Week 3

Question 1

What is the goal of airway clearance techniques (ACTs)?

Answer 1

to identify secretion over-production/retention problems and apply treatment to maintain clear lungs for our patients and prevent secondary complications

Question 2

What does normal airway clearance rely on?

Answer 2

mucociliary clearance (MCC) and an effective cough (as a backup to when the MCC is impaired)

Question 3

Impaired airway clearance can lead to…

Answer 3

uneven ventilation leading to reduce gas exchange and hypoxaemia

increased infection risk, inflammatory response, chemical mediators destroy lung tissue and can lead to unstable airways

Question 4

Describe the mucociliary escalator…

Answer 4

2 layers: gel layer superficially to catch foreign bodies and sol layer (more watery) to allow cilia to beat and move foreign material up and out of the lungs to be coughed or swallowed

cilia move foreign particles toward trachea at ~5-15mm/min

Question 5

What factors reduce mucociliary clearance?

Answer 5

1) decreased beating of cilia

temporarily due to:
-medications i.e. pain meds or anaesthetic
-dehydration
-high inspired O2 concentration (which dry out the airways)
-atelectasis/reduced lung volumes
-decreased cough effectiveness
-lack of sleep
-pollutants

permanently due to: smoking or disease i.e. bronchiectasis or cystic fibrosis

2) increased secretion volume/thickness

Question 6

How much mucus is produced in a healthy lung on a daily basis?

Answer 6

100ml per day

Question 7

What effects do congested airways have on a patients breathing?

Answer 7

leads to decreased cilial function, increase work of breathing and fatigue, decreased ventilation, decreased V/Q ration and decreased oxygen within the body

can lead to long term damage and scarring of lung tissue

Question 8

What are the 3 aims of airway clearance techniques?

Answer 8

1) get air behind secretions
2) mobilise secretions
3) remove secretions

Question 9

What is the difference between secretions and sputum?

Answer 9

secretions within the lung, sputum out of the lungs

Question 10

9 techniques in the ACT toolkit.

Answer 10

1) cough
2) active cycle of breathing technique (ACBT)
3) positive expiratory pressure (PEP)
4) autogenic drainage (AD)
5) postural drainage (PD, MPD)
6) percussion & vibration (P & V)
7) inhalation therapy
8) exercise therapy
9) suction

Question 11

How far does a cough reach to expel secretions?

Answer 11

only the first 6 generations

Question 12

When is a supported cough appropriate?

Answer 12

when our patient is in pain and unable to produce adequate expiratory force

support increases intra-abdominal pressure, reduces tension on wounds and reduced the ROM which the muscles contract

Question 13

When is an assisted cough appropriate?

Answer 13

when our patient is unable to produce adequate expiratory force due to reduced muscle capability

use bibasal compression or AP sternal compression depending on where the MOST movement is happening for the patient

Question 14

What techniques can be used to stimulate a cough in a semi/unconscious patient?

Answer 14

tracheal rub, mechanical insufflator/exsufflator devices i.e. CoughAssist machine

Question 15

Why is the Active Cycle of Breathing Technique (ACBT) so useful for physios?

Answer 15

it is flexible and can be adapted to patients, it is generally well tolerated by patients, it can be done on its own or in conjunction with other treatments and it can be done independently by patients

Question 16

What are the components of the ACBT?

Answer 16

breath control (BC), thoracic expansion exercise (TEE) and forced expiratory technique (FET)/also called a ‘huff’

Question 17

Explain the forced expiratory technique (FET).

Answer 17

relies on manipulating where the equal pressure points (EPPs) occur (EPP is when there is equal pressure between the pleural space and alveoli) to remain distal to secretions and ‘massage’ them upwards through the lungs like toothpaste

low lung volume= mobilisation at lowest point of the lungs

mid lung volume= mobilisation at mid point in the lungs

high lung volume= clearance of secretions from higher up in the lungs

Question 18

How long does a ACBT session generally take?

