Week 3 Flashcards
What is the goal of airway clearance techniques (ACTs)?
to identify secretion over-production/retention problems and apply treatment to maintain clear lungs for our patients and prevent secondary complications
What does normal airway clearance rely on?
mucociliary clearance (MCC) and an effective cough (as a backup to when the MCC is impaired)
Impaired airway clearance can lead to…
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
Describe the mucociliary escalator…
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
What factors reduce mucociliary clearance?
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
How much mucus is produced in a healthy lung on a daily basis?
100ml per day
What effects do congested airways have on a patients breathing?
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
What are the 3 aims of airway clearance techniques?
1) get air behind secretions
2) mobilise secretions
3) remove secretions
What is the difference between secretions and sputum?
secretions within the lung, sputum out of the lungs
9 techniques in the ACT toolkit.
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
How far does a cough reach to expel secretions?
only the first 6 generations
When is a supported cough appropriate?
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
When is an assisted cough appropriate?
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
What techniques can be used to stimulate a cough in a semi/unconscious patient?
tracheal rub, mechanical insufflator/exsufflator devices i.e. CoughAssist machine
Why is the Active Cycle of Breathing Technique (ACBT) so useful for physios?
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
What are the components of the ACBT?
breath control (BC), thoracic expansion exercise (TEE) and forced expiratory technique (FET)/also called a ‘huff’
Explain the forced expiratory technique (FET).
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
How long does a ACBT session generally take?
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
What are positive expiratory pressure (PEP) devices?
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
What is the ideal inspiration/expiration ratio for a patient using a PEP device? How do we adjust this?
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)
When would a mouthpiece vs a mask PEP device be more suitable?
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
What is a typical prescription for PEP devices for a) pulmonary disease and b) post-op patients?
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
When are PEP devices appropriate?
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)
What are some precautions to using PEP devices?
active haemoptysis
lung surgery
pneumothorax
undrained empyema or lung abscess
emphysematous bullae
haemodynamic instability
facial fractures or surgery
middle ear infection
sinusitis
Why would we add oscillations to our PEP device technique?
to allow easier clearance of secretions
works to mechanically rupture rigid mucous gel to thin out secretions
What are the 3 phases to autogenic drainage (AD)?
unstick, collect, evacuate
similar to ACBT but not prac assessable due to uncomfortable for patient and difficult to teach
What is postural drainage (PD)?
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
Why do we not use head down tilt during postural drainage?
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
What are some precautions for postural drainage positions?
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
What is the aim of percussion & vibration?
to increase cilial beat with vagal stimulation and reduce mucous cross-links
Precautions to percussion & vibration?
rib fracture, pain, SOB, lung cancer, osteoporosis
When is percussion used vs vibration?
percussion is used during both inspiration and expiration
vibration is used during expiration only, often to augment FET
Why do we incorporate TEE into percussion techniques?
reduces the risk of bronchospasm and hypoxaemia (reduced oxygen)
use 3-4 TEE and minimise length of treatment
What are 3 types of inhalation therapies and their purpose?
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
When is suction an appropriate ACT?
when all other techniques have been exhausted and the patient is unable to effectively clear the secretions from their lungs
