1. BRONCHIAL HYGIENE Dr. S Sai Janani INCLUDING RETAINED SECRETIONS, AEROSOL THERAPY AND HUMIDIFICATION University College of Medical Sciences & GTB Hospital, Delhi

2. PHYSIOLOGY OF RESPIRATORY TRACT 20 – 22C 50% humidity 29-32C 95%humidity 32-35C 100%humidity ISB

3. HUMIDIFICATION Humidity therapy refers to addition of water vapor and heat to the inspired gas as a direct therapeutic procedure or as an adjunct to other therapy.

4. CONSEQUENCES OF INADEQUATE HUMIDIFICATION Inadequate humidification of gases Impaired mucociliary clearance Retention of viscid tenacious secretions Bacterial infiltration of mucosa Atelectasis Pneumonia Hypothermia Drying of tracheobronchial tree

5. INDICATIONS PRIMARY: Humidifying dry medical gases Bypassed upper airway for ventilation SECONDARY: Treating bronchospasm caused by cold air Management of hypothermia

6. HUMIDIFIERS Humidifier is a device that adds molecular water to gas being delivered. TYPES: Pass- over humidifier Bubble diffusion humidifier Heat and moisture exchanger

7. PHYSICAL PRINCIPLES OF HUMIDIFIERS Affected by: Temperature Surface area Time of contact

8. BUBBLE DIFFUSION HUMIDIFIER Breaking of gas into small bubbles and allowing it to come into intimate contact with liquid

9. Bubble humidifier…… contd Disadvantage: – Aerosols are produced – High risk of spreading infections

10. MEMBRANE HUMIDIFIER

11. WICK TYPE HUMIDIFIER

12. HEAT MOISTURE EXCHANGER Passive humidifier Preserves heat and moisture of patient’s exhaled air and delivers it to patient’s respiratory tract on next inspiration Hygroscopic or Hydrophobic membranes – act as filters

13. HYGROSCOPIC CONDENSER HUMIDIFIER: 1.Condensing element of low thermal conductivity (paper, wool or foam) 2.Impregnation of hygroscopic salt (Ca or LiCl) HYDROPHOBIC CONDENSER HUMIDIFIER: 1.Condensing element with low thermal conductivity 2.Added bacterial filter – HMEF EFFICIENCY – 70%

14. HME

15. STANDARDS FOR HME Design and performance standards set by ISO: Ideal HME - 70% efficiency or better ( 30 mg/L water vapor) Use standard connections Low compliance Minimal weight to the circuit Minimal Dead space Minimal flow resistance

16. ADVANTAGES OF HME 1. Eliminates breathing circuit condensation 2. Hydrophobic bacterial filters

17. POSITION OF HME

18. HEATING SYSTEM HEATING ELEMENTS: 1. Hot plate 2.Wrap-around type 3.Yolk or collar type 4.Immersion type 5.Heated wire in the inspiratory limb CONTROLLED HEATING: 1.Attaching temperature monitors 2.Servo controlled

19. HME RESERVOIR Simple large reservoir systems:Manual refilling 1.Momentary disruption 2.Contamination Automatic feed systems: 1.Level compensated reservoir 2.Flotation type systems

21. SETTING HUMIDIFICATION LEVELS Current AARC guideline: 33 ˚ C within 2 C with a minimum of 30 mg/L of water vapor. The optimal level is 37 C with 100% relative humidity and 44 mg/L.

22. PROBLEM SOLVING AND TROUBLESHOOTING Condensation Cross contamination

23. CONDENSATION Factors influencing amount of condensation: – Temp difference across the system – Ambient temperature – Gas flow – Set airway temperature – Length, diameter of breathing circuit. Risk: – Disrupt or occlude gas flow – Aspiration – infection To minimize: – Water trap – Heated wire circuits

25. AEROSOLS Aerosol – suspension of very fine particles of liquid in a gas BLAND AEROSOL THERAPY: Sterile water hypotonic, isotonic and hypertonic saline.

26. FUNCTIONS Aids bronchial hygiene Hydrates dried and retained secretions Restores and maintains mucous blanket Promotes expectoration Improves effectiveness of cough Humidifies inspired gases Acts as a means to deliver medications

27. DEVICES ATOMIZER – device that generates an aerosol. NEBULIZER – device that generates aerosols of uniform particle size.

