|Year : 2014 | Volume
| Issue : 1 | Page : 15-21
Effect of lung squeeze technique and reflex rolling on oxygenation in preterm neonates with respiratory problems: A randomized controlled trial
Jaitty Kole, Deepa Metgud
Department of Paediatric Physiotherapy, KLE University's Institute of Physiotherapy, Belgaum, Karnataka, India
|Date of Web Publication||2-Jul-2014|
Department of Paediatric Physiotherapy, KLE University's Institute of Physiotherapy, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Purpose: Respiratory problems like RDS, pneumonia and acute respiratory failure in premature neonates are one of the leading causes of neonatal morbidity and mortality in developing countries. Decreased oxygenation and excess accumulation of secretion is common leading to increase in airway resistance, and complications like atelectasis requiring prolonged ventilatory assistance or oxygen support. Apart from convention chest physiotherapy techniques like percussion and vibration newer techniques like LST and vojta have been used to clear secretions, restore homogenous inflation of the lungs and improve oxygenation. In this study, we compared the effectiveness of CPT, LST and reflex rolling on oxygenation in preterm neonates with respiratory problems, in terms of blood gases and oxygen saturation.
Materials and Methods: This ra ndomized controlled trial included 60 neonates with RDS and pneumonia with gestational age of 30 to 37 weeks under O 2 therapy. The participants were randomly allocated into 3 groups. Group A received CPT, group B received LST with CPT and group C received Reflex rolling with CPT for 20 minutes duration per session at 0, 4 th and 8 th hour, three sessions per day, for a period of 2 weeks. Pre and post intervention values of pulse oximetry and Arterial Blood Gas was recorded to analyze oxygenation. Chest X-rays were taken on day 1 and last day.
Results: The results showed within group improvements in SPO 2 , PaO 2 which was statistically significant (P < 0.001) on day 1, and post intervention on last day for all the groups whereas between groups comparison showed no significant difference with P value 0.480 and 0.258 respectively. Chest radiographs demonstrated re-expansion of collapsed airways.
Conclusion: The present study concludes that the three treatment techniques viz. CPT, LST Technique and Reflex Rolling are safe and effective for improving Oxygenation in preterm neonates with respiratory problems and can be used in clinical settings.
Keywords: Chest physiotherapy, lung squeeze technique, reflex rolling, oxygen saturation, arterial blood gas, respiratory distress syndrome, preterm neonates
|How to cite this article:|
Kole J, Metgud D. Effect of lung squeeze technique and reflex rolling on oxygenation in preterm neonates with respiratory problems: A randomized controlled trial. Indian J Health Sci Biomed Res 2014;7:15-21
|How to cite this URL:|
Kole J, Metgud D. Effect of lung squeeze technique and reflex rolling on oxygenation in preterm neonates with respiratory problems: A randomized controlled trial. Indian J Health Sci Biomed Res [serial online] 2014 [cited 2019 Jan 20];7:15-21. Available from: http://www.ijournalhs.org/text.asp?2014/7/1/15/135028
| Introduction|| |
Respiratory problems in neonates are one of the leading causes of neonatal morbidity and mortality in developing countries. These respiratory problems are seen in premature neonates, which mainly include respiratory distress syndrome (RDS), pneumonia, bronchopulmonary dysplasia, diaphragmatic hernia, apnea requiring ventilatory assistance or oxygen support. This population, which most commonly suffer from respiratory disorders have distinct physiological characteristics, which make them vulnerable to nutritional deficits with detrimental short and long-term effects.  Prolonged intubation and Neonatal Intensive Care Units (NICU) stay is associated with complications such as chronic lung disease, respiratory infections, subglottic stenosis, feeding problems, weight loss, , and long-term neurodevelopmental problems. 
Respiratory distress in the neonate is a common problem  and responsible for 30-40% of admissions in the neonatal period. , Some of the conditions that cause distresses in preterm neonates are RDS also called as hyaline membrane disease  and pneumonia. , The exact incidence and prevalence of RDS and pneumonia in India is not known.
Respiratory distress syndrome of the newborn is an acute lung disease seen primarily in neonates younger than 36 weeks' gestational age and weighing <2500 g. A decreased production of chemically mature levels of surfactant is associated with RDS, , whereas, pneumonia occurs because of infectious etiology, acquired before, during, after birth as an isolated manifestation of infection or more commonly, in association with generalized infection.  These conditions lead to atelectasis, ventilation-perfusion (V/Q) inequality, hypoventilation, reduced lung volume and decreased lung compliance. , These conditions require a massive increase in work of breathing required to ventilate the lung. , leading to decreased oxygenation, asphyxia, metabolic acidosis, and acute respiratory failure, leading to complications like atelectasis, which can be fatal.  It may also lead to production of excess bronchial secretions thus causing an increase in airway resistance.
