ORIGINAL ARTICLE


https://doi.org/10.5005/jp-journals-11010-1071
Indian Journal of Respiratory Care
Volume 12 | Issue 4 | Year 2023

Evaluating the Immediate Effect of Preextubation Chest Physiotherapy Session on Postextubated Physiological and Diagnostic Cardiorespiratory Parameters in Neonates with Pneumonia: A Randomized Controlled Trial


Vrushali A Ambhore1https://orcid.org/0000-0002-5504-3361, Manish P Shukla2https://orcid.org/0000-0001-7416-4663

1,2Department of Cardiovascular and Respiratory Physiotherapy, MGM Institute of Physiotherapy, Chhatrapati Sambhaji Nagar, Maharashtra, India

Corresponding Author: Manish P Shukla, Department of Cardiovascular and Respiratory Physiotherapy, MGM Institute of Physiotherapy, Chhatrapati Sambhaji Nagar, Maharashtra, India, Phone: +91 9960290614, e-mail: manish.shukla20@gmail.com

Received: 10 June 2023; Accepted: 11 October 2023; Published on: 18 January 2024

ABSTRACT

Background: Chest physiotherapy (CPT) techniques are commonly employed to remove secretions in newborns undergoing mechanical ventilation for pneumonia. However, there is a lack of studies evaluating the impact of preextubation CPT on postextubation complications in pneumonia.

Materials and methods: In this randomized controlled study, a total of 68 participants were randomly assigned to either the intervention or control group. Physiological parameters, including heart rate (HR), respiratory rate (RR), and oxygen saturation (SpO2), were compared between the two groups before CPT, immediately after CPT, and at 5 and 15 minutes following extubation. Additionally, diagnostic findings and the incidence of extubation failure were recorded before and after CPT.

Results: The baseline characteristics of both groups were similar. Analysis of physiological parameters revealed nonsignificant changes in HR and RR in both groups. However, the intervention group showed a significant improvement in SpO2 levels at 15 minutes postextubation (p = 0.030). Significant differences were observed between the two groups in the findings of auscultation (p = 0.018) and chest radiograph (p = 0.025). The control group exhibited a higher incidence of extubation failure, although the difference was not statistically significant (p = 0.052).

Conclusion: Preextubation CPT is a safe and effective therapy option for newborns with pneumonia, regardless of their age or birth weight. It has the potential to reduce postextubation complications, as evidenced by improvements in physiological parameters and a lower incidence of extubation failure. Further research is warranted to explore the clinical implications and optimize the implementation of preextubation CPT in neonatal care.

How to cite this article: Ambhore VA, Shukla MP. Evaluating the Immediate Effect of Preextubation Chest Physiotherapy Session on Postextubated Physiological and Diagnostic Cardiorespiratory Parameters in Neonates with Pneumonia: A Randomized Controlled Trial. Indian J Respir Care 2023;12(4):292–298.

Source of support: Nil

Conflict of interest: None

Keywords: Chest, Chest physiotherapy, Extubation failure, Neonates, Physical therapy, Pneumonia

INTRODUCTION

Pneumonia is a common inflammatory lung condition characterized by lung tissue inflammation and fluid accumulation in the alveoli.1 It poses a significant global health burden, accounting for 10% of all child mortality worldwide and affecting approximately one-fourth of all newborns.2 Notably, India has the highest number of newborn pneumonia cases, with an estimated 43 million cases. Neonates differ physiologically from adults, exhibiting increased mucus production and airway obstruction due to narrow airway diameter. Additionally, their weak or absent cough reflex, which is normal for newborns, renders them more vulnerable to pulmonary complications.3 The risk of pneumonia is closely associated with low birth weight (<1500 gm) and the timing of disease onset (early or late onset),2,4 with group II Streptococcus being the primary cause during labor, followed by gram-positive and gram-negative bacteria post-birth.

