tomy. One hundred thirty-seven patients in lung infection rates compared with
randomly received mobilization (walking pulmonary complications between the
and arm exercises, two times daily) or two regimens.
chest physiotherapy (mobilization plus In 47 posttrauma patients requiring
breathing exercises, drainage, and mechanical ventilation and positive end
coughing) both with and without bron expiratory pressure (PEEP), Mackenzie
chodilator medication. All patients were and co-workers (1978) showed a marked
given effective pain relief by means of an improvement in auscultation and chest
intercostal nerve block. Postoperative x-ray appearance after chest physiother
pulmonary complications occurred in apy that included percussion and vibra
36% of th e patients and were similar in tion. On 42 similar patients, significant
a l l three study groups. No added benefit increases in total lung/thorax compli
was found with chest physiotherapy, per ance lasting for up to 2 hr after chest
haps because of the low incidence of pul physiotherapy were reported (Mackenzie
monary infection (three patients). Chest et a!., 1980) (see p. 218). I n both studies,
physiotherapy did not include either per indicators for treatment included atelec
cussion or vibration in this study. tasis, lung contusion, pneumonia, and
These studies contrast with those of respiratory distress syndrome. In 1985,
Torrington et a!. (1984), who studied 49 Mackenzie and Shin reported on the ef
morbidity obese patients for 48 hr after fects of postural drainage, percussion, vi
gastric stapling. Al l patients received (1) bration, and suctioning (CPT) on 19 pa
intermittent positive pressure breathing tients requiring mechanical ventilation
(IPPB) every 4 hr, (2) incentive spirome and PEEP for management of posttrau
try (IS) every 4 hr spaced between IPPB, matic respiratory failure. They found an
(3) nebulized mist by face mask for 30 immediate improvement in intrapulmo
min following each IPPB or IS session, nary shunt and an increase i n total lung/
and (4) deep breathing and coughing after thorax compliance 2 hr after CPT. Chest
each session. Additionally, at 4-hr inter physiotherapy treatment time was deter
vals, 24 of the patients were given 5-10 m ined by the clearance of adventitial
min of percussion while positioned head breath sounds and ranged from 30 to 105
down and supine or side-lying (CPT). It is min. No cardiac dysrhythmias or changes
in dead space, cardiac output, or arterial physiotherapy need not be withheld in

b lood gases were recorded. The findings patients with a PaO, < 60 mm Hg but
of these three studies-improved air that careful monitoring was indicated
entry by auscultation, increased compli during treatment (Tyler et a!., 1980). Per
ance, and decreased intrapulmonary cussion and vibration alone are not
shunt with no change in dead space proven to contribute to hypoxemia. How
suggest an increase in the number of ven ever, in most studies these techniques
tilated alveoli. This, along with the re are used along with bronchial drainage.
sults of others (Bateman et a!., 1979, 1981; Postural changes do cause alterations in
Sutton et a!., 1985), provides evidence cardiorespiratory function (see p. 94).
that in adults, percussion and vibration, These may become significant in patients
performed with postural drainage and with pulmonary or cardiac pathology and
cough or suctioning, are effective in re are perhaps the cause of the hypoxemia
moving secretions from the more periph or other types of deterioration reported
eral as well as larger airways. by some investigators in association with
Klein et a!. (1988) reported hemody chest physiotherapy.
namic and metabolic changes in 23 post Chest physiotherapy techniques, in
operative patients during chest physio cluding percussion and vibration, are
therapy. These changes were not also used on pediatric and neonatal pa
sustained after the chest therapy was tients. Conditions such as idiopathic res
completed and most were attenuated by piratory distress syndrome, meconium
administering short acting narcotics. In aspiration, bronchopulmonary dysplasia,
this study chest physiotherapy consisted neonatal pneumonia, and postoperative
of side-to-side turning, percussion, vibra pulmonary complications have led to
tion. and suctioning. The therapy was not more aggressive respiratory care, includ
directed to a specific lung pathology and ing intubation and mechanical ventila
was not performed by a physical thera tion in this age group (Crane, 1981). In in
pist. Mackenzie and associates (1978, fants, acute lung collapse unresponsive
1980, 1985) did not measure PaO" lung to other methods of treatment, including
compliance, cardiac output, or other in IPPB, has been reported to respond to
dices during chest physiotherapy. as po chest percussion and vibration by reinfla
sitional changes alone are known to alter tion (Mellins, 1974). Etches and Scott
cardiorespiratory function (see p. 26). Dif (1978) corroborated Mellins' clinical find
ferences due to postural changes may ings of increased secretion clearance
help to explain the findings of Barrell and after postural drainage with percussion
Abbas (1978) who studied spontaneously and vibration compared with suctioning
breathing patients within 24 hr of mitral alone in a study of six neonates. Unless
valve replacement. Decreased cardiac these maneuvers in themselves cause an
output and PVO, were noted during increase in the production of lung secre
chest physiotherapy (side lying, percus tions (which has not been documented),
sion, vibration, breathing exercises, and it may be assumed that the increase in
supported cough). These parameters re sputum is a result of percussion and vi
turned to baseline values within 15 min bration loosening and advancing small
after therapy. In this study, supplemental airway secretions more centrally. This is
oxygen was recommended as a means to supported by Finer and Boyd (1978), who
minimize PVO, changes in spontane compared the effect of postural drainage
ously breathing patients receiving chest alone and in conjunction with "contact
physiotherapy. Significant decreases in heel" percussion on arterial blood gases
PaO, are reported in critically ill patients in 20 neonates with respiratory distress.
receiving chest physiotherapy (postural They found a significant increase in PaD,
drainage and percussion). Interestingly, a when percussion was added to drainage.
regression analysis of the PaO, changes In 1979, Finer and associates investigated
showed that patients with lower baseline the role of postural drainage. vibration,
val ues had a less dramatic fall in PaO, and suctioning (chest physiotherapy) in
during therapy. Based on this finding, the preventing and reversing postextubation
investigators recommended that chest atelectasis in 85 neonates. The right
upper lobe was the most commonly re sure in adults (White and Mawdsley,
ported site of lung collapse. A significant 1983). It is unclear if the increases re
decrease in atelectasis was found in the ported by Crane et al. were the result of
infants receiving chest physiotherapy. the treatments, of suctioning or a combi
This occurred despite the fact that the nation of both.
control subjects were frequently put in In 1980, Tudehope and Bagley studied
postural drainage positions for the right the effects of three types of chest phys
upper lobe. These findings do not support iotherapy on 15 premature infants re
the clinical opinions of some (Meier, quiring mechanical ventilation for respi
1979) that drainage alone may prevent or ratory distress. All babies randomly
treat atelectasis in the sick neonate. received each of the following treatments
Curran and Kachoyeanos (1979) looked 2 hr apart: contact heel percussion. man
at the effect of percussion/vibration on ual percussion using a face mask, or
six neonates suffering respiratory dis chest vibration with an electric tooth
tress. Two subjects received 1 min of me brush. Each treatment was performed for
chanical chest vibration with an electric 3 min in four d i fferent postural drainage
toothbrush; another two were given 1 positions followed by suctioning. Indica
min of manual percussion with a padded tions for treatment were not given. Man
nipple; and two served as controls. Treat ual percussion and, to a lesser degree,
ments were given every other hour and contact heel percussion, resulted in sig
were followed by suctioning. No indica nificant rises in PaOzl which were main
tions for treatment were given. The au tained for up to 1 hr after therapy. Both
thors concluded that the neonates receiv manual techniques were better tolerated
ing chest vibration with the toothbrush than vibration with the mechanical
had increased PaO, and PaCO, along toothbrush. The authors theorize that the
with improved breath sounds and skin loosened terminal airway secretions
color compared with the others. How were responsible for the i mproved PaO,
ever, arterial blood gases were drawn at found with both types of manual
random times in reference to therapy, percussion.
and changes in the blood gases were not O'Rorke and co-workers (1984 ) studied
compared with baseline values (which the effects of chest physiotherapy on
may well have varied greatly with only tidal volume (V,) changes in six infants
two subjects in each group). Breath requiring intermittent mandatory venti
sounds were poorly evaluated (clear, lation (IMV). No indications for treatment
some or heavy congestion). Clinicians were noted. Baseline V, measurements
know that although rhonchi sound were compared with those d u ring per
"worse" than rales, they are more easily cussion and vibration while sidelying.
treated. Possibly the only finding worth Percussion and, to less extent, vibration
noting in this study is that suctioning resulted in Significant decreases in V"
rather than either form of therapy was which rapidly returned to baseline val
responsible for most of the deleterious ef ues after treatment. No detrimental ef
fects noted during the study. fects were associated with the drop in V"
Crane and associates (1978) tried to as Unfortunately, the authors did not report
sess the isolated effects of manual tech V, changes associated only with position
niques in 24 infants with hyaline mem change. It appears that some of the de
brane disease. They studied percussion crease in V, may have been due to side
and then vibration with the head down lying, in which case prone positioning in
and bed flat. The subjects were also suc creased inspired volume or a change in
tioned using supplemental 0, in all four the mode of ventilation may be appropri
study situations. No bradycardia or ate if chest physiotherapy is indicated.
apnea was noted. but there were signifi In most of the chest physiotherapy re
cant increases in heart rate, respiratory search, postural drainage, cough, suc
rate, and systolic pressure following all tioning, and breathing exercises were in
four treatments with suctioning. Neither cluded along with the manual techniques
percussion nor head-down positioning of percussion and vibration, making it dif
was found to increase systolic blood pres- ficult to assess the efficacy of each treat-
ment component. As noted in the previ proper patient positioning (Howell and
ously cited work, attempts to evaluate Hill, 1972). Whether this occurs is not
the specific contribution of either percus known; however, transbronchial aspira
sion or vibration are both rare and con tion of mucus from one area to another
flicting. To add further confusion, vari does happen, particularly when copious
ous forms of mechanical, manual, and secretions are present (Imle, 1983) (see
self-percussion and vibration have been Case History 7.1). Therefore, a knowl
studied. A few researchers have tried to edge of the segmental pulmonary anat
look at percussion or vibration as isolated omy and the overlying anatomical land
treatments. Their findings are discussed marks is essesntial for effective
in the subsequent sections of this chap percussion and vibration (see Fig. 2.1).
ter. Manual techniques have not been Note that the medial segment of the right
used historically as a treatment in and of lower lobe has minimal to no surface ac
themselves; rather, they have been con cessible for percussion; therefore, pos
sidered adjuncts to postural drainage. tural drainage accompanied by coughing
breathing exercises, coughing, and suc or suctioning may be used when treating
tioning. Therefore, it appears important this segment. For other segments, percus
to assess the added effects of percussion sion should be given directly over the
or vibration rather than examine their area of lung involvement. Normally, dur
isolated role. if any. If the major benefit ing maximal inspiration the lungs do not
of manual techniques is merely to expe extend below the tenth thoracic vertebra
dite the gravitational effects of bronchial posteriorly or below the level of the xi
drainage, this is an important finding. It phoid process anteriorly. Diaphragmatic
would suggest that the addition of per descent is often less in patients with post
cussion or vibration is of limited value to operative pain, weakness, or abdominal
the more stable patient; yet, in the criti distension. Manual techniques should be
cally ill or unstable patient, these tech limited to those areas with underlying
niques could shorten treatment time con lung.
siderably while providing improved
efficacy. PERCUSSION
To the clinician, it is generally ac
cepted that the appropriate postural The percussion technique consists of
drainage positions should be achieved rhythmic "clapping" with cupped hands
prior to initiating percussion or vibration over the involved lung segment (Fig. 4.1).
(see Chapter 3). It is possible that manual It was first described by Linton in 1934
techniques may assist secretions to move (Zadai, 1981). Percussion should produce
more peripherally if combined with im- a hollow sound, not a slapping sound. It
Figure 4.1. Percussion should b e performed with cupped hands and fingers adducted as shown
in A. The correct position of the palmar survace of the hand is demonstrated in B.
should impart an energy wave transmit or IMV. Percussion appears to be a safe

ted through the chest wall to cause a procedure for patients with rib fractures,
loosening of bronchial wall secretions however, it should not be performed by
(Sutton et aI., 1982). The hand should the novice therapist.
create an "air cushion" on impact, Chest percussion should not cause
which, it is proposed, aids in dislodging undue pain to the patient and need not
pulmonary secretions (Petty, 1974). This be forceful (Gaskell and Webber, 1980).
is confirmed by bronchoscopy (Kigin, Some of the conflicting data surrounding
1984). Percussion is performed during the use of percussion may result from the
both inspiration and expiration and misguided belief that this technique is
should not result in undue pressure on routinely carried out in a painful man
the soft tissues of the chest. Manual per ner, often referred to as pummelling
cussion is normally performed at a rate of (Reines et ai, 1982; Holoday and Gold
100-480 times per minute and is reported berg, 1982; Demers, 1986). Postoperative
to produce between 2 and 4 foot pounds pain is a well-recognized side effect of
and 58 and 65 Newtons of force on the su rgery and it is frequently exacerbated
chest wall (Flower et aI., 1979a; Gray. by deep breathing, moving, turning, and
1980; Hammon and Martin, 1981; Mur coughing. However, no clinician would
phy et aI., 1983; White and Mawdsley; et recommend withholding these maneu
aI., 1985; Van der Schans et al. ). vers as a means of decreasing pain. In
Percussion may be performed over rib stead, they would recommend appropri
fractures without any known complica ate analgesia. The many methods of pain
tions (see p. 331). This is based on the au relief are discussed on p. 341. In general,
thor's experience of providing chest analgesia should be used as indicated, ac
physiotherapy for 60 patients with cla cording to the severity of injury or dis
vicular or scapular fractures and 226 pa ease. Medication to reduce pain is given
tients with rib fractures during a 34- prior to treatment to aid patient comfort,
month period. Over 80% of the rib frac particularly for patients with long-bone
tures were multiple or bilateral (Appen fractures or multiple rib fractures and for
dix I, Table A1.8). Clinically, most pa those who have undergone thoracic and
tients with multiple rib fractures or flail abdominal surgery.
chest require ventilatory support during In addition to analgesia, patients with
the acute stage. It is theorized that con severe head injuries often require seda
trolled mechanical ventilation actually tion to minimize abnormal responses that
helps stabilize the fracture site by pre lead to raised intracrainal pressure (ICP).
venting negative intrathoracic pressures. Sedation is usually given prior to treat
Mechancial ventilation may act as a form ment, so effective chest physiotherapy
of internal fixation of the fracture sites by can be performed without compromising
encouraging synchronized rib cage and the patient's overall condition. Paralyz
soft-tissue motion. Assisted ventilation ing agents or barbiturates may also be
(A V) or IMV often leads to more move needed during the acute phase to mini
ment at the rib fracture site since nega mize brain injury (Mat jasko, 1986). It is
tive intrathoracic pressures are gener generally thought that head-down posi
ated by the patient. PEEP is frequently tioning and manual techniques increase
used in the management of patients with ICP. For this reason, chest physiotherapy
rib fractu re and lung contusion. Percus is often withheld from a patient popula
sion is shown to effect intrathoracic pres tion at great risk for pulmonary infection.
sure changes of 5-15 cm H20 (Flower et However, percussion is not normally as
aI., 1979a), which approximates the lev sociated with elevated ICP (see Fig. 8.2)
els of PEEP used in this patient popula and may actually lead to a decrease in
tion. When properly performed, percus this parameter (Gerradd and Bullock,
sion should cause less pressure over the 1986). The short period of increased ICP
thorax and ribs than coughing or lying on that may occur with chest physiotherapy
the side of involvement. In addition. it may not be detrimental unless it precip
probably causes less rib motion than oc itates a decrease in cerebral perfusion
curs during spontaneous breathing, AV, pressure (Hammon et aI., 1981; lmle et
alof 1988 see p. 259). In infants with head "air cushion" is lost in the toweling. In
injuries that require ICP monitoring, addition, any covering over the thorax
spontaneous movements are found to re prevents the therapist from noting skin
sult in the greatest increases in ICP erythema or petechiae. Towels may also
(Tomney and Finer, 1980). l t is the au interfere with detection of previously
thor's experience that, in most patients, undiagnosed rib fractures or subcutane
complaints of pain, changes in vital signs, ous emphysema.
or increases in ICP are a result of the po If skin redness or petechiae occur with
sition changes, coughing, or suctioning, percussion, it is usually a result of im
which are necesflary aspects of routine proper technique, most commonly slap
care after surgery. The pain and changes ping or of not enough air being trapped
in vital signs are not just specific to chest between the hand and the chest wall
physiotherapy intervention and should (Tecklin, 1979). The trapped air creates
not be viewed in isolation from the pa the hollow cupping sound, cushions the
tient's total needs. blows, and is believed to be responsible
Percussion is thought to cause bron for loosening the secretions. Patients
chospasm, which is evidenced by a fall in with coagulopathies after massive blood
FEV, in some studies of patients with tranfusions may also develop petechiae.
chronic lung disease (Campbell et aI., When chest physiotherapy is indicated in
1975; Wollmer et al.). In most cases this these patients, percussion should be per
decrease is both small and short lived. formed with care to minimize this effect
Others have reported no change or an in and still clear the retained secretions. Pa
crease in FE V, after chest physiotherapy tients with burns or large areas of skin
techniq ues (Clark et aI., 1973; Cochrane loss or abrasion may benefit from the use
et aI., 1977; Newton and Stephenson, of a sterile drape over the area being
1978; May and Munt, 1979; Feldman et treated. Sterile precautions should be
aI., 1979; DeCesare et al.; Kerrebijn et al.; used when indicated, and gloves may be
Zapletal et al.; de Boeck and Zinman; Falk worn during percussion. For modesty or
et al.; Mazzocco et al.; Webber et al). lt re in the presence of sensitive skin, a thin
majns unclear if percussion is responsi hospital gown or drape may be beneficial.
ble for the decrease in FEV, noted by Thicker coverings, such as towels or
some following chest physiotherapy. A blankets, should not be used. Obesity is
drop in FEV, by less than 10% may not be believed to decrease the effect of chest
clincially significant (but may reach sta percussion in much the same way as
tistical significance) (Rivington-Law et bulky dressings or towels. Chest tube or
aI., 1979). Because this pulmonary mea surgical dressings that cover the thorax
surement is effort dependent and forced should be kept to a minimum so they do
expiration can affect bronchoconstric not hinder percussion or chest wall ex
tion, it is difficult to determine the cause pansion (see p. 74).
of a fall in FEV,. If wheezing or other The use of chest tubes for either he
signs of bronchospasm are present prior mothorax or pneumothorax is not a con
to or occur during chest physiotherapy, traindication to chest percussion or vi
vibration and the FET may be more ap bration. In fact, chest tubes are often
propriate techniques to use than necessary as a result of thoracic surgery
percussion. or chest trauma and consequently indi
Egan (1977) states that percussion must cate that chest physiotherapy may be
be performed over the bare skin. lt is our necessary. Extrapleural hematomas are
belief that chest percussion should be not a precaution to percussion, nor are
preferentially performed directly over they an apparent sequelae of this tech
the thorax. Experience has shown that nique, as shown in a study of 250 pa
many less experienced therapists often tients, most having multiple rib fractures
attempt to percuss over b u l ky towels or (Ciesla et aI., 1987). Patients having sub
pads. Aside from covering anatomical cutaneous emphysema also respond fa
landmarks, towels often require that a vorably to chest physiotherapy. They do
greater force be applied to achieve the not complain of increased discomfort
same cupping effect, since much of the with percussion or vibration, nor has in-
creased emphysema been noted follow contraindicated in patients with signifi

ing such treatments (Ciesla et aI., 1981). cant hemoptysis. However, hemoptysis
If a mechanically ventilated patient has occurs from other causes such as lung
subcutaneous emphysema and no chest contusion or aspiration, for which per
tubes, the physical therapist should have cussion with postural drainange is not
confirmation that no pneumothorax is contraindicated. Also, bloody expecto
present before proceeding with therapy. rate is not uncommon in lung abscess be
Any i ncrease in subcutaneous emphy cause of tissue and vessel destruction.
sema either during or between treat Fatal pulmonary hemorrhage does occur
ments should be noted and brought to the as a consequence of lung cancer. Caution
physician's attention promptly. Subcuta is needed i n establishing cause and effect
neous emphysema may be associated based on a single case study, especially
with pneumothorax, chest tube leakage since the role of cough is unclear and
and other complications discussed on p. both disease processes place the patient
327. at risk for spontaneous fatal hemorrhage
A lung abscess or bronchopleural fis (Kigin, 1984). A more appropriate conclu
tual is not a contraindiction to postural sion may be that, i n a patient with de
drainage, percussion, or vibration. For creased platelet count and significant he
healing to occur, the connecting bronchi moptysis from carcinoma or lung abscess,
should be cleared of secretions by chest the expected benefit should be weighed
physiotherapy. In the case of brocho against the potential risk.
pleural fistula, the pleural space is Due to the increasing number of pedi
drained by open or closed thoracotomy. atric and neonatal intensive care units,
These patients may complain of pain as interest i n chest physiotherapy for this
sociated with the chest tube site, empy population has grown. Because lung seg
ema, or a cellulitis accompanying the fis ments are small in an infant, various ad
tula. These infectious processes should aptations to manual percussion have
not interfere with postural drainage, but been suggested in the l i terature (Tecklin;
slight modification of percussion and vi C urran and Kachoyeanos; Tudehope and
bration around the area of cellulitis helps Bagley; Parker, 1985; Irwin and Tecklin,
alleviate discomfort. For the spontane 1985). Three objects commonly modified
ously breathing patient, breathing exer for chest percussion are shown in Figure
cises are used in conjunction with man 4.2. They include an infant-sized anes
ual techniques. Patients with gross thesia mask with the smaller opening of
unilateral infection resulting from a lung the mask occluded by the therapist's
absecess or bronchopleural fistula re hand or by tape. This device requires
quire prophylactic treatment of the un minimal adaptation of readily available
involved lung following treatment of the equipment in a pediatric intensive care
involved side. This minimizes possible unit. Normally the bell end of a stetho
contamination or infection of the unin scope has rubber padding and need not
volved lung. If subsequent resection is be altered for percussion. When using a
expected, treatment may be concentrated 30-ml medicine cup, the rim should be
on the uninvolved areas of the lungs to covered and padded. Rubber nipples are
prevent or lessen the spread of infection. also used, both with and without pad
A single case of fatal pulmonary hem ding. Another percussion technique for
orrhage was reported by Hammon and neonates and infants is called "tenting";
Martin (1979) i n a patient with squamous this consists of overlapping the second
cell carcinoma and lung abscess. The pa finger over the first and third, as seen i n
tient received bronchial drainage and Figure 4.3. On l y th e fingers are used for
" light" percussion for 15 days. Hemop percussion. Contact-heel percussion, de
tysis was noted both during and indepen scribed for use in neonates with respira
dent of chest physiotherapy treatment. tory distress by Finer and Boyd (1978),
On the sixteenth day during drainage uses the thenar and hypothenar emin
with percussion, the patient suffered ences to apply percussion at a rate of 40
massive hemoptysis and died. From this times a minute. The force varied to
the authors concluded that percussion is achieve a thoracic displacement of 1-2
Figure 4.2. Objects used in per

forming percussion on pediatric
patients include (from left to right)
the bell end of a stethoscope. a
neonatal anesthesia mask, and a
padded medicine cup.
cm. It is not known if any one of these month of either manual percussion or
techniques is more advantageous than mechanical vibration (CPT) every 2 hr.
another. One study (Tudehope and Bag No fractures or apparent detrimental ef
ley, 1980) found the face mask to be su fects were noted. A few weeks later,
perior to contact-heel percussion, but when atelectasis recurred, CPT (using
both techniques resulted in significant the same techniques) was reinstituted.
increases in PaO, and were superior to Subsequent to this second treatment pe
mechanical vibration. riod, rib fractures were noted and CPT
In the neonatal population, one case of was suggested as the cause. The authors
rib fractures following chest physiother correctly point out that stress fractures or
apy is reported (Purohit et aI., 1975). This neonatal rickets are reported in infants
premature infant received at least one with prolonged respiratory dist ress. From
a single infant it is difficult to determine
if percussion was to blame, and whether
manual or mechanical techniques were
the culprit. As in all lCU settings, the ex
perience and skill of the personnel di
rectly treating patients are important
factors.
A decreased platelet count is a very
important finding in the patient with
acute leukemia and coagulopathy. In the
pediatriC population, it is suggested that
percussion can be expeditously per
formed if the platelet count is greater
than 50,000 ml' of blood. Postural drain
age with vibration is recommended with
counts between 20,000 and 50,000; drain
age with breathing exercises and cough
ing are continued with lower platelet lev
els (Irwin and Tecklin, 1985). These
guidelines from one institution imply
that for the patient with coagulopathy,
percussion is potentially more hazardous
than vibration and that both of these
techniques pose more of a risk than pos
tural drainage, breathing exercises, and
coughing. It is the author's opinion that
the amount of force used with either per
Figure 4.3. Tenting, a type of percussion
used on pediatric patients, is demonstrated in cussion or vibration is a greater determi
A and B. Only the area from the metacarpal nant of potential complication than
phalangeal joints, distally, is used for which type of manual technique is ap
percussion. plied. Cough is very forceful and pro-
duces large fluctuations in thoracic, ab

dominal, and intracrainal pressure (see
Chapter 5). It is likely that breathing ex
ercises, percussion, vibration, FET, and
alternative methods of expectoration
present less risk than coughing to a pa
tient with decreased platelet count. Re
search is needed to evaluate the effects of
manual techniques and cough on pa
tients with thrombocytopenia.
VIBRATION
Chest vibrat ion, like percussion, is

used in conjunction with postural drain
age. Although it is stated that chest wall
vibration often dislodges the most stub Figure 4.4. Vibration involves shaking the
born secretions in both large and small chest wall. It can be performed with one hand
placed posteriorly and the other anteriorly, or
airways (Wade, 1973), no data have been
the hands may be placed more laterally as
found to support the claim that vibration
shown.
alone mobilizes secretions from the small
airways. At our institution, when pos
tural drainage and vibration were per (Fig. 4.4). Various sources describe differ
formed during bronchoscopy, it was ing types of vibration as "rib springing"
noted that secretions became visible in or "chest shaking." All are more or less
the larger segmental bronchi during vi vigorous forms of the same general tech
bration. This was also observed by olhers nique, with "vibration" usually refering
(Opie and Spalding, 1958; Thacker, 1959; to a gentler, more oscillatory treatment
Kigin 1981, 1984). Denton (1962) reported than the other terms. Frequencies of 12-
that during bronchoscopy under general 20 Hz are reported for manual vibration,
anesthesia, vibration given during expi and 2 Hz is noted for chest shaking (Gor
ration squeezed the secretions from the mezano and Brainthwaite, 1972; Bateman
bronchioles into the larger bronchi. How et aI., 1981; Sutton et aI., 1985).
ever, fiberoptic bronchoscopy in trained The forcefullness or method of vibra
hands was only reported to reach the tion used on a particular patient is dic
fourth generation bronchi with 74% suc tated by the physical therapist's bias and
cess (Kovnat et al" 1974). Therefore, in knowledge of the patient's injuries, diag
formation on the effects of vibration, as nosis, and general condition. For the el
confirmed by bronchoscopy, pertains to derly or anxious patient, gentler or more
the larger airways. rhythmical vibration may be applied. In
Vibration is an intermittent chest wall itially, asthmatics tend to relax more
compression performed primarily during with vibration techniques and breathing
expiration. It may be initiated just before exercises than with percussion. Percus
the expiratory phase and extended to the sion may be added to the treatment regi
beginning of the inspiratory phase. This men later. Because percussion has been
technique can be used during voluntary noted by some to cause bronchoconstric
or ventilator-controlled expiration and tion, wheezing, or a decrease in FE V, in
should be performed over the involved patients with chronic lung disease
area of the l ung. If vibration is performed (Campbell et aI., 1975; Feldman et al.;
on a spontaneously breathing patient. en Wollmer et al.), vibration may be of
couragement toward a maximal inspira greater benefit in this patient population.
tory effort should precede chest wall vi However, these side effects have not
bration. Maximal inspiration is followed been reported in patients with acute lung
by shaking of the chest wall in the direc disease or normal subjects (Rivinton-Law
tion that the ribs and soft tissues of the et al.).
chest normally move during expiration Subacute head-injured patients or
heavily sedated patients who are difficult stability to the thorax, vigorous vibration
to arouse and have shallow respiration over unstable thoracic spine injuries is
may benefit from more vigorous vibra not advised. Because of the shaking as
tion, with a hold or pause applied until pect of vibration, the author does not rec
the patient starts to initiate inspiration. It ommend its use on patients with known
is thought that the i ncreased tactile stim rib or sternal fractures. This is in contrast
ulation associated with vibration may with others who believe vibration is
improve the inspiratory effort in these more comfortable than percussion and
patients. In the quadriplegic patient, tho does not effect rib motion (Kigin, 1981),
racic vibration, as well as splinting of the 1 984). Provided that the patient has an
abdominal musculature, may be benefi indication for chest physiotherapy. either
cial (see Fig. 8.8). "Bag squeezing" to hy technique (or both) appears to be safe in
perventilate the l ungs in association with the hands of those therapists skilled in
vibration has been described in the lit modifying treatment to individual pa
erature. As with "sighing," the efficacy of tient needs. Elderly patients or persons
this technique is unproven for patients who have used steroids over a long pe
receiving adequate mechanical ventila riod of time may have varying degrees of
tion. Hyperinflation with vibration usu osteoporosis. Chest vibration on these
ally requires the use of two persons and patients should be performed with this in
is associated with significant and delete mind.
rious increases i n ICP (Garradd and Bul
lock) and fluctuations in cardiac output MECHANICAL VIBRATORS AND
(Laws and McIntyre, 1 969). In spontane PERCUSSORS
ously breathing patients who cannot take
a deep breath but who have artificial air Mechanical percussors and vibrators
ways, an 800-1000 cm' manual resusci were develop primarily to assist in the
tator bag may be used as an adjunct to vi home care physiotherapy of patients with
bration and before and after suctioning chronic pulmonary pathology. More re
(Fig. 4.5). cently, they were introduced into the in
Although the ribs and normal anatomy tensive care unit. Because these mechan
of the thoracic spine provide inherent ical devices may produce vertical or
rotary movements, or a combination of
both, some studies refer to them as vibra
tors and some as percussors. Research on
the effectiveness of mechanical vibrators
compared with manual vibration is lim
ited, and only one study pertains to pa
tients i n the intensive care setting. Most
of the information on mechanical percus
sors is available through companies pro
ducing or marketing such devices and
thus is of questionable objectivity. The
data behind claims such as the G5 mas
sage apparatus provide "directional
stroke action to help mobilize muscus in
a selected direction rather than relying
solely on gravity for flow" (General Phys
iotherapy, 1986) and many similar state
ments remain unsubstantiated.
I n studying patients undergoing bron
chopulmonary lavage for alveolar pro
teinosis, Hammond and co-workers
Figure 4.5. When patients are tracheally in
tubated, yet spontaneously breathing, a man (1980. 1983. 1984) compared the effects of
ual resuscitator bag may be used to augment manual percussion, manual vibration,
the patient's inspiratory effort, thus making vi mechanical percussion, and mechanical
brati on more effecti ve
. vibration. The number of patients in
each study was small, but in all cases quate gas exchange during tracheal in
manual techniques were signifcantly sufflation. They theorized that vibration
more effective than mechanical means at may assist air flow to lung regions that
removing proteinaceous-lipid material are poorly ventilated during high-fre
from the alveoli. Neither mechanical per quency, low-pressure oscillations. Bitter
cussion nor vibration was superior to no man et a!. (1983) did not investigate the
treatment. lt is noteworthy that, during role of vibration during spontaneous
bronchopulmonary lavage, the patient is breathing or as an adjunct to conven
positioned so that the dependent lung re tional ventilation. Their aim was to eval
ceives percussion or vibration while it is uate gas exchange with vibration rather
filled with saline, which is in contrast to than mucus clearance.
normal chest physiotherapy techniques. King and co-workers (1983) studied the
However, similar conclusions are re effect of vibration, called high-frequency
ported by Rossman et a!. in patients with chest wall compression (HFCWC), on tra
cystic fibrosis. They found that postural cheal mucus clearance (TMC) in nine
drainage was not enhanced by mechani anesthetized dogs. Chest vibration was
cal percussion and that manual tech performed by oscillating the pressure in
niques were superior i n terms of aerosol a circumferentially applied thoracic cuff.
clearance and sputum production. In pa TMC was enchanced by 2 min of HFCWC
tients with chonic bronchitis, the effect at rates between 5 and 17 Hz. reaching a
of mechanical vibration at 41.0 5.4 Hz peak increase of 340% at 1 3 Hz. The au
on lung clearance in the semierect posi thors discussed two mechanisms for the
tion was evaluated (Pavia et a ! . , 1976). dramatically improved TMC: HFCWC
Comparison of sputum production and may stimulate vagal release of acetylcho
clearance rates between patients given l ine, thus augmenting the frequency of
no vibration and those receiving me Ciliary beating; alternatively, HFCWC
chanical vibration showed no significant may enhance the amplitude of cilia mo
differences. These findings are in con tion since the peak of 13 Hz closely cor
trast to those of Holody and Goldberg responds to known mammalian Ciliary
(1981), who studied the effect of 30 min beat frequencies. This article does not
of mechanical chest vibration followed shed light on bronchial or more periph
by tracheal suctioning in 10 hospitalized eral mucus clearance. However, it does
patients with lung pathology on chest x establish a peak beneficial range of vibra
ray. They reported significant increases tion at 1 1-15 Hz for TMC i n dogs. These
in PaG, at 30 and 60 min after treatment. findings are i n conflict with Radford et a!.
The vibration frequency was not re (1982) who studied in vitro mucociliary
ported. Appropriate postural drainage transport using excised rabbit tracheas.
was not used in either study. They reported that optimal mucociliary
Although the results of animal studies transport occurred between 25-35 Hz.
should not be assumed to be valid for hu In humans, George and associates
mans, Rowe et a!. (1973) investigated the (1985) studied the effect of orally applied
effect of mechanical vibration on 38 pig oscillations (8-12 Hz) on mucociliary
lets following thoracotomy. The use of clearance. They found significantly im
postural drainage was not specified, but proved tracheobronchial clearing using
radiographically the piglets given vibra vibration (oscillation) compared with a
tion showed an 89% improvement com control period. No postural drainage was
pared with a 71 % improvement in the used in this study and none of the sub
nonvibrated group. While investigating jects had pulmonary pathology. Because
the mechanism for high-frequency oscil of the size of the radioaerosol and the low
lation. Bitterman et a !. (1983) looked at penetraction index, it was assumed that
the role of high-frequency vibration (10- the majority of the tracer particles were
50 Hz) applied to the chest wall of para deposited in the larger airways. The au
lyzed cats and found that lateral and thors theorize that the improved muco
prone positions were optimal for vibra ciliary clearance was due to an alteration
tion. Frequencies from 20-35 Hz were in viscoelasticity caused by vibration.
equally effective in maintaining ade- These two studies i n dogs and humans
provide three possible mechanisms of ac al. recommended their use in the ab-
tion for vibration. They also provide evi Mechanical devices are also used i n
dence of improved tracheobronchial th e pediatric intensive care unit. Rowe et
clearing using frequencies consistent sence of a well-trained chest physical
with the manual vibration reported to be therapist. Thibeault (1979) described spe
of benefit in humans with lung pathology cifically how to adapt an electrical tooth
(Bateman et aI., 1981; Sutton et aI., 1 985). brush for use as a neonatal mechanical
The physical response of the human vibrator. Cu rran and Kachoyeanos re
lung and thorax 10 vibration at various ported some benefit from using an elec
frequencies has not been evaluated; tric toothbrush compared with a padded
therefore, it is not known which frequen nipple in two neonates. These findings
cies are best able to dislodge mucus from are in direct contrast with others who
the airways. This uncertainty may ex consider mechanical devices ineffective
plain the varying results found in the lit and inferior to manual techniques (Par
erature. Mucus is thought to be best mo ker; Tudehope and Bagley). The authors
bilized at resonant frequencies of 5-6 Hz also report better patient tolerance of
(Mellins) and 8-12 Hz (George et al.). manual techniques in terms of agitation
Flower et al. (1979a) recommended using with extensor posturing, skin color, and
a mechanical percussor at frequencies of bradycardia. They conclude that, in in
about 15 Hz with a force of 58-65 New fants, skin-to-skin contact often has a
tons. They reported that a higher and comforting effect. In neonates, W.W. Fox
more constant intrathoracic pressure (personal communication) recommended
(25-30 cm H,O) is achieved when the using mechanical percussors in place of
percussor is placed firmly on the chest to manual techniques because of the possi
the degree that voice quiver is produced bility of causing rib fractures. However,
(Dalek effect). Flower and co-workers in the only published case history asso
also stated that the force needed to pro ciating rib fractures with chest physio
duce voice quiver varied greatly depend therapy an electric toothbrush was used
ing on the size of the patient, the surface as part of the treatment (Purohit et aI.,
on which they lie, and the area of the 1975). It is hard to accept that mechanical
thorax receiving treatment. Intrathoracic devices applied manually to the thorax
pressures rose as high as 112 cm H,O produce less chest wall pressure than
(Flower et aI., 1979b). E xternal chest properly performed manual percussion.
force is not reported in this study but is It appears that the key to minimizing
assumed to be excessive to produce such complications and performing effective
high intrathoracic pressures. In view of chest percussion is not through the use of
these conflicting opinions, it appears that mechanical devices on neonates but,
further study is needed to determine rather, through utilizing specially trained
which levels of vibration are most effec individuals.
tive on the varying airways of infants and Mechanical devices are also used in
adults, diseased or normal lungs and me the home care of the pediatric patient to
chanically ventilated or spontaneously decrease the parental burden and en
breathing patients (Mellins; Kirilloff et courage patient independence (Lancet,
al., 1985). 1979). However, Maxwell and Redmond
Manual percussion can be performed found that the youngest child capable of
at varying frequencies, depending on the using such a percussor independently
experience of the therapist and whether was 13 years old. Flower and associates
it is carried out using one or two hands. (1978) studied the domiciliary use of pro
The frequency selected for mechanical totype mechanical percussor (Salford) on
percussion or vibration often is not spec 28 children with cystic fibrosis. They
ified i n the l iterature. Ranges of 3-65 Hz found self-administration to be appropri
are documented (Denton; Pavia et al.; ate to the front and, to a less degree, the
Maxwell and Redmond, 1979; General sides of the chest. Interestingly, in
Physiotherapy; Flower et aI., 1979a; Mur creased paternal involvement was noted
phy et a\.. 19831. with the addition of the mechanical aid.
In comparing manual 10 mechanical 1984). Therefore, mechanical devices in

techniques. most studies have been on volve both purchase and maintenance
adolescents or adults with cystic fibrosis. costs, provide no documented benefit,
Pryor and co-workers (1981) found a sig and still require the presence of a thera
nificant increase in FE V, and FVC with pist to administer the care i n the hospital
manual therapy but no difference in spu setting.
tum weight. In small samples of patients. SUMMARY
others have found no difference in the
two techniques i n terms of pulmonary Based on limited research, it appears
function or sputum volume (Hartsell. that percussion and vibration in conjunc
1978; Maxwell and Redmond; Murphy et tion with postural drainage are effective
al.. 1983). in mobilizing retained secretions. The lit
Drawbacks specific to mechanical de erature also suggests that these tech
vices include the weight. sensation, noise niques aid mucus clearance i n both pe
level, and cost of the device (Maxwell ripheral and more central airways and
and Redmond; Tecklin; Pryor et aI., 1981; may be more effective in patients with
Murphy et al.). In the literature, both the acute lung pathology. A lthough the me
type of equipment available and the cost chanisms of action are not clear, it is
tend to vary conSiderably. Prices from assumed that percussion and vibration
$375 to $995 are common, with addi augment gravity. Therefore, it is ques
tional costs for accessory parts and appli tionable if these techniques are of benefit
cators (General Physiotherapy). in the absence of postural drainage. Com
In treating patients after surgery or plications of percussion or vibration are
trauma who require intensive pulmonary very rarely reported and may be due to
care, it is the author's experience that poor technique. The frequencies of per
"manual techniques" have the following cussion and vibration that are most ben
advantages over mechanical devices. (1) eficial to mucus clearance have not been
Rib and sternal fractures that are not de established. There is limited evidence in
tected on routine chest x-rays may result animals and humans to suggest that op
from trauma or thoracic su rgery. These timal frequencies range between 8 and 15
fractures may be noted during chest Hz. This area requires further investiga
physiotherapy evaluation and treatment. tion. As a result of the positive effects at
requiring the modification in manual tribu ted to manual percussion and vibra
techniques described earlier. (2) Manual tion, mechanical devices have been
palpation and visual inspection during introduced. These devices collectively
treatment of the thorax allows the ther demonstrate wide ranges i n both opera
apist to monitor important changes in the tional frequencies and cost; yet mechan
patient's response to treatment, such as a ical percussors have not been found to be
change in skin color, chest excursion, more effective than manual percussion.
subcutaneous emphysema, or tactile Un less mechanical devices can be
fremitus. (3) The manual techniques of proven more effective than the manual
percussion and vibration may be adapted techniques, the added cost, with no cor
to fit the patient's need or tolerance; me responding decrease in personnel or
chanical devices are adjustable only treatment time, is unwarranted.
within the preset range of their manufac
References
turers. (4) Some benefit may result from
the direct skin contact that occurs with Ayella RJ: Radiologic Management of the MaSSively
manual techniques. (5) No existing data Traumali7..ed Polienl. pp. t 14-123. Williams &
Wilkins. Baltimore. 1978
demonstrate any advantages of mechan Barrell SE. Abbas HM: Monitoring during physio
ical devices over manual percussion and therapy after open heart surgery. Ph}7Siotherapy
vibration, and some research suggests 64:272-273. 1 978
that manual techniques are more effec Bateman JRM. Newman SP. Daunt KM, Pavia D.
Clarke SW: Regional lung clearance of excessive
tive (Tudehope and Bagley; Hammon et
bronchial secretions during chest physiotherapy
al" 1980; Pryor et aI., 1981; Rossman et al; in patients with stable chronic a i rways obstruc.
Hammon. 1983; Hammon and Freeman, tion. l.. oncel l:294-297. 1979
Bateman JRM. Newman SP. Daunt KM. Sheahan Finer NN, Moriartey RR. Boyd I. Phillips HI, Stew
NF. Pavia O. Clarke SW: Is cough as effective as art AR, Ulan 0: Post extubation atelectasis: a ret
chest physiotherapy in the removal of excessive rospective review and a prospective controlled
tracheobronchial secretions? Thorax 36:663-687. study. , Pedialr 94:1 10-1 1 3 . 1979
1981 Flower KA. Eden RJ. Lomax L: A new mechanical
Bitterman. H. Kerem DH, Shahlai Y. Gavriely N, aid to physiotherapy for patients with cystic fibro
Palli Y: Respiration maintained by externally ap sis (oral presentation). Eighth Eu ropean Working
plied vibration and tracheal insufflation in the Group Cystic Fibrosis. Austria, 1978
cat. Aneslh Anolg 62:33-38, 1983 Flower KA. Eden RI. lomax L, Mann NM. Burgess
Buscaglia AI. 51 Marie MS: Oxygen saturation dur I: New mechanical aid to physiotherapy in cystic
ing chest physiotherapy for acute exacerbation of fibrosis. Br Med 1 2:630-63 1 . 1979a
severe chronic obstructive pulmonary disease. Flower KA. Mann MN. lomax L: Intrathoracic pres
Resp Care 28:1009-1013, 1983 sure variations generated by mechanical percus
Campbell AH, O'Connell JM. Wilson F: The effect sion (oral presentation). Ninth E u ropean Working
of chest physiotherapy upon FEV1 in chronic Group Cystic Fibrosis. The Netherlands. 1979b
bronchitis. Med / Ausl 1 :33-35. 1975 Garradd J. Bullock M: The effect of respiratory ther
Ciesla NO. Klemic N. Im1e PC: Chest physical ther apy on intracranial pressure in ventilated neuro
apy to the patient with multiple trauma: Two case surgical patients. Ausl J Physiother 32:107- 1 1 1 .
studies. Phys Ther 61:202-205. 1981 1986
Ciesla N, Rodrieguez A. Anderson p, Norton B: The Gaskell OV. Webber BA: The Brompton Hospilal
incidence of extrapleural hematomas in patients Guide to Chest Physiotherapy. p 25. Blackwell Sci
with rib fractures receiving chest physical ther entific Publications. Boston. 1 980
apy (abstract). Phys Ther 67:766, 1 987 General Physiotherapy: G5 Massage Apparatus.
Clarke SW. Cochrane CM. Webber BA: Effects of General Physiotherapy. St Louis, 1 986
sputum on pulmonary function (abstract). Thorax George RIO. Johnson MA, Pavia 0, Agnew IE,
28:262. 1973 Clarke SW, Geddes OM: Increase in mucocilliary
Cochrane CM, Webber BA, Clarke SW: Effects of clearance in normal man induced by oral high
sputum on pulmonary function. Br Med J 2 : 1 1 8 1 - frequency oscillation. Thorax 40:433-437. 1985
1 183, 1977 Gormez.ano I. Brainthwaite MA: Pulmonary phys
Crane L: Physical therapy for neonates wilh respi iotherapy with assisted ventilation. Anaesthesia
ratory dysfunction. Phys Ther 61 : 1 764-1 773. 1981 27:249-257. 1 972
Crane LO, Zombek M , Krauss AN, Auld PAM: Com Gray l: Fatal pulmonary hemorrhage (letter). Phys
parison of chest physiotherapy techniques in in Ther 60:343-344. 1980
fants with HMO (abstract). Pedialr Res 1 2:559. Hallbook T. Lindblad B. Lindrolh B. Wolff T: Pro
1978 phylaxis against pulmonary complications in pa
Curran Cl, Kachoyeanos MK: The effects on neon tients undergoing gallbladder surgery. Ann Chi
ales of two methods of chest physical therapy. rurg Gyoaecol 73:55-58. 1 984
MCN 4:309-31 3. 1 979 Hammon WE: Manual versus mechanical perclls
deBoeck C. Zinman R : Cough versus chest physio sian for clearance of alveolar contents (abstract).
therapy a comparison of the acule effects on pul Phys Ther 63:756. 1983
monary function in patients with cystic fibrosis. Hammon WE. Freeman PC: Chest physical therapy
Am Rev Respir Dis 129:182-184, 1984 research in the treatment of pulmonary alveolar
proteinosis. Cardiopulm Q (APTA) 4:6-7. 1 984
DeCesare IA. Babchyck BM, Colten HR. Treves S: Hammon WE. Kirmeyer PC, Connors AF. Mc
Radionuclide assessment of the effects of chesl Caffree DR. Kaplan RI: Effect of bronchial drain
physical therapy on ventilation in cystic fibrosis. age on intracranial pressure in acute neurological
Phys Ther 62:820-825. 1982 injuries (abstract). Phys Ther 5 1 :735, 1981
Demers B: Contraindications for chest physiother Hammon WE. Martin RJ: Fatal pulmonary hemor
apy (letter). Chpsl 89:902-903. 1 986 rhage associated with chest physical therapy.
Denton R: Bronchial secretions in cystic fibrosis Phys Ther 59:1247-1248. 1979
the effects on treatment with mechanical percus Hammon WE. Martin R I ; Chest physical therapy for
sion vibration. Am Rev Rospir Dis 86:41-46, 1 962 acute atelectasis. Phys Ther 61:21 7-220, 1981
Egan 0: Fundamentals of Respiratory Therapy, p. Hammon WE, Martin RJ, Pennock B. Rogers RM:
473. CV Mosby, 51. Louis, 1977 Percussion versus vibration for clearance of al
Etches PC. Scoll B: Chest physiotherapy in the new veolar contents (abstract). Phys Ther 60:589. 1980
born: Effect on secretions removed. Pediatrics Hartsell M: The effects of postural drainage. manual
62:713-715, 1978 percussion and vibration vs. postural drainage
Falk M, Kelstrup M. Andersen IB, }\inoshila T, Falk and mechanical vibration on maximal expiratory
P. Stovring S. Gothger 1: Improving the ketchup nows (abstract). Am Rpv Respir Dis
bottle method with positive expiratory pressure. 1 77(suppl):204. 1978
PEP. in cystic fibrosis. Eur 1 Respir Dis 65:423-432. Hofmeyer IL. Webber BA, Hodson ME: Evaluation
1984 of positive expiratory pressure as an adjunct to
Feldman ,. Traver GA. Taussig lM: Maximal expi chest physiotherapy in the treatment of cystic fi
ratory nows after postural drainage. Am Rev Res brosis. Thorax 41:951 -954. 1 986
pir Dis 1 1 9:239-245, 1979 Holody B, Goldberg HS: The effect of mechanical vi
Finer NN, Boyd I: Chest physiotherapy in the noen brat ion physiotherapy on arterial oxygenation in
ate: A controlled study. Pediatrics 61 :282-285. acutely ill patients with atelectasis or pneumonia.
1978 Am Rev Respir Dis 1 24:372-375, 1981
Holody B. Goldberg HS: More on the vibrating fool usl and mechanical percussion technique with
pad (letter). Am Rev Respir Dis 1 25;782-783, 1982 gravity assisted bronchial drai nage in patients
Howell S. Hill 10: Acute respiratory care in the open with cystic fibrosis. Arch Dis Child 54:542-544.
heart surgery patient. Phys Ther 52:253-260. 1972 1979
1m Ie PC: Chest physical therapy gUidelines for May DB. Munt PW: PhysiologiC effects of chest per
treating lung contusion. Cordiopuim Q (APTA) cussion and postural drainage in patients with
4:5-6. 1983 stable chronic bronchitis. Chesl 75:29-32. 1979
Imle PC. Mars MP. Eppinghaus CEo Anderson p, Mazzocco MC. Owens GR. Kirilloff LH. Rogers RM:
Ciesla NO: Effect of chest physiotherapy (CPT) Chest percussion and postural drainage i n pa
positioning on intracranial (Iep) and cerebral per tients with bronchiectasis. Chest 88:360-363. 1985
fusion pressure (CPP) (abstract). Cril Core Med Meier P: CPT-Which method. if any? MCN 4:310-
16:382. 1 988 31 1 . 1979
Irwin S. Tecklin IS: Cardiopulmonary Physical Mellins RB: Pulmonary physiotherapy in the pedi
Therapy pp 325-328. 358. CV Mosby Co. 51. Louis, atric age group. Am Rev Respir Dis 1 1 0(Suppl
1985 2):137-142 . 1 974
Kerrebijn KF, Veenljer R. Banzel VO Water E; The Morran CC. Finlay IG, Mathieson M. McKay AI.
immediate effect of physiotherapy and aerosol Wilson N. McArdle CS: Randomized controlled
treatment on pulmonary function in children trial of physiotherapy for postoperative pulmo
with cystic fibrosis. Eur / Respir Dis 63:35-42. nary complications. Br / Anaesth 55: 1 1 13-1 1 1 6.
1982 1983
Kigin CM: Chest physical therapy for the acutely ill Murphy M . Concannon D. Fitzgerald MX: Chest
medical patient. Phys Ther 6 1 :1 724-1736. 1981 percussion: Help or hindrance to postural drain
Kigin CM: Advances in chest physical therapy. In age? Ir Med 1 76:1 89-190, 1983
Current Adva nces in Ilespiratory Core. edited by Newton OAG. Stephenson A : Effect of physiother
WI ODonohue. pp 37-71. American College apy on respiratory function. Lancet 2:228-230,
Chest Physicians. Park Ridge. 1984 1978
King M. Phillips DM. Gross D. Vartian V. Chang HK. Opie LH. Spalding 1M: Chest physiotherapy during
Zidulka A: Enhanced tracheal mucus clearance intermittent positive pressure respiration. Lancet
with high frequency chest wall compression. Am 2:671-674, 1958
Rev Respir Dis 128:511-515. 1983 O'Rourke PP. Schena IA. Thompson IE: The effects
Kirilloff LH. Owens GR. Rogers RM. Mazzocco MC: of pulmonary physiotherapy on delivered tidal
Does chest physical therapy work. Chesl 88:436- volume (abstractj. Crit Core Med 88:286. 1984
446. 1 983 Parker AE: Chest physiotherapy i n the neonatal in
Klein P. Kemper M. Weissman C. Rosenbaum SH. tensive care unit. Physiotherapy 7 1 :63-65. 1985
Askanazi J. Hyman AI: Attenuation of the hemo Pavia D. Thomson ML. Phillipakos 0: A preliminary
dynamic responses to chest physical therapy. study on the effect of a vibrating pad on bronchial
Chesl 93:38-42. 1988 clearance. Am Rev Respir Dis 1 1 3:92-96. 1976
Kovnat DM. Rath GS. Anderson WM. Snider GL: Pelty TL (ed): tntensive and Ilehabilitotive Respira
Maximal extent of visualization of the bronchial tory Core. pp 106, 108. Lea & Febiger. Philadel
tree by fiberoptic bronchoscopy. Am Ilev Ilespir phia 1974
.
Dis 1 1 0:88-90. 1974 Pryor IA. Webber BA. Hodson ME. Batten Ie: Eval
Lancet Editorial: Mechanical chest physiotherapy. uation of forced expiration technique as an ad
Lancet 2:729. 1979 junct to postural drainage in the treatment of cys
Laws AK. Mcintyre RW: Chest physiotherapy: A tic fibrosis. Br Med J 2:417-418. 1979
physiological assessment during intermittent pas Pryor IA. Parker RA, Webber BA: A comparison of
itive pressure ventilation in respiratory failure. mechanical and manual percussion as adjuncts to
Can Anaeslh Soc J 1 6:487-493. 1969 postural drainage i n treatment of cystic fibrosis in
Mackenzie CF. Shin B: Cardiorespiratory function adolescents and adults. Physiotherapy 67:140-
before and after chest physiotherapy in mechan. 1 4 1 . 1981
ically ventilated patients with post-traumatic Purohit OM. Caldwell C. Levkoff AH: Multiple rib
respiratory failure. Crit Care Med 1 3:483-486. fractures due to physiotherapy in a neonate with
1985 hyaline membrane disease (letter). Am 1 Dis Child
Mackenzie CF. Shin B. McAslan TC: Chest physio 1 2 9 : 1 1 03-1 104. 1975
therapy: The effect on arterial oxygenation. Reines HD. Sade RM. Bradford SF. Marshall I : Chest
Anestn Analg (Cleve) 57:28-30. 1978 physiotherapy fails to prevent post-operative at
Mackenzie CF. Shin B. Hadi F. lmle PC: Total lung/ electasis in children after cardiac surgery. Ann
thorax compliance changes following chest phys Surg 1 95:451-455. 1982
iotherapy. Anesth Anal (Cleve) 59:207-210. 1980 Rivington-Law B. Epstein SW. Thompson G: The ef
Marini 11, Pierson DJ. Hudson LO: Acute lobar atel fect of chest wall vibrations on pulmonary func
ectasis: A prospective comparison of fiberoptic tion in normal subjects. Physiother (Canada)
bronchoscopy and respiratory therapy. Am Rev 3 1 : 3 1 9-332. 1 979
Respir Dis 1 1 9:971-978, 1979 Roper PC. Von willer lB. Fisk Ge, Gupta 1M: Lobar
Matjasko f, Pitts L: Controversies in severe head in atelectasis after nasotracheal intubation in new4
jury management. In Clinical Controversies in born infants. Ausl Paedialr J 12:272-275, 1976
Neuroanesthesia and Neurosurgery, edited by J. Rossman CM. Waldes R . Sampson D. Newhouse
Matjasko and I Katz. pp 200-2 1 2 . Grune & Strat MT: Effect of chest physiotherapy o n the removal
ton. New York. 1 986 of mucus in patients with cystic fibrosis. Am Rev
Maxwell M, Redmond A: Comparative trial of man- Respir Dis 1 2 6 : 1 3 1 - 1 3 5 . 1982
Rowe MI. Weinberger M. Poole CA: An experimen in obese patients following gastric stapling. Chest
tal study on the vibration in post operative tra 86:891-895. 1 984
cheobronchial clearance. J Pediolr Surg 8:735- Tudehope 01. Bagley C: Techniques of physiother
738. 1973 apy in intubated babies with respiratory distress
Sutton pp, Lopez-Vidriero MT. Pavia D. Newman syndrome. Aust Poedialr J 1 6:226-228. 1980
sr, Clarke SW: Effect of chest physiotherapy on Tyler ML. Hudson LD. Crose BL. Huseby IS: Predic
the removal of mucus in patients with cystic fi tion of oxygenation during chest physiotherapy
brosis (letter). Am Rev Respir Dis 127:390-391. in critically ill patients (abstract). Am Rev Resp;r
1 984 Dis 1 2 1 (suppll:218. 1 980
Sutton PP. Lopez-Vidriero MT, Pavia D. Newman Van der Schans CPo Piers DA. Postma OS: Effect of
SP. Clay MM. Webber B. Parker RA. Clarke SW: manual percussion on tracheobronchial clear
Assessment of percussion. vibratory-shaking and ance in patients with chronic airnow obstruction
breathing exercises in chest physiotherapy. Eur / and excessive tracheobronchial secretion. Thorax
Respir Dis 66:147-152, 1985 41 :448-452. 1986
Sullon PP. Parker RA. Webber SA. Newman sr, Wade JF (ed); Respiralory Nursing Core. Physiology
Carland N, Lopez-Vidriero MT, Pavia D. Clarke and Technique. p 105. CV Mosby, 51 Louis.
SW: Assessment of the forced expiratory tech 1973
nique. postural drainage and directed coughing in Webber B. Parker R . Hofmeyr J. Hodson M: Evalu
chest physiotherapy. Eur J Respir Dis 64:62-68. alion of selfpercussion during postural drainage
1983 using the forced expiration technique. Physiother
Sutton PP. Pavia D. Bateman IRM. Clarke SW: Chest Pracl 1 :42-45. 1985
physiotherapy: A review. Eur J Respir Dis 63:188- White OJ. Mawdley RH: Effects of selective bron
201. 1982 chial drainage positions and percussion on blood
Teddin IS: Positioning. percussing. and vibrating pressure and healthy human subjects. Phys Ther
patients for effective bronchial drainage. Nursing 63:325-300. 1983
'79 9:64-71 . 1 979 \Vollmer P. Ursing K. Midgren B. Eriksson L: Ineffi
Thacker EW: Postural Drainage and Respiratory dency of chest percussion in the physical therapy
Control. 2nd ed .. p 19. L1oydLuke. Ltd .. London. of chronic bronchitis. Eur J Respir Dis 66:233-239.
1959 1 985
Thibeault OW. Gregory GA (eds): Neonatal Pulmo Zadai CC: Physical therapy for the acutely ill med
nary Care. pp 248-250. Addison-Wesley Publish ical patient. Phys Ther 61 :1 746-1754. 1981
ing. Menlo Park. 1979 Zapletal A. Stefanova J. Horak I . Vavrova V. Sama
Tomney PM. Finer NN: A controlled evaluation of nek M: Chest physiotherapy and airway obstruc
muscle relaxation in ventilated neonates (ab tion in palients with cyslic fibrosis-a negative
stract). Cril Core Med 8:228. 1980 report. Eur J Respir Dis 64:426-433. 1983
Torrington KG. Sorenson DE. Sherwood LM: Post
operative chest percussion with postural drainage
CHAPTER 5
Methods of Airway Clearance:

Coughing and Suctioning
P. Cristina Imle, M.S., P.T., and Nancy Klemic, B.S., P.T.
Ciliary Action
The Cough Mechanism
Stages o( a Cough
Glottic Function
Airway Compression
Two-Phase Concurrent Flow
Cough, Forced Expiratory Technique, and Chest Physiotherapy
Cough Supression
Methods o( Cough Stimulation
Tracheal Suctioning
Difficulty in Passing a Suction Catheter
Difficulty Cannulating the Left Main Stem Bronchus
Suction Catheters
Complications o( Tracheal Suctioning
Hypoxemia
Cardiac Dysrhythmias
Mechanicsl Trauma
Bacterial Contamination
Raised Intracranial Pressure
Nasotracheal Suctioning
Other Adjuncts to Coughing and Suctioning
Lavage
UBagging"
Bag-Squeezing Method o( Chest Physiotherapy
Manual Resuscitators or Bags
Ciliary activity may be impaired by a cough stimulation. The techniques and

history of smoking, surgery, anesthesia, hazards of suctioning are also consid
trauma, or preexisting lung disease. Pain ered. Pulmonary lavage and "bagging,"
and immobility accompany recovery and or lung hyperinflation are reviewed as
further impede secretion clearance and adjuncts to coughing and suctioning.
reduce lung volumes. Consequently, sec
ondary techniques for airway clearance, CILIARY ACTION
such as coughing and suctioning, become
increasingly important in the prevention Coughing is considered an extremely
of atelectasis and pulmonary infection. important mechanism for the removal of
This chapter reviews the literature on lung secretions. Normally, coughing oc
coughing, addresses the etiology of cough curs infrequently, suggesting that this is
suppression, and describes methods of not the only method active in secretion
153
clearance. Phagocytosis and lymphatic o Normal non-smokers

75 %
drainage are the most peripheral Chronic bronchitics
mechanisms involved in secretion clear
ance, and these occur beyond the termi

nal bronchioles. The terminal airways
are lined with surfactant that may also '0
l' 50
assist in airway clearance (Com roe, 1 966; .,'" 0

Leith, 1967). Cilia extend from the ter u
minal bronchioles to the larynx. The ""
'S; 0
0
rhythmical beating of these cilia is U -
'"
0
largely responsible for keeping the air '5 8

ways clear of excess mucus, and this pro '" 25 0

a:
0
vides adequate clearance in normal 0 8

'" 0
circumstances. Ciliary motion is contin !
uous, initiating a wave-like action that ., 0 ,
carries the entire mucus blanket cepha
...
lad. Although the overall rate of clear 0 -- i -
ance can vary, rates of up to 16 mm/min after 1 h after cough

mucociliary clearance
have been observed experimentally
(Comroe). Under normal circumstances, Figure 5.1. Comparison of the percentage of
phagocytosis, lymphatic drainage, and bronchial radioactivity eliminated after 1 hr by
ciliary action keep the alveoli sterile. mucociliary clearance and coughing in healthy
Three major factors influence ciliary nonsmoking subjects and chronic bronchitics.
clearance: cilia length, density, and beat (From Puchelle E: Eur J Respir Dis61 :254-264,
frequency, the quantity of mucus pres 1980.)

ent, and the viscoelastic properties of
mucus (King, 1980). Hypoxemia and de causing cellular damage to the cilia and
hydration can arrest ciliary action (New epithelium (Comroe).
house, 1973; Chopra et aI., 1977). This ad A tracheal tube can impair ciliary flow
verse effect is usually reversible once the while stimulating increased mucus pro
insult is removed. Dry gases such as sup duction, due to its effect as a foreign ob
plementary oxygen or other vehicles ject (Bucher, 1958; Leith, 1967). Secre
used to deliver anesthetic agents have tions raised to the level of an artificial
the same effect as dehydration unless ad airway are reported to pool in this area
equate humidity is added (see Chapter 9). due to the presence of the tracheal tube
Anesthetic agents themselves can sup (Leith, 1967). The cuffs of artificial air
press ciliary activity. A history of smok ways can addit ionally interfere with cil
ing and most chronic lung diseases result iary action and tracheal mucosal perfu
in reduced ciliary function as shown in sion. This may lead to tissue necrosis or
Figure 5.1 (Goodman et aI., 1 978; Moss scarring and further decrease ciliary
berg et aI., 1978: Puchell et aI., 1980: function. When mucociliary transport is
Mossberg and Cramner, 1980). The rheo impaired, cough can, in part. compensate
logical properties of sputum also affect for the loss (Mossberg and Cramner).
mucociliary transport. Altering either the
viscosity or elasticity diminishes normal THE COUGH MECHANISM
sputum clearance. Interestingly, sputum
that is either too thick or too runny de Stages of a Cough
creases mucus transport. Mucociliary
clearance is also significantly less in pa Coughing particularly affects the larger
tients with purulent sputum (leukocyte airways. I t is most important in the re
count greater than 3500/mm) (Puchelle moval of foreign bodies or excessive
et aI., 1980; King, 1980). Infection of the quantities of sputum and when normal
airways may increase secretion produc ciliary activity is absent. The cough
tion, further impeding mucus flow. mechanism provides the most rapid
Chronic infection magnifies this by also means of secretion clearance. Coughing
METHODS OF AIRWAY CLEARANCE: COUGHING AND SUCTIONING 155
is usually considered a reflex controlled 1977; King et a1.. 1985). Cough is not al
primarily by afferent stimulation of the ways preceded by inspiration. If foreign
vagus nerve. which leads to a complex material enters the larynx. it may imme
series of muscular actions (see Fig. 5.2). It diately elicit a cough from the existing
is normally triggered by mechanical or lung volume. thereby preventing impac
chemical stimulation of the larynx. ca tion of the material deeper into the air
rina. trachea. and large bronchi. in that way (Leith et a1.. 1986).
order (Widdicombe. 1980). Cough can The glottic closure that ocurs along
also be elicited experimentally by elec with expiratory muscle activity is often
trical and osmotic stimuli (Banner. 1 986). referred to as the compressive phase of
A normal cough consists of an inspira cough and lasts for about 0.2 sec. The
tory effort. glottic closure. and contrac contraction of any or all of the expiratory
tion of the expiratory muscles followed muscles in the chest wall. abdomen. and
by opening of the glottis. Inhaling large pelvic floor interacts with inspiratory
volumes prior to a cough results in im muscles to produce intrathoracic pres
proved expiratory muscle function. At sures as high as 200 cm H20. The expi
high lung volumes the length-tension re ratory phase of cough begins when the
lationships of the expiratory muscles are glottis opens and air is expelled. During
optimized and are therefore capable of this phase. compression of the central
generating greater the expiratory pres airways occurs and is associated with gas
sures and flows that increase cough effec velocities of up to Mach 0.6. The high ki
tiveness (Leith et a1.. 1986; McCool and netic energy. shearing force. and accel
Leith. 1987). However. the inspired vol eration of wave motion along the airway
ume at the beginning of a cough is vari wall are thought to provide airway clear
able. It is usually larger than a tidal ance. which is the major function of
breath and averages 2.5 liters (Lei th. coughing (Leith. 1 967, 1977, 1 985; Guy-
RECEPTORS AFFERENTS "COUGH CENTER" EFFERENTS
RESPIRATORY
LARYNX
TRACHEA
BRONCHI
VAGUS
VAGUS .upplles larynx
and tracheobronchial
tree
OTHER
r
NOSE
)'
TRIGEMINAL
PARANASAL SINUSES

Located dlHusely In
PHARYNX GLOSSOPHARYNGEAL medulla, separate
EAR CANALS & DRUMS from re'plratory
PLEURA VAGUS centers ,.
' PHRENIC and OTHER
}__
STOMACH
" SPINAL MOTOR
PERICARDIUM _ NERVES .upply the
PHRENIC 1/
DIAPHRAGM r I diaphragm and other
' expiratory musculature
"HIGHER CENTERS",
Figure 5.2. Anatomy of the cough reflex. Respiratory tract receptors are most numerous in the
larger airways, least in the smaller airways. and none is present beyond the respiratory bronchi
oles. They respond to chemical and mechanical stimuli and adapt rapidly. Other receptors probably
respond only to mechanical stimuli. "Higher centers" is included as afferent, since cough can be
voluntarily initiated, postponed or suppressed. (From Irwin RS et al.: Arch Intern Med 137:1186-
1191,1977.)
ton, 1977; Irwin et aI., 1 977; Leith et al" (Leiner et a I . , 1966), nor is the ability to
1986). Both airway compression and me develop peak airway pressures found to
chanisms of airway clearance are further depend upon glottic closure (Gal, 1980).
described in this chapter. Rather, it is the timing of both peak air
way pressure and flow that differentiates
Glottic Function a cough from a forced expiration (see Fig.
5.3). Glottic closure allows the expiratory
The role of the glottis during a cough is phase of coughing to occur at higher lung
debated in the literature, but there ap volumes and at greater intrathoracic
pears to be agreement that its action is pressures than occur with forced expira
significant. Leith (1967) claims that glot tion (Evans et aI., 1975; Melissinos et al..
tic closure is important in achieving 1976. 1978). The contractile force of the
maximum positive airway pressure. It is expiratory muscles, which control intra
the abrupt opening of the glottis follow thoracic pressure during cough. are en
ing its closure that differentiates a cough hanced by glottic closure (Leith et al..
from a forced expiration (Bucher; Leith 1986). With coughing. the closed glottis
et aI., 1986). This distinction is used prevents air flow until considerable pres
throughout the text. Ross et al. (1955) sure develops and then the glottis opens.
suggest that the reduction in lumen size In forced expiration and in patients with
differentiates a cough from a forceful ex artificial airways. flow begins and alters
piration in which flow rates equivalent to in relation to pressure changes. As a
those of a cough may be easily achieved. result, higher transpulmonary pres
In normal subjects, no significant differ sures and more marked tracheobron
ences are found between the peak flow chial compression occur with coughing
rates of forced expiration or coughing (Gal).
"
z
" 10
COW9h
I.-
10

0 0 20 40 60 80 100
g
,
0
Vol
2 4
I.t'n
6
nME mS.c

,.
Forced E,plratlOfl IO 15
10
0 Z
10 10

,

I 4
,
0
TIME 10 ",Sec IdlY
0 20 40 60 80 100
0 2 4 6
Vol. I.I,r. TIW[ mSec
Figure 5.3. (A) Flow time representations of cough and forced expiration at the same lung volume
in a normal subject. (B) On the left is a series of VOluntary coughs beginning at total lung capacity
and progressing sequentially down to vital capacity. superimposed on the subjects maximum ex
piratory flow-volume curve. On the right. the numbered coughs are represented as flow in time.
(C) Series of brief rapid expiratory effects are depicted in the same manner as the coughs. All data
shown are derived from the same normal subject. (From Knudson RJ et al.: J Appl PhysioI36:653-
67.1974.)
In a series of coughs, glottic closure al sound (Leith, 1977). The degree of airway
lows pressure in the airways to equalize collapse is significant as decreasing the
between coughs. It assists compressed cross-sectional area by half produces a
airways in regaining normal size for that fourfold increase in the kinelic energy of
lung volume (Langlands, 1967; Gal). The the gas stream (Gal).
glottis is also noted to oscillate violently The location and extent of airway com
during coughing, setting up pressure pression distal to the trachea and main
fluctuations that may play a part in loos stem bronchi are debatable and poorly
ening secrelions from the airway walls. understood. Because glottic closure pre
The rapid opening and closing of the glot vents air flow unlil peak pressure is
tis that may occur during the expiratory reached, coughing is associated with
phase of coughing also cause changes in more marked airway narrowing than
the airflow and pleural and abdominal forced expiralion. The locations in the
pressure (Leith, 1967). airways where peripheral flow is limited
but where flow downstream is usually
Airway Compression enhanced (by dynamic compression) are
referred to in the literature as choke
The lungs are designed so that the points, equal pressure points, or flow lim
cross-seclional area of the airways de iting segments (FLS) (Leith, 1977, 1985,
creases as one moves from the alveolus to 1986; Smaldone et aI., 1979; Smaldone
the mouth (McCool and Leith). When ex and Messina 1 985a,b; Smaldone and
piralion begins, alveolar pressure is Smith, 1985). There is general agreement
greater than ambient pressure, so air that at high lung volumes (as normally
flows from the peripheral airways, along precedes a cough), the FLS are confined
the pressure gradient and out of the to the trachea or mainstem bronchi. They
lungs. Simultaneously, pleural pressure are thought to move peripherally (an un
exceeds the pressure within the central certain distance) as lung volume de
airways, producing a rapid narrowing of creases (as with a series of coughs or
the central air passages and a dramatic forced expiralions) (Leith, 1977, 1 985).
increase in air flow from the compressed For this reason, coughing or forced expi
areas mouth ward (or downstream) ratory efforts from progressively smaller
(Leith, 1985). The high intrapleural pres lung volumes are suggested as methods
sure and smooth muscle aclivity are felt to improve peripheral airway clearance
to be responsible for the changes in air due to upstream movement of the FLS
way diameter noted during cough (Ross (Meade et aI., 1967; Pryor et aI., 1979).
et aI., Marshall and Holden. 1963; Leith. However, in addition to lung volume, the
1977; Gal). Tracheal narrowing occurs location of the FLS depends on age, lung
during both cough and forced expiration. and airway geometry, elastic recoil, gas
Compression is limited to the posterior density and viscosity, and the presence of
membranous portion of the trachea as secrelions or disease (Leith et a I . , 1986).
the rest of the trachea is made up of rigid Also, there is little evidence that FLS
cartilage (see Fig. 2.6). The increased in move outside of the central ai rways.
trapleural pressure causes invaginalion Some researchers have suggested that
of the posterior tracheal wall, thereby re they migrate as far as the fifth or sixth
ducing the lumen caliber. A pressure gra bronchial generalions (trachea = 0)
dient of 40 cm H,O is reported as suffi (Lambert et aI., 1981, 1982). More re
cient to reduce the cross-sectional area to cently, in studies of normal subjects.
roughly one-fifth its original size. This persons with chronic obstructive lung
decrease generates a force of about 25 disease and mechanically ventilated pa
limes that possible in the uncompressed tients with severe intracerebral injury,
trachea (Ross et al.). Tracheal narrowing FLS failed to move beyond the fourth
of up to 80%, reported from broncho generalion bronchi with coughing or
scopic and bronchographic exam inalion, forced expiration at low lung volumes
could result in velocities of up to 25,000 (Smaldone and Smith, 1985; Smaldone
cm/sec or three quarters the speed of and Messina, 1985a,b).
Two-Phase Concurrent Flow evaluated the effect of cough, postural

drainage, and exercise on the removal of
The clearance of secrelions by cough radioaerosols in eight patients with
ing depends on the combined effect of se chronic bronchitis. Coughing was pro
cretions and air flow within the airways. hibited during postural drainage. Aerosol
This gas-liquid interaction is termed two clearance was better during cough than
phase concurrent flow. Four proposed exercise and both were superior to pos
mechanisms are shown in Figure 5.4. tural drainage. The investigators claim
Bubble flow is not relevant to cough. Slug that cough is effective in improving the
flow is effective in removing large plugs peripheral clearance of secretions. How
of sputum from the central airways. The ever, the airways that they describe as
annular flow of mucus is thought to be peripheral (diameters approximately 2-4
slow despite the associated high air-flow mm) correspond to fifth- and six-order
velocities. Flow rates markedly decrease bronchi (Weibel, 1963). Their findings
as energy is transferred into dragging the also contrast to more recent research
liquid layer of secretions mouth ward. showing that the effects of coughing
The waves that occur in the liquid layer (even at low lung volumes) are limited to
with this annular flow probably enhance the central airways and proximal to fifth
droplet formation, necessary for misty generation bronchi (Smaldone and
flow. Misty flow is thought to be the most Smith, 1 985).
important means of clearing secretions Three studies looked at the role of
during cough. However, droplet forma cough or forced expiratory technique
tion, suspension, and clearance during (FET) in relation to chest physiotherapy
cough are complex and poorly under techniques in patients with stable cystic
stood (Leith, 1967, 1977, 1985; Leith et aI., fibrosis. Falk et a!. (1984) found reduced
1986). sputum production, oxygen tension, and
spontaneous cough in conjunction with
Cough, Forced Expiratory Technique, postural drainage, percussion, and vibra
and Chest Physiotherapy tion than with positive expiratory pres
sure (PEP) or with FET (see p. 1 35). They
There is some debate on the efficacy of conclude that both cough and FET affect
cough compared with chest physiother only the more central airways whereas
apy in removing tracheobronchial secre PEP also acts on the peripheral airways
tions. Oldenburg and co-workers (1979) and collateral channels. No significant
short-term benefit was found in pulmo
i i i
nary function tests or expectoration
i when cough was compared with postural
drainage, percussion, and vibration with
I 01 \ cough (deBoeck and Zinman, 1 984). Sim
\II . - . .
ilar findings were reported by Rossman
J,Ot.,\
. .
and associates (1982), who measured

''';Il mucus clearance using aerosol tracers.
... 0:1""
IOI They reported no added benefit of com
110
100/ bined chest physiotherapy maneuvers
001 r.
" .
10101
(postural drainage. percussion, and deep
.
1<>,.1
'I', I'II' breathing with vibration) compared with
.
01010
cough. This is not surprising as the ma
BUBBLE SLUG ANNULAR MISTY jority of the inhaled radioisotope was de
0-60 60-1000 1000-2500 )2500
em/sec em/sec em/sec em/sec
posited in the large ai rways, where cough
is particularly effective at removing ex
Figure 5.4. Four main types of two-phase
cess secretions.
concurrent flow, with the correspond,ng super
ficial velocity of gas. (From Leith DL: Cough. In
Bateman and colleagues (1981 ) com
Lung Biology in Health and Disease, Vol 5, pared the effect of cough alone and with
Respiratory Defense Mech anisms: ed,ted . by chest physiotherapy (postural drainage,
,
JD B rain , DF Proctor, and LM Re d , pp 545- vibration, shaking. percussion, and
592. Dekker , New York, 1977.) cough) in patients with chronic bronchi-
METHODS OF AIRWAY CLEARANCE: COUGHING AND SUCTIONING 1 59
tis and bronchiectasis. Using inhaled ra tions should be promptly expectorated or

dioaerosols, they found both regimens to suctioned before the effect of gravity
be equally effective in clearing the cen causes peripheral migration or trans
tral airways. Chest physiotherapy, but bronchial aspiration as in the intubated
not cough, significantly enhanced pe or unconscious patient (see Case History
ripheral lung clearance and increased 7. 1 ).
sputum yield. These findings are sup
ported by Sutton and associates (1983), Cough Suppression
who also measured inhaled radionuclide
clearance in patients with copious spu Smaller airways are more sensitive to
tum production (bronchiectasis, cystic fi chemical stimuli, while the larger air
brosis, and chronic asthma). They re ways respond more readily to mechani
ported that FET alone and FET during cal stimuli that elicit coughing: Both the
postu raJ drainage eliminated signifi large and small airways demonstrate ad
cantly more radioaerosol than either aptation to repeated stimulation. Apart
cough or a control period. In addition, from adaptation, the cough reflex can be
more sputum was cleared with FET and both voluntarily and involuntarily sup
postural drainage than any other treat pressed, as is commonly observed in the
ment. The effect of postural d rainage intensive care unit. Any predisposing
with cough was not compared with FET factor limiting the four stages of coughing
and cough in this study. (see p. 155) can interfere with its
When evaluating the effects of chest effectiveness.
physiotherapy on peripheral secretion
clearance, it is neither logical nor rele Involuntary Cough Suppression
vant to separate the effects of cough (or
FET) from other chest physiotherapy Involuntary cough suppression can re
techniques. Distal secretions must be ad sult from decreased inspiratory effort, in
vanced centrally before they can be re ability to close and then open the glottis,
moved. If the most effecti ve means of or diminished expiratory effort. Patients
large airway clearance, cough, is prohib having recurrent laryngeal nerve palsy
ited, it is not surprising that chest phys demonstrate difficulty in glottic or vocal
iotherapy appears relatively ineffective cord closure (Innocenti, 1969). Diseases
by comparison. Thus far, studies evalu disrupting neuromuscular function com
ating cough, FET, and chest physiother monly result in decreased cough effec
apy involved patients with chronic lung tiveness. In patients with quadriplegia,
diseases. The varying degrees of central, inspiration and particularly expiration
intermediate, and peripheral airway pa are limited (as detailed in Chapter 8), yet
thology in this population make both glottic function is intact. The only forces
aerosol deposition and clearance of the of expiration present in the quadriplegic
distal airways difficult to assess. The re patient are provided by the elastic prop
sults are not pertinent to patients with erties of the lung and thorax. Upper air
acute lung disease. From the existing re way compression, normally seen during
search, it appears that both cough and coughing, is minimal due to the low pres
FET enhance the removal of excess se sure gradients achieved (Siebens et al..
cretions from the larger, more central air 1964). Paraplegic patients primarily have
ways. Their effect in the intermediate the muscles of expiration affected, while
(fourth- to sixth-order) bronchi is debat inspiration is less involved.
able. Neither cough nor FET alone is Myasthenia gravis, Guillain-Barre syn
shown to improve mucus clearance in drome, poliomyelitis, and demyelinating
the peripheral ai rways (distal to sixth diseases may disrupt any or all aspects
generation bronchi). Therefore, mobiliz necessary for an effective cough, depend
ing peripheral secretions to the central ing on the degree of involvement. Simi
airways using postural drainage, percus larly, pharmacological neuromuscular
sion, vibration, ciliary action, or exercise blocking drugs interfere with all stages
enhances the effect of both cough and of coughing. Narcotics cause central
FET. Once in the upper ai rways, secre- nervous system depression. which can
inhibit the cough mechanism. Patients

with loss of consciousness or severe head
injury may display diminished or absent
cough reflexes for the same reason. Con
sequently. they are unable to protect
their airway from possible aspiration.
Tracheal intubation with a cuffed tube
may be req uired. Apart from the pooling
of secretions and diminished ciliary ac
tion discussed earlier, artificial airways
mechanically prevent normal tracheal
compression during coughing. As a re
sult, higher flow rates are necessary. to
achieve the linear velocities required to
clear secretions. Since tracheal tubes also
cause increased resistance to air flow,
higher lung volumes and excessive effort
are required to clear the airways (Gal). Figure 5.5. Following tracheostomy tube re
Tracheal tubes additionally disrupt moval, an airtight dressing should be placed
coughing by preventing gloltic closure. over the stoma. This must be supported during
making a cough resemble a forced expi coughing, as illustrated.
ration (Bucher; Gal).
lt is our opinion, based on these find
ings, that to restore an effective cough,
tracheal tubes should be removed as study of 20 normal subjects, Curry and
soon as ventilatory support is no longer Van Eeden (1977) evaluated the effect of
necessary or when protective laryngeal nine different positions on cough volume
reflexes return. The use of progressively and flow rates. They found that cough ef
smaller tracheostomy tubes to "wean" a ficacy increased as the posture was
patient from an artificial airway is not ad changed from side-lying to supine and
visable as it leads to a compromised from supine to progressively more up
cough and increased ventilatory effort. right silting. Hip flexion also resulted in
The stoma left after tracheostomy tube a larger volume and flow rate than
removal diminishes cough effectiveness coughing in the same position with the
until wound closure occurs. Though glot hips extended. These findings support
tic closure is not inhibited, Lhe increased the clinical impression that most patients
intrapleural pressures generated during a have a stronger cough while silting with
cough cause air to escape through the the hips flexed. However, it is the au
stoma. This can be prevented by sealing thors' opinion and that of others that
the stoma with an airtight dressing and cough and FET should also be performed
instructing the patient to support the during postural drainage where gravity
dressing manually during speaking and can assist these efforts in the clearance of
coughing (see Fig. 5.5). Fenestrated tra mucus (Pryor et aI., 1979; Hofmeyr et aI.,
cheostomy tubes are a compromise. In 1986). Further research is needed to eval
our opinion their use is very rarely jus uate the effects of coughing and FET in
tified, because, when they are present, postural drainage positions in palienls
secretion production is still stimulated, with pulmonary pathology.
ciliary action and tracheal compression Some conlroversy exists as to whether
during coughing are still impeded, and forced expiration or coughing is of
airway resitance is still i ncreased. grealer benefit lo the patient with ob
Posture also plays a role in coughing. In structive pulmonary disease. Leiner et al.
healthy individuals most lung volumes reported that peak expiratory flow rales
and functional residual capacity decrease were greater in patients with pulmonary
as the person moves from silting to su obstruction, whereas most researchers
pine to the head-down position. In a found the reverse to be true. There is
agreemenl that overall cough efficacy is Table 5.1

reduced. as air flow obstruction allows Complications of Cough'
less air to escape with each cough (Lang Respiratory
lands. Leiner et al.. Loudon and Shaw; Bronchoconstriction
Leith). Langlands also noted incomplete Trauma to airways and larynx
and inadequate glottic closure between Barotrauma: pneumomediastinum, pneumo
successive coughs in patients with bron thorax. interstitial emphysema
chitis. Lack of closure prevents com Hemodynamic
pressed airways from reassuming their Decreased venous return
Transient systemic hypertension.
normal size between coughs. The rapid
hypotension
expiratory flow associated with coughing Arrhythmias
was found to reduce obstruction in some Cerebral
airways. while compromising clearance Syncope
in others-notably in the patient with Apoplexy
chronic obstructive pulmonary disease Chest wall
(Menkes and Britt. 1 980). Because of the Rib fractures
potential for increased ai rway obstruc Ruptured rectus abdominus muscles
tion. FET is often used in place of cough Miscellaneous
ing for patients with chronic pulmonary Urinary incontinence
Pulmonary emboli
disease.
Kinking and knotting of venous catheters
Bouts of coughing may precipitate brief Fear attendant on loss of control
periods of dizziness and distress. partic
ularly in patients with preexisting heart 'From Banner AS: Lung 164:79-92. 1986.
or lung disease. These responses are due
to the increased transpulmonary pres
sure that accompanies coughing and following surgery. This is usually a result
causes decreased pulmonary. cardiac and of fear or pain. Fear can often be mini
cerebral blood flow (Langlands; Banner). mized in the patient for elective surgery
The decreased cerebral blood flow or in by instruction before the operation. This
creased cerebral spinal fluid pressure should include a general explanation of
that occurs during a cough is undesirable expected surgery and the importance of
for patients with brain injury. In most coughing despite discomfort after the op
cases. the deleterious response is tran eration (Thoren. 1954; Howell and Hill.
sient and rapidly returns to baseline val 1972).
ues. For some patients. the use of local or Pain after surgery cannot be elimi
systemic medication may be necessary to nated but can be alleviated with analge
control spasms of coughing. Other poten sics. especially if administration is coor
tial complications that may accompany dinated with the patient's efforts to
cough are shown in Table 5 . 1 . These as cough. The pain following thoracotomy
sociated findings may give rise to volun is particularly troublesome as these pa
tary or involuntary cough suppression tients are at increased risk of postopera
although they occur infrequently and tive pulmonary complications. Byrd and
usually in association with multiple Burns (1975) used esophageal balloon
coughing episodes. For these reasons. pressures to assess cough efficacy in 24
chest physiotherapy should not include adult males after thoracotomy. They
repetitive coughing. In the intensive care found voluntary cough pressures to be
unit both the effects and benefits gained reduced to 29% of preoperative values on
from coughing should beassessed. and the day of surgery and to still be only
modifications made accordingly. 50% of control values 1 week later.
Cough induced by ultrasound mist re
sulted in higher cough pressures on the
Voluntary Cough Suppression operative day (44%) and after 1 week
(60%). indicating that pain. rather than
Controlled suppression of the cough neuromuscular function. was the limi
reflex is common. particularly in patients ting factor. However. administering nar-
cotics did not consistently increase the

patient's ability to cough, More selective
types of analgesia may improve cough ef
forts by providing more appropriate pain
relief (see Chapter 10), Yamazaki et al.
(1980) also measured cough pressures in
20 patients following thoracotomy, They
directly recorded intrapleural pressure
by using a catheter inserted with the in
traoperative chest tube, Although more
accurate than using an esophageal bal
loon. this method did not allow for com
parison of preoperative and postopera
tive values, However. intrapleural cough
pressures were significantly improved in
the supine position by epidural anaesthe
sia but not in the sitting position, As re
ported by others (Curry and Van Eeden).
cough pressures were better in sitting
than in supine positions, Interestingly.
pressures in both positions were signifi
cantly improved by manual chest wall
compression or supported coughing, This
provides evidence for using assisted
cough techniques after surgery, It is the
authors' experience that pain may be de Figure 5,6. Incisional support may be manu
creased and voluntary cough improved ally applied by the patient or the therapiSt. Here
by manual support of the surgical inci both are supporting the incision (under the sur
sion or area of rib fractures with a pillow gical dressing) while the patient coughs
or folded sheet (Fig, 5,6), Breathing exer VOluntarily,
cises. as discussed in Chapter 3. may help
to relieve anxiety and incisional pain,
Again. an explanation of why coughing is lung capacity should be encouraged, This
important may improve the patient's is followed by active expiration during
ability and willingness to cough, which the patient incorporates two or
more pauses, Teaching the patient to say
METHODS OF COUGH "huff. huff. huff. " or "ha. ha, ha" during
STIMULATION expiration (much as in laughing) may be
helpful (Frownfelter, 1978; Hietpas et al..
When voluntary control of coughing is 1979), Huffing does not cause glottic clo
absent. methods to stimulate this re sure and is reported to generate lower in
sponse become necessary, Suctioning is trathoracic pressure than does coughing
one of these and is discussed separately (Gaskell and Webber: Hietpas et al.),
in this chapter, Another frequently used Therefore, this method may be specifi
maneuver to improve cough effective cally beneficial to patients with airway
ness is "huffing." This consists of a single diseases, such as asthma. cystic fibrosis,
large inspiration followed by short expi and emphysema, The lower intrathoracic
ratory blasts. interrupted by pauses, If se pressures may help decrease the small
cretions are mobilized centrally by pre airway closure associated with coughing
viously mentioned maneuvers. this in patients with chronic obstructive pul
technique. which causes rapid changes monary disease (Marshall and Holden;
in air flow. may oscillate the secretions Hietpas et al.) Huffing is reportedly effec
and. hence. mechanically stimulate a live in mobilizing secretions more cen
normal cough, Huffing can be taught to trally as visualized by fiberoptic bron
the patient in the following manner, choscopy (Hietpas et al.), It may be used
First. an inspiratory effort toward total with the previously described tech-
niques, such as manual incisional sup adults. Harris and Lawson (1968) found a
port. Its use with controlled diaphrag progressive decline in efficiency.
matic breathing is termed "forced External tracheal stimulation may be
expiration technique" (Pryor and Web necessary in infants or patients who are
ber, 1979) and is discussed on p. 1 2 1 . unwilling to cough. This is achieved by
Vibration i s reported to stimulate a applying manual pressure to the trachea
spontaneous cough for much the same above the manubrial notch (Ungvarski,
reason as huffing (Rowe et aI., 1973). It is 1971; Petty, 1974; Frownfelter). This cre
believed that either the movement of se ates partial tracheal compression, which
cretions into the larger airways, the in often causes mechanical stimulation of
creased tidal volume that follows a vibra the cough mechanism (Fig. 5.7). In chil
tory maneuver. or the rapid change in air dren. mild compression over the superior
flow during vibration may be sufficient to sternum is found to be particularly effec
stimulate a cough mechanically (Belin tive in eliciting the same response.
koff. 1976). Clinically, vibration seems When none of the above methods of
particularly effective in producing a cough stimulation is successful, stimula
spontaneous cough in patients with de tion of the oropharynx with a suction
creased levels of consciousness. In the catheter or oral suction tube has been
quadriplegic patient. manual pressure found to be effective. The catheter is in
over the chest and abdomen during ex serted orally and advanced to the oro
piration causes increased expiratory pharynx until a gag or cough is elicited.
force and may increase cough effective Oropharyngeal suctioning may also be
ness (Siebens et al.). This is ill ustrated in necessary in patients who have raised se
Chapter 8. cretions to this level but are unable to ex
Bucher states that the inspiratory effort pectorate them. Oropharyngeal stimula
preceding a normal cough is usually tion should not be performed without
deeper than resting inspiration. There short rest periods between attempts, es
fore, following surgery, instruction in pecially if gagging is the most frequently
deep breathing exercises may be benefi obtained response. If vomiting occurs
cial to increase cough effectiveness. A se while in a postural drainage position.
ries of three increasingly larger breaths. particularly in the head-down position
with the third followed by a voluntary (whether it be during the cough phase of
cough. is found to render a previously in treatment or not), the patient should be
effective cough productive. Similarly, pa suctioned until the therapist is certain
tients with inspiratory muscle weakness. that the oropharynx is clear of vomitus.
such as in quadriplegia, demonstrate If the patient has an airway in place, this
an improved inspiratory effort using
"summed breathing." This consists of
three to five successive inspirations with
out an intervening expiration. It is based
on the same principle as glossopharyn
geal breathing (described in Chapter 8).
The increased lung volume achieved by
accumulated inspiratory effort may make
a more effective cough possible. Repeti
tive coughing, however. should not be
encouraged. In addition to the reasons
stated earlier in this chapter, bouts of
coughing are usually more fatiguing than
controlled coughs or FET. Also Smaldone
et al. (1979) reported that multiple
coughs can retard and possibly arrest Figure 5.7. External tracheal compression
mucociliary transport in dogs. It is impor may elicit a cough. It is achieved by applying
tant to note that this finding was obtained gentle pressure to the anterior trachea be
after 50 to 100 coughs. In studying the ef tween the cricoid ca rtilage and sternal notch,
fect of successive coughs in healthy as shown.
should be suctioned prior to position abscess formation up to 1 month follow

change to prevent possible aspiration. ing the procedure are also documented
The patient should NOT be turned su (Deresinski and Stevens, 1974; Yoshi
pine or placed in the head-up position kawa et al.; Lourie, et al.). Therefore,
until proper suctioning is completed. transtracheal aspiration is a dangerous
The use of transtracheal catheters to procedure that should be avoided.
stimulate coughing following surgery Clinically, the necessity for transtra
was first reported in 1960. A short seg cheal aspiration is shown to decrease or
ment of polyvinyl tubing is introduced be eliminated by other less invasive pro
through a needle inserted into the crico cedures. Vraciu and Vraciu (1977) stud
thyroid membrane, and the needle is ied the effects of breathing exercises on
then withdrawn (Radigan and King, 1 960; patients in whom transtracheal catheters
Pecora and Kohl, 1962; Kalinske et al . . were frequently used following open
1 967; Hahn and Beaty, 1970; Pauker. heart surgery. These catheters were in
1970; Unger and Moser, 1973; Lourie et serted based on the clinical findings of
aI., 1974; Ries et aI., 1 974; Schillaci et aI., excessive secretions and an ineffective
1 976). This is followed by the instillation cough. Of the patients given assisted
of a respiratory tract detergent to encour breathing exercises by a physical thera
age coughing. Alternately, administering pist. only 1 of 1 9 (5%) requires transtra
short bursts of 0, through a transtracheal cheal puncture, as opposed to 7 or 14
catheter is described to stimulate cough (50%) of the controls, who were aided by
ing (perel et al.. 1988). Radigan and King the nursing staff in hourly turning, deep
advocated instilling fluid every 4 hr for breathing. and coughing. Although in the
2-3 days after surgery or until the patient early 1970s the use of transtracheal aspi
was able to cough effectively. ration was employed by some of the sur
Despite its introduction as a simple and gical staff in our institute, it was replaced
safe technique, literature reporting the by appropriate chest physiotherapy and
complications associated with transtra is no longer used.
cheal aspiration has multiplied since Another technique developed for the
1970. Subcutaneous and mediastinal em treatment of sputum retention is the
physema, transient hemoptysis, and mini tracheotomy. It was first described
bleeding at the puncture site are re by Matthews and Hopkinson (1984) and
corded by many authors (Spencer and consists of a 4-mm uncuffed pediatric en
Beaty, 1972; Ries et al.; Lourie et al.; dotracheal tube that is inserted into the
Yoshikawa et aI., 1974). Others reported trachea through a cricothyroid incision
vagal reflex stimulation following trans and then sutured to the skin. Suctioning
tracheal puncture that caused cardiac with up to a 10 French catheter can be
dysrhythmia and death (Spencer and performed through the minitracheotomy,
Beaty; Unger and Moser). Fatal and near yet speech is preserved. Because of the
fatal hemoptysis are also recorded (Spen small diameter of the suction catheter,
cer and Beaty; Unger and Moser; Schil there is a high resistance to flow; there
laci et al.), and fatal asphyxiation fore, strong and long periods of suction
occurred due to hematoma formation ing are necessary to remove viscid secre
(Pauker). Paroxysmal coughing attrib tions. As a result, supplemental oxygen is
uted to transtracheal puncture is noted to recommended (Charnley and Verma,
result in bronchospasm, laryngospasm, 1 986). The original minitracheotomy
and vomiting followed by aspiration of tubes did not have external airway adap
gastric contents and fatal rupture of tors and supplemental oxygen could only
esophageal varices (Radigan and King; be given by face mask. More recent mod
Spencer and Beaty; Unger and Moser; els have adaptors so resuscitator bags can
Schmerber and Deltenre, 1978; Perel et be used in conjunction with suctioning.
al.). Parsons and associates (1976) re However, lung inflation is limited by the
ported mediastinal emphysema, pneu increased resistance to air flow through
mopericardium, and subsequent bilateral the small bore tube and the lack of a cuff.
pneumothoraces after transtracheal as Tracheal contamination and the drying
piration. Cervical infections leading to of tracheal secretions are not reported
but are potential problems in the target (see p. 177). Patients with audible or
population. Reported complications in copious secretions may not benefit
clude fatal hemorrhage, spontaneous from lung inflation or supplemental
inhalation, and tracheal obstruction oxygen until after the secretions are
(Gwynn and Moustafa, 19B4; Yeoh et aI., removed.
19B5; Charnley and Verma). Experience 2. Check the amount of negative pres
with the minitracheotomy is limited. It sure produced by the suction appa
appears to be a compromise treatment ratus and, if necessary, adjust to 100-
that needs further evaluation. 1 60 mm Hg.
3. Put a sterile glove on the dominant
hand. Gloves should be worn on both
TRACHEAL SUCTlONING hands to protect the clinician from
contamination.
Suctioning is performed routinely on 4. Expose the vent end of the catheter
intubated patients to aid in secretion re and connect it to the suction tubing.
moval and cough stimulation. The fre Any part of the catheter that may
quency of suctioning is determined by contact the patient's trachea must be
the quantity of secretions. With the ex kept sterile.
ception of cardiogenic pulmonay edema,
5. Slide the catheter out of its packag
the more copious the lung secretions, the ing, taking care not to cause contam
more frequently the patient requires suc ination (Fig. 5.B8).
tioning. Secretions are commonly de 6. Disconnect the patient from the ven
tected after turning or placing a patient in tilator or oxygen source.
the head-down position. Patient mobili
7. Gently insert the catheter into the
zation usually causes secretions to grav
tracheal tube. No suction is applied
itate from the peripheral to more central during insertion of the catheter (Fig.
airways where they may be suctioned.
S.BC).
This is also the objective of percussion
B. If resistance to the catheter is pres
and vibration in the postural drainage
ent, pull the catheter back slightly
position. Suctioning is, therefore, a stan
and allempt to reinsert.
dard part of chest physiotherapy. Some
9. Apply suction by placing a finger
authors consider suctioning and cough
over the vent. Turn the catheter
ing the only important therapeutic ma
slowly while withdrawing it, so that
neuvers effective in removing retained
the side holes of the catheter are ex
lung secretions (Murray, 1 979). However,
posed to a greater su rface area (Fig.
when lung secretions are retained in the
5.BD).
small airways, postural drainage with
10. Reconnect the patient to the ventila
percussion and vibration appear neces
tor or oxygen source.
sary to mobilize them centrally, since the
11. If the patient is not receiving me
suction catheter can reach only the level
chanical ventilation, reinflate the pa
of the main stem bronchi.
tient's lungs with supplemental oxy
Aseptic technique is employed for tra
gen (Fig. 5-BE).
cheal suctioning, hands are washed be
fore and after the procedure, and a sterile Steps 6 and 10 are omilled for patients
glove and sterile catheter are used. If the suctioned through a port adaptor.
patient is monitored with an electrocar
diograph, pulse oximetry and indwelling
vascular catheters, these are observed Difficulty in Passing a Suction Catheter
during suctioning. The basic steps of the
If there is difficulty passing a suction
suctioning procedure shown in Figure
catheter through a tracheal tube, this
5.BA-E are as follows:
should create concern, as it may be an
1 . Provide the patient with supplemen early indication of occlusion of the air
tal oxygen before suctioning to in way. Some difficulty in passing the cath
crease arterial oxygenation (Fig. eter may be due to kinking of a long tra
S.BA). Patients receiving mechanical cheal tube. The remedy is to remove the
ventilation may not require this step excess length and use a more rigid cath-
Figure 5.S. (A) Before suctioning a sponta

neously breathing patient, supplemental oxy
gen is provided to increase arterial oxygen
ation. The volume and fractional inspired
oxygen of air delivered vary according to the
characteristics of the bag and oxygen source.
(6) The suction catheter is removed from its
packaging carefully so that the catheter is not
contaminated. Catheters packaged in a
straight position are found to be easier to han
die without contamination. (C) Insertion of the
suction catheter into the tracheal tube should
be gentle but quick. Suctioning is preferentially
performed through a port adaptor for patients receiving mechanical ventilation. Suction is not ap
plied as the catheter is inserted. Loss of PEEP and tidal volume through the catheter may be pre
vented during insertion, if the catheter is kinked as shown with the left hand. (0) As the catheter is
withdrawn, suction is applied by occluding the vent on the suction catheter, as shown. Removal of
the suction catheter should be done without undue delay but slowly enough for secretion removal
to be adequate. (E) After suctioning, lung reinflation is performed using the mechanical ventilator
or a resuscitator bag in order to facilitate lung reexpansion and replenish the patient's oxygen
supply.
eter. If resistance to the passage of the debris, and a physician should be notified
catheter is met soon after insertion, the immediately. Airway obstruction in the
patient may be biting on the tube. Proper patient receiving mechanical ventilation
placement of a bite block prevents this. results in a significant elevation of air
When kinking and biting of the tracheal way pressures and a decrease in volume
tube are excluded, obstruction to passage delivery. If difficulty is experienced
of a suction catheter may be due to im when suctioning a patient with a trache
proper positioning. viscous secretions. or ostomy, the tube may be occluded with
secretions, malaligned in the trachea, or with tracheostomy rather than nasotra

displaced into the subcutaneous tissues; cheal or orotracheal tubes when coude
this should be rectified immediately. catheters are used (Haberman et al.; Scott
et aI., 1977; Kabota et aI., 1980; Freedman
Difficulty Cannulating the Left Main
and Goodman). Selective entry of the left
main stem bronchus with curved tip
Stem Bronchus
catheters ranges from 8 to 61 % (Kirimli et
It is more difficult to pass a suction al.; Scott et al.; Anthony and Sieniewicz,
catheter into the left than the right main 1977; Kubota et aI., 1980; Freedman and
bronchus (Kirimli et aI., 1970; Haberman Goodman). Kubota and associates (1982,
et aI., 1973; Fewell et aI., 1979; Freedman 1983) demonstrated success rates of up to
and Goodman, 1982). In adults, the right 92% for left bronchial placement (com
main stem bronchus usually comes off at pared with 98% for the right) when a lon
an angle of about 20' from a midline sag gitudinal guide mark was added to the
ittal plane, whereas the left main stem curved-tip catheter. Similar findings are
bronchus has a more marked angle of reported by Placzek and Silverman using
about 35' and is longer (making the left a marked coude catheter in neonates.
more difficult to successfully cannulate). They also noted that stiff catheters were
The usual anatomy is not always found less likely to enter the left main bronchus
(Fig. 2.5). Similar angles of bifurcation than more flexible tubes. Using a con
are noted in the neonate (24' for the right trollable tip catheter originally deSigned
and 44' for the left) (Fewell et al.). Poor for bronchography, Wang et al. (1976)
cannulation and suctioning of the left achieved an 88% success rate in entering
main stem bronchus inhibit secretion the left bronchus. Other methods of cath
clearance in the upper airways of the left eter modification are described but so far
lung. This is clinically significant as se are of unproven benefit (Zaltzman, 1983;
cretion retention is more prevelant in the Kubota et aI., 1983).
left lung of adults, particularly the left Differential auscultation is recom
lower lobe (Sykes et aI., 1976; Jaworski et mended as an adjunct to selective bron
aI., 1989; Appendix I). A variety of tech chial cannulation (Kubota et aI., 1984;
niques are described to facilitate left Krumpe and Denham, 1984). This
bronchial catheter placement. It is sug method uses a stethoscope to determine
gested that turning the head to the right the position of the catheter tip before
(Haberman et al.) or tilting the body to suction is applied. It is thought to provide
the left (Salem et aI., 1978) increases the confirmation to the clinician that the ap
chances of successful cannulation of the propriate bronchus will be cleared of
left bronchus. There is also evidence that mucus. The potential problems of longer
turning the head to the right may facili suctioning time and cough stimulation
tate entering the left main stem bronchus are not addressed, nor is the fact that aus
in neonates (Fewell et aI., Placzak and cultation after suctioning should yield
Silverman, 1983). However, routine re similar feedback. Based on the existing
positioning of the head or patient is not literature, curved-tip catheters appear
recommended as the research is incon indicated when suctioning a patient with
clusive, the anatomy somewhat variable, left lung pathology. Other methods of
and moving the head can increase laryn catheter modification require further
geal or tracheal irritation and alter tube study as does the use of differential
placement, particularly in infants. auscultation.
Curved-tip (coude) catheters are
thought to improve the chances of enter Suction Catheters
ing the left lung during suctioning (Opie
and Smith, 1959). Kubota et al. (1980) In addition to tip design, there are
found optimal selective cannulation with many other features of suction catheters
the head in midline when curved-tip to consider. Table 5.2 lists some desirable
catheters were used. Left bronchial can features of suction catheters. Catheters
nulation is also more likely in adults are typically made of polyvinyl chloride
Table 5.2 The size of suction catheters ranges

