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 ?!