Bronchial Hygiene Test #6 PDF

Bronchial Hygiene Chapter 44- Airway Clearance Therapy Parts of a cough, factors inhibiting effective cough. Specific factors affecting specific parts of the cough. Irritation ● ● ● A stimulus provokes sensory fibers in the lungs to send signals to the brain saying it is time to cough. Things tha...

Bronchial Hygiene Chapter 44- Airway Clearance Therapy Parts of a cough, factors inhibiting effective cough. Specific factors affecting specific parts of the cough. Irritation ● ● ● A stimulus provokes sensory fibers in the lungs to send signals to the brain saying it is time to cough. Things that cause irritation ○ Infection ○ Thermal Changes ○ Inhaled Chemicals ○ Foreign bodies Factors ○ Anesthesia ○ CNS depression ○ Narcotic- analgesic Inspiration ● ● ● After irritation a deep inspiration is needed for an effective cough Normal amount needed ○ ~1-2 L Factors ○ ○ ○ ○ Pain Neurologic dysfunction Pulmonary restriction ( disease or compressed chest wall) Abdominal restriction Compression ● ● ● Reflex pulses cause the epiglottis to close and the expiration muscles to contract. ○ Time ~0.2 sec The glottis then opens Resulting in the expulsion phase Factors ○ Laryngeal nerve damage ○ Artificial airways ○ Abdominal muscle weakness ○ Abdominal surgery Expulsion ● ● ● ● The muscles continue to contract causing a explosive flow of air. ○ 500 miles /hour Shear forces cause the mucus to move away from the airway walls. Secretions are expelled or swallowed Fators ○ Airway compression ○ Airway obstruction ○ Abdominal muscle weakness ○ Inadequate lung recoil ( emphysema) What sort of drugs can impair the mucociliary escalator? ● ● ● ● General anesthetics ○ Depress mucociliary transport Narcotic analgesics ○ Depress mucociliary transport Anticholinergic ○ ↑ mucus viscosity and delay mucociliary clearance Antihistamines ○ Thicken mucus ○ Paralyze cilia Clinical Manifestations of retained secretions… (Signs and symptoms)’ ● ● ● ● Sputum retention not responsive to coughing Decreased or adventitious breath sounds indicating secretions in airway Abnormal chest x-ray- atelectasis, mucus plugging or infiltrates Assessment of patient indicating problems with secretions: tachycardia, tachyapnea, deterioration of ABGs, hypoxemia Factors utilized to determine need for different bronchial hygiene techniques ● ● ● Patients motivation Patients/ physician/caregiver goals Effectiveness of techniques ● ● ● ● Patients age, concentration, cooperation Ease of learning/ teaching Equipment needs Costs What things may impair the mucociliary escalator. ● ● ● ● ● Artificial airways ○ Increases secretions Cuff of ET tube ○ Blocks escalator Suctioning ○ Damages airway High FiO2 ○ Dries out secretions Underlying pulmonary disease What things may impair airway patency and cause abnormal secretion clearance ● ● ● ● ● ● ● ● ● ● Weight (Obesity) Trauma to airways Drugs Airway deformities Artificial airways COPD w/ retained secretions Pneumonia Anesthesia Narcotics Opiates What conditions/diagnosis are associated with chronic increased production of sputum ● ● ● ● ● ● Acute disease Immobile patients Postoperative patients ( anesthetics, opiates and narcotics) Inadequate Humidification Acute Exacerbations ( COPD, CF, Bronchiectasis) Chronic Disease ( CF, Neuromuscular disorders) Look. This goes somewhere. I can't figure out where. It goes here now. Problems with Retained secretions ● Full or partial airway obstruction ● Atelectasis ● Impaired oxygenation ● Increased work of breathing ● Air Trapping/ overdistention ● Growth of pathogenic organisms (pneumonia) ● Respiratory failure AARC clinical practice guidelines Postural drainage/ Directed cough/ Use of PAP Adjuncts Methods used in Bronchial Hygiene CPT/ postural drainage/ percussion/ vibration pg 957 table ● ● ● ● ● ● Indications ○ Need to remove retained secretions from the central airways ○ Prevent or treat atelectasis Contraindications ○ All contraindications should be weighed against the possible benefits of the therapy ○ Inability to control transmissions of infection ○ Increased ICP ( acute head, neck or spine) ○ Hemodynamic instability ○ Potential for aspiration ○ Osteoporosis/ flail chest Complications ○ Hemodynamic instability ( decrease BP, etc.