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    Severe Paediatric Respiratory Disease: Does Physiotherapy Have A Place?

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    bayan salah
    This document discusses the evidence and indications for chest physiotherapy (CPT) in paediatric respiratory disease. It notes that while CPT is commonly used to clear secretions and prevent complications in critically ill children, the evidence base is poor. CPT may do more harm than good by negatively impacting respiratory, cardiovascular and neurological systems. Specific conditions like cystic fibrosis may benefit from CPT, while others like asthma and bronchiolitis likely provide minimal benefit. Precautions should be taken in unstable patients. Further research is needed to determine which CPT modalities are most effective for different conditions and when CPT should be applied.

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    Severe Paediatric Respiratory Disease: Does Physiotherapy Have A Place?

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    bayan salah
    42 views45 pages
    This document discusses the evidence and indications for chest physiotherapy (CPT) in paediatric respiratory disease. It notes that while CPT is commonly used to clear secretions and prevent complications in critically ill children, the evidence base is poor. CPT may do more harm than good by negatively impacting respiratory, cardiovascular and neurological systems. Specific conditions like cystic fibrosis may benefit from CPT, while others like asthma and bronchiolitis likely provide minimal benefit. Precautions should be taken in unstable patients. Further research is needed to determine which CPT modalities are most effective for different conditions and when CPT should be applied.

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    This document discusses the evidence and indications for chest physiotherapy (CPT) in paediatric respiratory disease. It notes that while CPT is commonly used to clear secretions and prevent complications in critically ill children, the evidence base is poor. CPT may do more harm than good by negatively impacting respiratory, cardiovascular and neurological systems. Specific conditions like cystic fibrosis may benefit from CPT, while others like asthma and bronchiolitis likely provide minimal benefit. Precautions should be taken in unstable patients. Further research is needed to determine which CPT modalities are most effective for different conditions and when CPT should be applied.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    42 views45 pages

    Severe Paediatric Respiratory Disease: Does Physiotherapy Have A Place?

    Uploaded by

    bayan salah
    This document discusses the evidence and indications for chest physiotherapy (CPT) in paediatric respiratory disease. It notes that while CPT is commonly used to clear secretions and prevent complications in critically ill children, the evidence base is poor. CPT may do more harm than good by negatively impacting respiratory, cardiovascular and neurological systems. Specific conditions like cystic fibrosis may benefit from CPT, while others like asthma and bronchiolitis likely provide minimal benefit. Precautions should be taken in unstable patients. Further research is needed to determine which CPT modalities are most effective for different conditions and when CPT should be applied.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 45

    Severe paediatric respiratory disease:

    Does physiotherapy have a place?


    Chest Physiotherapy
    • accepted as part of the care of critically ill infants and
    children, largely due to risks of ETT tracheal tube
    obstruction.
    – (Krause and Hoehn 2000; Stiller 2000)
    • Short term, aim to remove obstructive secretions from the
    airways thereby
    – reducing work of breathing;
    – improving delivery of mechanical ventilation;
    – improving gaseous exchange;
    – preventing and resolving respiratory complications;
    – facilitating early weaning‫ فطام‬from the ventilator
    • Main et al, 2004; Ntoumenopoulos et al, 2002; Wallis and Prasad, 1999;
    Ciesla, 1996.
    • Longer term, aim to
    – Prevent postural deformities
    – Improve exercise tolerance
    – Return to optimal function
    Chest Physiotherapy
    • Poor evidence base
    – Many paediatric studies do not specify which techniques
    were used, their duration or the exact method of
    application.
    – Therefore not reproducible or generalisable.
    – Study designs are often flawed ‫ معيبة‬, with the resulting
    evidence being of a low level.
    Chest Physiotherapy

    • may do more harm than good ?


    – Chalumeau et al, 2002; Krause and Hoehn, 2000; Wallis
    and Prasad, 1999; Harding et al, 1998; Button et al, 1997;
    Cross et al, 1992; Reines et al, 1982.

    • CPT and suctioning may affect


    – Respiratory system
    – Cardiovascular system
    – Central nervous system
    – Metabolic demand.
    • CPT is met with the most pronounced variation in vital signs
    when compared to any other routine ICU interventions.

