Define bronchial hygiene therapy?
Bronchial hygiene therapy involves noninvasive airway clearance techniques to help mobilize secretions and improve gas exchange
What combined with exercise, bronchial hygeine therapy can improve functions in?
Cystic fibrosis PTs
What are the 3 things needed for normal airway clearance?
- Patent airway (open airway)
- Functional mucocilliary escalator
- Effective cough - an effective cough can move mucus from the lower airways to the upper airways
What are the 4 phases of a cough?
- 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
What is an abnormal clearance?
- 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.
What are some diseases associated with abnormal clearance?
- Asthma, lung cancer, kyphoscoliosis, chronic bronchitis, acute infections
- Cystic fibrosis
- Neuromuscular diseases can cause a weak cough
What is the primary goal of bronchial hygiene therapy?
- Help mobilize and remove retained secretions
- The ultimate goal is to improve gas exchange and reduce the WOB
What is retention of secretions?
Retained secretions in the lungs/airways
What are the 5 methods of bronchial hygeine therapy?
- 1. Postural drainage therapy
- 2. Coughing and related expulsion techniques
- 3. Positive airway pressure (PAP)
- 4. High-frequency compression/oscillation
- 5. Mobilization and exercise
What is postural drainage therapy?
- Involves the use of gravity and mechanical energy to mobilize secretions
- Turning, postural drainage, percussion and vibration
What are some indications of postural drainage therapy?
- 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
What are some contraindications of postural drainage therapy?
- 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
What are the 2 absolute contraindications?
- Head and neck injury until stabilized - spinal cord injury
- Active hemorrhage with hemodynamic instability - traction of arm abductors
What is the prone position?
What does the prone postion strategically treat PTs with?
Acute lung injury and ARDS
What are the 6 things that should be documented on an outcome assessment?
- 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
What should be on the documentation and follow up?
- Chart should include:
- Positions used
- Time in positions
- PT tolerance
- Indicators of effectiveness
- Any untoward effects observed
Define percussion and vibration?
- 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
Define a directed cough?
- 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
What are some indications of directed cough?
- 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
What are some contraindications of directed cough?
- Increased ICP
- MI = heart attack
- Unstable head, neck or spine
- Flail chest or osteporosis
What are some hazards and complications with directed cough?
- Reduced cerebral perfusion
- Reduced coronary artery perfusion
- Rib fracture
- Chest pain
- Central line displacement
Define FET or Forced Expiratory Technique?
- 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
What is Autogenic Drainage or AD?
- 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
What is MIE or Mechanical Inexsuffilation-exsufflation?
- 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
What kind of PTs is MIE used on?
- PTs with neuromuscular disorders
- Adults only
What is Positive Airway Pressure Adjuncts?
- Used to mobilize secretions and treat atelectasis
- Used in combination w/ other airway clearance techniques
What is PEP? Positive Expiratory Pressure
- 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
What is high frequency compression/oscilliation? 2 different ones
- Rapid vibratory movement of small volumes of air back and fourth in the respiratory tract
- Airway application: Flutter valve or acapella
What is the high frequency chest wall oscillation?
- The vest
- Typically a 30 min session at frequencies between 5-25Hz
Why is mobilization and exercise good for the PT?
- 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
What are some key factors in selecting a brnochial hygiene strategy?
- 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
What is CXR?
Chest radiograph demonstrating atelectasis and infiltrates