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Bronchial Hygiene
Coughing and Related Expulsion Techniques
Most bronchial hygiene therapies only help move secretions into the central airways. Actual clearance of these secretions requires either coughing or suctioning.
In this respect, an effective cough (or alternative expulsion measure) is an essential component of ALL bronchial hygiene therapy
Reading AssignmentEgan’s Fundamentals of Respiratory CareNINTH EDITION (pgs. 915-916, 932-941)
Bronchial Hygiene
Coughing and related expulsion techniques Directed cough
A deliberate maneuver that is taught, supervised, and monitored
Aims to mimic the features of an effective spontaneous cough in patients who are too weak to produce a forceful expiratory maneuver
Bronchial Hygiene
Coughing and related expulsion techniques Directed Cough
Not to be used in patients who are obtunded, paralyzed, or uncooperative
Good patient teaching is critical
Proper positioning of the patient is important
The technique may need to be modified in surgical patients, patients with COPD, and patients with neuromuscular disease
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough - Standard Technique
Instruct the patient to assume a sitting position, with shoulders rotated inward, the head and spine slightly flexed, forearms relaxed or supported
If the patient is unable to sit up, raise the head of the bed, knees should be slightly flexed with feet braced on the mattress
Instruct the patient to inspire slowly and deeply through the nose, using the diaphragm
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough - Standard Technique
Instruct the patient to bear down against a closed glottis
Instruct the patient to cough
Stage expiratory effort into two or three shout bursts for patient with pain or bronchiolar collapse
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough – Surgical Patients
Provide preoperative training Minimizes anxiety over pain
Coordinate coughing sessions with prescribed pain medications
Assist the patient to splint the operative site
The forced expiratory technique (FET) may be of value to these patients
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough – COPD Patients
Instruct the patient to assume a sitting position, with shoulders rotated inward, the head and spine slightly flexed, forearms relaxed or supported
Instruct the patient to take in a moderately deep breath through the nose
Results in less pleural pressure and less collapse of the smaller airways
Instruct the patient to exhale with moderate force through pursed lips, while bending forward
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough – COPD Patients
Patient should repeat the previous steps 3 – 4 times
Have the patient bend forward and initiate short staccato-like bursts of air
Technique relieves the strain of a prolonged cough and minimizes airway collapse
An alternative to this technique is called “huffing”
FET or Autogenic Drainage (AD) may also be used in these patients
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough – Neurological Patients
Instruct the patient to take a deep breath Assist as needed with IPPB or resuscitator bag/mask
At the end of inspiration, begin exerting pressure on the lateral costal margin or epigastrium, increasing the force of compression throughout expiration
Pressure to the lateral costal margins is contraindicated in patient with osteroporosis or flail chest
Epigastric pressure is contraindicated in unconscious patient with unprotected airways; in pregnant women; and in patient with acute abdominal pathology, abdominal aortic aneurysm, or hiatal hernia
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough – Forced expiratory technique (FET)
A modification of the directed cough
Also called the “huff cough”
Consists of one or two forced expirations of middle to low lung volumes without closure of the glottis
Goal is to clear secretions with less change in pleural pressure and less bronchial collapse.
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough – Forced expiratory technique (FET)
FET has been shown to increase sputum production, especially when combined with postural drainage
Most useful in patients with COPD, cystic fibrosis, or bronchiectasis
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough – Forced expiratory technique (FET)
Instruct the patient to take in a slow, deep breath, followed by a 1 – 3 second breath hold
Instruct the patient to perform 1 – 2 short, quick forced exhalation of middle to low lung volume with the glottis open
The patient should phonate or “huff” during expiration
Each session of “huffing” should be followed by diaphragmatic breathing and relaxation
Bronchial Hygiene
Coughing and Related Expulsion Techniques Directed Cough – Active Cycle of Breathing (ACB)
Repeated cycles of breathing control, thoracic expansion, and the FET
Breathing control; gentle breathing at normal tidal volumes with relaxation of the upper chest and shoulders – helps prevent bronchospasm
Thoracic expansion; deep inhalation which relaxed exhalation, which may be accompanied by percussion, vibration, or compression – designed to help loosen secretions, improve the distribution of ventilation, and provide the volume needed for FET
Bronchial Hygiene
Coughing and Related Expulsion Techniques Autogenic Drainage (AD)
During AD, the patient uses diaphragmatic breathing to mobilize secretions by varying lung volumes and expiratory airflow in three distinct phases.
Patient should be in the sitting position.
Coughing should be suppressed until all three phases are complete.