Desirable Characteristics of Suction from 3.5 to 18 French gauge, and it is fre
Catheter. quently proposed that the outer diameter
Material-polyvinyl chloride of the catheter should not be greater than
Number of side holes-more than one half of the inside diameter of the tube.
Size-half of the internal diameter of the tra- This allows an adequate flow of air into
cheal or airway tube through which it is to be the lungs around the catheter during suc
passed tioning (Rosen and Hillard, 1960, 1962).
Length-long enough to reach several inches French size 10-14 catheters are most
beyond the end of the tracheal tube
commonly used in adults. French size
Suction application vent-raised
can be converted to millimeters on divid
Packaging-catheter straight; easy to open
Tip design-curved tip catheters for entering
ing by 11'. If a catheter is too small, secre
the left mainstem bronchus tion removal is less effective.
A suction catheter should be of suffi
cient length to be advanced several
or rubber. Polyvinyl chloride catheters inches beyond the end of the tracheal
are preferred, as they are less likely to tube. This allows entry into one of the
cause irritation (O'Malley et aI., 1979). main stem bronchi. If the length of the
Polyvinyl chloride allows visualization suction catheter is not monitored, the
of the suctioned secretions because the catheter may kink and effective suction
catheter is clear; it is also easier to insert ing may be hindered. This problem may
into a tracheal tube and may be directed be overcome by having increments of
more easily. Lubricating the polyvinyl length marked on the catheter, indicat
chloride catheter before suctioning is ing how much has been inserted (Scott
usually unnecessary and only increases et al.).
the possibility for contamination. A catheter that has a raised vent for ap
Suction catheters with more than one plication of suction is preferrred to one
side hole or "eye" are preferable because having a flush vent. The raised vent
secretion removal is more effective and helps prevent clinician contact with se
results in less mucosal damage. During cretions and is easier to locate during the
direct visualization of the suctioning pro suctioning procedure.
cess, lung and Gottlieb (1976) observed Catheters are packaged either coiled or
that catheters with only one eye were not straight; coiled catheters take up less
as effective in removing mucus as those storage space but are more difficult to
with multiple eyes. This was confirmed handle, increasing the likelihood of con
by others who found that catheters with tamination. Catheters packaged in a
only one eye caused more mechanical straight position may be more effective at
damage to the trachea because they be entering the left main stem bronchus
came adherent to the tracheal wall (Link (Haberman et al.). Figure 5.9 illustrates
et aI., 1 976). three different suction catheters.
Figure 5.9. Three types of polyvi

nyl chloride suction catheters are
shown. They are (from top to bot
tom) a standard, straight-tip cathe
ter , a couda tip catheter, which is
designed to help enter the left main
stem bronchus, and a catheter with
a sleeve attached so that the op
erator is not required to wear
gloves other than for self
protection.
COMPLICATIONS OF TRACHEAL the lungs. Many techniques are routinely

SUCTIONING performed in association with suctioning
to ameliorate this problem. For clarity,
Hypoxemia the terms used in this text are defined in
Table 5.3. The level of oxygenation prior
It is well documented that suctioning to suctioning is an important factor in
may lead to a significant decrease in ar whether suctioning leads to significant
terial oxygenation. The hypoxemia asso hypoxemia (Taylor and Waters, 1971 ).
ciated with suctioning is usually more Obviously, a patient with a PaO, of 150
pronounced than that caused by apnea mm Hg is beller able to tolerate a 30 mm
alone (Boutros, 1970; Adlkofer and Po Hg drop in arterial oxygenation than a
waser, 1978; White et aJ., 1982). Presum patient with resting PaO, of 80. Contro
ably, this occurs when the catheter re versy exists over the optimal way to
moves oxygen as well as secretions from preoxygenate a patient prior to suction-
Table 5.3
Adjuncts Commonly Used with Suctioning
Term Definition
Affects volume delivery

Lung inflation Inflating the lungs using a manual resuscitator bag or mechanical
ventilator
May be performed before or after suctioning
Does not indicate a change in FlO" tidal volume, or respiratory
rate above resting levels
Hyperinflation Inflating the lungs with volume greater than a resting tidal volume
May be performed before. during' and after suctioning using a
manual resuscitator bagO or a mechanical ventilatorc
Does not indicate change in FlO,
Affects oxygen delivery
Preoxygenation Administering an increased FI02d above resting levels before
suctioning
May be performed with a resuscitator bag or mechanical ventilator
Does not indicate change in tidal volume or respiratory rate
Hyperoxygenation Increasing the FlO,' above resting levels before, during, or after
suctioning
May be performed with a manual resuscitator bag or a mechanical
ventilator
Does not indicate change in tidal volume or respiratory rate
Insufflation Administering a continuous flow of oxygen, often simultaneously
with suctioning, using a double lumen catheter, a modified
catheter, or a side arm adaptor of an endotracheal tube
Does not affect respiratory rate-
Affects respiratory rate
Hyperventilation Increasing the respiratory rate using a manual resuscitator bag or
mechanical ventilator
May be performed before or after suctioning
Does not indicate change in FlO, or tidal volume
'It is not possible to hyperinflate during suctioning with a manual resuscitator bag. Theoretically,
hyperinflation is possible with some mechanical ventilators. However, the actual volume delivered
is unknown as air is continuously removed during suctioning.
'Hyperinflation with a bag is possible only if the bag delivers a larger tidal volume than the patient
receives during resting ventilation.
'This is usually done by increasing the tidal volume or using the sigh feature.
'FlO, usually is increased to 1 .0.
'The change in tidal volume that may occur with continuous insufflation is not known as gases are
simultaneously removed during suctioning.
ing. Gold et al. (198 1 ) found four large tracheal suctioning also depends on the
breaths of 100% oxygen (in 30 sec) as ef patient's diagnosis, current medical sta
fective as administering 5 min of 100% tus, and oxygen requirements. Patients
oxygen to increase, both PaO, and arte with decreased cardiopulmonary reserve
rial oxygen content in 22 adult surgical or PaO, may sustain a greater fall in ar
patients. Therefore, it appears that when terial oxygenation during suctioning
preoxygenation is necessary, four (Taylor and Waters, 1971 ). The patient's
breaths are adequate for most patients. age is an additional consideration. Lung
Monitoring continuous arterial oxygen inflation after suctioning is particularly
saturation is another way to assess the important in children and geriatric pa
development of hypoxemia and the need tients who have a high closing volume
for and effect of preoxygenation. Suction and are therefore more likely to develop
ing causes significant falls in mixed ve small airway closure (Mansell et aI.,
nous 0, saturation that may be related to 1 972). If retained secretions are a primary
changes in cardiac output or oxygen con cause of hypoxemia, withholding suc
sumption (Walsh et aI., 1989). In patients tioning because of the expected further
demonstrating high intrapulmonary decrease in PaO, only aggravates the
shunt or significant cardiovascular com situation.
promise, hypoxemia may lead to serious Methods described to minimize or re
cardiac arrhythmias (Boba et aI., 1959; verse the hypoxemia associated with
Shim et aI., 1969), and these patients suctioning are shown in Table 5.4. A re
should be closely monitored during view of the literature does not provide
suctioning. the reader with one obviously superior
The fall in PaO, that occurs with suc method. This is, in part, due to the diver
tioning is directly related to the duration gent research designs, the variable meth
of suctioning; longer periods of suction odology, and the different patient popu
ing lead to larger declines in PaO, (Bou lations studied. Also, research and
tros). Therefore, each suctioning proce experience indicate that there are a va
dure is limited to a total of 1 5 sec. riety of patient responses to suctioning.
However, there is no point in removing a Yet, current practices in most hopsitals
patient from oxygen and having the pa are rigid and follow guidelines that are
tient undergo the mechanical trauma of based more on history and tradition than
suctioning if the procedure is performed fact. A rigid suctioning protocol results in
so quickly that little, if any, secretions unnecessary (and possibly hazardous)
are removed. An effective but expedient treatment of some patients and subopti
suctioning technique should be used. mal treatment of others who are usually
The degree of subatmospheric pressure at greater risk of hypoxemia. A flexible
should also be controlled during suction suctioning procedure is recommended to
ing. Vacuum pressures that are either in allow for optimal treatment of the pa
sufficient or excessive can cause compli tient, based on individual requirements
cations and should be avoided. If the and responses. However, flexibility can
suction is too low, longer periods of suc arise only from a sound theoretical and
tioning and repeated, but less effective, practical knowledge (Barnes and Kirch
passes of the catheter may be necessary. hoff, 1 986). Table 5.5 reviews the current
Excessive suction may lead to an in literature on hypoxemia and suctioning.
crease in mechanical trauma and hypox A discussion of the methods used to pre
emia, as air (as well as secretions) is more vent hypoxemia while suctioning
rapidly removed from the lungs. The spontaneously breathing and mechani
American Society for Testing and Mate cally ventilated patients is provided.
rials (1986) reports that static vacuum Lung inflation is usually performed
levels of up to 160 mm Hg for adults and using a manual resuscitator bag for spon
100 mm Hg for infants are regularly ex taneously breathing patients. The
perienced in clinical practice during tra amount of inspired oxygen that is deliv
cheal suctioning. They stress that suction ered varies according to the characteris
levels should be based on clinical consid tics of the specific bag. Tidal volume is
erations. The amount of hypoxemia after additionally affected by the operator's
Table 5.4
Methods to Minimize Hypoxemia during Suctioning
Tidal Volume Maintenance of Pressure
Method Researchers of Method FI02 Delivered Delivered PEEP Ease of Use Limit Comments
Use of manual Cabal at al. (1979); Baker at al. Varies according Varies according None maintained May be difficult for May not be Requires ventilator
resuscitator (1 980): Fitzmaurice and to bag design to bag size without a one person to controlled disconnection and
bag Barnes (1980); Brown at al. (often T to and valve perform both reconnection: may
(1 983). Pierce and Piazza 1 .0); during operator's 5uctioning and result in large
(1 987) disconnection ability bagging fluctuations in Pa02
times, patient functions
is without O2 adequately
source
Use of manual Bell et al. (1 980); Brown et al. Same as Same as Same as Easy to use We" May not be adequate for
assist or sigh ( 1 983): Benson and Pierson presuctioning presuctioning presuctioning controlled all patients; should
mode on (1 979): Brown el al. (1 983): level unless level unless level unless consider ventilator
ventilator Pierce and Piazza (1 987) ventilator ventilator ventitator " washout" time;
settings are settings are settings are operator may forget
changed changed changed to reset ventilator
settings when
finished
Use of suction Urban and Weitner (1 969); Presuctioning Presuctioning Presuctionlng Easy to use Well Some port adaptor
port adaptor Dryden el al. (1 977): Be"ing level level level controlled designs are not
on ventilator el al. (1 978): Cabal el al. maintained to maintained to maintained to occlusive:
(1979): Baker el al. (1 980): some degree, some degree, some degree, complications may
Be" el al. (1 980): Zmora and exact level exact level exact level occur with low
Merritt (1 980); Jung and not known not known not known ventilator flow rates
Newman (1982): Brown et
al. (1983): Bodai el al.
( 1 987): Durand el al (1 989)
Use of oxygen Boba et al. (1 959); Berman and Usually 1 .0 Variable None maintained May restrict Not known May not be adequate for
insufflation Slahl (1 968): Fe" and passage of all patients
Cheney (1971): Langrehr el suction catheter
al. (1981): Bodai el al.
(1 987); Graff el al. (1 987)
Use of additional Skelley el al. (1 980): Langrehr Can be set to Can be set to Can be set to Easy to use We" Impractical in most
ventilator el al. (1981) optimal level optimal level optimal level controlled centers due to cost
and space
requirements

Table 5.5 ....
..b '"
Recent Studies on Preventing Hypoxemia during Suctioning
Investigator Subjects Design Adjuncts Used Conclusions Comments
Kolly 01 al. (1987) 38 adults Compared 20 sec of Insufflation with 1 00% O2 insufflation Peak ! in PaOz and 8a02
anesthetized for conventional O2 at 1 0 liters/min: significantly occurred 60 sec after
open heart suctioning with 20 No hyperoxy- reversed suctioning and returned
surgery, muscle sec of 5uctioning genation hypoxemia and to baseline by 420 sec
relaxants were with O2 insufflation desaturation noted Suction efficacy not
used with conventional addressed
suctioning Baseline FIOz not a good
indicator of ! in PaOz
or 8a02. but baseline
PaOz is
Bodai et a1. 1 6 adults, moderate 1 . Compared Preoxygenation 1 . Both methods Used intermittent suction
(1 987) to severe preoxygenation/ Hyperinflation similarly prevented Suction included
respiratory hyperinflation with Insufflation at 1 00% hypoxemia: disconnecting from MV.
failure. and without O2 O2 at 10 liters/min hypoxemia noted instilling 3 ml of saline. 3 ()
eliminated insufflation in both groups hyperinflations with O2 ::r
3. Hypoxemia was m
patients with 2. Compared or sighs. 3-15 sec en
baseline Pa02 preoxygenation/ equally prevented passes of catheter -i
> 1 00 mm Hg hyperinflation with by bolh melhods; within 1 min. ."
::r
suctioning to O2 no added benefit reconnecting to MV -<
insufflation alone from O2 The different response to en
3. Compared insufflation; suctioning between 1 6
hyperinflation and preoxygenation/ and 2 was thought to -i
::r
suctioning through hyperinflation reflect individual m
a port adaptor with equally effective as differences :1J

and without O2 using the port Recommend O2 insufflation ."
insufflation to replace bagging and -<
adaptor
recommend using an Z
adaptor for patients on -i
::r
MY m
Pierce and 30 adults. following Compared ? Hyperinflation No difference in Pa02 Bagging performed with
one hand
Z
Piazza (1987) open heart postoxygenation Hyperoxygenation using other -i
surgery using bag or sigh melhod; pH I Sigh volume = 1 000 ml m
z
mechanism with bagging but FI02 = 1 .0 and 3 breaths en
T with sighing given for both regimens <:
Recommend using adaptor m
Graff 01 al. (1987) 20 newborns Compared O2 Preoxygenation O2 insufflation Suctioning included f ()

insufflation to ? Hyperinflation resulted in less FI02 20% above :1J
m
c
z
=i
conventional O2 insufflation at 4 in PtC02. fastest baseline, 0.5 ml saline ;::
suctioning liters/min recovery from instilled. bagging. m
hypoxemia. and suctioning for 5 sec and -i
I
less abnormal reconnected to MV or 0
responses in O2 insufflation 0
U>
PtC02; no Response considered
0
difference in HR abnormal if 40 < PtC02 ."
between groups < 90 mm Hg or heart

rate I > 100k :D
Douglas and 1 2 adults receiving Compared Pa02 Preoxygenation No significant Used intermittent suction
Larson (1 985) MV > 24 hr and and Sa02 Hyperoxygenation difference between :>
-<
PEEP between 5 levels using a Hyperinflation groups ()
and 1 8 cm H2O port adaptor r
to a manual m
:>
resuscitator :D
bag :>
z
Gateley and 1 1 adults after Compared Hyperinflation Pa02 fluctuations Recommend not j FI02 ()
Carson (1 985) coronary artery hyperinflation Preoxygenation and recovery time Noted 1 contamination r.'
bypass with a bag to Hyperoxygenation were greater with using the port adaptor ()
using a sigh; hyperoxygenation 0
C
compared the Gl
use and lack of I
hyperoxygenation; Z
compared Gl
using the port :>
z
adaptor with 0
not using it U>
Schumann and 1 5 critically ill Compared Hyperinflation Bagging with PEEP Used intermittent C
()
Parsons adults maintaining Preoxygenation caused a suctioning -i
(1985) PEep while Hyperoxygenation significant T in 6
bagging Pa02 Z
alone, before Z
and after Gl
suctioning
Goodnough 28 patients. 4-6 hr Four study Preoxygenation Only procedure 3 Hyperinflations= 150% of
(1985) after cardiac procedures Hyperoxygenation had significant 1 baseline VI
surgery; 26 were 1 . 1 FlO, Hyperinflation in Pa02 during FI02 was 1 to 1 .0 for 1
on MV before suctioning min pre- and/or
suctioning Procedure 4 was postsuctioning
and associated with Hyperinflation should be
hyperinflation significantly less aborted if hypotension
after 1 Pa02 and 1 and or bradycardia occurs
suctioning 2 during suctioning Recommend 1 min of
All procedures after 1 00% O2 before and
2. 1 FlO, ....
Co>

Table 5.5 (Continued) .....
...
Recent Studies on Preventing Hypoxemia during Suctioning ...
before and suctioning were atter suctioning
after successful in
suctioning restoring Pa02
3. Hyperinflation All procedures were
before and equally effective at
after 5 and 1 0 min after
suctioning suctioning
4. t FlO, and
hyperinflation
before and
after
suctioning
Brown at al 22 acutely ill Phase I: Preoxygenation Phase I: greatest Used intermittent
(1983) patients, most compared no Hyperoxygenation desaturation suctioning o
with preexisting extra breaths Hyperventilation occurred with no FI02 t 1 min before extra I
m
COPD to 4 hyperventilation; breaths initiated (f)
prescutioning desaturation Recommend using the -i
breaths, 4 significantly less adaptor without altering "
I
postsuctioning with adaptors; ventilator settings -<
breaths. and recovery best (f)
suctioning
through an
using the adaptor
or 4

I
adaptor (all at postsuctioning m
JJ
baseline FI02l breaths >
Phase II: Phase II: significantly "
-<
compared more desaturation
suctioning occurred with only Z
using an 6 postsuctioning -i
I
adaptor to 6 breaths; adaptor m
presuctioning equally effective to z
breaths and! other two methods -i
or 6 Phase III: adaptor m
z
postsuctioning equally effective at (f)
breaths at preventing <:
FlO, 1 .0 m
- desaturation
Phase III: o
>
compared 4 JJ
successive m
catheter c
z
passes using =i
an adaptor or ;::
6 extra m
--i
breaths I
before and 0
after each 0
(J)
catheter pass 0
a. FlO, - 1 .0 "T1
Jung and 1 8 medicalsurgical Compared None Desaturation All on IMV

Newman leu patients with suctioning significantly Instilled 1 0 ml of saline :ll
(1 982) acute lung through a attenuated when through the catheter :E
disease requiring port adaptor using the port; in prior to suctioning
-<
MV and FlO, with popping patients requiring Used intermittent (")
0.4 the patient off PEEP, significantly suctioning r
m
of MV less desaturation No patients developed
was noted with arrhythmias :ll
port use Suctioning time is shorter
z
using a port adaptor (")
Langrehr at al. 3 anesthetized O2 insufflation Hyperinflation Dog studies: Used a bonded suction fT1
(1981) mongrel dogs flow rates Hyperoxygenation When O2 catheterfeeding tube (")
less than, 0, insufflation insufflation for O2 insufflation 0
c
equal to, and exceeded suction Suction applied for 1 5 sec Gl
greater than flow rates, Pa02 at 18 liters/min with I
suction flow was significantly catheter fully inserted; z
rates were maintained above no suction was applied Gl
compared: baseline values while inserting or
z
also. apnea, withdrawing the catheter 0
insufflation, When used, O2 insufflation (J)
and was continuous C
(")
suctioning Used a second ventilator --i
alone were to deliver 6
compared hyperoxygenation (F102 Z
- 1 .0) and z
hyperinflation (VI - Gl
1 50%)
1 0 cardiac surgery Hyperinflation/ Hyperinflation Patient studies: The greatest fall in Pa02
patients within hyperoxygenation Hyperoxygenation Both O2 with hyperinflation/
1 0 hr of surgery with 1 or 3 O2 insufflation insufflation rates hyperoxygenation
breaths was prevented occurred at 30 sec after
compared significant suctioning
with 0, changes in Pa02 O2 insufflation may
insufflation at Fall in Pa02 interfere with secretion
1 0 and 1 5 greater following 1 removal
liters/min breath than 3
breaths prior to -
....
suctioning '"

Table 5.5 (Continued) ....
en
Recent Studies on Preventing Hypoxemia during Suctioning ..
Shelley et al. 3 anesthetized Protocols for dog Preoxygenation Dog studies: 1 1 2S..Jction applied for 1 5
( t 980) mongrel dog studies: Hyperinflation Protocol 1 sec
1 . Suetioning Hyperoxygenation produced the Total disconnect time =
without preoxy- greatest ! in 23 sec

genation Pa02 20 sec after Hyperoxygenation (FI02 =
2. 1 preoxygenation suctioning 1 .0) and hyperinflation

breath prior to Both 2 and 3 (VI
= 1 .5) given via a
5uctioning protected the dogs second ventilator
3. 3 preoxygenation from hypoxemia Patient response to
breaths before but were not suctioning is more
suctioning different from each variable than with dogs
4. 1 preoxygenation other The effects of
breath without Patient studies: hyperinflation cannot be
suctioning Protocol 1 produced separated from ()
5. 3 preoxygenation significant ! in hyperoxygenation in this I
m
breaths without Pa02 30 sec after study
suctioning suctioning Recommend
No significant hyperoxygenation 'U
I
difference between regardless of baseline -<
1 and 2 Pa02 (J)
Pa02 was (5
-<
significantty better I
1 1 cardiac surgery Patient s'tudies: Preoxygenation with protocol 3 m
patients within
JJ
compared Hyperinflation
1 2 hr of surgery protocols 1 , Hyperoxygenation 'U
-<
2, and 3
above Z
-<
I
m
z
-<
m
Z
(J)
-In all studies. subjects served as their own control. Continuous suction was used unless noted. <:
bPEEP, positive end expiratory pressure; MV, mechanical ventilation; F102 fraction of inspired oxygen; Ptc02. transcutaneous oxygen; 8a02' arterial oxygen m
saturation; VII tidal volume; IMV, intermittent mandatory ventilation; HA. heart rate. ()

JJ
m
c
Z
:::j
ability to compress the bag. Airway pres physiotherapy is performed with the pa
sure is not well controlled with a resus tient in a postural drainage position and
citator bag. When a pressure valve is in requires multiple passes of the suction
place, the pressure limit may be too low catheter, it is often difficult, if not impos
for adequate patient ventilation (Hirsch sible, for one clinician to quickly and ef
man and Kravath, 1982). However, if the fectively bag the patient without contam
relief valve is removed or not adequately inating the suction catheter. The
functioning, pulmonary barotrauma may operator's ability to squeeze the resusci
occur (Klick et aI., 1978). tator bag is also a factor, making both vol
An alternative to bagging the sponta ume and pressure delivery variable.
neously breathing patient is the use of a Many clinicians incorrectly assume that
double-lumen catheter, whereby one using a manual resuscitator bag produces
lumen is used for oxygen insufflation and lung hyperinflation. Frequently, this is
the other is used as a standard suction not the case: bagging may produce a
catheter. One inherent problem with smaller volume than that delivered by
using a double-lumen system is that the the ventilator, particularly when the bag
size of the port available for suctioning is compressed with one hand. Two other
may be restricted and therefore less ef disadvantages of bagging are the inter
fective. Continuous oxygen delivery may ruption of positive end-expiratory pres
also interfere with secretion aspiration sure (PEEP) and the wide variations in
(Langrehr et al .. 1 98 1 ). A variation of ox oxygenation that can occur. Research in
ygen insufflation allows for oxygen deliv dicates that suctioning through a port
ery and suctioning through the same adaptor is equally effective or superior to
lumen. With this sytem. when suction is bagging in minimizing arterial oxygen
applied, oxygen is not Simultaneously desaturation during suctioning (Bell et
delivered (Bodai et aI., 1987). Oxygen in al.; Baker et al.; lung and Newman;
sufflation techniques depend on the pa Brown et al.; Bodai et al.; Durand et al.).
tient's ability to breathe spontaneously, There is a potential complication to
which may not be adequate in mechani using a port adaptor that is totally occlu
cally ventilated patients with compro sive. Subatmospheric pressure develops
mised cardiorespiratory status or paraly if suction flow rates exceed ventilator de
sis (Fell and Cheney, 1971). This problem livery or if the patient is on controlled or
may be overcome by another variation of assisted ventilation (Brown et aI., 1983:
insufflation advocated by Spoerel and lung and Newman, 1 982: Guthrie et aI.,
Chan (1976), in which the second lumen 1 983; Craig et aI., 1984; Graff et aI., 1987;
is used to provide jet ventilation using a Dickert, 1 987; Taggart et al . . 1 988). The
constant airway pressure. This variation flow rates used for neonates may limit
is still under study. the widespread use of port adaptors for
In addition to using manual inflation or this population, although studies on the
oxygen insufflation, suctioning can be use of adaptors with infants are favorable
performed in several ways for the me (Cabal et al.: Zmora and Merrit, 1980;
chanically ventilated patient. They in Gunderson et aI., 1986; Graff et al.: Du
clude using the ventilator for lung infla rand et a l . ).
tion or suctioning through a port adaptor In conjunction with suctioning through
without disconnecting the patient from the port, a manual assist on some venti
mechanical ventilation. Both methods lators can be used to hyperventilate or
may be used either with or without the sigh feature can be used to increase
changing the ventilator settings. It is our volume delivery (hyperinflate). Hyper
opinion and that of others (Bell et aI., ventilating a patient using the manual as
1980: Baker et aI., 1 980; lung and New sist of the ventilator may be awkward for
man. 1982: Brown et aI., 1983; Tyler. the therapist suctioning a patient turned
1984; Bodai et aI., 1987; Durand et aI., away from the ventilator. Hyperinflation
1989) that suctioning through a well-de may have adverse hemodynamic effects,
signed port adaptor without ventilator particularly in patients with serious lung
adjustment is the preferred method for disorders (Skelley et al . . 1980; Langrehr
most patients requiring mechanical ven et al.). For some patients whose cardio
tilation. Since suctioning during chest espiratory status is very fragile, increas -
ing oxygen delivery may be necessary. are known to produce changes in cardiac
Elevating the FlO, (usually to 1 .0) is in function. Tracheal stimulation in normal
dicated in patients prone to arrhythmias subjects may produce increased sympa
or exhibiting significant decreases in ox thetic activity, resulting in tachycardia
ygen saturation. Whenever ventilator and hypertension. In neonates or when
settings are adjusted, it is all too easy for sympathetic control is lost (as in patients
the clinician to forget to return them to with spinal cord injury above T1), tra
their proper level Oung and Newman; cheal stimulation may induce bradycar
Tyler). The effects of short duration but dia and even cardiac arrest (Cordero and
wide fluctuations in PaD, that occur with Hon, 1 971 : Frankel et aI., 1 975). This may
preoxygenation and hyperoxygenation occur as a result of vasovagal reflex stim
are unknown. Leaving a patient on an ulation because the afferent fibers of the
FlO, of 1 .0 is associated with complica vagus nerve in the trachea and bronchi
tions that may be more detrimental than cause increased efferent vagal activity
suctioning without hyperoxygenation. (Dollfus and Frankel, 1 965; Frankel et
Based on the research and our clinical al.). After the acute period of spinal
experience, the use of an adaptor de shock is passed, there is a decrease
signed for simultaneous introduction of a in the vasovagal response asso
suction catheter with continued mechan ciated with tracheal stimulation in spinal
ical ventilation is the most effective cord injury (jennett, 1 970).
method of reducing hypoxic complica
tions associated with suctioning. A port
adaptor must be occlusive to allow for Mechanical Trauma
partial maintenance of FlO" tidal vol
ume, and PEEP during suctioning. Ven Mechanical trauma to Ihe tracheobron
tilator flow rates must be adequate. Using chial tree results from suctioning. Link et
an adaptor avoids the need for ventilator al. using catheters with more than one
disconnection time. Also, ventilator set side hole observed lhal lhe mucosal dam
tings normally do not need to be ad age occurred during insertion of the cath
justed, preventing possible complications eter rather than during mucosal "grab
from accidental prolonged hyperoxygen bing," even when vacuum pressures
ation. The port adaptor is easy to use in greater than 300 mm Hg were used. Sim
all patient positions. Pressure regulation ilar findings are reported by Kleiber et al.
is optimal, allowing adequate ventilation ( 1 988), who found tracheal damage after
in conjunction with a safeguard against catheter insertion even when suction
barotrauma. The use of an occlusive port was not applied. The use of single-eyed
adaptor allows for improved mainte catheters is reportedly more damaging
nance of FlO" tidal volume, PEEP, and because they cause a greater degree of
mean airway pressure. mucosal invagination. Sackner (1978)
An ideal method of minimizing hyp and Sackner et al. ( 1 973) advocate the use
oxemia, from a theoretical standpoint. of a catheter with a beaded edge designed
would be connecting the patient to a sec to prevent the side holes from coming in
ond ventilator preset to provide appro contact with, and irritating, the tracheo
priate hyperinflation, hyperventilation, bronchial mucosa. However, studies by
or hyperoxygenation for the patient's lung and Gottlieb and Link et al. did not
needs (Skelley et al.,; Langrehr et al.). find this catheter less irritating to the
This is expensive and impractical in the mucosa than traditional catheters. In ne
clinical setting as well as unnecessary onates. there is some evidence that in
when other less dramatic methods are serting a catheter a predetermined length
available. may be less traumatic than inserting it
until resistance is felt (Kleiber et al.).
Suctioning efficacy was not evaluated
Cardiac Dysrhythmias using this technique. Atelectasis is cited
by several sources as a mechanical com
Both the hypoxemia and tracheal stim plication of tracheal suctioning in in
ulation that can occur during suctioning fants. Lung reinflation after suctioning
may remedy this problem (Brands tater require education in the dangers of bac
and Muallem, 1 969), However, others terial contamination occurrring with the
have suggested that in infants, increased use of suctioning equipment.
right-to-Ieft shunting is the cause of the
hypoxemia, not atelectasis, since no Raised Intracranial Pressure
change in total lung/thorax compliance
or functional residual capacity is found Suctioning is associated with eleva
after suctioning (Fox et aI., 1 978), tions in intracranial pressure (ICP),
which may be significant for patients
with brain injury (see p, 259 ) , Rises in
Bacterial Contamination ICP are more marked when coughing oc
curs with suctioning but are not rou
Tracheal suctioning causes bacterial tinely associated with decreased' cerebral
contamination in three basic ways, First, perfusion pressure, In almost all cases,
incorrect suctioning technique may in ICP elevations due to suctioning are
troduce bacteria into the tracheobron short lived, returning to baseline values
chial tree, This may be prevented within minutes (White et al.; Fisher et aI.,
through maintenance of strict asepsis 1982; Perlman and Volpe, 1983; Parson
during the procedure, It seems possible and Shogan, 1 984; Rudy et al.. 1 986;
that increased tracheal contamination McQuillan, 1987; Imle et aI., 1988; Du
may occur with repeated passage of a rand et al.), Because preterm infants are
suction catheter through a port adaptor, predisposed to intraventricular hemor
Dryden et al. described the use of a cath rhage, this population may be at in
eter with an attached sleeve so that asep creased risk of developing complications
tic technique may be maintained without from suctioning-induced cerebral
using a sterile glove (see Fig, 5,9 ), Cathe changes, However, many of the therapies
ters with sleeves are commercially avail used to treat brain injury and raised ICP
able and convenient to use, They are not (such as tracheal intubation, mechanical
as easily contaminated as traditional hyperventilation, barbiturates, and pa
catheters, particularly when patients are ralysis) put the infant and adult patient at
turned for postural drainage, The user increased risk of respiratory complica
should wear gloves for additional self tion, Therefore, as with all medical pro
protection, Second, suctioning equip cedures, the potential benefit of suction
ment can produce a bacterial aerosol that ing must be weighted against any
may contaminate the patient and the pa potential complication,
tient care area, To help prevent bacterial
transmission by suctioning equipment, Nasotracheal Suctioning
Zelechowski (1980) suggests that a bac
terial filter be used with the suction col Nasotracheal suctioning of nonintu
lection unit and that disposal of the unit bated infants and adults is traumatic and
occur in an area isolated from patient hazardous (Boba et aI., Cordero and Hon;
care, The third type of contamination di Sykes et aI., Peterson et aI., 1979; Gaskell
rectly involves the clinician, It is recom and Webber, 1980), Several preferable al
mended that health care providers wear ternative methods to stimulate coughing
gloves on both hands during suctioning in the uncooperative patient are previ
for self-protection, This prevents possi ously described in this chapter, The com
ble contact between the "nonsterile" plications of nasotracheal suctioning are
hand and secretions, Hands should still potentially more dangerous than suction
be washed immediately after gloves are ing through a tracheal tube, They include
removed, Clinicians should also rou oxygen desaturation, hypoxemia, severe
tinely use masks and protective eyewear cardiac arrhythmias, apnea, and laryn
to prevent mucous membrane exposure geal spasm or bronchospasm, Should la
during procedures such as suctioning, ryngeal spasm occur when the catheter is
which are likely to generate droplets of in the trachea during the nasotracheal
blood or body fluids (Centers for Disease maneuver, rapid deoxygenation and col
Control. 1987), Intensive care unit staff lapse of the lung can occur when suction
is applied. The lung cannot be rapidly ways be viewed as a potentially Iife

reexpanded in the nonintubated patient, threatening procedure.
so with laryngospasm, hypoxemia and
death may result (Sykes et al.). Nasotra
cheal suctioning is specifically contrain
dicated in patients with stridor or sus OTHER ADJUNCTS TO COUGHING
pected cerebrospinal fluid leak. Aside AND SUCTIONING
from precipitating possible central ner
vous system infection, nasotracheal suc Lavage
tioning can cause bacterial contamina
tion of the trachea and more peripheral The infusion of sterile saline into the
airways (LeFrock et aI., 1 976). Nasotra lungs with the intent of washing out se
cheal suctioning is frequently ordered for cretions or mucus plugs is used in some
patients no longer in the ICU in whom centers. Typically, small amounts (usu
events such as acute hypoxemia and ally ::;: 1 0-ml increments) of sterile saline
cardic dysrhythmias may not be detected are instilled directly into the tracheal
unless they are catastrophic (Peterson et tube before suctioning. The effectiveness
al.). of the technique of using small-quantity
The patient who cannot cough up se tracheal lavage is not substantiated
cretions beyond the larynx has either a (Tyler; Ackerman. 1985) and should not
partial airway obstruction, an inadequate be used as an adjunct to chest physio
cough, or excessive secretions. Nasotra therapy. The increased quantity of spu
cheal suctioning is not the appropriate tum often attributed to lavage may be
therapy for these problems. Partial air due to aspiration of the lavage fluid itself
way obstruction cannot be satisfactorily or the effect of coughing. In fact, it is
managed by a suction catheter. Trauma doubtful that lavage has therapeutic
to an already edematous or narrowed lar merit other than to stimulate a cough (see
ynx or stenosed trachea by repeated at p. 162 for alternate methods of cough
tempts to pass a catheter translaryngeally stimulation). Undesirable spasms of
may precipitate complete airway ob coughing may accompany lavage and are
struction. Vomiting is associated with na associated with increased ICP (White et
sotracheal suctioning, particularly in in al.). The limited research on the deposi
fants and persons with decreased levels tion of lavage reveals that most of it
of consciousness or a depressed cough re remains in the trachea and mainstem
flex. The risks of aspirating vomitous into bronchi and that there is negligible dis
the lungs during this maneuver may be tribution to the peripheral airways; de
minimized by placing the patient in a position is not affected by lung hyperin
side lying position prior to suctioning flation (Hanley et aI., 1978). Because
(Gaskell and Webber). Such positioning lavage fluid is not instilled specifically
is rarely observed in the ICU, where pa into involved areas of the lung, if it re
tients are invariably either supine or mains in the ai rways and does move
semierect when nasotracheal suctioning peripherally, it most likely goes to the
is attempted. Excessive secretions need dependent or unobstructed airways.
ready, reliable, and repeated access for Adequate patient hydration and humidi
removal. Therefore, nasotracheal suc fication of inspired gases are the appro
tioning is not the appropriate treatment; priate means of liquefying secretions. It is
rather the patient should be tracheally our opinion, and that of others, that the
intubated with an artificial airway that practice of instilling small quantities of
allows passage of a suction catheter, lung lavage prior to suctioning should be
reexpansion, and, if necessary, mechani abandoned (Hanley et al.: Tyler; Acker
cal ventilation. All other methods to man). It is not substantiated through re
stimulate coughing and secretion re search and does not remedy the under
moval should be attempted before naso lying problem of dried secretions.
tracheal suctioning is considered. This Many authors have described the use
technqiue should never be performed of larger amounts of saline (50-100 ml)
without available oxygen and should al- lavage applied segmentally through a
transtracheal polyethylene catheter (Ra Bag-Squeezing Method of Chest

mirez et al.. 1963) or a flexible broncho Physiotherapy
scope (Weinstein et al.. 1977; Reynolds.
1 987). When used together. the therapeu Many centers advocate the use of the
tic effecls of bronchoalveolar lavage are bag-squeezing method of chest physio
difficult to differentiate from bronchos therapy for intubated patients (Clement
copy alone. In a technique that is fre and Hubsch. 1968; Windsor et al.. 1 972).
quently cited. a double-lumen endobron This consists of placing the patient in a
chial tracheal tube allows lavage of the modified postural drainage position and
dependent lung with saline. while the hyperinflating the lungs with a 2- to s
untreated lung is ventilated with high in liter bag. The chest is then vibrated dur
spired oxygen concentrations. Chest ing expiration. and the trachea suc
physiotherapy. including postural drain tioned.
age and vigorous percussion and vibra This is not part of our practice because
tion. is then given following turning to it considerably changes cardiac output.
enhance the mechanical effects of the la the method mimics the Valsalva maneu
vage and hastened fluid removal (Kylstra ver and the respiratory effects are only
et al.. 1971 ). Lavage of an entire lung is short lived (Laws and Mcintyre. 1 969;
beneficial for treatment of alveolar pro Windsor et al.). Manual hyperinflation is
teinosis (Ramirez. 1971; Reynolds) and also associated with rapid rises in ICP
chest physiotherapy technqiues are re (Gerradd and Bullock. 1986). The tech
ported to improve the efficacy of lung la nique also requires two people to per
vage (see p. 146). This procedure may form. Our regimen of suctioning through
also be usefu 1 in the treatment of bronchial a port adaptor or disconnecting and re
asthma (Kylstra et al.) and cystic fibrosis connecting the patient from the ventila
(Roger et al.. 1972). The use of lung la tor for suctioning requires only one
vage in chronic obstructive lung disease therapist. It is doubtful whether lung hy
and pneumonia is less conclusive (Rogers perinflation in the already mechanically
et al.). The role of bronchoalveolar lavage ventilated patient provides any addi
remains experimental in most diseases tional benefit. Studies fail to show im
and may play a more important role in provement in arterial oxygenation. gas
diagnosis than in the therapeutic exchange. and lung compliance with hy
management of lung pathology (Rey perinflation (Nunn et al.. 1965; Housley
nolds). et al.. 1970; Novak et al.. 1987). Secretion
removal by chest physiotherapy tech
niques that do not include manual hy
perinflation appears more effective at im
" Bagging'! proving total lung/thorax compliance
Bagging is a means of providing artifi (Mackenzie. 1989). It is also noted that
cial ventilation by use of a manual resus lung hyperinflation causes additional
citator bag. which is usually connected to discomfort in awake patients and no last
an oxygen supply. If the patient is not in ing pulmonary benefits (Laws and
tubated. a mask may be attached to the McIntyre).
bag and placed over the patient's face.
covering the nose and mouth. For the in Manual Resuscitators or Bags
tubated pateint. the mask is removed and
the bag is connected directly to the tra A manual resuscitation unit is typi
cheal tube. Bagging is performed by cally composed of a self-inflating bag. a
squeezing the bag rhythmically. to de one-way valve or diaphragm to eliminate
liver a volume of gas to the patient. Expi rebreathing and an adaptor to connect
ration is passive. Bagging is most the unit to the tracheal tube or a face
frequently used for resuscitation. trans mask. Although apparently simple in de
portation of a patient requiring mechan sign and use. there is a great deal of vari
ical ventilation. and in conjunction with ability among different types of resusci
suctioning of spontaneously breathing tator bags. Familiarity with the bag's
patients. characteristics allows efficient and safe
Table 5.6 The most serious complication of bag

Important Design Characteristics of Manual ging cited in the literature is barotrauma.
Resuscitators
In 1978, Klick and co-workers described
Bag capacity a patient in whom incorrect assembly of
Maximum and average stroke volume a resuscitator bag led to pleural tears and
Maximum oxygen concentration delivery multiple subpleural hematomas bilater
Performance of valves at high oxygen flow ally. The situation occurred because the
rates resuscitator bag was connected to a
Performance of bag when mucus is present
cuffed tracheal tube and high oxygen
Presence of relief valve
Ease of use and cleaning
flow rates jammed the valve, causing
Durability transmission of high pressures to the pa
tient's lungs. Klick warns against sbwly
releasing hand pressure on the bag,
use. Important characteristics are noted which may increase the likelihood of the
in Table 5.6. valve remaining in the position of inspi
In 1975, Carden and Hughes examined ration and prevent lung deflation. If this
the performance of eight commonly used should occur, the bag must be discon
bags and found several important defi nected immediately to allow emptying of
ciencies, including an inability to deliver the lungs. The pressure relief valve de
adequate oxygen concentrations and signed to limit barotrauma can also cause
malfunction of the valves when mucus inadequate ventilation of the patient
was present (Carden and Hughes, 1 975). with intrinsic lung disease, pulmonary
After revision, these problems were edema, or chest wall injury. Hirschman
eliminated in four of the bags (Carden and Kravath (1982) describe this compli
and Friedman, 1977). However, some cation and suggest overriding this
substandard bags may still be in use and "safety" feature to ensure effective ven
should be replaced. Eaton (1984) reported tilation, particularly during resuscitation
oxygen delivery to range from 25 to 100% or when increased airway pressure is
depending on the type of bag and if a res present. When the pressure relief system
ervoir was attached. A study by Priano is deactivated, it is advisable that the op
and Ham (1978) suggested that the prob erator be made aware of this fact by an
lem of low oxygen concentration deliv audible or visual warning (Eaton).
ery may be partly overcome by retarding
reexpansion of the bag manually in order SUMMARY
to obtain more oxygen entrainment. Ox
ygen delivery can be better controlled by Phagocytosis and ciliary activity pro
adding a reservoir to the resuscitator bag. vide adequate airway clearance under
but this makes the bag more cumbersome normal conditions. Only in the presence
to use (Barnes and Watson, 1982; Eaton). of excessive secretions or foreign objects
Manual resuscitators also provide a vari or when the primary mechanisms are al
able tidal volume. Bags are frequently tered is coughing of major importance.
compressed with one hand which pro This is often the case following surgery,
vides volume delivery from 400 to 800 when ciliary activity may be impaired
ml; a volume of at least 500 ml is recom due to the effects of decreased humidity,
mended. Two-handed operation yields diaphragm dysfunction, anesthetic
500-1000 ml; maximal volume should agents, supplemental oxygen, or tracheal
not exceed 1 500 ml (Hill and Eaton, 1983: intubation. Incisional pain and fear also
Eaton). Since a spontaneous breath may frequently accompany su rgery or trauma,
exceed this volume, the inspiratory re leading to voluntary cough suppression.
sistance of the bag should be low. Also, Various conditions. such as neuromus
the spontaneous breath should come cular disorders and chronic lung disease,
through the bag, rather than the atmo may further impair cough efficacy. As a
sphere, if supplemental oxygen is re result. the methods outlined in this chap
quired (Eaton). Rebreathing. leading to ter may be necessary to stimulate the
i ncreased inspired CO,. is another re cough mechanism or improve its effec
ported complication of some resuscitator tiveness. However, it is our opinion that
bags (Hill and Eaton). nasotracheal suctioning is an avoidable
and hazardous procedure and that trans Bateman JRM, Newman sr, Daunt KM. Sheahan
NF. Pavia D. Clarke SW: Is cough as effective as
tracheal puncture should be abandoned
chest physiotherapy in the removal of excessive
as a method to clear secretions. tracheobronchial secretions? Thorax 36:683-687,
Safe and appropriate suctioning guide 1981
lines are summarized as follows: The cli Belinkoff S (ed): Introduction to Respiratory Care, p.
nician should use sterile technique. A 165, Little. Brown. Boston. 1976
Bell R . Fein A, Kimble P: Post suclioning hypox
coude tip catheter is recommended for emia: Is it preventable? (abstract). Am Rev Respir
entering the left mainstem bronchus. Dis 121 (5uppl): 1 1 1 . 1980
Suction catheters should not be larger Belling D. Kelley R R . Simon R: Use of a swivel
than one-half the internal diameter (ID) adaptor aperture during suctioning to prevent
hypoxemia in the mechanically ventilated pa
of the airway (e.g., 1 4 French gauge cath
tient. Hearl Lung 7:320-322. 1978
eters are usually used with adults having Benson MS, Pierson OJ: Ventilator wa!ih-out vol
8- or 9-mm-ID airways). Lavage is not ume: A consideration in endotracheal suction
carried out during suctioning, and the preoxygenation. Respir Core 24:832-835. 1979
"bag squeezing" method of chest phys Berman IR, Stahl WM: Prevention of hypoxic com
plications during endotracheal suctioning. Sur
iotherapy is not routinely used. Supple gery 63:586-587. 1968
mental oxygen is indicated if hypoxemia Boba A, Cincotli J J . Piazza TE. Landmesser CM: The
occurs with suctioning; suctioning time effects of apnea, endotracheal suction and oxygen
should be limited to 1 5 sec. Care should insumation alone and in combination, upon ar
terial oxygen saluration in anesthetized patients.
be taken to reexpand the lungs after suc
J Lab Clin Med 53:680-685. 1959
tioning by using a mechanical ventilator, Bodai BI. Walton CB, Briggs S. Goldstein M: A clin
a manual resuscitator bag, or a volitional ical evaluation of an oxygen insuffiation/suction
deep breath. The clinician should be catheter. Heart Lung 16:39-46, 1987
aware of the limitations and variations of Boutros AR; Arterial blood oxygenation during and
after endotracheal suctioning in the apneic pa
resuscitator bags. Critically ill mechani tient. Anesthesi% gy 32:114-118, 1970
cally ventilated patients should be suc Brandstater n, Muallem M: Atelectasis following
tioned through a port adaptor whenever tracheal suctioning in infants. Anesthesiology
ventilator flow rates are adequate. This 31 :468-473. 1 969
Brown SE, Stansbury OW. Merrill EJ. Linden GS.
allows for shorter suctioning times and
Light RW: Prevention of suctioning-related arte
beller maintenance of PEEP, FlO" and rial oxygen desaturation. Chest 83:621-627.
tidal volume delivery. Suctioning is an 1983
integral part of chest physiotherapy for Bucher K: Pathophysiology and pharmacology of
the patient with a tracheal tube. The fre cough. Pharmacal Rev 10:43-57, 1958
Byrd RB. Burns JR: Cough dynamics in the post-tho
quency of this procedure depends on se
racotomy state. Chest 67:654-657. 1975
cretion production and individual pa Cabal L. Devaskar S. Siassi B. Plajstek C. Waffarn F,
tient need. Blanco C. Hodgman J : New endotracheal tube
adaptor reducing cardiopulmonary effects of suc
tjoni ng. Crit Care Med 7:552-555, 1979
Carden E. Friedman 0: Further studies of manually
References operated self-innaUng resuscitation bags. Anesth
Anolg (Cleve) 56:202-206. 1977
Anthony IS. Sieniewicz DI: Suctioning of the left
Carden E. Hughes T: An evaluation of manually op
bronchial tree in critically ill patients. Crit COfe
erated self-innaling resuscitation bags. Anesth
Med 5:161-162. 1977
Analg (Cleve) 54:133-138. 1975
Ackerman MH: The use of bolus normal saline in
Centers for Disease Control. Recommendations for
stillations i n artificial airways: Is it useful or nec
prevention of HIV transmission in health care sel
essary? Hearl Lung 14:505-506, 1985
l i ngs. MMWR 36(5uppl 25):1-18. Augusl 1987
Adlkofer RM. Pmvaser MM: The effect of endotra
cheal sllclioning on arterial blood gases in pa Charnley RM. Verma R : Inhalation of a minitrach
tients after cardiac surgery. Hearl Lung 7 : 1 0 1 1 - eotomy tube. Intensive Care Med 1 2 : 1 08-109,
1014. 1 978 1 986
Baker PO. Baker 1M. Koen PA: Effect of different Chopra SK. Taplin GV. Simmons DH, Robinson GO,
slictioning technqiues on arterial oxygenation Elam 0, Coulson A; Effects of hydration and
(abstract). Am Rev Respir Dis 121 (Suppl):l 09, 19S0 physical therapy on tracheal transport velocity.
Banner AS: Cough: Physiology, evaluation and Am Rev Respir Dis 1 1 5: 1 009-1014, 1977
treatmenL Lung 1 64:79-92, 1986 Clement AI. Hubsch SK: Chest physiotherapy by
Barnes CA, Kirchhoff KT: Minimizing hypoxemia the "bag squeezing" method. Physiolherapy
due to endotracheal suctioni ng: A review of the 54:355-359. 1968
literature, Heart l.ung 1 5 : 164-176, 1986 Com roe JH: The lung. Sci Am 2 1 4:56-58. 1966
Barnes TA, Watson ME: Oxygen delivery perfor Cordero L. Hon EH: Neonatal bradycardia following
mance of four adult resuscitation bags. Respir nasopharyngeal stimulation. J Pedialr 78:441-447,
Care 27: 139-146, 1982 1971
Craig KC. Benson MS, Pierson OJ: Prevention of ar methods of supplementing oxygen in minimizing
terial oxygen desaturation during closed-ariway suction-induced hypoxemia (abstract). Heart
endotracheal suction: Effect of ventilator mode. Lung 14:293. 1 985
Respir Core 29:1013-1018, 1984 Gerradd J. Bullock M: The effect of respiratory ther
Curry LO. Van Eeden C: The influence of posture apy on intracranial pressure in ventilated neuro
on the effectiveness of coughing. 5 Afr J surgical patients. Ausl / Physiother 32:107-1 1 1 .
Physio/her 33:8-1 1 . 1977 1 986
deBoeck C, Zinman R: Cough versus chest physio Gold MI. Duarte I, Muravchick S: Arterial oxygen
therapy. Am Rev Respir Dis 129:181-184. 1984 ation in conscious patients after 5 minutes and
Deresinski SC, Stevens DA: Anterior cervical infec after 30 seconds of oxygen breathing. Anesth
tions: Complications of transtracheal aspirations. Analg 60:313-316. 1981
Am Rev Respir Dis 1 1 0:354-356. 1974 Goodman RM. Yergin BM. Landa IF. Golinvaux
Dickert MS: Closed-system 5llctioning (letter). Cril MH. Sackner MA: Relationship of smoking his
Care Nurse 7:12-13. 1987 tory and pulmonary [unction tests to tracheal mu
Dollrus p, Frankel HL: Cardiovascular renexes in cous velocity in nonsmokers. young smokers. ex
tracheostomised tetraplegics. Paraplegia 2:227- smokers. and patients with chronic bronchitis.
235, 1 965 Am Rev Respir Dis 1 1 7:205-214. 1978
Douglas S. Larson EL: The effect of a positive end Goodnough SKC: The effects of oxygen and hyper
expiratory pressure adaptor and oxygenation innation on arterial oxygen tension after endotra
during endotracheal sllctioning. Heart Lung cheal suctioning. Heart Lung 14:11-17. 1985
14:396-400, 1985 Graff M. France J. Hiatt M. Hegyi T: Prevention of
Dryden CEo Albrecht WHo Cummins Of', Link WJ: hypoxia and hyperoxia during endotracheal sue
A non hypoxemic system for sterile tracheal as tioni ng. Crit Core Med 1 5 : 1 1 33-1135. 1987
piration without gloves. Aneslh Analg (Cleve) Gunderson LP. McPhee AI. Donovan EF: Partially
56:449-450, 1977 ventilated endotracheal suction. Am J Dis Child
Durand M. Sangha B, Cabal LA, Hoppenbrouwers T. 140:462-465, 1966
Hodgman JE: -Cardiopulmonary and intracra Guthrie MM. Pardowsky BI. Stephens JJ: Hazards of
nial pressure changes related to endotracheal endotracheal suctioning through an adaptor
511clioning in preterm infants. Crit Care Med while maintaining mechanical ventilation (ab
1 7:506-51 0 , 1 989. stract). Am Rev Respir Dis 127(Suppl):148. 1983
Eaton 1M: Adult manual resuscitators. Bf / Hasp Guyton AC: Basic Human Physiology: Normal
Med 3 1 :67-70. '984 Function and Mechanisms of Disease. pp 400-401.
Evans IN. Jaeger MJ: Mechanical aspects of cough WB Saunders. Philadelphia. 1977
ing. Pneumon% gie 1 5 2 :253-257. '975 Gwynn DR. Moustafa SM: Complications of a mini
Falk M . Kelstrup M . Anderson lB. Kinoshita T. Falk tracheotomy. I Royol Col/ege Surg Edinb 29:381.
p, Stovring S. Gothgen I: Improving the ketchup 1 964
bottle method with positive expiratory pressure. Haberman PB. Green IP. Archibald C. Dunn DL.
PEP, in cystic fibrosis. Eur / Respir Dis 65:423-432. Hurwitz SR. Ashburn WL. Moser KM: Determi
1 984 nants of successful selective tracheobronchial
Fell T. Cheney FW: Prevention of hypoxia during suctioning. N Engl / Med 289:1060-1063. 1973
endotracheal suction. Ann Surg 1 74:24-28. 1971 Hahn HH, Beaty HN: Transtracheal aspiration in the
Fewell J. Arrington R, Seibert I: The effect of head evaluation of patients with pneumonia. Ann In
position and angle of tracheal bifurcation on lern Med 72:183-187. 1970
bronchus catheterization in the intubated neo Hanley MV. Rudd T, Butler J: What happens to in
nate. Pediatrics 64:318-320. 1979 tratracheal saline instil lations? (abstract). Am Rev
Fisher OM. Frewen T. Swedlow DB: Increase i n in Respir Dis 1 1 7(Suppl):124. 1970
tracranial pressure during sllctioning-stimula Harris. RS. Lawson TV: The relative mechanical ef
tion vs rise in PaC02 Anesthesiology 57:416-417. fectiveness and efficiency of successive voluntary
1982 coughs in healthy young adults. Clin Sci 34:569-
Fox WW. Schwartz IG. Shaffer TM: Pulmonary 577, 1968
physiotherapy in neonates: Physiologic changes Hietpas BG. Roth RD. Jensen WM: Huff coughing
and respiratory management. / Pedio lr 92:977- and airway patency. Jlespir Core 24:710-713.
981. 1978 1979
Frankel HL. Mathias Cj. Spalding 1M: Mechanisms H i l l SL. Eaton 1M: Rebreathing during use of the
of renex cardiac arrest in telrapiegic patients. Air-Viva resuscitation bag: A hazard. Br Med I
Lancet 2 : 1 1 83-1885. 1975 267:563-584, 1 983
Freedman AP. Goodman L: Suctioning the left bron Hirshman AM. Kravath RE: Venting vs ventilating.
chial tree in the intubated adult. Crit Care Med A danger of manual resuscitator bags. Chest
10:43-45. 1 982 62(Suppl ):69-70, 1 982
Frownfelter DL (ed): Chest Physical Therapy and Hofmeyr IL. Webber SA. Hodson ME: Evaluation of
Pulmonary Rehabilitation. p. 184. Year Book Med positive expiratory pressure as an adjunct to
ical Publ ishers. Chicago. 1978 chest physiotherapy in the treatment of cystic fi
Gal TJ: Effects of endotracheal intubation on normal brosis. Thorax 4 1 :951-954. 1 986
cough performance. Anesthesiology 52:324-329. Housley E. Louzada N. Becklake MR: To sigh or not
1980 to sigh. Am Rev Respir Dis 101:61 1-614. 1 970
Gaskell OV. Webber BA: The Brompton Hospital Howell S, Hill JD: Acute respiratory care in the open
Guide 10 Chest Physiotherapy. 4th pp ed .. 1 9-20. heart surgery patient. Phys Ther 52:253-260. 1972
94-95. Blackwell Scientific Publications. Boston. 1m Ie PC. Mars MP. Eppinghaus CEo Anderson P.
1 980 Ciesia NO: Effect of chest physiotherapy (CPT)
METHODS OF AIRWA Y CLEARANCE: COUGHING AND SUCTIONING 185
posi tioning on i n tracranial (fep) and cerebral per bronchiectasis, and mucoviscidosis. Am Rev Res
fusion pressure (CPP) (abstract). Cril Care Med pir Dis 103:651-665, 1971
1 6:382. 1 988. Lambert RK: The use of a computational model for
Innocenti DM: Chesl conditions. Physiotherapy expi ratory flow to simulate the effects or two air
55:181- 189, 1969 way abnormalities. Aust Phys Eng Sci Med 4:100-
Irwin RS. Rosen MI. Braman 55: Cough: A compre 108. 1 981
hensive review. Arch Inlern Med 137:1186-1 1 9 1 . Lambert RK. Wilsm TA, Hyatt RE. Rodarte JR: A
1977 computational model for expi ratory flow. I Appl
Jaworski A. Goldberg SK. Walkenstein MD. Wilson Physiol: Respiral Environ Exercise Physiol 52:44-
B. Lippmann ML: Utility of immediate postlohec 56. 1 982
lomy flberoplic bronchoscopy in preventing atel Langlands J: The dynamics of cough in health and
ectasis. Chesl 94:38-43. 1 988 in chronic bronchitis. Thorax 22:88-96, 1 967
Jennelt 5: The response of heart rate to hypoxia in Langrehr EA. Washburn SC. Guthrie MP: Oxygen
man after cervical spinal cord transection. Para insufflation during endotracheal suctioning.
plegia 8:1-13. 1970 Hearl Lung 10:1028-1036, 1981
lung Re. Gottlieb LS: Comparison of tracheobron Langrehr EA, Washburn SC. Guthrie MP: Oxygen
chial suction catheters in humans. Visualization insufflation during endotracheal suctioning,
by fiberoptic bronchoscopy. Chest 69:179-181, Hearl Lung 10: 1028-1036. 1981
1976 Langlands I: The dynamics of cough in health and
lung Re, Newman J: Minimizing hypoxia during in chronic bronchitis. Thora x 22:88-96, 1 967
endotracheal airway care. Heart Lung 1 1 :208- Laws AK. Mcintyre RW: Chest physiotherapy. A
212. 1982 phYSiological assessment during positive pres
Kalinske RW, Parker RH, Brandt D. Hoeprich PO: sure ventilation in respiratory failure. Can An
Diagnostic usefulness and safety of transtracheal aeslh Soc J 1 6:487-493. 1 969
aspiration. N Eng! } Med 276:604-608, 1 967 LeFrock JL. Kleiner AS. Wu WH, Turndorf H: Tran
Kelly RE. Yao FF, Artusio JF: Prevention of suction sient bacteremia associated with nasotracheal
induced hypoxemia by simultaneous oxygen in suctioning. JAMA 236:1610- 1 6 1 1 . 1976
sumation. Crit Core Med 1 5:874-875, 1987 Leiner GC. Abramowitz S, Small MJ, Stenby VB:
King M: Rheological requirements for optimal Cough peak flow rate. Am } Med Sci 251:21 1 -214.
clearance of secretions: Ciliary transport versus 1 966
cough. Sur J Respir Dis 61 {Suppl ):39-42, 1980 Leith DE: Cough. Phys Ther 48:439-447. 1 967
King M, Brock G, Lundell C: Clearance of mucus by Leith DE: The development of cough. Am Rev Res
simulated cough. l App! Physiol 58:1776-1782, pir Dis 131 (Suppi):S39-S42. 1985
1985 Leith DE. Butler JP. Sneddon SL, Brain JD: Cough.
i\irimli B. King JE. Pfneme HI-!: Evaluation of tra In Handbook of Physiology. Vol III. The Respira
cheobronchial suction techniques. } Thoroe Cor tory System. edited by PT Macklem and I Mead.
diovosc Surg 59:340-344. 1 970 pp 3 1 5-336, American PhYSiological Society. Be
Kleiber C. Krutzfield N. Rose EF: Acute histologic thesda. MD. 1986
changes in the tracheobronchial tree associated Leith DE: Cough. In Lung Biology in Heallh and Dis
with different suction catheter insertion tech ease. Vol 5. Respira tory Defense Mechanisms. ed
niques. Heart Lung 17:10-14. 1 988 ited by JD Brain, OF Proctor. and LM Reid. pp
Klick 1M, Bushnell LS. Bancroft ML: Barotrauma, a 545-592, Dekker. New York, 1977
potential hazard of manual resuscitators. Anes Link WJ. Spaeth EE. Wahle WM. Penny W. Glover
thesiology 49:363-365. 1 978 JL: The influence of suction catheter tip design on
Knudson RI. Mead I. Knudson DE: Contribution of tracheobronchial trauma and fluid aspiration ef
airway collapse to supramaximaI expiratory ficiency. Aneslh Analg (Cleve) 55:290-297. 1976
flows. J App/ Physio/ 36:653-667. 1974 Loudon RG. Shaw GB: Mechanics of cough i n nor
Krumpe PE. Denham LC: Selective bronchial suc mal subjects and in patients with obstructive res
tioning guided by differential auscultation (ab piratory disease, Am Rev Respir Dis 96:666-677,
stract). Crit Core Med 1 2:260. 1 984 1 967
Kubota Y. Margaribuchi T. Ohara M , Fujita M. Toy Lourie B, McKinnon B. Kibler L: Transtracheal as
oda Y. Asada A, Harioka T: Evaluation of selec piration and anaerobic abscess (letter), Ann In
tive bronchial suctioning in the adult. Cril Core lern Md 80:417-418. 1974
Med 8:748-749. 1 980 Mackenzie CF: Do periodic hyperinflat ions improve
Kubota Y. Magaribuchi T, Toyoda Y. Marukawa M , gas exchange in patients with hypoxic respiratory
Urabe N, Asada A , Fujimori M . Ueda Y. Matsurra failure? (letter). Crit Core Med 17:595-596.1 988
H: Selective bronchial suctioning in the adult Marshall A. Bryan C. Levison H: A i rway closure i n
using a curve-tipped catheter with a guide mark, children. J Appl Physioi 33:71 1 -7 1 4 . 1972
Crit Core Med 10:767-769. 1 982 Mansell A, Bryan C. Levison H: Airway closure in
Kubota y, Toyoda Y. Sawada S. Murakawa M: The children. J Appl Physiol 33:711-714. 1972
utility of a handmade curve-tipped catheter on Marshall R. Holden WS: Changes i n calibre of the
selective left bronchial catheterization (letter), smaller airways in man, Thorox 18:54-58. 1 963
Crit Core Med 1 1 :765-766, 1 983 Matthews HR. I-!opkinson RB: Treatment of sputum
Kubota Y. Toyoda y, Ueda Y. Fugimori M, Mori K, retention by minilracheotomy. Br J Surg 71:147-
Okamoto T. Yasuda T. Matsuura H: Device for de 150. 1984
termining location or an endotracheal catheter McCool FD. Leith DE: Pathophysiology of cough
tip. Cril Core Med 1 2 : 1 25-126, 1 984 Clin Chesl Med 8:189-195. 1987
Kylstra lA, Rausch DC. Hall KD, Spack A: Volume Mcquillan KA: The effects or the trendelenburg po
controlled lung lavage in the treatment of asthma. sition for postural drainage on cerebrovascular
status in head injured patients (abstract). Hearl bronchial suction catheters in intubated neon
Lung 16:327. 1987 ates. Arch Dis Child 58:829-831. 1983
Mead J , Turner 1M, Macklem PT, Little JB: Signifi Priano LL. Ham J: A simple method to increase the
cance of the relationship between lung recoil and FOOl of resuscitator bags, Crit Care Med 6:48-49,
maximum expiratory flow. / AppJ Physio/ 22:95- 1978
108. 1967 Pryor IA. Webber SA: A n evaluation of the force ex
Melissinos CG, Bruce E. Leith 0: Factors affecting piration technique as an adjunct to postural
pleural pressure during cough in normal man (ab drainage. Physiotherapy 65:304-307. 1979
stract). Clin Res 25:421A, 1976 Pryor lA, Webber SA. Hodson ME. Batten IC: Eval
Melissinos CG. Leith DE. Brody JS, Bruce E. Mead I: uation of the forced expiration technique as an
Thoracoabdominal mechanics in spontaneous adjunct to postural drainage in the treatment of
cough (abstract). Am Rev Respir Dis 1 1 7:372, 1978 cystic fibrosis. Sr Med J 2:417-418. 1979
Menkes H. Britt J: Rationale for physical therapy. Puchelle E. Zahm 1M. Girard F, Bertrand A. Polu
Am Rev Respir Dis 122(Suppi 2):127-131. 1 980 1M. Aug F. Sadoul P: Mucocil i,ary transport in
Mossberg B. Cramner P: Mucociliary transport and vivo and in vitro. Eur J Respir Dis 61:254-264.
cough 8S tracheobronchial clearance mechanisms 1980
in pathological conditions. Eur ) Respir Dis Radigan LR. King RD: A technique for the preven
61(Suppl l 10):47-55. 1 980 tion of postoperative atelectasis. Surgery 47:184-
Mossberg B. Afzeli u s BA. Eliasson R , Camner P: On 187. 1 960
the pathogenesis of obstructive lung disease. Ramirez J: Alveolar proteinosis: Importance of pul
Sca n d ) Respir Dis 59:55-65. 1978 monary lavage. Am Rev Respir Dis 103:666-678.
Murray IF: Editorial: The ketchup-bottle method. N 1971
Engl J Med 300: 1155-1156. 1979 Ramirez RJ, Schultz RB, Dutlon RE: Pulmonary al
Newhouse MT: Factors affecting sputum clearance veolar proteinosis. A new technique and ration
{abstraCt}. Thorax 28:267. 1973 ale for treatment. Arch lnlern Med 1 1 2:419-431.
Novak RA. Shumaker L. Snyder IV. Pinsky MR: Do 1 963
periodic hyperinflation improve gas exchange in Reynolds HY: Bronchoalveolar lavage. Am Rev Res
patients with hypoxemic respiratory failure? Crit pir Dis 135:250-263. 1987
Care Med 15:1081-1085, 1987 Ries K. Levison ME. Kaye 0: Transtracheal aspira
Nunn IF. Bergman NA. Coleman AI: Factors influ tion in pulmonary infection. Arch tntern Med
encing the arterial oxygen tension during anes 1 33:453-458. 1974
thesia with artificial ventilation. Sr J Anaesth Rogers R. Braunstein MS. Shuman IF: Role of bron
37:898-91 4. 1 965 chopulmonary lavage in the treatment of respi
Oldenburg FA. Dolovich MB. Montgomery 1M. ratory failure: A review. Chest 62(Suppl):955-
Newhouse MT: Effects of postural drainage. ex 1 1 06. 1972
ercise and cough on mucus clearance in chronic Rosen M, Hillard EK: Tho use of suction in clinical
bronchitis. Am Rev Respir Dis 1 20:739-745. 1979 medicine. Sr J Anaeslh 32:486-504. 1 960
O'Malley p, Zankofski MA, Beaumont E : Disposable Rosen M , Hillard EK: The effects of negative pres
suction catheters: A Nursing 79 product survey. sure during tracheal suction. Aneslh Analg
Nursing '79 9:70-75. 1979 (Cleve) 4 1 :50-57. 1 962
Opie LH, Smith AC: Tracheobronchial toilet Ross BB, Gramiak R. Raho H: Physical dynamics of
through a tracheostome. Lancet 1:600-601. 1959 the cough mechanism. , App' Physiol 8:264-268,
Parsons GH. Price IE. Auston PW: Bilateral pneu 1955
mothorax complicating transtracheal aspiration. Rossman CM. Waldes R. Sampson D. Newhouse
West J Med 125:73-75. 1976 MT: Effect of chest physiotherapy on the removal
Pauker SG: Transtracheal aspiration (letter). Ann of mucus in patients with cystic fibrosis. Am Rev
Inlern Med 73:142-143, 1970 Respir Dis 126:131-135. 1982
Pecora DV. Kohl M: Transtracheal aspiration in the Rowe MI. Weinberger M. Poole CA: An experimen
diagnosis of acute lower respiratory tract infec tal study of the vibrator i n postoperative tracheo
tion. Am Rev Respir Dis 86:755-758. 1962 bronchial clearance. , Pedialr Surg 8:735-738.
Perel A. Pizor R. Fisher I, Goldberg M: Transtra 1973
cheal oxygen to produce cough (letter). Chesl Sackner MA: Tracheobronchial toilet. Weekly Up
93:447-448. 1 988 date. Pu lm Med 1-8. 1978
Perlman 1M. Volpe J J : Suctioning i n the preterm in Sackner MA, Landa F, Greeneltch N. Robinson MI:
fant: Effects on cerebral blood flow velocity. in Pathogenesis and prevention of tracheobronchial
tracranial pressure. and arterial blood pressure. damage with suction procedures. Chest 64:284-
Pediatrics 72:329-334, 1983 290. 1973
Petersen GM, Pierson OJ. Hunter PM: Arterial oxy Salem MR. Wong AY. Mathrubhutham M. Ramilio
gen saturation during nasotracheal suctioning. J. Jacobs HK. Bennett EJ: Evaluation of selective
Chest 76:283-287. 1979 bronchial suctioning techniques used for infants
Petty TL led): Intensive and Rehabilitative Respira and children. Anesthesiology 48:379-380. 1978
lory Care. p 108. Lea & Febiger. Philadelphia. 1974 Schillaci RF. lacovolli VE. Conte RS: Transtracheal
Pierce lB. Piazza DE: Differences in postsuctioning aspiration complicated by fatal endotracheal
arterial blood oxygen concentration values using hemorrhage. N Engl , Med 295:488-490. 1 976
two postoxygena!ion methods. Hearl Lung 16:34- Schmerber J. Deltenre M: A new fatal complication
38. 1987 of transtracheal aspiration. Scand J Respir Dis
Placzek M . Silverman M: Selective placement of 59:232-235. 1978
Schumann L, Parsons GH: Tracheal sllclioning and Tyler ML: Nursing care of patients in acute respi
ventilator tubing changes in adult respiratory dis ratory failu re. In Current Advances in Respiratory
tress syndrome: Use of a positive end-expiratory Ca re, edited by WI O'Oonohue. pp 137-148.
pressure valve. Heart Lung 14:362-367, 1 985 American Col lege of Chest Physicians. Park
Scott AA, Sandham C. Rebuck AS: Selective tra Ridge. IL. 1 984
cheobronchial aspiration. Thorax 32:346-348, Unger KM. Moser KM: Fatal complication of trans
1977 tracheal aspiration. Arch Intern Med 1 32:437-439.
Shim C. Fine N. Fernandez R. Williams MH: Car 1973
diac arrhythmias resulting from tracheal suclion Ungvarski P: Mechanical stimulation of coughing.
ing. Ann lnlern Med 7 1 : 1 1 49-11 53, 1 969 Am I Nurs 71 :2358-2361. 1971
Siebens AA. Kirby NA, Poulos DA: Cough following Urban BI. Weitzner SW: Avoidance of hypoxemia
transection of spinal cord at e-6. Arch Phys Med during endotracheal suction. Anesthesiology
RehabiI 45:1-6, 1964 3 1 :473-475, 1 969
Skelley BFH, Deeren SM. Powaser MM: The effec Vraciu JK. Vraciu RA: Effectiveness of breathing ex
tiveness of two preoxygenalion methods to pre ercises in preventing pulmonary compl ications
vent endotracheal suction-induced hypoxemia. fol lowing open heart surgery. Phys Thei- 57:1367-
Hearl Lung 9:316-323. 1980 1371. 1977
Smaldone CC. Itoh H. Swift D. Wagner H: Effect of Walsh 1M, Vanderwarf C. Hoscheit D, Fahey PI: Un
flow-limiting segments and cough on particle de suspected hemodynamic alterations during en
position and mucociliary clearance in the l u ng. dotracheal suctioning. Chesl 95:162-165, 1 989
Am Rev Respir Dis 1 20:747-758. 1979 Wang KP, Wise RA. Terry PB. Summer WR: A new
Smaldone CC. Messina MS: Enhancement of parti controllable suction catheter for blind cannula
cle deposition by flow-limiting segments in hu tion of the main stem bronchi. Crit Care Med
mans. J AppJ Physiol 59:509-514. 1 965a 6:347-346, 1976
Smaldone CC. Messina MS: Flow limitation, cough, Weibel ER: Morphometry of the Human Lung. p.
and patterns of aerosol deposition in humans. J 139. Academic Press. New York. 1 963
Appl Physiol 59:51 5-520, 1965b Weistein HC. Bone RC. Ruth WE: Pulmonary lavage
Smaldone CC. Messina MS: Enhancement of parti i n patients treated with mechanical ventilation.
cle deposition by flow-limiting segments in hu Chesl 72:563-567, 1977
mans. J Appl Physio/ 59:509-514. 1 985a White PF. Schlobohm RM, Pills LH. Lindauer 1M: A
Spencer CD, Beaty HN: Complications of transtra randomized study of drugs for preventing in
cheal aspiration. N Eng/ J Med 286:304-306. 1972 creases in intracranial pressure during endotra
Spaerel WE. Chan CK: Jel ventilation far trar:hea cheal sllclioning. Anesthesiology 57:242-244,
bronchial suction, Anest hesi% gy 45: 450-452. 1 962
1976. Widdicombe JC: Mechanism of cough and its regu
Standard Specification for Medical and Surgical lation. Eur 1 Respir Dis 61 (Suppl 1 1 0 }: 1 1 - 1 5, 1980
Suction and Drainage Systems American Society Windsor HM. Harrison GA. Nicholson Tf: "Bag
for Testing and Materials. Committee F-29. Sub squeezing." A physiotherapeutic technique, Med
committee 1"-29.07.01. 1916 Race SI.. Philadel I Ausl 2:829-832. 1972
phia, PA 19103, 1966, P 6 Yamazaki S. Owaga J . Shohzu A. Yamazaki Y: Intra
Sutton PP. Parker RA. Webber SA, Newman SP. pleural cough pressure i n patients after tharacot
Carland N. Lopez-Vidriero MT. Pavia D. Clarke omy. I Thoroc Cardiovosc Surg 80:600-604,
SW: Assessment of the forced expiralion tech 1960
nique. postural drainage and di rected coughing in Yeoh NTL, Wells FC. Coldstraw P: A complication
chest physiotherapy. Eur J Respir Dis 64:62-68. of minitracheostomy. Br / Surg 72:633. 1 985
1963 Yoshikawa TT. Chow AW, Montgomeriez fZ, Cuze
Sykes MK, McNicol MW. Campbell ElM: Respira LB: Parat racheal abscess: An unusual complica
tory Failure. pp 153-157. Blackwell Scientific tion of t ranstracheal aspiration. Chest 65:105-106.
Publications, Boston. 1976 1 974
Taggart IA. Dorinsky NL, Sheahan IS: Airway pres Zaltman 11: Selective Ie! bronchial suctioning using
sures during closed system suclioning. Heart a routine catheter with the programmed tip (let
Lung 1 7:536-542. 1968 ler). Grit Core Med 1 1 :765. 1983
Taylor PA. Waters HR: Arterial oxygen tensions fol Zelechowski CP: Suction collection and its relation
lowing endotracheal suction on IPPV. Anaesthe to nosocomial infection. Am J Infect Conlro/6:72-
sia 26:289-293. 1971 74, 1 960
Thoren L: Post-operative pulmonary complications. Zmora E. Merrill TA: Use of a side hole endotra
Observations on their prevention by means of cheal lube adaptor for tracheal aspiration. Am J
physiotherapy. Aclo Chir Scand 107:1 93-204. Dis Child 1 34:250-254, 1960
1954
CHAPTER 6
Changes with Immobility and

Methods of Mobilization
P. Cristina Imle, M.S., P.T., and Nancy Klemic, B.S., P.T.
The Effects of Immobilization

Cardiovascular System
Respiratory System
Metabolic System
Musculoskeletal System
Central Nervous System
Methods of Patient Mobilization
Bedridden Patients
Sitting
Standing and Ambulating
Equipment Used for Mobilization
THE EFFECTS OF IMMOBILIZATION caused by a variety of factors such as

those listed in Table 6.1. Restriction to
"The importance of immobilization has
been part of medicine's body of knowledge for
bed rest includes maintaining the patient
many. many years and can be accepted as fact. in the supine position rather than the
As with any fact. if not restated from time to normal erect position. The belief that the
lime it tends to be forgotten.... Our advanced detrimental effects of bed rest and im
knowledge and technology by themselves mobility can be better corrected once the
cannot save the patient. Instead something so patient is no longer acutely ill is not ac
simple as turning the patient ... at least ceptable. Preventing secondary compli
hourly, may make the difference between liv cations saves both time and money and
ing and dying for the intensive care patient."
may well affect the patient's recovery
(Bendixen, 1974)
and quality of life. Methods of mobilizing
The hazards of patient immbolization patients are discussed after a systematic
are often overlooked or not considered review of immobilization and its
important enough to merit thorough dis sequelae,
cussion, particularly for patients in the
intensive care unit [leU). However, re Cardiovascular System
striction to bed rest is known to alter the
normal physiological function of all the The effects of immobilization on the
organ systems described in this section. cardiovascular system have been inves
Most studies on the effects of immobility tigated since the 1 940s. Table 6.2 sum
are performed on normal subjects. More marizes the research in this area. The ef
delerterious findings can be assumed fects cited most frequently are decreased
when bed rest is combined with trauma, total blood volume, plasma volume, red
malnutrition, decreased level of con blood cell mass, and hemoglobin concen
sciousness, or chronic disease. Immobi tration. There is also a decrease in max
lization of the acutely ill patient is often imal oxygen uptake and orthostatic tol-
188
CHANGES WITH IMMOBILITY AND METHODS OF MOBILIZATION 189
Table 6.1 a decreased ability to perform aerobic

Factors leading to Immobilization of the work and decreased endurance. Taylor et
Intensive Care Patient a1. (1 949) studied six normal men and
Confinement to the intensive care unit found that after 3 weeks of bed rest. the
Confinement to bed rest heart rate was significantly higher with
Administration of anesthesia. sedation and the same level of exercise. Oxygen in
neuromuscular blockers take during exercise decreased while ox
Skeletal traction. casting and splinting ygen debt and blood lactate concentra
Neurological deficit including paralysis and tion increased. Saltin et a1. (1 968) studied
central nervous system depression
five normal young males before and after
Pain
General debilitation, weakness and a 20-day period of bed rest. Their findings
malnutrition included an increased heat rate during a
Use of monitoring equipment standardized level of exercise and de
creased cardiac output with exercise and
maximal work load. After studying 22
erance. Maximal and basal heart rates normal men who had undergone bed rest
are increased during immobilization. for 1 week. Friman (1 979) determined
that maximal oxygen uptake and work
capacity decreased. These studies were
Physical Decondilioning
done on previously normal patients.
Therefore. it is not known what varia
Following immobilization. the patient tions in deconditioning would occur in
becomes deconditioned. as evidenced by the intensive care patient with a history
Table 6.2
The Effects of Immobilization on the Cardiovascular System
length of
Effect Found Year/Researchers Population Studied
Immobilization
Decreased total blood 1945 Taylor et al . 3 wk 5 normal young men
volume 1967 Vogt et al. 14 days 4 normal young men
1970 Triebwasser et al. 5 wk 8 normal adults
1979 Friman 1 wk 22 normal men
Decreased plasma 1948 Deitrick et al. 6 or 7 wk 4 normal men
volume and red 1968 Georgiyevskiy et al. 20 days 4 normal men
blood cell mass 1967 Vogt et al. 14 days 4 normal men
1968 Saltin et al. 20 days 5 normal men
Decreased hemoglobin 1964 Lamb et al. 2 wk 26 normal men
concentration 1979 Friman 30 days 10 normal men
1 wk 22 normal men
Increased maximal 1948 Deitrick et al. 6 or 7 wk 4 normal men
heart rate 1974 Bassey and 2 wk 9 postoperative knee
Fentem surgery patients
(male)
1976 Stremel et al. 2 wk 7 normal young men
Increase in basal heart 1949 Taylor et al. 3 wk 6 normal young men
rate 1968 Georgiyevskiy et al. 20 days 3 normal young men
62 days 3 normal young men
Decreased transverse 1949 Taylor et al. 3 wk 6 normal young men
diameter of heart 1969 Krasnykh 70 days 16 normal young women
Decreased maximum 1949 Taylor et al. 3 wk 6 normal young men
oxygen uptake 1968 Saltin et al. 20 days 5 normal men
Decreased orthostatic 1949 Taylor et al. 3 wk 6 normal young men
tolerance 1963 Birkhead et al. 42 days 4 trained men
1966 Chase et al. 15 days 18 normal young men
30 days 18 normal young men
of preexisting disease or an acute multi embolism in patients undergoing elective

system insult. In addition, some degree of general surgery ranges from 0.1 % to 0.8%
malnourishment is present in many pa (Dalen, et a1.). Pulmonary embolus is dif
tients confined to the ICU. Malnutrition ficult to diagnose clinically, since similar
results in increased muscle fatigability symptoms are often seen in patients sus
and an altered pattern of muscle contrac taining multisystem injuries. In a 2-year
tion and relaxation (Lopes et aI., 1982). period at our facility, only 1 trauma pa
tient in 124 consecutive full autopsies
Decreased Orthostatic Tolerance
demonstrated pulmonary emboli (Mac
kenzie et aI., 1979). This low incidence of
One effect of immobilization fre pulmonary embolus may be a result of
quently seen in the clinical setting is a re early and aggressive patient mobilization
duction in circulating-yolume, which since symptomatic pulmonary embolism
may result in dizziness or fainting when is relatively uncommon in ambulant pa
the patient assumes the upright position. tients and fatal pulmonary embolism is
This happens because vasodilation oc very uncommon (Dalen et a1.).
curs in the supine position. After pro
longed bed rest, the blood vessels' ability Respiratory System
to vasoconstrict is impaired; therefore,
the upright position causes blood to pool Effects of Position Change
in the lower extremities. This results in
decreased cardiac filling pressures and In normal subjects, changes in respira
decreased cardiac output and may pro tory function occur only during the ini
duce mild cerebral hypoxemia (Browse, tial period of adjustment to the change in
1965). Orthostatic hypotension is partic position from upright to supine (see
ularly troublesome in the patient with Table 6.3). This position change may re
quadriplegia. sult in decreased total lung capacity with
decreased vital capacity, functional re
Venous Thrombosis and Pulmonary
sidual capacity (FRC), residual volume,
Embolus
and forced expiratory volume. The shape
of the rib cage and abdomen changes,
The incidence of venous thrombosis with the anteroposterior diameter de
increases with the duration of bed rest creasing, while the lateral diameter in
(Sevitt and Gallagher, 1961). However, creases. Pulmonary blood flow and ven
the etiology of venous thrombosis for tilation distribution are altered. In the
mation is not yet fully identified. Several presence of lung pathology, the alteration
factors are suggested, including changes in ventilation and perfusion due to posi
in blood composition, loss of vessel wall tion change may be dramatic (see p. 94).
integrity, and vascular stasis. The de In normal subjects, alveolar size de
creased Circulating blood volume that oc creases and small airways close in depen
curs with immobility is due more to the dent lung zones.
loss of plasma than to the decrease in red Of particular significance is the reduc
blood cell mass. The net effect of in tion in FRC that occurs in the supine po
creased blood viscosity may predispose sition and the relationship of FRC to clos
the bedridden patient to thromboembo ing volume, which results in increased
lism (Wenger, 1982). While venous airway closure at resting tidal volumes.
thrombosis is reportedly common in hos Craig et a1. (1971) studied the relation
pitalized (and immobilized) patients, ship between airway closure and age and
over 80% of the detected thrombi are found that closing volume became
small, asymptomatic, confined to the calf, greater than FRC at 49 years in the seated
and probably clinically insignificant position and at 36 years of age in the su
(Dalen et aI., 1986). Dislodgment of a ve pine position (see Fig. 6.1). A decrease in
nous clot can lead to a pulmonary em chest wall compliance also occurs with
bolus, which may have severe, even age (Estenne et aI., 1985). Dynamic and
fatal, consequences (Browse). The inci static lung compliance also decrease and
dence of postoperative fatal pulmonary resistance to flow increases in normal
Table 6.3
The Respiratory Ellects of Changing Position from Upright to Supine
Decreased total lung capacity 1957 Svanberg 25 normal people
1971 Craig et al. 1a normal men
Decreased vital capacity 1951 Wade and Gilson 1a normal men
1957 Svanberg 25 normal people
Decreased FRC' 1957 Svanberg 25 normal people
1971 Craig et al. 10 normal men
Decreased residual volume 1957 Svanberg 25 normal people
1971 Craig et al. 10 normal men
Decreased ERV 1983 Behrakis et al. 10 normal men
Decreased forced expiratory 1971 Craig et al. 10 normal men
volume
Decreased static and dynamic 1983 Behrakis et al. 10 normal men
lung compliance
Decreased rib cage
compliance
Increased diaphragm 1985 Estenne et al. 61 normal adults
abdomen compliance
Changes in pulmonary blood 1970 Reed and Wood Dogs
flow distribution
Closure of small airways in 1970 LeBlanc et al. 80 normal subjects
dependent regions 1971 Craig et al. 10 normal men
Decreased anteroposterior 1978 Vellody et al. 25 normal people
diameter and increased
lateral diameter of rib cage
and abdomen
Decrease in size of dependent 1967 Glazier et al. Greyhound dogs
alveoli 1983 Behrakis et al. 10 normal men
Decrease in PaO, 1966 Ward et al. 50 elderly hospital patients
'FRC, functional residual capacity; ERV, expiratory reserve volume.
subjects When moving from siting to su cally ill by factors such as the presence of
pine (Behrakis et al.. 1983). Due to the a tracheal tube, anesthesia or sedation,
changes in compliance, resistance, FRC, muscle weakness, neurological deficit in
expiratory reserve volume, pul monary cluding paralysis, chest trauma, and
blood flow. and closing volume while su pain. As a result, secretions tend to ac
pine, pulmonary gas exchange is im cumulate peripherally in gravity-depen
paired; retention of secretions and atel dent positions, resulting in small airway
ectasis can develop. The trapping of closure. These secretions cannot be
secretions distal to areas of small airway cleared with suctioning and frequently
closure, if not remedied, may lead to pul cause atelectasis. Therefore, specific po
monary infection. sitioning of the patient for postural drain
age with percussion and vibration is re
EHects of Immobilization
quired to mobilize secretions centrally
where they can be suctioned. Research
While it appears that respiratory func on the respiratory effects of immobiliza
tion in normal subjects may not be ad tion is summarized in Table 6.4.
versely affected by immobilization, criti Mobilization of patients may aid in
cally ill patients may suffer severe preventing the development of respira
respiratory complications from retention tory complications. Exercise has been
of secretions. This results from immobi shown to aid lung clearance of secretions
lization, coupled with inability to handle in patients with chronic bronchitis (Ol
secretion clearance adequately. Effective denburg et aI., 1 979). The beneficial ef
clearance may be hindered in the criti- fects of mobilizing patients following sur-
U
1.5-
seATED SUPINE lSI
1.0
.. ..
"'"
.s . ..
lD
.1.0
"1.5
JS .
::
,. , .. "'>'--30 ---""--'
;;;- ;;-
- -'
"
. ,--.'"
,. --
t--
U> 1.'
SUPINE LITHOTOMY
'"
.ISo HEAD OOWN +15oHEAD DOWN

w
1
:.
L.
=-.
:;
W ,
:I
=>
"
z
in
=---
. --
. ------
9
U
.

