Basecamp: Airway Clearance Techniques

Match the following with their appropriate position: Superior Segments of the Right Lower Lobe

Prone

What are the indications for Airway Clearance Techniques?

Retained secretions in the central airways Prophylaxis against post operative pulmonary complications Obtain sputum for diagnostic analysis Difficulty clearing secretions Atelectasis caused by or suspected of being caused by mucus plugging

Percussion

Rhythmic clapping or striking of the thorax with a cupped hand or mechanical percussor directly over the lung segment being drained lasting for several minutes

Match the following with their appropriate position: Apical Segments of the Right Upper Lobe

Sitting

Match the following with their appropriate position: Anterior Segments of the Right Upper Lobe

Supine

Match the following with their appropriate position: Anterior Basal Segments of the Right Lower Lobe

Supine with the foot of the bed elevated

Anterior segment Right and Left Upper Lobes

The Patient is in supine with the bed horizontal. Percussion and vibration are performed below the clavicles.

Vibration

The application of a fine, tremulous action on the chest wall over the lung segment being drained in the direction the ribs move during exhalation and is performed during exhalation.

Apical segments right and left upper lobes

The patient is in a sitting position, leaning back 30-40 degrees. Percussion and vibration are performed above the clavicles.

Posterior basal segments left and right lower lobes

The patient is in prone with the foot of the bed elevated 18 inches. Percussion and vibration are performed over the lower ribs on the left and right side

Anterior basal segments left and right lower lobes

The patient is in supine with the foot of the bed elevated 18 inches. Percussion and vibration are performed over the lower ribs on the left and right side

Superior segments left and right lower lobes

The patient is prone with the bed horizontal. Percussion and vibration are performed below the inferior border of the left and right scapulae.

Posterior Segment right upper lobe

The patient is turned 1/4 from prone on the left side with the bed horizontal and the head and shoulders raised on a pillow. Percussion and vibration are performed around the medial border of the right scapula.

Posterior Segment Left Upper Lobe

The patient is turned 1/4 from prone on the right side with the head of the bed elevated 45 degrees and the head and shoulders raised on a pillow. Percussion and vibration are performed around the medial border of the left scapula.

Lingula left upper lobe

The patient is turned 1/4 from supine on the right side with the foot of the bed elevated 12 inches. Percussion and vibration are performed over the left chest between the axilla and the left nipple.

Right Middle Lobe

The patient is turned 1/4 supine on the left side with the foot of the bed elevated 12 inches. Percussion and Vibration are performed over the right chest between the axilla and the right nipple.

(T/F) Uncontrolled HTN is a contraindication for the Trendelenburg Position

True

What are the contraindications for the trendelenburg drainage position?

Uncontrolled HTN Distended Abdomen Esophageal Surgery Recent gross hemoptysis related to lung carcinoma Uncontrolled airway at risk for aspiration

Describe the procedure for a cough:

inhale maximally, close glottic and hold breath for 2-3 seconds; contract expiratory muscles to produce increased intrathoracic pressure against glottis; cough sharply 2-3 times through slightly open mouth

What are the Precautions/Contraindications for Airway Cycle Breathing?

-Splinting post-op incisions to achieve adequate expiratory force -Bronchospasm or hyperactive airways

What are the precautions/contraindications for performing a Directed Cough or Huff?

- Inability to control possible transmission of infection by droplets • Elevated intracranial pressure or known intracranial aneurysm • Reduced coronary artery perfusion ( e.g. acute myocardial infarction) • Acute, unstable head/neck/spine injury •Untreated pneumothorax • Osteoporosis • Flail chest • Acute abdominal pathology, abdominal aortic aneurysm, hiatal hernia, pregnancy

What are the precautions/contraindications for performing High Frequency Airway Oscillations?

- Patient tolerance of increased work of breathing - Intracranial pressure >20mmHg - Hemodynamic instability - Recent facial, oral, skull surgery/trauma - Acute sinusitis/noseblood - Known or suspected tympanic membrane rupture or other middle ear pathology -Untreated pneumothorax

What are the three types of Airway Cycle Breathing?

-Breathing control (gentle, relaxed breathing) - Thoracic expansion exercises ( 3-4 deep, slow, relaxed inhalations to inspiratory reserve w/ passive exhalation that may be combined w/ chest percussion, vibration, or shaking - Forced expiratory technique (1-2 huffs at mid-low lung volumes w/ the glottis open unto expiratory reserve volume; brisk adduction of arms may be added to self-compress thorax)

When using an oral airway oscillation device, how many exhalation repetitions would be the most desirable before the two large exhalations? 5 15 25 35

15 When using an oral airway oscillation device such as the Flutter or Acapella, 10-20 active exhalations should be performed through the device followed by two large exhalations and finally a huff or cough to clear secretions.

