Phys ther 1996-ciesla-609-25
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1996; 76:609-625.PHYS THER.
Nancy D Ciesla
Care Unit
Chest Physical Therapy for Patients in the Intensive
http://ptjournal.apta.org/content/76/6/609found online at: The online version of this article, along with updated information and services, can be
Collections
Pulmonary Conditions: Other
Airway Clearance
in the following collection(s):
This article, along with others on similar topics, appears
e-Letters
"Responses" in the online version of this article. "Submit a response" in the right-hand menu under
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by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Nancy D Ciesla
Care Unit
Chest Physical Therapy for Patients in the Intensive
http://ptjournal.apta.org/content/76/6/609found online at: The online version of this article, along with updated information and services, can be
Collections
Pulmonary Conditions: Other
Airway Clearance
in the following collection(s):
This article, along with others on similar topics, appears
e-Letters
"Responses" in the online version of this article. "Submit a response" in the right-hand menu under
or click onhere To submit an e-Letter on this article, click
E-mail alerts to receive free e-mail alerts hereSign up
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Chest Physical Therapy for Patients
in the Intensive Care Unit
Chest physical therapy is used in the intensive care unit (ICU) to
minimize pulmonary secretion retention, to maximize oxygenation,
and to reexpand atelectatic lung segments. This article reviews how
chest physical therapy is used with patients who are critically ill.
A brief
historical review of the literature is presented. Chest physical therapy
treatments applicable to patients in the ICU are discussed. Postural
drainage, percussion, vibration, breathing exercises, cough stimulation
techniques, and airway suctioning are described in detail, with current
references. The importance of patient mobilization is emphasized. The
advantages of chest physical therapy over therapeutic bronchoscopy
also are discussed. Two patient examples are used to demonstrate the
beneficial effects that may be obtained with chest physical therapy.
Following the removal of retained secretions, arterial oxygenation and
partial pressure of arterial
oxygen/fraction of inspired oxygen concen-
tration ratios improved, and atelectasis resolved without the negative
hemodynamic side effects of therapeutic bronchoscopy. Physical ther-
apists trained in the ICU can safely perform chest physical therapy with
the majority of patients who are critically ill. [Ciesla
ND. Chest physical
therapy for patients in the intensive care unit.
Phys
Ther. 1996;
76:609- 625.1
Key Words: Airway suctioning, Breathing exercises, Bronchial hygiene, Cardiopulmonary, Chest physical
therapy, Cough, Intensive care units, Postural drainage, Thorax.
Nancy D Ciesla
Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
in the Intensive Care Unit
Chest physical therapy is used in the intensive care unit (ICU) to
minimize pulmonary secretion retention, to maximize oxygenation,
and to reexpand atelectatic lung segments. This article reviews how
chest physical therapy is used with patients who are critically ill.
A brief
historical review of the literature is presented. Chest physical therapy
treatments applicable to patients in the ICU are discussed. Postural
drainage, percussion, vibration, breathing exercises, cough stimulation
techniques, and airway suctioning are described in detail, with current
references. The importance of patient mobilization is emphasized. The
advantages of chest physical therapy over therapeutic bronchoscopy
also are discussed. Two patient examples are used to demonstrate the
beneficial effects that may be obtained with chest physical therapy.
Following the removal of retained secretions, arterial oxygenation and
partial pressure of arterial
oxygen/fraction of inspired oxygen concen-
tration ratios improved, and atelectasis resolved without the negative
hemodynamic side effects of therapeutic bronchoscopy. Physical ther-
apists trained in the ICU can safely perform chest physical therapy with
the majority of patients who are critically ill. [Ciesla
ND. Chest physical
therapy for patients in the intensive care unit.
Phys
Ther. 1996;
76:609- 625.1
Key Words: Airway suctioning, Breathing exercises, Bronchial hygiene, Cardiopulmonary, Chest physical
therapy, Cough, Intensive care units, Postural drainage, Thorax.
Nancy D Ciesla
Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
he purpose of this article is to review the role of
chest physical therapy in the intensive care unit
(ICU). Treatments are described and critiqued
for utility in the ICU. The ICU is a unique
environment, and patients are frequently mechanically
ventilated and have multiple invasive lines and drainage
tubes that are needed to optimize hemodynamic status.
Pulmonary artery, intracranial, and central venous pres-
sures are routinely monitored. Chest physical therapy is
often necessary due to retained secretions following
intubation and immobility. Some physicians advocate
volume-controlled mechanical ventilation or mandatory
synchronized intermittent ventilation, whereas others
recommend pressure support and pressure control
modes.' In my experience, most critically ill patients in
the ICU tolerate therapy when supplemental oxygen
delivery and ventilator adjustments are permitted before
or during chest physical therapy to enable them to
tolerate turning and mobilization.
Chest physical therapy usually consists of postural drain-
age, percussion, vibration, coughing and cough stimula-
tion techniques, breathing exercises, suctioning, and
patient mobilization. In my experience, mobilization
that includes side-to-side turning, transfer training, and
ambulation while ventilating the patient with a manual
resuscitator bag (MRB) usually minimizes the need for
postural drainage with manual techniques. The forced-
expiration technique, active cycle of breathing, positive
expiratory pressure, autogenic drainage, and use of a
flutter valve are newer airway clearance techniques that
appear to be beneficial for cooperative patients with
chronic sputum-producing diseases such as cystic fibro-
is.'-^ The focus of this article is the adult patient in the
ICU who is frequently intubated, receiving supplemental
oxygen, and unable to follow complex instructions.
Breathing exercise techniques, therefore, for patients
with less acute chronic sputum-producing disease are
not discussed.
Historical Review
Studies of chest physical therapy did not occur until the
1950s when Palmer and
Sellickhnd Thoren-tudied
352 patients following gastrectomy, hernia repair, and
cholecystecomy. These authors demonstrated that pos-
tural drainage, percussion and vibration, breathing exer-
cises, and coughing were more effective at reducing
postoperative pulmonary complications including atel-
ectasis and pneumonia than either no treatment or
breathing exercises alone.
The study of the effects of chest physical therapy on
arterial oxygenation, oxygen consumption, total lung/
thorax compliance, cardiac output, and airway resistance
was possible in the 1970s due to the routine use of
mechanical ventilation and hemodynamic monitoring.
Mackenzie et a17 demonstrated radiological improve-
ment without hypoxemia in 47 patients with multiple
trauma who received chest physical therapy and were
mechanically ventilated with positive end-expiratory
pressure (PEEP). The fraction of inspired oxygen con-
centration (FIO~) was not altered during chest physical
therapy for these patients. Chest physical therapy
improved lung/thorax compliance in 42 patients with
atelectasis, pneumonia, lung contusion, and adult respi-
ratory distress syndrome (ARDS) who were mechanically
ventilated following trauma."rway resistance was
unchanged immediately following and for 2 hours after
chest physical therapy.8 Mackenzie and colleag~es~~~
concluded, therefore, that chest physical therapy most
likely affects the small airways rather than large airways
in adult patients with traumatic injuries. Even in patients
with unstable vital signs following severe multiple
trauma, chest physical therapy has been shown to assist
in the resolution of left lower-lobe atelectasis and to
improve arterial o~ygenation.~ Investigatorsl0 also have
noted that suctioning decreases the saturation of venous
oxygen (SVO~) due to increased oxygen consumption
when there is an inadequate increase in cardiac output.
Klein et all] demonstrated an increase in cardiac output
with chest physical therapy, which returned to baseline
within
15 minutes of the procedure.
Only two research
gro~ps~~.~"ave examined the effect
of chest physical therapy on the resolution of acute
primary pneumonia. Outcome variables included dura-
tion of fever, radiographic clearing, hospital stay, and
m~rtality.~z.'"raham and Bradley12 demonstrated no
difference in the resolution of pneumonia for 27
patients treated with intermittent positive pressure
breathing (IPPB) and chest physical therapy compared
with a control group of 27 patients. Britton and col-
leagued3 studied 177 patients. Outcomes were the same
for the control group, which received advice on deep
breathing and coughing, and for the study group, in
which postural drainage, manual techniques, and
breathing exercises were used.lVn both studies, the
majority of patients received antibiotics. Patients with
nosocomial pneumonia, however, were not included in
either study. Patients who were intubated, patients who
had undergone thoracic or upper abdominal surgery,
ND Ciesla, PT, is Clinical Instructor, Department of Physical Therapy, University of Maryland School of Medicine,
Baltimore, MD 21201-1595 (USA)
([email protected]). She also was Director of Physical Therapy, R Adams Cowley
Shock Trauma Center, University of Maryland Medical Center, at the time this article was written.
610 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
chest physical therapy in the intensive care unit
(ICU). Treatments are described and critiqued
for utility in the ICU. The ICU is a unique
environment, and patients are frequently mechanically
ventilated and have multiple invasive lines and drainage
tubes that are needed to optimize hemodynamic status.
Pulmonary artery, intracranial, and central venous pres-
sures are routinely monitored. Chest physical therapy is
often necessary due to retained secretions following
intubation and immobility. Some physicians advocate
volume-controlled mechanical ventilation or mandatory
synchronized intermittent ventilation, whereas others
recommend pressure support and pressure control
modes.' In my experience, most critically ill patients in
the ICU tolerate therapy when supplemental oxygen
delivery and ventilator adjustments are permitted before
or during chest physical therapy to enable them to
tolerate turning and mobilization.
Chest physical therapy usually consists of postural drain-
age, percussion, vibration, coughing and cough stimula-
tion techniques, breathing exercises, suctioning, and
patient mobilization. In my experience, mobilization
that includes side-to-side turning, transfer training, and
ambulation while ventilating the patient with a manual
resuscitator bag (MRB) usually minimizes the need for
postural drainage with manual techniques. The forced-
expiration technique, active cycle of breathing, positive
expiratory pressure, autogenic drainage, and use of a
flutter valve are newer airway clearance techniques that
appear to be beneficial for cooperative patients with
chronic sputum-producing diseases such as cystic fibro-
is.'-^ The focus of this article is the adult patient in the
ICU who is frequently intubated, receiving supplemental
oxygen, and unable to follow complex instructions.
Breathing exercise techniques, therefore, for patients
with less acute chronic sputum-producing disease are
not discussed.
Historical Review
Studies of chest physical therapy did not occur until the
1950s when Palmer and
Sellickhnd Thoren-tudied
352 patients following gastrectomy, hernia repair, and
cholecystecomy. These authors demonstrated that pos-
tural drainage, percussion and vibration, breathing exer-
cises, and coughing were more effective at reducing
postoperative pulmonary complications including atel-
ectasis and pneumonia than either no treatment or
breathing exercises alone.
The study of the effects of chest physical therapy on
arterial oxygenation, oxygen consumption, total lung/
thorax compliance, cardiac output, and airway resistance
was possible in the 1970s due to the routine use of
mechanical ventilation and hemodynamic monitoring.
Mackenzie et a17 demonstrated radiological improve-
ment without hypoxemia in 47 patients with multiple
trauma who received chest physical therapy and were
mechanically ventilated with positive end-expiratory
pressure (PEEP). The fraction of inspired oxygen con-
centration (FIO~) was not altered during chest physical
therapy for these patients. Chest physical therapy
improved lung/thorax compliance in 42 patients with
atelectasis, pneumonia, lung contusion, and adult respi-
ratory distress syndrome (ARDS) who were mechanically
ventilated following trauma."rway resistance was
unchanged immediately following and for 2 hours after
chest physical therapy.8 Mackenzie and colleag~es~~~
concluded, therefore, that chest physical therapy most
likely affects the small airways rather than large airways
in adult patients with traumatic injuries. Even in patients
with unstable vital signs following severe multiple
trauma, chest physical therapy has been shown to assist
in the resolution of left lower-lobe atelectasis and to
improve arterial o~ygenation.~ Investigatorsl0 also have
noted that suctioning decreases the saturation of venous
oxygen (SVO~) due to increased oxygen consumption
when there is an inadequate increase in cardiac output.
Klein et all] demonstrated an increase in cardiac output
with chest physical therapy, which returned to baseline
within
15 minutes of the procedure.
Only two research
gro~ps~~.~"ave examined the effect
of chest physical therapy on the resolution of acute
primary pneumonia. Outcome variables included dura-
tion of fever, radiographic clearing, hospital stay, and
m~rtality.~z.'"raham and Bradley12 demonstrated no
difference in the resolution of pneumonia for 27
patients treated with intermittent positive pressure
breathing (IPPB) and chest physical therapy compared
with a control group of 27 patients. Britton and col-
leagued3 studied 177 patients. Outcomes were the same
for the control group, which received advice on deep
breathing and coughing, and for the study group, in
which postural drainage, manual techniques, and
breathing exercises were used.lVn both studies, the
majority of patients received antibiotics. Patients with
nosocomial pneumonia, however, were not included in
either study. Patients who were intubated, patients who
had undergone thoracic or upper abdominal surgery,
ND Ciesla, PT, is Clinical Instructor, Department of Physical Therapy, University of Maryland School of Medicine,
Baltimore, MD 21201-1595 (USA)
([email protected]). She also was Director of Physical Therapy, R Adams Cowley
Shock Trauma Center, University of Maryland Medical Center, at the time this article was written.
610 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
and patients with cystic fibrosis, lung abscess, lung Table 1.
contusion, and bronchiectasis were also excluded.
Indications for Chest Physical Therapya
Clinical examination and data gained from ventilation-
perfusion scans, computerized tomography, magnetic
resonance imaging, and portable radiographs are used
to determine an indication for chest physical therapy.
Monitoring in the ICU and pulse oximetry allow contin-
uous assessment of patients' vital signs and oxygen
saturation before, during, and after treatrnent.14 Unfor-
tunately, because studies evaluating treatment tech-
niques are limited, clinicians have frequently extrapo-
lated outcomes from studies of patients with chronic
disease or patients who are mobile to patients in the
ICU
who are immobilized and mechanically
ventilated.I5-l7
For example, Sutton and colleague^'^ studied eight
patients with copious sputum production (five patients
with br13nchiectasis, two patients with chronic bronchitis,
and one patient with cystic fibrosis) who were not in the
ICU
and concluded that tracheobronchial clearance is
unaffected by adding vibration shaking or percussion to
postural drainage with the forced-expiration technique.
Early ambulation following gallbladder and cardiac sur-
gery has almost eliminated the need for chest physical
therapy in these patients unless comorbidities are
pre~ent.'~-~~ Whether the positioning therapy recom-
mended by Dean and colleagues'2-a contributes to the
resolution of acute atelectasis is unknown. The resolu-
tion of acute atelectasis (37%-83%) demonstrated with
postural drainage and manual techniques, however, has
been shown to be equally as effective as therapeutic
bronct~oscopy for the treatment of acute lobar atelectasis
and has been studied in the ICU.738.'" The use of chest
physical therapy without regard to the patient popula-
tion or condition for which it is prescribed, and with no
standard definition of treatment components, has led, in
my opinion, to numerous negative reports on the
efficacy.
Efficacy of Chest Physical Therapy in the
Intensive Care Unit
The efficacy of chest physical therapy can be determined
by a reduction in the incidence of pulmonary infection
or an improvement in pulmonary function. The mortal-
ity rate from
nosocon~ial pneumonia remains high and
ranges from 30% to 60%.26327 Other benefits of chest
physical therapy may include decreased duration of
mechanical ventilation and prevention of tracheosto-
mies--benefits that reduce cost and shorten hospital
stays.
The diagnosis of pneumonia in the critical care setting is
difficult. The clinical criteria used to diagnose pneumo-
nia include the presence of fever, purulent sputum
expec~:oration, leukocytosis, a Gram stain showing many
polymorphonuclear cells and a single morphologically
Evidence of retained secretions (blood or sputum) not removed
by
suctioning, coughing, and turning
Radiological evidence of acute atelectasis or infiltrate
Decrease in Pao2 or Spo2 as a result of secretion retention
Prophylactic Use
Acute neurolo ical diseases affectin the innervation of the
intercostal, !iaphragmmatic, or aidominal muscles
Smoke inhalation
Acute moderate to severe brain iniury
- - -
" Pao,=partial pressure of oxygen, arterial: Spo,=oxygen ~aturation measured
. .
by pulse oximet~y. Adapted from Ciesla ND. Chest physical therapy for the
adult intensive care unit trauma patient. Pt~y\i(al ThmnIrj I%/~r.ticr. 1994;3:99.
distinct organism, and a new pulmonary infiltrate on
chest radi~graph.~"-' Patients in the ICU meeting these
criteria may respond to chest physical therapy without
antimicrobial therapy.'"oshi and colleagues2%tudied
39 patients with trauma (32 patients were intubated)
who met the criteria for diagnosis of pneumonia, at
which time chest physical therapy was initiated. Within
3
days of chest physical therapy, 31 of the 39 patients
showed complete or partial clearing of pulmonary infil-
trates and did not require antimicrobial therapy. Over-
use of antibiotics can result in toxicity, emergence of
resistant strains of bacteria,
superinfections, and
increased hospital cost^.^^^ For some patients in the
ICU, the response to chest physical therapy can differ-
entiate the diagnosis of atelectasis from pneumonia and
can be used to determine which patients require anti-
microbial therapy.26
Although activities in the ICU, including chest physical
therapy, have been reported to increase metabolic rate
up to 35%, the use of short-acting narcotics usually
diminishes any associated hemodynamic
The importance of an increase in oxygen consumption
and carbon dioxide production, which return to base-
line within
15 minutes, is questionable. Therefore, most
patients in the ICU who tolerate turning will tolerate the
positioning necessary for chest physical therapy.
Indications for Treatment
Many authors have described the inappropriate use of
chest physical therapy. For example, the American Asso-
ciation of Respiratory Care's clinical practice guideline
for postural
drainagegQonsiders recent spinal surgery,
rib fractures, and bronchopleural fistulas to be contra-
indications for postural drainage. This approach may be
a result of prescribing therapy without a clear-cut indi-
cation for treatment (Tab. 1) or of the health care
provider not having the training to position the patient
with neurologic and orthopedic injuries or the skills to
assess the patient's breath sounds, vital signs, and ability
to cough.
I believe that the patient's level of mobility is
Physical Therapy . Volume 76 . Number 6 . June 1996 Ciesla . 61 1
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
contusion, and bronchiectasis were also excluded.
Indications for Chest Physical Therapya
Clinical examination and data gained from ventilation-
perfusion scans, computerized tomography, magnetic
resonance imaging, and portable radiographs are used
to determine an indication for chest physical therapy.
Monitoring in the ICU and pulse oximetry allow contin-
uous assessment of patients' vital signs and oxygen
saturation before, during, and after treatrnent.14 Unfor-
tunately, because studies evaluating treatment tech-
niques are limited, clinicians have frequently extrapo-
lated outcomes from studies of patients with chronic
disease or patients who are mobile to patients in the
ICU
who are immobilized and mechanically
ventilated.I5-l7
For example, Sutton and colleague^'^ studied eight
patients with copious sputum production (five patients
with br13nchiectasis, two patients with chronic bronchitis,
and one patient with cystic fibrosis) who were not in the
ICU
and concluded that tracheobronchial clearance is
unaffected by adding vibration shaking or percussion to
postural drainage with the forced-expiration technique.
