Bronchial Hygiene

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    Bronchial Hygiene Techniques

    By Jim Clarke

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    What is Bronchial Hygiene

    Therapy (BHT)? It consists of a variety of non-invasive

    techniques designed to improve gas

    exchange by helping to mobilize andremove secretions

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    When to use Bronchial Hygiene

    Therapy? (BHT) During episodes in which there is an acute

    secretion clearance problem. Examples;

    Severe pneumonia with copious secretions Respiratory failure with inability to clear retained


    Acute lobar atelectasis (documented) Evidence of significant infiltrates and/or

    consolidation with hypoxemia present

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    Acute conditions in Which BHT is

    NOT Helpful Acute exacerbations of COPD

    Many patients cannot tolerate these procedures

    even if secretion clearance problems exist!

    Pneumonia without evidence of significant

    sputum production

    Not all pneumonias produce secretions!!

    Uncomplicated asthma

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    BHT for Chronic Conditions

    Used to prevent complications in the out-

    patient population and to treat acute

    problems seen in; Cystic Fibrosis


    Sometimes used in Chronic Bronchitiswhen large volumes of secretions become


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    Brief Look at CF & Bronchiectasis

    Cystic Fibrosis: characterized by increased

    sputum viscosity (thick mucus), increased mucus

    volume and impaired clearance Typically seen in children & young adults only

    Bronchiectasis: characterized by muco-stasis,

    retained secretions, loss of mucociliary escalator

    & repeated pneumonias

    Generally seen only in adults with a history of

    persistent & repeated lung infections

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    When Do Patients Need BHT ?

    (Are the following present?) Patient has a Dx of Bronchiectasis or

    Cystic Fibrosis? (Read the Hx & PE)

    They have evidence of copious secretions

    (>25-30 ml/day) with clearance problems?

    Do a cough evaluation

    Listen to breath sounds

    Check for evidence of tactile fremitus

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    Other Issues to Check When

    Evaluating Need for BHT Review Chest X-ray findings in chart OR

    view CXRs directly

    Very important in identifying Lobar pneumonias

    Assess oxygenation status by reviewing

    recent ABGs and/or SpO2 findings

    Check in chart for evidence of a sputumanalysis Culture & sensitivity findings

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    Causes of Mucociliary Impairment

    Presence of endotracheal or tracheostomy


    History of having to suction patients


    Poor humidification

    High FIO2s Drugs: General anesthetics; opiates;


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    Some Commonly Used Types of

    Bronchial Hygiene Therapies Postural Drainage with percussion and/or

    vibration (PD&P) (PDVP)

    High Frequency Compression/Oscillation Therapy

    Flutter Valve

    IntraPulmonary Percussive Ventilation

    ThAIRapy Vest - Thoracic Wall Vibration

    Positive Airway Pressure Techniques

    Positive Expiratory Pressure Therapy (PEP)

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    Other Less Commonly Used BHTs

    Coughing and related expulsion techniques

    Directed Coughing

    Huff coughing

    Quad cough

    Autogenic Drainage

    Mobilization and exercise techniques

    Frequent turning of patients

    Ambulation and exercise as tolerated

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    Postural Drainage Therapy

    Process of positioning patients to best

    utilize gravitational effects in the

    enhancement of secretion removal Turn &/or position the patient so that mucus

    drains out of the effected lung zone(s)

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    Review of Lung Segments

    Left Lung Right Lung

    Upper Lobe Upper Lobe

    Anterior; Posterior; ApicalLingular Anterior; Posterior;Apical Middle LobeLateral; Medial

    Lower Lobe Lower Lobe

    Superior; Lateral basal;

    Anterior basal; Posterior


    Superior; Lateral basal;

    Anterior basal; Posterior


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    Using Drainage Positions

    Use drainage position most appropriate to

    the lung segments involved

    Lower lobe positions are most typical

    Average drainage time 3-5 minutes/position

    Modify positions as needed

    Some patients may not tolerate Trendelenberg

    Many patients cannot assume prone position

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    Superior Segments Upper Lobes

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    Posterior Segments - Lower Lobes

    Refer to #2

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    Lateral Segments - Lower Lobes

    Refer to #9

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    Anterior Segments - Lower Lobes

    Refer to #8

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    Lingular Segments - L Upper Lobe

    Refer to #s 4 & 5

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    Right Middle LobeRefer to #s 4 & 5

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    Posterior Segments - Lower Lobes

    Refer to #6

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    Anterior Segments - Upper Lobes

    Refer to #3

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    Anterior & Apical Segments -

    Upper Lobes Refer to #s 1 & 2

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    Contraindications to Use of

    Trendelenberg Position Recent tube feeding or at high risk for

    aspiration of gastric contents

    Increased ICP in a recent intracranial injury

    Uncontrolled hypertension

    Severely distended abdomen

    Gross (bright red) hemoptysis

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    Contraindications to Percussion or

    Vibration of the Chest Wall Burns or recent skin grafts to chest

    Bleeding abnormalities


    Subcutaneous emphysema

    Suspected or active TB

    Recent insertion of pacemaker

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    Hazards of PD&P Techniques

    Worsening S.O.B.

    Pain or injury to chest wall or spine


    Nausea & Vomiting

    Tachycardia; Hypotension; Arrthymias

    Bronchospasm (not likely but possible in

    patients with Hx of asthma)

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    Assessment of Outcome

    Have the underlying issues that necessitated

    the use of PD&P improved?

    Less sputum production

    Improvement of breath sounds

    Improvement in oxygenation

    Improvement in CXR

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    P.E.P. Therapy Device

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    When to Use PEP Therapy

    Mostly used in treatment of Cystic Fibrosis

    & Bronchiectasis

    Utilizes a expiratory resister designed tocreate positive pressure during exhalation

    and lengthen the expiratory phase

    Aerosol therapy can be done inline &simultaneous with PEP treatments

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    Key Elements in Patient Instruction

    in Use of PEP Therapy Patients need to take a breath that is slightly

    larger than normal

    Expiratory pressure should be set between10 - 20 cmH2O in order to create an I:E

    ratio of 1:3 to 1:4

    Have patient perform 10 to 20 breaths andthen do 3 coughs

    Perform PEP for no more than 20 minutes

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    Additional Issues in PEP Therapy

    May reduce air trapping in COPD - asthma

    Is like pursed lipped breathing

    May prevent or reverse atelectasis

    May improve aerosol medication delivery

    Hazards of PEP therapy are similar to IPPB

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    High Frequency Chest Wall

    Vibration - ThAIRapy Vest

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    Flutter Valve

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    IntraPulmonary Percussive

    Ventilation Video Available

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    Autogenic Drainage

    A breathing technique designed to milk orsqueeze air out of the lungs

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    Steps in Autogenic Drainage

    Composed of 3 breathing phases

    Phase 1: Patient breathes in normally but exhales

    each breath close to RV (5-9 cycles) Phase 2: Breathes in slightly above normal Vt

    but exhales normally (5-9 cycles)

    Phase 3: Breathes in close to VC but exhales

    normally (5-9 cycles)

    All 3 Phases are repeated as necessary

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