Respiratory Care Therapeutics (RT 264) Airway Clearance Therapy (ACT) Part-1 PDF

Respiratory Care Therapeutics (RT 264) Airway Clearance Therapy (ACT) PART-1 1445(2024) 1 Outlines :  Background (Physiology of Airway Clearance) I. Normal Clearance Components (Phases) of cough I. Abnormal Clearance II. Diseases Ass...

Respiratory Care Therapeutics (RT 264) Airway Clearance Therapy (ACT) PART-1 1445(2024) 1 Outlines :  Background (Physiology of Airway Clearance) I. Normal Clearance Components (Phases) of cough I. Abnormal Clearance II. Diseases Associated With Abnormal Clearance  General Goals and Indications oF ACT  Determining the Need for ACT  Airway Clearance Methods: I. Chest Physical Therapy II. Coughing and Related Expulsion Techniques III. Positive airway pressure (PAP)/Positive expiratory pressure (PEP) IV. High-frequency oscillation devices V. mobilization and physical activity  Required readings 2 Physiology of Airway Clearance  Mucociliary Blanket It’s natural escalator functions to clear airways via function of the ciliated mucosa. This mechanism occurs from the larynx to the respiratory bronchioles. Mucus is produced by goblet cells and submucosal glands. Clara cells and tissue fluid transudation also contribute to airway secretions. A wave-like motion of the cilia then move secretions upward toward the larynx where it is either swallowed or expectorated. Bustamante-Marin, X. M., and Ostrowski, L. E. 2017. Cilia and mucociliary clearance. 3  Physiology of Airway Clearance  Source of mucus Secretion from (Clara, goblet, and serous) cells and submucosal glands The goblet cells, which are distributed throughout the epithelium of the mucosa, synthesize and secrete mucus into the airway. Healthy individuals produce 10 to 100 mL of secretions in the airway on a daily basis that are cleared by this mucociliary escalator *  Effects of Mucus Layer First line of defense, made up of different components that help it trap particles and germs. A physical barrier to protect the lung and has properties that help get rid of potentially infectious bacteria, fungi, and Laniece, Alexandra. (2018). Alveoli-on-a-chip. viruses. *Fahy JV, Dickey BF: Airway mucus function and dysfunction, N Engl J Med 363(23):2233–2247, 2010. 4 Physiology of Airway Clearance  Normal clearance Normal airway clearance requires:- Patent airway Functional mucocilary escalator ( from larynx to respiratory bronchioles) Adequate hydration Effective cough The cough reflex. (Modified from Cherniack RM, Cherniack L.  Components (Phases) of cough Respiration in Health and Disease, ed 3, Philadelphia, 1983, WB Saunders.) Egan's Fundamentals of Respiratory Care, 12TH Ed. Four components (Phases) to an effective cough 5  Physiology of Airway Clearance  Components (Phases) of cough: 1) Irritation Phase - Abnormal stimulation induces/causes sensory fibers to send impulses to the brain’s medullary cough center. - Stimulus is either:- A) Inflammatory (eg; infections), B) Mechanical (eg; foreign bodies), C) Chemical(eg; cigarette smoke) D) Thermal (eg; cold air) 2) Inspiration Phase: - Cough center generates a reflex stimulation of the respiratory muscles to initiate a deep inspiration (1 to 2 L in normal adult) www. https://www.regresearchnetwork.org/working- groups-committees/cough/ 6  Components (Phases) of cough (cont.) 3) Compression Phase - Reflex nerve impulses cause glottic closure and a forceful contraction of the expiratory muscle (normally take about 0.2 second). - This causes rapid rise in pleural and alveolar pressures (>100 mmHg). 4) Expulsion Phase - Glottis opens initiating the expulsion phase. - A large pressure gradient between the intrathoracic airways and atmospheric pressure is present causes a violent, expulsive flow of air from the lungs, combined with dynamic airway compression creates a shearing force that displaces mucus https://www.physio-pedia.com/ for the walls into the airstream. 7  Factors Impair Normal Cough Reflex. Chapter 44: Airway clearance therapy, Egan's Fundamentals of Respiratory Care, 12th Ed 8  Physiology of Airway Clearance Abnormal clearance:  - Abnormalities in airway patency, mucuciliary function, strength of breathing muscles, thickness of secretions or cough reflex can lead to mucus retention, end by worsening airway clearance and mucus plugging. - Mucus plugging can lead to atelectasis, V/Q imbalances & hypoxemia. Diseases associated with abnormal clearance:  - Internal obstruction or external compression of airway lumen can impair airway clearance. Examples include (Foreign Body, lung cancer, asthma, COPD, and kyphoscoliosis)*. - Diseases that alter normal mucociliary clearance also can cause retention of secretions (e.g., cystic fibrosis, ciliary dyskinesia, and Bronchiectasis). *Fahy JV, Dickey BF: Airway mucus function and dysfunction, N Engl J Med 363(23):2233–2247, 2010. updated by DR. ALI 9 General Goals & Indications of ACT Indications for ACT  The primary goal of ACT is to assist the patient to mobilize and remove retained secretions  Hence, it will improve gas exchange, promote alveolar expansion and reduce the work of breathing (WOB). Adapted from Egan's Fundamentals of Respiratory Care, 12th Ed updated by DR. ALI 10 General Goals & Indications of ACT (cont,…) Airway clearance therapy to prevent retention of secretions  Immobile patients  Postoperative patients (related to the effects of anesthesia, opiates and narcotics)  Inadequate humidification  Acute exacerbations of COPD, Asthma, CF & Bronchiectasis  Neuromuscular disorders. 