    – Weissman et al (1984) Crit Care Med


    Complications
    • hypoxia
    • increased metabolic demand and O2 consumption
    • cardiac arrythmias
    • changes in blood pressure
    • raised intracranial pressure and decreased cerebral
    oxygenation
    • gastro-oesophageal reflux
    • pneumothoraces
    • atelectasis partial or complete collapse of the lung
    • death.
    • Chalumeau et al, 2002; Krause and Hoehn, 2000; Wallis and Prasad,
    1999; Harding et al, 1998; Button et al, 1997; Cross et al, 1992;
    Reines et al, 1982.
    Complications
    Neonates
    • CPT ’s incidence of intracranial haemorrhages in preterm infants
    with RDS (respiratory distress)
    • Raval et al (1987) J. Perinatology

    • Associated with encephaloclastic porencephaly  characterized with 


    cysts or cavities within the cerebral hemisphere
    • Harding et al (1998) J. Pediatrics

    • Potentially severe hypoxaemia


    • Fox et al (1978) J. Pediatrics

    • Arrhythmia, apnoea,  BP,  ICP


    • Perlman and Volpe (1983) Pediatrics
    • Evans (1992) J Perinatol.

    • Reports of rib #’s and periosteal reactions new bone formation is


    seen in up to 1/3 of infants during the first few months of life
    • Purchit et al (1975) Am J Dis Child.
    When should one consider
    CPT?
    The “ventilated child”?
    • VILI (Ventilator Induced Lung Injury)
    • VAP( Ventilator-associated
    Pneumonia)
    • O2 toxicity
    • Hyperinflation
    • Positional atelectasis and/or consolidation
    ‫انخماصاو تعزيز‬
    • Impaired mucociliary‫ مخاطيهدبي‬clearance
    • Decreased FRC Functional Residual Capacity
    due to loss of laryngeal braking Pulmonary
    Function Test
    • Foreign body and inadequate humidification of
    vent gases → increased amount/tenacity
    secretions → obstruction, infection, atelectasis
    → chronic disease
    The “ventilated child”
    • Do all ventilated children need “prophylactic”
    ‫ وقائي‬physiotherapy?
    • Can “physiotherapy” prevent complications/infections?
    • Good general nursing and ventilatory management
    – Analgesia
    – Regular changes in position and early mobilisation
    – Lung protective ventilatory strategies
    – Minimal effective FiO2 Fraction of inspired oxygen 
    The ratio between partial pressure of oxygen in arterial blood (PaO2)
    and FiO2 is used as an indicator of hypoxemia per the American-European
    Consensus Conference on lung injury. A high FiO2has been shown to alter
    the ratio of PaO2/FiO2
    – Adequate humidification
    – Impeccablehygiene and infection control practices
    • Physiotherapists should engage in above holistic care practices
    • BUT formal, “conventional” CPT not indicated routinely
    – Schechter, 2007
    The “ventilated child”
    “In mechanically ventilated children, CPT cannot be regarded as a
    standard treatment modality.
    CPT must be considered as the most stimulating and disturbing
    intensive care procedure in mechanically ventilated patients”
    Krause et al (2000) Crit Care Med
    What conditions might benefit
    from CPT?

    • Clear benefit
    – Cystic fibrosis Long-term issues
    include difficulty breathing and
    coughing up mucus as a result
    of frequent lung infections
    • Schechter (2007) Resp Care
    What conditions might benefit
    from CPT?
    • Probable benefit
    – Atelectasis with mucus plugging incomplete expansion.
    Atelectasis is defined as diminished volume affecting all
    or part of a lung.
    – Peroni and Boner (2000) Paediatr Respir Rev.
    What conditions might benefit
    from CPT?
    • Probable benefit
    – Neuromuscular disease
    • Schechter (2007) Resp Care
    What conditions might benefit
    • Minimal to no benefit from CPT??
    – Acute asthma
    • Asher et al, Pediatr pulmonol 1990
    – Bronchiolitis
    • Webb et al (1985) Arch Dis Child
    • Nicholas et al (1999) Physiotherapy
    • Cochrane Systematic Review (Perrotta et al 2005)
    – Respiratory failure without atelectasis
    – Prevention of post-extubation atelectasis in neonates
    – Hyaline membrane disease proteins and dead cells lines the
    alveoli (the tiny air sacs in the lung), making gas
    exchange difficult or impossible(RDS)
    • Schechter (2007) Resp Care
    – Prevention of atelectasis following surgery
    • Reines et al, 1982
    – Undrained pleural collections
    Indications for CPT

