Airway Clearance Techniques

1. Airway Clearance Techniques PTP 673 CardioPulmonary Plan of Care July 16th, 2013 Emily E. Houser, PT, DPT, CCS

2. Objectives • Lecture: • Introduction to airway physiology • Continued information on airway clearance techniques • Apply differential for choice of intervention • Provide literature to support evidence based practice • Lab: • Hands on practice of techniques and devices • Apply differential for choice of intervention

3. Why is this important?? • If you can’t breathe, you can’t function! • DPT: We need to look at all body systems to properly assess and successfully treat a problem. • Linda Crane Memorial Lecture: The Patient Puzzle, Piecing it all together.

4. Breathing is a multisystem Event • MS • NM: GBS, SCI • CP • INT: burns, scerolderma • IO: Obesity, room for diaphragm

5. Respiration - Interconnection Every muscle of respiration is ALSO a muscle of posture Respiration and Posture = duality of function External and Internal pressures that affect one – will affect the other PRESSURE IS THE KEY

6. Soda-Pop Can Model

8. Soda-Pop Can Model

9. Work of Breathing • Work of breathing is the energy cost of inspiration and expiration. • In normal healthy individuals their work of breathing is not a limiting factor even with strenuous activity.

10. Function and Work of Breathing In the presence of respiratory or cardiac compromise work of breathing can be a major portion of the total energy expenditure for a person and can also be a primary limiting factor for function and survival.

11. Impaired Ventilatory Pump Function • Increased work of inspiration: • Posture/kyphosis • Connective tissue diseases • Pregnancy • Obesity • Pleural effusion • Pneumonia/inflammation • Neuromuscular disease/SCI/CVA/GuillianBarre • Ventilatory muscle length and strength • Excessive pulmonary secretions

12. Impaired Ventilatory Pump Function • Increased work of expiration • Secretions: cystic fibrosis • Bronchial smooth muscle tone • Structural stability of the airways • COPD • Inflammation of airways • Expiratory muscle weakness

13. Impaired Airway Clearance Mucociliary Elevator Pharmacological approaches Physical Approaches

14. Secretions

15. Chest Physical Therapy Incorporates all these aspects to achieve optimal functioning. ROLE: To minimize the impact of airway clearance and ventilatory impairments on a patient’s functional capacity, ADL’s, work, and leisure. Included with this, are airway clearance techniques.

16. Classics • Postural Drainage • Percussion • Vibration • Suctioning • Example: • ketchup bottle

17. Postural Drainage Positions

18. HFCWO: High Frequency Chest Wall Oscillation “The Vest”

19. The Vest • Used to help facilitate secretion mobilization. • Provides: • Compression • Vibration • Settings • Compression: between 1-8, 4 is most common • Vibration: Between 6-16, 12 is most common

20. Has actually been around and evolved over the past 20 years. Good option for patients who have need for daily secretion removal. Also for use in ICU pts. Can be done independently. Can be done in conjunction with nebulizer treatments. Is expensive: approx 15K. The Vest

21. The Vest • Important that it’s not too tight or vibrating too fast. • Need to find individual settings which work. • Recommend using at least 10 minutes, or until patient feels secretions moving. Typically 20 • Encourage coughing several times after each cycle, when there is something in upper airway to clear.

22. The Vest • Recommend changing positions; not just sitting • Recommend doing aerobic activity while using the vest • Such as: • Stair stepping • Marching in place

23. Most research will show that if properly instructed, can be as effective as classic techniques. But also is not ‘fool proof.’ In terms of PFT’s and sputum production as outcomes, it has also been shown to be less effective. (Kluft, 1996; Oermann, 2001; Phillips 2004) **Key, must fit the individual for their needs. Efficacy

24. PEP devices • PostiveEnd Pressure • Regular PEP (low pressure) • ‘Thera-PEP’ • Oscillatory PEP (low pressure) • Flutter • Acapella

25. Rationale for PEP therapy Collateral ventilation facilitates air movement between adjacent lung segments Airway wall splinting, stabilizing, back pressure (blunting effect) Decreases asynchronous ventilation - for equal filling (not shown) B. A.

26. Thera-Pep • Can use a mouth piece or facemask • Can change resistance • Gives an incentive meter – this device is similar to incentive spirometer, just opposite. • Tough to get buy in from patient

27. Flutter Valve • Blow air in; pushing steel ball which creates resistance and vibration for airway. • Positional Dependent. Need to hold at correct angle. • Requires strong expiratory force to use.

28. Acapella • Blow air in, pushing on diaphragm which creates vibration for airway. • Can be done in any position and angle. • Can adjust the resistance, and comes in different levels. • Can actual deliver nebulizer treatments through them.

29. Efficacy • PEP has significant advantages compared to conventional postural drainage and percussion. PM, McIlwaine et al. PediactricPul. Suppl 12, 1995. • Flutter may not be as effective as PEP in maintain pulmonary function in CF pt. PM McIlwaine. This may be due to having to maintain same position. • **Something is better than nothing, need to individually assess best results.