Finding consensus on the physiotherapy management of asymptomatic infants with cystic fibrosis

Role of the Physical Therapist in Cystic Fibrosis Care

In looking back on 2020 and 2021, this Perspective reflects on the monumental impacts of the rollout of cystic fibrosis (CF) transmembrane conductance regulator highly effective modulator therapies and the COVID-19 pandemic on the management of CF. Advancements in the clinical management of people with CF have been both enormous and rapid, and physical therapists specializing in the care of people with CF have been at the forefront of driving this evolution in care. This year sees the 30th anniversary of the UK Association of Chartered Physiotherapists in Cystic Fibrosis and, as is inevitable in reaching such milestones, thoughts have turned to origins, role, impacts, and the future. With the changing demographics of the population of people with CF after the introduction of highly effective modulator therapies, potentially with fewer secondary complications, the future role of the physical therapist who specializes in CF is in question. This Perspective reflects on and highlights the role of physical therapy within CF and provides insights into how physical therapists and respiratory therapists can evolve their roles to ensure relevance for the future.

Airway clearance and exercise for people with cystic fibrosis: Balancing longevity with life

Airway clearance has been an integral part of cystic fibrosis (CF) care for almost as long as CF has been identified as a condition. From diagnosis as a neonate through to end-of-life care, airway clearance is an everyday aspect of life, adding a considerable treatment burden to the lives of people with CF. There are many different techniques used for airway clearance which have evolved over time with an aim to improve effectiveness, support adherence and, more recently, to consider the impact of burden. A popular thought is whether airway clearance could be replaced by exercise. With new precision therapies in the form of CFTR modulators available, the CF landscape is rapidly changing, raising the question of whether certain treatments are needed at all. Depending on factors such as CFTR mutation, age, and pre-existing lung damage before starting a CFTR modulator, individuals with CF may need different levels of intensity and type of maintenance treatment. Precision medicine is likely to lead to the need for increased precision and individualized management around other maintenance therapies such as airway clearance.

Physiotherapy: At what cost? Parents experience of performing chest physiotherapy for infants with cystic fibrosis

Physiotherapy is one of the most burdensome aspects of cystic fibrosis (CF) care. Healthcare requirements for older children with CF are reported to impact parental quality of life and physiotherapy adherence. How parents of infants experience performing chest physiotherapy as a part of CF care is unknown. This study aimed to explore the experience of performing chest physiotherapy for parents of infants with CF. In this study, 13 parents of infants (aged 1-2 years) with CF participated in one in-depth semi-structured interview and completed a daily diary for five days. Principles of hermeneutic phenomenology guided interpretation of interview transcripts, diary entries, and field notes. For these parents, being responsible for performing chest physiotherapy was an ever-present experience of pressure, doubt, and guilt. Managing chest physiotherapy resulted in sacrifices that were perceived by parents as an expected and necessary part of meeting the healthcare needs of their child. Despite perceived sacrifices, performing chest physiotherapy was also experienced by parents as an opportunity to positively impact the health of their child. Awareness of parental perceptions and experiences of chest physiotherapy in CF may enhance the personalization of physiotherapy and minimize burden.

Developmentally appropriate supported self-management for children and young people with chronic conditions: A consensus

OBJECTIVE/S

To create a consensus list of self-management definitions, recommendations, and endpoints for children and young people (0-20 years) with chronic conditions.

METHODS

This study used a Delphi technique. Based on the number of relevant peer-reviewed publications, clinical academics were invited to participate in three survey rounds. Round one contained open-ended and multiple-choice questions eliciting general opinions on self-management. For round two, results were provided to the interdisciplinary expert panel as statements for rating their agreement using a 7-point Likert scale, with consensus predefined as moderately or extremely satisfied by >70% of participants. Statements not meeting consensus were re-presented in round three, with group feedback incorporated. Finalised statements informed creation of the 'Partners in Health: Self-Management Consensus List for Children and Young People'.

RESULTS

Sixteen clinical academics participated: 12 completed round one; 14 completed round two; and 12 completed round three. Of 101 statements, 90 reached consensus, with statements separated into five developmentally appropriate groups. Statements covered broad self-management and self-management support domains including knowledge, involvement, monitoring/responding to symptoms, transition, impact, lifestyle, and support. Division of responsibility and autonomy were distinct themes.

