Page 1 of 7 at Carolinas Medical Center 02.04 Pediatric Patient-Centered Respiratory Care Protocol Application of Chest Physical Therapy Created: 1/98 Reviewed: 4/03, 1/05, 6/08 Revised: Purpose: To describe the efficacious application of chest physiotherapy. For the purposes of this policy, chest physiotherapy (CPT) is defined as some combination of postural drainage (PD) and percussion and/or vibration (PV), diaphragmatic breathing, coughing, forced expiratory technique (FET), or incentive spirometry. Indications: 1. High volume sputum producing diseases: a. cystic fibrosis b. bronchiectasis c. chronic bronchitis 2. Lobar atelectasis due to retained secretions. 3. The presence of adventitious breath sounds consistent with retained secretions in the lower airway that do not clear with coughing, deep breathing and/or suctioning maneuvers. Contraindications: 1. Pleural effusion 2. Hemoptysis 3. Flail chest 4. Untreated pneumothorax 5. Pulmonary embolism 6. Foreign body aspiration 7. Abnormal coagulation profile (e.g. platelets <30,000/mm 3 8. Increased intracranial pressure 9. Brittle bones (e.g. osteogenesis imperfecta, long term steroid therapy) 10. Cyanotic cardiac malformation 11. Any patient whose medical condition is such that they cannot be placed in positions that allow gravity drainage of secretions to the central airways (example: head injury patients who cannot have their heads below 30 degrees above the plane of the body).
Page 2 of 7 Special Notes: Chest physiotherapy has been found to be deleterious or lack efficacy under the following conditions: All Patients: 1. Can cause hypoxemia 2. Has been shown ineffective to prevent post-operative atelectasis 3. Has been shown to provoke bronchospasm 4. Has been show ineffective on patients with an adequate cough or forced expiratory technique Neonates: 1. Can cause an increased incidence of intra-ventricular hemorrhage 2. Can cause rib fractures 3. Can cause hypoxemia Bronchiolitis: 1. Has been shown to be ineffective and cause hypoxemia Post Cardiac Surgery: 1. Has been shown not to prevent atelectasis in these patients. Pneumonia: 1. Shown to not be efficacious 2. Shown to cause hypoxemia Asthma: 1. Shown to be of no benefit in uncomplicated asthma. Definitions: For the purposes of this policy, we use the following terminology and definitions: Pulmonary regimen: This term refers to a combination of various treatments (as listed) intended to treat or prevent lung disease associated with retained secretions or atelectasis. The protocol for CPT illustrates various combinations of these interventions. Suctioning: Respiratory Therapy and Nursing will determine the best method of secretion removal--tracheal, nasal, oral, or bulb suctioning. Note: CF patients have a very high incidence of nasal polyps, so be careful when recommending nasal suctioning on these patients. Deep Breathing: (or Diaphragmatic Breathing) Generally to be used in conjunction with other aspects of the regimen. Encourage deep breathing to allow air to ventilate all segments of the lungs and to allow air to enter behind any mucus which will assist in allowing the patient to cough it up. This can be taught very straight forward in the older patient. The following are some ideas for teaching the younger population: Refer to the belly as a balloon - the balloon gets bigger as the patient breathes in and the balloon gets smaller as the air goes out. Place a small toy or folded paper animal on the child's belly and have the child give it a ride up and down. Breathing Games: These can be used alone or in conjunction with other therapies. They are also used to
Page 3 of 7 introduce the younger patient to diaphragmatic breathing techniques. Place a cotton ball on the table and have the child see how far he can blow it across the table. This can also be done using a cardboard mouthpiece and a cotton ball. Place a toy boat (or anything that floats) in a basin of water and have the child blow it across. Blow bubbles. Have the child blow on a pinwheel. Ambulation: The nurse or therapist may recommend a certain amount of ambulation or time sitting up in chair as long as it concurs with the general medical plan for the patient. Coughing: Huff coughing (or forced expiratory technique [FET]) or regular coughing may be used any number of times per day. Procedure: The Policy and Procedure is implemented when an MD writes an order for Chest Physiotherapy, Chest Physical Therapy, CPT, Postural Drainage, Percussion, Vibration, or Clapping Therapy or Respiratory Care Protocol. 1. Assess the utility of the ordered therapy according to the therapist-driven protocol for chest physiotherapy. If personnel utilize the protocol and change therapy from that which is ordered, the ordering physician will be consulted. a. If the ordered therapy is not indicated via the protocol and it is not an emergent situation, the RCP will attempt to contact the ordering physician. If immediate contact is not made, a note for the physician will be attached to the chart. b. The RCP will ensure that the physician is aware of the situation before the end of the shift. 2. Administer any bronchodilators - if indicated - according to policy and in Fowlers position, if possible. 3. After completion of aerosol therapy, position patient appropriately. 4. Percuss the patient for 3-5 minutes in each area. Encourage a cough or suction the airway. 5. Reassess respiratory status. 6. Deliver aerosolized antibiotics, if ordered. 7. Document the patient s response to the treatment, including the objective signs that indicate this. Be certain to include whether or not there is a productive cough. Positioning: CF Bronchiectasis and Chronic Bronchitis Protocol 1. Posterior upper lobes: percuss the upper scapula region on both sides of the spinal column with the patient in Fowlers position leaning slightly forward. 2. Anterior upper lobes: percuss between the clavicles and nipple line on both sides of the sternum with the patient in the Fowlers position leaning slightly back. 3. Alternate position for anterior upper lobes: (especially for patients with portacaths or who otherwise cannot tolerate the #2 position): percuss the tops of the shoulders with
