Discordance Between Cardiopulmonary Physiology and Physical Therapy
1994; Elsevier BV; Volume: 105; Issue: 1 Linguagem: Inglês
10.1378/chest.105.1.322b
ISSN1931-3543
Autores Tópico(s)Pleural and Pulmonary Diseases
ResumoIn the June 1992 issue of Chest, Dean and Ross1Dean E. Ross J. Discordance between cardiopulmonary physiology and physical theraphy: toward a rational basis for practice.Chest. 1992; 101: 1694-1698Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar provided an interesting noncritical review of a selection of literature relating to cardiopulmonary physiotherapy (CPP) and the lack of clinical trials demonstrating its efficacy. However, this narrow review does not reflect current practice or discuss the literature that clearly supports CPP interventions. I was unclear as to who was the target audience for this article, since it does not provide physiotherapists with new information and ignored many important aspects of CPP. Current CPP practice does not have a primary focus on removal of secretions unless they are the only pathologic change. Positioning and mobilation are integral components of CPP and will frequently be the only intervention required. I am not sure to whom Dean and Ross were referring when they cautioned against “primarily attributing the underlying mechanism of atelectasis to mucous plugging.”: but it is basic knowledge that atelectasis is the result of a number of different mechanisms.2Ali J. Weisel R.D. Layug A.B. Kripke B.J. Hechtman H.B. Consequences of post-operative alterations in respiratory mechanics.Am J Surg. 1974; 112: 376-382Abstract Full Text PDF Scopus (176) Google Scholar, 3Craig D.B. Post-operative recovery of pulmonary function.Anaesth Analg. 1981; 60: 46-52Crossref PubMed Google Scholar, 4Ford G.T. Whitelaw W.A. Rosenal T.W. Cruse P.J. Guenter C.A. Diaphragm function after upper abdonminal surgery in humans.Am Rev Respir Dis. 1983; 127: 431-436Crossref PubMed Scopus (241) Google Scholar, 5Meyers J.R. Lembeck L. Dikane H. Baue A.E. Changes in functional residual capacity of the lung after operation.Arch Surg. 1975; 110: 576-583Crossref PubMed Scopus (126) Google Scholar, 6Simmoneau G. Vivien A. Sartene R. Kunstlinger F. Samii K. Noviant Y. et al.Diaphragm dysfunction induced by upper abdominal surgery.Am Rev Respir Dis. 1983; 128: 899-903PubMed Google Scholar One cause of atelectasis is mucus plugging, and in this situation it is appropriate to use secretion removal techniques, alone or in combination with other CPP treatments. The authors' statement that “a primary focus on secretion removal cannot be supported” is misleading, since this is not the primary focus of CPP, but rather one aspect of treatment. In order to optimize the oxygen transport system, CPP must be focused on the underlying disease. The treatment chosen will depend on whether the disease is the result of inadequate ventilation, mucociliary clearance impairment, or respiratory muscle dysfunction. In addition, Dean and Ross state that there is mounting evidence failing to support the use of secretion removal techniques. A noncritical review by Murray7Murray J.F. The ketchup-bottle method.N Engl J Med. 1979; 300: 1155-1156Crossref PubMed Scopus (42) Google Scholar cited by Dean and Ross to support their position in fact concludes that trials of physiotherapy should be given if they successfully result in significant sputum production. While years ago physiotherapists may have thought it possible to effect a change through the use of “conventional” secretion removal therapy (CSRT) techniques, such as postural drainage, percussion, vibration, and coughing, on patients with minimal or no secretions, this does not reflect current practice. It is well accepted that patients without significant secretions (eg, those with COPD or cardiac pathology) do not respond to CSRT.8Anthonisen P. Riis P. Sogaard-Andersen T. The value of lung physiotherapy in the treatment of acute exacerbations in chronic bronchitis.Acta Med Scand. 