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Flashcards in Bronchopulmonary Hygiene Deck (148):

Normal Airway Clearance

Patent Airway

Functional Mucociliary Escalator-When the muscus travels up the epithelium via cilia to be expelled

Effective cough


Retention of Secretions

Retention of Secretions can lead to a full or partial airway obstruction

If pathogens are present retention of secretions can result in secretions

Compounding these problem may be a failure in the cough reflex

—In patients with retained secretions, interference with any one of the cough's four phases can result in ineffective airway clearance


Partial Obstruction

Restricts airflow

Will increase WOB which will lead to air trapping, overdistension, and ventilation/perfusion imbalances


Full Obstruction

—Muscus plugging

Atelectasis and imparied oxygenation due to shunting



Hypoxic Vasoconstriction

Compensatory mechanism for shunt, will decrease blood flow to portion of lung and in turn increased pulmonary vascular resistance which can inpact the heart (very important when pt. has heart problems)


What are the 4 phases of a Cough

1) Irritation

2) Inspiration

3) Compression

4) Expulsion




Irritation Phase of the Cough

—Something is bugging your lungs and you can sense it 

A stimulus will trigger airway sensory recpetors, sending impulses to the brain's medullary cough center

Causes can be-Inflammatory (cough), mechanical (sputum, foreign bodies), chemical (irritating gases such as cigarette smoke), and thermal (cold air)



Mechanisms that Impair Irritation Phase of a Cough:


CNS depression



Inspiration Phase of a Cough

—In response to afferent impulses, the cough center will reflexively stimulate the inspiratory muscles to initiate a deep inspiration (1-2L)



Mechanisms that Impair Inspirtion Phase of a Cough


Neuromuscular dysfunction

Pulmonary restriction 

Abdominal restriction

MAP and MIP-Maximial expirator pressure and maximum inspirtory pressure

Vasalva manuever


Compression Phase of a Cough

Compression-Closure of the glottis (vocal cord snap shut) in order to generate pressure

A reflex nerve will cause the glottis to close and the expiratory muscles to contract

—Pleural and alveolar pressures increase rapidly.

—This compression phase is normally about 0.2 second and results in a rapid rise in pleural and alveolar pressures, often in excess of 100 mm Hg.


Mechanisms that impair compression in a cough

Laryngeal nerve damage

Artificial airway

Abdominal muscle weakness

Abdominal surgery


Expulsion Phase of a Cough

—The glottis opens, causing a large pressure gradient between the alveoli and the airway opening.

—Expiratory muscles continue to contract.

—The pressure gradient causes a high-velocity gas flow that displaces the mucus from the airway walls and into the air stream.

—A violent, expulsive flow of air from the lungs, with velocities as high as 500 miles per hour.


Mechanisms that impair expulsion

Airway compression

Airway obstruction

Abdominal muscle weakness

Inadequate lung recoil (e.g., emphysema)


Patient may be unable to adequately clear secretions if:

There is loss of airway control

Increased secretion production or thickened secretions due to abnormal lung pathology

Inadequate cough


Causes of Impaired Mucociliary Clearance in Intubated Patients

—Endotracheal or tracheostomy tube Intubated patients

—  Tracheobronchial suction

—  Inadequate humidification

—  Drugs

—General anesthetics



—  Underlying pulmonary disease


Mucocillary Clearerance in Intubated Patients

  • —The tube's presence in the trachea
    • —increases mucus secretion
    • —the tube cuff mechanically blocks the mucociliary escalator.
    • —movement of the tube tip and cuff can cause erosion of the tracheal mucosa and further impair mucociliary clearance.
    • —endotracheal tubes impair the compression phase of the cough reflex by preventing closure of the glottis
    • —Although suctioning is used to aid secretion clearance, it, too, can cause damage to the airway mucosa and thus impair mucociliary transport.
      • —We have suction pressure on muciliary lining which can cause damage in itself
    • The cuff will obstruct the secretions and will take away the glotic closure takign away the ability to create a high pressure coug




—Removal of secretions or other semi-liquid fluids from the airways using mechanical aspiration.

—Application of negative pressure (vacuum) to the airways through a collecting tube (flexible or rigid catheter). 

Removal of foreign bodies, secretions, or tissue masses beyond the mainstem bronchi requires bronchoscopy.

Upper airway is verythign above the glottis 


Indications for Suctioning

  • —Coarse or absent Br/S on auscultation
  • An ineffective spontaneous cough
    • —Visible secretions in the airway
    • —The need to stimulate a cough in patients unable to cough effectively secondary to changes in mental status or the influence of medication (cough effort)
  • —Changes on Xray consistent with retained secretions-
    • atelectasis or consolidation
    • When we come to this point the patient may need a therapeutic bronchoscopy not just a suctionist
  • —Changes in monitored flow/pressure graphics
    • —Increased peak inspiratory pressure (PIP) on volume-control ventilation (VCV)
    • —Decreased tidal volume (Vt) on pressure control ventilation (PCV)
  • Suspected aspiration of gastric or upper airway secretions
  • Clinically apparent increased WOB
    • Resp rate & pattern
  • Changes in oxygenation- This is one of our big indications that suctioning is needed
    • Colour
    • Saturation (pulse oximetry)
    • ABG
  • Endotracheal tube aspirate
    • Patency check



What does coarse mean?

Very thick secretions may not move with airflow and thus may not create any adventitious sounds.

