Home SARS-CoV2 OMT: A Relative Contraindication to Thoracic Pump Technique and an Additional Indication for the Elderly
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SARS-CoV2 OMT: A Relative Contraindication to Thoracic Pump Technique and an Additional Indication for the Elderly

  • Jay B. Danto
Published/Copyright: September 1, 2020
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Journal of Osteopathic Medicine
From the journal Journal of Osteopathic Medicine Volume 120 Issue 9

To the Editor:

I enjoyed the Special Communication “Buying Time: Using OMM to Potentially Reduce the Demand for Mechanical Ventilation in Patients with COVID-19”1 and applaud Michael Stenta, OMS II, for authoring it. My concern, which may also be of concern to other neuromusculoskeletal medicine specialists,2 is that the use of the thoracic pump technique in this population may be contraindicated. Gattioni et al3 recently reported that patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2 or COVID-19) on mechanical ventilation seemed to have hyperperfusion of gasless tissue compared with typical patients with acute respiratory distress syndrome (ARDS), who have a loss of lung perfusion regulation and hypoxic vasoconstriction. The authors3 recommended that if a patient with SARS-CoV2 needs continuous positive airway pressure therapy or noninvasive ventilation, intubation with a lower positive end-expiratory pressure (PEEP) should be considered. Interventions that result in high PEEP, they theorized, may be associated with tissue damage and poorer outcomes.

Studies4,5 have shown that resistive loading of the thoracic cage results in increased work of lung respiration. Increased intrapulmonary pressures may result because of the need to achieve appropriate oxygenation when pulmonary compliance is diminished or restricted. Thus, the thoracic pump technique, because of its intermittent resistive loading of the thoracic cage, may result in increased intrapulmonary pressures that could be damaging to the injured epithelial cell lining of the lungs in patients with SARS-CoV2. The respiratory epithelial cell death that is part of the natural course of this disease's reproductive cycle contributes to its uniqueness and is a source for concern.

Osteopathic manipulative treatment (OMT) is, however, indicated to treat somatic dysfunction in SARS-CoV2 patients since increased rib cage compliance and motion should ultimately lower intrapulmonary pressure and the work of respiration. OMT may be particularly important for the elderly patients with SARS-CoV2, since they have an age-related decline in chest wall mobility.6 In a biomechanical model, this diminished chest wall mobility may be a contributing factor in the poorer outcomes seen in patients with SARS-CoV2 who are elderly. Consequently, this population may particularly benefit from the application of OMT due to its resultant increased chest wall compliance and mobility, which would, in Mr Stenta's words, “buy time.”

Prone position ventilation has been used for patients with ARDS and SARS-CoV-2 to improve oxygenation and to reduce mortality rate.7 The improvement in gas exchange due to prone positioning occurs by enhancement of the intra-pleural pressure becoming less negative in non-dependent and less positive in dependent portions of the lung, which results in redistribution of the lung in a way that is favorable to optimal oxygenation.8 Positioning the patient prone just for OMT is probably not indicated, since the usual positioning for prone ventilation is 16 hours. As OMT may be performed with any patient positioning, this author recommends that OMT be used in any position that supports patient comfort and optimizes oxygen saturation.

Department of Osteopathic Principles and Practices Noorda College of Osteopathic Medicine (proposed), Provo, Utah

References

1. Stenta, MA. Buying Time: Using OMM to potentially reduce the demand for mechanical ventilation in patients with COVID-19. J Am Osteopath Assoc. 2020;120(6):418-420. doi:10.7556/jaoa.2020.064Search in Google Scholar PubMed

2. AOA Online Learning. Osteopathic Manipulative Medicine (OMM) Techniques Addressing Respiratory Symptoms of COVID-19. American Osteopathic Association; 2020. https://aoaonlinelearning.osteopathic.org/course/info.php?id=310. Accessed May 27, 2020.Search in Google Scholar

3. Gattinoni, L, CoppolaS, CressoniM, BusanaM, RossiS, ChiumelloD. COVID-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020;201(10):1299-1300. doi:10.1164/rccm.202003-0817LESearch in Google Scholar PubMed PubMed Central

4. MengeotPM, BatesJH, MartinJG. Effect of mechanical loading on displacements of chest wall during breathing in humans. J Appl Physiol. 1985;58(2):477-484. doi:10.1152/jappl.1985.58.2.477Search in Google Scholar PubMed

