Chapter 43 Airway Clearance Therapy (ACT)

List three conditions that may cause internal obstructions or external compression of the airway lumen. A. (blank) B. (blank) C. (blank)

A. Foreign body: External B. Tumor: External C. Secretions, bronchospasm, inflammation: Internal

How long should you wait to schedule postural drainage after a patient eats? Why?

2 hr after meals or tube feedings to prevent aspiration and gastroesophageal reflux.

What is the minimum range of time for effective application of postural drainage therapy?

3 to 15 min

List two absolute and two relative contraindications to turning A. Absolute 1. 2. B. Relative 1. 2.

A. Absolute 1. Unstable spinal cord injuries 2. Traction of arm abductors B. Relative 1. Severe diarrhea 2. Marked agitation (increased ICP, drop in BP, hypoxia, and arrhythmias)

Give a recommended intervention for each of the complications of postural drainage listed below. Complication A. Hypoxemia B. Increased ICP C. Acute hypotension D. Pulmonary bleeding E. Vomiting F. Bronchospasm G. Cardiac dysrhythmias

A. Administer oxygen (O2), or raise the FiO2. Reposition patient. B. Stop. Restore patient position. Consult physician. C. Stop. Restore patient position. Consult physician. D. Stop. Restore position. Give O2. Get physician NOW! E. Stop. Suction. O2. Position. Airway. Physician ASAP. F. Stop. Position. O2. Request bronchodilator from physician. G. Stop. Position. Give/increase O2 and contact physician.

Describe the two cycles of MI-E in terms of time and pressure. A. Inspiratory B. Expiratory

A. An inspiratory pressure of 30 to 50 cm H2O is maintained for 1 to 3 sec. B. Pressure is abruptly reversed to -30 to -50 cm H2O for 2 to 3 sec.

Describe the two well-documented preventive, or prophylactic, uses of bronchial hygiene therapy.

A. Body positioning and patient mobilization may be effective to prevent retained secretions in acutely ill patients. B. Exercise and postural drainage, percussion, and vibration have been shown to be effective prophylaxis for patients with cystic fibrosis.

Describe the three repeated cycles of the ACB technique A. B. C.

A. Breathing control B. Thoracic expansion C. FET or huff cough

List four acute conditions in which bronchial hygiene is indicated

A. Copious secretions B. Acute respiratory failure with retained secretions C. Acute lobar atelectasis D. Unilateral lung disease

List two obstructive lung diseases that result in excessive secretion of mucus and impairment of normal clearance.

A. Cystic fibrosis B. Bronchiectasis

Describe the two general approaches to oscillation.

A. External-HFCC B. Internal-flutter

Compare the effects of full and partial airway obstruction caused by retained secretions. A. Full obstruction, or (blank) plugging results in (blank) B. Partial obstruction increases (blank) of breathing and leads to air (blank)

A. Mucus; atelectasis and shunt B. Work; trapping and poor

List four neurologic or musculoskeletal conditions that impair cough

A. Muscular dystrophy B. ALS C. Myasthenia gravis D. Poliomyelitis (and cerebral palsy, to name a few)

List five factors that must be documented after each postural drainage treatment:

A. Position(s) used B. Duration C. Patient tolerance D. Subjective and objective indications of effectiveness (amount of sputum) E. Adverse reactions

Give a brief explanation of the significance of each factor listed below Factor: A. History B. Airway C. Chest radiograph D. Breath sounds E. Vital signs

A. Pulmonary problems known to increase sputum; also, for patients with upper abdominal or thoracic survey who have high risk due to COPD, obesity, age, and duration of the procedure. B. Presence of artificial tracheal airway C. Atelectasis or infiltrates D. Decreased, crackles, rhonchi E. Fever, tachypnea, and tachycardia

Describe the four benefits or advantages of the flutter valve as a secretion management tool.

A. Readily accepted by patients B. Inexpensive C. Fully portable D. Self-administered

Positive airway pressure is popular way to help mobilize secretions. What art the four indications for PAP adjuncts according to the AARC Clinical Practice Guidelines?

