Bronchial Hygiene Therapy II

1
Bronchial Hygiene Therapy II

• RET 2275
• Respiratory Therapy Theory Lab 2

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 Assignment Egans Fundamentals of
Respiratory Care NINTH EDITION (pgs. 915-916,
932-941)
3
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

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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

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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

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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

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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

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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

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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

10
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

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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.

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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

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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

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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

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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.

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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.

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Bronchial Hygiene

• Hazards of Directed Cough

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Bronchial Hygiene

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

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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

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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 patients thorax

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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

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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 manufacturers website

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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 manufacturers website

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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

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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

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Bronchial Hygiene

• PEP
• Oscillating PEP
• acapella
• Combines the techniques of EPAP with
  high-frequency oscillations at the airway opening

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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

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EZ-PAP

• Clinical Procedure for PAP
• Requires a physicians 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

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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

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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
• Patients ability to self-administer (if
  applicable)