Question Answer
What is the definition of Bronchial Hygiene Therapy? The use of “noninvasive” airway clearance techniques designed to help mobilize and remove secretions and improve gas exchange.
What are the primary mechanisms used for secretion removal? 1. Patent airway (adventitia supports) 2. Functioning mucociliary escalator. 3. Effective coughing
What are the four stages of a cough? Irritation Inspiration Compression Expulsion
What are the main irritation stimuli? 1) inflammatory- (infection) 2)chemical- Cigarette Smoke 3) Mechanical- Foreign body (ice) 4)Thermal-Cold air
What are factors that affect secretion removal? 1) Instability of the airway 2)Dyskinesia of the cilia 3)Volume and character of secretions 4)Impaired cough
A cough may be impaired by a disruption in irritation. Anesthesia narcotics CNS depression
A cough may be impaired by disruption to inspiration. Pain Neuromuscular dysfunction Pulmonary or abdominal restriction
A cough may be disrupted to do disruption in compression. Laryngeal nerve damage Artificial Airway Abdominal muscle weakness Surgery
A cough may be disrupted due to disruption of expulsion. Airway compression Airway obstruction Abdominal Muscle weakness
Inspiration Inhale 1-2 L of gas in 1-2 seconds
Compression Glottis closure and compression. The pressure goes up in plural space. Consists of glottis and alveolar pressure.
Expulsion 500 mph. Occurs when the glottis opens A very high-pressure gradient and it shears off mucus on the bronchial tree.
What are factors that impair cilia? Dehydration Temperature Toxins Smoking
Abnormal airway clearance can result in. 1)Retained secretions- infections 2) restricted airflow- increased work of breathing. Airtrapping and overdistention (ball valve effect) 3)Complete or partial airway obstruction (atelectasis)
What are causes of impaired mucociliary clearance in intubated patients? ET or tracheostomy tube Tracheobronchial suction Inadequate humidification High Fi02 values Drugs Underlying pulmonary disease
What are some other things that can cause abnormal airway clearance? tumors and foreign bodies skeletal abnormalities bronchospasm ET Tubes
What is the goal of bronchial hygiene therapy? To help mobilize and remove secretions, with the ultimate aim to improve gas exchange and reduce the work of breathing.
What are the three indication for bronchial hygiene therapy? Treating acute conditions. Chronic Conditions that may cause copious secretions. Disorders associated with retention of secretions.
Treating acute conditions copious secretions acute respiratory failure with retained secretions. Acute lobar atelectasis V/Q abnormalities caused by unilateral lung disease.
Chronic conditions that may cause copious secretions. Cystic fibrosis Bronchiectasis Ciliary dyskinetic syndromes chronic bronchitis
Disorders associated with retention of secretions. Acute disease immobile patients exacerbations of COPD Chronic disease cystic fibrosis neuromuscular disorders.
Respiratory failure is increased C02 Decreased O2
Ventilitory failure increase on C02 only.
The need for bronchial hygiene is assessed by the medical record and the patient
medical record history, admission for upper abdominal or thoracic surgery, presence of artificial airway, chest radiograph, pulmonary function testing, ABG values
Patient always assess cough! Posture, muscle tone, the effectiveness of cough, sputum production, breathing pattern, general physical fitness, breath sounds, vital signs.
Sputum production must exceed what for bronchial hygiene therapy to significantly improve secretion removal? 25 to 35 ml/day (can fit in a shot glass)
What are the methods of bronchial hygiene? chest physiotherapy coughing techniques PAP therapy High Frequency Compression/Ossillation Mobilization Exercise
Chest physiotherapy includes postural drainage percussion vibration
coughing techniques include directed cough huff coughing forced expiratory technique active cycle of breathing autogenic drainage manually assisted coughing mechancial insufflation/exsufflation
PAP therapy includes CPAP PEP
High frequencey compression/opscillation includes flutter intrapulmonary percussive ventilation vest
Chest physiotherapy involves the use of gravity and mechanical energy to help mobilize secretions.
