Respiratory diseases in Childhood
Robyn Smith
Department of Physiotherapy
UFS
2011
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
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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 drainage
Manual techniques e.g. percussions,
vibration, shaking
Breathing exercises
Inhalation 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
failure
failure requiring ventilation
• Often do poorly despite maximal
ventilation
• Unstable
• Subsequently many of them
develop ARDS
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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)
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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
including
Postural drainage
forced expiratory techniques
Inhalation 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
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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 exercises
Manual CPT techniques for
areas collapse
postural drainage if associated
bronchiectasis
mobilization
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:
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Pedestrian or motor vehicle accidents
Falls from a height
Gunshot wounds
Knife wounds
Assault and physical
abuse cases
Trauma
Pneumothorax
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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
Trauma
Rib 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