Early ambulation following gallbladder and cardiac sur-
gery has almost eliminated the need for chest physical
therapy in these patients unless comorbidities are
pre~ent.'~-~~ Whether the positioning therapy recom-
mended by Dean and colleagues'2-a contributes to the
resolution of acute atelectasis is unknown. The resolu-
tion of acute atelectasis (37%-83%) demonstrated with
postural drainage and manual techniques, however, has
been shown to be equally as effective as therapeutic
bronct~oscopy for the treatment of acute lobar atelectasis
and has been studied in the ICU.738.'" The use of chest
physical therapy without regard to the patient popula-
tion or condition for which it is prescribed, and with no
standard definition of treatment components, has led, in
my opinion, to numerous negative reports on the
efficacy.
Efficacy of Chest Physical Therapy in the
Intensive Care Unit
The efficacy of chest physical therapy can be determined
by a reduction in the incidence of pulmonary infection
or an improvement in pulmonary function. The mortal-
ity rate from
nosocon~ial pneumonia remains high and
ranges from 30% to 60%.26327 Other benefits of chest
physical therapy may include decreased duration of
mechanical ventilation and prevention of tracheosto-
mies--benefits that reduce cost and shorten hospital
stays.
The diagnosis of pneumonia in the critical care setting is
difficult. The clinical criteria used to diagnose pneumo-
nia include the presence of fever, purulent sputum
expec~:oration, leukocytosis, a Gram stain showing many
polymorphonuclear cells and a single morphologically
Evidence of retained secretions (blood or sputum) not removed
by
suctioning, coughing, and turning
Radiological evidence of acute atelectasis or infiltrate
Decrease in Pao2 or Spo2 as a result of secretion retention
Prophylactic Use
Acute neurolo ical diseases affectin the innervation of the
intercostal, !iaphragmmatic, or aidominal muscles
Smoke inhalation
Acute moderate to severe brain iniury
- - -
" Pao,=partial pressure of oxygen, arterial: Spo,=oxygen ~aturation measured
. .
by pulse oximet~y. Adapted from Ciesla ND. Chest physical therapy for the
adult intensive care unit trauma patient. Pt~y\i(al ThmnIrj I%/~r.ticr. 1994;3:99.
distinct organism, and a new pulmonary infiltrate on
chest radi~graph.~"-' Patients in the ICU meeting these
criteria may respond to chest physical therapy without
antimicrobial therapy.'"oshi and colleagues2%tudied
39 patients with trauma (32 patients were intubated)
who met the criteria for diagnosis of pneumonia, at
which time chest physical therapy was initiated. Within
3
days of chest physical therapy, 31 of the 39 patients
showed complete or partial clearing of pulmonary infil-
trates and did not require antimicrobial therapy. Over-
use of antibiotics can result in toxicity, emergence of
resistant strains of bacteria,
superinfections, and
increased hospital cost^.^^^ For some patients in the
ICU, the response to chest physical therapy can differ-
entiate the diagnosis of atelectasis from pneumonia and
can be used to determine which patients require anti-
microbial therapy.26
Although activities in the ICU, including chest physical
therapy, have been reported to increase metabolic rate
up to 35%, the use of short-acting narcotics usually
diminishes any associated hemodynamic
The importance of an increase in oxygen consumption
and carbon dioxide production, which return to base-
line within
15 minutes, is questionable. Therefore, most
patients in the ICU who tolerate turning will tolerate the
positioning necessary for chest physical therapy.
Indications for Treatment
Many authors have described the inappropriate use of
chest physical therapy. For example, the American Asso-
ciation of Respiratory Care's clinical practice guideline
for postural
drainagegQonsiders recent spinal surgery,
rib fractures, and bronchopleural fistulas to be contra-
indications for postural drainage. This approach may be
a result of prescribing therapy without a clear-cut indi-
cation for treatment (Tab. 1) or of the health care
provider not having the training to position the patient
with neurologic and orthopedic injuries or the skills to
assess the patient's breath sounds, vital signs, and ability
to cough.
I believe that the patient's level of mobility is
Physical Therapy . Volume 76 . Number 6 . June 1996 Ciesla . 61 1
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
often not considered in the initial patient assessment by
non-physical therapists.
I have found that patients who
adequately clear
srcretions with side-to-side turning,
mobilization, and suctioning do not need postural drain-
age with manual techniques. In my experience, chest
physical therapy is frequently administered to both lungs
without directing therapy to the anatomic area of lung
involvement, is not continued until secretions reach the
upper airway, or is not terminated when the patient
stops producing secretions. The presence of chronic
sputum-producing lung diseases, with the exception of
cystic fibrosis, does rlot warrant chest physical therapy
unless another indication for treatment (Tab.
1) or
recurrent pneumonia is present.
Chest Physical Therapy Components
Mucociliary activity and an effective cough are needed
for normal airway clearan~e.~~.~" Viscous secretions, the
presence of a cuffed tracheal tube, dehydration, hypox-
emia, immobility, and poor humidification of gases
impede mucociliary clearance, causing secretion reten-
tiotls3(i-v Neurologic conditions and phar~nacologically
induced paralysis affecting the innervation of the glottis
or intercostal and abdominal muscles may diminish
airflow, resulting in an ineffective cough.:'Vatients in
the ICU usually have one or more of these conditions.
The treatment techniques used in the ICU are similar to
those advocated by ThorenQmore than 40 years ago.
Postural drainage, percussion, vibration, coughing, suc-
tioning, breathing exercises, patient mobilization, and
sometimes manual lung inflation are the usual treat-
ments used to renlove secretions. The effectiveness of
positioning alol~e to remove retained secretions is
unknown. Most patients in the ICU cannot tolerate
strenuous exercise programs. However, turning, suction-
ing, transfer training, and ambulation (with an MRB, if'
necessary) are integral parts of'the chest physical therapy
assessment and treatment and may minimize the need
for postural drainage using manual techniq~es.~~'
Positioning
The benefits of positioning versus postural drainage is
often difficult to discern. Changes in ventilation-
perfusion relationships with positional changes have
been doc~rnented.~~,~~ Side-to-side turning decreases
postoperative fever and improves o~ygenation.~~ Im-
provements in arterial oxygenation after patient posi-
tioning, including in patients with adult respiratory
distress syndrome (ARDS), have been sho~n.~~-~' Posi-
tioning patients for chest physical therapy with the
"good lung down" is associated with improved
ventilation-perfusion ratios and oxygenation.U4*
Patients with pathology in the superior, and frequently
the atelectatic posterior, segments of the lower lobes
may have better oxygenation with prone positioning
than with supine po~itioning.4"~"
Postural Drainage
Postural drainage refers to placing the body in a position
that allows gravity to assist drainage of mucus from the
lung periphery to the segmental bror~chus and upper
airway."" Eleven positions are commonly used to drain
14 lung segments.
A detailed description of positioning
the patient in the ICU is published elsewhere." Postural
drainage enhances peripheral
lung clearance, increases
functional residual capacity, and accelerates mucus
clearanCe.~~).~?.m Postural drainage in conjunction with
mechanical ventilation and PEEP is thought to increase
transpulmonary pressure, irllprove ventilation-perfusion
ratios, increase lung/thorax compliance of the non-
dependent hemithorax, and reduce collateral airway
re~istance.5~ Atelectasis may resolve more quickly when
the patient is turned with the affected lung ~ipperrnost.~:'
Obese patients placed in the 19degree Trendelenburg
position after abdominal surgery fbr postural drainage
of the lower lobes rarely demonstrate clinically signifi-
cant oxygen desaturation."" Transient decreases in oxy-
gen saturation measured by pulse oximetry (Spo,) that
occur with postural drainage positioning return to base-
line within a few minutes. Therefore, most spontane-
ously breathing and mechanically ventilated patients
tolerate positional changes necessary for segmental pos-
tural drainage. Infrequently, an increase in metabolic
demand or worsening ventilation-perfusion ratios result
in a decrease in oxygenation, insufficient gas flow, or low
lung volu~nes.~~'.~~ Increasing the patient's Fro, or addi-
tional ventilator adjustments are therefore required
prior to or during therapy. Positioning for postural
drainage is usually continued once the patient has
responded fivorably to changes in ventilator settings.
The duration of postural drainage may range from 15 to
60 minutes, depending on the patient's tolerance to
c:hanges in position and the amount of sputum
production.
Cooperative, spontaneously breathing patients who can
cough effectively may not need postural drainage. John-
son et a157 found no difference in the resolution of'
atelectasis when postural drainage and percussion were
added to deep breathing exercises in patients with acute
lobar atelectasis, although the diagnoses and mobility
level of the patients studied were not addressed.
Patient Example # 7
The following example demonstrates improvement in
both atelectasis and oxygenation after prone positioning
and chest physical therapy. The patient was discharged
8
days after treatment was initiated. Although it was ini-
tially felt that this patient would require extracorporeal
lung assistance to sustain life, after positioning and chest
physical therapy this was not necessary.
6 12 .
Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
non-physical therapists.
I have found that patients who
adequately clear
srcretions with side-to-side turning,
mobilization, and suctioning do not need postural drain-
age with manual techniques. In my experience, chest
physical therapy is frequently administered to both lungs
without directing therapy to the anatomic area of lung
involvement, is not continued until secretions reach the
upper airway, or is not terminated when the patient
stops producing secretions. The presence of chronic
sputum-producing lung diseases, with the exception of
cystic fibrosis, does rlot warrant chest physical therapy
unless another indication for treatment (Tab.
1) or
recurrent pneumonia is present.
Chest Physical Therapy Components
Mucociliary activity and an effective cough are needed
for normal airway clearan~e.~~.~" Viscous secretions, the
presence of a cuffed tracheal tube, dehydration, hypox-
emia, immobility, and poor humidification of gases
impede mucociliary clearance, causing secretion reten-
tiotls3(i-v Neurologic conditions and phar~nacologically
induced paralysis affecting the innervation of the glottis
or intercostal and abdominal muscles may diminish
airflow, resulting in an ineffective cough.:'Vatients in
the ICU usually have one or more of these conditions.
The treatment techniques used in the ICU are similar to
those advocated by ThorenQmore than 40 years ago.
Postural drainage, percussion, vibration, coughing, suc-
tioning, breathing exercises, patient mobilization, and
sometimes manual lung inflation are the usual treat-
ments used to renlove secretions. The effectiveness of
positioning alol~e to remove retained secretions is
unknown. Most patients in the ICU cannot tolerate
strenuous exercise programs. However, turning, suction-
ing, transfer training, and ambulation (with an MRB, if'
necessary) are integral parts of'the chest physical therapy
assessment and treatment and may minimize the need
for postural drainage using manual techniq~es.~~'
Positioning
The benefits of positioning versus postural drainage is
often difficult to discern. Changes in ventilation-
perfusion relationships with positional changes have
been doc~rnented.~~,~~ Side-to-side turning decreases
postoperative fever and improves o~ygenation.~~ Im-
provements in arterial oxygenation after patient posi-
tioning, including in patients with adult respiratory
distress syndrome (ARDS), have been sho~n.~~-~' Posi-
tioning patients for chest physical therapy with the
"good lung down" is associated with improved
ventilation-perfusion ratios and oxygenation.U4*
Patients with pathology in the superior, and frequently
the atelectatic posterior, segments of the lower lobes
may have better oxygenation with prone positioning
than with supine po~itioning.4"~"
Postural Drainage
Postural drainage refers to placing the body in a position
that allows gravity to assist drainage of mucus from the
lung periphery to the segmental bror~chus and upper
airway."" Eleven positions are commonly used to drain
14 lung segments.
A detailed description of positioning
the patient in the ICU is published elsewhere." Postural
drainage enhances peripheral
lung clearance, increases
functional residual capacity, and accelerates mucus
clearanCe.~~).~?.m Postural drainage in conjunction with
mechanical ventilation and PEEP is thought to increase
transpulmonary pressure, irllprove ventilation-perfusion
ratios, increase lung/thorax compliance of the non-
dependent hemithorax, and reduce collateral airway
re~istance.5~ Atelectasis may resolve more quickly when
the patient is turned with the affected lung ~ipperrnost.~:'
Obese patients placed in the 19degree Trendelenburg
position after abdominal surgery fbr postural drainage
of the lower lobes rarely demonstrate clinically signifi-
cant oxygen desaturation."" Transient decreases in oxy-
gen saturation measured by pulse oximetry (Spo,) that
occur with postural drainage positioning return to base-
line within a few minutes. Therefore, most spontane-
ously breathing and mechanically ventilated patients
tolerate positional changes necessary for segmental pos-
tural drainage. Infrequently, an increase in metabolic
demand or worsening ventilation-perfusion ratios result
in a decrease in oxygenation, insufficient gas flow, or low
lung volu~nes.~~'.~~ Increasing the patient's Fro, or addi-
tional ventilator adjustments are therefore required
prior to or during therapy. Positioning for postural
drainage is usually continued once the patient has
responded fivorably to changes in ventilator settings.
The duration of postural drainage may range from 15 to
60 minutes, depending on the patient's tolerance to
c:hanges in position and the amount of sputum
production.
Cooperative, spontaneously breathing patients who can
cough effectively may not need postural drainage. John-
son et a157 found no difference in the resolution of'
atelectasis when postural drainage and percussion were
added to deep breathing exercises in patients with acute
lobar atelectasis, although the diagnoses and mobility
level of the patients studied were not addressed.
Patient Example # 7
The following example demonstrates improvement in
both atelectasis and oxygenation after prone positioning
and chest physical therapy. The patient was discharged
8
days after treatment was initiated. Although it was ini-
tially felt that this patient would require extracorporeal
lung assistance to sustain life, after positioning and chest
physical therapy this was not necessary.
6 12 .
Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
A 33-year-old white man was admitted to a trauma center
following a near-drowning accident. He had been sub
1nergec-l for approximately
'LO minutes and had hypother~nic
cardiac arrest with
30 rninutes of cardiac asystole. His
admitting Glasgow
Coma Scak was 3. The patient had a
core temperature of
80°F. On admission to the hospital, he
was rewal-~ned with gastric pelitoneal lavage. During the
initial hospitalization, the patient developed progressive
I-espiratory failure requiring pressure-control ventilation
with
36 cln of water pressure, 18 cm of water pressure of
PEEP, and 100% of Flo,. Due to severe ARDS and increas-
ing ailway pressures, the patient was transferred to a trauma
center with expertise in extracorporal lung assistance. Five
<bays following the accident, the patient was t~ansferred to
the second trauma center. At this trauma center, comput-
erized tomography and chest radiography demonstrated
bilateral lower-lobe atelectasis and consolidation, with right
pleura~l effiision without evidence of ARDS (Figs.
1, 2A).
To optimize ventilation and treat the bilateral lower-lobe
consolidation, the patient was placed on a turning frame for
Figure 1.
Chest radiograph demonstrating bilateral lower-lobe atelectasis. Note
prone positioning and chest physical therapy. Twenty-four
+hat the diaphragmatic borders are obscured,
hours following admission to the second trauma center, the
patient was evaluated for chest physical therapy while phar-
macologically paralyzed with metabine and mechanically
ventilated via an endotracheal tube. Coarse rales were noted appear to be indicated u~ltil further research demon-
over the posterior lung zones. The initial treatment con- strates that positioning alone can be equally effective.
sisted of postural drainage and percussion to the posterior
basal segments of both lower lobes for
45 rninutes with the
patient in the prone head-down position. Less than
10 cc of Percussjon and Vibration
sputum was obtained with suctioning. Following treatment,
percussion and vibration
are the techniques ]nost fie-
improved air ent~y was noted by auscultation.
quently recommended for the patient who is intubated
and mechanically ventilated and for patients with
After
5 days of treatnlent, the patient was placed on a
impaired cognition or poor coughing Percus-
regular bed due to the marked improvement in his respi-
sion and vibration are used to enhance m~icociliary
ratory status. Chest physical therapy was administered for
7
days and consisted of postl~ral drainage, percussion, and
clearance fi-om both central and peripheral
vibration
to the lower lobes (Tab, 2). Sputllm
The exact niechanism of action of chest percussion is
incre:ased, with a gradual improvement in breath sounds unknown, bur there is some evidellce froln animal
and chest radiograph findings and marked in~provement models that physical stimulation alters airflow and is
shown in computerized tomography scan (Fig.
3). The associated with the release of pulmonary chemical medi-
patient was extubated on day
8. Following extubation, the ators, mediators that may improve ciliary trallsport speed
patient ambulated with assistance and had a good prodl~c- by as much as
340%,") Mllcociliary flow is dependent on
tive cough. Within
24 hours, the patient was discharged
the viscoelastic
property of the geometry of the
back to the original hospital, alert and oriented while
airnay, and the speed ofairflow.~o,~ Luterations
in aiMiay
following three-step commands.
diameter and airflow may decrease the viscosity of
mucus, making percussion more effective in mobilizing
Chest physical therapy and prone positioning were most
secretions that are adherent to the bronchial walls.
likely responsible for reexpansion of this patient's col-
lapsed lower lobes and for improved oxygenation, which
in turn led to successful weaning from ~nechanical
ventilalion. The physicians and physical therapists
involved with this patient did not know which interven-
tion was primarily responsible for the patient's improve-
ment. However, when faced with a patient with
increasing airway pressures and secretion retention who
is difficult to ventilate on
100% of Fro,, simultan-
eous treatment using gravity to maximize
ventilation-perfusion ratios and postural drainage with
manual techniques to mobilize retained secretions
Percussion with postiiral drainage has been used to
remove mucus and aspirated teeth from patients who are
medically too iinstable to undergo bronchoscopy. This
suggests that manual techniques can assist in clearing
secretions from both the central and peripheral air-
way~."~z Because of differences in aerosol deposition in
the airways and no standardization of manual versus
mechanical technique, controversy exists as to whether
the radionuclide clearance noted with percussion and
vibration indicates peripheral or central ainvay clear-
ance. Manual percussion and vibration, when performed
Physical Therapy. Volume
76 . Number 6 . June 1996 Ciesla . 61 3
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
following a near-drowning accident. He had been sub
1nergec-l for approximately
'LO minutes and had hypother~nic
cardiac arrest with
30 rninutes of cardiac asystole. His
admitting Glasgow
Coma Scak was 3. The patient had a
core temperature of
80°F. On admission to the hospital, he
was rewal-~ned with gastric pelitoneal lavage. During the
initial hospitalization, the patient developed progressive
I-espiratory failure requiring pressure-control ventilation
with
36 cln of water pressure, 18 cm of water pressure of
PEEP, and 100% of Flo,. Due to severe ARDS and increas-
ing ailway pressures, the patient was transferred to a trauma
center with expertise in extracorporal lung assistance. Five
<bays following the accident, the patient was t~ansferred to
the second trauma center. At this trauma center, comput-
erized tomography and chest radiography demonstrated
bilateral lower-lobe atelectasis and consolidation, with right
pleura~l effiision without evidence of ARDS (Figs.
1, 2A).
