Untitled Quiz

Cardiopulmonary Physiotherapy: Paediatric and Other Common Lung Diseases

• Course code: RS3770/RS5316
• Topic: Paediatric and other common lung diseases
• Instructor: Dr. David YU, Professor of Practice, Department of Rehabilitation Sciences

Terminology

• Neonates: Newly born infants (first 4 weeks after birth)
• Infants: From the end of the 4th week to the time of assuming an upright posture (12–14/24 months)

Differences in Pediatric Pulmonary Anatomy

• Rib orientation: In infants and young children, ribs are more horizontal than in adults, limiting chest movement.
• Rib cartilage: More flexible and springy in children, making the chest wall less rigid, which can affect tidal volume during respiratory distress.
• Intercostal muscles: Less developed in younger children, potentially impacting rib cage movement, especially when lying down.
• Head size: The back of a child's head may be larger than in adults, potentially restricting neck flexion and causing airway obstruction.
• Tongue size: Infants and children often have a proportionally larger tongue compared to their mouth space, which can cause potential airway obstruction.
• Breathing preference: Younger children are primarily nose breathers.
• Airway size: Children's airways are smaller and more prone to obstruction.
• Respiratory rate: Higher respiratory rates in children make them more vulnerable to airborne irritants.

Common Neonatal and Paediatric Respiratory Conditions

• Meconium aspiration
• Infant respiratory distress syndrome (IRDS)
• Bronchopulmonary dysplasia (BPD)
• Upper respiratory tract infection
• Acute epiglottitis
• Acute laryngotracheobronchitis
• Lower respiratory tract infection
• Bronchiolitis
• Bronchopneumonia

Meconium Aspiration

• Meconium is the first stool of a newborn, typically passed within the first day after birth.
• Meconium aspiration syndrome occurs when a newborn inhales meconium and amniotic fluid during or shortly after birth.
• It can block airways, damage lung tissue, and cause pneumonia.

Infant Respiratory Distress Syndrome (IRDS)

• Also known as surfactant deficiency disorder or Hyaline Membrane Disease.
• Developmental insufficiency of pulmonary surfactant production and structural immaturity in the lungs results in difficulty with breathing.
• More frequent in males, and in infants of diabetic mothers and premature twins.

Bronchopulmonary Dysplasia (BPD)

• A chronic lung disease that affects premature infants.
• The alveoli (air sacs in the lungs) may not fully mature.
• Infants requiring long-term supplemental oxygen are at higher risk.
• Common in low birth weight infants receiving prolonged mechanical ventilation.

Etiology of BPD

• Prolonged high-oxygen delivery can cause necrotizing bronchiolitis and septal injury resulting in inflammation and scarring.

Clinical Presentation of BPD

• Hypoxemia- reduced blood oxygen
• Crackles, wheezing, and decreased breath sounds
• Increased bronchial secretions
• Lung hyperinflation
• Frequent lower respiratory infections
• Delayed growth and development
• Cor pulmonale- heart disease
• CXR shows hyperinflation, low diaphragm, atelectasis, cystic changes

Management of BPD

• Nutritional supplementation
• Fluid restriction, diuretics
• Inhaled bronchodilators, inhaled corticosteroids (as a last resort)
• Oxygen therapy
• Non-invasive mechanical ventilation
• Chest physiotherapy

Upper Respiratory Tract Infections (URTIs)

• Rhinitis (common cold), sinusitis, ear infections, acute pharyngitis or tonsillopharyngitis, laryngitis, epiglottitis, laryngotracheobronchitis.
• Caused by viruses, but bacteria or other organisms are possible.
• Key causes for viral infection in URTI: parainfluenza, influenza types A and B.

Acute Epiglottitis

• Usually caused by Haemophilus influenzae type B bacteria.
• Other causes include: Streptococcus pneumonia, herpes simplex virus, varicella-zoster viruses.
• High fever and a sore throat are initial symptoms.

Symptoms and Treatment of Acute Epiglottitis

• Symptoms
  • Abnormal breath sounds (stridor) due to airway obstruction
  • Fever
  • Cyanosis
  • Drooling
  • Difficulty breathing
  • Difficulty swallowing
  • Voice changes (hoarseness)
• Treatment
  • Usually intensive care (ICU)
  • Intubation
  • Tracheostomy (as a last resort)
  • Humidified oxygen
  • Antibiotics
  • Anti-inflammatory (corticosteroids)
  • IV fluids

Acute Laryngotracheobronchitis (Croup)

• A viral respiratory infection.
• Common causes: Parainfluenza virus and Influenza A and B.
• Inflammation of the larynx, trachea, and bronchi.
• Causes obstruction of the upper airway.
• Stridor (a harsh, high-pitched sound during breathing) is a characteristic symptom.
• A croupy barking cough, inspiratory stridor, and varying degrees of respiratory distress frequently occur.

