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Nursing guidelines

Nurses role in advanced secretion clearance



  • Introduction

    Children who experience respiratory distress and have compromise to their physiological airway clearance mechanisms (e.g. children with neuromuscular weakness, weak cough, and chronic lung disease) may benefit from advanced secretion clearance techniques to optimise oxygenation and ventilation.

    In hours, this service is provided by physiotherapy. Should it be identified that physiotherapy input is required for secretion clearance, then a physiotherapy EMR referral should be completed, and physiotherapy contacted if within hours

    This guideline should be utilised to guide advanced secretion clearance outside of physiotherapy hours, where a physiotherapy treatment plan does not yet exist, or if a plan has been prescribed or ordered by physiotherapy.

    Please note – for typically developing children who do not have compromise to their own physiological airway clearance mechanisms, it is recommended to utilise sitting out of bed and/or mobilisation as first line management for secretion clearance

    Airway suctioning will not be discussed in this guideline as this is covered in local guidelines depending on department acuity.   

    Aim

    • Outline of appropriate patient groups for advanced secretion clearance
    • Outline the role of nurses in different departments for advanced secretion clearance techniques
    • Outline the precautions and contraindications associated with a range of advanced secretion clearance techniques

    Definition of Terms 

    • Advanced secretion clearance: techniques used to assist in clearing retained secretions in patients who physiological airway clearance mechanisms are compromised (e.g. weak cough, chronic lung disease). These techniques include positioning, sitting out of bed and mobilisation, use of bubble PEP, chest percussions and vibrations, bubble PEP, and mechanical in-exsufflation, as described below.
    • ARDS: Acute Respiratory Distress Syndrome
    • ETT: Endotracheal tube, and artificial airway bypassing the vocal cords to provide airway and ventilation support
    • Manual hyperinflation: A bagging technique performed in ventilated patients which utilises a slow inspiration (to approx. 20% greater than set PIP), followed by an inspiratory hold and rapid exhalation
    • Mechanical In-exsufflation: Use of a mechanical device (e.g. CoughAssist®) to provide cycles of insufflation and exsufflation pressures to the lungs to facilitate secretions clearance
    • PEP: Positive expiratory pressure techniques (e.g. PEP mask, bubble PEP) are prescribed by physiotherapists to facilitate secretion clearance by providing an expiratory resistance which can improve collateral ventilation, inflation of partially closed lung units and secretions clearance.
    • PIP: Peak Inspiratory Pressure
    • SMI: Performance of a voluntary Sustained Maximal Inflation at the peak of a deep inspiratory breath whereby the breath is held for 2-3 seconds before exhalation.  Used to facilitate recruitment of poorly filled lung units. 

    Assessment

    Criteria for advanced secretion clearance: 

    1. Advanced secretion clearance should not
      be considered routine and the rationale for treatment should be based on excessive secretions, atelectasis or abnormal gas exchange, in a patient whose physiological airway clearance mechanisms are compromised (e.g. weak cough, chronic lung disease). 
    2. Collaboration with physiotherapists regarding the patient’s cardiorespiratory physiology, chest mechanics and evidence for these techniques is essential.

    Patient assessment should include:

    Table 1 below outlines conditions where respiratory physiotherapy is NOT usually indicated. At times there may be patients who have a combination of conditions that may or may not be appropriate for respiratory physiotherapy. Please contact Physiotherapy if you have any questions regarding this.  

    Table 1

    Conditions where respiratory physiotherapy is NOT indicated

    Acute asthma/severe bronchospasm

    ARDS

    Bronchiolitis
    Croup
    Empyema

    Pleural effusion

    Pneumonia in typically developing child/ with no comorbidity (non-ventilated)

    Pneumothorax

    Management 

    Nursing scope of practice will vary regarding the degree of advanced secretion clearance that can be provided in different departments within the hospital. Non-intensive care areas are differentiated from the PICU due to variations in scope of practice and the clinical environment.

