The Effect of Respiratory Therapy on Intracranial Pressure in Ventilated Neurosurgical Patients Considerable concern has been expressed about the effect of respiratory therapy on intra- cranial pressure (ILC.P) in the acute stage of head injury. A study was performed to evaluate the effects of respiratory therapy techniques on the level of 1.C.P. in neurosurgical patients. Twenty subjects were studied in both the para- lysed and non-paralysed states. Their intracran- ial pressures were monitored during periods of ‘no treatment (the control), during the applica- tion of individual respiratory techniques and during a complete respiratory treatment. ‘Analyses revealed that total treatment time Is a crucial factor in the level of CP. Patients with a high resting .C.P. are more vulnerable to large increases, prolonged manual hyperin- fation raises 1.C.P. level and suctioning, in par- ticular, causes dramatic increases in I.C.P. JENNIFER GARRADD Jennifer Garradd, Dip. Phty. is a Senior Tutor in Physiotherapy at the University of Queensland. She was previously tha Senior Physiotherapist in th Neurosurgical Intensive Care Unit at Royal Bishan ph MARGARET BULLOCK Margaret Bullock, Ph.D., B.Sc. App, is Professor of Physiotherapy and Head of the Department of Physio- therapy at the University of Queensland. She has had many years of experience in research and has en- ‘couraged the mounting of clinical research pr to establish a more scientific basis for the practice (of physiotherapy. ‘With improved technology and ven- tiation, the rate of survival of neu rosurgical patients has increased in e- cent years. It should be stressed, hhowever, that it i the quality of sur vival that is important. ‘One of the factors affecting the prognosis of the neurosurgical patent Is the level of Intracranial Pressure (LCP). Normal intracranial pressure js defined as 0-15 mmHg, and many Studies have demonstrated that sus tained increases in 1.C.P. carry a poor prognosis (Mille: and Sullivan 1979, Vapalahti and Troupp 1971, Gibson et a1 1975). Mille ef af (1977) ound that inthe patient with diffuse brain injury, elevation of LCP. above 10 mm contributed significantly to abnormal neurological function Factors that can cause an elevated LCP. include cerebral oedema, intra- cranial haemorrhage, cerebro-spinal ‘uid obstruction, increases in jugular ‘venous pressure, hypoxia, infection and Increased cerebral blood volume. P,0,. ‘The partial pressures of arterial blood gases, especialy partial pressure ‘of arterial carbon dioxide (P,CO,) also ireetly affect the level of LCP. by ‘using immediate and often sustal increases in cerebral blood volume (Beks 1978, Miller and Sullivan 1979). ‘Small inereases in PCO; may cause large increases in dilatory effects of PCO, on cerebral arteries (Frost 1979). ifthe partial pres ‘ure of arterial oxygen (P,0,) de- creases, lactic acid in the tissues ofthe brain increases, causing acidosis and a subsequent increase in cerebral blood flow (Shapiro 1975). If hypercarbia ex- i fe a P{CO; of greater than 45 mmHg, a hypoxia of 70 mmHg can ‘magnify the response of an ineresse in CP. due to the _Nobl "Not only do abnormal arterial blood gases adversely affect ILC.P., but an Increased 1.C.P. may cause a ventila tion-peefusion imbalance (lennett and Hoff 1978). Deleterious arterial blood _stes inthe aeute neurosurgical patient can delay neurological recovery, extend ‘cerebro-vasclar lesions and contribute to the formation of cerebral oedema, Adequate therapy for the pulmonary sd system is therefore vitally important in ‘managing patients with intracranial ab- normalities Many authors (Gibson, Turner and 1975, Moss and MeDowal 1979, March, Marshall and Shapiro 977, Baigelman and O'Brien 1981, Lofgren 1976, Trubuhovich 1979 claim that respiratory physiotherapy results Jn an increase in I.C.P. This increase is atrbuted to such factors as systemic hypertension, increase in intrathoracic pressure, impedance of cerebro-spinal ‘uid flow from the cranial cavity, by percarbia, hypoxia, or stimulation of the cough reflex. Unfortunately, reports claiming that respiratory therapy increases 1.C.P. have described studies which do not appear to be satisfactory experimen- tally in terms of a consistent measure ment, presence of a control measure- Th Astaln Jou of Physteray. ol. 2, Ne. 2,885 107Respiratory Therapy and |.C.P. in Ventilated Neurosurgical Patients sent, oa statistically relevant number of subjects. Because of these views, many new- rological teams do not support the use fof respicatory therapy in the acute stage. However, lack of respiratory therapy can lead to secondary pulmo- ‘ary complications, causing an in- crease in LCP. Due to the uncertainty surrounding the use of respiratory therapy for neu- rosurgieal