airway clearance technique and devices ppt

pep therapy for bronchiectesis

1. AIRWAY CLEARANCE TECHNIQUE AND DEVICES By: Dr. Humaira Hanif (PT) Consultant-Pulmonary Rehabilitation MCRD, Metro Hospitals and Heart Institute

2. Belli et al, 2021

3. The following conditions may be associated with difficulty in mobilizing airway secretions. Difficulty in effectively mobilizing secretions can result from a combination of factors: Cystic fibrosis Bronchiectasis Atelectasis Respiratory muscle weakness Mechanical ventilation Neonatal respiratory distress syndrome Indications

4. Contraindications The use of the device is not recommended for the following conditions: Patients unable to tolerate the increased work of breathing, Intracranial pressure (ICP) > 20 mm Hg, Hemodynamic instability (blood pressure instability), Recent facial, oral, or skull surgery or trauma, Acute sinusitis, Epistaxis (bleeding nose), Esophageal surgery, Nausea, Active hemoptysis (bleeding from lungs), Untreated pneumothorax (untreated collapsed lung), Known or suspected tympanic membrane rupture or other middle ear pathology. Coppolo et al, 2021 Frownfelter 5 th edition

5. Postural Drainage Postural drainage is a technique in which different positions are assumed to facilitate the drainage of secretions from the bronchial airways. Gravity helps to move the secretions to the trachea to be coughed up easily. The goal of postural drainage is to help drain mucus from the affected lobes into the larger airways of the lungs so it can be coughed up more readily. After determining the lobe of the lung to be treated by auscultation and chest x-ray, position the patient in the appropriate position, If postural drainage is used exclusively, each position should be maintained for 5 to 10 minutes, if tolerated, or longer when focusing on a specific lobe. if percussion and vibration are performed while the patient is in each PD position, 3 to 5 minutes is sufficient.

6. Percussion under the clavicle Percussion above right scapula Percussion over nipple Percussion above right scapula Percussion above left scapula Percussion under the breast Percussion below the scapula Percussion under the breast

7. Percussion Percussion, sometimes referred to as chest clapping, is a traditional approach to secretion mobilization. A rhythmical force is applied with a caregiver’s cupped hands against the thorax, over the involved lung with the aim of dislodging or loosening bronchial secretions from the airways so they may be removed by suctioning or expectoration. This technique is performed during both the inspiratory and expiratory phases of breathing. Percussion is used in postural drainage positions for increased effectiveness and may also be used during ACBT

8. Vibration and Shaking The techniques of vibration and shaking are on opposite ends of a spectrum. Vibration involves a gentle, high-frequency force, whereas shaking is more vigorous in nature. Vibration is delivered through a sustained co-contraction of the caregiver’s upper extremities to produce a vibratory force while applying pressure to the chest wall over the involved lung segment. Shaking is similar in application to vibration, and is described as a bouncing maneuver, sometimes referred to as “rib springing,” supplying a concurrent, compressive force to the chest wall. Like percussion, vibration and shaking are used in conjunction with PD positioning

9. Active cycle of Breathing Technique The Active Cycle of Breathing Techniques (ACBT) is an active breathing technique performed by the patient to help clear sputum out of the lungs. Phases involves :

10. Autogenic Drainage 1.Unsticking phase 2 . Collecting phase 3. Evacuating phase The rationale behind this technique is that shear forces are generated, through the exhaled airflow to the various lung volumes, which should reduce the adhesion of the mucus, detach the secretions from the bronchial walls and transport them from the peripheral airways to the proximal ones Belli et al, 2021

11. Intrapulmonary Percussive Ventilation An apparatus known as the Phasitron is the functional component in the intrapulmonary percussive ventilator which provides high-frequency impulses during inspiration, while positive expiratory pressure is maintained throughout passive exhalation While the patient is breathing normally, the device provides the patient with high-frequency mini bursts of air (50–550 cycles per minute), thus creating an internal vibration (or percussion) in the lung. IPV can be used either as a single treatment via facemask or mouthpiece to spontaneously breathing patients or via artificial airway as an adjunct therapy for patients undergoing mechanical ventilation The IPV device can also provide ventilatory support in patients with neuromuscular disease and in patients with COPD The pressure generated is between 10 and 30 cm of H2O. Belli et al ,2021, Pulm Ther (2022)

