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Airway Clearance Modalities and Devices American Academy of Nurse

VIEWS: 6 PAGES: 10

									                                                                                                     7/6/2009



1    Airway Clearance Modalities and Devices
     American Academy of Nurse Practitioners
     24th National Conference
     June 2009

     Kimberly Allen, MS, ARNP
     Cathrin Carithers, MS, ARNP
2    Objectives

         Discuss mucus rheology & disease conditions which cause an impairment of airway clearance

         Identify medications used to promote mucus or sputum clearance & assist in airway opening

          Demonstrate & discuss airway clearance techniques & devices for persons with pulmonary
         disease

3    Introduction
      Excess or retained pulmonary secretions can cause a host of problems

        Difficulty breathing
        Risk/spread of infection
        Reduce oxygen
        Fatigue & cause muscles to become sore
        Induce vomiting
        Trigger an asthma attack
        Exacerbate flare ups
4    Stand Back, Give Him Some Air!!
5    Introduction

         Airway mucosa responds to infection & inflammation in a variety of ways

         Airway clearance is an integral part of therapy for patients with pulmonary conditions

      Airway clearance methods are available for patients with cystic fibrosis (CF), asthma, COPD,
      bronchitis & muscular disorders
6    Cystic Fibrosis
      Autosomal recessive disorder – 1:20 unaffected carrier
      Most common lethal inherited disease in white persons
      Affects 30,000 Americans
        2,500 infants/year
      Disease of exocrine gland function

7    Cystic Fibrosis
      Involves multiple organ systems
        chronic respiratory infections
        pancreatic enzyme insufficiency
        associated complications
      Pulmonary involvement occurs in 90% of patients
       End-stage lung disease principal cause of death

8        COPD
         4th leading cause of death in the U.S.

         Affects ~ 14.2 million



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           Chronic bronchitis = 12.5 million
           Emphysema = 1.7 million
           Asthma = 22 million
           Bronchiectasis
           ↑by 41.5% since 1982
           Affects 8-17% of men and 10-19% of women
           Prevalence rates ↑ in women by 30% last decade

         Characterized by presence of airflow obstruction
             typically progressive, may be accompanied by airway hyper-reactivity, & may be partially
           reversible

 9   Chronic Bronchitis
      Clinical Definition
         Presence of a chronic productive cough for 3 months during each of 2 consecutive years

         Histologic hallmark
           Mucous gland enlargement

      Ultimately cause airflow limitation by allowing airway walls to deform and narrow the airway
      lumen
10   Emphysema
      Abnormal, permanent enlargement of air spaces distal to the terminal bronchioles
        Accompanied by destruction of their walls
        Without obvious fibrosis

11   Asthma
      Affects 22 million in the US

         Most common chronic disease in childhood
          ~ 6 million children affected

         Chronic inflammatory disorder of the airways

       Many cells & cellular elements play a role
          Mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, & epithelial cells
12   Asthma
      Associated with widespread but variable airflow obstruction
        often reversible, though sometimes incomplete

         Inflammation causes ↑in existing bronchial responsiveness to stimuli

13   Bronchiectasis
      Uncommon disease
      Described 1st by Laennec in 1819;
      Further defined by Reid in 1950’s
      Abnormal & permanent distortion of ≥ 1 conducting bronchi or airways, often due to infectious
      process
      Presents with inflamed, easily collapsible airways
        air flow obstruction
        SOB
        impaired clearance of secretions
        cough
        occasionally hemoptysis



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      Severe cases end in respiratory failure
14   Restrictive Lung Disease
      Extrinsic Disorders of Pleura & Thoracic Cage
        Total compliance by respiratory system is ↓
        Kyphoscoliosis
          Mild deformities –    1: 1000 persons
          Severe deformity – 1:10,000 persons
15   Restrictive Lung Disease
      Neuromuscular Disorders
        Can be impaired at
          level of the CNS
          spinal cord
          peripheral nervous system
          neuromuscular junction
           respiratory muscle
        Affect respiratory pump
        Ventilatory impairment dependent on the specific disease

16   Assisted Cough Airway Clearance Methods

           Chest physiotherapy Methods

           Medications

           Handheld devices

           Oscillatory device

17   Mucous Rheology

         What is it?

         What does this mean to us?