Page 4 of 7 the patient in Fowlers position. 4. Lower lobes:(posterior basal segments and superior segments): with foot of bed elevated at least 30 degrees, position patient on their stomach and percuss over middle of the back below tip of scapula covering lower ribs on both sides of the spine. 5. Left lower lobe: (anterior basal segments and lateral basal segments): position patient on right side with foot of bed elevated at least 30 degrees, percuss over ribs just beneath axilla to bottom edge of rib cage and over lower portion of ribs anteriorly. 6. Right lower lobe and right middle lobe: (Right lateral segment, right medial segment, anterior basal segment and lateral basal segment): position patient on left side with foot of bed elevated at least 30 degrees, percuss over ribs beneath axilla to lower edge of the rib cage and anteriorly from nipple line to lower edge of rib cage always avoiding the sternum. 7. After each position has been percussed for 3-5 minutes, the patient should be instructed to take 3 diaphragmatic breaths, while still in the postural drainage position. 8. Following the diaphragmatic breaths, the patient should do 3 FET or huff cough maneuvers while still in position. Vibration should be done during these maneuvers. Infants and Toddles (term newborn to 2 years of age): 1. Because of the relative small airway size in infants and toddlers, a range of positions must be chosen for percussion on these patients. 2. Generally infants and toddlers will only tolerate a modified CPT routine, therefore, side lying positioning only is acceptable in this population. If therapy is being given for a documented upper lobe atelectasis, then the appropriate positioning should be used. 3. Palm percussors or hands may be used for percussion. 4. Coughing should always follow any percussion (or suctioning, if appropriate). Pediatric patients (above 2 years of age): 1. Position should be used according to the location of the area to be treated. (i.e. if the right upper lobe has a documented lobar atelectasis caused by retained secretions, then only the right upper lobe should be treated. 2. Trendelenburg positioning may be modified according to the therapist s discretion. 3. Coughing should always follow any percussion (or suctioning, if appropriate). Percussion and Postural Drainage for the Pediatric Patient: Postural Drainage (PD): The purpose of postural drainage is to aid the removal of mucus from the bronchial tree by utilizing gravity. Proper positioning also aides diaphragmatic breathing. The bronchus you wish to drain is placed in a vertical position so gravity can assist the removal of secretions. It is therefore important to know which segments you want to treat so that the proper positioning may be used. You may modify positions if the medical condition of the patient is such that they could not tolerate that position. Attempts should be made to remain as close to the desired position as possible. After the patient has been positioned, make sure that the patient is supported as needed. Percussion (P): Percussion is used to loosen mucus from the airways. The chest wall is rapidly and rhythmically clapped with alternating hands, using loose wrists. The hands are cupped as if drinking water from them. Percussion is applied over the surface landmarks of the affected segment. Sternum, spine, breast tissue, and any other lesions or bony prominence should be avoided. There should always be a thin material covering the area to be percussed, preferable a Tee-shirt type material. Percussion of each segment should last between 3-5 minutes, depending on cough productivity, patient tolerance, secretion thickness, and therapist discretion. Vibration (V):
Page 5 of 7 Vibration is a technique utilizing the expiratory phase to shake secretions toward the central airways. This should be done in the postural drainage position. It is only done during exhalation. Hand position is very important-both hands should be facing the same direction (the direction that you are draining) and even pressure should be exerted over the segment. Hands can be placed one on top of the other, but avoid digging in your fingertips. Diaphragmatic Breathing: Diaphragmatic breathing must be taught and utilized during CPT, especially for cystic fibrosis patients. The patient should be instructed to do 3 diaphragmatic breaths after each postural drainage position while still in position. This can be followed by 3 huff coughs or blowing maneuvers when the patient has learned these techniques. Coughing: Inhale through nose, breath hold, strong cough. FET (Forced Expiratory Technique or Huff Coughing): Forceful exhaling from low to mid lung volumes with an open glottis. Should be done following deep breathing or diaphragmatic breathing while still in postural drainage position. Coughing and FET can be as effective as P and PD and should always be incorporated into it, if possible.
Page 6 of 7 To Be Performed By: RCA, RT I, II, III, and Supervisor.
Page 7 of 7 MD Order Bronchiectasis or Cystic Fibrosis? Perform Regimen as Ordered RESPIRATORY ASSESSMENT FOR CPT Chest X-Ray After 48h Resolved? D/C CPT. Do Pulmonary Regimen Post Cardiac Surgery? CPT Q4 W/A x 48h Discuss Care with MD Add Pulmonary Regimen to CPT Documented lobar or major segment atelectasis? Start CPT Q2 to QID Assess After Each Treatment Assess CXR q24 to 48h Order Older Than 72 Hours? Documented Diffuse Atelectasis? Breath Sounds Revel Ronchi? Incentive Spirometry or Pulmonary Regimen Cough & Suction Pulmonary Regimen + CPT q2h to QID Assess After Each Treatment Resolved? DC Tx's. Notify MD. Breath Sounds Cleared? Do Pulmonary Regimen No Therapy Indicated Assessment Completed By: ADDRESSOGRAPH Name: Date: Time: This flow chart is a suggested guideline of care. The physician may change this plan at any time depending on the patient's individual needs.