The Role of Physiotherapy in a Neonatal Intensive CareUnit

The role of physiotherapy in the neonatal in­tensive care unit has historically been mainlyassociated with the care of the neonate's .lungs.Postural drainage coupled with percussion, vi­brationsand suction are all used in thephysio­therapy management of neonatal respiratorydisorders. At Monash Medical Centre all electiveextubations are performed by the physiothera­pist 1naccordance with the neonatal unit's pro­tocol: this includes four hourly respiratoryphysiotherapy for the first 24 hours after extu­bation to ensure that post-extubationatelec­tasis does not occur. In addition to respiratorycare, the physiotherapist is also engaged in theassessment and management .of neonates witheither neurological or musculoskeletal disor­ders.

NICOLINA BERTONE

Nicolina Bertone, B.App. Sc. (Phty), is Deputy ChiefPhysiotherapist at the Monash Medical Centre, Clay­ton, Victoria.

Over the last decade physiotherapyhas become an acknowledged and oftenintegral part of the management ofnewborn infants in neonatal intensivecare units around the world. It is awell-established practice to refer sickneonates with respiratory problems Jorphysiotherapy, however, this is not theonly area in which -physiotherapy hasa role. Physiotherapy is also indicatedin neonates with both neurological andorthopaedic problems. At MonashMedical Centre the physiotherapist isattached to the neonatal intensive careunitona full-time basis and the serviceis provided seven days a week.

H,istorical BackgroundOne of the earliest published clinical

studies on the effect of respiratoryphysiotherapy on the neonate was un­dertaken by Holloway et al in 1969.They noted that there was wide alveo­lar to arterial oxygen pressure gradientand failure to maintain normal arterialoxygenation among patients being ven­tilated on air by Intermittent Positive

Pressure Respiration (IPPR). The au­thors hypothesized that it was possibleto improve oxygenation by opening upareas of atelectasis or removing secre­tions which block bronchi and that onemethod of doing this was by means ofrespiratory physiotherapy. Subse­quently a research study was devisedand undertaken to test this .hypothesis.

.The sample size of this study COD­

sistedof51babies in total and all weregiven IPPR via a cuffed tracheostomy.One group was used as the controlgroup, another was given hyperinfla­tionand physiotherapy and tbe thirdgroup was given hyperinflation only.Two significant findings were reported:(1) Partial pressure of arterial oxygen

(P02) dropped significantly afterrespiratory physiotherapy and tookone hour to return to normal.

(2) Neither physiotherapy, nor hyper­inflation, nor hyperinflation plusphysiotherapy restored arterial p02to normaL

In retrospect many criticisms can bedirected at this particular study. For

example, all infants in the sample wereparalysed with curare and all were me­chanically ventilated via a tracheos­tomy tube, neither of these being rou­tine practice today. All infants wereventilated· with air only and no sup­plemental oxygen was used. In fact theteam concluded the study by advisingthat all ventilated infants. be given oxy­gen during physiotherapy, but did notmake any recommendation about en­suring adequate arterial oxygenation atall other times with the judicious useof supplemental oxygen.

During the next seven to eight yearsvery little material was published re­lating to the topic of respiratoryphysiotherapy in the neonatal unit.However, in the late seventies interestin .the area was renewed and materialrelated to this topic began to appeararound the world.

A .study designed tomeasureaccu­rately the amount of secretions re­moved with respiratory physiotherapywas conducted by Etches and Scott in1978. The sample size was small con-

The Australian Journal of Physiotherapy. Vol. 34, No.1, 1988 27

Physiotherapy in a Neonatal Intensive Care Unit

sistingof only six infants. The infantsacted as their own controls: upper air­way suction was preceded by physio­therapy on alternate occasions. Aftereach session of suction a balance ac­curate to 10 mgwas used to determinethe weight of secretions removed. Inall cases, the mean weight of secretionsremoved after physiotherapy wasgreater than that removed by suctionalone (p<O.005).