      Why should we care?
18   Mucoactive Agents
       Any medication used to improve the clearance of airway secretions

           Intended to serve one of two purposes
             increase the ability to expectorate sputum or to
             decrease mucus hyper-secretion

           Not synonymous with the word "mucolytic" as this strictly means a drug that decreases the
           viscosity of secretions

           Decreased viscosity will adversely affect cough transport


19   Mucoactive Agents

         Expectorants

         Mucolytics




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         Mucokinetic Agents

         Mucoregulatory Agents

         Anti-inflammatory Agents

         Adehsives

20   Mucolytic Agents/Expectorants

         Medications that promote the discharge or expulsion of mucus from the respiratory tract

         The medication changes the physical properties of the mucus by thinning it

         These medications also increase the ability of cilia to clear and drain mucus

      Thinner mucus can be more easily penetrated by other medications such as antibiotics
21   Expectorants
        Increase the volume or hydration of airway secretions
        Guaifenesin
        Most commonly prescribed expectorant
          Often found in many OTC cough & decongestant medications
           Mucinex
          Higher doses available by prescription in combination with a decongestant or cough
          medication
            Pseudovent PED
            Entex LA
            Mucinex D
            Muco-Fen DM

22   Mucolytic Agents

         Degrade polymers in secretions

           Acetylcysteine Solution

           Potassium Iodide

           Organadon

           Amiloride

23   Mucokinetic Agents

         Increase mucociliary efficiency or cough efficiency

         Adronergic Agents

           Albuterol

           Epinephrine

           Terbutaline




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        Metaproteronol
24   Mucoregulatory Agents
      Reduce the volume of airway mucus secretion
      N-acetylcysteine
        Antioxidant effect
      Anti-inflammatory agents
        Indomethacin
        Glucocorticosteroids
        Anticholinergic agents
        Macrolide antibiotics
          Erythromycin
          Clarithromycin
          Azithromycin

25   Adhesives

         Adhesives decrease mucus attachment to the cilia & epithelium

         Augmenting both cough & mucociliary clearance

        Surfactants
26   Airway Clearance Techniques

         Chest Physiotherapy

         Forced Expiration Techniques

         Respiratory Muscle Strength Training

         Positive Expiratory Pressure

         Oscillating Positive Expiratory Pressure

      High Frequency Chest Wall Oscillation
27   Chest Physiotherapy
      Uses combination of patient positioning & chest percussion/vibration to move secretions from
      smaller airways to larger airways
      Indications
        Patients with a large daily sputum production
        Asthma, CF, Bronchiectasis patients
      Advantages
        Free
        No equipment
      Disadvantages
        Time consuming-
          2-4 times a day for 10-30 minutes
        Needs to be performed by care provider
        Must be performed in conjunction with postural drainage
        Uncomfortable

28
29   Positive Expiratory Pressure (PEP)

         PEP devices provide constant back pressure to the airways during expiration



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          Used to facilitate mobilization of retained secretions & re-expand areas of atelectasis

          Improves clearance by building up gas behind mucus via collateral ventilation

          No clear evidence PEP was more or less effective overall than other forms of physiotherapy
30       Positive Expiratory Pressure
          Indications
            CF, chronic bronchitis, asthma, COPD, neuromuscular disease
          Mask or small handheld device
            PARI PEP
            HI-PEP
            TheraPep
          Advantages
            Portable
            Inexpensive
            Does not require electricity
            Can be performed with out assistance
            Good for patients who can not tolerate CPT


31
     1    Thera PEP
     2




32       Forced Expiratory Therapies

          Techniques which include standard chest physical therapy with active cycle of breathing

          More effective than chest physical therapy alone

          Evidence-based reviews suggest these drainage techniques may require greater control & training;
          however, patients with long-term secretion problems or lung disease should be taught these
          techniques

          Should not be used in people with severe dyspnea



33       Forced Expiratory Therapies

          Huffing

          Forced Coughing

          Autogenic Drainage

          Active Cycle Breathing
34       Huffing

          Performed by taking a breath in & forcefully exhaling

          Begin huffing softly



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         Work your way up to a more deep and forceful huff, like “huffing” onto a mirror or window to
         steam it up

         Not as forceful as a cough

      May be less tiring than other techniques
35   Forced Cough

         Coughing is a reflex that helps clear mucus with high-speed airflow

         Sometimes not effective enough

      Can cause shortness of breath
36   Autogenic Drainage

         Autogenic drainage uses varied airflows to move mucus

         Aims to reach very high airflows in different lung fields

         The person inhales to different levels & then adjusts how they exhale to maximize airflow & move
         mucus

