Congenital cardiac disorders are commonly classified as cyanotic or acyanotic depending on clinical manifestations. After birth, heart structures such as the foramen ovale, ductus venosus, and ductus arteriosus are no longer necessary to sustain life [1]. The ductus arteriosus is a shunt between the pulmonary artery and the aorta that permit oxygenated blood transfer from the placenta to pass the fetal lungs and enter systemic circulation [2]. Patent ductus arteriosus (PDA) is the failure of the ductus arteriosus to close after birth, which is largely a preterm disease. The ductus arteriosus remains open in 64 percent of infants born at 27 to 28 weeks of gestation and 87 percent of infants born at 24 weeks [2]. For hemodynamically significant PDA closure, PDA ligation, catheter intervention, or oral paracetamol may be suggested as lifesaving approaches [3]. An atrial septal defect (ASD) is a gap in the interatrial septum that allows blood to flow freely between the left and right sides of the heart. ASD is the third most prevalent kind of congenital heart defect (CHD), accounting for 30 to 40 percent of all CHDs [4]. Coarctation of the aorta (CoA) is a cardiac condition that causes a blockage in the aorta’s circulation. CoA is most usually observed slightly distal to the left subclavian artery, at the site where the ductus arteriosus unites to the aorta. Typically, there is medial hypertrophy with “shelf-like” tissue extending in the aortic lumen from the posterior aortic wall [5]. Pulmonary arterial hypertension (PAH) is characterized by increased pulmonary blood circulation, which leads to increased pressure in the pulmonary artery, which is often associated with cardiovascular dysfunction [6]. Bacterial pneumonia is a severe lung infection characterized by lower airway inflammation that primarily affects infants, young children, and the elderly. This disorder can be lethal if not treated immediately. Early indications and symptoms include a productive cough, temperature with chills, trouble in breathing, tachypnoea, and exhaustion [7]

Here, we report a case of a three months old female child who was brought to a tertiary care center with complaints of wet cough, poor feeding, and respiratory distress. Her mother was primigravida at term gestation with oligohydramnios and delivered via lower segment caesarean section. After one month of birth, she had repeated complaints of poor weight gain, lethargy and presence of a suck-rest-suck cycle, and pneumonia and admitted to a private hospital where investigations such as a two-dimensional (2D) echo were done and she was diagnosed as a case of patent ductus arteriosus and pulmonary artery hypertension and advised surgery and referred to a tertiary care center for surgery. On admission, the patient’s parents came with the complaint of fever, cough, difficulty in breathing, and difficulty in sucking the milk so investigations were done. The chest x-ray revealed aspiration pneumonia with left-sided left lung collapse. As a result, surgery was postponed and she was admitted to the pediatric intensive care unit (PICU), where she was on ventilator support for six days and then shifted to oxygen support for 15 days mentioned in (Table 1). She underwent physiotherapeutic treatment during this time and it helped in her recovery from lung collapse. After the infection was resolved, the patient underwent surgery for PDA ligation and coarctation repair via left posterolateral thoracotomy (partial pleura over descending thoracic aortic (DTA) opened. DTA aortic arch and left subclavian artery were dissected and looped) and was advised physiotherapy post-operatively.

Mode of Ventilator Duration
Ventilator CPAP mode 3 Days (week 1)
Ventilator SIMV mode 6 Days (weeks 1 and 2)
Oxygen support (4L/min) via nasal prongs 9 Days (weeks 2 and 3)

Clinical examination

Oral consent was taken from the patient’s parents before the beginning of the examination procedure. On inspection and observation, the patient was observed in the supine lying position. The patient was ectomorph in her body type and conscious co-operative and monitored through chest leads. She was breathing via nasal prongs and feeding via a Ryle’s tube. On general examination, the patient was febrile with a pulse rate was 146 beats/min, and a respiratory rate of 46 breaths/min, which suggests the patient was tachypneic. The patient weighed two and a half kg, height of 53 cm, basal metabolic index of 8.9, body surface area of zero point two, and a head circumference of 32 cm. On auscultation, mid-diastolic mitral flow murmur and bilateral crepitations were present in the upper and lower zones. There was a developmental delay, the patient did not achieve the neck control milestone as she completed three months of age. Peripheral smear shows red blood corpuscles (RBCs) predominantly, normocytic hypochromic with anisopoikilocytosis showing pencil cells and microcytes suggested of iron deficiency anemia. Platelets – reduced on smear. Antigen-presenting cell 26,000 cells/mm3 as per cell counter. Endotracheal secretion culture suggests the growth of acinetobacter species. Chest X-ray shown in (Figures 1A, 1B), pre-operative 2D echo, and colour doppler study suggest left atrium/ left ventricle dilation, large nonrestrictive PDA with a left to right shunt. Left ventricle inner dimension 3.3 cm (Z score 3.3), left atrium 1.6 cm (Z score 0.27), interventricular septum 0.6 cm (Z score 2.3), pulsed wave 0.5 cm (Z score 3.0). Shelf at isthmus – gradient 33 mmig – Coarctation of Aorta. Small Ostium Secundum – Atrial septal defect. The timeline of the event is shown in Table 2.

