Physiotherapy management in

adults vs neonates
INTRODUCTION
• The respiratory system in neonates differs significantly from adults, both
anatomically and physiologically .

• These differences have important consequences for physiotherapy care of

children in terms of respiratory assessment, treatment and choice of techniques.

• Where as the main reason for adult admission in hospital is cardiac failure ,the
principle reason for hospital admission for children aged 0-4 years is respiratory
illness.
•The main goal of physiotherapy is to maximize cardiorespiratory
function in both neonates and adults by treating or preventing
cardiopulmonary problems.

•This is usually achieved by assisting with the removal of

tracheobronchial secretions, removing airway obstruction , expanding
areas of collapsed lung, removing airway resistance ,optimizing gas
exchange and reducing the effort of breathing in patients with
respiratory distress.
Differences

• Postural drainage coupled with percussion, vibrations and suction are

all used in the physiotherapy management of respiratory disorders.
• Postural Drainage: In indult patients, deep-breathing exercises,
vibrations during expiration and huffing are incorporated in the
technique. In neonates the technique is applied without the active
participation of the neonate.
Postural drainage
• Postural drainage consists of placing the patient in a position that
employs gravity to move mucus centrally from the targeted lung unit.
A patient is taught to lie at certain angles or get into certain positions in
order to help drain the lungs of fluid.

• Postural drainage in a neonate is administered by positioning the

baby over the knees of the therapist .
Chest percussions
• Is an airway clearance that involves clapping on the chest/ back to
help loosen thick secretions.
• In adults a single cupped hand/both hands can be used while in
neonates “tenting” using the first two or three fingers of one hand
with slight elevation of the middle finger.
• Mechanical devices such as palm cups (small/bigger) and percussors
may be used .

1. Small palm cups 2. Percussor

Chest vibrations
• Chest vibrations helps to gently shake mucus and secretions into the
large airways ,making them easier to cough up.
• Placing a flat hand over the appropriate lung segment and stiffening
the arm and shoulder and applying light pressure to create the
shaking movement.
• In neonates great care should be taken not to do this springing too
vigorously as it may cause rib fracture.
• Mechanical vibrators are also available. Some are appropriate ONLY
for newborns whereas others are appropriate for adults.
Coughing
• Coughing In adults, promoting a cough is a basic aspect of treatment.
Unlike in adults, the cough reflex in neonates is not fully developed
until 32-34 weeks of gestation.

• The ribs of neonates are positioned horizontally and the intercostal

muscles are weak, resulting in a predominantly diaphragmatic
breathing pattern. neonates naturally use diaphragmatic breathing
pattern. Therefore, they are susceptible to diaphragmatic fatigue.
Because of this, their treatment is centred at increasing the rate of
breathing rather than depth of ventilation as it is the case for adults
diaphragmatic fatigue.
• exercise tolerance is seen to be an emphasis in adults as opposed to
neonates.
• Anatomically, a new-born has high larynx enabling the epiglottis to
guide the larynx up the soft palate to produce a direct airway from
the nasal cavity to the lungs. This makes them to be obligatory nose-
breathers. Therefore, mechanical oxygen supply is a must in neonates
in instances of nasal blockage
Conclusion
• A thorough assessment of neonates and adults in the respiratory
physiotherapy management is essential. It is a guideline to the
indication and the lung segment involved. Positioning is the baseline
of respiratory physiotherapy management in both neonates and
adults. Since respiratory conditions are characterized by the
production of sputum in the lungs, the removal of this sputum is the
ultimate goal so as to clear the airway..
Broncho-pulmonary dysphasia

•  Bronchopulmonary dysplasia (BPD) is a chronic lung condition that is

caused by tissue damage to the lungs.[1]  It usually occurs in immature
infants who have had severe lung disease at birth, such as respiratory
distress syndrome, and have needed to receive mechanical
ventilation and supplemental oxygen as treatment for more than a
few weeks after birth. The delicate tissues of the lungs can become
injured when the alveoli (air sacs) are hyper inflated (over-stretched)
by the ventilation or by high oxygen levels. As a result, the lungs
become inflamed and additional fluid accumulates within the lungs
• BPD is marked by inflammation, exudates, scarring, fibrosis,
and emphysema, and most commonly presents itself in pre-term
infants to 21 days post natal.
• Newborns who suffer from BPD may also experience trouble feeding,
leading to delayed development.

• It is believed that a variety of toxic factors contribute to the

formation of BPD by injuring the small airways, eventually resulting in
a reduction of the alveolar surface area. This affects gaseous
exchange which further compromises blood oxygenation.[4]
In stage 1 (1-3 days),
• the pathologic appearances of BPD are identical to those of
respiratory distress syndrome where there is not enough surfactant in
the lungs. Surfactant helps to lower surface tension in the airways
and this helps keep the lung alveoli open. It involves the presence of
hyaline membranes, atelectasis, vascular hyperemia, and lymphatic
dilatation
In stage 2 (4-10 days),
• lung destruction resulting in ischeamic necrosis of airways occurs due
to stretching of the terminal bronchioles. Immediate reparative
changes in the lungs as well as bronchiolar obstruction are also seen
in this stage. Hyaline membranes can persist into this stage and
emphysematous coalescence of the alveoli is seen
Stage 3 (11-20 days)
• involves progressive repair of the lung, with a decreased number of
alveoli. There is compensatory hypertrophy of the remaining alveoli,
and hypertrophy of bronchial-wall muscle and glands. Regenerating
clear cells are seen, along with exudation of alveolar macrophages
and histiocytes into airways. Airtrapping, pulmonary hyperinflation,
tracheomegaly, tracheomalacia, interstitial edema, and ciliary
dysfunction may also be present
In stage 4 (>1 month),
• emphysematous alveoli are seen. Chronic lung damage eventually
causes Pulmonary hypertension (caused by thickening of the inner-
most lining of pulmonary arterioles), and results in cor pulmonale.
Fibrosis, atelectasis, a cobblestone appearance due to uneven lung
aeration, and pleural pseudofissures are often seen. Marked
hypertrophy of peribronchiolar smooth muscle is present.[4]
• Causes and 
Causes and risk factors
• BPD occurs in severely ill infants who have received high levels of
oxygen for long periods of time or who have been on a ventilator
during treatment for respiratory distress syndrome. It is more
common in infants born early (premature) whose lungs were not fully
developed at birth.[
• The following risk factors have been identified:
• Premature birth.
• Respiratory Infection.
• Meconium aspiration.
• Congenital heart disease.
• It may also occur as a secondary problem for the neonate attached to
a mechanical ventilator
Signs and Symptoms
• The most noted signs in an infant with BPD. The most Common signs
of BPD are:
• Shortness of breath
• Cough
• Wheezing
• If BPD worsens, the infant will present with:
• Severely difficult breathing with grunting
• The chest and abdomen move in opposite directions with every
breath
• Rib retractions: ribs are visible during each breath
• Nasal flaring: nostrils open wide during each breath
• Use of accessory muscles: neck muscles are prominent during each
breath
• Rapid breathing rate
• Complications of BPD
Complications of BPD
• They are often more susceptible to respiratory infections such as
influenza and pneumonia. The infection is worse in children with BPD
than in normal infants.
• Pulmonary oedema, an excess fluid build-up in the lungs, which
decreases air entry into the lungs and infants cannot breathe which
results in respiratory distress.
• Infants with a history of BPD may also develop a rare complication in
their circulatory system known as pulmonary hypertension. This
occurs when the blood vessels carrying blood from the heart to the
lungs become narrowed, resulting in high blood pressure.
• Infants with BPD have stunted growth and have problems gaining
weight. They also tend to lose more weight when they are sick.
• Premature infants with severe BPD also have a higher incidence of
cerebral palsy
Prevention
• There are a number of things a mother can do to prevent her baby from
being born before their lungs have fully developed:
• During pregnancy, regular check ups with the doctor should be done.
• Dietary supplements are essential, along with good, healthy eating habits.
• Avoid smoking, consuming alcohol and taking illegal drugs.
• It is vital that the mother-to-be is controlling any chronic diseases (e.g.
Diabetes, Hypertension etc.) with proper medication.
• Mothers-to-be must make sure that they attend to all cuts and bruises as
soon as possible to prevent infections and other easily attainable
communicable diseases.
TREATMENT
• Breathing Support
• The baby is usually put on a mechanical ventilator. The ventilator, which is
connected to a breathing tube that runs through the baby's mouth or nose
into the windpipe, can be set to help a baby breathe or to completely control
a baby's breathing. It also is set to give the amount of oxygen the baby
requires. With help breathing, the baby's lungs have a chance to develop.[6]
• Surfactant Replacement Therapy
• The baby is given surfactant to open his or her lungs until the lungs have
developed enough to start making their own surfactant. Surfactant is given
through a tube that is attached to the ventilator, which pushes the
surfactant directly into the baby's lungs.
• Medication
• Medication is usually prescribed to reduce swelling in the airways and
improve the flow of air in and out of the lungs. These medications
include:
• Bronchodilators – Bronchoconstriction and airway hyper reactivity.
• Diuretics - Pulmonary edema, and removal of extra fluid in the lungs.
• Steroids - To decrease airway inflammation.
• Vasodilators - Cor pulmonale.
• Antibiotics - Control infections
Physiotherapy Management
• It must be noted that infants with Bronchopulmonary Dysplasia are cared for
in the Neonatal Intensive Care Unit.
• The mainstay of physiotherapy treatment is to clear the chest of secretions.
This can be done by:
• Vibrations and light percussions.
• Changing positions helps to mobilise secretions out of the small airways.
• Suctioning and mucolytics may be an option for tenacious sputum and when
the child has difficulty coughing.

• [7]
• [8]
Evidence
• There is limited evidence for the role of physiotherapy in the
treatment of BPD. A study carried out by Gomez-Comesa et al,
reported that physiotherapy treatment in the NICU was effective in
improving BPD in prematurely born children with respiratory distress
syndrome. Physiotherapy assisted in reducing the number of days
that ventilation and hospitalization were required and favoured the
prevention of future disabilitie
•.
• Different conditions may affect the growth of the fetus during the
pregnancy and may also lead to premature labor. Prenatal infections
or maternal complications such as smoking, drug use, placental
abnormalities (preeclampsia) and inflammation of the fetal
membranes (chorioamnionitis) may cause BPD.
• After birth, respiratory distress syndrome (RDS) is closely linked to the
development of BPD, though only some infants with RDS will develop
BPD. Another condition called patent ductus arteriosus, a heart
defect in which the blood vessel connecting the right and left side of
the heart fail to close and remain open, may lead to BPD if the child is
put on a ventilator.
Who Is at Risk for BPD?

• The degree of prematurity in an infant is largely what puts a child at

risk of developing BPD. A majority of newborns who develop BPD are
born more than 10 weeks early, weigh less than two pounds at birth,
and are born with breathing problems. BPD is rare in infants born
after
•
Symptoms of Bronchopulmonary
Dysplasia
• The symptoms of BPD vary depending on its severity. The most
common symptoms of bronchopulmonary dysplasia are:
• Rapid breathing
• Labored breathing (drawing in of the lower chest while breathing in)
• Wheezing (a soft whistling sound as the baby breathes out)
• The need for continued oxygen therapy after the gestational age of
36 weeks
• Difficulty feeding
• Repeated lung infections that may require hospitalization
Preventing Bronchopulmonary Dysplasia
• Ensuring that your baby is born after the lungs are fully developed is
the best prevention for bronchopulmonary dysplasia. Healthy
pregnancy practices may increase this likelihood. Simple steps every
mother should take are: avoid smoking, alcohol and drugs, eat right,
prevent infections and see your doctor regularly.
• If there is a risk of delivering your baby prematurely, your doctor may
give you injections of a corticosteroid medicine that speeds up the
development of the baby’s lung ability to produce surfactant. This will
lower the risk of your baby developing respiratory distress syndrome,
which can lead to BPD.
Treatment
• There is no specific cure for BPD, but treatment focuses on
minimizing further lung damage and providing support for the infant’s
lungs, allowing them to heal and grow. Newborns suffering from BPS
are frequently treated in a hospital setting, where they can be
continuously monitored. 
Types of drug therapies
• Diuretics: This class of drugs helps to decrease the amount of fluid in and
around the alveoli. They are usually given by mouth one to four times per day.
• Bronchodilators: These medications help relax the muscles around the air
passages, which makes breathing easier by widening the airway openings.
They are usually given as an aerosol by a mask over the infant's face and using
a nebulizer or an inhaler with a spacer.
• Corticosteroids: These drugs reduce and/or prevent inflammation within the
lungs. They help reduce swelling in the windpipe and decrease the amount of
mucus that is produced. Like bronchodilators, they are also usually given as an
aerosol with a mask, either with the use of a nebulizer or an inhaler with a
spacer.
• Viral immunization: Children with BPD are at increased risk for
respiratory tract infections especially respiratory syncytial virus (RSV).
Infants with moderate or severe BPD receive monthly injections with
a medication that helps prevent the infection during the RSV season.
• Cardiac medications: A few infants with BPD may require special
medications that help relax the muscles around the blood vessels in
the lung, allowing the blood to pass more freely and reduce the strain
on the heart.
• Patients with more severe disease may need oxygen for several
months. They may also need some form of support with a machine
that delivers pressure through the nose through special prongs or a
mask. These machines provide either nasal continuous positive
airway pressure (NCPAP) or bilevel positive airway pressure (BiPAP). A
small number of patients with very severe disease may need to stay
on a ventilator for a long time, in which case they will need to receive
a tracheostomy (a breathing tube inserted into the lungs through the
neck).
Managing Bronchopulmonary Dysplasia

• BPD tends to cause the most trouble during infancy and early
childhood, with symptoms receding by 2 or 3 years of age and
treatment ending by 5 years of age at the latest. However, the lungs
may not develop normally and this can cause other lung problems
later in life. This is why it is highly recommended that infants with
BPD receive regular check-ups, timely vaccinations and consultations
with a pediatric lung specialist at least during the first few years of
life.
• Premature infants with even mild BPD are at risk for other
developmental problems. Many newborns with BPD will experience
pauses in breathing (apnea), feeding complications that may be
severe enough to require a feeding tube, GERD, pulmonary
hypertension, neurologic complications, vision or hearing problems
and various learning disabilities. Most of these complications are rare
in those with mild to moderate BPD.
• After discharge from the hospital, growth may still be delayed. Your
child may continue to experience lung problems into adulthood.
Many people who have BPD as infants may develop reactive airway
disease or asthma and struggle with exercise intolerance for the rest
of their life. They may also be more susceptible to infections, such as
a cold or the flu. Symptoms of these viruses may be more severe, and
it may take them longer to recover.