Chest Percussion and Postural Drainage in Patients with Bronchiectasis

Chest Percussion and Postural Drainage in Patients with Bronchiectasis* Marion C. Mazzocco , R.N., M.S.N. ; Gregory R. Owens, M.D ., EC.C .P.; Leslie H. Kirilloff, R.N. , Ph.D. ; and Robert M. Rogers , M.D ., EC.C.P.

Patients with chronic obstructive pulmonary disease have been treated routinely with chest physical therapy for many years in spite of a lack of scientific validation of this procedure. Only recently have the indications for chest physical therapy been clarified. It is currently believed that such therapy is especially beneficial in patients with copious secretions, and that it is less effective in patients with scanty secretions. No study has specifically evaluated the efficacy ofchest physical therapy in patients with bronchiectasis. We

accordingly evaluated 13 patients with stable bronchiectasis to determine the effects of chest physical therapy on pulmonary function, arterial oxygenation, and sputum production and to assess whether this therapy was associated with any significant side-effects. We found that chest physical therapy was safe and well tolerated and assisted the patients in mobilizationof their sputum. However, such therapy had no immediate delayed effects on pulmonary function or oxygen saturation.

Chest physical therapy has been used in the routine care of patients with chronic obstructive pulmonary disease (COPD) for at least 50 years. Although regimens incorporating chest physical therapy components (p e rc ussio n, postural drainage, vibration , directed coughing, and suctioning) have been widely used, only recently have attempts been made to determine their efficacy. Published studies have shown that chest physical therapy is effective primarily in patients with copious secretions, 1-4 but has little or no beneficial effects in patients with scant secretions.P" One of the diseases associated with the production of copious, purulent secretions is bronchiectasis. In spite of the fact that chest physical therapy would seem particularly important for patients with this disease because of their sputum volume, there have been no studies evaluating a uniform group of patients with this disease. Cochrane and associates' performed the only study to date evaluating the effect of chest physical therapy on pulmonary function in patients with bronchiectasis. They studied 23 patients with copious sputum production , ten of whom had bronchiectasis. They found that specific airway conductance (SGaw) improved in 17 of their patients after chest physical therapy. No relationship was found between the volume of sputum produced and changes in SGaw. We have studied 13 stable outpatients with a diagnosis of bronchiectasis with two goals : (1) to determine the effect of chest physical therapy on pulmonary function, arterial oxygenation, and sputum production, and (2) to assess if such therapy was associated

with any untoward effects, specifically the development of arterial desaturation, arrhythmias, or worsening pulmonary function. We found that chest physical therapy had no immediate or delayed effect on indices of pulmonary function, oxygen saturation, or heart rate, but that it assisted patients in the mobilization of their sputum .

-From the Pulmonary Specialty, School of Nursing and the Division of Pulmonary Medicine. Department of Medicine, University of Pittsburgh and Presbyterian-University Hospital, Pittsburgh. Manuscript received January 22; revision accepted March 20. Reprint requests: Dr: Rogers , 440 Scaife Hall , 3550 Terrace Street, Pittsburgh 15139

360

METHODS

A total of 13 patients (11 men and two women ), ranging in age from 31 to 68 (mean 52) years, were included in this stud y. The patients were selected from individuals seen in outpatient pulmonary clinics of the University Health Center Hospitals . Patients were entered in the study if the y met the following criteria: (1) Were diagnosed as having bronchiectasis and were being followed as outpatients by the University of Pittsburgh Division of Pulmonary Medicine. The diagnoses were, in general, clinical (only two patients underwent bronchography). based on a history of chronic production of purulent sputum in the absence of cigarette smoking, usually with a past medical history of previous severe pertussis or measles infection. and a chest roentgenogram showing dilated bronchi. Patients with cystic fibrosis were excluded. (2) Produced at least 30 ml of sputum per day and used postural drainage at home for sputum mobilization. (3) Had no previous history of cardiac arrh ythmias, myocardial infarction . or cerebrovascular accident. Subjects were asked to abstain from chest percussion and postural drainage for at least six hours before the study, but were told to continue taking their routine medications. Pulmonary function indices studied included forced vital capacit y (FVC). forced expiratory volume in 1 second (FEV1). and peak expiratory flow rate (PEF). Pulmonary function testing was performed by one observer (MM) using accepted standards." Pulmonary function tests were performed on a rolling-seal spirometer (Gould 5000 IV). Predicted normal values for spirometry were those of Morris and colleagues. ,. Arterial oxygen saturation was measured by an ear oximeter. Heart rate and rhythm was measured and recorded on a cardiotach (Hewlett-Packard 783l2A). Pulmonary function tests. arterial oxygenation, and heart rates were measured at four time periods: (1) baseline; (2) after the patient Chest Percussion and Postural Drainage in Bronchiectasis (Mazzocco st a1)

Table I-BfJ8eline Pulmonary Function Tests Results and Oxygen Saturations Patient No.

