Phys ther 1996-ciesla-609-25

Chest Physical Therapy for Patients in the Intensive
Care Unit
Nancy D Ciesla
PHYS THER. 1996; 76:609-625.

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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 concentration ratios improved, and atelectasis resolved without the negative
hemodynamic side effects of therapeutic bronchoscopy. Physical therapists 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


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 pressures 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 drainage, percussion, vibration, coughing and cough stimulation 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 forcedexpiration 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 fibrois.'-^ 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 postural drainage, percussion and vibration, breathing exercises, and coughing were more effective at reducing
postoperative pulmonary complications including atelectasis 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 improvement 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 conwas
centration ( F I O ~ ) 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 respiratory distress syndrome (ARDS) who were mechanically
resistance was
ventilated following trauma."rway
unchanged immediately following and for 2 hours after
chest physical therapy.8 Mackenzie and c o l l e a g ~ e s ~ ~ ~
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 g r o ~ p s ~ ~ . ~ " a v e
examined the effect
of chest physical therapy on the resolution of acute
primary pneumonia. Outcome variables included duration 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 colleagued3 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) (nciesla@erols.com).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



and patients with cystic fibrosis, lung abscess, lung
contusion, and bronchiectasis were also excluded.
Clinical examination and data gained from ventilationperfusion 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 continuous assessment of patients' vital signs and oxygen
saturation before, during, and after treatrnent.14 Unfortunately, because studies evaluating treatment techniques are limited, clinicians have frequently extrapolated the 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 surgery has almost eliminated the need for chest physical
therapy in these patients unless comorbidities are
p r e ~ e n t . ' ~Whether the positioning therapy recom-~~
mended by Dean and colleagues'2-a contributes to the
resolution of acute atelectasis is unknown. The resolution 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 the treatment of acute lobar atelectasis
for
and has been studied in the ICU.738.'" The use of chest
physical therapy without regard to the patient population or condition for which it is prescribed, and with n o
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 mortality rate from nosocon~ialpneumonia 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 tracheostomies--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 pneumonia include the presence of fever, purulent sputum
expec~:oration,
leukocytosis, a Gram stain showing many
polymorphonuclear cells and a single morphologically

Physical Therapy . Volume 76

Table 1.
Indications for Chest Physical Therapya
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~yi(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 infiltrates and did not require antimicrobial therapy. Overuse 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 differentiate the diagnosis of atelectasis from pneumonia and
can be used to determine which patients require antimicrobial 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 baseline 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 Association of Respiratory Care's clinical practice guideline
for postural drainagegQonsiders recent spinal surgery,
rib fractures, and bronchopleural fistulas to be contraindications for postural drainage. This approach may be
a result of prescribing therapy without a clear-cut indication for treatment (Tab. 1) or of the health care
provider not having the training to position the patient
with neurologic and orthopedic injuries o r 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

. Number 6 . June 1996


Ciesla . 61 1

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 d o not need postural drainage 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) o r
recurrent pneumonia is present.

Chest Physical Therapy Components
Mucociliary activity and an effective cough are needed
~.~"
for normal airway c l e a r a n ~ e . ~Viscous secretions, the
presence of a cuffed tracheal tube, dehydration, hypoxemia, immobility, and poor humidification of gases
impede mucociliary clearance, causing secretion retentiotls3(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 a n 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, suctioning, breathing exercises, patient mobilization, and
sometimes manual lung inflation are the usual treatments used to renlove secretions. T h e effectiveness of
positioning alol~e to remove retained secretions is
unknown. Most patients in the ICU cannot tolerate
strenuous exercise programs. However, turning, suctioning, transfer training, and ambulation (with a n MRB, if'
necessary) are integral parts of'the chest physical therapy
assessment and treatment and may minimize the need
for postural drainage using manual t e c h n i q ~ e s . ~ ~ '
Positioning

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~chusand 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 nondependent 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 significant oxygen desaturation."" Transient decreases in oxygen saturation measured by pulse oximetry (Spo,) that
occur with postural drainage positioning return to baseline within a few minutes. Therefore, most spontaneously breathing and mechanically ventilated patients
tolerate positional changes necessary for segmental postural drainage. Infrequently, an increase in metabolic
demand o r worsening ventilation-perfusion ratios result
in a decrease in oxygenation, insufficient gas flow, o r low
~'.~~
lung v o l u ~ n e s . ~ Increasing the patient's Fro, or additional 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 1 5 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. Johnson 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.