'1
-
15
0 1.5'---":-:0---: .:.
' ' --.,.
::-
- ....,-
.::-
, - :-:.,--
,. JS 40 .5 5. ..
AGE-YEARS AGE -YEARS
Figure 6.1. Closing volume in normal subjects becomes greater than functional residual capacity
at 49 years in the seated position (A), at 36 years in the supine position (B), and progressively
earlier in the head-down position (C, 0). BTPS, body temperature and pressure saturation. (From
D. B. Craig et al.: Can Anaesth Soc J 18:92-99. 1971 .) -
.
Table 6.4
The Elleets of Immobilization on the Respiratory System
Length of
Immobilization
Decreased A-aDD,' 1967 Cardus 10 days 7 healthy young men
Increased pulmonary 1974 Ray et al. 6-10 hr 9 overhydrated dogs
arteriovenous Varied 2 overhydrated
shunting patients
Decreased PaD, 1967 Cardus 10 days 7 healthy young men
1968 Clauss et al. Length of surgery 13 open heart surgery
time (hr) patients
1974 Ray et al. 6-10 hr 9 overhydrated dogs'
Varied 2 overhydrated
patients
Increase FRC 1986 Beckett et al. 11-12 days 18 healthy adults
Physical changes in 1955 Lambert et al. Length of time of 33 tuberculosis
dependent lung thoracotomy (hr) patients'
(by x-ray or exam
on dissection) 1962 Craig et al. Length of surgery 100 thoracic surgery
time required patients (variety)'
(hr)
1974 Ray et al. 6-10 hr 9 overhydrated dogs'
Varied 2 overhydrated
patients
'A-aDO" alveolar-arterial oxygen gradient: FRC, functional residual capacity.
'Anesthetized.
192
gery is discussed in the second part of Possible etiological factors are decreased
this chapter. Early operative fixation of osteoblastic action. decreased blood flow
long bone fractures in patients with mul to the bone, and increased osteoclastic
tiple injuries allows early mobilization of activity (Browse). Osteoporosis may be
these patienls and has been cited as an painful for the patient and may lead to an
important factor in reducing the inci increased incidence of bone fracture.
dence of fat embolus (Riska et al.. 1977). Vertebral mineral bone loss of nearly 2%
In our experience over a 5-year period per week is reported following strict bed
(1975-1980). only 2 patients of 3210 con rest (Hansson et aI., 1975). A mean de
secutive trauma admissions showed clin crease in lumbar mineral content of al
ical signs of fat embolus. despite a mul most 1 % per week is reported in 34 pa
titude of orthopedic injuries. This low tients put on simple bed rest (mean, 2 7
incidence is more impressive when it is days) during Ireatment for back pain.
realized that these patients with frac Reambulation reversed the demineral
tures were roulinely and aggressively ization but took nearly 4 monlhs (Krolner
mobilized. Therefore. it is unlikely that and Toft, 1983).
early mobilization increases the inci
dence of a fal embolizalion. Formation of Kidney or Ureteral Stones
Metabolic System
As a result of increased calcium excre
tion through the kidneys and urinary
The melabolic consequences of immo tract. the incidence of stone formation
bilization during prolonged bed rest in may increase. The formation may be fur
clude increased excretion of nilrogen. ther enchanced when the patient lies in
calcium, potassium. magnesium and one position for too long. causing urine to
phosphorus (see Table 6.5). As a result, stagnate in the kidney. pelvis, or bladder
osteoporosis and kidney or ureteral stone (Hirschberg et aI., 1977).
formation may occur.
Osteoporosis
The effects of immobilization on the
Osleoporosis. loss of bone integrity musculoskelelal system include de
through demineralization and loss of creased muscle girth and strength,
bone malrix. is frequently seen during changes in periarticular and intraarticu
prolonged immobilization and is mani lar connective tissue, and loss of bone
fested by increased calcium excretion. density (see Table 6.6).
Table 6.5
The Effects 01 Immobilization on the Metabolic System
Length of
Immobilization
Increased calcium 1948 Deitrick et al. 6 or 7 wk 4 normal men
excretion 1969 Donaldson et al. 30-36 wk 3 normal men
1971 Hulley et al. 210 days 5 normal young men
Increased nitrog en 1948 Deitrick et al. 6 or 7 wk 4 normal men
excretion 1949 Taylor et al. 3wk 6 normal young men
1955 Heilskov et al. 16-18 days 3 normal young men
1971 Hulley et al. 210 days 5 normal young men
1973 Mack and 14 days 5 normal young men
Montgomery
I ncreased phosphorus 1948 Deitrick et al. 6 or 7 wk 4 normal men
excretion 1969 Donaldson et al. 30-36wk 3 normal men
1971 Hulley et al
. 210 days 5 normal young men
Increased magnesium 1969 Donaldson et al. 30-36 wk 3 normal men
excretion 1971 Hulley et al. 210 days 5 normal young men
Table 6.6
The Effects of Immobilization on the Musculoskeletal System
Length of
Effect Found Year/Researchers Populalion Siudied
Immobilization
Decreased muscle 1948 Deitrick et al. 6 or 7 wk 4 normal young men
girth 1963 Brannon et al. 60 days 30 normal young men
1969 Patel et al. 4-38 wk 14 male patients
(variety of
disorders)
1986 Grossman at al. 4 wk 23 rabbits
Decreased muscle 1948 Deitrick et al. 6 or 7 wk 4 normal young men
strength 1963 Brannon et al. 60 days 30 normal young men
1969 Yeremin et al. 70 days 16 normal men
Increased creatinine 1983 Krolner and Toft 11-61 days 34 adult patients
clearance/
decreased muscle
mass
Changes in 1963 Peacock 4 wk 8 dogs
periarticular and 1972 Enneking and Varied more than 1 10 male patients
intraarticular Horowitz year (variety of
connective tissue disorders)
1973 Akeson et al. 9 wk 10 male rabbits
1974 Akeson et al. 1. 2. 4. 6. or 9 wk 40 male rabbits
Decreased tendon 1982 Amiel et al. 9 wk 10 male rabbits
stiffness
Decreased bone 1967 Burkhart and Jowsey 3-12 wk 30 adult dogs
density 1969 Donaldson et al. 30-36 wk 3 normal men
1983 Krolner and Toft 11-61 days 34 adult patients
Atrophied, Weak Muscles tion caused by periarticular and intraar

ticular changes in connective tissue. An
After prolonged bed rest, muscles ap array of changes has been described.
pear atrophied, and the patient may have Akeson et al. (1961, 1973. 1974) found
substantial muscle weakness. Exercise biochemical changes in the composition
causes muscle hypertrophy through in of canine connective tissue, which may
creased amino acid transport. DNA and alter the mechanism of cross-linking.
RNA protein synthesis, and decreased Peacock (1963) determined that a signifi
breakdown of protein (Goldberg, 1972). cant increase in collagen production in
With prolonged bed rest, it is assumed connective tissue occurs in the popliteal
that a reversal of these biochemical ef space of dogs following 4 weeks of im
fects occurs. Immobility leads to dimin mobilization. Studying human knees that
ished skeletal muscle mass, girth. and were immobilized for extended periods
efficiency. Contractile strength may de of time (at least 1 year). Enneking and
crease by 10-15% within the first week of Horowitz (1972) frequently detected
bed rest (Wenger). Less efficient muscle obliteration of the joint space by fibro
function results in an increased oxygen fatty connective tissue.
demand, which may be intolerable to the
patient with cardiac or respiratory pa
thology. The malnutrition of many ICU Decubitus Ulcers
patients can further impair skeletal mus
Unrelieved pressure over an area
cle performance (Lopes et al.. 1982).
where skin closely overlies bone can
cause tissue necrosis. This can lead to de
Joint Contractures
cubitus ulcer formation, which not only
results in damage to skin, muscle or even
Contractures are restrictions i n joint bones but also causes a great deal of ex
range of motion following immobiliza- pense, loss of rehabilitation time and in-
fection (Kottke, 1966). However, decubi METHODS OF PATIENT

tus ulcer formation is one of the most MOBILIZATION
easily prevented secondary side effects of
immobilization. Good patient care, in To help prevent the detrimental se
cluding frequent turning with careful po quelae of bed rest and immobilization.
sitioning, is necessary to eliminate this maximal patient mobility is initiated in
problem in the ICU. Specialty beds are the ICU. As the paitent progresses, fol
not a substitute for good nursing care and lowing admission, activities may be mod
optimal pressure relief (see Chapter 3). ified accordingly. Passive positioning is
almost always possible despite numerous
intravascular lines and Iifesustaining
Central Nervous System equipment. Active exercising while bed
Central nervous system function is al ridden or sitting and early ambulation
tered by immobilization (see Table 6.7). are encouraged. In this section, each
Electroencephalogram activity slows. stage of patient progression is addressed,
Emotional and behavioral changes de as well as methods to facilitate patient
velop, including emotional lability, re mobility. Emphasis is placed on func
gression in behavior to childlike pat tional activities.
terns, increase in anxiety and depression,
and decrease in attention span (Spencer Bedridden Patients
et al . 1965). Psychomotor performance
.
decreases in the areas of intellect, per Mobility of patients confined to bed is

ception and coordination. Visual and au not as severely restricted as might be ex
ditory changes occur (Greenleaf and pected. Hospital beds allow patients to be
Kozlowski. 1982). Sleeping patterns passively positioned in many ways when
change, with an increase in deep or delta the knee break, head elevation or head
sleep and an increased memory for down mechanisms are used. When bed
dreams (Hammer and Kenan, 1980). Fur position change is combined with postur
ther impairment of central nervous sys ing the patient over the range of supine
tem function is seen in the critically ill to prone, a wide spectrum of possible
patient due to a variety of contributing movements become available. Even Stry
factors. as outlined in Table 6.8. ker frames allow variations from either
Table 6.7
The Ellects of Immobilization on the Central Nervous System
Length of
Ellect Found Year/Researchers Population Studied
Immobilization
Slowing of 1963 Zubeck and 1 wk 22 male college students
electroencephalogram Wilgosh 1 wk 32 male college students
activity 1966 Zubeck and 62 days 6 healthy young men
MacNeill
1968 Petukhov and 5 wk 8 healthy young men
Purakhin
1971 Ryback et al.
Emotional and 1966 Zubeck and 1 wk 32 male college students
behavioral changes MacNeill Not known
1969 Boganchenko el al. 5 wk 8 healthy young men
1971 Ryback et al.
Decreased psychomotor 1953 Heron et aI.' Varied Not known
performance 1963 Zubeck and 1 wk 22 male college students
Wilgosh 5 wk 8 healthy young men
1971 Ryback et al.
Changes in sleep 1971 Ryback et al. 5 weeks 8 healthy young men
patterns
'This study combined immobilization with severe sensory deprivation.
Table 6.8 halo ring and cervical traction while on a Stry

Factors Leading to Central Nervous System ker frame. A manual muscle test following
Impairment in the Critically III alignment revealed paralysis below C5 on the
left and C6 on the right. For the first 2 weeks
Physical inactivity and restraint
following admission. the patien!"s course was
Sensory deprivation
unremarkable. Chest roentgenograms re
Loss of circadian light pattern
mained free of pulmonary pathology, and chest
Anesthesia and sedation
physiotherapy was performed only prophylac
Fever
tically. Improved pulmonary capabilities al
Hypoxia
lowed the patient to be extubated, following
Electroly1e imbalance
which a halo vest was applied to provide cer
vical stabilization. The patient was moved out
supine to prone and head up to head of the ICU to a step-down unit. During this time
the patient became progressively mentally de
down. Passive mobilization of patients
pressed; watChing television was his only
may be coordinated with other necessary interest.
ICU procedures. such as linen or dressing Eighteen days following his injury the patient
changes and skin and wound examina complained of shortness of breath and was
tion. As illustrated in Chapter 3, a wide tachypneic upon examination. A chest x-ray
variety of both patient and bed positions taken at that time demonstrated collapse of the
can be assumed, despite the presence left lung (see Fig. 6.2A), so chest physiotherapy
of monitoring equipment, intravascular was reinstituted. Prior to treatment, bronchial
lines and a mechanical ventilator. breath sounds were heard over the left upper
Passive positioning is necessary to lobe, while breath sounds were completely ab
maintain normal joint and muscle ranges. sent over the entire left lower lobe. The tech
niques used to treat this patient included
It also helps to counteract some of the
segmental postural drainage, percussion, vi
sofl-tissue and vascular changes seen bration, summed breathing and supportive
with prolonged bed rest. Based on this coughing (as described in the preceding chap
premise, the continuous passive motion ters). Due to the patien!"s dyspnea and fear,
(CPM) machine was developed to im treatment was initially given to the anterior seg
prove range of motion and tissue healing ment of the left upper lobe, the lingula and then
as well as decrease pain and edema fol the anterior segment of the left lower lobe. The
lowing joint replacement or repair (Frank patient tolerated the head-down position well
et aI., 1984). It is our experience that the but was unable to tolerate turning until the
CPM machine can be applied to patients more anterior lung fields were clear to auscul
tation. During the 95 min of chest physiother
while in the ICU; it should not be consid
apy, all left lung segments were eventually
ered a substitute for good bed positioning treated as turning became better tolerated.
since CPM treatment to the lower ex However, the halo vest made percussion to the
tremity restricts the patient to lying su superior segment of the left lower lobe inade
pine. CPM therapy can be temporarily quate. Throughout the treatment, large
discontinued when postural drai nage, amounts of sputum were expectorated, though
bed positioning, or oUI-of-bed activities no mucus plugs were noted. When breath
are necessary. sounds returned to normal, another chest x-ray
E xercise, ambulation, and altering a was taken (see Fig. 6.28).
patient's bed position can have a pro During discussion after this treatment. it was
found effect on ventilation, particularly discovered that the patient had been posi
tioned either supine or lying on the left side,
in the face of respiratory dysfunclion as since this allowed him optimal viewing of his
is often seen in the intensive care unit. It television. Subsequently, the television and the
may even markedly reduce the need for patient were both positioned from side to side
chest physiotherapy. This is exemplified (the patient was also placed prone and supine).
by the following case history: These changes in the patien!"s daily care were
enough to prevent further pulmonary compli
Case History 6.1. A 17-year-old male was cations throughout the rest of his hospital stay.
admitted with a cervical spine dislocation of C6. There is little doubt that this incident and the
Initial respiratory dysfunction necessitated tra need for vigorous chest physiotherapy could
cheal intubation and mechanical ventilation. have been avoided altogether if adequate bed
Anatomical reduction of the spinal malalign positioning and early patient mobilization had
ment was established and maintained with a been performed.
Figure 6.2. (A) A complete left lung atelectas is is shown in this radiograph taken ju st prior to
treatment. (8) After 95 min of chest physiotherapy the left lung has cleared. and the diaphragmatic,
hilar and superior mediastinal borders are visible. (The radiopaque device at the top of both x-rays
is the metal portion of the halo vest. The rest of the vest is not apparent radiologically.)
Central nervous system injuries are aged in patients with upper motor neu
often accompanied by abnormally in ron lesions. Footboards can often contrib
creased muscular tone, which is seen ute to abnormal posturing by the patient.
particularly in the antigravity muscles of since they stimulate the plantar surface
the neck, trunk, and limbs. When spasti of the foot and can only be effectively
city is present, the supine position is used while the patient is supine. Tennis
known to increase extensor tone (Bobath, shoes do not maintain the ankle in neu
1974). Side-lying, as shown in Figure 6.3, tral position and are associated with skin
has been found to diminish this abnor b reakdown. Instead, passive positioning
mal tone [peterkin, 1 969). Although foot to maintain joint motion should be en
boards and high-top tennis shoes are couraged, particularly with the patient in
often recommended to prevent plantar the side-lying or prone position.
flexion contractures, their use is discour- Serial casting is indicated to prevent
Figure 6.3. Side-lying is reported

to decrease abnormal muscle tone
in patients with central nervous
system injuries. Despite requiring
intracranial pressure monitoring
and controlled mechanical ventila
tion, this patient demonstrates how
range of motion can be altered
passively.
contracture formation i n brain-injured usually fixed to the base of the bed.

patients who demonstrate decreased Therefore, when patients are moved to
ankle motion despite passive movement ward the head of the bed or turned on the
and positioning. Ankle casting can be side, the footboard becomes nonfunc
used to maintain or regain functional tional. Ankle splints, on the other hand,
joint position and may decrease abnor are fixed to the patient and can provide
mal muscle tone (see Fig. 6.3). For pa joint support in all positions. Similarly,
tients with severe head injury who were Stryker frames are fitted with adjustable
casted in the leU, cylindrical casts are re footboards, which should be used to pre
ported less likely to result in skin break vent foot-drop while the patient is supine
down than bivalved casts (Imle et aI., (Fig. 6.4).
1986). Dropout casts may also be used, Quadriplegic and quadriparetic pa
particularly when casting is used along tients require specific bed positions to
with muscle reeducation. Patients with minimize or eliminate upper extremity
peripheral nerve injuries or complete contracture formation. Full shoulder ex
spinal cord lesions resulting in foot-drop ternal rotation and complete elbow ex
may benefit from footboards. Splinting tension are essential for wheelchair
coordinated with range of motion exer transfer activities in patients without tri
cises, is preferable to using a footboard ceps function. The Stryker frame can be
with bedridden patients. Footboards are easily adapted in the prone and supine
Figure 6.4. (A) Ankles passively assume plantar flexion in the bedridden patient. Though placing
fluid bags under the ankles relieves calcaneal pressure, it can also accentuate plantar flexion. The
footboard, just visible at the bottom of the bed, is of no benefit in maintaining dorsiflexion. (B)
Splinting combined with passive ankle movement is effective in decreasing foot-drop in patients
with peripheral nerve lesions. Prefabricated splints may be as effective and less expensive than
custom-made splints. (C) A custom-made foot plate and metatarsal pins are used to maintain ankle
and toe pOSit ion in a patient with a pe riph era l nerve injury from an open compound tibial fracture.
(0) The use of an adjustable footboard on a Stryker frame is helpful in maintaining ankle joint range.
CHANGES WITH IMMOBILITY AND M ETHODS OF MOBILIZATION 199
positions for upper extremity placement. is achieved by proper positioning of the

While the patient is in the prone position, arm in shoulder abduction and supina
the armboards can be moved as far cra tion in the initial weeks following injury.
nially as necessary to maintain 90' shoul While the quadriplegic patient is in the
der abduction and full external rotation l CU, full, pain free range of motion
with elbow flexion. While the patient is should be preserved in both the upper
in the supine position, placing the arm and lower extremities. This can be done
boards caudally allows shoulder external in conjunction with necessary chest
rotation and full elbow extension (Fig. physiotherapy maneuvers. Once the pe
6.5). Resting hand splints are also indi riod of spinal shock is over, a more ac-
cated initially, with complete neurologi
cal lesions above the C6-C7 level. Fre
quently, full elbow extension is difficult Table 6.9
to maintain due to unopposed biceps ac Functionat Ranges of Motion Necessary for
Quadriplegic Patients,
tivity. If this is the case, range of motion,
exercises and positioning should stress Motion C4,C5 C6
maximal elbow extension as well as full
movement of the other joints. Positioning Shoulder
of the shoulders and elbows to prevent Flexion 900 180
Abduction 90t:! 180
contracture formation is a particular
Internal rotation 90 70
problem on the Rota rest bed (Imle and External rotation 30 90
Boughton, 1987). Patients who are capa Elbow
ble of independently performing upper Flexion WNL:150 WNL
limb range of motion exercises or func Extension 0' O
tional activities do not require passive Forearm
positioning to preserve adequate range of Pronation 90
motion. For all complete neurological le Supination 90
sions, the ankles should be maintained Wrist
as stated above; fluid bags under the Flexion 40 60
Extension 40
ankle can reduce heel pressure Hip
effectively. Flexion 95
Wilson et al. (1974) found the range of Straight leg raises 100.0
motion capabilities, shown in Table 6.9.
to be necessary for function in the quad 'Adapted from Wilson et al. (1974).
riplegic patient. Guttman (1976) states "For C5 injured patients capable of using
swivel bars for transfers, 160 of shoulder flex
that upper extremity contractures in
ion and abduction are needed.
volving shoulder adduction and forearm 'WNL, within normal limits.
pronation can be prevented in patients Needed for dressing.
with spastic lesions of C5 and above. This
Figure 6.5. Quadriplegic patients require specific upper limb positioning to prevent contracture
formation. The correct arm placement and use of resting splints while the patient is prone is illus
trated in A. Proper extremity positioning of a supine patient is seen in B.
curate assessment of functional motor The second method is particularly help

level and corresponding range of motion ful in patients following thoracotomy
can be made. Our philosophy is in agree who are hesitant to move their trunk and
ment with that of Etter (1968), who states upper extremities. As a result, they are
that to save the life of a quadriplegic pa more likely to develop postural deformi
tient at the expense of further impairing ties and the frozen shoulder syndrome
already-limited function is to add an un (Howell and Hill, 1972). To combat this,
necessary burden to an already-devastat one arm may be used to assist the motion
ing situation. of the other, allowing increased shoulder
Passive range of motion should be mobility (shown in Fig. 6.7).
maintained in bedridden patients. Once Strength may be improved by adding
there is active participation in the de resistance to movement by using the ef
sired motions, active exercising becomes fect of gravity (Fig. 6.8), manual resist
possible. Because exercise increases both ance, or weights and pulleys. Weighted.
cardiovascular and respiratory demands, pulley systems allow resistance to be ap
repetitive exercises to increase strength plied to motions that gravity normally as
or endurance are not carried out in pa sists (see Fig. 6.9), while weights alone in
tients requiring high levels of FlO, and crease the load applied by gravity (see
PEEP with mechanical ventilation and Fig. 6.10). Manual resistance can be used
inotrophic support. However, these pa to apply constant pressure throughout a
tients can perform active exercises; func wide range of movement or provide
tional activities, such as rolling and po graded pressure at various points
sitioning, should be encouraged (see Fig. through an arch of motion. Pulleys may
6.6). When the need for mechanical ven also be used to reduce the effect of grav
tilation diminishes, more vigorous forms ity on a motion, thereby making it easier
of exercise are possible even during bed for the patient to actively achieve a
restriction. Patients immobilized due to greater range in a joint than would oth
spinal fractures or skeletal traction are erwise be possible (see Fig. 6.11). Endur
susceptible to respiratory problems and ance is improved by increasing the num
may benefit from active exercise pro ber of repetitions of any given exercise.
grams. In addition to increasing range of
motion, strength and endurance, these
exercises may diminish the need for fu
ture chest physiotherapy.
Range of motion can be improved by
the patient in two ways: stretching the
area of limitation by actively contracting
the opposing muscle groups or by passive
stretch applied by another extremity.
Figure 6.7. Following thoracic surgery, trunk

and shoulder mobility must be encouraged to
decrease deformity. By using a towel, this pa
Figure 6.6. This mechanically ventilated pa tient is able to assist her weaker arm (on the
tient is able to assist in her own bed positioning thoracotomy side) achieve increased range of
by using the side rails. motion.
Sitting
Patients can be passively positioned in

a chair even during mechanical ventila
tion. Transferring a totally dependent pa
tient to a chair usually involves a two-to
four-person lift (shown in Fig. 6.12).
Chest tube connections, monitoring
equipment, and intravascular lines
should be checked to determine that
there is sufficient slack before moving
the patient. Patients should be temporar
ily disconnected from the mechanical
ventilator while being transferred to pre
vent unnecessary trauma to the trachea.
Some patients requiring lower extremity
skeletal traction may transfer out of bed
to a chair. Traction is maintained by a
Figure 6.S. After sustaining an incomplete therapist as the patient performs a stand
cervical spine injury. this patient exhibited pivot transfer or is lifted into the chair.
upper extremity, trunk and pelvic weakness. The weights are then reconnected once
Active hip extension with gravity acting to in the patient is seated, as in Figure 6.13.
crease resistance is being performed in A and Due to loss of sympathetic control, pa
B. tients with spinal cord transection often
Figure 6.9. While supine, gravity normally assists shoulder and elbow extension, as well as shoul
der horizontal abduction. Pulleys can be used to resist these motions. (A) A handle that allows
movement through a wide range of motion is demonstrated. (B) Active shoulder and elbow exten
sion is performed. (C) Instruction in horizontal abduction exercises is demonstrated.
Figure 6.10. Weights can be used to increase the resistance of gravity in both upper and lower
limbs. Knee extensor muscles are being exercised in A and S. C and 0 demonstrate elbow exten
sion exercises. Note that the presence of a left radial arterial line does not prohibit the use of cuff
weights or exercise.
Figure 6.11. The weight of ortho

pedic hardware or the strength re
quired to move an extremity across
bed linen may hinder active motion.
Pulley systems can be used to de
crease these effects, as illustrated
in A and S, in which the patient per
forms active-assistive hip adduc
tion and abduction.
Figure 6.12. (A) Some patients are unable to assist with transfers because of their injuries. This
patient sustained a severe brain injury and required abdominal surgery and orthopedic external
fixation. To perform a dependent transfer, the patient is first moved to the side of the bed nearest
the chair. Chairs may need to be placed on the same side of the bed as the mechanical ventilator
to ensure adequate length of ventilator tubing. Elevation of the right leg is interrupted during the
transfer. (6) With one person supporting the head and shoulders, another at the hips, and a third
supporting the lower extremities, the patient can be lifted into a chair. Note that the patient is mo
mentarily disconnected from the respirator during the transfer to minimize tracheal trauma. (C) As
the patient is settled in the chair, mechanical ventilation is resumed and the right leg is again ele
vated to minimize edema.
exhibit hypotension when sitting is ini and abdominal support. When properly
tiated. This response can be minimized applied, binders may increase vital ca
by wrapping the lower extremities with pacity, inspiratory capacity, and tidal
elastic bandages from the toes to the volume, particularly when worn while
groin before moving the patient. Abdom sitting (Maloney, 1979; Goldman et aI.,
inal binders or corsets may be used in pa 1986; McCool et al. ,1986).
tients with quadriplegia to provide trunk For patients who must spend a period
elastic wraps (as described above), the

head of the bed is elevated approxi
mately 20'. In the absence of hypoten
sion, the incline may be gradually in
creased until the limits of the bed are
achieved. When this posture can be
maintained for 30 min or longer, the pa
tient is ready to be transferred to a reclin
ing-back wheelchair. If at any stage the
patient is unable to tolerate this progres
sion to sitting, the head of the bed or back
of the wheelchair may be reclined to an
acceptable level. Initially, elevation of
the lower extremities may be necessary.
Once in a wheelchair, the time spent in
this position may be increased by 30-
minute intervals. Since skin sensation is
decreased or absent, it is advisable to use
a 4-inch high-density foam cushion to
better distribute skin pressure and pre
vent decubitus u lcer formation. A cutout
seat board may also be used to further re
duce ischial weight bearing and improve
trunk stability. Weight shifting from side
Figure 6.13. Traction is maintained while the to side or other methods of ischial pres
patient is out of bed by placing the traction sure relief must be instituted. Sitting in a
rope and weight over the back of a chair. The slouched position is discouraged, since it
patient must be held securely in the seat at the allows greater pressure over the sacrum.
hips to prevent slouching and loss of traction. Ischial tuberosity and sacral areas should
For most patients, traction must be maintained
constantly, yet extremity elevation (shown in always be examined following sitting.
Fig. 6.12) may be interrupted during a transfer. Patients in the ICU are encouraged to
assume the sitting posture either inde
pendently or with assistance. Once a pa
of time on bed-rest, such as those with tient can maintain sitting balance over
spinal cord injury, assuming the erect the side of the bed, as shown in Figure
posture by using a tilt-table is described. 6.14, transferring to and from a chair or
However, it is questionable if there is any bedside commode is possible. If a patient
advantage, psychological or physical, to cannot coordinate moving from the bed
placing a patient who is not a candidate to a chair, assistance may be necessary,
for ambulation in the standing position as i l l ustrated in Figure 6.15. Proper body
for short periods of time. Tilt-tables are mechanics should always be used by
not routinely found in the intensive care those persons transferring a patient. As
setting, are nearly as large as a bed, and sistive devices, such as a walker or over
can interfere with monitoring lines and head trapeze should be used as the pa
equipment. TiIt-tables also maintain the tient's condition and the environment
lower limbs in a markedly dependent po allow.
sition, which may facilitate a hypoten Once the patient is sitting, passive po
sive response. As a result, postponement sitioning or exercises may be performed
of sitting, until a patient can be trans to increase range of motion, strength or
ported to a physiotherapy department endurance. At rest, ankle joint motion
having a til t-table, may be detrimental should be passively maintained in a neu
and i ncrease rehabilitation time. Instead, tral position; footrests or stools may be
progressive sitting should begin in the helpful. Alternatively, if legs are ele
ICU as soon as the patient with spinal vated while the patient is sitting, tight
cord injury is allowed to sit up. Following hamstring or low back extensor muscles
application of an abdominal binder and may be stretched passively. However, pa-
Figure 6.14. (A) Sitting up from a su

pine position may require assistance.
Unassisted sitting balance (8 and C) is
necessary prior to performing inde
pendent transfers to a chair or bed
side commode.
tients with increased extensor tone similar to those described for use while
should be seated with the hips and knees the patient is bedridden. Weights or man
in at least 90' of flexion to minimize this ual resistance may be used to increase
effect. Serial casting of the ankles may the work being performed. Again. the ef
still be necessary. These patients also fect of gravity can be used to increase re
tend to demonstrate hip adductor Ught sistance. Patients should be instructed to
ness. which may be reduced by placing a perform chair push-ups to relieve ischial
rolled sheet or blanket between the pa tuberOSity pressure and strengthen the
tient's thighs. Again. slouched sitting upper extremities. Armrests are neces
should not be allowed. In addition to sary to perform chair push-ups in which
causing sacral pressure. it may result in the patient bears minimal to total body
increased trunk and lower extremity ex weight on the armrests. then extends the
tensor tone and the likelihood of the pa elbows and depresses the shoulders. lift
tient sliding out of the chair. To encour ing the gluteal area from the seat of the
age upright sitting and for patient safety. chair. This exercise is especially benefi
a securing strap can be placed across the cial for patients with spinal cord injury or
hips and around the chair (it should not those in whom future use of crutches or
be positioned around the waist). Chair a walker is indicated.
inserts are indicated for many patients
with brain injury and abnormal muscle Standing and Ambulating
tone. The inserts should be fitted with
adjustable trunk and head supports to When allowed. standing and ambula
improve sitting posture and stability. For tion should be encouraged. In general.
patients with poor balance reactions. patients who are unable to maintain sit
proper placement of a bedside table may ting balance should not be expected to be
provide additional trunk support. en able to walk without assistance. Standing
courage normal equilibrium responses. balance is also a prerequisite for inde
and increase proprioceptive input by al pendent ambulation. For patients who
lowing some weight bearing through the cannot bear full weight on one lower ex
elbows and shoulders (see Fig. 6.16). tremity (for example. a patient with a
Exercises to increase strength and en lower limb fracture or soft-tissue injury).
durance while the patient is sitting are a walker or crutches may be used. Intra-
Figure 6.15. Following a craniotomy and upper extremity fracture, this patient requires assistance
in transferring to a chair. (A) The therapist prepares to support the patient at the waist by means
of a belt as the patient grasps the far armrest of the chair. (6) The patient stands with the support
of the therapist and pivots until the chair is directly behind . (C and 0) The therapist assists in low
ering the patient onto the chair and then moving the hips back into the chair.
vascular lines do not prevent ambula They may be fi xed to the base of the roll
tion; they may be attached to a rolling in ing pole or walker during ambulation
travenous (IV) pole. Electrocardiogram (see Fig. 6.1 8). The need for supplemental
leads and arterial or central venous pres oxygen or humidity does not hinder mo
sure lines may be temporarily discon bilization. Oxygen tanks with added hu
nected from the recording module during midification (as used in the transporta
ambulation. At the physician's discre tion of patients) may be secured to a
tion, chest tubes and abdominal sumps standard walker or IV pole (see Fig. 6.19).
may be disconnected from wall suction Walkers that provide attachments for ox
to allow increased mobilization (see Fig. ygen tanks are available commercially;
6 . 1 7 ). As in other situations, collection walkers fitted with IV poles, oxygen and
bags from indwelling urinary catheters respirators have been described in the
are always kept lower than the bladder. literature (Burns and Jones, 1975).
Figure 6.16. (A) The chair back is reclined to provide increased trunk support, yet 90 of hip and
knee flexion are maintained by using a wedge in the seat and a roll under the feet. A bedside table
is placed uner the arms and raised to provide greater trunk and shoulder stability, thereby improv
ing the patient's head control. A sheet is tied across the hips for safety and to prevent slouching.
(B) A seat insert is used for patients requiring additional support. Chest cross straps are applied
in addition to a seat belt and lateral head supports are used. An effort is made to provide optimal
support for the brain-injured patient during sitting. The goal is to decrease abnormal posture and
muscle tone in order to allow more normal movement and respiratory patterns.
It has been our experience that early neither deep breathing exercises nor in
mobilization of patients often diminishes centive spirometry demonstrated benefit
the need for long or vigorous chest phys over the effects of early patient mobili
iotherapy. Spontaneous coughing follow zation (Dull and Dull, 1 983). Likewise,
ing exercise or exertion is common, and Frolund and Madsen (1986) found no
chest physiotherapy usually is not added benefit from positive expiratory
needed once routine walking is possible. pressure over chest physiotherapy that
In reviewing the study by Howell and primarily consisted of early mobilization
Hill, it was noled that increased patient and breathing exercises in 75 patients
mobilization, following open heart sur after thoracotomy. Both bed mobility and
gery, coincided with a decreased need for ambulation were included in the chest
chest physiotherapy. This same principle physiotherapy regimen used by Warren
is alluded to by Sternweiler (1968) in the and Grimwood (1 980). They reported
physiotherapy treatment of a patient fol fewer pulmonary complications in cho
lowing heart transplantation. A day after lecystectomy patients who received
the patient was allowed to sit up, lung chest physiotherapy. Patients undergoing
bases showed increased air entry and hysterectomy who received breathing
were free of crackles for the first time. exercises toward maximal inspiration
Chu lay et al. (1982 ) reported a decrease were found to have no additional benefit
in postoperative fever and ICU stay in pa compared to those encouraged to breathe
tients who were turned every 2 hrs for deeply and to ambulate (Giroux et aI.,
the first day after coronary artery bypass 1987). Similarly, Schwieger et al. (1986)
su rgery. In a similar patient population, reported no added benefit from incentive
Figure 6.17. (A) In preparation for ambula

tion, electrocardiogram leads may be discon
nected from the recording patches. (6) If arte
rial or central venous pressure catheters are
used, the transducers can usually be un
plugged from the manifold while the patient is
walking. (C) Abdominal sumps or drains may
also be disconnected from suction for short
periods of time.
spirometry in 40 patients who were mo finding that mobilizing a patient (from

bilized on the same day as their chole supine to sidelying or out of bed to a
cystectomy. From these studies it ap chair) often leads to spontaneous cough
pears that early patient mobilization, ing and improved breath sounds. In some
including ambulation, is a good form of instances, retained secretions and their
prophylaxis against postoperative secre sequelae are unresponsive to both chest
tion retention. physiotherapy and other methods of
For physical therapists, it is a routine clearance, yet pulmonary improvement
Figure 6.18. (A) Intravascular fluid bags are secured to a rolling IV pole prior to ambulation. Note
that the urine collection bag is attached to the pole below the level of the bladder. (8) Proper pos
ture is encouraged in this patient following surgery for liver lacerations and a ruptured diaphragm
and spleen. (C) The patienfs balance is controlled by using a waist belt while walking.
Figure 6.19. (A) Patients requiring supplemental oxygen and humidity can be ambulated. Walkers
are helpful in improving patient stability, especially in the elderly and debilitated. (8) Oxygen tanks
can be secured to rolling IV poles, as shown. The urine collection bag can also be attached to a
walker below the level of the bladder.
Figure 6.20. (A) Though this patient demon

strated recurrent bilateral infiltrates, a com
plete left lower lobe atelectasis occurred 3
weeks following admission (note the left air
bronchogram and loss of the left diaphragmatic
shadow). (8) The x-ray following treatment 10
the left basilar segments (including postural
drainage, percussion and suctioning but not vi
bration) showed clearing of this area but also a
right lower lobe collapse. Because of the
" ping-ponging" of secretions, therapeutic
bronchoscopy was performed rather than a
E second treatment of chest physiotherapy. (C)
Three hours after bronchoscopy, atelectasis of
both lower lobes and decreased aeration of the
left lung were radiologically apparent. None of these events corresponded with temperature ele
vations. Throughout the following week the patient's chest roentgenogram remained as shown in
D. Once the patient no longer required mechanical ventilation, the tracheostomy tube was re
moved. and walking was encouraged. (E) The following chest x-ray demonstrates improved aera
tion of both lung fields despite fluid persisting in the right major fissure.
has been noted to follow increased pa agnoses of a closed head injury with intrace
tient mobility. This is demonstrated by rebral hemorrhage, bilateral multiple rib frac
the following case history: tures with left flail chest, extra pleural
hematoma, and fractured left clavicle were
Case History 6.2. A 77-year-old-female was made. Respiratory management included tra
admitted following an automobile accident. Di- cheal intubation and use of intermittent man-
datory ventilation with positive end-expiratory SUMMARY

pressure throughout the patient's 1 month stay
in the critical care unit. Neurological improve Physiological alterations and second
ment was satisfactory, but generalized weak ary disabilities occur with immobiliza
ness resulted. During this same Interval, inter tion. In patients requiring intensive med
mittent infiltrates were present in both lung ical care, mobilization is found to be both
bases radiologically. These cleared periodically possible and advantageous. With fore
with chest physiotherapy and were unrespon sight, optimal patient mobility can be
sive to fiberoptic bronchoscopy (see Fig. achieved without interruption of moni
6.20A-C). Although the patient was turned rou
tinely and allowed to sit in a bedside chair, toring or l i fe-sustaining equipmenl. Pas
walking was not encouraged until ventilatory sive range of motion, postural changes
support was discontinued. On the same day and even active exercise can be incorpo
that the patient began breathing independently, rated into the care of the critically ill pa
her tracheostomy tube was removed; the tient to minimize the detrimental effects
stoma was covered with an occlusive dressing. of bed res I. Limited additional supplies
Cough effectiveness increased and ambulation are needed to provide these aspects of pa
with a walker also commenced. Subsequent tient care. It should be emphasized that
roentgenograms showed increased aeration of the methods of patient mobilization that
both lower lobes (see Fig. 6.20D-E). Continued are outlined not only counteract the com
radiological evidence of improvement coin
cided with increased ambulation and mobiliza plications' addressed at the beginning of
tion of the patient. this chapter, but also decrease rehabili
tation time and, therefore, the total hos
pital stay of a patienl.
Equipment Used for Mobilization
References
Minimal supplies, in addition to equip
Akeson WH: An experimental study of joint stiff
ment normally found in an intensive care ness. / Bone Joint Surg (AmI 43:1022-1034, 1961
selting, are necessary to maximize pa Akeson WH, Woo SL. Arniel D, Coutts RD, Daniel
lient mobilization. Plastic in Ira venous 0: The connective tissue response to immobility:
infusion bags, as well as cuff and dumb Biochemical changes i n periarticular connective
tissue of the immobilized rabbit knee. Clin Or
bell weights can be used 10 provide resis
.hop 93:35&-362, 1973
tive exercises. Cuff weights are advanta Akeson WHo Woo SL. Arniel D, Matt hews IV: Bio
geous, when available, because they are mechanical and biochemical changes in the peri
easily applied and cannot be dropped by articular connective tissue during contracture de
the palienl. However, they are not a ne velopment in the immobilized rabbit knee.
Connect Tissue Res 2:31 5-323. 1 974
cessity. Pulley systems can be adapted Amiel D. Woo SL. Harwood FL. Akeson WH: The
from standard overhead traction units, effect of immobilization on collagen turnover in
along with the ropes, weights and pulleys connective tissue: A biochemical-biomechanical
normally utilized in applying orthopedic correlation. Acla Orfhop Scand 53:325-332. 1 982
Iraction. Safety belts, used for Iransfer Bassey EJ, Fentem PH: Extent 01 deterioration i n
physical condition during postoperative bed rest
ring palients to a chair or when assisting and its reversal by rehabilitation. Sr Med J 4:194-
ambulation, are available commercially 1 96. 1 974
and can be used repeatedly. Adjustable Beckett \VS. Vroman NB. Nigro D. Thompson-Gor
walkers and crutches can be measured man S. Wilkerson IE. Fortney SM: Effect of pro
longed bed rest on lung volume in normal indi
and altered to fit different patients. Roll viduals. 1 AppJ Physio! 61: 91 9-925. 1986
ing IV poles and sources of supplemental Behrakis PK. Baydur A. Iaeger MJ, Milic-Emili J :
oxygen and humidity are available to any Lung mechanics i n sitting a n d horizontal body
ICU. Reclining-back wheelchairs with el positions. Chesl 83:643-646. 1983
evating leg rests are helpful for improv Bendixen HH: Editoral Comment. Arch Surg
109:541 . 1 974
ing silting lolerance in patients who dem Birkhead NC. Haupt GJ, Myers RN: Effect of pro
onslrate orthostatic hypotension. For longed bed rest on cardiodynamics. Am J Med Sci
facilities that normally treat patients 245: 1 18-119. 1 963
with spinal cord and head injury, high Bobath B: Adull Hemiplegia: Evaluation and Treat
ment. p. 79. William Heinemann Medical Books.
back chairs and adjustable inserts are London. 1974
recommended to increase trunk and Boga nchenko VP: Slate of psychic activity i n sub
head supporl. jects during prolonged confinement to bed. Probl
Kosm 8ioI 1 3 : 1 7 1 - 1 74, 1 969 (as cited in Greenleaf on physical performance. Acla Med Scand
et al.. 1976) 205:389-393. 1979
Brannon EW. Rockwood CA. Potts P: The influence Frolund L. Madsen F: Self-administered prophylac
of specific exercise in the prevention of debilitat tic postoperative positive expiratory pressure in
ing muscu loskeletal disorders: Implication in thoracic surgery. Acta Anaesthesiol Scand
physiological conditioning for prolonged weight 30:381-385. 1 986
lessness. Aerospace Med 34:900-906, 1963 Georgiyevskiy VS, Mikhaylov 8M: Effect of hypo
Browse Nl: The Physiology and Palhology of Bed kinesia on human circulation. Kosm Bioi Avia
rest, pp 29-31. 159-190. Charles C Thomas. kosm Med 2:48-51 . 1968 (as cited in Greenleaf et
Springfield. IL. 1 965 al.)
Burkhart JM. Jowsey J: Parathyroid and thyroid hor Giroux 1M, Lewis S. Holland LG, Black EE. Gow SA.
mones in development of immobilization osteo Langlotz 1M. Pomfret ME. Vanderkooy CL: Post
porosis. Endocrinology 8 1 : 1 053-1062, 1 967 operative chest physiotherapy for abdominal
Burns JR. Jones FL: Early ambulation of patients re hysterectomy patients. Physioth Can 39:89-93.
quiring ventilatory assistance (letter). Chesl 1 987
68:608. 1975 Glazier lB. Hughes JM. Maloney fE, West JB: Verti
Cardus D: O2 alveolar-arterial tension difference cal gradient of alveolar size in lungs of dogs fro
afler 1 0 days recumbency in man. I AppJ PhysioJ zen intact. I Appl PhysioI 23:694-705. 1967
23:934-937. 1 967 Goldberg AL: Mechanisms of growth and atrophy of
Chase GA, Grave C, Rowell LB: Independence of skeletal muscle. In Muscle Biology. edited by RG
changes i n functional and performance capacities Cassens. pp 89-1 18. Marcel Dekker. New York.
attending prolonged bed rest. Aerospace Med 1972
37:1 232-1238. 1 966 Goldman 1M. Rose LS. Williams 51. Silver fR. Den
Chulay M. Brown J . Summer W: Effect of postoper ison OM. Effect of abdominal binders on breath
ative immobilization after coronary artery bypass ing in tetraplegic patients. Thorax 4 1 :940-945,
su rgery. Cril Core Med 10:1 76-179. 1 982 1 986
Clauss RH, Scalabrini BY, Ray. JF. Reed GE: Effects Greenleaf IE. Kozlowski 5: Physiological conse
of changing body positions upon improved ven quences of reduced physical activity during bed
tilation-perfusion relationships. Circ (Supp/ 2) rest. Exerc Sporl Sci Rev 10:84-119, 1982
37:214-218. 1 968 Greenleaf lE. GreenleafCJ, Van Derveer 0, Dorchak
Craig DB. Wahba WM, Don H: Airway closure and KJ: Adaptation to prolonged bedrest in men: A
lung volumes in surgical positions. Con Anaesfh compendium of research. NASA Tech Memo
Soc / 1 8:92-99. 1971 TMX-3307. 1976
Craig 10. Bromley LL. Williams R: Thoracotomy Grossman MR. Rose SJ. Sahrmann SA, Katholi CR:
and the contralateral lung. A study of the changes Length and circu mference measurements in one
occurring in the dependent and contralateral lung joint and multi joint muscles in rabbils after im
during and after thoracotomy in lateral decubi mobilization. Phys Ther 66:51 6-520. 1986
tus. Thorax 17:9-15. 1962 Guttman L: Spinal Cord Injuries: Comprehensive
Dalen JE. Paraskos lA, Ockene IS. Alpert JS. Hirsh J: Management and Research, 2nd ed, p 565. Black
Venous thromboembolism scope of the problem. well Scientific Publications. Oxford, 1976
Chest 89(SuppI P 70S-373S. 1986 Hammer RL. Kenan EH: The psychological aspects
Deitrick IE. Whedon GO. Shorr E, Toscani V, Davis of immobilization. In The Immobili7..ed Palient.
VB: Effects of immobilization upon various met edited by FV Steinberg, pp 1 23-149. Plenum
abolic and physiologic functions of normal men. Medical Book Company. New York, 1980
Am / Med 4:3-36. 1948 Hansson TH, Roos BO, Nachemson A: Development
Donaldson CL. Hulley SB. McMillan DE. Hallner of osteopenia in the fourth lumbar vertebrae dur
RW, Bayers JH: The effect of prolonged simulated ing prolonged bed rest after operation for scolio
non-gravitational environment on mineral bal sis. Acla Orlhop Scond 46:621 -630, 1975
ance in the adult male. NASA Contraci CR- Heilskov NC. Schoriheyder F: Creatinuria due to
108314. 1 969 immobil ization in bed. Acla Med Scond 151;51-
Dull lL. Dull WL: Are maximal inspiratory breath 56, 1955 (as cited in Greenleaf et al.)
ing exercises or incentive spirometry better than Heron W, Bexton WHo Hebb DO: Cognitive effects
early patient mobilization after cardiopulmonary of a decreased variation to the sensory environ
bypass? Phys Ther 63:655-659, 1983 men!. Am Psychol 8:366, 1953
Enneking WF. Horowitz M: The intra-articular ef Hirschberg GG. Lewis L. Vaughan P: Promoting pa
fects of immobilization on the human knee. I tient mobility and other ways to prevent second
Bone loint Surg IAm1 54:973-985. 1972 ary disabilities. Nursing '77 7:42-46, 1977
Estenne M. Yernault J, DeTroyer A: Rib cage and Howell 5, Hill 10: Acute respiratory care in the open
diaph ragm-abdomen compliance in humans: Ef heart surgery patient. Phys Ther 52:253-260, 1972
fects of age and posture. I Appl Physio' 59:1842- Hulley SB. Vogel JM. Donaldson CL. Bayers JH.
1848. 1 985 Friedman RJ. Rosen SN: The effect of supplemen
Etter MF: Exercise for the Prone Patient, p 7. Wayne tal oral phosphate on the bone mineral changes
State University Press, Detroit. 1968 during prolonged bedrest. I Clin Invest 50:2506-
Frank C. Akesan WH, Woo SL. Amiel D. Dip.lng MS, 2518, 1971
Coutts RD: Physiology and therapeutic value of 1m Ie PC, Eppinghaus CEo Boughton AB: Efficacy of
passive joint motion. Clin Orlhop ReI Res nonbivalved and bivalved serial casting on head
185: 1 1 3-125. 1 984 injured patients in intensive care (abstract). Phys
Friman G: Effect of clinical bed rest for seven days Ther 66:748. 1 986
(mle PC. Boughton AC: T h e physical therapist's role fixation of long bone fractures in patients with
in the early management of acute spinal cord in multiple injuries. } Tra uma 1 7 : 1 1 1 - 1 2 1 . 1977
jury. Top Acufe Care Trauma Rehabil 1 :32-47, Ryback RS, Lewis OF. Lessard CS: Psychobiologic
1987 effects of prolonged bed rest (weightless) in
Kottke FJ: The effects of limitation of activity upon young. healthy volunteers (study II). Aerospace
Ihe human body. lAMA 1 96:625-630. 1 966 Med 42:529-535. 1971
Krasnykh IG: (nnucnce of prolonged hypodynamia Saltin B. Blomqvist G. Mitchell HH. Johnson RL I r,
on heart size and the functional slate of the myo Wildenthal K. Chapman CB: Response to exercise
cardium. Probl Kosm BioI 13:65-71. 1969 (as cited after bed rest and after training. A longitudinal
in Greenleaf et al.) study of adaptive changes in oxygen transport
Kreiner B. Toft B: Vertebral boneless: An unheeded and body composition. Circ (Suppl 7) 36:1-76.
side effect of therapeutic bed rcst. Clin Sci 64:537- 1966
540. 1963 Schwieger I. Gamulin Z. Forster A. Meyer P. Cem
Lamb LE. Johnson RL. Stevens PM. Welsh BE: Car perle M. Suter PM: Absence of benefit of incen
diovascular decondilioning from space cabin sim tive spirometry in low-risk patients undergoing
ulator confinement. Aerospace Med 35:420-428. elective cholecystectomy. Chest 69:652-656,
1964 1966
Lambert RL. WHlauer G. Dasch FW: Postoperative Sevilt S. Gallagher N: Venous thrombosis and pul
status of dependent lung. } Thorac Cardiovasc monary embolism. A clinicopathological study in
Surg 30:713-718, 1955 injured and burned patients, Br J Surg 48:475-
LeBlanc p, Ruff F. Milic-Emili J: Effects of age and 469. 1961
body posilion on "airway closure" in man. 1 Appl Spencer WA. Vallbona C. Carter RE: PhysiologiC
Physio! 28:448-451. 1 970 concepts of immobilization. Arch Phys Med
Lopes I . Russell OM. Whitwell I. Jeejeebhoy KN: Rehab 46:69-100. 1 965
Skeletal muscle funelion in malnutrilion. Am J Stern weiler MR: Physiot herapy and the South Af
Clin Nulr 36:602-610. 1962 rican heart transplant patient. Phys Ther 48:1 399-
Mack PB. Montgomery KB: Study of nitrogen bal 1406. 1966
ance and creatine and creatinine excretion dur Stremel RW. Convertino VA. Bernauer EM. Green
ing recumbency and ambulatian of five young leaf JE: Cardiorespiratory decondilioning with
adult human males. Aerospace Med 44:739-746. static and dynamic leg exercise during bed rest. }
1973 Appl Physio/ 41 :905-909. 1976
Mackenzie CF. Shin B. Fisher R. Cowley RA: Two Svanberg L: (nnuence of posture on the lung vol
year mortality in 760 patients transported by heli umes. ventilation and circulation in normals.
copter di rect from the road accident scene. Am Scond I Clin Lab Invesl 25(Suppl):7-17. 1957
Surg 45:101-108. 1979 Taylor HL. Eridson L. Henschel A. Keys A: Effect
Maloney FP: Pulmonary function in quadriplegia: of bed rest on the blood volume of normal young
Effects of a corset. Arch Phys Med Aehobil 60:261- men. Am J Physio! 144:227-232. 1945
265. 1979 Taylor HL. Henschel A. Brozek I. Keys A: Effects of
McCool FD. Pichurko BM. Slutsky AS. Sarkarati M. bed rest on cardiovascular function and work per
Rossier A. Brown R: Changes in lung volume and formance. } App! Physio! 2:223-239. 1 949
rib cage configuration with abdominal binding in Triebwasser JH. Fasola AF. Stewart A. Lancaster
quadriplegia. I Appl Physiol 60: 1 1 96-1202. 1 966 Me: The effect of exercise on the preservation of
Oldenburg FA. Dolovich MO. Montgomery JM. orthostatic tolerance during prolonged immobili
Newhouse MT: Effects of postural drainage. ex zation. Aerospace Med Assoc Preprints 65-66.
ercise and cough on mucus clearance in chronic 1970
bronchitis. Am Rev Aespir Dis 1 20:739-745. 1979 Vellody VP. Nassery M. Druz WS. Sharp IT: Effects
Patel AN. Razzak ZA. Dastur OK: Disuse atrophy of of body position change on thoracoabdominal
human skeletal muscles. Arch NeuroI 20:413-421. motion. } Appl Physio! 45:561 -569. 1978
1969 Vogt FB. Mack PB, Johnson PC. Wade L: Tilt table
Peacock EE: Comparison of collagenous tissue sur response and blood volume changes associated
rounding normal and immobilized joints. Surg with rourteen days of recumbency. Aerospace
Forum 1 4:440-441 . 1 963 Med 36:43-46. 1 967
Peterkin IiW: The neuromuscular system and the Wade QL. Gilson I e: The effect of posture on dia
re-education of movement. Physiofherapy phragmatic movement and vital capacity in nor
55:145-153. 1 969 mal subjects with a note on spirometry as an aid
Petukhov BN. Purakhin YN: Effect of prolonged in determining radiological chest volumes. Th(}
bed rest on cerebral biopotentials of healthy sub rax 6:103-126, 1951
jects. Kosm BioI Med 2:56-61. 1968 (as cited in Ward RJ. Tolas AG. Benveniste RI. Hansen 1M. Bon
Greenleaf et al.l ica JJ: Effect of posture on normal arterial blood
Ray IF. Yost L. Moallemsanoudos GM. Villamena P. gas tensions in the aged. Geriatrics 2 1 : 1 39-143.
Paredes RM. Clauss RH: Immobility. hypoxemia. 1 966
and pulmonary arteriovenous shunting. Arch Warren CPW. Grimwood M: Pulmonary disorders
Surg 109:537-541 . 1974 and physiotherapy in patients who undergo cho
Reed IH. Wood EH: Effect of body position on ver lecystectomy. Can } Surg 23:384-386. 1 960
tical distribution of pulmonary blood now. J App! Wenger NK: Early ambulation: The physiologic
PhysiO! 28:303-31 1 . 1 970 basis revisited. Adv Cordial 31:136-141. 1982
Risks EO. von Bonsdorff H. Hakkinen S. Jaroma Ii.
Kivil uoto O. Paavilainen T: Primary operative Wilson OJ, McKenzie MW. Barber LM: Spina! Cord
lnjury-A Trea tment Guide for Occupalionol Zubeck Jr. MacNeill M: Effects of immobilization:
Therapists. p 24. CB Slack. Thorofare. NJ. 1974 Behavioural and EEC changes. Con J Psychol
Yeremin AV, Bazhanov VV, Marishchuk VL. Sle 200316-336, 1966
panLsov VI, Ozhamgarov TT: Physical condition Zubeck JP. Wi lgosh L: Prolonged immobilization of
ing for man under conditions of prolonged hypo Ihe body: Changes in performance and in
dynamia. Probl Kosin Bioi 13:192-199, 1969 (as Ihe electroencephalogram. Science 140:306-308,
cited in Greenleaf et 81.) 1963
CHAPTER 7
Physiological Changes Following

Chest Physiotherapy
The Effects of Chest Physiotherapy

Arterial Oxygenation in Mechanically Ventilated Patients
Arterial Oxygenation in Spontaneously Breathing Patients
Total Lung/Thorax Compliance
Sputum Volume Production in Tracheally Intubated Patients
Cardiac and Respiratory Function
Mass Spectrometry Analysis of Expired Gases
Analysis of Chest Physiotherapy Data
Factors Influencing Physiological Measurement in the ICU
Facto,s Influencing Analysis of Data from Different ICUs
Long-Term Follow-up
Role of Collateral Ventilation in Gas Exchange with Obstructed Airways
Synthesis of Mechanisms of Action and Hypothesis for Benefit from Chest
Physiotherapy
Generally Accepted Statements
Suggested Questions That Need Answering
What Physiological Measurements Are Required and How Should They Be Made?
National Heart, Lung and Blood Institute Conferences of 1974 and 1979
1974 National Heart and Lung Institute Conference
1979 National Heart, Lung and Blood Institute Conference
In this chapter the author's investiga The need for objective assessment of
tional approach to clinical measurement maneuvers designed to remove secre
of the effects of chest physiotherapy is tions from the tracheobronchial tree is
described, and the problems encountered apparent from the variety of techniques
are discussed. As a result of this experi and claims described in the literature.
ence and that of others, some generally The ever-rising cost of these maneuvers
accepted statements concerning chest and their increasing contribution to the
physiotherapy are enumerated and pos overall cost of medical care make inves
sible mechanisms for chest physiother tigation of their benefits of great eco
apy action are postulated. The 1974 and nomic importance. However, before ob
1979 American Thoracic Society-spon jective assessment can be made, the best
sored conferences on the scientific basis indicators of beneficial change following
of respiratory therapy are summarized, these maneuvers must be decided. Once
and their conclusions concerning the re these indicators are identified, the factors
quirements and methods of physiological that influence their measurement can be
measurement are discussed. considered.
215
THE EFFECTS OF CHEST gen (PaO,/FIO,), for the same 14 patients

PHYSIOTHERAPY is shown in Figure 7.2. A PaO,/FIO, of
250 is approximately equivalent to a 15%
Arterial Oxygenation in Mechanically intrapulmonary shunt. A shunt of less
Ventilated Patients than 1 5% (greater than 250 PaO,/FIO,) is
one of the prerequisites often used for
In 1975-76, 47 patients who were me weaning from mechanical ventilation. It
chanically ventilated with positive end appears from the data that in some pa
expiratory pressure (PEEP) (5-10 cm tients, PaO,/FIO, is increased to above
H,O) were prospectively studied before 250 with chest physiotherapy. If these in
and after chest physiotherapy, to deter dicators are used to determine the need
mine changes in arterial oxygenation for mechanical ventilation, chest phys
(Mackenzie et al" 1978a). The 47 patients iotherapy should reduce the duration of
showed a variety of chest x-ray changes mechanical support.
before therapy, including atelectasis, All of the 47 patients studied to deter
pneumonia, or lung contusion. Eight of mine PaO, changes also had portable
the 47 patients were non trauma cases chest x-rays taken before chest physio
and had multiple pathology, as can be therapy. Radiological follow-up occurred
seen in Table 7.1. The 39 patients who within 38 hr in all instances, although in
suffered trauma also showed other pa the majority, chest x-ray was taken
thology, such as chronic lung or heart within 6 hr of the completion of chest
disease, but it was found less frequently physiotherapy. Unilobar lung pathology
than in the non trauma group. No signifi showed radiological improvement in
cant changes in partial pressure of arte 74% (20/27) and multilobar pathology
rial oxygen (PaO,) could be found after improvement in 60% (1 2/20). These find
analysis using the paired I-test (Fig. 7.1). ings are similar to those obtained by fi
There was also no difference in PaO, be beroptic bronchoscopy in patients resis
fore and after physiotherapy, between tant to routine respiratory therapy
patients with or without trauma or be (Lindholm et aI., 1974) and demonstrate
tween those treated with or without that by using either technique, a local
head-down postural drainage. ized lesion is more easily changed than a
For the last 14 patients studied, PaO, generalized one.
and total lung/thorax compliance (CT) Although most of this information
were simultaneously measured. The raw is not novel, it confirms our clinical im
compliance data are shown in Table 7.2. pression that in patients who are me
As can be seen from the raw data, CT rose chanically ventilated with PEEP, chest
immediately following chest physiother physiotherapy produces radiological im
apy in 8 of the 14 patients, in 1 patient provement without causing hypoxemia.
there was no increase, and in 4 patients There is, therefore, a very definite place
the increase did not take place until 1 . 5 for this therapy in the management of
hr after therapy ceased. The relationship critically ill patients in whom the hyp
of PaO, and CT to an approximation of in oxemia and hemodynamic changes asso
trapulmonary shunt, partial pressure of ciated with and occurring following
arterial oxygen/fractional inspired oxy- bronchoscopy might be hazardous
Table 7.1
Other Pathological States Found in Trauma and Nontrauma Patients Treated with Chest
PhYSiotherapy
Malel Chronic Chronic
Mean Renal Septic
Patient N umber Female Lung Heart Diabetes
Age (yr) Failure Shock
Ratio Disease Disease
Trauma 39 36 36/3 4 1 1 1
Nontrauma' 8 64 6/2 2 4 3 5
'Multiple p atho logy present in nontrauma group.
PHYSIOLOGICAL CHANGES FOLLOWING CHEST PHYSIOTHERAPY 217
140 Arterial Oxygenation in Spontaneously

Breathing Patients
130
To determine if mechanical ventilation
120
and PEEP were factors altering arterial
oxygenation, 17 spontaneously breathing
patients were studied before and after
V
110 chest physiotherapy. All patients had in
PaOt
torr dwelling arterial lines and were recov
100 ering from trauma. Six were breathing
Mean
room air; the remainder received oxygen
SO
by face hood. No patient breathed with
90
elevation of airway pressure above am
n=47 bient pressure. Indications for chest
80 '"
c.
'"
3 3 physiotherapy included segmental atel
0
'" : .<=
0
.<= 0 0
ectasis (7 patients), infiltrates (6 patients),
'" '" .<= .<=
'" . - '"
0'<= '0", ;!!. ;!!. N lung contusion (3 patients), and pneu
'io
CD '00 '" monia (1 patient). With the patient lying
'"
.<= supine in bed, arterial blood gases (ABCs)
c. TIME
were sampled before and immediately
Figure 7.1. Arterial oxygen tension levels be after chest physiotherapy and at half
fore and after chest physiotherapy. (From C. F.
Mackenzie et al.: Anesthesia and Analgesia
hourly intervals for up to 2 hr after ther
(Cleveland) 57:28-30. 1978a.)
apy. Figure 7.3 shows that there was no
statistically significant change in arterial
oxygenation. However, it is of interest to
(Lundgren et aI., 1982). It appears that note that there is a larger standard devi
chest x-ray appearance improved equally ation in PaD, values after therapy than
successfully with chest physiotherapy as before therapy. This suggests that the
fiberoptic bronchoscopy in expert hands. trend of unchanged arterial oxygenation
This finding was confirmed by others in spontaneously breathing patients was
(Marini et aI., 1979). It was not known not as obvious as in the patient who was
whether the falls in arterial oxygenation mechanically ventilated with PEEP (Fig.
that were reported by others to occur fol 7.1). In the latter group, standard devia
lowing chest physiotherapy could be re tion progressively decreased, indicating
versed by the use of PEEP. conformity to the trend. This diversity in
Table 7.2
Raw CT Data (ml/cm H20) in 14 Patients before, Immediately after, and for Hall-Hourly Intervals
lor 2 hr after Chest Physiotherapy
Immediately After Physiotherapy
Patient Before
after Diagnosis
Number Physiotherapy
Physiotherapy 0.5 hr 1 hr 1.5 hr 2 hr
33 22 24 24 24 29 29 Pneumonia
34 33 43 35 43 43 43 Contusion
35 47 54 50 54 50 57 Pneumonia
36 47 47 48 75 75 54 Chronic lung disease
37 70 65 65 65 70 70 Atelectasis
38 52 65 56 56 56 56 Contusion
39 40 40 37 37 43 52 Atelectasis
40 40 37 37 37 52 52 Contusion
41 44 55 68 55 68 55 Contusion
43 47 62 51 51 51 51 Atelectasis
44 35 38 38 43 43 47 Atelectasis
45 38 38 38 38 41 41 Atelectasis
46 41 44 47 54 44 41 Contusion
47 58 43 58 58 72 72 AtelectaSis
Figure 7.2. Simultaneous PaO,. 150

CT, and PaO,/FIO, for 14 mechani 140
cally ventilated patients before, im 130
mediately after, and at half hourly
P002120
intervals for 2 hr after chest ---
torr t 10
physiotherapy.
100
90
80 n 14
330
310
290
po02
270
F102 250 /'
230
,./
210
190
170
70 j
60
T r
CT 50
1 1
ml/cm Hf) 40
30 I- IMMED Y, IYz
I 2
BEFORE AFTER ""'" HOUR HOURS HOURS
MEAN 110 120 117 114 1 24 122

Po02
.:! SO 28.5 26.4 17.3 19 0 172 1 6. 8
po "EAN 237 262 255 246 270 265

F,02 SO 11.4 60.9 495 51.1 50.5 47.6
MEAN 4 4 47 47 49 53 51
CT SO 120 12.0 12 0 130 140 110
the spontaneously breathing patients is oxygenation may improve, remain un

confirmed by consideration of individual changed, or get worse following chest
patients. The greatest fall in PaO, re physiotherapy. Il was apparent from the
corded in a spontaneously breathing pa study of 47 mechanically ventilated and
tient was from 95 to 56 torr, 2 hr after 1 7 spontaneously breathing patients that
therapy. The greatest rise was from 59 to no method was found that predicted
1 81 torr. [n an individual patient, arterial which of these possibilities might occur.
150- Total LungJThorax Compliance (CT)

140-
130- The next step was to find a more objec
120- tive indicator of the clinical and radiolog
ItO- ical improvement noted. Initial calcula
poOz 100-
tions suggested that CT could quantitate
lorr 90- -
80-
any change in the small airways follow
70-
ing chest physiotherapy. A similar cal
60- n'17 culation was previously described by
50- tMIIED "z I 1'-'2 2 Winning et al. [1975), in which the expi
BEFORE IlFTER HOOft HOUR HOURS HOURS
IIIUN 886 94' 911 96.9 1004 986
ratory limb of a ventilator [Bennet MAl)
%.SO 2ll ]0.5 31 {; 359 ]9,11 16 (; was occluded and airway pressure was
Figure 7.3. PaO, before, immediately after, measured. However, this maneuver al
and at halfhourly intervals for 2 hr after chest ters lung mechanics. Since no patient or
physiotherapy in 17 spontaneously breathing ventilator adjustment is required to read
patients. end inspiratory pressure on the Engstr()m
300, the physician or physical therapist slowly, CT changes usually reflect an al

can observe these changes at the bedside teration of the small airways. The great
during therapy. The accuracy of the in est CT increase occurred 2 hr after ther
spiratory pause read off the airway pres apy had ceased, which suggested that
sure gauge is great, and is not signifi changes continue to occur even after the
cantly exceeded by transducing the completion of therapy.
airway pressure wave form to a paper
write-out (Mackenzie et aI., 1979). Other Airway Resistance (R)
more recently developed electronically
driven ventilators, such as the MA2, R.w is assessed by measurement of air
Servo 900, Bear I. and Foregger 210, may way pressure during peak flow. The mea
be adjusted to give an inspiratory pause surement is made in a mechanically
in the flow wave form. However, this ventilated patient by using a pneumo
does not appear as well defined in these tachygraph and a differential pressure
ventilators as the mechanical, piston transducer. Rubi et a!. (1 980) report that
driven Engstr(jm. Therefore, it may be in volume-preset ventilators with a sine
advisable to use a paper trace of the air wave form and a fixed inspiratory /expi
way pressure wave form to obtain the in ratory ratio of 1 : 2 (e.g., the Engstrom 300
spiratory pause pressure when using series ventilators), the pneumotachy
these other ventilators. graph-derived airway resistance [R.w)
The initial results suggesting an in could be closely approximated (r = 0.96)
crease in CT following chest physiother by using the bedside measurement of
apy were confirmed (Fig. 7.4) by the re peak [Pm,,) and end inspiratory (P'E) air
sults found following therapy in 42 way pressures and applying the formula,
mechanically ventilated patients who suf R.w = [(Pm" - P,d
fered trauma (Mackenzie et aI., 1 980).
X 10Jlminute ventilation.
There appeared to be no difference in the
CT i ncrease whether the patient had at By using this approximation to R.w, as
electasis, lung contusion, pneumonia. or sessments were made on the same pa
respiratory distress syndrome. Nor did tient population at the same time that the
differences occur between patients ven compliance data (Fig. 7.4) were obtained.
tilated with or without PEEP or between The results displayed in Figure 7.5 were
those treated for more or less than 1 hr. analyzed by using the paired t-test and
CT changes when there are alterations in show that there was no significant
either the small airways or chest wall or change in R.w for up to 2 hr after chest
in intraabdominal pressure. Since the lat physiotherapy. In view of the significant
ter two alterations generally change increase in CT in these same patients, the
,. Figure 7.4. Changes in C, in relation

to a single treatment with chest phys
iothera py (CPT) in 42 patients. [From C.
F. Mackenzie et al.: Anesthesia and An
algesia (Cleveland) 59:207-210, 1980.]
,. * * * *
CT !--
.. 1'11
"'II"
!: S D
4.
V
3.
n = 42
-r----
,.L- , ....... Ifto,
--_,-----r----r_--_,
,, l 1,; ho .... 20u"
11101 UTEI't CPT
*p< 0.01
" lung disease. Whether the quantity of

.. sputum obtained following chest physio
"
therapy correlates well with improve
"
"
ment in respiratory function remains
w
u controversial. It is generally agreed that
Z U I'
"" .., sputum should be produced for the ther
Ul 11
" apy to be of benefit, but there are doubts

a::q. l!t '- about the volume required, the accuracy
l;X
,. E " of sputum measurement (Bateman et aI.,
",0
"
<i 1979), and the importance of its visco
"
elastic properties and distribution in the
"

tracheobronchial tree (Clarke et aI.,
1973). To our knowledge, there is only
one report in the literature in which spu
tum is measured in some intubated pa
tients with acute lung pathology (Con
Figure 7.5. Changes in R in relation to a sin nors et aI., 1980). Tracheal intubation
gle treatment with chest physiotherapy from with a cuffed tube removes two sources
data obtained at the same time and in the same of error in sputum volume measure
42 patients as in Figure 7.4.
ment: addition of saliva, and swallowed
sputum.
R.w results might, at first, appear surpris To determine the relationship between
ing. However, the unchanged R.w con the quantity of sputum removed and
firmed that the larger airways were as changes in arterial oxygenation, PaO,/
clear before chest physiotherapy began FlO" CT and R.w were calculated after a
as they were up to 2 hr afterward. In gen single treatment with chest physiother
eral, CT monitors change i n small air apy; 1 5 sets of measurements were made
ways, whereas R.w reflects change in in 10 patients (no measurements were
large airways. If CT is increased and R.w less than 2 days apart) who had a mean
is unchanged following chest physiother age of 36.6 years. All patients were intu
apy, the secretions were removed from bated and mechanically ventilated for at
the small rather than the large airways. least 12 hr before study. PEEP with a
From a practical point of view, mea mean of 9 cm H,O (range, 2-20 em H,O)
surement of Pm,,' as described by Rubi was applied in 5 patients. Nine treat
and colleagues (1 980), has more sources ments were performed for left lower
of error than measurement of P,., Read lobe, 4 for right lower lobe and 2 for right
ing Pm" is more difficult; it is affected by upper lobe segmental or lobar atelectasis.
secretions in the tracheal tube, the inter Three patients had multilobar pathology.
nal diameter of the tube, and changes in Treatment time was 49 24.2 min (mean
patient sedation or intra-abdominal pres SD). Average sputum volume pro
sure. These variables do not normally af duced by chest physiotherapy was 9
fect P,., which occurs during a no-flow 10.2 ml. Nine treatments produced 5 ml
state that holds the pressure constant or less of sputum (Group A). The changes
long enough for equilibration to take following chest physiotherapy in Group
place. Even though both maneuvers are A were compared to the remaining six
only approximations, they are useful treatments (Group B), which produced 19
bedside monitors. CT may be used to con 1 1 .8 ml of sputum (Table 7.3). The C T
firm clinical improvement or to deter and R.w changes following chest physio
mine an end point for treatment. therapy in Group A and Group B are
compared in Figure 7.6.
Sputum Volume Production in The Group B treatments resulted in no
Tracheally Intubated Patients change in R.w or CT' Following Group A
treatments, R.w was unchanged, but PaO,
The volume of expectorated sputum is increased (p < 0.05), and CT rose signifi
often used to assess the efficacy of chest cantly (p < 0.05) immediately, 0.5 hr, and
physiotherapy in patients with chronic 1 hr after chest physiotherapy. PEEP was
Table 7.3
Comparison of Variables between Group A (Treatments Producing Less Than 5 ml of Sputum)
and Group B (Treatments Producing More Than 5 ml Sputum) and Their Significance
Group A Group B Significance
PEEP (cm H20) 7 3.5' 11 5.3 P < 0.05
Duration of therapy (min) 41 1 3.8 62 31.9 NS'
Age (yr) 45 21 .0 29 1 2.5 NS
PaO,
Before 126 35.8 1 27 29.9 NS
After 140 34.3' 1 43 65.5 NS
PaO,/FIO,
Before 338 131.7 242 56.1 NS
After 379 137.5 286 112.0 NS
Volume of sputum (ml) 3.8 1 .3 1 8.8 11.8
'Mean SO.
'NS, not significant.
'p < 0.05. Before and after values in Group A.
10 Figure 7.6. CT and R,w changes

after treatments producing less
T * than 5 ml of sputum (Group A) and
* more than 5 ml of sputum (Group
B).
60
,
T
,
*
,,
: T
,
,,
,
, ,
,
o i
,
,
,, ,
,
,..-r.,
, ,
, ' .. ..
......J :: cT
HzO
:
, // .......... ml/cm
: ....
"".r'
,
'-
-------- ..,
, I
I

....
40 :, :, !,
,
,
,
,
,
,
, , ,
: ! :
.: '
:
30
"'" - Group A n-g
, ---Group B n-6
,
*p <O.o
,
,
,
,

20 T
,
!
H:::- _::_:- .Ll; :r 1r
T RAW
em O / L...c
-
.. __-_- --_ ..--
_ _
_ _
_
-
-- _
----
10
I
l
;
,
1 -: I
. !
Before Immed. ' I
After Hour Hour
CT ml/cm H20
I Before
1 Irnmecl After
1 zHour IHou'
1
Group A 41 ! 11.9 48 :t 17.3 48 16.2 4
Group B 43 22.3 42:!: 9.1 41 12.1 43 13.0
iTile
RAW em tlzO flo e
Group A I 4.2
Group B 14
14
.6
1 13
:!: 2.9
4.0
1 1
13
1" 4.6
Z.!5
1 16
12 ! 3.6
:t 4.7
221
higher (p < 0.05), and mean duration of fissure (Fig. 7 . 1 0). Arterial oxygenation and
therapy was longer, in the group produc minute ventilation changes during mechanical
ing the greater quantity of sputum. The ventilation with a PEEP of 5 em H,O and an
increase in compliance and PaD, in FlO, equal to 0.47 are shown in Table 7.4.
Group A suggests that beneficial effect Case History 7.1 shows that transbron
following sputum removal depends not chial aspiration into the dependent lobe
on the volume of sputum removed, but may occur with postural drainage.
rather on the area of the tracheobron Therefore, the dependent lung should be
chial tree from which it is obtained. If the examined and. if secretion retention is
larger airways are already clear, any spu suspected, treated appropriately. This ,
tum removed comes from the smaller complication of postural drainage should
airways, always be considered if oxygenation fails
Benefit, after removal of a given quan to improve or lung/thorax compliance
tity of sputum, is additionally deter (not calculated in this case because ex
mined by the relation of the sputum vol pired minute ventilation was altered) is
ume removed to that still in the unchanged despite clinical evidence of
tracheobronchial tree. If the majority of clearance of secretions from the treated
the sputum is removed, a favorable out lung. Case History 7.1 also demonstrates
come can be expected. If a large quantity that although 21 ml of sputum was re
of sputum is obtained, yet a large quan moved from the left and right lower lobes
tity remains, the benefit is likely to be (Fig. 7.8), little improvement resulted.
limited. The relationship between the After removal of 46 ml of sputum, arte
volume of sputum removed and the vol rial oxygenation was virtually un
ume remaining and radiological evidence changed, but there was radiological evi
of benefit is clearly shown in Case His dence of benefit.
tory 7.1 . It is possible that a given volume of
Case History 7.1. A 47-year-old male was sputum removed from a similar area of
admitted following an automobile accident in lung of the same patient may produce re
which he sustained a right lung contusion, frac lated changes in cardiac and respiratory
tured ribs 1-7 on the right, and a fractured right function when it is obtained on two dif
clavicle. He also had a base of the skull fracture ferent occasions. It is, however, unlikely
and a wedge fracture of the body of T6 and re
that there will be similar changes when
quired a laparotomy for repair of a liver
laceration.
the same volume of sputum is removed
Nineteen days after admission an atelectasis from different patients.
of the left base and progressive atelectatic This point is illustrated by Case His
changes in the right base were noted on the 6 tory 7.2 in which assessment of benefit
A.M. chest x-ray (Fig. 7.7). Chest physiotherapy, following sputum removal was made by
including postural drainage, percussion, vibra use of an indwelling, thermistor-tipped,
tion, and suctioning, was given to both lower pulmonary artery catheter.
lobes. Treatment time was 75 min. Six milliliters
of sputum was suctioned while the patient was Case History 7.2. A 48-year-old male was
in the left lower lobe position, and 15 ml of admitted following an accident in which a tree
blood tinged sputum was suctioned while in the fell on his head and chest. The patient was un
right lower lobe bronchial drainage position conscious. Multiple rib fractures and a lung
(Fig. 7.8). contusion were seen on chest x-ray. Past med
At 1 :30 P.M. after therapy a chest x-ray was ical history was uneventful. Three days after
taken (Fig. 7.9). This showed a complete right admission despite continuous mechanical ven
upper lobe atelectasis with shift of the hilum tilation, there was a steady deterioration in pul
and mediastinum to the right. The left lower monary and cardiovascular function. The pa
lobe was completely reexpanded. Therefore, tient was ventilated with a tidal volume of 16.5
postural drainage, percussion, and suctioning ml/kg, a PEEP equal to 1 8 em H,O, and an FlO,
were performed to the right upper and lower of 0.6 1 . Intrapulmonary shunt (OJO,) was
lobes for 45 min. Twenty-five milliliters of spu 29.4%, and PaCO, was 48 torr. Cardiac output
tum was obtained from the right upper lobe (OJ was thought to be inadequate on the basis
(Fig. 7.8). Repeat chest x-ray at 5:05 P.M. of a pulmonary capillary wedge pressure (15"...)
showed clearance of the atelectasis with some ranging from 20 to 25 torr and a mixed venous
residual loculated fluid in the right horizontal PO, (PliO,) of 1 5-30 torr. It was supported with
Figure 7.7. Six A.M. portable anteroposterior chest x-ray showing left and right lower lobe atel
ectasis and compensatory overdistension of both upper lobes. Multiple rib fractures and a clavic
ular fracture are shown on the right side.
dopamine (3 g/kg/min) by continuous i.v. In contrast, a 54-year-old male was admitted

infusion. after he was trapped under a tractor trailer for
Chest physiotherapy with postural drainage 2 hr. The patient had multiple right-sided rib
of both lower lobes was administered. Sixty fractures, a pelvic fracture, a right radial, right
milliliters of brownish-red watery secretions patella, left fibula, and medial malleolar frac
was obtained following percussion and suc tures and a fracture of L5. He required a lapa
tioning while the patient was in the postural rotomy for multiple liver lacerations and for
drainage position. The changes following 60 contusion and laceration of the small bowel. He
min of therapy are seen in Table 7.5. had a lung contusion and an aortic arch he-
Figure 7.B. Sputum volumes

(from left to righ obtained from the
left lower lobe (LLL), right lower
lobe (RLL) and right upper lobe
(RUL). Note darker coloration
(blood) in RLL specimen.
Figure 7.9. Chest x-ray taken at 1 :30 P.M. of the same patient as in Figure 7.7 after chest phys
iotherapy shows clearance of the left lower lobe atelectasis. There is now a complete right upper
lobe and partial right lower lobe atelectasis.
Figure 7.10. Chest x-ray taken at 5:05 P.M. of the same patient as in Figure 7.7 after chest phys
iotherapy to right upper lobe and lower lobe shows clearance of atelectasis. There is still a residual
quantity of fluid in the right horizontal fissure.
Table 7.4
Arterial Blood Gas Changes in a 47-Year-Old Male Patient after Sputum Removal
PaO, (torr) pH PaCO, (torr) V, (liters/min)
Before first treatment 1 14 7.43 39 15
After removal of 21 ml of sputum 64 7.41 44 15
Before second treatment 75 7.53 31 18
After removal of 46 ml of sputum 1 23 7.58 27 18
matoma. Past medical history revealed that the trauma patients were studied (Macken
patient had chronic obstructive pulmonary dis zie et al.. 1985). Before investigation, all
ease and previous pulmonary tuberculosis. He were mechanically ventilated for at least
was also diabetic. Two days after admission he 6 hr with PEEP (Mean, 9 em H,O, range
was given chest physiotherapy for 50 min. This
5-18) and had indwelling arterial and
produced copious (>30 ml ) sputum and the
cardiorespiratory changes that are shown in
thermistor-tipped, pulmonary arterial
Table 7.6. lines in position. Intrapulmonary shunt
Despite the production of considerable (0,/0,), dead space (V./V,), cardiac out
quantities of sputum in both patients only the put (0,), and CT were measured before,
48year-old patient with previously normal immediately after, and 2 hr after chest
lungs showed beneficial effects from sputum physiotherapy. The indications for ther
removal (Table 7.5). QJQ" Q" pulse, and PaO, apy included secretion retention with
all fell in this patient but remained unchanged segmental or platelike atelectasis (11
in the other (Table 7.6). patients), lung contusion (6 patients),
and respiratory distress syndrome (2
Cardiac and Respiratory Function patients).
Respiratory failure following trauma
Both CT and R.w values shown in Fig may frequently result in high 0./0, that
ures 7.4 and 7.5 suggested that following requires increasing levels of inspired ox
chest physiotherapy, secretions were re ygen (FlO,) and PEEP to maintain ade
moved from the small airways. To inves quate oxygenation. If chest physiother
tigate this possibility further and to apy in the presence of retained secretions
quantitate the changes taking place with can reduce the requirements for high
objective measurement, cardiac and res FlO, and PEEP, it is beneficial. It may also
piratory function were measured before result in reduced morbidity and mortal
and after chest physiotherapy. Nineteen ity from respiratory failure after trauma.
Table 7.5
Cardiorespiratory Changes in a 48-Year-Old Male Patient after 60 Min of Chest Physiotherapy
Before Immediately after Two Hours after
Variable'
Physiotherapy Physiotherapy Physiotherapy
FlO, 0.61 0.61 0.61
PaO, (torr) U 71 1
PaCO, (torr) 48 32 33
a-vDO,(ml) 8.2 7.7 3.6
Pulse (beats/min) 125 1 10 1 00
P (torr) 68 80 95
PCWI' (torr) 25 20 24
Q, (I/min) 8.7 6.0 5.4
R.O', (dynes/sec/em ') 405 800 1 051
R", (dynes/sec/em ') 1 29 1 33 1 33
QJQ, (%) 29.4 1 7.3 20.7
C, (ml/cm H,O) 17 20 26
YO, (ml/min) 656 460 194
'a-vD02, arterial venous oxygen difference; Part. mean arterial pressure; R, resistance; V02 oxygen
consumption per minute.
Table 7.6
Cardiorespiratory Changes in a 54-Year-Old Male Patient after 50 min of Chest Physiotherapy
Before Immediately after Two Hours after
Variable
Physiotherapy Physiotherapy Physiotherapy
FlO, 0.54 0.54 0.54
PaO, (torr) 1 12 1 24 95
PaCO, (torr) 37 39 37
a-vOO, (ml) 5.0 5.3 37
Pulse (beats/min) 1 25 122 125
p,. (torr) 95 90 1 00
Pew. (torr) 21 21 18
a, (liters/min) 7.9 7.6 7.7
R,,., (dynes/see/em-') 61 8 745 858
R"", (dynes/see/em-') 1 32 1 36 165
0./0, (%) 1 7.5 14.8 1 8.7
C, (ml/em H,O) 48 36 41
VO, (ml/min) 394 403 368
a-vD02 arterial venous oxygen difference; p.rh mean arterial pressure; R. resistance; 'iJ02 oxygen
consumption per minute.
Chest physiotherapy produced a signifi were unchanged (Table 7.7). There was a
cant fall in 0./0,. The greatest decrease significant overall increase in total CT 2
in 0./0, was from 36.3% to 16.5% a nd 13 hr after CPT. Eleven patients showed a
patients showed a fall in 0./0, immedi rise in CT immediately after and 2 hr after
ately after therap. In six patients there CPT. In three patients CT was unchanged
was a rise in O./Q, (greatest from 14.8% and in five CT fell. The greatest CT rise
to 23.5%) that persisted for at least 2 hr in was from 34 to 51 mljcm H20, while the
three of the patients with lung contusion greatest CT decrease was from 48 to 36
(Fig. 7.11). Dead space, PaCO" and PaO, mljcm H,O. In three patients, all treated
Figure 7.11. Individual plots of 0./0, before, 40

immediately after, and 2 hr after a single chest
physiotherapy treatment. (From C.F. Macken
zie et al.: Crit Care Med 1 3:483-486.1985.)
30
....0
0
20
' - .
10
:
I -=
.------ .
0
PRE POST 2HRS POST

Table 7.7
Cardiorespiratory Function before, Immediately alter, and 2 hr alter CPT
Before CPT Im mediately after CPT Two Hours after CPT
CI (Iiters/min/m') 4.5 1.35' 4.2 1.23 4.0 0.92
LVSWI (g/m/m') 65 27.1 51 27.7 63 27.3
RVSWI (g/m/m') 19 6.0 17 6.6 18 6.6
Ca-V O, (ml/dl) 4.2 1.36 4.2 1.38 3.9 0.91
Pulse (beats/min) 94 23.2 95 23.0 90 23.5
0,/0, (%) 16.4 7.55 13.2 4.03" 14.5 6.10
V,jV, 0.47 0.16 0.46 0.15 0.45 0.13
C, (ml/cm H,O) 29 11.3 32 13.4 33 11.r
PaO, (torr) 128 36.6 143 31.5 137 24.9
PaCO, (torr) 34 7 .4 35 8.1 33 '6.7
From C.F. Mackenzie et al.: Crit Care Med 13:483-486,1985.'
Mean SO."
P < 0.05 before and immediately after.""
p < 0.05 before and 2 hr after.
for atelectasis, the fall in CT persisted for cardiac function (Rivara et aI., 1984) and
2 hr (Fig. 7.12). The mean values of car cause ventilation perfusion changes (Ka
diorespiratory function for the 11 pa neko et aI., 1966; Douglas et a!.. 1977;
tients with atelectasis were not clinically Zack et al.. 1979; Remolina et aI., 1981).
or statistically different from those of the Decreases in mixed venous oxygenation
six patients with lung contusion. There occur during suctioning (Bade et aI.,
were no hemodynamically significant 1982) and together with change in posi
cardiac dysrhythmias during or 2 hr after tion may explain the lack of significant
CPT. change in PaD, despite a fall in G./G, im
There was no significant change in car mediately after CPT. There are three
diac function after CPT (Table 7.7). But other reports of cardiac function after
no measurements were made during CPT in the literature (Laws and Mc
therapy because positional changes alter Intyre, 1969; Barrell and Abbas, 1978
70 Figure 7.12. Individual plots of CT before, im

mediately after, and 2 hr after a single chest
physiotherapy treatment. (From C.F. Macken
65 zie et al.: Crit Care Med 13:483-486.1985.)
0N 50
60
./
:I:
"
E
... 40
' L.' -/
E
u
/
:. "- -'
30 /
20
10

PRE POST 2 HRS POST
Klein et ai, 1988). All reported detrimen lasting effects? Can they be prevented
tal effects. In the Laws and Mcintyre with modifications of chest physiother
study cardiac output (by dye dilution) in apy and use of analgesia and sedation?
creased by 50% with artificial coughs While the decreased 0./0, in three of
produced by lung hyperinflation. Barrell the contusion patients may suggest an
and Abbas found mixed venous oxygen adverse effect of CPT, contusion is a rec
ation and cardiac output fell significantly ommended indication for CPT (Macken
during CPT but returned to baseline val zie and Shin, 1978b; Richardson et aI.,
ues within 10 min after the end of ther 1982). The greatest decrease in 0./0, also
apy. The differences may be accounted occurred in a patient with lung contu
for by CPT techniques and patient pop sion. The rise in 0./0, may reflect trans
ulation studied. Laws and Mcintyre 's pa bronchial aspiration of bronchial secre
tients had respiratory failure and re tions during positioning for CPT (see
ceived inflation pressures during the Case History 7.1). In patients with lung
artificial cough of 60-100 cm H,O, which contusion, in whom coagulopathy com
many patients found distressing. Barrell plicates management, CPT should be
and Abbas studied 14 patients who were given to the noncontused lung after ther
extubated after mitral valve replace apy to the contused area. Alternatively,
ments. Despite the changes in cardiac endobronchial intubation with a double
output and mixed venous saturation, ar lumen tube may prevent transtracheal
terial oxygenation was unchanged. The aspiration of blood. This study confirmed
same effects were not found in our study our clinical impression that in critically
of 19 trauma patients. This difference ill patients, mechanically ventilated with
may be because the trauma patients were PEEP, who have low lung compliance
young and did not have preexisting car and increased 0./0" CPT does not pro
diac disease. In addition, falls in mixed duce the deleterious cardiopulmonary
venous saturation may only be transient changes that have been reported with
and occur during CPT. All the trauma pa bronchoscopy (Lundgren et al.. 1982).
tients were ventilated with PEEP, which CPT may be used to manage retained
is known to restore functional residual lung secretions due to acute posttrau
capacity and improve oxygenation (Mc matic respiratory failure, without pro
Intyre et aI., 1969). The increase in CT in ducing hypoxemia,
11 patients was probably secondary to
the recruitment of more functioning al Mass Spectrometry Analysis of Expired
veolar units as a result of mobilization Gases
and clearance of secretions from small Mass spectrometry, as peviously de
airways. The process of recruitment may
scribed (McAslan, 1976), was used to an
have been assisted by PEEP and alyze breath-by-breath end-tidal carbon
interdependence.
dioxide (PHCO,) and oxygen (PHCO,) in
Klein et al. (1988) showed that cardiac mechanically ventilated patients, To de
output did rise by 50% over baseline val
termine the effects of chest physiother
ues during chest physiotherapy in two apy on the uptake and excretion of 0,
unsedated patients. In patients who re and CO" analyses were obtained before,
ceived continuous infusion of 3 I'g/kg during, and after treatment.
fentanyl there was still a 20-25% rise in
cardiac output during chest physiother Case History 7,3, An 18-year-old male was
apy that returned to baseline within 15 admitted following an automobile accident. He
min after the end of therapy. With the had a severe head injury, pulmonary edema,
analgesia there was no significant in and had suffered cardiac arrests 8 and 10 hr
crease in heart rate or blood pressure but previously. He was given chest physiotherapy
0, consumption and CO, production because of a complete atelectasis of the right
lower lobe and deterioration in arterial oxygen
were still increased. The important ques ation while mechanically hyperventilated, with
tions about changes in cardiac function an FLO, of O.S. The abnormal traces obtained
occurring during chest physiotherapy by mass spectrometry before chest physio
are: Are they clinically relevant? Are therapy are shown in Fig. 7.13. Note the ftuc
they associated ",ith detrimental long tuations seen in expired CO, during the latter
2 ..COftd--t
r
t. ,
t 1 "
2:[
Figure 7.13. Breath-by-breath 0, and CO, analysis in the patient before chest physiotherapy.
Note the lack of alveolar plateau and the presence of a terminal peak in the CO, curve. P.,. 0, and
P"CO, values are shown.
part of expiration. ABG analysis showed a chanically ventilated patients may be

PaO, of 69, a pH of 7.51. and a PaCO, of 30. abolished with PEEP (McAslan) or an ex
After 45 min of chest physiotherapy to the piratory retard (Ricker and Haberman.
right lower lobe and removal of copious secre 1976). p."CO,. in the presence of this ter
tions. there was clinical and radiological evi
minal increase in expired CO,. is unrep
dence of clearance of the atelectasis. The ex
pired gas wave form now showed a plateau
resentative of "average" mixed alveolar
(Fig. 7.14). The trace in Figure 7 .14 was made gas composition (McAslan. 1976). There
1.5 hr after that in Figure 7.13. ABGs sampled fore. the recorded a-ADCO, of 4 torr may
at the same time as the mass spectrometry be only an estimation of the gradient.
analysis in Figure 7.14 showed a PaO, of 148. This situation is thought to occur due to
a pH of 7.52. and a PaCO, of 34 despite un V/0 imbalance and premature airway
changed ventilator settings and FlO,. closure. If there is a large difference in
the distribution of ventilation causing a
The baseline traces obtained before spectrum of rates of emptying. the slope
therapy show a lack of constant "alveo of the alveolar plateau increases. Time
lar" CO,. suggesting that the CO, ten constants given as the product of regional
sions did not reach the same values as lung compliance and airway resistance
the pulmonary capillary CO, in all alve describe the rate of airway emptying dur
oli. Therefore. a considerable arterial al ing expiration. In obstruction. time con
veolar CO, gradient (a-ADCO,) would stants increase so that no alveolar pla
exist. P.-rCO, levels were inconsistent; teau may be visible on the expired CO,
well-ventilated alveoli emptied early; curve (Fig. 7.15). The abolition of the
poorly ventilated units in which alveolar peak by chest physiotherapy (Fig. 7.14)
gas was trapped emptied later. There is a and the change in shape of the expired
peak in the terminal plateau of the CO, CO, curve appeared to indicate that chest
curve (Fig. 7.13). Similar peaks in me- physiotherapy affected the small airways
Figure 7.14. Following chest

physiotherapy. an alveolar plateau
FO 0. 0.6 is apparent. and the terminal peak
'h a, 395 torr in the CO, curve is abolished. Note
P[T eo. 29 "'" the rise in the P.,.CO, value after
chest physiotherapy.
CO.
29
o
, - - - - 2 sec -- .
S C02
-6
-5
-4
-3
_2
_1
-0
Figure 7.15. Expired CO, curve of patient with chronic bronchitis and emphysema. Note the lack
of alveolar plateau suggesting inequality of emptying of alveoli and impaired distribution of
ventilation.
and their ability to take part in gas ex pired air column oscillations found with
change. The expired gas wave form after chest vibration. Mass spectrometry dem
chest physiotherapy shows a plateau onstrates that chest physiotherapy pro
with a constant value for P"CO,. The a duces changes in CO, and a, gas ex
ADCO, of 5 torr is increased. This sug change. The more normal CO, curves
gests that alveolar dead space is similarly found following chest physiotherapy sug
increased after chest physiotherapy and gest that the therapy has a favorable ef
removal of secretions. fect on the small airways.
The expired CO, curve of a patient out
of phase with a mechanical ventilator
shows a characteristic change (Fig. ANALYSIS OF CH EST
7.16A). This occurs because the patient PHYSIOTHERAPY DATA
attempts to breathe in non-CO,-contain
ing gases while the ventilator is in the ex Factors Influencing Physiological
piratory phase. This patient was thought Measurement in the leu
to be out of phase because of lung secre
tion retention. Following chest physio Physiological measurement in the ICU
therapy and removal of these secretions, is difficult. The patient, especially when
a normal CO, curve was produced (Fig. unstable, undergoes continual and often
7.16B). dramatic changes in cardiorespiratory
Breath-by-breath analysis of CO, and function. Because the patient may be
0, curves during chest physiotherapy critically ill, therapeutic intervention is
and chest wall vibration is shown in Fig frequently necessary, and this often al
ure 7.17. The CO, and a, analysis con ters cardiac or respiratory function.
firm that chest wall vibration causes While it is usually quite easy to exclude
changes in the expired gas wave form. such obvious cardiorespiratory changes
These variations occur due to the ex- as development of shock or tracheal in-
Figure 7.16. (Al Breath-by-breath
CO2 curve in a patient who was out
of phase with mechanical ventila
tion. (8) CO, analysis on the same
patient after chest physiotherapy
shows a normal curve.
8
Normal Co1ant ofler chell phYliolheroPJ
\-L." "'--
I
VIBRATI ON DORING EXPIRATION--+ , !5 I !1

". l !
,
r-r-
f---1S........
I
+
r ('
CO.
/' M. ( ('if I J\ (V' f\- f'1, r r r"
l "
,_
\ " "
.,..._
....--
, ""\ -
_ -... _
\ \. " "
-
,, \, ,,
ills: ..

....,....
Figure 7.17. Breath-by-breath 0, and CO, analysis during vibration chest physiotherapy. showing
a normal curve when vibration ceased and loss of the curve with suctioning of the tracheobronchial
tree.
tubation and mechanical ventilation, shortage and a large patient load.

other more subtle variables may easily go Twenty-one patients in the step-down
undetected or be attributed to the ther (ICU) unit were not treated by physical
apy under study. This is one argument therapists but. instead, received tracheal
for using a control population. Investiga suctioning and side-to-side turning. In
tion of chest physiotherapy in ICU pa that month, there were 14 readmissions
tients is made especially difficult because to the critical care recovery unit (CCRU)
there is no control or standardization of from the ICU because of deteriorating
the therapy itself. Many reports of chest respiratory function that was docu
physiotherapy include the use of bron mented by clinical examination, chest x
chodilating or mucolytic agents. Some ray, and blood gas analysis (c. F. Mac
centers do not use postural drainage, kenzie, personal communication to R. A.
while others exclude chest vibration of Cowley. M.D., Director MIEMSS, October
percussion. The duration and frequency 1977). In contrast, an average of three
of therapy vary enormously (see p. 39). readmissions/month occurred during
What control should be used to com the remainder of the year. This strongly
pare with chest physiotherapy in criti suggests that side-to-side turning and
cally ill patients? The commonly sug suctioning are not comparable or accept
gested control is side-to-side turning and able medical practice, compared to chest
tracheal suction (Murray, 1979b). How physiotherapy, when performed on ICU
ever, when researching the effects of patients with acute lung pathology.
therapy in humans, both standards of In addition to the ethics of using con
care must be comparable and acceptable trol groups in critically ill patients, and
medical practice. In our experience, side the difficulty of finding a comparable and
to-side turning and tracheal suctioning clinically acceptable control, some stan
are not comparable therapy for treatment dardization of chest physiotherapy
of conditions such as left lower lobe, pos should be achieved before physiological
terior segment atelectasis. Long-term fol measurements can be truly claimed to re
low-up studies suggest that this regime flect the effects of chest physiotherapy.
did not prevent deterioration in chest x Factors Influencing Analysis of Data
ray appearance, PaO,/FIO" and CT (see from Dillerent ICUs
pp. 233-237). Also, when side-to-side
turning and suctioning are used. as oc Therapist Variability
curred at our institution during a period
of understaffing of physical therapists, at When comparisons are made of chest
electasis was not prevented. In October physiotherapy between different ICUs, is
1977. there was a physical therapy staff it possible to exclude such a subjective
but very important factor as the clinical oxygenation and increase in Cr> The patient,
variability between one therapist's abil who regained consciousness, was placed on a
ity to clear an acute atelectasis and an T-piece and was successfully extubated.
other 's inability? It is our impression that Other investigators confirm that
physical therapists trained by staff expe trained physical therapists produce a
rienced in ICU work are more successful more favorable outcome than do nurses
in improving the patient's clinical and ra or physicians. Vraciu and Vraciu (1977)
diological signs than are nurses, respira found that breathing exercises adminis
tory therapists, or physicians. This im tered by a physical therapist reduced the
pression is confirmed by the following incidence of pulmonary complications
case history. after open heart surgery, compared to
Case History 7.4. A 23-year-old male was turning, deep breathing, and coughing
admitted with a head injury, cerebral contusion, every hour assisted by nursing staff.
and a ruptured spleen sustained in an auto Finer and Boyd (1978) noted that the im
mobile accident. He was tracheally intubated, proved oxygenation that occurred after
mechanically hyperventilated (paCO, < 30 chest physiotherapy in infants was re
torr) and given corticosteroids. Five nights after lated to a chest physiotherapist, rather
admission (that is, November 1 8) he developed than to the ICU nurses, performing chest
a complete left lower lobe atelectasis. This was physiotherapy. Lyager et al. (1979)
recognized following deterioration of arterial thought that the reduction in pulmonary
oxygenation and after a chest x-ray. The pa
tient was suctioned, FlO, was increased, and
complications that they reported, com
the ABG analysis was repeated. little improve
pared to those noted by Bartlett et al.
ment occurred as is shown in Table 7 . 8). After (1973), may have resulted from their use
suctioning, a nurse gave chest therapy with the of specially trained physical therapists
patient turned onto his right side. There was an rather than residents or nursing staff. Ap
increase in arterial oxygenation from 7 1 to 1 1 8 plication of a standard therapy, such as is
torr and of CT from 44 to 60 ml/cm H,O. The advocated in this book, may help reduce
patient was treated 3 hr later by a chest phys therapist variability.
ical therapist in the correct postural drainage
position, after which arterial oxygenation fur
ther improved to 1 85 torr and CT increased to Patient Population
68 ml/cm H,O.
The following morning (November 20), arte
How can compensation be made for the
rial oxygenation on the same ventilator settings variability between different patient
had again deteriorated despite tracheal suc populations? For example, can chest
tioning and "chest therapy" performed by the physiotherapy or any other therapy be
nurse. Chest physiotherapy by a physical ther compared between trauma and medical
apist again produced improvement in arterial ICUs? Admission to a trauma unit is not
Tabte 7.8
ABG, C" and PaOJFIO, Changes Occurring over a 3-Day Period
PaO, CT (ml/ PaOJ
Date Time
(torr)
pH PaCO,
cm H,O) FlO,
Event
November 1 8 1 1 :00 1 07 7 . 58 28 78 282

21 :30 57 7.51 31 68 1 50 Left lower lobe atelectasis
23:00 71 7.59 28 44 1 61 Suction, FI02 increased
November 1 9 05:00 118 7.58 27 60 268 Chest therapy by nurse
10:00 1 85 7.60 28 68 420 Chest physiotherapy by
physical therapist
22:00 94 7.54 33 60 214 ABG fall at night
November 20 Chest physiotherapy by
physical therapist
09:40 1 46 7.57 31 78 348 ABG following chest
physiotherapy
10:45 122 7.56 35 Spontaneous respiration T-
piece 40% O2
14:00 112 7.52 36 Extubated face tent 0,
determined by a history of preexisting point where the patient sits up, follows
pathology but usually by an acute insult commands, and takes deep breaths and
to an otherwise-healthy individual. Ap coughs, may be shortened when neuro
plication of physiotherapy is likely to muscular blockade is used. This may de
have a different effect in the trauma pa crease the incidence of respiratory
tient than in the medical patient. It may complications.
be possible to overcome this variability Water vapor loss may be reduced by
by considering a large patient population use of a closed or semiclosed rebreathing
studied over a long period. circuit on the anesthesia machine. Alter
natively, inclusion of a humidifier or
Method of Mechanical Ventilation nebulizer in the ventilator/anesthesia
machine ensures humidification of dry
Manufacturers of ventilators and ad anesthetic gases at all times. Lack of hu
vocates of different modes of mechanical midification during anesthesia or in the
ventilation and respiratory support claim period after surgery may be an important
that important differences result from determinant of subsequent respiratory
use of one or other ventilator or methods complications in the ICU. (See Chapter 9
of ventilation. If this is so, the outcome of for more details on humidification.)
chest physiotherapy in mechanically
ventilated patients is likely to be differ Therapeutic Intervention
ent, even when the patient population
and therapy are similar. In the long-term follow-up of patients
in ICUs, can the numerous other clini
Variability in Anesthetic Techniques cally essential therapeutic interventions
(such as intravenous fluids, vasoactive
Different anesthetic techniques pro drugs, and analgesics) be excluded from
duce different effects on the respiratory influencing the effects and outcome of
system. Regional anesthetic techniques chest physiotherapy? Standardization of
are credited with causing fewer deaths these therapies is unthinkable, yet pain
after surgery than general anesthetic relief is an important factor in the pre
techniques (Beecher and Todd, 1954). vention of respiratory complications after
However, there is a lack of controlled surgery and patient acceptance of chest
studies comparing regional anesthesia to physiotherapy and mobilization. The du
modern general anesthetic techniques. ration, type, and frequency of interven
Regional techniques are frequently not tions in four different types of patients
applicable, as, for example, in the man over an 8-hr period are described in Ap
agement of a patient with multisystem pendix IV. In some institutions there are
trauma. Regional techniques such as epi interventions that do not occur at others.
dural anesthesia are time consuming and For example, if there is variability be
require considerable expertise. Nonethe tween one surgical ICU and another i n
less, they are of enormous benefit for re t h e morbidity an d mortality associated
lief of pain after surgery, when an epi with the same surgical procedure, how
dural catheter is left in place. Regional can this discrepancy in standard of care
analgesia is more effective than narcotics be accounted for when comparing chest
for maintaining pulmonary function after physiotherapy at the two institutions?
surgery (Fairley, 1980). This may consid These are just a few of the difficulties of
erably alter the incidence of respiratory evaluating chest physiotherapy in the
complications and the need for mechan ICU. The solution, for the most part, re
ical ventilation (see Chapter 10, p. 341 for mains unknown.
details of pain relief in ICU).
General anesthesia with use of neuro Long-Term Follow-up
muscular blockade (and an opiate, or low
doses of inhalational agent) frequently A 2-hr follow-up of respiratory changes
produces a more awake patient, on rever after chest physiotherapy may be too
sal of the neuromuscular blockade, than long, since, allowing 1 hr for chest phys
occurs following the use of inhalational iotherapy and 2 hr for sampling and mea
agents alone. The recovery period, to the surement, variables are assumed to be
constant during a study period of about acutely ill patients from lengthy study of
3.5 hr. The number of interventions for the effects of chest physiotherapy on
four patients is shown in Appendix IV. these parameters.
The four patients studied demonstrate An alternative to long follow-up of
the care given to patients in a typical highly changeable parameters, such as
trauma ICU. They were observed from 8 pulse and cardiac output, is to record
A.M. to 4 P.M., and all interventions that more nonspecific indicators. If these vari
caused alterations in cardiac or respira ables are recorded for a long period and
tory function or that made physiological in a large enough patient population, use
study difficult were recorded. ful data may be generated concerning the
The mean number of clinically re effectiveness of chest physiotherapy. In
quired interventions was 59 (Table 7.9). formation on daily 8 A.M. ABC, lung/tho
These interventions took, on average, rax compliance, and chest x-ray appear
298 min or 5 min for each intervention. ance was, therefore, collected in 58
The nonintervention time was, therefore, mechanically ventilated patients be
limited to a mean of 93 min in the whole tween August and October 1977. All re
8 hr. The longest intervention-free pe ceived chest physiotherapy and had suf
riod averaged 34.5 min, which repre fered multiple system injuries (see
sented only 9.1% of the total 8 hr. The Appendix I, p. 352, Table A1.7 for defi
duration of restricted access was 145 min nition of systems) and were admitted to
on average. Restricted access was the the CCRU.
term used to refer to situations that alter The patients were divided into groups
the ability to monitor (for example, pa based on whether they had chest injury,
tient 3 left the CCRU for hyperbaric 0, head injury and other injury, pelvic frac
therapy and whirlpool debridement), ture, cervical spinal column injury, or
change the hemodynamic status (for ex extremity fracture (Table 7.10), Data
ample, patient 1 had dialysis that can were collected only in mechanically ven
cause considerable circulating volume tilated patients and lhe numbers in each
shifts), or make comparative physiologi category from which the data were ob
cal measurement impossible (for exam tained are shown at the top of Figures
ple, patient 2 was, at times, rotated on the 7.18-7.20. Not all the data could be col
Roto-Rest bed). This alters hemodynam lected on every patient each day.
ics, ventilation/perfusion relationships
within the lung, and respiratory mechan Chest X-Ray
ics and function. The changes in heart
rate, mean arterial blood pressure, mean The daily chest x-ray was assessed by
P A pressure, ICP and cerebral perfusion using the following system: clear, 0; infil
pressure (CPP) in patient 4 are shown trate or plate-like atelectasis, 1; atelecta
graphically in Appendix IV. The clini sis (segmental or lobar) or lung contu
cally necessary adjustments to ventila sion, 2; and pneumonia, 3. The results are
tion and cardiac function exclude shown in Figure 7.18. On admission, the
Table 7.9
Duration and Frequency of Interventions Causing Changes in Cardiac or Respiratory Function
in Three Critically III Patients'
longest Period
Direct
Nonintervention Restricted or No Access of Number of
Intervention
(min) Time (min) Nonintervention Interventions
(min)
(min)
Patient 1 448 32 359 (dialysis) 20 43

Patient 2 399 81 197 (rotation of Roto 20 75
Rest bed)
Patient 3 161 106 213 (hyperbaric chamber, 28 29
whirlpool debridement)
Patient 4 183 154 35 (visitors) 70 89
"Full details of aU interventions appear in Appendix IV; each patient was observed a total of 480 min.
Table 7.10 of mechanical ventilation, between the

Injuries Sustained by 58 Long-Term Follow chest-injured patients who received
Up Patients chest physiotherapy and the head-in
Average jured patients who received routine
Number Number Body turning and tracheal suctioning, but no
Injury
of Systems chest physiotherapy (unless the chest x
Patients Injured ray scored 2 or more). This suggests that
Rib fractures; lung 26 3.0 chest physiotherapy prevented further
contusion deterioration in chest x-ray changes and
Pelvic fracture 31 2.9 that routine turning and suctioning did
Unconscious 16 2.7 not.
Extremity fracture 29 2.7
Cervical spine 13 2.1
fracture PaOzlFIO,
The changes in PaO,/FIO, are shown
patients with chest injury presented with in Figure 7.19. The patients with head in
the highest score. and those with head jury presented with the highest ratio
injury, with the lowest. Two of the 19 pa (lowest intrapulmonary shunt), and the
tients with chest injury developed a patients with chest and cervical spine in
pneumonia-like process that lasted 9 and jury, with the lowest. After 1 week, two
3 days, respectively. On average, in pa distinct groups emerged; the patients
tients with multisystem injury, chest with chest, pelvis and extremity injury
physiotherapy was successful in preven had low PaO,/FIO" and those with head
tion of major atelectasis or pneumonia and cervical spine injury had high PaO,/
(Fig. 7.18). Chest injury or pelvic fracture FlO,. The differences between these two
(or a combination) produced the highest groups receiving chest physiotherapy are
score and the longest duration of chest x likely to be the result of the injuries sus
ray changes despite chest physiotherapy. tained by the different patient population
There is a lack of difference, after 4 days rather than the chest physiotherapy. The
CHEST I. ,. " " " " 12 " 10 10 4 > > > > > > > 2
NUMBER PELVIS 20 ,. I> " I> " 7 , , 7 > 2 > > 4 > I
OF HEAO " " 12 " " 10 " 7 , , 2
PATIENTS EXTflEM 17 I. I> I> 16 12 10 10 7 , > 2 > > 4 > I
ANALYSED C-SPINE 7 7 7 > > > > 2 2 > >
__ CHEST!CI
PELVIS (PI
HEAO ( H )
___._
EXTREMITY (E1
_____
C-SPINEICS)
_._._
__
2.0
C
1 .5

i
'
. ). /' ... ....... .... /
-'"
f.:::..:,..
/,. L.) .;-'f../ " ... " '.J
.....
AVERAGE DAILY ... . ..P
"> -.:,-;. "

CHEZofY c
I .0 ,/ ...'\ v'/ ' ,"
f. l,<:;..j/
_ _
.... .. .... \
PAftT cs
P /
-
'" '/ /' "/ " ';;" ii '
.
\J "0-_-.., \ \
;..:..... \ \
E/ '. \
0.5 ... " / cs I.
./
I
H 1 \, '/

o \H iE
I 2 3 4 5 6 7 8 9 10 II 12 13 i4 15 16 17 18 19 20 21 2 2 23
DAYS AFTER INJURY
Figure 7.18. Long-term follow-up of daily morning chest x-ray changes following admission day
(day 1 ). Assessment: clear, 0; infiltrate or plate-like atelectasis. 1 ; atelectasis (segmental or lobar)
or lung contusion, 2; pneumonia, 3. Numbers of chest x-rays examined appears above graph;
mean score is plotted. C, chest injury; H, head and other injury; P, pelviC fracture; CS, cervical
spine injury; E, extremity fracture.
CHEST 18 14 14 14 13 13 II 9 8 8 7 6 4 3 2 3 3 I
NUMBER PELVIS 19 15 15 12 15 II II II 10 II 10 8 7 7 7 6 , 3 4 3 3 2.
OF HEAD 12 14 12 13 14 I I II II 7 " 4 4 2
PATIENTS EXTREM 18 17 16 15 14 12 12 9 6 6 6 6 6 , 4 2 3 3 3 3
ANALYSED CSPINE 7 8 7 6 6 4 " 4 3 2 3 3 2
'\ I CS
500
/ .. '\ I
/ \ I
CHEST (e)
, PELVIS (PI
__
/"
/ I /,''" \"\ ,1 . H HEAD (HI
."
450 / EXTREMITY(E)
_____
/ ,' "
1 / V C-SPINE (CSI
_ _ _
/',
-,/--.!
__
-- -' '
" '\
- "
400 H
-- - -
//
I
....:"..v-'/
P o 02 350
: _ :"' 1..1
c __ ,
./_,
.
,// ',_ --;:. _ _
_
' ,
.
Fi0 2 CS ---/..
. / ... ,
. . ..... .. ,
.." / "
'- - - /
-..., .
300 .... \,- - / / ,

\
\
250
e .....\
. ..
200 ,,/
S I ..
103 128 .2 B. B' 1 1 2. 107 ., 101 160 174 259128 ....
STANDARD H 113 114
c 114
114
115
162
,,7
148
12'
171
77
135
92
125 67 B7 130 182 174 140
74 23
\p
P 159 144
DEVIATION 144 101 128 134 176 178 148 148 73 ,. 2.
1 50 148 135 127 143 t i l
E 131 125
'" .0 105 129 tOO 109 114 6 2 78 125 37 '0 .2 128 128
134 169 157 139 148 184 " . 137 147 120 116 117 1 4 6 132 104 99 101 "3 104 85
2 3 4 5 6 7 8 10 11 12 13 14 15 16 17 18 " 20 21 22 23
DAYS AFTER I NJURY
Figure 7_19. Long-term follow-up of daily 8 A.M. PaO,/FIO, changes following admission. Number
of values assessed appears above graph; mean value is plotted; standard deviation appears below
graph. Symbols used are the same as in Figure 7 . 1 8.
CHEST 19 14 " 14 " " " " 1O 7 7 6 4 3 2 2 3 3

NUMBER PELVIS 20 I. 12 " " " " 10 10 7 7 7 6 , 2 4 3
HEAD
"
OF 12 " " 13 " " " 7 4 6 4 , 3
PATIENTS EXTREM I. 17 16 14 " " 11 7 6 4 , 4 2 4 3 3
ANALYSED C-SPINE 7 7 , 5 , 4 3 2 2 2 , 2 2
CHEST (C)
PELVIS (PI
HEAD (Hl
._
EXTREMITY(EI
_____
_. _._
__ C-SPINEtCS)
70
,.
,
60 "
'. i
1
,,'\\ /.:':'\
.' . 1
LUNG/ i
I"
" ) (- / \ \
THORAX ;
COMPLIANCE 50 CS\. \ j/
" "
p '/ '
.
i -'./ '
.
/
,
/ I
\. .i
ml/cmH 0
2
t....
"
, " .
,V'1-,/\ \
./

. /.....
\:l:" .J'." - .:::=.:. ...

