Lung Expansion Therapy PDF

LUNG EXPANSION THERAPY AND AIRWAY CLEARANCE TECHNIQUE, INCLUDING SUCTIONING FOR CRITICALLY ILL PATIENTS. 1 Contents Introduction Indications of ACT A-Lung expansion therapy Devices For ACT Princip...

LUNG EXPANSION THERAPY AND AIRWAY CLEARANCE TECHNIQUE, INCLUDING SUCTIONING FOR CRITICALLY ILL PATIENTS. 1 Contents Introduction Indications of ACT A-Lung expansion therapy Devices For ACT Principles of Lung expansion therapy Selecting ACT Indications for Lung Expansion Therapy C - Suctioning for critically ill patients Devices/ techniques for lung expansion Why is suctioning needed? therapy Types of suctioning How to select an effective approach Equipment's required for suctioning B- Airway Clearance Techniques Recent advances Physiology of ACT 2 Introduction Lung expansion therapy, airway clearance techniques → set of chest physiotherapy techniques used by PT, RTS. Help improve ↑ lung volumes and capacities and maintain a clear airway that helps in gas exchanges. These can be achieved by using manual techniques and specific assistive devices. Below are mentioned about these techniques, the physiology of each technique, and how each of these techniques is indicated to help in respiratory conditions. 3 A. LUNG EXPANSION THERAPY Lung expansion therapy techniques help improve pulmonary function by ↑ the alveolar recruitment assisting in optimizing the clearance of airways. 4  PRINCIPLES OF LUNG EXPANSION THERAPY PTP=Palv-Ppl The greater the transpulmonary pressure gradient, the more alveoli recruitment. Either can increase the PTP gradient decreasing the surrounding pleural pressure increasing the alveolar pressure 5  INDICATIONS FOR LUNG EXPANSION THERAPY Any condition that causes the ¯ in lung volumes, i.e., pulmonary complications post abdominal and thoracic surgeries – atelectasis, consolidation, pneumonia, pneumothorax, acute respiratory failures, or even restrictive conditions. The most effective use of these methods is in atelectasis / in preventing atelectasis 6  ATELECTASIS Atelectasis - The term atelectasis describes a state of the collapsed and non-aerated region of the lung parenchyma, which is otherwise normal. Peroni DG et al., 2000 Two types Gas absorption atelectasis - collapsing of airways due to hyperoxygenation and nitrogen washout. Compression atelectasis- a collapse of a part of the lung due to an external force compressing the lung. 7  DEVICES/ TECHNIQUES FOR LUNG EXPANSION THERAPY 1.Incentive spirometry Introduced in the early 1970s as a handheld device to prevent postoperative pulmonary complications. Designed to encourage patients to improve their inspiratory volume while visualizing their inspiratory effort. It works on the principle of sustained maximal inspiration 8 PHYSIOLOGICAL BASIS Functionally equivalent to performing an FRC to IC maneuverer, followed by a breath-hold. During the inspiratory phase of spontaneous breathing, the decrease in Ppl caused by expansion of the thorax is transmitted to the alveoli. A pressure gradient is created between the airway opening and the alveoli, with Pal now negative. This trans respiratory pressure gradient causes gas to flow from the airway into the alveoli. The greater the trans respiratory pressure gradient within certain limits, the more lung expansion occurs. 9  INDICATIONS Conditions predisposing to the development of pulmonary atelectasis (upper abdominal surgery, thoracic surgery) Surgery in patients with COPD pulmonary atelectasis restrictive lung defect associated with quadriplegia or dysfunctional diaphragm Preventive measure when conditions exist that make the development of atelectasis likely. AARC Clinical Practice Guideline,2011 10 RELATIVE CONTRAINDICATIONS A patient cannot be instructed or supervised to ensure the appropriate use of a device Patient cooperation is absent, or the patient is unable to understand or demonstrate proper use of the device Presence of an open tracheostomy (is not a contraindication but requires adaptation of the spirometer) AARC Clinical Practice Guideline,2011 11  HAZARDS AND COMPLICATIONS Hyperventilation and respiratory alkalosis Dizziness and numbness around the mouth Inappropriate as the sole treatment for major lung collapse or consolidation Barotrauma (emphysematous lungs) Discomfort secondary to inadequate pain control Hypoxia owing to break in mask O2 therapy Exacerbation of bronchospasm Fatigue AARC Clinical Practice Guideline,2011 12  TYPES OF DEVICES Measure and visually indicate the volume achieved during an SMI. The device employs a bellows that rises according to the inhaled volume. Volume oriented devices When the patient reaches a target inspiratory volume, a controlled leak in the device allows the patient to sustain the inspiratory effort for a short period (usually 5 to 10 seconds). measure and visually indicate the degree of inspiratory flow Flow Oriented Devices This flow can be equated with volume by assessing the duration of inspiration or time (flow × time = volume). 