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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 82-85

Effect of prolonged slow expiratory technique as an adjunct to pulmonary rehabilitation in resolving pulmonary congestion in neonates with congenital pneumonia


1 Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana; Department of Physiotherapy and Rehabilitation, Medica Superspecialty Hospital, Kolkata, West Bengal, India
2 Department of Cardio-Thoracic Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana; Department of Physiotherapy, Narayana Health Rabindranath Tagore International Institute of Cardiac Sciences, Mukundapur, Kolkata, West Bengal, India
3 Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana, India

Date of Submission22-Feb-2019
Date of Decision09-Dec-2019
Date of Acceptance16-Dec-2019
Date of Web Publication29-Jan-2020

Correspondence Address:
Dr. Asir John Samuel
Department of Pediatric and Neonatal Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana - 133 207, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_22_19

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  Abstract 


Congenital pneumonia is a medical condition which can lead to life-threatening complication in the absence of prompt management. For improving breathing, clearing pulmonary secretions, and facilitating drainage, respiratory physiotherapy plays an important role. Here, we report two cases with congenital pneumonia, who were managed with prolonged slow expiratory (PSE) technique along with other pulmonary rehabilitation techniques. PSE technique is an advanced chest physiotherapy technique, in which expiration is prolonged beyond the normal phase. This helps in stimulating the diaphragm and facilitates the pulmonary clearance.

Keywords: Breathing, congenital pneumonia, diaphragm, drainage, respiratory physiotherapy


How to cite this article:
Mishra R, Dasgupta A, Samuel AJ. Effect of prolonged slow expiratory technique as an adjunct to pulmonary rehabilitation in resolving pulmonary congestion in neonates with congenital pneumonia. J Clin Neonatol 2020;9:82-5

How to cite this URL:
Mishra R, Dasgupta A, Samuel AJ. Effect of prolonged slow expiratory technique as an adjunct to pulmonary rehabilitation in resolving pulmonary congestion in neonates with congenital pneumonia. J Clin Neonatol [serial online] 2020 [cited 2020 Apr 7];9:82-5. Available from: http://www.jcnonweb.com/text.asp?2020/9/1/82/277237




  Introduction Top


neumonia is an infective condition of lung, which contributes to one of the most common risk factors for neonatal death.[1] Pulmonary infections lead to the accumulation of pus in the pleural cavity, commonly due to anaerobic bacterial infection.[2] These conditions are nowadays very common in both children and newborns and are highly associated with mortality rates. About 96% of neonatal deaths are reported in developing countries due to pneumonia.[1] These conditions are highly associated with lung pathologies, mainly lung consolidation. Associated pathologies which are related with the disease must be ruled out by means of computed tomography which provides a clear image of the differential diagnosis.[3] It is a serious medical condition that unusually resolves without any effective management.

The purpose of this case report is to explain the role of prolonged slow expiratory (PSE) technique in resolving the pulmonary complications, such as congestion, respiratory distress, and reduced chest compliance.


  Case Reports Top


Case 1

A 6-day-old baby girl was diagnosed with congenital pneumonia. The newborn was preterm and born at a gestational age of 35 weeks. The APGAR score after birth was 5 and after 5 and 10 min of birth was 8. Since birth, the newborn was suffering from low peripheral capillary oxygen saturation (SPO2) of 76% and pulmonary congestion. The neonate was put in incubators maintained at 37°C. Assisted ventilation was delivered via high-flow nasal cannula (HFNC) as it seems to cause alveolar recruitment and positive end-expiratory pressure was added. The flow of HFNC was set at 7 L/min to deliver FiO2 at 50% and VT40 mL to maintain SPO2 >96%.[4],[5] The neonate was on regular medical care and under sedation. Physiotherapy treatment was started from the 6th day of age of the newborn. On auscultation, air entry was absent in the right lung, and inspiratory crepitation was present in the left lung. There was grunting present at all the lobes of the left lung. The newborn was eliciting subxiphoidal and intercostal retraction and was on oxygen support since admission in the hospital. On percussion, all the lobes of the right side exhibited dull sound. On radiography, intercostal spaces of the right side were diminished, and there was right-sided atelectasis [Figure 1]a. After a treatment of 5 days with PSE technique in adjunction with kinesthetic and vestibular stimulation,[6],[7],[8] beneficial outcomes were noted which included equalized air entry bilaterally, with no oxygen support further needed from day 3 of treatment. Kinesthetic and vestibular stimulation were administered during the active wake state of the neonate.[6],[7],[8] There was no more grunting and retractions noted on further presentation. Inspiratory crepitation also improved which was present in the left lung. On repeat chest X-ray, the intercostal spaces improved with corrected atelectasis [Figure 1]b. Pre and post PSE application changes in vital parameter is displayed in [Table 1].
Figure 1: (a and b) Pre- and posttreatment X-ray findings of case 1

