“Airway Clearance Devices” Why we use them with Bronchiectasis National Jewish Medical and Research Center

What Else Can I do to feel Better? Airway Clearance Airway Clearance Devices - Why use them? Why did the chicken cross the road? (to get to the other side) Why use devices? (same reason) National Jewish Medical and Research Center

Impaired Airway Clearance – What Happens? Dyspnea (shortness of breath) And the risk factors rise for recurrent, ever-worsening episodes of: Vicious cycle of lung damage inflammation pulmonary infection increased mucus production airway obstruction (mucus plugging) lung damage (lung scarring and remodelling of airways) What will likely happen when normal airway clearance mechanisms become impaired? Increasing shortness of breath Inflammation Pneumonia Excessive mucus congestion and mucus plugging Increasing remodeling or scaring of the airways and lung tissue. This is a vicious cycle of lung damage when left untreated.

Impaired Airway Clearance – What Happens? Acceleration of the vicious cycle promotes: Infectious bronchitis, bronchiolitis, and pneumonia Air trapping, uneven ventilation, and increased work of breathing Increased risk of recurrent infections and acute exacerbations Increased risk of hospitalization Increased risk of mortality Increased cost of care When secretion retaining conditions are not treated, the cycle of decline leads to many other potential problems. Infectious bronchitis, bronchiolitis, and pneumonia. Air trapping, Uneven ventilation, Increased Work of Breathing. Rise in acute exacerbations of respiratory distress or recurrent pneumonias. Increased hospital admissions and an increased risk of mortality. All of that, of course, comes with an increased cost of care to match. Therefore, the goal is to stop or delay the cycle of lung damage and try to curtail such problems. Vicious cycle of lung damage GOAL 

Vicious cycle of lung damage What Should Be Done? In cases of impaired airway clearance it is necessary to provide: Routine administration of aggressive, effective airway clearance therapy. Airway clearance therapy is the most reliable means stopping or delaying the progression of mucus retaining lung disease. The way to stop or slow the vicious cycle of lung damage is to routinely administer aggressive and effective bronchial hygiene therapy (aka -- airway clearance therapy) each and every day, several times per day. Vicious cycle of lung damage GOAL 

What Should Be Done? For patients at risk for retained secretions provide them with the means to do bronchial hygiene therapy (BHT): 20 - 40 minutes per day Divided up into a few sessions per day Rx examples: 10 minutes – TID 15 minutes – BID Adjust as needed or tolerated What Should Be Done? What’s needed is: 20 - 40 minutes per day of Airway Clearance Therapy Divided up into several sessions, like 10-minute sessions, three times per day, or Two 15-minute sessions per day. Some patients may even need a total of 60 minutes per day of airway clearance therapy.

Airway Clearance Devices PEP (Positive Expiratory Pressure) devices Vibratory PEP Acapella®, Flutter Valve™, Quake® HFCWO (High Frequency Chest Wall Oscillation) Vest Systems Cough Assist® IPV® (Intrapulmonary Percussive Ventilation) Aerosol therapy to loosen thick secretions or to treat infections Mucolytics, Hypertonic Saline, Inhaled Antibiotics Palm Cups®, percussive vibrators positioning beds, tables, wedges or pillows Therapy names like PEP, OPEP, IPV, PDT, PD&C, BHT, or CPT can get confusing at times. Devices like the Acapella® and Vest™ are very popular right now at NJC. But we also use IPV® for some pediatric patients and the cough assist® for neuromuscular patients who lack the ability to cough. We also use nebulizer treatments in the process of managing the care of patients with thick phlegm but we are leery of nebulizers for use at home because of how easy it can be for this equipment to cause infection when it is not cleaned extremely well. And we still use equipment which can help with tradition bronchial hygiene therapy (Palm Cups®, percussive vibrators, and hospital beds that tilt head down. And someday, if we’re lucky, I look forward to using fancy speakers to knock the phlegm out of people. I’ll call it Boom box therapy  , just kidding. The VibraLung is the invention of a Colorado company using sound waves to clear sputum and my sources tell me it is being tried in the research phase on few select patients at Children’s Hospital, so far that is all I know about it.

Devices Often used at NJC HFCWO system: The Smart Vest HFCWO 10 to 20 minutes, two or three times per day. OPEP devices: Acapella ® DM Acapella ® DH Flutter Valve® (used mainly in the past) OPEP for 15 minutes, two times per day. Here is our airway clearance devices, OPEP devices are hand held and the pt blows through them, and the other devices the pt wears and the machine does most of the work of loosening the phlegm up. Web Sources: dhd.com, thevest.com, axcan.com

Important Mechanisms of Normal Airway Clearance Physiology It takes two: A functional mucociliary clearance system (MCC), also called the mucociliary escalator The ability to cough 1st of all let us review. A famous Colorado respiratory therapist once said, “It takes a healthy functional airway anatomy and the ability to cough well to keep one’s lungs free of the nasty lung butter which causes problems down there.” National Jewish Medical and Research Center

