Secretion management

Question 1

the lungs

Answer 1

lungs present a primary route for infection, they are remarkably resistant to environment injury despite continuous exposure to pathogens/particles and toxic chemicals, lungs have sophisticated defence mechanism, secretions are one of these essential defence mechanisms as the membranes need to keep moist and protected from dust/pollen/pollutants, virus and bacteria

Question 2

primary defence mechanisms- mucociliary clearance

Answer 2

antibacterial action within sol layer, cilia beat in sol layer of watery fluid (they hook onto fluid),, they reach up penetrating and propelling gel like mucus steadily from smaller airways to larger airways and toward the pharynx and mouth where it is swallowed or coughed, respiratory heal depends on consistent clearance of airway clearance

Question 3

importance of mucus

Answer 3

presence of mucus is normal but in health we don’t notice, insulates and prevents drying out of the airways, healthy mucus has low viscosity and is easily transported by the cilia, accumulation of mucus occurs because of overproduction or reduced clearance, persistent accumulation can lead to infection and inflammation by providing an environment ideal for microbial growth

Question 4

cilia

Answer 4

cilia extend from larynx to terminal bronchioles, mucus lines the airways from the nasopharynx to terminal bronchioles, hooks on cilia tips grab onto mucus as they waft forward, mucus flow is slower in the periphery and faster in the trachea

Question 5

factors which affect the mucociliary clearance mechanism

Answer 5

age, smoking (damage cilia), immobility, inflammation, anaesthetic agents, narrowed airways, height/presence of cilia, prolonged coughing, properties of mucus, embarrassment, hypercapnia, dehydration, hypoxia, age
depth of sol layer= to deep hooks can’t reach mucus, too shallow and the mucus clogs the cilia

Question 6

mucus in lungs

Answer 6

it has a gel like consistency- 97% water it holds its shape as 3% mucins and proteins- easily transported by cilia. Produce 10-100ml of mucus a day. It has properties of elasticity and viscosity, slimy texture, it moves like a soft elastic solid but when stress is placed on it, it flows like a viscous fluid (greater stress=less viscous- flows more)

Question 7

at risk patients of build up of sputum

Answer 7

increased production or altered composition, conditions- CF/ Pneumonia/ COPD, can be due to abnormality of cilia- not beat in uniform pattern, suction- can damage cilia epithelia

Question 8

when are secretions a problem for physio

Answer 8

they are seen or heard to obstruct things, excessive/ difficult to eliminate and/or causing distress, cause desaturation because of obstruction/atelectasis and poor ventilation

Question 9

what is the problem with retained secretions

Answer 9

long term persistent mucus stasis= infection and inflammation, retained secretions disable the antimicrobial chemical shield, potential for overwhelming infection as secretions remain stagnant, accumulation=major atelectasis=impaired gas exchange, accumulation= contamination with pathogens= inflammation and destruction of airways- airflow limitation

Question 10

what is the purpose of airway clearance

Answer 10

aims to promote clearance of excessive secretions from the distal airways to central airways where expectoration can occur through coughing or huffing

Question 11

choosing a airway clearance technique

Answer 11

influenced by underlying cause and acuity of patient condition, evidence to support technique, patient age and ability to learn the technique, patient motivation/ patient preference/ comfort, physio skill

Question 12

stable non acute COPD

Answer 12

excessive sputum may cause airflow obstruction- does not limit lung function but can cause infection, if patient is troubled by a cough and are able to clear sputum when required, daily routine chest clearance may not required- but patients need to taught clearance techniques if not needed

Question 13

what is sputum

Answer 13

sputum= excess tracheobronchial secretions, purelent meaning containing pus= greater viscosity and less elastic recoil so difficult to clear

Question 14

what is a bronchial cast

Answer 14

a large thick mucus mould or impression of the inner lining of the bronchial tree, occurs secondary to allergic inflammation/ infection/ or excessive reactivity to a foreign body, can be expectorated but if remains can cause SOB and poor O2 sats

Question 15

cough

Answer 15

forced exposure maneuver against a closed glottis. Helps clear large amounts of mucus or inhaled material when mucociliary clearance is overwhelmed or damaged

Question 16

normal cough mechanism- inspiration

Answer 16

deep inspiration to near total lung capacity- compression
snapping shut of glottis, short pause to allow distribution of air past secretions, sharp contraction of expiratory muscles, increase in intrathoracic pressure- inspiratory muscle contract against glotis

Question 17

normal cough mechanism- expiration

Answer 17

sudden opening of glottis, explosive acceleration of PEF and explosive airway narrowing, decrease cross sectional area= high velocity linear flow, the sheer forces then overcome viscous/ gravitational and frictional resistance tearing mucus from upper airways and suspending droplets in the lumen, large swing in the pleural pressure- dynamic airway compression, a subsequent deep breath will reopen airway

