ROLE OF PHYSIOTHERAPY

IN A
NEONATAL INTENSIVE CARE UNIT
CONTENTS

1 .INTRODUCTION

2. HISTORICAL BACKGROUND

3. ANATOMY AND PHSIOLOGY

4. INDICATIONS FOR RESPIRATORY PHYSIOTHERAPY

5. TECHNIQUES OF PHYSIOTHERAPY

6. EXTUBATIONS

7. ENVIORNMENTAL STIMULATION

8. ORTHOPEDIC AND MUSCULOSKELETAL PROBLEMS

9. CONCLUSION

10. REFERENCES
INTRODUCTION
 1 INTRODUCTION
the role of physiotherapy in the neonatal intensive care unit has historically deen
mainly associated with the care of the neonates lungs. Postural drainage coupled with
perpussion, vibrations and suction are all used in physiotherapy management of
neonatal respiratory disorders.

At monash medical centre all elective extubations are

performed by the physiotherapist in accordance with neonatal units protocol: this
includes four hourly respiration physiotherapy for the first 24 hours after extubation
to ensure that post-extubations atelectasis doesn’t not occur .in addition to respiratory
care, the physiotherapist is also engaged in the assessment and management of
neonates with either neurological or musculoskeletal disorders.

Over the last decade physiotherapy has become an

acknowledged and often integral part of the management of new born infants in
neonatal intensive care units around the world .it is well established practice to refer
sick neonates with respiratory problems for physiotherapy is also indicated in neonates
with both neurological and orthopaedic problems.

At monash medical centre the physiotherapist is attached

to the neonatal intensive care unit on a full-time basis and the service is provided seven
days a week.
 Historical background
One of the earliest published clinical studies on the effect of respiratory physiotherapy
on the neonate was undertaken by Holloway et al in 1969. They noted that there was
wide alveolar to arterial oxygen pressure gradient and failure to maintain normal
arterial oxygenation among patients being ventilated on air by intermittent positive
pressure respiration (IPPR).

The authors hypothesized that it was possible to improve

oxygenation by opening up areas of atelectasis or removing secretions which block
bronchi and that one method of doing this was by means of respiratory physiotherapy.
Subsequently a research study was devised and undertaken to test this hypothesis.

The sample size of this study consisted of 51 babies in total

and all were given IPPR via cuffed trachcostomy.one group was used to control group,
another was hyperinflation only

Two significant findings were reported:

(1) Partial pressure of arterial oxygen (pO2) dropped significantly after respiratory
physiotherapy and took one hour to return to normal.

(2) Neither physiotherapy, nor hyperinflation plus physiotherapy restored arterial

pO2 to normal.
In retrospect many criticisms can be directed at this particular study. For example all
infants in the sample were paralysed with curare and all were mechanically ventilated
via a tracheostomy tube, neither of these being routine practise today. All infants were
ventilated with air only and no supplemental oxygen was used. In fact the team
concluded the study by advising that all ventilated infants be given oxygen during
physiotherapy , but did not make any recommendation about ensuring adequate
arterial oxygenation at all other times with the judicious use of supplemental oxygen

During the next seven to eight years very little material was
published relating to the topic of respiratory physiotherapy in the neonatal unit.
However, in the late seventies interest in the area was renewed and material related to
the topic began to appear around the world.

A study designed to measure accurately the amount of

secretions removed with respiratory physiotherapy was conducted by etches and Scott
in 1978. In the same year finer and Boyd designed a controlled study to assess the effect
of respiratory physiotherapy on preterm In facts .

Finer et al followed up the previous study with another later

in the same year, this time studying the effects of postural drainage alone versus
postural drainage and percussion.

In 1979 Curran and Kachoyeanos attempted to determined

the most effective means of administering respiratory physiotherapy

Tudehope and Bagley in 1980 set up a controlled study to assess the effectiveness of
various physiotherapy techniques.
ANATOMY
AND
PHYSIOLOGY
 ANATOMY AND PHYSIOLOGY

 Prior to discussing various respiration physiotherapy techniques in detail a

brief discussion of the anatomic and physiologic differences between adults
and neonates is warranted.

