Airway Clearance, Postural Drainage, Assisted Cough, & Breathing Techniques

Question 1

Describe the grading for the 7 point dyspnea scale

Answer 1

• 1 = no trouble at all
• 2 = a tiny bit
• 3 = a little
• 4 = some
• 5 = quite a bit
• 6 = a lot
• 7 = very much trouble

Question 2

Being _____________ and ___________ is the physiological body position

Answer 2

• Upright and moving

Question 3

When body positions that are initially beneficial to the patient are assumed for too long, they eventually compromise _____________________ and offset any benefit

Answer 3

• Oxygen transport

Question 4

How often should turning be performed

Answer 4

• Every 2 hrs

Question 5

Effects of recumbent supine position

Answer 5

• Deleterious to oxygen transport
• Predispose the pt to airway closure & increased work of breathing
• May stimulate diuresis & lead to orthostatic intolerance due to fluid loss

Question 6

Effects of side-lying position

Answer 6

• Arterial blood gases improve in pts with unilateral lung disease w/good lung down

Question 7

Effects of prone position

Answer 7

• May reduce work of breathing
• Better ventilation of the dorsal lung regions
• Improvement in ventilation/perfusion matching

Question 8

Where are you trying to move the secretions toward when performing postural drainage techniques

Answer 8

• Toward the Angle of Louis

Question 9

Preparation for postural drainage

Answer 9

• Use electric beds to position more easily
• Be familiar with all lines 7 tubes, allow slack
• Have help as needed
• Use foam wedges or pillows for positioning
• Nebulized bronchodilators or mucolytics before postural drainage
• Specimen cup for sputum after cough

Question 10

Treatment with postural drainage

Answer 10

• Maintain position for 5-10 min or longer if tolerated
• Most affected lobes should be addressed first
• Take deep breathes & cough after each position & following treatment
• Mobilization of secretions could occur up to 1hr later

Question 11

Contraindications for postural drainage

Answer 11

• Intracranial pressure (ICP) >20mm Hg
• Head and neck injury until stabilized
• Active hemorrhage with hemodynamic instability
• Recent spinal surgery (e.g., laminectomy) or acute spinal injury
• Active hemoptysis
• Empyema
• Bronchopleural fistula
• Pulmonary edema associated with heart failure (HF)
• Large pleural effusions
• Pulmonary embolism
• Older, confused, or anxious patients
• Rib fracture, with or without flail chest
• Surgical wound or healing tissue

Question 12

Contraindications for Trendelenburg position

Answer 12

• Patients in whom increased ICP is to be avoided
• Uncontrolled HTN
• Distended abdomen
• Esophageal surgery
• Recent gross hemoptysis related to recent lung carcinoma
• Uncontrolled airway at risk for aspiration

Question 13

Describe airway percussion technique

Answer 13

• Rhythmical force applied with cupped hands against thorax over involved lung segments
• Performed during both inspiratory & expiratory phases of breathing
• Handheld mechanical pressures can also be used

Question 14

Treatment with percussion

Answer 14

• Position the hand in the shape of a cup with fingers and thumb adducted
• Keep wrists neutral
• Hollow sound should be heard
• Even steady rhythm between 100 and 480 beats per minute
• Equal force and pressure—slow rate of dominant hand to match non-dominant
• Do not percuss over bony prominences
• Do not perform over breast tissue
• One handed self percussion can be taught for areas that are reached comfortably

Question 15

Advantages & disadvantages of percussion

Answer 15

• May enhance secretion clearance and shorten the treatment
• Not well tolerated postoperatively
• Contraindicated in those with osteoporosis or coagulopathy
• Extended periods of time and on an ongoing basis can result in injury to the caregiver
• Minimal price for mechanical device

Question 16

Describe vibration & shaking

Answer 16

• Performed only during the expiratory phase of breathing
• Start with peak inspiration & continue until the end of expiration
• The compressive forces follow the movement of the chest wall
• Both techniques require the assistance of a caregiver, but a mechanical vibrator may be used in place of manual vibration

Question 17

What is the mechanism of action for vibration & shaking

Answer 17

• Enhance mucociliary transport from the periphery of the lung fields to the central airways, also increased chest wall displacement and stretch of the respiratory muscles

Question 18

Describe vibration technique

Answer 18

• Gentle, high frequency force
• Delivered through sustained co-contraction of caregiver’s UEs
• Hands must be placed side by side or on top of each other
• Frequency of manual vibration is b/w 12-20 Hz

Question 19

Describe shaking technique

Answer 19

• Moer vigorous in nature
• Described as a bouncing maneuver
• At peak inspiration apply a slow rhythmic bouncing pressure to the chest wall until the end of expiration
• Hands follow the movement of the chest as the air is exhaled
• Frequency of shaking is 2 Hz

Question 20

Advantages and disadvantages of vibration and shaking techniques

Answer 20

• Enhances mobilization of secretions with postural drainage
• Patient cannot apply these techniques without assistance

Question 21

Considerations with vibration and shaking techniques

Answer 21

• Mechanically ventilated: coordinate with ventilator-controlled exhalation
• Rapid respiratory rate: apply vibration or shaking only during every other exhalation
• Limited chest wall compliance: vibration will probably be better tolerated than shaking
• Mechanical vibrators may be used by the unattended pt, although only limited attention can be paid to the posterior portions of the lungs

Question 22

Relative contraindications for vibration and shaking techniques

Answer 22

• Hemoptysis
• Untreated tension pneumothorax
• Platelet count below 20,000 per mm3
• Unstable hemodynamic status
• Open wounds, burns in the thoracic area
• Pulmonary embolism
• Subcutaneous emphysema
• Recent skin grafts or flaps on thorax