In that same year Finer and Boyddesigned a controlled study to assessthe effect of respiratory physiotherapyon preterm infants. The sample con­sisted of twenty infants who were di­agnosed as having either Hyaline Mem­braneDisease, Transient Tachypnoeaor Pneumonia.. All infants requiredsupplemental oxygen to maintain theirarterial P02between 50 and 75 mmHg,the range of oxygenation consideredadequate for these small infants. Thestudy protocol required that each in­fant have blood gas determinations 5minutes prior to, and 15 minutes fol­lowing, suctioning of the airway.. Onthe same day each infant receivedphysiotherapy which entailed posturaldrainage, percussion and vibrations.Arterial blood gas determ~nation wasdone for each infant before and afterphysiotherapy, followed by suctioningof the airway .. The results showed thatall infants had an increase in arterialP02following physiotherapy, the meanincrease being 20.8 mmHg. There wasa statistical difference (P <0.01) for P02between the pre and post-physio­therapy means, with no difference ob­served between pre and post-suctioningonly values ..

Finer et al followed up the previousstudy with another later in the sameyear, this time studying the effects ofpostural drainage alone versus posturaldrainage and percussion.. The aim wasto determine which aspects of respi­ratory physiotherapy were responsiblefor the improvement in oxygenation.Twenty newborn infants diagnosed ashaving .Respiratory Distress Syndrome(RDS) were admitted to the study.. Teninfants randomly selected received pos-

tural drainage with percussion whilstthe other ten received postural drainagealone.. The results demonstrated a sta­tistically significant increase in arterialP02 following postural drainage andpercussion with a mean rise of 14.5mmHg (p<O..OOl).. There was no sig­nificant difference between the pre­drainage- and post-drainagep02(P> 0.. 5).

More detailed research directed to­wards the effectiveness of various tech.,.niques used for respiratory physio­therapy in the neonate was describedin papers published subsequently. In1979 Curran and Kachoyeanos (1t­tempted to ·determine the most effec­tive means of administering respiratoryphysiotherapy.. The sample consistedof six infants diagnosed as having RDSand their gestational age ranged from28 to 40 weeks. One set of infantsreceived respiratory physiotherapy forone minute through a common electrictoothbrush heavily padded to preventexcoriation of the infants' skin.. Thedevice wasgently guided back and forthacross the thoracic wall.. The secondset of infants received re"spiratoryphysiotherapy for one minute using apadded nipple (not described in detailin the text) which was moved rhythm­ically by hand across the thoracic walLA third control group, received no res­piratory physiotherapy at all.. Bloodgas determinations, heart rate, respi­ratoryrate, breath sounds, tissue per­fusion and activity levels were all meas­ured before and after the varioustechniques.. The results indicated thatinfants who received 'toothbrush'physiotherapy showed significantlyhigher levels of arterial pOH had clearerbreath sounds on auscultation andupon visual inspection had better tissueperfusion than the other two groups(p<0.05) .. The conclusion .made fromthis study was that an electric tooth­brush is more effective in obtainingsecretions. However,· it 'was noted thatrespiratory and heart rates as well asactivity level were all raised with thistechnique·and it also· appeared that thisform of physiotherapy may, in fact,

be more stressful to the infant than theother techniques studied ..

Tudehopeand Bagley in 1980 set upa controlled· study to assess the effec­tiveness of various physiotherapy tech­niques .. Fifteen newborn infants wereadmitted to the trial and all were onassisted ventilation for RDS. Each in­fant received each technique two hoursapart.. The order in which the tech­niques were delivered was randomlyselected.. The three techniques studiedwere 'contact heel percussion'whichwas continuously applied using thethenar-hypothenar eminence of thehand at a right angle to the infant'sthoracic wall; .cupping with a Bennettface mask and vibrations with anelec­tric toothbrush (General Electric) .. Theresults demonstrated that all infantshad an increase inarterialp02 follow­ing cupping with a mean rise of 16..6mmHg (p<O.OOl). Ten infants had arise in p02 following contact-heel per­cussion with a mean rise of 5.5mmHg(p<0.05). There was no statistical dif­ference in arterial p0 2before and aftervibration. Transcutan~ous p02 moni­toring recorded increased p02leveis forup to one hour, following 'contact­heel' percussion and cupping.. It wasrationalized that both these techniquesloosened secretions in the terminal air­ways, stimulated lung expansion andthereby improved ventilation-perfusionratios. Tudehope and Bagley con..eluded that the narrow airways of pre­mature infants do not allow secretionsto drain without mechanical assistancein the form of percussion or cupping.Consequently postural drainage withactive respiratory physiotherapy is re­quired in all intubated infantswithRDSto break loose secretions and assist out­ward drainage..

