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Chest physiotherapy and tracheobronchial suction in the ICU 

Chest physiotherapy and tracheobronchial suction in the ICU
Chapter:
Chest physiotherapy and tracheobronchial suction in the ICU
Author(s):

Gianluigi Li Bassi

and J. D. Marti

DOI:
10.1093/med/9780199600830.003.0121
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date: 05 December 2020

Key points

  • Ventilated patients often retain respiratory secretions because of hypersecretion, impaired clearance, and immobilization.

  • Several clinical studies that evaluated the role of chest physiotherapy in the intensive care unit have been limited by inappropriate outcomes, accurate definitions of complications, and diversity in the applied methods. Thus, well-designed clinical studies are warranted to substantiate benefits associated with routine use of chest physiotherapy techniques.

  • Posture change, chest percussion, incentive spirometry, and manual hyperinflation are the most common techniques applied in the intensive care unit to improve mucus clearance and prevent pulmonary complications.

  • In intubated or tracheostomized patients, endotracheal suctioning is essential to remove accumulated mucus within the large airways.

  • Endotracheal suctioning should be performed by qualified personnel with extensive training in recognizing indications, properly perform the procedure, and promptly respond to any potential complication.

Introduction

In mechanically-ventilated patients, chest physiotherapy and tracheobronchial suction are essential procedures to maintain airway patency and prevent pulmonary complications. Patients on invasive mechanical ventilation commonly present retention of airway secretions, which constitutes a daily challenge for respiratory therapists, nurses, and physicians.

Mucus clearance

The airway lining fluid is a biphasic layer, with antimicrobial and immunomodulatory properties, formed by a gel-phase (mucus), and a low-viscosity inner layer (sol-phase), which mainly provides lubrication for ciliary beating. Mucus production in healthy subjects is approximately 10–100 mL/day.

Mucociliary clearance

Mucociliary clearance is a primary defence mechanisms of the respiratory system [1]‌. Each ciliated cell has approximately 200 cilia on its surface, which move within the periciliary liquid layer at 8–15 Hz. Mucus overlying the periciliary fluid is transported by the outermost parts of the cilia [2]. Mucociliary clearance rates range between 4 and 20 mm/min.

Mucus clearance via two-phase gas–liquid mechanism

During mechanical ventilation, inspiratory and expiratory airflows interact with mucus. As a result, mucus is propelled in the direction of the highest airflow via the two-phase gas–liquid flow mechanism [3,4]. The majority of chest physiotherapy techniques rely on this mechanism to clear mucus. The critical factors necessary to move mucus through airflows are:

  • The shear stress exerted by the airflow on the liquid layer.

  • The ratio between thickness of the mucus layer and the airway diameter.

  • The rheological properties of secretions.

  • Gravity [3,4].

Inspiratory and expiratory airflows exert opposite shear forces on the mucus layer [5]‌. The difference between inspiratory and expiratory flow rate can be modulated by adjusting ventilator parameters that affect the inspiratory flow, i.e. duty cycle [6,7]. Additionally, in patients, positioned in the semirecumbent position, mucus transport mainly depends on a balance between the airflow shear forces on the liquid layer and gravitational force.

Mucus clearance in critically-ill patients

Mucus retention is highly prevalent in mechanically ventilated patients because mucociliary velocity is drastically reduced [8]‌, and the inflated endotracheal tube cuff averts mucus clearance. Therefore, mucus accrues [7], unless it is aspirated through suctioning. Contributing factors to mucus retention are hypersecretion of mucus, immobilization, weak cough, and muscle weakness.

Chest physiotherapy

Several chest physiotherapy techniques are routinely applied in critically-ill patients [9]‌ (Table 121.1). The role of chest physiotherapy in the intensive care unit (ICU) to mobilize secretions and improve patient’s outcomes lacks of compelling evidence [10,11]. Additionally, bedside techniques to routinely monitor mucus clearance are not available. Thus, surrogate end points have been used in research, all of which increase the odds for negative studies and produce controversy in the field. Only qualified personnel with appropriate training should perform chest physiotherapy. Appropriate analgesia is essential throughout the interventions in order to ensure patient’s comfort and efficacy of the intervention.

