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:
1Severe 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
2Chest Physiotherapyaccepted 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 therebyreducing work of breathing;improving delivery of mechanical ventilation;improving gaseous exchange;preventing and resolving respiratory complications;facilitating early weaning from the ventilatorMain et al, 2004; Ntoumenopoulos et al, 2002; Wallis and Prasad, 1999; Ciesla, 1996.Longer term, aim toPrevent postural deformitiesImprove exercise toleranceReturn to optimal function
3Chest 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.
4CPT showed higher Vte, Crs, alveolar deadspace Randomised cross-over trial comparing suctioning alone and chest physiotherapy with suctioningCPT showed higher Vte, Crs, alveolar deadspaceNo difference in PO2, PCO2 or pHGreater 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 treatmentNo standardisation of treatmentSome hyperinflated, saline instilledDuration and application variedMain et al 2004; Main and Stocks 2004Intensive Care Medicine
5Chest 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 affectRespiratory systemCardiovascular systemCentral nervous systemMetabolic demand.
6CPT 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
7Complications hypoxia increased metabolic demand and O2 consumption cardiac arrythmiaschanges in blood pressureraised intracranial pressure and decreased cerebral oxygenationgastro-oesophageal refluxpneumothoracesatelectasis anddeath.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.
8Complications Neonates CPT ’s incidence of intracranial haemorrhages in preterm infants with RDSRaval et al (1987) J. PerinatologyAssociated with encephaloclastic porencephalyHarding et al (1998) J. PediatricsPotentially severe hypoxaemiaFox et al (1978) J. PediatricsArrhythmia, apnoea, BP, ICPPerlman and Volpe (1983) PediatricsEvans (1992) J Perinatol.Reports of rib #’s and periosteal reactionsPurchit et al (1975) Am J Dis Child.
10The “ventilated child”? Risk ofVILIVAPO2 toxicityHyperinflationPositional atelectasis and/or consolidationImpaired mucociliary clearanceDecreased FRC due to loss of laryngeal brakingForeign body (ETT) and inadequate humidification of vent gases → increased amount/tenacity secretions → obstruction, infection, atelectasis → chronic disease
11The “ventilated child” Do all ventilated children need “prophylactic” physiotherapy?Can “physiotherapy” prevent complications/infections?What IS physiotherapy???Good general nursing and ventilatory managementAnalgesiaRegular changes in position and early mobilisationLung protective ventilatory strategiesMinimal effective FiO2Adequate humidificationImpeccable hygiene and infection control practicesPhysiotherapists should engage in above holistic care practicesBUT formal, “conventional” CPT not indicated routinelySchechter, 2007
12The “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
13What conditions might benefit from CPT? Clear benefitCystic fibrosisSchechter (2007) Resp Care
14What conditions might benefit from CPT? Probable benefitAtelectasis with mucus pluggingPeroni and Boner (2000) Paediatr Respir Rev.
15What conditions might benefit from CPT? Probable benefitNeuromuscular diseaseSchechter (2007) Resp Care
16What conditions might benefit from CPT?? Minimal to no benefitAcute asthmaAsher et al, Pediatr pulmonol 1990BronchiolitisWebb et al (1985) Arch Dis ChildNicholas et al (1999) PhysiotherapyCochrane Systematic Review (Perrotta et al 2005)Respiratory failure without atelectasisPrevention of post-extubation atelectasis in neonatesHyaline membrane diseaseSchechter (2007) Resp CarePrevention of atelectasis following surgeryReines et al, 1982Undrained pleural collectionsCPT does not reduce length of hospital stay, O2 requirements or improve the clinical severity score in infants with acute bronchiolitis.