::::. ...q...." .\-,
H

' ,
..,'" .
40 - /
-OJ
.
. .
e / .. ... ..
-...., /
p
30 e
es 36 I. 53 34 21 ,. 2. 2. 17 13 " 43 4' 20 13
STANDARD H 23 21 35 25 18 11 17 ,. 44 31 14 , . 20 17 10 10
DEVIATION P 20 15 32 14 17 24 17 1B 47 23 10 21 22 1B 12 20 1B 22 3.
I. I.
" "
13 " 21 " 25 14 " 10 14 I. 19 I. " 13 32 13 7 21 "
e 21 " 27 25 20 22 " 19 19 11 " ,. 23 38 17 I. " 20 " ,. 12
2 3 4 , 7 10 " 12 13 14 " I. 17 ,. 19 20 21
DAYS AFTER INJURY
Figure 7.20. Long-term follow-up of daily 8 A.M. C, changes following admission. Number of val-
ues assessed appears above graph; mean value is plotted; standard deviation appears below
graph. Symbols used are the same as in Figure 7.18 .
236
former group were more susceptible to ity and of drainage by gravity also de
respiratory complications, although only pended upon the presence of a normal
those who were sick enough to require content of air in the lung beyond an ob
continued mechanical ventilation were struction. Absorption of air resulted in
sampled, atelectasis when no collateral ventilation
was present. No mailer how great a res
Total Lung/Thorax Compliance piratory effort was made, without collat
eral ventilation, collapse rather than
The chest-injured patients presented reexpansion occurred. Van Allen and
with the lowest CT although those with l ung (1931) showed that binding of the
head injury also had decreased CT (pos chest did not decrease collateral flow but
sibly because of spasticity). On average, binding of the abdomen reduced tidal
despite chest physiotherapy, CT was low volume and collateral ventilation.
in all the patients studied (Fig. 7.20). It Baarsma et al. (1948) described two
was not until the third week of mechan children, one of whom had a metal for
ical ventilation that deterioration below eign body in the left lower main bron
30 ml/cm H,O occurred in the group of chus that resulted in atelectasis of the
patients studied. This is often considered left lower lobe. The other aspirated a
the lowest CT acceptable for weaning metal pellet that lodged tightly in a sub
from mechanical ventilation. It is appar lobar airway of the left lower lobe. There
ent from the study of Figures 7.18-7.20 was no trace of atelectasis on chest x-ray
that PaO,/FIO, and CT changes usually of the second patient. They restate Van
preceded chest x-ray changes. Allen and Lindskog'S hypothesis that in
spiration, without collateral ventilation,
Role of Collateral Ventilation in Gas would increase subatmospheric trans
Exchange with Obstructed Airways pulmonary pressures in the obstructed
lung. Mucus would be moved more
Distal to a complete airway obstruction firmly into the bronchus. Baarsma et al.
in the mainstem bronchus, alveolar gases (1948) hypothesized that postoperative
rapidly achieve equilibration with mixed atelectasis was due to accumulation of
venous gas tension. The alveolar gas is mucus, shallow breathing, weak cough,
absorbed, atelectasis develops, and no and diminished collateral ventilation.
further gas exchange takes place. Conse Chen et al. (1970) simultaneously re
quently, any perfusion of this area in corded pressure in the trachea and col
creases intrapulmonary shunt. However, laterally ventilated ai rways of dogs with
this does not occur if the obstruction is of an obstructed airway. During inspiration,
a sublobar airway. Van Allen and Lind pressure was greater in the trachea than
skog (1931) showed that collateral venti the obstructed pulmonary segment favor
lation has the effect of preventing the for ing inflation of the obstructed segment.
mation of atelectasis after lobular but not During exhalation air flowed from the
lobar obstruction. The pores of Kohn, the obstructed segment to the main airway
interbronchiolar channels of Martin through collateral channels. though the
(Martin, 1966), and the alveolar bronchi pressure difference was small. They sug
olar channels of Lambert (Lambert, 1955) gest that this would favor the develop
are suggested as pathways for collateral ment of enough force to help dislodge an
ventilation (Macklem, 1978) (Fig. 2.8, p. obstruction in a segmental bronchus and
61). Van Allen and Lindskog suggested prevent atelectasis. C u liner and Reich
that collateral ventilation assists bron (1961) suggested that segmental atelecta
choelimination by maintaining a normal sis was rare u nless collateral ventilation
volume of air in the lung parenchyma be was impeded by accumulation of bron
yond a mucus obstruction. Measurement chial and alveolar secretions.
of forces exerted by cough showed that
they failed to eliminate mucus when ab Collateral Airway Resistance
sorption atelectasis occurred within 30
min of obstruction. Similarly, Van Allen The resistance to collateral flow was
and Lindskog suggested that the expel first measured i n living subjects by Bar
ling forces of ciliary and peristaltic activ- tels (1972), and is influenced greatly by
lung volume. Increases in lung volume major pathways for collateral ventilation
above FRC were associated with dra (Mead, 1973). However, Traystman et al.
matic decreases in collateral airway re (1978) conclude that bronchiolar chan
sistance in humans (Inners et aI., 1979). nels of Lambert and Martin, because they
The fall in resistance could be due to en have smooth muscle, are the sites of col
largement of the airways alone or en lateral ventilation.
largement together with recruitment of
other collateral channels. It is possible Development and Role of Collateral
that different channels provide collateral Airways in Disease
ventilation at differing lung volumes. In
creasing lung volumes from 55% to 80% Collateral ventilation appears to in
of total lung capacity were associated crease with age (Terry et aI., 1987). Ro
with a decrease in collateral resistance of senberg and Lyon (1 979) showed collat
60% (Inners et aI., 1979). Despite this the eral ventilation in excised adult lungs
resistance in collateral airways is about but not in those of children. Martin
50-4000 times greater than normal air (1963) also observed that pores of Kohn
way resistance (Inners et aI., 1979; Bar are absent in newborn animals but reach
tels, 1972) so that flow is preferentially adult levels i n 1 year (see Fig. 8.1). Mack
through airways other than collateral lin (1 936) documented a reduced number
channels. However, in disease states of pores of Kohn in young humans. There
such as emphysema and when CO, reten is considerable variation in the amount
tion occurs as in chronic lung disease, of collateral ventilation in different
collateral airways resistance falls and regions of the lung. Specifically, there are
may approach that of airways resistance. less collateral ventilation channels in the
Kuriyama et al. (1984) examined the role middle lobe and lingula. The reason for
of collateral ventilation in ventilation this may be that the middle lobe and in
perfusion balance and concluded that ferior segment of the lingula interface
species with collateral ventilation have with only one segment while all other
an auxiliary respiratory mechanism that lung segments interface with at least two
could protect them from regional alveo other segments (Terry et aI., 1985).
lar hypoxia. Collateral ventilation was Because the channels of Martin and
found to be the first line of defense. be Lambert contain smooth muscle their
fore hypoxic pulmonary vasoconstric caliber and resistance to collateral flow
tion, against regional hypoxia. Because vary. Collateral resistance mediated
air is less dense than blood, the ability to through parasympathetic stimulation
redistribute ventilation rather than per changes with inhalation of common pol
fusion would seem to be an efficient lutants such as ozone, metacholine, his
arrangement. tamine, cholinergic blockade, oxygen,
Traystman et al. (1978) found that CO, CO" and atropine (Batra et aI., 1981). Col
was a major determinant of collateral air lateral airways were suggested by Kohn
ways resistance. High CO, reduced re (1 893) and others to be a means by which
sistance. If a portion of lung that has a pneumonia infected adjacent lung seg
low CO, is adjacent to a hypoventilating ments. Loosli (1937) suggested that tu
portion (with higher CO,), the high CO, mors may spread between alveoli by col
area facilitates collateral ventilation. A lateral airways. The frequent infections
homeostatic mechanism was preserved that occur in intralobar sequestrations
for increasing ventilation to the poorly may occur by entry through collateral
ventilated portion despite the adjacent airways.
hypocapnia. Trayslman et al. (1 978) also In aslhma, small airways are ob
showed that the surrounding lung exerts structed by inflammation and mucus
significant control over the resistance to plugging and up to half of an asymptom
flow in collateral airways. Failure to con atic asthmatic's airways may be closed.
sider the effects of this interdependence The binodal distribution of ventilation
of bronchiolar channels and the sur perfusion ratios seen in asthma is best
rounding lung erroneously suggests that explained by the presence of collateral
alveolar pores of Kohn might be the ventilation. Asthmatics breathing 100%
oxygen do not develop increased shunt (Andersen et aI., 1971 ; Macklem, 1971),
(Field, 1967). Prevention of shunting may then more air would enter an obstructed
be explained by effective collateral ven but not collapsed lung segment during
tilation (Terry et aI., 1985). Culiner and inspiration than could exit during exha
Reich (1961) suggest collateral ventila lation. Pressure would build up in the
tion may play an important role in devel obstructed segment forcing secretions
opment of emphysema because of a ball more centrally.
valve-like arrangement that allows air to Gravity changes collateral ventilation
enter a segment through collateral air and body position affects the response of
ways but prevents its escape. Collateral collateral channels to CO" 0" and cho
airway resistance is low in emphysema linergic blockade (Batra et aI., 1981). Re
and allows gas mixing in the lung periph sistance in collateral airways increased
ery and maintenance of adequate blood 54% when the obstructed segment was
gases (Filley et aI., 1968). Terry et al. rotated from a nondependent to depen
(1 978) showed that in emphysematous dent (segment down) position. Since
patients airways closed at pressures of 3- pleural pressure is lower in nondepen
8 em H,O above atmospheric pressure. dent lung, transpulmonary pressure (air
However, flow through collateral airways way less pleural pressure) is increased,
occurred at 5 em H,O suggesting that air and regional volume is greater. Kaplan et
was rapidly distributed in the emphyse al. (1979) showed that collateral airways
matous lung at FRC. resistance decreases 1 3% for each centi
meter increase in transpulmonary pres
Possible Therapeutic Effects of sure. Alternative suggestions for the me
Collateral Ventilation chanisms increasing resistance in the
dependent lung include differences in V/
Andersen et al. (1979) showed in nor o and intravascular volume. In normal,
mal human lungs at autopsy that col upright lung, V/0 is greater in nonde
lapsed lung can be recruited through col pendent than dependent regions and 0,
lateral airways using techniques that tensions are higher but CO, tensions are
employ continuous positive airway pres lower. Because increased CO, has a more
sure. Reexpansion was achieved by me potent dilating effect on collateral air
chanical ventilation with and without ways than reduced 0, has a constrictor ef
PEEP by deep breathing simulation fect, V/0 changes are unlikely to be the
in a pletysmograph with CPAP (which cause. It is unlikely that vascular disten
caused an increasing FRC), but reexpan sion affected collateral ai rway resistance
sion did not occur with normal breathing because even large changes in vascular
at constant FRC. In six of the seven lungs pressure cause trivial effects (Batra et aI.,
studied. collateral reinflation required 1981 ). In addition, the dilating effects of
lower pressures than reinflation through CO, on collateral airways are more ap
normal airways. Andersen et al. (1979) parent in the nondependent (segment
explain this lower pressure by a differ up) position. This may be due to different
ence in time constants between normal local levels of CO, in the obstructed seg
and collateral reinflation. During ordi ment. The clinical importance of these
nary conditions of lung expansion the changes is that postural drainage with
collateral time constant (product of air the obstructed lung segment placed in a
flow resistance and lung compliance) is nondependent position optimized collat
longest because of the large collateral eral airway flow by reducing its resist
flow resistance. However, when the lung ance and time constants for inflation of
is collapsed the normal bronchial route is the obstructed segment as well as opti
narrowed or closed by mucus, menisci mizing gravity-assisted drainage of
formation, or contraction of elements in mucus with coughing and exhalation.
the wall (Macklem, 1971). All these fac Since cholinergic blockade also dilates
tors increase the time constant for rein collateral airways (Batra et aI., 1981) ben
flation through normal air passages. If eficial effects of bronchodilaling drugs
collateral time constants are longer dur used in conjunction with chest physio
ing exhalation, which is thought to be so therapy should be greatest when the ob-
structed area is in the nondependent ence is determined by the amount of in

position. homogeneity. In respiratory distress syn
drome interdependence is also likely to
Interdependence be reduced and to be a less effective
mechanism of expanding atelectatic lung
Increasing pressure differences be segments because of increased surface
tween adjacent lung regions promotes tension due to lack of surfactant. Inter
flow through collateral channels. In liv dependence between adjacent portions of
ing subjects interdependence also in lungs should maintain the caliber of col
creases collateral ventilation (Macklem, lateral channels and maintenance of in
1971 ; Menkes and Traystman, 1977). terdependence would be clinically very
There is also interdependence between important if an obstructed segment
lung and chest wall (Zidulka et aI., 1976) tended to collapse.
that may contribute to the effectiveness
of deep breathing in reexpansion of ate
lectatic lung. Andersen et a!. (1979) ex Synthesis of Mechanisms of Action and
plain the effectiveness of application of Hypothesis for Benefit from Chest
subatmospheric pleural pressure during Physiotherapy
deep breathing, compared to using me
chanical ventilation with PEEP by this Around and within atelectatic lung
mechanism of lung/chest interdepen segments there are areas of lung that are
dence. Transpulmonary pressure swings partially aerated. It is possible that these
over an atelectatic area may be much partially aerated areas are the focus of
greater than over a nona tel ectatic area, physiotherapy effect during percussion,
and, if so, should increase collateral flow vibration. and coughing in the postural
during inspiration. Chest/lung interde drainage position. Collateral ventilation
pendence tends to promote homogeneous and interdependence increase the likeli
or synchronous ventilation throughout hood of reexpansion of such atelectatic
the lung. The chest wall i ncreases the ef lung using chest physiotherapy by the
fects of interdependence between adja following mechanisms.
cent portions or the lung about 10-fold
when the thorax is intact (Menkes and Increase in Transpulmonary Pressure
Traystman, 1977). With paralysis of res
piratory muscles the magnitude of inter Deep breathing increases the alveoiar
dependence decreases (Sylvester and pleural pressure difference. This in
Menkes, 1975), The chest wall appears to creases collateral flow by increasing the
affect interdependence by preserving the driving pressure between the atelectatic
shape of the obstructed segment during segment and open airways. There may be
inspiration. The chest wall prevents in greater transpulmonary pressure swings
creases in elastic recoil of the segment over an atelectatic than nonatelectalic
that result when it is unrestrained by the area. Increased rib cage expansion and
thoracic cage. diaphragmatic descent are encouraged
When lung volume increases, regional during breathing exercises and increase
interdependence decreases (Sylvester et transpulmonary pressure. Rib cage vibra
aI., 1975). When the volume of the ob tion is performed over the course of ex
structed segment is increased indepen halation and is followed by release of the
dently of the surrounding lung. interde rib cage compression. The effect is of
pendence appeared to increase. Sylvester "springing the ribs" outward causing a
et a!. interpret the increased interdepen sudden i ncrease in transpuimonary pres
dence as indicating that elastic recoil of sure. Since collateral airways resistance
the obstructed segment and interdepen falls 1 3% for each centimeter of water in
dence falls as it returns toward a homo crease in transpulmonary pressure (Kap
geneous shape. Clearly, changes in shape lan et aI., 1 979). flow is promoted into an
of an obstructed segment alter collateral obstructed segment through collateral
flow. Segmental-alveolar pressure differ- airways.
Positioning of Atelectatic Segment forced expiratory techniques or external

Nondependently chest vibration and percussion, pressure
gradients between the peripheral air
Postural drainage places the previously ways and mouth are increased without
identified atelectatic segment in the op dynamic compression of the airways.
timum position for gravity to assist the The increased pressure gradient between
drainage of secretions from the segmen air that entered an atelectatic segment by
tal bronchi toward the trachea. Postural collateral airways during inspiration and
drainage, therefore, always places the af the more proximal airways tends to pro
fected segment non dependently. The pel inspissated secretions in the ob
major effects of nondependent position structed segment more centrally during
ing are (1) transpulmonary pressure is in exhalation. Some flow occurs from the
creased, (2) V /Q is increased, (3) lung/ obstructed segment by collateral ventil
thorax compliance of the nondependent lation during exhalation. However, when
hemithorax is increased, and (4) collat high flows occur, resistance in the collat
eral airways resistance with cholinergic eral airways increases and so does the
blockage is reduced, which is not appar time constant. It is thought that the time
ent when the same segment is positioned constant for inflation of an obstructed
dependently. The combination of pos segment through collateral airways is
tural drainage with maneuvers such as shorter than that for deflation. For the
mechanical ventilation with PEEP prob time constant to be increased either com
ably increases the likelihood of reexpan pliance or resistance of the collateral air
sion of a nondependent atelectasis be ways must increase. Resistance could in
cause the uppermost hemithorax is crease by compression, by contraction of
preferentially ventilated and has a smooth muscle in the collateral airways,
greater absolute volume. Bronchodilators or by a valve mechanism. Aerodynamic
are likely to be most efficacious in their valving occurs independently of diame
action to reduce collateral airway resist ter changes in the airways. Valving may
ance and promote flow into an atelectatic be a factor decreasing outward flow
area when administered with the af through collateral airways and promoting
fected segment nondependent. CO, ten the expulsion of mucus or overcoming
sion in an obstructed lung segment is surface tension forces necessary to ex
equal to mixed venous CO, tension and pand an atelectatic lung segment.
is, therefore, usually about 4-6 mm Hg The effect of cough on clearance of se
higher than arterial CO, tensions. Since cretions from the peripheral airways is
CO, is a potent collateral airway dilator still unresolved (Rochester and Goldberg,
and it is present in higher tensions in ob 1980; Bateman et aI., 1981). Cough may
structed than ventilated airways, the el play a role as a necessary adjunct to chest
evated CO, promotes flow into the ob physiotherapy. It is quite possible that
structed segment. during the deep inspiration before
coughing, resistance in the collateral
Generation of Pressure Differences channels falls sufficiently to allow retro
between Atelectatic Segment and Open grade aeration of obstructed airways.
Airways During a cough the accelerated flow pro
pels mucus into more central airways.
During exhalation there is a pressure Percussion and chest vibration may as
gradient from the alveoli to the mouth sist the movement of mucus centrally by
that promotes flow. During a cough, huff causing oscillations in the airflow and
ing maneuver, or the forced expiratory changes in transpulmonary pressure.
technique, described in the chest phys Percussion vibrates alveoli, alveolar
iotherapy literature, the alveolar-mouth ducts, and bronchioles and may promote
pressure difference is increased. With flow of air through collateral and small
coughing from total lung capacity dy airways. Secretions loosened by these
namic airways compression sometimes maneuvers may then be propelled into
occurs limiting flow (see Chapter 5). With the larger airways. Chest wall vibration
oscillates air in larger airways and causes monary shunt when there is no exces
changes in the expired gas wave form an sive bleeding into the bronchi.
alyzed by mass spectrometry (Fig. 7.1 7). 4. Alteration in cardiac function and the
The effect is transmitted to speech caus body positions used during and after
ing different vocal pitches and variations chest physiotherapy may change arte
in air flow. rial oxygenation.
Interdependence Sputum
The process of reexpansion of atelec 1 . Sputum removal from major airways
tasis is greatly assisted by interdepen is achieved by coughing or suctioning
dence. which promotes synchronous through a tracheal tube and by pos
ventilation of all parts of the lungs. Dur tural drainage.
ing a thoracotomy when the lung is col 2. Retrograde aeration of obstructed air
lapsed. application of an expiratory re ways by collateral ventilation assists
sistance while the chest is open and the mobilization of mucus obstructions
l u ng visualized shows that the peripheral more centrally.
airways appear to help each other open 3. The more viscid and tenacious the
due to interdependence. Reexpansion sputum. the more difficult it is to
occurs from the normally ventilated lung remove.
bordering atelectatic areas inward. Inter 4. Sputum volume collected is an unre
dependence counteracts the inhomoge liable indicator of the efficacy of a
neity of ventilation found in an atel chest physiotherapy treatment for
ectatic segment and maintains the acute lung disease because of different
collateral airways open. pathophysiology of the pulmonary
disorder. swallowing of sputum. and
Generally Accepted Statements unexplained variations in sputum
production independent of chest
Subjective physiotherapy.
1 . Removal of sputum from the trach Cough

eobronchial tree is thought to be
beneficial. 1 . Ciliary action. not cough. is the usual
2 . Subjective benefits reported by pa mechanism for movement of secre
tients cannot always be supported by tions from the peripheral lung more
any measurable objective data. centrally.
3. Clinical examination of the chest. 2. When mucociliary transport is im
chest x-ray changes. sputum volume. paired. cough assists secretion re
and breathlessness are subjective moval.
assessments. 3. Repetitive coughing decreases mucus
4. In chronic lung diseases. copious transport and narrows the airways.
sputum production is essential for 4. There are many other less hazardous
the treatment to produce subjective techniques of cough stimulation than
improvement. nasotracheal suctioning and transtra
cheal catheters.
Arterial Oxygenation
Chest X-Ray
1 . Oxygenation improves. deteriorates.
or remains unchanged after chest 1. Identification of segmental lung pa
physiotherapy. There are no known thology by a recent chest x-ray in
predictors. creases the likelihood of correct posi
2. Marked changes in lung/thorax com tioning for postural drainage and
pliance are accompanied by little or treatment of the area of pathology.
no change in arterial oxygenation. 2. Acute atelectasis appears to respond
3. Treatment of lung contusion with as favorably to chest physiotherapy as
chest physiotherapy reduces intrapul- bronchoscopy. when it is evaluated by
chest x-ray and outcome in preven sputum production and mucociliary

tion of pneumonia. transport may be different in chronic
3. When an air bronchogram is visible to and acute lung disease.
the peripheral lung fields, bronchos
copy does not improve the radiologi Acute Lung Pathology
cal picture.
4. The silhouette sign is invaluable for Atelectasis
identification of lung segments on a 1 . Chest physiotherapy produces clinical
straight portable anteroposterior chest and radiological resolution in 70% of
x-ray. unilobar atelectasis with a single
treatment in mechanically ventilated
More Sophisticated Objective patients.
Measurements of Improvement 2. Resolution of acute atelectasis is not
related to the volume of sputum pro
1. Lung compliance increases after chest duced by chest physiotherapy.
physiotherapy and removal of re 3. Mechanical aids to lung expansion.
tained secretions in mechanically such as bronchoscopy, incentive spi
ventilated patients. rometry, IPPB, PEEP, and pressure
2. Intrapulmonary shunt falls after re support, are frequently more expen
moval of secretions from the periph sive and less effective than chest
eral airways. physiotherapy in treating acute at
3. Functional residual capacity measure electasis.
ment and closing capacity are objec
Lung Contusion
tive measures of the effect of chest
physiotherapy on ventilation to small 1 . On percussing, vibrating. and suction
airways. ing the tracheobronchial tree, a lung
4. V /0 scans are expensive and radio contusion produces blood, not spu
tum.
active, but measure localized changes
in V /Q that can be quantitated. The 2. Radiological evidence underestimates
multiple inert gas technique of Wag the extent of lung contusion. Maxi
ner et al. (1 974) overcomes many of mum radiological effect of lung con
the disadvantages of radioisotopes and tusion is commonly seen 12 hr or more
is more specific. Extensive investiga after injury. Contusion can be present
tion of chest physiotherapy remains to despite a lack of rib fractures. Rib
fractures and external signs of injury
be carried out.
correlate poorly with lung injury
found at autopsy.
Chronic Versus Acute Lung Disease 3. Bleeding from a lung contusion can
Treated with Chest Physiotherapy cause a deterioration of intrapulmo
1 . No study has shown that the chronic nary shunt after postural drainage.
lung disease processes can be reversed This can also cause transbronchial as
by chest physiotherapy. Several stud piration and confuse the radiological
ies have shown reversal of acute diagnosis by giving a segmental
atelectasis. distribution.
2. The results of chest physiotherapy in 4. Pulmonary edema seen with lung con
patients with chronic lung disease tusion is usually noncardiogenic.
cannot be extrapolated to patients Pneumonia
with acute lung pathology. 1 . Well-established pneumonia does not
3. Because therapist training differs and resolve with chest physiotherapy or
treatment methods, duration, and use mechanical ventilation.
of adjuncts, such as bronchodilators, 2. Systemic and local hydration and ap
mucolytics, and intermittent positive propriate antibiotic therapy are the
pressure breathing (IPPB), vary, rarely recognized treatments of pneumonia.
can comparisons be made of results 3. If retained secretions are allowed to
from different centers. remain with the lungs, pneumonia
4. The results of secretion removal on may develop.
4. If a pneumonia-like process is treated respiratory function are usually not as

during its development, pneumonia accurate or informative as the invasive
may be prevented. techniques. For example, what use is a
knowledge of cardiac output gained by
Despite the ability to make some gen impedance cardiography if intracardiac
erally accepted statements about chest filling pressures and mixed venous blood
physiotherapy there is still a great deal gases are unknown? How accurate is
that is unknown or unproven. Because trancutaneous oxygen analysis in the
there is so much that is disputed, per adult? Noninvasive assessments of res
sonal bias weighs heavily. The areas of piratory function by means of nitrogen
dispute are summarized in Chapter 1 , washout or lung/thorax compliance are
Table 1 . 3 together with our opinion and more easily obtained, but they lack the
practice. In our environment, it is diffi regional specificity available with the V/
cult to persuade a Human Volunteers Re Q scan and Wagner-West multiple inert
search Committee that it is ethically gas technique. If it is difficult to obtain
acceptable to withhold percussion, vibra objective evidence of benefit by using in
tion, and postural drainage and substi vasive techniques, one can expect a sim
tute tracheal suction and side-to-side ilar difficulty with less invasive proce
turning for the treatment of sick ICU pa dures. The solution to some of these
tients, since the former therapy is so problems is, therefore. a laboratory ap
strongly advocated, and the latter was proach using animals.
found to be ineffective in preventing res
piratory complications. Equally, random Suggested Questions That Need
allocation of two groups of patients to ei Answering
ther chest physiotherapy or bronchos
copy would, in our opinion, subject the 1 . What measurements should be made
mechanically ventilated patient with low to quantitate the efficacy of chest
lung compliance, high minute ventila physiotherapy maneuvers?
tion, and PEEP to an unacceptable risk 2. What are the indications for chest
with bronchoscopy. physiotherapy?
There is quite naturally a wish to use 3. Is chest physiotherapy better than
noninvasive techniques to assess respi simple postural drainage and suc
ratory function following chest physio tioning in removal of retained lung
therapy maneuvers. secretions?
The techniques of choice include V/Q 4. Which component of chest physio
scanning of the lungs with xenon and therapy among post ural drainage,
technetium tracers and the multiple inert breathing exercises, percussion, vi
gas indicator technique (Wagner et aI., bration, cough, and tracheal suction
1974). Radioactive safety procedures is most effective in clearing secre
with xenon and techneti urn tracers pre tions from the small airways?
vent the routine use of the V/Q scan in 5. Are mechanical devices, such as in
other than nuclear medicine depart centive spirometers, electrical vibra
ments, the laboratory, or a specifically tors, and CPAP face masks as effec
designed side ward in the ICU. The Wag tive as therapist-assisted manual
ner-West technique requires expensive techniques in altering respiratory
and sophisticated equipment but is quite function?
suitable for use in the ICU provided the 6. How important is cough in clearance
patient is stable for the period of study. of secretions from the smaller air
The magnetometer derived Konno-Mead ways?
plot (1 967) may be used to measure re 7. How important is suction in clear
gional chest wall function. Together with ance of secretions from the smaller
pneumotadygraph-derived values of lung airways?
and chest wall compliance and resist 8. What are the optimum frequencies
ance, this provides useful noninvasive for vibration and percussion of the
information about the mechanics of the chest wall?
chest wall and abdomen. Other nonin 9. Is sputum volume, viscosity, and
vasive techniques assessing cardiac and rheology important?
10. Is postural drainage with specific seg Thoracic Society. It is frequently referred
mental positioning beller than turn to as the "Sugarloaf Conference" and was
ing from side to side? published as a supplement to the journal,
11. Does duration of chest physiotherapy American Review of Respiratory Disease.
alter secretion clearance? This conference was held because of the
controversy about the effectiveness of
SUMMARY various maneuvers designed to remove
secretions from the tracheobronchial
Arterial oxygenation may increase, tree. It was necessary for some objective
fall, or remain unchanged following judgments to be made by experts in the
chest physiotherapy in mechanically field and for the state of the art to be de
ventilated or spontaneously breathing fined. The conference had three objec
patients. No method was found to predict tives: ( 1 ) to assess the existing data con
which possibility might occur. CT was cerning the efficiency of respiratory
found to be a useful assessment of benefit therapy in the treatment of patients with
from chest physiotherapy and with clin chronic obstructive pulmonary disease.
ical signs an end point for therapy. R.w (2) to determine the additional data re
was not such a reliable indicator. Benefit quired to assess various modes of respi
after removal of sputum in the patient ratory therapy more adequately, and (3)
with acute lung pathology does not de to make these findings available to stim
pend on the volume removed. Mechani ulate appropriate investigations. The
cally ventilated patients may show in modes of respiratory therapy examined
creased PaO, and CT despite less than were chest phYSiotherapy, and IPPB with
5-ml sputum production during chest mucolytic agents and aerosolized de
physiotherapy. Cardiac and respiratory tergents.
function changes during and after chest Pelly (1 974b) introduced the section on
physiotherapy suggested that secretions physical therapy and asked some specific
were moved from the larger and smaller questions: How will benefit following
ai rways, resulting in improved function respiratory therapy be measured? What
apparent for up to 2 hr after therapy. will be measured? Will symptomatic im
Many factors, such as postural and car provement, reduction in dyspnea, or mo
diorespiratory changes and therapeutic bilization of increased volumes of spu
interventions. make long-term follow-up tum be considered beneficial? If these
difficult in the critically ill patient. Dif items are too subjective, can studies be
ferences in methods of ventilation, appli designed with acceptable controls and
cation of therapy, anesthetic techniques, identifiable and reproducible end points?
and patient population make compari Six years later, these questions have not
sons between ICUs questionable. Gener been answered and are still being asked
ally accepted statements about chest (Cherniack, 1 980; Peters and Turnier,
physiotherapy that appear on pp. 242- 1 980).
244 and areas of dispute considered in Since the conference was specifically
Table 1.3 summarize our opinion on addressed to respiratory therapy in pa
some controversial points. tients with chronic obstructive pulmo
nary disease, the state of the art presen
WHAT PHYSIOLOGICAL tation Uones, 1 974) and other papers in
MEASUREMENTS ARE REQUIRED this conference made no mention of the
AND HOW SHOULD THEY BE patients with acute lung disease. Some of
MADE? NATIONAL HEART, LUNG the questions posed were, nonetheless,
AND BLOOD INSTITUTE
relevant to chest physiotherapy in the
CONFERENCES OF 1 974 AND 1 979 ICU. A particular question that Jones
asked was, "Does postural drainage,
1 974 National Heart and Lung Institute chest vibration and percussion increase
peripheral airway sputum removal?"
In 1974, the National Heart and Lung Sputum rheology and volume, and the
Institute organized a conference on the relation of these to respiratory function,
scientific basis of respiratory therapy, were discussed. It appeared that there
which was sponsored by the American might be some weak correlation between
respiratory function and sputum viscos focusing attention on the problems and
ity. The effect of the volume of sputum by providing a diversity of expert opin
removed on respiratory function was, ion. Many of the studies suggested in
and still is, controversial. The results of 1974 have still not been performed. The
chest physiotherapy on the peripheral 1979 conference adds to this backlog. At
airways were discussed earlier (see p. least a further 23 groups of studies were
2 19). Grimby (1974) reviewed the knowl suggested by the authors of the 1979 con
edge on breathing exercises and stressed ference, who wrote on chest phYSiother
the importance of deep breathing in pre apy and mechanical aids to lung expan
vention of airway closure. A lteration in sion. It appears, therefore, that it is the
flow rates, achieved with breathing ex practitioner's obligation to complete this
ercises, may alter distribution of ventila research before the next conference.
tion, but this required further evaluation There are eight papers concerning
using different breathing patterns. chest physiotherapy and mechanical aids
Mellins (1 974) wrote on pulmonary to lung expansion. The authors of these
physiotherapy in the pediatric age group articles quote over 300 references, of
and credits the beginning of physical which only about 40% were published
means for removing secretions in this age since 1974. This lack of progress in re
group to the early obstetricians who per search was not adequately addressed by
cussed the buttocks, not the chest. He any of the authors, and only two groups
was one of the few discussants in this acknowledged restricting their com
conference to comment on the apparent ments to updating information gained
success of chest physiotherapy in revers since 1974 (Darrow and Anthonisen,
ing pulmonary complications in acute 1980; Rochester and Goldberg, 1980).
conditions. Success of therapy was based This is surely an important point. One
on subjective measures such as clinical reason why these studies were not per
appearance, chest x-ray, and ausculat formed may be that the suggested re
tory changes. In general, this 1974 con search required sophisticated techniques
ference was very thought provoking to and equipment not available in the av
those interested in respiratory therapy. It erage hospital. Alternatively, the end
posed many questions, suggested many points may not be well enough defined,
studies. and played the devil's advocate or the nonstudy factors may be too vari
to many traditionally held views. The de able, to determine any significant differ
tails should be read because there is still ences. The difficulties encountered in
a lot that can be learned from it. producing a steady state. allowing only
study variables in a critically ill patient.
1 979 National Heart, Lung and Blood were already addressed (see p. 234).
Institute (NHLBI) Conference In the three sections dealing with me
chanical aids to lung expansion in the
The 1 979 NHLBI conference on the sci 1 979 NHLBI conference, incentive inspir
entific basis of in hospital respiratory atory spirometry was generally favored
therapy was published as a supplement over expiratory spirometry, which was
to the November 1 980 issue of the Amer condemned (Ponloppidan, 1 980). IPPB
ican Review of Respiratory Disease. It in was also unfavorably compared to other
tended to establish what is known and techniques. However. Murray (1 980)
accepted about respiratory therapy, what noted that it might be useful to alter lung
needs to be found out so that therapy can compliance in patients with chronic lung
be more rationally given, and what stud disease. The assumption of all these tech
ies should be done to fulfill the necessary niques. and of the whole conference, was
research. The conference was aimed to that the patient was fit and well enough
ward the use of respiratory therapy out to cooperate. This may be the case with a
side the ICU. great many people who receive therapy
There was not much that was novel in outside the ICU, but the majority of crit
this conference, compared to the 1974 ically ill patients who receive chest phys
version on the same topics. However, re iotherapy require tracheal intubation
views such as this undoubtedly help by and ventilatory support. Frequently they
are unconscious, making continuous pos ing chest physiotherapy. Some of the dif
itive airway pressure by face mask and ficulties of using sputum volume. ABGs.
incentive spirometry both impractical and airways resistance as indicators of
and hazardous. It is unfortunate that the changes in peripheral airways were
conference did not include physiother discussed.
apy and other respiratory maneuvers for The article by Peters and Turnier
the sick. mechanically ventilated patient (1980) discussed indications for. and ef
in the ICU. It is possible that this group of fects of. physiotheraphy in surgical pa
patients may benefit the most from these tients. They reviewed the literature and
techniques. listed some agents promoting collapse
Ingram (1980). in the summary on me after surgery. Immobility and pain were
chanical aids to lung expansion. suggests stressed as important factors in the de
some very pertinent questions. The most velopment of respiratory complications.
notable are. Is supervised deep breathing They noted that a difference between
as effective in producing acute pulmo mechanical aids. such as incentive spi
nary function changes as incentive spi rometry and IPPB. and chest physiother
rometry. IPPB. or continuous positive air apy was the presence of a skillful. sym
way pressure? Is the benefit gained by pathetic therapist. This may be a vital
periodic hyperinflation sufficiently great determinant of whether secretions are
to justify a major investigative effort? cleared. Finally. these authors enumer
The incidence of these problems can be ated several problems in evaluation of
judged from the finding that 106 (1%) of chest physiotherapy effectiveness.
10.931 chest physiotherapy treatments Techniques of respiratory therapy
given to critically ill patients in a 22- were divided into two functionally dis
month period between September 1978 crete entities by Rochester and Goldberg
and June 1980 consisted of coughing and (1980): pulmonary physical therapy for
deep breathing exercises only. However. patients with increased sputum produc
in this same period. 232 (30.2%) of the tion and breathing training for patients
769 patients treated were mobilized. Mo with dyspnea or poor exercise tolerance.
bilization included ambulation and ex The variation in techniques termed
ercises (see Chapter 6). The low inci "chest physiotherapy" in the articles that
dence (1%) of problems that were felt to they quoted was not discussed. nor were
be avoidable by use of breathing exer some of the different conclusions in the
cises alone reflects the aggressive ap currently published literature resolved.
proach to early mobilization and the fact However. their summary brings out im
that the majority of treatments were portant points concerning treatment of
given to mechanically ventilated pa the patient with chronic bronchitis. bron
tients. In our experience. without the use chospasm. hypoxia or pneumonia. They
of mechanical aids to lung expansion. suggest that failure to exclude the effect
breathing exercises supervised by the of cough may change some previously ac
chest physical therapists are sufficient to cepted conclusions of beneficial effects of
reverse the problem in nonintubated pa pulmonary physiotherapy. Breathing ex
tients who are conscious, cooperative. ercises were thought to be best judged on
and breathing spontaneously. the basis of respiratory muscle strength
The rationale for physical therapy dis and endurance rather than on the basis of
cussed by Menkes and Britt (1980) is of pulmonary function tests. They hypoth
great interest. It is one of the few papers esized that the patient 's metabolic and
presented at either conference that at nutritional status will affect the outcome
tempts to answer questions rather than of a breathing training program.
pose them. These authors reviewed the What did these experts consider the
importance of lung volume in affecting best indicators of benefit from chest
resistance to flow through the collateral physiotherapy? Cherniack (1980) recom
channels. the factors that may affect re mended studies in three areas. First.
gional distribution of ventilation. the re the effectiveness of bronchial drainage
sponses to mucociliary clearance. and V/ should be compared to deep breathing
Q changes that might take place follow- and cough. The suggested indicators of
benefit included volume of sputum pro critically i l l patients. Aneslh Analg 61:51 3-516.
duced, alterations in gas exchange, and 1 982
Barach A. Segal MS: The indiscriminate use of
mucociliary clearance. The techniques IPPB. lAMA 231:1141-1 142. 1975
for assessing mucociliary clearance were Barrell SE. Abbas HM: Monitoring during physio
not identified, but the gamma camera therapy after open heart surgery. Physiotherapy
and radioactive tracers are the most ad 64:272-273. 1978
BarreH CR: Flexible fiberoptic bronchoscopy in the
vanced assessments presently available.
critically ill patient. Ches t 73:746-749. 1 978
Clearance of radioactive-labeled secre Bartels M: Collateral ventilation beirn menchen he
tions of different viscosity, placed at var bihtalion schort ens der medizinischen. Thesis.
ious sites in the tracheobronchial tree, TUbingen Universitatsk linik. 1972
may be compared by using postural Bartlett RH. Brennan ML. Gazzaniga AB. Hansen
EL: Studies on the pathogenesis and prevention of
drainage, percussion, vibration, cough postoperative pulmonary complications. SUfg Gy
ing, and huffing. The second area for neco/ Obstet 1 3 7:925-933, 1973.
study was to evaluate the balance be Bateman JRM. Newman SP. Daunt KM. Pavia D.
tween changes in energy cost and gas ex Clarke SW: Regional lung clearance of excessive
bronchial secretions during chest physiotherapy
change following breathing exercises. in patients with stable chronic ai rways obstruc
E nergy cost was not defined but would tion. Lancet 1 : 294-297, 1979
certainly include measurement of oxy Batra C. Traystman R, Rudnick H. Menkes H: Ef
gen consumption and carbon dioxide ex fects of body position and cholinergic blockade
cretion. Diaphragmatic and costal excur on mechanics of collateral ventilation. J AppJ
Physio/ SO:358-362. 1981
sion exercise techniques may then be Beecher HK, Todd DP: A study of the deaths asso
compared to determine if breathing re ciated with anesthesia and su rge ry. Ann Surg
training is of value. The importance of 1 40:2-34. 1 954
controlling other treatment variables that Chen C. Sealy WC, Seaber AV: The dynamic nature
of collateral ventilation. J Thorac Cardiovasc Surg
occur after surgery, including changes in 59:518-529. 1970
nutritional and metabolic status, was Cherniack RM: PhYSical therapy. Am Rev Respir Dis
stressed. Maximal inspiratory and expi 1 22(2),25-27. 1980
ratory and transdiaphragmatic pressures Clarke SW. Cochrane CM. Webber B: Effects of spu
were suggested as relatively accurate as tum on pulmonary function (abstract). Thorax
28:262. 1973
sessments of respiratory muscle strength. Cochrane CM. Webber BA. Clarke SW: Effects of
However, specific respiratory muscle en sputum on pulmonary function. Br Med 1 2: 1 1 8 1 -
durance tests were noted to be lacking. 1 1 83, 1977
The third area recommended for study Connors AF. Hammon WE. Marlin RI. Rogers RM:
Chest physical therapy. The immediate effect on
by Cherniack was pulmonary rehabilita oxygenation in acutely ill patients. Chesl 78:559-
tion. The cost effectiveness, staffing, and 564. 1 980
impact of rehabilitation on the course of Culiner MM. Reich SB: Collateral ventilation and
chronic respiratory disease should be de localized emphysema. Am J Roetgenol 85:246-
termined and then evaluated. The meth 252, 1961
Darrow C. Anthonisen NR: Physiotherapy in hos
ods of evaluation were not suggested, but pitalized medical patients. Am Rev Respir Dis
patients with moderate respiratory dys 122(2):155-158. 1 980
function and employment were consid Dohi 5, Cold MI: Comparison of two methods of
ered the best group to study. postoperative respiratory care. Chest 73:592-595.
1978
Douglas WW. Rehder K. Beyneu FM, Sessler AD,
Marsh HM: Improved oxygenation in patients
References
with acute respiratory failure: the prone position.
Andersen lB. Qvist J. Kano T: Recruiting collapsed Am Rev Respir Dis 1 1 5:559-566. 1977
lung through collateral channels with positive Fairley HB: Oxygen therapy for surgical patients.
end-expiratory pressure. Scand J Resp Dis 60:260- Am Rev Respir Dis 1 22(2}:37-44. 1980
266. 1979 Feldman NT. Huber GL: Fiberoptic bronchoscopy
Aylward M: A between-patient. double-blind com in the intensive care unit. In! Anesthesiol Clin
parison of S-carboxymethylcysteine and brom 14:31-42. 1976
hexine in chronic obstructive bronchitis. Curr Field CB: TIle effects of posture. oxygen. isoprote
Med Res Opin 1:219-227. 1973 nerol and atropine on ventilation. Clin Sci 32:279.
Baarsma PRo Dirken MNJ. Huizinga E: Collateral 1 967
ventilation in man. } Thorae Surg 1 7:252-263. Filley CF. Beckwilt HI. Reeves IT. Mitchell RS:
1 948 Chronic obstructive bronchopulmonary disease
Bade PL. McMichan Ie. Marsh HM: Continuous II: oxygen transport in two clinical types. Am I
monitoring of mixed venous oxygen saturation i n Med 44:26. 1 968
Finer NN. Boyd J: Chest physiotherapy in the neo berschmid M: Can postoperative pulmonary can
nate: A controlled study. Pediatrics 61:282-285. ditions be i mproved by treatment with the 8art
1 978 lell-Edwards Incentive Spirometer after upper
General Physiotherapy: G5 Massage Apparatus. abdominal s urgery? Acto A noesthesiol Scond
General Physiotherapy. St. Louis. 1 979 23,312-319. 1 979
Gold MI: Is intermitlenl positi ve-pressure breathing Mackenzie CF. Shin B. McAslan TC: Chest physio
therapy (JPPB Rx) treatment necessary in the sur therapy: The effect on arterial oxygenation.
gical patient? Ann Surg 184:122-123. 1976 Aneslh Anolg (Cleve) 57,28-30. 1 978a
Gormezano I. Branlhwaite MA: Effects of physio Mackenzie CF. Shin B: Evaluation of physical ther
therapy during intermittent positive pressure apy [Ieller). N Engl J Med 301 ,665-666. 1978b
ventilation. Anaesthesia 27:258-263. 1972 Mackenzie CF. Shin B. Friedman S. Wai M: Evalu
Graham WGB. Bradley DA: Efficacy of chest phys ation of total l ung/thorax vs stalic lung compli
iotherapy and intermittent positive-pressure ance. Anesthesiology 51:5381. 1979
breathing in the resolution of pneumonia. N Engl Mackenzie CF. Shin B. Hadi F. lmle PC: Changes in
J Med 299,624-627. 1978 total l u ng/thorax compliance following chest
Crimby G: Aspects of lung expansion in relation to physiotherapy. Aneslh Analg (Cleve) 59:207-210.
pulmonary physiotherapy. Am Rev Respir Dis 1 980
1 10[2),145-1 53. 1 974 Mackenzie CF. Shin B: Cardiorespiratory function
Hedstrand U. Liw M. Rooth C. Ogren CH: Effect of before and after physiotherapy in mechanically
respiratory physiotherapy on arterial oxygen ten ventilated patients with post-traumatic respira
sion. Acta Anaesthesial Scand 22:349-352. 1978 tory failure. Crit Care Med 1 3 :483-486. 1 985
Ingram RH: Mechanical aids to lung expansion. Am Macklem PT: Airway obstruction and collateral
Rev Respir Dis 122(2):23-24, 1 980 ventilation. Physiol Rev 5 1 :368-436. 1971
Inners CR. Terry PD. Traystman RJ. Menkes HA: Ef Macklem PT: Collateral ventilation. N Engl J Med
fect of lung volumes on collateral and airway re 298,49-50. 1978
sistance in man. J App/ PhysiaI 46:67-73. 1979 Macklin CC: Alveolar pores and their significance
Jones NJ: PhYSical therapy-present slate of the art. in the human lung. Arch Potho/ 21 :202-216. 1936
Am Rev Respir Dis 1 1 0(2): 1 32-136. 1974 Marini JI. Pierson OJ. Hudson LD: Acute lobar atel
Kaneko K. Millic-Emili J. Oolovich MD: Regional ectasis. A prospective comparison of fiberoptic
distribution of ventilation and perfusion as a bronchoscopy and respiratory therapy. Am Rev
function of body position. J Appl PhysioI 2 1 : 767- Respir Dis 1 1 9:971-978. 1 979
782. 1966 Martin HB: The effect of aging on the alveolar pores
Kaplan I. Koehler RC. Terry PB. Menkes HA. of Kahn in the dog. Am Rev Respir Dis 88:773-
Traystman RJ: The effects of l u ng volume on col 778. 1 963
lateral and small airways resistance in the dog. Martin HB: Respiratory bronchioles as the pathway
(Abstract) Am Rev Respir Dis 1 1 9:322. 1979 for collateral ventilation. J App/ Physiol 21:1443-
"'Iein P. Kemper M . Weissman C. Rosenbaum SH. 1447. 1 966
Askanazi J. Hyman AI: Attenuation of the hemo May DB. Munt PW: Physiologic effects of chest per
dynamic responses to chest physical therapy. cussion and postural drainage in patients with
Chesl 93,38-42. 1988 stable chronic bronchitis. Chest 75:29-32. 1979
Kahn HN: Zur histologic der indurirended fibren McAslan TC: Au tomated respiratory gas monitoring
053 pneumonie. Munch Med lVochensdir 40:42- of critically ill patients. Crit Core Med 4:255-260.
45. 1893 1976
Konno K. Mead I: Measurement of the separate vol McConnell DH. Maloney IV. Buckberg GO; Postop
ume changes of the rib cage and abdomen during erative intermittent positivepressure breathing
brea1hing. J Appl Physio/ 22,407-422. 1 967 treatments. J Thoroc Cordiovosc Surg 68:944-952.
I(uriyama T. Latham LP. Horwitz LD. Reeves IT. 1974
Wagner WW: Role of collateral ventilation in ven Mcintyre RW. Laws AK. Ramanchandran PR: Posi
tilation-perfusion balance. J App/ Physio' tive expiratory pressure plateau: Improved gas
56,, 500-, 506. ,984 exchange during mechanical ventilation. Can An
Lambert MW: Accessory bronchiolealveolar com oeslh Soc / 1 6:477-486. 1969
munications. J Pothol 80clerioI 70:311-314. 1955 Mead I: Respiration: pulmonary mechanics. Ann
Laws AK. Mcintyre RW: Chest Physiotherapy: A Rev Physio/ 35:169-192. 1973
phYSiological assessment during intermittent pos Mellins RB: Pulmonary physiotherapy in the pedi
itive pressure ventilation in respiratory failure. atric age group. Am Rev Respir Dis 1 1 0(2):137-
Can Anoeslh Soc / 1 6:487-493. 1969 142. 1 974
Lindholm C-E. Oilman B. Snyder J. Millen E. Gren Menkes HA, Britt J: Rationale for physical therapy.
vik A: Flexible fiberoptic bronchoscopy in critical Am Rev Respir Dis 122(2):127-131. 1980
care medicine. Crit Care Med 2:250-261. 1974 Menkes H. Gardiner A. Gamsu G. Lempert J. Mack
Loosli CG: Interalveolar communications in normal lem PT: Influence of s urface forces on collateral
and in pathologic mammalian l ungs. Arch Pothol ventilation. / Appl Physio/ 3 1 :544. 1971
24:743-767. 1937 Menkes HA. Traystman RJ: State of the art. Collat
Lundgren R. Haggmark S. Reiz S: Hemodynamic ef eral ventilation. Am Rev Respir Dis 1 1 6:287-309.
fects of flexible fiberoptic bronchoscopy per 1977
formed under topical anesthesia. Chest 82:295- M u rray IF: Reply to correspondence on evaluation
299. 1 982 of respiratory physical therapy. N Engl I Med
Lyager S. Wernberg M. Rajani N. B0ggild-Madsen B. 301 ,666. 1979
Nielsen L. Nielsen HC. Andersen M. Meller I. SiI- M u rray JF: Indication for mechanical aids to assist
lung innalion in medical patients. Am Rev Respir Shim C. Bajwa S, Williams MH: The effect of inha
Dis 122(2): 1 2 1 - 1 25. 1 980 lation therapy on ventilatory function and expec
Newton DAG. Stephenson A: Effect of physiother toration. Chest 73:798-801. 1978
apy on pulmonary (unclion. Lancet 2:228-230. Sinha R, Sergofsky EH: Prolonged alteration of lung
1978 mechanics in kyphoscoliosis by positive-pressure
O'Donohue WI: Maximum volume (PPB for the hyperinflation. Am Rev Resp;r Dis 106:47-57,
management of pulmonary atelectasis. Chest 1972
76:683-687. 1979 Sylvester IT. Menkes HA: Pulmonary interdepen
Opia LH. Spalding JMK: Chest physiotherapy duro dence during spontaneous and artificial ventila
ing intermittent positive pressure respiration. tion in the pig. {Abstract} Am Rev Respir Dis
Loncet 2:671-674. 1958 1 1 1 :942. 1975
Pavia D, Thomson ML. Phillipakos 0: A preliminary Sylvester IT. Menkes HA. Stitik F: Lung volume and
study of the effect of a vibrating pad on bronchial interdependence in the pig. 1 Appl Physiol 38:395,
clearance. Am Rev Respir Dis 1 1 3:92-96. 1976 1975
Peters RM. Turnier E: Physical therapy: Indications Terry PS, Menkes HA. Trayslman RI: Effecls of
for and effecls in surgicaJ patients. Am Rev Respir maturation and aging on collateral ventilation in
Dis 122(2t.147-154. 1 980 sheep. } App/ Physio/ 62:1 028-1032. 1 987
Pelly TL: A critical look at IPPB (editorial). Chest Terry PD. Traystman RI. Menkes HA: The clinical
66:1-3. 19748 significance of collateral ventilation. Personal
Petty TL: Physical therapy. Am Rev Respir Dis communication. 1 985
1 1 0(2):129-130. 1 974b Terry PS, Traystman RI. Newball HH, Balra G,
Pontoppidan H: Mechanical aids to IUl1g expansion Menkes HA: Collateral ventilation in man. N Engl
in non-intubated surgical patients. Am Rev Respir I Med 298:10-15. 1 978
Dis 1 22(2):109- 1 1 9 . 1 980 Thomson ML, Pavia D, Jones CI, McQuiston TAC:
Remolina C, Khan AV. Santiago TV. Edelman NH: No demonstrable effect of S-carboxymethyl
Positional hypoxemia i n unilateral lung disease. cysteine on clearance of secretions from the
N Eng/ ) Med 304:523-525. 1981 human lung. Thorox 30:669-673. 1975
Richardson 10, Adams L. Flint LM: Selective man Trayslman RJ. Terry PB. Menkes HA: Carbon di
agement of flail chest and pulmonary contusion. oxide-a major determinant of collateral venti
Ann Surg 1 96:481-485. 1982 lalion. 1 App/ PhysioI 45: 69-74 . 1978
Ricker lB. Haberman B: Expired gas monitoring by Van Allen CM. Jung TS: Postoperative atelectasis
mass spectrometry i n a respiratory intensive care and collateral respiration. J Thoroc Surg 1 : 13-14.
unit. Crit Care Med 4:223-229, 1916 1931
R i vara 0, Artudo H . Arcos J. Hiriart C: Positional Van Allen CM. Lindskog GE: Collateral respiration
hypoxemia during artificial ventilation. Crit Care in the lung. Surg Gyneco! Obstet 53:16-21. 1931
Med 1 2:436-438. 1984 Vraciu JK, Vraciu RA: Effectiveness of breathing ex
Rochester OF, Goldberg SK: Techniques of respira ercises in preventing pulmonary complication
tory physical therapy. Am Rev Respir Dis following open heart surgery. Phys Ther 57:1 367-
122(2):133-146. 1 980 1 3 7 1 . 1977
Rosenberg DE. Lyons HA: Collateral ventilation in Wagner PO. Dantzker VE. lacovoni we. Tomlin
excised human l u ngs. Respiration 37:125-134, WC. West IB: Ventilat ion-perfusion inequality in
1979 asymptomatic asthma Am Rev Respir Dis
Rubi JAG. Sanartin A . Oiaz GG. Apezteguia C, Mar 1 1 8:51 1-524. 1 978
tinez GT. Rubi ICM: Assessment of total pul mo Wagner PO, Saltzman HA. West IB: teasurement of
nary airway resistance under mechanical venti continuous distributions of ventilat ion-perfusion
lation. Crit Care Med 8:633-636. 1 980 ratios: Theory. 1 Appl Physiol 36:588-599. 1974
Sackner MA. Wanner A, Landa I: Applications of Wei ply NC. Mathias CI, Frankel HL: Circulatory re
bronchofiberscopy. Chesl (Suppl) 62:70-78, 1972 Oexes in tetraplegics during artificial ventilation
Sackner MA: State of the art bronchofiberscopy. Am and general anesthesia. Paraplegia 13:172-182.
Rev Respir Dis 1 1 1 :62-88. 1915 1975
Sands IH. Cypert C. Armstrong R, Ching S, Trainer Winning TJ. Brock-Utne IG. Goodwin NM: A simple
D. Quinn W. Stewart 0: A controlled study using clinical method of quantitating the effects of
routine intermittent positive-pressure breathing chest physiotherapy in mechanica lly ventilated
in the post-surgical patient. Dis ChesI 40:128-133, patients. Anoeslh In tensive Core 3:237-238. 1975
1961 Zack MB. Pontoppidan H. Kazaim H: The effects of
Schmerber I, Deltenre M: A new fatal complication lateral position on gas exchange in pulmonary
of transtracheal aspiration. Scand 1 Respir Dis disease. Am Rev Respir Dis 1 10:49-55. 1979
59:232-235. 1978 Zidulka A. Demedts M, Nadler S. Anthonisen NR:
Shim C, Fine N. Fernandez R. Williams MH: Car Pleural pressure with lobar obstruclion indogs.
diac arrhythmias resulting from tracheal suction Resp Physiol 26:239-248, 1976
ing. Ann Intern Med 7 1 : 1 1 49-1153. 1 969
CHAPTER 8
Chest Physiotherapy for Special

Patients
Pediatric Patients
Infants
Children with Cystic Fibrosis
Neurologically Impaired Children
Patients with Brain Injury
Guidelines for Chest Physiotherapy Treatment
Measures to Reduce ICP
Routine Care for the Unconscious Patient
Quadriplegic Patients
Respiratory Muscle Function/Thoracic Cage Mobility
Chest Physiotherapy Treatment
Patients with ChronIc Lung Disease
Asthmatic Patients
This chapter discusses chest physio and acute bronchiolitis receIVIng chest
therapy for patients with specific prob physiotherapy (Webb et al.. 1985; Levine.
lems predisposing to retention of lung se 1978).
cretions. Acute and chronic diseases are
included and individual approaches to Infants
treatment are described for each group of
patients. The literature appropriate to Ful l-term infants and adults have ana
these groups is reviewed. tomical similarities and differences. At
birth. all large airways are formed; the
trachea and bronchi rapidly i ncrease in
PEDIATRIC PATIENTS
length and diameter during the first few
months of l i fe (Doershuk et aI., 1975). I n
Physiotherapy is indicated i n pediatric the neonatal period t h e trachea i s funnel
patients with neurological impairment. shaped (upper end wider than the lower
asthma. cystic fibrosis. or following me end). and becomes cylindrical within the
conium aspiration (Crane. 1981; 1985; first 5 years of life (Wailoo and Emery,
DeCesare. 1985; DeCesare et al . 1982;
. 1 982). The respiratory zone of the lung is
Parker, 1 985). It is also indicated when composed of three generations of respi
secretion retention occurs after surgery. ratory bronchioles and one order of al
As with the adult population, decreased veolar ducts and sacs. By 2 months of age.
morbidity and duration of fever, and im four generations of respiratory bronchi
provement in chest x-ray are not docu oles and three of alveolar ducts are pres
mented in patients with viral pneumonia ent. Because of the lack of smooth muscle
251
development until 3-4 years of age, the a!. (1975) report twice as many glands per
bronchiole walls are weak in early child unit surface area in children under 4
hood. Alveolar surface area is 5% that of compared with the adult. Goblet cells
the adult Oohnson et a!., 1978). Collateral may extend beyond the cartilaginous
ventilation is acquired after birth. The portion of the tracheobronchial tree into
pores of Kohn appear in the first year of the bronchioles and replace ciliated cells
life and increase in size and number with in disease (DeCesare, 1985).
age (Menkes and Traystman, 1977). The rib cage of an infant is circular in
Channels of Lambert are most l i kely the horizontal plane (Muller and Bryan,
present by 6 years of age (Macklem, 1979) and the diaphragm has a horizontal
1977). Alveolar ducts are thought to in insertion. Twenty-five percent of the
crease in number until 8 years of age, al muscle fibers are type I red, slow-twitch,
though the precise age at which alveolar fatigue-resistant muscle fibers compared
growth stops is unknown (Angus and with 50% in the adult.
Thurlbeck, 1972). Alveolar ducts in The physiological consequences of
crease in size until adulthood when the these anatomical differences between
chest wall is fully developed. Elastic fi child and adult include reduced compli
bers surrounding the alveoli are not fully ance of the i n fant lung with i ncreased
mature until adolescence. Therefore, the chest wall compliance. A decreased
majority of lung development occurs by number of oxidative muscle fibers in the
2 years of age with lung growth continu diaphragm make the infant more suscep
ing until adulthood (Fig. 8.1). tible to respiratory muscle fatigue and
The i nfant and child under 4 years of subsequently respiratory muscle failure
age have more mucus glands per surface (Muller and Bryan). Decreased surfactant
area of bronchi than adults (Lough et a!., leads to alveolar collapse. Premature in
1974; Hislop and Reid, 1974). Doershuk et fants may also have decreased flow rates
FETAL AND POSTNATAL LUNG DEVELOPMENT AND GROWTH
'------' I W"
I IPSf"
-"'='"
LUNG DEVELOPMENT :;i; LUNG GROWTH
r-
20 6 9 1 2 3 4 5 6 7
Fertihzdion YEARS AGE
BIrth
Figure 8.1. Fetal and postnatal lung development from fertilization to age 7. Note that the majority
of lung development takes place before age 3; alveolar growth continues until adulthood. (From
The postnatal development and growth of the human lung. II. Morphology. B Zeltner and PH Burri:
Respir Physio/67:269-282, 1987.)
CHEST PHYSIOTHERAPY FOR SPECIAL PATIENTS 253
and increased resistance in the periph age from suctioning. Pediatric respiratory
eral airways (Stocks and Godfrey, 1976). disease is a risk factor for development of
Children have less pulmonary reserve atelectasis and chronic lung disease
than adults, probably related to increased (Streider, 1974). Long-term residual ab
resting oxygen consumption in relation normalities i n lung function may occur
ship to lung surface area (Doershuk et (Kallen, 1979).
al.). The small airway diameter, large Chest physiotherapy does not appear to
size, and high density of mucus glands alter the disease processes of hyaline
and reduced struclural support of the air membrane disease, acute bronchiolitis,
way may increase the chance of airway and meconium aspiration. In a controlled
occlusion. The sick neonate may be more study evaluating the effects of chest
prone to increased secretion production physiotherapy on 90 i n fants with acute
and therefore retention. In fants who de bronchiolitis chest physiotherapy did not
velop bronchopulmonary dysplasia have decrease the severity or length of the dis
a high incidence of recurrent pulmonary ease process (Webb et al. 1985). Treat
infection in the first 2 years of life Uohn ment included 3 m i n of chest percussion
son et aI., 1974). Myers et al. (1 986) did i n 5 postural drainage positions followed
nol find an increased risk in the by assisted coughing or oropharyngeal
frequency of respiratory illness in a com suction. Indications for treatment did not
parison of preterm infants with and specifically relate to the infant's secre
without respiratory distress syndrome tion production or radiological evidence
(RDS), although RDS survivors experi of atelectasis or infiltrate. The primary
enced more severe and lower respiratory indications for chest physiotherapy treat
infections at a younger age. In fants may ment are retained secretions resulting
also have a higher incidence of laryngeal from prolonged intubation and mechani
injury following extubation. Fan et aI., cal ventilation, i ncreased mucus produc
1982, documented a 44% incidence of tion, narrowing and decreased smooth
moderate or major laryngeal injury after muscle of i n fant airways, decreased col
extubation. lateral ventilation, and immobility.
Intubation may also contribule to se Marked variations i n technique may
cretion retention in the neonate. Whit account for conflicting results noted in
field and Jones (1 980) found that the in research evaluating chest physiotherapy.
tubated infant with hyaline membrane I n some studies the methods of perform
disease, weighing less than 1500 gm, had ing chest physiotherapy are not de
an increased incidence of atelectasis, di scribed, while in others the duration of
rectly related to the duration of intuba treatment and the use of hyperinflation,
tion. The right upper lobe is most fre percussion, vibration, or postural drain
quently involved both while the infant is age differ. One important difference i n
intubated and following extubation. The administering chest physiotherapy 10 the
right lung is more often affected than the neonate versus the adult is the i n fant's
left. The primarily right-sided atelectasis response to handling. This may signifi
may be due to malalignment of the tra cantly alter both the scheduling and d u
cheal tube or mucosal damage of the ration o f therapy. It i s also more difficult
right main stem bronchus resulting from to clinically assess lobar or segmental
prolonged intubation, suctioning, and sa lung pathology. Chest x-ray reports and
line lavage (Roper et aI., 1976; Whitfield the secretions obtained during and after
and Jones). For this reason, Roper and treatment may be more important deter
colleagues recommend vigorous chest minants of appropriate positioning and
physiotherapy primarily to the right duration of therapy than auscultation
upper lobe, commenced as soon as the in and diagnostic percussion. Infants with
fant is intubated and continued for sev prolonged respiratory distress are prone
eral days after removal of the tracheal to stress fractures of the ribs (Burnard et
tube. These authors also recommend that aI., 1965; Parker, 1985). Manual tech
chest physiolherapy should not be per niques Iherefore should be carefully
formed more frequently than every 3 hr. performed by experienced health care
This minimizes bronchial mucosal dam- personnel (pp. 144).
Clinical Assessment the reduced occurrence of apnea in the

prone position may result from improved
The clinical assessment of the i n fant is ventilation and oxygenation. Martin and
the same as that for the adult (p. 74) with colleagues studied 16 preterm infants
a few exceptions. The therapist should with a mean birth weight of 1.53 kg and
be aware of additional clinical signs of concluded that placing infants in the
respiratory distress, for example, expira prone position may significantly reduce
tory grunting, head bobbing, retractions morbidity and mortality. The prone po
of the rib cage, and stridor. Treatment sition may stabilize the compliant chest
should be carried out after assessing the wall of the infant and improve coordina
specific indications for treatment and the tion between rib cage, diaphragm, and
infant's oxygenation. Information gained abdominal movement. As with other pa
from chest x-ray. auscultation, the in tient populations, routine positioning
fant's response to handling, position and suctioning may minimize the need
change, and suctioning is utilized to plan for chest physiotherapy treatmenl (Tu
appropriate treatment. Tactile stimula dehope and Bagley, 1980).
tion associated with auscultation of the
chest should be minimized (Klaus et aI.,
1979). Positioning may be determined by
the quantity or quality of secretions ob Arterial Oxygenation
tained from draining specific lung
Holloway et al. (1 966) found a tempo
segments.
rary decrease in arterial oxygenation
after chest physiotherapy in eight neo
Handling/Positioning nates suffering from tetanus. Oxygen
ation returned to normal 1 hr after treat
Excessive handling of the low-birth ment. In 1969, Holloway et al. published
weight infant causes hypoxemia (Long et similar findings, but noted that the fall in
aI., 1980; Speidel, 1978). Yeh and col oxygenation could be reversed with lung
leagues (1982) documented significant in hyperinflation. This did not alter any
creases i n oxygen consumption with in long-term decrease in PaO,. Fox et al.
travenous line insertion, heel sticks, and (1978) also found that mean PaO, de
chest percussion. Danford et al. (1983) creased 30 torr in 13 neonates breathing
noted positioning for chest x-rays had the with continuous positive airway pres
greatest fall i n TcP02. when studying 8 sure. Chest physiotherapy consisted of
routine ICU procedures. Continuous mechanical chest vibrations and suction
monitoring of pulse oximetry or trans ing in the supine position. This fall was
cutaneous oxygen pressure (TcP02) al thought to be the result of increased
lows identification of u nacceptable oxy right-to-Ieft cardiac shunting due to
genation during routine intensive care coughing and suctioning. In 1978, Finer
unit procedu res such as chest physio and Boyd noted that PaO, rose during
therapy, handling, and suctioning (Spei chest physiotherapy treatment. Etches
del). For infants whose PO, d rops during and Scott (1978) found that four hourly
handling, chest physiotherapy should be chest physiotherapy treatments to the
scheduled around other routine proce lower lobes of six neonates produced
d ures. greater quantities of secretions than did
Research is inconclusive regarding op suctioning alone. During chest physio
timum positioning of infants. Tidal vol therapy and monitoring of transcutane
ume and minute ventilation increase and ous oxygen tension (TcP02) in a crying
periods of apnea are reduced i n the prone infant, fell. However, it remained stable
compared to supine position; a 25% in when the child was quiet. Ten minutes
crease i n PaO, is also documented (Mar following the procedure, TcP02 in
tin et aI., 1979; Dhande et aI., 1982). Spe creased (Gregory, 1980). Tudehope and
cific anatomical areas of lung pathology Bagley (1 980) evaluated contact heel per
were not described in either study. cussion, cupping with a Bennett face
Dhande and colleagues studied five pre mask, and vibration using an electric
term infants with birth weights of 1030 to toothbrush applied to 15 consecutively
1817 gm. These authors speculated that born infants with respiratory distress
syndrome (RDS). The infants tolerated than controlled ventilation to minImize

chest physiotherapy with the first two decreases in PaO, associated with suc
techniques very well with a statistically tioning. Simbruner and colleagues also
significant i ncrease in PaO, (see Chapter noted TcP02 measurements to have a 2
4). Chest physiotherapy given to 7 neo min delayed response when compared to
nates, which consisted of positioning i n PaO,. Tracheal stimulation is associated
the head-up and head-down positions for with i ncreased i ntracranial pressure i n
60 sec and suctioning, showed no signif brain injured children (Fisher e t aI.,
ieant improvement in TcP02 [Raval et 1982). Preterm infants may be at greater
aI., 1981}. Walsh et a!. (1987) and Barnes risk of intraventricular hemorrhage after
et a!. (1981) noted a decrease in TcP02 suctioning (Perlman and Volpe, 1983).
during chest physiotherapy although Suctioning of intubated infants is rec
postural drainage was not used in either ommended when secretions are most
study. The results of these studies may likely present . Suctioning should be car
have been different if longer periods of ried out during chest physiotherapy
postural drainage were given to the most treatment or in conjunction with routine
involved lung lobes or segments. This i n position changes. The child's response to
itself would minimize handling and suctioning is observed closely. The non
allow more time for secretions to drain intubated infant who does not cough
from peripheral airways. I n view of these spontaneously should have the orophar
results, no definite conclusions can be ynx suctioned after postural drainage;
drawn as to whether chest physiotherapy this may cause secretions to gravitate to
produces hypoxemia in the neonate, es the carina and stimulate a cough. Mild
pecially since the cardiac effects of chest stimulation over the trachea is another
physiotherapy were not evaluated. beneficial cough stimulation technique
that may be used following postural
drainage. Head-up, head-down, prone,
and supine positions and lying on the
Lung Hyperinflation, Suctioning,
right and left sides are encouraged i n the
Postural Drainage
patients turning schedule. Mobilization
Chest care for the pediatric intensive helps prevent stagnation of peripheral
care unit (ICU) patient with retained se secretions in the gravity dependent areas
cretions does not vary much from the of the lung and minimize the need
care provided to a similar adult patient. for chest physiotherapy treatment (Fig.
Hyperinflation with supplemental oxy 8.2).
gen before and after suctioning may be Chest physiotherapy treatments are
critical to reverse hypoxemia and airway modified according to secretion produc
closure (see Chapter 5). The literature is tion, the incidence of apneic episodes,
inconclusive as to whether bagging with clinical signs of respiratory distress,
100% oxygen. which may result in hy changes in vital signs and changes or a
peroxemia, is necessary when 5uctioning fall in TcP02. Crane (1981) recommends
neonates. Raval et a!. (1980) recommend treatment be given for 3-5 min per lung
using 1 00% 0, only when the infant's segment. The most involved lung seg
baseline PaO, is hypoxemic. Barnes ments are treated first. It is more impor
(1 981) found decreases in oxygenation tant to adequately treat involved lung
associated with suctioning to be mini segments than routinely perform treat
mized when the ventilator rather than ment to all lung segments. It may be nec
bagging was used prior to suctioning. essary to address different lung segments
Walsh and associates suggest that con during each treatment. Chi ldren with
trolling supplemental oxygenation with meconium aspiration should receive
out manual bag ventilation is sufficient chest physiotherapy from birth until they
with a shorter recovery time. Ok ken et are free of meconium staining. The effect
a!. (1978) found bag ventilation to be ben of short sessions (5-10 min) given every
eficial in quiet infants while PaO, signif hour or two versus longer sessions ( 1 5-45
icantly decreased in restless infants, yet min) given every 4-6 hr requires further
Simbruner et a!. (1981) advocate using investigation. Differences in alveolar
ventilators with simultaneous rather number and size, collateral ventilation,
Figure 8.2. An infant with respi

ratory distress syndrome is posi
tioned prone over a rolled towel to
promote drainage of secretions
from the posterior segments of the
lower lobes.
and airway diameter may affect treat piration technique (see Chapter 3). A 25
ment time in the infant compared with head-down position improves mucus
procedures used i n the adult. transport rates in patients with cystic fi
brosis (Wong et aI., 1977). Whether
Children with Cystic Fibrosis
mucus is primarily mobilized from the
central or peripheral airways is currently
The objective of a chest physiotherapy unknown.
program in the treatment of cystic fibro Several studies on patients with cystic
sis is to prevent or delay irreversible pul fibrosis have tried to document improve
monary fibrotic changes resulting from ment in pulmonary function after chest
repeated infections. It is generally ac physiotherapy. The most consistent im
cepted that chest physiotherapy is indi provement is in peak expiratory flow rate
cated once the diagnosis is made. Physi (PEFR). Tecklin and Holsclaw (1975)
cal therapists usually perform treatment found significant increases in forced vital
during acute exacerbations of the disease capacity (FYC), PEFR, inspiratory capac
that require hospitalization. Parents as ity, and expiratory reserve volume 1 0
sume the responsibility at home until the min after treatment, which included six
child can perform treatment indepen postural drainage positions. Motoyama
dently. Compliance is often a problem (1973) showed significant improvement
because of the time and stress placed on in FYC, PEFR, and maximum expiratory
the family and psychosocial effects of the flow at 50% and 25% vital capacity (YC)
disease, particularly during adolescence. both at 5 and 45 min after chest physio
Currie et aI., 1986, documented only a therapy. Feldman et al. (1979; Feldman
46% compliance with postural drainage 1976) documented improvement in FVC,
at home in 50 outpatients with chronic PEFR, forced vital capacity in 1 min
respiratory diseases which included cys (FEY,), and Ymu 50 and V m.. 25 (maxi
tic fibrosis. The optimum frequency or mum expiratory flow rates at 25 and 50%
duration of chest physiotherapy relative vital capacity) 5, 15, and 45 min after 30
to severity of disease is not yet deter min treatment, which included six pos
mined. The effects of cough alone or gen tural drainage positions. More recent in
eral physical conditioning influence vestigators of cystic fibrosis were unable
treatment necessity and frequency. The to reproduce many of these findings. Za
effects of chest physiotherapy are eval pletal and colleagues (1983) did not find
uated by pulmonary function tests, significant improvement in any pulmo
measurements of expectorated sputum nary function measurements 30 min after
volume, and the inhalation of radionu treatment; V m" 25 deteriorated. A second
cleides. Chest physiotherapy is shown to group of patients with cystic fibrosis was
increase the volume of sputum expecto studied at 3-month intervals 20 min and
rated (Denton, 1 962; Lorin and Denning, 2 hr after treatment: no significant im
197 1 ; Sutton et aI., 1 985). Treatment time provement was noted. Specific airway
ranged from 1 2 to 30 min for bronchial conduction showed some improvement
drainage, percussion, and vibration. Den in 20% of the patients. Kerrebijn et al.
ton used mechanical percussion and vi (1982) also evaluated changes in pulmo
bration, Sutton et al. added the forced ex- nary function 1 and 4 hr after treatment.
The only statistically significant im ference in sputum characteristics or pul

provement noted was i n two patients monary function. It is interesting to note
whose expiratory resistance to flow of that Bain and colleagues eliminated sub
the upstream airways improved. Sulton jects under 7 years who did not have an
et al. (1 985) found no change in pulmo effective cough, or were u n reliable with
nary function when evaluating four dif pulmonary function testing. This may be
ferent chest physiotherapy regimes. Wel the group of patients most responsive to
ler et al. (1 980) demonstrated significant chest physiotherapy. Pulmonary func
improvement in PEFR on days when tion and aerosol clearance techniques de
chest physiotherapy was given versus posited i n the central airway may not be
the control day. FVC and FEV, improved sensitive enough to measure the effect of
on both treatment and control days, most chest physiotherapy treatment on the i n
likely as a result of normal physical ac termediate an d smaller airways. Krypton
tivity. When Desmond et al. (1 983) eval scintigraphy is thought by some investi
uated pulmonary function in eight chil gators to provide a more sensitive mea
dren with stable mild to moderate sure of peripheral airway clearance.
disease, 30 min after treatment, only DeCesare et aJ. (1982) demonstrated im
PEFR improved significantly. Chest provement in ventilation (peripheral air
physiotherapy was withheld for 3 weeks, way clearance) in three patients with se
resulting in a significant decrease in FVC, vere disease, although the results of the
FEV" forced expiratory flow rate be study were not statistically Significant.
tween 25 and 75% vital capacity (FEF25- The outcome may have been different if
75), and the maximal expiratory flow rate the primary areas of lung involvement
at 60% of total lung capacity (Vm"tlc). were determined prior to treatment and
Reinstituting a single treatment of chest therapy directed speCifically to diseased
physiotherapy increased FVC and V m"t1c lung segments.
30 min after treatment; the i ncreased air The effect of regular exercise on pul
flow limitation completely reversed 3 monary function was recently evaluated
weeks after resuming treatment. I t ap with the goal of replacing chest physio
pears that pulmonary function is not sig therapy treatment with a less time-con
nificantly altered as a result of a single suming, more normal activity. Henke and
chest physiotherapy treatment but may Orenstein (1 984) studied 91 stable and
deteriorate if treatment is withheld when hospitalized patients with cystic fibrosis
assessed by serial pulmonary function and found the majority to tolerate maxi
tests. mal exercise without significant oxygen
A major area of controversy in the lit desaturation. Oxygen aesaturation was
erature is the effect of cough versus chest not related to severity of the disease.
physiotherapy treatment, and whether Cropp et al. (1982) found that 20 cystic fi
either treatment removes secretions from brosis subjects with m i l d or moderate
the central versus peripheral airways disease exercised as well as normal sub
(see Chapter 5). Rossman et al. (1982) jects. Daily physical exercise may i n
evaluated the removal of radiolabeled clude swimming, hiking, and jogging, and
serum albumin aerosol from the large replace chest physiotherapy treatment.
airways and concluded that cough was as Forced vital capacity, FEV" FEF25-75,
effective as chest physiotherapy treat and PEFR improved with these activities
ment in stable disease. Zinman and (Zach et aI., 1981, 1982). Most pulmonary
DeBoeck (1984) evaluated nine patients function measurements returned to base
with cystic fibrosis in stable condition line 8-10 weeks after training. Keens
who had moderate disease. Twenty-five (1977) demonstrated that physical exer
minutes of chest physiotherapy in 11 po cise was as effective as ventilatory mus
sitions was compared with vigorous cle training (see Chapter 3). Improvement
coughing 11 times in 10 min. Neither of airway function is thought to depend
treatment demonstrated improvement i n on physical activity. Orenstein and col
pulmonary function. Comparing super leagues (1981) fou n d that 3 months of a
vised coughing to chest physiotherapy i n jog-walk exercise program significantly
3 8 patients Bain et al. (1988) found n o dif- increased exercise tolerance and peak
oxygen consumption. Parameters used to impaired. This may lead to secretion re

determine when strenuous exercise can tention, orthostatic pneumonia, and re
be performed safely, without supervised current chest infections. A habilitative
exercise testing and ear oximetry include physiotherapy program for these patients
a FEV, less than 50% vital capacity or is aimed at facilitating normal motor de
pulmonary function score >12 deter velopment. Parental participation is
mined from 6 pulmonary function meas encouraged.
urements (Cropp et al.. 1982; Henke and The cerebral palsy child with marked
Orenstein. 1984). Daily physiotherapy spasticity sufficient to interfere with nor
may be replaced by frequent swimming mal intercostal and diaphragmatic activ
or other physical activity, particularly in ity may require specific body positioning
mild to moderate disease, following fur to minimize spasticity and encourage re
ther investigation. laxation (Finnie, 1971). This allows pos
In summary, chest physiotherapy is tural drainage and improved costal ex
often performed for cystic fibrosis regard cursion to occur more easily. Vibration,
less of the severity of disease. This may or any stimulation, may increase exten
account for the conflicting evidence re sor spasticity. As a result, treatment may
garding the efficacy of chest physiother be limited to postural drainage with gen
apy. Treatment is directed to 4-11 lung tle percussion. Normal active or sponta
segments per treatment lasting 2-30 min. neous movement is encouraged while
Some authors (Pryor and Webber, 1979) the child is in the ICU. Individual child
advocate use of the forced expiration evaluation is essential and beyond the
technique to enhance sputum expecto scope of this book.
ration and minimize airway collapse as
sociated with coughing. Currie et al. PATIENTS WITH BRAIN INJURY
(1986) believe that percussion and shak
ing should not be taught to cystic fibrosis Approximately 500,000 Americans
patients. They believe these techniques sustain brain injury per year, with a mor
should be replaced by the forced expira tality ranging from 17 to 70% Uennett and
tion technique (pp. 121-122) and directed Teasdale, 1981; Geisler and Saleman,
cough. The effect of chest physiotherapy 1987; Seigel. personal communication).
treatment compared with cough alone Brain injury is estimated to be present in
and physical exercises requires further 75% of young people who die from motor
study to determine when each of these vehicle accidents (Auer et aI., 1980). The
therapies is most appropriate. Patients highest mortality is in centers without
with acute exacerbations of cystic fibro specialty neurotrauma units (Matjasko
sis continue to require chest physiother and Pitts, 1 986). Siegel (personal com
apy treatment. Treatment is emphasized munication) evaluated 1709 traumatic
in lung areas where radiological or clini brain-injured patients with Glascow
cal evidence of disease is present. Fre Coma Scales (GCS) of 3-14 admitted to a
quency of treatment is determined by the level one trauma center from 1983 to
patient's activity level and sputum pro 1986 inclusive. Excluding cardiac arrests
duction; duration is judged by the pa on admission the overall mortality was
tient's clinical response to treatment. 17.5%. Single system injured patients
had a mortality of 11.1% compared to a
21.8% mortality when two or more sys
Neurologically Impaired Children
tems were injured. Three hundred eighty
Children with neurological impair (22.2%) of these patients had chest injury
ment are prone to respiratory complica in addition to brain injury and a 27.6%
tions requiring treatment in the ICU. mortality. Lung injury in 187 patients,
Muscular dystrophy, myelomeningocele which included lung contusion. lacera
with paraplegia, and cerebral palsy are tions, pneumothorax, and hemothorax,
just a few of the diseases which may in i ncreased the mortality to 34.2%.
terfere with the respiratory musculature. Twenty-eight percent of these patients
As a result. the cough mechanism and required in-patient rehabilitation. Mac
normal neuromuscular development are kenzie et al. (1979). including patients
dead on arrival to the trauma center, doc percussion in the supine head-down po
umented a higher mortality (49%) in 173 sition did not significantly alter cerebral
patients with closed head injuries admit perfusion pressure (CPP). McQuillan
ted directly from the scene of a motor ve studied 20 adult head-injured patients
hicle accident. Fulton and Jones (1975) receiving chest physiotherapy treatment
reported a 20% incidence of respiratory either in the side-lying flat or head-down
failure in patients with trauma affecling position. ICP was statistically higher in
the central nervous system. These statis the head-down position but returned to
tics demonstrate the need for intensive baseline more rapidly than for subjects in
pulmonary and rehabilitative care for the the nat position. CPP and mean arterial
brain-injured person, especially with as blood pressure (MABP) remained ade
sociated extracerebral injuries. quate throughout all treatments and PaD,
Damage to the central nervous system improved only after chest physiotherapy
may result in hypoxemia, noncardiac in the head-down position. 1mIe and as
pulmonary edema, altered patterns of sociates studied 16 patients following
respiration, and aspiration (Baigelman craniocerebral trauma with a GCS of 3-8.
and O'Brien, 1 981). Lack of spontaneous Chest physiotherapy was given to the
cough and immobility following brain in lower lobes, lingula, or right middle lobe
jury cause secretion retention and sub for 1 5 min. Subjects were randomly pos
sequent hypoxemia that may lead to the t ured head nat or head down. Positioning
development of cerebral edema. Patients was determined by latest chest x-ray and
with head injury, a normal chest x-ray, clinical assessment. No significant differ
and normal pulmonary capillary wedge ence in heart rate, MABP, ICP, end tidal
pressure have decreased ventilation and carbon dioxide tension (P"CO,), or CPP
increased perfusion while spontaneously was noted in the two positions before and
breathing (Schumacker et a!., 1979). The after treatment. ICP was greater in the
altered mental status, inability to protect head-down group but CPP and MABP re
the airway, and neurological deficits as mained adequate. Brimioulle and col
sociated with head trauma predispose leagues (1988) studied the effects of chest
the patient to aspiration. Hypoxemia as percussion on ICP in 32 brain-injured pa
sociated with secretion retention, atelec tients. ICP was not affected by chest per
tasis, and aspiration are indications for cussion but markedly increased while
chest physiotherapy treatment. Airway turning patients into the lateral decubi
suctioning and the position changes as tus position. Moraine et a!. (1988) evalu
sociated with routine nursing care and ated 18 patients with ICP monitoring and
chest physiotherapy treatment may be noted a significant but transient decrease
particularly hazardous to the brain-in in ICP with incentive spirometry and
jured person with elevated intracranial deep breathing exercises.
pressure. Therefore, chest physiotherapy Garradd and Bullock (1986) docu
treatment should be performed by mented that prolonged manual hyperin
trained health care personnel familiar flation raises ICP. CPP was not measured
with positioning the patient with abnor in the 20 subjects studied. ICP did not
mal muscle tone and acquainted with significantly increase in the pharmaco
ICU equipment, particularly intracranial logically paralyzed patients. Clinicians in
pressure monitoring (ICP) devices. many centers are reluctant to position
patients with head injury head down for
chest physiotherapy treatments to the
lower lobes, lingula, and right middle
Recent studies support giving chest lobe. However, the lower lobes are the
physiotherapy treatment following brain most frequently atelectatic or diseased
injury utilizing head-down postural (see Appendix A1.3). Respiratory dys
drainage positions (Hammon et a!., 1981; function increases shunt, decreases PaD"
McQuillan, 1 987; Imle et a!., 1 988). Ham and may increase mortality in patients
mon studied 11 patients, 8 with an initial with brain injury. It is the authors opin
ICP less than 17 and 3 with an initial ICP ion that chest physiotherapy which in
greater than 20. Bronchial drainage with cludes the manual techniques of per-
cussion and vibration can be safely per

formed in the head-down position with
the precautions described below. 80
ICP normally rises with coughing, Intracranial 60
sneezing, straining, or the head-down po Pressure
sition. Flexion, rotation, and extension of
the head may significantly affect ICP if I torr I 40
cerebral spinal fluid is squeezed from the B

20
subarachnoid space and trapped i n the A
cranial cavity (Shalit and Umansky,
1977). Spontaneous movements are asso Intracranial
ciated with the greatest i ncreases in ICP Volume
in infants (Tomney and Finer, 1980). In
the normal brain, ICP elevations may Figure S.3. Idealized intracranial pressurel
briefly reach 40-50 mm Hg during ma volume relationships. It may be necessary to
restrict chest physiotherapy only in patients
neuvers such as coughing but return to
whose cerebral compliance is low, beyond the
baseline levels rapidly because cerebral elbow of the curve between Band C.
compliance is high (Schullz and Taylor,
1977). In a patient with low cerebral com
pliance, elevations in ICP are prolonged, Guidelines for Chest Physiotherapy
and cerebral perfusion is reduced and Treatment
can be life t hreatening. CPP is calculated
as the difference between mean arterial 1. Observe ICP and MABP with patient
pressure and intracranial pressure (CPP supine in bed, head elevated 30-45';
= MAP - ICP). When CPP reaches 50 calculate CPP.
mm Hg total cerebral blood flow is de 2. If ICP is less than 15 mm Hg and CPP
creased approximately 25%. When CPP greater than 50 mm Hg, lower the bed
is below 40 mm Hg cerebral perfusion is into the flat position and turn the pa
compromised. Reduced CPP results i n tient into the appropriate bronchial
reflex vasodilation o f t h e cerebral vas drainage position. When an intraven
culature and i ncreased cerebral blood tricular catheter is in place, cerebral
volume, which leads to elevation of ICP spinal fluid can be drained prior to
and ultimately decreased cerebral blood treatment to lower ICP.
flow. Cessation of blood flow, bilateral 3. When the head-down position is indi
fatal cerebral infarction. and brain death cated and ICP is elevated, a modified
may occur following severe brain injury. tilt test may be performed. Observe
Close monitoring is essential, especially ICP and CPP while the patient is po
during chest physiotherapy for those pa sitioned with the bed horizontal. If
tients who are at the elbow of the cere ICP exceeds 20 mm Hg and CPP is less
bral pressure/volume curve (Fig. 8.3). It than 50 mm Hg the head of the bed is
is our opinion that chest physiotherapy elevated and the patient is reposi
can be safely administered when the ICP tioned supine. If ICP returns to base
is less than or equal to 15 mm Hg in the line in a short period of time, the pa
upright position and does not exceed 25 tient has high cerebral compliance.
mm Hg in the head-down position. CPP Proceed with the head-down position
should remain greater than 50 mm Hg. for treatment. If ICP fails to return to
Percussion does not adversely affect ICP baseline the neurosurgical staff is no
in patients with space occupying lesions ti fied. Therapeutic intervention is in
(Hammon et al; McQuillan; Brimioulle et dicated to decrease ICP. Barbiturates
al.) (Fig. 8.4). A n ICP that rises above 25 or fentanyl may be used. Once CPP is
mm Hg with suctioning or other stimu adequate, the patient is positioned
lation and returns to baseline i n 30-60 head-down for treatment of the appro
sec indicates high cerebral compliance priate lung lobes.
and should not interfere with chest phys 4. Perform manual techniques and suc
iotherapy treatment. tioning as described in C hapters 4 and
ECG I
-'I"'"r ..-;, ;.
...
... -.. ,...--
ART BP tOff
ICP torr
"J+
"" I--
-- ' rl
t
CVP to"
it MWIIoI 1 r-
I_......-_
JI . -
A o
Figure 8.4. The effects of turning and the head-down position on arterial blood pressure (ART
BP) and ICP are shown in A. The ICP transducer was attached to the patient's head. The effects
of suction and chest percussion and vibration on ART BP, ICP. and central venous pressure (CVP)
are shown in B. Pressure traces during chest percussion (C) and vibration (0) are shown at a faster
paper speed (30 mm/sec). Note in A the rise in ICP with flattening of the bed and turning and
positioning the patient with the head down. Note in e, C, and 0 that chest percussion and vibration
have no effect on ART BP, ICP, or CVP but that suction caused a decrease in ART BP and a rise
in ICP and CVP. (Traces in Figures 8.4 and 8.5 were made and provided by C. F. Mackenzie, M .
8., Ch.B., F.F.A.R.C.S.)
5. Hyperventilation via the ventilator the discretion of the neurosurgeon.

or a manual resuscitator bag may be Using these guidelines. the authors
necessary fol lowing suctioning if ICP have found treatments longer than 15
does not rapidly return to baseline. m i n necessary only for 1-2 sessions.
5. When ICP exceeds 25 mm Hg or CPP
is less than 50 mm Hg with the head Measures to Reduce ICP
down position the neurosurgical staff
is notified. The indication for chest Suctioning the upper airway i ncreases
physiotherapy and severity of lung pa ICP. Shalit and Umansky noted that in
thology and brain injury determines patients where the trachea is blocked by
whether medical intervention is indi secretions suctioning may have a favora
cated to continue treatment. ble effect on ICP. This is also the authors
6. Chest physiotherapy routinely lasts 15 clinical i mpression. Suctioning is neces
min for patients with ICP monitori ng. sary and routinely performed on brain
Chest physiotherapy duration may ex injured persons in the ICU. To prevent
ceed 15 min when treatment is admin spillage of secretions into dependent lung
istered to lung segments not requiring regions, patients should be suctioned
the head-down posi tion for drainage during chest physiotherapy and before
(all upper lobe segments and superior changing position. White et al. (1982)
segments of the lower lobes). When studied the effects of several drugs used
copious secretions are mobilized with to prevent the acute i n tracranial hyper
chest physiotherapy, or a lobar col tension associated with endotracheal
lapse does not improve with a 15-min suctioning. Intravenous lidocaine and
session in the head-down position thiopental produced an initial 4-6 mm
treatment time may be extended at Hg decrease i n ICP but neither drug af-
fected the increase in ICP after endotra tioned with the [CP monitoring device
cheal suctioning. Succinylcholine was ef dependent. The stimulation associated
fective i n abolishing increases i n ICP due with position changes is usually associ
to suctioning. Fentanyl produced no ated with higher transient i ncreases in
acute changes in ICP. Cerebral perfusion ICP than lying in the lateral and head
pressure was not significantly altered by down positions. Multiple interventions
any of the prophylactic medications. For that result in i ncreased [CP or decreased
patients requiring sedation prior to treat CPP should be avoided i n the patient
ment drugs such as fentanyl or diazepam with brain injury. CPP may be a more re
may be helpful, although barbiturates liable indicator than ICP of the brain-in
that reduce ICP and cerebral 0, con jured patient's ability to tolerate chest
sumption may be more beneficial. Lido physiotherapy treatment.
caine in doses of 1.5 mg/kg was found to
be as effective as thiopental for rapid Routine Chest Care for the Unconscious
(within 66 sec) reduction in ICP (Bedford Patient
et aI., 1980). Other methods to reduce ICP
to allow chest physiotherapy treatment For the patient with head injury, a
and routine nursing care include venting clear chest x-ray, minimal secretions,
cerebrospinal fluid through an intraven and low i ntrapulmonary shunt, routine
tricular monitoring catheter and admin turning and suctioning are found to be
istration of diuretics. For patients in bar adequate chest care. Positioning the un
biturate coma the cough reflex is absent conscious patient who does not have
and position changes do not cause such problems with i ncreased [CP follows the
marked i ncreases in [CPo White and col normal postural drainage routine. Re
leagues recommend short-term paralysis striction of treatment time is unneces
for patients who develop i ntracranial hy sary i n this group of patients. In fact, pro
pertension in response to tracheal suc longed periods of the head-down position
tioning; Garradd and Bullock noted that may be indicated in nonintubated uncon
[CP was not elevated during chest phys scious or semiconscious patients who
iotherapy when patients were pharma have copious secretions noted clinically
cologically paralyzed. However, the ben but have no spontaneous cough (Fig. 8.6).
efit of reducing [CP with neuromuscular After postural drainage, secretions may
blockers must be weighed against the be suctioned from the oropharynx. If suc
risk of eliminating the cough reflex as tioning the oropharynx and the other
sociated with suctioning. Paralysis may methods of cough stimulation discussed
be necessary on[y when [CP is elevated i n Chapter 5 are i neffective after postural
for prolonged periods which prohibit ef drainage, tracheal i ntubation may be
fective nursing care and chest physio necessary. Nasotracheal suctioning
therapy treatment. Details of cough effi should not be performed (see p. 179).
cacy and suctioning procedures can be This is especially the case in patients
found in Chapter 5. with CSF rhinorrhea or facial fractures.
Patients should be adequately sedated
prior to stimulation that i ncreases [CPo QUADRIPLEGIC PATIENTS
Routine turning and positioning for nurs
ing care and chest physiotherapy treat During the first 3 months after acute
ment may be prevented if [CP increases. traumatic quadriplegia, death is most fre
Position changes may cause the most quently due to pulmonary complications
marked changes in [CP (Fig. 8.4). Al (Cheshire, 1964; Bellamy et aI., 1973).
though sedation is often beneficial, Shalit Reines and Harris (1987) documented an
and Umansky (1977) found patient posi 18% mortality in 123 consecutive spinal
tioning more effective than mannitol i n cord injury patients, 49 of whom were
reducing I C P (Fig. 8.5). Placement o f the quadriplegic. Sixty-three percent of the
head i n a neutral position or at times deaths were attributed to pulmonary
elevated on an i.v. bag (see Chapter 3) is complications. Mortality increased to
effective in reducing ICP. [CP often ap 30% in the quadriplegic patient who de
pears higher when the patient is posi- veloped atelectasis or pneumonia. There-
ECI;
! I
.
'. . . . '..
" ?"I
ART BP torr
,
....
_,.".
'"-; .:",
,
[
ROLL PLACED "ENT PLaCED

0 UNDER HAO HEAD UP
L

'rr
6 _
ICP
0
".
... " .......
CVP torr
B
Figure 8,5, Pressure trace changes following placement of a roll under the head of the patient
without any changes in bed or patient position are shown in A. The effects on arterial blood pres,
sure (ART BP), ICP, and central venous pressure (CVP) of placing the patient with the head up are
shown in B, Note the fall in ICP shown in A, resulting from head elevation after placement of a roll,
The ICP transducer was attached to the head and similarily elevated, This technique may be used
to reduce ICP once the patient is appropriately positioned for postural drainage. Note the fall in
ICP following head elevation, shown in B, The rise in ART BP and CVP was an artefact due to
constant transducer height. This was rectified 30 sec after the head,up pOSition was assumed,
Figure 8,6, This brain,injured pa,

tient with facial fractures required
30 min of postural drainage to mo,
bilize secretions to the oropharynx
because he was unable to cough
spontaneously,
fore. the importance of close observation muscles are thought to pull the sternum
and intensive respiratory care for the cranially. The scalenes and sternoclei
acutely injured quadriplegic cannot be domastoid muscles also increase the AP
overemphasized. Cough is severely af chest diameter (Danon et al.. 1979: De
fected by paresis or paralysis of the ab Troyer and Kelly. 1984: DeTroyer et al ..
dominal muscles. Loss of intercostal 1985. 1986). After studying the thoracic
muscle innervation and decreased dia mobility in a C1 and C2 quadriplegic.
phragmatic movement result in reduced DeTroyer and colleagues concluded that
lung volumes (Fig. 8.7). Trunk and ex the sternocleidomastoid. platysma. tra
tremity muscles are paralyzed and sym pezii. mylohyoid. and sternohyoid mus
pathetic cardiac innervation is lost. Posi c1es all contribute to quiet breathing in
tion changes are more precarious and quadriplegia. The neck inspiratory mus
require assistance of two or three persons cles pull the sternum cranially and the
for turning and sitting out of bed. Re trapezii fix the head to prevent excessive
duced lung volumes. impaired cough. shortening of the sternocleidomastoid.
and decreased mobility affecting aclivi This allows the sternocleidomastoid
ties of daily living make the quad riplegic muscles to work at a greater mechanical
patient extremely susceptible to respira advantage.
tory problems. The clavicular portion of the pectoralis
major may play a role in expiration fol
lowing quadriplegia (De Troyer et al.. 1 986).
In 10 subjects. a decrease in upper rib cage
Respiratory Muscle Function/Thoracic
motion during expiration was associated
Cage Mobility
with active use of the clavicular portion
Several authors have investigated the to the pectoralis major. Changing the ori
role of the muscles of respiration and rib entation of the muscle fibers using shoul
cage mobility both in normal and quad der abduction reduced expiratory reserve
riplegic patients. The diaphragm. para volume by 60% . Clinically. increaSing the
sternal intercostal and scalene muscles. strength and endurance of this muscle or
sternocleidomastoid. platysma. sterno upper extremity ergometry (Walker and
hyoid. trapezii. and mylohyoid muscles Cooney. 1987) may improve cough effec
may all assist in inspiration after quadri tiveness.
plegia. Specific muscle activity depends There is much variability in the liter
on the level of the lesion (Fig. 8.8). The ature rega rding inspiratory muscle func
parasternal intercostal muscles are tra tion and the thoracic and abdominal
ditionally considered accessory muscles components of respiration both in normal
of inspiration. Whether they increase the and quad riplegic subjects. In normal sub
anterior posterior (AP) or transverse di jects. rib cage movement accounts for
ameter (DeTroyer and Kelly. 1984) of the 33% of vital capacity and the diaphragm
chest is controversial. These accessory contributes to 66% (Campbell et al..
Inspiratory >
:: Reserve 2 ;- IRV
u
'u Volume o uu ;1
" 0 - :;..=. ..,
( I RV I
0. ..
0. ",
">
. 0
cU
-+ u i
0' ''' "' -
-' - - - ..
J
""
.... c
- , !
-' :> .... ...
Expiratory Reserve ;1
( ERV I
.. ;; 'i - ..
..
;
Volume g :I u U 0
Residual Volume - 191%

( RV I :- .140'10
A B
Figur. 8.7. Comparison of lung volumes in the normal (A) and the quadriplegic (8) patient. Note
decreased VC. total lung capacity. and ERV in the quadriplegic patient. (... . Estenne. 1987: O. Fugl
Meyer. 1 971 a:. Haas. t 965).
SpLnal Figure 8.8. (left). The respiratory

Inspiratory Expiratory
segment
muscles. Inspiratory muscles to the
C I left and expiratory muscles to the
right of the spinal segmental indi
:rr cator. 'Primary respiratory muscles
:m: (different opinions in the literature
on whether these are primary or
Jl[
auxiliary). (From A. R. Fugl-Meyer:
:l[ Scandinavia Journal of Rehabilita
tion Medicine 3:141-150. 1 971 a.)
:l[
:llI[
:lZII[
Th I
:rr
i c
I !. I
"
,
:m:
Jl[
:l[
,
"
,
i
, T
,
I
,
:lZ[ i
I

I
:llI[ I !

