BRONCHIAL HYGIENE

Dr. S Sai Janani

INCLUDING RETAINED SECRETIONS, AEROSOL THERAPY AND HUMIDIFICATION

University College of Medical Sciences & GTB Hospital, Delhi

PHYSIOLOGY OF RESPIRATORY TRACT

20 – 22C50% humidity

29-32C95%humidity

32-35C100%humidity

ISB

HUMIDIFICATION

• Humidity therapy refers to addition of water vapor and heat to the inspired gas as a direct therapeutic procedure or as an adjunct to other therapy.

CONSEQUENCES OF INADEQUATE HUMIDIFICATION

Inadequate humidification of

gases

Impaired mucociliary clearance

Retention of viscid tenacious

secretions

Bacterial infiltration of

mucosa

AtelectasisPneumonia

Hypothermia

Drying of tracheobronchial

tree

INDICATIONS

• PRIMARY:• Humidifying dry medical gases• Bypassed upper airway for ventilation• SECONDARY:• Treating bronchospasm caused by cold air• Management of hypothermia

HUMIDIFIERS

• Humidifier is a device that adds molecular water to gas being delivered.

• TYPES:• Pass- over humidifier• Bubble diffusion humidifier• Heat and moisture exchanger

PHYSICAL PRINCIPLES OF HUMIDIFIERS

Affected by:TemperatureSurface area

Time of contact

BUBBLE DIFFUSION HUMIDIFIER

Breaking of gas into small bubbles and allowing it to come into intimate contact with liquid

Bubble humidifier…… contd

• Disadvantage:– Aerosols are produced– High risk of spreading infections

MEMBRANE HUMIDIFIER

WICK TYPE HUMIDIFIER

HEAT MOISTURE EXCHANGER

• Passive humidifier

• Preserves heat and moisture of patient’s exhaled air and delivers it to patient’s respiratory tract on next inspiration

• Hygroscopic or Hydrophobic membranes – act as filters

• HYGROSCOPIC CONDENSER HUMIDIFIER:1. Condensing element of low thermal conductivity

(paper, wool or foam)2. Impregnation of hygroscopic salt (Ca or LiCl)

• HYDROPHOBIC CONDENSER HUMIDIFIER:1. Condensing element with low thermal conductivity2. Added bacterial filter – HMEF

• EFFICIENCY – 70%

HME

STANDARDS FOR HME

Design and performance standards set by ISO:

Ideal HME - 70% efficiency or better ( 30 mg/L water vapor)

• Use standard connections• Low compliance• Minimal weight to the circuit• Minimal Dead space• Minimal flow resistance

ADVANTAGES OF HME

• 1. Eliminates breathing circuit condensation• 2. Hydrophobic bacterial filters

POSITION OF HME

HEATING SYSTEM

HEATING ELEMENTS:1. Hot plate2. Wrap-around type3. Yolk or collar type4. Immersion type5. Heated wire in the inspiratory limb CONTROLLED HEATING:6. Attaching temperature monitors7. Servo controlled

HME RESERVOIR

• Simple large reservoir systems:Manual refilling1. Momentary disruption2. Contamination

• Automatic feed systems:1. Level compensated reservoir2. Flotation type systems

SETTING HUMIDIFICATION LEVELS

Current AARC guideline:• 33˚C within 2 C with a minimum of 30 mg/L

of water vapor.• The optimal level is 37 C with 100% relative

humidity and 44 mg/L.

PROBLEM SOLVING AND TROUBLESHOOTING

• Condensation• Cross contamination

CONDENSATION

• Factors influencing amount of condensation:– Temp difference across the system– Ambient temperature– Gas flow– Set airway temperature– Length, diameter of breathing circuit.

• Risk: – Disrupt or occlude gas flow– Aspiration – infection

• To minimize:– Water trap– Heated wire circuits

AEROSOLS

• Aerosol – suspension of very fine particles of liquid in a gas

BLAND AEROSOL THERAPY: Sterile waterhypotonic, isotonic and

hypertonic saline.

FUNCTIONS

• Aids bronchial hygiene• Hydrates dried and retained secretions• Restores and maintains mucous blanket• Promotes expectoration• Improves effectiveness of cough

• Humidifies inspired gases• Acts as a means to deliver medications

DEVICES

ATOMIZER – device that generates an aerosol.

NEBULIZER – device that generates aerosols of uniform particle size.

