Bronchial Hygiene Therapy II

RET 2275

Respiratory Therapy Theory Lab 2

Bronchial Hygiene

Coughing and Related Expulsion Techniques

Most bronchial hygiene therapies only help move secretions into the central airways. Actual clearance of these secretions requires either coughing or suctioning.

In this respect, an effective cough (or alternative expulsion measure) is an essential component of ALL bronchial hygiene therapy

Reading AssignmentEgan’s Fundamentals of Respiratory CareNINTH EDITION (pgs. 915-916, 932-941)

Bronchial Hygiene

Coughing and related expulsion techniques Directed cough

A deliberate maneuver that is taught, supervised, and monitored

Aims to mimic the features of an effective spontaneous cough in patients who are too weak to produce a forceful expiratory maneuver

Bronchial Hygiene

Coughing and related expulsion techniques Directed Cough

Not to be used in patients who are obtunded, paralyzed, or uncooperative

Good patient teaching is critical

Proper positioning of the patient is important

The technique may need to be modified in surgical patients, patients with COPD, and patients with neuromuscular disease

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough - Standard Technique

Instruct the patient to assume a sitting position, with shoulders rotated inward, the head and spine slightly flexed, forearms relaxed or supported

If the patient is unable to sit up, raise the head of the bed, knees should be slightly flexed with feet braced on the mattress

Instruct the patient to inspire slowly and deeply through the nose, using the diaphragm

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough - Standard Technique

Instruct the patient to bear down against a closed glottis

Instruct the patient to cough

Stage expiratory effort into two or three shout bursts for patient with pain or bronchiolar collapse

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough – Surgical Patients

Provide preoperative training Minimizes anxiety over pain

Coordinate coughing sessions with prescribed pain medications

Assist the patient to splint the operative site

The forced expiratory technique (FET) may be of value to these patients

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough – COPD Patients

Instruct the patient to assume a sitting position, with shoulders rotated inward, the head and spine slightly flexed, forearms relaxed or supported

Instruct the patient to take in a moderately deep breath through the nose

Results in less pleural pressure and less collapse of the smaller airways

Instruct the patient to exhale with moderate force through pursed lips, while bending forward

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough – COPD Patients

Patient should repeat the previous steps 3 – 4 times

Have the patient bend forward and initiate short staccato-like bursts of air

Technique relieves the strain of a prolonged cough and minimizes airway collapse

An alternative to this technique is called “huffing”

FET or Autogenic Drainage (AD) may also be used in these patients

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough – Neurological Patients

Instruct the patient to take a deep breath Assist as needed with IPPB or resuscitator bag/mask

At the end of inspiration, begin exerting pressure on the lateral costal margin or epigastrium, increasing the force of compression throughout expiration

Pressure to the lateral costal margins is contraindicated in patient with osteroporosis or flail chest

Epigastric pressure is contraindicated in unconscious patient with unprotected airways; in pregnant women; and in patient with acute abdominal pathology, abdominal aortic aneurysm, or hiatal hernia

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough – Forced expiratory technique (FET)

A modification of the directed cough

Also called the “huff cough”

Consists of one or two forced expirations of middle to low lung volumes without closure of the glottis

Goal is to clear secretions with less change in pleural pressure and less bronchial collapse.

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough – Forced expiratory technique (FET)

FET has been shown to increase sputum production, especially when combined with postural drainage

Most useful in patients with COPD, cystic fibrosis, or bronchiectasis

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough – Forced expiratory technique (FET)

Instruct the patient to take in a slow, deep breath, followed by a 1 – 3 second breath hold

Instruct the patient to perform 1 – 2 short, quick forced exhalation of middle to low lung volume with the glottis open

The patient should phonate or “huff” during expiration

Each session of “huffing” should be followed by diaphragmatic breathing and relaxation

Bronchial Hygiene

Coughing and Related Expulsion Techniques Directed Cough – Active Cycle of Breathing (ACB)

Repeated cycles of breathing control, thoracic expansion, and the FET

Breathing control; gentle breathing at normal tidal volumes with relaxation of the upper chest and shoulders – helps prevent bronchospasm

Thoracic expansion; deep inhalation which relaxed exhalation, which may be accompanied by percussion, vibration, or compression – designed to help loosen secretions, improve the distribution of ventilation, and provide the volume needed for FET

Bronchial Hygiene

Coughing and Related Expulsion Techniques Autogenic Drainage (AD)

During AD, the patient uses diaphragmatic breathing to mobilize secretions by varying lung volumes and expiratory airflow in three distinct phases.

Patient should be in the sitting position.

