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CHHS18/069

Canberra Hospital and Health ServicesClinical Guideline Physiotherapy – Respiratory ManagementContents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – Cough assist to enhance pulmonary secretion clearance.......................................3

Background........................................................................................................................... 3

Indications, Precautions and Contraindications....................................................................4

Equipment and Assembly......................................................................................................5

Procedure..............................................................................................................................5

Cleaning and Maintenance 7.................................................................................................7

Section 2 – Inspiratory Muscle Training....................................................................................8

Background........................................................................................................................... 8

Acute IMT Program:..............................................................................................................9

Equipment.............................................................................................................................9

Procedure............................................................................................................................10

Guidelines for Concern........................................................................................................11

Outcome/Progression Measures........................................................................................11

Patient Education................................................................................................................11

Documentation...................................................................................................................11

Cleaning Of Equipment.......................................................................................................11

Threshold IMT Device......................................................................................................... 12

Indications...........................................................................................................................12

Equipment...........................................................................................................................12

Procedure............................................................................................................................12

Guidelines for Concern........................................................................................................13

Outcome/Progression Measures........................................................................................13

Cleaning Of Equipment.......................................................................................................13

Section 3 – Hyperinflation.......................................................................................................13

Background......................................................................................................................... 13

Doc Number Version Issued Review Date Area Responsible PageCHHS18/069 1 26/02/2018 01/02/2022 Medicine – Acute

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/069

Indications for Hyperinflation36...........................................................................................14

Outcome Measures.............................................................................................................14

Precautions for Hyperinflation37..........................................................................................15

Contraindications for Hyperinflation...................................................................................15

Performing MHI.................................................................................................................. 15

Performing VHI....................................................................................................................17

Section 4 – Induced Sputum Collection...................................................................................18

Referrals - general...............................................................................................................19

Weekends/out of business hours........................................................................................19

Safety.................................................................................................................................. 20

Preparation......................................................................................................................... 20

Equipment...........................................................................................................................21

Procedure............................................................................................................................21

Cleaning.............................................................................................................................. 22

Implementation...................................................................................................................... 22

Related Policies, Procedures, Guidelines and Legislation.......................................................22

References.............................................................................................................................. 23

Definition of Terms................................................................................................................. 26

Search Terms.......................................................................................................................... 26

Attachments............................................................................................................................26

Attachment 1 – Assessing Peak cough flow........................................................................28

Attachment 2 – Assembly of Cough Assist Machine...........................................................29

Attachment 3 –Modifying Cough Assist Machine settings..................................................30

Attachment 4 – Cough Assist Machine Competency Assessment for Physiotherapists......32

Attachment 5 – Physiotherapy Competency Assessment Inspiratory Muscle Training......34

Attachment 6 –Hyperinflation Competency Assessment....................................................36

Attachment 7 – Ventilator Assessment Tool for Physiotherapists......................................39

Attachment 9 – List of negative pressure rooms in CHHS...................................................46

Attachment 10 – Induced Sputum mouthpiece components and assembly.......................47

Attachment 11 – Flowchart for requests for Induced Sputum collection...........................48


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Guideline Statement

This guideline outlines respiratory interventions performed by physiotherapists at Canberra Hospital and Health Services (CHHS).

BackgroundThis document has been developed to guide physiotherapists working in acute care who utilise Cough Assist, inspiratory muscle training, manual and ventilator hyperinflation and who perform induced sputum procedures.

Key ObjectiveTo ensure the delivery of safe, evidence based, best practice respiratory management in adult and paediatric patients by acute care physiotherapists.

Back to Table of Contents

Scope

This document applies to the following staff working within their scope of practice: Physiotherapists Nursing staff Physiotherapy students under direct supervision Carers trained or under instruction/prescription by physiotherapists.


Section 1 – Cough assist to enhance pulmonary secretion clearance

This section pertains to usage of the Emerson CA-3200 cough assist machine and the Phillips Respironics Cough Assist E70, in suitable adult and paediatric patients at the CHHS, who have the problem of retained secretions and an ineffective cough. The cough assist machine (CAM) is an optional adjunct to standard physiotherapy treatment.

Background Coughing is an essential reflex which clears excess secretions and foreign matter from the airway. The essential components include deep inspiration, closure of the glottis and forceful expiration. In order for a cough to be effective, an adequate expiratory flow must be generated. A normal peak expiratory flow is in the range of 6-12L/sec1 with peak cough flows reaching up to 20L/sec. Cough strength can be reduced in patients with inspiratory and expiratory muscle weakness, leading to low lung volumes and difficulty clearing secretions2. Mechanical insufflation-exsufflation (in-exsufflation) via a CAM can assist in the removal of pulmonary secretions without the need for more invasive techniques such as open (guedel or nasopharyngeal) airway suctioning.


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Mechanical in-exsufflation consists of insufflating the lungs with positive pressure, followed by a quick change to negative pressure exsufflation. This creates a peak and sustained flow high enough to mimic a cough and thereby to loosen and move secretions toward the oropharynx for suctioning or expectoration2. Published pressures which were reported to be clinically effective include ranges of +15 to +40cmH2O for insufflation and -20 to -45cmH2O for exsufflation3 4,5. This range of pressures has also been reported to be safe and comfortable in children6.

Indications, Precautions and ContraindicationsIndications3,4,7 : Any patient who is at risk or has evidence of retained secretions with a weak cough or

low lung volumes due to:o Neuromuscular deficits (i.e. muscular dystrophy, myasthenia gravis, poliomyelitis,

motor neurone disease, spinal cord injury, aspiration following cerebrovascular accident etc.).

o Intrinsic lung disease such as COPD, cystic fibrosis or bronchiectasis.

Note: CAM treatment is usually not appropriate for an acutely unwell/deteriorating patient with a high respiratory rate, where intubation is likely required for sputum clearance. Outcome measures Peak cough flow (refer to Attachment 1) Vital capacity via spirometry Oxygen saturations Chest radiograph (CXR) Auscultation Palpation Cough quality Volume/ consistency of sputum

Contraindications4,7

Undrained pneumothorax or the presence of an intercostal catheter (ICC) with continuous leak

Unstable cardiovascular system such as unstable arrhythmias, mean arterial pressure (MAP) <65, the presence of an Intra Aortic Balloon Pump (IABP); increasing inotropic or vasopressor support (as high intra-thoracic pressures may compromise venous return)

Large lung abscess or bullae Recent barotraumas Patients ventilated on lung protective strategy for Acute Respiratory Distress Syndrome

(ARDS), severe pneumonia, pulmonary contusions Acute bronchospasm

Precautions4


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Ribs fractures excluding pneumothorax. This includes multiple rib fractures and flail segments

Patients with cardiac compromise as increased thoracic pressures in the insufflation phase can reduce cardiac output

Facial fractures, facial trauma, sinus surgery. In this case a mouthpiece may be used as opposed to the facemask in consultation with senior physiotherapist/ medical staff.

Equipment and AssemblyEquipment Emerson CA-3200 Cough Assist machine or Phillips Respironics Cough Assist E70 Patient circuit

o Bacterial/viral filtero Breathing hoseo Connector o Patient interface (face mask, mouthpiece, or tracheostomy adapter)

Pulse oximeter Tissues or wall suction for sputum clearance Mask/eye protection for staff member if indicated (infection or multi-resistant

organism) Assembly1. Connect the machine to power and position it within easy reach.2. Connect the patient circuit to the machine (see Attachment 2).

Procedure1. Physiotherapists may only utilise CAM as part of physiotherapy treatment once they

have completed the CAM competency package with the appropriate HP3 Physiotherapist (Attachment 3).

2. Identify indications for use of CAM and any precautions or contradictions and select the appropriate interface. If precautions exist, discuss with senior physiotherapist and medical staff prior to initiating cough assist.

3. If the CAM is being used with a spinal cord patient, refer to the Physiotherapy - Adult Patient with a Spinal Cord Injury Guideline.

4. Perform hand hygiene, apply personal protective equipment (PPE) and observe any other precautions.

5. Explain the treatment and gain informed consent from the patient/carer. 6. Assess appropriate outcome measures

o If assessing peak cough flow as indicated. Refer to Attachment 1 or Clinical Guideline: Physiotherapy- Adult Patient with a spinal cord injury, found on the policy register, on how to assess peak cough flow, Attachment 3.

