Week 3 Flashcards
What are the effects of increased secretions
congest airways
- decreasing cilial function
- increase WOB - leading to fatigue
- Decreasing ventilation - leading to V/Q mismatch and hypoxia
- Long term damage/scarring
Physio techniques to improve airway clearance
cough active cycle of breathing (ACBT) Positive expiratory pressure (PEP) Autogenic drainage percussion and vibration inhalation therapy exercise therapy
How does a supported cough help
increases intraabdominal pressure with support
increases force = increases effectiveness of the cough
decreases tension on the wound during contraction
decrease ROM through which the muscles contracts
Aim of the assisted cough
assist in generation of explosive force
Why do physio’s care about airway clearance
airway clearance strategies are essential to your physio toolkit
aim
- identify secretion production/retention problems or those at risk of these problems
- select and implement most appropriate technique for that individual
Normal airway clearance
2 mechanisms
- mucociliary clearance
- cough
Mucociliary escalator
Propels mucous by the cilia
coordinated
unidirectional wave like motion
move foreign particles toward the trachea at a rate of 5-15mm/min
Factors decreasing mucociliary clearance
decreased ciliary beating -medications - GA, narcotics -drying mucous - dehydration high FiO2 Positive Pressure Ventilation ETT Decreased lung volumes Pollutants Decreased cough effectiveness
Cough
protective reflex 1st 6 generations of airways cleared mechanism -increased inspiratory volume -closure of glottis -increased intra-thoracic pressure (ITP) -Abdominal muscle contractions -Increased intra thoracic and intra-abdominal pressures (IAP) against a closed glottis -Ascent of diaphragm -Forceful expulsion of air/secretions/foreign bodies
What can go wrong with a cough
Decreased lung volume
- pain
- restriction
- obstruction
- fear/anxiety
- muscle weakness
- neurological impairment
Solution : methods of increasing lung volume
Decreased expiratory force
- pain
- muscle weakness
- poor elastic recoil (emphysema)
- Inability to close glottis (bulbar palsy)
Solution: assist the expiratory phase
- supported cough
- assisted cough
techniques of assisted cough
- bibasal compression if compliant chest and bibasal expansion
- AP sternal compression if apical movement
- Substernal angle compression can assist diaphragm ascent
- Subcostal thrust used for SCI patients - unable to contract abdominals to generate force
Other techniques for cough
tracheal rub
stimulated cough
cough assist machines
adverse affects of vigorous coughing
Abnormal cardiovascular response abnormalities of the genitourinary tract - stress in continence Gastrointestinal symptoms - GORD, hernia Msk problems Neuro features respiratory complications
ACBT Active Cycle of Breathing
Aims
- mobilise and clear excess secretions
- improves lung functions
advantages :
flexible - adapt to suit individual
-use with a variety of patients/ conditions
-not comfortable
-use in any position
-combine with other treatment, no equipment required
-can be performed independently
Duration - 10 -30 mins
- Depends on productivity of patient
- repeat until no longer productive or patient fatigues
FET Forced Expiratory Technique
Huff with BC
Emphasis on expiration - squeeze not wheeze
Different lung volumes (low, mid, high) to mobilise then remove secretions
Use equal pressure points
BC Prevents airflow obstruction
Length of BC depends on patient
PEP Positive Expiratory Pressure
Aim
-re-inflate collapsed part of lung by increasing collateral ventilation
-splints airways open
-Air behind secretions to mobilise upwards
Increases FRC
Increases lung volumes
Mouthpiece
more common
smaller more portable device
muse keep cheeks flat
Mask
if unable to keep cheeks flat
if unable to keep mouth sealed around mouthpiece
Selecting resistance
Consider
- size of resistor (1-5)
- smaller resister number = smaller hole = greater PEP
- -larger resistor number = larger hole = less PEP
- Patient’s expiratory flow
- greater flow = greater PEP
- -Less flow = less PEP
Test
- 6-8 breaths with PEP
- Pressure of 10-20cm H2O
- Able to maintain I:E = 1:3 and can complete for 2 mins
- Check no increased WOB (Accessory muscle use) for SOB