If they are able to cough we  may only need to assist them in the cough instead of a full deep suctioning


•Crackles or diminished breath sounds

•You can see it on the vent waveform


True or False Is suction routinely Done on a Schedule



Contraindications to Suctioning

—Most contraindications are relative to patient’s risk of developing adverse reactions or worsening clinical condition as a result of procedure

—When indicated, there are no absolute contraindications for endotracheal suctioning

If we do not clear secretions it can kill the patient, which is why there are only relative contraindications

Ex.When we cough we are increasing ICP which can be dangerous in TBI patient, what we can do to help this is to administer Lidocaine or even paralyze them in order to blunt their cough during suctioning 



Suction Equitment

  • —Adjustable suction source/collection system
  • —Sterile suction catheter
  • —Personal Protective Equipment (PPE)
    • —Sterile glove(s)
    • —Goggles, mask, and gown (standard precautions)
  • —Sterile basin
  • —Sterile bulk saline
    • Some clinican use water some prefer saline as it is an isotonic 
  • —Sterile saline for instillation
  • —Oxygen delivery system (BMV or ventilator) 


Types of Suction Regulators

  • —Continuous suction regulators: Either on or off
    • Adjustable from 0 to –200 mmHg
  • Intermittent suction regulators: Designed to cycle from on to off
    • Cycle time & suction can be adjusted
    • Three preset ranges (don’t need to memeorize know that we have it and you don’t use it for invasive suctioning)
      • Low 50- 70 mmHg
      • Medium 80- 100 mmHg
      • High 110- 130 mmHg
  • Older application: gastric tubes
  • Latest application of intermittent suction: surgical drainage


Collection System

—Used to collect waste…

——Prevent contamination of  suction regulator/ suction  machine

—Contains valves to protect system from overflow

—Valves interrupt suction when container full


Connection Tubing

—Regulator -> waste container—

—Waste container -> suction catheter

Often canister is mounted on the wall on the wall. Short or long tubing doesn’t really matter. Because it is on the wall, a short piece of tubing is used to connect canister to regulator, and then a long piece from the canister to reach the patient.

Remember to check the pressure you are subjecting your patient to at the end nearest them. Distal to the vacuum source.



Flexible Suction Catheters 

—Inserted directly into artificial airways (or through the nose/ nasopharynx)

Can be used in the mouth, but not commonly seen in adults (have rigid/tonsillar suction )

Everytime before you suction a pt. even if they are sedated always warn your pt. first

—Flexible  (prevent damage to airway mucosa) but rigid enough to be passed through an airway

—Various sizes

—Smooth and molded edges to prevent trauma to airway mucosa

—Produce minimal resistance due to friction when passed through airway


Flexible Suction Catheters-Sizes

  • —Various sizes (Fr)
    • —Size determined by outside circumference  of catheter
    • —Most often seen/available in even sizes
  • —Too large can obstruct the endotracheal airway.
    • —Application of negative pressure evacuates lung volume and causes atelectasis and hypoxemia.
    • —Never suction a patient with a catheter whose outer diameter is greater than one half the internal diameter of the artificial airway


Rule of Thumb for Sizing Flexible Catheter

—To estimate the proper flexible catheter size:

—Multiple inner diameter (ID) of ETT x 2 & use next smallest even catheter

—e.g. size 7 ID ETT will require a suction catheter with size:  7*2= 14 à use 12 Fr


Catheter Tips

  • —Several catheter types available:
    • — straight
    • — angled or curved   “coude”
  • —Variability in # & size of orifices (eyes)
  • diameter of orifice/eyes larger than catheter’s inner diameter


Closed Multiuse System

—Can be incorporated directly in the mechanically ventilated circuit (ETT or Trach) to be used repeatadly. 

Because this system allows suctioning without disconnecting the patient from the ventilator, high Fio2 and positive end-expiratory pressure (PEEP) can be maintained, resulting in less likelihood of hypoxemia (preoxygenation with 100% O2 is still required).

After suctioning the catheter needs to be completely removed from the airway (check your markings)

Cross contamination is less likely and will cost lower

The extra weight an in-line catheter adds to a ventilator circuit may increase tension on the tracheal tube. Also, the presence of the catheter in the airway increases resistance. This will result in an increase in the peak inspiratory pressure and can alter the volumes delivered by a ventilator depending on how the ventilator is operating.

The reduced airway pressure during suctioning can cause the ventilator to inadvertently trigger.


Indications for Closed System (Inline) Catheters

Hemodynamic instability

—High ventilatory requirements

—On isolation

—Receiving inhaled agents

—Frequent suctioning



—Endotracheal suctioning can be done through an endotracheal tube that is inserted:

—Nasally or Orally

—May be via an open or closed technique

—Should be a sterile procedure



—Tracheostomies may be suctioned

—Via an open or closed technique

—Sterile in ICU, will see “clean” on wards


Endotracheal Suction Levels

—Adult 80-120 mmHg (open)

—Adults full wall ~160 mmHg (closed)

—Children 60-100 mmHg (open & closed)

—Infants 60-80 mmHg (open & closed)


—Suction Levels have Direct Effect on Lung Pressures:

Decreased Lung Volumes -> Atelectasis -> hypoxemia -> Hypoxia 



Sputum COCA

COCA: colour, odour, consistency, amount


The Three S of Suctioning






How to Oxygenate the Patient

30 sec-3 min on 100% oxygen following procedure (adults only)



Instillation is not routinely done because of irritation to the patient which can cause bronchoconstriction (very dangerous in asthma) and it can uncomfortable. Can also produce biofilm into the lungs

Indications: Tenacious secretions, blood clots, etc

Instillation is to help mobilize secretion and produce a cough by putting saline down the tube


