Week 2 Flashcards
Neuromuscular disorders with respiratory involvement
- Duchene muscular dystrophy
- Becker muscular dystrophy
- Spinal muscular atrophy
- Congenital muscular dystrophy
- Myotonic dystrophy
- Limb girdle dystrophy
- Motor neurone disease
- Amyotrophic lateral sclerosis
- Postpolio syndrome
Respiratory muscle weakness
- Expiatory > inspiratory = normal populations
- Expiratory muscles significantly weaker than inspiratory muscles in SMA Type II
➢Susceptibility to infection
➢Reduced ability to cough and clear secretions
➢Difficulty in taking deep breaths to keep lungs inflated
➢Breathing fatigue and underventilation
Ineffective cough
- Most NMD patients have normal mucociliary clearance at baseline
- Without an effective cough, secretion mobilisation will not result in secretion clearance
- Cough requires adequate airway flow (360-1200L/min)
- To optimise cough - precede cough by deep insufflation
Respiratory issues in paediatrics
Respiratory muscle weakness
Weak cough
Immobility
Reduced tidal volumes
Chest wall deformity
Paradoxical breathing patterns
Respiratory failure
Goals of chest physio in paediatrics
- Promotion of the development, restoration and maintenance of optimal respiratory function
- Prevention of further respiratory disorder
- Enhance of the patients QOL
Breath stacking
- Increase volume of air in thorax by stacking consecutive breaths on
inspiration until maximum insufflation capacity (MIC) is reached - Takes maximum inspiration
- Inspire in coordination with lung volume recruitment bag
- Hold breath (glottis closure)
- Repeat until MIC achieved
- Improves tidal volumes, MIC, CPF, secretion mobilisation
- Maintains/improves lung compliance and elastic recoil
- Prevents atelectasis
NIV
- Used with ACBT
- Early non-invasive positive pressure ventilation
- increases survival compared to late NIPPV
- increases QOL (Miller et al 2009).
- Non-invasive ventilation (NIV) provides relief from symptoms such as fatigue, breathlessness and disturbed sleep patterns, but does not prevent progressive weakening of the respiratory muscles
IPPB
- IPPB-assisted hyperinsufflation improves CPF in paediatric neuromuscular disorders.
- Can be used to improve clearance of airway secretions and therefore reduce respiratory morbidity in children with NMD
Cough assist
- Mechanical insufflator/exsufflator
- Portable electrical powered device
- Uses positive pressure to deliver maximal lung inhalation
- Rapid change to negative pressure in airway to assist cough
Benefits:
- Improve CPF (Anderson et al 2005, Physical Therapy)
- Shortens airway clearance treatment times
- Maintains vital capacity, lung compliance and chest wall ROM
- Prevention of chest infection
- Reduction in hospitalisations and morbidity/mortality
Treatment:
- Use sets of 3-5 cough cycles
- Incorporate with ACBT +/- manual techniques (3 insp breaths before insp/exp cough assist, recovery breaths with CA or NIV)
- Always end treatment with insufflation
Contraindications:
- Emphysematous bullae
- Undrained pneumothorax
- Recent barotrauma
- Impaired consciousness/inability to communicate
Peripheral ACTs
Sputum mobilising
- Manual techniques
- HFCWO (high frequency chest wall oscillation)
- HFCWC (high frequency chest wall compressions)
- IPV
- Chest wall strapping
Importance of early rehab in PICU
- Prevent ICU acquired weakness secondary to prolonged bed rest and critical illness
- Accelerate physical/functional recovery
- ↓ cognitive/psychiatric implications
- ↑ QoL
- ↓ burden on family
- ↓ cost
- ↑ survival rates
Considerations and precautions in PICU
- Understand the child’s cardio-respiratory status
- Assess readiness for input
- Continual assessment of the effect of intervention
- Prepare and ensure safety
- Breathing support/ adjuncts to PT e.g. NIV, increase O2
- Airway clearance
- Weaning
- Feeding
- Attachments
- Monitor for acute illness
- Cease/ modify intervention based on child’s reaction to input
Strategies in PICU
- Age appropriate and enjoyable
- Short sessions
- Frequent rests: Low stimulation when resting
- Consider the environment: Restricted to a bed vs able to get
out on floor/ walk - Family-centred/ supportive focus: HEP/ photo programs, signs of increased WOB
- Time your input: Other medical procedures, sleep,
weaning, feeds, consistent, regular times to assist
with routine (time tables) - Positions: Assist breathing not hamper it, more supportive initially and progress as child improves
- Level of input: begin slowly – e.g. positioning and nesting when more acutely unwell, progress to floor play sessions when
medically stable - When to start input is different for every child
