1. Initiation and Modification of Therapeutic Procedures
Remove Bronchopulmonary Secretions

2. Many of your patients will require assistance in removing bronchopulmonary secretions in order to maintain a patent airway.
Therapies include postural drainage, percussion, vibration, directed coughing, and use of adjunct mechanical devices to aid secretion clearance.
Drugs and bland aerosols can be used to facilitate secretion clearance
All of these techniques ultimately intend to improve ventilation and gas exchange.

3. Selecting the Best Approach
Important factors include the patient’s:
Age
Preexisting condition
Personal preference
Selection and implementation should be based on patient’s
Diagnosis
Volume of sputum produced
Ability to cough effectively

4. Postural Drainage, Percussion, Vibration, and Turning
Postural drainage, percussion, and vibration (PDPV) is indicated in conditions that increase the likelihood of mucous plugging and atelectasis.
Contraindications, hazards, and complications must be considered before beginning therapy.
You should monitor patient’s clinical status before, during, and after the therapy:
Overall appearance
Vital signs
Breathing pattern
Pulse oximetry

5. Postural Drainage, Percussion, Vibration, and Turning
Effectiveness and outcome of PDPV is assessed by monitoring:
Changes in chest x-ray
Changes in vital signs
Changes in pulse oximetry
Sputum production
Breath sounds
Recommend discontinuing when sputum production drops below 30 ml/day and patient can generate an effective spontaneous cough

6. Instruct and Encourage Bronchopulmonary Hygiene Techniques
Directed Cough
Instruction in the three phases of a cough
Deep inspiration
Compressions against a closed glottis
Explosive exhalation
Splinting incisional sites with a pillow

7. Instruct and Encourage Bronchopulmonary Hygiene Techniques
Forced Expiratory Technique (FET) – “Huff” Coughing
2-3 exhalations, or huffs, with glottis open
Best suited for post-op patients for whom explosive exhalation is very painful, and COPD patients prone to airway closure on forced exhalation
Abdominal Thrust
Push on the upper abdomen with an upward motion towards the epigastrium in synchrony with the expiratory phase of the patient’s own cough effort
Autogenic Drainage
Usually combined with directed coughing

8. Mechanical Devices to Facilitate Secretion Clearance
High-frequency Chest Wall Oscillation systems, simple and vibratory PEP devices, Intrapulmonary percussive ventilation
Mechanical insufflator-exsufflator (MI-E) (cough assist)
Indications: Weak cough effort as suggested by maximum expiratory pressure less than 60 cm H2O
Contraindications:
History of bullous emphysema
Susceptibility to pneumothorax or pneumomediastinum
Recent barotrauma

9. Clearance of Secretions via Suctioning
Indications:
Presence of a weak, loose cough
Auscultation revealing rhonchi
Direct observation of secretions in the mouth or oropharynx
Fremitus felt on the chest wall
Patient feedback suggesting retained secretions
Precaution: Suctioning is the one of the most dangerous procedures you will perform. Careful implementation of patient safety measures before, during and after, as well as careful monitoring throughout can prevent or minimize most risks.

10. Clearance of Secretions via Suctioning
Routes for Suctioning
Oropharyngeal
Normal use Yankauer suction tip
Suctioning though a tracheal airway
Properly set suction pressures
Always select suction catheter with an outside diameter (OD) no larger than ½ the inner diameter of the patient’s artificial airway.
Estimate correct Fr. size by doubling the internal diameter (ID) of the tracheal tube and selecting the next smallest catheter size
Maintain adequate PEEP levels during mechanical ventilation by using a closed suction system

11. Clearance of Secretions via Suctioning
Nasotracheal suctioning
The most common method used to clear secretions in patient who do not have artificial airways, but do have an ineffective cough
Assessment of Effectiveness of Suctioning
Amount of secretions removed
Changes in breath sounds
Changes in vital signs and oxygenation

12. Administer Aerosol Therapy with Prescribed Medications
Bland Aerosols
May be helpful for patients with bypassed upper airways or those otherwise predisposed to retain secretions.
May benefit the patient by
Ease of secretion clearance
Deceased work of breathing
Improved vital signs
Decreased stridor
Improved arterial blood gas values
Improved oxygen saturation as indicated by pulse oximetry
Generally provided continuously via large volume jet nebulizer

13. Administer Aerosol Therapy with Prescribed Medications
Administration of Prescribed Agents
Bronchodilators are designed to dilate or open the airways
Mucolytics thin secretions
Inhaled corticosteroids reduce airway inflammation and help maintain airway patency and may reduce secretion production
Diluting agents (aerosolized hypertonic saline) thin secretions and help with mucous removal

14. Common Errors to Avoid on the Exam
Avoid performing postural drainage, particularly in a head- down position, in the presence of an intracranial pressure (ICP) greater than 20 mmHg or an unstable head or neck injury, with an active hemorrhage, or in the presence of hemodynamic instability.
Don’t apply an abdominal thrust maneuver to help clear secretions on a patient with abdominal trauma or surgical incisions
Avoid using positive expiratory pressure (PEP) adjuncts on patients with acute exacerbations of asthma or COPD, or on any patient who cannot tolerate the short-term added work of breathing caused by these devices.

15. More Common Errors to Avoid on the Exam
Don’t use excessive suction pressures on patients; many hazards may be avoided. In general, suction pressures should never exceed -120 mmHg for adults, -100 mmHg for children, and -80 mmHg for infants.
Avoid applying suction to the airway for more than 15 seconds for each attempt.
Avoid performing percussion and vibration therapy immediately before or after meals.

16. Exam Sure Bets
Always monitor a patient before, during and immediately following bronchial hygiene therapy to assure that they are tolerating the therapy. Such assessment should include their overall appearance, vital signs, breath sounds, and possible other indicators, such as pulse oximetry.
Always remember that if a patient appears to be having an adverse reaction to bronchial hygiene therapy, stop the therapy, stay with the patient and monitor him or her, help stabilize the patient, and immediately notify the nurse and physician

17. More Exam Sure Bets
Always consider that a patient with recent thoracic or abdominal surgery may have trouble with the inspiratory and expiratory phases of coughing. For such patients, splinting the incision site with a pillow often permits them to generate a more effective cough.
Always recognize that some patients with an ineffective cough may need help both loosening secretions through percussion and vibration as well as clearing mucous through such means as cough assist or suctioning.

18. More Exam Sure Bets
Always remember that patients with a weak cough, rhonchi, visible secretions, or fremitus on the chest wall may need bronchial hygiene therapy
Always oxygenate a patient with an FiO2 of 100% at least a minute before each suction attempt.
Always consider recommending the addition of bland aerosol and the administration of prescribed agents, such as bronchodilators and mucolytics if a patient is unable to clear secretions in spite of percussion, vibration, and turning, as well as other adjuncts such as PEP and cough assist.
Always remember that the effectiveness of bronchial hygiene therapy can be assessed through an improvement in breath sounds, vital signs, oxygenation, and overall appearance.

19. Reference:
Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli
Jones and Bartlett Publishers