Role of Chest Physical Therapist
Moving from Provider to Educator
By Renée C. Cocchi
While chest physical therapy (CPT) is taught in PT school, not many therapists have the opportunity to perfect their skills in the field. PTs are finding that many hospitals are turning to respiratory therapists to provide postural drainage, percussion and vibration (PDPV). Speculation as to why this is happening points to managed care as it may be more cost effective for respiratory therapists to perform these duties than PTs.
For the most part, CPT encompasses breathing exercises postural drain-age, percussion and vibration. However, due to the contraindications and precautions of PDPV (see table), patient compliance, patient needs and research, other techniques like alternative airway clearance techniques and mechanical clearance devices have been appearing over the years.
No matter what CPT technique is used the goals are the same:
* prevent the accumulation of secretions
* improve mobilization and drain-age of secretions
* promote relaxation to avoid muscle splinting
* maintain and improve chest wall mobility
* regain the most efficient breathing pattern, improve ventilation and vital capacity
* instruct and retrain patients in the use of respiratory muscles
* develop respiratory muscle endurance
* prevent venous stasis
* improve cardiopulmonary exercise tolerance
* prevent atelectasis
* increase cough efficiency
In the pediatric population, the primary pulmonary disorders for which CPT is indicated are bronchiectasis; cystic fibrosis; atelectasis; neuromuscular diseases such as muscular dystrophy, spinal muscular atrophy, myasthenia, polio myelitis and quadriplegia; lung injury aspiration; and near drowning.
CPT can be done on children of all ages including infants in neonatal intensive care units.
In the majority of cases, a physician referral is needed to start CPT. In the medical history part of the evaluation, therapists should ask their patients how they've been feeling, whether they've received prior breathing treatment and if they've been coughing and, if so, whether it has been productive.
A thorough evaluation of patients' physical condition and pulmonary status is then conducted. In the evaluation, PTs examine vital signs, level of consciousness, signs and symptoms of respiratory distress, mode and quantity of oxygen delivery, chest wall movement, line leads and incisions, detailed Cathy Mennes, MS, PT, former co-team leader of the chest physical therapy department at Texas Children's Hospital in Houston. (Physical therapists at this facility no longer conduct PDPV, but they still teach alternative CPT techniques.)
Sometimes a treatment plan can be based on the physician's orders, which are often derived from findings on X-ray film. At other times, therapists have to determine the treatment plan based on auscultation of breath sounds and medical history.
FREQUENCY AND duration of treatment can vary depending on the condition and progress. It can range from every hour to three times a day, but normally CPT is done four times a day. For children with cystic fibrosis, treatments typically consist of 30- to 45-minute treatment sessions four times a day because treatment focuses on all lung fields. Children with atelectasis, on the other hand, may have 15-minute treatment sessions four times a day, because they only need one or two lobes treated, explained Judi Linton, MS, PT, former co-team leader with Mennes. Treatments are progressed by lessening the frequency.
Despite the fact that postural drainage, percussion and vibration are the "gold standard" of CPT, there are numerous contraindications to all three modes. Because of this and individual patient needs, a big part of the therapist's job is to educate physicians on new alternative techniques to offer their patients. For example, for teenagers with cystic fibrosis who are going to college, a more independent form of treatment is necessary because PDPV requires another person to perform it. Other therapies such as the flutter device and the mechanical chest percussion vest offer some independence to this patient population. Knowing the options available allows caregivers to provide their patients with the best possible treatment strategies, emphasized the therapists.
Both percussion and vibration can be performed in postural drainage positions. There are nine common postural drainage positions that therapists can employ. At Texas Children's Hospital, there were five standard for children with cystic fibrosis: upper lobes anterior and posterior segments, lower lobes posterior and right lateral and left lateral segments. The remaining four postural drainage positions are upper lobes apical segments, right middle lobe segment, left lingula segment and lower lobes anterior segments. These are used depending on chest X-ray or auscultation results.
AFTER THE TECHNIQUES are performed, patients are asked to take several deep breaths and cough or huff to clear the secretions that have been loosened and brought into the larger airways. At this time therapists should examine the color and texture of the sputum for documentation purposes. Auscultation should also be done again at the end of the treatment session to determine changes in the breath sounds.
Linton noted that for patients who are on assistive respiratory devices or are unable to mobilize their secretions via coughing, suction is an alternative mode of removing them.
For patients to progress in treatment their improvement must be apparent on X-ray film, their temperature must normalize, they must have a productive cough and their breath sounds must improve.