13 Flow Oriented Devices Volume Oriented Devices 14  POTENTIAL OUTCOMES OF SPIROMETRY Absence of or improvement in signs of ↑SpO2 atelectasis ↑ VC and peak expiratory flows ↓ respiratory rate Restoration of preoperative FRC or VC Normal pulse rate Improved inspiratory muscle performance Resolution of abnormal breath sounds and cough Normal or improved chest radiograph Attainment of preoperative flow and volume levels Improved PaO2 and ↓ PaCO2 ↑ FVC 15  DEVICES/ TECHNIQUES FOR LUNG EXPANSION THERAPY 2.NON-INVASIVE VENTILATION(NIV) In the early 1980s, NIV was pioneered first by Rideau and colleagues in France and subsequently by Bach and colleagues in the United States It provides breathing support to patients with inadequate ability to ventilate. It has been documented to have beneficial effects for patients who may need periodic, short-term support or patients experiencing exacerbations of pulmonary disease. NIV offers some benefits over traditional, invasive ventilation owing to lower infection risk and reduced need for sedation because of the absence of an artificial airway. 16  Recognized as an effective treatment for respiratory failure in chronic obstructive pulmonary disease, cardiogenic pulmonary edema and other respiratory conditions without complications such as respiratory muscle weakness, upper airway trauma, ventilator-associated pneumonia, and sinusitis Works by creating a positive airway pressure, i.e., the pressure outside the lungs is more significant than the pressure inside the lungs. This causes air to be forced into the lungs, lessening the respiratory effort and reducing the work of breathing. It also helps keep the chest and lungs expanded by ↑ FRC after a routine (tidal) expiration; this is the air available in the alveoli open for gaseous exchange. 17  DEVICES/ TECHNIQUES FOR LUNG EXPANSION THERAPY 3.INTERMITTENT POSITIVE AIRWAY PRESSURE BREATHING(IPPB) Intermittent short-term delivery of positive pressure to a patient to improve lung expansion, deliver aerosolized medications, and assist ventilation It was one of the most popular therapeutic modalities prescribed in the 1960s and 1970s and was regarded as a solution for all pulmonary ailments. Not until the American College of Chest Physicians conference on oxygen therapy in September 1983, when both its overuse and its doubtful efficacy were discussed, did IPPB decline as a treatment modality. Today, newly practiced modalities, such as bi-level positive airway pressure (BI-PAP) and incentive spirometry, have rendered IPPB obsolete. Most institutions do not own an IPPB device. 18  PHYSIOLOGICAL BASIS The intent of IPPB is not to provide full ventilatory support but to provide machine- assisted deep breaths assisting the patient to a deep breath and stimulate a cough. IPPB has historically consisted of providing an aerosol under positive pressure, ↑ the patient's inspiratory efforts → resulting in a larger tidal volume than could be spontaneously generated. Lung volumes are ↑ in IPPB because Alveolar pressure is more significant than Pleural pressure. Depending on the mechanical properties of the lung, Pleural pressure may exceed atmospheric pressure during a portion of inspiration. As with spontaneous breathing, the recoil force of the lung, stored as potential energy during the positive pressure breath, causes a passive exhalation. As gas flows from the alveoli out to the airway opening, Alveolar pressure decreases to atmospheric level, while Pleural pressure is restored to its normal sub-atmospheric range. 19  INDICATIONS Need to improve lung expansion clinically significant pulmonary atelectasis when other forms of therapy have been unsuccessful or the patient cannot cooperate Inability to clear secretions adequately short-term non-invasive ventilatory support for hypercapnic patients (as an alternative to intubation and continuous ventilatory support) To deliver aerosol medication to patients with ventilatory muscle weakness, fatigue, or chronic conditions in which intermittent non-invasive ventilatory support is indicated. AARC Clinical Practice Guideline 2003 20  CONTRAINDICATIONS No absolute contraindications Recent oesophageal surgery ICP >15 mm Hg Active hemoptysis Hemodynamic instability Nausea Recent facial, oral, or skull surgery air swallowing Tracheoesophageal fistula Active, untreated tuberculosis Radiographic evidence of bleb Singultus (hiccups) AARC Clinical Practice Guideline 2003 21  HAZARDS AND COMPLICATIONS Increased airway resistance Secretion impaction (inadequate humidity) Barotrauma, pneumothorax Psychological dependence Nosocomial infection The impedance of venous return Exacerbation of hypoxemia Hyperventilation or hypocapnia Hypoventilation Haemoptysis Increased V/Q¬ mismatch Hyperoxia when O2 is the gas source Air trapping, auto-PEEP, overdistended Gastric distention alveoli AARC Clinical Practice Guideline 2003 22  Using IPPB Bird series-Mark 7 series Puritan Bennett PR Series 23  DEVICES/ TECHNIQUES FOR LUNG EXPANSION THERAPY 4. POSITIVE AIRWAY PRESSURE THERAPY Positive airway pressure (PAP) adjuncts use positive pressure to ↑ the PTP gradient and enhance lung expansion. In contrast to IPPB, PAP therapy requires no complex machinery. Some methods do not even need a source of pressurized gas There are three current approaches to PAP therapy: - PEP* - Flutter* - CPAP 24 PHYSIOLOGICAL BASIS All three techniques are effective in treating atelectasis in most postsurgical patients. PEP and flutter valves only create positive expiratory pressure CPAP maintains a positive airway pressure throughout inspiration and expiration. 