BRONCHIAL HYGIENE

TECHNIQUES OR
AIRWAY CLEARANCE
TECHNIQUES
-Aishwarya Gatty
MPT (Cardiopulmonary Sciences)
DEFINITION
• Manual or mechanical procedures that facilitate the
mobilization of secretions from the airways.
CLASSIFICATION

Bronchial hygiene or Airway

clearance techniques Traditional
techniques
Breathing
Exercises

Devices
INDICATIONS
• Oxygen transport is the primary purpose of the
cardiopulmonary system
• Ventilation of the alveoli is an important step in the oxygen
transport chain; it allows optimal delivery of oxygen to the
tissues.
• Several medical and surgical conditions may interfere with this
process.
• Retained secretions or mucus plugs in the airways may
interfere with the exchange of oxygen.
• The secretions must be mobilized from the peripheral, or
smaller, airways to the larger, more central airways, where
coughing or suction may remove them.
• Respiratory diseases: Chronic Obstructive Pulmonary Disease,
Bronchiectasis, Bronchial Asthma, Cystic Fibrosis

• Atelectasis

• Mechanical Ventilation
Contraindications and Precautions
for Manual and Mechanical Airway
Clearance Techniques
• Percussion has been shown to contribute to a fall in PaO2 in acutely
ill patients especially in patients with cardiovascular instability and
in neonates. The factor that seems most closely associated with or
predictive of this effect is the patient’s baseline PaO2.
• Cardiac dysrhythmias have been associated with chest percussion
for bronchial drainage hypothesizes that hypoxemia may be the
underlying mechanism of CPT-caused cardiac arrhythmias.
• Patients with hyperreactive airways (e.g., asthma) show intolerance
for percussion as part of airway clearance. Administration of a
bronchodilator before treatment with percussion precluded the fall
in FEV1.
• Wheezing has also been associated with percussion and vibration in
patients with cystic fibrosis and COPD.
TRADITIONAL TECHNIQUES
(MANUAL)
POSTURAL DRAINAGE
• Postural drainage (PD), also known as bronchial drainage, is a
passive technique in which the patient is placed in positions
that allow gravity to assist with the drainage of secretions
from the bronchopulmonary tree.
• The mechanism of postural drainage is considered to be a
direct effect of gravity on bronchial secretions

• Preparation
-X-ray
- Pillows
-Tilt Table
TREATMENT

• If postural drainage is used exclusively, each position should

be maintained for 5 to 10 minutes
• If percussion and vibration are performed while the patient is
in each PD position, 3 to 5 minutes is sufficient
• It is not always necessary to treat each affected lung segment
during every treatment; this may prove to be too fatiguing for
the patient.
• The patient should be encouraged to take deep breaths and
cough after each position, if possible, and again after the
treatment is completed.
• Having the patient sit upright or lean forward optimizes this
effort by allowing the use of the abdominals for a stronger
cough.
SEGMENTS OF THE LUNGS
ADVANTAGES
• Postural drainage is relatively easy to learn
• Home treatment can be coordinated with activities such as
reading or watching television
• Cost of the equipment required for PD is minimal
• A family member should be taught the procedure, if possible,
to decrease the cost and provide flexibility in scheduling

DISADVANTAGE
• Adherence to PD may be a challenge because of the length of
the treatment
 MODIFIED POSTURAL
DRAINAGE
• Modifying position in patients who are not able tolerate
postural drainage positions
-Critically ill patients
- Vertigo
- Head injury or surgery
 PERCUSSION
• Percussion, sometimes referred to as chest clapping, is a
traditional approach to secretion mobilization.

• A rhythmical force is applied with a caregiver’s cupped hands

against the thorax, over the involved lung segments, trapping
air between the patient’s thorax and the caregiver’s hands

• Aim: Dislodging or loosening bronchial secretions from the

airways so they may be removed by suctioning or
expectoration.

• This technique is performed during both the inspiratory and

expiratory phases of breathing.
• Mechanism: Transmission of a wave of energy through the
chest wall into the lung. This wave loosens secretions from
the bronchial wall and moves them proximally, where ciliary
motion and cough (or suction) can remove them.