1964; 175: 715-719Crossref PubMed Scopus (38) Google Scholar, 9Buscaglia A.J. St Marie M.S. Oxygen saturation during chest physiotherapy for acute exacerbation of severe chronic obstructed pulmonary diseas.Respir Car. 1983; 2: 1009-1013Google Scholar, 10Connors A.F. Hammon W.E. Martin R.J. Rogers R.M. Chest physical therapy: the immediate effect on oxygenation in acutely ill patients.Chest. 1980; 78: 559-564Crossref PubMed Scopus (87) Google Scholar, 11Gormezano J. Branthwaite M.A. Effects of physiotherapy during intermittent positive pressure ventilation.Anesthesiology. 1973; 27: 258-264Google Scholar, 12Laws A.K. McIntyre R.N. Chest physiotherapy: a physiological assessment during intermittent positive pressure ventilation in respiratory failure.Can Anaesth Soc J. 1969; 16: 487-493Crossref PubMed Scopus (43) Google Scholar, 13May D.B. Mint P.W. Physiologic effects of chest percussion and postural drainage in patients with stable chronic bronchitis.Chest. 1979; 75: 29-32Crossref PubMed Scopus (51) Google Scholar, 14Newton D.A.G. Bevans H.G. Physiotherapy and intermittent positive-pressure ventilation of chronic bronchitis.BMJ. 1978; 2: 1525-1528Crossref PubMed Scopus (34) Google Scholar However, there is significant support for the use of CSRT in patients with impairment of mucociliary clearance (eg, the critically ill and patients with cystic fibrosis and bronchiectases10Connors A.F. Hammon W.E. Martin R.J. Rogers R.M. Chest physical therapy: the immediate effect on oxygenation in acutely ill patients.Chest. 1980; 78: 559-564Crossref PubMed Scopus (87) Google Scholar,15Cochrane G.M. Webber B.A. Clarke S.W. Effects of sputum on pulmonary function.BMJ. 1977; 2: 1181-1183Crossref PubMed Scopus (87) Google Scholar, 16Denton R. Bronical secretions in cystic fibrosis.Am Rev Respir Dis. 1962; 86: 41-46PubMed Google Scholar, 17Desmond K. Schwenk W.F. Thomas E. Beaudry P.H. Coates A.L. Immediate and long term effects of chest physiotherapy in patients with cystic fibrosis.J Paediatr. 1983; 103: 538-542Abstract Full Text PDF PubMed Scopus (99) Google Scholar, 18Feldman J. Traver G.A. Taussig L.M. Maximal expiratory flows after postural drainage.Am Rev Respir Dis. 1979; 119: 239-245PubMed Google Scholar, 19MacKenzie C.F. Shin B. McAslan T.C. Chest physiotherapy: the effect on arterial oxygenation.Anaesth Analg. 1978; 57: 28-30Crossref PubMed Google Scholar, 20MacKenzie C.F. Shin B. Hadi F. Imle P.C. Changes in total lung/ thorax compliance following chest physiotherapy.Anaesth Analg. 1980; 59: 207-210Crossref PubMed Scopus (35) Google Scholar, 21MacKenzie C.F. Shin B. Cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with post-traumatic respiratory failure.Crit Care Med. 1985; 13: 483-486Crossref PubMed Scopus (58) Google Scholar, 22Marini J.J. Pierson D.J. Hudson L.D. Acute lobar atelectasis: a prospective comparison of fiberoptic bronchoscopy and respiatory therapy.Am Rev Respir Dis. 1979; 119: 971-978PubMed Google Scholar, 23Mazzocco M.C. Owens G.R. Kirilloff L.H. Rogers R.M. Chest percussion and postural drainage in patients with brochiectasis.Chest. 1985; 88: 360-363Crossref PubMed Scopus (51) Google Scholar, 24Reisman J. Rivington-Law B. Corey M. Marcotte J. Wanamaker E. Harcourt D. et al.Role of conventional therapy in cystic fibrosis.J Paediatr. 1988; 113: 632-636Abstract Full Text PDF PubMed Scopus (103) Google Scholar, 25Winning T.J. Brock-Utne J.G. Goodwin M.N. Bronchodilators and physiotherapy during long term mechanical ventilation of the lungs Anaest Crit Care. 1977; 5: 48-50Google Scholar, 26Wong J.W. Keens T.G. Wannamaker E.M. Effects of gravity on tracheal mucus transport rates in normal subjects and in patients with cystic fibrosis.Pediatrics. 1977; 60: 146-152PubMed Google Scholar) and as a first-line treatment for lung collapse.22Marini J.J. Pierson D.J. Hudson L.D. Acute lobar atelectasis: a prospective comparison of fiberoptic bronchoscopy and respiatory therapy.Am Rev Respir Dis. 1979; 119: 971-978PubMed Google Scholar, 27Jaworski A. Goldberg S.K. Walkenstein M.D. Wilson B. Lippmann M.L. Utility of immediate postlobectomy fiberoptic bronchoscopy in preventing atelectasis.Chest. 1988; 94: 38-43Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 28Olopade C.O. Prakash U.B.S. Bronchoscopy in the critical-care unit.Mayo Clin Proc. 1989; 64: 1255-1263Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar In addition, CSRT improves thoracic compliance, intrapulmonary shunt20MacKenzie C.F. Shin B. Hadi F. Imle P.C. Changes in total lung/ thorax compliance following chest physiotherapy.Anaesth Analg. 1980; 59: 207-210Crossref PubMed Scopus (35) Google Scholar, 21MacKenzie C.F. Shin B. Cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with post-traumatic respiratory failure.Crit Care Med. 1985; 13: 483-486Crossref PubMed Scopus (58) Google Scholar, 29Winning T.J. Brock-Utne J.G. Goodwin N.M. A simple clinical method of quantitating the effects of chest physiotherapy in mechanically ventilated patients.Anaesth Intensive Care. 1975; 3: 237-238Google Scholar and specific airway conductance.15Cochrane G.M. Webber B.A. Clarke S.W. Effects of sputum on pulmonary function.BMJ. 1977; 2: 1181-1183Crossref PubMed Scopus (87) Google Scholar Dean and Ross state that evidence fails to support percussion and vibration as efficacious procedures. Research in this area is inadequate and nonuniform, making it impossible to draw definite conclusions concerning the efficacy of specific techniques.13May D.B. Mint P.W. Physiologic effects of chest percussion and postural drainage in patients with stable chronic bronchitis.Chest. 1979; 75: 29-32Crossref PubMed Scopus (51) Google Scholar,16Denton R. Bronical secretions in cystic fibrosis.Am Rev Respir Dis. 1962; 86: 41-46PubMed Google Scholar,26Wong J.W. Keens T.G. Wannamaker E.M. Effects of gravity on tracheal mucus transport rates in normal subjects and in patients with cystic fibrosis.Pediatrics. 1977; 60: 146-152PubMed Google Scholar,30Bateman J.R.M. Newman S.P. Daunt K.M. Is cough as effective as chest physiotherapy in the removal of excessive tracheobronchial secretions?.Thorax. 1981; 36: 683-687Crossref PubMed Scopus (64) Google Scholar, 31Chopra S.K. Taplin G.V. Simons D.H. Effects of hydration and physical therapy on tracheal transport velocity.Am Rev Respir Dis. 1977; 115: 1009-1014PubMed Google Scholar, 32De Boeck C. Cough versus chest physiotherapy: a comparison of the acute effets on pulmonary function in patients with cystic fibrosis.Am Rev Respir Dis. 1984; 129: 182-184PubMed Google Scholar, 33Oldenburg F.A. Dolovich M.B. Montgomery J.M. Effects of postural drainage, exercise and cough on mucus clearance in chronic bronchitis.Am Rev Respir Dis. 1979; 120: 739-747PubMed Google Scholar, 34Pavia D. The role of chest physiotherapy in mucus hypersecretion.Lung. 1990; 168: 614-621Crossref PubMed Scopus (18) Google Scholar, 35Rossman C.M. Waldes R. Sampson D. Newhouse M.T. Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis.Am Revc Respir Dis. 1982; 126: 131-135PubMed Google Scholar, 36Sutton PP. Lopez-Vidiero VIT, Pavia D. Assessment of percussion. vibratory shaking and breathing exercises in chest physiotherapy. Eur J Respir Dis 66: 147-52Google Scholar, 37Van Der Schans C.P. Piers D.A. Postma D.S. Effect of manual percussion on tracheobronhial clearance in patients with chronic airflow obstruction and excessive tracheobronchial secretions.Thorax. 