R e s e a r c h A r t i c l e P o s t u r a l D r a i n a g e in In t u b a t e d P a t ie n t s w it h A c u t e L o b a r A t e l e c t a s is - A P il o t S t u d y ABSTRACT: Objectives: The movement and mobilisation o f an intubated patient in the intensive care unit is restricted by the presence o f various drains and intravenous lines. Difficulty to position the patient in the cor­ rect postural drainage positions, often leads physiotherapists to using m odified postural drainage positions to mobilise secretions. A comparison o f effectiveness between the correct postural drainage positions and the m odified postural drainage positions during the treatment o f acute lobar atelectasis in the intubated patient was conducted. Subjects: Intubated men and women between the ages o f 13 and 85 years in the intensive care units o f Pelonomi and Universitas Hospitals in Bloemfontein diagnosed with acute lobar atelectasis o f the lower lobes were considered f o r inclusion in this pilo t study. Intervention: A controlled randomised clinical experiment was conducted. Group A received inhalation therapy whilst placed in a postural drainage position f o r 15 minutes. Thereafter percussion was done f o r fiv e minutes follo w ed by a sterile suction procedure. Group B received the same treatment but m odified postural drainage positions were used. Both groups received treatment twice daily. Results: On average, group A required three treatments and nil follow -up chest X-rays before the collapse was resolved, as opposed to the average o f 4.5 treatments and one follow -up chest X-ray required by group B before the same result was obtained. In group A the oxygenation compared to Group B was improved. The findings were not statistically significant. Conclusion: The use o f postural drainage positions in intensive care suggests quicker resolution o f acute lobar atelec­ tasis and improves oxygenation. KEYWORDS: INTENSIVE CARE UNIT, ATELECTASIS, PO STU RAL DRAINAGE, M ODIFIED PO STURAL DRAINAGE, OXYGENATION. KRAUSE MW, MSc'; VAN ASWEGEN H, MSc’; DE WET EH, MBChB, MMed, MD2; JOUBERT G , BA, BSc, MSc ? 2 Department of Physiotherapy and Medical Physiology , University of the O ra n g e Free State, Bloemfontein. INTRODUCTION Postural drainage is a recognised tech­ nique used in physiotherapy for the treat­ ment o f patients with acute or chronic lung conditions (Conners et al, 1980). Postural drainage com prises the pro­ motion o f drainage o f secretions from the lungs by m aking use o f gravity (Downie, 1987). The potential positions are determ ined by the individual clinical problem (Belinkoff, 1969). The m ove­ ment and mobilisation o f an intubated patient in the intensive care unit is restricted by the presence o f various drains and lines connected to the patient. For this reason it is sometimes difficult to place such a patient in the correct postural drainage position for the speci­ fic area o f the lung that requires drainage. For the sake o f convenience, m any physiotherapists prefer to use a modified postural drainage position to mobilise secretions during physiotherapy. Very little literature is available on the differ­ ence in effectiveness between modified postural drainage positions and postural drainage positions. As far back as 1933 Jackson and /Jackson described the com bination o f pulm onary drainage and coughing in the treatm ent o f respiratory conditions (Jackson and Jackson, 1933). Since the 1940s, oxygen supply lias been an impor­ tant focal point in the physiological literature and has form ed the basis for the contem porary medical treatm ent of the cardiopulm onary system (Dean and Ross, 1992). Oxygen supply involves the ventilation o f the alveoli, diffusion over the alveolar-capillary m embrane, per­ fusion o f the lungs, the biochem ical reactions o f oxygen in the blood, the pum ping o f the oxygenated blood to the metabolically active tissue by the heart via the peripheral circulation, as well as , the withdrawal and utilisation o f th e^ oxygen by the tissues. Cardiopulm onary dysfunction develops when one or more o f these steps are obstructed. D