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Goals of Chest Physical Therapy
- Prevent accumulation of secretions
- Improve mobilization
- Improve ventilation
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Indications for Chest Physical Therapy
- Accumulated or retained secretions
- Ineffective cough
- Ciliary dysfunction
- Prophylactic care of patients
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Techniques Promoting Bronchial Hygiene
- Postural Drainage
- Percussion
- Vibration
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Contraindications for Chest Physical Therapy
- Unstable cardiovascular system
- Unstable pulmonary system
- Unstable post-op status
- Absolute contraindications
- ~ Head/Neck injury
- Relative contraindications
- ~ ICP > 20 mmHg
- ~ Empyema
- ~ Rib fractures
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Contraindications for Percussion
- Subcutaneous emphysema
- Recent skin graft
- Burns or open wounds
- Lung contusion
- Osteomyelitis of ribs
- Osteoporosis
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Hazards for Vibration
- Rib cage trauma
- Soft tissue trauma
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Hazards for Chest Physical Therapy
- Hypoxemia
- Cardiovascular instability
- Hemorrhage, hemoptysis
- Fracture ribs
- Increased ICP
- Dyspnea
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Percussion
Technique of clapping the chest wall with cupped hands
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Vibration
Isometric manuever performed with the arm and hand that is performed on exhalation only
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Effective Pulmonary Clearance
- To move secretion, must get air behind secretions to mobilize
- To allow for distribution of inhaled air, breath hold is extremely important
- To avoid airway closure, exhale in a manner that does not cause dynamic collapse of airway
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Pulmonary Clearance Techniques
- Postural Drainage and Percussion
- Positive Expiratory Pressure (PEP)
- Oscillation PEP
- Autogenic Drainage
- High Frequency Chest Wall (HFCWC)
- Intra-pulmonary Percussive Ventilation
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Postural Drainage
Method used to remove pooled secretions by positioning the patient to allow gravity to assist in the movement of secretions.
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PEP
Exhale against a resistance to hold airways open and promote secretion movement up the airway
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Huff Cough
- Critical part of all forms of pulmonary clearance
- Goal is to maintain open airway without inhibiting secretion movement
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Coaching Huff Cough
- Take a deep breath, hold briefly, huff out air (similar to fogging up glass)
- Toward the end of exhalation have patient cough to clear secretions
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Performing PEP
- Sit upright, back straight, NO SLOUCHING
- Take in slightly larger than tidal volume breath
- Hold breath for 2-3 seconds
- Exhale through mouth against the resistance (Should be slightly active, maintaining pressures between 10-20 cm H20
- Repeat for 10 breaths
- Perform good huff cough and allow patient to expectorate secretions
- Repeat for 6 full cycles of 10 breaths each
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Performing Oscillating PEP
- Sit up straight
- Take in larger that tidal volume breath, but not TLC
- Hold breath for 2-3 seconds
- Exhale normally through device beyond normal level, but not entirely
- Cheeks should be kept flat
- Repeat for 10-15 breaths or until secretion movement is detected
- When patient is ready to cough, have them take in full breath and actively exhale through the device
- At the end of exhalation, patient should cough and expectorate
- Repeat the entire process until secretions have cleared (15-20 minutes or 6 cycles)
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Autogenic Drainage Goal
To move secretions from smaller airways to larger airways so they can be easily expelled
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3 Phases of Autogenic Drainage
- Unsticking - Small Airways
- Collecting - Mid-Sized Airways
- Evacuation - Large Airways
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Performing Autogenic Drainage
- Sit upright
- Place hands on front and back of chest
- Instruct patinet to take a deep breath in and exhale fully (well into ERV)
- Take in small volume of air and hold for 3 seconds
- Huff air out through mouth (slightly active), keeping airways open
- Repeat until you hear secretions move ( crackling sound)
- Have patient take in a deeper breath to mid sized airways and hold for 3 seconds
- Huff air out in the same manner
- Repeat at this volume until you can feel or hear secretions
- Encourage patient not to cough until the end of the last phase
- Have patient take in full breath and hold for 3 seconds
- Huff air out through mouth in same manner, being conscious of keeping airways open
- Once secretion have accumulated in large airways, have patient take in full breath and perform a huff cough to expectorate
- Repeat the cycles until chest feels clear
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High Frequency Chest Wall Oscillation
- Uses the rapid compression and release of the chest wall to loosen secretions from the airway wall and decrease the viscosity of the secretions
- Uses compression frequencies of 5-25 Hz, but only up to 15 Hz for therapeutic reasons
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HFCWO Devices
- The Vest airway clearance system by Hil-Rom
- The MedPulse Respiratory Vest System
- The InCourage system by Respirtech
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Incentive Spirometry
- Mimic natural sigh
- Encourage patient to take slow deep breaths
- Device provides visual clue for patient
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IPPB
- Intermittent Positive Pressure Breathing
- Application of positive pressure to spontaneously breathing patients
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Equipment for Incentive Spirometry
- Voluime - Oriented Devices
- Flow - Oriented Devices
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Equipment for IPPB
- Positive Pressure Machine
- PR-2
- Bird Mark 7 or 8
- AP-5
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Goals and Indications for Incentive Spirometry
- Presence of Pulmonary Atelectasis
- Presence of Conditions Predisposing to Atelectases
- Presence of Restrictive Lung Defect
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Goals and Indications for IPPB
- General: Patient cannot voluntarily cough effectively and take a deep breath