! :lZIJ[
I
o
1

R
!
IX t :
I
!
X
XI: ;
III
L I
][
][
Jl[
:l[
5 I
:n:
:m:
Jl[
:l[
1970). Bake et a!. (1972) found that the component of ventilation that ranges
abdominal contribution to quiet respira from 22 to 90% of total ventilation (Mc
tion was 31% in normal subjects and 50% Kinley et a ! . , 1 969). Estenne and De
in the quadriplegic patient. Therefore, Troyer (1985) studied 20. C4-C7 quadri
tetraplegic subjects have a smaller rib plegic patients between 10 days and 312
cage contribution and a greater diaphrag months after injury with EMG recordings
matic contribution to tidal volume than of the parasternal intercostals and sca
healthy subjects (Fugl-Meyer 1971b; lene muscles. The degree of rib cage mo
Mortola and Sant'Ambrogio, 1978; Es tion could not be predicted; there was no
tenne and DeTroyer, 1985, 1987). Acces relationship between thoracic motion
sory muscle activity is variable in quad and duration of quadriplegia. Spastic or
riplegics; this may affect the thoracic silent scalene EMG activity was associ-
ated with paradoxical upper rib cage AP 1979). Reduced residual volume is
motion. These authors conclude that thought to be related to the effect of grav
quadriplegics have a very complex pat ity on the abdominal contents and not an
tern of muscle activity during inspiration abnormal i ncrease in intrathoracic blood
and that coordination of the scalenes and volume (Estenne and DeTroyer. 1987).
diaphragm may be important. Three McMichan and colleagues associated the
forces act upon the rib cage when the di i ncreased lung volumes with shortened
aphragm contracts: a fall i n pleural pres diaphragmatic descent and lack of ab
sure. a rise in abdominal pressure. and a dominal rebound. Increased paradoxical
force on the insertion of the diaphragm inward movement of the lateral chest
elevating the lower ribs. wall is also noted in the supine position
when compared to silting (Moulton and
Pulmonary Function Silver. 1 970; Mortola and Sanl' Ambro
gio. 1978; Estenne and DeTroyer). The re
Vital capacity has been shown to dou duced lower rib cage expansion in the
ble within 3 months of injury and con supine position is thought to be due to
t i n ue to i ncrease spontaneously 4-10 the i ncrease in abdominal compliance
months after quadriplegia (Ledsome and that occurs with assuming this position
Sharp. 1981; Haas et al.. 1986; Axen et al.. (Estenne and DeTroyer).
1985). Proportional i ncreases in inspira Cardiac function is also affected by
tory capacity and total lung capacity changes in position after cervical cord
(TLC) and maximum inspiratory pres transection or spine i n jury. Rapid
sure (Plm,,) also occur in the acute stage changes in body position for the acute
(McMichan et al.. 1980; Haas et al.. 1986). quadriplegic patient during spinal shock
During the chronic stage. vital capacity may cause marked changes in cardiac
i ncreases and functional residual capac function. Head elevation of greater than
ity decreases while TLC remains the 20' may cause a sudden decrease in car
same. Absolute improvement i n vital ca diac filling pressures. a resulting fall in
pacity cannot be predicted by pulmonary cardiac output. and even cardiac arrest.
function tests. neurologic examinations. Similarly. sudden head-down positioning
or muscle function evaluations per may cause a rise in cardiac filling pres
formed in the early stage of recovery sures. Because of loss of sympathetic car
(Axen et al.). diac i n nervation associated with lesions
Postural Dependence. Pulmonary above the T1 level. the steep head-do W'n
function varies with body position and position may precipitate acute myocar
the use of abdominal binders in the spon dial failure with pulmonary edema.
taneously breathing quadriplegic patient. Therefore. in the early stages of acute
Unlike normal subjects whose vital ca quadriplegia. these movements should
pacity decreases by 7.5% in the supine be performed with careful monitoring of
position (Allen et al. . 1 985). patients with arterial and venous pressures. Ace wraps
cervical cord transection have a de around the lower extremities. a G suit. or
creased vital capacity. tidal volume. and M ASTrousers may be used to minimize
inspiratory capacity. increased residual orthostatic hypotension until vasomotor
volume (RV). and decreased ventilation control is established.
in the lung bases when changing from Abdominal Binders. Abdominal bind
the supine to seated position (Maloney. ers are used to align the abdominal con
1979; Haas et al.. 1965: Fugl-Meyer. tents under the diaphragm. thus improv
1971a; Bake et al.. 1972; McMichan et al.. ing respiratory function both in the acute
1980; Estenne and DeTroyer 1987). Vital and chronic phases of quadriplegia.
capacity is increased by the 20' head When comparing eight C5-C7 quadriple
down position (Cameron et al.. 1955). gic subjects 1-456 months after injury to
Total l u ng capacity is smaller i n the su five normal subjects. McCool et al. (1986)
pine position (Estenne and DeTroyer. demonstrated that abdominal binding in
1987) probably because of a reduction i n creased IC. TLC. and decreased FRC in
R V . although inspiratory capacity (IC). the quadriplegic subjects. FRC and TLC
VC. and tidal volume increase (Maloney. decreased in normal subjects in all three
positions tested [supine, seated, and both to decrease respiratory rale and in
tilted head-down 37). The greatest im crease VC and tidal volume when used i n
provement i n inspiratory capacity for supine a n d sitting positions. Pulmonary
quadriplegic patients was in the seated function testing may be performed when
and tilted positions, because of the nor using binders, particularly with supine
mal lengthening of the diaphragm that positioning. Binders are worn until pul
occurs in the supine position. Maloney monary function ceases to improve with
studied 15 quadriplegic patients 1 year their use, or breathing fails to appear eas
postinjury. lt was found that wearing a ier during functional activities.
corset in the sitting [not supine) position
improved lC, VC, and tidal volume. The Chest Physiotherapy Treatment
authors conclude that the increased ab
dominal pressure associated with binder Reduced VC, restricted deep breath
use improves rib cage expansion. Gold ing, and cough, together with an inability
man and colleagues [1986) also demon to change body position, lead to secretion
strated an increase in transdiaphragmatic retention. Quadriplegic patients are,
pressure and VC with abdominal binding therefore, very susceptible to pulmonary
i n the sitting position, although VC was complications [McMichan et a1.). In order
not altered i n the supine position. Es to improve respiratory management,
tel).ne and OeTroyer [1987) noted that ab chest physiotherapy treatment, including
dominal binding abolished the postural breathing exercises and specific active
dependence of RV in the supine position, and passive range of motion exercises are
the effect on TLC is not mentioned. Imle necessary [see pp. 163). Chest physio
et a1. [1986) studied the affects of abdom therapy is reported to be highly success
'inal binding on acute quadriplegics and ful in reducing pulmonary complications
also documenled Ihat VC was unchanged in these patients [McMichan et a1.).
with binding in the supine position. Treatment is instituted prophylactically
Binder type and placement may be cru and continued, with emphasis on any
cial in demonstrating improvement in areas showing radiological involvement.
pulmonary function. Elastic binders No benefit from the use of bronchodila
wrapped tightly around the abdomen, tors for Ihe quadriplegic patient was doc
extending over the iliac cresls to Ihe umented by Fugl-Meyer [1 976). It is our
pubis, are preferred [McCool et aI., 1986; opinion thai adventitial breath sounds,
Goldman et aI., 1986). The binder should including wheezing, are often a result of
not be positioned more cranially than the retained secretions, since they clear with
floating ribs because of interference with chest physiotherapy. Both the mechani
epigastric rise during inspiration [Alva cally ventilated and spontaneously
rez et aI., 1981). It is the author's experi breathing quadriplegic patient require
ence that binders placed below the ante immediate attention to prevent atelecta
rior superior iliac spine are more prone to sis and pneumonia.
tissue breakdown, particularly in the sit Quadriplegic patients should have
ting posi tion. When improperly donned, chest physiotherapy performed during
thoracic mobility may be impaired. Bind weaning from mechanical ventilation.
ers with an orthoplast front are not as The authors are i n agreement with Wicks
effective as conventional binders in im and Menter [1 986) that IMV is not partic
proving end inspiratory tidal and trans ularly beneficial for Ihese patients. Re
diaphragmatic pressure during maximal tained secretions are removed prior to a
sniffs [Goldman, et a1.). weaning session to enhance gas exchange
The overall benefits of wearing an ab- and decrease the work of spontaneous
_ dominal binder remain unknown be breathing. This is particularly important
cause of the decrease i n FRC that may for the quadriplegic who may lack the
impair gas exchange. Improvement in VC necessary intercostal and accessory mus
enhances cough ability, yet decreased cle strength to decrease diaphragmatic
FRC leads to alveolar collapse. The au muscle fatigue [Lerman and Weiss, 1987).
thors have found binders clinically ben While spontaneously breathing cough as
eficial for some quadriplegic palienls sistance and breathing exercises are con-
Figure 8.9. The physical therapist

clinically assesses a quadriplegic
patient prior to performing per
cussion over the posterior seg
ments of the lower lobes. The
turning frame allows head-down
positioning
.
tinued for secretion removal, ventilatory pared to the kinetic bed the turning
muscle strengthening, and relaxation. frame and standard bed allow more op
timum postural drainage of the lower and
Postural Drainage, Percussion, and middle lobes and better positioning for
Vibration exercises to enhance early rehabilitation
and prevent contractu res. The manufac
Both the turning frame and a standard turers claims of improved pulmonary
bed permit chest physiotherapy in 7 of function and decreased tissue break
the 11 bronchial drainage positions. Per down and contracture formation with the
cussion and vibration may be performed kinetic bed are not substantiated by our
over appropriate lung segments (Fig. 8.9). clinical practice. Skin breakdown occurs
Thoracic excursion i n varied positions on the heels and buttocks and shoulder
that include more than one plane of mo contractures may develop when quadri
tion may prevent cavus deformity and plegic patients are managed on a kinetic
flaring of the lower rib cage, particularly bed. See Chapter 3 for details regarding
in children (Massery, 1987). Position specialty beds and positioning the spinal
changes for quadriplegic patients should injury patient. Quadriplegic patients may
be made carefully by experienced health be taught to cough while lying supine"on
care personnel because of their effect on their side, and prone (Fig. 8.10). The turn
cardiac and pulmonary function. I t is our ing frame may be positioned in the head
opinion that a standard bed and turning up, head-down, prone, and supine posi
frame are superior to the kinetic bed for tions (Fig. 8.11). Adequate diaphragmatic
care of the quadriplegic patient. Com- excursion can be obtained for patients
Figure 8.10. Cough assistance

for a quadriplegic patient is
achieved by placing a towel over
the abdomen and the therapist ap
plying even pressure during
expiration.
surgical intervention and use of a vest for

spinal stabilization are indicated. A halo
vest is preferred to the use of a body cast.
Manual chest physiotherapy techniques
are more easily performed because the
straps can be u n fastened and vest opened
(Fig. 8.14). The jacket is u n fastened on
both sides and the back raised to allow
percussion over the posterior basal seg
ments of the lower lobes. Padding can be
added for patient comfort. two or three
staff members are required to position
the patient prone i n a vest. Jacket straps
should be closed prior to changing the
patients position. Chest physiotherapy is
also performed when a Yale brace is re
q u i red for spinal stabilization (Fig. 8.1 5).
When body casts are used windows
Figure 8.11. One person may raise or lower
th head of the Stryker frame. should be cut to expose the chest wall
(Fig. 8.16). Casts compromise respiratory
function. i n terfere with chest-ray inter
positioned prone on a turning frame by pretation. and cause pressure sores. I n
placing a roll under the iliac crests (Fig. patients w i t h quadriplegia and copious
8.12). Well-padded straps may be used to secretions. prolonged periods of the
prevent the patient from slipping and los head-down position may be necessary to
ing traction while in the head-down po assist secretion drainage into the oro
sition (Fig. 8.13). If straps are used they pharynx. I n a minority of patients. 90-
should be released immediately follow 120 min of drainage is required for one or
ing treatment to prevent tissue break two treatments before clinical clearance
down or circulatory occlusion. Cameron is noted. This is especially the case i n
et al. (1955) describe padded boots to spontaneously breathing patients wh o d o
achieve the same effect. Once adequate n o t cough well.
traction is assured. both hydraulic and
manual frames may be positioned for Cough
postural drainage. During rehabilitation.
the prone on elbows position may be Due to abdominal and i n tercostal mus
used on a bed or mat to strengthen neck cle weakness. cough is often severely im
accessory muscles while limiting and re paired in the quadriplegic patient. If the
sisting diaphragmatic excursion. patient is taught to take as large an inspi
The philosophy of the neurosurgical or ration as possible. followed by a forceful
orthopedic staff will determine when expiration during which the abdomen is
Figure 8.12. A roll under the iliac

crests allows anterior diaphragmatic
excursion during prone positioning
on a turning frame .
Figure 8.13. Kerlex and abdomi

nal dressing pads are easily ob
tained in the ICU and can be util
ized to prevent the patient on a
turning frame from slipping when
placed headdown.
Figure 8.14. A quadriplegic pa

tient is receiving chest percussion
over the left lower lobe after the
vest used for spinal stabilization is
opened and taped to the siderails
of the bed. The vest was opened
after proper patient positioning.
Figure 8.15. When a Yale brace is used for Figure 8.16. When body casts are used for
spinal stabilization. the straps may be unfas spinal stabilization in the quadriplegic patient.
tened to allow chest physiotherapy treatment. windows must be cut to expose the chest wall.
Table 8.1
Comparison 01 Air Flow, Duration, and Volume 01 Cough in Quadriplegic and Normal Subjects
Peak Air Duration of Volume Resistance to Air Flow
Flow Cough of Cough (Peak Flow) (cm H,O/
(liters/sec) (sec) (liters) liters sec)
Normal 7.09 1 .09 3.14 12.50
Quadriplegic 4.54 2.3 2.91 2.59
supported. a more effective cough may be to the quadriplegic patient in the supine
achieved (Fig. 6.10). The patient can be position because of the associated in
taught to perform this maneuver inde crease in vital capacity. Resistive dia
pendently. Huffing is also helpful (see p. phragmatic exercises are achieved by
1 62). placing dish or cuff weights over the epi
Siebens et al. (1964) found abnormal gastric region (Fig. 8.17). Inspiratory ca
volume and pressure changes during pacity and vital capacity are measured to
coughing in three male quadriplegic pa determine the maximum weight used
tients with C5 and C6 spinal cord tran during training while achieving a full
secfiDns (Table 6.1). Flow and resistance epigastric rise. During breathing exer
were decreased compared to those values cises and pulmonary function testing.
in three healthy men. nose clips are worn u n less the patient is
tracheally intubated. In the acute phase.
Breathing Exercises
for the spontaneously breathing quadri
plegic patient the authors advocate dia
Breathing exercises to increase tidal phragmatic breathing exercises for 40 re
volume and assist coughing are advo petitions twice daily five days per week
cated for the nonintubated quad riplegic or inspiratory muscle training for 15 min
patient. Quadriplegic patients with a twice daily.
vital capacity less than 1 .000 ml usually Ciesla et al. (1 989) compared the effec
require mechanical ventilation (Wicks tiveness of abdominal weight training to
and Menter, 1986). Because alternating inspiratory muscle training on 29 acute
periods of rest and exercise improve pul C4-C7 quadriplegic subjects. FVC. IC,
monary function in some patients (Braun MVV. PEFR. and Plm" were measured be
et aI., 1963), the authors use breathing fore and after 3 weeks of training. No sig
exercises during periods of spontaneous nificant difference was found between
breathing while weaning from mechani
cal ventilation. Exercising the intact res
piratory muscles such as the diaphragm,
sternocleidomastoid, levator scapulae,
platysma. and trapezius may increase
thoracic and abdominal excursion. there
fore increasing tidal volume (Cullmann.
1976; McMichan et al.. DeTroyer and
Heilporn. 1 980; Wetzel et al.. 1 985).
Breathing exercises most often taught
to quadriplegic patients include active
and resistive diaphragmatic breathing.
summed breathing exercises. inspiratory
muscle training. and glossopharyngeal
breathing. Fifteen chronic quadriplegics
improved VC after 7-12 weeks of incen
tive spirometry and arm ergometry
(Walker and Cooney. 1967). Active dia Figure 8.17. A quadriplegic patient performs
phragmatic breathing exercises and in diaphragmatic progressive resistive exercises
spiratory muscle training are described with dish weights. Weights are added until the
in Chapter 3. patient's inspiratory capacity is greater than or
Breathing exercises are initially taught equal to baseline measurements.
these treatment modalities, although sig by encouraging the patient to take sev
nificant improvement (p < .05) was eral quick, shallow but cumulative
noted in both subject groups. breaths before expiration. The patient
can gradually increase the volume of in
Glossopharyngeal Breathing
spired air once this is mastered.
Fugl-Meyer [1 971b) devised a manu
Glossopharyngeal breathing (GPB) is ally operated pump and valve system
recommended for the patient with quad that was used as a passive breathing ex
riplegia. The technique can be broken ercise and increased total lung capacity
into four steps [Fig. 8.18 A-C). Oail and 14% in quadriplegic patients. Productive
Affeldt (1955) studied GPB in patients coughing was improved. This was most
with poliomyelitis. Of 100 patients who effective with patients in the sit t ing
were taught GPB, 69 used i t to assist nor position.
mal breathing, and 31 used it to assist In summary, prophylactic chest phys
speech and stretch the chest to help iotherapy is important for the patient
coughing. Forty-two of these patients with acute quadriplegia. Emphasis on in
found that GPB freed them of the need creasing VC and cough efficacy are essen
for respiratory support. tial in the spontaneously breathing pa
Ardran et al. (1959) found that the GPB tient. Exercising the remaining accessory
rate varied from 60 to 200 times/min in muscles, performing diaphragmatic, in
individuals with poliomyelitis. Those pa spiratory resistive, glossopharyngeal, and
tients who could swallow normally were summed breathing, or the use of a pump
capable of GPB; those with palatal and la and valve system may all improve pul
ryngeal weakness were sometimes capa monary function. I n order to maintain rib
ble of GPB if a nose clip was used. It may cage mobility, these exercises are started
not, therefore, be necessary to close the as soon as possible following injury. Ac
larynx for GPB. Affeldt et al. found no re tivities of daily living may eventually re
lationship between the polio patient's place the need for chest physiotherapy
proficiency a t GPB and the severity of and breathing exercises.
respiratory muscle paralysis. VC was in
creased from 0.28 to 2.40 liters, with GPB PATIENTS WITH CHRONIC LUNG
ranging from 14 to 48 strokes/min, and DISEASE
normal arterial blood gases were main
tained. The mean increase of VC ranged Evidence of the benefits of chest phys
from 11 to 50% of the predicted normal, iotherapy for patients with chronic ob
in seven patients. Metcalf (1 966) and structive lung disease is limited. Anthon
Montero et al. (1967) specifically studied isen et al. (1964), Petersen et al. (1967),
quadriplegic patients. Metcalf found that March (1971), Newton and Bevans (W78),
vital capacity was increased from 60 to Newton and Stephenson (1978), an il Ol
81% of normal by means of GPB. Montero denburg et al. (1979) were unable to dem
and colleagues believed that if 700-1,000 onstrate improvement in pulmonary
ml of air could be added to a patient's VC function or sputum clearance with chest
with 10-20 glossopharyngeal gulps, the physiotherapy. May and Munt (1979)
technique was then mastered. This vol found postural drainage and percussion
ume provides sufficient supplemental air effective in augmenting the volume of
for effective coughing and secretion expectorated sputum, but this did not
clearance. Many quadriplegic patients produce significant alterations in air flow
who require respiratory support undergo or gas exchange. Campbell et al. (1975)
tracheostomy to reduce the problems as found a fall in FEV, when percussion was
sociated with long-term translaryngeal added to postural drainage and coughing.
intubation. Therefore, GPB is limited to The patient who is subacutely ill and
extubated patients or those without an has chronic lung disease with retained
inflated tracheostomy tube cuff [G. T. secretions is encouraged to become in
Spencer, personal communication). dependent in activities of daily living, as
"Summed breathing" may also in opposed to having a vigorous chest phys
crease tidal volume. This is carried out iotherapy regime implemented. Pulmo-
CJ
..
,gC.LAORSYENXD
o
0
(I
3
A
Figure 8.18. (A) Steps of GPB: (1) The mouth and throat are filled with air; the tongue, jaw and
larynx are depressed. (2) The lips are closed, and the soft palate is raised to trap air. (3) The larynx
is opened; the jaw and floor of the mouth and larynx are then raised. With repeated motion of the
tongue, air is forced through the opened larynx into the trachea. (4) The larynx is closed, and air is
trapped in the trachea and lungs. (From C. W. Dail and J. E. Affeldt: Journal of the American Med
ical Association 1 58:445-449, 1 955.) (8) GPB steps 1 and 2: The jaw and larynx are depressed;
the soft palate is raised. (C) GPB steps 3 and 4: Air is forced through the opened larynx into the
trachea.
nary rehabilitation that includes patient gen; inspiratory muscle training (IMT)
education and exercise testing and train may also be indicated (pp. 1 2 2 ) (Butts,
ing are indicated. Exercise training may 1981: Stein et aI., 1982; Ries et aI., 1983).
include PaO, measurements during ex Whether (IMT) alone improves respira
ercise and the use of supplemental oxy- tory muscle endurance in patients with
chronic lung disease is unknown (Bel with chronic obstructive lung disease or
man and Sieck, 1 982). lMT has not been cardiac disease may become dyspneic
shown to increase exercise tolerance when placed in the head-down position.
when compared to a pulmonary rehabil Increasing the mandatory ventilation
itation program (Casaburi and Wasser rate or fractional inspired oxygen con
man, 1 986), although Ries et a! . ( 1 986) centration, using controlled mechanical
demonstrated improvement in ventila ventilation, or pressure support may
tory muscle endurance and exercise per allow these patients to tolerate better the
formance when IMT was compared to a head-down positions necessary for pos
walking program. See Chapter 3 for de tural drainage of the middle and lower
tails regarding IMT. The major indica lobes.
tions for chest physiotherapy in the pa
tient with chronic lung disease are
excess sputum production, exacerbations ASTHMATIC PATIENTS
of the disease resulting in immobility, or
major abdominal surgery or trauma. Physiotherapy for patients with
Cochrane et a!. (1977) showed reduced asthma consists of breathing retraining
air flow obstruction, and Bateman et a!. exercises, physical conditioning, and
(1 979) and Sutton et a!. ( 1 982) showed postural exercises (Livingstone, 1952;
increased clearance of radioactive poly Wood et a!., 1970; Mascia, 1976; Landau,
styrene particles from central and pe 1 977). Breathing exercises are often used
ripheral airways following chest physio to reduce anxiety and relieve dyspnea
therapy in patients producing regular (Freedberg et a!., 1987). Singh (1987)
daily sputum. Similarly, Feldman et a!. studied 12 asthmatics with nocturnal
demonstrated increased expiratory air wheeze. In a controlled study statistically
flow i n ten patients with chronic bron significant increases i n PEFR were noted
chitis up to 45 min after postural drain following breathing exercises using a
age, percussion, and vibration in six "pink city lung exerciser." This device
positions. maintained a 1 : 2 inspiratory-expiratory
After surgery, spontaneously breathing ratio, similar to that obtained with dia
and mechanically ventilated patients phragmatic breathing exercises (see
with chronic sputum-producing lung dis Chapter 3). Postural drainage with per
ease are likely to retain secretions as a re cussion and vibration is only necessary
sult of immobility, pain and the use of when the asthmatic patient has excess
dry anesthetic gases. A l tered pulmonary mucus production or secretion retention
function before surgery puts these pa which is present after physical condition
tients at a greater risk for respiratory ing, breathing, or postural exercises.
complications. Prophylactic chest phys The spontaneously breathing asth
iotherapy, which includes the forced ex matic with retained bronchial secretid)'ls
piration technique, is, therefore, indi may require breathing exercises or relax
cated. Chronic lung diseased patients ation before postural drainage. The pa
may need to be coaxed into the necessary tient is positioned to promote relaxation
postural drainage positions. If retained of the upper chest and shoulder girdle
secretions i nterfere with gas exchange, musculature. Relaxation in several posi
tolerance to treatment usually improves tions, such as sitti ng, lying on the side,
as treatment is continued. The sponta and standing, should be incorporated
neously breathing patient who becomes when possible into the treatment. Pos
more dyspneic with treatment may ben tural drainage with percussion and vibra
efit from relaxation and gentle condition tion often cannot be tolerated unless the
ing exercises i n the sitting position. This patient is relaxed. Chest physiotherapy is
may aid muscular relaxation and help directed at the speCific areas of segmental
conserve energy needed for effective atelectasis (Wood et a!.; McKaba, 1 976).
deep breathing and coughing. As the pa Huber et a!. (1974) showed up to a 40%
tient's shortness of breath improves, pos increase in forced expiratory volume, 30
tural drainage may then be administered. min following percussion and vibration
If low rates of intermittent mandatory in 1 1 asthmatic children with mild-to
ventilation (IMV) are in use. the patient moderate airway obstruction. This sug-
gesls that chest physiotherapy and secre tory of asthma and shortness of breath on
tion removal decrease bronchospasm. Pa exertion.
tients with asthma, hospitalized for Following admission, the patient underwent
treatment other than asthma, usually tol laparotomy, and a suprapubic cystostomy was
erate chest physiotherapy. The head performed. After surgery the patient showed
radiological evidence of a right upper lobe at
down position may be used when it is in
electasis that cleared with chest physiother
dicated. This is exemplified by the fol apy. The patient was given prophylactic chest
lowing case study. physiotherapy every 4 hr because of her his
tory of asthma. This was supplemented in the
Case History 8.1. A 1 5-year-old female was evening and at night by the nurSing staff. There
admitted to the trauma center after an auto ac were no turning restrictions, and the patient's
cident in which she was a backseat passenger. chest x-ray remained clear until the fifth day
The patient sustained a fractured right pubis after surgery when, due to concern over the
and sacroiliac jOint, a ruptured bladder, liver pelviC fracture (Fig. 8.19A), turning was limited
lacerations, a serosal tear of the rectum, and a to lying on the left side only. Two days later the
retroperitoneal hematoma. Her past medical patient developed atelectasis of the left lower
hl story was noncontributory except for a his- lobe (Fig. 8.19B) and an associated tempera-
Figure 8.19. (A) Pelvic fracutres include a fractured right pubis and sacroiliac joint. (B) Chest x
ray showing left lower lobe atelectasis. (C) The left lower lobe atelectasis has cleared following 45
min of chest physiotherapy.
ture spike to 1 02F. Turning was again permit by manual techniques, may be more im
ted, and chest physiotherapy was given. Treat portant in children because of their small
ment consisted of postural drainage and airways which are more easily occluded
vigorous percussion. vibration and assisted with retained secretions and the in
coughing with the patient in the head-down po creased number of mucus glands. Pa
sition. Side-lying prone and supine positions
tients with cystic fibrosis respond favor
were included while the patient was in the
head-down position. Treatment lasted 45 min, ably to chest physiotherapy, which
at which time the physiotherapist believed that includes the forced expiration technique,
the lungs were clear on auscultation, except for although further research is needed to
some wheezing which was apparent since determine if the effects of therapy vary
admission. with the severity of the disease and gen
Repeat chest x-ray revealed complete clear eral physical conditioning. Patients with
ing of the left lower lobe atelectasis (Fig. spinal cord injury and neurological defi
B.19C). Temperature decreased to 99F. A cit involving intercostal and abdominal
turning frame was subsequently used to man muscle activity require prophylactic
age both the patient's pelvic fracture and her
chest physiotherapy to assist mobiliza
pulmonary condition.
tion and expectoration of secretions. In
The patient in status asthmaticus does the quadriplegic patient, specific breath
not usually require chest physiotherapy ing exercises are beneficial to improve
initially (British Medical Journal edito coughing and secretion clearance. Ab
rial, 1972). However, following medical dominal binders may improve vital ca
treatment, breathing control and chest pacity and cough ability. Unconscious
physiotherapy may be instituted to assist patients with closed head injuries are
secretion removal (Wood et aI., Webber, prone to i ncreased retention and stagna
1973). The i ntubated asthmatic patient is tion of secretions because of immobility
especially prone to secretion retention as and poor cough. These patients usually
a result of bronchospasm, immobility, tolerate chest physiotherapy in the head
decreased ciliary activity, and i nterfer down position despite transient increases
ence with the normal cough mechanism. i n ICP. The primary indications for chest
Therefore, routine turning and suction physiotherapy in patients with obstruc
ing are performed. In addition, chest tive lung disease or asthma occur during
physiotherapy treatment of any areas of acute exacerbations and after surgery or
the l ungs with clinical or radiological ev trauma. In chronic stages of these dis
idence of secretion retention may be eases, the benefit of chest physiotherapy
helpful in reducing bronchospasm. Re is not established.
tained secretions may cause airway ob
struction resulting in wheezing and
should, therefore, be removed. Treat References
ment of the asthmatic should be guided Affeldt IE. Dail CW, Collier CR, Fa" AF': Glclsso
by sputum production and patient toler pharyngeal breathing: Ventilation studies. J AppJ
Physio1 8:1 1 1 -1 1 3, 1 955
ance. Chest physiotherapy treatment of
Allen SM. Hunt B, Green M. Fall in vital capacity
the asthmatic patient should follow pre with posture. Bf J Dis Chest 79:267-272, 1985
scribed bronchodilator administration Alvarez SE. Peterson M. Lu nsford BR: Respiratory
whenever possible. treatment of the adult patient with spinal cord in
jury. Phys Ther 61:1 737-1745. 1981
Angus E. Thurlbeck W: Number of alveoli in the
human lung. J Appl Physio/ 32(4):483-485, 1912
SUMMARY Anthonisen p, Riis P. SogaardAnderson T: The
value of lung physiotherapy in tho treatment of
Chest physiotherapy when adminis acute exacerbation in chronic bronchitis. Aclo
Med Scand 175:715-719. 1 964
tered to different patient populations has Ardran GM. Kelleher WHo Kemp FH: Ci neradio
variable effects. In neonates, chest phys graphic studies of glossopharyngeal breathi ng. Br
iotherapy appears to be more hazardous J Radio 32:322-328. 1959
than in adults, and there is evidence of Auer LM. Cell C . Richling B. el al.: Predicting lethal
outcome after severe head injury-a computer
hypoxemia associated with suctioning, assisted analysis of neurological symptoms and
handling. and chest physiotherapy. Con laboratory values. Aclo Neurochir 52:225-238.
versely, removal of secretions, mobilized 1 980
Axen K. Pineda H. Shunfenthal H. Haas F: Dia Crane L: Physical Therapy in neonates with respi
phragmatic function [ollowing cervical cord in ratory dysfunction. Phys Ther 61(12):1764-1 773.
jury: Neurally mediated improvement. Arch Phys 1981
Med Rehobil 66:219-222. 1985 Crane L: PhYSical Therapy for the neonate with res
Baigelman W, O'Brien I: Pulmonary effects in head piratory disease. In Ca rdiopul monary Physical
trauma. Neurosu rgery 9(6):729-740, 1981 Therapy. edited by S Irwin and J Tecklin. pp. 305-
Bain J. Bishop J . Olinsky A: Evaluation of directed 310. Mosby. SI. Louis. 1985
coughing in cystic fibrosis. 8r. / Dis ChesI 82:138- Cropp GI, Pullano TP. Cerny FJ. Nathanson IT: Ex
148. 1 988 ercise tolerance and cardiorespiratory adjust
Bake B. Fugl.Meyer AR. Gimby C: Breathing pal ments at Peak Work Capacity in Cystic Fibrosis.
terns and regional ventilation distribution in Am Rev Respir Dis 126:211-216. 1982
lelrapiegic patients and in normal subjects. Clio Currie DC. Munro C. Gaskell D. Cole I: Practice.
Sci 42:117-128, 1972 problems and compliance with postural drainage:
Barnes CA, Asonye UO. Vidyasaqar 01: The effects A survey of chronic sputum producers. Br I Dis
of bronchopulmonary hygiene on Pt(;OZ values in Chesl 80:249-253. 1 986
critically ill neonates. Cril Care Med 9(12):819- Dail CWo Affeldt IE: Clinical aspects of glossopha
822. 1981 ryngeal breathing. lAMA 1 58:445-449. 1955
Bateman IRM. Newman SP, Daunt OM, Pavia D. Danford O. Miske S. Headley I. Nelson RM: Effects
Clarke SW: Regional lung clearance of excessive of routine care procedures on transcutaneous ox
bronchial secretions during chest physiotherapy ygen in neonates: A quantitative approach. Arch
in patients with stable chronic airways of ob Dis Childhood 58:20-23. 1983
struction. La ncel 1 :294-297. 1979 Danon J . Druz WS. Goldberg NB. Sharp IT: Function
Bedford RF, Persing IA. Pobereskin L. Butler A: Lo of the isolated paced diaphragm and the cervical
docaine or thiopental for rapid control of int racra accessory muscles in CI quadriplegics. Am Hev
nial hypertension? Anesth Analg (Cleve) 59:435- Respir Dis 1 1 9:909-919. 1979
437. 1980 DeCesare I: Physical therapy for the child with res
Bellamy R. Pills FW. Stauffer ES: Respiratory com piratory dysfunction. In Cardiopulmonary Physi
plications in traumatic quadriplegia. I Neurosurg cal Therapy. edited by S Irwin and I Tecklin. pp.
39:596-600. 1973 334-338, Mosby. SI. Louis, 1985
Belman MJ, Sieck G: The ventilatory muscles. fa DeCesare J. Babchyck BM. Colten HR. Treves S: Ra
tigue. endu rance and traini ng. Chest 82(6):761- dionuclide assessment of the effects of chest
766. 1 982 physical therapy on ventilation in cystic fibrosis.
Braun NM. Faulkner J. Hughes R, Roussos C. Sahgal Phys Ther 62(6):820-825. 1982
V: When should the respiratory muscles be ex Denton R: Bronchial secretions in cystic fibrosis:
ercised? Chest 84(1 }:76-84. 1983 The effects of treatment with mechanical percus
Brimioulle S. Moraine JJ, Kahn RI: Passive physical sion vibration. Am Hev Respir Dis 86:41-46. 1 962
therapy and respiratory therapy effects on intra Desmond KI. Schwenk WF. Thomas E. Beaudry PH.
cranial pressure (Abstract). Crit Core Med Coates AL: Immediate and long-term effects of
16(4 ):449. 1 988 chest physiotherapy in patients with cystic fibro
Brifish Medical lournal Editorial: Treatment of sta sis. J Pediolr 103:538-542. 1983
tus asthmaticus. Br Med J 4:563-564. 1972 DeTroyer A. Heilporn A: Respiratory mechanics in
Burnard ED, Grattan-Smith P. et a1.: Pulmonary in quadriplegia: The respiratory function of the in
sufficiency in prematurity. Ausl Paedialr J 1:12- tercostal muscles. Am Rev Respir Dis 122:591-
38. 1965 599. 1 980
Butts J: Pulmonary rehabilitation through exercise DeTroyer A. Kelly S: Action of neck accessory mus
and education. GVP 17-61. December-January. cles on rib cage in dogs. J Appl Physio/ 56:326-
1981 332. 1984
Cameron GC. Scott JW, lousse AT. Bolterell EH: Di DeTroyer A, Estenne M. Ninane V: Rib cage me
aphragmatic respiration in the quadriplegic pa chanics in simulated diaphragmatic paralysis.
tient and the effect of position on his vital capac Am Rev Respir Dis 1 3 2:793-799. 1985
ity. Ann Surg 141 :451-456. 1955 DeTroyer A. Estenne M . Heilporn A : Mechanism of
Campbell AH. O'Connell JM. Wilson F: The effect active expiration in tctraplegic subjects. N Engl I
of chest physiotherapy upon the F'EV. in chronic Med 314:740-744. 1 986
bronchitis. Med I Aust 1 :33-35. 1975 Dhande VG. Kattwinkei l , Darnall RA: Prone posi
Campbell EJM. Agostoni E. David IN: The Respira tion reduces apnea in preterm infants. Pediafr Res
tory Muscles: Mechanics and Neural Control. p 46. 1 6(2):285. 1982
WB Saunders. Philadelphia. 1970. Doershuk CF. Fisher BI. Matthews LW: Pulmonary
Casaburi R. Wasserman K: Exercise training in pul physiology of the young child. In Pulmonary
monary rehabilitation. N Engl I Med 314:1 509- Physi% gy o! the Fetus Newborn and Child. edited
1 5 1 1 . 1986 by EM Scarpelli, pp. 167-169. Lea & Febiger. Phil
Cheshire DIE: Respiratory management in acute adelphia. 1975
traumatic tetraplegia. Paraplegia 1 : 252-261. 1 964 Estenne M. DeTroyer A: Relationship between res
Ciesla N. Simpson N. Derrickson I . Salmon M: A piratory muscle elect romyogram and rib cage mo
comparison of two different breathing exercises tion in tetraplegia. Am Rev Respir Dis 1 32:53-59.
for quadriplegic patients (abstract). Phys Ther 1985
69:393. 1 989 Estenne M . DeTroyer A: Mechanism of the postural
Cochrane M. Webber BA. Clarke SW: Effects of spu dependence of vital capacity in tetraplegic sub
tum on pulmonary funclion. Br Med I 2: 1 181- jects. Am Rev Respir Dis 135:367-371. 1987
1183. 1 977 Etches MB. Scott B: Chest physiotherapy in the
newborn: Effect on secretions removed. Pediol Hammon WE. Kirmeyer PC. Connors AF. McCaffee
ries 62:713-715. 1978 DR, Kaplan RI: Effect of bronchial drainage on in
Fan LL. Flynn JW, Pathak DR. Madden \VA: Predic tracranial pressure in acute neurological injuries
tive value of stridor in detecting laryngeal injury (abs'rac'). Phys Ther 61 (5):735. 1981
in ext ubated neonates. Crit Care Med 10(7):453- Henke KG. Orenstein OM: Oxygen saturation dur
455. 1 982 ing exercise in cystic fibrosis. Am Rev Respir Dis
Feldman J. Changes in maximal expiratory flow 1 29:708-7 1 1 . 1 984
volume cu rves after postural drainage in patients Hislop A. Reid L: Growth and development of the
wilh cystic fibrosis or chronic bronchitis (ab respiratory system-anatomical development. In
stract). Am Rev Respir Dis 1 1 3:272. 1976 ScientifiC Foundations of Pedialries. edited by IA
Feldman J. Traver CA. Taussig LM: Maximal expi Davis and , Dobbing. p. 221. WB Saunders. Phil
ratory flows after postural drai nage. Am Rev Res adelphia. 1974
pir Dis 1 1 9, 239-245. 1979 Holloway R. Adam EB. Desai SO. Thabiran AK: Ef
Finer NN. Boyd J: Chest physiotherapy in the neo fect of chest physiotherapy on blood gases of ne
nate: A controlled study. Pedialrics 61:282-285. onates treated by intermittent positive pressure
1978 respiration. Thorax 24:421-426. 1 969
Finnie NR: Handling the Young Cerebral Palsied Holloway R. Desai MO. Kelly SD. Thambiran AK.
Child 01 Home, pp 24-28. William Heinemann Strydom SE. Adams EO: The effect of chest phys
Medical Books, London, 1971 iotherapy on arterial oxygenation of neonates
Fisher 0, Frewen T, Swedlow DB: Increase in intra during treatmenl of tetanus by intermit ten posi
cranial pressure during suclioni ngstimulation tive pressure respiration. 5 Afr Med 1 40:445-447.
vs, rise in PaC02, Anesthesiology 57:416-417, 1 966
1 982 Huber AL. Eggleston PA. Morgan J: Effect of chest
Fox WW, Schwartz IG, Shaffer TH: Pulmonary physiotherapy on asthmatic children (abstract). 1
physiotherapy in neonates: Physiological changes Allergy Clin Immunol l l l :109- 1 10. 1974
and respiratory management. Pediatrics 92:977- Imle PC. Anderson PA. Ciesla ND: The effect of
981. 1978 wearing an abdominal binder during the acute
Freedberg PO, Hoffman LA, Light WC, Kreps M: Ef phase follOWing quadriplegia (abstract). Arch
feet of progressive muscle relaxation on the ob Phys Med Rehabil 67:656. '986
jective symptoms and subjective responses asso Imle PC. Mars MP. Eppinghaus CEo Anderson P.
dated with asthma. Heart Lung 1 6:24-30. 1 987 Ciesla N: Effect of chest physiotherapy position
FuglMeyer AR: Effects of respiratory muscle paral. ing on intracranial and cerebral perfusion pres
ysis in tetraplegic and paraplegic patients. Scand sure (abstract). Crjj Core Med 16(4):449. 1988
I Rehobil Med 3:141-150, 1971a !ennell B. Teasdale G: Management of Hp.od Inju
Fugl.Meyer A R: A model for treatment of impaired ries. Davis. Philadelphia. 1981
ventilatory function in tetraplegic patients. Scond Johnson ID. Malachowski NC. Grobstein R. et al.:
I Rehabil Med 3:168-177. 1971b Prognosis of children surviving with the aid of
FuglMeyer AR: Handbook ofCli ncal Neurology. /n mechanical ventilation in the newborn period. J
juries of the Spine and Spinal Cord, Chap 19. The Pedial 84:272. 1 974
Respiratory System. pp. 335-349. American El Johnson TK. Moore EM. Jeffries I E editors: Children
sevier Publishing, New York. 1976 Arp Differen l: Developmenlal Physiology. 2nd ed.
Fulton RL. lones CE: The course of post-traumatic Ross Laboratories. Columbus. 1 978
pulmonary insufficiency in man. Surg Gynpcol Kattan M: Long term sequelae of respiratory ill ness
140:179-186. 1975 in infancy and childhood. Pp.diulr Clin Norlh Am
Garradd J . Bullock M: The effect of respiratory Iher 26(3):525-535, 1979
apy on intracranial pressure in ventilated neuro Keens TG. Krastins IRB. Wannamaker EM. Livison
surgical patients. Aust J Physiol 32(2):107- 1 1 1 . H. Crozier ON. Bryan AC: Ventilatory muscle en
1986 durance training in normal subjects and patients
Geisler FH. Salcman M: The head injury patient. In with cystic fibrosis. Am Rev nespir Dis ' 1 6:853-
Emergency Su rgery and Critical Care. edited by 860. 1977
JH Siegel. pp. 91 9-946. Churchill Livingstone. Kerrebijn KF. Veentzer R. Bonzet E. Water VD: The
New York. 1987 immediate effect of physiotherapy and aerosol
Goldman 1M. Rose LS. Williams SI. Silver JR. Den treatment on pulmonary function in children
ison OM: Effect of abdominal binders on breath with cystic fibrosis. Eur I Respi r Dis 63:35-42.
ing in tetraplegic patients. Thorax 41 :940-945. 1 982
1 986 Klaus M, Fanaroff A. Marlin R: Respiratory prob
Gregory GA: Respiratory care of the child. Cril Care lems. In Care of Ihe High Risk Neonale. edited by
Med 8:582-586. 1 980 M Klaus and A Fanaroff. p. 1 90. Saunders. Phila
Guttmann L: Spinal Cord Injuries. Comprehensive delphia. 1 979
Monagemenl and Research. 2nd ed. pp. 209-215. Landau L1: Management of a child with asthma
575. Blackwell Scientific Publications. London. Med J Ausl 1 :340-344. 1977
1976 Ledsome JR. Sharp 1M: Pulmonary [unction in acute
Haas A. Lowan EW. Bergofsky EH: Impairment of cervical cord injury. Am Rev Respir Dis 124:41-
respiration afler spinal cord injury. Arch Phys 44. 1981
Med Rehabil 46:399-405. 1 965 Lerman RM. Weiss MS: Progressive resistive exor
Haas F. Axen K. Pineda H. Gandino D. Haas A: Tem cise in weaning high quadri plegiCS from the ven
poral pulmonary function changes in cervical tilator. Paraplegio 25:130-135. 1 987
cord injury. Arch Phys Med Aehabil 66:1 39-144, Levine AL: Chest physical therapy for children
1986 with pneumonia. JAOA 78:122-125. 1978
Livingstone JL: Physical trealment in asthma. Bf / Morraine I I . Brimioulle S, Kahn R: Active physical
Phys Med 1 5 : 1 36-139. 1952 therapy and respiratory therapy effects on intra
Long fG. Philip AGS. Lucey JF: Excessive handling cranial pressure (Abstract). Crit Care Med
as a cause of hypoxemia. Pediotrics 65(2):203-207. 16(4):450. 1988
1 980 Mortola JP, Sant'Ambrogio G: Motion of the rib cage
Lorin MI. Denning ER: Evaluation of postural drain and the abdomen i n tetraplegic patients. Clin Sci
age by measurement of sputum volume and con Mol Med 54:25-32. 1 978
sistency. Am J Phys Med 50:215-219, 1971 Motoyama EK: Lower airway obstruction. I n Fun
Lough MD. Doershuk CF. Stern RC: Pediatric Res damenlal Problems of Cystic Fibrosis ond Reloted
piratory Therapy. p. 9. Year Book Medical Pub Diseases. edited by JA Mangos and RC Talamo. pp
lishers. Chicago. 1974 335-343. Stratton Intercontinental Medical Book
Mackenzie CF. Shin S, Fisher R. Cowley RA: Two Corporation. New York. 1973
year mortality in 760 patients transported by heli Moulton A, Silver IR; Chest movements in patients
copter di rect from the road accident scene. Am with traumatic inju ries of the cervical cord. Cli n
SlIrg 45:10'1-108, 1979 Sci 39:407-422. 1970
Macklem P1: Airway obstruction and collaleral Muller NL. Bryan AC: Chest wall mechanics and
ventilation. Am Rev Hespir Dis 1 1 6:287-289. 1977 respiratory muscles in infants. Pediotr Clin North
Maloney FP: Pulmonary function in quadriplegia. Am 26(3):503-516. 1979
Effects of a corsel. Arch Phys Med Rehabil 60:261- :Myers MG. Mcguiness GA, Lachenbrunch PA.
265. 1979 Koontz FP, Holli ngshead R, Olson DB: Respira
March H: Appraisal of postural drainage for chronic tory illness in survivors of infant respiratory dis
obstructive pulmonary disease. Arch Phys Med tress syndrome. Am Rev Respir Dis 133:101 1 -
Rehobil 1 1 :528-530. 1971 1018. 1986
Martin RL. Herrell N. Rubin D, Fanaroll A: Effect of Newton DAG. Bevans HG: Physiotheray and inter
supine and prone positions on arterial oxygen mittent positive-pressure ventilation of chronic
tension in the preterm infant. Pediatrics bronchitis. Br Med / 2:1525-1 528. 1978
63(4):528-531. 1979 Newton DAG. Stephenson A: Effect of physiother.
Mascia AV: Manual on the standardization of care apy on pulmonary function. Lancel 2:228-230,
of the severely asthmatic child. I Asthma Res 1 978
1 3 : 1 1 5-127. 1 976 Ok ken A, Rubin IL. Martin R I : Intermittent bag
Massery M: Respiratory rehabilitation secondary to ventilation of preterm infants on continuous pos
neurological deficits: understanding the deficits. itive airway pressure. The effect on transcutane
In Chest Physical Therapy and Pulmon a ry Reha ous PO,. ) Peclialric 93(2):279-282. 1978
bilitation. edited by D Frownfelter, pp. 501, 541. Oldenburg FA, Dolovich MB, Montgomery JM,
2nd ed. Year Book, Chicago, 1987 Newhouse MT: Effects of postural drainage, ex
Matjasko I, Pilts L: Controversies in severe head in ercise and cough on mucous clearance in chronic
jury management. In Clinical Controversies in bronchitis. Am Rev Respir Dis 20:739-746. 1979
Neurooneslhesia and Neurosurgery. edited by J Orenstein OM. Franklin SA. Doershuk C . Heller
Matjasko and J Katz. pp. 181-231 Grune & Strat stein 11K, Germann KI. Horowitz IG. Stern RC:
Ion. New York. 1 986 Exercise conditioning and cardiopulmonary fit
May DB. Munt PW: Physiologic effects of chest per ness in cystic fibrosis. Chest 80(4):392-397. 1981
cussion and postural drainage in patients with Parker AE: Chest physiotherapy in the neonatal in
stable chronic bronchitis. Chesl 75:29-32, 1979 tensive care unit. Physiotherapy 7 1 (2):63-65. 1985
McCool FD. Pichurko BM. Slutsky AS. Sarkarati 1\1. Perlman J. Volpe J: Suctioning the preterm infant:
Rossier A. Brown R: Cha nges in lung volume and Effects on cerebral blood now velocity. intracra
rib cage configuration with abdominal binding in nial pressure. and arterial blood pressure. Pedi
quadriplegia. , Appl P hysioI 60(4): 1 1 98- 1 202. 1 986 alrics 72(3):329-334. 1983
.
McKaba PG: Treatment of asthma in adults. Culis Petersen ES. Esmann V. Honcke P. Munkner C: Ef
17:1 1 1 5- 1 1 19. 1976 fect of treatment on chronic bronchitis. ACla Med
MCKinley CA, Auchincloss JH, Gilbert R. Nicholas Scand 182:295-303. 1 967
J: Pulmonary function, ventilatory control. and Pryor IA. Webber SA: An evaluation of the forced
respiratory complications in quadriplegic sub expiration technique as an adjunct to postural
jects. Am Rev Respir Dis 100:526-532. 1969 drainage. Physiotherapy 65:304-307. 1 979
McMichan IC. Michel L, Westbrook PR: Pulmonary Purohit OM. Caldwell C. Levkoff AH: Clinical
dysfunction following traumatic quadri plegia. memorandum, multiple rib fractures due to phys
lAMA 243:528-531. 1960 iotherapy in a neonate with hyaline membrane
McQuillan KA: The effects of the trendelenberg po disease. Am I Dis Child 129:1103-1 104. 1975
sHion for postural drainage on cerebrovascular Rava P. Yeh TF, Mora A. Pildes RS: Changes in
status in headinjured patients. Hearl Lung transcutaneous P02 during tracheobronchial hy
16:327. 1 987 giene in neonales. Peri notologyNeono lology
Menkes HA. Traystman RJ: Collateral ventilation. 4:41-45. 1 980
Am Rev Respir Dis 1 1 6:287-289, 1977 Reines AD, Harris RC: Pulmonary complications of
Metcalf VA: Vital capacity and glossopharyngeal acute spinal cord injuries. Neurosurgery
breathing in traumatic quadriplegia. Phys Ther 21(2): 1 93-1 96. 1987
46:835-838. 1 966 Ries AL. Fedullo PF. Clausen JL: Rapid changes in
Montero IC. Feldman OJ, Montero 0: Effects of glos arterial blood gas levels after exercise in pulmo
sopharyngeal breathing on respiratory function nary patients. Chest 83(3):454-456. 1983
after cen'ical cord transection. Arch Ph ys Med Ries AL, Moser K: Comparison of isocapnic hyper
RehabiI 48:650-653. 1 967 ventilation and walking exercise training at home
in pulmonary rehabilitation. Chest 90(2):285-289. Wailoo MP. Emery JL: Normal growth and devel
1 986 opment of the trachea, Thorax 37:584-587, 1 982
Roper PC. Vonwiller lB. Fisk ce. Gupta 1M: Lobar Walker I . Cooney M: Improved respiratory function
atelectasis after nasotracheal i ntubation in new in quadriplegics after pulmonary therapy and
born i nfants. Aust Poediofr J 1 2:272-275. 1976 arm ergometry. N Eng' J Med 3 1 6(8):485-487. 1987
Rossman eM, Waldes R. Sampson D. Newhouse Walsh CM, Bada H. Korones SB. Carter M, WongSP,
MT: Effect of chest physiotherapy on the removal Arheart K: Controlled supplemental oxygenation
of mucus i n patients with cystic fibrosis. Am Rev during tracheobronchial hygiene. Nurs Res
Respir Dis 126:131-135. 1 982 3614 ):211-215. 1987
Schumacker PT. Rhodes CR. Newell IC. Dullon RE. Webb MSC. Martin lA, Cartl idge PH; NGYK. Wright
Shah DM. Scovill WA. Powers SR: Ventilation NA: Chest physiotherapy in acute bronchiolitis.
perfUSion imbalance after head trauma. Am Rev Arch Dis Child 60: 1078-1079. 1985
Respir Dis 1 1 9:33-43, 1979 Webber BA: Current trends in the treatment of
Schultz H , Taylor FA: Intracranial pressure and ce asthma. Physiotherapy 59:386-390. 1973
rebral blood flow monitoring in head injuries. Weller PH. Bush E. Preece MA. Matthew 01: Short
Can Med Assac J 1 1 6:609-613. 1977 term effects of chest physiotherapy on pulmonary
ShaHt MN. Umansky F: Effect of routine bedside function in children with cystic fibrosis, Respi
procedures on intracranial pressure. Israel J Med ralion 40:53-56. 1980
Sci 1 319):881-886. 1977 Wetzel J. Lunsford BR. Peterson MJ, Alvarez SE:_
Siebens AA. Kirby NA. Poulos DA: Cough fol lowing Respiratory rehabilitation of the patient with R
transection of spinal cord at e-6. Arch Phys Med spinal cord injury. In Cardiopulmonary PhYSical
RehabiI 45:1-8. 1 964 Therapy. edited by S Irwin and J Tecklin. pp, 395-
Simbruner G . Coradello H, Fodor M, Havelec L. 4 1 1 . Mosby. St. Louis. 1 985
Lubec G. Pollak A: Effect of tracheal suction on While PF. Schlobohm RM, Pitts LH. Lindauer JM: A
oxygenation. circulation. and lung mechanics i n randomized study of drugs for preventing in
newborn infants. Arch Dis Child 56:326-330, 1981 creases in intracranial pressure during endotra
Singh V: Effect of respiratory exercises on asthma cheal suctioning. Anesthesiology 57:242-244,
the pink city lung exerciser. J Aslhma 24(6):355- 1 982
359. 1987 Whitfield 1M. lanes MD: Atelectasis associated with
Speidel BD: Adverse effects of routine procedures mechanical ventilation for hyaline membrane
on preterm infants. Lancet 1 :864-866. 1 978 disease. Cri! Core Med 8:719-732. 1980
Stein DA, Bradlwy BL. Miller WC: Mechanisms of Wicks AB. Menler RR: Long-term outlook in quad
oxygen effects on exercise i n patients with riplegic patients with initial ventilator depen
chronic obstructive pulmonary disease, Chest dency. Chest 9013):406-410. 1 986
8 1 :6-1 O. 1 982 Wong JW. Keens TG, Wannamaker EM. Crozier ON,
Sutton pp, Pavia D, Bateman IRM. Clarke SW: Chest Levison H, Aspin N: Effects of gravity on tracheal
physiotherapy: A review. Eur J Respir Dis 63:188- mucus transport rates in normal subjects and in
201 . 1 982 patients with cystic fibrosis. Pediatrics 60:146-
Sutton PP. Lopez-Vidriero MT. Pavia D, Newman 1 5 1 . 1977
SP. Cloy MM. Webber B. Parker A. Clarke SW: Wood DW, Kravis LP. Lecks HI: Physical therapy for
Assessment of percussion. vibratory shaking. and children with intractable asthma. J Asthma Res
breathing exercises in chest physiotherapy. Eur J 7:1 77-182. 1970
Respir Dis 66:147-152. 1 985 Yeh TF. Leu ST. Pyati S. Pildes RS: Changes in O2
Stocks I, Godfrey 5: The role of artificial ventilation, consumption in response to NICU care proce
oxygen and CPAP in the pathogenesis of lung dures i n premature infants, Pedialr Res 16(2):315.
damage in neonates, Assessment by serial mea 1 982
surements of lung function, Pediatrics 57:352- Zach M. Oberwalder B. Hansler F: Cystic fibrosis:
357. 1976 Physical exercise versus chest physiotherapy.
Streider 01: Pediatric origins of chronic obstructive Arch Di, Child 57:587-589. 1 982
lung disease. Bull Physiopolhol Respir 1 1 :273. Zach M. Purrer e. Oberwaldner B: Effect of swim
1 974 ming on forced expiration and sputurh clearance
Tecklin IS. Holsclaw DS: Bronchial drainage i n pa in cystic fibrosis, Lancet 1:1201-1 203. 1981
tients with cystic fibrosis. Phys Ther 55:1081- Zapletal A. Stefanova J. Horak J. Vavrova V. Sarna
1084. 1975 nek M: Chest physiotherapy and airway obstruc
Tomney PM. Finer NN: A controlled evaluation of tion in patients with cystic fibrosis-a negative
muscle relaxation i n ventilated neonates (ab report. Eur J Respir Dis 64:426-433, 1 983
stract). Cril Care Med 8:228. 1 980 Zinman R. De Boeck C: Cough versus chest physio
Tudehope 01. Bagley C: Techniques of physiother therapy: A comparison of the acute effects on pul
apy in intubated babies with the respiratory dis monary function in patients with cystic fibrosis.
tress syndrome. Aust Paedialr J 16:226-228, 1 980 Am Rev Rcspir Dis 1 29:182-184, 1984
CHAPTER 9
Adjuncts to Chest Physiotherapy

flumidity
Normal and Supplemental Humidity
Controlled Environment
Controlled Inspired Atmosphere
IPPB
Aerosol Delivery
Work of Breathing
Pulmonary Function
Psychological E"ect
Prevention of Pulmonary Complications Associated with Surgery
Complications Associated with IPPB
The Cost of IPPB
Bronchodilating and Mucolytic Aerosols
Bronchodilators
Mucolytic Agents
Complications
Mechanical Devices Used to Encourage Lung Expansion Following Surgery
Blow Bottles
Incentive Spirometry
Continuous Positive Airway Pressure and Positive Expiratory Pressure
Bronchoscopy
Complications and Precautions
Restrictions
Comparison with Chest Physiotherapy
Often the therapy given to patients re HUMIDITY

quiring intensive respiratory care affects
both the airways and the types of secre Normal and Supplemental Humidity
tions they produce. As a result. there is
much investigation into techniques for Adequate humidity is necessary for
improving secretion clearance. Supple proper respiratory function. Studies on
mental humidity is routinely given to the humidification of inspired air show
most intensive care unit [ICU) patients; that by the time the gas reaches the sub
other methods advocated to clear pul glottic region of the trachea. it not only is
monary secretions include intermittent warmed to 37'C but also is fully satu
positive pressure breathing [IPPB), aero rated with water vapor [Robinson. 1974).
sols. incentive spirometry [IS). continu It is well documented that ciliary activity
ous positive airway pressure [CPAP). is dependent on humidification levels
positive expiratory pressure [PEP). blow [Dalhamn. 1956; Toremalm. 1961; Kil
bottles. and bronchoscopy. This chapter burn. 1967; Graff and Benson. 1 f\9; As
discusses some of the i ndications. effec mundsson and Kilburn. 1970). Cilia ex
tiveness. and complications of these tend from the respiratory bronchioles to
techniques. the larynx [Hilding. 1 957). and ciliary ac-
281
tion is considered the most efficient and trolled inspired atmosphere systems in
physiological means of cleansing the res that they are susceptible to infection
piratory tract (Graff and Benson). There transmission. which is primarily bacte
fore. it can be concluded that normal rial. Controlled environment devices are
clearance of secretions from the lungs is more expensive and limited in their mo
also dependent upon proper humidifica bility. especially compared with most
tion. Both Dalhamn and Forbes (1973) controlled inspired atmosphere equip
found significant reductions or cessation ment (Chamney).
of mucus flow at 50% relative humidity
(RH)* levels in animals. Controlled Inspired Atmosphere
Based on these findings. Graff and Ben
son. along with many others. believe that Controlled inspired atmosphere sys
all inspired gases must be humidified. if tems alter the inspired gases of a patient
not by the nose and pharynx. then by ar but not the entire environment. They can
t i ficial means-hence the use of humid be divided into four main groups. which
ifiers. Various types of humidifiers are are discussed in greater detail below: ( 1 )
available. In the literature. addition of heat a n d moisture exchangers o r con
humidity is specifically recommended densers. (2) instillation or infusion meth
for patients who are intubated. venti ods. (3) nebulizers. both pneumatically
lated. anesthetized. or receiving supple driven and mechanically or ultrasoni
mental oxygen; for the newborn; and for cally activated. and (4) water bath
those with severe chest injury. chronic humidifiers.
obstructive pulmonary disease (COPD).
asthma. pneumonia. atelectasis. respira Heat and Moisture Exchangers/
tory burns. or innumerable other clinical Condensers
conditions (Sara. 1965; Egan. 1967;
Rashed et al.. 1 967; Chamney. 1969; Graff Heat and moisture exchangers/con
and Benson; Forbes; Downie. 1 9 79; and densers minimize heat and humidity loss
others). In short. it seems widely agreed from the upper respiratory tract and are
that anyone breathing dry gases. having commonly referred to as "artificial
an artificial airway. or having abnormally noses" (Walley. 1956; Toremalm; Maple
thick secretions should receive supple son et al.. 1963; Siemens-Elema. 1979;
mental humidity. There are two class Weeks and Ramsey. 1983). They function
ifications of humidifiers. controlled as follows: Humidified expired gases pass
environment and controlled inspired through a sponge. paper. metal. or gauze
atmosphere. mesh. which causes condensation of
moisture and heat retention. Most cur
Controlled Environment rently used condensers are composed of
a synthetic felt and cellulose sponge. The
Controlled environment systems are retained heat and moisture are then
applicable to spontaneously breathing added to the inspired gases. Heat and
patients but not necessarily those whose moisture exchangers can be used,during
upper respiratory tracts are bypassed. spontaneous or artificially controlled
They consist of such devices as fog ventilation. Over the past decade. there
rooms. steam or mist tents. and incuba has been increased emphasis on airway
tors. These systems are all constructed so humidification during anesthesia as well
that the patient is contained and cared as for postoperative management. When
for in the humidified environment. They added to inhaled anesthetic systems. the
suffer the same complication as con- newer condensers have been shown ef
fective in conserving some of the heat
and moisture loss that would otherwise
Relative humidity is the vapor content of a gas ex occur. They are also easy to use and re
pressed as a percentage of that gas at full saluration quire no supplemental power source.
at the same temperature. Another way of describing
water content is in milligrams per liter. AI 31C,
The role of condensers for patients in
fully saturated water content can be expressed as 44 the ICU or requiring mechanical venti
mg/liter or 100% relative humidity. lation for longer than 24 hr is more con-
ADJUNCTS TO CHEST PHYSIOTHERAPY 283
troversial. Primiano and associates (1 984) Although there is some debate as to the
found that adding a condenser (compared minimal acceptable levels of supplemen
with using no supplemental humidity tal humidity, the American National
source) improved the RH to 69.2% at Standards Institute (1 979) suggests a min
body temperature in six ICU patients. imum output of 30 mg H,O/liter gas
Macintyre and co-workers (1983) re while the Emergency Care Research In
ported no significant difference in airway stitute (1983) recommends a minimum
pressure, compliance, resistance, or ar output of 21-24 mg H,O/liter gas. Not all
terial blood gases in 26 ICU patients condensers provide acceptable humidifi
when co ,?ventional cascade humidifica cation, particularly at increasing flow
tion was compared to a condenser for 24 rates, tidal volume, or oxygenation. The
hr. The authors also estimated sputum overall effectiveness of condensers de
volume (over 4 hr) and radioaerosol pends on the heat and humidityalready
clearance (over 1 hr) to be similar with present in the gas before exposure to the
both types of humidifiers. The tempera exchanger system. Mapleson et al. re
ture settings used during cascade humid ported that from 40 to 90% of the mois
ification in this study were not specified. ture that might otherwise be lost may be
Others question the use of condensers retained by this method. Unlike the na
when longer periods of mechanical ven sopharynx. which increases heat and
tilation are needed (Hay and Miller, 1982; moisture retention under colder and
Kahn, 1983; Perch and Realey, 1984; drier conditions, full saturation of dry
Cohen et aI., 1988). Significant increases gases is not possible with a condenser
in endotracheal tube occlusion (within (Robinson, 1 9 74). The condenser's ability
12 hr), pneumonia, atelectasis, and bron to humidify is inversely related to vol
chial cast formation have been associated ume and FlO, delivery (Hay and Miller;
with condenser use compared with cas Weeks and Ramsey; Perch and Realey;
cade humidification (Perch and Realey; Cohen et al.). Heat and moisture ex
Cohen et al.). Microscopic studies on the changers also cause an increase in resist
effects of condenser humidification (less ance and dead space which should be
than 100% RH at body temperature) are considered during use with children and
limited. When inspired air is only 60- "borderline" patients during spontane
70% saturated, there is evidence that the ous breathing (Siemens-Elema; Weeks;
lower airways can supply additional heat Hay and Miller; Branson et aI., 1 986). In
and moisture for up to 3 hr. It is not weak or critically ill patients the added
"known what happens to the subcarinal breathing load imposed by the condenser
airways of humans during prolonged per may cause respiratory muscle fatigue and
iods of reduced RH (Kahn) or reduced interfere with weaning from the ventila
systemic hydration. Histologic damage to tor (Ploysonsang et aI., 1988). Cas leakage
the tracheal epithelium of dogs exposed around the condenser is another concern,
to desiccation and then rehumidification particularly with neonates; however,
did not correspond with the noted condenser humidification may be suc
changes in mucus velocity that rapidly cessfully used in this patient population
improved (Hirsh et aI., 1975). Our clinical (Cedeon et aI., 1987).
experience is similar to Cohen and asso-' The earlier model condensers were
ciates. We believe that condenser humid found most effective when the gauze or
ifiers are not adequate for all ICU pa mesh was kept reasonably dry. Frequent
tients. Particular attention should be changing was thought to minim ize bac
given to patients with thick secretions or terial contamination. There is some evi
respiratory muscle weakness and those dence that the new type of heat and
who are spontaneously breathing, re moisture exchangers may reduce venti
quire delivered minute volumes of >10 lator contamination by trapping exhaled
liters/min, or a FlO, > 0.4. When con bacteria in the inner core of the humidi
densers are used, they should be re fier (Stange and Bygdeman, 1980). This
placed with conventional humidifiers if has not been associated with an in
sputum becomes tenacious or if difficulty creased risk of airborne inhaled bacteria
occurs with suctioning. during mechanical ventilation (Powner
et al.. 1986). However. when mucus is trained gases with a nebulizer or water
trapped in the condenser. the system bath humidifier. while some method of
should be changed due to the increased instillation/infusion is commonly used
airway resistance or obstruction (Robin to humidify the injected gas (Berman et
son; Sykes et al.. 1976; Weeks); other al.. Doyle et al.. 1984; Ophoven et al.). For
wise. changing the heat and moisture ex paitents with adequate lung compliance
changer every 24 hr is recommended and no significant lung pathology. the
(Siemens-Elema). ratio of entrained-to-injected gas is high.
Therefore. entrained gas that is optimally
InstillBtion/lnfusion
humidified may partially compensate for
the effect of the dry injected gas. Prob
Instillation/infusion is a simple yet lems with tracheal m ucosa damage arise
controversial method of humidifying in when the proportion of entrained gas de
spired gases. It consists of instilling a creases. as occurs in patients with pul
fluid. usually physiological saline or a monary pathology or poor compliance.
mucolytic agent. at a set rate into the in who may require HFV. When instilla
spiratory limb of the ventilator tubing or tion/infusion of injected gas is used
directly into the tracheal tube. Though without humidified entrained gas. mucus
this method is easy to perform. the effect transport is markedly reduced (Klain et
is probably no different from instilling al.. 1982). Warming the instillate or the
fluid directly into the trachea (see p. 180). injected gas does not prevent heat loss
Hayes and Robinson (1970) found that since rapid cooling occurs during the
humidity levels decreased sharply when aerosolization of the infused water or sa
this method of humidification was used line. These factors are thought to be par
in comparison to a hot water bath humid tially responsible for the increase in in
ifier or a nebulizer. Instillation can also spissated secretions and tracheal damage
lead to increased airway resistance seen with HFV (Berman et al.; Doyle et
(Sykes et al.). Another hazard of instilla al.; Ophoven et al.).
tion is the uncontrolled or improperly
controlled rate of infusion. which could Nebulizers
lead to drowning. At best. this intermit
tent flooding of the respiratory mucosa is There are two basic types of nebuliz
unlikely to be an acceptable physiologi ers. the pneumatically powered and the
cal substitute for normal conditions and mechanically or ultrasonically activated.
may have serious consequences. espe Both can be used on spontaneously
cially if large amounts of fluid are ab breathing patients as well as those re
sorbed through the lungs (Huber and Fin quiring intubation or mechanical venti
ley. 1965; Chamney). It is doubtful that lation. However. nebulizers are reported
instillation of fl uid into the artificial air to interfere with mechanical ventilation
way has any effect on humidifying distal (Sara and Clifton. 1962; Glover. 1965; Bo
airways. Although it may be helpful in somworth and Spencer. 1965; Hayes and
compensating for humidity loss from the Robinson; Klein et al.. 1973). If the gas
upper airways of an intubated patient. it flow delivered to the patient by the ven
is considered an u nsatisfactory method tilator also operates the nebuli ter. inad
of humidification during mechanical or equate humidity can result. especially at
spontaneous respiration (Hayes and low flow rates (Hayes and Robinson;
Robinson). Klein et al.). Alternatively. if the nebu
Supplemental saline or water is often lizer is driven by an auxiliary oxygen
added during high frequency ventilation supply. humidification may improve. but
(HFV) where adequate airway humidifi the concentration of delivered oxygen
cation has emerged as a problem (Berman can also increase significantly (Bosom
et al.. 1984; Ophoven et al.. 1 984). Two worth and Spencer).
gas sources. entrained and injected. must Pneumatically Powered Nebulizer. The
be considered during this mode of venti pneumatic-powered humidifier works on
lation. Moisture may be added to en- the Bernoulli prinCiple. A narrow jet of
high-pressure gas is blown across a water of ultrasonically or mechanically acti

reservoir. Both water vapor and droplets vated nebulizers is achieved by dropping
are formed and blown against an anvil or water onto a disc rotating at high speeds
system of bames, which usually filters or onto a crystal Vibrating at very high
out the larger water particles. The gas en frequencies (Chamney). These methods
tering the patient's delivery tube still are reported to produce varying levels of
contains a visible mist of both water humidification ranging from 30 to 200
vapor an droplets ranging from 5 to 20 II mg/liter (Smith, 1966; Robinson). The
(Robinson). This dense mist does not nec potentially large amount of humidity de
essarily imply complete gas saturation livered by this method, though thought
with humidity, since visible mists with to be effective in loosening thick secre
relative humidities of less than 78% are tions by acting as a solvent, has also led
possible (Robinson). Klein and associates to much criticism (Robinson; Downie).
found that no correlation could be made Because of the lack of output control on
between the visible mist and the water ultrasonic nebulizers, fluid gain, in
content of a gas. Heated and unheated creased airway resistance and water in
pneumatic-powered humidifiers are toxication were reported to occur, espe
available commercially. Studies show cially in i nfants (Glover; Harris and
that humidities of only up to 29 mg/liter Riley, 1967; Modell et aI., 1967; Cheney
(at the patient's end of the delivery tube) and Butler, 1968; Pflug et aI., 1970; Malik
are possible with unheated nebulizers, and jenkins, 1 9 72). Modell and associates
while up to 50 mg/liter can be achieved studied the effects of continuous ultra
using heated types (Sara and Curie, 1965; sonic nebulization on dogs. Pathological
Sara; Bosomworth and Spencer). More re changes compatible with bronchopneu
cently, some unheated pneumatically monia were seen i n all eight dogs ex
driven nebulizers are reported to deliver posed to a physiological saline aerosol.
nearly 100% relative humidity (Klein et This effect was only seen in two of the
al. ). eight dogs receiving nebulized distilled
Marked condensation along the deliv water, yet five of the eight demonstrated
ery tube is a problem, particularly with mild to moderate focal atelectasis.
heated pneumatic-powered humidifiers. Other authors i nvestigating the effects
In fact, this system should not be used of short-term use of ultrasonic nebuliza
with narrow-gauge delivery tubing, since tion reported excessive coughing and
condensation can effectively block both wheezing in patients with chronic l u ng
gas and humidity flow to the patient. disease a nd in normal subjects (Cheney
jones and co-workers (1 969) demon and Butler; Pflug et al; Malik and jen
strated how a fluid-lined tube could in k i ns). Cheney and Butler found in
crease resistance to gas flow. Much as a creased airway resistance in patients and
fluid-lined delivery tube can increase re normal subjects using ultrasonic nebuliz
sistance or block air flow, the inhalation ers. This repsonse was not seen with
of high-density mists can i ncrease the other forms of nebulizers. In patients
fluid lining of the respiratory tract, caus with chronic bronchitis, Pflug and co
ing greater airway resistance (Robinson). workers reported significant decreases i n
Due to the small water particle size de forced expiratory volume i n 1 sec (FEV,)
livered to the airways, the problem of and vital capacity following ultrasoni
transmitting bacterial i nfections is also cally delivered aerosols. Similarly, in
great. Therefore, cleaning and steriliza creased airway resistance was noted by
tion are extremely important. Despite Malik and jenkins, who reported that
these complications, the pneumatically these physiological alterations were most
driven humidifiers are more effective marked when a 5% saline solution was
than those previously described, espe nebulized, as opposed to distilled water
Cially when used on the spontaneously or normal saline. The results of these
breathing patient. studies provide evidence that a seem
Mechanically or Ultrasonically Acti i ngly i nnocuous procedure, such as ul
vated Nebulizer, The small particle size t rasonic nebulization of water or saline,
produces definite side effects that may be respiratory tract. This has a potentially
disastrous, particularly i n patients with great impact because bacteria carried by
chronic airway disease (Cheney, 1 972). small water particles may be delivered to
Ultrasonic nebulization can deliver the distal airways (Chamney; Klein et al.;
water particles of 1-5 JL in size. In fact, Sykes et al.).
97% of ultrasonically nebulized humid
ity, but only 55% of the pneumatically WBterBBth
nebulized humidity, are delivered in par
ticles within this range (Moffet et aI., In water bath humidifiers, inspired gas
1967). A droplet-size spectrum of 2-10 JL is either blown over or bubbled through
is recommended for water deposition water. This may allow full saturation for
throughout the airways, since alveolar a given temperature. The humidified gas
sacs and ducts may be theoretically then passes through a delivery tube to
reached by 1 - to 3-JL droplets, bronchioles the patient. Both heated and unheated
by around 6-JL droplets, and bronchi and water bath models are available. The un
upper airways, by 10-JL droplets (Robin heated models are capable of saturating a
son). However, Sawyer (1963) states that gas only at ambient temperature and,
in the spontaneously breathing patient, therefore, do not allow full saturation at
approximately 50% of particles 1-5 JL i n body temperature. Consequently, only
size are retained in the nasopharynx, inadequate humidities of 7-22 mg/liter
while only 1 0-40% are deposited in the are possible (Wells et aI., 1963; Bosom
depths of the lungs. The pharynx and worth and Spencer; Darin et aI., 1982).
upper trachea are bypassed in tracheally Heated water bath humidifiers lead to
intubated patients. As a result, droplet heavy condensation in the delivery
delivery to the smaller airways may be tubes. This results from heating and sat
altered. Aerosol deposition is dependent urating the air at above body tempera
on many variables and is not well lure, therefore increasing the water
understood. vapor-carrying capacity, and then allow
The complication of transmitted infec ing the air to cool while in the delivery
lion is a greater hazard with ultrasonic tubes. Heated models can provide up to
and mechanical nebulization due to the 42 mg/liter at 35'C (Wells et al.; Cham
higher percentage of minute-sized water ney). Humidifiers with a thermostat on
particles. The smaller size potentially al the inspiratory limb of the ventilator tub
lows particles to reach the distal airways ing can deliver up to 44 mg H20/liter al
where pulmonary clearance mechanisms 37'C (Robinson).
may not be as efficient. This is com Because of the amount of condensa
pounded by the fact that these same par tion, water bath humidifiers should al
ticles can carry a signficant number of vi ways be kept lower than the patient to
able bacteria (Reinarz et aI., 1965; prevent accidental spillage into the pa
Edmondson et aI., 1966; Ringrose et aI., tient's airway. Excess condensation also
1968). The small droplet size also allows often calls for frequent delivery lube
some particles to leave the lungs during drainage or moisture traps. If the temper
expiration and to remain airborne, ature at the patient's end of the delivery
thereby providing a vehicle of transmis tube is controlled, condensation can be
sion from one patient to another. minimized (Chamney). Problems of bac
Generally, pneumatic and ultrasonic terial infection from waler bath, humidi
nebulizers have four disadvantages: (1 ) fiers are reported low. nearing that of am
There is poor control over the upper bient air (Reinarz et al.; Edmondson el
level of humidity delivered; (2) delivery al.; Moffet et a I . , 1967; Schulze et aI.,
tubes require frequent checking to pre 1967). This is possible because water
vent obstruction by condensation; (3) bath systems deliver humidity in vapor
lengthy warm-up periods may be neces form, which does not carry bacteria
sary to achieve steady outputs in some (Chamney). Although condensate is fre
heated models; and (4) nebulizers can in quently contaminated during 24 hr of
troduce massive doses of bacteria to the mechanical ventilation, the patient's se-
cretions are reported as the primary let size is theoretically of greater benefit
source of colonization. Nonetheless, care than that of the ultrasonic nebulizer
should be taken to prevent inadvertent (Robinson). There are fewer complica
lavage with the condensate (Craven et tions of overhumidification and in
aI., 1984). Also, water bath humidifiers creased airway resistance associated
can be used on both ventilated and spon with pneumatic nebulizers. Both meth
taneously breathing patients, since their ods of nebulization interfere with me
humidit production tends to be less sus chanical ventilation. However, heated
ceptible to changes in flow or tidal vol water bath humidifiers are surprisingly
ume (Hayes and Robinson). efficient and, when incorporated in a
ventilator circuit, create less interference
Summary with ventilation (Chamney; Hayes and
Robinson; Robinson). They probably rep
There is a wide range in the effective resent the best method of providing hu
ness of commercially available humidifi midity for the majority of patients (Sykes
ers. The optimal amount of water content et a 1 . ). Water bath humidifiers are also
that should be added to inspired gases is less prone to bacterial contamination
still a matter of controversy. It is gener than the nebulizers. Although often re
ally agreed that humidification should ferred to as "old fashioned," water bath
approach 44 mg H20/liter. The three ac humidi fiers are recommended for the pa
ceptable methods of humidifying gases tient in the ICU who requires mechanical
use a heat and moisture exchanger or ventilation for more than 24 hr. As with
condenser, a nebulizer, or a water bath all types of heated humidifiers, care must
system (Robinson). Instillation of infu be taken to prevent overheating.
sion is of no proven benefit except possi
bly with HFV, where appropriate airway
IPPB
humidification remains a problem. The
new types of condensers are able to re The effects of IPPB have been studied
tain most of the heat and moisture that since its introduction over 40 years ago
would otherwise be lost, but they are less (Motley et aI., 1948). During this time, it
effective when increased oxygenation or has been prescribed for use both before
volume delivery is necessary. Condens and after surgery and in the treatment of
ers increase resistance and their use with COPD. asthma, emphysema, and cystic
pafients requiring mechanical ventila fibrosis. Because of this wide spectrum, it
tion for longer than 24 hr remains under is hard to compare the results found in
scrutiny. When used, condensers should one group of patients with those in an
be replaced with conventional humidifi other. Much of the original information
ers if complications occur with inspis on IPPB was based on studies of patients
sated secretions or during spontaneous with chronic lung disease. These findings
ventilation. were often extrapolated and claimed to
Both water baths and nebulizers cause be valid for surgical patients with acute
condensation in the delivery tubing; they secretion retention. The most commonly
should be frequently checked to prevent cited benefits of lPPB include improved
blockage or inadvertent patient lavage. aerosol delivery, reduced work of breath
By controlling the temperature of the pa ing, improved respiratory function in pa
tient's inspired air, condensation pro tients with chronically diseased lungs,
duced by water bath humidifiers can be psychological support, and prevention of
markedly decreased. Ideally, all heated pulmonary complications in the surgical
humidifiers should contain a tempera patient. Currently, there is little scien
ture control alarm to warn of potential tific support for IPPB as a therapeutic mo
overheating. Though both types of neb dality (Gold, 1982; American Thoracic
ulizers may provide adequate humidifi Society; 1987). This section addresses the
cation, in comparing the two, the heated, claimed benefits and complications of
pneumatically driven type is preferable. IPPB, including its uncontrolled growth
It is up to one-sixth the cost, and its drop- and cost.
Aerosol Delivery able to breathe, a simple aerosol genera

tor can be used just as effectively as IPPB
IPPB is commonly used to deliver aer and possibly better (0' Donohue, 1982),
osols. There is little controversy in the Aerosol deposition to the larger or
literature about its efficacy in this area. smaller airways is not enhanced by IPPB
Many authors report that IPBB is useful compared with quiet breathing (New
in delivering bronchodilating aerosols, house and Ruffin, 1978).
though IPPB is not known to have any Ziment (1973) delineates four disad
bronchodilatory effect of its own (Gold vantages of aerosol delivery with IPPB:
berg and Cherniack, 1965; Chang and (1) Because gas flow follows the pathway
Levison, 1972; Smeltzer and Barnett, of least resistance, aerosols are preferen
1973; Cherniack, 1974; Loren et aI., 1977; tially delivered to the compliant airways.
Sackner, 1978). In fact, significant in Therefore, less is delivered to the more
creases in airway resistance, air trapping. spastic airways that may benefit most
and dead space, as well as reductions in from bronchodilator therapy. (2) Con
expiratory flow rates and alveolar venti trolled dosages of medication delivery
lation, were found following IPPB when are not possible with IPPB. Aerosol dos
no bronchodilator was used (Wu et a I . , ages may be 10-20 times greater than
1955; Kamat et a I . , 1962; Moore e t a I . , those used subcutaneously or intrave
1972; Ziment, 1973; Fouts and Brashear, nously. yet only 5-15% of a total dosage
1976). Increased sputum production is normally retained in the lungs. If, how
without correspond i ng improvement in ever, IPPB is connected directly to an ar
vital capacity or FEY, was also reported tificial airway and no dosage reduction fs
following IPPB, implying that mucus pro made, considerably larger quantities may
duction may be stimulated by IPPB itself be retained in the body. Systemic effects
(Shim et aI., 1978). are not eliminated with aerosol delivery,
The real question is not whether IPPB since variable amounts of the medication
is effective in del ivering aerosols but, may be retained in the mouth, esopha
rather, whether IPPB is the most effective gus, stomach, duodenum, and trachea as
method of delivery. The research done in well as the lungs. (3) Some inhaled bron
this field is extensive, though Petty chodilators that are beta stimulators,
(1974) states that no well-designed study such as isoproterenol, result in pulmo
has shown convincingly that a broncho nary vascular vasodilation. This can
dilator, or any other drug delivered by cause increased ventilation/perfusion
IPPB, is more effective than inhalation of mismatch, particularly in the presence
the same aerosol delivered by a powered of severe bronchospasm (Pierson and
or hand-held nebulizer. N umerous stud Grieco, 1969). (4) IPPB is more expensive
ies support Petty's claims (Froeb, 1960; yet no more effective in delivering bron
Goldberg and Cherniack; Smeltzer and chodilators and m ucolytic agents than
Barnett; Cherniack; Cherniack a nd Svan are hand-held or compressor-driven ne
hill, 1976; Loren et al.; Shim et al.). Chang bulizers. Water or humidification is be
and Levison found no difference in deliv lieved to be the best mucus-softening
ering isoproterenol by means of IPPB or a agent and is without the side effects of
powered nebulizer, except that the latter currently used medications.
produces the same results at much lower
dosages (5 mg compared to 0.225 mg). Work of Breathing
Goldberg and Cherniack and Wu and as
sociates suggest that IPPB may be of The ability of IPPB to affect the work of
added benefit for the patient who is un breathing has caused much debate in the
able to take a deep breath or coordinate literature. Sukuma1chantra and co-work
breathing with a hand-held nebulizer. ers (1965) found that IPPB increased the
However, Murray (1974) states that the work of breathing in some patients but
inability to teach patients how to use a reduced it in others. Sinha and Bergofsky
hand-held or compressor-driven nebu (1972) reported that IPPB at large infla
lizer constitutes a failure of instruction, tion pressures (average, 22 cm H,O) may
not an indication for IPPB. If a patient is be beneficial in patients with kyphosco-
Iiosis and chronically decreased lung IPPB did cause an increase in tidal vol
compliance. In six patients this parame ume in normal subjects but not in pa
ter was found to increase 70%, for up to tients with emphysema. A study on
3 hr, and was accompanied by decreases similar patients reported significant in
in the work of breathing. Recent studies creases in tidal volume with mechanical
on patients with neuromuscular disease chest percussion, IPPB, manual chest
do nol sub&lantiale these findings. Pa percussion and voluntary deep breathing
tients with muscular dystrophy and (Petty and Guthrie, 1971). Other re
quadriplegia demonstrated no improve searchers claimed that the effects of IPPB
ment in respiratory system compliance on gas distribution and tidal volume
(neither chest wall nor static lung com were similar to those of voluntary hyper
pliance) following IPPB treatment that ventilation (Torres et aI., 1960; Emman
delivered volumes up to three times rest uel el aI., 1966; Wohl, 1968; McConnell et
ing tidal volumes (DeTroyer and Deisser, aI., 1974). For persons who are unable to
1981; McCool et aI., 1986). increase Iheir tidal volume voluntarily,
In part, the ability of IPPB to alter the Torres and associates suggested IPPB
work of breathing appears to depend on as a way of improving pulmonary gas
the degree of patient cooperation and re distribution.
laxation (Ayres et al.. 1963; Sukumal Petty and Gu thrie noted that increased
chantra et al.). Bader and Bader (1969) dead space ventilation was associated
noted that increased respiratory work with deep breathing but not with IPPB.
was associated with high flow rates. Sim Other researchers reported the opposite.
ilar findings were reported by Ayres and SukumaIchantra and co-workers found
associates, when patients actively led the that the majority (mean, 56%) of the tidal
IPPB apparatus. Increases in airway col volume increase achieved by IPPB re
lapse, expiratory resistance, and air trap sulted in increased dead space. Volun
ping, which are associated with IPPB, tary hyperinflation by the same patients
may also result in a rise in the work of caused marked improvement in alveolar
breathing Uones et aI., 1960; Kamat et ventilation, and only a small portion
al.; SukumaIchantra et al.; O'Donohue, (mean, 17%) of the tidal volume increase
1982). Alterations in the work of breath was dead space. This suggests that IPPB,
ing, that may accompany IPPB, were not in comparison to voluntary hyperinfla
found to change the overall metabolic tion, overventilates alveoli that are al
rate. The fraction of total body metabo ready well ventilated. Consequently, its
lism expended on ventilation is normally effect is wasted. In order to improve al
small. As a result, if a decrease in respi veolar ventilation, increased driving
ratory work is accompanied by i ncreased pressures were suggested. However, this
non respiratory work, such as agitation or can cause increased alveolar pressure
discomfort (also attributed 10 IPPB), the that may result in pulmonary vascula
desired effect may be neutralized (Suku ture compression (Riley, 1962; Daly et aI.,
malchantra et al.). The data generated on 1963). Therefore, increasing inspiratory
the work of breathing associated with flow or pressure may decrease perfusion,
IPPB must also be viewed in light of the creating an even greater ventilation/per
difficulty in making accurale and repro fusion mismatch.
ducible measurements of this parameter, In eight supine subjects, Bynum and
especially in spontaneously breathing associates (1976) studied the effects of
patients. IPPB and spontaneous breathing at tidal
volume and large lung volumes (greater
Pulmonary Function than twice the tidal volume). The effect
of these maneuvers on the distribution of
Tidal Volume ventilation, perfusion, and ventilation/
perfusion ratios was measured by using
IPPB is often prescribed because it is radioactive gas techniques. During tidal
felt to increase tidal volume and, there volume breathing, ventilation and per
fore, prevent small airway collapse. Cul fusion were diminished in the lung bases
len and co-workers (1957) concluded that (areas adjacent to the diaphragm) as com-
pared to other areas. However. this de or more beneficial effects are usually
crease was greater in the subjects receiv seen with voluntary hyperventilation.
ing IPPB. despite the fact that the volume When IPPB does increase tidal volume. it
of air. inspiratory flow. and frequency of is not clear in the literature if this corre
breathing were the same for both groups. lates with either increased alveolar ven
Both voluntary and IPPB-induced hyper tilation or improved arterial blood gases.
inflation caused improved basilar venti None of these changes is reported to be of
lation and perfusion; yet. the spontane any long-term significance (Bader and
ously increased volume resulted in Bader; Morris et al.. 1970; Ziment. 1973;
significantly higher ventilation/perfu Leith. 1974; Schemer and Delaney. 1981).
sion ratios than were found with IPPB. Murray concludes that neither hypox
Bynum et al. concluded that at similar emia nor CO2 retention is an indication
lung volumes. IPPB was inferior to spon for IPPB. since any change is only tran
taneous breathing in ventilating and per sient. Instead. significant CO, retention.
fUSing the lung bases. As a result. vol hypoxemia. and acute ventilatory failure
untary hyperinflations may be more ef are more often indications for mechani
fective in preventing atelectasis than cal ventilation. Maneuvers that attempt
lPPB. IPPB should not be considered as to treat the symptoms and provide tran
an alternative to deep breathing unless sient improvement in gas exchange are
an increase in volume of at least 25% of doomed to certain failure unless the pre
that obtained by voluntary deep breath cipitating cause of respiratory failure is
ing is obtained. It is generally accepted removed.
that IPPB has no benefit over volitional
hyperinflation. in part because it empha Psychological Effect
sizes the least appropriate component of
inspiration. pressure rather than volume Whether IPPB is of psychological ben
(George and ODonohue. 1980 and 1982; efit is controversial. The claim by the pa
Gold. 1982; American Thoracic Society. tient of "I feel better" after receiving
1987). IPPB should not be ignored. This. in it
self. may be an important finding. despite
the fact that laboratory tests failed to sub
ArterialBlood Gases
stantiate any measurable changes (Mur
ray; Thornton et al.. 1974). Particularly in
Blood gas changes that occur after IPPB the capo patient. improvement in activ
treatment were found both to improve ities of daily living or quality of life fol
and to worsen. Following IPPB. reduced lowing intensive rehabilitation are doc
arterial carbon dioxide levels were re umented. while no significant changes in
ported in some patients and normal sub pulmonary function tests or correspond
jects (Cullen et al.; Sukumalchantra et ing signs of disease reversal may be
al.; Petty and Guthrie). However. signifi noted. However. subjective claims of im
cant decreases in PaCO, were also dem provement following IPPB treatment may
onstrated following mechanical and be unreliable for the following reasons:
manual chest compression on patients (1) Some patients may not wish to disap
with obstructive lung disease (Petty and point their physician or therapist and
Guthrie). The reported changes in arte therefore. claim improvement. (2) Tran
rial blood gases following IPPB were of sitory improvement of symptoms is com
short duration. Ziment (1973) empha mon when initiating a new treatment
sized that these fluctuations may be program. especially in patients with
harmful. since short-lived decreases in chronic diseases. Improvement is also
PaCO, or increases in PaO, following noted when the person performing the
IPPB may diminish respiratory drive and treatment is highly motivated or enthu
result in hypoventilation. Reduced res siastic. (3) The mystique surrounding an
piratory rates were also noted by Cullen expensive and complicated-looking ma
and associates (1957). chine that makes hissing noises and
In general. it appears that IPPB may in emits clouds of vapor can undoubtedly
crease tidal volume. However. the same serve to persuade some patients that dra-
matic relief is imminent (Murray). The apy (including postural drainage, percus
problem of psychological dependence, sion and supervised coughing) should be
with LPPB serving as a security blanket, given after IPPB or the patient may well
is most often. described in reference to be harmed by the IPPB treatment.
long-term users, such as COPD patients. In 15 patients following surgery, Jones
Murray states that the machine pre (1968) found that voluntary deep breath
scribed to alleviate symptoms of pulmo ing was more effective in i ncreasing tidal
nary disease has developed into a com volume than IPPB at conventional pres
plication that is more debilitating than sures (15 cm H20). When pressures of 25
the disease for which it was prescribed. cm H20 were used, IPPB was superior. It
There is no evidence that IPPB is helpful must be emphasized that this study did
or desirable for home use (IPPB trial not attempt to establish whether IPPB at
group, 1983). 25 cm H20 was beneficial in preventing
complications following s urgery (Ziment,
Prevention 01 Pulmonary Complications 1974). It was merely concerned with
Associated with Surgery methods to improve tidal volume. Se
quencing of the various therapies studied
IPPB is believed by some to prevent, as was not altered, and rest periods of only
well as treat, atelectasis after surgery by 10 min existed between trials. Conse
dilating collapsed bronchi and expanding quently, there may have been an additive
underventilated atelectatic alveoli. To effect, since the values may not have re
quote McConnell and his associates, it turned to normal between therapies.
seems that "since Elisha (11 Kings 4:34) Also, no follow-up was documented as to
first used positive pressure breathing to the long-term effect of these maneuvers
resuscitate a Shunammite child, this in preventing airway collapse.
method has found great favor with the In contrast, O'Donohue (1979) reported
medical profession." Because pulmonary that IPPB was effective in the manage
complications account for 6-70% of prob ment of pulmonary atelectasis in four
lems seen following upper abdominal case reports (only one involved a surgical
surgery (Pontoppidan, 1980), it is no won patient). Changes in arterial blood gases
der that all posssible methods of redUCing and chest x-rays were the criteria for
this mtlrbidity were tried. The over improvement. Inspiratory pressures be
whelming acceptance of IPPB, as judged tween 35 and 45 cm H20 were used.
by its widespread use, would lead one to These values are in excess of the normal
believe it is beneficial; yet, the routine pressures prescribed during IPPB, yet
use of IPPB prior to su rgery is of un complications of mediastinal emphysema
proven value in preventing atelectasis (reported following conventional pres
following surgery (Ziment, 1974; Gold, sures) were not noted. Although chest
1982). Similarly, its efficacy in preventing physiotherapy, incentive spirometry,
complications, such as atelectasis and broncho-dilators, antibiotics, and fiber
pneumonia following surgery, has not optic bronchoscopy were initially found
been proven in any study of acceptable ineffective in clearing the atelectasis in
design (Petty). these patients, some of these treatments
IPPB is most commonly administered were continued along with maximal vol
with the patient in the head-up position. ume IPPB therapy. IPPB treatments were
This may aid the flow of secretions to the performed every 2 hr and repeated for
dependent lung zones. Postoperative pul 36-72 hr. Because the degree of patient
monary complications most commonly mobilization was not specified. it is pos
occur in the lower lobes of adult patients sible that some of the pulmonary im
(Jaworski et al" 1988; Appendix 1.3). provement was due to increased patient
Therefore, the sitting postion is the most activity (see Case Histories 6.1 and 6.2).
unfavorable for postural drainage in this Similarly, since other therapies were
patient population. IPPB also delivers an given simultaneously, it is difficult to
inspiratory pressure that may impede conclude that any changes in atelectasis
normal mucus flow. Based on these find or arterial blood gases were due to the ef
ings, Ziment (1973) feels that physiother- fect of IPPB alone.
Meyers et al. (1975) studied the effects expectoration. In addition, IPPB was not
of IPPB on functional residual capacity found to reduce discomfort after surgery,
(FRC) in 10 patients following abdominal to result in earlier patient ambulation, or
surgery. This parameter was chosen be to result in decreased hospital stay, as
cause it was believed to most accurately was expected.
reflect alterations in alveolar ventilation On the other hand, Anderson et al.
or collapse. IPPB was found to have no (1963) found that pulmonary complica
influence on changes in FRC. Browner tions were markedly decreased when
and Powers (1975) also investigated the IPPB was used following surgery. Baxter
effects of IPPB on FRC in patients follow and Levine commented on this study as
ing surgery. Of those having normal or involving a far more heterogeneous
reduced FRC prior to treatment, they group of patients and attributed the low
found that IPPB caused a significant fall pulmonary complication rate to the dili
(416 m l ) in this value. They also reported gence of the therapist rather than the
significant decreases in PaD, and oxygen IPPB apparatus. Fouts and Brashear state
saturation. Therefore, they suggest that that Anderson and co-workers' conclu
administering IPPB to patients after sur sions are difficult to accept because of the
gery may not only be of questionable disparity in nu mbers (160 control pa
benefit but may be potentially harmful. tients and 42 treated), and the lack of in
N umerous studies were undertaken to formation about the respiratory care
evaluate IPPB and its effectiveness in given to the controls. Noehren and asso
preventing or treating pulmonary com ciates (1958) may have a better
plications after surgery. Baxter and Lev explanation: ,
ine (1969) studied 200 patients. Compar
ing radiological and clinical findings Most suggestions for the improvement of
before and after surgery, they concluded postoperative management of patients have
that IPPB was not effective in reducing demonstrated improvement in results. and
the common denominator for each of these
the incidence of pulmonary complica
appears to be closer attention to the patient
tions. Becker et al. (1960) studied 100 pa
postope ratively. This factor alone will often
tients after upper abdominal surgery and be sufficient without any additions. mechani
concluded that routine IPPB (2-3 times/ cal or otherwise. Perhaps the success with in
day for 3 days) did not prevent or clear termittent positive pressure breathing on in
atelectasis, when compared with a con spiration has been on the same basis.
trol group. Cottrell and Siker (1973)
reached the same conclusion in studying Studies in the last decade tend to sup
60 patients treated before and after sur port this statement. In 1980, Schuppisser
gery. Although pulmonary function tests et al. found IPPB of no benefit over chest
were found to improve in the patients physiotherapy in altering ventilatory
with COPD who received IPPB before function or the incidence of pulmonary
their operation, findings following sur complications following upper abdomi
gery were not affected. nal surgery. Although both types of ther
In evaluating the effectiveness of IPPB apy were equally effective, the authors
for patients following thoracic surgery, recommend physiotherapy because of
McConnell and colleagues concluded the added complications and cost associ
that although the depth of respiration ated with IPPB. The specific treatment
was increased with IPPB, verbal encour referred to as "chest physiotherapy" is
agement of the patient to breathe deeply not defined in this study. Ali and co
was just as effective. Sands and co-work workers (1984) compared the added ef
ers (1961) studied 84 patients receiving fect of IPPB with chest physiotherapy
IPPB after upper abdominal surgery and alone in 30 patients u ndergoing cholecys
found results in agreement with those tectomy. Physiotherapy was described as
described above. They also noted that the deep breathing, coughing, turning, leg
patients treated with IPPB complained of exercises, and early ambulation. The
"more mucus" than did the control only statistical difference between the
group, but that this did not lead to in two groups was a severely depressed
creased cough stimulation or subsequent postoperative vital capacity in patients
during IPPB treatment. The authors con Table 9.1

clude that IPPB is very costly and not Reported Complications and Hazards of
beneficial to patients receiving physio IPPB'
therapy after surgery. Although both 1 . Bronchospasm, distension of cysts and
studies reached similar conclusions, nei bullae, air trapping, pneumothorax
ther compared IPPB and chest physio 2. Gastric distension and ileus
therapy with a control group, in part for 3. Overdosage or adverse reactions of
ethical reasons. nebulized drugs
A few studies have compared the effect 4. Acquired infection from contaminated
equipment
of IPPB with incentive spirometry (IS) for
5. Reduction of venous return causing
reducing pulmonary complications after
hypotension
surgery and have failed to show an ad 6. Reduction of respiratory drive in patients
vantage of either therapy (Gale and San with chronic respiratory failure
ders, 1980; Jung et aI., 1980; Alexander et 7. Further impaction of mucus in patients
aI., 1981 ). Similarly, Indihar and Associ unable or unwilling to expectorate
ates (1982) found IPPB, IS, and turning following IPPB treatment
with deep breathing and coughing to be 8. Exhaustion of patients who do not
equally effective in reducing pulmonary participate with treatment effectively
complications in 300 surgical patients. 9. Complications of malfunctioning
equipment
The variety of operative sites may have
1 0 . Psychological dependence
masked any possible benefit since ex
tremity and lower abdominal surgery are 'Adapted from Ziment (1 973), Karetsky (1975),
less likely to cause pulmonary problems and Shapiro et al. (1 982).
from secretion retention. Celli and co
workers (1984) are one of the few inves
tigators to use a control group when com often exceeded both intentionally and
paring the effect of IPPB, IS, and deep unintentionally. This occurs when pa
breathing exercises on preventing pul tients exhibit air trapping or are out of
monary complications after abdominal phase with the machine. Macklin and
surgery. They found all three methods to Macklin (1944) reported that intraalveo
be significantly better than no treatment lar and pulmonary vascular pressure gra
at reducing postoperative lung pathology; dients need not exceed 40 cm H20 before
undesirable side effects were observed air can escape from the alveoli into the
only in the 18% of patients receiving vascular sheaths. Since 1960, extrapul
IPPB. monary air has been reported with in
creasing frequency in children with
Complications Associated with IPPB acute asthma (McGovern et aI., 1961; Jor
gensen et aI., 1963; Bierman, 1967). This
The complications associated with complication parallels the increased use
IPPB are shown in Table 9.1. Most are not of IPPB therapy in the treatment of child
life-threatening and were discussed ear hood asthma. The pressurized flow of gas
lier in this chapter. Others have more se from the IPPB machine was also noted to
rious sequelae and require further cause gastric insufflation in patients. Re
discussion. portedly, this can lead to colonic ileus
IPPB is reported to cause broncho and cecal perforation but more often re
spasm which may produce increased air sulted in patient discomfort (Ruben et aI.,
way obstruction and air trapping (Zi 1961; Golden and Chandler, 1975; Gold,
ment, 1973; Petty; Moore et a1.; Shapiro et 1976).
aI., 1982). Karetzky (1975) reported acute Humidification and medications are
pneumothorax associated with IPPB re delivered in aerosol form by IPPB. How
sulting in fatality. These complications ever, IPPB ofers no advantages over other
are believed to be particularly important less expensive methods of delivering hu
when IPPB is used in the treatment of pa midity or aerosols (Gold, 1975; O'Dono
tients with acute asthma. Though pres hue, 1982; American Thoracic SOCiety).
sures commonly used during IPPB range As with all nebulizers, IPPB nebulization
between 10 and 1 5 cm H20, this limit is is a source of bacterial contamination,
and careful sterilization of the apparatus the average number of patients receiving
is mandatory. Based on the spread of in IPPB per number of patient admissions to
fection attributed to IPPB, both Browner be 6% (range, 3-12%). Baker reported
and Powers and Gold (1976) recommend that generally, a greater number of treat
abandoning such treatment for surgical ments were performed at hospitals asso
patients. Because IPPB is most often pre ciated with schools of inhalation therapy
scribed for persons prone to pulmonary and university hospitals showed a
complications, its ability to spread infec greater use of chest physiotherapy, sug
tion is significant. Sanders et al. (1970) re gesting the application of alternative
ported an outbreak of nosocomial infec methods to IPPB treatments. Of interest,
tion with Serratia marcescens that was Schemer and Delaney also found that
traced to contaminated medications de teaching hospitals showed a dramatic re
livered by IPPB. The number of patients duction (70%) in the number of IPPB
with Serratia isolated from their sputum treatments per 100 admissions between
was proportional to the total number of 1976 and 1979. Bet ween 1971 and 1979,
IPPB treatments administered. Mertz and the monthly number of IPPB treatments
co-workers (1967) described an outbreak at Massachusetts General Hospital fell
of Klebsiella pneumonia (resulting in five from a high of nearly 1 7,000 (1972) to a
deaths in 1 month). All patients involved low of 500 (1 979), while the number of
in the o utbreak received IPPB with bron chest physiotherapy treatments re
chodilator treatments. The spread of this mained unchanged over this period (Pon
hospital-acquired infection was attrib toppidan). Braun et al. (1981 ) also re
uted to a contaminated stock bottle of ported a significant decrease in IPPB use
bronchodilator solution. Contamination by two Wisconsin hospitals between 1971
with gram-negative bacilli was reported and 1979. The hospital (university) hav
as high as 91% in IPPB machines with ing a larger critical care population and
reservoir nebulizers (Reinarz et al.). generally more seriously ill patients
showed a concurrent increase in the use
of chest physiotherapy. The other hospi
The Cost of IPpe
tal (a smaller private hospital) demon
IPPB is primarily used on surgical pa strated a trend of substituting incentive
tients and those with COPD. The average spirometry treatment for IPPB therapy.
number of treatments performed, aver Pontoppidan attributes the rapid decline
age cost of treatment. and the types of pa in IPPB therapy over the past years to
tients receiving treatment differ from fa increased challenges as to its cost effec
cility to faci lity. In 1974, McConnell and tiveness, efficacy and scientific basis
associates found the incidence of IPPB for use in both surgical and medical
treatment at UCLA Hospital (700 beds) to patients.
be 7.000/year at a patient cost of In 1974. both usage and charges for
$370,000/year. If these findings are ex IPPB showed wide variations that were
trapolated to acute general hospital usage not necessarily geographical in nature.
nationwide, an amount in excess of $400 The costs ranged from $3.75 to $7.50/
million is figured. This sum, presumably, treatment; daily maximums ranged be
does not include amounts spent on out tween $ 1 5 and $96 within the same city
patient, extended care, or home care (Baker). In 1980, Hughes sampled five
treatments and is based on 1974 costs. Chicago hospitals and found that initial
For the same year, Leith states that $2 treatment costs for IPPB ranged from
billion/year was collected from the pub $8.33 to $18. For all hospitals studied by
lic for IPPB treatments. Schemer and Delaney, an average of 60
In sampling both university and com treatments were given for every 100 pa
munity hospitals, Baker (1974) found that tient admissions. However. large discrep
a wide variation existed in IPPB usage ancies were noted between "for profit"
(0.9-9% of all hospital admissions). Sim hospitals, which averaged 190 treat
ilarly, in surveying the 43 Washington. ments/100 admissions, an'd federal hos
D.C. hospitals that provide respiratory pitals, where an average of 11 treat
therapy, Schemer and Delaney reported ments/100 admissions was performed.
Likewise, the hospital bed number was ume, and arterial blood gases. At best,