To optimize ventilation and treat the bilateral lower-lobe
consolidation, the patient was placed on a turning frame for
Figure 1.
Chest radiograph demonstrating bilateral lower-lobe atelectasis. Note
prone positioning and chest physical therapy. Twenty-four
+hat the diaphragmatic borders are obscured,
hours following admission to the second trauma center, the
patient was evaluated for chest physical therapy while phar-
macologically paralyzed with metabine and mechanically
ventilated via an endotracheal tube. Coarse rales were noted appear to be indicated u~ltil further research demon-
over the posterior lung zones. The initial treatment con- strates that positioning alone can be equally effective.
sisted of postural drainage and percussion to the posterior
basal segments of both lower lobes for
45 rninutes with the
patient in the prone head-down position. Less than
10 cc of Percussjon and Vibration
sputum was obtained with suctioning. Following treatment,
percussion and vibration
are the techniques ]nost fie-
improved air ent~y was noted by auscultation.
quently recommended for the patient who is intubated
and mechanically ventilated and for patients with
After
5 days of treatnlent, the patient was placed on a
impaired cognition or poor coughing Percus-
regular bed due to the marked improvement in his respi-
sion and vibration are used to enhance m~icociliary
ratory status. Chest physical therapy was administered for
7
days and consisted of postl~ral drainage, percussion, and
clearance fi-om both central and peripheral
vibration
to the lower lobes (Tab, 2). Sputllm
The exact niechanism of action of chest percussion is
incre:ased, with a gradual improvement in breath sounds unknown, bur there is some evidellce froln animal
and chest radiograph findings and marked in~provement models that physical stimulation alters airflow and is
shown in computerized tomography scan (Fig.
3). The associated with the release of pulmonary chemical medi-
patient was extubated on day
8. Following extubation, the ators, mediators that may improve ciliary trallsport speed
patient ambulated with assistance and had a good prodl~c- by as much as
340%,") Mllcociliary flow is dependent on
tive cough. Within
24 hours, the patient was discharged
the viscoelastic
property of the geometry of the
back to the original hospital, alert and oriented while
airnay, and the speed ofairflow.~o,~ Luterations
in aiMiay
following three-step commands.
diameter and airflow may decrease the viscosity of
mucus, making percussion more effective in mobilizing
Chest physical therapy and prone positioning were most
secretions that are adherent to the bronchial walls.
likely responsible for reexpansion of this patient's col-
lapsed lower lobes and for improved oxygenation, which
in turn led to successful weaning from ~nechanical
ventilalion. The physicians and physical therapists
involved with this patient did not know which interven-
tion was primarily responsible for the patient's improve-
ment. However, when faced with a patient with
increasing airway pressures and secretion retention who
is difficult to ventilate on
100% of Fro,, simultan-
eous treatment using gravity to maximize
ventilation-perfusion ratios and postural drainage with
manual techniques to mobilize retained secretions
Percussion with postiiral drainage has been used to
remove mucus and aspirated teeth from patients who are
medically too iinstable to undergo bronchoscopy. This
suggests that manual techniques can assist in clearing
secretions from both the central and peripheral air-
way~."~z Because of differences in aerosol deposition in
the airways and no standardization of manual versus
mechanical technique, controversy exists as to whether
the radionuclide clearance noted with percussion and
vibration indicates peripheral or central ainvay clear-
ance. Manual percussion and vibration, when performed
Physical Therapy. Volume
76 . Number 6 . June 1996 Ciesla . 61 3
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
with postural drainage, are thought to expedite drainage
of secretions from the central and peripheral airways,
which may reduce treatment This is particu-
larly important for patients in the ICU who have periods
of hernodynamic instability and require multiple diag-
nostic and therapeutic procedures. Both techniques are
used with postural drainage.
Manual techniques should be applied only over the lung
that approximates the chest wall with full in~piration.~~
Cornmonly accepted anatomic landmarks for percussion
and vibration include the level of the 10th thoracic
vertebra posteriorly and the xiphoid process anteriorly
with normal respiration. Posteriorly, the lower borders
of the lung descend to T-12 with deep inspiration and
rise to T-9 with forced ex~iration.~~
The lower lung borders may be two to three levels higher
in patients with abdominal distention and in patients
with liver or kidney disease. Lower lung borders can be
assessed with auscultation and mediate percussion (per-
cussion as part of the physical examination to determine
the density of underlying structures). One lung segment,
the medial segment of the right lower lobe, is not
accessible to manual techniques because of its anatomic
location. Percussion and vibration should be applied
directly over the skin to allow the therapist to observe
anatomic landmarks, skin redness, or petechiae, as well
as chest tube and line insertion sites, and to detect
undiagnosed rib and sternal fractures or the presence of
subcutaneous emphysema (air in the subcutaneous tis-
sue). The presence of, and any increases in, subcutane-
ous ernphysema may be associated with a life-threatening
pneumothorax. This condition should therefore be
monitored closely, and the physician or nurse should be
notified when airway pressures are increasing. The phy-
sician or nurse should also be notified when subcutane-
ous emphysema is increasing, as noted with palpation.
Redness or petechiae are usually a result of improper
technique. For patients with thoracic abrasions or burns
needing manual techniques, a sterile drape should be
placed over the chest wall. When treating a patient with
spinal injuries who is stabilized in either a halo vest or
thoracic corset, the therapist opens the vest after the
patient is placed in the appropriate postural drainage
position. Opening the vest in this manner allows access
to the thorax without disrupting spinal stabilization. For
the patient with severe brain injury requiring intracra-
nial pressure (ICP) monitoring, manual techniques are
not contraindicated because they do not increase
ICP.(j"b7 The force and frequency of manual percussion
and vibration vary depending on the therapist's experi-
ence; whether a one- or two-handed technique is used;
and the patient's pain tolerance, especially when rib
fractures are present.
Percussion. Percussion is used during both the inspira-
tory and expiratory phases of respiration. The therapist's
hand should create an air cushion, and the energy wave
created by that hand is transmitted through the chest
wall and
is thought to dislodge secretions from the
bronchial ~alls.~~~~ronchospasm is the most fre-
quently discussed adverse effect of percussion in patients
with chronic
bronchi ti^.^,^^^ Gallon71 noted that bron-
chospasm can be prevented when a forced-expiration
technique or the active cycle of breathing is incorpo-
rated into chest physical therapy. Bronchospasm is rare
in patients in the ICU who have undergone trauma or
surgery. More often, particularly in patients with quad-
riplegia, wheezes are noted as secretions are mobilized
from the lung ~eriphery.~' Once the secretions are
removed by coughing or suctioning, breath sounds
improve.7' Patients with reactive airway disease may
require inhaled bronchodilators prior to or following
treat~nent.~%en bronchospasm persists as a result of
Figure 2.
Computerized tomography scans showing (A) bilateral lower-lobe atelectasis and right pleural effusion and (B) improvement in bilateral lower-lobe
atelectasis.
6 14 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
of secretions from the central and peripheral airways,
which may reduce treatment This is particu-
larly important for patients in the ICU who have periods
of hernodynamic instability and require multiple diag-
nostic and therapeutic procedures. Both techniques are
used with postural drainage.
Manual techniques should be applied only over the lung
that approximates the chest wall with full in~piration.~~
Cornmonly accepted anatomic landmarks for percussion
and vibration include the level of the 10th thoracic
vertebra posteriorly and the xiphoid process anteriorly
with normal respiration. Posteriorly, the lower borders
of the lung descend to T-12 with deep inspiration and
rise to T-9 with forced ex~iration.~~
The lower lung borders may be two to three levels higher
in patients with abdominal distention and in patients
with liver or kidney disease. Lower lung borders can be
assessed with auscultation and mediate percussion (per-
cussion as part of the physical examination to determine
the density of underlying structures). One lung segment,
the medial segment of the right lower lobe, is not
accessible to manual techniques because of its anatomic
location. Percussion and vibration should be applied
directly over the skin to allow the therapist to observe
anatomic landmarks, skin redness, or petechiae, as well
as chest tube and line insertion sites, and to detect
undiagnosed rib and sternal fractures or the presence of
subcutaneous emphysema (air in the subcutaneous tis-
sue). The presence of, and any increases in, subcutane-
ous ernphysema may be associated with a life-threatening
pneumothorax. This condition should therefore be
monitored closely, and the physician or nurse should be
notified when airway pressures are increasing. The phy-
sician or nurse should also be notified when subcutane-
ous emphysema is increasing, as noted with palpation.
Redness or petechiae are usually a result of improper
technique. For patients with thoracic abrasions or burns
needing manual techniques, a sterile drape should be
placed over the chest wall. When treating a patient with
spinal injuries who is stabilized in either a halo vest or
thoracic corset, the therapist opens the vest after the
patient is placed in the appropriate postural drainage
position. Opening the vest in this manner allows access
to the thorax without disrupting spinal stabilization. For
the patient with severe brain injury requiring intracra-
nial pressure (ICP) monitoring, manual techniques are
not contraindicated because they do not increase
ICP.(j"b7 The force and frequency of manual percussion
and vibration vary depending on the therapist's experi-
ence; whether a one- or two-handed technique is used;
and the patient's pain tolerance, especially when rib
fractures are present.
Percussion. Percussion is used during both the inspira-
tory and expiratory phases of respiration. The therapist's
hand should create an air cushion, and the energy wave
created by that hand is transmitted through the chest
wall and
is thought to dislodge secretions from the
bronchial ~alls.~~~~ronchospasm is the most fre-
quently discussed adverse effect of percussion in patients
with chronic
bronchi ti^.^,^^^ Gallon71 noted that bron-
chospasm can be prevented when a forced-expiration
technique or the active cycle of breathing is incorpo-
rated into chest physical therapy. Bronchospasm is rare
in patients in the ICU who have undergone trauma or
surgery. More often, particularly in patients with quad-
riplegia, wheezes are noted as secretions are mobilized
from the lung ~eriphery.~' Once the secretions are
removed by coughing or suctioning, breath sounds
improve.7' Patients with reactive airway disease may
require inhaled bronchodilators prior to or following
treat~nent.~%en bronchospasm persists as a result of
Figure 2.
Computerized tomography scans showing (A) bilateral lower-lobe atelectasis and right pleural effusion and (B) improvement in bilateral lower-lobe
atelectasis.
6 14 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
percussion, appropriate intervention should be
implemented.
The optimal frequency and force of chest percussion are
not known. Frequencies of
100 to 480 cycles per minute,
producing
2 to 4
ft-lb (2.7-5.4 Nsm) and 58 to 65 N of
force 011 the chest wall have been reported.58 There is
some evidence that both fast and slow percussion
increase sputum production in patients with bronchiec-
tasis and alveolar proteinosis. Gallon7l and Hammon
(WE Hammon, PT, Chief of Rehabilitative Services,
Oklahoma Memorial Hospital, Oklahoma City, Okla;
personal communication) report that fast percussion
(240 cycles per minute) demonstrated the greatest spu-
tum production, although slow percussion
(6-12 cycles
per minute) was more effective than no percussion.
Hammon reported that when large amounts of
protein-
aceous material are present in the alveoli, percussion is
more effective than vibration
(WE Hammon, personal
communication). In patients in the ICU, the quantity of
sputum produced has not been shown to correlate with
improvements in pulmonary
function.54 Differences in
technique may account for discrepancies in therapy
advocated in different parts of the United state^.^^^^^
The use of percussion over rib fractures remains contro-
versial. Extrapleural pathology, pneumothorax, and
hemothorax that develop as a result of the initial injury
should not be considered a contraindication to percus
sion. I11 a retrospective study of 252 patients with rib
fractures who received chest physical therapy (including
manual percussion),
24 patients developed extrapleural
pathology.75 Ten of these patients developed extrapleu-
ral pathology before chest physical therapy was started,
and
14 patients developed extrapleural pathology after
chest physical therapy was started. There was no differ-
ence in the development of extrapleural hematomas
between the patients who received manual percussion
and those who did not receive manual
percu~sion.~"
Followng treatment of more than 500 patients with rib
fractures, physical therapists at the R Adams Cowley
Shock Trauma Center (Baltimore, Md) have noted that
patients who are intubated and who are being mechan-
ically kentilated usually tolerate percussion in conjunc-
tion with analgesics and sedation. Greater alterations in
intrathoracic pressure occur with coughing than with
properly performed percussion." For patients with rib
and sternal fractures, controlled mechanical ventilation
may even stabilize the fracture site by minimizing nega-
tive intrathoracic pressure^.^^ The force and frequency
of percussion can be modified to patient tolerance.
Percussion is not indicated for the spontaneously breath-
ing patient with rib fractures who is responding to
breathing exercises and assistive coughing techniques.
-Y
a $
L
h VIS
N m+
*
a
0-
m
*
C
2
s -&Z
.oe
mmo 0
7-1 0"
N =
*
0
m
") 0
0
- m
0
0
m
-
k 2
Z'I'E&! 7.E 0
-E x z
2 E k+
-UPS
A
m
r
N
~C"O"2I.
8 22
I I
C 0
.2 E
121 N
*LC NO"bww
3
426 2 2
a 9
C
0 .-
H
H
-i
2 0
2
5
e
.-
*
0 - .-
0 f
6
P .=
c !? ,o .g
?! f ~2 - g 0,
LL a
>* .-
: s" "sop
Zlr2228u
7
Physical Therapy . Volume 76 . Number 6 . June 1996 Ciesla . 6 15
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
implemented.
The optimal frequency and force of chest percussion are
not known. Frequencies of
100 to 480 cycles per minute,
producing
2 to 4
ft-lb (2.7-5.4 Nsm) and 58 to 65 N of
force 011 the chest wall have been reported.58 There is
some evidence that both fast and slow percussion
increase sputum production in patients with bronchiec-
tasis and alveolar proteinosis. Gallon7l and Hammon
(WE Hammon, PT, Chief of Rehabilitative Services,
Oklahoma Memorial Hospital, Oklahoma City, Okla;
personal communication) report that fast percussion
(240 cycles per minute) demonstrated the greatest spu-
tum production, although slow percussion
(6-12 cycles
per minute) was more effective than no percussion.
Hammon reported that when large amounts of
protein-
aceous material are present in the alveoli, percussion is
more effective than vibration
(WE Hammon, personal
communication). In patients in the ICU, the quantity of
sputum produced has not been shown to correlate with
improvements in pulmonary
function.54 Differences in
technique may account for discrepancies in therapy
advocated in different parts of the United state^.^^^^^
The use of percussion over rib fractures remains contro-
versial. Extrapleural pathology, pneumothorax, and
hemothorax that develop as a result of the initial injury
should not be considered a contraindication to percus
sion. I11 a retrospective study of 252 patients with rib
fractures who received chest physical therapy (including
manual percussion),
24 patients developed extrapleural
pathology.75 Ten of these patients developed extrapleu-
ral pathology before chest physical therapy was started,
and
14 patients developed extrapleural pathology after
chest physical therapy was started. There was no differ-
ence in the development of extrapleural hematomas
between the patients who received manual percussion
and those who did not receive manual
percu~sion.~"
Followng treatment of more than 500 patients with rib
fractures, physical therapists at the R Adams Cowley
Shock Trauma Center (Baltimore, Md) have noted that
patients who are intubated and who are being mechan-
ically kentilated usually tolerate percussion in conjunc-
tion with analgesics and sedation. Greater alterations in
intrathoracic pressure occur with coughing than with
properly performed percussion." For patients with rib
and sternal fractures, controlled mechanical ventilation
may even stabilize the fracture site by minimizing nega-
tive intrathoracic pressure^.^^ The force and frequency
of percussion can be modified to patient tolerance.
Percussion is not indicated for the spontaneously breath-
ing patient with rib fractures who is responding to
breathing exercises and assistive coughing techniques.
-Y
a $
L
h VIS
N m+
*
a
0-
m
*
C
2
s -&Z
.oe
mmo 0
7-1 0"
N =
*
0
m
") 0
0
- m
0
0
m
-
k 2
Z'I'E&! 7.E 0
-E x z
2 E k+
-UPS
A
m
r
N
~C"O"2I.
8 22
I I
C 0
.2 E
121 N
*LC NO"bww
3
426 2 2
a 9
C
0 .-
H
H
-i
2 0
2
5
e
.-
*
0 - .-
0 f
6
P .=
c !? ,o .g
?! f ~2 - g 0,
LL a
>* .-
: s" "sop
Zlr2228u
7
Physical Therapy . Volume 76 . Number 6 . June 1996 Ciesla . 6 15
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
adult patients in the ICU, use of these devices increases
cost, does not reduce staffing requirements, and intro-
duces the risk of cross-infection, without documented
benefit over manual techniques. Although Radford and
colleagues77 advocate mechanical percussion at
25 to
35 Hz, their research using an animal model has not
been extended to human subjects. Mechanical devices,
used with patients who have chronic pulmonary disease,
offer no benefit over forced-expiration techniques com-
bined with postural drainage.7R-H0 In patients with pul-
monary alveolar proteinosis, manual percussion
(180-
270
cycles per minute) was almost twice as effective as
mechanical percussion
(36 Hz) in removing protein-
aceous material from the al~eoli.~' Recently, Hammon
and McCaffree" studied the effects of manual percus-
sion, saline alone, and a commercially available pneu-
Figure 3. matic percussor on the removal of alveolar material in
Chest radiograph showing improvement in right lower-lobe atelectosis. three patients with pulmonary alveolar proteinosis. Mea-
surements of optical density were better with manual
percussion than with saline alone or the pneumatic
per cuss or.^ Although these results cannot be extrapo-
Vibration. Vibration is a more forceful technique than
lated directly to non-saline-filled lungs, they suggest that
percussion. At
12 to 20 HZ, vibration is similar to the manual percussion is capable of removing secretions
normal beat frequencies of human ciliaa7"he rib cage is
from the most distal airnays and alveoli and is more
"shaken" during the expiratory phase of respiration. effective than mechanical percussors, vibrators, or saline
Some clinicians define vigorous vibration as "rib shak- alone.
ing" or "rib springing."I7 Vibration is used with both
patients who are spontaneously breathing and patients High-frequency chest compression (HFCC) has recently
who are mechanically ventilated. Secretions move into gained popularity as a means
of enhancing mucus
the upper aimaJ's when vibration is performed during clearance in patients with cystic fibrosis.60 patient
broncho~copy.~~ Forceful vibration is not recommended wears
an inflatable vest that covers any lung lobes
over rib fractures, which may perforate the pleura and affected with pathology. Frequencies are adjusted to
cause
a pneumothorax, intrapleural bleeding, or an
optimize airflow and to maximize mucus
extrapleural hematoma. Some clinicians use a mild
clearance. Whitman and colleagues," however, found
vibration of light, fast oscillations over rib fractures and
no increase in mucus clearance over traditional tech-
report no adverse effects. Vibration in patients with
niques in six patients who had been mechanically venti-
thoracic spinal fractures should be mild and performed lated
for 90 to 1,203 days. Percussion was applied for 2
by clinicians trained in chest physical therapy tech- minutes to five lung regions with postural drainage. No
niques. S~ontaneously breathing patients who are diffi- indications for treatment were stated other than that the
cult to arollse (such as those with acute brain injury) may patients were mechanically ventilated. The practicality of
benefit from vibration to erlcourage deep inspiration
using HFCC with mechanical ventilation in the JCU is
and stimulate a cough. questionable when patients are at high risk for cross-
contamination and access to the thorax is required for
In my clirlical experience, dysrhythmias are more likely cardioascular
monitoring. Further study is needed to
to occur as a result of hemodynamic instability associated determine whether HFCC and use of a flutter valve
with positiorlal change than as a result of the actual facilitate mucus clearance from central and peripheral
manual technique. Percussion and vibration adjacent to
for patients who are critically ill and immobile.
