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Acute W6-8 > W8 MC: Secretions > Flashcards

W8 MC: Secretions Flashcards

1
Q

What are the benefits of secretion clearance?

A

Reduced risk of infection
Avoid deterioration of breathing mechanics (ie increase in WOB)
Improve ventilation/gas movement

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2
Q

A physio is required for secretion clearance if:

A
  • Patient cannot clear secretions independently eg post-op pain, weak cough, confusion
  • If the patient has excessive secretions (eg chronic lung disease)
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3
Q

What airway clearance techniques are there?

What would influence your choice of ACT?

A

Cough & Huff
Breathing exercises (ACBT/autogenic drainage)
Positioning
Manual techniques (Percussions and vibrations)
Devices
Exercises

These are all non-invasive. Suctioning = invasive.

ACT choice dependent on a range of factors eg volume and consistency of sputum, presence of co-morbid conditions, cognitive status, availability and cost, etc

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4
Q

Cystic fibrosis (evidence for ACT)

While airway clearance techniques seem effective in comparison to control treatments, ….. ….. of airway clearance has been shown to be ….. to any other.
- Grade A evidence suggesting …… are appropriate for CF (Hint: 3)

A

No technique is superior

All appropriate for CF:
ACBT (active cycle of breathing technique)
PEP devices
Chest wall compressions/oscillations

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5
Q

Bronchiectasis (evidence for ACT)

A

PEP therapy and manual chest physiotherapy, have proven effective, with benefits demonstrated in stable and acute states (long term not certain).

Grade A evidence suggesting active cycle of breathing technique & PEP devices are effective for bronchiectasis

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6
Q

COPD (evidence for ACT)?

A

Active cycle of breathing and autogenic drainage.

Both seem to be safe and offer some clinical outcomes such as short-term reductions in the need for increased ventilatory assistance, duration of ventilatory assistance, and hospital length of stay in both acute and stable disease.

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7
Q

What are some adjuncts/medications used to assist with secretions?

A
  • Bronchodilators: opens airway prior to secretion clearance (medication)
  • Mucolytic: Used before physio to thin mucus and make it easier to clear (medication).
  • Nebuliser: converts liquid medication into aerosol droplets (mist) suitable for inhalation. Uses O2, compressed air or ultrasonic power to break up solutions

(Cannot give without nursing supervision!)

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8
Q

What is a bronchodilator?

What muscle does it target?

What is its purpose?

What can be used to enhance administration?

A
  • Medication indicated for individuals that have lower than optimal airflow through the lungs, caused by bronchospasm/bronchoconstriction (short and long acting)
  • Targets smooth muscles in the bronchioles of the lung, causing dilation and opening of the airway
  • Increase the availability of oxygen to assist with secretion clearance
  • Spacer (holding chamber device)

(Cannot give without nursing supervision!)

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9
Q

What is a mucolytic?

What does it increase & alter?

What can it stimulate?

A
  • Class of medications that thins mucus, making it less viscous, sticky and easier to cough up.
  • Increase airway hydration
  • Alter mucus rheology (decrease viscosity)
  • Stimulate cough –> Aid airway clearance

Note: Can be oral or inhaled. May be prescribed for patients with chronic secretion issues. EG: COPD, Bronchiectasis, Cystic Fibrosis

(Cannot give without nursing supervision!)

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10
Q

What is a nebuliser?

What is the gas flow rate?

How is it administered?

A
  • A nebuliser is a device that converts liquid medication into aerosol droplets (mist) suitable for inhalation
  • Gas flow rates of 6 - 8 L/min are required to produce small enough particles (<5 microns) to reach distal airways
  • Can be administered via mask or mouthpiece in non-intubated patients.
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11
Q

What can be given after physio treatment to aid in secretion management?

A

Antibiotics & corticosteroids

(Cannot give without nursing supervision!)

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12
Q

What is the only medication that can be administered without nursing supervision?

A

SALINE

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13
Q

How do airway clearance techniques work & what are their 3 main goals?

A

Airway clearance techniques work by modulating the parameters of airflow

  1. Increases in expiratory airflow
  2. Increasing lung volumes
  3. Oscillation of airflow – manually or intermittent resistance
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14
Q

A cough and huff is classified as a…

A

Forced expiratory technique

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15
Q

Cough and hough:
- What is its mechanism & the two main concepts behind its use?

