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Presentation on theme: "AIRWAY CLEARANCE Karen Conyers, BSRT, RRT."— Presentation transcript:


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


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

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

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

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

8 Age 8 Years 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 Gradual loss of volume Loss of elasticity
Decreasing compliance Environmental effects Smoking Air pollution Occupational hazards Disease effects

10 Factors Affecting Airflow
Airway resistance Turbulent airflow 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. Cross-sectional areas: trachea diameter cm 4th generation bronchi cm bronchioles cm acinus cross-section cm Greatest airway resistance in large airways; laminar airflow in small airways

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

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


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

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

17 Impaired airway clearance
A Vicious Cycle Impaired airway clearance Mucus retention Mucus plugging, obstruction Lung damage Lung infection Inflammation, mucus production

18 Impaired airway clearance
Entering the Cycle ASTHMA NEURO- MUSCULAR WEAKNESS Impaired airway clearance PRIMARY CILIARY DYSKINESIA Mucus Retention Mucus plugging, Obstruction ASPIRATION Lung Infection Lung Damage CYSTIC FIBROSIS GASTRO- ESOPHAGEAL REFLUX Inflammation, Mucus production ASPERGILLOSIS


20 Airway Clearance Techniques
Goals Conventional Methods Newer Therapies Therapy Adjuncts

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

22 Conventional methods Cough Chest Physiotherapy Exercise

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

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

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

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

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

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

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

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

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

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

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

34 Forced Expiratory Technique
“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
Three steps: Breathing control Thoracic expansion / breath hold Forced expiratory technique May be performed independently Easily tolerated

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

UNSTICKING VT Normal Breathing ERV RV Complete Exhalation


39 Therapy Adjuncts Antibiotics Bronchodilators Anti-inflammatory drugs
Mucolytics Nutrition

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

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

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

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

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

45 Interrupting the Vicious Cycle
Impaired airway clearance NUTRITION MUCOLYTICS Mucus plugging, obstruction Mucus retention AIRWAY CLEARANCE TECHNIQUES BRONCHODILATORS Lung Damage Lung infection INFLAMMATORIES ANTI - ANTIBIOTICS Inflammation, mucus production

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