Respiratory Physiotherapy for Cerebral Palsy


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Respiratory Physiotherapy for Cerebral Palsy

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Respiratory Physiotherapy for Cerebral Palsy

  1. 1. This presentation will be looking at respiratory physiotherapy for patients withcerebral palsy. 1
  2. 2. Obviously with cerebral palsy being such an umbrella term covering a wide range ofdisability, the assessment and treatment of patients with CP will vary greatly andshould be individualised, considering things such as mental capacity, age, symptomsand function. 2
  3. 3. While CP itself does not directly cause lung dysfunction, the consequences ofneuromuscular impairment may lead to lung damage and reduced lung function.Proper respiratory function depends on the ability to breath properly, cougheffectively, and identify respiratory infections promptly.These patients are at risk of respiratory complications due to:Immobility as a result of muscle dyscoordination and weakness, frequentlycomplicated by cognitive impairment and shallow, irregular breathingIneffective cough as a result of dyscoordination of bulbar muscles and weakness ofthe muscles of the abdomen and diaphragm (stages of a cough)Chronic aspiration as a result of dysphagia, gastroesophageal reflux, and seizuresDelay in diagnosis due to inability to disclose discomfort & unsuitable assessmenttechniques (for example peak cough flow)Restrictive lung disease components as a result of respiratory muscle weakness andstructural deformity such as scoliosisThey are often premature babies- so frequently associated respiratory problems eg.bronchopulmonary dysplasia and respiratory distress syndromeWeakened immune systemAll of this contributing towards a greater risk of developing respiratory complications. 3
  4. 4. What are the consequences of these respiratory complications?Retained secretions physically obstruct airways, leading to:• Infectious exacerbations and bacterial colonization, resulting from stagnation ofsecretions• Immobilization of cilia• Ventilation/perfusion mismatch• Atelectasis & Airway obstructionThere is also chemical damage to airways as pooled secretions contain highconcentrations of cytotoxic inflammatory mediators(such as cytokines and leukotrines)which can cause:• Increased mucus production• Intensified inflammatory response• Oedema• Bronchospasm• Destruction of cilia• Progressive parenchymal damage• Irreversible fibrosis(Braverman 2001) 4
  5. 5. The main indication for treatment will come from your assessment.This may include objective measures such as PCF, InspVC, MIPS/MEPS etc, assubjective assessment of cough is generally considered to be not accurate enough,however the parameters of poor or normal or effective are less clearly defined forchildren than adults (eg. PCF>160lpm to be effective in adults).There may also be problems with inability to comply with Ax such an ineffective sealor comprehension or coordination difficulties.The Mental Capacity Act should also be considered with regard to whether thepatient has the capacity to make decisions about their Ax & Rx.The RCH CP chest infection guidelines state that:Chest physiotherapy is helpful if children have large airway secretions and a poorcough, or focal consolidation.And this should have been identified from your assessment.The primary focus of respiratory management for individuals with CP must be toprevent mucus stasis that will lead to atelectasis and infection. Aggressive attentionto airway clearance is central to breaking the lethal cycle of recurrent infection andprogressive pulmonary deterioration. (Braverman 2001) 5
  6. 6. A very general table of some interventions that may be appropriate for a patient withCP, some of these may not fit easily into one category so these are not definitive andit is far from an exhaustive list.It does show that we’ve come a long way from the ketchup bottle method, so tippingit up, shaking it and squeezing it. (Otherwise known as postural drainage, percussion,vibs and cough assistance: Falk 1984)The British Thoracic Society guidelines do not cover patients with CP, and theevidence is extremely lacking in terms of respiratory treatments, so intervention mustbe clinically reasoned by the assessment findings and individual requirements of thepatient.Intervention is aimed at optimising quality of life for the child foremost. The views ofthe parents must also be taken into account. (Seddon and Khan 2003)When selecting a technique, the severity of airway clearance impairment, patientcomfort, and ease of performance of the available techniques should be considered.In order to achieve optimal outcomes, it is critical to identify at an individual levelwhich form of treatment is most effective. (Braverman 2001) 6
  7. 7. Reduced physical activity is a risk factor for pulmonary complications, and theimpaired neuromotor control in these patients can inhibit the amount of mobilityachievable. But depending on their level of function, there should be an appropriateway of getting some movement. Even if their only mobility is being passively rolled orhoist transferred, sometimes that can be enough to get some secretions moving.With the more mobile, younger patients, you can use games, make believe, blowingbubbles, musical instruments are great for some expiratory muscle strengthening…Anything can be made into play, so that they don’t even realise that it’s therapy.(Instruments: Charususin 2010)A study by Ersöz et al (2006) recommended that pulmonary rehabilitation -involvingbreathing exercises for proper expansion, regularity of respiration and strengtheningof expiratory and postural muscles- be started as early as possible to preventworsening chest mobility and hence respiratory function.Whilst most hydrotherapy evidence in CP is relating to its effects on gross motorfunction and spasticity,In a study by Hutzler et al (1998) into exercise and swimming for children with CP, theintervention group showed a considerable increase in VC at a mean rate of 65%above base-line values, while the control group improvement was only 23%.This was a greater increase than shown in a previous study by Rothman (1978), whichshowed a 31% increase in VC using breathing exercises alone. 7