Medical management comprises of the number of interventions that begin immediately after birth, which include surfactant treatment, ventilator support, antibiotics and general supportive care. , Oxygen supplementation and arterial blood gas (ABG) monitoring being an essential part of it. Oxygen therapy is commonly used in NICU as an integral part of respiratory support. Prolonged oxygen therapy and can lead to accumulation of excess of bronchial secretions, which need to be removed using chest physiotherapy.
Conventional chest physiotherapy (CPT) has become an integral part of airway management in NICU settings.  with an aim to remove excess of bronchial secretions, thus improving oxygenation.  Various manual techniques for airway clearance are used in neonatal settings, including postural drainage, percussion, and vibration , based on rationale to facilitate secretion removal and are used as conventional treatment. ,, Few newer techniques have been introduced, which include lung squeeze technique (LST) and reflex rolling. LST is a form of manual chest wall compression performed on the whole hemithorax.  Reflex rolling is a Vojta's program that employs isometric strengthening techniques through tactile stimulation, to encourage the development of normal movement patterns and therefore to improve respiration. ,
Role of CPT in reducing respiratory morbidity in neonates remains debated and needs further
evaluation. ,, Use of CPT thus needs to be validated using well-controlled studies with large sample size, especially in relation to techniques and specific protocols employed. To the best of our knowledge, there has been little research to support claims for the benefits of LST, reflex rolling, in the treatment of preterm neonates with respiratory problems. Hence, it is important from physiotherapeutic point of view to use an effective approach that aids in improving and maintaining adequate oxygen saturation (SpO 2 ) levels and blood gas parameters (PaO 2 , SO 2 ) in preterm neonates with respiratory problems.
| Materials and Methods|| |
This was a single blinded randomized controlled trial with two experimental groups and one control group. A total of 60 male and female neonates between 30 and 37 weeks of gestational age were included in the study. The study was conducted in NICU of K.L.E'S Dr. Prabhakar Kore Hospital and Medical Research Center Belgaum, India.
Inclusion criteria: (1) 30-37 weeks of gestation admitted to NICU with diagnosis of RDS or pneumonia. (2) On oxygen therapy. (3) No major airway interventions like manual hyperinflation or bronchial lavage performed in previous 12 h. (4) Hemodynamically stable. (5) Written informed consent from parents. Exclusion criteria: (1) Neonates with respiratory and cardiac congenital anomalies. (2) Neonates with seizures.
(3) Mechanically ventilated neonates. (4) Acute stage of RDS. (5) Neonates who underwent surgical procedures. (6) Neonates with genetic syndromes.
Participants diagnosed by the neonatologist as having RDS or pneumonia were screened to find their suitability as per the inclusion and exclusion criteria and were requested to participate in the study. Those willing to participate were briefed about the nature of the study and the intervention and a written consent was obtained from the parents or caregivers of each participant. Demographic data were collected along with details of gestational age, birth weight, Apgar score, breath sounds, heart rate, respiratory rate, oxygen administered, postnatal age, and from clinical notes. All the procedures were carried out by the principal investigator under aseptic precautions to be maintained in the NICU. To quantify the amount of oxygen saturation (SpO 2 ) in neonates a Hewlett Packard pulse oximeter (Hewlett Packard Neonatal Viridia 24C, System no. M1205 A, manufactured in 71034 Boeblingen, Germany) was used. A band like sensor was placed across neonate's foot which was connected to monitor that displayed SpO 2 . ABG analysis was done using a blood sample from the radial artery at the wrist which was sent to the laboratory, which analyzed partial pressure of oxygen (PaO 2 ) and arterial oxyhemoglobin saturation (SaO 2 ). A total of 60 participants were randomly
allocated into three groups of 20 each using an envelope method. The three groups were, Control group (Group A), LST (Group B), and reflex rolling (Group C). Group A received only conventional CPT, Group B received CPT and LST, Group C received CPT and reflex rolling.
Conventional chest physiotherapy
Chest percussion was administered using a size zero neonatal face mask, with motion primarily from the wrist, with firm support applied to the side of the thorax opposite that being percussed. Vibration of the chest were done manually by placing the fingers on the chest wall over the segment being drained and isometrically contracting the muscles of the forearm and hand to cause a vibratory motion.