11  Determining the Need for ACT Effective ACT requires proper formulation of the respiratory care plan which depends on: 1) Symptoms & Physical findings such as:  History of pulmonary problems causing increased secretions  Tachypnea/tachycardia  Fever  Loose, ineffective cough  Labored breathing pattern  Coarse inspiratory & expiratory crackles  Muscle weakness 2) Chest radiograph: demonstrating atelectasis & infiltrates 12  Determining the Need for ACT (Cont,..) 3) Admission for upper abdominal surgery, we consider the followings:  Age  History of COPD  Obesity  Nature of the procedure  Type of anesthesia  Duration of the procedure 4) Presence of artificial airway 5) Results of pulmonary function testing 6) Arterial blood gases values or O2 saturation 13  Five general approaches to ACT, which can be used alone or in combination: Chest Physical Therapy (CPT) Mobilization Coughing and and physical related activity Airway expulsion techniques Clearance Methods High-frequency Positive airway oscillation pressure /positive devices expiratory pressure 14 Chest Physical Therapy (Postural Drainage, Percussion, and Vibration) Chest Physical Therapy (CPT) involves the use of positioning, gravity, and mechanical energy to help:  mobilize and the expectoration of secretion  Improve gas exchange  Increase FRC and Reduce WOB CPT Therapy Methods: I. Postural Drainage II. Percussion & Vibration (PD/P/V) III. Modified breathing/coughing techniques, and new devices 15  Indications: In Acute Conditions In Chronic Conditions 58 site At least > 25-30 ml/day of sputum production for CPT to be effective), in the following news Acutely ill with copious secretions diseases: I. Cystic Fibrosis (CF) II. Bronchiectasis Acute respiratory failure with clinical signs of retained secretions III. Ciliary dyskinetic syndromes y.it IV. Chronic bronchitis f Lobar atelectasis Prevention:  PD/P/V combined with exercise may be used V/Q abnormalities due to unilateral to maintain normal function in CF lung infiltrates or consolidation  Possible in Neuromuscular Disorders to prevent chest infection. 16  s Contraindications to the Use of CPT Absolute 6105 Relative 51 3118 Head and neck injury until stabilized 9 0 Intracranial pressure (ICP) greater jf than 20 mm Hg Active hemorrhage Normal 15mHz af c.pe Hemodynamic instability* Recent spinal surgery her_ Severe08 Hypertinton died Active hemoptysis e Uncontrolled hypertension Hypo Rib fracture* w se gcugnout.I _broad IN S *Egan's Fundamentals of Respiratory Care, 12th Ed one S 17 Determining the need for CPT: Bedside assessment: Medical Record: H/O secretion retention or pulmonary Ineffective cough disease process indicating the need Absent or increased sputum for PD Upper abdominal or thoracic surgery production Age (elderly) Labored breathing pattern H/O COPD Decreased breath sounds Obesity Nature of procedure Crackles or rhonchi Type of anesthesia Tachypnea, tachycardia Duration of procedure Fever Endotracheal (ET) Tube or Tracheostomy tube General physical fitness Chest X-ray (CXR): revealing Posture, muscle tone atelectasis or infiltrates Pulmonary function (PFT) abnormalities Arterial blood gases (ABG) abnormalities 18  Airway Clearance (Postural Drainage) Methods: Ña Postural Drainage (PD):89 16,612.5 moni ff  Mechanism of action: utilization of gravity to help move secretions from distal lung To segments toward the central airway, then coughed OR suctioned out. soi Iw 6d yff.im PD positions are usually held for 3-15 minutes depends on tolerance and patient's conditions PD most effective if: – There is excessive Sputum production (>25-30 ml/day) – For maximum effect, Head-down positions should exceed 25 degrees below horizontal – Patient should be adequately hydrated (Airway & Systemic) Airway  may need bland aerosol Systemic may need IV fluids as normal saline (NS) Eds IT 19  Postural Drainage (cont.,) PD frequency: orig - Performed every 4-6 hours (in critically ill patient & patient on MV) and re- evaluated at least every 48 hours based on assessments from individual treatments. - In spontaneously breathing patients according to response to therapy - Acute care patient orders