Effectiveness of Assisted Autogenic Drainage & Percussive Ventilation in Pediatric Bronchi, Apuntes de Administración de Empresas

¡Descarga Effectiveness of Assisted Autogenic Drainage & Percussive Ventilation in Pediatric Bronchi y más Apuntes en PDF de Administración de Empresas solo en Docsity! Pediatric Pulmonology Effectiveness of Airway Clearance Techniques in Children Hospitalized With Acute Bronchiolitis F. Van Ginderdeuren, PT, MSc,1,2* Y. Vandenplas, MD, PhD,3 M. Deneyer, MD, PhD,3 S. Vanlaethem, PT, MSc,2 R. Buyl, PT, PhD,4 and E. Kerckhofs, PT, PhD1 Summary. Objective: To evaluate the effectiveness of two airway clearance techniques (ACT’s) in children<24months hospitalized with mild to moderate bronchiolitis. Design: One hundred and three children were randomly allocated to receive one 20-min session daily, either assisted autogenic drainage (AAD), intrapulmonary percussive ventilation (IPV), or bouncing (B) (control group), ninety-three finished the study.Outcomemeasures:Mean time to recovery in dayswasour primary outcome measure. The impact of the treatment and the daily improvement was also assessedbya validated clinical and respiratory severity score (WANGscore), heart rate (HR), and oxygen saturation (SaO2). Results: Mean time to recovery was 4.5
1.9 days for the control group, 3.6
1.4 days, P<0.05 for the AAD group and 3.5
1.3 days, P¼0.03 for the IPV group. Wang scores improved significantly for both physiotherapy techniques compared to the control group. Conclusion: Both ACT’s reduced significantly the length of hospital stay compared to no physiotherapy. Pediatr Pulmonol. 2016; 9999:XX–XX.
2016 Wiley Periodicals, Inc. Key words: airway clearance techniques; respiratory physiotherapy; intrapulmonary percussive ventilation; autogenic drainage; bronchiolitis. Funding source: none reported. INTRODUCTION Acute bronchiolitis is the most common lower respiratory tract infection in infants and children younger than 2 years of age and occurs in a seasonal pattern. It is mostly a self-limiting condition associated with the respiratory syncytial virus (70–85%).1 Usually it is a mild tomoderate disease, characterized by acute inflammation, edema, increased mucus production and bronchospasm, which affect the flow and permeability of the small airways, causing hyperinflation, wheezing, and even atelectasis. However in 1–3% of the cases, severe disease is developed and hospitalization is necessary.2 The treatment of bronchiolitis in children is largely symptomatic and supportive. Supplemental oxygen, fluid therapy, and respiratory support remain the mainstay of treatment.3 In 2013, a Cochrane meta-analysis concluded that hypertonic saline (HS) significantly reduced the hospital length of stay among children hospitalized with mild-to-moderate bronchiolitis and also improved clinical severity scores. HS increases the surface liquid by its osmotic action on the submucosal edema, improves mucociliary function and facilitates airway clearance.4 However, recent studies suggest that HS has no effect on length of hospital stay.5–7 Chest physiotherapy aims to clear airway obstruction, thereby decreasing airway resistance, improving gas exchange, and reducing respiratory load. It is widely used in the treatment of children with chronic respiratory disease, but has been debated for a long time as a treatment in bronchiolitis. No evidence was found that chest physiotherapy has a clinical benefit in children with acute bronchiolitis.2,8 The latest Cochrane review concluded that chest physiotherapy (chest percussion, vibrations in postural drainage positions, and forced 1Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels 1090, Belgium. 2Department of Physiotherapy, UZ Brussel, Brussels, Belgium. 3Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium. 4Information Research Group, Department of Public Health, Biostatistics and Medical Informatics, Vrije Universiteit Brussel, Brussels, Belgium. Conflicts of interest: None. Correspondence to: F. Van Ginderdeuren, PT, MSc, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels 1090, Belgium. E-mail: Filip.Vanginderdeuren@telenet.be Received 9 November 2015; Revised 5 May 2016; Accepted 13 May 2016. DOI 10.1002/ppul.23495 Published online in Wiley Online Library (wileyonlinelibrary.com).
