Severe paediatric respiratory disease:
Does physiotherapy have a place?
Brenda Morrow (PhD)
Division of Paediatric Critical Care and Children’s Heart Disease,
University of Cape Town
Chest Physiotherapy
• accepted as part of the care of critically ill infants and
children, largely due to risks of ETT obstruction.
– (Krause and Hoehn 2000; Stiller 2000)
• Short term, aim to remove obstructive secretions from the
airways thereby
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reducing work of breathing;
improving delivery of mechanical ventilation;
improving gaseous exchange;
preventing and resolving respiratory complications;
facilitating early weaning from the ventilator
• Main et al, 2004; Ntoumenopoulos et al, 2002; Wallis and Prasad, 1999;
Ciesla, 1996.
• Longer term, aim to
– Prevent postural deformities
– Improve exercise tolerance
– Return to optimal function
Chest Physiotherapy
• Poor evidence base
– Many paediatric studies do not specify which techniques
were used, their duration or the exact method of
application.
– Therefore not reproducible or generalisable.
– Study designs are often flawed, with the resulting evidence
being of a low level.
• Randomised cross-over trial comparing
suctioning alone and chest
physiotherapy with suctioning
– CPT showed higher Vte, Crs,
alveolar deadspace
– No difference in PO2, PCO2 or pH
– Greater drop in Rrs in CPT group
– ± 30% respiratory function
deteriorated following both CPT
and suction!
– Unable to identify patients who
were more/less likely to respond to
treatment
• No standardisation of treatment
– Some hyperinflated, saline instilled
– Duration and application varied
• Main et al 2004; Main and Stocks
2004
– Intensive Care Medicine
Chest Physiotherapy
• ? may do more harm than good
– Chalumeau et al, 2002; Krause and Hoehn, 2000; Wallis
and Prasad, 1999; Harding et al, 1998; Button et al, 1997;
Cross et al, 1992; Reines et al, 1982.
• CPT and suctioning may affect
– Respiratory system
– Cardiovascular system
– Central nervous system
– Metabolic demand.
• CPT is met with the most pronounced variation in vital signs
when compared to any other routine ICU interventions.
– Weissman et al (1984) Crit Care Med
Complications
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hypoxia
increased metabolic demand and O2 consumption
cardiac arrythmias
changes in blood pressure
raised intracranial pressure and decreased cerebral
oxygenation
gastro-oesophageal reflux
pneumothoraces
atelectasis and
death.
• Chalumeau et al, 2002; Krause and Hoehn, 2000; Wallis and Prasad,
1999; Harding et al, 1998; Button et al, 1997; Cross et al, 1992;
Reines et al, 1982.
Complications
Neonates
• CPT ’s incidence of intracranial haemorrhages in preterm
infants with RDS
• Raval et al (1987) J. Perinatology
• Associated with encephaloclastic porencephaly
• Harding et al (1998) J. Pediatrics
• Potentially severe hypoxaemia
• Fox et al (1978) J. Pediatrics
• Arrhythmia, apnoea,  BP,  ICP
• Perlman and Volpe (1983) Pediatrics
• Evans (1992) J Perinatol.
• Reports of rib #’s and periosteal reactions
• Purchit et al (1975) Am J Dis Child.
When should one consider
CPT?
The “ventilated child”?
Risk of
• VILI
• VAP
• O2 toxicity
• Hyperinflation
• Positional atelectasis and/or
consolidation
• Impaired mucociliary clearance
• Decreased FRC due to loss of
laryngeal braking
• Foreign body (ETT) and inadequate
humidification of vent gases →
increased amount/tenacity secretions
→ obstruction, infection, atelectasis
→ chronic disease
The “ventilated child”
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Do all ventilated children need “prophylactic” physiotherapy?
Can “physiotherapy” prevent complications/infections?
What IS physiotherapy???
Good general nursing and ventilatory management
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Analgesia
Regular changes in position and early mobilisation
Lung protective ventilatory strategies
Minimal effective FiO2
Adequate humidification
Impeccable hygiene and infection control practices
• Physiotherapists should engage in above holistic care practices
• BUT formal, “conventional” CPT not indicated routinely
– Schechter, 2007
The “ventilated child”
“In mechanically ventilated children, CPT cannot be regarded as a
standard treatment modality.
