Retained secretions Treatment HB (2)

Question 1

what is the aim of physiotheraphy for patients with impaired airway clearance

Answer 1

assist removal of secretions

Question 2

How does Impaired Airway Clearance occur

Answer 2

When the usual methods of airway clearance

(mucociliary escalator + cough reflex) are impaired by thick sputum or damaged airways.

Question 3

what can physiotheraphy do about retained secretions

Answer 3

can help to break this vicious cycle of retained sputum and repeated respiratory infection.

The aim of physiotherapy for patients with impaired airway clearance is to assist with the removal (clearance) of respiratory secretions (sputum).

Question 4

Patient positioning

Answer 4

Assisting with secretion clearance can be performed with the patient in a position of
ease (WOB hand book)

= helpful for patients who are also breathless, or to put the patient in a comfortable position when first learning airway clearance techniques.

Once the patient has learnt the
techniques, specific positioning to aid sputum mobilisation may be appropriate.

Question 5

Why would the normal cough mechanism be affected

Answer 5

immobility, weakness and/or pain.

Question 6

what happens to the mucous which remains in the airways rather than being coughed out or swallowed

Answer 6

predisposes the patient to infection and can cause further airway damage.

Optimal conditions for bacterial growth warm and moist

Question 7

Postural drainage

Answer 7

Involves positioning the patient to allow gravity to assist the movement of secretions from specific areas of the lungs towards the mouth.

Question 8

What are positions based on

Answer 8

The anatomy of the bronchial tree, with each
bronchopulmonary segment having its own specific position.

Due to the orientation of the tertiary bronchi, gravity-assisted drainage of the middle and lower lobe segments require the patient to be in a head-down tilt position.

Question 9

What do patients do during postural drainage

Answer 9

Patients actively participate with postural drainage as it is often combined with airway clearance breathing exercises and/or manual chest wall shakes/vibrations/percussion.

Question 10

Indications for postural drainage

Answer 10

• more than 30mls sputum/day+ (copious volume)
• difficulty clearing sputum in upright position
• more sputum produced with postural drainage than without
• patient preference
• consolidation

Question 11

Contraindications postural drainage

Answer 11

• Cerebral oedema
• Unstable epilepsy
• Acute spinal cord lesion
• Hypertension
• Subcutaneous emphysema
• Undrained pneumothorax
• Dyspnoea
• Recent, frank haemoptysis
• Pulmonary oedema or acute cardiovascular instability
• Recent pneumonectomy or surgery to the aorta, oesophagus, cardiac
sphincter or stomach
• Symptomatic hiatus hernia or gastric reflux
• Abdominal distension, pregnancy, obesity
• Trauma, burns or recent surgery to head or neck
• Headache
• Epistaxis (nose bleed)

Question 12

what is a result of these contraindications

Answer 12

A modified postural drainage regime is most
commonly used for patients with generalised, copious secretions.

This involves alternate flat side lying with head and hips level (avoiding the head down tilt).

Question 13

Active cycle of breathing technique

Answer 13

This is a set of breathing exercises that helps to loosen and remove respiratory
secretions from the airways.

1. Loosen and clear secretions from the lungs
2. Improve ventilation in the lungs.
3. Improve the effectiveness of a cough
4. Breathing Control
5. Deep Breathing Exercises or Thoracic Expansion Exercises
6. Huffing or Forced Expiratory Technique (FET)

ACBT

Question 14

What techniques are included in the Active cycle of breathing technique

Answer 14

The ACBT exercises include

1. breathing control (WOB handbook)
2. thoracic expansion exercises (deep
   breathing)
3. forced expiratory technique (FET/ huff) which are performed in a cycle until the patient has cleared their sputum.

Question 15

Thoracic expansion techniques

Answer 15

Thoracic expansion exercises are essentially deep breaths, where the patient is instructed to perform a maximal inhalation followed by a passive (relaxed)
exhalation.

Question 16

what can thoracic expansion techniques be used for

4

Answer 16

• assist in loosening and removing excess secretions
• aid re-expansion of lung tissue
• mobilise the thoracic cage
• improve ventilation and therefore gaseous exchange

Question 17

**What does TEE do for collateral ventilation and how does it aid removal of secretions

Answer 17

Expanding the rib cage and underlying lung, increases air flow through the collateral channels of ventilation.

