CHAPTER 8 BRONCHOPULMONARY HYGIENE TECHNIQUES
PRETEST QUESTIONS
1. Postural drainage and percussion are not indicated in which of the following conditions?
2. In which of the following airway clearance techniques is the patient instructed to alter VT in three phases before a cough effort?
3. The respiratory care practitioner receives an order for postural drainage on a patient to mobilize secretions from the anterior segment of the right upper lobe of the lung. How should the patient be positioned for the lung to drain most effectively?
4. A 34-year-old patient using a 40% aerosol mask has right lower lobe pneumonia. He becomes short of breath and his SpO2 decreases from 96% to 89% when lying on his right side. What should the respiratory therapist recommend?
REVIEW
CRT Exam Content Matrix: IIA14a, IIIA1a-b, IIIC1a, IIIC4, IIIF1, IIIF2f1-2
Exam Note
1. A means of improving the mobilization of pulmonary secretions by manually striking the chest wall with a cupped hand or placing a mechanical percussor on the chest wall. Both of these techniques are generally performed with the patient in postural drainage positions.
2. Mechanical percussors operate on either compressed air or electricity and are thought to be more effective than manual hand percussion.
g. Bare skin: Although some practitioners advocate manually percussing over bare skin, the energy wave produced by the air trapped under the hand is not significantly reduced by a light covering, such as a hospital gown.
1. For manual vibration, place one hand on top of the other over a specified lung segment, and with a vibrating motion, apply moderate pressure.
3. Mechanical vibrators may be used; place the vibrator attachment over specified areas. Do not apply the vibrator to one area for more than 45 to 60 s at a time.
c. May be minimized by administration of a bronchodilating agent before CPT and delivery of supplemental O2 during the treatment.
b. Suction equipment should be readily available for patients having difficulty expectorating secretions.
b. CPT should be performed no sooner than 1 h after a meal. Continuous tube feedings should be stopped 1 h before and during treatment.
1. Instruct the sitting patient to inhale deeply through the nose and to hold his or her breath for 3 to 5 s.
2. Instruct the patient to clasp his or her arms across the abdomen and produce two to three sharp coughs without taking a breath, while pressing the arms into the abdomen.
3. Use a pillow to splint thoracic or abdominal incisions to decrease pain and improve the cough effort.
II. OTHER BRONCHOPULMONARY HYGIENE TECHNIQUES
CRT Exam Content Matrix: IIA14b-c, IIIA1a-b, IIIC1d, IIIC4, IIIF2f1-2
RRT Exam Content Matrix: IIIA1a-b, IIIC1d, IIIC14
1. Autogenic drainage is a modified coughing technique that is comparable in secretion clearance to postural drainage and percussion techniques.
2. Place the patient in a sitting position and instruct him or her to use a breathing pattern that varies lung volume and expiratory flow in three different phases.
a. Phase 1: From the resting expiratory level, the patient takes the deepest breath possible (inspiratory capacity maneuver) followed by breathing at low lung volumes for several breaths.
b. Phase 2: The patient increases VT to low to middle volumes for several breaths. (These breaths are slightly larger the than normal VT.)
c. Phase 3: The patient then increases VT to moderate volumes for several breaths. After this phase is completed, instruct the patient to cough.
3. This type of breathing pattern helps loosen secretions and moves them into larger airways so that they may be mobilized with an effective cough.
4. This technique has shown some promise in patients with cystic fibrosis. It appears to mobilize secretions in a way comparable to postural drainage and percussion but without the degree of O2 desaturation, and it is tolerated better in these patients.
5. This technique is difficult to teach the patient, which can pose a problem because it is taught for the patient’s independent use.
1. This airway clearance technique uses a pneumatic ventilator to deliver a series of small VTs at high frequency (110 to 225 cycles/min).
2. The length of each percussive cycle is controlled by either the practitioner or the patient using a thumb control button.
3. These pressurized bursts of gas are delivered to the patient via a mouthpiece. Bronchodilating or mucolytic agents may be administered through a pneumatic nebulizer during this 15- to 20-min treatment.
4. The pulsed gas flow is as effective in breaking up secretions for easier mobilization as postural drainage and percussion are in patients with cystic fibrosis.
