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
State factors that may impair cough mechanism
Altered flow properties of secretions:↑ viscosity and elasticity of sputum = Tenacious secretions. Tenacious secretions will ↓ cough effectiveness
Inability to generate sufficient expiratory flow: Severely reduced Vital capacity - impair inspiration. Respiratory muscle weakness/dysfunction, I.e. Neuro-muscular disorders (GBS, MND,MS, Myasthenia Gravis, Muscular Dystrophy, Tetraplegia), Chronic lung disease: COPD (high WOB too fatigued), Bronchiectasis (airflow obstruction), Chest wall disorders (Kyphoscoliosis, Rib fractures). Airways that collapse easily on exhalation/Airflow limitation. Dilated airways. Fear and anxiety - particularly chronic pts; fear of incontinence and panic attacks
Fear of pain: Post op, Chest trauma
Reduced cough reflex: LOC (level of consciousness), GA (general anaesthetic), narcotic analgesia (morphine), Damage to vagal or glossopharyngeal nerve - cough won’t be triggered, Laryngectomy /intubation/tracheostomy cough weakened as glottis bypassed (inability to close glottis)
Adverse effects of vigorous/persistent cough
- Urinary incontinence - particularly elderly woman; related to increase in pressure on pelvic floor during cough
- GOR (gastroesophageal reflux), hernia
- Rib # (may be OP), ruptured rectus abdominus
- Cough syncope (pass out), headache
- Stroke, seizures (rare)
- Laryngeal or tracheobronchial trauma, pneumothorax
- Airflow limitation - dynamic compression
↑ or ↓BP, heart rhythm problems - due to large swings in pressure
What is the purpose of airway clearing techniques
Aim: to promote clearance of excessive secretions from the distal airways to central airways where expectoration can occur through coughing or huffing
What factors should you consider when choosing an airway clearing technique
- Influenced by underlying cause and acuity of patient condition
- Excessive or retained secretions
- Patient age and ability to learn the technique - any co-morbidities (OP, Dementia)
- Patient motivation
- Patient preference and comfort
- Understanding effects of technique
- Hydration/humidification
- Does cough need to be augmented or supressed
- Indications and contraindications
- How will you measure outcome & effectiveness
Purpose of airway clearance techniques with chronic patients
During hospital admission PT may take a more active role and frequency and duration of treatment may increase in those patients with chronic conditions
A change of technique may be indicated and it is the PTs role (in consultation with the patient) to select a technique that addresses the CHANGING condition.
Stable non-acute COPD:
Less active role ff a patient is not troubled by a cough and are able to clear sputum when required, daily routine chest clearance may not be necessary BUT patients may need to be taught when to recognise they have a chest infection and an effective chest clearance technique they feel comfortable with for such times (self-management techniques).
State causes of impaired airway clearance
Dehydration Increased levels/lack of O2 Infection Altered composition of mucus/increased mucus Impaired cough Immobility Airway damage Weakness Pain Anxiety and fear
General principles of airway clearance techniques
Airway clearance techniques aim to enhance mucociliary clearance and mucus transport. Mobilising secretions toward the mouth to aid expectoration
There is no evidence to support the use of one airway clearance technique over any other
Practice is influenced by culture, skills of the therapist, finances of healthcare provision, and where possible patient preference and is effective
Other considerations:
Giving patients the ability to clear their airways
Prevent excess energy expenditure
Ensure adequate oxygen
Ensure adequate energy supply
Long term airway clearance regimes need to be negotiated and reassessed on a regular basis.
State airway clearance techniques
Active Cycle of Breathing Technique (ACBT) Hydration (Humidification) Positioning Mobilisation Manual techniques Adjuncts Autogenic Drainage Suctioning
What is included in ACBT
Breathing Control (Diaphragmatic/relaxed breathing)
Thoracic Expansion Exercises (TEEs)/Deep Breathing Exercises (DBE’s)
Huffing/Forced Expiratory Technique (FET)
ACBT = 3 phased cycle, flexible ‘hands on’ technique
Cyclical approach of the three elements of breathing techniques in an order that suits the patient
How do breathing control exercises and DBEs aid in sputum clearance
- In normal lung resistance to airflow and collateral channels is high
- In the presence of high lung volume/pathology resistance to airflow and collateral channels decreases allowing airflow behind secretions
Define Huffing/Forced Expiratory Technique (FET)
A ‘Huff’ is a forced exhalation through an open mouth and glottis instead of/with coughing
Theory behind huffing
- Helps mobilise sputum up the airways toward the mouth in a controlled way
- Uses the abdominal muscles and chest wall to facilitate expiratory airflow
- Huffing should always be followed by breathing control and should not be so forced that it causes wheezing or tightness in the chest
- Huffing usually starts from low lung volume but once secretions start to move proximally huffs can be taken from a higher lung volume
Technique for huffing
- To ‘huff’ you squeeze air
quickly from your lungs, out through your open
mouth and throat, as if you were trying to mist
up a mirror or your glasses - Many patients mistake blowing for huffing – the use of a peak flow mouth piece can help them get the technique right
- Huffing into low lung volume may be easier if patients take a normal sized breath in, then partially breathe out and finally huff near the end of exhalation
- Small-long huff
This will move sputum from low down in your
chest. Take a small to medium breath in and
then huff (squeeze) the air out until your lungs
feel quite empty, as detailed above. - Big-short huff
This moves sputum from higher up in your chest, so use this huff when it feels ready to
come out, but not before. Take a deep breath in
and then huff the air out quickly. This should clear your sputum without coughing - When secretions have reached the larger proximal airways a huff or cough from a high lung volume can be used to clear them
How does huffing aid in sputum clearance
- Any forced expiratory manoeuvre (including coughing) causes dynamic compression and collapse of airways. - During a huff, pleural pressure becomes positive and equal to airway pressure at a point called the Equal Pressure Point (EPP).