2016 Wiley Periodicals, Inc. expiratory techniques) and passive expiratory techniques showed no effect on hospital stay, oximetry, and severity scores.9 Preliminary results on the prolonged slow expiration technique, a slow passive and progressive expiration from functional residual capacity to expiratory reserve volume, showed significant effects on clinical symptoms in moderate bronchiolitis and a cumulative day-to-day improvement. Larger randomized controlled trials are necessary to confirm these findings.10 Autogenic drainage (AD) is a breathing routine utilizing good body knowledge and expiratory airflow throughout the whole range of breathing from residual volume to total lung capacity. The aim of AD is to move secretions progressively from peripheral to more central airways by achieving an optimal expiratory flow progressively through all generations of bronchi without causing dynamic airway collapse.11,12 The effectiveness of AD has been demonstrated in cystic fibrosis (CF) patients13–15 and patients with chronic obstructive pulmonary disease (COPD).16 Assisted autogenic drainage (AAD) is the adaptation of AD in infants and young children not yet capable of carrying out this technique actively themselves. No data on AAD in children with bronchiolitis are available. Intrapulmonary percussive ventilation (IPV) improves airway secretion clearance in Duchenne muscular dystrophy,17 children with atelectasis,18 COPD exacerba- tion,19,20 tracheostomized patients,21 and patients with acute respiratory failure.20 Encouraging results with IPV have been obtained in patients with CF.22,23 To our knowledge there have been no trials of IPV in children with bronchiolitis. The primary objective of this open randomized clinical trial (RCT) was to evaluate the effectiveness of AAD and IPV in reducing the time to clinical stability and discharge from hospital in children aged less than 24 months old admitted for mild to moderate acute bronchiolitis, compared to children not receiving physiotherapy. The impact of the treatment and the daily improvement was also assessed by a validated clinical and respiratory severity score (WANG score), heart rate (HR), and oxygen saturation (SaO2). MATERIALS AND METHODS Study Population During three consecutive bronchiolitis outbreaks from December 2012 through January 2015, patients were recruited among children under the age of 2 years, hospitalized with a first episode of bronchiolitis. Bronchiolitis was diagnosed on the basis of clinical findings, including wheezing or wheezing with crackles and respiratory distress. Children were eligible within 24 hr of admission if they presented as a mild to moderate bronchiolitis with a Wang clinical severity score 3 and 8. The Wang clinical severity scoring system assigns a value between 0 and 3 to each of four variables: respiratory rate, wheezing, retractions, and general condition (Table 1). A higher Wang score indicated a worse condition.24 Exclusion criteria were: Wang score <3 and >8, comorbidities such as cystic fibrosis, neuromuscular, or congenital heart disease; respiratory distress, necessitating immediately admission to the intensive care unit, gestational age<34weeks, immediate treatment with corticosteroids, antibiotics, or more than three inhalations with bronchodilators at hospital intake. Patients were recruited by the participating physiothera- pists or by the study physician. Informed consent was obtained by one of the parents. Children were randomized to the different treatment modalities by the attribution of a computer generated number (Randomization.com, 2011), using the method of randomly permuted blocks.25 Each number was contained in a sealed opaque envelope opened by the physiotherapist after inclusion. Envelopes were prepared by a physiotherapist, not involved in the clinical phase of the study. All pediatric department staff and parents were blind to treatment assignment. Study Intervention Treatment, either intervention or control, began at least 2 hr. after the latest inhalation and feeds in order to exclude their influence on the outcome measures. Children had one 20-min treatment session daily, performed by two well-trained physiotherapists in the different modalities. If no spontaneous coughing occurred, coughing was triggered every 5min by a gentle pressure on the suprasternal notch. Children were randomly assigned to one of the following treatment modalities during their hospital stay: Assisted autogenic drainage: AAD is based upon the principles of autogenic drainage and used in children and patients unable to assist in the treatment. By modulating manually the functional breathing level within the vital capacity, optimal airflow will be obtained at the targeted airway generations, where secretions have been identi- fied. AAD is carried out in a gentle and progressive way, using the patient’s breathing pattern and stabilizing the child’s abdominal wall to avoid paradoxical movements. A gentle increase of manual pressure on the chest during each inspiration is performed to guide the breathing of the patient towards the desired lung volume level. By restricting manually the inspiratory level the patient is stimulated to exhale slightly more than the previous breathing cycle. During expiration, the breathing move- ment of the patient is followed gently. No thoracic compression or excessive force is performed, which could lead to a resisting response by the patient. Feedback plays a key-roll, feeling or hearing the secretions move while avoiding any early or abnormal airway compression or 2 Van Ginderdeuren et al. Pediatric Pulmonology linear airflow velocity provides the turbulent flow, high shearing forces at the airway walls, and