Based on information found in American Association for Respiratory Care: Clinical practice guideline: postural drainage therapy, Respir Care 36:1418, 1991.

TURNING

• Patient unable to change his or her body position (e.g., the patient has a cerebral injury or neuromuscular disease, is being mechanically ventilated, or has been medicated to cause sedation or paralysis)

• Atelectasis or the potential for its development

• Hypoxemia associated with a particular position; if one-sided lung disease is present, the patient is typically turned so that the affected lung is superior

• Patient with an artificial airway

POSTURAL DRAINAGE

• Mobilize retained secretions so that they can be coughed or suctioned; patient has difficulty expectorating secretions but produces more than 25 to 30 mL/day; evidence or indications that a patient with an artificial airway has retained secretions

• Atelectasis that is known or is believed to be caused by a mucous plug

• Patient diagnosed with cystic fibrosis, bronchiectasis, or cavitating lung disease

• Foreign body in an airway

• Removal of aspirated foreign body or stomach contents

PERCUSSION AND VIBRATION

• Patient receiving postural drainage who has a large volume of thick sputum; this suggests that external manipulation of the thorax would assist gravity in its movement toward a more central airway

BOX 10-2 Contraindications for Turning/Postural Drainage and Percussion and Vibration

Based on information found in American Association for Respiratory Care: Clinical practice guideline: postural drainage therapy, Respir Care 36:1418, 1991.

TURNING/POSTURAL DRAINAGE ^*

All positions are contraindicated for patients with the following:

1. Unstabilized head or neck injury, or both (absolute)

2. Active hemorrhage and hemodynamic instability (absolute)

3. ICP† greater than 20 mm Hg

4. Recent spinal surgery, such as a laminectomy, or acute spinal injury

5. Active hemoptysis

6. Empyema

7. Bronchopleural fistula

8. Pulmonary edema as a result of congestive heart failure

9. Large pleural effusions

10. Advanced age, anxiety, or confusion and intolerance of position changes

11. Fractured rib(s) with or without flail chest

12. Healing tissue or surgical wound

Trendelenburg position is contraindicated in patients with the following:

1. ICP greater than 20 mm Hg

2. Sensitivity to increased ICP (e.g., neurosurgery, cerebral aneurysms, eye surgery)

3. Uncontrolled hypertension

4. Distended abdomen

5. Esophageal surgery

6. Recent gross hemoptysis (especially if associated with lung cancer that was recently treated surgically or by radiation therapy)

7. Uncontrolled airway if at risk for aspiration (recent meal or tube feeding); many authors consider < 1 hour after eating as a contraindication

Reverse Trendelenburg position is contraindicated in patients who are:

1. Hypotensive

2. Receiving a vasoactive medication

PERCUSSION AND VIBRATION

1. All of the previously listed contraindications

2. Subcutaneous emphysema (several authors list an untreated pneumothorax as an absolute contraindication)

3. Spinal anesthesia or recent epidural spinal infusion for pain control

4. Recent thoracic skin grafts or skin flaps

5. Thoracic burns, open wounds, or skin infections

6. Recently placed transvenous or subcutaneous pacemaker (especially true if a mechanical percussor/vibrator is to be used)

7. Suspicion of pulmonary tuberculosis

8. Lung contusion

9. Bronchospasm

10. Osteomyelitis of the ribs

11. Osteoporosis

12. Clotting disorder (coagulopathy)

13. Complaints of chest wall pain

In addition, a number of authors have listed the following as contraindications to percussion and vibration:

1. Not over bare skin

2. Not over buttons, zippers, folded clothes, or seams of clothing

3. Not over female breast tissue

4. Not over the spine, sternum, or kidneys

5. Not over an area with a known lung tumor

ICP, intracranial pressure.

^* These are relative contraindications except those marked as absolute.

BOX 10-3 Hazards/Complications, with Recommended Actions, and Limitations of Postural Drainage and Percussion and Vibration

Based on information found in American Association for Respiratory Care: Clinical practice guideline: postural drainage therapy, Respir Care 36:1418, 1991.

HAZARDS/COMPLICATIONS

• Hypoxemia. The patient known to be hypoxic or prone to hypoxemia during the procedure should be given a higher inspired O₂ percentage. Administer 100% O₂ to any patient who becomes hypoxic during the procedure. Stop the treatment, return the patient to the original resting position, make sure ventilation is adequate, and consult with the physician before continuing.

• Increased intracranial pressure or acute hypotension during the procedure. If either of these complications occurs, stop the treatment, return the patient to the original resting position, and consult with the physician before continuing.

• Pulmonary hemorrhage. If this occurs, stop the treatment, return the patient to the original resting position, and call the physician immediately. Give the patient supplemental O₂ and keep an open airway until the physician responds.

• Pain or injury to the patient’s muscles, ribs, or spine. Stop the therapy that appears to be causing the problem. Carefully move the patient to a more comfortable position, and call the physician before continuing.

• Vomiting and aspiration. Stop the treatment, apply suction as needed to clear the airway, give supplemental O₂, maintain a patent airway, return the patient to the original resting position, and call the physician immediately.

• Bronchospasm. If this develops, stop the treatment, return the patient to the original resting position, and give or increase the supplemental O₂ while calling the physician. Give the patient any aerosolized bronchodilators that the physician orders.

• Arrhythmias. If this occurs, stop the treatment, return the patient to the original resting position, and give or increase supplemental O₂ while calling the physician.

LIMITATIONS

• Be careful to give postural drainage therapy only to those patients who would benefit from it. Do not rely on past experiences with other patients when you judge current situations.

• Patients with ineffective coughs may be unable to clear their airways as well as desired.

• Critically ill patients are difficult to position optimally.

