“A STUDY TO ASSESS THE KNOWLEDGE AND PRACTICE OF CHEST PHYSIOTHERAPY ON CHILDREN SUFFERING WITH RESPIRATORY SYNDROME AMONG NURSES WORKING IN PAEDIATRIC WARDS OF SELECTED HOSPITALS OF TUMKUR CITY, KARNATAKA WITH A VIEW TO DEVELOP SELF INSTRUCTION MODULE.”
PROFORMA FOR REGISTRAION OF SUBJECT
FOR DISSERTATION
Mr. HEMANTH H.S
CHILD HEALTH NURSING
ARUNA COLLEGE OF NURSING
RING ROAD, MARALUR,
TUMKUR - 572 105
2012 – 2013
6. BRIEF RESUME OF THE INTENDED WORK
6.1.1 INTRODUCTION
The respiratory infections like pneumonia, bronchiolitis, bronchiectasis and conditions like Atelectasis, cystic fibrosis and Asthma can be treated with pharmacological and non pharmacological interventions which had shown good prognosis. The chest physiotherapy indicated for pneumonia, post-operatively in older children, chronic lung diseases, lower respiratory tract infections, bronchitis and bronchiectasis, atelectasis, cystic fibrosis, chronic obstructive pulmonary diseases etc.4
Chest physiotherapy consists of various manipulative procedures like positioning, chest percussion, vibration, thoracic squeezing and cough stimulation. Breathing exercise is an integral part of chest physiotherapy. It plays a significant role in airway clearance and parenchyma expansion by improving the efficiency of respiratory muscles. 2
Chest physiotherapy is essential in the airway clearance of acute and chronic respiratory disorders with retained airway secretions. This definitely helps to improve and maintain the well being of the patients within the limitations imposed by the impaired lung function. Regular CPT plays a significant role in reducing the morbidity in children with chronic lung diseases like cystic fibrosis.5
CPT is a time proven, widely accepted method for airway clearance. It generally requires a minimal amount of effort on the part of the patient, but is much more effective when coughing and deep breathing accompany it. CPT does not require the purchase of specialized equipment. If a tilt table is not available, CPT can be performed on a bed or sofa with the use of pillows or wedges. CPT also promotes a special time together for the caregiver and the patient. 4
The goal is to motivate the nurses so that they will update their knowledge on procedure of chest physiotherapy and practice it effectively.
Chest percussion
It is the striking of the chest wall over the area being drained.The hand position is such that the fingers and thumb touch and the hand is cupped. When the surface of the chest wall is percussed,waves of varying amplitude and frequency are sent through the chest wall. The force of these waves helps to dislodge the sputum, as well as change the consistency of sputum. Percussion must be done directly over the affected area. 3
Vibration
It is a fine, shaking pressure applied to the chest wall,only during exhalation. This procedure may increase the velocity and turbulence of exhaled air and facilitate removal of secretion. Vibration increases the exhalation of trapped air and may shake mucous loose and induce a cough.
6.1.2 NEED FOR THE STUDY
Today increasing emphasis is placed on health, health promotion and wellness. Paediatrics therefore concerned with the health of infants, children and adolescents. The high proportion of the total morbidity and mortality in developing countries, such as India, is still accounted by the paediatric age group.1
The below shown figure gives an idea about the disease pattern in patients admitted to our paediatric indoors. An appraisal of figure makes it clear that the scene is dominated by gross malnutrition, serious systemic infections (Primarily tuberculosis, Pneumonias, measles, Whooping cough) and diarrhoeal diseases.2
Fig. 1: Relative frequency of diseases responsible for admission of infants and children in Indian hospitals.
The principle causes of infant mortality in India are low birth weight, respiratory infections, diarrhoeal diseases, congenital malformations and cord infections. Many of us have the general misconception that respiratory disorders and chronic pulmonary diseases are mainly adult problems. Nonetheless, statistics show that respiratory diseases in infants and children are major problems that accounts for a large share of childhood mortality and morbidity.3 Acute respiratory infections (ARIs) are responsible for 20-40% of OPD attendance, 12 to 45% of admissions and 33% of mortality in the developing world, directly or indirectly. Over 15 to 20% of preschool mortality is related to ARI.2
Young children fall an easy prey to infectious diseases. The leading childhood diseases are diarrhoea, respiratory diseases, measles, pertusis, polio, T.B, and diphtheria etc. The statistics show that respiratory diseases in infants and children is a major problem that accounts for a large share of childhood mortality and morbidity.3 .
