Adult Paediatric On-Call Training

Authors: Emily and Sammy (adapted from L. Murphy, S. Reed, and M. Revell) Source: Adult Paeds On Call Training.pptx (56 slides) Learning Level: Intermediate to Advanced

Learning Objectives

• Understand indications for on-call physiotherapy
• Identify contraindications and precautions to respiratory physiotherapy
• Conduct a respiratory assessment in a paediatric patient
• Understand paediatric anatomy and physiology relevant to respiratory care
• Recognise common conditions encountered on call
• Apply practical treatment options
• Work through on-call clinical scenarios

Part 1: Scope of On-Call Practice

1.1 Appropriate Call-Outs (Indications for On-Call Physio)

The following are legitimate reasons for on-call physiotherapy attendance:

• Secretion retention
• Increasing ventilatory requirements
• Increasing FiO2 requirements
• Poor blood gases
• Increased work of breathing (WOB)
• Decreased tidal volumes (TVs)
• Altered pCO2 or EtCO2
• Weak cough
• Increased respiratory rate (RR)
• New CXR changes
• Close to intubation

1.2 Inappropriate Call-Outs

The following are not appropriate indications for on-call physiotherapy:

• Pulmonary oedema
• Undrained pneumothorax
• Pleural effusion
• Changes to NIV/LTV (ventilator adjustments)
• Suction alone (nursing skill)
• Stable patient — routine treatment
• Normal physiotherapy not optimised during working hours
• General medical/nursing care not optimised

1.3 What to Ask on the Phone

When receiving an on-call referral, gather the following information:

• Name / age / hospital number of patient
• Ward and bed number
• HPC — history and lead-up to this point
• PC — current difficulties
• Have they had a CXR / bloods / blood gas?
• PMHx — anything to be aware of (e.g. ex-prem, recurrent admissions, metabolic bone disease, osteopenia), usual baseline
• Your respiratory assessment findings
• What has been tried already
• Is the NIC / medical team aware?

1.4 Contraindications and Precautions to Respiratory Physiotherapy

Part 2: Respiratory Assessment Framework

2.1 Systematic Assessment

Use an A-E (Airway, Breathing, Circulation, Disability, Exposure) systematic approach for respiratory assessment.

2.2 Normal Paediatric Values

Respiratory Rate

Heart Rate

2.3 PEWS Score (Paediatric Early Warning Score)

• Monitors: HR, RR, conscious level, O2 need, and respiratory distress
• Score range: 0-15
• Higher score = deteriorating patient

Early warning scores are generated by combining the scores from a selection of routine observations. Different observations are selected for children and adults due to their naturally different physiological responses. If a child’s clinical condition is deteriorating the score will usually increase, giving an early indication that intervention may be required. Early intervention can fix problems and can avoid the need to transfer a child to a higher level of care, thus avoiding or reducing harm.

Updated (2026): It is important to note that the only large RCT of a Paediatric Early Warning System — the EPOCH trial (Parshuram CS et al., 2018) — evaluated implementation of BedsidePEWS across 21 hospitals in 7 countries (144,539 patient discharges) and found that PEWS implementation did NOT decrease all-cause mortality. PEWS remains widely used as a structured framework for recognising deterioration and triggering escalation, and pre-/post-implementation studies have shown associations with reduced mortality and unplanned code events (Trubey et al. 2022, low-quality evidence). However, learners should be aware that the strongest available trial-level evidence does not demonstrate a mortality benefit. References: Parshuram CS et al. JAMA. 2018;319(10):1002-1012. DOI: 10.1001/jama.2018.0948. Trubey R et al. Resuscitation Plus. 2022;11:100262.

