Airway Clearance Techniques PDF

# Airway Clearance Techniques ## Airway Clearance Techniques - The cough reflex - Postural drainage - Percussion - Vibration/shaking - Active cycle of breathing technique - Autogenic drainage ## The Cough Reflex - Coughing is an extremely important mechanism for the removal of lung secretions. -...

# Airway Clearance Techniques ## Airway Clearance Techniques - The cough reflex - Postural drainage - Percussion - Vibration/shaking - Active cycle of breathing technique - Autogenic drainage ## The Cough Reflex - Coughing is an extremely important mechanism for the removal of lung secretions. - Coughing is a major defense against retained secretions. ### There are four distinct phases to a normal cough: 1. Irritation 2. Inspiration 3. Compression 4. Expulsion - The stimulus might be inflammatory, mechanical, chemical, or thermal. ## Mechanisms impairing cough reflex: ### Irritation: - Anesthesia - CNS depression - Narcotic - analgesics ### Inspiration: - Pain - NM dysfunction - Pulmonary or abdominal restriction ### Compression: - Laryngeal nerve damage - Artificial airway - Abdominal muscle weakness or surgery ### Expulsion: - Airway compression - Airway obstruction - Abdominal muscle weakness - Inadequate lung recoil (eg., emphysema) ## The Primary Goal of Airway Clearance Therapy - To help mobilize and remove retained secretions. - To improve gas exchange. - To promote alveolar expansion. - To reduce the work of breathing. ## The Normal Cough Pump - Cough may be reflexive or voluntary. ### When a person coughs, a series of actions occurs as follows: 1. Deep inspiration occurs 2. Glottis closes 3. Vocal cords tighten 4. Abdominal muscles contract 5. Diaphragm elevates 6. An increase in intrathoracic and intra-abdominal pressures 7. Glottis opens 8. ​Explosive expiration of air occurs ## Teaching an Effective Cough - Because an effective cough is an integral component of airway clearance, a patient must be taught the importance of an effective cough. - A patient must be taught how to produce an efficient and controlled voluntary cough. - A patient must be taught when to cough. ### The following sequence and procedures are used when teaching an effective cough: 1. Assess the patient's voluntary or reflexive cough. 2. Have the patient assume a relaxed, comfortable position for deep breathing and coughing. 3. Sitting or leaning forward usually is the best position for coughing. 4. The patient's neck should be slightly flexed to make coughing more comfortable. 5. Teach the patient controlled diaphragmatic breathing, emphasizing deep inspirations. 6. Demonstrate a sharp, deep cough. 7. Demonstrate the proper muscle action of coughing (contraction of the abdominals). 8. Have the patient place the hands on the abdomen and make three huffs with expiration to feel the contraction of the abdominals. 9. Have the patient practice making a "K" sound to experience tightening the vocal cords, closing the glottis, and contracting the abdominals. 10. When the patient has put these actions together, instruct the patient to take a deep but relaxed inspiration, followed by a sharp cough. 11. The second cough during a single expiration is usually more productive. 12. Use an abdominal binder or glossopharyngeal breathing in selected patients with inspiratory or abdominal muscle weakness to enhance the cough, if necessary. ## Additional Techniques to Facilitate a Cough and Improve Airway Clearance - To maximize airway clearance, several techniques can be used to stimulate a stronger cough, make coughing more comfortable or improve the clearance of secretions. ### Manual Assistive Cough - If a patient has abdominal weakness (e.g., as the result of a mid-thoracic or cervical spinal cord injury), manual pressure on the abdominal area assists in developing greater intra-abdominal pressure for a more forceful cough. ### Therapist-Assisted Techniques: 1. With the patient in a supine or semi-reclining position, the therapist places the heel of one hand on the patient's abdomen at the epigastric area just distal to the xiphoid process. 2. The other hand is placed on top of the first, keeping the fingers open or interlocking them. 3. After the patient inhales as deeply as possible, the therapist manually assists the patient as he or she attempts to cough. The abdomen is compressed with an inward and upward force, which pushes the diaphragm upward to cause a more forceful and effective cough. 