CVP II unit 3: Interventions for impaired oxygen transport and obstructive pulmonary disease II

what are postural drainage techniques

using specific body positions to enhance mucus mobilization from the bronchopulmonary segments through gravity

what is the main principle of postural drainage

positioning the body so the bronchus of the targeted lung segment is perpendicular to the floor to facilitate mucus movement from peripheral airways to the central bronchi

what is the postural drainage position for the anterior upper segments

semi fowlers position

what is the postural drainage position for the right posterior segment

between L sidelying and prone

what is the postural drainage position for the L lingular drainage

Trendelenburg position (12 inches raised)mrotated to the R

what is the postural drainage position for left lateral segment drainage

R sidelying in Trendelenburg position (18 inches raised)

what is the postural drainage position for posterior apical segment drainage

seated leaned forward with chest over thighs

what is the postural drainage position for left posterior segment drainage

Prone with head of bed elevated to fowlers slightly rotated to the R

what is the postural drainage position for anterior lower lobe segment drainage

Trendelenburg position (18 inches raised)

what is the postural drainage position for posterior segment drainage

prone Trendelenburg (18 inches raised

what is the postural drainage position for anterior segment drainage

supine

what is the postural drainage position for right middle lobe drainage

slight Trendelenburg (12 inches raised) with pillow under R side

what is the postural drainage position for right lateral segment drainage

sidelying on L in trendelenburg (18 inches raised)

what is the postural drainage position for superior segment drainage

prone with pillow under thorax

when is postural drainage indicated

for pts who demonstrate retained secretions that they cannot clear independently

what postural drainage positions are used for more caudal segments affected

the lower the head of the bed needs to be

how long are postural drainage positions held

often 5-10 minutes or until the pt is ready to expectorate

what should the pt do in postural drainage positions

take deep breaths or use airway clearance strategies like active cycle breathing techniques

what is monitored during postural drianage

signs of intolerance or need to cough

vitals

what is a precaution

we can proceed with treatment but use clinical judgement to potentially modify or increase monitoring

what is a relative contraindication

suggests the technique should generally be avoided unless the benefits outweigh the risks and only under strict observation

what are the precautions for postural drainage (5)

pulmonary edema

hemoptysis

massive obesity

large pleural effusion

massive atelectasis

why is pulmonary edema, hemoptysis, and large pleural effusions and atelectasis a precaution for postural drainage

shifting secretions can worsen symptoms or impair gas exchange

why is severe obesity a precaution for postural drainage

it may limit position options or make Trendelenburg intolerable

what are the relative contraindications for postural drainage (7)

increased ICP

unstable hemodynamics

recent esophageal anastomosis

recent spinal fusion or injury

recent head trauma

diaphragmatic hernia

recent eye surgery

why are increased ICP and recent spinal surgery or injury a relative contraindication for postural drainage

they are dangerous in head down positions

why is recent esophageal surgery, eye surgery, or diaphragmatic hernias a relative contraindication for postural drainage

they are at risk of pressure related complications in positions that increase intraabdominal or intrathoracic pressure

why is hemodynamic instability a relative contraindication for postural drainage

the positions have physiologic demands and positional shifts

what are signs of intolerance with postural drainage (7)

dyspnea

nausea

anxiety

dizziness

HTN

vital changes

bronchospasm

what manual techniques are often used with postural drainage techniques

percussion and vibration

what is chest physical therapy

postural drainage techniques combined with vibration and/or percussion

what does percussion with postural drainage do

it generates a rhythmic mechanical energy wave through the chest wall to help dislodge mucus from the bronchial walls allowing it to move proximally

how is percussion performed

using cupped hands with fingers and thumbs adducted and wrists relaxed with the air between the hand and chest wall producing a hollow sound

delivered in a steady rhythm during inspiration and expiration for 2-5 minutes per segment

what areas should be avoided with percussion

bony prominences

incisions

medical devices

how is vibration used with postural drainage

using the full surface of one or both hands over the lung segment with gentle but sustained pressure, and oscillating the chest wall as the pt exhales