a cardiac electrode may produce artifacts. After consul-
tation with nurses and physicians, electrodes can usually
Manual lung /nflation
be repositioned or, in rare cases, temporarily discon- Manual lung inflation, which involves disconnecting the
nected. The therapist should then closely monitor the
patient
from the mechanical ventilator and inflating the
clinical status of the patient and any alterations in blood
lungs with a large tidal volume via an MRB, is a common
pressure or heart rate. practice in Great Britain, Canada, and Au~tralia.~~ After
the lungs are hyperinflated, the bag is quickly released,
Mechanical devices. Mechanical percussors and vibra- producing a high expiratory flow. ~l~~ rates range from
tors were introduced in the late
1960s to permit patients
123 to 340 L/rnin, depending on the type of bag used
with cystic fibrosis more independence with therapy. For
6 16 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
cost, does not reduce staffing requirements, and intro-
duces the risk of cross-infection, without documented
benefit over manual techniques. Although Radford and
colleagues77 advocate mechanical percussion at
25 to
35 Hz, their research using an animal model has not
been extended to human subjects. Mechanical devices,
used with patients who have chronic pulmonary disease,
offer no benefit over forced-expiration techniques com-
bined with postural drainage.7R-H0 In patients with pul-
monary alveolar proteinosis, manual percussion
(180-
270
cycles per minute) was almost twice as effective as
mechanical percussion
(36 Hz) in removing protein-
aceous material from the al~eoli.~' Recently, Hammon
and McCaffree" studied the effects of manual percus-
sion, saline alone, and a commercially available pneu-
Figure 3. matic percussor on the removal of alveolar material in
Chest radiograph showing improvement in right lower-lobe atelectosis. three patients with pulmonary alveolar proteinosis. Mea-
surements of optical density were better with manual
percussion than with saline alone or the pneumatic
per cuss or.^ Although these results cannot be extrapo-
Vibration. Vibration is a more forceful technique than
lated directly to non-saline-filled lungs, they suggest that
percussion. At
12 to 20 HZ, vibration is similar to the manual percussion is capable of removing secretions
normal beat frequencies of human ciliaa7"he rib cage is
from the most distal airnays and alveoli and is more
"shaken" during the expiratory phase of respiration. effective than mechanical percussors, vibrators, or saline
Some clinicians define vigorous vibration as "rib shak- alone.
ing" or "rib springing."I7 Vibration is used with both
patients who are spontaneously breathing and patients High-frequency chest compression (HFCC) has recently
who are mechanically ventilated. Secretions move into gained popularity as a means
of enhancing mucus
the upper aimaJ's when vibration is performed during clearance in patients with cystic fibrosis.60 patient
broncho~copy.~~ Forceful vibration is not recommended wears
an inflatable vest that covers any lung lobes
over rib fractures, which may perforate the pleura and affected with pathology. Frequencies are adjusted to
cause
a pneumothorax, intrapleural bleeding, or an
optimize airflow and to maximize mucus
extrapleural hematoma. Some clinicians use a mild
clearance. Whitman and colleagues," however, found
vibration of light, fast oscillations over rib fractures and
no increase in mucus clearance over traditional tech-
report no adverse effects. Vibration in patients with
niques in six patients who had been mechanically venti-
thoracic spinal fractures should be mild and performed lated
for 90 to 1,203 days. Percussion was applied for 2
by clinicians trained in chest physical therapy tech- minutes to five lung regions with postural drainage. No
niques. S~ontaneously breathing patients who are diffi- indications for treatment were stated other than that the
cult to arollse (such as those with acute brain injury) may patients were mechanically ventilated. The practicality of
benefit from vibration to erlcourage deep inspiration
using HFCC with mechanical ventilation in the JCU is
and stimulate a cough. questionable when patients are at high risk for cross-
contamination and access to the thorax is required for
In my clirlical experience, dysrhythmias are more likely cardioascular
monitoring. Further study is needed to
to occur as a result of hemodynamic instability associated determine whether HFCC and use of a flutter valve
with positiorlal change than as a result of the actual facilitate mucus clearance from central and peripheral
manual technique. Percussion and vibration adjacent to
for patients who are critically ill and immobile.
a cardiac electrode may produce artifacts. After consul-
tation with nurses and physicians, electrodes can usually
Manual lung /nflation
be repositioned or, in rare cases, temporarily discon- Manual lung inflation, which involves disconnecting the
nected. The therapist should then closely monitor the
patient
from the mechanical ventilator and inflating the
clinical status of the patient and any alterations in blood
lungs with a large tidal volume via an MRB, is a common
pressure or heart rate. practice in Great Britain, Canada, and Au~tralia.~~ After
the lungs are hyperinflated, the bag is quickly released,
Mechanical devices. Mechanical percussors and vibra- producing a high expiratory flow. ~l~~ rates range from
tors were introduced in the late
1960s to permit patients
123 to 340 L/rnin, depending on the type of bag used
with cystic fibrosis more independence with therapy. For
6 16 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
and the amount of pressure generated.HVhis tech-
nique, often referred to as the "bag-squeezing method,"
was introduced in the 1960s to prevent pulmonary
segmental collapse, reexpand collapsed alveoli, mini-
mize the risk of hypoxemia, and stimulate a cough in the
patient who is int~bated.~~~~ Vibration is sometimes
performed during the expiratory phase to enhance
mobilization of secretions from the central airways.5H
The additional tidal volume delivered, however, most
likely reaches the most compliant lung zones and there-
fore expands normal rather than collapsed alveoli.
Because the patient is removed from the ventilator, lung
volumes., PEEP, flow rates, and FIO, are not controlled.
Novak and colleaguesHH studied 16 patients with hypox-
emic relspiratory failure in a surgical ICU and were
unable to demonstrate any improvement (<5 minutes)
in gas exchange or pulmonary compliance with hyper-
inflations of 40 cm H,O of pressure for 15 to 30 seconds.
Flow rates were not documented. Although Jones and
colleaguesw found an increase in lung compliance for
up to 2 hours in patients without pulmonary disease with
bagging and percussion, the same results have been
demonstrated with postural drainage, percussion, and
vibration in patients with pulmonary pathol~gy.~
Hyperinflation may be hazardous in patients with severe
ARDS, because high airway pressures and overdistension
of normal alveoli may damage normal lung parenchyma
and increase the quantity of lung tissue contributing to
the respiratory distress syndrome.'") The effect of hyper-
inflation on cerebral perfusion pressure in patients with
brain injury who are not medically paralyzed is
unknown. Garrard and BullockY1 used ICP monitoring
to study 20 patients with brain injuries. Prolonged man-
ual hyperinflation with a 2-L rebreathing bag caused a
5-mm Hg increase in ICP in patients who were medically
paralyzed and in patients who were not paralyzed.
Because cerebral perfusion pressures were not reported,
the clinical significance is unknown. Hyperinflation,
with a plateau pressure of 80 cm H,O of pressure for 2
to
3 seconds, of 13 patients with severe brain injuries
who were paralyzed and well-sedated did not decrease
cerebral perfusion
pres~ure.~~or patients who are
mechar~ically ventilated, lung hyperinflation with vibra-
tion is associated with large fluctuations in cardiotho-
racic pressure, and the physiologic benefit is therefore
questi~nable.~?
Cough ing
Coughing removes secretions from the trachea, main-
stem bronchi, and up to the fourth generation of
segmental bronchi." Many patients spontaneously
breathing in the ICU are unable to cough effectively
because of respiratory muscle weakness, pain, or a
decreased level of consciousness. Therapists working in
the ICIJ, therefore, should be familiar with cough stim-
ulating and assistance techniques. Compressing the tra-
chea just above the sternal notch or huffing (after a
maximal inspiration, the patient exhales several times
quickly) is indicated when the patient has sufficient
neuromuscular function of the respiratory and abdomi-
nal muscles. While huffing, the glottis remains open and
intrathoracic pressure is lower than with c~ughing.~~
When incisional pain is the limiting factor, support of
thoracic and abdominal incisions and huffing are indi-
cated. Upright positioning also improves cough pres-
sures." Coughing is also enhanced by early tracheos-
tomy removal, placing an airtight dressing over the
tracheostomy stoma, and supporting the stoma site
during expiration.
Loss of innervation of the intercostal and abdominal
muscles decreases airflow in individuals with quadriple-
gia.g"upport and compression of the upper abdomen
during expiration facilitates an effective, productive
cough. Abdominal support and pressure during exhala-
tion are necessary with injuries or diseases that result in
abdominal muscle weakness that prohibits effective
coughing.
Tracheal
Suctioning
Tracheal suctioning is an integral component of chest
physical therapy for the patient who is intubated. Deep
suctioning is necessary for patients who cannot mobilize
secretions to the proximal portion of the tracheal tube
by coughing or huffing. Withholding suctioning may
result in airway occlusion and hyp~xemia."~ Because
upper-airway secretions are most prevalent before and
after a change in patient position and during or follow-
ing chest physical therapy, the suctioning procedure
should be timed with these interventions, particularly in
patients who have difficulty tolerating the procedure.
Suctioning is a sterile procedure. Occupational Safety
and Health Administration guidelinesYH for exposure to
blood and body fluids, therefore, must be followed. Eye
protection, a mask for protection from bloody or mucus
secretions, and sterile gloves should be worn. As part of
the initial assessment, the therapist should evaluate the
patient's need for and response to suctioning. Airway
suctioning frequently improves breath sounds and may
lower airway pressures. When no segmental or lobar
pathology is present, suctioning may be adequate and
postural drainage with manual techniques may not be
indicated. Patients who are intubated and who have a
poor cough usually require tracheal suctioning.
As with
all physical therapy in the ICU, the patient's vital signs
should be assessed before, during, and after the proce-
dure. Table
3 lists the most frequently cited complica-
tions associated with tracheal suctioning and the recom-
mended interventions to minimize side effects.
Physical Therapy . Volume 76 . Number 6 . June 1996
Ciesla . 617
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
nique, often referred to as the "bag-squeezing method,"
was introduced in the 1960s to prevent pulmonary
segmental collapse, reexpand collapsed alveoli, mini-
mize the risk of hypoxemia, and stimulate a cough in the
patient who is int~bated.~~~~ Vibration is sometimes
performed during the expiratory phase to enhance
mobilization of secretions from the central airways.5H
The additional tidal volume delivered, however, most
likely reaches the most compliant lung zones and there-
fore expands normal rather than collapsed alveoli.
Because the patient is removed from the ventilator, lung
volumes., PEEP, flow rates, and FIO, are not controlled.
Novak and colleaguesHH studied 16 patients with hypox-
emic relspiratory failure in a surgical ICU and were
unable to demonstrate any improvement (<5 minutes)
in gas exchange or pulmonary compliance with hyper-
inflations of 40 cm H,O of pressure for 15 to 30 seconds.
Flow rates were not documented. Although Jones and
colleaguesw found an increase in lung compliance for
up to 2 hours in patients without pulmonary disease with
bagging and percussion, the same results have been
demonstrated with postural drainage, percussion, and
vibration in patients with pulmonary pathol~gy.~
Hyperinflation may be hazardous in patients with severe
ARDS, because high airway pressures and overdistension
of normal alveoli may damage normal lung parenchyma
and increase the quantity of lung tissue contributing to
the respiratory distress syndrome.'") The effect of hyper-
inflation on cerebral perfusion pressure in patients with
brain injury who are not medically paralyzed is
unknown. Garrard and BullockY1 used ICP monitoring
to study 20 patients with brain injuries. Prolonged man-
ual hyperinflation with a 2-L rebreathing bag caused a
5-mm Hg increase in ICP in patients who were medically
paralyzed and in patients who were not paralyzed.
Because cerebral perfusion pressures were not reported,
the clinical significance is unknown. Hyperinflation,
with a plateau pressure of 80 cm H,O of pressure for 2
to
3 seconds, of 13 patients with severe brain injuries
who were paralyzed and well-sedated did not decrease
cerebral perfusion
pres~ure.~~or patients who are
mechar~ically ventilated, lung hyperinflation with vibra-
tion is associated with large fluctuations in cardiotho-
racic pressure, and the physiologic benefit is therefore
questi~nable.~?
Cough ing
Coughing removes secretions from the trachea, main-
stem bronchi, and up to the fourth generation of
segmental bronchi." Many patients spontaneously
breathing in the ICU are unable to cough effectively
because of respiratory muscle weakness, pain, or a
decreased level of consciousness. Therapists working in
the ICIJ, therefore, should be familiar with cough stim-
ulating and assistance techniques. Compressing the tra-
chea just above the sternal notch or huffing (after a
maximal inspiration, the patient exhales several times
quickly) is indicated when the patient has sufficient
neuromuscular function of the respiratory and abdomi-
nal muscles. While huffing, the glottis remains open and
intrathoracic pressure is lower than with c~ughing.~~
When incisional pain is the limiting factor, support of
thoracic and abdominal incisions and huffing are indi-
cated. Upright positioning also improves cough pres-
sures." Coughing is also enhanced by early tracheos-
tomy removal, placing an airtight dressing over the
tracheostomy stoma, and supporting the stoma site
during expiration.
Loss of innervation of the intercostal and abdominal
muscles decreases airflow in individuals with quadriple-
gia.g"upport and compression of the upper abdomen
during expiration facilitates an effective, productive
cough. Abdominal support and pressure during exhala-
tion are necessary with injuries or diseases that result in
abdominal muscle weakness that prohibits effective
coughing.
Tracheal
Suctioning
Tracheal suctioning is an integral component of chest
physical therapy for the patient who is intubated. Deep
suctioning is necessary for patients who cannot mobilize
secretions to the proximal portion of the tracheal tube
by coughing or huffing. Withholding suctioning may
result in airway occlusion and hyp~xemia."~ Because
upper-airway secretions are most prevalent before and
after a change in patient position and during or follow-
ing chest physical therapy, the suctioning procedure
should be timed with these interventions, particularly in
patients who have difficulty tolerating the procedure.
Suctioning is a sterile procedure. Occupational Safety
and Health Administration guidelinesYH for exposure to
blood and body fluids, therefore, must be followed. Eye
protection, a mask for protection from bloody or mucus
secretions, and sterile gloves should be worn. As part of
the initial assessment, the therapist should evaluate the
patient's need for and response to suctioning. Airway
suctioning frequently improves breath sounds and may
lower airway pressures. When no segmental or lobar
pathology is present, suctioning may be adequate and
postural drainage with manual techniques may not be
indicated. Patients who are intubated and who have a
poor cough usually require tracheal suctioning.
As with
all physical therapy in the ICU, the patient's vital signs
should be assessed before, during, and after the proce-
dure. Table
3 lists the most frequently cited complica-
tions associated with tracheal suctioning and the recom-
mended interventions to minimize side effects.
Physical Therapy . Volume 76 . Number 6 . June 1996
Ciesla . 617
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Table 3.
Complications of Endotracheal Suctioning
I Complication Recommended Intervention I
I
Hypoxemia, death Adequate oxygenation prior to and
following the procedure
Limit suctioning to 15-20 so
I
Bacterial contamination Sterile technique, changing the
suction catheter every
2-4 passes
I
Mechanical trauma Polyvinyl chloride catheters with
multiple side holes and an end
holeb; minimize the number of
times the catheter is inserted into
the airway; use continuous
suctionC
Flow rate of 16 L/mind
Negative pressure < 160 mm Hg
Atelectasis Lung inflation prior to and following
the procedure
Minimize use of 100% oxygen
" Boutros AR. Arterial blood oxygenation during and after endotracheal
. -
suctioning in the apneic patient. Awsthesiolo~. 1970;32:114-118.
"Jung RE. Gottlieb LS. Comparison of tracheobronchial suction catheters in
humans: visualization by fiberoptic bronchoscopy.
Chest.
1976;69:179-181.
' Czarnik RE, Stone KS, Everhart C, et al. Differential effects of continuous
versus intermittent suction on tracheal tissue. Heart Lung. 1991;20:144-151.
"DePew CL, Noll ML. In-line closedaystem suctioning: a research analysis.
Dimmsionc (f f;ri/irrrl Care Nursing 1993;13:73-83.
Precautions and contraindications. Suctioning through
an artificial airway of a patient with adequate oxygen-
ation and stable vital signs has relatively few contraindi-
cations. Prior to suctioning the patient with unstable
vital signs or a low Spo, , the benefit of suctioning versus
the risk of causing additional arrhythmias or desatura-
tion should be weighed in consultation with medical and
nursing staff. When coughing results from mechanical
stimulation of the trachea caused by heavy ventilator
tubing or a malpositioned tracheal tube, suctioning is
not indicated. Appropriate treatment is to remove the
stimulus triggering the coughing. For patients who have
retained secretions, are unable to cough effectively, and
have difficulty tolerating suctioning, suctioning should
be timed with chest physical therapy to minimize the risk
of hypoxemia.
Nasotracheal suctioning (suctioning through the nose
into the trachea without an artificial airway in place) is
contraindicated in the presence of stridor because of the
increased risk of mechanical trauma to an edematous
airway." Because the catheter may enter the brain,
nasotracheal suctioning
with basilar skull fracture, facial
fractures, and known or suspected cerebrospinal fluid
leaks is also
contraindicated." Nasotracheal suctioning
may result in apnea, laryngospasm, bronchospasm, and
severe cardiac arrythmia~.~7 Nasotracheal suctioning is
recommended only when vigorous chest physical ther-
apy, including prolonged postural drainage, cough stim-
Table 4.
Recommended Features of Suction Catheters
Size less than one half the Usually
12-14 French for adults
diameter of the
airway with a 7- to 9-mm endotracheal
tubeo; reduces airwa occlusion
and suction-induced iypoxemia
Material PolPinylchlorideb
Tip design Straight-for routine use
Coude-when it
is necessary to intubate the leh main-stem
bronch~s~,~
Side holes Two or more to minimize tracheal
mucosal damage and optimize
secretion removale
" DePew CL, Noll ML. In-line closed-system suctioning: a research analysis.
Dimensions of Critical Care Nuwing. 1993;13:73-83.
"ubota Y, Magaribuchi T, Ohara M, et al. Evaluation of selective bronchial
suctioning in the adult. CKL Care Med. 1980;8:748-749.
"Panacek E. Albertson TE, Rutherford WF, et al. Selective bronchial
suctioning in the adult using a curved-tip catheter with a guide
mark.
Cnt Care
Med. 1989;8:748-749.
"Hart TP, Mahutte CK. Evaluation of a closed-system, directional-tip suction
catheter. Respir Care. 1992;37:1260-1265.
