Secretion clearance

Question 1

Why do we need ACTs?

Answer 1

1. Ciliary impairments
   
   2. Hypersecretions
   3. Airway disease leading to early airway closure
   4. Muscle weakness
   5. Risk of secretion retention (e.g. post operative)
      a. General anesthesia
      b. Impairment of mucociliary system by tracheal tube
      c. Pain

Question 2

Benefits of ACTs

Answer 2

1. Prevent infection
   
   2. Ensures good lung function which can help
      a. Increase ventilation
      b. Decrease WOB
      c. Prevent or delay use of supplemental oxygen
      d. Increase QOL
      e. Decrease mortality risk

Question 3

Coughing phases

Answer 3

1. Inspiratory - maximize lung volume
2. Compressive - increase intrathoracic pressure
3. Expiratory - sudden opening of glottis with violent release of air from lungs
4. Recover/relaxation

Question 4

The 2 types of assisted cough

Answer 4

Costophrenic cough assist - targets lower airways
○ Patient with weak/paralyzed intercostal or abdominal muscles
○ Patient supine and place hands on lower ribs
○ Synchronize down and in compression with cough (following chest wall)
Heimlich-type cough assist
○ Patient supine
○ Place hands between belly button and xiphoid process
- push hands down and up as they cough

Question 5

Assisted cough contraindication

Answer 5

ruptured diaphragm, fractured ribs, incision and wound

Question 6

HUFF mechanism

Answer 6

FET uses compression and narrowing within the airways at the equal pressure point to move secretion

Question 7

Huff benefits

Answer 7

• Less fatiguing
• Produces less bronchospasm
• Produces less dynamic airway collapse below of lower transpulmonary pressures
• Moves secretion from smaller more peripheral airways
• Repeated coughing can hurt the chest and ribs

Question 8

Active Cycle breathing technique mechanism

Answer 8

Active secretion mobilization with deep breath (thoracic expansion phase) combined with. The mechanism of huffing and/or coughing

Question 9

3 phases of Active Cycle Breathing Technique

Answer 9

1. Breathing control (relaxation)
   a. 30-120s at normal tidal volume and resp rate
2. Thoracic expansion (active secretion mobilization)
   a. 30 seconds/3-5 breaths thoracic expansion (deep breathing)
3. FET
   a. 2-3 huffs or coughs interspersed with breathing control

Question 10

Positive Expiratory Pressure device Mx

Answer 10

Provides constant pressure (10-20cm H2)) during expiration via an expiratory resistance device with a one way valve
- Splints airways open and improves collateral ventilation –> help mobilize mucus and improves airway clearance
- Technique: involves breathing cycles using a PEP device and manometer feedback ensures target pressure is maintained during expiration

Question 11

Oscillating positive expiratory pressure device Mx

Answer 11

Similar to PEP but applies an oscillating pressure rather than a constant pressure to create vibration in the airways
Technique: breathing cycles using an oscillating PEP device for airway clearance

Question 12

2 types of oscillating PEP devices

Answer 12

Flutter device
○ Mx: high density steel ball that sits inside “pipe”
○ Expiration causes ball to rise and fall to generate PEP (10-35cm H@)) and airflow oscillations pulsations in the airways
○ Perform this against gravity. (in sitting)

Acapella
○ Mx: provides oscillations to the airways during expiration using a counterweighted lever and magnet creates PEP (7-35cm H2o) and oscillations
○ Oscillation frequency and PEP adjusted via dial
- 1 is easiest and 5 is hardest
- Can be done in sitting or supine

Question 13

Absolute contraindications for all ACTs

Answer 13

Servere hemoptysis, large undrained pneumothorax