24 Airway Clearance Dysfunction
Jan Stephen Tecklin
Objectives Pathology Examination Patient History Systems Review Tests and Measures Evaluation, Diagnosis, and Prognosis Intervention Coordination, Communication, and Documentation Patient/Client-Related Instruction Airway Clearance Techniques Therapeutic Exercise Devices and Equipment Case Study Chapter Summary Additional Resources Glossary References
including airway obstruction, inﬂammation, infection, atelectasis, abnormal ventilation/perfusion relationships, and deterioration of arterial blood gas (ABG) values. Airway obstruction occurs in many groups of individuals and is a deﬁning feature of chronic obstructive pulmonary disease (COPD) in adults and of cystic ﬁbrosis (CF) in children, adolescents, and adults.
Airway clearance dysfunction occurs in many diseases and conditions. In reviewing the codes from the International Classiﬁcation of Diseases—Ninth revision (ICD9)1 that are listed in the Guide to Physical Therapist Practice2 for preferred practice pattern 6C: Impaired ventilation, respiration/gas exchange, and aerobic capacity/endurance associated with airway clearance dysfunction, it appears that patients in three large diagnostic groups are at risk for airway clearance dysfunction. One group includes patients with disorders caused by chronic inhalation of particulate matter, including organic (generally tobacco smoke) and inorganic dusts; another group of patients have infectious disorders; and the third large group is associated with operative procedures, including cardiovascular and orthopedic procedures and solid organ transplantation. In addition, the nature of the pathological process in CF, which leads to tenacious and voluminous bronchial secretions, inevitably produces airway clearance problems.
After reading this chapter, the reader will be able to: 1. Identify four common causes of airway clearance dysfunction. 2. Describe associations between speciﬁc pathological ﬁndings and airway clearance techniques. 3. Apply valid and reliable tests to determine whether airway clearance techniques are appropriate for a particular patient. 4. Design and execute safe and effective interventions for improving airway clearance. 5. Document and communicate the examination ﬁndings, prognosis, plan of care, and reexamination ﬁndings for any patient with airway clearance dysfunction. 6. Identify when airway clearance techniques should be taught to a patient’s family members.
EXAMINATION PATIENT HISTORY
The patient history should include questions about the following areas:
irway clearance dysfunction is a problem common to individuals with a wide variety of medical and surgical diagnoses. Airway clearance dysfunction implies an inability to adequately clear the airways of obstructing material such as mucus, secretions, ﬂuid, cellular debris, inﬂammatory exudate, or other items such as aspirated foreign objects. Many immediate and potentially adverse outcomes may result from an inability to clear the airways, 642
Employment/work Does the patient’s current employment contribute to the airway dysfunction? Is there exposure to fumes, dusts, gases or other particulate matter? Such exposure often causes and/or exacerbates lung disease.3,4 Does the physical disability limit the ability to perform workrelated tasks?
Airway Clearance Dysfunction • CHAPTER 24
Living environment Does the home or other discharge destination provide space and resources (including adequate electrical outlets) for necessary respiratory support items such as oxygen, a ventilator, and suction devices? General health status Is the patient mobile at home? Is the patient depressed? Depression is common in individuals with COPD.5 Has there been a change in community, leisure, and social function because of the illness? Social/health habits Is the patient a smoker and has there been an attempt to stop smoking? It is clear that smoking cessation, even on an intermittent basis, can reduce the long-term decline in pulmonary function associated with smoking.6 Can and does the patient participate in ﬁtness activities? Long-term exercise for individuals with chronic lung disease may reduce self-reported disability and improve functional status.7 Medical/surgical history Were there recent hospitalizations or illnesses? Are there comorbidities that may affect rehabilitation participation and effort? Current condition/chief complaint What current concern has led to the request for rehabilitation intervention and is this a recurrence? What are the current therapeutic interventions? Has the patient been performing any type of airway clearance or exercise regimen? What are the patient’s and family’s expectations for this episode of care? Functional status/activity level Was the patient previously independent at home and with activities of daily living (ADLs)? What is the current and recent status regarding work and community activities? Medications What medications is the patient taking and can these be expected to impact the physical therapy regimen? Patients with airway clearance dysfunction often use aerosolized bronchodilator and mucolytic medications. Taking these before airway clearance and exercise interventions can optimize beneﬁts from such treatments.8
Clinical Tests. Available records should be reviewed. Pulmonary function test results and ABG values can help guide the appropriate intensity of interventions and the need for rest during interventions.
The systems review is used to target areas requiring further examination and to deﬁne areas that may cause complications or indicate a need for precautions during the examination and intervention processes. See Chapter 1 for details of the systems review.
ment should therefore be performed on any patient with chronic lung disease (see Chapter 4).10 Patients with longterm hyperinﬂation have several typical ﬁndings, including tight pectoral, sternocleidomastoid, scalene, and scapular muscles and an increased anterior-posterior (AP) diameter of the thorax. The normal ratio of the AP diameter to the transverse diameter of the thorax in the absence of hyperinﬂation is approximately 1 : 2. This ratio is termed the thoracic index. In the presence of hyperinﬂation, the thoracic index increases and is often ≥2 : 1. This is termed a barrel chest.11 The muscle shortening and increase in thoracic index associated with hyperinﬂation are generally accompanied by an increase in thoracic kyphosis. Overall, the rigidity of the continually enlarged thoracic cage reduces both thoracic excursion and spinal ﬂexibility. Measurement of chest circumference with a tape measure at the level of the xiphoid process can be used to determine thoracic expansion. Chest calipers, also called pelvimeters, may also be used to determine the thoracic index and changes in thoracic index with active efforts at chest expansion and with hyperinﬂation. Range of Motion. Because of the degree of chronic inactivity and lack of mobility in many individuals with chronic lung disease, it is important to test range of motion (ROM) at all major joints in this group of patients. Shoulder girdle and thoracic spine ROM are of particular importance to assure that chest expansion is not impeded by soft tissue tightness or lack of joint mobility. In addition, people with chronic lung disease, who commonly are not able to be very active, tend to spend a great deal of time seated or supine, which often reduces ROM in the lower extremities. Examination of ROM using classical goniometric techniques, inclinometry, and observation of functional ROM are all appropriate in this population. Muscle Performance. Individuals with COPD often have muscle weakness in their extremities, shoulder girdle, neck, and chest that limits physical activity.12 There is increasing evidence that peripheral muscle dysfunction exists independent of ventilation limitations in individuals with COPD and CF.12 Studies indicate that chronic lung disease results in muscle weakness and that oxidative stress reduces muscle endurance in individuals with COPD.13 Regardless of the cause, it is clear that the peripheral muscle strength deﬁcits in this population lead to exercise limitation and intolerance.14-16 With airway clearance dysfunction, the patient beneﬁts from an effective cough. The power behind a cough is achieved by a sudden and forceful contraction of the abdominal muscles and expiratory muscles of the thorax. Expiratory muscle function is reﬂected by maximal static expiratory pressure and peak expiratory ﬂow (see Chapter 26).17,18 These can be measured easily and inexpensively with an analog “bugle” dynamometer or a digital device.19
Pain. Assessment of pain—both its source and perceived level—is an important part of the examination of the patient with airway clearance difﬁculties. Chest wall pain resulting from musculoskeletal problems is common. This pain is usually nonsegmental, localized to the anterior chest, and aggravated by deep breathing and has a
TESTS AND MEASURES
Posture. Posture is commonly altered by chronic lung disease, particularly when hyperinﬂation is present for a long period of time.9 An examination of postural align-
PART 3 • Cardiopulmonary System
palpable source. Chest wall pain is also usually unrelated to exercise. In contrast, chest pain caused by cardiac ischemia (angina pectoris) is typically a viselike, crushing midline pain that radiates to the jaw and arm and is aggravated by exercise. Thoracic nerve root inﬂammation can also cause chest pain, but this will follow a dermatomal distribution. If the patient has chest wall pain, a pain scale (see Chapter 22) should be used to determine the level of pain. A pain diary may be helpful to determine the effects of pain on daily activity and to evaluate the effects of interventions on this symptom.
