Bronchial Hygiene Therapy

RET 2275

Respiratory Therapy Theory 2

Bronchial Hygiene

Bronchial hygiene therapy involves noninvasive airway clearance techniques to help mobilize secretions and improve gas exchange

Reading AssignmentEgan’s Fundamentals of Respiratory Care

NINTH EDITION (pgs. 921-932)

Bronchial Hygiene

Normal clearance Normal airway clearance requires a(an)

Patent airway Functional mucocilary escalator Effective cough

An effective cough can effectively move mucus from the lower airways to the upper airway.

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Normal clearance

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Abnormal clearance Abnormalities in airway patency, mucuciliary function,

strength of breathing muscles, or cough reflex can lead to mucus retention.

Mucus plugging can lead to atelectasis, pneumonia, and hypoxemia.

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Diseases associated with abnormal clearance Internal or external compression of an airway lumen

(e.g., asthma, lung cancer)

Cystic fibrosis

Bronchiectasis

Neuromuscular diseases can cause a weak cough.

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General Goals and Indications Bronchial hygiene therapy for acute conditions

1. Acutely ill patient with copious secretions

2. Patient in acute respiratory failure with clinical signs of retained secretions

3. Patient with acute lobar atelectasis

4. Patient with hypoxemia due to lung infiltrates

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General Goals and Indications (cont.) Bronchial hygiene therapy to prevent retention of

secretions May be useful in acutely ill patients when combined with

patient mobilization

Cystic fibrosis patients benefit from chest physical therapy combined with exercise to maintain lung function.

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Determining Need for Bronchial Hygiene Therapy Bedside findings such as

Loose, ineffective cough Labored breathing pattern Coarse inspiratory and expiratory crackles Tachypnea/tachycardia Fever

The chest radiograph demonstrating atelectasis and infiltrates

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Bronchial Hygiene Methods1. Postural drainage therapy

2. Coughing and related expulsion techniques

3. Positive airway pressure (PAP)

4. High-frequency compression/oscillation

5. Mobilization and exercise

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Postural drainage therapy Involves the use of gravity

and mechanical energy to mobilize secretions

Includes turning, postural drainage, and percussion and vibration

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Postural drainage therapy Indications

Inability or reluctance of patient to change position Poor oxygenation associated with position (e.g.,

unilateral lung disease) Potential for or presence of atelectasis Evidence or suggestion of difficulty with secretion

clearance Difficulty clearing secretions, with expectorated

sputum production >25 – 30 ml/day (adult)

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Postural drainage therapy Indications (cont.)

Evidence or suggestion or retained secretions in the presence of an artificial airway

Diagnosis of diseases such a cystic fibrosis, bronchiectasis, or cavitating lung disease

External Manipulation of the Thorax Sputum volume or consistency suggesting a need for

additional manipulation (e.g., percussion and/or vibration to assist movement of secretions by gravity in a patient receiving postural drainage

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Postural drainage Turning

Primarily done to promote lung expansion, improve oxygenation, and prevent retention of mucus

Proning has been used in patients with acute lung injury to improve lung function.

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Postural drainage Turning and “Plumbing Problems”

Ventilator disconnection Accidental extubation Accidental aspiration of ventilator

circuit condensate Disconnection of vascular lines or

urinary catheters – ouch!

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Postural drainage (cont.) The process placing the

patient in various positions to drain specific segmental bronchi

Positions are typically held for 3 to 15 minutes.

Most effective in patient with excessive mucus secretion

Patient positions for Postural Drainage

Postural Drainage

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Postural Drainage Monitoring

Subjective response to pain Pulse, arrhythmia, and ECG if available Breathing pattern and rate Sputum production Mental function Skin color Breath sounds Blood pressure SpO2 ICP

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Postural drainage Outcome assessment

Change in sputum production Change in breath sounds Change in dyspnea level Change in vital signs Change in chest radiograph/ABG results Change in ventilator variables

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Postural drainage Documentation and follow-up

The chart entry should include The positions used Time in positions Patient tolerance Indicators of effectiveness Any untoward effects observed

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Postural drainage Percussion and vibration

The application of mechanical energy to the chest wall by use of the hands or various electrical or pneumatic devices

Designed to aid in movement of mucus toward the central airways

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Postural drainage Vibration

Place one hand on the patient’s chest over the involved area and place the other hand on top of the first

Ask the patient to take a deep breath

Exert slight to moderate pressure on the chest wall and initiate a rapid vibratory motion of the hands throughout expiration

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Postural Drainage Absolute Contraindications

Head and neck injury until stabilized Active hemorrhage with hemodynamic instability

Relative Contraindications Active hemoptysis Pulmonary embolism Recent spinal surgery Aged, confused, or anxious patients who do not tolerate position

changes

Refer to AARC Clinical Practice Guidelines for complete list

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Postural Drainage Trendelenburg position is contraindicated for:

Recent gross hemoptysis ICP >20 mm Hg Uncontrolled hypertension Distended abdomen Patient in whom increased ICP is to be avoided (neurosurgery,

aneurysms, eye surgery) Uncontrolled airway at risk for aspiration (tube feeding or recent

meal) Esophageal surgery

Refer to AARC Clinical Practice Guidelines for complete list

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Postural Drainage Complications/Hazards

Hypoxemia Increase ICP Acute hypotension during procedure Pulmonary hemorrhage Pain or injury to muscles, ribs, or spine Vomiting and aspiration Bronchospasm Arrhythmias