Bronchial Hygeine And IS Flashcards
Normal clearance of secretions for effective cough
- Irritation
* stimulates sensors
* chemical, thermal, inflammatory - Inspiration
- Compression
- Expulsion
Retention of secretions
Artificial airways Inadequate humidification High FiO2’s Paralytic, anesthetics Mucus plugging, can cause atelectasis and infection
Examples of impairments in compression phase of cough
Artificial airway
Abdominal surgery
Goals for bronchial hygiene
To mobilize secretions and remove retained secretions
— immobile patients
— chronic lung disease
To improve gas exchange
—treats atelectasis caused from retained secretions
To reduce work of breathing
Bronchial hygiene indications
Cystic fibrosis
Ciliary dyskinesia syndrome
Bronchiectasis
Chronic bronchitis
Bronchial hygiene therapy bedside signs and symptoms of the need for bronchial hygiene
Ineffective cough
Decreased breath sounds, crackles, and/or rhonchi
Fever
Methods of bronchial hygiene therapy
Postural drainage Chest percussion Coughing and deep breathing Positive airway pressures Breathing exercises (diaphragmatic breathing, segmental breathing, pursed lips breathing)
What is the primary purpose of turning a patient
Improves oxygenation
Place the bad lung up which improves V/Q relationship
Turning indications
Poor oxygenation associated with position (unilateral lung disease [bad lung up])
Turning absolute contraindications
Worsening of SpO2
Unstable spinal cord injury
Traction of arm abductors
Postural drainage uses gravity and mechanical energy to
Mobilize secretions
Improve V/Q balance
Normalize FRC
Postural drainage is best for
Excessive secretions >25 ml/day
Modify the trendelenberg with the condition
Decreased SpO2
What should be assessed to establish the need for postural drainage therapy
Decreased breath sounds and/or crackles and/or rhonchi suggesting secretions in the airway
Abnormal chest X ray consistent with atelectasis, mucus plugging, or infiltrates
Postural drainage indications
Evidence of difficulty clearing secretions
Presence of atelectasis
Diagnosis of diseases such as CF, bronchiectasis, cavitation lung disease
Presence of foreign body in airway
External manipulation of the thorax to assist the movement of secretions by vibrations
All positions are contraindicated for
ICP
Empyema
Large pleural effusions
Trendelenburg position is contraindicated for
Empyema
Hazards of postural drainage
Hypoxemia Increased ICP Acute hypotension Pulmonary hemorrhage Pain or injury to muscles, ribs, or spine Vomiting and aspiration Bronchospasm Dysrhythmias Headache, dizziness
Lung segment
Apical (anterior upper ) segments of both upper lobes
Semi-Fowler’s position with the head of the bed raised 45 degrees
Lung segment
Anterior segments of both upper lobes
Patient supine with the bed flat
Posterior (posterior apical) segments of both upper lobes
Patients sitting up and leaning forward
Right middle lobe (medial and lateral segments)
Patient 1/4 turn from supine with right side up and foot of the bed elevated 12”
Lingular segment of left upper lobe (superior and inferior segments)
Patient 1/4 turn from supine with left side up and foot of the bed elevated 12 “
Superior segments of both lower lobes
Patient prone with bed flat and pillow under abdomen
Anterior segments of bot lower lobes
Patient supine with foot of bed elevated 20”
Posterior segments of both lower lobes
Patient prone with foot of bed elevated 20”
Right lateral segment of right lower lobe
Patient directly on left side with right side up and the foot of the bed elevated 20”
Left lateral segment of right lower lobe
Patient directly on right side with left side up and the foot of the bed elevated 20”
What rule do you follow when you see an adverse patient response during postural drainage therapy
Follow the triple s rule
Stop the therapy
Stay with the patient
Stabilize the patient
Assessment of outcome in bronchial hygiene therapy
Change in ventilator variables
Airway resistance
Peak pressures
Monitoring patient during bronchial hygiene therapy
Sputum production and cough effectiveness
— color, consistency, amount
SpO2
Modify therapy if needed