Lung squeeze technique
Each set of "lung squeezes" consisted of three or four sustained chest compressions lasting for about 5 s, followed by a gentle slow "release phase," with the chest wall being completely released; these compressions were given without vibration and not in gravity-assisted position. ,
In this maneuver, neonates head was rotated towards the side from which stimulus was delivered. A slight digitopressure (dorsal medial and cranial direction, diagonally to spine) was exerted on the chest area at the level of the 6 th rib, or between 5 th and 6 th , or between 6 th and 7 th . Each treatment consisted of delivering four stimuli, two to the left and two to the right. 
Neonates were placed in asymmetrical supine position during the intervention. Intervention for each group was given at 0, 4 th and 8 th h that is, 3 sessions/day, of 20 min duration for a period of 2 weeks. Suctioning was done if needed. In case the neonate was weaned off from O 2 hood in <2 weeks of duration, intervention was discontinued and postintervention values were recorded for that session. Outcome values were recorded 5 min after intervention. SpO 2 , PaO 2 , and SaO 2 was recorded pre- (0 h) and post-intervention (8 th h) on day 1 and postintervention (8 th h) on the last day by the nurse who was blinded to study group and nature of intervention given. Chest X-ray was taken on day 1 and last day of the intervention.
The statistical software SAS 9.2 was used for the analysis of the data. ANOVA was used to find the significance of study parameters between groups, Student's t-test (two-tailed, dependent) was used to find the significance of study parameters. Chi-square/Fisher Exact test was used to find the significance of study parameters on categorical scale between groups.
| Results|| |
Subjects participating in this study had a mean gestational age (weeks) of 31.85 ± 1.71 weeks in Group A, 30.98 ± 1.98 in Group B and 31.52 ± 1.93 in Group C. The mean weight (kg) of neonates in Group A was 1.70 ± 0.25, 1.70 ± 0.32 in Group B and 1.78 ± 0.33 in Group C. The mean height (cm) of participants was 42.35 ± 1.09 in Group A, 41.25 ± 2.05 in Group B, 41.20 ± 3.00 in Group C. The mean pondral index (kg/m 3 ) for Group A was 22.35 ± 3.24, Group B was 22.53 ± 5.75 and Group C was 26.57 ± 9.42 [Table 1]. The demographic data for all the groups did not show any significant difference thus demonstrated the homogeneity in the groups [Table 1].
Subjects in this study had a mean postnatal age (days) of 3.50 ± 1.36 in Group A, 3.55 ± 1.28 in Group B, and 3.95 ± 1.15 in Group C, which was not statistically significant for all three groups. Whereas, we found a significant difference in O 2 supplemented and number of days of intervention with P value 0.012 and 0.041 in all the three groups [Table 2].
|Table 2: Clinical characteristics of the participants in the three groups|
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Paired t-test showed a significant increase in SpO 2 within the groups on day 1 with P < 0.001, whereas between groups comparison showed no significant difference with P value 0.480 and 0.258. The ANOVA of the means of the three groups for the preintervention (day 1) measures showed that P value 0.480 was not significant and for the postintervention measures
(last day) showed that P value (0.849) was not significant, whereas paired t-test done for within the group showed a significant increase in SpO 2 within the groups with P < 0.001 [Table 3] and [Table 4].
|Table 3: Comparison of SpO<>sub>2, PaO2 and SO2 in all the three groups on day 1|
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|Table 4: Comparison of arterial blood gas values on day 1 and last day in three groups|
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Paired t-test showed a significant increase in PaO 2 within all the three groups on day 1 with P < 0.001, whereas between groups comparison showed no significant difference with P value 0.298 and 0.9187. The ANOVA of the means of the three groups for the preintervention (day 1) measures showed that P value 0.298 was not significant and for the postintervention measures (last day) showed that P value 0.616 was not significant, whereas paired t-test done for within the group showed a significant increase in PaO 2 in Group A and C with P < 0.001 and with P = 0.001 in Group B [Table 3] and [Table 4].