• The combination of postural drainage and percussion has

been shown to be effective in secretion removal
• Position the hand in the shape of a cup with the fingers and
thumb adducted. It is important to maintain this cupped
position with the hands throughout the treatment, while
letting the wrists, arms, and shoulders stay relaxed.

• The sound of percussion should be hollow as opposed to a

slapping sound. The patient will better tolerate an even,
steady rhythm.

• The force applied to the chest wall from each hand should be
equal

• The rate of manual percussion delivered by caregivers can

vary between 100 and 480 times per minute
• A handheld mechanical percussor can be used by a caregiver to
minimize fatigue or may be used by the patient to self-administer
percussion (electric or pneumatic percussors)

• Several devices, including, pediatric anesthesia masks, padded

medicine cups, or the bell end of a stethoscope may be used to
provide percussion to infants whose chest walls are too small to
accommodate the size of an adult’s hand.

• If the size of an infant does not allow use of a full hand, percussion
may be done manually with four fingers cupped, three fingers with
the middle finger “tented,” or the thenar and hypothenar surfaces
of the hand

• A thin towel or hospital gown should cover the patient’s skin where
the percussion is to be applied. The force of percussion over bare
skin may be uncomfortable; however, padding that is too thick
absorbs the force of the percussion without benefit to the patient.
• Hand position should be such that percussion does not occur
over bony prominences of the patient. The spinous processes
of the vertebrae, the spine of the scapula, and the clavicle
should all be avoided.

• Percussion over the floating ribs should also be avoided

because these ribs have only a single attachment.

• Percussion should not be performed over breast tissue. This

will produce discomfort and diminish the effectiveness of the
treatment. In the case of very large breasts, it may be
necessary to move the breast out of the way with one hand
(or ask the patient to do this) and percuss with the other
hand.
ADVANTAGES

• Shorten the PD treatment.

• Family member or other caregiver to provide the treatment.
• Can be used on young children or unresponsive patients

DISADVANTAGE

• Not well tolerated by many patients postoperatively without

adequate pain control repetitive motion injuries of the upper
extremities of caregivers
 VIBRATION
• Vibration involves a gentle, high-frequency force

• It is delivered through a sustained co-contraction of the

caregiver’s upper extremities to produce a vibratory force
while applying pressure to the chest wall over the involved
lung segment.

• They are performed only during the expiratory phase of

breathing, starting with peak inspiration and continuing until
the end of expiration.
• Mechanism: enhance mucociliary transport from the
periphery of the lung fields to the larger, central airways

• Equipments: Caregiver’s hands , Mechanical vibrators, padded

electric toothbrush (for infants).

Method:
• Place a thin towel or hospital gown over the patient’s skin.
The material should not be thick enough to absorb the effect
of the vibration or shaking.
• For vibration, the hands may be placed side by side or on top
of each other.
• A gentle but steady co-contraction of the upper extremities is
performed to vibrate the chest wall, beginning at the peak of
inspiration and following the movement of chest deflation.
• The frequency of manual vibration is between 12 and 20 Hz
 SHAKING
• Shaking is more vigorous in nature and is described as a
bouncing maneuver, sometimes referred to as “rib springing,”
supplying a concurrent, compressive force to the chest wall.

• The frequency of shaking is 2 Hz.

• They are performed only during the expiratory phase of

breathing, starting with peak inspiration and continuing until
the end of expiration.

• Because the compressive force to the thorax is greater with

shaking than vibration, it produces increased chest wall
displacement, and the stretch of the respiratory muscles may
produce an increased inspiratory effort and lung volume
Mechanism
• Enhance mucociliary transport from the periphery of the lung
fields to the larger, central airways

Method
• For shaking, with the patient in the appropriate PD position,
place your hands over the lobe of the lung to be treated and
instruct the patient to take in a deep breath.

• At the peak of inspiration, apply a slow (approximately 2 times

per second), rhythmic bouncing pressure to the chest wall
until the end of expiration. The hands follow the movement of
the chest as the air is exhaled. The patient is instructed to take
in a deep breath while in a proper PD position.

