Bronchial Hygiene Therapy Edited

RESY 301
Bronchial Hygiene Therapy

Objectives
• Describe how normal airway clearance mechanisms work and the

factors that can impair their function
• Identify pulmonary diseases associated with abnormal clearance of
secretions
• State the goals and clinical indications for bronchial hygiene therapy
• Describe the proper technique and potential benefit of each of the
following:
• Chest physical therapy
• Directed coughing and related expulsion techniques
• High-frequency positive airway pressure devices
• High-frequency compression/oscillation methods
• Mobilization and exercise
• Evaluate a patient’s response to airway clearance therapy
• Modify airway clearance therapies on the basis of patient response
2
Introduction
 Airway clearance therapy uses noninvasive techniques
designed to improve gas exchange
 Assisting in the mobilizing and removing secretions
 Broad application of airway clearance therapy is
costly
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Inc. All Rights Reserved.
Physiology of Airway Clearance
Normal clearance
 Normal airway clearance requires a(an)
 Patent airway
 Functional mucocilary escalator
 Effective cough
 An effective cough can effectively move mucus from

the lower airways to the upper airway.
4
Normal Clearance

Abnormal Clearance

Abnormal Clearance (Cont.)
 Diseases associated with abnormal clearance:
 Internal or external compression of airway lumen
 Cystic fibrosis
 Bronchiectasis
 Neuromuscular diseases can cause a weak cough

 Causes of impaired mucociliary clearance in intubated
patients
 Endotracheal or tracheostomy tube
 Tracheobronchial suction
 Inadequate humidification
 High FiO2 values
 Drugs
 General anesthetics
 Opiates
 Narcotics
 Underlying pulmonary disease

General Goals and Indications
 Airway clearance therapy for acute conditions
 Copious secretions
 Inability to mobilize secretions
 Ineffective cough
 Airway clearance therapy for chronic conditions

 Cystic Fibrosis
 Bronchiectasis
 Ciliary dyskinetic syndromes
 COPD patients with retained secretions

General Goals and Indications (Cont.)
 Airway clearance therapy to prevent retention of
secretions
 May be useful in acutely ill patients when combined with

patient mobilization
 Cystic fibrosis patients benefit from chest physical therapy
combined with exercise to maintain lung function

Determining the Need for Airway
Clearance Therapy
 Physical findings such as:
 Loose, ineffective cough
 Labored breathing pattern
 Coarse inspiratory and expiratory crackles
 Tachypnea/tachycardia
 Fever
 Chest radiograph demonstrating atelectasis and infiltrates

Airway Clearance Methods
 Five general approaches to ACT, which can be used alone
or in combination
1. Chest Physio- Therapy

2. Coughing and related expulsion techniques
3. Positive airway pressure (PAP) adjuncts (positive
expiratory pressure [PEP], vibratory PEP, high-frequency
positive airway pressure devices)
4. High-frequency compression/oscillation methods
5. Mobilization and physical activity

1.Chest Physical Therapy
 Description
 Involves the use of positioning, gravity, and mechanical energy
to help mobilize secretions
 Manually striking the chest wall with cupped hands in a
rhythmic fashion
 Vibrating chest wall with a mechanical device
 Loosens secretions from the airways and propels them
forward
 Patient is placed in various positions so gravity can assist in
draining the secretions from lung segment to larger airways to
be cleared

Chest Physical Therapy
(Cont.)
 Potential limitations
 It requires help of a caregiver
 CPT’s effectiveness may be dependent on appropriate
positioning
 Patients with shortness of breath may not tolerate
Trendelenburg position
 Patients are unable to perform concurrent aerosol therapy

(Cont.)

(Cont.)

(Cont.)

Bronchial Hygiene Methods
(cont.)
Postural drainage (cont.)
 The process placing the patient in various positions
to drain specific segmental bronchi
 Positions are typically held for 3 to 15 minutes.
 Most effective in patient with excessive mucus

secretion
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Mosby, Inc., an affiliate of Elsevier Inc.
Bronchial Hygiene Methods
(cont.)

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2. Coughing and related expulsion techniques
A. Directed Cough
B. Forced Expiratory Technique (FET)
C. Active Cycle of Breathing
D. Manual Assisted Cough
E. Autogenic drainage (AD)
F. Mechanical Insufflation-Exsufflation (MIE)

A. Directed Cough
 Deliberate maneuver that is taught, supervised, and
monitored
 Aims to mimic features of effective spontaneous cough
 Instruction on proper positioning
 Instruction on breathing control
 After confirming that the patient can take a good, deep
inspiration, the RT has the patient bear down against the glottis
 Exercises to strengthen the expiratory muscles

Directed Cough (Cont.)
 Not to be used in patients who are obtunded, paralyzed,
or uncooperative
 Good patient teaching is critical
 Proper positioning of patient is important
 Technique may need to be modified in surgical patients,
patients with COPD, and patients with neuromuscular
disease

B. Forced Expiratory Technique (FET)
 Modification of directed cough
 Also called “huff cough”
 Consists of one or two forced expirations of middle to
low lung volumes without closure of glottis
 Goal is to clear secretions with less change in pleural
pressure and less bronchial collapse

Forced Expiratory Technique (FET)
(Cont.)
 Has been shown to increase sputum production,
especially when combined with postural drainage
 Most useful in patients with COPD, cystic fibrosis, or
bronchiectasis.