The benefits of positioning versus postural drainage is
often difficult to discern. Changes in ventilationperfusion relationships with positional changes have
been d o c ~ r n e n t e d . Side-to-side turning decreases
~~,~~
~~
postoperative fever and improves o ~ y g e n a t i o n .Improvements in arterial oxygenation after patient posiPatient Example # 7
tioning, including in patients with adult respiratory
The following example demonstrates improvement in
~-~
distress syndrome (ARDS), have been s h o ~ n . ~ Posi- '
both atelectasis and oxygenation after prone positioning
tioning patients for chest physical therapy with the
and chest physical therapy. The patient was discharged 8
"good lung down" is associated with improved
days after treatment was initiated. Although it was inioxygenation.U4*
ventilation-perfusion
ratios and
tially felt that this patient would require extracorporeal
Patients with pathology in the superior, and frequently
lung assistance to sustain life, after positioning and chest
the atelectatic posterior, segments of the lower lobes
physical therapy this was not necessary.
may have better oxygenation with prone positioning
than with supine po~itioning.4"~"

6 12 . Ciesla



A 33-year-old white man was admitted to a trauma center
following a near-drowning accident. He had been s u b
1nergec-lfor 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 increasing ailway pressures, the patient was transferred to a trauma
center with expertise in extracorporal lung assistance. Five
<baysfollowing the accident, the patient was t~ansferredto
the second trauma center. At this trauma center, computerized 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
prone positioning and chest physical therapy. Twenty-four
hours following admission to the second trauma center, the
patient was evaluated for chest physical therapy while pharmacologically paralyzed with metabine and mechanically
ventilated via an endotracheal tube. Coarse rales were noted
over the posterior lung zones. The initial treatment consisted 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
sputum was obtained with suctioning. Following treatment,
improved air ent~y noted b auscultation.
was
y
After 5 days of treatnlent, the patient was placed on a
regular bed due to the marked improvement in his respiratory status. Chest physical therapy was administered for 7
days and consisted of postl~raldrainage, percussion, and
vibration to the lower lobes (Tab, 2). Sputllm
incre:ased, with a gradual improvement in breath sounds
and chest radiograph findings and marked in~provement
shown in computerized tomography scan (Fig. 3). The
patient was extubated on day 8. Following extubation, the
patient ambulated with assistance and had a good prodl~ctive cough. Within 24 hours, the patient was discharged
back to the original hospital, alert and oriented while
following three-step commands.
Chest physical therapy and prone positioning were most
likely responsible for reexpansion of this patient's collapsed 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 intervention was primarily responsible for the patient's improvement. However, when faced with a patient with
increasing airway pressures and secretion retention who
is difficult to ventilate on 100% of Fro,, simultaneous
treatment
using
gravity
to
maximize
ventilation-perfusion ratios and postural drainage with
manual techniques to mobilize retained secretions

Figure 1.
Chest radiograph demonstrating bilateral lower-lobe atelectasis. Note
+hat the diaphragmatic
bordersare obscured,

appear to be indicated u~ltilfurther research demonstrates that positioning alone can be equally effective.

Percussjon and Vibration
percussion and vibration are the techniques ]nost fiequently recommended for the patient who is intubated
and mechanically ventilated and for patients with
impaired cognition or poor coughing
Percussion and vibration are used to enhance m~icociliary
clearance fi-om both central and peripheral
The exact niechanism of action of chest percussion is
unknown, bur there is some evidellce froln animal
models that physical stimulation alters airflow and is
associated with the release of pulmonary chemical mediators, mediators that may improve ciliary trallsport speed
by as much as 340%,") Mllcociliary flow is dependent o n
the geometry of the
the viscoelastic property of
airnay, and the speed o f a i r f l o w . ~ o , ~
Luterations in aiMiay
diameter and airflow may decrease the viscosity of
mucus, making percussion more effective in mobilizing
secretions that are adherent to the bronchial walls.
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 airway~."~z
Because of differences in aerosol deposition in
the airways a n d no standardization of manual versus
mechanical technique, controversy exists as to whether
the radionuclide clearance noted with percussion and
vibration indicates peripheral o r central ainvay clearance. Manual percussion and vibration, when performed

Physical Therapy. Volume 76 . Number 6 . June 1996


Ciesla . 61 3

with postural drainage, are thought to expedite drainage
of secretions from the central and peripheral airways,
which may reduce treatment
This is particularly important for patients in the ICU who have periods
of hernodynamic instability and require multiple diagnostic and therapeutic procedures. Both techniques are
used with postural drainage.

