Attachment 04 - MCM 11-74 Chest Physical Therapy.pdf

VA SAN DIEGO HEALTHCARE SYSTEM MEMORANDUM 11-74

SAN DIEGO, CA January 16, 2019

CHEST PHYSICAL THERAPY

1. PURPOSE: To establish policy and procedures for Chest Physiotherapy (PT) at VA San Diego Healthcare Systems (VASDHS).

2. POLICY: Chest PT consists of a variety of procedures that are applied depending on the patient's health and condition. It is the policy of VASDHS to establish which procedures are most effective and best tolerated and to ensure uniformity, continuity, and safety for patients in need of assistance with airway secretion management by establishing a uniform set of guidelines for treatments aimed at mobilization of airway secretions.

3. DEFINITIONS:

a. Chest Physical Therapy (CPT): A component of bronchial hygiene therapy. It consists of postural drainage, positioning, turning and is sometimes accompanied by chest percussion and/or vibration. It is an airway clearance technique whose purpose is to mobilize secretions.

b. Postural Drainage (PD): The drainage of secretions by the effect of gravity from one or more lung segments to the central airways where the secretions can be removed by coughing or suctioning. The target lung segments are positioned above the carina and maintained in this position for 3 to 15 minutes.

c. External Manipulation: Manipulation of the thorax by percussion or vibration is used to assist secretion drainage. This is accomplished by rhythmically striking or vibrating the involved chest area, manually or mechanically.

4. RESPONSIBILITIES:

a. Chief, Respiratory Therapy Unit

1) Responsible to review all CPT orders and efforts.

2) Review all CPT complications.

b. Respiratory Therapist:

1) Responsible for evaluation of patient to include potential contraindications; selection of the method of CPT (including draining positions) that best suits the patient.

2) Documentation of the assessment and recording of the outcomes in the Computerized Patient Record System (CPRS).

3) There must be documentation in CPRS that the respiratory therapist had a discussion with the treating physician relating to orders for CPT that are outside the limits of this policy, and the outcome of the discussion must be noted as well in the CPT template in CPRS.

4) Evaluation of outcomes of therapy, including volume of sputum production, expiratory flow rate before and after therapy, clearing of breath sounds or increase in aeration of involved lung, or improvement in chest x-ray.

5) Reassessment by the respiratory therapist of the patient's need for ongoing CPT / PD will occur every 24 hours.

c. Physician:

6) Orders CPT within the scope of this policy

7) Orders Pulmonary Consultation to review and approve or deny any

CPT orders beyond the scope of this policy

d. Section Chief of Pulmonary or designee:

1). Responsible to evaluate and approve CPT outside the limits of this policy.

5. PROCEDURES:

a. The respiratory therapist will evaluate the patient upon receipt of the physician’s order.

1) Before performing chest physical therapy (CPT), the therapist will assess the patient and identify any absolute or relative contraindications to therapy

2) Patients with an effective cough will have a trial of CPT TID for 24 hours while recording sputum volume and peak expiratory flow rates before and after each treatment. If sputum production is less than 5cc for each treatment in a 24-hour period, then CPT will be discontinued and the treating physician will be notified before the next scheduled CPT treatment.

3) Assess the ability of the patient to take a deep breath and cough spontaneously,

4) List the indication(s) for therapy. Orders should specify the region of the lung from which drainage is desired.

5) CPT/PD will not be administered on a “prophylactic" basis. However, patients who receive ongoing CPT at home can be continued in the hospital setting with the approval of a Pulmonary Consult or Medical Director of Respiratory Therapy.

6) Any deviation from the CPT/PD policy requires written approval in CPRS from a Pulmonary Consultant or the Medical Director of Respiratory Therapy.

b. CPT will then be delivered according to evidence-based criteria as described in Attachment A . Attachment B will describe Absolute Contraindications and Relative Contraindications and expected actions to take when contraindications are identified.

1) Patients with a diagnosis of cystic fibrosis, bronchiectasis, or cavitating lung disease with sputum production will receive postural drainage, and percussion and/or vibration up to three times a day (TID). Therapy should be discontinued when secretion clearance is < 5 cc for each of three treatments in a 24-hour period.

2) Patients with COPD or with an acute respiratory tract infection who can cough effectively and mobilize secretions without assistance will be encouraged to continue deep coughing. CPT should not be implemented when secretions are being mobilized effectively.