Events Date
Diagnosed as PDA with PAH 15/12/2021
Referred to the tertiary care centre 23/02/2022
Lung infection and collapse and transferred to PICU and put on mechanical ventilator support 25/02/2022
Pre-operative physiotherapy commencement (Table 3) 25/02/2022
Patient weaned off from ventilator and put on oxygen support (4 L/min) 07/03/2022
Patient underwent PDA ligation surgery 16/03/2022
Post-operative physiotherapy begins 17/03/2022

Therapeutic interventions

In this report, the primary objective is to highlight the preoperative chest physiotherapy (Table 3) administered with continuous positive pressure for aspiration pneumonia and left lung collapse is to make the patient fit for surgery, to minimised the work of breathing, reduced airway resistance and up surge gaseous exchange followed by postoperative physiotherapy management focused on the advance techniques to prevent lung complications, improved breathing patterns, removed secretions, and normalize lung condition. Table 4 displays physiotherapeutic intervention. Figures 2A, 2B shows the post-operative physiotherapy management of three months old female infant. 

Physiotherapeutic Goals Physiotherapeutic Rehabilitation Rehabilitation Regimen
To educate the patient’s guardians regarding the condition and the operative procedure the patient is going to undergo A counselling session was carried out for the patient’s guardians Just prior to the surgery
To enhance the lung compliance and thoracic expansion of the patient Passive end-expiratory pressure applied at the end of inspiration One set of 10 repetitions was given
To promote excursion of thoracic movement and epigastric movement Peri-oral pressure was given Three repetitions with five sec hold
To optimise breathing and promote secretions to migrate up from the lungs’ base into the considerably larger airways Bronchial drainage and percussion was given every two hours Positioning with the help of the pillows was given
To improve the joint flexibility and mobility of the patient         Passive movements were given to the patient One set of 10 repetitions were given for each joint
Sr. Physiotherapeutic Goals Physiotherapeutic Rehabilitation Rehabilitation Regimen
1. To make the patient’s parents aware of the problem, and to get their cooperation and approval for further plan of management. Education and counseling for caregivers regarding the patient’s condition and the need for the following physiotherapeutic measures. At the commencement of the intervention, caregivers were taught about the role of physiotherapists in the patients’ care.
2. To improving ventilation/ perfusion matching Positioning using a cushion is beneficial because a baby’s lungs are not supported by the thoracic cavity, the baby’s normal resting pleural pressure is nearer to atmospheric pressure than in adults, causing airway closure in more dependent zones. Every two-hourly positioning, Alternate positioning to the opposite side.
3. To remove excess phlegm secretions from smaller airways to the center of the chest 1. Chest percussion: percussor cup is used to percuss various portions of the chest wall based on auscultatory results. 2. Expiratory vibration: The neonatal resuscitation mask is attached to the nebulizer machine, which provides a vibratory effect when it is powered on. Holding the percussor cup between the fingers, gently pat over the infant’s chest and back for two to four minutes. Vibration is given for five minutes during the expiratory phase from the periphery to the centre of the chest.
4. To promote clear airways and eliminate mucosal secretions and foreign particles. Suctioning: Oropharyngeal and Nasopharyngeal suctioning was done as required. To remove secretions from central airways following chest physiotherapy.
5. To minimize pulmonary congestion in infants suffering from pneumonia. The PSE technique [8]: The patient is lying supine with the therapist one hand on the chest cavity and the other on the peritoneal cavity. At the termination of the exhalation phase, the therapist applies compressive pressure in the caudal direction from the above hand and cranial direction from the below hand. The compressive force is sustained for four to five seconds  following a gradual relaxation. Three sets of three compressions are applied three times a day, with a 30-seconds break among each compression.
6. To restore uniform pulmonary inflation with low frequency rhythmic thoracic compressions The LST technique: The physiotherapist places one hand on the patient’s anterior thoracic wall and the other on the posterolateral aspect, then applies sustained compression for 5 seconds. Each set includes two to five thoracic compression, three times per day, the hemithorax should be compressed for at least ten min, five mins maximum on each side.
7. To promote the establishment of suitable normal movement patterns, and as a result, noted an improved breathing pattern. Vojta Technique: The infants progressed via the stage of reflex rolling in a supine position. Slight tilting of the head to the direction where the stimulation is given.  Each simulation consists of a slight amount of pressure given to the spine diagonally in the dorsal, medial, and cranial directions. Every session comprises four stimuli, two given to the left side of the thorax and the other two stimuli given to the right side of the thorax. The therapy must be performed three times every day.
8. To avoid muscle tightness and to enhance joint stability and flexibility Passive joint mobility exercises for bilateral upper and lower extremities. 10 repetitions x one set a couple of times a day in the beginning, then gradually progressed to 10 repetitions x two sets three times a day.

