L6-7: ACTs Flashcards
1
Q
What do coarse crackles VS fine crackles indicate?
A
Coarse crackles: Secretions
Fine crackles: Atelectasis
2
Q
What are the abbreviations for terms?
A
3
Q
Why do we care about ACTs?
A
- Airway clearance is a vital skill in Physio toolkit
- Aim = Identify secretion over-production / retention problems –> select and implement most appropriate technique/s for individual
- Ax outcome and modify Rx as needed
4
Q
What are the 2 main mechanisms of normal airway clearance?
A
- Mucociliary clearance (MCC)
- Effective cough (as a backup for impaired MCC)
Further secretions causing complications (mircrobes)
- Eg. pneumonia
5
Q
What does the flow of impaired airway clearance?
A
6
Q
What are 3 characteristics of mucociliary escalator?
A
7
Q
What are the 2 main mechanisms of impaired airway clearance?
A
- Impaired mucociliary clearance
- Ineffective cough
8
Q
What are the 10 factors for reducing temporary muscociliar clearance?
A
↓ cilial beating
- Medications (eg, GA, narcotics)
- Drying of mucosa, dehydration (mucous = 95% H2O)
- High inspired O2 concentration (FiO2)
- Positive Pressure Ventilation
- Endotracheal intubation
- Atelectasis, ↓ lung volumes
- ↓ Cough effectiveness
- Lack of sleep
- Pollutants
9
Q
What are the 2 factors for reducing permanent muscociliar clearance?
A
- Smoking
- Disease states (eg. CF, bronchiectasis)
10
Q
What are the 2 factors for reducing muscociliar clearance?
A
- ↓ Cilial beating
- ↑ Secretion volume / thickness
- (eg: CF, bronchiectasis, infection, dehydration)
11
Q
What ae the effects of increased secretions?
A
Healthy lung = 100ml mucous / day
Aim of ACTs: clear excess / retained secretions to reduce these effects (Achieving one or all of these steps)
- Presence of secretions = normal
- Excess/retained secretions = abnormal
- Get air behind secretions
- Secretion MOBILISATION
- Secretion REMOVAL
12
Q
What are 4 effects of congested airway?
A
- ↑ Cilial function
- ↑ WOB fatigue
- ↓ Ventilation, ↓ V/Q ratio, ↓ PaO2
- • Long term damage / scarring
Congested airway = narrow orifices
13
Q
What is important when checking sputum?
A
Quality and quantity of sputum
Infection control (tissue, clean hands, cup, PPE- gloves, goggles, gown)
14
Q
What are 9 ACTs in the tool kit?
A
- Cough (Supported + Assisted)
- Active Cycle of Breathing Technique (ACBT)
- Positive Expiratory Pressure (PEP)
- Autogenic Drainage (AD)
- Postural Drainage (PD, MPD)
- Percussion and Vibration (P & V)
- Inhalation therapy
- Exercise therapy
- Suction
15
Q
What is a cough?
A
- Protective reflex ridding airway of secretions / foreign bodies
- 1st 6 generations cleared by cough
16
Q
1st ______ generations cleared by cough
A
6
Mobilise more peripherally to top 6 generations => cough
17
Q
What are 7 components of cough?
A
- ↑ Inspiratory volume
- Closure of glottis
- ↑ ITP
- Abdominal muscle contraction
- ↑ IAP and ITP against a closed glottis
- Opening of glottis
- Ascent of diaphragm
- Forceful expulsion of air and / or secretions / foreign bodies
18
Q
What are 6 causes of decreased lung volume for what can go wrong in a cough?
A
- Pain
- Restriction
- Obstruction
- Fear / anxiety
- Muscle weakness
- Neurological impairment
19
Q
What is the solution for decreased lung volume for what can go wrong in a cough?
A
Methods of improving lung volume
- Pain, positioning (upright), TEE, collateral ventilation, alveolar interdependence, allow different time constants,
20
Q
What are 4 causes of decreased expiratory force for what can go wrong in a cough?
A
- Pain (eg, incision)
- Muscle weakness
- Poor elastic recoil (eg, Emphysema)
- Inability to close glottis (eg, Bulbar Palsy)
21
Q
What are 4 solutions of decreased expiratory force for what can go wrong in a cough?
