Airway Clearance
A 55-year-old female patient with a neuromuscular disorder is intubated and receiving vest oscillation to help mobilize secretions into the larger airways. She is having difficulty clearing the secretions. Which of the following techniques would you recommend?
A. Mechanical insufflation-exsufflation B. Positive expiratory pressure therapy C. Acetylcysteine via small volume nebulizer D. Postural drainage, percussion and vibration
All of the following conditions impair secretion clearance by affecting the cough reflex except:
Chronic bronchitis.
What is the condition called where the respiratory tract cilia do not function properly?
Ciliary dyskinetic syndrome.
What kind of breath sounds may you hear after therapy?
Coarse crackles. Their breath sounds may get worse due to the secretions moving into the larger airways.
What is an example of cough stimulation caused by thermal stimulation?
Cold air.
What is Chest Physical Therapy?
Collection of therapeutic techniques designed to aid clearance of secretions, improve ventilation, and enhance the conditioning of the respiratory muscles; includes positioning techniques, chest percussion and vibration, directed coughing and various breathing and conditioning exercises.
Which of the following determines effectiveness of high-frequency external chest wall compression therapy?
Compression frequency and Flow bias.
Autogenic Drainage (AD)
utilizes different speeds of breathing at different volumes in order to loosen and mobilize secretions into the larger airways for removal.
What are the five general approaches to airway clearance therapy?
(1) CPT, (2) coughing, (3) PAP, (4) High Frequency Compression/Oscillation Methods, and 5) Mobilization and physical activity.
In patients with neuromuscular conditions, what 3 options are there to help them get rid of retained secretions since cough is hard for them to obtain?
(1) The placement of an artificial airway , (2) manually assisted cough, and (3) manual insufflation-exsufflation.
Percussion and Vibration
- Application of mechanical energy to chest wall by use of hands or variable electrode or pneumatic devices - Designed to aid in movement of mucus toward central airways during exhalation
Postural Drainage therapy
- Involves use of gravity and mechanical energy to mobilize secretions - Includes turning, postural drainage, percussion, and vibration
Intrapulmonary Percussive ventilation
- Provides high-frequency oscillation of airway while administering aerosol particles - Aerosol generator should be placed in circuit as close to patient's airway
Which of the following measures would you use to ask patients for the presence of copious mucus production?
1 ounce.
What are the 3 most important aspects involved in patient teaching with directed cough?
1) Instruction in proper positioning, (2) instruction in breathing control, and (3) exercises to strengthen the expiratory muscles.
Indications of positive response to therapy include:
1. Change in sputum production 2. Change of lung sounds ( ind. that fluids are being drained) 3. Patient subjective response to therapy 4. Change in vital signs 5. Change in radiograph (X-ray) 6.Change in ABG values, or Pa02 saturation 7. Change in vent variables * Achievement of one or more indicated therapy is meeting objectives and should be continued*
Mucus plugging can lead to?
Ateletasis Pneumonia Hypoxemia Acidosis
Bronchopulmonary hygiene methods?
1.) Mobilization and exercise 2.) Postural Drainage therapy, percussion & vibrations 3.) Coughing and related expulsion techniques 4.) Positive airway pressure (PAP) 5.)High- frequency compression/oscillation
To avoid gastroesophageal reflux and the possibility of aspiration, how long should you wait before treatment after a meal?
1.5 to 2 hours before or after feedings.
How long should the RT wait to see sputum production?
24 Hours after optimal systemic hydration has been achieved WHY? : secretion clearance is affected by patients hydration
What is considered copious production of secretions?
25 to 30 ml/day, which is about 1 ounce or about the size of a shot glas
How much sputum production must be produced in order for therapy to be initiated?
25-30 ml per day for airway clearance therapy.
Evidence of difficulty clearing secretions with greater than?
25-30Ml/day
How long should you administer postural drainage?
3-15 minutes
How long do you typically perform HFCWO?
30 minutes.
In general, chest physical therapy can be expected to improve airway clearance when a patient's sputum production exceeds what volume?
30 ml/day
What are the hertz ranges for high frequency chest wall oscillators?
5-25 hertz
Directed Cough
A deliberate maneuver that is taught, supervised, and monitored. It aims to mimic the features of an effective spontaneous cough in patients who are too weak to produce a forceful expiratory maneuver
Aerosol drug therapy may be added to a PEP session by means of what?
A handheld nebulizer or an MDI (attached to one-way valve inlet of the system).
