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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 9.3.16 1 7/6/2009 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 9.3.16 2 7/6/2009 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 9.3.16 3 7/6/2009 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 9.3.16 4 7/6/2009 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 9.3.16 5 7/6/2009 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 9.3.16 6 7/6/2009 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 9.3.16 7 7/6/2009 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 9.3.16 8 7/6/2009 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 9.3.16 9 7/6/2009 Respiratory Muscle Strength Training Positive Expiratory Pressure Oscillating Positive Expiratory Pressure High Frequency Chest Wall Oscillation 52 Questions 53 54 55 References attached 9.3.16 10
"Airway Clearance Modalities and Devices American Academy of Nurse"