FVC (L)

FEV. (L)

1 2 3 4 5 6 7 8 9 10 11 12 13

1.64 (34)* 3.32 (73) 3.79 (55) 2.16 (43) 0.68 (16) 1.68 (44) 3.96 (88) 4.16 (lll) 4.65 (94) 3.10 (71) 2.30 (83) 4.14 (105) 3.45 (84)

1.08 (31) 1.69 (52) 1.82 (36) 1.02 (26) 0.65 (20) 1.37 (48) 1.70 (52) 2.79 (94) 3.25 (92) 1.57 (45) 1.32 (67) 1.24 (44) 2.40 (83)

FEV/FVC 66 51 48

47 96 82 43 67 70 51 57 30 70

PEF Us

O2 sat.

3.22 (37) 3.78 (44) 3.37 (28) 3.51 (39) 3.46 (43) 3.78 (51) 2.71 (32) 3.83 (59) 12.69 (139) 5.47 (64) 4.65 (86) 4.84 (64) 10.29 (132)

87t 91 98 86 95

(%)

94 94

97 92 94

96 91 93

*Numbers in parentheses indicate percent of predicted. tPatient tested on oxygen. was lying in the right lateral decubitus position with the foot of the

bed elevated 1.2 inches (approximately 10°ofTrendelenburg) for at least ten minutes (postural drainage alone); (3)immediately after ten minutes of chest percussion or postural drainage given with the patient in the above position; and (4)30 minutes after completion of the chest percussion and postural drainage. No effort was made to randomize the two physical therapy procedures. At each interval , at least three FVC maneuvers were performed by each subject. All initial and subsequent measurements of pulmonary function were done with the patients in the sitting position. The subjects were encouraged to expectorate sputum after each period. Expectorated sputum was collected in a graduated container. Measurements were made of the amount expectorated: (1) during the initial pulmonary function tests ; (2) during the ten minutes of postural drainage and subsequent pulmonary function tests ; (3)during the chest percussion and postural drainage and subsequent pulmonary function tests ; and (4) from the beginning of the 3O-minute rest period until completion of pulmonary function measurements. The numerical data obtained were analyzed using Students t-test. Approval to conduct this study was obtained from the Biomedical Institutional Review Board of the University of Pittsburgh. Each patient gave informed consent. RESULTS

Results of baseline pulmonary function tests and resting oxygen saturations for the study population are shown in Table 1. The patients had a wide range of pulmonary function abnormalities with reductions in forced vital capacity (mean 3.00 ± 1.20 L - 69 ± 29 percent of predicted), FEV. (mean 1.66 ± 0.74 Table 2-Changes in Pulmonary FUnction, Arterial Oxygen Saturation, and Heart Rate During Chest Physiotherapy Variable

Control

FVC(L) FEV,(L) PEF (Us) Sa02 (%) HR (beats/minute)

3.00~ 1.2

2.98~

1.66~ .74

1.66~ .79

5 .05~3 .0

4 .70~3 .0

4.49~3 .1

4 .68~2 .9

93~4

93~4

93~3

93~3

88~14

87~16

85~16

87~15

PO*

PDP

1.3 3.01 ~ 1.3 1.61 ~ .87

30 mm Rest 2.98 ~ 1.4 1.58 ~ .89

*PO is postural drainage; and PDp, percussion and postural drainage.

L - 53 ± 24 percent of predicted), and PEF (mean 5.05 ± 3.00 Us - 36 percent of predicted). The results of pulmonary function testing, oxygen saturation measurements, and heart rate measurements for the four test periods are shown in Table 2. There were no statistically significant changes in FVC, FEV., or PEF after either postural drainage or percussion with postural drainage when compared to baseline data . Likewise, there was no improvement or deterioration in any measured pulmonary function index 30 minutes after completion of the chest physical therapy procedures. There was also no statistically significant change in oxygen saturation or heart rate at any of the testing intervals when compared to baseline results. Four individuals were noted to have cardiac irregularities during the postural drainage with or without percussion. These arrhythmias consisted of occasional ventricular premature beats in one individual and combined atrial and ventricular premature beats in the remaining three. No patient with arrhythmia was symptomatic or experienced desaturation. None of the arrhythmias resulted in an alteration in blood pressure. The total amount of sputum expectorated by the subjects during the testing period ranged from 0 to 110 ml. One subject produced no sputum. Five subjects produced 1 to 10 ml of sputum . Five subjects produced 12 to 30 ml. Only two subjects produced more than 30 ml of sputum . All patients were instructed to save their sputum produced during the day of testing. Total daily sputum production ranged from 30 to 360 ml. The percentage of total daily sputum production obtained during the physical therapy ranged from 2 percent to 50 percent (mean 19 percent) of the total daily sputum production in the 12 patients who produced sputum during the physical therapy session . The total amount of sputum produced varied during the testing period. In all but five patients, the first two testing periods (initial baseline pulmonary function tests and ten minutes of postural drainage and pulmonary function tests) accounted for the greatest amount of sputum production. As a group, the patients expectorated 20 percent of their total sputum volume during the baseline period, 48 percent after postural drainage, 15 percent after percussion and postural drainage, and 17 percent in the 30-minute rest period. Expectoration during the baseline period resulted from coughing induced during pulmonary function testing. Four of 13 subjects expectorated sputum during this period. All were large daily sputum producers (~50 mllday). DISCUSSION

