IJCRR - Vol 02 Issue 01, January, 2010
Date of Publication: 30-Nov--0001
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CHEST PHYSIOTHERAPY FOR ATELECTASIS IN NEONATE WITH PULMONARY HEMORRHAGE- A CASE REPORT
Author: Vaishali, Jithendra Kumar, V. Prem, Sushmitha.N, Shailendra Lende
Abstract:Chest physiotherapy is often used to correct Atelectasis in the neonatal intensive care unit. This case report
describes about the importance and effectiveness of chest physiotherapy in a 24 days old neonate who presented with pulmonary haemorrhage and right upper lobe collapse. Chest physiotherapy was
administered every four hours for three days. Chest X ray revealed full expansion after three days of
Chest physiotherapy (CPT) has been used in many neonatal nurseries around the world to improve airway clearance and treat lung collapse; however, the evidence to support its use has been conflicting. There is not enough evidence to determine whether active chest physiotherapy is beneficial or harmful in neonates on mechanical ventilation. Babies who require mechanical ventilation are at risk of lung collapse from increased secretions. Chest physiotherapy (patting or vibrating the chest) is used to improve clearance of secretions from the airway to try to prevent lung collapse1 .
Acute lobar Atelectasis is a common problem in infants receiving mechanical ventilation2 . Atelectasis contributes to morbidity in the neonatal nursery, necessitating prolongation of oxygen administration3 . In the neonatal population, CPT is used to prevent and treat lung collapse and consolidation. CPT in the neonates consists of a variety of techniques that include positioning, active techniques such as percussion and vibration, and suction1 .
Case report - A 24 day old full term female baby admitted to the hospital on 5-07-2008, with the complaints of bleeding from the nose, scanty in quantity for about half an hour. There was no history of fall, cough, breathlessness or seizures. Baby with a normal natal history, normal vaginal delivery, birth weight 2.8 kgs, with APGAR score 8 at first minute.
Baby was diagnosed to have pulmonary haemorrhage and respiratory distress by the Paediatrician. Chest x-ray on the day of admission showed non homogenous opacity and infiltrates suggestive of pulmonary haemorrhage (picture 1). CT scan confirmed the diagnosis of diffuse alveolar pulmonary haemorrhage.
Baby was mechanically ventilated on the same day with the following settings: PSIMV, RR 40 per min, FiO2 – 50%, PEEP- 6, Peak inspiratory pressure (PIP)- 22, oxygen saturation-94%, and ABG showed uncompensated respiratory alkalosis. Haemoglobin-16.2 gm%, Total count-12060, platelets-2.51 lakhs, WBCs-high, Calcium-9.0, SGPT-51, Creatinine-0.3, CRP-negative, stool for occult blood- positive, Prothrombin time- test-13.6, control-13.5, INR-1.
The next day (i.e.) on 6-07-2008, the ventilatory settings were P-SIMV, FiO2 – 30%, PEEP- 6, Flow rate- 7, PIP- 20, oxygen saturation- 95%.Heart rate 156 /min. Spontaneous respiratory rate was 40/ min. On auscultation, absence of breath sounds in right upper zone. ABG report showed respiratory alkalosis. Child was treated with IV antibiotics and supportive measures were given. In view of repeat chest x-ray on the next day which showed right upper lobe collapse and pneumonitis, the baby was referred for physiotherapy.
The baby was given chest physiotherapy from 6-07-2008 at 11 am. On observation, child skin colour was pink, no cyanosis, diminished chest movements on the right upper zone anteriorly, shallow breathing with respiratory rate 40/min. on palpation right upper zone chest asymmetry, no tracheal deviation, and positive tactile fremitus. On auscultation, diminished breath sounds in the right upper zone with occasional crepitations heard during expiration. Parameters were noted before and after chest physiotherapy sessions. The baby was positioned in upright with the help of towel rolls for 25 minutes. Proprioceptive neuromuscular facilitation (PNF) was given by tactile stimulation for five minutes on bare chest (tactile stimulation is a technique of placing therapist?s forefingers on baby?s chest i.e. on right upper zone).Gentle vibrations were given on the right upper zone with the help of three fingers (three finger technique i.e. with index, middle and ring fingers kept on the baby?s bare chest and vibrations were given for one minute during alternate expiration as the rate was high). Five sets of vibrations with one minute durations were carried out. After PNF for five minutes and vibrations for five minutes in the upright position, baby was positioned in supine, endotracheal (ET) and oral suctioning was done. The suctioning was terminated following no secretion removal from ET suctioning. All the parameters were noted. Five minutes post suction, the baby was positioned in the same upright position and PNF was given for five minutes. Position was maintained for two hours. Physiotherapy was given every six hourly. Same procedure was carried out six hourly for three days. On third day, there was an improvement in chest expansion, no asymmetry, decreased respiratory rate, improved breath sounds on right upper zone with expansion of right upper zone on chest x ray (picture 2). The ventilator parameters on the same day were as follows, P-SIMV, FiO2 30%, RR 26, HR 138/min, SpO2 100%, PIP-20, flow rate 4Lit. The baby was extubated the next day and was put on 2 litres of oxygen through face mask
Picture 2: x ray showing re expansion of the lung on third day of physiotherapy intervention
The aim of chest physiotherapy in this baby with pulmonary haemorrhage was to re expand the atelectatic lung and to improve the lung expansion. Positioning was used as it helps in optimizing oxygen transport through its effects of improving ventilation/perfusion (V/Q) matching, increasing lung volumes, reducing the work of breathing, minimizing the work of the heart, and enhancing mucociliary clearance. Upright position dimension of the chest wall is greatest, and the compression of heart and lungs is minimized. The Vibration technique used by us increased clearance of airway secretions by the transmission of an energy wave through the chest wall. Endotracheal Suctioning was used with the aim of removing secretions from the central airways and stimulating cough reflex. The proprioceptive and tactile stimuli selected by us produced expansion of the thoracic cage, reduced asymmetry and decreased respiratory ratewas used in this patient to maximize lung volumes and capacities, the vertical gravitational gradient is maximal, the anteroposterior.
Future studies with large sample size and randomized trials are needed.
Careful administration of chest physiotherapy can re expand the atelectatic lung in a pulmonary haemorrhage neonate.
1. Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Review) Hough JL, Flenady V, Johnston L, Woodgate PG, The Cochrane Library 2008, Issue 3
2. Who needs chest physiotherapy? Moving from anecdote to evidence, Colin Wallis and Ammani Prasad, Arch. Dis. Child. 1999;80;393-397
3. Ehrlich R, Arnon RG. The intermittent endotracheal intubation technique for the treatment of recurrent atelectasis. Pediatrics 1972; 50:144–7
4. Jan Stephen Tecklin: Respiratory Failure in the Neonate. In Scot Irwin, Jan Stephen Tecklin, Cardiopulmonary Physical Therapy a Guide to Practice, ed 4, 2004, Mosby.
5. Jennifer A Pryor, Barbara A Webber Physiotherapy techniques. In: Jennifer A Pryor, S Ammani Prasad. Physiotherapy for respiratory and cardiac problems, adults and pediatrics. 3 rd edition, Elsevier, pg 161-234.
6. Elizabeth Dean Body positioning. In: Cardiovascular and Pulmonary Physical Therapy, Evidence and Practice. 4 th edition, Elsevier, pg 307-321.