Chest Physiotherapy and Airway Clearance in Pediatrics

Rob DiBlasi RRT-NPS, FAARCProgram Manager Research/QI, Respiratory TherapyPrinciple Investigator, SCRIMarch 22, 2017

Conflict of Interest

I have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to

merely illustrate a point of emphasis.

Objectives

Learning objectives for this presentation:• Discuss different forms of airway clearance

therapies (ACTs) • Review the literature related to the use of

ACTs in pediatric lung disease• Discuss ways to embrace judicious use of

ACTs in patients using evidence-based approaches

Background

Airway Clearance Techniques (ACTs) are used in variety of settings for a variety of clinical ailments:

1) evidence of retained pulmonary secretions 2) weak or ineffective cough 3) focal lung opacity on chest x-ray consistent with mucous plugging and/or atelectasis and 4) intrapulmonary shunt requiring oxygen

Chest Physiotherapy

Postural Drainage

http://www.cfbarbados.org/content/treatment

Chest Physiotherapy

Other Airway Clearance Options: ACTs

Therapy Vest

Hand-Held Airway Clearance

Cough Assist

Nasotracheal Sx

ACTs cont’d

Incentive Spirometry

Ambulation

Breathing games

Literature Search

• ACTs have only been shown to be effective in children with CF, Bronchiectasis and neuromuscular weakness

• Lack of definitive data for ACT for common forms of pediatric respiratory failure• Pneumonia (may cause patients condition to worsen)• Bronchiolitis, asthma, pleural effusion• Prevention of atelectasis

Bronchiolitis

• Systematic review to determine efficacy of CPT in infants with acute viral bronchiolitis <2 years old

• Reviewed improvement in disease severity, LOS, and oxygen use

• Nine clinical trials including 891 participants were included comparing CPT with no intervention

• CPT was not found to improve the severity of the disease, respiratory parameters, or reduce length of hospital stay or oxygen requirements in infants

Roqué i Figuls Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2012

Are ACTs a useful option with pneumonia?

Pneumonia

• RCT with children (29 d to 12 y old) hospitalized with acute pneumonia, and compared twice-daily CPT and standard pneumonia therapy (n =51) to standard treatment alone (n =47)• The CPT group had a longer median duration

of coughing (5.0 d vs 4.0 d, P =0.04) and longer duration of rhonchi (median 2.0 d vs 0.5 d, P= 0.03) than the medical treatment only group

Paloudo, Thorax, 2008

ACT in Asthma

• Randomized Placebo Controlled Trial • 38 children aged 6 to 13 years with severe

asthma • 19 children received chest physical therapy

(PT) and 19 children received placebo visits• Lung function at the end of the study was

similar in both groups

Asher I et al., Pediatr Pulmonol, 1990

Can ACT resolve acute lobar atelectasis during mechanical ventilation?

• Larger ventilated patients (Templeton M et al., Intensive Care Med,2007)• CPT may be useful for acute lobar or segmental

atelectasis based on radiographic evidence• Neonates-post-extubation (Flenady et al.,

Cochrane 2002)• No benefit to peri-extubation CPT• No decrease in post-extubation lobar collapse• Lower re-intubation rate in babies treated with CPT

Can CPT and other ACTs prevent atelectasis?

Cardiac Transplant

CXR from 4/15/15. CPT ordered TID. Reason for order: “Lobar Atelectasis.”  Radiologist noted “no focal infiltrates” on 4/15/15. 

CXR from 4/16/15. CPT provided TID. Radiologist noted “lungs are somewhat overinflated mild shadowing in infrahilar areas”

Room Air HHFNC 4‐6 L/min 

Tricuspid AtresiaRoom Air HFNC 5 L/min for 72 hours

4/14 “Mild Perihilar haziness suggestive of edema” Receiving CPT TID to RULRT attempted to get this DC’dMD: “well, I guess you are going to have to do it anyway.”RT: “how about increasing PEEP”?

4/16/15 Radiologist noted “No lobar consolidation” CPT reordered for “Right sided lobar collapse.”

4/16/15 0610 CPT Q4 for 72 hours Radiologist noted “mild increase in RUL opacity”Cost to patient: $6,300.00RT time: 6 hours at the bedside

6 L/min HHFNC FiO2 35

4/14/15 Ordered for “left hemidiaphragm paresis” and then order changed to “lobar atelectasis”

Can ACT prevent lobar atelectasis or VAP?