ecreased alv eo lar ven tilatio n im pairs oxygen ' supply and, in its turn, accum ulation ̂ of sputum impairs the alveolar ventila- 1 tion (Dean, 1994). The application of r this approach to oxygen supply is illus­ trated by the clinical treatm ent o f p ul­ m onary atelectasis, a co n d itio n for which physiotherapeutic treatm ent is often prescribed (Dean and Ross, 1992). f CO RRESPONDENCE: M aria W K rause D epartm ent of Physiotherapy UOFS P O Box 339 9300 Bloem fontein, South Africa Tel: (05.1)401-3289 Faxr: (051) 401-3304 E-mail: gnftm w k@ m ed.uovs.ac.za S A Jo u r n a l o f Physiotherapy 2000 V o l 56 No 3 29 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. ) mailto:gnftmwk@med.uovs.ac.za T h erap eu tic body po sitio n in g and m obilisation are regarded as the prim ary I intervention for the purpose o f im prov­ ing respiratory functions during the treatm ent o f acute and chronic cardio­ pulm onary dysfunctions (Dean, 1994). In 1990 Stiller and co-workers conducted a research project on patients with acute/ lobar atelectasis in order to com pare two physiotherapeutic lung treatm ents. The 14 patients included in this study were divided into two groups. The treatment o f the patients in the first group involved positioning, vibration, hyperinflation (or deep breathing) and suction (or cough-' ing).' The patients in the second group were treated by means o f hyperinflation (or deep breathing) and suction (or coughing) only. The researchers found that the patients in Group One experi­ enced a significantly higher resolution ■ o f the atelectasis after only one treat­ ment than the patients in Group T w o / It was concluded that during the initial phase o f the treatm ent o f acute lobar atelectasis additional positioning and vibration reinforce a basic physiothera­ peutic treatm ent o f hyperinflation and suction. Stiller and co-workers posed the following question which still needs to be researched: would the use o f pos­ tural drainage positions, o f which some' ' involve the head-dow n tilting o f the patient, improve the reaction to the treat- ' m ent even further (Stiller et al, 1990). METHOD The protocol was subm itted to and approved by the Ethics Com m ittee o f the University o f the Orange Free State. Intubated men and women betw een the ages o f 13 and 85 years in the intensive care units o f the Pelonom i and Univer- sitas Hospitals in B loem fontein suffering from acute lobar atelectasis o f the low er " lobes were included in the study. ' C on­ sent was obtained from the consultant o f these units and fam ily mem bers as most o f these patients were sedated. Only 17 patients m et the criteria for inclusion in the project as the other patients were excluded due to contra­ indications for use o f the Trendellenburg position. }Acute lobar atelectasis was diagnosed by the consultant, from the chest x-rays taken on adm ission to the / unit. Time from diagnosis to first treat­ ment was 2 - 4 hours. Each patient was subjected to one o f two treatm en ts according to a standardised random i­ sation list. G roup A: T hese 9 sedated patients received inhalation therapy administered via the ventilator, consisting o f Mercapto- / ethanesulphonate and Sodium Chloride (2 ml Mercapto-ethanesulphonate diluted ' by means o f 2 ml 0,9 % Sodium Chlo- / ride solution). The adm inistration o f this m ucolitic m ixture is standard prac­ tice in these intensive care units. During inhalation the patient was placed in the postural drainage position for 15 minutes. ̂ (The specific position was determ ined by the lung lobe that had collapsed.) The follow ing postural drainage posi­ tions were used: (a) for collapse o f the ! anterior basal segm ents o f the low er ̂ lobes, the patient was treated in supine ̂ with the foot o f the bed raised 46 cm, (b*) for collapse o f the posterior basal seg- / ments o f the low er lobes, the patient was treated in V4 to prone, head turned to the side and the foot o f the bed raised 46 cm, 7 (c) for collapse o f the medial basal seg- ) ment, the patient was treated in right- ' side-lying with the foot o f the bed raised 46 cm, (d) for