clinical parameters as an outcome tool

The Genesis ISSN 2395-2164 Volume: 7 Issue: 4 October – December - 2020

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CLINICAL PARAMETERS AS AN OUTCOME TOOL Mrs. G. Sarojini * | Dr. Manjubala Dash **

*Ph.D. Scholar, Himalayan University, Itanagar, Arunachal Pradesh, India & Professor, Department of Paediatric Nursing, Sacred Heart Nursing College, Madurai, Tamilnadu, India.

** Research Guide, Professor & HOD, Department of OBG Nursing, Mother Theresa Post Graduate & Research Institute of Health Sciences, Puducherry, India.

DOI: http://doi.org/10.47211/tg.2020.v07i04.012

ABSTRACT Lower Respiratory tract infections in under 5 children constitute a major public health problem all over the world especially in developing countries .There are nearly 156 million new episodes each year, of which India accounts for a bulk of 43million Acute respiratory infections (ARI) which are the leading causes of neonatal and child mortality. Pneumonia and Bronchiolitis are the most common illness affecting infants and children globally. It is the most common cause of under-5 (U-5) mortality and contributes to 15% of U-5 mortality killing an estimated 808,920 children. India is one of the largest contributors to under-five mortality in the world. (WHO). Multiple infection control techniques and strategies simultaneously may offer the best opportunity to reduce the morbidity and mortality. Many non-pharmacological interventions to prevent and reduce risk of antibiotic-resistant organisms are to improve efficacy of antibiotics given to patients who do acquire infections. In that, Chest physiotherapy is a vital adjuvant in the treatment of most respiratory illnesses and is commonly used in children with Chronic Respiratory or Neuromuscular disease. The main goal of Paediatric Chest Physiotherapy is to help with the clearance of trachea bronchial secretions, thereby to reduce airway resistance, enhance gas exchange and make breathing easier. There are some clinical parameters that can be used as outcome tools to assess the effectiveness of chest physiotherapy for Children with Lower Respiratory Infection It can be used as pre- and post-intervention assessment measures. KEY WORDS: Lower Respiratory Tract Infection, Bronchiolitis, Pneumonia, less than five children Chest physiotherapy. ABOUT AUTHORS:

Author Mrs. G. Sarojini, Ph.D. Scholar, Himalayan University, Itanagar, Arunachal Pradesh, India & Professor,

Department of Paediatric Nursing, Sacred Heart Nursing College, Madurai, Tamilnadu, India. She is active

researcher and has attended various Seminars and conferences.

Author Dr. Manjubala Dash is Research Guide, Professor & HOD, Department of OBG Nursing, Mother Theresa

Post Graduate & Research Institute of Health Sciences, Puducherry, India. She has published various research

articles in National and International Journals.


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INTRODUCTION Respiratory tract infections are common diseases in children Pneumonia is a leading cause of morbidity and mortality in children younger than the age of 5 years worldwide. Almost 150 million new episodes of pneumonia are identified worldwide per year of which more than 90% occur in developing countries. Nearly 30% of total annual deaths occur in children less than 5 years old (UNICEF2019) Respiratory infections increase morbidity, mortality and medical costs. Interventions such as proper hand and surface cleaning, better nutrition, sufficient numbers of nurses and better ventilator management are associated with significantly lower infection rates. Multiple infection control techniques and strategies simultaneously may offer the best opportunity to reduce the morbidity and mortality. Many non-pharmacological interventions to prevent and reduce risk of antibiotic-resistant organisms are to improve efficacy of antibiotics given to patients who do acquire infections. In that, Chest physiotherapy is a vital adjuvant in the treatment of most respiratory illnesses and is commonly used in children with Chronic Respiratory or Neuromuscular disease. The main goal of Paediatric Chest Physiotherapy is to help with the clearance of tracheobronchial secretions, thereby to reduce airway resistance, enhance gas exchange and make breathing easier. (Elsevier, 2020). RO LE OF NURSE Nurses as main drivers of hospitals have an important role in improving the quality of care provided to the infants with lower respiratory problems thus speeding up recovery. Implementation of training program to nurses can be used for monitoring, evaluating and improving quality of care at the health sectors. In addition, it may allow nurses to carry out their professional roles acquainted with required knowledge and skills that help them to orient new staff and guide them in their Paediatric Intensive Care Unit. Respiratory problems represent the most common diseases during childhood in both developing and developed countries. The, Lower Respiratory Infections are the third leading cause of death worldwide (Elrahman 2019). CHEST PHYSIOTHERAPY Paediatric physiotherapists treat babies, children and young people from birth to 19 years of age. We understand that it is significant to work with the child and their family to help keep the hospital stay as short as possible. If children have difficulty in breathing because of problems in their lungs, Chest Physiotherapy may help to clear secretions (mucus) to make it easier to breathe. It is a widely used adjuvant treatment in paediatric patients with respiratory illnesses. A variety of airway clearance techniques have been developed and are used to assist infants in mobilizing secretions from the lower respiratory tract and it is to improve respiratory efficiency, promote expansions of lungs, strengthen respiratory muscles and eliminate secretion from respiratory system. This has been shown to improve gas exchange, reverse pathological progression, and reduce or avoid the need for artificial ventilation when it is provided very early in other respiratory conditions. (Auwal Abdullah2020)However, it is important to consider children's specific respiratory system features. There are changes in respiratory structure and function from birth to adulthood that require continuous adaptation in the application of the ches t physiotherapy techniques according to age. INDICATIONS The indication of Chest Physiotherapy is Lower Respiratory Tract Infection/ Pneumonia/ chest infection, infective exacerbation of asthma and Cystic fibrosis (Paediatric Respiratory Physiotherapy Care–2018). TECHNIQUES USED FOR CHEST PHYSIOTHERAPY Descriptions of the techniques used for Chest Physiotherapy are Percussion, Vibration and Cough stimulation with the assistance of gravity to mobilise the secretions. Percussion can use single or both cupped hands or three fingers with the middle finger tented, or a facemask with a port either covered or occluded by a finger and strike repeatedly at a rate of three per second over the part of the bronchopulmonary segment. Vibration technique plays a rapid vibratory impulse which 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. Child can be asked to cough. In uncooperative or small children, Tracheal stimulation or tickling can be performed by placing index finger or thumb on the anterior side of the neck against trachea just above sternal notch with gentle but firm inward pressure in a circular pattern as the child begins to exhale. Cough stimulation can be performed by placing index finger or thumb on the anterior side of the neck against trachea just above sterna notch with gentle but firm inward pressure in circular pattern as the child begins to exhale. The most usual treatments for children who need Chest Physiotherapy comprise of; Breathing exercises, Positioning, Percussion (gentle pats on the chest to help loosen and move secretions in the lungs), Vibrations - gentle shakes applied to the chest to help loosen and move secretions in the lungs, Blowing games, Activity


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and play. All these treatments aim to work together to move the secretions upwards so the child can cough them out. Chest Physiotherapy should be performed 1-4 times a day, preferably half an hour prior to meals or one and a half an hour after meals. The total duration should not exceed 30 minutes with 3-6 minutes in each position. Prior broncho-dilator inhalation may successfully clear the lung secretions in children with bronchospasm. CONTRAINDICATION The contraindication of the Chest physiotherapy includes fractures, spinal fusion, pulmonary embolus, haemorrhage, severe bronchospasm and recent neurosurgery. (Redondo MT2020) ADVANTAGES The advantages of percussion along with the position may enhance secretion clearance and shorten the treatment. Young children and infants find the rhythm soothing and are relaxed & sedated by the percussion, effective in patients with chronic lung disease. Mechanical precursors reduce fatigue of the caregiver and are useful when the patient requires on-going treatment at home. Use of mechanical devices is less expensive than caregiver or health care provider to deliver percussion. ( Redondo MT2020). Chest physiotherapy (CPT) is an airway clearance technique that merges manual percussion of the chest wall by the caregiver and strategic positioning of the patient for mucus drainage with cough and breathing techniques. Chest Physiotherapy includes different manipulative procedures like positioning, chest percussion, vibration, shaking, thoracic squeezing, cough stimulation and breathing exercise Conventional chest physiotherapy can be self-administered or performed with the assistance of another person (a Nurse. physiotherapist, parent, or caregiver). These are some clinical parameters that can be used as outcome tools to assess the effectiveness of chest physiotherapy for Children with Lower Respiratory Infection It can be used as pre - and post-intervention assessment measures. However, there are few such scoring systems for acute respiratory infection in childhood

Temperature Respiratory rate Heart rate chest in drawing oxygen saturation Breath sounds(wheez, rales) General condition (Feeding &Behaviour).

Scoring is given based on Lower Respiratory Tract Infection sign and symptoms. There were totally 7 items .Each item consists of 3 options with a correct answer. The scores were given as per the presence of the signs and symptoms. Total score given to the item was 21. A score of ‘0’ indicates normal respiratory status .A score of 1-7 was given for mild respiratory illness, a score of 8-14 was given for moderate respiratory illness. A score of 15-21 was given for severe respiratory illness. The scores were interpreted as

CLINICAL EVIDENCE Sarojini .G (2019) conducted a study to evaluate the effect of chest physiotherapy among 230 children between 1 month to 5 years with Lower Respiratory Tract Infection in selected paediatric hospital at Madurai. Observational checklist on signs and symptoms of Lower Respiratory Tract Infections (modified paediatric respiratory severity score) with the above clinical parameters were used as outcome tool to classify the level of respiratory symptoms. The tool was given to nursing faculty of paediatrics and observations were marked by the researcher and other faculty simultaneously. In both the cases, the observations were similar. The tool was measuring the same attribute. The reliability score was r-0.8. Thus, the tool was found to be a reliable one. Regarding the pulse oximeter, it was [Po1] fixed to the patients right leg. Another pulse oximeter [Po2] was fixed to the left leg of the same patient.Po1 andPo2 was taken for each patient and the same procedure was repeated for 30 patients. Reading from Po1 was co-related. Have concluded that the scoring system is useful for the initial assessment of respiratory symptoms in children to identify the need for hospitalization and evaluate the effect of Chest Physiotherapy.

Respiratory status Score

Mild 1-7

Moderate 8-14

Severe 15-21


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Nayani K et al (‎6102)‎ dtsvi‎ em‎ editidev‎ eCv‎ dist tme‎ hitetadi‎ av otidemia‎ Score (CRS)‎ dsmea‎ 112children (1 month to 16 years) with respiratory distress in Aga Khan University Hospital, Karachi. A total of 112 children (70% male) of median age 12 months were enrolled, of which 55 (49.1%) were under 1 year of age. Patients with severe score (score 8–12) 90% vs. 23% with mild moderate. Results revealed that the sensitivity and specificity of Clinical Respiratory Score> 3 in predicting outcome were 94% (95% CI 79.8–99.3) and 40% (95% CI 35–45), respectively, with a positive likelihood ratio of 1.6 (95% CI 1.31–1.98) and negative predictive value of 94% (95% CI 81–98). The score was analysed as a continuous variable (0–12) and also divided into 2 categories: mild (0–4) and moderate-severe (5–12). Association between the Clinical Respiratory Score scores and the clinical outcomes were explored. The association among groups was determined. A p-value of 0.05 was significant Sonja Andersson-Marforio, et al. (2020) conducted a study to “assess the effect of physiotherapy including frequent changes of body position and stimulation to physical activity for infants hospitalised with acute airway infections among 162 Infants age 0–24 months in the south of Sweden”. All three groups received the standard care at the ward, and the two intervention groups received additional treatment, including different movements of the body. The primary outcome measure was based on determinants for hospitalisation. and the secondary outcome measures include vital signs, the parents’ observations, time spent at the hospital ward, and referrals to an intensive care unit compared with the assessments after 24 hours. The study results showed significant difference in post-tests at p value 0.05.They concluded that the position is a very effective method in reducing the respiratory symptoms in children. REFERENCES

1. Sonja Anderson Marforio et al. (2020) The effect of physiotherapy including frequent changes. https://. www.researchgate.net › publication › 344354944DOI: 10.1186/s13063-020-04681-9 www. physio-pedia.com › Chest _Physiotherapy _in_ Pedi.

2. World Health Organization /The United Nation Children’s Fund (UNICEF), 2019 (http://www.who.int/maternal_child_adolescent/documents/IMCI_chartbooklet/en/).

3. www.nationwidechildrens.org › helping-hands › chest-... Chest Physiotherapy - Infants New-born to 12 Months.

4. Yumiko Miyaji (2015) Pediatric Respiratory Severity Score (PRESS) for Respiratory austinpublishinggroup.com › fulltext › avrv-v2-id100.

clinical parameters as an outcome tool

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