A. Reduce air trapping in asthma and COPD. B. Mobilize retained secretions in cystic fibrosis and chronic bronchitis. C. Prevent or reverse atelectasis. D. Optimize delivery of bronchodilators in patients receiving bronchial hygiene.

Standard directed cough must frequently be modified. Give three examples of types of patients who may need modified cough techniques.

A. Surgical B. COPD C. Neuromuscular disorders

Postural drainage therapy includes up to four components, not counting cough. What are they?

A. Turning B. Postural drainage C. Percussion D. Vibration

How long does it take to determine the effectiveness of postural drainage? If therapy is effective, how often should you reevaluate in the hospital? In the home? A. How long? B. Reevaluate hospital patients? C. Reevaluate home patients

A. Up to 24 hr B. 2 to 3 days for other hospitalized patients C. Every 3 months for home

What type of monitoring is essential regardless of the equipment used to deliver positive airway pressure to help mobilize secretions?

Actual airway pressures, not set or intended pressures. Use a manometer at some point to see what is really going on.

What should you specifically monitor when exercising patients with lung problems?

Assess for fatigue and O2 desaturation.

Active patient participation is an important part of which of the following procedures? 1. Postural drainage 2. Directed cough techniques 3. Airway sucioning 4. Positive expiratory Pressure (PEP) A. 1 and 2 only B. 2 and 4 only C. 1 and 3 only D. 3 and 4 only

B. 2 and 4

An RT is preparing a patient with bronchiectasis for discharge. Which of the following techniques would be most appropriate for self-administered therapy in the home? A. IPPB B. Flutter C. Suctioning D. Percussion and Postural drainage

B. Flutter

Describe percussion and vibration as techniques to loosen secretions. Are they really effective?

Both involve application of mechanical energy to the chest wall. In theory, percussion jars loosen the stuck secretions, while vibration moves secretions upward during exhalation. Effectiveness is unclear.

Discuss bronchial hygiene therapy for chronic lung conditions. How much sputum needs to be produced daily for the therapy to be useful? What are three typical diseases that we treat?

Bronchial hygiene therapy for chronic conditions has proved to be effective if copious sputum production is present. Examples include cystic fibrosis, bronchiectasis, and, in some patients, chronic bronchitis. In general, sputum production must exceed 25 to 30 ml/day for bronchial hygiene therapy to be significantly helpful.

In explaining the therapeutic goal of PEP therapy to a patient, it would be most appropriate to say: A This will help prevent pneumonia B. This will increase your intrathoracic pressure C. This will help you cough more effectively D. This will prevent atelectasis

C. "This will help you cough more effectively."

A COPD patient with left lower lobe infiltrates is unable to tolerate a head-down position for postural drainage. What action would you recommend? A Perform the drainage with the bed raised B Do not perform the therapy until 2 hours after the last meal C Administer a bronchodilator prior to a postural drainage D Notify the physician and suggest a different secretion management technique.

D. Notify the physician and suggest a different secretion management technique.

During the initial treatment , a PEP device is set to deliver a pressure of 15cm H2o. The patient complains of dyspnea and can maintain exhalation only for a short period of time. Which of the following should the RT recommend? A. Decrease the PEP level to 10 cmH20 B. Increase the PEP level to 20 cm H20 C. Discontinue the PEP therapy D. Add a bronchodilator to the PEP therapy

Decrease the PEP level to 10 cm H2O.

How does hydration affect secretion clearance? What respiratory therapy modality can augment hydration of the airway?

Dehydration or lack of humidification results in thicker secretions. Cool, bland aerosol therapy may enhance clearance in some patients.

Describe the benefits of adding exercise as a mobilization technique.

Exercise enhances sputum clearance. It also improves aeration and ventilation perfusion relationships. Finally, exercise may improve fitness, self-esteem, and quality of life.

A 60 year old professor who had a colon resection for an intestinal tumor is receiving incentive spirometry to help expand his lungs. You asked to assess the patient for retained secretions. Auscultation reveals course rhonchi bilaterally in the upper lobes. A few scattered crackles are heard in the bases. SpO2 on room air is 94%. The patient states he is unable to cough up anything "because it hurts too much" What type of cough would you teach this patient?