4. This same maneuver can be performed with the patient in a chair the therapist or family member can stand in back of the patient and apply manual pressure during expiration. ### Precaution: Avoid direct pressure on the xiphoid process during the maneuver. ### Self-Assisted Technique 1. While in a sitting position, the patient crosses the arms across the abdomen or places the interlocked hands below the xiphoid process. 2. After a deep inspiration, the patient pushes inward and upward on the abdomen with the wrists or forearms and simultaneously leans forward while attempting to cough. ### Splinted Cough - If incisional pain from recent surgery is restricting the cough teach the patient to splint over the incision. - The patient hands or a pillow held gently but firmly against the incision while coughing makes the process less painful. ## Methods to Stimulate Cough: ### Tracheal Stimulation 1. Tracheal stimulation, sometimes called a tracheal tickle, may be used with infants or disoriented patients who cannot cooperate in the treatment. 2. This is somewhat uncomfortable maneuver, performed to elicit a reflexive cough. 3. The therapist places two fingers at the sternal, notch and applies a circular motion with pressure downward into the trachea to facilitate a reflexive cough. ### Pressure: 1. Apply external pressure on mid rectus abdominis area after inspiration may improve cough effectiveness. 2. Or pressure applied along the lower costal border during exhalation also improve effectiveness of cough. ### Neuromuscular Facilitation: - Intermittent ice application 3-5 seconds along the paraspinal area to improve the strength of cough. ### Precaution: It is associated with increased blood pressure so hypertensive patients must be closely monitored. ### Humidification: - If secretion are very thick, work with the patient after humidification therapy or ultrasonic nebulizer (USN) therapy, both of which enhance the mucociliary transport system and facilitate a productive cough. ## Precautions for Teaching an Effective Cough: ### Never allow a patient to gasp in air: - Because this increases the work (energy expenditure) of breathing, causing the patient to fatigue more easily. - It also increases turbulence and resistance in the airways, possibly leading to increased bronchospasm and further constriction of airways. - A gasping action also may push mucus or a foreign object deep into air passages. ### Avoid Uncontrolled Coughing Spasms (Paroxysmal Coughing) ### Avoid Forceful Coughing - If a patient has a history of a cerebrovascular accident or an aneurysm. - Have these patients huff several times to clear the airways, rather than cough. ### Be Sure That the Patient Coughs While in a Somewhat Erect or Side-Lying Posture ### Huff - A gentle way of coughing, which speeds airflow without closing the glottis with minimal change of the pleural pressure - Effective in clearing the peripheral lung regions at mid to low lung volumes while cough is effective in clearing the central lung regions at high lung volumes. ## The "Huff" Technique: 1. Sit on a chair with both feet on the floor. 2. Take a slow, deep breath through your nose. Hold for 2 counts. 3. To breathe out, open your mouth and make a "huff" sound in your throat. 4. Huff 2 to 3 times as you breathe out. 5. Relax for a few seconds. 6. Repeat the steps as needed. ## Techniques to Aid in Mobilizing Secretions - In addition to cough and huff, there are techniques that aid in mobilizing secretions. - Some of the frequently used techniques are the 3 techniques of the conventional chest physiotherapy (Percussion, Vibration and postural drainage). ## Percussion - Percussion, sometimes referred to as chest clapping, is a traditional approach for mobilization and loosening of retained secretions from airways so they are removed by suctioning or expectoration. - The therapist rhythmically strikes the chest wall in a waving motion, using both hands alternately in sequence with the elbows partially flexed and wrists loose. - Ideally, the therapist should percuss the back and force over the localized area for 3 to 5 minutes to mobilize secretions. - Performed during inspiration and expiration. ### Preparation of Percussion 1. Place the patient in appropriate postural drainage positions. 