BOX 10-4 Assessment of the Patient’s Needs for Postural Drainage Therapy (PDT)^*

Based on information found in American Association for Respiratory Care: Clinical practice guideline: postural drainage therapy, Respir Care 36:1418, 1991.

Excessive production of sputum

Ineffectiveness of cough

Patient history of PDT that was helpful in treating past problem (e.g., bronchiectasis, cystic fibrosis, lung abscess)

Abnormal breath sounds (e.g., decreased breath sounds, crackles, or rhonchi, suggesting airway secretions)

Change in the patient’s vital signs

Abnormal chest radiograph finding consistent with infiltrates, atelectasis, or mucous plug

^* These problems should be assessed together to evaluate the patient’s need for PDT. Not all patients experience all of these problems. The seriousness of these problems should be assessed by the clinician in determining which patients will benefit from PDT.

3. Perform postural drainage (Code: IIIC1a) [Difficulty: ELE: R, Ap; WRE: An]

Turning involves rotating the patient’s body in the longitudinal (head-to-toe) axis to promote unilateral or bilateral lung expansion. Patients can be turned from the back to one side, side to side, or one side to back to other side, depending on their needs. The bed may be moved to any head-up or head-down position, as the patient needs and tolerates. Patients should be turned every 1 to 2 hours as tolerated. The patient can turn himself or herself, be turned by a caregiver, or be placed in a bed that is motorized and programmed to change positions in a set pattern.

Postural drainage (bronchopulmonary drainage) is performed to clear secretions or prevent the accumulation of secretions. The patient is positioned so that the bronchus of a particular segment is as vertical as possible. Gravity pulls the secretions toward a major bronchus or the trachea; the secretions are then either expectorated or suctioned. The anatomy of the pulmonary lobes with their segments and respective bronchi should be reviewed (Figure 10-1).

Figure 10-1 Names and locations of the lung segments and their respective bronchi.

(From Shibel EM, Moser KM, editors: Respiratory emergencies, St Louis, 1977, Mosby.)

Note that each segment and its bronchus adjoin the right or left mainstem bronchus at a particular angle. This critical angle determines the positioning that must be used to drain the various segments. Obviously, positioning the patient incorrectly does nothing to drain the desired segment. Auscultation, palpation, and percussion of the chest should lead the practitioner to know where the secretions are located.

Individual segments should be drained when the physician’s order specifies them or when the practitioner determines that secretions are present. Individual segments are generally drained for 3 to 15 minutes. Drainage may be provided for a longer period in special situations. Postural drainage and the external manipulation of the patient’s thorax (percussion and vibration) can be very strenuous or contraindicated in some patients. Watch for hypoxemia or an increase in dyspnea. If the patient normally is being administered supplemental O₂, it should be continued while in the drainage positions. Some patients need supplemental O₂ only when in certain positions, and it must be made available to them.

Coughing should be encouraged after each segment is drained. The patient should not cough in a head-down position, however, because of the risk of increased intracranial pressure. Have the patient sit up to cough vigorously.

a. Pulmonary drainage positions

1. Lower lobes

a. Posterior basal segment (Figure 10-2)

1. The patient lies face down on the bed. A pillow is placed beneath the hips.

2. The foot of the bed is elevated 18 inches or 30 degrees.

3. If ordered, perform percussion or vibration over the lower ribs near the spine on either or both sides, depending on whether one or both segments are to be drained. Note the shaded areas in Figure 10-2.

Figure 10-2 Drainage position for the posterior basal segments of both lower lobes.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

b. Lateral basal segment (Figure 10-3)

1. The patient is shown in a position to drain the right lateral basal segment. The left lateral basal segment would be drained by placing the patient in the same position on the opposite side.

2. The patient lies one-fourth turn up from the face-down position. A pillow may be placed in front of the patient for support or between the knees for comfort.

3. The foot of the bed is elevated 18 inches or 30 degrees.

4. If ordered, percussion or vibration would be performed over the posterolateral areas of the lower ribs. See the shaded areas in Figure 10-3.

Figure 10-3 Drainage position for the lateral basal segment of the right lower lobe. The same segment in the left lung would be drained by positioning the patient similarly on the right side.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

c. Anterior basal segment (Figure 10-4)

1. The patient is shown in a position to drain the left anterior basal segment. (NOTE: This combined segment is the anatomic equivalent of the medial basal segment and anterior basal segment of the right lung.) The right anterior basal and medial basal segments would be drained by placing the patient in the same position on the opposite side.

2. The patient lies straight up on his or her side. Pillows may be used in front or behind the patient (or both) for positioning or between the knees for comfort.

3. The foot of the bed is elevated 18 inches or 30 degrees.

4. If ordered, percussion or vibration would be performed over the lower ribs below the axilla. See the shaded areas in Figure 10-4.

Figure 10-4 Drainage position for the anterior basal segment of the left lower lobe. The same segment in the right lung would be drained by positioning the patient similarly on the left side.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

d. Superior segment (Figure 10-5)

1. The patient lies face down on the bed. A pillow is placed beneath the hips.

2. The bed is flat.

3. If ordered, percussion or vibration would be performed over the middle of the back below the scapula on either or both sides of the spine, depending on whether one or both segments are to be drained. See the shaded areas in Figure 10-5.

Figure 10-5 Drainage position for the superior segments of both lower lobes.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

2. Right middle lobe and left lingula

a. Right lateral and medial segments (Figure 10-6)

1. The same position is used to drain both segments.

2. The patient lies one-fourth turn up from the back-down position. A pillow may be placed in back of the patient for support or between the flexed knees for comfort.

3. The foot of the bed is elevated 14 inches or 15 degrees.

4. If ordered, percussion or vibration would be performed below the right nipple area in a male patient. See the shaded area in Figure 10-6. Percussion and vibration may not be possible on a female patient.

