Respiratory Diseases
in Infancy and Childhood
Respiratory diseases in infancy and childhood are very common, comprising about one-half of all illnesses in children less than 5 years of age and about one-third of illnesses in primary-school children. Most of these illnesses are mild, but about 5% are more serious, involving the lower respiratory tract. The highest morbidity and mortality from lower respiratory tract diseases occurs in the first year of life.
Obstructive Diseases of the lower airway:
- Asthma.
- Bronchiolitis.
- Bronchiolectasis.
- Cystic fibrosis.
Pulmonary complications:
- Lobar atelectasis.
- Bronchiactasis.
- Pneumothorax.
- Hemoptysis.
- Pulmonary hypertension.
- Corpulmonale.
Physical Therapy
a) Assessment
Aims:
- To provide the therapist with additional information on the physical and functional status of the pulmonary patient.
- To develop an individualized treatment plan for the patient.
- To establish baseline information on the patient in order to measure his progress and the effectiveness of treatment.
- To determine when to discontinue the treatment.
- To plan and implement a home program.
Methods:
(1) Patient’s file:
- Diagnosis:
- Frequency of treatment:
a) History:
- Personal history: Name, age, sex, occupation and address.
- Past history: Previous illnesses.
- Present history: Clinical course of the current illness (signs and symptoms).
- Family history: Similar conditions in the family.
- Medical history: Previous treatments.
- Chest X-rays.
b) Vital signs:
The normal values for vital signs are represented in the following tables:
* Respiratory rate:
Age/year /Breaths/minute
0 / 40:601:3 / 20:30
3:6 / 20:30
>6 / 15:20
Adult / 15
* Heart rate:
Age/year / Beats/minute0 / 125
1:3 / 130
3:8 / 105
8:12 / 85
* Blood pressure:
Age/year / mmHg0:2 / 80/50 : 90/60
3:5 / 90/60
> 5 / 90/60 : 110/80
(2) Inspection:
a) General observation:
* Level of consciousness.
* Clubbing of fingers.
* Jugular vein engorgement.
* Hypertrophy of accessory muscles of respiration.
* Skeletal abnormalities.
* Use of special equipment.
* Head and neck.
* Color and condition of the skin.
* Evaluation of head and neck:
There are two common signs of respiratory distress in the infant or young child:
- Nasal flaring: It is a universal sign of respiratory distress in the neonate in order to widen the airways to reduce the resistance to airflow, because he is an obligate nose-breather.
- Head bobbing: It is an attempt to increase the ventilation by using the accessory muscles of respiration.
* Evaluation of skin color:
Shortly after birth, normal neonates have pink skin, mucous membranes and nail beds. Abnormal skin coloration includes:
- Cyanosis: Bluish coloration of the skin, mucous membranes and nail beds, being secondary to some cardiopulmonary disorders.
- Pallor: A general sign of respiratory distress and asphyxia.
* Audible sounds of respiration:
- Expiratory grunting: It does not have a clearly defined mechanism, thought to be an attempt to improve ventilation.
- Stridor: It is an inspiratory crowing sound, commonly associated with obstruction of the extra thoracic portion of the trachea.
b) Specific evaluation:
* Evaluation of unmoving chest:
- Shape and symmetry of the thorax.
- Musculo-skeletal deformities.
- Rashes, scars, incisions and bruises.
- Thoracic diameter:
* In the adult, the antero-posterior thoracic diameter is only about one-half of the transverse diameter.
* In the neonate, the antero-posterior thoracic diameter is approximately equal to the transverse diameter (thoracic index or round thorax).
- Chest deformities:
* Barrel chest: It is characterized by increasing the antero-posterior diameter of the chest (the sternum appears prominent). It is found in chronic obstructive pulmonary diseases.
* Funnel breast (pectus excavatum): It is characterized by depression of the lower part of the sternum. It is found in diaphragmatic breathers.
