CPT in infanT bronchiolitis arguments for a new approach

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CPT in infanT bronchiolitisarguments for a new
approach

• Guy Postiaux (), Caroline Patte (), Jacques
  Louis ()
• Groupe détude pluridisciplinaire stéthacoustique
  
• ()Grand Hôpital de Charleroi (B)
• ()Maître de Conférence, Université Libre de
  Bruxelles (B)

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Definition

• Bronchiolitis is a disorder most commonly caused
  in infants (lt2years) by viral lower respiratory
  tract infection. It is the most common LRI in
  this age group. It is characterized by acute
  inflammation, edema, and necrosis of epithelial
  cells lining small airways, increased mucus
  production, and bronchospam.

Définit les options thérapeutiques
OBSTRUCTION MULTIFACTORIELLE

• Diagnosis and management of Bronchiolitis.
  Subcommittee on diagnosis and management of
  Bronchiolitis. Pediatrics 20061181774-1793.
• http//www.pediatrics.org/cgi/content/full/118/4/1
  774

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Several methodologies have been proposed

• In anglo-saxon countriesconventional Chest
  PhysioTherapy - cCPT
• In FranceAccélération du Flux Expiratoire - AFE

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cCPT (FET Clapping Postural Drainage
Suctioning)

• Controversial, not supported by controlled
  studies (Prasad, Arch Dis Child 1999)
• Not recommended (Cincinnati Med Cent 2001)
• Banned, deleterious (Purchit, Am J Dis Child
  1975 Harding, J Pediatr 1998)
• Has failed to show any benefit (Webb, Arch Dis
  Child 1985 Bohe, Medicina 2004)
• Does not reduce length of hospital stay, oxygen
  requirements, or improve the severity clinical
  score (Perrotta Cochrane Rev 2005,2007)

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AFE (passive FET)

• Several mechanical drawbacks
• Vigorous !
• Interrupting breath sounds at the mouth thus no
  concomitant expiration! (Postiaux 1992)
• Rib fractures (Chalumeau, Pediatr Radiol 2002)
• Forced expiratory technique needs to be evaluated
  by clinical research. (Perrotta C. Cochrane Rev
  issue 2007)
• Not supported by controlled studies (Perrota)
  (Perrotta C. Cochrane Rev issue 2007)

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therefore ?? which alternative?
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We propose an other approach

• PSET - ELPr Prolonged Slow Expiration Technique
• CP - TP Coughing Provoked

a passive, and progressive bimanual
thoraco-abdominal pressure exerted by the
physiotherapist to obtain a prolonged SLOW
expiration into the expiratory reserve volume
ERV controlled by breath sounds at the mouth
is a reflexive coughing provoked triggered by a
brief tracheal pressure applied just above the
sternal notch
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Aim of the 1st study (1992)

• To explore the mechanical behaviour of the infant
  respiratory system during chest physiotherapy
  maneuvers ie
• PSET- ELPr
• AFE - passive FET and
• CP - toux provoquée compared to
• SB spontaneous breathing- tidal volume.

Postiaux G. Ann Kinésithér 1992,t.19,n8,pp.
411-427
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PSET - ELPr
AFE - FET
CP-TP
Postiaux G. Ann Kinésithér 1992,t.19,n8,pp.
411-427
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Conclusion of this 1st study

• Slow maneuvers such as ELPr have to be preferred
  to rapid maneuvers as AFE-FET possibly
  deleterious in infant lt 24 mths aged.

Postiaux G. Ann Kinésithér 1992,t.19,n8,pp.
411-427
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Aim of the 2d study (1997)

• 1st stepA prospective study of 11 obstructed
  infants to study the relationship between the
  wheezing rate - TWh/TotT computed on-line and
  the ventilatory mechanical parameters Rl, Eldyn,
  RR, TV.
• 2d stepStudying TWh/TotT during 36
  physiotherapic sessions (PSET CP) following
  nebulised bronchodilators

Postiaux et al. Rev fr Allergol Immunol Clin,
199737(2)206-22.
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A significant correlation was found between Rl
and Wh
!
Postiaux et al. Rev fr Allergol Immunol clin,
199737(2)206-22
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2d step

• To study the effects of a treatment combining
  nebulised therapy (NaCl 0,9 salbutamol) with
  PSETCP in infants

ns
ns
Hs
Hs
Postiaux G. Arch Ped 2001 8 suppl. 1
117-25 Proc 21th European Cystic Fibrosis Conf.
Davos June 1997.
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Conclusion of the 2d study

• Nebulised BrDilat therapy Physiotherapy
  including PSETCP is an efficient therapeutic
  protocol to relieve symptoms of bronchial
  obstruction in infancy
• We have an argument to follow-up our treatments
  with auscultation i.e wheezing

Postiaux G. Arch Ped 2001 8 suppl. 1
117-25StagnaraJ, et al ARCH Pediatr 2001 Jan 8
Suppl111S-23S.
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AIM of the 3TH STUDY (2004)

• To evaluate the efficacy of an isolate chest
  physiotherapy protocol including PSET CP in
  hospitalized infants with mild acute viral
  bronchiolitis.