Ventilation and Respiration/Gas Exchange. Two important indicators of potential problems with respiration include the rate of perceived exertion (RPE) and the level of dyspnea, commonly quantiﬁed with the revised 10point Borg Scale20 and with dyspnea scales, respectively. The Borg Scale of perceived exertion was originally a scale with a range of scores from 6 to 20 (see Box 23-3). A score of 6 indicated no exertion at all and 20 indicated very, very hard exertion. The scale was later revised to a 10point scale from 0-10 with 0 equating to no exertion at all and 10 indicating very, very strong exertion (Box 24-1). This revision has been shown to be both valid and reliable in more than 400 consecutive patients with dyspnea in an emergency department.21 It has also been shown to be reproducible over long time periods.22 There are numerous dyspnea scales that range from simple and unidimensional to more complex and multidimensional (see Fig. 23-3). In addition, dyspnea measures often appear within more wide-ranging questionnaires about respiratory diseases and their effects on the quality of life. A visual analog scale (VAS) similar to the visual analog scale used to quantify pain severity (see Chapter 22) can also be used to quantify dyspnea. A 10-cm horizontal line is presented with end points of “not breathless at all” to “worst breathlessness I can imagine.” The patient indicates his or her level of breathlessness on the line. Scoring of breathlessness on the VAS has strong concurrent validity with the Borg Scale23 and is reproducible at varying levels of exercise.24 Two very commonly employed valid and reliable disease-speciﬁc instruments that include dyspnea are the Chronic Respiratory Questionnaire (CRQ)25 and the St. George’s Respiratory Questionnaire (SGRQ).26 Both instruments are self-report questionnaires that examine the impact of respiratory problems on daily life. Both have been used extensively in research and allow for ready comparison of results from different studies.27 (See Additional Resources for information on obtaining copies of these instruments.) Many of the ﬁndings associated with impaired ventilation and gas exchange have a direct bearing on procedural intervention selection. These ﬁndings are best gathered through the tools of a traditional chest examination, which include inspection, auscultation, palpation, and percussion. Inspection. The inspection phase of the chest examination involves looking at the patient, speciﬁcally seeking
signs of problems with breathing. Inspection should ﬁrst focus on the patient’s general appearance. The therapist evaluates body type as normal, obese, or cachectic and then examines posture, taking particular note of any spinal misalignment or unusual postures as noted previously. The therapist should look for and document the presence of kyphosis, scoliosis, and forward bend, or professorial posture (Fig. 24-1). During inspection of the extremities the therapist should look for nicotine stains on the ﬁngers, digital clubbing, painful swollen joints, tremor, and edema. Nicotine stains suggest a history of heavy smoking and are important in the evaluation of the unconscious patient. Clubbing of the ﬁngers or toes is associated with cardiopulmonary and small bowel disease.28 Painful swollen joints in certain patients with lung disease may indicate pseudohypertrophic pulmonary osteoarthropathy rather than the osteoarthritis or rheumatoid arthritis more familiar to physical therapists (PTs).29 Bilateral pedal edema may indicate cor pulmonale or right-sided heart failure in those with long-standing chronic lung disease. The therapist should also note all equipment used in managing the patient. For example, the use of a cardiac monitor, a Swan-Ganz catheter, or a left ventricular assist device suggests potential or actual cardiac rhythm disturbances or hemodynamic or cardiac output problems, respectively. When inspecting the head and neck, the therapist should check the face for signs of respiratory distress and oxygen desaturation. Signs commonly seen in individuals with signiﬁcant respiratory distress include ﬂaring of the alae nasi and cyanosis of the mucous membranes.30 Inspection of the unmoving chest should include looking for congenital defects such as pectus carinatum (pigeon breast) and pectus excavatum (funnel chest or hollow chest). The therapist should next inspect the rib angles and intercostal spaces. Normally, the rib angles are less than 90 degrees, and the ribs attach to the vertebrae at an angle of about 45 degrees. The spaces between the ribs are broader posteriorly than anteriorly. Widening of the rib angles and broadening of the anterior intercostal spaces suggests hyperinﬂation of the lungs. Inspection of the musculature around the chest often reveals bilateral trapezius and sternocleidomastoid muscle hypertrophy as a result of overuse of these accessory muscles of ventilation associated with acute respiratory distress and chronic dyspnea. However, a prominent appearance of these muscles is most often caused by an increase in thoracic kyphosis and a forward-head position rather than actual muscle hypertrophy.31 The two hemithoraces should be compared for asymmetry such as unilateral chest wall retraction. Inspection of the moving chest begins with assessment of the respiratory rate, which normally ranges from 12-20 breaths per minute (breaths/min) in adults. This normal, or eupneic, pattern of breathing supplies one breath for every four heartbeats. Tachypnea refers to a ventilatory rate faster than 20 breaths/min. Bradypnea refers to a ventilatory rate slower than 10 breaths/min. Fever affects ventilatory rate which increases by 3-4 breaths/min for every
Airway Clearance Dysfunction • CHAPTER 24
Borg CR10 Scale
Instruction. Use this rating scale to report how strong your perception is. It can be exertion, pain, or something else. Ten (10) or “Extremely strong”—“Maximal” is a very important intensity level. It serves as a reference point on the scale. This is the most intense perception or feeling (e.g., of exertion) you have ever had. It is, however, possible to experience or imagine something even more intense. That is why we’ve placed “Absolute maximum” outside and further down on the scale without any corresponding number, just a dot “•”. If your experience is stronger than “10,” you can use a larger number. First look at the verbal expressions. Start with them and then the numbers. If your experience or feeling is “Very weak,” you should say “1,” if it is “Moderate,” say “3.” Note that “Moderate” is “3” and thus weaker than “Medium,” “Mean,” or “Middle.” If the experience is “Strong” or “Heavy” (it feels “Difﬁcult”) say “5.” Note that “Strong” is about 50 percent, or about half, of “Maximal.” If your perception is “Very strong” (“Very intense”) choose a number from 6 to 8, depending upon how intense it is. Feel free to use half-numbers like “1.5” or “3.5,” or decimals like “0.3,” “0.8,” or “2.3.” It is very important that you report what you actually experience or feel, not what you think you should report. Be as spontaneous and honest as possible and try to avoid under- or over-estimating. Look at the verbal descriptors and then choose a number. When rating perceived exertion give a number that corresponds to your feeling of exertion, that is, how hard and strenuous you perceive the work to be and how tired you are. The perception of exertion is mainly felt as strain and fatigue in your muscles and as breathlessness or aches in the chest. It is important that you only think about what you feel, and not about what the actual load is.
