Emma Shkurka

Background: Invasively ventilated, critically ill children are at risk of retained respiratory secretions, which can obstruct airways, impair gas exchange, and cause lung collapse or ventilator-acquired pneumonia. Endotracheal suctioning partially removes secretions, but additional airway clearance interventions may be required. Mechanical insufflation-exsufflation (MI-E), is a cough augmentation device used to improve secretion clearance in adult intensive care, however it is not well characterised in paediatrics. Aim: To explore MI-E use in invasively ventilated, critically ill children. Method: This multi-methods study used an anonymous, electronic survey of UK-based paediatric physiotherapists. A scoping review searched seven electronic databases (1995–2025), using key terms (“airway clearance technique*”) OR (“mechanical insufflation exsufflation”) AND (“mechanical ventilation”) OR (“invasive ventilation”). Data were analysed descriptively for both methods, with content analysis for free text survey responses. Mixed-evidence, narrative integration compared and contrasted survey and scoping review findings. Results: Twenty-nine physiotherapists from across the UK completed the survey, 76% ( n = 22/29) were advanced specialists, and all reported access to an MI-E device. Six studies (2010–2024), one prospective, the remaining retrospective or case studies, were identified. Both data sources indicated MI-E was most frequently used with acutely unwell neuromuscular patients, though survey responses described a broader clinical application, including children with complex neurological conditions, general respiratory illnesses, trauma, and post-operative surgical or orthopaedic needs. MI-E settings and outcomes were inconsistently reported. Contraindications aligned across sources. Conclusions: MI-E appears increasingly accessible within paediatric critical care. Future research should assess MI-E safety in intubated patients and investigate broader critically ill populations.

Physiotherapy guidelines and protocols in paediatric intensive care: a document analysis

Background and Purpose: Respiratory physiotherapy is a treatment option for children on paediatric intensive care units (PICUs), aiming to facilitate airway clearance and improve ventilation. Given the vulnerable nature of this patient group, safety and adverse events related to respiratory physiotherapy are important considerations. The aim of this qualitative study was to understand what physiotherapists perceive to be risk factors for instability and adverse events and how they manage these. Method: This study involved virtual semi‐structured interviews and focus groups with PICU physiotherapists. Sixteen interviews and two focus groups ( n = 7) were completed. These were audio‐recorded and transcribed verbatim. Framework analysis was used. Results: From the interview analysis, a framework Strategies for managing instability and adverse events was developed. Two frameworks were developed from the focus group analysis: Instability and adverse events and Managing instability and adverse events . Physiotherapists provided a comprehensive list of perceived risk factors for instability and adverse events, including clinical presentations and support required. Practical strategies were reported to promote efficiency, including readiness of equipment and two‐person treatments. Physiotherapists described accepting short‐term unwanted effects for longer‐term improvement, discussed in terms of risk versus benefit. The patient's parents/family were involved in the sharing of responsibility for treatment decisions. Multidisciplinary team involvement included collaborative discussion with practical assistance as required. Discussion: This study provides novel data about physiotherapists' management of instability and adverse events in PICUs. Preparation and planning, involving the multidisciplinary team, family inclusion, reacting and adapting, and accepting instability were important strategies. The findings from this study highlight several areas that require consideration from a workforce support and education perspective.

Objectives To understand healthcare professionals’ views on current physiotherapy service provision in children with congenital heart disease (CHD), how physiotherapy could be better used post-cardiac surgery and perceived barriers to service expansion. Design Cross-sectional survey using a one-off self-completed online questionnaire, with open and closed questions, in June–August 2024. Setting Each of the 12 level 1 paediatric cardiac surgical centres in the UK National Health Service and Children’s Health Ireland. Participants Healthcare professionals providing clinical care to children undergoing cardiac surgery. Results 80 responses were obtained, with at least one response from each centre. Healthcare professionals conduct motor, developmental and functional evaluations across all age groups, with referrals to physiotherapy primarily based on physical examination (39, 87%). They expressed dissatisfaction with community physiotherapy services (64, 81%) compared with inpatient services (29, 36%), although they indicated that expanding services would positively impact patients and families. There is a lack of consensus regarding intervention frequency, duration and which patient groups should be prioritised. Respondents identified a lack of funding as the primary barrier to service expansion (76, 95%). Reported barriers for families included volume of medical appointments (69, 86%), transportation (66, 83%) and finances (62, 78%). Conclusions Healthcare professionals appreciate the positive impact physiotherapy can have on post-surgical management of children with CHD. The importance of expanding services was emphasised. However, to effectively support clinical practice, it is crucial to understand which patient groups should be prioritised and at what stage, as well as determining the optimal amount of physiotherapy that positively impacts patient outcomes.