high kinetic energy that moves secretions cephalad.33 In this study, analyzing the subscores of theWang score separately to better distinguish the impact of AAD and IPVon different respiratory and general items, wheezing improved significantly after IPV compared to AAD and control and the effect maintained after 1 hr, probably due to the positive pressure delivered by the IPV device. Cambonie et al. reported previously a sharp reduction of expiratory wheezing after 1 hr of nasal continuous positive airway pressure in children with bronchiolitis.34 In viral bronchiolitis, characterized by inflammation, oedema, and necrosis of epithelial cells lining small airways and increased mucus production, ACT’s could be efficacious in helping the clearance of airway secre- tions.31 Higher sputum volumes are correlated with a higher degree of lung obstruction. In children the intercostal muscles are underdeveloped and mechanically less efficient due to the horizontal alignment of the ribs. Therefore, children depend on their diaphragm for respiration. The flatter diaphragm is mechanically less efficient and has proportionallymore fast twitch fibers and fewer slow twitch (endurance) fibers and is, therefore, more vulnerable to respiratory fatigue than in the mature individual. A higher degree of obstruction leads to more respiratory distress, resulting in subcostal and intercostal retractions.11 AAD and IPVare both effective in removing Fig. 1. Flow chart. Fig. 2. Proportion of hospitalized patients versus hospitalization time. Airway Clearance Techniques in Bronchiolitis 5 Pediatric Pulmonology secretions from the respiratory tract in a short period of time. Unfortunately, there is no technique available to measure the amount of coughed up secretions in children, because they do not expectorate. Counting the number of coughs is inadequate, because dry coughs occur. Due to the bouncing, children appeared to tolerate well both ACT’s during our study and displayed no crying or distressed behavior with an increase of HR. Children even showed a significant decrease of HR in the IPV group 80min after treatment at day 1. In our long experience, children felt “very threat- ened” during respiratory physiotherapy, often leading to resistance against or crying during therapy, which decreased the efficacy or the intended effects. A significant association between crying, increased reflux episodes, and lower oxygen saturation has been recorded in children with CF.35 Therefore, bouncing in a well-supported 908 upright position is used to maximize the relaxation of the child. There are some limitations to this study: Awell-defined group of children hospitalized withmild to moderate bronchiolitis was selected. More research on the effect of respiratory physiotherapy is necessary in children suffering from very mild bronchiolitis managed on an outpatient basis, or severely ill children, eventually admitted to ICU. No significant differences between the three groups in SaO2 at T20 and T80 were observed. Differences in SaO2 were probably wiped out by the scores of the children receiving oxygen, because SaO2 remained 100% before, at T20 and T80 in 64% of the control group, 58% in the AAD group and 51% in the IPV group. Oxygen was administered if SaO2 was 92%. The nursing staff recorded HR, respiratory frequency, SaO2 and general well-being every 4 hr. Oxygen supply was decreased in a very conservative way depending on the SaO2 and the general state of the child. It was the observers opinion that in some children too much oxygen was administered for a too long period of time, resulting in 100% SaO2. Although the setting in our control group was similar to the one in the study of Luo et al.,30 we found a discrepancy in length of hospital stay (4.5
1.9 days in our control group vs. 6.0
1.2 days in Luo’s study). A possible explanations could be Wang scores at admission in Luo’s group (5.8
1.2) were slightly worse than in our control group (5.3
0.9). A fourth group combining AAD and IPV would have been of interest to detect a possible strengthening effect of both techniques. Both physiotherapy techniques used in this study are highly specialized and need awell-trained physiotherapist to perform. Equipment for IPV is unfortunately very expensive and not available in every hospital to perform these treatments. CONCLUSION This study showed the effectiveness of AAD and IPV, combined with bouncing, in this well-defined group of hospitalized children with mild to moderate bronchiolitis. Both ACT’s reduced significantly the length of hospital stay and some respiratory symptoms of bronchial obstruction compared to no physiotherapy. It is important to recall that these observations cannot be extended to outpatients or critically ill children, whether admitted to ICU or not. Further research is necessary. REFERENCES 1. Bush A, Thomson AH. Acute bronchiolitis. BMJ 2007;335: 1037–1041. 2. Gajdos V, Katsahian S, Beydon N, Abadie V, de Pontual L, Larrar S, EpaudR, Chevallier B, Bailleux S,Mollet-Boudjemline A, et al. Effectiveness of chest physiotherapy in infants hospitalized with acute bronchiolitis: a multicenter, randomized, controlled trial. PLoS Med 2010;7:e1000345. 3. Castro-Rodriguez JA, JR G, ER-M C. Principal findings of systematic reviews of acute asthma treatment in childhood. J Asthma 2015;52:1038–1045. 4. Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2013;7:CD006458. TABLE 3—Length of Hospital Stay and Mean Differences of Wang Score, SaO2, and HR Between the Groups Over All Hospitalization Days Bouncing AAD IPV PB-AAD PB-IPV PAAD-IPV Hospital stay (days)
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SD 5
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