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PHTY3250 > L6-7: ACTs > Flashcards

L6-7: ACTs Flashcards

1
Q

What do coarse crackles VS fine crackles indicate?

A

Coarse crackles: Secretions

Fine crackles: Atelectasis

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2
Q

What are the abbreviations for terms?

A
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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
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4
Q

What are the 2 main mechanisms of normal airway clearance?

A
  1. Mucociliary clearance (MCC)
  2. Effective cough (as a backup for impaired MCC)

Further secretions causing complications (mircrobes)

  • Eg. pneumonia
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5
Q

What does the flow of impaired airway clearance?

A
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6
Q

What are 3 characteristics of mucociliary escalator?

A
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7
Q

What are the 2 main mechanisms of impaired airway clearance?

A
  1. Impaired mucociliary clearance
  2. Ineffective cough
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8
Q

What are the 10 factors for reducing temporary muscociliar clearance?

A

↓ cilial beating

  1. Medications (eg, GA, narcotics)
  2. Drying of mucosa, dehydration (mucous = 95% H2O)
  3. High inspired O2 concentration (FiO2)
  4. Positive Pressure Ventilation
  5. Endotracheal intubation
  6. Atelectasis, ↓ lung volumes
  7. ↓ Cough effectiveness
  8. Lack of sleep
  9. Pollutants
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9
Q

What are the 2 factors for reducing permanent muscociliar clearance?

A
  1. Smoking
  2. Disease states (eg. CF, bronchiectasis)
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10
Q

What are the 2 factors for reducing muscociliar clearance?

A
  1. ↓ Cilial beating
  2. ↑ Secretion volume / thickness
    • (eg: CF, bronchiectasis, infection, dehydration)
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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
  1. Get air behind secretions
  2. Secretion MOBILISATION
  3. Secretion REMOVAL
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12
Q

What are 4 effects of congested airway?

A
  1. ↑ Cilial function
  2. ↑ WOB  fatigue
  3. ↓ Ventilation, ↓ V/Q ratio, ↓ PaO2
  4. • Long term damage / scarring

Congested airway = narrow orifices

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13
Q

What is important when checking sputum?

A

Quality and quantity of sputum

Infection control (tissue, clean hands, cup, PPE- gloves, goggles, gown)

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14
Q

What are 9 ACTs in the tool kit?

A
  1. Cough (Supported + Assisted)
  2. Active Cycle of Breathing Technique (ACBT)
  3. Positive Expiratory Pressure (PEP)
  4. Autogenic Drainage (AD)
  5. Postural Drainage (PD, MPD)
  6. Percussion and Vibration (P & V)
  7. Inhalation therapy
  8. Exercise therapy
  9. Suction
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15
Q

What is a cough?

A
  • Protective reflex ridding airway of secretions / foreign bodies
  • 1st 6 generations cleared by cough
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16
Q

1st ______ generations cleared by cough

A

6

Mobilise more peripherally to top 6 generations => cough

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17
Q

What are 7 components of cough?

A
  1. ↑ Inspiratory volume
  2. Closure of glottis
  3. ↑ ITP
  4. Abdominal muscle contraction
  5. ↑ IAP and ITP against a closed glottis
  6. Opening of glottis
  7. Ascent of diaphragm
  8. Forceful expulsion of air and / or secretions / foreign bodies
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18
Q

What are 6 causes of decreased lung volume for what can go wrong in a cough?

A
  1. Pain
  2. Restriction
  3. Obstruction
  4. Fear / anxiety
  5. Muscle weakness
  6. Neurological impairment
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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,
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20
Q

What are 4 causes of decreased expiratory force for what can go wrong in a cough?

A
  1. Pain (eg, incision)
  2. Muscle weakness
  3. Poor elastic recoil (eg, Emphysema)
  4. Inability to close glottis (eg, Bulbar Palsy)
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21
Q

What are 4 solutions of decreased expiratory force for what can go wrong in a cough?

A

Augment the expiratory phase

  1. Supported cough (pillow, towel, binder)
  2. Assisted cough (bibasal, AP sternal)
  3. Substernal angle compression
  4. Subcostal thrust
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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

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23
Q

What are 3 features of a supported cough?

A
  1. ↑ IAP with support
  2. ↓ Tension on the wound during contraction
  3. ↑ ROM through which the muscle contracts

↑ Force –> ↑ Effectiveness of cough

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24
Q

What is the aim of an assisted cough?

A

Assist generation of explosive force

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25
Q

What are the 4 features of an assisted cough?

A
  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)

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26
Q

What is bibasal compression in an assisted cough?

