Airway Clearance Techniques

Question 1

What are the three phases of active cycle breathing?

Answer 1

1- Breathing Control
2-Thoracic Expansion Exercise
3-Forced Expiratory Technique

Question 2

What does active cycle breathing always couple breathing exercise with?

Answer 2

A huff cough

Question 3

What is breathing control in active cycle breathing?

Answer 3

First phase of Active Cycle of Breathing
-gentle, relaxed breathing (may be diaphragmatic breathing at patient’s tidal volume and RRR for 5-10secs or as long as the patient needs to prepare for next phase)

Question 4

What is thoracic expansion Exercise in Active Cycle of Breathing?

Answer 4

2nd phase of ACoB

• 3 to 4 deep, slow, relaxed inhalation to inspiratory reserve with passive exhalation
• chest percussion, vibration, or shaking may be combined with exhalation

Question 5

What is forced expiratory technique in active cycle of breathing?

Answer 5

3rd phase of ACoB

• one or two huffs at mid to low lung volumes with the glottis open into the expiratory reserve volume
• a brisk adduction of the arms may be added to self compress the thorax

Question 6

What are the precautions and contraindications for Active Cycle of Breathing?

Answer 6

• splinting post-operative incisions to achieve adequate expiratory force
• bronchospasm or hyperreactive airways

Question 7

What is autogenic drainage?

Answer 7

A method of airway clearnace which uses controlled breathing to mobilize secretions by varying expiratory airflow w/o using postural drainage or coughing. It is an in depth technique and takes patience to learn but does not require assistance from another person or equipment which makes it easy to use at any time and in any place.

The theory is to improve airflow in small airways to facilitate the movement of mucus

Question 8

What is the procedure for Autogenic Drainage?

Answer 8

• patient is sitting upright in a chair with back support
• controlled breathing at three lung volumes
• exhalation through pursed lips may be used to control expiratory flow rate
• average treatment is 30-45 minutes

Question 9

What are the three phases of controlled breathing in Autogenic Drainage?

Answer 9

Unsticking Phase-slowly breathe in through the nose at low-lung volumes followed by a two to three second breath-hold to allow collateral ventillation to get air behind the secretions, then exhale down into the expiratory reserve volume

Collecting Phase: breathe at tidal volume, interspersed by two to three second breath holds

Evacuating Phase: deeper inspirations from low to mid inspiratory reserve volume with breath holding followed by a huff

Question 10

What are the precautions/contraindications of Autogenic Drainage?

Answer 10

It takes motivation and concentration to learn

Question 11

What is directed cough and huffing?

Answer 11

A cough is used to compensated for body’s limitation to elicit a maximum forced exhalation

A huff is similar but less violent and more akin to fogging a window and does not produce the same amount of airflow velocity but also has less of chance to cause airway collapse

Question 12

What is the procedure for a controlled cough?

What is the procedure for a controlled huff?

Answer 12

Cough

• inhale maximally and hold breath for 2-3 seconds with glottis closed
• contract expiratory muscles to build pressure against the closed glottis
• cough sharply 2-3 times with a slightly open mouth
• splint any post-surgical incisions on the trunk or thorax with a pillow or blanket roll

Huff

• inhale deeply through an open mouth
• contract the abdominal muscle during a rapid exhale with the glottis open saying “ha, ha, ha”

Question 13

What are the precautions and contraindications for coughing or huffing?

Answer 13

• inhability to control transmission of infection from patients with potentially contagious pathology
• elevated intracranial pressure or know intracranial anuerysm
• reduced coronary artery perfusion
• acute unstable head, neck, or spine injury
• potential for regurgitation/aspiration
• untreated pnuemothorax
• osteoporosis
• flail chest

Question 14

What is high frequency airway oscillation?

Answer 14

devices (“acapella” and “flutter”) that combine positive expiratory pressure and high frequency airway vibrations to mobilize mucus secretions in the airways

Question 15

What is the procedure for high frequency airway oscillation?

Answer 15

• place device in the mouth with the lips firmly sealed around the mouthpiece
• inhale slowly to 75% of a full breath
• hold the breath for 2-3 seconds
• exhale through the device for three to four seconds
• repeat for 10-20 breaths
• remove the device and perform two or three coughs or huffs to raise secretions

Question 16

What are precautions/contraindications for high frequency airway oscillation?