Equitment in OPEN Suction

—Adjustable suction source/collection system

—Sterile suction catheter

—PPE-Sterile glove(s), goggles, mask, and gown (standard precautions)

—Sterile basin

—Sterile saline for lubricating and/or flushing catheter

—Sterile saline for instillation

—Oxygen source-BMV 


Equitment in CLOSED Suction

—Adjustable suction source/collection system

—Multiuse/in-line suction catheter


—Sterile saline for flushing the catheter and/or instillation

—Oxygen source-ventilator


Factors that Affect the Rate of Suction Flow

Magnitude of Suction Applied

Diameter of Tubing

Viscosity of Fluid Being Suctioned 


‘Caution’ Regarding High Suction Levels

  • Rate of suction flow is portportional to suction level if flow is smooth and laminar
    • 50% increase suction level results in 50% increase in suction flow rate
  • Flow within suction system is turbulent and disorderly
    • Increased suction level by 50% may only increase flow by 20-25%
  • Try to increase suction flow by increasing magnitude of suction level 
    • Not the best apprach but also not wrong 
    • Increasing suction will not increase flow because it will increase turbulent flow 
  • To try and get more laminar flow get a larger diameter of tubing, try to thin out secretions, and tryign to decrease magnitude


Other Types of Airway Clearing

—Secretions or fluids can also be removed from the adult oropharynx by using a rigid, tonsillar or Yankauer suction.

—Saliva, mucous, pulmonary secretions, blood or vomit

Oral/Oropharyngeal suctioning (massive)- Used to remove large or excessive amounts of secretions from oral cavity & oropharynx (no gag reflex!)

Will be at every pt. bedside


Suction Ranges

Infant/Child: 0- 100 mmHg

Adult: ~ 160 mmHg (~ full suction)


—Nasopharyngeal Suctioning

Used for non intubated patients who are unable to properly clear their airway and you can not access the mouth

A lubricated flexible catheter will be inserted via the nasopharyngeal airway (NPA or trumpet). The NPA will be left in place in order to facilitate suctioning, but should be changed from one nare to the other every 24-48 hours. 

NPA will be only used on adults, and they will restrict activity of the patient (requires physician orders to suction; whereas an OPA does not)

Nasal suction of infants should be done cautiously. Fishing with a flexible catheter may cause more swelling & compound the problem.


The Death Rattle in Pallative Care

NPA are commonly used in pallative care

The "death rattle" is when pallative patients have a decreased level of consiousness and can not clear secretions.

These patients will produce a gurgling sound and even though it may not bother the patient it tends to bother the family members, this is tricky though because you also need to be mindful that it can be hard on the patient to be suctioned 



Different Suction For Different parts of the Airway

  • Nasal
    • Flexible catheter or bulb
    • This is the preferred rout in awake non intubated patients
  • Mouth
    • Rigid (aka. Tonsillar, Yaunkauer), bulb, or flexible
    • Rigid will be used for adults and not on infants where we only use flexible catheters
    • Oropharyngeal suctioning should not be done in awake patients with a gag reflex
  • Lower Airway
    • Multi use (inline/closed)
    • Single use (open)
    • Flexible 




DeLee Suctioning

Will not be used much as there is not a lot of research supporting it 

Will be used for meconium which is when babies poop inside of mother womb and leads to meconium aspiration syndrome


Complications and Hazards from Suctioning

—Hypoxia  or hypoxemia


—Blood  pressure changes (increase or decrease)

—Cardiac dysrhythmias

—Cardiac or respiratory arrest

—Bronchospasm, laryngospasm (vocal cords shut), uncontrolled coughing, gagging, or vomiting

—Increased intracranial pressure

—Mechanical trauma

—Tearing, bleeding & perforation

—Discomfort and pain

—Nosocomial infection


Preventing VAP

-HAND HYGIENE- Most Important!!

-Oral Hygiene

-Don’t break the circuit and minimize circuit changes

-cuff pressure


-Moving HOB to 30-45

- Early nutritional support via GI tract: Reduce risk of bacterial translocation thereby minimize catabolic state imposed by resulting activation of imflammatory cascade

-Gastric Tube placed orally to minimize risk of sinusitis: NG tubes should be changed to OG tubes if expected to require mechanical ventilaiton for more then 24 hours. —Once feeding tolerance has been established, these larger size tubes can be replaced by smaller bore tubes (i.e. silastic tubes) which can then be placed nasally for patient comfort. 

-Gastroesophageal Reflux: —Occurs during mechanical ventilation. Gastric fluid is more likely to be aspirated into the respiratory tract when patients are in the supine position. The head of the bed should be elevated (~ 35-45 degrees).


Gastric Tubes

  • —Gastric suctioning (via nasogastric or orogastric tubes) is done to suction gastric contents and decompress stomach
    • —Prevent vomiting and aspiration
    • —Obtain specimen of the gastric contents
    • —Assessment of GI bleed
  • —To treat gastric immobility and bowel obstruction
  • —For drainage/ lavage (old treatment)
    • —Patients with drug overdose or poisoning
  • —In addition gastric tubes can also be inserted for :
    • —Feeding (enteral)
      • Way to provide food through nose
      • Orogastric tubes are preferred in patient with ETT for more than 24 hours
      • Infants less than 6 months are nose breathers and OG is preferred
    • —Medication administration


Complications of Gastric Tubes

—Insertion of catheter can induce gagging or vomiting leading to aspiration

—Tissue trauma


Contraindications of Gastric Tubes

—Severe facial trauma  (further trauma and bleeding while insertion)

—Trauma to esophagus, stomach or duodenum (further trauma and bleeding while insertion)

—Esophageal varices (possibility if hemorrhage while insertion)

—Basal skull fractures or maxillofacial injury (for nasogastric tubes)


Basal Skull Fracture

—Raccoon eyes are bilateral periorbital ecchymoses that don’t result from facial soft-tissue trauma.