Forced Expiratory Technique (FET)
A modification of the directed cough Consists of one or two forced expirations of middle to low lung volumes without closure of glottis
Lab data and other essentials needed for assessment of need for bronchial hygiene therapy include?
Chest x-ray, PFT results, ABG values or oxygen saturation.
Normal airway clearance requires?
A patent airway A functional mucociliary escalator An effective cough " An effective cough"= generates enough force to move mucus from the lower airways to the upper airways
What makes a normal airway clearance?
A patent airway ( open) Functional mucocilary escalator ( traps particles & move out of lungs) Effective cough ( moves mucus from lower airways to the upper airway)
What are the 3 things needed for normal airway clearance?
A patent airway (open airway), functional mucocilliary escalator, and effective cough, because an effective cough can move mucus from the lower airways to the upper airways for removal.
In which of the following patients would you consider modifying any head-down positions used for postural drainage?
A patient with unstable blood pressure, A patient with a cerebrovascular disorder, A patient with systemic hypertension, and A patient with orthopnea.
What should be used during postural drainage if hypoxemia is suspected?
A pulse oximeter.
Directed coughing is useful in helping to maintain bronchial hygiene in all of the following cases except:
Acute asthma.
Bronchial hygiene would not be beneficial to patients with what condition?
Acute exacerbation of COPD.
Contraindications for positive airway pressure therapies include all of the following except:
Air-trapping/pulmonary overdistention in chronic obstructive pulmonary disease.
Active Cycle of Breathing (ACB)
Airway clearance strategy consisting of repeated cycles of breathing control and thoracic expansion, followed by forces excitatory technique.
What is bronchopulmonary hygiene?
Airway clearance techniques use to mobilize secretions and improve gas exchange
What kind of devices are believed to work based on the principle of collateral ventilation, which suggests that airflow can occur between adjacent lung segments thru the canals of Lambert and thru the pores of Kohn?
Airway oscillating devices that produce PEP with oscillations in the airway during expiration.
Which of the following should be charted after completing a postural drainage treatment?
Amount and consistency of sputum produced, Patient tolerance of procedure, Position(s) used (including time), and Any untoward effects observed.
What are the contraindications for PAP adjuncts to bronchial hygiene therapy?
An ICP greater than 20 mmHg, Untreated pneumothorax, Recent facial, oral, skull surgery or trauma.
What is Intra-pulmonary Percussive Ventilation (IPV)?
An airway clearance technique that uses a pneumatic device to deliver a series of pressurized gas mini-bursts at rates of 100 to 225 cycles per minute.
What factors can affect a patient's cough?
An effective cough requires: 1.) Large volume of air in lungs ( Neuromuscular disease; reduce lung expansion) 2.) Rapid compression of air ( Neuromuscular disease) 3.) Quick Expulsion of air out of lungs ( Increase in Raw caused by constriction of airway lumen ; bronchospasm, asthma, lung cancer)
What postural drainage position would be used for a patient with aspiration pneumonia of the anterior upper lobes?
Anterior Segments.
Impaired airway clearance and retention of secretions can be a result of what?
Any abnormality that alters airway patency such as mucociliary function, strength of the inspiratory or expiratory muscles, thickness of secretions, or effectiveness of the cough reflex.
Mechanical insufflation-exsufflation ( Cough Assist)
Apply positive pressure of 30-50 cmH20 to the airway for 1-3 seconds Then reverses the airway pressure to 30 to -50cmH20 Five cycles followed by normal spontaneous breathing.
Manually Assisted Cough
Apply pressure to the upper abdominal area during the compression and expiratory phase of the cough (for neuromuscular patients)
What are some diseases associated with abnormal clearance?
Asthma, lung cancer, kyphoscoliosis, chronic bronchitis, acute infections, Cystic fibrosis, Bronchiectasis, and neuromuscular diseases.
When should the postural drainage order be reevaluated?
At least every 48 hours for patients in critical care and at least every 3 days for other hospitalized patients and every 3 months for patients receiving home care.
A physician orders bronchodilator drug therapy in combination with positive expiratory pressure (PEP). Which of the following methods could you use to provide this combined therapy?
Attach a metered-dose inhaler to the system's one-way valve inlet, and Place a small-volume nebulizer in-line with the PEP apparatu
What are the clinical signs of patients with retained secretions?
Audible abnormal breath sounds, deteriorating arterial blood gases, chest x-ray changes.
