Bronchial Hygiene Therapy RCP111 Unit I
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| 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.
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| What are the primary mechanisms used for secretion removal? | 1. Patent airway (adventitia supports)
2. Functioning mucocilliary escalator.
3. Effective coughing
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| What are the four stages of cough? | Irritation
Inspiration
Compression
Expulsion
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| What are the main irritation stimuli? | 1) inflammatory- (infection)
2)chemical- Cigarette Smoke
3) Mechanical- Foreign body (ice)
4)Thermal-Cold air
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| 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
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| A cough may be impaired by disruption in irritation. | Anesthesia
narcotics
CNS depression
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| A cough may be impaired by disruption to inspiration. | Pain
Neuromuscular dysfunction
Pulmonary or abdominal restriction
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| A cough may be disrupted to do disruption in compression. | Laryngeal nerve damage
Artificial Airway
Abdominal muscle weakness
Surgery
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| A cough may be disrupted due to disruption of expulstion. | Airway compression
Airway obstruction
Abdominal Muscle weakness
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| Inspiration | Inhale 1-2 L of gas in 1-2 seconds
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| Compression | Glottis closure and compression.
The pressure goes up in plural space.
Consists of glottis and alveolar pressure.
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| Expulsion | 500 mph.
Occurs when the glottis opens
A very high pressure gradient and it shears off mucus on the bronchial tree.
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| What are factors that impair cilia? | Dehydration
Temperature
Toxins
Smoking
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| 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)
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| 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
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| What are some other things that can cause abnormal airway clearance? | tumors and foreign bodies
skeletal abnormalities
bronchospasm
ET Tubes
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| 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.
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| 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.
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| Treating acute conditions | copious secretions
acute respiratory failure with retained secretions.
Acute lobar atelectasis
V/Q abnormalities caused by unilateral lung disease.
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| Chronic conditions that may cause copious secretions. | Cystic fibrosis
Bronchiectasis
Ciliary dyskinetic syndromes
chronic bronchitis
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| Disorders associated with retention of secretions. | Acute disease
immobile patients
exacerbations of COPD
Chronic disease
cystic fibrosis
neuromuscular disorders.
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| Respiratory failure is | increased C02
Decreased O2
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| Ventilitory failure | increase on C02 only.
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| The need for bronchial hygiene is assessed by | the medical record and the patient
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| medical record | history, admission for upper abdominal or thoracic surgery, presence of artificial airway, chest radiograph, pulmonary function testing, ABG values
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| Patient | always assess cough!
Posture, muscle tone, effectiveness of cough, sputum production, breathing pattern, general physical fitness, breath sounds, vital signs.
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| 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)
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| What are the methods of bronchial hygiene? | chest physiotherapy
coughing techniques
PAP therapy
High Frequency Compression/Ossillation
Mobilization
Exercise
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| Chest physiotherapy includes | postural drainage
percussion
vibration
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| coughing techniques include | directed cough
huff coughing
forced expiratory technique
active cycle of breathing
autogenic drainage
manually assisted coughing
mechancial insufflation/exsufflation
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| PAP therapy includes | CPAP
PEP
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| High frequencey compression/opscillation includes | flutter
intrapulmonary percussive ventilation
vest
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| Chest physiotherapy involves | the use of gravity and mechanical energy to help mobilize secretions.
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| 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.
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| Each posture is held for how long? | Between 20-30 minutes
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| External manipulation of the thorax includes? | percussion and vibration
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| Percussion | involves rapid clapping, cupping or striking of the external thorax directly over the lung segment drained with either cupped hands or mechanical device.
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| Vibration | involves manually pressing in the direction that the ribs and soft tissues of the chest moves during exhalation.
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| External manipulation of the thorax last for how long? | Generally 5 minutes
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| When is vibration performed? | Don one exhalation
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| 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
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| What are indications for percussion/vibration? | The need for additional manipulation of the chest to assist in secretion removal.
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| 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
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| Contraindications for Trendelenburg position | ICP>20 or potential for high ICP
uncontrolled hypertension
distended abdomen
esophageal surgery
hemoptysis
aspiration risk
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| Percussion/vibration contraindications | subcutaneous air
recent epidural
recent skin grafts or flaps
burns/open wounds
pace maker
TB
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| Percussion/vibration contraindications | lung contusion
bronchospasm
oseomyelitis of the ribs/osteoporosis
coagulopathy
chest wall pain
recent feedings
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| CPT hazards and complications | hypoxemia
increased ICP
acute hypertension
pulmonary hemorrhage
pain or injury to chest wall
vomiting or aspiration
bronchospasm
dysrhythmias
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| 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.
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| 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.