Figure 10-6 Drainage position for the lateral and medial segments of the right middle lobe.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

b. Left superior and inferior lingula segments (Figure 10-7)

1. The same position is used to drain both segments.

2. The patient lies one-fourth turn up from the back-down position. A pillow may be placed in back of the patient for support or between the flexed knees for comfort.

3. The foot of the bed is elevated 14 inches or 15 degrees.

4. If ordered, percussion or vibration would be performed below the left nipple area in a male patient. See the shaded area in Fig. 10-7. Percussion and vibration may not be possible on a female patient.

Figure 10-7 Drainage position for the superior and inferior segments of the lingula.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

3. Upper lobes

a. Posterior segment (Figure 10-8)

1. The patient leans forward 30 degrees. This can be over the back of a chair (as shown in Figure 10-8) or in bed. A pillow can be used to lean against or support the chest.

2. If ordered, percussion or vibration would be performed over the upper portion of the back on either or both sides of the spine, depending on whether one or both segments are being drained. See the shaded areas in Figure 10-8.

Figure 10-8 Drainage position for the posterior segments of both upper lobes.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

b. Apical segment (Figure 10-9)

1. The patient leans backward 30 degrees. This can be done in bed (as shown in Figure 10-9) or in a chair. A pillow can be leaned against to support the lower portion of the back.

2. If ordered, percussion or vibration would be performed between the clavicle and the top of the scapula on either or both sides, depending on whether one or both segments are being drained. See the shaded areas in Figure 10-9.

Figure 10-9 Drainage position for the apical segments of both upper lobes.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

c. Anterior segment (Figure 10-10)

1. The patient lies supine in bed with a pillow placed under the knees. This enables the abdominal muscles to relax so that the patient can breathe more easily.

2. If ordered, percussion or vibration would be performed between the clavicle and the nipple of a male patient on either or both sides, depending on whether one or both segments are being drained. See the shaded areas in Figure 10-10. Percussion and vibration may not be possible on a female patient.

Figure 10-10 Drainage position for the anterior segments of both upper lobes.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

Some authors may list slightly different positions or several additional positions. The most commonly accepted postural drainage positions have been presented. The postural drainage positions in the infant are basically the same as those in the adult. Positioning can be accomplished more easily by using pillows. Figure 10-11 shows the various segmental drainage positions.

Figure 10-11 Drainage positions in infants. A, Apical segment of upper lobes. B, Posterior segments of upper lobes. C, Anterior segments of upper lobes. D-F, Superior segments of lower lobes. G and H, Anterior basal segments of both lower lobes (H on right and left sides). I, Segments of the right middle lobe and lingula (shown). J, Posterior basal segments of the lower lobes.

(From Crane LD: Physical therapy for the neonate with respiratory disease. In: Irwin S, Tecklin JS, editors: Cardiopulmonary physical therapy, ed 3, St Louis, 1995, Mosby.)

Exam Hint 10-1 (ELE, WRE)

The examination usually contains at least one question that deals with knowing the correct position to drain a particular lobe. The lower lobes are usually tested. The question may give information on an opaque area seen on the chest radiograph. The therapist is expected to know what segment or lobe needs to be drained. Review Figure 1-8 for a drawing showing areas of consolidation.

4. Perform percussion (Code: IIIC1a) [Difficulty: ELE: R, Ap; WRE: An]

Percussion (also known as clapping, cupping, and tapotement) is the act of rhythmically striking the adult patient’s chest with cupped hands over an area with secretions. A properly cupped hand traps air against the chest and causes a popping sound. The wrists, elbows, and shoulders should be kept as loose as possible to enable the practitioner to keep the proper loose waving motion of the hand and minimize fatigue (Figure 10-12). Infants can be percussed by putting the index, middle, and ring fingers together into a kind of three-sided tent, or specially designed palm cups. This enables the practitioner to percuss a small area of the chest wall. Percussion is performed throughout the breathing cycle and can be done with one or both hands. Percussion should not be painful to the patient. As an added precaution, most authors recommend that the chest be covered lightly with the patient’s gown or towel. Percussion should not be done over buttons or zippers or female breast tissue.

Figure 10-12 Movement of the cupped hand at the wrist during chest percussion.

(From Shapiro BA, Kacmarek RM, Cane RD, et al: Clinical application of respiratory care, ed 4, St Louis, 1991, Mosby.)

Percussion will not help to move secretions if the patient is not in the proper postural drainage position. (See the previous discussion on the drainage positions.) When the patient is properly positioned, percussion should help to vibrate the secretions more quickly down a vertical bronchus. Percussion is recommended for 5 minutes or longer in each position. Some patients, however, may not tolerate this length of treatment; 1 minute seems to be the shortest time for some therapeutic benefit. No agreement exists on the ideal manual rate of percussion. The practitioner must vary the rate, depending on how the patient feels and what seems to produce the best clearance of secretions. Recent research indicates that the ideal percussion rate is about 13 to 15 Hz (Hertz or cycles per second). Since this is faster than humanly possible, a mechanical percussor (discussed below) can be used to percuss the patient’s chest.

5. Perform vibration (Code: IIIC1a) [Difficulty: ELE: R, Ap; WRE: An]

Vibration is the gentle, rapid shaking of the chest wall directly over the lung segment that is being drained. It may be performed alone or with percussion. The practitioner places his or her hands side by side if the chest area is large enough or one on the other for a smaller chest area. The elbows are locked with the arms straight (Figure 10-13). The patient’s chest is gently but effectively shaken during exhalation. The patient should exhale at least the complete tidal volume (VT) as the chest wall is vibrated. Blowing out the expiratory reserve volume should help to clear out more secretions. A vibration rate of 200 per minute (about 3 per second) has been recommended as ideal to help move secretions. The literature differs as to how the patient should exhale during the procedure. Both breathing out slowly through pursed lips and breathing out forcefully through an open mouth have been recommended. A pursed-lip exhalation pattern seems reasonable if the patient has a problem with bronchospasm and air trapping. A patient without this problem should exhale forcefully because this helps to clear more secretions. Vibration should be performed for several expiratory efforts or until it is no longer effective in helping to mobilize secretions.