What technique uses the diaphragmatic breathing to mobilize secretions by varying lung volumes and expiratory airflow in 3 distinct phases?
Autogenic drainage.
What landmarks should the respiratory therapist avoid during manual percussion
Avoid tender areas or sites of trauma or surgery, and one should never percuss directly over bony prominences, such as the clavicles or vertebrae
Why is coughing or suctioning pertinent in airway clearance therapy?
Because the therapies applied only help to move secretions into the central airways — they still need to be removed and you do that by coughing or suctioning.
What type of breath sounds would you hear once postural drainage therapy has been administered?
Breath sounds may worsen. You may hear coarse crackles after treatment.
Which of the following conditions are associated with chronic production of large volumes of sputum?
Bronchiectasis, Cystic fibrosis, and Chronic bronchitis.
What disease state is the airway permanently damaged, dilated, and prone to constant obstruction by retained secretions?
Bronchiectasis.
What is the disease where the airway is permanently damaged, dilated and prone to constant obstruction by retained secretions?
Bronchiectasis.
Before airway clearance therapy is started, what is something that may be administered to help improve the overall effectiveness of treatment?
Bronchodilator therapy.
When using flutter, patients can control the pressure by?
By changing their expiratory flow.
Airway clearance therapy for chronic conditions
CF Bronchoiectasis Ciliary dyskinetic syndromes COPD patients with retained secretions
FET is most useful in patients with?
COPD Cystic Fibrosis Bronchiectasis
What is involved in application of mechanical energy to the chest wall by the use of either hands or various electrical or pneumatic devices?
CPT, i.e. percussion and vibration.
Postural Drainage outcome assessment?
Change in sputum production Change in breath sounds Change in dyspnea level Change in vital signs Change in chest radiograph/ABG results Change in ventilator variables
Autogenic Drainage?
Controlled breathing to remove secretions, breath shallow and slow to start for a few minutes, then more deeply with larger exhale, then even deeper
A patient recovering from abdominal surgery is having difficulty developing an effective cough. Which of the following actions would you recommend to aid this patient in generating a more effective cough?
Coordinating coughing with pain medication, Using the forced expiration technique (FET), and "Splinting" the operative site.
Indications for Airway Clearance for acute conditions
Copious secretions Inability to mobilize secretions Ineffective cough
103. What should you do as a therapist if you know the patient will be in pain during postural drainage therapy?
Correlate their therapy sessions with scheduled pain medications.
What is the most important protective reflex?
Cough
Factors effecting the mucociliary transport system?
Cough ( the ability to cough and strength of it) Mucous characteristics ( want thin, white, watery) Airway diameter changes
Chronic conditions that may cause copious secretions and indicate the need for bronchial hygiene include?
Cystic Fibrosis, Bronchiectasis, and Chronic bronchitis.
What disease has the solute concentration of the mucus is altered because of abnormal sodium and chloride transport? It increases the viscosity of mucus and impairs its movement up the respiratory tract.
Cystic Fibrosis.
What are the six adjunctive breathing techniques?
Directed cough (controlled cough), Diaphragmatic breathing, Unilateral chest expansion, Acute chest expansion, Pursed-lipped breathing, and Forced expiratory technique (FET).
What type of cough is a deliberate maneuver that is taught, supervised, and monitored?
Directed cough.
What causes Impaired Mucociliary Clearance in intubated patients?
E.T tube/ Trach Suctioning ( damage to airway/swelling) Inadequate humidification High Fi02 Drugs: anesthetics, opiates, narcotics, etc " Can Slow Down" Underlying pulmonary disease
In patients with muscle weakness, such as COPD patients and patient with neuromuscular disease, what must be done to help remove their secretions?
Either suctioning or mechanical insufflation-exsufflation.
A chronic obstructive pulmonary disease patient cannot develop an effective cough. Which of the following would you recommend to help this patient generate a more effective cough?
Enhancing expiratory flow by bending forward at the waist, Using short, expiratory bursts or the "huffing" method, and Using only moderate (as opposed to full) inspiration.
How often should postural drainage techniques be performed on critically ill patients and patients on mechanical ventilation?
Every 4-6 hours. The frequency should be determined by assessing the patient's response to therapy.
Which of the following is true about exercise and airway clearance?
Exercise can enhance mucus clearance, Exercise can improve pulmonary function, Exercise can improve V/Q matching, and Exercise can cause desaturation in some patients.