25  CPAP elevates and maintains high alveolar and airway pressures throughout the entire breathing cycle; this increases the PTP gradient throughout inspiration and expiration. Typically, a patient on CPAP breathes through a pressurized circuit against a threshold resistor, with pressures maintained between 5 cm H2O and 20 cm H2O. To maintain system pressure throughout the breathing cycle, CPAP requires a source of pressurized gas. The following factors involving PAP, flutter, and CPAP therapy contribute to the beneficial effects- recruitment of collapsed alveoli via an increase in FRC decreased work of breathing secondary to increased compliance or elimination of intrinsic positive end-expiratory pressure (PEEP) improved distribution of ventilation through collateral channels (e.g., pores of Kohn), and increase in the efficiency of secretion removal. 26  INDICATIONS Although evidence exists to support the use of CPAP therapy in treating postoperative atelectasis, as with all mechanical techniques, the duration of beneficial effects appears limited. The corresponding ↑ FRC may be lost within 10 minutes after the end of the treatment. For this reason, it has been suggested that CPAP should be used continuously until the patient recovers. To treat cardiogenic pulmonary enema. CPAP ¯ venous return and cardiac filling pressures in such patients, which helps mitigate pulmonary vascular congestion. Improve lung compliance ¯ WOB 27  CONTRAINDICATIONS A hemodynamically unstable patient is unlikely to tolerate CPAP for even a short period A patient suspected of having hypoventilation is not a good candidate for CPAP because it does not ensure ventilation, but the patient may be an ideal candidate for consideration of NIV Other problems that may indicate CPAP is inappropriate are nausea, facial trauma, untreated pneumothorax, and elevated intracranial pressure. 28  HAZARDS AND COMPLICATIONS caused by either the ↑ pressure or the apparatus The ↑ work of breathing can lead to hypoventilation and hypercapnia. In addition, because CPAP does not augment spontaneous ventilation, patients with an accompanying ventilatory insufficiency may hypo ventilate during application. Barotrauma (emphysema and blebs) Gastric distention may occur, especially if CPAP values greater than 20 cm H2O are needed. This condition may lead to vomiting and aspiration in a patient with a bad gag reflex 29  DEVICES/ TECHNIQUES FOR LUNG EXPANSION THERAPY 5. EARLY MOBILIZATION Mobilization does not only include walking, but also sitting, standing, and getting out of bed into a chair. As the patient changes body position, their breathing, and gas distribution within the lung changes. Improvements in ventilation result in less alveolar collapse Because of the beneficial pulmonary effects from the early mobilization of the post–abdominal surgery patient, it has been suggested that mobilization should be considered as early as the day of surgery. Having a patient who is able to respond to the caregiver allows for better pain control with decreased risk of sedation- related complications. Although early mobilization does not classify as a procedure, it does have distinct benefits in decreasing morbidity and mortality. 30  How to select an effective approach 31 B. AIRWAY CLEARANCE TECHNIQUES (ACT) Refers to a variety of different strategies used to eliminate excess secretions. The aim is to reduce airway obstruction caused by secretions occupying the airway lumen and so prevent respiratory tract infections by re-expanding the collapsed areas of the lung, thus improving gas exchanges and decreasing the inflammatory response Belli S et.al , 2021 32 PHYSIOLOGY OF ACT Airway clearance in normal lungs 1. Mucociliary escalator/ mucociliary clearance – 2. Cough 3. Macrophages 33 1.MUCOCILIARY ESCALATOR term used to define the process in which the cilia of the airways continually move mucus and other foreign materials from the lower respiratory tract to the oral cavity, where it is subsequently removed by swallowing This system consists of mucous and serous cells in the submucosal glands secretory goblet cells in the airway epithelium (secrete water, mucus, other proteins to produce a fluid layer on the airway surface) the ciliated cells that propel the fluid out of the lung toward the mouth -Encyclopedia of respiratory medicine, 2006, PG 466-470.L.E. Ostrowski, et al. 34  The efficiency of the mucociliary clearance system at removing airway