A

Bibasal compression if compliant chest + flaring

  • Augment bucket handle
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27
Q

What is AP sternal compression in an assisted cough?

A

AP sternal compression if apical movement

  • Augment pump handle
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28
Q

What is substernal angle compression in an assisted cough?

A

Substernal angle compression can assist diaphragm ascent

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29
Q

What is subcostal thrust in an assisted cough?

A

Subcostal thrust used for people with SCI (when unable to contract abdominals to generate force)

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30
Q

What are 3 other techniques for a cough?

A
  1. Tracheal rub
  2. Stimulated cough
  3. Mechanical insufflator/exsufflator devices (CoughAssistTM machine)
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31
Q

What are the 6 adverse effects of vigorous/chronic coughing?

A
  1. Cardiovascular
  2. Genitourinary
  3. Gastrointestinal
  4. Musculoskeletal
  5. Neurological
  6. Respiratory
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32
Q

What are 3 summaries of cough?

A
  1. Natural defence mechanism to clear secretions
  2. May be compromised –> retained secretions
    • Use techniques
  3. May be too vigorous / chronic –> adverse effects
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33
Q

What are 2 ways to increase cough effectiveness?

A
  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
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34
Q

What are 2 aims of Active Cycle of Breathing Technique (ACBT)?

A
  1. Mobilises & clears excess secretions
  2. Improves lung function
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35
Q

What are 6 advantages of Active Cycle of Breathing Technique (ACBT)?

A
  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
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36
Q

What are the components of ACBT?

A
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37
Q

What are 7 characteristics of breathing control (BC) as a componenent of ACBT?

A
  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++
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38
Q

What are 7 characteristics of throacic expansion exercises (TEE) as a componenent of ACBT?

A
  1. Slow, Laminar flow
  2. +/- Inspiratory Hold (~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
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39
Q

What are 2 aims of thoracic expansion exercises (TEE) as a componenent of ACBT?

A
  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
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40
Q

What is collateral ventilation of thoracic expansion exercises (TEE) as a componenent of ACBT?

A
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41
Q

What is alveolar interdependence of thoracic expansion exercises (TEE) as a componenent of ACBT?

42
Q

What are 6 characteristics of Forced Expiratory Technique (FET / Huff) as a componenent of ACBT?

A
  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
Q

What is Equal Pressure Points (EPP)?

44
Q

What are the 4 steps of EPP?

45
Q

What is the low VS mid VS high lung volume?

46
Q

What are 5 characteristics in the duration of ACBT?

A
  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
Q

What are 5 summaries of ACBT?

A
  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
Q

What are 3 techniques in ACBT?

A
  1. BC
  2. TEE (+/- IH)
  3. Huff / FET (low, mid, high vol)

Tailored to suit patient

49
Q

What are 4 aims of Positive Expiratory Pressure as the 3rd ACT?

A

(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
Q

What is the theory of PEP as the 3rd ACT?

51
Q

What is collateral ventilation of PEP as the 3rd ACT?

A
  1. Collateral Ventilation
  2. Splints airways
  3. Air behind secretions to mobilise upwards
52
Q

What are components of PEP as the 3rd ACT?

53
Q

What are 3 characteristics when selecting resistance in PEP as the 3rd ACT?

A
  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
Q

What are 4 mouthpieces as the 3rd ACT?

A

(eg. PariPEP, TheraPEP):

  1. More common device
  2. Smaller, more portable
  3. Must keep cheeks flat
  4. Use with nose clip
55
Q

What are 2 masks as the 3rd ACT?

A
  1. If unable to keep cheeks flat
  2. If unable to keep mouth sealed around mouthpiece
56
Q

What is the PEP duration for the 2 conditions (stable pulmonary disease; hospitalisation/post-op) as the 3rd ACT?

57
Q

What are 8 PEP indications as the 3rd ACT?

EXAM QUESTION

A
  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
Q

What are 8 PEP clinical precautions as the 3rd ACT?

EXAM QUESTION

59
Q

What are 2 characteristics of HiPEP (high pressure) as the 3rd ACT?

A
  1. Forced expiration (FVC) against PEP mask
  2. Expiratory pressure of 50-120cmH2O (standard PEP is10-20cmH2O)
60
Q

What are 3 disadvantages of HiPEP (high pressure) as the 3rd ACT?

A
  1. If incorrect resistance –> deterioration
  2. Spirometry required for regular reAx
  3. High expiratory effort for patient
61
Q

What are 4 patients that are not recommended for HiPEP (high pressure)​ as the 3rd ACT?

