1. Improving ventilation & reducing the work of breathing in infants and children Robyn Smith Department of Physiotherapy University of Free State 2011

2. Aims of Chest Physiotherapy Other aims of chest physiotherapy apart from mobilising and clearing secretions are: ◦improve ventilation and ◦decrease the work of breathing (WOB)

3. Ventilation

4. Challenges in children Maintaining adequate lung volumes and ensuring adequate ventilation remains a challenge in children whose immature airways have a tendency to closure/collapse Physiotherapy aims to: ◦Re-expand atelectatic segments ◦ prevent secondary lung complications due to atelectasis

5. Physiotherapy techniques to improve ventilation and lung volume Positioning Play and exercise Breathing exercises ACBT Incentive spirometry Postural drainage and manual techniques In this section only positioning and breathing exercises will be discussed. Please refer to the presentation regarding mobilisation of secretions for information regarding the other techniques

6. Differentiating between shortness of breath and dyspnoea

7. Shortness of breathDyspnoea Associated rapid RR or tachypnoea largely Common in children with acute respiratory disease Sense of breathlessness cannot get enough breath

8. Shortness of breath and dyspnoea Teach relaxation positions and breathing control in older children  Position in relaxation position  Relax shoulder girdle  Encourage diaphragmatic breathing

9. Positioning

10. Positioning Positioning is one of the most important ways one can optimise respiratory functioning Small children breathe more comfortably in a slightly head up position

11. Position in semi-fowlers or head up position: ◦Not slumped as this compresses the diaphragm ◦Knees in slight flexion to decrease the load on the diaphragm Can even use sitting up on parents lap Can use cuddly toys to aid positioning Positioning

12. Breathing exercises

13. It is possible to encourage children to breathe deeply from about 2 years Can make use of games and activities in younger children e.g. Blowing bubbles, pinwheels or even incentive spirometry (flutter) or bubble PEP

14. Blowing activities children

15. Neurophysiological stimulation of respiration Makes use of tactile and proprioceptive stimulation A stimulus (intercostal stretch) is given at the end of expiration This facilitates improved chest expansion and therefore ventilation

16. Localised breathing exercises Used to improve thoracic expansion in older children Physiotherapists hands at the level of the 8 th rib Child is instructed to expand the lower ribs against her hands

17. Improving the ventilation/ perfusion ration Physiological characteristics of the immature respiratory system influence the inability of ventilated areas of the lung to match the perfused areas in a child. In young children ventilation is preferably distributed to the uppermost lung areas and the dependant areas are poorly ventilated. This happens due to the airway closing pressure in young child being before the FRC is reached and the highly compliant chest wall. The dependant lung areas have better perfusion.

19. Improving the ventilation/ perfusion ration Principles to improve gaseous exchange in a child are the opposite to those in an adult (up until 10 years of age) e.g. Child with right sided pathology should be placed on the right side to optimise ventilation and reduce mismatching Children may desaturate and their respiratory function deteriorate significantly when placing child with the affected lung uppermost

20. References Hardy, L. 2007. Cardiorespiratory physiotherapy for the acutely ill, non-ventilated child. In Physiotherapy for Children. Poutney, T (Ed). Butterworth Heinemann Elsevier pp 285-290 Anderson, JM & Innocenti, DM. 1992. Techniques used in physiotherapy. In Cash’s Textbook of chest, vascular disorders for Physiotherapists. Downie PA (ed). 4 th ed. Pp 325-354 Ammani Prasad, S & Main, E. 2008. Respiratory disease in childhood. In Physiotherapy for respiratory and cardiac problems.Adults and children. Pryor, JA & Ammani Prasad, S (eds).4 ed. Churchill Livingstone Elsevier pp 337-343

21. References Pryor, JA & Ammani Prasad, S. 2008. Physiotherapy techniques. In Physiotherapy for respiratory and cardiac problems.Adults and children. Pryor, JA & Ammani Prasad, S (eds).4 ed. Churchill Livingstone Elsevier pp136-176 Hough, A. 2001. 2001. Physiotherapy to clear secretions. In Physiotherapy in Respiratory care. An evidence based approach to respiratory and cardiac management. 3 rd edition. Nelson Thornes. London pp184- 210