• Shaking or vibration may be better tolerated than percussion,

especially in the postsurgical patient.
CONTRAINDICATIONS
 MANUAL HYPERINFLATION
(AMBU)
• For patients requiring mechanical ventilation.
• Aim: Mobilize secretions and reinflate collapsed areas of the
lung and is likened to simulating a cough—deep inspiration,
pause, and forceful exhalation.
• Phases
Slow inspiration- Causes laminar flow of air
Inspiratory hold- Activates collateral ventilation
Quick release- Mobilization of secretions to the central airway
Collateral Ventilation
SUCTIONING
• Suctioning is the application of negative pressure (vacuum) to
the airways through a collecting tube (flexible catheter or
suction tip).
• Secretions or fluids also can be removed from the oropharynx
• by using a rigid tonsillar or Yankauer suction tip (Figure 36-1).
• Access to the lower airway is by introduction of a flexible
suction
• catheter (Figure 36-2) through the nose (nasotracheal
suctioning)
• or artificial airway (endotracheal suctioning).
Classification
Endotracheal Open
suctioning

Closed
Tracheostomy
suctioning

Suctioning
Nasotracheal
suctioning

Oral suctioning
STEPS FOR SUCTIONING
• Step 1: Assess Patient for Indications.
• Step 2: Assemble and Check Equipment.
• Step 3: Assess Patient for Hyperoxygenation.
• Step 4: Insert Catheter.
• Step 5: Apply Suction and Clear Catheter.
• Step 6: Reoxygenate Patient.
• Step 7: Monitor Patient and Assess Outcomes.
Step 1: Assess Patient for Indications.
ENDOTRACHEAL SUCTIONING
NASOTRACHEAL SUCTIONING
Closed suctioning
Step 2: Assemble and Check Equipment.
 Suction Catheter

Nell (Nelaton) Catheter

Method 2:

Multiply size of tube by 3/2

Eg: Size of the tube-8
8*3/2=12
Therefore size of catheter=12

Rationale: Size of the catheter should

be less than half of the diameter of
the tube
(larger=increases airway resistance )
Step 3: Assess Patient for Hyperoxygenation.
• Before suctioning, delivery of 100% oxygen (O2) for 30 to 60
seconds to pediatric and adult patients is suggested, especially
to patients who are at risk for hypoxemia.
• The O2 concentration should be increased by 10% in neonates
before suctioning. This may be done by increasing the set FiO2
or activating the temporary 100% setting on microprocessor
ventilators.
• Manual ventilation is not recommended because it is
sometimes difficult to deliver 100% O2 this way and high
pressure potentially causing lung injury can inadvertently be
applied.
• However, if there is no other alternative to hyperoxygenate
the patient, PEEP should be maintained by adding a PEEP
valve to the manual resuscitator during manual ventilation
with 100% O2.
 Step 4: Insert Catheter.
Step 5: Apply Suction and Clear Catheter.
Step 6: Reoxygenate Patient.
Step 4: Insert Catheter.
• To prevent tracheal mucosal trauma, especially in infants, the
shallow suction method should be used, advancing the
catheter just to the end of the artificial airway .

Step 5: Apply Suction and Clear Catheter.

• Suction is applied while withdrawing the catheter. Total
suction time should be kept to less than 15 seconds.
• After removing the catheter, it should be cleared using a
sterile cup filled with sterile water or saline.
• The closed suction catheter has an adapter for saline vials to
be placed in line with the device.
• The catheter is cleared by squeezing the saline vial and
applying suction at the same time. Caution must be used to
ensure saline is being drawn into the catheter and not down
the airway.
Step 6: Reoxygenate Patient.
• The patient should be hyper-oxygenated by the same method
used in Step 3 for at least 1 minute.
 Oral suctioning

Tongue Depressor

Oropharyngeal Airway
Endotracheal Suctioning
Closed Suctioning
Tracheostomy suctioning
Nasotracheal suctioning
Step 7: Monitor Patient and Assess Outcomes.
SPUTUM SAMPLING