5. This procedure has an advantage over conventional CPT in that fatigue and practitioner technique are not a factor.
1. High-frequency chest wall oscillation (HFCWO) is a technique to improve sputum clearance from the airways.
2. An inflatable vest is wrapped around the patient’s chest and is attached to an air-pulse generator, which intermittently injects small volumes of air into the vest and then ejects them out at a high rate. This creates oscillatory movement that helps mobilize secretions.
3. The duration of therapy is usually about 30 min, and an oscillation frequency of between 5 and 25 Hz (300 to 1500 cycles/min) is used.
4. This technique has not yet been proven to be as effective as postural drainage or percussion in patients with cystic fibrosis.
1. PEP is a bronchial hygiene therapy used in the management of airway secretions and postoperative atelectasis.
2. It is becoming increasingly popular as an alternative to CPT and incentive spirometry, especially in pediatric patients with cystic fibrosis and bronchiectasis.
3. It is also effective in preventing postoperative atelectasis by opening airways and improving gas exchange.
4. PEP is achieved by having the patient exhale through a mask or mouthpiece with a resistance valve. The valve creates back pressure into the patient’s airway. Different sizes of resistors or adjustable resistors are used to increase or decrease the amount of PEP. Generally, PEP levels of 10 to 20 cm H2O are used.
a. Improved distribution of inspired volume in the lung by means of collateral air channels (pores of Kohn).
b. Position the patient sitting up with elbows resting on the table; apply the mask tightly (to prevent leaks) over the nose and mouth.
c. Instruct the patient to inhale a larger-than-normal volume but not quite as deep as possible and then actively exhale but not forcefully; expiration should last two to three times longer than inspiration.
d. The patient should perform 10 to 20 of these PEP breaths, and then remove the mask and perform two to three “huff” coughs, also referred to as the forced expiratory technique (FET), which requires forceful exhaling from a middle to low lung volume with an open glottis. This is very effective for secretion clearance.
8. PEP therapy may be an effective alternative to postural drainage and percussion and has the added benefit that the patient can perform this simple task independently with fewer side effects.
9. PEP therapy may also be combined with aerosolized bronchodilator therapy if a nebulizer or an inhaler is attached to the one-way inspiratory valve of the PEP device.
10. If the pressure being used appears to be ineffective while assessing the patient during therapy, increase the PEP level by 3 to 5 cm H2O and continue to monitor.
FIGURE 8-11 Flutter valve.
From Wilkins RL, Stoller JK, Kacmarek R: Egan’s fundamentals of respiratory care, ed 9, St Louis, 2009, Mosby.
1. The flutter valve is a pipe-shaped oscillatory PEP device (see diagram) through which the patient exhales to produce a PEP of between 10 and 25 cm H2O. The angle at which this device is held will determine the PEP. The more upright the flutter is held, the higher the PEP generated back down the airway.
2. Instruct the patient to inhale slowly, just a bit more than a normal breath (not totally filling the lungs), and hold the breath for 2 to 3 s. The patient should then exhale reasonably fast, but not forcefully, through the flutter device, which causes a stainless steel ball to be pushed up into the angled portion of the device to produce PEP. The angle causes the ball to oscillate, or “flutter,” up and down. The oscillations are transmitted down the respiratory tract, creating vibrations that result in mobilization of secretions.
3. This technique should be repeated 5 to 10 times to help loosen secretions and should be followed by coughing to aid in the removal of sputum. The treatment should last 5 to 15 min.
4. The effectiveness of the device is controversial, but some studies have shown improved secretion clearance in patients with cystic fibrosis.
5. The flutter valve may be disassembled after each use and rinsed in tap water and dried before reassembly. In the home, the device should be cleaned every 2 days in a soap solution and disinfected at regular intervals; it should be soaked in a 1 : 3 solution of white vinegar and water for 15 min, dried, and reassembled for future use.
2. It uses a counterweighted plug and magnet that directs the patient’s exhaled air through a pivoting cone to generate vibrations down the tracheobronchial tree. The PEP level and vibration frequency may be adjusted to meet the patient’s clinical needs.
Exam NotePOSTCHAPTER STUDY QUESTIONS
1. What is the most appropriate pressure range for PEP therapy?
2. What is the range of pressure used for flutter valve therapy?
3. What types of patients seem to benefit the most from intrapulmonary percussive ventilation?
4. Intrapulmonary percussive ventilation, flutter valve therapy, and PEP therapy may be alternatives for what other popular therapy?
5. List five complications of CPT.
6. To drain the posterior basal segment of the lower lobe of the lung, how should the respiratory care practitioner position the patient?