Coughing should be suppressed until all three phases are complete.

Bronchial Hygiene

Autogenic Drainage (AD) Spirogram of lung volumes during three

phases of autogenic drainage.

Phase 1 involves a full inspiratory capacity maneuver, followed by breathing at low lung volumes. This phase is designed to “unstick” peripheral mucus.

Phase 2 involves breathing at low to middle lung volumes in order to collect mucus in the middle airways.

Phase 3 is the evacuation phase, in which mucus is readied for expulsion from the large airways.

Bronchial Hygiene

Hazards of Directed Cough

Bronchial Hygiene

Coughing and Related Expulsion Techniques Mechanical Insufflation-Exsufflation (MIE)

Bronchial Hygiene

Coughing and Related Expulsion Techniques Mechanical Insufflation-Exsufflation (MIE)

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

The device then abruptly reverses the airway pressure to –30 to –50 cm H2O.

Treatment sessions consist of about five cycles of MIE followed by normal spontaneous breathing. This process is repeated five or more times until secretions are

cleared

Bronchial Hygiene

High Frequency Chest Wall Oscillation (HFCWO) Consists of a variable air-pulse generator and a non-stretch

inflatable vest Small gas volumes are alternately injected into and withdrawn

from the vest by the air-pulse generator at a fast rate (5 – 25 Hz) creating a oscillatory motion against the patient’s thorax

Bronchial Hygiene

HFCWO Oscillations at frequencies of 12

– 25 Hz enhance clearance of secretions Acts as a physical “mucolytic”

by altering the physical properties of secretions

Transient increases in airflow produce cough-like shear forces

Therapy sessions are approximately 30 minutes in duration

One to 6 treatments per day

Bronchial Hygiene

HFCWO Common Conditions/Situations for HFCWO

Patient with evidence of retained secretions Independent patient without access to a caregiver Patient with reduced mobility Patient who cannot tolerate Trendelenburg positioning Fragile patient who cannot tolerate the force of CPT Ventilator-dependent patient experiencing frequent

pneumonias

Information obtained from manufacturer’s website

Bronchial Hygiene

HFCWO Most Common Diagnoses Utilizing HFCWO

Cystic Fibrosis Bronchiectasis Cerebral Palsy Spinal Muscular Atrophy Muscular Dystrophy Chronic Obstructive Pulmonary Disease (COPD)

Information obtained from manufacturer’s website

Bronchial Hygiene

Positive Expiratory Pressure (PEP) Active expiration against a variable flow

resistance Helps move secretions into larger

airways Filling underaerated or nonaerated

segments via collateral ventilation Preventing airway collapse during

expiration Subsequent huff or FET maneuver allows

patient to generate the flows needed to expel mucus

Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator

Bronchial Hygiene

PEP Oscillating PEP

Flutter Valve Combines the techniques of

EPAP with high-frequency oscillations at the airway opening

Actively exhaling into the pipe creates a positive expiratory pressure between 10 – 25 cm H2O

Changing the angle of the device alters the oscillations

The device can decrease mucus viscoelasticity within the airways, allowing it to be cleared more easily by cough

Bronchial Hygiene

PEP Oscillating PEP

acapella® Combines the techniques of EPAP with high-

frequency oscillations at the airway opening

Bronchial Hygiene

EZ-PAP Lung expansion therapy during

inspiration and PEP therapy during exhalation

Used for the treatment or prevention of atelectasis and the mobilization of secretions

Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator

EZ-PAP

Clinical Procedure for PAP Requires a physician’s order Explain purpose and procedure of therapy to the patient

Teach directed cough, e.g., “huff” Have the patient sit comfortably If using a mouthpiece

Instruct the patient to place lips firmly around mouthpiece and to breathe through their mouth

If using a mask Ensure a comfortable but tight fit around the nose and mouth

EZ-PAP

Clinical Procedure for PAP Instruct the patient to take a larger than normal breath, but not to

fill the lungs completely Have the patient exhale actively, but not forcefully, creating a

positive pressure of 5 to 20 cm H2O during exhalation (determined with a monometer)

Patient should perform 10 – 20 breaths Remove the mask or mouthpiece and perform 2 – 3 “huff”

coughs; allow rest as needed Repeat above cycle 4 – 8 times, not to exceed 20 minutes

EZ-PAP

Clinical Procedure for PAP If the patient is receiving bronchodilators via aerosol, administer

in conjunction with PAP device Document the procedure in the patients medical record

Device Settings (if applicable) Pressure (if possible) Number of breaths per treatment Patients response to therapy Patient education provided Patient’s ability to self-administer (if applicable)