Percussion and vibration help to
Shake the secretions toward the central airways during exhalation
What are the four components of an effective cough
Irritation
Inspiration
Compression
Expulsion
What is a directed cough
A deliberate maneuver to mimic spontaneous cough
Directed cough indications
The need to aid the removal of retained secretions from central airways
The presence of atelectasis
Prophylaxis against post-operative complications
Routine part of bronchial hygiene for CF, bronchiectasis, chronic bronchitis, necrotizing pulmonary infection, spinal cord injury
Integral part of bronchial hygiene therapy’s
—postural drainage, PEP therapy, incentive spirometry, aerosol therapy
To obtain sputum specimens for diagnostic analysis
For directed cough technique, patient needs to have
Hydration
Pain control
Be able to sit at bedside with feet on floor or sit them up and bend their knees
Hazards and complications of directed cough
Incisional pain, evisceration
Coordinate with pain medications
Assessment of need for directed cough
Spontaneous cough that fails to clear secretions
Ineffective spontaneous cough
Post operative patients
Long term care patients with tendency to retain airway secretions
Presence of ETT or trach tube
Positive airway pressure (PAP)
Indications
To reduce air trapping in asthma and COPD
To aid in mobilization of retained secretions
To prevent or revers atelectasis
To optimize delivery of bronchodilators in patients receiving bronchial hygiene therapy
Hazards and complications of PAP
Fatigue, shorten treatment time and continue with SVN
Barotrauma
Increased ICP
Cardiovascular compromise
Skin break down and discomfort from mask
Air swallowing, vomiting, aspiration
Claustrophobia
Increased WOB that may lead to hypoventilation and hypercapnia
Bronchial hygiene therapy PAP
What is PEP for
Great for CF patients or to treat air trapping
Can be used with SVN for patient who need medication and have documented atelectasis
Flutter valve
Good for CF patients, especially if they cannot tolerate chest physical therapy
Chest wall compression
Increases patient compliance to bronchial hygiene therapy, especially in the home
Resorption atelectasis
When lesions or mucus plugs are present in the airways and block ventilation to the affected region (nitrogen is absorbed and not replaced)
Passive atelectasis
Caused from patients breathing shallow
Anesthesia, sedatives, bed rest, painful deep breathing
Who is lung expansion therapy good for
Upper abdominal or thoracic surgery patients
Best time to orient patient is prior to surgery
Clinical signs of atelectasis
Increased RR
Breath sounds have fine, late inspiratory crackles.
The trans pulmonary pressure gradient can be increased by
Decreasing surrounding pleural pressures
What is IS designed to mimic
Natural sighing, by encouraging patients to take slow, deep breaths through their mouths
What is an SMI
A slow, deep inhalation after normal expiration (in other words they begin the breath at FRC)
They should have a 5-10 second breath hold
Indications for lung expansion therapy
Treating existing atelectasis
Presence of conditions predisposing to atelectasis, upper abdominal surgery, thoracic surgery, COPD surgery patients
Presence of a restrictive lung defect with quadriplegic and/or dysfunctional diaphragm
IS contraindications
Unconscious or obtruded patients
Patients unable to cooperate
Vital capacity <10 ml/kg
Inspiratory capacity < 1/3 predicted normal
Hazards of IS
Hyperventilation and respiratory alkalosis
Incentive spirometry outcome assessment
Absence or improvement in the signs of atelectasis
Decreased RR
Normal HR
Temperature should normalize
Breath sounds should clear and/or improve
Normal chest X-ray
Increased SpO2, PaO2, and or PAO2
Increased VC and peak expiratory flow rate
Flow oriented IS equipment calculation of approximate volume inspired
of spheres raised x total #seconds
IS instructions
Exhale normally
Take deep slow breath through mouthpiece, keeping flow indicator in proper position
Hold breath 5 - 10 seconds once lungs are full
Wait 30 seconds to 1 minute between attempts
Repeat procedure 5-10 times every hour
