Personalising airway clearance in chronic lung disease.

This review describes a framework for providing a personalised approach to selecting the most appropriate airway clearance technique (ACT) for each patient. It is based on a synthesis of the physiological evidence that supports the modulation of ventilation and expiratory airflow as a means of assisting airway clearance. Possession of a strong understanding of the physiological basis for ACTs will enable clinicians to decide which ACT best aligns with the individual patient's pathology in diseases with anatomical bronchiectasis and mucus hypersecretion.The physiological underpinning of postural drainage is that by placing a patient in various positions, gravity enhances mobilisation of secretions. Newer ACTs are based on two other physiological premises: the ability to ventilate behind obstructed regions of the lung and the capacity to achieve the minimum expiratory airflow bias necessary to mobilise secretions. After reviewing each ACT to determine if it utilises both ventilation and expiratory flow, these physiological concepts are assessed against the clinical evidence to provide a mechanism for the effectiveness of each ACT. This article provides the clinical rationale necessary to determine the most appropriate ACT for each patient, thereby improving care.

Use of a Moisture Wicking Fabric for Prevention of Skin Damage Around Drains and Parenteral Access Lines.

BACKGROUND: Skin damage under various drainage tubes and parenteral access lines occurs frequently in pediatric patients. Our team sought an alternative to the use of gauze or foam for prevention and management of peritubular skin damage. CASES: We used a moisture wicking fabric in select patients in a tertiary children's hospital in Northern California. The fabric was placed under tracheostomy ties and around gastrostomy tubes and Penrose drains. CONCLUSION: The moisture wicking fabric was effective in absorbing moisture and maintaining skin integrity. This new approach has been incorporated into our facility policy.

A modified postural drainage position produces less cardiovascular stress than a head-down position in patients with severe heart disease: a quasi-experimental study.

QUESTION: Does a modified postural drainage position (horizontal) produce less cardiovascular and respiratory stress than a head-down postural drainage position (30 degrees) in people with severe heart disease? DESIGN: A quasi-experimental study. PARTICIPANTS: Thirty-one patients (mean age 69 years, SD 13) with severe left ventricular systolic dysfunction (mean ejection fraction 23%, SD 7) who were stable, receiving regular medication and free of acute respiratory illness. INTERVENTION: Two manoeuvres were performed--one from long sitting to a modified (horizontal) postural drainage position, and one from long sitting to a head-down (30 degrees) postural drainage position. OUTCOME MEASURES: Cardiovascular responses examined were blood pressure, sphygmocardiographic indices, and cardiac rhythm. Respiratory responses examined were respiratory rate, transcutaneous arterial oxyyhaemoglobin saturation, and dyspnoea. RESULTS: Three participants were intolerant to the postural drainage positions--two during head-down and one during modified positioning. The remaining 28 participants maintained their resting cardiac rhythm and did not complain of chest pain or dyspnoea. The changes in cardiovascular responses during the sitting to head-down postural drainage manoeuvre in the tolerant participants were significantly greater (p < 0.05) than the changes during the sitting to the modified postural drainage manoeuvre for most of the sphygmocardiographic indices. In contrast, there were no significant respiratory responses to either postural drainage manoeuvre. CONCLUSION: Modified positioning is associated with less cardiovascular stress than head-down positioning, yet for most patients with severe heart disease, both positions are generally well tolerated. For a subset of these patients, either position may be inappropriate. This suggests that modified positioning should be attempted first but that a head-down position may be attempted if the modified position proves ineffective.

Postural drainage in cystic fibrosis: is there a link with gastro-oesophageal reflux?

OBJECTIVES: To determine the clinical effects of a change from postural drainage (PD) to positive expiratory pressure chest physiotherapy (PEP) in children with cystic fibrosis (CF) and symptoms of gastro-oesophageal reflux (GOR). To measure the effects of PD on GOR in children with CF. METHODS: Study 1: Six adolescents with CF and symptoms of GOR during PD were changed to upright PEP physiotherapy. The effects on lung function, reflux symptom scores and annual hospital days were measured. Study 2: Twenty-four children with CF (mean age 11 years) and symptoms suggestive of GOR underwent 24-h pH monitoring, including periods of chest physiotherapy. RESULTS: Study 1: All six patients reported a reduction in reflux symptoms during PEP therapy (P < 0.001). Lung function parameters improved during the first 6 months of PEP (P < 0.001). This improvement was sustained for a further 18 months. Annual hospital days decreased significantly (P < 0.0005). Study 2: Nine of 24 patients (37.5%) had pathological GOR. Reflux episodes were significantly increased during PD (P < 0.0001), as was fractional reflux time (P < 0.01). CONCLUSIONS: Upright PEP physiotherapy may be more appropriate than PD in selected patients with CF and symptomatic GOR. The role of GOR as a cofactor in the progression of pulmonary disease in CF needs further evaluation.

