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ANASARCA IN THE NEWBORN
729 MECHANICAL CHEST PHYSIOTHERAPY
ANASARCA IN THE NEWBORN
some critical debate lately about the usefulof physiotherapy in certain chest conditions,1,2 the fact remains that many patients voluntarily undertake regular postural bronchial drainage to help clear their sputum. A substantial number also find rapid chest percussion over affected lung segments useful in loosening the sputum, and often enlist the services of a spouse. When a child has retention of sputum-for example, due to cystic fibrosis-the mother commonly becomes a skilful amateur percussor; but a natural reluctance to continue the practice tends to appear on both sides as the child enters adolescence. In such cases, chest percussion by a mechanical device controlled by the patient himself seems worthy to trial. A prototype, the Salford precursor, generates higher and less variable pressures than a physiotherapist.3 Maxwell and Redmond4 have compared a commercial device (costing about 100) with manual percussion during postural bronchial
UNTIL this decade cedema in a baby usually meant hæmolytic disease, but with effective prophylaxis against rhesus haemolytic disease the oedematous or hydropic baby is more of a challenge. The best known influences
DESPITE
ness
drainage. The subjects were a group of fourteen Belfast children with cystic fibrosis, aged between 7 and 21 years. Each received physiotherapy of similar duration on two successive days, done by the manual technique on one occasion and by a mechanical percussor on the other, the order being randomised. Sputum production was measured by weight, and pulmonary function (FEVB, FVC and PEFR) was measured after each session. The two techniques resulted in expectoration of similar quantities of sputum, although all but one patient felt subjectively that the machine delivered better-quality percussion (it was set at 230 strokes per minute). There was no overall improvement in pulmonary function after either type of physiotherapy, and in some patients the FEV actually fell. This was also found by Newton and Stephenson last year, but no-one should be surprised since airflow resistance is influenced more by widespread changes in medium and small airways than by plugs of sputum in scattered segmental or major bronchi. The reason for recommending regular sputum clearance is surely to avoid complications of poor segmental drainage, rather than to improve generalised small-airway narrowing. Before parents and others are advised to buy percussing machines, we need a formal study of postural drainage with and without chest percussion. Many single patients seem to manage well enough with self-tipping exercises, and it would be interesting to know just how much extra sputum is really "loosened" by additional percussion. Nevertheless, for patients who clearly value the percussion technique, self-administered physiotherapy offers independence; the mechanical percussor may therefore prove useful for the growing number of teenage and young adult patients with cystic fibrosis.
1. Newton DAG, Stephenson A. Effect of physiotherapy on pulmonary function. Lancet 1978; ii: 228-29. 2. Graham WGB, Bradley DA. Efficacy of chest physiotherapy and intermittent positive-pressure breathing in the resolution of pneumonia. N Engl J Med
1978; 299: 624-27. 3. Flower KA, Eden KI, Lomax L, Mann NM, Burgess J. New mechanical Aid to Physiotherapy in Cystic Fibrosis. Br Med J 1979; ii: 630-31. 4. Maxwell M, Redmond A. Comparative trial of manual and mechanical percussion technique with gravity-assisted bronchial drainage in patients with cystic fibrosis. Arch Dis Child 1979; 54: 542-44.