A
Augment the expiratory phase
- Supported cough (pillow, towel, binder)
- Assisted cough (bibasal, AP sternal)
- Substernal angle compression
- Subcostal thrust
22
Q
When should you use a assisted cough VS supported cough?
A
Supported cough = pain is present (eg. surgery)
Assisted cough = weakness is present
23
Q
What are 3 features of a supported cough?
A
- ↑ IAP with support
- ↓ Tension on the wound during contraction
- ↑ ROM through which the muscle contracts
↑ Force –> ↑ Effectiveness of cough
24
Q
What is the aim of an assisted cough?
A
Assist generation of explosive force
25
What are the 4 features of an **assisted cough**?
1. **Bibasal compression** if compliant chest + flaring
* Augment bucket handle
2. **AP sternal compression** if apical movement
* Augment pump handle
3. **Substernal angle compression** can assist diaphragm ascent
4. **Subcostal thrust** used for people with SCI (when unable to contract abdominals to generate force)
Weakness (become the patient's muscles)
26
What is *bibasal compression* in an **assisted cough**?
Bibasal compression if compliant chest + flaring
* Augment bucket handle
27
What is *AP sternal compression* in an **assisted cough**?
AP sternal compression if apical movement
* Augment pump handle
28
What is *substernal angle compression* in an **assisted cough**?
Substernal angle compression can assist diaphragm ascent
29
What is *subcostal thrust* in an **assisted cough**?
Subcostal thrust used for people with SCI (when unable to contract abdominals to generate force)
30
What are 3 other techniques for a **cough**?
1. Tracheal rub
2. Stimulated cough
3. Mechanical insufflator/exsufflator devices (CoughAssistTM machine)
31
What are the 6 adverse effects of **vigorous/chronic coughing?**
1. Cardiovascular
2. Genitourinary
3. Gastrointestinal
4. Musculoskeletal
5. Neurological
6. Respiratory
32
What are 3 summaries of **cough**?
1. Natural defence mechanism to clear secretions
2. May be compromised --\> retained secretions
* Use techniques
3. May be too vigorous / chronic --\> adverse effects
33
What are 2 ways to increase **cough effectiveness**?
1. ↑ Inspiratory volume
2. ↑ Expiratory force:
1. Supported cough
* Pain/soreness (ribs or abdomen)
2. Assisted cough
* Weakness
3. Substernal angle compression
4. Subcostal thrust
34
What are 2 aims of Active Cycle of Breathing Technique (ACBT)?
1. Mobilises & clears excess secretions
2. Improves lung function
35
What are 6 advantages of Active Cycle of Breathing Technique (ACBT)?
1. Flexible --\> adapt to suit *individual*
2. Use with a variety of patients
3. Well-tolerated
4. Use in any position
5. Combine with other Rx
6. Can be performed independently
36
What are the components of ACBT?
37
What are 7 characteristics of **breathing control (BC)** as a *componenent of ACBT*?
1. Gentle tidal breathing
2. Emphasise lower chest, not upper chest
3. --\> Minimal effort expended
4. Inspire through **nose** to warm, humidify and cleanse air (but through mouth if nose is blocked)
5. Intersperse throughout other techniques for recovery & to prevent airflow obstruction
6. Duration of BC depends on pt’s presentation
7. 2-3 breaths, up to minutes++
38
What are 7 characteristics of **throacic expansion exercises (TEE)** as a *componenent of ACBT*?
1. **Slow, Laminar flow**
2. +/- **I**nspiratory **H**old (~3sec)
3. +/- ‘sniff’ manoeuvre
4. Emphasis on inspiration
5. Encourage lower chest expansion (can use proprioceptive stimulation)
6. 3-4 TEE, then BC (\>5 TEE may --\> hyperventilation/ light headed / fatigue)
7. \*Can be used during P & V to ↓ hypoxaemia
39
What are 2 aims of **thoracic expansion exercises (TEE)** as a *componenent of ACBT*?
1. ↑ Lung volume
* Collateral Ventilation:
1. Air behind secretions
2. Mobilise secretions
2. Re-expand lung
1. Alveolar Interdependence
2. Surfactant release
3. Newtonian’s Law of Viscosity- (sticky surfaces --\> better when slow)
4. Allows for different time constants
40
What is **collateral ventilation** of **thoracic expansion exercises** **(TEE)** as a *componenent of ACB*T?