Pneumonia is a leading cause of ventilation in term and preterm neonates as decreased oxygenation and excessive secretion production lead to increased airway resistance and complications like atelectasis. Prolonged ventilatory assistance or oxygen support further amplifies the risk of nosocomial infection.4 Although therapeutic oxygen and positive-pressure ventilation can be lifesaving, they may also induce damage to immature lungs, resulting in adverse acute pulmonary complications and neurodevelopmental outcomes. Therefore, it is crucial to extubate preterm infants from mechanical ventilation as early as possible. However, approximately one-third of preterm newborns are unable to extubate and require continuous respiratory support, such as continuous positive airway pressure (CPAP) or re-ventilation, due to factors like trauma, severe prematurity, thick secretions, prolonged ventilation, or failed spontaneous breathing trials.5,6

Mechanically ventilated neonates produce excessive mucus due to the inhibition of the cough reflex and mucociliary escalator by artificial airways, thereby increasing the risk of complications like extubation failure and ventilator-associated pneumonia.7,9 Chest physiotherapy (CPT), consisting of techniques like postural drainage (PD), percussion, and vibration, has been utilized in ventilated children with respiratory and neuromuscular conditions.8,9 These techniques aid in the removal of inflammatory exudates and tracheobronchial secretions, improving the clinical condition of pneumonia patients by facilitating the breakup and displacement of mucus from smaller to larger airways, which can then be suctioned away.4 CPT also reduces airway obstruction and resistance, thereby enhancing breathing and gas exchange.10,11 Consequently, CPT holds promise for removing inflammatory exudates and tracheobronchial secretions, as well as improving respiratory status and reducing infection-related complications.12,13

However, evidence regarding the effectiveness of chest physical therapy in neonatal pneumonia during ventilator support remains limited. Furthermore, no study to date has examined the immediate impact of preextubation CPT followed by suctioning on postextubation complications, despite the fact that endotracheal intubation and mechanical ventilation can lead to airway injury, inflammation, and increased secretion production in the lungs, consequently increasing the risk of complications such as secretion retention, respiratory distress, and extubation failure.

Hence, it is imperative to investigate the potential advantages of preextubation CPT in mitigating postextubation complications and enhancing the prognosis of neonates diagnosed with pneumonia. This study’s primary objective is to assess the immediate influence of a solitary CPT session administered just prior to extubation on the postextubation physiological and diagnostic cardiorespiratory parameters in neonates with pneumonia. By bridging this existing research gap, we aspire to furnish valuable insights into the efficacy and safety of employing preextubation CPT as a therapeutic intervention for neonates with pneumonia. Ultimately, our endeavor aims to contribute substantively to the refinement of clinical management practices and the overall outcomes for this particularly vulnerable patient population.

MATERIALS AND METHODS

Study Design

This prospective, randomized, open-label parallel trial was conducted in the neonatal intensive care unit (NICU) of a tertiary care hospital from March 2020 to July 2021. The study analyzed data from 68 neonates diagnosed with pneumonia who were receiving mechanical ventilation and planned for extubation.

Participants and Settings

The study included neonates of both genders, aged 1–28 days after birth, who were medically diagnosed with pneumonia by a neonatologist and were on mechanical ventilation. Pneumonia diagnosis was based on clinical criteria, radiological findings, and laboratory investigations. Neonates with congenital anomalies, cardiac defects, congestive cardiac failure, pulmonary interstitial emphysema, bronchopulmonary dysplasia, and neurological involvement were excluded. Ethical approval was obtained from the Institutional Ethics Committee on March 13, 2020 (ECRHS/2020/17), and the trial was prospectively registered with the Clinical Trials Registry—India (CTRI/2021/05/043970). Written consent was obtained from the parents of the included neonates.

The primary investigator has over 2 years of experience in NICUs with professional certification. The research team, led by experienced academics with 12+ years of expertise and postgraduate degrees in cardiovascular and respiratory physiotherapy, specializes in intensive care unit (ICU) patient treatment. A single physiotherapy staff consistently delivered the intervention, closely monitored for protocol adherence by a dedicated supervisor who ensured intervention fidelity and quality through feedback.

Randomization

The study employed a block randomization method, and the randomization process was conducted by a blinded external investigator using www.sealedenvelope.com prior to the study’s commencement. The randomization list was generated without stratification, with predefined block sizes and list length. Through this process, participants were randomly assigned in a 1:1 ratio to two groups—the intervention group (group I) and the control group (group II).

