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Irritation Phase

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Stimulus may be inflammatory, mechanical, chemical or thermal, afferent impulse sent to the brains medullary cough center.

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Deep inspiration Phase

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Inspiration usually 1 to 2 liters in adults

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Compression Phase

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Glottis closes and expiratory muscles contract, pleural pressure rises in excess of 100mmHg

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Expulsion Phase

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Opening of glottis, high expiratory flows, velocities as high as 500 mph.

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Irritation Impairment

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- Anesthesia - CNS depression - Narcotics

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Inspiration Impairment

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-Pain - Neuromuscular dysfunction - Pulmonary restriction or abdominal restriction

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Compression Impairment

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- Laryngeal nerve damage - Artificial Airway - Abdominal muscle weakness - Abdominal surgery

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Expulsion Impairment

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-Airway compression / collapse -Airway obstruction -Abdominal muscle weakness - Inadequate lung recoil

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Mechanisms Impairing Mucociliary Clearance in Intubates Patients (6)

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- Endotracheal or tracheostomy tube - Tracheobronchial suction - Inadequate humidification - High FiO2s - Drugs (General Anesthetics, Opiates, Narcotics - Underlying Pulmonary Disease

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Problem with Artificial Airways (5)

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Presence of tube increases secretions - Cuff on ET tube mechanically blocks mucociliary escalator - Movement of cuff and tip can cause tissue damage and impair mucociliary movement. - Repeated suctioning can also cause tissue damage - Tube can impair compression phase of cough

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Internal or External compression of airway (Diseases associated with abnormal clearance)

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foreign objects, tumors, congenital or acquired thoracic abnormalities (kyphoscoliosis)

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Internal obstruction can with mucus hypersecretion, inflamm. changes and bronchospasms. (diseases associated w/ abnormal clearance)

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Asthma, Chronic Bronchitis, acute infections

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Alteration of normal mucociliary clearance (diseases assoc. w. abnormal clearance)

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Cystic Fibrosis Ciliary dyskinetic syndrome (impaired cilia) Bronchiectasis

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Conditions which effect the cough reflex (diseases assoc. w/ abnormal clearance)

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Muscular dystrophy Amy otropic lateral sclerosis spinal muscular atrophy Myasthenia gravis poliomyelitis (inflamm. of brainstem and spinal cord)

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Indications

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-Acutely ill patients with copious secretions -Acute Resp. failure w/signs of retained secretions -Acute lobar atelectasis -Hypoxemia due to lung infiltrates or consolidation

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Acute Conditions where Bronchial Hygiene is probably not indicated

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- Acute exacerbation of COPD - Pneumonia w/o clinically significant sputum production - Uncomplicated asthma

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Bronchial Hygiene for Chronic Conditions

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- Chronic conditions w/excessive sputum 1. Cystic Fibrosis 2. Bronchiectasis 3. Chronic bronchitis - 25 to 30 ml of sputum production a day (full shot glass)

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Assessment of Need for BHT (Review Medical Record)

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- History of pulmonary problem causing increased sercetions. - Admission of upper thoracic surgery - Presence of artificial tracheal airway - CXR indicating atelectasis of infiltrates - PFT results - ABG values

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Assessment of NEED of BHT (Patient)

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- Effectiveness of cough - Sputum production - Breathing pattern - Breath sounds - PFT results - Vital signs - Subjective response - Sensorium - General physical fitness

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Chest Physical Therapy (CPT)

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is designed to improve mobilization of retained secretions. improve V/Q matching and normalize (FRC)

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CPT includes

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Turning Postural drainage Percussion Vibration

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Turning

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rotation or movement of body to promote lung expansion and improve arterial oxygenation

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Postural Drainage (PD)

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the drainage of sections by the effect of gravity from small airways to large airways. - moves secretions from distal lung lobes or segments into central airways, removed by coughing or suctioning. - positions held for 3-15 mins. - hydration greater success - vent. pts. receive q 4-6 hrs.

