Physiotherapy Assessment and Treatment on PICU

Kath RonchettiPhysiotherapy PICU Lead UHW

November 2009

Aims

• Respiratory pathologies seen on PICU• Indications for treatment• Assessment – things to consider with

critically ill paediatric patient• Treatment options • Our experience of H1N1

Primary Respiratory Pathologies

• Lower airway • Bronchiolitis• Pneumonia / LRTI • Asthma• Pulmonary oedema / haemorrhage

• Upper airway • Croup• Foreign body aspiration• Epiglottitis• Tracheomalacia• Laryngomalacia

Respiratory Complications

• Secondary respiratory complications– VAP

• Those at risk of needing critical care – Neurological compromise – Respiratory compromise

• CLD / Bronchiectasis / Recurrent CI s

– Cardiac history

Indications for Assessment

• Patients respiratory function is objectively deteriorating due to:

– Retained secretions

– Increase in WOB

– Atelectasis / decreased lung volume

Babies and Infants are NOT small Adults!!

• Anatomical and physiological differences • Suffer from different pathologies • Deteriorate quickly BUT also can improve

quickly• Age appropriate assessment techniques• However basic principles of assess in adult

patients do also apply – so don’t be scared your skills are transferable!

Handle with extra caution

• FOR – First few hrs of admission – period of ‘stabilisation’– Those with high oxygen indices – Poor handlers – Neonates– Cardiac history

• Pulmonary HT • Shunts

– Inotropes

Assessment on PICU

• Follow your normal respiratory assessment outline BUT things to consider – PMH

• Prematurity – ? presence of CLD / BPD• Congenital heart disease – consider their normal O2 sats• Conditions which prevent normal development of the lungs

e.g. congenital diaphragmatic hernia • Long standing / chronic lung disease e.g. CF / PCD / asthma /

bronchiectasis• Multiple previous admissions due to C.I’s esp with

neuromuscular conditions • GORD & Swallowing problems

Assessment on PICU

• DH– Mucolytics e.g. DNAase, Hypertonic NaCl– Bronchodilators e.g. salbutamol, atrovent– Antimuscaric drugs e.g. hyoscene,

glycopyronium bromide– Analgesia– Anti seizure meds – Cardiac meds

Assessment on PICU

• SH / Birth History / FH– Labour / delivery history– APGAR scores– ? Premature – Family structure / siblings / main carer – Development history – ? Delayed for age.

Assessment on PICU

• Subjective – specific for PICU – HANDLING – bradycardias/desats?– Feeds – Sedation - Need bolus before handling ? – Positioning– Parents

Assessment on PICU

• Observation – Signs of respiratory distress– Respiratory pattern – Colour – Position – Expansion – Abdomen– ETT position / security – Lines / drains – Activity

Assessment on PICU

• CNS – Sedation / Analgesic – Midaz / Morphine – Sedation score – Paralysing agents – Vecuronium

• CVS – Know normal values for age / paeds responses

• Infusions • Fluid balance • Blood results

– Be aware of thrombocytopenia

Sedation Score at PICU UHW

• Under – Fully awake & alert – Frightened & unco-operative– Fights ventilator, choking, biting, gagging on

ETT– Vigorous movt risking dislodging ETT & lines– Lifting head / torso – Demonstrating frowning & grimacing

Sedation Score Cont

• Well– Lightly asleep / drowsy– Awake at times but co-operative – Spontaneous respiration / not fighting

ventilator/ occ coughing – Occ movts of limbs– Occ purposeful movts– Occ facial movts

Sedation Score Cont

• Over– Deeply asleep – Calm and totally relaxed– No coughing / response to suctioning– No movt– Facial muscles totally relaxed

Assessment on PICU

• Respiratory – Vent settings – Resp drive – ETCO2– O2sats – Gases – consider what type ? Art line ? – Variable objective markers on ventilator

• TV • PIP

Tidal Volume in Paediatrics

• Use as objective marker if on pressure control ventilation

• Work out through weight• Aim for 6 – 8 mls / kg • Examples

– 3 kg baby – aim for TV of 21mls (7mls / kg) – If a 5 kg pt had a TV of 21mls they would only

ventilating at 4.2mls/kg • 21 / 5 = 4.2

PIP in Paediatrics

• Use as objective marker if on volume control mode of ventilation

• If reaching pressures of high 20s – 30 then that is considered high

• If getting to 30 and above then consider HFOV

Assessment on PICU

• Palpation– Very useful tool as auscultation can be difficult – Feel for equal expansion / tactile secs / areas of

pain.– Make sure warm hands up!