—Raccoon eyes may be the only indicator of a basal skull fracture, which isn’t always visible on skull X-rays. Their appearance signals the need for careful assessment to detect underlying trauma because a basil skull fracture can injure cranial nerves, blood vessels, and the brain stem.

—Battle’s Sign: Bluish discoloration behind one or both ears


Equitment for Gastric Tube Insertion

  • —Personal protective equipment
  • —NG/ OG tube
    • —NG: 5- 18 Fr
    • —OG: 24- 42 Fr
  • —Catheter tip irrigation 60 ml syringe
  • —Water soluble lubricant
  • —Adhesive tape
  • —Suction equipment
  • —Stethoscope
  • —Felt pen
  • —Glass of water with straw/ soother
  • —You want your pt. to swallow
  • —Flashlight
  • —Non- sterile gloves


Clean Procedure for Gastric Tube

  • —Check physician orders & any relevant history
    • —Explain the procedure to the patient
    • —Gather equipment & don non- sterile gloves
  • —Determine the site of insertion
    • —Measure tube from tip of nose (nasogastric) or from end of the mouth (orogastric) to ear lobe, then to point half way between end of sternum (xiphoid process) and naval
  • —Note/ mark the length
  • —Lubricate 2- 4 inches of tube with water soluble lubricant (nasogastric)
  • Instruct the patient to swallow and advance the tube past pharynx into esophagus and then stomach
    • NG: gently insert tube into appropriate nostril, aiming towards back of head, tip parallel to nasal septum and superior to hard palate
    • OG: pass tube through lips and over tongue, aiming down and back toward pharynx with patient’s head flexed forward
    • —If resistance met, rotate tube slowly with downward advancement without applying force
  • —Advance tube until marked/ noted length is reached
  • Secure and attach to suction
  • Tidy Up, Wash Hands and Chart


Withdrawal the Gastric Tube Immediately If

—if changes occur in patient’s respiratory status

—if tube coils in the mouth

—if patient starts to cough, desaturate or gets cyanotic


How to Check for Correct Placement of Gastric Tube


—Attach syringe to free end of the tube

—Aspirate gastric contents

—Instill air into tube and auscultate (5 to 20cc)

—Any doubt regarding proper placement, hold any instillations through the tube!


Ventilator Associated Pneumonia (VAP)

  • —VAP complicates the treatment of a significant number of patients that are mechanically ventilated.
  • —The morbidity rates vary but can reach 76%.
  • —The main organisms responsible for infection are
    • —Staphylococcus aureus
    • —Pseudomonas aeruginosa
    • —Enterobacteriaceae
  • Using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation.


Bland Aerosol Administration Includes Delivery Of

  • —Hypotonic saline
  • —Isotonic (normal) saline
    • —Would be used in aiding in suction, secretion mobility
  • —Hypertonic saline
    • —Would be used in sputum induction
  • —Sterile/distilled water—

—FYI: Bland aerosol administration may or may not be accompanied by oxygen administration.


Hypotonic Saline

Solution <0.9% saline (less than normal concentration of saline)

Is indicated in patient who cannot tolerate sodium intake

Will not call irritation to the mucosal lining

Causes fluid to pass from bronchial lumen into cells because of osmotic pressure gradient



Normal Saline

—0.9 % saline

—Delivers fluid which is physiologically compatible and isotonic with the body tissue fluids

——Irritation of tracheobronchial tree is minimal


Hypertonic Saline

—Saline solution > 0.9 % NaCl (3-10%)

—Used to induce sputum sample by stimulating a cough

—Increase concentration of saline solutions tend to be very irritating to airways and can induce bronchospasm

Mucosal cells tend to dehydrate and bronchial lumen receives additional water



Sterile/Distilled Water—

Is hypotonic in comparison to tissue fluid 

Some water moves into the mucosal cells and some enters bronchial secretions thus thinning the secretions and promoting expectoration


Indications for a bland aerosol

—Minimizing humidity deficit when the upper airway has been bypassed

—The use of cool, bland aerosol therapy is primarily indicated for upper airway edema

—Sputum induction or secretion mobilization


The presence of one or more of the following may be an indication for administration of  sterile water or isotonic or hypotonic saline aerosol:

–Bypassed upper airway

–Stridor or hoarseness post extubation

–Diagnosis of LTB or a brassy croup-like cough

–Clinical history suggesting upper airway irritation and increased work of breathing (eg, smoke inhalation)  

–Patient discomfort associated with airway instrumentation or insult



Sputum Induction

Sputum Induction: Facilitates mobilization, coughing, and clearning of secretions. Hydration will thin secretion and help expectoration. Irritation results in a cough

The presence of the need for sputum induction is an indication for administration of hypertonic saline aerosol.

