20 P H Y S I O T H E R A P Y CORRESPONDENCE JUNE 1978 D e a r M a d a m , I t b e h o v e s m e to w rite to y o u c o n c e rn in g c e rta in b a sic p rin c ip le s in v o lv e d in th e a d m in is tr a tio n o f in h a la tio n th e r a p y /n e b u liz a tio n w h ic h a p p e a r to h a v e b e e n o v e rlo o k e d b y c e rta in o f m y c o lle a g u e s in th is c o u n try . F i r s t ly o n e sh o u ld , I b e lie v e, see th is t r e a t­ m e n t m o d a lity as o n ly h a v in g a sm a ll ro le in th e g a m u t o f p h y s io th e r a p y m o d a litie s u sed in a tre a tm e n t session. N e b u liz a tio n o f s a lin e o r o f a d ru g is p u re ly a m e a n s to a n e n d . T h e re st o f th e tre a tm e n t m o d a li­ ties, su c h a s b r e a th in g exercises, c o u g h in g in s tru c tio n , p o s tu r a l d ra in a g e , v ib r a tio n , sh a k in g , p o s tu r a l c o rre c ­ tio n , e x e rc is e s f o r m o b ility a n d to im p ro v e p h y sic a l fitness a n d c o u n se llin g a re a b s o lu te ly e sse n tia l to t r e a t ­ m e n t a n d c a n n o t b e fo rg o tte n . I t seem s t h a t in h a la tio n th e r a p y /n e b u liz a tio n is b e in g s e c o n d e d to n o n - p r o f e s ­ sio n a l sta ff/a id e s b e c a u se o f s o -c a lle d “ sta ff s h o r ta g e ” . T h is is a p o o r e x c u s e b e c a u se if n e b u liz a tio n is to be o f a n y effect it m u s t b e e x p e rtly a d m in is te re d w h ils t th e p a ti e n t b re a th e s c o rre c tly a n d to t r a i n a p a tie n t to b re a th e c o rre c tly c e rta in ly n e e d s so m e e x p e rtis e ! In a d d itio n , a id e s h a v e n o g a z e tte d sc o p e a n d if th e y a d m in is te r in h a la tio n th e r a p y in a n a re a p r e s c rib e d fo r p h y s io th e ra p y th e y a r e p ra c tis in g illegally. S e c o n d ly , p h y s io th e ra p is ts a r e n e ith e r c a p a b le o f p re s c rib in g n o r a llo w e d to p r e s c r ib e m e d ic a tio n fo r th e p u rp o s e s o f n e b u liz a tio n . T h e m e d ic a tio n s h o u ld be p r e s c rib e d b y th e re fe r r in g m e d ic a l p r a c titio n e r . I t r u s t t h a t th e s e fe w w o rd s o f w a rn in g w ill be h e e d e d a n d re fe r to G o v e rn m e n t G a z e tte s N o . 5349 a n d 5811 w h e re th e p re s c rib e d a re a s a r e p ro m u lg a te d a n d to G o v e r n m e n t G a z e tte N o . 4525 w h e re th e sc o p e o f th e p ro fe s s io n o f p h y s io th e r a p y is defined. M . J. R U N N A L L S (M iss) H e a d a n d S e n io r L e c tu re r D e p a r tm e n t o f P h y s io th e r a p y U n iv e rs ity o f S te lle n b o sc h G e a g te M e v ro u , E k h e t d ie v o lg e n d e b r ie f v a n ’n k o lle g a o n tv a n g : “ N a a a n le id in g v a n d ie te le fo o n g e s p re k , d ie v o lg e n d e b e so n d e rh e d e : D ie m a a k v a n d ie d ro e y s p a k k e is C o l-P a c , H y d r o c o lla to r : C h a tta n o o g a P h a rm a c a l C o. ( C h a tta n o o g a , T e n n e ss e e 37405, U .S .A .) N a 2 o f 3 d a e se a a n w e n d in g is ’n v e r h a r d e ver- k le u rd e re a k s ie g e v in d ( 1 0 m in u te sessies p e r