5. ForkertL. Effect of regional chest wall restriction on regional lung function. J Appl Physiol Respir Environ Exerc Physiol.1980;49(4):655-662. doi:10.1152/jappl.1980.49.4.655Search in Google Scholar PubMed

6. Adachi, D, MYamada, SNishiguchi, et al.. Age-related decline in chest wall mobility: a cross-sectional study among community dwelling elderly women. J Am Osteopath Assoc. 2015;115(6):384-389. doi:10.7556/jaoa.2015.079Search in Google Scholar PubMed

7. CarsettiA, Damia PaciariniA, MariniB, PantanettiS, AdrarioE, DonatiA. Prolonged prone position ventilation for SARS-CoV-2 patients is feasible and effective. Crit Care. 2020;24(1):225. doi:10.1186/s13054-020-02956-wSearch in Google Scholar PubMed PubMed Central

8. ElkattawyS, NooriM. A case of improved oxygenation in SARS-CoV-2 positive patient on nasal cannula undergoing prone positioning. Respir Med Case Rep. 2020;30:101070. doi:10.1016/j.rmcr.2020.101070Search in Google Scholar PubMed PubMed Central

Published Online: 2020-09-01
Published in Print: 2020-09-01

© 2020 American Osteopathic Association

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  2. Portable Ultrasonography to Assess Adult Hepatosteatosis in Rural Ecuador
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  12. Rib Somatic Dysfunction Among General Surgical Patients
  13. ORIGINAL CONTRIBUTION
  14. Clinical Efficacy of Mesenteric Lift to Relieve Constipation in Traumatic Brain Injury Patients
  15. Cranial Strain Patterns Associated With Concussions
  16. Effectiveness of Osteopathic Manipulative Medicine vs Concussion Education in Treating Student Athletes With Acute Concussion Symptoms
  17. BRIEF REPORT
  18. Effects of Osteopathic Manipulative Treatment on Sleep Quality in Student Athletes After Concussion: A Pilot Study
  19. CLINICAL IMAGES
  20. Trichoepithelioma
  21. LETTER TO THE EDITOR
  22. SARS-CoV2 OMT: A Relative Contraindication to Thoracic Pump Technique and an Additional Indication for the Elderly
  23. LETTERS TO THE EDITOR
  24. Osteopathic Medicine and the Osteoporosis Management Gap
https://doi.org/10.7556/jaoa.2020.093

Articles in the same Issue

  1. ORIGINAL CONTRIBUTION
  2. Portable Ultrasonography to Assess Adult Hepatosteatosis in Rural Ecuador
  3. REVIEW
  4. Time-Restricted Feeding and Potential for Type 2 Diabetes Mellitus: A Narrative Review
  5. JAOA/AACOM MEDICAL EDUCATION
  6. Practice Locations of Michigan Ophthalmologists as a Model to Compare Practice Patterns of DO and MD Surgical Subspecialists
  7. ORIGINAL CONTRIBUTION
  8. Mindfulness-Based Stress Reduction in the Management of Chronic Pain and Its Comorbid Depression
  9. REVIEW
  10. Pathophysiologic Mechanisms of Concussion, Development of Chronic Traumatic Encephalopathy, and Emerging Diagnostics: A Narrative Review
  11. ORIGINAL CONTRIBUTIONS
  12. Rib Somatic Dysfunction Among General Surgical Patients
  13. ORIGINAL CONTRIBUTION
  14. Clinical Efficacy of Mesenteric Lift to Relieve Constipation in Traumatic Brain Injury Patients
  15. Cranial Strain Patterns Associated With Concussions
  16. Effectiveness of Osteopathic Manipulative Medicine vs Concussion Education in Treating Student Athletes With Acute Concussion Symptoms
  17. BRIEF REPORT
  18. Effects of Osteopathic Manipulative Treatment on Sleep Quality in Student Athletes After Concussion: A Pilot Study
  19. CLINICAL IMAGES
  20. Trichoepithelioma
  21. LETTER TO THE EDITOR
  22. SARS-CoV2 OMT: A Relative Contraindication to Thoracic Pump Technique and an Additional Indication for the Elderly
  23. LETTERS TO THE EDITOR
  24. Osteopathic Medicine and the Osteoporosis Management Gap
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