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Percussion

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rhythmic striking of the thorax with a cupped hand or mechanical device to loosen retained secretions

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Vibration

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rapid tremorous movement during expiration to facilitate the movement of secretions

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Purposes for turning (5)

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- Promote lung expansion - Improve oxygenation - Prevent retention of secretions - Prevent venostasis ( clot formation) - Prevent skin ulcers

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Contraindications for Turning

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- Unstable spinal cord injuries - Traction of arm abductors - serve diarrhea - marked agitation - a rise in ICP - a large drop in BP, greater that 10 % - worsening dyspnea, hypoxia, and cardiac arrhythmias

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Plumbing Problems

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- Ventilator disconnection - Accidental extubation - Accidental aspiration of ventilator circuit - Disconnection of lines

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Proning

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- used for patients with ARDS - improve oxygenation with negative effects on hemodynamics ( lower Fio2 and pressure ventilation) - Possible mechanism of benefit - improved ventilation dorsal lung regions - improved blood flow away from shunt regions - decrease lung injury associated w/ + pressure ventilation

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indications for PD, Percussion, and Vibration

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- inability to mobilize retained secretions - atelectasis caused by mucus plugging - diagnose w/ cystic fibrosis, bronchiectasis or cavitating lung dx. - Presence of foreign body in airway

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Triple S Rule

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- Stop therapy - Stay with the patient - Stabilize

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Assessment of Need

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- Excessive sputum production - Effectiveness of cough - Hx of pulmonary diseases - Diminshed bs or crackles - Change in vital signs - Abnormal chest x-ray - Deterioration in ABG's or O2 sat.

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Complications

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- Hypoxemia ( admin. higher fio2) - Increased ICP - Acute hypotension - Pulmonary hemorrhage - Pain or injury to muscles, ribs, or spine - Vomiting and aspiration - Bronchospasm - Arrhythmias

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Monitoring of therapy

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- subjective response (pain, discomfort, dyspnea, response to therapy) - Pulse rate - Breathing pattern and rate - Sputum production - mental function - skin color - breath sounds - BP - O2 sat. - ICP

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Contraindications to positioning

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- ICP pressure > 20 mmHg - Head and neck injury - Active hemorrhage - Hemodynamic instability - recent spinal injury - Empyema - Bronchopleural fistula - Pulmonary edema assoc. w/ CHF - Aged - Rib fractures - Surgical wounds

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Contraindications in trendelenburg position

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- ICP > 20 mmhg - neurosurgery or eye - uncontrolled HTN - distended abdomen - Esophageal surgery - Gross hemoptysis - aspiration risk

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Contraindications for Percussion and Vibrations

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- Subcutaneous emphysema - Recent epidural - skin graphs on thorax - burns, open wounds or skin infections - recent pacemakers - TB - lung contusion - bronchospasm - osteomyelitis of ribs - Osteoporosis - Chest wall pain - Coagulopathy

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Outcome Assessment

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- increase in sputum production - improvement in breath sounds - restoration of normal vital signs - resolution of abnormal CXR - normalization or ABG's & O2 sat.

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Directed cough

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- used for bronchial hygiene to mobilize secretions - is taught, supervised, and monitored - pep devices to help enhance the cough

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Forced Expiratory technique (FET)

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Huff coughing is an example of directed cough

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Manual assisted cough

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we assist the cough - used w/ neuromuscular conditions unable to generate cough - artificial airways - Deep inspiration by IPPB or manual resuscitator

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Direct cough techniques

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Diaphragmatic breathing Pursed lip Breathing

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Huff Cough

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- Glottis is kept open - mild to low lung volumes are used - pt. makes 1 to 2 forced expirations producing a huffing sound - followed by period of relaxed controlled diaphragmatic breathing.

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Contraindications for Manual assisted cough

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- osteoporosis - flail chest - unconscious pts - pregnant women - gastric distention - abd. aortic aneurysm or hiatal hernia

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indications for direct cough techniques

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- retained secretions - Presence of atelectasis - prophylaxis for postoperative atelectasis - bronchial hygiene - neurological

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Administration of direct cough

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- sitting up / semi to high fowlers - shoulder rotated inward - head and neck slightly flexed - forearms relaxed - inspire deeply and slowly through nose - use diaphragmatic breathing - valsalva maneuver - expiratory phase

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(ACB) active Cycle of Breathing

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- Relaxation & breathing control w/normal Vt - 3-4 thoracic expansions, deep inspire. with relax exhal - 3 normal and then 3 deeper - not for children under 2 or extremely ill pts.

