COUGH COMPONENTS Inspiratory Phase

Compressive Phase Glottis closingBuilding of pressure

Expiratory Phase (glottis opening)

HUFF Not the same components of a cough

Can be more effective in clearing secretions

To train patients, DEMONSTRATION.

FET – active cycle of breathing

ASSISTED COUGH TECHNIQUES Splinting

CABG, thoracotomy, belly surgeries, incision in “pop can”.

Quad CoughingWho?: ALS, SCI

Variety of different ways to increase expulsion force through positioning and careful manual pressure through CHEST WALL and ABDOMEN. (Interconnection)

COUGH ASSIST MACHINE AKA – Coughalator,

Mechanical In-Exsufflator, “The Cougher”

Non-invasive way to clear secretions. (alternative to suctioning)

Two Way Vaccuum

WHO?

Indications for Use:

Any patient unable to cough or clear secretions effectively due to reduced peak cough expiratory flow (less than 3 liters per second), resulting from: High spinal cord injuries Neuromuscular deficits or Severe weakness

associated with intrinsic lung disease, is a candidate for the CoughAssist.

OUR Indications for Use?

Ineffective Cough Unable to clear secretions Diagnoses:

SCI ALS MD Trached patients Pneumonia Atelectasis Bronchiectasis: chronic

secretions. Scarring and damage of lungs.

CONTRAINDICATIONS Bullous Emphysema: airways collapse Known susceptibility to pneumothorax Recent Barotrauma: trauma deep in lungs related

to pressure

EVIDENCE BASED PRACTICE Massery et al. 2003, Cardiopulmonary PT Journal. Showed that

cough assist was just as effective as suctioning. Marchant and Fox 2002, Br J Anaesthesia. Case study preventing

tracheostomy. Kan and Bach 2000, Chest. Deep insufflations improved ability to

air stack; and cough effectiveness. John R. Bach – multiple studies on progressive neuromuscular

diseases. Show cough assist machine even more effective with manual assist (peak cough flows).

Chatwin et al. 2003, Sivasothy et al. 2001. Showing cough assist machine effective with cough augmentation

PROCESS

Set up: Filter is hooked to the port of machine, then

connected to blue tubing (RT) Green plastic connector, then smaller blue tubing Mouth piece, face mask, trach adaptor Throw out small blue tubing at end of session.

Cost – approximately $3,500-5,000

SUCTIONING Sterile Technique

Don sterile glovesKeep one hand sterile and always on the

suction tubeThe other hand touches the valve and

other equipment Ballard

Closed systemUse clean gloves

SUCTIONING Get equipment ready

Suction deviceGlovesAmbu bag

Suction pressure 60-120 mmHg Ventilate, especially if removing vent–

bag 3-5 times Insert to level of carina, no suction

going in Remove and twist, suction on way out

SUCTIONING 10 sec duration in body 20-30 in between suction technique 3-4 times max Clean suction in between contact with

body with sterile saline

Some PTs do use sterile saline or hypertonic saline

SUCTIONING

Indications Pt is unable to clear

secretions independently.

Pt is having difficulties breathing due to secretions/obstruction.

Unable to clear secretions by any other method.

Types Tracheal (only within the

trach.) Deep (further than trach

and into lung tissue). Procedure:

Sterile vs Clean Suction set 120-140

mmHg 10-12 seconds

SUCTIONING

Enter catheter: cautiously but quickly, until you feel resistance (carina)

Apply suction and slowly pull catheter out.

Twist catheter as you pull out catheter.

Monitor saturations, and assist with ambu bag prior/following.

SUCTIONING

What vitals do you want to monitor??Heart Rate Blood PressureSPO2Respiratory Rate

SUCTIONING

Complications Desaturation/hypoxia Cardiac arrhythmias, Tachy cardia and Hypertension Pulmonary hemorrage/bleeding Bronchospasm Elevated ICP

Is one of the most invasive techniques we do as physical therapists.

DEAN’S HIERARCHY FOR TREATMENT WITH IMPAIRED OXYGEN TRANSPORT

1. Mobilization and Exercise2. Body Positioning3. Breathing Control Maneuvers4. Coughing Maneuvers5. Relaxation and Energy Conservation

Interventions6. ROM exercises7. Postural Drainage Positioning8. Manual Techniques9. Suctioning

APPLICATION TO ICU PT

WONG 2000

Patient in respiratory distress.

PT performed multiple treatments. STG to improve V/Q, decrease WOB, and airway clearance

WONG 2000 DAY 1 ICU

PT performed treatments every 2 hours and all through the night

Total of 6 PT treatments

DAY 2 ICUPT performed 5

treatments

DAY 3 FLOORPT performed

treatments 2x per day

OVERALL21 PT sessions (11

sessions during 48 hour ICU; 2 sessions daily on floor for 4 days)

Day 1 Day of Discharge

SUMMARY OF CURRENT EVIDENCE Airway Clearance techniques assist in

short term for secretion removal but currently there is no evidence supporting long term benefit above cough alone.

All techniques show improvement in secretion removal though no one technique has been proven better than the others and different patients will show different benefits from each technique.

SUMMARY OF CURRENT EVIDENCE Method of airway clearance for any

particular patient needs to be tailored to that patient’s needs to assure effective therapy with the greatest independence.

What works for any particular patient now may not work in the future with that patient, and what does not currently work for any particular patient now may become more helpful in the future.

SUMMARY OF CURRENT EVIDENCE Position change is the only consistently

demonstrated method of changing ventilation to any particular part of the lung

ULTIMATELY – use of ANY technique is better than nothing.

EX: if had pneumonia in left, then best on right, which is nice for moblization.