Positioning/Postural drainage Patient positional so that secretions drain from specific segments and lobes of the lung toward gravity-dependent central airways, where it can be more easily removed with a cough or suction.
Each posture is held for how long? Between 20-30 minutes
External manipulation of the thorax includes? percussion and vibration
Percussion involves rapid clapping, cupping or striking of the external thorax directly over the lung segment drained with either cupped hands or mechanical device.
Vibration involves manually pressing in the direction that the ribs and soft tissues of the chest move during exhalation.
External manipulation of the thorax last for how long? Generally 5 minutes
When is vibration performed? Don one exhalation
What are the indications for positioning/postural drainage? Inability to change body positon. Poor oxygenation with unilateral lung disease. Potential for atelectasis Presence of artificial airway. Difficulty with secretion clearance Evidence of retained secretions/ foreign body diagnosis of pulmonary disease
What are indications for percussion/vibration? The need for additional manipulation of the chest to assist in secretion removal.
Contraindications for all positions. ICP > 20 mmHG Unstabilized head/neck injury Active hemoptysis/hemmorhage Spinal surgery or injury empyema bronchopleural fistula pulmonary edema pleural effusion PE Age, confused or anxious rib fractures/wounds
Contraindications for Trendelenburg position ICP>20 or potential for high ICP uncontrolled hypertension distended abdomen esophageal surgery hemoptysis aspiration risk
Percussion/vibration contraindications subcutaneous air recent epidural recent skin grafts or flaps burns/open wounds pace maker TB
Percussion/vibration contraindications lung contusion bronchospasm oseomyelitis of the ribs/osteoporosis coagulopathy chest wall pain recent feedings
CPT hazards and complications hypoxemia increased ICP acute hypertension pulmonary hemorrhage pain or injury to chest wall vomiting or aspiration bronchospasm dysrhythmias
What are CPT considerations? choose appropriate position maintain 5 to 10 minutes per position continually observe patient avoid percussion and vibration over bony structures or breast tissue.
What are more CPT considerations mechanical percussor available avoid percussion and vibration directly on the skin. some patients may require oxygen during therapy. Wait 2 hours past meals schedule around pain medication if necessary.
What might coughing techniques require? Splinting of surgical sites
How do you assess the effectiveness of therapy? Decrease in sputum vitals improve x-ray improves sputum changes color improved breath sounds lab work improved oxygenation
Directed cough indications include lung disease COPD Diseases that air trap
Directed cough is not possible with? obtunded, paralyzed, and uncooperative patients. Some restrictive disorders and advanced COPD
Direct cough is? A deliberate maneuver that is taught, supervised and monitored. It aims to mimic the features of an effective spontaneous cough in patients who are too weak to produce a a forceful expiratory maneuver.
What might limit the success of directed cough? fear of pain or pain systemic dehydration thick, tenacious secretions artificial airways use of CNS depressants
What is essential in directed cough? Good patient teaching.
What are the three most important aspects involved in patient teaching? Instruction on proper positioning insturction on breathing control exercises to strengthen expiratory muscles.
How do you do directed cough? Assume a sitting position with one shoulder rotated inward and the head/spine slightly flexed. Teach the patient to inspire slowly and deeply through the nose. Have patient bear down against the glottis while like you would with a bm.
What should individuals do between coughs with directed cough? diaphramatic breathing
What is the Huff cough/forced expiratory technique (FET) Sharp forced exhalations without glottis closure.
FET is a low pressure cough that prevents collapse in COPD patients. It is a modification of the direct cough
During FET there are one or two forced expirations of middle to low lung volume without closure of the glottis. They should phonate during the cough and follow up with diaphramatic breathing
FET goal is to clear secretions w/less change in pleural pressure to help prevent distal airway collapse/bronchospasm.
Why might FET not be possible with intubated patients? Increased airway resistance
The active cycle of breathing is a modified FET that combines breath control, thoracic expansion control and FET
Step one of active cycle: repeated cycle of breathing gentle diaphramatic breathing at normal tidal with relaxation of upper chest/shoulders.