Match the following with their appropriate percussion region: Apical Segments

Above the clavicular region

What are the different types of airway clearance techniques?

Active Cycle of Breathing Autogenic Drainage Directed Cough and Huffing High Frequency Airway Oscillation Postural Drainage, percussion, and vibration

What are the precautions/contraindications for Percussion or Vibrations?

All those for drainage positioning. Subcutaneous emphysema Recent epidural Recent skin grafts on thorax Burns, open wounds and skin infections on thorax Recently placed transvenous or subcutaneous pacemaker Suspected pulmonary TB Lung contusion Bronchospasm Osteomyelitis of the ribs Osteoporosis Complaint of chest wall pain

What are the expected outcomes of airway clearance?

Easier clearance of secretions and increased volume of secretions during and after treatments. Improved breath sounds Increase in sputum production Change in vital signs Resolution or improvement of atelectasis and localized infiltrates observed with chest X ray Improvement in arterial blood gss values or O2 Sat

Match the following with their appropriate percussion region: Superior Segments of the lower Lobes

Below the inferior border of the scapulae

Match the following with their appropriate percussion region: Right Middle Lobe

Between the axilla and the right nipple

Which of the following is a contraindication to active cycle breathing? Bronchospasms Osteoporosis Atelectasis Retained Secretions

Bronchospasms

What is the procedure for Percussion in postural Drainage?

Cover the skin. Rhythmically strikes the chest witha cupped hand for two to three minutes per lung segment

What are the contraindications for all postural drainage positions?

Intracranial pressure > 20 mmHg Head and Neck injury until stabilized Active hemorrhage Recent spinal surgery Active Hemoptysis Empyema Bronchopleural fistula Pulmonary edema associated with CHF PE Confused or anxious patients who do not tolerate position changes Rib fracture (with or without flail chest) Surgical wound or healing tissue

Autogenic Drainage (AD)

Modification of directed coughing, beginning with low lung volume breathing, inspiratory breath holds, and controlled exhalation and progressing to increased inspired volumes and expiratory flows

Match the following with their appropriate percussion region: Anterior basal Segments

Over the lower ribs

What is the procedure for Vibration in postural Drainage?

Place one hand on top of the other over the affected area or one hand on each side of the rib cage. Vibrate as the patient exhales by tensing the muscle of the hands and arms while applying moderate pressure downward. Encourage pt to cough or huff two to three times following virbation

What may post surgical patients need to do in order to perform a Directed Cough?

Post-surgical pt may need to splint chest or abdomen by applying pressure over incision w/ a pillow or blanket roll

What is the procedure for High-frequency Airway Oscillation?

W/ device in mouth, inhale slowly to 75% full breath; hold breath 2-3 seconds; exhale through device 3-4 seconds, repeat 10-20 breaths • Remove device and perform 2-3 coughs or huffs to raise secretions •

Which of the following airway clearance techniques can a patient perform independently after proper instruction? percussion vibration high frequency chest compression active cycle of breathing techniques

active cycle of breathing techniques A patient can perform active cycle of breathing techniques without needing any additional devices. This technique works to clear secretions through breathing control phases, thoracic expansion exercises, and forced expiratory techniques.

The depicted image shows percussion being applied to the: apical segments of the upper lobes anterior segments of the upper lobes superior segments of the lower lobes posterior basal segments of the lower lobes

anterior segments of the upper lobes The anterior segments of the upper lobes require the patient to be in a supine position. Percussion is performed below the clavicles.

Which lung segment would require the patient to be in sitting when performing postural drainage? apical segments of the upper lobe posterior segments of the upper lobe posterior basal segment right middle lobe

apical segments of the upper lobe Postural drainage to the apical segments of the upper lobes is performed with the patient in a sitting position, leaning back 30-40 degrees.

Which of the following airway clearance techniques is not considered a manual technique? percussion suctioning autogenic drainage manual compression

autogenic drainage Autogenic drainage uses controlled breathing to mobilize secretions by varying expiratory airflow without using postural drainage positions or coughing. Since autogenic drainage does not require the assistance of another person or equipment, it can be performed during activities of daily living.

Describe the procedure for a Huff:

inhale deeply though open mouth; contract abs during a rapid exhalation w/ glottis open saying "ha, ha, ha"

The most appropriate indication for suctioning is: consolidation pleural effusion pneumonia retained secretions

etained secretions Indications for suctioning include increased or thickened secretions and inadequate cough. The frequency of suctioning is dependent on the amount of secretion produced.

