EXPERT SPEAKS: A Neonatologist's Perspective On The Role Of Physiotherapy In NICU - DR. S. M.DHADED

Physiotherapist is an important team member in the management of a high risk neonate especially those with severe respiratory and neurological complications. Our experience with babies receiving Chest physiotherapy in the NICU has shown to be beneficial in terms of early weaning from ventilator, improved oxygenation and decrease length of stay in hospital. This in turn has been beneficial for parents in terms of cost and early recovery which decreases the stress level of parents. We have observed babies with severe respiratory problems like pneumonia survive with effective chest physiotherapy. It has been useful in babies with erb’s palsy, babies with feeding difficulty and also in preventing joint stiffness and contractures due to immobilization. Chest Physiotherapy has to be individualized and need based rather than as routine program in NICU babies. Chest PT should not be given just during day time as routine but if baby requires should be given at night or on call basis. Arterial blood gases and chest X-rays have improved after practice of night duty for physiotherapists in NICU in our hospital setting. Physiotherapy is frequently used in neonatal unit apart from respiratory management. The techniques have possible detrimental effects as a consequence should not be used routinely.

BRONCHOPULMONARY HYGIENE: The clinician must keep the chest clear of secretions in the conducting airway and also must keep artificial airway patent by ensuring proper humidification and suctioning of the endotracheal tube. These procedures are done as required but normally are performed immediately followed by administration of aerosolized medications. Chest physiotherapy (CPT) involving postural drainage in concert with percussion or vibration has been shown to be beneficial in removing secretions and preventing atelectasis in recently extubated neonates. It has also been shown to remove secretions in intubated baby and improve oxygenation after completion of CPT. Its use should be individualized as use of these techniques has been associated with variety of negative effect especially in infants weighing less than 1000 gms. Positioning of the patient for postural drainage involves use of various positions in which the different mainstem bronchi are positioned vertically so that drainage from the smaller bronchi moves into the larger bronchi (Annexure I). The two forces at work during this procedure are gravity and air flow. Any area of the bronchial tree that is to be drained (with exception of medial basal segment) must be upper most. These position may not be possible for implementation in critically ill babies, who have chest tube, endotracheal tube or at risk for intraventricular hemorrhage. Significant oxygen desaturation during procedure should cause the care taker to pause and initiate measures necessary to correct hypoxemia.

PERCUSSION AND VIBRATION: Two types of hand pressure can be applied to the neonatal chest to expedite drainage: percussion and vibration. Percussion can be performed with small plastic cups with padded rims or with soft circular masks with their adapters plugged, so that air pockets are maintained. The chest is percussed over the area to be drained for 1 – 2 minutes. Percussion may be reserved for infants who weigh more than 1500 gms and are older than 2 weeks because of potential risk for intraventricular hemorrhage. The traditional view of the vibration is that it is effective only during exhalation because it causes secretions to move from the periphery of lung with the outflow of air. For vibration the wrist is extended and arm muscles are contracted in a manner similar to that used for isometric exercise. The placement of fingers flat against chest walls of infant suffices. A light touch with rapidly vibrating fingers have been considered effective in mobilizing secretion in neonates. Vibration can be done with a padded electric toothbrush, a small hand vibrator or a commercially available pulmonary vibrator. Vibration is tolerated by a greater number of patients than is percussion. The duration of vibration therapy is subject to the infants tolerance.

PRECAUTION DURING CHEST PERCUSSION AND VIBRATION: Percussion with hand or fingertips should be performed over clothing or a sheet to reduce the risk of skin damage. Face mask should have soft plastic cuff. Percussion or vibration should not be applied over surgical incisions and their use should be avoided in infants with osteoporosis and those born very preterm. Percussion and Vibration have been implicated as a cause of rib fracture. Percussion is probably better tolerated and more useful than vibrations in preterm infants.

ROUTINE VERSUS INDIVIDUALISED PHYSIOTHERAPY: A study suggested that routine physiotherapy was not well tolerated by certain individuals. Infants with median gestation of 32 weeks tolerated physiotherapy better at 5 than at 3 days of age. Routine physiotherapy in post cardiac surgery was associated with more atelectasis than breathing exercise, coughing or suction alone.

COMPLICATIONS OF PHYSIOTHERAPY: Chest Physiotherapy has been associated with a number of important complications. These include intraventricular hemorrhage, multiple rib fracture and generalized periosteal reaction. Physiotherapy may also increase the risk of porencephaly. It is suggested that head movement during physiotherapy might be responsible for the lesion. Physiotherapy should never be undertaken routinely, but only when there is clear indication and baby in a fit state.  

INDICATIONS FOR PHYSIOTHERAPY: 1) Lobar / lung collapse 2) Meconium aspiration 3) Aspiration of feed / vomitus 4) Pneumonia 5) Post surgery 6) Chronic lung disease 6) Peri - extubation

CONTRAINDICATIONS FOR PHYSIOTHERAPY: 1) Respiratory distress syndrome 2) Pulmonary hemorrhage 3) Treacheo and bronchomalacia

We would like to share a case report in our hospital which showed marked improvement after chest Physiotherapy

Case report on effect of Chest Physiotherapy  in a baby on mechanical ventilator

A 3 month old premature infant presented to the neonatal intensive care unit with respiratory distress and aspiration pneumonia. Baby was on mechanical ventilator, simv mode, fio2- 94%, sao2- 92% pressure- 21 and breaths/min- 25. 6 antibiotics ( ciprofloxacin, netilimycin, metronidazole, inipencium, tobramycin, intralipiz) digoxin, fentayl infusion, rantac, asthalin and mucomix were being administered. Intrathecal surfactant was administered twice and baby received chest physiotherapy 2 times a day (between 9-5), as followed by the hospital protocol, but baby was unable to maintain saturation. Fio2 was increased to 100% pressure and breaths/min were also increased by 2 each, following which frequency of cpt increased and regular on call physical therapy was started along with routine supportive care. Abg’s and chest x-rays were used as outcome measures. CPT included tenting followed by vibrations and lung squeeze technique. Gentle oral nasal suction followed by et suctioning. Postural drainage position was maintained for 20 minutes. Positioning of the child was carried on after every session. Baseline measurements included pulse rate, respiratory rate, oxygen saturation, ventilator settings along with abg scores.  During each therapy session these values were noted before and after the procedure. After 3 days of on call cpt, abgs started stabilizing and lung fields cleared. Child could be weaned off from the ventilator within a week.




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