1.  Inspiratory Phase  Compressive Phase  Glottis closing  Building of pressure  Expiratory Phase (glottis opening)

2.  Not the same components of a cough  Can be more effective in clearing secretions  To train patients, DEMONSTRATION.  FET – active cycle of breathing

3.  Splinting  CABG, thoracotomy, belly surgeries, incision in “pop can”.  Quad Coughing  Who?: ALS, SCI  Variety of different ways to increase expulsion force through positioning and careful manual pressure through CHEST WALL and ABDOMEN. (Interconnection)

5.  AKA – Coughalator, Mechanical In- Exsufflator, “The Cougher”  Non-invasive way to clear secretions. (alternative to suctioning)  Two Way Vaccuum

6. Indications for Use:  Any patient unable to cough or clear secretions effectively due to reduced peak cough expiratory flow (less than 3 liters per second), resulting from:  High spinal cord injuries  Neuromuscular deficits or  Severe weakness associated with intrinsic lung disease, is a candidate for the CoughAssist. OUR Indications for Use?  Ineffective Cough  Unable to clear secretions  Diagnoses: SCI ALS MD Trached patients Pneumonia Atelectasis Bronchiectasis: chronic secretions. Scarring and damage of lungs.

7.  Bullous Emphysema: airways collapse  Known susceptibility to pneumothorax  Recent Barotrauma: trauma deep in lungs related to pressure

8.  Massery et al. 2003, Cardiopulmonary PT Journal. Showed that cough assist was just as effective as suctioning.  Marchant and Fox 2002, Br J Anaesthesia. Case study preventing tracheostomy.  Kan and Bach 2000, Chest. Deep insufflations improved ability to air stack; and cough effectiveness.  John R. Bach – multiple studies on progressive neuromuscular diseases. Show cough assist machine even more effective with manual assist (peak cough flows).  Chatwin et al. 2003, Sivasothy et al. 2001. Showing cough assist machine effective with cough augmentation

9.  Set up:  Filter is hooked to the port of machine, then connected to blue tubing (RT)  Green plastic connector, then smaller blue tubing  Mouth piece, face mask, trach adaptor  Throw out small blue tubing at end of session.  Cost – approximately $3,500-5,000

10.  Sterile Technique  Don sterile gloves  Keep one hand sterile and always on the suction tube  The other hand touches the valve and other equipment  Ballard  Closed system  Use clean gloves

11.  Get equipment ready  Suction device  Gloves  Ambu bag  Suction pressure 60-120 mmHg  Ventilate, especially if removing vent– bag 3- 5 times  Insert to level of carina, no suction going in  Remove and twist, suction on way out

12.  10 sec duration in body  20-30 in between suction technique  3-4 times max  Clean suction in between contact with body with sterile saline  Some PTs do use sterile saline or hypertonic saline

13.  Indications  Pt is unable to clear secretions independently.  Pt is having difficulties breathing due to secretions/obstruction.  Unable to clear secretions by any other method.  Types  Tracheal (only within the trach.)  Deep (further than trach and into lung tissue).  Procedure:  Sterile vs Clean  Suction set 120-140 mmHg  10-12 seconds

14.  Enter catheter: cautiously but quickly, until you feel resistance (carina)  Apply suction and slowly pull catheter out.  Twist catheter as you pull out catheter.  Monitor saturations, and assist with ambu bag prior/following.

15. What vitals do you want to monitor?? Heart Rate Blood Pressure SPO2 Respiratory Rate

16.  Complications  Desaturation/hypoxia  Cardiac arrhythmias, Tachy cardia and Hypertension  Pulmonary hemorrage/bleeding  Bronchospasm  Elevated ICP  Is one of the most invasive techniques we do as physical therapists.

17. 1. Mobilization and Exercise 2. Body Positioning 3. Breathing Control Maneuvers 4. Coughing Maneuvers 5. Relaxation and Energy Conservation Interventions 6. ROM exercises 7. Postural Drainage Positioning 8. Manual Techniques 9. Suctioning

20.  Patient in respiratory distress.  PT performed multiple treatments. STG to improve V/Q, decrease WOB, and airway clearance

21.  DAY 1 ICU  PT performed treatments every 2 hours and all through the night  Total of 6 PT treatments  DAY 2 ICU  PT performed 5 treatments  DAY 3 FLOOR  PT performed treatments 2x per day  OVERALL  21 PT sessions (11 sessions during 48 hour ICU; 2 sessions daily on floor for 4 days)

22. Day 1 Day of Discharge

23.  Airway Clearance techniques assist in short term for secretion removal but currently there is no evidence supporting long term benefit above cough alone.  All techniques show improvement in secretion removal though no one technique has been proven better than the others and different patients will show different benefits from each technique.

24.  Method of airway clearance for any particular patient needs to be tailored to that patient’s needs to assure effective therapy with the greatest independence.  What works for any particular patient now may not work in the future with that patient, and what does not currently work for any particular patient now may become more helpful in the future.

25.  Position change is the only consistently demonstrated method of changing ventilation to any particular part of the lung ULTIMATELY – use of ANY technique is better than nothing. EX: if had pneumonia in left, then best on right, which is nice for moblization.