collapse o f the lateral basal / segment, the patient was treated in left- side-lying with the foot o f the bed raised 46 cm'. A fter this the patient was sub­ jected to percussion for five minutes follow ed by a sterile suction procedure. G roup B : T hese 8 sedated patients received the same inhalation therapy as G roup A. During inhalation the patient was p laced in a m odified postural ■; drainage position in supine (an terio r'' basal lobe collapse) or side lying (lateral basal lobe collapse and medial basal lobe collapse) or to prone/(posterior basal lobe collapse) (not head down, i.e. in the Trendellenburg position). This was • follow ed by treatm ent identical to that received by G roup A. C hest X -rays were taken o f each patient and arterial blood-gas values were d eterm in ed before physio th erap eu tic treatm ent was started. The chest X-rays were taken on a daily basis and were evaluated by the consultant o f the inten­ sive care unit who was unaware as to w hich group the patient was in. A rterial blood-gas values were taken every 6 hours and were docum ented by the researcher in data form. From these values the diffusion gradient (A a D p 0 2) was calculated as A a D p 0 2 = P a ^ 2 — Pa^ 2 T he oxygen tension ratio between arterial blood and alveolar air (a /A p 0 2) was calculated as a /A p 0 2 = Pa0 2 / PA0 2. The respiratory index (RI) was calculated as RI = A a D p 0 2 / Pa0 2 and the venous shunt as P a0 2 / F i 0 2. The patient was subjected to a sterile endo­ tracheal suction procedure perform ed every two hours by the nursing personnel as is the custom in these units. The p atients received physiotherapy treat­ ment twice daily. The underlying patho­ logies for all patients are listed in Table 1. P n eo m o th o rax and pleural effusions were drained before physiotherapy treat­ m ent started. " RESULTS Num erical variables were sum m arised throughout in the form o f m edians, m inim um s, and maximums. On average the patients in the postural drainage position group (Group A) required three treatm en ts before the collapse was resolved as opposed to the average o f 4,5 treatm ents required by the patients in the m o d ified postu ral drainage position group (Group B) before the same result Table 1. Underlying pa thology causing atelectasis. G roup A G roup B G uillian - Barre Syndrome 0 1 Obstruction o f bronchi / bronchioles 1 1 Pain due to rib fracture, post surgery 3 2 Pleural effusion 1 2 Pneumonia 2 1 Pneumothorax / Haemothorax 2 1 Total o f patients 9 8 30 SA Jo u r n a l o f Physiotherapy 2000 V o l 56 No 3 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. ) Table 2. Real Values (Median Values). A rterial blood gas values Before firs t treatm ent A fte r fina l treatm ent G roup A G roup B G roup A G roup B pH 7,43 7,40 7,45 7,4 5 P aC 02 38,10 40 ,5 0 4 3 ,5 0 35 ,0 0 Pa02 7 4 ,0 0 89,00 97 ,0 0 90 ,0 0 S a 0 2 9 3 ,9 0 96,10 97 ,8 0 96,40 A a D p 0 2 112,00 96,30 86 ,0 0 92,50 a / A p 0 2 39 ,7 0 47 ,8 5 52 ,9 5 49 ,3 0 Rl 151,00 110,50 88,50 102,00 Venous shunt 185,00 22 2 ,5 0 25 9 ,2 5 22 5 ,0 0 Table 3. Differences (Median Values). A rteria l blood gas values A fte r first treatm ent - before first treatm ent A fte r fina l treatm ent - before first treatm ent G roup A G roup B G roup A G roup B pH 0,0 0 0,01 0,03 0,0 4 P a C 0 2 -2,00 -1,00 -4,00 -7,00 P a 0 2 7,00 0,0 0 21 ,00 1,00 S a 0 2 1,90 0,0 5 2,1 5 0 ,1 0 A a D p 0 2 -7.10 -0.15 -19 .8 5 -0.50 a / A p 0 2 3,80 0 ,1 0 10,70 0 ,3 0 Rl -9,00 -2,50 -46 ,5 0 -1,00 Venous shunt 26 ,00 0,6 0 48 ,7 5 2,50 was obtained. In the case o f the patients in group A, the collapse had already resolved on the follow-up chest X-ray which was taken the next day. Thus an average o f 0 X -rays was required before the collapse was resolved. In the case of the patients in group B, the collapse had not resolved on the follow -up chest X-ray, taken the next day, and an aver­ age o f 1 X-ray was required before the collapse was resolved. The arterial oxy­ gen tension ( P a 0 2), oxygen saturation (Sa02), diffusion gradient (A a D p 0 2), oxygen tension ratio between arterial blood and