Assessment on PICU

• Auscultation– Can be difficult due to high resp rate and

transmission of sounds.– Always take note of what you can hear from the

upper airways first. – If possible get appropriate sized stethoscope

and warm this up !

Paeds CXR

• Carina – situated at T3 in the neonate, T4/5 in the child and T6 in the adult.

• Thymus gland larger – at 2 years of age• Flattened ribs • ETT position – not uncommon for it to slip

down the right main bronchus• Heart size – 50% ratio, 2/3rd seen to the left

and 1/3rd to the right.

Treatment Options

• WHAT NOW !!

Treatment Options – Your tools!

• Cough assist • IPPB

• Positioning• Manual hyperinflation• Manual techniques • Instillation • Lavages• Suction • Nebulisers • Mucolytics

Positioning

• Effective ventilation to the problematic area • Think about V/Q mismatch in paediatric pts • Instillation vrs ventilation to the effected area• Consider WOB • Think of the reasons why you would position them

a certain way – what is your primary problem ? • VAP prevention

Manual Hyperinflation

• Use a lot in PICU – as assessment & treatment

• Indications– Mobilise secretions – Re inflation of lung collapse

• Also used by nursing staff for ‘rescue bagging’

Manual Hyperinflation

• Ayres T piece - Intersurgical• 3 different sizes

– 0.5L open ended bag 0 – 20kg – 1L closed end bag – 20-40kg – 2L closed end bag - > 40kg

• Flow rates used– 0.5 L = 6L– 1 L = 6 -10 L– 2L = 10 -15 L

Manual Hyperinflation

• Aim for no higher than +20% of PIP and try to maintain PEEP

• Aim to keep with pts RR • Interspersing deep insp breaths with every

3-4 tidal breaths • Breath hold / quick release • Feel for compliance / pt effort / secretions• Use a manometer!!

Manual Hyperinflation • Contraindications

– Undrained pneumothorax– Acute pulmonary oedema– Low/labile blood pressure– Hypoplastic lungs – e.g CDH– Pre term infants – Severe bronchospasm– High levels of PEEP – Nasal CPAP – Evidence of hyperinflation on CXR – Unstable CVS– Surgical Empysema– Lobar Emphysema

Manual Hyperinflation

• Always first look at expansion and distribution of ventilation

• Check obs throughout • Check pt colour • Care with

– Pulmonary HT– Raised ICP– Presence of bronchial anastamosis

Manual Hyperinflation

1L closed end bag:

Manual techniques

• Percussion - Can use soft rimmed face mask – different sizes

available - Use tenting technique with fingers / cupped hand

• Expiratory vibs– Can be more effective at moving the secretions

centrally – Localise to area being treated – Can cause atelectasis if beyond FRC

• Head support – definitely in neonates & infants.

Manual Techniques

• Care with – Neonates / Prematurity

• Osteopenia• Thrombocytopenia

– Thrombocytopenia – esp in septic children – Our guidelines in Cardiff for platelet count:

• Care below 50 – only perform if clinical benefit overides risk & there are no active signs of bleeding

• Below 20 – contraindication for MT • Active signs of bleeding – contraindication for MT

Manual Techniques Contraindications / Precautions

• Rib # or potential – osteopenia / rickets • Loss of skin integrity • Pain • Haemoptysis / severe clotting disorders • CVS instability / arrythmias• Head injury

Instillation of NaCl

• Limited evidence for and against use – Even more limited evidence in paediatrics !

• Experience in Cardiff – Found to be effective in mobilising stubborn secretions

• Ridling et al (2003) suggested these amounts and can be used as guidance:– Age < 1 yr – 0.25 – 0.5mls– Age 1 – 8 yrs – 0.5mls – Older children – 1 – 2 mls

• Although use clinical judgement also !

