What aids expectoration in children?

Aiding Expectoration in Children

For children with difficulty expectorating secretions, individualized airway clearance techniques (ACT) taught by a pediatric-trained chest physiotherapist are strongly recommended as the primary intervention. 1

Age-Appropriate Airway Clearance Techniques

The selection of appropriate techniques depends on the child's age and developmental stage:

For Infants:

• Positioning (gravity-assisted drainage)
• Expiratory flow modification
• Chest percussion with gentle vibration
• Nasal saline irrigation followed by gentle aspiration 2, 3

For Toddlers:

• Modified gravity-assisted drainage
• Assisted autogenic drainage
• Positive expiratory pressure (PEP) via bottle, mouthpiece or mask
• Oscillating PEP devices with/without nebulizer

For School-Age Children:

• Forced expirations and huffing
• Active cycle of breathing technique
• Oscillating PEP with forced expiration technique
• Bouncing on a fitball
• Blowing games

For Adolescents:

• Autogenic drainage
• High-frequency chest wall oscillation ("vest" therapy)
• Exercise
• Musical wind instruments

Adjunctive Therapies

Mucoactive Agents:

• Hypertonic saline (6-7%) may be considered in selected patients with difficulty expectorating, but should not be used routinely 1

  • Best for children with high daily symptoms, frequent exacerbations, or poor quality of life
  • First dose should be administered under medical supervision
  • Short-acting β2-agonists should be used prior to inhalation

• Inhaled mannitol may be considered as an alternative to hypertonic saline but is substantially more expensive 1

  • Similar considerations as hypertonic saline apply

• Avoid recombinant human DNase (rhDNase) as it may worsen respiratory symptoms and increase exacerbation rates 1

• Avoid bromhexine due to limited evidence of benefit and potential adverse events 1

Nasal Irrigation:

• Saline nasal lavage is beneficial for clearing nasal passages, especially in infants who are obligate nasal breathers 2, 4
• For infants and young children, gentle aspiration following saline irrigation helps remove secretions 3

Implementation Considerations

Frequency and Duration:

• ACT frequency should be individualized based on the child's condition
• Techniques should be reviewed at least biannually by physiotherapists
• During acute exacerbations, increase the frequency of ACT sessions 1

Practical Challenges:

• Access to pediatric-trained physiotherapists may be limited
• Adherence to prescribed regimens can be challenging, especially over prolonged periods
• Adjustment to ACT type may be necessary during exacerbations (e.g., exercises may not be feasible) 1

Special Considerations

For Children with Neuromuscular Disorders:

• Additional techniques include breath stacking, manually assisted cough, and mechanical insufflation/exsufflation 1

For Children with Bronchiectasis:

• More intensive ACT may be required
• Consider antibiotic therapy for persistent wet cough lasting >4 weeks 1

For Children with Pleural Infections:

• Chest physiotherapy is not beneficial and should not be performed in children with empyema 1
• Early mobilization and exercise is recommended instead 1

Monitoring Effectiveness

• Regular follow-up to assess symptom improvement
• Monitor for resolution of wet/productive cough
• Assess quality of life improvements
• Evaluate ease of expectoration

Common Pitfalls to Avoid

1. Using inappropriate techniques for the child's developmental stage
2. Inadequate training of parents/caregivers in performing ACT
3. Insufficient frequency or duration of ACT sessions
4. Relying solely on medications without implementing ACT
5. Using recombinant human DNase which may worsen symptoms
6. Failing to adjust techniques during acute exacerbations

By implementing these evidence-based approaches to expectoration in children, respiratory symptoms can be effectively managed, leading to improved quality of life and reduced morbidity associated with respiratory conditions.