Table 121.1 Indications for different physiotherapy regimes

Specific indications

Absolute contraindications

Relative contraindications

Scientific evidence to support the routine use in ICU*

Frequency of treatment

Duration of treatment

Posture change

  • Deep sedation

  • Neuromuscular disease

  • Pharmacological paralysis

Unstabilized spine Fractures

  • Rib fractures

  • Spine fractures

Sufficient

Every 1–2 hours

NA

Postural drainage

  • Lung atelectasis

  • Unilateral lung injury

  • Increased intracranial pressure

  • Unstabilized spine Fractures

  • Spine fractures

  • Haemodynamic instability

  • Respiratory instability

  • Obesity

Insufficient

Every 4–6 hours

30 minutes to 12 hours

Percussion

  • Lung atelectasis

  • Presence of thick mucus

  • Deep sedation

  • Neuromuscular disease

  • Pharmacological paralysis

Bone diseases associated with extremely fragile bones

  • Bronchospasm (consider bronchodilators before and following the intervention)

  • Rib fractures

  • Subcutaneous emphysema

  • Recent thoracic surgery

  • Coagulopathy or thrombocytopenia

Insufficient

Every 4–6 hours

15–30 minutes

Assisted high-frequency airway clearance techniques

  • Cystic fibrosis

  • Chronic obstructive pulmonary disease

  • Bronchiectasis

NA

  • Bronchospasm

  • Rib fractures

  • Subcutaneous emphysema

  • Recent thoracic surgery

Insufficient

Every 6 hours

20–30 minutes

Forced expiratory technique

  • Neuromuscular disease

  • Slight sedation

Untreated pneumothorax

  • Recent abdominal surgery

  • Recent thoracic surgery

  • Deep sedation

  • Increased intracranial pressure

  • Active tuberculosis

  • Pneumothorax

  • Bullous emphysema

  • Coagulopathy or thrombocytopenia

Insufficient

Every 2–4 h

5–10 minutes

Cough-assist device

Neuromuscular disease

Untreated pneumothorax

  • Pneumothorax

  • Bullous emphysema.

  • Recent thoracic surgery

  • Increased intracranial pressure

  • Coagulopathy or thrombocytopenia

Insufficient

Every 6 h

10 minutes

Incentive spirometry

  • Abdominal surgery

  • Thoracic surgery

  • Conscious patient

NA

  • Uncooperative patient

  • Vital capacity less than 10 ml/kg

Insufficient

10 times every h

1 breath

Manual hyperinflation

  • Lung atelectasis

  • Deep sedation

  • Excessive mucus production

  • Inefficient cough

Untreated pneumothorax

  • Haemodynamic instability

  • Pneumothorax

  • Bullous emphysema.

  • Increased intracranial pressure

Insufficient

Every 6 hours

2–4 minutes

Manual ribcage compression

  • Lung atelectasis

  • Inefficient cough

NA

  • Haemodynamic instability

  • Pneumothorax

  • Bullous emphysema.

  • Increased intracranial pressure

Insufficient

Every 6 hours

15 minutes

* Although there is insufficient evidence to support routine clinical use of chest physiotherapy techniques in the intensive care unit, it is pivotal to identify patients at greater risk of pulmonary complications and to prescribe treatments on an individual basis.

ICU, intensive care unit; NA, not available.

Posture change and postural mucus drainage

The deleterious effects of prolonged immobility have been extensively studied [12]. As a general rule, in ICU patients, changes in posture should be performed every 1 or 2 hours.

Postural mucus drainage therapy consists of placing atelectatic pulmonary segments in a position that allows drainage of mucus through gravity and redistribution of pulmonary ventilation. Postural drainage can be associated with other physiotherapy techniques to enhance benefits. The therapeutic indications must be carefully reviewed, due to the associated potential complications [13].