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| What might coughing techniques require? | Splinting of surgical sites
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| 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
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| Directed cough indications include | lung disease
COPD
Diseases that air trap
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| Directed cough is not possible with? | obtunded, paralyzed, and uncooperative patients.
Some restrictive disorders and advanced COPD
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| 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.
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| What might limit the success of directed cough? | fear of pain or pain
systemic dehydration
thick,tenacious secretions
artificial airways
use of CNS depressents
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| What is essential in directed cough? | Good patient teaching.
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| What are the three most important aspects involved in patient teaching? | Instruction on proper positioning
insturction on breathing control
exercises to strengthen expiratory muscles.
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| 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.
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| What should individuals do between coughs with directed cough? | diaphramatic breathing
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| What is the Huff cough/forced expiratory technique (FET) | Sharp forced exhalations without glottis closure.
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| FET is | a low pressure cough that prevents collapse in COPD patients. It is a modification of the direct cough
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| 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
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| FET goal is to | clear secretions w/less change in pleural pressure to help prevent distal airway collapse/bronchospasm.
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| Why might FET not be possible with intubated patients? | Increased airway resistance
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| The active cycle of breathing is | a modified FET that combines breath control, thoracic expansion control and FET
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| Step one of active cycle: repeated cycle of breathing | gentle diaphramatic breathing at normal tidal with relaxation of upper chest/shoulders.
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| Step two of active cycle: Thoracic expansion | Deep inhalation w/relaxed exhalation. the relaxation prevents bronchospasm.
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| Step three of active cycle: FET | Huff coughing technique which is shap forced exhalation without glottis closure.
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| 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
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| Autogenic Drainage | Staged breathing at different lung volumes.
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| 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.
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| How does it work? | Diaphramatic breathing mobilized secretions by varying lung volumes an expiratory airflow in 3 distinct phases.
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| First Phase: Unsticking | moves secretions from smaller airways. Patient should prevent cough
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| Second Phase: COllecting | moves secretions from to moderate airways. Patient should prevent cough.
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| Third Phase: Evavcuation | Moves secretions into large airw
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| Maunually assisted cough | Also known as Quad Cough.
Manually assisted cough for the weak, paralyzed and patients with neurological disorders.
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| what is the thrusting for in a manually assisted cough? | It increases pressure in the thoracic cage
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| 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.
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| The artificial cough machine was developed when? | In the 1950's to help polio patients clear secretions.
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| How is the insufflator-exsufflator used now? | It is used on patients with neuromuscular disorders.
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| 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.
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| How can the artificial cough machine be used? | It can be used with an artificial airway or mask
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| Positive expiratory pressure is also know as | PEP therapy
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| What is PEP therapy? | A device which stimulates pursed-lip breathing. Prolonged exhalation against resistance stabilizes smaller airways, pushing secretions to larger airways.
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| PEP has an expiratory pressure of | 10-20 cm H20 expiratory pressure
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| It is important to be aware of high PEP levels with obstructive diseases because | it can cause further air trapping.
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| 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.
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| What is a flutter valve? | Hand held device which combines high frequency oscillations and PEP therapy.
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| What does the flutter valve do? | It shears mucus from airway wall and facilitates mucus flow, prevents airway closure.
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| Active exhalations do what? | Transmits ossillation back down the airway.
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| You cannot do what with the flutter valve? | Hook up aerosol therapy but that can be done with the acapella?
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| What is intrapulmonary percussive ventilation (IPV)? | Mechanical device which provides miniburst of positive pressure to the airway via a mouthpiece.
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| How many miniburst a minute? | 100-225 p/minute. The duration of pressure is controlled by therapy.
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| When was IPV approved? | 1993
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| How does it work? | It's believed to open areas of atelectasis and deliver air behind mucus plugs helping to dislodge them.
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| What does the modern IPV version do? | It utilizes a small volume nebulizer type of system. High frequency intrapulmonary percussive nebulizer.
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| What is the vest? | It consists of an inflatable vest which covers the thorax and is attached with hoses to an air-pulse generator.
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| 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.
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| What is a bias flow? | A continues flow out.
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| What does the vest also do? | It improves gas-liquid interactions decreasing viscosity of mucus.
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| What is the major factor contributing to retention of secretions? | Immobility
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| What helps improve overall aeration and ventilation? | Frequent position changes and exercises.
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| What must you consider with mobilization and exerecise? | Fatigue
SOB
Decrease in Sp02
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| What are some pulmonary exercises? | Diaphragmatic breathing
inspiratory resistance training.
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| What is inspiratory resistance training? | A device that acts like an inspiratory muscle resistor.
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| What are other modalities that aid in secretion removal but are not bronchial hygiene therapy? | SVN therapy
Mucoactive agents
Bland aerosol therapy
suctioning
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