Lecture 23: Pulmonary Interventions and Airway Clearance Techniques Flashcards
what is diaphragmatic breathing
optimal use of diaphragm to breath deeper than normal
conscious use to take deep breaths to use more lung capacity compared to resting tidal volume
benefits of diaphragmatic breathing
strengthens diaphragm
improves O2 ventilation efficiency by decreasing RR and effort
improves O2respiration via decreasing alveolar dead space
increases PaO2 and SpO2
activates PNS why suppressing SNS
increases venous return, lowers BO
lowers stress and cortisol
facilitates relaxation
technique of diaphragmatic breathing
hooklying or with pillow under knee
place one hand on chest and one on abdomen
breathe in slowly, focus on full inhale and expanding abdomen
hand on chest should remain still and hand on abdomen should rise
slowly let the abdomen down while breathing out
PPT will encourage diaphragmatic breathing pattern
what is pursed lip breathing
type of diaphragmatic breathing
provides back pressure to small airways that maintain opening = improved gas exchange
airways are open longer = air can be exhaled easier, especially with obstructive pathology
promotes slower RR
reduces effort of breathing
facilitates relaxation, reduced stress response
I:E = 1:2
what is incentive spirometry
can be used for assessment, intervention, and edu
prevents passive atelectasis that can turn into PNA
practices diaphragmatic breathing
can stimulate a cough
provides visual feedback
inhalation should be paired with what for effective breathing facilitation
shoulder flexion, abduction and ER
thoracic and cervical extension
upward eye gaze
exhalation should be paired with what for effective breathing facilitation
shoulder extension, adduction, and IR
thoracic and cervical flexion
downward eye gaze
what positions relieve dyspnea
tripoding
trunk extension
sidling
trunk elevation/sitting
what is tripoding and how does it help relieve dyspnea
anchoring distal mm attachments allows proximal attachments to assist more effectively in thoracic cavity extension
forward leaning tripoding can increase intraabdominal pressure and push diaphragm into a more lengthened position = stronger contraction
how does trunk extension help relieve dyspnea
allows more more effective thoracic cavity extension
how does side lying help relieve dyspnea
assists in superior lung expansion
not as restricting into the spine as much as supine may be
how does trunk elevation/sitting help relieve dyspnea
more upright postion allows gravity to naturally pull the diaphragm down to create more space in the thoracic cavity
what are airway clearance techniques (ACTs) and what is optimal technique based on
manual or mechanical procedures that facilitate mobilization of secretions from airways
improved O2 transport is critical for pts to be able to progress to wards any other functional goal
park of “pulmonary toilet” strategies
optimal technique is based on:
- pathology and S&S
- medical stability
- pt cooperation and/or adherence to techniques
goals of ACTs
optimize airway patency
increase V/Q matching
promote alveolar expansion and ventilation
increase or improve gas exchange
indications for ACTs
excessive pulmonary secretions
impaired mucociliary transport
ineffective or absent cough
when should ACTs be performed and things to be aware of/to do before/during ACTs
performed before or at least 30 min following a meal; consider tube feedings if oral intake is not occurring
inhaled bronchodilators should be given before ACTs
inhaled antibiotics, steroids, etc will have better deposition if given after ACT
awareness of indications and contraindications is KEY
don’t forget about exercise; increased ventilation during activity enhances mucociliary transport
what is postural drainage
assuming one or more body positions that allow gravity to assist with draining secretions from individual lung segments
segmental bronchus of the segment to be drained must be PERPENDICULAR to the floor
priority given to treating most affected segments first
each position maintained >/= 5-10 min
additional ACTs can be used simultaneously
positions may need to be modified if a pt qualifies for PD but may have a relative contraindication or precaution
precautions for postural drainage
pulmonary edema
hemoptysis
massive obesity
pleural effusion
thoracic cavity structural deficits
ascites
GERD
cognition/behavior
ability to follow instructions
contraindications for postural drainage
increased ICP
hemodynamically unstable
recent esophageal anastomosis or sx
recent spinal fusion or injury
recent head trauma
diaphragmatic or hiatal hernia
recent eye sx
what is percussion
loosening retained secretions performed manually or with a device via rhythmical clapping with cupped hands
what is vibration
loosening retained secretions via exertion of pressure and oscillation during exhalation
can be used as an alternative to percussion if needed due to discomfort
goal = loosen secretions enough that pt can expectorate them or they can be drained via PD
precautions for vibration and percussion
uncontrolled bronchospasm
osteoporosis/osteomyelitis
rib fx
spinal or rib metastasis
tumor obstruction of airway
anxiety
coagulopathy
seizure disorder