Primarily sputum induction is done using hyperosmolar saline (hypertonic)

The hyperosmolarity of the saline induces cough in the patient, resulting in effective cough and sputum production for sampling 

Can also use sterile water, mucolytics, normal saline

If sending sample for C&S or for eosinophil count have patient rinse mouth prior to expectorating into sample cup – this prevents having saliva mixed with sputum. Do a smear to tell if there is microbacterium and then so a stain to say if it is TB, COPD

Here in Calgary we use H2O, in states they use club soda


Hazard and Complication of Bland Aerosol Therapy

•Patient discomfort: Bronchospasm, bronchoconstriction or wheezing

•Infection: There is a big push in the hospital to get rid of aerosolizing stuff

•Caregiver exposure to droplet nuclei (Mycobacterium tuberculosis) or other airborne contagious microorganism produced as a consequence of coughing

•Over hydration


Bland Aerosol Contraindications

—History of airway hyper-responsiveness or bronchoconstriction

—Sputum induction by hypertonic saline inhalation can cause bronchoconstriction with patients who have COPD, asthma, cystic fibrosis, or other pulmonary diseases.


Indications for Sputum Indiction

  • —Obtain sample for laboratory analysis
    • —Bland aerosols
    • —Medications (acetylcysteine & pulmozyme)
  • —Mobilize secretions
    • —Humidification
    • —Aerosols
    • —Systemic

Efficacy of using bland aerosol to reduce mucous has not been established; physical properties of mucous are only minimally effected by the addition of water aerosol; bland aerosol is not a replacement for system hydration

Mucomyst, dornase alpha

Pulmozyme is typically used for cycstic fibrosis

Both acetlysteine and pulmonzyme are mucolytics?


Sterile Fluids-No Microorganisms



—Pleural (if secondary to increase hydrostatic pressures)



—Non Sterile – “Normal Flora”


—Upper Respiratory Tract Secretions



Gram smear (slide) & exam

—+ve or –ve depending on their staining

—Shape: cocci (spheres) or rods (elongated)

—Acid fast (aka Ziehl-Neelsen) for tuberculosis


Culture and Sensitivty

—Culture “grow” 1 day to 6 weeks

—Sensitivity- if bacterial, what antibiotic will prevent further growth?

—C & S help us determine what bug is causing our patient’s infection & which drug is most appropriate to use to treat it.

—Prior or current use of ABXs is usually noted as that may influence C & S results.



—Gram-Negative Organisms


Pseudomonas aeruginosa

Haemophilus influenzae

Legionella pneumophila



Gram-Positive Organisms

Streptococcus pneumoniae (80% of all bacterial pneumonias)

Staphylococcus aureus



—Viral Organisms

Mycoplasma pneumoniae

Respiratory syncytial virus


Respiratory secretion

  • —Samples will be examined for cellular debris, microorganisms, blood, and pus
  • How is a sample collected
    • ETT or trach tube aspiration
  • Sputum: Expectorated through the mouth
    • Ask -> Spontaneous
    • Assist -> "Facillitated" (aka induction)
  • Bronchial lavage or washing (unproductive cough & unsuccessful induction)
    • Induction =Process of bringing something up 
    • Done through brconchoscopy


Process to Facilitate a Sputum Sample

  • Sputum induction involves short-term application of high-density hypertonic saline (3% to 10%) aerosols to the airway to assist in mobilizing pulmonary secretions for evacuation and recovery.
  • Devices most commonly used:
    • SVN
    • USN
  • The exact mechanism by which high-density hypertonic aerosols aid mucociliary clearance is unknown.
  • However, an increased volume of surface fluid delivered to the airways, combined with stimulation of the irritant (cough) reflex, is a likely mechanism.


Sputum samples aid in diagnoses

  • —Pts expectorate sputum into containers ® sent to lab for analysis
    • —Collected first thing in morning
    • —Deep cough
    • —Containers made of clear plastic
    • —Should be examined regularly
      • —Colour
      • —Odour
      • —Consistency
      • —Amount/volume


Sputum Induction Procedure 

  • —Standard precautions (N95 mask) & negative pressure room
  • AM sample x 3
  • —Equipment
  • —Introduction & identification
  • —Explain procedure
  • —Provide sterile container 
  • —Have patient rinse mouth & pretreat with a bronchodilator aerosol if needed
    • The bronchodilator is because the hypertonic saline is very irritating in the lungs
      • Place solution in neb and have pt. breath from neb
        • On insp patient inhales through mouth
          • Don’t get the to breath through the nose because it will filter the particles we want to get into the lungs for the sample
        • On exp patient exhales through nose
        • Slow inspiration and breath hold
  • Continued until either acceptable sputum specimen  collected or  patient unable to tolerate procedure





—Brown/dark “rusty” sputum

—Brown/dark “rusty” sputum = old blood.



hemoptysis sputum

Bright Red (hemoptysis)= fresh blood.



Clear/translucent Sputum

Clear/translucent = normal



purulent sputum

Purulent = the presence of WBCs or pus makes the secretions appear creamy (bacterial


Fetid Sputum

Fetid = foul smelling



—Frank hemoptysis

—Frank hemoptysis = massive amount of blood



—Green sputum

—Green sputum = old, retained secretions; enzyme from stagnant pus .

—Green and foul-smelling secretions are frequently found in patients with anaerobic or Pseudomonas infection.



