Wednesday, May 25, 2011

Chest Physical Therapy Catastrophes

Chest Physical Therapy (CPT) is ordered at many institutions for numerous conditions, from patients with chronic respiratory conditions-to-Acute Respiratory Distress Syndrome. The main goal of these therapies is to augment secretion mobilization & airway clearance[1]. Even though CPT is ordered liberally it does have associated risks and there is no supporting evidence that CPT is more valuable than a direct cough (Schans, 2007). At one institution I work at there have been 4 adverse events related to CPT in a short six month time span. I previously described two of the incidences on the same patient in the posting Shook to Death: a Case Study of High-Frequency Chest Wall Compression”. The other two cases will be presented.

Case 1
An 83 year old patient whose initial compliant was for abdominal pain and nausea and vomiting. The patient was ordered CPT via Vest every four hours for unknown reasons (probably because the physician observed COPD in then dictated medical history). The patient’s pre-existing medical history included COPD, atrial fibulation, and left lung resection.  CPT was initiated and the patient immediately went into atrial fib, the therapy was stopped to make sure the vibrations did not cause an inappropriate reading of the ECG. The A-fib remained present after stopping the CPT and the patient had to be medically treated for her symptoms. Thus increasing her ICU observation period.

Case 2
A 60 year old female patient admitted for respiratory distress was ordered CPT via percussion secondary to a left lower lobe infiltrate. The patients pre-existing medical history included cardiomyopathy, diabetes, hypertension, chronic renal insufficiency.
During the CPT procedure the patient experienced cardiopulmonary arrest, secondary to mucus plugging. The patient was resuscitated, placed on mechanical ventilation, and bronchoscopy was performed the following day. The patient had a lengthy intensive care unit stay and was eventually discharged.

CPT is a commonly prescribed therapy, with little evidence of success. Practitioners’ should be aware of the risk factors associated CPT and screen patients appropriately for their ability to clear the mobilized secretions. Always, consider if there is a rational for CPT and which therapy is likely to provide the greatest benefit with the least amount of harm.

[1] Schans, C. (2007). Conventional Chest Physical Therapy for Obstructive Lung Disease. Respiratory Care. 52 (9): 1198.