Bronchial Hygiene Therapy II

1. Bronchial Hygiene Therapy II RET 2275 Respiratory Therapy Theory Lab 2

2. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Most bronchial hygiene therapies only help move secretions into the central airways. Actual clearance of these secretions requires either coughing or suctioning. • In this respect, an effective cough (or alternative expulsion measure) is an essential component of ALL bronchial hygiene therapy Reading Assignment Egan’s Fundamentals of Respiratory Care NINTH EDITION (pgs. 915-916, 932-941)

3. Bronchial Hygiene • Coughing and related expulsion techniques • Directed cough • A deliberate maneuver that is taught, supervised, and monitored • Aims to mimic the features of an effective spontaneous cough in patients who are too weak to produce a forceful expiratory maneuver

4. Bronchial Hygiene • Coughing and related expulsion techniques • Directed Cough • Not to be used in patients who are obtunded, paralyzed, or uncooperative • Good patient teaching is critical • Proper positioning of the patient is important • The technique may need to be modified in surgical patients, patients with COPD, and patients with neuromuscular disease

5. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough - Standard Technique • Instruct the patient to assume a sitting position, with shoulders rotated inward, the head and spine slightly flexed, forearms relaxed or supported • If the patient is unable to sit up, raise the head of the bed, knees should be slightly flexed with feet braced on the mattress • Instruct the patient to inspire slowly and deeply through the nose, using the diaphragm

6. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough - Standard Technique • Instruct the patient to bear down against a closed glottis • Instruct the patient to cough • Stage expiratory effort into two or three shout bursts for patient with pain or bronchiolar collapse

7. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough – Surgical Patients • Provide preoperative training • Minimizes anxiety over pain • Coordinate coughing sessions with prescribed pain medications • Assist the patient to splint the operative site • The forced expiratory technique (FET) may be of value to these patients

8. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough – COPD Patients • Instruct the patient to assume a sitting position, with shoulders rotated inward, the head and spine slightly flexed, forearms relaxed or supported • Instruct the patient to take in a moderately deep breath through the nose • Results in less pleural pressure and less collapse of the smaller airways • Instruct the patient to exhale with moderate force through pursed lips, while bending forward

9. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough – COPD Patients • Patient should repeat the previous steps 3 – 4 times • Have the patient bend forward and initiate short staccato-like bursts of air • Technique relieves the strain of a prolonged cough and minimizes airway collapse • An alternative to this technique is called “huffing” FET or Autogenic Drainage (AD) may also be used in these patients

10. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough – Neurological Patients • Instruct the patient to take a deep breath • Assist as needed with IPPB or resuscitator bag/mask • At the end of inspiration, begin exerting pressure on the lateral costal margin or epigastrium, increasing the force of compression throughout expiration • Pressure to the lateral costal margins is contraindicated in patient with osteroporosis or flail chest • Epigastric pressure is contraindicated in unconscious patient with unprotected airways; in pregnant women; and in patient with acute abdominal pathology, abdominal aortic aneurysm, or hiatal hernia

11. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough – Forced expiratory technique (FET) • A modification of the directed cough • Also called the “huff cough” • Consists of one or two forced expirations of middle to low lung volumes without closure of the glottis • Goal is to clear secretions with less change in pleural pressure and less bronchial collapse.

12. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough – Forced expiratory technique (FET) • FET has been shown to increase sputum production, especially when combined with postural drainage • Most useful in patients with COPD, cystic fibrosis, or bronchiectasis

13. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough – Forced expiratory technique (FET) • Instruct the patient to take in a slow, deep breath, followed by a 1 – 3 second breath hold • Instruct the patient to perform 1 – 2 short, quick forced exhalation of middle to low lung volume with the glottis open • The patient should phonate or “huff” during expiration • Each session of “huffing” should be followed by diaphragmatic breathing and relaxation

14. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Directed Cough – Active Cycle of Breathing (ACB) • Repeated cycles of breathing control, thoracic expansion, and the FET • Breathing control; gentle breathing at normal tidal volumes with relaxation of the upper chest and shoulders – helps prevent bronchospasm • Thoracic expansion; deep inhalation which relaxed exhalation, which may be accompanied by percussion, vibration, or compression – designed to help loosen secretions, improve the distribution of ventilation, and provide the volume needed for FET

15. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Autogenic Drainage (AD) • During AD, the patient uses diaphragmatic breathing to mobilize secretions by varying lung volumes and expiratory airflow in three distinct phases. • Patient should be in the sitting position. • Coughing should be suppressed until all three phases are complete.