7. Appropriately position the patient to maximise ventilation.


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Alert: The Emerson CA-3200 does not support oxygen to be entrained into the circuit as it is an electrical hazard. If you need to entrain oxygen use the Phillips Respironics Cough Assist E70

8. Select either automatic or manual mode. This depends on patient presentation but generally: a. Manual mode will be used for acutely unwell patients where the cough assist is used

as a new treatment modality. b. Automatic mode is used in long term use of cough assist and for those patients with

cough assist previously set up for the treatment of a chronic condition. 9. Manual or automatic mode can be used in patients presenting to hospital with acute

issues that use the cough assist as a long term treatment at home. This depends on patient presentation at the time of treatment.

10. Titrate pressures delivered to the maximal expiratory and inspiratory pressures as tolerated by the patient by adjusting the machine parameters as per Attachment 4. This needs to be individualised depending on patient presentation.

Alert: Tracheostomy/Endotracheal tube (ETT)If using a tracheostomy interface either: inflate cuff and perform treatment place speaking valve/cap over tracheostomy and perform therapy through mouth.

Ensure cuff is completed deflated prior to placing speaking valve.

Be sure to disconnect the patient from the CAM immediately after the cough cycle and allow adequate rest.

Patients with an artificial airway may require higher pressures to achieve therapeutic levels due to the resistance to air flow created by the tube8.

7. Determine the dosage: treatment can involve any combination of deep breaths (insufflations only) and cough/s (insufflations followed immediately by exsufflations) and should be individualised depending on patient presentation and tolerance.

8. In patients with neuromuscular weakness, an attempt to cough should also be encouraged, whereas patients with emphysema should be encouraged to allow passive exsufflation as glottis closure and high intrathoracic pressures are thought to encourage distal collapse and ineffective cough4.

9. If in automatic mode, therapy will commence as per the set parameters once the machine is in therapy mode.

10. If in manual mode, deliver the set dosage of insufflations and exsufflations through the interface using the manual lever or foot pedal on the Philips Respironics Cough Assist E70. Insufflations should be delivered for 3 seconds. Incorporate adjunct techniques such as manual techniques, active cycle of breathing technique, saline nebuliser4 and manual assisted cough3,8 as required (see Clinical Guideline: Physiotherapy – Adult patient with a


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spinal cord injury, on the policy register, attachment 5 for details on how to perform Manual Assisted Cough).

Alert: If the foot pedal on the Philips Respironics machine is plugged into the machine the manual lever will be disabled.

11. After a treatment cycle, disconnect the patient from the device (return the patient back to the ventilator, if applicable). Allow time for a normal breathing pattern to return (20 to 30 seconds) to prevent hyperventilation.

Alert: The unit Emerson CA-3200 cough assist is designed for Intermittent Operation Only and not for continuous use i.e. not cycled continuously for more than 5 minutes.

12. Clear secretions that may have become visible in the mouth, throat or tracheostomy tube using tissues or suction (e.g. Yankauer, Y- catheter or closed suction system).

13. For sputum clearance, continue sets until outcome measures indicate that sputum has been cleared. If you believe that the treatment is not adequate discuss immediately with the treating team.

14. Perform hand hygiene. 15. Document patient position, mode of delivery, pressure, dosage, outcome measures and

ongoing management plan.

Alert: Patients who are receiving this treatment may strain a muscle and can complain of soreness or discomfort post therapy. If this is the case, refer to the medical team for review. Treatment may need to be ceased it the pain is too severe.

Cleaning and Maintenance 7

The mask and tubing require cleaning. The bacterial filter can be left in place as long as it is not blocked by sputum or trapped moisture. If it is soiled it will need to be replaced. Replace the mask, tubing and filter when there are obvious signs of wear and tear. The mask can also be replaced when it is no longer possible to get a good seal.

Daily Cleaning: Wipe down the interface with a clean detergent wipe. If the circuit is visibly soiled (for

example, with sputum), wash the tubing as per the instructions below.

Weekly Cleaning: Wash the tubing and mask in warm soapy water and allow to air dry. The mask can be

left to dry in the patient’s room on a clean towel. The tubing should be left to dry in a hanging position and must be completely dry before re-use.


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After final use by the patient, the circuit consisting of tubing, patient interface, adapters and bacterial/viral filter is disposed of. The patient circuit cannot be sterilised for reuse.

If the device is to be used by more than one patient concurrently, the circuit including the tubing, patient interface, adapters and bacterial/viral filter must be replaced between patients to prevent cross contamination.

The exterior of the machine is to be wiped down with a mild detergent and water, detergent wipes or with a bactericidal cleaning solution such as 70% isopropyl alcohol.


Section 2 – Inspiratory Muscle Training

Inspiratory muscle training (IMT) increases the strength and endurance of the inspiratory muscles (diaphragm and accessory muscles). This treatment is relevant to 3 main groups of patients at CHHS:a) Chronic Obstructive Pulmonary Disease (COPD)b) Chronic Heart Failure (CHF)c) Intensive Care patients who have been mechanically ventilated for > 7 days.

This section provides guidelines for IMT to assist patients to: Increase inspiratory muscle strength and endurance Facilitate weaning from mechanical ventilation (Intensive Care Unit (ICU) patients) Improve patient quality of life Reduce dyspnoea Improve exercise tolerance.

BackgroundIMT has been shown to improve respiratory muscle strength, endurance, exercise performance and quality of life, and reduce dyspnoea, in individuals with inspiratory muscle weakness and poor exercise tolerance (e.g. COPD9, CHF10). IMT has also been shown to reduce length of weaning and increase muscle strength in ventilated patients11, and improve quality of life in patients recently weaned from prolonged mechanical ventilation12. IMT is safe to perform in selected ventilated patients13. High intensity, interval IMT programs are ideal for improving inspiratory muscle strength within just a few weeks14, with significant changes detectable as early as 2 weeks of training15,16. The ‘acute’ IMT protocol described in this guideline is based on a high-intensity, interval-based approach as described in several case series17-19 and a good quality randomised trial12, and is relevant to both ICU patients (both ventilator-dependent and recently weaned) and patients with acute exacerbation of COPD towards the end of their inpatient stay. The ‘chronic’ IMT protocol is based on evidence in stable community-dwelling patients with chronic COPD and is more suitable in a pulmonary rehabilitation context. The chronic approach can also be applied to patients with stable congestive heart failure.


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Acute IMT Program:Indicationsa. Ventilated ICU patients (> 7 days) that are alert and are able to actively participate with

training but have failed to wean from mechanical ventilation by usual strategies (e.g. decreasing pressure support or t-piece trials)

b. ICU patients recently weaned from mechanical ventilation > 7 days who are breathing spontaneously

c. Patients admitted to the respiratory ward with an acute exacerbation of COPD, where a goal is long-term management of dyspnoea.

Note: Patients are only suitable when the acute exacerbation is resolving and they are no longer distressed at rest. Ideally, prescription of IMT should occur in the 1-3 days prior to discharge, with the patient to continue independently following discharge.

Patients are not suitable for IMT if the patient: cannot actively participate or communicate (gestures, pointing or mouthing words) is younger than 16 years of age is pregnant unstable in any way (e.g. cardiovascular, neurological) requires excessive ventilatory support (e.g. positive end expiratory pressure (PEEP) > 10

cm H20 or fraction of inspired oxygen (FiO2) > 0.6 or are critically PEEP-dependent has severe dyspnoea at rest or the medical or physiotherapy staff deem the risks of brief disconnection from ventilation

to be unacceptable for any reason.

Equipment Alcohol based hand rub Threshold Inspiratory Muscle Trainer device (Phillips Respironics): allows incrementally

adjusted training pressures from 9cmH2O up to 41cmH2O pressure (refer to Figure 1)

Figure 1. Threshold IMT device

Flexible connector (ICU equipment store) for ICU patients with an ETT or tracheostomy.


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Procedure1. IMT is only performed by physiotherapists who have completed the IMT Competency

Package (see Attachment 5). IMT is initiated by the Health Professional (HP) level 3 Physiotherapist and may be performed by HP level 1-2 physiotherapists and physiotherapy students under supervision.

2. Perform hand hygeine.3. Training should be conducted with the patient in high sitting position, preferably in a

chair (Figure 3).4. For a spontaneously breathing patient, attach the mouth piece to the IMT device and

apply the nose peg if the patient tends to breathe through their nose (optional). For a ventilator-dependent patient, attach the flexible tubing to the Threshold IMT. This will allow the Threshold IMT to attach directly to the tracheostomy/ETT (no mouthpiece required) (Figure 2).