    Table 2 outlines which conditions have been acknowledged as receiving benefit from advanced airway clearance techniques strategies by a nurse, as well as providing a summary of the precautions and contraindications for a range of advanced secretion clearance techniques. The performance of advanced secretion clearance techniques is not without risk in certain patient conditions, and therefore it is essential to review the precautions and contraindications prior to initiation of any advanced secretion clearance technique. Please consider patient’s illness profile when selecting treatment options and always seek guidance from medical colleagues when planning to provide advanced secretion clearance.

    In addition to this, patients with chronic respiratory disease will often have a baseline (home) airway clearance regime, and this should be encouraged for these patients.

    Other conditions, such as neuromuscular disease, have no benefit from the advanced airway clearance techniques described below, and usually require specific and specialised techniques and equipment such as mechanical in-exsufflation (also known as ‘cough assist’). If the patient is already set up with a home regime using cough assist, this may be completed by a trained family member, a trained carer/support worker, and/or a trained registered nurse who is familiar with the patient's cough assist regime. If they do not have an established home cough assist regime, techniques such as cough assist should only be undertaken by a physiotherapist, or someone who has received training from a physiotherapist.

    As described below, sitting out of bed and/or mobilisation should be considered as first line management for secretion clearance in typically developing children.

    Table 2

    Advanced secretion clearance treatment technique Conditions where technique may be indicated Contraindications (do NOT perform technique) Precautions (seek medical clearance prior)
    Percussions and vibrations

    Chronic respiratory disease with large amounts of sputum, for example:

    • Cystic Fibrosis
    • Bronchiectasis
    • Chronic Bronchitis

    Pneumonia in a neurologically compromised child.
    • Asthma
    • Bronchospasm
    • Chest wall pain
    • Coagulopathy 
    • Lung contusions
    • Osteopenia or osteoporosis with previous fractures
    • Over area of subcutaneous emphysema
    • Over wound areas (including over thoracotomy)
    • Rib fractures
    • Thrombocytopenia or other haematological abnormalities (e.g. immunology/oncology/critically ill patients with neutropenia, reduced platelet counts, post liver transplant)
    • Bronchiolitis (can worsen symptoms)
    • Critically ill patients
    • Paediatric patients post cardiac surgery
    • Reduced head control (will need to stabilise head with one hand)
    • Reduced sensation or recent epidural
    • Young infants
    Positioning and sitting out of bed

    Chronic respiratory disease with large amounts of sputum, for example:

    • Cystic Fibrosis
    • Bronchiectasis
    • Chronic Bronchitis

    Pneumonia in a neurologically compromised child.

    Atelectasis (post extubation).

    Trauma patients (pending injuries and completion of tertiary survey).

    Abdominal or cardiothoracic surgery patients.
    • Head down tilt NOT allowed, especially in patients with GOR.
    • Cardiovascular instability
    • Pain
    • Raised ICP
    • Respiratory instability
    • Trauma patients – based on injuries, spinal precautions and tertiary survey status, will need clearance of these and clear positioning/mobility recommendations prior to completing any positioning or transfers.
    Deep breathing with SMI and coughing

    Chronic respiratory disease with large amounts of sputum, for example:

    • Cystic Fibrosis
    • Bronchiectasis
    • Chronic Bronchitis

    Atelectasis (post extubation).

    Trauma patients (pending injuries and completion of tertiary survey).

    Abdominal or cardiothoracic surgery patients.
    • Inability to follow commands
    • Pain – will need adequate pain control prior
    Bubble PEP

    Trauma patients

    Abdominal or cardiothoracic surgery patients.