17Indications 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
18Indications for CPT and/or retention of secretions Impacting on lung mechanics and/or gaseous exchangePotential for further complicationsAcute lung/ lobar collapse due to mucus pluggingPeroni and Boner (2000) Paediatr Respir RevDecreased mobility (general/trunk)Potential postural deformitiesPoor exercise tolerance
20Contraindications and precautions severely ill, unstable childcoagulopathy (plt <100 with care, no Rx if plt < 50)pulmonary haemorrhagepulmonary oedemaraised intracranial pressurepulmonary hypertensionvery premature infants
21CPT 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)
23Physiotherapy Prevent Respiratory Rehabilitation deformities Clear secretionsMuscle strengtheningPMs and stretchingReexpandcollapsed lobesThoracic mobilitySplintingImprove V/QmatchingMovement reeducationPositioningWeaningImprove ex toleranceDevelopmentalstimulation
24Physiotherapy Prevent Respiratory Rehabilitation deformities Clear secretionsMuscle strengtheningPMs and stretchingReexpandcollapsed lobesThoracic mobilitySplintingImprove V/QmatchingMovement reeducationPositioningImprove ex toleranceWeaningDevelopmentalstimulation
25Positioning Improve V/Q matching Clear secretions Reexpand collapsed lobesUse gravity to move secretions from peripheral proximal airwaysOptimise V/QPositions used: supine, prone, side lying and sitting
26Positioning Improve V/Q matching Clear secretions Reexpand collapsed lobesNo head-down tiltIncreases systemic BP with potential for IVHCrane et al. 1978Increases GORButton et al. 2003Increases ICPEmery and Peabody 1983Diaphragm at mechanical disadvantageVivian-Beresford et al. 1987May increase venous return thereby increasing work of heartThe upright position increases end expiratory lung volume, optimises oxygenation and prevents VAPStark et al. 1984; Dellagrammaticas et al. 1991; Drakulovich et alNO EVIDENCE SUPPORTING EFFICACY!
31Chest manipulations Clear secretions Reexpand collapsed lobes Mucus liquefies on agitation (thixotropic)Mechanical energy transmitted through chest wall with percussion/vibesLiquid secretions moved centrally by gravity / cough / Forced Expiratory Technique
32Suctioning Clear secretions Needed in patients with artificial airway or ineffective cough.Complications includehypoxiaarrythmia’smucosal traumapneumothorax ICPbacteraemialoss of ciliary functionatelectasis
33Suctioning Clear secretions Some complications can be prevented/minimised byAdequate sedation and analgesia / paralysisPreoxygenatingUsing correct sized catheterreducing suction pressuresLimiting depth of insertionCorrect techniqueOnly suctioning when indicatedNo routine use of salineHumidificationMorrow and Argent (2008) Pediatr Crit Care Med
34Case examplesHaemodynamically unstable child with isolated RUL collapse and hypoxia.Should you refer for CPT?
35Case 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 >>>> benefitsDO NOT TREAT!
36Case examples Haemodynamically unstable child with R lung collapse Ask – is the collapse causing significant hypoxia?IF YES: potential benefits of CPT >> risksIF NO: wait until more stable before treatingTAKE NECESSARY PRECAUTIONSTRIAL OF TREATMENT
37Case examples Child with raised ICP CPT and suction causes ICP, MABP and cerebral perfusion pressureParsons and Shogan (1984), Heart Lung
38Case examples Child with raised ICP Consider CPT if Respiratory pathology is affecting CO2 eliminationincreased PaCO2 further increases ICP.Severe hypoxia caused by amenable lung pathologyanaerobic metabolism lowers pH → dilates blood vessels → further increases ICP.
39Case examples Child with raised ICP Type of treatment Depends on ICP, other injuries, general condition.Ensure adequate sedation, analgesia and/or paralysisPainful stimuli and stress increase metabolic demands, BP and ICPMonitor ICP, BP, HRConsider brief preintervention hyperventilationreflex cerebrovascular constrictionKeep Rx to minimumSupine may be best position with head up.
40Case examples Infants with pulmonary hypertension Pulmonary Hypertensive crisisMay cause systemic hypovolaemia due to decreased flowRisk of sudden cardiac arrest!
41Case examples Infants with pulmonary hypertension Common factors triggering a crisis include:HypoxiaHypercarbiaSuctioningPainAtelectasisNoiseColdAgitation
42Case examples Infants with pulmonary hypertension Consider CPT If large segment collapse with mucus pluggingRetained secretions with hypoxiaIf you treatTake appropriate precautionsMonitor PAP throughoutSedation and analgesia++, paralyse if necessarySedation and analgesia++, paralyse if necessaryFiO2 at 100% (if not on NO)Monitor PAPIf > 50% systemic BP, stop treating and wait to settleIf 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 CO2Increased PaO2 reduces pulm vasc resistance
43Chest Physiotherapy Potential benefits for specific patients Careful clinical and radiological assessmentDetermine risk:benefit for each patientHolistic 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