Outcome Measures

The study’s primary outcome variables encompassed essential physiological parameters—heart rate (HR), respiratory rate (RR), and oxygen saturation (SpO2). These parameters were meticulously measured using a cardiac monitor and pulse oximeter. Additionally, the study examined secondary outcome variables, which included auscultation findings that were assessed by experienced clinicians before and after CPT using a stethoscope. The assessment included listening for breath sounds and air entry in various lung zones. For the purpose of this study, “improved” in auscultation was defined as the presence of clear breath sounds, improved air entry, and a reduction in adventitious breath sounds, such as crackles or wheezes, compared to the pretreatment assessment. Conversely, “not improved” indicated the persistence or exacerbation of adventitious breath sounds or no significant change in breath sounds and air entry.

Additionally, chest radiographic findings obtained within 6–8 hours after extubation were used to assess changes in lung status. In the context of this study, “improved” in chest radiograph findings referred to a reduction in lung infiltrates, consolidation, or other pathological findings compared to the pretreatment radiograph. Conversely, “not improved” indicated the persistence or exacerbation of pathological findings or no significant change in lung status.

These comprehensive measurements were documented at three distinct time points—prior to treatment (preextubation), at 5 minutes postextubation, and at 15 minutes postextubation. Furthermore, the study also investigated the frequency of extubation failure, precisely defined as the necessity for reintubation within 48 hours subsequent to extubation.

Procedure

A total of 68 neonates were recruited, and baseline demographic information, including chronological age, gestational age, gender, birth weight, and method of ventilation received, was documented for each newborn. In the intervention group (group I), preextubation CPT was performed, including PD placement, percussion, and vibration as well as passive range of motion (PROM) exercises. The control group (group II) received only preextubation PROM exercises.

Chest Physiotherapy (CPT)

The CPT procedure in this study consisted of a carefully executed sequence of steps aimed at promoting effective airway clearance in neonates with pneumonia.

Postural Drainage (PD)

The baby was positioned in a supine posture on a suitable surface, such as an examination table or an infant warmer, ensuring comfort and stability during the procedure. PD placement was determined based on the specific lobes affected by the pneumonia. For instance, if the lower lobes were involved, the baby’s lower body was elevated using a rolled blanket or wedge. This positioning facilitated the drainage of secretions from the affected lung segments (Fig. 1).

Fig. 1: Postural drainage (PD) position

Percussion

Following PD placement, percussion was administered. The percussion was given by tenting the middle finger on the first and third fingers (Fig. 2). The finger was slightly cupped, and a gentle rhythmic tapping motion was applied to the chest wall over the affected lung segments. The percussion pressure was carefully controlled, ensuring it did not exceed 5 cmH2O. The rate of percussion was maintained at approximately three taps per second.

Fig. 2: Percussion

Vibration

Immediately after percussion, vibration was applied. It involved co-contracting the hand muscles while the baby exhaled. The resulting fine trembling motion was transmitted to the chest wall, aiding in the mobilization of secretions. Vibration was applied for a few seconds in each lung segment (Fig. 3).

Fig. 3: Vibration

Suctioning

After completing the percussion and vibration techniques, suctioning was performed to effectively remove the secretions that had been mobilized from the airways. Strict adherence to guidelines and precautions ensured the safety of the neonates during the suctioning procedure. A suction catheter of an appropriate size was carefully selected based on the neonate’s age and size. The diameter of the catheter was chosen to ensure compatibility with the endotracheal or nasotracheal tube being used. Before initiating suctioning, the neonate’s vital signs, including HR, RR, and SpO2, were recorded as a baseline measurement. This provided a reference point for comparison during and after the suctioning process. To maintain optimal oxygenation and prevent hypoxemia during suctioning, a technique called hyperoxygenation was employed. The neonate was temporarily disconnected from the ventilator or respiratory support, and a self-inflating bag connected to a high-flow oxygen source was used to deliver a higher concentration of oxygen. This measure ensured an adequate oxygen supply throughout the suctioning procedure. The suction pressure was carefully set at an appropriate level to effectively remove the secretions without causing harm to the delicate airway tissues. The recommended suction pressure for neonates typically ranges from 80 to 100 mm Hg. It was crucial to apply the suction pressure cautiously, avoiding excessive force that could potentially lead to airway trauma. The suction catheter was gently inserted into the endotracheal or nasotracheal tube using a slow and controlled motion. Care was taken to avoid exerting excessive force to prevent any trauma to the airways. The depth of insertion was adjusted according to the length of the tube, ensuring that the catheter tip reached the desired position within the airway. Suctioning was performed for a limited duration to minimize the risk of hypoxemia or bradycardia. Typically, the duration of suctioning was kept relatively short, ranging from a few seconds, such as 5–10 seconds. This approach helped prevent prolonged interruptions in ventilation and oxygenation, ensuring the neonate’s stability during the procedure.