alveolar air (a/Ap0 2), respira­ tory index (Rl), and venous shunt values in group A changed considerably between the first and the final treatm ent, as opposed to the sm aller changes that took place in the case o f group B. The differ­ ences w ith regard to the above- mentioned variables after the first treat­ ment as opposed to before the first treat­ ment and after the final treatment (as opposed to before the first treatment) were apparently much greater in group A than in group B. A Spearman Rank correlation test was performed to com pare the P a 0 2 and the S a 0 2 before the first treatment, after the first treatm ent and after the final treatment. The correlation test was also perform ed for the differences after the first treatment - before the first treatment and after the final treatm ent - before the first treatm ent for group A and group B. For both groups there was a very strong correlation between the P a 0 2 and the S a 0 2 throughout. Non-parametric 95% confidence inter­ vals were calculated for the median o f the differences between the two groups. For example, after the first treatm ent - before the first treatm ent P a 0 2 equalled -8 1 for group A and 5,2 for group B which indicated that P a 0 2 in group A increased more. Furtherm ore the corre­ sponding differences in S a 0 2 were -1 4 ,2 and 0,5 which indicated that S a 0 2 in group A increased more. The venous shunt differences o f -2 0 1 ,3 and 11,2 for the two groups respectively indi­ cated a better gas exchange in the lungs o f patients in group A, while the differences in A a D p 0 2 o f -4 ,7 and 81,8 for the two groups indicated that the diffusion gradient in group A decreased more. DISCUSSION As this pilot study involved only 17 patients (n = l7 ), the group was too small to obtain a statistically significant differ­ ence between group A and group B with regard to the num ber o f treatments and X -rays required before the collapse was resolved. However, there is a trend to suggest that the treatm ent o f group A appeared more effective than that of group B because the patients in group A showed greater changes in the real arte­ rial blood gas values with regard to P a 0 2, S a 0 2, A a D p 0 2, a /A p 0 2 R l and venous shunt values from before the first treatm ent to after the final treatm ent (see Table 2). As far as the differences in arterial blood gas values from after the first treatm ent - before the first treat­ ment as opposed to after the final treat­ ment (before the first treatm ent are con­ cerned), the trend seems to suggest a greater change (improvement) in group A as far as P a 0 2, S a 0 2, A a D p 0 2 a /A p 0 2, R l and venous shunt values are con­ cerned, as opposed to the m inim al changes in group B (see Table 3). In group A, Table 2 shows an increase in P a 0 2 values from 74 prior to treat­ ment to 97 after the final treatment. P a 0 2 values for group B increased slightly from 89 prior to treatm ent to 90 after the final treatment. S a 0 2 for group a increased 93,9 to 97,8 and for group B from 96,1 to 96,4. The A a D p 0 2 for group A decreased from 112 to 86 after the final treatment. For group B this param eter decreased from 96,3 to 92,5. The greatest change was recorded for the venous shunt values. For group A, it increased from 185 prior to treatm ent to 259,25 after the final treatment. For group B, the venous shunt values increased slightly from 222,5 prior to treatment to 225 after the final treatment. "A venous shunt value o f more than 200 \ is indicative o f satisfactory gas exchange. Reading these results it would seem that group B was not as severely ill as group A, but still group A had a larger venous shunt value after the final treatm ent than group B. A s the P a 0 2, S a 0 2, A a D p 0 2 SA Jo u r n a l o f Physiotherapy 2000 V o l 56 No 3 31 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. ) and venous shunt have a direct influence on the oxygenation process in the lungs, there is a trend suggesting that the oxy­ genation process in the lungs o f the patients in group A im proved markedly in com parison to group B where the oxygenation process im proved m inim al­ ly according to values in Tables 2 and 3. REFERENCES B elink off S 1969 Introduction to inhalation therapy. 