the distribution of intravascular and interstitial components of extracellular fluid are hydrostatic pressure, colloid osmotic pressure (principally albumin), and the function of lymphatics in draining excess interstitial fluid. Recent work suggests other factors-a complex interstitial tissue gel of protein, salts, and mucopolysaccharides ; activity of the autonomic nervous system; acidbase status; oxygenation; and blood viscosity-and these are particularly important in the preterm infant, in whom -capillary transfer of albumin is high and the water compartments of skin and subcutaneous tissues are large. The colloid osmotic pressure is low in the preterm infant and increases with gestational age. Even in normal newborn babies pitting may commonly be observed after prolonged pressure, but generalised oedema is unusual: it is not confined to dependant parts, the face, hands, and feet being typically affected. Common causes of cedema are those familiar perinatal insults hypoxia, infection, hypothermia, and over-hydration-insults to which preterm babies and those being artificially ventilated are especially prone. Blood conditions (haemolysis, haemoglobinopathies, vitamin-E deficiency), cardiac disorders (heart-failure, paroxysmal tachycardia), and nephrotic syndrome (primary or secondary to intrauterine infection) are rarer. Lymphoedema is more commonly a manifestation of Turner’s syndrome than of chronic lymphatic obstruction (Milroy’s disease). The primary condition should be sought and treated, and the temptation to try a dose of frusemide should be resisted until the oedema is troublesome. It is wise to try a thiazide preparation before resorting to the more powerful loop diuretics; if there is hypoproteinxmia an infusion of salt-poor albumin should be given before diuretic treatment. Most cases are self-limiting and improve with regulation of salt and water intake.
on
THE PRESS AND THE H.S.E.
THE Health and Safety Executive has an important and difficult job to do, but it seems overanxious to demonstrate the strength of its bite. One effect of the threat to prosecute the University of Birmingham after the escape of smallpox virus was to hold up official publication of a report from which lessons might have been learned. The H.S.E. announced that it had banned smallpox work in Birmingham days after the university had taken this obvious step. Now the H.S.E. has upset virus diagnostic laboratories by a Sept. 11 announcement on laboratory inspections that was both tactless and misleading. The need for different standards for category-A diagnostic and research work and the practicability of sending all suspect smallpox material to one centre are important policy issues which Professor Grist (last week) and Dr Selkon (p. 746) raise. These letters also suggest that the H.S.E. should pay attention to the manner in which its decisions are publicised. 1. Tina LU, Calcagno PL. Edema of the pre-term and term infant. Contrib Nephrol 1979; 15: 67-77. This volume, on nephrological problems of the newborn, is edited by J. F. PASCUAL and P. L. CALCAGNO. BASLE: Karger. Pp. vi+78.
$19-75.
ANASARCA IN THE NEWBORN
some critical debate lately about the usefulof physiotherapy in certain chest conditions,1,2 the fact remains that many patients voluntarily undertake regular postural bronchial drainage to help clear their sputum. A substantial number also find rapid chest percussion over affected lung segments useful in loosening the sputum, and often enlist the services of a spouse. When a child has retention of sputum-for example, due to cystic fibrosis-the mother commonly becomes a skilful amateur percussor; but a natural reluctance to continue the practice tends to appear on both sides as the child enters adolescence. In such cases, chest percussion by a mechanical device controlled by the patient himself seems worthy to trial. A prototype, the Salford precursor, generates higher and less variable pressures than a physiotherapist.3 Maxwell and Redmond4 have compared a commercial device (costing about 100) with manual percussion during postural bronchial
UNTIL this decade cedema in a baby usually meant hæmolytic disease, but with effective prophylaxis against rhesus haemolytic disease the oedematous or hydropic baby is more of a challenge. The best known influences
DESPITE
ness
drainage. The subjects were a group of fourteen Belfast children with cystic fibrosis, aged between 7 and 21 years. Each received physiotherapy of similar duration on two successive days, done by the manual technique on one occasion and by a mechanical percussor on the other, the order being randomised. Sputum production was measured by weight, and pulmonary function (FEVB, FVC and PEFR) was measured after each session. The two techniques resulted in expectoration of similar quantities of sputum, although all but one patient felt subjectively that the machine delivered better-quality percussion (it was set at 230 strokes per minute). There was no overall improvement in pulmonary function after either type of physiotherapy, and in some patients the FEV actually fell. This was also found by Newton and Stephenson last year, but no-one should be surprised since airflow resistance is influenced more by widespread changes in medium and small airways than by plugs of sputum in scattered segmental or major bronchi. The reason for recommending regular sputum clearance is surely to avoid complications of poor segmental drainage, rather than to improve generalised small-airway narrowing. Before parents and others are advised to buy percussing machines, we need a formal study of postural drainage with and without chest percussion. Many single patients seem to manage well enough with self-tipping exercises, and it would be interesting to know just how much extra sputum is really "loosened" by additional percussion. Nevertheless, for patients who clearly value the percussion technique, self-administered physiotherapy offers independence; the mechanical percussor may therefore prove useful for the growing number of teenage and young adult patients with cystic fibrosis.