patients, a clinical study was institute atthe Department of Physio- therapy, University of Queensland, to investigate the individual and collective effects of percussion, manual hyper- Inflation, expiratory’ vibration and endotracheal suction on the level of LCP. in neurosurgical patents. Method Subjects "Twenty ventilated neurosurgical pa- tients were included inthe study. Thetr ages ranged from twelve to sity years, with 15 of the 20 patents, between 20 to 28 years. The conditions comprised diffuse brain injury (Chirteen patients), subdural or extraduras haematoma (ree patients) and intracranial hae- ‘morthege (four patients) Patents were ‘excluded from this study if they were ‘experiencing incipient tentorial heria- tion, fulfilled the criteria for brain tem death, diagnosed as having senile or preseile dementia, receiving positive end expiratory pressure or had pre- existing respiratory disease. Measurement of 1.C.P. ‘Measurement of I.C.P. was by a ‘Richmonds’ serew and involved the threading of a small hollow bolt into the skull via burr hole so that the tip was below the open dura (Vries, Becker and Young 1973) ‘This was connected through a short length of tubing toa pressure sensitive Aiaphragm (maintained atthe level of the Richmonds screw) attached to the patiet’s bed. Movement of the dia- phragm resuiting from a change in LCP., was converted to electrical en- ‘rey and this figure was displayed dig tally. The equipment was calibrated dally. Procedure ‘Neurosurgical patients are often par- lysed and sedated for the fist 48 to 72 hours, after which the paralysing gents are withdrawn and the patient's conscious state assessed. To determine ‘whether the state of sedation and pa- ralysis modifies the influence of res piratory therapy on LC.P., the tech- niques were administered during the paralysed sate and again when these agents were withdrawn. In each ofthese cases, recordings were made while the patient received no stimulation what- Soever, this measurement acting as the control. 1.C.P. was then monitored during either @ full respiratory teat- ment ora series of four individual es- piratory techniques. Each patient was ‘ventilated by a volume cycled venta tor and maintained in a state of by- pervenilation, ie a P,Co, between 28- 432 mg during the paralysed state In the absence of evidence relating to optimal treatment times, the dura- tion of treatment followed in the In- tensive Care Unit of Royal Brisbane Hospital was adopted for this study. Percussion of the chest wall was per- formed for five minutes, followed by disconnection of the patient from the tespirator and connection to @ manual Ihyperinflation bag. The patients ngs ‘were then hypernflated with 100% ox- ygen ata flow rate of eight litres per minute, via a two litre rebreathing bag ‘while vibrations were applied t0 the chest wall to coincide with the expi- ratory pase of manual hyperinflation, Following six breaths with the manual hyperinflation bag, the patient's en dotracheal tube was suctioned, This procedure was repeated twice and the Patient then reconnected to the respit- Each respiratory technique, that is percussion, vibration, manual hyper {inflation and suction were also. per- formed separately to ensure that no fone technique influenced the response 100 Te Austr Juma! of Pyne. Vl 2 Na 2,186 to another. To provide a form of con- trol in case any changes occurred in the subject over the ime of applica- tion, the order of presentation of tech- nigues was systematically rotated for consecutive patients. Unfortunately the force of percussion, vibration and ‘manual hyperinflation could not be standardized. However, the same physiotherapist aplied percussion and fxpiratory vibrations during the full ‘treatment sesion, and each ofthe four techniques when applied individually. ‘Any disturbance or stimulation prior to treatment can result in abnormally high values of LC.P. For ths reason, patients were not disturbed or handled fifteen minutes prior to any measure- rent being taken. Pre-trial testing had revealed that fifteen minutes provided sufficient time for IC.P. to return to baseline level after any disturbance. During this study patients were po- shioned in right or left side lying, with the bed horizontal and no head up or head down tt, a this was the position desired by the medical staff in charge ofthe Unit. Because ic has been shown that rotating or flexing a neurosurgical patient's head may result in a consid- erable increase in 1.C.P. (Shalit and Umansky 1977, Shapiro 1975), the sub- jects head was maintained strictly in a neutral position prior to and during "When subjects were receving para lysing agents, treatment commenced ‘uniformly ten minutes after intrave- ‘ous administration. The amount of sedation and paralysing