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AIRWAY CLEARANCE. Karen Conyers, BSRT, RRT. Airway Clearance. Pulmonary Physiology and Development Impaired Airway Clearance Airway Clearance Techniques Therapy Adjuncts. PULMONARY PHYSIOLOGY AND DEVELOPMENT. Birth. Respiratory Function Terminal respiratory unit not fully developed

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AIRWAY CLEARANCE

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AIRWAY CLEARANCE

  • Karen Conyers, BSRT, RRT


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Airway Clearance

  • Pulmonary Physiology and Development

  • Impaired Airway Clearance

  • Airway Clearance Techniques

  • Therapy Adjuncts


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PULMONARY PHYSIOLOGY

AND DEVELOPMENT


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Birth

  • Respiratory Function

    • Terminal respiratory unit not fully developed

    • Respiratory function performed by alveolar-capillary bed

  • Airways

    • Little smooth muscle

    • Small airway diameter

    • Increased airway resistance

  • Lung compliance

    • Incomplete elastic recoil

    • Decreased lung compliance


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Age 2 Months

  • Alveoli

    • 24 million alveoli present

    • Alveoli small but fully developed

    • Ability to form new alveoli

  • Respiratory muscles

    • Underdeveloped accessory muscles

    • Diaphragm is primary muscle of respiration

  • Response to increased ventilatory demands

    • Respiratory rate increases, not tidal volume


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Ages 3 to 9 Months

  • Increasing strength

    • Baby learns to hold head up, reach for things

    • Upper body strength develops, including accessory muscles for respiration

  • Changes in respiratory function

    • Learns to sit up: rib cage lengthens

    • Greater chest excursion

    • Increased tidal volume


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Age 4 Years

  • Lung development

    • Development of pre-acinar bronchioles and collateral ventilation (pores of Kohn)

    • Development of airway smooth muscle


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Age 8 Years

  • Continued lung development

    • Alveolar development complete

    • Alveolar size increases

    • Total lung volume increases

    • 300 million alveoli (increased from 24 million at age 2 months)


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Adult Lung

  • Gradual loss of volume

  • Loss of elasticity

    • Decreasing compliance

  • Environmental effects

    • Smoking

    • Air pollution

    • Occupational hazards

  • Disease effects


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Factors Affecting Airflow

  • Airway resistance

  • Turbulent airflow

  • Airway obstruction


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Normal Airway Resistance

  • Decreasing cross-sectional area from acinus to trachea causes increased resistance, as airflow moves from small to large airways.

  • Cross-sectional areas:

    • trachea diameter 2 cm

    • 4th generation bronchi 20 cm

    • bronchioles 80 cm

    • acinus cross-section 400 cm

  • Greatest airway resistance in large airways; laminar airflow in small airways


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Airway Obstruction

  • Increased airway resistance

    • Bronchospasm

    • Inflammation

  • Hypersecretion of mucus

    • Acute process

    • Chronic disorder


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Mucus

  • Mucus produced by goblet cells in airway

  • Chronic airway irritation increased numbers of goblet cells larger quantities of mucus

  • Cilia move together in coordinated fashion to move mucus up airways


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IMPAIRED

AIRWAY CLEARANCE


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Impaired Airway Clearance: Factors

  • Ineffective mucociliary clearance

  • Excessive secretions

  • Thick secretions

  • Ineffective cough

  • Restrictive lung disease

  • Immobility / inadequate exercise

  • Dysphagia / aspiration / gastroesophageal reflux


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Results of Impaired Airway Clearance

  • Airway obstruction

  • Mucus plugging

  • Atelectasis

  • Impaired gas exchange

  • Infection

  • Inflammation


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A Vicious Cycle

Impaired airway clearance

Mucus

retention

Mucus plugging,

obstruction

Lung

damage

Lung

infection

Inflammation,

mucus production


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Entering the Cycle

ASTHMA

NEURO-

MUSCULAR

WEAKNESS

Impaired airway clearance

PRIMARY

CILIARY

DYSKINESIA

Mucus

Retention

Mucus plugging,

Obstruction

ASPIRATION

Lung

Infection

Lung

Damage

CYSTIC

FIBROSIS

GASTRO-

ESOPHAGEAL

REFLUX

Inflammation,

Mucus production

ASPERGILLOSIS


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AIRWAY CLEARANCE

TECHNIQUES


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Airway Clearance Techniques

  • Goals

  • Conventional Methods

  • Newer Therapies

  • Therapy Adjuncts


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Goals

  • Interrupt cycle of lung tissue destruction

  • Decrease infection and illness

  • Improve quality of life


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Conventional methods

  • Cough

  • Chest Physiotherapy

  • Exercise


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Cough

  • Natural response

  • Only partially effective

  • Frequent coughing leads to “floppy” airways

  • May be suppressed by patient


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Chest Physiotherapy (CPT)