Figure 2: Attaching IMT device to ETT

5. Adjusting intensity: If Negative Inspiratory Force (NIF) or Maximum Inspiratory Pressure (MIP) testing is available, intensity should be set at 50% of maximum effort to begin with. To adjust the pressure indicator to the setting prescribed, align the red edge of the pressure indicator by turning the control knob at the bottom of the Threshold IMT. The higher the number, the greater the resistance and effort required. If no NIF/MIP testing is available, the physiotherapist should aim for the highest tolerable intensity for a 6 breath sequence (achieved through trial and error).The intensity of resistance is adjusted incrementally between sets by the physiotherapist to ensure patient can just complete the 6th breath in each set.

6. The patient inhales through the device to generate an inspiratory pressure greater than the indicated threshold pressure setting to compress the spring and open the poppet valve.

7. The inspiratory pressure should be maintained for at least 1 second, with respiratory rate < 30 bpm. Audible air flow indicates a successful breath.

8. The patient exhales through the training device via a low resistance one-way valve.9. Training sessions consist of 5 sets of 6 training breaths for a total of 30 training breaths

per day. IMT should be conducted once per day, ideally in the morning, 5 days per week. Including rests between sets, this should take less than 10 minutes per day.


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10. If ventilator-dependent, patients are returned to mechanical ventilation for rest between training as needed. If spontaneously breathing, allow rests between sets as required (typically < 1 minute)

11. The patient’s clinical parameters and response during training should be monitored if ventilator-dependent (i.e. Blood Pressure (BP), Heart Rate (HR), Respiratory Rate (RR), and SpO2 (peripheral capillary oxygen saturation)). Otherwise, monitor SpO2 and RR if oxygen-dependent (noting that supplemental oxygen is not required during IMT breaths)20

Guidelines for Concern Pulse Oximetry Saturation decreases >5% from baseline Subjective signs of distress or severe sharp pain on inspiration Cardiac arrhythmias Signs and symptoms of secretion retention in ventilated patients – provide suction if

indicated.

Outcome/Progression Measures Continue training with the acute plan until patients have reached goal inspiratory

muscle strength (eg MIP of 80 – 100 in previously well patient). This may include independent IMT at home following discharge from hospital.

In patients with COPD, consider switching to chronic IMT approach after 6-8 weeks for maintenance.

Patient EducationPatients/family/nursing staff should be carefully instructed on rationale for IMT, precautions and guidelines for treatment.

DocumentationAll documentation should follow the Clinical Record Documentation Procedure. However with respect to IMT, the following should be specifically mentioned: Informed consent, see Consent and Treatment Policy on the policy register. Training Parameters used (resistance, sets, breaths) Response to treatment (any adverse outcomes).

Cleaning Of EquipmentEquipment used for inspiratory muscle training is single-patient use only and disposable, therefore no cleaning or sterilising is required.

Threshold IMT DeviceThe Threshold IMT device is for single patient use only. It should be stored in the patient’s bedside trolley with the patient’s sticker on it and can be used following discharge should the patient wish to.

Chronic IMT Program21:


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Indicationsa) Patients with stable COPD who have inspiratory muscle weakness

i. particularly those unable to participate in a weight-bearing exercise program like Pulmonary Rehabilitation

ii. particularly those who have made minimal improvements following completion of a Pulmonary Rehabilitation program

b) Patients with stable CHF.

Patients are not suitable for IMT if: They have an undrained pneumothorax or are at risk of spontaneous pneumothorax

(e.g. history of same) They are at risk of rib fractures (e.g. history of same) They have large bullae on chest x-ray They have had lung surgery within the last 12 months.

Equipment Threshold IMT device (Phillips Respironics): allows incrementally adjusted training

pressures from 9cmH2O up to 41cmH2O pressure.

Procedure1. Training should be conducted with the patient in high sitting position, preferably in a

chair with upper limbs supported (Figure 3).

Figure 3. Position for IMT2. Adjusting intensity: intensity (target load) should be titrated to 30% of MIP to begin

with. To adjust the pressure indicator to the setting prescribed, align the red edge of the pressure indicator by turning the control knob at the bottom of the Threshold IMT.

3. Attach the mouth piece to the IMT device and apply the nose peg. 4. The patient inhales through the device to generate an inspiratory pressure greater than

the indicated threshold pressure setting to compress the spring and open the poppet valve. Audible air flow indicates a successful breath.


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5. Training should follow the pattern of 7 lots of 2 minute cycles, where target training equals 30% of MIP, and the warm-up load is 15% of MIP. Intensity should be increased as tolerated to maintain an RPE of 13-14 / 20 (or 4/10).

6. IMT should be performed 3 days a week for a minimum of 8 weeks, and then continued indefinitely at 2 days a week for maintenance.

Guidelines for Concern Patient reports in sudden sharp pain on inspiration (refer for medical review, due to risk

of pneumothorax)

Outcome/Progression Measures Recommend monitoring SpO2 and RR during initial training session Review progress with MIP after 8 weeks of training – if no changes, cease IMT. If patient

has improved, continue with maintenance program for life (2 sessions/week).

Cleaning Of EquipmentEquipment used for IMT is single-patient use only and disposable, therefore no cleaning or sterilising is required.


Section 3 – Hyperinflation

BackgroundHyperinflation is the delivery of a slow, deep inspiration greater than baseline tidal volume up to a peak inspiratory pressure (PIP) of 40cm H2O, followed by an inspiratory hold of up to three seconds, and a quick, unobstructed expiration to patients with an artificial airway22. The slow deep inspiration to 35-40cm H20 re-expands areas of atelectasis23, the inspiratory hold recruits lung segments via collateral channels, allows for gas exchange and mobilises secretions, while the quick release increases expiratory flow rates, allows for annular two phase gas liquid flow, and mimics a huff and/or cough, mobilising pulmonary secretions from distal to proximal lung segments24. Hyperinflation has been shown to be an effective technique for mobilising sputum25-27 reversing atelectasis28, 29 improving oxygenation and pulmonary compliance25,30.

Traditionally, hyperinflation has been delivered to mechanically ventilated patients by disconnecting them from the ventilator and connecting them to a manual resuscitation circuit and is known as manual hyperinflation (MHI). At CHHS, the technique is delivered via the Laerdal Silicone Resuscitator bag (Figure 4). Disadvantages of this technique include loss of PEEP, de-recruitment of lung segments, and poor tolerance or dyssynchrony with the technique by agitated patients. When completed manually, substantial clinical experience is required to deliver the technique consistently and to prevent barotrauma or volutrauma31.

Ventilator Hyperinflation (VHI) is the delivery of hyperinflation breaths via adjustments of ventilator settings and when compared to MHI, VHI has been shown to be as effective in


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mobilising secretions, improving lung compliance, oxygenation and restoring lung volumes32-

35. It requires no disconnection from mechanical ventilation, so there is no loss of PEEP and it is synchronous with patient breaths. Volumes are delivered consistently and PIP and volume are controlled by the ventilator, thus reducing the risk of barotrauma or volutrauma in appropriately selected patients.

In clinical practice, VHI is utilised in patients currently undergoing mechanical ventilation while MHI is mainly utilised in patients no longer requiring mechanical ventilation.

Figure 4. Laerdal Silicone Resuscitator bag

Indications for Hyperinflation36

Evidence of retained secretions Evidence of collapse or loss of volume Poor lung compliance Decreased oxygenation caused by one of the above.

Outcome Measures Arterial blood gases Oxygen saturations Chest Radiograph (CXR) Volume/consistency of sputum suctioned Tidal Volumes (Vt) Vital Capacity Peak Inspiratory Pressure (PIP) Ventilator Wave Forms Static Compliance (Cstat=VT/Pplat-PEEP) Auscultation Palpation (chest wall movement/fremitus).

Alert:


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1. In the presence of precautions to hyperinflation, treatment should proceed with caution after direct consultation with a senior physiotherapist, senior registrar or consultant.

2. All paediatric cases where hyperinflation is indicated it must be discussed with a senior physiotherapist and the treating consultant. Consideration for seeking advice from paediatric specialty centres in the clinical reasoning process for complex cases is recommended.

Precautions for Hyperinflation37

Unstable cardiovascular system such as unstable arrhythmias, mean arterial pressure (MAP) <65 mmHg, the presence of an IABP; increasing inotropic or vasopressor support (as high intra-thoracic pressures may compromise venous return).