Immediately after suctioning, a thorough post-suction assessment was conducted. The neonate’s vital signs, including HR, RR, and SpO2, were reassessed to monitor any potential changes or adverse effects resulting from the suctioning process. If necessary, appropriate interventions were promptly implemented to maintain a stable cardiorespiratory status. The PD position was maintained for 10–15 minutes, and percussion and vibration were applied within that period. The entire CPT session, including PD, percussion, vibration, and suctioning, lasted approximately 15–20 minutes, ensuring comprehensive treatment and effective airway clearance. This timeframe allowed for thorough treatment and effective clearance of the airways.

Statistical Analysis

The statistical analysis was performed using SPSS version 27.0 software. The sample size calculation was based on a pilot study using G power software, considering a predicted SpO2 value, a confidence level of 0.95, and a standard deviation (SD) of 10.8. It was determined that 34 neonates were required in each group, with an alpha of 0.05 and a power of 80%. The normality of the continuous variables, including chronological age, gender, birth weight, gestational age, and mode of breathing, was assessed using a Kolmogorov–Smirnov test.

For the primary outcomes, we computed descriptive statistics, including mean and SD, for both the intervention and control groups. To assess changes over time within each group, paired t-tests were conducted. Independent t-tests were utilized for between-group comparisons at each time point, with the resulting p-values indicating statistical significance.

Regarding the secondary outcomes, our analysis focused on auscultation and chest radiograph findings and extubation failure incidence. We calculated frequencies and percentages to quantify improved findings in both intervention and control groups, using the Chi-squared test to detect differences between them.

RESULTS

The study enrolled a total of 68 neonates diagnosed with pneumonia, with ages ranging from 1 to 28 days. Figure 4 illustrates the flow of participants throughout the study.

Fig. 4: Consolidated Standards of Reporting Trials (CONSORT) diagram showing the flow of participants in the study

Table 1 presents the baseline characteristics of the neonates. The distribution of neonates across different age groups, gender, birth weight categories, gestational age, and mode of ventilation was examined. The results showed that there were no significant differences between the control and intervention groups in terms of chronological age (p = 0.55), gender (p = 0.61), birth weight (p = 0.85), gestational age (p = 0.96), and mode of ventilation (p = 1.00). The distribution of neonates in these categories was similar between the two groups, indicating a balanced representation of baseline characteristics.

Table 1: Baseline characteristics of neonates
Characteristics Control group (n = 34) Intervention group (n = 34) p-value
Chronological age
 1–10 days 21 (61.76%) 17 (50%) 0.55
 11–20 days 8 (23.53%) 9 (26.47%)
 21–30 days 5 (14.71%) 8 (23.53%)
 Total 10.32 ± 7.30 13.64 ± 9.39
Gender (%)
 Male 20 (58.8%) 22 (64.7%) 0.61
 Female 14 (41.2%) 12 (35.5%)
Birth weight (gm)
 Normal birth weight 8 (23.5%) 9 (26.5%) 0.85
 Low birth weight 22 (64.7%) 19 (55.9%)
 Very low birth weight 3 (8.8%) 5 (14.7%)
 Extreme low birth weight 1 (2.9%) 1 (2.9%)
Gestational age (weeks)
 Postterm 1 (2.9%) 1 (2.9%) 0.96
 Term 19 (55.9%) 18 (52.9%)
 Preterm 14 (41.2%) 15 (44.1%)
Mode of ventilation (%)
 PC 21 (61.8%) 21 (61.8%) 1.00
 Synchronized intermittent mandatory ventilation 13 (38.2%) 13 (38.2%)

