AIRWAY CLEARANCE TECHNIQUES

THIS PRESENTATION INCLUDES VARIOUS TECHNIQUES FOR AIRWAY CLEARANCE LIKE COUGHING, SUCTION, AD, ACBT, ETC. IT IS MADE FOR LEARNING PURPOSE ONLY.

1. AIRWAY CLEARANCE TECHNIQUES BRONCHIAL HYGIENE TECHNIQUE/THERAPY DR.SAMIR JADAV (PT)

2. DEFINITION Bronchial hygiene therapy/techniques or airway clearance techniques is a variety of non-invasive techniques designed to improve gas exchange by helping to mobilize and remove secretions. GOALS To reduce tissue destruction To improve ventilation perfusion ratio (v/q). Decrease infection and illness. Improve quality of life.

3. CONTENTS COUGHING BREATHING EXERCISES POSTURAL DRAINAGE ACTIVE CYCLE OF BREATHING TECHNIQUE (ACBT) AUTOGENIC DRAINAGE (AD) POSITIVE EXPIRATORY PRESSURE (PEP) SUCTION HIGH FREQUENCY CHEST COMPRESSION (HFCC) MANUAL HYPERINFLATION

4. coughing A cough can either be a reflex or a voluntary action. Stages: 1) Adequate inspiration 2) Closure of glottis 3) Increase intrathoracic pressure 4) Expulsion (forceful expiration) Precautions: 1) Recent pneumonectomy 2) Aneurysm 3) Raised ICP 4) Recent eye surgery

5. Breathing exercises Glossopharyngeal breathing Diaphragmatic breathing Pursed lip breathing Segmental breathing

6. Postural drainage Percussion Vibration Shaking

7. acbt The active cycle of breathing involves three phases repeated in cycles. 1)Breathing control 2)Thoracic expansion 3)Forced expiratory technique This method encourages active participation of the patient. More effective when performed by patient alone as with aid with therapist.

8. PREPARATION OF PATIENT Treatment of two or three productive areas during one session may be tolerated by most patients. The patient is positioned or positions herself in a PD position/normal sitting to stimulate the drainage of a productive area of the lungs. A minimum of 10 mins in any productive position may be necessary to clear moderate amount of secretions. Patients after surgery or with minimal secrtions may nit require as much time and very ill patients may fatigue before optimal treatment is given.

9. Treatment technique

10. 1. Breathing control The patient is instructed to breathe in a relaxed manner using normal tidal volume. Upper chest and shoulders should remain relaxed. Lower chest and abdomen should be active. Period of breathe control between other phases is essential to prevent bronchospasm.

11. 2. Thoracic expansion exercise The emphasis during this phase is on inspiration. The patient is instructed to take 3-4 deep breathe to inspiratory reserve volume. Expansion of lung Decrease collapse of lung tissue

12. 2. Thoracic expansion exercise (cont..) The expiration is passive and relaxed. Chest percussion , shaking or vibration may be performed in combination with thoracic expansion.

13. 3. Forced expiratory technique This phase consist of huffing. A huff is a rapid, forced exhalation but not with maximal effort. 1 or 2 huffs performed at mid to low lung volume. Abdominal muscle contraction to produce forced exhalation. After surgery , the patient may be shown how to support the incision.

14. Indications of acbt Post surgical / pain. Chronic increased sputum production. Eg -chronic bronchitis, cystic fibrosis. Poor expansion. Sputum retention. Atelectasis. Bronchiectasis. Respi . Muscle weakness. Asthma. Mechanical ventilation. Increased breathing effort. Palpable secretions. Cystic fibrosis.

15. Contraindications of acbt Patients not spontaneously breathing. Unconscious patient. Patient unable to follow instructions. Agitated or confused.

16. Advantages of acbt Patient participates actively in secretion mobilization. Technique can be introduced as early as 3-4 years of age. It is adopted for patients with bronchospasm and acute exacerbation. Reduction in oxygen saturation caused by chest percussion may be avoided by ACBT.

17. PRECAUTIONS OF ACBT Inadequate pain control where needed. Bronchospam . Acute , unstable head , neck or spinal injury / surgery.

18. AUTOGENIC DRAINAGE It is a breathing technique that uses expiratory airflow to mobilize bronchial secretions. It is a self drainage method that is performed independently by the patient in the siting position. AD consists of 3 phases. Unsticking phase- loosen secretions in the peripheral airways.

19. AD (CONT..) 2) Collecting phase- moves secretions to central airways. 3) Evacuating phase- removal of secretions. This technique of airway clearance requires much patience and concentration to learn. So , not suitable for young children , ideal for adolescent or adult who prefers an independent method.

20. Preparation of patient Patient should be seated upright in a chair with a back support. Surrounding area should be free of distraction and provide good concentration. Upper airways (nose and throat) should be cleared of secretions by huffing or blowing nose. One hand should be placed on abdomen to feel the work of abdominal muscles and other hand placed on upper chest.