2. Place a thin towel or hospital gown over patient's skin. 3. Adjust the level of the bed so that the therapist uses the proper body mechanics during the treatment. ### Precautions of Percussion: 1. Position the hand in the shape of cup with the fingers and thumb adducted, this position traps a cushion of air between the hand and chest wall. It is important to maintain this cupped position of the hand throughout the treatment with the rests arms and shoulders stair relaxed. 2. The sound of percussion should be hollow with the force applied to the chest wall from each hand should be equal. 3. Use the bell of stethoscope or the three middle fingers with the middle finger tended to percuss infants. 4. Percussion should not allowed over bony prominence or breast tissues of the patient. 5. One handed self-percussion can be used to the areas that can be reached comfortably. ### Disadvantages of Percussions: 1. Over fractures or osteoporotic bone. 2. Over tumor area. 3. If patient has pulmonary embolus. 4. If patient with conditions in which haemorrhage could happen. 5. Patients with decreased pain threshold. ## Vibration - Gentle vibratory movement performed against the thorax during expiration only. ### Aim: Mobilize secretions and assist cough ### Technique: The therapist places one hand flat against the thorax and the other hand above it or side by side with extended elbows and performs vibratory movement ### Criteria: High frequency, Low amplitude. ## Postural Drainage - A technique of clearing the air way secretions by placing the patient in various positions so that gravity will assist in the flow of secretions. - These positions are based on the anatomy of the tracheobronchial tree and are designed to drain specific areas of the lung. - Secretions are moved from affected bronchioles to larger bronchi and trachea where it can be coughed or suctioned out. ### Indications: 1. Prevent accumulation of secretions in patients with diseases associated with increased mucus production such as chronic bronchitis and cystic fibrosis. 2. Conditions that require prolonged bed rest. 3. Post-surgical patients who received general anaesthesia. 4. Patients who have Painful incisions that affect deep breathing and coughing. 5. Any patient who is on a ventilator and is stable enough to tolerate treatment. 6. Remove the secretions already accumulated in the lungs such as in the cases of COPD elderly people and artificial Airways. ### Preparation for PD: 1. Bronchodilators before PD may facilitate sputum mobilization. 2. An adequate intake of hot fluids decreases the viscosity of the secretions allowing easy mobilization. 3. In the ICU it is important to be familiar with multiple lines tubes and other devices attached to the patient. 4. Make sure there are enough Personnel to position the patient with as minimal stress to both the patient and the stuff as possible. 5. Have suction and Equipment ready to remove secretions from the artificial Airway of the patient's nasal cavity after treatment. 6. Tissues or cup must be available for the patient to expectorate secretions. 7. Loosen tight or bulky clothing the patients May wear lightweight shirt or gown. 8. Explain the treatment procedures to the patient. 9. Never administer PD directly after meals. ### Choose Times of a Day That Will Be of Benefit to the Patients: 1. A patient's cough tends to be very productive in the morning due to our situation from the night before. 2. In the early evening will clear. Prior to sleep and help the patients rest more easily. ### Frequency of the Treatments: Will depend on the pathology of the patient's condition. ### Copious Amounts of Sputum: From 2 to 4 times per day until lungs are clear. ### Maintenance: From 1 to 2 times per day to prevent further accumulation of secretions. ### If PD is used exclusively: - Each position should be maintained for 5 to 10 minutes. - If it is to be continued for longer, coordinating PD positioning with nursing care for skin pressure relief is mandatory. ### Percussion Vibration and Shaking: May be used in conjunction with PD positioning. ### If PD is used in conjunction with other techniques: - The time in each position may be decreased. - Total duration of PD treatment is 40 to 45 minutes. ### If the patient is alert: - He should be encouraged to take deep breaths and cough after each position if possible. ### Expectoration: - May not occur immediately after the treatment, but it may occur up to one hour later. ### The Patient's Effectiveness of the Treatment: - Is noted by noting the type, color, consistency and the amount of secretions produced. - After the session, auscultate over the segment that was drained and note change in breathing sounds, also check the symmetry of the chest wall expansion. ## Contraindications to PD: 1. Large amount of blood in sputum (severe haemoptysis). 