A
  1. Venous clotting when PE likely
  2. Cardiac disease
  3. Malnourishment
  4. Weakness
62
Q

What are 4 characteristics of oscillating PEP as the 3rd ACT?

A
  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
Q

What are 4 types of oscillating PEP?

A
  1. Flutter
  2. Acapella
  3. Aerobika
  4. Bubble
64
Q

What are 7 characteristics of oscillating Flutter PEP as the 3rd ACT?

A
  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
Q

What are 3 characteristics of oscillating Acapella and Aerobika PEP as the 3rd ACT?

A
  1. Oscillatory PEP
  2. Can inspire through device
  3. Oscillations independent of gravity

Able to lye down (does not have to be perpendicular)

66
Q

What are 5 characteristics of oscillating Bubble PEP as the 3rd ACT?

A
  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
Q

What are the 3 summaries for the Positive Pressure during Expiration as the 3rd ACT?

A
  1. Increased collateral ventilation
  2. Splints airways
  3. Secretion mobilisation effect –> assists removal
68
Q

What are the 4 types of PEP as the 3rd ACT?

A
  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
Q

What do the 6 different PEPs look like?

70
Q

What are 3 characteristics of Autogenic Drainage AD as the 4th ACT?

A
  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
Q

What are 3 disadvantages of Autogenic Drainage AD as the 4th ACT?

72
Q

What are 3 steps of Autogenic Drainage (AD) as the 4th ACT?

73
Q

What are 4 characteristics of Autogenic Drainage (AD) as the 5th ACT?

A

[/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
Q

What is postural drainage as the 5th ACT?

75
Q

What are precautions and contraindications of postural drainage as the 5th ACT?

76
Q

What are 4 charactersitics of percussions & vibrations as the 6th ACT?

A

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
Q

When are percussions VS vibrations done as the 6th ACT?

A

Percussions: inspiration and expiration

Vibrations: only expiration

78
Q

When are 5 precautions of percussions/ vibrations as the 6th ACT?

A
  1. Rib #
  2. OP
  3. Pain
  4. SOB
  5. Lung cancer
79
Q

When is the caution of percussions as the 6th ACT?

A

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
Q

When is the percussions (for a baby) as the 6th ACT?

81
Q

When are 4 characteristics of vibrations as the 6th ACT?

A
  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
Q

What are precautions and contraindications of percussions and vibrations as the 6th ACT?

83
Q

What is inhalation therapy as the 7th ACT?

84
Q

What are 6 roles of exercise/physical activity as the 8th ACT?

A
  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
    • Consider the many other benefits of PA
85
Q

What are 4 safety features of exercise/physical activity as the 8th ACT?

A
  1. Exercise testing, prescription
  2. Monitor:
    1. SpO2
    2. RPE / RPB
  3. Hydration
  4. Heat control
86
Q

What are 4 conditions (patient) that must be taken with care in exercise/physical activity as the 8th ACT?

A
  1. Severe COPD (may lead to hyperinflation, bronchospasm)
  2. Bronchospasm / EIA (bronchodilators pre-exercise, monitor)
  3. Deconditioning / fatigue
  4. Diabetes, IHD… other conditions
87
Q

What is the indication of suction as the 9th ACT?

A

‘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
Q

What is the route of suction as the 9th ACT?

A

If not intubated (ie, not on mechanical ventilation)

  • Nasopharynx, oropharynx, tracheostomy
89
Q

What are 4 conditions if intubated of suction as the 9th ACT?

A
  1. Nasopharyngeal airway (NPA)
  2. Oropharyngeal airway (OPA)
  3. Endotracheal tube (ETT)
  4. Tracheostomy
90
Q

What ACTs should be chosen to mobilise secretions (3)?

A
  1. MPD position
    • Percussion
    • ACBT (low-med vol FETs augmented with vibrations)
91
Q

What ACTs should be chosen to remove secretions (1)?

A

High vol FET –> assisted cough

92
Q

What are 3 evidences of PEP?

A
  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
Q

What are 2 evidences of oscillatory (flutter/acapella) PEP?

A

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
Q

What is the evidence of ACTs in CF?

A

Improved mucus transport vs no ACTs

95
Q

What is the evidence of PEP in CF?

A
  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
Q

What is the evidence of nebulised hypertonic saline in CF?

A

Improved mucociliary clearance and lung function

97
Q

What is the evidence of exercise in CF?

A

Evidence for benefits

98
Q

What is the layout of the selection?

99
Q

What are the problems?

100
Q

What are the considerations?

101
Q

What is the ISOBAR?

102
Q

What are the APA CRPA guidelines?

PHTY3250 (20 decks)

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