CP

• - laboratory techniques:
•   - radioaerosol tracers- radioactive tracer inhaled, clearance from lung measured by reduction in tracer
•   - sputum volume and weight- wet weight- includes saliva, dry weight- no saliva

• - patient reporting of seretions
• - amount of sputum
• - characteristics- colour, thickness
• -ease of clearance
• - clearance techniques- what pt used in the pass
• - SOB- may relate to increased WOB due to airway obstruction

• - fever
• - temp
• - HR

• - productive/ non productive
• - moist/ dry
• - strong/ weak
• - tight
• - effective/ ineffective (size of cough)

- noisy breathing- gurgling

• - wheeze
• - crackles
• - URTNs (upper respiratory tract noises)
• - reduced BS

• - may be normal
• - LBE may be reduced or an abnormal pattern of breathing may be present
• - may feel the secretions through the chest wall (only if in large airways)

• - CXR (may have signs of collapse, consolidation)
• - PFTs (pulmonary function tests)- may have reduced FEV1 due to obstruction of airflw, not allowed useful clinically
• - lab tests such as sputum culture, MC&S- (microbiology, culture and sensitivity)

• - treat underlying cause eg infection
• - hydration
• - drugs - mucolytics eg pulmozyme- decrease viscosity, suppressants eg codeine
• - mini tracheostomy- for secretion clearance 
• - intubation

• - increase ventilation/ lung volumes
• - mobilisation
• - cough
• - huff
• - FET
• - ACBT
• - percussion
• - vibrations
• - postural drainage
• - postive expiratory pressure masks
• - flutter
• - autogenic drainage
• - manual hyperinflation
• - suction

• - shallow huff from the peripheries
• - deep from the major trachea etc

• - important to consider if the problem with secretions is initially caused by reduced ventilation
• - more volume- better flow
• - air behind secretions
• - better mechanical advantage for resp mm
• - clearance of airways not specific
• - Gamsu 

• - effect of exercise on MCC
• - increase volume and flow rates
• - non specific- general clearance- global affects common with bronchiectasis and cystic fibrosis
• - no specific research

• - normal clearance mechanism used to clear secretions from the main airways (6-7th generation of airway branching)
• - clearance of secretions from large airways
• - commonly used in combo with other secretion clearance techniques
• - need to consider- high pressure, pain and fatigue/ SOB

• - ability to increase lung volume 
• - ability to close glottis
• - sufficient respiratory abd ab mm strength
• - ability to maintain airways calibre due cough (dont collapse due to force)

- wound support

- external pressure to helpgenerate increased force- cough machine

• - tracheal rub
• - something in the pahrynx- eg suction catheder
• -drink water
• - percussion

• - forced expiration with an open glottis
• - developed to overcome the negative aspects of the cough
• - airwat compression
• - pain, exhausting
• - aim is to have good airflow with minimal dynamic airway collapse/ compression
• - less effort, fatigue, less painful but equally good clearance to cough
• - aim is to maximise flow while minimizing airway colapse
• - huff can be taught with spirometry mouthpeice- stops closing glottis

• - huff fom low volumes- to clear the peripheral airways
• - huff from high volues to clear secretions from larger airways
• - generally medium sized inspiration

• - if the expiratory time is too short the huff may be ineffective
• - if clearance from  back of throat and trachea is needed a quick short huff is good
• - if huff is too long paroxysmal coughing and bronchospasm will occur (sudden and ongoing)

• - forced expiration technique
• - huff with relaxed diaphragmatic breathing
• - BC- 1-2 huffs - BC

- slow relaxed breathing. Physio provides manual feedback- when u want pt to relax

- breathing control is advocated to reduce the posibility of dynamic airway collapse from huffing and minimise energy expenditure and desaturation

• - minimise airway compression/ colapse
• - minimise airflow obstruction
• - reducing fatigue
• - shown to help increase efficiency of secretion clearance in CF

• - active cycle of breathing techniques
• - useful for clearing secretions for major airways and from lung
• - TEE- increase volume
• - aimed at maintaining alveolar volume, preventing collapse of airways and alvoli

• - deep LBE with insp hold
• - to improve alveolar ventilation by collateral channels increasing lung volume
• - not for hyperinflated pts as it will make them more hyperinflated