* Evaluation of moving chest:
- Evaluation of breathing pattern:
Ratio of inspiration to expiration time (I.E. ratio) is approximately 1:2. Children with bronchiolitis and asthma may have an increase in the expiratory time (I.E. ratio may become 1:4 or 1:5).
- Abnormal breathing patterns include:
* Dyspnea: Shortness of breath.
* Tachypnea: Rapid and shallow respiration (increased rate).
* Hyperventilation: Rapid and deep respiration (increased rate).
* Orthopnea: Difficult breathing in the supine position.
* Apnea: Cessation of breathing in the expiratory phase.
* Apneusis: Cessation of breathing in the inspiratory phase.
- Regularity of breathing:
Periodic breathing is seen in pre-mature and very young neonates. Alternating periods of irregular rate and depth of respiration with periods of apnea, usually less than 15 seconds occur.
- Symmetry and synchrony of thoracic motion:
* Symmetry: By comparing the right to the left hemi-thorax.
* Synchrony: By comparing the thoracic and the abdominal movement.
(3) Palpation:
Evaluation of chest mobility:
* Examination of the trachea:
To indicate the position of the media-sternum: Deviation of the trachea from its normal central position may indicate significant abnormality. It may be either:
- Extra-thoracic: Space-occupying lesion.
- Intra-thoracic: *Atelectasis, pulling to the same side or *pleural effusion, pushing the trachea to the contralateral side.
* Chest expansion:
- Symmetry of chest movement during inspiration and expiration is checked.
- Depth of excursion: The chest girth is measured at three levels (axilla, xyphoid and subcostal), during both inspiration and expiration.
(4) Other assessments:
a) Coughing, sneezing and sputum:
- An effective cough is sharp and deep.
- Sneezing is the process, by which the neonate clears airway.
- Sputum should be examined for color and consistency.
b) Pulmonary function tests:
- Vital Capacity (VC).
- Forced Vital Capacity (FVC).
- Forced Expiratory Volume in One second (FEV1).
- Forced Expiratory Rates (FER 25-75%).
- Residual Volume (RV).
- Total Lung Capacity (TLC).
c) Exercise testing:
Through progressive workload on a bicycle ergometer or treadmill:
- Heart Rate (HR).
- Ventilation Oxygen uptake (VO2).
- Carbon Dioxide production (VCO2).
Treatment techniques
In normal health, mucous produced by the trachio-bronchial tree is propelled upstream by cilial action, toward the upper respiratory tract, from where it can be expectorated or swallowed, thus maintaining a clear airway. Respiratory pathology may alter this process.
Goals:
- To enhance trachio-bronchial clearance.
- To reduce the work of breathing.
- To improve oxygenation.
- To maintain lung volume.
- To improve exercise tolerance.
- To improve function and posture.
Methods:
1) Removal of secretions:
A) Traditional methods:
1. Postural drainage:
It enhances the drainage of pulmonary secretions by positioning lung segments above their respective bronchi, allowing gravity to assist drainage of secretions into the more central airways. It has also been suggested that gravity could assist cilial action and therefore, mobilization of mucous toward major bronchi occurs.
Goals:
- To prevent accumulation of secretions (prophylaxis).
- To remove secretions already accumulated (therapeutic).
Contra-indications:
- Hemorrhage (severe hemoptysis).
- Untreated acute conditions:
* Severe pulmonary edema.
* Congestive heart failure.
* Pulmonary embolism.
* Pneumo-thorax.
- Cardiovascular instability:
* Cardiac arrhythmia.
* Severe hypotension or hypertension.
- Recent neurosurgery.
2. Manual techniques:
They are used to loosen or dislodge secretions from the bronchial wall, to allow easier removal by coughing or sneezing.
a) Percussion:
It is the rhythmic clapping of the chest wall with a cupped hand over an involved lung segment or lobe to assist the mobilization of broncho-pulmonary secretions.
