Physiotherapy Assessment and Treatment on PICU

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Physiotherapy Assessment andTreatment on PICU

Kath Ronchetti

Physiotherapy PICU Lead UHWNovember 2009


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Aims

Respiratory pathologies seen on PICU Indications for treatment

Assessment things to consider withcritically ill paediatric patient

Treatment options

Our experience of H1N1


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Primary Respiratory Pathologies

Lower airway Bronchiolitis Pneumonia / LRTI

Asthma

Pulmonary oedema / haemorrhage

Upper airway Croup

Foreign body aspiration Epiglottitis

Tracheomalacia

Laryngomalacia


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Respiratory Complications

Secondary respiratory complications VAP

Those at risk of needing critical care

Neurological compromise

Respiratory compromise

CLD / Bronchiectasis / Recurrent CI s

Cardiac history


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Indications for Assessment

Patients respiratory function is objectivelydeteriorating due to:

Retained secretions

Increase in WOB

Atelectasis / decreased lung volume


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Babies and Infants are NOT

small Adults!!

Anatomical and physiological differences Suffer from different pathologies

Deteriorate quickly BUT also can improvequickly

Age appropriate assessment techniques

However basic principles of assess in adultpatients do also apply so dont be scared

your skills are transferable!


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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


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Assessment on PICU

Follow your normal respiratory assessment outlineBUT 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 withneuromuscular conditions

GORD & Swallowing problems


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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


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Assessment on PICU

SH / Birth History / FH Labour / delivery history

APGAR scores

? Premature

Family structure / siblings / main carer

Development history ? Delayed for age.


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Assessment on PICU

Subjective specific for PICU HANDLING bradycardias/desats?

Feeds

Sedation - Need bolus before handling ?

Positioning

Parents


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Assessment on PICU

Observation

Signs of respiratory distress

Respiratory pattern

Colour

Position

Expansion

Abdomen

ETT position / security

Lines / drains

Activity


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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


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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


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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


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Sedation Score Cont

Over Deeply asleep

Calm and totally relaxed

No coughing / response to suctioning

No movt

Facial muscles totally relaxed


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Assessment on PICU

Respiratory

Vent settings

Resp drive

ETCO2 O2sats

Gases consider what type ? Art line ?

Variable objective markers on ventilator TV

PIP


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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


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PIP in Paediatrics

Use as objective marker if on volumecontrol mode of ventilation

If reaching pressures of high 20s 30 then

that is considered high

If getting to 30 and above then consider

HFOV


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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!


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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 theupper airways first.

If possible get appropriate sized stethoscopeand warm this up !


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Paeds CXR

Carina situated at T3 in the neonate, T4/5in 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.


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Treatment Options

WHAT NOW !!


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Treatment Options Your tools!

Cough assist

IPPB

Positioning

Manual hyperinflation

Manual techniques

Instillation

Lavages

Suction Nebulisers

Mucolytics


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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


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Manual Hyperinflation

Use a lot in PICU as assessment &treatment

Indications

Mobilise secretions

Re inflation of lung collapse

Also used by nursing staff for rescuebagging


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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


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Aim for no higher than +20% of PIP and tryto maintain PEEP

Aim to keep with pts RR

Interspersing deep insp breaths with every3-4 tidal breaths

Breath hold / quick release Feel for compliance / pt effort / secretions

Use a manometer!!


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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


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Always first look at expansion anddistribution of ventilation

Check obs throughout

Check pt colour Care with

Pulmonary HT Raised ICP

Presence of bronchial anastamosis


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1L closed end bag:


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Manual techniques

Percussion

- Can use soft rimmed face mask different sizesavailable

- Use tenting technique with fingers / cupped hand

Expiratory vibs

Can be more effective at moving the secretionscentrally

Localise to area being treated

Can cause atelectasis if beyond FRC

Head support definitely in neonates & infants.


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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


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Manual Techniques

Contraindications / Precautions

Rib # or potential osteopenia / rickets

Loss of skin integrity

Pain

Haemoptysis / severe clotting disorders

CVS instability / arrythmias

Head injury


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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 andcan 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 !


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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


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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


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Lavages

Therapeutic

Acute lobar / lung collapse

Retained viscous secretions

Preoxygenate

Consider position head turn / side lying

1ml / kg NaCl up to 10mls max


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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

C i di i /P i


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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).


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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)


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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 adequatesedation and using correct suction

pressures.


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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


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Suction Pressures

Infant - 6 9 kPa / 44 88mmHg

Child 9 11 kPa / 66-80mmHg

Older child 11- 15 kPa / 80-110mmHg


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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 pre-

oxygenate if there is no clinical need


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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


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Precautions of Oxygen in Paeds Consider role of oxygen free radicals in the

pathogenesis of many diseases associatedwith prematurity BPD NE

ROP Periventricular leukomalacia IVH

Care with neonates / premature babies


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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


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Oxygenation in Paeds

However

Paediatric Advanced Life Support Guideline

Oxygen, in the highest possible concentration

should be administered to all seriously ill or injuredpatients (children) with respiratory insufficiency,

shock or trauma even if measured arterial tension is

high

Nebulisers / Medications on


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Nebulisers / Medications on

PICU Bronchodilators

Salbutamol / Atrovent

Mucolytics

DNAase

Hypertonic NaCl 5% / 7%

Acetylcysteine

Carbocysteine enteral

Steroids

Adrenaline


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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 complexanatomy and respiratory conditions


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Cough Assist on PICU Our experience beneficial

Used with pts with a mechanically impaired coughe.g. Neuromuscular disorders

Spinal injuries Impaired neurology

Used through a catheter mount

Cant be very oxygen dependant Contraindications / precautions same as positive

pressure


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Phew Any Questions ?!

Physiotherapy Assessment and Treatment on PICU

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