Lecture 23: Pulmonary Interventions and Airway Clearance Techniques

Question 1

what is diaphragmatic breathing

Answer 1

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

Question 2

benefits of diaphragmatic breathing

Answer 2

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

Question 3

technique of diaphragmatic breathing

Answer 3

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

Question 4

what is pursed lip breathing

Answer 4

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

Question 5

what is incentive spirometry

Answer 5

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

Question 6

inhalation should be paired with what for effective breathing facilitation

Answer 6

shoulder flexion, abduction and ER

thoracic and cervical extension

upward eye gaze

Question 7

exhalation should be paired with what for effective breathing facilitation

Answer 7

shoulder extension, adduction, and IR

thoracic and cervical flexion

downward eye gaze

Question 8

what positions relieve dyspnea

Answer 8

tripoding
trunk extension
sidling
trunk elevation/sitting

Question 9

what is tripoding and how does it help relieve dyspnea

Answer 9

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

Question 10

how does trunk extension help relieve dyspnea

Answer 10

allows more more effective thoracic cavity extension

Question 11

how does side lying help relieve dyspnea

Answer 11

assists in superior lung expansion

not as restricting into the spine as much as supine may be

Question 12

how does trunk elevation/sitting help relieve dyspnea

Answer 12

more upright postion allows gravity to naturally pull the diaphragm down to create more space in the thoracic cavity

Question 13

what are airway clearance techniques (ACTs) and what is optimal technique based on

Answer 13

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

Question 14

goals of ACTs

Answer 14

optimize airway patency

increase V/Q matching

promote alveolar expansion and ventilation

increase or improve gas exchange

Question 15

indications for ACTs

Answer 15

excessive pulmonary secretions

impaired mucociliary transport

ineffective or absent cough

Question 16

when should ACTs be performed and things to be aware of/to do before/during ACTs

Answer 16

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

Question 17

what is postural drainage

Answer 17

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

Question 18

precautions for postural drainage

Answer 18

pulmonary edema
hemoptysis
massive obesity
pleural effusion
thoracic cavity structural deficits
ascites
GERD
cognition/behavior
ability to follow instructions

Question 19

contraindications for postural drainage

Answer 19

increased ICP
hemodynamically unstable
recent esophageal anastomosis or sx
recent spinal fusion or injury
recent head trauma
diaphragmatic or hiatal hernia
recent eye sx

Question 20

what is percussion

Answer 20

loosening retained secretions performed manually or with a device via rhythmical clapping with cupped hands

Question 21

what is vibration

Answer 21

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

Question 22

precautions for vibration and percussion

Answer 22

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

Question 23

contraindications for percussion and vibration

Answer 23

hemoptysis
tension PNX
thrombocytopenia < 20
hemodynamically unstable
thoracic burns or wounds
PE
subcutaneous emphysema
skin grafts or sx flaps to thorax

Question 24

what is an assisted cough

Answer 24

first line interventions to promote effective cough s to address positioning and teaching proper cough techniques

effective cough consists of 4 stages

1. inhalation greater than tidal volume (>/= 60% VC)
2. closure of glottis
3. contraction of abdominal and internal intercostal mm to provide a positive intrathoracic pressure
4. sudden opening of the glottis and forceful expulsion of the inspired air

Question 25

what is the glottis

Answer 25

opening between the vocal cords in the larynx

opens and closes with talking, coughing, breathing, swallowing

Question 26

assisted cough strategies

Answer 26

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

Question 27

what is the huffing technique

Answer 27

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

Question 28

technique or huffing

Answer 28

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

Question 29

what is the active cycle of breathing

Answer 29

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

Question 30

steps of active cycle of breathing

Answer 30

1. breathing control
   - normal tidal volume breathing
   - in through nose, out mouth
   - pursed lip if needed
   - eyes closed helps focus/relax
2. thoracic expansion
   - 4-5 deep inhales with hands on lower ribs to feel expansion
   - percussion/vibration with exhale
3. forced expiratory technique
   - 1-2 deep huff cough techniques with strong abdominal contraction

Question 31

what are mechanical coughing aids

Answer 31

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

Question 32

what is tracheal suctioning

Answer 32

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

Question 33

describe oral suctioning

Answer 33

wand like device attached to suction used for mouth

pt can use independently

not meant to go past the back teeth

Question 34

describe deep in line suctioning

Answer 34

incorporated into an artificial airway (ETT or trace) to maintain sterile suction catheter

decreased risk of infection

can go from might/throat to carina

Question 35

describe deep sterile suctioning

Answer 35

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

Question 36

describe correct suctioning technique

Answer 36

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)

Question 37

“DO’s” of suctioning

Answer 37

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

Question 38

“DON’Ts” of suctioning

Answer 38

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

Question 39

medical considerations for selecting appropriate airway clearance

Answer 39

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