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Bronchial Hygiene Th
Bronchial Hygiene Therapy RCP111 Unit I
| Question | Answer |
|---|---|
| What is the definition of Bronchial Hygiene Therapy? | The use of "noninvasive" airway clearance techniques designed to help mobilize and remove secretions and improve gas exchange. |
| What are the primary mechanisms used for secretion removal? | 1. Patent airway (adventitia supports) 2. Functioning mucocilliary escalator. 3. Effective coughing |
| What are the four stages of cough? | Irritation Inspiration Compression Expulsion |
| What are the main irritation stimuli? | 1) inflammatory- (infection) 2)chemical- Cigarette Smoke 3) Mechanical- Foreign body (ice) 4)Thermal-Cold air |
| What are factors that affect secretion removal? | 1) Instability of the airway 2)Dyskinesia of the cilia 3)Volume and character of secretions 4)Impaired cough |
| A cough may be impaired by disruption in irritation. | Anesthesia narcotics CNS depression |
| A cough may be impaired by disruption to inspiration. | Pain Neuromuscular dysfunction Pulmonary or abdominal restriction |
| A cough may be disrupted to do disruption in compression. | Laryngeal nerve damage Artificial Airway Abdominal muscle weakness Surgery |
| A cough may be disrupted due to disruption of expulstion. | Airway compression Airway obstruction Abdominal Muscle weakness |
| Inspiration | Inhale 1-2 L of gas in 1-2 seconds |
| Compression | Glottis closure and compression. The pressure goes up in plural space. Consists of glottis and alveolar pressure. |
| Expulsion | 500 mph. Occurs when the glottis opens A very high pressure gradient and it shears off mucus on the bronchial tree. |
| What are factors that impair cilia? | Dehydration Temperature Toxins Smoking |
| Abnormal airway clearance can result in. | 1)Retained secretions- infections 2) restricted airflow- increased work of breathing. Airtrapping and overdistention (ball valve effect) 3)Complete or partial airway obstruction (atelectasis) |
| What are causes of impaired mucociliary clearance in intubated patients? | ET or tracheostomy tube Tracheobronchial suction Inadequate humidification High Fi02 values Drugs Underlying pulmonary disease |
| What are some other things that can cause abnormal airway clearance? | tumors and foreign bodies skeletal abnormalities bronchospasm ET Tubes |
| What is the goal of bronchial hygiene therapy? | To help mobilize and remove secretions, with the ultimate aim to improve gas exchange and reduce the work of breathing. |
| What are the three indication for bronchial hygiene therapy? | Treating acute conditions. Chronic Conditions that may cause copious secretions. Disorders associated with retention of secretions. |
| Treating acute conditions | copious secretions acute respiratory failure with retained secretions. Acute lobar atelectasis V/Q abnormalities caused by unilateral lung disease. |
| Chronic conditions that may cause copious secretions. | Cystic fibrosis Bronchiectasis Ciliary dyskinetic syndromes chronic bronchitis |
| Disorders associated with retention of secretions. | Acute disease immobile patients exacerbations of COPD Chronic disease cystic fibrosis neuromuscular disorders. |
| Respiratory failure is | increased C02 Decreased O2 |
| Ventilitory failure | increase on C02 only. |
| The need for bronchial hygiene is assessed by | the medical record and the patient |
| medical record | history, admission for upper abdominal or thoracic surgery, presence of artificial airway, chest radiograph, pulmonary function testing, ABG values |
| Patient | always assess cough! Posture, muscle tone, effectiveness of cough, sputum production, breathing pattern, general physical fitness, breath sounds, vital signs. |
| Sputum production must exceed what for bronchial hygiene therapy to significantly improve secretion removal? | 25 to 35 ml/day (can fit in a shot glass) |
| What are the methods of bronchial hygiene? | chest physiotherapy coughing techniques PAP therapy High Frequency Compression/Ossillation Mobilization Exercise |
| Chest physiotherapy includes | postural drainage percussion vibration |
| coughing techniques include | directed cough huff coughing forced expiratory technique active cycle of breathing autogenic drainage manually assisted coughing mechancial insufflation/exsufflation |
| PAP therapy includes | CPAP PEP |
| High frequencey compression/opscillation includes | flutter intrapulmonary percussive ventilation vest |
| Chest physiotherapy involves | the use of gravity and mechanical energy to help mobilize secretions. |
| Positionining/Postural drainage | Patient positional so that secretions drain from specific segments and lobes of the lung toward gravity-dependent central airways, where it can be more easily removed with cough or suction. |