Radiological Changes in Croup

• Lateral neck X-rays show a slightly dilated hypopharynx (red arrow), dilatation of the laryngeal ventricle (white arrow), and narrowing of the subglottic trachea (blue arrow).

Acute Laryngotracheobronchitis (croup) Management

• Condition improves with relaxation, reassurance and breathing warm humidified gas.
• Intubation if necessary.
• Suction avoided if possible.

Lower Respiratory Tract Infections

• Acute bronchitis/bronchiolitis- involving bronchi and bronchioles
• Fever, coughs, hyperinflated lungs in bronchiolitis
• Severe cases: barrel chest, prominent neck vein
• Management: supportive care for viral infection/ antibiotics for bacterial infection

Acute Bronchiolitis

• Usually caused by respiratory syncytial virus (RSV).
• Causes swelling and irritation and mucus build-up in the bronchioles.

Clinical Presentations of Acute Bronchiolitis

• Increasingly fussy and difficulty feeding during 2-5 day incubation period.
• Low-grade fever (<101.5°F), possible hypothermia in infants under one month.
• Increasing coryza and congestion
• Apnea- may be the presenting symptom in early disease
• Respiratory distress, tachypnea, nasal flaring, retractions
• Irritability.
• Possibly cyanosis

Bronchopneumonia

• Inflammation of the bronchi and surrounding lung tissue.
• Caused by viral or bacterial infection.

Chronic Coughs and Inflammation

• Loss of cilia
• Mucosal oedema
• Necrosis of epithelial cells
• Obstruction of the lumen by cellular debris
• Thick secretions

Lower Respiratory Tract Infections: Management

• Oxygen therapy
• Antibiotics
• Removal of bronchial secretions

Special Considerations in Pediatric Respiratory Care

• Exercise and airway clearance techniques
• Positioning (NEVER use head-down position in children with increased intracranial pressure)
• Percussion and vibration techniques
• Suctioning (naso/oro-pharyngeal) and endotracheal suction.
• Avoid nasopharyngeal suction in patients with stridor and recently extubated children.
• Keep suction pressure as low as possible to avoid tracheal mucous membrane trauma.
• Manual hyperinflation should be performed with caution in premature infants, children with pre-existing lung conditions such as asthma and bronchiolitis.

Common Lung Diseases

• COPD
• Asthma
• Bronchiectasis
• Lung carcinoma
• Pneumothorax
• Pleural effusion
• Empyema
• Interstitial lung disease
• Occupational lung disease
• Tuberculosis
• Acute Respiratory Distress Syndrome (ARDS)

Lung Carcinoma

• Non-small cell lung carcinoma (NSCLC)
  • Adenocarcinoma
  • Squamous cell carcinoma
  • Large cell carcinoma
• Small cell lung carcinoma (SCLC)

Staging of Lung Cancer (TMN)

• Primary tumor (T)

• Regional lymph node (N)

• Distant metastasis (M)

• Detailed Staging criteria include specific tumor size, extension, and involvement of regional lymph nodes, with associated classifications for different stages (e.g., Stages IA through IV).

Symptoms of Lung Cancer

• Early stage: no symptoms; may have nonspecific respiratory problems like coughing, shortness of breath, or chest pain.
• Later stages: loss of appetite, weight loss, chest pain, shortness of breath (potentially due to pleural effusion), bone pain (metastasis), hoarseness (recurrent laryngeal nerve compression), neurological signs (brain metastasis).

Diagnosis of Lung Cancer

• CXR
• CT thorax
• Lung biopsy (FOB, FNAC)
• PET scanning or combined PET-CT scanning

(For stage-specific treatment, there are different management strategies involved.)

Management of Lung Cancer

• Stage I and II NSCLC: often treated with surgical removal of the affected lung lobe.
• Stage III NSCLC: surgery with lymph node removal and chemotherapy/radiotherapy.
• Stage IV NSCLC: combinations of pain management, radiotherapy, immunotherapy, and chemotherapy.
• SCLC: chemotherapy and radiotherapy are the main treatment strategies.