A
  • Use changes to lung volumes and generation of rapid expiratory airflow to remove secretions from the lungs

Two main concepts
- 2 phase gas liquid flow mechanism
- Dynamic compression

**note cough is also used as an assessment. Commonly used in conjunction with other ACT’s.

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16
Q

What is the 2 phase gas liquid flow mechanism related to cough/huff?

A

Interaction of liquid (secretions) and gas (air) within the airway.

3 Basic patterns of gas-liquid flow which are relevant for mucus clearance from the lungs.

  • Slug flow:
  • Annular flow:
  • Mist flow
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17
Q

What is slug flow (2 phase gas liquid flow mechanism)?

A

Large bubbles of air pass through the airways which can get behind the plug & force the secretion out of the airway

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18
Q

What is annular flow (2 phase gas liquid flow mechanism)?

A

When the increase in expiratory flow rate moves secretions which line the airway in a wave like pattern towards the oropharynx.

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19
Q

What is mist flow (2 phase gas liquid flow mechanism)?

A

When very fast expiratory flow rate shears the secretions off the walls of the airway in small particles (mist) towards the oropharynx eg a cough (deep breath in, quick forceful breath out)

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20
Q

What is dynamic compression and its relation to cough & huff?

A

During a forced expiration parts of airways narrow creating high airflow (velocity) & turbulence pushing mucus towards the mouth

There is greater pressure in the more peripheral airways and that pressure gradually reduces along a gradient as it moves towards the mouth and the airway starts to narrow.

There will be a point along the airway where the pressure inside the airway and the pressure outside of the airway are equal. We call this the equal pressure point and this equalisation of pressure would generally cause dynamic compression of the airway and helps remove secretions along the airway.

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21
Q

At the equal pressure point in dynamic compression pleural pressure equals…

A

Alveolar pressure

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22
Q

Physiology behind a cough?

What mechanisms are required for an effective cough

A

Aims to clear secretions from central airways which may have been moved from the periphery via a huff.

Effective cough mechanisms
1. Deep inspiration (to TLC)
2. Closure of the glottis
3. Contraction of abdominal muscles
4. Opening of glottis & an explosive breath out

We need a big volume of air and explosive expiration to produce mist flow. If a patient is unable to perform any of these steps, cough effectiveness would be reduced.

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23
Q

Low vs high volume huff?

A
  • Low volume huff: help to move secretions that are lower in the airways. Take a normal breath in, then an active long breath out until the lungs feel quite empty.
  • High volume huff: move secretions in the upper airways. Take a normal breath in, then a short sharp breath out
24
Q

In a high volume huff if the secretion is where?

A

Higher up secretions (will mean the equal pressure point is also higher up)

25
Q

What is the physiology of a low lung volume huff?

A

Medium breath in –> less alveolar recoil –> less alveolar pressure to start with –> equal pressure point will be closer to the alveoli

26
Q

What is the physiology of a high volume huff?

A

Big breath in –> more alveoli recoil –> greater alveoli pressure to start with –> equal pressure point will be closer to the mouth.

27
Q

There are three phases involved in active cycle of breathing: What are they and their purpose?

A
  • Breathing control/relaxed breathing: prevents bronchospasm + desaturation (completed for 20-30 seconds)
  • Deep breathing (thoracic expansion) aims to loosen secretions and enhance collateral ventilation (3-4 deep breaths)
  • Huff and coughing helps clear secretions through changes in thoracic pressure and airway dynamics
28
Q

What is the general cycle involved in active cycle of breathing?

A
  • Breathing control (20-30 seconds)
  • 3-4 deep breaths
  • Breathing control
  • 3-4 deep breaths
  • Breathing control
  • Huffing followed by cough if needed

(REPEAT CYCLE)

29
Q

What is autogenic drainage?

A

Autogenic drainage is a very controlled technique of breathing which uses different depths and speeds of exhaled breath to move mucus up the airways resulting in a spontaneous or voluntary cough (secretions move from smaller airways to larger airways)

30
Q

What are the three phases of autogenic drainage?