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(AD) Autogenic Drainage

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- modification of direct cough - Phase 1 - full inspiratory capacity maneuver followed by breathing at low lung volumes - Phase 2 - breathing at low to middle lung volumes - Phase 3 - breathing at middle to high lung volumes prior to expulsion phase - mobilize secretions from small to large airways prior to coughing

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MI-E Mechanical insufflation Exsurfflation Definition

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- delivers a + pressure breath of 30 to 50 cmH2O over 1 to 3 sec period. by oral/nasal mask or artificial airway - airway pressure abruptly reversed to -30 to -50cmH20 and maintained for 2-3 seconds. - includes 5 cycles of MI-E followed by normal or assisted breathing. - process repeated 5 or more times until secretions are cleared. - treatment as often as every 10 mins.

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MI-E used for

answer

- neuromuscular disorders alternative to suctioning - severe restrictive dx. - abd. distention - MI-E artificial airways the cuff must be inflated - delivered by mask and time w/expiratory phase

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Monitoring the Patient

answer

- Patient response - Sputum characteristics - Breath sounds - Presence of adverse neurological signs - Presence of adverse cardiac signs - Measurement of pulmonary mechanics when indicated

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Limitations

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- limited value in obtunded, paralyzed or uncooperative patients. - severe COPD - severe restrictive diseases - Pain exacerbated by coughing - Fear of pain - Neurological, muscular or skeletal abnormalities - Systemic dehydration - use of antitussives - Bypassed upper airway - Thick, retained secretions requiring other therapies for mobilization.

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Contradictions

answer

- Presence of elevated ICP or intracranial aneurysm - acute MI - Acute unstable, head, neck, or spine injury - TB or chickenpox

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Hazard Complications

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-reduced coronary artery perfusion - reduced cerebral perfusion leading to alteration in consciousness, syncope, lightheadedness - incontinence -Fatigue - headache - Bronchospasms - Muscular damage or discomfort - Barotrauma: pneumothorax - Cough paroxysms - Chest pain - Rib fractures -incision pain - visual disturbances - central line displacement - Gastroesophageal reflux

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Bronchial hygiene indications

answer

- Mobilize thick secretions - sputum production - better oxygenation

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3 pulmonary conditions that have large volume of secretions. (CBC)

answer

- Cystic Fibrous - Bronchiectasis - Chronic Bronchitis

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Types of Bronchial Hygiene

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- Threshold (NO SVN) - Ezpap (SVN) - Flutter Valve (not in hospitals) - Acapella (SVN) - Aerobika (SVN) - High Frequency Chest wall Compression (HFCC or HFCWC) - Intrapulmonary Percussive Ventilation ( IPV) - MI-E

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Types of Positive Airway Pressure

answer

- Threshold ( expiratory pressure only) - Ezpap ( inspiratory & expiratory) - Flutter valve ( positive pressure w/ vibration) - Acapella (PEP) - Aerobika (PEP) Oscillating

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PEP therapy

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- Positive Expiratory Pressure - During PEP therapy the patient exhales against variable-orifice resistor - used on: CF, COPD, postoperative patients, post-op atelectasis PEP- helps move secretions to larger airways By: 1. Filling underaerated or nonaerated segments via collateral ventilation. 2. Preventing airway collapse during expiration 3. To loosen secretions by vibration

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Basic Applications for PEP

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- Assess need for therapy - Explain the purpose of therapy - Patient should sit comfortably - If mask is used apply tight but comfortable - If mouthpiece is used, place lips tightly around it and breathe through mouth - Exhale actively but not forcefully (pressure b/w 10-20 cmH20) - Perform 10-20 breaths - Remove device and perform 2-3 Huff coughs - Repeat device 4-8 times not to exceed 20 mins. - Teach patient to self-administer

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EZ-PAP

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- Positive Airway pressure on inspiratory and Expiratory - indicated for use as a lung expansion therapy and the treatment and prevention of atelectasis. - EZPAP may be used with nebulizer b/w patient device - Need two flow meters (with SVN) - Flow meter for SVN set @ 7-8 lpm - Flow meter for EZPAP set @ 5 lpm and increase

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Instructing EZ-PAP

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- instruct pt to relax while performing diaphragmatic breathing. - set flow rate to 5 lpm on air or oxygen - place mouthpiece in pt's mouth and instruct them to breathe easily against the pressure from the device. - Apply mask tightly if using mask - While monitoring airway pressure, slowly adjust flow meter until desired expiratory airway pressure is reached. - slow inhalations and exhalations by pt will maintain the airway pressure during breathing cycle - The greater the expiratory flow the higher the airway pressure. - The greater the inspiratory flow the lower the airway pressure