3) Patients with lobar collapse from consolidated secretions documented by chest x-ray will have a trial of CPT every four hours for 72 hours. Treatments will continue for an additional 72 hours if the involved region of the lung has not begun re-expanding by chest x-ray or by physical exam and auscultation of the chest, and the treating physician will be notified.

c. To ensure patient safety, CPT will not be performed on any patient with an absolute contraindication (see section 5.e for contraindications). If orders are written on a patient with an absolute contraindication, the respiratory therapist must contact the treating physician and advise him / her that these orders cannot be carried out because it violates established medical staff policy. The treating physician can discuss this further, if they so choose, with the Medical Director of Respiratory Therapy.

d. To ensure patient safety, CPT should be avoided in any patient with a relative contraindication (see section 5.e for contraindications). If there are orders written on a patient with a relative contraindication, the respiratory therapist must contact the treating physician and review the limits of the policy with the treating physician. If there is no resolution from the treating physician, then the respiratory therapist should notify his/her supervisor or technical director for resolution. In the rare event that there is still no resolution, the pulmonary fellow must be contacted and ultimately the Medical Director of Respiratory Therapy must be contacted for final resolution, Initiation of CPT / PD will be deferred on any patient with a relative contraindication until CPT / PD is approved by a Pulmonary consultant and documented by a note in the chart

e. In addition, evaluation or re-evaluation of the patient will include:

1) If the therapist observes an adverse response, or if the patient fails to respond to therapy, the treating physician will be informed.

2) Patients wearing Kydex Jackets or similar devices restricting access to the chest who otherwise meet indications for CPT / PD will be placed in Trendelenburg and positioned to drain the appropriate segments. No external manipulation will be attempted. If Trendelenburg cannot be tolerated, then consult with the treating physician regarding using modified CPT such as The MetaNeb device or a type of flutter valve for direct oscillation of the airway.

3) The therapist will evaluate the patient's ability to tolerate Trendelenburg position, the patient's ability to tolerate the percussion vest, and the patient's ability to use any type of flutter valve to mobilize pulmonary secretions. If the percussion vest is recommended, then there should be a pulmonary consult.

4) In any patient with an intracranial pressure (ICP) monitor in place who otherwise meets treatment indications, the therapist will check the ICP and, if <15 cm H20, place the patient in supine position. Therapy will be initiated only if ICP remains below 15 cm H20 while the patient is supine.

CPT will be discontinued if the ICP rises 15mm Hg or above during treatment and a no position dependent type of CPT implemented instead.

The same process of evaluating ICP response to position and therapy will be carried out with each treatment in any patient with an ICP monitor in place.

5) For patients with CPT induced bronchospasm who otherwise meet treatment guidelines, the therapist will contact the managing physician and suggest additional or more intensive bronchodilator therapy to be given prior to CPT. If the bronchospasm cannot be blunted, CPT will be discontinued unless approved by a Pulmonary Consultant.

6) Reassessment of the patient will occur every 24 hours and ongoing need for CPT documented by the respiratory therapist. The therapist will note the volume of sputum produced with spontaneous coughing.

It is imperative to monitor sputum production since the purpose of the therapy is to facilitate secretion clearance.

6. REFERENCES:

a. Christensen EF, Schultz P, Jensen OV, et al. Postoperative pulmonary complications and lung function in high-risk patients: a comparison of three physiotherapy regimens after upper abdominal surgery in general anesthesia.

b. Hall JC, Tarala R, Harris J, Tapper J, Christiansen K. Incentive spirometry versus routine chest physiotherapy for prevention of pulmonary complications after abdominal surgery. c. Hall JO, Tapper J, Tarala R.

The cost-efficiency of incentive spirometry after abdominal surgery. Aust N Z J surg 1993; 63:356-359.

d. Hammon WE, Connors AFJ, McCaffree DR. Cardiac arrhythmias during postural drainage and chest percussion of critically ill patients. Chest 1992;

102:18361841 .

e. Stiller K, Geake T, Taylor J, Grant R, Hall B. Acute lobar atelectasis. A comparison of two chest physiotherapy regimens. Chest 1990; 98:1336- 1340.

f. Dennis McCool and Mark Rosen Nonpharmacologic Airway Clearance.

Therapies. Craig Scanlon and Mary Jane Myslinski Bronchial Hygiene Therapy Egan’s Fundamentals of Respiratory.

7. REVIEW DATE: December 2021.

8. FOLLOW-UP RESPONSIBILITY: Chief, Medicine (111)

9. RESCISSION: MCM 11-74 dated 17 December 2015.

10. DATE APPROVED BY MEC: January 16, 2019.

X Kathleen Kim, MD, MPH Chief of Staff

X Robert M. Smith, MD Director

Attachment: A

Distribution: Docushare

Attachment A

CONTRAINDICATIONS TO CPT

Absolute Contraindications

• Increased ICP > 15 mm Hg

• Unstable head, neck, or spinal injury

• Hemodynamic instability

• Recent spinal surgery (e.g.

laminectomy) Active hemoptysis Rib fractures w or w/o flail chest

• Surgical wound or healing tissue (e.g. skin graft or open incision)

• Lung contusion

Relative Contraindications Increased ICP < 15 mm Hg Empyema Bronchopleural fistula Large pleural effusion Distended abdomen Esophageal surgery Risk for aspiration (tube feeding) Patients unable to tolerate supine or Trendelenburg positions Pulmonary Embolism Osteoporosis