This allows air to enter alveoli lying adjacent to collapsed or poorly ventilated alveoli and inflate them or get behind secretions to move them towards the mouth for expectoration.

Question 18

teaching thoracic expansion

Answer 18

Thoracic expansion exercises are usually performed in either a position of ease or a postural drainage position.

Inspiration is preferably through the nose and is usually combined with a 3 second
hold.

Expiration is passive and forced abdominal contractions during expiration are discouraged.

The physiotherapist may position their hands on the lateral aspect of the rib cage with the fingers parallel to the ribs.

The patient is then instructed to breathe in and to attempt to push the ribs out against the therapist’s hands which provides some proprioceptive feedback

The patient can place their own hands on the ribcage (wrists extended and palms of hands placed well back in mid-axillary line) to provide self- feedback on technique.

Whilst it is not possible to selectively ventilate any particular region of the lungs, it can be useful to place the hands over the lower ribs to give feedback on basal expansion or to place them over an area where secretions have been felt or heard.

Between 3 and 6 expansion exercises can be carried out consecutively depending on the patient’s potential to fatigue. Patients should be asked about dizziness if taking more than 3 consecutive deep breaths as they may hyperventilate

Question 19

Forced expiratory technique FET

Answer 19

FET involves varying depths of inspiration and expiration which increases the expiratory flow rate, producing shearing forces which loosen sputum from the airways and propel it mouth-wards.

It can be manipulated to clear desired airways by manipulating equal pressure point

Question 20

Recap of respiratory mechanics

Answer 20

Alveolar pressure is equal to the sum of the intra-pleural pressure plus the elastic recoil pressure of the alveoli.

During inspiration, pleural pressure is negative,
therefore alveolar pressure is negative which draws air into the lungs from the atmosphere (Boyle’s Law).

During passive exhalation, intra-pleural pressure remains negative, but the elastic recoil pressure increases, making alveolar pressure higher
than atmospheric pressure which pushes air back out of the lungs.

Active exhalation differs from passive exhalation because the pleural pressure is positive which combines with the elastic recoil pressure to exert a large force on the alveoli.

The greatest alveolar pressure occurs during forced exhalation from a maximal breath in, this creates a large, propulsive, expiratory force towards the
mouth.

Question 21

Equal pressure point and the signifigance in FET

Answer 21

The point at which the pressure inside the airway is equal to the pressure outside it (intra-plueral pressure)

Position of EPP depends on lung volume and pressure outside airway

As airway pressure gradually falls along the airways from the alveolar pressure (its peak) to zero at the mouth,

This “squeezes” the airway and mobilises secretions away from the airway walls and towards the mouth.

During a forced expiration, the pressure outside the airway remains relatively constant, whilst the pressure inside the airway decreases as you go towards the mouth,

EPP moves towards the alveoli when the volume inside the lungs decreases and/or the pressure outside the airway increases.

The EPP moves towards the mouth when the volume inside the lungs increases and/or the pressure outside the airway decreases.

Therefore, to move secretions from airways to mouth it is more effective to commence huffing at low lung volumes i.e short long and to progress long short. Turbulant airflow is also created.

Question 22

What do you do to clear secretions in smaller distal airways

Answer 22

small inspiration followed by long expiration

EPP moves towards the alveoli when the volume inside the lungs decreases and/or the pressure outside the airway increases.

Question 23

What do you do to clear secretions in larger proximal airways

Answer 23

A large inhalation followed by a rapid forced
exhalation

The EPP moves towards the mouth when the volume inside the lungs increases and/or the pressure outside the airway decreases.

Question 24

Advantages of FET

Answer 24

• uses less energy than a cough
• less painful than coughing post-operatively
• causes less bronchospasm than coughing
• does not generate high intra-thoracic pressures

Question 25

Disadvantages FET

Answer 25

• some patients have difficulty learning this technique

* if performed wrongly, the technique is ineffective

Question 26

Teaching FET

Answer 26

performed in either a position of ease or a postural drainage position.