12. HFCO High-frequency chest wall oscillation, also referred to as high-frequency chest compression, consists of an inflatable vest linked to an air-pulse generator. HFCWO works by differential airflow (i.e., the expiratory flow rate is higher than the inspiratory flow rate), allowing the mucus to be transported from the periphery to the central airways for expectoration. This device provides oscillation of the entire thoracic cavity at varying frequencies (5 to 25 Hz). The lung volume expired tends to increase with lower frequencies (less than 10 to 12 Hz), whereas the flow rates tend to increase with higher frequencies (12 to 20 Hz). Continuous aerosolized medication or saline administered concurrently may assist with secretion mobilization

13. PPP Expiratory Pressure(PEP)P PEP includes a one-way breathing valve and adjustable level of expiratory resistance that creates a back pressure to stent the airways open during exhalation. It is theorized that PEP breathing reinflates collapsed alveoli by allowing air to be redistributed through collateral channels-the pores of kohn and the lambert canals It allowing pressure to build up distal to the obstruction and promoting the movement of secretions toward the larger airways. Reference: Frownfelter 5 th edition, Demchuk et al, 2021 POSITIVE EXPIRATORY PRESSURE

14. Precautions The use of PEP for airway clearance carries an increased risk for pneumothorax. Bronchodilator premedication should be considered when applying PEP in patients who show clinical or physiological signs of airway hyperreactivity. The increased airflow produced by the huff cough, as in the ACBT, may aggravate bronchospasm. Additionally, Hietpas90 cautions that the movement of secretions into the larger airways by the huff cough may precipitate spontaneous explosive coughing

15. Oscillatory PEP Devices OPEP devices produce positive expiratory pressure with the addition of oscillations as the patient inspires a slightly larger than normal tidal volume and actively exhales through the device. Fleet et al, 2017

16. Physiology Basic principles of OPEP involve an expiratory oscillating air-flow brake, thereby inducing 2 main physiological effects. Moreover, turbulent air-flow spikes that are elicited reduce mucus viscoelasticity and promote its detachment and cephalad movement. Hence, air-flow oscillations facilitate mucociliary clearance Poncin et al, 2020

17. TheraPEP The TheraPEP device consists of a mouthpiece and an expiratory resistor that can accommodate many levels of expiratory flow. It comes with a detachable pressure monitoring port and indicator to show 10 to 20 cm of H2O. The TheraPEP can accommodate a mask of different sizes

18. Acapella The Acapella consists of a mouthpiece attached to the body of the unit that uses a counterweighted plug and magnet to create airflow oscillation and a dial for expiratory resistance at the other end It comes in several models: green for patients who can maintain an expiratory flow of 15 L/min or more, blue for patients whose expiratory flow rate is less than 15 L/min.

19. Acapella

20. Flutter This pipelike device consists of a steel ball, a plastic cone, a perforated cover, and a mouthpiece. Exhaled air causes the steel ball to roll up and down the cone causing airflow vibration. The PEP maintained by the Flutter (5 to 35 cm of H2O) prevents dynamic airway compression and improves airflow acceleration. The full effects of the vibration induced by the Flutter (6 to 20 Hz) may be received by changing the angle of the device.

21. Aerobika The Aerobika OPEP device has a compact handheld design through which the patient exhales via its mouthpiece against a manually adjusted variable resistance created by a one-way valve housed within a cartridge located inside the chamber housing It is approximately 11 cm in length from the mouthpiece to the rear of the device, 10.5 cm deep and 3 cm wide. There are five resistance settings adjustable by means of an externally mounted lever-dial extending from the chamber and located towards the base of the device beneath the mouthpiece .

