Chest Physiotherapy in Pediatrics Patients With Pneumonia
- 1 Introduction
- 2 Epidemiology
- 3 Medical Intervention
- 4 Types of Intervention
- 4.1 Chest Physiotherapy
- 4.1.1 Conventional chest physiotherapy
- 4.1.2 Modern techniques
- 4.1.3 Instrumental techniques
- 4.1 Chest Physiotherapy
- 5 Benefits of Chest Physiotherapy
- 6 Contraindications
- 7 Clinical Parameters as an outcome tool
- 8 Evidence
- 9 Resources
- 10 References
Pneumonia is the type of lung infection which is caused by bacteria, viruses, and fungi.
- These foreign microbes are responsible for inflammation of the lungs causing fluid collection in the alveoli and thus hamper the ventilation-perfusion ratio.
- As a protective mechanism, the accumulation of secretions in the airways occurs which worsens clinical symptoms and leads to an increase in airway resistance with each breath.
These signs and symptoms of Pneumonia (fever, tachypnoea, nasal flaring, cough, breathlessness, lower chest wall indrawing, and reduced oxygen saturation) are useful in diagnosing pneumonia. Chest Assessment also helps to determine the diagnosis and prognosis of the disease. Chest radiographic images are the gold standard for diagnoses of pneumonia.
Pneumonia is a leading cause of morbidity and mortality in children younger than the age of 5 years worldwide. Annually, there are an estimated 120 million cases of pneumonia worldwide, resulting in as many as 1.3 million deaths. Younger children under the age of 2 in the developing world, account for nearly 80% of pediatric deaths secondary to pneumonia. 
The etiology of pneumonia in the pediatric population can be classified by age-specific versus pathogen-specific organisms. neonates are more prone to have bacterial pneumonia whereas viral pneumonia is more common in toddlers. Community-acquired pneumonia ( CAP) is common among children globally, but incidence and mortality rates are significantly higher in low‐income countries. The factors for increasing incidence and mortality rates in developing countries include prematurity, malnutrition, low socioeconomic status, exposure to tobacco smoke, and child care attendance.
The original guidelines by WHO classified the severity of illness using simple clinical signs of children 2 to 59 months of age into four categories:
- Children with cough and cold who did not have signs of pneumonia were classified as “no pneumonia”, and their caregivers were advised on appropriate home care.
- Children with fast breathing were classified as “pneumonia” and were given an oral antibiotic (cotrimoxazole/ amoxicillin-at least 40 mg/kg/dose twice daily or 80mg/kg/day) to take at home for five days.
- Children who had chest indrawing with or without fast breathing were classified as “severe pneumonia” and were referred to the closest health facility for treatment with injectable penicillin.
- Children who had any general danger signs (Not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child or severe malnutrition) were classified as “severe pneumonia or very severe disease”. These children received the first dose of oral antibiotics and were then urgently referred to a health facility for further evaluation and treatment with parenteral antibiotics.
Supportive and symptomatic management is key and includes supplemental oxygen for hypoxia, antipyretics for fever, and fluids for dehydration. This is especially important for non-infectious pneumonitis and viral pneumonia for which antibiotics are not indicated. Cough suppressants are not recommended.
Types of Intervention
Chest physiotherapy is a widely used adjuvant treatment in pediatric patients with respiratory illnesses. The mechanical principles of physiotherapy techniques applied for children are similar to adults. However, it is important to consider children's specific respiratory system features. There are changes in respiratory structure and function from birth to adulthood that require continuous adaptation in the application of the chest physiotherapy techniques according to age.
Conventional chest physiotherapy
Postural drainage, vibration, percussion, huffing and coughing, and thoracic squeezing are conventional techniques that aim to facilitate mucociliary clearance. Conventional chest physiotherapy can be self-administered or performed with the assistance of another person (a physiotherapist, parent, or caregiver).
Postural drainage involves the positioning of the child with the assistance of gravity to mobilize secretions towards the main bronchus. Positioning for postural drainage can be directed by chest radiograph and auscultation to provide more effective drainage of secretions and exudated from the most affected area. 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.