Paired t-test showed a significant increase in SO 2 within Group A with P value 0.001, whereas there was no significant difference in Group B and C with P value 0.080 and 0.280, respectively on day 1 between the groups comparison showed no significant difference with P value 0.632 and 0.925. The ANOVA of the means of the three groups for the preintervention (day 1) measures showed that P value 0.632 was not significant and for the postintervention measures (last day) showed that P value 0.283 was not significant, whereas paired t-test done for within the group showed a significant increase in SO 2 within the groups with P < 0.001 in Group A and C and with P = 0.001 in Group B [Table 3] and [Table 4]. Chest radiographs analyzed preintervention suggested that no findings in 10% of participants in Group A, 15% participants in Group B, and 5% of participants in Group C. There were the presence of air bronchograms in 15% of participants in Group A, 20% of participants in Group B, and 10% of participants in Group C. Congestion in upper lobes was observed in 55% of participants in Group A, 50% participants in Group B, and 70% of participants in Group C. Congestion in the middle lobe was seen in 10% of participants in Group A, 145% participants in Group B, and 5% participants in Group C. Congestion in the lower lobe was observed in 10% of participants in Group A, and 10% of participants in Group C, whereas lower lobe was not involved in Group B participants [Table 5].
| Discussion|| |
The results of this study justify the alternate hypothesis that there will be a significant improvement on oxygenation with LST and reflex rolling. We also found improvement in oxygenation with CPT. These results are consistent with previous studies, which indicate that CPT, LST and reflex rolling significantly improves oxygenation in preterm neonates. ,,,,,
In this study, we used percussion and vibration as a CPT intervention. Chest percussions help unstick mucus from the lungs so that it can be coughed out, which improve chest sound.  The effects are based on shear thinning of secretions, "squeezing" secretions from distal airways with changes the intrathoracic pressures, formation of central mucus globules that are easier to ex-pectorate, freeing the adhesive secretions from the airway walls.  With effective percussion, breath sound improved as secretions move into the larger airways. In a study conducted in preterm neonates with RDS, chest vibrations were administered prior to endotracheal suctioning. This study suggested that vibrations facilitates to loosen lung secretion and to move them to larger airways, these findings related to improvement in oxygenation.  We used vibration in addition to percussion, which caused thinning and loosening of secretions with further movement of these secretions to the larger airways. Suctioning following these two techniques thus helped in removal of secretions thus improving chest sounds further improving oxygenation. In addition, suctioning was done if needed this, which was in accordance with an evidence, which reports that suctioning should be performed when obstructive secretions are present, rather than routinely. ,
A case study conducted in Karnataka, India, on a neonate with RDS treated with 8 L of oxygen through the hood with SpO 2 of 92% and respiratory rate 40/min revealed absence of air entry in the right upper zone. ABG report showed reduced oxygenation (PaO 2 86 mmHg). Gentle percussion using the face mask was given along with vibrations with minimal compressive pressure every 3 hourly during the day time which showed improved oxygenation in a day.  In the present study CPT was given in the form of percussion and vibration every 4 th hourly thrice a day. We had a larger sample (n = 20) in each group. SpO 2 and ABG was recorded pre- and post-intervention on day 1, with a follow up on the last day of the intervention. Our study was thus better in term of study design, sample size and intervention. We also found significant improvement in SpO 2 and PaO 2 values on day 1, which was in accordance with the above study. CPT, including percussion, vibration and postural drainage techniques increased oxygen saturation and tidal volume in children with acute bronchiolitis, which is due to bronchial sputum clearance.  A review conducted in order to report different therapeutic techniques used in CPT (which included active and nonactive physiotherapy techniques) in preterm neonates reports similar finding.  In our study, we used active CPT, which included percussion and vibration, which caused bronchial clearance and thus increased SpO 2 , PaO 2 , and SO 2, thereby increasing oxygenation. We did not include postural drainage as it leads to desaturation. 
Study conducted on ventilated preterm neonates, which compared LST with conventional percussion and vibration, suggested that LST is more effective in treating atelectasis and can be used to treat signs of uneven distribution of ventilation, bronchial clearance and prevent the development of atelectasis.  In our study, we found a significant increase in oxygen saturation in Group A and Group B. Our results suggest that CPT and LST are equally effective in improving oxygenation and bronchial clearance. In addition to this, we also found that the mean number of days of intervention was 4.30 ± 1.17 days in Group B and 5.30 ± 1.17 days in Group A, which is because of additional effect of LST administered in Group B thus suggests that less number of days of intervention was required in Group B, which means that participants in Group B improved at a faster rate.
