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    Implications For Secretion Clearance

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    arbaz
    1. The document discusses secretion clearance techniques for people with obstructive lung diseases like COPD and asthma. 2. It considers factors that affect airflow such as airway resistance and dynamic airway closure. High expiratory flow rates are needed to effectively clear secretions. 3. Evidence-informed techniques discussed include coughing, huffing, positive expiratory pressure, active cycle breathing, and autogenic drainage. These techniques aim to increase expiratory flow rates and mobilize secretions.

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    Implications For Secretion Clearance

    Uploaded by

    arbaz
    27 views27 pages
    1. The document discusses secretion clearance techniques for people with obstructive lung diseases like COPD and asthma. 2. It considers factors that affect airflow such as airway resistance and dynamic airway closure. High expiratory flow rates are needed to effectively clear secretions. 3. Evidence-informed techniques discussed include coughing, huffing, positive expiratory pressure, active cycle breathing, and autogenic drainage. These techniques aim to increase expiratory flow rates and mobilize secretions.

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    A_Review_of_Obstructive_Respiratory_Disease___Implications_for_Secretion_Clearance_Obstructive_Respiratory_Disease___Implications_for_Secreation_Clearance_Tania_Larsen_PPT

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    1. The document discusses secretion clearance techniques for people with obstructive lung diseases like COPD and asthma. 2. It considers factors that affect airflow such as airway resistance and dynamic airway closure. High expiratory flow rates are needed to effectively clear secretions. 3. Evidence-informed techniques discussed include coughing, huffing, positive expiratory pressure, active cycle breathing, and autogenic drainage. These techniques aim to increase expiratory flow rates and mobilize secretions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    27 views27 pages

    Implications For Secretion Clearance

    Uploaded by

    arbaz
    1. The document discusses secretion clearance techniques for people with obstructive lung diseases like COPD and asthma. 2. It considers factors that affect airflow such as airway resistance and dynamic airway closure. High expiratory flow rates are needed to effectively clear secretions. 3. Evidence-informed techniques discussed include coughing, huffing, positive expiratory pressure, active cycle breathing, and autogenic drainage. These techniques aim to increase expiratory flow rates and mobilize secretions.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Implications for Secretion Clearance

    Presented by: Tania Larsen, PT, PhD


    London Health Sciences Centre
    Western University
    London, Canada
    Outline
    1. What is obstructive disease?
    1. Definition
    2. Characteristics
    2. Factors to consider with respect to secretion
    clearance
    1. Airway resistance
    2. Mechanisms limiting airflow
    3. Evidence-informed secretion clearance options for
    people with obstructive disease
    Airway Obstructive Disease
    ‘those that interfere with airflow’

    conducting zone

    alveolus

    • Limitation to airflow in
    the conducting zone
    (tracheobronchial tree)

    Photo taken from : https://asthmawa.org.au/new-airphysio-device/


    Clinical Diagnostics: Pulmonary Function Tests
    used to distinguish 2 broad categories of disorders

    Obstructive Restrictive
    conducting zone

    alveolus parenchyma
    alveolus

    impediment to airflow in expansion of lung restricted either


    conducting zone of lung because of alterations in the lung
    (tracheobronchial tree) parenchyma or because of disease of
    the pleura, or dysfunction of the
    respiratory pump **
    Characteristics of Obstructive Disease
    • High resting lung volumes
    • Lower inspiratory & expiratory volumes
    • Low flow rates

    FEV1/FVC
    FEF25-75%

    • Difficulty getting air out (air trapping)


    • Limitation of expiratory airflow

    Photo taken from: https://step2.medbullets.com/pulmonary/120664/pulmonary-function-tests


    Review of Factors that Affect Airflow
     Airway Resistance
     Size of airways
     Big ‘O’ versus little ‘o’

     Chief site of airway resistance


     Bronchus (medium sized airways)

    Image taken from: https://www.researchgate.net/figure/Location-of-the-chief-site-of-airway-resistance-Note-that-the-intermediate-sized-bronchi_fig6_49583713


    Review of Factors that Affect Airflow
     Airway Resistance
     Dynamic Airway Closure

    Equal Pressure Point (EPP)

    narrowing of the airway on


    expiration beyond EPP

    Image taken from: http://www.pathwaymedicine.org/airflow-resistance


    Review of Factors that Affect Airflow
     Airway Resistance
     Airway obstruction
     Mucous, swelling, bronchospasm +/- collapsible airways

    Image taken from: http://www.pathwaymedicine.org/airflow-resistance


    Mechanisms of Airflow Limitation
    Obstructive Disorders

    * emphysema
    asthma

    chronic bronchitis
    cystic fibrosis

    * normal ageing associated with gradual breakdown of elastic tissue


    *slide credit SD Lucy
    Mechanisms Underlying Airflow
    Limitation in COPD
    Bronchi
    Mucous gland hypertrophy
    and hyperplasia
    Thickened walls →
    decreased lumen size
    Increased airway resistance
    Bronchioles Parenchymal Destruction
    Airway inflammation and
    Loss of alveolar attachments
    fibrosis
    Luminal mucous plugs Loss of bronchiolar support
    Increased airway resistance Decrease of elastic recoil

    Airflow
    Limitation
    Let’s Recap….
     Limitations to airflow
     Secretions, inflammation, dynamic airway compression
    +/- collapsible airways
     Low expiratory volumes and flow rate

     Why is airflow important?


