Chest physiotherapy in Pediatrics

Chest physiotherapy is an airway clearance technique that combines manual percussion of the chest wall by the caregiver, strategic positioning of the patient for mucus drainage with cough and breathing technique.

Techniques

• Positioning (postural drainage)
• Chest percussion
• Vibration
• Thoracic squeezing
• Cough stimulation

Positioning (Postural Drainage)

It is mere positioning of the child with assistance of gravity to stabilize the secretions toward the main bronchus.

Upper lobe

• Apical bronchus: Sitting upright with slight variation according to the position of the lesion, that is, slightly leaning backward, forward, or sideways
• Anterior bronchus: Lying supine with the knees slightly flexed
• Posterior bronchus:
• Right-lying on the left side and turn his face 45° resting against a pillow, with another pillow supporting the head.
• Left lying on the right side turning his/ her face 45° with three pillows arranged to lift the shoulders by 12 inches.

Middle lobe (right)

Lateral and medial bronchus-lying supine with the body a quarter turned to the left maintained by a pillow under the left side from shoulder to hip and foot end raised by 14 inches (35 cm).

Lingular (left)

Superior and inferior bronchus-lying supine with the body a quarter turned to the right maintained by a pillow under the left side from shoulder to hip and foot end raised by 14 inches (35 cm).

Lower lobe

• Apical basal bronchus-lying prone with a pillow under the hips.
• Anterior basal bronchus-lying supine with the buttocks resting on a pillow and the knees flexed. The foot of the bed raised by 18 inches (45 cm).
• Posterior basal bronchus-lying prone with a pillow under the hips. The foot of the bed raised by 18 inches (45 cm).
• Lateral basal bronchus-lying on the opposite side with a pillow under the hips.
  Foot of the bed raised by 18 inches (45 cm).
• Medial basal (cardiac) bronchus-lying on the right side with a pillow under the hips.
  Foot of the bed raised by 18 inches (45 cm).

Chest Percussion

Depending on the available area, the therapist can use a single or both cupped hands or three fingers with the middle finger tented or a face mask with either the part covered or occluded by a finger and strike repeatedly at a rate of 3/s over that part of the bronchopulmonary segment, which needs to be drained. T

he cupped hand/ mask tends to trap a cushion of air, which softens the blow while striking, and the air column inside the cupped hand causes effective dislodgement of the secretions in the underlying bronchus as the compression wave is presumably transmitted to the underlying bronchus and gravitational aid causes flow of secretions from the bronchus toward the glottis.

The movement should be only at the wrist without causing pain or discomfort and can be done throughout inspiration and expiration; rings (if any) should be removed before percussion.

Percussion should be vigorous but not painful and should not be done on bare skin, but over soft comfortable clothing or towels. Properly done percussion produces only sound rather than discomfort which the child gets used to in due course. Mechanical percussors are also available and may be useful in adolescents.

Vibration

In this 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. Vibration is a technical procedure and is usually effectively executed only by a physiotherapist.

Thoracic Squeezing

The expiratory phase is reinforced in this maneuver. The child is asked to take a deep breath and then exhale through the mouth as completely and rapidly as possible, as would be done for a forced expiratory volume determination. The depth of expiration is increased by brief firm pressure from the operator’s hand compressing the sides of the thorax (thoracic squeeze). This is usually done by a physiotherapist.

Cough Stimulation

Child can be requested to cough. In uncooperative or small children, tracheal stimulation or tickling can be done by placing index finger or thumb on anterior side of the neck against trachea just above sternal notch with gentle but firm inward pressure in circular pattern as the child begins to exhale. In certain diseases with respiratory involvement, the child may have feeble or ineffective cough and cough reinforcement is of much help in such conditions.

Here the child should be advised to cough out while the hand of the operator reinforces anticipated cough by synchronously compressing the lower half of the chest. The sputum may be collected in a container to quantify or demonstrate to the child and their parents. In small infants and children, a bulls sucker can be used to clear the oral and nasal secretions.

Note: For home therapy, postural drainage with cupped hand percussion and oral suction is advised. The caregivers have to be taught and demonstrated about the techniques before discharge.

Timing and Duration of Chest physiotherapy

Chest physiotherapy should be done one to four times a day, preferably hall an hour before meals or 1 and 0.5 hours after meals. The total duration should not exceed 30 minutes with 3-6 minutes in each position. Prior bronchodilator inhalation (preferably salbutamol) may effectively clear the lung secretions in children with associated bronchospasm. Breathing exercise or deep breathing or vigorous activity, such as skipping and jumping can precede postural drainage in order to loosen the secretions, provided such activity is not contraindicated. A printed sheet with pictures of various drainage positions explaining the procedures should be made available to the parents.

Physiotherapy in Young Infants

Position: Baby lying on the physiotherapist or mother’s lap and pillows could be added to achieve the required position.

During physiotherapy: the baby should be positioned in such a way that the facial color and breathing can be checked frequently. Toys and musical boxes can be shown to hold the attention of the toddlers while doing

CPT to overcome their fear and apprehension.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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