Infections of the respiratory tract are perhaps the most common ailment in children. Every year acute respiratory tract infections (ARI) are responsible for an estimated 4.1 million deaths worldwide. It is estimated that Bangladesh, India, Indonesia, and Nepal together account for 40% of the global ARI mortality. About 90% of the ARI are due to pneumonia. On an average, children below 5 years of age suffer about 5 episodes of ARI are responsible for about 30%to 50% of visits to health facilities and for about 20-40% of admissions to hospitals. 1
In India, the states and districts with high infant and child mortality rates, ARI is one of the major causes of death. Hospital records from states with high infant mortality rates show that up to 13% of in patient death in pediatric wards are due to ARI. 1
The appropriate treatment for respiratory diseases in time, generally showed good prognosis with pharmacological therapy and non – pharmacological interventions like Chest physiotherapy and Oxygenation improve airway clearance there by improving ventilation and breathing in respiratory conditions. 5
Chest physiotherapy (CPT) is an airway clearance technique that combines manual percussion of the chest wall by the care- giver, strategic positioning of the patient for mucus drainage with cough and breathing techniques.5
Chest physiotherapy (CPT) is the term for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.6
The central function of chest physiotherapy in pediatric respiratory diseases is to assist in the removal of tracheobronchial secretions. The intention is to remove airway obstruction, reduce airway resistance, enhance gas exchange, and improve the breathing. In an acute situation, recovery should be hastened but in child with a chronic respiratory disorder, the progression of the lung disease should be hopefully delayed. Chest physiotherapy can improve a patient’s respiratory status and expedite recovery.7
The literature highlights the enormous benefits of chest physiotherapy in patient care and that it is an integral aspect of the nursing care of those who are suffering with respiratory conditions and risk for developing respiratory complications. A vast range of techniques now exist which are regarded under the heading of chest physiotherapy. The techniques include clapping or cupping (cupped hand percussion), positioning, shaking and vibrations, cough and breathing techniques and suctioning.8
It is reported that incentive spirometry and deep breathing exercises are more effective in reducing pulmonary complications.9 Another study recently reported that chest physiotherapy including positioning, chest wall regulation and suctioning; reduced the incidence of ventilator associated pneumonia in more sick infants.10
Finer and associates reported that, a significant decrease in the incidence of post-extubation atelectasis in infants who were treated with bronchial drainage, vibration and oral suctioning when compared with the similar control group.3
A study concluded that chest physical therapy appears to be beneficial for patients who were acutely and chronically ill and have large volumes of pulmonary secretions. Usually children with respiratory conditions face many complications unless the chest physiotherapy performed effectively. Chest physiotherapy reduces associated complications and enhances quality care of children with respiratory conditions. Having many benefits attached to chest physiotherapy in children with respiratory conditions and to prevent associated complications; the investigator observed that there is necessity to assess knowledge and practices of nurses who are working in pediatric units of Selected Hospitals at Tumkur.