Bronchial Hygiene
Autogenic Drainage (AD) Spirogram of lung volumes during three
phases of autogenic drainage.
Phase 1 involves a full inspiratory capacity maneuver, followed by breathing at low lung volumes. This phase is designed to “unstick” peripheral mucus.
Phase 2 involves breathing at low to middle lung volumes in order to collect mucus in the middle airways.
Phase 3 is the evacuation phase, in which mucus is readied for expulsion from the large airways.
Bronchial Hygiene
Coughing and Related Expulsion Techniques Mechanical Insufflation-Exsufflation (MIE)
Bronchial Hygiene
Coughing and Related Expulsion Techniques Mechanical Insufflation-Exsufflation (MIE)
MIE devices apply positive pressure of 30 to 50 cm H2O to the airway for 1 to 3 seconds.
The device then abruptly reverses the airway pressure to –30 to –50 cm H2O.
Treatment sessions consist of about five cycles of MIE followed by normal spontaneous breathing. This process is repeated five or more times until secretions are
cleared
Bronchial Hygiene
High Frequency Chest Wall Oscillation (HFCWO) Consists of a variable air-pulse generator and a non-stretch
inflatable vest Small gas volumes are alternately injected into and withdrawn
from the vest by the air-pulse generator at a fast rate (5 – 25 Hz) creating a oscillatory motion against the patient’s thorax
Bronchial Hygiene
HFCWO Oscillations at frequencies of 12
– 25 Hz enhance clearance of secretions Acts as a physical “mucolytic”
by altering the physical properties of secretions
Transient increases in airflow produce cough-like shear forces
Therapy sessions are approximately 30 minutes in duration
One to 6 treatments per day
Bronchial Hygiene
HFCWO Common Conditions/Situations for HFCWO
Patient with evidence of retained secretions Independent patient without access to a caregiver Patient with reduced mobility Patient who cannot tolerate Trendelenburg positioning Fragile patient who cannot tolerate the force of CPT Ventilator-dependent patient experiencing frequent
pneumonias
Information obtained from manufacturer’s website
Bronchial Hygiene
HFCWO Most Common Diagnoses Utilizing HFCWO
Cystic Fibrosis Bronchiectasis Cerebral Palsy Spinal Muscular Atrophy Muscular Dystrophy Chronic Obstructive Pulmonary Disease (COPD)
Information obtained from manufacturer’s website
Bronchial Hygiene
Positive Expiratory Pressure (PEP) Active expiration against a variable flow
resistance Helps move secretions into larger
airways Filling underaerated or nonaerated
segments via collateral ventilation Preventing airway collapse during
expiration Subsequent huff or FET maneuver allows
patient to generate the flows needed to expel mucus
Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator
Bronchial Hygiene
PEP Oscillating PEP
Flutter Valve Combines the techniques of
EPAP with high-frequency oscillations at the airway opening
Actively exhaling into the pipe creates a positive expiratory pressure between 10 – 25 cm H2O
Changing the angle of the device alters the oscillations
The device can decrease mucus viscoelasticity within the airways, allowing it to be cleared more easily by cough
Bronchial Hygiene
PEP Oscillating PEP
acapella® Combines the techniques of EPAP with high-
frequency oscillations at the airway opening
Bronchial Hygiene
EZ-PAP Lung expansion therapy during
inspiration and PEP therapy during exhalation
Used for the treatment or prevention of atelectasis and the mobilization of secretions
Aerosol drug therapy may be added to a PEP session to improve the efficacy of bronchodilator
EZ-PAP
Clinical Procedure for PAP Requires a physician’s order Explain purpose and procedure of therapy to the patient
Teach directed cough, e.g., “huff” Have the patient sit comfortably If using a mouthpiece
Instruct the patient to place lips firmly around mouthpiece and to breathe through their mouth
If using a mask Ensure a comfortable but tight fit around the nose and mouth
EZ-PAP
Clinical Procedure for PAP Instruct the patient to take a larger than normal breath, but not to
fill the lungs completely Have the patient exhale actively, but not forcefully, creating a
positive pressure of 5 to 20 cm H2O during exhalation (determined with a monometer)
Patient should perform 10 – 20 breaths Remove the mask or mouthpiece and perform 2 – 3 “huff”
coughs; allow rest as needed Repeat above cycle 4 – 8 times, not to exceed 20 minutes
EZ-PAP
Clinical Procedure for PAP If the patient is receiving bronchodilators via aerosol, administer
in conjunction with PAP device Document the procedure in the patients medical record
Device Settings (if applicable) Pressure (if possible) Number of breaths per treatment Patients response to therapy Patient education provided Patient’s ability to self-administer (if applicable)