Anatomy and PhysiologyPrior to discussing various respira­

tory physiotherapy techniques in detaila brief discussion of the anatomic andphysiologic differences between adultsand neonates is warranted.

28 The Australian Journal of Physiotherapy. Vol. 34, No. 1,1988

Physiotherapy in a Neonatal Intensive Care Unit

The major differences are:• A newborn has a high larynx ena­

bling the epiglottis to guide the lar­ynxup behind the soft palate to pro­duce a direct airway from the nasalcavity to the lungs. This causes neo­nates to be obligatory nosebreathers.They .are able also to simultaneouslybreathe and swallow until two tothree months of age (Pang and Mel­lins1975).

• The ribs of the newborn are posi­tioned horizontally and the intercos·tal muscles are weak, resulting in apredominantly abdominal· or dia­phragmatic pattern of breathing.

• The Jungsaf a neonate are less com­pliant than those of an adult,how­ever, the thoracic wall is more com­pliant due to the cartilaginous natureof the ribs and lack of intercostalmuscle strength.. This difference canlead to an increase in both airwaysresistance and obstruction. The nar­row diameter of the infant's airwayand a weak or absent cou~h reflexcan also lead to airways obstruction.

• The newborn or premature infant ishighly susceptible to diaphragm fa·tigueand comp~nsates Jor respira­tory difficulty by increasing the raterather than the depth of ventilation.

eThecough reflex ina premature babyis not fully developed until 32-34weeks gestation.All these factors, although normal

for a neonate, contribute to respiratorydistress and possible respiratory fail­ure.

Indications for RespiratoryPhysiotherapy

The most commonly referred con·ditions for physiotherapy are hyalinemembrane disease (HMO), meconiumaspiration,pneumonia, and surgery in­volving the thorax or abdomen.

The most common cause of respi­ratory .distress in the neonate is HMOwhich is related to insufficient levels ofsurfactant in the lung (Farrell and Av­ery 1975). It is most often associatedwith prematurity, Caesarian section de-

livery, maternal diabetes, perinatal as­phyxia and shock, ·and thesecondbomof twins. Symptoms usually appearwithin two to ·three hours after birthwith progressive deterioration within24 to 48 hours. Prominent clinical signsinclude increased respiratory rate,ex·piratory grunting, intercostal and ster­nal retractions, nasal flaring and a see­saw pattern of respiration between thechest wall and abdomen. The majorpathophysiologic manifestation ofHMD ishypoxaemiaresulting fromperfusion of atelectatic air spaces..Themedical··management is supportive andgenerally includes oxygen therapy,thermal regulation,humidification,nutrition and assisted ventilation.Common pulmonary complicationssecondary to intubation, mechanicalventilation and oxygen therapy, in­clude.oxygen toxicity, bronchopulmon­ary dysplasia (BPO) pneumothorax,pneumonia,sepsis (Storm 1980), in­creased mucous production, mucousplugging and residual pulmonary. dis­ease. Respiratory physiotherapy for in­fants with HMO is directed towardsprevention of complications that affectairway clearance. Bronchial drainagetechniques are begun when signs ofatelectasis, infiltrate or uncontrolledsecretions are noted clinically or byradiographs. In the intensive care unitat the Monash Medical Centre physio­therapy techniques .are ·commenced atleast 72 hours after birth when the re­covery phase commences and retentionof viscous secretions becomes a prob­lem. Physiotherapy management of therespiratory problems continues until thebaby is clinically well and the chest x­ray is clear.

Meconium aspiration results fromaspiration of meconium-stained am­niotic fluid by the foetus or neonate.It most frequently occurs in full-term,post..;mature and intra-uterine growth­retarded infants. Tachypnoea is themost prominent sign of respiratory dis­tress and usually appears within 12 to24·hours of birth. Infants have a char­acteristicbarrel-chested appearance.Possible complications include bron-

chiolitis, pneumonitis, cor pulmonale,atelectasis and persistent foetalcircu­lation. Medical management once againis supportive. Antibiotic therapy, as­sisted ventilation with positive end-ex­piratory pressure (PEEP) and supple­mental oxygen are often used.Physiotherapy commences as soon aspossible and includes positioning, per­cussion, vibration and suctioning.These techniques .are continued untilsecretions are free from meconium andtherapy may need to be continued forseveral days to ensure clearance of theairways and to help prevent.secondarylower respiratory tract infection~