be- h a n d e lin g ). In d ie a fg e lo p e 1 j a a r 2 m a a n d e h e t 5 p a s ie n te h ie r d ie re a k s ie g e k ry . A s d ie h o e v e e lh e id p a s ie n te w a t ys- b e h a n d e lin g k ry in ag g e n ee m w o rd , is d it se k e r ’n p e rs e n ta s ie v a n + 1 5 - 2 0 % . D i t is slegs v e rk ry by d o n k e rk le u rig e ra sse , nl. D a m a ra s , O v a m b o ’s en H e r e r o ’s. D ie n u u ts te geval k a n as v o o rb e e ld ge n ee m w o rd : N a 2 y s b e h a n d e lin g s is d ie re a k s ie g e v in d o o r v a stu s m e d ia lis e n b ic e p s fe m o ris. L a a sg e n o e m d e w a s m in d e r p y n lik e n u l tr a l a n k (0,75 w / c n r k o n tin u v ir 5 m in u te ) is slegs o o r d ie a n t-m e d . a sp e k gegee, w a t d a n d ie v o l­ g e n d e d a g b a ie m in d e r p y n lik w as as d ie p o s t-la t. deel w a t n ie u ltr a k la n k g e h a d h e t n ie. N a 2 v e rd e re u ltra - k la n k b e h a n d e lin g s o o r b e id e a re a s w a s d a a r g een p y n p o st-la t. n ie , m a a r ’n h a r d e s u b k u ta n e r i f + H cm. b re e d e n ± 8 cm . la n k h e t a n t-m e d . n e t p y n lik e r ge- w o r d (v e ra l by lo o p e n m e t b e ta stin g ). D ia d in a m ie s e s tro m e is o o r d ie eebieH ■, 1 b e h a n d e lin g w a s d a a r o o m b lik lik e p y n v e rlio r Nla d ie v o lg e n d e dag m in im a le p y n . N a d ie 2de beh 7 t;n w a s g een p y n te e n w o o rd ig n ie , selfs m e t h a n t '?iin(; D ie r i f w as e g te r n o g te e n w o o rd ig , h o w el sa e te r ” H e t e n ig e f is io te ra p e u t s o o rtg e ly k e o n d p ™ ;^ - h a d ? E k sa l d it b a ie w a a rd e e r in d ie n h ufle e n ia " 8 8 g e ly k e ge v alle a a n m y k a n ra p p o rte e r asook S„°0r1' m en in g s w a t h u lle o m tr e n t b o g e n o e m d e h e t 8c Mi r J ' R U N N A L L S (M e ,, H o o f e n S e n io r Leklrisc T ! n p a , r t e m e n t F i s ' ° t e r a n U m v e rs ite it v a n Stellenbosch D e a r M a d a m R e c e n tly m e m b e rs o f th e S o u th e rn T ra n sv a a l B r a n c h o f o u r S o c ie ty h a d th e p le a s u re o f h e a rin g a lecture h M iss G a sk e ll, o f B ro m p to n C h e st H o s p ita l. I p le a se d to h e a r h e r e m p h a sise th a t v e n tila to r therani b y p h y s io th e ra p is ts s h o u ld b e c a rrie d o u t o nly under th e g u id a n c e o f m e d ic a l p ra c titio n e r s experienced in th e ir use. M a n y p h y s io th e ra p is ts a re re g u la rly u sin g ventilators in th e tre a tm e n t o f th e ir p a tie n ts , a n d one m ust take le a v e to q u e s tio n w h e th e r th e y a re alw ay s fully con­ v e rs a n t w ith th e d e ta ils o f p u lm o n a ry physiology or w h e th e r th e y a re fu lly a w a re o f th e p o te n tia l dangers o f su c h tre a tm e n t. O n a n u m b e r o f o c c a sio n s I h a v e b e en involved in th e tr e a tm e n t o f p a tie n ts w h o h a v e h a d to undergo p u lm o n a ry s u rg e ry a f te r th e o v e r-z e a lo u s use o f venti­ la to rs h a d re su lte d in r u p tu r e o f em p h y sem ato u s bullae. T h e s a d th in g is th a t th e p h y s io th e ra p is ts w ho use the v e n tila