airway clearance in paediatric cf - child health...
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Airway Clearance
in Paediatric CF Emma DixonSpecialist Paediatric Physiotherapist in CF
The Royal Brompton Hospital, London, UK
Ukraine July 2011
ED,RBH 2011
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CF Physiotherapist
Independence
and
life goals
Airway ClearanceInhalation
therapy
Stress
incontinence
management
Posture
assessment
& advice
Exercise
ED,RBH 2011
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Why Chest Physiotherapy?
� Integral part of the multidisciplinary
approach to management of CF
� Great importance to have a physiotherapy
routine BOTH at home and as an
inpatient/outpatients
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Aims of airway Clearance
Short term
� ↓airway obstruction
� ↓airway resistance
� ↓mucus viscosity
� ↓ work of breathing
� ↑ gas exchange
Long Term
� Delay disease
progression
� Maintain optimal
respiratory function
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Airway Clearance Techniques
� Postural drainage/GAP and percussion (“Conventional Physiotherapy”)
� ACBT
� PEP
� Flutter
� Acapella
� HFCWO
� AD
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Chest Physiotherapy
� To fit into daily life at home
� Effective at clearing sputum
� Individual
� Adaptable for age and disease severity
� Regularly reviewed by physiotherapist
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Which Airway
Clearance
Technique(ACT)?
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Babies and Toddlers
� Passive
� Chest percussion and MPD/GAP
� Age appropriate Exercise
� Blowing games
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Manual Techniques
(Percussion & Shakes/Vibrations)
Percussion:
� Produces oscillation
� Mucus viscosity
� In infants = 30 sec intervals to
prevent hypoxia or
bronchospasm
� Clothing/towel for comfort
� Precautions – CVS instability,
reduced BMD
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Gravity Assisted Positioning
� Used with ACBT and Manual Techniques
� Based on anatomy of the bronchial tree (Nelson et al 1934)
Sputum clearance with gravity (Sutton et al 1983)
� Precautions: CVS instability, haemoptysis, uncontrolled GORD
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Gravity Assisted Positions
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Child
� Increase ACTIVE participation in
physiotherapy
� Blowing games
� ACBT +/- Percussion/GAP/MPD
� Exercise
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Active Cycle of Breathing
Technique (ACBT)
Breathing
control
Thoracic
Expansion
exercises
( 3-4 deep
breaths with
inspiratory
hold (3 sec))
Breathing
control
FET (1-2
huffs with
breathing
control)
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ACBT
� Aim: To mobilise and clear excess
bronchiole secretions
� Flexible, free, tailored to the individual
� Originated in NZ as FET (Thompson, 1968, NZJ
Physiotherapy, 319-21)
� Modified in UK to become ACBT (Pryor, 1979, BMJ,
2, 417-8)
� Principles of ACBT begun at age 2
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ACBT
� CF pts never having done ACBT before were given it over 3 days – all showed a statistically significant increase in FEV1, FVC, PEFR and MEF50 (Webber et al, 1986,British Journal of Disease of the Chest,80,353-59)
� 80 pts 6-18 yrs (7 month period) 3x sessions PT per day, randomised into: PD with clapping, PD with clapping and vibs, ACBT, Flutter
Statistically significant increase in PFT in ACBT group (Orlik and Sands, 2001, Med Wieku, Rozwoj, 5, 3, 245-57)
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Older Child/Teenager
� Motivation
� Increasing Independence
� ACBT/Autogenic drainage
� Exercise
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Autogenic Drainage
� Originated in Belgium (Chevaillier, 1960’s)
� Aims to reach highest possible expiratory airflow velocity whilst maintaining the lowest possible resistance
� 3 phase breathing regimen – moves mucus by sheering forces
� Low lung volumes mobilise secretions
� Mid lung volumes collect secretions
� High lung volumes evacuate secretions
� Now felt to be a more fluid regimen
� Modified in Germany (Lindeman, 1990)
� AD vs ACBT & PD 18 pts (18-25 years) RCT, 2 day crossover
AD appeared to clear mucus more quickly from the lungs, no significant difference in PFTs between the groups (Miller et al, 1995,50,10, 1123-4)
