CHEST PT FOR NEONATES Aim to improve airway clearance Bronchial drainage- Increased diameter of airways through suction

mobilization- in creased ventilation- increased work of breathing

POSITIONAL ROTATION Frequent changing of position- prevents dependency of any one portion of

the lung Pooling of secretions can be limited/ avoided Improved ventilation (Menkes and Britt 1980) Should emphasize all lung areas Rt upper lobe, middle lower lobe common for Atelectasis

PREMATURE INFANTS TOLERATE AND BENEFIT PRONE POSITIONING○ Prone positioning in infants causes

Improved oxygenationTidal volumeDynamic lung complianceSynchrony of chest wall movement

Positional rotation done every two hours manually

Continuous positional oscillation in a chest physical therapy program decrease the duration of oxygen supplementation without adversely affecting the cardiopulmonary status of the neonates

POSITIONAL ROTATION

ESSENTIALS OF POSITIONAL ROTATION PROGRAM

Care should be taken to coordinate any change in the infants position with other nursing procedures to avoid unnecessary stimulation

Infants should never be left unattended when in a head down position

Vital signs should be monitored closely by respiration and heart rate monitors. the alarms should be turned on

The infants chest should be auscultated for adventitious breathe sounds after positioning

While the infant is in the drainage position, suctions will be more easily mobilized. the infant’s trachea or endotracheal tube should be suctioned as needed

Avoid placing the infant in a head down position for approximately one hour after eating to avoid aspiration of regurgitated food

Any change in the infants position should be done slowly to minimize stress on the cardiovascular system

Some infants might require modified drainage positions. infants with severe cardiovascular instability or suspected intracranial bleeding should not be placed in a head down position

SEQUENCE FOR POSITIONAL ROTATION POSITION 1: Segments that come off the left lower bronchus posteriorly are drained

by positioning the infant on the right side, three fourths prone with a head down angle

POSITION2: The post. segment of the Rt upper lobe is drained by positioning on the left side, three fourth,s prone with the bed flat

POSITION 3: The anterior segments of the upper lobe are drained by positioning supine with the head of the bed elevated or flat

POSITION 4: Segments that come of the right lower lobe bronchus posteriorly are drained by positioning on the left side, ¾ th prone with head down angle

POSITION 5: The posterior segment of the left upper lobe is drained by positioning on the right side, ¾ th prone with the head of the bed elevated

POSITION 6: Segments that come off the Tracheobronchial tree anteriorly will be drained in a supine position slightly head down angle

POSITION 7 AND 8: Segments such as the right middle lobe or Lingula that come off the tracheobronchial tree anterolaterally will be drained in a ¾ th spine position slightly head down

POSTURAL DRAINAGE Promote gravity assisted drainage of specific segmental airways Rule for modification- position close to the classical ( anatomically correct)

position for that segment Horizontal to slightly elevated position of the head may be best ( thoresan,

cowan,1998)

POSTURAL DRAINAGE

POSTURAL DRAINAGE

POSTURAL DRAINAGE

POSTURAL DRAINAGE

POSTURAL DRAINAGE

PRECAUTIONS FOR TRENDELENBERG POSITIONING

○ Abdominal distension○ Congestive heart failure○ Dysrhythmia’s○ Hydrocephalus○ Frequent episodes of apnea and bradycardia○ Acute resp. distress

CHEST PERCUSSION AND VIBRATION

Given together to augment effect of gravity removal of secretions For larger infants- cupped hand Smaller infants- some modification needed

↓ Use of tenting three fingers, four fingers or using

commercial available percussion devices made for neonates A small anaesthesia mask or palm cup can be used

PRECAUTIONS- Unstable cardiovascular oxygenation status, coagulability, subcutaneous emphysema, intraventricular haemorrhage

CONTRAINDICATIONS- Healing thoracotomy incision, child displays irritability, signs of resp. distress

VIBRATION- Manual vibratory motion of therapists fingers on the infants chest wall or using mechanical vibrator

Electric toothbrush adapted by padding bristle portion with foam ( Curran and Kachoyeanos, 1979)

PRECAUTION- Increased irritability with development of bradycardia and resp. distress

Use of chest percussion and vibration depend on medical condition of the infant, infants tolerance to handling