41
What is **alveolar interdependence** of **thoracic expansion exercises (TEE)** as a *componenent of ACBT*?
42
What are 6 characteristics of **Forced Expiratory Technique (FET / Huff)** as a *componenent of ACBT*?
1. **Huff** with **BC**
2. Emphasis on expiration (“squeeze not wheeze”)
3. Different lung volumes (**low, mid, high**) to mobilise then remove secretions
4. **BC** prevents airflow obstruction;
5. Duration of **BC** depends on pt
43
What is Equal Pressure Points (EPP)?
44
What are the 4 steps of EPP?
45
What is the **low** VS **mid** VS **high lung volume**?
46
What are 5 characteristics in the duration of ACBT?
1. Generally = 10 to 30 mins
2. If productive = usually 10mins in productive position
3. ~2 positions per Rx session
4. If minimal secretions (eg, asthma) = less time
5. Repeat until effective huff to low lung volume (mobilise most periphery area of lungs) has become dry sounding and non-productive
1. Eg: 2 consecutive cycles OR when / if fatigue occurs
47
What are 5 summaries of ACBT?
1. Cycle of breathing exercises
2. Can be modified to suit patient (not rigid routine)
3. Can be combined with other Rx techniques
4. Can be performed independently
5. No equipment required
48
What are 3 techniques in ACBT?
1. BC
2. TEE (+/- IH)
3. Huff / FET (low, mid, high vol)
Tailored to suit patient
49
What are 4 aims of **Positive Expiratory Pressure** as the *3rd ACT*?
(same for all types of PEP devices)
1. Reinflates collapsed parts of lung by **collateral ventilation**
2. **Splints** airways
3. **Air behind secretions** to **mobilise** upwards
4. Increase FRC
5. Increase lung volumes
Can also attach nebuliser to PEP devices.
50
What is the **theory of PEP** as the *3rd ACT*?
51
What is **collateral ventilation of PEP** as the *3rd ACT*?
1. Collateral Ventilation
2. Splints airways
3. Air behind secretions to mobilise upwards
52
What are **components of PEP** as the *3rd ACT*?
53
What are 3 characteristics when **selecting resistance in PEP** as the *3rd ACT*?
1. **Size** of resistor (numbered 1 --\> 5; 1 = smallest hole)
1. Smaller resistor number (smaller hole)--\> greater PEP generated
2. Larger resistor number (larger hole)--\> less PEP generated
* Usually start with middle size (too small can be too much pressure in head)
* (eg. breath out through pursed lips, smaller orifices)
2. Patient’s **expiratory flow**
1. Greater flow --\> greater PEP generated
2. Less flow --\> less PEP generated
3. **Test:** 6-8 breaths with PEP:
1. Pressure of 10-20cmH2O
2. Able to maintain correct technique
3. I:E = 1:3
4. Inspiration: expiration
* Check no…
* Increase WOB (accessory / abdo muscle use)
* SOB
54
What are 4 **mouthpieces** as the *3rd ACT*?
(eg. PariPEP, TheraPEP):
1. More common device
2. Smaller, more portable
3. Must keep cheeks flat
4. Use with nose clip
55
What are 2 **masks** as the *3rd ACT*?
1. If unable to keep cheeks flat
2. If unable to keep mouth sealed around mouthpiece
56
What is the PEP duration for the 2 conditions (stable pulmonary disease; hospitalisation/post-op) as the 3rd ACT?
57
What are 8 **PEP indications** as the *3rd ACT*?
**EXAM QUESTION**
1. CF
2. COPD
3. Bronchiectasis
4. Chronic bronchitis
5. Restrictive lung disease
6. Post op secretions / atelectasis
7. Collapsible airways ; tracheobronchial instability
8. Productive asthma (with care, ensure \<10cmH2O)
* Not getting reactive/hyperactivity of airways
***Chronic conditions (not for single use)***
58
What are 8 PEP clinical precautions as the 3rd ACT?
**EXAM QUESTION**
59
What are 2 characteristics of **HiPEP (high pressure)** as the *3rd ACT*?