'Jung RE, Gottlieb LS. Comparison of tracheobronchial suction catheters in
humans: visualization by fiberoptic bronchoscopy.
Chest.
1976;69:179-181.
ulation techniques, and suctioning of the oropharynx, is
ineffective and the medical team does not plan to
intubate the patient.
Systems. Suctioning can be performed using either an
open or closed system. When using an open system, the
patient is disconnected from the mechanical ventilator
and suctioned using a conventional catheter. The
patient remains on the mechanical ventilator for closed-
system suctioning. Closed-system suctioning is accom-
plished by using either a "port adapter" or the more
recently introduced in-line sucti~ning.~~~~~~ The
recommended features of suction catheters are listed
in Table
4.
Prior to suctioning a patient who is mechanically venti-
lated, the therapist should be aware of the washout time
(the time necessary for the gas volume in the ventilator
circuit to be replaced with gases at the higher
FIO,) of
the ventilator in use.'Ol With current technology, the
washout time may be as little as three to five breaths for
ventilators such as the SERVO 900C.'02
Interventions fbr minimizing hypoxemia. The harmful
effects of tracheal suctioning include hypoxia, cardiac
arrhythmias, and death." Accepted methods for mini-
mizing suction-induced oxygen desaturation include use
of a port adapter, lung hyperinflation, preoxygenation,
and in-line suctioning. Placing a valve or port adapter
over the end of the endotracheal or tracheal tube allows
ventilation during the procedure, maintains PEEP, and
preserves functional residual capacity. The result is
improved oxygenation during sucti~ning.~~~~~Wsing the
6 1 8 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Complications of Endotracheal Suctioning
I Complication Recommended Intervention I
I
Hypoxemia, death Adequate oxygenation prior to and
following the procedure
Limit suctioning to 15-20 so
I
Bacterial contamination Sterile technique, changing the
suction catheter every
2-4 passes
I
Mechanical trauma Polyvinyl chloride catheters with
multiple side holes and an end
holeb; minimize the number of
times the catheter is inserted into
the airway; use continuous
suctionC
Flow rate of 16 L/mind
Negative pressure < 160 mm Hg
Atelectasis Lung inflation prior to and following
the procedure
Minimize use of 100% oxygen
" Boutros AR. Arterial blood oxygenation during and after endotracheal
. -
suctioning in the apneic patient. Awsthesiolo~. 1970;32:114-118.
"Jung RE. Gottlieb LS. Comparison of tracheobronchial suction catheters in
humans: visualization by fiberoptic bronchoscopy.
Chest.
1976;69:179-181.
' Czarnik RE, Stone KS, Everhart C, et al. Differential effects of continuous
versus intermittent suction on tracheal tissue. Heart Lung. 1991;20:144-151.
"DePew CL, Noll ML. In-line closedaystem suctioning: a research analysis.
Dimmsionc (f f;ri/irrrl Care Nursing 1993;13:73-83.
Precautions and contraindications. Suctioning through
an artificial airway of a patient with adequate oxygen-
ation and stable vital signs has relatively few contraindi-
cations. Prior to suctioning the patient with unstable
vital signs or a low Spo, , the benefit of suctioning versus
the risk of causing additional arrhythmias or desatura-
tion should be weighed in consultation with medical and
nursing staff. When coughing results from mechanical
stimulation of the trachea caused by heavy ventilator
tubing or a malpositioned tracheal tube, suctioning is
not indicated. Appropriate treatment is to remove the
stimulus triggering the coughing. For patients who have
retained secretions, are unable to cough effectively, and
have difficulty tolerating suctioning, suctioning should
be timed with chest physical therapy to minimize the risk
of hypoxemia.
Nasotracheal suctioning (suctioning through the nose
into the trachea without an artificial airway in place) is
contraindicated in the presence of stridor because of the
increased risk of mechanical trauma to an edematous
airway." Because the catheter may enter the brain,
nasotracheal suctioning
with basilar skull fracture, facial
fractures, and known or suspected cerebrospinal fluid
leaks is also
contraindicated." Nasotracheal suctioning
may result in apnea, laryngospasm, bronchospasm, and
severe cardiac arrythmia~.~7 Nasotracheal suctioning is
recommended only when vigorous chest physical ther-
apy, including prolonged postural drainage, cough stim-
Table 4.
Recommended Features of Suction Catheters
Size less than one half the Usually
12-14 French for adults
diameter of the
airway with a 7- to 9-mm endotracheal
tubeo; reduces airwa occlusion
and suction-induced iypoxemia
Material PolPinylchlorideb
Tip design Straight-for routine use
Coude-when it
is necessary to intubate the leh main-stem
bronch~s~,~
Side holes Two or more to minimize tracheal
mucosal damage and optimize
secretion removale
" DePew CL, Noll ML. In-line closed-system suctioning: a research analysis.
Dimensions of Critical Care Nuwing. 1993;13:73-83.
"ubota Y, Magaribuchi T, Ohara M, et al. Evaluation of selective bronchial
suctioning in the adult. CKL Care Med. 1980;8:748-749.
"Panacek E. Albertson TE, Rutherford WF, et al. Selective bronchial
suctioning in the adult using a curved-tip catheter with a guide
mark.
Cnt Care
Med. 1989;8:748-749.
"Hart TP, Mahutte CK. Evaluation of a closed-system, directional-tip suction
catheter. Respir Care. 1992;37:1260-1265.
'Jung RE, Gottlieb LS. Comparison of tracheobronchial suction catheters in
humans: visualization by fiberoptic bronchoscopy.
Chest.
1976;69:179-181.
ulation techniques, and suctioning of the oropharynx, is
ineffective and the medical team does not plan to
intubate the patient.
Systems. Suctioning can be performed using either an
open or closed system. When using an open system, the
patient is disconnected from the mechanical ventilator
and suctioned using a conventional catheter. The
patient remains on the mechanical ventilator for closed-
system suctioning. Closed-system suctioning is accom-
plished by using either a "port adapter" or the more
recently introduced in-line sucti~ning.~~~~~~ The
recommended features of suction catheters are listed
in Table
4.
Prior to suctioning a patient who is mechanically venti-
lated, the therapist should be aware of the washout time
(the time necessary for the gas volume in the ventilator
circuit to be replaced with gases at the higher
FIO,) of
the ventilator in use.'Ol With current technology, the
washout time may be as little as three to five breaths for
ventilators such as the SERVO 900C.'02
Interventions fbr minimizing hypoxemia. The harmful
effects of tracheal suctioning include hypoxia, cardiac
arrhythmias, and death." Accepted methods for mini-
mizing suction-induced oxygen desaturation include use
of a port adapter, lung hyperinflation, preoxygenation,
and in-line suctioning. Placing a valve or port adapter
over the end of the endotracheal or tracheal tube allows
ventilation during the procedure, maintains PEEP, and
preserves functional residual capacity. The result is
improved oxygenation during sucti~ning.~~~~~Wsing the
6 1 8 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
adapter may minimize the need for preoxygenation,
therefore eliminating the potential hazards of exposure
to 100% oxygen."J4 A port adapter is recommended for
patients who are mechanically ventilated patients and
require
a PEEP of
> 10 cm H20 and for patients who are
at high risk for suction-induced arrhythmias and
hypo~ernia.~~*~')"
Proponents of in-line suctioning report less oxygen
desaturation than with an open system; however, the
same results have been achieved by using a port adapt-
er.9!',100,104.106 Clinical impressions of in-line suctioning
that need to be substantiated with further research
include the following: (1) The catheter is more difficult
to maneuver,
(2) the additional weight of the catheter
may increase tracheal damage,
(3) higher inspiratory
flow rates may be required, and
(4) airway pressure may
drop
as a result with suctioning and intermittent man-
datory
ventilation (IMV) .100.104,106
Preoxygenation is the most commonly used method for
preventing oxygen de~aturation.~~~.~~Yhe mechanical
ventilator or an MRB is used to inflate the lungs and
increase the inspired oxygen concentration prior to
suctioni~ng. For patients who are mechanically ventilated,
the ventilator is preferred over the MRB. Minute venti-
lation, PEEP, and FIO, are all controlled, and there are
no ~ari~ations in lung volume, flow rates, and pressure
based on the clinician's bagging te~hnique.l~~~~l~ When
using tlhe ventilator, the second clinician who may be
required when using an MRB is not needed. When using
an MRB, the FIO, varies from 33% to loo%, depending
on flow rate, minute ventilation, and whether the bag
has
a
re~ervoir.lll.~~~
The miajority of studies evaluating tracheal suctioning
have compared the effects in patients who had cardiac
surgery.10i.10"111~113 Although hyperoxygenation is com-
mon practice, it may not be necessary for all patients.
Based on my clinical experience,
I believe that
suction-
induced hypoxemia may not be as significant in patients
such as8 young patients with traumatic injuries but with-
out cardiac disease.
A suctioning protocol that encour-
ages clinical judgment is
recommended.l14 When
patients are hyperoxygenated prior to or during chest
physical therapy, the effect of chest physical therapy on
Sao,, Spo,, or partial pressure of arterial oxygen (Pao,)
may be masked.
The most important indicators as to whether a patient
will desaturate with suctioning are the resting Spo, and
the resting Pao,. Depending on the patient being suc-
tioned, hyperoxygenation is recommended when the
Spo, is less than 90% (95% for high-risk patients).
Hyperoxygenation also is recommended when the Spo,
drops below 85% during suctioning and does not return
to baseline within 10 to
15 seconds and when the resting
Pao, is below 85 mm Hg.
Saline installation. Saline instillation is commonly used
before and during tracheal suctioning to "loosen" secre-
tions.ll"aline instilled through a tracheal or endotra-
cheal tube is not likely to reach the peripheral airways,
where secretions are most prevalent."s To be effective,
the saline must pass through several generations of
segmental bronchi and reach the terminal bronchioles
and alveoli. Patients should, however, receive adequate
systemic hydration and airway humidification rather
than saline in~tillation.~~~,ll~ Patients with copious puru-
lent secretions (eg, bronchiectasis) may require saline
installation to remove viscid secretions from the upper
airways and tracheal tube.
Breathing Exercises
Once extubated, alert, and cooperative, the patient in
the
ICU may benefit from breathing exercises to
increase tidal volume, improve thoracic-cage mobility,
increase inspiratory capacity, enhance cough efficacy,
and assist in removal of ~ecretions.5~ Breathing exercises
are indicated in the ICU setting for patients with neuro-
muscular disease or injury affecting the respiratory mus-
cles. Breathing exercises also are used when thoracic
excursion is decreased as a result of retained secretions
or pain or when a patient is immobile following surgery.
Breathing exercises are not indicated during mechanical
ventilation but may be used during weaning from
mechanical ventilation.
There are several types of breathing exercises. Diaphrag-
matic breathing and lateral costal and segmental costal
expansion exercises are used most often postoperative-
ly?l Use of a flutter valve, the forced-expiration tech-
nique-more recently referred to as the active cycle of
breathing (huffing at various lung volumes interspersed
with diaphragmatic breathing)-and autogenic drain-
age (using a sequence of breathing maneuvers at various
lung volumes to optimize airflow within multiple gener-
ations of bronchi) are beneficial in patients with cystic
fibrosis, although the efficacy of these procedures after
surgery has not been determined.5"11i Inspiratory mus-
cle training and resistive diaphragmatic breathing exer-
cises may be beneficial while weaning the patient with
quadriplegia or chronic obstructive pulmonary disease
from the ~entilator.~~-~2~ Incentive spirometry is com-
monly used postoperatively, although it is no more
advantageous or costeffective than instruction in deep
breathing and coughing.I2l Following coronary artery
bypass or gall-bladder surgely, breathing exercises offer
no advantage over early patient m0bilization.~*-21
Physical Therapy. Volume 76 . Number 6 .June 1996 Ciesla . 6 19
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
therefore eliminating the potential hazards of exposure
to 100% oxygen."J4 A port adapter is recommended for
patients who are mechanically ventilated patients and
require
a PEEP of
> 10 cm H20 and for patients who are
at high risk for suction-induced arrhythmias and
hypo~ernia.~~*~')"
Proponents of in-line suctioning report less oxygen
desaturation than with an open system; however, the
same results have been achieved by using a port adapt-
er.9!',100,104.106 Clinical impressions of in-line suctioning
that need to be substantiated with further research
include the following: (1) The catheter is more difficult
to maneuver,
(2) the additional weight of the catheter
may increase tracheal damage,
(3) higher inspiratory
flow rates may be required, and
(4) airway pressure may
drop
as a result with suctioning and intermittent man-
datory
ventilation (IMV) .100.104,106
Preoxygenation is the most commonly used method for
preventing oxygen de~aturation.~~~.~~Yhe mechanical
ventilator or an MRB is used to inflate the lungs and
increase the inspired oxygen concentration prior to
suctioni~ng. For patients who are mechanically ventilated,
the ventilator is preferred over the MRB. Minute venti-
lation, PEEP, and FIO, are all controlled, and there are
no ~ari~ations in lung volume, flow rates, and pressure
based on the clinician's bagging te~hnique.l~~~~l~ When
using tlhe ventilator, the second clinician who may be
required when using an MRB is not needed. When using
an MRB, the FIO, varies from 33% to loo%, depending
on flow rate, minute ventilation, and whether the bag
has
a
re~ervoir.lll.~~~
The miajority of studies evaluating tracheal suctioning
have compared the effects in patients who had cardiac
surgery.10i.10"111~113 Although hyperoxygenation is com-
mon practice, it may not be necessary for all patients.
Based on my clinical experience,
I believe that
suction-
induced hypoxemia may not be as significant in patients
such as8 young patients with traumatic injuries but with-
out cardiac disease.
A suctioning protocol that encour-
ages clinical judgment is
recommended.l14 When
patients are hyperoxygenated prior to or during chest
physical therapy, the effect of chest physical therapy on
Sao,, Spo,, or partial pressure of arterial oxygen (Pao,)
may be masked.
The most important indicators as to whether a patient
will desaturate with suctioning are the resting Spo, and
the resting Pao,. Depending on the patient being suc-
tioned, hyperoxygenation is recommended when the
Spo, is less than 90% (95% for high-risk patients).
Hyperoxygenation also is recommended when the Spo,
drops below 85% during suctioning and does not return
to baseline within 10 to
15 seconds and when the resting
Pao, is below 85 mm Hg.
Saline installation. Saline instillation is commonly used
before and during tracheal suctioning to "loosen" secre-
tions.ll"aline instilled through a tracheal or endotra-
cheal tube is not likely to reach the peripheral airways,
where secretions are most prevalent."s To be effective,
the saline must pass through several generations of
segmental bronchi and reach the terminal bronchioles
and alveoli. Patients should, however, receive adequate
systemic hydration and airway humidification rather
than saline in~tillation.~~~,ll~ Patients with copious puru-
lent secretions (eg, bronchiectasis) may require saline
installation to remove viscid secretions from the upper
airways and tracheal tube.
Breathing Exercises
Once extubated, alert, and cooperative, the patient in
the
ICU may benefit from breathing exercises to
increase tidal volume, improve thoracic-cage mobility,
increase inspiratory capacity, enhance cough efficacy,
and assist in removal of ~ecretions.5~ Breathing exercises
are indicated in the ICU setting for patients with neuro-
muscular disease or injury affecting the respiratory mus-
cles. Breathing exercises also are used when thoracic
excursion is decreased as a result of retained secretions
or pain or when a patient is immobile following surgery.
Breathing exercises are not indicated during mechanical
ventilation but may be used during weaning from
mechanical ventilation.
There are several types of breathing exercises. Diaphrag-
matic breathing and lateral costal and segmental costal
expansion exercises are used most often postoperative-
ly?l Use of a flutter valve, the forced-expiration tech-
nique-more recently referred to as the active cycle of
breathing (huffing at various lung volumes interspersed
with diaphragmatic breathing)-and autogenic drain-
age (using a sequence of breathing maneuvers at various
lung volumes to optimize airflow within multiple gener-
ations of bronchi) are beneficial in patients with cystic
fibrosis, although the efficacy of these procedures after
surgery has not been determined.5"11i Inspiratory mus-
cle training and resistive diaphragmatic breathing exer-
cises may be beneficial while weaning the patient with
quadriplegia or chronic obstructive pulmonary disease
from the ~entilator.~~-~2~ Incentive spirometry is com-
monly used postoperatively, although it is no more
advantageous or costeffective than instruction in deep
breathing and coughing.I2l Following coronary artery
bypass or gall-bladder surgely, breathing exercises offer
no advantage over early patient m0bilization.~*-21
Physical Therapy. Volume 76 . Number 6 .June 1996 Ciesla . 6 19
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Table 5.
Patient Example 2: Improved Oxygenation and Chest Radiograph 1 Hour Following Chest Physical Therapya
---- --
Day/Time Positioning/Chest Physical Therapy
--- - - - --
Chest Radiograph Pao, /FIo,
Results Sao, Ratio
- ---
Admission Positioned supine on turning frame Clear
Days 1-2 Positioned prone four times and suctioned for copious secretions Clear
Day
3 Positioned prone
7% hours, supine 9'12 hours, suctioned for 5:20 PM, LLL,
copious secretions prior to chest radiograph atelectasis
Day 4, 12: 15
PM Turned into the right
sidelying head-down position for segmental Leh lung collapse
postural drainage of the posterior and loterol segments of the LLL; (see Fig. 4)
percussion and vibration over appropriate segments while in the
drainage position; copious viscid blood-tinged secretions
suctioned; following a 45-minute treatment, auscultation revealed
improved air entry over the
LLL and
lingula with expiratory
wheezes
I
Day 4,
2:00 PM Repeat chest radiograph Leh lung reexpanded 99% 420/100
(see Fig. 5) 420 I
"Sao,=oxvgr~~ ~atu~arion rnc;~cured by pulsr oxinretry; Pat,,=partial pressure of oxygcrl, arterial; F~o,=fractiotr 01' inspirrcl oxygen concentration; LL.L=left lowel-
Iohc.
Patient Mobilization
Mobilizirig the patient in the ICU is important, but the
patient's medical condition usually prohibits indepen-
dent ambulation and vigorous activity. The severity of
injury or disease and life-sustaining paraphernalia also
usually lirnit n~obilization of patients who are mechani-
cally ventilated to dependent or stand-pivot transfers and
active- and passive-range-of-motion exercises. Upright
positioning of patients is encouraged to improve cough-
ing and lung volumes, including functional residual
capacity, and lung compliance. Patients who are difficult
to wean fi-om the ventilator frequently benefit from
transfer training and ambulation with portable ventila-
tor. Rehabilitative techniques are used while monitoring
vital signs to note any alterations from baseline. The
details of n~obilizing the patient in the ICU are beyond
the scope of this article but are described el~ewhere.~~',]2'
Chest Physical Therapy Versus Therapeutic
Bronchoscopy
Several
inve~tigators~'.""-'2(~ have compared the efficacy
of chest physical therapy versus therapeutic bronchos-
copy for treatment of' atelectasis and foreign-body aspi-
ration. Both treatments are indicated for aspiration of
blood, gastric contents, and foreign bodies. Lung con-
tusion, lung abscess, smoke inhalation, and pneumonia
also are indications for chest physical therapy or bron-
choscopy. In the surgical ICU, chest physical therapy is
recommended because it is less costly and less invasive
for treatment of an atelectasis or infiltrate for
24 to 48
hours before therapeutic
bronchoscopy or starting anti-
biotics
(M Joshi, personal communication). Chest phys-
ical therapy can be performed regardless of
tracheal
tube size, as long as the appropriate-size suctio~l catheter
is used, and does not require physician participation.
