Pulmonary Treatment.

The treatment goal is to

prevent and treat respiratory infections. Respiratory

drainage is provided by thinning the secretions and by

mechanical means, such as postural drainage and clapping,

to loosen and drain secretions from the lungs.

Inhalation therapy can be preventive or therapeutic.

A bronchodilator drug such as theophylline or a

beta-adrenergic agonist (metaproterenol, terbutaline,

or albuterol) may be administered either orally or

through nebulization. Recombinant human DNA

(DNase, Pulmozyme) breaks down DNA molecules in

sputum, breaking up the thick mucus in the airways.

A mucolytic such as Mucomyst may be prescribed

during acute infection. Hand-held nebulizers are easy

to use and convenient for the ambulatory child.

Humidifiers provide a humidified atmosphere. In

summer, a room air conditioner can help provide

comfort and controlled humidity.

Chest physical therapy, a combination of postural

drainage and chest percussion, is performed routinely

at least every morning and evening, even if little

drainage is apparent (Fig. 19-7). Performed correctly,

chest percussion (clapping and vibrating of the

affected areas) helps to loosen and move secretions out

of the lungs. The physical therapist usually performs

this procedure in the hospital and teaches it to the

family. Chest physical therapy, although time consum- ing, is part of the
ongoing, long-term treatment and

should be continued at home.

Inhalation of Bronchodilators

Airway obstruction that is at least partially reversed by a bronchodilator can be

seen in CF, bronchiolitis, and bronchopulmonary dysplasia, as well as in acute
and chronic asthma.

The beta-adrenergic agonists may be delivered by metered-dose inhaler, dry

powder inhaler, or nebulizer. Metered-dose inhalers are convenient and best
combined with valved holding chambers, especially for children who lack the
ability to coordinate actuation of the metered-dose inhaler with inhalation. In
contrast, the nebulizer is an effective method of delivering medication to
infants and young children. Long-acting inhaled 2-adrenergic agents that are
relatively selective for the respiratory tract are described in Chapter 34.
Inhaled bronchodilators are as effective as injected agents for treating acute
episodes of airway obstruction and have fewer side effects. These drugs can be
safely administered at home as long as both the physician and the family
realize that a poor response may signify the need for corticosteroids to help
restore -adrenergic responsiveness.

Airway Clearance Therapy

Chest physical therapy, with postural drainage, percussion, and forced

expiratory maneuvers, has been widely used to improve the clearance of lower
airway secretions even though there are limited data on the efficacy of these
techniques. Children with cystic fibrosis have been shown to benefit from
routine airway clearance. Many airway clearance techniques exist, but only a
few long-term studies have compared the various options. The various
techniques currently available include chest physiotherapy, autogenic drainage,
positive expiratory pressure (Flutter or Acapella), intrapulmonary percussive
ventilation, or high-frequency chest compression. The decision about which
technique to use should be based on the patient's age and preference after
trying different approaches. Often bronchodilators or mucolytic medications
are given prior to or during airway clearance therapy. Inhaled corticosteroids
and inhaled antibiotics should be given after airway clearance therapy so that
the airways are first cleared of secretions, allowing the medications to
maximally penetrate into the lung.

Perrotta C et al: Chest physiotherapy for acute bronchiolitis in paediatric

patients between 0 and 24 months old. Cochrane Database Syst Rev
2005:CD004873. [PMID: 15846736]

Wagener JS, Headley AA: Cystic fibrosis: Current trends in respiratory care.
Respir Care 2003;48:234; discussion 246. [PMID: 12667274

Anticholinergic agents may also acutely decrease airway obstruction.

Furthermore, they may yield a longer duration of bronchodilation than do
many adrenergic agents. Selected patients may benefit from receiving both -
adrenergic and anticholinergic agents. In general, this class of drugs is most
effective in the treatment of chronic bronchitis.

Rubin BK, Fink JB: The delivery of inhaled medication to the young child.
Pediatr Clin North Am 2003;50:717. [PMID: 12877243]
Most medications are given by Inhalation (Figure 20-12 .. ).

This route of administration enubles the pulmonary blood vessels

to rapidly absorb the medication while minimizing the

systemic effects. (~ the Clinkill Skills Milnrml.j The inhaled

droplets provide the added benefit of mol5lure. Continuous inhalation

treatments by nebulizer may be used for some children

with severe exacerbation,