MECHANISM- BAFFLING

• Baffle = device that deflects gas flow

• When a baffle device is placed in the path of gas flow that contains water particles, the large particles impact on the baffle and ‘rain out’ of the aerosol whereas the smaller particles pass with the gas stream around the baffle.

• More baffles in series = more small and uniform the particle size

• Water surface, sides of container, rt. angled bends = Baffles

TYPES OF NEBULIZERS

Steam nebulizer (Hand held

nebuliser) - steam

Pneumatic nebulizer –

pressurised gas

Electric nebulizer – electric source

• Jet nebulizer• Hydronamic

nebulizer

• Ultrasonic nebuliser

ULTRASONIC NEBULISER

PROBLEMS WITH NEBULISERS• Cross contamination• Infection• Environmental safety (immunocompromised pts)• Inadequate mist production• Over hydration :

– cautious use in pediatric age group– Worsening airway obstruction

• BRONCHOSPASM– History– Initial monitoring required every 8 hrs – If occurs during therapy – conservative management.

• NOISE

BRONCHIAL HYGIENE THERAPY

DEFINITION

• Refers to the use of non invasive airway clearance techniques designed to help mobilize and remove secretions and improve gas exchange

• Primary bronchial hygiene mechanisms:1. Mucociliary complex2. Cough

MUCOCILIARY ESCALATOR

PHYSIOLOGY OF COUGH REFLEX

NEED FOR BRONCHIAL HYGIENE THERAPY

• Abnormal clearance• Retained secretions-

Mucus pluggingPartial or complete obstructionAtelectasis

V/Q mismatchImpaired oxygenation

Impaired mucociliary clearance

• Endotracheal or tracheostomy tube• Tracheobronchial suction • Inadequate humidification• High FiO2

• Drugs– General anesthetics, narcotics.

IMPAIRED CILIARY ACTIVITY

Mechanisms impairing cough reflex

•Anesthesia•CNS depression

•Narcotic – analgesics

IRRITATION:

• Pain•NM dysfunction

•Pulmonary or abdominal restriction

INSPIRATION:

•Laryngeal n damage

•Artificial airway

•Abd muscle weakness or surgery

COMPRESSION:

•Airway compression

•Airway obstruction

•Abd muscle weakness

•Inadequate lung recoil (eg., emphysema)

EXPULSION:

INTIAL ASSESSMENT OF NEED FOR BHT :

• History:– H / O pumonary problems causing increased

secretions– If pt. for upper abdominal or thoracic surgery :• Age• COPD• Obesity• Nature of procedure• Type of anesthesia• Duration of procedure

EXAMINATION

• Posture of patient• Effectiveness of cough• Sputum production• Breathing pattern• General physical fitness• Breath sounds• HR, BP,RR

COMPONENTS OF BRONCHIAL HYGIENE

BREAK DOWN SIZE

•Mucolytics

•humidification

DISLODGE them

•Chest physiotherapy

MOBILIZE TO

CENTRAL AIRWAYS

•Postural drainage

•Chest physiotherapy

REMOVE FROM LUNGS

•Directed cough

•ET suctioning

RE EXPAND

THE LUNGS

•Incentive spirometry

•Bronchodilation (aerosols)

•IPPB, PEP, CPAP

CHEST PHYSIOTHERAPY•Chest percussion•Vibration•Postural drainage•Directed cough

Includes

CHEST PERCUSSION

• Rhythmic “clapping” with cupped hands over the involved lung segments, with the patient in appropriate postural drainage positions

• FUNCTIONS:• Loosens / dislodges the adherent bronchial secretions• Mobilizes secretions towards central airways• Increases efficiency and distribution of ventilation

• TECHNIQUE:• Strike chest wall with cupped hands• Move from periphery to central airways• Perform throughout inspiration and expiration• Avoid bony prominences and breast tissue

Cupped hands = compressed

air

Mechanical energy wave

Chest wall to lung tissue

DISLODGE SECRETIONS

• Pain and discomfort • Bruising • Rib #s • Spread of tumor cells• Contaminates other

areas of the lung• Hemorrhagic

conditionsSIDE EFFECTS AND CONTRAINDICATIONS:

CHEST VIBRATIONS

• Loosens adherent bronchial secretions and mobilizes them towards central airways

• TECHNIQUE:• Hands placed one over the other or either side of the chest • Rapid vibrations produced in the arms while compressing

chest wall in the direction of ribs• During exhalation or end inspiration

– FREQUENCY = 200/ min

POSTURAL DRAINAGE

• Drainage of secretions by effect of gravity from one or more lung segments to the central airways