What is the recommended airway clearance technique for a patient with asthma with mucus plugging?
Exercise, PEP, PDPV, Flutter valve, and HFO.
Proper instructions for positive expiratory pressure include all of the following except:
Exhale forcefully and maintain an expiratory pressure of 10 to 20 cm H2O.
Which of the following best describes positive expiratory pressure (PEP) therapy?
Expiration against a variable flow resistance.
Which of the following occurs during the compression phase of a cough?
Expiratory muscle contraction.
High Frequency/oscillation
External (chest wall) application of the vest Airway Application (Intrapulmonary percussive ventilation)
What are the 2 general approaches to oscillation?
External chest wall application and airway application.
In theory, how does positive expiratory pressure (PEP) help to move secretions into the larger airways?
Filling under-aerated segments through collateral ventilation, and Preventing airway collapse during expiration.
What are the names of some PEP devices?
Flutter Accapella Aerobika
What airway clearance device can decrease viscoelasticity of mucus within the airways modifying mucus and allowing it to be cleared more easily by cough?
Flutter valve.
Conditions that can affect airway patency and cause abnormal clearance of secretions include which of the following?
Foreign bodies, Tumors, Inflammation, and Bronchospasm.
What is an example of cough stimulation caused by a mechanical stimulation?
Foreign bodies.
If the procedure causes a vigorous cough, you should have the patient should do what?
Get into a sitting position until the cough subsides.
Advantages of the flutter valve over other bronchial hygiene methods include all of the following except:
Greater effectiveness.
Maintaining an open glottis during coughing (as with the FET) can help to minimize increases in pleural pressure and lessen the likelihood of bronchiolar collapse. Which of the following techniques can aid the teaching the patient this maneuver?
Having the patient phonate or "huff" during expiration.
All of the following laboratory data are essential in assessing a patient's need for bronchial hygiene therapy except:
Hematology results.
Strenuous expiratory efforts in some chronic obstructive pulmonary disease (COPD) patients limit the effectiveness of coughing. Why is this so?
High expiratory pleural pressures compress the small airways.
What is external application of oscillation referred as?
High-frequency chest wall compression (HFCWC).
What device uses a two part system with a variable air pulse generator and a non-stretch inflatable vest that covers the patient's entire torso?
High-frequency chest wall oscillation.
Forced expiratory techniques is also called the?
Huff Cough
What consists of one or two forced expirations of middle to low lung volume without closure of the glottis, followed by a period of diaphragmatic breathing and relaxation?
Huff cough or forced expiratory technique.
Under which of the following conditions would mechanical insufflation-exsufflation with an oronasal mask probably NOT be effective?
If the glottis collapses during exsufflation, or the presence of a fixed airway obstruction
What makes an abnormal airway clearance?
If you don't have airway patency ex: Asthma If you don't have a functional mucocilary escalator ex: medications, smoking, disease etc. If you don't have an effective cough ex: neuromuscular disease ( strength of breathing muscles Cough reflex ( suppressant meds) *ALL CAN LEAD TO MUCUS RETENTION*
Mobilization and Exercise?
Immobility = Major factor of retained secretions "Early mobilization & Exercise"= standard of care for surgery patients Exercise improves overall gas exchange and lung function
All of the following are hazards of positive airway pressure therapies (EPAP, PEP, CPAP) except:
Improvement of the ABG values.
Without an effective cough, most airway clearance techniques cannot succeed in what?
In fully clearing secretions.
In what area of the lungs is cough most effective?
In the central area, not the peripheral.
All of the following are considered bronchial hygiene therapies except:
Incentive spirometry.
Contraindications for Bronchopulmonary hygiene?
Increase ICP Head & Neck Injury Active hemorrhage/hemoptysis ( coughing up blood) Recent Spinal Surgery Pneumothorax CHF( Pulmonary edema) Hemodynamic instability Bronchospasm Reflux/aspiration
What is known as the artificial cough machine, cough assist device, or coughlator?
MIE (mechanical insufflation-exsufflation).
While reviewing the chart of a patient receiving postural drainage therapy, you notice that the patient tends to undergo mild desaturation during therapy (a drop in SpO2 from 93% to 89% to 90%). Which would you recommend to manage this problem?
Increase the patient's FIO2 during therapy.
Hazards of positive airway pressure therapies associated with the apparatus used include which of the following?
Increased work of breathing, Claustrophobia, Increased ICP, Vomiting and aspiration, and Skin breakdown and discomfort.