found to be Inversely related to the pro- any improvements in pulmonary func
portion of patients receiving lPPB. These tion accredited to IPPB are short-lived,
findings are mostly supported by 0'00- since most treatment times are 20 min or
nohue (1985), who found significantly less and are commonly given only 2-4
less use of lPPB for treating postoperative times/day. The psychological aspect of
atelectasis in hospitals with more than this treatment seems to vary consider
400 beds, compared to smaller facilities. ably and often depends on what other
He also reported a significantly lower use therapies are concurrently employed.
of chest physiotherapy in hospitals with IPPB is not an effective means of decreas
200 beds or less. Although lPPB appears ing or preventing pulmonary complica
to be more selectively prescribed from tions in surgical patients. Though the
this study than in the past [Baker), it is hazards associated with IPPB are rela
still reportedly used in 82% of all hospi tively small, the cost of IPPB is astronom
tals to treat postoperative atelectasis. ical. In addition, the relationship be
This seems incongruous with the fact tween contract services and both the
that studies have not proven that lPPB quality and cost of their "service" should
benefits surgical patients postoperatively not be ignored. The ineffectiveness of
[Gold, 1982). IPPB may, in part, be attributed to the ab
Another complication associated with sence of uniform treatment indications
lPPB is the use of contract services to and expectations. There must be clear ra
provide it. To quote Petty, the use of this tionale for implementing IPPB, along
"practice is deplorable and offers the with a clear understanding of its indica
greatest chance of harm because the tions, contra indications, risks, cost, and
overuse and misuse of IPPB is very likely cost effectiveness [Petty). This has not oc
when there is no medical director as an curred in the past. The burden of proof of
established member of the hospital staff efficacy and economic justification lies in
I where the 'service' is provided." The the hands of those who order and per
controls surrounding "big business" are a form such treatment [Gold, 1975). The
poor means of managing therapeutic authors do not recommend IPPB for pro
treatment and do not lend themselves to phylactic use or for the management of
minimizing patient costs. Respiratory postoperative pulmonary complications.
therapy departments are reported to de
pend on IPPB income for greater than BRONCHODlLATlNG AND
75% of their billing [Kittredge, 1973). A MUCOLYTIC AEROSOLS
recent study in New England demon
strates that IPPB usage can be reduced by A symposium of those that advocate
greater than 92% without any change in the use of theophylline in the manage
mortality or morbidity [Zibrak et aI., ment of COPD patients was published as
1986). Considering the investments in a supplement to Chest [Vol. 92, 1S-43S,
machinery, equipment, and payroll of 1987). Ziment (1987) analyzes evidence
contract companies, it is easy to imagine for the effects of theophylline on muco
how IPPB became economically oriented ciliary clearance and suggests the drug
rather than a carefully controlled aspect may directly and indirectly improve mu
of patient care. cociliary clearance. Theophylline in
creases the secretory output of bronchial
Summary glands. The transepithelial secretion of
fluid into the respiratory tract is in
It is hard to conclude much that is ther creased. Theophylline stimulates the
apeutic about lPPB. Though it is an effec chloride pump that is controlled by cy
tive method of aerosol delivery, IPPB is clic AMP. Ciliary motility is also stimu
more expensive yet no more effective lated by theophylline. The major effects
than simple mechanically powered or of theophylline that are likely to be ben
hand-held nebulizers. Substantial con eficial in the CO PO patient occur proba
troversy exists over the ability of IPPB to bly due to bronchodilation and because
improve alveolar ventilation, tidal vol- theophylline improves diaphragm con-
tractility and reverses diaphragm fatigue fects detected in minutes. but the efficacy
(Aubier. 1987). Whether the bronchodi of aerosol compared to intravenous use
lating effects of theophylline occur by of bronchodilators needs to be deter
aerosol inhalation alone or are improved mined (Brain. 1980; jenne. 1987a). The
by intravenous administration and addi indications for use and toxicity of bron
tion of f/,-agonists such as salbutamol re chodilators in young children. in the
mains controversial (Brain. 1984; jenne. presence of cardiovascular impairment.
1987a). There is no evidence that theoph and in the long-term therapy of such dis
ylline is beneficial in the patient with eases as COPD. asthma. and cystic fibro
acute lung disease. sis need to be determined (Featherby et
Benefit from use of aerosol-delivered al.. 1970; Brain. 1980; jenne. 1987b). The
mucolytic agents is poorly substantiated. significance of the nonbronchodilator
with the possible exception of its use in pharmacological effects of these medica
children with cystic fibrosis (Brain. 1984). tions also requires further investigation
There are no data to substantiate the use (Brain. 1980). The benefits of using bron
of mucolytic agents to assist removal of chodilators in patients with acute lung
secretions in acute lung disease. In our pathology including lung contusion and
clinical experience. neither bronchodi flail chest are not established. In this
lators or mucolytic agents delivered by patient population. some clinical signs
aerosol appeared to be of benefit in pa of bronchospasm. such as wheeZing.
tients with acute lung disease receiving may be relieved by removing excess
chest physiotherapy. Intuitively it seems secretions.
that benefit for acutely atelectatic lung is
likely to be minimal since nonventilated Mucolytic Agents
areas of lung do not directly receive any
aerosolized drugs. Intravenously admin Mucolytic agents are ineffective in im
istered bronchodilators. given by contin proving airway clearance. with the pos
uous infusion after a loading dose and sible exception of patients with cystic fi- .
monitored by blood levels. appear bene brosis (Thomson et al.. 1975; Brain and
ficial in reversing severe bronchocon Valberg; Brain. 1980. 1984). Although
striction. Mild bronchospasm is fre aerosols of these drugs can alter mucus
q uently found to reverse following the characteristics in vitro and probably in
removal of retained secretions. which is vi vo. it is not known if the changes en
assisted by adequate systemic hydration hance mucociliary activity and the cough
of the patient. inhaled humidity and mechanism (Brain and Valberg). Ade
chest physiotherapy. quate humidification (100% relative hu
However. the use of aerosol-delivered midity) is probably the best means of Iiq
mucolytic agents and bronchodilators is uifying secrections and is without the
widespread in the management of pa side effects associated with mucolytic
tients with acute chest disorders. It ap agents (Wanner and Rao. 1980). Bland
pears that these therapies are inappropri aerosols including distilled water. saline.
ately and. often. reflexly prescribed. A and half normal saline have no substan
review of the literature does not provide tiated benefits in treating lower airway
many concrete facts about the indica disease. Moreover such aerosols may
tions for and clinical effectiveness of elicit bronchoconstriction in adults and
these aerosols (Brain and Valberg. children (Brain. 1984).
1979). Present understanding of aerosol de
position and location of airway receptors
Bronchodilators for various drugs is inadequate (New
house and Ruffin. 1978). For aerosol de
There is evidence that some broncho livery to be effective. particle size must
dilating aerosols are useful in certain pa be tailored to the delivery system and
tients with chronic pulmonary disease. site of receptors as well as coordinated
particularly asthma and cystic fibrosis. with specific breathing maneuvers. Posi
Beta-adrenergic aerosols tend to have a tive pressure breathing of aerosols does
rapid and predictable onset with peak ef- not produce a more uniform or more pe-
ripheral distribution of aerosols than celvlng chest physiotherapy. nebuliza

quiet breathing (Newhouse and Ruffin. tion of N-actey1cysteine (a mucolytic
1978). agent) rendered subsequent physiother
apy treatments less effective in increas
ing pulmonary compliance (Winning et
Complications
al.. 1975). N-Acety1cysteine is also re
It is difficult to measure the received ported to cause bronchoconstriction in
dose of a drug given by aerosol (Brain and patients with asthma and chronic airway
Valberg). Even if the principles govern disease (Bernstein and Ausdenmore.
ing aerosol deposition. retention. and 1964; Rao et al.. 1970) and in normal in
clearance are understood. the amount of tubated subjects (Waltemath and Berg
medication reaching a specific area of the man. 1973).
lungs is only an estimate (Brain. 1980). It appears that based on the cost and
Although the small particles produced by potential hazards of mucolytic agents
some nebulizers are capable of reaching and bronchodilators. use should be re
the terminal airways. the percentage of stricted to those aerosols whose clinical
the drug delivered to these areas also de value is documented. The currently pre
pends upon the tidal volume. breathing scribed mucolytic aerosols do not meet
frequency. expiratory reserve volume this requirement (Wanner and Rao.
and length of breath holding of the pa 1980). The indications. complications.
tient. the presence of an artificial airway. and benefits of aerosol-delivered bron
and the length of delivery tubing from chodilators in patients suffering acute
the source to the patient (Brain and Val lung pathology are not established (Brain.
berg; Swift. 1980). Nose breathing com 1980). The minimal effective dose. opti
pared with mouth breathing effects par mal method of delivery. and type of
ticle deposition and can markedly patient who can most benefit from short
increase the quantity of medication re term and continued bronchodilator treat
tained by the nasal m ucosa and pharynx ment still need to be determined (Brain.
(Brain and Valberg). This. in turn. may be 1980).
swallowed and systemically absorbed.
resulting in general effects as opposed to
local changes. The efficacy of a broncho MECHANICAL DEVICES USED TO
dilator or mucolytic agent on the lungs ENCOURAGE LUNG EXPANSION
depends on successful delivery to the af FOLLOWING SURGERY
fected area. In the presence of pulmonary
collapse. obstruction. or constriction. air For many years. mechanical aids to
flow and. therefore. aerosol flow are im lung expansion enjoyed tremendous pop
peded. Nonventilated areas of the lung ularity without critical analysis of either
do not directly receive any benefit from their rationale or usefulness (Pontoppi
inhaled medications (Brain. 1980). Many dan). A wide array of maneuvers and de
aerosol devices used by patients with vices were suggested in attempts to pre
chronic lung diseases require intelligent vent pulmonary complications after
use by the patient and they are fre surgery. Transtracheal aspiration and
quently misused (Brain. 1984). deep breathing were proposed. and these
The possibility of infection through are discussed elsewhere (see pp. 164 and
contamination by aerosol-generating 119). Inhaling carbon dioxide. once be
equipment is well documented in the lit lieved to be of benefit (Alder. 1967; Jones.
erature and is discussed on pp. 284 and 1968). is no longer used. Aside from IPPB
293. Because aerosols can be deposited in and breathing exercises. the methods
the most distal airways and are most most in vogue appear to be forms of in
often used on patients already suffering centive spirometry (IS). continuous posi
from pulmonary complications. the tive airway pressure (CPAP). and posi
added insult of iatrogenic i nfection can tive expiratory pressure (PEP). Blow
be significant and should be avoided by bottles represent a type of expiratory IS.
proper sterilization. while most currently used IS emphasize
In mechanically ventilated patients re- the inspiratory phase of respiration. For
clarity, the term IS refers only to the in not been shown to decrease pulmonary
spiratory devices in this text. Both CPAP complications postoperatively. Adjuncts
and PEP primarily affect expiration. The emphasizing inspiration, not expiration,
use of these techniques is based on are thought to be better at improving res
research by Anderes et a!. (1979), piratory function after surgery.
who found improved lung reexpansion
through collateral airway channels when Incentive Spirometry
CPAP was applied.
Many authors compared IS to IPPB as a
Blow Bottles means of reducing respiratory complica
tions after surgery (see p. 293). Both of
In eight patients, Colgan et a!. (1970) these devices emphasize inspiration;
studied the effects of resistance breathing IPPB is performed passively, while in
on FRC, using blow bottles and sustained centive spirometry involves an active
hyperintlations with the Elder demand maneuver toward maximal inspiration.
valve resuscitator. Both methods were Van de Water and associates [1972) stud
found to produce marked increases in ied 30 consecutive women following ad
airway pressure similar to that seen dur renalectomy; 15 of them received IS and
ing a Valsalva maneuver, and neither the rest IPPB. Both groups were able to be
was found to be beneficial in treating at treated with other therapies, which in
electasis following surgery. Significant cluded blow bottles, rebreather tubes,
increases in FRC were reported after and thoracic physiotherapy. Only three
blow bottle use, but this was believed to patients in the IS group developed py
be the result of the sustained deep breath rexia (at least 38.5C) and clinical find
performed prior to treatment. O'Connor ings indicative of pulmonary complica
(1975) also examined blow bottles, but he tions, compared with six of the patients
compared them to a device that added in who received IPPB. The average hospital
creased dead space and expiratory pres stay was 9 days for those treated with IS
sure. In the 23 patients studied following and 1 1 days for IPPB-treated patients.
laparotomy, a significantly greater in The authors claim good patient accep
crease in vital capacity was reported in tance of IS at one-tenth the cost of IPPB.
those using the dead space, expiratory Due to the variety of therapies used in
pressure device. Based on these findings, each group, it is not possible to tell which
O'Connor suggested that this device may therapy, if any, actually altered the
result in a decreased incidence of respi morbidity.
ratory complications after surgery. Fur Iverson and co-workers [1978) evalu
ther information on this device is not ated three methods commonly used after
available. Heisterberg et a!. (1979) com surgery to reduce pulmonary complica
pared the effect of using blow bottles (for tions. Of the 145 patients in their study,
10 min every 4 hr) with chest physiother 42 received IPPB, 45 used blow bottles,
apy (breathing exercises, postural drain and 58 received IS. The incidence of pul
age, and coughing, two times per day) in monary complications, evaluated by
98 patients u ndergoing elective gastric or chest x-ray interpretation, clinical find
biliary tract surgery. They found the ings, and arterial blood gas results, was
incidence of radiological pulmonary 30% with IPPB, 8% with blow bottles,
changes to be the same in both groups and 15% with IS. Also associated with
and concluded that blow bottles are pref IPPB was a significant increase in gastro
erable to chest physiotherapy because intestinal complications. Dohi and Gold
they are less time consuming. There are (1978) studied 64 patients: 30 received
no documented complications of blow IPPB and the rest received IS. All patients
bottle use; theoretical concerns include were treated for 5 days after surgery and
hyperventilation, increased atelectasis, were observed for pulmonary complica
barotrauma, and cost (Shapiro et a1.. tions by chest x-ray and clinical exami
1982). Based on the existing literature, nation. Because the data favoring IS over
blow bottles have not been found more IPPB were statistically slim, the authors
effective than other techniques and have claimed no conclusive difference be-
tween the two therapies. Based on these was undertaken i n 79 patients (Lederer et
findings, they also stated that the use of aI., 19S0). Instruction in how to use the
IS rather than IPPB may be justified, assigned device was given prior to sur
since the former is much cheaper. An gery. Though only monitored once daily
other study comparing the postoperative afterwards, all patients were encouraged
use of IS and IPPB did not find a change to use their assigned IS 10 times every
in the incidence of pulmonary dysfunc waking hour. On each day following sur
tion with the two modes of therapy (Gale gery, a substantial number of patients in
and Sanders, 19S0). each group did not use their device at all.
The previous authors failed to compare Other types of therapy, including ultra
either IPPB or IS with deep breathing. sonic nebulization, chest percussion,
However, McConnell et al. contrasted the postural drainage, or any combination of
effects of voluntary deep breathing, IPPB, these, were given to some patients in
and IS on transpulmonary pressure gra each group. There was liltle statistical dif
dients in 1 1 thoracotomy patients and 6 ference between the three types of IS in
normal subjects. Deep breathing pro terms of the patient's pulmonary func
duced an average gradient of 24.6 cm tion, vital signs, and white blood cell
H20, IPPB of 2 1 . 7 cm H20, and IS of 29.4 count, and there was no difference in the
cm H20. The authors state that increased length of hospital stay. It would be more
transpulmonary pressure gradients are a interesting if the three groups were com
principal determinant of alveolar and pared to both a control group and a group
bronchial expansion. Therefore, they performing voluntary deep breathing.
claim that IS is more convenient and less Because of the lack of a control group, i t
costly than IPPB in achieving alveolar i s still not known whether any device at
and bronchial expansion. The fact that all was of benefit to these patients
deep breathing is even less expensive (Hughes, 19S0).
arid requires no more instruction than A few studies evaluating the use of IS
the other two methods was not ad were performed on patients requiring
dressed. Alexander and co-workers cardiac surgery. Krastins et al. (19S2)
(19S1) failed to show a decrease in pul studied 17 children and found that when
monary complications when IS (up to IS (every 2 hr for 12 hr a day) was used in
So% of the preoperative maximal inspir conjunction with chest physiotherapy, a
atory volume), IPPB (3 times per day), or dramatic decrease in atelectasis resulted.
IS with IPPB was compared to a control However, there was no difference be
group (encouraged to breathe deeply and tween the postoperative pulmonary
ambulate). Similarly, Indihar et al. (19S2) function tests (PFT) of children receiving
found no benefit of IS or IPPB over turn IS with physiotherapy (study group) and
ing, coughing and deep breathing in 100 those receiving chest physiotherapy
surgical patients. Two studies compared (control group). The incidence of atelec
the effects of IS and continuous positive tasis in this study was higher than that
airway pressure (CPAP). One evaluated reported by others (SS%); also pleural ef
CPAP, IS, and coughing and deep breath fusion occurred in all control and two
ing in 65 adults. Patients received their study patients. In 25 adults undergoing
assigned treatment for 15 min, every 2 hr coronary artery surgery, the efficacy of
(while awake), for 3 days after abdominal two different IS techniques was com
surgery (Stock et aI., 19S5). The authors pared with chest physiotherapy (cough,
concluded that IS offered no advantage deep breathing, postural drainage, per
over coughing and deep breathing. Rick cussion, and vibration) (Oulton et al..
sten et al. (19S6) studied 43 similar pa 1 9 S 1 ). No added benefit was found when
tients but compared IS to CPAP and PEP. one type of IS (Triflow) was performed in
They found both CPAP and PEP superior addition to chest physiotherapy; how
to IS in improving gas exchange, lung ever. when the other IS (Spirocare) was
volumes, and radiological clearing after used. fever and less severe pulmonary
upper abdominal surgery. complications were noted on chest x-ray.
A study comparing three types of IS The investigators attributed the differ
used following upper abdominal surgery ence between IS modalities to the fact
that Triflow is more flow dependent monary complications were found in

while Spirocare is more volume sensi both groups of patients having prior
tive. These conclusions are in conflict chronic respiratory disease, although pa
with those of Lederer et a!. who found no tients receiving IS showed significantly
significant difference between the two IS fewer complications than those receiving
studied by Oulton et a!. or another IS chest physiotherapy. The authors con
(Bartlett-Edwards) that is also volume de cluded that though there is a need for
pendent. Additionally, the Spirocare unit chest physiotherapy in treating major
is more expensive than other IS, is not pulmonary collapse, IS may be a more ef
disposable, and requires an electrical fective means of prophylaxis.
power source (Van de Water, 1980). Work by other investigators (Vraciu
Vraciu and Vraciu (1977) studied the and Vraciu, 1977; Lyager et aI., 1979; Van
effects of physical therapist-assisted de Water, 1 980) appears to conflict with
breathing exercises that included lateral that of Craven et a!. (1974). Lyager and
and posterior basal expansion, diaphrag associates studied the added effect of IS
matic breathing, and coughing on 40 pa (every waking hour) on patients already
tients following open heart surgery. The receiving instruction by physical therap
patients who performed breathing exer ists. On the basis of random selection, 34
cises had statistically fewer pulmonary upper abdominal surgical patients were
complications (3 of 19) than the controls given physical therapist-assisted breath
(8 of 2 1 ), even though both groups re ing exercises and coughing, and 49 re
ceived IS every 2 hr. The control patients ceived IS in addition to this treatment.
were also turned hourly and assisted in Radiological and clinical findings (in
deep breathing and coughing by the cluding coughing, expectoration, dys
nursing staff. Pulmonary complications pnea, auscultation, temperature, and res
were defined by the presence of a tem piratory rate) and arterial blood gas
perature greater than 38.S'C, radiological analysis revealed no differences between
evidence of atelectasis, and abnormal the two groups. The incidence of,pulmo
breath sounds. nary complications after surgery was also
In 1983, Dull and Dull compared the ef the same, even in the subgroup of pa
fects of early mobilization to deep tients who used their IS on the average of
breathing and IS in 49 patients after car 10 times every hour. The results of this
diopulmonary bypass surgery. Mobiliza study suggest that no further benefit is
tion consisted of extremity exercises, gained by adding IS to aggressive pul
coughing, and assistance with turning, monary physiotherapy. Although the re
sitting, or standing. Because IS could not sults are of doubtful clinical significance,
be performed during mechanical venti Hedstrand and associates (1978) also
lation, the patients began their assigned found that physical therapist-encouraged
exercise regimen within 4 hr of extuba techniques of deep breathing were supe
tion. The incidence of pulmonary com rior to voluntary or device-assisted deep
plications was high in this study and was breathing in raising arterial oxygenation.
defined as a temperature increase of 4'F A controlled study was undertaken to as
above baseline or 2-3'F increase in tem sess whether bedside coaching to breathe
perature along with rales, rhonchi, ab deeply was as effective as IS in prevent
sent breath sounds, or purulent sputum. ing postoperative atelectasis (Van de
The authors conclude that neither IS nor Water, 1980). Encouragement by the
deep breathing offers any therapeutic ad nursing staff was superior to IS in return
vantage over patient mobilzation in pre ing pulmonary function to preoperative
venting pulmonary complications after values. The authors conclude that fre
cardiopulmonary bypass surgery. quent patient contact appears to be an
Craven et a!. (1974) compared the ef important component. This human ele
fects of chest physiotherapy (including ment opens up an area of subjective dif
postural drainage, percussion, breathing ferences. The rapport between an indi
exercises, and assisted coughing) to IS in vidual therapist or nurse and patient may
70 patients after surgery. Increased pul- well make a difference in patient perfor-
mance. Likewise, the emphasis placed by after surgery, early mobilization and vo
a therapist on a maneuver or treatment litional deep breathing offer more cost-ef
may also influence its effectiveness. fective treatment than IS for the sponta
In 1986, Schwieger et al. performed a neously breathing patient at risk for
well-designed, controlled study on 40 pa postoperative pulmonary complications.
tients to assess the effect of IS following
cholecystectomy. IS use was supervised Continuous Positive Airway Pressure
and consisted of a slow, deep inspiratory and Positive Expiratory Pressure
effort with a volume oriented device. IS
was performed for 5 min, hourly, at least Although originally used with neo
12 times a day, for 3 days after operation. nates, face-mask CPAP is recommended
All patients were mobilized on the day of by some as a means to reduce or reverse
surgery. Subjective and objective clinical the incidence of postoperative respira
data (oxygenation, temperature, PFT, tory complications in adults. The use of
white blood cell count, chest x-ray, and PEP, a modification of CPAP, has also
auscultation) were evaluated to establish been studied. In 1 979, Anderes and co
the incidence of pulmonary complica workers evaluated the effect of CPAP
tions. There were no significant differ and positive and expiratory pressure
ences in any of the measured parameters (PEEP) on 30 adults undergoing elective
between the two groups, although chest upper abdominal surgery. Half of the pa
radiograph changes indicating lung pa tients [Group A) were ventilated without
thology occurred in 40% of the IS patients PEEP during surgery, were extubated,
compared with 30% of the controls. None and breathed spontaneously afterward.
of the study subjects was classified as The others [Group B) received PEEP (10
high risk for developing postoperative cm H,O) during anesthesia and CPAP [3
respiratory problems. This study does cm H,O) while intubated for 3 hr before
not support the theory of some investi extubation. The author reported signifi
gators who attribute the lack of benefit cant deterioration in PaO, and right to
from IS in controlled studies to inade left shunt [Q./QT) and adverse radiologi
quate supervision, coaching, or patient cal findings in Group A compared with
use. Group B. These changes occurred over 3
Although compelling support for pro days after surgery although PEEP was
phylactic or paliative IS therapy is not given only during, and CPAP was given
available, few complications are associ once, only immediately after surgery. I t
ated with its use. Theoretical problems i s difficult t o separate t h e effects o f CPAP
include hyperventilation and baro from PEEP in this study. Carlsson and as
trauma (Shapiro et al.). Cost is also an sociates (1981) studied 24 patients under
issue, especially when more expensive or going elective cholecystectomy. Face
nondisposable types of IS are recom mask CPAP (about 5-10 cm H,O) was
mended. IS is reportedly used in 95% of given to 13 patients for 4 hr after surgery;
the hospitals surveyed in the United the other patients wore a face mask but
States as a prophylactic maneuver to im did not receive CPAP. PEEP was not
prove lung expansion and in the treat used. All subjects were evaluated during
ment of postoperative atelectasis (0'00- treatment and for 24 hr postoperatively.
nohue, 1985). This compares with a use No significant difference between groups
of 44% in the United Kingdom (in high was found in chest x-ray findings or spi
risk, postoperative coronary artery by rometry or blood gas measurements. The
pass patients) (Jenkins and Soutar, 1 986). results of these two investigations are dif
Cost and questionable efficacy were the ferent although similar patients were
major reasons for the much lower use of studied. Information on other types of
IS in Great Britain. Even a relatively pulmonary therapy, including patient
small cost becomes significant when mobilization, was not addressed but may
multiplied by 95% of hospitalized pa be responsible for the different findings.
tients receiving surgery in the United Anderson et al. (1 980) evaluated the ef
States. It is the authors conclusion that fect of face-mask CPAP in reversing at-
electasis in a variety of surgical patients were observed in any study situations.

during the first 24 hr after operation. Contrary findings are reported by Hof
Twelve subjects received conventional meyr and co-workers (1986), who found
therapy (including posteral drainage, that oxygen saturation was unchanged
deep breathing, and suctioning three and that sputum clearance was less ef
times a day) and 12 patients additionally fective when PEP (12-17 cm H20) was
received CPAP (at about 15 cm H,O for incorporated in a regimen of breath
25-35 respirations, hourly while awake ing exercises, postural drainage, and
and twice at night). Treatment was con FET.
sidered successful if PaO, increased by Two studies have looked at whether
1 5% of predicted value or if chest x-ray intermittent PEP augments the effects of
findings improved by 50%. CPAP was chest physiotherapy in the management
found to significantly improve atelectasis of postoperative pulmonary complica
resolution; augmented collateral ventila tions. Campbell and associates (1 986)
tion was thought to be the mechanism re randomly assigned 71 patients to receive
sponsible for the change. This is one of chest physiotherapy (control) or chest
the few studies that used a modality to physiotherapy plus PEP (study group)
reverse, rather than prevent, chest after abdominal surgery. Chest physio
pathology. therapy in both groups consisted of
Two studies compared the effects of IS breathing exercises, huffing, and cough
and CPAP in preventing postoperative ing, while sitting, every 2 hr. Postural
pulmonary complications. In 65 adults drainage was used if indicated. The study
u ndergoing elective upper abdominal group also received PEP for 10 breaths
surgery, Stock and associates (1985) eval every 2 hr. Thirty-one percent of the con
uated the use of face-mask CPAP, IS, and trol patients developed respiratory com
coughing with deep breathing. All treat plications compared to 22% of the study
ments were given for 15 min, every 3 hr patients. This difference corresponded to
while awake for 3 postoperative days. the larger number of smokers in the con
Very few differences were found be trol group. The effect of PEP in addition
tween treatment groups; a more rapid in to chest physiotherapy was studied in 56
crease in FRC occurred in patients who patients after thoracotomy (Frolund and
received CPAP, but x-ray changes and Madsen, 1986). Chest physiotherapy was
fever were not significantly different be given two times a day and consisted of
tween groups. In 50 patients undergoing early mobilization, arm exercises, deep
similar surgery, Ricksten et al. (1 986) breathing, and coughing. Patients were
compared IS, CPAP (10- 1 5 cm H,O), and encouraged to use face-mask PEP (about
PEP (10-15 cm H,O). Each treatment was 10 em H,O) at least 10 m'n each waking
applied for 30 breaths, every waking hour and were supervised in its use two
hour, for 3 days after operation. The au times a day. All patients were evaluated
thors reported that both CPAP and PEP for 3 days after surgery. The authors con
were superior to IS with respect to im clude that PEP offered no benefit over
proving gas exchange, preserving lung conventional physiotherapy in prevent
volumes, and resolving atelectasis after ing atelectasis or improving arterial
upper abdominal surgery. They advocate oxygenation.
using the simple PEP mask since it was Although research on the effects of
as effective and less complicated than postoperative PEP or CPAP is conflicting,
face-mask CPAP. complications are not associated with its
Conflicting results are also found on use. The added expense of this modality
the effect of PEP on patients with cystic is a concern, but research on the cost of
fibrosis. Falk et al. (1984) reported that PEP or CPAP is scarce. In the treatment
PEP i ncreased skin oxygen tension and of postoperative atelectasis, CPAP is re
sputum production over that obtained portedly used in 25% of hospitals in the
from posteral drainage with percussion United States and use is dramatically
and vibration or forced expiratory tech greater in hospitals with more than 200
nique (FET). No radiographic changes beds (O'Donohue, 1985).
Summary iotherapy including patient mobilization.

It is important to note that CPAP, PEP, IS,
Few conclusions can be drawn from all blow bottles, and [PPB are of limited
the research on the mechanical aids to value in the [CU, since they cannot be
lung expansion discussed in this section. used on patients requiring mechanical
Differing durations and frequencies are ventilation. Chest physiotherapy does
recommended for the same device, and not have this limitation.
few authors compared similar tech Despite the huge cost and widespread
niques, other than contrasting lPPB to IS. use of mechanical aids following surgery,
It is no surprise that the results are so in the incidence of respiratory complica
consistent. Only the finding that [PPB is tions has not significantly changed with
more costly and less effective than the any single or combination of treatments.
other methods mentioned appears with It appears that the type of patient who
regularity. The benefit (or lack of i t ) ob could perhaps benefit from IS, CPAP, or
tained from using blow bottles is no more PEP still needs to be defined. Alternately,
substantiated than the outdated method it may mean that none of the described
of having a patient inflate a rubber sur modalities represents an optimal method
gical glove (Hl1ghes). Similarly, there is of preventing pulmonary complications.
no supporting evidence that blow bottles Ford and Guenter (1984) suggest research
decrease the incidence of pulmonary into specific diaphragm function during
complications following surgery (Pontop the early postoperative phase (see p. 1 5 ).
pidan). Though forced expiration against
resistance is encouraged by those rec
ommending and ordering blow bottles (or BRONCHOSCOPY
inflatable surgical gloves), forced expira Bronchoscopy is used both therapeuti
tion alone is reported to produce atelec cally and diagnostically. The indications
tasis and hypoxemia (Nunn et aI., 1965). for therapeutic bronchoscopy include as
Pontoppidan notes that improper use of piration, secretion retention, atelectasis,
blow bottles may decrease both end-ex lung contusion, and lung abscess (Wan
piratory volume (if the patient exhales ner et aI., 1973; Lindholm et aI., 1974;
too forcefully) and cardiac output due to Sackner, 1975; de Kock, 1977; Barrett,
the increased airway pressure. 1978; Dreisin et aI., 1978). Bronchoscopy
While in agreement with Kasik and is often used as an adjunct to chest phys
Schilling (198 1 ) that little is gained by re iotherapy. However, since chest physio
placing [PPB with yet another form of therapy was introduced to our facility in
therapy (such as IS, CPAP, PEP, or chest mid-1973, the need for therapeutic bron
physiotherapy techniques) that is still choscopy has diminished markedly
under investigation, the ethical issue of (Table 1 .2). Complications, restrictions,
withholding a treatment that has been and precautions of therapeutic bronchos
shown to be beneficial by some, cannot copy are discussed and compared to
be ignored. Methods that encourage max chest physiotherapy.
imal inspiration, such as [S and deep
breathing, may, in theory, be more ben
eficial than blow bottles. However, the Complications and Precautions
available research has not proved [S su
perior in terms of cost and effectiveness Suratt and co-workers (1976) reported
to deep breathing and the other aspects of a 0.022% death rate and a 2.92% inci
chest physiotherapy. The principle that dence of serious-to-life-threatening com
CPAP improves collateral ventilation plications associated with fiberoptic
and therefore lung reexpansion is excit bronchoscopy. [n reviewing 24,521 fiber
ing. However, studies on the efficacy of optic bronchoscopic procedures, Credle
CPAP or PEP to reduce postoperative et al. (1973) reported a low incidence of
pulmonary complications are conflicting. major complications 1 %) and a mortal
These modalities appear to be of little ity of 0.01%. [n prospective studies,
added benefit to a regimen of chest phys- Dreisin et al. and Pereira et al. (1978)
found the overall complication rate to be al.; de Kock; Dreisin et al.; Periera et al..
1 1 % and 8%. repectively (Table 9.2). 1978; Shrader and Lakshminarayan.
None of the authors reported the mortal 1978; Lundgren et al.. 1982).
ity or morbidity resulting solely from use In addition to pneumonia. febrile reac
of fiberoptic bronchoscopy in the treat tions and bacteremia are noted following
ment of retained secretions. and a wide both rigid and fiberoptic bronchoscopy
spectrum of patients ranging from those (Burman. 1960; Pereira et al.. 1974. 1978;
in the lCU to the office outpatient were Timms and Harrell. 1975; Dreisin et al.).
included in these studies. Pneumonia. Patients over 60 years of age or those
bronchospasm and laryngospasm. pneu with a history of cardiovascular disease
mothorax. hypoxemia. hemodynamic or immunoincompetence appear to be at
changes. cardiac dysrhythmia. respira increased risk of developing these com
tory arrest. and hemorrhage of sufficient plications. In patients with bronchial
quantity to compromise the airway are asthma. life-threatening laryngospasm
among the serious complications associ and bronchospasm from fiberoptic bron
ated with bronchoscopy (Credle et al.; choscopy are reported despite prior
Dubrawsky et al.. 1973; Harrell et al.. premedication. application of topical an
1973; Britton and Nelson. 1974; Albertini esthetics. and supplemental oxygen de
et al.. 1974; Karetzky et al.. 1974; Salis livery (Sahn and Scoggin; Dreisin et al.;
bury et al.. 1 975; Feldman and Huber. Pereira et al.. 1 978). As a result. fiberoptic
1976; Sahn and Scoggin. 1976; Suratt et bronchoscopy should be performed with
Table 9.2
Reported Complications Within 24 hr of Fiberoptic Bronchoscopy (Prospective Studies)'
Dreisin at al. Pereira et al.
Complications
(205 Procedures) (908 Procedures)
Major
Pneumonia -' 5
Bronchospasm/laryngospasm or airway obstruction 4(1 ') 4
Pneumothorax requiring chest tube 2 4
Hemoptysis (40 ml in 1 5 min or 200 ml in 24 hr) 4
Respiratory arrest 2(1 ')
Total 10 15
Minor
Vasovagal reactions 22
Fever 11
d
Cardiac dysrhythmias 8'
Bleeding (nosebleed) (2) 6
Obstruction of airways 4
Infiltrates without fever 4
Nausea and vomiting 2
Pneumothorax 2
Dyspnea 2
Subcutaneous emphysema 2
Electrocardiogram abnormality d 2'
Acute maxillary sinusitis
Psychotic/hysterical reaction 1
Aphonia 1
Total 12 59
'Adapted from Dreisin et al. (1 978) and Pereira et al. (1 978).
'-Information not given.
<Denotes mortality.
dApparently not routinely monitored.
'Only 24% of all patients received cardiac monitoring.

great caution and only when absolute in hanced myocardial sensitivity to circu
dications are present in this patient lating catecholamines. Although sinus
population. tachycardia is observed during bronchos
copy, it is of doubtful clinical significance
Hypoxemia and Cardiac Dysrhythmia
(Lindholm et al.; Credle et al.; Khan,
1978: Luck et aI., 1978). Cardiac dys
Decreases in arterial oxygenation re rhythmias, including bradycardia, ven
sulting from fiberoptic bronchoscopy are tricular ectopic beats, ventricular tachy
due to the combined effects of ( 1 ) me cardia and "cardiac arrest," are reported
chanical obstruction of the airways, (2) to occur during and following bronchos
alveolar filling with lavage or anesthetic copy (Credle et al.; Surall et al.). The
solutions, and (3) the effects of suctioning low incidence of cardiac dysrhythmias
(Khan, 1978). Changes in PaD, are noted shown in Table 9.2 is probably a result of
by many authors, as shown in Table 9.3. the limited number of patients that were
Hypoxemia is reported not only during monitored with electrocardiography.
bronchoscopy itself but also following Pereira et al. (1978) and Zavala (1978)
the procedure (Harrell et aI., Albertini et maintain that the incidence of cardiac
al.; Lundgre" et al.). Harrell and co-work complications associated with bronchos
ers found that the magnitude of the fall copy cannot be predicted by evidence of
in PaD, was related to the duration of the prior heart disease alone. However, if
bronchoscopic examination. However, cardiac compromise is the result of hyp
Albertini and associates found no corre oxemia, complications may be mini
lation between decreases in PaD, and ei mized by either increasing the fractional
ther the duration of the procedure or the inspired oxygen, flow rate or tidal vol
amount of anesthetic or lavage fluid left ume (in mechanically ventilated pa
in the lungs. Lundgren et al. found the tients) (Dubrawsky et al.; Albertini et al.;
greatest fall in PaD, occurred during the Pierson et aI., 1974; Karetzky et aI., 1974;
suctioning phase of bronchoscopy and Perry, 1978; Shrader and Lakshminar
continued for up to 15 min after the pro ayan). Lundgren et al. suggest that reflex
cedure was completed. sympathetic discharge from mechanical
The cardiac dysrhythmias reported stimulation may be a major cause of the
during and following bronchoscopy may hemodynamic changes that occur during
be related to hypoxemia. Shrader and bronchoscopy. In addition, patients hav
Lakshminarayan studied 70 patients un ing low lung compliance or high intra
dergoing fiberoptic bronchoscopy; all pa pulmonary shunt may require mechani
tients were spontaneously breathing, cal ventilation and PEEP to prevent
receiving supplemental oxygen, and pre hypoxemia. Since sudden and prolonged
disposed to cardiac dysrhythmias due to decreases in PEEP or inspired volume
chronic cardiac or pulmonary pathology. may occur with bronchoscopy, allempts
Arterial blood gases and cardiac rhythm to minimize these effects are necessary.
were monitored for an hour preceding, In our experience, a disposable adaptor
during, and after bronchoscopy. Thirty (by Portex) appears to be an effective
nine patients demonstrated dysrhyth means of reducing both PEEP and vol
mias during the control period. Forty ume loss. Care should be taken to ensure
nine patients had dysrhythmias during that ventilator volume delivery exceeds
bronchoscopy; of these, 8 (11 %) were the volume evacuated while suclioning
considered major or having the potential during bronchoscopy.
to cause hemodynamic compromise.
Hypoxemia (mean PaD" 53 mm Hg) fol Lavage
lowing bronchoscopy was seen in 12 pa
tients and correlated significantly with Because the outer diameter of fiberop
the development of dysrhythmias. Khan tic bronchoscopes is small, the suction
(1978) suggested that patients with poor port is correspondingly diminished or ab
oxygenation initially, further aggravated sent (Table 9.4). Khan et al. (1976) and
by bronchoscopy, may demonstrate en- Sanderson and McDougall (1978) note dif-
Co>
Table 9.3
Reported Changes in Arterial Blood Gases from Fiberoptic Bronchoscopy'
:;:
Number and Type of
Author Patient (A and B Denote Reported Changes (Before to After, Comments
Subgroups) Unless Stated)
Dubrawsky et al. 49, SB PaCO, and pH unchanged 60 to 80 ml of lavage used
(1 973) A. 30, room air A. PaO, ! 22.4 mm Hg (p < Bronchial lavage results in hypoxemia
B. 19, supplemental 0, O.OOOS) after insertion Initially hypoxemic and normal patients
PaO, ! 18.8 mm Hg (p < O.OOOS) showed similar PaO, ! after
after lavage and suctioning procedure
B. PaO, unchanged
Harrell et al. (1 973) 1 S, SB PaO, ! > 1 a mm Hg (in 2 patients) Degree of hypoxemia did not correlate
PaCO, t ;":S mm Hg with extent of lavage or
preprocedural PaO, levels
Degree of hypoxemia did relate to ()
procedure time and amount of I
m
suctioning
t PaCO, was related to bronchospasm
."
Kleinholz et al. 10, SB 6 patients, PaO, ! ;,,: 9 mm Hg; No supplemental 0, given I
-<
(1 973) 3 patients, PaO, unchanged; (f)
1 patient, PaO, t from 5
....
hyperventilation I
m
Albertini et al. (1 974) 1 8, SB A. PaO, ! 20 mm Hg (range, 4-38) ! PaO, did not correlate with amount :D
A. 1 6, SB B. A-aDO, t S6 mm Hg (range, 2- of anesthetic or lavage material used
."
B. 1 S, SB (FlO, = 1 .0) 1 88) or duration of treatment -<
PaO, remained ! from < 1 hr to >4 hr; Z
most returned to values obtained ....
I
before procedure by 2 hr m
Karetzky et al. 1 4, SB PaO, ! 1 2 mm Hg during (range, Z
....
(1 974) -2--21) m
PaO, ! S m m Hg after (range, +3- z
(f)
,
- 1 9) <:
m
Pierson et al. (1 974) 1 0 MV PaO, t 1 0 mm Hg during (range, All patients had retained secretions or ()
+ 1 00- - 1 32) atelectasis
PaCO, t S.2 mm Hg during (range, FlO, t to 1 .0, 20 min prior to procedure :D
m
-4-+ 14) pH ! 0.06 during in most instances c
PaO, t 14.3 mm Hg after (range, z
+7S--39) =<
Salisbury et al. 23, SB A. PaO, ! 1 2 3 mm Hg 3 controls had PaO, j > 1 5 mm Hg
o
(1 975) A. 1 0 controls, SB B. PaO, j 1 0 3 mm Hg; 2 patients had PaO, ! > 22 mm Hg <
c
B. 18 COPO, SB PaCO, and pH unchanged PaO, did not ! significantly with t z
treatment time (average, 25 min)
...
PaO, returned to initial level 1 5-30 min @
after procedure
No patients had significant amounts of
d
()
secretions :x:
m
Brach et al. ( 1 976) 1 6, SB PaCO, unchanged Mucus plugs or thick secretions noted
A. 6 with ! V/0 mismatch A. PaO, 1 7.0 8.4 mm Hg (SO); in 4 of 6 patients in A
"U
B. 1 0 with 1 or no A-aDO, j 7.7 2.4 mm Hg (SO) No excessive secretions noted in B :x:
change in V/0 B. PaO, j 6.8 5.4 mm Hg (SO) One patient receiving 250 ml of lavage -<
CJ)
mismatch A-aDO, 1 7.7 5.5 mm Hg (SO) showed t V/a mismatch and t A
aDO,.
:x:
de Kock (1 977) 9 PaO, j 1 2.4 mm Hg (range, +3-- Supplemental 0, given during m
:ll
23) procedure
"U
Shrader and 70, SB PaO, j 30 mm Hg (range, + 9 - - Supplemental 0, given during -<
Lakshminarayan 78) procedure
(1 978) Duration of procedure averaged 30 min
Marini et al. (1 979) 1 6, SB and MV A-aDO, t 8.4%
Lundgren et al. 1 0, SB with pulmonary MAP t during and for 7 min after 50 ml of warmed lavage was used
(1 982) fibrosis (p < 0.05) Laryngeal and bronchial stimulation
HR t during and for 1 5 min after responsible for most hemodynamic
(p < 0.05) changes
MPAOP t during insertion,
suctioning, and after (p < 0.05)
CI t during and for 7 min after (p
< 0.05)
PaO, j during suctioning and for
1 5 min after (p < 0.05)
3 patients showed ST-T segment
depression (p < 0.05)
PaCO, unchanged
'SB, spontaneously breathing; MV, mechanically ventilated; FlO" fractional inspired oxygen; A-aDO" alveolar-arterial oxygen difference; V/
a, ventilation/perfusion ratio; MAP, mean arterial pressure; HR, heart rate; MPAOP, mean pulmonary arteriolar occlusion pressure; CI, car
diac index; t , increase; ! , decrease.
'"
o
"
Table 9.4
Diameters 01 Fiberoptic Bronchoscopes
Model Outside Diameter (mm) Suction Channel Diameter (mm)
Olympus BF-B S.O' 2.0'
Olympus BF-3A 3.0' None
Olympus BF-4B 4.0' 0.8'
Olympus BF-SB 5.0' 1 .5',1 .4'
Olympus BF-FB2 5.2' 2.0'
Olympus BF-SB2 S.8',S.O' 2.0',1 .9'
Olympus BF-3C4 35' 1 .2'
Manchida FBS-4 4.0' O.S'
Manchida FBS-S 5.0' 1 .4'
Manchida FBS-S S.O' 2.2'
Manchida FBS-ST 5.8' 2.2'
Manchida FBS-STL 5.8' 2.S'
Manchida FBS-STL-W 5.8' 2.S'
'Adapted Irom Sackner (1 975).
'Adapted from Barrett (1 974).
'Adapted from Feldman and Huber (1 97S).
'Adapted from Nussbaum (1 982).
ficulty in removing bloody or excessive a result, the ability to pass a broncho

secretions through the small suction scope may also be limited (Sackner,
channel, thus lengthy periods of suction 1975). Perry states thai Iracheal lubes at
ing may be necessary. Feldman and least 8.5 mm in internal diameter (10) are
Huber report plugging of the suction necessary to allow adequate gas ex
channel with thick secretions. Therefore, change around a fiberoptic broncho
some authors recommend using the rigid, scope. Other researchers conclude that
rather than fiberoptic, bronchoscope bronchoscopy should be cautiously per
when copious or viscous secretions are formed through a cuffed airway of no less
present (AyeHa, 1978; Landa, 1978). Oth than 8 mm (10); smaller tracheal tubes
ers advocate using lavage in conjunction may compromise air flow and reduce
with fiberoptic bronchoscopy to assist the tidal volume even during mechanical
removal of tenacious secretions. Aliquots ventilation (Rauscher, 1 972; Grossman
of 5-20 ml, totaling up to 200 ml of la and Jacobi, 1974; Pierson et a1.; Baier el
vage, are suggested in the literature aI., 1976; Feldman and Huber; Barrett).
(Sackner et aI., 1972; Wanner et a1.; Mil Baier and co-workers report 'increased
ledge, 1976; de Kock; Barrett; Mahajan et airway pressures (up to 70 cm H,O), a
aI., 1978; Marini et aI., 1979; Lundgren et 50% reduction in flow rate, and an 20%
a 1 . ). However, Sackner et a1. and Wanner decrease in delivered tidal volume when
et a1. report deterioration in chest x-ray a fiberoptic bronchoscope is introduced
appearance when large quantities of la through a 7.5-mm (10) tracheal tube. Sim
vage are used. It appears thai limiting ilarly, critical increases in air flow resisl
both the quantity of lavage and the du ance are noted when larger caliber bron
ration of suctioning may decrease the choscopes are used (Fig. 9.1 ).
hazards associated with fiberoptic Despite some favorable reports (Nuss
bronchoscopy. baum, 1982) fiberoptic bronchoscopy is
generally of limited use in the pediatric
Restrictions patient (Sackner, 1975; Berci, 1978; Wood
and Fink, 1978). The decreased airway
The use of fiberoptic bronchoscopy is diameters of children necessitate the use
restricted in certain patients requiring of smaller caliber bronchoscopes. These
artificial airways. Nasotracheal intuba lack or have limited suction ports that
tion, which may be used because of oral are not effective in removing retained se
lacerations, oral fractures, or out of pref cretions (Table 9.4) (Sackner, 1975; Wood
erence, can restrict Iracheal tube size. As and Fink). In order to avoid further
60
X NO SCOPE
4 mm SCOPE
so 5 mm SCOPE
o 6 mm SCOPE
-
40
"-
-'
"- ____ 0
0
N
"
30
E
2
w . O
U
Z
20
0 ---- . ---

'" 0-- . - .--- .-
ili
w
a:
10
______

... .&_ - .a -
O ======X==lX::::==X-=-=-=-=-=-=-=-=-X
0.2 0.4 0.6 0.8 1 .0
FLOW Illsi
Figure 9.1 . Resistance to air flow through 8.S-mm-ID endotracheal tube with fiberoptic broncho
scope inserted. Adapted from l. B. Perry (1 978).
trauma or infection, nonintubated pa and were ventilated during this study.

tients with nasal or facial fractures or a Because the atelectasis reexpansion rate
CSF leak should not receive transnasal was lower and the relapse rate higher i n
bronchoscopy. Allempts at oral fiberoptic patients with segmental rather than lobar
bronchoscopy may prove to be very atelectasis, the authors reported that pe
expensive if the patient bites the ripheral secretions could not be removed
bronchoscope. as effectively as those that were more
centrally located. Harada and associates
Comparison with Chest Physiotherapy (1983) reported successful bronchoscopic
clearing in 14 or 15 patients with atelec
The literature comparing the advan tasis and a recurrence rate of 43%. Nei
tages and effectiveness of bronchoscopy ther paper reported trying chest physio
to chest physiotherapy for acute secre therapy prior to bronchoscopy. Because
tion retention is limited. Mackenzie et al. of the recurrence rate in both studies and
(1978) reported that a single chest phys the reduced efficacy when segmental at
iotherapy treatment resulted in clinical electasis was present, chest physiother
and radiological improvement in 68% of apy appears to have advantages over
the 47 patients studied. The 27 patients bronchoscopy. lt is cheaper, easily re
having unilobar densities demonstrated a peated, associated with fewer complica
74% improvement. These findings are tions, and may be beller able to clear pe
similar to those of Lindholm et al. who ripheral secretions (Marini et aI., 1984;
reported a 67% (17 of 70) improvement in Mackenzie and Shin, 1986).
chest x-rays after fiberoptic bronchos Marini et al. (1979) compared the effec
copy in patients previously unresponsive tiveness of fiberoptic bronchoscopy and
to routine respiratory therapy. chest physiotherapy in 31 patients with
In 51 patients with a variety of diag acute lobar atelectasis. The bronchos
noses, therapeutic bronchoscopy (rigid or copy procedure included cannulation of
fiberoptic) was 47-85% successful in every segmental and most subsegmental
clearing atelectasis, depending on the 10- bronchi, accompanied by suction and sa
cation of the pathology (Perruchoud et line lavage. Chest physiotherapy (per
aI., 1980). Thirty-one of the patients were formed every 4 hr) consisted of [5 for 3
receiving mechanical ventilation. Nine min (or multiple 1-2 liter inflations if the
additional patients received intubation patient was intubated), coughing and tra-
cheal suctioning, nebulized isoetharine, only when improvement is not noted fol
and postural drainage with chest percus lowing physiotherapy (usually 1 -3 treat
sion to each involved area for 5 min. ments). Depending on the preference of
Chest x-rays were compared immedi the physician, either rigid or fiberoptic
ately following and 24 and 48 hr after bronchoscopy is utilized. Over a 6-7 year
these procedures. All patients who did period after the introduction of chest
not demonstrate at least 50% improve physiotherapy in 1973, fewer than 20 pa
ment immediately following chest phys tients/year required therapeutic bron
iotherapy underwent bronchoscopy. It choscopy (Table 1 .2). Between 1973 and
was concluded that in acute atelectasis, 1987, 7,123 patients were treated with
no demonstrable benefit was obtained by chest physiotherapy (see Appendix AU ).
using routine bronchoscopy in addition In 1979, 18 therapeutic bronchoscopies
to chest physiotherapy. In fact, improve were performed on 14 patients; only
ment following fiberoptic bronchoscopy three procedures resulted in radiological
was nearly identical to that demon evidence of improvement. Although ear
strated following a single treatment with lier bronchoscopy may have been more
chest physiotherapy. successful, it appears that little benefit is
Jaworski et al. (1988) evaluated the ef gained by performing bronchoscopy in
fect of fiberoptic bronchoscopy in 20 pa addition to aggressive chest physiother
tients after lobectomy. All subjects re apy. It is the authors' experience that
ceived chest physiotherapy while 10 also chest physiotherapy is frequently more
underwent postoperative bronchoscopy. effective than therapeutic bronchoscopy
The incidence of atelectasis was similar in the ICU. The following two case his
for both groups. Of the 5 patients who de tories demonstrate that chest physiother
veloped atelectasis, 60% responded fa apy improved oxygenation and radiolog
vorably to chest physiotherapy alone; ical appearance of the chest when
2 patients underwent bronchoscopy, bronchoscopy was unsuccessful.
which was palliative in 1 case. The au
thors conclude that routine postlobec
tomy bronchoscopy offers no advantage Case History 9.1. During a motor vehicle ac
cident a 36-year-old white male was thrown
over usual physiotherapy in preventing
through the windshield and sustained multiple
postoperative atelectasis. severe facial lacerations. No loss of conscious
Marini and associates (1984) believe ness was reported prior to admission to the
that there are few appropriate indica trauma center. After admission, the patient be
tions for therapeutic bronchoscopy. came bradycardic, hypotensive, and his level of
Whenever possible, they recommend consciousness deteriorated. The patient was
chest physiotherapy. Only when an im intubated, ventilated, and resuscitated with
portant diagnostic question coexists or fluids. Admitting chest x-ray showed no car
when a massive collapse is unresponsive diac, lung, pleural, or skeletal pathology. Two
(within 24 hr) to respiratory therapy and hours after admission, repeat chest x-ray dem
onstrated a right upper lobe atelectasis (Fig.
the patient remains intolerably symp
9.2A). A bronchoscopy was performed and
tomatic is fiberoptic bronchoscopy con thick mucus was suctioned from the right
sidered. They regard the presence of an upper lobe bronchus. Repeat chest x-ray I
air bronchogram as a contraindication to showed worsening of the right upper lobe at
bronchoscopy. This approach avoids the electasis (Fig. 9.28). A second bronchoscopy
expense, discomfort, and potential com was performed, after which a repeat chest x
plications of an unnecessary bronchos ray showed complete atelectasis of the right
copy. Similarly, O'Donnell (1975) states upper lobe (Fig. 9.2C). Three hours after the
that bronchoscopy should not be used as second bronchoscopy a 60-min chest physio
a substitute for chest physiotherapy in therapy treatment was given to the area of lung
pathology. Treatment consisted of segmental
treating secretion retention; rather, it
postural drainage to the anterior, apical, and
should be reserved for cases with persis posterior segments of the right upper lobe,
tent radiological findings. The authors manual percussion. and suctioning. Copious
support these statements and consider secretions were suctioned from the endotra
chest physiotherapy the treatment of cheal tube. Repeat chest x-ray demonstrated
choice in clearing retained secretions at considerable improvement of the right upper
our faCility. Bronchoscopy is performed lobe atelectasis (Fig. 9.20). Chest physiother-
Figure 9.2. (A) A chest x-ray taken 2 hr after admission shows a right upper lobe atelectasis. The
tracheal tube is correctly positioned. (B) The right upper lobe atelectasis persists following the first
bronchoscopy. (C) After a second bronchoscopy, the right upper lobe atelectasis is still evident on
chest x-ray. (D) Improved aeration is evident in the right upper lobe after chest physiotherapy
apy cleared an atelectasis that did not respond oxygenalion and removed retained se
favorably to bronchoscopy and significantly im cretions from airways that were inacces
proved oxygenation (Table 9.5). The FlO, was sible 10 the bronchoscope. Bronchoscopy,
decreased from 1 .0 to 0.6 after this treatment which requires physician and nurse par
and the patient was extubated 1 2 hr later. Total
licipation, failed to produce beneficial
hospital stay was 3 days.
effects.
This case study demonstrales Ihat Case History 9.2. A 37-year-old white male
chest physiotherapy treatment improved was transferred to the trauma center from an-
Table 9.5
Arterial Blood Gases
Intervention Time
03:35 SR' 0:530 0:655 SR 1 0:00 1 3:00 CPT' 14:45 1 5:45
FlO, 1 .00 1 .00 1 .00 1 .00 1 .00 1 .00 0.6
PEEP 8 8 10 10 10 10 12
PaO, 340 1 55 1 25 1 56 1 92 409 117
pH 7.38 7.33 7.25 7.36 7.39 7.35 7.40
PaCO, 28 35 47 40 37 42 40
'SR, bronchoscopy; CPT, chest physiotherapy.
Figure 9.3. (A) A left lower lobe atelectasis is shown. (8) After bronchoscopy the left lung appears
atelectatic and subsegmental atelectasis is present in the right lower lobe. (C) After chest physio
therapy by a nurse there is some improved aeration in the left lung. (0) Complete reexpansion of
both lungs occurs after treatment by a physical therapist.
other medical institution after a fall from a sive chest physiotherapy treatment consisting
three-story building the previous day. Admitting of postural drainage, manual percussion, and
diagnoses included a left pelvic fracture, left vibration to the left lower lobe, followed by tra
hemothorax, and fractured left eighth and ninth cheal suction. Copious yellow secretions were
ribs. The patient underwent an exploratory la obtained and arterial oxygenation markedly im
poratomy for a suspected diaphragm rupture proved (Table 9.6). Follow-up chest x-ray
and a splenic tear. The patient was intubated showed clearing of the left lower lobe and right
and mechanically ventilated due to deteriorat lower lobe atelectasis (Fig. 9.30). The FlO, was
ing arterial blood gases and a left lower lobe reduced from 0.8 to 0.5 1 0 hr later. The patient
atelectasis (Fig. 9.3A). Bronchoscopy was per was extubated in 5 days and discharged 1 3
formed after which a repeat chest x-ray re days after admission.
vealed complete opacification of the left hemi
thorax with mediastinal shift to the left and Chest physiotherapy treatment per
minimal subsegmental atelectasis in the right
formed by both the nursing and physical
lung base (Fig. 9.3B.) After two chest physio
therapy staff was more effective than
therapy treatments by the nursing staff, the left
lung was partially reaerated but the subseg bronchoscopy in treating a left lung atel
mental atelectasis in the right lung base was ectasis. The treatment by the physical
unchanged (Fig. 9.3C). Arterial blood gases im therapist resulted in a longer lasting and
proved after the first nursing treatment (Table greater improvement in PaD" oxygen
9.6). Three hours after the second nursing saturation, and chest x-ray than that by
treatment a physical therapist gave an inten- the nurse. This may be related to the
Table 9.6
Arterial Blood Gases and Nursing Treatment
,
Time 0105 031 5 NCPT' 0415 NCPT 0530 0705 0810 PT CPT 1 020 2000
F102 1 00 100 100 60 80 80 80 50
PEEP 5 10 10 10 12 15 15 15
Pa02 1 68 95 158 53 56 65 267 1 73
pH 7.39 7.29 7.44 7.35 7.35 7.4 7.44 7.49
PaC02 42 50 35 35 42 41 35 33
0, sat 99 96 99 85 87 92 99 99
'Bronchoscopy.
'NCPT. nursing chest physiotherapy; PT CPT, physical therapy chest physiotherapy.
longer treatment time and segmental pos beroptic bronchoscope is reported de

tural drainage that is not routinely per spite radiological confirmation of col
formed by the nursing staff. lapse (Wanner et al.; Bowen et aI., 1 974;
. Visualization of the respiratory tract is Lindholm et al.; Brach et aI., 1976; de
a frequently stated advantage of perform Kock; Marini et aI., 1 979). When mucus
ing bronchoscopy rather than chest phys plugs are present, large amounts of la
iotherapy in the presence of retained se vage are often needed to loosen and
cretions. Rigid bronchoscopy is reported break up the obstruction so it can be as
to allow observation 0.5-1 cm distal to pirated through the small suction port.
the lobar orifices (Sackner, 1 975). Using Lindholm and co-workers found no bron
fiberoptic bronchoscopy, Ikeda (1970) choscopic evidence of mucus plugs or
noted that visualization was limi ted to bronchial obstruction in 18 (26%) pa
just beyond the segmental bifurcation. tients demonstrating x-ray evidence of
During diagnostic bronchoscopy (mean atelectasis. This suggests that the pul
duration of 72 minutes), Kovnat and co monary collapse was not a result of more
workers (1974) reported examining all central obstruction or plugging; rather,
fourth-order and most fifth- and sixth more peripheral secretions were proba
order bronchi. However, the diameters of bly present, beyond the field of the fiber
adult airways are relatively small, as optic bronchoscope. Mucus plugs are fre
shown in Table 9.7. Based on these find quently the result of inadequate airway
ings, it is apparent that the majority of fi humidification. In our clinical experi
beroptic bronchoscopes in Table 9.4 are ence, mucus plugging and tenatious se
physically unable to enter the average cretions can be minimized or eliminated
adult segmental bronchus, even during by providing patients with optimal sys-
three fourths maximal lung inflation.
With current technology, visualizing the
infant or small child's airway beyond the
lobar bronchi is not practical. Bronchos
copy is often accompanied by broncho Tabte 9.7
spasm, coughing, and reduced tidal vol Average Adutt Airway Diameters at Three
ume delivery. These result in greater Fourths Maximal Inflation
airway narrowing, making bronchial can Anatomical Diameter
Generation
nulation even more difficult. Broncho Description (mm)'
scopes of small caliber, allowing maxi
Trachea o 18
mal visualization of the airways, have a Main stem bronchus 1 1 2.2
reduced suction port size, that decreases Lobar bronchus 2 8.3
their therapeutic value in removing re Segmental bronchus 3 5.6
tained secretions. First subsegmental 4 4.5
The added dimension of pulmonary vi bronchus
sualization is sometimes considered of Second 5 3.5
particular benefit in removing mucus subsegmental
plugs. Yet, the absence of secretions or bronchus
mucus plugs within the range of the fi- 'Adapted from Wiebel (1 963).
temic hydration and supplemental in References

haled humidity.
Albertini, RE. Harrell JH. Kurihara N, Moser KM:
When air bronchograms accompany Arterial hypoxemia induced by fiberoptic bron
pulmonary collapse, neither fiberoptic choscopy. lAMA 230:1 666-1667. 1 974
bronchoscopy nor chest physiotherapy is Alder RA: A rebreather for prophylaxis and treat
reported of benefit (Marini et a!., 1979 ment of postoperative respiratory complications.
Dis Chest 52:640-647. 1967
and 1984). It is not surprising that bron
Alexander GO. Schreiner RI. Smiler Bl. Brown EM:
choscopy is ineffective because air bron Maximal inspiratory volume and postoperative
chograms (extending more peripherally) pul monary complications. Surg Gyn ecol Obstal
represent patent larger airways sur 1 5 2:601-603. 1 9a1
rounded by areas of atelectasis. The short Ali J. Serratte C. Wood LOH. Anthonisen NR: Effect
of postoperative intermittent positive pressure
duration of physiotherapy treatment de breathing on lung function. Chest 85:192-196,
scribed by Marini and associates may ac 1 984
count for their lack of benefit from this American National Standards Institute {ANSI).
therapy when air bronchograms are pres American national standard ror humidifiers and
ent. It is our experience that longer treat nebulizers ror medical use. ANSI Z19.9. 1979
American Thoracic Society: Standards for the di
ment times are necessary to clear more agnosis and care of patients with chronic obstruc
peripheral, as opposed to central, tive pulmonary disease (COPD) and asthma. Am
secretions. Lung Assoc. 1987
Chest physiotherapy has certain ad Anderes C. Anderes U. Gasser D. Dittmann M. Tur
ner J. Brennwald J. Keller R. Ferstl A. Wolff G:
vantages over therapeutic bronchoscopy. Postoperative spontaneous breathing with CPAP
Chest physiotherapy does not require to normalize late postoperative oxygenation. In
physician participation or the purchase tensive Core Med 5:15-21. 1979
and maintenance of expensive equip Andersen lB. Olesen KP. Eikard B. Jansen E. Qvist
ment. It is less costly for the patient and J: Periodic continuous positive airway pressure.
CPAP. by mask in the treatment or atelectasis.
can be easily repeated, if necessary. Eur 1 Respir Dis 61 :20-25. 1980
Bronchoscopy is more invasive, and mul Andersen lB. Qvist J, Kann T: Recruiting collapsed
tiple treatments can cause airway lung through collateral channels with positive
trauma. Physiotherapy treatments are end expiratory pressure. Scond 1 Respir Dis
60:260-266. 1979
not limited by tracheal tube size, and
Anderson WHo Dossett BE. Hamilton GL: Preven
usually no additional sedation is needed tion of postoperative pul monary complications.
(beyond that normally used to provide lAMA 186:763-766. 1963
relief for discomfort following surgery). Asmundsson T. Kilburn KH: Mucociliary clearance
rates at various levels in dog lu ngs. Am Rev Res
pir Dis 102:388-397. 1 910
Aubier M: Effect of theophylline on diaphragmatic
Summary muscle function. Chest 92:275-315. 1 987
Ayella RJ: Radiologic Management of the MaSSively
The reported side effects of bronchos Troumali7..ed Palient. p 1 1 4. Williams & Wilkins.
copy outlined in Table 9.2 appear to be Baltimore. 1978
more severe than those experienced with Ayres SM. Kozam RL. Lukas OS: The effects or in
termittent positive pressure breathing on the in
chest physiotherapy. The patient with trathoracic pressure. pulmonary mechanics. and
preexisting hypoxemia, low lung compli work of breathing. Am Rev Respir Dis 87:370-379.
ance, or high intrapulmonary shunt, re 1963
quiring mechanical ventilation and PEEP Bader ME. Bader RA: Intermittent positive pressure
breathing. Adv Ca rd iopu J Dis 4:271-284. 1969
(> 1 5 cm H20), is a particularly poor can Baier H. Begin R. Sackner MA: Effect of ai rway di
didate for bronchoscopy (Mackenzie and ameler, suction catheters. and bronchofiberscope
Shin, 1 986). Yet, this same patient can on airnow in endotracheal and tracheostomy
frequently tolerate chest physiotherapy tubes. Heart L.ung 5:235-238. 1976
without cardiorespiratory disturbance. In Baker IP: Magnitude or usage of intermittent posi
tive pressure breathing. Am Rev Respir Dis
our experience, and that of others (Ma 1 1 0: 1 70-178. 1 974
rini et a!., 1979, 1984; Jaworski et a!.; M. Barrell CR: Flexible fiberoptic bronchoscopy in the
A. Branthwaite, personal communica critically ill patient. Chesl ISuppJI 73:746-749.
tion), bronchoscopy offers no therapeutic 1978
Baxter WD. Levine RS: An evaluation of intermit
advantage over chest physiotherapy in
tent positive pressure breathing in the prevention
the management of acute secretion of postoperative pulmonary complications. Arch
retention. $u rg 98:795-798. 1 969
Becker A. Bara S. Braun E. Meyers MP: The treat cises in preventing pul monary complications
menl of postoperative pu lmonary atelectasis with after abdominal surgery. Am Rev Respir Dis
intermittent positive pressure breathi ng. Surg Gy 130:12-15. 1984
necol Obslel l 1 1 :51 7-522. 1 960 Chamney AR: Humidification requirements and
Berci G: Flexible fiber and rigid (pediatric) broncho techniques: Including a review of the perfor
scopic instrumentation and documentation. Chest mance of equipment i n current use. Anoeslhesio
ISupplJ 73:768-775. 1978 24:602-61 7 . 1 969
Berman LS, Heard SQ, Banner MJ: Humidification Chang N. Levison H: The effect or a nebulized bron
techniques for high frequency jet ventilation (ab chodilator admi nistered with or without inter
stract). Cril Core Med 1 2:284. 1984 mittent positive pressure breathing on ventila
Bernstein It. Ausdenmoore RW; Iatrogenic bron tory function in children with cystic fibrosis
chospasm occurring during clinical trials of a new and asthma. Am Rev Respir Dis 1 06:867-872.
mucolytic agent. acetylcysleine. Dis Chesl 1972
46:469-473. l964 Cheney FW: Editorial expression. Chesl 62:664.
Bierman CW: Pneumomediastinum and pneumo 1972
thorax complicating asthma in chi ldren. Am } Dis Cheney FW. Butler J; The effect of ullrasonically
Child 1 1 4:42-50. 1967 produced aerosols on airway resistance in man.
Bosomworth PP. Spencer FC: Prolonged mechanical Aneslhesiology 29;1 099- 1 1 06. 1 968
ventilation. I. Factors affecting delivered oxygen Cherniack RM: Intermittent positive pressure
concentrations and relative humidity. Am Surg breathing in management of chronic obstructive
'
31:3 77-38 1 . 1965 pulmonary disease: Current state of the art. Am
Bowen TE. Fishback ME. Green DC: Treatment of Rev Respir Dis 1 1 0: 1 88-192. 1974
refractory atelectasis. Ann Thoroc Surg 1 8:584- Cherniack RM. Svanhill E: long-term use of inter
589. 1974 mil lent positive-pressure breathing (IPPB) in
Brach SB. Escano GG. Harrell JH. Moser KM: Ven chronic obstructive pulmonary disease. Am Rev
tilation-perfusion alterations induced by fiberop Respir Dis 1 1 3:721-728. 1976
tic bronchoscopy. Chest 69:335-337. 1976 Cohen Il. Weinberg PF. Fein A, Rowinski CS: En
Brain J: Aerosol and humidity therapy. Am Rev Res dotracheal tube occlusion associated with the use
pir Dis 122(21:17-21. 1980 of heat and moisture exchangers in the intensive
Brain JD: Aerosol and humidity therapy. In Currenl care unit. Cril Core Med 1 6:277-279. 1 988
Advances 10 Respiratory Core. edited by WI 0'00- Colgan FI, Mahoney PD. Fanning CL: Resistance
nohue. Chap 5. pp 72-85. American College Chest breathing (blow hollies) and sustained hyperin
Physicians. Park Ridge IL. 1984 nations in the treatment of atelectasis. Aneslhe
Brain 'D. Valberg PA: State of the art. deposi tion of sio/ogy 32:543-550. 1970
aerosol in the respiratory tract. Am Rev Respir Dis Cottrell IE. Siker ES: Preoperative intermittent pos
120:1325-1373. 1 979 itive pressure breathing therapy i n patients with
Branson RD. Ploysongsang Y. Hurst J. Rushkin MC: chronic obstructive lung disease: Effects on post
Flow resistance characteristics of commonly used opera tive pulmonary complications. Aneslh
hygroscopic condensers hum idifiers (abstract). Anolg (CleveI 52:258-262. 1973
Cril Core Med 14:368. 1986 Craven Il. Evans GA, Davenport PI. Williams HP:
Braun SR. SmUh FR, McCarthy TM. Minsloff M: The evaluation of the incentive spirometer in the
Evaluating the changing role of respiratory ther management of postoperative pulmonary compli
apy services at two hospitals. lAMA 245:2033- cations. Br J Surg 61:793-797, 1974
2037. 1981 Craven DE. Goularte. TA. Make BI: Contaminated
Brillon RM, Nelson KG: Improper oxygenation dur condensate in mechanical ventilation circuits.
ing bronchofiberoscopy. Anesthesiology 40:87-89. Am Rev Respir Dis 1 29:625-628. 1984
1974 Credle WF. Smiddy JF, Elliott RC: Complications of
Browner B. Powers SR: Effect of IPPB on functional fiberoptic bronchoscopy (abstract). Am Rev Respir
residual capacity and blood gases in postopera Dis 107:1091. 1973
tive patients. Surg Forum 26:96-98. 1975 Cullen JH. Brum VC. Reidt WU: An evaluation of
Burman SO: Bronchoscopy and bacteremia. I the ability of intermittent positive pressure
Thoroc Cordiovasc Surg 40:635-639. 1960 breathing 10 produce effective hyperventilation
Bynum ll. Wilson IE. Pierce AK: Comparison of in severe pulmonary emphysema. Am Rev Tuberc
spontaneous and positive-pressure breathing in Pulm Dis 76:33-46. 1957
supine normal subjects. J App/ Physio/ 41:341- Dalhamn T: Mucous flow and ciliary activity in the
347. 1976 trachea of healthy rats. and rats exposed to res
Campbell T. Ferguson N. McKinlay RGC: The use piratory irritant gases. Aclo Physio/ Scond (Supp/
of a simple self-administered method of positive 1231 36: 1 - 1 61 . 1956
expiratory pressure (PEP) in chest physiotherapy Daly WI. Ross Ie. and Behnke RH: The effecI of
after abdominal surgery. Physiother 72:498-500. changes in pul monary vascular bed produced by
1986 atropine, pulmonary engorgement and positive
Carlsson C. Sonden B. Thylen U: Can postoperative pressure breathing on diffusion and mechanical
continuous positive airway pressure (CPAP) pre properties of the lung. J Clin Invesl 42:1083-1094,
vent pulmonary complications after abdominal 1963
surgery? fnlensive Core Med 7:225-229. 1981 Darin I . Broadwell ! . MacDonell R: An evaluation of
Celli BR. Rodriguez KS. Snider GL: A controlled water-vapor output from four brands of un
trial of intermittent positive pressure breathing. heated. prefilled bubble humidifiers. Respir Core
incentive spirometry. and deep breathing exer- 27:41-50. 1982
de Kock MA: Dynamic Bronchoscopy. pp 32-34. Gale GO. Sanders DE: Incentive spirometry: Its
SpringerVerlag, New York. 1977 value after cardiac surgery. Can Anoesth Soc J
oeTroyer A. Deisser P: The effects of inlermitLent 27:475-480. 1980
positive pressure breathing on patients with res Gedeon A. Mebius C. Palmer K: Neonatal hygro
piratory muscle weakness. Am Rev Respir Dis scopic condenser humidiller. Cril Care Med
124:132-137. 1981 15:51-54. 1987
Doh; S, Gold MI: Comparison of two methods of George RB. O'Donohue WJ: Guidelines for the use
postoperative respiratory care. Chest 73:592-595. of intermittent positive pressure breathing (IPPBJ.
1978 Respir Care 25:365-370, 1980
Downie PA (ed): Cosh's Textbook of Chest, Heart Glover WJ: Mechanical ventilation in respiratory
and Vascular Disorders for Physiotherapists, pp insufficiency in inrants. Proc R Soc Med 58:902-
87-93. fB Lippincott. Philadelphia. 1979. 904. 1965
Doyle HI. Napolitano AE. Lippman HR, Cooper KR. Gold MI: The present status of IPPB therapy. Chest
Duncan IS. Eakins K . Glauser FL: Different hu 67:469-47 1 , 1975
midification systems for high-frequency jet ven Gold MI: Is intermittent positivepressure breathing
tilation. Crit Core Med 12:815-819. 1984 therapy (IPPB RXl necessary in the surgical pa
Dreisin RB. Albert RK. Talley PA. Kryger MH. Seag tient? (editorial) Ann Surg 184:122-123. 1976
gin CH. Zwillich CW: Flexible fiberoptic bron Gold MI: IPPB therapy. a current overview. Respir
choscopy in the teaching hospital. yield and com Core 27:586-587. 1 982
plications. Chest 74:144-149, 1978 Goldberg I. Cherniak RM: The effect of nebulized
Dubrawsky C, Awe RJ, Jenkins DE: Effect of fiber bronchodilator delivered with and without IPPB
optic bronchoscopy on oxygenation of arterial on ventilatory function in chronic obstructive
blood (abstractI. Chest 64:393. 1973 emphysema. Am Rev Respir Dis 91:1 3-20. 1965
Dull IL. Dull WL: Are maximal inspiratory breath Golden GT. Chandler IG: Colonic ileus nad cecal
ing exercises or incentive spirometry better than perforation in patients requiring mechanical ven
early mobilization after cardiopulmonary bypass? tilatory support. Chest 68:661-664. 1975
Phy Ther 63:655-659. 1 983 Graff TO. Benson OW: SystemiC and pulmonary
Edmondson EB. Reinarz IA. Pierce AK. Sanford JP: changes with inhaled humid atmospheres: CHni
Nebulization equipment: A potential source of in cal application. Anesthesiology 30:199-207. 1969
fection in gram-negative pneumonias. Am J Dis Grossman E. Jacobi AM: Minimal optimal endatra
Child 1 1 1 :357-360. 1 966 cheal tube size for fiberoptic bronchoscopy.
Egan OF: Humidity and water aerosol therapy. Aneslh Analg (CleveJ 53:475-476. 1974
Conn Med 3 1 :353-355, 1967 Harada K, Mutsuda T, Saoyama N. Taniki T. Ki
Emergency Care Research Institute. Heat and mois mura H: Re-expansion of rerractary atelectasis
ture exchangers. Health Devices 1 2 : 1 55-167. 1983 using a bronchofiberscope with a balloon cuff.
Emmanuel GE. Smith WM. Briscoe WA: The effect Chest 84:725-728. 1983
of intermittent positive pressure breathing and Harrell lB. Albertini RE. Kurihara N. Moser KM:
voluntary hyperventilation upon the distribution Gas exchange abnormalities induced during fi
of ventilation and pulmonary blood flow to the beroplic bronchoscopy (abstract). Am Rev Respir
lung in chronic obstructive lung disease. J Clin In Dis 107:1019, 1973
vest 45:1221-1233. 1966 Harris RL. Riley HD: Reactions to aerosol medica
Falk M . Kelstrup M. Andersen lB. Kinoshita T. Falk tion in infants and chi ldren. lAMA 201:953-955,
P. Slovring S. Gothgen I: Improving the ketchup 1967
boll Ie method with positive expi ratory pressure. Hay R. Miller WC: Efficacy or a new hygroscopic
PEP. in cystic fibrosis. cur J Respir Dis 65:423-432. condenser humidifier. Cril Care Med 16:277-279.
1984 1982
Featherby EA. Weng TR. Levison H: The effect of Hayes B. Robinson. JS: An assessment of methods of
isoproterenol on airway obstruction in cystic fi humidification of inspired gas. Br J Anoesth
brosis. Can Med Assoc J 102:835-838. 1970 42:94-104. 1 970
Feldman NT. Huber GL: Fiberoptic bronchoscopy Hedstrand U. Liw M, Rooth G. Ogren CH: Effect of
in the intensive care unit. lnt Anesthesiol Clin respiratory physiotherapy on arterial oxygen ten
14:31-42. 1 976 sion. Acta Anaeslhesio' Scond 22:349-352. 1978
Forbes AR: Hu midification and mucus flow in the Heisterberg L. Staehr Johansen T. Werner Larsen H.
intubated trachea. Br J Anoeslh 45:874-878. 1973 Holm M. Anderson B: Postoperative pulmonary
Ford GT. Guenter CA: Toward prevention of post complications in upper abdominal surgery. ACla
operative pulmonary complications. Am Rev Res Chir Scond 145:505-507. 1979
pir Dis 1 30:4-5. 1984 Hilding AC: Ciliary streaming in the lower respira
Fouts lB. Brashear RE: Intermittent positive-pres tory tract. Am J PhysioI 191 :404-410. 1957
sure breathing. a critical appraisal. Poslgrad Med Hirsh fA. Tokayer Jl. Robinson MJ. Sackner MA: Ef
59:103-107. 1976 fects of dry air and subsequent humidillcation on
Froeb HF: On relief of bronchospasm and the in tracheal mucous velocity in dogs. J Appl Physio'
duction of alveolar ventilation: A comparative 39:242-246. 1975
study of nebulized bronchodilators by deep Hofmeyr Jl. Webber BA. Hodson ME: Evaluation of
breathing and intermittent positive pressure. Dis positive expiratory pressure as an adjunct to
Chest 38:483-489. 1960 chest physiotherapy in the treatment of cystic fi
Frolund L. Madsen F: Selfadministered prophylac brosis. Thorax 41:951 -954. 1986
tic postoperative positive expi ratory pressure in Huber GL, Finley TN: Effect of isotonic saline on al
thoracic surgery. Acto Anaesthesiol Scond veolar architecture (abstract). Anesthesiology
30:381-385. 1986 26:252-253. 1965
Hughes RL: Do no harm-cheaply (editorial). Chesl (Rona contesbiona) lung I Appl Physiol 23:804-
77:582-584. 1980 610. 1 967
Ikeda 5: Flexible bronchofiberscope. Ann 0101 Kit tredge P: IPPB-the pressure is building (edito
Rhinol LaryngoJ 79:916-923, 1970 rial). Respir Care 18:644-648. 1973
Indihar Fl. Forsberg DP. Adams AS: A prospective Klain M. Nordin U. Keszler H: Musociliary trans
comparison of Ihese procedures used in attempts port with and without humidification in high fre
to prevent postoperative pulmonary complica quency ventilation (abstract). Anesthesiology
tions. Aespir Core 27:564-568. 1 982 57:66. 1962
Intermittent Positive Pressure Breathing Trial Klein EF. Shah DA. Shah NJ. Modell JH. Desautels
Croup: Intermittent positive pressure breathing 0: Performance characteristics of conventional
therapy of chronic pulmonary disease. Ann In and prototype humidifiers and nebulizers. Chest
lern Med 99:61 2-620, 1 983 64:690-696. 1973
Iverson L1. Ecker RR, Fox HE. May IA: A compara Kleinholz EI, Fussell I, McBrayer R: Arterial blood
tive study of IPPS. the incentive spirometer. and gas studies during fiberoptic bronchoscopy. Am
blowbottles: The prevention of atelectasis follow Rev Respir Dis 108:1014. 1973
ing cardiac surgery. Ann Thoroc Surg 25:1 97-200. Kovnal DM. Rath GS. Anderson WM. Snider GL:
1976 Maximal extent of visualization of bronchial tree
Jaworski A, Goldberg SK, Walkenstein MD, Wilson by flexible fiberoptic bronchoscopy. Am Rev Res
B. Lip p mann ML: Utility of immediate postlobec pir Dis 1 10:88-90, 1974
tomy R beroptic bronchoscopy in preventing atel Kraslins IRB. Corey ML. McLeod A. Edmonds 1.
ectasis, Chest 94:38-43, 1988 Levison H. Moes F: An evaluation of incentive
Jenkins SC, Soutar SA: A survey into the use of in spirometry i n the management of pulmonary
centive spirometry following coronary artery by complications after cardiac su rgery i n a pediatric
pass graft surgery, Physiotherapy 72:492-493, population. Cri/ Core Med 10:525-528. 1982
1966 Landa IF: Indications for bronchoscopy. Chest
Jenne JW: Theophylline as a bronchodilator in ISuppI1 73:666-690. 1 976
COPD and its combination with inhaled Beta-ad Lederer DH, Van de Water JM. Indech RB: Which
renergic drugs, Chest 92:75-145, 1 987a deep breathing device should the postoperative
Jenne JW: Introduction. Chest 92:1S. 1987b patient use? Chest 77:610-613. 1 980
lones FL: Increasing postoperative ventilation: A Leith DE: Review of comments concerning presen
comparison of five methods. Anesthesiology tations and discussions of intermittent positive
29:1212-1215. 1 966 pressure breathing session. Am Rev Respir Dis
Jones IG. Clarke SW, Oliver DR: Two-phase gas-liq 1 1 0:200-201 . 1974
uid flow in airways (abstract). Sr J Anoeslh Lindholm CAE. Oilman B. Snyder I . Millen E. Gren
41 :192-193. 1969 vik A: Flexible fiberoptic bronchoscopy in critical
lones RH, MacNamara I, Gaensler EA: The effects care medicine-diagnosis, therapy and compli
of intermitlent positive pressure breathing in cations. Crit Core Med 2:250-261. 1974
simulated pulmonary obstruction. Am Rev Respir Loren M. Chai H. Miklich D. Barwise G: Compari
Dis 82:164-185, 1 960 son between simple nebulization and intermit
Jorgensen JR, Falliers CJ. Bukantz SC: Pneumotho tent positive-pressure in asthmatic children with
rax and mediastinal and subcutaneous emphy severe bronchospasm. Chesl 72:145-147. 1977
sema in chi ldren with bronchial asthma. Pediat Luck IC. Messeder OH. Rubenstein MI. Morrissey
rics 31 :824-832. 1963 WL. Engel TR: Arrhythmias from fiberoptic bron
lung R, Wight J, Nusser R, Rosoll L: Comparison of choscopy. Chest 74:139-143. 1978
three methods of respiratory care following upper Lundgren R . Haggmark S. Reiz S: Hemodynamic ef
abdominal surgery. Chest 78:31-35, 1980 fects of nexible fiberoptic bronchoscopy per
Kahn RC: Humidification of the airways. Adequate formed under topical anesthesia. Chesl 82:295-
for function and integrity (editorial)? Chest 299. 1962
64:510-5 1 1 . 1963 Lyager S, Wernberg M . Rajani N. Boggild-Madsen B.
Kamal SR, Dulfano Mj, Segal MS: The effects of in Nielsen L, Nielsen HC. Andersen M. M0ller J. Sil
termittent positive pressure breathing (IPPS/I) berschmid M: Can postoperative pulmonary com
with compressed air in patients with severe plications be improved by treatment with the
chronic nonspecific obstructive pulmonary dis BartlettEdwards incentive spirometer after
ease. Am Rev Respir Dis 86:360-380, 1962 upper abdominal surgery? Acta Anaesthesiol
Karetzky MS, Carvey )W. Brandstetter RD: Effect of Scand 23:312-319. 1979
fiberoptic bronchoscopy or arterial oxygen ten Mackenzie CF, Shin B. McAslan TC: Chest physio
sion. NY Stote J Med 1 :62-63. 1974 therapy: The effect on arterial oxygenation.
Karetzky MS, Asthma mortality associated with Anesth Analg (Cleve) 57:26-30. 1976
pneumothorax and intermittent positive-pres Mackenzie CF. Shin B: Chest physiotherapy vs.
sure breathing_ Lancet 1:828-829. 1975 bronchoscopy (letter). Cril Care Med 1 4:79. 1986
Kasik IE. Schilling JP: Good news! Bad news? The Macintyre NR, Anderson H R . Silver RM. Schuler
status of respiratory therapy in the 1 980s (edito FR. Coleman RE: Pulmonary function in mechan
rial) JAMA 245:2059. 1961 ically-ventilated patients during 24-hour use of a
Khan MA: Fiberoptic bronchoscopy revisited (edi hygroscopic condenser humidifier. Chesl 84:560-
torial). Chest 74:119-1 20. 1978 564, 1 983
Khan MA. Whitcomb ME. Snider GL: Flexible fiber Macklin MT. Macklin CC: Malignant i n terstitial
optic bronchoscopy. Am J Med 61:151-155. 1976 emphysema of the lungs and mediastinum as an
Kilburn KH: Mucociliary clearance from bul lfrog important occult complication in many respira-
tory diseases and other conditions: an i nterpre NA. Laws JW: Hypoxaemia and atelectasis pro
tation of the clinical literature in light of labora duced by forced expiration. Sr J Anaeslh 37:3- 1 ' ,
tory experiment. Medicine 23:281-358, 1944 1 965
Mahajan VK. Calron PW. Huber GL: The value of Nussbaum E: Flexible nberoptic bronchoscopy and
fiberoptic bronchoscopy in the management of laryngoscopy in children under 2 years of age.
pulmonary collapse. Chesl 73:817-820, 1 978 Cril Care Med 10:770-772, 1982
Malik SK. Jenkins DE: Allerations i n airway dynam O'Connor MJ: Comparison of two methods of post
ics following inhalation of ultrasonic mist. Chest operative pul monary care. Surg GynecoJ Obslel
62:660-664, 1972 140:615-61 7, 1 975
Mapieson WW. Morgan fG, Hi llard EK: Assessment O'Donnell IE: Fiberoptic endoscopy of the respira
of condenser-humidifiers with special reference tory tract in the intensive care ward. Anoesth In
to a multiple-gauze model. Br Med / 1 : 300-305, tensive Care 3:139-141. 1975
1 963 O'Donohue WJ: Maximum volume IPPB for the
Marini jJ. Pierson DJ. Hudson LD: Acute lobar atel management of pulmonary atelectasis. Chest
ectasis: A prospective comparison of fiberoplic 76:683-687, 1979
bronchoscopy and respiratory therapy. Am Rev O'Donohue WI: (PPB past and present. Respir Care
Respir Oir 1 1 9:971-978, 1979 27:588-590, 1 982
Marini II. Pierson Of, Hudson LD: Comparison of n O'Donohue WJ: National survey of the usage of lung
beroptic bronchoscopy and respiratory therapy expansion modalities for the prevention and
(letter). Am Rev Respir Dis 1 26:368. 1 984 treatment of postoperative atelectasis following
McConnell DH, Maloney IV. Buckberg GO: Postop abdominal and thoracic surgery. Chest 87:76-80.
erative intermittent positive pressure breathing 1 985
treatments. } Thorac Cardiovosc Surg 68:944-952. Ophoven JP. Mammel MC. Gordon MI. Boros SI:
1 974 Tracheobronchial histopathology associated with
McCool FO. Mayewski RF. Shayne OS, Gibson Cf. high-frequency jet ventilation. Cril Core Med
Griggs RC. Hyde RW: Intermittent positive pres 1 2:829-832, 1 984
sure breathing in patients with respiratory mus Oulton IL. Hobbs GM. Hicken P: Incentive breath
cle weakness. Chesl 90:546-552. 1986 ing devices and chest physiotherapy: A controlled
McGovern JP. Ozkaragoz K. RoeH K. Haywood TJ. trail. Can } Surg 24:638-640. 1981
Hensel AE: Mediastinal and subcutaneous em Perch SA. Realey AM: Effectiveness of the Servo SH
physema complicating atopic asthma in infants 150 "artificial nose" humidifier: a case report.
and children. Pediolrics 27:951-960. 1961 Respir Core 29:1009-1012. 1 984
Mertz II. Scharer L. McClement JH: A hospital out Pereira W. Kovnat D. lacovino I. Kahn M. Natsios G.
break of Klebsiella pneumonia from inhalation Spivack M, Snider GL: Fever and pneumonia fol
therapy with contaminated aerosol solulions. Am lowing fiberoptic bronchoscopy (abstract). Am
Rev Respir Dis 95:454-460. 1967 Rev Resp;r Dis 109:692. 1974
Meyers JR. Lembeck L. O'Kane H. Baue AE: Pereira W. Kovnat OM. Snider GL: A prospective
Changes in functional residual capacity of the study of the complications following flexible fi
lung after operation. Arch Surg 1 1 0:576-583. 1975 beroptic bronchoscopy. Chest 73:813-816. 1978
Milledge IS: Therapeutic nberoptic bronchoscopy Perruchoud A. Ehrsam R. 1-leHz M. Kapp C. Tschan
in intensive care. Br Med } 2:1427-1 429. 1976 M. Herzog H: Atelectasis of the lung: Brancho
Modell JH. Giammona ST. Davis JH: Effect of scopic lavage with acetylcysteine. Experience in
chronic exposure to ultrasonic aerosols on the 51 patients. Eur J Respir Dis 61 (Suppl}: 163 168.
-
lung. Anesthesiology 28:680-688. 1 967 1 980

Moffet HL. Allan O. Williams T: Survival and dis Perry LB: Topical anesthesia for bronchoscopy.
semination of bacteria in nebulizers and incuba Chesl [Suppl) 73:691-693, 1978
tors. Am 1 Dis Child 1 1 4:1 3-20. 1 967 Pelly TL: A critical look at IPPB (editorial). Chest
Moore RB. Cotton EK. Pinney MA: The effect of in 66:1-3. 1 974
termittent positive pressure breathing on airway Pelty TL. Guthrie A: The effects of augmented
resistance in normal and asthmatic children. I Al breathing maneuvers on ventilation in severe
lergy Clin ImmunoI 49:137-1 4 1 . 1972 chronic airway obstruction. Respir Care 16:104-
Morris JF. Robertson WE. Glauser FL: Comparative 1 1 2, 1971
study of two hand-held respirators. lAMA Pflug AE. Cheney FW. Butler J: The effects of an ul
2 1 1 :802-806, 1970 trasonic aerosol on pulmonary mechanics and ar
Motley HL. Lang LP. Gordon B: Use of intermittent terial blood gases in patients with chronic bron
positive pressure breathing combined with neb chitis. Am Rev Respir Dis 101:710-714. 1970
ulization in pulmonary disease. Am I Med 5:853- Pierson OJ. Iseman MD. Sullon FO. Zwillich CWo
856, 1948 Creagh CE: Arterial blood gas changes in nber
Murray IF: Review of the slate of the art in inter optic bronchoscopy during mechanical ventila
mittent positive pressure breathing therapy. Am tion. Chest 66:495-497. 1 974
Rev Raspir Dis 1 1 0:193-199. 1 974 Pierson RN, Grieco MH: Isoproterenol aerosol in
Newhouse MT. Ruffin RE: Deposition and fate of normal and asthmatic subjects. Am Rev Respir
aerosolized dr ugs. Chest 73:936-943. 1978 Dis 100:533-541. 1 969
Noehren TH. Lasry fE. Legters LJ: Intermittent pos Ploysongsang Y. Branson R. Rashkin MC. Hurst 1M:
itive pressure breathing (IPPB) for the prevention Pressure flow characteristics of commonly used
and the management of postoperative pulmonary heat-moisture exchangers. Am Rev Respir Dis
complications. Surgery 43:658-665. 1 958 1 38:675-678, 1 988
Nunn IF. Coleman AI. Sachithanandan T. Bergman Ponloppidan H: Mechanical aids to lung expansion
i n nonintubated surgical patients. Am Hev Respir routine intermittent positive-pressure breathing

Dis 1 22(2}:109- 1 1 9. 1 980 in the post-surgical patient. Dis Chest 40:128-133.
Pawner OJ. Sanders es. Bailey BJ: Bacteriologic 1961
evaluation of the Servo 150 hygroscopic con Sara C: The management of patients with a trache
denser-humidifier. Cril Care Med 14:135-137. ostomy. Med J Aust 1 : 99-103. 1965
1 986 Sara CA. Clifton BS: Techniques and mechanical
Primiano FP, Moranz ME. Montague FW. Miller RB, aids for artificial respiration. Med J Ausl 2:447-
Sachs DPL: Conditioning of inspired air by a hy 458. 1 962
groscopic condenser humidifier. Crir Care Med Sara C. Currie T: Humidification by nebulization.
12:675-678. 1984 Med I Ausl 1 : 1 74-1 79. 1 965
Rao S. Wilson DB. Brooks Re. Sproule 81: Acute ef Sawyer WD: Airborne infection. MWt Med 128:90-
fecls of nebulization of N-acetylcysteine on pul 93. 1 963
monary mechanics and gas exchange. Am Rev Schemer RM. Oelaney M: Assessing Respiratory
Respir Dis 102:1 7-22, 1970 Therapy Modalities: Trends and Relative Costs in
Rashad K, Wilson K. Hurt HH. Graff TO. Benson Washington DC. Backround Paper #2. Case Stud
OW; Effect of humidification of anesthetic gases ies of Medical Technology. Office of Technology
on static compliance. Aneslh Anals (Cleve) Assessment of the US Congress. Government
46:127-1'32. 1967 Printing Office. Washington DC. 1981
Rauscher C; Respiratory failure. Direct visualiza Schulze T. Edmondson EB. Pierce AK. Sanford JP:
tion of the bronchial tree. J Kons Med Soc 73:481- Studies of a new humidifying device as a poten
482. 1972 tial source of bacterial aerosols. Am Rev Aespir
Reinarz IA. Peirce AK. Mays BB, Sanford IP: The Dis 96:517-519. 1 967
potential role of inhalation therapy equipment in Schuppisser IP. Brandli O. Meili U: Postoperative
nosocomial pulmonary infection. I Clin Invest intermittent positive pressure breathing versus
44:831-839. 1 965 physiotherapy. Am I Surg 140:682-686. 1980
Rick.sten SE. Bengtsson A. Soderberg C. Thorden M, Schwieger J. Gamulin Z. Forster A. Meyer P. Gem
Kvist H: Effects of periodic positive airway pres perle M. Suter PM: Absesnce of benefit of incen
sure by mask on postoperative pulmonary func tive spirometry in low-risk patients undergoing
tion. Chest 89:774-781 , 1986 elective cholecystectomy. Chest 89:652-656. 1 986
Riley RL: Effect of lung inflation upon the pulmo Shapiro BA. Peterson J. Cane RO: Complications of
nary vascular bed. In Pulmonary Structure and mechanical aids to intermittent lung inflation.
Function (A Ciba Foundation Symposium), edited Respir Core 27:467-470. 1 982
by AVS de Reuck and M OConnor. pp 261-272. Shim C. Bajwa S, Williams MH: The effect of inha
Little, Brown. Boslon, 1962 lation therapy on ventilatory function and expec
Ri ngrose RE. McKown B. Felton FC. Barclay BO, toration. Chest 73:798-801 . 1978
Mushmore HG, Rhoades ER: A hospilal outbreak Shrader OL. Lakshminarayan S: The effect of fiber
of Serratia marcescens associated with ultrasonic optic bronchoscopy on cardiac rhythm. Chest
nebulizers. Ann In tern Med 69:719-729, 1 968 73:821-824. 1 978
Robinson jS: Humidi fication. In Scientific Founda Siemens-Elema: Servo Humidifier J50 and 1 5 1 Op
lions of Anaesthesia, edited by C Scurr and S erating Manual. Siemens-Elema. Solna. Sweden.
Feldman, pp 488-496. William Heinemann Med 1979
ical Books, London. 1974 Sinha R. Bergofsky EH: Prolonged alteration of lung
Ruben H. Knudsen EI. Carugati G: Gastric insuffla mechanics i n kyphoscoliosis by positive pressure
tion as influenced by the pressure used during in hyperinnation. Am Rev Respir Dis 106:47-57.
termittent positive pressure venlilalion. Nord 1972
Med 6:957-959. 1961 Smeltzer TH, Barnett TB: Bronchodilator aerosol.
Sackner MA: Stale of the art-bronchofiberscopy. comparison of administration methods. lAMA
Am Rev Respir Dis 1 1 1 :62-88, 1975 223:884-889. 1973
Sackner MA: Tracheobronchial toilet. Weekly up Smith RM: Diagnosis and treatment: Nasotracheal
date. Pulm Med 1-8. 1 978 intubation as a substitute for tracheostomy. Pe
Sackner MA. Wanner A. Landa I: Applications of diatrics 38:652-654, 1966
bronc:hofiberscopy. Chesl ISuppJ! 62:70-78. 1972 Stange K. Bygdeman S: 00 moisture exchangers
Sahn SA. Scoggi n C: Fiberoptic bronchoscopy in prevent patient contamination of ventilators?
bronchial asthma, a word of caution. Chest 69:39- Acto Anoesth Scond 24:487-490. 1980
42. 1976 Stock MG. Downs lB. Gauer PK. Alster 1M. Imrey
Salisbury BC. Metzger LF. Allose MO. Stanley NN. PB: Prevention of postoperative pulmonary com
Cherniack NS: Effect of fiberoptic bronchoscopy plications with CPAP. incentive spirometry. and
on respiratory performance in patients with conservative therapy. Chest 87:151-157. 1 985
chronic airways obstruction. Thorax 30:441-446. Sukumalchantra Y. Park SS. Williams MH: The ef
1975 fect of intermittent positive pressure breathing
Sanders CV. Luby JP. Johanson WG. Barnett JA. (IPPB) in acute ventilatory failure. Am Rev Respir
Sanford IP: Serratia marcescens infections from Dis 92:885-893. 1 965
inhalation therapy medications: Nosocomial oul Surall PM. Smiddy IF. Gruber B: Deaths and com
break. Ann Intern Med 73:15-21. 1 970 plications associated with fiberoptic bronchos
Sanderson DR. McDougall IC: Transoral bronchofi copy. Chesl 69:747-75 1 . 1976
berscopy. CheSl ISuppl) 73:725-726. 1 978 Swift DL: Aerosols and humidity therapy. genera
Sands IH. Cypert C. Armstrong R. Ching S, Trainer tion and respiratory deposition of therapeutic
D. Quinn W. Stewart D: A controlled study using aerosols. Am Rev Respir Dis 1 22(2):71-77. 1 980
Sykes MK. McNicol MW, Campbell ElM: Respira of bland. mucolytic. and antimicrobial aerosols.
tory Failure. pp 1 87-192. Blackwell Scientific Am Rev Respir Dis 122(2):79-87. 1 980
Publications. London. 1976 Wanner A. Landa IF. Neiman RE. Vevaina J. Del
Thomson ML. Pavia D, Jones CJ. McQuiston TAC: gado I: Bedside bronchofiberscopy for atelectasis
No demonstrable effect of S-carboxymethylcy and lung abscess. lAMA 224:1281-1283. 1973
steine on clearance of secretions from the human Weeks DB: Evaluation of a disposable humidifier
lung. Thorax 30:669-673, 1975 for use during anesthesia. Anesthiolo8Y 54:337-
Thornton IA. Darke es. Herbert P: Intermittent pos 340. 1981
itive pressure breathing (IPrS] in chronic respi Weeks DB. Ramsey FM: Laboratory investigation of
ratory disease. Anaesthesia 29:44-49, 1974 six artificial noses for use during endotracheal
Timms RM. Harrell JH: Bacteremia related to fiber anesthesia. Anesth Ana/g 62:758-763. 1983
optic bronchoscopy. Am Rev Aespir Dis 1 1 1 :555- Weibel ER: Morphometry o/ the Human L.ung. p 139.
557. 1975 Academic Press. New York. 1963
Toremalm NG: A i r-flow patterns and Ciliary activ Wells RE. Perera RD, Kinney JM: Humidi fication of
ity in the trachea after tracheotomy. Acto Otolar oxygen during inhalation therapy. N Engl } Med
yngol 53:442-454. 1961 268:644-647. 1 963
Torres C. Lyons HA. Emerson P: The effects of in Winning TI. Brock-Ulne IG. Goodwin NM: A simple
termittent positive pressure breathing on the in clinical method of quantitating the effects of
trapulmonary distribution of inspired air. Am ) chest physiotherapy in mechanically ventilated
Med 29:946-954. 1 960 patients. Anaesth Intensive Core 3:237-238.
Van de Water 1 M . Watring WG. Linton LA. Murphy 1975
M. Byron RL: Prevention of postoperative pul Wohl MEB: Atelectasis. Phys Ther 48:472-477. 1968
monary complications. Surg Gynecol Obstet Wood RE, Fink RJ: Complications of flexible fiber
1 3 5:229-233. 1 972 optic bronchoscopes in infants and children.
Van de Water 1M: Preoperative and postoperative Chest ISuppI1 73:737-740. 1978
techniques in the prevention of pulmonary com Wu N. Miller WF. Cade R. Richburg P: Intermittent
plications. Surg Clin N Am 60:1339-1 348. 1980 positive pressure breathing in patients with
Vraciu JK. Vraciu RA: Effectiveness of breathing ex chronic bronchopulmonary disease. Am Rev Tub
ercises in preventing pulmonary complications erc Pulm Dis 71:693-703. 1955
following open heart surgery. Phys Ther 57:1 367- Zavala DC: Complications following fiberoplic
1371. 1977 bronchoscopy (editorial). Chest 73: 783-786. 1978
Walley RV: Humidifier for use with tracheotomy Zibrak JD. Rossetti P. Wood E: Effect of reductions
and positive-pressure respiration. Lancet 1:781- in respiratory therapy on patient outcome. N Engl
783. 1 956 } Mod 3 1 5:292-295. 1986
Waltemath CL. Bergman NA: Increased respiratory Zimenl I: Why are they saying bad t hings about
resistance provoked by endotracheal administra IPPB? Respir Core 18:677-689. 1973
tion of aerosols. Am Rev Respir Dis 108:520-528. Ziment l: Leller. Respir Core 19:586-587. 1 974
1973 Zimenl I: Theophylline and mucociliary clearance.
Wanner A. Rao A: Clinical indications for and effect Chest 92:38S-43S. 1987
CHAPTER 10
Undesirable Effects, Precautions,

and Contraindications of Chest
Physiotherapy
Undesirable Effects
Contraindicstions and PrecButions
Respiratory System
Cardiovascular
Gastrointestinal
Genitourinary
Hemopoietic System
Burns and Skin Grafts or Flaps
Pain
Any therapy is associated with disad precautions, and side effects that were
vantages, side effects, and contraindica routinely observed.
tions. This chapter attempts to cover the
undesirable effects, precautions during UNDESIRABLE EFFECTS
administration, and contraindications of
chest physiotherapy. During the years The undesirable effects that may po
1974-1987 chest physiotherapy was used tentially occur with chest physiotherapy
at our institution to treat over 7,000 for the critically ill patient are tabulated
critically ill trauma patients who had i n Table 1 0 . 1 . This table identifies the
multiple ailments besides trauma. The problem and when in the course of chest
additional problems included sepsis, co physiotherapy it may occur. Effects and
agulopathy, chronic and acute respira appropriate remedies or alternatives to
tory failure, and neurological, renal, prevent recurrence are suggested.
hepatic, and cardiac diseases. Some un
desirable effects were seen, and many
CONTRAINDICATIONS AND
potential problems were considered dur
PRECAUTIONS
ing this 1 3-year experience. When stan
dard therapy was not carried out, the In order to simplify reading, compre
compromises and alternatives that were hension, and information retrieval, con
used are described. This chapter is in traindications and precautions are cov
tended to illustrate the contra indications, ered i n a systematic manner.
321
Table 10.1
Potential Undesirable Effects of Chest Physiotherapy (CPT) in the Critically III Patient
Problem Effects Treatment/Prevention
During Turning
Displacement of Exsanguination, air embolus Suture and tape lines and shunts
intravenous or Lack of venous access Secure
intraarterial lines, Trauma of reinsertion
hemofiltration devices, or
shunts
Tracheal extubation Hypoxia Tape tracheal tube well, restrain
patient if necessary
Tracheal trauma from tube Tracheal stenosis alter Move ventilator tubing with patient or
movement extubation disconnect during turning
Displacement of fractures Hematoma, malalignment, Use mobile traction or an external
or joint injury pain fixator; turn patient with extremity
in neutral alignment
Open abdominal wounds or Evisceration Use abdominal binder, synthetic
dehiscence mesh: remove or treat source of
infection; therapist should be
aware of problem
Chest tube dislodgement Pneumothorax, infection Suture and tape tube adequately;
position drainage bottle to prevent
tension on chest tube
Cardiovascular and Dysrhythmia, dyspnea or Monitor carefully during and
respiratory dysfunction hypoxia following turning; increase FlO"
change ventilator settings, call a
physician; return to supine if
problem
Pain Patient distress causes Use analgesics, barbiturates,
raised heart rate, blood lidocaine, regional block,
and intracranial extradural or intrathecal narcotics,
pressures inhaled N,O, TENS, or patient
controlled analgesia (PCA); careful
handling of the patient; turn in
stages
During Segmental Drainage
Head-down position In spontaneously breathing Assume head-down position
patient, this may cause gradually; if there is distress,
respiratory distress if reduce head-down tilt and notify
there is already physician
compromised respiratory
function, distended
abdomen, or obesity
In mechanically ventilated Tracheal tube position to prevent
patient, tracheal tube kinking is shown in Figure 3.7;
may become kinked larger tracheal tube will reduce
when the patient is peak airway pressures, or the
turned or positioned ventilator pressure limit may be
prone; ventilator set higher
pressures may rise
Cardiovascular disturbance Put flat or sit up; reevaluate after
including dysrhythmia, therapeutic intervention
pulmonary edema and
hypertension
Elevation of intracranial Give barbiturate, short acting
pressure narcotic, or lidocaine
intravenously, vent CSF through
intraventricular catheter, give
diuretics, and elevate the head on
a pillow (in reference to the body)
Loss of cervical spine Secure feet to foot of turning frame
traction
322
Table 10.1 continued
Potential Undesirable Ellects of Chest Physiotherapy (CPT) in the Critically III Patient
Head-up position Hypotension, shock, Place flat, give fluids to increase

dysrhythmia cardiac filling pressures, then
intropic agents; slowly sit the
patient up
Respiratory function in the Use abdominal binder if sitting up a
quadriplegic is best with quadriplegic because respiratory
a slight head-down tilt function is compromised
Side position If patient is in a halo vest, Turn the patient more prone or place
this may dig into shoulder rolls under the vest
With pelvic injury there may Use pelviC external fixators: fracture
be displacement of bony brace provides stability and allows
fractures turning
Fractured clavicle, scapula More prone position may relieve
or humerus may be pressure on fractured scapula,
displaced, and a clavicle, or humerus; internal or
previously dislocated external fixation or fracture brace
shoulder may be on humerus may prevent
redislocated displacement
Rib fracture may puncture Chest monitoring is advisable; if
lung, causing pneumothorax develops a chest
pneumothorax tube is required
Pain when turning onto flail Pain relieved with systemic local or
chest inhaled analgesics or TENS
Major plastic surgery or Protect all operative sites; place
neurosurgery on the intravenous bag around
head and face may be craniotomy or operative site;
traumatized protect eyes, especially in
unconscious patients; monitor
increasing facial edema following
facial surgery frequently
Secretions may pass into Treat dependent lung last
dependent lung
In mechanically ventilated Limit duration of position with
patients, side-lying with bronchopleural fistula uppermost
the affected lung
uppermost increases
leakage through
bronchopleural fistula
Prone position Airway obstruction; reduced Turn head to the side or position
respiratory excursion, with a roll under forehead where
occlusion of vascular possible; rolls under chest or
lines, and disruption of across pelviS (roll may help chest
monitoring devices; injury excursion and allow function of
to eyes or operalive site vascular lines and monitoring
devices); protect eyes and
operative sites, especially in
unconscious patients
During Chest Physiotherapy
Percussion Petechiae, pain and Use systemic, local, or inhaled
fractured rib analgesics, regional, PCA, or
displacement if TENS for pain
incorrectly performed;
pathological rib fractures
may occur independent
of chest percussion
323
Table 10,1 continued

Potential Undesirable Enects of Chest Physiotherapy (CPT) in the Critically III Patient
Vibration Pain, fractured ribs, and rib The therapy should cease. and the
or thoracic spine fracture therapist should receive
displacement; tracheal instruction in correct procedure
cuff pressure rises techniques; only trained therapists
should treat critically ill patients;
patient should be investigated for
cause of rib fractures; avoid
vibration over rib fractures and in
patients with thoracic spine
fractures
Bagging Patient distress, Sedate patient or omit procedure
pneumothorax, cardiac entirely; use chest tube for
output changes; pneumothorax
increased intracranial
pressure
Suctioning May produce hypoxemia Give additional 0,; suction through a
(see Chapter 5) port adaptor; limit duration and
choose appropriate suction
catheter size
Reduction in PEEP or Many devices advocated; port
CPAP' adaptors can minimize loss of
PEEP; ventilator flow rates must
exceed suctioning flow rates;
high-frequency positive pressure
ventilation may be the most
effective prevention
Cough May cause airway closure. Usually considered an advantage in
dizziness and syncope if aiding the clearance of secretions
repetitive; raises airway, but should be used discriminately;
blood and intracranial repetitive cough may be
pressure (see Chapter 5) disadvantageous; forced
expiratory technique is an
alternative (see Chapter 3); if
cough is undesirable. prevent with
lidocaine. sedation. or muscle
paralysis
Transbronchial aspiration of Lung abscess may cause Lung abscess rupture. fatal
pus, blood, or secretions infection in opposite lung; pulmonary hemorrhage. and
pulmonary hemorrhage transbronchial aspiration of
may occur with lung secretions may occur
contusion, infection, or independently of CPT; clinical
carcinoma of bronchus examination showing deterioration
eroding into pulmonary of respiratory function and
vessels; secretions impairment of oxygenation (fall in
loosened with CPT may SaO,) should strongly suggest
pass into anatomically transbronchial aspiration; a chest
opposite and dependent x-ray and treatment to the newly
lung affected areas of suspected
aspiration should be carried out
CPAP, continuous positive airway pressure.