C. Active Cycle of Breathing
 The patient alternates cycles of deep breathing, relaxed

breathing and forced expiration technique to mobilize
secretions.
 It is difficult to perform during exacerbations or when
patients are unable to take a deep breath.

D. Manual Assisted Cough
 External application of pressure to the thoracic cage or
epigastric region, coordinated with forced exhalation
 Patient takes as deep an inspiration as possible, assisted as needed by the
application of positive pressure via a self-inflating bag or intermittent
positive pressure breathing device
 At the end of the patient’s inspiration, the RT begins exerting pressure
on the lateral costal margins or epigastrium
 Used in patients with neuromuscular conditions that are
unable to generate the forceful expulsion

E. Autogenic drainage (AD)
 Patient uses diaphragmatic breathing to mobilize
secretions by varying lung volumes and expiratory airflow
in three distinct phases
 Patient should be in sitting position
 Coughing should be suppressed until all three phases are
complete

Autogenic Drainage (AD) (Cont.)

F. Mechanical Insufflation-Exsufflation
(MIE)
 MIE devices apply positive pressure of 30 to 50 cm H 2O
to airway for 1 to 3 seconds
 Device then abruptly reverses airway pressure to −30 to
−50 cm H2O for 2 to 3 seconds
 Treatment sessions consist of about five cycles of MIE
followed by normal spontaneous breathing

Mechanical Insufflation-Exsufflation
(MIE) (Cont.)

3. Positive Airway Pressure Adjuncts
 Used to mobilize secretions and treat atelectasis
 Used in combination with other airway clearance
techniques
 Three applications are used: continuous PAP (CPAP),
expiratory PAP (EPAP), and positive expiratory pressure
(PEP)

Positive Expiratory Pressure (PEP) and
Vibratory PEP
 The PEP devices use a fixed or variable orifice expiratory
flow resistor to generate expiratory pressures of 10 to
20 cm H2O as the patient actively exhales through the
device
 Vibratory or oscillatory PEP incorporates flow
interruptions during the active expiration to create flow
oscillations in addition to the PEP

Positive Expiratory Pressure (PEP) and
Vibratory PEP (Cont.)

4. High-Frequency
Compression/Oscillation
 External (chest wall) application
 Vest airway clearance systems
 Generator inflates and deflates the vest, creating pressure pulses
against the thorax that cause chest wall oscillations and move
secretions forward
 Airway application
 Intrapulmonary percussive ventilation
 A pneumatic device to deliver a rapid series of pressurized gas
minibursts to the airway at rates of 100 to 225 cycles per minute (1.7
to 5 Hz)

High-Frequency
Compression/Oscillation

Intrapulmonary Percussive Ventilation

5. Exercise, Mobilization and Physical
Activity
 Physical activity that results in:
 Increased tidal ventilation
 Increased heart rate
 Increased cardiac output
 Improved physical conditioning

Selecting Bronchial Hygiene
Techniques

40
Airway Clearance Methods (Cont.)
 Outcome assessment
 Change in sputum production
 Change in breath sounds
 Change in dyspnea level
 Change in vital signs
 Change in chest radiograph/ABG results
 Change in ventilator variables

Airway Clearance Methods (Cont.)
 Documentation and follow-up
 Chart entry should include
 Positions used
 Time in positions
 Patient tolerance
 Indicators of effectiveness
 Any untoward effects observed

43
References:
• Egan's fundamentals of respiratory care.

By: Kacmarek, R. M., In Stoller, J. K., In Heuer, A.
J., In Chatburn, R. L., & In Kallet, R. H.
44

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RESY 301

Bronchial Hygiene Therapy

• Describe how normal airway clearance mechanisms work and the

3 Copyright © 2017 Elsevier

 An effective cough can effectively move mucus from

5 Copyright © 2017 Elsevier

6 Copyright © 2017 Elsevier

7 Copyright © 2017 Elsevier

8 Copyright © 2017 Elsevier

 Airway clearance therapy for chronic conditions

9 Copyright © 2017 Elsevier

 May be useful in acutely ill patients when combined with

10 Copyright © 2017 Elsevier

11 Copyright © 2017 Elsevier

1. Chest Physio- Therapy

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13 Copyright © 2017 Elsevier

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 Positions are typically held for 3 to 15 minutes.

 Most effective in patient with excessive mucus

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 The patient alternates cycles of deep breathing, relaxed

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39 Mosby items and derived items © 2009 by

41 Copyright © 2017 Elsevier

42 Copyright © 2017 Elsevier

• Egan's fundamentals of respiratory care.

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