    Chronic respiratory disease with large amounts of sputum, for example:

    • Cystic Fibrosis
    • Bronchiectasis
    • Chronic Bronchitis
    • Acute asthma/severe bronchospasm
    • Frank/large haemoptysis
    • Post lung surgery where lung pleura has been damaged
    • Pulmonary cysts
    • Recent nasal surgery or severe sinusitis
    • Surgical emphysema
    • Head injury
    • Immuno-compromised (infection risk if not cleaned appropriately)
    • Lung transplants
    • Patients requiring FiO2 >0.5
    • Poor swallow, decreased GCS or inability to follow commands (aspiration risk)
    • Reactive airways

    Manual hyper-inflation

    (PICU only)

    		 Intubated & ventilated patients with:
    • Chronic respiratory disease with large amounts of sputum
    • Acute lobar atelectasis
    • Pneumonia with evidence of secretions
    • Bronchopleural fistula
    • Fractured fibs
    • Lung transplant
    • Pneumothorax with no ICC insitu
    • Acute asthma/severe bronchospasm
    • Acute head injury (risk of increased ICP)
    • ARDS (often already overinflated)
    • Bullae/cysts
    • Frank haemoptysis
    • Haemodynamic instability (risk of decreased MAP)
    • Oesophageal surgery
    • PEEP >10cmH2O (risk of de-recruitment with disconnection of ventilator)
    • Presence of ICC (draining pneumothorax)
    • Restrictive lung conditions (pulmonary fibrosis, scoliosis – greater risk of barotraumas)
    • Ventilator PIP >30cmH2O

    Non intensive care areas

    Effective coughing in a patient who can follow instructions:

    • Determine the optimal position for the patient to cough:
      • For typically developing children – position patient in an upright position supporting their head and neck if required
      • For children with neuromuscular weakness (e.g. spinal muscular atrophy) and/or a significant neurodevelopmental condition (e.g. cerebral palsy GMFCS level IV/V) – ask the parent which position the patient coughs best in, OR try positioning the patient in side-lying
    • Provide adequate analgesia and support of any surgical wounds or sutures to prevent damage. For example: holding a pillow or folded towel in front of their chest for sternal wound
    • Ask patient to take a few deep breaths and observe the expansion of their thorax
    • Ask the patient to take a deep breath and hold it at the peak of inspiration
    • Ask the patient to “huff” a few times then followed by a hard “huff” at the end of inspiration – this should trigger a cough 

    Effective coughing in a patient who cannot follow instructions:

    • Determine the optimal position for the patient to cough, as described above.
    • Provide adequate analgesia and support of any surgical wounds or sutures to prevent damage, as described above.
    • Use the following techniques (as appropriate based on the patient’s background and presentation, and your knowledge, skill set, and local policies and procedures) to assist in inducing a cough:
      • Re-positioning/movement/activity as developmentally appropriate
        • This may include assisted rolling side to side for children unable to roll on their own, through to walking for children who are more active and independent
      • Nebulisation of normal saline (0.9%) solution (if prescribed)
      • Oropharyngeal or nasal pharyngeal suction

    Sitting out of bed and/or Mobilisation:

    • Upright positioning, such as sitting out of bed and/or mobilisation, is one of the simplest interventions that can help with improving respiratory status in a typically developing child. In these children, upright positioning and mobilisation improve gas exchange and mobilise secretions through a number of beneficial physiological responses that occur, including increased total lung capacity, increased tidal volume, increased vital capacity, increased functional residual capacity, and so on.
    • In addition to the above, upright positioning and mobilisation also have positive impacts on other bodily systems and general function, including maintenance of muscle strength/muscle strengthening, improving gastrointestinal function, improving sleep/wake cycle, reducing chance of delirium, and improving mental health and quality of life.
    • Based on the information above - sitting out of bed and/or mobilisation should be considered as first line management for secretion clearance in typically developing children.
    • However – please be aware that for children with neuromuscular weakness or neuro-disability, upright positioning, sitting out of bed and/or mobilisation may increase the demands on their respiratory system, at a time when they have minimal reserve, potentially resulting in fatigue and respiratory deterioration, and therefore should not be utilised in the acute phase of a respiratory illness.