Outcome measure

The outcome are shown in Tables 4, 5.

FLACC
Components  Post-operative physiotherapy Intervention (day 1)  Post-operative physiotherapy Intervention (day of discharge)
Face 1 – occasional grimace 0 – no particular expression or smile
Legs 1 – uneasy, restless, tense 0 – normal position
Activity 2 – jerking 0 – moves easily
Cry 2 – sobs 1 – occasional complaints
Consolability 2- difficult to console 0 – content, relaxed

 

ABG Analysis Pre-operative physiotherapy day 1 Pre-operative physiotherapy last day Post-operative physiotherapy day 1 Post-operative physiotherapy (day of discharge)
PH 6.556 7.224 6.891 7.321
PaCo2 (mmHg) 49.3 38.2 51.8 37.2
PaO2 (mmHg) 120.2 75 115.1 73.8
HCO3ˉ(mmol/L) 24.6 22 27.2 24
SaO2 (%) 83 92 90 95

Novel chest rehabilitation strategies, particularly designed for infants, have been recently employed. According to the literature effect of PSE on breathing mechanics in infants suggest that PSE deflates the lung to expiratory reserve volume (ERV) and causes no modifications in peak expiratory flow (PEF), triggered sigh breaths, and reduces tidal volume, which is usually the primary mechanical feature for mucus removal [8]. Exercise is a successful therapy for CHD in emerging adults, as per earlier research. However, there is a paucity of research on how exercise affects newborns with CHD who have had a cardiac catheterization. Passive exercises and physical activity may be beneficial to infants with CHD by, enhancing cardiac function, and boosting bone strength [9]. The evacuation of secretions to the centre airway is made easier by percussion and vibration. The percussion was chosen by 74 percent of those physiotherapists as the preferred chest physiotherapy treatment for infants [10]. The infants developed severe acute pulmonary infectious diseases, prompting intensive care unit stay, intubation, and ventilator support. These are all the recognized components that increase the likelihood of Acinetobacter, a multidrug-resistant bacterium that causes the spread of infection [11] [12]. The impacts of a developmental physiotherapy regimen on vital signs in preterm infants were demonstrated by the researchers. Physical therapy’s advantages and hazards in specific developmental progress and caused hemodynamic stress are significant factors in supporting intervention with preterm babies. The results of this study indicate that preterm infants responded to six developmental activities with a significant increase in mean heart rate, but no significant change in mean Sao2 [13].

The therapeutic purpose was to maintain tissue perfusion, promote better functional capacity, optimize breathing, completely eradicate chest secretions, and restore normal cardiovascular and respiratory function. The effectiveness of the cardiorespiratory physiotherapy treatment like the prolonged slow expiratory technique, lung squeeze technique, and other pulmonary physiotherapy regimens show positive results to minimize atelectasis in the patient with pneumonia. The implication of pre-and post-operative physiotherapy strategies aids in the recovery from the pathologic condition and also helps to avoid complications and has shown optimum functional recovery.



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