Percussion and high-frequency airway clearance techniques

Chest percussion and high-frequency airway clearance techniques cause a change in airways diameter and airflow, ultimately resulting in mobilization of secretions adherent to the bronchial walls. Preventive or curative percussion can be applied in intubated or tracheostomized patients [14]. Assisted high-frequency airway clearance techniques, through external devices such as the Percussionaire®, the Vest Airway Clearance System®, and the Hayek Oscillator System®, develop small airflow pulses that alter the rheological properties of mucus and enhance the expiratory-inspiratory flow bias [15]. Following extubation, their use can be indicated on a case-by-case basis in patients who regularly use these devices in out-of-hospital settings.

Directed cough and cough-assist devices

In patients with neuromuscular weakness, who present paradoxical abdominal outward motion during coughing, it is beneficial to compress the lower thorax and upper abdomen to improve peak cough expiratory airflow. Forced expiratory technique (FET), also called ‘huffing’, is indicated for patients, who present with compliant central airways that collapse during cough. FET consists of coughing efforts with an open glottis at mid- to low lung volume followed by ample ventilation. Huffing can also be applied in tracheally-intubated patients, exerting manual pressure to the thorax and epigastric zone during exhalation.

The mechanical insufflation–exsufflation is a technique applied through the CoughAssist In-Exsufflator (Respironics, Murrysville, Pennsylvania) to simulate cough. The device delivers a pressure-targeted lung insufflation. This is immediately followed by a forced exsufflation, applying negative pressure.

Incentive spirometry

Incentive spirometry (IS) is the most widely applied physiotherapy technique in surgical patients at risk of developing lung atelectasis. The evidence supporting its use is limited by heterogeneous techniques, inconsistent definitions of outcomes, and poor-quality trials. Thus, IS should be used within a well-organized post-surgical physiotherapy programme to accelerate lung recovery and avoid post-operative complications. The technique is best taught prior to surgery. Several volume- or flow-orientated IS are available, aimed at achieving a 1.5 L maximal inspiratory volume and 600–900 mL/sec inspiratory flow. Studies have shown that volume-orientated devices require less inspiratory efforts, generate greater diaphragmatic motion and higher tidal volumes [16]. Cough is essential to mobilize secretions following IS.

Manual hyperinflation

The goals of MH are mobilization of retained secretions, recruitment of atelectatic lung regions and improvement of gas exchange. MH is performed by disconnecting the patient from the ventilator and slowly insufflating a large tidal volume (up to 50% above baseline or up to 40 cmH2O of inspiratory pressure), via a resuscitator bag. After an inspiratory hold, the circuitry pressure is quickly released in order to assure a high expiratory flow rate. The Mapleson-C circuit generates faster expiratory flow and improved mucus retrieval than do circuits with self-inflating bags [17]. During the procedure, in-line manometers should be used to avoid injurious airway pressures.

Manual rib-cage compression

Manual rib-cage compression (MRCC) technique consists of gentle compression of the rib cage during the expiratory phase and release from the compression at the end of the expiration.

Tracheobronchial suctioning

Box 121.1 details tracheobronchial suctioning indications and methods.

Patient preparation

Adequate patient preparation is necessary to avoid complications. Patients commonly remember endotracheal suctioning as one of the most uncomfortable procedures throughout their stay in the ICU; thus, if the patient is conscious, the procedure should be overly explained. Additionally, suctioning should not be performed routinely to minimize the risk of unnecessary complications [18].

Material

Catheter

A larger catheter increases endotracheal tube resistance and facilitates loss of lung volume, because aspirated gas is not rapidly replaced by gas flowing through the endotracheal tube. In patients with thick secretions, catheters with larger and non-parallel side holes should be applied [19].

Closed versus open suctioning

Endotracheal suctioning can be performed either by disconnecting the patient from the ventilator (open suctioning) or through the use of a catheter in-line with the ventilatory circuit (closed suctioning). During closed suctioning, triggered ventilator autocycling should compensate for the loss of pressure. Studies suggest that closed suctioning is beneficial in patients with most severe lung failure [20]. A quasi–closed suctioning system, via a swivel adapter is a potential alternative.

Sterile water

The use of saline, instilled into the endotracheal tube before suctioning remains controversial. The main concern is that saline instillation, may drip into the lungs and cause adverse effects.

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