CIS Peds Lower Resp (Lopez, Oct 27)

Question 1

3 factors in asthma

Answer 1

obstruction+ inflammation + autonomic imbalance

Question 2

Asthma: Background

Answer 2

obstructive pulmonary disease w/ inflammatory component

The dynamic balance of sympathetic and parasympathetic influences in the lung is distorted in asthma

Aspects of anatomical and physiological immature in young children with asthma result in vulnerability for respiratory muscle fatigue, inefficiency of diaphragmatic mechanics, and ineffectiveness of tissue recoil

There are biomechanical, respiratory-circulatory, metabolic, and neurological influences that need to be considered in the management of asthma
Osteopathic manipulative medicine used in conjunction with standard care may improve the severity of asthma symptoms and decrease the need for pharmaceutical management

Question 3

Triggers

Answer 3

cold/ weather changes
exercise
viral respiratory infections
medications (ASA, NSAIDs)
Allergens
Pollution/ smoke
Emotional stress 
GERD
Mechanical injuries

Question 4

Hypersensitivity reaction

Answer 4

inflammation –> edema
bronchospasm
mucous plugging

Bronchial smooth muscle is innervated by vagus nerve; vasovagal reflexes can cause bronchoconstriction; overactivity of the bronchial branches of the vagus nerve can worsen the issue

Question 5

Airway obstruction

Answer 5

difficulty breathing
wheezing
nighttime cough
prolonged expiratory phase
air trapping

Question 6

Repetitive episodes of inflammation

Answer 6

lead to a production of matrix proteins and growth factors that can potentially cause airway remodeling

Remodeling + increased muscle mass + mucosal edema + reduced elasticity –> decreased efficacy of bronchodilators and decreased O2:CO2 exchange

Question 7

Osteopathic Management of asthmatic patient

Answer 7

Start or continue pharmacological management according to asthma severity and state of exacerbation
Optimize breathing mechanics (Biomechanical Model)
Normalize autonomic nervous system (Neurologic Model)
Optimize respiratory/ circulatory/ lymphatic function (Respiratory/ Circulatory Model)
Optimize lifestyle and diet (Metabolic Model)
Remove barriers to health: identify and minimize triggers, educate patient in proper usage of medications, help patient obtain medications, etc. (Behavioral Model)

Question 8

Asthma: Initiating Therapy

Answer 8

Intermittent asthma - step 1 (short acting beta-2 agonist)
Mild persistent asthma - step 2 (low-dose inhaled corticosteroid)
Moderate persistent asthma - step 3 (medium-dose inhaled corticosteroids option) and consider short course of oral corticosteroids
Severe persistent asthma - step 3 (medium-dose inhaled corticosteroids option) or 4 and consider short course of oral corticosteroids
Evaluate level of asthma control in 2-6 weeks and adjust therapy accordingly

Question 9

Asthma: Treatment During Exacerbation

Answer 9

Increasing frequency of short-acting beta-2 agonists
Possibly start oral steroids
Consider starting inhaled steroids
Give oxygen to maintain O2 sat >90-92%
Ipratropium in ED patients refractory to initial short-acting beta-2 agonist
Magnesium sulfate may be considered to avoid intubation
Intubation for impending respiratory failure, apnea, or coma

Question 10

Biomechanical Model:Effects of Airway Obstruction

Answer 10

A child with an obstructive airway suffers from:

Increased effort to maintain normal air movement through bronchioles

Decreased mechanical effectiveness of diaphragm and rib cage

• Children have a flatter diaphragm than adults
• Rib cage is more flexible than adults

Increased O2 demand and waste production
- Alters pH

Increased work of breathing

Question 11

Biomechanical Model: Treatment Goals

Answer 11

OMT: to decrease work of breathing by facilitating mechanics

• Facilitate normal motion of thoracic cage and pelvic diaphragm
• Remove fascial, bony and ligamentous restrictions
• Decrease muscle hypertonicity of primary and accessory muscles of respiration

Breathing exercises that strengthen peripheral and accessory muscles that aid breathing and facilitate exhalation

Yoga, tai chi, noncontact martial arts that integrate breathing with movement

Question 12

The Thoracic Diaphragm:

Answer 12

Primary muscle of respiration

Alters arterial and venous circulation
– Fluid movement through vena cava dependent on effective diaphragmatic excursion

Alters lymphatic circulation

Moves extracellular fluid in abdomen into lymph system
– Removal of cellular waste

Question 13

Respiratory-Circulatory Model

Answer 13

Respiration is a constant and powerful modulator of cardiovascular control

During breathing, the diaphragm reduces negative intrathoraic pressure through inhalation, enhancing venous drainage

Lymphatic flow depends on rhythmicity and stretching of diaphragm, then on intraperitoneal pressure and posture of the individual

Cisterna chyli, located under diaphragmatic crural region, main destination point for lymph

Question 14

goals of Respiratory-Circulatory Model

Answer 14

Restore optimal motion at the diaphragm and pelvic diaphragm

Remove restrictions to lymphatic, arterial, and venous systems
– Including Thoracic Outlet Release

Question 15

Neurologic Model and asthma

Answer 15

Asthmatics suffer from an imbalance of the autonomic nervous system

Smooth muscles are innervated by sympathetic, parasympathetic, and primary afferent fibers

Vagus nerve –> Jugular foramen –> Cervicals –> Thoracic inlet –> Lungs

Sympathetics to lungs: T1-6
– Viscerosomatic reflexes/ Facilitated segments

Somatic dysfunction may lead to/ be a result of imbalance of the neuroendocrine immune system resulting in more inflammation