Figure 10-13 Vibration of the chest during postural drainage therapy.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

6. Modify the postural drainage therapy (ELE code: IIIF2f1) [ELE difficulty: R, Ap, An]

d. Change the postural drainage therapy position based on the patient’s response.

During the treatment, the patient’s secretions may be found to be more effectively drained if he or she is repositioned from what would seem to be the ideal angle. The patient’s airway anatomy may be different from what is expected. Patients with chronic lung disease, such as cystic fibrosis or bronchiectasis, often know what positions and angles are best for draining their lungs. Follow their advice if it produces good results.

Some patients cannot tolerate being properly positioned because their underlying lung or heart disease is aggravated by the unnatural body position. This is most commonly seen in the head-down positions to drain the lower lobes. Watch for signs of hypoxemia and SOB. The patient may have to be placed in a better-tolerated but less-desirable position. As long as some downward angle to the bronchus exists, mucus will drain. Each patient must be evaluated on an individual basis.

7. Coordinate the sequence of bronchial hygiene therapies: postural drainage, percussion, vibration, and positive expiratory pressure (ELE code: IIIF2f2) [ELE difficulty: R, Ap, An]

All of the various therapeutic options should be individualized to best meet the patient’s needs. Be prepared to modify the options to use on different lung segments as the patient’s condition either worsens or improves. In addition, be prepared to deliver bland and therapeutic aerosols to the patient before bronchial hygiene therapy is performed.

8. Stop the treatment if the patient has an adverse reaction to it (Code: IIIF1) [Difficulty: ELE: R, Ap; WRE: An]

Be prepared to stop the treatment if the patient has an adverse reaction. Often this results when a patient is placed into a head-down position. Review Box 10-3 for hazards and complications of postural drainage, percussion, and vibration.

Exam Hint 10-2 (ELE, WRE)

Be prepared to stop the treatment if the patient becomes short of breath, becomes hypoxic, develops a headache or dizziness, or needs to cough.

9. Manipulate postural drainage therapy equipment by order or protocol: percussors and vibrators (ELE code: IIA14a) [Difficulty: R, Ap, An]

a. Get the necessary equipment for the procedure.

The terms percussor and vibrator are sometimes used interchangeably. Several manufacturers produce either electrically or pneumatically powered percussors/vibrators. Some are large enough to be wheeled into the patient’s room (Figure 10-14). Obviously, electrically powered units need a standard electrical outlet for power, and the pneumatically powered units must be plugged into a 50-psi O₂ or air source.

Figure 10-14 The Vibramatic/Multimatic electrically powered mechanical percussor/vibrator.

(Courtesy General Physiotherapy, Inc., St. Louis, Mo.)

Handheld battery-powered pediatric units are smaller to focus accurately on the much smaller target area of the infant’s chest. Some practitioners find that an electric toothbrush with padded bristles works very well. Manual percussion of infants can be aided by using soft rubber palm cups that are available in several pediatric sizes.

b. Put the equipment together and make sure that it works properly.

Because various devices are powered by wall electrical output, 50-psi source gas, or batteries, check the power source if the device fails to work. Some units have different patient applicators and connectors. These must be fastened properly so that the vibrating action does not cause them to loosen or fall off. For example, the Vibramatic/Multimatic has several patient applicators that must be screwed into the percussion adapter, which is then screwed into the ring adapter (Figure 10-15).

Figure 10-15 Right-angle adapter for Vibramatic chest percussor. The percussion adapter must be tightly screwed into the ring adapter, and the various patient applicators must be tightly screwed into the percussion adapter.

(Courtesy of General Physiotherapy, Inc., St Louis, Mo.)

Some electrically powered units use a rubber belt and different sized wheels to change gears and produce several vibration rates. Others electrically vary the motor speed to change the vibration rate. Some pneumatically driven units can have their percussion force and rate varied.

c. Troubleshoot any problems with the equipment.

Pneumatically powered units would suddenly fail if the high-pressure hose to the wall gas outlet or the O₂ tank became disconnected. Electrically powered units would fail if the electrical cord was unplugged or the batteries were depleted.

MODULE B

Positive expiratory pressure therapy

Positive expiratory pressure (PEP) therapy involves having a cooperative, spontaneously breathing patient exhale against a flow-limiting orifice to create expiratory pressures between 10 and 20 cm H₂O. Since the patient’s expiratory flow is limited, the faster the patient tries to exhale, the higher the airway pressure. This therapy also is called PEP mask therapy because many pediatric patients find it easier to exhale against a face mask rather than through a mouthpiece.

Box 10-5 lists indications for PEP therapy. In patients with air trapping because of small airways disease (asthma or COPD), PEP therapy acts like pursed-lips breathing to keep the small airways from collapsing. This allows the trapped alveolar gas to be more completely exhaled. Patients with atelectasis, or at risk for developing atelectasis, respond well to PEP therapy if incentive spirometry is not effective. PEP seems to push air through the Kohn pores of open alveoli into adjacent areas of atelectasis to force the alveoli open. There is evidence that PEP therapy is better than incentive spirometry (IS) or intermittent positive pressure breathing (IPPB) in the treatment of patients with postoperative atelectasis.