Pneumonia may develop at any timeduring the neonatal period and con·ditions that increase a-neonate's riskof developing pneumonia include:• Premature rupture of membranes.• Intrauterine asphyxia.• Prematurity.• Intubation and mechanical ventila­

tion.• Thoracic and upper abdominal sur­

gery with general anaesthesia.Crane (1981) recommends that

physiotherapy techniques are beneficialinpatients with pneumonia and com­promised airway clearance, especiallyin the later, clearing"'up stages of theinfectious process. For this reason allbabies in our unit with pneumonia aregiven regular chest physiotherapy.

The aims of respiratory physio­therapy are to:• Maintain a clear airway;• Clear excess or accumulated secre­

tions from the respiratory tract;• Re-expand collapsed segment/s of

the lung;• Prevent respiratory complications

such as atelectasis, infection and re­tained secretions;

• Maintain adequate levels of oxygen­ation;

• Improve the general respiratoryfunction of the neonate.On the other hand, the contra-indi­

cations for physiotherapy are:e Very unstable condition of the baby.• Severe hypothermia - temperature

less than 36.3°C.

The Australian Joumal of Physiotherapy. Vol. 34, No.1, 1988 29

Physiotherapy in a Neonatal Intensive Care Unit

-Recent pneumothorax which doesnot have an intercostal catheter insitu.

• Pulmonary haemorrhage in the pres­ence of fresh blood-stained secre­tions.It must be remembered that these

are guidelines only and may alter withindividual babies. For example, hand­bagging of a child whose condition isunstable during physiotherapy may benecessary if the infant's poor physicalcondition is due to severe lung disease.

Techniques of PhysiotherapyThe techniques that are employed

include postural drainage, percussion,vibration and suctioning.Fortunatelythe cots are so designed that the babymay be tipped according to the tradi­tional postural.drainage positions (Fig­ure 1). If, for some reason, the cot willnot tip, fo~dednappiesare used to pro­duce the desired tip.

However, there are times when theinfalltwill not tolerate tipping. Theseinclude:• Marked instability of the infant's

condition;, -The first 24 hours following abdom­

inal and· thoracic surgery;• Immediately after vomiting large

amounts of milk;• Less than .48 hours after suspected

or proven intracranial haemorrhage;-The presence of an abdominal mass

which impedes the downward excur­sion of the diaphragm. eg diaphrag­matic hernia;

• Raised intracranial pressure, as mayoccur in hydrocephalus.In these cases vibration and/or per­

cussioncan still be· used. The infantcan be placed in the appropriate .pos­tural drainage positions without the cotbeing tipped.

Vibrations and percussion are bothused to move secretions in the lungfrom the smaller to the larger airwaysand thence to the trachea,especiallywhen used in conjunction with posturaldrainage.. Vibrations consist of a finesh~king of the hand or fingers which

Figure 1: Cot tipped for postural drainage

Figure 2: Manual vibrations

are placed over the area of the lung tobe treated and are performed duringexpiration (Figure 2). Vibrations arecombined with over-pressure and gentle'springing' or squeezing of the rib cageat the end of expiration. If the infanthas stiff, non-compliant lungs .thengreat care is taken not to do.this spring­ing too vigorously as .it may cause ribfracture. These. techniques are mostuseful in pushing the loosened secre;..

tions along the bronchi to the trachea,and so the pressure of the vibrationsand the rib squeezing are done in thedirection of the trachea.

Percussion results in a coarseshak;..ingof the underlying tissue and is usedto initiate the movement of thesecre­tions to he drained (Figure ·3). Themost effective method of applying per­cussion employed in this unit is theBennetts .Face Mask (puritan-Bennett

30 The Australian Joumalof Physiotherapy. Vol 34, No.1, 1988

Physiotherapy in a Neonatal Intensive Care Unit

Figure 3: Percussion with Bennett's face mask

Corporation), which all babies have aspart of their bagging circuit. A fingeris placed in the central porthole andmovement is then carried out from thewrist as in traditional manual percus­sion. The rim is made of 80ft pliablerubber,so it is· not necessary to protectthe child with layers of clothing.