2.4 CXR Interpretation

Key paediatric CXR features:

• Thymus gland visible (ages 2-8 years)
• Heart — approximately half the width of the chest
• Ribs are horizontal with a rounder chest shape
• Epiphyses visible (growth centres)

2.5 Blood Results — Key Values

2.6 Blood Gas Interpretation

Types of Blood Gas

• ABG (Arterial Blood Gas) — most accurate
• CBG (Capillary Blood Gas) — contains more arterial blood than venous due to higher pressures on arterial side of circulation
• VBG (Venous Blood Gas)

Key principles:

• Find out what is normal for the patient
• Trends are important
• Know the type of gas
• Squeezed samples may have more venous blood

Acid-Base Interpretation

• CO2 dissolves in plasma as carbonic acid: too much CO2 = acidotic
• HCO3- acts as a buffer: too little = acidotic
• Lungs compensate quickly (e.g. hypoventilation to retain CO2)
• Metabolic compensation is slower

Normal Blood Gas Values

Blood Gas Quiz (Worked Examples)

Part 3: Paediatric Anatomy and Physiology

3.1 Key Differences from Adults

1. Nose breathing: Babies are obligatory nose breathers until age 4-6 months. If their nasal passage is at all occluded, their work of breathing is increased.

2. Airway compliance: Adult airways are more cartilaginous than children’s. This makes children’s airways more floppy/malacic and therefore more at risk of collapse, obstruction, and secretion retention.

3. Rib mechanics: There is no bucket-handle action and external intercostal muscles are poorly developed. Inspiration is less efficient as rib movement is reduced in both the AP and transverse planes.

4. Cardiac space: The younger the child, the more space their heart takes up in the thoracic cavity.

5. Diaphragm shape: Due to horizontal insertion, children’s diaphragms are less dome-shaped, meaning they cannot flatten as much as adults to increase tidal volumes. To increase minute volume, their RR must be higher.

6. Heart rate and muscle fibres: Adult HRs are lower than children’s due to lower oxygen demands. Children have fewer fast-twitch muscle fibres, meaning they are more prone to fatigue and bradycardias.

7. Respiratory reserve: Children have fewer fatigue-resistant muscle fibres, which means they have reduced respiratory reserve. A significant sign of fatigue is apnoeas, so they are more likely to have a respiratory arrest than adults.

3.2 Signs of Respiratory Distress

Observable signs:

• Nasal flaring
• Head bobbing
• Tracheal tug
• Accessory muscle involvement
• Intercostal recessions
• Sternal recessions
• Subcostal recessions
• Sea-saw breathing
• Tripod positioning

Appearance:

• Colour: pale, red, cyanosed
• Temperature: hot, cold, clammy

Sounds:

• Noisy breathing (wheeze, secretions)
• Grunting
• Gasping
• Stridor
• Apnoeas

Behaviour:

• Irritable
• Quiet / withdrawn

Objective markers:

• Increased respiratory rate
• Decreased SpO2
• Increased CO2
• Increased HR

Part 4: Common Respiratory Conditions

4.1 Bronchiolitis

Key features:

• Inflammation of the bronchioles
• Viral infection (e.g. RSV)
• Affects children < 2 years old
• Coryzal symptoms with poor feeding
• Patchy CXR changes

Management (per NICE Guidelines):

No physiotherapy unless significant co-morbidities or intubated

• Oxygen therapy
• CPAP
• IV fluids
• No indication for regular suction (unless respiratory distress) or nebulisers
• May be offered Palivizumab vaccination against RSV

Updated (2026): Palivizumab is more accurately described as passive immunisation with a monoclonal antibody rather than a “vaccination”. From 2025, nirsevimab (a longer-acting, single-dose monoclonal antibody) has begun replacing palivizumab in NHS England. See JCVI statement, 11 September 2023.

