Airway Clearance Interventions

Question 1

Define obstructive lung disease.

Answer 1

Obstructive lung disease is characterized by chronic inflammation and narrowed airways.

• Making it difficult to exhale air completely.

- Examples

• COPD
• Emphysema
• Asthma
• Chronic Bronchitis
• Bronchiectasis
• Cystic Fibrosis

Question 2

What is the purpose of postural drainage?

Answer 2

Postural Drainage:

• Uses gravity to drain secretions from specific lung segments toward central airways for easier removal.
• Improves ability to clear out secretions in lower lobes thatcannot be cleared with cough or other breathing techniques.
• Often combined with other airway clearance techniques.

Question 3

Define percussion and vibration in airway clearance.

Answer 3

Percussion:

• Involves rhythmic clapping on the chest to loosen mucus.
• Should last for several minutes and should not be painful (3-5 min/lobe, 100-480/minute).
• Purpose to loosen up mucus and increase mucociliary clearance

Vibration:

• Applies a fine, tremulous action during exhalation to aid mucus clearance.
• Completed for 3-5 exhalations

Question 4

What is…

• Active Cycle of Breathing (ACB) = ?
• Phases = ?

Answer 4

Active Cycle of Breathing (ACB):

- A series of breathing maneuvers performed to independently clear secretions and improve thoracic expansion.

- Phases:

• (1) Breathing control: Performs diaphragmatic breathing at normal tidal volume for 5-10 seconds
• (2) Thoracic expansion exercises: 3-4 deep, slow, relaxed inhalations to inspiratory reserve volume with passive exhalation. Can include 3 second hold at top of full inhalation.
• (3) Forced expiratory technique: 1-2 huffs at mid to low lung volumes

Question 5

What is…

• Autogenic drainage = ?
• Phases = ?

Answer 5

Autogenic Drainage:

• A controlled breathing technique to mobilize secretions without coughing or postural drainage, using varying lung volumes and expiratory flows.
• More beneficial for patients who cannot tolerate postural drainage patients or increased thoracic pressure.

Phases:

1) Unsticking phase (Small Breath):

• Slowly breath in through the nose at low-lung volumes followed by a 2-3 second breath hold to allow collateral ventilation to get to air behind the secretions
• Then exhale down into expiratory reserve volume
• Repeat 2-3 times

2) Collecting Phase (Medium Breath):

• Tidal volume breathing, interspersed by 2-3 second breath-holds
• Repeat 2-3 times

3) Evacuating Phase (Large Breath):

• Deeper inspiration from low-to-mid inspiratory reserve volume
• Hold breath for minimum of 3 seconds, then an active but not forced expiration through an open glottis
• Huffing technique can be used as well in this phase

Question 6

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Answer 6

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Question 7

What does hypoxemia mean?

Answer 7

Hypoxemia refers to low oxygen levels in the blood

• PaO2 (partial pressure of oxygen) < 55 mmHg, or
• SaO2 (oxygen saturation of hemoglobin) < 88% on room air

Question 8

What is the purpose of a directed cough?

Answer 8

A directed cough aims to expel mucus and secretions from the airways by using a series of controlled breathing and coughing techniques.

Question 9

What is a contraindication for postural drainage?

Answer 9

• elevated intracranial pressure
• recent spinal surgery
• pulmonary embolism
• rib fractures
• active hemorrhage

Question 10

What is high-frequency airway oscillation?

Answer 10

High-frequency Airway Oscillation:

• Devices that combine positive expiratory pressure and high frequency airway vibrations to mobilize mucus secretions in the airways
• Common devices: acapella and flutter
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Question 11

Define the Trendelenburg position in airway clearance.

Answer 11

Trendelenburg Position:

• Optimal for facilitating secretion drainage from the lower lobes of the lung
• Supine with foot of bed elevated so head is declined below feet.

Question 12

What are the main goals of airway clearance techniques?

Answer 12

• Optimize airway patency
• Increase ventilation and perfusion matching
• Promote alveolar expansion and ventilation
• Improve gas exchange
• Clear out secretions

Question 13

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Answer 13

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Question 14

What are the primary components of a directed cough?

Answer 14

Effective cough stages:

• Inspiration greater than tidal volume, maximal inhale as possible
• Closure of glottis with holding breath for 2-3 seconds.
• Contract the abdominal and intercostal muscles to produce increased intrathoracic pressure against the closed glottis.
• Sudden opening of the glottis and forceful expulsion of the inspired air by coughing sharply 2-3 times

Question 15

How does the huff technique differ from a cough?

