Vol. 14 •Issue 1 • Page 48
Acclimating Children to Airway Clearance Techniques
Give Patients and Families Opportunities to Choose Which Therapies Work Best for Them
Deciding which airway clearance technique to use for a pediatric patient can be like choosing hamburger toppings for a fussy eater — eliminating the pickles, onions or tomatoes one by one until he’s willing to eat what’s in front of him. Narrowing the many modes down to a method the patient prefers is paramount to successful therapy.
Although no absolute algorithm exists for determining which airway clearance technique matches each patient, different diseases will respond better to certain types of therapy, said Steven Julius, MD, a faculty member at Children’s Healthcare of Atlanta’s Scottish Rite Campus.
“The considerations regarding which type of therapy to choose are vast, and sometimes it simply requires a fair bit of trial and error,” Dr. Julius said. “Techniques are incredibly variable in terms of their cost and effort to administer.”
Regardless of the method that’s selected, children must acclimate to these interventions, and depending on their level of understanding, they may require a little more expertise and explanation before settling on a device.
THE AGE FACTOR
Age is one of the first factors cystic fibrosis specialist Catherine O’Malley, RRT, considers when helping her patients choose an airway clearance technique at Children’s Memorial Hospital, Chicago. Age is tied to ability and toleration, variables upon which the success of therapy clearly depends.
“There are some techniques and devices that are passive and others that require a patient to perform a breathing maneuver for them to work,” O’Malley said. “You know automatically that very young children are not able to follow instructions for more sophisticated techniques such as autogenic drainage, and so you use more passive techniques like chest physical therapy.”
CPT is the mainstay for airway clearance in young children, but as soon as a patient is willing and able to participate in therapy by deep breathing, blowing and huffing, O’Malley encourages active patient participation in therapy.
“As kids get older, it opens up the door for a slew of techniques we can use, assuming that the patient is cognitively normal and able to follow direction,” Dr. Julius said.
By age 6, most patients are able to perform breathing maneuvers and cooperate with an array of methods, including positive expiratory pressure therapy and active cycle of breathing. They also should have acquired a higher tolerance for devices that inflate the lungs and induce cough such as mechanical insufflator-exsufflators, intermittent positive pressure breathing, and intrapulmonary percussive ventilation.
By age 12, children requiring daily airway clearance should be cognitively capable of using any of these airway clearance techniques. It’s a matter of identifying which therapy is most helpful and which modality the patient prefers.
“The bottom line is you want something that’s going to be effective, and you want something that’s feasible in order to get the job done,” O’Malley said.
At any age, cooperating with airway clearance maneuvers often is easier said than done, and it’s not uncommon for children not to comply with these devices even if they’ve helped to choose them. Older children who are capable of performing their own airway clearance may not be motivated and simply not adhere.
“It’s a very abnormal sensation to have your lungs inflated or deflated with air, so there’s definitely a learning curve associated with success,” Dr. Julius said.
Sometimes it takes creative convincing to make young patients comfortable with their modality of choice.
“I had one patient who really liked Billy Ray Cyrus, so I’d sing his ‘Achy Breaky Heart’ song,” said Glenn Hildreth, RRT, from Nemours Children’s Clinic, Pensacola, Fla. “When she’d see me coming, instead of dreading getting CPT performed, she’d look forward to it.”
Making a game out of airway clearance or providing an incentive for following through with a treatment also encourages children to cooperate with therapy. For example, allow children to watch their favorite TV show while undergoing high-frequency chest wall oscillation or other passive methods. Putting a child’s attention elsewhere helps them through airway clearance without as much trouble.
“You can bribe children as well,” Hildreth said. “That works sometimes, too, and I’ve seen many parents do this.” The promise of a sticker, ice cream or even a new toy may motivate a child to adhere to therapy.
“In due time, most children will sense that these modalities are effective at clearing out their secretions. Nevertheless, they must acclimate to these sophisticated devices,” Dr. Julius said.
UPPER AIRWAY CLEARANCE
Excessive mucus in the upper respiratory tract also requires special attention and adherence to other clearance techniques, particularly in patients with atopy and CF. Acute and chronic sinusitis are common upper respiratory complications that can cause significant symptoms that adversely affect the lungs.
Choosing an upper airway clearance method is extremely important for two reasons, according to Bradley Chipps, MD, a Sacramento, Calif.-based pediatric pulmonologist and allergist.
For one, mucus collecting in the upper airway is a breeding ground for bacteria. Secondly, if excess mucus isn’t cleared from the airway, then medicines used to treat sinusitis and other infections can’t reach the epithelial surface, the area a drug must penetrate to exert its full therapeutic effect.