4.2 Lower Respiratory Tract Infection (LRTI)

• Infection and inflammation of the lower airways or pulmonary tissue
• Bacterial or viral
• Symptoms: cough, SOB, fever, CXR changes, increased WOB, desaturations, irritability
• Management includes: antibiotics, fluids, oxygen, cough

4.3 Neuromuscular Conditions

Examples: SMA, Duchenne’s Muscular Dystrophy, Myasthenia Gravis

Key features:

• Usually genetic disorders
• Progressive (could be asymptomatic initially)
• Symptoms include:
  • Muscle weakness
  • Reduced swallow
  • Tonal changes
  • Regression in milestones

4.4 Neurodisability

Definition: Impairment involving the nervous system (umbrella term)

Examples: Cerebral palsy, autism

Key features:

• Static conditions from birth
• Symptoms include:
  • Muscle contractures
  • Scoliosis
  • Poor swallow
  • Poor secretion management
  • Visual impairments
  • Learning difficulties

4.5 Other Conditions Encountered

The following conditions may be encountered on call (familiarity expected):

CF, PCD, Bronchiectasis, CLD/BPD, Sickle Cell, Asthma, T21, SMA, Di-George Syndrome, Leukodystrophy, Apert Syndrome, Fanconi’s Anaemia, Congenital Myopathy, General Developmental Delay, Ataxia Telangiectasia, Idiopathic Scoliosis, HIE, Batten’s Disease, Dravet’s Disease, Krabbe’s Disease, Woree Syndrome, Q22

Part 5: Medications and Nebulisers

5.1 Bronchodilators

Physiotherapy relevance:

• Improve airway patency
• Improve airflow
• Improve secretion clearance
• Some physio techniques can induce a wheeze — consider pre-treatment bronchodilator

5.2 Hypertonic Saline (3% and 7%)

• Rehydrates airways
• Increases the depth of the liquid layer on epithelial surfaces by osmotically drawing water onto the airway surface
• Fast acting
• 0.9% saline nebulisers can be effective if natural humidification is lost (e.g. patients with tracheostomies)

5.3 Mucolytics

5.4 Nebulised Antibiotics

• Acts on certain organisms in the sputum to clear infection
• Administer AFTER chest physiotherapy
• Example: Colomycin

Part 6: Treatment Options

6.1 Available Treatment Modalities

• MI:E (Mechanical Insufflation-Exsufflation / Cough Assist)
• HFCWO (High-Frequency Chest Wall Oscillation / Vest)
• Positioning / handling
• Suction
• Manual techniques (percussions, vibrations, manual assisted cough [MAC])

6.2 Suction

Ensure correct size and depth of catheter. NOT deep suction (this is a separate competency).

6.3 Positioning

Considerations include:

• Postural drainage positions
• V/Q matching (ventilation-perfusion matching)

Important considerations for positioning:

• Subluxed / dislocated hips
• Scoliosis
• Fractures
• Osteopenia
• Pressure sores
• Pain

6.4 Drying Agents (Glycopyrronium vs Hyoscine)

When to consider:

• Too much saliva = potential risk of aspiration
• Too little saliva = thick secretions, dry mouth, discomfort, oral trauma

6.5 MDT Support

Remember to consider what the wider MDT can aid with (e.g. medical team for escalation, nursing for suctioning regimes, medical team for ventilatory support changes).

Part 7: Inhaled Nitric Oxide (iNO) and Physiotherapy

7.1 iNO Machine — Key Readings

Top of the machine:

Bottom of the machine:

7.2 iNO Safety

CRITICAL: Do NOT disconnect iNO to perform MHI.

Disconnecting can cause:

• A sudden rise in pulmonary artery pressure
• Severe strain on the right-hand side of the heart
• Potential hypoxaemia

Instead, connect the bag to the iNO machine.

7.3 Physiotherapy Benefit with iNO

• Physiotherapy can help clear the lungs of sputum and improve airflow
• This enables iNO to reach the alveoli and aid vasodilation
• Improves V/Q matching and gas exchange

Part 8: Clinical Scenarios

8.1 Case Study 1: SMA Type 1 — LRTI with Secretion Retention

Patient: 21-month-old male

Presentation: Admitted to the ward with parents from ED. 24-48 hour history of increased lethargy, thick yellow secretions at home.

