CIS Peds Lower Resp (Lopez, Oct 27) Flashcards
3 factors in asthma
obstruction+ inflammation + autonomic imbalance
Asthma: Background
obstructive pulmonary disease w/ inflammatory component
The dynamic balance of sympathetic and parasympathetic influences in the lung is distorted in asthma
Aspects of anatomical and physiological immature in young children with asthma result in vulnerability for respiratory muscle fatigue, inefficiency of diaphragmatic mechanics, and ineffectiveness of tissue recoil
There are biomechanical, respiratory-circulatory, metabolic, and neurological influences that need to be considered in the management of asthma
Osteopathic manipulative medicine used in conjunction with standard care may improve the severity of asthma symptoms and decrease the need for pharmaceutical management
Triggers
cold/ weather changes exercise viral respiratory infections medications (ASA, NSAIDs) Allergens Pollution/ smoke Emotional stress GERD Mechanical injuries
Hypersensitivity reaction
inflammation –> edema
bronchospasm
mucous plugging
Bronchial smooth muscle is innervated by vagus nerve; vasovagal reflexes can cause bronchoconstriction; overactivity of the bronchial branches of the vagus nerve can worsen the issue
Airway obstruction
difficulty breathing wheezing nighttime cough prolonged expiratory phase air trapping
Repetitive episodes of inflammation
lead to a production of matrix proteins and growth factors that can potentially cause airway remodeling
Remodeling + increased muscle mass + mucosal edema + reduced elasticity –> decreased efficacy of bronchodilators and decreased O2:CO2 exchange
Osteopathic Management of asthmatic patient
Start or continue pharmacological management according to asthma severity and state of exacerbation
Optimize breathing mechanics (Biomechanical Model)
Normalize autonomic nervous system (Neurologic Model)
Optimize respiratory/ circulatory/ lymphatic function (Respiratory/ Circulatory Model)
Optimize lifestyle and diet (Metabolic Model)
Remove barriers to health: identify and minimize triggers, educate patient in proper usage of medications, help patient obtain medications, etc. (Behavioral Model)
Asthma: Initiating Therapy
Intermittent asthma - step 1 (short acting beta-2 agonist)
Mild persistent asthma - step 2 (low-dose inhaled corticosteroid)
Moderate persistent asthma - step 3 (medium-dose inhaled corticosteroids option) and consider short course of oral corticosteroids
Severe persistent asthma - step 3 (medium-dose inhaled corticosteroids option) or 4 and consider short course of oral corticosteroids
Evaluate level of asthma control in 2-6 weeks and adjust therapy accordingly
Asthma: Treatment During Exacerbation
Increasing frequency of short-acting beta-2 agonists
Possibly start oral steroids
Consider starting inhaled steroids
Give oxygen to maintain O2 sat >90-92%
Ipratropium in ED patients refractory to initial short-acting beta-2 agonist
Magnesium sulfate may be considered to avoid intubation
Intubation for impending respiratory failure, apnea, or coma
Biomechanical Model:Effects of Airway Obstruction
A child with an obstructive airway suffers from:
Increased effort to maintain normal air movement through bronchioles
Decreased mechanical effectiveness of diaphragm and rib cage
- Children have a flatter diaphragm than adults
- Rib cage is more flexible than adults
Increased O2 demand and waste production
- Alters pH
Increased work of breathing
Biomechanical Model: Treatment Goals
OMT: to decrease work of breathing by facilitating mechanics
- Facilitate normal motion of thoracic cage and pelvic diaphragm
- Remove fascial, bony and ligamentous restrictions
- Decrease muscle hypertonicity of primary and accessory muscles of respiration
Breathing exercises that strengthen peripheral and accessory muscles that aid breathing and facilitate exhalation
Yoga, tai chi, noncontact martial arts that integrate breathing with movement
The Thoracic Diaphragm:
Primary muscle of respiration
Alters arterial and venous circulation
– Fluid movement through vena cava dependent on effective diaphragmatic excursion
Alters lymphatic circulation
Moves extracellular fluid in abdomen into lymph system
– Removal of cellular waste
Respiratory-Circulatory Model
Respiration is a constant and powerful modulator of cardiovascular control
During breathing, the diaphragm reduces negative intrathoraic pressure through inhalation, enhancing venous drainage
Lymphatic flow depends on rhythmicity and stretching of diaphragm, then on intraperitoneal pressure and posture of the individual