• Sputum samples are often

collected to identify organisms
infecting the airway.
• To obtain the samples, the
suctioning procedures described
previously should be followed.
• In addition to the usual
equipment, a sterile specimen
container is needed.
 ASSISTED COUGH
TECHNIQUES
STAGES OF COUGH
• Four stages are involved in producing an effective cough.
• The first stage requires inspiring enough air to provide the
volume necessary for a forceful cough. Generally, adequate
inspiratory volumes for a cough are noted to be at least 60%
of the predicted vital capacity for that individual.
• The second stage involves the closing of the glottis (vocal
folds) to prepare for the abdominal and intercostal muscles to
produce positive intrathoracic pressure distal to the glottis.
• The third stage is the active contraction of these muscles.
• The fourth and final stage involves opening of the glottis and
the forceful expulsion of the air. The patient usually is able to
cough three to six times per expiratory effort. A minimal
threshold of FEV1 (forced expiratory volume in 1 second) of at
least 60% of the patient’s actual vital capacity is a good
indicator of adequate muscle strength necessary for effective
cough.
Cough Evaluation
Stage 1: Adequate Inspiration
Stage 2: Glottal Closure
Stage 3: Building-Up of Intrathoracic and Intraabdominal
Pressure
Stage 4: Glottal Opening and Expulsion
Pump Cough
• The pump cough extends the huff technique and, clinically, is
more effective.

• The patient is instructed to take three midsized huffs followed

by three short, easy coughs at low lung volume, not deep
breaths or deep lung volumes.

• Three or four sequences are performed: (1) huff, huff, huff;

cough, cough, cough; (2) huff, huff, huff; cough, cough, cough;
(3) huff, huff, huff; cough, cough, cough.

• Usually, if secretions are present, a spontaneous cough occurs,

or the secretions will mobilize with the small coughs.
Series of Coughs
• Another variation that decreases stress on the patient is to
use a series of coughs consisting of a small breath and a small
cough, then a medium breath and a medium cough, and
finally a large breath and a large cough.

• This is a good technique to use with postoperative patients,

who often become fatigued trying to cough maximally each
time.

• For these patients, it is an effort to get air distal to the

secretions invarious parts of the lungs, a form of autogenic
drainage.
Breath stacking
• Breath stacking is a technique that is achieved by a patient
independently performing inspiration to maximal inspiratory
capacity, then holding the breath and taking in 2 or 3 more
breaths “on top” of the initial breath to increase vital capacity.
• This is followed by a cough.
BREATHING TECHNIQUES
 ACTIVE CYCLE BREATHING
TECHNIQUE
• ACBT consists of repeated cycles of three ventilatory phases:
breathing control, thoracic expansion exercises, and FET.

• Breathing control is described as gentle tidal volume

breathing with relaxation of the upper chest and shoulders.

• The thoracic expansion phase consists of deep inspiration and

may be accompanied by percussion or vibration performed by
a caregiver or the patient. This phase helps to loosen
secretions.

• The forced expiration technique involves one or two huffs, as

when fogging a window or cleaning glasses with one’s breath.
• The period of breathing control between the other phases is
essential in order to prevent bronchospasm.

• The period of thoracic expansion, which increases lung

volume and promotes collateral ventilation, allows air to get
behind secretions and assist in their mobilization.

• FET- clearance of secretions

• EPP is the point in the airways where the pressure is equal to
the pleural pressure.

• The forced expiratory maneuver produces compression of the

airway peripherally to EPP

• Because huffing has been shown to stabilize collapsible

bronchial walls, it increases the expiratory flow in patients
with obstruction without causing airway collapse.

• Another benefit of this technique is its ability to maintain

oxygen saturation.

• The decrease in oxygen saturation that has been

demonstrated with postural drainage and percussion has been
prevented by the use of ACBT.
• ACBT may be performed in the sitting position but has been
shown to be more effective in gravity-assisted positions;
although horizontal side lying may have fewer adverse effects
than the head-down position.

• Chest percussion, shaking, or vibration may be performed in

combination with thoracic expansion as the patient exhales.