1 3 5 7 10 • 0 0.3 0.5 0.7 1 1.5 2 2.5 3 4 5 6 7 8 9 10 11 • Very light. As for a healthy person taking a short walk at his or her own pace. Moderate is somewhat but not especially hard. It feels good and not difﬁcult to go on. The work is hard and tiring, but continuing isn’t terribly difﬁcult. The effort and exertion are about half as intense as “Maximal.” Quite strenuous. You can still go on, but you really have to push yourself you are very tired. An extremely strenuous level. For most people this is the most strenuous exertion they have ever experienced. Is “Absolute maximum ,” for example “12” or even more. Nothing at all Extremely weak Very weak Weak Moderate Strong Very strong Heavy Light Just noticeable
degree Fahrenheit of fever, and by even more in young children32 (see Chapter 22 for further details of how to measure respiratory rate). Next, the therapist inspects the ratio of inspiratory and expiratory time (the I : E ratio). Normally, expiration lasts twice as long as inspiration, giving an I : E ratio of 1 : 2. In obstructive lung disease, expiration is prolonged, commonly producing I : E ratios of 1 : 4 or 1 : 5. When examining the moving chest, one also examines the sounds associated with breathing. Detection of stridor,
a crowing sound during inspiration, suggests upper airway obstruction and may indicate laryngospasm.33 Stertor, a snoring noise created when the tongue falls back into the lower palate, may be heard in patients with depressed consciousness. Expiratory grunting, commonly heard in infants with respiratory distress, may be a physiological attempt to prevent premature airway collapse. Gurgling sounds heard during inspiration and expiration may indicate copious secretions in the larger airways. The therapist next determines the pattern of breathing to identify
PART 3 • Cardiopulmonary System
the rate, depth and regularity of the ventilatory cycle. Some commonly encountered breathing patterns appear in Table 24-1. After inspecting the pattern and sounds of breathing, the therapist determines the symmetry and synchrony of breathing. The timing and relative motion of one hemithorax to the other and to the abdomen are compared during both normal tidal breathing and deep breathing. Individuals with respiratory muscle dysfunction because of neuromuscular disease often have asymmetrical or paradoxical thoracic motion. Paradoxical motion occurs when the diaphragm or rib cage muscula-
FIG. 24-1 Forward-bend or professorial posture.
ture are impaired preferentially. Paradoxical motion involves chest wall motion contradictory to the expected inspiratory motion.34 The chronically hyperinﬂated thorax and ﬂattened diaphragm, often seen with severe COPD, can result in a simultaneous in-drawing of the lower ribs and expansion of the upper ribs during inspiration.35 Gross observation of the respiratory muscles facilitates detection of accessory inspiratory or expiratory muscle activity. Moreover, careful observation of the intercostal spaces may reveal inspiratory retraction associated with decreased pulmonary compliance or expiratory bulging associated with expiratory obstruction.36 Inspection of the chest continues with evaluation of speech, breath, cough, and sputum. Speech patterns associated with breathing difﬁculties or speciﬁc breath problems can often be recognized during casual conversation, particularly shortness of breath that causes frequent interruptions in speech known as “dyspnea of phonation.” This may be quantiﬁed by the number of words that can be spoken between sequential breaths and called, for example, “three word dyspnea” or “four word dyspnea.” Malodorous breath detected during conversation may indicate anaerobic infection of the mouth or respiratory tract.37 If a patient has complaints of coughing, the clinician next identiﬁes characteristics of the cough, including whether it is persistent, paroxysmal, or occasional; dry or productive; and the circumstances associated with the onset or cessation of coughing. Examination of voluntary coughing can also assist in patient evaluation because certain cough characteristics are associated with different pathologies. For example, patients with COPD often cough with poor inspiratory effort and negligible abdominal muscle compression, making the cough ineffective for airway clearance. Patients with COPD also often have
Breathing Patterns Commonly Found in the Examination of Patients with Airway Clearance Problems Description
Absence of ventilation Apnea with concomitant mouth opening and closing; associated with neck extension and bradypnea Normal rate, normal depth, regular rhythm Slow rate, shallow or normal depth, regular rhythm; associated with drug overdose Fast rate, shallow depth, regular rhythm; associated with restrictive lung disease Normal rate, increased depth, regular rhythm Increasing then decreasing depth, periods of apnea interspersed with somewhat regular rhythm; associated with critically ill patients Slow rate, shallow depth, apneic periods, irregular rhythm; associated with CNS disorders such as meningitis Slow rate, deep inspiration followed by apnea, irregular rhythm; associated with brainstem disorders Fast inspiration, slow and prolonged expiration yet normal rate, depth, regular rhythm; associated with obstructive lung disease Difﬁculty breathing in postures other than erect Fast rate, increased depth, regular rhythm; results in decreased arterial carbon dioxide, tension; called “Kussmaul breathing” in metabolic acidosis; also associated with CNS disorders such as encephalitis Normal rate, regular intervals of sighing; associated with anxiety Rapid rate, shallow depth, regular rhythm; associated with accessory muscle activity Normal rate and rhythm; characterized by abrupt cessation of inspiration when restriction is encountered; associated with pleurisy
From Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to Practice, ed 4, Philadelphia, 2004, Elsevier Science. CNS, Central nervous system.
