Mobilisation of secretions in infants and children Robyn Smith Department of Physiotherapy University of Free State 2011

What exactly is chest physiotherapy (CPT) ? Chest physiotherapy is the term for a group of treatments and techniques designed to: improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions What exactly is chest physiotherapy (CPT) ?

Indications for CPT Secretion retention Decreased lung volume or ventilation Ventilation perfusion mismatching Chronic secretion production Increased work of breathing Indications for CPT

How does the application of CPT differ in children Most of the techniques used in adults can be used in children The physiological and anatomical difference of immature respiratory system need to be taken into account however in the case of child (Ammani Prasad & Main, 2008) How does the application of CPT differ in children

Aim of CPT of to improve respiratory function in the child Mobilise secretions Improve ventilation

Which techniques are used to mobilise secretions ? Postural drainage Mobilisation & physical activity Manual techniques Huffing/cough Humidification ACBT PEP Manual hyperinflations Nasopharyngeal suctioning Which techniques are used to mobilise secretions ?

Manual techniques

Childs conditions needs to be assessed to determine the appropriateness and need CPT should preferably be done before meals or at least 30 minutes after a meal to reduce the risk of vomiting and aspiration Evidence base for use of manual techniques efficacy is currently lacking. No studies to show their efficacy in clearing secretions. Considerations

Manual technique used to cause vibrations by clapping over the chest wall to loosen secretions In children there are various ways of applying this technique: Single handed percussions in small children Soft facemask Tenting Should be done over a towel to cushion the chest wall Chest percussions

Correct hand position is essential when doing percussions and must be done rhythmically Chest percussions

Percussion done on your lap in children http://www.pedilungdocs.com/education/cpt_infant.pdf Percussion done on your lap in children

Chest percussions Need to monitor how the child tolerates technique In neonates stabilise the head to reduce the risk of “shaken baby syndrome” some articles suggest that only gentle vibrations are to be done in neonates and LBW infants .....much contradiction though Duration of treatment may vary depending on the child’s tolerance and conditions: Infants 5-10 minutes per lobe Older children up to15 minutes Chest percussions

Vibrations to the chest wall are done during expiratory phase of breathing An oscillatory extra-thoracic compressive force is applied by the hands of the physiotherapist on the chest wall Difficult to apply in children with high RR Aids secretion clearance by increasing peak expiratory flow Chest Vibrations

Amount of force indicated varies age due to the changing compliance of chest wall Done on alternate breaths Used extensively in children where the chest wall is more compliant In case of paralysis e.g. SCI or GBS “assisted” cough” or “ rib springing” may be useful to aid the clearing of secretions Chest Vibrations

Precautions percussions/ vibrations Coagulopathies before transfusion (low platelet count) due to risk of causing pulmonary haemorrhaging or severe bruising Dietary deficiencies e.g. Vitamin D (Rickets) or osteopenia due to the risk of fracturing ribs Metastatic carcinoma with metastases to ribs due to the risk of fractures Over surgical incisions, burn wounds or drainage tubes due to discomfort Chest trauma with rib fractures Precautions percussions/ vibrations

Precautions percussions/vibrations Extreme care must be taken in the case of due to the risk of intracerebral bleeding premature infants Percussions may aggravate bronchospasm or induce bronchospasm in children with an hyper-reactive airway Can be poorly tolerated by some children May cause hypoxaemia and be tiring to some children Avoid vibrations in the case of ↑ICP, rib fractures and chest trauma An undrained pneumothorax Precautions percussions/vibrations

Manual hyperinflations (MHI) in the ventilated patient

Manual hyperinflations Child is disconnected from the ventilator and is given manual hyperinflations using an ambu bag. Aim of technique is to: Improve thoracic compliance Enhance secretion mobilisation by increasing the peak expiratory flow Reinflates atelectatic areas Improves gaseous exchange Assists in the clearance of secretions in sedated child limited ability to cough Manual hyperinflations

