Respiratory diseases in Childhood

Robyn SmithDepartment of Physiotherapy

UFS2011

Bronchiolitis

Bronchiolitis• Seasonal disease, and is common in winter months • Most commonly caused (60% cases) by RSV

(Respiratory Syncitial Virus)• Most common severe lower respiratory tract infection in

infancy• Mainly affects infants <2 years

Bronchiolitis

Pathophysiology:

Viral infection causing inflammation of the bronchioles.

This leads to necrosis and destruction of the cilia and epithelial cells

Leads to obstruction of the small airways

Bronchiolitis

Increased risk

• Prematurity• Immuno-compromised children e.g.

HIV infected infants• Chronic lung and heart diseases

Bronchiolitis

Clinical signs and symptoms• Initially looks like a common cold• Develops a dry cough and difficulty

feeding• Wheezing• Respiratory distress

Bronchiolitis• Management consists of

Oxygen therapy• Minimal handling• CPT not indicated

especially if wheezing still present

• May require intubation or trachae

• Only if secondary infection develops

• Tenacious nasal secretions might need clearing

Croup/laryngotracheobronchietis

Croup/laryngotracheobronchietis• = laryngeal infection

• Child has a hoarse barking cough and stridor

• No indication for CPT• Oxygen therapy• Adrenaline inhalations• Minimal handling• Usually clears spontaneously within 12-48

hours• May require intubation (CIP) or

tracheostomy• CPT and suctioning may make it worse.

May however suction in the presence of an artificial airway

Asthma

Asthma

Asthma

• No universally accepted definition

• Asthma is a lung disease with the following characteristics:– Reversible airway obstruction either

spontaneously or with treatment – Airway inflammation– Increased airway responsiveness to a variety of

stimuli

Asthma• No active CPT is child is wheezing

or has a silent chest• CPT can exacerbate

bronchospasm• Inhalation therapy• Dyspnoea management• May be indicated if child is

ventilated or a secondary lung infection developed

Lobar Pneumonia• Infection with consolidation of one or more

lobes• Pleuritic pain common• CPT only indicated once the pneumonia is in

resolution and the child is productive• Postural drainage• Active CPT including:

Postural drainageManual techniques e.g. percussions, vibration, shakingBreathing exercisesInhalation therapy if indicated

Bronchopneumonia• Acute inflammation of the bronchi and

bronchioles with collapse and consolidation of associated groups of alveoli

• Scattered irregularly throughout the lung • More often in lower lobes• No consolidation so one can immediately

commence with CPT• Active CPT including:

– Postural drainage– Manual techniques e.g. percussions,

vibration, shaking– Breathing exercises– Inhalation therapy if indicated

Pnemocystis jiroveci (PCP)• Pneumocystis jiroveci pneumonia

(formerly called Pneumocystis carinii or PCP) is most common opportunistic infection found in HIV positive patients

• Patients are often acutely ill on admission with severe respiratory distress leading to respiratory failurefailure requiring ventilation

• Often do poorly despite maximal ventilation

• Unstable • Subsequently many of them

develop ARDS

• Have an oxygenation and not a ventilation problem (thickening of the respiratory membrane with impaired gaseous exchange)

• Minimal white frothy secretions and unproductive cough

Pnemocystis jiroveci (PCP)Physiotherapy:

• Unstable – sensitive to position changing

• Minimal handling • Often sound clear on

auscultation, minimal secretions

• Postural drainage if indicated

• Active CPT if indicated • Proning to improve V/Q

mismatch

Pertussis (whooping cough)

• Necrosis of surface epithelium of the respiratory tract, which becomes covered in thick purulent exudate. This blocks the bronchi and bronchioles causing atelectasis.

• Paroxysmal coughing spells• Child becomes cyanosed and

red in the face

• CPT not indicated during the acute stage

• If atelectasis and mucous plugs are present may become indicated

Foreign body aspiration

• CPT is only indicated post bronchioscopic removal of the foreign body.

• Usually to treat underlying collapse or atelectasis

Bronchiectasis• Chronic inflammation of the

bronchi with destruction of the cilia.

• Resulting in impaired drainage of secretions leading to persistent lung infections of affected segments and lobes

• Commonly associated with CF, pertussis and immunodeficiency (HIV)

• Child has a productive cough with excessive, purulent secretions

Bronchiectasis• Active CPT during exacerbation

• Essential to teach a home clearance programme is taught includingPostural drainageforced expiratory techniquesInhalation therapy

• Breathing and thoracic mobility exercises

• Activity to improve exercise tolerance

Cystic Fibrosis

• Hereditary disorder of the exocrine glands and is characterised by hypertrophy and hyperplasia of the mucus secreting glands

• CPT is important to assist in the clearance of secretions through

Cystic Fibrosis• Postural drainage routine and home programme• Active CPT • Inhalation therapies• IPPB• Active cycle of breathing• Forced expiration techniques• ↑physical activity• Breathing exercises• Trunk mobility and postural correction

Pulmonary Tuberculosis• Exposure to Mycobacterium

Tuberculosis• Deposits in the lung and

causes a primary infection

• Physiotherapy:Breathing exercisesManual CPT techniques for areas collapsepostural drainage if associated bronchiectasismobilization

Lung tumours• Controlled breathing exercises• Gentle vibrations. Vigorous

percussions, vibrations and shaking are contra-indicated due to the poor general condition of the patient, possibility of haemoptysis, and presence of metastases of the underlying ribs or spine

• Postural drainage

Trauma related injuries

A lot of patients we see in the PICU have trauma related injuries. Common trauma related injuries include:

• Pedestrian or motor vehicle accidents• Falls from a height• Gunshot wounds• Knife wounds• Assault and physical

abuse cases

TraumaPneumothorax

• Accumulation of air or gas in the pleural cavity

• Compressing the lung• Can occur spontaneously or due to

trauma• No CPT is to be performed before the

pneumothorax is drained by inserting a intercostal drain

• Positioning• Older children mobilization, breathing

exercises, coughing with drain support and shoulder girdle exercises are important

Trauma

Lung contusion

• No active CPT if there is still active bleeding

• CPT helps in improving lung expansion

TraumaRib fractures and flail chest

• Patient should be given adequate analgesia

• May need ventilation and PEEP• Breathing exercises• Assisted coughing by stabilizing

cheat wall with hands may be indicated

• Use of mechanical vibrations above percussion???

• No shaking and manual vibration• Positioning and postural drainage

as injuries allow

References

• Images courtesy of GOOGLE• Paediatric dictate (2009)• Downie, P. A. 1992. Cash’s Textbook of chest, heart

and vascular disorders for physiotherapists. 4 ed. • Poutney, T. 2007. Physiotherapy for children• Morrow, B. Chest physiotherapy in PICU. Red Cross

children’s Hospital, UCT