| Each posture is held for how long? | Between 20-30 minutes |
| External manipulation of the thorax includes? | percussion and vibration |
| Percussion | involves rapid clapping, cupping or striking of the external thorax directly over the lung segment drained with either cupped hands or mechanical device. |
| Vibration | involves manually pressing in the direction that the ribs and soft tissues of the chest moves during exhalation. |
| External manipulation of the thorax last for how long? | Generally 5 minutes |
| When is vibration performed? | Don one exhalation |
| What are indication for positioning/postural drainage? | Inability to change body positon. Poor oxygenation with unilateral lung disease. Potential for atelectasis Presence of artificial airway. Difficulty with secretion clearance Evidence of retained secretions/ foreign body diagnosis of pulmonary diseas |
| What are indications for percussion/vibration? | The need for additional manipulation of the chest to assist in secretion removal. |
| Contraindications for all positions. | ICP > 20 mmHG Unstabilized head/neck injury Active hemoptysis/hemmorhage Spinal surgery or injury empyema bronchopleural fistula pulmonary edema pleural effusion PE Age, confused or anxious rib fractures/wounds |
| Contraindications for Trendelenburg position | ICP>20 or potential for high ICP uncontrolled hypertension distended abdomen esophageal surgery hemoptysis aspiration risk |
| Percussion/vibration contraindications | subcutaneous air recent epidural recent skin grafts or flaps burns/open wounds pace maker TB |
| Percussion/vibration contraindications | lung contusion bronchospasm oseomyelitis of the ribs/osteoporosis coagulopathy chest wall pain recent feedings |
| CPT hazards and complications | hypoxemia increased ICP acute hypertension pulmonary hemorrhage pain or injury to chest wall vomiting or aspiration bronchospasm dysrhythmias |
| What are CPT considerations? | choose appropriate position maintain 5 to 10 minutes per position continually observe patient avoid percussion and vibration over bony structures or breast tissue. |
| What are more CPT considerations | mechanical percussors available avoid percussion and vibration directly on the skin. some patients may require oxygen during therapy. Wait 2 hours past meals schedule around pain medication if necessary. |
| What might coughing techniques require? | Splinting of surgical sites |
| How do you assess the effectiveness of therapy? | Decrease in sputum vitals improve x-ray improves sputum changes color improved breath sounds lab work improved oxygenation |
| Directed cough indications include | lung disease COPD Diseases that air trap |
| Directed cough is not possible with? | obtunded, paralyzed, and uncooperative patients. Some restrictive disorders and advanced COPD |
| Direct cough is? | A delioberate maneuver that is taught, supervised and monitored. It aims to mimic the features of an effective spontaneous cough in patients who are too weak to produce a a forceful expiratory maneuver. |
| What might limit the success of directed cough? | fear of pain or pain systemic dehydration thick,tenacious secretions artificial airways use of CNS depressents |
| What is essential in directed cough? | Good patient teaching. |
| What are the three most important aspects involved in patient teaching? | Instruction on proper positioning insturction on breathing control exercises to strengthen expiratory muscles. |
| How do you do directed cough? | Assume a sitting position with one shoulder rotated inward and the head/spine slightly flexed. Teach the patient to inspire slowly and deeply through the nose. Have patient bear down against the glottis while like you would with a bm. |
| What should individuals do between coughs with directed cough? | diaphramatic breathing |
| What is the Huff cough/forced expiratory technique (FET) | Sharp forced exhalations without glottis closure. |
| FET is | a low pressure cough that prevents collapse in COPD patients. It is a modification of the direct cough |
| During FET | there are one or two forced expirations of middle to low lung volume without closure of the glottis. They should phonate during the cough and follow up with diaphramatic breathing |
| FET goal is to | clear secretions w/less change in pleural pressure to help prevent distal airway collapse/bronchospasm. |
| Why might FET not be possible with intubated patients? | Increased airway resistance |
| The active cycle of breathing is | a modified FET that combines breath control, thoracic expansion control and FET |
| Step one of active cycle: repeated cycle of breathing | gentle diaphramatic breathing at normal tidal with relaxation of upper chest/shoulders. |