Indications
Diseases
- CF
- COPD
- Bronchiectasis
- Chronic Bronchitis
- Restrictive Lung Disease
Post op secretions and atelectasis
Collapsible airways
Productive asthma - pressures
Contra-indications
lung surgery clamped ICC Increased ICP Frank Haemoptysis Severe CV disease Surgical emphysema Severe bronchospasm Emphysematous Bullae Undrained pneumothorax
PEP - Bubble
Fun
Cheap
Temporary
PEP - oscillating
devices
-flutter
-acapella
Oscillations of expiratory flow combined with PEP
-alters physical properties of secretions -mechanically ruptures rigid mucous gel
-aims to decrease viscosity
facilitates mobilisation and clearance of secretions
-Prevents airway collapse
-Reduces expiratory effort
Flutter
small portable device aim -decrease sputum viscoelasticity -increases diameter of peripheral airway Endobronchial pressures = 10-25cmH2O Tilt to optimum position - 8-16Hz = natural pulmonary resonance = cilial beat Vibration of bronchial wall not cheeks cannot inspire through the device position - sitting
Acapella
can inspire through device
dial up resistance - unable to measure through manometer
Oscillations dependant of gravity - can do in any position
Autogenic Drainage (AD)
self drainage utilising BC and breaths at various lung volumes to mobilise secretions -from smaller airways to central to be removed 3 phases -unstick -collect -evacuate Suppress cough until end of routine Disadvantages -difficult to learn -can be uncomfortable -time consuming
AD
Unstick -low volume -from smaller airways -inspire, hold 3 seconds, expire fully through mouth, use abdominal muscles Collect -mid volume -from middle airways -inhale slowly to higher (tidal) volume -expire only to TV Evacuate -high volume -from central airways -inspire to higher lung volumes -can use huff or cough to remove secretions Progress to next stage when -crackling through all expiration -feel mucous moving up -feel urge to cough
Postural drainage
Allows gravity to assist drainage from specific bronchopulmonary segments
-aim to get bronchi 90 degrees to horizontal
improves ventilation/perfusion
Can use with other ACT
Usually modified positions are used - no head down tilt
PD contraindications
dyspnoea desaturation after a meal hiatus hernia severe haemoptysis abdominal distension Late stage pregnancy congestive cardiac failure aortic or cerebral aneurysm Surgery/trauma to head/neck GORD Severe uncontrolled hypertension cerebral oedema, early head injury
Percussion and vibrations
aim -enhance mucociliary clearance by -increasing cilial beating with vagal stimulation -decrease mucous cross links -increase peak expiratory flow Precautions -Rib # -Osteoporosis -Pain -SOB -Lung cancer
Percussion
procedure
- rhythmic hitting of chest wall with a cupped hand
- use towel between hand and chest wall skin
- can perform in PD positions
cautions
- can cause bronchospasm and decrease PaO2
- –incorporate TEE
- –minimise length of Rx
Vibration
vibratory force during expiration along normal movement of the ribs
Can be used to augement FETs
Fine or coarse
Need to feel the compliance of the chest wall motion prior to technique
-basal excursion
-AP sternal movement
Inhalation therapy
administered -inhaler -nebuliser Therapy -bronchodilator- Ventolin -- decrease airway resistance --increases cilial beat --administer prior to physio Rx -Mucolytics - saline, pulmozyme --decreases viscosity of secretions --administer prior, during or post physio Rx -Inhaled steroids --decreases inflammation --administer after physio Rx
Exercise Therapy
Role in airway clearance
- prior to ACTs to loosen secretions
- increase mucous clearance and ventilation
- different positions - assist with drainage
other benefits
- increases BMD
- improves posture, positive body image and wellbeing
- improves CV fitness, muscle strength and endurance
- improves core stability, mobility and flexibility
Exercise therapy safety
exercise testing
monitor
hydration
heat control
selection of strategies
patient related factors
- cognitive ability
- goals
- ease of learning
- age
- preference
- concentration
Technique related factors
- effectiveness
- limitation
- equipment
Physio related factors
- goals
- skill
- time
- combination with other Rx
