HYPERINFLATION AND SECRETION CLEARANCE FOR THE 21 ST CENTURY

Transcription

1 HYPERINFLATION AND SECRETION CLEARANCE by Susan Jett Lawson RCP, RRT-NPS RC Educational Consulting Services, Inc Van Buren Blvd, Suite B, Riverside, CA (800) 441-LUNG / (877) 367-NURS

2 BEHAVIORAL OBJECTIVES UPON COMPLETION OF THE READING MATERIAL, THE PRACTITIONER WILL BE ABLE TO: 1. Briefly describe the normal function of the mucociliary escalator. 2. Briefly describe what changes occur in the mucociliary escalator when normal function is impaired. 3. List the three main problems that stem from impairment of the conducting airways. 4. Describe what ultimately occurs as a result of inflammation, retained secretions and bronchospasm. 5. List the indications for directed cough, IPPB, incentive spirometry, postural drainage and PAP. 6. List the contraindications for directed cough, IPPB, incentive spirometry, postural drainage and PAP. 7. List the hazards and complications for directed cough, IPPB, incentive spirometry, postural drainage and PAP. 8. Briefly describe the techniques and methods of directed cough, IPPB, incentive spirometry, postural drainage, thorax manipulation and PAP. 9. Describe what positive outcomes to look for that would be a result of effective hyperinflation and secretion clearance therapy. 10. Define positive airway pressure (PAP). COPYRIGHT 2003 BY RC EDUCATIONAL CONSULTING SERVICES, INC. T AUTHORED (2003) BY SUSAN JETT LAWSON RCP, RRT-NPS AUTHORED (2008) BY SUSAN JETT LAWSON RCP, RRT-NPS ALL RIGHTS RESERVED This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 2

3 This course is for reference and education only. Every effort is made to ensure that the clinical principles, procedures and practices are based on current knowledge and state of the art information from acknowledged authorities, texts and journals. This information is not intended as a substitution for a diagnosis or treatment given in consultation with a qualified health care professional. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 3

4 TABLE OF CONTENTS INTRODUCTION... 7 PHYSIOLOGY OF AIRWAY MUCUS CLEARANCE... 7 Normal Function...7 Impairment of Normal Function... 8 Impact of Impaired Function... 9 BRONCHIAL HYGIENE THERAPY OR SECRETION CLEARANCE TECHNIQUES Directed Cough (DC) Indications Contraindications Hazards and Complications Techniques and Methods Huff Maneuver Autogenic Drainage Active Cycle of Breathing (ACB)/Forced Expiratory Technique (FET) Evidence-Based Medicine / Assessment of Outcomes Postural Drainage Therapy (PDT) Indications Contraindications Hazards and Complications Percussion / Vibration Techniques and Methods This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 4

5 Manual Electrical and Pneumatically Powered Percussors Assessment of Outcome HYPERINFLATION OR VOLUME EPANSION THERAPY Intermittent Positive Pressure Breathing (IPPB) Indications Contraindications Hazards and Complications Assessment of Outcome Incentive Spirometry (IS) Indications Contraindications Hazards and Complications Methods of Delivery Assessment of Outcome POSITIVE AIRWAY PRESSURE (PAP) CPAP PEP EPAP Indications Patient Indications Contraindications This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 5

6 Assessment of Outcome Methods of Delivery PEP EPAP EzPAP Vibratory PEP High Frequency Airway Oscillation Interpulmonary Percussive Ventilation (IPV) High Frequency Chest Wall Compression (HFCC) Oscillation (HFCWO) The Vest CHOOSING THE MOST APPROPRIATE MODALITY FOR YOUR PATIENT Decision Making SUMMARY SUGGESTED READING AND REFERENCES This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 6

7 INTRODUCTION The purpose of this course is not to restate how to give Intermittent Positive Pressure Breathing (IPPB) or perform Postural Drainage and Percussion (PD & P). We are briefly reviewing the majority of modalities available, but the focal point is to bring the clinician up to date in the latest hyperinflation and secretion clearance techniques. I am a firm believer that the more tools we have in our toolboxes, the more individualized and effective our care of the patient. This leads to efficient utilization of therapist power, hospital resources and better outcomes for the patient. Hospital administration will appreciate shorter hospital stays, fewer patient complications and a lower incidence of nosocomial pneumonias. Thirty years ago, our floor care practice consisted of mostly giving intermittent positive pressure breathing treatments and extensive postural drainage and chest percussion and vibration (by hand). It is noted that IPPB was overused and not indicated for everything from toothaches to GI bleed! AARC guidelines and evidence-based medicine have clarified the indications, purpose and contraindications for most of our routine therapies. IPPB has transitioned to hyperinflation therapy. PD & P has transitioned as well, to secretion clearance techniques. Indications, purpose and contraindications are now defined. Instead of spending an hour or so turning, positioning and performing manual percussion and vibration, the clinician has a choice of mechanisms to accomplish the goals of bronchial hygiene. We will explore advances in postural drainage, hyperinflation techniques, coughing, deep breathing and devices that assist in these processes. First, we will begin with a brief review of the normal mechanisms of secretion clearance and then, the results of impairment of this natural function. PHYSIOLOGY OF AIRWAY MUCUS CLEARANCE Normal Function M ucociliary clearance of secretions is accomplished within our conducting airways. A blanket of mucus-secreting epithelium lines the inner diameter of these airways. Beneath this airway epithelium lays a separating basement membrane, then the lamina propria. The lamina propria contains smooth muscle, blood vessels, nerves and elastic fibers. This combination (epithelium and lamina propria) constitutes the respiratory mucosa. Underneath the respiratory mucosa, most appropriately named, is the sub mucosa. This submucosa contains glands that have ducts extending to the surface of the epithelial lumen. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 7