Sitting upright is recommended.

Take a medium normal quite breath in through your nose open the mouth wide as if yawning (to open the glottis) and breath out with a moderate force as if you are steaming up a mirror

If they cant open glottis they can exhale through a clean spirometry mouthpiece 3cm inside mouth

Then take a bigger breath in and a sort sharp breath out

Question 27

The complete active cycle

Answer 27

Once the patient has learnt the techniques of breathing control, thoracic expansion
and FET, they can practice using the exercises in a cyclical fashion to help them with
sputum clearance.

The cycle can be adapted to each individual patient’s needs for example a particularly breathless patient may need to spend longer on the breathing control
sections or a patient with reduced lung volume

(see Reduced Lung Volume handbook) may revisit thoracic expansion exercises multiple times before moving onto the FET

Question 28

Supported cough

Answer 28

Whilst cough is generally discouraged in favour of FET as part of the ACBT, it is important that patients are able to perform an effective cough effort.

Patients following cardiothoracic, abdominal or head and neck surgery are often reluctant to cough strongly due to pain from and apprehension regarding their incision/s.

supported cough technique= involves using padding (pillow or folded towel) supported by gentle pressure from their hands over the wound.

This gives the patient confidence to cough + can limit the tension on the wound from the increased intra-thoracic pressure and/or muscle work associated with coughing.

Patients with fractured ribs can wrap a folded towel around their ribcage and pull the ends firmly together when coughing.

Question 29

Adjuncts

Answer 29

These are techniques which could be used in addition to positioning and ACBT.

Include manual techniques and mechanical adjuncts which may be indicated if positioning and ACBT is not sufficient in removing secretions.

Question 30

Manual techniques

Answer 30

The patient’s chest wall can be passively percussed, shaken, compressed or vibrated by the therapist with the aim of loosening sputum away from the airway walls and mobilising it mouth-wards

Question 31

Compression vibration and shake explanation

Answer 31

Oscillatory/Vibratory effect (percussion & vibrations)

Rapid increase in expiratory flow (vibrations, shakes, compression)

Passive recoil of the chest wall improving inspiratory depth (vibrations,
shakes, compression).

Question 32

Oscillatory/Vibratory effect (percussion & vibrations)

Answer 32

o Thought to affect the viscoelastic properties of sputum, making it less thick and tenacious by stimulating secretion of airway surface liquid

o May stimulate cilial beating if frequency is 3-17 Hz (≥3 x per second)

Question 33

• Rapid increase in expiratory flow (vibrations, shakes, compression)

Answer 33

o Particularly effective if well-timed with the onset of expiration from
peak inspiration.

Question 34

• Passive recoil of the chest wall improving inspiratory depth (vibrations,
shakes, compression).

Answer 34

o Timing of the technique is key to achieving this effect as pressure
should be maintained throughout expiration and released immediately
prior to inspiration

Question 35

what are manual techniques used in combination with

Answer 35

Manual techniques are often used in conjunction with postural drainage positions
and can fit well with the active cycle of breathing technique as an adjunct to the
thoracic expansion exercises.

Question 36

Contraindications manual techniques

Answer 36

• Osteoporosis or Rib fractures
• Skin loss, for example, burns; surgery; chest drains
• Recent excessive haemoptysis, for example lung abscess or lung contusion
• Significant clotting disorders
• Unstable angina, cardiac arrhythmias
• Active pulmonary tuberculosis (TB)

Question 37

Percusson

Answer 37

This consists of rhythmic clapping over the chest wall which can be localised to a specific lobe or segment as required.

Patients usually adopt a postural drainage (or modified) posture during percussion and are instructed to breathe at tidal volume during the technique.

Draping a towel over the chest may improve patient comfort during treatment.

Question 38

Vibrations

Answer 38

This consists of a fine, inwards oscillation of the chest wall during exhalation.

The patient should be instructed to take a deep breath in and the vibrations are performed as the patient exhales.

To achieve maximal expiratory flow, the initial force should be greatest, followed by vibrations whilst maintaining the inwards pressure.

