Severe paediatric respiratory disease: Does physiotherapy have a place?

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. 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

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

26. Clear secretions Improve V/Q matching Reexpand collapsed lobes Positioning • 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. Clear secretions Reexpand collapsed lobes Improve V/Q matching Weaning Mobilisation • 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. Clear secretions Reexpand collapsed lobes Improve V/Q matching Weaning Mobilisation

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

31. Clear secretions Reexpand collapsed lobes Chest manipulations • 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

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 brenda.morrow@uct.ac.za