5 - Lung Clearance

deep breathing

• negative force inflates lungs better than mechanical

• key component for effective cough

coughing techniques

• directed cough

• huff cough

• quad cough

• active cycle breathing

• mechanical insufflation-exsufflation

huff coughing

• forced expiratory effort (FET)

• high-to-mid lung volumes through open glottis

• slow, deep breath → 1-3 breath hold → short quick forced exhalations with open glottis

quad coughing

manual assisted coughing

• indicated for neuromuscular disease and quadriplegia

• hand positioned on abdomen

• compress on expiration

mechanical insufflation-exsufflation (MIE)

aka, cough assist

• 4-6 cycles (repeat every 10 minutes)

• positive/negative pressure to lungs

  • positive inspiratory pressure

    • initial: 10-15 cmH₂O

    • work to 15-20 cmH₂O for 1-2 seconds

  • negative expiratory pressure

    • initial: 10-15 cmH₂O

    • work to 35-45 cmH₂O for 1-2 seconds

• contraindications

  • cardiac instability

  • bullous emphysema

  • susceptibility to air leaks

  • recent barotrauma

conventional chest physiotherapy (CPT)

combination of:

• forced exhalation

• postural drainage

• percussion and/or shaking

indication for postural drainage

patients with excessive sputum production that patient has difficulty clearing/expectorating

contraindications for turning patients for postural drainage

• ICP > 20 mmHg

• unstabilized head/neck injury

• recent spinal surgery or acute spinal injury

• active bleeding with hemodynamic instability

• active hemoptysis

• empyema

drainage for CPT

• gravity, distal lung (lobe/segment) to central airway

• 5-10 minutes per area

percussion in CPT

• rapid clapping/cupping, striking to loosen secretions

• contradictions

  • suspected pulmonary TB

  • lung contusion

  • bronchospasm

  • osteomyelitis of ribs

  • osteoporosis

  • coagulopathy

  • complaint of chest wall pain

  • subcutaneous emphysema

  • recent spinal infusion/anesthesia

  • recent skin grafts/flaps on thorax

  • burns, open wounds, or skin infections on thorax

  • recently placed transvenous pacemaker or subcutaneous pacemaker