Total treatment time is limited to 10or 15 minutes so as not to handle theinfant excessively and inadvertently in­crease the oxygen demands (Fox et af1978). Usually two to three minutes isspent .treating each affected segmentwith a maximum of three segments pertreatment. If the baby is being fed or­ally or via a nasogastric· tube, physio­therapy treatment is scheduled approx­imately 15 to 20 minutes prior to afeed and at least 45 minutes after thelast feed. In this way the baby is notconstantly disturbed and is thus al­lowed to spend as much time as pos..sible sleeping undisturbed betweenfeeds.

Treatment frequency depends on theseverity of the condition and on theinfant's tolerance. Two hourly treat..

ment is indicated only in the presenceof severe collapse or consolidation ofpart or all of the lung, or in the pres­ence of excessive secretions which arenot being effectively removed by suc­tion alone or by less frequent physio­therapy. Only in exceptional circum­stances is this frequency of treatmentmaintained for longer than 48 hoursas it tires the baby excessively.

Four hourly treatment is indicatedin the presence of collapse or consol­idation of part of the lung or if thesecretions are accumulating rapidly andare not being removed effectively bysuction alone. In fact, most babies withacute conditions are commenced onfour hourly treatment and their respi­ratory status continually re-assessed.Six or eight hourly treatment is usedwhen the condition is resolving andonly small to moderate amounts ofse­cretions are being aspirated.

Normally, secretions from each seg"mentare removed by suction as clear­ance of each is completed. Suction iseither via· the oropharynx in non-ven­tilated· infants or the endotracheal tube

(ETT) in ventilated infants. A steriletechnique is used in ventilated infantsensuring that the catheter is not at­tached to the suction as it is beingthreaded into the ETT. Suction ismaintained as the catheter is beingwithdrawn with only 10-15 secondsbeing allowed for this manoeuvre. Itis suggested that suction pressure notexceed 200 mmHg with the optimumbeing between 100 to 150 mmHg (pooleet a/1974). At the end of the treatmentthe nasopharynx is suctioned in non­ventilated infants. However, prior tothis, it is vital to ensure that the oro­pharynx has been cleared totally as na­sopharyngeal suction will often stimu­late a deep inspiration. If secretionshave pooled in the oropharynx thesemay be aspirated into the respiratorytract. For intubated infants the se­quence for 8uctioning is ETT first, fol~

lowed by the oropharynx and the othernares. Amount, consistency and colourof all secretions aspirated is recordedon the infant's ventilation chart as isthe need for increased oxygen or hand­bagging during physiotherapy treat­ment.

All catheters have a Y-connection sothat suction may be controlled at alltimes. Depending on the diameter ofthe ETT, various size catheters are in­dicated. Young (1984) recommends thatcatheters should be less than half thediameter of the trachea. Thus, at theMonash Medical Centre Size FG5 cath­eters are used for 2.5mm ETT, SizeFG6 for 3.00mmETT and Size FG8for 3.5mmETT.

Suctioning is used at other times· aswell as in conjunction with physio­therapy treatment. It is carried out rou­tinelyevery four hours on all ventilatedinfants as part of the nursing care.During routinesuctioninga lavage con­sisting of 0.5mls normal saline is in­stilled into the ETT to help~prevent

tube blockages as advocated by Drewet a/ (1986). If the infant shows signsof excessive secretions and· is obviouslydistressed, the frequency of. suctioningmay be increased as the< need arises.

The Australian Journal of Physiotherapy~ Vol. 34, No.1, 1988 31

Physiotherapy in a Neonatal Intensive Care Unit

Extubations

All extubations except those classi­fiedas emergencies are performed bythe physiotherapist. Example of emer­gencies include a blocked ETT or ac­cidental removal by the infant. Therationale for this routine is bas.ed onthe findings ofFiner et al (1979). Theseauthors reported on a retrospective re­view of post-extubation atelectasis.Finer et af noted that in previous re­ports up to 50 percent of intubatedneonates weighing less than 1250 gmrequired re-intubation because of thecomplication of post-extubation atelec­tasis. The Finer study found that eightof twenty-one infants receiving nophysiotherapy developed post-extuba­tion atelectasis. Of these eight, sevenrequired re-intubulation because ofright upper lobe or right lower lobeatelectasis. Only one of twenty infantsreceiving physiotherapy developed ate­lectasis post-extubation and this infantdid not require re-intubation.