     It’s what moves secretions
    Obstructive Disease
     Cystic fibrosis
     Bronchiectasis
     COPD with secretions
     Asthma with secretions
     Ciliary dyskinesia

     Characterized by impairments primarily in expiratory


    volumes and flow rates
     Goal is to get air behind secretions and optimize
    expiratory flow rates to move secretions
    Considerations for Secretion Clearance

    Image taken from: Gosselink et al., 2008


    Considerations for Secretion Clearance

    • Ensure sufficient inspiration to allow air to enter and get


    behind the secretions

    • Limit airway resistance – maximize size of ‘o’ on expiration


    • Maximize expiratory flow rate
    Image taken from: Gosselink et al., 2008
    Secretion Clearance Guidelines

    Thorax, 2009

    Eur Respir Rev, 2017

    Respiratory Care, 2013


    Evidence-informed Secretion
    Clearance for People with
    Obstructive Disease
    1. Cough/Huff
    2. PEP/Flutter
    3. Active Cycle Breathing Technique
    4. Autogenic Drainage
    Increasing Expiratory Flow Rate
    Cough Huff
     Deep inspiration (> TV)
     Deep inspiration
     Glottis closes
     Forced expiration through
     ↑ intrathoracic pressure open glottis
     Glottis opens  Ha, Ha, Ha
     Rapidly expelled volume of
    air
    No compression phase and thus
    Premature airway closure in stabilizes collapsible airway walls
    patients with collapsible airways
     Less airway resistance in
     Clears large airways expiration, bigger ‘o’
     Major bronchi compressed to  Expiratory flow slowly
    ½ size pushes secretions cranially
    PEP
    What?
     Low Pressure
     10-20 cm H2O

     High Pressure
     40-100 cm H2O

     Oscillating PEP/Flutter
    PEP
     Why?
     Expiration against a resistor :

    1. Avoids airway compression during expiration and so airways


    are splinted open to increase expiratory flow and assist in
    mobilizing secretions

    2. Increases intrathoracic pressure distal to retained secretions


    thus allowing air to move behind secretions via collateral
    ventilation and increased FRC

     Who?
     People with Obstructive disease
    PEP: How?
    E.g, - product specific
     Inspiration
     Inspire through mask/mouth piece to normal or slightly above
    TV

     Expiration
     Expire (slightly active) through mouth against the resistor to
    create back pressure to normal level of expiration

     Repeat 12-15 breaths then remove mask


     Huff/Cough to clear secretions
     Repeat 5-6 cycles or until no more secretions
    Active Cycle Breathing
     What?
     Active cycle breathing techniques incorporate breathing
    control, thoracic expansion exercises and huffing
     Breathing exercises at TV or above

     Why?
     to mobilize and clear bronchial secretions

     Who?
     Obstructive disease, secretions obstructing airways
    Active Cycle Breathing
    How?
    Breathing Control (BC)– diaphragmatic breathing at normal volume
    (relaxed breathing, cue no shoulder movement)
    Thoracic expansion (TEE) – deep inspiration (cue lateral costal expansion)
    with unforced expiration
    Forced Expiratory Technique (FET) - Huff

    •Incorporate 3 second breath


    hold to treat atelectasis and get
    air behind secretions

    •Incorporate huffing at different


    lung volumes to move secretions
    up airways
    BC = 3 – 4 breaths
    •Cough to clear secretions once TEE = 3 – 4 breaths
    in large airways Huff = 1- 2 huffs
    Image taken from: https://bronchiectasis.com.au/physiotherapy/techniques/the-active-cycle-of-breathing-technique
    Autogenic Drainage
     What?
     Breathing technique is to achieve the highest possible
    expiratory flow simultaneously in different generations
    of bronchi, keeping bronchial resistance low, and
    avoiding bronchospasm and dynamic airway closure
     Why?
     Optimizes speed of expiratory flow mobilises secretions
    by shearing them from the bronchial wall and moving
    them from peripheral airways to the mouth
     Who?
     Obstructive disease
    Autogenic Drainage
     How?
     By adjusting lung volumes ERV → IRV

     Position
     Sitting or lying

     Inspiration
     Breathe in slowly through the nose and hold for 2-4 seconds
    (diaphragmatic breathing)

     Expiration
     An active sigh through open glottis with appropriate airflow to avoid
    abnormal airway compression
    How?
    Phases of Autogenic Drainage
    Let’s Recap
     All secretion clearance techniques are not created
    equal!

     To optimize effectiveness, secretion clearance


    techniques should be tailored to type of lung disease
     Obstructive vs Restrictive
    References
    1. Physiotherapy for Cardiac and Respiratory Problems. Pryor JA & Prasad SA.
    3rd Ed 2002. Churchill Livingstone.
    2. Pulmonary Physiology. Levitsky MG. 7th Ed. 2007. McGraw Hill
    3. Respiratory Physiology – the essentials. West JB. 4th Ed. 1990. Williams &
    Wilkins.
    4. Principles of Pulmonary Medicine. Weinberger SE. 3rd Ed. 1998. Saunders
    5. Gosselink et al. “Physiotherapy for adult patients with critical illness:
    recommendations of the European Critical Care Society of Intensive Care
    Medicine Task Force on Physiotherapy for Critically Ill Patients”. Intensive
    Care Medicine. 2008. 34:1188-1199.
    6. Strickland et al. 2013. Respiratory Care, Vol 58(12)
    7. McIlwaine et al. 2017. Eur Respir Rev, Vol 26.
    8. Bott et at al., Joint BTS/ACPRC Guidelines. 2009. Thorax. Vol 64 (Suppl 1)
    9. Agostini P, Knowles N. “Autogenic drainage: the technique, physiological
    basis and technique”. Physiotherapy. 2007. 93(2): 157-63.

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