Bronchial Hygiene Techniques

1. Bronchial Hygiene Techniques By Jim Clarke

2. What is Bronchial Hygiene Therapy (BHT)? It consists of a variety of non-invasive techniques designed to improve gas exchange by helping to mobilize and remove secretions

3. When to use Bronchial Hygiene Therapy? (BHT) During episodes in which there is an acute secretion clearance problem. Examples; Severe pneumonia with copious secretions Respiratory failure with inability to clear retained secretions Acute lobar atelectasis (documented) Evidence of significant infiltrates and/or consolidation with hypoxemia present

4. Acute conditions in Which BHT is NOT Helpful Acute exacerbations of COPD Many patients cannot tolerate these procedures even if secretion clearance problems exist! Pneumonia without evidence of significant sputum production Not all pneumonias produce secretions!! Uncomplicated asthma

5. BHT for Chronic Conditions Used to prevent complications in the out-patient population and to treat acute problems seen in; Cystic Fibrosis Bronchiectasis Sometimes used in Chronic Bronchitis when large volumes of secretions become problematic

6. Brief Look at CF & Bronchiectasis Cystic Fibrosis: characterized by increased sputum viscosity (thick mucus), increased mucus volume and impaired clearance Typically seen in children & young adults only Bronchiectasis: characterized by muco-stasis, retained secretions, loss of mucociliary escalator & repeated pneumonias Generally seen only in adults with a history of persistent & repeated lung infections

7. When Do Patients Need BHT ? (Are the following present?) Patient has a Dx of Bronchiectasis or Cystic Fibrosis? (Read the Hx & PE) They have evidence of copious secretions (>25-30 ml/day) with clearance problems? Do a cough evaluation Listen to breath sounds Check for evidence of tactile fremitus

8. �Other� Issues to Check When Evaluating Need for BHT Review Chest X-ray findings in chart OR view CXR�s directly Very important in identifying Lobar pneumonias Assess oxygenation status by reviewing recent ABG�s and/or SpO2 findings Check in chart for evidence of a �sputum analysis� Culture & sensitivity findings

9. Causes of Mucociliary Impairment Presence of endotracheal or tracheostomy tube History of having to suction patient�s trachea Poor humidification High FIO2�s Drugs: General anesthetics; opiates; narcotics

10. Some Commonly Used Types of Bronchial Hygiene Therapies Postural Drainage with percussion and/or vibration (PD&P) (PDVP) High Frequency Compression/Oscillation Therapy Flutter Valve IntraPulmonary Percussive Ventilation ThAIRapy Vest - Thoracic Wall Vibration Positive Airway Pressure Techniques Positive Expiratory Pressure Therapy (PEP)

11. Other Less Commonly Used BHT�s Coughing and related expulsion techniques Directed Coughing Huff coughing Quad cough Autogenic Drainage Mobilization and exercise techniques Frequent turning of patients Ambulation and exercise as tolerated

12. Postural Drainage Therapy Process of positioning patients to best utilize gravitational effects in the enhancement of secretion removal Turn &/or position the patient so that mucus drains out of the effected lung zone(s)

13. Review of Lung Segments

14. Using Drainage Positions Use drainage position most appropriate to the lung segments involved Lower lobe positions are most typical Average drainage time 3-5 minutes/position Modify positions as needed Some patients may not tolerate Trendelenberg Many patients cannot assume prone position

15. Superior Segments Upper Lobes

16. Posterior Segments - Lower Lobes Refer to #2

17. Lateral Segments - Lower Lobes Refer to #9

18. Anterior Segments - Lower Lobes Refer to #8

19. Lingular Segments - L Upper Lobe Refer to #�s 4 & 5

20. Right Middle LobeRefer to #�s 4 & 5

21. Posterior Segments - Lower Lobes Refer to #6

22. Anterior Segments - Upper Lobes Refer to #3

23. Anterior & Apical Segments - Upper Lobes Refer to #�s 1 & 2

24. Contraindications to Use of Trendelenberg Position Recent tube feeding or at high risk for aspiration of gastric contents Increased ICP in a recent intracranial injury Uncontrolled hypertension Severely distended abdomen Gross (bright red) hemoptysis

25. Contraindications to Percussion or Vibration of the Chest Wall Burns or recent skin grafts to chest Bleeding abnormalities Osteomylitis Subcutaneous emphysema Suspected or active TB Recent insertion of pacemaker

26. Hazards of PD&P Techniques Worsening S.O.B. Pain or injury to chest wall or spine Hypoxemia Nausea & Vomiting Tachycardia; Hypotension; Arrthymias Bronchospasm (not likely but possible in patients with Hx of asthma)

27. Assessment of Outcome Have the underlying issues that necessitated the use of PD&P improved? Less sputum production Improvement of breath sounds Improvement in oxygenation Improvement in CXR

28. P.E.P. Therapy Device

29. When to Use PEP Therapy Mostly used in treatment of Cystic Fibrosis & Bronchiectasis Utilizes a expiratory resister designed to create positive pressure during exhalation and lengthen the expiratory phase Aerosol therapy can be done inline & simultaneous with PEP treatments

30. Key Elements in Patient Instruction in Use of PEP Therapy Patients need to take a breath that is slightly larger than normal Expiratory pressure should be set between 10 - 20 cmH2O in order to create an I:E ratio of 1:3 to 1:4 Have patient perform 10 to 20 breaths and then do 3 coughs Perform PEP for no more than 20 minutes

31. Additional Issues in PEP Therapy May reduce air trapping in COPD - asthma Is like pursed lipped breathing May prevent or reverse atelectasis May improve aerosol medication delivery Hazards of PEP therapy are similar to IPPB

32. High Frequency Chest Wall Vibration - ThAIRapy Vest

33. Flutter Valve

34. IntraPulmonary Percussive Ventilation Video Available

35. Autogenic Drainage A breathing technique designed to �milk� or squeeze air out of the lungs

36. Steps in Autogenic Drainage Composed of 3 breathing phases Phase 1: Patient breathes in normally but exhales each breath close to RV (5-9 cycles) Phase 2: Breathes in slightly above normal Vt but exhales normally (5-9 cycles) Phase 3: Breathes in close to VC but exhales normally (5-9 cycles) All 3 Phases are repeated as necessary

37. THE END