A
  • Unstick secretions- breathe as much air out of your chest as you can, then take a small breath in, using your tummy, feeling your breath at the bottom of your chest. You may head secretions start to crackle. Resist any desire to cough. Repeat for at least 3 breaths.
  • Collect Secretions: as the crackle of secretion starts to get louder, change to a medium sized breath in. Feel the breath more in the middle of your chest. Repeat for at least 3 breaths.
  • Evacuate secretions: When the crackles are louder, still take a long slow full breath to your absolute maximum. Repeat for at least 3 breaths.
31
Q

What are the advantages to autogenic drainage?

A
  • Flexible and allows patient independence
  • No equipment is required
  • Less effort is required which reduces stress on the pelvic floor
32
Q

What are the disadvantages to autogenic drainage?

A
  • Complex treatment - takes time and patience (& skill to teach)
  • Generally too complicated for children (< 8 years)
  • To benefit from the auditory feedback, need moderate/large amount of sputum
33
Q

What is the purpose of an oscillation? x3
What are the two kinds of oscillations?

A
  • Increase in expiratory flow rate
  • Mechanical stimulation of ciliated epithelial cells of the airway and chest wall which may stimulate cilial beat
  • Alters the rheology of the mucus which may facilitate mucociliary clearance

Two kinds: percussions and vibrations

34
Q

Oscillation of airflow can be created by….

A
  1. intermittent positive pressure applied to the chest wall manually (percussion & vibrations)
  2. Applying intermittent resistance to airflow at the mouth (oscillating PEP devices)
35
Q

What is a percussion?

A
  • Rhythmical clapping of the chest wall with cupped hand(s) over specific lung segments
  • Often applied in conjunction with PD (postural drainage?)
  • Imparts mechanical energy to airways to
  • Cause oscillation of airflow within the airways
  • ↑ expiratory flow rate
  • Stimulate cilial beat
36
Q

Precautions/contraindications for percussion

A

Precautions/contraindications
* Fractured (#) ribs/flail chest/unstable sternum
* Frank haemoptysis
* Undrained pneumothorax
* Over malignant tumour
* Over new skin grafts, burns, surgical incisions,
* Severe bronchospasm
* Osteoporosis
* Low platelets <150 x 109
* Platelets, or thrombocytes, are small, colorless cell fragments in our blood that form clots and stop or prevent bleeding.

37
Q

What is a vibration?

A
  • Application of a vibratory action (compression and oscillation) to the chest wall with a flat hand.
  • Applied during expiration over affected lung region.
38
Q

How does a vibration increase secretion clearance? 4x

A
  • Increasing peak expiratory flow rate to move secretions
  • Increase annular flow of mucus
  • Increase mucus transport by decreasing viscosity of mucus
  • Eliciting spontaneous coughs
39
Q

What is postural drainage?

A
  • Type of specific positioning- affected lung will be placed upper most.
  • Based on the concept of gravity-assisted mobilisation and transport of secretions.
  • Involves positioning a particular lung segment uppermost and perpendicular to horizontal to allow gravity to drain secretions centrally for expectoration.
  • Often used in conjunction with percussions & vibrations
  • 12 specific positions, some involving head down tilt. Many clinicians prefer modified options for safety.
40
Q

What is trendelenburg?

What have studies found regarding the trendelenburg?

A

Head down tilt (component of postural drainage)

Studies have shown no differences in the amount of sputum expectorated between head down and horizontal positions (Cecins et al, 1999)

41
Q

In what patients is the trendelenburg position contrainidcated?

A
  • Elevated intracranial pressure (head injuries)
  • Haemodynamic compromise (uncontrolled hypertension, cardiovascular instability)
  • Impaired lung mechanics (pulmonary disorders)
  • Orthopnoea
  • Risk of aspiration
  • Gastro-oesophageal reflux
  • Cardiac failure

**In general the position should be avoided?

42
Q

What is a positive expiratory pressure (PEP) device?

What does it generate?

A
  • Devices that apply resistance to expiratory flow to help clear secretions
  • Generate positive expiratory pressure (backpressure) during expiration, which splints small airways open & stabilises collapsible airways.
43
Q

What are the two types of PEP devices?

A

Non-oscillating and oscillating

44
Q

How do non-oscillating PEP devices work?

A
  • PEP temporarily increases FRC via progressive recruitment of collapsed alveoli via collateral ventilation
  • The air in the recruited lung volumes gets behind the secretions
  • Combined with the FET (forced expiration technique), the secretions can then be moved more centrally for clearance.