Partial pressure of oxygen (PaO2)/FiO2 Ratio <200 PIP >35 cmH20 Airway Pressure Release Ventilation (APRV) Intra Cranial Pressure (ICP)>15 mmHg Florid Acute Pulmonary Oedema (APO) Restrictive or obstructive lung disease Significant pulmonary hypertension or evidence of right ventricular dysfunction

Contraindications for Hyperinflation37 Undrained pneumothorax or the presence of an ICC with continuous leak Broncho-pulmonary Fistula Thoracic surgery with lung resection Patients ventilated on lung protective strategy for ARDS, severe pneumonia, pulmonary

contusions Acute bronchospasm Patients ventilated for an exacerbation of COPD with elevated intrinsic PEEP or other

conditions where hyperinflation would be detrimental

Performing MHIEquipment Appropriate size Laerdel Silicone Resuscitator Bag (adult/paediatric) Heat Moist Exchange (HME) Filter

In addition, ventilated patients require: PEEP Valve Test lung

Procedure for MHI1. Physiotherapists may only perform MHI once they have completed the Hyperinflation

Competency package with the appropriate HP level 3 or above (Attachment 6).2. Identify indications for MHI and any precautions or contraindications. If precautions

exist, discuss with appropriate senior physiotherapy staff and treating Consultant/Senior Registrar prior to initiating MHI.


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3. Ensure appropriate number of staff are available to carry out the treatment. Physiotherapists with less clinical experience or who have not performed the technique recently should consider a second staff member (nurse or physiotherapist) to be available to suction and place the ventilator on standby in the more unstable patient. For patients on vasoactive infusions or who have ICP monitoring, MHI should be carried out with the bedside nurse present as titration of infusions may be required during treatment. A second physiotherapist is required if manual techniques are indicated as an adjunct to MHI.

4. Explain the treatment to the patient. 5. Appropriately position the patient to maximise ventilation and perfusion (V/Q) matching

and to drain secretions.6. To set up the MHI circuit (Figure 5), attach a HME filter to the Laerdel bag. For ventilated

patients, ensure a PEEP valve set at the patient’s baseline PEEP setting is incorporated into the circuit.

Figure 5. Circuit set up for the ventilated patient

7. Attach the oxygen tubing to the oxygen outlet and turn the oxygen flow to 15 litres/minute. Ensure the reservoir bag is not split and is filling with gas. A manometer is not required to be used as the Laerdel circuit has a safety valve that prevents PIP from exceeding 35 cm H2O26.

8. For the ventilated patient, silence the ventilator, disconnect the ventilator from junction of the Bennet’s connector and connect the patient to the Laerdel circuit. For the self-ventilating tracheostomised patient, disconnect oxygen and attach the Laerdel circuit to the tracheostomy via the flexible connector only (Figure 6).


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Figure 6. Circuit connection for the ventilated patient

9. Commence hand ventilating the patient at the same rate and volume as baseline. Once satisfied that the patient is ventilating, place the ventilator in standby mode as per Physiotherapy Ventilator Assessment Tool (Attachment 7) and attach the ventilator to the test lung.

10. Commence MHI with a two handed technique, delivering a larger than baseline tidal volume, an inspiratory hold and a quick release44. The literature recommends six sets of six MHI breaths to treat atelectasis and compliance32,39. For sputum clearance, continue MHI if patient is stable until outcome measures indicate that sputum has been cleared.

11. For all patients, monitor HR and SPO2 throughout. If available, monitor MAP, electrocardiogram (ECG), ICP and Cerebral Perfusion Pressure (CPP). ICP should remain below target, and CPP should remain >60 mmHg (CPP=MAP-ICP). Modify or cease treatment as appropriate.

12. Suction the patient as indicated.13. Once treatment is complete, for ventilated patients restart the ventilator before

reconnecting the patient and ensure the patient is ventilating at baseline or appropriate respiratory rate and with adequate tidal volumes and End Tidal Carbon Dioxide (ETCO2) prior to putting the Laerdal bag away. For ward patients, return patient to previous oxygen circuit e.g. humidified or Swedish nose.

14. Reassess outcome measures and reposition patient appropriately.15. Document patient position, level of PEEP (if applicable), duration of MHI, appropriate

outcome measures and any adverse events

Performing VHI 1. Physiotherapists may only perform VHI once they have completed the Hyperinflation

Competency package and ventilator training package with the appropriate HP Level 3 or above Physiotherapist (Attachments 6 and 7). The bedside nurse must be present during VHI.

2. Identify indications for VHI, most appropriate mode of ventilation to deliver. hyperinflation for the specific patient, and any precautions or contraindications. If precautions exist, discuss with appropriate senior physiotherapy staff and treating Consultant/Senior Registrar prior to initiating VHI.


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Alert: VHI can only be performed in SIMV-Volume Control on the GE Carescape Ventilator.

3. Explain the treatment and gain consent from the patient/carer and inform the bed side nurse.

4. Appropriately position the patient to maximise ventilation and perfusion (V/Q) matching and to drain secretions.

5. Adjust ventilator alarm limits (refer to Attachment 8).6. Adjust ventilator settings to achieve hyperinflation breaths (refer to Attachment 8). 7. Titrate settings during treatment as required to maintain PIP at 35-40 cm of H20.8. Once target PIP is reached, manual techniques (i.e. percussion or vibration) may be

incorporated if indicated.9. Monitor HR, MAP, ECG and ETCO2 throughout. If measured, ICP should remain below

target, and cerebral perfusion pressure should remain >60 mmHg (CPP=MAP-ICP). Modify or cease treatment as appropriate.

10. For patients who may require breaks during treatment due to intolerance of the technique or to prevent haemodynamic instability, return them to their baseline settings in that mode of ventilation. When resuming hyperinflation breaths, the determined values required to reach PIP of 40cmH2O can be resumed without the gradual increase in settings.

11. Suction the patient as required.12. Dosage - The literature recommends six sets of six VHI breaths to treat atelectasis and

improve compliance32,33,38. For sputum clearance, continue VHI if patient is stable until outcome measures indicate that sputum has been cleared.

13. Once treatment is completed, return ventilator settings to baseline return patient to previous mode of ventilation and return alarm settings to previous limits. Inform the bedside nurse that alarm limits and ventilator settings are at baseline. Ensure patient is ventilating at adequate rate, Vt and ETCO2 prior to reassessing outcome measures and repositioning the patient as required.

14. Document the patient position, mode of ventilation, RR, PIP reached, Vt reached, duration of treatment and any adverse events.


Section 4 – Induced Sputum Collection

This section outlines the processes for receipt and management of referral and safe collection of an induced sputum sample through inhalation of hypertonic saline.

BackgroundThe inhalation of hypertonic saline solutions via an ultrasonic nebuliser has been shown to induce production of small amounts of secretions from the airways in patients who are not able to expectorate sputum. The mechanism of this process is not fully understood though


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hypothesised that increased osmolarity of bronchial lining fluid increase vascular permeability in the bronchial mucosa and production of mucus by submucosal glands. Induced sputum is used in the diagnosis of pulmonary Tuberculosis (TB) and Pneumocystis Jirovecii Pneumonia (PJP), formally known as Pneumocystis Carinii Pneumonia (PCP) 39.

Current guidelines suggest that for PJP a single sample needs to be induced for testing. For TB, three samples on consecutive days are required to increase sensitivity of the test40, 41.

These can be either spontaneous sputum samples or induced samples. There is evidence to suggest that airway clearance techniques such as percussion and vibrations have no benefit in inducing sputum42.

Precautions/Contraindications43 Inadequate respiratory reserve or acute respiratory distress Inability to follow instructions FiO2 >50% Haemoptysis of unknown origin Unstable cardiovascular status Thoracic, abdominal or cerebral aneurysms FEV1 <1.0 Litres Pneumothorax Pulmonary emboli.

Referrals - general Referral for induced sputum collection will be accepted from a Medical Specialist/VMO

from Intensive Care, Respiratory, Oncology, Haematology or Infectious Diseases only. For inpatients, referral must be documented in the patient’s clinical file, including the

purpose for collection. The medical team is to contact the ward physiotherapist via pager to alert them to the referral as soon as possible.

Requests are accepted during standard business hours (excluding special circumstances). Refer to “Weekends/out of business hours” for details.

For outpatients, a written referral (including patient contact details) will be sent to: Physiotherapy Department Building 15, Canberra Hospital, Yamba Drive Garran 2605, or faxed on 62443692, with a pathology form attached.

Alert: If induced sputum is requested for conditions other than TB and PCP, this must be discussed by the treating consultant with a senior physiotherapist.

Weekends/out of business hours Microbiology is unable to routinely process an induced sputum sample on weekends or

public holidays. If the testing is urgent then the requesting medical team will contact the Microbiologist on-call to ensure availability of laboratory staff prior to referral to the physiotherapist for collection.

PCP collection requests made over a weekend/Public Holiday will be collected as soon as possible and sent to Microbiology, even if they are unable to be processed over the weekend, to allow for higher diagnostic yield.


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Requests made for collection after 3.30pm will be delayed until the following business day due to the time taken to collect and process.