  • Can be used with infants

  • Requires caregiver participation

  • Technique dependent

  • Time consuming

  • Physically demanding

  • Requires patient tolerance

  • Effectiveness debated


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Exercise

  • Recommended for most patients

  • Pulmonary rehabilitation expectation

  • Training

    • Ability to exercise related more to muscle mass than to pulmonary function

    • Improves oxygen uptake by muscle cells

  • Many patients limited by physical disability


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Newer Therapies

  • PEP valve

  • Flutter

  • In-Exsufflator

  • HFCWO (Vest)

  • Intrapulmonary percussive ventilation (IPV)

  • Cornet

  • PercussiveTech HF


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PEP valve

  • Positive Expiratory Pressure

  • Action: splints airways during exhalation

  • Can be used with aerosolized medications

  • Technique dependent

  • Portable

  • Time required: 10 - 15 minutes


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Flutter

  • Action: loosens mucus through expiratory oscillation; positive expiratory pressure splints airways

  • Used independently

  • Technique dependent

  • Portable

  • May not be effective at low airflows

  • Time required: 10 - 15 minutes


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In-Exsufflator

  • Action: creates mechanical “cough” through the use of high flows at positive and negative pressures

  • Positive/negative pressures up to 60 cm of water

  • Used independently or with caregiver assistance

  • Technique independent

  • Portable


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ABI Vest (HFCWO)

  • Action: applies High Frequency Chest Wall Oscillation to entire thorax; moves mucus from peripheral to central airways

  • Used independently or with minimal caregiver supervision

  • May be used with aerosolized medications

  • Technique independent

  • Portable

  • Time required: 15-30 minutes


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Intrapulmonary Percussive Ventilation (IPV)

  • Action: “percussion” on inspiration, passive expiration; dense, small particle aerosol

  • Used independently or with caregiver supervision

  • Used with aerosolized meds

  • Technique dependent

  • May not be well tolerated by patient

  • Time required: 20 minutes


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Other devices

  • Cornet

    • Similar to action of Flutter

    • Lower cost, disposable

  • PercussiveTech HF

    • Hand-held device used with aerosol meds

    • Similar to action of IPV

    • Requires 50 PSI gas source


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European / Canadian Techniques

  • Huff cough (forced expiratory technique)

  • Active Cycle of Breathing Technique (ACBT)

  • Autogenic Drainage


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Forced Expiratory Technique

  • “Huff” cough

    • Three second breath hold

    • Open glottis

    • Prevents airway collapse

    • Effective technique for “floppy” airways

    • Easy to learn


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Active Cycle of Breathing Technique

  • Three steps:

    • Breathing control

    • Thoracic expansion / breath hold

    • Forced expiratory technique

  • May be performed independently

  • Easily tolerated


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Autogenic Drainage

  • Three phases

    • Unsticking

    • Collecting

    • Evacuating

  • May be performed independently

  • Harder to teach and to learn than other techniques

  • May be difficult for very sick patients to perform


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Autogenic Drainage

Cough

IRV

COLLECTING

EVACUATING

UNSTICKING

VT

Normal

Breathing

ERV

RV

Complete

Exhalation


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THERAPY

ADJUNCTS


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Therapy Adjuncts

  • Antibiotics

  • Bronchodilators

  • Anti-inflammatory drugs

  • Mucolytics

  • Nutrition


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Antibiotics

  • Oral

  • Intravenous

  • Nebulized

    • Aminoglycosides: P. aeruginosa

      • Gentamycin: 40-80 mg

      • Tobramycin: 40-120 mg

      • Tobi: 300 mg per dose: high dose inhibits mutation of P. aeruginosa in lung


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Bronchodilators

  • Hyperreactive airways common in many pulmonary conditions

  • Albuterol, Atrovent

  • MDI or nebulized

  • Administered prior to other therapies


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Mucolytics

  • Mucomyst (acetylcysteine)

    • Breaks disulfide bonds

    • Airway irritant

  • Pulmozyme (dornase alfa or DNase)

    • Targets extracellular DNA in sputum

    • Specifically developed for cystic fibrosis

  • Hypertonic saline

    • Sputum induction

    • Australian studies


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Anti-inflammatory Drugs

  • Inhaled steroids via metered dose inhaler

  • Oral or IV prednisone

  • High-dose ibuprofen (cystic fibrosis)


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Nutrition

  • Connection between nutrition and lung function!

  • Worsening lung function increased work of breathing & frequent coughing increased caloric need

  • Increasing dyspnea decreased caloric intake

    malnutrition decreased ability to fight infection worsening lung function


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Interrupting the Vicious Cycle

Impaired airway clearance

NUTRITION

MUCOLYTICS

Mucus plugging,

obstruction

Mucus

retention

AIRWAY

CLEARANCE

TECHNIQUES

BRONCHODILATORS

Lung Damage

Lung infection

ANTI -

INFLAMMATORIES

ANTIBIOTICS

Inflammation,

mucus production


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