Airway Clearance - Physiotherapy Flashcards
What are the active sputum clearance techniques?
- Mobilisation
- Positive expiratory pressure (PEP)
- Breathing exercises (ACBT)
What are the passive sputum clearance techniques?
- Postural drainage
- Percussion & vibrations
- High frequency oscillating vests (HFOV)
What are the effects of mobilisation?
- Increased flow rates
- Higher FRC (functional residual capacity)
- Moving more gas - more pressure behind cough
What does PEP involve?
- Using positive pressure of blowing to create a back pressure in the airways
- Using collateral ventilation to force air behind sputum in collapsed airways
- I.e. uses lateral channels as a back door to get around sputum
- Holds airways open whilst providing expiratory flow
What devices are used for PEP?
- Bubble PEP
- TheraPEP, PariPEP
- Oscillating PEPs - Acapella, Flutter
What type of patient would a TheraPEP/PariPEP be used for?
Someone with chronic disease requiring ongoing PEP therapy, e.g. chronic bronchitis, CF
What is the function of an oscillating PEP?
- Creates positive pressure
- Plus adds vibration during exhalation
When would you use specific breathing exercises?
When mobilisation isn’t enough and/or you can’t use PEP
What are the specific breathing exercises for the larger and smaller airways?
Larger: Cough & high volume huff
Smaller: Forced expiratory technique (FET) & active cycle of breathing technique (ACBT)
What is forced expiratory technique (FET)?
- 1-2 huffs from mid-low lung volume
- Followed by breathing control (period of relaxed, controlled breathing to reduce the possibility of airway closure, desaturation or fatigue)
What is the active cycle of breathing technique?
- Technique to clear bronchial secretions
- Cycles of breathing control, thoracic expansion exercises (TEE) & FET (1-2 huffs, breathing control)
When would you begin using passive airway clearance techniques?
When the patient is too tired to continue active techniques or cannot participate in active techniques
What does postural drainage involve?
- Uses gravity to position affected lung segment uppermost
- Sputum should drain into larger airways to be coughed out
- Combined with other techniques
What does percussion/vibration involve?
- Tapping or shaking chest wall to loosen sputum from airways
- Cupped hand and rhythm essential for percussion
- Time vibrations with exhalations
What should you do if active and passive techniques don’t work?
Consider more invasive techniques (learning in CI2)
What should be considered when choosing a treatment for sputum clearance?
- Mobilisation treats multiple problems
- Start active if possible, passive if necessary
- Patient experience/preference
- Patient effort/compliance/fatigue
- Cost & availability
- Evidence
What factors should be considered when looking for evidence?
- Experimental design (RCT, sample size, outcomes)
- Disease process
- Acuity (chronic vs acute)
- Patient characteristics/settings
- Specifics of technique used e.g. duration
What does the evidence tell us about airway clearance techniques?
- Results vary depending on pathology
- Most techniques tend to have short term benefits
- Patients often prefer PEP
- Don’t know about long term outcomes
How do you re-assess following sputum clearance?
- Auscultation - crackles/wheezes
- Palpation - fremitus
- Sputum volume
- SpO2
- Patient comfort
- Respiratory rate
- Dyspnoea
What are the components of an effective cough?
- Deep breath in
- Closure of glottis
- Contraction of abdominal muscles to build up intra-abdominal pressure & intra-thoracic pressure
- Opening of glottis
- Explosive cough
What are the warnings associated with cough?
- Pain
- SOB
- Dizziness
- No more than 2 coughs in a row
What are thoracic expansion exercises (TEE)?
- Deep breathing exercises emphasising inspiration
- Inspiration followed by 3 second hold, then passive relaxed expiration
- Approx 5 breaths/holds
- Can be encouraged with proprioceptive stimulation (placing hands either side of lower lobes)
What are the contraindications to bubble PEP?
- Undrained pneumothorax
- Frank haemoptysis (coughing up blood)
- Extensive bullae or cysts
- Recent pneumonectomy
What are the precautions to bubble PEP?
- Altered consciousness/confusion (risk of drinking the water)
- Paediatric patients (risk of drinking/aspirating)
- Patients requiring high/continuous oxygen therapy (switch to nasal prongs, monitor SpO2)
What are the precautions to the head down tip position (postural drainage)?
- Hypertension
- Unstable CV system (arrhythmias etc)
- Immediately following oesophageal surgery (risk gastric aspiration & places strain on anastomoses)
- Immediately following a meal
- Hiatus hernia (hernia above diaphragm)
- GORD
- Orthopnoea/severe dyspnoea
- Recent head injury &/or neurosurgery, raised ICP
- Patient distress/distress in that position
- Pulmonary oedema/severe cardiac failure
- Severe obesity/abdominal distension (increase pressure on diaphragm, compresses lung volumes)
- Recent head/neck surgery/facial trauma (risk of upper airway obstruction)
- Cerebral/aortic aneurysm
What are the warnings associated with postural drainage?
- Pain
- SOB
- Headache
- Dizziness
- Nausea
What are the precautions to percussion & vibrations?
- Fractured ribs
- Frank haemoptysis (coughing up fresh blood)
- Rib cancer
- Osteoporosis/long term steroid use (causes osteoporosis)
- Burns
- Surgical incisions
- ICC
- Severe bronchospasm
- Severe pleuritic pain (without adequate pain relief)
- Very low platelet level/clotting disorders
