Impaired Airway Clearance

Question 1

Causes of abnormal muco-ciliary clearance

Answer 1

Alterations to mucus -
increased viscosity of secretions
- cystic fibrosis
- dehydration (either systemic or airway)
increased volume of secretions produced by the goblet cells
- due to airway inflammation
- caused by having a foreign body in the airway
- infection

Destruction of the muco-ciliary system 
dysfunction of the cilia 
- primary ciliary dyskinesia 
- general anaesthetic 
destruction of the ciliated epithelial cells 
- smoking 
- chronic inflammatory disorders 

Ineffective cough

• respiratory muscle weakness
• abdominal muscle weakness
• reduced consciousness
• reduced cough reflex
• reduced lung volumes
• airway narrowing
• pain

Question 2

Factors that reduce MCC

Answer 2

anaesthetic drugs
drying of the mucosa/dehydration 
high FiO2 concentration 
medications 
hypoxia 
artifical airways 
positive pressure ventilation 
lack of sleep

Question 3

Impaired airway clearance - clinical significance

Answer 3

Repeated cycles fo infection/inflammation
Reduced lung volumes - due to the obstruction of airflow through the airways
Impaired gas exchange - due to reduced lung volumes, less oxygen is able to reach the alveoli
Dyspnoea - body attempts to compensate for altered blood gas concentrations
Reduced exercise tolerance - individual avoids activity due to other impairments

Question 4

Impaired airway clearance - clinical features

Answer 4

Patient describes having difficulty clearing their secretions
Repeated infection with chronic disease
Increased work of breathing
Auscultation - low pitch wheeze/crackling with expiration
- reduced or absent breath sounds over the consolidated lung
- bronchial breath sounds over the consolidated lung

Palpation - reduced chest expansion over the collapsed areas of lung

Cough - moist or dry
- can be effective and productive OR ineffective and weak

CXR - can reveal consolidation or collapse

Reduced SpiO2

Question 5

Airway Clearance Techniques - factors to consider

Answer 5

Patient Factors

• age
• motivation
• goals
• preference
• concentration and ease of learning
• disease process and severity

Physiotherapist Factors

• goals of treatment
• own skill
• time
• combination with other treatment

Technique Factors

• effectiveness
• limitations to technique
• availability of equipment

Question 6

What causes an ineffective cough?

Answer 6

Decreased expiratory force 
- muscle weakness
- poor elastic recoil 
- inability to close the glottis 
Decreased inspiratory volume 
- pain 
- obstruction 
- restriction 
- fear/anxiety 
- muscle weakness
- neurological impairment 
Other 
- fatigue 
- cough syncope 
- dynamic airway collapse in obstructive disease

Question 7

Techniques to improve cough

Answer 7

Improving expiratory flow 
- supported cough 
- assisted cough 
- stimulated cough 
Improving lung volumes 
- pain control 
- positioning 
- thoracic expansion exercises 
- glossopharyngeal breathing 
- cough assistance machines 
- NIV

Question 8

Supported Cough

Answer 8

useful for patient with surgical wounds or chest/abdominal trauma
their cough is limited by pain
use towel or pillow - hold over their chest so as to limit excursion of the painful area

Question 9

Assisted Cough

Answer 9

useful for patients with weakness
needs to be used in combinations with other techniques which increase lung volume
apply compressive force inwards and upwards under the diaphragm

Question 10

Cough Assistance Machines

Answer 10

via machine and mouthpiece
insufflation - creates a positive pressure to assist with inspiration
exsuffation - creates a negative pressure to assist with expiration

Question 11

Cough Stimulation

Answer 11

Rolling, moving or percussing - can be enough to trigger a cough in patients with copious secretions
Tracheal Rub - don’t use on alert patients as is extremely uncomfortable, rubbing areas above the sternal notch
Suctioning - only in critical circumstances, will immediately trigger a cough

Question 12

Positive Expiratory Pressure Devices

Answer 12

creates resistance to airflow during expiration which creates back pressure into the lungs, temporarily increasing FRC
mainly for patients who have chronic sputum production and obstruction

Works via forcing air into collateral ventilation channels and splinting open the airways

Question 13

Oscillating PEP

Answer 13

Oscillating resistance rather than constant
Alters the rheology (flow) of mucus in order to facilitate muco-ciliary clearance
Stimulates the cilia - increased cilial beat
Induces vibration - dislodges mucus from the wall into the airway lumen
loosens mucus due to accelerated airflow

Flutter Device
Acapella Device

Question 14

Physio Management

Answer 14

positioning?
ACBTs
chest wall manouevres
PEP

Question 15

PEP perscription

Answer 15

F - twice a day
I - tidal volume breathing
T - 3-4 secs per round, 10-15 times, for 15-20 mins

Question 16

PEP CIs

Answer 16

late stage cystic fibrosis 
emphysematous bullae 
lung surgery 
irritable asthma 
undrained pneumothorax 
severe bronchospasm

Question 17

Chest Wall Manouevres

Answer 17

generate energy into chest wall in order to assist with airway clearance
Percussion - tapping
Vibrations
Shaking

Don’t use on

• old patient
• underweight
• lot of pain
• surgical wound