Airway Clearance Techniques PTP 673 CardioPulmonary Plan of Care July 16th, 2013 Emily E. Houser, PT, DPT, CCS

Objectives Lecture: Lab: Introduction to airway physiology Continued information on airway clearance techniques Apply differential for choice of intervention Provide literature to support evidence based practice Lab: Hands on practice of techniques and devices

Why is this important?? If you can’t breathe, you can’t function! DPT: We need to look at all body systems to properly assess and successfully treat a problem. Linda Crane Memorial Lecture: The Patient Puzzle, Piecing it all together.

Breathing is a multisystem Event MS NM: GBS, SCI CP INT: burns, scerolderma IO: Obesity, room for diaphragm

Respiration - Interconnection Every muscle of respiration is ALSO a muscle of posture Respiration and Posture = duality of function External and Internal pressures that affect one – will affect the other PRESSURE IS THE KEY

Soda-Pop Can Model Low pressure system: trachy and low tone

Cystic fibrosis: hump is were pressure is coming out.

Soda-Pop Can Model COPD, high pressure, hyper-inflated

Work of Breathing Work of breathing is the energy cost of inspiration and expiration. In normal healthy individuals their work of breathing is not a limiting factor even with strenuous activity.

Function and Work of Breathing In the presence of respiratory or cardiac compromise work of breathing can be a major portion of the total energy expenditure for a person and can also be a primary limiting factor for function and survival. EX: cant breathe when eating: look at posture, leaning against chiar?

Impaired Ventilatory Pump Function Increased work of inspiration: Posture/kyphosis Connective tissue diseases Pregnancy Obesity Pleural effusion Pneumonia/inflammation Neuromuscular disease/SCI/CVA/Guillian Barre Ventilatory muscle length and strength Excessive pulmonary secretions

Impaired Ventilatory Pump Function Increased work of expiration Secretions: cystic fibrosis Bronchial smooth muscle tone Structural stability of the airways COPD Inflammation of airways Expiratory muscle weakness

Impaired Airway Clearance Mucociliary Elevator Pharmacological approaches Physical Approaches

Secretions MOBILIZATION EXPECTORATION MANAGEMENT Chest wall stretching Assisted Cough Techniques Oral suctioning Percussion/ Vibration/ PD Positioning Breathing Exercises/ PEP Devices Suctioning Equipment Aerobic exercise Cough assist machine

Chest Physical Therapy Incorporates all these aspects to achieve optimal functioning. ROLE: To minimize the impact of airway clearance and ventilatory impairments on a patient’s functional capacity, ADL’s, work, and leisure. Included with this, are airway clearance techniques.

Classics Postural Drainage Percussion Vibration Suctioning Example: ketchup bottle

Postural Drainage Positions Don’t do the inverted position, so B sidelying with change in arm position, prone, and sitting edge of bed.

HFCWO: High Frequency Chest Wall Oscillation “The Vest” All CF pt use, CP, TBI can also use. For secretion mobilization.

The Vest Used to help facilitate secretion mobilization. Settings Provides: Compression Vibration Settings Compression: between 1-8, 4 is most common Vibration: Between 6-16, 12 is most common

The Vest Has actually been around and evolved over the past 20 years. Good option for patients who have need for daily secretion removal. Also for use in ICU pts. Can be done independently. Can be done in conjunction with nebulizer treatments. Is expensive: approx 15K. Still need a regime for vest, can help get a lung transplant. $15,000, but maintaince is for life.

The Vest Important that it’s not too tight or vibrating too fast. Need to find individual settings which work. Recommend using at least 10 minutes, or until patient feels secretions moving. Typically 20 Encourage coughing several times after each cycle, when there is something in upper airway to clear.

The Vest Recommend changing positions; not just sitting Recommend doing aerobic activity while using the vest Such as: Stair stepping Marching in place

Efficacy Most research will show that if properly instructed, can be as effective as classic techniques. But also is not ‘fool proof.’ In terms of PFT’s and sputum production as outcomes, it has also been shown to be less effective. (Kluft, 1996; Oermann, 2001; Phillips 2004) **Key, must fit the individual for their needs. FVI: used for transplant, closer to 20% is transplant.

PEP devices Postive End Pressure Regular PEP (low pressure) ‘Thera-PEP’ Oscillatory PEP (low pressure) Flutter Acapella

Rationale for PEP therapy B. A. COPD: airways collapse, so need to keep open. Collateral ventilation facilitates air movement between adjacent lung segments Airway wall splinting, stabilizing, back pressure (blunting effect) Decreases asynchronous ventilation - for equal filling (not shown)

Thera-Pep Can use a mouth piece or facemask Can change resistance Gives an incentive meter – this device is similar to incentive spirometer, just opposite. Tough to get buy in from patient

Flutter Valve Blow air in; pushing steel ball which creates resistance and vibration for airway. Positional Dependent. Need to hold at correct angle. Requires strong expiratory force to use.

Acapella Blow air in, pushing on diaphragm which creates vibration for airway. Can be done in any position and angle. Can adjust the resistance, and comes in different levels. Can actual deliver nebulizer treatments through them.

Efficacy PEP has significant advantages compared to conventional postural drainage and percussion. PM, McIlwaine et al. Pediactric Pul. Suppl 12, 1995. Flutter may not be as effective as PEP in maintain pulmonary function in CF pt. PM McIlwaine. This may be due to having to maintain same position. **Something is better than nothing, need to individually assess best results.