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
Manual techniques should be applied only over the lung
to the thorax without disrupting spinal stabilization. For
that approximates the chest wall with full i n ~ p i r a t i o n . ~ ~
the patient with severe brain injury requiring intracraCornmonly accepted anatomic landmarks for percussion
nial pressure (ICP) monitoring, manual techniques are
and vibration include the level of the 10th thoracic
not contraindicated because they do not increase
vertebra posteriorly and the xiphoid process anteriorly
ICP.(j"b7 The force and frequency of manual percussion
with normal respiration. Posteriorly, the lower borders
and vibration vary depending on the therapist's experiof the lung descend to T-12 with deep inspiration and
ence; whether a one- or two-handed technique is used;
and the patient's pain tolerance, especially when rib
rise to T-9 with forced e x ~ i r a t i o n . ~ ~
fractures are present.
The lower lung borders may be two to three levels higher
in patients with abdominal distention and in patients
Percussion. Percussion is used during both the inspirawith liver or kidney disease. Lower lung borders can be
tory and expiratory phases of respiration. The therapist's
assessed with auscultation and mediate percussion (perhand should create an air cushion, and the energy wave
cussion as part of the physical examination to determine
created by that hand is transmitted through the chest
the density of underlying structures). One lung segment,
wall and is thought to dislodge secretions from the
the medial segment of the right lower lobe, is not
bronchial ~ a l l s . ~ ~ ~ ~ r o n c h o sis a s m most frep the
accessible to manual techniques because of its anatomic
quently discussed adverse effect of percussion in patients
location. Percussion and vibration should be applied
with chronic bronchi ti^.^,^^^ Gallon71 noted that brondirectly over the skin to allow the therapist to observe
chospasm can be prevented when a forced-expiration
anatomic landmarks, skin redness, or petechiae, as well
technique or the active cycle of breathing is incorpoas chest tube and line insertion sites, and to detect
rated into chest physical therapy. Bronchospasm is rare
undiagnosed rib and sternal fractures or the presence of
in patients in the ICU who have undergone trauma or
subcutaneous emphysema (air in the subcutaneous tissurgery. More often, particularly in patients with quadsue). The presence of, and any increases in, subcutaneriplegia, wheezes are noted as secretions are mobilized
ous ernphysema may be associated with a life-threatening
from the lung ~ e r i p h e r y . ~Once the secretions are
'
pneumothorax. This condition should therefore be
removed by coughing or suctioning, breath sounds
monitored closely, and the physician or nurse should be
improve.7' Patients with reactive airway disease may
notified when airway pressures are increasing. The phyrequire inhaled bronchodilators prior to or following
sician or nurse should also be notified when subcutanetreat~nent.~%en bronchospasm persists as a result of
ous emphysema is increasing, as noted with palpation.

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

percussion, appropriate
implemented.

intervention

should

be
-Y

a
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 bronchiectasis 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 sputum production, although slow percussion (6-12 cycles
per minute) was more effective than no percussion.
Hammon reported that when large amounts of proteinaceous 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 controversial. 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.75Ten of these patients developed extrapleural pathology before chest physical therapy was started,
and 14 patients developed extrapleural pathology after
chest physical therapy was started. There was no difference 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 mechanically kentilated usually tolerate percussion in conjunction 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 negative intrathoracic pressure^.^^ The force and frequency
of percussion can be modified to patient tolerance.
Percussion is not indicated for the spontaneously breathing patient with rib fractures who is responding to
breathing exercises and assistive coughing techniques.

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Ciesla

. 6 15

Figure 3.
Chest radiograph showing improvement in right lower-lobe atelectosis.