Upper airway clearance includes anything to help remove mucus, such as nose blowing and saline flushes, or saline nasal sprays that moisturize mucus so it can be blown out more easily. Physician-assisted flushes and more aggressive interventions often are recommended for patients with frequent pulmonary exacerbations.
As with pulmonary mucus clearance, some children may squirm when faced with clearing the upper airway.
“Some kids hate having stuff blown up their nose, and they have a tough time accepting the procedure,” Dr. Chipps said. “It can take some patience to get a child to do this and get used to the time it takes.”
For patients who can’t tolerate nasal flushing, antibiotic therapy also can be used to thin secretions for easier removal. Antibiotics can be delivered systemically through the mouth or vein, or locally by inhalation or direct injection into the sinuses — a process called antibiotic flushing. Systemic antibiotics are the standard of care and usually treat sinus and pulmonary exacerbations simultaneously.
Before an antibiotic course is initiated for sinusitis, ensure the drugs, duration and dosing are appropriate in accordance with the patient’s other medical therapy. Combination antibiotic therapies are recommended often, and dosing can be significantly different for patients with different pulmonary disorders.
Although they’re of limited utility when used alone, certain pharmacological products can be used to supplement upper and lower airway clearance. Dornase alfa, hypertonic saline, acetylcysteine and other mucolytics are of the more popular pharmacological adjuncts available to patients.
“Mucolytics are helpful adjuncts because they make the mucus easier to clear,” Dr. Chipps said. “I find anything compared to just airway clearance itself can be expected to have a significant improvement in effectiveness.”
Mucolytics help to thin, or liquefy, the mucus for patients requiring it, but they aren’t effective without concurrent physical therapy.
“Just breaking down the viscosity of mucus isn’t good enough if you don’t get it into the large airways where you can get it up,” Hildreth said. “At Nemours, we use physical therapy with every cystic fibrosis patient we have, and most of our CF patients use dornase alfa in conjunction with CPT, high-frequency chest wall oscillation or PEP therapy.”
Some medicines delivered by aerosol don’t necessarily address secretions, but they target other problems by reducing inflammation (inhaled corticosteroids) or opening up the airways (bronchodilators), which make the airways more patent for mucus clearance, Dr. Julius explained. The advantage of devices such as IPV and IPPB is they provide airway clearance at the same time they deliver a nebulizer treatment of these drugs.
With all of the various techniques available for upper and lower airway clearance, being able to afford a method also is a critical part of choosing a suitable therapy. Most medical insurance companies have carefully drawn policies for reimbursing airway clearance and determining when it’s medically necessary.
“Insurance pays for many of these airway clearance devices, but not always all of them,” Dr. Julius said. “If I have a child whose insurance approves an expensive and well-accepted device but that patient feels a less expensive method works better, I would use the patient-preferred technique because it’s a fraction of the cost. There’s no point sending a child home with an expensive intervention if the child doesn’t think it’s helpful or feels better using something else.”
An insurance company may consider home chest physiotherapy by a respiratory therapist medically necessary upon the initial prescription of CPT in order to stabilize the patient and train family members to administer CPT. CPT provided by an RT also may be considered necessary for a patient whose pulmonary condition is unstable. In general, CPT isn’t reimbursable when a patient’s condition is stable, and the CPT can be completely administered by a family member.
Small handheld PEP devices may be reimbursable as an adjunct to airway clearance in patients who can demonstrate effective use of the device and when other devices have proven inadequate or ineffective in mobilizing pulmonary secretions.
Similarly, mechanical percussors may be reimbursable when the patient or operator of the percussor has received appropriate training by a physician or therapist.
An insufflator-exsufflator device usually is reimbursable in patients with neuromuscular diseases resulting in inability to clear their airways with standard airway clearance methods. For insurance to cover these devices, there usually should be evidence of significantly low forced expiratory flow and vital capacity not associated with obstructive disease.
Some insurance companies are still investigating the merits of reimbursing IPV and IPPB devices.
HFCWO devices sometimes are given a separate policy from coverage of other devices because their use as an adjunct to CPT and their use in conditions other than CF may be considered investigational by some insurers. For patients unable to get immediate coverage for vest devices, one vest manufacturer has a grant set aside to help expedite payment for the device.
“Up to this point, the vest companies have been very lenient with letting us order the vest and ship it out as soon as we do to get the patient started on it,” Hildreth said. “Then they’ll pursue payment via insurance or other source. I’ve never heard of a patient having their device taken way because of lack of payment.”
Whether a patient is prescribed a more advanced airway clearance device or a simpler method, keep in mind that the customer is always right. Giving patients and their families the opportunity to help choose which therapies work best for them physically and financially will open the door to greater airway clearance success.
Debra Yemenijian is assistant editor of ADVANCE. She can be reached at firstname.lastname@example.org.