Assessment
The physical assessment of a child needs to take into account the behavioural and psychosocial issues as the child is always developing and changing, not only physically, but also intellectually and emotionally.
Communication must be in an age appropriate manner which will assist in gaining the cooperation of the child. Parental/care giver involvement is essential during assessment (and treatment) as the parent/care giver can answer many subjective questions that are the basis for assessment regarding the type of cough and frequency and exercise levels. The parent/care giver has essential information regarding what physiotherapy techniques have/currently work well and what techniques have/currently did not work well.
The assessment of the child is ongoing throughout the assessment and treatment sessions using observational skills as to the work of breathing and activity levels and listening to the cough.
Assessment categories will be similar to that of adults and will include:
Ascertain the child’s baseline – what is usual – especially cough frequency, sound, pattern, activity preferences and tolerance
History of present illness
Cough
Sputum (if the child is able to expectorate)
Exercise/activity levels
Airway Clearance technique(s) and inhalation therapy
Medications
Imaging
Musculoskeletal assessment
Stress incontinence
Many of the overall aspects of assessment of an adolescent will be similar to the adult assessment. The adolescent is encouraged to be independent and participate in an open and honest manner to help facilitate optimal and individualised treatment options.
Listening to and understanding a child’s cough
Listening to a child’s cough can be confusing and difficult to describe. Most parents share this difficulty as they grapple with learning about their child and how best they can manage his or her illness.
The most important thing is to record and understand the child’s baseline observations.
How often does he/she cough? (perhaps on waking, during or after exercise, or during physiotherapy only)
What does his/her cough sound like?(no cough/dry/wet)
What is his/her breathing like? (no effort/looks puffed)
The GP or physician should be consulted if:
The child has a moist/wet sounding cough that does not seem to be getting better
The child has a dry cough but it sounds harsh or tight
The child is breathing faster or harder than usual (i.e. more effort is being used which you can see by the in-drawing around the ribs or around the trachea)
When the physiotherapist asks a parent if the cough is ‘wet’ (‘moist) or ‘dry’ sounding, they are trying to work out if there is more mucus than there should be in the child’s air passages. A moist or wet sounding cough can mean that the mucus is below the vocal cords and not being cleared sufficiently, but does not necessarily indicate that there is a chest infection.
The number, or duration, of physiotherapy treatments per day should increase in the presence of a wet or moist sounding cough.
Managing bronchiectasis in children
The management of children and adolescents with bronchiectasis will differ to that of adults. Many of the established techniques have been extrapolated from adult practices to the paediatric population group. A few studies have been reported in the paediatric population and mostly in the cystic fibrosis group; however the majority are still adult studies.
The focus of paediatrics in this website does not include infants, but a small section will refer to the management of infants.
The use of physiotherapy in paediatric bronchiectasis is a combination of expert clinical experience and moderate evidence based medicine. It is important that the airway clearance program is reviewed regularly by the physiotherapist to ensure that the technique is being done correctly, to assist with any difficulties and to ensure that all aspects of care are optimised.
Education and Engagement
Education at the time of diagnosis is crucial for the family and/or child/adolescent
Handouts regarding physiotherapy management and adjuncts will assist with retaining the information and act as a reminder when things are forgotten
Education needs to be ongoing as often there is so much information to be absorbed and with the changing nature of the persons condition – relevant education to the child at that time is crucial
As the adolescent progresses towards self management and greater independence, education is directed towards their learning needs, understanding their disease and it’s management, and understanding the importance of physiotherapy.
Support and advise is required for the parents in ‘letting go’ as the adolescent becomes more independent and takes charge of their life
It is essential for carers and the adolescent to engage with the therapist to ensure that their physiotherapy program is optimised for the individual, using the right time = right technique.
Health professionals are aware that difficulties do arise in terms of completing the therapy required, but open and honest communication between the patient/carer and physiotherapist is essential to ensure the best quality of life.
