Emma BarrettBand 7 PhysiotherapistPaediatric Respiratory

Care

Causes of respiratory conditions in this patient groupAssessment specifics Management optionsPhysiotherapy techniques

Prematurity / chronic lung diseaseAcute /chronic aspirationGORSkeletal abnormalitiesMuscle weaknessExcessive secretions

Poor nutritional healthSusceptability to infections/ virusesPost op complicationsLong term breathing at low lung volumes

Cerebral palsyMuscular dystrophiesMyopathiesSpinal muscular atrophyDevelopmental delay/ hypotoniaPost head injury/ brain tumourSpinal cord injury

Subjective history:Baseline respiratory status – secretions, cough, RR, resp patternMedications /nebulisersPhysiotherapy/ adjunctsHome oxygenHome suctionNIVResults of sleep studies/ TOSCAs

Mucolytics – DNAse, HTSAntimuscarics – glyco, hyoscine patchesBronchodilators – short/long acting/ steroidsAnalgesia -Sedation - lorazepamTone meds – baclofenAnti reflux medication – ranitidine, omeprazole

As for previous respiratory assessment Understanding/ communication/ complianceChest wall movement/ symmetryUpper airway problemsMobility/ postureNIV (pressures/ interface)O2 – delivery?Baseline CXRBaseline oxygen saturations

GORD/ swallowing probs Respiratory team inputPlans for escalation of treatment/ resus statusPhysical examinationPalpationExpansionCoughAuscultationInspiratory ability

fiO2spO2CO2 monitoring - TOSCALFTsPCFNIV settings / pressuresCXRAuscultation/ palpation

Positioning/ postural correctionMucolyticsAntimuscaricsAntibiotics – obtain samples for MC&SBronchodilatorsHydrationNutritionSwallowing assessment ? NBMfiO2 (ensure correct delivery)

Optimise respiratory functionUse aids/ equipment/ supportive seating

(adapt)Mobilise Consider contractures/ deformitiesModified postural drainage (GOR **)Balance secretion clearance with optimisingventilation

Percussion (be effective)VibrationsEnsure analgesia !?? With HTS/ NaCl nebsWhilst on NIV ?

PEP (mask/ mouthpiece/ bubble)Incentive spirometerIPPB (the ‘bird’, cough assist, NIPPY)

Will depend on compliance/ muscle control/ability

ManualMechanical (cough assist)

Cough assist

MIE – application of positive & negative pressures to mimic/ augment pts own cough.Effective in pts with poor inspiratory effort, weak cough, poor swallowPCF 160 l/min & below thought to be ineffective to clear secretions Some NM pts will have cough assist at home for prophylactic/ regular use

Cough assist research

Increases peak cough flow and improves airway clearance in NMDReduces hospital admissions, pneumonias, resp failure & tracheostomyShortens airway clearance sessions in NMD pts with chest infection

YankeurOral pharyngealNasal pharyngeal (very effective in paeds)Consider airway – d/w medical teamBe aggressive to avoid deterioration

Others techniques

Breath stackingInterpulmonary percussive ventilation‘the vest’

Indications that the patient is deteriorating:Increasing fiO2Decreasing SaO2Retaining secretionsIncreased WOBFatigueWorsening blood gases – resp failureCO2 retention

NIV – BIPAP, CPAP, IFDInvasive ventilationtracheostomy

BIPAP VISION NASAL MASK NIV

NIV - definition

‘Application of positive pressure via upper respiratory tract for the purpose of augmenting alveolar ventilation & removing C02 whilst resting patient’

BTS guidelines 2002

NIV indications (acute)

Pt does not require intubation to protect airway or for secretion removal Can be used in acute respiratory failure to avoid intubation, improve gas exchange and prevent atelectasisCan prevent admission to PICU/ invasive ventilation and facilitate weaning from invasive ventilationAvoids risk of ventilator acquired pneumonias, resp muscle weakness, excessive sedation

NIV in paediatrics

BIPAPCPAPIFD (infant flow driver)

BIPAP

Bi level positive airway pressureIPAP – positive inspiratory pressure- for assisting ventilation and aiding lung recruitmentEPAP – positive expiratory pressure to recruit lung volume, maintain lung expansion and improve oxygenation (same as PEEP/ CPAP)IPAP - EPAP = PS (pressure support)

BIPAP cont …..

Increases tidal volumeDecreases work of breathingAids removal of CO2Rests respiratory muscles

Paediatric considerations

Acceptance, co operation and complianceNasal masks facilitate cough, speech, eating, playing but consider mouth breathers !! ? Chin strapGradually increase pressures to aid toleranceMonitor TVs, chest expansion& blood gases for effectivenessAllow children to play with masks etc before applyingMay require some sedation/ application once asleep

CPAP

Continuous positive airway pressurePEEP/ EPAP – pressure at one level delivered continuously through the breathing cycle

Splints airways openPrevents airway collapse at end expirationIncreases FRCImproves oxygenation

IFD – infant flow driver

Nasal CPAP for infantsDelivers constant stable pressure to the airwaysRestores FRC and corrects hypoxaemiaReduces work of breathingEffective due to airway instability in infants (airway collapse)

Initiating and trouble shooting

Involve pt and family – explanation of aims and goals –increases complianceChoose correct interface/ sizeHave clear plan and objective markers (blood gases, SpO2, fiO2, RR, TV, HR, GCS)Regularly re evaluate/ adjust – gases after 1 hr of initiation or changes to settingsEvaluation should consider – pt comfort, chest wall movement, co ordination of resp effort with ventilatorHave a plan if NIV is not successful – if CO2 and pH do not improve within 4 hours ?? Invasive ventilation

Physiotherapy implications

Allow patient to settle onto NIV before attempting physiotherapy

Consider if secretions are the primary problem ? – if not it may be appropriate to delay physiotherapy for the benefits of NIV.

Airway clearance techniques can be carried out whist pt on NIV and remove only for coughing/ suction

Research

Reddy et al – 2004 – NIV in acute NMDPadman et al – 1998 – NIV via BIPAP in

paediatric practiceNiranjan & bach – 1998 – non invasive

management of paed neuromuscular ventilatory failure

Bach et al – 2000 – SMA type 1 – non invasive management

conclusions

Paediatric pts with neuromuscular disorders are susceptable to chest infections, and acute respiratory failure

This patient group require comprehensive management to prevent deterioration

Physiotherapy management needs to be timely and agressive in order to be effective

NIV can be effective in the management of this patient group

References

Bach et al (2000) – Chest 117:1100-5Bach et al (1993) – Arch phys med rehab – 74: 170 – 176Bach et al (2007) – Am j phys med rehab – 86 (4) 295-300Chatwin et al (2003) – eur resp journal – 21: 502-508Chatwin & Simmonds (2009) – resp care – 54 (11)1473 -9Dohna-schwake (2006) – paed pulm – 41 (6) 551 - 7Fauroux et al (2008) Chest 133: 161-168Inal-Ince et al (2009) Spine – (8) Miske et al (2004) Chest 125 (4) 1406 – 1412Niranjan & Bach (1998) crit care med 26 (12):1952-3Padman et al (1998) crit care med 26: 169-73Redding et al (2008) spine - 8 (4)639-44

Thank you for listening any questions ?