8 The trachea and bronchi are lined with tall, columnar, ciliated, pseudostratified epithelial cells interspersed with goblet cells. Goblet cells along with the submucosal glands secrete mucus onto the surface of the ciliated epithelial cells. In normal function, the cilia beat about 1300 time per minute, establishing a continual wave sweeping the mucus blanket (gel and sol layers) towards the pharynx. The visco-elastic gel layer traps inhaled particles and the cilia sweep the foreign material in this gel where it can be expelled or swallowed. This natural defense mechanism is called the mucociliary escalator. MUCOCILIARY ESCALATOR Gel Layer Cilia Sol Layer Goblet Cell Ciliated Epithhelium Bronchial Gland Impairment of Normal Function If impairment of any part of this mechanism takes place, defenses mechanisms are compromised and the patient becomes less resistant to infection and disease. When the body becomes dehydrated, the mucous water content is decreased and the mucociliary escalator comes to a halt. Alternatively, if over hydration occurs, the mucous becomes too thin and watery and cannot be propelled effectively by the cilia. The production of mucous in a normal, healthy individual is approximately ml. per day. With acute and chronic airway inflammation and in diseases such as asthma, chronic bronchitis, pneumonitis and cystic fibrosis the amount of mucous produced increases. The secretions accumulate, block the airways and become a stagnant breeding ground for microorganisms. Patients who have ciliary disorders such as situs inversus, where the cilia beat in reverse, or immotile cilia syndrome, where the cilia do not beat, will have retained secretions and require assistance to expel the mucous, which is produced on a daily basis. Their mucous will easily become stagnant, possibly plug the airways and microorganisms will flourish. Speaking of cilia action the smoker s cilia looses beating action. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 8

9 Airway inflammatory processes cause white blood cells to enter the airways; specifically, eosinophils and leukocytes, which will thicken the mucous. Polymorphonuclear leukocytes are the pus cells. All of these cells leave cellular debris; the polymorphonuclear leukocytes cause purulent secretions. Mast cells, which are located in the airways near smooth muscle, contain preformed mediators of inflammation. Inhaled antigens in those who are sensitized activate these mediators of inflammation. The array of leukotrienes, histamines, prostaglandins, thromboxane and platelet activating factors released increase epithelial permeability. The vicious cycle of mast cell breakdown leading to mucosal edema, vascular leakage and bronchospasm are classic features of asthma. Impact of Impaired Function Compliments of diseases-explained.com The three main problems that stem from impairment of the conducting airways are: Inflammation Retained secretions Bronchospasm Which result in: Diminished pulmonary function This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 9

10 Reduced lung defenses Increased risk of infection As therapists, we are very much aware that we generally treat inflammation with cool aerosols and corticosteroids and bronchospasm with corticosteroids and bronchodilators. We may also give our bronchospasmodic patients leukotriene inhibitors or treat their allergies in a pro-active manner. The objectives of therapy for these patients are to increase lung volumes and mobilize secretions. When the patient s airway is plugged with secretions, ventilation is impaired downstream of the plug. The alveoli are also affected. The alveoli shrink and eventually collapse (atelectasis) having been deprived of the gas exchange mechanism. The alveolar capillaries cannot diffuse oxygen or carbon dioxide and an intrapulmonary shunt is created. Hypoxemia is the end result, but oxygen is not the primary treatment. The treatment includes mobilization and expectoration of secretions. We can accomplish this goal with bronchial hygiene and hyperinflation techniques. The principles of airway clearance are based on a central goal, airflow behind the mucus. Velocities greater than 1.0 to 2.5 m/s without airway collapse are ideal. Getting airflow past the secretions in order to produce an effective cough, which propels the secretions out of the airways, forms collateral ventilation channels. BRONCHIAL HYGIENE THERAPY OR SECRETION CLEARANCE TECHNIQUES Directed Cough (DC) Directed cough is a component of bronchial hygiene therapy. Its purpose is to assist in the clearance of secretions. Examples of directed cough are forced expiratory technique (FET or huff) and the manually assisted cough. Indications for directed cough include: Ineffective cough (no secretions cleared with coughing) Patient requires assistance in the removal of secretions Atelectasis originating from ineffective coughing Postoperative abdominal or thoracic surgery Chronic retained secretions Absence of cough mechanism This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 10

11 The contraindications for directed cough are few and relative in nature. The hazards and complications include (and seem to be just about the same as for deep, spontaneous coughing): Paresthesia or numbness Reduced coronary artery perfusion Reduced cerebral perfusion Incontinence Fatigue Headache Bronchospasm Muscular damage or discomfort Spontaneous pneumothorax, pneumo-mediastinum, subcutaneous emphysema Cough paroxysms Chest pain Rib or costochondral junction fracture Incisional pain, evisceration Anorexia, vomiting, and retching Visual disturbances including retinal hemorrhage Central line displacement Gastroesophageal reflux This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 11

