AN AGGRESSIVE CHEST PHYSIOTHERAPY TECHNIQUE IN ACUTE LOBAR COLLAPSE IN ELEVEN PATIENTS WITH AN ARTIFICIAL AIRWAY
DAVID F. MATUSZAK PhD. RRT HENRI NAMMOUR MD. F.C.C.P. MARYLAND GENERAL HOSPITAL BALTIMORE, MARYLAND
General clinical practice suggests the performance of CPT as percussion and postural drainage q4hr for 24-48 hours before alternative therapy is employed in acute lobar collapse. An alternative approach was utilized in patients with artificial airways (endotracheal /tracheostomy tubes) using a combination of ipsilateral hyperinflation, percussion and postural drainage with bronchial lavage. The purposes of the technique were to maintain patient safety, decrease therapy utilization time with associated cost savings, normalize pulmonary mechanics and prevent bronchoscopy. Eleven patients with radiograhic evidence of acute lobar or greater collapse assumed due to mucoidal plugging were administered this approach with permission of the Medical Director. The patients were appropriately positioned and placed in trendelenburg. Increased tidal volumes to the range of sigh breaths (1.5´ Vt) were utilized with PEEP application at 5 to 10cm/H2O. PAP was maintained as close as possible to £ 40 torr. Respiratory rates were established at 8 -12/min. The FIO2 was increased as needed to maintain an SPO2 ³ 95% throughout the procedure. Breaths were administered either by mechanical or manual ventilator. Percussion was performed to the affected region no less than 20 minutes with suctioning performed as indicated (coughing, rhonchi, increased PAP) through the artificial airway. If the airway secretions were minimal in volume or moderately tenacious bronchial lavage with a 4.0% solution of NaHCO3 was utilized in 10 -15 cc aliquots. Patients were monitored utilizing RR, continuous SpO2, Cst, Raw and PAP measurements pre/post when possible, breath sounds, cardiovascular stability, spontaneous Tv and pre/post radiographs. The results demonstrated in all eleven patients essentially complete reexpansion of the affected area. Post procedure the SpO2 moderately increased on previously established FIO2's, no significant changes in Raw, increased compliance, increased aeration throughout the affected area, increased spontaneous Tv on previously established PSV, spontaneous respiratory rates did not significantly change. This modification of traditional CPT strongly suggests effectiveness and safety as there were no adverse effects or complications (volutrauma, airway plugging, decreased SpO2, severe cardiac instability, change in mental status, or respiratory distress). Three patients eventually were bronchoscoped due to recollapse of the affected region. This one time procedure lasted approximately a continuous hour. Cost savings are institutionally related to total bronchoscopic costs and/or the institutional charges for multiple CPT, suctioning and therapist times.