Background: Spinal muscular atrophy (SMA) type 1, recurrent hospital admissions for LRTIs, growing pseudomonas.

What to Ask the Parents

• Home oxygen?
• Home nebulisers?
• Home suctioning? What type? How frequent?
• Home physio plan? When well regimen and unwell careplan?
• Usual secretion viscosity / volume
• Cough strength
• Positioning
• Feeding regime
• Developmental milestones achieved
• Any helpful information (e.g. favourite side, likes/dislikes)
• On experimental trials? (e.g. Spinraza / nusinersen)

Home regimen (when well — mum reports once daily in the morning):

• 3% hypertonic saline nebuliser
• Cough assist (2 x 2 ASL)
• Suction: size 7, to 16 cm depth
• All completed by mother

Assessment Findings

• Cough: Weak cough, intermittently clearing to back of throat
• Position: Sitting in mum’s arms
• CBG (8:30 am):
  • pH: 7.403
  • CO2: 4.47 kPa
  • O2: 5.53 kPa
  • HCO3: 21.5 mmol/L
  • BE: -3.2 mmol/L
  • Interpretation: Compensated
• CXR: Right-sided collapse with mediastinal shift

Airway Clearance Techniques

• Manual techniques: percussions, vibrations, manual assisted cough (MAC)
• Cough assist (MI:E)
• Nebulisers
• Positioning
• Suction
• May differ from home regimes when acutely unwell

Key Considerations for Neuromuscular/Neurodisability Patients

IMPORTANT: Children with neuromuscular/neurodisability disorders cannot compensate for respiratory failure in the same way as other children.

They may appear: withdrawn, pale, and sweaty

They may NOT show:

• Increased respiratory rate
• Increased abdominal work or accessory muscle use

Treatment Session Plan

• Fatigue management is important (monitor length of session)
• Patient may not show signs of WOB despite deterioration
• Treatment options: Atrovent, 7% HTS or NAC, manual techniques, cough assist, MAC, suction, positioning
• Colomycin nebuliser post-physiotherapy
• Escalation to medical team for increased ventilatory support (e.g. BiPAP, possible transfer to RLH)

8.2 Case Study 2: Cerebral Palsy with Viral Illness

Patient: 8-year-old male

Presentation: Admitted to ward with a 3-day history of increased thicker secretions and a temperature. Parents and sibling also unwell at home. Admitted overnight, now with increasing Optiflow requirement and requiring frequent nasal suction. Large volumes of saliva, audible secretions; nursing staff struggling to clear secretions.

Background: Cerebral palsy GMFCS 5, CLD, scoliosis, PEG fed, dystonia, known to various community services. Extensive drug history.

Investigations: Flu A positive.

Further history from mother:

• Unwell for 3 days
• Vomiting and high fevers (highest 38 degrees)
• Mother also became unwell with fever and headache
• Got worse and mother called ambulance
• Had salbutamol in ambulance and ED
• Reviewed in 2 hours post burst

What to Gather

• Know the child’s baseline (home regimes, cough strength, activity levels)
• Nebuliser history
• Suction needs
• Mouthcare regimen
• Drying agents in use
• Physio adjuncts available (cough assist, vest)

Management Considerations

• Nebulisers (as per clinical need)
• Suction (OP, NP — ensure correct size and depth)
• Mouthcare
• Drying agents (Glycopyrronium or Hyoscine — see Section 6.4)
• Physio adjuncts (cough assist, vest)
• Positioning (accounting for subluxed/dislocated hips, scoliosis, fractures, osteopenia, pressure sores, pain)

Escalation Pathways

When to escalate to the medical team:

• Patient close to intubation
• Increasing ventilatory support requirements
• Deteriorating blood gases
• Failure to respond to physiotherapy interventions
• Patient showing signs of fatigue (especially neuromuscular/neurodisability)
• Any new concerning clinical findings

Always ensure the NIC/medical team is aware of the patient’s status and your assessment findings.