secretions and associated trapped substances depends on three primary factors the beat frequency and coordination of the cilia the quantity and rheology of airway secretions derived from surface goblet cells and submucosal glands and the periciliary fluid depth that is modulated by ion transport of the airway epithelium In healthy individuals, this system is very effective at clearing mucus and associated bacteria and toxins from the lung. But in a variety of airway diseases, this apparatus becomes dysfunctional, leading to further exacerbation of airway inflammation and obstruction. -Encyclopedia of respiratory medicine, 2006, PG 466-470.L.E. Ostrowski, et al. 35 2.COUGH Irritation Inspiration Cough Compression Expulsion 36 3.MACROPHAGES The mucociliary escalator does not extend to the alveoli. Particles deposited in this region are engulfed by macrophages on the surface of the alveoli. The foreign particles engulfed by these macrophages either move up to join the mucociliary escalator or escape via the lymphatic or venous system. 37  HOW CAN THESE MECHANISMS BE IMPAIRED? Any abnormality altering airway patency mucociliary function the strength of the inspiratory or expiratory muscles thickness of secretions effectiveness of the cough reflex some therapeutic interventions, used in critical care, such as an endotracheal tube, can result in abnormal clearance. 38  Impaired Retention of airway secretions clearance Full/partial obstruction / Lung damage mucus plugging atelectasis / Infection 39 MECHANISMS THAT IMPAIR COUGH REFLEXES Phases Impairments Irritation Anaesthesia CNS depression Narcotic Analgesic Inspiration Pain NMD Pulmonary restriction Abdominal restriction Compression Laryngeal nerve damage Artificial airways Abdominal muscle wakens Expulsion Airway compression Airway Obstruction Abdominal muscle weakness Inadequate lung recoils 40  INDICATIONS OF ACT IN ACUTE CONDITIONS IN CHRONIC CONDITIONS Copious secretions Conditions associated with copious sputum production - cystic fibrosis, Bronchiectasis , Ciliary dyskinetic syndromes, COPD patients with retained secretion Inability to mobilize secretions Ineffective cough V/Q Abnormalities Patients with retained secretions ((coarse crackles, worsening oxygenation and/or ventilation, volume loss on chest radiograph)) 41  POSTURAL DRAINAGE Use of gravity to move secretions from peripheral airways to the larger bronchi →easily expectorated. Patient placed in various positions i.e. designed to drain specific lung segments. PD may be used exclusively given or combined with other airway clearance techniques. Priority should be given to treating the most affected lung segments first, and the patient should be encouraged to take deep breaths in the PD position and cough (or be suctioned) between positions as secretions mobilize. The number of PD positions tolerated per treatment session will vary with each patient. Signs of treatment intolerance include increased shortness of breath, anxiety, nausea, dizziness, hypertension, and bronchospasm 42 43  PERCUSSION Chest percussion is a technique aimed at loosening retained secretions from the bronchiole walls to loosen these secretions from the airways so they may be removed by suctioning or expectoration. During percussion, care should be taken to apply the device to the affected lung segments individually and not just generally on the lungs. It can be performed manually or with a mechanical device. Manual Percussion Percussion Mechanical Percussion 44 MANUAL PERCUSION MECHANICAL PERCUSSION consists of a rhythmical clapping with cupped Mechanical percussion is similar in hands over the affected lung segment. effectiveness to manual percussion.. Air is trapped between each cupped hand Electrically or pneumatically powered and the patient's chest with each clap. percussion devices can enable patients to (Slapping sounds indicate poor technique treat themselves independently as their and may cause discomfort or injury to the medical condition improves patient.) The ideal percussion frequency is unknown; however, some reports recommend a frequency of 5 to 6 Hz (300-360 blows per minute), whereas others suggest slow, rhythmic clapping. 45 Percussors 46  ADVANTAGE AND DISADVANTAGE OF PERCUSSION The addition of percussion to a PD treatment may enhance secretion clearance and shorten the treatment. Patients with chronic lung disease, who have used PD and percussion for many years and have found it compelling, are reluctant to try an alternative method of airway clearance. Compliance with this method is dependent on the availability of a family member or other caregiver to provide the treatment. Mechanical percussion allows the patients more independence or decreases fatigue of a caregiver and is especially useful in patients requiring ongoing treatment at home 47  Not well-tolerated by many patients postoperatively without adequate pain control. The percussion force is also a threat to patients with osteoporosis or coagulopathy. Has been associated with a fall in oxygen saturation(which can be eliminated with concurrent thoracic expansion exercises and pauses for breathing control.) Delivering percussion for extended periods on an ongoing basis can injure the caregiver, whether a family member or a health care provider. Repetitive motion injuries of the upper extremities may occur in long-term delivery of percussion for airway clearance. The expense of a mechanical device for percussion is minimal compared with the ongoing cost to provide percussion and PD in the hospital setting or a home care situation. 