Contraindications:
- Reduced oxygenation during treatment.
- Rib fracture.
- Any thoracic trauma.
- Hemoptysis.
b) Vibration:
It is the intermittent chest wall compression, performed during expiration in the direction, in which the ribs and soft tissues move during exhalation, to dislodge both peripheral and central secretions.
Contraindications:
- Reduced oxygenation during treatment.
- Hemoptysis.
- Pain.
3. Coughing and suctioning of the airway:
a) Coughing:
Infants and toddlers seldom cough on request. Young children and school-aged children can understand the request but often choose not to cough. By promoting these young children to either laugh or cry, a useful and productive cough can often be elicited. External stimulation of the trachea (tracheal tickling), using either a circular or vibratory motion of the fingers against the trachea, may be another useful technique for removing loosened secretions.
b) Suctioning:
Airway aspiration by suctioning is often needed, particularly in the neonate, to remove secretions. Suctioning must always be done carefully because of its significant risks.
(B) Contemporary techniques:
1. Autogenic drainage (huffing):
Secretions are removed in this way by the patient himself. He is asked to take deep breaths, after which either gentle cough or slightly forced expiration will aid the process.
2. Forced expiratory technique (FET):
The primary benefit of such technique is that it can be performed without an assistant, as with autogenic drainage. The FET consists of one or two huffs (forced expirations) followed by a period of relaxed, controlled diaphragmatic breathing. Bronchial secretions are then mobilized to the upper airways, to be expectorated.
3. Positive expiratory pressure (PEP) mask:
This technique employs an anesthesia facemask, fitted with a one-way expiratory valve, capable of offering variable levels of resistance. This resistance prevents airway collapse, and hence enhances removal of secretions, following directed cough.
2) Breathing exercises:
Patients with lung diseases are taught controlled breathing. Breathing exercises are designed to re-train muscles of respiration and improve ventilation. Exercises are only a part of the treatment program that improves the overall patient’s endurance and daily living activities. Techniques of breathing control may be also taught to promote relaxation, either in isolation, for the relief of respiratory distress, or as a part of a more active technique, to clear secretions.
3) Physical retraining:
Children with asthma, cystic fibrosis and respiratory diseases secondary to neuromuscular (myopathy or spinal muscle atrophy) or musculoskeletal (juvenile rheumatoid arthritis) problems, represent two distinct groups, for whom physical training is important. Physical training usually includes:
* Remedial exercises:
- Children with severe asthma and moderately advanced cystic fibrosis are often limited in strength. An endurance training program, involving isotonic resistive exercises, performed at a high number of repetitions, rather than high levels of resistance, is utilized. Exercises should stress on the shoulder girdle and thoracic musculature as a means of facilitating respiratory pump.
- Children with neuromuscular or musculoskeletal problems have weakness that prohibits their full participation in normal childhood activities. Therefore, a carefully planned strengthening program should be helpful.
* Range of motion (ROM) exercises:
Decreased ROM is a common problem for the neuromuscular / musculoskeletal group, than for those with asthma and cystic fibrosis. Exercises for deep breathing, thoracic expansion and upper extremity function can help to either prevent loss of motion (prophylaxis) or regain motion, which has been already lost (therapeutic).
- Inspiratory muscles strengthening results in improvement in numerous physiological indices.
- Expiratory muscles strengthening may benefit exercise tolerance and should enhance the force of expiratory maneuvers, including coughing.
- Patients with cystic fibrosis participate throughout organized walking or jogging groups.
Contraindications:
It is vital that those involved in the care of the child with respiratory disease are aware that physiotherapy is neither necessary nor appropriate in several situations. Thereby, avoiding distress to both the child and family and the potential serious consequences of inappropriate intervention are avoided. The most common contraindications are:
* Inhaled foreign body.
* Severe broncho-spasm.
* Acute bronchiolitis.
* Lobar pneumonia.
13