to rs p r o b a b ly d id n o t ev en h e a r a b o u t the d is a s tro u s effects o f th e ir w e ll-m e a n t tre a tm e n t and most lik e ly still c o n tin u e d to tr e a t a ll “ c h e s t” p a tie n ts in the sa m e w a y irre s p e c tiv e o f th e b a sic lu n g condition. I w o n d e r w h e th e r th is ty p e o f th e ra p y is n ot often a n e asy s u b s titu te f o r p u lm o n a r y p h y sio th e ra p y which is tim e -c o n s u m in g a n d re q u ir e s th e full und iv id ed atten­ tio n o f th e th e r a p is t f o r t h e w h o le tre a tm e n t period M o re stre ss, in m y o p in io n , sh o u ld b e la id on the f a i t h a t n o th in g can re p la c e a ctiv e b re a th in g e x erc is^ c o u g h in g , a n d , a f te r th o r a c ic su rg e ry especially, chest- w a ll m o b iliz a tio n . V e n tila to r th e r a p y can only be an a d ju n c t to su c h tre a tm e n t b y re a s o n o f its ability to d e liv e r n e b u liz e d b r o n c h o d ila to r ag en ts a n d mucolytic agents. H o w e v e r, M iss G a sk e ll a n d so m e m em b ers of her a u d ie n c e p o in te d o u t th a t re s e a rc h h a s show n that the a m o u n t o f th e n e b u liz e d d ru g s re a c h in g the terminal r e s p ir a to r y p a ssa g es is in fa c t v e ry sm all, a n d therefore o n e w o n d e rs w h e th e r th e im p ro v e m e n t a scribed to the u se o f th e v e n tila to r m a y n o t p e rh a p s re su lt from any o t h e r fo rm s o f tre a tm e n t th e p a tie n t is concurrently re c e iv in g . M a y I in th is re sp e c t d ra w y o u r readers a tte n tio n to a le tte r f r o m S. H . M . B l a c k w o o d in *nc M a rc h 1978 issu e o f o u r J o u rn a l. . . , V e n tila to r s a r e se ld o m u se d in th e t h o r a c i c surgi u n i t to w h ic h I a m a tta c h e d . O v e r a p e rio d of twe y y e a rs I h a v e b e en a sso c ia te d w ith five th o ra c ic n o n e o f w h o m e v e r r e q u ir e d m e to tr e a t a patient a v e n tila to r. . h to I n o u r u n it th e u se o f v e n tila to rs is c o n f open- im m e d ia te p o s to p e ra tiv e s u p p o r t in s o m e cases or I . h e a r t su rg e ry , u n til a r te r ia l o x y g e n te n s io n is no R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) of in tra c ta b le b ro n c h o s p a s m a n d to cases o f 10 ci Sel utu m re te n tio n . scv'erc o ften fo u n d th a t p a tie n ts w h o u se th e v e n ti- 1 *iaVveral tim e s p e r d a y , e sp e c ia lly w ith m u c o ly tic s, |aWr se ^ v e a tre m e n d o u s in c re a s e in flu id se c re tio n s tend, to severe e m b a rra s s m e n t o f a lv e o la r gas ex ch a n g e. cau.sin®ggests th a t v e n tila to r tre a tm e n t s h o u ld cease as This sl‘f=f=jie p a tie n t is c a p a b le o f re s p o n d in g to con- soDIl-nnal p h y sio th e ra p y . those few p a tie n ts f o r w h o m v e n tila to r th e r a p y is 1? HLj th e y a re ta u g h t to u s e th e v e n tila to r by 'n(*rfied n u rsin g staff u n d e r m e d ic a l s u p e rv is io n , a n d 11 • truct th e m to a lt e rn a te th e i r h o u r ly b re a th in g I ins. ro u tin e w ith t h e ir v e n tila to r sessions. T h is c 'erc' js q Uite s e p a ra te f r o m th e tw o to th r e e fo rm a l re8 ' 7 otherapy tre a tm e n ts p e r d a y in th e e a r ly p o st- ^prative p eriod. 