cognition/behavior/cooperation
recent pacemaker
other recent invasive line placement
contraindications for percussion and vibration
hemoptysis
tension PNX
thrombocytopenia < 20
hemodynamically unstable
thoracic burns or wounds
PE
subcutaneous emphysema
skin grafts or sx flaps to thorax
what is an assisted cough
first line interventions to promote effective cough s to address positioning and teaching proper cough techniques
effective cough consists of 4 stages
- inhalation greater than tidal volume (>/= 60% VC)
- closure of glottis
- contraction of abdominal and internal intercostal mm to provide a positive intrathoracic pressure
- sudden opening of the glottis and forceful expulsion of the inspired air
what is the glottis
opening between the vocal cords in the larynx
opens and closes with talking, coughing, breathing, swallowing
assisted cough strategies
position pt to facilitate trunk ext (inhalation) and flexion (exhalation)
maximize inspiratory phase via verbal cues, upright positioning, upward gaze, UE AROM, thoracic extension
improved respiratory hold at end of inhalation
maximize intraabdominal and intrathoracic pressure via positioning or mm contraction for exhalation
brace or splint abdomen for increased cough strength
can manually assist abdominal contraction of pt is in supine
what is the huffing technique
alternative to coughing
helps prevent bronchoconstriction or collapse of weak airways
stabilizes bronchial walls and support structures
can produce less stressful or painful coughing with more control
technique or huffing
mouth open throughout, O shaped
glottis doesn’t close over the trachea
chest and abdominal mm contraction
forced exhalation that sounds like a loud forced sigh
long and slow forced exhalation moves secretion in from the distal periphery
short and string forced exhalation moves secretions more proximally to cough
what is the active cycle of breathing
series of maneuvers to emphasize independent secretion clearance from distal to proximal and thoracic extension
incorporates normal breathing, deep inhalation, and huffing
helps prevent bronchospasm,
focused thoracic extension increases volume and promotes ventilation but allowing air behind the secretions to help force them more proximally
huffing stabilizes bronchial walls
performed in sitting and helps avoid GERD
steps of active cycle of breathing
- breathing control
- normal tidal volume breathing
- in through nose, out mouth
- pursed lip if needed
- eyes closed helps focus/relax - thoracic expansion
- 4-5 deep inhales with hands on lower ribs to feel expansion
- percussion/vibration with exhale - forced expiratory technique
- 1-2 deep huff cough techniques with strong abdominal contraction
what are mechanical coughing aids
devices/techniques that apply manual or mechanical forces to the body or intermittent changes to the airway to assist with coughing or talking a
very common in neuromuscular disorders that are accompanied by considerable respiratory impairments
inspiratory birds provide adequate pressure during attempts at inhalation
expiratory aids provide negative pressure via vacuum to airway during attempts to cough, along with manual abdominal thrust
what is tracheal suctioning
if sectresions can be cleared into mouth, oral suctioning can be performed to prevent aspiration of them back into airways
if secretions cant be cleared into the mouth, suctioning may be performed to rid the deeper airways of retained material
least invasive method always preferred
can also be used to stimulate a cough reflex
should never be performed without training, check off, etc
describe oral suctioning
wand like device attached to suction used for mouth
pt can use independently
not meant to go past the back teeth
describe deep in line suctioning
incorporated into an artificial airway (ETT or trace) to maintain sterile suction catheter
decreased risk of infection
can go from might/throat to carina
describe deep sterile suctioning
stand alone suction device that is passed through an airway opening (nose/mouth/trach) to the carina
must maintain sterile technique
lubrication must be used for nasotracheal tube
describe correct suctioning technique
hand hygiene and sterile technique (if performing sterile suctioning)
ensure negative pressure is engaged or turned on
advance suction Cath gently but quickly into airway without applying suction yet
stop advancement if any resistance is felt
smoothly withdraw Cath with CONSTANT suction application
no more than 10 seconds total (deep suctioning occludes airway)
“DO’s” of suctioning
seek out training
proper hygiene
quick but gentle technique
always maintain suction with removal
fully remove Cath once you start
allow >1 min between trails
“DON’Ts” of suctioning
hesitate to ask for help/instructio
apply suction during Cath advancement
inter Cath past any resistance or too far
stop and start advancement or suction
perform if you’re unsure you should
medical considerations for selecting appropriate airway clearance
GERD: pt needs to remain upright
osteoporosis or osteopenia
bronchospasm or risk of it
hemoptysis or risk of it
severity of pulmonary disease
acute exacerbation needs medical/pharm intervention first
precautions specific to selected ACT