      Breathing out may best be done by huffing with this airway clearance technique
37   Active Cycle Breathing
      Breathing Control
        Gentle breathing with the lower chest while relaxing    the upper chest and shoulders
      Thoracic Expansion
        Exercises deep breaths in
        Use a three-second breath-hold to get more air behind the mucus
        This may be done with chest clapping or vibrating, followed by breathing control
      Forced Expiration Technique
        Huffs of varied lengths with breathing control which can be changed to meet each person's
        needs
38
39   Inspiratory Muscle Strength Training

         Have been shown to improve respiratory muscle strength & exercise performance in individuals
         with inspiratory muscle weakness & poor exercise tolerance

         Can be performed with resistance or pressure threshold devices

         Reduces exertional dyspnea in patients with emphysema and CF

40   Non Respiratory Muscle Strength Training

         Diaphragm & abdominal muscles can be recruited during non-respiratory maneuvers

         Transdiaphragmatic pressures are elevated to levels that could potentially provide a strength-
         training

         Types of exercise
           Sit-ups
           Bi-cep curls



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41   Oscillating Devices
      Generate intra- or extra-thoracic oscillations orally or external to the chest wall
      Internally create variable resistances within the airways, generating controlled oscillating positive
      pressure which mobilizes mucus
      Extra-thoracic oscillations generated by forces outside the respiratory system
        Flutter
        Aquapella
        Quake
42   Flutter
      Secretion Removal Device
      Provides
        Positive Expiratory Pressure (PEP)
          Holds airways open
        Airway Oscillation
          Vibrates mucus from airway walls
        Intermittent Flow Acceleration
          Pushes mucus upward for expectoration
      Indications
        Atelectasis
        Bronchitis
        Bronchiectasis
        Cystic fibrosis
        Chronic Obstructive Pulmonary Diseases (COPDs)
        Asthma

43   Flutter
      How Used
        Handheld device
        Steel ball oscillates up & down in a cone
        Vibrates the column of air between mouth & lower airways
      Advantages
        Easy to use
        Portable
        Durable
        Studies indicate produces as much sputum removal as CPT
      Disadvantages
      Cost
        Under $50

44   Acepella

         Flow operated oscillating PEP device designed to enhance secretion removal
         Uses a counterweighted plug & magnet that interrupts expiratory flow through a pivoting cone at
         varying frequencies
         Advantages
           Versatile
           For use by virtually all patients
           Easy to clean
           Works independent of patient positioning
           Can be used with nebulizer
         Disadvantages
           May be hard for some patients to use
         Cost
           $60



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45   Quake
      Oscillates a column of air in both the inspiratory & expiratory phase
       Uses a manually turned cylinder within the device to control frequencies

46   Quake
      Indications
        CF, bronchiectasis
        Most beneficial in patients with COPD or other diseases where high peak expiratory phases can
        not be reaches
        Short term sputum producing disease
      Advantages
        Offers higher frequency and pressure resulting in greater vibration of patients airways
        Mimics CPT the closet
        Easy to clean
      Disadvantages
      Cost
47
48   High Frequency Positive Expiratory Pressure
      High frequency chest wall compression device
        An inflatable vest connected to an external compressor that provides high-frequency chest wall
        oscillation
          The Vest
          The Medline Smart Vest
      Increases sputum production & removal of secretions
      Indications
        CF
        Bronchiectasis
49   High Frequency Positive Expiratory Pressure
      Advantages
        Covered by some insurances
        Company with get insurance approval
        Lifetime Warranty
        Small compressor, handbag size
      Disadvantages
        Cost: range $12,000-16,000
        Upgrade to smaller compressor adds $1,000-6,000

50
51
     Pulmonary Toolbox for the NP
        Treatment strategies
          Breathing & Exercise Techniques
          Autogenic Drainage
          Active Cycle Breathing
        Pharmacologic
          Expectorants
          Mucolytics
          Mucoregulatory
          Mucokinetics
          Adhesives
        Therapeutic devices
          Chest Physiotherapy
          Forced Expiration Techniques



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         Respiratory Muscle Strength Training
         Positive Expiratory Pressure
         Oscillating Positive Expiratory Pressure
         High Frequency Chest Wall Oscillation



52   Questions
53
54
55   References
      attached




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