Cisterna chyli, located under diaphragmatic crural region, main destination point for lymph
goals of Respiratory-Circulatory Model
Restore optimal motion at the diaphragm and pelvic diaphragm
Remove restrictions to lymphatic, arterial, and venous systems
– Including Thoracic Outlet Release
Neurologic Model and asthma
Asthmatics suffer from an imbalance of the autonomic nervous system
Smooth muscles are innervated by sympathetic, parasympathetic, and primary afferent fibers
Vagus nerve –> Jugular foramen –> Cervicals –> Thoracic inlet –> Lungs
Sympathetics to lungs: T1-6
– Viscerosomatic reflexes/ Facilitated segments
Somatic dysfunction may lead to/ be a result of imbalance of the neuroendocrine immune system resulting in more inflammation
neurologic model treatment
Bronchodilators, corticosteroids, anticholenergics:
- Influence neuronal control and inflammatory mechanisms
- Leukotriene inhibitors and mast cell stabilizers – to control allergy symptoms
OMT can help reduce necessary dosage of medication required to control symptoms
- Rib raising to stimulate sympathetic chain ganglion and alter symphathetic flow to visceral organs
- Suboccipital release to influence parasympathetics
Behavioral Model
physical, spiritual, mental, emotional, socioeconomic
Metabolic Energy
Structure Function
Encourage: Fresh, whole food diet Vitamin C with bioflavonoids and B vitamins Shown benefit: IV Mag Breastfeeding Probiotics
Avoid:
Processed, devitalized food
Food coloring, sulfites, preservatives, food modifiers
Asthmatic children may benefit from avoiding: dairy and processed flour, sugar, & corn syrup sweeteners
Goals of OMT in pediatric asthma
Optimize dynamic balance between parasympathetic and sympathetic input to the pulmonary system
Remove mechanical restrictions that adversely affect respiratory mechanics
Decrease the workload of breathing
Facilitate the child’s ability to function normally
Education + Allergen prevention/Reduce Triggers + Medication + Diet + OMT
Visceral Layer of Fascia
is a continuous “tube” throughout the body
Forms the packing surrounding the body cavities and visceral organs
Conduit for neurovascular and lymphatic bundles
In the neck, the Pretracheal (Visceral) layer contains trachea, esophagus, thyroid, infrahyoid muscles
Extends into thorax as endothoracic fascia, accommodates pleural cavities, surrounds great vessels of the heart, thickens anteriorly (pericardium), posteriorly is loose surrounding aorta, esophagus, trachea, primary bronchi, thoracic duct
Extends into abdomen to become endoabdominal fascia posteriorly and transversalis fascia anteriorly
Extends into pelvis as endopelvic fascia, where inferior border is pelvic diaphragm
The Prevertebral layer of fascia
is also continuous throughout the body
Longus and scalenes muscles in the neck
Intercostals muscles in thorax
Oblique and rectus muscles in abdomen
The fascial layers can be envisioned as existing in a series of concentric tubes.
Thoracic Cage Release with Respiratory Assist
With pediatrics patients, the physician must be able to meet the patient where she/he is: lying down/ seated/ on the move
At least two options for contact:
- Bilateral rib cage
- One side at a time with thumbs in midaxillary line
Gently encourage motion in inhalation and exhalation (in bucket and pump handle) with the patient’s breath. You may move more slowly if they are breathing fast.
Continue until motion is freer in both inhalation and exhalation
Repeat by moving your contact to upper or lower ribs as needed
Reassess
Diaphragm & Pelvic Diaphragm
Works synchronously with the abdominal diaphragm
During normal respiration, or during coughing, a symmetric change in the pelvic floor can be observed
During inspiration, both diaphragms descend
- Studies show electrical activity can be observed before inhalation in the pelvic floor, transverse & obliquus internus abdominis muscles
Ensures steadiness of the human trunk and maintaining urinary continence during respiration and coughing
Balanced Ligamentous Tension (BLT)/ Balanced Membranous Tension (BMT)
Balanced membranous/ligamentous tension is a treatment principle which an area of strain is brought to a point of balanced tension to engage and utilize the inherent forces within the patient’s body to make the correction
- Inherent forces: “reset” nervous system, reduce firing of joint receptors and nociceptors, expression of inherent motion (respiration, pulse, PRM)
- Direct (into restrictive barrier) or Indirect (exaggeration)
