Airway clearance therapy in acute paediatric respiratory illness: A state-of-the-art review

Abstract

Background: Despite unclear evidence of effectiveness or safety, airway clearance therapy (ACT) is frequently performed in infants and children with acute pulmonary disease.

Objectives: The aim of this review was to critically synthesise published evidence, expert opinion and pathophysiological principles to describe the indications, effects, precautions and application of commonly used ACT modalities for managing infants and children with acute pulmonary disease.

Method: A comprehensive narrative review of published literature was conducted. Articles describing paediatric populations were prioritised, but adult and animal studies were also considered where appropriate.

Results: There is a dearth of high-level evidence supporting the use of ACT in acutely ill infants and children. Conversely, studies have highlighted the lack of effect of different modalities for a variety of conditions, and in some cases serious associated complications have been reported.Airway clearance therapy may be considered when there is retention of pulmonary secretions, and the consequential airway obstruction impacts either acutely on respiratory mechanics and gaseous exchange and/or has the potential for long-term adverse sequelae [a condition that is the consequence of a previous disease or injury]. However, it should not be considered a routine intervention.

Conclusion: Airway clearance therapy should not be performed routinely in children admitted to hospital with acute respiratory conditions. Patients should be clinically assessed and treatment planned according to individual presentation, in those with signs and symptoms that are potentially amenable to ACT.

Clinical implications: This review can serve as a guide for physiotherapists in the respiratory management of children with acute respiratory illness, as well as identifying areas for clinical research.

Keywords: acute; airway clearance therapy; chest physiotherapy; lower respiratory tract infection; paediatric; physical therapy.

FIGURE 1

The International Classification of Functioning, Disability and Health model (World Health Organisation).

FIGURE 2

Selected examples of the inter-relationships among different systems and physiotherapeutic interventions in infants and children.

FIGURE 3

Components and examples of variations in the active cycle of breathing technique.

FIGURE 4

The equal pressure point during a forced expiratory technique at different lung volumes, (a) low volume, (b) mid volume and (c) high volume.

FIGURE 5

The author’s then 4-year old daughter doing ‘fun’ positive expiratory pressure therapy following Nissen’s funduplication surgery and postoperative pulmonary complications.