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Indian Journal of Physiotherapy and Occupational Therapy

Chest physiotherapy in post extubation atelectasis in neonates - A case study

Author(s): Narasimman S, Varadaraj Shenoy K, Natraj R, Anita Maria Andrade

Vol. 2, No. 3 (2008-07 - 2008-09)

Narasimman S1, Varadaraj Shenoy K2, Natraj R3, Anita Maria Andrade4

1Asst. Professor, Dept of Physiotherapy, 2Professor, HOD, Dept of Pediatrics, 3Resident, Dept. of Pediatrics, 4Post Graduate Student, Dept of Physiotherapy, Father Muller Medical College, Mangalore

Abstract

Chest physiotherapy is often used to correct post extubation atelectasis in the neonatal intensive care units. This case study explains the efficacy of carefully administered chest physiotherapy in a 2 day old neonate, who developed post extubation right upper lobe collapse followed by pneumonia. Chest physiotherapy was administered every three hours followed by gentle oral and nasal suction. Chest X ray revealed full expansion of the lung after a day of chest physio physiotherapy.

Key Words: Chest Physiotherapy, Atelectasis, postextubatin, Neonates

Introduction

Literature states that about 10 to 50% of the neonates develop atelectasis after extubation1. The risk of pulmonary complications is more in neonates due to immaturity of the respiratory system. Chest physiotherapy is often used in critically ill neonates in the neonatal intensive care unit. The aim of chest physiotherapy in the newborn is to increase the clearance of lung secretions and maintain the lung expansion2,3. This case study describes the efficacy of chest physiotherapy in correcting post extubation atelectasis.

History

A male child 2 days of age born to a primi mother by LSCS was admitted in the NICU with a history of respiratory distress. The Baby had cried immediately after birth. Apgar score was not known since the child was not born in our hospital. Immediate chest X-ray suggested pneumonia and the sepsis workup were positive. Since the baby was not maintaining saturation , he was intubated and connected to the mechanical ventilator on P-CMV mode with respiratory rate 35 breath per minute and FiO2 60%. On day four the baby was weaned from the mechanical ventilator after normalization of the ABG report and clinical improvement. Baby was then extubated. The post extubation X ray revealed right upper lobe collapse and the baby was referred for physiotherapy. Antibiotics were continued thorough out the course.

Physiotherapy Assessment

On observation, baby was receiving 8 liters of Oxygen through hood. SpO2 was 92% with respiratory rate 40 per minute.

On auscultation, absence of air entry in the right upper zone was noticed. ABG report showed reduced Oxygenation (PaO2 86 mmHg)

X-Ray X-Ray

Chest Physiotherapy

Prior to chest physiotherapy base line heart rate, respiratory rate, and oxygen saturation was noted during every session. The baby was held in up right and right lateral position. Gentle percussion using the face mask was given along with vibrations with minimal compressive pressure. The Baby’s head was supported by the therapist’s free hand during the physiotherapy session. Gentle oral and nasal suction was done after 20 minutes of chest physiotherapy. Every hourly the position of the baby was changed. Same physiotherapy was continued every three hourly during the day time. Gentle upper intercostal stretching was added. All the details of the treatment were documented. Repeat chest X ray was done on the next day which showed expansion of the right lower lobe.

Discussion

The aim of chest physiotherapy in this baby was to re expand the atelectatic lung and to improve the lung expansion. Prior to each session of physiotherapy the vital parameters were noted and were observed during the entire course of physiotherapy to ensure that there were no adverse effects. A Cochrane systematic review by 4Flenady V. J, and coauthor revealed only 4 randomized controlled trails. They concluded that there was insuffient data to comment on the effects of chest physiotherapy in post extubation atelectasis. They added that active chest physiotherapy reduces the rate of post extubation atelectasis. In this case utmost care was taken in order to avoid complications and chest physiotherapy was given only after consultation with the resident pediatrician. The protocol given by Department of Neonatal Medicine, Royal Prince Alfred Hospital5 also suggests that careful administration of chest physiotherapy could be useful in preventing and correcting post extubation atelectasis. Some studies revealed that chest physiotherapy improved oxygenation, and reduced airway resistance. These studies were only observational.6,7

Conclusion

Though there is limited evidence for the efficacy of chest physiotherapy in correcting post extubation atelectasis, Chest physiotherapy could be considered as an adjunct in the management of post extubation atelectasis. In view of cost effectiveness, careful administration of chest physiotherapy could be effective in correcting post extubation atelectasis.

References

  1. Finner NN, Moriartey RR, Boyd J, Philips HJ, Stewart AR, Ulan O. “Post extubation atelectasis: a retrospective review and a prospective controlled study”. J Pediatric 1979;94:110-3
  2. Krause MF, Hoehn T “Efficiency and risk of chest physiotherapy in newborn review of literature” Klin Paediatr 1999 Jan Feb; 211(1): 11-7 ( Abstract)
  3. Colin Wallis, Ammani Prasad “Who needs chest physiotherapy? Moving from anecdote to evidence” Arch Dis Child 1999; 80: 393 397
  4. Flenady VJ, Gray PH “Chest physiotherapy for preventing morbidity in being extubated from mechanical ventilation”. The Cochrane Database of systematic Reviews 2002, Issue CD 000283:10.1002/ 14651858.CD000283.
  5. Department of Neonatal Medicine Protocol Book, Royal Prince Alfred hospital, Chest Physiotherapy. http. // www. cs.nsw.gov.au
  6. Tudehope D, Bagley C. “Techniques of Physiotherapy in intubated babies with the respiratory syndrome”. Aust. Paediatr. J 1980; 16: 226 228
  7. Dall’ Alba P, Burns Y. “The relationship between arterial blood gases and removal of airway secretions in neonates”. Physiotherapy theory and practice 1990:10: 107- 116
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