UNDESIRABLE EFFECTS, PRECAUTIONS, AND CONTRAINDICATIONS 325
Respiratory System gas flow during passage of a suction cath

eter through a side arm adapter are avail
Hypoxemia able. In order for any of these techniques
to minimize the loss of PEEP and not in
Chest physiotherapy may cause a fall duce atelectasis, the ventilator flow rates
in partial pressure of arterial oxygen must greatly exceed the vacuum pro
(PaO,) in neonates (Holloway et aI., 1 969; duced by suctioning, because suction is
Fox et aI., 1978), in mechanically venti applied in a closed system.
lated patients with cardiovascular insta In the hypoxemic patient, suctioning
bility (Gormenzano and Branthwaile, must be limited in duration and per
1972), and in acutely ill patients who do formed by using an appropriately sized
not produce much sputum (Connors et catheter, only when secretions are audi
aI., 1980). The use of higher inspired ox ble in the larger airways. Mechanical
ygen concentrations (FlO,) may over ventilatory support may be necessary be
come these falls in arterial oxygenation fore a hypoxemic spontaneously breath
(Kigin, 1981). Increased FlO, should be ing patient can tolerate chest phys
used, before and during chest physio iotherapy.
therapy, for patients in whom a drop in Blind nasotracheal suctioning is not
PaO, of 20 mm Hg or less would be con advocated (see pp. 1 79-180) and may re
sidered hazardous. Monitoring of arterial sult in cardiac arrest (Fineberg et al . .
saturation (SaO,) by pulse oximetry en 1960). Suctioning may cause cardiac dys
ables rapid bedside indication of hypox rhythmias, hypotension, and hypoxemia.
emia. When during chest physiotherapy, Recent evidence identifies a significant
SaO, falls below 90% (equivalent to a fall in mixed venous 0, saturation with
PaO, of about 60 mm Hg) FlO, should be suctioning. 0, consumption increases
increased. while cardiac output rises or even falls
Chest physiotherapy is used to clear with the suctioning procedure. Fall in
secretions from the airways of children cardiac output occurred when suctioning
with acute bronchiolitis. There is no clin was not accompanied by coughing. The
ical evidence of benefit (Webb et aI., fall was thought to occur due to a de
1985). Furthermore there is an anecdotal crease in intrathoracic pressure dimin
report that babies with bronchiolitis may ishing left ventricular preload (Walsh et
deteriorate rapidly during handling and aI., 1989). If this is the mechanism then
vigorous chest physiotherapy. Tracheal closed sheath suction catheters that pre
intubation and mechanical ventilation vent entrainment of air d u ring suclioning
may be required (Milner and Murray, may potentiate this effect.
1989). The effects of ventilation/perfusion
If a patient is hypoxemic (PaO, < 60 changes occurring with postural drainage
mm Hg), positive end-expi ratory pres may be reduced by shortening postural
sure (PEEP) may be used to improve in drainage time or by administration of
trapulmonary shunt. This may subse supplemental oxygen. The prone posi
quently allow chest physiotherapy to be tion is associated with improved oxygen
performed. There is a relative contrain ation (Douglas et aI., 1977; Albert et aI.,
dication to chest physiotherapy for pa 1987). When there is unilateral lung dis
tients with persistent hypoxemia that oc ease due to atelectasis or pneumonia, ox
curs despite the use of high levels of ygenation is optimized when the patient
PEEP and FlO,. Restriction of chest phys is placed with the good lung dependent
iotherapy in these circumstances should (Zack et aI., 1974; Seaton, 1979; Remolina
be considered in comparison to the ad et aI., 1981 ). However positioning the
vantages that may be gained if chest good lung down is likely to be less effi
physiotherapy is able to reverse a process cacious for other types of localized pul
that standard therapy (i.e.. PEEP) has monary disease such as bullae (Fishman,
failed to improve. 1981 ). These techniques are used during
Removal of PEEP during suctioning treatment of the hypoxemic patient.
may cause hypoxemia. Several tech Lastly, unless there is a specific indica
niques that maintain or increase inspired tion other than prophylaxis and unless
some sputum is produced, the patient l u ng; this "contre coup" effect may be
should not receive any therapy, come apparently only later.
Lung Contusion Pulmonary Hemorrhage

If pulmonary contusion is the indica There are two case reports of fatal pul
tion for chest physiotherapy, treatment monary hemorrhage associated with
should begin as soon as the patient is sta chest physiotherapy [Hammond and
bilized. In a 22-month period, 1 7 9 pa Martin, 1 979; Rasanen et aI., 1988) and a
tients with rib fractures were treated letter [Campbell, 1 980) describing a fatal
with chest physiotherapy. One hundred pulmonary hemorrhage temporally asso
and fifty of these patients [83.7%) had ciated with chest physiotherapy. All
multiple rib fractures and, t herefore, three patients had carcinoma of the lung
most probably had some degree of under and had received radiation therapy.
lying lung contusion. Over a 7-year pe Whether chest physiotherapy was re
riod 1 ,1 4 1 patients with chest injury lated to the hemoptysis is not certain,
received chest physiotherapy [see Ap since hemoptysis as a cause of death with
pendix I). Chest physiotherapy was usu bronchial carcinoma and radiation is
ally uneventful and appeared beneficial. well documented. In none of the patients
In this patient population the advantages was chest vibration given and only one
outweighed the problems. received chest percussion. All patients
The most freq uent problem occurred had hemoptysis independent of chest
in patients with copious bloody tracheal physiotherapy. It remains uncertain
secretions and severe lung contusion whether fatal pulmonary hemorrhage
who required multiple blood transfu would have occurred irrespective of
sions and developed a coagulopathy. lt chest physiotherapy. In our opinion these
may be inadvisable in these patients to reports do not justify withholding chest
posturally drain the lung contusion until physiotherapy in all patients with
hemorrhage is reduced or the coagulop hemoptysis.
athy is controlled. If postural drainage is
used, the anatomically dependent, non
Major Airway Rupture
injured lung may become filled with
blood. Therefore, the "good lung," not Major airway rupture may occur due to
the contused l ung, should be treated, blunt or penetrating trauma. This is con
keeping the contused bleeding lung de sidered by some following surgical repair
pendent with the patient supine or to be a contraindication to suctioning,
turned to the contused side. This may re coughing or positive airway pressure. It
duce the effectiveness of oxygenation of is thought that these maneuvers may
the good l u ng. In our experience nonde cause breakdown of the tracheobronchial
pendent placement of the good lung pre anastomosis. In penetrating lung injury
serves gas exchange. If the good lung is not associated with blunt chest trauma
placed down blood drains transbronchi [Fig. 1 0 . 1 A and 8), early extubation, pa
ally and gas exchange is compromised in tient mobilization, breathing exercises,
both l ungs. A double-lumen tracheal and assisted coughing are the rule. How
tube with an endobronchial cuff may be ever, the patient who sustains a tracheo
helpful i n these circumstances to prevent bronchial tear as the result of a high
spillage and allow postural drainage. speed automobile accident may have an
However, in our practice, this was only associated lung contusion and other ex
used for greater than 24 hr with indepen trathoracic injuries [Fig. IO.2A and 8).
dent lung ventilation. The potential com Management of these injuries requires
plications of airway obstruction with dis mechanical ventilation, PEEP, and vig
lodgment of the double-lumen tube and orous chest physiotherapy. Chest phys
damage to the bronchi from the endo iotherapy, if indicated, should not be
bronchial cuff should be considered. The withheld because of the possibility of de
apparently "good lung" may also have hiscence of the anastomosis. Restriction
suffered an injury similar to the contused of turning, coughing and suctioning. and
Figure 10,1, (A) Anteroposterior (AP) chest x-ray shows midline penetrating trauma. (B) Lateral
chest x-ray shows extent of penetration into lung. This patient was extubated immediately after
aortography and surgical removal of the knife. No vascular, neurological, or respiratory sequelae
persisted, and the patient was discharged from the hospital 2 days after surgery.
early extubation in the patient with A hemopneumothorax or large fluid

major blunt chest injury and a tracheo collection may make maneuvers such as
bronchial lear increase the likelihood of percussion and vibration i neffective.
anastomosis infection. Infection is Ihe Drainage of the fluid would seem worth
most common reason for dehiscence. while before percussion and vibration
are attempted. However, following a sin
Pneumothorax and Hemothorax gle treatment with chest physiotherapy
after reexpansion of an atelectasis, small
Any maneuver, such as coughing, suc effusions may reabsorb completely (Fig.
tioning, or frequent turning, that could lO.3A and B). Therefore, a treatment may
result in significant increases of airway be tried; if it is unsuccessful, the effusion
pressure is a contraindication to chest should be tapped, and if this is bloody or
physiotherapy for a mechanically venti recurrent, it should be drained. Hemo
lated patient with an unrelieved pneu Ihorax and pneumothorax may occur in
mothorax. Such patients should have a association with other chest injuries. A
chest tube placed to prevent the devel common denominator may be a fractured
opment of a lens ion pneumothorax. If. rib that punctured Ihe lung and caused
however, the pneumothorax is loculated the pneumothorax or that tore an inter
or minimal. conservative observation costal or pulmonary vessel.
may be used instead of a chest tube. In
this case, frequent clinical examination, Flail Chest
observation of ventilator airway pres
sures, and monitoring with serial chest x Should physical maneuvers be per
rays and pulse oximetry are indicated. If formed on the patient with a flail chest?
the pneumothorax remains stable on this Displacemenl of fractured ribs occurs
regimen, chest physiotherapy is not during inspiration, expiration, and turn
contraindicated. ing. The rib displacement that occurs
Figure 10.2. (A) Admission supine
portable AP chest xray after inser
tion of a right-sided chest tube for
tension pneumothorax sustained in
a high-speed motor vehicle acci
dent. This patient had a severe
right upper lung and midlung field
contusion, hemothorax, fractured
ribs 2-6, and a torn right main stem
bronchus. Massive subcutaneous
emphysema outlines the thoracic
musculature and the mediastinum
and ascends into the neck. This pa
tient also had multiple facial frac
tures, dislocation of the right hip,
and fractures of the left tibia and
fibula and right ankle. He required
mechanical ventilation for 5 days
after repair of the torn bronchus.
(8) Twelve days after injury the
chest x-ray showed resolution.
During this time the patient re
ceived chest physiotherapy. One
therapeutic bronchoscopy was
necessary to remove a blood clot
after suctioning was restricted. Fol
lowing this episode, standard chest
physiotherapy techniques were
reinstituted.
,NI',A'TE'1
1'0;,- "Y'o'T>iE."" p t
Figure 10.3. (A) AP erect portable chest x-ray shows atelectasis of the basal segments of the left
lower lobe. There is loss of the left hemidiaphragm shadow and a pleural effusion at the left base.
(8) After chest physiotherapy and reexpansion of all but the posterior basal segment atelectasis,
the lateral two-thirds of the left hemidiaphragm and the left costophrenic angle become visible. The
pleural effusion has reabsorbed.
328
during coughing, defecation, sitting up, tain a clear chest. Does chest physiother
and lying down may be considerably apy cause rib fractures? One report in a
more than can be achieved with appro neonate with hyaline membrane disease
priate percussion and vibration. Con suggests that percussion of the chest was
trolled positive pressure mechanical ven a probable additive or singular cause of
tilation was introduced for internal rib fractures (Purohit et a I . , 1975). How
pneumatic stabilization of the nail chest ever, rib fractures are known to occur
(Avery et aI., 1956). However, there are with hyaline membrane disease indepen
now many advocates of intermittent dent of chest physiotherapy (Burnard et
mandatory ventilation (IMV) who suggest a I . , 1965). Pathological rib fractures in
that this is more physiological because of adults are associated with secondary car
the substmospheric intrathoracic pres cinoma, myeloma, and chronic cough.
sure associated with the spontaneous
breath. Although the spontaneous breath Chest Tubes and Subcutaneous
may have advantages in aiding cardiac Emphysema
filling, for the patient with nail chest it
results i n considerable rib displacement Chest tubes are not a contraindication
(Shin et a I . , 1979a). This is impressively to chest t herapy; i n fact, they usually in
demonstrated in Figure 10.4A-C. Venti dicate that the patient has a respiratory
lation with pressure support is a means problem and may benefit from chest ther
of preventing the subatmospheric intra apy. Care should be taken when turning
thoracic pressures that caused such in such patients to prevent the tube from
ward rib displacement as shown in Fig becoming dislodged or kinked. Chest
ure 10.4. tubes should be sutured in place and
There are numerous other maneuvers taped to the chest wall and the drainage
that the patient carries out, or that are bottle should be positioned to prevent
part of the daily routine of nursing pro tension on chest tubes. If the tube slips
cedure, that cause some, if not more, rib out, subcutaneous emphysema or a
displacement than does chest physio pneumothorax may result. A pneumo
therapy. No one would dispute that the thorax may also occur i f a chest tube be
jagged edge of a fractured rib sticking comes disconnected from its underwater
into the lung is hazardous, but the addi seal. All connections should be made
tional hazard associated with correctly with plastic adaptors and should be
performed percussion is grossly over wired and taped in place. Subcutaneous
rated. When correctly performed by a air may occur following rupture of a
trained therapist, percussion is not force small airway. This may be a relatively
ful, because of the air trapped in the common finding d u ring mechanical ven
cupped hand. However, novice therapists tilation, especially if the patient is out of
and non therapists may perform percus phase with, or "fighting," the ventilator.
sion incorrectly; this should be avoided, Subcutaneous air may be a precursor of
especially in patients with nail chest. pneumothorax and may appear in the
Therefore, percussion should be carried mediastinum, in the neck, or beneath the
out by a trained therapist. When lung diaphragm (Macklin and Macklin, 1944).
contusion accompanies nail chest, per It is not, however, a contraindication to
cussion may be most beneficial, since it chest physiotherapy, provided that there
is frequently the lung under the rib frac is no pneumothorax present. Chest phys
tures that requires the therapy (Fig. iotherapy may be effectively carried out
10.5A-C). Vibration is a more forceful despite subcutaneous emphysema, with
maneuver; since the chest wall is manu no apparent i ncrease i n crepitus or radi
ally compressed, it should not be per ological evidence of air (Ciesla et aI.,
formed over rib fractures. For the spon 1981 ).
taneously breathing patient who has rib
fractures with little underlying lung in Empyema
jury, pain relief and breathing exercises
with supportive coughing and ambula Empyema may result from an inade
tion may be all that is required to main- quately drained pleural cavity, an under-
Figure 10.4. (A) This AP erect portable chest x-ray taken on admission after a motor vehicle ac
cident shows multiple left rib fractures. a left lung contusion. and a left clavicular fracture. The
patient is intubated and receiving controlled mechanical ventilation. (B) The patient was placed on
IMV 24 hr after admission. This AP erect portable chest x-ray was taken after 4 hr of IMV, when
the mandatory rate was 6 breaths/min. During the 4 hr, the patient showed paradoxical movement
of the left chest wall but maintained adequate arterial blood gases. (C) The patient had a trache
ostomy performed and was placed on controlled mechanical ventilation. This chest x-ray shows
chest wall reexpansion which took place within 4 hr of reinstitution of controlled mechanical ven
tilation. [Figure 10.4A-C is from a presentation by B. Shin et al. (1979a) at the Eighth Annual Meet
ing of the Society of Critical Care Medicine, May 1979.)
lying pneumonia or a bronchopleural fis loculations should be searched for and

tula. For treatment of this condition, a drained. If adequate drainage cannot be
chest tube, or empyema tube (as it is fre obtained or if pleural thickening pre
quently called), may stay in position for vents adequate lung reexpansion, decor
weeks rather than days and is often not tication may be indicated. Chest physio
connected 10 an underwater seal. Ade therapy is not effective if the pleura is
quate drainage is imperative; therefore, grossly fibrotic and thickened.
Figure 10.5. (A) Admission AP supine portable chest x-ray shows fractured left clavicle and ribs
2-11. There is also a left pneumomediastinum, most visible around the aortic knob. A left lung
contusion is apparent underlying fractured ribs 5-7. (8) A left lower lobe basal segment atelectasis
developed the day after admission, and the patient became hypoxemic despite controlled mechan
ical ventilation and routine turning and suctioning. A left chest tube was placed, but the pneumo
mediastinum persisted. A pulmonary artery catheter was placed to exclude cardiac causes for de
teriorating pulmonary function (see C). (C) Chest physiotherapy, including postural drainage,
percussion, coughing, and tracheal suctioning, was carried out despite the clavicular fracture, mUl
tiple rib fractures, pneumomediastinum, and detriorating pulmonary function. This chest x-ray was
taken within 12 hr of a single treatment with chest physiotherapy and shows clearance of the left
lower lobe atelectasis and radiological improvement of the left lung contusion. Respiratory function
improved, and the patient was extubated 5 days after admission.
Lung Abscess out to be the approach of choice to re

duce bronchopleural pressure differ
A loculated empyema may rupture ences and allow rapid healing. Several
into the airway or a traumatic cyst a t the authors have suggested reducing the leak
center of a lung contusion may become from the fistula by applying positive pres
infected. Lung abscess is also associated sure equally through the tracheobron
with pneumonia, pulmonary malig chial tree and a chest tube. (Downs and
nancy, and tuberculosis. Rupture of a lo Chapman, 1976; Gallagher et a\., 1976;
calized abscess is preceded by blood Powner and Grenvik, 1981).
staining of the sputum. Abscesses may
rupture spontaneously and result i n
coughing w i t h expectoration o f large Extrapleural Hematoma
quantities of pus. If rupture occurs i n as Extrapleural hematomas associated
sociation with chest physiotherapy spill with rib fractures or chest wall injury
age may occur into the opposite lung re commonly may overlie damaged lung.
sulting in a spread of infection (Rasanen Restriction of therapy to other areas of
et a\., 1988). If transbronchial aspiration the chest prevents treatment of the lung
of infected material occurs the depen most likely to benefit. Chest physiother
dent lung opposite the abscess should be apy is often cited as a cause for extra
managed with chest physiotherapy in pleural hematoma associated with rib
cluding postural drainage. fractures. In our experience chest phys
iotherapy does not increase the inci
Sronchopleural Fistula dence of extrapleural hematomas and
need not be withheld. Twenty-four of
Chest physiotherapy may be carried 252 patients with rib fractures had extra
out despite a bronchopleural fistula. By pleural pathology diagnosed by chest x
reexpansion of atelectatic lung around a ray. In 10 this was noted before chest
fistula, closing of the fistula may be has physiotherapy and in 14 after 3 1 3 chest
tened. If the fistula is acute, drainage of physiotherapy treatments. There was no
lung secretions may abort infection. statistical difference in the incidence of
However, in mechanically ventilated pa extrapleural bleeding, pneumo- or he
tients, prolonged periods of postural mothorax, or displacement of rib frac
drainage with the fistula uppermost in t ures before and after chest physiother
crease the leakage through the fistula and apy. There was also no difference in the
may result in a sudden rise i n PaCO,. changes occurring with chest physiother
This occurs when the patient is lying on apy whether the patients had single or
the normal lung, because the upper lung multiple rib fractures. (Ciesla et a\., 1988,
is preferentially ventilated with positive personal communication). Therefore, un
pressure ventilation, as it has a higher less the extrapleural hematoma is ex
compliance. In patients ventilated with panding (when percussion or vibration
PEEP, the reduction i n alveolar ventila may stimulate further bleeding) or the
tion and increased fistula leak may be patient has a coagulopathy, chest phys
particularly troublesome. Chest therapy, iotherapy need not be restricted. Novice
while the fistula is uppermost. should be therapists and non therapists should not
carried out provided secretions are ob treat these patients, as i ncorrect applica
tained. Since the patient is usually tion of manual external chest pressure
n u rsed supine or with the unaffected must be avoided.
lung uppermost, it is essential that the
lungs be kept clear of secretions. The Cardiovascular
newer methods of mechanical support,
Cardiac Failure
such as pressure support, airway pres
sure release (Stock et a\., 1981), and in For patients in whom there is doubt
verse ratio ventilation (Willats, 1985), about the diagnosis of cardiac failure, as
high frequency oscillation (Butler et a\., sessment of reserve cardiac function may
1980) or ventilation (Carlon et a\., 1979a; be made before chest physiotherapy is
Sjostrand and Eriksson, 1980), may turn performed. This can be achieved by leg
raising, inAation of MASTrousers, or observed immediately on occurrence, as

rapid Auid infusion sufficient to raise car a diminution i n the wave form of an ar
diac filling pressures greater than 2 mm terial pressure tracing. Provided me
Hg above baseline. If "Aat" ventricular chanical damping is excluded, the de
function curves are obtained, cardiac crease in pulse pressure should be
contractility may be improved by inotro treated by ceasing the stimulus, placing
pic agents or reduction of systemic vas the bed horizontal, placing the patient
cular resistance, before placing the pa supine, and taking appropriate phar
tient in the head-down position for macological action. Pharmacology may
postural drainage and chest physio include increased inspired oxygen con
therapy. centrations as the initial step before an
Patients in borderline cardiac failure tiarrhythmic drugs. Sitting the patient up
should be observed very carefully during decreases cardiac filling pressures and
chest physiotherapy. They are frequently may assist the return to sinus rbythm for
monitored with intravascular catheters, the patient i n cardiac failure.
as well as electrocardiogram (ECG) and With a 3 Ilg/kg continuous infusion of
pulse oximetry when in the intensive fentanyl, cardiac output rose 20-25%
care unit (ICU). In our institution in the above baseline values during chest phys
past 13 years over 1,300 patients with iotherapy. Without analgesic infusion
some degree of heart failure were moni cardiac output rose 50%. 0, consumption
tored with pulmonary artery and arterial and CO, production i ncrease during
indwelling catheters and also received chest physiotherapy. The rise in blood
chest physiotherapy. Although dysrhyth pressure and heart rate that occurs when
mias rarely occurred during percussion no a nalgesic is given is attenuated by fen
or vibration, some of these patients be tanyl infusion (Klein et a!., 1988). In our
came tachycardic or bradycardic or opinion these changes are not an indica
noticeably cyanotic in the head-down po tion to withhold chest physiotherapy in
sition. The detrimental effects of the patients with cardiac dysfunction be
head-down position on cardiorespiratory cause these are often the very patients
function for patients with impaired car who can least tolerate respiratory com
diac function may be diminished by ino promise. Baseline values of cardiac func
tropic drugs, reducing the duration of tion return within 15 m i n of ceasing
postural drainage, or by support with chest physiotherapy (Mackenzie and
controlled mechanical ventilation and Shin, 1985; Klein et a!., 1988). The appro
PEEP. In this sort of patient, others be priate management includes use of anal
lieve that the desired effect of chest phys gesia and sedation to reduce the adverse
iotherapy may be obtained with the cardiovascular and metabolic affects of
patient Aat (B. A. Webber, personal com chest physiotherapy.
munication). Bradycardia is seen with
suctioning i n patients with borderline Pulmonary Edema
cardiac failure. The hazards of suctioning
are fully described i n Chapter 5. In the The patient with borderline cardiac
last 5 years use of pulse oximetry has en failure or impaired cardiac function can
abled direct feedback of detrimental ef usually tolerate chest physiotherapy in
fects on SaO, of maneuvers such as head the head-down position if the above pre
down positioning and suctioning. If sat cautions are taken. If, however, the pa
uration falls below 90% the intervention tient cannot tolerate the head-down po
should cease. Inspired 0, is increased to sition because of severe cardiac failure
allow therapy to continue. and pulmonary edema, this should be
During physiotherapy treatment of pa avoided. There should be a definite re
tients with impaired cardiac function, striction of tracheal suctioning. The more
the therapist should continually observe suctioning that is performed, the more
the ECG, intravascular pressures, and surfactant and protein are lost in the
SaO,. Development of a dysrhythmia is edema Auid. It is a vicious circle. Surfac
visible on the ECG and frequently dimin tant loss allows small airways to close,
ishes cardiac output; this may readily be increasing secretion retention and the in-
dication for chest physiotherapy. Acute associated with dysrhythmia. Since myo
cardiac failure needs treatment directed cardial perfusion occurs mostly during
at decreasing cardiac preload or afterload diastole, maneuvers that cause tachy
or increasing cardiac contractility. Be cardia reduce coronary perfusion and
cause of loss of sympathetic innervation should be avoided, where possible, in the
to the heart and peripheral vasculature, patient with coronary artery disease. If,
patients with acute cervical spinal cord for example, the patient becomes tachy
injury may be unable to increase cardiac cardic after 1 5 min in the head-down
contractility in response to elevation of position, rather than persisting in
cardiac filling pressures (Mackenzie et order to complete the treatment, the
aI., 1985). Pulmonary edema is a common therapist should elevate the head of the
cause of death during spinal shock and bed. The therapy may be finished later
may be precipitated by head-down posi when heart rate has slowed or the
tioning that may elevate central venous patient has received sedation, such as
pressures. Patients with acute spinal cord morphine.
injury who are positioned head down
should be monitored for signs of pulmo
Myocardial Contusion
nary edema.
Pulmonary edema may occur second Myocardial contusion is a commonly
ary to noncardiac as well as cardiac touted but rarely proved diagnosis in the
causes. Therefore, not all pink frothiness living, traumatized patient. In 1 7 3 con
seen on suctioning is caused by fluid secutive patients who died following di
overload or inadequate cardiac function. rect helicopter admission from road ac
The most frequent cause of noncardi cidents to a trauma unit 1 7 had some
ogenic pulmonary edema seen in the degree of myocardial contusion (Macken
trauma patient is I ung contusion. Chest zie et aI., 1979). The significance of myo
physiotherapy is indicated to treat lung cardial contusion remains unknown. De
contusion, and suctioning need not usu spite ECG and cardiac enzyme changes
ally be restricted because the edema suggestive of myocardial contusion,
is localized, not generalized. Massive Technetium-99m scans in 1 2 trauma
bleeding from an associated lung lacera patients did not demonstrate any abnor
tion or a major coagulopathy may, how mality (A. Rodriguez, personal com
ever, contraindicate chest therapy and munication). Sutherland and colleagues
suctioning. The lung laceration may re ( 1 98 1 ) report that radionuclide angiog
quire bronchoscopy (although frequently raphy is the diagnostic tool of choice.
nothing can be visualized because of all During chest physiotherapy these pa
the blood) and operation. The coagulop tients are not treated any differently
athy requires correction with blood prod from those patients with impaired car
ucts. Other noncardiogenic causes of pul diac function.
monary edema include nitrogen dioxide
inhalation, high inspired oxygen concen Ruptured Aorta
tration, heroin overdosage, and high-al
titude pulmonary edema. These and Traumatic rupture of the aorta may
other causes are fully described else occur secondary to rapid deceleration in
where (Fishman, 1 980). automobile accidents. At our institution
If cardiac failure and pulmonary an average of 5 patients/year have been
edema develop during therapy, sitting diagnosed, with a reported survival rate
the patient up and PEEP (in the already of 75% (27/36) (Ayella et aI., 1977). There
tracheally intubated patient] are the im is again no contraindication to chest
mediate bedside therapies of choice. physiotherapy following repair, provided
monitoring equipment is appropriately
observed during maneuvers that may
Myocardial Ischemia
cause cardiovascular disturbance, such
Myocardial ischemia or infarction as acute position change and tracheal
commonly reduces cardiac output and is suctioning.
Pulmonary Embolus improve the prognosis. Prevention of

chest complications in this group of pa
Pulmonary embolus is reported to tients is of great importance. Despite all
occur frequently following long-bone or the intracranial pressure monitoring, hy
pelvic fractures. lt may present as either perventilation, intracranial pressure re
the results of fat embolization or as acute ducing drugs, and maneuvers, unless ad
cardiovascular collapse from emboliza equate lung function is maintained,
tion of a massive thrombus. Clinically, cerebral outcome may be jeopardized in
significant embolization may not always the important group of patients with
occur. In our experience it was ex head injury who survive.
tremely rare. Considering the patient The great recent advance in the treat
population studied, it was not a frequent ment of the patient with cerebral contu
cause of death. Only 1 pulmonary embo sion was the use of intracranial pressure
lus was identified in 1 24 consecutive full monitoring. Previously, therapy was
autopsies of patients who died following withheld that might, in some circum
motor vehicle accidents (Mackenzie et stances, be thought to affect cerebral per
al.) Conventional autopsy studies in in fusion adversely. Now, with the intelli
tensive care unit patients report an inci gent use of the intracranial pressure
dence of 9-27% of pulmonary emboli monitor. therapy can be tailored to its ef
(pingelton, 1988). Pulmonary thrombi fect on cerebral perfusion. The patient
also occur and confuse the diagnosis. De may no longer need to be dehydrated, to
spite the availability of lung scans and the detriment of the kidney and ciliary
pulmonary angiograms the diagnosis of activity of airway m ucosa. Barbiturates
pulmonary embolus is difficult. In 5 years may be given more discriminately to only
(1975-1980) only 2 patients of 3 , 2 1 0 con those patients with perSistently high in
secutive trauma admissions were seen tracranial pressure. Chest physiotherapy
showing the classic signs of fat embolus. with the head-down position may be
The possibility of precipitating throm used allowing clearance of retained se
bus or fat embolization by chest physio cretions. During 1 979-88 1 ,684 patients
therapy and turning seems, in our expe with head injury received chest physio
rience, remote. In fact, this low incidence therapy. Of these 720 (42.7%) patients re
suggests that the aggressive approach quired intracranial pressure monitors.
with early mobilization may be a possible Over 90% of these patients had lower
mechanism preventing pulmonary em lobe problems that required a head-down
bolus. position for postural drainage and ther
apy. Intracranial pressure monitoring en
abled this to be carried out while allow
ing any resultant compromise in cerebral
perfusion to be observed and, therefore,
Cerebral Contusion
rectified (see Figs. 8.4 and 8.5).
The most common pathology of the Sixteen patients with pulmonary com
central nervous system found i n trauma plications and severe head injury (aver
patients is cerebral contusion. Forty age Glasgow Coma Scale = 5 ) had resting
seven percent of 1 73 deaths from road ac ICP sitting up of 1 5 mm Hg and were ran
cidents occurring in a 2-year period were domly assigned to head-down (HD) or nat
due to head injury (Mackenzie et al.). (HF) positioning for CPT (Imle et a I . ,
The distressing factor associated with ce 1 988). Although ICP rose during 1 5 min
rebral trauma is that the damage is fre of CPT while both HD and HF, cerebral
quently irreversible despite appropriate perfusion pressure (CPP) was not differ
therapy. Use of predictors of outcome, ent. There were no differences in heart
such as the Glasgow Coma Scale (Jennett rate, mean arterial pressure, or end-tidal
et aI., 1976) and the Maryland Coma CO, after CPT. CPT while H D does not
Scale (Saleman et a I . , 1981 ), are impor result in decreased CPP despite the in
tant in order to determine those patients creased ICP because of cerebrovascular
in whom aggressive treatment is likely to autoregulation. CPP (mean arterial BP-
ICP) is a more clinically relevant monitor can be improved by placing pillows or

of the cerebral effects of CPT than simple rolls across the anterior iliac crests and
measurement of ICP. Perfusion and chest enlarging the hole in the canvas of the
vibration were not found to adversely af Stryker frame to allow free movement of
fect ICP or CPP in this study. the diaphragm and dependent abdomen.
Suctioning should be carried out with
Cerebrospinal Fluid (CSF) Leak monitoring of ECG and SaO, (by pulse
oximetry). Tracheal suctioning in a pa
A CSF leak due to a dural tear may be tient in the prone position on a Stryker
a relative contraindication to the head frame is an acrobatic achievement per
down position for chest therapy. Leakage formed kneeling; this may not allow the
implies decompression of any intracra monitors to be seen by the person
nial pressure elevation, but if the leakage suctioning.
increases during the head-down position Despite all these precautions, attention
and persists at a higher rate despite head to respiratory therapy on a prophylactic
elevation, the dural tear was most prob basis is of the utmost importance in re
ably reopened. CSF leaks may be associ ducing early mortality in quadriplegic
ated with facial injury and skull fracture. patients (Fugl-Meyer, 1 976; McMichan et
Leakage may occur through the ear, the a!., 1 980) (see Chapter 8). For the paraple
nose or an open fracture. If leakage con gic patient in whom prognosis is more
tinues, operative closure of the dural tear likely to be favorable and chest compli
may be required. cations less common, chest physiother
apy is usually applied only when specif
Spinal Cord Injury ically indicated. With functional arm
movement, the abdomen can be com
Cervical spinal cord transection causes pressed by the high paraplegic, greatly
interruption of the autonomic nervous enhancing the effectiveness of coughing.
system and loss of motor function below If treated on a Stryker frame initially, pa
the level of the spinal cord injury. This tients with cervical spine injury and no
disturbs the normal compensatory car neurological deficit can often be mobi
diovascular reflexes because of loss of lized by means of a halo vest or other
sympathetic nervous system control over type of orthopedic stabilization. Because
the heart and peripheral circulation. of the early mobilization allowed by sur
Quadriplegia also results i n impairment gical fusion or external stabilization, res
of respiratory function. Chest physio piratory problems may be prevented.
therapy in a quadriplegic patient must, However, if the orthotic device restricts
t herefore, be performed with caution, chest excursion it may lead to secretion
since acute postural changes may precip retention. Some patients with thoracic
itate cardiac decompensation and cause spine injury may require prolonged bed
acute pulmonary edema or profound hy rest. Nonetheless, these patients may be
potension. Acute pulmonary edema is a instructed in breathing exercises and can
commonly reported cause of death i n be log-rolled to allow appropriate chest
acute quadriplegia (Meyer e t a ! . , 1 97 1 ). therapy when required. Most thoracic
Suctioning is also reported to be a haz spine injuries are inherently stable and
ardous procedure in the acute quadriple allow the performance of chest physio
gic (Welply et a!., 1 975). In our experi therapy. However, an unstable thoracic
ence of treating 51 patients with cervical spine injury is considered to be a contra
spine injury during 15 months, there indication to vigorous chest vibration.
were two deaths that occurred during
suctioning of quadri plegic patients when
Surgical Procedures about the Head
they were in the prone position on a Stry
ker frame. Both instances occurred at Patients with a craniotomy and re
night in the step-down unit when the pa moval of bone flap should be carefully
tients were in their recovery phase. Tol positioned during turning and head
erance of the prone position in sponta down tilt. The edges of the surgical area
neously breathing quadriplegic patients should be supported. A 500- or 1 ,000-ml
plastic infusion bag may be used (see Fig. prevent evisceration if the abdomen is
3.13). Ear injuries or major plastic surgi open or the dehiscence is infected and
cal repairs around the head and neck draining. Turning and posturing for chest
should be supported similarly if the area physiotherapy can then be achieved (Fig.
might be traumatized during positioning; 10.6).
this protection is especially important
when treating the unconscious patient Tracheoesophageal Fistula
and should include measures to prevent
damage to the eyes when the patient is In order to prevent leakage and allow
turned from the supine position. Simi adequate alveolar ventilation, overinfla
larly, care should be taken when turning tion of the tracheal tube cuff may be un
and positioning patients with skin grafts avoidable i n mechanically ventilated
or flaps or those with extensive burns. patients with increased dead space, car
Chest percussion and vibration are con bon dioxide production, intrapulmonary
traindicated over recent plastic or skin shunt, and PEEP. Carbon dioxide excre
graft procedures. A sterile drape should tion capabilities of the lung may be con
cover chest burns to prevent contamina siderably compromised in the critically
tion during chest physiotherapy. ill patient by hyperalimentation (Kinney
et aI., 1980). Because of tracheal cuff
overi nflation, causing compression of the
GastrOintestinal
esophagus, tracheoesophageal fistula
may occur during prolonged intubation.
Dehiscence
This should not restrict chest physiother
Dehiscence of an abdominal wound oc apy even in the critically ill patient;
curs as a complication after surgery. The rather, attention to optimizing respira
precipitating faclors causing dehiscence tory function should be mandatory. It is
include diminished healing due to mal our experience that bronchoscopy is ex
nutrition, age, use of corticosteroids, in tremely hazardous in patients who re
adequate surgical technique, obesily, di quire PEEP greater than 15 cm H20 and
abeles, infection, or hemorrhage in lhe have low lung compliance (Mackenzie
wound (Schwartz, 1979). Coughing is a and Shin, 1988). This is not, t herefore, a
possible mechanical cause of early dehis reasonable alternative to chest physio
cence. However, chest physiotherapy therapy for such patients with a tracheo
should nol be restricted, nor is it with esophageal fistula.
held even when dehiscence has oc In order to prevent continued aspira
curred. Mechanical means, such as bind tion of secretions, palliative occlusion of
ers and synthetic mesh, can be used to the lower and upper esophagus and a gas-
Figure 10.6. This obese diabetic patient developed peritonitis, abdominal wound dehiscence, and
left lower lobe atelectasis. Evisceration was prevented by the abdominal binder. The patient is
shown positioned for chest physiotherapy treatment.
trostomy may overcome the immediate used at our institution prior to 1979. This
problem until respiratory dysfunction did not deter turning when required for
can be rectified and any precipitating fac a specific respiratory problem. Turning
tors treated. In the critically i l l patient a without external stabilization was not
definitive repair must be delayed. knowingly associated with increased he
matoma, stimulation of bleeding, or any
urethral damage. There were no in
Abdominal Distension
stances of hematuria after turning for
Major abdominal distension or gross chest physiotherapy, and no patients had
obesity may compromise respiratory marked changes in vital signs, or hemat
function in the spontaneously breathing ocrit, or went into shock during or after
patient. Respiratory dysfunction may be therapy. Most pelvic fractures are rela
further aggravated in the head-down po tively stable and self-supported. This
sition. Because of unfavorable changes i n clinical impression of stability is con
diaphragmatic a n d chest wall function firmed by the considerable amount of
due to abdominal distension and gross traction that is often required to alter the
obesity, tracheal intubation and mechan displacement of a fracture, during appli
ical ventilation are often required to as cation of the external pelvic fixators, de
sist lung expansion and prevent devel spite a highly favorable mechanical ad
opment of atelectasis. vantage from an intramedullary pin into
Generalized edema secondary to alter the ileum.
ations in capillary permeability may pro
duce edema of the abdominal wall and Renal Dialysis
bowel. I t may also cause peritoneal effu
sion. Mechanical ventilation would be Renal dialysis can cause considerable
the treatment of choice for these patients, shifts in intravascular volume. Reports of
and the obese patient with Pickwickian hypoxemia during dialysis have ap
syndrome rather than assisted respira peared. Explanations include loss of car
tion. This would be instituted before bon dioxide through the dialysate mem
chest physiotherapy in the head-down brane, which significantly decreases the
position. Similarly, quadriplegic patients respiratory quotient (Aurigemma et aI.,
who develop abdominal distension 1 977), ventilation/perfusion changes,
should be decompressed by an endogas and diffusion abnormalities related to
tric tube and receive mechanical venti leukoagglutination (Carlon et aI., 1979b).
latory support before postural drainage of The experience in our institution is fre
the lower lobes. quently the reverse. PaD, is noted to in
crease during dialysis. Aggressive fluid
therapy, which has reduced the inci
Genitourinary
dence of acute renal failure and has in
creased nonoliguric renal failure (Shin et
Pelvic Fracture
aI., 1979b), results in fluid overload in
The association of pelvic fracture and a those patients who require dialysis. The
bladder injury may in some centers con improved respiratory function, during
traindicate turning of the patient. The and following dialysis can be explained
use of external fixation ( Hoffmann, 1954) by fluid removal from the lungs. Chest
to the displaced pelvis allows turning but physiotherapy is indicated when respi
may hinder prone positioning. Alterna ratory function warrants treatment and
tively, patients with pelvic fractures may may be given during dialysis when the
be log-rolled, placed in MASTrousers, a dialysate is draining from the abdominal
fracture brace, or transferred to a turning cavity. It should not be performed in the
frame. In a 7-year period 4 1 7 patients re head-down position, when severe ab
ceived chest physiotherapy despite a dominal distension occurs. The head-up
fractured pelvis (Appendix I). In less than position is contraindicated if volume de
5% of patients were any turning restric pletion results from hemodialysis. In the
tions ordered. Pelvic traction was not unstable patient. chest physiotherapy
can be carried out after dialysis is com these desirable assets and allows more
pleted and coagulation and intravascular complete mobilization by altering the
volume have returned to normal. point of suspension of the cast during
turn ing. The use of a halo vest, i n a
Musculoskeletal System patient with cervical spine injury with
out neurological deficit, also allows
Multiple Trauma turning to both sides for postural
drainage and mobilization, neither of
Conflicting therapeutic aims inevitably which can be achieved with a turning
occur i n a patient with multisystem frame.
trauma. What is the ideal treatment for These alternatives enable more satis
one system may compromise another; factory treatment to be given to patients
this is the case with musculoskeletal in immobilized because of bony fractures.
jury. While immobilization is the ideal This is a major advance in respiratory
way to obtain good bony union after sat care for the trauma patient, since bony
isfactory reduction is achieved, it impairs fractures are a common problem. In a 7-
respiratory function (see Chapter 6). As year period 2,029 (30%) of 6,697 trauma
in any situation when multisystem dis patients had peripheral bony fractures
ease occurs, priorities must be estab (excluding skull, rib and facial bones)
lished to determine which problem is po and were treated with chest physiother
tentially the most life-threatening to the apy in the critical care recovery unit. Of
critically ill patient. I t is not considered these patients 70% had more than one
good therapeutics for the patient with system injured (e.g., in addition to pe
fractures maintained i n perfect align ripheral bony injury, there was head,
ment to die of pulmonary complications chest. or abdominal injury). Injury sever
following immobilization; rather, a com ity scores of trauma patients receiving
promise must be reached. chest physiotherapy are shown in Ap
In instances in which a patient has an pendix I. Because of the successful use of
isolated bony injury and atelectasis, ther alternative techniques, less than 2% had
apy includes postural drainage and posi any turning restrictions imposed. Turn
tioning. This may be limited by the re ing restrictions were ordered only i f the
straints of traction and casts. Percussion, orthopedist felt bony alignment was un
vibration, and breathing exercises may acceptably displaced during turning and
be carried out with patient cooperation. the patient's respiratory condition was
However, when the patient is uncon not life-threatening. Similarly, although
scious, has multiple bony injuries, and is osteoporosis of the spine or ribs requires
suffering from severe acute lung prob that percussion and vibration be per
lems requiring high FlO, and PEEP, im formed with caution, this compromise
proved positioning must be obtained to must be weighed against the necessity for
allow effective chest physiotherapy. If chest physiotherapy.
this is not possible, alternative methods In 7 years, 1 981 -88, 380 patients had
must be employed. external fixators used instead of casts;
Better positioning may be achieved by the majority were applied to tibial frac
altering the means of joint immobiliza tu res. In the same period, 736 patients
tion. Immobilization by means of exter with other orthopedic fixation devices
nal fixators (see Fig. 3 . 1 5 ) enables a pa required chest physiotherapy. The other
tient to be turned into all postural devices included Neufeld traction (5%),
drainage positions despite bilateral long internal fixation (41%), spinal rods (7%),
bone fractures. These positions would be and skeletal traction (13%), including
impossible to achieve with orthodox traction through a Steinmann pin and
splints and traction. If traction needs to Bucks traction or a combination of exter
be used, a more mobile device allows nal fixators and skeletal traction. These
more complete turning; therefore, more alternative traction techniques enabled
ideal postural drainage positions can be more complete mobilization of the pa
achieved. Neufeld traction has many of tient and allowed turning into appropri-
ate postural drainage positions for chest ulation correction can be achieved. This,
physiotherapy. however, frequently becomes a vicious
The alternative compromise to not circle, since bleeding within the tracheo
using chest physiotherapy was to use bronchial tree may lead to acute atelec
some other treatment to clear retained tasis and result in a need, and a specific
secretions from the l u ngs. The most often indication, for chest physiotherapy. In
considered alternative was bronchos this case, postural drainage, percussion,
copy. Some of the advantages and disad vibration, and assisted coughing with
vantages of bronchoscopy are considered limited tracheal suction are used. When
in Chapter 9. Other alternatives, such as precipitation of bleeding during turning
incentive spirometry, paper coils, and is considered a possibility, turning for
blow bottles, have no application in the chest therapy may coincide with some
unconscious or mechanically ventilated other necessity, such as changing bed lin
patient and are of unproven value in ens or relief of pressure areas. Vigorous
comparison to deep breaths i n spontane percussion, in the presence of an expand
ously breathing patients. Circulomatic ing extrapleural hematoma and rib frac
and kinetic beds were occasionally used tures, is contraindicated in patients with
as a preventative means but remain un a coagulopathy.
proven in effectiveness and value in Transbronchial aspiration of blood
clearing pulmonary secretions (see pp. from unilateral lung pathology into an
109 to 1 1 7). otherwise normal lung during chest
physiotherapy should be managed by
Hemopoietic System
giving chest physiotherapy to the normal
lung at the end of therapy. Varying de
Precautions observed during chest grees of pulmonary hemorrhage may
physiotherapy for patients with hemo occur from hemoptysis to copious frank
poietic disease relate to the care with blood. At all times a cause for hemoptysis
which the patient must be handled so should be determined. If frank hemor
that bleeding is not precipi tated. Coagu rhage occurs, bronchoscopy or surgery
lopathy is the most common hemopoietic may be required.
problem seen in a trauma unit (perhaps
also in the average surgical ICU). In the Burns and Skin Grafts or Flaps
trauma patient this is frequently due to
thrombocytopenia. When the platelet Chest physiotherapy may be indicated
count falls below 30,000, problems are in patients with chest burns. Care should
likely to be encountered. However, if be taken to avoid contamination of the
platelet malfunction is present, even burned area. During the acute stage the
higher levels may give rise to abnormal chest should be covered with a thin ster
bleeding. In the surgical patient, antico ile drape, and the physical therapist
agulation may be used to prevent or treat should wear a cap, mask, and sterile
pulmonary embolus, or it may occur as a gown and gloves. Chest percussion and
secondary response to another patholog vibration are carried out within the pa
ical factor, such as disseminated intra tient's tolerance and depending on the
vascular coagulation precipitated by type of burn. For third-degree burns,
shock. chest physiotherapy is not painful.
Patients with bleeding disorders Skin grafts over the chest or other
should be suctioned very carefully to areas of the body should not have any
avoid undue trauma to the airway. Blind prolonged pressure or shearing forces ap
nasotracheal suctioning is absolutely plied. The patient must be positioned
contraindicated because of the likelihood carefully for chest physiotherapy and the
of precipitating bleeding from the nasal graft area supported in the position least
mucous membranes; it is also contrain likely to cause pressure or dislodgment.
dicated for its other undesirable effects Similarly, any pedicle flap grafts should
(see p. 1 79). If secretions suctioned be positioned so that tension is mini
through a tracheal tube are profusely mized and trauma during chest physio
bloody, therapy should cease until coag- therapy reduced. Breathing exercises
and assisted coughing may be used in h r duration. Fentanyl and meperidine

place of percussiop and vibration for the are also used epidurally. The continuous
spontaneously breathing patient with infusion techniques avoid the peak and
fresh skin grafts. trough concentrations associated with re
peated injections. Both intravenous and
intraspinal narcotics can be patient con
Pain
trolled within predetermined limits of
Pain associated with chest physiother maximum and minimum infusion rates
apy is a commonly claimed contraindi by using bedside or portable infusion
cation. There is no doubt that following pumps. Techniques such as instillation
major surgery or trauma, deep breathing of local anesthetics through intrapleural
and coughing are painful! Whether chest catheters are also useful to improve chest
physiotherapy is contraindicated de movement following upper abdominal
pends on the consequences of withhold surgery. Control of pain can improve res
ing therapy and the initial indication. If it piratory function (Fairley, 1960).
is thought that as a result of not receiving Some patients are more tolerant of pain
the treatment the patient would suffer than others. The relationship with the
respiratory dysfunction and require even physical therapist, augmented by the
more painful and stressful therapy, such medical and nursing staff, is an important
as intubation and mechanical ventila factor in pain tolerance. If patients un
tion, effective methods of pain relief derstand that the treatment is important
must be found. If treatment is prophylac and beneficial, they are almost always
tic or if breathing exercises and assisted cooperative. The therapist should give
coughing would suffice in place of per the patient a brief, clear description of
cussion, vibration, and expectoration, what is going to happen and why the
these should be used. therapy is required. Rapport is best es
There are several means of pain relief tablished before surgery, so that the need
following surgery including systemic an for therapy is understood. This is not al
algesic medications, intravenous local ways possible.
anesthetics, nerve blocks with local an Pain relief should be given when re
esthetics, or narcotics and stimulation quired before the start of chest physio
produced analgesia such as transcutane therapy; time should be allowed for the
ous electrical nerve stimulation (TENS) analgesic effect to occur. Since pain may
and acupuncture. Systemic narcotics be a major cause of the initial respiratory
bind to specific opiate receptors in the difficulty, effective pain relief should
CNS and inhibit conduction of nociocep greatly assist clearance of retained secre
tive stimuli. More recently narcotic ago tions and prevent their reaccumulation
nist-antagonists such as nalbuphine and (Fairley, 1960). Reports suggest that pain
butorphanol and partial agonists such as relief may reduce (Trinkle et aI., 1 975) or
buprenorphrine are used for acute pain avoid (Shack ford et a I . , 1 96 1 ) the need for
(Raj, 1966). mechanical ventilation. These tech
Intravenous anesthetics, particularly niques require a physician's skills and
2-chloroprocaine, may be safe and effi are time-consuming; risks must be
cacious in managing musculoskeletal weighed against the other available
pain. The mechanism of action is unclear methods of pain control. Continuous in
but may involve antagonism of chemical travenous infusion techniques may be
mediators such as substance P or modu useful for providing successful analgesia
lations of nocioceptive stimuli in afferent and allowing chest physiotherapy to be
nerves within the spinal cord. Monitor carried out in the ICU (M. A. Branth
ing for local anesthetic toxicity is essen waite, personal communication, 1980).
tial during infusion. Klein (1966) found that 3 ltg/kg fentanyl
Epidural or spinal anesthesia may be infusion but not 1 . 9 ltg/kg fentanyl atten
given as a single bolus or by continuous uated increases in blood pressure and
infusion. Morphine is the only narcotic heart rate occurring with chest physio
approved for epidural or spinal use. A therapy. Neither dose of analgesic pre
single bolus provides analgesia of 1 2-24 vented rises in cardiac output averaging
20-25% above baseline or rises in CO, may be minimized by the compromises

production and 0, consumption during and precautions outlined in this chapter.
chest physiotherapy. The therapist's role involves coordina
It is quite apparent that intravenous or tion of information about the patient
i ntramuscular analgesics are not the pan from the radiologist and from the physi
acea for all patients. Local anesthetic cians and nurses in charge of the patient.
techniques have the advantage of little A therapist trained in ICU work is best
systemic effect, but they require skillful able to integrate this information. Aware
administration and must be frequently ness of potential problems that may
repeated. Inhaled 50% nitrous oxide may occur during chest physiotherapy is the
be useful to enable some patients to therapist's part of the multidisciplinary
breathe and cough more deeply during approach to treatment of the critically ill
chest physiotherapy but may cause bone patient with respiratory complications. It
marrow depression and neuropathy (Lay is the physician's responsibility to be
zer, 1 978). As an alternative to these similarly aware of the complications and
methods stimulation-produced analgesia to give considered thought to the hazards
such as acupuncture or TENS may be of chest physiotherapy in relation to the
used to relieve pain (Abram et aI., 1981 ); l ikelihood of improvement occurring
the physical therapist may have consid with existing or alternative treatment.
erable expertise in TENS application.
The reports of its use in the ICU are fa
vorable (Ali et aI., 1 9 8 1 ). Encouragement, References
intravenous or intramuscular analgesics, Abram SE. Reynolds AC. Cusick IF: Failure of nal
intravenous local anesthetics, spinal or oxone to reverse analgesia from transcutaneous
electrical stimulation in patients with chronic
epidural blocks, or stimulation-produced
pain. Aneslh Analg (Cleve) 60:81-84. 1981
analgesia, heat, or cold may be used to re Albert RK. Leasa D. Sanderson M, Robertson HT.
duce the patient's appreciation of pain, Hlastala MP: The prone posilion improves arte
allowing chest physiotherapy to be per rial oxygenation and reduces shunt in oleic acid
formed. The appropriate patient(s) bene induced acute lung injury. Am Rev Respir Dis
1 3 5:628-633. 1 987
fiting most from each of these methods of A l i J. Yaffe es. Serrelte C: The effect or transcuta
pain relief needs to be established. If a neous electric nerve stimulation on postoperative
patient finds one aspect of treatment. pain and pulmonary function. Surgery 89:507-
such as vigorous chest vibration, partic 512. 1 981
Aurigemma NM. Feldman NT. Gottlieb M. Ingram
ularly unpleasant, the therapist can, per
RH. Lazarus 1M. Lowrie EG: Arterial oxygenation
haps, emphasize other aspects, such as during hemodialysis. N Engl J Med 297:871-873.
postural drainage and assisted coughing. 1977
The therapist should be as gentle as pos Avery EE. Morch ET. Benson OW: Critically
sible while treating the patient in pain, crushed chests. A new method of treatment with
continuous mechanical hyperventilation to pro
yet still be vigorous enough to perform duce alkalotic apnea and internal pneumatic sta
the therapy effectively. bilization. J Thorac Cardiovasc Surg 32:291 -311.
1956
Ayella RA. Hankins JR. Turney SZ. Cowley RA:
Ruptured thoracic aorta due to blunt trauma. 1
SUMMARY
Trauma 1 7 : 1 99-205. 1977
Burnard ED. Gratton-Smith P. Docton-Warlow CG:
The complications, precautions, and
Pulmonary insufficiency in prematurity. Aus!
contraindications presented in this chap Poedio!r 1 1 : 1 2-38, 1 965
ter represent the results of an aggressive Butler WI. Bohn OJ. Bryan AC. Froese AS: Ventila
approach to chest physiotherapy for the tion by high rrequency oscillation in humans.
trauma patient. In our experience the po Anesth Analg (Cleve) 59:577-584. 1 980
Campbell C: Appreciation for advice (letter). Phys
tential benefits of chest physiotherapy Ther 60:809-810. 1 980
must be weighed against the risk for the Carlon GC. Howland WS. Klain M. Goldiner PL. Ray
patient of continuing the same approach C: High frequency positive pressure ventilation
which resulted in deterioration of pul ror ventilatory support i n patients with broncho
pleural fistulas. Cril Care Med 7:128. 1979a
monary function. Often the risks claimed
Carlon GC. Campfield PB. Coldinor PL, Turnbull
to be associated with chest physiother AD: Hypoxemia during hemodialysis. Crit Care
apy are unsubstantiated in practice or Med 7:497-499. 1 979b
Ciesla NO. Klemic N. Imle PC: Chest physical ther Klein P. Kemper M. Weissman G. Rosenbaum SH.
apy to the patient with multiple trauma: Two case Askanazi J. Hyman AI: Attenuation of the hemo
studies. Phys Ther 61 :202-205. 1981 dynamic responses 10 chest physical therapy.
Ciesla N, Rodriguez A, Anderson p, Norton B: The Chesl 93:38-42. 1988
incidence of extrapleural hematomas i n patients Layzer RB: Myeloneuropathy after prolonged ex
with rib fractures receiving chest physiotherapy. posure to nitrous oxide. Lancel 2:1 227-1230, 1978
Personal communication. 1 988 Mackenzie CF, Shin B. Fisher R . Cowley RA: Two
Connors AF. Hammon WE, Martin RJ. Rogers RM: year mortality i n 760 patients transported by heli
Chest physical therapy. The immediate effect on copter direct from the road accident scene, Am
oxygenation in acutely ill patients. Chest 78:559- Surg 45:101-108. 1979
564. 1 980 Mackenzie CF, Shin B. Krishnaprasad D, McCor
Douglas WW. Rehder K, Beynen FM, Sessler AD, mack F, Illingworth W: Assessment of cardiac and
Marsh HM: Improved oxygenation i n patients respiratory function during surgery on patients
with acute respiratory failure: the prone position. with acule quadriplegia. } Neurosurg 62:843-849,
Am Rev Respir Dis 1 1 5:559-566, 1977 1985
Downs lB. Chapman RL: Treatment of broncho Mackenzie CF, Shin B: Chest physiotherapy vs
pleural fistula during continuous positive pres bronchoscopy, Cril Care Med 14:78-79. 1986
sure ventilation. Chest 69:363-366. 1976 Macklin MT. Macklin CC: Malignant interstitial
Fairley HB: Oxygen therapy for surgical patients. emphysema of the l u ngs and mediastinum as an
Am Rev Respir Dis 122(2):37-44, 1980 important occult complication in many respira
Fishman AP: Pulmonary Edema. In Pulmonary Dis tory diseases and other conditions: An i nterpre
eases and Disorders. edited by AP Fishman. pp tation of the clinical literature in the light of
733-753. McGraw-Hill. New York, 1 980 laboratory experiment. Medicine 23:281-538.
Fishman AP: Down with the good lung. (Editorial). 1 944
N Engl l Med 304:537-538. 1981 McMichan IC, Michel L, Westbrook PR: Pulmonary
Fineberg C. Cohn HE. Gibbon IH: Cardiac arrest dysfunction following traumatic quadriplegia.
during nasotracheal aspiration. lAMA 174:148- lAMA 243:528-5 3 1 . 1 980
150. 1960 Meyer GA. Berman IR. Doty DB, Moseley R V . Gu
Fox WW. Schwartz IG. Schaffer TH: Pulmonary tierrez VS: Hemodynamic responses to acute
physiotherapy in neonates: Physiologic changes quadriplegia with or without chest trauma. I Neu
and respiratory management. I Pedialr 92:977- rasurg 34:168-177, 1971
981. 1978 Milner AD, Murray M: Acute bronchiolitis i n in
Fugl-Meyer AR: Handbook of Clinical Neurology. fancy: Treatment and prognosis, Editorial. Tho
Injuries of the Spine and Spinal Cord, chap. 19, rax 94:1-5, 1989
The Respiratory System, pp 335-349, American Pingelton SK: Complications of acute respiratory
Elsevier Publishing, New York. 1976 failure: Slale of the art. Am Rev Respir Dis
Gallagher TI. Smith RA, Kirby RR: Intermittent in 137: 1463-1493. 1988
spiratory chest tube occlusion to limit broncho Powner 01. Grenvik A: Ventilator management of
pleural cutaneous air leaks, Crit Core Med 4:328, life threatening bronchopleural fistulae. Crit Core
1976 Med 9:54-58. 1981
Gormenzano I , Branthwaite MA: Effects of physio Purohit OM. Caldwell C. Lerkoff AH: Multiple rib
therapy during intermittent positive pressure fractures due to physiotherapy i n a neonate with
ventilation. Anaesfhesia 27:258-263. 1972 hyaline membrane disease, Am } Dis Child
Hammon \<\'E, Martin Rl: Fatal pulmonary hemor 129: 1 1 03-1104. 1975
rhage associated with chest physical therapy. Raj P: Drug administration techniques for chronic
Phys Ther 59:1247-1248. 1979 pain. In Current Practice in Anesthesiology. edited
Hoffmann R: Osteotaxis. osteosylhese externe par by M Rogers, e, C. Decker Inc" Toronto. pp 243-
fiches et rotules. Acla Chir Scand 107:72-81. 1954 248. 1988
Holloway R. Adams EB. Desai SO. Thambiran AK: Rasanen I. Bools IC, Downs IB: Endobronchial
Effect of chest physiotherapy on blood gases of drainage of undiagnosed lung abscess during
neonates treated by intermittent positive pres chest physical therapy. Phys Ther 68:371-373.
sure respiration. Thorax 24:421-426. 1969 1988
Imle Pc. Mars MP, Eppinghaus CEo Anderson P. Remolina C. Khan AV. Sant iago TV. Edelman NH:
Ciesla NO: Effect of chest physiotherapy (CPT) Positional hypoxemia i n un ilateral lung disease,
positioning on intracranial (ICP) and cerebral per N Engl l Med 304:523-525. 1981
fusion pressure. Crif Care Med 16:382, 1988 Salcman M, Schepps RS. Ducker TB: Calculated re
Jennett B. Teasdale G, Braakinar R, Minderhound I. covery rates in severe head trauma. Neurosurgery
Kni ll-lanes R: Predicting outcome in individual 8:301-308. 1981
patients after severe head injury. LanceI 1 : 1 0 3 1 - Schwartz SI: Principles of Surgery. p 496. McGraw
1034. 1976 Hill. New York. 1979
Kigin CM: Chest physical therapy for the postoper Seaton D: Effect of body position on gas exchange
alive or traumatic injury patient. Phys Ther after thoracotomy. Thorax 34:518-522. 1979
61 :1 724-1736, 1981 Shad.ford SR. Virgilio RW. Peters RM: Early extu
Kinney 1M, Askanazi I. Gump FE, Foster RI. Hyman bation versus prophylactic ventilation i n the high
AI: Use of ventilatory equivalent to separate hy risk patient: A comparison of postoperative man
permetabolism from increased dead space venti agement i n the prevention of respiratory compli
lation i n the injured or septic patient. } Trauma cations. Aneslh Analg (Clevel 60:76-80. 1981
20:1 1 1-1 19. 1980 Shin B. Mackenzie cr, Chodoff P: Is IMV superior
to controlled ventilation in the management of Walsh JH. Vanderntarf C. Hoscheil D. Fahey NPJ:
flail chest? Crit Care Med 7:138, 19798 Unsuspected hemodynamic alterations during
Shin B. Mackenzie CF. McAslan Te. Helrich M. endotracheal suctioning. Chest 95:163-165.
Cowley R : Postoperative renal failure in trauma 1 989
patients. Anesthesiology 5 1 :218-221. 1979b Webb MSC, Martin l A , Cartlidge PHT, Ng YK.
Sjostrand UH, Eriksson IA: High rates and low vol Wright NA: Chest physiotherapy in acute bron
umes in mechanical ventilation-not just a mat chiolitis. Arch Dis Child 60:1078-1079. 1985
ter of ventilatory frequency. Anesfh Ana/g (Cleve) Welply NC. Mathias CJ. Frankel HL: Circulatory re
59:567-576, 1 980 nexes in telraplegics during artificial ventilation
Sutherland GR. Calvin IE. Driedger AA, Holliday and general anaesthesia. Paraplegia 13:1 72-182,
RL. Sibbald WJ: Anatomic and cardiopulmonary 1975
responses La trauma with associated blunt chest Willats SM: Alternative modes of ventilation. Part
injury. / Trauma 21:1-12, 1981 II. High and low frequency positive pressure ven
Trinkle JK. R ichardson ID. Franz fL. Grover FL, Arc tilation. PEEP. CPAP, reverse ratio ventilation.
KV. Holmstrom FMC: Management of flail chest Intensive Core Med 1 1 :51-55, 1985
without mechanical ventilation. Ann ThoracSurg Zack MB. Ponloppidan H. Kazemi H: The effect of
19:355-363, 1 975 laleral positions on gas exchange in pulmonary
Tyler ML: Complications of positioning and chest disease. Am Rev Respir Dis 1 1 0:49-55. 1974
physiotherapy. Resp Core 27:458-466. 1982
APPENDIX I
Chest Physiotherapy Statistics

Showing Type and Number of
Patients Treated
Table AI.1
Number of Palients Treated with Chest Physiotherapy 1974-87'
Fiscal Number of Number of Total
Year Admissions Patients Treated Admissions (%)
1974 872 372 0.43
1975 920 330 0.36
1 976 1105 418 0.38
1977 1023 580 0.57
1 978 1053 590 0.56
1 979 1249 681 0.55
1 980 1240 322' 0.27
1 981 1324 396 0.30
1 982 1505 342 0.23
1 983 1692 532 0.31
1 984 1953' 778 0.40
1 985 2104 676 0.32
1 986 2445 705 0.29
1 987d 2534 401 0.1 6
Total 20994 7123 0.36

'Data collected by Department of Physical Therapy MIEMSS.
'Calculated from 6 months of available data.
'MIEMSS available beds increased from 32 to 1 07 in this time frame. Acute beds increased from
26 to 42. Note that although available beds increased by 64% there is only a 38% increase in acute
beds.
dFiscal year 1 987 three staff physical therapy positions were vacant.
345
2600
2500
2400 -
2300 -
2200
2104
2100
2000
1900 -
'3
1800
1700 2
'
1600 -
1000
1500 -
1400
1300 - '4
1200 - '"40
"""
1100
1023 10M
1000 - r
900 982
r .20
800 .
W
700
6,.
600
...
o 500
II:
'" 400-
]
II)
::I
:> 300
L r r ""
f] "'J1I
z .,. L- r r- h-- "''110 .1:"': r- e..... t- It ..... I0,...
II ,II I 1- ti [12011 ,12

200 ;"
(Oo! F-
'
t- tt..O'I.
u .... tz. 4...... .. .
!I 1
) 20, 1'110 . ... ". !I'" (2'1) 111"'
j _ I IU') :) I
;;'

I Itl1 ..
100 u...... : .. I
' 27:Iii2l:'II7tG d
;J
o -lu;t r I7d r t : 4b1;
l.:2tr t

.
fiSCAL YEAR
Figure Al.l. Number of patients admitted for fiscal years 1972-87. Mortality is shown as the dot
ted portion of the histogram. The percentage mortality varies from 25.4% to 10.0%. The number
of patients this mortality represents is shown in parentheses. Data from C.F. Mackenzie and from
Annual Report of MIEMSS.
Figure A1.2. Information included in this profile shows that 768/1221 (62.9%) of patienls arrived
directly from the scene of injury and 453/1221 indirectly after management at another medical in
stitution. Only 520/1221 (42.6%) required surgery in the operating room and 29/1221 (2.4%) were
inappropriate admissions and were discharged home directly from the admitting area. Data from
M. Moody.
APPENDIX I 347
Distribution of 1,221 admissions' to OR, t CCRU, ICU and ward t0gether with
duration of stay and placement for 1979.

Direct Indirect
Air Land Air Land

661 . 213
1 221
\'
79
Morgue
27
University of
Maryland Hospital
11
To Other
Hospitals
29
Discharged
Home
520
OR
152
CCRU
259
ICU
148
Ward
37 4 o o 321 160 7
Morgue University of To other Home CCRU ICU Ward
Maryland Hospital Hospitals
I
95 17 1 0 332 21

Morgue University of To Other Home Ward
/
ICU
751
,CO
Average Length
of Stay. 5.9 Days
31 63 40 45 566
Morgue University of To Other Home
Average Length
of Stay. 6.4 Days
11 160 110 443 Average Length of Total

Morgue University of To Other Home Stay. 11.9 Days
Totals
249 291 163 517
* The discrepancy in admissions shown is due to 28 readmissions.
t OR, operating room.

.00
.. ' ...............
92 ISS=20+
z .50 0155=13-19
w
u 8. ISS='-'2
'"
ISS=Z[RO
i"
w
..
76
w
> - FY 1985 '00
;= 68 FY 1986 ;=

:s n 1987 (Smos) ..

" 60 0
'"
u w 50
52 m

.. z
20 28 36 u 52 60 68 76
a
1985 1986 1987 (6mos)
.55
Figure A1.3. Injury severity score (ISS) above Figure AI.4. ISS for patients receiving chest
20 is plotted against cumulative percentage of physiotherapy during 1985, 1986, and 6
patients with that ISS admitted for years 1985- months of 1987. The number of patients in
1987. There is a remarkable similarity in ISS each category of ISS is shown on the vertical
score over the 3 years with a trend for higher axis. Data from Trauma Registry Database and
scores, indicating more severe injury, with data collected by Department of Physical Ther
each successive year. Data from Annual Re apy MIEMSS.
port of MIEMSS.
100
CJ FY 1985
0- lSS'l FY 1986
n.
u - FY 1987(6 me 5,

75

0' .

c

>
'<;
u N

.,
50 :::
N

N
Ul
Il
C
. .
N
.
.,

25
Q.
'0

0
20-2 26-30:)1-35 .36-40 41-45 46-5051-':15 56-6061-65 66-70 71 76
ISS Score
Figure A1.5. The annual number of patients (1985-87) with a specific ISS above 20 (the most
severely injured patients) treated with CPT is shown as a number at the top of each bar histogram.
This number of patients who were treated with CPT is plotted as a percentage of the total number
of patients who had the same ISS (on the vertical axis). For example, in 1986 100% (8 of 8) patients
with ISS score 46-50 received CPT. Data from Annual Report of MIEMSS and data collected by
Department of Physical Therapy MIEMSS.
APPENDIX I 349
150 hJusonds)
.32 _ Acute do)'
[212'; Sub acute doys
o Word days
28
i!'
;:. 1 ,.
"
<
o
16
w "
m
,
" 8
z
Heed Spine Head Spine o

Head Spine
1985 1986 1987 (6 mOflths) fiSCAL YEARS
Figure AI.S. Number of severe head injured Figure A1.7. MIEMSS patient days 1981 to
and spine injured patients who received chest 1987. Note consistency of acute days and sig
physiotherapy during 1985, 1986, and 1987 (6 nificant increase in subacute and ward days
months). Data collected by Department of over 7 years. The increase in subacute and
Physical Therapy MIEMSS. ward days accounts for the decrease in per
centage of admissions receiving chest physio
therapy since most patients were managed
with chest physiotherapy while in acute beds.
Data from Annual Report of MIEMSS.
Table AI.2 Thousands) _ Acute

Patients in Acute Beds Treated with Chest .10 I.'22'J Sub o,ule
PhYSiotherapy, Fiscal Years 1981-1987 o Word
(July-Dec)'
Critical care recovery unit 1588
Intensive care unit 1229
Neurotrama unit 682
Total 3499
'Note: 3639 patients received chest physio
therapy in this time period; 96% of patients o
JUL AUG SEP OCT NOV OCC JAN r(a MAR APR MAY JUN
treated were in acute beds. MONTHS
Figure A1.8. MIEMSS patient days by month

in 1987. Note consistent proportions of acute,
subacute, and ward days and also seasonal
changes. Patient days were under 2,400 in Jan
uary, February, and April. Data from Annual
Report of MIEMSS.
Table AI.3
Chest Physiotherapy Treatments to Specific Lung Lobes, Fiscal Years 1981-1987'"
Percentage of Total Treatments
1981 1982 1983 1984 1985 1986 1987
(3.510)' (2,675) (3,915) (6,21 1) (5.230) (5,396) (3.888)
Lung Lobe
Right upper lobe 3 2 4 3 4 3 5
Left upper 1 1 1 1 1 1 1
lobe(excluding
lingula)
Right middle lobe 3 2 3 3 2 3 4
Lingula 1 1 1 1 2 3 2
Right lower lobe 40 41 39 41 38 38 36
Left lower lobe 52 53 52 51 53 52 52
Additional coughing 249 226 348 886 530 348 313
and deep
breathing
exercise
sessions
'Note consistency of chest physiotherapy treatments to specific lung lobes. Ninety-one percent
were directed to the lower lobes, 52% left lower lobe, 39% right lower lobe. Patients mobilized as
part of chest physiotherapy treatment are not represented in this table.
'Total number of treatments.
Table AI.5
Table AI.4 Number of Trauma and Nontrauma Patients
Average Chest Physiotherapy Treatment Treated with Chest Physiotherapy, Fiscal
Time (Minutes), Fiscal Years 1981-1987" Years 1981-1 987'
Year Time (min) Trauma Nontrauma
Year
(%) (%)
1981 29
1982 29 1981 91 9
1983 30 1982 91 9
1984 27 1983 95 5
1985 29 1984 85 15
1986 33 1985 95 5
1987 34 1986 96 4
1987 96 4
'Data collected by Department of Physical
Therapy MIEMSS.
7 -year average 93 7
'Seven-year average, 30 min per treatment.
Therapy MIEMSS.
APPENDIX I 351
450
0
/\,
400
til
0
z
0
350 ?
:,,:\ \
iii
!C! 300
'"
0
250
"-
0
\'<\<"-
'" 200
w
(D
'" 150
'"
lJ:
z
100
0--0 0__& 6 /
-6-"'-6<:::""'----
50 0-0-0_
0--0-0.....----
0
0-10 " -'516-2 021-25 26-3031-35 36-4 041-45 46-5 051-55 55 -60 6
1-65 6
6+
AGE
0-0 1979 6-6 1983 0-0 1 9 87
Figure AI.9. Age distribution of MIEMSS admissions, fiscal years 1 979, 1 983, 1 987. The 1 6-35
year age group accounts for the majority of admissions. There is an increase in the over 65 year
age group in 1 987. Data from Annual Report of MIEMSS.
2.0
74
Figure A I.10 . Sex distribution for
1.9
1.8 MIEMSS primary admissions (ex
1.7 cludes readmissions) for fiscal
1.6
1.5 '" fA 11 years 1 98 1 - 1 987. The percentage
-;;- 1.4 of annual admissions is shown
-g 1.3 above each histogram. Admissions
o 1.2
1.1
o 1.0 '"
,.u' increased 48% over the 7 years, al
2.. 0.9
though the greatest variance is
0.8 only 7%. Data from Annual Report
0.7

'61
of MIEMSS.
Vl 0.6
,.
i

0.5
0.4
0.3
,
02
0.1
0.0

1981 1982 1983 1984 1985 1986 1987
CJ MALE FEMALE
2.0 Figure AI.11. Race distribution of

1.9 MIEMSS primary admissions, fis
1.8
1.7 7 ,
cal years 1 981 -1 987. The annual
1.6
'" 7 ,
percentage is shown above each
1.5
{g 1.4 '"
histogram. Note consistency within
c 1.3 5% for black or white patients. Data
g 1.2
'01
J 1.1 00' from Annual Report of MIEMSS.
.. 1.0
_ 0.9
w 0.8
u 0.7
0.6
m 0'
h
0.5
0.' '0'
0.3
0.2
0.1
0.0 [ ,
1981 1982
"
1983
"
1984
" "
'!
1985 1986 1987
o WHITE BLACK RSZSl OTHER
Table AI.6 Table AI.9

Monitored Status of Patients Treated with Spinal Injury Level of Injury Among Patients
Chest Physiotherapy. Fiscal Years 1981- Treated with Chest Physiotherapy. Fiscal
1988 (July-December 1987)' Years 1981-1988 (July-December 1987)''
Number of Number of
Type of Catheter Injury
Patients Patients Treated
Arterial 2245 Cervical 446 (1 cancer)
Central venous (not PAl 1224 Thoracic 153
Pulmonary artery (PA) 916 Lumbar 84
Intraventricular 720
Therapy MIEMSS. 'Data available on 683 of 775 patients; 297 of
the 775 spinal injury patients received chest
physiotherapy on a turning frame.
Table AI.7
Body Systems Injured Among Patients
Receiving Chest Physiotherapy. Fiscal Years Table AI.10
1981-1988 (July-December 1987)' Orthopedic Fixation Devices in Use on
Patients Treated with Cheat Physiotherapy.
Injury Number of Patients Fiscal Years 1981-1988 (July-December
Head 1684 (3 CVAs) 1987)''
Chest 1141 Device Number of Patients
Abdomen 651
Spine 775' Internal fixation 452
Pelvis 417 External fixator 380
limbs injured 2029 Skeletal traction 148
Spinal rods 83
'Data collected by Department of Physical Neufeld traction 53
Therapy MIEMSS.
'Fiscal years 1981-1987; 370 spinal injury 'Data collected by Department of Physical
patients had neurological deficit. Therapy MIEMSS.
'In the first 6 months of fiscal year 1988 20
patients were also treated with continuous
passive motion of the hip and knee.
Table AI.8
Patients with Bony Injuries Who Were
Treated with Chest Physiotherapy in a 34-
Month Period'
Number of
Injury
Patients
Rib fracture 226 (39 single)
Scapular fracture 16
Clavicular fracture 60
limb fracture 379
Pelvic fracture 136
Total 817
Total number of
limbs fractured 671
Therapy MIEMSS.
APPENDIX II
Abbreviations and Symbols
APPENDIX II FLS flow limiting segment

FRC functional residual
AP anteroposterior capacity
ARDS adult respiratory FVC forced vital capacity
distress syndrome gm gram
a-ADCO, arterial alveolar carbon GPB glossophrayngeal
dioxide difference breathing
A-aDO, alveolar arterial oxygen HD head down
difference HF head flat
AV assisted ventilation HFCWC high-frequency chest
A-vDO, arterial venous oxygen wall compression
difference HFV high frequency
C cervical or centigrade ventilation
CCRU critical care recovery Hg mercury
unit H/L ratio high/flow amplitude
cm centimeter electromyogram ratio
CO, carbon dioxide HMD hyaline membrane
COPD chronic obstructive disease
pulmonary disease H,O water
CPAP continuous positive Hz Hertz or cycles per
airway pressure second
CPM continuous passive ICP intracranial pressure
motion ICU intensive care llnit
CPP cerebral perfusion ID internal diameter
pressure I/E inspiratory to expiratory
CPT chest physiotherapy ratio
CNS central nervous system IMT inspiratory muscle
CSF cerebrospinal fluid training
c,. total lung/thorax IMV intermittent mandatory
compliance ventilation
cv closing volume IPNV intermittent positive
CXR chest x-ray negative ventilation
DNA deoxyribonucleic acid IPPB intermittent positive
ECG electrocardiogram pressure breathing
EEG electroencephalogram IPPV intermittent positive
EMG electromyography pressure ventilation
ERV expiratory reserve IS incentive spirometry
volume ISS injury severity score
F fahrenheit I.V. intravenous
FET forced expiratory kg kilogram
technique L lumbar
FEV, forced expiratory LLL left lower lobe
volume in one second LUL left upper lobe
FlO, fraction of inspired MASTrousers military antishock
oxygen trousers
353
MIEMSS Maryland Institute for Q. cardiac output per

Emergency Medical mintue
Services Systems R.w airway resistance
mg milligram Rpul pulmonary vascular
ml milliliter resistance
mm millimeter R.f systemic vascular
MSVC maximum sustained resistance
ventilatory capacity RDS respiratory distress
N normal syndrome
N,O nitrous oxide RH relative humidity
NHLI National Heart and RLL right lower lobe
Lung Institute RML right middle lobe
NHLBI National Heart, Lung RNA ribonucleic acid
and Blood Institute RUL right upper lobe
0, oxygen SaO, arterial oxygen
P pressure saturation
p probability SD standard deviation
PaCO, partial pressure of SE standard error
arterial carbon dioxide T thoracic
p." mean arterial pressure TcPO. transcutaneous oxygen
PaO. partial pressure of tension
arterial oxygen TcPCO, transcutaneous carbon
PCA patient controlled dioxide tension
analgesia TENS transcutaneous
Pew. pulmonary capillary electrical nerve
wedge pressure stimulation
PEE end-expiratory pressure TLC total lung capacity
PEEP positive end-expiratory Tmu. maximum daily
pressure temperature
PEF peak expiratory flow TMC tracheal mucus
PEP positive expiratory clearance
pressure torr the pressure supporting
PeMn maximum expiratory 1 mm Hg at O'C and
mouth pressure standard gravity
PETCO, partial pressure of end- V volume
tidal carbon dioxide VC vital capacity
PETO. partial pressure of end- V, dead space volume
tidal oxygen V, expired minute
PFT pulmonary function test ventilation
pH -log,,[H+] VO. oxygen consumption per
PIE end-inspiratory pressure minute
Pl mu.
maximum inspiratory V/Q venti lation /perf usion
mouth pressure per minute
PmCrit critical mouth pressure V, tidal volume
P ma,
maximum airway WBC white blood cell count
pressure x-ray roentgenogram
PNIP peak negative I' micron (micrometer)
inspiratory pressure ! decrease
PsO. skin oxygen tension t increase
PT physical therapist )'\0 slightly increased or
P1I:OZ transcutaneous oxygen decreased
tension % percent
PVO, partial pressure of < less than
mixed venous oxygen > greater than
Q./Q. intrapulmonary shunt 6. change
APPENDIX III
Summary of Chest Physiotherapy

Treatment and Evaluation
FREQUENCY OF TREATMENT
As Symptoms and Signs Indicate
1. Ideal frequency.
2. Therapist must be well trained in clinical evaluation.
3. Close communication with the physician is essential.
4. Works well with experienced therapists assigned to a specific unit.
Four Hourly
1. Usual frequency that is necessary for critically ill patients.

2. Treatment is continued throughout a 24-hr period for mechanically ventilated
patients.
3. Spontaneously breathing patients in no acute distress usually benefit from sleep at
night; cooperation is then improved with daytime treatments.
More Frequently than Four Hourly
1. Indicated for patients with copious secretions that are not removed by four hourly
chest physiotherapy treatments.
2. Patients with closed head injuries and secretion retention who are limited in the
amount of time they may remain in the head-down position.
3. The need for treatment more frequently than four hourly should be reevaluated
after 12-24 hr of treatment.
4. Increased frequency of treatment often makes optimal treatments impossible be
cause of multiple other therapeutic interventions.
Less Frequently than Four Hourly
1. Mobilized patients.
2. Patients who clear their secretions spontaneously with deep breathing and
coughing.
3. Patients with minimal secretions with or without radiological evidence of atelec
tasis or pneumonia.
355
4, Acute lobar collapse usually responds to 1-2 vigorous chest physiotherapy treat
ments and may then be replaced by patient mobilization,
ROUTINE EVALUATION OF CHEST PHYSIOTHERAPY
During Mechanical Ventilation
1. Examine the patient as previously described (pp, 73-80), Particularly auscultate

the chest over the area to be treated and compare with the opposite side, A sigh or
mandatory breath may be useful in evaluation of breath sounds,
2, Note the mode of ventilation, Identify tidal volume, minute ventilation, inspired
oxygen concentration, and respiratory rate, Measure airway pressures with the
bed flat and the patient supine, calm, and in phase during a tidal volume ventilated
breath,
3, Obtain the most recent values for arterial blood gas analysis,
4, Obtain information about the most recent chest x-ray,
5, Position the patient appropriately, Make a note of any change in vital signs, aus
cultatory findings, ventilator airway pressures, and volumes when the patient is
correctly positioned,
6, Apply therapy as described in the section "Essentials of Chest Physiotherapy
Treatment."
7, Note changes in airway pressures, A fall in peak airway pressure (fall in R.w) usu
ally indicates secretion removal from the central larger airways, A fall in plateau
or end-expiratory pressure (increase in CT) usually indicates secretion removal
from more peripheral smaller airways,
8, Note changes in auscultation of the chest. Changes in the character of the breath
sounds from bronchial to vesicular or in the clearance of adventitial sounds or in
improvement of air entry are favorable findings,
g, Note sputum volume removed, This may be measured,
10, Clinical examination of the chest and measurement of airway pressure (in the pos
tural drainage position) are repeated throughout therapy, Clearance of the chest to
auscultation, increased CT, and termination of sputum production are all suitable
end points for therapy,
11. The patient is returned to the supine flat position, the chest is reexamined, airway
pressures and volumes are remeasured, and vital signs noted, Arterial blood gases
are analyzed if PaO,/FIO, was less than 250 before therapy,
12, If a complete lobar atelectasis was present before therapy, a chest x-ray is
repeated,
During Spontaneous Respiration
1. Examine the patient. Particularly observe the rate and pattern of respirations and
use of accessory muscles, Auscultate the chest over the area to be treated and com
pare with the opposite side,
2, Obtain the most recent values for arterial blood gas analysis,
3, Obtain information about the most recent chest x-ray,
4, Position the patient appropriately, Make note of any complaints of discomfort, dys
pnea, or wheezing, Observe the patient for appearance of cyanosis or change in
respiratory rate, Reexamine the patient in the postural drainage position, Observe
ECG or other monitoring devices,
5, Apply therapy as described in the section "Essentials of Chest Physiotherapy
Treatment. "
6, Note changes in auscultation of the chest. Changes in the character of the breath
sounds from bronchial to vesicular or in the clearance of adventitial sounds or in
improvement of air entry are favorable findings,
7, Note sputum volume removed, This may be measured,
APPENDIX III 357
8. Clinical examination of the chest is repeated throughout therapy. Clearance of the

chest to auscultation and termination of sputum production are suitable end points
for therapy.
9. The patient is returned to the supine position, the chest is reexamined, and vital
signs noted. Arterial blood gases are analyzed if PaO,/FIO, was less than 250 be
fore therapy.
10. If a complete lobar atelectasis was present before therapy, a chest x-ray is
repeated.
POSITIONING THE PATIENT FOR CHEST PHYSIOTHERAPY TREATMENT
Figure AIII.1. (1) Both hands are placed under the trunk (8) while a second person places both
hands under the hips (b). The patient is lifted to the side of the bed. (2) (8) With one hand over the
uppermost shoulder and the other over the uppermost hip, the patient is pulled onto the side.
(Crossing the patient's legs prior to turning facilitates rolling the patient.) (b) A second person lifts
the hips back. (c) For obese or difficult patients, a third person may simultaneously lift the shoulders
back. (3) To keep an agitated patient side-lying, the writsts are restrained (8 and b), and sheets are
tied around the thighs to the bed raii. The upper hip is flexed (c) and the lower hip is extended (d).
(4) To turn the patient from the side to prone, two people (8 and b) lift the trunk while a third person
(c) pulls the dependent arm under the patient. (5) If a tracheal tube is present, while two people
hold up the patient's trunk, the third places a roll under the upper thorax. The patient remains
poSitioned as in Part 5.
Essentials of Chest Physiotherapy Treatment
Treatment
Purpose How to Perform When to Usa Things to Avoid Important Details to Remember
Components
Postural Mobilize retained secretions Patient positioned so that When coughing or suctioning, Avoid significant changes Patient must be property positioned
drainage through assistance of involved segmental breathing exercises, forced in patient's vital signs. lor bronchial drainage of the
gravity bronchus is uppermost (see expiratory technique, and increase in intracranial involved lung segment; this can
pp. 97-99 for postural patlent mobilization are not pressure, and stress be attained despite the
drainage positions) adequate to clear retained to Intravascular lines pressence at multiple injuries.
secretions and Indwelling tubes monitoring equipment, and lines
(p.l0l)
Percussion As an adjunct to postural Rhythmical clapping of cupped Same as above Avoid skin redness or May be performed In the presence
drainage lor mobilization hands over bare skin or thin petechiae (indicates of rib fractures, chest tubes, and
of secretions material covering area of improper hand subcutaneous emphysema:
lung involvement; positioning by should produce a hollow sound:
performed during therapist, or patient should not cause undue pain:
inspiration and eKpiration coagulopathy) does not need to be forceful to
be effective it performed
properly
Vibration As an adjunct to postural Intermittent chest wan Same as above Avoid excessive Not recommended for use over rib
drainage for mobilization compression over area of pressure, pinching, or tractures or unstable thorack:
of secretions lung involvement; shearing ot soft tissue spine injuries; be sure to vibrate
performed during expiration chest waU, not Just shake soft
only tissue; forcefulness should vary
according to patient's needs and
Co>
'" tolerance
00
Breathing Assists in removing Patient taught to produce a full For use with spontaneously Avoid use of undesired May be used Independently or in
eKercises secrellons, relaxation, inspiration followed by a breathing patients respiratory muscles conJunction with other chest
and to increase thoracic controlled expiration: use and fatigue physiotherapy techniques;
cage mobility and tidal hand placement for sensory patient must be cooperative:
volume: inspiratory feedback; leaning fOfWard breathing eKerclses aimed at
resistive devices or posture used with COPO; relaxation should not increase
weights to improve increased resistance the work of breathing: strength
ventilatory muscle applied during inspiration versus endurance should be
strength/endurance using resistors or considered with respiratory
abdominal weights (see p. muscle training
119)
Coughing Removal of secretions from Steps: For use with spontaneously Avoid bronchospasm Coughing is less effective In
the larger airways 1. Inspiratory gasp breathing patients Induced by repetitive tracheally intubated patients;
2. Closing of the glottis coughing coughing ability can be Improved
3. Contraction of expiration by manual support of the
muscles patient's incision and tracheal
4. Opening of the glottis (see stoma. following tube removal;
p.155) an effective cough is preceded
by a large inspiration: methods
of cough stimulation, including
"huffing," vibration. summed
breathing, eKternal tracheal
compression, and oral
pharyngeal stimulation. are used
(see p. 162)
Forced As an adjunct to clear Patient performs a contrOlled Same as above; used as an Avokl excessive fatigue May be used independently or with
expiratory excess secretions diaphragmatic inspiration, alternative to other other chest physiotherapy
technique fOllowed by huffing, or breathing exercises and techniques; requires patient
forced expirations from mid coughing cooperatlon; use not reported in
to low lung vOlume patients with tracheal tubes;
described for patients with cystic
fibrosis and other chronic lung
diseases; may be as effective as
postural drainage or manual
techniques for these patients
Suctioning Removal of secretions from Use aseptic technique Tracheal suctioning lor use Avo+d hypoxemia In intubated patients, suctioning is
the larger airways 1. Provide supplemental only with patients who (cyanosis and performed routinely and is an
oxygen, jf indicated have an artificial airway in significant changes in integral part of chest
2. Fully insert suction catheter ",ace vital signs) and cardiac physiotherapy; frequency is
without applying suction; dysrhythmlas, determined by the quantity of
be gentle mechanical trauma secretions; the suctioning
3. Apply suction while and bacterial procedure should be limited to a
withdrawing catheter contamination of total of 15 sec; the suction
4. Reexpand lung with tracheobronchial tree, catheter can reach only to the
mechanical ventilator or and increase in level of the main stem bronchus;
resuscitator bag intracranial pressure it is more difficult to cannulate
5. PEEP, lidal volume, and the left main stem bronchus than
F102, are better maintained the right; nasotracheal
using a port adapter (see p, suctioning should be avoided
'" 177) (see p. 179)
.
Bagging Provide artificial ventilation; Attach the manual resuscitator Before and after suctioning Avoid barotrauma and Bagging can be used to Improve
restore oxygen and bag to an oxygen source, patients who are not tracheal irritation clinical assessment of breath
reexpand the lungs after then carefully connect it to mechanically ventilated sounds; it is also used in
suctioning the patienfs tracheal tube; and who cannot conjunction with vibration when
squeeze bag rhythmically in spontaneously take a deep treating patients not breathing
COOfdination with the breath deeply: hyperinflation can
patient's own breathing produce alterations In cardiac
pattern; expiration is output and intracranial pressure;
passive (see p. 181) know the limitations of manual
resuscitator bags at your facility
Patient To prevent the detrimental Turning and passively Used to some degree with Avoid patient fatigue, Mobilization Is possible to some
mobilization sequelae of bedrest and positloning the patient; every patient according to stress to Intravascular degree fOf every patient; minimal
immobilization; to appropriate splint usage; patient's diagnosis and lines, and indwelling supplies are needed fOf
decrease rehabilitation passive and active range 01 tolerance tubes, orthostatic mobilization; emphasis should
time motion; active and resistive hypotension, be placed on functional activities;
exercises; sitting, standing, significant changes in proper positioning may decrease
and ambulating the patient vital signs, and contracture formation and
dyspnea spasticity: ECG leads and
arterial and central monitoring
lines should be temporarily
disconnected from the recording
module during ambulation; at the
physician'S discretion, chest
tubes and abdominal sumps may
be disconnected from wall
suction to allow ambulation
APPENDIX N
Duration, Type, and Frequency of

Interventions in Four Critically III
Patients
To document the interventions likely to cause cardiac or respiratory changes, four

critically ill patients were observed in the CCRU at MlEMSS between 8 A.M. and 4 P.M.
All interventions were recorded and timed. The weekday of observation was randomly
chosen, but the patients observed were four of the most ill patients in the CCRU.
PATIENT #1
Problem: Gunshot wound to abdomen with lacerations of liver, right renal vein, gall
bladder, and inferior vena cava, renal failure
Admission: 12 days previously
Monitors: ECG, temperature, Foley catheter, central venous and radial arterial lines,
orogastric tube, abdominal sump
Medications:
Amphojel Gentamycin Parenteral nutrition
Ticarcillin Morphine sulfate Dopamine infusion
Afrin spray Blood and fresh frozen
Tylenol plasma
State: Sedated, mechanically ventilated through translaryngeal tracheal tube
Time: 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00

Temperature 1C): 39.2 39.4 39.4 39.3 39.2 39.3 39.4
8:10-11 Ventilator adjusted

8:11-20 Physicians' rounds
8:22 Bed adjusted
8:23-25 Vital signs taken
8:25-50 Physicians discussing patient
8:50-00 Vital signs and blood taken: respiratory function testing
9:20-25 Examined by chest physical therapist
9:27-57 Chest physiotherapy
9:41 Dopamine infusion rate decreased
10:01 Nurse applied cream to perineum
10:00-10 Physician altering ventilator
10:15 Mouth suctioned
360
APPENDIX IV 361
10:25-55 Clean abdominal sump and wound

10:47 New intravenous line started
10:53 Dialysis started
10:55-00 Suture of abdominal wound that had minimally dehisced
11:00-12 Nurse dressed wound
1 1:08 Physician working on mass spectrometer attachment to ventilator
11:18 Dopamine infusion readjusted
11:21 Fluid infusion increased
11:21 Bed position readjusted
11:34 Plasma given and infusion rate of other fluids increased
11:43 Arterial and central venous lines flushed
1 1:45 Trachea suctioned
1 1 :47-02 Physician irrigating abdominal sump tube; dressing of internal jugular central
venous insertion site
12:03 Intravenous infusion rate adjusted
1:40 Morphine given intravenously
1:45-55 Ankles bandaged
2:00-07 Manual ventilation by resuscitator; mouth suctioned and mouth care
performed
2:40-50 ECG trace taken
3:30 Vital signs taken
3:47-49 Eyes checked; eye drops added
3:51 Nurse auscultated chest and abdomen
3:54 Tube feeding
3:58 Tracheal tube suctioned
3:59 Nose suctioned
4:00 Patient still on dialysis (started 10:53)
PATIENT #2
Problems: Ruptured left diaphragm

Right hip fracture
Left femur fracture with Neufeld traction
Facial fracture and lacerations
Hematuria from ruptured bladder
Monitors: ECG, temperature, indwelling arterial line, Foley catheter, chest tube on
left, nasogastric tube
Medications:
Maalox Valium Tobramycin
Amphojel Tylenol Parenteral nutrition
State: Patient is conscious and mechanically ventilated through a tracheostomy tube and was on
a Roto-Rest bed
Time: 8:00 9:00 10:00 11 :00 12:00 13:00 14:00 15:00 16:00
Temperature (OF) 99.8 100.2 100 100 100.2

8:23 Vital signs taken
8:25-28 Physicians' examination and rounds
8:30-31 Nurse filled water in Pleurivac
8:33-36 Mouth care
8:37-45 Tracheostomy area cleaned
8:46-48 Physicians' examination of patient
8:48-51 Nurse placed intravenous line in arm
8:45-01 Nurse cleaned intravenous site

