[Mucous clearing respiratory-physiotherapy in pediatric pneumology]. / Die sekretfördernde Atemphysiotherapie in der pädiatrischen Pneumologie.

Chest physiotherapy for mucus clearance may be seen as a therapeutic application of respiratory physiology; the basic mechanical principles do not differ between the treatment of paediatric and adult patients. However, children present with a developmentally defined, age-specific situation regarding respiratory structure and function that calls for a specialised therapeutic approach. Inspiration dilates bronchi and thus brings air behind obstructing mucus plugs. Newborns and infants have the special problem of an overly compliant, instable thorax and an easily obstructed upper airway; hence they require special help with lung volume management. Forced expirations mobilise and transport secretions by expiratory airflow in combination with a wave of moving choke points. Early in life, low stability of airways threatens to hamper this mechanism by complete closure; this calls for special therapeutic assistance. Positioning regionally modifies ventilatory excursions and is thus used to target gas-liquid pumping. However, lateral decubitus position does not affect ventilation in children in the same way as in adults. Disease-inflicted changes of structure and function call for further modification of the therapeutic approach. Finally, the psychology of therapist-patient interaction differs substantially between different age groups.

Physiotherapy for airway clearance in paediatrics.

The basic therapeutic principles in paediatric chest physiotherapy (CPT) are identical to those applied in adults. However, the child's growth and development results in continuing changes in respiratory structure and function, and the requirement for different applications of CPT in each age group. Forced expiratory manoeuvres and coughing serve as basic mechanisms for mobilization and transport of secretions, but the reduced bronchial stability after birth requires special techniques in very young patients. High externally applied transthoracic pressures have to be avoided in order to prevent interruption of airflow. In addition, airway patency is maintained by the application of back pressure and by liberal use of continuous positive airway pressure. Since sympathomimetic bronchodilators might further decrease bronchial stability, their use must be individualized in newborns and young infants. Inspiration is a basic mechanism for inflating alveolar space behind obstructing mucus plugs. Due to a highly unstable chest, the premature baby, newborn and infant cannot distend their lung parenchyma to the same extent as can older patients. Consequently all chest physiotherapy strategies applied in this age group have to incorporate appropriate techniques for raising lung volume. Positioning serves to redistribute ventilation, but the young infant's response to gravitational forces differs substantially from that of the adult, and consequently strategies used in older patients have to be modified. In addition, the therapist has to consider pathology such as bronchial instability lesions and airway hyperresponsiveness and has to adjust the therapeutic response accordingly. It is particularly important to consider the special vulnerability of newborns and young infants and to modify therapeutic interventions to avoid the harm that could otherwise be inflicted. Consideration of these differences between infant, child and adult and careful analysis of the available mucus clearance techniques allows tailoring of an individualized therapeutic approach to the paediatric patient.

[Pediatric tracheostomy care]. / Pädiatrische Tracheostomapflege.

Long term tracheostomy has become a rare caregiving problem in Paediatrics, but remains the only therapeutic strategy for a spectrum of complex anomalies of the paediatric airway. The present state-of-the-art article describes the practical routine of tracheostomy care as developed in the Paediatric Department of Graz. Commencing with indications for tracheostomy and a brief comment on relevant operations, it discusses routine and special tracheostomy tubes, valves, and other accessory devices. One chapter on specialised care is focussed on the paediatric airway, another more general one is concerned with the tracheostomized child. Then follows teaching tracheostomy care to parents; the article ends with a discussion of control investigations and decannulation.

Self-administered chest physiotherapy in cystic fibrosis: a comparative study of high-pressure PEP and autogenic drainage.

Fourteen patients with cystic fibrosis were trained in 2 self-administered chest physiotherapy (PT) techniques: high-pressure PEP-mask physiotherapy (PEP), and autogenic drainage (AD). They then visited the clinic on 5 consecutive days, and, in a random order, performed 1 of the following: PEP, AD, PEP followed by AD (PEP-AD), AD followed by PEP (AD-PEP), and, no PT except for spontaneous coughing. Lung function was measured repeatedly before, during, and after PT; time needed for and sputum produced by each form of PT was recorded. PEP produced the highest amount of sputum, followed by PEP-AD, AD-PEP, and AD; all 4 forms of PT produced significantly more sputum than coughing. Lung function improved significantly after PEP, AD, and PEP-AD, but PEP-induced changes did not exceed those after AD. Within the investigated group, the PEP-induced lung function improvement per milliliter of sputum produced was significantly lower for those patients with airway hyperreactivity. The fact that the highest sputum yield with PEP was not reflected in higher PEP-effected lung function changes might thus be explained by PEP-induced bronchospasm in patients with airway hyperreactivity. PEP clears more sputum than AD or combined techniques; patients with airway hyperreactivity, however, should either prefer AD or should take a bronchodilator premedication before PEP.