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Table 1: Before and after the application of prolonged slow expiratory technique as an adjunct to pulmonary rehabilitation in resolving pulmonary congestion inc neonates with congenital pneumonia

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Case 2

A 4-day-old baby boy was diagnosed with pneumonia. The newborn was delivered at complete gestational age. The APGAR scoring at and after birth was 7. On auscultation, air entry was absent in the upper lobe of the right lung, and inspiratory crepitus was present in the left lung. Assisted ventilation was provided via an oxygen hood or a box with a flow rate of 7 L/min to deliver FiO2 at 80% to maintain SPO2 >96%.[9] The neonate was on regular medical care and under sedation. There was grunting present at the left side. On percussion, all the lobes of the left side and upper lobe of the right side exhibited dull sound. On radiography, apical and posterior segments of the right upper lobe and medial segment of the left lower lobe were consolidated [Figure 2]a. After a treatment of 7 days with PSE technique in adjunction with Yakson touch[6],[7],[8] and vestibular stimulation, beneficial outcomes were noted which included equalized air entry bilaterally, with no oxygen support further needed from day 2 of treatment. There was no more grunting on further presentation. Inspiratory crepitation also relieved which was present in the left lung. On repeat chest X-ray after a week of physiotherapy treatment, the consolidation improved [Figure 2]b. Pre and post PSE application changes in vital parameter is displayed in [Table 1].
Figure 2: (a and b) Pre- and posttreatment X-ray findings of case 2

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Prolonged slow expiratory technique: Procedure

PSE technique is an emerging chest physiotherapy technique. In this technique, the patient is positioned in supine lying under comfortable and normal condition. Normal condition is evaluated by stable vitals, relaxed body position, and patient's calm behavior. Under this situation, one hand is placed over the thoracic cavity and the other hand over the abdominal cavity, just above the umbilicus. At the end-expiratory phase, the therapist provides a compressive force with the hypothenar eminence and at the same time a caudal pressure from the above hand (hand over the chest cavity), and a cranial pressure from the below hand (hand over the abdominal cavity) was applied [Figure 3]. This compression is maintained for a period of 4–5 s followed by a gentle release. A set of three compression is administered for three times with 30 s rest between each compression.[10]
Figure 3: Prolonged slow expiratory technique being performed on the patient

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  Discussion Top


Normal respiration is a dynamic process of diaphragm and is a vital process of the living system which is related to the extensive functioning of all major systems of the body. Accumulation of fluid in lungs can lead to its splinting. This pathology interferes with the normal phenomenon of inhalation and exhalation, which ultimately predisposes to pulmonary congestion and secondarily respiratory distress.[11] Any respiratory pathology if continues in long term may cause multisystem involvement. In order to manage and prevent complications developing from pulmonary insufficiency, normal respiration is facilitated. Normal respiration is a dynamic function of diaphragm and is an active phenomenon. Effective management of pulmonary congestion includes drainage of pus, resolving infection, and attaining chest expansion.[12]

Preterm babies are at an increased risk of developing serious pulmonary infections. The cause of this risk is determined to be underdeveloped immune system due to the fact that immunoglobulin E and neutrophils are insufficient in quantity as compared to that in full-term babies.[13] Pneumonia is a common bacterial infection encountered in newborns, which has a higher incidence of still births and mortality rate.[1]

Pain developing from stressful environment of neonatal intensive care unit (NICU) may be one of the possible factors of abnormal findings. The role of manual contact in pain management is also remarkable. A child in pain can be best treated when a touch of comfort is included in the treatment protocol. Manual contact puts down apprehension and can help the baby to cope up with the condition.[14]

The PSE technique is often applied to facilitate clearance of bronchial secretions in infants.[10] This helps in improving secretion clearance and maximizing chest expansion. The technique has been used for treating pleural empyema with the purpose of treating the associated respiratory complication – bronchial congestion. With the clearance of bronchial congestion, the other pathologies tend to relieve. This report, therefore, provides an opportunity to incorporate an advanced method of pulmonary physiotherapy, the effect of which can be assessed and compared with other pulmonary physiotherapy protocol. Immediate- and short-term clinical improvement is evident. Hence, PSE technique might be an adjunct to pulmonary rehabilitation in resolving pulmonary congestion in neonates with congenital pneumonia.