Question 16

neurologic model treatment

Answer 16

Bronchodilators, corticosteroids, anticholenergics:

• Influence neuronal control and inflammatory mechanisms
• Leukotriene inhibitors and mast cell stabilizers – to control allergy symptoms

OMT can help reduce necessary dosage of medication required to control symptoms

• Rib raising to stimulate sympathetic chain ganglion and alter symphathetic flow to visceral organs
• Suboccipital release to influence parasympathetics

Question 17

Behavioral Model

Answer 17

physical, spiritual, mental, emotional, socioeconomic

Question 18

Metabolic Energy

Answer 18

Structure Function

Encourage:	
Fresh, whole food diet
Vitamin C with bioflavonoids and B vitamins
Shown benefit: IV Mag
Breastfeeding
Probiotics

Avoid:
Processed, devitalized food
Food coloring, sulfites, preservatives, food modifiers
Asthmatic children may benefit from avoiding: dairy and processed flour, sugar, & corn syrup sweeteners

Question 19

Goals of OMT in pediatric asthma

Answer 19

Optimize dynamic balance between parasympathetic and sympathetic input to the pulmonary system
Remove mechanical restrictions that adversely affect respiratory mechanics
Decrease the workload of breathing
Facilitate the child’s ability to function normally
Education + Allergen prevention/Reduce Triggers + Medication + Diet + OMT

Question 20

Visceral Layer of Fascia

Answer 20

is a continuous “tube” throughout the body

Forms the packing surrounding the body cavities and visceral organs

Conduit for neurovascular and lymphatic bundles

In the neck, the Pretracheal (Visceral) layer contains trachea, esophagus, thyroid, infrahyoid muscles

Extends into thorax as endothoracic fascia, accommodates pleural cavities, surrounds great vessels of the heart, thickens anteriorly (pericardium), posteriorly is loose surrounding aorta, esophagus, trachea, primary bronchi, thoracic duct

Extends into abdomen to become endoabdominal fascia posteriorly and transversalis fascia anteriorly

Extends into pelvis as endopelvic fascia, where inferior border is pelvic diaphragm

Question 21

The Prevertebral layer of fascia

Answer 21

is also continuous throughout the body
Longus and scalenes muscles in the neck
Intercostals muscles in thorax
Oblique and rectus muscles in abdomen

The fascial layers can be envisioned as existing in a series of concentric tubes.

Question 22

Thoracic Cage Release with Respiratory Assist

Answer 22

With pediatrics patients, the physician must be able to meet the patient where she/he is: lying down/ seated/ on the move

At least two options for contact:

• Bilateral rib cage
• One side at a time with thumbs in midaxillary line

Gently encourage motion in inhalation and exhalation (in bucket and pump handle) with the patient’s breath. You may move more slowly if they are breathing fast.

Continue until motion is freer in both inhalation and exhalation

Repeat by moving your contact to upper or lower ribs as needed

Reassess

Question 23

Diaphragm & Pelvic Diaphragm

Answer 23

Works synchronously with the abdominal diaphragm

During normal respiration, or during coughing, a symmetric change in the pelvic floor can be observed

During inspiration, both diaphragms descend
- Studies show electrical activity can be observed before inhalation in the pelvic floor, transverse & obliquus internus abdominis muscles

Ensures steadiness of the human trunk and maintaining urinary continence during respiration and coughing

Question 24

Balanced Ligamentous Tension (BLT)/ Balanced Membranous Tension (BMT)

Answer 24

Balanced membranous/ligamentous tension is a treatment principle which an area of strain is brought to a point of balanced tension to engage and utilize the inherent forces within the patient’s body to make the correction

• Inherent forces: “reset” nervous system, reduce firing of joint receptors and nociceptors, expression of inherent motion (respiration, pulse, PRM)
• Direct (into restrictive barrier) or Indirect (exaggeration)

Question 25

Seated Pelvic Diaphragm BLT

Answer 25

Contact the ischial tuberosities bilaterally with the patient seated (they will sit on your hands) with your palms

Gently slide your fingers just medially and slightly superiorly to contact the pelvic diaphragm. Notice motion as your patient breathes.

Notice which side is more restricted. Bring the pelvic diaphragm to a point of balanced ligamentous tension.
- You may bring your attention to the innominates and the whole pelvic bowl

Continue until you feel respiratory motion restored at the pelvic diaphragm, then reassess

Question 26

The Base Spread (BMT)- setup

Answer 26

For Diagnosis and Treatment of the Temporal bones, Occiput, and Occipitomastoid (OM) Suture

With patient supine, place index fingers along mastoid and middle fingers on the other side of the OM suture on the occiput. Other fingers can gently rest on the skull.

Gently separate index and middle fingers apart from each other on both sides, while bringing them posteriorly. The vector at the index finger will be 45° from the midline for control of the temporal bone, and the middle finger will be 30° for control of the occipital condyle.

Question 27

The Base Spread- dx and treatment

Answer 27

Diagnosis: Sense where you find greatest tension

• Between fingers: OM suture
• Index finger: Temporal bone
• Middle finger: Occipital condyle

Treatment: Bring all parts to a point of balanced membranous tension

Maintain BMT until all parts are moving more freely

Reassess by initiating the Spread again

Or as you learn new approaches, you may treat that area specifically, then return to the Base Spread to re-evaluate and re-balance.