agent admin- istered was dependent on the weight, ‘age and medial condition of the pat tient and was adjusted until the patient exhibited no voluntary movement or reaction to pain. If at any stage during ‘weatment the patent showed signs of instability, (for example, tachycardia for LCP. vsing above 30 mmHg), the treatment or technique in use was ceased immediately and the patient re- connected to the vento ‘When collecting data for both the control period and the full respiratory treatment, LC.P. was recorded at theRespiratory Therapy and I.C.P. in Ventilated Neurosurgical Patients end of each thirty seconds for a total period of seventeen minutes. Time of ‘dministraton foreach ofthe individ- ‘al techniges varied slighty. Percus- sion, vibration and manual hypeciatla- tion were continued for seven and half minutes. However, as suctioning is a relatively dangerous technique, it ‘was repeated only twice over @ period ‘of two and a half minutes. Results The data collected in this study al- lowed not only the determination of any changes in LC.P. with respiratory ‘therapy, But also the identification of the technique responsible andthe time ‘of such influence, To achieve these ob- jestives, a Factorial Analysis of Vari ance (FANOVA) was applied to gre main factors in the study, that i “tech- nique’ and ‘time’. For each category of time period, computational analysis provided the means of twenty scores ‘AS a result of this analysis, a dif- ference in the effec of treatment on paralysed and non-paralysed subjects twas revealed, In no-paralysed ps tients, the continuous application of 2 full respiratory treatment resulted in a statistically significant effect on L.C.P. @ < 01). As Figure 1a illustrates, its level rose above that of the control period once manual hyperinflation and ‘vibration were introduced, and contin ued to rise as further procedures were ‘administered (ee Table 1). After thie teen minutes of the treatment regime, the LC.P. increased to @ potentially dangerous level. For paralysed pa tients, the overall measure of 1.C.P. monitored throughout the full teat~ ‘ment did not increase by a statistically significant amount, Nevertheless, time proved to be an important factor for {hese patients also and examination of Figure Ib demonstrated that by the end of the full application of treatment, the LC-P, ofthese patients had reached level similar to the end point for non- paralysed subjects (Table 2). ‘On examination of the raw scores of individual subjects, it was revealed that femme owes ST ewe, IE te I 1a TM Ea Nae FY ' it ' 1 tt 1 " 1 wt 1 |e serra | i ‘ 7 1 1 1 1 ‘ we i Ru 1 13 : | Figure t: Comparison of intracranial pressure during periods of respiratory therapy ‘pnt no treatment Table +: ‘The mean intracranial pressure of twor ‘nonparalysed patients during ro treatment and during respiratory phystothe ‘specified time treat 19 respiratory phy id spect Time ‘No Treatment Treatment (inutes) ‘SD, = Standard Deviation B= Percussion. MH. + ¥. = Manual Hyperinflation and Vibration Suction ‘he Avil Jol of Pysotray. Yak. 2, No.2, 1088 108Respiratory Therapy and |.C.P. in Ventilated Neurosurgical Patients Table ‘The mean intracranial pressure of twenty paralysed patients during no treatment and’ during Febpratory physiotnerepy durlng specified time Time "No Treatment Treatmont (nutes) Mean SD. Moan__SD. 95 82 G90 130 Gee) 28 135 604090 5 sD io Ma ty 8B G1] Hg Ga 10° MH + 338 © G2) 1420 (G09, 25 Bi Be) ae 3 MH. + vy e064) tas 8 134 136%) SD, = Standard Deviation = Percussion MH. + V-= Manual Hyperinflation and Vibration 3. = Suction an increase occurred only in subjects plained by intracranial volume pressure ‘whose resting I.C.P. was above 15 relationships. Those patients with @ ‘mile. Eight patients inthe paralysed lower resting LC.P. appear to have froup and eleven inthe non-paralysed more compensation available. froup had a resting LC.P. above 15 An analysis of the effect of indvid- mmHg. In subjects whose resting, ual techniques (sing a Factorial Anal LCP, was less than this, the effect of ysis of Variance) revealed that “rea treatment tended to follow that of the ment” was significant in increasing control period and didnot result in an .C.P.