CHEST PERCUSSION

CHEST PHYSICAL THERAPY FOR CHILDREN( 2YRS OR OLDER) Capable of following directions- deep breathing, coughing, active exercise Improving ventilation, improving breathing efficiency, increasing general

strength, endurance with emphasis on muscles of resp. , improving posture, addressing relaxation, breathing control and pacing

POSITIONAL ROTATION Goal- prevent accumulation of secretions and to aid their removal Especially for children inactive, receiving artificial ventilation, not

expanding chest adequately○ Needs positional rotation every 2 hours

YOUNG CHILDREN (18 MON. TO 3 YRS) Deep breathing- blowing bubbles, paper, balloons, whistling For maximal chest expansion- child positional sidelying on each side while

playing blowing games

For child with inadequate coughing- nasopharynx suctioning

OLDER CHILDREN

Breathing exercises- purselip breathing Segmental lateral costal breathing Relaxed deep breathing for control and pacing activity Paediatric incentive spirometers available with cheerful/ cool pictures to

make respiratory exercises more like a game Firm pressure over trachea in suprasternal notch

PREOPERATIVE AND POST OPERATIVE CARE Preoperative assessment, instruction and treatment

○ Decrease postoperative complications

Parent and family education

Level of preoperative teaching depends on childs age

Child less than 2 yrs- parents explained purpose of bronchial drainage treatment, potential airway clearance problems, possible complications

Explain to parents the procedures after surgery○ Positioning○ Chest percussion○ Vibration○ Airway suctioning

If child able to understand○ Breathing games○ Incentive spirometer○ General upper and lower extremity exercises

Children 8 yrs or older○ Explain procedures, deep breathing, coughing○ Child shown to splint incision using pillows or stuffed animal to

assist comfort○ Diaphragmatic, pursed lip breathing with inspiratory hold

maneovre, incentive spirometer

CHILDREN AT RISK Preexisting lung disease Thoracic or upper abdominal location of the incision Prolonged postoperative bedrest of restricted mobility Neuromuscular involvement

POSTOPERATIVE TREATMENTS Increasing ventilation Coughing Active mobility Specific bronchial drainage Arm, shoulder, trunk movement encouraged to prevent post operative

complications Young child- chest mobility encouraged by clapping hands overheads Child should be active

PAEDIATRIC PULMONARY REHABILITATION

MOST COMMON- ASTHMA, CYSTIC FIBROSIS

EXERCISE AND ASTHMA○ Improved chest and trunk mobility○ Control of breathing○ Strength○ Posture○ Increased tolerance to exercise ( magee, 1970)

Child’s participation in physical education

Running in a cool dry environment aggravates exercise induces asthma

Swimming excellent activity

Continuous or high burst exercise○ Bronchospasm○ Short periods of exercise ( less than 6 continuous minutes) – beneficial for

conditioning without bronchial aggravation ( magee, 1991)

May need pre exercise aerosol to participate in pe without pulmonary consequences

EXERCISE Exercise tolerance helps to mobilize secretions in children

Exercise programme designed on individual basis

Preexercise assessment done Assessment of ROM, Strength and Posture Complete chest evaluation Evaluation of ADL tolerance and limitation Improving muscle strength and endurance testing Exercise tolerance testing performed with ECG, blood pressure, O2 monitoring

Basic exercise activities for children with cystic fibrosis Activities to strengthen the back, shoulder extensors Elongate trunk flexors Address overall endurance

Older children:An aerobic exercise programme require careful monitoring of pulmonary support during exercise

MOTOR APPROACHES TO MAXIMIZE TRUNK AND VENTILATORY FUNCTION

pulmonary development is clearly interrelated with musculoskeletal, motor development of the trunk

Approach to motor therapy to children with trunk weakness, tightness, alterations in tone, general immobility can

NDT approach has a dual focus on movement quality and ventilation

PROPRIOCEPTIVE INPUT ON POST. THORAX

○ Reinforces active thoracic extension and ant. chest expansion○ The therapists hands can stabilize the rib cage to reinforce abdominal

oblique function during movement○ Activities requiring alternating extension rotation and flexion rotation

will recruit control of the abdominal oblique and maintain upper trunk extension

BUBBLE BLOWING, WHISTLE TOYS AND SINGINGExcellent means of monitoring ventilatory changes that occur with active use of increased upper chest expansion

Tidal volume increases- vocalisation should increase frequency, sound higher and become louder

Functional carryover

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