When normal airway clearance becomes impaired the following can occur: Dyspnea (shortness of breath) And the risk factors rise for recurrent, ever-worsening episodes of: inflammation pulmonary infection increased production of excess mucus airway obstruction (mucus plugging) lung damage (lung scaring & remodeling of airways) A vicious cycle of lung damage In many disease states or conditions in which the ability to cough is dysfunctional or the normal mucociliary escalator system is not functioning or becomes overwhelmed retained secretions increases Dyspnea (shortness of breath), and the risk factors rise for recurrent, ever-worsening episodes of: inflammation pulmonary infection increased production of excess mucus airway obstruction (mucus plugging) lung damage (lung scaring & remodeling of airways) respiratory failure & increased risk of mortality Source: NJMRC & www.thevest.com

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Take Bronchiectasis for example In b’ect, mucus production increases, the cilia are destroyed or damaged, and areas of the bronchial wall become chronically inflamed and are destroyed. Something is needed to get rid of mucus in those swollen airways which requires either the airway be splinted open (stretch open) just a little bit more to get air behind this thick stuck mucus and get the flow of air moving behind it which will then push or squeeze all that mucus from the small airway up or out into the larger airways so the patient can then cough out this thick phlegm easier. Flow of air is what will move sputum in bad airways like this one. Source: THE MERCK MANUAL--SECOND HOME EDITION Online, Ch. 47, Bronchiectasis http://www.mercksource.com

Examples of some Chest PT positions & equipment to treat a disease like Bronchiectasis or CF You can treat that pt with B’ect we just looked at with this classic therapy. It require time and help to knock that thick phlegm loose and to get it to drain from the small airways into the bigger ones. If you were the patient here you would need a family member to help you or a hired hand, you may need some Palm Cups, a percussive vibrator, or even special tilt tables or platforms or wedge pillows to aid in your therapy at home. What problems might exist with Chest PT for patients at home compared to receiving therapy like this in a hospital? Physical & emotional toll on the partner or the patient themselves Lack of access to a CPT partner Not a practical task for most patients Tends to lead to non-compliance Risk of complications, discomfort, or pain Gravity is the primary force at work, the energy from clapping or vibration on the chest is secondary -- the energy may only partially reach the airways -- may not be as efficient as other therapies, like PEP, OPEP, or HFCWO. A waste of time if done improperly Expensive to pay for on your own if not covered by insurance if family can’t help

Traditional Therapy Equipment examples  tools to help treat chronic phlegm-retaining diseases the traditional way Manual percussion assistive devices Palm Cups ® Source: www.smiths-medical.com Percussive vibrators Flimm Fighter ® Vibracare ® Neocussor ® Source: www.g5.com Examples of traditional therapy tools to help make CPT more effective include: Manual percussion assistive devices, like Palm Cups®, or electrically or pneumatically powered percussive vibrators, like the Flimm Fighter® or Neocussor®. Not pictured here, are other tools like drainage tilt tables, electric beds, body wedges, body pillows, or large therapy balls to assist with doing postural drainage positioning. Pt compliance with therapy from hospital to the home setting varies and typically diminishes as time goes by. If patients fail to do traditional therapy they end up with that vicious cycle of lung damage again. Images used by permission from the manufacturers

Other Airway Clearance Techniques: Best used in combination with each other or with hand held airway clearance devices Other Airway Clearance Techniques: Coughing and breathing techniques Directed Coughing Huff coughing “Quad cough” Autogenic Drainage (AD) Active Cycle Breathing Technique (ACBT) The focus of this talk is about devices -- but be aware that other techniques are used and you should be aware of them. I always teach Directed Coughing and Huff coughing to all of my patients who need airway clearance device therapy. Having patients use a airway clearance devices and expulsion techniques needs to go hand in hand. The patients I’ve seen who were initially taught to just blow through the device alone for therapy, without combining huffing and a strong cough, generally have failed with their home therapy efforts. National Jewish Medical and Research Center

PEP & OPEP hand held devices PEP (Positive Expiratory Pressure) Cost, usually less than $100 TheraPEP® PARI PEP™ various other brands Vibratory PEP (Oscillatory PEP) Cost, usually < $150 Flutter Valve® Acepella® Quake® Let’s contrast how hand held devices work and function compared to what PDPV therapy does for patients. PEP devices may reduce air trapping in asthma, chronic bronchitis, emphysema, bronchiectasis, CF, and other obstructive airway diseases. PEP may prevent or reverse atelectasis, help to mobilize retained secretions, and may improve aerosol medication delivery (e.g.. PARI PEP®) Resources: smiths-medical.com, pari.com, axcan.com, thayermedical.com