1. Forced expiration (FVC) against PEP mask
2. Expiratory pressure of 50-120cmH2O (standard PEP is10-20cmH2O)
60
What are 3 **disadvantages** of **HiPEP (high pressure)** as the *3rd ACT*?
1. If incorrect resistance --\> deterioration
2. Spirometry required for regular reAx
3. High expiratory effort for patient
61
What are 4 patients that are **not recommended for HiPEP (high pressure)** as the *3rd ACT*?
1. Venous clotting when PE likely
2. Cardiac disease
3. Malnourishment
4. Weakness
62
What are 4 characteristics of **oscillating PEP** as the *3rd ACT*?
1. Oscillations of expiratory flow (combined with PEP)
2. Alters physical properties (rheology) of secretions
1. Mechanically ruptures rigid mucous gel
2. Decreased viscosity; thinner relative to autogenic drainage
3. Facilitates secretion mobilisation and clearance
4. Prevents airway collapse (via PEP)
5. Reduces expiratory effort
63
What are 4 types of oscillating PEP?
1. Flutter
2. Acapella
3. Aerobika
4. Bubble
64
What are 7 characteristics of **oscillating Flutter PEP** as the *3rd ACT*?
1. Small portable pipe-like device
2. Decreased sputum **viscoelasticity**
3. Increased diameter of peripheral airway
4. Endobronchial pressures = 18-35cmH2O
5. Tilt to optimum position: **8-16Hz** (natural pulmonary resonance of cilial beat)
6. Vibration of bronchial wall (ensure vibrations do not occur at cheeks)
7. **Cannot inspire** through device
65
What are 3 characteristics of oscillating **Acapella and Aerobika PEP** as the *3rd ACT*?
1. Oscillatory PEP
2. Can inspire through device
3. Oscillations independent of gravity
Able to lye down (does not have to be perpendicular)
66
What are 5 characteristics of **oscillating Bubble PEP** as the *3rd ACT*?
1. Inexpensive
2. Fun, but not limited to paeds
3. PEP principles
4. Previously “DIY” with empty milk bottle, now commercialised, eg:
1. AguaPEP
2. HydraPEP
3. TheraBubble
5. \*Not appropriate if pt has confusion/ cognitive impairment (aspiration risk due to inhaling water)
67
What are the 3 summaries for the **Positive Pressure during Expiration** as the *3rd ACT*?
1. Increased collateral ventilation
2. Splints airways
3. Secretion mobilisation effect --\> assists removal
68
What are the 4 **types of PEP** as the *3rd ACT*?
1. Standard PEP (mask vs mouthpiece)
2. HiPEP (won’t perform in prac class / exam)
3. Oscillating PEP (Flutter, Acapella, Aerobika)
4. Bubble PEP
69
What do the 6 different PEPs look like?
70
What are 3 characteristics of **Autogenic Drainage AD** as the *4th ACT*?
1. Self drainage utilising BC and breaths at various lung volumes to mobilise secretions --\>from smaller airways to central to be removed
2. 3 phases: unstick, collect, evacuate
3. Suppress cough until end of routine
71
What are 3 **disadvantages of Autogenic Drainage AD** as the *4th ACT*?
72
What are 3 **steps** of **Autogenic Drainage (AD)** as the *4th ACT*?
73
What are 4 characteristics of **Autogenic Drainage (AD)** as the *5th ACT*?
[/GAP = “Gravity-Assisted Positioning”]
1. Allows gravity to assist drainage from specific segments (aim to get bronchi 90° to horizontal)
2. Improves ventilation / perfusion (can position with ‘good’ lung dependent)
3. Can combine with other ACTs (eg ACBT, P&V)
4. Usually **Modified Positions (MPD)** are used
1. No head down tilt (HDT)- Risk of GOR
2. No difference in sputum expectorated when used with ACBT, compared with HDT
74
What is **postural drainage** as the *5th ACT*?
75
What are **precautions and contraindications of postural drainage** as the *5th ACT*?
76
What are 4 charactersitics of **percussions & vibrations** as the 6*th ACT*?
Enhance **mucociliary clearance** by:
1. Increased Cilial beat with vagal stimulation
2. Decreased Mucous cross-links
3. Increased Peak Expiratory Flow
4. (During **inspiration** and **expiration**)
77
When are **percussions VS vibrations** done as the *6th ACT*?
