RCP Exam 3 Part 3

Bronchial Hygiene Therapy methods

hyperinflation therapy, positive airway pressure adjuncts, and chest wall manipulation.

Therapies used in addition to bronchial hygiene therapy

Cough techniques, mobilization, and exercise.

Basis for choosing a therapy combination

Assessment of the patient.

Hyperinflation Therapy Goal

Hyperinflation / lung expansion

Ways to hyper expand

Patient produces negative pressure, draws in larger volume to recruit atelectatic/consolidated areas

Inhalation Hyperinflation Devices

Incentive spirometer and positive pressure adjuncts

Exhalation Hyperinflation Method

PEP (Positive Expiratory Pressure)

Hyperinflation Therapy Sequence

Try inhalation first and if that doesn't work then try exhalation

Incentive Spirometry (SMI)

Sustained maximal inspiration

Incentive Spirometry Indication

Predisposed to/presence of atelectasis, Upper-abdominal surgery, thoracic surgery, COPD + surgery

Incentive Spirometry Indication cont'd

Presence of restrictive lung defect w/ quadriplegia/dysfunctional diaphragm

Incentive Spirometry Absolute Contraindication

Pt cannot be supervised or instructed, Inability of pt to use device properly

Incentive Spirometry Contraindication cont'd

Vital Capacity < 10mL/kg, Inspiratory Capacity < 1/3 of predicted

Incentive Spirometry Effort

Relies on voluntary patient effort to perform a hyperinflation maneuver.

Incentive Spirometry & FRC

Prevents atelectasis by manipulating FRC (air left in lung after passive expiration).

Incentive Spirometry Benefit

Cough promotion.

Incentive Spirometry Methods

Flow dependent, volume displacement, and photoelectric measurement.

IS Goal Chart Factors

Takes into account sex, height, and age (weight is not a factor).

IS Goal Chart Initial Attempt

Healthy patients may be able to reach goal on initial try.

IS Goal Chart Patient Progression

Many patients we see will need to work toward this goal.

IS Goal Chart gas source and function

No gas source and it mobilizes mucus towards the airway.

Flow-Dependent IS Mechanics

Applies sub-ambient pressure above a piston or ball and converts flow registered to volume reading.

Flow-Dependent IS Example

Voldyne (Hudson RCI)

Flow-Dependent IS Features

Marker on side shows set goal for pt, disposable, and most common option you will see at bedside.

Volume-Displacement IS Mechanism

Volume is measured by how much gas is moved out of the bellow into the patient's lungs (bellow moves up as the patient inspires).

Volume-Displacement IS Example

Starting volume in the bellow of 4000ml, patient breathes in a tidal volume of 1.5L, remaining volume of 2.5L, 1.5L was displaced from the total 4L volume.

Volurex (DHD Medical) Operation

Operates using true volume displacement and uses a flexible bellows that moves as the patient inspires.

Volurex (DHD Medical) Requirements

Big in size and needs to have the full volume available to be displaced.

Photoelectric Measurement Principle

The faster the turbine spins the more volume being produced by the patient

Photoelectric Measurement Example

Body Plethysmograph

Intermittent Positive Pressure Breathing (IPPB) Therapy

Machine driven incentive spirometer that pushes breath in (we provide flow) instead of relying on patient breath alone.

IPPB Therapy Mechanism

Uses positive pressure to push air into the alveoli and open them up.

IPPB Therapy Status

Predecessor to PEP therapy & mechanical ventilation; not used in bedside practice anymore.

Positive Expiratory Pressure (PEP) Mechanism

Utilizes back pressure generated by the patient's expiratory flow to recruit alveoli and stent open airways.

PEP Clinical Application

Often added when Incentive Spirometry (IS) alone does not work.

PEP Indications

Reduce air trapping (asthma, COPD), mobilize secretions (CF, chronic bronchitis), prevent/reverse atelectasis, and optimize bronchodilator delivery.

PEP Contraindications

No absolute contraindications, but consider factors like ICP > 20 mmHg, hemodynamic instability, untreated pneumothorax, and facial/skull surgery.

PEP Resistance and Pressure

Back-pressure is manipulated by changing flow resistance, in which resistance is inversely related to diameter.

PEP Secretion Mobilization

Fills alveoli via collateral ventilation (back pressure build up behind mucus plugs), prevents airway collapse during exhalation, and moves secretions to larger airways.