For percussion, the therapist uses a single hand or both cupped hands or three fingers with the middle finger tented, or a facemask with the port either covered or occluded by a finger and strikes repeatedly at a rate of three per second over the part of the bronchopulmonary segment that needs to be drained.
In this technique, a rapid vibratory impulse is transmitted through the chest wall from the flattened hands of the therapist by isometric alternate contraction of forearm flexor and extensor muscles, to loosen and dislodge the airway secretions.
The child is requested to cough. In uncooperative or small children, tracheal stimulation or tickling can be performed by placing an index finger or thumb on the anterior side of the neck against a trachea just above the sternal notch with gentle but firm inward pressure in a circular pattern as the child begins to exhale.
This method stimulates the normal cough mechanism through the elevation of intrathoracic pressure. This technique, which does not require any special equipment, is used exclusively for the thorax. The hands are placed on the lower third of the thorax. The therapist then applies pressure to increase the forced expiratory volume (FEV) by 30%. It is not necessary to disconnect the patient from the ventilation machine during treatment, which decreases episodes of hypoxemia and the use of a high fraction of inspired oxygen (FiO₂).
Modern techniques use a variation of flow through breath control to mobilize secretions. Techniques include forced expiration, active cycle of breathing, autogenic drainage, assisted autogenic drainage, slow and prolonged expiration, increased expiratory flow, total slow expiration with the glottis open in a lateral posture, and inspiratory controlled flow exercises.
Autogenic drainage is a three‐phase breathing technique using high expiratory flow rates and variable lung volumes to unstick, collect, and evacuate secretions. It can be used to the children who can follow commands.
Assisted autogenic drainage:
This is a modified form of autogenic drainage, used for babies and young children because it does not require active participation. The physiotherapist influences the level of breathing without the child consciously influencing the level of breathing.
Slow and prolonged expiration:
This is an entirely passive technique used when the age of a young child makes them unable to co‐operate. The child is positioned supine. The therapist places one hand on the child's chest and the other on the abdomen. At the end of a spontaneous expiration, the pressure is applied to the chest caudally and on the abdomen in a cephalic orientation. The pressure is maintained for two to three respiratory cycles. No pressure is exerted during the first part of the expiration.
Increased expiratory flow:
This technique should be performed during the expiratory time using pressure exerted by the physiotherapist's hand on the child's chest, with the child lying supine. The other hand remains static over the abdomen to prevent the dissipation of pressure to the abdominal compartment, with the goal of deflation, the speed of which should be more than a spontaneous expiration.
Total slow expiration with the glottis open in a lateral posture:
The child is placed in a lateral position, and ma be helped by the physiotherapist or perform independently. The child takes nasal inspiration at the tidal volume level and slowly expires the breath with the open glottis at residual volume level..
Exercises of controlled inspiratory flow:
This technique can be performed in two positions: posterolateral and anterolateral. In the first position, the child is placed in a lateral position with the trunk and pelvis tilted slightly above perpendicular to the plane of support. In the second position, the child is placed in a lateral position with the limb flexed and the upper hand on the occipital region to promote the elongation of the pectoral musculature. In both placements, the child performs a slow, deep inspiration recruiting the inspiratory reserve volume, then a two‐ to three‐second post-inspiratory pause, followed by oral expiration at the functional residual capacity level.
Instrumental techniques, such as non‐invasive ventilation, have been considered useful as an adjunct therapy to airway clearance, and to provide respiratory support. A common instrumental technique is continuous positive airway pressure (CPAP). Continuous positive airway pressure can be provided conventionally or as bubble CPAP (bCPAP), by providing gentle air pressure to keep the airways open.
Positive expiratory pressure mask:
It provides resistance to expiration through a mouthpiece or facemask, followed by forced expirations. This treatment must be carried out in a sitting position: the child inhales and exhales through the mask 15 times (approximately two minutes). The inhalation is at tidal volume, and the expiration is slightly active against the mask. The child then removes the mask and performs two or three forced expirations followed by a cough to clear secretions that are mobilized to the central airways. This procedure is followed by a one‐ to a two‐minute period of relaxed, controlled breathing.