Answer 15

- Huff: Good alternative to cough if coughing is too painful

- Steps to huffing

• Sit up in upright position
• Take a deep breath in through an open mouth
• Hold for 1-2 seconds
• Forcefully and quickly exhaling 2-3 bursts of air without glottis closure

- Tips for huffing

• Huffing sound as if patient was saying “Hu-Ff” or “Ha Ha Ha” (Hu = vibration of mucus / Ff = abdominal contraction)
• Longer sounds help for smaller airways, shorter sounds help with larger airways
• Splinting can be used to assist with tolerance

Question 16

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Answer 16

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Question 17

What are the phases of the Active Cycle of Breathing (ACB)?

Answer 17

The phases include:

• breathing control
• thoracic expansion exercises
• forced expiratory technique

Question 18

What are contraindications for percussion and vibration techniques?

Answer 18

Contraindications include recent thoracic surgery, burns, open wounds, osteoporosis, and active bronchospasms.

Question 19

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Answer 19

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Question 20

How does high-frequency airway oscillation improve airway clearance?

Answer 20

It combines positive expiratory pressure and vibrations to mobilize mucus and enhance secretion clearance.

Question 21

What is the role of supplemental oxygen in pulmonary interventions?

Answer 21

Supplemental oxygen improves oxygen saturation, supports exercise tolerance, and reduces dyspnea in patients with hypoxemia.

Question 22

How would you differentiate between the huff and cough techniques?

Answer 22

• Huffing uses forceful exhalation without glottis closure, reducing pain and strain.
• Coughing involves glottis closure and higher intrathoracic pressure to expel mucus.

Question 23

What are the differences between Active Cycle of Breathing (ACB) and autogenic drainage?

Answer 23

ACB incorporates controlled breathing, thoracic expansion, and forced expiration, while autogenic drainage relies on varying expiratory airflow without coughing or postural changes.

Question 24

When would postural drainage be contraindicated?

Answer 24

Postural drainage is contraindicated in conditions like elevated intracranial pressure, recent spinal surgery, active hemorrhage, or pulmonary embolism.

Question 25

Which airway clearance technique would you choose for a patient with osteoporosis?

Answer 25

Gentler techniques like huffing or autogenic drainage are preferred to avoid the potential harm caused by percussion or vibration.

Question 26

How would you modify airway clearance for a postoperative patient with incisional pain?

Answer 26

Use splinting with a pillow to support the incision during coughing or huffing and opt for techniques that minimize thoracic pressure, such as autogenic drainage.

Question 27

Why is the Trendelenburg position used in airway clearance, and when should it be avoided?

Answer 27

It uses gravity to drain lower lung segments but should be avoided in cases of uncontrolled hypertension, CHF, or risk of aspiration.

Question 28

How does high-frequency airway oscillation differ from manual percussion?

Answer 28

• High-frequency oscillation uses devices like acapella to combine positive expiratory pressure with vibrations.
• Manual percussion involves rhythmic clapping with the hands.

Question 29

What is the purpose of combining percussion with postural drainage?

Answer 29

• Percussion loosens mucus, making it easier for gravity in postural drainage to move secretions toward the central airways.

Question 30

Why might a patient with chronic bronchitis benefit from autogenic drainage?

Answer 30

It allows secretion mobilization without coughing, reducing strain and improving secretion clearance in patients with mucus hypersecretion.

Question 31

What are the key considerations when titrating supplemental oxygen during activity?

Answer 31

Monitor oxygen saturation levels (≥90%), adjust flow rates as needed, and use breathing exercises like pursed-lip breathing to optimize oxygen use.

Question 32

How would you instruct a patient to perform a directed cough?

Answer 32

Guide them to:

• Inspiration greater than tidal volume, maximal inhale as possible
• Closure of glottis with holding breath for 2-3 seconds
• Contract the abdominal and intercostal muscles to produce increased intrathoracic pressure against the closed glottis
• Sudden opening of the glottis and forceful expulsion of the inspired air by coughing sharply 2-3 times

Question 33

What are the phases of autogenic drainage, and what is the purpose of each?

Answer 33

Phases include unsticking (small breaths to mobilize secretions), collecting (tidal breathing to move secretions upward), and evacuating (large breaths to clear secretions).

Question 34

Why might a patient prefer high-frequency airway oscillation over traditional techniques?

Answer 34

It is less physically demanding, more comfortable, and can be performed independently, making it suitable for patients with limited mobility.

Question 35

How do you decide the order of lung segments to treat in postural drainage?

Answer 35

Prioritize the most affected segments based on patient symptoms, imaging findings, and auscultation results.

Question 36

How can a therapist ensure infection control during airway clearance?

Answer 36

Use gloves, masks, and other barriers, and handle sputum with care to prevent transmission of infections.