Table 2 presents the comparison of physiological parameters between the control and intervention groups at pretreatment, postextubation 5 minutes, and postextubation 15 minutes. The parameters analyzed include HR, RR, and SpO2. In HR, both the control and intervention groups showed a significant increase from pretreatment to postextubation 5 minutes (p < 0.0001). However, there was no significant difference between the two groups at any time point (p > 0.05). For RR, both groups exhibited a significant increase from pretreatment to postextubation 5 minutes (p < 0.0001). There was no significant difference between the groups at any time point (p > 0.05). In SpO2, both groups experienced a significant decrease from pretreatment to postextubation 5 minutes (p < 0.0001). The intervention group showed a significant increase from postextubation 5 minutes to postextubation 15 minutes (p = 0.024). There were significant differences between the groups at postextubation 15 minutes (p = 0.03).

Table 2: Comparison of primary outcome parameters between control and intervention groups at pretreatment, postextubation 5 minutes, and postextubation 15 minutes
Parameters Group Pretreatment Pretreatment to postextubation 5 minute p-value Pretreatment to postextubation 15 minutes p-value
HR Control 143.47 ± 14.31 151 ± 13.73 0.0001 146.58 ± 14.62 0.0001
Intervention 144.29 ± 13.02 150.47 ± 11.75 0.0001 144.58 ± 12.62 0.68
p-value 0.8 0.86 0.54
RR Control 51.52 ± 7.21 56.11 ± 7.08 0.0001 53.41 ± 8 0.0001
Intervention 50.82 ± 6.57 54.91 ± 6.64 0.0001 50.94 ± 7.42 0.79
p-value 0.67 0.47 0.19
SpO2 Control 95.64 ± 2.47 91.52 ± 3.22 0.0001 94.61 ± 2.51 0.0001
Intervention 95.23 ± 2.10 90.97 ± 2.98 0.0001 96.47 ± 3.22 0.024
p-value 0.46 0.46 0.03

Table 3 presents the comparison of diagnostic parameters and the incidence of extubation failure between the control and intervention groups. In the control group, 55.9% of neonates showed improved auscultation findings compared to 82.4% in the intervention group (p-value = 0.018). Similarly, for radiograph findings, 44.1% of neonates in the control group showed improvement compared to 73.5% in the intervention group (p-value = 0.025). The assessment was not conducted for a small proportion of cases. Regarding extubation failure, it was observed in 41.17% of the control group and 14.7% of the intervention group. Although the p-value (0.052) indicates a trend toward significance, these findings suggest that the intervention group had higher rates of improvement in auscultation and radiograph findings, potentially indicating a positive effect of the intervention.

Table 3: Comparison of secondary outcome parameters and incidence of extubation failure between control and intervention groups
Characteristics Control group Intervention group p-value
(n = 34) (%) (n = 34) (%)
Auscultation findings
 Improved 19 (55.9%) 28 (82.4%) 0.018
 Not improved 15 (44.1%) 6 (17.6%)
Radiograph findings
 Improved 15 (44.1%) 25 (73.5%) 0.025
 Not improved 13 (38.2%) 4 (11.8%)
 Not assessed 6 (17.6%) 5 (14.7%)
Extubation failure
 Yes 14 (41.17%) 5 (14.7%) 0.052
 No 20 (58.83%) 29 (85.3%)

DISCUSSION

The present study aimed to assess the immediate effect of a single preextubation CPT session on physiological parameters and postextubation complications in neonates with pneumonia. CPT has been widely used in newborns to facilitate the removal of obstructive secretions, enhance lung ventilation, and promote mucociliary clearance.14,16 The findings of the study revealed that the majority of participants were term neonates aged 1–10 days with low birth weight. These demographic factors did not significantly influence the outcomes, indicating that they were not confounding variables. Among the different modes of ventilation, pressure control (PC) mode was most commonly used due to better patient tolerance.17