Answer 18

10 to 30 minutes depending on the amount of secretions present

repeat until effective huff to low lung volume has become dry-sounding and non-productive

OR

patient fatigues

Question 19

What are positive expiratory pressure (PEP) devices?

Answer 19

devices that work to reinflate collapsed parts of the lung by utilising collateral ventilation which splints airways open and prevents collapse during expiration

during airway clearance, this works to get air behind the secretions rather than mobilise or expel them

Question 20

What is the ideal inspiration/expiration ratio for a patient using a PEP device? How do we adjust this?

Answer 20

I:E 1:3

i.e. 3 seconds inhale and 9 seconds exhale

as tested with 6-8 breaths with desired resistance cap attached

start with mid-sized resister and adjust (i.e. if the patient expiration too short/pressure of 10-20cmH20 not being reached, increase resistance by reducing size of hole)

Question 21

When would a mouthpiece vs a mask PEP device be more suitable?

Answer 21

mouthpiece devices are more common, portable but patient must be able to keep cheeks flat and tolerate a nose clip

masks are if the patient is unable to keep cheeks flat or unable to keep mouth sealed around the mouthpiece

Question 22

What is a typical prescription for PEP devices for a) pulmonary disease and b) post-op patients?

Answer 22

stable pulmonary disease= 10-15 minutes 1-2 times a day (i.e. 8 sets of 10 breaths)

post-op patients= shorter sessions more frequently

Question 23

When are PEP devices appropriate?

Answer 23

for any illness that causes airway collapse or patients at risk of retaining secretions or atelectasis (used primarily for airway clearance but also helps with ventilation)

Question 24

What are some precautions to using PEP devices?

Answer 24

active haemoptysis
lung surgery
pneumothorax
undrained empyema or lung abscess
emphysematous bullae
haemodynamic instability
facial fractures or surgery
middle ear infection
sinusitis

Question 25

Why would we add oscillations to our PEP device technique?

Answer 25

to allow easier clearance of secretions

works to mechanically rupture rigid mucous gel to thin out secretions

Question 26

What are the 3 phases to autogenic drainage (AD)?

Answer 26

unstick, collect, evacuate

similar to ACBT but not prac assessable due to uncomfortable for patient and difficult to teach

Question 27

What is postural drainage (PD)?

Answer 27

using gravity/different positions to assist drainage from specific segments of the lung (aim to get bronchi 90 degrees to horizontal)

can be used inconjuction with other ACT’s i.e. ACBT and P&V

Question 28

Why do we not use head down tilt during postural drainage?

Answer 28

reduce the likelihood of aspiration of gastric contents in patients with reflux

evidence shows no difference in effectiveness of PD techniques with or without head tilt down

Question 29

What are some precautions for postural drainage positions?

Answer 29

severe haemoptysis
dyspnoea
cardiac failure
severe hypertension
aortic or cerebral aneurysm
cerebral oedema
raised ICP
surgery/trauma to head/neck
after a meal
gastroesophageal reflux
abdominal distension
preterm infants

Question 30

What is the aim of percussion & vibration?

Answer 30

to increase cilial beat with vagal stimulation and reduce mucous cross-links

Question 31

Precautions to percussion & vibration?

Answer 31

rib fracture, pain, SOB, lung cancer, osteoporosis

Question 32

When is percussion used vs vibration?

Answer 32

percussion is used during both inspiration and expiration

vibration is used during expiration only, often to augment FET

Question 33

Why do we incorporate TEE into percussion techniques?

Answer 33

reduces the risk of bronchospasm and hypoxaemia (reduced oxygen)

use 3-4 TEE and minimise length of treatment

Question 34

What are 3 types of inhalation therapies and their purpose?

Answer 34

bronchodilator i.e. ventolin (reduces airway resistance and increased cilial beat) used before treatment

mucolytics (reduces viscosity of secretions) used before, during or after treatment

inhaled steroids (reduces inflammation) used after treatment

Question 35

When is suction an appropriate ACT?

Answer 35

when all other techniques have been exhausted and the patient is unable to effectively clear the secretions from their lungs