 A new born has a high larynx enabling the epiglottis to guide the larynx up
behind the soft palate to produce direct airway from the nasal cavity to the
lungs .this causes neonates to the obligatory nose breathers .they are able also
to simultaneously breathe and swallow until two to three months of age (pang
and mellins 1975).

 The ribs of the new born are positioned horizontally and the intercostal
muscles are weak ,resulting in a predominantly abdominal or Dia-
phragmactic pattern of breathing.

 The lungs of neonate are less compliant than those of an adult, however the
thoracic wall is more compliant due to cartilaginous nature of the ribs and
lack of intercostal muscle strength. This difference can lead to an increase in
both airways resistance and obstruction. The narrow diameter of the infants
airway and a weak or absent cough reflex can also lead to airways
obstruction.

 The new born or premature infants is highly susceptible to diaphragm fatigue

and compensates for respiratory difficulty by increasing the rate rather than
the depth of ventilation

 The cough reflex in a premature baby is not fully developed until 32-34 weeks
gestation.

All the factors, although normal for a neonate, contribute to respiratory distress
and possible respiratory failure.
 INDICATION
FOR
RESPIRATORY PHYSIOTHERAPY

Indications for respiratory physiotherapy

 The most commonly referred conditions for physiotherapy are hyaline
membrane disease(HMD),meconium aspiration ,pneumonia ,and surgery
involving the thorax or abdomen .

 The most common cause of respiratory distress in the neonate is HMD which
is related to insufficient levels of surfactant in the lung (Farrell and a-very
1975).it is most often associated with prematurity. Caesarean section
delivery, maternal diabetes, perinatal asphyxia and shocks and the second
born of twins.

 Symptoms usually appear within two or three hours after birth progressive
deterioration within 24 to 48 hours .prominent clinical signs include
increased respiratory grunting, intercostal and sternal retractions, nasal
flaring and see saw pattern of respiration between chest wall and abdomen.

 The major pathophysiologic manifestation of HMD is hypoxaemia resulting

from perfusion of atelectatic air spaces.

 The medical management is supportive and generally includes oxygen

therapy, thermal regulation, humidification, nutrition and assisted
ventilation.

 Common pulmonary complications secondary to intubation, mechanical

ventilation and oxygen therapy , include oxygen toxicity bronchopulmonary
dysplasia (BPD) pneumothorax, pneumonia, sepsis (storm 1980),increased
mucous production ,mucous plugging and residual pulmonary disease.
Respiratory physiotherapy for infants with HMD is directed towards
prevention of complications that affect airway clearance.

 Bronchial drainage techniques are begum when signs of atelectasis ,infiltrate

or uncontrolled secretions are noted clinically or by radiographs .

 In the intensive care unit at the monash medical centre physiotherapy are
commenced at least 72 hours after birth when the recovery phase
commences and retention of viscous secretions becomes a problem .

 Physiotherapy management of the respiratory problems continues until the

baby is clinically well and the chest x-ray is clear .
 Meconium aspiration results from aspiration of meconium-stained amniotic
fluid by the foetues or neonate.

 It is most frequently occurs in full-term, post-mature and intra-uterine

growth –retarded infants.

 Tachypnoea is the most prominent sign of respiratory distress and usually

appears within 12 to 24 hours of birth .

 Infants have a characteristic barrel- chested appearance .

 Possible complications include bronchiolitis, pneumonitis, cor pulmonale,

Atelectasis and persistent foetal circulation .

 Medical management once again is supportive .

 Antibiotic therapy, assisted ventilation with positive and expiratory pressure

(PEEP) and supplemental oxygen are often used.

 Physiotherapy commences as soon as possible and includes positioning,

percussion, vibration and suctioning.

 These techniques are continued until secretions are free from meconium and
therapy may need to b continued for several days to ensure clearance of the
airways and to help prevent secondary lower respiratory tract infection.

Pneumonia may develop at any time during the neonatal period and conditions
that increase a neonate’s risk of developing pneumonia include:

 Premature rupture of membranes.

 Intrauterine asphyxia.

 Prematurity.

 Intubation and mechanical ventilation.

  Thoracic and upper abdominal surgery with general anaesthesia .

Crane(1981) recommends that physiotherapy techniques are beneficial

in patients with pneumonia and compromised airway clearance, especially in the later,
clearing-up stages of the infectious process. For all the reason all babies in our unit with
pneumonia are given regular chest physiotherapy.