Chest physiotherapy in hospitalized patients with cystic fibrosis: a study of lung function effects and sputum production.

In order to evaluate the short-term lung function effects of high-pressure positive expiratory pressure (PEP)-mask physiotherapy (PT) in relation to PT-assisted sputum production, we studied 18 patients with cystic fibrosis (CF), hospitalized for a pulmonary exacerbation. Lung functions were measured before (a) and after PT (b) on day one (1), five (2), ten (3) and fifteen (4). Five functions improved significantly from a1 to b1, eight from a2 to b2, seven from a3 to b3, and seven from a4 to b4. Baseline (a) measurements improved only slightly, but post-PT (b) values improved more markedly from 1 to 4, and this improvement reached statistical significance for six functions; consequently, a-to-b lung function changes tended to increase from investigation 1 to 4. Eleven PT-induced lung function changes correlated to the weight of sputum produced. High-pressure PEP-mask PT therefore resulted in significant lung function improvements, and not only maintained but increased its effect in the course of the hospitalization.

Airway obstruction and airway wall instability in cystic fibrosis: the isolated and combined effect of theophylline and sympathomimetics.

Multiple aspects of lung function were measured in 17 cystic fibrosis (CF) patients on four occasions: without therapy (0); with oral theophylline medication (Th); after inhalation of salbutamol (beta 2); and with combined medication (Th + beta 2). In addition to routine measurements, partial and maximum expiratory flow-volume (MEFV) curves were superimposed, and the flow transient equivalent of the MEFV curve was determined. Its volume dimension (volume of airway contribution, VACMEFV) partially reflects airway distensibility. Changes in airway compressibility--the other consequence of airway wall instability--were assessed by observing changes in end-expiratory flow rate. Airway resistance, expired volumes, and early expired flow rates, as well as VACMEFV improved significantly after beta 2 medication. Mean end-expiratory flow also increased after beta 2; in two patients, however, it decreased significantly, indicating that enhanced airway compression dominated over the release of bronchospasm. The alone had only minor effects on lung function. Early expired volume and flow rates as well as VACMEFV showed no significant difference between beta 2 alone and Th + beta 2; airway resistance even decreased significantly with this drug combination. End-expiratory flow rate, however, was significantly lower after Th + beta 2 than after beta 2 alone. Although theophylline does not alter lung function in most patients with CF, sympathomimetics relieve bronchospasm in many, but they enhance airway compressibility and thereby decrease peripheral expiratory airflow in some.(ABSTRACT TRUNCATED AT 250 WORDS)

Chest physiotherapy--the mechanical approach to antiinfective therapy in cystic fibrosis.

Chest physiotherapy is a treatment program that attempts to compensate for impaired mucociliary clearance. By removing mucopurulent secretions, it reduces airway obstruction and its consequences, such as atelectasis and hyperinflation; furthermore, physiotherapy can decrease the rate of proteolytic tissue damage by removing infected secretions. Conventional physiotherapy (clapping, vibration and compression, together with postural drainage and assisted coughing) is the most efficient physiotherapy for sick infants and young children. Later, mechanical chest percussion can reduce the patient's dependency on others. The forced expiration technique is another method of self-treatment, employing expiratory techniques to blow secretions out of the bronchi. Autogenic drainage, a special breathing technique, aims at avoiding airway compression by reducing positive expiratory transthoracic pressure. PEP-mask-physiotherapy achieves the same goal by expiring against an external airflow obstruction. Last but not least, physical exercise can clear the lungs of some CF patients and thus offers an attractive adjunct to physiotherapy.

Forced expirations against a variable resistance: a new chest physiotherapy method in cystic fibrosis.

Twenty patients with cystic fibrosis (CF) were trained to mobilize intrabronchial secretions by a new method of positive expiratory pressure mask (PEP mask) physiotherapy (PT). Patients repeatedly expired forcefully through the PEP mask; expiratory resistance was varied by eight different internal diameter resistors at the outlet. Forced vital capacity with the mask (FVCPEP) was determined for each resistor and was compared with the one measured without the instrument (FVC); simultaneously the sustained expiratory pressure (SEP) developed against the resistance was recorded. After training, each patient exceeded FVC with one or more resistors; "optimum" FVCPEP was 124 +/- 16% FVC at a SEP of 61 +/- 21 cm H2O. Using the PEP mask, patients cleared a higher percentage of their daily sputum volume than with conventional PT (78 +/- 22% versus 53 +/- 17%, p less than 0.01). In 11 patients (subgroup 1), multiple aspects of lung function were measured at the beginning of the study, after 10 months with PEP mask PT, after two further months without using the mask but with conventional PT, and after six more months with PEP mask PT. Results showed significantly increased expiratory flow rates, significantly decreased hyperinflation and airway instability with PEP mask PT, and a marked decline of lung function without it. The remaining nine patients (subgroup 2) entered into the same protocol; based on findings in subgroup 1 and on ethical considerations, however, the control period without PEP mask PT was then omitted, resulting in a steady and statistically significant improvement of lung function over the entire observation period. In the course of preliminary trials, two children transiently used a suboptimal resistance (FVCPEP less than FVC) and responded with a deterioration of lung function. By dilating airways and evacuating trapped gas, this method of PEP mask PT improves lung function and mucus clearance in CF. Thorough practice with the technique and frequent control of the optimal resistance are mandatory.