Releasing the pressure of the therapist’s hands immediately before the next inspiration can result in passive recoil and a larger subsequent inhalation

Question 39

Shaking

Answer 39

Very similar to the vibrations technique described above apart from shaking involves a coarser, lower frequency oscillation of the chest wall.

When choosing between shaking and vibration techniques, therapist and patient preference are often the deciding factors

Question 40

Compression manual assisted cough

Answer 40

This technique is only indicated for patients who are paralysed either due to neurological illness/injury or chemically paralysed due to sedation in the intensive
care unit.

It involves the therapist simulating the expiratory phase of a cough by rapidly compressing the thorax and the abdomen concurrently during exhalation.

The link will take you to a video demonstrating the technique combined with a cough assist machine (mechanical in-exsufflator).

Question 41

Medical adjuncts

Answer 41

Other adjuncts which may assist the removal of secretions involve the use of mechanical devices which manipulate flow and pressure to enhance sputum clearance.

These adjuncts are important in the self-management of conditions where secretions are produced on a regular basis.

Physiotherapists will typically teach patients with chronic, suppurative (sputum-producing) lung disease to use these devices regularly at home. They are not particularly appropriate for patients with a transient pathology (such as post-operative chest infection).

Question 42

Oscillatory Positive Expiratory Pressure (PEP)

Answer 42

Oscillatory PEP devices consist of two main elements: oscillation and PEP.

Positive expiratory pressure (PEP) occurs when breathing out against resistance which creates positive pressure within the airways.

This pressure is transmitted throughout the conducting passageways and acts as a “splint” to airways, keeping them open during exhalation. In patients with chronic respiratory disease such as

COPD, bronchiectasis and cystic fibrosis, the airways can become “floppy” and prone to collapse during exhalation due to the loss of elasticity in the lung tissue.

As well as trapping air within the lungs leading to hyperinflation, this can also trap sputum in
the small airways, therefore PEP devices are particularly helpful for these patients.

Question 43

Contraindications Oscillatory Positive Expiratory Pressure (PEP)

Answer 43

include: undrained pneumothorax, haemoptysis & raised ICP.

Question 44

oscillatory PEP devices

Answer 44

Flutter

Bubble PEP

Acapella

Mechanical In-Exsufflator (MI:E; Cough Assist®, Clearway®)

Nebulisation

Humidification

Question 45

what does the oscillatory element (similar to oscillatory manual techniques) affect

Answer 45

The viscoelastic properties of sputum, making it less thick and tenacious by stimulating secretion of airway surface liquid.

The oscillations also produce variable levels of PEP
which may help to shear mucous away from different parts of the airway.

Question 46

What can the FET component of the ACBT be substituted for

Answer 46

oscillatory PEP for some patients, whilst others may perform FET after using the device.

There are various oscillatory PEP devices available

Question 47

Bubble PEP

Answer 47

Mainly with children but can also been used with
adults.

It is a simple and cheap way of providing oscillatory PEP.

The patient is encouraged to inhale deeply then blow bubbles in water as long as they can exhale.

This creates and oscillatory positive pressure within the airways and can assist the removal of secretions.

Question 48

Flutter

Answer 48

The flutter is a pipe-shaped device which the patient blows into.

It contains a ball bearing which generates positive pressure by resisting exhalation and oscillates as the patient exhales.

The flutter is simple to use and clean and cheaper than other adjuncts (such as the Acapella).

Its major drawback is that it only
works with an upright posture making it unsuitable for patients whose regime includes lying or side lying.

Question 49

Acapella

Answer 49

This is a very similar device to the Flutter however as it uses magnets to create the resistance to exhalation (and hence is independent to gravity), it can be used in any position. It has a dial which alters the frequency of the oscillations – lower settings are easier for the patient.

The dial should be set to the highest level that the patient can comfortably exhale for 3-4 seconds against.

Question 50

Mechanical In-Exsufflator (MI:E; Cough Assist®, Clearway®)

Answer 50

This uses positive pressure to deliver a maximal lung inhalation followed by an abrupt switch to negative pressure.

This rapid change from positive to negative
pressure aims to simulate the airflow changes that occur during a normal cough.

MI:E can be delivered via a tight seal face mask or a mouthpiece. It is most commonly used for patients with neuromuscular disorders which limit the efficacy of
their own cough mechanism.