Mucoid Sputum

—Mucoid = clear & thick


—Pink, frothy Sputum

—Pink, frothy = pulmonary edema




—Tenacious Sputum

—Tenacious = secretions that are sticky, adhesive or otherwise tend to hold together



—Viscous Sputum

—Viscous = thick, gelatinous, sticky



—white/grey/stringy Sputum

—white/grey/stringy) = asthma, chronic bronchitis



—Yellow or opaque Sputum

—Yellow or opaque = purulent 


—Purulent or green  and yellow sputum is seen in:

—Acute Bronchitis


—Lung abscess

—Cystic fibrosis


—Aspiration pneumonitis




Sputum with bright red blood is seen in:

—Carcinoma of lung



—Pulmonary infarction


—Darker blood (Rusty) sputum is expectorated in:


—Several types of pneumonia




White or Clear mucoid sputum is seen in:


—Chronic bronchitis




Fetid Sputum is seen in:

—Lung abscess


—Cystic fibrosis

—Aspiration pneumonitis


Chest Physical Therapy (CPT)

—Cough techniques

—Postural drainage



—Incentive spirometry and adjuncts

—Breathing techniques

We don’t do this on anyone rather we only do based on need as research only does not show benefit from doing patient at risk

Chest physical therapy is a combination of lung expansion techniques and bronchial hygiene used to prevent or correct atelectasis and prevent secretion accumulation.


Purpose of CPT 

—Prevent secretion accumulation

—Improve secretion clearance

—Improve breathing efficacy

—Improve ventilation distribution

—Improve cardiopulmonary exercise tolerance and strength



Cough Techniques

—Bronchial hygiene depends on an effective cough

—Some disease states inhibit or blunt the cough reflex, making it ineffective

—Patients that have no effective cough need to learn cough techniques in order to improve their cough or to clear secretions

—The most commonly taught techniques are the directed cough and the forced expiratory technique


Directed Cough

—Position the patient sitting up

—Have the patient take a slow big breath in through the nose using diaphragmatic breathing (when you breathing by pushing out your belly-coach pt. saying when you breath stick out your belly 

—Have the patient then bear down against the glottis (Valsalva), but this expiratory bearing down may have to be staged in short bursts for some patients to decrease fatigue and increase effectiveness

—The bearing down mimics a spontaneous cough

—This technique should be modified for COPD’ers: have them breathe in only moderately and breathe out via pursed lip breathing while bending forward slightly – this forward flexion should help mimic a cough

—“huff, huff, huff”


Assisted Cough

—Useful for assisting patients with restrictive or paralytic disorders that impair lung excursion and increase the risk of secretion clearance failure

—Have the patient take 3 breaths in and force out a cough

—During the cough phase, the practitioner applies force 2 inches below the xiphoid and pushes up towards the head of the patient

—Refer to hand out for technique


Peak cough flow (Pcf)

—Useful for monitoring patients with restrictive or paralytic disorders that impair lung excursion and increase the risk of secretion clearance failure

—Have the patient take a big breath in and force out a cough – measure with a peak flow meter

—Normal = 300 L/min

—Less than 160 L/min – patient needs secretion clearance control interventions like chest physiotherapy

—Refer to hand out for technique


Forced Expiratory Technique (FET)

  • —A modified directed cough – a huff cough
  • —Consists of two forced exhalations without closing the glottis  followed by relaxation and diaphragmatic breathing
  • —Verbal huffing during exhalation keeps glottis open
  • —Modification: Active Cycle of Breathing
    • —Breathing control: relaxed diaphragmatic breathing
    • —Thoracic expansion: deep inspirations X3 with passive exhalation
    • —FET’s X2 followed by relaxed breathing
    • —Done in cycles of 2 to 4 times


Postural Drainage

—Postural drainage involves positioning the patient using gravity to drain secretions from lung segments into the central airways for expulsion by coughing or suctioning

—This is accomplished by using the patient’s bed and pillows to position the patient, and also includes turning

Also called autogenic drainage

There are also many reasons why we would not want to put pt. in these positions so be very careful (so always get a physician order before doing)

This is pretty much just allowing gravity to help us out


Postural Drainage Indications

—Chronic inability to clear secretions

—Increased sputum production

—Retained secretions in patients with artificial airways

—Mucus plugging leading to atelectasis

—Documented diagnosis of any disorder that may cause copious secretions: cystic fibrosis or bronchiectasis


Postural Drainage Contraindications

—Any head, neck, esophageal, spine injury or recent surgery

—Active hemorrhage with hemodynamic instability

—Bronchopleural fistula

—Cardiogenic pulmonary edema

—Large pleural effusions, pulmonary embolus

—Acute hemoptysis, empyema, SubQ E, TB

—Rib fractures, with or without flail

—Any state with an uncontrolled airway and the risk of aspiration

—Any patient who is frail and aged and cannot tolerate position changes

—Any patient who is confused or agitated or in pain



Postural Drainage Hazards

—Cardiac output may decrease due to position changes, especially in the Trendelenburg or head-down position

—Increased ICP

—PaO2 may decrease due to V/Q changes with position changes: Patients who are in positions where blood may be pooled in consolidated lung areas may experience a large shunt when re-positioned

—COPDer’s may experience orthopnea in some positions

—Pulmonary hemorrhage, pain, vomiting



Postural Drainage Precautions

—Assess all vital signs prior for a baseline

—Postural drainage should be performed prior to meals or tube feeds to prevent aspiration

—Pain medications should be coordinated with postural drainage to prevent causing the patient discomfort

—Use an SaO2 monitor to watch for desaturation

—Know the patient’s diagnosis and history before postural drainage to prevent problems

—Observe the patient carefully for signs of discomfort or changes in patient status i.e.: changes in their respiratory rate or pattern



Principles and Techniques of Postural Drainage:


—Check that pain control has been initiated for the comfort of the patient

—Check recent X-rays and oxygen requirements

—Explain the procedure to the patient Check the patient’s vital signs and breath sounds

—Ensure that clothing, IV lines, and O2 tubing will be moveable when re-positioning