Vibration. Vibration is a more forceful technique than
percussion. At 12 to 20 HZ, vibration is similar to the
normal beat frequencies of human ciliaa7"he rib cage is
"shaken" during the expiratory phase of respiration.
Some clinicians define vigorous vibration as "rib shaking" or "rib springing."I7 Vibration is used with both
patients who are spontaneously breathing and patients
who are mechanically ventilated. Secretions move into
the upper aimaJ's when vibration is performed during
b r o n c h o ~ c o p yForceful vibration is not recommended
.~~
over rib fractures, which may perforate the pleura and
cause a pneumothorax, intrapleural bleeding, or an
extrapleural hematoma. Some clinicians use a mild
vibration of light, fast oscillations over rib fractures and
report no adverse effects. Vibration in patients with
thoracic spinal fractures should be mild and performed
by clinicians trained in chest physical therapy techniques. S~ontaneously
breathing patients who are difficult to arollse (such as those with acute brain injury) may
benefit from vibration to erlcourage deep inspiration
and stimulate a cough.

In my clirlical experience, dysrhythmias are more likely
to occur as a result of hemodynamic instability associated
with positiorlal change than as a result of the actual
manual technique. Percussion and vibration adjacent to
a cardiac electrode may produce artifacts. After consultation with nurses and physicians, electrodes can usually
be repositioned or, in rare cases, temporarily disconnected. The therapist should then closely monitor the
clinical status of the patient and any alterations in blood
pressure or heart rate.
Mechanical devices. Mechanical percussors and vibra-

tors were introduced in the late 1960s to permit patients
with cystic fibrosis more independence with therapy. For
6 16 . Ciesla

adult patients in the ICU, use of these devices increases
cost, does not reduce staffing requirements, and introduces 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 combined with postural drainage.7R-H0In patients with pulmonary alveolar proteinosis, manual percussion (180270 cycles per minute) was almost twice as effective as
mechanical percussion (36 Hz) in removing proteinaceous material from the a l ~ e o l i . ~ '
Recently, Hammon
and McCaffree" studied the effects of manual percussion, saline alone, and a commercially available pneumatic percussor on the removal of alveolar material in
three patients with pulmonary alveolar proteinosis. Measurements of optical density were better with manual
percussion than with saline alone or the pneumatic
per cuss or.^ Although these results cannot be extrapolated directly to non-saline-filled lungs, they suggest that
manual percussion is capable of removing secretions
from the most distal airnays and alveoli and is more
effective than mechanical percussors, vibrators, or saline
alone.
High-frequency chest compression (HFCC) has recently
gained popularity as a means of enhancing mucus
clearance in patients with cystic fibrosis.60 The patient
wears an inflatable vest that covers any lung lobes
affected with pathology. Frequencies are adjusted to
airflow and to maximize mucus
optimize
clearance. Whitman and colleagues," however, found
no increase in mucus clearance over traditional techniques in six patients who had been mechanically ventilated for 90 to 1,203 days. Percussion was applied for 2
minutes to five lung regions with postural drainage. No
indications for treatment were stated other than that the
patients were mechanically ventilated. The practicality of
using HFCC with mechanical ventilation in the JCU is
questionable when patients are at high risk for crosscontamination and access to the thorax is required for
cardiorascular monitoring. Further study is needed to
determine whether HFCC and use of a flutter valve
facilitate mucus clearance from central and peripheral
for patients who are critically ill and immobile.

Manuallung
/nflation
Manual lung inflation, which involves disconnecting the
patient from the mechanical ventilator and inflating the
lungs with a large tidal volume via an MRB, is a common
practice in Great Britain, Canada, and A u ~ t r a l i aAfter
.~~
the lungs are hyperinflated, the bag is quickly released,
producing a high expiratory flow. ~l~~ rates range from
123 to 340 L/rnin, depending on the type of bag used

Physical Therapy . Volume 7 6 . Number 6 . June 1996


and the amount of pressure g e n e r a t e d . H V h i s technique, often referred to as the "bag-squeezing method,"
was introduced in the 1960s to prevent pulmonary
segmental collapse, reexpand collapsed alveoli, minimize the risk of hypoxemia, and stimulate a cough in the
patient who is i n t ~ b a t e d 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 therefore 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 hypoxemic relspiratory failure in a surgical ICU and were
unable to demonstrate any improvement (<5 minutes)
in gas exchange or pulmonary compliance with hyperinflations 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 p a t h o l ~ g y . ~
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 hyperinflation 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 manual 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 p r e s ~ u r e . ~ ~ o r
patients who are
mechar~ically
ventilated, lung hyperinflation with vibration is associated with large fluctuations in cardiothoracic pressure, and the physiologic benefit is therefore
questi~nable.~?
Coughing
Coughing removes secretions from the trachea, mainstem 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, o r a
decreased level of consciousness. Therapists working in
the ICIJ, therefore, should be familiar with cough stim-