  Conclusion Top


PSE technique with other pulmonary physiotherapy protocol might be an effective pulmonary rehabilitation approach in treating neonates with congenital pneumonia admitted in NICUs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that name and initial of the child will not be published, and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Acknowledgments

This case report was presented as a poster presentation at Synapse-2018, 1st International Physiotherapy Conference, organized by Synapse Physio Pvt. Ltd., and Chitkara University, Rajura, Punjab, India, on October 13, 2018.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Duke T. Neonatal pneumonia in developing countries. Arch Dis Child Fetal Neonatal Ed 2005;90:F211-9.  Back to cited text no. 1
    
2.
Varkey B, Rose HD, Kutty CP, Politis J. Empyema thoracis during a ten-year period. Analysis of 72 cases and comparison to a previous study (1952 to 1967). Arch Intern Med 1981;141:1771-6.  Back to cited text no. 2
    
3.
Walters J, Foley N, Molyneux M. Pus in the thorax: Management of empyema and lung abscess. Contin Educ Anaesth Crit Care Pain 2011;11:229-33.  Back to cited text no. 3
    
4.
Lodeserto FJ, Lettich TM, Rezaie SR. High-flow nasal cannula: Mechanisms of action and adult and pediatric indications. Cureus 2018;10:e3639.  Back to cited text no. 4
    
5.
Chikata Y, Ohnishi S, Nishimura M. Humidity and inspired oxygen concentration during high-flow nasal cannula therapy in neonatal and infant lung models. Respir Care 2017;62:532-7.  Back to cited text no. 5
    
6.
Parashar P, Samuel AJ, Bansal A, Aranka VP. Yakson touch as a part of early intervention in the neonatal intensive care unit: A systematic narrative review. Indian J Crit Care Med 2016;20:349-52.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Parashar P, Samuel AJ. Yakson touch and kinesthetic stimulation on development of high-risk neonates in neonatal intensive care units: A randomized controlled trial. J Clin Neonatol 2018;7:12-9.  Back to cited text no. 7
  [Full text]  
8.
Parashar P, Samuel AJ, Aranha VP. Efficacy of early Yakson touch and kinaesthetic stimulation (yakin) on the development of high risk neonates: A randomized controlled trial protocol. J Nepal Paediatr Soc 2017;37:184-90.  Back to cited text no. 8
    
9.
St Clair N, Touch SM, Greenspan JS. Supplemental oxygen delivery to the nonventilated neonate. Neonatal Netw 2001;20:39-46.  Back to cited text no. 9
    
10.
Lanza FC, Wandalsen G, Dela Bianca AC, Cruz CL, Postiaux G, Solé D. Prolonged slow expiration technique in infants: Effects on tidal volume, peak expiratory flow, and expiratory reserve volume. Respir Care 2011;56:1930-5.  Back to cited text no. 10
    
11.
Rimmer S, Fawcitt J. Delayed clearance of pulmonary fluid in the neonate. Arch Dis Child 1982;57:63-7.  Back to cited text no. 11
    
12.
Bryant RE, Salmon CJ. State-of-the-art clinical article. Clin Infect Dis 1996;22:747-64.  Back to cited text no. 12
    
13.
Inoue N, Kim TY, Birkbeck-Garcia AM, Givner A, Denmark TK. Incidence of serious bacterial infections in ex-premature infants with a postconceptional age less than 48 weeks presenting to a pediatric emergency department. West J Emerg Med 2009;10:37-40.  Back to cited text no. 13
    
14.
McGrath PJ, Finley GA, Ritchie J, Dowden SJ. Pain management. In: Pain, Pain, go Away : Helping Children with Pain. 2nd ed. Nova Scotia, Canada: Halifax; 2003. p. 8–10.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
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