0 r the tw enty y e a rs o f m y e x p e rie n c e cases o f re- • torv fa ilu re h a v e b e e n v e ry ra re . I a m c o n v in c e d ^ 'T t h e re aso n f o r o u r g o o d re s u lts is th a t w e re ly i upon “g a d g e ts” b u t u p o n so lid , o ld -fa s h io n e d .ujng exercises, c o u g h in g , c h est-w a ll m o b iliz a tio n , / f ? a sm all a m o u n t o f p o s tu ra l d ra in a g e a n d o c c a sio n a l Jrcussion o f th e ch est-w a ll. T h e g r e a t se c re t, h o w e v e r, ^w illingness to d e v o te sufficient tim e to m a k e th e tr e a t ­ ment work. ,UNIE 1978 I t h a s b e en su g g e ste d to m e th a t I m a n a g e w ith o u t v e n tila to rs b e c a u se I t r e a t th o r a c ic su rg ic a l cases a n d n o t th o r a c ic m e d ic a l cases. I m u s t c o rre c t th is m is ­ a p p re h e n s io n . W h o a r e th e p a tie n ts w h o c o m e fo r t h o r a c ic su rg e ry ? A r e th e y n o t th e p a tie n ts w ith b ro n c h ie c ta s is o r silic o sis? A re th e y n o t th e h e a v y sm o k e rs w ith p ro g re s s iv e e m p h y s e m a w h o h a v e d e ­ ve lo p e d p u lm o n a r y m a lig n a n c ie s ? A r e th e y n o t th e p a tie n ts w h o s e lu n g fields h a v e b e e n d e s tro y e d a n d th e ir v ita l c a p a c itie s re d u c e d b y p u lm o n a r y cysts? A re th e y n o t th e p a tie n ts w ith fe s te rin g , sp a c e -o c c u p y ­ ing lu n g a b sc esses re s u ltin g f r o m n e g le c te d p n e u m o n ia ? A re th e y n o t th e p a tie n ts w ith lu n g s s c a rre d by tu b e r ­ c u lo sis? A r e th e y n o t th e p a tie n ts w ith c h r o n ic v a lv u la r h e a r t d ise a s e w ith lu n g c o m p lic a tio n s ? W h a t c o u ld b e m o re “m e d ic a l” th a n su c h su rg ic al cases? I n c o n c lu sio n , I do n o t w ish to c o n d e m n th e use o f v e n tila to rs w h ic h u n d o u b te d ly h a v e th e i r v a lu e ; b u t such m e c h a n ic a l a id s c a n n o t re p la c e th e a p p lic a tio n o f so u n d k n o w le d g e, c o n v e n tio n a l te c h n iq u e s , a sufficient e x p e n d itu re o f tim e , a n d th e h a rd -w o n sk ill o f th e p h y s io th e ra p is t. J O A N L . L E M M E R B .Sc (P h y s io th e ra p y ) W itw a te rs ra n d 21F I S I O T E R A P I E THE EMS THERASONIC a tru ly portable U ltra so n ic U nit W e ig h t: o n ly 5,7 kg. Size: 30,5 x 17,8 x 19,0 cm. O utput: Up to 3 w a tts per sq./cm . C ontinuo us as w ell as pulsating output For further details contact the Sole S.A. Agents and Distributors M E D I C A L D I S T R I B U T O R S ^MSLTBDPK ’ CA PE Y O R K ' | 252 JEPPE ST. | J O H A N N E S B U R G | De W a a l H o u se, 172 V ic to ria Road | W o o d s to c k , C.P. PLEASE A D D R E S S A LL C O R R E S P O N D E N C E TO P .O . BO X RIG A S S E B L IE F ALLE K O R R E S P O N D E N S IE A A N P O S B U S 3378 J O H A N N E S B U R G 2000 TEL. A D D . 'D IS M E D ' PHONE | FO O N 2 3-810 6 TELEX: 4 3-712 9 S .A . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )