Complications of Positioning and Chest Physiotherapy

Abstract

Chest physiotherapy (CPT) is administered to mobilize respiratory secretions and to increase the amount of tracheobronchial mucus cleared from the respiratory tree. CPT consists of one or more of the following: therapeutic positioning, percussion, vibration, and coughing. In therapeutic positioning, also called postural or bronchial drainage, the position of choice is “good”-lung-down,-“bad”-lung-up, and positioning is gaining in popularity as a means of enhancing air entry into alveoli that have collapsed as a result of localized conditions. Complications of CPT have been infrequently reported but are severe when they occur. Some of these are massive pulmonary hemorrhage, perhaps caused by clots dislodged during percussion, a decrease in PaO₂ from positioning the "bad" lung down, and rib fractures in a neonate with hyaline membrane disease. Percussion and vibration should not be done when bright red hemoptysis is present and recent, and head-down positioning should be used cautiously and only when the affected lung is uppermost. Adverse physiologic effects associated with CPT occur in a small proportion of the patients studied and generally are of modest clinical significance. Some that have been reported are an increase in intracranial pressure (ICP), a fall in PaO₂, a decrease in cardiac output, which may make CPT hazardous in the first 24 hours after a procedure like mitral valve replacement, a fall in FEV1, possibly caused by percussion without the prior administration of a bronchodilator, a fall in specific airways conductance, and a decrease in total lung/thorax compliance. Patients with increased ICP, hypoxemia, cardiovascular or hemodynamic instability, and marked bronchospasm should be treated with extreme caution and monitored carefully. Recognition of the nature of and potential for the complications and adverse effects of CPT allows the therapist to modify therapy so that it may be safely administered to both the critically and the chronically ill.