CPT must be considered as the most stimulating and disturbing
intensive care procedure in mechanically ventilated patients”
Krause et al (2000) Crit Care Med
What conditions might benefit
from CPT?
• Clear benefit
– Cystic fibrosis
• Schechter (2007) Resp Care
What conditions might benefit
from CPT?
• Probable benefit
– Atelectasis with mucus plugging
– Peroni and Boner (2000) Paediatr Respir Rev.
What conditions might benefit
from CPT?
• Probable benefit
– Neuromuscular disease
• Schechter (2007) Resp Care
What conditions might benefit
from CPT??
• Minimal to no benefit
– Acute asthma
• Asher et al, Pediatr pulmonol 1990
– Bronchiolitis
• Webb et al (1985) Arch Dis Child
• Nicholas et al (1999) Physiotherapy
• Cochrane Systematic Review (Perrotta et al 2005)
– Respiratory failure without atelectasis
– Prevention of post-extubation atelectasis in neonates
– Hyaline membrane disease
• Schechter (2007) Resp Care
– Prevention of atelectasis following surgery
• Reines et al, 1982
– Undrained pleural collections
Indications for CPT
• “indications or contraindications for or against
chest physiotherapy should never be formulated
on the basis of diagnostic entities but should
rather stem from a detailed analysis of the
prevailing individual pathophysiology.”
– Oberwaldner (2000) Eur Respir J
Indications for CPT
•  and/or retention of secretions
– Impacting on lung mechanics and/or gaseous exchange
– Potential for further complications
• Acute lung/ lobar collapse due to mucus plugging
• Peroni and Boner (2000) Paediatr Respir Rev
• Decreased mobility (general/trunk)
• Potential postural deformities
• Poor exercise tolerance
“Primum non nocere”
“First do no harm”
Contraindications and
precautions
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severely ill, unstable child
coagulopathy (plt <100 with care, no Rx if plt < 50)
pulmonary haemorrhage
pulmonary oedema
raised intracranial pressure
pulmonary hypertension
very premature infants
CPT Modalities
• “…in the case of young children with
respiratory disease, we have few
effective therapies, and when [you
think] your only tool is a hammer,
everything starts to look like a nail.
• …patients have respiratory difficulties
from a variety of causes, but we have
one hammer, so we try it on
everybody.”
– Michael Schechter (2007)
Physiotherapy in the PICU
Physiotherapy
Respiratory
Rehabilitation
Prevent
deformities
Clear secretions
Muscle strengthening
PMs and stretching
Reexpand
collapsed lobes
Thoracic mobility
Splinting
Improve V/Q
matching
Movement reeducation
Positioning
Weaning
Improve ex tolerance
Developmental
stimulation
Physiotherapy
Respiratory
Rehabilitation
Prevent
deformities
Clear secretions
Muscle strengthening
PMs and stretching
Reexpand
collapsed lobes
Thoracic mobility
Splinting
Improve V/Q
matching
Movement reeducation
Positioning
Weaning
Improve ex tolerance
Developmental
stimulation
Positioning
Clear secretions
Improve V/Q
matching
• Use gravity to move secretions from
peripheral  proximal airways
• Optimise V/Q
• Positions used: supine, prone, side lying
and sitting
Reexpand
collapsed lobes
Positioning
Clear secretions
Improve V/Q
matching
Reexpand
collapsed lobes
• No head-down tilt
– Increases systemic BP with potential for IVH
• Crane et al. 1978
– Increases GOR
• Button et al. 2003
– Increases ICP
• Emery and Peabody 1983
– Diaphragm at mechanical disadvantage
• Vivian-Beresford et al. 1987
– May increase venous return thereby increasing work of heart
– The upright position increases end expiratory lung volume,
optimises oxygenation and prevents VAP
• Stark et al. 1984; Dellagrammaticas et al. 1991; Drakulovich et al
– NO EVIDENCE SUPPORTING EFFICACY!
Mobilisation
Clear secretions
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Reexpand
collapsed lobes
Improve thoracic mobility
Improve lung volumes
Assist secretion clearance
Improve exercise tolerance and
muscle strength
Increase cardiovascular fitness
Prevent postural deformities
Bone ossification
Bladder and bowel function
Psychological benefits!
