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Karen Conyers, BSRT, RRT

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... developed for cystic fibrosis. Hypertonic saline. Sputum ... High-dose ibuprofen (cystic fibrosis) Nutrition. Connection between nutrition and lung function! ... – PowerPoint PPT presentation

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Title: Karen Conyers, BSRT, RRT


1
AIRWAY CLEARANCE
  • Karen Conyers, BSRT, RRT

2
Airway Clearance
  • Pulmonary Physiology and Development
  • Impaired Airway Clearance
  • Airway Clearance Techniques
  • Therapy Adjuncts

3
  • PULMONARY PHYSIOLOGY
  • AND DEVELOPMENT

4
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

5
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

6
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

7
Age 4 Years
  • Lung development
  • Development of pre-acinar bronchioles and
    collateral ventilation (pores of Kohn)
  • Development of airway smooth muscle

8
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)

9
Adult Lung
  • Gradual loss of volume
  • Loss of elasticity
  • Decreasing compliance
  • Environmental effects
  • Smoking
  • Air pollution
  • Occupational hazards
  • Disease effects

10
Factors Affecting Airflow
  • Airway resistance
  • Turbulent airflow
  • Airway obstruction

11
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

12
Airway Obstruction
  • Increased airway resistance
  • Bronchospasm
  • Inflammation
  • Hypersecretion of mucus
  • Acute process
  • Chronic disorder

13
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

14
  • IMPAIRED
  • AIRWAY CLEARANCE

15
Impaired Airway Clearance Factors
  • Ineffective mucociliary clearance
  • Excessive secretions
  • Thick secretions
  • Ineffective cough
  • Restrictive lung disease
  • Immobility / inadequate exercise
  • Dysphagia / aspiration / gastroesophageal reflux

16
Results of Impaired Airway Clearance
  • Airway obstruction
  • Mucus plugging
  • Atelectasis
  • Impaired gas exchange
  • Infection
  • Inflammation

17
A Vicious Cycle
Impaired airway clearance
Mucus retention
Mucus plugging, obstruction
Lung infection
Lung damage
Inflammation, mucus production
18
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
19
  • AIRWAY CLEARANCE
  • TECHNIQUES

20
Airway Clearance Techniques
  • Goals
  • Conventional Methods
  • Newer Therapies
  • Therapy Adjuncts

21
Goals
  • Interrupt cycle of lung tissue destruction
  • Decrease infection and illness
  • Improve quality of life

22
Conventional methods
  • Cough
  • Chest Physiotherapy
  • Exercise

23
Cough
  • Natural response
  • Only partially effective
  • Frequent coughing leads to floppy airways
  • May be suppressed by patient

24
Chest Physiotherapy (CPT)
  • Can be used with infants
  • Requires caregiver participation
  • Technique dependent
  • Time consuming
  • Physically demanding
  • Requires patient tolerance
  • Effectiveness debated

25
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

26
Newer Therapies
  • PEP valve
  • Flutter
  • In-Exsufflator
  • HFCWO (Vest)
  • Intrapulmonary percussive ventilation (IPV)
  • Cornet
  • PercussiveTech HF

27
PEP valve
  • Positive Expiratory Pressure
  • Action splints airways during exhalation
  • Can be used with aerosolized medications
  • Technique dependent
  • Portable
  • Time required 10 - 15 minutes

28
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

29
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

30
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

31
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

32
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

33
European / Canadian Techniques
  • Huff cough (forced expiratory technique)
  • Active Cycle of Breathing Technique (ACBT)
  • Autogenic Drainage

34
Forced Expiratory Technique
  • Huff cough
  • Three second breath hold
  • Open glottis
  • Prevents airway collapse
  • Effective technique for floppy airways
  • Easy to learn

35
Active Cycle of Breathing Technique
  • Three steps
  • Breathing control
  • Thoracic expansion / breath hold
  • Forced expiratory technique
  • May be performed independently
  • Easily tolerated

36
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

37
Autogenic Drainage
Cough
IRV
COLLECTING
EVACUATING
UNSTICKING
VT
Normal Breathing
ERV
Complete Exhalation
RV
38
  • THERAPY
  • ADJUNCTS

39
Therapy Adjuncts
  • Antibiotics
  • Bronchodilators
  • Anti-inflammatory drugs
  • Mucolytics
  • Nutrition

40
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

41
Bronchodilators
  • Hyperreactive airways common in many pulmonary
    conditions
  • Albuterol, Atrovent
  • MDI or nebulized
  • Administered prior to other therapies

42
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

43
Anti-inflammatory Drugs
  • Inhaled steroids via metered dose inhaler
  • Oral or IV prednisone
  • High-dose ibuprofen (cystic fibrosis)

44
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

45
Interrupting the Vicious Cycle
Impaired airway clearance
NUTRITION
MUCOLYTICS
Mucus plugging, obstruction
Mucus retention
AIRWAY CLEARANCE TECHNIQUES
BRONCHODILATORS
Lung Damage
Lung infection
ANTIBIOTICS
ANTI - INFLAMMATORIES
Inflammation, mucus production
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