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BRONCHIAL HYGIENE

INCLUDING RETAINED SECRETIONS, AEROSOL THERAPY AND HUMIDIFICATION. BRONCHIAL HYGIENE. Dr. S Sai Janani. University College of Medical Sciences & GTB Hospital, Delhi. PHYSIOLOGY OF RESPIRATORY TRACT. 20 – 22C 50% humidity. 29-32C 95%humidity. ISB. 32-35C 100%humidity. HUMIDIFICATION.

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BRONCHIAL HYGIENE

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  1. INCLUDING RETAINED SECRETIONS, AEROSOL THERAPY AND HUMIDIFICATION BRONCHIAL HYGIENE Dr. S SaiJanani University College of Medical Sciences & GTB Hospital, Delhi

  2. PHYSIOLOGY OF RESPIRATORY TRACT 20 – 22C 50% humidity 29-32C 95%humidity ISB 32-35C 100%humidity

  3. HUMIDIFICATION • Humidity therapy refers to addition of water vapor and heat to the inspired gas as a direct therapeutic procedure or as an adjunct to other therapy.

  4. CONSEQUENCES OF INADEQUATE HUMIDIFICATION

  5. INDICATIONS • PRIMARY: • Humidifying dry medical gases • Bypassed upper airway for ventilation • SECONDARY: • Treating bronchospasm caused by cold air • Management of hypothermia

  6. HUMIDIFIERS • Humidifier is a device that adds molecular water to gas being delivered. • TYPES: • Pass- over humidifier • Bubble diffusion humidifier • Heat and moisture exchanger

  7. PHYSICAL PRINCIPLES OF HUMIDIFIERS Affected by: Temperature Surface area Time of contact

  8. BUBBLE DIFFUSION HUMIDIFIER Breaking of gas into small bubbles and allowing it to come into intimate contact with liquid

  9. Bubble humidifier…… contd • Disadvantage: • Aerosols are produced • High risk of spreading infections

  10. MEMBRANE HUMIDIFIER

  11. WICK TYPE HUMIDIFIER

  12. HEAT MOISTURE EXCHANGER • Passive humidifier • Preserves heat and moisture of patient’s exhaled air and delivers it to patient’s respiratory tract on next inspiration • Hygroscopic or Hydrophobic membranes – act as filters

  13. HYGROSCOPIC CONDENSER HUMIDIFIER: • Condensing element of low thermal conductivity (paper, wool or foam) • Impregnation of hygroscopic salt (Ca or LiCl) • HYDROPHOBIC CONDENSER HUMIDIFIER: • Condensing element with low thermal conductivity • Added bacterial filter – HMEF • EFFICIENCY – 70%

  14. HME

  15. STANDARDS FOR HME Design and performance standards set by ISO: Ideal HME - 70% efficiency or better ( 30 mg/L water vapor) • Use standard connections • Low compliance • Minimal weight to the circuit • Minimal Dead space • Minimal flow resistance

  16. ADVANTAGES OF HME • 1. Eliminates breathing circuit condensation • 2. Hydrophobic bacterial filters

  17. POSITION OF HME

  18. HEATING SYSTEM HEATING ELEMENTS: • Hot plate • Wrap-around type • Yolk or collar type • Immersion type • Heated wire in the inspiratory limb CONTROLLED HEATING: • Attaching temperature monitors • Servo controlled

  19. HME RESERVOIR • Simple large reservoir systems:Manual refilling • Momentary disruption • Contamination • Automatic feed systems: • Level compensated reservoir • Flotation type systems

  20. SETTING HUMIDIFICATION LEVELS Current AARC guideline: • 33˚C within 2 C with a minimum of 30 mg/L of water vapor. • The optimal level is 37 C with 100% relative humidity and 44 mg/L.

  21. PROBLEM SOLVING AND TROUBLESHOOTING • Condensation • Cross contamination

  22. CONDENSATION • Factors influencing amount of condensation: • Temp difference across the system • Ambient temperature • Gas flow • Set airway temperature • Length, diameter of breathing circuit. • Risk: • Disrupt or occlude gas flow • Aspiration – infection • To minimize: • Water trap • Heated wire circuits

  23. AEROSOLS • Aerosol – suspension of very fine particles of liquid in a gas BLAND AEROSOL THERAPY: Sterile water hypotonic, isotonic and hypertonic saline.

  24. FUNCTIONS • Aids bronchial hygiene • Hydrates dried and retained secretions • Restores and maintains mucous blanket • Promotes expectoration • Improves effectiveness of cough • Humidifies inspired gases • Acts as a means to deliver medications

  25. DEVICES

  26. MECHANISM- BAFFLING • Baffle = device that deflects gas flow • When a baffle device is placed in the path of gas flow that contains water particles, the large particles impact on the baffle and ‘rain out’ of the aerosol whereas the smaller particles pass with the gas stream around the baffle. • More baffles in series = more small and uniform the particle size • Water surface, sides of container, rt. angled bends = Baffles

  27. TYPES OF NEBULIZERS

  28. ULTRASONIC NEBULISER

  29. PROBLEMS WITH NEBULISERS • Cross contamination • Infection • Environmental safety (immunocompromised pts) • Inadequate mist production • Over hydration : • cautious use in pediatric age group • Worsening airway obstruction • BRONCHOSPASM • History • Initial monitoring required every 8 hrs • If occurs during therapy – conservative management. • NOISE

  30. BRONCHIAL HYGIENE THERAPY

  31. DEFINITION • Refers to the use of non invasive airway clearance techniques designed to help mobilize and remove secretions and improve gas exchange

  32. Primary bronchial hygiene mechanisms: • Mucociliary complex • Cough

  33. MUCOCILIARY ESCALATOR

  34. PHYSIOLOGY OF COUGH REFLEX

  35. NEED FOR BRONCHIAL HYGIENE THERAPY • Abnormal clearance • Retained secretions- Mucus plugging Partial or complete obstruction Atelectasis V/Q mismatch Impaired oxygenation

  36. Impaired mucociliary clearance • Endotracheal or tracheostomy tube • Tracheobronchial suction • Inadequate humidification • High FiO2 • Drugs • General anesthetics, narcotics.

  37. IMPAIRED CILIARY ACTIVITY

  38. Mechanisms impairing cough reflex

  39. INTIAL ASSESSMENT OF NEED FOR BHT : • History: • H / O pumonary problems causing increased secretions • If pt. for upper abdominal or thoracic surgery : • Age • COPD • Obesity • Nature of procedure • Type of anesthesia • Duration of procedure

  40. EXAMINATION • Posture of patient • Effectiveness of cough • Sputum production • Breathing pattern • General physical fitness • Breath sounds • HR, BP,RR

  41. COMPONENTS OF BRONCHIAL HYGIENE

  42. CHEST PHYSIOTHERAPY

  43. CHEST PERCUSSION • Rhythmic “clapping” with cupped hands over the involved lung segments, with the patient in appropriate postural drainage positions • FUNCTIONS: • Loosens / dislodges the adherent bronchial secretions • Mobilizes secretions towards central airways • Increases efficiency and distribution of ventilation

  44. TECHNIQUE: • Strike chest wall with cupped hands • Move from periphery to central airways • Perform throughout inspiration and expiration • Avoid bony prominences and breast tissue

  45. CHEST VIBRATIONS • Loosens adherent bronchial secretions and mobilizes them towards central airways • TECHNIQUE: • Hands placed one over the other or either side of the chest • Rapid vibrations produced in the arms while compressing chest wall in the direction of ribs • During exhalation or end inspiration • FREQUENCY = 200/ min

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