Step two of active cycle: Thoracic expansion Deep inhalation w/relaxed exhalation. the relaxation prevents bronchospasm.
Step three of active cycle: FET Huff coughing technique which is shap forced exhalation without glottis closure.
Active Cycle of Breathing considerations Can accompany with percussion and vibration. Sitting position and beneficial with postural drainage. It is not for children less than 2 or extremely ill
Autogenic Drainage Staged breathing at different lung volumes.
Autogenic draining was developed when? In the 1960’s for the asthmatic patient. It is a modification for directed cough and can be done by themselves if trained.
How does it work? Diaphramatic breathing mobilized secretions by varying lung volumes an expiratory airflow in 3 distinct phases.
First Phase: Unsticking moves secretions from smaller airways. Patient should prevent cough
Second Phase: COllecting moves secretions from to moderate airways. Patient should prevent cough.
Third Phase: Evavcuation Moves secretions into large airw
Maunually assisted cough Also known as Quad Cough. Manually assisted cough for the weak, paralyzed and patients with neurological disorders.
what is the thrusting for in a manually assisted cough? It increases pressure in the thoracic cage
The mechanical insufflator-exsufflator Is the artificial cough machine. It augments tidal volumes. It inflates the lungs with positive pressure followed by a negative pressure to stimulate cough.
The artificial cough machine was developed when? In the 1950’s to help polio patients clear secretions.
How is the insufflator-exsufflator used now? It is used on patients with neuromuscular disorders.
How does it work? It delivers a positive pressure at 30 to 50 cm H20 for 1 to 3 seconds. Then removes at -30 to -50 cm H20 for 2-3 seconds.
How can the artificial cough machine be used? It can be used with an artificial airway or mask
Positive expiratory pressure is also know as PEP therapy
What is PEP therapy? A device which stimulates pursed-lip breathing. Prolonged exhalation against resistance stabilizes smaller airways, pushing secretions to larger airways.
PEP has an expiratory pressure of 10-20 cm H20 expiratory pressure
It is important to be aware of high PEP levels with obstructive diseases because it can cause further air trapping.
More facts about PEP can be used with a nebulizer. Was originated in Denmark. Is not useful in Chronic bronchitis and kids less than 3.
What is a flutter valve? Hand held device which combines high frequency oscillations and PEP therapy.
What does the flutter valve do? It shears mucus from airway wall and facilitates mucus flow, prevents airway closure.
Active exhalations do what? Transmits ossillation back down the airway.
You cannot do what with the flutter valve? Hook up aerosol therapy but that can be done with the acapella?
What is intrapulmonary percussive ventilation (IPV)? Mechanical device which provides miniburst of positive pressure to the airway via a mouthpiece.
How many miniburst a minute? 100-225 p/minute. The duration of pressure is controlled by therapy.
When was IPV approved? 1993
How does it work? It’s believed to open areas of atelectasis and deliver air behind mucus plugs helping to dislodge them.
What does the modern IPV version do? It utilizes a small volume nebulizer type of system. High frequency intrapulmonary percussive nebulizer.
What is the vest? It consists of an inflatable vest which covers the thorax and is attached with hoses to an air-pulse generator.
How does the vest work? It rapidly inflates and deflates from 5 to 25 times per second, creating a bias flow that moves secretions to the trachea.
What is a bias flow? A continues flow out.
What does the vest also do? It improves gas-liquid interactions decreasing viscosity of mucus.
What is the major factor contributing to retention of secretions? Immobility
What helps improve overall aeration and ventilation? Frequent position changes and exercises.
What must you consider with mobilization and exerecise? Fatigue SOB Decrease in Sp02
What are some pulmonary exercises? Diaphragmatic breathing inspiratory resistance training.
What is inspiratory resistance training? A device that acts like an inspiratory muscle resistor.
What are other modalities that aid in secretion removal but are not bronchial hygiene therapy? SVN therapy Mucoactive agents Bland aerosol therapy suctioning