What are the factors that provoke a cough?
Infection, foreign bodies, and irritating gases.
What is an example of cough stimulation caused by an inflammatory process?
Infection.
What factors can affect a patient's cough?
Inhibiting factors/diseases: 1.) Internal obstruction/ external compression of the airway lumen: (Foreign bodies occluding airway, tumors, congenital or thoracic abnormalities such as kyphoscoliosis) 2.) Diseases inhibiting the full expansion of the lungs ( air trapping, Pleural effusion, etc.) 3.). Abnormalities altering airway patency (bronchospasms, curvature of the spine, Asthma, COPD, Lung Cancer, etc.) 4.) Factors reducing the strength of the insp. exp. muscles (neuromuscular diseases) 5.) Impairment of the cough reflex ( anesthesia)
A patient about to receive postural drainage and percussion is attached to an (ECG) monitor and is receiving both intravenous (IV) solutions and O2 (through a nasal cannula). Which of the following actions would be appropriate for this patient?
Inspect and adjust the equipment to ensure function during therapy.
Diseases associated with Abnormal airway clearance?
Internal/External compression of an airway lumen (Asthma, COPD, Lung Cancer) Cystic Fibrosis Bronchiectasis Neuromuscular disease can cause a weak cough.
What device is an airway clearance device that uses a pneumatic device to deliver a series pressurized gas mini-bursts at rates of 100 to 225 cycles per minute to the respiratory tract, usually via a mouthpiece?
Intrapulmonary percussive ventilation (IPV)
The airway clearance technique that uses a pneumatic device to deliver compressed gas mini-bursts to the airway at rates above 100/min best describes what?
Intrapulmonary percussive ventilation.
What are the 4 distinct phases to a normal cough?
Irritation, inspiration, compression, and expulsion.
What advantage does the Acapella have over the flutter valve?
It can be used in any position.
Adding exercise to mobilization and coughing can do what?
It can enhance mucus clearance, improve V/Q matching, improve pulmonary function, and result in oxygen desaturation.
What are the results of mucus plugging?
It can result in atelectasis, impaired oxygenation secondary to shunting, WOB, air trapping, overdistention, and ventilation/perfusion imbalance.
What is the Acapella?
It has a customizable frequency and flow resistance. It can be used in any posture and is NOT as portable as the flutter valve.
Which of the following is not an advantage of the Acapella over the flutter?
It is more portable.
Which of the following is/are TRUE of postural drainage?
It is most effective in disorders causing excessive sputum, It is most effective in head-down positions greater than 25 degrees, and It requires adequate systemic hydration to be effective.
Why should a patient avoid coughing when using the head down position during therapy?
It markedly increases ICP.
Which of the following is false about the FET?
It occurs from mid to high lung volume without glottis closure.
All of the following are typical of high-frequency external chest wall compression therapy except:
Long inspiratory oscillations.
How do you know if a patient is having issues with retained secretions?
Look at the physical findings such as a loose, ineffective cough, labored breathing pattern, decreased or bronchial breath sounds, coarse inspiratory and expiratory crackles, tachypnea, tachycardia, or fever may indicate a potential problem with retained secretions. A chest radiograph often shows atelectasis and areas of increased density in such cases.
The clinical signs that there is a problem with retained secretions are?
Loose, ineffective cough, Labored breathing pattern, Course inspiratory and expiratory crackles, and Fever.
What are the 3 categories of chest percussors?
Manual, pneumatic, and electrically powered devices
Soon after you initiate postural drainage in a Trendelenburg position, the patient develops a vigorous and productive cough. Which of the following actions would be appropriate at this time?
Move the patient to the sitting position until the cough subsides.
What does mucous plugging lead to?
Mucous plugging can result in atelectasis and impaired oxygenation secondary to shunting. By restricting airflow, partial obstruction can increase the work of breathing and lead to air trapping, over distention, and ventilation/perfusion (V/Q) imbalances.
Conditions that can lead to bronchiectasis include all of the following except:
Muscular dystrophy
What common conditions affect the cough reflex?
Muscular dystrophy, Amyotrophic lateral sclerosis, and Cerebral palsy.
What are the most common conditions that affect the cough reflex?
Musculoskeletal and neurologic disorders.
All of the following are contraindications for directed coughing except the presence of:
Necrotizing pulmonary infection.
What are the indications for the directed cough?