…) ○ Pulmonary hemorrhage ○ Hypotension ○ Fatigue ○ Increased ICP- visual disturbances, headache. Etc..) ○ Vomiting ○ Pain ○ Displacement of “tubes” Assessment of need ○ excessive sputum production ○ effectiveness of cough ○ history of pulmonary problems treated successfully with PDT (eg, bronchiectasis, cystic fibrosis, lung abscess) decreased breath sounds or crackles or rhonchi suggesting secretions in the airway change in vital signs ● ● ● Abnormal chest x-ray consistent with atelectasis, mucus plugging, or infiltrates deterioration in arterial blood gas values or oxygen saturation Assessing outcomes and monitoring ○ Change in sputum production ○ Change in breath sounds of lung fields being drained ○ Subjective response to therapy ○ Change in chest X-ray ○ Change in vitals ○ Change in ABG/ O2 Saturation ○ Change in ventilator variables Pay attention to the Contraindications ● Notice that some have to do with positioning ● Notice about the absolute and relative. Positions ● How to perform ○ ● How long with each segment ○ Positions are held for 3-15 minutes ● When to terminate therapy in an adverse reaction ○ IMMEDIATELY ■ Stop therapy ■ Return pt to original position ■ Monitor pt ■ Consult physician ● Where to and not to percuss ○ Bony areas ■ Clavicles ■ Vertebrae ○ May use a sheet or gown to cover patient- (something thin) ○ Wounds ○ Recent surgical areas ○ Tubes/ ports You will also have some positions (may be in the form of pictures or verbal explanation of positions. (Most likely verbal explanations) Directed Cough ● ● ● ● ● ● ● Indications ○ The need to aid in the removal of retained secretions from central airways(the suggestion that FET at lower lung volumes may be effective in preferentially mobilizing secretions in peripheral airways while larger volumes facilitate movement in the central airways lacks validation). The presence of atelectasis As prophylaxis against postoperative pulmonary complications As a routine part of bronchial hygiene in patients with cystic fibrosis, bronchiectasis, chronic bronchitis, necrotizing pulmonary infection, or spinal cord injury As an integral part of other bronchial hygiene therapies such as postural drainage therapy (PDT),positive expiratory pressure therapy (PEP), and incentive spirometry (IS) To obtain sputum specimens for diagnostic analysis Contraindications ○ Inability to control possible transmission of infection from patients ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ○ suspected or known to have pathogens transmittable by droplet nuclei (eg,M tuberculosis) Presence of an elevated intracranial pressure or known intracranial aneurysm Presence of 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 presence of increased potential for regurgitation/aspiration (eg, unconscious patient with unprotected airway) acute abdominal pathology, abdominal aortic aneurysm, hiatal hernia, or pregnancy a bleeding diathesis, untreated pneumothorax Manually assisted directed cough with pressure to the thoracic cage may be contraindicated in presence of osteoporosis, flail chest Complications ○ Reduced coronary artery perfusion ○ Reduce cerebral perfusion leading to syncope or alterations in consciousness, such as, light-headedness or confusion, vertebral artery dissection Incontinence Fatigue Headache Paresthesia or numbness Bronchospasm Muscular damage or discomfort Spontaneous pneumothorax, pneumo-mediastinum, subcutaneous emphysema Cough paroxysms Chest pain Rib or costochondral junction fracture Incisional pain, evisceration Anorexia, vomiting, and retching Visual disturbances including retinal hemorrhage Central line displacement Gastroesophageal reflux Assessment of need ○ Spontaneous cough that fails to clear secretions from the airway ○ Ineffective spontaneous cough as judged by clinical observation ○ evidence of atelectasis ○ results of pulmonary function testing ○ Postoperative upper abdominal or thoracic surgery patient ○ Long-term care of patients with tendency