Continuous positive airway pressure (CPAP)
It is generated by exhalation against a constant opening pressure; this produces positive end‐expiratory pressure (PEEP). Continuous positive airway pressure can also be delivered by commercially available pressure drivers. These generally require tightly fitting nasal prongs or a CPAP facemasks.
It consists of an interface (nasal cannula), inspiratory tubing, and expiratory tubing immersed in an underwater bottle system. The child breathes spontaneously with positive pressure airflow, during both inspiration and expiration. Continuous positive airway pressure is thus maintained throughout the breathing cycle. Bubble CPAP requires the use of an adjustable flow generator, a pressure regulator, and an interface. The gas flow rate required to generate CPAP is usually 5 to 10 L/min. This alone can generate CPAP, without additional oxygen (FiO₂ = 0.21). A pressure control tube submerged in a bottle of water controls end‐expiratory pressure.
This is a pipe‐shaped device that creates oscillation and positive pressure on expiration that is used in conjunction with forced expirations. The child performs a nasal inhalation, followed by an inspiratory pause lasting two to three seconds. Oral exhalation must be fast enough to move the ball. The sequence should be repeated for 10 to 15 breaths.
This is referred to as sustained maximal inspiration and is accomplished by using a device that provides feedback when the recipient inhales at a predetermined flow or volume and sustains the inflation for at least five seconds.
Benefits of Chest Physiotherapy
The purpose or benefits of chest physiotherapy are:
- Evacuating inflammatory exudates and tracheobronchial secretions
- Removing airway obstructions.
- Decreasing airway resistance.
- Improving gas exchanges.
- Diminishing work of breathing.
- Not to percuss immediately after a meal. Do percuss before eating or wait at least one hour after.
Clinical Parameters as an outcome tool
These are some clinical parameters that can be used as outcome tools to assess the effectiveness of chest physiotherapy. It can be used as pre- and post-intervention assessment measures.
- Severe signs (chest indrawing, nasal flaring, cyanosis),
- Respiratory rate
- Arterial oxygen saturation ⩾95%
- Length of hospital stay (in days)
- Adventitious sounds on lung auscultation
- Time to clinical resolution.
Based on a recent Cochrane review published in 2019, no reliable conclusion can be made for chest physiotherapy in the pediatric population for pneumonia due to the small number of included trials with differing study characteristics and statistical presentation of data. Thus the further study is recommended.
Despite improving the child's respiratory status and expediting recovery, in certain situations physiotherapy may not be useful, or may even be harmful, increasing bronchospasm, inducing pulmonary hypertension, repositioning foreign bodies, or destabilizing a sick infant. Thus individualized physiotherapy intervention plan based upon assessment is crucial.
- Chaves GS, Freitas DA, Santino TA, Nogueira PA, Fregonezi GA, Mendonça KM. Chest physiotherapy for pneumonia in children. Cochrane Database of Systematic Reviews. 2019(1).
- Ebeledike C, Ahmad T. Pediatric Pneumonia. InStatPearls [Internet] 2020 Jan 6. StatPearls Publishing.
- Stuckey-Schrock K, Hayes BL, George CM. Community-acquired pneumonia in children. American family physician. 2012 Oct 1;86(7):661-7.
- World Health Organization. Revised WHO classification and treatment of pneumonia in children at health facilities: evidence summaries.2014
- Health Care Volunteers International (hcvi.org). CPAP for Neonatal and Pediatric Patients Training Video. Available from: https://www.youtube.com/watch?v=3xGSdJwYlnk. Lasted accessed: 30th August, 2020
- NICU Ed Portal. NICU Procedures- Bubble CPAP. Available from: https://www.youtube.com/watch?v=2Fp_3ucWAho. Last accessed: 30th August, 2020
- Paludo C, Zhang L, Lincho CS, Lemos DV, Real GG, Bergamin JA. Chest physical therapy for children hospitalised with acute pneumonia: a randomised controlled trial. Thorax. 2008 Sep 1;63(9):791-4.