• For surgical patients or those with lung collapse, a breath hold

or a sniff at the end of inspiration encourages collateral
ventilation to redistribute air into collapsed segments and
assist with reexpansion of the lung.
Advantages and Disadvantages of Active Cycle of Breathing
• Incorporation of ACBT into a treatment of PD and percussion allows
the patient to participate actively in secretion mobilization and
offers the prospect of independently managing airway clearance
• ACBT may be introduced at 3 or 4 years of age, with a child
becoming independent in the technique at 8 to 10 years of age.
• The technique may be adapted for patients with gastroesophageal
reflux, bronchospasm, and an acute exacerbation of their pulmonary
disease.
• A decrease in oxygen saturation caused by chest percussion may be
avoided by using ACBT.
• When the technique is performed independently, the cost of using
ACBT for the long term is minimal.
• In young children or extremely ill adults, it may be necessary for a
caregiver to assist the patient with this technique.
• An assistant will also be required for the patient in whom percussion
or shaking during the thoracic expansion phase increases the
effectiveness of the treatment.
Equal Pressure Point
• The FETs are the principle component of ACBT. They are a
combination of one to two forced expirations (huffs) and BC.
• Airway pressure falls along the airway from the alveolus down
towards the mouth
• As the pressure falls, at some point the airway pressure equals
the pleural pressure, which is known as the equal pressure
point (EPP).
• Proximal to this point, towards the mouth, airway pressure
falls below the pleural pressure, resulting in dynamic
compression and a narrowed airway.
• This is an important part of the clearance mechanism of either
a huff or cough.
• At lung volumes above FRC, the EPPs are located in lobar or
segmental bronchi. As lung volume decreases during a forced
expiratory manoeuvre, the EPPs move distally into the smaller
more peripheral airways. This phenomenon can be utilized by
the patient to assist airway clearance during the FET
 AUTOGENIC DRAINAGE
• Autogenic drainage (AD) aims to maximize airflow within the
airways to improve the clearance of mucus and ventilation .

• Chevaillier developed this concept in Belgium

• AD is breathing at different lung volumes and an active

expiration is used to mobilise the mucus.

• Chevaillier described three phrases: 'unstick', 'collect' and

'evacuate‘.
• Breathing at low lung volumes is said to mobilize peripheral
mucus. This is the first or 'unstick' phase.

• It is followed by a period of tidal breathing which is said to

'collect' mucus in the middle airways.

• Then, by breathing at higher lung volumes, the 'evacuate'

phase, expectoration of secretions from the central airways is
promoted.

• A huff from high lung volume is now encouraged to clear the

secretions from the trachea. Coughing is discouraged.
• Autogenic drainage is usually practised in the sitting position.

• It takes 10-20 hours to teach the main principles and sessions

of 30-45 minutes twice a day are necessary.

• Children under the age of about 8 years would find it difficult

to concentrate for any length of time on the different levels of
breathing involved.
 MODIFIED AUTOGENIC
DRAINAGE
• AD has been altered in Germany and is not split into the three
phases as the patients were found to be uncomfortable
breathing at low lung volumes. This technique is known as
modified autogenic drainage (M AD).

• The patient breathes around tidal volume while breath

holding for 2-3 seconds at the end of each inspiration.
Coughing is used to clear mucus from the larynx
DEVICES
 POSITIVE EXPIRATORY
PRESSURE (PEP) DEVICES
• PEP therapy involves the patient breathing out against a flow
or threshold-limited resistance in order to produce positive
airway pressure.

• PEP devices usually incorporate a one-way valve allowing

unrestricted (or supported) inspiration and a resistance to
expiration either through a resistor valve or via an orifice,
which may be varied depending on individual requirements.

• PEP therapy is applied using a face mask or mouthpiece via

the one-way valve.
• The physiological rationale of PEP therapy is that in the
presence of small airway obstruction caused by secretion
retention, PEP therapy promotes air flow past the obstruction
or through collateral channels during inspiration to improve
ventilation distribution, which allows an increased volume of
air to accumulate behind secretions.

• The pressure gradient across the sputum plug forces

secretions centrally towards the larger airways, where
expectoration may occur.

• During expiration, the positive pressure generated encourages

airway splinting to stabilize peripheral airways and prevent
premature airway collapse during expiration.

• Because of these effects, the most common indications for

PEP therapy are retained secretions and atelectasis.
• There are a wide variety of commercially available devices for
the provision of PEP therapy. These include PEP devices both
with and without an oscillatory airflow component.

• During PEP therapy, the individual is required to perform a

controlled expiration against the resistance, aimed at
maintaining typical expiratory pressures at the mouth
between 10–20 cmH2O (aiming for 15 cmH2O). Inserting a
manometer into the circuit can provide both a useful monitor
for the therapist and a very useful feedback mechanism for
the patient
PEP DEVICE WITH MASK
ATTACHMENT
• PEP therapy is an independent technique which can be
combined with other airway clearance options, including
positioning and inhalation therapy, and is beneficial for those
patients with unstable or compliant airways.