6.2 REVIEW OF LITERATURE
A prospective controlled systematic allocation trial design study was conducted on whether chest physiotherapy designed to enhance sputum clearance decreases the occurrence of ventilator-associated pneumonia (VAP). Study was conducted in Tertiary teaching hospital ICU. The result shown that VAP occurred in 39% (14/36) of the control group and 8% (2/24) of the intervention group (OR=0.14, 95% CI 0.03 to 0.56, P=0.02). In this small trial, chest physiotherapy in ventilated patients was independently associated with a reduction in VAP.12
A randomized control trial study was conducted on the effects of chest physiotherapy in patients with acute lung injury being ventilated mechanically. Patients were randomized into one of three treatment groups: Group 1 (suctioned only); Group 2(positioned and suctioned); and Group 3 (positioned, manually hyper inflated and suctioned). Baseline and 10, 30 and 60 minutes' post-treatment data were recorded for dynamic pulmonary compliance, arterial blood gases and haemo-dynamic variables. Results revealed that, eighteen patients fitted the inclusion criteria. Significant changes were observed in both PaCO2 (p = 0.026) and dynamic compliance (p = 0.019) over time for all three groups. Study concludes that, Patients with acute lung injury are notably complex to nurse and may require protracted physiotherapy intervention. 13
A study was conducted on ChestPhysiotherapyin Cystic Fibrosis: Improved Tolerance with Nasal Pressure Support Ventilation. Sixteen CF patients in stable condition with a mean age of 13±4years participated in the study. For CPT, investigator used the forcedexpiratory technique (FET), which consisted of one or more slowactive expirations starting near the total lung capacity (TLC)and ending near the residual volume. During the study, each patient receivedtwo CPT sessions in random order on two different days, at thesame time of day, with the same physiotherapist. The results shown that mean lung function parameters were comparable before the PSV and the control sessions. Baseline pulse oxyimetry (SpO2) wassignificantly correlated with the baseline vital capacity (%predicted)and forced expiratory volume in 1second (FEV1, %predicted).PSV was associated with an increase in tidal volume (Vt) from0.42±0.01liters to 1.0±0.02liters. Study revealed that PSV performed with a nasal mask during the CPT was associated with an improvement inrespiratorymuscle performance and with a reduction in oxygen desaturation.The improvement in patient comfort may help to improve compliancewith CPT in CF patients. Respiratory muscles, lung function,children, cystic fibrosis, oxygenation, inspiratory assistanceby positive airway pressure, mucus. 14
A study was conducted on Chest physiotherapy in the form of airway clearance techniques and exercise has played an important role in the treatment of cystic fibrosis. The primary airway clearance technique used was postural drainage combined with percussion and vibration (PD&P). These techniques include the Active cycle of breathing technique, formally called the Forced expiration technique and Autogenic drainage. Both these breathing techniques aim at using expiratory airflow to mobilize secretions up the airways and incorporate breathing strategies to assist in the homogeneity of ventilation. Results of the study suggested that exercise used in addition to an airway clearance technique there is enhanced secretion removal and an overall benefit to the patient.15
Airway clearance techniques are an important part of the respiratory management in children with cystic fibrosis, bronchiectasis and neuromuscular disease. They are also, however, frequently prescribed in previously healthy children with an acute respiratory problem with the aim to speed up recovery. The current review explores the evidence behind this use of airway clearance techniques in children without underlying disease. Few studies have been performed; many different techniques are available and the therapies used are often poorly specified. It is necessary to name the specific airway clearance technique used in treatment rather than to just state "chest physiotherapy," a term that is often confused with chest clapping or vibration plus postural drainage. There is little evidence that airway clearance techniques play a role in the management of children with an acute respiratory problem. 16
A randomized controlled trial was conducted on chest physical therapy for children hospitalized with acute pneumonia in two tertiary hospitals in southern Brazil. Children aged 29 days to 12 years hospitalised with pneumonia between February and October 2006 were recruited; 51 were randomly allocated to the intervention group (chest physical therapy plus standard treatment for pneumonia) and 47 to the control group (standard treatment for pneumonia alone). The primary outcome was time to clinical resolution. The secondary outcomes were length of stay in hospital and duration of respiratory symptoms and signs. The study results revealed that there were no significant differences in terms of median time to clinical resolution (4.0 vs 4.0 days, p = 0.84) and median length of hospital stay (6.0 vs 6.0 days, p = 0.76) between the intervention and control groups. The intervention group had a longer median duration of coughing (5.0 vs 4.0 days, p = 0.04) and of rhonchi on lung auscultation (2.0 vs 0.5 days, p = 0.03) than the control group. Study concluded that Chest physical therapy as an adjunct to standard treatment does not hasten clinical resolution of children hospitalised with acute pneumonia and may prolong duration of coughing and rhonchi. 17