Vibratory PEP via an acapella Choice® After a pt performs about 10 to 12 loosening blows through a device like this then the patient needs to huff 3 to 4 times followed by a directed cough effort. This set of activities is then repeated over and over again to clear phlegm from their lungs. National Jewish Medical and Research Center

National Jewish Medical and Research Center Huff Cough “Huff Cough” or Force Expiration Technique (FET)– is an alternative to deep coughing Huff coughing involves taking a deeper breath than normal. Then use the diaphragm and stomach muscles to make a series of rapid exhalations, with the airway open, making a, “ha, ha, ha,” or “H” sound. This is then followed diaphragmatic breathing, and then a deep cough if mucus is felt moving within the larger airways or trachea. Huff cough -- we will be practicing this together. One definition says: “huff coughing involves taking a deeper breath than normal. Then use the diaphragm and stomach muscles to make a series of 3 rapid exhalations, with the airway open, making a, “ha, ha, ha,” or “H” sound. This maneuver is then followed by controlled diaphragmatic breathing, and then a deep cough if mucus is felt moving within the larger airways or trachea”. Let’s all practice this. Watch me do it then you try it. National Jewish Medical and Research Center

High Frequency Chest Wall Vibration (Oscillation) – HFCWO therapy Airway Clearance Devices 14/04/2017 High Frequency Chest Wall Vibration (Oscillation) – HFCWO therapy SmartVest™, Electromed, New Prague, Minnesota The Vest™ Airway Clearance System, Hill-Rom, St. Paul, Minnesota InCourage™, RespirTech, St. Paul, Minnesota The Vest™, the SmartVest™, and the InCourage™, are models of High-frequency Chest Wall Compression devices currently available in the US. The term “HFCWO” is also used interchangeably to describe these devices. High-frequency Chest Wall Oscillation has often been used to refer to The Vest™ for example -- but a recent review of the studies available as of 2007 suggests that the term High-frequency Chest Wall Compression or just HFCC would be more technically correct or descriptive for devices that use a vest or wrap to vibrate the chest. The system consists of an inflatable vest or wrap, a hose or hoses which connect the vest to an air-pulse generator, and it is this generator which inflates/deflates the vest so it can compresses the chest wall while oscillations occur with a predetermined degree of pressure and vibration speed depending on how the controls are set up. Usually a predetermined amount of time is also set. Variable shaking speeds can be used during a therapy session with brief breaks to expel sputum by using huffing technique and directed coughing. There is ample research evidence behind this technology for certain applications or disease processes. Other forms of HFCWO systems use a chest cuirass to provide similar therapy but do not compress the chest but instead attach to the patient with an external shell by suction pressure to the anterior chest and abdominal wall and then oscillate pressure and flow to facilitate airway clearance, some European companies specialize in this type of system. The proposed mechanism for high frequency chest wall compression or oscillations systems is differential airflow. The expiratory flow rate exceeds the inspiratory flow rate with the mucus moving from the periphery toward the more central airways. Hill-Rom, Inc., www.thevest.com ElectroMed, Inc., www.electromed-usa.com RespirTech, Inc., www.respirtech.com Images used by permission from the manufacturers National Jewish Medical and Research Center 19

Resource: www.coughassist.com Cough Assist Device™ Also known as the insufflator/exsufflator is a cough simulator for people incapable of generating their own cough effort It gives positive pressure during inhalation to expand the lungs Then negative pressure is applied to simulate a cough & clear secretions The Cough Assist™ device is also known as the insufflator/exsufflator is a device that functions as a cough simulator. Positive pressure is given during inhalation and the lungs expand. Negative pressure is then applied to simulate cough and induce secretion clearance. Used with patient’s incapable of generating their own cough effort. “coughalator” Resource: www.coughassist.com

IntraPulmonary Percussive Ventilation Percussive PEP (IPV types of nebulizer): Impulsator® (IPV®) by PERCUSSIONAIRE® Corp. PercussiveNEB™(P-NEB), by Vortan Medical Corp. These are aggressive aerosol devices with an air jack hammer like effect that may be appropriate for some patients, however, disadvantages can include: availability, cost, cleaning, and complexity of use. www14.inetba.com/percussionaire www.vortran.com Percussionaire & Vortran Medical - Corporations

Sound Wave Airway Clearance Devices / Emerging Technologies Products not fully approved or adopted yet as mainstream airway clearance devices that use sound or acoustic waves to help loosen mucus in the chest. Possible methods: (1) Externally applied to the chest wall. (2) Internally applied to the airways at the mouth. The Frequencer™ The Lung Flute™ VibraLung™ Products still being researched, or that have not yet become mainstream airway clearance devices use sound or acoustic waves to help loosen mucus in the chest: The Frequencer™, The Lung Flute™, and the VibraLung™. Emerging technologies like these have two possible design methods in which acoustic energy can be applied as an airway clearance tool, either, externally applied to the chest wall, or internally applied to the airways via the mouth. Images used by permission from the manufacturers

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