Breathing Re-education & Sputum Management Flashcards
Aim of breathing re-education for chronic patients
Normally to reduce WOB and give patients confidence in their ability to control breathless attacks
Aim for breathing re-education for acute patients
Aim = often to help reverse the problem or treat the signs & symptoms manifesting themselves as a consequence
Type of approach to chronic patients
Minimalist approach is advised, their unnatural breathing pattern may be optimum for them
Practice in a calm state can enable a breathing technique to be used more easily when required, especially when getting their breath back after exertion
Define breathing control (diaphragmatic/relaxed breathing) exercises
Breathing using abdominal movement, reducing the degree of chest wall movement as much as possible.
Theory breathing control (diaphragmatic/relaxed breathing) exercises
Thought to: • Decrease airway turbulence • Decrease dead space • Favour dependent regions • Relaxes shoulder girdle • Important to do Breathing Control in between the more active exercises of ACBT as it allows airways to relax. • Breathing control can also help SOB or feeling fearful, anxious or in a panic
Instructions in breathing control (diaphragmatic/relaxed breathing) exercises
- Treat in relation to outcome - relaxed breathing outcome thus talk in a relaxed manner; potentially touch patient (can be calming or innerving depending on patient)
- Explain to patient we want ‘relaxed breathing’
- Comfortable and symmetrical position
- Rest a hand on abdomen
- Keep shoulders relaxed
- Breathe in and out gently through your nose
if you can. If you cannot, breathe through your
mouth instead - If you breathe out through your mouth you
can use breathing control with ‘pursed lips
breathing’ - Gradually try to make the breaths slower
- Try closing your eyes to help you to focus on
your breathing and to relax
Emphasis is initially on rhythmic breathing and avoiding breath holding and relaxation of the shoulder girdle
On observation and palpation the abdomen should swell on inspiration
Theory behind DBEs
AKA Thoracic Expansion Exercises (TEEs)
Thought to:
○ Increase lung volume - by use of IRV to create larger bucket handle movement
○ Increase ventilation
○ Decrease airway resistance
○ Increase surfactant secretion - increase lung compliance
○ Decrease dead space - recruiting more alveoli
○ Aid V/Q matching - by increasing ventilation so helps more gas travel to alveoli
○ Increase O2 saturation ultimately
Instructions for TEEs
• More often patients are in an heightened state thus require breathing control exercises first to relax state; However acute patients without increased WOB do not require breathing control exercises prior
• Treat in relation to outcome - deep breathing outcome thus talk in a motivational manner
○ ‘I want you to try push my hands out’
○ ‘I want to you take a deep breath, we are trying to get air to all areas in your lungs’
1. Try to keep shoulders and chest relaxed
2. Taking a long slow deep breathe in through the nose - natural humidification system; less airflow resistance
3. Use end inspiratory hold at full inspiration (count of 3) Utilises channels - pors of Kohn, channels of Martin, Canals of Lambert
4. Possible ‘sniff’ - Utilises IRV
5. Breath out of mouth gently not forced ‘long’ & ‘slow’
6. Physiotherapist places hands over thorax to evaluate/facilitate
7. Max 3 breaths - excess ventilation can cause dizzyness in patients as they can hyperventilate and blow off too much CO2. A fall in CO2 in the blood causes cerebral vasocontriction which is what causes the dizzyness as cerebral blood flow reduces
State the primary lung defence mechanism
The mucociliary Transport system (mucociliary clearance mechanism or the mucociliary escalator)
The mucociliary transport system help reduce the incidence of respiratory infections.
Particles (dust, pollen, pollutants, viruses and bacteria) are trapped in the sticky mucus
Coughing Mechanism:
Coughing is an important host defence mechanism which supports mucociliary transport.
Coughing helps clear large amounts of mucus or inhaled material when the primary mucocilliary transport mechanism is damaged or overwhelmed.
Coughing is actually quite a complex procedure which results in the production of a forced expulsive manoeuvre against a closed Glottis.
Mucociliary Clearance (MCC) is the main defence mechanism in health but cough becomes a more prevalent mechanism for those with lung disease
Components of MCC
Cilia
Aqueous (sol) layer (periciliary fluid)
Viscous (gel) layer
Describe the cilia
Cilia are microscopic hair like structures (microfilaments) with hooks on their tips. Ciliated epithelium is present in the upper respiratory tract and lines the airways all the way down to the terminal bronchioles.
Cilia sit in the sol layer but waft and bend rhythmically backwards and forwards at great speed. Approximately 20 times per second.
Mucus flow is slower in the periphery and faster in the trachea
On the forward stroke they reach their hook tips into the gel layer and as they move forward they propel the mucus toward the laryngopharynx. On the return or recovery stroke they bend and dive down into the sol layer.
Cilia in the area below the larynx beat in an upward direction toward the laryngopharynx whilst cilia in the area above the larynx beat in a downward direction toward the laryngopharynx.
To work optimally the cilia need warm and humid conditions (37 degrees Centigrade and 100% humidity)
Describe periciliary fluid of MCC
layer of watery fluid & creates very little resistance to the motion of the cilia and provides an anti-bacterial action.
The Cilia beat backward and forward and the watery periciliary fluid sits most of the way up the shaft of the cilia.
Describe the viscous (gel) layer of MCC
The goblet cells secrete mucus and in healthy adults we produce around 10 -100mL (20-30ml normally) per day
This forms a gel like sticky layer which traps foreign particles, dust, pollen, pollutants, viruses and bacteria.