Respiratory system compliance (Crs) is defined as the change in lung volume in response to a change in transpulmonary pressure and is affected by tissue clearance. An immediate increase in Crs was found after LST in a previous study suggestive of lung clearance.  LST for 10 min improves mean Crs in mechanically ventilated preterm neonates, this improvement is related to the recruitment of more lung units.  In this study, we introduced CPT in addition to LST thus the improvement seen in SpO 2 , PaO 2 and SO 2 which may be due to lung clearance and improvement in Crs which enhanced blood gas exchange and prevented lung collapse due to recruitment of more lung units.  We found 20% of neonates in Group B who had a presence of air bronchograms suggestive of collapse of airways. LST may have resulted in re-expansion of the collapsed airways with a continuous process of recruitment of atelectaticacni due to changes in lung tissue and surface tension characteristics thus improved ventilation. This was thereby demonstrated by the positive effect on SpO 2 , PaO 2 and SO 2 values which were significant.
Vojta noticed a global reaction, consisting of rotation of the head with flexion of the lower limbs and rotation of the pelvis, opening of the hands and an increase in depth of costal respiration, with an expansion of the ribcage, initiation of swallowing and increase in the depth of breathing. We observed similar findings on applying these stimulations. The importance of these stimulations, especially if repeated, lies in the fact that the afferences due to induced physiologic muscle activity are imprinted in the central nervous system and memorized.  The results of the present study showed improvement in, SpO 2 , PaO 2, and SO 2 values with application of these stimulations supporting the finding of this study. Previous study conducted to check the efficacy of reflex rolling in preterm neonates. The study included 34 preterm and had a single group. The results of this study suggested increase in SpO 2 and PaO 2 values and concluded that reflex rolling was a safe method to be used in preterm neonates.  We conducted a randomized controlled trail using three groups to study the effectiveness of reflex rolling along with LST and CPT in preterm neonates with a larger sample size of 60 neonates, 20 in each group. Thus our study was better in terms of study design and protocol administered
In our study, we found an increase in PaO 2 values (>100 mmHg) suggesting of hyperoxia on day 1 in all the three groups, which was in line with previous studies conducted on mechanically ventilated pediatric and adult patients which concluded that an increase in oxygen consumption often occurs when a patient receives CPT.  We noticed hyperoxia, which may be due to higher levels of oxygen administered in order to maintain saturation, in addition effect of physiotherapy intervention resulted in an increase in oxygen consumption. This in turn improved oxygenation which further prevented lung collapse.
Atelectasis is common in neonates with RDS. Eight of 23 infants extubated developed atelectasis in the "prephysio" period, whereas only one collapse occurred in 20 infants treated with a routine of physiotherapy at extubation. Subsequently, a prospective controlled trial compared the use of a routine of physiotherapy at extubation with no physiotherapy. Eight of 21 infants not receiving physiotherapy developed postextubation atelectasis and none of 21 infants receiving physiotherapy developed atelectasis.  In our study, 10-20% of neonates in all the groups presented air bronchograms and 70% cases had involvement in the upper lobe as seen on chest radiographs on day 1 suggestive of atelectasis, which resolved on the last day of the intervention. These findings suggest that CPT, LST and reflex rolling helped in resolving atelectasis.
Four hourly treatment is indicated in the presence of collapse or consolidation of part of lung or if secretions are accumulating rapidly.  In our study, chest radiographs were suggestive of air bronchograms in all the three groups, we also found congestion in upper lobes prior to intervention. Thus, 4 th hourly CPT, LST and reflex rolling proved to be beneficial in clearance and re-expansion of collapsed airways, which was demonstrated on chest radiographs on the last day of the intervention. CPT after extubation does not reduce alveolar atelectasis but it decreases the need for re-intubation.  In this study, we found that atelectasis was resolved in all three groups following CPT, LST and reflex rolling. This effect may be due LST and reflex rolling, which was given in addition to CPT thus reduced atelectasis. No participants in the three groups were intubated following intervention thus suggesting similar findings of the above study. Efficacy of CPT is questionable as studies report adverse effects of CPT such as bruising, rib fractures,  periosteal reaction of the ribs,  and intraventricular hemorrhage.  We did not observe any adverse effects due to CPT, LST and reflex rolling in our study.
The results of this study cannot be generalized to other population. Our study had participants with RDS. Term or ventilated neonates might respond differently to the protocols used. We did not record prior history of intubation. Dosage of oxygen administered was not recorded every day.
| Conclusion|| |
The present study concludes that CPT, LST and reflex rolling is a safe and effective method in improving Oxygenation in preterm neonates with respiratory problems and can be applied in clinical settings. Newer physiotherapy techniques like LST and reflex rolling are equally effective in improving oxygenation in preterm neonates with respiratory problems.
Future clinical research should investigate lung mechanics during application of LST and reflex rolling. Studies should be conducted on ventilated neonates and neonates with postoperative conditions.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]