This study demonstrates that chest physical therapy in patients with bronchiectasis is safe and helpful in the mobilization of secretions. However, this removal of CHEST I 88 I 3 I SEPTEMBER, 1985

361

secretions is not associated with any change in the pulmonary function indices which were measured. The results of chest physical therapy on pulmonary function in this study are comparable to that found in other studies ofadult patients with stable chronic lung disease. Both May and Munt" and March" studied patients with chronic obstructive lung disease with scant secretions and found no improvement in FVC or FEVl after treatment with chest physical therapy. In addition, Campbell and colleagues" and Newton and Stephenson' evaluated the effects of chest physical therapy on pulmonary function in patients with an exacerbation of chronic bronchitis. In the former study, the use ofchest physical therapy was associated with a fall in FEV.. while the latter study could show no improvement in pulmonary function after chest physical therapy. Other studies have evaluated the effects of chest physical therapy on sputum volume and radioaerosol clearance in patients with copious sputum production, some of whom had the diagnosis of bronchiectasis. Bateman and colleagues" studied the effect of chest physical therapy, consisting of postural drainage, percussion, vibration, and shaking, on radioaerosol clearance in ten patients, four of whom had bronchiectasis. They found that clearance was significantly increased in both central and peripheral lung regions after chest physical therapy. In a following study, " these investigators compared chest physical therapy to directed coughing in a small group of patients with chronic bronchitis and bronchiectasis. They found that both cough alone and physical therapy were equally effective in increasing clearance of radioaerosol from central lung regions, but that only chest physical therapy improved peripheral lung clearance. Sutton and colleagues' also compare directed coughing with chest physical therapy in a group of ten patients, five of whom had bronchiectasis. Like Bateman et al," they could find no effect of directed coughing on radioaerosol clearance. However, the application of a specialized cough technique, the forced expiration technique, did increase sputum clearance. Coughing induced by spirometric maneuvers was also effective in mobilizing sputum in some of our patients. Of the 13 subjects, four expectorated during baseline testing as a result of coughing induced by forced expiratory spirometry. The only group that appears to consistently benefit frequently from chest physical therapy are patients with cystic fibrosis since this therapy has been shown to increase mucus clearance, J3 increase sputum volume, I• •is and improve pulmonary function. 16 Although bronchiectasis is found in patients with cystic fibrosis, there are numerous differences between these patients and those with bronchiectasis including alterations in mucous viscosity, impaired ciliary function, and re-

peated or chronic infection with agents such as Pseudomonas aeroginosa which are found in patients with cystic fibrosis . Whether one of these factors or other factors such as the younger age, the briefer clinical course, or the larger sputum volumes produced by patients with cystic fibrosis underlies their different response to chest physical therapy is unclear. Although we could demonstrate no improvement in pulmonary function, chest physical therapy was clearly associated with the mobilization of secretions. Our patients expectorated from 2 percent to 50 percent of their daily sputum production after the physical therapy session . Because all patients were tested as outpatients, the testing procedure could not be performed upon arising as is usual clinical practice. This necessary delay may have allowed some patients to have partially mobilized their secretions prior to therapy, and may well have led to an underestimation of the effects of chest physical therapy on both sputum volume and pulmonary function . The brief period of observation after the chest physical therapy session may also have led to an underestimation of the effect of such therapy on sputum production. Because of the distance that peripheral secretions must traverse before reaching central airways where rapid clearance might occur, many clinicians believe that periods considerably in excess of30 minutes are necessary for expectoration of such secretions. Our study design does not shed any light on this clinical impression. Finally, it is possible that the positioning used was suboptimal for some patients in our study, resulting in less than maximal production of sputum. However, all but one of our patients with bronchiectasis had diffuse bilateral disease . Therefore, we do not believe that any other position would have been more or less effective in causing secretion mobilization. Our study clearly demonstrates a fact important to clinicians who care for patients with bronchiectasis: chest physical therapy in these patients is a safe procedure, unlike the findings in some previous studies of acutely-ill patients. Both Connors and associates" and Tyler and colleagues" found large decreases in arterial oxygen tension in acutely-ill patients with a variety of pulmonary disorders who were treated with chest physical therapy. However, the majority of patients in both of these studies were in a critical phase of their illness. Of 22 patients studied by Connors and associates," ten were hospitalized in an intensive care unit and seven required mechanical ventilation. All 27 patients studied by Tyler and colleagues" were characterized as critically-ill. In a more similar population compared to patients in our study, Buscaglia and St. Marie" round no change in Sa02 when postural drainage and percussion were given to patients hospitalized with an acute exacerbation of their chronic obstructive pulmonary disease. In addition to a lack of change in Chest P9rcussion and Postural DraJnage In Bronchleclasls (Mazzocco st aI)