• It is suitable for patients who are clinically stable or

experiencing an acute exacerbation of their respiratory
condition at varying levels of disease severity.

• PEP therapy can also be used in patients of all ages from

infancy to older age.
• PEP therapy is an independent technique which can be
combined with other airway clearance options, including
positioning and inhalation therapy, and is beneficial for those
patients with unstable or compliant airways.

• It is suitable for patients who are clinically stable or

experiencing an acute exacerbation of their respiratory
condition at varying levels of disease severity.

• PEP therapy can also be used in patients of all ages from

infancy to older age.

• An inspiratory hold just before breathing out is also

recommended, to allow for the physiological mechanisms of
pendullar flow, interdependence and collateral ventilation to
take place.
INFANT PEP
• Infant PEP is usually delivered via an appropriately sized face
mask which is held in place over the infant’s nose and mouth
by the parent/carer and is usually performed in combination
with some physical activity; for example, sitting and bouncing
on a gym ball.

• This is because infants are unable to change the size of their

breath on command, and the additional activity will result in
natural modulation of lung volumes.

• The mechanism of action of infant PEP is therefore different to

that of PEP therapy for older children and adults.
• Infant PEP is primarily aimed at changing
the ventilation distribution in infant’s lungs
while also creating the positive expiratory
airways pressures to assist in splinting open
the airways on expiration. These
mechanisms facilitate changes in ventilation
distribution and potentially clearance of
secretions.

• The generation of specific airways pressures

is not the focus of treatment when using
infant PEP, as infants have poorly developed
collateral ventilation.

• A pressure manometer is therefore not

required in the infant PEP circuit
Oscillatory PEP (OPEP)
• They are similar to the PEP device in that they involve
breathing against an expiratory resistance, but the resistance
is intermittent or interrupted by a ball valve, lever or
collapsible tubing, such that oscillations of variable frequency
(depending on device or use), are transmitted to the airways
during the expiratory cycle.

• The PEP component encourages air flow behind secretions,

oscillation induces vibrations within the airway wall to
displace secretions into the airway lumen and the repeated
accelerations of expiratory air flow favour movement of
secretions from the peripheral to the central airways
Acapella
• The Acapella is also a flow operated oscillatory device which
uses a counterweighted plug and magnet to create air flow
oscillations, which are produced by breathing and reforming
the magnetic attraction by the plug as it intermittently
occludes air passing through the device.

• The frequency/ resistance dial allows adjustments to the

expiratory pressure and the frequency of oscillations.

• It has the option of adjusting the flow pressure and frequency

of the oscillations for each individual patient and may be used
with a mouthpiece or mask with a nebulizer in situ

• The Acapella is flexible in the positions in which it can be used

(options include sitting, side lying or gravity-assisted drainage
positions).
Flutter
• The Flutter is a small, pipe shaped, handheld device with a
mouthpiece, a perforated cover which encases a stainless steel
ball resting in a circular cone.

• During expiration, the high-density ball rolls up and down the

cone, creating interruptions in expiratory flow and generating PEP
within the range of 18–35 cmH2O.

• An oscillatory vibration of the air within the airways is also

generated which shear secretions from the airways and alter
sputum rheology, reducing the viscoelasticity of the secretions.

• The frequency of oscillations mimic cilia beat frequency and are

determined by the angle at which the device is held.

• The device is commonly used in an upright seated position, but

can applied in other positions, provided that effective oscillation
can be achieved.
Quake
• The Quake does not rely on an oscillating valve, but uses a
manually turned cylinder that its within another cylinder.

• Air flow only occurs when the slots within the two cylinders
correspond.

• Air flow is interrupted at regular intervals as the patient turns

the crank.

• The rate at which the device is cranked will determine the

frequency of flow interruption.

• For this reason, it may be a useful device in patients who are

limited in generating high expiratory flow rates.
R C Cornet
• The RC-Cornet consists of a mouthpiece, a curved tube, a
valve hose and a sound damper.

• Expiration through the tube creates an increasing pressure

within the hose until it is sufficient to cause the hose end to
open, allowing air to flow through the device, creating a PEP
and oscillatory vibrations within the airways.