    Postural drainage positions:

    • Postural drainage utilises the patient position to facilitate the removal of secretions with gravity.  In children modified postural drainage positions are used that do not involve any head-down positions
    • Auscultate the chest to determine the areas of the chest that need drainage
    • Administer appropriate pain relief and explain the procedure to the patient
    • Bronchodilators, nebulised saline or mucolytic agents may be administered prior to repositioning if prescribed 
    • Position the patient with the affected lung segment positioned uppermost, utilise pillows to maintain patient’s position.  If this does not appear to be having benefit or the patient is desaturating in this position try lying on the other side as some patients will clear more secretions from the dependent lung.
    • Encourage patient to cough or suction the patient’s airway to assist in secretion clearance.
    • Monitor the patients HR, RR and Sp02. Discontinue postural drainage (or change the postural drainage position) if tachycardia, dyspnoea or hypoxia occur.

    Chest percussion and vibrations:

    • Vibrations and percussions may be used in chronic disease with large amounts of sputum e.g. Cystic Fibrosis 
    • Obtain a physiotherapy assessment in all patient groups prior to using this technique
      • There are risks associated with using this technique, especially for patients who are osteopenic (susceptible to fractures) or who have a low platelet count (susceptible to bleeding and trauma)
    • Position the patient according to location of specific lung pathology (or perform in alternate side-lie)
    • Ensure adequate padding with use of a folded towel over the rib area

    Percussion: 

    • Place patient in optimal postural drainage position
    • Perform rhythmic, firm tapping to the chest wall using a cupped hand over a segment of lung that has demonstrated consolidation or collapse (see figure 1)
    • Never perform on bare skin or over surgical incisions, below the ribs or over the spine or breasts due to risk of tissue damage
    • Percuss area for up to up to 5 minutes. You may alternate percussion with vibration (described below) 

    Figure 1: Hand position for chest percussions (photo credit RCH)

    Nsg Advanced secretion fig 1

    Vibration

    • Place patient in optimal postural drainage position
    • Perform firm compressive vibrations to the chest wall during expiration (see figure 2). Movement sets up course vibrations in the airways to help loosen the secretions sticking to the walls of the airways.
    • Vibrations should be avoided over patients breasts, spine and sternum to avoid discomfort
    • 1-5 minutes of vibration is usually performed in each selected position.

    Figure 2: Hand position for chest vibrations (photo credit RCH)
    Nsg Advanced secretion fig 2

    Bubble PEP

    Bubble PEP is an airway clearance technique usually implemented by a physiotherapist with much consideration as to the indications, precautions, and contraindications. If you have any questions regarding Bubble PEP please contact the Physiotherapy team.

    This is a technique that involves breathing with a slightly active expiration against an expiratory resistance, which in turn creates a rise in functional residual capacity thereby opening previously closed airways, increasing lung volumes and mobilising secretions through collateral ventilatory flow.

    • PEP is usually used with children who have retained secretions and difficulty clearing through usual methods, such as their own effective cough, deep breathing, positioning, mobilisation and activity. This may include children with a history of lung disease (usually prescribed by a physiotherapist), or children whose mobility is limited post operatively/post trauma/due to pain. However - PEP is not without risks, so please ensure you check the precautions and contraindications list prior to implementation, and contact a physiotherapist if you have any questions or concerns.
    • A low cost version of PEP, known as Bubble PEP, can be created using equipment that is readily available in the hospital, as shown below. Equipment required:
      • Water for irrigation bottle with the lid removed – fill with water to 13cm
      • Suction tubing - cut into a 30-40cm length

     

    • Once the bubble PEP is set up as shown above – encourage the patient to breathe OUT or blow into the tubing to create bubbles in the water – aiming for a 2-3cm expiration. This should be repeated 10x. The number of cycles and sets across the day will vary based on the patient’s need.
    • Infection Risk: Bubble PEP poses an infection risk and therefore strict hygiene and washing instructions must be followed if using Bubble PEP. After each use it is essential to:
      • Empty the bottle (not safe to leave the water in the bottle during the day due to risk of infection)
      • Wash the equipment in warm soapy water and air dry

    Mechanical in-exsufflation (e.g. CoughAssist®)

    Mechanical in-exsufflation should only be performed in patients who have already been commenced on the treatment by a physiotherapist.