should be re-evaluated based on patient response to therapy at least every 72 hours or with change of patient status. - Domiciliary patients should be re-evaluated every 3 months and with change of status. i Assess patient surroundings before application of PD – Monitors b – Intravenous (IV) or other lines – Nasogastric (NG) tube. – O2 therapy equipment. IN 20 Postural Drainage (cont.,) Technique ( after initial assessment) 1 may 60199 – Identify appropriate lobe or segment www.E.s.EE – Determine need for position modification given your assessment as in: Unstable hemodynamics Hypertension 081611.68401 Designesa Cerebrovascular disorders 8 Orthopnea dificity bretting rebreathing FEE Teleif – Schedule treatment before or at least 1.5-2 hours after meals or tube by feeding to avoid GERD and prevent possibility of aspiration. – Assess need for pain medications Gastro now gg or af 93112.0J S 21  Postural Drainage (cont.,) Equipment needed for PD 1- Bed or table that can be adjusted for a range of positions. 2- Pillows for supporting patient. II 16 s 3- Light towel for covering area of chest during percussion is.is 4- Tissues for collecting expectorated sputum ig ii y 5- Suction equipment for patients unable to clear secretion ie I 6-PPEs; Gloves, goggles, gown, and mask as indicated for caregiver protection 7-Optional: hand-held and mechanical precursor or vibrator hypoxingada 8- Oxygen It j's source and O2 delivery device. f 9- Recent chest x-ray, if available. need 10- Stethoscope for auscultation 22  Secretions don’t always come up Explain procedure immediately. to the patient May take several trials 1.8 to be successful soso.ua L.ie ITblondpressure p Assess vitals, pulse-oximetry and breath sounds pre, during and post procedure Tempreture Postural IEEE Encourage appropriate coughing Drainage techniques pre, during, and post coughjuringand procedure after (cont.,) Subjective response Mental function Other assessments Skin color Intracranial pressure (ICP) Documentation 9 41 23  Postural Drainage (cont.,) L's Complications & Recommended interventions: – Hypoxia 81 Is idiot's Give higher FiO2 during procedure 2 3693 If hypoxia occurs during treatment , give 100% position a 3 FiO2  stop therapy  return to original – Acute hypotension during treatment S Stop therapy  return to original position – Pulmonary Hemorrhage Stop therapy  return to original position  call Doctor immediately  O2  maintain airway – Bronchospasm 0 opin airways Stop  return to original position O2 call 0261 9 Doctor  bronchodilators as ordered 24  Postural Drainage (cont.,) Recommended interventions upon complications (cont.,) Vomiting/Aspiration 26 Stop clear airway/suction  O2  maintain airway  return to original position  call Doc It Dysrhythmias monitor.to e Is Stop  return to original position O2 call Doc w. Pain or injury fI Stop therapy  return to original position carefully Increased ICP Stop therapy  return to original position 25  Outcome assessment (cont.,) w̅ I II IT Documentation (Charting) Outcomes – Patient’s subjective – Date and time response to treatment – Position(s) – Vital signs and ECG – Time in position(s) – Patient tolerance – Breathing pattern, rate, chest expansion, etc. – Subject/objective indicators of treatment effectiveness – Sputum production Sputum color, viscosity, – Breath sounds volume – Chest X-ray – Pre, during, post assessment 94 – SaO2, SpO2, ABGs – Signature – Ventilator variables 26 27 Right 3parts Left 2PM LS apper apper low low RT LT 28  hope N we segment 1e.ms f 29 Patient positions for postural drainage 30 Patient positions for postural drainage 31 Upper Lobes; anterior apical w Segment the apical GE Bed or drainage table flat. Patient leans back on pillow at 30 11 65 degree angle (High fowler’s lower 55 position). wg1ope tw clavicle and (Clap over area between top of scapula on each side.) of Upper Lobes; Posterior apical Segment Bed or drainage table flat. Patient leans over folded pillow at 30 degrees angle. (Clap over upper back on each side of chest.) 32  Upper Lobes; Anterior Segment Bed or drainage table flat. 8 44 Patient lies flat on back with pillow under knees. (Clap between clavicle and nipple on each side of chest.) of bet own www i 235 2151 monoathe aif.gs from rest 33  Upper lobe right posterior segment Bed or drainage table is flat Patient lies on his left side and quarter turn towards prone (clap over the right scapula) 6.05 Upper Lobes left posterior segment Patient lies on his right side and quarter turn towards prone Head and shoulders are elevated 18 inches (30 degrees). (Clap over the left scapula.) ir 9 4 112111 34  1 1 1 is Right Middle Lobe: lateral segment-& medial segment y.JO Foot of table or bed elevated 14 inches or about 15 degrees (Trendelenburg) Patient lies head down on Lt. side and rotates ¼ turn backward. Pillow may be placed behind patient from shoulder to hip. Knees should be flexed (clap over Rt. Nipple area. s S 35 Left : Lingular Segment:- Superior-8 & Inferior Foot of table or bed elevated 14 inches or about 15 degrees (Trendelenburg).. Patient lies head down on right side and rotates 1/4 turn backward. Pillow may be placed behind patient from shoulder to hip. Knees should be flexed. (Clap over left nipple area.) or apical Lower Lobes: Superior Segment Bed or table flat. 96 I go with pillows Patient lies on abdomen under hips y (Clap over middle of back below tip of scapula on either side of spine.) 