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

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.

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:

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

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:

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.

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

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

3. Upper lobes

c. Anterior segment (Figure 10-10)

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.

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.)