    • A mechanical in-exsufflation machine works by blowing air into the lungs at a positive pressure, followed by sucking air +/- secretions out of the lungs via a negative pressure. Mechanical in-exsufflation is predominantly used by patients with neuromuscular conditions to improve the strength and effectiveness of their cough.

    Nursing staff should only perform mechanical in-exsufflation if they have attended an annual education session by a physiotherapist or have had bedside training with a physiotherapist in the past year.  A patient-specific review and handover by a physiotherapist is also advised.

    • Position the patient appropriately ensuring their head is supported.
    • Check the settings on the mechanical in-exsufflation device against those prescribed for the patient in the EMR order or written recommendations.
    • Provide a mechanical in-exsufflation cycle as outlined in the EMR order or written recommendations, clear secretions via suction if required, and repeat as needed (monitoring for fatigue)
    • Setting prescriptions should only be modified by a physiotherapist.
    • Some patients utilise mechanical in-exsufflation at home and in the community, in which case their parents and/or carers will be trained. A parent and/or carer may provide this treatment to their child if they have been trained and signed off previously by a physiotherapist.

    Rosella (PICU) 

    Effective coughing, Postural drainage positions, Mobilisation, Bubble PEP, Chest Percussions & Vibrations, & Mechanical in-exsufflation (e.g. CoughAssist®)

    • As described above

    Deep breathing with SMI following extubation:

    • Provide adequate pain relief
    • Maintain the patients head in a neutral position with the bed elevated 30-40 degrees
    • Educate the patient to take a deep breath and hold it for approximately 3 seconds, encourage them to do this at least 10 times every hour whilst awake
    • Include the parents in the education and encourage them to prompt their child each hour whilst awake
    • Provide a rolled-up towel or pillow to patients who have undergone a sternotomy or other surgery to the thorax or abdomen and encourage them to hug the towel to their chest or wound site when coughing to minimise discomfort

    Manual hyperinflation

    • Manual hyperinflation should only be undertaken by nursing staff in the intensive care if it has been deemed an appropriate treatment by review from physiotherapy. Physiotherapists should provide nursing staff with a documented plan for manual hyperinflation including maximum pressures and frequency of treatment.

    Family Centred Care

    Patients with chronic respiratory conditions will often have some prior exposure to secretion clearance techniques, either from previous admissions or from their  baseline secretion clearance regime. Home regimes  are developed by the patient’s MDT and completed as part of routine care by trained family members and carers. It is recommended that patients, families and carers are asked about their experience with secretion clearance techniques, to better inform treatment choices. If appropriate, the family and/or carer may assist with secretion clearance in the acute environment.

    Special Considerations 

    • Aerosol Generating Procedures - should an aerosol generating procedure be undertaken on a patient under droplet precautions then increase to airborne precautions by donning N95/P2 mask for at least the duration of the procedure.
    • Precautions and contraindications – there are several precautions and contraindications that should be checked prior to the use of certain advanced secretion clearance techniques – please see Table 3 for details.