Answer 16

• patient tolerance increased work of breathing
• intracranial pressure over 20 mm Hg
• hemodynamic instability
• recent oral, facial, or skull trauma or surgery
• acute sinusitis
• nosebleed
• esophageal surgery
• active hemoptysis
• nausea
• untreated pnuemothorax
• middle ear pathology such as tympanic membrane rupture

Question 17

What is the difference between percussion and vibration for posture drainage?

Answer 17

• both should be applied to lung segment that is being treated
• percussion is also known as cupping and clapping and is striking of the thorax with an open hand that should be painless and purposeful for several minutes
• vibration is a tremulous action on the chest wall in the direction that the ribs move during respiration and should be performed during exhalation.

Question 18

What is the procedure for postural drainage?

Answer 18

• patient assumes the appropriate position for lung segment being targeted
• maintain position for 2-3 minutes

Question 19

What are the contraindications for all postural drainage positions?

Answer 19

• intracranial pressure over 20 mmHg
• head and neck injury until stabilized
• active hemorrhage with hemodynamic instability
• recent spinal surgery or acute spinal injury
• active hemoptysis
• empyema
• bronchopleural fistula
• pulmonary edema associated w/ congestive heart failure
• large pleural effusion
• pulmonary embolism
• rib fracture
• surgical wound or healing tissue

Question 20

What are the contraindications specifically for the trendelenburg position for postural drainage?

Answer 20

• uncontrolled hypertension
• distended abdomen
• esophageal surgery
• recent gross hemoptysis related to lung carcinoma treated surgically or with radiation therapy
• uncontrolled airway at risk for aspiration

Question 21

Name the position for each Lung segment:

1. right and left apical segments
2. right upper lobe posterior segment
3. left upper lobe posterior segment
4. left upper lobe lingula
5. right and left upper lobes anterior segment
6. right middle lobe
7. right and left lower lobe superior segment
8. left and right anterior basal segments of lower lobes
9. left and right lower lobe posterior basal segments
10. lower lobes lateral basal segments

Answer 21

1. patient is in sitting position and leaning back 3-40 degrees. percussion and vibration are above the clavicles
2. patient is turned 1/4 from prone on left side. percussion/vibration to medial border of R scapula
3. patient turned 1/4 to the right in prone with head of bed elevated 45 degrees and head/shoulders are raised on pillow. percussion/vibration to L scapula medial border
4. patient turned 1/4 from supine on right side with foot of bed elevated 12 inches. percussion/vibration over the left chest between axilla and left nipple
5. patient is in supine, percussion/vibration below clavicles
6. patient is turned 1/4 from supine on left side with foot of bed elevated 12 inches. percussion/vibration over the right chest between axilla and right nipple
7. patient is in prone. percussion/vibration below inferior border of left and right scapula
8. patient is in supine with feet elevated 18inches. percussion/vibration over lower ribs
9. patient is in prone with feet elevated 18 inches. percussion/vibration over lower ribs and side of chest
10. patient is in side-lying with foot of bed elevated 18 inches. percussion/vibration over lower ribs

Question 22

What is the procedure for percussion and vibration during postural drainage?

Answer 22

• place patient in appropriate position
• cover skin that is being treated with thin material
• therapist rhythmically strikes the chest with a cupped hand for 2-3 minutes per lung segment
• therapist places one hand on tip of the other over affected area or one hand on each side of the rib cage
• vibrate the chest wall as the patient exhales by tensing the muscles of the hand and arms while applying moderate pressure downwards
• the maneuver is performed in the direction in which the ribs move on expiration
• encourage patient to cough or huff after two or three vibrations

Question 23

What are the precautions/contraindications for percussion/vibration?

Answer 23

• all postural drainage contraindications
• subcutaneous emphysema
• recent epidural spinal infusion
• recent skin graft over thorax
• burns or open wounds of the thorax
• recently placed pacemaker
• suspected pulmonary tuberculosis
• lung contusion
• bronchospasm
• osteomyelitis/osteoporosis
• chest wall pain complaints

Question 24

What are the expected outcomes for airway clearance?

Answer 24

• easier clearance of secretions and increased volume of secretions during and after treatment
• improved breath sounds in the lungs being treated
• increase in sputum production
• change in vital signs-moderate change in RR and or pulse rate are expected
• resolution or improvement of atelectasis and local infiltrates observed with chest x-ray
• improvement in arterial blood gas values or oxygen saturation