PURPOSE The role of chest physiotherapy in the NICU POLICY STATEMENTS In principle chest physiotherapy should be limited to those infants considered most likely to benefit with significant respiratory distress and thick tenacious secretions. Concerns regarding cerebral injury in extremely pre-term infants suggest that infants at risk of intraventricular haemorrhage should only receive chest physiotherapy if the benefit is considered to outweigh any potential harm. SITE APPLICABILITY Patients in the NICU with the following: 1. Significant atelectasis 2. Thick and / or copious secretions 3. Pneumonia / Aspiration 4. Recently extubated patients at risk for deterioration 5. Significant BPD with secondary atelectasis +/- secretions 6. Parent education PRACTICE LEVEL/COMPETENCIES Advanced Skill - Provides physiotherapy assessments using advanced skill, knowledge and clinical reasoning within assigned area. Applies advanced clinical knowledge and reasoning to the development and implementation of physiotherapy treatment programs in accordance with established standards of the College of Physical Therapists of BC. PROCEDURE Rationale Assessment 1. Confirm physician s orders. Goals: 2. Review recent chest x-rays 3. Review nursing Flow Sheet, blood gases, and chart and discuss patient s condition with nurse. 4. Review Respiratory Therapy flow sheet 5. Chest Assessment (Chest Assessment Procedure in NICU) 6. Prior to commencing active chest physiotherapy treatment the physiotherapist must note the baseline heart rate, mean blood pressure, oxygen saturation, as well as the ventilator mode, rate and pressures. Treatment 1. Treatment typically includes gentle percussions, gentle active vibrations and suctioning. 2. Treatments are given according to individual need and assessment and maybe 4, 6, 8 or 1. Clearance of lung secretions 2. Maintain lung expansion 3. Reducing the need for ventilatory support 4. Improving oxygenation 5. Prevention of endotracheal obstruction and the need for endotracheal tube changes 6. Prevention of failed extubation due to secretion retention. The principal of chest physiotherapy is to not adversely impact on the cardio-respiratory status. Oxygen desaturations can be compensated for by a small increase in inspired oxygen supply. Policy # PT.08.04 BCCH Child & Youth Health Policy and Procedure Manual Page 1 of 6
12 hourly. Guidelines and Precautions during Postural drainage, percussion and vibration 1. For all treatment techniques the infant s head must be fully supported and excessive neck flexion/ extension should be avoided. 2. TIPPING BABIES HEAD DOWN MUST NOT BE CONSIDERED WHEN POSITIONING BABIES IN THE NURSERY 3. Major changes in position are not usually required for infants in NICU and should be based on chest x-ray findings and auscultation. Positions may be selected from the positioning chart set up by the physiotherapist and found at the patient s bedside. A maximum of two positions maybe used but in unstable or very small babies only one position may be appropriate. 4. Neonates < 1000g. 2 minutes per position or (Mechanical Vibrator) or 2 finger percussions approximately 60/minute 5. Neonates 1000 3500 g Mask percussions x 3 minutes per position followed by 5 spaced vibrations 6. Neonates > 3500 g Hand or mask percussions x 3 minutes per position followed by 5 spaced vibrations Special Treatment Considerations 1. Chest tubes use mechanical vibrations near the chest tube site. 2. Following thoracic, cardiac and abdominal surgical procedures chest physiotherapy is usually withheld for 24 hours (consult with physician). Note: Select type of treatment based on tolerance to treatment, however, recent studies have shown percussions to be more effective than vibration in neonates. (Tudehope and Bagley, 1980). Note: When stable and in an open crib, neonates may be treated on therapist s lap Policy # PT.08.04 BCCH Child & Youth Health Policy and Procedure Manual Page 2 of 6
3. Handling intolerance (mechanical) vibrations may be better tolerated however, some neonates prefer mask percussions. 4. Meconium aspiration chest physiotherapy is beneficial within the first 8 hours. 5. Necrotizing Enterocolitis Chest physiotherapy is usually withheld. Discuss with physician. 6. Abdominal distension avoid prone postural drainage positions. 7. Severe intraventricular hemorrhage, hydrocephalus, recent VP shunts / reservoirs, lumbar punctures and seizures consult with physician re: chest physiotherapy (i.e. decrease frequency or hold treatment.) 8. Umbilical artery line avoid prone position unless written physician s order. 9. IV s especially Jelco s consult with nurse re: positions. 10. Significant skin breakdown / infection mechanical vibrations recommended. 11. Neonates at risk for Biochemical Rickets. Often neonates with all of the following: - Ventilated > 1 month - Birth weight < 1000 g - TPN > 2 weeks - Corrected chronological age < 4 months - Use caution with percussion and vibrations; tendency for fractures to occur - Write precautionary note on P.D. Positions sheet. - Raised Alkaline Phosphate level 12. Recent tracheostomies consult with physicians re: chest physiotherapy 13. Neonates with high alkaline phosphate levels (>600) are at risk for fractured ribs, therefore write precautionary note on P.D. Positions sheet. 14. Do not treat over area where central line is inserted. Guidelines for Suctioning Ventilated Neonates 1. In line suction systems should be in place. 2. Suction pressure should be 80 100 mmhg. If patient has skin infection, then a mechanical vibrator is designated solely to ONE patient; when no longer required vibrator, it shall be cleansed with hibitane before using it on other patients. Policy # PT.08.04 BCCH Child & Youth Health Policy and Procedure Manual Page 3 of 6