- Specific: If patient's vital capacity is less than 15 ml/kg or ispiratory capacity is less than 33%
- Therapeutic: treat and prevent atelectasis
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Contraindications for Incentive Spirometry
- Unconscious patient
- Patient who can not use incentive spirometer after instruction
- Patient unable to generate adequate inspirations - Vital capacity less than 10 ml/kg or Inspiratory capacity less than 1/3 of the predictid normal
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Contraindications of IPPB
- Tension pneumothorax
- ICP> 15 mmHg
- Hemodynamic instability
- Active Hemoptysis
- Air Swallowing
- Nausea
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Hazards and Complications Associated with Incentive Spirometry
- Hyperventailation
- Discomfort
- Pulmonary Barotrauma
- Hypoxemia
- Exacerbation of Bronchospasm
- Fatigue
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Hazards and Complications Associated with IPPB
- Increased mean airway pressure
- Pulmonary Barotrauma
- Nosocomial Infection
- Hyperoxia
- Decrease venous return
- Gastric distension
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Describe the Procedure for Incentive Spirometry
- Determine need
- Select appropriate equipment
- Determine initial goal of where on the Chart they need to be
- Patient instructed to inspire slowly and deeply
- Then exhale normally
- Allow patient to rest
- Then repeat
- 5-10 sustained maximal inspirations per hour
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Describe the Procedure for IPPB
- Knowledgeable well trained therapist
- Relaxed, informed, cooperative patient
- Concept of goals
- Pressure-limited machine
- Appropriate cough/breathing instruction
- Honest evaluation of therapy
- Treatment length 15 to 20 minutes
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Monitoring IPPB Therapy Machine Performance
- Sensitivity
- Peak Flow and Setting
- FiO2 Ordered
- I:E Ratio
- 40-60 lpm
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Monitoring IPPB Therapy Patient Response
- RR and Expired Volume
- HR and Rhythm
- Sputum Production
- Skin Color
- Subjective Response to Therapy
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Follow Up of IPPB - Pre and Post Treatment Assessment
- Vital Signs
- Sensorium
- Breath Sounds
- Sputum Production
- Positive and Negative Effects
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Indications for use of an Artificial Airway
- Prevent/relieve upper airway obstruction
- Protect airway from aspiration
- Facilitate suctioning
- Provide sealed, closed system for mechanical ventilation/ CPAP
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Oropharyngeal Airway
- Prevent/relieve upper airway obstruction
- Poorly tolerated in alert patients
- Use in unconscious patients
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Nasopharyngeal Airway
- Prevent/relieve upper airway obstruction
- Facilitate suctioning
- Alternate every 24 hours between right and left nares
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Oroendotracheal Tube
- Easy to insert
- Short-term intubation
- Larger tube size than nasal
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Nasoendotracheal Airway
- Easy to stabilize
- Easy to suction
- Well tolerated
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Tracheostomy Tube
- No complications of upper airway/ glottis
- Easy to suction
- Easy to stabilize
- Best tolerated artificial airway
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Tracheal Buttons
- Used to maintain patency of tracheal stoma
- Patient can be suctioned in an emergency
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EOA, EGOA
Placed in esophagus and used to suction stomach
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Complications Associated with a Nasopharyngeal Airway
- Sinusitis
- Otitis Media
- Nasal Necrosis
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Complications Associated with an Oroendotracheal Tube
- Poorly tolerated
- Difficult to stabilize
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Complications Associated with a Nasoendotracheal Airway
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Complications Associated with a Tracheostomy
- Bleeding
- Pneumothorax
- Infection
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Indications for Cuffs
- Mechanically ventilate patient
- protect airway from aspiration
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Hazards of Cuffs
- @ 30 mmHg - Cessation of arterial blood flow
- @ 18 mmHg - Obstruct venous flow
- @ 5 mmHg - Inhibit lymphatic flow
- Mucosal edema and redness
- Mucosal ischemia and necrosis
- Mucosal inflammation
- Exposure to cartilage
- Tracheal ring destruction
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High-Volume, low-pressure cuffs
- Cuffs of choice
- Inflates Evenly
- Produces low lateral tracheal wall pressure
- Can herniate over end of tube
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Low-volume, high-pressure cuffs
- Small contact on tracheal wall
- Inflates unevenly
- Exceeds safe pressures
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Cuff Inflation Technique
- Minimal Leak Technique (MLT) - Maintain seals except at max inspiratory pressure
- Minimal Occluding Volume (MOV) - Matain seal @ peak inspiratory pressure
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Airway Suctioning
- Invasive procedure that involves insertion of a small catheter into the airways
- Application of a vacuum to aspirate secretions of foreign material
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Indications for Airway Suctioning
- Gurgling expiratory sounds
- Visible secretions
- Inability to cough
- Sputum induction
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Hazards of Airway Suctioning
- Hypoxemia
- Arrhythmias
- Hypotension
- Lung Collapse
- Cardiac Arrest
- Infection
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Describe Suctioning Technique
- Sterile technique
- Preoxygenate
- Insert catheter w/out suction
- Apply suction only during removal
- No longer than 10-15 seconds
- Reoxygenate and ventilate
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Suction Pressures
- Adults: 100-120 mmHg
- Children: 80-100 mmHg
- Infants: 60-80 mmHg
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Proper Catheter Size for Suctioning
Should not be greater than 1/2 the internal diameter of the artificial airway
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Indications for Manual Resuscitation
- Support Ventilation
- Respiratory Arrest
- CPR
- Suctioning
- Patient Transport
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Hazards for Manual Resusicitation
- Unrecognized equipment failure
- Gastric distension
- Aspiration
- Diminished cardiac output
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