Potential complications include abdominal distension and increased BP.

Use of MI:E should be avoided in patients with an undrained pneumothorax or subcutaneous emphysema, bullous emphysema, acute asthma, recent lung or upper GI surgery, raised ICP and haemodynamic instability.

Question 51

Autogenic breathing velocity of airflow

Answer 51

When removing sputum you need to identify which air ways it is trapped in and to remove it you adjust the velocity of inspiration and expiration

highest amount of airflow is reached without being high enough that airways collapse during coughing

Autogenic drainage does not utilise postural drainage positions but is performed
while sitting upright

Question 52

Hummidification

Answer 52

If secretions are very thick, they may be difficult to expectorate and this will affect the gel layer of the mucociliary escalator (MCE).

Therefore the addition of heat and
moisture to the airway via a humidifier will assist the thinning of secretions and ease of expectoration.

Dry, cold oxygen delivered to the patient can also significantly inhibit the MCE, so consider additional humidification for all patients receiving
oxygen.

Heated, humidified high flow nasal oxygen can be used to provide 100% relative humidity at body temperature which can help to rehydrate the mucociliary system and improve airway clearance.

Secretions may be thick if a patient is dehydrated, therefore encouraging fluid intake should be advised. The sol layer can become dehydrated if the patient is systemically dehydrated.

Question 53

Autogenic breathing 3 phases

Answer 53

Autogenic drainage is a respiratory self-drainage technique that utilises controlled expiratory airflow (tidal breathing) to mobilise secretions.

It consists of three phases:

• Loosening peripheral secretions by breathing at low lung volumes (slow, deep
air movement)

• Collecting secretions from central airways by breathing at low to middle lung
volumes (slow, mid-range air movement)

• Expelling secretions from the central airways by breathing at mid to high lung
volumes (shallow air movements)

Question 54

Nebulisation

Answer 54

Aerosolised inhaled (nebulised) drugs may be prescribed for patients with impaired airways clearance.

Normal saline (0.9% NaCl) is most commonly used and although its effect on the MCE itself is thought to be minimal, it may act as a cough stimulant.

Hypertonic saline (7% NaCl), however can increase the volume of liquid in the airway surface layer of the MCE, thereby hydrating it and reducing the viscosity of the gel layer.

This has been shown to be most effective in patients with chronic airways disease, particularly cystic fibrosis.

Mucolytics are enzymes which actively breakdown sputum, making it less thick and easier to expectorate.

DNase is an example of a mucolytic and it is administered via nebuliser.

Similarly to hypertonic saline, it is most commonly researched and used in the cystic fibrosis population.

Question 55

Advice and education

Answer 55

Expectorate sputum.

Vicious cycle of sputum, infection, inflammation and damage to the airways= clear airways to reduce risk of chest infection

Appropriate ACBT FET TEE etc which will remove their secretions

Frequency is patient specific and could be as frequently as half hourly when acutely unwell or once daily for chronic disease maintenance.

Regular fluid intake is recommended to ensure that secretions remain thin and easy to expectorate.

Check the colour and volume of sputum, any significant changes to be reported to their GP as antibiotics may be indicated.

Physiotherapists may need to check the patient’s understanding of this plan.

Question 56

Exercise

Answer 56

Exercise induces spontaneous deep breathing and is associated with increased expiratory flow rates and the mobilisation of respiratory secretions.

It can trigger coughing and improve expiratory muscle strength.

Patients should be advised to gradually return to previous activity after acute exacerbations of chronic conditions. Some patients (for example those with COPD) may be eligible for pulmonary rehabilitation classes and referral and attendance at these sessions should be encouraged.

Mobilisation on a regular basis is encouraged and all patients should be encouraged to exercise regularly at an appropriate functional level.

Question 57

Additional Techniques: Metaneb®

Answer 57

Nebuliser = uses (+) expiatory pressure + oscillatory pressure

Continuous High Frequency

Oscillation mode is a pneumatic form of chest physiotherapy ( operated by air or gas under pressure)

It delivers medicated aerosol while oscillating the airways with continuous pulses of positive pressure.

Common with cystic fibrosis.