Which of the following occurs during a huff compared to a directed cough? glottis remains closed decreasing risk of airway collapse glottis remains open increasing risk of airway collapse glottis remains closed increasing risk of airway collapse glottis remains open decreasing risk of airway collapse

glottis remains open decreasing risk of airway collapse A huff occurs when the glottis remains open and a patient says "ha, ha, ha." This procedure does not produce as much airflow velocity as a cough, however, it does reduce the risk of airway collapse. A cough occurs when the glottis is closed.

Which piece of objective data would most likely result in a therapist determining that a patient is unable to participate in a scheduled airway clearance session? blood pressure: 145/87 mm Hg heart rate of 101 beats per minute oxygen saturation of 88% intracranial pressure of 22 mm Hg

intracranial pressure of 22 mm Hg An intracranial pressure monitor measures the pressure exerted against the skull using pressure sensing devices placed inside the skull. Intracranial pressure greater than 20 mm Hg is contraindicated for postural drainage because the required positioning may further elevate intracranial pressure.

Which airway clearance technique would most likely be considered too aggressive for a patient with sternal precautions following a recent surgery? vibration percussion autogenic drainage postural drainage

percussion Percussion uses more aggressive "pats" with a cupped hand to deliver a force large enough to loosen secretion in the lungs. The force may be considered excessive for individuals with sternal precautions.

Postural Drainage

positioning a patient so that gravity aids in the drainage of secretions from the bronchi and lobes of the lungs

What lung segment would be targeted for postural drainage if a patient is positioned as shown in the image? apical segment of upper lobe middle lobe posterior basal segment of lower lobe superior segment of lower lobe

posterior basal segment of lower lobe The posterior basal segments of the left and right lower lobes are treated with the patient in prone with the foot of the bed elevated 18 inches. Percussion and vibration are performed over the lower ribs on the left and right side of the chest.

Which lung segment would be most difficult to treat if a patient is unable to tolerate being positioned in prone? posterior basal segments of the lower lobe apical segments of the upper lobe posterior segments of the upper lobe anterior segments of the lower lobe

posterior basal segments of the lower lobe Postural drainage to the posterior basal segments of the left and right lower lobes requires the patient to be positioned in prone with the foot of the bed elevated 18 inches. Percussion and vibration are performed over the lower ribs on the left and right side of the chest.

Which of the following muscles is most active during huffing and coughing? rectus abdominis anterior scalene upper trapezius external intercostals

rectus abdominis The abdominal muscles include the rectus abdominis, transversus abdominis, and internal and external obliques. These muscles work to raise intra-abdominal pressure when a sudden expulsion of air is required in maneuvers such as huffing and coughing.

What are the precautions/contraindications for Autogenic Drainage (AD)?

requires motivation and concentration to learn

Which position best facilitates postural drainage to the bilateral posterior segment of the upper lobe for a patient with orthopnea? prone, with bed flat supine, with bed flat seated, leaning back 30 degrees seated, leaning forward 30 degrees

seated, leaning forward 30 degrees Orthopnea refers to difficulty breathing when lying flat. Seated, leaning forward will expose the area to be percussed and allow gravity to drain the posterior segment of the upper lobe. The position will also allow the patient to breathe easier since they are in an upright position.

Lateral basal segments lower lobes

the patient is in sidelying with the foot of bed elevated 18 inches. percussion and vibration performed over the lower ribs. L sidelying for R lobe and R sidelying for L lobe.

What are airway clearance techniques intended for?

to manage or prevent the consequences of impaired mucocillary transport or the inability to protect the airway (e.i impaired cough)

Which of the following conditions is a contraindication for postural drainage performed in the Trendelenburg position? uncontrolled hypertension atelectasis impaired cough retained secretions

uncontrolled hypertension In the Trendelenburg position the patient's head is lower than their feet. Uncontrolled hypertension is a contraindication for postural drainage performed in the Trendelenburg position.

Vibration following postural drainage should be performed: with cupped hands during expiration with cupped hands during inspiration with total palmar contact during expiration with total palmar contact during inspiration

with total palmar contact during expiration Vibration requires the palmar aspect of the hands to be in full contact with the affected lung segment. Vibration is applied following a deep inspiration and is maintained through the end of expiration.

High Frequency Airway Oscillation

• *Acapella and Flutter* are handheld devices that combine *positive expiratory pressure and high frequency airway vibrations to mobilize mucus secretions in airways* *Precautions/Contraindications:*

Active Cycle of Breathing

• Developed under the name "forced expiratory technique" to *assist secretion clearance in patients with asthma; name changed to ACB to emphasize coupling of breathing exercise w/ huff cough

Directed Cough and Huffing

• Directed cough tries to compensate for patient's physical limitations to elicit a max forced exhalation • Huffing is forced expiratory maneuver performed w/ glottis open