Oscillating PEP Therapy Overview

Still considered PEP, but with an added effect.

Oscillating PEP Therapy Mechanism

Oscillations in pressure/flow work to "shake" secretions loose (still need a way to remove them).

Oscillating PEP Therapy Types

3 main types on the market: Flutter valve & Acapella and Aerobika

Is PEP better with a mouthpiece or a mask?

mouthpiece is the better PEP option

Flutter Valve Therapy Design

Single weighted ball valve

Flutter Valve Therapy Setting

Only one setting (10-25 cmH2O of PEP)

Flutter Valve Therapy Operation

Rapidly opens/closes w/ exhalation

Flutter Valve Therapy Pressure Effect

Creates positive pressure in airways & oscillating pressure waves

Flutter Valve Therapy Protocol

10-20x then encourage vigorous cough

Flutter Valve Therapy Reminder

Shaking the secretions loose is only step one they still have to get them out

Acapella Device Mechanism

Controlled by an adjustable knob where the proximity of the magnet to the lever adjusts resistance, frequency, and amplitude.

Acapella Magnet Resistance

Closer the magnets = harder to break apart = higher resistance.

Acapella Protocol & Reminder

Perform 10-20x then encourage vigorous cough. Remember that shaking the secretions loose is only step one.

Inspiratory Muscle Training Device

Strengthens inspiratory muscles by providing variable gas flow resistance.

Inspiratory Muscle Training Device Orifice Size and Resistance

Decreasing orifice size increases resistance to gas flow.

Nose Clips in IMT

Used to discourage cheating during training.

IMT relation to PEP Devices

Not PEP devices, but share the principle of manipulating diameter.

IMT Mechanism of Flow Resistance

Varies the size of the orifice to change resistance.

Chest Percussive Therapy

Application of mechanical energy to the chest wall over a lobe or segment attempting to be drained.

Chest Percussive Therapy usually done with

Usually done in conjunction with postural drainage.

Chest Percussive Therapy Methods

Can be done via hands or electric/pneumatic device.

Goal of Chest Percussive Therapy

To jostle loose the secretions so that they can travel up the tracheobronchial tree.

Manual CPT Technique

Cupped hands trap air between hand & chest wall.

Manual CPT DIY Equipment

Can create your own using a soft seal mask and some tape.

Manual CPT can be performed on

May perform on skin or through hospital gown/bedsheet.

Manual CPT Parameters and Precautions

3-5 taps minutes per segment. Avoid tender areas and bony prominences.

Mechanical Percussors (other cpt option)

Electrically or pneumatically powered; take the place of your arm creating driving energy and reducing practitioner fatigue.

Decline of Mechanical Percussors

Not seen as commonly anymore with the introduction of The Vest.

Vibrational Beds

Some ICUs have beds offering percussion therapy; becoming more common as an option for patients that cant be moved to place the vest on.

Limitation of Vibrational Beds

Limited ability to target lobes.

Postural Drainage Therapy Definition

Use of gravity to mobilize secretions from distal to central airways. (often in conjunction with percussive vibration)

Goal of Postural Drainage

Move secretions to central airways so they can be coughed out.

Target Segment Positioning for Postural Drainage

Place the segment to be drained in a vertical position above the carina.

Hydration Importance

Patient must be adequately hydrated to prevent thick, retained secretions.

PDT Therapy Frequency

Every 4 to 6 hours as indicated, typically following CPT.

Scheduling Considerations for PDT

Schedule treatments around meals and tube feedings.

Absolute Contraindications for PDT

Unstable spinal cord & Traction

Relative Contraindications for PDT

Diarrhea, Agitation, ICPs, Hypotension, Dyspnea, Hypoxia, Cardiac arrhythmias or Stabilization of ETT, vent circuit, IV, etc.

Turning Bed-Bound Patients

Prevents bed sores, reduces venostasis, promotes lung expansion, improves oxygenation, and prevents retained secretions.

Prone Placement Definition

Face down positioning typically seen in patients with acute lung injury.

Prone Placement increases

Increases transpulmonary pressure to combat atelectasis and increases V/Q by shifting blood flow.

Rotoprone Bed Purpose

Helps with oxygenation.

High Frequency Chest Wall Oscillation (HFCWO) Therapy Definition

Application of external chest wall compression using a self-inflating/deflating pneumatic vest.

Components of HFCWO Therapy

Air-pulse generator, Two hoses, A vest that the patient applies.