BOX 10-5 Indications for Positive Expiratory Pressure Therapy

To reduce air trapping in patients with emphysema, bronchitis, and asthma

To prevent or reverse atelectasis

To help mobilize retained secretions in patients older than 4 years who have cystic fibrosis, chronic bronchitis, bronchiectasis, or bronchiolitis obliterans

To maximize the delivery of aerosolized medications, such as bronchodilators, to patients receiving bronchial hygiene therapy

PEP therapy has proven effective in helping patients with chronic, copious amounts of secretions, primarily children ages 4 years or older with cystic fibrosis. It also helps patients with chronic bronchitis, bronchiectasis, or bronchiolitis obliterans more effectively clear their secretions. Clinical evidence indicates that the PEP dilates the small airways so that air is able to pass obstructing secretions. This fills the alveoli and, on expiration, tends to force the secretions into the larger airways for coughing or suctioning. PEP therapy also seems to increase the effectiveness of inhaled aerosolized bronchodilators.

Box 10-6 lists relative contraindications to PEP therapy. No absolute contraindications exist. Box 10-7 lists hazards or complications of PEP therapy. These should be weighed against the benefits to the patient when making the recommendation to start PEP therapy. Other considerations include the patient’s history of pulmonary disease and the response to CPT, ineffective cough to clear retained secretions, and breath sounds and chest radiograph findings of secretions.

BOX 10-7 Hazards or Complications of Positive Expiratory Pressure Therapy

Pulmonary barotrauma

Increased intracranial pressure

Myocardial ischemia or decreased venous return to the heart

Increased work of breathing

Air swallowing that can lead to vomiting

Discomfort from mask or skin breakdown from mask pressure

Claustrophobia

PEP therapy is currently provided via two different equipment modalities. The original PEP therapy devices use a fixed-orifice resistor and are presented in Part 1. The newer PEP devices also provide airway vibrations or oscillations and are presented in Part 2.

1. Part 1: Adjustable fixed-orifice type PEP device

a. Perform positive expiratory pressure therapy (Code: IIIC1d) [Difficulty: ELE: R, Ap; WRE: An]

The patient must be old enough to understand instructions and be able to perform the procedure. Box 10-8 lists the steps in performing a proper PEP therapy treatment. Be prepared to adjust the expiratory resistance to meet the clinical goal of PEP therapy. Initially the resistance to exhalation should be kept low. As the training continues, the resistance the patient breathes against can be increased. The goal is to maintain a PEP of 10 to 20 cm H₂O with an inspiratory/expiratory (I:E) ratio of about 1 : 3. If the expiratory orifice is too small, the expiratory airway pressure will be too high or the expiratory time too long. The patient will likely become fatigued. If the expiratory orifice is too large, the pressure will not be high enough to be of any benefit. In any situation, the patient will probably become tired if the total treatment time lasts longer than 20 minutes.

BOX 10-8 Steps in Performing Positive Expiratory Pressure (PEP) Therapy

1. Assemble the equipment as shown in Figures 10-16 and 10-17. Set the expiratory resistance to the desired setting.

2. Have the conscious patient sit up straight, rest elbows on a table, and hold the PEP mask comfortably but tightly over the nose and mouth. The patient may use a mouthpiece and nose clips if preferred.

3. The patient should inhale a deeper than normal breath, but not to total lung capacity, by using the diaphragm. The unconscious patient will inhale only a tidal volume breath.

4. The conscious patient should exhale to functional residual capacity fast enough to generate 10 to 20 cm H₂O in the manometer. Have the patient look at the pressure manometer to judge how fast to exhale. The unconscious patient will exhale passively but will still benefit from the increased baseline pressure.

5. The patient should have an expiratory time that is about three times longer than the inspiratory time (an inspiratory/expiratory ratio of 1 : 2 to 1 : 4 is acceptable). The clinician can accomplish this by changing the expiratory resistor and/or having the patient change the force of exhalation.

6. Between 10 and 20 proper PEP breaths should be performed.

7. The patient should now perform a directed cough or two or three “huff”-type coughing efforts to raise secretions.

8. Repeat steps 2 to 7 between four and eight times (for approximately 10 to 20 min) for a full PEP treatment.

Patients in the intensive care unit can perform PEP therapy as often as every hour or as rarely as every 6 hours. They should be reevaluated for treatment effectiveness every 24 hours. Patients in the acute care or home care setting can perform PEP therapy between two and four times each day. The acute care patient should be reevaluated every 72 hours; the home care patient can be evaluated at longer intervals or when a change in pulmonary status occurs.

b. Coordinate the sequence of bronchial hygiene therapies: postural drainage, percussion, vibration, and positive expiratory pressure (ELE code: IIIF2f2) [ELE difficulty: R, Ap, An]

All of the various therapeutic options should be individualized to best meet the patient’s needs. Be prepared to modify PEP therapy and CPT as the patient’s condition either worsens or improves. In addition, be prepared to deliver bland and therapeutic aerosols to the patient before or during PEP therapy.

Coordinate PEP therapy with effective directed coughing, “huff” cough techniques, CPT, or aerosolized medication delivery. As listed in Box 10-8, PEP breaths can be alternated with huff coughs to clear secretions. Huff coughs are not full, deep coughs; rather, they are performed as follows:

1. Have the patient inhale a slow, deep breath but not to total lung capacity (TLC).

2. Hold the breath for 1 to 3 seconds.

3. Perform several quick, forced exhalations with an open epiglottis.

4. Small children may be taught to say “huff” with each quick exhalation. It also may help to have the young patient perform a “chicken breath” by flapping his or her arms against the sides of the chest during the exhalation.

