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  • 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

  • -2

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    4

    Problem: RT Staffing CrisisD

    aysh

    ift R

    T FT

    E

  • 0

    400

    800

    1200

    1600

    2000

    2400

    2011 2012 2013 2014

    # C

    hest

    Phy

    siot

    hera

    py C

    harg

    es

    JanFebMarApr

    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

    0.00

    0.10

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    Trea

    tmen

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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

    -0.05

    0.00

    0.05

    0.10

    0.15

    0.20

    0.25

    0.30

    1/1/

    121/

    19/1

    22/

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