  8. 8. There are different reasons for altering the position of a patient, to reduce breathless,to improve ventilation/perfusion matching and also for postural drainage. Hussey(1992) describes how it is important to regularly change position to prevent themucous pooling and atelectasis that occurs in the pos basal regions when supine.Lying prone has been shown by Mackenzie et al (1989) to increase TV and MV with a25% increase in arterial oxygen tension in babies, this stabilises the anterior chestwall, limiting inward collapse of the ribcage, but patients should be monitoredcarefully due to the position being implicated in sudden infant death syndrome. SLcan remove abdominal loading on diaphragm and being sat upright gives betterdiaphragm excursion.[V/Q] Young children (below about 10) ventilate their uppermost lung preferentially,due to an incomplete airway support system, and so to optimise gas exchange, the‘good’ lung should be places uppermost.However, physiotherapists may wish to place the ‘bad’ lung up in order to drainsecretions and to open up areas of atelectasis. This may cause oxygen saturation todrop unless an increased fraction of inspired oxygen is given, as shown by Davies et al(1985). There is now increasing evidence that challenges the safety of the traditionalhead down PD positions, due to gastroesophageal reflux, and the diaphragm being ata mechanical disadvantage causing dyspnoea and desaturation. Consequently themodified postural drainage positions are now more commonly used for this pt group.(Finder 2010) 8
  9. 9. [Modified postural drainage positions]•Supine 30° head up•Prone horizontal•Left and right horizontal side lying•Upright sitting for apical segment of upper lobe (this is done leaning against thetherapists/carers shoulder or sitting upright). 8
  10. 10. Often used in CP, as it is passive and effective at mobilising secretions. Should becombined with the modified postural drainage positions to remove secretions fasterthan positioning alone, but still remains time consuming for the patient. (Gallon1992)There is great variation in how percussion and chest wall vibrations can be delivered,and should be adapted based on the individual patient circumstances, for instance forsmall infants, a face mask may be used to tap on.Wollmer et al (1985) suggested that a slow rate of percussion is preferred, as firm orfast percussion can disturb airflow, causing local airway closure and timing to allow aninfant to take a breath between each percussion reduces this risk.Whilst an article by Balachandran et al (2005) suggests percussion should bedelivered at a rate of 3 per second, Blazey et al (1998) discusses how the rate ofoptimal percussion has not and possibly can not be established due to the differencesin patient circumstances, recommending that it be considered for each individualpatient alone.A study by Shannon and Robyn Stiger et al (2010) suggested that chest wall vibrationsmay vary in application but must be applied at the beginning of, or slightly before,expiration to generate sufficient expiratory flows to be effective. 9
  11. 11. Aka. The Vest. It works by an air pressure generator rapidly inflating and deflating thevest, which compresses and releases the chest wall at a frequency and pressuredesignated by settings on the machine, up to 25 times per second. This processdislodges mucus from the bronchial walls, moving it along toward more centralairways for eventual expectoration.It is commonly used in CF, however evidence for use in cerebral palsy is limited, arandomised control trial by Yuan et al (2010) showed excellent safety, tolerability, andbetter compliance with high-frequency chest wall oscillation compared to standardchest physiotherapy.Another small study (Plioplys et al 2002) demonstrated more frequent removal ofsecretions by suction, reduced incidence of pneumonia, and reduced number ofhospitalizations for pneumonia.No special positioning or breathing techniques are required, and it is techniqueindependent, as is Intrapulmonary Percussive Ventilation, however it doesn’t requirean effective seal around a mouthpiece like IPV does, so therefore can be useful forpatients with CP, however it could potentially be strange or uncomfortable to apatient without the capacity to comprehend the therapy. 10
  12. 12. There are different devices available, bubble PEP, PEP by facemask, by mouthpiece,the Cornet, Acapella, Flutter…An evidence review by Finder (2010) stated that most devices which deliveroscillating PEP (positive airway pressure) are effort dependent and as such aregenerally ineffective in the very weak neuromuscular patient.However a study into PEP treatment in children with multiple severe disabilitiesshowed that PEP increases blood oxygen tension immediately after treatment inseverely disabled children with airway mucus accumulation. (Lagerkvist 2005) 11
  13. 13. These techniques often require a level of comprehension and cooperation,glossopharyngeal breathing in particular is a difficult technique and requires intactbulbar function and coordination, and is rarely used in the presence of a trachy.The bird (IPPB) may be useful for individuals who are unable to take a sufficientlydeep breath for an effective cough, however may require some ability to synchronizeand tolerate inspiration with the machine.(Braverman 2001) 12
  14. 14. It may be said that without an effective cough, secretion mobilization will not resultin secretion clearance.When considering manual assisted cough it is important to consider the patient’scomprehension as it can be quite a forceful manoeuvre.Cough stimulation for expectoration may be something as simple as tickling, or moreclinical using a suction catheter or tracheal stimulation (which is still somewhatcontroversial).The mechanical in-exsufflator augments both insp & exp and may be usesul iftolerated by the patient. 13
  15. 15. Combining (using timing) of physio treatment and medications for optimal effectAnd a combination of techniques to unstick the secretions, move them up therespiratory tract, augment inspiration to achieve greater lung volumes and aidexpiration for effective expectoration. 14
  16. 16. Involving the consideration of all elements of patient needs such as spasticity,pressure sores, positioning, transfers, social situation etc.Health promotion- is not only encouraging exercise and stop smoking advice but alsogiving advise on ensuring that they have their regular vaccinations, are taking theirmedications as prescribed, wearing any splints and anything else that may be ofpertinence to the individual patient and their holistic care needs.(Jones et al 2007) 15
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