    • “indications or contraindications for or against


    chest physiotherapy should never be formulated
    on the basis of diagnostic entities ‫ وجود‬but
    should rather stem from a detailed analysis of
    the prevailing‫سائد‬ individual
    pathophysiology.”
    – Oberwaldner (2000) Eur Respir J
    Indications for CPT
      and/or retention of secretions
    – Impacting on lung mechanics and/or gaseous exchange
    – Potential for further complications
    • Acute lung/ lobar collapse due to mucus plugging
    • Peroni and Boner (2000) Paediatr Respir Rev

    • Decreased mobility (general/trunk)


    • Potential postural deformities
    • Poor exercise tolerance
    “First do no harm”
    Contraindications and
    precautions
    • severely ill, unstable child
    • coagulopathy (plt <100 with care, no Rx if plt < 50)
    • pulmonary haemorrhage
    • pulmonary oedema
    • raised intracranial pressure
    • pulmonary hypertension
    • very premature infants
    CPT Modalities

    • “…in the case of young children with


    respiratory disease, we have few
    effective therapies, and when [you think]
    your only tool is a hammer, everything
    starts to look like a nail.

    • …patients have respiratory difficulties


    from a variety of causes, but we have
    one hammer, so we try it on everybody.”
    – Michael Schechter (2007)
    ventilation/perfusion ratio
    V/Q
    • "V" – ventilation – the air that reaches the alveoli
    • "Q" – perfusion – the blood that reaches the
    alveoli
    • the ratio of the amount of air reaching the alveoli
    to the amount of blood reaching the alveoli.
    These two variables, V & Q, constitute the main
    determinants of the blood oxygen (O2) and
    carbon dioxide (CO2) concentration.
    Physiotherapy in the PICU
    Physiotherapy

    Prevent
    Respiratory Rehabilitation deformities
    Clear secretions Muscle strengthening PMs and stretching

    Reexpand
    collapsed lobes Thoracic mobility Splinting
    Improve V/ Q
    Matching Movement reeducation Positioning

    Improve ex tolerance
    Developmental
    stimulation
    Physiotherapy

    Prevent
    Respiratory Rehabilitation deformities
    Clear secretions Muscle strengthening PMs and stretching

    Reexpand
    collapsed lobes Thoracic mobility Splinting

    Improve V/Q
    matching Movement reeducation Positioning

    Improve ex tolerance
    Developmental
    stimulation
    Positioning
    Improve V/Q Reexpand
    Clear secretions matching collapsed lobes

    • Use gravity to move secretions from


    peripheral  proximal airways
    • Optimise V/Q
    • Positions used: supine, prone, side lying
    and sitting
    Positioning
    Improve V/Q Reexpand
    Clear secretions matching collapsed lobes
    • No head-down tilt
    – Increases systemic BP with potential for IVH intra ventricular haemorrhage
    • Crane et al. 1978
    – Increases ICP
    • Emery and Peabody 1983
    – Diaphragm at mechanical disadvantage
    • Vivian-Beresford et al. 1987
    – May increase venous return thereby increasing work of heart
    – The upright position increases end expiratory lung volume, optimises
    oxygenation and prevents VAP Ventilator-Associated Pneumonia 

    • Stark et al. 1984; Dellagrammaticas et al. 1991; Drakulovich et al

    – NO EVIDENCE SUPPORTING EFFICACY!


    Mobilisation
    Reexpand Improve V/Q
    Clear secretions collapsed lobes matching

    • Improve thoracic mobility


    • Improve lung volumes
    • Assist secretion clearance
    • Improve exercise tolerance and
    muscle strength
    • Increase cardiovascular fitness
    • Prevent postural deformities
    • Bone ossification
    • Bladder and bowel function
    • Psychological benefits!
    Mobilisation
    Reexpand Improve V/Q
    Clear secretions collapsed lobes matching
    Breathing exercises
    Reexpand
    Clear secretions collapsed lobes