    Companion Documents

    RCH Nursing Guidelines

    RCH Departmental Guidelines

    Evidence Table

    Reference

    Source of Evidence

    		Key findings and considerations
    Chatwin, M., Toussaint, M., Goncalves, M. R., Sheers, N., Mellies, U., Gonzales-Bermejo, J. … Morrow, B. M. (2018). Airwayclearance techniques in neuromuscular disorders: A state of the art review. Respiratory Medicine 136, 98-110. doi: 10.1016/j.rmed.2018.01.012 
    		 Systematic review
    • Comprehensive review on the entire evidence base for airway clearance techniques in both adults and children with neuromuscular disorders.
    • For proximal airway clearance techniques they recommend manual assisted cough and assisted inspirations for patients with higher peak cough flows, and use of mechanical insufflation-exsufflation (MI-E), also known as cough assist, for patients with lower peak cough flows (<160L/min).
    • There are a range of options available for peripheral airway clearance for patients with neuromuscular disease, with things like availability and local expertise needing to be factored into selection.
    Chaves, G. S. S., Freitas, D. A., Santino, T. A., Nogueira, P. A. M. S., Fregonezi, G. A. F., Mendonca, K. M. P. P. (2019). Chest physiotherapy for pneumonia in children (review). Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD010277.pub3.
    		Systematic review
    • Based on the evidence available, the authors could not confirm if chest physiotherapy was beneficial or not for typically developing children with pneumonia. They did note that physiotherapy techniques were not associated with shorter hospital stays.
    Clini, E., & Ambrosino, N. (2005). Early physiotherapy in the respiratory intensive care unit. Respiratory Medicine, 99(9), 1096-1104. doi: 10.1016/j.rmed.2005.02.024 Review article
    • Manual hyperinflation has been found to be equally as effective as ventilator hyperinflation at clearing pulmonary secretions and improving static pulmonary compliance.
    • Manual hyperinflation may prevent atelectasis and re-expand atelectasis, increase secretion clearance, and reduce the incidence of nosocomial pneumonia in mechanically ventilated patients.
    • There is minimal evidence available for the use of percussions and vibrations in ICU patients, with some showing no improvement to blood gases and lung compliance, yet others demonstrating a direct relationship between physiotherapy treatment and reduction in the incidence of ventilator associated pneumonia.
    • Early rehabilitation in the respiratory ICU is essential to enhance functional capacity, reduce or reverse the potential effects of immobility and prolonged bed rest, and optimise respiratory recovery and function.
    Fitzgerald, D. A., Follett, J., & Van Asperen, P. P. (2009). Assessing and managing lung disease and sleep disordered breathing in children with cerebral palsy. Paediatric Respiratory Reviews, 10(1), 18-24. doi: 10.1016/j.prrv.2008.10.003 Review article
    • The major morbidity and mortality associated with cerebral palsy (CP) relates to respiratory compromise, for which multi-disciplinary management is essential. Common respiratory problems and potential therapies are highlighted in this article. 
    • Chest physiotherapy is discussed in terms of positioning, percussions, vibrations, suction, and positive expiratory pressure (PEP), but it is also highlighted that there is a dearth of evidence regarding airway clearance techniques in children with CP. 
    • Some potential adverse effects of airway clearance techniques are highlighted, particularly relating to suction
    • It is also highlighted that not all children with CP require daily airway clearance, and assessment and regular re-assessment is essential.
    Harris, M., Clark, J., Coote, N., Fletcher, P., Harnden, A., McKean, M., Thomson, A. on behalf of the British Thoracic Society Standards of Care Committee (2011). British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 66(Suppl2), ii1-ii23. doi: 10.1136/thoraxjnl-2011-200598 Guideline & Consensus Statement • Chest physiotherapy is not beneficial and should not be performed in typically developing children with pneumonia.


    Johnston CL, James R, Mackney JH. The current use of positive expiratory pressure (PEP) therapy by public hospital physiothera- pists in New South Wales. N Z J Physiother 2013;41(3) 88-93.  Cross sectional survey study
    • The most commonly selected indication for use [of PEP therapy] was excessive respiratory secretions (n=60, 88%).
    • Improvised devices such as bubble (or bottle) PEP were used by more respondents (n=61, 90%) than commercially-available devices (n=30, 44%)
    • PEP therapy (particularly variably constructed bubble-PEP) was regularly utilised for the treatment of patients with cardiorespiratory conditions. 
    • Further research into the effectiveness of PEP delivered with improvised devices and more specific training of healthcare practitioners regarding optimal design parameters for PEP therapy may be beneficial.
    Liverani B, Nava S, Polastri M. An integrative review on the positive expiratory pressure (PEP)- bottle therapy for patients with pulmonary diseases. Physiother Res Int. 2020;25:e1823. https://doi.org/10.1002/ pri.1823 Review
    • PEP-bottle therapy has been proved to improve lung volume, to reduce hyperinflation, and to remove secretions.
    • The device delivers a pressure equal to the water column only if the inner diameter of the tubing and the width of the air escape orifice are equal or greater than 8 mm, and the length of tubing ranges between20 and 80 cm.
    • The cost of a PEP-bottle device is significantly lower if compared with other commercially available devices having the same therapeutic purposes.
    • Hygiene of the PEP-bottle is fundamental as well as the safety of patients who could run the risk of aspiration if the airway protection is impaired.
    Main, E., & Denehy, L. (Eds.). (2016). Cardiorespiratory Physiotherapy Adults and Paediatrics: Fifth Edition. Elsevier. Textbook
    • Extensive multi-system benefits of upright positioning and mobilisation.  