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Flutter Valve

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- Combination of expiratory vibrations along with PEP - Device consists of a pie-shaped device with a heavy steel ball sitting in an angled "bowl" - Pipe covered with a perforated cap - During exhalation the ball creates a PEPE of 10-25 cmH2O and the ball flutters or vibrates at 15 Hz. - Hortizontal position its 15 Hz - Changes b/w 6 to 20 as angle changes - Patients can control the pressure by changinh their expiratory flows - Patients can alter the oscillations by changing the angle of the device. - increases by going up decrease by going down.

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Instructing the Flutter Valve

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- Sit up with head titled upward - Close lips around stem of flutter valve - Experiment with tilting flutter upward and downward while the patient exhales. - Use the angle with strongest vibration - Inhale slowly and hold your breath (2-3 seconds) - Breathe out a little more than normal exhalation - The patient should feel vibrations in airway - Urge to cough - 5-10 breathes - above steps are for mucus loosening phase - Chough phase - Breathe in slowly to maximum breathe - Breathe hold 2-3 secs. - Breathe out forcefully and cough - Goal based rather then time based

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Acapella

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- use for PEP therapy - use with nebulizer

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Instructing the Acapella

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- to relax whike performing diaphramgtic bething and inspiring a volume of air larger than normal tidal volume - instruct them to exhale to functional residual capacity FRC actively, but not forcefully. through device, - Adjust the dial to increase the ressisstance - start @ 1

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Acapella Procedure

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- the patient should be able to exhale 3-4 secs. while the device vibrates. - Clockwise adjustment increases the resistance of the vibrating which allows the pt. to exhale at a lower flow rate. - Counter-clockwise adjustment decreases the resistance.

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Aerobika

answer

- Oscillating Positive Expiratory Pressure Therapy - OPEP - uses PEP - can be used with SVN - used with patients capable of generating exhalation of 10 lpm or 3-4 secs.

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instructing the Aerobika

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- Start with resistance at the lowest setting - inhale through the device taking a deeper breath that normal. - Exhale briskly but not to forcefully through the device. - therapy lasts 10-20 mins.

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Aerobika contraindications/ precautions

answer

- Non patient tolerance - ICP > 20 mmhg - Hemodynamic instability - Facial, oral or skull surgery or trauma - Acute sinusitis - Epistaxis - Esophageal -Nausea - Hemoptysis - Untreated Pneumothorax - tympanic membrane rupture

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High Frequency Compression / oscillation

answer

- Oscillation refers to rapid vibratory movement of small volumes of air back and forth in the respiratory tract - frequencies are 12-25 Hz - 1 Hz equals 60 breaths or cycles - Oscillations or vibrations act as a physical mucokinetic force - HFCWC -IPV

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HFCWO

answer

- two main components 1, variable air-pulse generator 2, non-stretch inflatable vest - small gas volumes are injected into and from the vest at a rapid rate producing a vibratory effect - Therapy session generally last for 30 mins. at a frequency of 1 to 6 times per day -

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Hayek Oscillator

answer

- now in US - uses a chest shield (turtle shell, strapped to anterior chest wall) - Connected to negative / positive generator ( provides oscillations up to 15 Hz)

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Intrapulmonary Percussive Ventilation

answer

- device creates vibration internally in the patient airways. - similar to IPPV - pneumatic device delivers a series of gas mini-burst at a rate of 1.6 - 3.75 Hz per minute. - 100 to 300 bpm - vibrations are delivered to the respiratory tract via a mouthpiece or mask. - circuit that includes a nebulizer allows for the delivery of aerosolized medications - duration of percussive to manually control by patient or therapist - during the percussive cycle positive airway pressure is maintained - 20 mins treatment time - no side effects - can be used with artificial airways

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PAtient who may benefit from IPV

answer

- acute and chronic pulmonary diseases - COPD - restrictive or neurologically induced pulmonary disorders - trauma burns post-op complications sepsis - pts that receive PEP, CPT, Oscillatory PEP, or external vibratory therapies - can be uses on all patients including infants, pediatrics, and adults.

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