The physiotherapy evening service (5pm-9pm) will not routinely perform induced sputum collection.

SafetyTo minimise the risk of transmission of airborne disease: All induced sputum collections are to be completed in a single room with adequate

room ventilation. Refer to attachment 9 for list of appropriate rooms. PPE is compulsory during collection including gown, gloves, goggles and fine particulate

respiratory mask. All staff performing a TB collection are required to have a baseline Mantoux test or

Tuberculin Skin Test (TST) with CHHS Department of Respiratory and Sleep Medicine (DRSM), which requires 12 monthly updates/reviews.

The physiotherapist conducting the procedure will remain with the patient. Should the patient be required to leave the ward for collection then a nurse escort may

be required at the discretion of the Clinical Nurse Consultant (CNC) (depending on the patient’s acuity).

Alert: It is recommended that bronchodilators and anti-emetics are charted prior to commencing sputum induction due to risk of bronchospasm and nausea. It is recommended that known asthmatic patients have a bronchodilator prior to collection to minimise the risk of bronchospasm and airway compromise44.

PreparationOn referral for an induced sputum, the following preparation is required:Referring medical team: inform ward CNC and patient flow unit of the need for the patient to be in a negative

pressure room contact microbiology if outside normal business hours to ensure sample able to be

processed Chart 6% Hypertonic saline Chart bronchodilators and anti-emetics if required.

The ward CNC/Team Leader: Ensure that a negative pressure room is available on the treating ward If a negative pressure room cannot be organised on the treating ward, liaise with Patient

Flow Unit to source a negative pressure room on another ward. Refer to attachment 9 for a list of appropriate rooms.

Physiotherapist: Arrange a room for outpatient collections. Ensure all equipment required is available.


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Equipment Suchatzki Ultrasonic nebuliser and one-way mouthpiece, including disposable items:

1. bacterial filter2. medicine cup3. dust filter

6% Hypertonic saline solution (in premix 10ml sachet)44,45,46 PPE including gown, gloves, goggles and high particulate respiratory mask Sputum specimen jar Tissues Sterile water Pulse oximeter

Procedure1. Gain informed consent from the patient, as per Consent and Treatment Policy on the

policy register.2. Access negative pressure room for collection. If using the room solely for collection

purposes, drape a sheet over where the patient will be sitting.3. Administer bronchodilators and supplemental oxygen if indicated.4. Perform hand hygiene and don PPE.5. Explain the procedure to the patient what to expect.6. Ensure patient is comfortable and in a sustainable position.7. Perform baseline observations (SpO2, RR and auscultation).8. Prepare nebuliser with 10ml hypertonic saline solution in disposable cup, and sterile

water in the main water chamber up to the recommended marked ‘fill’ line. Refer to Attachment 10 for machine setup.

9. Instruct patient to breathe slowly and deeply.10. After 5 minutes of inhalation, if no spontaneous cough has occurred, instruct patient to

cough. Repeat at 5 minute intervals until a sample is produced44-46. Continue to monitor patient throughout procedure.

11. After 30 mins if no sample obtained, cease the procedure and inform medical team.12. Repeat observations and ensure patient is stable.13. Document result of collection attempt in the patient’s clinical record, and data collection

of the attempt in the Physiotherapy record book for Induced Sputum.14. If successful, label sample as “Induced Sputum” and send with pathology form to

Microbiology. Refer to Attachment 11 if procedure is unsuccessful. 15. If used, place any draped sheets into the linen skip.16. Dispose of consumables in yellow bin outside the room.17. The room requires cleaning before use by another patient. Leave the room vacant for

one hour and then contact the cleaning service to clean the floors, walls and furniture with detergent and water.

18. Clean the machine as below.

Alert: Morning sample collection is preferable as they are more sensitive for detecting TB47


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Cleaning Wipe nebuliser with soap impregnated wipe Tubing and water vessel are sent to DRSM for thermal disinfection and air dried. Mouthpiece and one way valve are sent to Gastroenterology & Hepatology Unit for

sterilization Filters and the medicine cup are disposable after each test.


Implementation

This guideline will be implemented via the following: Available for reference to all CHHS Physiotherapy staff and Physiotherapy students via

the policy register on SharePoint. Distribution at department communication and team meetings. Inclusion in staff orientation. Communication with key stakeholders and workgroups. Monitoring through peer review, documentation audits and clinical practice audits.


Related Policies, Procedures, Guidelines and Legislation

Policies Work Health and Safety Policy Consent and Treatment Policy Clinical Records Management Policy

Procedures CHHS Healthcare Associated Infections Clinical Procedure CHHS Patient Identification and Procedure Matching Policy Adult Nebulisation Therapy Procedure Inhaled Bronchodilator Delivery for Adults Only Clinical Record Documentation Procedure

Guidelines Physiotherapy – Adult Patient with a Spinal Cord Injury Tracheostomy Management Adult Patients Clinical Supervision for Allied Health Clinicians Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals Oxygen Therapy and or Non-Invasive Ventilation Paediatrics Physiotherapy – Adult Patient with a Spinal Cord Injury

Legislation Health Records (Privacy and Access) Act 1997


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Human Rights Act 2004 Work Health and Safety Act 2011


References

1. Irwin RS, Boulet LP, Cloutier MM, et al. Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. Chest. 1998;114(2 Suppl Managing):133S-181S.

2. Homnick DN. Mechanical insufflation-exsufflation for airway mucus clearance. Respir Care. 2007;52(10):1296-1305; discussion 1306-1297.

3. Whitney JA, Harden B, Keilty S. Assisted cough: a new technique. Physiotherapy. 2002;88(4):201-207.

4. Liszner K, Feinberg M. Cough assist strategy for pulmonary toileting in ventilator dependent spinal cord injured patients. Rehabilitation Nursing. 2006;31(5):218-221.

5. Chatwin M, Simonds AK. The addition of mechanical insufflation/exsufflation shortens airway-clearance sessions in neuromuscular patients with chest infection. Respir Care. 2009;54(11):1473-1479.

6. Fauroux B, Guillemot N, Aubertin G, et al. Physiologic benefits of mechanical insufflation-exsufflation in children with neuromuscular diseases. Chest. 2008;133(1):161-168.

7. Emerson 3200 User Manual.8. Guerin C, Bourdin G, Leray V, et al. Performance of the coughassist insufflation-

exsufflation device in the presence of an endotracheal tube or tracheostomy tube: a bench study. Respir Care. 2011;56(8):1108-1114.

9. Shoemaker MJ, Donker S, Lapoe A. Inspiratory muscle training in patients with chronic obstructive pulmonary disease: the state of the evidence. Cardiopulm Phys Ther J. 2009;20(3):5-15.

10. Dall'Ago P, Chiappa GR, Guths H, Stein R, Ribeiro JP. Inspiratory muscle training in patients with heart failure and inspiratory muscle weakness: a randomized trial. J Am Coll Cardiol. 2006;47(4):757-763.

11. Cader SA, Vale RG, Castro JC, et al. Inspiratory muscle training improves maximal inspiratory pressure and may assist weaning in older intubated patients: a randomised trial. J Physiother. 2010;56(3):171-177.

12. Bissett BM, Leditschke IA, Neeman T, Boots R, Paratz J. Inspiratory muscle training to enhance recovery from mechanical ventilation: a randomised trial. Thorax. 2016;71(9):812-819.

13. Bissett BG, M. Leditschke, IA. Inspiratory muscle training is safe in selected ventilated patients: a case series. in preparation. 2010.

14. Hill K, Jenkins SC, Philippe DL, et al. High-intensity inspiratory muscle training in COPD. Eur Respir J. 2006;27(6):1119-1128.

15. Johnson MA, Sharpe GR, Brown PI. Inspiratory muscle training improves cycling time-trial performance and anaerobic work capacity but not critical power. Eur J Appl Physiol. 2007;101(6):761-770.


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16. Cahalin LP, Semigran MJ, Dec GW. Inspiratory muscle training in patients with chronic heart failure awaiting cardiac transplantation: results of a pilot clinical trial. Phys Ther. 1997;77(8):830-838.

17. Sprague SS, Hopkins PD. Use of inspiratory strength training to wean six patients who were ventilator-dependent. Phys Ther. 2003;83(2):171-181.

18. Martin AD, Davenport PD, Franceschi AC, Harman E. Use of inspiratory muscle strength training to facilitate ventilator weaning: a series of 10 consecutive patients. Chest. 2002;122(1):192-196.

19. Bissett B, Leditschke IA. Inspiratory muscle training to enhance weaning from mechanical ventilation. Anaesth Intensive Care. 2007;35(5):776-779.