    Mestriner, R. G., Fernandes, R. O., Steffen, L. C., & Donadio, M. V. (2009). Optimum design parameters for a therapist-constructed positive-expi- ratory-pressure therapy bottle device. Respiratory Care, 54(4), 504–508.  Article
    • The distal tip of the PEP bottle tube was 10 cm below the surface of the water (ie, a 10-cm water column), and 3 cm above the bottom of the bottle.
    • With tubing of 2–6 mm inner diameter, the length of the tubing and the flow significantly affected the PEP pressure (ie, the system was not a threshold resistor). With tubing >8mm inner diameter there were no significant PEP-pressure differences with any of the tubing lengths or flows tested, which indicates a threshold-resistor system.
    • The 4-mm and 6-mm air-escape orifices significantly increased the PEP pressure, whereas the 8 mm air-escape orifice did not increase the PEP pressure.
    • To obtain a threshold-resistor PEP bottle system (ie, the PEP pressure is generated only by the water-column pressure), the tubing must be > 8 mm inner diameter, and the air-escape orifice must be > 8 mm.
      Roque-Figuls, M., Gine-Garringa, M., Granados Rugeles, C., Perotta, C., & Vilaro, J. 2023. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old (review). Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD004873.pub6. Systematic review
      • No effect of conventional physiotherapy on disease severity of infants with moderate bronchiolitis.
      • Forced expiratory techniques also failed to show an effect on bronchiolitis severity in infants with severe disease, while important adverse events were reported.
        Tamburro, R. F., & Kneyber, M. C. (2015). Pulmonary specific ancillary treatment for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Critical Care Medicine, 16(5 Suppl 1), S61-72. doi: 10.1097/PCC.0000000000000434 Consensus Statement
        • The efficacy of chest physiotherapy for pulmonary acute respiratory distress syndrome (PARDS) has not been testing in a single RCT to date (at the time of writing this article), nor have there been any published case series or observational data. Therefore chest physiotherapy is not recommended as standard of care in PARDS patients.
        Unsworth, A., Curtis, K., & Asha, S. E. (2015). Treatments for blunt chest trauma and their impact on patient outcomes and health service. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 23(17), 1-9. doi: 10.1186/s13049-015-0091-5 Systematic review
        • A multi-disciplinary pathway improved outcomes for patients and decreased ICU and hospital LOS, pneumonia and mortality – applied to patients greater than 45 years of age with 4 or more rib fractures, and included physiotherapy input for deep breathing exercises.
        • Chest physiotherapy, including incentive spirometry, and CPAP have decreased complications in rib fracture treatment.
        • Limited evidence in the role of chest physiotherapy and allied health in the outcomes of patients with blunt chest trauma and primarily focused on patients with multiple rib fractures. Rib fractures are reported to be the most common clinical fracture in older people and this demographic is the most at risk of rib fracture related morbidity. Rapid mobilisation through physiotherapy is considered a key factor in preventing complications, including pneumonia, respiratory failure and ARDS. However to facilitate this, effective pain control is necessary.


          Please remember to read the disclaimer.


          The development of this nursing guideline was coordinated by Elisha Porter, CNC, Rosella Ward and Lisa Robson, Physiotherapist, PICU and Neurodevelopment and Disability Team and approved by the Nursing Clinical Effectiveness Committee. Updated May 2025.