Tuesday, January 15, 2013

History of Chest Physiotherapy

Scientists have recently discovered evidence of emphysema, chronic bronchitis, pneumonia and other diseases that cause thick secretions in mummified human remains.  So it's evident humans have had to deal with these conditions from the beginning of human existence.

Ancient Assyrian texts that may date back 3,000 years show evidence that doctors way back then made efforts to help these patients.  One Assyrian text describes the following:

"If the patient suffers from hissing cough, if his wind-pipe is full of murmurs, if he coughs, if he has coughing fits, if he has phlegm: bray together roses and mustard in purified oil, drop it on his tongue, fill, moreover, a tube with it and blow it into his nostrils. Thereafter he shall drink several times beer of the finest quality; thus he will recover." (1, 2)

There were various herbal and medicinal options available to doctors in various regions of the world, although due to lack of communication between civilizations, and the lack of any organized medical groups, methods of airway clearance didn't become uniform in the medical community until recent times.

Chest physiotherapy (CPT) is one of the simplest methods of helping a patient clear thick secretions.  The technique involves cupping your hands and clapping on the patient's back and chest. This is often accompanied with postural drainage, which involves having the patient lie in different positions in order to promote the drainage of secretions from different areas of the chest.

The use of postural drainage was first mentioned by S. H. Quincke in 1898.  He recommended "intermittent" use of postural drainage to treat patients with thick secretions.  Yet this technique wasn't adapted by the medical community until William Ewart recommended CPT with postural drainage in 1901.  (2)

Ewart worked with children with bronchiectasis, and he recommended "continuous postural drainage" as opposed to "intermittent" to these children in order to promote the removal of thick tenacious secretions.  By continuous he meant that it should be done frequently, as opposed to just once a day.   Generally, the treatment was prescribed 3-4 times a day for up to 10 minutes, and this is still how it's ordered today for the same reasons.(3)

While Ewart may have spearheaded the idea of CPT and postural drainage for bronchiectasis and eventually cystic fibrosis patients, the use of these techniques was ultimately found to be useful to prevent and treat complications that result from performing surgeries.  Physicians noted many of their post operative patients were developing respiratory complications not related to the surgery itself, and they sought to understand and find a solution.

This concept of using CPT to prevent and treat post operative respiratory complications was first described in 1915 by MacMahon in an article about how to treat post operative trauma patients patients.  In fact, not only did he recommend the use of CPT, he also recognized the importance of exercising as soon as possible after a surgery to get the lungs back to normal, or their pre-operative status.  (4)

Most of the patients MacMahon treated were soldiers injured in battle.  He recommended CPT with exercise, and forced exhalation, and reported that the results were "remarkable," particularly within one week.  By 1919 there was an increasing body of evidence to suggest that where there is "serious lung collapse and chest deformity following wounds or illness, breathing and physical exercises should, in certain cases, be given as accessories to medical and surgical treatment, if the best possible recovery is to be assured."  (2)

Yet it wasn't until the 1950s, when surgeries started to be a mainstay in hospitals, that studies any extensive studies were perfomed to determine the efficacy of doing the procedure, according to Colleen M. Kigin in her 1981 article in Physical Therapy "."Chest Physical Therapy for the Postoperative or Traumatic Injury Patient,"  (5)

Kigin explained that Loius Pasteur first recognized atelectasis in 1908 after "temporary inhibition of muscular activity." In the 1930s studies showed a link between post operative respiratory distress and hypoxemia (low oxygen in the blood).  In 1952 atelectasis was recognized by R.N.V. Palmer and BA Sellick as the most common cause of post operative complications.  (5, 6)

Palmer and Sellick described that some of the best results in treating these complications are by using percussion, postural drainage, and treatments with isoprenaline.  They were among the first to recognize the value of using beta adrenergics to treat and prevent post operative complications.  The idea was that anesthesia causes "reflex bronchospasm" and this results in the retention of secretions.  They concluded that Isoprenaline given before and during anesthesia treated this perceived problem by dilating airways and enhancing secretion clearance in that way.  (7)

It was during the 1950s that the medical community decided that intermittent positive pressure breathing was an effective method of preventing and treating post operative respiratory complications.  This technique forced air into the patients lungs, and it was believed that this helped them take a deep enough breath to open collapsed alveoli.  This technique was proven to be ineffective in the 1970s.  I wrote about the IPPB revolution in this post.

Overall, and other than trials of IPPB therapy, the "gold standard" for preventing post operative pulmonary complications was chest physiotherapy until the 1960s when other methods, such as the incentive spirometer, were discovered to also benefit such patients.  There were also some mechanical percusors available, yet there was never any conclusive evidence they did any better of a job than CPT.  Whether to use cupped hands or a mechanical device was generally left to the institution or therapist. (2) 

In 1970 the incentive spirometer (IS) was invented.  It was believed to be more effective than any of the other methods used to promote airway clearance because it could be done by the patient alone.  Seeing this device on the bedside table acted as a reminder or an incentive to take deep breaths.  Likewise, being able to see how high they could make the bellow or balls move up acted as positive feedback.  The patient and the physician could also monitor progress. I wrote about the history if the IS here

During the 1970s many studies were done to determine the effects of both the incentive spirometer and CPT.  A 1974 article in the British Journal of Surgery studied a group of post operative patients that were treated with CPT and another group treated with IS therapy.  The CPT was done only twice a day, and the IS every hour.  Those in the group receiving CPT had a 63 percent chance of developing post operative complications, and those in the IS group had only a 37% chance of developing complications.  The researchers decided CPT may have been less effective because deep breathing exercises weren't encouraged. (8)