20. Bissett B, Leditschke, I.A., Green, M. Specific inspiratory muscle training is safe in selected patients who are ventilator-dependent: A case series. Intensive and Critical Care Nursing. 2012;28:98-104.

21. Hill K, Cecins NM, Eastwood PR, Jenkins SC. Inspiratory muscle training for patients with chronic obstructive pulmonary disease: a practical guide for clinicians. Arch Phys Med Rehabil. 2010;91(9):1466-1470.

22. McCarren B, Chow CM. Manual hyperinflation: a description of the technique. Aust J Physiother. 1996;42(3):203-208.

23. Rothen HU, Sporre B, Engberg G, Wegenius G, Hedenstierna G. Re-expansion of atelectasis during general anaesthesia: a computed tomography study. Br J Anaesth. 1993;71(6):788-795.

24. Maxwell L, Ellis E. Secretion clearance by manual hyperinflation. Possible mechanisms. Physiotherapy Theory and Practice. 1998;14:189-197.

25. Hodgson C, Denehy L, Ntoumenopoulos G, Santamaria J, Carroll S. An investigation of the early effects of manual lung hyperinflation in critically ill patients. Anaesth Intensive Care. 2000;28(3):255-261.

26. Hodgson C, Ntoumenopoulos G, Dawson H, Paratz J. The Mapleson C circuit clears more secretions than the Laerdal circuit during manual hyperinflation in mechanically-ventilated patients: a randomised cross-over trial. Aust J Physiother. 2007;53(1):33-38.

27. Berney S, Denehy L, Pretto J. Head-down tilt and manual hyperinflation enhance sputum clearance in patients who are intubated and ventilated. Aust J Physiother. 2004;50(1):9-14.

28. Stiller K, Geake T, Taylor J, Grant R, Hall B. Acute lobar atelectasis. A comparison of two chest physiotherapy regimens. Chest. 1990;98(6):1336-1340.

29. Maa SH, Hung TJ, Hsu KH, et al. Manual hyperinflation improves alveolar recruitment in difficult-to-wean patients. Chest. 2005;128(4):2714-2721.

30. Ntoumenopoulos G, Gild A, Cooper DJ. The effect of manual lung hyperinflation and postural drainage on pulmonary complications in mechanically ventilated trauma patients. Anaesth Intensive Care. 1998;26(5):492-496.

31. Rusterholz B, Ellis E. The effect of lung compliance and experience on manual hyperinflation. Aust J Physiother. 1998;44(1):23-28.

32. Berney S, Denehy L. A comparison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients. Physiother Res Int. 2002;7(2):100-108.


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33. Savian C, Chan P, Paratz J. The effect of positive end-expiratory pressure level on peak expiratory flow during manual hyperinflation. Anesth Analg. 2005;100(4):1112-1116.

34. Ahmed F, Shafeeq AM, Moiz JA, Geelani MA. Comparison of effects of manual versus ventilator hyperinflation on respiratory compliance and arterial blood gases in patients undergoing mitral valve replacement. Heart Lung. 2010;39(5):437-443.

35. Dennis DM, Jacob WJ, Samuel FD. A survey of the use of ventilator hyperinflation in Australian tertiary intensive care units. Crit Care Resusc. 2010;12(4):262-268.

36. Hanekom S, Berney S, Morrow B, et al. The validation of a clinical algorithm for the prevention and management of pulmonary dysfunction in intubated adults--a synthesis of evidence and expert opinion. J Eval Clin Pract. 2011;17(4):801-810.

37. Dennis D, Jacob W, Budgeon C. Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients. Anaesth Intensive Care. 2012;40(1):142-149.

38. Paratz J, Lipman J, McAuliffe M. The effect of manual hyperinflation, gas exchange, and respiratory mechanics in ventilated patients. . Journal of Intensive Care Medicine. 2002;17(6):317-324.

39. Paggiaro PL, Chanez P, Holz O, et al. Sputum induction. Eur Respir J Suppl. 2002;37:3s-8s.40. Al Zahrani K, Al Jahdali H, Poirier L, Rene P, Menzies D. Yield of smear, culture and

amplification tests from repeated sputum induction for the diagnosis of pulmonary tuberculosis. Int J Tuberc Lung Dis. 2001;5(9):855-860.

41. McWilliams T, Wells AU, Harrison AC, Lindstrom S, Cameron RJ, Foskin E. Induced sputum and bronchoscopy in the diagnosis of pulmonary tuberculosis. Thorax. 2002;57(12):1010-1014.

42. Elkins MR, Lane T, Goldberg H, et al. Effect of airway clearance techniques on the efficacy of the sputum induction procedure. Eur Respir J. 2005;26(5):904-908.

43. http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2009_006.pdf44. Fahy JV, Boushey HA, Lazarus SC, et al. Safety and reproducibility of sputum induction in

asthmatic subjects in a multicenter study. Am J Respir Crit Care Med. 2001;163(6):1470-1475.

45. Kelly MG, Brown V, Martin SL, Ennis M, Elborn JS. Comparison of sputum induction using high-output and low-output ultrasonic nebulizers in normal subjects and patients with COPD. Chest. 2002;122(3):955-959.

46. Popov TA, Pizzichini MM, Pizzichini E, et al. Some technical factors influencing the induction of sputum for cell analysis. Eur Respir J. 1995;8(4):559-565.

47. Schoch OD, Rieder P, Tueller C, et al. Diagnostic yield of sputum, induced sputum, and bronchoscopy after radiologic tuberculosis screening. Am J Respir Crit Care Med. 2007;175(1):80-86.


Definition of Terms

PaO2/FiO2 Ratio-the ratio of partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2), also known as the PF ratio19.


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Peak Inspiratory Pressure (PIP)-point of maximal airway pressure on inspiration, measured in centimetres of water19


Search Terms

CAM, Cough assist, Cough assist machine, Physiotherapy, Airway clearance, Inspiratory Muscle Training, Intensive Care, Critical Care, Mechanical ventilation, Respiratory management, Sputum clearance, Atelectasis, Manual Hyperinflation, Induced Sputum Collection


Attachments

Attachment 1 – Assessing Peak cough flow Attachment 2 – Assembly of Cough Assist MachineAttachment 3 – Modifying Cough Assist Machine settingsAttachment 4 – Cough Assist Machine Competency Assessment for Physiotherapists Attachment 5 – Physiotherapy Competency Assessment- Inspiratory Muscle TrainingAttachment 6 – Physiotherapy Competency Assessment-HyperinflationAttachment 7 – Ventilator Assessment Tool for PhysiotherapistsAttachment 8 – Ventilator Hyperinflation Procedure Flowchart Attachment 9 – List of rooms for Induced Sputum collection at Canberra HospitalAttachment 10 – Induced Sputum mouthpiece components and assemblyAttachment 11 – Physiotherapy Induced Sputum flowchart


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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 24/01/2018 Complete Review Kerry Boyd, DAH,

MedicineCHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS13/513 Physiotherapy - Induced Sputum CollectionCHHS13/327 Physiotherapy Use of Manual HyperinflationCHHS13/441 Physiotherapy Inspiratory Muscle Training for Ventilated Patients (Adults)CHHS15/159 Physiotherapy - Ventilator Hyperinflation in Adult Mechanical Ventilated PatientsCHHS16/240 Physiotherapy use of Cough assist to enhance pulmonary secretion clearance


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Attachment 1 – Assessing Peak cough flow

Peak Cough Flow can be assessed using the Phillips Respironics Cough Assist E70

Assessing Peak Cough Flow:1. Perform hand hygiene.2. Set up a pre-set to be in manual mode, inhale pressure 0cmH2O and exhale pressure

0cmH2O.3. For a patient with spinal cord injury, place them supine to maximise vital capacity.4. Select Therapy from the Standby screen.5. Apply the interface to the patient.6. Ask the patient to take a deep breath and cough.7. While the patient is taking the deep breath turn the manual control lever to inhale. 8. When the patient commences coughing, quickly turn the manual control lever to exhale.9. Remove the interface and record the baseline peak cough flow.10. Perform hand hygiene.

For further information on interpretation of peak cough values see the Appendix 3 in the Physiotherapy – Adult Patient with a Spinal Cord Injury clinical guideline on the policy register.


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Attachment 2 – Assembly of Cough Assist Machine

Emerson CA-3200 Cough Assist

Phillips Respironics Cough Assist E70


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Attachment 3 –Modifying Cough Assist Machine settings

Phillips Respironics Cough Assist E7010

Navigating the standby screen1. When the machine is turned on the standby screen will appear

2. Detailed view will either be turned on or off. To turn detailed view on or off enter the Menu and select Options. Then scroll to Detailed View and toggle between on/off.