Question 37

What are the expected outcomes of supplemental oxygen therapy during exercise?

Answer 37

Improved oxygen saturation, reduced dyspnea, and enhanced exercise tolerance with safe SpO2 levels maintained.

Question 38

When would you choose the Active Cycle of Breathing (ACB) over postural drainage?

Answer 38

Choose ACB for patients who can actively participate and prefer independent techniques without the need for specialized positions.

Question 39

How does pursed-lip breathing benefit patients during airway clearance?

Answer 39

It helps maintain airway patency, reduces work of breathing, and promotes efficient exhalation to support secretion clearance.

Question 40

What adjustments are needed for a patient with anxiety during airway clearance?

Answer 40

Use calming techniques, avoid positions that may increase discomfort, and provide clear explanations to reduce fear and enhance participation.

Question 41

Why is it important to monitor vitals before, during, and after airway clearance?

Answer 41

To assess patient response, ensure safety, and adjust techniques or intensity to avoid adverse effects such as hypoxemia or fatigue.

Question 42

A patient with cystic fibrosis reports difficulty clearing mucus. Which airway clearance technique would you recommend, and why?

Answer 42

High-frequency airway oscillation, such as using the acapella device, because it combines positive expiratory pressure and vibrations to mobilize mucus effectively.

Question 43

During a postural drainage session, the patient complains of dizziness. What is your immediate response?

Answer 43

Stop the session, assess vitals, reposition the patient to a more upright posture, and investigate potential causes like hypotension or discomfort.

Question 44

A patient has a recent history of rib fractures. Which airway clearance techniques should you avoid?

Answer 44

Avoid percussion and vibration techniques due to the risk of causing further injury or discomfort.

Question 45

A patient with COPD is unable to tolerate prolonged activity due to dyspnea. What adjustments would you make?

Answer 45

Incorporate interval training with frequent rest periods and focus on techniques like pursed-lip breathing to manage dyspnea.

Question 46

A patient recovering from abdominal surgery finds coughing painful. What alternative technique could you suggest?

Answer 46

Huffing, as it avoids glottis closure and reduces intrathoracic pressure, making it less painful while still clearing secretions.

Question 47

How would you assess the effectiveness of postural drainage?

Answer 47

Monitor for increased sputum production, improved breath sounds, better oxygen saturation, and patient-reported ease of breathing.

Question 48

A patient with asthma experiences bronchospasms during percussion. What should you do?

Answer 48

Discontinue percussion, provide a bronchodilator if prescribed, and consider alternative techniques like autogenic drainage or ACB.

Question 49

A patient with significant mucus retention in lower lung segments cannot tolerate Trendelenburg positioning. What is your plan?

Answer 49

Use alternative positions for lower lung drainage and incorporate techniques like autogenic drainage or ACB to assist clearance.

Question 50

What instructions would you give to a patient using an acapella device for airway clearance?

Answer 50

Seal lips around the mouthpiece, inhale slowly to 75% capacity, hold for 2-3 seconds, exhale through the device for 3-4 seconds, and repeat for 10-20 breaths followed by 2-3 coughs or huffs.

Question 51

A patient reports increased fatigue after airway clearance sessions. How would you modify the treatment?

Answer 51

Shorten session duration, reduce intensity, allow more rest periods, and monitor the patient’s response closely during therapy.

Question 52

A postoperative patient develops hypoxemia during therapy. What immediate actions would you take?

Answer 52

Stop therapy, provide supplemental oxygen as prescribed, perform breathing exercises like pursed-lip breathing, and reassess before continuing.

Question 53

How would you handle a situation where a patient refuses airway clearance due to discomfort?

Answer 53

Discuss alternative techniques, address their concerns, and adjust the therapy plan to accommodate their comfort and preferences.

Question 54

What adjustments are needed for a patient with high anxiety during airway clearance sessions?

Answer 54

Use calming techniques, avoid complex or stressful procedures, and provide clear explanations to build trust and reduce anxiety.

Question 55

A patient’s oxygen saturation drops below 88% during activity. What steps should you take?

Answer 55

Pause the activity, provide supplemental oxygen, allow the patient to rest, and monitor SpO2 until it stabilizes above 90%.

Question 56

A patient using autogenic drainage struggles with the unsticking phase. What advice would you offer?

Answer 56

Encourage small, slow breaths through the nose, followed by a 2-3 second hold to allow collateral ventilation before exhaling slowly to expiratory reserve volume.

Question 57

How would you evaluate the success of an airway clearance program for a patient with chronic bronchitis?

Answer 57

Assess sputum production, ease of breathing, improved oxygen saturation, and patient-reported quality of life improvements.