Lung Resections: Procedures Methods

• Wedge resection
• Segmentectomy
• Lobectomy
• Pneumonectomy

Physiotherapy Management for Lung Resections

• Chest expansion of remaining lung tissue.
• Secretion mobilization
• Maintain physical integrity (i.e., shoulder range of motion, including strengthening exercises).
• DVT prevention
• Early mobilization to allow safe and early discharge.
• Home exercises for endurance improvement.

Pleural Effusion

• Excessive fluid accumulation in the pleural space.
• CXR shows dense homogeneous shadows occupying the hemithorax.

Types of Pleural Effusions

• Transudates (protein content < 30g/L): caused by Heart failure, Hypoproteinaemia, Liver cirrhosis, Constrictive pericarditis, Hypothyroidism
• Exudates (protein content > 30g/L): caused by Parapneumonic effusion (pneumonia), Malignancy (various cancers or metastases), Infection (empyema), Tuberculosis, Trauma, Pulmonary infarction, pulmonary embolism, Autoimmune disorders, Pancreatitis, Ruptured esophagus, Rheumatoid pleurisy, Drug-induced lupus

Pneumothorax

• Air in the pleural space.

• Direct trauma (e.g., chest injury, surgical procedures).

• Spontaneous pneumothorax (e.g., ruptured bullae)

• Tension pneumothorax: life threatening and requires urgent medical intervention.

  • Tracheal deviation
  • Ipsilateral diaphragm depression/flattening
  • Mediastinum shifting, and heart being pushed to the opposite side.

• Symptoms and treatment may vary depending upon the type of pneumothorax.

Surgical Emphysema

• Air becomes trapped in subcutaneous tissues/skin.
• Crackling sensation when palpating affected skin or tissue.
• Texture in palpated subcutaneous areas
• Potential discomfort or difficulty breathing depending on how much air is trapped.

Chest Drain and Pigtail

• Tubes used for draining fluid from the pleural space, which may aid in treating pneumothorax and other respiratory complications.

Atrium Chest Drain System

• A system commonly used for monitoring and managing pleural drainage (in patients who have had lung surgery, for example).
• Includes monitoring of fluid suction, allowing for observation of drainage amount and rate.

Moving Patients with Drains

• Procedures performed when moving patients with respiratory devices such as drains and ventilators.
• Cautious moving of chest drains/pigtail to avoid any complications.

Pleurodesis for Pneumothorax and Pleural Effusions

• Procedures used for prevention of repeat/recurrent pneumothorax and pleural effusions.
• Performed through chemical or surgical pleurodesis methods.
• Chemical method used for chemicals like tetracycline and talc.

Empyema Thoracis

• Presence of pus within the pleural cavity, typically resulting from bacterial spread from a pneumonia or from a ruptured lung abscess.

Decortication for Empyema

• Surgery used to remove inflamed and thickened pleural tissue (pleural peel) which restricts pulmonary expansion.
• Usually performed after pus drainage.

Interstitial Lung Disease (ILD)

• A group of lung diseases affecting the tissue between air sacs.
• Characterized by scarring or thickening of tissue, impairing normal functioning.
• Common cause: idiopathic pulmonary fibrosis (IPF)

Secondary Causes of ILD

• Connective tissue disorders (e.g., sarcoidosis, rheumatoid arthritis, systemic lupus erythematosus).
• Drug-induced: certain antibiotics, chemotherapeutic drugs, and others.
• Infections (e.g., COVID-19, pneumonia, etc.)
• Inhaled substances (pneumoconiosis e.g., silicosis, asbestosis, berylliosis).
• Hypersensitivity/allergic responses- hypersensitivity pneumonitis.

Symptoms of ILD

• Chronic cough
• Progressive dyspnea (shortness of breath)
• Worsening exercise intolerance
• Velcro crackles on auscultation
• Significant oxygen desaturation during exercise
• Finger clubbing

Diagnosis of ILD

• CXR: fibrotic changes, increased infiltrates
• High-resolution CT (HRCT): honeycombing
• Lung function tests: restrictive pattern
• Diffusion capacity of carbon monoxide (DLCO) reduced alveolar/blood capillary transport

Treatment for ILD

• Oxygen therapy (LTOT)
• Pulmonary rehabilitation
• Lung transplant (selected cases)
• Antituberculosis drugs. May be beneficial in specific disease conditions.

Occupational Lung Disease

• Diseases resulting from exposure to harmful materials at work.
• Often caused by various types of dust, particles, gases, or fumes (e.g., asbestos, coal dust, silica).
• Symptoms often include coughing, shortness of breath, chest pain, wheezing, and other breathing problems.