22. OPEP Devices are NOT all the Same The mechanism of action for devices can differ, which may result in different patient outcomes. 1,2,3 Variations in positive pressure oscillations may impact therapeutic effectiveness 4 It is important to consider the clinical evidence that supports efficacy in each device. Usability / “patient friendly” factors are important to consider as these may affect adherence to the therapy. Aerobika* OPEP Device AirPhysio † Flutter † Acapella † 1 Tse, J., et al . Int J Chron Obstruct Pulmon Dis. 2020 Oct 19;15:2527-2538. 2 Suggett, J. et al. CHEST 2017. 3 Suggett, J., et al . Assessment of two oscillating positive expiratory pressure (OPEP) devices: how do the differing mechanisms of action impact lab performance. British Thoracic Society Winter Meeting 2022. 4 Van Fleet H, et al. Evaluation of Functional Characteristics of 4 Oscillatory Positive Pressure Devices in a Simulated Cystic Fibrosis Model. Respiratory Care 2017;62(4):451-458. * trademarks and registered trademarks of Trudell Medical International (TMI). † trade-marks of the respected companies.

23. Resistance setting Although appropriate PEP values described are those ranging between 10 and 20 cm H2O, higher PEP levels are at least as effective to produce physiological meaningful effects as long as they do not induce excessive respiratory muscle fatigue. The optimal PEP value was then determined as 10 cm H2O. Conversely, increasing the resistance level decreased oscillation amplitude in all devices with the exception of the Aerobika , where oscillation amplitude increased from low to medium resistance and then remained stable at high resistance setting . Increasing the resistance level consistently improved the performance of each device. All gravity-dependent devices had excellent performance characteristics at medium and high resistance settings. Aerobika and Acapella devices generated lower oscillation frequency values under simulated expiratory waveforms representing significant air-flow obstruction, so their therapeutic efficacy may be mitigated in patients with more advanced lung disease severity . Poncin et al, 2020

24. A. Stage 1:Adequate inspiration B, Stage 2: Glottal closure, Stage 3:building up of intrathoracic and intraabdominal pressure C, Stage 4:glottal opening and expulsion COUGH AUGMENTATION TECHNIQUE

25. Clear verbal direction and coordination between the person helping and the patient is essential to techniques to be successful. 1. PIace the heels of hands underneath the ribs as illustrated. 2. As the patient attempts to cough push inwards and upwards. Place one forearm across the patient’s upper abdomen with a hand curved around the opposite side of the chest. Other hand is placed on the near side of the chest. As the patient attempts to cough, push simultaneously inwards and upwards with your forearm, squeezing and stabilising with the other hand. MANUALLY ASSISTED COUGH TECHNIQUES

26. Tetraplegic version of self-assisted cough in a long sitting position. A, Maximizing the inspiration phase. B, Maximizing the expiration, or coughing, phase Paraplegic version of self-assisted cough in a long sitting position . A, Inspiration. B, Expiration SELF ASSISTED COUGH TECHNIQUE

27. Mechanical devices Cough assist (or Mechanical Insufflator/ Exsufflator ) The Mechanical Insufflator/ Exsufflator (I/E) is a device that produces changes in the airflow inside the bronchial tree in such a way as to vicariate the cough. MI-E devices such as the CoughAssist ™ (Philips Respironics Corp, Millersville, PA) alternate the delivery of positive (inflation) and negative pressures (rapid deflation) delivered to the patient via an oronasal interface, mouthpiece, endotracheal or tracheostomy tube (Bach et al 2013). It is used mainly in patients with neuromuscular pathologies or respiratory muscle deficiency, who have a hypo valid or ineffective cough.