CPT may be used before or after PEP therapy, or it may be alternated with PEP therapy, to help in the removal of secretions. Likewise, aerosolized medications may be inhaled before or simultaneously with PEP therapy. Bronchodilators and mucolytic agents should be very helpful with PEP therapy to mobilize secretions. Evaluate sputum for quantity, color, odor, and thickness.

c. Terminate the treatment if the patient has an adverse reaction to it (Code: IIIF1) [Difficulty: ELE: R, Ap; WRE: An]

During the treatment, ask the patient if he or she feels dyspnea, pain, or chest discomfort. Also monitor the patient’s breath sounds, blood pressure, heart rate, and breathing pattern and rate. Monitor oxygenation by pulse oximetry, mental clarity, and skin color. Be prepared to stop the treatment if necessary. Review the contraindications listed in Box 10-6 and hazards listed in Box 10-7.

d. Manipulate fixed-orifice PEP therapy equipment by order or protocol (ELE code: IIA14c) [ELE difficulty: R, Ap, An]

1. Get the necessary equipment for the procedure

Currently, several positive expiratory pressure (PEP) systems are available for selection, based on the patient’s needs. Figure 10-16 shows the TheraPEP device. The following basic components are included:

• Patient mouthpiece. Nose clips can be added, if needed.

• Mouthpiece adapter with hose to pressure generator.

• Inspiratory one-way valve. (Fit this into the mouthpiece if medications are not being delivered.)

• Pressure generator. Insert one of the six available fixed-orifice resistance diaphragms to suit the patient’s expiratory flow goal. The pressure gauge displays the airway pressure generated during exhalation.

Figure 10-16 Drawing of the DHD TheraPEP device. 1, Patient mouthpiece. 2, Hose to connect the mouthpiece to the pressure generator. 3, One-way inlet valve for inspiration. 4, Pressure generator through which the patient exhales to create positive expiratory pressure.

(From Wilkins RL, Stoller JK, Kacmarek RM, editors: Egan’s fundamentals of respiratory care, ed 9, St Louis, 2009, Mosby.)

The following optional components are included:

• Substitute a pediatric, small adult, or regular adult face mask for the mouthpiece.

• A small volume nebulizer (SVN) or metered dose inhaler (MDI) T-piece adapter can be inserted between the mouthpiece adapter and one-way valve for medication delivery.

• Necessary adapters for the SVN or MDI are included.

Figure 10-17 shows the Resistex unit. Basic components include the following:

• Patient mouthpiece. Nose clips can be added, if needed.

• Expiratory resistor with four fixed-orifice settings.

• Pressure manometer calibrated in centimeters of water.

• Small-bore oxygen tubing to connect the expiratory resistor to the pressure manometer.

Figure 10-17 Positive expiratory pressure (PEP) mask components. The basic PEP assembly necessitates a transparent mask or mouthpiece, expiratory resistor (this shows the Resistex by Mercury Medical, Clearwater, Fla), and pressure manometer with connecting oxygen tubing. If a nebulized medication is added, the following also are needed: small volume nebulizer with T-piece, oxygen tubing to flowmeter, and large-bore tubing for an aerosol reservoir.

(From Malmeister MJ, Fink JB, Hoffman GL, et al: Positive-expiratory-pressure mask therapy: theoretical and practical considerations and a review of the literature, Respir Care 36[11]:1218, 1991.)

Optional components, shown in Figure 10-17, include the following:

• Substitute a pediatric, small adult, or regular adult face mask for the mouthpiece. If the patient has an endotracheal or tracheostomy tube, substitute a universal airway (elbow) adapter for the mouthpiece.

• SVN—Note that an MDI and holding chamber can be substituted for an SVN and aerosol tubing.

• T-piece and female adapter to connect the SVN to the expiratory resistor.

• Large-bore aerosol tubing to act as a medication reservoir.

Procedural accessories include a basin and tissues to collect and dispose of sputum. For infection control purposes, the respiratory therapist should have gloves, mask, goggles, and gown if indicated. With either unit, if a PEP mask is used it should be transparent, flexible, and fitted to the patient’s facial contours so that no air will leak out as the pressure is increased.

2. Put the equipment together and make sure that it works properly

As described previously and shown in Figures 10-16 and 10-17, the component pieces must be gathered and properly assembled. Make sure that all connections are airtight. If a leak is present, the desired PEP goal will not be reached or maintained. In addition, an air leak may be felt or a high-pitched sound may be heard. If an SVN or MDI is added, it must be tested to ensure that it works properly. Connect the SVN (or MDI) into the system, as shown in Figure 10-17. Add the medication and run a flow of O₂ or compressed air at 4 to 6 L/min through the nebulizer (as is customary). The slowed exhalation during PEP breathing should promote better deposition of medication into the small airways.

Be prepared to adjust the expiratory resistance to meet the clinical goal of PEP therapy. One of six small-exit diaphragms can be added to the pressure generator part of the TheraPEP device. Select the one that best meets the patient’s clinical goal. The Resistex unit has four fixed-orifice settings from which to choose. The orifice interior diameters are 4, 3.5, 3, and 2.5 mm. Adjust the dial for the desired size to meet the patient’s clinical goal. With either unit, the patient’s treatment should begin with the largest opening for exhalation. If appropriate, smaller expiratory openings may be used to meet the patient’s clinical goal.

3. Troubleshoot any problems with the equipment

Any leaks in the system will prevent the PEP goal from being reached. Tighten any loose connections. If the one-way valves in the Resistex or TheraPEP units are assembled backward, the patient will inspire against a resistance instead of exhaling against it. Observe the one-way valves in use, and ask the patient if he or she finds it easy to inhale but more difficult to exhale. Move the valves to their proper positions if incorrectly placed. If an SVN is used, check that aerosol is coming from the nebulizer. If not, check the capillary tube or baffle for an obstruction; clear it by running tap water or a sterile needle through it. See Chapter 8, if necessary, for more information on fixing problems with SVNs.

