Bronchial Hygiene Flashcards
Patent airway
good breath sounds and strong effective cough
Effective cough
Volume and flow- which maintains a patent airway- able to clear secretions
COPD constrictive or obstructive?
obstructive
Effective cough steps
- Deep enough breaths (1-2 liters)
- Adequate lung recoil (emphysema would inhibit)
- Level of airway resistance (Bronchospasm-asthma pt)
- Strength of expiratory resp muscles
Expiratory respiratory muscles
Rectus abdominal muscles, External Abdominal obliques, Internal abdominal obliquus, Transverses abdominis muscles, Internal intercostals muscles
Four phases of cough
- Irritation 2. Inspiration 3. Compression 4. Expulsion
Irritation phase
Medullary response
Inspiration phase
1-2 liters
Compression phase
Glottis Closure, Expiratory muscle contraction-0.2 seconds, Increased pleural and alveolar pressure
Expulsion Phase
Glottis opens, Mucus is displaced from airway walls into the air stream, can be swallowed or expectorated
What stimulates us to cough?
Inflammation (infection), Mechanical (foreign body/ aspiration), Chemical (pollutant), Thermal (drastic change in temp)
Snowball effect
Mucus plugging, atelectasis, impaired oxygenation, increased WOB, Air trapping-overdistention, infection, inflammatory response
Cough Impairment
Anesthesia, narcotics. Inadequate pain control, artificial airway- lose compression of cough, Neurologic and or physical dysfunction, inadequate lung recoil, surgery
Primary Goal and indication for bronchial Hygiene therapy
- Help mobilize and remove retained secretions 2. improve gas exchange and reduce work of breathing- collateral ventilation through Pores of Kohn, canals of lambert
Indications
- Pt produce copious amounts of secretion
- Pt unresponsive to coughing techniques
- Reduce air trapping
- Prevent or treat atelectasis
- pt immobile
- Optimize delivery of bronchodilator
- pt in acute resp failure with clinical signs of retained secretions
- Chronic conditions that need continuous secretion removal
Pt unresponsive to coughing techniques=
secretions retained/ stuck
copious amounts of secretions=
more than 30ml. day/ 100cc
Acute respiratory failure, clinical signs of retained secretions=
Adventitious breath sounds, deteriorating arterial blood gases, CXR changes, Physical assessment
Chronic conditions that need continuous secretion removal
Cystic fibrosis, Bronchiectasis, Ciliary dyskinectic syndromes, chronic bronchitis
Ciliary Dyskinectic
Cilia doesnt work
Mucus production and bronchial hygiene
Normal pulmonary tract mucus production is approx 100ml per day and is usually swallowed or reabsorbed in the airway, Bronchial hygiene is appropriate for pt who produce more than 30mL of sputum per day and have trouble clearing it
Sputum color
Purulent, clear, mucoid, and hemoptysis
Purulent
Infection, containing pus. Yellow, green, rusty, red currant jelly
Mucoid
over production of mucus do to exacerbation- asthma
Hemoptysis
blood streaked or frank
frank
all red mucus, get help= BAD!= active hemorrhaging
Mucous amount
scant and copious
scant
few teaspoons (moderate)
Copious
shot glass to a pint or more
Mucous consistency
Thin/ thick, Tenacious, Frothy
Tenacious
Extremely sticky
Frothy
foamy
Contraindications, absolute
Unstable head or neck injury (postural drainage), active hemorrhage with hemodynamic instability
Relative Contraindications
Unable to tolerate increased WOB, ICP> 20mmHg, Unstable hemodynamics, Active hemoptysis, Untreated pneumothorax, Tympanic membrane rupture, Facial/ oral/skull surgery or trauma, Epistaxis, Esophageal surgery, nausea
Epistaxis
Nosebleed
Hazards and Complications
- Pulmonary barotrauma 2. Increased ICP 3. Decreased venous return 4. Breakdown of skin 5. Air swallowing 6. Claustrophobia 7. Hypoventilation and hypercapnea
Hypercapnia
high CO2
Assessment of outcome
- change in sputum 2. change in breath sounds 3. change in vitals 4. change in CXR 5. change in ABG’s/ labs
Coughing techniques
Directed cough, Manually assisted cough, splinting, forced expiratory technique (FET) or “huff coughing”, Active cycle breathing (ACB), Autogenic drainage (AD), Cough assist (Insuflattor/ Exuflattor)