A study was conducted to investigate whether a hospital-supervised program of chest physical therapy improves lung function in children with chronic pulmonary diseases, twenty-four children (4 with Kartageners syndrome, 12 with common variable immunodeficiency, and 8 with primary ciliary dyskinesia) average age 11.2 +/- 3.2 years, were randomly assigned to a one-month hospital-supervised program of chest physical therapy (13 patients) or to a control group (11 patients) that continued unsupervised chest physical therapy at home. Lung function was assessed before the program, and one and 12 months after. At the one-month assessment, thoracic gas volume was significantly lower in the supervised group than in the controls. At the one-year assessment, forced expiratory volume in one second was significantly higher in the supervised group than in controls. A supervised program of chest physical therapy significantly improved lung function in children with chronic pulmonary diseases. 18
Chest physiotherapy in the management of obstructive lung diseases in children Physiotherapists play a key role in the management of obstructive lung diseases in children. Obstructive lung diseases most frequently found are bronchiolitis, asthma and cystic fibrosis. The major objective of the physiotherapists, using various chest physiotherapy methods is the deobstruction of upper and lower airway. Aerosol therapy is frequently prescribed and contributes to reach this aim. However educative action towards the patient and parents are also important in some situation. 19
A study was conducted to evaluate the effectiveness of chest physiotherapy in ventilated children with acute bronchiolitis. The main goal of this study was to evaluate its short-term efficacy in children under mechanical ventilation for acute bronchiolitis. Twenty children were studied. All were under mechanical ventilation on a pressure-controlled mode. The results revealed after performing thirty-eight analyses where baseline tidal volume, oxygen saturation and transcutaneous PCO2 were not modified after endotracheal suction. Immediately and 1 hour after CP, SpO2 (98% vs. 94.5%), and tidal volume (66 vs. 55 ml) significantly increased. The study concluded that the increase of O2 saturation and tidal volume may be linked to the improvement of bronchial sputum clearance. Further studies are needed to estimate the long-term efficacy of CP in acute bronchiolitis. 20
Clinicians who care for cystic fibrosis (CF) patients have many techniques to choose from to facilitate mucus clearance. It is very important to teach adherence to therapy at an early age. Adherence to an airway clearing regimen assists in maintaining good pulmonary function in CF patients. Knowing when and how to introduce airway clearance techniques beyond chest physiotherapy (CPT) is clinically relevant and useful. A 5-position modified CPT routine can be used with infants and children, and it takes less time and may improve adherence. Infants and toddlers can be taught breathing games that eventually lead them to perform diaphragmatic breathing and huffing. Once they have mastered diaphragmatic breathing and huffing, children can be taught the active cycle of breathing technique. Modified CPT can be phased out at that point. 21
The effect of chest physiotherapy in the treatment of pediatric pulmonary disorders was evaluated for one year by means of a specially devised progress chart. A high percentage of atelectases was successfully reopened. The right upper lobe was most frequently involved, followed by the left upper, right lower and left lower lobe. The incidence of postextubation atelectasis in neonates with hyaline membrane disease was significantly lower when chest physiotherapy was commenced before extubation. The value of chest physiotherapy in chronic respiratory disorders remains uncertain, whereas it does constitute an essential part of therapy in acute conditions. 22
An article on chest physiotherapy in pediatric practice is generally considered as a separate and specialized treatment modality that should be rendered only by a physiotherapist. Actually this is not difficult if one has a proper understanding of the basic concept and principle behind the maneuver. This article aims at making CPT simple, so that it could be incorporated in routine pediatric practice for managing respiratory ailments. 23
Chest physiotherapy in the form of airway clearance techniques and exercise has played an important role in the treatment of cystic fibrosis. It was introduced into the treatment of CF with little evidence to support its efficacy and once established, it has been difficult ethically to perform a study comparing PD&P to no treatment. A common question, yet unanswered is when should it be commenced, especially for the newly diagnosed asymptomatic CF patient? Recently, the technique of PD&P has been modified to include only non-dependant head-down positioning due to the detrimental effects of placing a person in a Trendelenburg position. When exercise is used in addition to an airway clearance technique there is enhanced secretion removal and an overall benefit to the patient. Further research needs to be directed at assessing the effects of an airway clearance technique on the individual patient using appropriate outcome measures. 24