(p < 01). ATukey’ test, which Increase after the fourteenth minute. is designed to determine which pais of Figure 2 demonstrates this difference sample means are significanly differ- in response. This finding could be ex- ent, was applied and this demonstrated Figure 2: intracranial pressure In two parlysed patients 190 The Asian Jura of Physnerpy. Vl 2 Ma 2,186 that suction was the technique respon sible for increasing 1.C.P. in both par- alysed and non-paralysed subjects (Wright 1976). Figure 3 compares the levels of LCP. recorded in non-paralysed pa tients during the application of indi- vidual techniques, and the early and potentially detrimental effeee of suc- tioning can be clearly seen on this raph. Other individual eects of res- piratory techniques can also be ob- served. For example, percussion low- cred LCLP., especially after a period of five and a half minutes, while man- ‘al hyperinflation increased 1.C.P. with time. ‘The statistical analyses demonstrated that while similar tends occurred for both paralysed and non-paralysed pa tients, the increases in LCP. asa result ‘of manual hyperinflation and suction were more marked when the subject was in the non-paralysed state. Discussion ‘These results do indicate certain trends and provide implications for res- piratory therapy in neurological pa- tients. The following points should be made: 12) Analyses demonstrated the im- portance of treatment time on the evel ‘Of LCP. and shoved that respiratory ‘therapy applied to neurosurgical pa- tients for the seventeen minute dura- tion considered standard at some hos- pitals is likely 10 produce potentially dangerous levels of CP. in some pa- tients. Reducing respiratory therapy ‘ueatment 10 a total of no greater than thirteen minutes and substieting more frequent but shorter treatments forthe previous prolonged treatments would ‘com advisable while sill ensuring ad- ‘equate respiratory function ') Since patients with a starting LCP. level of 15 mmHg or higher are ‘more vulnerable to incteass in 1.C.P. with respiratory therapy, it is recom: ‘mended that physiotherapists monitor these patients carefully and, should LCP. approach 18 mmHg, delay resRespiratory Therapy and |.C.P. in Ventilated Neurosurgical Patients Figure 8: Th piratory therapy until LCP. falls to a Tower level, unless i i felt that poor respiratory status is contributing fo the ‘neurological sate, ©) Applications of manual hyperin- Aation should be Kept brief (ess than 3.5 minutes) in patients vulnerable to increase to LC.P. a6 this technique ‘was shown to increase .C.P. with time. ‘An explanation for this increase may ‘be increased intrathoracic pressure due to a Valsalva manoeuvre. The 100% ‘oxygen inthe rebreathing bag, should Ihave had a slightly vasoconstrictve ef- fect on cerebral arteries, decreasing cer- bral blood volume and s0 decreasing Ler. 4) Suction was shown to be a ela- tively dangerous procedure causing a dramatic rise in I.C.P. Previous studies have suggested several mechanisms for this, including hypercarbia, hypoxia, systemic activation and stimulation of the trachea (Baigelman and O'Brien 1981, Shapiro 1975, Lofgren 1976, Fisher, Frewin and Swediow 1982), Donegan and Bedford (1979) demon- strated that intravenous lidocaine ad- ‘ministered prior to suctioning can pre- vent an increase in L.C.P. AS scion oct ofinviual respiratory techniques In nor paralysed pationts of the endotracheal tube is a necessary procedure, either lidocaine or addi- tional sedation could be provided prior ©) Non-paralysed patients should be treated with caution, as the study showed that for these patients, a con- tinuously progessing full ratment did produce a significant increase in 1.C.P. Itmay be even more important in non- paralysed patients than for those who ate paralysed to wait uni the patient's LCP. is below 15 mmHg before commencing treatment. Patients in this study did not have arterial blood gases measured fre- ‘quently enough to correlate with LC.P. measurements. This study would have improved had P,CO, been measured. ‘A further stady including measurement ofthis variable is under way. Conclusions By accurately documenting the ef: fects of respiratory care on I.C-P., this study has provided useful information for respiratory treatment of neuro- surgical patients. Although this paper ‘makes no attempt to explain changes in LCP., knowledge ofthis important area could be further expanded by col- Jeetng such data as arterial blood gases, ‘specially P,CO,, mean arterial blood pressure and cerebral perfusion pres sure. In the meantime, i is hoped tht implementation of the recommenda- tions emanating from this study may help to enhance the management of this group of acutely il patients. References Supcman W an O'Ben J (198, Palonsey ‘Si of bad oa Mewar. MO mand, 339) 1619 Pot EAM 99), atopy of eetion emma me Naren i Dish Chel enone of «mech of omnia ree cr ‘eur pan a Ln. Pots {dN ost ay ranma Pry, Sp evele Pablenione, Be seinen Sand Hot FF GS), Aer! ood pt “forme rae nari reve eta tener conde vena, Journal ty Nearer. a 3040. ten), Arey rere — meaurg- ‘cl pate, Aneel, 150), 320 EE on ecm sei Te ae ren Pee ee rae Se cera SE cee tion ets Journal of Ameren, 81,97 sBhocaevmman tm. meges waa mes eycekrsmarea ts sa cm, meen me Sa op sere an trata! 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