1986; 41: 448-452Crossref PubMed Scopus (44) Google Scholar In the future, treatments such as the forced expiratory technique, use of the positive expiratory pressure mask, and autogenic drainage may prove to be effective, alone or in combination with CSRT. A review of these techniques was carried out by Lapin in 1990.38Lapin A. Chest physical therapy in cystic fibrosis: a review.Cardiopulmonary Phys Ther. 1990; 7: 11-13Google Scholar The authors focus on the importance of the oxygen transport chain and assert that CSRT addresses only one part of the chain. However, CPP goals must also address other complications of retained secretions, namely, (1) preventing mucus plugging and lung collapse, which can result in cardiorespiratory compromise as a result of mediastinal shift; (2) reducing the potential for nosocomial pneumonia; and (3) improving pulmonary compliance and reducing the work of breathing. The article discusses the association of CSRT with adverse effects. When CSRT is appropriately administered, however, patients are stable or improved with treatment.9Buscaglia A.J. St Marie M.S. Oxygen saturation during chest physiotherapy for acute exacerbation of severe chronic obstructed pulmonary diseas.Respir Car. 1983; 2: 1009-1013Google Scholar, 10Connors A.F. Hammon W.E. Martin R.J. Rogers R.M. Chest physical therapy: the immediate effect on oxygenation in acutely ill patients.Chest. 1980; 78: 559-564Crossref PubMed Scopus (87) Google Scholar, 19MacKenzie C.F. Shin B. McAslan T.C. Chest physiotherapy: the effect on arterial oxygenation.Anaesth Analg. 1978; 57: 28-30Crossref PubMed Google Scholar, 21MacKenzie C.F. Shin B. Cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with post-traumatic respiratory failure.Crit Care Med. 1985; 13: 483-486Crossref PubMed Scopus (58) Google Scholar, 25Winning T.J. Brock-Utne J.G. Goodwin M.N. Bronchodilators and physiotherapy during long term mechanical ventilation of the lungs Anaest Crit Care. 1977; 5: 48-50Google Scholar, 29Winning T.J. Brock-Utne J.G. Goodwin N.M. A simple clinical method of quantitating the effects of chest physiotherapy in mechanically ventilated patients.Anaesth Intensive Care. 1975; 3: 237-238Google Scholar, 39Finer N.N. Boyd J. Chest physiotherapy in the neonate: a controlled study.Pediatrics. 1978; 61: 282-285PubMed Google Scholar Many studies have attempted to address the relationship between secretions and pulmonary function. Newton and Stephenson,40Newton D.A.G. Stephenson A. Effect of physiotherapy on pulmonary function.Lancet. 1978; 2: 228-229Abstract PubMed Scopus (35) Google Scholar cited by Dean and Ross, demonstrated an inconsistent relationship between secretions and pulmonary function. Other studies, however, revealed an improvement in pulmonary function.15Cochrane G.M. Webber B.A. Clarke S.W. Effects of sputum on pulmonary function.BMJ. 1977; 2: 1181-1183Crossref PubMed Scopus (87) Google Scholar, 18Feldman J. Traver G.A. Taussig L.M. Maximal expiratory flows after postural drainage.Am Rev Respir Dis. 1979; 119: 239-245PubMed Google Scholar, 20MacKenzie C.F. Shin B. Hadi F. Imle P.C. Changes in total lung/ thorax compliance following chest physiotherapy.Anaesth Analg. 1980; 59: 207-210Crossref PubMed Scopus (35) Google Scholar, 25Winning T.J. Brock-Utne J.G. Goodwin M.N. Bronchodilators and physiotherapy during long term mechanical ventilation of the lungs Anaest Crit Care. 1977; 5: 48-50Google Scholar, 29Winning T.J. Brock-Utne J.G. Goodwin N.M. A simple clinical method of quantitating the effects of chest physiotherapy in mechanically ventilated patients.Anaesth Intensive Care. 1975; 3: 237-238Google Scholar Although there is a real need for longitudinal studies on the benefits of secretion removal, it is dangerous to suggest that this is not an integral aspect of physiotherapy in some populations.17Desmond K. Schwenk W.F. Thomas E. Beaudry P.H. Coates A.L. Immediate and long term effects of chest physiotherapy in patients with cystic fibrosis.J Paediatr. 