1. Newton DAG, Stephenson A. Effect of physiotherapy on pulmonary function. Lancet 1978; ii: 228-29. 2. Graham WGB, Bradley DA. Efficacy of chest physiotherapy and intermittent positive-pressure breathing in the resolution of pneumonia. N Engl J Med
1978; 299: 624-27. 3. Flower KA, Eden KI, Lomax L, Mann NM, Burgess J. New mechanical Aid to Physiotherapy in Cystic Fibrosis. Br Med J 1979; ii: 630-31. 4. Maxwell M, Redmond A. Comparative trial of manual and mechanical percussion technique with gravity-assisted bronchial drainage in patients with cystic fibrosis. Arch Dis Child 1979; 54: 542-44.
the distribution of intravascular and interstitial components of extracellular fluid are hydrostatic pressure, colloid osmotic pressure (principally albumin), and the function of lymphatics in draining excess interstitial fluid. Recent work suggests other factors-a complex interstitial tissue gel of protein, salts, and mucopolysaccharides ; activity of the autonomic nervous system; acidbase status; oxygenation; and blood viscosity-and these are particularly important in the preterm infant, in whom -capillary transfer of albumin is high and the water compartments of skin and subcutaneous tissues are large. The colloid osmotic pressure is low in the preterm infant and increases with gestational age. Even in normal newborn babies pitting may commonly be observed after prolonged pressure, but generalised oedema is unusual: it is not confined to dependant parts, the face, hands, and feet being typically affected. Common causes of cedema are those familiar perinatal insults hypoxia, infection, hypothermia, and over-hydration-insults to which preterm babies and those being artificially ventilated are especially prone. Blood conditions (haemolysis, haemoglobinopathies, vitamin-E deficiency), cardiac disorders (heart-failure, paroxysmal tachycardia), and nephrotic syndrome (primary or secondary to intrauterine infection) are rarer. Lymphoedema is more commonly a manifestation of Turner’s syndrome than of chronic lymphatic obstruction (Milroy’s disease). The primary condition should be sought and treated, and the temptation to try a dose of frusemide should be resisted until the oedema is troublesome. It is wise to try a thiazide preparation before resorting to the more powerful loop diuretics; if there is hypoproteinxmia an infusion of salt-poor albumin should be given before diuretic treatment. Most cases are self-limiting and improve with regulation of salt and water intake.
on
THE PRESS AND THE H.S.E.
THE Health and Safety Executive has an important and difficult job to do, but it seems overanxious to demonstrate the strength of its bite. One effect of the threat to prosecute the University of Birmingham after the escape of smallpox virus was to hold up official publication of a report from which lessons might have been learned. The H.S.E. announced that it had banned smallpox work in Birmingham days after the university had taken this obvious step. Now the H.S.E. has upset virus diagnostic laboratories by a Sept. 11 announcement on laboratory inspections that was both tactless and misleading. The need for different standards for category-A diagnostic and research work and the practicability of sending all suspect smallpox material to one centre are important policy issues which Professor Grist (last week) and Dr Selkon (p. 746) raise. These letters also suggest that the H.S.E. should pay attention to the manner in which its decisions are publicised. 1. Tina LU, Calcagno PL. Edema of the pre-term and term infant. Contrib Nephrol 1979; 15: 67-77. This volume, on nephrological problems of the newborn, is edited by J. F. PASCUAL and P. L. CALCAGNO. BASLE: Karger. Pp. vi+78.
$19-75.