Question 18

adverse effects

Answer 18

urinary incontinence, GOR (gastric oesophagus reflux), rib fracture or ruptured RA, headache, respiratory trauma, strokes, airflow limitation, increased/decreased blood pressure, heart rhythm problem

Question 19

what factors will impair cough- altered flow properties of secretions

Answer 19

increased viscosity and elasticity of sputum= tenacious secretions= decrease cough effectiveness

Question 20

what factors will impair cough- inability to generate sufficient expiratory flow

Answer 20

several reduced VC, respiratory muscle weakness, airways that collapse easily on exhalation/airflow limitation, dilated airways and fear and anxiety

Question 21

what factors will impair cough- pain/fear, reduced cough reflex

Answer 21

pain- post op or chest trauma, cough- damage to vagal or glossopharyngeal nerve, laryngectomy/intubation/tracheostomy cough weakened as glottis bypassed

Question 22

inability to generate sufficient expiratory flow

Answer 22

neuro-muscular disorder, respiratory muscle dysfunction/ reduced strength or endurance, chronic lung disease- COPD and bronchiectasis, chest wall disorder= kyphoscoliosis and rib fractures

Question 23

humidification

Answer 23

hydrogen affects the function of the cilia as well as the quality and quantity of mucus, to prevent secretions thickening- systemic hydration by oral or intravenous fluids and inhalation of vapour/ nebulized by inhalation of an aerosol

Question 24

techniques to remove excess secretions

Answer 24

ACBT, autogenic drainage, hydration, positioning, mobilisation, mannual techniques, adjuncts, suctioning,

Question 25

techniques to remove excess secretions- general principles

Answer 25

airway clearance techniques aim to enhance mucociliary clearance and mucus transport- mobilise secretions toward the mouth to aid expectoration, practice is influenced by- culture/ skill of therapist/ finances of healthcare provision/ where possible patient performance

Question 26

techniques to remove excess secretions- other considerations

Answer 26

prevent excess energy expenditure, ensure adequate oxygen/energy supply, long term airway clearance regimes need to be negotiated and reassessed on a regular basis

Question 27

what is huffing

Answer 27

a forced exhalation through an open mouth and glottis instead of coughing, referred to as FET, helps mobilize sputum up the airways towards the mouth in a controlled way, uses the abdominal muscles and chest wall to facilitate expiratory flow, huffing should always be followed by breathing control and should not be so forced that it causes wheezing or tightness in the chest, huffing usually starts from lung volume but once secretions start to move proximally huffs can take place from high lung volume

Question 28

how does huffing work- EPP

Answer 28

Any forced expiratory manoeuvre causes dynamic compression and collapse of airways, during a huff pleural pressure becomes positive and equal to airway pressure at a point called EPP- from this point to the mouth the pressure outside is greater- causing dynamic compression (narrowing and squeezing of airways) which moves to mouth

Question 29

how does huffing work- EPP location

Answer 29

the position of EPP depends on the lung volume at start of huff, it occurs nearer to the mouth at high lung volume and further at low lung volume, huffing from low lung volumes assists moving secretions from peripheral areas, huffing from large lung volume= proximal area

Question 30

how does huffing work- other factors

Answer 30

coughing creates greater airway narrowing than huffing, limiting airflow and reducing the efficiency of bronchial clearance, huffing provides slight oscillation or hidden vibrations in addition to the squeezing action, high velocity airflow interactis with liquid lined airway surface causing shear forces which reduce viscosity and propel sputum in the direction of flow

Question 31

ACBT demonstration- first phase

Answer 31

breathing control- place hand on stomach and take relaxed breath in through nose and out through mouth (can add in purse lip breathing)- expand stomach- repeat 5 times

Question 32

ACBT demonstration- second phase

Answer 32

TEE- place hands on rib cage- take longer deeper breath through nose and exhale gently through mouth- movement of ribs out- repeat 5 times- then go back to stage 1 or progress to stage 3

Question 33

ACBT demonstration- 3 phase

Answer 33

FET- take a long breathing through nose and huff out through mouth- can use hand as a visual aid of streaming up mirror, can be longer breath in and shorter huff, or short berath and longer huff

Question 34

autogenic drainage

Answer 34

can be more effective for sputum clearance, drawbacks- difficult to teach and master- only used as chronic clearance, cannot have break in between fazes

Question 35

autogenic drainage- first phase

Answer 35

unstick- breath down into EV, then take normal tidal breaths in EV, take little breath in and out

Question 36

autogenic drainage- second phase

Answer 36

collect- patient breath at normal TV

Question 37

autogenic drainage- third phase

Answer 37

evacuate- patient progressively take larger breaths into IV volume