Chest physical therapy is directed to the area of periph-
eral lung pathology; during bronchoscopy, secretion
removal is limited to the level of the segmental bron-
chus. Cardiac arrhythmias are reported with both pro-
cedures, although fatal dysrhythrnias were noted only
with bron~hoscopy.'"~~27 The major fall in Pao, associ-
ated with bronchoscopy has riot been seen with chest
physical therapy. lfl,"H
Several case studie~'"~-':'l have demonstrated a favorable
response to chest physical therapy for lobar collapse
when bronchoscopy was either too high-risk or unsuc-
cessful. Raghu and Piersoliw reported successful
removal, with chest physical therapy, of
a tooth aspirated
during intubation. Due to the patient's life-threatening
myocardial infarction,
bronchoscopy was considered too
invasive. There are two reports of the effectiveness of
selective lung insufflation through a balloon-tipped cath-
eter in expansion of collapsed lobes in patients with
atelectasis who were unresponsive to chest physical ther-
apy, but the treatment regimen was not
Haenel and colleag~es':~~ advocate use of a kinetic
(rotating) bed that in itself prohibits postural drainage
of the most frequently affected lower-lobe segments
(posterior, superior, and lateral) and of the posterior
segments of both upper lobes.
620 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996 by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Patient Example 2: Improved Oxygenation and Chest Radiograph 1 Hour Following Chest Physical Therapya
---- --
Day/Time Positioning/Chest Physical Therapy
--- - - - --
Chest Radiograph Pao, /FIo,
Results Sao, Ratio
- ---
Admission Positioned supine on turning frame Clear
Days 1-2 Positioned prone four times and suctioned for copious secretions Clear
Day
3 Positioned prone
7% hours, supine 9'12 hours, suctioned for 5:20 PM, LLL,
copious secretions prior to chest radiograph atelectasis
Day 4, 12: 15
PM Turned into the right
sidelying head-down position for segmental Leh lung collapse
postural drainage of the posterior and loterol segments of the LLL; (see Fig. 4)
percussion and vibration over appropriate segments while in the
drainage position; copious viscid blood-tinged secretions
suctioned; following a 45-minute treatment, auscultation revealed
improved air entry over the
LLL and
lingula with expiratory
wheezes
I
Day 4,
2:00 PM Repeat chest radiograph Leh lung reexpanded 99% 420/100
(see Fig. 5) 420 I
"Sao,=oxvgr~~ ~atu~arion rnc;~cured by pulsr oxinretry; Pat,,=partial pressure of oxygcrl, arterial; F~o,=fractiotr 01' inspirrcl oxygen concentration; LL.L=left lowel-
Iohc.
Patient Mobilization
Mobilizirig the patient in the ICU is important, but the
patient's medical condition usually prohibits indepen-
dent ambulation and vigorous activity. The severity of
injury or disease and life-sustaining paraphernalia also
usually lirnit n~obilization of patients who are mechani-
cally ventilated to dependent or stand-pivot transfers and
active- and passive-range-of-motion exercises. Upright
positioning of patients is encouraged to improve cough-
ing and lung volumes, including functional residual
capacity, and lung compliance. Patients who are difficult
to wean fi-om the ventilator frequently benefit from
transfer training and ambulation with portable ventila-
tor. Rehabilitative techniques are used while monitoring
vital signs to note any alterations from baseline. The
details of n~obilizing the patient in the ICU are beyond
the scope of this article but are described el~ewhere.~~',]2'
Chest Physical Therapy Versus Therapeutic
Bronchoscopy
Several
inve~tigators~'.""-'2(~ have compared the efficacy
of chest physical therapy versus therapeutic bronchos-
copy for treatment of' atelectasis and foreign-body aspi-
ration. Both treatments are indicated for aspiration of
blood, gastric contents, and foreign bodies. Lung con-
tusion, lung abscess, smoke inhalation, and pneumonia
also are indications for chest physical therapy or bron-
choscopy. In the surgical ICU, chest physical therapy is
recommended because it is less costly and less invasive
for treatment of an atelectasis or infiltrate for
24 to 48
hours before therapeutic
bronchoscopy or starting anti-
biotics
(M Joshi, personal communication). Chest phys-
ical therapy can be performed regardless of
tracheal
tube size, as long as the appropriate-size suctio~l catheter
is used, and does not require physician participation.
Chest physical therapy is directed to the area of periph-
eral lung pathology; during bronchoscopy, secretion
removal is limited to the level of the segmental bron-
chus. Cardiac arrhythmias are reported with both pro-
cedures, although fatal dysrhythrnias were noted only
with bron~hoscopy.'"~~27 The major fall in Pao, associ-
ated with bronchoscopy has riot been seen with chest
physical therapy. lfl,"H
Several case studie~'"~-':'l have demonstrated a favorable
response to chest physical therapy for lobar collapse
when bronchoscopy was either too high-risk or unsuc-
cessful. Raghu and Piersoliw reported successful
removal, with chest physical therapy, of
a tooth aspirated
during intubation. Due to the patient's life-threatening
myocardial infarction,
bronchoscopy was considered too
invasive. There are two reports of the effectiveness of
selective lung insufflation through a balloon-tipped cath-
eter in expansion of collapsed lobes in patients with
atelectasis who were unresponsive to chest physical ther-
apy, but the treatment regimen was not
Haenel and colleag~es':~~ advocate use of a kinetic
(rotating) bed that in itself prohibits postural drainage
of the most frequently affected lower-lobe segments
(posterior, superior, and lateral) and of the posterior
segments of both upper lobes.
620 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996 by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Figure 4.
Complete collapse of the left lung prior to chest physical therapy
Patient Example #2
The following example demonstrates the development
of a left :lung collapse (Fig.
4) despite prone positioning
and tracheal suctioning. Chest physical therapy that
includedl postural drainage with percussion and vibra-
tion was necessary to reexpand the patient's left lung.
Chest pllysical therapy eliminated the need for thera-
peutic bronchoscopy, a more costly procedure with risks
of hypoxemia and life-threatening cardiac arrhythmias.
A 22-year-old white man was admitted to the trauma center
fbllowing
a diving injury with a C-4 teardrop compression
ti-acturr. Neut-ological examination following American Spi-
nal Injury Association Standards revealed incomplete sen-
sory deficit (impaired sensation at
C-6, C-7, T-3 to T-5, L-3,
and a111 sacral segments). Motor level was C-4. The patient
required mechanical ventilation for respiratory support.
'Table
5 describes the sequence of therapeutic positioning,
airway siictioning, and the need for chest physical therapy
due to an increasing left-lung atelectasis.
Following chest physical therapy, the patient's Sao,
increased from
87% to 99% and his Pao,/Flo, ratio
increased from
53 to 420. The patient's FIO, was lowered
from 100% to
40% within 24 hours of treatment. In
addition, the left-lung atelectasis resolved immediately fol-
lowing
45 minutes of chest physical therapy, as noted in
Figure
5. Prone positioning and suctioni~~g did not prevent
the secretion retention that resulted in collapse of the
patient's left lung.
Figure 5.
Reexpansion of the left lung 1 hour following one chest physical therapy
treatment.
Special Conditions
Table 6 summarizes the medical conditions commorilv
found in patients in the ICU, indications for chest
physical therapy, and treatment guidelines.
Summary
This article provides a discussion of the literature relat-
ing to chest physical therapy, indications for treatment,
and the rationale for its use in the ICU. Comparisons are
made with therapeutic bronchoscopy and therapeutic
positioning. The complications of tracheal suctioning
are discussed as well as methods for minimizing hypox-
emia, and the necessary features of suction catheters are
described. Although patient mobilization and deep-
breathing exercises with coughing can often replace
postural drainage, percussion, and vibration, many
patients in the ICU cannot be mobilized sufficiently to
eliminate the sequelae of secretion retention due to the
severity of injury or illness and the paraphernalia neces-
sary to sustain life.
I believe that when a clear indication for chest physical
therapy is present, it can be performed safely and
effectively by clinicians who have received training in the
ICU.
I contend that the recommended treatment of
lobar and segmental atelectasis is postural drainage with
percussion and vibration in conju~lction with airway
suctioning for patients who are intubated. Further
research is needed to assess the efficacy of manual
hyperinflation
i11 patients who are mechanically venti-
lated and the efficacy of therapeutic positioning without
postural drainage and manual techniques.
Physical Therapy . Volume 76 . Number 6 . June 1996 Ciesla . 62 1
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Complete collapse of the left lung prior to chest physical therapy
Patient Example #2
The following example demonstrates the development
of a left :lung collapse (Fig.
4) despite prone positioning
and tracheal suctioning. Chest physical therapy that
includedl postural drainage with percussion and vibra-
tion was necessary to reexpand the patient's left lung.
Chest pllysical therapy eliminated the need for thera-
peutic bronchoscopy, a more costly procedure with risks
of hypoxemia and life-threatening cardiac arrhythmias.
A 22-year-old white man was admitted to the trauma center
fbllowing
a diving injury with a C-4 teardrop compression
ti-acturr. Neut-ological examination following American Spi-
nal Injury Association Standards revealed incomplete sen-
sory deficit (impaired sensation at
C-6, C-7, T-3 to T-5, L-3,
and a111 sacral segments). Motor level was C-4. The patient
required mechanical ventilation for respiratory support.
'Table
5 describes the sequence of therapeutic positioning,
airway siictioning, and the need for chest physical therapy
due to an increasing left-lung atelectasis.
Following chest physical therapy, the patient's Sao,
increased from
87% to 99% and his Pao,/Flo, ratio
increased from
53 to 420. The patient's FIO, was lowered
from 100% to
40% within 24 hours of treatment. In
addition, the left-lung atelectasis resolved immediately fol-
lowing
45 minutes of chest physical therapy, as noted in
Figure
5. Prone positioning and suctioni~~g did not prevent
the secretion retention that resulted in collapse of the
patient's left lung.
Figure 5.
Reexpansion of the left lung 1 hour following one chest physical therapy
treatment.
Special Conditions
Table 6 summarizes the medical conditions commorilv
found in patients in the ICU, indications for chest
physical therapy, and treatment guidelines.
Summary
This article provides a discussion of the literature relat-
ing to chest physical therapy, indications for treatment,
and the rationale for its use in the ICU. Comparisons are
made with therapeutic bronchoscopy and therapeutic
positioning. The complications of tracheal suctioning
are discussed as well as methods for minimizing hypox-
emia, and the necessary features of suction catheters are
described. Although patient mobilization and deep-
breathing exercises with coughing can often replace
postural drainage, percussion, and vibration, many
patients in the ICU cannot be mobilized sufficiently to
eliminate the sequelae of secretion retention due to the
severity of injury or illness and the paraphernalia neces-
sary to sustain life.
I believe that when a clear indication for chest physical
therapy is present, it can be performed safely and
effectively by clinicians who have received training in the
ICU.
I contend that the recommended treatment of
lobar and segmental atelectasis is postural drainage with
percussion and vibration in conju~lction with airway
suctioning for patients who are intubated. Further
research is needed to assess the efficacy of manual
hyperinflation
i11 patients who are mechanically venti-
lated and the efficacy of therapeutic positioning without
postural drainage and manual techniques.
Physical Therapy . Volume 76 . Number 6 . June 1996 Ciesla . 62 1
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Table 6.
Chest Physical Therapy With Special Conditions"
Condition Treatment
Increased intracranial pressure
Coagulopathy
Bronchopleural fistula
Spinal fracture
Rib fractures
Pulmonary embolus
Continuous arterial-venous hemodialysis
Continuous venovenous hemodialysis
Peritoneal dialysis
Extracorporeal lung assistance
Adult respiratory distress syndrome [ARDS)
Extrapleural
hematoma
Pnemothorax, hemothorax
Lung abscess, lung contusion
Maintain cerebral perfusion pressure >50 mm Hg and ICP <25 mm Hg in the headdown
positionb; routine headdown positioning is limited to 15 min; headdown positioning
should be restricted when it exacerbates an increase in a cerebrospinal fluid leak
Determine cause; when copious bleeding occurs in the tracheobronchial tree, risk/benefit
must be weighed; treatment is coordinated with other nursing interventions; suction
carefully
Chest physical therapy is continued to decrease incidence of infection and enhance
healing; avoid prolonged periods of time with affected lung uppermost with positive-
pressure ventilation and PEEP, which may increase leakage through the fistula
Vest may be opened after patient positioning; after stabilization, use headdown
positioning as indicated by the patient's clinical condition
Avoid vigorous vibration
Therapy is withheld until medical intervention
Avoid line occlusion; bed may need to be elevated to maximize flow
Avoid line occlusion
Treatment is given while the dialysate is draining from the abdomen to minimize intra-
abdominal pressure
Avoid line occlusion; ensure that flow
is within preset guidelines
Prone positioning may optimize oxygenation; may require evaluative treatment to
determine whether the patient is productive of secretions or whether lung volumes and
Spa, improve with manual techniques and postural drainage
Therapy may be restricted when the hematoma is expanding or the patient has a
coagulopathy
Treatment is initiated after chest tube placement has been confirmed radiologically
Follow treatment of involved lung lobe or segment with treatment of dependent area to
minimize tronsbronchial aspiration
" ICP=intr-acraoial pressure; PEEP=positivr el~dexpiratory pressure; Spo,=oxygen saturation measured by pulse oximetry.
" Ciesla N. Chest physical therapy for the adult intensive care unit trauma patient. Physiral 7'hmapy Practice. 1994;3:92-108.
Acknowledgments
I acknowledge Bill Hammon, PT, Alex Sciaky, PT, CCS,
and Susan Ludwick-Mihans, PT, for their critical review
of the manuscript as it pertains to patients in the ICU.
I thank Marianne Mars, PT, Jill Kuramoto, PT, and Faith
Kousalis, PT, for their critique of the manuscript and for
providing data for the case studies.
References
1 Shapiro BA, Peruzzi
WT. Changing practices in ventilator manage-
ment: a review of the literature and suggested clinical correlations.
Su~gay. 1995;117:121-133.
2 Hardy KA. A review of airway clearance: new techniques, indications,
and recommendations. Retpiratoly Care. 1994;39:440-452.
3 Pryor .]A, Webber B. Physiotherapy for cystic fibrosis: which trch-
nique?
Physiothmapy. 1992;78:105-I
08.
4 Mortenson J, Falk M, Groth S, et al. The effects of postural drainage
and positive expiratory pressure physiotherapy on tracheohronchial
clearance in cystic fibrosis.
Chest.
1991;100:1350-1357.
5 Palmer KNV, Sellick BA. The prevention of post operative pulmonary
atelectasis.
Lancet. 1953;
1: 164-1 68.
6 Thoren L. Postoperative pulmonary complications: obselvations of
their prevention by means of physiotherapy. Acta Chir Srand. 1954;107:
193-204.
7 Mackenzie CF, Shin B, McAslan TC. Chest physiotherapy: the effect
on arterial oxygenation.
Anesth Analg.
1978;57:28-30.
8 Mackenzie CF, Shin B, Hadi F, lmle PC. Changes in total lung/
thorax compliance following chest physiotherapy.
Anesth Analg. 1980; 59:207-210.
9 Ciesla ND, Iilemic N, lmle PC. Chest physical therapy for the patient
with multiple trauma.
Phys
Thm. 1981;61:202-205.
10 Walsh J, Vanderwarf D, Hoscheit C, et al. Unsuspected hernody-
namic alterations during endotracheal suctioning. Chest. 1989;95:162-
165.
11 Klein P, Kemper M, Weissman C, et al. Attenuation of the hemody-
namic responses to chest physical therapy. Chest. 1988;93:38-42.
12 Graham M'G, Bradley DA. Efficacy of chest physiotherapy and
intermittent positive pressure breathing in the resolution of pneumo-
nia.
N
Engl J Med. 1978;299:624-627.
13Britton S, Bejstedt M, Vedin L. Chest physiotherapy in primary
pneumonia.
BMJ.
1985;290: 1703-1704.
14 Severinghaus JW, Kelleher JF. Recent developments in p~~lse oxim-
etry.
Anstthesiology. 1992;76:
1019.
622 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
Chest Physical Therapy With Special Conditions"
Condition Treatment
Increased intracranial pressure
Coagulopathy
Bronchopleural fistula
Spinal fracture
Rib fractures
Pulmonary embolus
Continuous arterial-venous hemodialysis
Continuous venovenous hemodialysis
Peritoneal dialysis
Extracorporeal lung assistance
Adult respiratory distress syndrome [ARDS)
Extrapleural
hematoma
Pnemothorax, hemothorax
Lung abscess, lung contusion
Maintain cerebral perfusion pressure >50 mm Hg and ICP <25 mm Hg in the headdown
positionb; routine headdown positioning is limited to 15 min; headdown positioning
should be restricted when it exacerbates an increase in a cerebrospinal fluid leak
Determine cause; when copious bleeding occurs in the tracheobronchial tree, risk/benefit
must be weighed; treatment is coordinated with other nursing interventions; suction
carefully
Chest physical therapy is continued to decrease incidence of infection and enhance
healing; avoid prolonged periods of time with affected lung uppermost with positive-
pressure ventilation and PEEP, which may increase leakage through the fistula
Vest may be opened after patient positioning; after stabilization, use headdown
positioning as indicated by the patient's clinical condition
Avoid vigorous vibration
Therapy is withheld until medical intervention
Avoid line occlusion; bed may need to be elevated to maximize flow
Avoid line occlusion
Treatment is given while the dialysate is draining from the abdomen to minimize intra-
abdominal pressure
Avoid line occlusion; ensure that flow
is within preset guidelines
Prone positioning may optimize oxygenation; may require evaluative treatment to
determine whether the patient is productive of secretions or whether lung volumes and
Spa, improve with manual techniques and postural drainage
Therapy may be restricted when the hematoma is expanding or the patient has a
coagulopathy
Treatment is initiated after chest tube placement has been confirmed radiologically
Follow treatment of involved lung lobe or segment with treatment of dependent area to
minimize tronsbronchial aspiration
" ICP=intr-acraoial pressure; PEEP=positivr el~dexpiratory pressure; Spo,=oxygen saturation measured by pulse oximetry.
" Ciesla N. Chest physical therapy for the adult intensive care unit trauma patient. Physiral 7'hmapy Practice. 1994;3:92-108.
Acknowledgments
I acknowledge Bill Hammon, PT, Alex Sciaky, PT, CCS,
and Susan Ludwick-Mihans, PT, for their critical review
of the manuscript as it pertains to patients in the ICU.
I thank Marianne Mars, PT, Jill Kuramoto, PT, and Faith
Kousalis, PT, for their critique of the manuscript and for
providing data for the case studies.