12 Techniques and Methods Huff Maneuver The huff maneuver is a forced expiratory maneuver. It is initiated at mid to low lung volumes and performed with an open glottis. It is used in conjunction with many therapies. The benefits of huff coughing are that it avoids the potential for airway collapse and generates an adequate flow for secretion clearance. Autogenic Drainage The principle behind autogenic drainage is that high expiratory flows can be achieved in various generations of the bronchi through controlled breathing. The technique avoids coughing and airway closure. There are three phases of the process of autogenic drainage. Phase one is the unsticking portion. It is having the patient breathe mid-tidal volume inhalations to their expiratory reserve volume with a breath hold. The second phase is collection where the patient gradually increases their tidal volume. Lastly, phase three is the evacuation initiated by a breath hold followed by a gentle forced exhalation. Active Cycle of Breathing (ACB)/Forced Expiratory Technique (FET) This is a repetitive cycle that consists of one or two huff breaths from mid-to-low lung volume range, controlled diaphragmatic breathing and then thoracic expansion exercises. Evidence-Based Medicine / Assessment of Outcomes There is evidence-based medicine that notes improvement in pulmonary function values, equivalency to other techniques and preference of these techniques by the cystic fibrosis patient. The American College of Chest Physicians in their article Nonpharmacologic Airway Clearance Therapies: ACCP Evidence-Based Clinical Practice Guidelines, concluded that some nonpharmacologic therapies are effective in increasing sputum production, but their longterm efficacy in improving outcomes compared with unassisted cough alone is unknown. According to a study published in the JAMA (2006), it was determined that pre-operative chest physiotherapy is effective in the prevention of postoperative pulmonary complications in highrisk patients undergoing coronary artery bypass surgery. A single blind randomized controlled trial to determine the effectiveness of manual chest physiotherapy techniques in the management of COPD patients with infective exacerbations is presently being conducted in the United Kingdom. This study started in 2004 and the anticipated end date is August, The outcome of this study will definitely be of interest to all clinicians involved in the care of COPD patients and those with indications for manual chest physiotherapy. A study conducted at a London Children s Hospital found that a flutter valve and active cycle of breathing techniques are equally effective in a group of cystic fibrosis patients. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 12

13 Postural Drainage Therapy (PDT) AARC Clinical Practice Guideline: Postural Drainage defines postural drainage as a component of bronchial hygiene therapy. It consists of postural drainage, positioning, turning and is sometimes accompanied by chest percussion and/or vibration. Alternative names for this procedure are chest physiotherapy, chest physical therapy, postural drainage and percussion and percussion and vibration. Indications for postural drainage therapy include: Excessive sputum production Ineffective cough Evidence of retained secretions History of cystic fibrosis, lung abscess or bronchiectasis Contraindications There are fourteen contraindications for positioning alone in the guidelines with an additional seven for trendelenburg specifically. Twelve contraindications are cited for external manipulation of the thorax (percussion and vibration). Hazards and Complications Hypoxemia Increased intracranial pressure Acute hypotension Pulmonary hemorrhage Pain or injury to muscles, ribs or spine Vomiting and aspiration Bronchospasm Dysrhythmias This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 13

14 Various postural drainage positions. The lung segment/lobe that is being drained is denoted by the circled areas. Courtesy of the University of Wisconsin Cystic Fibrosis Center. Percussion / Vibration Techniques and Methods Manual Manual chest percussion and/or vibration can be accomplished with the hands. Percussion may be done manually with specially designed palm cups. I have also observed therapists using the infant and pediatric size resuscitation masks and resuscitation masks with a one-way valve added to percuss small chests. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 14

15 Palm Cups Compliments of DHD Healthcare Electrical and Pneumatically Powered Percussors This type of equipment adjunct to postural drainage comes in many configurations and comprises infant through adult sizes. Theoretically, they replace the therapist s hands in the manipulation of the thorax. Neocussor Neonatal Vibrator Compliments of General Physiotherapy, Inc. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 15

16 Assessment of Outcome Change in sputum production G5 Vibramatic Compliments of General Physiotherapy, Inc. Change in breath sounds of the lung fields being treated Patient subjective response to therapy Change in vital signs Change in chest -ray Change in arterial blood gas values or oxygen saturation (SpO 2 ) Change in ventilator variables HYPERINFLATION OR VOLUME EPANSION THERAPY Intermittent Positive Pressure Breathing (IPPB) Indications Improve lung expansion Short-term ventilatory support Deliver medications This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 16

17 Contraindications The only absolute contraindication for IPPB is the untreated tension pneumothorax. Intracranial pressure greater than 15 Torr Hemodynamic instability Recent facial, oral or skull surgery Tracheoesophageal fistula Recent esophageal surgery Active hemoptysis Nausea Air swallowing Active untreated tuberculosis Bleb on chest -ray Hiccoughs Hazards and Complications Many of the hazards and complications of IPPB therapy relate to providing a positive pressure breath and the results of such. Assessment of Outcome VT via IPPV greater than VT spontaneously (25%) Increase in FEV1 or PEFR More effective cough Enhanced secretion clearance Improved chest -ray This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 17