Note:PEP devices create resistance when a patient exhales, causing positive pressure in the airways during exhalation. This resistance helps maintain the airways open for a longer period, preventing their collapse.

The constant positive pressure keeps the smaller airways from closing prematurely, allowing air to get behind mucus and facilitate its clearance.

When the main airways are blocked by mucus or collapse, collateral ventilation provides an alternate route for air to reach these alveoli.

The increased pressure from the PEP device helps air navigate through collateral pathways, progressively inflating alveoli that had previously collapsed due to airway obstruction or pressure imbalances.

45
Q

How do oscillating PEP devices work?

A
  • Oscillating PEP therapy provides the combination of positive expiratory pressure with high frequency oscillations
  • It involves breathing with a slightly active expiration against an expiratory resistance through a device.
46
Q

What is the ideal set rate of oscillation frequency?

A
  • Range of oscillation frequency shown to be effective for secretion movement is 3-17Hz (cycles per second), with optimal clearance at 13 Hz (Gross et al, 1985)

Note: a resistance of 4 can replicate our cilial beat

47
Q

What is the risk of bubble PEP

A

Risk of aspiration
Must evaluate cognitive appropriateness

48
Q

How does moving a patient into a different position aid in secretion clearance?

A
  • Increases collateral ventilation and expiratory air flow velocity- essentially allows air to get behind secretions and helps move them out of the lungs
  • Increase strength & quality of a cough
  • Increases mucociliary transport and airway clearance.
49
Q

What is the evidence for exercise?

A
  • Physical training should be advised for improvements in fitness and cardiorespiratory performance in patients with asthma. (Grade B)
  • Exercise should be an integral part of the management of patients with cystic fibrosis. (Grade B)
  • Consider pulmonary rehabilitation soon after exacerbation for patients with COPD. (Grade B)
  • Offer pulmonary rehabilitation to individuals with non-cystic fibrosis-related bronchiectasis with breathlessness affecting activities of daily living. (Grade A)
50
Q

When is suctioning used?

A
  • Used when active treatments are ineffective to move secretions.
  • Can be performed on mechanically ventilated patients and self ventilating patients when clinically indicated.
51
Q

What are the three types of suctioning?

A

tracheal, oropharyngeal and nasopharyngeal

52
Q

How does suctioning work?

A
  • Involves inserting an artificial airway and then passing a suction catheter into the airway. Suction pressure is then used to remove the secretions as the suction catheter is removed from the artificial airway.
53
Q

How do you determine the type of suctioning to use?

A

The type of suctioning depends on the location of secretions

  • Upper airways- oropharangeal and nasopharangeal suctioning options
  • Lower airways- open or closed tracheal suctioning
54
Q

When is closed suctioning preferred?

A
  • When it comes to mechanically ventilated patients, closed suctioning techniques are preferred.
  • Closed suctioning techniques, also referred to as “in-line suctioning,” is where a multiuse suction catheter placed inside a sterile plastic sleeve.
  • Allows for maintenance of oxygenation and ventilation support
  • Maintains PEEP as the circuit is not interrupted
  • More secure environment to reduce the risk of infection to the patient
  • Reduces the risk of aerosolisaton (ie they aren’t carried through the air) of tracheal secretions during coughing– reduces infection to therapist/staff
55
Q

What ausculation sound would indicate the need for suctioning?

A
  • Auscultation of adventitious lung sounds (rhonchi) or course crackles over the trachea, mainstem bronchi, or both
56
Q

What are some indications for suctioning?

A
  • Gradual or sudden decrease in oxygen saturation
  • Increase in peak airway pressures when the patient is receiving mechanical ventilation
  • Increased respiratory rate, frequent coughing, or both
  • Secretions in the artificial airway
  • Sudden onset of respiratory distress when airway patency is questioned (ie: decreased breath sounds, cyanosis, ventilator alarm sounding, altered LOC)
  • Suspected aspiration of gastric or upper-airway secretions
57
Q

What wave pattern for ventilation would indicate the need for suctioning?

A

Saw tooth - Mucus in the patient’s airway can cause turbulent airflow, leading to irregularities that are reflected as a sawtooth pattern on the flow or pressure waveform. This turbulence disrupts the smooth delivery of air.

Acute W6-8 (5 decks)

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