"Children with cystic fibrosis continue to receive CPT three to four times a day while they are in the hospital because the pulmonary physicians want to make sure they get the most aggressive pulmonary treatment they can while they are in the hospital," said Linton. "In fact, many children with cystic fibrosis return to the hospital for what we call 'tune ups'--aggressive treatment to get their lungs in the best possible shape--before they go to school or on college breaks."
Children with cystic fibrosis are never discharged from CPT. It is part of their everyday life, and they will need to perform CPT throughout their lifetime, explained Linton. "That's why one of the biggest elements [of the job for PTs performing CPT]: education. We educate the families on how to perform chest PT, the patients on why they need it and how to do the techniques."
Phyllis Dibbern, PT, staff therapist at National Jewish Medical and Research Center in Denver, explained that her facility has day patients, those who spend the entire day at the facility (it has no inpatients), and traditional outpatients. Respiratory therapists provide PVPD to the day patients, and PTs provide it to the outpatients. But when therapists in the outpatient department perform CPT it is typically done while teaching parents how to perform the techniques correctly themselves.
In the outpatient department, patients may be treated anywhere from one to three weeks, then the parents are taught the technique. "When teaching parents how to perform PVPD, we start with positioning and move onto percussion. If a parent isn't able to perform the percussion due to a physical condition, we figure out ways for them to do it," explained Dibbern. For example, palm cups, which are soft plastic cups with a hollow area. For people who can't cup their hand or hold their wrist in a fixed position, the cups allow users to maintain the position by holding onto the top of the device by sliding their fingers through an opening.
To make sure that the parents are doing the technique correctly, Dibbern observes them. "We spend a lot of time making sure that the parents are performing the positioning and other techniques correctly because it is a permanent and important part of their lives," emphasized Dibbern.
Linton agreed, noting, "Our goal is to give patients whatever technique is best for them so that they will do some kind of chest physical therapy at home. Because even if you give them the most wonderful technique, if they don't like it, they won't do it. So we help them find their treatment of choice."
Both the education and the treatment is vital to survival, especially for those with cystic fibrosis. While the life expectancy in the early 1930s for children with the disease was under 2 years, with medical advances and therapeutic techniques such as chest physical therapy, their life expectancy continues to increase and they now survive to middle adulthood. In addition, it helps them, along with other children with respiratory conditions, live active and productive lives.
Contraindications for PDPV
* gastroesophageal reflux
* patient with neurologic conditions (cerebral aneurysms, external ventricular drainage device, increased intracranial pressure, coma, loss of consciousness, recent CVA, uncontrolled seizures)
* postoperative procedures: neurosurgery, recent cardiovascular surgery, recent neck and face surgery, orthopedic procedures where compression on joints is contraindicated
* unstable cardiovascular system (acute MI, arrhythmias, pulmonary hypertension)
* nausea and vomiting
* continuous tube feedings
* esophageal procedures
* unstable fluid balance (congestive heart failure, during dialysis, ascites)
* acute GI bleeding
* ascending aortic aneurysm
SIDELYING AND QUARTER TURN TO SIDELYING PD
* thoracotomy incisions on weight bearing side
* portacath placement pain
* fresh tracheostomy placement
* ECMO cannula
* pain from chest tube
* recent skin graft
* fresh burn
* open wound on ventral thorax or buttocks
* recent sternotomy causing pain
* recent clam shell or anterior thoracotomy incisions
* flail chest
* recent abdominal surgery
* recent gastrostomy/jejunostomy
* central venous line causing pain
* right atrial or PA line
* untreated pneumothorax
* platelet count below 20,000
* PEEP of 10 or greater
* unstable cardiovascular conditions
* pathological rib fracture or rib lesions at percussion site
* recent clam shell incision: no anterior percussion
* recent anterior thoracotomy incisions: no anterior or posterior/laterally
* recent sternotomy: no anterior percussion
* over recent skin graft, fresh burn or open wound
* conditions prone to hemorrhage: petechiae, coumadin or heparin therapy, disseminated intravascular coagulopathy
* frank hemoptysis
* undrained empyema
* subcutaneous emphysema
* pulmonary embolus
* flail chest
* rule out MI
* severe pain
* acute TB without underlying secretions
* recent spinal fusion
* all contraindications to percussion
* prolonged expiratory phase
information/courtesy chest physical therapy department, Texas Children's Hospital, Houston.