16. Bronchial Hygiene • Autogenic Drainage (AD) • Spirogram of lung volumes during three phases of autogenic drainage. • Phase 1 involves a full inspiratory capacity maneuver, followed by breathing at low lung volumes. This phase is designed to “unstick” peripheral mucus. • Phase 2 involves breathing at low to middle lung volumes in order to collect mucus in the middle airways. • Phase 3 is the evacuation phase, in which mucus is readied for expulsion from the large airways.

17. Bronchial Hygiene • Hazards of Directed Cough

18. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Mechanical Insufflation-Exsufflation (MIE)

19. Bronchial Hygiene • Coughing and Related Expulsion Techniques • Mechanical Insufflation-Exsufflation (MIE) • MIE devices apply positive pressure of 30 to 50 cm H2O to the airway for 1 to 3 seconds. • The device then abruptly reverses the airway pressure to –30 to –50 cm H2O. • Treatment sessions consist of about five cycles of MIE followed by normal spontaneous breathing. • This process is repeated five or more times until secretions are cleared

20. Bronchial Hygiene • High Frequency Chest Wall Oscillation (HFCWO) • Consists of a variable air-pulse generator and a non-stretch inflatable vest • Small gas volumes are alternately injected into and withdrawn from the vest by the air-pulse generator at a fast rate (5 – 25 Hz) creating a oscillatory motion against the patient’s thorax

21. Bronchial Hygiene • HFCWO • Oscillations at frequencies of 12 – 25 Hz enhance clearance of secretions • Acts as a physical “mucolytic” by altering the physical properties of secretions • Transient increases in airflow produce cough-like shear forces • Therapy sessions are approximately 30 minutes in duration • One to 6 treatments per day

22. Bronchial Hygiene • HFCWO • Common Conditions/Situations for HFCWO • Patient with evidence of retained secretions • Independent patient without access to a caregiver • Patient with reduced mobility • Patient who cannot tolerate Trendelenburg positioning • Fragile patient who cannot tolerate the force of CPT • Ventilator-dependent patient experiencing frequent pneumonias Information obtained from manufacturer’s website

23. Bronchial Hygiene • HFCWO • Most Common Diagnoses Utilizing HFCWO • Cystic Fibrosis • Bronchiectasis • Cerebral Palsy • Spinal Muscular Atrophy • Muscular Dystrophy • Chronic Obstructive Pulmonary Disease (COPD) Information obtained from manufacturer’s website

24. Bronchial Hygiene Positive Expiratory Pressure (PEP) • Active expiration against a variable flow resistance • Helps move secretions into larger airways • Filling underaerated or nonaerated segments via collateral ventilation • Preventing airway collapse during expiration • Subsequent huff or FET maneuver allows patient to generate the flows needed to expel mucus • Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator

25. Bronchial Hygiene • PEP • Oscillating PEP • Flutter Valve • Combines the techniques of EPAP with high-frequency oscillations at the airway opening • Actively exhaling into the pipe creates a positive expiratory pressure between 10 – 25 cm H2O • Changing the angle of the device alters the oscillations • The device can decrease mucus viscoelasticity within the airways, allowing it to be cleared more easily by cough

26. Bronchial Hygiene • PEP • Oscillating PEP • acapella® • Combines the techniques of EPAP with high-frequency oscillations at the airway opening

27. Bronchial Hygiene • EZ-PAP • Lung expansion therapy during inspiration and PEP therapy during exhalation • Used for the treatment or prevention of atelectasis and the mobilization of secretions • Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator

28. EZ-PAP • Clinical Procedure for PAP • Requires a physician’s order • Explain purpose and procedure of therapy to the patient • Teach directed cough, e.g., “huff” • Have the patient sit comfortably • If using a mouthpiece • Instruct the patient to place lips firmly around mouthpiece and to breathe through their mouth • If using a mask • Ensure a comfortable but tight fit around the nose and mouth

29. EZ-PAP • Clinical Procedure for PAP • Instruct the patient to take a larger than normal breath, but not to fill the lungs completely • Have the patient exhale actively, but not forcefully, creating a positive pressure of 5 to 20 cm H2O during exhalation (determined with a monometer) • Patient should perform 10 – 20 breaths • Remove the mask or mouthpiece and perform 2 – 3 “huff” coughs; allow rest as needed • Repeat above cycle 4 – 8 times, not to exceed 20 minutes

30. EZ-PAP • Clinical Procedure for PAP • If the patient is receiving bronchodilators via aerosol, administer in conjunction with PAP device • Document the procedure in the patients medical record • Device • Settings (if applicable) • Pressure (if possible) • Number of breaths per treatment • Patients response to therapy • Patient education provided • Patient’s ability to self-administer (if applicable)