3. Check depth of insertion on Respiratory Therapy flow sheet. 15. Preoxygenate if required (increase Fi02 between.05 to.20) 16. Flush catheter with NaCl or using.3 to.5 cc prior to insertion of catheter. 17. With extremely tenacious secretions in term babies instill.3 cc if absolutely necessary provided that ETT is at least a size 3 (however, this must not be routine) NOTE: May administer several instillations when secretions are thick. Wet suction is usually concluded with a dry suction. Non Ventilated Neonates 1. All neonates suctioned post physiotherapy treatment nasally 2. Neonates on nasal CPAP shall be suctioned nasally 3. Use sterile technique with suctioning Nasopharyngeal CPAP 1. Consult with nurse re: suctioning procedure Reduction or Cessation of Treatment Cessation or reduction of physiotherapy should be considered when there is evidence of re- expansion of collapsed/ consolidated lung plus there is a significant reduction in the production of excessive or tenacious secretions. Completion of Treatment 1. Review patient s condition 2. Check equipment i.e. monitors, ventilators, O2 supply, etc 3. Re-adjust equipment to settings prior to treatment if patient s condition is stable 4. Inform nurse of patient s condition, tolerance to treatment, significant findings, etc DOCUMENTATION 1. Chart on nursing Flow Sheet after every assessment or treatment session using Focus method of charting. 2. Document in patient s chart after every treatment/ assessment and with any changes in patient s condition / management (as per POR Policy). 3. Adjust any changes made on Respiratory Management Plan and P.D. Positions sheets. Policy # PT.08.04 BCCH Child & Youth Health Policy and Procedure Manual Page 4 of 6
SUMMARY OF EVIDENCE Active chest physiotherapy increases the clearance of lung secretions Active chest physiotherapy prevents extubation failure Active chest physiotherapy as performed at RPA Hospital is not associated with adverse outcomes Use of saline instillation prevents endotracheal tube obstruction Active chest physiotherapy leads to improvement in oxygenation Active chest physiotherapy leads to improvement in airways resistance 4 7 11 8 1, 2, 5,6 3 REFERENCES 1. Tudehope D, Bagley C. (1980). Techniques of physiotherapy in intonated babies with the respiratory distress syndrome. Australian Paediatric Journal, 16, 226-228. 2. Dall Alba P, Burns Y. (1990). The relationship between arterial blood gases and removal of airway secretions in neonates. Physiotherapy Theory and Practice, 10, 107-116. 3. Fox W, Schwartz J, Shaffer T. (1978). Pulmonary physiotherapy in neonates: Physiologic changes and respiratory management. Journal of Paediarics, 92, 977-981. 4. Etches P, Scott B. (1978). Chest Physiotherapy in the Newborn: Effect on secretions removed. Paediatrics, 62, 713-715. 5. Finer N, Boyd J. (1977). Chest physiotherapy in the neonate with respiratory distress. Pediatr Respiratory, 11, 570. 6. Finer N, Boyd J. (1978). Chest physiotherapy in the neonate: a controlled study. Paediatrics, 61, 282-285. 7. Flenady VJ Gray PH. Chest physiotherapy for prevention of morbidity in babies being extubated from mechanical ventilation (Cochrane Review). In: The Cochrane Library, Issue 2, 1999. Oxford: Updat Software. 8. Drew J, Padoms K, Clabburn S. (1986). Endotracheal tube management in newborn infants with hyline membrane disease. Aust J Physiotherapy, 32, 3-5. 9. Beeram M, Dhanireddy R. (1992). Effects of saline instillation during tracheal suction on lung mechanics in newborn infants. J Perinatology, 12, 120-123. 10. Shorten D, Byrne P, Jones R. (1999). Infant responses to saline instillations and endotracheal suctioning. JOGNN, 20, 464-469. 11. Beeby P, Henderson-Smart D, Lacey J, Reiger I. (1998). Short- and long-term neurological outcomes following neonatal chest physiotherapy. J Paediatr Child Health, 34, 60-62. 12. Raval D, Yeh T, Mora A, Cuevas D, Pyati S, Pildes R. (1987). Chest physiotherapy in preterm infants with RDS in the first 24 hours of life. J. Perinatology, 7, 301-304. Policy # PT.08.04 BCCH Child & Youth Health Policy and Procedure Manual Page 5 of 6
13. Cross J, Harrison C, Preston P, Ruston D, Newell S, Morgan M, et al. (1992). Postnatal encephaloclastic porencephaly A new lesion? Arch Dis Child, 67, 307-311. 14. Harding J, Miles F, Becroft D. (1998). Chest physiotherapy may be associated with brain damage in extremely premature infants. J Pediatr, 123, 440-444. Policy # PT.08.04 BCCH Child & Youth Health Policy and Procedure Manual Page 6 of 6