wk3 speech-language therapy & Airway clearance Flashcards
4 key role of speech-language therapy in acute care
- maximize person’s ability to communicate
- assess and manage swallowing disorders, minimising risk of aspiration pneumonia
- develop plan for communication and/or swallowing rehabilitation
- education and support for family and health care team
Who needs to be seen by an SLT?
- Anyone with communication difficulties
2. Anyone with swallowing difficulties
problems associated with dysphagia for both short term and long term
Short term
-coughing, chocking
Long term
- malnutrition, dehydration, aspiration pneumonia, lung damage, death
xx % of stroke patients have dysphagia
44%
The more severe the dysphagia, the more likely it is to be ?
silent - could become very serious problem
assessment tools for dysphagia
- Cranial nerve test
- cough reflex testing - citric acid via nebuliser. 3x15 sec/trials. need > 2 coughs in > 2 trials
- Cervical auscultation - compare pre/post swallow pharyngeal sound
- Bronchial auscultation
- FEES - direct visualisation of pharynx
What is role of PT in patient with dysphagia
support with positioning, use of affected arm in feeding, auscultation
Risk of aspiration pneumonia is higher if
aspirated material is food or thick fluid
management of dysphagia
diet modification position changes - upright, support weak side bolus change (small mouthful amount, salt / pepper to activate more sensation to help with swallowing) supervision with oral intake
5 golden rules of of communication with patient with aphagia
- use gesture
- speak simply, breaking instructions down
- allow time for the person to respond
- always have a pen and paper at hand
- minimise distractions - noise, light, people, TV
Airway clearance techniques (ACT)
- ACBT (combined GAD and/or manual technique)
- PEP + oscillating PEP
- HFCC (high-frequency chest-wall compression)
- autogenic drainage
- supported coughing
- assisted coughing
What does ACBT consist of?
- BC
- TEE
- FET
Rationale for PEP device
- obtain temporary increase in FRC
- allow collateral ventilation to recruit alveoli
- Gets air behind secretions
- use FET to mobilise and clear secretions
PEP- evidence
many studies in chronic sputum production population
-reduced exacerbations
-reduced antibiotic use
-preserved lung function
-decreased morbidity
(Christensen et al, 1990; Mcllwaine et al, 1997)
method of PEP
- sit lean forward with elbow supported, holding device
- 5-8 breaths slightly larger than TV
- breath hold at the end of inspiration if possible
- slightly active expiration against the device
- Aim to increase FRC across the cycle i.e. pumping up
- Huff through device
- BC at the end of cycle
- aiming to leave airways as open as possible
Evidence of using ACBT, PEP and autogenic drainage in patient with cyctic fibrosis
Consider the active cycle of breathing techniques when
recommending an airway clearance technique for adults
with cystic fibrosis. (Grade A)
Consider autogenic drainage when recommending an air-way clearance technique for adults with cystic fibrosis.
(Grade A)
Consider positive expiratory pressure when recommending an airway clearance technique for adults with cystic fibrosis.
(Grade A)
(Bott et al, 2009)
Evidence of combined standard physio therapy, ACT and FET
It has been suggested that standard physio therapy with Active Cycling of breathing and Forced expiratory technique is more effective than Chest physiotherapy alone. (Fink, no date)
Evidence of PEP therapy with FET in patient with COPD
4 week PEP therapy with FET significantly increased diffusing capacity and 6MWTD, and reduced coughing difficulty compared to FET only in COPD patient with mucus hypersecretion. (Su et al, 2007)
Which sputum clearance technique can we use for patient without coughing ability due to neurological condition
Assisted cough -deep breathing (px) + passive push (PT)
- incr build up of intra-thoracic pressure
- incr forced expiration
Cough Assist Device (CAD)
Who might get benefit from assisted cough / CAD
predominantly neuromuscular weakness population
e.g. spina bifida, muscular dystrophy, SCI, CP, patient who are drowsy/ hypoventilating post-op
over-narcosed patients with secretion retension
evidence of CAD use
prevention or reversal of oxyhaemoglobin desaturation
reduces number of hospitalisation
reduces length of hospitalisation
Morrow et al, 2012
Types of humidification / nebuliser
Humidified oxygen nebulised bronchodilators nebulised saline (normal saline 0.9%) hypertonic saline mucolytic agents
evidence of using nebulised bronchodilators for sputum clearance
using nebulised beta 2 agonists prior to treatment enhances sputum clearance
Pasteur et al, 2010
evidence of using ‘normal’ saline for airway clearance
-Sterile water inhalation may be used before airway clearance to facilitate clearance.
- use of nebulised normal saline prior to airway clearance could be considered to increase sputum yeild, reduce sputum viscosity, improve ease of expectoration
Pasteur et al, 2010
evidence of using ‘hypertonic saline’ prior to airway clearance
increase sputum yield, reduce sputum viscosity, ease expectoration (Pasteur et al,, 2010)
increase ciliary transport of sputum
increased lung function (pryor and prasad 2008)
Precautions of using hypertonic saline
- may induce bronchospasm
- when first dose, record PEFR or FEV1 pre and 5 mins post inhalation
AIm of Mucolytic agents
change physical properties of sputum
reduce oxidative stress/lung damage
evidence of using mucolytic agents
reduced number of exacerbations reduced number of hospitalisation improved lung function improved QoL Davies & Calverley, 2010)
evidence of using mucolytic nebulizers in CF population
breaks down the DNA in sputum/ mucus
reduces its viscosity
promotes improved clearance of secretions
Bott et al, 2009
evidence of ‘timing[ of using mucolytic nebulizer in CF population
30mins before airway clearance may be more beneficial than inhalation after the airway clearance. But lack of evidence.
Dentice and Elkin, 2011
evidence of physical activity in patient with CF
exercise alone should not be used as an airway clearance.
addition of physical activity to chest physiotherapy significantly improves lung function compared to PT alone