The cilia reach up and penetrate into the viscous gel like mucus layer with hooks on their tips as they move forward . The cilia then dive beneath into the sol layer on the recovery stroke
This steadily propels the mucus from smaller airways to larger airways and on toward the laryngopharynx where the mucus is swallowed or expectorated through coughing.
Cilia in the area above the larynx beat in a downward direction toward the laryngopharynx and again the mucus is swallowed or expectorated through coughing
Describe respiratory mucosa (mucus)
Mucus lines the airways from the nasopharynx all the way to the terminal bronchi
The presence of mucus in the airways is entirely normal & helps insulate and prevent drying out of the airways
Antibacterial action within the sol layer
The mucus is also sticky which helps trap and protect the lungs from dust, pollen, pollutants, viruses and bacteria.
However the mucus and the debris that it collects does not remain static otherwise this would allow time for bacteria to multiply and infection to develop
State properties of respiratory mucosa (mucus)
We produce anything from 10 to 100ml (20-30ml normally) of mucus a day
It has a gel like consistency so whilst mostly made of water (97%), it holds its shape because of mucins and proteins.
It has a slimy texture (Consistency of egg whites) because of Glycoproteins.
It has properties of elasticity and viscosity so mucus moves like a soft elastic solid, however, when stress is placed on it, it flows more like a viscous liquid.
The greater the stresses, the less viscous it becomes and the more readily it will flow - like paint or Ketchup. An important property which Physiotherapists manipulate with some of their techniques. Physiotherapists use the fact that mucus becomes more runny when shearing forces are applied during some airway clearance techniques
Describe sputum
Sputum is XS tracheobronchial secretions
Mucus in the airways is normal - sputum is not
Sputum may contain mucus, cellular debris, micro-organisms, pus, blood and foreign particles and so as physiotherapists we ask questions about the colour, quantity and consistency. This helps to establish possible causes and if patients actually require physiotherapy and whether patients are getting better or worse.
Purulent sputum means containing pus. It has greater viscosity and less elastic recoil so clears poorly.
Describe a bronchial cast
A large thick mucus mould or impression of the inner lining of the bronchial tree.
Occurs secondary to allergic inflammation, infection or excessive reactivity to inhalation of aspergillosis fungus (from soil), may lead to allergic bronchopulmonary aspergillosis (ABA)
Can be expectorated but if remains can cause shortness of breath and poor oxygen saturations
State the importance of the MCC
- Respiratory health depends on consistent clearance of airway secretions
- Healthy mucus has low viscosity and is easily transported by the cilia
- Accumulation of mucus occurs because of over production or reduced clearance
- Problem with impaired clearance/retained secretions is it has the potential to cause:
a. Retained secretions disable the antimicrobial chemical shield
b. Potential for overwhelming infection as secretions remain stagnant
c. Persistent accumulation can lead to infection and inflammation by providing an environment ideal for microbial growth
d. Accumulation → major atelectasis (small airway and alveolar collapse) → Impaired gas exchange
e. Accumulation → contamination with pathogens → inflammation and destruction of airways → Airflow limitation (an abnormal resistance or obstruction to airflow)
Who are at risk of accumulation of mucus
Productive diseases (CF, Bronchiectasis, Pneumonia)
COPD - due to smoking temporarily/permanently damaging cilia
State factors of impaired MCC
Mucus:
Changes in viscosity of mucus E.G. Dehydration or an ↑ in production and volume of mucus can slow mucociliary clearance.
Colonisation of mucus with viral, bacterial or fungal organisms can affect the viscosity and quantity of mucus.
Depth of the sol layer:
Cilia movement can be impaired by increased levels of periciliary fluid (pulmonary oedema) or too little (dehydration, ventilation post general anasethetic)
Cilia:
Smoking affects ciliary action by reducing beat frequency and by shortening the cilia so they cannot reach into the mucus gel layer.
General anaesthetic & inhalation of cold air can all reduce the beat frequency of cilia.
Primary ciliary dyskinesia is an inherited condition which affects the structure of the cilia making them move in an uncontrolled way.
Suctioning can damage cilia
Age and sleep:
Increasing age and sleep also slows down mucociliary transport
Ineffective/prolonged cough:
Ineffective cough will also impair mucociliary clearance as coughing is your backup mechanism. Prolonged cough can cause damage to cilia
Immobility
COMBINATION OF ABOVE
When are secretions a Physiotherapy problem
If:
They are seen or heard to obstruct breathing
Excessive, difficult to eliminate and/or causing distress
Cause desaturation because of obstruction/atelectasis and poor ventilation
State the phases of an effective cough
Inspiratory component - Deep Inspiration to near total lung capacity. Expiratory muscles lengthened, optimising expiratory length-tension relationship thus, inhaling to high lung volumes will enable the expiratory muscles to generate greater positive intrathoracic pressures
Compression - A Snapping shut of glottis. A short pause to allow distribution of air past the secretions. Glottic closure minimizes expiratory muscle shortening, promoting strong isometric contraction of expiratory muscles, allowing expiratory muscles to maintain a more advantageous force-length relationship to generate greater positive intraabdominal and intrathoracic pressures. An increase in intrathoracic pressure (100mmhg)
Expiratory component - A Sudden opening of the Glottis resulting in explosive acceleration of peak expiratory flow (PEF) and expulsive airway narrowing. This results in high velocity linear flow of air & greater shearing forces. These Shearing forces overcome viscous, gravitational and frictional resistance causing mucus to be torn from the upper airways and suspending as droplets in the lumen. Large swings of pleural pressure → Dynamic airway compression . A subsequent deep breath will reopen airways