| Step two of active cycle: Thoracic expansion | Deep inhalation w/relaxed exhalation. the relaxation prevents bronchospasm. |
| Step three of active cycle: FET | Huff coughing technique which is shap forced exhalation without glottis closure. |
| Active Cycle of Breathing considerations | Can accompany with percussion and vibration. Sitting position and beneficial with postural drainage. It is not for children less than 2 or extremely ill |
| Autogenic Drainage | Staged breathing at different lung volumes. |
| Autogenic draining was developed when? | In the 1960's for the asthmatic patient. It is a modification for directed cough and can be done by themselves if trained. |
| How does it work? | Diaphramatic breathing mobilized secretions by varying lung volumes an expiratory airflow in 3 distinct phases. |
| First Phase: Unsticking | moves secretions from smaller airways. Patient should prevent cough |
| Second Phase: COllecting | moves secretions from to moderate airways. Patient should prevent cough. |
| Third Phase: Evavcuation | Moves secretions into large airw |
| Maunually assisted cough | Also known as Quad Cough. Manually assisted cough for the weak, paralyzed and patients with neurological disorders. |
| what is the thrusting for in a manually assisted cough? | It increases pressure in the thoracic cage |
| The mechanical insufflator-exsufflator | Is the artificial cough machine. It augments tidal volumes. It inflates the lungs with positive pressure followed by a negative pressure to stimulate cough. |
| The artificial cough machine was developed when? | In the 1950's to help polio patients clear secretions. |
| How is the insufflator-exsufflator used now? | It is used on patients with neuromuscular disorders. |
| How does it work? | It delivers a positive pressure at 30 to 50 cm H20 for 1 to 3 seconds. Then removes at -30 to -50 cm H20 for 2-3 seconds. |
| How can the artificial cough machine be used? | It can be used with an artificial airway or mask |
| Positive expiratory pressure is also know as | PEP therapy |
| What is PEP therapy? | A device which stimulates pursed-lip breathing. Prolonged exhalation against resistance stabilizes smaller airways, pushing secretions to larger airways. |
| PEP has an expiratory pressure of | 10-20 cm H20 expiratory pressure |
| It is important to be aware of high PEP levels with obstructive diseases because | it can cause further air trapping. |
| More facts about PEP | can be used with a nebulizer. Was originated in Denmark. Is not useful in Chronic bronchitis and kids less than 3. |
| What is a flutter valve? | Hand held device which combines high frequency oscillations and PEP therapy. |
| What does the flutter valve do? | It shears mucus from airway wall and facilitates mucus flow, prevents airway closure. |
| Active exhalations do what? | Transmits ossillation back down the airway. |
| You cannot do what with the flutter valve? | Hook up aerosol therapy but that can be done with the acapella? |
| What is intrapulmonary percussive ventilation (IPV)? | Mechanical device which provides miniburst of positive pressure to the airway via a mouthpiece. |
| How many miniburst a minute? | 100-225 p/minute. The duration of pressure is controlled by therapy. |
| When was IPV approved? | 1993 |
| How does it work? | It's believed to open areas of atelectasis and deliver air behind mucus plugs helping to dislodge them. |
| What does the modern IPV version do? | It utilizes a small volume nebulizer type of system. High frequency intrapulmonary percussive nebulizer. |
| What is the vest? | It consists of an inflatable vest which covers the thorax and is attached with hoses to an air-pulse generator. |
| How does the vest work? | It rapidly inflates and deflates from 5 to 25 times per second, creating a bias flow that moves secretions to the trachea. |
| What is a bias flow? | A continues flow out. |
| What does the vest also do? | It improves gas-liquid interactions decreasing viscosity of mucus. |
| What is the major factor contributing to retention of secretions? | Immobility |
| What helps improve overall aeration and ventilation? | Frequent position changes and exercises. |
| What must you consider with mobilization and exerecise? | Fatigue SOB Decrease in Sp02 |
| What are some pulmonary exercises? | Diaphragmatic breathing inspiratory resistance training. |
| What is inspiratory resistance training? | A device that acts like an inspiratory muscle resistor. |
| What are other modalities that aid in secretion removal but are not bronchial hygiene therapy? | SVN therapy Mucoactive agents Bland aerosol therapy suctioning |
Created by:
kparkerlehman
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