what is the goal of vibration

assist in mucocilliary transport and enhance expiratory airflow making the subsequent inspiration more forceful and cough more productive

what pts may benefit from vibration over percussion

those recovering from surgery or with chest wall discomfort

when should percussion and vibration techniques be scheduled

well before or long after meals to minimize risk of aspiration or reflux

what can be administered before vibration or percussion

nebulizer treatments which can help loosen secretions

what are the precautions for percussion and vibration (10)

uncontrolled bronchospasm

osteoporosis

rib fracture

metastatic cancer to ribs

tumor obstruction to airway

anxiety

coagulopathy

convulsive or seizure disorder

recent PM placement

chest tube

what are the relative contraindications to vibration and percussion (8)

hemoptysis

untreated tension pneumothorax

platelet count <50,000

unstable hemodynamic status

open wounds, burns in thoracic area

PE

subcutaneous emphysema

recent skin grafts or flaps in thorax

when is suctioning used for airway clearance

when all other techniques have been tried and failed

what pts are indicated for suctioning

pts with tracheostomies or endotracheal tubes who are unable to clear secretions independently

what is the goal of suctioning

access secretions within the trachea reaching as far as the level of the carina which marks the bifurcation into the mainstem bronchi

what negative effects can occur from suctioning (4)

irritation

bleeding

tracheal stenosis

trauma to tracheal mucosa

what do positive expiratory pressure devices (PEP devices) do

they enhance secretion mobilization and airway patency

what is the goal of PEP devices

to stand open the airways during exhalation by applying a set positive pressure to prevent airway collapse and promote mucus movement to larger airways

what pressure is typically used in PEP devices

10-20 cm of H2O

how is PEP administered

a one way breathing valve with adjustable resistance delivered via mouthpiece or facemask

what occurs as the pt exhales against the resistance in the PEP device

the resulting back pressure helps maintain small airway patency and promotes collateral ventilation building pressure distal to the mucus obstruction

what does a standard PEP session look like

taking a deep breath in and exhaling slowly through the device to maintain constant pressure for 10-20 breaths followed by a huff or cough

what is a low pressure PEP (theraPEP)

a PEP that delivers smooth resistance often including a manometer to ensure the expiratory pressures remain within the desired therapeutic range

what is an oscillatory PEP device

devices that combine expiratory resistance with vibratory forces to further loosed secretions

what are flutter oscillatory PEP devices

a gravity dependent steel ball housed within a cone to generate oscillations between 6-20 hertz held horizontally

what are Acapella oscillatory PEP devices

devices that use magnetically controlled resistance that is gravity independent allowing it to be used in any position

what is the Aerobika oscillatory PEP device

a PEP device that generated higher pressure amplitudes and delivers nebulized meds useful for pts with moderate to severe pulmonary disease

what are the benefits of PEP therapy (4)

increased sputum production compared to other strategies

reduced pulmonary hyperinflation

improves expiratory flow rates

decreased hospitalizations with chronic pulmonary disease

what pts benefit the most from PEP

those who can generate adequate expiratory flow and follow coordinated instructions

what pts shouldn't use PEP therapy

those with profound NM impairments or cognitive impairments

what position should pts be in for PEP therapy

seated upright with back supported and elbows resting to promote diaphragmatic breathing and enhance comfort to reduce accessory muscle use

can also be used in postural drainage positions

what may be used with a mouthpiece PEP device

a nose clip to reduce nasal air escape

how is the appropriate resistance set for PEP devices

have the pt inhale gently then exhale actively but not forcibly

the resistance is set at a level that allows steady prolonged exhalation with a time of 3-4 times longer than inspiration

what can occur if a PEP device resistance is too high

the pt can become short of breath or increase their breathing rate too fast

what can occur if a PEP device resistance is too low

the therapeutic effect is diminished

how are PEP devices used

the pt takes a normal breath using diaphragmatic breathing, pause for 2-3 sec at the top for collateral ventilation, then exhale slowly through the device for 10-20 breaths then performing 2-3 coughs or huffs

typically lasts 15-20 min 1x-2x/day

what is high frequency chest wall oscillation

a mechanical airway clearance method using an inflatable chest attached to an air pulse generator delivering bursts of air between 5-25 Hz

