Respiratory diseases in Childhood

1. Respiratory diseases in Childhood Robyn Smith Department of Physiotherapy UFS 2011

2. Bronchiolitis

3. 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

4. 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

5. Bronchiolitis Increased risk • Prematurity • Immuno-compromised children e.g. HIV infected infants • Chronic lung and heart diseases

6. Bronchiolitis Clinical signs and symptoms • Initially looks like a common cold • Develops a dry cough and difficulty feeding • Wheezing • Respiratory distress

7. 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

8. Croup/laryngotracheobronchietis

9. 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

10. Asthma

11. Asthma

12. 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

13. 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

14. 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

15. 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

16. 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 • Have an oxygenation and not a ventilation problem (thickening of the respiratory membrane with impaired gaseous exchange) • Minimal white frothy secretions and unproductive cough

17. Pnemocystis jiroveci (PCP) 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

18. 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

19. Foreign body aspiration • CPT is only indicated post bronchioscopic removal of the foreign body. • Usually to treat underlying collapse or atelectasis

20. 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 andimmunodeficiency (HIV) • Child has a productive cough with excessive, purulent secretions

21. 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

22. 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

23. Cystic Fibrosis • 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

24. 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

25. 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

26. A lot of patients we see in the PICU have trauma related injuries. Common trauma related injuries include: Pedestrian or motor vehicle accidents Falls from a height Gunshot wounds Knife wounds Assault and physical abuse cases Trauma related injuries

27. Trauma Pneumothorax • 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

28. Trauma Lung contusion • No active CPT if there is still active bleeding • CPT helps in improving lung expansion

29. 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

30. 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