21. Treatment technique In all phases, inhalation should be done slowly, thgrough the nose if possible, using diaphragm or lower chest. A 2 to 3 seconds of breathe hold should follow, allowing collateral ventilation to get air behind the secretions. Exhalation should occur through mouth with the glottis open, causing the secretions to be heard. The vibrations of the mucus may also be felt with the hand placed on the upper chest.

22. Treatment technique (CONT..) High frequency means that the secretions are located in the small airways, low frequency means that the secretions have moved to the large airways. The Unsticking phase : Inspiration followed by deep expiration by contracting abdominal muscles. The collecting phase : Tidal volume breathing is than changed gradually from ERV towards the IRV. The evacuating phase : - The patient increases inspiration into the IRV. - Collected mucus can be evacuated by stronger expiration or a high volume huff.

23. Treatment technique (CONT..) Duration of each phase depends on the location of secretions. The duration of a session depends on the amount and viscosity of the secretions. An average treatment will be 30 – 45 minutes.

24. Phases of AD

25. Indications and contraindications Same as ACBT DISADVANTAGES Difficult to teach Takes more practice than others.

26. ADVANTAGES No equipment is required. Patient perform independently. Less effort required to expectorate which reduces stress on the pelvic floor. Doesn’t require PD position. Use in patients with hyperactivity.

27. POSITIVE EXPIRATORY PRESSURE (PEP) PEP creates a back pressure to stent the airways open during the exhalation and promotes collateral ventilation, allowing pressure to build up distal to the obstruction. A form of intermittent PEP is provided by a device called the flutter. This pipe like device provides : Positive expiratory pressure Oscillation of the airways Accelerated expiratory flow rates to loosen secretions and move them centrally.

28. PEP PEP is performed in the upright position and can be used during acute episodes as well as chronic pulmonary conditions. Children over 4 years may be instructed in technique. It may provide independent method of airway clearance in older children and adults. Equipment required for PEP : Flutter device A PEP mask

29. PEP T-tube One way valve Resistors of various sizes Manometer Nebulizer Supplemental oxygen

30. PEP Preparation of patient : The patient should be seated upright with elbows resting on atable . Use of mask may require securing the device with both hands. Flutter device : Pipe like device Mouthpiece

31. PEP High density steel ball Perforated plastic cover Circular cone

32. Treatment technique Inhale deeply and hold breath for 2-3 seconds. Place flutter in mouth as stiff possible. Exhale through flutter. Exhalation need to be forced. Best result depends on the speed of exhalation. Perform multiple exhalation through the flutter (usually 5 to 15) with breath hold to maximize mobilization of mucus.

33. After multiple performance, to precipitate coughing and mucus expectoration. Repeat entire sequence until mucus clear. Indications & contraindications : Same as ACBT.

34. SUCTION Suctioning is “the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place”. Suctioning – negative pressure applied within the airway. It can be done via nose, mouth or via tracheostomy tube. Indication : Patient has an inability to clear secretions - Ineffective or absent cough - Evidence of retained secretions in upper airway

35. suction A sample of sputum is to be obtained for lab analysis purposes. Hazards : Hypoxia Tracheal/bronchial mucosal trauma Cardiac arrest Pulmonary haemorrhage Cardiac dysrhythmias Pulmonary atelectasis Bronchospasm Hypotension/hypertension Elevated ICP Interruption of mechanical ventilation

36. suction Equipment : Vaccum source with adjustable regular suction jar Stethoscope Sterile and clean gloves Suction tube/catheter Connector Clear protective goggles, apron and mask Sterile normal saline Ambu bag Suction tray

37. Type of suctioning 1) Open suction system : - regularly using system in the intubated patient. 2) Closed suction system : - This is used to facilitate continuous mechanical ventilation and oxygenation during the suctioning.

38. Mode of entry : The suction catheter may be introduced into respiratory tract via - Nose ( Nasopharangeal ) - Mouth ( Oropharangeal ) - Tracheotomy tube Contraindications : Risk of infection Acute bleeding/trauma Hypoxia Cardiac arrythmias Atelectasis Acute facial, head or neck injury Bronchospasm

39. High frequency chest compression ( hfcc ) It consist of a vest linked to an air-pulse generator. HFCC works by differential airflow, the expiratory flow rate is higher than the inspiratory flow rate, allowing mucus to transport from peripherals to central. At the end of session, patient instructed to cough or huff to remove secretion.

40. Manual hyperinflation Used on patients with endotracheal or tracheostomy tube that can attached to manual ventilation bag. One caregiver/therapist uses bag to hyperinflate lungs with slow, deep inspiration and short inspiratory pause, provide quick release to allow rapid exhalation. Second caregiver/therapist applies shaking/vibration at very beginning of exhalation to mobilize secretions.