ulating and assistance techniques. Compressing the trachea 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 abdominal muscles. While huffing, the glottis remains open and
intrathoracic pressure is lower than with c ~ u g h i n g . ~ ~
When incisional pain is the limiting factor, support of
thoracic and abdominal incisions and huffing are indicated. Upright positioning also improves cough pressures." Coughing is also enhanced by early tracheostomy 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 quadriplegia.g"upport
and compression of the upper abdomen
during expiration facilitates an effective, productive
cough. Abdominal support and pressure during exhalation 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 o r huffing. Withholding suctioning may
~
result in airway occlusion and h y p ~ x e m i a . "Because
upper-airway secretions are most prevalent before and
after a change in patient position and during or following 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 o r 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 procedure. Table 3 lists the most frequently cited complications associated with tracheal suctioning and the recommended interventions to minimize side effects.



Ciesla . 6 1 7

Table 3.

Table 4.

Complications of Endotracheal Suctioning

Recommended Features of Suction Catheters

I Complication

II

Hypoxemia, death

Recommended Intervention
Adequate oxygenation prior to and
following the procedure
Limit suctioning to 15-20 so

Bacterial contamination

Sterile technique, changing the
suction catheter every 2-4 passes

Mechanical trauma

I

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 C L , Noll ML. In-line closedaystem suctioning: a research analysis.
Dimmsionc (ff;ri/irrrl Care Nursing 1993;13:73-83.

Precautions and contraindications. Suctioning through
an artificial airway of a patient with adequate oxygenation and stable vital signs has relatively few contraindications. 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 desaturation 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 therapy, including prolonged postural drainage, cough stim6 18 . Ciesla

Usually 12-14 French for adults
with a 7- to 9-mm endotracheal
tubeo; reduces airwa occlusion
and suction-inducediypoxemia

Material

I

Size less than one half the
diameter of the airway

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 closedsystem suctioning. Closed-system suctioning is accomplished by using either a "port adapter" or the more
The
recently introduced in-line s u c t i ~ n i n g . ~ ~ ~ ~ ~ ~
recommended features of suction catheters are listed
in Table 4.

Prior to suctioning a patient who is mechanically ventilated, 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 minimizing 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
~W
improved oxygenation during s u c t i ~ n i n g . ~ ~ ~ ~ the s i n g


adapter may minimize the need for preoxygenation,
therefore eliminating the potential hazards of exposure
to 100% oxygen."J4A port adapter is recommended for
patients who are mechanically ventilated patients and
require a PEEP of >10 cm H 2 0 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 adaptClinical impressions of in-line suctioning
er.9!',100,104.106
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 mandatory ventilation (IMV).100.104,106