Need to aid in the removal of retained secretions from central airways, Presence of atelectasis, Prophylaxis against postoperative pulmonary complications, Routine part of bronchial hygiene in patients CF, bronchiectasis, chronic bronchitis, necrotizing pulmonary infection, spinal cord injury, To obtain sputum specimens for diagnostic testing.
Will there be an immediate production of secretions in doing postural drainage therapy?
No, not always.
What are potential problems with mechanical vibration devices?
Noise, excess force, electrical shock, and mechanical failure.
Directed Cough
Not to be used in patients who are obtunded, paralyzed, or uncooperative Good PT teaching is critical Proper positioning is important ( sitting up) Need to be modified in surgical PTS, PTs with COPD, & PTs with neuromuscular disease
What is the movement of small volumes of air back and forth in the respiratory tract at high frequencies (12 to 25 Hz) called?
Oscillation
What term refers to the rapid vibratory movement of small volumes of air back and forth in the respiratory tract?
Oscillation
What are the appropriate airway clearance techniques that may be used for CF, ciliary dyskinesia syndrome, bronchiectasis?
PDPV
What is the recommended airway clearance technique for patients with cystic fibrosis, ciliary dyskinesia, bronchiectasis or infants?
PDPV (postural drainage, percussion, vibration).
What is the recommended airway clearance technique used for a patient with neurologic abnormalities?
PDPV, suction, and MIE.
What is the recommended airway clearance technique used for a patient with musculoskeletal weakness such as muscular dystrophy, myasthenia gravis, and poliomyelitis?
PEP and MIE.
What is the recommended airway clearance technique for a patient with atelectasis?
PEP, PDPV, ACBT
How should hands be positioned when percussing?
Parallel to the ribs.
Which of the following is/are necessary for normal airway clearance?
Patent airway, Functional mucociliary escalator, and Effective cough.
A physician orders postural drainage for a patient with aspiration pneumonia in the superior segments of the left lower lobe. Which of the following positions would you recommend for this patient?
Patient prone with a pillow under abdomen, bed flat.
A physician orders postural drainage for a patient with aspiration pneumonia in the anterior segments of the upper lobes. Which of the following positions would you recommend for this patient?
Patient supine with a pillow under knees, bed flat.
Which of the following acutely ill patients is LEAST likely to benefit from the application of chest physical therapy?
Patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD).
For which of the following patients directed coughing might be contraindicated?
Patient with poor coronary artery perfusion, and Patient with an acute unstable spinal injury.
Which of the following should be considered when selecting a bronchial hygiene strategy?
Patient's goals, motivation, and preferences; Effectiveness and limitations of technique or method; Patient's age, ability to learn, and tendency to fatigue; and Need for assistants, equipment, and cost.
Before starting postural drainage what assessments should be completed?
Patients vital signs and chest auscultation.
A directed cough is useful in helping maintain bronchial hygiene in patients with what?
Patients with CF, Patients with bronchiectasis, and Patients with a spinal cord injury.
What are the contraindications for a directed cough?
Patients with pathogens transmitted by droplets (TB), Presence of an elevated ICP, Poor coronary artery perfusion, and a spinal cord injury.
What should you do between positions?
Pause for relaxation and breathing control to prevent hypoxemia.
What does CPT consist of?
Percussion, postural drainage, and vibration
In assessing an adult outpatient for bronchial hygiene therapy, has (1) no history of cystic fibrosis or bronchiectasis, (2) sputum production of 30 to 50 ml/day, (3) an effective cough, and (4) good hydration. Which of the following would you recommend?
Positive expiratory pressure therapy.
What are the bronchial hygiene methods?
Postural drainage therapy (including percussion and vibration), Positive airway pressure (PAP), and Oscillation.
The application of gravity to achieve specific clinical objectives in respiratory care best describes which of the following?
Postural drainage therapy.
Which of the following airway clearance techniques would you recommend for a patient with a neurologic abnormality (bulbar palsy) and intact upper airway?
Postural drainage, percussion, and vibration; and Mechanical insufflation-exsufflation.
What therapy uses gravity and mechanical energy to help mobilize secretions?
Postural drainage.
What type of therapy involves the use of gravity and mechanical energy to help mobilize secretions?
Postural drainage.
Key considerations in initial and ongoing patient assessment for chest physical therapy include which of the following?
Posture and muscle tone, Breathing pattern and ability to cough, Sputum production, and Cardiovascular stability.
Key considerations in assessing a patient for CPT include what?
