Bronchial Hygiene Therapy RET 2275 Respiratory Therapy Theory 2

Bronchial Hygiene Bronchial hygiene therapy involves noninvasive airway clearance techniques to help mobilize secretions and improve gas exchange Reading Assignment Egan’s Fundamentals of Respiratory Care NINTH EDITION (pgs. 921-932)

Bronchial Hygiene Normal clearance Normal airway clearance requires a(an) Patent airway Functional mucocilary escalator Effective cough An effective cough can effectively move mucus from the lower airways to the upper airway.

Bronchial Hygiene Normal clearance

Bronchial Hygiene Abnormal clearance Abnormalities in airway patency, mucuciliary function, strength of breathing muscles, or cough reflex can lead to mucus retention. Mucus plugging can lead to atelectasis, pneumonia, and hypoxemia.

Bronchial Hygiene

Bronchial Hygiene Diseases associated with abnormal clearance Internal or external compression of an airway lumen (e.g., asthma, lung cancer) Cystic fibrosis Bronchiectasis Neuromuscular diseases can cause a weak cough.

Bronchial Hygiene General Goals and Indications Bronchial hygiene therapy for acute conditions Acutely ill patient with copious secretions Patient in acute respiratory failure with clinical signs of retained secretions Patient with acute lobar atelectasis Patient with hypoxemia due to lung infiltrates

Bronchial Hygiene General Goals and Indications (cont.) Bronchial hygiene therapy to prevent retention of secretions May be useful in acutely ill patients when combined with patient mobilization Cystic fibrosis patients benefit from chest physical therapy combined with exercise to maintain lung function.

Bronchial Hygiene Determining Need for Bronchial Hygiene Therapy Bedside findings such as Loose, ineffective cough Labored breathing pattern Coarse inspiratory and expiratory crackles Tachypnea/tachycardia Fever The chest radiograph demonstrating atelectasis and infiltrates

Bronchial Hygiene Bronchial Hygiene Methods Postural drainage therapy Coughing and related expulsion techniques Positive airway pressure (PAP) High-frequency compression/oscillation Mobilization and exercise

Bronchial Hygiene Postural drainage therapy Involves the use of gravity and mechanical energy to mobilize secretions Includes turning, postural drainage, and percussion and vibration

Bronchial Hygiene Postural drainage therapy Indications Inability or reluctance of patient to change position Poor oxygenation associated with position (e.g., unilateral lung disease) Potential for or presence of atelectasis Evidence or suggestion of difficulty with secretion clearance Difficulty clearing secretions, with expectorated sputum production >25 – 30 ml/day (adult)

Bronchial Hygiene Postural drainage therapy Indications (cont.) Evidence or suggestion or retained secretions in the presence of an artificial airway Diagnosis of diseases such a cystic fibrosis, bronchiectasis, or cavitating lung disease External Manipulation of the Thorax Sputum volume or consistency suggesting a need for additional manipulation (e.g., percussion and/or vibration to assist movement of secretions by gravity in a patient receiving postural drainage

Bronchial Hygiene Postural drainage Turning Primarily done to promote lung expansion, improve oxygenation, and prevent retention of mucus Proning has been used in patients with acute lung injury to improve lung function.

Bronchial Hygiene Postural drainage Turning and “Plumbing Problems” Ventilator disconnection Accidental extubation Accidental aspiration of ventilator circuit condensate Disconnection of vascular lines or urinary catheters – ouch!

Bronchial Hygiene Postural drainage (cont.) The process placing the patient in various positions to drain specific segmental bronchi Positions are typically held for 3 to 15 minutes. Most effective in patient with excessive mucus secretion

Patient positions for Postural Drainage

Bronchial Hygiene Postural Drainage Monitoring Subjective response to pain Pulse, arrhythmia, and ECG if available Breathing pattern and rate Sputum production Mental function Skin color Breath sounds Blood pressure SpO2 ICP

Bronchial Hygiene Postural drainage Outcome assessment Change in sputum production Change in breath sounds Change in dyspnea level Change in vital signs Change in chest radiograph/ABG results Change in ventilator variables

Bronchial Hygiene Postural drainage Documentation and follow-up The chart entry should include The positions used Time in positions Patient tolerance Indicators of effectiveness Any untoward effects observed

Bronchial Hygiene Postural drainage Percussion and vibration The application of mechanical energy to the chest wall by use of the hands or various electrical or pneumatic devices Designed to aid in movement of mucus toward the central airways

Bronchial Hygiene Postural drainage Vibration Place one hand on the patient’s chest over the involved area and place the other hand on top of the first Ask the patient to take a deep breath Exert slight to moderate pressure on the chest wall and initiate a rapid vibratory motion of the hands throughout expiration

Bronchial Hygiene Postural Drainage Absolute Contraindications Head and neck injury until stabilized Active hemorrhage with hemodynamic instability Relative Contraindications Active hemoptysis Pulmonary embolism Recent spinal surgery Aged, confused, or anxious patients who do not tolerate position changes Refer to AARC Clinical Practice Guidelines for complete list

Bronchial Hygiene Postural Drainage Trendelenburg position is contraindicated for: Recent gross hemoptysis ICP >20 mm Hg Uncontrolled hypertension Distended abdomen Patient in whom increased ICP is to be avoided (neurosurgery, aneurysms, eye surgery) Uncontrolled airway at risk for aspiration (tube feeding or recent meal) Esophageal surgery Refer to AARC Clinical Practice Guidelines for complete list

Bronchial Hygiene Postural Drainage Complications/Hazards Hypoxemia Increase ICP Acute hypotension during procedure Pulmonary hemorrhage Pain or injury to muscles, ribs, or spine Vomiting and aspiration Bronchospasm Arrhythmias