- From this EPP, to the mouth, the pressure outside the airway is greater than that within the airway
- This creates narrowing and a squeezing action (dynamic compression) which moves progressively toward the mouth
How can target huffing in the peripheral airways VS central airways
EPP location depends on lung volume at the start of the huff:
- EPP occurs nearer to the mouth at high lung volumes and further from the mouth at low lung volumes.
- Huffing to low lung volumes should assists moving secretions from more peripheral areas i.e. those secretions furthest away from the mouth whilst huffing from high lung volumes moves secretions from more proximal airways i.e. nearer to the mouth
- Small inspiration = low lung volume. When forced manoeuvre produced it does not take long until EPP and the pressure in the airways is quickly reduced therefore DC occurs close to alveoli
- Mid-sized inspiration = mid lung volume. When forced manoeuvre is performed it will take slightly longer to reach EPP as more pressure in airways from mid-sized inspiration. EPP and ultimately DC moves further from alveoli closer to mouth
- Large inspiration = high lung volume. When forced manoeuvre performed EPP will take longer to reach due to high lung volume creating greater airway pressure. EPP and DC occurs much closer to mouth
Reasons to use huffing rather than coughing
- Huffing works like coughing but requires less effort.
- Coughing creates greater airway narrowing than huffing, limiting airflow and reducing the efficiency of bronchial clearance.
- Huffing provides slight oscillation or hidden vibrations in addition to the squeezing action.
- High velocity airflow interacts with liquid lined airway surfaces causing shear forces which will reduce viscosity and (if fast enough) propel sputum in the direction of flow
Examples of ACBTs depending of varying symptoms
Accumulation of sputum - lot of huffing and breathing control
SOB w/ not a lot of sputum - lots of BC and little of huffing and TEEs
Atelactasis w/ sputum as cause - lots of TEEs, followed by BC, huffing for sputum
How long do to ACBT for?
aim to continue your exercises for
about 10 minutes and ideally until your chest
feels clear of sputum
Define Autogenic Drainage (AD)
• A sputum removal technique that aims to maximise airflow within the airways to improve clearance and ventilation
Principle behind AD
- Linear flow of air moving with sufficient speed through a tube, will create shear forces and thus mobilise a deposit, i.e. mobilise mucous in the respiratory tract.
- Laminar flow prevents turbulence and dynamic compression of the airway walls.
State aims of AD
- Keeping the bronchial tree and upper airways open
- Maintaining lowest possible airway resistance
- Maximizing respiratory flow rate
- Minimizing airway collapse on expiration
- Mobilize mucus from small airways to mouth
State requirements for AD to be effective
- A pump generating high flows
- Satisfactory Respiratory muscles
- Strong tube with stable walls
- The airway wall must be stable
- Low intra-tubular resistance
- Slow flow, laminar flow
- Non-sticky deposit
- As watery secretions as possible
State phases of breathing cycle in AD
Starts at lower lung volumes and move secretions from small airways to larger ones.
As the patient feels the mucus move, increase the lung volume, breathing at greater volumes until the mucous can be expectorated.
•Phase 1. Unstick.
Nose is cleared first. Breath into ERV, followed by normal tidal breaths in ERV. Breathing at low lung volumes to move secretions in the small airways.
•Phase 2. Collect.
Breathing at normal tidal volume (mid lung volumes); to move secretions up mid-sized airways
•Phase 3. Evacuate. Progressively taking larger breaths into IRV. Breathing at larger lung volume to move secretions up central airways
No break in-between phases.
Explain humidification principles
Hydration affects the function of cilia as well as the quality and quantity of mucus
To prevent secretion thickening;
1. Systemic hydration by oral or intravenous fluids (nil by mouth)
2. Inhalation of a vapour
3. Nebulization by inhalation of an aerosol (salbutamol bronchodilator in saline nebuliser)
Done prior/during ACBTs
Hydration is difficult for COPD, elderly patients as it is high effort to for them to get up and drink water plus increases their need for urination, particularly if on diuretics
Usually by mask but may be by mouth piece
State manual techniques
Percussions
Vibrations
Shakes
State principle of manual techniques
Aim to move loose secretions from the airway walls and aid mucociliary transport
Commonly carried out in modified postural drainage positions
Interspersed with huffing and coughing
Adequate pain relief prior to MTs is vital
CF patients - DNase prior
Describe percussion technique
Rhythmic clapping on the chest
Loose wrist and cupped hand.
Energy wave created is transmitted to the airways
Skin is covered with a thin layer cloth (NOT ON BARE SKIN)
Single/Double handed - double can cause bronchospasm (wheeze) and/or can worsen SOB
Duration of 30secs-1minute (longer duration increase risks of side effects)
Systematically from lower -> upper airways
Which patients are percussion most effective on
Those with sputum retention
Consideration of percussion in paediatrics
Children may not like technique - teach techniques to parents
Describe Vibs/Shakes techniques
Vibrations are fine oscillations of the hands
Shaking is a coarser movement
Directed inwards against the chest
Performed on exhalation after a deep inhalation
Patient needs to be on a firm surface
Is self percussion effective
Yes - not as effective however
State contraindications and precautions to MTs
Contraindications: Current large frank haemoptysis Rib fractures/flail segment/Osteoporosis/Ca Active pulmonary TB Pneumothorax/Surgical emphysema
Precautions: Severe clotting disorder Uncontrolled thoracic pain Over incisions, burns or frail skin Implanted venous access devices
Forms of mobilisation
Rolling in bed
Sitting
Standing
Walking
