Secretion Management

Question 1

What two defence mechanisms does the lungs have?

Answer 1

Mucociliary clearance/ Escalator

Cough

Question 2

What does healthy mucus look like

Answer 2

Low viscosity and easily transported by the cilia

Question 3

What factors affect the mucociliary clearance mechanism?

Answer 3

Hypoxia
Dehydration
Hyper apnea 
Properties of mucus
Smoking
Inflammation

Question 4

What is the problem with retained secretions?

Answer 4

Long term persistent mucus causes infection and inflammation
Retained secretions disable the anti microbial chemical shield
Accumulation- major atelectasis- impaired gas exchange
Accumulation- contamination with pathogens-inflammation and destruction of the airways- causes airflow limitation

Question 5

What is the purpose of airway clearance techniques?

Answer 5

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

Question 6

How do you decide which airways clearance technique to use?

Answer 6

Influenced by underlying cause and acuity of patient condition
Evidence supporting the technique
Patient age and ability to learn the technique
Patient motivation
Patient preference and comfort
Physios skill in teaching the technique

Question 7

What is the difference between sputum and mucus

Answer 7

Mucus is normal and sputum is not
Sputum= excess tracheobronchial secretions
Purulent means containing pus
Purulemt sputum has greater viscosity and less elastic recoil so it is difficult to clear

Question 8

What is a cough

Answer 8

Forced explosive manoeuvre against a closed glottis. It helps clear large amounts of mucus or inhaled material when the defence system is overwhelmed

Question 9

What 3 components are required for a normal cough mechanism

Answer 9

1. Inspiration
2. Compression
3. Expiration

Question 10

What are the effects of persistent coughing

Answer 10

Urinary incontinence 
Headache
Stroke or seizure
Airflow limitation
Rib fracture 
Heart rhythm problems

Question 11

What factors may impair cough?

Answer 11

Altered flow properties of secretions with increased viscosity and elasticity
Inability to generate sufficient expiratory flow
Pain/Fear - post operation and chest trauma
Reduced cough reflex

Question 12

What disorders or disease may prevent the ability to generate sufficient expiratory flow?

Answer 12

Neuro muscular disorders - GBS, MND,MS,MYASTHENIA GRAVIS, TETRAPLEGIA
Chronic lung diseases- COPD and Bronchiectasis
Chest wall disorders- Kyphosdoliosis and rib fractures

Question 13

Why is secretion clearance impaired

Answer 13

Infection, music properties, I’m,obi,it’s, airway damage, weakness, pain, impaired cough, anxiety and fear, dehydration, lack of oxygen

Question 14

How do you prevent secretion thickening when using humidification?

Answer 14

Iv fluids
Inhalation of vapour
Nebulization by inhalation of an aerosol

Question 15

What are the techniques to remove excess secretions?

Answer 15

Suctioning
ACBT
Autogenic drainage
Hydration
Positioning
Mobilisation
Manual techniques
Adjuncts

Question 16

What is breathing control

Answer 16

Relaxed breathing, symmetrical position, breath in and out gently through the nose, if not breath through the mouth instead, emphasis is on rhythmic breathing and avoiding breath holding and relaxation of the shoulder girdle. On observation and palpation the abdomen should swell on inspiration

Question 17

What are TEES

Answer 17

Taking a long slow deep breathe in through the nose, try to keep the shoulders and chest relaxed, end the inspiration hold and sniff, breath out gently and relaxed like a sigh
Repeat 3 times

Question 18

What is huffing?

Answer 18

A forced exhalation through an open mouth and glottis instead of coughing. Imagine steaming up a mirror and drawing a smiley face, uses the abdominals and chest wall to facilitate expiratory airflow. Huffing should be followed by breathing control

Question 19

What is the pathology behind doing huffing?

Answer 19

Any forced expiratory manoeuvre including coughing causes dynamic compression and collapse of airways. During a huff, pleural pressure becomes positive and equal to airway pressure. This is called the EPP and from this EPP to the mouth, the pressure outside the airway is greater than that within the airway. This crates narrowing and a squeezing action which moves progressively towards the mouth. The location of the equal pressure point of compression depends on the lung volume at the start of the huff.
Huffing to low lung volumes assists moving secretions from more peripheral areas
Huffing from high lung volumes moves secretions from more proximal airways.
Ie. nearer to the mouth
Huffing provides slight oscillation or hidden vibrations in addition to the squeezing action.
High velocity airflow interacts with liquid lined airway surfaces causing shear forces which will reduce viscosity and propel sputum to be able to do expectoration.

Question 20

How long should the huff be

Answer 20

For peripheral lung volumes, you need a longer huff as the air has further to travel
For proximal lung volumes, you need a shorter huff

Question 21

What would you do for a patient that cant take short breath

Answer 21

Take a normal breath in, half a breath out and half a huff

Question 22

Why use a huff and not a cough

Answer 22

Cough can be used for when the secretions hit the carina and are more proximal, advice the patient not to cough.
The EPP is behind the huff and can be measured easier. It pushes the secretions upwards.

Question 23

Why cant you get a v/q match in mechanical ventilation?

Answer 23

As the dependent regions can’t expand due to positioning of the abdomen and diaphragm.
CPAP

Question 24

What is apical breathing?

Answer 24

Pattern of breath that contains most movement to the upper chest

Question 25

How does mucocilliary clearance work?

Answer 25

The cilia line all the airways. They are microscopic hairs with hooks on their tips. They can bend backwards and forwards and to work best they need warmth and humidity.
They have a sol layer (aqueous) layer, it is like an antibacterial action.
They have a gel layer (viscous) the goblet cells secrete mucus and they create a sticky gel layer which traps dust, foreign parts, bacteria.

The cilia beat in the sol layer, they reach up penetrating and propelling the gel mucus- steadily from small airways to larger ones- towards pharynx and mouth where they are coughed up or swallowed