28. MECHANISM- BAFFLING Baffle = device that deflects gas flow When a baffle device is placed in the path of gas flow that contains water particles, the large particles impact on the baffle and ‘rain out’ of the aerosol whereas the smaller particles pass with the gas stream around the baffle. More baffles in series = more small and uniform the particle size Water surface, sides of container, rt. angled bends = Baffles

29. TYPES OF NEBULIZERS Steam nebulizer (Hand held nebuliser) - steam Pneumatic nebulizer – pressurised gas Electric nebulizer – electric source Jet nebulizer Hydronamic nebulizer Ultrasonic nebuliser

30. ULTRASONIC NEBULISER

31. PROBLEMS WITH NEBULISERS Cross contamination Infection Environmental safety (immunocompromised pts) Inadequate mist production Over hydration : – cautious use in pediatric age group – Worsening airway obstruction BRONCHOSPASM – History – Initial monitoring required every 8 hrs – If occurs during therapy – conservative management. NOISE

32. BRONCHIAL HYGIENE THERAPY

33. DEFINITION Refers to the use of non invasive airway clearance techniques designed to help mobilize and remove secretions and improve gas exchange

34. Primary bronchial hygiene mechanisms: 1.Mucociliary complex 2.Cough

36. MUCOCILIARY ESCALATOR

37. PHYSIOLOGY OF COUGH REFLEX

38. NEED FOR BRONCHIAL HYGIENE THERAPY Abnormal clearance Retained secretions- Mucus plugging Partial or complete obstruction Atelectasis V/Q mismatch Impaired oxygenation

39. Impaired mucociliary clearance Endotracheal or tracheostomy tube Tracheobronchial suction Inadequate humidification High FiO 2 Drugs – General anesthetics, narcotics.

40. IMPAIRED CILIARY ACTIVITY

41. Mechanisms impairing cough reflex Anesthesia CNS depression Narcotic – analgesics IRRITATION: Pain NM dysfunction Pulmonary or abdominal restriction INSPIRATION: Laryngeal n damage Artificial airway Abd muscle weakness or surgery COMPRESSION: Airway compression Airway obstruction Abd muscle weakness Inadequate lung recoil (eg., emphysema) EXPULSION:

42. INTIAL ASSESSMENT OF NEED FOR BHT : History: – H / O pumonary problems causing increased secretions – If pt. for upper abdominal or thoracic surgery : Age COPD Obesity Nature of procedure Type of anesthesia Duration of procedure

43. EXAMINATION Posture of patient Effectiveness of cough Sputum production Breathing pattern General physical fitness Breath sounds HR, BP,RR

44. COMPONENTS OF BRONCHIAL HYGIENE BREAK DOWN SIZE Mucolytics humidification DISLODGE them Chest physiotherapy MOBILIZE TO CENTRAL AIRWAYS Postural drainage Chest physiotherapy REMOVE FROM LUNGS Directed cough ET suctioning RE EXPAND THE LUNGS Incentive spirometry Bronchodilation (aerosols) IPPB, PEP, CPAP

45. CHEST PHYSIOTHERAPY Chest percussion Vibration Postural drainage Directed cough Includes

46. CHEST PERCUSSION Rhythmic “clapping” with cupped hands over the involved lung segments, with the patient in appropriate postural drainage positions FUNCTIONS: Loosens / dislodges the adherent bronchial secretions Mobilizes secretions towards central airways Increases efficiency and distribution of ventilation

47. TECHNIQUE: Strike chest wall with cupped hands Move from periphery to central airways Perform throughout inspiration and expiration Avoid bony prominences and breast tissue

48. Cupped hands = compressed air Mechanical energy wave Chest wall to lung tissue DISLODGE SECRETIONS

49. Pain and discomfort Bruising Rib #s Spread of tumor cells Contaminates other areas of the lung Hemorrhagic conditions SIDE EFFECTS AND CONTRAINDICATIONS:

50. CHEST VIBRATIONS Loosens adherent bronchial secretions and mobilizes them towards central airways TECHNIQUE: Hands placed one over the other or either side of the chest Rapid vibrations produced in the arms while compressing chest wall in the direction of ribs During exhalation or end inspiration – FREQUENCY = 200/ min

