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Severe paediatric respiratory disease: Does physiotherapy have a place? Brenda Morrow (PhD) Division of Paediatric Critical Care and Children’s Heart.

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Presentation on theme: "Severe paediatric respiratory disease: Does physiotherapy have a place? Brenda Morrow (PhD) Division of Paediatric Critical Care and Children’s Heart."— Presentation transcript:

1 Severe paediatric respiratory disease: Does physiotherapy have a place?
Brenda Morrow (PhD) Division of Paediatric Critical Care and Children’s Heart Disease, University of Cape Town

2 Chest Physiotherapy accepted as part of the care of critically ill infants and children, largely due to risks of ETT 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 from 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

3 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, with the resulting evidence being of a low level.

4 CPT showed higher Vte, Crs, alveolar deadspace
Randomised cross-over trial comparing suctioning alone and chest physiotherapy with suctioning CPT showed higher Vte, Crs, alveolar deadspace No difference in PO2, PCO2 or pH Greater drop in Rrs in CPT group ± 30% respiratory function deteriorated following both CPT and suction! Unable to identify patients who were more/less likely to respond to treatment No standardisation of treatment Some hyperinflated, saline instilled Duration and application varied Main et al 2004; Main and Stocks 2004 Intensive Care Medicine

5 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.

6 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

7 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 and 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.

8 Complications Neonates
CPT ’s incidence of intracranial haemorrhages in preterm infants with RDS Raval et al (1987) J. Perinatology Associated with encephaloclastic porencephaly 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 Purchit et al (1975) Am J Dis Child.

9 When should one consider CPT?

10 The “ventilated child”?
Risk of VILI VAP O2 toxicity Hyperinflation Positional atelectasis and/or consolidation Impaired mucociliary clearance Decreased FRC due to loss of laryngeal braking Foreign body (ETT) and inadequate humidification of vent gases → increased amount/tenacity secretions → obstruction, infection, atelectasis → chronic disease

11 The “ventilated child”
Do all ventilated children need “prophylactic” physiotherapy? Can “physiotherapy” prevent complications/infections? What IS physiotherapy??? Good general nursing and ventilatory management Analgesia Regular changes in position and early mobilisation Lung protective ventilatory strategies Minimal effective FiO2 Adequate humidification Impeccable hygiene and infection control practices Physiotherapists should engage in above holistic care practices BUT formal, “conventional” CPT not indicated routinely Schechter, 2007

12 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

13 What conditions might benefit from CPT?
Clear benefit Cystic fibrosis Schechter (2007) Resp Care

14 What conditions might benefit from CPT?
Probable benefit Atelectasis with mucus plugging Peroni and Boner (2000) Paediatr Respir Rev.

15 What conditions might benefit from CPT?
Probable benefit Neuromuscular disease Schechter (2007) Resp Care

16 What conditions might benefit from CPT??
Minimal to no benefit 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 Schechter (2007) Resp Care Prevention of atelectasis following surgery Reines et al, 1982 Undrained pleural collections CPT does not reduce length of hospital stay, O2 requirements or improve the clinical severity score in infants with acute bronchiolitis.

17 Indications for CPT “indications or contraindications for or against chest physiotherapy should never be formulated on the basis of diagnostic entities but should rather stem from a detailed analysis of the prevailing individual pathophysiology.” Oberwaldner (2000) Eur Respir J

18 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

19 “Primum non nocere” “First do no harm”

20 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

21 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)

22 Physiotherapy in the PICU

23 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 Weaning Improve ex tolerance Developmental stimulation

24 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 Weaning Developmental stimulation

25 Positioning Improve V/Q matching Clear secretions Reexpand
collapsed lobes Use gravity to move secretions from peripheral  proximal airways Optimise V/Q Positions used: supine, prone, side lying and sitting

26 Positioning Improve V/Q matching Clear secretions Reexpand
collapsed lobes No head-down tilt Increases systemic BP with potential for IVH Crane et al. 1978 Increases GOR Button et al. 2003 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 Stark et al. 1984; Dellagrammaticas et al. 1991; Drakulovich et al NO EVIDENCE SUPPORTING EFFICACY!

27 Mobilisation Clear secretions Reexpand collapsed lobes Improve V/Q
matching Weaning 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!

28 Mobilisation Clear secretions Reexpand collapsed lobes Improve V/Q
matching Weaning

29 Breathing exercises Reexpand Clear secretions Weaning collapsed lobes
Deep breathing exercises Localised expansion techniques PEP therapy Active Cycle of Breathing Technique Autogenic drainage

30

31 Chest manipulations Clear secretions Reexpand collapsed lobes
Mucus liquefies on agitation (thixotropic) Mechanical energy transmitted through chest wall with percussion/vibes Liquid secretions moved centrally by gravity / cough / Forced Expiratory Technique

32 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

33 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

34 Case examples Haemodynamically unstable child with isolated RUL collapse and hypoxia. Should you refer for CPT?

35 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!

36 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

37 Case examples Child with raised ICP
CPT and suction causes  ICP, MABP and cerebral perfusion pressure Parsons and Shogan (1984), Heart Lung

38 Case examples Child with raised ICP Consider CPT if
Respiratory pathology is affecting CO2 elimination increased PaCO2 further increases ICP. Severe hypoxia caused by amenable lung pathology anaerobic metabolism lowers pH → dilates blood vessels → further increases ICP.

39 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 Supine may be best position with head up.

40 Case examples Infants with pulmonary hypertension
Pulmonary Hypertensive crisis May cause systemic hypovolaemia due to decreased flow Risk of sudden cardiac arrest!

41 Case examples Infants with pulmonary hypertension
Common factors triggering a crisis include: Hypoxia Hypercarbia Suctioning Pain Atelectasis Noise Cold Agitation

42 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 Sedation and analgesia++, paralyse if necessary Sedation and analgesia++, paralyse if necessary FiO2 at 100% (if not on NO) Monitor PAP If > 50% systemic BP, stop treating and wait to settle If prone to crises prophylactically hyperventilate before suctioning. If nearing or reaching systemic BP, hyperventilate with 100% O2 (or NO) Induce resp alkalosis by blowing off CO2 Increased PaO2 reduces pulm vasc resistance

43 Chest Physiotherapy Potential benefits for specific patients
Careful clinical and radiological assessment Determine risk:benefit for each patient Holistic approach. RESEARCH NEEDED!

44 “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

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


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