Airway Clearance Dysfunction • CHAPTER 24
much paroxysmal coughing that can be very fatiguing because it is so frequent and ineffective. Sputum inspection attempts to estimate or measure the quantity of expectorate raised per day. In addition to quantity, the color and consistency of any sputum raised should be evaluated. The inspection phase of the chest examination closes with a brief examination of the abdomen to detect anything that may affect diaphragmatic function. Findings affecting diaphragm function may include morbid obesity; previous and recent abdominal surgeries, including colostomy; or insertion of a feeding tube. Findings from the inspection phase of the examination may be further elucidated and validated by the auscultation phase of the chest examination,. Auscultation. Auscultation provides information about which parts of the lungs are being ventilated during breathing and about the location and presence of secretions in the lungs. Poor ventilation of an area may be addressed by breathing retraining or positional change, whereas accumulation of secretions may be addressed by speciﬁc airway clearance activities. During chest auscultation the patient should breathe in and out deeply with the mouth open. A wide range of terminology is used to describe breath sounds.38 Breath sounds are generated by the vibration and turbulence of airﬂow into and out of the airways and lung tissue during inspiration and expiration. Normal breath sounds can be divided into four speciﬁc types: Tracheal, bronchial, bronchovesicular, and vesicular. Each of these is considered normal when heard over a speciﬁc region of the thorax. However, when heard in a different region, these sounds are considered abnormal. Tracheal breath sounds are high-pitched, loud noises that sound like wind blowing through a pipe. There is a distinct absence of sound during the transition from inspiration to expiration. These sounds are considered normal when heard over the trachea. Bronchial breath sounds, which are similar to but quieter than tracheal sounds, are normal when heard next to the sternum near the major airways. When heard in any other area of the lungs, bronchial sounds usually indicate lung tissue that is consolidated, compressed, ﬁlled with ﬂuid, or airless because of atelectasis. Vesicular breath sounds are lowpitched mufﬂed sounds that have been described as a rustling sound similar to a gentle breeze blowing through the leaves of a tree.39 Vesicular sounds are louder, longer, and higher in pitch during inspiration than expiration and are considered normal over all areas of the lung except where tracheal or bronchial sounds are expected. Vesicular breath sounds are abnormal if they are diminished or absent. Diminished or absent vesicular breath sounds can occur when underlying lung tissue is poorly ventilated, or when extensive hyperaeration reduces the transmission of vesicular sounds from the lung tissue. Bronchovesicular sounds, as one might expect, combine characteristics of bronchial and vesicular sounds. Inspiration and expiration are heard for similar times, at the same pitch, and with a slight break between the two phases. These sounds are normal when heard next to the sternum at the costosternal border at the sternal
angle and between the scapulae from about T3 through T6.40 Adventitious breath sounds are breath sounds that are always abnormal. These sounds are commonly placed into two categories (although more exist): Crackles, previously called rales, and wheezes, previously called rhonchi. Crackles are nonmusical sounds that may be mimicked by rolling several strands of hair near your ear or by listening to a bowl of cereal that crackles when the milk is added. Crackles may be heard throughout inspiration or only at its termination. Inspiratory crackles are common at the bases of the lungs in an erect subject. Inspiratory crackles may represent the sudden opening of airways previously closed by gravity and therefore may be a sign of abnormal lung deﬂation.41,42 Expiratory crackles may be rhythmical or nonrhythmical. Rhythmical crackles may indicate the reopening of previously closed airways. Nonrhythmical crackles are generally low pitched and occur throughout the ventilatory cycle. They may indicate the presence of ﬂuid in the large airways. Wheezes are continuous and musical sounds that sound like whistling or growling. Wheezes are probably produced by air ﬂowing at high velocities through narrowed airways. Their pitch varies with the velocity of airﬂow and the diameter of the airway. Wheezes may be monophonic (single tone) or polyphonic (multiple tones) and may be heard during inspiration or expiration. Inspiratory wheezes may be caused by airway stenosis and other types of intrinsic or extrinsic obstruction such as bronchospasm or foreign-body aspiration. Expiratory wheezes are more common than inspiratory wheezes.39 They tend to be low pitched and polyphonic and may reﬂect unstable airways that have collapsed. Expiratory wheezes are associated with diffuse airway obstruction as may occur in patients with extensive secretions in their airways as associated with chronic bronchitis or cystic ﬁbrosis. Monophonic expiratory wheezes occur when only one airway reaches the point of collapse. Other adventitious sounds that may be detected during auscultation of the lungs include rubs and crunches. Rubs are coarse, grating leathery sounds. Pleural rubs are heard concurrently with the ventilatory cycle, whereas pericardial rubs are heard during the cardiac cycle. Rubs generally indicate inﬂammation.39 Crunches are crackling sounds heard over the pericardium during systole and suggest the presence of air in the mediastinum, called mediastinal emphysema. With these deﬁnitions and descriptions in mind, the therapist compares the quality, intensity, pitch, and distribution of the breath and voice sounds of homologous bronchopulmonary segments of the anterior, lateral, and posterior aspects of the chest. Fig. 24-2 presents one method for auscultating the chest. On completing auscultation, the therapist must record and interpret the ﬁndings in a nomenclature acceptable to the institution. Normal breath and voice sounds in all bronchopulmonary segments suggest a normal examination. If inspection was also normal and the patient denied all pulmonary symptoms, one considers this portion of the chest examination normal and further examination is deferred. If breath sounds are abnormal or if adventitious
PART 3 • Cardiopulmonary System
FIG. 24-2 A suggested method for chest auscultation. A, Anteriorly; B, posteriorly. From Buckingham EB: A Primer of Clinical Diagnosis, ed 2, New York, 1979, Harper & Row. In Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to Practice, ed 4, St. Louis, 1995, Mosby. sounds are present, the examination ﬁndings are abnormal but at this point inconclusive. Generally, decreased or absent breath sounds or inspiratory crackles suggest reduced ventilation. Crackles during both ventilatory cycles suggest impaired secretion clearance. Monophonic, biphasic wheezing suggests stenosis or bronchial smooth–muscle spasm. Polyphonic wheezing suggests diffuse airway obstruction. The absence of crackles and wheezes does not, however, ensure the absence of acute disease because patients with chronic obstructive lung disease may have hyperinﬂation so severe that adventitious sounds cannot be heard through the excessive air in the lungs. In summary, auscultation either conﬁrms the ﬁndings of inspection or identiﬁes areas of impaired ventilation or impaired secretion clearance. Palpation. In general, palpation reﬁnes the information obtained previously. It further identiﬁes any thoracoabdominal asymmetry or asynchrony detected during inspection by further examining the position of the mediastinum and motion of the thorax. Palpation of accessory muscles of inspiration permits speciﬁc examination of muscle activity identiﬁed grossly during inspection. The sternocleidomastoid and scalene muscle groups are the primary accessory muscles of inspiration.43 Normally, accessory muscles are inactive during quiet breathing. Palpation of increased accessory muscle activity during inspiration indicates that the work of breathing is increased. Their use during stressful situations, such as physical exertion or acute illness, may be appropriate, but accessory muscle use during rest may add unnecessarily to the work of breathing. Patients with airway clearance dysfunction who have chronic lung disease often habitually and unnecessarily use their accessory muscles. Intervention may be directed at reducing accessory muscle use to conserve energy.
FIG. 24-3 Palpation of scalene muscle activity. From Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to Practice, ed 4, St. Louis, 1995, Mosby.
3. Feel for activity and movement of scalenes and sternocleidomastoid muscles (Fig. 24-3). 4. Examine the area through at least two respiratory cycles.
Steps for palpating the activity of accessory muscles of breathing 1. Position the patient with his or her back toward you. 2. Place your thumbs over the spinous processes so that your ﬁngers reach around to the anterolateral aspect of the neck.
