Physiotherapy Assessment and Treatment on PICU

Kath Ronchetti Physiotherapy 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 Croup Foreign body aspiration Epiglottitis Tracheomalacia Laryngomalacia

Upper airway

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 dont 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.Is 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!

Positioning Manual hyperinflation Manual techniques Instillation Lavages Suction Nebulisers Mucolytics Cough assist IPPB

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 Dont automatically use 100% to preoxygenate 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 ROP IVH NE Periventricular leukomalacia

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 Cant be very oxygen dependant Contraindications / precautions same as positive pressure

Phew Any Questions ?!