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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
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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
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What obs do u make of a pt?
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what assessment do we have for secretion clearance and a cough?
- - productive/ non productive
- - moist/ dry
- - strong/ weak
- - tight
- - effective/ ineffective (size of cough)
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Listen for?
- noisy breathing- gurgling
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What do you listen for when you auscultate?
- - wheeze
- - crackles
- - URTNs (upper respiratory tract noises)
- - reduced BS
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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)
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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)
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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
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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
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Huff
- - shallow huff from the peripheries
- - deep from the major trachea etc
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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
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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
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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
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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)
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What must you do when you get your pt to do a cough post op?
- wound support
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what is used to help pts cough if they have weak mm?
- external pressure to helpgenerate increased force- cough machine
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how can you stimulate a cough?
- - tracheal rub
- - something in the pahrynx- eg suction catheder
- -drink water
- - percussion
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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
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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
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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)
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What is FET?
- - forced expiration technique
- - huff with relaxed diaphragmatic breathing
- - BC- 1-2 huffs - BC
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What is breathing control?
- slow relaxed breathing. Physio provides manual feedback- when u want pt to relax
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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
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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
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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
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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
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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
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What are the indications for FET and ACBT?
- secretion clearance/ alveolar ventilation
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Contraindications to FET and ACBT?
- - essentially none
- - care with TEE and hyperinflation
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Percussion
- - 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
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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)
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What are the precautions of percussion?
- - haemodynamic instability
- - # rib
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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)
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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
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What are the indications and contraindications for vines?
- same as percussion
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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
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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
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What is the non dependent lung?
- upper most
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What are the indications for postural drainage?
- - secretion clearance
- - excessive secretions and difficulty clearing
- - can be used for global or regional secretion clearance
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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
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What is PEP?
- mechanical device that increases resistance to airflow- creating positive expiratory pressure in the airways during expiration
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When is PEP used?
- - post op to reinflate areas of lung collapse by increasing collateral ventilation
- 1984 falk
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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
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PEP rationale
- - 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)
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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
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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
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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
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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
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