• Mechanically ventilated adult patients (Chen YC, J Clin Med Assoc, 2009)• No differences in VAP between CPT and no intervention

ACT in pleural effusion

Systematic Review

• Included 24 RCTs, seven crossover RCTs, and one prospective cohort study in adults and patients (n=2,453)

• Patients with CF and neuromuscular disease were excluded

• Based on these data, this review found no evidence from RCTs to support the use of CPT or any other form of ACT in adults or pediatrics to:• improve oxygenation, reduce length of time on the ventilator, reduce

stay in the ICU, resolve atelectasis/consolidation, and/or improve respiratory mechanics versus usual care in this population

Andrews et al., Resp Care, 2013

Evidence Based Review-Pediatrics

Andrews et al., Resp Care, 2013

Risks Associated with ACT

• Gastroesophageal reflux (Button BM, Pediatr Res 1994)

• Decreased oxygenation and increased oxygenation requirements (Hough JL, Cochrane, 2008)

• Rib fracture (Purchit DM, Am J Dis Child, 1975)

• Increased intracranial pressure and intracranial bleeding (Harding JE, J Pediatr, 1998)

• Longer duration of fever (Britton S, BMJ, 1985)

• Increased vomiting and respiratory instability (Roque et al., Cochrane, 2012)

• Increased SOB, arrhythmia, bronchospasm, thoracic hematoma (Andrews J, Resp Care, 2013)

Photo courtesy of Seattle Children’s Hospital RT Dept with permission

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Problem: RT Staffing CrisisD

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Allocation of RT resources: Airway Clearance

$548,310

$908,670 $1,017,660

$1,431,150

Reasons “other” than those indicated in the order set

“prevention of lobar atelectasis, diffuse pneumonia, increased work of breathing, inability to clear secretions, obstruction of V-P shunt and pleural effusion, complete lung opacification while on extracorporeal life support, wheezing, microaspiration, comfort (soothing), decreased breath sounds, no abdominal domain, poor pulmonary compliance, bronchiolitis, excessive nasal and/or oral pooling, junky breath sounds, , post-operative fever and paroxysmal cough.”

Goal

• We proposed a therapist‐driven protocol that allows RTs to provide appropriate and judicious ACT care to patients– Less risk to the patient– Less expense to payers– Less strain on RT resources– Improved job satisfaction for RTs

UCL 0.28

CL 0.20

LCL 0.12

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Calendar Days

Total Tx Per Patient Day- All PatientsPatients with moderate-high level evidence for ACT use: 67% increase

All Patients, All Diseases: All Airway Clearance Therapies

Patients with low level evidence for ACT use: 65% increase

UCL 0.11

CL 0.07

LCL 0.03

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Total Tx's per Patient Day- Group APatients with Bronchiolitis, Pneumonia, Pleural Effusion, Asthma

as Primary or Secondary Diagnoses

UCL 0.20

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Tx P

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Tx's per Patient DayPatients without Pneumonia, Bronchitis, Bronchiolitis or Asthma

as Primary or Secondary Dx

Step 1: MD orders RT Airway Clearance Consult

Step 2: Assess and Treat

Step 3: Entering the Power Plan per Protocol on behalf of the ordering provider

Post-Protocol 7/1/2016 - 1/31/2016

All patients billed for Airway Clearance Procedures

Excluded CF Patients

Pre-Protocol 2/5/2012 - 6/30/2015

All patients billed for Airway Clearance Procedures

Excluded CF Patients

CPT Only Other ACT

Metrics:• Tx’s per Pt Day• Tx’s per Calendar Day• Revenue per Pt Day*• Revenue per Calendar Day*

Study Design: Ongoing Metrics

CPT Only Other ACT

* Revenue data were inflation adjusted to keep all data in constant 2012 dollars

Metrics:• Tx’s per Pt Day• Tx’s per Calendar Day• Revenue per Pt Day*• Revenue per Calendar Day*

44% reduction Tx/PPD39% reduction in revenue 

4% increase in Tx/PPD17% increase in revenue 

Sudden Clinical DeteriorationsAmong Non-CF Patients Receiving CPT or ACT

Before and After Protocol Implementation

SCD? PRE POSTNO 2646 392YES 122 13

RATE 4.6% 3.3%

COUNT OF ENCOUNTERS

There was no significant difference in SCDs between PRE and POST Airway Clearance Consult, P=0.264 (Chi‐Square)

Shared Learnings

• Developing a hospital-wide RT Driven Protocol (clinical standard work) is not EASY work

• Clinical Standard Work can result in significant cost savings and potentially lower risk to the patient

• Must engage/include key stakeholders from multiple disciplines• Share evidence-based data and publications• Solicit input from RN, MD, RT leadership• Work with IS to develop an appropriate order set

• Ongoing assessment of metrics is necessary to evaluate the success of our efforts

Conclusion

• The effectiveness of airway clearance therapy lacks definitive data in different pediatric populations

• CPT may do more harm than good in some patients and clinicians should weigh risk vs benefit with tx• Bronchiolitis, post-op, pneumonia, prevention of atelectasis

• Educating clinicians and patients on ACTs is essential• Not all patients can be managed with a standardized

ACT protocol and care may need to be modified or individualized