Figure 4: Nebulization for neonateAt the Monash Medical Centre ex­tubation is timed at least 45 minutesafter the last feed. The infant receivesappropriate respiratory physiotherapyjust prior to extubation. The treatmentsession is directed towards clearing allsegments of the right upper lobe. Suc­tion is applied in the usual manner atthe end of clearing each segment. Be­fore the tube is withdrawn the oro­pharynx and other nares are cleared ofall secretions. The tube is then with­drawn with a suction catheter in situ.At the same time as both tube andcatheter are withdrawn suction is ap­plied ensuring that the limit of 200mmHg is not exceeded. Oxygen via aface mask is kept close by the infant'sface, the concentration of which is atleast 5 per cent greater than that whichthe infant was receiving from the ven­tilator. Suction is continued until bothoropharynx and nasopharynx arecleared. The infant is placed within aheadbox with the appropriate oxygenconcentration, arid .anoxygen monitorand thermometeraie placed within the

headbox. The infant is then nursedprone with the head up as this positionallows better gas exchange and a moresynchronous breathing pattern (Hough1984). The infant receives nil by mouthfor at least four hours post-extubation~

Prior to recommencing feeds, fourhourly physiotherapy is instigated. Apostural drainage chart is drawn upand left by the cotside so that the nurs­ing staff may continue physiotherapyovernight. At least one segment of theright upper lobe and right lower lobeis included in each treatment session,as these are the most common sites ofpost-extubation atelectasis. Chest x-rayand arterial blood gas measurementsare taken four to. six hours post-extu­bation to ensure that no' atelectasis hasdeveloped and that the infant is re­ceiving the correct oxygen concentra­tion. Four hourly respiratory physio­therapy is continued for at least 24

hours post-extubation or until the chestx-ray is clear.

Lobar collapse following extubationof the trachea may occur as a resultof retained secretions and mucosal oed­ema. Frequent intubation may trau­matize the airways leading to furtherdamage and a higher incidence of post­extubation complications such assubglottic stenosis. The other majorpost-extubation complication is the oc­currence of tracheal and laryngeal oed­ema resulting in stridor and upper air­way obstruction. Dexamethasone given24 hours prior to extubation may min­imize this occurrence. However, lately,it has been preferred to use a 2.5010solution of racemic adrenaline admin­istered as an inhalation in the post­extubation period (Figure 4). Inhala­tions of racemic adrenaline normallydo not need to be used .after the first24 hours following extubation.

32 The Australian Joumalof Physiotherapy. Vol. 34, No. 1J 1988

Physiotherapy 1n a Neonatal Intensive Care Unit

Environmental StimulationIn the neonatal unit of Monash Med­

ical Centre a strict protocol or policyof environmental stimulation for allpreterm infants is not· usual. However,each infant's individual needs are as­sessed. Close communication is main­tained between the neonatologists andphysiotherapist so that interventionprogrammes may be instigated whenappropriate for individual children.

Serial cerebral ultrasonography willindicate presence of intraventricularhaemorrhage, hydrocephalus, braincysts or cerebral atrophy and thus si­multaneously indicate which infants re­quire earlier or more intense physio­therapy intervention. Nursing staff andmothers are instructed in the handlingof these children with special needs.

The environment in a neonatal in­tensivecare unit is not at aU .similar tothat of foetal life. However, somemeasures can help to make the preterminfant's extra-uterine life as non-stress­ful as possible. It is certainly wellknown and accepted that excessivehandling will cause hypoxaemia· (Longet at 1980) and so for this reason thebabies are allowed to sleep undisturbedfor periods of four hours during bothday and night. That is, every four hoursall nursing care is given includingchange of position, change of nappy,feed, suction, observations and physio­therapy. In this way the infants aredisturbed once every four hours andallowed to sleep with minimal disrup­tions in between the routine nursingcare.

The infants are also nursed on wa­terbeds to simulatethe intra-uterine en­vironment. Komer etal (1975) suggestthat waterbeds be used to provide com­pensatory vestibular stimulation simi­lar in kind to that preyailing in utero.Waterbedsalsohelp reduce the inci­dence of skin breakdown, asymmetryof head shape and the occurrence ofapnoeic periods. The incubators arepartially covered so as to reduce theintensity of bright illumination withintheir environment. Noise level is re-

duced as much as possible by suchmeans as turning down the sound onmonitors and alarms, turning down thetone of the telephones and encouragingthe neonatal intensive care unit per­sonnel to keep voice levels low.