Manually Assisted cough (quad cough)
- Manual thrust similar to heimlich maneuver, performed during expiration splinting
ACB
Active cycle breathing 1. Relaxation and breathing control 2. Thoracic expansion exercises 3. Huff cough
AD
Autogenic drainage 1. Varying lung volumes with controlled expiratory flows 2. Cough is suppressed until you complete a cycle 3. Moving secretions from the small, med, large airways 4. Mucus rattle
Cough Asisst (insuflattor/ exuflattor)
- Delivers a positive pressure for 2-3 seconds followed by an abrupt change into expiration created with a neg pressure (mimics a cough)
PEP Therapy
Active expiration agains variable flow resistance, preventing airway collapse during exhalation
Patient instruction during PEP Therapy
- Have pt sit up 2. Instruct them to take a slightly larger than norm breath 3. Exhale actively but not forceful (through mouthpiece or mask) 4. Have the pt perform 10-20 breaths per cycle 5. have pt cough 6. Evaluate for independent use (if apparatus allows)
Therapeutic pressures on PEP therapy
10-20 cm H2O, pressure is measured with manometer
How many breath cycles on PEP therapy
repeat: 4-8 cycles
PEP I/E ratio
1:3 or 1:4
Total treatment time on PEP therapy
no more than 20 minutes
PD (postural drainage)
Invovled the use of gravity to help move resp tract secretions from distal lung lobes or segments into the larger central airway where they can be removed via coughing or suctioning
Head down positions should exceed
25 degrees below horizontal (hess- 12 inches for lingula/ RML and 18 inches for lower lobes)
Perform PD
every 4 to 6 hours or as ordered, must have adequate hydration for secretion mobility
How many PD positions? (times)
approx 11 positions are possible each position is held for 5 to 10 minutes, total treatment time is typically 20-30 minutes up to one hour
PD scheduled when
before meal or more than 1 hour after mules or tube feeding. coordinate with pain medications. can be done with percussion therapy
Special Beds for rotating/ turning a pt
Rotorest, Rotoprone. Triadyne. May also provide percussion. Prone position
Rotorest/ triadyne
bed that holds body and rotates
Concerns of PD
may need to modify positions, Medically intensive pt
Contraindications of PD
Absolute- unstable spinal cord injuries, Traction of arm abductors, Emphysema, Bronchopleural fistula, Pulmonary embolism, Large pleural effusion
Hazards specific to PD
hypoxemia (positional), acute hyptension, pulmonary hemorrhage, pain or injury to muscles/ribs/ spine, Vomiting and aspiration, bronchospasm, arrhythmias
Percussion and vibration involves
the application of mechanical energy to chest wall by the use of either hands or various electrical or pneumatic devices- Percussion should loosen secretion- vibration should aid in the movement of secretions toward the central airways
Hand clapping
Cupped position-fingers and thumb closed which creates a cushion of air when striking pt, rhythmically strike the chest wall with loose wrists, alternating hands , percuss in circular pattern over a localized area for 3-5 minutes, avoid bony prominences
Vibration
- Performed during exhalation, vibrating the chest wall with hands 2. Mechanical and pneumatic machines provide frequencies of up to 20-30 Hz
Oscillatory PEP and high frequency chest wall compression/ oscillation
vest, flutter, acapella, IPV (intrapulmonary percussive ventilation), Metaneb
IPV
Intrapulmonary percussive ventilation- a pneumatic device that delivers a series of pressurized gas mini-bursts at a rate of 100 to 225 cycles per min usually with a mouthpiece, contains nebulizer, maintains constant PAP, the percussion is controlled by the pt or person giving the treatment
A pneumatic device that delivers a series of pressurized gas mini-bursts at a rate of
100-225 cycles per minutes usually with a mouthpiece
Selecting bronchial hygiene
- Pts motivation/ compliance/ goals 2. physician/ caregiver goals 3. Effectiveness of technique 4. pts learning ability 5. Skill of therapist/ availability, work required 6. disease process 7. Equipment 8. cost