Manual hyperinflations Evidence for studies on the technique have shown: ↑ TV ↑ inspiratory time ↑inspiratory pressure ↑collateral ventilation increased release of surfactant Manual hyperinflations

Manual hyperinflations Aspects of technique noted in the evidence to be of importance: Inspiratory hold: long inspiration then a hold Fast release Intensivist physiotherapist use a sigh breath as recruitment manoeuvre Manual hyperinflations however can be extremely dangerous in children if a pressure manometer is not present and can cause barotrauma to the delicate lung tissue Ventilator hyperinflations then can be used as an alterantive Manual hyperinflations

Precautions MHI Premature infants Haemodynamic instability (hypotensive) can further compromise CVS function Children with lung hyperinflation e.g. Asthma and Bronchiolitis due to the increased risk of causing a pneumothorax Undrained pneumothorax Severe bronchospasm Precautions MHI

Physical activity & exercise

Regular physical activity is important as a means of mobilising secretions The type of activity is dependent on the child’s age Play e.g. Games e.g. ball, hoola hoop, skipping etc. Older children more traditions CVS exercise e.g. Stair climbing, walking, running Often mobilising the child is the most effective means of mobilising secretions and improve endurance and exercise tolerance Physical activity

Coughing & huffing

An effective cough is needed to expectorate secretions that have been cleared into the larger airways, Coughing often occurs spontaneously in children as secretions are mobilised Young children cannot cough on command complicating expectoration Children under the age of 5 years battle to expectorate effectively (take this into consideration when collecting sputum specimen) Coughing

In cases where the patient does not cough on command or where cough is weak cough can be “ stimulated” by gentle compression on the trachea just below the thyroid cartilage In case of simply weak cough can assist with manual pressure on the chest wall In cases where secretions are not cleared effectively the child will have to be suctioned Coughing

Risks with tracheal stimulation In children under 2 years can damage the cartilage in the trachea causing fibrosis Can stimulate a vagal response resulting in bradycardia Risks with tracheal stimulation

Huffing Huffing or forced expiratory technique from mid volume Can be successfully taught to children as young as 3 years Very effective means of secretion clearance Expends less energy than coughing Huffing

PEP

Oscillatory Positive Expiratory Pressure

Oscillatory Positive Expiratory Pressure These devices cause oscillation of the air within the airways during expiration with a variable positive end expiratory pressure Flutter is a small portable device frequently used Oscillatory Positive Expiratory Pressure

Flutter Various child appropriate flutter devices are available Can be used in children from age approximately 4 years The Mouthpiece to be placed in mouth, the child is to breathe in, slightly deeper than normal Breath hold for 3-5 seconds Child is to exhale into the flutter slightly faster than normal into the flutter Flutter

Flutter This cycle is repeated 4-8 times The oscillation of the ball in an attempt to elevate the ball to the marked level mobilises secretions Can be used preferably in sitting or semi fowlers This is followed by a deep breath and forced expectoration – mucus elimination phase Flutter

Can be combined with huffing or coughing and breathing control Flutter

Bubble PEP

What is Bubble PEP? PEP stands for Positive Expiratory Pressure. Bubble PEP is a treatment to help children who have a build up of secretions in their lungs Bubble PEP is used for any child who has difficulty clearing secretions e.g. cystic fibrosis (CF) or after surgery. The child is be encouraged to blow big bubbles through water – this is fun for them! What is Bubble PEP?

Bubble PEP: how does it work? The child is encouraged to blow down the tubing into the water, and make bubbles. This creates positive pressure back up the tubing and into the child’s airways and lungs. As the pressure holds open the child’s airways, it helps more air to move in and out of their lungs. The air flow helps to move secretions out of the lungs into the bigger airways. From here, it can be coughed up (cleared), which is the aim of treatment. Bubble PEP: how does it work?