CONCLUSION AND PRACTICE IMPLICATIONS

This research provides consensus-based guidance for clinicians providing paediatric self-management support.

Airway Clearance Techniques for Primary Ciliary Dyskinesia; is the Cystic Fibrosis literature portable?

Primary Ciliary Dyskinesia (PCD) is a rare inherited disease with impaired mucociliary clearance. Airway clearance techniques (ACTs) are commonly recommended for patients with PCD to facilitate mucus clearance, despite a lack of evidence in this group. Current physiotherapy practice in PCD is based on evidence extrapolated from the field of Cystic Fibrosis (CF). This paper focuses on the available evidence and outlines challenges in extrapolating evidence between the conditions for best clinical practice.

A framework for assessing outcomes from newborn screening: on the road to measuring its promise

Newborn screening (NBS) is intended to identify congenital conditions prior to the onset of symptoms in order to provide early intervention that leads to improved outcomes. NBS is a public health success, providing reduction in mortality and improved developmental outcomes for screened conditions. However, it is less clear to what extent newborn screening achieves the long-term goals relating to improved health, growth, development and function. We propose a framework for assessing outcomes for the health and well-being of children identified through NBS programs. The framework proposed here, and this manuscript, were approved for publication by the Secretary of Health and Human Services' Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC). This framework can be applied to each screened condition within the Recommended Uniform Screening Panel (RUSP), recognizing that the data elements and measures will vary by condition. As an example, we applied the framework to sickle cell disease and phenylketonuria (PKU), two diverse conditions with different outcome measures and potential sources of data. Widespread and consistent application of this framework across state NBS and child health systems is envisioned as useful to standardize approaches to assessment of outcomes and for continuous improvement of the NBS and child health systems.

SIGNIFICANCE

Successful interventions for newborn screening conditions have been a driving force for public health newborn screening for over fifty years. Organizing interventions and outcome measures into a standard framework to systematically assess outcomes has not yet come into practice. This paper presents a customizable outcomes framework for organizing measures for newborn screening condition-specific health outcomes, and an approach to identifying sources and challenges to populating those measures.

Breathing exercises for children with asthma

BACKGROUND

Asthma is the most common chronic disease in childhood. Breathing exercise techniques have been widely used by researchers and professionals in the search for complementary therapies for the treatment of asthma.

OBJECTIVES

To assess the effects of breathing exercises in children with asthma.

SEARCH METHODS

We searched for trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL and AMED and handsearched respiratory journals and meeting abstracts. We also consulted trial registers and reference lists of included articles.The literature search was run up to September 2015.

SELECTION CRITERIA

We included randomised controlled trials of breathing exercises alone versus control or breathing exercises as part of a more complex intervention versus control in children with asthma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. The primary outcomes were quality of life, asthma symptoms and serious adverse events. The secondary outcomes were reduction in medication usage, number of acute exacerbations, physiological measures (lung function (especially low flow rates) and functional capacity), days off school and adverse events.

MAIN RESULTS

The review included three studies involving 112 participants. All the included studies performed the comparison breathing exercises as part of a more complex intervention versus control. There were no trials comparing breathing exercises alone with control. Asthma severity of participants from the included studies varied. The studies measured: quality of life, asthma symptoms, reduction in medication usage, number of acute exacerbations and lung function. Breathing exercise techniques used by the included studies consisted of lateral costal breathing, diaphragmatic breathing, inspiratory patterns and pursed lips. One study included in the review did not specify the type of breathing exercise used. The control groups received different interventions: one received placebo treatment, one an educational programme and doctor appointments, and one was not described. There were no reported between-group comparisons for any of the primary outcomes. We judged the included studies as having an unclear risk of bias.

AUTHORS' CONCLUSIONS

We could draw no reliable conclusions concerning the use of breathing exercises for children with asthma in clinical practice. The breathing exercises were part of a more comprehensive package of care, and could not be assessed on their own. Moreover, there were methodological differences among the three small included studies and poor reporting of methodological aspects and results in most of the included studies.

