Bronchopulmonary Hygiene Therapy

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10 Bronchopulmonary Hygiene Therapy

Note 1: This book is written to cover every item listed as testable on the Entry Level Examination (ELE), Written Registry Examination (WRE), and Clinical Simulation Examination (CSE).

The listed code for each item is taken from the National Board for Respiratory Care’s (NBRC) Summary Content Outline for CRT (Certified Respiratory Therapist) and Written RRT (Registered Respiratory Therapist) Examinations (http://evolve.elsevier.com/Sills/resptherapist/). For example, if an item is testable on both the ELE and the WRE, it will simply be shown as: (Code: …). If an item is only testable on the ELE, it will be shown as: (ELE code: …). If an item is only testable on the WRE, it will be shown as: (WRE code: …).

Following each item’s code will be the difficulty level of the questions on that item on the ELE and WRE. (See the Introduction for a full explanation of the three question difficulty levels.) Recall [R] level questions typically expect the exam taker to recall factual information. Application [Ap] level questions are harder because the exam taker may have to apply factual information to a clinical situation. Analysis [An] level questions are the most challenging because the exam taker may have to use critical thinking to evaluate patient data to make a clinical decision.

Note 2: A review of the most recent Entry Level Examinations (ELE) has shown an average of 3 questions (out of 140), or 2% of the exam, will cover bronchopulmonary hygiene therapy. A review of the most recent Written Registry Examinations (WRE) has shown an average of 3 questions (out of 100), or 3% of the exam, will cover bronchopulmonary hygiene therapy. The Clinical Simulation Examination is comprehensive and may include everything that should be known by an advanced level respiratory therapist.

MODULE A

Bronchopulmonary hygiene therapy

The phrase bronchopulmonary hygiene is preferred by the NBRC to encompass the following cluster of related therapeutic activities: postural drainage, percussion, vibration, and directed cough. Traditionally, the phrase chest physical therapy (CPT) is used by many practitioners to include the same activities. Additionally, the terms postural drainage therapy (PDT), chest physiotherapy, and bronchopulmonary drainage have been used to describe the same therapeutic procedures.

1. Recommend starting bronchopulmonary hygiene procedures (Code: IIIG1a) [Difficulty: ELE: R, Ap; WRE: An]

2. Instruct and encourage bronchopulmonary hygiene techniques (Code: IIIC4) [Difficulty: ELE: R, Ap; WRE: An]

The directed cough is one of the simplest, yet most important bronchopulmonary hygiene procedures to teach a patient with retained secretions. Ideally, the surgical patient is taught proper coughing techniques before surgery. If not, it is necessary to teach the patient postoperatively:

1. Minimize traction or tension on the incision, to decrease the pain, by placing either your hands or the patient’s hands on both sides of the incision. A pillow also can be held against the incision by the practitioner or patient.
2. Instruct the patient to breathe two or three times in through the nose and out through the mouth.
3. Instruct the patient to take in as deep a breath as possible and to perform a normal cough.
4. If the patient cannot cough normally because of pain, a serial or huff cough can be performed.

Teach the patient with chronic obstructive pulmonary disease the following cough techniques:

1. Avoid an ineffective, shallow, hacking cough.
2. Position the patient in a sitting position, bent slightly forward, with feet on the floor or supported. The patient who must lie in bed can be positioned on the preferred side with the legs flexed at the knees and hips.
3. Instruct the patient to perform a mid-inspiratory cough (also called a huff cough):

a. Breathe two or three times in through the nose and out through the mouth.
b. Breathe in to a comfortable volume larger than the tidal volume but not as deeply as possible.
c. Briefly hold the breath.
d. Cough hard or perform a serial cough at relatively low flows. This should help to raise secretions without causing airway collapse.
e. Squeezing the knees and thighs together at the instant of coughing helps to increase the airflow and volume.

Coaching is important because patients in pain or suffering from chronic lung disease tend to be uncooperative and do not try hard. Give positive reinforcement when the patient does well. Correct any problems the patient is having following the instructions. Demonstrations are often useful so that the patient can copy a good example.

If the patient cannot cough effectively, other secretion clearance procedures will be needed. Postural drainage therapy (PDT) and other procedures follow. The American Association for Respiratory Care (AARC) Clinical Practice Guideline on PDT was used to help develop the following information. See Box 10-1 for indications for turning, postural drainage, percussion, and vibration. Contraindications are listed in Box 10-2, and recommended actions for problems are listed in Box 10-3. Beyond the patient assessment issues listed in Box 10-4, the following should be evaluated to determine whether PDT is needed:

• PDT is not indicated if an optimally hydrated patient is producing less than 25 mL of secretions per day with the procedure.
• A dehydrated patient should have apparently ineffective PDT continued for at least 24 hours after the patient is rehydrated. The combination of rehydration and PDT may help to mobilize previously thick secretions.
• PDT is not indicated in a patient producing more than 30 mL of secretions daily (if the PDT treatments do not increase the sputum production) because the patient is already able to expectorate the sputum effectively.

BOX 10-1 Indications 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

• 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).

image

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.
image

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.
image

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.
image

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.
image

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.
image

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.
image

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.
image

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.
image

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.
image

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.

image

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.

image

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.

image

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]

a. Change the length of treatment time.

Lung segments should generally be drained for 3 to 15 minutes. If the patient is tolerating the position, and secretions are still being cleared, the position can be held longer. Stop the treatment if the patient is showing any signs of intolerance.

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