RTH 131Unit 1 Bronchial Hygiene Therapy

What are the contraindications of PEP Therapy?

Active Hemoptysis Untreated pneumothorax Patients unable to tolerate increase WOB Hemodynamic instability Esophageal surgery

What are the contraindications of Autogenic Drainage?

Acute Respiratory Failure Asthma Attack Acute episode of Bronchitis

What are the contraindications of Forced Expiratory Technique?

Acute Respiratory Failure Asthma Attack Acute episode of Bronchitis

Describe how an external percussive device operates?

Are either electrically or pneumatically powered Eliminates therapist fatigue, especially when large areas of the chest need to be done or several patient Particularly helpful with neonates because chest often smaller than therapist hand Most have knobs to adjust frequency, some have knobs to adjust the intensity

Describe Autogenic Drainage?

Autogenic drainage uses diaphragmatic breathing to mobilize secretions by varying lung volumes and expiratory airflow in three phases. Autogenic drainage is beneficial to those with immobilized secretions especially Cystic Fibrosis Autogenic drainage is difficult to teach

What are the indications of Autogenic Drainage?

Autogenic drainage uses diaphragmatic breathing to mobilize secretions by varying lung volumes and expiratory airflow in three phases. Is beneficial to those with immobilized secretions especially Cystic Fibrosis Unfortunately, autogenic drainage is difficult to teach

What are indications for Positive Expiratory Pressure Therapy (PEP Therapy)?

Best used with patients with excessive sputum production [ >30 ml/day ] Example: Cystic fibrosis Reduce air trapping for patients with small airway disease Aid in mobilization of secretions Optimize bronchodilator therapy

What are Postural Drainage cautions and contraindications?

Cautions •Never leave patient alone when performing Postural Drainage •Avoid having the patient in a head down position while coughing strenuously Contraindications •Unstable cardio-vascular system •Unstable pulmonary system •Unstable post-operative status •Untreated Tuberculosis

Purpose/indications of directed cough?

Clear secretion from central airways Atelectasis Post-op preventative In conjunction with bronchial hygiene for cystic fibrosis, bronchiectasis, necrotizing infection, spinal cord injury To obtain sputum sample for analysis

Briefly describe the technique for performing percussion therapy?

Cupped hand position, thumb next to fingers, wrist relaxed Use one or both hands rhythmically over area of chest Percuss each area 3-5 minutes May use "cups" designed for this method in size appropriate for patient

What are the Postural Drainage Indications?

Diagnosis of Cystic Fibrosis, Bronchiectasis Auscultation reveals retained secretions Inability to change body positions Weak cough

Explain Directed Cough?

Directed cough is a deliberate maneuver which is: • taught • supervised and • monitored

List Postural Drainage assessment of need:

Excessive sputum production Effectiveness of cough History of problems treated successfully with postural drainage Change in Vital Signs When there is only one lung that needs to be drained always place patient with bad lung up and good lung down. This helps to improve oxygenation of the good lung by using gravity to deliver blood flow to the well ventilated lung EXCEPTION: Lung contusion or abscess Postural drainage should be scheduled before or 1-1 1/2 hours after tube feedings or meals

How should the RT perform percussion on a child or infant?

Gentle with cupped hand

Briefly describe the technique for performing vibration therapy?

Hand Positions: • Parallel • Hand over hand Instruct patient to take deep breath Vibrate chest while they EXHALE

Describe 2 hazards or contraindications for vibration?

Hazards Soft tissue trauma, rib trauma

What is the contraindication of MI-E?

Head, neck or spinal injuries Increased ICP

Name two absolute contraindications for Postural Drainage?

Head/neck injuries until stabilized Active hemorrhage with hemodynamic instability

What are the hazards and complications of PEP Therapy?

Increased WOB that may lead to hypoventilation and hypercapnia Skin breakdown and discomfort from the mask Increased ICP Vomiting

Describe the indications for percussion?

Indicated when secretions are difficult to dislodge

What is Intrapulmonary Percussive Ventilation?

Intrapulmonary Percussive Ventilation (IPV) is used as an airway clearance technique Pneumatic device used to deliver pressurized gas to the respiratory tract at a rate of 300 to 400 cycles per minute

What are the four phases of the cough?

Irritation Inspiration Compression Expulsion

Describe a flutter valve device and it's principle of operation?

It is a controlled vibration system which produces positive expiratory pressure and cyclic oscillation of the airways during expiration. The Flutter device is a portable device designed to help clear mucus in patients with lung disorders. The device consists of a tube based on oscillations of a steel ball during expiration through a pipe-type device.

Indications for BHT:

Lung conditions resulting in an increased difficulty in mobilizing pulmonary secretions Acute respiratory failure with the presence of retained secretions V/Q abnormalities from retained secretions Ineffective cough Cilliary dysfunction/ cilliary dyskinesia Producing > 30 ml/day of secretions ( about 1fl. oz. or a full "shot" glass)

What are the indications for Mechanical Insufflation-Exsufflation?