The position of the mediastinum is generally determined by palpating the position of the trachea, which is normally in the midline. A lateral shift in the mediastinum, as determined by a shift of the trachea, occurs when intrathoracic pressure or lung volume differs between the two hemithoraces. The mediastinum shifts toward the affected side when lung volume is unilaterally decreased. The mediastinum shifts toward the unaffected side or contralaterally when pressure or volume is unilaterally increased. Palpation can also be used to compare expansion of the upper, middle, and lower lobes of the lungs during quiet and deep breathing. In each case the therapist places the hands on the appropriate portion of the thorax and asks the patient to take in a normal or deep breath. The therapist compares the timing and extent of movement of each hand as the chest expands. Lobar motion, as reﬂected by thoracic motion, is considered normal when both hands move the same amount at the same time. This phase of palpation allows the therapist to localize any disproportionate expansion observed during inspection. For example, if inspection reveals asymmetrical chest expansion, palpation may not only localize the problem to the right upper lobe but may also identify a shift of the mediastinum to the right of midline. Together these signs suggest that the problem is either a loss of volume in the
Airway Clearance Dysfunction • CHAPTER 24
right upper lobe or an increase of volume in the left upper lobe. Vocal fremitus is the vibration produced by the voice and transmitted to the chest wall, where it can be detected by the hand as a tactile vibration called fremitus. The therapist evaluates fremitus by comparing the intensity of the vibrations detected by each hand during quiet breathing and speech. It is normal for the vibrations to be equal and moderate during speech. Fremitus is abnormal when it is increased or decreased. Increased fremitus suggests a loss or decrease in ventilation in the underlying lung because sound is transmitted more strongly through non–air-ﬁlled lung tissue.44 Decreased fremitus suggests increased air within the underlying lung because sound is transmitted more poorly through hyperinﬂated lung tissue.37 Rhonchal fremitus describes vibrations detected during quiet breathing caused by turbulent airﬂow through or around retained secretions in the airways. Rhonchal fremitus is therefore always abnormal. Identiﬁcation of rhonchal fremitus permits the therapist to locate secretions or to better identify reasons for decreased breath sounds found during auscultation. Palpation may also be used to identify and localize some types of chest pain to help determine the safety of continuing further examination and intervention. Palpation facilitates identiﬁcation of characteristics and descriptors associated with the pain for more complete and effective communication with the patient’s physician and may provide information about the source of chest pain, which may include musculoskeletal problems, coronary artery disease, malignancy, cervical disk or nerve root disease, thoracic outlet syndrome, herpes zoster, or pulmonary embolism. Identifying the probable anatomical source of chest pain requires associating the type of pain and its stimulus (Table 24-2). Matching the sensory distribution of the pain to the appropriate anatomical structure may also help the therapist identify the anatomical source of the pain. Table 24-3 presents the segmental innervation of the structures of the chest and abdomen. Fig. 24-4
illustrates the distribution of the cervical and thoracic dermatomes. When chest pain is identiﬁed, the therapist should also ask about the onset, character, duration, and severity of this pain. Chest pain associated with cardiac disease is important to identify because of its serious potential consequences. Such pain is often described as heaviness or crushing pain that radiates toward the neck, jaw, left
Guideline for Identifying the Probable Source of Chest Pain Effective Stimulus
Fine touch Pinprick Heat Cold Movement Deep pressure
Sharp Superﬁcial Burning Precisely localize Dull or sharp Intermediate depth Aching Generally located Dull Deep Aching Diffuse, vaguely localized
C8 CX S1 S2 L2
S3 S4 S5 L1
L3 L4 L4 L5 L4
Ischemia Distention Muscle spasm
S L I R
Adapted from Edmeads J, Billings RF: Neurological and psychological aspects of chest pain. In Levene DL (ed): Chest Pain: An Integrated Diagnostic Approach, Philadelphia, 1977, Lea and Febiger.
FIG. 24-4 Dermatome distribution of the spinal nerves. From Thibodeau GA, Patton KT: Anatomy and Physiology, ed 6, St. Louis, 2006, Mosby.
PART 3 • Cardiopulmonary System
FIG. 24-5 Palpation of diaphragmatic motion. A, At rest. B, At the end of a normal inspiration. From Cherniack RM, Cherniack L, Naimark A: Respiration in Health and Disease, ed 2, Philadelphia, 1972, WB Saunders. In Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to Practice, ed 4, St. Louis, 1995, Mosby. upper extremity, and midscapular region and generally is not affected by palpation.45 During the last phase of palpation, movement of the diaphragm is identiﬁed as normal or abnormal. Fig. 24-5 presents one method of examining diaphragmatic motion. Normal motion of the diaphragm produces equal upward motion of the costal margins. Inward motion of the costal margins during inspiration is associated with a ﬂattened diaphragm that commonly occurs in individuals with chronic airway clearance dysfunction and COPD.46 Flattening of the diaphragm caused by severe hyperinﬂation may reduce the ability of the diaphragm to contract because it alters the length-tension relationship of the muscle ﬁbers.46 Percussion. Percussion (mediate percussion) is the fourth and ﬁnal part of the chest examination. It enables the clinician to associate any symptoms and signs previously uncovered that suggest changes in lung density, and it allows one to establish the borders of abnormally dense lung areas and normally occurring organs. Finally, percussion allows examination of the extent of diaphragmatic motion. Percussion is performed by tapping the ﬁnger of one hand against the middle ﬁnger of the other hand placed on the chest wall. The middle ﬁnger should be placed at rib interspaces. The sound produced by the tapping will be affected by the density of the underlying tissue, with denser tissue (poorly inﬂated lung or other solid tissue) sounding ﬂat or dull and less dense tissue (hyperinﬂated lung) sounding hyperresonant or tympanic. When examining lung density by percussion, the therapist may identify one of three sounds or notes: Normal, dull, or tympanic. (It should be noted that physicians identify ﬁve notes: Tympanic, hyperresonant, resonant, dull, and ﬂat, but three serve the purpose for PTs.) A normal note is produced when percussion is performed over the thorax adjacent to resonant lung of normal density. A dull note is soft, brief, high-pitched, and thudlike and is heard over the thorax with lung of increased density because it is less air-ﬁlled. A dull note can be simulated by percussion over the liver or the thigh. A tympanic note is loud, lengthy, low pitched, and hollow and is heard over the thorax in areas of excessive air such as
FIG. 24-6 Normal resonance pattern of the chest with percussion. A, Anteriorly; B, posteriorly. Adapted from Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to Practice, ed 4, St. Louis, 1995, Mosby.
FIG. 24-7 Correct hand position for diagnostic percussion. Adapted from Buckingham EB: A Primer of Clinical Diagnosis, ed 2, New York, 1979, Harper & Row.
hyperinﬂated lung. A tympanic note can be simulated by percussion over the empty stomach. Normally dense, resonant lung can be found from the clavicle to the sixth rib anteriorly, the eighth rib laterally, and the tenth rib posteriorly (Fig. 24-6). The correct hand position for percussion is presented in Fig. 24-7. In a normal examination, the resonance is similar across homologous lung segments (i.e., in lung segments in similar positions within each hemithorax). Moreover, to be normal, the resonance must extend throughout the anatomical limits of the lungs. Abscesses, tumors, cysts, pneumonia, and areas of atelectasis can produce changes in lung density and result in abnormal percussive notes. Lung borders are affected by volume changes in either the abdomen or lungs. Abnormally high lung bases are associated with increased abdominal volume as seen in pregnancy. Abnormally low lung bases are associated with
Airway Clearance Dysfunction • CHAPTER 24
increased lung volumes because of hyperinﬂation as is typical in chronic obstructive lung disease. These and other variations in lung borders can be identiﬁed by mediate percussion.47 Aerobic Capacity and Endurance. Among the many reasons for testing for aerobic capacity and endurance are the following: (1) identifying through standardized protocols the baseline ability of the patient, (2) determining the capacity of the patient to perform functional activities, (3) predicting the response of the patient to physiological demands during periods of increased or stressful physical activity, and (4) recognizing symptoms that may limit the patient’s ability to respond to an increased workload. The many modes of testing range from noting symptomatic responses to a standard exercise challenge to instrumented technically sophisticated invasive aerobic testing in an exercise laboratory. Exercise testing to determine aerobic capacity typically involves progressive or incremental increases in exercise intensity while walking on a treadmill or riding a bicycle ergometer, as described in detail in Chapter 23.
assisted living situation and often require ongoing case management. In addition, collaboration with various agencies, such as home care practitioners, equipment providers, and third party payers, is often necessary to ensure continuation of care across varied settings. Complex cases often include an interdisciplinary effort that requires communication across and between disciplines, with occasional referral to other professionals not involved with the team.
