Physiotherapy
The main problem for the lungs is the presence of increased amounts of sticky mucus that are prone to becoming colonised with bacteria. Although the lungs are normal at birth repeated infections and inflammation in the airways damages the lungs over time. The role of physiotherapy is to remove as much of this mucus as possible either through mechanical means (physiotherapy techniques) or in combination with nebulised treatments to loosen mucus enabling easy expectoration (coughing up phlegm). Techniques used by the child at home are reviewed at each clinic visit. The parents/patients techniques are assessed, advice is given on exercise, advice on pelvic floor management and incontinence management is also given, this becomes a problem due to frequent episodes of coughing
Babies
Many babies appear completely well with no chest symptoms, others have problems from the beginning. In either case the first things parents learn is how to assess the chest and how to carry out physiotherapy. Most babies will require physiotherapy twice every day, some only when they have a cold or a cough.
What physiotherapy techniques can be used in babies?
1. Postural drainage – uses the force of gravity to drain secretions from the chest. The baby is placed in different positions to help secretions drain from different areas of the chest. Usually there are 4 positions which the baby is placed in for a few minutes at a time. This can be done on a pillow on a parents lap and takes about 15 minutes. More frequent or longer treatments are given when the baby is unwell. All babies are treated flat; ‘tipping’ techniques are no longer used.
2. Percussion or chest clapping is often combined with postural drainage positions. The baby’s chest is clapped repeatedly with a cupped hand. The baby remains lightly clothed. They usually enjoy the attention and it is not painful.
3. Positive Expiratory Pressure (PEP) mask. A face mask is used.
4. Assisted autogenic drainage – uses deep and shallow breathing in sequences so aid movement of mucus from the small airways to the large.
5. Some babies may be on nebulised drug treatments.
Toddlers
Children aged 2 to 3 years can co-operate with and learn techniques for themselves gradually taking a more active role in their own physiotherapy. For example they can learn huffing and play blowing games e.g. blowing bubbles under water (bubble PEP). Most children will require two 15 minute sessions of physiotherapy, and time taken will vary depending on mood and co-cooperativeness of the child, whether they cough up secretions or vomit with coughing. Physiotherapy may seem like an endless battle for some at this age. Some children will have begun nebulised treatments at this age.
Older children
Older children can co-operate with physiotherapy and will gradually learn to manage their therapy for themselves. Typically children are encouraged to do their treatment independently with help and supervision from the parent carer in the same room from age 8. Taking responsibility for their own treatment and ensuring it is done is the next milestone and this might be achieved by age 14. For example a teenager may carry out all of their own physiotherapy except for when they are unwell with an exacerbation. In practice teenagers doing their own treatments without supervision tend to cut corners. Parents may take no active part in treatments at this age but perform an important role prompting and supervising the majority of treatments. A child’s ability to manage their physiotherapy will depend on their maturity and their state of health.
The following physiotherapy techniques are commonly used:
- Postural drainage – positioning the body to take advantage of gravity to clear secretions.
- Percussion or chest clapping – clapping the chest with a cupped hand to loosen secretions often combined with postural drainage.
- Chest shaking/vibrations – shaking or vibrating the chest wall whilst breathing out.
- Huff – important airway clearance technique – forced breath out with mouth open as if steaming up a mirror with a breath.
- Autogenic drainage – a series of breathing exercises that increase flow of air to move secretions and improve ventilation. There are 3 phases of breathing:
- Mobilising phase
- Collecting phase
- Clearing phase – huff
- High Frequency Chest Wall Oscillation (HFCWO)/vest therapy – an inflatable jacket is worn, this is pressurised and vibrates, so loosening secretions. This is used rarely but may be useful in patients who have problems with adherence or who have significant disease, as an adjunct to other techniques.
- Positive Expiratory Pressure (PEP) – applies back pressure to the airways to prevent them from collapsing when they are empty when breathing out. This can help move secretions and open the airways. There are various small devices that can be used to provide positive pressure. 8 -12 breaths are taken using the device followed by huffs to clear secretions. This is repeated until the chest feels clear. They are called PEP devices.
- Oscillating positive expiratory pressure (PEP) devices: These are also small non-electrical devices that contain moving parts that can transmit vibration to the airways and aid in loosening secretions. The devices include:
- The flutter
- The Acapella
- The Cornet
Exercise
Vigorous exercise improves lung function and children will be encouraged to do some every day.