48  VIBRATION Vibrations represent an additional method of transmitting energy through the chest wall to loosen or move bronchial secretions. It can be performed manually or with a mechanical device. As with percussion, vibration is utilized in postural drainage positions to clear secretions from the affected lung segments. To perform vibration, the palmar aspect of the clinician's hands is in complete contact with the patient's chest wall, or one hand may be partially or fully overlapping the other and At the end of deep inspiration, the clinician exerts pressure on the patient's chest wall and gently oscillates it through the end of expiration. 49  Manual vibration frequency has been reported to be 12 to 20 Hz. This sequence is repeated until secretions are mobilized. Vibration may be a valuable alternative to percussion in acutely ill patients with chest wall discomfort or pain. The clinician may assess the depth and pattern of breathing during manual vibration. The pressure on the thorax exerted during vibration on expiration often causes a volume of air to be expired that is greater than what is exhaled during tidal breathing. This may encourage a deeper-than-tidal inspiration to follow and support a more effective cough. Mechanical vibration devices are also available for use; however, they may be more challenging to coordinate with the patient's breathing pattern. 50  ADVANTAGES AND DISADVANTAGES OF VIBRATION The use of vibration with PD may enhance the mobilization of secretions. Vibration may be better tolerated than percussion, especially in the postsurgical patient. Manual vibration allows the caregiver to assess the pattern and depth of respiration. The stretch on the muscles of respiration during expiration may encourage a more profound inspiration to follow. 51 Manual Vibrations Mechanical Vibrations 52  MANUAL HYPERINFLATION The technique of manual hyperinflation is used in patients with an artificial airway, who are mechanically ventilated or who have a tracheostomy. This method of airway clearance promotes mobilization of secretions and reinflates collapsed areas of the lung. Two caregivers are necessary to provide this treatment, and the coordination between these two people is key to achieving satisfactory results. Manual hyperinflation with AMBU 53  ADVANTAGES / DISADVANTAGES OF MANUAL HYPERINFLATION Manual hyperinflation may help manage airway secretions in those patients requiring long-term mechanical ventilation. In this patient population, the choice of airway clearance techniques is limited, especially when the patient is unresponsive. MIH simulates a cough by enhancing the inspiratory effort, momentarily maintaining a maximal inspiratory hold, and causing an increased expiratory flow. However, hyperinflation has the potential to cause significant barotrauma. There are several contraindications to this technique, including unstable hemodynamic pulmonary edema air leak, and severe bronchospasm. MIH requires two well-trained caregivers. This may be its most significant disadvantage 54 55  COUGHING Most ACTs only help move secretions into the central airways. Clearance of these secretions requires either coughing or suctioning. Different techniques for coughing Directed coughing FET Manual assisted techniques Self-assisted techniques 56  DIRECTED COUGHING Directed cough is a maneuver that is taught, supervised, and monitored. It aims to assist in creating a productive cough in patients unable to clear secretions with an effective spontaneous cough. In patients with copious secretions, directed coughing is an effective clearance method clearing secretions from the central—but not peripheral—airways. In addition to aiding in removing retained secretions from central airways, it should be a routine part of all ACT and may help obtain sputum specimens for diagnostic analysis. 