The aims of respiratory physiotherapy are to :

 Maintain a clear airway;

 Clear excess or accumulated secretion from the respiratory tract;

 Re-expand collapsed segment/s of the lung;

 Prevent respiratory complications such as atelectasis, infection and retained

secretions;

 Maintain adequate levels of oxygenation;

 Improve the general respiratory function of the neonate.

On the other hand the contra-indications for physiotherapy are:

 Very unstable condition of the baby.

 Severe hypothermia – temperature less than 36.3 C.

 Recent pneumothorax which does not have an intercostal catheter in situ.

 Pulmonary haemorrhage in the presence of fresh blood –stained secretions.

 It must remembered that these are guidelines only and may alter with
individual babies for example hand bagging of a child whose conditions is
unstable during physiotherapy may be necessary if the infant’s poor physical
conditions is due to severe lung disease.
 TECHNIQUES
OF
PHYSIOTHERAPHY
 TECHINQUES OF PHYSIOTHERAPY
 The techniques that are employed include postural drainage ,percussion ,
vibration and suctioning.

 Fortunately the cots are so designed that the baby may be tipped according
to the traditional postural drainage position (figure-1) if some reasons the
cot will not tip, folded nappies are used to produce the desired tip.

However , there are times when the infant will not tolerate tripping . these
include:

 Marked instability of the infants conditions;

 The first 24 hours following abdominal and thoracic surgery;

 Immediately after vomiting large amount of milk;

 Less than 48 hours after suspected or proven intracranial haemorrhage;

 The presence of an abdominal mass which impedes the downward excursion

of the diaphragm . eg diaphragmatic hermia;

 Raised intracranial pressure ,as may occur in hydrocephalus.

 In these, cases vibration and or percussion are both used to move secretions
in the lung from smaller to the larger airways and thence to trachea ,
especially when used in conjunction with postural drainage .

 Vibrations consists of a fine shaking of the hand or fingers which are placed
over the area of the lung to be treated and are performed during expiration (
figure2) .

 Vibrations are combined with over- pressure and gentle ‘springing’ or

squeezing of the rib cage at the end of expiration

 If the infant has the stiff, non-compliant lungs then great care is taken not to
do this springing too vigorously as it may cause rib fracture.

 These techniques are useful in publishing the loosened secretions along the
bronchi to the trachea, and so the pressure of the vibrations and the rib
squeezing are done in the direction of trachea.
 Percussion results in a coarse shaking of the underlying tissue and is used to
initiate the movement of the secretions to be drained (figure 3).

 The most effective method of applying percussion employed in this unit is the
Bennetts face mask( puritian- Bennett Corporation), which all babies have as
their bagging circuit.

 A finger is replaced in the central porthole and movement is then carried out
from the wrist as in traditional manual percussion .

 The rim is made soft pliable rubber, so it is not necessary to protect the child
with layer of clothing.

 Total treatment time is limited to 10 or 15 minutes so as not to handle the

infant excessively and inadvertently increase the oxygen demands (for et al
1978).

 Usually two or three minutes is spent treating each effected segments with a
maximum of three segments per treatment.

 If the baby is being fed orally or via a nasogastric tube, physiotherapy

treatment is scheduled approximately 15 to 20 minutes prior to a feed and
at least 45 minutes after the last feed.

 In this way the baby is not constantly disturbed and thus lowed to spend as
much time as possible sleeping undisturbed between feed.

 Treatment frequency depends on the severity of the condition and on the

severity of the condition and on the infants tolerance.
 Two hourly treatment is indicated only in the presence of severe collapse or
consolidation of part of all the lung, or in the presence of excessive secretions
which are not being effectively removed by suction alone .
 In fact , most babies with acute conditions are commenced on four hourly
treatment and their respiratory status continually re accessed.

 six or eight hourly treatment is used when the condition is resolving and only
small to moderate amount of secretion are being aspirated.

 Normally , secretions from each segment are removed by suction as

clearance of each is completed.

 Suction is either via the oropharynx is non-ventilated infants or the

endotracheal tube (EET) in ventilated infants .

 A sterile technique is used in ventilated infants ensuring that the catheter is

not attached to the suction as it is being threaded into EET.

 Suction is maintained as the catheter is being withdrawn with only 10-15

seconds being allowed for the manoeuvre.

