Chest Physiotherapy in the NICU/NSCU

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Chest Physiotherapy in the NICU/NSCU
Neonatal Respiratory Cares Program On the Spot
Education Series

• Guidelines for Providing CPT to Neonatal
  Ventilator Patients

Approved by Dr. Leif Nelin, Neonatal Respiratory
Care Medical Director Daniel Baird, Neonatal
Respiratory Care Program Manager
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Purpose

• Chest physiotherapy involving postural
  drainage in concert with percussion or vibration
  has shown to result in the removal of more
  secretions from intubated neonates.

CPT on ventilated patients in the NICU is a
shared responsibility between respiratory and
nursing services. Therefore, CPT should be
executed by respiratory only when coordinated
with nursing. If RT is unable to perform
service, RT must document that CPT will be
performed by RN.
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Positioning

• Traditional postural drainage positioning of
  the intubated/ critically ill infant is not
  practical. Positioning should therefore, be
  modified to fit within the framework of the
  infants turning and positioning schedule.
• The infant should be turned to allow the
  targeted area/s to be up during the delivery of
  CPT.

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Considerations

• The duration of CPT as well as number of
  positions employed will be dependent upon infants
  condition and tolerance. This will also depend
  upon the judgment of the practitioner
• CPT should only occur for definite indications
  (atelectasis, consolidation, infiltrates, etc.)
  when the infant is fit and able to tolerate
  procedure.
• CPT will not be performed without an order.

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Positioning

• Trendelenberg position is not to be used in the
  NICU for CPT

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Recommendations

• Use CPT cautiously
• Do not use CPT on very low birth weight
  infants in the first week of life.
• Keep infants head steady during delivery of
  CPT.
• CPT should never be done routinely but on an
  individual basis after careful and thorough
  assessment.

NCH Small Baby Guidelines Part 1
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Recommendations

• CPT should be used when secretions are not
  cleared by suction alone.
• CPT should be coordinated with infants care
  schedule.

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Complications

• The most severe complication reportedly
  resulting from CPT are an increased risk in
  intraventricular hemorrhage and cerebral
  encephalopathy in preterm infants

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Other Complications

• Bradycardia
• Cyanosis
• Fighting
• Struggling
• Alterations in oxygenation
• Rib fractures

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Monitoring

• Heart rate, respiratory rate, color and
  saturations should be monitored continuously.
• Significant changes should be documented.

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Percussion and Vibrations

• The chest is percussed/ vibrated over the area
  to be drained typically for 1 to 2 minutes.
• Percussion may be reserved for infants
  weighing gt 1500 g and older than 2 weeks of age
  because of the potential risk of intraventricular
  hemorrhage.
• Infants weighing lt than 1500 g should receive
  vibrations.

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Percussion

• Percussion can be performed with small plastic
  cups with padded rims or with soft circular masks
  with their adaptors sealed so that the air pocket
  is maintained.
• Safe adaptations (approved by department)
  dependent on patient size may be augmented for
  effective care.

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Vibrations

• Vibrations or vibes can be delivered with the
  use of a padded electric toothbrush or a
  commercially available pulmonary vibrator.
• Vibration is typically tolerated by a greater
  number of patients than percussion.
• An individualized vibratory head should be used
  for each patient. The delivery device may be
  wiped per infection control policies between
  patients.

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Optimization of Drug Delivery

• The administration of aerosolized medications
  commonly precedes bronchopulmonary hygiene.
• This is done on the basis of custom rather
  than on any scientifically verified practice.
• Per OT recommendations, use hand containment
  maneuvers when possible.

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Suctioning

• Suctioning should be performed after CPT is
  delivered.
• Suction per NICU RT Guidelines.

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References

• Goldsmith, Jay P., Karotkin, Edward H.
  Assisted Ventilation of the Neonate 3rd Ed.
  Saunders. 1996. Pg 113-115.
• Merenstein, Gerald B., Gardner, Sandra L.
  Handbook of Neonatal intensive Care 6th Ed.
  Mosby. 2006. Pg 494-495.
• Contributing Author
• Brandon Kuehne, MBA, RRT, RPFT, NPS