18 Improved breath sounds Patient s favorable response to treatment Incentive Spirometry (IS) Indications Presence of conditions that predispose the patient to atelectasis Presence of atelectasis Presence of a restrictive lung defect associated with dysfunctional or paralyzed diaphragm Contraindications The only contraindication to incentive spirometry therapy is when the patient cannot be instructed or supervised to assure appropriate use of the device. Hazards and Complications Incentive spirometry (IS) may be ineffective if done incorrectly or not often enough. It is too little too late for a lung collapse or consolidation. Barotrauma may occur in those with emphysema. The patient may hyperventilate if using the IS device without spacing maneuvers. Postoperative patients often complain of pain, many complain of fatigue. If the patient is removed from supplemental oxygen, they may become hypoxic. The deep breathing and inflation holds may exacerbate bronchospasm. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 18

19 Methods Of Delivery There are two types of incentive spirometers, volume and flow. The Cliniflo is an example of a flow type spirometer. Assessment of Outcome Cliniflo Incentive Spirometer Compliments of DHD Healthcare Absence of or improvement in the signs of atelectasis Improved inspiratory muscle performance Positive Airway Pressure (PAP) P ositive airway pressure adjuncts are emerging as effective alternatives to the traditional therapeutic modalities. These adjuncts have been proven to be more effective than incentive spirometry or IPPB for lung expansion. Breathing techniques as outlined earlier are essential components of PAP therapies. The modalities and methods under this heading are those where positive pressure therapy and bronchial hygiene therapy both may be indicated. The central principle of PAP therapy is alveolar recruitment through collateral ventilation. PAP modalities include PEP, CPAP and EPAP. CPAP is where: A pressurized circuit maintains preset airway pressure during inspiration and expiration. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 19

20 PEP is: Exhalation against a fixed orifice resistor that generates a pressure during exhalation. EPAP is: Exhalation against a threshold resistor that generates a pressure during exhalation. Indications Retained sputum not responsive to directed or spontaneous coughing History of pulmonary conditions treated successfully with postural drainage (also includes manipulation of the thorax) Evidence of retained secretions Reduce air trapping Prevent or reverse atelectasis Optimize delivery of aerosol bronchodilators Patient Indications Cystic fibrosis Bronchiectasis Asthma Lung transplants Chronic bronchitis with air trapping and excessive secretions Postoperative upper abdominal surgery Atelectasis Contraindications No absolute contraindications Relative contraindications: This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 20

21 Inability to tolerate increased work of breathing Increased intracranial pressure Hemodynamic instability Oral or facial trauma or surgery Assessment of Outcome Change in sputum production Change in breath sounds Patient subjective response to therapy Change in vital signs Change in chest -ray Improvement in gas exchange values Methods of Delivery PEP PEP EzPAP Vibratory PEP High frequency airway and chest oscillation PEP therapy advantages: Addresses underlying defect Can be used in conjunction with medication delivery devices Can be performed independently Easy to learn This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 21

22 Few limitations compared to postural drainage/ippb Delivery procedure: PEP therapy devices: TheraPEP Select appropriate expiratory resistance Target 1:3 or 1:4 ratio Decrease setting if I:E is 1:1 or 1:2 Increase setting if I:E is 1:5 or 1:6 Inhale large than normal tidal volume Exhale actively Maintain expiratory pressure cmh 2 O Maintain I:E of 1:3 or 1:4 Perform breaths Perform huff cough maneuver Repeat process 4-6 times TheraPEP has a fixed orifice resistor. A nebulizer may be used in-line. A feature includes a pressure indicator for immediate feedback and is adjustable to six settings. A mouthpiece or mask may be used. TheraPEP Device Compliments of DHD Healthcare This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 22

23 PariPEP PariPEP has two therapeutic options: combined PEP and aerosol delivery or conventional PEP. There are eight adjustable settings. It may be placed in the top rack of the dishwasher for cleaning. It is reusable and durable. Circulaire PariPEP Device Compliments of Pari Respiratory Equipment The Circulaire nebulizer with drug reservoir has a pep kit available that consists of a variable resistor, luer port and cap and 24 inches of pressure monitoring tubing. They also carry a manometer, plus or minus 60 cmh 2 O and pediatric and adult masks that are not vented for the purpose of pep administration. Circulaire with Resistor Compliments of Westmed This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 23

24 AeroPep Plus AeroPep Plus is a valved holding chamber with adjustable fixed orifice resistor. EPAP AeroPEP Compliments of Trudell Medical Threshold PEP is an adjustable PEEP device that functions with a threshold resistor to provide positive pressure upon expiration. ThresholdPEP Compliments of Summit Technologies This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 24

25 EzPAP EzPAP is indicated for use in conjunction with a medical need for lung expansion therapy and the treatment and prevention of atelectasis. Unlike IPPB, EzPAP pressures never drop below zero. Pressure in the system decreases during inspiration, but is still positive. This pressure helps to splint open the airways and re-inflate collapsed alveoli. During exhalation, the positive expiratory pressure provides PEP therapy to further splint the airways open. EzPAP provides a flow assist during inspiration and a positive pressure on exhalation. The exhalation against the resistance caused by the airflow creates positive expiratory pressure. The flowmeter is attached and set at 5-15 LPM. The Coanda effect amplifies the flow by approximately four times. The amplified flow creates the positive pressure throughout the patients breathing cycle. The Coanda effect is that a stream of air or fluid emerging from a nozzle tends to follow the path of a nearby curved surface as long as the curvature of the surface is not too much of a sharp angle. 2. The Coanda effect amplifies the flow by approximately four times 1. Flowmeter is attached to PSI gas source and adjusted to 5-15 lpm Air from gas source Patient Entrained ambient air The amplified flow creates a positive airway pressure throughout the patients breathing cycle EzPAP Schematic: Coanda Effect Compliments of DHD Healthcare This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 25