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DESIGN

• A prospective longitudinal study of 19 infants
  (7,75 /- 6,6 months, mean /- SD).
• nCPT protocol including PSET-ELPr-Expiration
  Lente Prolongée and CP-TP-Toux Provoquée.
• Patients were evaluated before and after 57 nCPT
  sessions, once daily until discharge. Wang's
  Clinical Severity score (CS), pulse oxymetry
  (SpO2), heart rate (HR), previous episodes of
  bronchiolitis (AB), prematurity (AP) and presence
  of Rx abnormalities (Rx) were calculated for
  sessions and day effects at D1, D2, DL (last day).

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CS Wangs Clinical Severity score
The scoring system assigns a number from 0 to 3
to each variable with increased severity
receiving a higher score . Cs sum.
Wang EE et al. Arch Dis Child 1992,67289-93. Sarr
ell EM et al. Chest 2002 122 2015-2020. Mandelbe
rg A et al. Chest 2003 123481-487. Beck R. Et
al. BMC Pediatrics 2007722-7.
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RESULTS on CS
Session effects of nCPT on CS at D1, D2 and DL.
CS differed significantly (plt0,001) before and
after nCPT at each day. The day effect was
significant (p0,028). N57 S.

• Mean number of sessions was 3,8 /- 1, 7. (Usual
  median duration of illness for children lt24
  months with bronchiolitis is 12 days (Cincinnati
  guideline 2002, nov 28.9p-82 ref.)
• One adverse effect was observed (transient
  increasing of Wh after TP)

Postiaux G. et al. Chest physiotherapy in
Bronchiolitis a new approach - nCPT.Proc CIPP VI
6th International Congress on Pediatric
Pulmonology, Lisbon, Feb-March 2004. Postiaux G,
et al. Effets de la kinésithérapie associant ELPr
TP dans la bronchiolite du nourrisson.
Kinésither Rev, 2006(55)35-41.
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But !!!! No control group!!
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Aim of the 4th study (2008, RCT)

• To evaluate during 3 winters seasons (2004-2005,
  2005-2006, 2006-2007) the efficacy of a nCPT
  protocol including PSET CP (Prolonged Slow
  Expiration Technique Coughing Provoked)
  following nebulised HS/3 and Salbutamol on the
  Wangs clinical severity score of hospitalized
  infants with RSV bronchiolitis.

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Inclusion criteria

• 1st clinical episode of acute bronchiolitis or
  wheezing
• Infant lt 12 months
• CS 3
• Presence of RSV in the naso-pharyngeal secretions

Exclusion criteria

• Parents refusal
• RSV ()
• Underlying cardiac or neurologic disease
• Previous episode of wheezing
• Chronic lung disease (bronchodisplasia)
• Immunodeficiency
• Congenital anomaly
• Patients needing ventilatory support

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Design Randomized Controlled Trial

• Control Group (1)Nebulisation (3HS/Salb)Physi
  os Smile

• Treated Group (2)Nebulisation(3HS/Salb)nCPT
  (PSET CP)

• CS, SpO2, HR evaluated by 2 uniformed fellow
  pediatricians at t0 (before the session), t30
  (end of the session) and t150.

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p NS 0,008
0,001 lt0,002
RESULTS (1) CS at t0, t30 and t150, for each
patient. Comparison of average vs t0.
n 27 sessions/8 pat. 31 sessions/12
pat.
nCPT
NS
Postiaux G. et al. Eur Resp J 2008 sept. n
0126-2008, E-com ERS Berlin meeting.
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RESULTS (2) Daily evolution of CS baseline
values (t0) for both groups.
Postiaux G. et al. Eur Resp J 2008 sept. n
0126-2008, E-com ERS Berlin meeting.
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Conclusions

• This study is the first scientific argument in
  favour of physiotherapy nCPT in acute RSV
  bronchiolitis
• The nCPT protocol including PSET CP can be a
  safe complement and a relevant alternative to the
  presently limited options to treat infants with
  acute RSV bronchiolitis
• nCPT contributes to a relevant reduction in the
  lenght of hospital stay LOS
• In infants lt 12 months, a part of wheezes is the
  clinical sign of the presence of secretions in
  the mid and proximal airways
• Given the observed dataset of 20 subjects, those
  results are to be considered as preliminary and a
  way for future larger trials

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Message pour lundi

• Comment vais-je faire passer linformation dun
  nouveau protocole validé du traitement de la
  bronchiolite associant- nébulisation de
  solution hypertonique à 3 ventoline- PSET CP
  (ELPr TP)auprès de mes prescripteurs
  habituels?
• Comment je perçois laspect éthique de la
  nécessité dadapter ma pratique aux acquis de la
  science?

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Thanks for your attention