—Position the patient in the prescribed position, and check that the patient is tolerating the positioning well without adverse side effects HEAD DOWN 25º OR UP 45º

—Maintain the position for 3 - 15 minutes, depending on hospital policy and the tolerance of the patient

—Restore the patient to their pre-treatment position and monitor their vital signs and breath sounds

—The patient should be encouraged to cough during and after postural drainage

—NOTE: Turning the patient from side to side using a rotational bed or pillows is also used in some hospitals to improve lung expansion, but is not considered actual postural drainage


Percussion and Vibration

  • —Percussion and vibration both utilize the application of energy (manual or mechanical) to the skin’s surface above the lung segment to be drained
  • —Percussion and vibration are designed to encourage secretion clearance:
    • —Percussion jars retained secretions loose from the tracheobronchial tree so they can be removed by coughing or suctioning
    • —Vibration moves secretions into the larger airways during exhalation for removal by coughing or suctioning


Percussion and Vibration Indications

To be used an adjunct to postural drainage and coughing when these alone cannot provide adequate secretion clearance


Percussion and Vibration Contraindications

Subcutaneous emphysema, any lung or skin injury/surgery

Recent epidural or spinal anesthesia

New subcutaneous or transvenous pacers



Osteomyelitis or osteoporosis

Bleeding disorders

Chest wall pain


Percussion and Vibration Hazards

—Pain and discomfort to the patient



—Rib fractures


Percussion and Vibration Precautions

Never percuss directly over breast or bone

—Precautions associated with postural drainage are indicated here as well


Principles and Techniques of Percussion:

—Percussion manually done by an experienced therapist is considered the most effective method used in clinical practice

—Manual percussion is performed with the hands in a cupped position, with fingers and thumbs closed inward

—This creates an energy wave with a cushion of air between the hand and the patient’s chest wall

—The wrists are loose, rhythmically clapping the patient’s chest in a waving motion

—This manual technique is easy, but requires practice to develop a rhythm and pattern that is effective and comfortable to use

—Percussion regimen’s differ from hospital to hospital, but the length of time required for postural drainage is also adequate in percussion


Principles and Techniques of Vibration:

—Vibration is performed on exhalation, either manually or with mechanical devices

—Manual vibration is accomplished by lying one hand on top of the other on the chest area or on either side of the chest

—After the patient maximally inhales, the therapist exerts pressure on the chest will in a rapid vibratory motion throughout the patient’s exhalation


Mechanical percussors and vibrators

—There are several electrical and pneumatic mechanical vibrators and percussors used in the clinical setting to apply the energy waves needed for percussion and vibration – cycle at 20-30 cycles/sec (20-30 Hz)

—Pneumatic percussors and vibrators use a gas source for the energy needed, while electrical ones use a wall outlet power source

—Most mechanical devices have several settings, so that the therapist can adjust the amount level of energy used

—Currently there is no firm evidence that these devices are any more effective than a well trained and practiced therapist



Percussors and Vibrators-How Do You Know It Works

—Subjective patient improvement: decreased respiratory rate, remission of fever, normal pulse, and improved breath sounds

—Improvement of atelectasis on X-Ray

Follow-up by the RRT should include:

  • —Observation of patient’s secretion clearance and comfort
  • —Vital signs and breath sound assessment


What is Atelectasis?

A collapsed or airless secretion of the lung

Can lead to pneumonia, true shunt leading to V/Q mismatch


Atelectasis Causes

—Absorption -> due to high alveolar O₂ concentrations

—Passive -> due to shallow breathing and no sighing

—Reabsorption -> due to obstruction by a mucus plug


Signs of Atelectasis


Late inspiratory crackles

—Decreased breath sounds

—Increased heart rate due to hypoxia


I.S.   (Incentive Spirometry)

—Increases transpulmonary P gradients by decreasing Ppl

—Incentive spirometry (IS): same as SMI - sustained maximal inspiration (American)

—Used for lung expansion therapy - mimics physiologic sighing through slow deep breathing patterns

—Achievement of visual goals (markers/floats on the IS device) encourages the patient to continue and meet their predicted goal settings


I.S.   (Incentive Spirometry) Indicationas

—Documented atelectasis

—Impending atelectasis: thoracic/abdominal/cardiac surgery, post-op

—Restrictive diseases/movement


Incenive Spirometry Contraindications

—Uncooperative or unable to perform procedure

—Unable to understand instructions

—Too weak or sick

—VC less than 10 ml/kg


Incentive Spirometry Hazards

—Hyperventilation and respiratory alkalosis

—Discomfort due to poor pain control


—Hypoxemia if O2 has to be removed



—Vagal stimulation


Incentive Spirometry Instruction

—Setting an IS goal for a specific patient differs with hospital policy - some hospitals use the inserts that are included with IS units that determine the patients predicted values based on their height and age and some hospitals use the patient’s pre-surgery IS levels as their goals

—IS should be done 5 - 10 maneuvers/hour post surgery as the patient can tolerate

—Instruct the patient to take a DEEP SLOW breath in using the diaphragm and not the accessory muscles

—After this maximal inspiration, have the patient breath-hold (if they are able) for 5 - 10 seconds, and exhale normally

—One IS maneuver has been completed

—The patient may need to rest before the next maneuver

—10 maneuvers an hour is optimal

—Follow-up and coaching should be done


Incentive Spirometry Equitment

  • The IS units most often used:
    • —Flow-directed - measures flow achieved i.e.: 600 cc/sec, volume can be calculated by extrapolation =
      • Multiplied flow by inspiratory time  V=V cc/sec X time/sec/1000
    • —Volume-orientated - measures actual volume achieved by a displacement bellows (mls or cc’s)


Incentive Spirometry - How do You Know It Works?