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Autogenic Drainage (AD)
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High Frequency Chest Wall
Oscillation (HFCWO)� PROS
� May Increase Adherence
� Short term- Inpatients ↑ sputum load
� Not appear to have adverse physiological effects (Osman 2010)
� CONS
� Less sputum cleared with HFCWO than ACT (Osman, 2010)
� No evidence to suggest HFCWO more effective than current ACT
� Expensive- £6,500
� Must not be used without other forms of ACT(HILLROM)
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PEP (Positive Expiratory Pressure)
�Mobilises secretions via collateral ventilatory channels
�Valves Resistance
�Active expiration for 6-10 breaths
�Check pressure with manometer 10-20cmH20
�Can be combined with AD, Postural drainage and manual techniques
* Contraindications as all positive pressure devices
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Flutter
� Oscillatory PEP device
�During expiration the steel ball creates PEP and an oscillatory vibration of air within the airways
�Reduces visco-elasticity of mucus
�Mobilises secretions via collateral ventilatory channels and shearing forces
�Can be combined with ACBT
�Positional therefore best done in sitting
* Contraindications as all positive pressure devices
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Acapella
� Oscillatory PEP device
� Magnet and rocker design creates oscillatory vibration of air
� Mobilises secretions via collateral ventilation and shearing forces
� Reduces visco-elasticity of mucus
� Can be combined with ACBT, postural Drainage positions and manual techniques
* Contraindications as all positive pressure devices
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Does Airway Clearance Work?
� ‘Chest Physiotherapy versus no Chest Physiotherapy in CF – A Cochrane Systematic Review’ – Van der Schans, Prasad, Main, 2000� No ‘Gold Standard’ technique
� Most studies compare to PD and percussion (defined as conventional physio)
� Cochrane review (2002) 29/78 studies included. ☺ No advantage of conventional physiotherapy over other ACTs in
terms of lung function.
� Difficulty with research as no true control groups
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Which is the Best ACT in CF?
Adult study:
� RCT, 1 yr, 75 pts, age 17-63 (median 27)
� ACBT, AD, Cornet, Flutter and PEP (all in sitting)
� FEV1 primary outcome measure
� FVC, MEF25, RV/TLC%, BMI, exercise capacity (modified shuttle), QOL,
� No statistically significant difference between groups in primary (FEV1 P=0.35) or secondary outcome measures
� Greater consideration should be given to pt preference when choosing an ACT
Pryor et al, 2006, Journal of Cystic Fibrosis, 5, 1, abstract 347
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Exercise
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What are the benefits of
exercise?
� Mobilisation of secretions
� Improved cardiovascular fitness
� Improved body image
� Slows decline in lung function
� Reduced sensation of breathlessness
� Maintenance of bone mineral density
� Increased Quality of Life
� Increased Muscle strengthED,RBH 2011
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Physical Handling Activities
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Older Children
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Order of Medications with
Physiotherapy
1. Bronchodilator/combination inhaler (straight before physio or before Hypertonic Saline)
2. Hypertonic Saline
3. Physio
4. Steroid Inhaler
5. Nebulised Antibiotic
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Chest Physiotherapy
� To fit into daily life at home
� Effective at clearing sputum
� Individual
� Adaptable for age and disease severity
� Regularly reviewed by physiotherapist
ED,RBH 2011
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ED,RBH 2011
Thank you
Any questions?
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Abbreviations
� CF – Cystic Fibrosis
� GAP – Gravity Assisted Positioning
� MPD/PD – Modified Postural Drainage/Postural Darinage
� ACBT –Active Cycle of Breathing technique
� FET – Forced expiration technique
� PEP-Positive expiratory Pressure
� HFCWO- High frequency chest wall oscillation
� AD –Autogenic Drainage
� ACT –Airway clearance techniques
� RCT –Randomised control trial
ED,RBH 2011