Chapter 40

Bronchial hygiene therapy involves noninvasive airway clearance techniques to help mobilize secretions and improve gas exchange

Cystic fibrosis PTs

• Patent airway (open airway)
• Functional mucocilliary escalator
• Effective cough - an effective cough can move mucus from the lower airways to the upper airways

• 1. Irritation - abnormal stimulus (inflammatory, mechanical, chemical, thermal) provokes sensory fibers in the airways to send impulses to the brains cough center
• 2. Inspiration - Once impulses are recieved, the cough center generates a reflex stimulation to initiate deep inspiration
• 3. Compression - reflex nerve impulses can cause glottic closure and a forecful contraction of the expiratory muscles
• 4. Expulsion - glottis opens, the large pressure gradient causes a large expulsion of air

• Abnormalities in airway patency, mucocilliary function, strength of breathing muscles or cough reflex can lead to mucus retention.
• Retention of secretions can result in full or partial airway obstruction.

• Asthma, lung cancer, kyphoscoliosis, chronic bronchitis, acute infections
• Cystic fibrosis
• Bronchiectasis
• Neuromuscular diseases can cause a weak cough

• Help mobilize and remove retained secretions
• The ultimate goal is to improve gas exchange and reduce the WOB

Retained secretions in the lungs/airways

• 1. Postural drainage therapy
• 2. Coughing and related expulsion techniques
• 3. Positive airway pressure (PAP)
• 4. High-frequency compression/oscillation
• 5. Mobilization and exercise

• Involves the use of gravity and mechanical energy to mobilize secretions
• Turning, postural drainage, percussion and vibration

• Inability of the PT to change body position
• Poor oxygenation associated with position
• Potential or prescence of atelectasis
• Prescence of an artificial airway
• Difficulty clearing secretions
• Evidence or difficulty with secretion clearance
• Diagnosis or disease such as CF, bronchiectasis

• Head and neck injury
• Active hemorrhage with hemodynamic instability
• ICP > 20mmHg
• Recent spinal surgery or acute spinal injury
• Active hemoptysis
• Empyema (puss in pleural space)
• Bronchopleural fistula
• Pulmonary edema associated with CF
• Pulmonary embolism
• Aged, confused or anxious PTs who do not tolerate position changes
• Rib fracture
• Large pleural effisions

• Head and neck injury until stabilized - spinal cord injury
• Active hemorrhage with hemodynamic instability - traction of arm abductors

Face down

Acute lung injury and ARDS

• Change in sputum production
• Change in breath sounds
• Change in dyspnea level
• Change in vital signs
• Change in in chest radiograph/ABG results
• Change in ventilator variables

• Chart should include:
• Positions used
• Time in positions
• PT tolerance
• Indicators of effectiveness
• Any untoward effects observed

• The application of mechanical energy to the chestwall by use of the hands or various electrical or pneumatic devices
• Vibration should aid in the movement of secretions toward the central airways during exhalation

• Deliberate maneuver that is taught, supervised and monitored
• Aims to mimic the features of an effective spontaneous cough
• It has little direct effect on PTs who do not produce sputum

• The need to aid in the removal of retained secretions from the central airways
• Prescence of atelectasis
• Routine part of bronchial hygiene with cystic fibrosis, bronchiectasis, chronic bronchitis, pulmonary infection and spinal cord injury

• TB
• Increased ICP
• MI = heart attack
• Unstable head, neck or spine
• Flail chest or osteporosis

• Reduced cerebral perfusion
• Reduced coronary artery perfusion
• Rib fracture
• Headache
• Bronchospasm
• Vomitting
• Chest pain
• Central line displacement

• Modification of the directed cough also called, Huff Cough
• Consists of one or two forced expirations of middle to low lung volumes w/o closure of the glottis

• Another modifcation of the directed cough designed to be performed independtly by trained PTs
• PT uses diaphragmatic breathing to mobilize secretions and achieve a mucus "rattle" in sitting position

• Synchronizes with PTs breathing cycle
• MIE devices apply to positive pressure of 30-50cm of H2O to the airway for 1-3 seconds
• The device then abruptly reverses the airway pressure to -30 - -50 cm H2O

• PTs with neuromuscular disorders
• Adults only

• Used to mobilize secretions and treat atelectasis
• Used in combination w/ other airway clearance techniques

• Involves active expiration against a variable flow resistance
• PEP helps move secretions into larger airways by improving ventilation of underaerated segments and by preventing airway collapse during expiration

• Rapid vibratory movement of small volumes of air back and fourth in the respiratory tract
• Airway application: Flutter valve or acapella

• The vest
• Typically a 30 min session at frequencies between 5-25Hz

• Immobility is a major factor contributing to retention of secretions
• Earlu mobilization and exercise are standard care for surgical PTs
• Exercise improves overall gas exchange and lung function

• PTs motivation
• PTs goals
• Physician/caregiver goals
• Effectiveness of technique
• PTs age
• PTs ability to concentrate
• Ease of learning and teaching
• Skill of therapists/teachers
• Fatigue or work required
• Need for assisstants or equipment
• Limitations of technique based on disease type and severity
• Costs, direct and indrect
• Desirability of combing methods

Chest radiograph demonstrating atelectasis and infiltrates