Subjective patient improvement: decreased respiratory rate, remission of fever, normal pulse, and improved breath sounds

Improvement of atelectasis on X-Ray


Follow Up From Incentive Spirometry

Observation of patient’s technique

Additional instruction if needed

Making sure the device is within the patient’s reach and that they are using it on their own

Setting new and increased inspiratory goals every day if improving

Vital signs and breath sound assessment


Lung Volume Recruitment (LVR)

—Recruitment maneuver used in patients with paralytic disorders like ALS that have high risks of atelectasis and secretion clearance failure

—Uses a resuscitation bag to stack breaths to achieve maximum insufflation and promote alveolar recruitment (“stretch”) and allow for a strong cough on exhalation if required

—Often followed by assisted cough maneuvers to promote secretion clearance

—Refer to handout for technique


Breathing Techniques

Some patients require training in order to breath more

effectively to:

  • —Encourage more use of the diaphragm and less use of accessory inspiratory muscles
  • —Decrease the tendency to use gasping respirations
  • —Teach patients to cope with dyspnea
  • —Decrease muscle inefficiency
  • —Coordinate breathing with motion and daily activities
  • —Relieve exertional dyspnea
  • —Improve cardiopulmonary fitness and exercise tolerance



—COPD patients requiring more effective breathing patterns

—Patients with neurological deficits that require respiratory muscle retraining

—Patients in restricted movement states

—Smoke free for 30 days



—Patients who cannot understand or comprehend instructions

—Intubated or trached patients

—Patients with guarded conditions or multisystem failure

—Patients whose disease process prohibits them from any rehabilitative therapy



—Improper instruction by the therapist leading to hyperventilation


—Discomfort or confusion for the patient


Diaphragmatic (Abdominal) Breathing

—The purpose of diaphragmatic breathing is to teach patients better use of their diaphragm and decreases their dependency on accessory muscle usage

—The long term benefits to the patient are an increased alveolar ventilation efficiency via increased tidal volume, improved and slower respiratory rate, and an improved exercise tolerance


Diaphragmatic Breathing Instructions

—Position the patient sitting up

—Have the patient distend their belly out as they breathe in to lower the diaphragm and flatten their belly on exhalation to elevate the diaphragm

—This is done to strengthen inspiratory and expiratory effort

—The patient should be able to repeat this 5 times in total, at least 3 times a day

—The purpose is to use the belly and intercostals on I to pull the diaphragm out and down, and on E to push the diaphragm up



Lateral Costal Breathing:

—This method is intended to augment diaphragmatic breathing, and is a modification of abdominal breathing

—It involves the contracting and expanding of the costal margin, which increases diaphragmatic mobility

—It is considered an alternative to diaphragmatic breathing for patients who cannot tolerate or perform it or abdominal surgery patients.  Patient benefits are the same as with diaphragmatic breathing


Lateral Costal Breathing Instruction

—Position the patient sitting up

—Have the patient take a few big relaxed breaths

—Have the patient place their hands on their sides of their ribcage or place your hands in the same place

—Have the patient take a big breath in then apply gentle pressure inwards at the end of the last big breath out  - this provides resistance that the patient has to use their intercostals to work against for the next 5 consecutive breaths in and out and then a rest

—This is done to strengthen inspiratory and expiratory effort

—The patient should be able to repeat this 5 times in total, at least 3 times a day 



  • —Pursed-lip breathing is used mainly by COPDer’s because they are prone to early airway collapse
  • — It is usually manifested by the patients on their own as a physiological response to air trapping cause by COPD
  • —Pursed-lip breathing increases expiratory flow resistance which:
    • —Decreases early bronchiolar collapse by increasing pressure in the tracheobronchial tree during expiration causing the equal pressure point to move up to the larger airways
    • —Decreases expiratory flow rates
    • —Deecreases respiratory rate and increases expiratory time



—The patient should be in a comfortable position

—The patient is instructed to inhale slowly through their mouth

—During exhalation, the patient is instructed to purse their lips as if to whistle, which controls expiratory flow and slows it down

—This should decrease the patient’s respiratory rate and increase expiratory time to 2 or 3 times longer than inspiratory time

—The therapist should instruct the patient to practice often and use pursed-lip breathing when they experience dyspnea


Artificial Cough Devices:

Most common is the chest vest oscillator

Works by rapidly oscillating air volumes within the vest to rapidly compress and vibrate the chest of the patient

Generally used for patients with CF

Effective chest physical therapy is more efficient


—The CoughAssist improves secretion clearance by gradually applying a positive pressure to the airway, and then rapidly shifts to negative pressure

—The rapid shift in pressure produces a high expiratory flow from the lungs, simulating a cough

—Useful in patients with Neuromuscular disease and a weak cough


Flutter Valves

—HFOA, Uses expiratory pressure and high frequency oscillation through the valve

—On exhalation, the expiratory pressure created ranges from 10 - 25 cmH2O, and the oscillations (15 Hz) created are transmitted into the chest wall

—Very effective for CF and CB patients in cycles of 10 – 20 breaths at a time


Resistance Trainers

Most common is the PEP device

Uses positive expiratory pressure (10 – 20 cmH20)with variable flow resistance

Have the patient exhale slowly through the device, then remove the device and huff 3 times to cough and mobilize secretions