    • Deep breathing exercises


    • Localised expansion techniques
    • PEP therapy Positive Expiratory
    Pressure (PEP) Therapy
    • Active Cycle of Breathing Technique
    • Autogenic drainage
    Chest manipulations
    Reexpand
    Clear secretions collapsed lobes

    • Mucus liquefies on agitation ‫اثارة‬


    (thixotropic)
    • Mechanical energy transmitted through
    chest wall with percussion/vibes
    • Liquid secretions moved centrally by
    gravity / cough / Forced Expiratory
    Technique
    Suctioning
    Clear secretions

    • Needed in patients with


    artificial airway or ineffective
    cough.
    • Complications include
    – hypoxia
    – arrythmia’s
    – mucosal trauma
    – pneumothorax
      ICP
    – bacteraemia
    – loss of ciliary function
    – atelectasis
    Suctioning
    Clear secretions
    • Some complications can be
    prevented/minimised by
    – Adequate sedation and analgesia /
    paralysis
    – Preoxygenating
    – Using correct sized catheter
    – reducing suction pressures
    – Limiting depth of insertion
    – Correct technique
    – Only suctioning when indicated
    – No routine use of saline
    – Humidification
    • Morrow and Argent (2008) Pediatr
    Crit Care Med
    Case examples

    Haemodynamically unstable
    child with isolated RUL
    collapse and hypoxia.

    • Should you refer for CPT?


    Case examples

    Haemodynamically unstable
    child with RUL collapse

    • Ask – how much does RUL impact


    on oxygenation?
    • Answer – NOT MUCH!
    • If this is the only focal problem, CPT
    risks >>>> benefits

    • DO NOT TREAT!
    Case examples

    Haemodynamically unstable child


    with R lung collapse
    • Ask – is the collapse causing significant
    hypoxia?
    • IF YES: potential benefits of CPT >> risks
    • IF NO: wait until more stable before treating

    • TAKE NECESSARY PRECAUTIONS


    • TRIAL OF TREATMENT
    Case examples

    Child with raised ICP

    • CPT and suction causes  ICP,


    MABP arterial blood pressure and
    cerebral perfusion pressure
    – Parsons and Shogan (1984), Heart Lung
    Case examples

    Child with raised ICP

    Consider CPT if
    • Respiratory pathology is affecting CO2 elimination
    – increased PaCO2 partial pressure of carbon dioxide further
    increases ICP.
    • Severe hypoxia caused by amenable lung pathology
    – anaerobic metabolism lowers pH → dilates blood vessels
    → further increases ICP.
    Case examples

    Child with raised ICP

    Type of treatment
    • Depends on ICP, other injuries, general condition.
    • Ensure adequate sedation, analgesia and/or paralysis
    – Painful stimuli and stress increase metabolic demands, BP
    and ICP
    • Monitor ICP, BP, HR
    • Consider brief preintervention hyperventilation
    – reflex cerebrovascular constriction
    • Keep Rx to minimum respiratory rate
    • Supine may be best position with head up.
    Case examples

    Infants with pulmonary hypertension

    • Pulmonary Hypertensive crisis


    – May cause systemic hypovolaemia due to decreased flow
    • Risk of sudden cardiac arrest!
    Case examples
    Infants with pulmonary hypertension
    • Common factors triggering a crisis include:
    – Hypoxia
    – Hypercarbia
    – Suctioning
    – Pain
    – Atelectasis
    – Noise
    – Cold
    – Agitation
    Case examples
    Infants with pulmonary hypertension

    Consider CPT
    • If large segment collapse with mucus plugging
    • Retained secretions with hypoxia

    If you treat
    • Take appropriate precautions
    • Monitor PAP throughout Pulmonary artery pressure
    • Sedation and analgesia++, paralyse if necessary
    Chest Physiotherapy

    • Potential benefits for specific patients


    • Careful clinical and radiological assessment
    • Determine risk:benefit for each patient
    • Holistic approach.

    • RESEARCH NEEDED!
    “In the meantime, those involved in the
    management of paediatric respiratory
    disorders should avoid the unnecessary
    distress to both the child and family of
    useless treatment and the potentially serious
    consequences of inappropriate intervention”

    – Wallis and Prasad (1999), Arch Dis Child


    "Our success will and must be measured in the happiness and welfare of our children."
    Nelson Mandela

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