57  CONTRAINDICATIONS Relative contraindications - Inability to control the possible transmission of infection from patients suspected or known to have pathogens transmittable by droplet nuclei (e.g., Mycobacterium tuberculosis) elevated intracranial pressure/ known intracranial aneurysm reduced coronary artery perfusion, such as in acute myocardial infarction Acute unstable head, neck, or spine injury Manually assisted directed cough with pressure to the epigastrium may be contraindicated in the presence of increased potential for regurgitation or aspiration, acute abdominal pathology, abdominal aortic aneurysm, hiatal hernia, pregnancy, bleeding diathesis, or untreated pneumothorax Manually assisted directed cough with pressure to the thoracic cage may be contraindicated in the presence of osteoporosis or flail chest 58  HAZARDS AND COMPLICATIONS Reduced coronary artery perfusion Incisional pain, evisceration Reduced cerebral perfusion Anorexia, vomiting Incontinence Gastroesophageal reflux Fatigue Spontaneous pneumothorax Rib or costochondral fracture Pneumomediastinum Headache Subcutaneous emphysema Visual disturbances, including retinal Cough paroxysms haemorrhage Chest pain Bronchospasm Central line displacement Muscular damage or discomfort 59  FORCED EXPIRATORY TECHNIQUES FET consists of one or two forced expirations of middle to low lung volume without glottis closure, followed by a period of diaphragmatic breathing and relaxation. This method aims to help clear secretions with a minor change in pleural pressure and less likelihood of bronchiolar collapse. To help keep the glottis open during FET, the patient is taught to phonate or "huff" during expiration. The period of diaphragmatic breathing and relaxation following the forced expiration is essential in restoring lung volume and minimizing fatigue. Comparative clinical studies on the effectiveness of FET have shown favorable results. The technique is beneficial in patients prone to airway collapse during regular coughing's, such as patients with COPD, CF, or bronchiectasis 60  1-2 huffs (mid to low lung volume with glottis open) Slow Relaxation diaphragmatic breathing 61  COUGH TECHNIQUES Manual Assisted techniques Self-assisted techniques Costophrenic assist Prone on elbows head flexion self- assisted cough Heimlich-type assist or abdominal thrust assist Long-silting self-assisted coughs Anterior chest compression assist Short-sitting self-assisted coughs Counterrotation assist Hands-knees rocking self-assisted cough Standing self-assisted coughs 62  ACTIVE CYCLE OF BREATHING TECHNIQUE To emphasize that FET should include breathing exercises, the originators of this technique modified the procedure and renamed it the ACBT. ACBT consists of repeated cycles of breathing control, thoracic expansion, and FET. Breathing control involves gentle diaphragmatic breathing at normal tidal volumes for 5 to 10 seconds with the relaxation of the upper chest and shoulders. This phase is intended to help prevent bronchospasm. The thoracic expansion exercises involve deep inhalation, approaching vital capacity, and relaxed exhalation, accompanied by percussion, vibration, or compression. The thoracic expansion phase is designed to help loosen secretions, improve ventilation distribution, and provide the volume needed for FET. The subsequent FET moves secretions into the central airways. 63  Postoperative patients may require splinting at the thoracic or abdominal incision site. Although ACBT can be performed in the sitting position, it is most beneficial when combined with PD. When ACBT is compared with similar methods of secretion clearance, studies indicate that ACBT can provide comparable results in both sputum production and distribution of ventilation. ACBT is not helpful with young children (< 2 years old) or critically ill patients. Caution should be taken in patients with reactive airway during ACBT 64  Breathing Coughing control 20-30 sec 3-4 deep Huffing breaths Breathing Breathing control control 3-4 deep breaths 65  AUTOGENIC DRAINAGE AD is another modification of directed coughing, designed as an airway clearance mechanism that trained patients can perform independently. During AD, the patient uses diaphragmatic breathing to mobilize secretions by varying lung volumes and expiratory airflow in three distinct phases For maximum benefit, the patient should be in the sitting position. Patients are taught to control their expiratory flows to prevent airway collapse while achieving a mucous "rattle" rather than a wheeze. Coughing should be suppressed until all three breathing phases are completed. In patients with CF, AD provides sputum clearance comparable to postural drainage percussion on a vibration (PDPV) but is less likely to produce O2 desaturation. In addition, AD seems to be tolerated better by patients and has the advantage of being performed without assistance from a caregiver. 66 67 MECHANICAL INSUFFLATION-EXSUFFLATION The MIE device (also called cough-assist device or "coughlator") has gained popularity in managing secretions in patients with certain neuromuscular disorders. The reason is growing evidence that MIE helps prevent respiratory complications in patients with NMD by assisting them to generate sufficient expiratory flow rates needed for adequate secretion clearance. 