Education and training about the lung disease underlying the airway clearance dysfunction is critically important for self-efﬁcacy in patients in this preferred practice pattern.48 The American Thoracic Society cites education as one of the four major components of any pulmonary rehabilitation program and includes the items in the following list as important parts of the educational component:49 1. Structure and function of the lung 2. Information regarding their speciﬁc disease 3. Instruction and participation in correct inhaler technique 4. Airway clearance techniques 5. Breathing, relaxation, and panic control techniques 6. Respiratory muscle training 7. Exercise principles 8. ADLs and instrumental ADLs (IADLs) 9. Nutrition interventions and considerations 10. Medications—their effects and side effects 11. Psychosocial interventions and means of coping with stress, anxiety, and depression 12. Avoidance of environmental irritants 13. Smoking cessation 14. Oxygen rationale and proper use of oxygendelivery devices 15. Travel and leisure activities 16. Sexuality 17. End-of-life issues and planning for those with progressive diseases Individualized teaching or a series of short, interactive lectures are commonly employed. Videotapes, digital video disks (DVDs), and CD ROMs are available regarding speciﬁc topics as are various Internet web sites. If the patient seems overwhelmed by the amount of information presented, it may be helpful to provide them with a wellorganized notebook to refer to as needed. The ultimate goal for patient-related instruction in individuals with airway clearance dysfunction is to provide basic knowledge about their disease, its medical management, and daily techniques and activities to enhance their quality of life while recognizing the limitations imposed by the disease process.
Orthotic, Protective, and Supportive Devices. Individuals with respiratory difﬁculty leading to airway clearance dysfunction often use supplemental oxygen devices, including metal oxygen cylinders of various sizes, liquid oxygen systems, oxygen concentration devices, and oxygen from wall-mounted oxygen sources in hospitals and nursing homes (as described in detail in Chapter 26). Oxygen may be delivered from these sources by nasal cannula or mask. The PT must determine the level of oxygen being used and portability of the oxygen device if gait training and ambulation activities are employed.
EVALUATION, DIAGNOSIS, AND PROGNOSIS
Outcomes from therapy for the patient with airway clearance dysfunction can include signiﬁcant reduction in a pathological process such as atelectasis. Most commonly, impairments that improve will include ABG levels, pulmonary function test performance, breathing pattern and rate, and dyspnea scores. Rating of perceived exertion during activities will also commonly improve, as well as participation in functional abilities such as transfers, ambulation and other modes of mobility. Safety, health, wellness, and patient satisfaction can also be affected by instruction of the patient and family in home use of airway clearance techniques.
INTERVENTION COORDINATION, COMMUNICATION, AND DOCUMENTATION
Coordination, communication, and documentation are interventions used for all patients and are particularly important for this preferred practice pattern because patients with impaired airway clearance generally have needs for intervention by many different types of health care professionals. Patients may need various types of equipment, help at home, or placement in some type of
AIRWAY CLEARANCE TECHNIQUES
Airway clearance techniques include a range of therapeutic interventions intended to clear the airways of secretions and other debris in individuals with pulmonary disease or respiratory impairment or those who are at risk for developing those conditions. The interventions include various physical maneuvers, manual procedures, breathing techniques, use of equipment, and instruction.
PART 3 • Cardiopulmonary System
A PT, a respiratory therapist, a nurse or other health care worker, a family member, or the patient may apply airway clearance techniques to maintain patent airways and thereby reduce or eliminate airway obstruction, enhance ventilation, and reduce the likelihood of new or continuing infection of the respiratory tract. The medical profession recognizes that providing airway clearance intervention is important despite its high costs in terms of treatment time and ﬁnancial resources. Several major “state-of-the-art” reviews on airway clearance interventions have appeared in the literature over the past quarter century.50-52 At least two professions, physical therapy and respiratory therapy, have promulgated standards of practice regarding some of the skills employed in airway clearance.2,53 Interdisciplinary educational efforts that incorporate the professions involved in airway clearance have received federal funding in past decades. Furthermore, more than “. . . two generations of physicians have been taught that retention of excessive secretions in the respiratory tract is not only bad for pulmonary function but can also be lethal to the patient.”54 Airway clearance, in one of its many forms, is a universally employed intervention for patients with virtually all types of pediatric and adult lung diseases. There are many approaches, speciﬁc techniques, and traditions for removal of secretions and other debris from the patient’s airway. However, there is a dearth of well-designed, methodologically sound, properly carried out, statistically adequately analyzed studies to support one particular technique over another. The choice of airway clearance approach should therefore be based on patient needs, therapist skill, and personal choices regarding the effectiveness of these techniques. This section presents the major approaches and techniques for airway clearance.
• Breath control, another name for diaphragmatic breathing, is performed for 15-30 seconds in a quiet, relaxed manner. • Several attempts at thoracic expansion are performed. (There is divergence of opinion regarding the necessity of having the patient assume one of the many postural drainage positions during this phase. Some might also suggest using the manual techniques of percussion or vibration during the expiratory phase of breathing.) • Breath control is repeated for 15-30 seconds. • Thoracic expansion is repeated. This alternating cycle of breath control and thoracic expansion may continue until the patient feels ready to expectorate the built-up secretions. FET and hufﬁng or coughing, as described, is performed next to help evacuate the accumulated secretions. The repeated sequence of breath control and expansion is begun again. Autogenic Drainage. Autogenic drainage (AD) is another airway clearance technique that permits selftreatment.56 AD is performed in a sitting position and requires that patients determine (through proprioceptive, sensory, and auditory signals) when bronchial secretions are present in the smaller, medium, or larger airways. The patient then learns to breathe at low, medium, and high lung volumes to mobilize secretions in those airways.
Breathing Strategies for Airway Clearance
Forced Expiratory Technique. The forced expiratory technique (FET) employs a forced expiration or huff after a medium-sized breath.55 The patient is instructed to take a medium breath (to midlung volume) then tighten the abdominal muscles ﬁrmly while hufﬁng (expiring forcibly but with an opened glottis), without contracting the throat muscles. The “huff” should be maintained long enough to mobilize and remove distal bronchial secretions without stimulating a spasmodic cough. The important part of FET is the period (15-30 seconds) of relaxation with gentle diaphragmatic breathing following 1 or 2 huffs. This helps relax the airways as secretions continue to be mobilized during the deep breathing. Once secretions are felt in the larger, uppermost airways, a huff or double cough should remove them. Active Cycle of Breathing Technique. Because of alleged misinterpretation of the technique by other practitioners, the FET was reconﬁgured into the active cycle of breathing technique (ACBT). ACBT uses several individual breathing strategies in sequential combination to accomplish the goals of mobilization and evacuation of bronchial secretions. As with FET, self-treatment without the need for an assistant or caregiver is the major advantage to ACBT. A suggested sequence for ACBT is as follows:
Sequence of autogenic drainage 1. The patient sits upright with a minimum of distractions in the room. 2. After a brief period of diaphragmatic breathing, the patient exhales to a low lung volume and breathes at a normal tidal volume at that low lung volume. This is the “unsticking phase” of AD. 3. As the patient becomes aware of secretions in those smaller airways, breathing becomes a bit deeper and moves into midlung volume. This is the “collecting phase” in which secretions are mobilized proximally into the midsized airways. 4. At this point, breathing becomes deeper at normal to high lung volumes. The patient is asked to suppress coughing until it cannot be avoided. This “evacuation phase” enables secretions to accumulate in central airways and be evacuated by hufﬁng or a cough, using minimal effort.
