chest physiotherapy and airway clearance in · pdf filechest physiotherapy and airway...

Chest Physiotherapy and Airway Clearance in Pediatrics

Rob DiBlasi RRT-NPS, FAARCProgram Manager Research/QI, Respiratory TherapyPrinciple Investigator, SCRIMarch 22, 2017

Conflict of Interest

I have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to

merely illustrate a point of emphasis.

Objectives

Learning objectives for this presentation: Discuss different forms of airway clearance

therapies (ACTs) Review the literature related to the use of

ACTs in pediatric lung disease Discuss ways to embrace judicious use of

ACTs in patients using evidence-based approaches

Background

Airway Clearance Techniques (ACTs) are used in variety of settings for a variety of clinical ailments:

1) evidence of retained pulmonary secretions 2) weak or ineffective cough 3) focal lung opacity on chest x-ray consistent with mucous plugging and/or atelectasis and 4) intrapulmonary shunt requiring oxygen

ChestPhysiotherapy

PosturalDrainage

http://www.cfbarbados.org/content/treatment

ChestPhysiotherapy

Other Airway Clearance Options: ACTs

Therapy Vest

Hand-Held Airway Clearance

Cough Assist

Nasotracheal Sx

ACTs contd

Incentive Spirometry

Ambulation

Breathing games

Literature Search

ACTs have only been shown to be effective in children with CF, Bronchiectasis and neuromuscular weakness

Lack of definitive data for ACT for common forms of pediatric respiratory failure Pneumonia (may cause patients condition to worsen) Bronchiolitis, asthma, pleural effusion Prevention of atelectasis

Bronchiolitis

Systematic review to determine efficacy of CPT in infants with acute viral bronchiolitis

Are ACTs a useful option with pneumonia?

Pneumonia

RCT with children (29 d to 12 y old) hospitalized with acute pneumonia, and compared twice-daily CPT and standard pneumonia therapy (n =51) to standard treatment alone (n =47) The CPT group had a longer median duration

of coughing (5.0 d vs 4.0 d, P =0.04) and longer duration of rhonchi (median 2.0 d vs 0.5 d, P= 0.03) than the medical treatment only group

Paloudo, Thorax, 2008

ACT in Asthma

Randomized Placebo Controlled Trial 38 children aged 6 to 13 years with severe

asthma 19 children received chest physical therapy

(PT) and 19 children received placebo visits Lung function at the end of the study was

similar in both groups

Asher I et al., Pediatr Pulmonol, 1990

Can ACT resolve acute lobar atelectasis during mechanical ventilation?

Larger ventilated patients (Templeton M et al., Intensive Care Med,2007) CPT may be useful for acute lobar or segmental

atelectasis based on radiographic evidence Neonates-post-extubation (Flenady et al.,

Cochrane 2002) No benefit to peri-extubation CPT No decrease in post-extubation lobar collapse Lower re-intubation rate in babies treated with CPT

Can CPT and other ACTs prevent atelectasis?

CardiacTransplant

CXRfrom4/15/15.CPTorderedTID.Reasonfororder:LobarAtelectasis.Radiologistnotednofocalinfiltrateson4/15/15.

CXRfrom4/16/15.CPTprovidedTID.Radiologistnotedlungsaresomewhatoverinflatedmildshadowingininfrahilar areas

RoomAirHHFNC46L/min

TricuspidAtresiaRoomAirHFNC5L/minfor72hours

4/14MildPerihilarhazinesssuggestiveofedemaReceivingCPTTIDtoRULRTattemptedtogetthisDCdMD:well,Iguessyouaregoingtohavetodoitanyway.RT:howaboutincreasingPEEP?

4/16/15RadiologistnotedNolobarconsolidationCPTreorderedforRightsidedlobarcollapse.

4/16/150610CPTQ4for72hoursRadiologistnotedmildincreaseinRULopacityCosttopatient:$6,300.00RTtime:6hoursatthebedside

6L/minHHFNCFiO235

4/14/15Orderedforlefthemidiaphragmparesisandthenorderchangedtolobaratelectasis

Can ACT prevent lobar atelectasis or VAP?

Mechanically ventilated adult patients (Chen YC, J Clin Med Assoc, 2009) No differences in VAP between CPT and no intervention

ACT in pleural effusion

Systematic Review

Included 24 RCTs, seven crossover RCTs, and one prospective cohort study in adults and patients (n=2,453)

Patients with CF and neuromuscular disease were excluded

Based on these data, this review found no evidence from RCTs to support the use of CPT or any other form of ACT in adults or pediatrics to: improve oxygenation, reduce length of time on the ventilator, reduce

stay in the ICU, resolve atelectasis/consolidation, and/or improve respiratory mechanics versus usual care in this population

Andrews et al., Resp Care, 2013

Evidence Based Review-Pediatrics

Andrews et al., Resp Care, 2013

Risks Associated with ACT

Gastroesophageal reflux (Button BM, Pediatr Res 1994)

Decreased oxygenation and increased oxygenation requirements (Hough JL, Cochrane, 2008)

Rib fracture (Purchit DM, Am J Dis Child, 1975)

Increased intracranial pressure and intracranial bleeding (Harding JE, J Pediatr, 1998)

Longer duration of fever (Britton S, BMJ, 1985)

Increased vomiting and respiratory instability (Roque et al., Cochrane, 2012)

Increased SOB, arrhythmia, bronchospasm, thoracic hematoma (Andrews J, Resp Care, 2013)

Photo courtesy of Seattle Childrens Hospital RT Dept with permission

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Problem: RT Staffing CrisisD

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2011 2012 2013 2014

# C

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Allocation of RT resources: Airway Clearance

$548,310

$908,670 $1,017,660

$1,431,150

Reasons other than those indicated in the order set

prevention of lobar atelectasis, diffuse pneumonia, increased work of breathing, inability to clear secretions, obstruction of V-P shunt and pleural effusion, complete lung opacification while on extracorporeal life support, wheezing, microaspiration, comfort (soothing), decreased breath sounds, no abdominal domain, poor pulmonary compliance, bronchiolitis, excessive nasal and/or oral pooling, junky breath sounds, , post-operative fever and paroxysmal cough.

Goal

WeproposedatherapistdrivenprotocolthatallowsRTstoprovideappropriateandjudiciousACTcaretopatients Lessrisktothepatient Lessexpensetopayers LessstrainonRTresources ImprovedjobsatisfactionforRTs

UCL 0.28

CL 0.20

LCL 0.12

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Calendar Days

Total Tx Per Patient Day- All PatientsPatients with moderate-high level evidence for ACT use: 67% increase

All Patients, All Diseases: All Airway Clearance Therapies

Patients with low level evidence for ACT use: 65% increase

UCL 0.11

CL 0.07

LCL 0.03

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