26 16 14 CPAP EzPAP Airway Pressure (cmh 2 O) Expiration Expiration Inspiration Expiration Expiration Expiration Inspiration Inspiration Expiration Expiration EzPAP Compared to CPAP Compliments of DHD Healthcare EzPAP is used with proven outcomes in many facilities. At Shriners Hospital a four-year study of patients who developed atelectasis prompted the Respiratory Care department to institute a protocol with either IPPB or EzPAP. The reason they used the EzPAP is that, other than IPPB of course, it was the only hand-held device that combined positive-airway pressure with a mask and provide in-line aerosolized medications. St. Joseph s Hospital Hyperinflation Protocol recommends EzPAP for those patients without retained secretions and the Acapella (see Vibratory PEP section) for those who also require bronchial hygiene. EzPAP Device Compliments of DHD Healthcare This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 26

27 Vibratory PEP These devices combine PEP with a flutter effect. Vibratory PEP devices provide a percussive effect that disengages mucus from the airway walls. They pulsate the mucus forward towards the larger airways. Vibratory PEP also reduces the visco-elasticity of the mucus. The flutter valve was the first vibratory PEP device. It contained a weighted ball that required over 25 LPM and proper positioning to be effective. Flutter Valve Compliments of Millennium Medical Acapella is a vibratory PEP device. It functions well in any position. The frequency of the vibrations and the resistance is adjustable. There are two flow levels; green for an expiratory flow greater than 15 LPM, blue for an expiratory flow less than 15 LPM. Aerosolized medications may be placed in-line, pressure monitoring is available and there are a variety of patient-device interfaces that may be used. The Acapella improves clearance of secretions, may reduce the need for postural drainage and facilitates opening of airways with patients who have disease processes or conditions that cause retained secretions. The acapella may also be used to prevent or reverse atelectasis. The Acapella may be connected to the TheraPEP pressure port and gauge to allow for pressure measurement. Acapella Compliments of DHD Healthcare This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 27

28 High Frequency Airway Oscillation Interpulmonary Percussive Ventilation (IPV) Percussionaire IPV is a continuous airway pressure with high flow rate of mini-bursts at greater than 200 Hz. The outcomes in comparative studies are fairly equal to postural drainage/thorax manipulation. Many feel this modality is unproven and experimental. Clinically, though, there has been a consistent history of positive outcomes anecdotally. Interpulmonary Percussive Ventilator Compliments of Percussionaire High Frequency Chest Wall Compression (HFCC) Oscillation (HFCWO) The Vest The Vest provides high frequency external chest wall compression and vibration. The equipment consists of an air pulse generator and vests that are available in various sizes, pediatric through adult. This modality has been used for years to assist the cystic fibrosis patient in secretion clearance and most recently has been added to the tools in the acute care setting. Evidencebased medicine reveals that The Vest is more effective in increasing secretion production that postural drainage with thorax manipulation. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 28

29 The Vest Compliments of Advanced Respiratory Mechanical Insufflation-Exsufflation Compliments of Emerson Medical CHOOSING THE MOST APPROPRIATE MODALITY FOR YOUR PATIENT The clinician may wish to begin their analysis and assessment process by examining the limitations of method as set forth in the AARC Clinical Practice Guidelines for the modalities specific to hyperinflation and bronchial hygiene therapy. Postural drainage and percussion have been the standard treatment for retained secretions for decades. IPPB or incentive spirometry has been the gold standard for prevention or treatment of atelectasis. Although widely accepted and used, there are drawbacks of these therapies for both the patient and the therapist. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 29

30 Limitation of Method Limitations Deep breathing alone without mechanical aides can be as beneficial in preventing or reversing pulmonary complications. There is concern of overuse. Mechanical effects only last about one hour. MDI or hand-held nebulizers are the devices of choice for aerosol therapy to COPD and stable asthmatics. Delivery of a therapeutic dose of medication may require as much as a tenfold increase in medication amount over MDI. Efficacy is technique dependent (coordination, breathing pattern, selection of appropriate inspiratory flow, peak pressure, inspiratory hold). Efficacy is dependent on device design as well as aerosol output and particle size. Equipment and labor-intensive way of delivering aerosol. Limited portability may affect patient compliance. Lack of convenience may affect patient compliance. Patient must be breathing spontaneously. CPAP least desirable of PAP therapies. Effectiveness based on tradition and anecdotal report not on scientific evidence. Used excessively. Used for patients in whom it is not indicated. Airway clearance may be less than optimal in patients with an ineffective cough. Optimal positioning is difficult in critically ill patients Limited value in the obtunded, paralyzed or uncooperative patient. Many clinical entities may compromise the effectiveness of a directed cough maneuver. Effective cough may be limited in those patients who cannot effectively close their glottis. Thick, tenacious sputum may limit effectiveness and Other supplemental strategies may be required. Methods IPPB IS PD PAP DC This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 30