Improve V/Q
matching
Weaning
Mobilisation
Clear secretions
Reexpand
collapsed lobes
Improve V/Q
matching
Weaning
Breathing exercises
Clear secretions
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Reexpand
collapsed lobes
Deep breathing exercises
Localised expansion techniques
PEP therapy
Active Cycle of Breathing Technique
Autogenic drainage
Weaning
Chest manipulations
Clear secretions
Reexpand
collapsed lobes
• Mucus liquefies on agitation (thixotropic)
• Mechanical energy transmitted through
chest wall with percussion/vibes
• Liquid secretions moved centrally by
gravity / cough / Forced Expiratory
Technique
Suctioning
Clear secretions
• Needed in patients with
artificial airway or ineffective
cough.
• Complications include
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hypoxia
arrythmia’s
mucosal trauma
pneumothorax
 ICP
bacteraemia
loss of ciliary function
atelectasis
Suctioning
Clear secretions
• Some complications can be
prevented/minimised by
– Adequate sedation and analgesia /
paralysis
– Preoxygenating
– Using correct sized catheter
– reducing suction pressures
– Limiting depth of insertion
– Correct technique
– Only suctioning when indicated
– No routine use of saline
– Humidification
• Morrow and Argent (2008) Pediatr
Crit Care Med
Case examples
Haemodynamically unstable
child with isolated RUL
collapse and hypoxia.
• Should you refer for CPT?
Case examples
Haemodynamically unstable
child with RUL collapse
• Ask – how much does RUL impact
on oxygenation?
• Answer – NOT MUCH!
• If this is the only focal problem, CPT
risks >>>> benefits
• DO NOT TREAT!
Case examples
Haemodynamically unstable child
with R lung collapse
• Ask – is the collapse causing significant
hypoxia?
• IF YES: potential benefits of CPT >> risks
• IF NO: wait until more stable before treating
• TAKE NECESSARY PRECAUTIONS
• TRIAL OF TREATMENT
Case examples
Child with raised ICP
• CPT and suction causes  ICP, MABP
and cerebral perfusion pressure
– Parsons and Shogan (1984), Heart Lung
Case examples
Child with raised ICP
Consider CPT if
• Respiratory pathology is affecting CO2 elimination
– increased PaCO2 further increases ICP.
• Severe hypoxia caused by amenable lung pathology
– anaerobic metabolism lowers pH → dilates blood vessels
→ further increases ICP.
Case examples
Child with raised ICP
Type of treatment
• Depends on ICP, other injuries, general condition.
• Ensure adequate sedation, analgesia and/or paralysis
– Painful stimuli and stress increase metabolic demands, BP
and ICP
• Monitor ICP, BP, HR
• Consider brief preintervention hyperventilation
– reflex cerebrovascular constriction
• Keep Rx to minimum
• Supine may be best position with head up.
Case examples
Infants with pulmonary hypertension
• Pulmonary Hypertensive crisis
– May cause systemic hypovolaemia due to decreased flow
• Risk of sudden cardiac arrest!
Case examples
Infants with pulmonary hypertension
• Common factors triggering a crisis include:
– Hypoxia
– Hypercarbia
– Suctioning
– Pain
– Atelectasis
– Noise
– Cold
– Agitation
Case examples
Infants with pulmonary hypertension
Consider CPT
• If large segment collapse with mucus plugging
• Retained secretions with hypoxia
If you treat
• Take appropriate precautions
• Monitor PAP throughout
• Sedation and analgesia++, paralyse if necessary
Chest Physiotherapy
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Potential benefits for specific patients
Careful clinical and radiological assessment
Determine risk:benefit for each patient
Holistic approach.
• RESEARCH NEEDED!
“In the meantime, those involved in the
management of paediatric respiratory
disorders should avoid the unnecessary
distress to both the child and family of
useless treatment and the potentially serious
consequences of inappropriate intervention”
– Wallis and Prasad (1999), Arch Dis Child
"Our success will and must be measured in the happiness and welfare of our children."
Nelson Mandela
brenda.morrow@uct.ac.za