Use a 2 liter fruit juice or milk carton Use a 2 liter fruit juice or milk carton. Fill the bottle with 1 liter of water and about 5 squirts of liquid soap, plus food colouring if you want coloured bubbles. Put the plastic tubing into the water, through the handle of the bottle. Put the bottle into a tray or bowl to catch the bubbles Bubble PEP treatment

Ask the child to take a breath in and blow out through the tubing, into the water to create bubbles. The breath out should be as long as possible. Aim to get the bubbles out of the top of the bottle each time – it may be messy but should be fun! Repeat 5 times. This is one cycle. Ask the child to huff (forced expiration technique) and cough to clear the phlegm, as taught by the physiotherapist. Encourage your child to cough the phlegm out rather than swallow it. Bubble PEP treatment

Bubble PEP treatment Repeat this cycle (steps 1 - 3). The tubing, bottle and tray should be washed out and left to dry, or dried with a disposable towel and stored in a clean place until next used. You should throw the bottle and tubing away, replacing it with clean equipment, at least once a week. Use clean water at each session Each child should have his own apparatus. Bubble PEP treatment

As with all airway clearance devices it is very important that equipment is kept clean to prevent infection. There have been no reported problems with the use of bubble PEP. Care should however be taken with children who have had neurosurgery, facial or oesophageal surgery. Be on the lookout for signs of shortness of breath, chest pain or haemoptysis. Risks of Bubble PEP

Postural Drainage

What is postural drainage? Implies the drainage of secretions by the effect of gravity from one or more lung segments to the central airways where they can be removed by cough or suctioning What is postural drainage?

Indications for postural drainage Aid in sputum clearance and to Improve respiratory functioning (ventilation) Indications for postural drainage

Timing of postural drainage Preferably before a meal/feed Or 30 minutes, but preferably an hour after a meal/feed Reduces the risk of vomiting or aspiration Timing of postural drainage

Postural drainage positions Upper lobe Apical segment sitting or semi-fowlers Posterior segment R + L (more elevated) side 1/4 turn to prone Anterior segment: supine flat Middle lobe Medial segment (R) :back ¼ to side 35 cm tip Lingula (L): back ¼ turn side 35 cm tip Lower lobe Anterior basal: supine with 46 cm tip Posterior basal: prone with 46 cm tip Lateral basal: side lying with 35 cm tip Postural drainage positions

T rendelenburg position Clear indication for use –child with excessive, tenacious secretions or a child who is battling to expectorate secretions Monitor child in position -respiration, heart rate, colour, saturation In some cases a modified postural drainage position is indicated –simply with bed flat In extremely ill and unstable children it is often not possible to make use of even modified postural drainage positions At times even a head-up position may be required T rendelenburg position

Preterm infants and Neonates (≤ 1 month) it is completely contraindicated: intercostals muscles are immature ribs run horizontally. The diaphragm does most of the work of breathing but is at a mechanical disadvantage because of its horizontal angle. Also: Due to the increased risk of cerebral bleeding Decreased SaO2 in the position Increased risk of gastro-oesophageal reflux Contra-indications

In all children monitor respiration carefully in a head down position Also evaluate how well the child tolerates the position. In such cases use a modified Pd position Monitoring child

Contra-indications Severely ill and haemodynamically unstable child Increased ICP / intracerebral bleed/ head injury Child is hypertensinsive Cardiac failure and impaired cardiac function Pulmonary bleeding or pulmonary oedema Abdominal distension History of seizures Contra-indications

Contra-indications Diaphragmatic hernia Facial oedema Pneumothorax without an ICD Respiratory distress Gastro-oesophageal reflux Oesophageal surgery Obesity Haemoptysis Contra-indications

Uncontrolled airway at risk for aspiration (tube feeding or recent meal) Contra-indications

Postural drainage positions in children – superior posterior lobe

Postural drainage positions in children – anterior lobes

Postural drainage positions in children – posterior basal lobe

Active cycle of Breathing (ACBT)

ACBT Well described means of mobilising secretions Consists of periods of breathing control (relaxed abdominal breathing), deep breathing with inspiratory holds Mid to low volume huffing and coughs ACBT

