The basic therapeutic principles in paediatric chest physiotherapy (CPT) are identical to those applied in adults. However, the child's growth and development results in continuing changes in respiratory structure and function, and the requirement for different applications of CPT in each age group.Forced expiratory manoeuvres and coughing serve as basic mechanisms for mobilization and transport of secretions, but the reduced bronchial stability after birth requires special techniques in very young patients. High externally applied transthoracic pressures have to be avoided in order to prevent interruption of airflow. In addition, airway patency is maintained by the application of back pressure and by liberal use of continuous positive airway pressure. Since sympathomimetic bronchodilators might further decrease bronchial stability, their use must be individualized in newborns and young infants.Inspiration is a basic mechanism for inflating alveolar space behind obstructing mucus plugs. Due to a highly unstable chest, the premature baby, newborn and infant cannot distend their lung parenchyma to the same extent as can older patients. Consequently all chest physiotherapy strategies applied in this age group have to incorporate appropriate techniques for raising lung volume.Positioning serves to redistribute ventilation, but the young infant's response to gravitational forces differs substantially from that of the adult, and consequently strategies used in older patients have to be modified.In addition, the therapist has to consider pathology such as bronchial instability lesions and airway hyperresponsiveness and has to adjust the therapeutic response accordingly. It is particularly important to consider the special vulnerability of newborns and young infants and to modify therapeutic interventions to avoid the harm that could otherwise be inflicted. Consideration of these differences between infant, child and adult and careful analysis of the available mucus clearance techniques allows tailoring of an individualized therapeutic approach to the paediatric patient. The basic concepts of chest physiotherapy (CPT) in paediatric patients are identical to those in adults; this applies to the objectives of this therapeutic approach as well as to the mechanical principles applied for the clearance of abundant intrabronchial secretions from the airways [1].The objectives of CPT are to prevent or reduce the mechanical consequences of obstructing secretions, such as hyperinflation, atelectasis, maldistribution of ventilation, ventilation/perfusion mismatch and increased work of breathing. Another therapeutic concept focuses on removing infective material, inflammatory mediators, and proteolytic and oxidative activity from the airways and in doing so reduces or even prevents host-mediated inflammatory tissue damage [2].CPT might be seen as the therapeutic application of mechanical interventions based on respiratory physiology. As far as these mechanical approaches to airway clearance are concerned, CPT in paediatr...

Twenty patients with cystic fibrosis (CF) were trained to mobilize intrabronchial secretions by a new method of positive expiratory pressure mask (PEP mask) physiotherapy (PT). Patients repeatedly expired forcefully through the PEP mask; expiratory resistance was varied by eight different internal diameter resistors at the outlet. Forced vital capacity with the mask (FVCPEP) was determined for each resistor and was compared with the one measured without the instrument (FVC); simultaneously the sustained expiratory pressure (SEP) developed against the resistance was recorded. After training, each patient exceeded FVC with one or more resistors; "optimum" FVCPEP was 124 +/- 16% FVC at a SEP of 61 +/- 21 cm H2O. Using the PEP mask, patients cleared a higher percentage of their daily sputum volume than with conventional PT (78 +/- 22% versus 53 +/- 17%, p less than 0.01). In 11 patients (subgroup 1), multiple aspects of lung function were measured at the beginning of the study, after 10 months with PEP mask PT, after two further months without using the mask but with conventional PT, and after six more months with PEP mask PT. Results showed significantly increased expiratory flow rates, significantly decreased hyperinflation and airway instability with PEP mask PT, and a marked decline of lung function without it. The remaining nine patients (subgroup 2) entered into the same protocol; based on findings in subgroup 1 and on ethical considerations, however, the control period without PEP mask PT was then omitted, resulting in a steady and statistically significant improvement of lung function over the entire observation period. In the course of preliminary trials, two children transiently used a suboptimal resistance (FVCPEP less than FVC) and responded with a deterioration of lung function. By dilating airways and evacuating trapped gas, this method of PEP mask PT improves lung function and mucus clearance in CF. Thorough practice with the technique and frequent control of the optimal resistance are mandatory.