to retain airway secretions ○ Presence of endotracheal or tracheostomy ● Assessing outcomes and monitoring ○ The presence of sputum specimen following a cough(4) ○ Clinical observation of improvement ○ Patient's subjective response to therapy ○ Stabilization of pulmonary hygiene in patients with chronic ○ pulmonary disease and a history of secretion retention Prone Positioning ● ● Lying on the stomach. ○ To improve oxygenation(improve the V/Q mismatch) You will have the patient lay on the unaffected side FET (huff cough) AKA: FET – forced expiratory technique ● AKA: ACB- active cycle breathing ● ● Active cycle breathing ○ Autogenic drainage ○ Insufflation and Exsufflation (MIE) ○ “artificial cough machine” ○ The machine delivers positive pressure to the airways at a pressure you set between +30 to +50 cm H2O ( this pressure is delivered over a 1-3 second time period. ○ The negative pressure at a pressure you set between -30 to -50 cm H2O over a 2-3 second time period Turning ● ● Contraindicated in ○ unstable spinal cord injuries ○ traction Relative: diarrhea, agitation, Increased ICP, blood pressure drops, increased dyspnea, hypoxia and cardiac arrhythmias Positive airway pressure adjuncts (expiratory PAP, PEP) ● Indications ○ ○ ○ ○ ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● To reduce airtrapping in asthma or COPD To aid in mobilization or retained secretions (CF, bronchitis etc…) To prevent or reverse atelectasis To optimize delivery of bronchodilators in patients receiving bronchial hygiene( secretions are removed so that bronchodilator is deposited) Contraindications Although no absolute contraindications to the use of PEP, CPAP, or EPAP mask therapy have been reported,4,39 the following should be carefully evaluated before a decision is made to initiate PAP mask therapy. Patients unable to tolerate the increased work of breathing (acute asthma, COPD) Intracranial pressure (ICP) > 20 mm Hg Hemodynamic instability(4) Recent facial, oral, or skull surgery or trauma4 Acute sinusitis(39) Epistaxis Esophageal surgery Active hemoptysis(39) Nausea Known or suspected tympanic membrane rupture or other middle ear pathology Untreated pneumothorax Complications ○ Increased work of breathing that may lead to hypoventilation ○ and hypercarbia ○ Increased intracranial pressure ○ Cardiovascular compromise ○ myocardial ischemia ○ decreased venous return ○ Air swallowing with increased likelihood of vomiting and aspiration ○ Claustrophobia ○ Skin break down and discomfort from mask ○ Pulmonary barotrauma Assessment of need ○ Sputum retention not responsive to coughing ○ Decreased or adventitious breath sounds indicating secretions in airway ○ Abnormal chest x-ray- atelectasis, mucus plugging or infiltrates ○ Assessment of patient indicating problems with secretions: tachycardia, tachypnea, deterioration of ABGs, hypoxemia Assessing outcomes and monitoring ○ Positive outcomes: ■ Increase in sputum production ■ ■ ■ ■ ■ Improvement in breath sounds, decreased WOB Positive subjective response Improvement in vitals Improvement in chest radiograph Improvement in ABG’s/ Sao2 How to perform (remember you have patients do a active exhalation not a forced Why do these work? ● Works two ways: 1. filling underaerated or nonaerated segments via collateral ventilation 2. prevents airway collapse during expiration HFCWO ( hertz?)- how many breaths /hertz? THE VEST ● ● ● ● 30 minute sessions may be given up to 6x a day Has a pulse generator and a inflatable vest Frequencies of 5-25 HZ Great for patients with long term secretion problems IPV-Intrapulmonary percussive ventilation ● ● ● ● Internal delivery of 100-225 cycles per minute (1.6-3.75 Hz) Uses a thumb button control 20 minute sessions Great for patients with long term secretion problems Flutter valve ● Has a weighted ball that “flutters” during exhalation. ● Internal delivery of oscillation. ● Must maintain proper position to get good “flutters” Acapella ● The pickle Indications for Airway Clearance Therapy Acute Conditions · Copious secretions · Acute Respiratory Failure with retained secretions · Acute Lobular