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ADJUNCTS TO BRONCHOPULMONARY HYGIENE THERAPY
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• Bronchial Hygiene Therapy involves the use of
  noninvasive airway clearance techniques designed
  to help mobilize and remove secretions and
  improve gas exchange.

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Indications

• Components for a patient to receive bronchial
  hygiene regimes are
• Excessive sputum production. Most authors state
  that more than
• 25-30 ml/day ( 1/4 cup or 12 teaspoons) is
  excessive.
• Examples of common pathologies include cystic
  fibrosis bronchitis and bronchiectasis.
     

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• The second component required for bronchial
  hygiene therapy is an ineffective cough.
• Examples of causes for an ineffective cough are
• weakness,
• pain, and
• placement of an artificial airway.

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Contraindications

• Specific contraindications for bronchial hygiene
  therapy are
• elevated intracranial pressure
• acute, unstable head, neck or spine injury
• increased risk of aspiration
• cardiac instability
• Other medical conditions that would be of concern
  when considering bronchial hygiene therapy are
• pulmonary embolism and
• pulmonary edema associated with congestive heart
  failure.

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Traditional Forms Of Bronchopulmonary Hygiene
Therapy

• The three traditional methods of BHT are
• Directed cough
• Postural drainage
• External manipulation of the thorax.

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• Directed Cough is one of the simplest techniques
  to employ when the patient's own spontaneous
  cough is not adequate in clearing secretions.

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The spontaneous cough consists of four steps

• 1) a maximal inspiratory effort
• 2) closure of the glottis
• 3) contraction of the expiratory muscles
  producing an increased intrathoracic pressure
• 4) the expulsion of gasses (and secretions) at
  high velocity as the glottis opens
• Directed cough is an attempt to teach the patient
  one or more phases of the cough reflex that they
  can no longer perform.

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Techniques employed in Directed cough...

• Forced Expiratory Technique (FET),(Huffing)
• The patient "huffs" one or two times from mid to
  low lung volumes with the glottis open and then
  follows with a period of relaxed controlled
  diaphragmatic breathing.
• Manually assisted cough employs the external
  application of pressure to the epigastric region
  or chest cage coordinated with forced exhalation.

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Indications

• Aid in the removal of retained secretions
• The presence of atelectasis
• As prophylaxis against postoperative pulmonary
  complications
• As a routine part of bronchial hygiene in
  patients with cystic fibrosis, bronchiectasis,
  chronic bronchitis, or spinal cord injury
• To obtain sputum specimens for diagnostic
  analysis

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Relative Contraindications

• Inability to control possible transmission of
  infection from patients suspected or known to
  have pathogens transmittable by droplet nuclei
  (eg,M tuberculosis)
• Presence of an elevated intracranial pressure
• Presence of reduced coronary artery perfusion,
  such as in acute myocardial infarction
• Acute unstable head, neck, or spine injury
• Manually assisted directed cough with pressure to
  the thoracic cage may be contraindicated in
  presence of
• Osteoporosis, flail chest

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Limitations

• Patients who are uncooperative , or comatose
• Patients with an artificial airway, effective
  closure of the glottis is not possible
• Extremely thick, tenacious secretion may require
  other modes of therapy
• If the patient has
• incisional pain,
• Splinting with a
• pillow or towel
• may be beneficial.

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External Manipulation of the Thorax

• Commonly known as percussion and vibration.
• The patient is placed in the appropriate position
  for postural drainage. The therapist then either
  manually "claps" over the affected area or
  applies a mechanical percussor to the affected
  area for 3 to 5 minutes.
• The force applied with the clapping or percussor
  varies greatly primarily due to the patient's
  tolerance.

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• Vibration is the manual application of a fine,
  tremorous motion in the direction the ribs move
  during exhalation. The patient is asked to take a
  deep breath and, on exhalation, the vibrations
  are administered.
• Various electrical and pneumatic devices have
  been developed to generate and apply the energy
  waves used during percussion and vibrations.

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Positive Airway Pressure Adjuncts Positive
Airway Pressure Adjuncts

• Positive airway pressure (PAP) adjuncts are used
  to mobilize secretions and treat atelectasis.
• Cough or other airway clearance techniques are
  essential components of PAP therapy when the
  therapy is intended to mobilize secretions.
• Types of PAP Adjuncts
• Continuous positive airway pressure (CPAP)
• Expiratory positive airway pressure (EPAP)
• Positive expiratory pressure (PEP)

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Indications of PAP Adjuncts

• To reduce air trapping in asthma and COPD
• To aid in mobilization of retained secretions (in
  cystic fibrosis and chronic bronchitis)
• To prevent or reverse atelectasis
• To optimize delivery of bronchodilators in
  patients receiving bronchial hygiene therapy

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Continuous Positive Airway Pressure (CPAP)

• During CPAP therapy, the patient breathes from a
  pressurized circuit against a threshold resistor
  (water-column, weighted, or spring loaded) that
  maintains consistent preset airway pressures from
  5 to 20 cm H2O during both inspiration and
  expiration.
• CPAP requires a gas flow to the airway during
  inspiration that is sufficient to maintain the
  desired positive airway pressure.

