RCP Exam 3 (part 4)

The Vest: Indications

Mucous plugging, retained secretions, disease.

The Vest: Contraindications

Unstable thoracic cage injuries, high ICP.

The Vest: Settings

Frequency: 5-25Hz, Amplitude: 1-10, Time: 10-30m.

Airway Clearance Requirements

Patent airway & Functional mucociliary escalator (Respiratory bronchioles to larynx)

Phases of an Effective Cough

4 distinct phases: Irritation, Inspiration, Compression, Expulsion

Cough Phase: Irritation

Abnormal stimulus causes message to be sent to cough center in medulla

Cough Phase: Inspiration

Reflex stimulation causes deep inspiration

Cough Phase: Compression

Forceful expiratory muscle contraction against a closed glottis

Cough Phase: Expulsion

Glottis opens, causing violent expulsion of air from the lungs

Abnormal Airway Clearance

Anything that alters airway patency, mucociliary function, or cough reflex that can cause retention of secretions.

Failure of Cough Reflex Causes

ETT, Trach, Anesthesia, Pain, Nerve damage, Muscle weakness, Poor elastance (COPD).

Inadequate Humidification Effects

Inspissation of secretions, Mucous plugging, Airway obstruction.

High FiO2 Effects

Impair mucociliary clearance and cause acute tracheobronchitis.

Drug Effects on Airways

Depress mucociliary transport.

Bronchial Hygiene

Only moves secretions to central airways (an effective cough is needed to clear them)

Splinting

Using a pillow to help support fresh operative sites and control pain

Directed Cough: Goal

To mimic the features of an effective spontaneous cough & compensate for physical limitations

Directed Cough: Ineligible Patients

Obtunded, Paralyzed, Uncooperative, Severe restrictive disorders

Directed Cough: Breathing Control

Inspire slowly & deeply through nose using diaphragm, bear down against closed glottis, allow 3 expulsions

Directed Cough: Expiratory Muscle Strengthening

If too weak, try inexsufflator

Forced Expiratory Technique (FET)

Modified directed cough (aka "huff cough") w/1 or 2 forced expirations @ middle/low lung volume with open glottis.

FET Requirements & Efficiency

Requires high EFR. More effective than directed cough, especially when used w/ PD.

Active Cycle of Breathing: Positions

May be performed sitting or with postural drainage (PD)

Active Cycle of Breathing: Sequence

Relaxation/breathing control, 3-4 thoracic expansion exercises, relaxation,3-4 thoracic expansion, 1-2 FETs, relaxation

Autogenic Drainage: Position

Sitting position

Autogenic Drainage: Mechanism

Patient mobilizes secretions by varying lung volumes & expiratory flow

Autogenic Drainage: Breathing Technique

10 slow small breaths, 10 medium breaths, 10 large breaths, resisting the urge to cough until completed, followed by huff cough

Mechanical In/Exsufflator (Cough Assist)

Simulates the phases of a natural cough.

Cough Assist positive pressure

Augments tidal volume.

Cough Assist negative pressure

Augments expiratory flow.

Cough Assist indications

Neuromuscular disorders and quadriplegia.

Cough Assist delivery methods

ETT, tracheostomy, and oral-nasal interface.

MI-E Inhalation settings

Positive pressure and time.

MI-E Exhalation settings

Negative pressure and time.

MI-E additional settings

Pause time, oscillation, and flow.

MI-E pressure limits

Capped at -/+ 60 cmH2O.

MI-E max flow

10 L/s.