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N Karen Conyers, BSRT, RRT AIRWAY CLEARANCE. Airway Clearance n Pulmonary Physiology and Development n Impaired Airway Clearance n Airway Clearance Techniques.

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Presentation on theme: "N Karen Conyers, BSRT, RRT AIRWAY CLEARANCE. Airway Clearance n Pulmonary Physiology and Development n Impaired Airway Clearance n Airway Clearance Techniques."— Presentation transcript:


2 Airway Clearance n Pulmonary Physiology and Development n Impaired Airway Clearance n Airway Clearance Techniques n Therapy Adjuncts


4 Birth n Respiratory Function – Terminal respiratory unit not fully developed – Respiratory function performed by alveolar-capillary bed n Airways – Little smooth muscle – Small airway diameter – Increased airway resistance n Lung compliance – Incomplete elastic recoil – Decreased lung compliance

5 Age 2 Months n Alveoli – 24 million alveoli present – Alveoli small but fully developed – Ability to form new alveoli n Respiratory muscles – Underdeveloped accessory muscles – Diaphragm is primary muscle of respiration n Response to increased ventilatory demands – Respiratory rate increases, not tidal volume

6 Ages 3 to 9 Months n Increasing strength – Baby learns to hold head up, reach for things – Upper body strength develops, including accessory muscles for respiration n Changes in respiratory function – Learns to sit up: rib cage lengthens – Greater chest excursion – Increased tidal volume

7 Age 4 Years n Lung development – Development of pre-acinar bronchioles and collateral ventilation (pores of Kohn) – Development of airway smooth muscle

8 Age 8 Years n Continued lung development – Alveolar development complete – Alveolar size increases – Total lung volume increases – 300 million alveoli (increased from 24 million at age 2 months)

9 Adult Lung n Gradual loss of volume n Loss of elasticity – Decreasing compliance n Environmental effects – Smoking – Air pollution – Occupational hazards n Disease effects

10 Factors Affecting Airflow n Airway resistance n Turbulent airflow n Airway obstruction

11 Normal Airway Resistance Decreasing cross-sectional area from acinus to trachea causes increased resistance, as airflow moves from small to large airways. n Cross-sectional areas: – trachea diameter 2 cm – 4th generation bronchi 20 cm – bronchioles 80 cm – acinus cross-section 400 cm n Greatest airway resistance in large airways; laminar airflow in small airways

12 Airway Obstruction n Increased airway resistance – Bronchospasm – Inflammation n Hypersecretion of mucus – Acute process – Chronic disorder

13 Mucus n Mucus produced by goblet cells in airway n Chronic airway irritation increased numbers of goblet cells larger quantities of mucus n Cilia move together in coordinated fashion to move mucus up airways


15 Impaired Airway Clearance: Factors n Ineffective mucociliary clearance n Excessive secretions n Thick secretions n Ineffective cough n Restrictive lung disease n Immobility / inadequate exercise n Dysphagia / aspiration / gastroesophageal reflux

16 Results of Impaired Airway Clearance n Airway obstruction n Mucus plugging n Atelectasis n Impaired gas exchange n Infection n Inflammation

17 A Vicious Cycle



20 Airway Clearance Techniques n Goals n Conventional Methods n Newer Therapies n Therapy Adjuncts

21 Goals n Interrupt cycle of lung tissue destruction n Decrease infection and illness n Improve quality of life

22 Conventional methods n Cough n Chest Physiotherapy n Exercise

23 Cough n Natural response n Only partially effective n Frequent coughing leads to floppy airways n May be suppressed by patient

24 Chest Physiotherapy (CPT) n Can be used with infants n Requires caregiver participation n Technique dependent n Time consuming n Physically demanding n Requires patient tolerance n Effectiveness debated

25 Exercise n Recommended for most patients n Pulmonary rehabilitation expectation n Training – Ability to exercise related more to muscle mass than to pulmonary function – Improves oxygen uptake by muscle cells n Many patients limited by physical disability

26 Newer Therapies n PEP valve n Flutter n In-Exsufflator n HFCWO (Vest) n Intrapulmonary percussive ventilation (IPV) n Cornet n PercussiveTech HF

27 PEP valve n Positive Expiratory Pressure n Action: splints airways during exhalation n Can be used with aerosolized medications n Technique dependent n Portable n Time required: minutes

28 Flutter n Action: loosens mucus through expiratory oscillation; positive expiratory pressure splints airways n Used independently n Technique dependent n Portable n May not be effective at low airflows n Time required: minutes

29 In-Exsufflator n Action: creates mechanical cough through the use of high flows at positive and negative pressures n Positive/negative pressures up to 60 cm of water n Used independently or with caregiver assistance n Technique independent n Portable

30 ABI Vest (HFCWO) n Action: applies High Frequency Chest Wall Oscillation to entire thorax; moves mucus from peripheral to central airways n Used independently or with minimal caregiver supervision n May be used with aerosolized medications n Technique independent n Portable n Time required: minutes

31 Intrapulmonary Percussive Ventilation (IPV) n Action: percussion on inspiration, passive expiration; dense, small particle aerosol n Used independently or with caregiver supervision n Used with aerosolized meds n Technique dependent n May not be well tolerated by patient n Time required: 20 minutes

32 Other devices n Cornet – Similar to action of Flutter – Lower cost, disposable n PercussiveTech HF – Hand-held device used with aerosol meds – Similar to action of IPV – Requires 50 PSI gas source

33 European / Canadian Techniques n Huff cough (forced expiratory technique) n Active Cycle of Breathing Technique (ACBT) n Autogenic Drainage

34 Forced Expiratory Technique n Huff cough – Three second breath hold – Open glottis – Prevents airway collapse – Effective technique for floppy airways – Easy to learn

35 Active Cycle of Breathing Technique n Three steps: – Breathing control – Thoracic expansion / breath hold – Forced expiratory technique n May be performed independently n Easily tolerated

36 Autogenic Drainage n Three phases – Unsticking – Collecting – Evacuating n May be performed independently n Harder to teach and to learn than other techniques n May be difficult for very sick patients to perform

37 Autogenic Drainage Normal Breathing Complete Exhalation VTVT RV ERV IRV Cough UNSTICKING COLLECTINGEVACUATING


39 Therapy Adjuncts n Antibiotics n Bronchodilators n Anti-inflammatory drugs n Mucolytics n Nutrition

40 Antibiotics n Oral n Intravenous n Nebulized – Aminoglycosides: P. aeruginosa n Gentamycin: mg n Tobramycin: mg n Tobi: 300 mg per dose: high dose inhibits mutation of P. aeruginosa in lung

41 Bronchodilators n Hyperreactive airways common in many pulmonary conditions n Albuterol, Atrovent n MDI or nebulized n Administered prior to other therapies

42 Mucolytics n Mucomyst (acetylcysteine) – Breaks disulfide bonds – Airway irritant n Pulmozyme (dornase alfa or DNase) – Targets extracellular DNA in sputum – Specifically developed for cystic fibrosis n Hypertonic saline – Sputum induction – Australian studies

43 Anti-inflammatory Drugs n Inhaled steroids via metered dose inhaler n Oral or IV prednisone n High-dose ibuprofen (cystic fibrosis)

44 Nutrition n Connection between nutrition and lung function! n Worsening lung function n Worsening lung function increased work of breathing & frequent coughing increased caloric need n Increasing dyspnea decreased caloric intake worsening lung function malnutrition decreased ability to fight infection worsening lung function


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