2. Untreated acute conditions such as congestive heart failure, severe pulmonary oedema, large pleural effusion and pneumothorax. 3. Cardiovascular instability in cases of cardiac arrhythmia, severe hypertension or hypotension and recent myocardial infarction. 4. Recent neurosurgery, as the head down position may cause increased intracranial pressure. ## PD Techniques and Positions: ### Upper Lobes - Right and Left Lung | Segment | Position | Site of Percussion | Illustration | |---|---|---|---| | Apical | an upright position | vibration percussion or shaking is applied directly under the clavicle | | | Anterior | supine position | slightly over the nipple or just above the breast | | | Posterior | prone position or sitting and slightly leaning forward | Directly over the scapula | | ### Middle Lobe – Right Lung | Segment | Position | Site of Percussion | Illustration | |---|---|---|---| | Medial | lying on left side supported with pillows, leaning backward 45° & the bed raised about 30° from its lower end | | | | Lateral | lying on left side supported with pillows, leaning forward 45° & the bed raised about 30° from its lower end | directly under the right breast | | ### Lingula – Left Lung | Segment | Position | Site of Percussion | Illustration | |---|---|---|---| | Superior | lying on right side supported with pillows, leaning forward 45° & the bed raised about 30° from its lower end | | | | Inferior | lying on right side supported with pillows, leaning backward 45& the bed raised about 30° from its lower end end | directly under the left breast | | ### Lower Lobes - Right and Left Lung | Segment | Position | Site of percussion | Illustration | |---|---|---|---| | Apical | Prone position with pillows under his abdomen to flatten the back | applied directly below the scapula | | | Anterior | Supine position with pillows under knees. The bed raised 45° from lower end | over the lower portion of the ribs | | | Posterior | Prone position. The bed raised 45° from lower end | over the lower portion of the ribs | | | Lateral | Lying on the opposite side to be drained supported with pillows & leaning forward 45°. Bed raised 45° from lower end | Directly under the lateral aspect of the ribs of the rib cage of the drained side | | ### Lower Lobe Right Lung Only | Segment | Position | Site of Percussion | Illustration | |---|---|---|---| | Medial | Lying on right side, supported with pillows & leaning backward 45°. Bed raised 30° from lower end | Directly under the lateral aspect of the ribs of the rib cage of the drained side | | ## Active Cycle of Breathing Technique (ACBT) - Is one way to help you to clear sputum from your chest. - It is a set of breathing exercises that loosens and moves the sputum from your airways. - It is best to be taught ACBT by a physiotherapist. ### The ACBT Exercises: - Breathing control, deep breathing and huffing. - They are performed in a cycle until your chest feels clear. ### Breathing Control (Belly Breathing) - Gentle diaphragmatic breathing at normal tidal volumes for 5 to 10 seconds with relaxation of the upper chest and shoulders. ### Aim: To prevent bronchospasm. ### Position of the Patient: Patient should be in a relaxed sitting or reclined position. ### Order: 1. Breathe normally in through your nose, keeping your upper chest and shoulders relaxed. 2. Place one hand on your stomach and feel your belly move out as you breathe in and fall as you breathe out. 3. This controlled, gentle breathing relaxes the airways and brings more air into the lungs. Apply 3-5 belly breaths. ### Thoracic Expansion Exercises - Deep inhalation, approaching vital capacity, with relaxed exhalation (may be accompanied by percussion, vibration, or compression). ### Aim: 1. To help loosen secretions. 2. To improve the distribution of ventilation. 3. To provide the volume needed for FET. ### Order: 1. Next, starting with your diaphragm, take in a deep breath to fill your upper chest and expands your ribs. Hold it for 3 to 4 seconds, then let out air gently. This breath helps move the mucus. Apply 3-5 times. ### Forced Expiratory Techniques (Low Huff/High Huff/Cough) - FET are consisting of huffing and must be combined with breathing control. - Huffing is exhaling through an open mouth and throat instead of coughing. ### Aim: It helps move sputum up your airways so that you can clear it in a controlled way. ### Order: 1. Low huff: Take a normal-size breath using your diaphragm and hold it for 3 to 4 seconds. Exhale slowly and completely with your mouth open. It's like fogging a mirror. Do 3 low huffs. 