Initiation and Modification of Therapeutic Procedures

1. Initiation and Modification of Therapeutic Procedures Remove Bronchopulmonary Secretions

2. Many of your patients will require assistance in removing bronchopulmonary secretions in order to maintain a patent airway. • Therapies include postural drainage, percussion, vibration, directed coughing, and use of adjunct mechanical devices to aid secretion clearance. • Drugs and bland aerosols can be used to facilitate secretion clearance • All of these techniques ultimately intend to improve ventilation and gas exchange.

3. Selecting the Best Approach Important factors include the patient’s: • Age • Preexisting condition • Personal preference Selection and implementation should be based on patient’s • Diagnosis • Volume of sputum produced • Ability to cough effectively

4. Postural Drainage, Percussion, Vibration, and Turning Postural drainage, percussion, and vibration (PDPV) is indicated in conditions that increase the likelihood of mucous plugging and atelectasis. Contraindications, hazards, and complications must be considered before beginning therapy. You should monitor patient’s clinical status before, during, and after the therapy: • Overall appearance • Vital signs • Breathing pattern • Pulse oximetry

5. Postural Drainage, Percussion, Vibration, and Turning Effectiveness and outcome of PDPV is assessed by monitoring: • Changes in chest x-ray • Changes in vital signs • Changes in pulse oximetry • Sputum production • Breath sounds Recommend discontinuing when sputum production drops below 30 ml/day and patient can generate an effective spontaneous cough

6. Instruct and Encourage Bronchopulmonary Hygiene Techniques Directed Cough • Instruction in the three phases of a cough • Deep inspiration • Compressions against a closed glottis • Explosive exhalation • Splinting incisional sites with a pillow

7. Instruct and Encourage Bronchopulmonary Hygiene Techniques Forced Expiratory Technique (FET) – “Huff” Coughing • 2-3 exhalations, or huffs, with glottis open • Best suited for post-op patients for whom explosive exhalation is very painful, and COPD patients prone to airway closure on forced exhalation Abdominal Thrust • Push on the upper abdomen with an upward motion towards the epigastrium in synchrony with the expiratory phase of the patient’s own cough effort Autogenic Drainage • Usually combined with directed coughing

8. Mechanical Devices to Facilitate Secretion Clearance • High-frequency Chest Wall Oscillation systems, simple and vibratory PEP devices, Intrapulmonary percussive ventilation • Mechanical insufflator-exsufflator (MI-E) (cough assist) • Indications: Weak cough effort as suggested by maximum expiratory pressure less than 60 cm H2O • Contraindications: • History of bullous emphysema • Susceptibility to pneumothorax or pneumomediastinum • Recent barotrauma

9. Clearance of Secretions via Suctioning Indications: • Presence of a weak, loose cough • Auscultation revealing rhonchi • Direct observation of secretions in the mouth or oropharynx • Fremitus felt on the chest wall • Patient feedback suggesting retained secretions Precaution: Suctioning is the one of the most dangerous procedures you will perform. Careful implementation of patient safety measures before, during and after, as well as careful monitoring throughout can prevent or minimize most risks.

10. Clearance of Secretions via Suctioning Routes for Suctioning • Oropharyngeal • Normal use Yankauer suction tip • Suctioning though a tracheal airway • Properly set suction pressures • Always select suction catheter with an outside diameter (OD) no larger than ½ the inner diameter of the patient’s artificial airway. • Estimate correct Fr. size by doubling the internal diameter (ID) of the tracheal tube and selecting the next smallest catheter size • Maintain adequate PEEP levels during mechanical ventilation by using a closed suction system

11. Clearance of Secretions via Suctioning • Nasotracheal suctioning • The most common method used to clear secretions in patient who do not have artificial airways, but do have an ineffective cough Assessmentof Effectiveness of Suctioning • Amount of secretions removed • Changes in breath sounds • Changes in vital signs and oxygenation

12. Administer Aerosol Therapy with Prescribed Medications Bland Aerosols • May be helpful for patients with bypassed upper airways or those otherwise predisposed to retain secretions. • May benefit the patient by • Ease of secretion clearance • Deceased work of breathing • Improved vital signs • Decreased stridor • Improved arterial blood gas values • Improved oxygen saturation as indicated by pulse oximetry • Generally provided continuously via large volume jet nebulizer

13. Administer Aerosol Therapy with Prescribed Medications Administration of Prescribed Agents • Bronchodilators are designed to dilate or open the airways • Mucolytics thin secretions • Inhaled corticosteroids reduce airway inflammation and help maintain airway patency and may reduce secretion production • Diluting agents (aerosolized hypertonic saline) thin secretions and help with mucous removal

14. Common Errors to Avoid on the Exam • Avoid performing postural drainage, particularly in a head-down position, in the presence of an intracranial pressure (ICP) greater than 20 mmHg or an unstable head or neck injury, with an active hemorrhage, or in the presence of hemodynamic instability. • Don’t apply an abdominal thrust maneuver to help clear secretions on a patient with abdominal trauma or surgical incisions • Avoid using positive expiratory pressure (PEP) adjuncts on patients with acute exacerbations of asthma or COPD, or on any patient who cannot tolerate the short-term added work of breathing caused by these devices.

15. More Common Errors to Avoid on the Exam • Don’t use excessive suction pressures on patients; many hazards may be avoided. In general, suction pressures should never exceed -120 mmHg for adults, -100 mmHg for children, and -80 mmHg for infants. • Avoid applying suction to the airway for more than 15 seconds for each attempt. • Avoid performing percussion and vibration therapy immediately before or after meals.

16. Exam Sure Bets • Always monitor a patient before, during and immediately following bronchial hygiene therapy to assure that they are tolerating the therapy. Such assessment should include their overall appearance, vital signs, breath sounds, and possible other indicators, such as pulse oximetry. • Always remember that if a patient appears to be having an adverse reaction to bronchial hygiene therapy, stop the therapy, stay with the patient and monitor him or her, help stabilize the patient, and immediately notify the nurse and physician

17. More Exam Sure Bets • Always consider that a patient with recent thoracic or abdominal surgery may have trouble with the inspiratory and expiratory phases of coughing. For such patients, splinting the incision site with a pillow often permits them to generate a more effective cough. • Always recognize that some patients with an ineffective cough may need help both loosening secretions through percussion and vibration as well as clearing mucous through such means as cough assist or suctioning.

18. More Exam Sure Bets • Always remember that patients with a weak cough, rhonchi, visible secretions, or fremitus on the chest wall may need bronchial hygiene therapy • Always oxygenate a patient with an FiO2 of 100% at least a minute before each suction attempt. • Always consider recommending the addition of bland aerosol and the administration of prescribed agents, such as bronchodilators and mucolytics if a patient is unable to clear secretions in spite of percussion, vibration, and turning, as well as other adjuncts such as PEP and cough assist. • Always remember that the effectiveness of bronchial hygiene therapy can be assessed through an improvement in breath sounds, vital signs, oxygenation, and overall appearance.

19. Reference: Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli Jones and Bartlett Publishers