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" secretions.ll"aline
instilled through a tracheal or endotracheal 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
~~,ll~
than saline i n ~ t i l l a t i o n . ~ Patients with copious purulent 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,
Preoxygenation is the most commonly used method for
increase inspiratory capacity, enhance cough efficacy,
mechanical
preventing oxygen d e ~ a t u r a t i o n . ~ ~ ~ . ~ ~ Y h e
ventilator or an MRB is used to inflate the lungs and
and assist in removal of ~ecretions.5~
Breathing exercises
increase the inspired oxygen concentration prior to
are indicated in the ICU setting for patients with neurosuctioni~ng. patients who are mechanically ventilated,
For
muscular disease or injury affecting the respiratory musthe ventilator is preferred over the MRB. Minute venticles. Breathing exercises also are used when thoracic
lation, PEEP, and FIO, are all controlled, and there are
excursion is decreased as a result of retained secretions
no ~ari~ations lung volume, flow rates, and pressure
in
or pain or when a patient is immobile following surgery.
~~~
based on the clinician's bagging t e ~ h n i q u e . lWhen ~ l ~
Breathing exercises are not indicated during mechanical
using tlhe ventilator, the second clinician who may be
ventilation but may be used during weaning from
mechanical ventilation.
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
There are several types of breathing exercises. Diaphragmatic breathing and lateral costal and segmental costal
has a r e ~ e r v o i r . l l l . ~ ~ ~
expansion exercises are used most often postoperativeThe miajority of studies evaluating tracheal suctioning
ly?l Use of a flutter valve, the forced-expiration techhave compared the effects in patients who had cardiac
nique-more recently referred to as the active cycle of
surgery.10i.10"111~113
Although hyperoxygenation is combreathing (huffing at various lung volumes interspersed
mon practice, it may not be necessary for all patients.
with diaphragmatic breathing)-and
autogenic drainBased on my clinical experience, I believe that suctionage (using a sequence of breathing maneuvers at various
induced hypoxemia may not be as significant in patients
lung volumes to optimize airflow within multiple genersuch as8
young patients with traumatic injuries but withations of bronchi) are beneficial in patients with cystic
out cardiac disease. A suctioning protocol that encourfibrosis, although the efficacy of these procedures after
ages clinical judgment is recommended.l14 When
surgery has not been determined.5"11i Inspiratory muspatients are hyperoxygenated prior to or during chest
cle training and resistive diaphragmatic breathing exerphysical therapy, the effect of chest physical therapy on
cises may be beneficial while weaning the patient with
quadriplegia or chronic obstructive pulmonary disease
Sao,, Spo,, or partial pressure of arterial oxygen (Pao,)
may be masked.
from the ~ e n t i l a t o r . ~ ~ - ~ 2 ~ spirometry is comIncentive
monly used postoperatively, although it is no more
The most important indicators as to whether a patient
advantageous or costeffective than instruction in deep
breathing and coughing.I2l Following coronary artery
will desaturate with suctioning are the resting Spo, and
the resting Pao,. Depending on the patient being sucbypass or gall-bladder surgely, breathing exercises offer
no advantage over early patient m0bilization.~*-21
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

Physical Therapy. Volume 76 . Number 6 .June 1996


Ciesla . 6 19

Table 5.
Patient Example 2: Improved Oxygenation and Chest Radiograph 1 Hour Following Chest Physical Therapya
-

-

Day/Time

-

-

-

-

- - -

Positioning/Chest Physical Therapy
-

-

Chest Radiograph
Results

Sao,

-

-

Pao, /FIo,
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
copious secretions prior to chest radiograph

5:20 PM, LLL,
atelectasis

Day 4, 12: 15 PM

I

-

Turned into the right sidelying head-down position for segmental
postural drainage of the posterior and loterol segments of the LLL;
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

Leh lung collapse
(see Fig. 4)

Day 4, 2:00 PM

Repeat chest radiograph

Leh lung reexpanded
(see Fig. 5)

99%

"Sao,=oxvgr~~ a t u ~ a r i o n
rnc;~curedby pulsr oxinretry; Pat,,=partial pressure of oxygcrl, arterial; F~o,=fractiotr 01' inspirrcl oxygen concentration;

420/100
420

I

LL.L=leftlowel-

Iohc.

ical therapy can be performed regardless of tracheal
Patient Mobilization
Mobilizirig the patient in the ICU is important, but the
tube size, as long as the appropriate-size suctio~l
catheter
patient's medical condition usually prohibits indepenis used, and does not require physician participation.
dent ambulation and vigorous activity. The severity of
Chest physical therapy is directed to the area of peripheral lung pathology; during bronchoscopy, secretion
injury or disease and life-sustaining paraphernalia also
of
removal is limited to the level of the segmental bronusually lirnit n~obilization patients who are mechanically ventilated to dependent o r stand-pivot transfers and
chus. Cardiac arrhythmias are reported with both proactive- and passive-range-of-motion exercises. Upright
cedures, although fatal dysrhythrnias were noted only
with bron~hoscopy.'"~~27 major fall in Pao, associThe
positioning of patients is encouraged to improve coughated with bronchoscopy has riot been seen with chest
ing and lung volumes, including functional residual
physical therapy. l f l , " H
capacity, and lung compliance. Patients who are difficult
to wean fi-om the ventilator frequently benefit from