As a child is nearing full-term andis medically stable, an individual pro­gramme of handling, feedirtgandstimulation will be commenced. At thisstage both nursing staff and mothersare instructed in the programme. How­ever, no strict timetable is devised forthe child, but rather a list of require­ments is left by the bedside. For ex­ample, ifa child has feeding difficultiesthen diagrams and instructions are pro­vided so that the techniques may becontinued by the nursing staff at eachfeed time.

Children who remain in the neonatalintensive care unit well beyond theneo­natal period, because ofongoingmed­ical problems, require special attentionto promote their motor development.For these infants, periods of stimula­tion and play are necessary in.additionto basic nursing care. SQ.ch childrenmay be three to four months of agecorrected for the period of gestation.They require stimulation to allow nor­mal maturation of the Central NervousSystem in order to minimize possiblenenro-developmental deviations whichhave been well documented in past lit­erature (Burns etal 1982, Burns et al1984). Babymassage·may be·taught tomothers ·and nursing .staff especially ifthe infant is noticed not to either re­spond to or show signs of pleasure withnormal handling.

As the time of discharge approaches,the mothers of these infants who haverequired prolonged hospitalization willbe taught a more intense programmeof handling and therapeutic techniquesin order to develop confidence in thehandling and care of their infant. Spe­cial feeding techniques, positioning tohelp normalize tone, and respiratoryphysiotherapy are taught to the moth­ers, if indicated.

If postural deformities or tonalproblems are suspected, the mother is

introduced to the senior paediatricphysiotherapist who then sees bothmother and infant on a regular out­patient basis.

Orthopaedic andMusculoskeletal Problems

Fortunately, not many orthopaedicor musculoskeletal problems are seenin the neonatal intensive care unit. Themost common of these which do pres­ent is talipesequino varus. Strappingis the treatment of choice in the pre­term infant with special attention beinggiven to the infant's skin condition.Rarely are fractures of long bones en­countered, but if they do occur,splint..ing using thermoplastic materials is thetreatment of choice. Both these splint­ing techniques are undertaken by thephysiotherapist in charge of the uniL

Occasionally an infant diagnosed ashaving extremely severe HMDwhich isrequiring unusually high. ventilationmaybe paralyzed electively with Pan­curonium (a neuromuscular blockingagent) in order toallowoptimal.gasexchange and tissue perfusion to occur.In such an event occurring, the nursingstaff are instructed in full passive rangeof movements for each major joint.Daily re-assessment is performed bythe physiotherapist who also providesguidance in positioning and handlingof these infants.

Contracturesmay occur occasionallydue to malpositioning of limbs in intra­venous splints or from chemical burnsfrom intra-venous drips which haveleaked their contents into subcutaneoustissues. Once again the nursing staffare instructed in passive stretchingtechniques after the infant has beenassessed by the physiotherapist. Thephysiotherapist continues to monitorthe· infant's progress and will advisethe nursing staff of any change re­quired in the infant's management.

ConclusionThe aim of this paper has been to

discuss the role of physiotherapy·in theneonatal intensive care unit in a major

The Australian Journal of Physiotherapy. Vol.34, No. 1J 1988 33

Physiotherapy in a Neonatal Intensive Care Unit

hospital. The majority of the physio­therapist's time is spent treating infantswith respiratory disorders. However,the physiotherapist also has a role inoffering assessment and managementof other problems such as musculos­keletal and neurodevelopmental dis...orders. The physiotherapist is seen tobe an essential member of the neonatalteam because of the varied skillsbrought to the infant's management bythis professionaL

AcknowledgementI wish to acknowledge the contri...

butions of my colleagues, the help andsupport given by Professor V Y H Yu,Director of the Neonatal Intensive CareUnit, during the development of thisprogram.

I am also grateful to Ms BarbaraWalker, Chief Physiotherapist, for heradvice and encouragement and to MissRosemary Cox for her expert secretar...ialwork in preparing this manuscript.

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34 The Australian Journal of Physiotherapy. Vol. 34, No. 1, 1988