Proponents of AD believe it can be applied in all types of obstructive lung disease and for postoperative treatment and can be taught to children as young as 5-6 years of age. Intensive training in the technique is necessary before it can be used effectively. Recent research on AD found that ACBT and AD were comparable in improving ventilation, removing secretions, and enhancing pulmonary function.57 AD in subjects with CF was less likely to cause oxygen desaturation during treatment than traditional postural drainage with percussion (as described in the section on Manual and Mechanical Technique).58 Another study examined the effects of either AD or ACBT randomized as a treatment to 30 males with COPD over a
Airway Clearance Dysfunction • CHAPTER 24
20-day period. The two techniques were comparable in that each improved performance on standard pulmonary functions tests and perception of dyspnea. However, AD resulted in better improvement in both oxygen saturation and hypercapnia.59 Coughing and Hufﬁng. Coughing and hufﬁng is an effective means of removing secretions and is critically important for the individual with airway clearance dysfunction. Coughing may be reﬂexive or voluntary. A reﬂexive cough has four phases: Irritation, inspiration, compression, and expulsion, whereas a voluntary cough has only the latter three phases. To be effective for airway clearance, either type of cough must generate enough force to clear secretions from the larger airways and move secretions from as far down as the twelfth generation of bronchial branching.60 Hufﬁng is a popular airway clearance technique consisting of a single large inspiration followed by short expiratory efforts interrupted by pauses. The glottis remains open during hufﬁng to reduce the potential for side effects that may occur from cough (bronchoconstriction, spasms of coughing, and marked swings in thoracic pressure or cerebral blood ﬂow). Hufﬁng has been recommended in lieu of coughing because it is thought to reduce the physical work of the activity. However, research has not shown hufﬁng to be any more energy efﬁcient than coughing.61 Some studies have shown that coughing alone can be as effective at airway clearance as traditional bronchial drainage with percussion in certain patient populations, particularly those with intact strength such as patients with CF.62,63 If these techniques fail to clear the airway, endotracheal suctioning may be necessary, but where possible, coughing or hufﬁng are preferred because suctioning can injure the tracheal epithelium and may cause sudden hypoxemia or vagal stimulation, which may lead to cardiac dysrhythmias.64,65 Proper cough technique, which facilitates airway clearance, requires that the patient sequentially (1) inspires to or near a maximal inspiration; (2) closes the glottis; (3) “bears down” by tightening the abdominal, perineal, gluteal, and shoulder depressor muscles to increase intrathoracic and intraabdominal pressures; and (4) suddenly opens the glottis to enable the pressurized inspired air to suddenly escape to provide the expulsive force. The patient should cough no more than two times during each expulsive, expiratory phase—a “double cough.” To continue beyond this “double cough” usually produces little added beneﬁt. Proper cough technique after surgery may also require incisional splinting. Splinting an abdominal or thoracic incision is commonly performed by having the patient hold a small pillow ﬁrmly against the incision while attempting to cough or using the hands to approximate the edges of the incision while attempting to cough. There is no scientiﬁc evidence that this type of splinting improves cough, but there is a great deal of anecdotal commentary on the usefulness of the techniques. Following are techniques that can be used to improve cough: 1. Positioning—sitting in the forward leaning posture with the neck ﬂexed, the arms supported, and the feet ﬁrmly planted on the ﬂoor—promotes effective coughing (Fig. 24-8).
FIG. 24-8 Recommended position for effective coughing. From Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to Practice, ed 4, St. Louis, 1995, Mosby.
2. Tracheal stimulation—pressure or vibration applied to the extrathoracic trachea—may elicit a reﬂex cough. 3. Pressure applied to the midrectus abdominis area after inspiration—may improve cough effectiveness if the pressure is suddenly released. 4. Pressure applied along the lower costal borders during exhalation—may improve the effectiveness of an impaired cough.
Manual and Mechanical Techniques
Postural Drainage with Chest Percussion, Vibration, and Shaking. This group of techniques is often referred to as “chest physiotherapy,” “chest PT,” “postural drainage,” “bronchial drainage,” or simply “physio” and represents the classic and traditional approach to airway clearance that has been used for many decades. Although the evidence for superiority of this technique over other more modern approaches is lacking, a number of studies have found it to be as effective as some of the newer equipmentintensive approaches to airway clearance described, including high-frequency chest compression,66 intrapulmonary percussive ventilation (IPV),67 and treatment with Flutter devices.68 Furthermore, the experience of several generations of committed physicians, PTs, respiratory therapists and nurses has borne out the ongoing utility of
PART 3 • Cardiopulmonary System
Right upper lobe
Apical posterior segment left upper lobe
Right middle lobe
Lingular inferior segment left upper lobe
Elevate foot 12–14"
Elevate foot 12–14"
Right lower lobe
Left lower lobe
Elevate foot 18–20"
Elevate foot 18–20"
FIG. 24-9 Positions for postural drainage of different parts of the lungs.
this approach to airway clearance. In addition, the face validity of airway clearance for properly selected patients is undeniable. As a result, most patients with chronic and acute respiratory problems that produce voluminous secretions are currently treated with some airway clearance technique, whether it be manual or mechanical. Positioning. Before manual or mechanical approaches are used to loosen and mobilize secretions, it is generally recommended that the patient be positioned to optimally drain a particular lung segment or lobe. This requires that the area to be drained is uppermost, with the bronchus from the area in as close to a vertical position as possible or reasonable. Some refer to this notion as the “ketchup bottle theory.” To get ketchup from the bottle, it must be turned upside down (and shaken).69 Fig. 24-9 shows positions for postural drainage of different parts of the lungs. These positions may need to be modiﬁed under certain conditions, including increased intracranial pressure, decreased arterial oxygen tension, decreased cardiac output, decreased forced expiratory volume in 1 second (FEV1), decreased speciﬁc airway conductance, pulmonary hemorrhage (hemoptysis), gastroesophageal reﬂux (particularly common in infants and children), and severe dyspnea. Typically, the modiﬁcation consists of reducing the angle for head-down positions for the middle lobe, lingula, and lower lobes. With severe dyspnea or gastroesophageal reﬂux and with increased intracranial pressure, all positions for the middle lobe, lingula, and lower lobes
should be performed with the patient ﬂat with no decline. Recent research indicates that in infants with CF, the head–down tipped position should be avoided for the ﬁrst year of life because this position stimulates gastroesophageal reﬂux that can adversely affect lung tissue.70 Percussion and Vibration. Often referred to as “manual techniques” of airway clearance, percussion and vibration of the thorax are performed to loosen accumulated secretions. These techniques are intended to enhance movement of secretions to the more proximal airways during positioning for gravity-assisted postural drainage. Some clinicians also advocate “chest shaking,” a more vigorous type of vibration. Percussion and vibration are usually performed in an area of the thorax corresponding to the lung segment being drained while the patient is positioned speciﬁcally to allow gravity to assist in secretion drainage. Percussion, a massage stroke originally called “tapotement,” involves rhythmically clapping with a cupped hand for 2-5 minutes over the appropriate area of thorax being drained by gravity (Fig. 24-10). Percussion may feel uncomfortable but should not be painful; a layer of clothing or towel may be employed to reduce any discomfort. Vibration often follows percussion, although some advocate its use in lieu of percussion, particularly in postoperative treatment and in those for whom percussion should be done with caution (see Table 24-4). Vibration involves placing one’s hands on the area previously per-
Airway Clearance Dysfunction • CHAPTER 24
Conditions in Which Caution in the Application of Therapeutic Percussion Is Recommended Characteristics
Chest wall pain Unstable angina Hemodynamic lability Low platelet count Anticoagulation therapy Unstable or potentially lethal dysrhythmias Osteoporosis Prolonged steroid therapy Costochondritis Osteomyelitis Osteogenesis imperfecta Spinal fusion Rib fracture or ﬂail chest Bronchospasm Hemoptysis Severe dyspnea Untreated lung abscess Pneumothorax Immediately after chest tube removal Pneumonia or other infectious process Pulmonary embolus Cancer metastasis to the ribs or spine Carcinoma in the bronchus Resectable tumor Osteoporosis secondary to chemotherapeutic agents Recent skin grafts Burns Open thoracic wounds Skin infection in the thoracic region Subcutaneous emphysema in the head or back regions Immediately after cataract surgery
Type of Condition
FIG. 24-10 Correct hand position for therapeutic chest percussion. From Potter PA, Perry AG: Fundamentals of Nursing, ed 6, St. Louis, 2005, Mosby.