Changing between full access and limited accessTo change patient settings full access needs to be enabled. Once the machine has been configured, the access should be returned to limited access in order to prevent the settings being changed by someone that is not trained to do so.

To turn on full access: From the standby screen press the down button and hold the manual control lever to

the right (inhale). The unlocked graphic in the top right hand corner of the screen indicates that the machine is in full access mode.

To turn on limited access: From the standby screen select Menu > Options > Menu Access. Press the Modify key

and toggle to Limited Access.

Adjusting patient settings1. Ensure ‘full access’ has been enabled. 2. Press the left key (under the word ‘settings’ on the screen).3. The screen below will appear. 4. Use the up/down and modify keys to change the settings for each pre-set.5. To return to the standby screen select Finish by using the left key.


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Emerson CA-3200 cough assist3

Pressure adjustment1. Perform hand hygiene.2. Turn on the power switch.3. Select inhale flow to full or reduced.4. Block the mask end of the breathing hose with your hand.5. Set the manual/ auto switch to manual.6. Push the manual control lever to the exhalation phase (to the left). Observe the pressure

gauge on the device and adjust the maximum negative pressure by using the pressure knob to achieve the correct reading on the gauge.

7. Shift the manual control lever to the inhalation phase (push to the right). Adjust the pressure reading by turning the inhale pressure knob to achieve the desired reading on the pressure gauge.

8. Cycle the manual control lever from inhale to exhale and back a few times to ensure that the pressure and suction readings are correct.

9. On release of the manual control lever check that the pressure returns to 0cmH2O.


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Attachment 4 – Cough Assist Machine Competency Assessment for Physiotherapists

Outcome Statement: The Physiotherapist demonstrates appropriate knowledge and skill to clinically reason and safely use the CAM in the management of adult and paediatric patients.

Assessment Requirements

Theory Completed: □ Read Physiotherapy Respiratory Management clinical guideline, Section 1 – Cough Assist to enhance pulmonary clearance□ Read Physiotherapy – Adult Spinal Cord Injury (excluding staff who

work solely with paediatric clients)

2 types of CAM are available, the Emerson CA-3200 and the Philips Respironics Cough Assist E70. Staff must be assessed as competent on the machine that they are planning to use to treat the patient.

This assessment is made up of PARTS A-D. o All staff must be assessed as competent in PART A: Indications and Contraindicationso Staff assessed as competent in PART C: CAM Application/Treatment but not PART B:

CAM Set-up and Prescription may use the CAM as a treatment option once it has been set-up and prescribed by a staff member who has been assessed as competent in PART B

o Staff must be assessed as competent in PART D: Peak Cough Flow to measure peak cough flow through the CAM. Note that this can be measured using a face mask and a peak flow meter (refer to Physiotherapy – Adult Spinal Cord Injury Guideline on the policy register)

If a staff member is found not yet competent against an assessment item further training is conducted until that staff member is assessed as competent. Staff members can request training and assessment to be conducted by another staff member.

Overall Assessment: COMPETENT (C) / NOT YET COMPETENT (NYC)/ CONDITIONAL (please circle)

Comments: .............................................................................................................................................

.................................................................................................................................................................

.................................................................................................................................................................

.................................................................................................................................................................

Candidate: Date:

Signature Print Name Designation

Assessor: Date:


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Signature Print Name DesignationPerformance Criteria C NYC

PART A – Indications & ContraindicationsDiscuss the clinical indication/s for the CAM and 3 therapy adjuncts to assist with secretion clearanceList 3 patient populations/diagnosis who may require the CAM List 2 contraindications/precautions and explain the clinical reasoning for eachDiscuss clinical reasoning for performing CAM in supine for patients with a spinal cord injuryPART B – CAM Set-up and PrescriptionDiscuss different interfaces available and rationale for selectionDiscuss factors to consider when initiating CAM for the first time and ranges of pressure required to achieve effective secretion clearance

Emerson CA-3200

Philips E-70

Set-up & Prescription C NYC C NYCEquipment assembled and per procedurePerforms appropriate pressure and timing adjustments to achieve effective prescriptionExplains rationale for in-sufflation and ex-sufflation (repetitions & sets, rests) PART C – CAM Application/TreatmentInformed consent / consent obtained from patient (if possible) or reason consent unable to be obtained noted in medical fileMachine settings checked with prescriptionDemonstrates ability to use manual and automatic modeTreatment performed as prescribed and/or treatment outcome achievedTherapy Adjuncts and Monitoring C NYCAppropriate adjunct techniques performed as clinically indicatedAppropriate monitoring during treatment and treatment modified as/if indicatedDocumentationProcedure documented in accordance to Physiotherapy Documentation standards. Including: Sets, repetitions, rests, mode, timing adjustment, pressures, physiological

response to treatmentPART D – Peak Cough Flow (Phillips Respironics E-70)Discuss clinical reasoning for assessing peak cough flowMeasures peak cough flow as per procedureDiscuss clinical implications of the patients peak cough flowProcedure documented in accordance to Physiotherapy Documentation standards.


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Attachment 5 – Physiotherapy Competency Assessment Inspiratory Muscle Training

Outcome Statement: The Physiotherapist demonstrates appropriate knowledge and skill to clinically reason and safely use IMT in adult mechanically ventilated patients.Assessors: Physiotherapy staff with specialised skills in intensive care and inspiratory muscle training as identified by the Physiotherapy Manager/Team Leader (Health Professional level 4).

Assessment Requirements Staff must be assessed as competent in all assessment criteria to achieve overall IMT

competency.

Performance Criteria C NYCIndications & ContraindicationsNeed for IMT is identified (based on low NIF / MIP)Checked for any contraindications/precautions to IMTExplains procedure and rationale to patient Informed consent gained from patientProcedure Appropriately positions the patientApplies IMT device to tracheostomy / ETT via connectorFollows training guidelines (6 breaths, 5 sets)Monitors patient’s parameters and response during training against parameters set by ICU Consultant.Training progressed as per guidelines (just complete 6th breath each set)MonitoringMonitors appropriate parameters throughout treatmentModifies treatment as required or discusses how treatment may need to be modified in certain clinical situationsCeases treatment in presence of safety concerns or discusses safety criteria when treatment would need to ceaseDocumentationProcedure documented in MetaVision using the IMT form.


Comments: _________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________


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Candidate: Date:


Assessor: Date:



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Attachment 6 –Hyperinflation Competency Assessment

Outcome Statement: The Physiotherapist demonstrates appropriate knowledge and skill to clinically reason and safely use hyperinflation.

Assessors: physiotherapy staff with specialised skills in respiratory management as identified by the Physiotherapy Manager/Team Leader (Health Professional Level 4).


Theory Completed: Read Physiotherapy Respiratory Management guideline-Hyperinflation (Section 3) Hyperinflation Self Directed Learning Package or Department inservice Attended Physiotherapy Ventilator Competency completed (for VHI)

Staff may be assessed as competent in either MHI or VHI. Staff must be deemed competent in all assessment criteria to achieve overall competency. Staff

are required to achieve competency performing VHI in each of the modes of mechanical ventilation. Achieving competency in performing VHI in one mode of ventilation does not mean the staff member is competent in performing VHI in another mode. Staff must not perform VHI in a mode of mechanical ventilation that they have not been assessed as competent in.

Simulation may be used in training and assessment. In addition to achieving competency in hyperinflation, staff must also be assessed as ventilator

competent for VHI, as well as in closed suction for both techniques before the treatment technique can be performed independently.

If a staff member if found not yet competent against an assessment item further training is conducted until that staff member is assessed as competent. Staff members can request training and assessment to be conducted by another staff member.


Comments

.................................................................................................................................................................

.................................................................................................................................................................

Candidate Name...................................................... Date ....................................................................

Signature ............................................................... Designation .........................................................

Assessor Name ....................................................... Date ....................................................................



