When to do chest physio?

[GE90]

Recently moved to a new facility to look after kiddos with tracheostomy on long-term ventilation. I'm quite amazed to see that most of the nurses here would suction the child every 2hours even when there's absolutely no increased WOB, nil decreased AE, nil changes in TV/vital signs or Sats.

They'd also do chest percussion literally at least 2-3 times a shift even when there's absolutely no indications for it and said frequent chest physio helps reduced VAP? (But to be fair I did witness this one time where the child had extremely minimal secretions overnight and at the end of the shift the nurse did one chest percussion and got large amount of thick secretions).

Coming from PICU I always thought that chest percussion should not be something you do simply because you could as there are risks associated with it.

I'm just wondering whether there's any evidence behind frequent suctioning and chest percussion when there's no or minimal indications for it? Or if this is common practice for patients needing prolonged mechanical ventilation?

[aries]

yeah Im curious too

[NRSKarenRN, BSN, RN]

I've always performed Chest PT 2x shift for trached vent dependent children/adults who were not capable of some mobility/getting OOB in chair to help mobilize secretions. Agree that q2hr routine suctioning without indication for it excessive, no longer recommended 1-2 x in 8hr shift usually sufficient and done AFTER Chest PT performed as secretions now loosened.

Indications of Chest Physiotherapy

It is indicated for patients in whom cough is insufficient to clear thick, tenacious, or localized secretions. Examples include:

• Cystic fibrosis
• Bronchiectasis
• Atelctasis
• Lung abscess
• Neuromuscular diseases
• Pneumonias in dependent lung regions.

http://currentnursing.com/reviews/chest_physiotherapy.html

Chest physiotherapy with early mobilization may improve extubation outcome in critically ill patients in the intensive care units.

https://www.ncbi.nlm.nih.gov/pubmed/30264933

Tracheostomy in Infants and Children | Respiratory Care

http://rc.rcjournal.com/content/62/6/799

Clinical Guidelines (Nursing) : Tracheostomy management (Australia)

Quote

Suctioning

Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. The frequency of suctioning varies and is based on individual patient assessment.

Indications for suctioning include:

Audible or visual signs of secretions in the tube

Signs of respiratory distress

Suspicion of a blocked or partially blocked tube

Inability by the child to clear the tube by coughing out the secretions

Vomiting

Desaturation on pulse oximetry

Changes in ventilation pressures (in ventilated children)

Request by the child for suction (older children)

Safety considerations:

Tracheal damage may be caused by suctioning. This can be minimised by using the appropriate sized suction catheter, appropriate suction pressures and only suctioning within the tracheostomy tube.

The depth of insertion of the suction catheter needs to be determined prior to suctioning. Using a spare tracheostomy tube of the same type and size and a suction catheter insert the suction catheter to measure the distance from the length of the tracheostomy tube 15mm connector to the end of the tracheostomy tube. Ensure the tip of the suction catheter remains with-in the tracheostomy tube.

Record the required suction depth on the tape measure placed at the bedside and in the patient records. Attach the tape measure to the cot/bedside/suction machine for future use.

Use pre - measured suction catheters (where available) to ensure accurate suction depth

The pressure setting for tracheal suctioning is 80-120mmHg (10-16kpa). To avoid tracheal damage the suction pressure setting should not exceed 120mmHg/16kpa.

It is recommended that the episode of suctioning (including passing the catheter and suctioning the tracheostomy tube) is completed within 5-1

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Tracheostomy_management/

Suctioning - Johns Hopkins Medicine

https://www.hopkinsmedicine.org/tracheostomy/living/suctioning.html

[Kitiger, RN]

I work private duty home care, pediatrics. Most of my kiddos have mobility issues along with trachs, vents, etc..

I do chest physiotherapy based most often on congestion (audible or visual signs of secretions in the tube) desaturation on pulse oximetry, changes in ventilation pressures (in ventilated children), and decreased aeration (in nonventilated children).

As a general rule in nonventilated children, I would rather hear rales with good aeration than clear breath sounds with decreased aeration even when the SpO2 is good. The ones with clear breath sounds and decreased aeration are the ones who will cough up a ton of mucus after Albuterol, percussion & postural drainage, and suction. Of course, I need to know what the child's normal is, before deciding that he is decreased.

At night, if the decreased aeration is because he's in a deep sleep, I take that into account. In this case, I may reposition him side to side and only suction if repositioning causes audible or visual congestion. Then, the first respiratory treatment of the morning will often bring up a bunch of mucus.