FIG. 24-11 Correct hand position for chest vibration. From Frownfelter D, Dean E: Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice, ed 4, St. Louis, 2006, Mosby.
cussed (Fig. 24-11) and having the patient perform several deep breaths using sustained maximal inspiration as in the ACBT maneuver. During the expiratory phase, the therapist performs a ﬁne, tremulous vibration to the chest wall. This may be repeated several times, although in individuals with copious secretions, the ﬁrst vibratory effort often stimulates coughing and evacuation of secretions and debris. As with positioning, there are pathological conditions that may be contraindications to manual techniques or that may require that such techniques be applied cautiously (Table 24-4). The basis for the recommendations in Table 24-4 is not always clear.
Mechanical Devices for Airway Clearance
High-Frequency Chest Wall Oscillation. Highfrequency chest wall oscillation (HFCWO) is provided by a device that uses an air compressor and a garment (a vest) that has inﬂatable bladders attached to the compressor by large, ﬂexible tubing (Fig. 24-12). The compressor pumps bursts of air at varying frequencies (1-20 Hz) and varying pressures into the bladders within the vest. The bursts
of air entering the vest bladder transmit oscillations or vibrations to the chest wall. Studies on HFCWO in dogs suggest that the bursts of air produce a shearing force on secretions within the airways and increase airﬂow into and out of the airways.70 Clinical studies have shown that HFCWO is as effective in the short term as manual bronchial drainage techniques.66,71 Warwick and Hansen followed 16 patients with CF using HFCWO for a period of 22 months. They determined that regression slopes for pulmonary function were slightly improved when compared to the period of time before instituting HFCWO.72 HFCWO produced changes in 50 patients with CF hospitalized for acute pulmonary exacerbation equivalent to the improvements typically produced by traditional postural drainage with percussion and vibration.66 Tecklin and colleagues found that HFCWO applied to 102 children with CF produced similar outcomes in terms of various pulmonary function tests, clinical radiology scores, and days hospitalized across 1 year, as did bronchial drainage techniques applied to 55 other children with CF.72 HFCWO, which is typically used twice each day at several different frequencies for a total of 30 minutes per treat-
ment, can be used concurrently with nebulized bronchodilators and mucolytics, whose deposition may increased by the enhanced airﬂow generated by HFCWO.73 Originally used for young adults with CF, HFCWO is now also used in other people with long-term need for airway clearance such as those who have undergone heart/lung transplantation and those with respiratory pump dysfunction secondary to chronic neuromuscular disorders. Intrapulmonary Percussive Ventilation. Intrapulmonary percussive ventilation (IPV) is a type of airway clearance administered via a pneumatic device called a highfrequency intrapulmonary percussive device. The patient breathes through a mouthpiece that delivers a preset driving pressure and frequency of intra-airway oscillations from a nebulizer-like apparatus. The device automatically activates during exhalation to provide intrapulmonary percussion at 11-30 Hz. The device simultaneously delivers positive expiratory pressure at 2-8 cm H2O and an aerosol inhalation of normal saline at 1 ml/min, with particle size distribution of 2-4 µm. During the percussive bursts of air and saline into the lungs, the inspiratory ﬂow opens airways and enhances secretion mobilization. Although it is not used as frequently in the United States as other modes of airway clearance, some data support the efﬁcacy of IPV. Newhouse and colleagues found no signiﬁcant differences among IPV, traditional chest physical therapy, and Flutter in the ability to produce sputum in subjects with CF.74 Varekojis et al found that dry sputum weights were not different among IPV, HFCWO, and vigorous chest physical therapy delivered for 2 days each in 24 subjects with CF.67 IPV appears to be a reasonable alternative for airway clearance, although it has not been a particularly popular approach in the United States. Positive Expiratory Pressure. Positive expiratory pressure (PEP) breathing employs another mechanical device for airway clearance dysfunction (Fig. 24-13). This device tries to maintain airway patency by applying positive pressure during expiration with the goal of dislodging and moving secretions proximally in the respiratory tract. PEP was originally provided via an anesthesia face mask, but a
mouthpiece can also be used to deliver this treatment. As the patient exhales, the valve of the PEP device provides a positive pressure of 10-20 cm H2O within the airways. This positive pressure stabilizes the small airways and prevents their collapse, which would otherwise trap the secretions distal to the point of collapse and interfere with evacuation of secretions by hufﬁng or coughing. In addition to assisting in secretion removal, PEP may help reduce air trapping by stabilizing the small airways and thus enhancing collateral ventilation through pores of Kohn and canals of Lambert (interconnections between adjacent alveolar sacs and respiratory bronchioles, respectively). When using PEP, patients should take a large breath in and then breathe out slowly. While breathing out, the patient will experience positive pressure from the PEP device. Many PEP devices have an indicator that shows how much pressure is being exerted. Pressure of 10-20 cm H2O should be maintained throughout the full expiration. This procedure is repeated for 10-20 breaths and is followed by hufﬁng or coughing to expel accumulated secretions. Some recommend performing the PEP maneuver while the patient is in bronchial drainage positions. PEP has been shown to be more effective than bronchial drainage and vibratory positive expiratory pressure in patients with cystic ﬁbrosis.75,76 PEP is an effective, inexpensive, well-researched, and universally employed airway clearance device. It can be used effectively by people who can understand and follow the instructions. It is not particularly useful, however, for patients with signiﬁcant neuromuscular weakness or dyscoordination who may not be able to achieve adequate ﬂows to receive the beneﬁts.
Use of a PEP device Therapist washes hands and assembles the PEP device.
Airway Clearance Dysfunction • CHAPTER 24
Patient sits upright with elbows resting on a table. Patient completes a diaphragmatic breath with a larger than normal volume. Patient holds the inspiratory breath for 2-3 seconds. Patient exhales fully but not forced to functional residual capacity (FRC) through the device. The pressure manometer should read 10-20 cm H2O pressure during exhalation. Therapist adjusts the oriﬁce to result in an inspiratoryto-expiratory time ratio of 1 : 3. Patient performs 10-20 breaths. Follow with hufﬁng or coughing. Repeat the cycle of 10-20 breaths at least 3-4 times.
Vibratory Positive Expiratory Pressure. