Biological factors for at-risk infants
- Premature birth (EPT, VPT, PT)
- Low birth weight/SGA (ELBW, VLBW, LBW, SGA)
- Congenital disorders
- Prenatal exposures
- Conditions limiting mobility
- Neonatal distress/dysfunction (respiratory distress, major surgery and neurobehavioral abnormalities (CNS, HIE, infection, HBR, sensory loss)
Premature birth
- Birth <37 weeks gestation
- 6-12% of all deliveries
Late preterm
- 32-36 weeks GA
- 85% preterm births
Very preterm
- 28-31 weeks GA
- 1-2% of all deliveries
Extremely preterm
- <28 weeks GA
- Most at risk
Birth weight
- LBW < 2500g
- VLBW < 1500g
- ELBW < 1000g
Outcomes of premature birth
Mod-severe disability in 10% of very preterm birth
- Neurological impairments (CP), 6.8% VPT; 10% EPT
- Cognitive impairment 4.4% EPT
- Uncorrectable vision impairment
- Deafness
- Epilepsy 4.1% EPT
- Growth deficits: height circumference, weight, height, strength
- Cardio respiratory deficits: obstructive airways disease
40-50% developmental difficulties
- Motor learning deficits
- Learning deficits
- Disorders of behaviour
Biological factors - congenital disorders
Chromosomal disorders
- Downs syndrome
- Prada-Willi syndrome
- Retts syndrome
- Fragile X syndrome
Syndrome disorders
- Foetal alcohol syndrome
- Noenatal abstinence syndrome
- Prenatal exposure to infection
Inborn errors of metabolism
- Amino acid metabolism disorder
- Carbohydrate disorders (GSD)
- Hurler’s disorders
TORCH
Biological factors - prenatal exposures
- Infection of a developing fetus or newborn by any of a group of infectious agents.
- T = Toxoplasmosis
- O = Other agents
- R = Rubella
- C = Cytomegalovirus
- H = Herpes simplex
APGAR scoring system
- 0-3 severely depressed
- 4-6 Moderately depressed
- 7-10 excellent condition
- 0-2 points based on activity (muscle tone), pulse, grimace (reflex irritability), appearance (skin colour), respiration
Aims of neonate respiratory physiotherapy
- To maintain a clear airway
- To prevent respiratory complications of atelectasis, infection, retained secretions
- Assist re-expansion of any collapsed pulmonary segments and clear any areas of consolidation
- Improve respiratory function
- Maintain adequate oxygenation
Assessment in NICU
History
- Communication with caregiver
- Medical and cot chart
- Recent investigations eg. CXR, USS
Additional history
- Pregnancy, labour, delivery
- Apgar scores
- Gestational age and weight
- Tolerance to handling
- Temperature
- Apnoea and bradycardia
Observations
- Respiratory support
- Vital signs
- Analgesia
- Inspection of baby: alertness, pattern, rate and work of breathing, colour
Auscultation
- Difficult
- Air entry, secretions, wheeze, grunt and or other sounds
Palpation
Treatment techniques in NICU
Positioning
- Optimise lung function (improving VQ ratio, lung volume and reducing WOB)
- Prevent pooling of secretions and collapse by enhancing mucociliary clearance
- Prevent pressure area build up
- Other effects: feeding, sleep, energy expenditure, development
- Prone, lateral positioning, supine, 1/4 turn, NO HDT
Active techniques
- Enhance secretion clearance
- Percussion
- Vibration on expiration
- Lung squeezing technique
Suctioning
- Most frequent invasive procedure performed on ventilated infants
- Risks: atelectasis, hypoxaemia, CV instability, changes in cerebrovascular volume and lung volume changes
- precautions: the tiny neonate is extremely frail-fragile bones, thin skin and hypotonic with lax ligaments, unstable CV, immature CNS, immuno-suppressed, susceptible to cold stress
Prone
Advantages
- Improves ventilation and pattern
- Maximises diaphragmatic movement
- Reduces risk of GOR and aspiration
- Improves gastric emptying
- More time in quiet sleep
- reduces risk of GOR and aspiration
- lower metabolic rate
- reduces apnoea of prematurity
Disadvantages
- Contributes to postural asymmetries: frog legs, externally rotated hips, retracted shoulders
- Inability to observe umbilical lines
- Extreme neck rotation: increased risk of IVH
1/4 turn from prone
- Similar respiratory advantages to prone
- Less neck rotation: less ICP, reduced risk of ICH
- Drains posterolateral right upper lobe
- Prevents orthopaedic complications
Supine
- Gravity acting directly on diaphragm
- Increased WOB
- Increase in central apnoea
- Increased risk of GOR
- Contributes to postural asymmetries
Lateral positioning
- Facilitates flexor muscle development and midline orientation
- Right side lie reduces milk pooling in fundus of stomach
- Similar respiratory effects to supine
Aims of active techniques
Enhance secretion clearance
Percussion
- Cupped hand
- Face mask (cupping)
- Contact heel percussion
Vibration on expiration
- Ventilator
- Manual breaths
Lung squeezing technique
Precautions for active techniques
- Low platelet count or coagulopathies
- Mineral deficiency
- Pulmonary haemorrhage
- Bronchospasm
- Pain
