The Somatic Connection  |   July 2013
Multimodal Chest Physiotherapy Is Beneficial for Patients Receiving Ventilation
Author Affiliations
  • Michael A. Seffinger, DO
    Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California
Article Information
The Somatic Connection   |   July 2013
Multimodal Chest Physiotherapy Is Beneficial for Patients Receiving Ventilation
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 573-575. doi:10.7556/jaoa.2013.013
The Journal of the American Osteopathic Association, July 2013, Vol. 113, 573-575. doi:10.7556/jaoa.2013.013
Pattanshetty RB, Gaude GS. Effect of multimodality chest physiotherapy on the rate of recovery and prevention of complications in patients with mechanical ventilation: a prospective study in medical and surgical intensive care units. Indian J Med Sci. 2011;65(5):175-185. doi:10.4103/0019-5359.106608.  
A recent Cochrane review1 did not find sufficient evidence to recommend chest physiotherapy for hospitalized patients with pneumonia, even though pneumonia is one of the causes of respiratory failure and the subsequent need for mechanical ventilation.2 The findings from several osteopathic clinical trials, including the Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE),2 which was not included in the review, support the use of osteopathic manipulative treatment (OMT) in addition to standard therapy to prevent the need for ventilation for elderly hospitalized patients with pneumonia. However, a paucity of osteopathic medical literature exists on the application of OMT for patients already receiving mechanical ventilation for respiratory failure in hospital intensive care units. It is well known that, of all hospitalized patients, those receiving mechanical ventilation have an increased risk of morbidity (including pneumonia, atelectasis, and sputum retention), which makes it difficult to wean patients from the ventilator and increases the risk of death. This study, performed by critical care clinical researchers at a tertiary care referral hospital in India, demonstrates the positive effects of multimodality chest physiotherapy for the prevention of complications in adults receiving ventilation and their rates of recovery. 
A total of 200 adult patients who were receiving ventilation were enrolled in the study and randomly assigned to either an experimental group or a control group. Underlying disease was not taken into consideration. Patients were excluded if they had hemodynamic instability, had just undergone coronary artery bypass grafting, were receiving bedside dialysis, had untreated pneumothorax, or had either a condition that contraindicated raising the head of the bed or any condition for which chest physiotherapy was considered to be contraindicated. After 13 patients in the study group and 14 patients in the control group withdrew from the study, data on 173 participants were available for final analysis. The 86 patients in the control group (67 men, 19 women; mean [standard deviation (SD)] age, 49.7 [16.21] years) received manual hyperinflation (MH) and suctioning, whereas the 87 patients in the study group (64 men, 23 women; mean [SD] age, 49.4 [16.13] years) were treated with multimodality chest physiotherapy. Both groups received their interventions twice daily until extubation was performed. 
Chest physiotherapy consisted of suctioning of secretions before and after chest vibrations and MH followed by positioning (head of the bed was elevated 30° to 45°). The control group was treated with MH and suctioning only. Systematic reviews of the literature have not recommended the use of MH alone as being beneficial for patients receiving ventilation.3 Pattanshetty and Gaude4(p71) provided details on the protocol for this intervention, as follows:

A 2.0-L reusable manual resuscitator (Hudson RCI-nondisposable and autoclavable (silicone) was used to deliver the MH breaths. It was connected to a flow of 100% oxygen at 15 L/min. The resuscitator was slowly compressed with both hands, and an inspiratory breath was maintained for 3-5 s at the end of half of the resuscitator and then it was kept completely pressed. The resuscitator expiration was maintained at passive mode and unobstructed to facilitate expiratory flow with no positive end expiratory pressure applied. Sufficient time was allowed for the resuscitator to fill completely prior to the next breath. The MH procedure was carried out daily at the rate of 8-13 breaths/min for a period of 20 min at each session twice a day (9.30 a.m. and 3.30 p.m.).

The chest vibration protocol used in this study was also described in the same article,4(p71-72) as follows:

Chest vibration defined as the manual application of a fine oscillatory movement combined with compression to the patient's chest wall which helps to loosen and mobilize the secretions was given prior to suctioning. The patient was positioned in supine, and then randomly positioned either to right or left side lying in the bed. The principal investigator placed her hands anteriorly and laterally on the patient's chest with fingers placed in the inter-rib space, and then applied vibrations in the expiratory phase of breathing. This technique was repeated thrice in each of the three zones, i.e., upper zone, middle zone, and lower zone of the chest.

In a study published in 2012,5 chest vibrations were determined to be beneficial in children receiving ventilation. These maneuvers appear to be similar to the OMT technique known as thoracic lymphatic pump and may be similar to rib raising, procedures that were both used in the MOPSE trial. The purposes of these manual procedures are slightly different in that chest vibrations are used to loosen secretions, whereas the lymphatic pump is designed to enhance lymphatic drainage and rib raising allegedly increases chest wall compliance and is intended to alter sympathetic activity. 
The outcomes that were measured included successful weaning from ventilation, recovery and discharge from the hospital, death, total length of stay while receiving ventilation, discharge from the hospital against medical advice, and any complications that occurred during mechanical ventilation. 
The rate of recovery was higher in the study group (58 patients [66.7%]) compared with the control group (28 patients [32.6%]) (P=.000; χ2=22.577). Complication rates were higher in the control group (53 patients [61.6%]) compared with the study group (23 patients [26.4%]) (P=.000). Although the 2010 publication by these researchers4 supported the conclusion that multimodal chest physiotherapy prevented ventilator-associated pneumonia, this study did not. In addition, the mean (standard deviation) length of stay in the hospital was longer for participants in the study group (16 [9.40] days) than for participants in the control group (12.8 [6.12] days) (P=.000). Twenty-four patients (27.6%) in the study group died compared with 39 patients (45.3%) in the control group. Five participants (5.7%) in the study group left the hospital against medical advice, whereas more than 3 times that number (17 patients [19.8%]) in the control group left against medical advice. 
Although not all outcome measures favored multimodality chest physiotherapy, this therapy seems to be a safe protocol that can improve clinical outcomes in patients receiving ventilation. Whether these physiotherapy maneuvers have the same, better, or worse impact on clinical outcomes than the OMT procedures that were used in the MOPSE study2 is yet to be determined. Further clinical trials assessing comparative effectiveness are warranted. 
Yang M, Yan Y, Yin Xet al. Chest physiotherapy for pneumonia in adults. Cochrane Database Syst Rev. 2013;(2):CD006338. doi:10.1002/14651858.CD006338.pub3.
Noll DR, Degenhardt BF, Morley TFet al. Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial. Osteopath Med Prim Care. 2010;4:2. Accessed May 30, 2013.
Paulus F, Binnekade JM, Vroom MB, Schultz MJ. Benefits and risks of manual hyperinflation in intubated and mechanically ventilated intensive care unit patients: a systematic review. Crit Care. 2012;16(4):R145. [CrossRef] [PubMed]
Pattanshetty RB, Gaude GS. Effect of multimodality chest physiotherapy in prevention of ventilator-associated pneumonia: a randomized clinical trial. Indian J Crit Care Med. 2010;14(2):70-76. doi:10.4103/0972-5229.68218. [CrossRef] [PubMed]
Gregson RK, Shannon H, Stocks J, Cole TJ, Peters MJ, Main E. The unique contribution of manual chest compression-vibrations to airflow during physiotherapy in sedated, fully ventilated children. Pediatr Crit Care Med. 2012;13(2):e97-e102. doi:10.1097/PCC.0b013e3182230f5a. [CrossRef] [PubMed]