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Performance Criteria C NYCIndications & ContraindicationsDiscuss the 2 main clinical indications for hyperinflationOutline the theoretical background of hyperinflation, including the target peak airway pressureDiscuss 5 contraindications/precautions and explain the clinical reasoning for eachIdentifies appropriate outcome measures to assess the effectiveness of treatmentAble to identify the differences between VHI and MHIAble to justify the choice of either VHI or MHI and indications/benefit of chosen treatment modalityProcedure-VHIInformed consent / consent obtained from patient (if possible) or reason consent unable to be obtained noted in medical fileAppropriately positions the patientSelects the most appropriate mode of ventilation to perform VHI

GE CarescapeVentilator

Marquet Servo U

C NYC C NYCIdentifies baseline alarm settingsAdjusts alarms

Performs & titrates VHI

Volume controlPressure control

Provides appropriate dosage

MonitoringMonitors appropriate parameters throughout treatmentModifies treatment as required or discusses how treatment may need to be modified in certain clinical situationsCeases treatment in presence of safety concerns or discusses safety criteria when treatment would need to ceaseRe-assessment & Post Treatment Procedure GE

CarescapeVentilator

Marquet Servo U

C NYC C NYCRe-assesses outcome measuresReturns patient to baseline ventilator settingsReturns alarm settings to baseline parametersDocumentationProcedure documented in accordance to Physiotherapy Documentation standards in MetaVision using the VHI form. Including: Mode of ventilation, Peak Inspiratory Pressure, respiratory rate, tidal

volume, dosageProcedure -MHI


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Performance Criteria C NYCInformed consent / consent obtained from patient (if possible) or reason consent unable to be obtained noted in medical fileAppropriately positions the patientPrepares equipment and work area (Laerdal bag, PEEP valve, suction, ventilator)Appropriately disconnects patient from the ventilator/oxygen therapy, safely connects patient to Laerdel bag and places ventilator in standby modeDemonstrates effective manual hyperinflation techniqueProvides appropriate dosageMonitoringMonitors appropriate parameters throughout treatmentModifies treatment as required or discusses how treatment may need to be modified in certain clinical situationsCeases treatment in presence of safety concerns or discusses safety criteria when treatment would need to ceaseRe-assessment & Post Treatment ProcedureRe-assesses outcome measuresTakes ventilator off standby, safely reconnects patient to ventilator/oxygen therapyDocumentationProcedure documented in accordance to Physiotherapy Documentation standards in patients clinical record Including: PEEP level, position of patient, dosageAdvanced Hyperinflation-PaediatricAble to describe to physiological differences between adults and childrenAble to modify treatment technique based on patients age, lung development and size


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Attachment 7 – Ventilator Assessment Tool for Physiotherapists

Outcome Statement: The physiotherapist demonstrates appropriate knowledge and skill to independently and safely treat adult patients mechanically ventilated via the GE Carescape ventilator and the Marquet Servo U.


Training Completed: This assessment consists of 2 parts:

o PART A – Mechanical Ventilation Knowledge and Skills o PART B – Advanced Mechanical Ventilator Skills

Staff must be assessed as competent in all criteria of PART A prior to independently assessing and treating a mechanically ventilated patient.

PART B may be completed for staff developing specialised skills in mechanical ventilation. Competency must be achieved prior to performing any skill or procedure independently.

If a staff member is found ‘not yet competent’ against an assessment item further training is conducted until that staff member is assessed as competent. Staff members can request training and assessment by another staff member.

This assessment can be completed over time and does not need to be completed in a single assessment session.


Comments: ..............................................................................................................................................

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Candidate Name...................................................... Date ....................................................................


Assessor Name ....................................................... Date ....................................................................



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PART A – Mechanical Ventilation Knowledge and Skills C NYC

Describes the different types and modes of ventilation

Pressure Support Ventilation (PSV)Synchronised Intermittent Mandatory Ventilation-Pressure Control (SIMV-PC)Synchronised Intermittent Mandatory Ventilation-Volume Control (SIMV-VC)Pressure Regulated Volume Control (PRVC)

GE Carescape Ventilator

Marquet Servo U

C NYC C NYCIdentifies pre-set parameters where applicable: Mode, PEEP, Pressure Support, FiO2, tidal volume (Vt), respiratory rate (frequency)Identifies patients:

o Peak Airway Pressure (PAw), o PEEP o FiO2o Vt o respiratory rate (frequency) o end tidal CO2 (ETCO2)

Alarm Settings:o Locates and identifies alarm limits (Vt, RR, PIP, ETCO2)o Demonstrates how to adjust alarm limits (PIP, Vt)o Demonstrates how to silence alarms

Locate the: Humidifier and demonstrate how to silence the alarm ETCO2 monitor and where to attach the laerderal bag Inspiratory and expiratory ventilator tubing

Identify which breaths are spontaneous and which breaths are mandatory on SIMV or PCVApnoea Ventilation:

Discuss the role of apnoea ventilation including the mode of ventilation

Locate the apnoea ventilation settings Outline 2 treatments that could cause apnoea

ventilation to be triggered and the theoretical Doc Number Version Issued Review Date Area Responsible PageCHHS18/069 1 26/02/2018 01/02/2022 Medicine – Acute

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rationale for each Identify a patient who is in apnoea ventilation Reset apnoea ventilation

Demonstrates how to change the mode of ventilation, FiO2, PEEP & PS and outline the process to follow if ventilator settings require changingDemonstrates how to pre-oxygenate patients prior to suction and how many second remainOutline the process to follow if the ventilator stopped workingDemonstrate how to safely remove excess water from ventilator tubingDemonstrates how to put the ventilator in ‘Stand-by Mode’ and safety factors to consider

PART B – Advanced Mechanical Ventilation Skills GE Carescape Ventilator

Marquet Servo U

C NYC C NYCAccurately calculates static compliance (Cstat=VT/Pplat-PEEP) and discusses how it can be used as an outcome measureSafely perform Negative Inspiratory Force (NIF) manoeuvre (through diagnostics) & Inspiratory HoldMeasures Vital Capacity (VC) and discusses clinical reasoning for measuring VCMeasures FRC and is able to apply to clinical decision makingSet-up and applies High Flow Nasal Prongs through the ventilator Set-up and applies Non-Invasive Ventilation through the ventilatorMobilisation C NYCOutline the Multidisciplinary Team process to follow prior to mobilising a ventilated patient away from the bedspaceSafely sets-up the ventilator to be used in battery mode for mobilisation

Transfers onto portable oxygen with a spare oxygen cylinder available

Portable suction available and set up ready for useSafely leads a mobilisation episode with the ventilator in battery modeVentilator WaveformDiscuss when to assess waveformsIdentifies and discusses implications for physiotherapy of the following waveforms:

o Saw tooth expiratory patternso Prolonged expirationo Gas trapping


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Attachment 8-Ventilator Hyperinflation Procedure Flowchart


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Determine most appropriate

mode

Alter alarm limits:- Ppeak (PIP) 45 cmH2O-Rate lower limit 6

Change ventilation

mode to SIMV (VC)

Alter settings to:- Rate 6- T pause 1-1.5-Rise 0.4-Insp time 3.5-4 secs

Titrate volumes slowly by

100-200ml to achieve PIP

35-40 cm H2OMonitor patient

response and continue to

titrate settings as required Complete

therapeutic dosage and

reasses patient

Return ventilator settings to previous settings

Return alarms to previous settings

Document in VHI tab on Metavision

Change ventilation mode to

SIMV (PC)

Alter settings to:- Rate 6-Rise 0.4-Insp time 3.5-5 secs

Titrate PC above PEEP by 5cm at a time until

PC+PEEP =35-40cm H2O

VHI procedure for the Marquet

Servo U

CHHS18/069


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Change alarms- Peak pressure: 42cmH20- Rate: 6-VTexp: Off

Change ventilation mode

to SIMV VC

Change ventilator settings:-Rate: 6-Insp Time: 5-Flow Rate: 15

Titrate volumes slowly by 100-

200ml to achieve PIP 35-40 cm

H2O

Monitor patient response and continue to

titrate settings as required

Complete therapeutic dosage and

reasses patient

Return rate, insp time, volume

and flow rate to previous settings

Return alarms to previous settings

Document in VHI tab on

Metavision

VHI Procedure for GE Ventilator

CHHS18/069

Attachment 9 – List of negative pressure rooms in CHHS

Location Number of RoomsAntenatal 1Coronary Care Unit 2Intensive Care Unit 4Neonatal Intensive Care Unit 1Ward 5B 1Ward 6A 1Ward 7A 2Ward 7B 1Ward 8A procedure rooms* 2Ward 8B 1Ward 14B 1Emergency Department 3Paediatric adolescent ward 2Paediatric medical ward 3Paediatric surgical ward 1Gastroenterology and Hepatology Unit(GEHU)*

1

*If a negative pressure room is unavailable, these rooms are available via booking. Bookings for 8A procedure rooms are through the 8B CNC. Bookings for GEHU are arranged through GEHU CNC or team leader, phone 62443970. Note: these rooms may have limited availability due to other procedures.


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Attachment 10 – Induced Sputum mouthpiece components and assembly

Exploded view showing all components

Mouthpiece assembled


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Attachment 11 – Flowchart for requests for Induced Sputum collection


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