1st edition. pp79. Little, Brown and Company, London. C onners AF, H am m on W E, Martin RJ, Rogers RM, 1980 The immediate effect o f oxygenation in acutely ill patients. Chest 78(4):559-564. LoCicero J, 1989 Bronchopulmonary aspira­ tion. Surg Clin North America 69(1): 71-76. M eyer BJ 1988 D ie fisio lo g ie se basis van geneeskunde, 4th edn. pp 41.1 - 44.6. HAUM , Pretoria. M oore KL 1985 C linically Oriented Anatomy, 2nd edn. The Thorax, pp 83 - 146. W illiam s and W ilkens, Baltimore. R oss J, Dean E, Abboud RT, 1992 The effect o f postural drainage positioning on ventilation hom ogeneity in healthy subjects. Phys Ther 72(11): 794-799. Sch m id l-N ow ara W, Altm an A, 1984 A telectasis and neurom uscular respiratory failure. Chest 85: 792-795. Shapiro B A , Kacmarek RM, Care RD 1991 Clinical A pplications o f Respiratory Care, 4th edn. pp 271 - 393. Mosby-Year B ook Inc, St Louis. Stiller K, Geake T, Taylor J, Grant R, Hall B, 1990 Acute lobar atelectasis: a comparison o f tw o ch est physiotherapy regim ens. Chest 98(6): 1336-1340. Sunderrajan EV, D avenport J, 1985 The Guillain Barre syndrome: pulmonary-neuro- logical correlations. M edicine 64: 333-341. Susini G, S isillo E, Bortone F, Salvi L, Moruzzi P, 1992 Postoperative atelectasis reexpansion by selective inflation through a balloon-tipped catheter. Chest 102(6): 1693-1696. Tokics L, Hedenstierna G, Strandberg A, Brismar B , Lundquisl H, 1987 Lung collapse and gas exchange during general anaesthesia: e ffe c ts o f sp ontan eou s breathing, m uscle paralysis and positive end-expiratory pressure. A n esthesiolgy 66: 157-167. Tyler ML, 1982 Com plications o f positioning and chest physiotherapy. Respiratory Care 27(4): 4 5 8-466 CONCLUSION From the results and discussion o f this pilot study, there is a trend to suggest that postural drainage positions lead to a ) greater im provem ent in the oxygenation process in the lungs and may lead to a quicker resolution o f acute lobar atelec­ tasis in the intubated patient. Shortcom ings o f this study include a too small patient population to obtain a statistical difference between group A and group B. Also the length o f stay in the intensive care unit and the period o f intubation were not calculated. It is suggested that a similar study be repeated on a larger group o f patients over a longer time period in order to obtain statistical differences betw een patients treated in postural drainage positions and patients treated in m odi­ fied postural drainage positions in the intensive care unit. The period o f intuba­ tion and the length o f stay in the intensive care unit should be monitored. The results o f such a study could then determ ine the importance o f the use o f postural drainage positions with physiotherapy treatm ent in the intensive care unit. Dean E, 1987 Effect o f body position on pul­ monary function. Physical Therapy 65(5): 613-618. Dean E 1994 O xygen transport: a ph ysiologi­ cally-based conceptual framework for the practice o f cardiopulmonary physiotherapy. Physiotherapy 80: 347-355. Dean E, Ross J, 1992 Discordance between cardiopulm onary p h y sio lo g y and ph ysical therapy. Chest, 101(6): 1694-1698. D ow nie PA 1987 Textbook o f chest, heart and vascular disorders for physiotherapists. 4th edn. pp341 - 352. Faber and Faber Lim ited, London. Jackson C, Jackson CL, 1933 Peroral pul­ monary drainage: natural and therapeutic with special reference to the tussive squeeze. Am J Med Sci 186:849-854. Junqueira LC, Carneiro J 1980 B asic Histology, 3rd edn. Respiratory System s, pp 35 8 - 377. Lange M edical Publications, California. K ollef MH, Legare EJ, Dam iano M, 1994 Endotracheal tube misplacement: incidence, risk factors and impact o f a quality improve­ ment program. South Med J 87(2): 248-254. Lew is FR, 1980 M anagement o f atelectasis and pneumonia. Surg Clin North America 60: 1391-1401. 32 SA Jo u r n a l o f Physiotherapy 2000 V o l 56 No 3 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. )