Insights into the increased oxygen demand during chest physiotherapy.

OBJECTIVES: To determine the mechanism responsible for the increase in oxygen consumption (VO2) during chest physical therapy. Specifically, to examine the hypothesis that muscular activity is the major contributor to the increase in oxygen demand. DESIGN: Prospective, observational study. SETTING: University hospital surgical intensive care unit. PATIENTS: Phase one included 13 patients who were mechanically ventilated after coronary artery bypass surgery. Phase two involved seven mechanically ventilated patients who had undergone major vascular or abdominal surgery. INTERVENTIONS: Phase one involved turning patients to the lateral decubitus position. During the second phase, patients were given midazolam (0.15 microg/kg) 2 mins before an initial chest physiotherapy session and midazolam plus vecuronium (0.7 mg/kg) before a subsequent session. Physiologic measurements were made during the resting periods before and following each session, as well as at the completion of the intervention. MEASUREMENTS AND MAIN RESULTS: Turning patients to the lateral position resulted in significant increases in oxygen uptake and CO2 elimination (VCO2). VO2 increased from 219 +/- 21 (SD) mL/min at rest to 324 +/- 58 mL/min (p <.05) with turning. These increases in oxygen demand were met by increases in both oxygen delivery (852 +/- 238 mL/min at rest to 1116 +/- 430 mL/min, p < .05) and extraction (0.27 +/- 0.7 at rest to 0.32 +/- 0.09, p < .05). There were associated increases in hemodynamic and respiratory variables including heart rate and systolic blood pressure. The administration of vecuronium completely suppressed the 50% increases in VO2 and VCO2 seen without the use of a muscle relaxant. The increases in systolic blood pressure were unaffected by vecuronium. The magnitude of the increase in PaCO2 (32 +/- 5 torr [4.3 +/- 0.7 kPa] at rest to 36 +/- 5 torr [4.8 +/- 0.7 kPa] during therapy, p < .05), was not accentuated by vecuronium (30 +/- 4 torr [4.0 +/- 0.5 kPa] to 35 +/- 6 torr [4.7 +/- 0.8 kPa], p < .05) despite a lack of any increase in minute ventilation or respiratory rate. This change was due to the parallel suppression of VCO2. CONCLUSIONS: The increase in metabolic demand during chest physiotherapy is the result of increased muscular activity as evidenced by the suppression of VO2 following the administration of the muscle relaxant and the observation that turning a patient into the lateral decubitus position produces similar increases in VO2. The increases in blood pressure and cardiac output are due to another mechanism, most likely enhanced sympathetic output. The increase in physiologic activity produced by chest physiotherapy is thus secondary to both exercise-like and stress-like responses.

Postural drainage and gastro-oesophageal reflux in infants with cystic fibrosis.

UNLABELLED: Gastro-oesophageal reflux is increased in cystic fibrosis and it is possible that postural drainage techniques may exacerbate reflux, potentially resulting in aspiration and further impairment of pulmonary function. AIM: To evaluate the effects of physiotherapy with head down tilt (standard physiotherapy, SPT) on gastroesophageal reflux and to compare this with physiotherapy without head down tilt (modified physiotherapy, MPT). METHOD: Twenty (mean age 2.1 months) infants with cystic fibrosis underwent 30 hour oesophageal pH monitoring during which SPT and MPT were carried out for two sessions each on consecutive days. RESULTS: The number of reflux episodes per hour, but not their duration, was significantly increased during SPT compared with MPT (SPT 2.5 (0.4) v MPT 1.6 (0.3), p = 0.007) and to background (1.1 (0.)1, p = 0.0005). Fractional reflux time was also increased during SPT (11.7 (2.6)%) compared with background (6.9 (1.3)%) p = 0.03) but not compared with MPT (10.7 (2.7)%). There was no significant difference between MPT and background for number of reflux episodes, their duration, or fractional reflux time. CONCLUSIONS: SPT, but not MPT, was associated with a significant increase in gastro-oesophageal reflux in infants with cystic fibrosis.

Continuous oscillation therapy improves the pulmonary outcome of intubated newborns: results of a prospective, randomized, controlled trial.

OBJECTIVES: To determine the effects of continuous postural changes produced by an oscillating bed on cardiopulmonary function and on the duration of endotracheal intubation and oxygen supplementation with large premature and term infants. DESIGN: A prospective, randomized, controlled trial. SETTING: Neonatal intensive care unit. PATIENTS: Nineteen 1-day-old newborns weighing > 1500 g with various respiratory diseases. INTERVENTIONS: The treatment group received continuous postural therapy on an oscillating bed; the control group received conventional frequency of manual postural changes. Both groups received physiotherapy. Patients were studied until they were extubated and oxygen supplementation was stopped. MEASUREMENTS AND MAIN RESULTS: Selected cardiopulmonary variables and ventilator settings during the first 6 hrs of study and the overall duration of endotracheal intubation and oxygen supplementation were determined. Oscillation therapy significantly decreased the duration of oxygen supplementation and had no adverse effects on cardiopulmonary variables. In a subgroup of infants with respiratory distress syndrome from prematurity or asphyxia, oscillation therapy also significantly shortened the duration of oxygen supplementation; a trend toward reduced duration of intubation was observed. CONCLUSIONS: Continuous postural changes using an oscillating bed reduced the duration of oxygen supplementation in infants with various respiratory disorders. Furthermore, this oscillation therapy was not associated with adverse cardiopulmonary or thermal complications.

Cardiac arrhythmias during postural drainage and chest percussion of critically ill patients.

In this study we determine the prevalence and type of arrhythmias that occur during postural drainage and chest percussion (PDP) of critically ill patients, and identify those patients who are most at risk of developing them. We monitored the vital signs and ECGs of 72 ICU patients during their initial PDP treatment. Eight patients (11.1 percent) had development of major arrhythmias, 18 (25 percent) had minor arrhythmias, and 46 (63.9 percent) had none. Increased age (p < 0.0001) and the presence of acute cardiac disorders (p < 0.001) were associated with increased risk of arrhythmias. Individuals experiencing major arrhythmias had a significantly decreased BP and respiratory rate with an increased heart rate during PDP. We conclude that arrhythmias are common during PDP of critically ill patients and recommend that ICU patients be carefully monitored during PDP. When considering PDP for older patients and patients with acute cardiac disease, physicians should carefully weigh the risk of arrhythmias against the benefits of this treatment.

Esophageal pH monitoring data during chest physiotherapy.

Sixty-three infants, aged from 1 to 4 months, were examined for gastroesophageal reflux (GER) using esophageal pH monitoring. Thirty were examined because of chronic vomiting, 21 were healthy controls examined for GER as part of a screening program for sudden infant death syndrome, and 12 had an acute respiratory disease (RD). The 24-h pH monitoring data were within normal ranges in 26 infants (20 controls, 2 babies with emesis, and 4 with RD). Data were abnormal in 37 infants (1 control, 28 infants with emesis, and 8 with RD). All babies were submitted during a fasting awake period to a 30-min chest physiotherapy session. In the three groups studied, the incidence of GER episodes detected by the pH probe was significantly higher during physiotherapy if compared (a) to the calculated mean incidence during a 30-min period of the 24-h investigation or (b) to the incidence during a fasting awake period such as that during which the physiotherapy was given (p less than 0.001; Wilcoxon rank-sum test). We conclude that chest physiotherapy significantly increases GER incidence. We therefore propose restricting chest physiotherapy to fasting periods. These data add to the confusion that already exists regarding the possible causal relationship between (acid) GER and respiratory disease.

Expectoration disturbances and bronchial obstruction.

UNLABELLED: Two methods for the efficacy evaluation of the respiratory tract clearance by cough, measuring the time of expectoration (Texp) of sputum mixed with hem-containing indicators after their inhalation were used in patients with bronchial obstruction. In the first method, the patients studied inhaled their own hemoglobin (Hb) and in the second one they inhaled a finely pulverized powder of hem-containing substances which were obtained from donor erythrocyte mass. 195 subjects were examined: 44 with intrinsic bronchial asthma (BA), 71 with obstructive bronchitis (OB) and 22 with purulent obstructive bronchitis (POB). Patients expectorating not less than 30 ml/day of sputum were selected. The control group consisted of 18 patients with non-obstructive bronchitis (NOB) and 40 healthy volunteers, nonsmokers. The sputum for analysis after the inhalation of the indicator in healthy persons was collected during coughing stimulated by inhaling a hypertonic solution (15% NaCl+1% NaHCO3). It was found that Texp depends on the form of illness (means +/- SEM): (1) with Hb technique, BA: 41.5 +/- 3.4 h; OB: 59.3 +/- 5.7 h and POB: 128.8 +/- 15.3 h and (2) with the powdered indicator technique, BA: 53.4 +/- 7.6 h; OB: 68.8 +/- 6.6 h and POB: 101.1 +/- 11.8 h. CONTROL GROUP: in patients with NOB, Texp measured with the Hb technique was 31.4 +/- 4.3 h and with the powdered indicator 30.0 +/- 10.3 h. In healthy volunteers, the presence of hem-containing substances in sputum after 36 h was not found.(ABSTRACT TRUNCATED AT 250 WORDS)

[Overdrainage in the treatment of hydrocephalus]. / L'hyperdrainage dans le traitement de l'hydrocéphalie.

In infants or children, hydrocephalus is usually the consequence of an obstacle in the cerebro-spinal fluid (CSF) pathways and is most frequently treated by the insertion of a ventriculo-peritoneal shunt (rarely ventriculo-atrial). The CSF flow through such a shunt is equal to the ratio of the difference (DP) between the CSF input and output pressures over the valve resistance. When the child is in the upright position, a DP increase occurs due to the height of the hydrostatic column between the inlet and the shunt outlet. Thus if the shunt drains correctly in the prone position, it overdrains in the upright position. As the CSF flow through the shunt in standing patients is higher than the CSF secretion, the excess fluid will be taken out of the ventricles, resulting in pericerebral collections, slit ventricles or post-shunt craniostenoses. Many different techniques have been proposed to reduce overdrainage. The Orbis-Sigma shunt was designed in the "Service des Enfants-Malades" precisely for this purpose. In the upright position this shunt becomes a flow regulator and thus reduces overdrainage. Its use has decreased by 2-fold the number of mechanical complications related to overdrainage.

Cerebrovascular status and Trendelenburg position in severe head injury.

The literature review revealed increasing sophistication of neuroscience nursing research since 1978. Conclusions of the papers reviewed have contributed to the acceptance as "fact" that nursing actions may increase ICP, but few have systematically studied effects upon cerebral perfusion pressure, the more critical variable. McQuillan's study (11) has examined the conflict between the goals of respiratory care and those of maintaining adequate cerebral perfusion, concluding that an intervention often discouraged for use with this patient group may in fact offer hope for reduction of complications. The methodology and results suggest that repeating the study would be both feasible and ethical.

Paresia diafragmática adquirida como complicación del drenaje de neumotórax por toracotomía cerrada / Diaphragmatic paresia acquired as complication of pneumothorax drainage by closed thoracotomy

La parálisis diafragmática traumática secundaria al drenaje pleural para la evacuación de un neumotórax hipertensivo es una rara complicación pero que debe ser tenida en cuenta ya que agrava la insuficiencia respiratoria del paciente, prolonga el tiempo de asistencia respiratoria e incrementa los riesgos relacionados a internaciones prolongadas. Es importante la comprobación de la ubicación del catéter en la radiografía post drenaje y la inmediata corrección de la misma en caso que ésta sea inadecuada. Si se comprueba paresia/parálisis diafragmática debe colocarse al paciente en Trendelenburg invertido. De persistir la parálisis la consulta quirúrgica determinará la oportunidad y beneficio de la plicatura.

Paresia diafragmática adquirida como complicación del drenaje de neumotórax por toracotomía cerrada / Diaphragmatic paresia acquired as complication of pneumothorax drainage by closed thoracotomy

La parálisis diafragmática traumática secundaria al drenaje pleural para la evacuación de un neumotórax hipertensivo es una rara complicación pero que debe ser tenida en cuenta ya que agrava la insuficiencia respiratoria del paciente, prolonga el tiempo de asistencia respiratoria e incrementa los riesgos relacionados a internaciones prolongadas. Es importante la comprobación de la ubicación del catéter en la radiografía post drenaje y la inmediata corrección de la misma en caso que ésta sea inadecuada. Si se comprueba paresia/parálisis diafragmática debe colocarse al paciente en Trendelenburg invertido. De persistir la parálisis la consulta quirúrgica determinará la oportunidad y beneficio de la plicatura.(AU)