Mobilisation of secretions in infants and children

Robyn SmithDepartment of Physiotherapy

University of Free State2011

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

Indications for CPT

Secretion retention Decreased lung volume or ventilationVentilation perfusion mismatchingChronic secretion productionIncreased work of breathing

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)

Mobilise secretions

Improve ventilation

Aim of CPT of to improve respiratory function in the child

Which techniques are used to mobilise secretions ?

Postural drainageMobilisation & physical activityManual techniquesHuffing/coughHumidificationACBTPEPManual hyperinflationsNasopharyngeal suctioning

Manual techniques

Considerations

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.

Chest percussions

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 childrenSoft 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

Percussion done on your lap in children

http://www.pedilungdocs.com/education/cpt_infant.pdf

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 lobeOlder children up to15 minutes

Chest Vibrations

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

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

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

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 complianceEnhance secretion mobilisation by increasing the peak

expiratory flowReinflates atelectatic areasImproves gaseous exchangeAssists in the clearance of secretions in sedated child limited

ability to cough

Manual hyperinflations

Evidence for studies on the technique have shown:

↑ TV ↑ inspiratory time↑inspiratory pressure↑collateral ventilation increased release of surfactant

Manual hyperinflations

Aspects of technique noted in the evidence to be of importance:

Inspiratory hold: long inspiration then a holdFast releaseIntensivist 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

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

Physical activity & exercise

Physical activity

Regular physical activity is important as a means of mobilising secretions

The type of activity is dependent on the child’s agePlay 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

Coughing & huffing

Coughing

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

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

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

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

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

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

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!

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 treatment

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

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 sessionEach child should have his own apparatus.

Risks of Bubble PEP

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.

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

Indications for postural drainage

Aid in sputum clearance and to

Improve respiratory functioning (ventilation)

Timing of postural drainage

Preferably before a meal/feedOr 30 minutes, but preferably an hour

after a meal/feed

Reduces the risk of vomiting or aspiration

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

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

Contra-indications

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

Monitoring child

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

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

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)

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

Autogenic drainage

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 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

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

Nasopharyngeal suctioning

Nasopharyngeal suctioning

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

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

Risks associated with Nasopharyngeal suctioning

HypoxaemiaDamage to the bronchial mucosaBronchial perforationVagal stimulation with bradycardia and

arrythmiasLarygeal spasmInducing pathogens resulting in secondary

lung infectionsAtelctasis

Contraindications

Child with a skull base fracture

due to the risk of infecting the CSF

Suggested catheter size6

•Neonate

•≤ 6 months

8 •1 year

10 •2 years

12 •6 years

Suctioning depth

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

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

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

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

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/physiotherapy_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

Hough, A. 2001. Physiotherapy for children and infants. In Physiotherapy in Respiratory care. An evidence based approach to respiratory and cardiac management. 3rd edition. Nelson Thornes. London pp435

Parker, A. 1992. Paediatric and Neonatal Intensive therapy. In Cash’s Textbook of chest, Heart and Vascular Disorders for Physiotherapists. Downie, P.A. (ed). 4th edition. Mosby . London. P316

  Cystic Fibrosis Foundation.2005. Consumer Fact shhet: An introduction

to postural drainage and percussion. Maryland, USA

Hardy, L. 2007. Cardiorespiratory physiotherapy for the acutely ill, non-ventilated child. In Physiotherapy for Children. Poutney, T (Ed). Butterworth Heinemann Elsevier pp 285-290

Anderson, JM & Innocenti, DM. 1992. Techniques used in physiotherapy. In Cash’s Textbook of chest, vascular disorders for Physiotherapists. Downie PA (ed). 4th ed. Pp 325-354

References

Ammani Prasad, S & Main, E. 2008. Respiratory disease in childhood. In Physiotherapy for respiratory and cardiac problems .Adults and children. Pryor, JA & Ammani Prasad, S (eds).4 ed. Churchill Livingstone Elsevier pp 337-343

Pryor, JA & Ammani Prasad, S. 2008. Physiotherapy techniques. In Physiotherapy for respiratory and cardiac problems .Adults and children. Pryor, JA & Ammani Prasad, S (eds).4 ed. Churchill Livingstone Elsevier pp136-176

Hough , A. 2001. 2001. Physiotherapy to clear secretions. In Physiotherapy in Respiratory care. An evidence based approach to respiratory and cardiac management. 3rd edition. Nelson Thornes. London pp184- 210