2. High huff: Starting with your diaphragm, take the deepest breath you can and hold it for 3 to 4 seconds. Keep head up and mouth open as your produce a high speed, short huff. Do 3 high huff. 3. Cough: Cough out mucus. 4. Repeat the cycle 2-4 times as tolerated. ## Autogenic Drainage - Autogenic Drainage is a breathing technique that uses controlled breathing and minimal coughing to clear secretions from your chest. - It involves hearing and feeling your secretions as you breathe out and controlling the desire to cough until secretions are high up and easily reached with minimal effort. ### How Does Autogenic Drainage (AD) Work? - Autogenic drainage (AD) works by adapting your breathing and maximizing airflow within the airways to improve ventilation and clear sputum. - The breath out is like sighing, with the air moving out of the mouth as fast as possible, but not too hard, as this can result in wheezing (tight airways), which can trap sputum. ### Position of the Patient: - A relaxed, comfortable position in which breathing does not feel restricted & places one hand over the abdomen and the other over the chest. - (3-5) deep breaths where abdomen rises before the chest and long slow expiration is performed through an open mouth or pursed lips. ### 3 Phases of AD Technique: 1. **Unsticking** of mucus by low lung level breathing: Breathe as much air out of your chest as you can then take a small breath in, using your abdomen, feeling your breath at the bottom of your chest. You may hear secretions start to crackle. Resist any desire to cough. Repeat for 3-5 breaths. 2. **Collecting** the mucus in larger or mid-sized airways: As the crackle of secretions starts to get louder change to medium sized breaths in. Feel the breaths more in the middle of your chest. Repeat for 3-5 breaths. 3. **Evacuating** the mucus in the central airways is achieved by breathing at normal to high volumes: When the crackles are louder still, take long, slow, full breaths in to your absolute maximum. Repeat for 3-5 breaths. When mucus is felt in the larger, central airways, do 2-3 effective "Huff". ## Airway Clearance Devices - A large variety of airway clearance devices are commercially available. - Most airway Clearance oscillation devices (Acapella, Flutter, lung flute and others), which deliver OPEP (Oscillating positive expiratory pressure) are effort dependent. ### In Some Cases, Doctors or Respiratory Therapists Might Recommend We Use a Hand-Held Mechanism That Vibrates and Loosens the Mucus to Make It Easier to Cough Out. - These small devices vibrate when we breathe into them and are known by various names, such as "percussive airway devices," or "vibratory positive expiratory pressure (PEP) devices." - They use vibrations and air pressure to reduce the thickness of mucus. - Although the devices are used more commonly for individuals with Cystic Fibrosis and bronchiectasis, they are also used to help those of us with COPD who have difficulty getting rid of mucus. ### There Are a Number of Brands of PEP Devices on the Market. - They all require a prescription. - The most commonly recognized brands are Acapella, Flutter, RC-cornet, and Quake, although there are others. ### The Quake - Consists of a mouth piece integrated into the outer housing and a crank that interrupts air flow and allows the user to manually adjust the frequency of the vibration. - This allows a wider range of oscillation frequencies than other devices as the flutter. - When using the Quake, it's recommended to rotate the handle at a steady comfortable rate of about 1 to 2 rotations per second during exhalation. - Both the inhalation and exhalation rate and speed of handle rotation may be varied to produce ideal level of vibration in the lungs. - Quake may alter the rheology of mucous and increase the ciliary beat through stimulation of the ciliated epithelial cells. - The oscillation frequency of Quake (6-24Hz) is closer to the optimal frequency for secretion clearance. - The natural frequency of the ciliary beat is 11 to 15 Hz and if airflow oscillates at a similar frequency, this resonance may