68 POSITIVE AIRWAY PRESSURE ADJUNCTS PEP therapy involves active expiration against a fixed orifice flow resistor or variable orifice threshold resistor capable of developing pressures of 10 to 20 cm H2O. Most fixed orifice devices allow adjustment of the orifice size to achieve a targeted PEP level. In theory, PEP therapy helps move secretions into the larger airways by providing a constant back-pressure that prevents airway collapse during expiration and the airway behind the mucus fills via collateral ventilation. A subsequent huff or FET maneuver may allow the patient to generate the flows needed to expel mucus from blocked airways. 69 POSITIVE AIRWAY PRESSURE ADJUNCTS A PEP device increases resistance to expiratory Positive expiratory airflow to promote mucus clearance by preventing airway closure and increasing collateral pressure devise ventilation. An oscillating/vibratory positive expiratory Oscillating Positive pressure device is a form of PEP that combines expiratory pressure high-frequency air flow oscillations with positive expiratory. devise 70 Flutter Acapella – types RC Cornet Aerobika 71  HIGH-FREQUENCY POSITIVE AIRWAY PRESSURE DEVICES High-frequency positive airway pressure devices / intrapulmonary percussive ventilation (IPV). Uses a pneumatic device to deliver a rapid series of pressurized gas mini-bursts at rates of 100 to 225 cycles per minute (1.7 to 5 Hz) to the airway. During the percussive cycle, the patient can inhale and exhale through the device as this oscillating airway pressure is applied. These devices also deliver aerosolized medication and rely on chest wall recoil or an active patient exhalation. The therapy is well tolerated by stable patients and may provide a more practical alternative for airway clearance in patients unable to take a deep inspiration 72 HIGH-FREQUENCY CHEST WALL OSCILLATION High-frequency chest wall oscillation (HFCWO) devices are passive oscillatory devices. These devices use a two-part system: a variable air-pulse generator and a nonstretch inflatable vest that wraps around the patient’s entire torso (Vest Airway Clearance Systems, Hill-Rom Services, Inc., Batesville, IN). Either one or two large-bore tubing(s) connect the vest to the air-pulse generator. The generator inflates and deflates the vest, creating pressure pulses against the thorax resulting in chest wall oscillations and moving secretions forward. These devices are used in hospital or home settings. The therapy is typically performed for a 30-minute session 2 to 6 times per day at oscillatory frequencies between 5 to 25 Hz. These therapy sessions depend on patient need and response 73 74 75 76 77 Belli et al , 2021 78 SELECTING ACT 79 80 C - SUCTIONING FOR CRITICALLY ILL PATIENTS 81  SUCTIONING Invasive type of airway clearance technique Process of mechanically aspirating airway secretions with the application of negative pressure/vacuum to the airways through a collecting tube. Normal Suction Pressure For adults – is ↓ 200mmhg 82 WHY IS SUCTIONING NEEDED ? Difficulty is WOB → hypoxemia, Infiltrates in X-rays hypercapnia, infection Deterioration in ABG findings (¯ SpO2) ↑ airway resistance Presence of consolidation on auscultation Supressed cough reflexes Patients on artificial airways Sputum sampling 83  Nasopharyngeal Upper airway suctioning Rigid tonsillar suctioning /Yankauer suction (Oropharynx) tip Oropharyngeal Suctioning Types Of Nose – suctioning Naso- tracheal suctioning Lower airway suctioning Artificial airway – Flexible suction Endotracheal (Trachea and catheter suctioning bronchi) Tracheal suctioning 84 Upper Airway Suctioning Lower Airway Suctioning 85  EQUIPMENT'S REQUIRED FOR SUCTIONING Adjustable suctioning/collecting systems Sterile suction catheter Sterile gloves, goggles, masks Sterile water/saline O2 delivery system AMBU bag 86  ENDOTRACHEAL SUCTIONING necessary practice carried out in intensive care units. It involves the removal of pulmonary secretions from a patient with an artificial airway in place. Caroline J Wood, 1998 87  INDICATIONS Need to maintain patency and integrity of ¯ O2 saturation /blood gas values the artificial airway Visible secretions in the airway Remove accumulated pulmonary secretions Decreased cough efforts The sawtooth pattern on the flow-volume Acute respiratory distress loop on the monitor screen of the ventilator or the presence of coarse Suspected aspiration of gastric or upper crackles over the trachea airway secretions ↑ peak inspiratory pressure on volume- Need a sputum sample control ventilation or ↓ tidal volume on pressure control ventilation AARC Clinical Practical Guidelines 2010 88  CONTRAINDICATIONS Most contraindications are relative to the patient's risk of developing adverse reactions or worsening clinical conditions due to the process. When indicated, there is no absolute contraindication to endotracheal suctioning because the decision to withhold suctioning to avoid possible adverse reactions may be lethal AARC Clinical Practical Guidelines 2010 89  HAZARDS AND COMPLICATIONS ¯ in dynamic lung compliance and functional Cardiac dysrhythmias residual capacity Routine use of normal saline instillation may be associated with the following adverse Atelectasis events Hypoxia or hypoxemia Excessive coughing Decreased O2 saturation Bronchospasm Tissue trauma to the tracheal/bronchial mucosa Dislodgment of the bacterial biofilm that colonizes the endotracheal tube into the Bronchoconstriction/bronchospasm lower airway Pain, anxiety, dyspnoea ↑microbial colonization of the lower airway Tachycardia Changes in cerebral blood flow and ↑ intracranial pressure ↑intracranial pressure AARC Clinical Practice Guideline 2010 Hypertension/Hypotension 90 TECHNIQUES FOR ET SUCTIONING Open Sterile Techniques Closed suction system 91  STEPS TO ET SUCTIONING Assess Apply Monitor Assess Assemble Patient for Insert Suction Reoxygena Patient Patient for and Check Hyperoxyg Catheter and Clear te Patient and Assess Indications Equipment enation Catheter Outcomes. 