Egans Chapter 44: Airway Clearance Therapy

During the initial treatment, a PEP device is set to deliver a pressure of 15 cmH2O. The patient complains of dyspnea and can maintain exhalation only for a short period of time. Which of the following should the RT recommend?

A. add a bronchodilator to the PEP therapy

B. discontinue the PEP therapy

C. decrease the PEP level to 10

D. increase the PEP level to 20

C. decrease the PEP level to 10

A patient is lying on her left side, turned one-quarter toward her back, with the head of the bed down. What division of the lung is being drained?

A. Posterior segments of the right upper lobe

B. Right middle lobe

C. Left upper lobe, lingular segments

D. Right upper lobe

B. Right middle lobe

In explaining the therapeutic goal of PEP therapy to a patient, it would be most appropriate to say:

A. This will prevent atelectasis

B. This will help prevent pneumonia

C. This will help you cough more effectively

D. This will increase your intrathoracic pressure

C. This will help you cough more effectively

A COPD patient with left lower lobe infiltrates is unable to tolerate a head-down position for postural drainage. What action would you recommend?

A. Administer a bronchodilator prior to the postural drainage

B. Notify the physician and suggest a different secretion management technique

C. Do not perform the therapy until 2 hours after the last meal

D. Perform the drainage with the head of the bed raised

B. Notify the physician and suggest a different secretion management technique

Active patient participation is an important part of which of the following procedures?

I. Postural drainage

II. Directed cough technique

III. Airway suctioning

IV. Positive expiratory pressure

II & IV

An RT is preparing a patient with bronchiectasis for discharge. Which of the following techniques would be most appropriate for self-administered therapy in the home?

A. IPPB

B. Flutter or PEP device

C. Percussion and postural drainage

D. Suctioning

B. Flutter or PEP device

List the four phases of the cough reflex in correct order:

irritation, inspiration, compression, expulsion

Identify example(s) of impairment of the compression phase for the cough reflex:

I. Laryngeal nerve damage

II. Anesthesia

III. Abdominal surgery

IV. CNS depression

I & III

Identify example(s) of acute conditions that may indicate need for airway clearance therapy:

I. Ineffective cough

II. Inability to mobilize secretions

III. Cystic fibrosis

IV. Ciliary dyskinetic syndrome

I & II

What is the final phase during autogenic drainage?

A. inspiration and cough

B. evacuation

C. normal breathing

D. IC maneuver

B. evacuation

What is needed to produce an effective cough?

You need to take in a deep breath and have the glottis close briefly to allow an increase in the intrathoracic pressure. This will be followed by the expulsive glottic opening that is partnered with an abdominal contraction. This will all result in the air being forcefully expelled out of the airway.

In 4-6 sentences, explain what is occurring during mechanical insufflation-exsufflation devices.

When mechanical insufflation-exsufflation devices are being used it will startwith a deep inspiration, insufflation, this is meant to "fill" the lungs. This will befollowed by a deep expiration (exsufflation), this is when the lungs are "emptied",this is done by applying sequentially positive and negative pressure swingsprovided by a full-face mask or catheter mount that is attached to the artificialairway. The point of the rapid switch from positive to negative pressure is tostimulate the airflow changes, this is what happens a normal cough occurs, and itcan potentially assist in secretion clearance.

What happens when you lose the ability to close the glottis and/or vocal cords?

A. What are 2 diseases that commonly effect this ability?

When you lose the ability to close the glottis and/or vocal cords you also lose the ability to cough and swallow.

A. What are 2 diseases that commonly effect this ability?

1. Amyotrophic lateral sclerosis (ALS)

2. Spinal muscle atrophy (SMA) type 1

In 4-6 sentences, explain what is occurring during a manually-assisted cough.

A manually-assisted cough is a combination of manual Heimlich/abdominal thrust maneuver and manual costo-phrenic compression. The point of this combination is to increase the expiratory flow. Expiratory assistance can also be achieved byself-induced thrust to the abdomen, or chest, from a stationary object. This compression will cause an increase in the abdominal pressure causing the contents to push the diaphragm upwards to increase the expiratory airflow.

In 4-6 sentences, explain what is occurring during high frequency chest wall oscillations.

High frequency chest wall oscillations are when compression are provided on thechest wall with frequencies with similar resonant frequency of the lungs, this isdone by a negative pressure ventilation that is attached to a cuirass. Theventilator that is being used will deliver a negative pressure through the air. Thatair is sucked into the lungs, when this negative pressure ceases and is let goduring expiration the device will deliver a high frequency intermittent negativepressure. The high frequency intermittent negative pressure is delivered on thepatient's spontaneous or NIV supported breathing, this will also produce atransient/oscillatory increase in airflow in the airways that will vibrate thesecretions from the peripheral airways and towards the mouth.