Symptoms of Occupational Lung Disease

• Cough
• Shortness of breath (especially with exertion)
• Chest pain and tightness
• Abnormal breathing patterns
• Wheezing
• Scratchy, dry, or sore throat

Complications of Occupational Lung Disease

• Progressive lung fibrosis.
• Decline in lung function
• Severe shortness of breath even at rest.
• Increased risk of lung cancer and tuberculosis (TB)

Tuberculosis (TB)

• Infectious disease caused by Mycobacterium tuberculosis.
• Transmission via inhalation of infectious droplets (nuclei containing viable bacilli).
• Notifiable disease in Hong Kong since 1939

Following Inhalation of M. tuberculosis…

• Failure to register infection
• Become infected, but clear infection
• Contain infection, but latent TB infection persists
• Develop progressive TB disease

Symptoms of Tuberculosis

• Cough lasting more than 3 weeks (sometimes with blood-stained sputum)
• Feeling tired
• High temperature or night sweats
• Loss of appetite
• Weight loss

Extrapulmonary TB Effects

• Central nervous system (e.g., meningitis)
• Lymphatics (e.g., scrofula)
• Pleura (pleurisy)
• Bones and joints (e.g., Pott's disease)
• Urogenital system

Diagnosis of Tuberculosis

• CXR: irregular patches in the lungs
• Lymph node swelling
• Sputum test: acid-fast bacilli (AFB) smear, or culture.
• Mantoux tuberculin skin test – less common

Tuberculosis Treatment

• 6-month standard four-drug short course (isoniazid, rifampicin, pyrazinamide, and either streptomycin or ethambutol).
• Directly observed therapy (DOT) is used to monitor the patient and ensure adherence to the medical regimen.

Complications of Tuberculosis

• Multiple drug-resistant TB (MDR-TB)
• Lung fibrosis
• Cavitary lesions
• Tuberculoma

Tuberculosis Prevention

• BCG (Bacille Calmette-Guérin) vaccine: live-attenuated vaccine form of Mycobacterium bovis; used to prevent TB and other mycobacterial infections.
• Wearing N95 masks when handling active TB patients.

Acute Respiratory Distress Syndrome (ARDS)

• A type of respiratory failure with a rapid onset of widespread lung inflammation.

• Also commonly known as Adult Respiratory Distress Syndrome

ARDS: Berlin Definition

• Timing: within 1 week of a clinical precipitating event
• Radiological changes: Bilateral opacities in the chest X-ray
• Fluid overload: no history of cardiac failure
• Oxygenation: PaO2/FiO2 ratio is less than or equal to 300

ARDS Causes: Direct Causes

• Pneumonia
• Aspiration (e.g., stomach contents)
• Inhalation of toxic substances
• Chest trauma
• Near-drowning
• Fat embolism
• Lung transplantation

ARDS Causes: Indirect Causes

• Sepsis
• Severe trauma
• Massive blood transfusion
• Pancreatitis
• Cardiopulmonary bypass
• Drug overdose

ARDS Pathophysiology

• Inflammation-mediated disruption in alveolar-capillary permeability.
• Pulmonary oedema
• Reduced alveolar clearance and collapse (decruitment).
• Reduction in lung compliance and increased pulmonary vascular resistance.
• Abnormal gaseous exchange (shunting and ventilation-perfusion mismatch).

ARDS Clinical Presentations

• Shortness of breath
• Tachypnea
• Cyanosis
• Muscle fatigue, general weakness, low blood pressure, dry, hacking cough and fever.

ARDS Complications

• Lung damage like barotrauma/volutrauma, pulmonary embolism (PE), or VAP
• Gastrointestinal issues like bleeding or dysmotility, and possibly bacterial translocation.
• Neurological damage due to hypoxia.
• Cardiac abnormalities such as abnormal heart rhythms and myocardial dysfunction.
• Kidney issues including acute kidney failure and electrolyte abnormalities
• Mechanical issues such as vascular injury or pneumothorax, including injuries related to endotracheal tubes and placement of pulmonary artery catheters
• Nutritional problems: malnutrition (catabolic state), electrolyte abnormalities
• Lung atelectasis- lung collapse, DVT- Deep vein thrombosis, Pulmonary hypertension, and Acute respiratory distress syndrome.

ARDS Management

• Lung-protective ventilation- 4-8mL/kg predicted bodyweight, plateau pressure controlled less than 30 cmH₂O
• Early administration of corticosteroids within 14 days of ARDS onset
• Inhaled vasodilators (e.g., inhaled nitric oxide (iNO)).
• Use of prone positioning for 12 hours daily.
• Extracorporeal Membrane Oxygenation (ECMO).
• Prevention of complications.