PHYSIOTHERAPY ADJUNCTS Billie Hurst Part-Time Lecturer QMUC

Content Oxygen therapy Humidification Non Invasive ventilation - BIPAP/CPAP Bronchoscopy

Oxygen therapy For over 200 years oxygen therapy has often been used and sometimes misused (Hough 2001)

Oxygen Therapy Should be prescribed Acute and chronic respiratory conditions Personnel should be trained in its use Protocols

Oxygen therapy - Indications Hypoxaemia (PaO2<8KPA, O2sats<90%) Acute or chronic respiratory condition Pre and post suction Routinely post operatively Optimise oxygen delivery

Oxygen therapy - limitations Giving oxygen does not guarantee it’s arrival at the mitochondria Oxygen does not improve ventilation directly (Hough 2001)

Oxygen therapy – complications/cautions Respiratory depression if hypoxic drive Pulmonary oxygen toxicity Tracheobronchitis Absorption atelectasis Fire Variable delivery

Oxygen Therapy - Monitoring Oxygen saturations continuous/intermittent Arterial blood gases Observation

Oxygen Therapy - Delivery Piped oxygen Portable oxygen Compressors/concentrators

Oxygen therapy – delivery devices Low Flow masks (variable performance) High flow masks (fixed flow)/venturi Nasal cannulae Mask and reservoir bag Tracheal mask/t-piece Tracheal speaking valves Mechanical ventilator

Oxygen Therapy - low flow masks Commonly used Variable performance

Oxygen therapy – high flow masks Guaranteed percentage of oxygen Venturi system More expensive Up to 60%

Nasal cannulae 1l/min 24% oxygen 2l/min28% oxygen 3l/min32% oxygen 4l/min36% oxygen

Oxygen therapy – bag and mask High concentrations of oxygen Mask and reservoir bag 55-90%

Oxygen Therapy tracheostomy T-piece Mask Swedish nose Speaking valve

Long term oxygen therapy Chronic hypoxaemia Increases survival Aim to raise PaO2 to >8Kpa Worn as much as possible >15hours Cylinders/concentrators/liquid

Oxygen Therapy - Implications Assessment Limitations to physiotherapy techniques

Humidification Mucocillary escalator Adequate hydration is vital Bacterial contamination!!!

Humidification - indications URT bypassed Thick retained secretions High flow oxygen/non-invasive mechanical aids

Humidification - Cautions Hyper-reactive airways - bronchospasm Infection Burns

Humidification - Types Nebulisers Large/Small/Ultrasonic Steam

Humidification - Humidifiers Hot - Increases moisture content - Increases risk of infection Cold - Poor moisture content

Humidification - HME Heat moisture exchangers Hygroscopic Hydrophobic Swedish nose Tracheostomy bibs

Non-invasive ventilation BiPAP CPAP IPPB

Contraindications/Cautions to non- invasive ventilation Undrained pneumothorax,surgical emphysema Unstable Cardiovascular system Frank haemoptysis Facial fractures Vomiting Raised ICP Active TB Lung abcess Recent GI surgery Pneumonectomy/lobectomy with poor stump

Continuous Positive Airway Pressure Constant flow of gas through inspiration and expiration Invasive/non-invasive Endotracheal/tacheostomy/mask Improve oxygenation not ventilation

CPAP - indications Type I respiratory failure Volume loss Sleep apnoea Pulmonary oedema Flail segment

CPAP - Problems Tolerance Discomfort/fit Air swallowing Difficulty coughing Aspiration Mild haemodynamic changes Note pneumothorax

Bilevel positive airway pressure BiPAP Invasive/Non-invasive ventilation Endotracheal tube/tracheostomy/mask Constant pressure with independent inspiratory pressure and expiratory pressure

BiPAP - Indications Respiratory type II failure Weaning

BiPAP - Problems Tolerance Discomfort/mask fit Air swallowing Mild haemodynamic changes Expectoration

NIV – Implications for treatment YES Positioning Manual techniques Thoracic expansion exercises ACBT? NO Mobilisation Incentive spirometry

Bronchoscopy Fiberoptic bronchoscope Diagnostic Therapeutic Bronchial lavage