• MECHANISM:– Mobilises secretions in the direction of gravity to

promotr removal of retained secretions– Matches V&Q

• TECHNIQUE:• Segment that needs to be drained is placed in the non

dependent position (superior to carina)• Position changed

– Awake patient: 3-15 min– Intubated and hemodynamically unstable pts: 2 hrly

• Alone or with other techniques

Paterson’s Postural drainage

Patient positioning for postural drainage

• SIDE EFFECTS AND CONTRAINDICATIONS:– Hypoxemia– Acute hypotension – Dysrhythmias– Bronchospasm– Vomiting & aspiration– Undrained lung abscess

MUCOLYTICS

• Bromhexine• Acetylcysteine• Carbocysteine

BROMHEXINE ACETYLCYSTEINE CARBOCYSTEINE

MOA Depolymerises mucopolysaccharides – network of fibres broken

Opens disulfide bonds in mucoproteins present in sputum

Similar to acetylcysteine

SIDE EFFECTS GI irritation, lacrymation, rhinnorhea

GI irritation GI irritationRashes

ROUTE Oral Aerosol Tracheal instillation

Oral

DOSE 4mg/5 mL 2 tsf TDS (adults)4 mg BD (1-4 yrs)4 mg TDS (5-10 yrs)

1,2,5 mL ampoules(200 mg/mL)

250 – 750 mg TDS

COMPONENTS OF BRONCHIAL HYGIENE

BREAK DOWN SIZE

•Mucolytics

•humidification

DISLODGE them

•Chest physiotherapy

MOBILIZE TO

CENTRAL AIRWAYS

•Postural drainage

•Chest physiotherapy

REMOVE FROM LUNGS

•Directed cough

•ET suctioning

RE EXPAND

THE LUNGS

•Incentive spirometry

•Bronchodilation (aerosols)

•IPPB, PEP, CPAP

DIRECTED COUGH

• Deliberate manouvre to simulate spontaneous cough.

• Technique:• pt taught to assume a position that facilitates

easy thoracic compressionInspiration done slowly and deeply through the noseFollowed by chest percussion and vibration to loosen secretions Stimulates cough.

Indications:COPD, lobar pneumonia

FORCED EXPIRATORY TECHNIQUE

• Alternative to directed cough• “Huff cough”• Principle: 1 -2 forced expirations of middle to

low lung volume without closure of the glottis, followed by a period of diaphragmatic breathing and relaxation.

• Indicated: COPD, lobar pneumonia

COUGH ASSIST EXSUFFLATOR

PAP

• Used to mobilize secretions and prevent atelectasis

• TECHNIQUES:– CPAP– Expiratory PEP– PEP

PEP

• PRINCIPLE:• Helps move secretions to larger airways by• 1. filling underaerated or nonaerated segments via collateral

ventilation• 2. preventing airway collapse during expiration

• TECHNIQUE:• Active expiration against variable flow resistance• A subsequent huff or FET manouvre allows the patient to

generate airway pressures needed to expel the secretions.

• Combined with other strategies for bronchial hygiene, it is a very effective manouvre

PAP ADJUNCTS

COMPONENTS OF BRONCHIAL HYGIENE

BREAK DOWN SIZE

•Mucolytics

•humidification

DISLODGE them

•Chest physiotherapy

MOBILIZE TO

CENTRAL AIRWAYS

•Postural drainage

•Chest physiotherapy

REMOVE FROM LUNGS

•Directed cough

•ET suctioning

RE EXPAND

THE LUNGS

•Incentive spirometry

•Bronchodilation (aerosols)

•IPPB, PEP, CPAP

ENDOTRACHEAL AND TRACHEOSTOMY TUBE SUCTIONING

• Principle:• Negative pressure applied to airway

• Technique: • Sterile precautions

• Closed vs. open devices• Catheter diameter = < ½ OD of the endotracheal tube

used.• Suction pressure = 100 mmHg ( ADULTS)• 60 -80 mmHg (PEDIATRIC)

Bibliography

1. Egan’s Respiratory care – 9th edition2. The ICU Book- Paul L.Marino- 3rd edition3. Miller’s Anesthesia – 6 th edition4. AARC guidelines for bronchial hygiene

therapy – 20085. Textbook of Mechanical Ventilation – Chang

3rd edition