51. POSTURAL DRAINAGE Drainage of secretions by effect of gravity from one or more lung segments to the central airways MECHANISM: – Mobilises secretions in the direction of gravity to promotr removal of retained secretions – Matches V&Q

52. TECHNIQUE: Segment that needs to be drained is placed in the non dependent position (superior to carina) Position changed – Awake patient: 3-15 min – Intubated and hemodynamically unstable pts: 2 hrly Alone or with other techniques

53. Paterson’s Postural drainage

54. Patient positioning for postural drainage

55. SIDE EFFECTS AND CONTRAINDICATIONS: – Hypoxemia – Acute hypotension – Dysrhythmias – Bronchospasm – Vomiting & aspiration – Undrained lung abscess

56. MUCOLYTICS Bromhexine Acetylcysteine Carbocysteine

57. BROMHEXINEACETYLCYSTEINECARBOCYSTEINE MOADepolymerises mucopolysaccharid es – network of fibres broken Opens disulfide bonds in mucoproteins present in sputum Similar to acetylcysteine SIDE EFFECTSGI irritation, lacrymation, rhinnorhea GI irritation Rashes ROUTEOralAerosol Tracheal instillation Oral DOSE4mg/5 mL 2 tsf TDS (adults) 4 mg BD (1-4 yrs) 4 mg TDS (5-10 yrs) 1,2,5 mL ampoules (200 mg/mL) 250 – 750 mg TDS

58. COMPONENTS OF BRONCHIAL HYGIENE BREAK DOWN SIZE Mucolytics humidification DISLODGE them Chest physiotherapy MOBILIZE TO CENTRAL AIRWAYS Postural drainage Chest physiotherapy REMOVE FROM LUNGS Directed cough ET suctioning RE EXPAND THE LUNGS Incentive spirometry Bronchodilation (aerosols) IPPB, PEP, CPAP

59. DIRECTED COUGH Deliberate manouvre to simulate spontaneous cough. Technique: pt taught to assume a position that facilitates easy thoracic compression Inspiration done slowly and deeply through the nose Followed by chest percussion and vibration to loosen secretions Stimulates cough. Indications: COPD, lobar pneumonia

60. FORCED EXPIRATORY TECHNIQUE Alternative to directed cough “Huff cough” Principle: 1 -2 forced expirations of middle to low lung volume without closure of the glottis, followed by a period of diaphragmatic breathing and relaxation. Indicated: COPD, lobar pneumonia

61. COUGH ASSIST EXSUFFLATOR

62. PAP Used to mobilize secretions and prevent atelectasis TECHNIQUES: – CPAP – Expiratory PEP – PEP

63. PEP PRINCIPLE: Helps move secretions to larger airways by 1. filling underaerated or nonaerated segments via collateral ventilation 2. preventing airway collapse during expiration TECHNIQUE: Active expiration against variable flow resistance A subsequent huff or FET manouvre allows the patient to generate airway pressures needed to expel the secretions. Combined with other strategies for bronchial hygiene, it is a very effective manouvre

64. PAP ADJUNCTS

65. COMPONENTS OF BRONCHIAL HYGIENE BREAK DOWN SIZE Mucolytics humidification DISLODGE them Chest physiotherapy MOBILIZE TO CENTRAL AIRWAYS Postural drainage Chest physiotherapy REMOVE FROM LUNGS Directed cough ET suctioning RE EXPAND THE LUNGS Incentive spirometry Bronchodilation (aerosols) IPPB, PEP, CPAP

66. ENDOTRACHEAL AND TRACHEOSTOMY TUBE SUCTIONING Principle: Negative pressure applied to airway Technique: Sterile precautions Closed vs. open devices Catheter diameter = < ½ OD of the endotracheal tube used. Suction pressure = 100 mmHg ( ADULTS) 60 -80 mmHg (PEDIATRIC)

67. Bibliography 1.Egan’s Respiratory care – 9 th edition 2.The ICU Book- Paul L.Marino- 3 rd edition 3.Miller’s Anesthesia – 6 th edition 4.AARC guidelines for bronchial hygiene therapy – 2008 5.Textbook of Mechanical Ventilation – Chang 3 rd edition