• The pressure and flow rate can be adjusted by rotating the

mouthpiece in the tube.
Lung Flute
The Lung Flute uses low-
frequency acoustic wave
technology to facilitate
secretion clearance.

Expiration through the

mouthpiece over a reed
within the horn of the lung
flute generates an acoustic
wave that travels into the
lower airways to facilitate
secretion transport.
Shaker
Classic and Shaker Deluxe
devices are similar to the
Flutter. They also contains a
high-density stainless steel
ball enclosed in a small cone,
but have a detachable
mouthpiece, making them
easier to use in positions
other than sitting.
Thera PEP
Aerobika
BUBBLE PEP (Pediatrics)
• For older infants under the age of 4 who no longer tolerate
infant PEP but who are unable to progress to other forms of
ACT, ‘bubble PEP’ may be a useful OPEP bridging ACT.

• Bottle or bubble PEP is an alternative method to administer

low pressure OPEP therapy.

• It is a threshold resistor type of PEP in that the expiratory

pressure remains constant once the tubing diameter is ≥8
mm, independent of tube length.

• It is a simple improvised device that can be constructed using

easily accessible and low-cost equipment in the home or
hospital setting.
• It consists of a length of smooth bore rubber tubing and a
plastic bottle (1–2 L in size) that is approximately half filled
with water.

• The child is instructed to inhale through their nose or around

the tube in their mouth using slightly active tidal volume
breathing and expire through the tube into the column o f
water, with the number of breaths and cycles similar to that
described for the Flutter.

• Blowing through the tubing creates bubbles in the bottle. The

height of water in the bottle (approximately 10 cm above the
bottom of the fexible tube) provides the threshold resistance
to expiration and the bubbling effect produces an oscillatory
effect in the airways
HIGH FREUENCY CHEST WALL
OSCILLATORS (HFCWO)
• HFCWO (also known as HFCWC or high-frequency chest
compression (HFCC)), is administered by an inflatable vest that
fits snugly over the thorax and is attached to an air pulse
generating compressor which delivers intermittent positive
pressure air flow into the jacket.

• The rapid inflation and deflation of the jacket creates airway

oscillations at the chest wall at frequencies of 5–25 Hz
• The hypothesis is that mucus clearance is enhanced as a
consequence of this air flow oscillation and vibration of the
airway walls.

• The proposed mechanism is that increased mucus–air flow

interaction leads to increased cough-like shear forces and
decreased mucus viscoelasticity.

• Furthermore, HFCWO supposedly creates an expiratory bias

to air flow, promoting movement of mucus towards the
mouth, and may also enhance ciliary activity
MECHANICAL INSUFFALATORS
EXSUFFALATOS
• A mechanical insuflator/exsuflator uses positivepressure to
deliver a maximal lung inhalation followed by an abrupt switch
to negative pressure to the upper airway.
• The rapid change from positive to negative pressure is aimed
at simulating the air flow changes that occur during a cough,
thereby assisting sputum clearance.
• In 1953, various portable devices were manufactured to
deliver mechanical insufalation/ exsufalation (e.g. OEM Cof-
ater portable cough machine, St Louis, MO USA).
• The most commonly used mechanical insuflulator/exsufultor
devices today include; CoughAssist and CoughAssist E70
(Philips- Respironics, Pittsburgh Murrysville, USA); NIPPY
Clearway (B & D Electromedical, Warwickshire, England) and
Pegaso (Dimla Italia, Bologna, Italy).
• These devices can produce expiratory air flows of greater than
160 L/min
 INTRAPULMONARY PURCUSSIVE
VENTILATION (IPPV)
• The IPV device consists of a high-pressure flow generator, a
valve for flow interruption and a breathing circuit with
nebulizer that can be attached to a face mask, mouthpiece or
catheter mount.
• IPV is actually a modified method of IPPB which superimposes
high-frequency mini bursts of air (50–550 cycles per minute)
on the individual’s intrinsic breathing pattern; all this creates
an internal vibration (percussion) within the lungs.
• Internal or external vibration of the chest is hypothesized to
promote clearance of sputum from the peripheral bronchial
tree. IPV may provide ventilatory support in patients with
neuromuscular disease and in patients with COPD .
MECHANISMS
• Mucocilary escalator
• Gravity
• EPP
REFERENCES
• Cardiopulmonary books-Linda
-Donna Frownfelter