Neurophysiological Facilitation of Breathing

till not much research (except two original) has been published on Neurophysiological facilitation of breathing. if anyone aware of such things done in your setup let me know. as well or at least discuss the objective meaasures used in the study.

ok, here are some ideas. i hesitate to say everything without you revealing what you're thinking. why? because if any student i had went away with a problem and got it all answered by someone else i'd not so much be annoyed that they hadn't done the work themselves but be disappointed that they hadn't really gotten the best out of the assignment. you can't improve your clinical reasoning more than the slowest, slowest speed by getting someone else to do it for you. you probably think i sound like a real bastard clinical educator you hopefully never meet, but it's very true. i'm not too mean though......

priority is to correct his collapse which will resolve his hypoxaemia issue and reduce his RR and put a smile back on his face.

i'm guessing they've put in the raised temperature bit to make you think that a new chest infection is the source of his deterioration, and he has clogged up his right lower lobe with sputum, it has collapsed and hence all the other signs/symptoms.

first and foremost with any respiratory patient is ensuring adequate oxygenation before you start anything. no good making an unnecessarily hypoxic patient get active. next comes positioning. possible even more important with this particular fellow, however, will be his pain.

1. up his oxygen so his sats are more acceptable than 85%
2. ensure adequate analgesia - discuss with medical staff, pain team etc
3. position. for RLL collapse left side-lying bed flat would be nice and this is ok because his rib fractures are not on the left

3. now i stop helping. what do you think about ACBT, manual techniques, IPPB, saline nebs...... ???

post your ideas and i'll discuss further

Martin,,, first and foremost,,, many thanks for your feedback,,, and whilst I was not expecting to be given the answers on a plate, I fully take on board your views on being able to apply clinical reasoning etc,,, (However, as I have not yet undertaken any clinical/hospital based practice, my clinical reasoning is somewhat limited at the present to information gleaned from lectures and relevant literature etc). Hence, the following are a list of ideas that I have been mulling over,,, but should you feel they are in any way inappropriate, or that I am completely on the wrong track, I would be grateful for any clues, hints and or guidance that you may be able to offer, so that I may once again plough through the relevant literature to gain a better understanding of this area.

Consequently, whilst I have concerns for this pt’s deteriorating ABG’s, (especially his currently borderline pO2 level),,, I would first want to attempt the following treatment plan,,, prior to advising the use of any invasive management (ventilation) has its own associated risk factors. Therefore,,,

as this pt’s ABG’s levels appear comparable with type 1 respiratory failure, I was also suspicious of ARDS due to the nature of this traumatic event (RTA) and associated timing of onset,,, Additionally, this pt’s pH level also suggests a borderline respiratory alkalosis,,,, however, sats/ABG’s may resolve if,,, (as you have stated,,, with I hope some satisfactory explanantion from myself),,, the following plan is successful?

1. Upping this pt’s FiO2 could help increase his sats,,, which may currently be reduced due to the pain associated with having to expand/contract his chest on breathing with broken ribs,,, which is probably why he may be breathing shallowly and thus impacting of his Respiratory Rate. (However, I am concerned that by increasing his FiO2 above the already administered 0.60, there will be a potential for nitrogen washout, which may further complicate his RLL collapse/atelectasis?)

2. By treating this pt’s pain (refer to MDT/pain team for appropriate analgesia – eg: PCA or as Bulger et al. (2004) suggests using an Epidural analgesia). Why?, because by reducing his level of pain, it may allow him to take slightly deeper breaths, thus reducing his work of breathing, respiratory and heart rates. Additionally, I would hope that this might help to increase his sats and even level out his ABG’s. (The MDT may also be able to administer meds to reduce/limit onset of infection/possible sepsis and thus help reduce his temp?)

3. As referenced by your good self, appropriate positioning for RLL collapse may also assist with the above complications; however, I would obviously want to include intermittent turning to prevent pressure sores etc. (Question: with appropriate pain management, could this patient be placed on the side that has the rib fractures or even a ¼ turn from supine in order to facilitate a better V/Q match?)

4. Whist I would possibly use supported ACBT, I might be inclined to use only light percs/vibs on the NON-fractured side, providing adequate pain management had been achieved. (Light percs/vibs would take into consideration any secondary changes that this pt’s osteoarthritis may have had on his skeletal system). However, I am also concerned that manual techs might be contraindicated due to the continuous shape of the thorax (thoracic ring) and thus any treatment applied to one area of the chest may ultimately affect the contra lateral side?

5. Although the crackles might suggest consolidation/retained sputum,,, I was also considering that they may be a factor associated with this pt having smoked 30 a day for the past 50 years,,, and thus difficult to remove,,, even if a neb or suctioning were utilised?

6. If none to the above help to stabilise this pt or his deteriorating sats/ABG’s continued, then I would have to suggest intubation,,, especially as Manual Hyperinflation appears contraindicated/precautionary due to his as yet un-drained pneumothorax? Settings for this invasive ventilation might possibly be SIMV (on volume / pressure control??), TV 450-500; a low PEEP of 5-10 (due to the still resolving pneumothorax); FiO2 0.60. (However, it is my understanding that it is not the job of a general PT to apply settings on invasive ventilation,,, and that the above figures will be dependant upon the pt’s size, statue and consideration or any baro/volu trauma that may be caused by this intervention,,, although, I would be interested in any feedback that you may suggest is applicable?) Obvioulsy, if invasive ventilation is undertaken, a pt’s normal positioning will alter due to associated physiological changes. On a positive point, this form of intervention will allow for easier application of suctioning (especially if a closed circuit airway is utilised).