Profile of cystic fibrosis in two reference centers in southern Brazil

OBJECTIVE

to compare the characteristics of cystic fibrosis patients treated in two reference centers in southern Brazil in order to observe trends in the treatment and clinical outcomes that may produce changes in clinical conduct.

METHODS

cross-sectional, retrospective study with 83 patients diagnosed with cystic fibrosis, aged one month to eighteen years. The variables analyzed were obtained through review of medical records, including: demographic and clinical characteristics, socioeconomic status, pulmonary function test, bacterial colonization profile, medication and physiotherapy.

RESULTS

between the two centers there was significant difference in the variables, including admissions in the previous year (p<0.001), lifetime hospital admissions (p<0.001), use of Dornase alpha (p=0.003) and inhaled antibiotic therapy (p=0.006), which were higher at the Santo Antônio Children's Hospital (HCSA), while age at first colonization with Staphylococcus aureus (p=0.008), maternal age (p=0.030), clinical score (p=0.001), socioeconomic score (p=0.021) and use of hypertonic saline (p<0.001) were lower at HCSA compared to São Lucas Hospital (HSL).

CONCLUSION

the study centers seem to receive a different population of patients, both in socioeconomic terms, as well as disease severity, which interferes with the choice of medication treatment. At the HCSA, preventive actions against infection due to the high incidence of Burkholderia cepacia Complex and careful research into early lung changes will be encouraged.

Maximal respiratory pressures of healthy children: comparison between obtained and predicted values

PURPOSE

To compare maximal inspiratory and expiratory pressures (PImax and PEmax, respectively) obtained in Brazilian children who are healthy with reference and predicted values from previous studies.

METHODS

Respiratory muscle strength of 144 children (63 boys), aged 7 to 11 years, was assessed. A digital manovacuometer was used to measure PImax and PEmax from residual volume and total lung capacity, respectively. Children were assessed in the sitting position while wearing a nose clip.

RESULTS

Mean values of PImax for boys and girls were 81.6 ± 20.2 and 66.1 ± 19.5 cmH2O, respectively. Mean values of PEmax in boys and girls were 95.6 ± 21.1 and 78.9 ± 19.7 cmH2O, respectively.

CONCLUSIONS

Published reference values demonstrated a wide diversity across age groups studied, and published equations were not successful in predicting maximal respiratory pressures; thus, the assessment of respiratory muscle strength of children should consider the minimization of ethnic and methodological differences.

Use of palivizumab in infants and young children with severe respiratory disease: a Delphi study

OBJECTIVE

To achieve a consensus of opinion among an expert group of pediatric pulmonologists regarding the appropriateness of the off-label use of palivizumab for some pediatric patients with severe respiratory diseases.

METHODS

A two-round modified Delphi technique was used. A 43-item self-administered questionnaire grouped into seven clinical scenarios was developed. Level of agreement for each statement was ranked on a 0-9 scale with 0 being total disagreement and 9 total agreement. Consensus was sought through the feedback of information and iteration. The final responses were evaluated for median and interquartile range to determine which questions the group had reached consensus about, either affirmatively or negatively.

RESULTS

Consensus was obtained for 24/43 statements (55.81%), including use of palivizumab for prevention of respiratory syncytial virus (RSV) infection in children with severe respiratory involvement due to neuromuscular disease, congenital or acquired immunodeficiency, storage disease, cystic fibrosis, diseases involving impaired ciliary clearance, patients operated on esophageal atresia and/or tracheoesophageal fistula, diaphragmatic hernia, bronchopulmonary malformations, severe tracheomalacia, lung transplant recipients and patients in the waiting list for lung transplant, patients oxygen-dependent for severe interstitial pulmonary disease and patients with severe pulmonary hypertension. Consensus against the use of palivizumab as prevention of RSV infection was also achieved in almost all the recurrent wheezing/asthma attacks situations.

CONCLUSION

A set of indication for off-label uses of palivizumab in pediatric pulmonology was developed in accordance with the degree of professional consensus on which they were based. The applicability of the present results to clinical practice should be evaluated individually and reviewed periodically in the light of new emerging evidence. Further studies are needed to add evidence to the most frequent and clinically oriented scenarios that have shown higher levels of uncertainty.

