1. Airway Clearance Techniques
PTP 673 CardioPulmonary Plan of Care
July 16th, 2013
Emily E. Houser, PT, DPT, CCS

2. Objectives Lecture: Lab: Introduction to airway physiology
Continued information on airway clearance techniques
Apply differential for choice of intervention
Provide literature to support evidence based practice
Lab:
Hands on practice of techniques and devices

3. Why is this important?? If you can’t breathe, you can’t function!
DPT: We need to look at all body systems to properly assess and successfully treat a problem.
Linda Crane Memorial Lecture: The Patient Puzzle, Piecing it all together.

4. Breathing is a multisystem EventMS
NM: GBS, SCI CP
INT: burns, scerolderma
IO: Obesity, room for diaphragm

5. Respiration - Interconnection
Every muscle of respiration is ALSO a muscle of posture
Respiration and Posture = duality of function
External and Internal pressures that affect one – will affect the other
PRESSURE IS THE KEY

6. Soda-Pop Can Model
Low pressure system: trachy and low tone

7. Cystic fibrosis: hump is were pressure is coming out.

8. Soda-Pop Can Model
COPD, high pressure, hyper-inflated

9. Work of Breathing
Work of breathing is the energy cost of inspiration and expiration.
In normal healthy individuals their work of breathing is not a limiting factor even with strenuous activity.

10. Function and Work of Breathing
In the presence of respiratory or cardiac compromise work of breathing can be a major portion of the total energy expenditure for a person and can also be a primary limiting factor for function and survival.
EX: cant breathe when eating: look at posture, leaning against chiar?

11. Impaired Ventilatory Pump Function
Increased work of inspiration:
Posture/kyphosis
Connective tissue diseases
Pregnancy
Obesity
Pleural effusion
Pneumonia/inflammation
Neuromuscular disease/SCI/CVA/Guillian Barre
Ventilatory muscle length and strength
Excessive pulmonary secretions

12. Impaired Ventilatory Pump Function
Increased work of expiration
Secretions: cystic fibrosis
Bronchial smooth muscle tone
Structural stability of the airways
COPD
Inflammation of airways
Expiratory muscle weakness

13. Impaired Airway Clearance
Mucociliary Elevator
Pharmacological approaches
Physical Approaches

14. Secretions MOBILIZATION EXPECTORATION MANAGEMENT Chest wall stretching
Assisted Cough Techniques
Oral suctioning
Percussion/
Vibration/ PD
Positioning
Breathing Exercises/ PEP Devices
Suctioning
Equipment
Aerobic exercise
Cough assist machine

15. Chest Physical Therapy
Incorporates all these aspects to achieve optimal functioning.
ROLE: To minimize the impact of airway clearance and ventilatory impairments on a patient’s functional capacity, ADL’s, work, and leisure.
Included with this, are airway clearance techniques.

16. Classics Postural Drainage Percussion Vibration Suctioning Example:
ketchup bottle

17. Postural Drainage Positions
Don’t do the inverted position, so B sidelying with change in arm position, prone, and sitting edge of bed.

18. HFCWO: High Frequency Chest Wall Oscillation
“The Vest”
All CF pt use, CP, TBI can also use. For secretion mobilization.

19. The Vest Used to help facilitate secretion mobilization. Settings
Provides:
Compression
Vibration
Settings
Compression: between 1-8, 4 is most common
Vibration: Between 6-16, 12 is most common

20. The Vest Has actually been around and evolved over the past 20 years.
Good option for patients who have need for daily secretion removal. Also for use in ICU pts.
Can be done independently.
Can be done in conjunction with nebulizer treatments.
Is expensive: approx 15K.
Still need a regime for vest, can help get a lung transplant. $15,000, but maintaince is for life.

21. The Vest Important that it’s not too tight or vibrating too fast.
Need to find individual settings which work.
Recommend using at least 10 minutes, or until patient feels secretions moving. Typically 20
Encourage coughing several times after each cycle, when there is something in upper airway to clear.

22. The Vest Recommend changing positions; not just sitting
Recommend doing aerobic activity while using the vest
Such as:
Stair stepping
Marching in place

23. Efficacy
Most research will show that if properly instructed, can be as effective as classic techniques.
But also is not ‘fool proof.’ In terms of PFT’s and sputum production as outcomes, it has also been shown to be less effective.
(Kluft, 1996; Oermann, 2001; Phillips 2004)
**Key, must fit the individual for their needs.
FVI: used for transplant, closer to 20% is transplant.

24. PEP devices Postive End Pressure Regular PEP (low pressure)
‘Thera-PEP’
Oscillatory PEP (low pressure)
Flutter
Acapella

25. Rationale for PEP therapyB. A.
COPD: airways collapse, so need to keep open.
Collateral ventilation facilitates air movement between adjacent lung segments
Airway wall splinting, stabilizing, back pressure (blunting effect)
Decreases asynchronous ventilation - for equal filling (not shown)

26. Thera-Pep Can use a mouth piece or facemask Can change resistance
Gives an incentive meter – this device is similar to incentive spirometer, just opposite.
Tough to get buy in from patient

27. Flutter Valve
Blow air in; pushing steel ball which creates resistance and vibration for airway.
Positional Dependent. Need to hold at correct angle.
Requires strong expiratory force to use.

28. Acapella
Blow air in, pushing on diaphragm which creates vibration for airway.
Can be done in any position and angle.
Can adjust the resistance, and comes in different levels.
Can actual deliver nebulizer treatments through them.

29. Efficacy
PEP has significant advantages compared to conventional postural drainage and percussion. PM, McIlwaine et al. Pediactric Pul. Suppl 12,
Flutter may not be as effective as PEP in maintain pulmonary function in CF pt. PM McIlwaine. This may be due to having to maintain same position.
**Something is better than nothing, need to individually assess best results.