31 IPPB: Intermittent Positive Pressure Breathing IS: Incentive Spirometry PD: Postural Drainage PAP: Positive Airway Pressure DC: Direct Cough Decision Making Questions involved in the critical thinking process in order to make the most appropriate decision could include: Which modalities will accomplish both hyperinflation and bronchial hygiene goals? If my patient needs aerosolized medications, which delivery method is most appropriate for them? Why use alternatives to the conventional? Is there a physiologic rationale for use of the therapy? Which therapy is likely to provide the greatest benefit with the least harm? Which therapy is likely to provide the greatest benefit at the least cost? Is the patient able to assist in the therapy? Is the patient cooperative? Is the patient in need of an acute therapy or longer-term therapy? Does the patient need a portable device to continue therapy at home? If therapy requires assistance, will this impact patient compliance? First of all, many patients cannot physically tolerate or cooperate with PD & P or IPPB. If a patient needs their right lower lobe drained, but is a fresh neurological injury, the position required to drain that area is contraindicated not to mention the effect on the ICP of actually percussing the patient s thorax! How many patients have you had to give IPPB with a mask or a mouth seal, pressing firmly to avoid leaks? Most patients are not in favor of having either interface device pressed over their face! And how do you feel as a therapist? Here you are, trying to do the best for your patient and making them uncomfortable. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 31

32 Another aspect today is definitely patient rights. Is it acceptable to ensure the therapy is accomplished no matter how much the patient protests? IPPB machines, percussors on rollers just more equipment for the therapist to carry around. Let s add the stethoscope, calculator, medications and pulse oximeter. I often imagine myself dressed somewhat as a Ghostbuster with a backpack loaded for patient care. Handheld, single patient use devices can be left at the bedside not just for our convenience, but for patient compliance as well. I think that is a definite benefit! There is often a question of the ability of the therapist to give an effective IPPB treatment. In many parts of the country IPPB is almost obsolete. I know therapists who have been out of school for 3-5 years and still have not given one single treatment since completing their clinical performance objectives in their Respiratory Therapy program. Most hand-held devices are training simplistic and easily learned by the therapist. Therapist effort and technique plays a significant role in the success of PD & P or IPPB. Proper IPPB requires patient cooperation and training. Often, the patient is not coordinated enough. What about the patient s ability to understand directions? Language barriers in our blended culture are not uncommon and may create communication problems during patient education. Therapists throughout the country have been feeling the medical shortage for a long while. There are often too many patients, too little time, too few therapists, and too few nurses. A conscientious therapist wants to ensure that the patient receives the appropriate treatment and that it gets delivered in an effective manner. We all want positive outcomes for our patients. So, logically, the least time and labor-intensive therapeutic modality for the patient s disease or condition is the goal. PD & P and IPPB are labor-intensive and can be time consuming if done correctly. There are many contraindications, hazards and complications of IPPB and PD & P. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 32

33 SUMMARY I n this 21 st century, the clinician now has many modalities to choose from to provide hyperinflation and/or bronchial hygiene. Thirty years ago, we were habitually using IPPB, PD & P and blow gloves! Throughout the years more tools have been added to our toolbox to accomplish the same goals as the original modalities: resolution and prevention of atelectasis and secretion removal. AARC Guidelines and evidence-based medicine has given us guidelines and standards we can use as resources to make the best decision for our patients. Mucus clearance during normal function of the mucociliary escalator is a natural and not thought much about function. Impairment of lung function can easily result from impairment of the mucociliary escalator. Three main problems stem from impairment of the conducting airways: 1; inflammation, 2; retained secretions and 3; bronchospasm. These problems may lead to diminished pulmonary function, reduced lung defenses and increased risk of infection. As therapists, the responsibility for treating patients with the above dysfunctions is comprised within our daily practice. It may be our decision to determine which modality will be most effective for the patient. This is why it is essential that we fully understand the options available. Each facility may have a different selection of devices that may influence your decision. Bronchial hygiene therapy/secretion clearance techniques include directed cough and postural drainage. Hyperinflation/volume expansion therapy includes IPPB and incentive spirometry. PAP therapy includes PEP, CPAP and EPAP. The less invasive the modality, the less contraindications, complications and hazards. The more complex the modality, the more limitations of method are noted. Knowing the indications, contraindications, hazards, complications, limitations of method and devices/techniques that may be employed gives the clinician the basis for making an educated decision. Coupled with perceptive and comprehensive patient assessment, the clinician has the best combination of knowledge to come to a decision on how to treat their patient with atelectasis or retained secretions. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 33