Bronchodilators increase airway instability in cystic fibrosis.

Supramaximal flow transients of partial expiratory flow-volume curves are caused by a rapidly emptying compartment. By superimposing a maximal and a series of partial expiratory flow-volume curves, the volume of the flow transient equivalent for the maximal curve was estimated (volume of airway contribution = VACMEFV). This flow transient equivalent is caused by an extra dead space, created in the large airways by a full inspiration. In 18 children with cystic fibrosis (CF), routine pulmonary functions and VACMEFV were measured before and after bronchodilator medication. Baseline VACMEFV correlated directly with the curvilinearity of the flow-volume curve and inversely with the clinical and radiologic score. Significantly, bronchodilator medication improved FVC, FEV1, FEF25-75, VC, PEF, Raw, and also VACMEFV. In 6 children, VEmax25 increased as a result of apparent peripheral bronchodilation. In 3 others, end-expiratory flow increased slightly but the expanded VACMEFV included the measuring point invalidating the measurement. In the remaining 9 patients, VEmax25 decreased after bronchodilator. As an apparent discrepancy, FEV1, FVC, PEF, VC, FEF25-75 increased, and Raw decreased in 4 to 9 patients. The volumes and flow rates measured early in forced expiration and the end-expiratory flow behaved differently because VACMEFV expanded beyond the measuring points of early expiratory and mid-expiratory flow rates. As the bronchodilator rendered the compliant large airways still more distensible, the amount of air emptied from the dead space in early forced expiration increased. Simultaneously, end-expiratory flow decreased because of enhanced airway compression.(ABSTRACT TRUNCATED AT 250 WORDS)

Cystic fibrosis: physical exercise versus chest physiotherapy.

Twelve children with cystic fibrosis were admitted to a paediatric rehabilitation hospital for 17 days to take part in a training programme of vigorous physical exercise and sport. The daily inhalation-physiotherapy routine was stopped. Ventilatory status was assessed by spirometry and measurement of lung volumes one day before admission, one day after the end of the hospital stay, and 8 weeks later. Flow measurements of forced expiration had improved appreciably by the end of the course, but most of them returned to pretraining levels 8 weeks later. Lung volumes did not change significantly. Daily recordings of peak flow indicated improvement of airways function plus some ventilatory muscle training. Regular physical exercise could replace the inhalation-physiotherapy routine in some children with cystic fibrosis.

[Chest physiotherapy in childhood respiratory disorders (author's transl)]. / Thoraxphysiotherapeutische Behandlung bronchopulmonaler Erkrankungen des Kindesalters.

The effect of chest physiotherapy in the treatment of pediatric pulmonary disorders was evaluated for one year by means of a specially devised progress chart. A high percentage of atelectases was successfully reopened. The right upper lobe was most frequently involved, followed by the left upper, right lower and left lower lobe. The incidence of postextubation atelectasis in neonates with hyaline membrane disease was significantly lower when chest physiotherapy was commenced before extubation. The value of chest physiotherapy in chronic respiratory disorders remains uncertain, whereas it does constitute an essential part of therapy in acute conditions.

Effect of swimming on forced expiration and sputum clearance in cystic fibrosis.

Ten children with cystic fibrosis participated in swimming training over 7 weeks. Ventilatory status, assessed by spirometry, had improved significantly after the course. 10 weeks after the end of the training most measurements had returned to their preswimming levels. In the majority of the children sputum production on swimming days was higher than on nonswimming days. Regular swimming can assist in mucus clearance and improve ventilatory function in children with cystic fibrosis.

Haemophilia home infusions with dried fresh plasma.

A group of 26 haemophilic patients was successfully managed on a home infusion programme over a one-year period. Single donor units of dried fresh plasma, the coagulant activity of which was adequate to ensure haemostasis of most of the haemorrhagic episodes treated, were used. The transmission of hepatitis was kept to a minimum by careful selection of regular, known donors and by the utilisation of single donor units of plasma in preference to plasma pools. Although the programme was costly, it was less expensive than it would have been had alternate antihaemophilic products been used. The advantages and disadvantages of self-administration are discussed. No serious mishaps occurred, and the programme was considered an outstanding success by both laymen and medical personnel. Minor alterations in liver function tests were demonstrated in several of the recipients. No factor VIII inhibitors were detected.