The physiological response following CPT showed a slight increase in HR and RR postextubation, possibly due to increased arousal, agitation, crying, or stress associated with the procedure. However, bradycardia episodes were transient and resolved promptly after suctioning.18,19 These findings align with previous studies that reported similar changes in cardiorespiratory parameters after CPT, all within the normal physiological range.5,20 The absence of increased RR and HR at 15 minutes postextubation could be attributed to improved oxygenation and increased tidal volume resulting from CPAP and noninvasive positive pressure ventilation (NIPPV).21,22 Additionally, the removal of secretions may contribute to improved ventilation/perfusion matching and delayed airway closure, leading to increased SpO2.

Auscultation and chest radiographic findings revealed notable enhancements in adventitious breath sounds, decreased air entry in lung zones, and a reduction in pneumonia infiltrates following extubation within the intervention group when compared to their pretreatment status. This observed improvement might be associated with the effective mobilization of tracheobronchial secretions facilitated by CPT and subsequent suctioning, which led to an overall enhancement in SpO2.16 Additionally, the preextubation suctioning process could have potentially contributed to a decrease in postextubation complications, reduced secretion retention, and improved ventilation/perfusion matching, consequently aiding in the resolution of infiltrates.

Among the participants, 19 neonates required reintubation. The reasons for reintubation included repeated episodes of apnea and desaturation, prolonged ventilatory support, incomplete resolution of pneumonia, significant respiratory distress in preterm neonates, and severe respiratory acidosis due to poor respiratory effort. Although previous studies have associated low gestational age and low birth weight with extubation failure,3,23,24 this study did not observe such findings, possibly due to the smaller number of extremely low birth weight (ELBW) babies included.25,26 Importantly, no adverse events were reported during the study, further supporting the safety and beneficial effects of preextubation CPT in reducing postextubation complications in neonates with pneumonia.27

Limitations of this study include the lack of measurement of airway clearance using sputum weight or volume, which could have provided more precise information on the effectiveness of CPT and suctioning. Additionally, the inclusion of neonates with both pneumonia and respiratory distress syndrome (RDS) might have influenced the results, and future studies should focus solely on neonates with pneumonia to minimize potential confounding effects. Furthermore, the study had a relatively small number of ELBW infants, limiting the generalizability of findings for this specific subgroup.

Future studies can address these limitations and explore additional aspects. Incorporating sputum weight or volume measurements would offer objective data on the extent of secretion mobilization and its impact on postextubation outcomes. Comparing different durations and modes of ventilation could help identify optimal strategies for improving outcomes in neonates with pneumonia. Additionally, extending the investigation to adult populations and assessing the impact of immediate preextubation CPT on postextubation complications would provide valuable insights for broader clinical practice.

CONCLUSION

The inclusion of preextubation CPT as a routine protocol in neonates with pneumonia yielded favorable results in this study. The findings indicate that CPT had a stabilizing effect on postextubation physiological parameters, with no extreme variations observed. Furthermore, diagnostic parameters showed improvement, and the incidence of extubation failure was lower in the intervention group, suggesting a sustained effect of CPT. Therefore, preextubation CPT administered for 15–20 minutes can effectively prevent postextubation complications and is a safe and beneficial treatment approach for neonates with pneumonia, regardless of their age and birth weight.

Clinical Significance

This study holds clinical significance as it provides evidence for the immediate effects of preextubation CPT in neonates with pneumonia. The findings demonstrate that incorporating CPT as a routine protocol prior to extubation can lead to improved outcomes, such as enhanced SpO2, resolution of lung collapse, and improved diagnostic parameters. Additionally, the study highlights the safety and effectiveness of CPT in reducing postextubation complications. These findings emphasize the importance of considering CPT as an integral part of respiratory care in neonates with pneumonia, ultimately contributing to improved patient outcomes and potentially reducing the need for reintubation.

ORCID

Vrushali A Ambhore https://orcid.org/0000-0002-5504-3361

Manish P Shukla https://orcid.org/0000-0001-7416-4663

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