transfer training and ambulation with portable ventilaSeveral case studie~'"~-':'l
have demonstrated a favorable
tor. Rehabilitative techniques are used while monitoring
response to chest physical therapy for lobar collapse
vital signs to note any alterations from baseline. The
when bronchoscopy was either too high-risk or unsucdetails of n~obilizingthe patient in the ICU are beyond
cessful. Raghu and Piersoliw reported successful
the scope of this article but are described el~ewhere.~~',]2'
removal, with chest physical therapy, of a tooth aspirated
during intubation. Due to the patient's life-threatening
Chest Physical Therapy Versus Therapeutic
myocardial infarction, bronchoscopy was considered too
Bronchoscopy
invasive. There are two reports of the effectiveness of
Several inve~tigators~'.""-'2(~
have compared the efficacy
selective lung insufflation through a balloon-tipped cathof chest physical therapy versus therapeutic bronchoseter in expansion of collapsed lobes in patients with
copy for treatment of' atelectasis and foreign-body aspiatelectasis who were unresponsive to chest physical therration. Both treatments are indicated for aspiration of
apy, but the treatment regimen was not
Haenel and c o l l e a g ~ e s ' : ~ ~
advocate use of a kinetic
blood, gastric contents, and foreign bodies. Lung con(rotating) bed that in itself prohibits postural drainage
tusion, lung abscess, smoke inhalation, and pneumonia
of the most frequently affected lower-lobe segments
also are indications for chest physical therapy or bronchoscopy. In the surgical ICU, chest physical therapy is
(posterior, superior, and lateral) and of the posterior
recommended because it is less costly and less invasive
segments of both upper lobes.
for treatment of an atelectasis or infiltrate for 24 to 48
hours before therapeutic bronchoscopy o r starting antibiotics (M Joshi, personal communication). Chest phys620 . Ciesla



Figure 4.
Complete collapse of the left lung prior to chest physical therapy

Patient Example

Figure 5.
Reexpansion of the left lung 1 hour following one chest physical therapy
treatment.

#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 vibration was necessary t o reexpand the patient's left lung.
Chest pllysical therapy eliminated the need for therapeutic 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-ologicalexamination following American Spinal Injury Association Standards revealed incomplete sensory deficit (impaired sensation at C-6, C-7, T-3 to T-5, L-3,
and a111sacral 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. I n
addition, the left-lung atelectasis resolved immediately following 45 minutes of chest physical therapy, as noted in
Figure 5. Prone positioning and suctioni~~g not prevent
did
the secretion retention that resulted in collapse of the
patient's left lung.

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 relating 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 hypoxemia, and the necessary features of suction catheters are
described. Although patient mobilization and deepbreathing 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 necessary 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~lctionwith airway
suctioning for patients who are intubated. Further
research is needed to assess the efficacy of manual
hyperinflation i11 patients who are mechanically ventilated and the efficacy of therapeutic positioning without
postural drainage and manual techniques.



Ciesla . 62 1

Table 6.
Chest Physical Therapy With Special Conditions"

Condition

Treatment

Increased intracranial pressure

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

Coagulopathy

Determine cause; when copious bleeding occurs in the tracheobronchial tree, risk/benefit
must be weighed; treatment is coordinated with other nursing interventions; suction
carefully

Bronchopleural fistula

Chest physical therapy is continued to decrease incidence of infection and enhance
healing; avoid prolonged periods of time with affected lung uppermost with positivepressure ventilation and PEEP, which may increase leakage through the fistula

Spinal fracture

Vest may be opened after patient positioning; after stabilization, use headdown
positioning as indicated by the patient's clinical condition

Rib fractures

Avoid vigorous vibration

Pulmonary embolus

Avoid line occlusion; bed may need to be elevated to maximize flow

Continuous venovenous hemodialysis

Avoid line occlusion

Peritoneal dialysis

Treatment is given while the dialysate is draining from the abdomen to minimize intraabdominal pressure

Extracorporeal lung assistance

Avoid line occlusion; ensure that flow i s within preset guidelines

Adult respiratory distress syndrome [ARDS)

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

Extrapleural hematoma

Therapy may be restricted when the hematoma is expanding or the patient has a
coagulopathy

Pnemothorax, hemothorax

Treatment is initiated after chest tube placement has been confirmed radiologically

Lung abscess, lung contusion

"

Therapy is withheld until medical intervention

Continuous arterial-venous hemodialysis

Follow treatment of involved lung lobe or segment with treatment of dependent area to
minimize tronsbronchial aspiration

ICP=intr-acraoial pressure; PEEP=positivr el~dexpiratorypressure; 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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622 . Ciesla

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Physical Therapy. Volume 76 . Number 6 . June 1996


Ciesla . 625

Chest Physical Therapy for Patients in the Intensive
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Nancy D Ciesla
PHYS THER. 1996; 76:609-625.

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