Physiology of ACT: abnormal clearance

- Any abnormality that alters:

1. Airway patency

2. Mucociliary function

3. Strength of breathing muscles

4. Thickness of secretions

5. Cough reflex

- Retention of secretions can result in:

1. Full obstruction, or mucous plugging, can result in atelectasis, which causes hypoxemia due to shunting

2. Partial obstruction restricts airflow, increasing work of breathing and possibly leading to air trapping, lung overdistention, and "v" ̇/"Q" ̇ imbalances

Physiology of ACT: normal clearance

- Normal airway clearance requires a(an)

1. Patent airway

2. Functional mucocilary escalator (larynx down to respiratory bronchioles)

3. Effective cough

- Effective cough can move mucus from lower airways to upper airway

The cough reflex:

irritation, inspiration, compression, expulsion

cough reflux: irritation

- Inflammatory: mechanical, chemical or thermal stimulus that provokes sensory fibers in the airways --> sends impulse to medulla --> cough center is located in medulla

cough reflex: inspiration

- Deep breath is stimulated (1-2 L)

cough reflex: compression

- Glottic closure combined with forceful contraction of the respiratory muscles

cough reflex: expulsion

- Glottis opens, large pressure gradient between lungs and atmosphere is violently released with high velocity of airflow

- Shear stress pulls mucus or sputum off airway wall to clear it from the airway

diseases associated with abnormal clearance

-Internal or external compression of airway lumen

-cystic fibrosis

-bronchiectasis

-neuromuscular diseases (ALS, myasthenia gravis)

Postural drainage positions

Upper lobes: back at 45 degrees, towel under knees

posterior apical segment: sitting up, back curved, pillow under knees

anterior segments: laying flat, pillow under knees

right posterior segment: laying on stomach, pillow under right side

left posterior segment: back of bed at 45 degrees, laying on stomach, pillow under left side

right middle lobe: laying on back, pillow under right side, feet raised 12 inches

left lingular: laying flat on back, pillow under left side, feet raised 12 inches

anterior segments (lower lobes): laying on bakc, pillow under knees, feet raised 18 inhes

right lateral segment: laying on left side flat, feet raised 18 inches

left lateral: laying on right side, feet raised 18 inches

posterior segments: laying on stomach, pillow under stomach, feet raised 18 inches

superior segments: laying flat, pillow under stomach and ankles

ACT patient assessment

-posture, muscle tone

-effectiveness of cough

-sputum production

-breathing pattern

-general physical fitness

- breath sounds

-vital signs, HR, and rhythm

Mechanical percussion: analysis

1. MIE devices apply positive pressure of 30 to 50 cm H2O to airway for 1 to 3 seconds

2. Device then abruptly reverses airway pressure to −30 to −50 cm H2O for 2 to 3 seconds

- 5 sets of 5, break in between each set

3. Treatment sessions consist of about five cycles of MIE followed by normal spontaneous breathing

4. E.g. Cough assist device (Coughlator)

PEP: assessment

-Positions used

-Time in positions

-Patient tolerance

-Indicators of effectiveness

-Any untoward effects observed

HFCWO two components

variable airpulse genrator

tubing connecting to non-stretch inflatable vest

HFCWO: vest airway clearance systems

•Generator inflates and deflates the vest, creating pressure pulses against the thorax that cause chest wall oscillations and move secretions forward

ACT: exercise and mobilization

Physical activity that results in:

-Increased tidal ventilation

-Increased heart rate

-Increased cardiac output

-Improved physical conditioning

ACT: selection factors

-Patient's motivation

-Patient's goals

-Patient's ability to comprehend—literacy and cognition levels

-Patient's physical limitations

-Physician/caregiver goals

-Effectiveness of technique

-Ease of learning and teaching

-Skill of therapists

-Patient fatigue associated, or work required to use device

-Need for assistance to use the equipment

-Limitations of technique based on disease type and severity

-Costs (direct and indirect)

-Desirability of combining methods

PAP: contraindications

-patient unable to tolerate increased WOB (acute asthma, COPD)

- intracranial pressure greater than 20 mmHg

- hemodynamic instability

-acute sinusitis

-acute hemoptysis

-untreated pneumothorax

-nausea

-esophageal surgery

-expistaxis

- recent facial, oral, or skull surgery or trauma

-known or suspected tympanic membrane rupture or other middle ear pathology

HFCWO: airway application

(Intrapulmonary percussive ventilation)

•A pneumatic device to deliver a rapid series of pressurized gas mini-bursts to the airway at rates of 100 to 225 cycles per minute (1.7 to 5 Hz)

ACT: assessment outcomes

-Change ins sputum production

-change in breath sounds of lung fields being drained

-patient subjective response to therapy

-change in vital signs

-change in chest radiograph

-change in ABG values or O2 saturation

-change in ventilator variables