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Expiratory Positive Airway Pressure (EPAP)

• During EPAP therapy the patient exhales against a
  threshold resistor, generating preset pressures
  of 10 to 20 cm H2O.
• EPAP does not require a pressurized external gas
  source.

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Positive Expiratory Pressure (PEP)

• PEP therapy involves active expiration against a
  variable flow resistance.
• During PEP therapy, the patient exhales against a
  fixed-orifice resistor, generating pressures
  during expiration that usually range from 10 to
  20cm H2O.
• PEP improves aeration to alveoli through
  collateral ventilation by prolonging exhalation
  against a positive pressure (10 to 20 cmH2O).
  This creates a back pressure in the lungs and
  stabilizes smaller airways.
• PEP prevents airway collapse during expiration

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• Positive expiratory pressure (PEP), developed in
  Denmark, requires the patient to breathe in and
  out five to 20 times through a flow resistor,
  which creates a positive pressure in the airways
  during exhalation.
• Active exhalations and a ratio of inspiration to
  exhalation of 13 or 14 are suggested.
• This process is repeated until the patient has
  expelled secretions, usually within 20 minutes or
  less.

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High Frequency Chest Wall Compression (HFCC)

• It is a method to deliver high frequency
  vibration over the chest wall to cause transient
  increases in airflow and improve mucus movement.

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• Two types of systems are currently available.
• High Frequency Chest Wall Oscillation (HFCWO)
• It is a two-part system the first, a variable
  air-pulse generator, and the second, an
  unstretchable, inflatable vest that covers the
  patients entire torso
• Small gas volumes are alternately injected into
  and withdrawn from the vest by the air-pulse
  generator at a fast rate, creating an oscillatory
  motion against the patients thorax.
• HFCWO increases airflow velocity, which creates
  repetitive cough-like shear forces and decreases
  the viscosity of secretions.
• Therapy is usually performed in 30-minute
  sessions at varying oscillatory frequencies (
  525 Hz ). Depending on need, one to six therapy
  sessions may occur per day.

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High Frequency Chest Wall Oscillation (HFCWO)
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• The second system, the Hayek Oscillator which
  employs a microprocessor controlled noninvasive
  ventilator. The unit is connected to the patient
  via a cuirass. Since this is a ventilator,
  positive and negative pressure may be applied
  during the breathing cycle.

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Intrapulmonary Percussive Ventilation

•   Intrapulmonary Percussive Ventilation (or IPV)
  was created by Dr. Forest Bird to enhance
  traditional forms of chest physical therapy.
• Dr. Bird created a device he calls, the
  Percussionaire. It is a pneumatic device that
  delivers both continuous airway pressure and high
  flow mini-bursts. The patient or therapist is
  able to control the duration of the palsatile
  bursts using a thumb control.

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• Technique The patient breathes through a
  mouthpiece, which delivers a series of small
  bursts of pressurized gas to the respiratory
  tract at rates of 100 to 225 cycles per minute
  (1.6 to 3.75 Hz).
• The treatment duration is 20 minutes.
• The device also incorporates a pneumatic
  nebulizer for delivery of aerosols.
• The device is designed to treat patchy
  atelectasis while mobilizing and clearing
  secretions by delivering high frequency puffs of
  air behind mucus plugs, helping to dislodge them.
  

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Flutter Valve Therapy
The Flutter Valve combines the technique of PEP
with high frequency oscillations at the airway
opening. The device consists of a mouthpiece
connected to a cylinder in which a stainless
steel ball rests in a cone shaped valve. The
patient exhales through the cylinder and causes
the ball to move up and down during the
exhalation.
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• The effect is threefoldFirst, to vibrate the
  airways and thus, facilitate movement of mucus
  Second, to increase endobronchial pressure to
  avoid air trapping and Third, to accelerate
  expiratory airflow to facilitate the upward
  movement of mucus

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Mobilization and Exercise

• Immobility is a major factor contributing to
  retention of secretions
• Early mobilization and frequent position changes
  are preventive interventions for atelectasis.
• Exercise also improves overall aeration and
  ventilation perfusion matching.
• Exercise can improve a patients general fitness,
  self esteem and quality of life.
• On the other hand, exercise can be fatiguing and
  result in oxygen desaturation among patients with
  significant pulmonary impairment.

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The appropriate form of BHT depends on

• The degree of the patients motivation to adhere
  to therapy.
• The goals to be achieved.
• The patients age.
• The need for equipment and assistance with
  devices.
• The cost.
• Limitations of technique basedon disease type and
  severity.

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Thank You