34 SUGGESTED READING AND REFRENCES AARC Clinical Practice Guidelines: Directed Cough Respir Care 1993; 38(5): AARC Clinical Practice Guidelines: Incentive Spirometry Respir Care 1991; 36(12): AARC Clinical Practice Guidelines: Intermittent Positive Pressure Breathing Revision and Update Respir Care 2003: 48(5): AARC Clinical Practice Guidelines: Postural Drainage Therapy Respir Care 1991; 36(12): AARC Clinical Practice Guidelines: Use of Positive Airway Pressure Adjuncts to Bronchial Hygiene Therapy Respir Care 1993; 38(5): Anderson, J., Ovist, J., Kann, T. Recruiting collapsed lung through collateral channels with positive end-expiratory pressure: Scand J. Respir Dis Oct Boujoukos, A., Delgado, F., Tuttle, R. Cardiothoracic ICU Post-Extubation Protocol: AARC Times, May Branson, R., Hess, D., Chatburn, R. Respiratory Care Equipment (1999) 2 nd ed. Lippincott, Philadelphia. Branson, R., Hurst. K/. DeHaven, C. Mask CPAP: State of the Art: Respiratory Care, Oct Burton, G., Hodgkin, J., Ward, J. Respiratory Care A Guide to Clinical Practice (1997) 4 th ed. Lippincott, Philadelphia. Byrne, N. et al The Use of the Flutter VRPI as a Form of Chest Physiotherapy in Cystic Fibrosis, Coates, A. Chest physiotherapy in cystic fibrosis: Spare the hand and spoil the cough? (1997) The Journal of Pediatrics (1997) Vol. 131 No. 4 and A single blind randomized controlled trial to determine the effectiveness and cost utility of manual chest physiotherapy techniques in the management of infective exacerbations of Chronic Obstructive Pulmonary Disease. Daniel, B., Tarnow, J. EzPAP An Alternative in Lung Expansion Therapy. Presented at the AARC International Respiratory Congress December This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 34

35 Davis, K. Airway Clearance Strategies for the Pediatric Patient. Respiratory Care, July 2002 Vol. 47 No. 7. Fink, J. Positioning Versus Postural Drainage. Respiratory Care, July 2002 Vol. 47 No. 7. Fink, J. Positive Pressure Techniques for Airway Clearance. Respiratory Care, July 2002 Vol. 47 No. 7. Fink, J., Mahlmeister, M. High-Frequency Oscillation of the Airway and Chest Wall Respiratory Care, July 2002 Vol. 47 No. 7. Fink, J., Mengr, B. New Horizons in Respiratory Care: Airway Clearance Techniques. Respiratory Care, July 2002 Vol. 47 No. 7. Gerson, V. Living Independently The Journal for Respiratory Care Practitioners, Feb/Mar Hardy, K. A Review of Airway Clearance: New Techniques, Indications, and Recommendations. Respiratory Care. May Vol. 39. No. 5. Huang, M. The Role of Positive Expiratory Pressure Therapy in Decannulating Subacute Care Patients. Subacute Care Today Jan./Feb Hulzebos, EH et al. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery; a randomized clinical trial. JAMA, 2006 Oct 18; 296(15); Lantz, G. Ventilation for Life AARC Times, May Lapin, C. Airway Physiology, Autogenic Drainage, and Active Cycle of Breathing. Respiratory Care, July 2002 Vol. 47 No. 7. Lewis, R. Airway Clearance Techniques for the Patient with an Artificial Airway. Respiratory Care, July 2002 Vol. 47 No. 7. Lindner, K., Lotz, P., Ahnefeld, F. Continuous Positive Airway Pressure Effect on Functional Residual Capacity, Vital Capacity and Its Subdivisions: Chest. July Mahlmeister, M., Fink, J., Hoffman, G., Fifer, L. Positive-Expiratory-Pressure Mask Therapy: Theoretical and Practical Considerations and a Review of the Literature. Respiratory Care Nov. (1991) Vol. 36 No. 11. McCool, F.D., Rosen, M. Nonpharmacologic Airway Clearance Therapies: ACCP Evidence- Based Clinical Practice Guidelines. Chest, 2006; 129:250S-259S. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 35

36 McIllwaine, P.M. Flutter Versus PEP: A Long-Term Comparative Trial of Positive Expiratory Pressure (PEP) Versus Oscillating Positive Expiratory Pressure (Flutter) Physiotherapy. Pediatric Pulmonary Suppl 12, abst 268 (1995). McIllwaine, P. M. et al. Long-term comparative trial of conventional postural drainage and percussion versus positive expiratory pressure physiotherapy in the treatment of cystic fibrosis. The Journal of Pediatrics Vol. 131, No. 4 (1997) MEngr, B. Physiology of Airway Mucus Clearance. Respiratory Care, July 2002 Vol. 47 No. 7. Rau, J., Tornianen, M. Combining a Positive Expiratory Pressure Device with a Metered-Dose Inhaler Reservoir System Using Chlorofluorocarbon Albuterol and Hydrofluoroalkane Albuterol: Effect on Dose and Particle Size Distribution. Respiratory Care, March Vol. 45. No. 3. Ricksten, S., Bengstsson, A., Soderberg, C., Thorden, J., Kevist, H. Effects of periodic positive airway pressure by mask on postoperative pulmonary function: Chest June, Stock, M., Downs, J., Gauer, P., Alster, J., Imrey, P. Prevention of postoperative pulmonary complications with CPAP, incentive spirometry, and conservative therapy. Chest, 1985 Feb: 87. Stock, M., Downs, J. Administration of Continuous Positive Airway Pressure by Mask: Acute Care Stock, M., Downs, J., Corkran, M. Pulmonary function before and after prolonged continuous positive airway pressure by mask: Critical Care Medicine. November Tarnow, J., Daniel, B., Shaughnessy, T., Cohen, N. Outcome and Cost After Unilateral Lung Transplantation: Comparison of Chest Physiotherapy Versus Positive Expiratory Pressure Therapy: Presented at the ACCP (1996, 1997) Volsko, T., DeFiore, J., Chatburn, R. Acapella vs. Flutter: Performance Comparison AARC Respiratory Care Open Forum Abstract Oct (2000) Wilson, R. Positive Expiratory Pressure Therapy: The Key to Effective, Low-cost Removal of Bronchial Secretions. RT, The Journal for Respiratory Care Practitioners. Feb/Mar Yost, H., Miller, L., Bush, T. Reduction of Hospital Admission Rate for Chronic Lung Disease Patients by Pulmonary Rehabilitation That Includes Positive Expiratory Pressure Therapy (1999) AACVPR Abstract. Zamost, B. et al Description and clinical evaluation of a new continuous positive airway pressure device. Critical Care Medicine Vol. 9 No. 2. (1981) This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 36