Question 23

What are the 4 stages of a cough

Answer 23

• Inspiration (irritation)
• Glottal closure (inspiration)
• Increased intrathoracic & intra-abdominal pressure (compression)
• Glottal opening & expulsion

Question 24

Describe huffing

Answer 24

• Alternative to coughing
• Deep inspiration followed by a forced expiration without glottal closure
• Often used in post-operative pts who find coughing to be too painful

Question 25

Describe breath stacking

Answer 25

• Pt independently performs inspiration to maximal inspiratory capacity
• Hold their breath
• Take 2-3 more breaths on top of the initial breath to increase vital capacity
• follow with a cough

Question 26

Describe chest compression

Answer 26

• For a pt with a neuromuscular weakness
• Therapist or a family member can assist with a chest compression to assist the cough during exhalation

Question 27

Describe the costophrenic assist cough technique

Answer 27

• Performed in any position
• Therapist place hands on costophrenic angles of the rib cage
• At the end of pt’s exhale provide a quick manual stretch down & in toward pt’s navel
• Have pt hold it & just a moment before asking the pt to actively cough, therapist applies a strong pressure again
• Most commonly used for pts with weak or paralyzed intercostal or abdominal muscles

Question 28

Describe the abdominal thrust cough technique (Heimlich-type)

Answer 28

• Therapist places heel of hand at the patients navel
• Patient takes in a deep breath and holds it
• As the patient is instructed to cough, the therapist quickly pushes up and in under the diaphragm
• Only use when the pt doesn’t respond to other techniques

Question 29

Why can the abdominal thrust technique be uncomfortable

Answer 29

• Abrupt nature
• Concentrated area of contact
• Force may cause GER

Question 30

What are the steps to airway suctioning

Answer 30

• 1. Administer supplemental oxygen to the patient via manual resuscitator bag or mechanical ventilator to increase arterial oxygenation.
• 2. Monitor oxygen saturation with a pulse oximeter.
     Document drops in oxygen saturation below 90% and continue bagging with 100% O2 until saturation is above 90% before continuing.
• 3. Adjust the pressure on the suction apparatus to 100 to 150 mm Hg, as needed.
• 4. Connect the vent end of the catheter to the suction tubing.
• 5. Don sterile gloves. Remove the catheter packaging without causing contamination; maintain sterility of any part of the catheter that will touch the patient’s trachea.
• 6. Disconnect the patient from the ventilator or oxygen source.
• 7. Give five to 10 breaths via manual resuscitator bag.
• 8. Quickly and gently insert the catheter into the tracheal tube without applying suction. The diameter of the catheter should be no larger than one-half of the diameter of the airway.
• 9. Stop advancing the catheter once gentle resistance is met at the level of the carina or one of the mainstem bronchi. Apply suction by placing a finger over the catheter vent.
• 10. Then, while applying suction, withdraw the catheter slowly, rotating the catheter to optimize the exposure of the side holes to the secretions.
• 11. Reconnect the patient to the oxygen source and reinflate the patient’s lungs with the manual resuscitator bag or the ventilator for 5 to 10 breaths.
• 12. Repeat steps 6 through 9 until the airway is cleared of secretions, the patient is too fatigued to continue, or intolerance develops.

Question 31

Describe the anterior chest compression assisted cough technique

Answer 31

• Therapist puts one arm across the pectoralis region to compress the upper chest
• Other arm placed parallel on the lower chest or abdomen
• Inspiration is facilitated first
• Followed by a hold
• Force is applied
• Down and back on the upper chest
• Up and back on the lower chest
• Effective for patients with very weak chest wall muscles

Question 32

Describe the coutner-rotation assist cough technique

Answer 32

• Position hands over the shoulder and pelvis
• Therapist gently assists inhalation and exhalation
• Repeat 3-5 cycles
• Patient then takes as deep a breath as possible and holds it
• Therapist commands them to cough out as hard as possible while they forcefully compress the chest in a diagonal pattern

Question 33

What are the benefits of the counter-rotation cough assist technique for patients with low cognitive functioning

Answer 33

• Natural inhibitor of high tone
• Mobilizer for a tight chest
• Rotation can be a vestibular stimulator

Question 34

Describe the self assisted prone on elbows technique

Answer 34

• Have patient position prone on elbows
• Instruct them to bring head and neck back as far as possible, inhale maximally, cough out while throwing head forward and down

Question 35

Describe the self assisted short sitting cough technique

Answer 35

• Patient places one hand over the wrist and places them in her lap
• Patient extends backwards while inhaling maximally, followed by a strong voluntary cough
• Patient uses their hands like in the Heimlich to mimic the abdominal muscles
• Good for those who are in a wheelchair
• Effective for patients with weak diaphragms or abdominal musculature

Question 36

Describe the self assisted long sitting cough technique

Answer 36

• Patient in long sitting with UE support
• Patient is instructed to extend their body backwards while inhaling maximally
• Therapist tells them to cough as the patient moves their upper body into completely flexed posture

Question 37

Describe the self assisted quadruped cough technique

Answer 37

• Patient gets in quadruped
• Rock forward while looking up when inhaling
• Cough as they quickly rock back on their heels with flexed head and neck
• Used most commonly in multipurpose activity to increase balance, strength, coordination, and functional use of breathing patterns
• For patients with generalized or spotty weakness throughout

Question 38

What is the cough assist T70

Answer 38

• Machine that patients can use to self-assist cough at their own homes
• Very expensive – many insurances do not cover
• Patient using the CoughAssist

Question 39

Inspiration movement strategies

Answer 39

• Trunk extension
• Shoulder flexion/abduction/ER
• Upward eye gaze

Question 40

Expiration movement strategies

Answer 40

• Trunk flexion
• Shoulder extension/adduction/IR
• Downward eye gaze