Consultant physio Michelle Chatwin contributes to interdisciplinary guidance on treating pneumonia
Physiotherapists do not need to treat patients with pneumonia using airway clearance techniques (ACTs) as a matter of routine, according to guidance published today (6 March) by the British Thoracic Society (BTS).
A section in the publication dealing with respiratory physiotherapy suggests that, in most cases of aspiration pneumonia (AP), lung consolidation exists without excess secretions. ‘In this situation, there is no evidence that respiratory physiotherapy is of benefit,’ it notes.
Existing BTS guidelines state that patients with pneumonia should not be treated routinely with ACTs, according to the publication, which is titled ‘The BTS clinical statement on aspiration pneumonia’.
However, the statement suggests that respiratory physiotherapy should be initiated ‘when secretions are present clinically’, or ‘when there is radiological evidence of atelectasis’. The initial aims are to clear secretions resulting from aspiration and to re-expand areas of atelectasis, in the expectation of improving oxygenation, it notes.
AP: the 'Cinderella of pneumonia'
‘Respiratory physiotherapy seeks to loosen secretions and move them to the central airways (peripheral ACTs). Once secretions reach the central airways a huff or cough should be sufficient to clear them. However, in patients with respiratory muscle weakness, techniques to enhance cough are likely to be required (proximal ACTs).'
We hope this statement will raise the profile of, and increase interest in, aspiration pneumonia (AP) ... we have tried to emphasise the importance of preventing AP, and to stress the value of an interdisciplinary approach to management [John Simpson]
Lead author John Simpson said: ‘Aspiration pneumonia is a common and important clinical problem, particularly in older patients and in people with learning disability. Because there are excellent guidelines on community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP), and because aspiration contributes to the development of CAP and HAP, aspiration pneumonia has perhaps become the Cinderella of pneumonia.
‘We hope this statement will raise the profile of, and increase interest in, AP. Throughout, we have tried to emphasise the importance of preventing aspiration pneumonia, and to stress the value of an interdisciplinary approach to management.’
Co-author physiotherapist Michelle Chatwin
Of Professor Simpson’s 13-strong team of co-authors, who have a variety of disciplines, one is a physiotherapist by background (as far as PhysioUpdate could ascertain). Michelle Chatwin is based at the Royal Brompton Hospital and the National Hospital for Neurology and Neurosurgery in London.
Stroke and AP
‘Conventional’ physiotherapy has been shown to be effective in cases of AP that occur secondary to a stroke, the statement notes. ‘Once ACTs have been initiated, these should be continued until the patient is free of secretions and atelectasis.’
The BTS statement offers a series of options for physiotherapists to refer to when aspiration has led to airway changes and secretions, or when patients have an ineffective cough or a reduced conscious level.
‘An approach tailored to the individual patient and their circumstances is recommended, guided by expert local respiratory physiotherapists. Patients with chronic aspiration or persistently ineffective cough are likely to need a long-term home treatment programme of ACTs and ongoing review by a respiratory physiotherapist,' it notes.
Learning disability statement
ACTs for use with people with a learning disability are discussed in a linked learning disability statement, which was published simultaneously by the BTS.
Aspiration pneumonia refers to inflammation and infection of the lungs caused by food or liquid being breathed into the lungs, instead of being swallowed. This differs from community acquired pneumonia, which is largely caused by breathing in pathogens such as bacteria or viruses.
Community acquired pneumonia (CAP) is a major cause of death and a significant contributor to the increased risk of hospital admission observed in people with learning disability.
The BTS's two clinical statements align with its aim of addressing health inequalities, with both AP and CAP being 'significant drivers' of morbidity and mortality in more vulnerable groups in the UK. Those affected are often people with learning disability, older people, those of lower socio-economic status, those who have other co-morbidities, or a weakened immune system.
To access the BTS clinical statement on aspiration pneumonia, visit: https://www.brit-thoracic.org.uk/quality-improvement/clinical-statements/aspiration-pneumonia/
To access the BTS clinical statement on community acquired pneumonia in people with learning disability, visit: https://www.brit-thoracic.org.uk/quality-improvement/clinical-statements/cap-in-people-with-learning-disability/Author: Ian A McMillan