The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts

Evaluation Airway Clearance Procedures and Clinical Effectiveness in a Pediatric Intensive Care Setting


Kathleen Deakins RRT-NPS, Michael Tracy RRT-NPS, Timothy Myers RRT-NPS.
Rainbow Babies & Children's Hospital. Cleveland, OH.

Introduction: Airway clearance techniques (ACT) are non-invasive methods used to assist in the removal of secretions from the lungs, and improve oxygenation and ventilation when the mucociliary transport mechanism is impaired during acute or chronic illness. ACT are often implemented in the ICU as adjunctive therapy to improve effectiveness of cough, mobilize and facilitate removal of secretions, and promote the resolution of atelectasis. A quality improvement project was initiated to evaluate the current process of determining appropriate ACT based on patient diagnosis, a set of predetermined indications, contraindications, and resulting clinical outcomes.

Methods
: The Respiratory Department was asked to evaluate trends in ordering ACT, ordering physician services, and disease-specific indications for patients in the PICU. During a three-month period, 62 PICU patients received physician ordered ACT. Daily ACT was documented by staff members on a ACT sheet and evaluated by two respiratory therapists for the following data: age, weight, diagnosis, type of treatment ordered, indication and contraindications, duration of treatment, outcomes and other respiratory support required. Indications were defined as; ineffective cough, secretion retention, documented atelectasis or infiltrate on chest radiograph and not indicated. Contraindications were evaluated and noted as therapy-specific. Clinical outcomes established were: improved cough, resolved infiltrate or atelectasis, improved mobilization or reduction in secretions or no change. Data were analyzed as percentages of frequencies.

RESULTS:
62 patients received a total of 70 ACT that resulted in 320 days of therapy (average 4.72 days). Service Line breakdown for ACT was 82.9% (58 patients) for Critical Care (CC) and 17.1% (12 patients) for Cardiothoracic Surgery (CTS). The overall percentage of procedures order were as follows: chest physiotherapy (CPT) 50%, high-frequency vest 10%, vibes 1.4%, intrapulmonary percussive ventilation (IPV) 28.6%, and PEP Therapy 10%. Indications for ACT was apparent in 88% of patients ordered on therapy. Positive clinical outcomes by service line were: 56.6% for CC and 25% for CTS. Approximately one-third of the time, ACT that target specific clinical indications demonstrate positive outcomes toward those indications. An additional 20% of the ordered ACT produced a non-targeted clinical (secondary) outcome that was not initially indicated. Fifty percent of ACT ordered resulted in no detectable improvement in clinical outcomes. These procedures account for 129 days of schedule therapy or approximately 40% of the total days of ACT. The tables below displays indicated ACT to resulting outcomes (target or secondary) and ordered therapies that produced no change in any clinical outcomes.

Resulting Outcomes No Change in Outcomes
Indications Targeted Outcome Secondary Outcome No Change Technique % of Total Procedure Ordered
Ineffective Cough 33.3% 16.7% 50% CPT (n=24) 68.6%
Secretions 33.3% 25% 41.7% Vest (n=5) 71.4%
Collapse/Atelectasis 34.1% 21.9% 43.9% Vibes (n=1) 100%
No Indication   11.1% 88.9% IPV (n=3) 20.0%
        PEP (n=2) 28.6%


Conclusions: The utilization of chest physiotherapy needs to be more heavily scrutinized as it frequently results in no detectable improvement in patient outcomes. The use of PEP therapy in non-intubated patients with ineffective cough or retained secretions and IPV therapy for patients with atelectasis or collapse should be protocolized as the preferred method of airway clearance in these patient populations.

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