Instillation of NaCl

• Assess the viscosity of the secretions first • Pre oxygenate • Care with reactive airways • Consider the position of the patient • Normally used in conjunction with manual

hyperinflation +/- manual techniques• Check aliquot with 2nd person before using

Lavages / NBBAL

• Can be diagnostic or therapeutic• Diagnostic NBBAL – Indications

– Primary respiratory focus – Non resolving LRTI – Immunocompromised / Atypical presentation – Raised inflammatory / infection markers – Sepsis ? Cause

Lavages

• Therapeutic – Acute lobar / lung collapse – Retained viscous secretions

• Preoxygenate• Consider position – head turn / side lying• 1ml / kg NaCl up to 10mls max

Lavages

• Care with pts with high oxygen indices

• If pt has any of the following the clinical benefit must be weighed up with the potential adverse effects– Team decision – discuss with consultant

Contraindications /Precautions NBBAL

• Haemodynamic instability• Pulmonary haemorrhage • Pulmonary oedema• Cor pulmonale with pulmonary hypertension• Raised intracranial pressure• Congestive cardiac failure• Coagulopathy, • Platelet count < 20 mgl x 10• Neonatal respiratory distress syndrome – care with washing out of surfactant• Premature, small for gestational age – risk of intraventricular haemorrhage• Inadequate sedation • Bronchospasm(Morrow et al 2006, ERS Task Force 2000).

Potential Complications NBBAL• Transient bradycardia• Hypoxia • Loss of lung volume • Interference with aveolocapillary oxygen exchange • Fever & transient pulmonary infiltrates • Acute pulmonary oedema • Changes in BP• Bronchial haemorrhage• Pneumothorax• Bronchospasm (Morrow et al 2006)

Lavages

• The risk of complications associated with NBBAL can be reduced by ensuring that the patient is cardio-vascularly and respiratory stable, pre-oxygenating, ensuring adequate sedation and using correct suction pressures.

Suction

• Catheter size – ETT / trache size x 2 = catheter size

• Cardiff – use open suction unless indication for closed suction – High PEEP – Infection control

• Watch out for vaso – vagal stimulation – Bradycardia

Suction Pressures

• Infant - 6 – 9 kPa / 44 – 88mmHg• Child – 9 – 11 kPa / 66-80mmHg• Older child – 11- 15 kPa / 80-110mmHg

Oxygenation in Paediatrics

• Oxygen should be regarded as a drug (BMJ 2006)

• Establish target saturations • Care with certain paediatric conditions • Don’t automatically use 100% to pre-

oxygenate if there is no clinical need

Precautions of Oxygen in Paeds

• Careful monitoring of O2 therapy may be required in some children who have congenital heart defects with left to right shunts’ Hermann et al (2002)

• Defects – PDA, atrial septal defects, ventricular septal defects – prone to congestive heart failure

• O2 – potent vasodilator • Blood flow to pulmonary bed could be increased

Precautions of Oxygen in Paeds

• Consider role of oxygen free radicals in the pathogenesis of many diseases associated with prematurity– BPD NE– ROP Periventricular leukomalacia– IVH

• Care with neonates / premature babies

Precautions of Oxygen in Paeds

• Children with chronic chest conditions – High levels of oxygen may reduce respiratory

drive in these children (BMA 2003)

• Aware of signs of hypercarbia

Oxygenation in Paeds

• However – Paediatric Advanced Life Support Guideline

• ‘Oxygen, in the highest possible concentration should be administered to all seriously ill or injured patients (children) with respiratory insufficiency, shock or trauma even if measured arterial tension is high’

Nebulisers / Medications on PICU

• Bronchodilators – Salbutamol / Atrovent

• Mucolytics– DNAase– Hypertonic NaCl 5% / 7% – Acetylcysteine– Carbocysteine – enteral

• Steroids• Adrenaline

IPPB in Paeds

• Can be used for paediatric patients• Dependent on size of patient (not used in

babies and small children) approx >10yrs• Discuss with ICU consultant if treatment

option and pressures• Caution with children with complex

anatomy and respiratory conditions

Cough Assist on PICU

• Our experience beneficial • Used with pts with a mechanically impaired cough

e.g.– Neuromuscular disorders– Spinal injuries– Impaired neurology

• Used through a catheter mount • Can’t be very oxygen dependant • Contraindications / precautions same as positive

pressure

Phew – Any Questions ?!