37 POST TEST DIRECTIONS: IF COURSE WAS MAILED TO YOU, CIRCLE THE MOST CORRECT ANSWERS ON THE ANSWER SHEET PROVIDED AND RETURN TO: RCECS, VAN BUREN BLVD, SUITE B, RIVERSIDE, CA OR FA TO: (951) IF YOU ELECTED ONLINE DELIVERY, COMPLETE THE TEST ONLINE PLEASE DO NOT MAIL OR FA BACK. 1. The main problems that stem from impairment of the conducting airways does not include: a. Diminished pulmonary function b. Diabetes c. Reduced lung defenses d. Increased risk of infection 2. Normal function of the mucociliary escalator is impaired when the conductive airways become: a. Dehydrated b. Overhydrated c. Chronically inflamed d. All of the above 3. There is smooth muscle, blood vessels, nerves and elastic fibers in the: a. Goblet cells b. Cilia c. Lamina propria d. None of the above 4. Indications for directed cough include: a. Ineffective cough b. Chronic retained secretions c. Absence of cough mechanism d. All of the above. 5. The contraindications for directed cough are: a. Atelectasis b. Inability to cough c. There are no contraindications for directed cough d. Pneumonia This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 37

38 6. Contraindications for incentive spirometry include: a. Presence of atelectasis b. Patient unable to be instructed c. Patients with a restrictive lung defect d. Lung consolidation 7. The indications for IPPB are to: a. Improve lung expansion b. Deliver medications c. Deliver short-term ventilatory support d. All of the above 8. According to AARC Clinical Practice Guidelines, postural drainage consists of all of the following except: a. Hyperinflation therapy b. Percussion c. Vibration d. Positioning 9. PAP therapy does not include: a. Incentive spirometry b. PEP c. EPAP d. CPAP 10. Patients with the following conditions/diseases may benefit from PAP therapy: a. Cystic fibrosis b. Asthma c. Chronic Bronchitis d. All of the above 11. The absolute contraindication for PAP therapy is: a. Increased intracranial pressure b. Change in chest -ray c. Hemodynamic instability d. None of the above This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 38

39 12. Which of the following devices is an example of vibratory PEP therapy? a. Acapella b. Circulaire c. EzPAP d. All of the above 13. EzPAP delivers a. A flow assist during inspiration b. A positive pressure on exhalation c. PEP therapy d. All of the above 14. Which of the following PAP devices cannot be used to deliver aerosol medications? a. EzPAP b. Flutter valve c. Acapella d. IPV 15. Of the methods of hyperinflation and secretion clearance discussed in this course, which has the least limitations of method? (please refer to Limitations of method chart) a. IPPB b. Incentive Spirometry c. Postural drainage d. Direct Cough SL: Test Version B This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 39

40 ANSWER SHEET NAME STATE LIC # ADDRESS AARC# (if applic.) DIRECTIONS: (REFER TO THE TET IF NECESSARY PASSING SCORE FOR CE CREDIT IS 70%). IF COURSE WAS MAILED TO YOU, CIRCLE THE MOST CORRECT ANSWERS AND RETURN TO: RCECS, VAN BUREN BLVD, SUITE B, RIVERSIDE, CA OR FA TO: (951) IF YOU ELECTED ONLINE DELIVERY, COMPLETE THE TEST ONLINE PLEASE DO NOT MAIL OR FA BACK. 1. a b c d 2. a b c d 3. a b c d 4. a b c d 5. a b c d 6. a b c d 7. a b c d 8. a b c d 9. a b c d 10. a b c d 11. a b c d 12. a b c d 13. a b c d 14. a b c d 15. a b c d SL: Test Version B This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 40

41 EVALUATION FORM NAME: DATE: AARC # (if applic.) STATE LICENSE #: RC Educational Consulting Services, Inc. wishes to provide our clients with the highest quality CE materials possible. Your honest feedback helps us to continually improve our courses and meet CE regulations in many states. Please complete this form and return/submit it with your answer sheet. Thank you. YES NO Were the objectives of the course met? Was the material clear and understandable? Was the material well-organized? Was the material relevant to your job? Did you learn something new? Was the material interesting? Were the illustrations, if any, helpful? Would you recommend this course to a friend? What was the most valuable portion of the material? What was the least valuable portion of the material? Suggestions for future courses: Comments: What is your specialty area? Credentials? How did you hear about RCECS? This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 41