7. Finally, passive mvt’s can help maintain ROM, as well as help the PT to recognise any onset of soft tissue shortening? Once the pt has stabilised though, more active mvt’s/X’s could possibly be introduced?

dd

good work mate. i'll stick with your numbers

1. you're right about shallow breathing in response to rib fracture pain... it's pretty much a guarantee here. his rate is high because his PaO2 has dropped as a result of the collapse.

in the short term, using a very high FiO2 and losing your nitrogen pressure in the alveoli is probably not going to be a great concern. i've never heard anyone even consider this in the acute situation. it doesn't help but i think the other forces/actions/effects involved are much, much greater. good thought though. probably wouldn't need to be as high as 100% for this man. he'll immediately feel a lot better and may then be more compliant with the rest of your treatment than if he remains hypoxic.

2. for rib fractures i like the epidural idea. sometimes you can do a local/regional nerve block. in any case you want something fairly strong but would be keen to avoid morphine for its respiratory drive suppressing action. fentanyl through an epidural, ideally a PCA version would probably be great.

i'm sure the medical staff would have already prescribed paracetamol for his temp (slight help for pain too) and will await a sputum sample from yourself to send for urgent culturing. he may be started on antibiotics by them prior to receiving a sample based on "most likely" pathogens causing his infection.

your ideas about need for analgesia are right on.... deeper breaths are going to be the key here. multiple knock-on effects. i don't think there'd be a huge improvement in his ABGs just with this, though everything helps.


3. certainly you'll want to turn him intermittently but in the immediate situation you'd be just wanting him on his left side. he may not tolerate lying dead flat, so head up a bit is perhaps better.

you'll want to position him like this to put that lung on stretch - distending forces can assist with opening up collapsed alveoli. there's also increased expansion of teh uppermost lung's adjacent chest wall. there's another treatment idea i have to combine with this (see below).

he could possibly tolerate lying on the fractured rib side, although i doubt it. he'd also be lying on his chest drain which (a) risks kinking it and (b) would probably be uncomfortable. until his collapse has resolved i wouldn't be putting him on that side. for pressure area care, i'd just switch between left s/l and supine. i'd treat him with head of bed flat or close to, but i wouldn't leave him down like that. i'd put the head of the bed up fairly high so he's in high side-lying or supine head up 60 degrees or so.

4. ACBT.... yes. let's now see what he can do with analgesia on board and in this position.
i don't do percussion on anyone other than patients with cf or bronchiectasis, ie those with large amounts of peripheral secretions with impaired clearance. otherwise i think it's a waste of time and the evidence for it is weak.
chest wall vibrations can work well and could be an option here although if he's in side-lying wouldn't work on the side that is down.

5. the fact that he's got a big smoking history doesn't necessarily mean anything about the characteristics of the secretions he has. it will probably mean he has increased secretions and perhaps the person who made up this scenario was thinking that reduced clearance of these secretions because of shallow breathing/pain etc has led to infection... sputum plugging... collapse ?

6. intubation? not yet
manual hyperinflation is not contraindicated - his HPTx has been drained. the drain is not bubbling, so you can use techniques that involve positive pressure. question here would be how? via a facemask? very uncomfortable. don't worry much about stating ventilator settings - that is indeed beyond what you need to know.
what would probably be ideal is intermittent positive pressure breathing (IPPB, examples include Bennett and Bird). not sure if you're familiar with this. it uses positive pressure on inspiration, but there is no peep. it can augment tidal volumes, reverse areas of atelectasis/collapse and mobilise secretions. even better, you can nebulise saline at the same time. this last bit won't be nearly as effective as using a standard nebuliser which you would consider if his secretions are tenacious. the fact that it uses positive inspiratory pressure goes perfectly with the positioning. in left side lying it will preferentially go to the uppermost lung which is just where you want it.

6a. non-invasive ventilation would be an option before invasive i think. cpap would be more appropriate than bipap. i'm sure you've got stuff to read on cpap. one problem is that cpap circuits are very rarely humidified and you can get impaction of secretions because of the high flowrates and dry air. i don't think this will be necessary if everything else works.

6b. suctioning if he can't do a strong huff/cough. you might consider inserting a nasopharyngeal airway if he's going to need repeated suctioning.

6c. yes, intubate if all this fails. in my experience patients with rib fractures that need intubation are ones who just cannot get adequate pain relief and slip into worsening atelectasis/secretion retention etc because they can't take deep breaths and/or cough effectively.

7. passive movements? why not active? he should be able to do active limb ex's in the bed on his own, though limit this whilst he's sydpnoeic. progress as soon as his chest problems have become less severe. if his gas exchange has improved a lot and his work of breathing is right down get him mobilising as able - use a walking aid, oxygen and your assistance as needed.

hey regarding neurophysiological facilitation.there is a journal on that which is very old. neurophysiological facilitation of breathing in the unconscious adult patients. physiotherapy canada 1975.bethune dd.