28. GUIDELINES AND RECOMMENDATIONS

29. British Thoracic Society Guideline for Bronchiectasis in Adults

30. Research evidences Tse et al, 2020 Patients receiving the Aerobika OPEP device, compared to the Acapella device, had lower rates of subsequent severe disease exacerbation and all-cause inpatient admission. This suggests that Aerobika OPEP device may be a beneficial add-on to usual care and that OPEP devices may vary in clinical effectiveness

31. This study demonstrates that adding tools for airways clearance (both T-PEP as well O-PEP) to medical therapy can help the management of severe COPD patients improving dyspnea, lung function, exercise capacity and reducing exacerbations (only for T-PEP) better than the best bronchodilator therapy alone

32. Overall, our results provide evidence that a short treatment period with oPEP , in particularly the Aerobika device, on top of concomitant medication is able to improve airway geometry and redistribute the airflow, consequently influencing drugs’ deposition patterns in CO Abbreviation: IAD –Internal airflow distribution Leemans et al, 2020

33. Cost-Effectiveness of the Aerobika ® Oscillating Positive Expiratory Pressure Device in the Management of Chronic Obstructive Pulmonary Disease Exacerbations in Canada Thanh et al, 2019 For a patient after 1 year, the use of the Aerobika ® device would save $694 in healthcare costs and produce 0.04 more in quality-adjusted life years (QALYs) in comparison with no positive expiratory pressure (PEP)/OPEP therapy

34. It has been reported that sputum-producer patients were shown to have improvements in a number of other parameters, namely forced vital capacity (FVC), 6-minute walk test, Saint George’s Respiratory Questionnaire (SGRQ) and Patient Evaluation Questionnaire (PEQ). Additionally, patients were also shown to benefit from Aerobika in terms of HRQoL : 64% and 62% COPD patients with chronic bronchitis had a clinically-meaningful improvement in SGRQ and COPD Assessment Test (CAT) after using this device for three to four or eight weeks, respectively.8

35. The findings of ACTs demonstrate a reduction in the impact of cough, improvement in health-related quality of life and reduction in the risk of exacerbations in adults with bronchiectasis Cortina et al, 2023

36. JOURNAL/ PUBLICATION YEAR/AUTHOR TITLE METHODOLOGY FINDINGS Pediatr Pulmonol . 2017/Impact factor- 2.85 F. Van Ginderdeuren , PT, MSc, Y. Vandenplas et al Effectiveness of Airway Clearance Techniques in Children Hospitalized With Acute Bronchiolitis Design: One hundred and three children were randomly allocated to receive one 20-min session daily, either assisted autogenic drainage (AAD), intrapulmonary percussive ventilation (IPV), or bouncing (B) (control group), ninety-three finished the study. Outcome measures: Mean time to recovery in days was our primary outcome measure. The impact of the treatment and the daily improvement was also assessed by a validated clinical and respiratory severity score (WANG score), heart rate (HR), and oxygen saturation (SaO2 Conclusion: Both ACT’s reduced significantly the length of hospital stay compared to no physiotherapy.

37. JOURNAL/ PUBLICATION YEAR/ AUTHOR TITLE METHODOLOGY FINDINGS International Journal of COPD/2018/ Impact factor- 3.157 Antonello Nicolini1 Bruna Grecchi2 Maura Ferrari-Bravo Cornelius Barlascini Safety and effectiveness of the high-frequency chest wall oscillation  vs intrapulmonary percussive ventilation in patients with severe COPD. Chest physiotherapy is an important tool in the treatment of COPD. Intrapulmonary percussive ventilation (IPV) and high-frequency chest wall oscillation (HFCWO) are techniques designed to create a global percussion of the lung which removes secretions and probably clears the peripheral bronchial tree. We tested the hypothesis that adding IPV or HFCWO to the best pharmacological therapy (PT) may provide additional clinical benefit over chest physiotherapy in patients with severe COPD. The two techniques improved daily life activities and lung function in patients with severe COPD. IPV demonstrated a significantly greater effectiveness in improving some pulmonary function tests linked to the small bronchial airways obstruction and respiratory muscle strength and scores on health status assessment scales (BCSS and CAT) as well as a reduction of sputum inflammatory cells compared with HFCWO.