Fourteen patients with cystic fibrosis were trained in 2 self-administered chest physiotherapy (PT) techniques: high-pressure PEP-mask physiotherapy (PEP), and autogenic drainage (AD). They then visited the clinic on 5 consecutive days, and, in a random order, performed 1 of the following: PEP, AD, PEP followed by AD (PEP-AD), AD followed by PEP (AD-PEP), and, no PT except for spontaneous coughing. Lung function was measured repeatedly before, during, and after PT; time needed for and sputum produced by each form of PT was recorded. PEP produced the highest amount of sputum, followed by PEP-AD, AD-PEP, and AD; all 4 forms of PT produced significantly more sputum than coughing. Lung function improved significantly after PEP, AD, and PEP-AD, but PEP-induced changes did not exceed those after AD. Within the investigated group, the PEP-induced lung function improvement per milliliter of sputum produced was significantly lower for those patients with airway hyperreactivity. The fact that the highest sputum yield with PEP was not reflected in higher PEP-effected lung function changes might thus be explained by PEP-induced bronchospasm in patients with airway hyperreactivity. PEP clears more sputum than AD or combined techniques; patients with airway hyperreactivity, however, should either prefer AD or should take a bronchodilator premedication before PEP.

SUMMARY Twelve children with cystic fibrosis were admitted to a paediatric rehabilitation hospital for 17 days to take part in a training programme of vigorous physical excercise and sport. The daily inhalation-physiotherapy routine was stopped. Ventilatory status was assessed by spirometry and measurement of lung volumes one day before admission, one day after the end of the hospital stay, and 8 weeks later. Flow measurements of forced expiration had improved appreciably by the end of the course, but most of them returned to pretraining levels 8 weeks later. Lung volumes did not change significantly. Daily recordings of peak flow indicated improvement of airways function plus some ventilatory muscle training. Regular physical exercise could replace the inhalation-physiotherapy routine in some children with cystic fibrosis.Aerosol inhalation followed by chest physiotherapy is an essential part of the life-long therapeutic routine in cystic fibrosis (CF). Patient compliance however, is often poor, especially in older children.The efficacy of these procedures to mobilise and remove secretions seems to decrease with age. A more effective and popular alternative is needed.Swimming in conjunction with the inhalationphysiotherapy routine has been shown to increase sputum production and to improve ventilatory function.1 This stimulated us to study the changes in pulmonary function after inhalation and chest physiotherapy had been replaced by a short programme of intense physical exercise and sport. Patients and methodsSix boys and 6 girls, with a median age of 0I years (range 2 4/12 to 16 3/12) and a median clinical Shwachman score2 of 69 (range 37 to 86) were sent to a paediatric rehabilitation hospital situated in a mountainous area in upper Styria (altitude 1180 m above sea level). They were chosen from children attending the CF clinic at the University Children's Hospital, Graz, on the-basis of repeatedly positive sweat tests,3 a stable clinical condition, and willingness to participate.The routine therapeutic regimen of these children had included pancreatic enzyme replacement and appropriate diet. Chest physiotherapy administered by either a parent or the patient had followed aerosol inhalation twice daily. In addition 5 children were on oral antibiotics. None used bronchodilators. Five children had taken part in a previous study.' Two months before admission parents and children were instructed to keep strictly to the inhalationphysiotherapy routine.In order to reduce any seasonal or occupational influences on clinical condition or pulmonary function, the study was conducted in the summer holidays. The hospital stay lasted 17 days and during this time aerosol inhalation and chest physiotherapy were stopped.

Inhaled antibiotics are an established treatment for chronic Pseudomonas aeruginosa (PA) infection in patients with cystic fibrosis (CF). However, inhaled antibiotics might also have prophylactic potential to delay acquisition of PA in early stages of the disease. From 1986-1999, all CF patients at this center who experienced defined risk situations for acquisition of PA (28 patients) received inhaled gentamicin (80 mg BID for those < 12 months; 120 mg BID for those > 12 months) for a minimum of 3 years. Twelve patients had repeated risk situations and continued this prophylaxis without interruption during the entire study period (group 1). In the remaining 16 patients, inhaled antibiotics were discontinued at various times for a variety of reasons (group 2). None of the patients in group 1, but 7 in group 2, became chronically infected with PA (P = 0.01). Lung function and chest X-ray scores were significantly worse in those 7 infected patients, when compared to the noninfected ones in both groups. This suggests that long-term-prophylaxis with inhaled gentamicin can effectively delay acquisition of PA and decrease disease progression in children with CF.