What is are some assessment of secretion clearance?
- - 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
What questions do you need to ask pt about their sputum?
- - 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
What obs do u make of a pt?
what assessment do we have for secretion clearance and a cough?
- - productive/ non productive
- - moist/ dry
- - strong/ weak
- - tight
- - effective/ ineffective (size of cough)
- noisy breathing- gurgling
What do you listen for when you auscultate?
- - wheeze
- - crackles
- - URTNs (upper respiratory tract noises)
- - reduced BS
What do you need to be aware of when looking at chest exapnsion for secretion clearance?
- - 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)
What are some assessments of secretion clearance measures?
- - 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)
What are some medical managements strategies for secretion clearance?
- - treat underlying cause eg infection
- - hydration
- - drugs - mucolytics eg pulmozyme- decrease viscosity, suppressants eg codeine
- - mini tracheostomy- for secretion clearance
- - intubation
What are the techniques for secretion clearance?
- - 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
What is the physiological rationale behind alveolar ventilation?:
- - 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
How does mobilisation help with seretion clearance?
- - 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
how does a cough help clear secretions?
- - 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
What do you need to have an effective cough?
- - 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)
What must you do when you get your pt to do a cough post op?
- wound support
what is used to help pts cough if they have weak mm?
- external pressure to helpgenerate increased force- cough machine
how can you stimulate a cough?
- - tracheal rub
- - something in the pahrynx- eg suction catheder
- -drink water
- - percussion
What is a huff?
- - 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
What order should you huff and why?
- - huff fom low volumes- to clear the peripheral airways
- - huff from high volues to clear secretions from larger airways
- - generally medium sized inspiration
time of a huff?
- - 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)
What is FET?
- - forced expiration technique
- - huff with relaxed diaphragmatic breathing
- - BC- 1-2 huffs - BC
What is breathing control?
- slow relaxed breathing. Physio provides manual feedback- when u want pt to relax
what is the purpose of FET?
- breathing control is advocated to reduce the posibility of dynamic airway collapse from huffing and minimise energy expenditure and desaturation
what is the aim of BC?
- - minimise airway compression/ colapse
- - minimise airflow obstruction
- - reducing fatigue
- - shown to help increase efficiency of secretion clearance in CF
What is the technique of secretion clearance ACBT?
- - 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
What is TEE in ACBT?
- - 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
What tis the ACBT pattern?
- - BC
- - 3-4 TEE
- - BC
- - 3-4TEE
- - BC
- - 1-2 huffs
- - BC
- - repeat whatever is appropriate
- no more than 2 huffs if non productive
What are the indications for FET and ACBT?
- secretion clearance/ alveolar ventilation
Contraindications to FET and ACBT?
- - 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
When are percussions used?
- - 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)
What are the precautions of percussion?
- - haemodynamic instability
- - # rib
What are the contraindications to percussion>?
- = 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)
What is the secretion clearance- vibes
- - application of oscillatory force to the pts thorax during expiration- consists of both oscillation and compression components
- - commonly used techniques with PD, ACBT
What are the indications and contraindications for vines?
- same as percussion
What is the rationale behind vibes?
- - transmission of mechanical energy to the airway thought to assist with secretion clearance
- - may increase/ augument expiratory airlow
- - ?reduces sputum viscosity
- - stimulate cough
What is the idea behind postural drainage?
- - 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
What is the non dependent lung?
- upper most
What are the indications for postural drainage?
- - secretion clearance
- - excessive secretions and difficulty clearing
- - can be used for global or regional secretion clearance
What are the contraindications/ precautions of postural drainage?
- - 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
What is PEP?
- mechanical device that increases resistance to airflow- creating positive expiratory pressure in the airways during expiration
When is PEP used?
- - post op to reinflate areas of lung collapse by increasing collateral ventilation
- 1984 falk
What is the physiological rationale of PEP?
- - 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)
How do you apply low pressure PEP?
- - 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
What are the indications of PEP?
- - secretion clearance- excessive secretions and difficulty clearing
- - persistent lung collapse/ atelectasis
- - particularly useful with patients who have significant reflux
What are the contraindications/ precautions of PEP?
- - 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
What is the techniques for secretion clearance - PEP
high pep therapy
- - 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