Airway Clearance Therapy

Objectives - Determine indications for chest physiotherapy, determine steps for intrapulmonary percussive ventilation, and determine steps for airway clearance via percussive vest therapy.

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Therapy Modalities

Airway clearance therapy modalities listed in the source include:

• Postural drainage (PD)
• Chest percussion therapy (CPT) and chest vibration
• Manual percussion by hand
• Mechanical or pneumatic percussion
• Positive expiratory pressure (PEP) with or without vibration
• Intrapulmonary percussive ventilation (IPV)
• High-frequency chest wall oscillation (HFCWO)

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Indications for Airway Clearance

Acute Conditions

Airway clearance may be indicated for:

• Abnormalities caused by unilateral lung disease
• Copious secretions
• Acute lobar atelectasis with V/Q mismatch from mucus plugging
• Acute respiratory failure with retained secretions

Chronic Conditions

Chronic indications include:

• Cystic fibrosis
• Bronchiectasis
• Chronic bronchitis
• Ciliary dyskinetic syndromes

Disorders Associated With Retained Secretions

The source also lists:

• Acute disease
• Immobile patients
• Postoperative patients affected by general anesthetics, opiates, and narcotics
• Inadequate humidification with infiltrates visible on chest radiograph

Always view the chest X-ray for appropriateness of the airway clearance order.

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Chest Physiotherapy Goals

The goals of chest physiotherapy are to:

• Reduce and manage accumulation of pulmonary secretions
• Decrease airway resistance
• Improve mobilization and removal of retained secretions
• Improve ventilation-perfusion distribution
• Prevent or treat atelectasis

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Postural Drainage

Postural drainage uses gravity to enhance mobilization of secretions within the airways.

Key points:

• Secretions move from small airways toward larger airways.
• Body positioning is critical to direct secretion movement.
• Affected areas must be positioned above large airways.
• CPT may be performed alone or with postural drainage.
• Postural drainage may be performed alone or with CPT.

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Percussion

Percussion improves mobilization of pulmonary secretions.

Procedure

• Manual percussion physically strikes the chest wall, back, or ribs with cupped hands.
• Mechanical or pneumatic percussion is applied to the back or chest wall.
• Percussion is always performed with the patient in an appropriate postural drainage position.
• Apply a folded towel over the percussion area to prevent pain.
• The patient should periodically perform a strong, effective cough.

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Vibration

Manual Vibration

Manual vibration uses crossed hands over an affected lung segment with rapid shaking motion and moderate pressure.

Procedure:

1. Place the patient in an appropriate postural drainage position as tolerated.
2. Instruct the patient to breathe in deeply.
3. Apply vibration manually during exhalation.
4. Repeat several times for at least 5 minutes.
5. Direct the patient to deep breathe and cough.

Electromechanical Vibration

Electromechanical vibration follows the same general technique as a pneumatic percussor.

• Apply a towel over the vibration area for comfort and to prevent irritation.
• The patient should periodically perform a strong, effective cough.

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Positive Expiratory Pressure Therapy

Positive expiratory pressure therapy includes resistance-only and vibratory devices.

Threshold Resistance Devices

Threshold expiratory resistance devices provide resistance on exhalation only.

• Vibration is not incorporated.
• The source describes this as lung expansion therapy that leads to mobilization of secretions.
• Examples listed: EzPAP and Resistex.

Vibratory Resistance Devices

Vibratory expiratory resistance devices produce both resistance and vibration. The vibration transmits through the airways to shake loose pulmonary secretions.

Examples listed:

• Flutter Valve
• Acapella
• Quake
• Aerobika

Expiratory Resistance and Vibration Procedure

Goal: splint airways open and enhance mobilization of secretions.

1. The patient inhales slowly and fills the lungs to maximum capacity.
2. The patient performs a 3-second breath hold.
3. The patient exhales steadily and produces sustained vibration to loosen secretions.
4. The technique is repeated several times, up to 15 minutes.
5. Productive coughing follows the repeated cycles.

The procedure may be performed with or without postural drainage. SVN or MDI therapy often precedes the intervention.

Do not perform this in Trendelenburg position for patients with elevated intracranial pressure or increased risk for stroke.

Flutter Valve

The Flutter Valve is a pipe-shaped expiratory resistance and vibration device.

• It produces positive expiratory pressure between 10 and 25 cmH2O.
• A metal ball vibrates within the device.
• The goal is to shake secretions loose and mobilize them.

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Intrapulmonary Percussive Ventilation

Intrapulmonary percussive ventilation (IPV) augments the patient's own spontaneous breathing pattern.

The patient breathes pressurized, pulsating, dense aerosolized gas into the lungs.

Mechanism

• Pulsatile flow and a high delivery rate of sub-tidal gas expand the airways.
• Mucus breaks loose from airway walls and moves toward the large airways.
• Dense aerosol, either saline or medication, is delivered simultaneously.
• Aerosol reduces adhesive and cohesive forces of retained secretions.
• The therapy enables the patient to cough, mobilize, and expectorate secretions.

Bi-Phasic IPV

Bi-phasic IPV uses pulsating bursts of gas at controlled breath rates and pressure.

Bi-phasic gas flow delivers oxygen to the alveoli while convectively flushing CO2 out of the lung. Mucus mobilizes from peripheral to large airways, resulting in productive cough and improved airway clearance.

Therapy Interfaces and Settings

The source lists IPV in:

• Inpatient hospital settings
• Outpatient or home therapy for cystic fibrosis patients
• Ventilator use in the intensive care unit
• Thoracic surgery
• Multiple rib injuries
• Burn injuries

Treatment details:

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High-Frequency Chest Wall Oscillation

High-frequency chest wall oscillation (HFCWO) uses an inflatable, non-compliant vest that fits over the upper torso down to the iliac crest.

Three-Part System

Pressure pulses loosen mucus. Mucus mobilizes into larger airways for expectoration.

Treatment Frequency

• Administered twice or more daily
• Minimum time: 30 minutes

Treatment Administration

1. Connect pressure hoses between the air pulse generator and patient vest.
2. Adjust vest pressure and frequency for effect and patient comfort.
3. Use the listed pressure range of 25 to 40 mmHg.
4. Use the listed frequency range of 5 to 25 Hz.

Frequency conversion:

Effectiveness may be enhanced with proper use of a PEP device during oscillation. Vest therapy is managed independently by the patient at home.

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