Huff coughing (FET) could be tried if directed cough with splinting is not effective.

Describe the way IPV delvers gas to the airway

IPV gives minibursts of pressurized gas at 100 to 225 cycles/min. During the bursts, a positive airway pressure is maintained. The patient or therapist controls the duration of the percussive burst.

What is the primary problem with autogenic drainage?

It is difficult to teach/learn.

What special form of cough assistance is used with patients who have neuromuscular conditions?

Manually assisted cough-exerting pressure on the lateral ribs or epigastrium

A 75 year old woman with bronchiectasis states she coughs up cups of awful mucus every day. She is admitted with a diagnosis of pneumonia. As you provide the therapy, you find out that the patient is a widow who lives alone. She takes albuterol treatment via SVN when she has difficulty breathing. What therapy alternatives could you recommend for home use?

PEP or flutter

List the four phases of the normal cough Give examples of impairments of each Phase A. B. C. D. Impairments A. B. C. D.

Phase A. Irritation B. Inspiration C. Compression D. Expulsion Impairments A. Anesthesia, CNS depression, narcotics B. Pain, neuromuscular dysfunction, restriction C. Laryngeal damage, artificial airway, abdominal D. Airway compression, obstruction, abdominal weakness

A 75 year old woman with bronchiectasis states she coughs up cups of awful mucus every day. She is admitted with a diagnosis of pneumonia. What therapy is indicated while this patient is in the hospital?

Postural drainage, percussion/vibration; PEP is an alternative.

A patient is receiving postural drainage in the Trendelenberg position. The patient begins to cough uncontrollably. What actions should the RT take at this time? A. Encourage the patient to use a huff cough B. Administer oxygen therapy C. Administer a bronchodilator D. Raise the head of the bed

Raise the head of the bed. (Option A is an alternative answer.)

A patient is lying on her left side, turned one-quarter toward her back, with the head of the bed down. What division of the lung is being drained? A.Lateral segments of the right lower lobe B. Right middle lobe C. Left upper lobe, lingular segments D. Posterior segment of the right upper lobe

Right middle lobe

How would you position a patient (ideally) for an effective cough?

Sitting upright, head slightly flexed, with arms and feet supported; if the patient cannot sit up, at least raise the head of the bed.

A 60 year old professor who had a colon resection for an intestinal tumor is receiving incentive spirometry to help expand his lungs. You asked to assess the patient for retained secretions. Auscultation reveals course rhonchi bilaterally in the upper lobes. A few scattered crackles are heard in the bases. SpO2 on room air is 94%. The patient states he is unable to cough up anything "because it hurts too much" What technique could you use to decrease the pain associated with cough in a postoperative patient?

Splinting

What is splinting?

Supporting the area of an incision (abdominal or thoracic)

Describe the forced expiratory technique (FET)

The FET or huff cough has the patient take a moderately large breath then exhale rapidly while saying "huff." The backpressure generated assists in preventing bronchiolar collapse. This enhances secretion removal, particularly in patients with obstructive lung disease.

Compare manual and mechanical methods of percussion and vibration.

The ultimate selection of the best way to percuss or vibrate may be patient preference. Machines do not get tired and deliver very consistent therapy. Manual percussion by a skilled practitioner may be preferred.

Your text mentions never clapping directly over the spine or clavicles. Can you think of other areas you should not clap over.

This is not made really clear in the text; however, you should only clap over the ribs. You should not clap over or close to incisions, organs (kidney, abdomen), or women's breasts.

ACBT

active cycle of breathing therapy

AD

autogenic drainage

CPT

chest physical therapy

CPAP

continuous positive airway pressure

EPAP

expiratory positive airway pressure

FET

forced expiratory technique

HZ

hertz

HFCWC

high-frequency chest wall compression

ICP

intracranial pressure

IPV

intrapulmonary percussive ventilation

MI-E

mechanical insufflation-exsufflation

PEP

positive expiratory pressure

PDPV

postural drainage, percussion, and vibration