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Chapter 40 Airway Clearance Therapy

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1 Chapter 40 Airway Clearance Therapy
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

2 Learning Objectives Describe how normal airway clearance mechanisms work and the factors that can impair their function. Identify pulmonary diseases associated with abnormal clearance of secretions. State the goals and clinical indications for bronchial hygiene therapy. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

3 Learning Objectives (cont.)
Describe the proper technique and potential benefit of each of the following. Postural drainage Directed coughing and related expulsion techniques Positive expiratory pressure (PEP) therapy High-frequency compression/oscillation methods Mobilization and exercise Evaluate a patient’s response to airway clearance therapy. Modify airway clearance therapies on the basis of patient response. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

4 Introduction Airway clearance therapy involves noninvasive techniques to help mobilize secretions and improve gas exchange Broad application of airway clearance therapy is costly & ineffective Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

5 Physiology of Airway Clearance
Normal clearance Normal airway clearance requires a(an) Patent airway Functional mucocilary escalator Effective cough Effective cough can move mucus from lower airways to upper airway Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

6 Normal Clearance Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

7 Physiology of Airway Clearance (cont.)
Abnormal clearance Abnormalities in airway patency, mucuciliary function, strength of breathing muscles, thickness of secretions or cough reflex can lead to mucus retention Mucus plugging can lead to atelectasis, pneumonia, & hypoxemia Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

8 All of the following can lead to excess mucus retention, except:
Vocal cord paralysis Inspissated secretions Impaired mucocilary escalator Loss of cough reflex Answer: A Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

9 Physiology of Airway Clearance (cont.)
Diseases associated with abnormal clearance Internal or external compression of airway lumen (e.g., asthma, lung cancer) Cystic fibrosis Bronchiectasis Neuromuscular diseases can cause a weak cough Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

10 General Goals & Indications
Airway clearance 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 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

11 General Goals & Indications (cont.)
Airway clearance 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 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

12 Determining the Need for Airway Clearance Therapy
Physical findings such as: Loose, ineffective cough Labored breathing pattern Coarse inspiratory & expiratory crackles Tachypnea/tachycardia Fever Chest radiograph demonstrating atelectasis & infiltrates Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

13 All of the following findings would indicate a need for airway clearance therapy, except:
Coarse secretions Pain Tachypnea Labored breathing Answer: B Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

14 Airway Clearance Methods
Chest physical therapy Coughing & related expulsion techniques Positive airway pressure (PAP) High-frequency compression/oscillation Mobilization & exercise Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

15 All of the following are methods of airway clearance, except:
Exercise Oscillation Chest physical therapy Low-frequency compression Answer: D Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

16 Airway Clearance Methods (cont.)
Postural drainage therapy Involves use of gravity & mechanical energy to mobilize secretions Includes turning, postural drainage, & percussion & vibration Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

17 Airway Clearance Methods (cont.)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

18 Airway Clearance Methods (cont.)
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 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

19 Decrease in sputum production
All of the following are positive outcomes associated with performing postural drainage, except: Decrease in sputum production Breath sound change, diminished to wheezing Increase in SpO2 Decrease in dyspnea level Answer: A Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

20 Airway Clearance Methods (cont.)
Postural drainage (cont.) Documentation & follow-up Chart entry should include Positions used Time in positions Patient tolerance Indicators of effectiveness Any untoward effects observed Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

21 Airway Clearance Methods (cont.)
Postural drainage (cont.) Percussion & vibration Application of mechanical energy to chest wall by use of hands or various electrical or pneumatic devices Designed to aid in movement of mucus toward central airways during exhalation Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

22 Percussion and Vibration
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

23 Percussion and Vibration
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

24 Airway Clearance Methods (cont.)
Coughing & related expulsion techniques Directed cough Deliberate maneuver that is taught, supervised, & monitored Aims to mimic features of effective spontaneous cough Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

25 Airway Clearance Methods (cont.)
Directed cough (cont.) Not to be used in patients who are obtunded, paralyzed, or uncooperative Good patient teaching is critical Proper positioning of patient is important Technique may need to be modified in surgical patients, patients with COPD, & patients with neuromuscular disease Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

26 Airway Clearance Methods (cont.)
Forced expiratory technique (FET) Modification of directed cough Also called “huff cough” Consists of one or two forced expirations of middle to low lung volumes without closure of glottis Goal is to clear secretions with less change in pleural pressure & less bronchial collapse Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

27 Airway Clearance Methods (cont.)
Forced expiratory technique (FET) (cont.) Has been shown to increase sputum production, especially when combined with postural drainage Most useful in patients with COPD, cystic fibrosis, or bronchiectasis. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

28 Active cycle of breathing (ACBT)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

29 Airway Clearance (cont.)
Autogenic drainage (AD) Patient uses diaphragmatic breathing to mobilize secretions by varying lung volumes & expiratory airflow in three distinct phases Patient should be in sitting position Coughing should be suppressed until all three phases are complete Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

30 Autogenic Drainage Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

31 All of the following are part of Autogenic drainage therapy, except:
Patient should be in supine position Coughing should be avoided until all 3 phases are complete Patient should be in semifowlers position Patient should use diaphragmatic breathing techniques Answer: A Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

32 Airway Clearance Methods (cont.)
Mechanical insufflation-exsufflation (MIE) MIE devices apply positive pressure of 30 to 50 cm H2O to airway for 1 to 3 seconds Device then abruptly reverses airway pressure to –30 to –50 cm H2O Treatment sessions consist of about five cycles of MIE followed by normal spontaneous breathing Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

33 MIE Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

34 Airway Clearance Methods (cont.)
Positive airway pressure adjuncts Used to mobilize secretions & treat atelectasis Used in combination with other airway clearance techniques Three applications are used: continuous PAP (CPAP), expiratory PAP (EPAP), & positive expiratory pressure (PEP) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

35 Positive Airway Pressure
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

36 Airway Clearance Methods (cont.)
PEP therapy to clear secretions Involves active expiration against variable flow resistance Helps move secretions into larger airways by improving ventilation of underaerated segments & by preventing airway collapse during expiration Studies have shown mixed results Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

37 Airway Clearance Methods (cont.)
High-frequency compression/oscillation External (chest wall) application Airway application Flutter valve Intrapulmonary percussive ventilation Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

38 High-frequency Compression/Oscillation
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

39 Flutter Valve Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

40 Intrapulmonary Percussive Ventilation
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

41 Airway Clearance Methods (cont.)
Mobilization & exercise Immobility is major factor contributing to retention of secretions Early mobilization & exercise are standard care for surgical patients Exercise improves overall gas exchange & lung function Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

42 Selecting Airway Clearance Techniques
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

43 Selecting Airway Clearance Techniques (cont.)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

44 Which of the following is the most appropriate airway clearance method for an infant with cystic fibrosis? PDPV MIE PEP Exercise Answer: A Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.


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