Bronchial Hygiene Techniques

By Jim Clarke

What is Bronchial Hygiene Therapy (BHT)?

It consists of a variety of non-invasive techniques designed to improve gas exchange by helping to mobilize and remove secretions

When to use Bronchial Hygiene Therapy? (BHT)

During episodes in which there is an acute secretion clearance problem. Examples; Severe pneumonia with copious secretions Respiratory failure with inability to clear retained secretions Acute lobar atelectasis (documented) Evidence of significant infiltrates and/or consolidation with hypoxemia present

Acute conditions in Which BHT is NOT Helpful

Acute exacerbations of COPD

Many patients cannot tolerate these procedures even if secretion clearance problems exist!

Pneumonia without evidence of significant sputum production

Not all pneumonias produce secretions!!

Uncomplicated asthma

BHT for Chronic Conditions

Used to prevent complications in the outpatient population and to treat acute problems seen in;
Cystic Fibrosis Bronchiectasis

Sometimes used in Chronic Bronchitis when large volumes of secretions become problematic

Brief Look at CF & Bronchiectasis

Cystic Fibrosis: characterized by increased sputum viscosity (thick mucus), increased mucus volume and impaired clearance
Typically seen in children & young adults only

Bronchiectasis: characterized by muco-stasis, retained secretions, loss of mucociliary escalator & repeated pneumonias
Generally seen only in adults with a history of persistent & repeated lung infections

When Do Patients Need BHT ?

(Are the following present?)

Patient has a Dx of Bronchiectasis or Cystic Fibrosis? (Read the Hx & PE) They have evidence of copious secretions (>25-30 ml/day) with clearance problems?
Do a cough evaluation Listen to breath sounds Check for evidence of tactile fremitus

Other Issues to Check When Evaluating Need for BHT

Review Chest X-ray findings in chart OR view CXRs directly

Very important in identifying Lobar pneumonias

Assess oxygenation status by reviewing recent ABGs and/or SpO2 findings Check in chart for evidence of a sputum analysis
Culture & sensitivity findings

Causes of Mucociliary Impairment

Presence of endotracheal or tracheostomy tube History of having to suction patients trachea Poor humidification High FIO2s Drugs: General anesthetics; opiates; narcotics

Some Commonly Used Types of Bronchial Hygiene Therapies

Postural Drainage with percussion and/or vibration (PD&P) (PDVP)

High Frequency Compression/Oscillation Therapy Flutter Valve IntraPulmonary Percussive Ventilation ThAIRapy Vest - Thoracic Wall Vibration

Positive Airway Pressure Techniques

Positive Expiratory Pressure Therapy (PEP)

Other Less Commonly Used BHTs

Coughing and related expulsion techniques

Directed Coughing Huff coughing Quad cough Autogenic Drainage

Mobilization and exercise techniques

Frequent turning of patients Ambulation and exercise as tolerated

Postural Drainage Therapy

Process of positioning patients to best utilize gravitational effects in the enhancement of secretion removal
Turn &/or position the patient so that mucus drains out of the effected lung zone(s)

Review of Lung Segments

Left Lung
Upper Lobe
Anterior; Posterior; Apical Lingular

Right Lung
Upper Lobe
Anterior; Posterior; Apical

Middle Lobe
Lateral; Medial

Lower Lobe
Superior; Lateral basal; Anterior basal; Posterior basal

Lower Lobe
Superior; Lateral basal; Anterior basal; Posterior basal

Using Drainage Positions

Use drainage position most appropriate to the lung segments involved

Lower lobe positions are most typical

Average drainage time 3-5 minutes/position Modify positions as needed

Some patients may not tolerate Trendelenberg Many patients cannot assume prone position

Superior Segments Upper Lobes

Posterior Segments - Lower Lobes

Refer to #2

Lateral Segments - Lower Lobes

Refer to #9

Anterior Segments - Lower Lobes

Refer to #8

Lingular Segments - L Upper Lobe

Refer to #s 4 & 5

Right Middle Lobe

Refer to #s 4 & 5

Posterior Segments - Lower Lobes

Refer to #6

Anterior Segments - Upper Lobes

Refer to #3

Anterior & Apical Segments Upper Lobes Refer to #s 1 & 2

Contraindications to Use of Trendelenberg Position

Recent tube feeding or at high risk for aspiration of gastric contents Increased ICP in a recent intracranial injury Uncontrolled hypertension Severely distended abdomen Gross (bright red) hemoptysis

Contraindications to Percussion or Vibration of the Chest Wall

Burns or recent skin grafts to chest Bleeding abnormalities Osteomylitis Subcutaneous emphysema Suspected or active TB Recent insertion of pacemaker

Hazards of PD&P Techniques

Worsening S.O.B. Pain or injury to chest wall or spine Hypoxemia Nausea & Vomiting Tachycardia; Hypotension; Arrthymias Bronchospasm (not likely but possible in patients with Hx of asthma)

Assessment of Outcome

Have the underlying issues that necessitated the use of PD&P improved?
Less sputum production Improvement of breath sounds Improvement in oxygenation Improvement in CXR

P.E.P. Therapy Device

When to Use PEP Therapy

Mostly used in treatment of Cystic Fibrosis & Bronchiectasis Utilizes a expiratory resister designed to create positive pressure during exhalation and lengthen the expiratory phase Aerosol therapy can be done inline & simultaneous with PEP treatments

Key Elements in Patient Instruction in Use of PEP Therapy

Patients need to take a breath that is slightly larger than normal Expiratory pressure should be set between 10 - 20 cmH2O in order to create an I:E ratio of 1:3 to 1:4 Have patient perform 10 to 20 breaths and then do 3 coughs Perform PEP for no more than 20 minutes

Additional Issues in PEP Therapy

May reduce air trapping in COPD - asthma

Is like pursed lipped breathing

May prevent or reverse atelectasis May improve aerosol medication delivery Hazards of PEP therapy are similar to IPPB

High Frequency Chest Wall Vibration - ThAIRapy Vest

Flutter Valve

IntraPulmonary Percussive Ventilation Video Available

Autogenic Drainage

A breathing technique designed to milk or squeeze air out of the lungs

Steps in Autogenic Drainage

Composed of 3 breathing phases Phase 1: Patient breathes in normally but exhales each breath close to RV (5-9 cycles) Phase 2: Breathes in slightly above normal Vt but exhales normally (5-9 cycles) Phase 3: Breathes in close to VC but exhales normally (5-9 cycles) All 3 Phases are repeated as necessary

THE END