Bronchial Hygiene Techniques

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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 and remove 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 secretions
• 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
• Bronchiectasis
• Sometimes used in Chronic Bronchitis when large
  volumes of secretions become problematic

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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 (gt25-30
  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 sputum
  analysis
• Culture sensitivity findings

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Causes of Mucociliary Impairment

• Presence of endotracheal or tracheostomy tube
• History of having to suction patients trachea
• Poor humidification
• High FIO2s
• Drugs General anesthetics opiates narcotics

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Some Commonly Used Types of Bronchial Hygiene
Therapies

• Postural Drainage with percussion and/or
  vibration (PDP) (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
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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
• Osteomylitis
• Subcutaneous emphysema
• Suspected or active TB
• Recent insertion of pacemaker

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Hazards of PDP Techniques

• Worsening S.O.B.
• Pain or injury to chest wall or spine
• Hypoxemia
• 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 PDP 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 to create
  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 between 10 - 20
  cmH2O in order to create an IE ratio of 13 to
  14
• Have patient perform 10 to 20 breaths and then 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 or
  squeeze 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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THE END