1983; 103: 538-542Abstract Full Text PDF PubMed Scopus (99) Google Scholar, 24Reisman J. Rivington-Law B. Corey M. Marcotte J. Wanamaker E. Harcourt D. et al.Role of conventional therapy in cystic fibrosis.J Paediatr. 1988; 113: 632-636Abstract Full Text PDF PubMed Scopus (103) Google Scholar While current physiotherapy practice would not include CSRT interventions for stable COPD, it is interesting to note that some authors have shown benefits in this patient population.18Feldman J. Traver G.A. Taussig L.M. Maximal expiratory flows after postural drainage.Am Rev Respir Dis. 1979; 119: 239-245PubMed Google Scholar, 30Bateman J.R.M. Newman S.P. Daunt K.M. Is cough as effective as chest physiotherapy in the removal of excessive tracheobronchial secretions?.Thorax. 1981; 36: 683-687Crossref PubMed Scopus (64) Google Scholar, 37Van Der Schans C.P. Piers D.A. Postma D.S. Effect of manual percussion on tracheobronhial clearance in patients with chronic airflow obstruction and excessive tracheobronchial secretions.Thorax. 1986; 41: 448-452Crossref PubMed Scopus (44) Google Scholar, 40Newton D.A.G. Stephenson A. Effect of physiotherapy on pulmonary function.Lancet. 1978; 2: 228-229Abstract PubMed Scopus (35) Google Scholar, 41Bateman J.R.M. Newman S.P. Daunt K.M. Regional lung clearance of excessive bronchail secretions during chest physiotherapy in patients with stable chronic airways obstruction.Lancet. 1979; 1: 294-297Abstract PubMed Scopus (52) Google Scholar The importance of a CPP focus on optimizing steps of the oxygen transport system is repeatedly emphasized by Dean and Ross. While physiotherapists would always have this as a treatment goal, the authors focused on only one aspect of the oxygen transport system. The goals of positioning, mobilization, and CSRT are to reduce physiologic shunting and to improve ventilation-perfusion matching, gas exchange, and pulmonary function. The potential effect of physiotherapy intervention on the partial pressure of arterial carbon dioxide, and thereby the affinity of hemoglobin for oxygen, and the beneficial effects of exercise on oxygen transport and delivery,42Astrand P. Exercise physiology and its role in disease prevention and rehabilitation.Arch Phys Med Rehabil. 1987; 68: 305-309PubMed Google Scholar, 43Ernst E. Peripheral vascular disease: benefits of exercise.Sports Med. 1991; 12: 149-151Crossref PubMed Scopus (10) Google Scholar, 44Painter P. Zimmerman SW Exercise in end-stage renal disease.Am J Kidney Dis. 1986; 3: 386-394Abstract Full Text PDF Scopus (39) Google Scholar, 45Posner J.D. Gorman K.M. Windsor-Landsberg L. Low to moderate intensity endurance training in healthy older adults: physiological responses after four months.J Am Geriatr Soc. 1992; 40: 1-7Crossref PubMed Scopus (86) Google Scholar, 46Weiss T. Fujita Y. Kreimeier U. Messmer K. Effect of intensive walking exercise on skeletal muscle blood flow in intermittent claudication.Angiology. 1992; 43: 63-71Crossref PubMed Scopus (26) Google Scholar for example, are not discussed. In summary, until research clearly establishes the efficacy of different CPP interventions, it is premature to make strong conclusions. While it is accurate to point to the lack of research to support all aspects of CPP, it is incorrect to imply that physiotherapists do not keep abreast of research or base practice on sound physiologic principles. In my experience with undergraduates and qualified therapists, it is clear that physiotherapy practice is based upon sound reasoning, a comprehensive knowledge of physiologic principles, response to treatment, and critical application of existing research. Discordance Between Cardiopulmonary Physiology and Physical TherapyCHESTVol. 105Issue 1PreviewWe appreciate having an opportunity to respond to Ms. O'Callaghan's response to our article, for it is only with such dialogue that the field can advance. Full-Text PDF
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