Physiotherapy in cystic fibrosis: optimising techniques to improve outcomes

Optimisation of physiotherapy techniques to improve outcomes is an area of cystic fibrosis (CF) care, which has developed considerably over the last two decades. With the introduction of newborn screening and an increase in median life expectancy, the management of individuals with CF has needed to adapt to a more dynamic and individualised approach. It is essential that CF physiotherapy management reflects the needs of a changing cohort of paediatric CF patients and it is no longer justifiable to adopt a 'blanket' prescriptive approach to care. The areas of physiotherapy management which are reviewed and discussed in this paper include inhalation therapy, airway clearance techniques, the management of newborn screened infants, physical activity and exercise.

Exercise as part of a cystic fibrosis therapeutic routine

The role of exercise in cystic fibrosis (CF) is well established, and over the last three decades it has become an important component in the management of all individuals with CF. The role of exercise as a prognostic indicator or therapeutic tool is an important area of research interest in CF care internationally. This article summarizes the currently available evidence regarding exercise capacity in CF, the potential effects of exercise on health outcomes in CF and the challenges faced when trying to incorporate exercise into a CF therapeutic routine, and highlights some methods to facilitate the incorporation of exercise into CF therapeutic routines.

Acid and non-acid reflux during physiotherapy in young children with cystic fibrosis

BACKGROUND

Gastro-esophageal reflux (GOR) may contribute to lung disease in children with cystic fibrosis (CF). There is conflicting evidence regarding the effect of chest physiotherapy (CPT) in the head-down position on GOR. Furthermore, there is currently no evidence on the impact of physiotherapy on GOR as assessed by pH-multichannel intraluminal impedance (pH-MII).

AIMS

(1) To characterize GOR in young children with CF. (2) To determine whether the head-down position during physiotherapy exacerbates GOR.

METHODS

Children were studied using pH-MII monitoring over 24-hr, during which they received two 20-min sessions of CPT. One session was performed in "modified" drainage positions with no head-down tilt and the alternate session in "gravity-assisted" drainage positions, which included 20° head-down tilt.

RESULTS

Twenty children with CF (8 males), median age 12 months (range 8-34) were recruited. A total of 1,374 reflux episodes were detected in all children, of which 869 (63%) were acid and 505 (37%) were non-acid. Seventy-two percent of the episodes migrated proximally. During CPT, there was no significant difference between total number of reflux episodes in the modified or gravity-assisted positions, median [inter-quartile range (IQR)] 1 (0-2.5) compared to 1 (0.75-3) episode, respectively, P = 0.63. There was also no significant difference between the number of reflux episodes which migrated proximally, median (IQR) 1 (0-2) compared to 0 (0-2) episodes, respectively, P = 0.75.

CONCLUSION

In young children with CF, GOR is primarily acidic and proximal migration is common. Physiotherapy in the head-down position does not appear to exacerbate GOR. The impact of GOR on lung disease remains to be elucidated.

Knowledge of oxygen administration, aerosol medicine, and chest physiotherapy among pediatric healthcare workers in Italy

BACKGROUND

Oxygen administration, aerosol devices and drugs, or the use of chest physiotherapy are common practices in pediatrics; however, little is known about the knowledge of pediatric healthcare workers concerning the right utilization of these tools. The aim of this study was to fill this gap as a preliminary step in the implementation of appropriate educational programs.

METHODS

This cross-sectional survey of a nationally representative sample of Italian pediatricians and nurses was carried out between September 1 and October 8, 2008. A self-administered, anonymous questionnaire concerning the approach to respiratory disease in infants and children was distributed to all of the participants at the Annual Congress of the Italian Society of Pediatrics, together with a stamped envelope addressed to the trained study researchers.

RESULTS

Of the 900 distributed questionnaires, 76.7% were completed and returned by 606 physicians (199 primary care pediatricians, 245 hospital pediatricians, and 162 pediatric residents) and 84 pediatric nurses. The vast majority of the respondents did not know the percentage of hemoglobin saturation indicating hypoxemia that requires oxygen administration. Most of the nurses admitted to overusing mucolytics and inhalatory corticosteroids, did not know the role of ipratropium bromide, were unable to indicate the first-line drug for respiratory distress, and did not know the correct dose of salbutamol. Only a minority of the respondents were able to specify the indications for chest physiotherapy. The nurses gave the fewest correct answers regardless of their age, gender, work setting, or the frequency with which they cared for children with respiratory distress in a year cared.