92  NASOTRACHEAL SUCTIONING For patients who have retained secretions but do not have an artificial airway. The nasal passages are highly vascularized. Mucosal trauma and bleeding can occur with repeated suctioning, adding to difficulty managing secretions. The use of soft suction catheters and a nasopharyngeal airway is recommended to prevent these complications 93  INDICATIONS Visible secretions in the airway Deterioration of arterial blood gas values suggesting hypoxemia or hypercarbia Chest auscultation of coarse, gurgling breath sounds, rhonchi, or ¯ breath sounds Chest radiographic evidence of retained secretions resulting in atelectasis or Feeling of secretions in the chest consolidation (increased tactile fremitus) Restlessness Suspected aspiration of gastric or upper airway secretions Stimulate cough or for unrelieved coughing ↑WOB Obtain a sputum sample for microbiologic or cytologic analysis AARC Clinical Practice Guideline,2004 94  CONTRAINDICATIONS Occluded nasal passages Upper respiratory tract infection Nasal bleeding Tracheal surgery Epiglottitis or croup—absolute Gastric surgery with high anastomosis Acute head, facial, or neck injury Myocardial infarction Coagulopathy or bleeding disorder Bronchospasm Laryngospasm Irritable airway AARC Clinical Practice Guideline,2004 95 HAZARDS AND COMPLICATIONS Mechanical trauma Uncontrolled coughing/ Gagging or vomiting Laceration of nasal turbinate's Laryngospasm/Bronchoconstriction or bronchospasm Perforation of pharynx Discomfort and pain Nasal irritation or bleeding Nosocomial infection Tracheitis Atelectasis Mucosal haemorrhage Misdirection of the catheter Edema of the uvula ↑ICP Hypoxia/hypoxemia Intraventricular haemorrhage Cardiac dysrhythmias or arrest Exacerbation of cerebral edema Bradycardia Pneumothorax ↑ blood pressure/Hypotension Respiratory arrest AARC Clinical Practice Guideline 2004 96 OTHER FORMS OF SUCTIONING Oropharyngeal Suctioning Nasopharyngeal suctioning Tracheostomy suctioning 97  RECENT ADVANCES A short review done titled “Airway Clearance Techniques: The Right Choice for the Right Patient” had few suggestions on the usage of ACT for Covid patients in regards to the Clinical Practice Covid 19 Guidelines by Karin M et al. and Lazzeri et al Airway Clearance procedures should be administered only when strictly needed when a Patient has specific comorbidities where there is ↑ secretion or retention, ineffective cough:- different techniques and devices can be applied to mobilization or evacuation PEP device with/ without oscillation (PEP, TPEP, OPEP), should be considered, alone or in combination with lung expansion strategies, to enhance lung volume recruitment, to control the expiration flow, and to facilitate peripheral and proximal mucus mobilization. In Patients with cough FET should be preferred to expectorate. Belli S et al. 2021 98  RECENT ADVANCES A Pilot study on “Short-Term Effects of a Respiratory Telerehabilitation Program in Confined COVID-19 Patients in the Acute Phase” This was a telerehabilitation program – that included breathing exercises (ACBT) and other breathing exercises. The study concluded that Breathing exercises through telerehabilitation appeared to provide a promising approach for improving outcomes related to physical condition, dyspnea, and perceived effort among people exhibiting mild to moderate COVID-19 symptoms in the acute stage. Gonzales- Gerez J, 2021 99  RECENT ADVANCES An RCT titled “Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: a pragmatic, double-blinded, multicenter randomized controlled trial.” This was A RCT done to note the effects of prehabilitation reducing postoperative complications in elective abdominal surgery patients Here, The interventional group received education focused on PPCs and their prevention through techniques of early ambulation, self-directed breathing exercises with usual physiotherapy in the preoperative period And it was found that with the addition of exercises and training in the preoperative period, the postoperative complications were reduced in half. Boden I, et al., 2018 100 References Kacmarek RM, Stoller JK, Heuer A. Egan's Fundamentals of Respiratory Care E-Book. Elsevier Health Sciences; 2017 Kacmarek RM, Stoller JK, Heuer A. Egan's Fundamentals of Respiratory Care E-Book. 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