36 Lower Lobes: Anterior Basal Segment Foot of table or bed elevated 18 inches or 30 degrees (Trendelenburg).. Patient supine , head down, pillow under knees. (Clap over lower portion of ribs.) Lower Lobes: right Lateral Basal Segment Foot of table or bed elevated 18 inches or 30 degrees (Trendelenburg).. Patient lies side lying on his left side. Upper leg can be flexed over a pillow for support. (Clap over lower aspect of right rib cage) 37 Lower Lobes: left Lateral Basal Segment Foot of table or bed elevated 18 inches or 30 degrees (Trendelenburg).. Patient lies side lying on his right side. Upper leg can be flexed over a pillow for support. (Clap over lower aspect of left rib cage) Lower Lobes: Posterior Basal Segment Foot of table or bed elevated 18 inches or 30 degrees (Trendelenburg).. Patient lies on abdomen, head down, with pillow under hips.. (Clap over lower ribs close to spine on each side of chest.) 38 Modified Some patients who require postural postural drainage cannot tolerate the positions optimal for postural drainage: drainage:  265 a patient with congestive heart failure; may exhibit manifestations of orthopnea (can not lying flate). Pri I II  After neurosurgery; the patient may not be 84 allowed to assume a head-down position because f Mead 159 this position causes increased intracranial pressure. down  After thoracic surgery; the patient may have chest tubes and monitoring wires that limit positioning. a session III 39  Percussion and Vibration Application of mechanical energy to the chest wall 2 METHODS: during Hands (manual) Pneumatic devices (mechanical or electrical) expization Percussion  break secretions loose for tracheobronchial tree Vibration aids in moving secretions toward the central airways Manual Percussion and Vibration Unclear as to how much force or frequency should be used to be effective Effectiveness is controversial Goal of percussion: mechanical dislodging of retained secretions. Used in conjunction with postural drainage Percussion over the lobe or segment being drained This procedure should not be painful or uncomfortable. 91 5 6 pis 255 40  Percussion 9 This should be done with the hands in the cupped position, with the thumb and fingers closed to trap air. Hold your arms with the elbows partially flexed and wrists loose This technique should be applied against a thin layer of cloth, such as a hospital gown or bed sheet to help improve patient comfort Rhythmically strike the chest wall in a waving motion using both hands alternately in sequence. Percuss back and forth in a circular pattern over the specific segment for 3-5 minutes according patient toleration. ifs 41  Vibration technique s 5mi Place hands on either side of the chest After the patient takes a deep breath, exert slight-to-moderate pressure on the chest g wall Initiate a rapid vibratory motion of the hands throughout expiration 1.609014 Correct hand position for chest vibration 42 89 Mechanical Percussion and 9 Vibration Devices have both frequency and percussion force control Most units provide frequencies up to 20 to 50 cycles per second (20 to 50 Hz). Noise, excess force, mechanical failure and electrical shock are all potential hazards. Mechanism of action: Shock waves transmit through chest loosening secretions in the airways—often dependent on positioning to drain mucus into upper airways Technique: Patient is positioned for optimal drainage of lobe to be percussed with each area being treated for 2-5 minutes Considerations: Patient’s mental and physical limitations may impede, technique dependent, labor intensive, and positioning tolerance These devices may improve hospitalized patients’ compliance, especially when chest wall discomfort or injury is present. G5 Vibramatic Digital Professional However, there is no firm evidence that such devices are more Massager, VM24WD effective than manual techniques. For this reason, the selection of manual or mechanical methods should be based on individual patient factors such as age, condition, and tolerance. 43 Required readings: Mosby's Respiratory Care Equipment10th Ed., (chapter 7) Egan’s (chapter-44) Airway Clearance Therapy. AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients https://rc.rcjournal.com/content/58/12/2187 44