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Chest.
1991;100:1350-1357.
5 Palmer KNV, Sellick BA. The prevention of post operative pulmonary
atelectasis.
Lancet. 1953;
1: 164-1 68.
6 Thoren L. Postoperative pulmonary complications: obselvations of
their prevention by means of physiotherapy. Acta Chir Srand. 1954;107:
193-204.
7 Mackenzie CF, Shin B, McAslan TC. Chest physiotherapy: the effect
on arterial oxygenation.
Anesth Analg.
1978;57:28-30.
8 Mackenzie CF, Shin B, Hadi F, lmle PC. Changes in total lung/
thorax compliance following chest physiotherapy.
Anesth Analg. 1980; 59:207-210.
9 Ciesla ND, Iilemic N, lmle PC. Chest physical therapy for the patient
with multiple trauma.
Phys
Thm. 1981;61:202-205.
10 Walsh J, Vanderwarf D, Hoscheit C, et al. Unsuspected hernody-
namic alterations during endotracheal suctioning. Chest. 1989;95:162-
165.
11 Klein P, Kemper M, Weissman C, et al. Attenuation of the hemody-
namic responses to chest physical therapy. Chest. 1988;93:38-42.
12 Graham M'G, Bradley DA. Efficacy of chest physiotherapy and
intermittent positive pressure breathing in the resolution of pneumo-
nia.
N
Engl J Med. 1978;299:624-627.
13Britton S, Bejstedt M, Vedin L. Chest physiotherapy in primary
pneumonia.
BMJ.
1985;290: 1703-1704.
14 Severinghaus JW, Kelleher JF. Recent developments in p~~lse oxim-
etry.
Anstthesiology. 1992;76:
1019.
622 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
15 Sutton I'P. Chest physiotherapy: time for reappraisal. BrJDis Chest.
1988;82:127-137.
16 Pavia D. The role of chest physiotherapy in mucus hypersecretion.
Lung. 1990;168(suppI):614-621.
17 Sutton I'P, Lopez-Vidriero MT, Pavia D, et al. Assessment of percus-
sion, vibratory shaking and breathing exercises in chest physiotherapy.
EurJRespir Dis. 1985;66:147-152.
18 Jenkins S, Soutar SA, Loukota JM, et al. Physiotherapy after coro-
nary artery surgery: Are breathing exercises necessary?
Thorax. 1989; 44:634-639.
19 Dull JI, Dull WL. Are maximal inspiratory breathing exercises or
incentive spirometry better than early mobilization after cardiac sur-
gery?
Phys
Ther. 1983;63:655-659.
20 Hallbook T, Lindbald B, Lindroth B, et al. Prophylaxis against
pulmonary complications in patients undergoing gallbladder surgery:
a comparison between early mobilization, physiotherapy with and
without bronchodilation. ~nk Chir Gynaecol. i984;73:55-58.
21 Stiller R, Montarello J, Wallace M, et al. Efficacy of breathing and
coughing exercises in the prevention of pulmonary complications after
coronary artery surgery. Chest. 1994;105:741-747.
22 Dean E, Ross J. Oxygen transport: the basis for contemporary
cardiopulmonary physical therapy and its optimization with body
positioning and mobilization.
Physical
Therapr Practice. 1992;1:34-44.
23 Dean E, Ross J. Discordance between cardiopulmonary physiology
and physical therapy.
Chest.
1992;101:1694-1698.
24 Dean E. Oxygen transport: a physiologically based conceptual
framework; for the practice of cardiopulmonary physiotherapy. Physie
therapy.
1994;80:347-355.
25 MariniJ, Pierson DJ, Dudson L. Acute lobar atelectasis: a prospec-
tive comparison of fiberoptic bronchoscopy and respiratory therapy.
Am
Rm Respir Dis. 1979;119:971-978.
26 Light KB. Pneumonia. In: Hall JB, Schmidt GA, Wood LD, eds.
Pn'ncipb rf Critical Care. New York, NY McGraw-Hill; 1992:1249.
27 Ruiz-Santana S, Gimenez A, Esteban A, et al. ICU pneumonias: a
multi-institutional study.
Crit Care Med.
1987;15:930-932.
28 Stevens RM, Teres D, Skillman J, et al. Pneumonia in an ICU. Arch
Inta Met!. 1974;143:106-111.
29 Joshi PI, Ciesla N, Caplan E. Diagnosis of pneumonia in critically ill
patients.
Chest.
1988;94:4s. Abstract.
30 Finland M. Changing ecology of bacterial infections
as related to
antibacter.ia1 therapy. J Inj2ct Dis. 1970;122:419-431.
31 McDermott W. The John Barnwell Lecture: microbial drug resis-
tance.
Am
Reu Dis. 1970;102-857-876.
32 Weissman C, Kemper M, Damast MC, etal. Effect of routine
intensive care interaction on metabolic rate.
Chest.
1984;86:815-818.
33 American Association of Respiratory Care Clinical Practice Guide-
line: Postural Drainage Therapy. Respiratoly Care. 1991;36:1419.
34 Leith DE. The development of cough. Am Reu Respir Dis SuppL
1985;141:s39-s42.
35 Mossberg B, Cramer P. Mucociliary transport and cough as tracheo-
bronchial clearance mechanisms in pathological conditions. Eur J
Respir Dis Suppl. 1980;61:47-55.
36 King h4. Rheological requirements for optimal clearance of secre-
tions: cili.ary transport versus cough. Eur J Respir Dis. 1980;61 (suppl):
39-42.
38
Newhouse MT. Factors affecting sputum clearance. Thurax. 1973;
28:267. Abstract.
39 Siebens AA, Kirby NA, Poulos DA. Cough following transection of
the spinal cord at C-6.
Arch Phys Med
Rehabil. 1964;45:1-8.
40 Imle PC, Klemic N. Changes with immobility and methods of
mobilization. In: Mackenzie CF, ed.
Chest Physiotherapy in the Intensive
Care Unit.
2nd ed. Baltimore, Md: Williams
& Wilkins; 1989:188-214.
41 Clauss RH, Scalabrini BY, Ray JF, et al. Effects of changing body
position upon improved ventilation-perfusion relationships.
Circula-
tion.
1968;37(suppl 2):214-217.
42 Douglas WW, Rehder K, Beynen EM, et al, Improved oxygenation in
patients with acute respiratory failure: the prone position.
Am
Rm
Respir Dis. 1977;115:559-566.
43 Chulay M, Brown J, Summer W. Effect of post-operative immobili-
zation after coronary artery bypass.
Crit Care Med.
1982;10:176-179.
44 Remolina C, Khan AU, Santiago TV, et al. Positional hypoxemia in
unilateral lung disease.
N Engl J Med.
1981;304:523-525.
45 Langer M, Mascheroni D, Marcolin R, et al. The prone position in
ARDS patients. Chest. 1988;94:103-107.
46 Arborelius M, Granqvist U, Lija B, et al. Regional lung function and
central hemodynamics in the right lateral body position during
hypoxia and hyperoxia.
Respiration.
1974;31:193-200.
47 Pappert D, Rossaint R, Klaus S, et al. Influence of positioning on
ventilation-perfusion relationships in severe adult respiratory distress
syndrome.
Chest.
1994;106:1511-1516.
48 Zack MB, Pontoppidan H, Kazemi H. The effect of lateral positions
on gas exchange in pulmonary disease.
Am Reu
Respir Dis. 1974;llO:
49-55.
49 Piehl
MA, Brown MS. Use of extreme position changes in acute
respiratory failure.
Crit Care Med.
1976;4:13-15.
50 Wong JW, Keens TG, Wannamaker EM, et al. Effects of gravity in
tracheal transport rates in normal subjects and in patients with cystic
fibrosis.
Pediatrics.
1977;60:146-152.
51 Ciesla N. Postural drainage, positioning, breathing exercises. In:
Mackenzie CF, ed.
Chest Physiotherapy in the Intensive Care Unit. Balti-
more, Md: Williams
& Wilkins; 1989:97-99.
52 Bateman J, Newman S, Daunt K, et al. Is cough as effective as chest
physiotherapy in the removal of excessive tracheobronchial secretion?
Thurax.
1981;36:683-687.
53 Sutton PP, Parker RA, Webber BA. Assessment of the forced
expiration technique, postural drainage and directed coughing in
chest physiotherapy. Eur J Respir Dis. 1983;64:62-68.
54 Mackenzie CF. Physiological changes following chest physiotherapy.
Mackenzie CF, ed.
Chest
Physiotherapr in the Intensive Care Unit. 2nd ed.
Baltimore, Md: Williams & Wilkins; 1989:240-242.
55 Stiller K, Geake T, Taylor J, et al. Acute lobar atelectasis: a compar-
ison of two chest physiotherapy regimens.
Chest.
1990;98:1336-1340.
56 Bien MY, Zadai CC, Kigin CM. The effect of selective drainage
positions on oxygen saturation in obese patients after abdominal
surgery.
Chin Med J (Engl).
1993;51:183-192.
57 Johnson NT, Marini J, Pierson DJ, et al. Acute lobar atelectasis:
effect of chest percussion and postural drainage (CPPD) on resolution.
Am Reu Respir Dis.
1987;135:A433. Abstract.
58 Imle PC. Percussion and vibration. In: Mackenzie CF, ed. Chest
Physiotherapy in the Intensive Care Unit.
2nd ed. Baltimore, Md: Williams & Wilkins; 1989:134, 135, 138, 141, 146.
37 Leith IDE. Cough.
Phys
Tho: 1968;48:439-447.
Physical Therapy . Volume 76 . Number 6 .June 1996 Ciesla . 623
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
1988;82:127-137.
16 Pavia D. The role of chest physiotherapy in mucus hypersecretion.
Lung. 1990;168(suppI):614-621.
17 Sutton I'P, Lopez-Vidriero MT, Pavia D, et al. Assessment of percus-
sion, vibratory shaking and breathing exercises in chest physiotherapy.
EurJRespir Dis. 1985;66:147-152.
18 Jenkins S, Soutar SA, Loukota JM, et al. Physiotherapy after coro-
nary artery surgery: Are breathing exercises necessary?
Thorax. 1989; 44:634-639.
19 Dull JI, Dull WL. Are maximal inspiratory breathing exercises or
incentive spirometry better than early mobilization after cardiac sur-
gery?
Phys
Ther. 1983;63:655-659.
20 Hallbook T, Lindbald B, Lindroth B, et al. Prophylaxis against
pulmonary complications in patients undergoing gallbladder surgery:
a comparison between early mobilization, physiotherapy with and
without bronchodilation. ~nk Chir Gynaecol. i984;73:55-58.
21 Stiller R, Montarello J, Wallace M, et al. Efficacy of breathing and
coughing exercises in the prevention of pulmonary complications after
coronary artery surgery. Chest. 1994;105:741-747.
22 Dean E, Ross J. Oxygen transport: the basis for contemporary
cardiopulmonary physical therapy and its optimization with body
positioning and mobilization.
Physical
Therapr Practice. 1992;1:34-44.
23 Dean E, Ross J. Discordance between cardiopulmonary physiology
and physical therapy.
Chest.
1992;101:1694-1698.
24 Dean E. Oxygen transport: a physiologically based conceptual
framework; for the practice of cardiopulmonary physiotherapy. Physie
therapy.
1994;80:347-355.
25 MariniJ, Pierson DJ, Dudson L. Acute lobar atelectasis: a prospec-
tive comparison of fiberoptic bronchoscopy and respiratory therapy.
Am
Rm Respir Dis. 1979;119:971-978.
26 Light KB. Pneumonia. In: Hall JB, Schmidt GA, Wood LD, eds.
Pn'ncipb rf Critical Care. New York, NY McGraw-Hill; 1992:1249.
27 Ruiz-Santana S, Gimenez A, Esteban A, et al. ICU pneumonias: a
multi-institutional study.
Crit Care Med.
1987;15:930-932.
28 Stevens RM, Teres D, Skillman J, et al. Pneumonia in an ICU. Arch
Inta Met!. 1974;143:106-111.
29 Joshi PI, Ciesla N, Caplan E. Diagnosis of pneumonia in critically ill
patients.
Chest.
1988;94:4s. Abstract.
30 Finland M. Changing ecology of bacterial infections
as related to
antibacter.ia1 therapy. J Inj2ct Dis. 1970;122:419-431.
31 McDermott W. The John Barnwell Lecture: microbial drug resis-
tance.
Am
Reu Dis. 1970;102-857-876.
32 Weissman C, Kemper M, Damast MC, etal. Effect of routine
intensive care interaction on metabolic rate.
Chest.
1984;86:815-818.
33 American Association of Respiratory Care Clinical Practice Guide-
line: Postural Drainage Therapy. Respiratoly Care. 1991;36:1419.
34 Leith DE. The development of cough. Am Reu Respir Dis SuppL
1985;141:s39-s42.
35 Mossberg B, Cramer P. Mucociliary transport and cough as tracheo-
bronchial clearance mechanisms in pathological conditions. Eur J
Respir Dis Suppl. 1980;61:47-55.
36 King h4. Rheological requirements for optimal clearance of secre-
tions: cili.ary transport versus cough. Eur J Respir Dis. 1980;61 (suppl):
39-42.
38
Newhouse MT. Factors affecting sputum clearance. Thurax. 1973;
28:267. Abstract.
39 Siebens AA, Kirby NA, Poulos DA. Cough following transection of
the spinal cord at C-6.
Arch Phys Med
Rehabil. 1964;45:1-8.
40 Imle PC, Klemic N. Changes with immobility and methods of
mobilization. In: Mackenzie CF, ed.
Chest Physiotherapy in the Intensive
Care Unit.
2nd ed. Baltimore, Md: Williams
& Wilkins; 1989:188-214.
41 Clauss RH, Scalabrini BY, Ray JF, et al. Effects of changing body
position upon improved ventilation-perfusion relationships.
Circula-
tion.
1968;37(suppl 2):214-217.
42 Douglas WW, Rehder K, Beynen EM, et al, Improved oxygenation in
patients with acute respiratory failure: the prone position.
Am
Rm
Respir Dis. 1977;115:559-566.
43 Chulay M, Brown J, Summer W. Effect of post-operative immobili-
zation after coronary artery bypass.
Crit Care Med.
1982;10:176-179.
44 Remolina C, Khan AU, Santiago TV, et al. Positional hypoxemia in
unilateral lung disease.
N Engl J Med.
1981;304:523-525.
45 Langer M, Mascheroni D, Marcolin R, et al. The prone position in
ARDS patients. Chest. 1988;94:103-107.
46 Arborelius M, Granqvist U, Lija B, et al. Regional lung function and
central hemodynamics in the right lateral body position during
hypoxia and hyperoxia.
Respiration.
1974;31:193-200.
47 Pappert D, Rossaint R, Klaus S, et al. Influence of positioning on
ventilation-perfusion relationships in severe adult respiratory distress
syndrome.
Chest.
1994;106:1511-1516.
48 Zack MB, Pontoppidan H, Kazemi H. The effect of lateral positions
on gas exchange in pulmonary disease.
Am Reu
Respir Dis. 1974;llO:
49-55.
49 Piehl
MA, Brown MS. Use of extreme position changes in acute
respiratory failure.
Crit Care Med.
1976;4:13-15.
50 Wong JW, Keens TG, Wannamaker EM, et al. Effects of gravity in
tracheal transport rates in normal subjects and in patients with cystic
fibrosis.
Pediatrics.
1977;60:146-152.
51 Ciesla N. Postural drainage, positioning, breathing exercises. In:
Mackenzie CF, ed.
Chest Physiotherapy in the Intensive Care Unit. Balti-
more, Md: Williams
& Wilkins; 1989:97-99.
52 Bateman J, Newman S, Daunt K, et al. Is cough as effective as chest
physiotherapy in the removal of excessive tracheobronchial secretion?
Thurax.
1981;36:683-687.
53 Sutton PP, Parker RA, Webber BA. Assessment of the forced
expiration technique, postural drainage and directed coughing in
chest physiotherapy. Eur J Respir Dis. 1983;64:62-68.
54 Mackenzie CF. Physiological changes following chest physiotherapy.
Mackenzie CF, ed.
Chest
Physiotherapr in the Intensive Care Unit. 2nd ed.
Baltimore, Md: Williams & Wilkins; 1989:240-242.
55 Stiller K, Geake T, Taylor J, et al. Acute lobar atelectasis: a compar-
ison of two chest physiotherapy regimens.
Chest.
1990;98:1336-1340.
56 Bien MY, Zadai CC, Kigin CM. The effect of selective drainage
positions on oxygen saturation in obese patients after abdominal
surgery.
Chin Med J (Engl).
1993;51:183-192.
57 Johnson NT, Marini J, Pierson DJ, et al. Acute lobar atelectasis:
effect of chest percussion and postural drainage (CPPD) on resolution.
Am Reu Respir Dis.
1987;135:A433. Abstract.
58 Imle PC. Percussion and vibration. In: Mackenzie CF, ed. Chest
Physiotherapy in the Intensive Care Unit.
2nd ed. Baltimore, Md: Williams & Wilkins; 1989:134, 135, 138, 141, 146.
37 Leith IDE. Cough.
Phys
Tho: 1968;48:439-447.
Physical Therapy . Volume 76 . Number 6 .June 1996 Ciesla . 623
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92 Carlsson H, Ersson U. Hedstrand U, et al. Observations on intra-
cranial dynamics at endotracheal suction and bag squeezing in patients
with severe brain trauma. Acta Neurochir (Wien). 1988;91:155. Abstract.
93 Laws AK, Mcintrye RW. Chest physiotherapy: a physiological assess-
ment during intermittent positive pressure ventilation in respiratory
failure.
Can Anaesth
Sor J. 1969;16:487-493.
94 Smaldone GC, Messina MS. Flow limitation, cough, and patterns of
aerosol deposition in humans.
J
Appl Physiol. 1985;59:515.
95 Heiptas BG, Roth RD, Jensen \'M. Huff coughing and airway
patency. hpir Care. 1979;24:710-713.
96 Curry LD, Van Eeden C. The influence of posture on the effective-
ness of coughing. S Aj? JPhysiothw: 1977;33:8-11.
97 Stone KS, Turner B. Endotracheal suctioning. Ann Rm Nurs Kes.
1989;7:28.
98 Goodner B. The OSHA Handbook: Int~@retatzv~ Guzdelines for the
Blood-Home Pathogen Standard. El Paso, Tex: Skidrnore Roth; 1993:lO.
99 Bodai BI. A means of suctioning without cardiopulmonary depres
sion. H~art I,ung. 1982;111:172-176.
100 Mayhill CG. The Trach CareTM closed tracheal suction system: a
new medical device to permit tracheal suctioning without interruption
of ventilatory assistance. Infect Cont~ul Hosp Epidemiol. 1988;9:125-126.
101 Benson MS, Pierson DJ. Ventilator wash-out volume: a consider-
ation in endotracheal suction preoxygenation.
Respir
Cr1t.p. 1990;35:
1257-1 260.
624 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
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Am
Reu Respir
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28:5 1 1-5 15.
