Secretion Management

1
Secretion Management

• Chest Percussion
• And
• Postural Drainage

2
Chest Percussion

• Defn chest percussion refers to a series of
  manipulative techniques designed to assist with
  bronchial hygiene the mobilization of secretions
  from the tracheobronchial tree.

3
Chest Percussion

• Integrated modalities
• Postural drainage
• Vibration
• Cough assistance
• Breathing instruction

4
Chest Percussion

• Goals
• Prophylaxis to prevent retained secretions
• Improve mobilization of secretions
• Improve distribution of ventilation
• Promote more efficient breathing patterns
• Promote effective cough

5
Chest Percussion

• Indications
• Acute conditions
• Acute pulmonary disease with copious secretions
• Acute lobar atelectasis
• Acute conditions of questionable benefits
• Exacerbation of COPD w/scant secretions
• Pneumonia w/o sputum production, e.g., viral
• Status asthmaticus
• Status Post (S/P) coronary artery bypass graft
  surgery (CABG)

6
Chest Percussion

• Indications
• Chronic conditions
• Chronic production of large amounts (30 ml/day)
  of secretions
• Cystic fibrosis
• Bronchiectasis
• Chronic bronchitis
• Lung abcess
• Collection of pus within the lungs as opposed to
  empyema, which is pus in the pleural space.
  Chest tube drainage is required for empyema.

7
Chest Percussion

• Hazards/Complications
• Hypoxemia when affected side is dependent
• Cardiovascular instability
• Internal hemorrhage post Sx
• Hemoptysis after lung surgery
• Fractured ribs, e.g., osteoporosis
• Increased ICP
• Dyspnea
• Pain

8
Chest Percussion

• Contraindications
• Hemoptysis after lung resection
• Uncontrolled hypertension
• ICP 20 mm Hg
• S/P neurosurgery, aneurysm, eye surgery
• Suspected TB
• Osteomyelitis
• Osteoporosis
• Chest pain
• Resected tumors of the thorax or neck

9
Chest Percussion

• Hazards/Complications
• Vomiting
• Wheezing
• Bronchospasm
• Acute hypotension
• Aggravate lung contusion, coagulopathies

10
Percussion Techniques

• Hand
• Cupped hand will trap air to cause a popping
  sound on contact
• Use the cover sheet or patient gown over skin
• Vibes
• Arms extended tensed when pushing firmly against
  pts chest during exhalation
• Shaking
• Shaking hands on pts chest during exhalation
• Percussor, Swedish massager, etc.
• Good for pts who do not tolerate hand percussion

11
Postural Drainage

• Defn method of removing pooled secretions in
  the tracheobronchial tree by positioning the
  patient to allow gravity to assist in the
  movement of secretions.

12
Postural Drainage

• Goals
• Facilitate mobilization of secretions in the
  bronchial tree
• Improve distribution of ventilation
• Improve gas exchange by improving V/Q mismatch
• Indications
• Same as for chest percussion
• OK for those who do not tolerate percussion

13
Postural Drainage

• Contraindications
• Unstable hemodynamics
• Untreated hypertension
• Internal and external head injuries
• Gross obesity
• Empyema
• Severe dyspnea at rest in high Fowlers or supine
• Recent meals or tube feedings (allow 30 mins
  after)
• Spinal cord injuries

14
Postural Drainage

• Bed position
• Flat
• Tredenlenburg 15-18 foot of bed ?
• Reverse Trendelenburg 15-18 head of bed ?
• High Fowlers 30-45º head upright
• Semi or mid Fowlers 15-30 º head upright

15
Postural Drainage

• Body position
• Dependent position down side
• Independent position upside
• Prone
• Supine
• Lateral
• 3/4 prone
• 3/4 supine

16
Postural Drainage

• Moving patients into position
• Explain to patient what you will be doing
• If patient alert, let him or her know to let you
  know if he or she experiences SOB, headache,
  pain, etc.
• If patient is ambulatory, ask him or her to move
  into position assist if necessary
• Ask for help if patient is unconscious and large
• Move patient into position prior to placing bed
  into Trendelenburg

17
Postural Drainage

• Positioning patient for safety and comfort
• Patient should always be turned and face YOU
• Monitor patients facial expressions for pain,
  discomfort, and signs of breathing distress
• Adjust patients arms and legs using pillows b/t
  the knees avoid bone to bone contact
• Support the head with a pillow
• Tuck pillow behind back and abdomen for stability
• Watch those IV lines and urinary catheter
• Urinary catheter should be on your side
• Make sure side rails are up opposite you

18
Lung Segments

• Right lung (10 segments)
• RUL
• Apical segment of the RUL
• Anterior segment of the RUL
• Posterior segment of the RUL
• RML
• Middle (medial) segment of the RML
• Lateral segment of the RML

19
Lung Segments

• Right lung
• RLL
• Anterior basal or segment of the RLL
• Lateral basal or segment of the RLL
• Medial basal (cardiac lobe) or segment of the RLL
• Posterior basal or segment of the RLL
• Superior basal or segment of the RLL

20
Lung Segments

• Left lung (8 segments)
• LUL
• Apical-posterior segment of the LUL
• Anterior segment of the LUL
• LML
• Superior lingula
• Inferior lingula
• LLL
• Anterior-medial basal or segment of the LLL
• Posterior basal or segment of the LLL
• Lateral basal or segment of the LLL
• Superior basal or segment of the LLL