Atelectasis ( caused by secretion obstruction of Lobar Bronchi) · V/Q abnormalities caused by unilateral lung disease Chronic Conditions · CF · Bronchiectasis · Ciliary dyskinetic syndromes · Chronic Bronchitis Disorders Associated with Retention of Secretions · Acute disease · Immobile patients · Postoperative patients ( anesthetics, opiates and narcotics) · Inadequate Humidification · Acute Exacerbations ( COPD, CF, Bronchiectasis) · Chronic Disease ( CF, Neuromuscular disorders) Recommended Airway Clearance techniques in Specific Conditions and Age **** (REMEMBER TABLE) Problem Area Appropriate Techniques A. CF ,ciliary dyskinesia syndromes, bronchiectasis Infants PDPV 3-12 Years Exercise, PEP, PDPV, ACBT, HFO >12 years Exercise, PEP, PDPV, ACBT, HFO, AD B. Atelectasis PEP, PDOV, ACBT C. Asthma ( with mucus plugging) Exercise, PEP, PDPV, HFO ( flutter valve) D. Neurologic abnormalities ( spasticity, bulbar palsy , aspiration prone) PDPV, Suction, MIE E. Musculoskeletal weakness ( muscular dystrophy, myasthenia gravis, polio, MS, ETC PEP, MIE PDPV- Postural Drainage/ Percussion/ Vibration PEP- Positive Expiratory Device AKA: PAP ACBT- Active Cycle Breathing Technique HFO- High frequency Oscillation (vest-IPV) AD- Autogenic drainage MIE- Manual Inspiration and Expiration BRONCHIAL HYGEINE SUMMARY · Normal Airway Clearance requires a patent airway, a functional mucociliary escalator and an effective cough. · Primary goal of airway clearance is to help mobilize and remove retained secretions, improve gas exchange and reduce the work of breathing · Retained secretions can increase work of breathing, cause air trapping, worsen V/Q imbalances, promote atelectasis and shunting and increase the incidence of infection · Disorders associated with abnormal secretions clearance include fording bodies, tumors congenital or acquired thoracic anomalies, asthma, chronic bronchitis, CF, bronchiectasis, and acute infections · Musculoskeletal and neurologic disorders and impair coughing and lead to mucous plugging, airway obstruction and atelectasis · Both mechanical and treatment factors impair mucociliary clearance in intubated patients · Clinical signs consistent with retained sections include ineffective cough, absent or increased sputum production, labored breathing, abnormal or adventitious lung sounds, ( crackles, decrease breath sounds or bronchial breath sounds over affected area) · Turning promotes lung expansion, improves oxygenation and presents retention of secretions. ( bad lung up/good lung down ) · Postural drainage position can be held for 3- 15 minutes · Effectiveness of percussion and vibrations of the chest is controversial · In patients with copious secretions, directed coughing is a clearance method as acceptable as more complicated methods · Cough methods must be codified in surgical patient, COPD and neuromuscular disorder · FET ( Huff Cough ) consists of one or two forced expirations of middle to low lung volume without closure of the glottis, followed by period of diaphragmatic breathing relaxation · ACBT consists of repeated cycles of breathing control, thoracic expansion and EFT · During AD the patient uses the diaphragmatic breathing to mobilize secretions by varying lung volumes and expiratory airflow in three distinct phases · MIE involves delivery of a positive pressure breath followed by a quick application of negative pressure, positive expiratory flows exceed flows developed with manually assisted coughing · PEP therapy is a self-administered clearance techniques involving active expiration against a variable flow resistance, followed by FET , patients frequently prefer PEP over other methods · At high frequencies ( 12- 25 Hz) airway oscillations enhance cough clearance · Airway oscillations can be created externally ( HFCWC) or at the airway opening ( flutter valve, IPV) · Adding physical activity to mobilization and coughing enhances mucus clearance, improves overall aeration and VQ matching, and improves pulmonary function · Numerous factors must be considered in trying to select the best airway clearance strategy for a given patient.