Posture, muscle tone, Effectiveness of cough, Sputum production, Breathing pattern, and Cardiovascular stability.
The primary objectives for postural drainage include all of the following except:
Prevent pneumonia
The primary objectives for turning include all of the following except to:
Prevent postural hypotension
What are the best documented preventive uses of bronchial hygiene therapy?
Prevent retained secretions in the acutely ill; and Maintain lung function in cystic fibrosis.
Airway Clearance therapy is needed also to?
Prevent retention of secretions Useful for acutely ill patients when combined with patient mobilization Cystic fibrosis Patients- Chest PT combined with exercise to maintain lung function
Which of the following is NOT a hazard or complication of postural drainage therapy?
Pulmonary barotraumas.
Which of the following are potential indications for positive airway pressure therapies?
Reduce air-trapping in asthma or chronic obstructive pulmonary disease, Help mobilize retained secretions, Prevent or reverse atelectasis, and Optimize bronchodilator delivery.
High Frequency Techniques Work by?
Reducing viscosity of mucous shearing of the air-mucous interface Reinforce ciliary movement stimulate fresh secretion production
All of the following are goals of bronchial hygiene therapy except:
Reverse the underlying disease process.
What postural drainage position would be used for a patient an abscess in the right middle lobe?
Right lateral segment.
A typical mechanical insufflation-exsufflation treatment session should continue until what point?
Secretions are cleared; The vital capacity (VC) returns to baseline; and The SpO2 returns to baseline.
The factors that may hinder an effective cough include?
Severe restrictive disorders (COPD), Fear of pain, Systemic dehydration, Thick, tenacious secretions, Artificial airways, and the use of CNS depressants.
What is the term used for when a clinician can use his or her hands to support the area of incision during the expiratory phase of a cough?
Splinting
A physician orders positive expiratory pressure therapy for a 14-year-old child with cystic fibrosis. Which of the following should be monitored?
Sputum production, Breath sounds, Pulse rate, and Breathing pattern.
If a patient experiences hemoptysis during postural drainage therapy, what action should be taken?
Stop the therapy, return the patient to their previous resting position, administer or increase their FIO2, and contact the physician.
During chest physical therapy, a patient has an episode of hemoptysis. Which of the following actions would be appropriate at this time?
Stop therapy, sit the patient up, give O2, and contact the physician.
A key consideration in teaching a patient to develop an effective cough regimen includes which of the following?
Strengthening of the expiratory muscles, Instruction in breathing control, and Instruction in proper positioning.
When a patient is in the head down position, what should the patient avoid?
Strenuous coughing to avoid an increased ICP.
What postural drainage position would be used for a patient with aspiration pneumonia in the superior segments of the left lower lobe?
Superior segments.
ercussion should NOT be performed over which of the following areas?
Surgery sites, Bony prominences, and Fractured ribs.
How does the mucocilary escalator work?
Sweep forward and move things out and return and move things out again
Postural Documentation and follow up?
The chart entry should include: The positions used Time in positions Patient tolerance Indicators of effectiveness Any untoward effects observed
What does airway application of oscillation methods include?
The flutter valve and intrapulmonary percussive ventilation.
What is a popular approach to PEP therapy?
The flutter valve.
When assessing the potential need for postoperative bronchial hygiene for a patient, all of the following factors are relevant except:
The number of prior surgical procedures.
The documentation of postural drainage therapy should include what?
The position(s) used, Time in each position, Patient tolerance, Amount and consistency of sputum produced, and Any untoward effects observed.
How does postural drainage work?
The process placing the patient in various positions to drain specific segmental bronchi Position held 3-15 mins Most effective in patients with excessive mucus secretions
Patients can control a flutter valve's pressure by changing what?
Their expiratory flow.
What type of patients may not be able to do the direct cough regimen?
Those that are obtunded, paralyzed, uncooperative patients, patients with COPD and neurologic, muscular and skeletal abnormalities. Also dehydration, thick secretions, artificial airways and depressants can thwart direct cough techniques.
Properly performed chest vibration is applied at what point?
Throughout expiration.
What is the goal of FET?
To clear secretions with less change in plural pressure and less bronchial collapse.
What is the primary goal of bronchial hygiene therapy?
To help mobilize and remove retained secretions. The ultimate goal is to improve gas exchange and reduce the work of breathing.
What type of patients do you recommend EzPAP for?
To patients with a decreased FRC.