2. Part 2: Adjustable vibratory-type PEP device

a. Perform vibratory positive expiratory pressure therapy (Code: IIIC1d) [Difficulty: ELE: R, Ap; WRE: An]

The NBRC refers to this type of PEP therapy as vibratory PEP. However, since the professional literature refers to it as oscillatory PEP or OPEP, that terminology will be used here. OPEP has the same indications (Box 10-5), contraindications (Box 10-6), hazards (Box 10-7), and clinical benefits as PEP delivered through a fixed-orifice resistor. In theory, the airway oscillations produced with OPEP improve airway clearance better than PEP. However, this has not been proven in clinical trials. Two widely known OPEP devices will be presented here. Box 10-9 will present the basic steps in performing an OPEP treatment. Other general considerations for OPEP and related therapies are the same as those for PEP and were presented previously.

BOX 10-9 Steps in Performing Oscillatory Positive Expiratory Pressure (OPEP) Therapy

1. Assemble the equipment shown in Figures 10-18 or 10-19.

2. Have the conscious patient sit up straight with head erect. (While not ideal, the patient may lie on either side as long as the Flutter can be held upright. The Acapella may be held in any position and work properly.)

3. The patient should inhale a deeper than normal breath, but not to total lung capacity (TLC). Hold the breath.

4. Place the Flutter or Acapella into the mouth, seal lips, and exhale actively. (Coach the patient to exhale about twice as fast as normal but not as fast as possible.)

5. Continue to actively exhale until the patient has reached functional residual capacity (FRC).

6. During the exhalation adjust the device so that the patient has the greatest sense of vibration felt within the lungs. With the Flutter, adjust the vertical tilt of the bowl. With the Acapella, adjust the dial at the distal end.

7. Repeat steps 3 to 6 while adjusting the expiratory flow rate and oscillation rate to “fine tune” the lung maximal vibrations to mobilize secretions. Perform about 10 to 20 breaths.

8. Finish with one or two maximal efforts: Inhale to TLC, hold the breath for 2 to 3 seconds, and exhale as fast as possible to FRC.

9. Perform either a maximal coughing effort or mid-inspiratory/huff-type cough to clear out any secretions.

10. Repeat steps 3 to 9 for four to eight cycles. Total treatment time should not exceed 20 minutes.

Of all the OPEP devices, the Flutter (Figure 10-18) has been used the most, primarily with cystic fibrosis patients. Because of its simplicity, both small children and adults can be instructed in its use. The Flutter is a pipe-shaped device with a steel ball nesting loosely inside the covered bowl. A perforated cap over the bowl keeps the ball from falling out but allows exhaled air to escape. The exhaled breath pushes the ball up in the bowl, air briefly escapes, and the ball falls back down again. When the ball falls back, more pressure is exerted against the patient’s airway. The airway pressure generated during the exhalation varies from 5 to 35 cm H₂O, depending on how fast the patient exhales. The rate at which the ball flutters up and down ranges between 2 and 32 Hz (Hertz or cycles/sec) and varies with the angle of the bowl. The high-frequency oscillations of backpressure on the airway caused by the fluttering steel ball are believed to help dislodge viscous secretions. Through trial and error the patient varies the expiratory flow rate and angle of the bowl to find the best oscillation rate to mobilize secretions.

Figure 10-18 A, Patient correctly holding the Flutter for an exhalation. B, Cross-section drawing of the Flutter showing how the steel ball is lifted by the patient’s exhaled tidal volume. When the ball drops back down into the cup, the backpressure is transmitted to the airways.

(From Fink JB, Hess DR: Secretion clearance techniques. In Hess DR, MacIntyre NR, Mishoe SC, et al, editors: Respiratory care principles and practice, Philadelphia, 2002, WB Saunders.)

The Acapella (Figure 10-19) is available in two expiratory flow models that allow the practitioner to better match the patient’s needs with the equipment. A third model, the Choice, can be disassembled for easy cleaning in the home or hospital. All models allow the user to adjust the frequency and amplitude of the oscillations. When the best expiratory flow, frequency, and amplitude of oscillations is found, the patient’s secretions will be optimally mobilized. See Box 10-9 for the steps in the procedure.

Figure 10-19 An Acapella oscillatory PEP device. This device can be a blue DM model for patients with an expiratory flow of <15 lpm, or a green DH model for patients with an expiratory flow of >15 lpm.

(Courtesy Smiths-Medical, Carlsbad, California.)

b. Coordinate the sequence of bronchial hygiene therapies: postural drainage, percussion, vibration, and positive expiratory pressure (ELE code: IIIF2f2) [ELE difficulty: R, Ap, An]

If inhaled bronchodilator or mucolytic medications are ordered for the patient using the Flutter, they should be taken before the OPEP treatment. This is because it is not designed to be used with an SVN or MDI. All of the various therapeutic options should be individualized to best meet the patient’s needs. Be prepared to modify OPEP therapy and CPT as the patient’s condition either worsens or improves.

Coordinate OPEP therapy with effective maximal cough or “huff” cough techniques, CPT, or aerosolized medication delivery. As listed in Box 10-9, OPEP breaths should be alternated with directed coughing to clear secretions. Huff coughs are not full, deep coughs; rather, they are performed as follows:

1. Have the patient inhale a slow, deep breath but not to total lung capacity (TLC).

2. Hold the breath for 1 to 3 seconds.

3. Perform several quick, forced exhalations with an open epiglottis.

CPT may be used before or after OPEP therapy, or it may be alternated with OPEP therapy, to help in the removal of secretions. Aerosolized bronchodilators and mucolytic agents should be very helpful with OPEP therapy to mobilize secretions. Evaluate sputum for quantity, color, odor, and thickness.

c. Terminate the treatment if the patient has an adverse reaction to it (Code: IIIF1) [Difficulty: ELE: R, Ap; WRE: An]

It is unlikely that a patient will have an adverse reaction from using the Flutter or Acapella device. However, it is possible that some patients will not like the feeling of increased pressure in the lungs. In this case, it may be better to stop the treatment and switch to another method of secretion management.

d. Manipulate vibratory-type PEP therapy equipment by order or protocol (ELE code: IIA14c) [ELE difficulty: R, Ap, An]

1. Get the necessary equipment for the procedure

The Flutter (Figure 10-18) is a pipe-shaped device with a steel ball nesting loosely inside the bowl. The Flutter valve has been used with cystic fibrosis patients to help them loosen their secretions. It is believed that the highfrequency oscillations of backpressure on the airway caused by the fluttering steel ball help to dislodge thick (viscous) secretions. The Flutter valve must be kept upright during the patient’s exhalation to work properly.