Mechanical Insufflation-Exsufflation (MI-E) was previously used to help patients with Polio clear secretions It is now geared toward patients with neuromuscular disorders

How should the RT administer CPT to a post-op patient with chest tubes?

Modified techniques

Describe how the RT should instruct the patient to perform PEP therapy?

Patient needs to take a breath that is slightly larger than normal Expiratory pressure should be set between 10 - 20 cmH2O in order to create an I:E ratio of 1:3 to 1:4 Have patient perform 10 to 20 breaths and then do 3 coughs Perform PEP for no more than 20 minutes

Who are these patients?

Patients with acute secretion clearance problem. Examples: •Severe pneumonia with copious secretions •Acute lobar atelectasis •Evidence of significant infiltrates and/or consolidation with hypoxemia present •Cystic Fibrosis •Bronchiectasis •Sometimes used in Chronic Bronchitis when large volumes of secretions become problematic

What does PEP therapy stand for?

Positive Expiratory Pressure Therapy (PEP Therapy)

What is the purpose of percussion?

Purpose: To help dislodge secretions by causing a coarse vibration through the chest Can be done with hands or mechanical percussors Indicated when secretions are difficult to dislodge

Directed Cough Technique:

Sitting position Inhale deeply Breath hold 3-5 sec. Expulsive cough

List 4 contraindications/hazards of percussion?

Soft tissue trauma Rib cage trauma Hemoptysis Pulmonary emboli (fresh) Pulmonary effusion Metastatic conditions Tuberculosis (untreated) ***Untreated pneumothorax - only true contraindication

List each body positions and indications?

Supine-Patient lying on their spine • Best for post-craniotomy Semi-Fowlers • Sitting up with back at 45o angle Best for patients who are: Hypoxic Obese Pulmonary edema Note: If patients back cannot be bent, use reverse Trendelenberg Trendelenberg • Body straight, head down • Used for shock or low blood pressure • Do not use for fresh CVA or craniotomy Lateral Flat • Lying flat, on side • Best position to prevent aspiration in the vomiting patient or the unconscious

What are the indications of Forced Expiratory Technique?

The Forced Expiratory Cough (FET) is also known as the Huff Cough Helps clear secretions with less change in pleural pressure and prevents collapsation of the bronchioles Very useful in patient whose airways are prone collapse during normal coughing -Emphysema -Cystic Fibrosis -Bronchiectasis

List Postural Drainage Hazards/Complications?

Vomiting and aspiration Bronchospasm Hypoxemia Dysrhythmias

When would it be appropriate to discontinue CPT?

-Clear breath sounds -Ambulating well -Strong cough -Clear CXR

When could one discontinue bronchial hygiene therapy?

Assessment made after every treatment and therapy modified to only those areas still effected

How should the RT evaluate the progress of a patient receiving CPT? Name 6

Auscultation Inspection -color, chest expansion Cough Toleration Vital signs Chest x ray

When would vibration therapy be indicated for a patient?

Indication: Use as adjunct to postural drainage and percussion

How should the effectiveness of bronchial hygiene be assessed?

Inspection •Color •Chest expansion Cough •sputum characteristics •sputum amount Toleration •Fatigue •WOB •Pain Vital Signs •Pulse •Respirations •BP •ECG •Monitor Chest film •Improved pattern

Explain Mechanical insufflation-exsufflation Therapy?

Mechanical insufflation-exsufflation is a therapy in which the device (the Cough Assist In-Exsufflator is the only currently marketed insufflation-exsufflation device) gradually inflates the lungs (insufflations), followed by an immediate and abrupt change to negative pressure, which produces a rapid exhalation (exsufflation), which simulates a cough and thus moves secretions cephalad. Mechanical insufflation-exsufflation is used with patients with neuromuscular disease and muscle weakness due to central nervous system injury.

What are the different types of Bronchial Hygiene Methods?

Postural drainage Percussion (Chest Physical Therapy) Vibration Coughing Techniques: •Directed cough •Normal cough •Forced expiratory technique (Huff cough) •Active Cycle of Breathing •Autogenic Drainage •Mechanical insufflation-Exsufflation PEP Therapy (Positive Expiratory Pressure) •High frequency compression /Oscillation •Flutter valve/Acapella •Intrapulmonary percussive ventilation

What are the goals of BHT (Bronchial Hygiene Therapy)?

Prevent the accumulation of pulmonary secretions Improve the mobilization of retained secretions Improve the distribution of ventilation Decrease airway resistance

List assessments for BHT?

Review Chart (esp. Progress Notes) Interview Patient Perform Physical Assessment Review Pulmonary Function Testing Results Review Radiology Reports Remember the problem may be: • a single lobe • limited to one lung or • involve both lungs

What is Postural Drainage?

Simply using GRAVITY to help move secretions to larger airways Positions chosen by lobe and segment to be drained May be used with percussion and/or vibration

If patient is known to have aspirated in a specific position

place in opposite position for percussion and drainage. Example: Patient lying down on right when aspirated. Turn to left and place head down.