Chest & Breathing

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Niamh's Journey

Managing Secretions

Children with neurological impairment often have difficulties coordinating their swallow reflex.
As a result, they often breathe in (aspirate) excess secretions like saliva, mucous or refluxed feed.

Problem

This inability of the child to cough up or swallow their secretions can lead to a constant rattle as the child breaths and may or may not affect the child's oxygen saturation levels. When this happens over a prolonged time it can lead to chest infections or pneumonia.

It is often not possible to stimulate a child with neurological problems to cough these up, so there are a number of other options available to reduce these secretions and thus reduce the incidence of chest infections that they may cause.

Causes of Excess Secretion

* A side effect of some anti-convulsant medications cause excess secretions to be produced - particularly the
  benzodiazapines, nitrazepam, clonazepam, diazepam, mizdazolam (to name a few).
* Seizures may stimulate excess secretions (saliva) to be produced
* Teething
* Common cold

Reducing Aspiration - Prevention

1. Drugs - there are medications that can be given to reduce or dry up excess secretions Hyoscine (Scopoderm). These are actually antispasmodic drugs and are used to reduce sickness (added bonus in our children) but they actually have the effect of drying up secretions.
Niamh wore these as "patches" behind her ear but they are also available in a liquid (Glycopyrrolate) and they worked very well.

2. Manual - Suction Machines can be used to suck away the excess secretion but depending on how severe your child’s case is this could become a full time job.
Suction can be used to remove secretions directly from the mouth (oral suction) or using a finer catheter up the nose and down the throat to the lung entrance (deep suctioning).
This method manually removes the secretions so the child cannot aspirate these.
However, suction should be used with caution as it is also possible to stimulate further secretions by doing this too often.

3. Alternative feeding methods.
If a child’s swallow reflex is poor, then feeding by an alternative route (via tube) will prevent them inhaling their feed by mistake whilst sucking a bottle.

4. Reducing sickness
Reducing sickness by effective control of reflux and other gastro-intestinal problems also reduces the risk of chest infections as there is less chance there stomach contents will end up in the lungs.

Reducing Wheezing/Rattling

Nebulizers generate an aerosol vapour of a drug so that it can be taken in through a child breathing rather than them actively having to inhale sharply.
They are a good way of helping a child who is struggling with congestion/mucous.

Saline solution is good for breaking up thick mucous and making it easier to manage whilst Salbutamol is good for opening up the airways making breathing easier.

Chest Infections & Pneumonias - Prevention & Treatment

Despite all of the above, our children will still get chest infections and pneumonias.

Prevention: We were advised to administer a 3 day course of Azithromycin (broad spectrum antibiotic) every two weeks over the winter months to basically limit the chance of anything nasty getting a grip - it worked really well and the two winters which we did this, were pneumonia free.

Treatment: If pneumonias do get a grip then chest physiotherapy (see below), oxygen therapy, oral or IV antibiotics are the usual procedure.

Chest Physiotherapy - Percussion Vests

For children that are prone to repeated chest infections and pneumonias, physical chest physiotherpay is a good option to use in conjunction with antibiotics or in some cases, as an alternative therapy.

Chest physiotherapy can be performed manually or with the aid of a percussion vest.

Percussion vests use pulse vibrations to move secretions from the small airways to the larger airways making them easier to
cough or remove by suction. It also thins thicker secretions again making them easier to expel.
Therapy times can be varied to suit your child and repeated as often as required depending on the individuals need.

In some cases where repeated antibiotic use has caused children to become resistant, where oral antibiotics cause upset
tummies, or where repeated IV attempts have made a child's veins fragile, then these vests may offer a more appealing
treatment for infection or even for straightforward congestion.

Micah who is a friend of Niamh's used this vest very successfully and his mummy Rachel has given some information on her
experience of the Pro's and Cons:

Pro's
- The vest reduced the duration of Micah's infections.
- It avoided the need for Micah to have repeated oral or IV line antibiotics.
- The equipment is portable allowing Micah to have therapy outside the home or hospital setting.
- All instructions on how to use, were given to the parents over the phone and they commented on how easy the
  equipment was to operate, including the initial setting up of the machine.
- Micah did not object to his sessions and on occasion he would vocalise during these.
- Rachel and her family thought very highly about the vest as a treatment for Micah.

Cons
- Occasionally during times of illness the sessions had to be skipped as they sometimes caused Micah to gag.
- If the child has a gastrostomy then any movement/friction on their button/stoma may cause irritation or bleeding but this can be minimised by using foam around the feed site. Prolonged use may cause problems with bleeding if this area is already leaky, loose or not completely healed.
- Rachel's experience was that Micah could not feed an hour or so each side of therapy. This regieme may be difficult to accommodate if a child is on continuous feeds.

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Micah wearing his percussion vest

How to get One?

Depending on which country you are from, this vest may (or may not) be available through your health service.

We think that wherever you live, the initial referral should be through your child's pulmonologist or consultant.

Attached is a link where Rachel got Micah's vest from - This company has to be used through a referral from a doctor and there are programs for people who cannot afford the cost of this where there is a clinical need.

http://www.thevest.com

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