9:02 Urine volume measured and recorded
9:03-04 Tracheal suctioning and manual ventilation while tracheal stoma is suctioned
9:05-10 Nurse shaving patient
9:10-15 Cleaned other intravenous sites
9:26-27 Tracheal suctioning and manual ventilation with resuscitator
9:29-30 Steinmann pin in left femur cleaned
9:30-35 Teeth brushed
9:32 Nails cut
9:36-42 Trachea suctioned; patient lifted further up the bed
9:42-47 Roto-Rest bed fixtures rearranged
9:47 Bed turned on to right side
9:55 Bed turned further on same side
9:56-10 Chest physical therapist examined patient and chart
10:10 Bed starts rotating
10:24 Bed stopped rotating (15 min); trachea suctioned
10:27 Dextrose started intravenously
10:32-35 Manual resuscitator bag ventilation while patient is suctioned by nurse
10:40 Bed starts rotating
11:30-35 Vital signs and blood taken; neck cleaned
11:45 Trachea suctioned
12:05 Blood taken
12:07 Urine volume measured and charted
12:09 Trachea suctioned
12:13-15 Bed turned supine; rotation stopped (93 min); bed fixtures taken off
12:15-18 Patient pulled further up the bed; fixtures put back in place on bed; bed
turned to the left side
12:18-25 Cleaned perineum;' repositioned bed in horizontal position
12:25-50 Bed began rotating; eye drops given; bed rotation stopped (25 min)
12:50-1:30 Chest physiotherapy given; bed rotation stopped
1:30 Nasogastric feeding
1:30 Bed rotation begun; stopped at 2;06 (36 min)
2:06-10 Cleaned perineum
2:19-25 Removed bed fixtures after rotation was stopped; patient moved further up
the bed; replaced bed fixtures
2:30 Bed turned to right side
2:35 Urine volume measured and recorded; bed turned to right tilt side
2:43-50 Manual ventilation with resuscitator while the ventilator tubing was changed
2:50 Rotating bed started; stopped 10 min later
3:00-10 Chest physical therapist examined the patient; patient position readjusted
on the Roto-Rest bed
3:10 Chest physiotherapy given for 20 min (no bed rotation)
3:35 Bed repOSitioned: rotation started for 10 min
3:45 Vital signs taken; fixtures taken off; patient adjusted on bed
3:48 Urine volume measured and recorded
3:50 Bed fixtures replaced
3:50-53 Patient given range of motion exercises in bed
3:53-4:00 Bed rotation restarted (8 min)
PATIENT #3
Problem: Extensive gangrenous cellulitis of the left thigh

Monitors: ECG; temperature; triple-lumen, thermistor-tipped, pulmonary artery
catheter; radial arterial line; Foley catheter; nasogastric tube
Medications:
Cortisporin Amphojel Insulin
Silvadene Morphine sulfate Hyperalimentation
Ticarcillin Plasma Blood
Tobramycin Lasix
APPENDIX IV 363
State: Conscious and mechanically ventilated through a translaryngeal tracheal tube
Time: 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00

Temperature (OF) 99.8 98.9
8:00-10 Dressing wound

8:15-1 8 Blood intravenous line started
8:25-27 Intravenous infusion rate increased
8:28-32 Nasogastric feeding
8:28-33 Physicians' examination and rounds
8:33-43 Nurse cleaned wound area and changed dressing
8:47 Given intravenous antibiotics
8:50-00 Vital signs and blood taken
9:00-06 Physicians' examination
9:07-30 Wound area cleaned and dressing changed
9:34 Fluid infusion rate changed
9:41 Foley catheter taped into place on leg
9:42-49 New intravenous line started
10:17-22 Patient moved to a stretcher
10:37 Fluid infusion rate adjusted
10:53 Patient taken to hyperbaric chamber and for whirlpool and
debridement
2:35 Patient returned
2:30 Patient reattached to monitors
2:30-55 Dressing of gangrenous wound
3:00 Arterial blood drawn; line flushed
3:15-25 Nurse removed bandage
3:25-42 Suture procedure on wound
3:42-50 Wound bandaged
3:53 Patient lifted to put sheet underneath
PATIENT #4
Problem: 19-year-old female ejected from automobile; bilateral temporal contusions,

subarachnoid hematoma, multiple facial and mouth lacerations, left
pneumothorax
Admission: 15 days earlier
Monitors: ECG, Foley catheter, central venous and arterial lines, Richmond screw,
orogastric tube
Medications:
Pentobarbital Tylenol Nafcillin
Nystatin Sublimaze Lipids
KCL Lidocaine Alupent
State: In Pentobarbital coma, mechanically ventilated through a tracheostomy tube
Time: 8:00 9:00 10:00 11:00 12:00 13:00 14:00

Temperature: 101.8 102
Time Intervention HR MABP PA ICP CPP

8:35 Change ventilator tubing
8:40 Resting on right side
Head of bed 45 97 96 17 8 88
8:43 Calibrating respiratory monitoring system 97 95 17 9 86
8:43-8:57 Resting (same position) 1 00 95 17 8 87
8:58-9:02 Physicians examining patient 99 106 19 7 99
9:06-9:25 Resting (same position) 105 106 21 11 95
9:25 Lower head of bed (0 incline) 112 97 19 26 71
9:26 Nurse administers sublimase 117 101 19 27 74
9:27 Nurse rolls patient to side 106 98 26 38 60
9:28 Roll patient back supine 100 94 20 34 60
9:29 Uncross legs, preparation for pull up in 103 93 17 29 64
bed
9:30 Pull straight up in bed 106 91 17 30 61
9:31 Raise head of bed 45 96 97 22 15 82
9:31 Readjust ventilator tubing 100 100 21 10 90
9:32 Retape catheter tubing 94 96 20 04 92
9:34 Retape arterial and intravenous line 85 98 19 03 95
9:37 Resting 86 95 19 01 94
9:39 x-ray 102 118 25 02 116
9:40 After x-ray and lift 93 99 23 08 91
9:41-9:43 Lower head of bed 0 112 94 21 20 74
9:44 Turn onto left side 116 92 26 30 62
9:44 Raise head of bed 45 (still on side) 1 09 103 26 19 84
9:45-9:47 Reposition head and arms 119 146 26 24 122
9:48 Lower head slightly 101 124 23 18 106
9:49 Resting 98 110 22 16 94
9:51 Raise head back to 45 94 102 22 15 87
9:52-9:54 Physical therapy (ankle exercises) 116 106 24 15 91
9:55 Readjust neck collar 120 1 02 26 17 85
9:56 Readjust legs 117 150 25 21 1 29
9:57 Bagging 127 138 42 35 1 03
9:58 Reposition (uncross legs) 124 101 26 18 83
10:00-10:02 Suctioning 121 114 35 33 81
Suctioning 123 120 43 48 72
Bagging 123 116 37 56 60
Suctioning 120 111 49 52 59
Bagging 126 117 31 30 87
Mouth care 126 115 31 20 95
10:02 Lidocaine instillation through 116 116 27 30 86
tracheostomy
10:03 Readjust arterial line 114 122 28 37 85
10:05 Resting 101 107 24 25 82
10:07 Pentothal 109 98 23 07 91
10:10 Resting on left side 91 1 03 19 04 99
10:15-10:20 Shivering 115 1 09 21 8 101
10:21 Adjustments to lower arterial line 121 1 24 24 13 111
10:23 Resting 121 1 07 23 14 156
10:24 Physical therapy (goniometry) 116 1 21 21 10 111
10:26 Resting 109 1 04 21 7 97
11:24 Checking pupils-nurse talking 118 108 21 9 99
11:30-11:40 Resting 125 117 24 13 104
11:41 Gagging 117 107 33 22 85
11:42 Suction of mouth 120 110 23 14 96
11:43 Nurse talking to patient 123 112 25 16 96
11:49 Resting 119 112 24 15 97
11:51 Sublimase given 124 1 17 23 11 106
11:52 Head of bed lowered (0) 106 92 16 19 73
11:53 Pulled up in bed 113 85 17 20 65
11:54 Rolled to right side 114 96 19 27 69
11:55 Head up 45 104 1 02 22 16 86
11:56 Alupent inhaler 104 1 01 21 11 90
12:00 Nursing care 97 103 19 9 94
12:03 Wedging PA line 87 104 19 8 96
12:08 Application of lacrilube ointment around 108 127 22 11 1 16
eyes
364
12:09 Karaphate down N/G tube 110 112 25 13 99
12:10 Application of lotion on buttocks/thigh 110 107 24 15 92
12:12 Thermometer inserted 118 107 25 18 89
12:12 Rolled head flat 109 95 21 25 70
12:14-12:16 Chest P.T. by nurse 110 91 22 23 68
12:16 Na pentothal given Lv. 104 105 23 19 86
12:17 Thermometer (1 01.8) taken out 95 97 19 18 79
12:17 Resume chest P.T. 1 02 98 18 18 80
12:20 Stop chest P.T. 94 98 18 19 79
12:22 Suctioning 118 1 23 60 67 56
Bagging 1 28 104 57 50 54
Suctioning 128 112 24 34 78
Bagging 120 108 35 58 50
Suctioning 130 112 57 75 37
Bagging 114 1 26 45 55 71
12:25 End suctioning 125 120 31 40 80
12:26 Head of bed up 119 123 31 41 82
12:27-12:28 Suction out mouth 1 28 125 42 45 80
12:30-12:35 Resting-45 of back up-on right side 104 119 23 10 109
1:00-1:14 Resting-same position 1 08 109 22-25 8 111
1:15 Gagging 121 112 33 16 96
1:20-1:30 Resting 119 113 23 9 104
1:34-1:38 Dressing change (left chest tUbe)-start 120 108 25 14 94
1:39 Suction-mouth 126 115 35 26 89
1:43-1:44 Discontinue pentobarbital 117 110 22 12 98
1:45 Auscultation 114 108 22 10 98
1:48 Resting 111 107 21 11 96
1:50 Insertion of thermometer 1 02 104 20 11 93
1:51 Nurse speaking to patient for response 115 105 22 10 95
1:55 Hanging intra lipid infusion 117 109 22 10 99
1:58 Resting 125 1 23 38 27 96
1:58 Suctionlng 119 147 60 56 91
Bagging 121 138 49 25 1 13
Suctioning 1 18 135 51 46 89
2:00 Bagging 119 130 35 40 90
Suctioning 118 125 28 31 94
Bagging 1 18 126 32 35 91
2:01 Suction by mouth 121 1 23 29 21 102
2:02 Head down 114 113 23 28 85
2:03 Rolled on right side-remove 116 113 23 28 85
thermometer
2:04 Cleaned up and lotioned 114 1 08 25 28 80
2:05 Turn back 116 109 22 26 83
2:05 Rolled to left side 105 105 21 30 75
2:06-2:12 Head of bed raised 107 157 26 18 1 39
2:13 Resting (left side-head of bed at 45) 111 108 21 6 102
2:14-2:49 Visitors 103 104 20 6 98
2:50 Na pentothal given Lv. 1 12 108 24 9 99
2:50 Suctioning 1 11 149 56 30 119
2:51 Bagging 118 124 37 22 102
2:52 Suction mouth 120 1 22 26 14 108
2:56-3:04 Arterial line, reposition patient 112 136 23 11 125
3:30 Resting-wedging PA catheter 108 109 27 11 98
3:32 Pupils checked 1 12 111 28 11 100
3:37 Resting 106 109 26 11 98
3:45 Resting 111 116 29 10 106
3:46-47 Gagging 116 114 36 14 100
3:48 Cough/gagging 1 23 116 50 27 89
3:50 Resting 115 120 29 12 108
3:55 Occupational therapy 119 113 28 13 100
4:00 Resting 105 110 26 11 99
365
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Figure AIV.1. Heart rate (beats/min). mean arterial blood pressure (BP). pulmonary artery (PA).
intracranial (ICP). and cerebral perfusion pressure (CPP) are plotted against time from 8 A.M. to 4
P.M. for Patient 4. The raw data are tabulated. The plotted data in this figure illustrate the great
variability in all these measured parameters. Because of therapeutic interventions or general nurs-
ing care it is extremely difficult. if not impossible. for these vital signs to reflect only the effects of
a single intervention such as chest physiotherapy.
Index
Abbreviations and symbols, 353-354 Airway

Abdomen, gunshot wound. 360 conduction with cystic fibrosis treatment. 256
Abdominal binder. 322, 323 development. 251-252
placement. 267 resistance in infants. 252
quadriplegia and. 266-267 Airway closure. 90
Abdominal"compression diaphragm and. 30 compression. dynamic during cough, 241
Abdominal dehiscence. 3 2 2 conductance. 63
Abdominal distension. spontaneous respiration cough and. 324
and. 338 generations. 59. 61
Abdominal injury, incidence in patients with CPT. narrowing. repetitive cough and. 242
352 obstruction. criteria. 6
Abdominal muscles, 64 prone position and. 323
Abdominal surgery, CPAP and. 29 pressure gauge, compliance and. 75
Abdominal weight training (see Breathing pressure. pneumothorax and. 75, 327
exercises) resistance, 63
Abnormal airway resistance. causes, 63 collateral vs. normal, 238
Abnormal lung compliance. causes, 63 CPT and, 219-220
Accessory inspiratory muscles, 30 sputum volume and. 221-222
Accessory muscles Airway rupture
function with quadriplegia, 264-266 CPT and, 326, 326
Acini, 65 PEEP, 326
Acupuncture, 342 Airway secretion, drugs and. 72
Acute atelectasis. 45 (see also atelectasis) Airway length, 63
reversed with CPT for trauma patients. 1 1 Airway resistance. inspiratory and CPT in neonate.
Acute bronchiolitis 6
CPT and, 325 Alcoholic, PO depletion. muscle fatigue. 14
CPT lack of benefit. 26 Alternatives to standard CPT. 321
Acute indications. CPT and. 84-89 Alveolar capillary membrane, 64
Acute lung disease Alveolar COt. lack of plateau, 229-230
blow bottles. effect on. 298 Alveolar dead space, 68
bronchodilators. effect on. 296 Alveolar fibrosis. benefits of CPT. 6
bronchoscopy. effect on. 309-314 Alveolar gas. 7 1
cough. effect on. 159 Alveolar gas. inequalities o f mixing. 65
CPT and, 36 Alveolar macrophage impairment. and atelectasis,
IPPB. effect on. 387 13
IS. effect on. 298-301 Alveolar pressure. 63
percussion and vibration. effect on. 134. 136- CPT and, 7
136, 145 pulmonary capillaries and. 66
Acute quadriplegia. CPT and. 89 Alveolar proteinosis. 146-147. 1 8 1
Adrenergic agonists and tracheal secretions. 72 Alveolar ventilation, effects o n COz, 70
Adrenergic drugs and airway secretions. 72 Ahteolar-capillary block. 65
Advantages claimed for IMV. 36 Alveoli
Advantages and techniques of pain relief. 341-342 development. 251
Adventitial sounds in lung. 77-79 Alveolus
Aerodynamic valving. collateral airways and. 241 emphysema. 64
Aerosol normal. 64
clearance. 134-136. 147. 158-159. 283. 297 Analgesics (see also under Pain)
deposition. 134-136. 265-286. 287-288. 293. intramuscular. 342
296-297 turning and, 322. 323
size, 285 Analysis data from different ICUs. 231-236
Aerosolized detergents. 245 Anaphylaxis. 72
Age Anastomosis, airway rupture, 326
collateral ventilation and. 238 Anatomical dead space. 65
distribution of admissions. 351 Anatomical intrapulmonary shunt, 68
postoperative hypoxemia and. 13 Anatomy
Air bronchogram. 82-84, 310, 3 1 3 airway. 57-59
bronchoscopy and, 1 0 . 2 4 3 bronchial. 167
Air embolus. 3 2 2 lung lobes, 54-55
Airflow tung segments, 55. 60
cough and quadriplegia with. 271 Anesthesia. halothane and atelectasis, 1 7
367
368 INDEX
Anesthetic techniques. effects on respiratory left lower lobe. 328

system. 233 left lower lobe on chest x-ray. 81. 84
Apnea left upper lobe. 85
with infant positioning, 254 lower lobe. postural drainage. 82
Arachidonic acid metabolism products. 72 lung/thorax compliance and. 219
ARDS. elastin fibers and. 1 6 obesity and. 338
Arm exercises. dyspnea and. 1 5 on daily x-ray. 234-235
Arterial catheters. number with CPT, 352 partial gastrectomy and, 3
Arterial COt. CPT and. 225-227 positioning of segment nondependentiy. 241
Arterial line displacement turning and. 322 progressing to ..infection. 24
Arterial lines quadriplegia. 262, 261
turning with. 102 radiological resolution. 106. 1 1 2 . 243, 215
Arterial O2 saturation. during suctioning. 2 7 re-expansion by interdependence. 242
Arterial oxygenation (see PaOt) reabsorption of efusion, 321-328
CPT and. 3. 4. 5. 9. 2 1 6-218. 225-227. 228-23 1 . re-expansion through collateral airways. 11
325 right upper lobe. 1. 82
during bronchoscopy. 32 Sf'6 washout and. 15
increase with CPT. 2 1 sputum volume and, 220-222
lung/thorax compliance and. 242 surgery and. 2-3
PEEP and. 36 transpulmonary pressure and. 240
posture and. 3 1 V IQ and. 69
prone position, 325 volume of sputum and, 243
renal dialysis and. 338 x-ray. 2-3
sputum and. 242 Atropine, airway secretions and. 12
unchanged after CPT in trauma patient. 8 collateral airways and. 238
with CPAP. 2 6 Auscultation of chest. 14. 16-80
Arterial pressure. CPT and. 225-227
mean over 8 hours. 363-366 Bacterial filters, postoperative pulmonary infection
Arterialalveolar CO2 gradient. 229-230 and. 1 3
Arterial-venous Ol difference. CPT and. 225-221 Bactrim, postoperative chest infection. 13
Artificial coughs. CPT and, 4. 5. 228 Bagging. 147. 170. 1 71-1 78. 181-183
Artificial nose. 282 (see Humidifiers) details to remember. 355
Aspiration. 89 how performed. 359
CPT and. 89 problems, 324
prevention. 56 purpose, 359
transbronchial. 222, 224. 324 things to avoid. 359
Assisted ventilation. 31 when used. 359
Asthma Barbiturates
bronchial. 0 and. 65
..... head-down position and. 322
case study. 215 head injury and. 335
chest physiotherapy. 214-216 reduction of lep and, 262
collateral ventilation and. 238-239 turning and, 322
Asthma. mucus hypersecretion and. 13 Bed
Atelectasis. 136, 131. 196-191. 210-211. 282, 2 9 1 . ability to exercise patient. 115
298. 299. 300. 302. 310-312 air fluidized. 110-111
abdominal surgery and. 2 associated deep vein thrombosis, 1 1 6
after extubation. 1 associated infection. 1 1 6
after pediatric surgery, 126 case history. 112
alternative therapies to CPT. 243 cost. 111
anesthesia and, 2-3 effect bedside diagnostic tests, 113
blood flow and. 14 effect on patient care, 195-196
bronchopleural fistula and. 332 elevated intracranial pressure and, 1 1 4
bronchoscopy and, 32 kinetic. 1 11-119. 268
bronchoscopy compared to CPT. 10. 242-243 large person. 110. 113-116
case studies improving. 106. 112. 215 low air 1055. 1 1 0-111. 113-118. 119
cholecystectomy and. 3 modifications for postural drainage, 109
clinical examination. 3 mortality. 116
CO2 curves and. 15 patient comfort. 1 1 3
CO2 excretion and. 10 patient evaluation. 1 1 3
collateral ventilation and. 239-242 patient mobility. 1 1 5
CPT and. 2 1 7 postural drainage. 114
diaphragm function and. 15 pressure sores. 115
expanded by bronchoscopy. 32 recommendations for specialty, 113
expansion by CPT, 1 Rota-Rest, 199. 361-362
hernia repair and. 3 safety. 116
incidence. 2-3 specialty (table). 113-1 1 7
infants and. 1 spinal alignment, 114
isolated bony injuries and, 339 standard. 109-110
INDEX 369
sllctioning. 1 1 4 IPPB. 289-293

turning ease, 1 1 3 isocapneic exercise. 1 2 1
turning frame. 105. 106. 1 10-119, 268-269. 275 magnetometry with. 1 2 1
types. 1 1 0-119 methods o f teaching, 127-128
Benefit from CPT with pneumonia. 86-86 number treatments per year. 350
Binder (see Abdominal binder) purpose. 358
Biofeedback pursed lip breathing. 120
breathing exercises. 1 2 1 quadriplegia and, 267, 271-272
Bladder rupture, 361 relief of dyspnea. 274
Blood-gas changes. acute indications for CPT, segmental. 1 1 9
84-85 shoulder exercises and, 1 2 8
Blood pressure skin graft and. 341
attenuation increase with CPT. 26 summed breathing. 272
turning and. 322 surgical patient and, 1 1 9
Blood-gas barrier. 64 things to avoid. 358
Blow bottles. 281, 297, 298, 303 unilateral. 7
compared with CPT. 298 ventilatory muscle training, 1 2 2
Body cast. 74 table. 123-125
Body systems injured. patients receiving CPT when used, 358
Bohr. effect. 70 Breathing regulation, 64
Dony injuries. CPT and. 352 Bronchi Ibronchiole
Bradycardia. suction and. 333 anatomy. 57-59
Brain injury. 1 6 1 . 198. 201 . 203 (see Head injufY) collapse, 59
guidelines for chest physiotherapy. 260-261 Bronchial breath sounds, 76
ICP Bronchial drainage. (see Postural drainage)
monitoring. 103, 259 thoracic surgery and, 2
measures to reduce. 261-262 vs. deep breathing and cough, 247-
indications for chest physiotherapy. 259 248
medications to reduce ICP. 261-262 Bronchiectasis. 9 . 136. 159
mortality. 258 Bronchiectasis. CPT and. 26
positioning after craniotomy. 104 Bronchiolar channels. 238
sedation for treatment. 262 Bronchiolitis
turning patient for chest physiotherapy. 103 acute in infants. 251. 253
Breath sounds. 76-79 effect of chest physiotherapy. 253
clinical exam. 78-79 Bronchitis, chronic (see Chronic bronchitis)
Breathing, at low lung volume. 69 Bronchoalveolar lavage (BAL). 1 7 , 87
Breathing exercises. 2. 3. 37. 1 3 5 . 1 38, 139. 140. Bronchoconstriction. chronic bronchitis and. 6
143. 145. 246, 247,271-274 Bronchodilators, vii. 1 3 7 . 288. 291. 294. 295-297
abdominal weight training, 271-272 arterial oxygenation and. 7
airway rupture and. 326 collateral airways and. 239-241
biofeedback with, 1 2 1 use, 37, 42
breathing control. 1 1 9, 1 2 0 affecting comparisons between therapies. 243
breathing retraining. 120, 1 2 1 effect of. 296
chronic lung disease and. 273-274 IPPB. 288. 291 . 294
chronic sputum production and. 89 tOXicity, 296
compared to incentive spirometry, 126, 297-301 Bronchopleural fistula, 143
compared to intermittent positive pressure CPT and. 332
breathing. 126. 287-301 empyema and. 330
compared to positive expiratory pressure. 126. HFV and. 37
302 high frequency ventilation and. 332
comparison with exercise. 1 2 1 , 257 side position and. 323
COPO and, 119-121 Bronchopulmonary dysplasia
costal. 8 associated pulmonary infection. 253 (see Infants)
costal excursion. 126-128 Bronchopulmonary lavage. effect of percussion &
details to remember. 358 vibration. 146-147 (see also Lavage)
diaphragmatic. 1 19 , 120, 126-128, 2 7 1 Bronchopulmonary segment on xray. 80-89
effect after pediatriC surgery. 1 2 6 Bronchopulmonary segments, 2. 59-60
effect after surgery. 122,126, 127 Oronchoscopy, 32. 43. 162. 1 4 1 , 145. 1 8 1 , 2 1 1 . 2 9 1 .
effect of leaning forward posture, 120 301-3. 1 4. 340
EMG evaluation. 1 2 1 air bronchogram. 83. 310. 3 1 3
forced expiration technique. 1 2 1 . 256, 258, 274. cardiac dysrhythmias, 304-307
276 compared to CPT. 309-314
glossopharyngeal breathing, 272 compared to incentive spirometry. 1 0
goals. 1 19 complications of, 303-308. 3 1 3-314
how performed, 358 contraindication. 33
inspiratory muscle training lable, cough, 162
123-125. 271-272. 2 7 3 vs. CPT. 26. 32. 228. 309-314
intracranial pressure wilh, 259 efficacy in nonintubated patient. 32
370 INDEX
Bronchoscopy-continued Cardiovascular dysfunction. turning and. 322

ha7.ards. 337 Cardiovascular instabilitv.
. CPT and. 325
hemodynamic changes during. 32 Carina. 57-58
hypoxemia. 305-307 Cascade humidiiers (see Humidifiers). 283
incidence and usage. 38 Casts
indications. 10, 32 ankle. 189. 197-198. 205
IPPB and. 391 skin breakdown. 198
lavage. 305-30B. 309 Catecholamines. airway secretions and. 72
neonates. 309. 312 Central nervous. output and diaphragm runction.
percussion. 141 16
precautions, 303-308 Central venous catheters. number with CPT. 352
resistance. 308-309 Cerebral compliance
restrictions to use, 308-309 evaluation with brain injury. 260
suctianing during. 305-306 Cerebral contusion. 335-336
therapeutic. 21" 328 CPT and. 335-336
too hazardous in criticallv
. ill, 11 Cerebral palsy
unacceptable risk. 244 chest physiotherapy with. 258
vibration during. 141 Cerebral perfusion pressure. (CPP). 141
visualization, 312-313 head down positioning and. 259
Bronchospasm. 141. 145. 164, 288, 293. 296. 297. turning and. 104
304. 312 Cerebrovascular autoregulation. 335
asthma and. 275, 276 Cervical spine injury. 234-237
quadriplegia and, 267 Cervical spine traction loss. head down position
Bronchospirometry. 7 and. 322
Bronchus tear. CPT and. 328 Channels of Lambert. 252
Bulk convection. 64, 65 Chest
Burns. CPT and. 337. 340 clinical examination. 73-80
complications sher surgery. incidence. 12. 13
Capillary pressures diameter. with respiration. 63
specialty beds and. 111 injury. 234-237
Capillaries. pulmonary. 65-67 percussion. chronic bronchitis and. 6
Carbon dioxide. diffusion. 60 splinting. pain and. 7
airway obstruction and. 239-242 tube. bloody drainage. 75
bronchopleurallislula and. JJ2 CPT and. 329
collateral airways and. 238 turning with. 102
dissociation curve. 70 tube dislodgement. turning and. 322
end tidal CPT and. 335 vibration. chronic bronchitis and. 6
excretion. hyperalimentation and. 337 Chest Physiotherapy (CPT). 21-27
increase with CPT. 26 abdominal gunshot wound and. 360
normal values in circulation. 66 abdominal injury and. 352
partial pressure with CPT. 5 acute bronchitis and. 3. 4
production CPT and. 342 acute lung pathology and. 3
Carbon monoxide. affinity for hemoglobin. 65 alternatives to standard therapy. 321
Carcinoma lung. abscess and. 332 arterial alveolar COl gradient and. 228-230
Carcinoma of bronchus. 324 arterial COl and. 225-227
Carcinoma of lung. CPT and. 326 arterial oxygenation and. 216-218. 225-227. 325
Cardiac arrest. 228 arterial pressure and. 225-227
Cardiac changes. interventions and. 360-366 arterial venous OJ difference and. 225-227
Cardiac disability. CPT and. 5 asthma. hypersecretion and. 73
Cardiac disease. CPT and. 321 atelectasis and. 8
Cardiac dysrhylhmias bag squeezing and. vii
cough. 161 barbiturates and. 335
CPT. 137. 148 blow bottles. compared to. 298
suctioning. 27. 170. 172-176. 178, 179 brain injury and. 260-261
Cardiac failure bronchodilators. used with. 295-297
CPT restriction and. 332-333 bronchopleura fistula and. 332
sitting patient up. 333. 334 bronchoscopy. compared 10. 309-314
Cardiac function bronchus tear and. 328
acute 234 burns and. 337
baseline return. 333 cardiac function and. 26. 227-228
following quadriplegia . 256 cardiac output and. 225-227. 333
position and. 242 cardiovascular instabi lity and. 325
Cardiac output. 138. 146. 170. 181. 189. 190. 303 cerebral contusion palie;lt and. 363-265
bagging and. 324 cerebral contusion and. 86
CPT and. 4 . 5. 225-227. 228 cerebrospinal leak and. 336
increase during CPT. 6. 26 cervical spine injury and. 234-237. 352
measurements. 244 chest injury and. 234-237. 352
normal. 65 chest xray and. 216. 234-235
Cardiorespiratory function after CPT. 225-227 chronic bronchitis and. 4
INDEX 371
chronic disease and, 2 1 6 lung/thorax compliance and. 216-219. 225-227

chronic lung disease and. 272-274 manual and CPT
chronic V5. acute lung disease. 243 mass spectrometry and, 228-231
c08gulopathy and. 228 mass spectrometry during. 231
collateral airways and. 238-242 mechanisms of action. 237-242
combination of components. 22 medical vs. trauma patient. 233
compared to broncho!;copy. 32 monitors on patients receiving. 352
contention and conflict. 41-45 mucolytics. used with. 295-297
continuous infusion analgesia and. 26 multisystem injury and. 235
contraindications. 321-342 neonates and. 325
contusion and, 2 1 7-218 Neufeld traction and. 105. 352
cost. 2 1 5 neurologically involved child and. 258
CPAP. compared with. 301-303 nonlrauma patients and. 321
critically ill patient and. 26. 216-217 number in critical care unit. 349
cystic fibrosis and. 21. 256-258 number in ICU. 349
duration. 258 number i n neurotrauma unit. 349
frequency. 258 number nontrauma patients receiving. 350
deadspace and. 225-227 number spine injury and. 349
description. 33 number trauma patients receiving. 350
detrimental in bronchiolitis. 26-27 number treatments per year. 350
differences at different centers. 40. 46 number with arterial catheters and. 352
differences in techniques. 38 number with central venous catheters and, 352
duration. 5, 33 number with intraventricular catheters and. 352
duration of followup. 233-237 number with pulmonary artery catheters and.
effectiveness when parts omitted, 22 352
effects. misconceptions. 38 nurses and. 34
effects of mechanical ventilation. 233 01 consumption and. 69. 225-227
eHects of therapeutic interventions. 233 objectives. 33-34
end points. 33 organization. 34
end tidal COl during. 231 orthopedic fixation and. 352
evaluation. 247 oximetry and. 24
evaluation during mechanical ventilation. 356 pain and. 341-342
evaluation during spontaneous respiration. 356- pain medication and, 341
357 PaOllFl0l and. 85. 216. 218. 235-236
extrapleural hematoma and. 332 patient cooperation and. 246
extremity rracture and. 234-237 patient population and. 232-233
fat embolus and. 335 PEEP and. 216-217
fentanyl infusion and. 228 pelvic fracture and. 234-237
follow.up. 34 pelvic injury and. 352
for postoperative or traumatic injury patient. 2 1 PEP. compared to. 301-303
for trauma patient. 216-218 physicians responsibility. 342
frequency of treatment. 355 physiological changes. 215-248
head injury and. 234-237. 352 physiological changes and. 234-237
hemoptysis and. 326 plastic surgery and. 337
historical summary. 1-2 pneumonia and. 8 . 86
hypoxemia and. 325 positioning for. 357
in asthma. 274-275 vs. postural drainage. 244
in infant. 253-256 precautions in use. 321-342
clinical assessment. 254 prophylactic use, 89-90
duration. 255 pulmonary catheter and. 331
frequency. 253. 255 pulmonary hemorrhage and, 326
indications, 253 pulmonary vascular resistance and. 225-227
in patients with no fracture. 326 quadriplegic patient. 267-271
incidence in head injury, 335 radiological indications. 80-89
indications for therapy. 225 raising intrathoracic pressure. 3, 4
indications in chronic lung disease. 10 rationale. 247
individual components. 24 reducing requirements for PEEP. 225
injury severity score and, 348 response to treatment. 95
internal fixation and, 352 retained lung secretions and, 3
intracranial pressure monitor and. 335 risk benefit and. 8
IPPB, compared to. 289. 291-292 risks minimized. 342
IS, compared to, 289-301 Rota-Rest bed and. 361-362
lack of standardization. 40 routine evaluation, 356-357
laparotomy CPT and. 3 ruptured aorta and. 334
limb injury and. 352 see Breathing exercises
literature review, 1-33 see Bagging. 170. 111-178. 180-183
lumbar spine injury and. 352 see Cough, 154-165
lung abscess and. 89 see Mechanical percussors/vibralors, 144, 146-
lung contusion, 8. 87. 89, 326. 331 149
372 INDEX
Chest Physiotherapy---con!inued effect of cough. 158-159, 162-163

see Mobilization of patients. 137. 165. 195-211 effect of lavage. 1 80-181
see Percussion. 124-149 effect of mobilization, 191
see Rib fracture effect of mucolytics, 295-297
see Suctioning. 165-180 effect of PEP, 302
see Vibration. 124-149 effect of percussion and vibration. 135. 136
skeletal IracUon and. 352 effect of turning. 94
small airways and. 231 eHect of ventilatory muscle training. 121
smoke inhalation and. 89 humidity for. 282. 285-286
spinal injury level and. 352 indications for chest physiotherapy. 274
spinal rods and. 352 IPPB. 287-291, 293-295
spine injury and. 336, 352 oxygenation. 94
spontaneous respiration and. 4 postural drainage. 94
sputum volume and. 220-222 Chronic obstructive pulmonary disease. collaleCtlI
statistics. 345-352 airways and, 238-239 (see Chronic lung
subarachnoid hematoma and. 363-365 disease)
subcutaneous emphysema and. 328 CPT and. 24. 225, 245
summary. 355-359 Chronic respiratory failure. CPT and. 321
systemic vascular resistance and. 225-227 Chronic sputum producing disease. CPT and. 89
the neonate and. 8 Chronic vs. acute lung disease. CPT and. 43
thoracic spine injury and, 352 Cilia. 147. 153-154. 182, 295-297 (see also Mucus)
thrombocytopenia and. 340 bronchodilators and mucolytics, eHect of. 295-
to speCific lobes. 350 297
traction and. 339 dynein arms, 17
transbronchial aspiration and. 222, 224 humidification of. 281-282
trauma patient and. 8 Circulomatic bed, 340
unconsciousness and. 246-247 Clapping. 4
unconscious patient. 262 Clapping of hand on chest. frequency. 24
undesirable effects. 321-342 Clara cells and mucus. 71
unsedated patient and. 228 Clavicle fracture. side position and, 232
V/Q mismatch and. 85 Clavicular fracture CPT and. 332
ventricular function and. 333 Clavicular fracture incidence in patients with CPT.
visual aids. 34 352
wedge pressure and. 225-227 Clinical indications CPT. summary. 90
Chest tubes. turning and. 102 Closing volume. 190-192
Chest wall. Coaguiopalhy, 142. '144-145
dyssynchronous movements. 16 CPT and. 326
eHects on interdependence. 2-40 exlrapulmonary hematoma and. 332
lung/thorax compl iance and. 219 Collateral airway resistance. 237-240
obesity and, 338 Collateral airways. 11. 59. 61
postoperative hypoxemia and. 13 interdependence and. 238
regional function. 244 recruiting lung, 27
strapping. 2 8 role in disease. 238-239
Chest x-ray. after CPT, 2 1 6 surfactant and. 240
CPT and, 234-235 time constant. 239. 241
portable. 216 Collatera l channels. CPT and. 4
segmental identification. 242 Collateral ventilation. 298. 303
technique. 80-89 atelectasis and. 239-242
2, chloroprocaine. musculoskeletal pain and. 341 development of. 238-239
Cholecystectomy. 137. 206-208. 292. 301 gas exchange and. 237-240
diaphragmatiC function and. 1 5 gravity and. 239
incentive spirometry and. 2 9 lung volume and, 1 2
prophylactic CPT. 23 regional distribution. 238-239
Cholinergic agonists and tracheal secret ions, 72 Comparison CPT to other regimens. 40
Cholinergic blockade. collateral airways. 238-239 Complement. mucus production and. 73
Chronic bronchitis. 5. 6. 44. 136. 158-159 Compliance. 63
acute exacerbations. 9 CPT and. 8
comparison with sham treatment. 10 definition. 63
duration of hospital stay. 10 Complications. respiratory therapy. 21-32
expiratory flow and CPT. 10 Components of CPT. 244
lack of benefit of CPT. 10 Composition of respiratory mucus. 71-73
sputum production. 10 Compression chest PT and. 4
stable and CPT, 10 Compromises. CPT and bony fractures. 339-340
9'J"'Tc in expectorated secretions. 1 0 Computerized axial tomographic scans and
Chronic lung disease atelectasis. 17
CPT and. 38. 216, 272-274 Conciousness. depressed, CPT and. 89-90
effect of breathing exercises. 119. 120 Condensers. 282-284 (see also Humidifiers)
effect of bronchodilators, 295-297 Conductance. rise with CPT. 9
INDEX 373
Conducting air passages, 59, 64 mucolytics. effect. 196

Conflicting data about CPT, 41-45 nebulizers. 285
Contact heel percussion. 138. 143-144 pain. 153, 161-162. 182
Contamination posture. effect on. 160-161
condensers. 283 preoperative training. 161
incubators. 282 pressures generated with. 155. 156-157, 161-
IPPB. 293-29' 162
mist tents, 282 prevention. 324
nebulizers. 265-286. 297 problems, 324
suctioning. 179. 180 pus and. 332
water bath humidifiers. 286-287 quadriplegia and, 267-269
Continuous passive motion (ePM). 196 radioactive tracer clearance and. 1 0
Continuous positive airway pressure (CPAP). 281. renex. 1 54-155
297-298. 301-302. 303 repetitive. 242
and FRC. 27. 29. 43 small airway clearance and. 244
compared 10 CPT. 2 7 . 302-303 spontaneous. 207. 208
reduction with suction. 324 sputum and, 242
weaning. 36 stages of. 154-156
Continuous flow ventilation. 37, 65 stimulation of. 154-155. 159. 162-165. 179-180.
Continuous intravenous analgesia. 34: 1 180-183. 2.2. 292
Continuous passive motion (ePM). 196 summed breathing. 163
ContracLurcs. 194. 199 suppression. 159-162
Contraindications, CPT and. 321-342 tracheal stimulation, 163
Contro coup. lung contusion. 326 tracheal tubes. effect on. 160
Contral lo compare CPT, 231 transtracheal aspiration. 164-165, 297
Controlled ventilation. atelectasis and anesthesia. two phase concurrent low. 158
17 velocity, ISS. 157. 1 5 8
Contusion vibration. effect on. 163
coagulopathy. CPT and. 228 vomit. 163
indication for CPT. 228 Coughing. 2-3
transbronchial aspiration and. 222. 224 assisted. treatments per year. 350
Coronary perfusion. 334 deep breathing incidence and. 247
Coronary sinus. 68 details t o remember. 359
Cost. CPT and. 215 how performed. 358
Cost effectiveness. rehabilitation. 248 prolonged adverse effects. 23
Costophrenic angle. blunting on xray. 80 purpose, 358
Coud6 catheters. 167 (see also Suctioning) things to avoid. 358
Cough. 4 1 . 135-142. 154-165. 299. 300 when used. 358
acute lung disease. effect on, 159 Crackles. 75-80
airway compression with. 155, 156-159 Crainotomy. side position and. 323
airway rupture and. 326 (see Head injury)
bronchoscopy, 309, 312 Craniotomy. precautions with, 336-337
vs. ciliary action. 242 Cricoid cartilages. 57
vs. CPT. 22. 158-159 Criteria for pneumonia diagnosiS. 87
clearance of secretions. 241 Criticnl care unit. duration stay. 347
collateral airways and. 241 number receiving CPT. 349
compared to chest physicotherapy. 158-159 Critically ill. CPT and. 216-217
compared to Nacetylcysteine. 7 Cerebrospinal fluid vent. 322
complications or. 161 Curfed tracheal tube and sputUnl. 40
control of. 154-155 Curve, Ol hemoglobin dissociation. 69-70
controversy. 2 2 Cyclooxygenase pathway. 72
cystic fibrosis. 9 5 . 257 Cystic fibrosis. 6. 9, 28. 45. 135. 136. 158-159. 1 8 1 .
effectiveness, 154-155, 157, 161. 163 287. 296-297. 301
effect of pectoralis major. 264 and PEP. 31
enhanced in quadriplegia, 336 benefits of CPT, 6
forced expiratory technique, 1 2 1 . 158-159. 1 60- cough vs. postural drainage, 95. 254, 257
161. 162-163. 258 errect of exercise. 257
failure to exclude. 247 effects of ventilatory muscle lraining. 1 2 2
flow generated with. 155. 156. 157. 158 expiratory reserve volume. 6
flow limiting segments (FLS), 157 forced expiration technique, 121
forced expiration, 156-159. 162-163 forced vital capacity, 6
glossopharyngeal breathing and. 163. 272 inspiratory reserve capacity. 6
glottiS function during. 155-157. 161 large airways. 6
head injury. 160 mucociliary clearance and. 6
huffing, 162-163 peak expiratory flow rate, 6
IPPB. use with. 291 Pulmonary function with CPT. 254-258
manual support. 162-163 quiescent vs. active. 21
minitracheostomy, 164-165 treatment time. 256
374 INDEX
Oalck eHect. 148 DNA in sputum with CPT. 24

Dead space. 68, 71 Double lumen tracheal tube. 326
anatomic. 59 Doxopram and purulent sputum. 13
CPT and. 225-227 Dressings on chest. clinical examination. 74
Decort icate patients. 35 Drugs and mucus. secretory responses. 73
Decortication. empyema and. 330 Dry spirometry. assessment of ventilatory capacity.
Deep breathing. 8, 1 3 7 . 240-242. 288-290. 292, 7
297. 298-303 (see Breathing exercises) Duct cells and mucus. 71
collateral airways and. 240 Dural tear. CPT and. 336
collateral ventilation and. 12 Duration
exercises. 28 average annual of CPT. 350
vs. incentive spirometry. 247 benefit CPT. cystic ibrosis and. 6
Deflation. time constant. 241 CPT. 33
Dehiscence. cough and. 337 CPT. variability. 39
Dependent good lung. 325 ecreets. 245
Diagnosis pneumonia. dificuity. 87 Dye dilution cardiac output. CPT and. 4
Diagnostic criteria for pneumonia. 16 Dyspnea. breathing exercises and. 247
DialYSiS. renal 234 effect of leaning forward posture. 120
Diameter. airways. 63 reduction, 245
bronchi. 59 Dvsrhthmias. nasotracheal suction and. 325
Diaphragm. 63 (see Breathing exercises) with CPT. 333
contraction. 94 Dyssynchronous movements of abdomen. 16
dysfunction arter surgery. 1 2 6
excursion o n a turning frame. 269 Effecl, of CPT. 38
exercises, 248 Elastic recoil force. chest wall. 63
rlatlening. 16 lung. 63
function and thoracic epidural. 20 Elastin fibers. pneumonia and. 16
function with quadriplegia. 264-266 Electrocardiogram. cardiac failure and. 333
movement and mechanical ventilation. 19 Emergency tracheal intubation. 35
muscle fibers. 252 EMG
pacing. 27 evaluation of breathing exercises. 121
phrenic nerve and. 16 respiratory muscle evaluation in quadriplegia,
postoperative hypoxemia and. 13 265-266
quadriplegia and. 89 Emphysema. 136. 162. 287. 289
rupture. 361 collateral airways and. 238. 239
silhouette sign. chest x-ray and. 80-84 Empyema CPT and. 329-330
tone and anesthesia. 1 8 End-points CPT. 33. 246
Diaphragmatic breathing (see Breathing exercises) End-tidal CO,. 84
Diaphragmatic function changes with brain injury treatment. 259
after cholecystectomy. 1 5 CPT and. 228-23 I
after upper abdominal surgery. 1 5 emphysema and. 230
and hypoxemia. 1 5 Endurance. respiratory muscles. 248
and reduced vital capacity. 1 5 Engstrom 300. lung thorax compl iance. 2 1 8-219
atelectasis and. 1 5 Epidural anesthesia
impairment b y surgery. 1 5 diaphragm function. 15
neuromuscular dysfunction and. 1 5 pain and. 341
obesity and. 338 Epidural. thoracic. and diaphragm function, 20
opiate epidural analgesia and. 15 Epiglottis. 57
pain and. 15 Erect chest x-ray. 80-89
Diazepam Errors of shunt calculation on 100% OJ' 69
to reduce ICP. 262 Esophageal bal loon. 63
Differences. CPT techniques. 228 pressures with cough. 161-162
Differential lung ventilation. 37 Essentials CPT treatment. 358-359
Dirfusion capacity Ethics, CPT and. 244
for CO (D,,, ) . 65 Evaluation CPT. routine. 356-357
for 01, 65 Evisceration. 322
Dirfusion constant. 64 Examination of chest with mechanical ventilation.
in disease. 65 73-80
passive. 64 Exercise. 1 3 7
Diminished movement. chest. 74 asthma and. 274-275
Directed supervised coughing. cystic fibrosis and. chronic lung disease and. 272-273
27 compared to chest physiotherapy. 257
Discharge home. numbers. 347 (see Breathing exercises and Mobilization)
Displacement of fracture. turning and. 322 Exercise tolerance. breathing exercises and, 247
Disseminated intravascular coagulation, 340 Expiratory now rates
Distended abdomen. head down position and. 322 cystic fibrosis treatment and, 257
Distribution of ventilation and blood flow. 7 Expiratory muscles and FRC. 1 5
in lung. 67 muscles of. 64
INDEX 375
Expiratory reserve volume, 62 CPT and small airways. 243

effect or pectoralis major. 262 effects of breathing exercises. 1 1 9
External fixator. 322 PEEP and. 85
Extraalveolar vessels. lung volume and. 66 reduction postoperatively. 2 9
Extracorporcal membrane, COl removal. 37 rise with CPT. 9
Extrapleural hematoma, 332 sitting. 62
Extremity fracture. 234-237 supine. 62
Eyes. protection, 323 Functions of respiratory mucus. 71-73
rvc (see Vital capacityl
Facial fractures, 328
Factors affecting measure of airway resistance. 220
Gangrene. 362-363
Fat embolism. CPT and, 335
Gas exchange, 64
Fat embolus. 193
and CPT. 4
Feeding tubes
collateral ventilation, 237-240
postural drainage and, 102-103
Gas mixing. 65
Femur. fracture. 361
Gas transport. 64
Fenestrated tracheostomy, 35
Gas trapping. 37
Fentanyl
Gastroesophageal reflux
epidural. 341
postural drainage precautions. 102-103
infusion with CPT, 26
General anesthesia. 233
to reduce ICP. 262
Glasgow Coma Scale. CPT and, 335
FET and copious sputum, 25
Glossopharyngeal breathing. 163 (see Breathing
FeV1 and bronchoconstriclion. 6
exercises)
FeV, fall with CPT. 6
Glottis. 57
Fiberoptic bronchoscopy (see Bronchoscopy)
function during cough. 156-157. 159. 161
Fiheroptic bronchoscopy compared to CPT 8, 216
function with huffing. 162
(see also Bronchoscopy)
humidity. 281
Finger clubbing. 75
Goblet cells. 252
FIOI requirements reduced by CPT. 225
and mucus, 71
Fissure horizontal. 54
Gram stain and pneumonia. 16
Fissure oblique. 54
Gravity
Flail chest
atelectasis and. 241
CPT and. 327-328
collateral ventilation and. 239
side position and. 323
drainage from bronchus. 2
Fluid. horizontal fissure and. 222. 224
Forced expiratory technique (FET) 22. 28. 4 1 . 135-
136. 142.156-159. 162-163. 302 . 303. 324 Haldane effect. 70
(see Breathing exercises) Halo vest. 74. 196-197. 336
compared with cough. 158-159 problems with side position. 323
details to remember. 359 (see Spinal fracture. quadriplegia)
how performed. 359 Handling (see Infants)
postural drainage and. 2 2 Head down position
pressure gradients. 241 acute spinal cord injury and. 334
purpose. 359 cardiac failure and. 333
things to avoid. 359 cerebrospinal leak and. 336
when used. 359 contraindicated with peritoneal dialysis, 338
Forced expiratory volume (FEV1) CPT and. 335. 349. 352
asthma treatment and. 274 myocardial ischemia and. 334
chronic lung disease and, 272 problem. 322
cystic fibrosis treatment and, 256. 257. 258 Head injury. 141. 145. 157. 234-237 (see olso
r'owler. dead space. 59 Brain injury)
Fractures. 193, 199 bed positioning for. 197-198
abdominal binder and. 266 cough, 160, 161
CPT and. 339 head down. 335
positioning with dislocation. 106 incidence in patients with CPT. 352
positioning with femur. 105-106 number CPT and, 349
positioning with pelvic. 105-107 Head up position problems. 323
quadriplegia and. 264 Head-injury. decerebrate. 35
spinal (see Spinal fracture) Heart. left. 66
Frequencies chest percussion. 244 Heart rate. over 6 hours. 363-366
Frequency CPT treatment. 355 Heat and moisture exchangers. 262-284 (see
Frozen shoulder. 200 Humidifiers)
Functional residual capacity (FRC). 28. 60. 62 Hematoma
abdominal binder and. 266 absence with pelvic fracture. 338
after PEP and CPAP, 31 pelvic fracture and, 338
collateral airways and. 238 Hemoptysis. 143. 164-165. 304
changes with postural drainage. 94 CPT and. 326
CPT and. 8 Hepatic disease. CPT and. 3 2 1
376 INDEX
High frequency compared to conventional response of handling. 254

ventilation. 37 suction and. 169-178. 179. 324
High frequency oscillation Hypoxia. postoperative mechanism. 13
bronchopleural ristula and. 332 Hypoxic pulmonary vasoconstriction. 69
effects on mucus. 30 abolition. 6
High frequency ventilation. 30. 37, 65 collateral airways and. 238
Hip. fracture. 361
Hospital stay shortened by respiratory therapy. 28- I CU
29 duration stay. 347
Hospital transfers number. 347 number receiving CPT. 349
Huff (see a/so Breathing exercises) Immobility. 153. 188-195
Huff. collateral airways and. 241 cardiovascular system. effects on. 188-190
Huffing. 2 7 . 162-163, 358 casting. 189. 197-198, 205
Humerus fracture. side position and. 323 central nervous system. effect on. 195-196
Humidification use, 37 closing volume. effects. 190-192
Humidification, anesthesia and. 233 contractures. 194
Humidifiers. 281-287. 293 decubitus ulcers. 194-195. 197. 204
artificial nose, 282 fat embolus. 193
cascade. humidifiers. 282 fractures. 193
condensation. 285, 286 kidney stones. 193
condensers, 282-284, 287 malnutrition. 189-190
contamination. 283. 285-287. 297 metabolic system. 193
dead space, eHect on, 283 musculoskeletal system. 193-195
heat and moisture exchangers. 282-284 orthostatic hypotension, 1 68-190. 201-204. 2 1 1
high frequency ventilation, 284. 287 osteoporosis. 193
instillationlinfusion, 284 pain. 189, 191
lavage. 285-287 physical deconditioning, 1 89-190
mechanical ventilation. use with. 282-287 pulmonary embolus. 190
minimum output. 282. 283, 287 quadriplegia, 190
mucolytics. 296 respiratory system. effects on. 190-193
muscle fatigue. use with. 283 sleep patterns. effect on. 195
nebulizers. 284-286. 287, 299 splinting. 189. 198
neonates. use with. 283. 285 venous thrombosis, 190
normal humidity. 281-282 Immobilization, problems in multiple trauma. 339
pulmonary function. eHect on. 285 Immunosuppression from general anesthesia, 13
resistance effect on. 283. 285 IMV
water bath, 286-287 benefit in muscle fatigue, 14
weaning. use with, 283 compared to conventional ventilation. 36
Hyaline membrane disease. 139 intermittent mandatory ventilation vii. 3. 36-37.
rib fractures 329 (see Bronchopulmonary 74
dysplasia. infants) rib fracture displacement and. 329-330
Hydration. pneumonia and. 243 Incentive spirometry. (IS). 8, 28, 43. 137. 207. 297-
Hyoid bone. 56 301. 303. 340
Hyperbaric chamber. gangrene and. 362-363 chest physiotherapy. compared with. 298-
Hyperinflation. 5, 169, 171-178. 180, 181-182. 301
289-290 compared to breathing exercises. 126
Arterial blood gas and. 5 compared to mobilization. 29
brain injury and. 259 complications of. 301
hypoxemic respiratory failure and. 20 IPPB. compared with. 291. 293. 298-299
lung. in infants. 253. 255 no benefit. 29
Hyperoxygenation. 169. 1 7 1-178 PEP. compared with. 302
Hypertension. head down position and. 322 unproven efficacy. 28
Hyperventilation. 35. 169. 171 178, 179. 289-290. vs. expiratory spirometry, 246
301. 306 Incidence
blow bottles use with. 298 acute quadriplegia, 336
bronchoscopy. 306 coughing and deep breathing. 247
IS use with. 301 extrapleural hematoma. 332
voluntary, 289-290 fractures. 339
Hypotension. head up position and. 323 head injury, 335
Hypoventilation. hypoxemia and. 68 myocardial contusion. 334
Hypoxemia. 136, 138-139. 290 pelvic fracture. 338
bronchoscopy. 305-307. 314 pulmonary embolus. 335
causes. 68 respiratory complications. anesthesia and. 233
CPT and. 325 rib fracture. 326
infant chest physiotherapy and. 255 ruptured aorta. 334
inspiratory power deficiency and. 1 5 traction devices and CPT, 339
lack of with CPT. 216-217 Increased sputum production. CPT and. 247
renal dialysis and, 338 Independent lung ventilation. 95. 326
INDEX 377
Indications for CPT, S, 54, 244 Intrapleural pressure, 66

Indicators of benefit from CPT. 215-230, 247-248 Intrapulmonary shunt, 68, 7 1
Individual plots Qs/Qt after CPT. 226 bronchoscopy. during 305-307
Infants chest physiotherapy. 94
airway development. 251-252 chest physiotherapy. effects on. 5, 6, 43, 65. 137-
chest physiotherapy technique. 253 138. 225-227
cystic fibrosis and. 256-258 CPAP. effects of. 301
effect of chest physiotherapy, 254-255 IPPB. effects on. 288. 289-290
effects of position change. 94 lung contusion and. 87, 228. 242
elevation of ICP, 260 PEEP. effects of. 301
response to handling. 253, 254 (see 0150 pneumonia and. 69
Pediatric patients) position changes. effect of. 190-192
I nfection, airway ruplure, 326 suctioning. 170
lung and aspiration. 324 Intrathecal morphine. turning and, 322. 323
Infusion pump. portable. 341 Intravascular pressure. normal, 66
Inhalation isoprenaline. 3 Intravenous line displacement turning and. 322
Inhalational anesthetics. 233 turning with. 101
Inhomogeneity. lung and, 240 Intraventricular catheter. 322
Injury severity score. above 20. 348 number with CPT. 352
Inotropic agents. head up position and. 323 Intraventricular hemorrhage
Inspection of chest, 74-75. 79 preterm infants and. 255
Inspiratory capacity. 9, 62 Intubation
abdomir.al binder and. 266 secret ion retention. neonate. 253
flow. 63 mucosal damage, infants. 253
incentive spirometry. 2 7 Inverse ratio ventilation. 37
power. deficiency and atelectasis. 1 5 bronchopleural fistula and. 332
quadriplegia and, 266 IPPB. 137. 138. 2 8 1 . 287-295. 303
reserve volume. 62 aerosol delivery. 288. 293
resistive breathing. 2 7 aHecting comparisons. 243
Inspiratory muscle function arterial blood gases. 290, 291
quadriplegia and. 264-266 bronchospasm, 288. 293
Inspiratory muscle training (see Breathing compared to breathing exercises. 126
exercises) compared with CPT, 137, 138
Instillation/infusion. 284. (see Humidifiers) complications. 2 9 1 . 293-294. 295. 29B
InsuHlation. oxygen. 169. 1 7 1-179 (see also cost. 294-295
Oxygen insurflation) cough. 2 9 1 . 292
Intensive care unit (see leU) dead space. effect on. 289
Interbronchiolar channels of Martin. 11. 59 FEVI' effect on. 288
Intercostal muscles. 63 FRC. effect on. 292
function with quadriplegia. 264-266 hazards. 2 1
Interdependence home use of. 291
atelectasis and. 15 hyperventilation, compared to. 289-290
collateral airways and. 238. 240 hypoventilation from. 290
lung and chest wall. 240 vs. incentive spirometry. vii. 5. 43. 246
re-expansion atelectasis and. 242 incentive spirometry compared to. 291 . 293. 298
recruitment and, 228 machine. use. 37
Intermittent mandatory ventilation (see IMV and mobilization compared to. 303
mechanical ventilation) nebulizers. 288. 293
Intermiuent positive pressure breathing (see IPPB) postoperative pulmonary complications.
Internal fixation. CPT and, 352 prevention with. 291. 293. 295
Intraabdominal pressure. 63 pressures. airway. with, 291. 293
Intracranial pressure (ICPl. 234 psychological effect. 290-291
bagging and. 1 8 1 . 324 tidal volume. effect on. 289-290
cough and. 144. 324 usage. 294-295
eHect of suctioning infants. 255 vital capacity. 292
elevation. head down position and. 322 work of breathing. effect on. 288-289
lavage. effect of. 180 Isocapneic exercise (see Breathing exercises)
medications to reduce. 261-262 Isoetharine. IPPB and CPT. 10
monitored over 8 hrs 363-365 Isoprenaline inhalation. 7
monitoring with chest physiotherapy. 103. 259- Isoproterenol. 288
262
monitors. 16 Kartageners syndrome and mucociliary clearance.
percussion, effect of. 141-142 17
posilioning. 197 Kinetic bed. 340
specialty beds (see Beds) Kahn. pores of. 59. 238
suctioning. effect on. 1 79 Krypton SCintigraphy
turning and. 322 evaluating treatment in cystic fibrosis. 257
Intrapleural catheters. pain relief and. 341 Kyphoscoliosis. 75
378 INDEX
Lad of benefit. side to side turning. 231 sounds. classification. 78

Lambert. channels or. 238 thorax compliance. 1 1 . 236-237
Laryngeal cartilages, 56-57 arterial oxygenation and. 242
Laryngeal injury contusion and, 2 1 9
following extubation, infants. 253 CPT and. 1 1 . 40. 216-219. 225-227. 243
Larynx. anatomy, 58 individual plots after CPT. 227
Larynx, infant. 56 secretions and. 220
Larynx. stabilization. 64 sputum volume and. 220-222
Lateral costal excursion exercises-(see Breathing postural drainage and. 94
exercises) volume. airway. conductance. and. 63
Lavage. 180-1 8 1 . 183. 284-287 volume. collateral airways and. 236
bronchopulmonary, 146-147 volume. regional interdependence and. 240
bronchoscopy, during. 305-30B. 309 volume rise with CPT. 9
humidification. 284-287 volumes in quadriplegia, 264
saline in infants, 253 volumes. spirometric, 62
Leak. bronchopleural fistula. 332 changes with postural drainage. 94
Leak. cerebrospinal fluid and, 336
Leaning forward posture
breathing control and, 120 Magnetometer. 244
Left lower lobe. percent CPT treatments, 350 Magnetometry
LeCt upper lobe. bronchopulmonary segments. 81 utilized with breathing exercises. 1 2 1
percent CPT treatments, 350 Malnutrition. effects of. 189-190
Lidocaine Mannitol
to reduce lCP. 261 to reduce ICP, 262
Limb fracture. incidence in patients with CPT. 352 Martin. channels of. 59. 236
Lingula. 54 Mass spectrometry. CPT and. 228-231
atelectasis. 80-8 1 . 83 Mass transport of gas. 64
percent CPT treatments. 350 Mast cell. 72
Literature update summary. 33 Mechanical aids. atelectasis and. 243
Liver laceration. 360 Mechanical aids to lung expansion. 246
Lobar atelectasis. blood low and. 1 4 Mechanical chest percussors/ vibrators. 42
CPT and. 4 Mechanical devices. CPT and. 244
sputum and. 40 Mechanical hyperventilation. 228
Lobar bronchi. anatomy. 57. 60 Mechanical ventilation
Lobar distribution of infiltrates. 80-89 COPD and. 274
Local anesthetic. block of aHerent pathways. 16 effects on CPT. 233
Local lung expansion. CPT and. 33-34 evaluation CPT, 356
Lower lobe collapse. 38 independent lung ventilation. 95
Lumbar spine injury in patients with CPT. 352 indications to reinstitute. 36
Lung intermittent mandatory ventilation (see IMV)
abscess. 89. 96. 324. 332 pneumonia and. 243
postural drainage. 96 pressure support. 95
anatomy. 54-60 pulmonary complications and.
capacities. spirometric. 62 quadriplegia and. 267. 2 7 1
compliance CPT and. 243 sedation. 3 5
compliance in infant. 252 technique. 3 5
contusion. 45. 87. 89. 96 ventilator adjustment for treatment. vii, 34-37,
CPT and. 242. 326. 332 95
mortality. 69 weaning. 36
on daily x-ray. 234-235 Mechanical vibrator. neonate CPT and. 8
postural drainage. 96 Mechanically vibrating pad, 7
radiological evidence. 243 expectoration and. 7
torn bronchus and. 328 Mechanics chest wall. 244
transbronchial aspiration and. 222. 224 Mechanism. CPT of. 240-242
cyst. traumatic. 89 Mechanism of percussion. 240-242
development. 251-253 Mechanism of postural drainage. 238-242
hemorrhage. 340 Mechanism of vibration. 240-242
hyperinflation. 28. 37 Meconium aspiration. 138
hyperinflation. CPT and, 4 effects of chest physiotherapy. 253. 255
inflation, 169 Mediastinal air. 75. 328. 329
inflation and blood low. 14 Medical vs. trauma patient. CPT and. 233
injury. contusion and. 243 Metabolic rate, increase with CPT. 26
insufflator. 6 Metabolic status, breathing training and. 247
lobe. anatomy. 54-55 Minitracheostomy. 44
pathology and clinical exam. 78-79 Minute ventilation
segment anatomy. 55, 60 changes with infant positioning. 254
bronchial drainage. 96-99 Mitochondria. OJ and. 66
illustrations. 97-99 Mitral valve replacement CPT and. 228
postural drainage. 96-99 Mixed expired and inspired gases. CPT and. 4
INDEX 379
Mixed venous saturation. CPT and, 228 humidifiers. effect on. 284
during 5llclioning. 27, 227. 325 IPPB. 292
Mobile lraction. 322 obtained with forced expiration technique. 1 2 1
Mobilization after cardiopulmonary bypass. 207 obtained with postural drainage. 94
Mobilization, incidence in ICU. 247 plugs. 83. 196, 313
Mobilization, obesity and. 90 respiratory human. 7 1
Mobilization of patients. 137. 165, 195-211. 291 Multibolar lung pathology. CPT and. 8
abdominal binders. 203 Multiple inert gas elimination, atelectasis and. 1 7
ambulation. 205-211 washout. CPT and. 243-244
ankle motion. 197-198, 204-205 Multisystem injury. CPT and, 235
bed positioning. 295-201 Muscarinic effects on irway. 7 2
cenlral nervous system injuries. 1 97-198. 201 . Muscle paralysis. diaphragm position and. 18. 1 9
203-205, 207. 2 1 1 diaphragmatic fibers. 252
compared t o chest physiotherapy. 126. 207-2 1 1 relaxants and mechanical ventilation. 35
continuous passive motion (CPM). 196 respiratory. function i n quadriplegia. 264-266
corsets, 203 (see Diaphragm. intercostal. accessory)
crutches. 205 weakness. PO depletion and, 1 4
endurance. 199-200, 205 Muscular dystrophy. 289
equipment for. 2 1 1 Myocardial contusion. 334
exercise. 1 9 1 . 196. 199, 200-202, 2 1 1 , 300. 302 Myocardial ischemia. 334
foot boards. 197-198
fractures. 100-1 0 1 . 105-109, 193. 199, 201-205
halo vest. 196-197 N.acetylcysteine. 135. 297
hypotension, 201-204 bronchial drainage and. 7
IS. compared to, 299-30 1 . 303 coughing. 7
pain. 199 cystic fibrosis and, 7. 2 1
PEP, compared to, 301-303 maximum mid expiratory flow and. 7
prevents pulmonary complication. 207-21 1 reflex small airway constriction, 7
pulleys. 200-201 N,O
quadriplegia. 1 96-200 disadvantages. 342
range of motion. 194, 196-200 pain relief. 342
respiratory system. effects on. 196-197. 207-2 1 1 turning and. 322, 323
sensation. 204 Nalbuphine. 341
serial casting, 197-198. 205. 207 Narcotics, cough, 159. 161
sitting activities, 201-205 Nasogastric tubes. clinical exam and. 80
sitting program, 204 Nasotracheal suctioning. 1 79-180, 182. 325
strength, 199-200. 205 National Heart and Lung Institute, 245-248
Stryker frame, 195, 196, 198-199 National Heart and Lung Institute in-hospital
tilt table. 204 respiratory therapy, 246-248
traction. skeletal. 201. 204 National Heart and Lung Institute, Sugarloaf
transfer, 201. 204 Conference, 245-246
walkers. 204-206, 209 National Heart Lung & Blood Conference. 245-248
Molecular diffusion. 65 Nebulizers. 284-286. 295-297, (see also
Monthly patient days acute. 349 Humidifiers)
Monthly patient days subacute, 349 Neonate. apnea and CPT. 8 (see Infant)
Monthly patient days ward, 349 aspiration. CPT and. 8
Morbidity after trauma, 225 CPT and. 4
Morphine epidural. 341 hyperventilation distress. CPT and. 8
Morphine. spinal and breathing pattern, 20 respiratory failure CPT and, 8
Mortality from respiratory failure. 225 suction, 8
Mucociliary clearance large and small airways, 6 Neonates, bronchoscopy. 309, 3 1 2
Mucociliary transport, 7 1 cough stimulation. 163
Mucociliary transport, cough and, 242 CPT and. 325
Mucociliary transport. effect of sputum removal. humidity for. 282. 283
243 percussion. 138-139. 143-144. 148
Mucolytic agents, arterial oxygenation and. 7 suctioning, 172-179
Mucolytic agents. vii, 42, 245, 288, 295-297 vibration. 138-139. 148
benefit. 296 Neostigmine. airway secretions and. 72
hazards. 296-297 Neufeld traction. 361
IPPB, use with, 288 Neufeld traction CPT and. 352
Mucus (see also Sputum) Neurological disease. CPT and. 321
bronchoscopy. 305-308. 309. 3 1 3 Neuromuscular blockade. 233
clearance of. 147. 149, 153-154, 295-297 Neurotrauma unit, number receiving CPT. 349
capo and. 274 Neutrophil mobility. N20 and. 1 3
cystic fibrosis treatment and, 256 Nitrogen washout. FRC and. 62-63
complications of HFV. 284 Noncardiac pulmonary edema. 334
complications of suctioning, 168, 1 7 8 Noninvasive techniques to assess CPT, 244
glands. 252 Noncardiogenic pulmonary edema. 243
humidification. 288 Nondependent good lung. 326
380 INDEX
Nonlrauma patients Pa02

CPT and. 321-342 effect of turning. 94
number receiving CPT. 350 infants. 254. 255
Number black patients admitted. 351 case histories. 105. 1 1 2
Number females admitted. 351 changes with breathing exercises. 120, 1 2 1 , 126
Number males admitted. 351 effect on handling infants. 254
Number patients over 65 yrs admitted. 351 head down positioning and. 259
Number white patients admitted. 351 measurements with exercise capo, 273
Nurses compared to physical therapists. 232 PaOl/Fl0l. 85
PaOl/rtOl, CPT and. 216. 218. 235-236
O2 consumption. CPT and. 225-227. 342 PaO,/Fl02 PEEP and. 36
02-CO diagram, 68, 71 Pa01/Fl02 sputum volume and, 220-222
Obesity. 90. 137. 1 4 2 Paradoxical chest motion
head down position and. 322. 338 quadriplegia and. 264 266
postoperative pneumonia and. 1 3 Paralysis diaphragm, 63
tracheostomy and. 90 Paraplegia. 150
Objectives of CPT. 33-34 cough. 159
Omission of CPT components. 38 Parasympathetic stimulation. collateral ventilation
Orthopedic fixation. CPT and. 352 and. 238
Orthopedic fixation devices Patient
case study. 109 controlled analgesia. 322, 323. 341
exoskeletal fixator. 105-106 cooperation, CPT and. 246
Neufeld traction, 1 0 5 days
traction limitations, 1 07-108 acute, 349
Orthopedic injuries subacute. 349
obtaining postural drainage positions. 1 05-109 ward, 349
Orthostatic hypotension. 188-190 interventions, 360-366
Osteoporosis. 146. 1 9 3 mobilization. details to remember. 359
Out of phase. end-tidal COl and. 230 how performed. 359
Out of phase with ventilator. 35 purpose. 359
Outpatient surgery. pulmonary complications. 13 things to avoid, 359
Oximetry. CPT and. 24 when used. 359
Oxygen population. CPT outcome and, 232-233
carriage, 69 Patients. duration stay. 347
consumption, breathing and. 248 injury severity score and CPT. 348
in children. 254 mortality 1972-87. 346
CPT and, 69 number admitted 1972-87. 346
in exercise with cystic fibrosis. 257 number ambulance admissions. 347
delivery 69 number helicopter admissions, 347
diffusion. 60 number requiring surgery. 346-347
insufflation. 169, 171-179 treated with CPT 1974-67. 346
saturation of hemoglobin. 69 Peak expiratory flow rate (PEFR)
Oxygenation. arterial CPT and. 4 asthma and. 274
arterial fall. 6 cysHc fibrosis and. 256-257
arterial improvement with CPT Peaks in end tidal Cal abolished with PEEP, 229
changes with chest physiotherapy Pediatric CPT. 246
case histories. 105, 1 1 2 Pediatric patients (see also Infants)
failure to improve after CPT, 222, 225 effect of breathing exercises. 126
impaired, 324 indications for chest physiotherapy, 251
normal values in circulation, 66 Pedjcle graft CPT and, 340
postural drainage and, 94 PEEP (see Positive end expiratory pressure)
shunt and. 69 Pelvic external fixators. 323
Oxyhemoglobin dissociation, 69-70 Pelvic fracture. 234-237
curve shift. 69-70 Pelvic fracture. CPT and. 338. 352
Pelvic injury. side position and. 323
Pain. 137. 1 4 1 . 143. 153. 161-162. 182. 189. 1 9 1 . Pendelluft, 65
196-199. 3 1 0 . 341-342 Penetrating lung injury, 327
diaphragm function and, 15 Penetrating lung injury, airway rupture. 326
management postoperatively. 1 2 PEP (see Positive expiratory pressure)
medication, timing t o CPT, 341 Percent at different injury severity scores and CPT,
percussion and. 323 348
relief and reduced need for ventilation, 341 Percussion. vii. 5. 4 1 . 75-76. 79. 1 34-149. 165
relief following surgery. 341-342 acute lung disease. effect on. 134. 136-138. 140
tolerance. 341 alveolar proteinosis. effect on, 146-147
turning and. 322. 323 asthmatic and, 274
Palpation of chest. 75, 79 brain injury and. 259. 260
PaCOl breathing exercises and, 1 2 6
changes with breathing exercises, 1 2 0 bronchopleural fistula. 143
INDEX 381
bronchoscopy. compared with. 309-314 Phonation. 56

cardiac output. effect on, 138 Physical Activity (see Exercise)
cholecystectomy, 1 3 7 Physical therapist. coordination role, 342
chronic bronchitis. 2 5 . 2 6 . 1 3 6 Physicians. compared to physical therapists. 232
clinical examination diHiculties. 74 responsibility for CPT. 342
coagu lopalhy. 143. 144-145. 340 PhYSiological changes. CPT and. 215-248
compared with cough. 158-159 dead space, 68
compliance. total lung/ thorax. 1 3 7 effects CPT. summary. 245
contact heel. 1 3 8 , 143-144. 254 measurement in ICU. 230-236
contraindication skin graft. 337 variables, stability. 233-234
correctly performed. 329 Physiology. respiratory. 54. 59-71
cystic fibrosis. 135. 136 Pickwickian syndrome. 338
details to remember. 358 Plmax
dysrhythmias and. 333 quadriplegia and. 266
effects on mucus, 24 Plastic surgery, precautions with. 337
electric toothbrush. 254 Plastic surgery. side position and. 323
emphysema, 136 Plate-like atelectasis. CPT and. 225
extrapleural hematoma. 142, 332 Plethysmograph. 9
face mask and. 254 Pleural pressure. 28. 63
FEV. 136. 142. 145. 149 collateral airways and. 239
force of. 24. 1 4 1 , 143. 149 Pneumomediastinum. 3 3 1
forced expiratory technique {FET}, 1 2 1 . 135-136. Pneumonia, 43. 4 6 . 1 3 6 . 137. 138, 282. 283. 294,
142 304
FVC. 135-137. 149 bronchopulmonary dysplasia and. 253
hemoptysis. 143 bronchoscopy, 304
how performed . 358 collateral ventilation and. 238
ineffective with hemopneumothorax. 327 CPT and. 9. 86. 2 1 7 . 243-244
intracranial pressure. 141-142 duration of hospital stay. 9
intrapulmonary shunt, effect on, 137-138 diagnosis. 9
IPPB, compared with 289, 291 difficulty in diagnosis. 1 6 . 87
IS, compared with, 299-300 humidity. 282. 283
kinetic bed and, 1 1 1 lPPB. use with. 291 . 294
large airways, effect on, 134-135, 138, 1 4 1 , 1 9 1 lung abscess and. 332
mechanical. 1 4 4 , 146-149 lung/ thorax compliance and. 2 1 0
mechanical vibrator as alternative, 2 1 nosocomial. 1 6 . 1 7 . 87
mechanism of action, 149, 240-242 obesity and. 1 3
neonates, 134, 138-139. 143-144. 148 o n daily x-ray. 234-235
novice therapists and. 329 quadriplegia and. 262, 267
obesity. 137. 142 specialty beds and, 1 1 1 . 1 1 4
optimum frequency and force. 21 sputum and. 40
osteoporosis and, 339 topical antibiotics and, 1 7
pain, 137. 1 4 1 . 143 V/Q and
PaOI, effect on. 136-139. 144. 147 Pneumothorax
petechiae. 142 bagging and. 324
pneumonia, 137. 138 contraindication to CPT and, 327
positive expiratory pressure, 136. 302 diagnosis. 75-76
postural drainage ideal position. 82 from chest tube displacement. 329
problems. 323 mediastinal air and. 75
pulmonary function tests, effect on. 135-136 side position and. 323
p!!,rpose. 358 tension. 327, 328
PVO:. effect on. 138 Pores of Kohn, 252
radioaerosol clearance. effect on, 134-136. 147 Portable chest x-ray. 243
rib fractures. 141-142. 144, 146, 148, 149 Position and arterial oxygenation. 31
scintigraphy. 135. 136 Position change
small airways. effect on. 134-135. 1 3 8 cough, effect on. 160-161
spinal fractures and. 108 quadriplegia. 1 88-190. 201-204
sputum. effect on, 134-137, 141, 146-147 respiratory system. effect on. 190-192
subcutaneous emphysema, 142. 149 Positioning (see Turning. postural drainage)
technique, 140-145, 148 CPT and skin graft . 341
things to avoid. 358 patient for CPT. 357
tidal volume. effect on, 139 to improve minute ventilation. 120
when used, 358 Positive end expiratory pressure (PEEP). 137. 1 4 1 .
with and without cough. 26 199, 301
x-ray. effect on. 135-137. 147 airway rupture. 326
Pcdusion. regional differences in lung. 67 atelectasis. 18
Peripheral airway clearance and cystic fibrosis, 22 bronchopleural fistula and, 332
Peritoneal effusion. 338 bronchoscopy. 305. 3 1 4
Pharynx. 54. 55 cardiac failure and. 333
382 INDEX
Positive and expiratory pressure-continued Prevention of atelectasis PEP and CPAP. 3 1

CPT and. 8. 36. 216-217. 228 Prevention of problems
hypoxemia and. 325 head down position. 322
indications. 36 head u p position. 323
pulmonary artery catheter. 36 segmental drainage. 322. 323
reduction with suction. 324 bagging and. 324
selectively applied i n atelectasis. 14 suction and. 324
sputum volume and. 220-222 vibration and. 324
5uctioning. 170-178. 183 Prevention percussion poblems. 323
Positive expiratory pressure (PEP). 28, 136. 281. prone position problems. 323
297-298. 301-303 side position problems. 323
compared to breathing exercises. 126 transbronchial aspiration. 324
effect on mucus production. 1 2 1 Problem with respiratory therapy. 29
PEP therapy reduces alveolar arterial POJ' 3 1 Problems transbronchial aspiration. 324
PEP with o r without postural drainage. 3 1 Problems with head down position diminished.
Posterior or basal segment left lobe atelectasis. 84 333
Postextubation atelectasis. 1 38 Problems with restriction of CPT. 326-327
Posttraumatic respiratory failure. 26 Prone position. 31
Postural dependence acute Quadriplegia. 336
with quadriplegia, 266 pelvic fracture. 338
Postural drainage. 93-99 (see also Turning) problems. 323
abnormal muscle tone and, 104 Prophylactic antibiotics. pulmonary infection and.
after pediatric surgery. 126 13
associated cardiorespiratory function. 94 Prostaglandins. 7 2 , 73
bronchopleural ristula and. 332 Pulmonary artery. 65-67
chest x-ray and. 242 Pulmonary artery
chronic bronchitis and. 10 catheter incidence of with CPT, 333
collateral airways and. 239 catheters. number with CPT. 352
comparison. 3 1 pressure. decrease with CPT. 6
controversy. 22 pressure. mean over 8 hours. 363-366
cough and. 26 Pulmonary blood flow. 65
cough prohibited. 10 Pulmonary capil laries. 64
details to remember. 358 Pulmonary complication
determination of position. 80-89 after abdominal surgery. 28
forced expiration technique and. 1 2 1 after choleystectomy. 3. 29
head down positioning. 104 arter surgery. 3
head injury and. 103-105. 335 obesity and. 90
how performed. 358 Quadriplegia and. 89
improved PaOJ in neonates. 8 Pul monary edema, head down position and. 322
in infants. 254. 255 lung contusion and. 243
intermittent. 95 suction and. 333
intracranial pressure monitoring and. 103-104 Pulmonary embolus. 190, 335
mechanism of action 240-242 Pulmonary function
methods to obtain positions. 96. 100-103 chronic lung disease and, 272
position for clearance lower lobe atelectasis. 82 cystic fibrosis treatment and. 256-258
positions. 54. 97-99 exercise and. 257
purpose. 358 quadriplegia and, 266-267
Quadriplegia and. 268-269 Pulmonary function tests (PFT)
shortened duration. 325 effect chest physiotherapy. 135-136. 158
specialty beds (see Beds) effect of humid ification. 285
sputum volume and. 5 effect of IS. 299. 301
thi ngs to avoid. 358 Pulmonary hemorrhage. aspiration and. 324 (see
transbronchial aspiration and. 222-224 also Hemoptysis)
vs. cough. 93 CPT and. 326
'Is. side to side turning. 245 Pulmonary infection. bacterial filters and. 1 3
vii. 1-3 . 4 1 predisposing factors. 1 3
when used. 358 Pulmonary infiltrates. segmental. 80-89
without percussion and. 22 Pulmonary macrophage. 73
Precautions CPT and. 321-342 Pulmonary vascular pressure. apex to base. 67
Preoxygenation Pulmonary vein. 65-67
bronchoscopy for. 304. 306-307 Pulmonary vessel distension. 66
suctioning for. 169. 171-179 Pulmonary vessels. types. 66
Prescribing respiratory therapy. 29 Pulse oximeter. 84
Pressure support. 27 Pulse oximetry. 325
bronchopleural fistula and. 332 cardiac failure and. 333
rib fracture and. 329-330 pneumothorax and. 327
weaning. 36 Pursed lip breathing. 120
Pressure volume curve. lung. 67 Pus. expectoration, 332
INDEX 383
Quadriplegia, 64. "336 Respiratory

abdominal binders with. 266-267 dysfunction, turning and. 322
abdominal distension and, 338 failure. after trauma. 225
breathing exercises. 163. 267. 271-272 failure. CPT and. 5
cardiac function. 266 flow, 62
chest physiotherapy trealment. 267-272 function. CPT and. 26
cough. 159, 163 management. 34-36
halo vest, 196-197 mortality. quadriplegia. 336
head-down position. 268-269 mucus. 7 1
hypotension. 168-190, 201-204 mucus. secretory responses. 73
immobility, effect of. 196-197 Respiratory care exclusions. 37-38
(PPB. 289 changes. interventions and. 360-366
mortality, 262 complications. pathophysiology. 1 1
optimum respiratory function, 323 complications, risk factors. 1 1
phrenic nerve pacing and, 30 complications. therapy and. 21-32
positioning for. 198-200. 203 Respiratory distress
postural dependence. 266 in infants. 138, 144. 254
pulmonary function. 266 Respiratory distress syndrome. 1 3 7
respiratory impairment and. 89 lung thorax compliance and. 2 19
respiratory muscle function. 264-268 (see Spinal collateral airways and. 240
fracture) CPT and. 225
Rota-Rest bed. 199 (see Bronchopul monary dysplasia)
sitting program, 204 Respiratory muscle fatigue. 13-14
Stryker frame. 195-196. 198-199 Respiratory muscle function
suction and. 336 quadriplegia and. 264-266
thoracic cage mobility, 264-265 Respiratory muscle. 63
vibration. 146 paralysis. interdependence and. 240
recruitment. 30
weakness. JPPB and. 29
Race distribution of admissions. 351 Respiratory pressures. 63
Radiation therapy. hemoptysis and. 326 Respiratory rate
Radio aerosols. difficulty in peripheral deposition, effect of breathing exercises. 1 20. 1 2 1
6 (see Aerosols) Respiratory system CPT and. 325
Radioactive tagged Teflon. cough and. 10 effects of anesthetics. 233
tracers. 248 Respiratory therapy assessment. 245
mucociliary clearance and. 6 outside ICU. 246
penetration lung. 6 priority setting. 29
Radiological atelectasis improved with CPAP, 28 Restricted access to monitoring. 234
benefit of CPT, 1 1 Restriction of CPT component. 342
improvement. CPT and Restrictions. pelvic rracture and. 338
Radiology follow.up after lobar atelectasis, 34 Retained secretions, pneumonia and. 243
segmental identification, 34 Rhonchi. 75-80
Radionucleide angiography, myocardial contusion Rib
and, 334 cage development. 252
Range of motion, 194, 196-200 fracture in infants. 253
quadriplegia. for, 198-200 Rib cage, 63
Rebreather tubes. 298 expansion. CPT and, 240-242
Recruitment alveolar units after CPT. 228 Rib fracture. 75. 141-142. 144. 146, 148. 149, 162.
collateral airways and. 238 210
pulmonary vessels. 66 chest percussion causing, 329
Regional alveolar hypoxia. collateral airways and. displacement. CPT and. 327-329
238 incidence in patients with CPT. 352
anesthesia. 233 lung contusion and. 243
block. 341 pathological causes. 329
nerve block vs. IV morphine, apnea and. 13 percussion and. 141-142. 146. 148-149. 323
Relative humidity, 283, 296 side position and. 323
Relaxation exercises (see Breathing exercises) vibration and. 329
Relevance of cardiac function changes and CPT. Rib springing. 240-241
228 Ribcage motion. 30
Removal of secretions. ketchup bottle, 1 1 Richmond screw. CPT and. 363-365
Renal dialysis, 234, 338-339 Right lower lobe. percent CPT treatments, 350
Residual volume, 62 Right middle lobe, bronchopulmonary segments.
quadriplegia and. 264. 266 81
Resistance. airway, definition Right middle lobe. percent CPT treatments.
collateral vs, normal airways, 238 350
pulmonary. 66, 67 Right to left shunts. 68
systemic vascular. 66 Right upper lobe
Respiration. neonatal. 138, 144 bronchopulmonary segments. 8 1
384 INDEX
Right upper lobe-conlinued Spinal cord injury. 336

percent CPT treatments, 350 Spinal cord injury. cardiac failure and. 334
Risk factors for atelectasis. 1 2 Spinal fracture
pneumonia. 1 3 . 1 6 chest physiotherapy with halo vest. 108-109,
postoperative respiratory complications, 1 1 269-270
Risks of CPT minimized. 342 positioning patient with specialty bed. 1 1 3-117
Rota-Rest bed. 234. 361-362 (see olso Bed) (see Quadriplegia)
Ruptured aorta. CPT and. 334 Spinal injury level in patients with CPT. 352
Spinal morphine. 341
S-carbomelhylcysteine chronic bronchitis and. 7 Spinal rods. CPT and. 352
SaOl Spinal shock, pul monary edema and, 334
effect of pursed lip breathing, 1 2 0 Spine injury
monitoring with chest physiotherapy. 96 incidence in patients with CPT. 352
Salbutamol. 296 number CPT and. 349
Scaleni muscles. 64 Spirometry. 62
Scapula fracture. side position and. 323 Spontaneous breathing
Scapular fracture incidence in patients with CPT. atelectasis during anesthesia and. 1 7
352 CPT and. 2 1 7- 2 1 8
Scoliosis. pulmonary function and. 15 unconciousness and. 89
Seasonal changes in admission. 349 Spontaneous cough vs. postural drainage. 22
Secretion retention Spontaneous respiration
intubation, neonate and. 253 evaluation CPT. 356-357
Segmental atelectasis. CPT and. 225 head down position and, 322
Segmental distribution of infiltrates. 80-89 rib fracture and, 329
Segmental drainage problems. 322-323 Sputum (see also Mucus)
Selective positive pressure. atelectasis and. 27 accepted statements about. 242
Selective positive pressure with bronchoscope. 32 arterial oxygenation and. 242
Septal defects. 68 beneficial effects on removal. 222-225
Sex distribution of admissions. 351 characteristics of. 155
Shaking and CPT. 4 CPT benefit and. 39
Shifting dullness. 75 dehydration. 154
Short duration of therapy. 42 distribution in bronchial tree, 6
Shoulder dislocation. side position and. 323 humid ification of, 40. 282, 283. 285
Shunt (see Inlrapulmonary shunt) IPPB. effect of. on. 288
Side position problems. 323 lavage, effect of. 180-181. 305-308
Side to side turning. 3. 2 3 1 . 244 minimum volume necessary for CPT benefit, 39
Significant loss. suction and. 333 normal clearance of. 153-154
Signs of pneumonia. 87 percussion/vibration. effect of, 134-137. 141.
Silhouette sign. chest x-ray and. 80-84. 243 146-147
Singing. 64 production, 6, 135-137. 147, 196. 288, 292
Sitting position for CPT. 38 pulmonary function and. 6. 22
Skeletal lraction. CPT and. 352 purulent. 154
Skin graft . CPT and. 340 purulent and ciliary beat frequency. 30
Skull fracture. cerebrospinal leak and. 336 removal and phYSiological changes. 40
Small airway clearance removal. lack of benefit. 222-224
chest physiotherapy vs. bronchoscopy. 309- removal long term benefit. 40
314 rheology. 244, 245
cough. eCfect of. 154-155. 157, 161-162 VIQ and. 39
IPPB. ellect 01. 289. 291-293. 299 viscoelastic propert ies. 7
IS ellect 01. 299 viscous. 183
lavage. errect of. 180-181 volume. 39-40, 42, 149. 245. 248
normal. 154 accuracy. 220
percussion/vibration. effect of. 134-135. 138, CPT and. 4, 6. 220-222
147 less than 5 m l 220-222
position change. effect of. 190-192 multilobar pathology. 220-222
Small airways. CPT and. 2 3 1 tracheal intubation and. 220-222
Smoke inhalation. 89 unreliability. 242
Solubility CO2 64 weight and CPT in maneuvers. 25
Solubility OJ. 64 Standardization, lack of with CPT and. 231
Spastic respiration. 89 Standardized CPT, 232
Specific airway conductance. 7. 9 Sternocleidomastoid, 64
CPT and. 6 Sternum, movement with inspiration. 63
Specific airway conductance and 30 ml or more Stony dul lness. percussion and. 75
sputum per day. 7 Strapping of chest wall. FRC and. 28
Specific airway conductance measured in chronic Stridor
sputum production, 7 in infants. 254
Speech, chest vibration and. 242 Stryker frame. 195. 196. 198-199
Spinal anesthesia, 341 Subarachnoid hematoma, CPT and. 363-365
INDEX 385
Subclavian lines viscous secretions, 283

turning with. 101 vomit, 180
Subcutaneous emphysema. 75. 142. 149. 328 when used. 359
chest tubo and. 329 Sugarloaf conference. 245-246
Sublobar atelectasis. blood flow and. 14 Sulbutamol. 296
Substance p, 72. 341 Summary CPT. 355-359
Succinylcholine Summed breathing. 163, 196
to reduce ICP. 262 Sump drains. clinical exam and. 80
Sucralfate. Gbacilli and. 1 7 turning with. 103
Sucralfate. nosocomial pneumonia and, 87 Superior segments lower lobes. silhouette sign, 81
Suction Surface markings of lung. 55. 60
airway rupture and. 326 Surface tension. atelectasis and. 241
bleeding disorders and. 340 Surfactant. 240
bradycardia and. 333 in infant. 252
catheter. closed sheath. 325 Surgical patient
catheter size, 325 eHects of breathing exercises, 1 1 9 . 1 2 2 . 126, 1 2 7
indication to restrict. 333 Syncope. cough and. 324
mixed venous saturation and, 325 Systemic hydration. 283, 296
port adaptor and. 324. 325 Systemic vascular resistance, CPT and. 225-227
sputum and, 242
\'5. CPT. 244 Tpiece weaning. 36
Suctioning. 27. 137-138. 140. 142. 146. 153. 165- Tachycardia. myocardial ischemia and. 334
160 Talking. 64
adjuncts to, 169-178. 181-183 TcPOz
bagging. 1 7 1-178. 181-162. 183 infant chest physiotherapy and, 254. 255
brain injury and. 261 positioning infants and. 254
bronchoscopy, during. 305-309 Te99m chronic bronchitis and. 7
cardiac dysrhythmias. 170. 172-176. 178. 179 Te99m. removal of lung secretion and. 7
catheter insertion. 165-166 Techniques to change transpulmonary pressures.
catheter size. 168. 165. 183 27-32
catheters. types of. 167-168 TENS. 341
complications of. 1 69-180 TENS. turning and, 322. 323
contamination. 179. 180 Terminal bronchioles. 59
coud. 167. 183 Tetanus. CPT and. 4
CPT and neonales. 4 Tetraplegia (see Quadriplegia)
deaths and. 336 Thebesian veins. 6
decreased mixed venous oxygenation and. 227 Theophylline. 295-296
details to remember. 350 Therapeutic effects. collateral ventilation and. 239-
fall in arterial oxygenation in neonate. 8 242
how performed. 359 Therapeutic interventions. 233-234
hyperinflation. 169. 171-1 78. 180. 181-182 Therapies to reduce excess mucus. 73
hyperoxygenalion. 169. 171-178 Therapist variability. 231-232
hyperventilation. 169. 1 7 1-178. 179 Thiopental
hypoxemia. 169-178. 179 to reduce ICP. 262
increase in right to left shunt in neonate. 8 Thoracic cage mobility
infants. 255 quadriplegia and. 264
intracranial pressure. effect on. 179. 180 Thoracic epidural. diaphragm function and. 20
lavage. 180-181. 183 gas volumes. 9
left lung cannulation. 1 6 7 spine injury. 336
mini tracheostomy. 164 in patients with CPT. 352
mucosal damage in infants. 253 Thoraco abdominal breathing postoperatively. 15
nasotracheal. 1 79-180, 1 8 2 Thoracotomy. 143. 147. 161-162. 292
neonates. 172-179, 180 Thrombocytopenia. CPT and. 340
oropharangeal. 163 Tidal volume. 62. 139
oxygenation. 169. 171-179 aerosol delivery. effect on. 297
PEEP and. 325 bagging. 182
portadaptor, 171-178. 1 83 . 325 bronchoscopy. 305, 308. 3 1 2
precautions in quadriplegics. 336 changes with breathing exercises. 120. 1 2 1
problems, 324 changes with infant positioning, 254
purpose. 359 humidification. 287
rise in pleural pressure position change. effect on. 190-192
specialty beds Isee Beds) suctioning. 177-178. 183
sputum and, 222-224 vibration. effect of. 163
technique. 165-167, 170-178, 183 with quadriplegia. 265, 2 7 1
things to avoid. 359 with abdominal binder, 267
turning and. 235 Time constant. airway inflation. 239
vacuum pressure. 165-170 Time constants, airway emptying and. 229
vasovagal reflex, 178 Tissue perfusion. inadequate. 69
386 INDEX
Topical antibiotics and pneumonia. 1 7 intracranial pressure monitoring. 103. 262

Total lung capacity. 62 intravascular lines. 101
abdominal binder and. 266 mechanical ventilation. 101
cough and. 241 multiple injuries. 96. 100
quadriplegia and. 264, 266-267 pelvic fracture and. 338
Toxicity. local anesthetic. 341 problems and prevention. 322
Trachea anatomy. 56-59 prone. 100. 101
development. 251 quadriplegia. 266-269
shape, 58-59 restriction. incidence. 339
Tracheal cuff pressure. vibration and. 324 tracheal tube. 100-102
extubation, turning and. 322 Yale brace. 270
intubation, indications for. 35 see Beds
lavage. vii. 37 suction ineffect ive. 3 3 1
length. adult vs. infant. 59 suctioning. 235
suction. control comparison. 231 Turning frame (see Beds)
5uctioning in nonintubated patient. 42
tube link. head down position and. 322 Ultrasonic nebulizers. 285-287. 299
tube obstruction. 77 cough. 161
Tracheal tubes Unconcious patients
turning with, 100-102 prone position and. 323
Tracheobronchial anastamosis. 326 precautions with. 337
lavage. 43 Unconsciousness CPT and. 246-247
secretions normal volume. 71 post traumatic respiratory failure and. 339
tear, lung contusion and. 326. 328 Undesirable enects CPT and 321-342
Tracheoesophageal fistula. 337 Unilateral diaphragm paralysis. 30
Tracheostomy, Unilobar lung pathology CPT and. 8
cilia. effect on. 154 Unilobar pathology. sputum volume and. 220-222
cough, effect on. 160. 2 1 1 Upper abdominal surgery. 28-29. 30-31
indications, 3 5 diaphragm function and. 15
mini. 44. 164-165 pain and. 341
sputum. effect on. 154. 191 Upper airway anatomy. 54. 56-57
suctioning. 165. 167 Upper airway obstruction. postoperatively.13
trauma. 201. 203 Urinary catheter
Traction. postural drainage and. 339 turning with. 103
Transbronchial aspiration. 140. 143. 159. 222. 224. Usage of incentive spirometry. 29
324
lung contusion and. 243 Vacuum. suction and. 325
Transcutaneous 0:. abdominal surgery. CPT and. Valsalva maneuver. 1 6 1 . 296
80 Variability in interventions in ICU. 233
Transpulmonary pressure. 27. 63. 67 Variation i n techniques CPT. 247
airway recruitment and. 20 Vasovagal reflex. 164. 176. 304
collateral airways and. 239 Venous admixture. 66
increase. 240-242 Venous thrombosis. 190
Transpulmonary pressures. atelectasis and. 240 Vent CSF. head down position and. 322
Transtracheal aspiration. 164-165. 183. 297 Ventilation. distribution differences. 229
Transtracheal catheter. 44. 164-165. 242 Ventilation/ perfusion (V/ Q] relationships. 67-69
Trauma patients. 136. 1 3 7 . 142. 196-197. 310-312 improvement in cystic fibrosis. 257
number receiving CPT. 350 quadriplegia and. 265-266
Traumatic cyst, 332 atelectasis and. 69
Tuberculosis, 7 changes and CPT. 4
Tuberculosis, lung abscess and. 332 collateral airways and. 236. 239
Turning distinguished from intrapulmonary shunt.
abnormal muscle tone and. 104 69
a craniotomy and, 104 effect of breathing exercises. 119
arterial lines and, 102 effect of gravity. 94
asthmatic. 275 eHect of kinetic bed. 1 1 1
brain injury and. 259 imbalance. end tidal CO: and. 229
chest lubes and, 102 postural drainage. 96. 241. 325
dehiscence and. 337 scans. CPT and. 243
eHect after surgery. 94 with age. 69
effect on dependent lung, 94 Ventilation
effect on oxygenation, 94 regional differences in lung. 67
effect on V IQ. 96 techniques for bronchopleural ristula. 332
head down positioning. 104. 259, 266 Ventilator tube change and infection. 16
head injury and. 103 Ventilatory muscle training (see Breathing
illustrations. 100-101 exercises)
inefective suction, 3 3 1 Ventricular [unction CPT and. 333
infants. 9 4 . 254 Vesicular breath sound. 76
INDEX 387
Vibration. PEP. compared with. 302 rib fractures. 1 4 6 . 148. 149. 324
Vibration. 134-149. 163, 165. 299-300 scintigraphy, 135. 136
acute lung disease. effect on, 134, 136-138. 145 small airways, eUect on. 134-135. 138. 145
alveolar proteinosis. 146-147 sputum. effect on, 134-137. 146-147
as alternative to postural drainage. 21 subcutaneous emphysema. 142. 149
bagging with. 146 technique, 144. 145-146
bronchopleural fistula. 143 things to avoid, 358
bronchoscopy compared with. 309-314 thoracic spine fracture and. 324
cardiac output. effect on. 138. 146 tidal volume. effect on, 139
chest wall, end tidal COl and. 230-231 vii. 4 . 4 1
cholecystectomy. 1 3 7 when used. 358
coaguiopathy. 144-145 osteoporosis and, 339
compared with cough, 156-159 x-ray, effect on. 135-137. 1 4 7
compliance, total lung/ thorax, 137-138 Vibratory percussion. 3
contraindication. 336 Vital capacity (VC). 9. 30, 62
contraindication skin graft. 337 abdominal binder and. 267
cystic fibrosis. 135. 136 cystic fibrosis treatment and. 256. 257
details to remember. 356 glossopharyngeal breathing and. 272
dysrhythmias and, 333 quadriplegia and. 266-268, 271
effect on cough, 136 Vrnax
electric toothbrush and. 254 cystic fibrosis treatment and. 256-257
emphysema. 136 Vocal cords. 57
exlrapJeural hematoma. 142 Vocal fremitus, 75
FEV. 136, 142. 145. 149 Volume of sputum. differences between patients,
force of. 145, 148 222-225
forced expiratory technique (f'ET). 135-136. 142 Volume sputum. changes after removal and. 220-
FVC. 135-137, 149 225
how performed. 358 Vomit
ineffective with hemopneumothorax. 327 associated with bronchoscopy, 304
intra pulmonary shunt. effect on. 137-138 associated with cough stimulation. 163. 164
intracranial pressure. 146 associated with nasotracheal suction, 180
IS. compared with. 309-314
large airways. effect on. 134-135. 138. 145. 1 9 1
Ward. duration of stay. 347
mechanical. 144. 146-149
Water seal. chest tube and. 75
mechanism of action. 1 4 7 . 149. 240-242
Water vapor loss. anesthesia and. 233
neonates. 138-139. 148
Weaning from mechanical ventilation.
obesity. 1 3 7
prerequisites. 2 1 6
of bronchial tree. 24
Weaning mechanical ventilation and. 237
optimum frequency. 244
Wedge pressure CPT and. 225-227
pain. 137. 143
West zones. 67. 71
PaOl o effect on. 136-139. 147
Wheezes on clinical exam. 77-79
pneumonia, 137. 138
White blood cell count. CPT and. 86
positive expiratory pressure. 136. 302
Work of breathing
problems. 324
IPPB. effect on. 288-289
pulmonary function tests. effect on. 135-136
p!!,rpose, 358
PVO), effect on. 138 Xenon. 244
radioaerosol clearance. effect on. 134-136. 1 4 7 X-ray. portable. 80-89

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Chest

Colin F. Mackenzie, M.B., Ch.B., Editor

P. Cristina Imle, M.S., P.T.

Nancy Ciesla, B.S., P.T.

With a contribution in the 1st Edition to Chapters 5 and

WILLIAMS & WILKINS

Printed in the United SIOles of America

First Edition 1981

Library of Congress Cataloging-in-Publication Data

Chest physiotherapy in the intensive care unit/Colin f'. Mackenzie.

anesthesiologists, surgeons, internists, book presents our experience with chest

Preface to the Second Edition . . . . ........ . ... . . . ..... . . ..... . v

Chapter 1 History and Literature Review of Chest Physiotherapy, ICU Chest

Chapter 2 Clinical Indications and Usage of Chest Physiotherapy: Anatomy,

Chapter 3 Postural Drainage, Positioning, and Breathing Exercises 93

Chapter 5 Methods of Airway Clearance: Coughing and Suctioning . . . . . . ... 153

Chapter 6 Changes with Immobility and Methods of Mobilization 188

Chapter 7 Physiological Changes Following Chest Physiotherapy. . ......... 215

Chapter B Chest Physiotherapy for Special Patients 251

Chapler 9 Adjuncts to Chest Physiotherapy 281

Chapler 10 Undesirable Effects, Precautions, and Contraindications of Chest

AppendixI Chest Physiotherapy Statistics Showing Type and Number of

Appendix II Abbreviations and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

Appendix III Summary of Chest Physiotherapy Treatment and Evaluation . . . 355

Appendix IV Duration, Type, and Frequency of Interventions in Four

Index. . . . . . . . . . . . . . . . . . . . . . . . . . ... .. . . 367

History and Literature Review of

Historical Summary and Literature Review

As an introduction to this book, Chap controversial aspects of respiratory care

vances in surgery, anesthesia, and anti ventilation in 1 953 (Crampton Smith et

veolar pressure by means of a retard midexpiratory now rate worsened, show

Chest physiotherapy produced a differ to be a pneumonic process was cleared in

volume. The increased collateral venti tainly avoid narcotic-induced ventilatory

expansion, and the postoperative fall in electasis on vascular pressure-flow rela

ercises increased dyspnea and lead to The difficulties in diagnosis of nosoco

of Ih e pharynx from the stomach. The in microbes with resistance to significant

.01 t '0. 100

(Tecklin and Holsclaw; Weller et al.) do rheology. Newhouse suggested that

postural drainage positions and stimula fects of prolonged coughing. Narrowing

that routine prophylactic chest physio manual vibration, percussion, shaking,

recommend chesl physiotherapy in the chanica I means that generate a subat

was considered to be an increase in PaO, ance caused by quiet breathing. They

racic strapping. Respiration g -20 -10 0 10 20 -20 -10 0 10 20

United States. Chest physiotherapy was cruitment of respiratory muscles, or the

Figure 1.9. Upper and lower rib I'tf'IENIC PACED BREATHS

tient positioning should be used as a sive to respiratory therapy, or when pa

chodilators, mucolytic agents, IPPB, pres fore. supplements chest physiotherapy

CHEST PHYSIOTHERAPY Physiolherapy should not be consid

Indications for Intubation, Ventilation, chanica I ventilation are no longer

Intubation Mechanical Ventilation

Weaning from Mechanical Ventilation PaO,/FIO, is still not in excess of 200.

physiotherapy was given to mechanically lowing chest physiotherapy in these pa

diagnosis. prevention. and management anesthesia with controlled ventilation. N Eng/ J

Clinical Indications and Usage of

Anatomy of the Airway and Lung Segments and Lobes

Prophylactic Use of Chest Physiothe",py

Breathing can, therefore, continue even Lower horn

larynx is composed mostly of the thyroid

Figure 2.4. The glottis-on the

lung known as the bronchopulmonary scribed by Martin (1966). and bronchio

lateral View Lateral View

Medial and Basal View Medial and Basal View

Figure 2.9. A comparison of human airway