increase the amplitude of cephalad ciliary beat, which could in turn increase mucous transport. - As the Quake demonstrated a wide range of vibration frequencies which facilitates vibrations delivered to the airways, this translates more vigorous airway percussion and causes effective secretion loosening. ### Flutter - Is a hand-held device which is made of hardened plastic material. - It consists of mouth-piece at one end and stainless steel ball resting on the cone at the other end. - During the expiration through the flutter, the expiratory flow causes the steel ball up and down movement, creating an oscillatory positive expiratory pressure with a back transmission to the patient. - The flutter is small and easily manageable pocket device. ### The Vest System - Is a small medical device, employing (High Frequency Chest Wall Oscillation) HFCWO technology. - The system consists of an inflatable soft, flexible vest which is worn over the torso, and flexible plastic hoses attached to it that connect to an air pulse generator which produces and delivers the oscillating air pulses that rapidly inflates and deflates the vest, gently against the thorax, compressing and releasing the chest wall 5-20 times/second to create airflow within the lungs. - The vest air pulse generator was set at low pressures and frequency and then increased to the recommended pressure/frequency (optimum oscillating frequency of 13-15Hz) based on individual patient tolerance during the "tuning procedure," and a pressure setting to achieve a tight but comfortably snug fit. - These air pulses oscillate the chest and the vibrations reportedly cause transient flow increases in the airways, loosening mucus and producing cough like sheer forces. - Can be used while doing other things during treatment. - Recently, HFCWO therapy has been used in many diseases, such as cystic fibrosis, chronic obstructive pulmonary disease, thoracic trauma and bronchial asthma. - Improving lung function, safety, tolerability after using of the HFCWO has been reported in the treatment of these diseases. - HFCWO is associated with better comfort, compared to manual percussion of conventional physical therapy; despite the use of HFCWO equipment is high cost. ### Acapella - Device creates PEP and it has been proposed that positive expiratory pressure therapy creates a positive back pressure during expiration that splints open the peripheral airways, temporarily increases lung volume and allowing air to move behind the obstructed lung segments through collateral ventilation pathways. - Acapella generates oscillations 0-30Hz during expiration which further facilitates the mobilization of secretions. ### RC-Cornet - An oscillating physiotherapy device generating PEP are used to help in mucous clearance. ### Lung Flute - The Lung Flute is a new small self-powered audio device that belongs to the family of Oscillatory Positive Expiratory Pressure (OPEP) devices, which includes the Flutter and the Acapella. - When blown into with an exhalation vigorous enough to make the reed oscillate, the Lung Flute® generates a sound wave of 16 to 22Hz with an output of 110 to 115 dB using 2.5cms H2O of pressure. - This sound wave has the ability to travel down the tracheobronchial tree and vibrate tracheobronchial secretions. - This vibration enhances mucociliary clearance of the lower respiratory tract thereby resulting in the induction of sputum. - This functionality of the Lung Flute® has been applied to sputum induction for diagnostic testing. - People with COPD can use the Lung Flute® a small, self-powered, flute-shaped respiratory device, to generate sound waves that loosen respiratory secretions. - The user exhales vigorously into the device creating a sound wave that travels down the tracheobronchial tree where it vibrates lower respiratory tract secretions. - The vibration enhances mucociliary clearance and the removal of sputum. - Use of the Lung Flute has been associated with improvements in COPD symptoms and health status. - Lung Flute provided an adequate physiotherapy method to patients with AECOPD, helped sputum expectoration, contributes in stabilization or improvement of respiratory function, enhance patients' compliance and independence. - Assessment of severity of COPD and improvement with treatment modalities can be done with simple tests like dynamic exercise testing such as 6-MWT or with the administration of quality-of-life questionnaires (CAT).