The indications for PAP adjuncts to bronchial hygiene therapy include what?
To reduce air trapping, To aid in mobilization of retained secretions, To prevent or reverse atelectasis, and To optimize delivery of bronchodilators in patients receiving bronchial hygiene therapy.
Whether using traditional methods or the FET, a period of diaphragmatic breathing and relaxation should always follow attempts at coughing. What is the purpose of this approach?
To restore lung volume and minimize fatigue.
General Indications of airway clearance?
Treatment of Acute Conditions: -Difficulty clearing secretions with greater than 25-30 ml/day ( 1 shot glass full of secretions) -Prevent retentions of secretions -Ineffective cough coarse inspiratory/expiratory crackles Treatment of Chronic Conditions: -Cystic Fibrosis (CF) ( Copious sputum production) -Bronchiectasis ( copious sputum production) -COPD patients with retained secretions -Ciliary dyskinetic syndromes
What are the indications for postural drainage?
Turning, Inability or reluctance of patients to change body positions, Poor oxygenation associated with position, Potential for or presence of atelectasis, Presence of artificial airway, Evidence or suggestion of difficulty with secretion clearance, Difficulty clearing secretions, with expectorated sputum production greater than 25 to 30 ml/day, Evidence of suggestion of retained secretions in the presence of an artificial airway, diagnosis of diseases such as CF or bronchiectasis, Presence of foreign body in airway.
What type of breathing method is useful for COPD patients that can't get an effective cough?
Use pursed lip breathing while leaning forward.
Which of the following parts are required to conduct high-frequency external chest wall compression?
Variable air-pulse generator, and a Non-stretch inflatable thoracic vest.
Which of the following are mandatory components of the pre-assessment for postural drainage?
Vital signs and Auscultation.
What is an example of cough stimulation caused by chemical stimulation?
When irritating gases are inhaled, such as cigarette smoke.
Which of the following is the only absolute contraindication to turning?
When the patient has unstable spinal cord injuries.
What is the triple S rule?
Whenever you observe an untoward patient response during postural drainage, the respiratory therapist should stop the therapy (return patient to original resting position) and stay with the patient until he/she is stabilized.
High Frequency Chest Wall compression
commonly used in patients with Cystic Fibrosis that uses an inflatable vest that helps mobilize secretions by creating oscillations against the patient's thorax and chest wall.
Active Cycle of Breathing
cycles of deep breathing with relaxed breathing and forced expiration maneuvers.
MIE ( COUGH ASSIST)
device to provide alternating positive and negative pressure to give an artificial cough in order to help mobilize and remove secretions.
chest physiotherapy (CPT)
form of therapy that is designed to help clear secretions, improve ventilation, and strengthen the respiratory muscles of breathing. It includes : chest percussion and vibration, directed coughing, positioning techniques, and other types breathing and conditioning exercises
What position should the patient be in while performing the directed cough
he patient should assume the sitting position with one shoulder rotated inward and the head and spine slightly flexed. The patient's feet should be supported to provide abdominal and thoracic support for the patient. If the patient is unable to sit up, the clinician should raise the head of the bed and ensure that the patient's knees are slightly flexed with the feet braced on the mattress.
What maneuver may a patient do to help clear secretions with less change in pleural pressure and less likelihood of bronchiolar collapse?
less likelihood of bronchiolar collapse?
Bronchopulmonary hygiene bedside findings?
loose, ineffective cough labored breathing pattern coarse inspiratory and expiratory crackles Tachypnea/Tachycardia ( unable to mobilize) Fever ( pulmonary infection)
Peak Expiratory cough flow
measures cough strength Simple testing format: peak flow meter & mask measure PCF (Peak Cough Flow) Normal: 6-12L/s or 360-720L/m
What common drugs can impair mucocilliary clearance in intubated patients?
mucocilliary Clearance in intubated patients?
What is the clinical procedure for PAP therapy?
nstruct the patient to: Take in a breath that is larger than normal, but do not completely fill lungs, Exhale actively, but NOT forcefully, Perform 10 - 20 breaths, Repeat the cycle four to eight times but do not exceed 20 minutes.
Positive Expiratory Pressure ( PEP) therapy?
patient exhales against backpressure which helps mobilize into the larger airways so that they can be removed via coughing.
Intrapulmonary Percussive Ventilation
pneumatic machine to deliver small pressurized breaths at a fast rate to help mobilize secretions. It is often combined with aerosolized bronchodilator therapy.