Autogenic drainage

Aims to maximise the airflow in the airways to improve ventilation and mobilise secretions. Utilises gentle breaths at different lung volumes to loosen mobilise and clear secretions Autogenic drainage

Autogenic drainage technique Consists of 3 phases of breathing: Low lung volumes to mobilise secretions from the peripheral airways (unstick phase) Tidal volume breathing with slightly prolonged expiration to collect secretions from the middle airways (collection phase) When sufficient mucus has been collected the child is asked to cough to clear (clearance phase ) Treatment takes approximately 45 minutes Used in older children Autogenic drainage technique

Hydration & Humidification

Humidification Ensure adequate fluid intake Nasal canulae unsuitable for providing adequate humidification Cold water “bubble through” does not humidify air beyond the upper respiratory tract Children receiving nasal oxygen or have tenacious secretions will require additional humidification to loosen secretions; Saline nose drops Nebulisation with saline Humidification

Nasopharyngeal suctioning

Nasopharyngeal suctioning Nasopharyngeal/ tracheal suction is a very uncomfortable procedure for an awake child and should only be considered if absolutely necessary Nasopharyngeal suctioning

The procedure should be carefully explained to the child/and parent and written consent attained

Indications for suctioning a child ? Inability to cough e.g. Neuromuscular disease, SCI, decreased LOC Secretions not cleared effectively using the other techniques Child still show signs of distress/discomfort Indications for suctioning a child ?

Risks associated with Nasopharyngeal suctioning Hypoxaemia Damage to the bronchial mucosa Bronchial perforation Vagal stimulation with bradycardia and arrythmias Larygeal spasm Inducing pathogens resulting in secondary lung infections Atelctasis Risks associated with Nasopharyngeal suctioning

Contraindications Child with a skull base fracture due to the risk of infecting the CSF Contraindications

Suggested catheter size 6 Neonate ≤ 6 months 8 1 year 10 2 years 12 6 years Suggested catheter size

Gauging the suctioning depth one can use an estimated distance, by calculating the distance from the to of the child’s nose to the ear it is approximately the same distance to the nasopharynx Need to decide on the aim of suctioning be it to stimulate cough or deeper suction Suctioning depth

Oropharyngeal suctioning If suctioning through an airway the suction depth needs to be adjusted Make use of use a suitably sized airway Be careful during oropharyngeal suctioning not to elicit a gag reflex oropharyngeal suctioning can be also used to suction secretions already coughed up into mouth Oropharyngeal suctioning

Considerations when suctioning Infants need to be retrained by rolling them in a towel restraining the arms so as to avoid them contaminating catheter Never let a parent restrain a child it is not fair call for assistance prom RN Use a side lying position, this is advantageous in case where the child might vomit to avoid aspiration Keep the head in a neutral position even slight extension Considerations when suctioning

Considerations when suctioning Infection control measures Clean technique ??? Or sterile remain debatable Use the lowest possible effective vacuum pressure The use of a lubricant e.g. KY-Jelly is also debated as has been suggested that it blocks the airway Supplemental oxygen to counteract hypoxaemia via facemask/ head box must always be available Monitor RR and SaO2 Considerations when suctioning

References Images courtesy of GOOGLE image Great Ormond Street hospital for Children NHS Trust. May 2010. http://www.gosh.nhs.uk/gosh_families/information_sheets/physiothe rapy_bubble_pep/physiotherapy_bubble_pep_families.html Golonka, D. Cystic fibrosis: Helping your child cough up mucus. Retrieved on 26 January 2010. Available at: http://health.yahoo.com/respiratory-treatment/cystic- fibrosis-helping-your-child-cough-up-mucus/healthwise-- ug1720.html AARC Clinical Practice Guideline. Postural Drainage Therapy. Respir Care 1991;36(12):1418–1426]. Retrieved on 26 January 2010.Available at: http://www.rcjournal.com/cpgs/pdtcpg.html References

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