what does high frequency chest wall oscillation do

it created oscillatory forces that transmit through the chest wall, shaking the lungs and mobilizing mucus from peripheral airways toward the central bronchi

reduces mucus viscosity and elasticity

what pts are appropriate for high frequency chest wall oscillation

those with chronic sputum production or impaired ability to generate an effective cough or perform other airway clearance activities

how long is high frequency chest wall oscillation used for

30 min 1-2x/day

what can be combined with high frequency chest wall oscillation

nebulized bronchodilators or mucolytics to enhance mucus clearance

how should the vest for with high frequency chest wall oscillation

it should extend to the top of the thigh when seated and fit snug without restricting breathing when deflated

how is the pressure setting determined for high frequency chest wall oscillation

it should be adjusted to the highest level that remains comfortable

what do lower frequencies in high frequency chest wall oscillation do

enhance lung volume expansion

what do higher frequencies in high frequency chest wall oscillation do

increase expiratory flow and mobilize secretions

how long do high frequency chest wall oscillation frequency phases last

about 10 min but it can be adjusted

what should occur after each frequency block in high frequency chest wall oscillation

a huff or cough to clear secetions

what is inspiratory muscle training

a form of resistance training for the breathing muscles primarily the diaphragm and accessory muscles

what clinical signs show an indication for inspiratory muscle training (IMT) (2)

abnormal breathing patterns

reduced measured inspiratory pressure

how does IMT work

pts breath against resistance which overloads the inspiratory muscles leading to adaptations such as muscle fiber hypertrophy and enhanced oxidative ability/fatigue resistance

what is high pressure low flow resistance IMT

similar to high weight low reps

increases maximal inspiratory pressures or strength

what is lower pressure but high flow IMT

similar to low weight high reps

improves inspiratory endurance and the ability to sustain ventilation

what is required for inspiratory muscle maintenance

2x/wk can preserve most improvements

what does a stronger diaphragm allow

it can generate more pressure for a given effort so the relative effort and oxygen costs of breathing at rest and during activity are reduced

how is a pts inspiratory muscle strength assessed

the maximal inspiratory pressure(MIP)

what is the maximal inspiratory pressure (MIP)

the highest negative pressure in cm of H2O that a person can generate by inhaling as forcefully as possible against an occluded airway

what can measure MIP

a hand held manometer or digital respiratory pressure meter

what is a normal MIP

80-130 cmH2O in men

60-100 cmH2O in women

what MIP indicates weakness

<60 cmH2O

below 70% of expected max for age and sex

what is the procedure of obtaining a pts MIP

the pts exhales fully to empty the lungs then makes a maximal inhalation effort against a blocked mouthpiece for 1-2 sec

what is maximal expiratory pressure (MEP)

a measure of abdominal and intercostal muscle strength obtained by plowing out forcefully from full inspiration

what is a normal MEP value

100-160 cmH2O in men

80-120 cmH2O in women

how is MIP affected by age

MIP decreases by about .5-1 cmH2O per year after the third decade of life

how is MIP predicted

Men: 137-.57 x age

Women: 107 -.4 x age

what may be seen in pts with low MIP (6)

difficulty inhaling effectively

quick drop off in generated pressure after a short effort

accessory muscle overuse

impairments with deep breaths

paradoxical breathing

orthopnea

what are threshold loading devices

a spring loaded one way valve that stays closed until a pt generates a set amount of negative pressure to pop the valve open allowing airflow to begin and resistance remains steady through the breath

what are resistive loading devices

narrowing of the aperture through which the pt must inhale to increase the resistance at higher flow rates

what is a disadvantage of resistive loading devices for IMT

the resistance varies with how fast the pt inhales

what are taper flow devices for IMT

devices used to impose a higher load at the beginning of the breath when inspiratory muscles are at their strongest and then gradually decreasing the resistance as the lungs fill

what intensity should be used at the start of IMT

around 30% of the measured MIP

what intensity and reps should be used for IMT strength

high resistance low reps

50-60% MIP

5-10 breaths