The Acapella devices (Figure 10-19) use an adjustable counterweighted lever and magnet to produce variable frequency and amplitude of the expiratory pressure. They have the same clinical indications as the Flutter device. The original Acapella is available with a choice of two models based on the patient’s expiratory flow. The green DH model is indicated for patients with an expiratory flow >15 L/min (>0.25 L/sec). The blue MD model is indicated for patients with an expiratory flow <15 L/min (<0.25 L/sec). This allows for a better match of the unit with the patient’s pulmonary function. The newer Choice model can be disassembled for easier cleaning. A possible advantage of the Acapella devices over the Flutter devices is that they can be used in any patient position.

2. Put the equipment together and make sure that it works properly

The Flutter device is preassembled by the manufacturer. A perforated cap should be over the bowl to keep the ball from falling while letting exhaled air escape. The Flutter does not have accessories for pressure monitoring or adding medications.

All Acapella models and adult mouthpiece are preassembled by the manufacturer. Each has an adjustable knob at the opposite end of the unit from the patient’s mouthpiece. As the knob is rotated, a magnet is moved closer to or farther from a counterweighted lever. Rotate the knob, as needed, to set the patient’s expiratory frequency and amplitude pressure. The following accessories can be added, if needed:

• A pressure port with tubing to connect to a pressure manometer can be added.

• A pediatric or adult size mask can be substituted for the mouthpiece.

• With the proper adapter, an SVN can be added for medications.

These accessories allow for the patient’s airway pressure to be monitored, the unit to be fitted to the patient for better compliance, and therapeutic aerosols to be given.

3. Troubleshoot any problems with the equipment

The patient must keep the Flutter in the proper position with the perforated cap in the upright position. This keeps the patient’s exhaled air blowing through the device to push up the steel ball. If a patient should cough secretions into the unit, it will become clogged. Air will not flow through it. Try clearing the obstruction from the mouthpiece with a cotton swab or by running warm water through the unit. If necessary, the cap can be unscrewed from the bowl and the steel ball and cup can be removed. Wash out any secretions and reassemble.

With the Acapella, if the adjustable knob cannot move or the frequency and amplitude pressure cannot be adjusted, the unit may be obstructed by secretions or may be defective. The DM and DH models can be washed with warm, soapy water. The Choice model can be disassembled into four parts, each of which can be washed with warm, soapy water. For disinfection purposes this model is put through a dishwasher, boiled, autoclaved, or soaked in glutaraldehyde. If after cleaning and reassembly it still does not function, it is defective and must be replaced.

Exam Hint 10-3 (WRE)

Expect to see at least one question about PEP therapy. Be prepared to recommend it in a patient with a secretion problem. PEP therapy may have to be modified to maximize secretion mobilization, or PEP therapy may be added to another treatment such as incentive spirometry, an SVN for medications, or high-frequency chest wall oscillation to help the patient mobilize and clear secretions.

MODULE C

High-frequency chest wall oscillation

1. Perform high-frequency chest wall oscillation (Code: IIIC1d) [Difficulty: ELE: R, Ap; WRE: An]

High-frequency chest wall oscillation (HFCWO) is indicated to help mobilize and clear secretions. This procedure may be used in patients with cystic fibrosis, bronchiectasis, or chronic bronchitis who do not tolerate other secretion mobilization procedures. For example, a cystic fibrosis patient may have an adverse effect when put into head-down positions for postural drainage therapy.

The patient should be instructed to sit up during the treatment, put on the inflatable vest or cuirass, and connect the air hose(s) between the vest/cuirass and the pumping unit. A general recommendation is to have the patient set whatever oscillation (chest wall compression) rate results in the greatest production of secretions. Common sense indicates that it is appropriate to start at the lowest rate and pressure and progress to a faster rate and higher pressure as the patient tolerates. However, there is laboratory evidence that an HFCWO rate of about 13 to 15 Hz (Hertz; cycles/second) is best at improving mucus movement. Treatments typically last 30 minutes and can be repeated up to six times per day. This procedure cannot be used in a patient with a chest wall injury such as broken ribs.

2. Modify high-frequency chest wall oscillation equipment by order or protocol (WRE code: IIA14b) [WRE difficulty: R, Ap]

a. Get the necessary equipment for the procedure

Currently, two HFCWO devices are available. The Vest (Figure 10-20) consists of a nonstretchable inflatable vest that covers the entire torso, an electrically powered pumping and control system, and two connecting hoses. The controls allow an adjustable air pulse rate of either 5 Hz (producing a vest pressure of 25 mm Hg) or 25 Hz (producing a vest pressure of 40 mm Hg).

Figure 10-20 The Vest high-frequency chest wall oscillation device. A, The power unit with controls for air pulse rate and vest pressure, along with two hoses to connect to the vest. B, The inflatable vest with two ports for the hoses from the power unit.

The Hayek oscillator (Figure 10-21) consists of a flexible chest cuirass, an electrically powered pumping and control panel, and a connecting hose. This machine can deliver both positive and negative pressure to the patient’s chest throughout the breathing cycle. Added negative pressure around the patient’s chest will increase inspiration. Added positive pressure around the patient’s chest will increase expiration. The therapist can adjust an oscillation rate of 8 to 999 oscillations/min, with an I:E ratio of 6 : 1 to 1 : 6, and inspiratory and expiratory pressures of up to +70 cm water.