• - BC
• - 3-4 TEE
• - BC
• - 3-4TEE
• - BC
• - 1-2 huffs
• - BC
• - repeat whatever is appropriate
• no more than 2 huffs if non productive

- secretion clearance/ alveolar ventilation

• - essentially none
• - care with TEE and hyperinflation

• - application of force to the chest wall with a cupped hand- transfer mechanical energy
• - ketch up bottle method
• - increase flow in underlying segments
• - increased lung volume
• - increase cilial beat frequency
• - stimulate cough

• - seretion clearance- excessive secretions and difficulty
• - effective with large volume of secretions
• - not effective with little or no secretions
• - clearance from lung and airway
• - doesnt resolve consolidated lung (solid stuff)

• - haemodynamic instability
• - # rib

• = frank haemoptysis
• - rib cancer
• - bronchospasm
• - serve osteoporsis
• - low platelet levels (can make them bleed)
• - raised ICP- usually only an issue in ICU (after pt has brain damage)

• - application of oscillatory force to the pts thorax during expiration- consists of both oscillation and compression components
• - commonly used techniques with PD, ACBT

- same as percussion

• - transmission of mechanical energy to the airway thought to assist with secretion clearance
• - may increase/ augument expiratory airlow
• - ?reduces sputum viscosity
• - stimulate cough

• - uses gravity to assist the clearance of secretions from lung segments
• - segment to be drained is placed non dependent with the orientation of the bronchus such that secretions will be drained towards the main airways where they can be cleared with a huff or cough

- upper most

• - secretion clearance
• - excessive secretions and difficulty clearing
• - can be used for global or regional secretion clearance

• - high ICP, recent neuro injury (ICU pt)
• - CVS instability
• - hypertension
• - pulmonary oedema/ heart failure (ask pt how many pillows they slep with)
• - orthopnoea- SOB when lying flat
• - respiratory distress- extreme SOB
• - post pneumonectomy (dont lie with affected side uppermost)
• -  upper GIT surgery (oesophagectomy, gastrectomy, hiatus hernia repair)
• - eye surgery, head and neck surgery- pressure
• - servere abd distension, obesity, late preg- supine (push down on vas), head down- ush up to lungs
• - if pt is distressed and in position
• - hiatus hernia, vom, reflux, GORD
• - recent meal

- mechanical device that increases resistance to airflow- creating positive expiratory pressure in the airways during expiration

• - post op to reinflate areas of lung collapse by increasing collateral ventilation
• 1984 falk

• - positive pressure acts to splint the airway open during expiration and prevent dynamic collapse of airway- allow greater expiratory airflow and therefore better secretion clearance
• - FRC is increased during tidal volume breathing using the PEP mask
• - residule volume (trapped gas) is decreased
• - a 2 min closed system breathing cycle is recommended for PEP efficacy on FRC

• - when resistance by the ordinary route is increased, resistance in collateral channels distal to the obstruction is relatively reduced
• - more air enters the collateral channels during inspiration than escapes during expiration
• - this results in better lung volume, better alveolar ventilation, recruitment of atelectatic lung units and allows air to get behind secretions and assist in clearance (better expiratory flow)

• - in sitting or in postural drainiange
• - via face mask or mouth piece
• - small valve is fitted into mask- reduced expiratory expiratory diameter
• - positive pressure measured with manometer- should be 10-20cm H2O at mid expiration
• - ratio of inspiration to exhalation= 1:3-4
• - breathing is tidal (or slightly greater in recent reviews), slightly active exhalation
• - FRC is maintained at a raised level (avoid complete expiraation, maintain seal)
• - number of breaths = 5-10, cycle concluded with FET
• - Rx duration = 15-20 min
• - finish with huff

• - secretion clearance- excessive secretions and difficulty clearing
• - persistent lung collapse/ atelectasis
• - particularly useful with patients who have significant reflux

• - undrained pneumothorax
• - frank haemoptysis
• - recent lung surgery
• - recent upper GIT, eye or face/ head/ neck surgery
• - increased ICP
• - unstable CVS
• - undrained pneumothorax
• - gross hyperinflation with bullae
• - recent facial surgery

• - oberwaldner, sustained expiratory pressure of 40-100cmH2O generated
• - documented as safe (PTx, haemoptysis)
• - can make from O2 tubing and water
• - good for independent
• SEE the notes for pictures