Background: Children with congenital heart disease demonstrate developmental and functional impairment throughout their life. Published literature is limited but suggests postsurgical physiotherapy positively impacts developmental and functional outcomes in these children. We aimed to understand parental opinions of their child’s development or function, their experiences of physiotherapy services, how they feel physiotherapy could be used to support their child and what impacted access to services. Methods: A qualitative study using semistructured online interviews was conducted among parents of children with a diagnosis of congenital heart disease under the age of 16 years, who had undergone cardiac surgery in the UK. Data were collected between July and December 2024. The data were explored using reflexive thematic analysis and the study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist. Results: 12 semistructured interviews were completed involving 12 mothers and 1 father. Themes identified were parental priorities; understanding and experience of physiotherapy; access to physiotherapy and ideal physiotherapy service. Parental expectations of their child’s development were influenced by antenatal care and postnatal experiences. Parents continually evaluate the need for their child to access developmental and functional support. Engagement with physiotherapy is influenced by parental understanding, quality of service provision, impact of interventions on their child and the practical and emotional consequences to their family. Parents want physiotherapy services to deliver parental education and individualised support throughout their child’s life, particularly around key life events. Conclusions: Parental engagement with physiotherapy services is influenced by parental expectations of their child’s development and function, and their understanding of the potential benefits of physiotherapy. Physiotherapists should prioritise promoting and increasing awareness of physiotherapists’ role in children with congenital heart disease, alongside parental education and individualised care, to facilitate engagement.

Respiratory physiotherapy is a commonly used treatment for children in paediatric intensive care units (PICUs). A wide range of interventions are available, and practice varies. There is no literature exploring how physiotherapists make decisions regarding treatment choice and delivery in this vulnerable and complex population. The aim of this study was to understand physiotherapists’ decision-making regarding delivery of respiratory physiotherapy in UK PICUs. This was a qualitative study, involving virtual semi-structured interviews and focus groups with PICU physiotherapists. Sixteen interviews and two focus groups (n = 7) were completed. They were audio-recorded and transcribed verbatim. Framework analysis was used. From the interview analysis, five themes were developed within a ‘Factors influencing decision-making’ framework: physiotherapist knowledge, the physiotherapist, consideration of family, other health care professionals and external influences. Clinical knowledge and understanding were key factors in decision-making. Approaches evolved with experience, opportunities for reflection and learning, plus the development of intuition. Collaboration was integral to physiotherapists’ decision-making, however this posed additional challenges. A ‘Clinical decision-making’ framework was developed from the focus groups, including three themes: information gathering, listening to the patient, and learning from experience. Active information gathering and comprehensive patient assessment were described. Listening to the patient and being able to react and adapt at the bedside were important processes involved in decision-making. A conceptual model has been developed, which depicts physiotherapists’ decision-making as complex, iterative and collaborative, with experience and expertise important factors. The findings have highlighted several areas that require consideration from a workforce and education perspective.

Objective: Awake Extracorporeal Life Support (aECLS) with active mobilization has gained consensus over time, also within the pediatric community. This individual patient data (IPD) meta-analysis summarizes available evidence on pediatric aECLS, its feasibility, and safety regarding sedation weaning, extubation, and physiotherapy. Methods: PubMed/Medline and Cochrane Database were screened until February 2022. Articles reporting on children (≤18 years) undergoing aECLS were selected. IPD were requested, pooled in a single database, and analyzed using descriptive statistics. Primary outcome was survival to hospital discharge. Secondary outcomes included extubation during ECLS, physiotherapy performed, tracheostomy, and complications. Results: Nineteen articles and 65 patients (males: n = 30/59,50.8%) were included. Age ranged from 2 days to 17 years. ECLS configurations included veno-venous ( n = 42/65, 64.6%), veno-arterial ( n = 18/65, 27.7%) and other ECLS settings ( n = 5/65, 7.7%). Exclusive neck cannulation was performed in 51/65 (78.5%) patients. Extubation or tracheostomy during ECLS was reported in 66.2% ( n = 43/65) and 27.7% ( n = 18/65) of patients, respectively. Physiotherapy was reported as unspecified physical activity ( n = 34/63, 54%), mobilization in bed ( n = 15/63, 23.8%), ambulation ( n = 14/63, 22.2%). Complications were reported in 60.3% ( n = 35/58) of patients, including hemorrhagic (36.2%), mechanical (17.2%), or pulmonary (17.2%) issues, and need for reintubation (15.5%). Survival at discharge was 81.5% ( n = 53/65). Conclusion: Awake ECLS strategy with active physiotherapy can be applied in children from neonatal age. Ambulation is also possible in selected cases. Complications related to such management were limited. Further studies on aECLS are needed to evaluate safety and efficacy of early physiotherapy and define patient selection.