Flutter Valve
During the early 1990s the flutter device was introduced to the market as an alternative to CPT to help with mucus clearance.  It's a hand held device that the patient blows into.  This causes ball bearings inside it to "oscillate at a high frequency, aresulting in vibrations of the airways and intermittent positive expiratoto facilitate mucus expectoration."  While studies show CPT is a better method of helping patinets with cystic fibrosis remove secretions and improve lung volumes, other studies showed that use of a flutter device was even more effective.  Studies also showed that CF patients coughed up three times as much with the flutter as compared to CPT. (10) 

Since study sample sizes of studies comparing the various devices for airway clearance have been small, it's difficult to get a dininitive answer as to which one is best to use.  However, based on present study results, it does seem that the flutter valve is a useful technique (11)  Still, which technique to use is a personal preference.  Use of a flutter device is nice because the patient can do it on his own, although the initial expense of flutter devices cost significantly more than CPT. 

Acapella (PEP devices)
Another device introduced about the same time as the Flutter valve to help with airway clearance was a Positive Expiratory Pressure (PEP) device called the Acapella. These devices create both oscillations and PEP similar to the flutter valve, although the mechanisms are different.  (12) Some studies show PEP therapy may be even more effective than flutter valves in helping patinets remove secretions, although, once again, sample sizes are small, so obtaining a difinitive answer is difficult.  (13)

Other studies are even more inconclusive, and state there is no evidence one method is any better than the other.  (14)

While CPT, PEP and flutter valves are ordered in hospitals based on availability and personal preference, most hospitals continue to have regular protocols for giving incentive spirometers to most post operative patients.  While there has never been a study that has proven the incentive spirometer has any effect on treating and preventing post operative respiratory complications, (9) most hospitals have developed protocols that recommend all post operative patients be given an incentive spirometer by a respiratory therapist, be educated on how to use it, and encouraged to use it at least 10 times every hour.

Many hospital protocols go a step further and instruct patients how to use these devices prior to surgeries, especially those who will get upper abdominal and thoracic surgeries.  I think this is a good idea because it can be difficult to teach this device to patients when they are sedated after surgery.  It's also nice to know how well they did on it before surgery so we know when their lung volumes are back to normal.

Some physicians throw the gamete at all post operative patients. We have one doctor who orders post operative patients to get an albuterol breathing treatment, incentive spirometer, and CPT four times every day for three day.  Some doctors only order one or more of these procedures when a patient develops a fever, which is a common sign of atelectasis.  However, it must be known that there has never been a conclusive study showing any of these methods do any good.

Yet regardless of all the technology, CPT continues to be the gold standard method of helping patients promote airway clearance.  Regardless of what studies say, just havintg a respiratory therapist in the room moving the patient from side to side assures the physician the patient will be assessed and moved on a regular basis.  This alone may all that most patients need for a speedy recovery. 

References:  
  1. Sigerist HE, "A History of Medicine. Vol 1. Primitive and Archaic Medicine," 1951, New York, Oxford University Press, 1951; p. 481
  2. Pryor, JA, "Physiotherapy for airway clearance in adults," European Respiratory Journal, 1999, 14, pages 1418-24
  3. Nelson, HP, "Postural Drainage of the Lungs," The British Medical Journal, August 11, 1934, pages 251-255
  4. MacMahon, C, "Breathing and physical exercises for use caes of wounds in the pleura, lung and diaphragm," Lancet, 1915, pages 769-70
  5. Kigen, Colleen M, "Chest Physical Therapy for the Postoperative or Traumatic Injury Patient," Physical Therapy, 1981; 61; pages 1724-1736
  6. Palmer, RNV, Sellick BA, "The Prevention of Post Operative Pulmonary Atelectasis," Lancet, 1953, 1; pages 164-168
  7. Odell, J.R., "Prevention of Post Operative Chest Complicaitons," Anesthesia, January, 1959, Vol 14, no. 1, pages 68-75
  8. Craven, J.L., et al, "The evaluation of incentive spirometer in the management of post operative pulmonary complications," British Journal of Surgery, 1974, 61, pages 793-7
  9. Overland, Tom J., et al, "The Effect of Incentive Spirometry on Postoperative Pulmonary Complications: A Systemic Review," Chest, September 2001, vol. 120, no. 3, pages 971-978
  10. Gondor, Megdalen, et al, "Comparison of Flutter Device and Physical Therapy in the Treatment of Cystic Fibrosis Pulmonary Exacerbation," Pediatric Pulmonology, 1999, 28; pages 255-260
  11. Homnick, DN, K. Anderson, JH Marks, "Comparison of the flutter device standard chest physiotherapy in hospitalized patients with cystic fibrosis: a pilot study," Chest, 1998, 114, pages 993-997
  12. Volsko, Teressa, et al, "Performance Comparison of Two Oscillating Positive Expiratory Pressure Devices: Acapella versus Flutter," Respiratory Care, 2003, 48 (2), pages 124-130
  13. Mcllwaine, P.M., et al, "Long-term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure (flutter) physiotherapy in the treatment of cystic fibrosis, Journal of Pediatrics, 2001, June, 138 (6), pages 845-50
  14. Westerdahl, Orman J, "Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review," 2009, Oct. 29, vol. 54, issue 3, pages 261-267

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