What is the approach to chest physiotherapy (Chest Physical Therapy) in patients with alveolar hemorrhage?

Chest Physiotherapy in Alveolar Hemorrhage: Contraindicated

Chest physiotherapy is contraindicated in patients with active alveolar hemorrhage due to the high risk of worsening bleeding and mortality. The primary management focus must be on treating the underlying cause with immunosuppression and supportive care, not mechanical airway clearance techniques.

Why Chest Physiotherapy is Dangerous in Alveolar Hemorrhage

Avoid all traditional chest physiotherapy techniques including manual hyperinflation, percussion, vibration, postural drainage, and forced expiratory maneuvers in patients with diffuse alveolar hemorrhage (DAH). 1, 2

The European Respiratory Society guidelines explicitly warn that manual hyperinflation can precipitate marked hemodynamic changes and decreased cardiac output from large fluctuations in intrathoracic pressure—this is particularly dangerous when alveolar capillaries are already disrupted and bleeding. 1

Specific Contraindications

• Manual hyperinflation: Creates pressure fluctuations that can extend capillary damage and worsen hemorrhage 1
• Postural drainage with head-down positioning: May increase pulmonary blood flow to damaged areas and exacerbate bleeding 1
• Percussion and vibratory shaking: Direct mechanical trauma to hemorrhaging lung tissue 1, 3
• Forced expiration techniques (FET) and assisted cough: Generate high intrathoracic pressures that can propagate bleeding 1

What to Do Instead: Treatment Algorithm

Immediate Priorities (First 24-48 Hours)

Step 1: Secure airway and optimize oxygenation without aggressive mechanical interventions. Intubation may be required for severe hypoxemia, but avoid high peak pressures. 2, 4

Step 2: Initiate high-dose intravenous glucocorticoids plus either cyclophosphamide or rituximab immediately if immune-mediated DAH is suspected (ANCA-associated vasculitis, Goodpasture syndrome, connective tissue disease). 1, 2, 5

Step 3: Consider plasma exchange for DAH with hypoxemia, particularly if serum creatinine >3.4 mg/dL, requiring dialysis, or concomitant anti-GBM disease, despite mixed evidence from PEXIVAS trial. 1, 2

Ventilator Management (If Intubated)

Use lung-protective ventilation strategies adapted from ARDS protocols, but recognize these were not specifically studied in DAH: 1

• Tidal volumes: 6-8 mL/kg predicted body weight 1
• Plateau pressure: ≤30 cmH₂O 1
• PEEP: Moderate levels (6-8 cmH₂O) to maintain oxygenation while avoiding high recruitment pressures that could worsen bleeding 1
• Avoid aggressive recruitment maneuvers: Continuous positive airway pressure recruitment at 35 cmH₂O has been shown to increase ICP and decrease cerebral perfusion pressure in similar populations 1

When Secretions Become an Issue

Only after hemorrhage is controlled (typically 48-72 hours with appropriate immunosuppression), gentle airway clearance may be cautiously considered: 2, 6

• Gentle suctioning only: Use minimal negative pressure and brief duration 1, 6
• Positioning: Lateral positioning with bleeding side down (if unilateral) once stable, avoiding head-down positions 1
• Avoid nasal suctioning: Particularly with coagulopathy or recent upper airway trauma 1

Critical Monitoring Parameters

Track these to determine when bleeding is controlled: 2

• Serial hemoglobin/hematocrit: Stabilization indicates hemorrhage control
• Oxygenation parameters: PaO₂/FiO₂ ratio improvement
• Sequential bronchoscopy (if performed): Decreasing bloody returns in BAL aliquots
• Chest imaging: Resolution of ground-glass opacities and consolidation 1, 2

Common Pitfalls to Avoid

Do not treat DAH like pneumonia or COPD exacerbation where aggressive secretion clearance is beneficial. The pathophysiology is fundamentally different—you're dealing with fragile, bleeding capillaries, not mucus hypersecretion. 5, 3

Do not delay immunosuppression while pursuing extensive diagnostic workup in critically ill patients with suspected immune-mediated DAH and hypoxemia. Mortality is high without prompt treatment. 2, 5

Do not use chest physiotherapy as "supportive care" in the acute phase—it is actively harmful. 1, 2

Prognosis and Follow-up

Mortality risk correlates with degree of hypoxemia, extent of lung involvement (>50% lung area), severe renal failure, and older age in ANCA-associated vasculitis. 2

Once remission is achieved, continue maintenance immunosuppression for 18 months to 4 years to prevent relapse. 2

Initiate venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state. 2