CONCLUSIONS

The knowledge of primary care pediatricians, hospital pediatricians, and pediatric nurses in Italy concerning the use of pulse oximetry, aerosol devices and drugs, and chest physiotherapy is far from satisfactory and should be improved. Educational programs are therefore required for both nurses and pediatricians.

Chronic pain in the neonate: a research design connecting Ancient Delphi to the modern ‘Dutch Polder’

Introduction: To date research on neonatal pain has focused mainly on acute or procedural pain. It is recognised that prolonged or chronic pain exists in this age group. Studies on this subject fail to provide a clear description of chronic pain in the neonate.

Objectives: To identify the most appropriate consensus-building method in order to answer three research questions concerning the definition of chronic pain in the neonate, the etiology and the clinical signs and symptoms.

Methodology: We performed a literature search with regards to the methodology of the Delphi method, the Nominal Group Technique and the Consensus Development Conference.

Results: We found only sparse data reviewing the Nominal Group Technique and the Consensus Development Method. More data was found for the Delphi method.

Discussion: We chose to design a Delphi survey in the light of our research questions. The main arguments were the ability to include experts from all over the globe, and the low probability of introducing bias.

Conclusion: All three methods have strong and weak points. A major criterion should be the validity of the design. However, conclusions on validity are hampered by the marginal amount of papers found for two of the three designs.

Interpreting clinical trial results of patient-perceived onset of effect in asthma: methods and results of a Delphi panel

OBJECTIVE

The purpose of this study was to determine if empirically observed differences in patient perception of, and satisfaction with, onset of effect between an active maintenance treatment and placebo are clinically meaningful to practicing clinicians. A secondary objective was to determine the lowest threshold for a clinically meaningful difference in terms of both between-group differences and maximum acceptable placebo effect.

METHODS

Twelve community-based healthcare professionals participated in a Delphi consensus panel. Panelists were provided with blinded results of two clinical trials showing statistically significant treatment effects for treatment A (budesonide/formoterol [Symbicort*]) over placebo in the proportion of patients who could perceive the medication working right away and the proportion of patients satisfied with this perception. Panelists were then asked to respond to a series of questions to identify a threshold for clinically important differences in patient-perceived onset of effect and satisfaction with speed of onset of effect. All expert panelists participated in two rounds of the Delphi process.

RESULTS

Panelists were unanimous in their conclusion that the statistically significant results from the two trials were clinically meaningful. According to these practitioners, the empirical results presented to them, showing that patients could feel a maintenance inhaler therapy work right away, were meaningful to clinical decision-making, and the attribute could potentially improve patient adherence with therapy. A group consensus was reached that a minimum active treatment response for these outcomes should range from 50% to 75% and be 2-3 times larger than the placebo response, with a maximum placebo effect of 26-40%.

CONCLUSION

A Delphi panel study of practitioners was used to establish a meaningful range of response and a minimal important difference for interpreting results of clinical trials in which patient perception of onset of effect and satisfaction with this perception are tested. While the views of this panel may not be generalized to the entire population of practitioners in the United States, results provide insight into how a typical practitioner is likely to view clinical trial results and how the information might be used in clinical practice.

American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography

OBJECTIVE

To define competence in critical care ultrasonography (CCUS).

DESIGN

The statement is sponsored by the Critical Care NetWork of the American College of Chest Physicians (ACCP) in partnership with La Société de Réanimation de Langue Française (SRLF). The ACCP and the SRLF selected a panel of experts to review the field of CCUS and to develop a consensus statement on competence in CCUS.

RESULTS

CCUS may be divided into general CCUS (thoracic, abdominal, and vascular), and echocardiography (basic and advanced). For each component part, the panel defined the specific skills that the intensivist should have to be competent in that aspect of CCUS.

CONCLUSION

In defining a reasonable minimum standard for CCUS, the statement serves as a guide for the intensivist to follow in achieving proficiency in the field.