60 Hansen LG, Wanvick WJ, Hansen KL. Mucus transport mechanisms
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on mucus clearance.
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1994;17: 1 13-1 18.
61 Selby D, Jones JG. Some phvsiological and clinical aspects of chest
physiotherapy. Rt. J Anaesth. 1990;64:621-631.
62 Raghu G, Pierson D. Successful removal of an aspirated tooth by
chest phvsiotherapy. R@zr Care. 1986;31:1099-1101.
63 Petty TL, ed. Int~nsiue and Rthabilitative Respiratory Care. Philadel-
phia, Pa: Lea
& Febiger;
1974:106, 108.
64 Peruzzi WT, Shapiro BA. Respiratory support. In: Tinker J, Browne
DR, Sibbald M'J, eds. Critiral Care: Standards, Audit, andEthics. London,
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65 Seidel HM, Ball JW, Dains JE, Benedict GM'. Mosby's Guide to Physical
Examination.
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66 Brimoulle S, Moraine J, Kahn RJ. Passive physical therapy and
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1988;16:449. Abstract.
67 Moraineg, Brimioulle S, Kahn RJ. Effects of respiratory therapy on
intracranial pressure. J Crit Care. 1991;6: 197-20 1.
68 Sutton PP, Pavia D, Bateman JRM, Clarke SW. Chest physiotherapy:
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69 Wollmer P, Ursing K, Midgren B, Eriksson L. lnefficiency of chest
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70 Campbell AH, O'Connell JM, Wilson F. The effect of chest physirr
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71 Gallon A. Evaluation of chest percussion in the treatment of
patients with copious sputum production. Resflir Med. 1991;85:45-51.
72 Ciesla ND. Chest physiotherapy for special patients. In: Mackenzie
CF, ed. Chest Physiotherupy in th~ Intensiup Care Unit. 2nd ed. Baltimore,
Md: Williams
&
Wilkins; 1989:267.
73 Imle PC:. Physical therapy for patients with cardiac, thoracic, or
abdominal conditions following surgery or trauma. In: lnvin C, Tecklin
.JS, eds. Cardiopulmonary Phpsiral 'I'hmpy. 3rd ed. St Louis, Mo: Mosby;
1995:382-383.
74 Kigin C:M. Advances in chest physical therapy. In: O'Donohue W,
ed. Cumt Advances in Respiratoq Care. Park Ridge, 111: American
C:ollege of Chest Phvsicians; 1984:145.
75 Ciesla ND, Rodriguez A, Anderson P, et al. The incidence of
extrapleural hematomas in patients with rib fractures receiving chest
physical therapy. Phys ?'her. 1985;76:766. Abstract.
76 Dulfano MJ, Lik C:K, Beckage M, et al. Ciliary beat frequency in
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77 Radford G, Barutt J, Billingsley JG, et al. A rational basis for
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556-563.
78 Hammon WE. Manual versus mechanical percussion for clearance
of alveolar contents. I'hys 7'hpr. 1983;63:756. Abstract.
79 Rossman CM, Waldes R, Sampson D, Newhouse MT. Effect of chest
physiotherapy on the removal of mucus in patients with cystic fibrosis.
Am
RPU Kpspir Dis. 1982;126:131-135.
80 Rubin EM, Scantlen GE, Chapman GA, et al. Effect of chest wall
oscillation on mucus clearance: comparison of two vibrators. Pediatl-
Pulmonol. 1989;6:122-126.
81 Hammon WE. McCaffree DR, Cucchiara AJ. A comparison of
manual to mechanical chest percussion for clearance of alveolar
material in patients with pulmonar). alveolar proteinosis. Che.51. 1993;
103:1409-1416.
82 Hammon WE, McCaffree DR. Manual percussion compared to
pneumatic percussion for clearance of alveolar material in patients
with pulmonary alveolar prote~nosis. In: Proceedings of the 12th Inlerna-
tional Congress of the World Confederntlo,~ for Phyciral 7'h~rupy; Jun~ 25-30,
1995; Washzngton, DC. 1995:591. Abstract.
83 Whitman J, Van Beusekom R, Olson S, et al. Preliminary evaluation
of high-frequency chest compression for secretion clearance in
mechanically ventilated patients.
Respir Care.
1993;38:1081-1087.
84 Respiratoly and physical therapy. In: Tinker J, Browne DR, Sibbald
WJ, eds. Cntical Care: Standards, Audit, and Ethirs. London, England:
Edward Arnold (Publishers) Ltd; 1996:234-244.
85 Jones Am, Jones RD, Bacon-Shone J. A comparison of expiratory
flow rates in
two breathing circuits used for manual inflation of the
lungs.
Physiotherapy.
1991;77:593-595.
86 Brandstater B, Muallem M. Atelectasis following tracheal suction in
infants. An~.cthesiology. 1969;31:468-473.
87 Clement AJ, Hubsch SK. Chest physiotherapy by the hag squeezing
method.
Physiotherapy.
1968;54:355-359.
88Novak
RA,
Shumaker L, Snyder JV, Pinsky MR. Do periodic
hyperinflations improve gas exchange in patients with hypoxemic
respiratoly failure? Crit Care Med. 1987; 15:1081-1085.
89 Jones AY, Hutchinson RC, Teik EO. Effects of bagging and percus-
sion on total static compliance of the respiratory system. Physiolherapp.
1992;78:661-666.
90 Gattinoni L, Pesenti A, Bombino M, et al. Role of extracorporeal
circulation in adult respiratory distress syndrome management.
New Hm'z. 1993;1:603-612.
91 Garrard J Bullock M. The effect of respiratory therapy on intracra-
nial pressure in ventilated neurosurgical patients. Ausl J Physiol. 1986;
32:107-111.
92 Carlsson H, Ersson U. Hedstrand U, et al. Observations on intra-
cranial dynamics at endotracheal suction and bag squeezing in patients
with severe brain trauma. Acta Neurochir (Wien). 1988;91:155. Abstract.
93 Laws AK, Mcintrye RW. Chest physiotherapy: a physiological assess-
ment during intermittent positive pressure ventilation in respiratory
failure.
Can Anaesth
Sor J. 1969;16:487-493.
94 Smaldone GC, Messina MS. Flow limitation, cough, and patterns of
aerosol deposition in humans.
J
Appl Physiol. 1985;59:515.
95 Heiptas BG, Roth RD, Jensen \'M. Huff coughing and airway
patency. hpir Care. 1979;24:710-713.
96 Curry LD, Van Eeden C. The influence of posture on the effective-
ness of coughing. S Aj? JPhysiothw: 1977;33:8-11.
97 Stone KS, Turner B. Endotracheal suctioning. Ann Rm Nurs Kes.
1989;7:28.
98 Goodner B. The OSHA Handbook: Int~@retatzv~ Guzdelines for the
Blood-Home Pathogen Standard. El Paso, Tex: Skidrnore Roth; 1993:lO.
99 Bodai BI. A means of suctioning without cardiopulmonary depres
sion. H~art I,ung. 1982;111:172-176.
100 Mayhill CG. The Trach CareTM closed tracheal suction system: a
new medical device to permit tracheal suctioning without interruption
of ventilatory assistance. Infect Cont~ul Hosp Epidemiol. 1988;9:125-126.
101 Benson MS, Pierson DJ. Ventilator wash-out volume: a consider-
ation in endotracheal suction preoxygenation.
Respir
Cr1t.p. 1990;35:
1257-1 260.
624 . Ciesla Physical Therapy . Volume 76 . Number 6 . June 1996
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
102 Sb.'RI'O 900C Operating Manual. Solna, Sweden: Siemens-Elema.
1085;2:7.
103 Kulmar A, Falke KJ, Gefin B, et al. Continuous positive pressure
ventilation in acute respiratory failure. NKngl JMed. 1970;282:1439.
104 Jung RE, Newman J. Minimizing hypoxia during endotracheal
airway care. Heart 1,ung. 1982;11:208-212.
105 Brown SE, Stansbury DW, Merrill EJ. Prevention of suctioning-
related arterial oxygen desaturation. Chest. 1983;4:621-627.
106 Noll IML, Hix CD, Scott G. Closed tracheal suction systems:
effectiveness and nursing implications. American Association of Critical
Care Aiurser. 1990;1:318-328.
107 Taggart JA, Dorinsky NL, Sheahan JS. Airway pressures during
closed system suctioning.
Heart Lung.
1988;17:536-542.
108 Chulay M. Arterial blood gas changes with a hyperinflation and
hyperoxygenation suctioning intervention in critically ill patients.
Heart
I,ung. 1988;17:654-661.
109 Stone KS, Talaganis SA, Preusser B, et al. Effect of lung hyper-
inflation and endotracheal suctioning on heart rate and rhythm in
patients after coronary artery bypass surgey. Heart Lung. 1991;20:443-
450.
110 McCabe SM, Smeltzer SC. Comparison of tidal volumes obtained
by one-harided and two-handed ventilation techniques. Am J Crit Care.
1993;2:467-473.
111 Chulzy M. Hyperinflation/hyperoxygenation to prevent endotra-
cheal suctioning complications. Critical Care Nurse. 1987;7:100-102.
112 Glass C, Grap MJ, Corley MC, et al. Nurses' ability to achieve
hyperinflation and hyperoxygenation with a manual resuscitation bag
during endotracheal suctioning. Heart Lung. 1993;22:158-165.
113 DePevi CL, No11 ML. In-line closed-system suctioning: a research
analysis.
Dimensions of Critical Care
Nursing. 1993;13:80.
114 Imle F'C. Methods of airway clearance: coughing and suctioning.
In: Mackenzie CF, ed.
Chest Physiotherapy in the Intensive Care Unit. 2nd
ed. Baltimore, Md: Williams
& Wilkins; 1989:70.
115 Hanley hW, Rudd T, ButlerJ. What happens to intratracheal saline
instillations?
Am
ElPO hpir Dis. 1979;117(suppl):124.
116 Imle PC. Adjuncts to chest physiotherapy. In: Mackenzie CF, ed.
C,'hest Physzotherapy in the Intensive Care L'nit. 2nd ed. Baltimore, Md:
M'illiams &: Wilkins; 1989:281.
117 Webber B, Parker R, HofmeyrJ, et al. Evaluation of self-percussion
during postural drainage using the forced expiration technique.
Physical
7'herapy Practire. 1985;1:42-45.
119 Hornstein S, Ledsome J. Venti1atot-y muscle training in acute
quadriplegia.
Physiotherapy Canada.
l986;38:145-149.
120 Derrickson J, Ciesla N, Simpson N, Imle PC. A comparison of two
different breathing exercises for quadriplegic patients.
Phgs
?'her.
1992;72:763-769.
121 Van de Water JM. Preoperative and operative techniques in the
prevention of pulmonary complications.
Surg Clin North Am.
1980;60:
1339-1348.
122 Sciaky AJ. Mobilizing the intensive care unit patient: pathophysi-
ology and treatment. Physical Therapy Practice. 1994;3:69-80.
123 Jaworski A, Goldberg SK, Walkenstein MD, et al. Utility of imme-
diate postlobectomy fiberoptic bronchoscopy in preventing atelectasis.
Chest. 1988;94:38-43.
124 Stern RC, Boat TF, Orenstein DM, et al. Treatment and prognosis
of lobar and segmental atelectasis in cystic fibrosis.
Am
ElPO &S& Dis.
1978;118:821-826.
125 Cotton EK, Abrams G, Van Houtte J, et al. Removal of aspirated
foreign bodies by percussion and postural drainage.
Clin Pediatr. 1973;12:270-276.
126 Pereira W, Kovnat D, Iacovino J, et al. A prospective study of the
complications following flexible fiberoptic bronchoscopy.
Chest. 1978; 73:813-816.
127 Hammon WE, Connors AF, McCaffree DR. Cardiac arrhythmias
during postural drainage and chest percussion of critically ill patients.
Chest.
1992;102:1836-1841.
128 Shrader DL, Lakshminarayan S. The effect of fiberoptic bronchos-
copy on cardiac rhythm. Chest. 1978;73:821-824.
129 Ciesla ND. Chest physical therapy for the adult intensive care unit
trauma patient.
Physical
Therapy Practice. 1994;3:92-108.
130 Mars M, Ciesla ND. Chest physical therapy may have prevented
bronchoscopy and exploratory laparotomy: a case report. Curdtopultno-
naly Physical Therapy. 1993;4:4-5.
131 Hammon WE, Martin RJ. Chest physical therapy for acute atelec-
tasis: a report on its effectiveness. Phys Ther. 1981;61:217-220. Clinical
report.
132 Susini G, Sisillo
E, Bortone F. Postoperative atelectasis reexpansion
by selective insufflation through a balloon-tipped catheter.
Chesl.
1992;102:1693-1696.
133 Haenel JB, Moore FA, Moore EE, et al. Efficacy of selective
intrabronchial air insumation in acute lobar collapse.
Am J
Surg.
1992;164:501-505.
118 Aldrich TK, Karpel JP. Inspiratory muscle training in the mechan-
ically ventilated patient.
Physzotherapy Canada.
1987;39:305-307.
Physical Therapy. Volume 76 . Number 6 . June 1996 Ciesla . 625
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
1085;2:7.
103 Kulmar A, Falke KJ, Gefin B, et al. Continuous positive pressure
ventilation in acute respiratory failure. NKngl JMed. 1970;282:1439.
104 Jung RE, Newman J. Minimizing hypoxia during endotracheal
airway care. Heart 1,ung. 1982;11:208-212.
105 Brown SE, Stansbury DW, Merrill EJ. Prevention of suctioning-
related arterial oxygen desaturation. Chest. 1983;4:621-627.
106 Noll IML, Hix CD, Scott G. Closed tracheal suction systems:
effectiveness and nursing implications. American Association of Critical
Care Aiurser. 1990;1:318-328.
107 Taggart JA, Dorinsky NL, Sheahan JS. Airway pressures during
closed system suctioning.
Heart Lung.
1988;17:536-542.
108 Chulay M. Arterial blood gas changes with a hyperinflation and
hyperoxygenation suctioning intervention in critically ill patients.
Heart
I,ung. 1988;17:654-661.
109 Stone KS, Talaganis SA, Preusser B, et al. Effect of lung hyper-
inflation and endotracheal suctioning on heart rate and rhythm in
patients after coronary artery bypass surgey. Heart Lung. 1991;20:443-
450.
110 McCabe SM, Smeltzer SC. Comparison of tidal volumes obtained
by one-harided and two-handed ventilation techniques. Am J Crit Care.
1993;2:467-473.
111 Chulzy M. Hyperinflation/hyperoxygenation to prevent endotra-
cheal suctioning complications. Critical Care Nurse. 1987;7:100-102.
112 Glass C, Grap MJ, Corley MC, et al. Nurses' ability to achieve
hyperinflation and hyperoxygenation with a manual resuscitation bag
during endotracheal suctioning. Heart Lung. 1993;22:158-165.
113 DePevi CL, No11 ML. In-line closed-system suctioning: a research
analysis.
Dimensions of Critical Care
Nursing. 1993;13:80.
114 Imle F'C. Methods of airway clearance: coughing and suctioning.
In: Mackenzie CF, ed.
Chest Physiotherapy in the Intensive Care Unit. 2nd
ed. Baltimore, Md: Williams
& Wilkins; 1989:70.
115 Hanley hW, Rudd T, ButlerJ. What happens to intratracheal saline
instillations?
Am
ElPO hpir Dis. 1979;117(suppl):124.
116 Imle PC. Adjuncts to chest physiotherapy. In: Mackenzie CF, ed.
C,'hest Physzotherapy in the Intensive Care L'nit. 2nd ed. Baltimore, Md:
M'illiams &: Wilkins; 1989:281.
117 Webber B, Parker R, HofmeyrJ, et al. Evaluation of self-percussion
during postural drainage using the forced expiration technique.
Physical
7'herapy Practire. 1985;1:42-45.
119 Hornstein S, Ledsome J. Venti1atot-y muscle training in acute
quadriplegia.
Physiotherapy Canada.
l986;38:145-149.
120 Derrickson J, Ciesla N, Simpson N, Imle PC. A comparison of two
different breathing exercises for quadriplegic patients.
Phgs
?'her.
1992;72:763-769.
121 Van de Water JM. Preoperative and operative techniques in the
prevention of pulmonary complications.
Surg Clin North Am.
1980;60:
1339-1348.
122 Sciaky AJ. Mobilizing the intensive care unit patient: pathophysi-
ology and treatment. Physical Therapy Practice. 1994;3:69-80.
123 Jaworski A, Goldberg SK, Walkenstein MD, et al. Utility of imme-
diate postlobectomy fiberoptic bronchoscopy in preventing atelectasis.
Chest. 1988;94:38-43.
124 Stern RC, Boat TF, Orenstein DM, et al. Treatment and prognosis
of lobar and segmental atelectasis in cystic fibrosis.
Am
ElPO &S& Dis.
1978;118:821-826.
125 Cotton EK, Abrams G, Van Houtte J, et al. Removal of aspirated
foreign bodies by percussion and postural drainage.
Clin Pediatr. 1973;12:270-276.
126 Pereira W, Kovnat D, Iacovino J, et al. A prospective study of the
complications following flexible fiberoptic bronchoscopy.
Chest. 1978; 73:813-816.
127 Hammon WE, Connors AF, McCaffree DR. Cardiac arrhythmias
during postural drainage and chest percussion of critically ill patients.
Chest.
1992;102:1836-1841.
128 Shrader DL, Lakshminarayan S. The effect of fiberoptic bronchos-
copy on cardiac rhythm. Chest. 1978;73:821-824.
129 Ciesla ND. Chest physical therapy for the adult intensive care unit
trauma patient.
Physical
Therapy Practice. 1994;3:92-108.
130 Mars M, Ciesla ND. Chest physical therapy may have prevented
bronchoscopy and exploratory laparotomy: a case report. Curdtopultno-
naly Physical Therapy. 1993;4:4-5.
131 Hammon WE, Martin RJ. Chest physical therapy for acute atelec-
tasis: a report on its effectiveness. Phys Ther. 1981;61:217-220. Clinical
report.
132 Susini G, Sisillo
E, Bortone F. Postoperative atelectasis reexpansion
by selective insufflation through a balloon-tipped catheter.
Chesl.
1992;102:1693-1696.
133 Haenel JB, Moore FA, Moore EE, et al. Efficacy of selective
intrabronchial air insumation in acute lobar collapse.
Am J
Surg.
1992;164:501-505.
118 Aldrich TK, Karpel JP. Inspiratory muscle training in the mechan-
ically ventilated patient.
Physzotherapy Canada.
1987;39:305-307.
Physical Therapy. Volume 76 . Number 6 . June 1996 Ciesla . 625
by guest on July 21, 2013http://ptjournal.apta.org/Downloaded from
1996; 76:609-625.PHYS THER.
Nancy D Ciesla
Care Unit
Chest Physical Therapy for Patients in the Intensive
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Nancy D Ciesla
Care Unit
Chest Physical Therapy for Patients in the Intensive
Cited by
http://ptjournal.apta.org/content/76/6/609#otherarticles
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