oxygen saturation in our own patients, we could find no change in heart rate compared to the baseline period, nor were any serious cardiac arrhythmias noted . In summary, we have found that postural drainage and percussion are safe and effective procedures in the care of patients with bronchiectasis, but that they are not associated with an improvement in spirometric indices or oxygen saturation during short term evaluation. Further studies are required to determine the long-term effects of chest physical therapy on these parameters. REFERENCES

1 Cochrane G, Webber B, Clarke S. Effects of sputum on pulmonary function. Br Med J 1977; 2:1181-83 2 Bateman J, Daunt K, Newman S, Pavia D, Clarke S. Regional lung clearance of excessive bronchial secretions during chest physiotherapy in patients with stable chronic airways obstruction. Lancet 1979; 1:294-97 3 Bateman J, Newman S, Daunt K, Sheahan N, Pavia D, Clarke S. Is cough as effective as chest physiotherapy in the removal of excessive tracheobronchial secretions? Thorax 1981: 36:683-87 4 Sutton P, Parker R, Webber B, Newman S, Garland N, LopezVidriero M, et aI. Assessment of forced expiration technique, postural drainage and directed coughing in chest physiotherapy. Eur J Respir Dis 1983; 64:62-68 5 Anthonisen P, Riis P, Sogaard-Andersen T. The value of lung physiotherapy in the treatment of acute exacerbations in chronic bronchitis . Acta Med Scand 1964; 175:715-19 6 Campbell A, O'Connell J, Wilson F. The effect of chest physiotherapy upon the FEV, in chronic bronchitis. Med J Aust 1975: 1:33-35

7 Newton D, Stephenson A. Effect of physiotherapy on pulmonary function. Lancet 1978: 2:228-30 8 Graham W, Bradley D. Efficacyofchest physiotherapy and intermittent positive pressure breathing in resolution of pneumonia. N Eng! J Med 1978; 299:624-27 9 American Thoracic Society. Report of snowbird workshop in standardization of spirometry. ATS News, 1977 10 Morris J, KoskiA, Johnson L. Spirometric standards for healthy non-smoking adults . Am Rev Respir Dis 1971; 103:57-67 11 May D, Munt P. Physiologic effects of chest percussion and postural drainage in patients with stable chronic bronchitis. Chest 1979; 75:29-32 12 March H. Appraisal of postural drainage for chronic obstruction pulmonary disease. Arch Phys Med Rehabil 1971; 52:528-30 13 Rossman C, Waldes R, Sampson D, Newhouse M. Effect ofchest physiotherapy on the removal of mucus in patients with cystic fibrosis. Am Rev Respir Dis 1982; 126:131-35 14 Pryor S, Webber B, Hodson M, Batten J. Evaluation ofthe forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. Br Med J 1979; 2:417-18 15 Loring M, Denning C. Evalution of postural drainage by measurement of sputum volume and consistency. Am J Phys Med 1971: 50:215-19 16 Tecklin J, Holsclaw D. Evaluation of bronchial drainage in patients with cystic fibrosis. Phys Ther 1975: 55:1081-84 17 Connors A, Hammon W, Martin R, Rogers R. Chest physical therapy: the immediate effect on oxygenation in acutely ill patients . Chest 1980; 78:559-64 18 Tyler M, Hudson L, Grose B, Huseby J. Prediction of oxygenation during chest physical therapy in critically ill patients . Am Rev Respir Dis 1980: 121(suppl):218 19 Buscaglia A],St Marie MS. Oxygen saturation during chest physiotherapy for acute exacerbation of severe chronic obstructive pulmonary disease. Respir Care 1983: 28:1009

CHEST I 88 I 3 I SEPTEMBER, 1985

383