Percussions: inspiration and expiration
Vibrations: only expiration
78
When are 5 **precautions of percussions/ vibrations** as the *6th ACT*?
1. Rib #
2. OP
3. Pain
4. SOB
5. Lung cancer
79
When is the **caution of percussions** as the *6th ACT*?
Can cause **bronchospasm** and **decreased PaO2**
Therefore…
1. Incorporate 3-4 TEE (Pryor et al, 1990)
2. Minimise length of Rx
Maintain breathing (not breath holding)
**Inspiration and expiration**
80
When is the **percussions** (for a baby) as the *6th ACT*?
81
When are 4 characteristics of **vibrations** as the *6th ACT*?
1. Vibratory force during **expiration** along the normal movement of the ribs
2. Can be used to augment FETs
3. Fine (vibrations) or coarse (shaking) movement (but never just shaking skin)
4. Must feel the compliance of the chest wall prior to technique
1. Bibasal excursion /
2. AP sternal movement
82
What are **precautions and contraindications** of **percussions and vibrations** as the *6th ACT*?
83
What is **inhalation therapy** as the *7th ACT*?
84
What are 6 **roles of exercise/physical activity** as the 8*th ACT*?
1. Prior to / during ACTs to loosen secretions
2. Increased ucous clearance, ventilation
3. Vertical movement --\> shear secretions
4. To clear mobilised secretions, use cough or ACBT with FET / cough used to clear mobilised secretions
5. Recommended to be used as an adjunct to (not a replacement for) other ACTs
6. + Consider the many other benefits of PA
85
What are 4 **safety** features of **exercise/physical activity** as the *8th ACT*?
1. Exercise testing, prescription
2. Monitor:
1. SpO2
2. RPE / RPB
3. Hydration
4. Heat control
86
What are 4 **conditions (patient)** that must be taken with care in **exercise/physical activity** as the *8th ACT*?
1. Severe COPD (may lead to hyperinflation, bronchospasm)
2. Bronchospasm / EIA (bronchodilators pre-exercise, monitor)
3. Deconditioning / fatigue
4. Diabetes, IHD… other conditions
87
What is the **indication** of **suction** as the *9th ACT*?
‘Inability to cough effectively and expectorate when airway secretions are retained’
\*Should not be undertaken until every other attempt to achieve effective coughing has failed
88
What is the **route of suction** as the *9th ACT*?
If not intubated (ie, not on mechanical ventilation)
* Nasopharynx, oropharynx, tracheostomy
89
What are 4 **conditions if intubated of suction** as the *9th ACT*?
1. Nasopharyngeal airway (NPA)
2. Oropharyngeal airway (OPA)
3. Endotracheal tube (ETT)
4. Tracheostomy
90
What ACTs should be chosen to mobilise secretions (3)?
1. MPD position
2. + Percussion
3. + ACBT (low-med vol FETs augmented with vibrations)
91
What ACTs should be chosen to remove secretions (1)?
High vol FET --\> assisted cough
92
What are 3 evidences of PEP?
1. ↑ Lung function, sputum expectoration and SpO2 compared to no PEP in CF
2. ↑ Sputum production compared to cough alone in exacerbation of COPD
3. No difference in sputum clearance compared to FET and PD in COPD
93
What are 2 evidences of oscillatory (flutter/acapella) PEP?
_Flutter:_ Same sputum clearance as ACBT in bronchiectasis
1. ↑ Lung function and exercise tolerance compared to ACT program in CF
2. ↑ Sputum production compared to PD alone in exacerbation of chronic bronchitis
_Acapella_: Same sputum clearance as ACBT in bronchiectasis
94
What is the evidence of ACTs in CF?
Improved mucus transport vs no ACTs
95
What is the evidence of PEP in CF?
1. No clear evidence that PEP was more effective than other forms of PT
2. Suggests greater patient preference for PEP devices than standard PT
96
What is the evidence of nebulised hypertonic saline in CF?
Improved mucociliary clearance and lung function
97
What is the evidence of exercise in CF?
Evidence for benefits
98
What is the layout of the selection?
99
What are the problems?
100
What are the considerations?
101
What is the ISOBAR?
102
What are the APA CRPA guidelines?