 It is suggested that the suction pressure not exceed 200mmHg with the
optimum being between 100 to 150mmHg(poole et al 1974).

 At the end of the treatment the nasopharynx is suctioned in non ventilated

infants.

 However , prior to this it is vital to ensure oropharynx has been cleared

totally as nasopharyngeal suction will often stimulate a deep inspiration.

 All catheters have a Y-connection so that suction may be controlled at all

times .
 Depending on the diameter of the ETT, various size catheters are indicated.

 Young (1984) recommends that catheters should be less than half of the
diameter of the trachea.

 Thus at the monash medical centre size FG5 catheters are used for 2.5mm
ETT, size FG6 for 3.00mm ETT and size FG8 for 3.5mm ETT.

 Suction is used at other times as well as in conjunction with physiotherapy

treatment.

 It is carried out routinely every few hours on all ventilated infants as part of
the nursing care.

 During routine suctioning a lavage consisting of 0.5mls normal saline is

instilled into the ETT to help prevent tube blockages as advocated by drew et
al (1986).

 If the infant show signs of excessive secretions and is obviously distressed ,

the frequency of suctioning may be increased as the need arises.
EXTUBATIONS

EXTUBATIONS
 All extubations except those classified as emergencies are performed by the
physiotherapist example of emergencies include a blocked ETT or accidental
removal by the infant.

 The rationale for this routine is based on the findings of finer et al (1979) .

 These authors reported on a retrospective review of post –extubation

atelectasis.

 Finer el at noted that in previous reports up to 50 per cent of intubated

neonates weighing less than 1250gm required re-intubation because of
complication of post –extubation atelectasis.

 Of these eight seven required re- intubulation because of right upper lobe or
right lower lobe atelectasis .

 Only one of twenty infants receiving physiotherapy developed atelectasis post

extubation and this infant did not require re-intubation.

 At the monash medical centre extubations is timed at least 45 minutes after

the last feed .

 The infant receive appropriate respiratory physiotherapy just prior to the

extubation.

 The treatment session is directed towards clearing all segments of the right
lobe.

 Suction is applied in the usual manner at the end of clearing segment .

 Before the tube is withdrawn the oropharynx and other nares are cleared of
all secretions.
 The tube is then withdrawn with a suction catheter in situ.

 At the same time both tube and catheter are withdrawn suction is applied
ensuring that the limit of 200mmHg is not exceeded.

 Oxygen via face mask is kept close by the infants face, the concentration of
which is at least 5% greater than that which the infant was receiving from
the ventilator .

 Suction is continued untill both oropharynx and nasopharynx are cleared

 The infant is placed within a head box with the appropriate oxygen
concentration and the oxygen monitor and thermometer are placed within
the head box.

 The infant is then nursed prone with the head up as this position allows
better gas exchange a more synchronous breathing pattern (Hough1984).

 The infant receive nil by mouth for at least four hours post – extubation.

 Prior to recommencing feeds, four hour physiotherapy is instigated .

 A postural drainage chart is drawn up and left by the cotside so that the
nursing staff may continue physiotherapy over night.

 At least one segment of the right upper lobe and the right lower lobe is
included in each treatment session, as these are the most common sites of
post – extubation atelectasis .

 Chest x-ray and arterial blood gas measurements are taken four to six hours
post extubation to ensure that no atelectasis has developed that the infants is
receiving the correct oxygen concentration .
 Four hour respiratory physiotherapy is continued for at least 24 hours post
– extubation or un till the chest x-ray is clear.

 Lobar collapse following extubation of the trachea may occur as a result of

retained secretions and mucosaloedema .

 Frequent intubation may traumatize the airways leading to further damage

and a higher incidence of post extubation complications such as subglottic
stenosis.

 The other major post - extubation complication is the occurrence of tracheal

and laryngeal oedema resulting in stridor and upper air way obstruction .

 Dexamethasone given 24 hours prior to extubation may minimize this

occurrence .

 However , lately it has been preferred to use a 2.5% solution of racemic

adrenaline administered as an inhalation in the post extubation period
(FIGURE4) normally do not need to be used after the first 24 hours
following extubatio
 ENVIRONMENTAL
STIMULATION

ENVIRONMENTAL STIMULATION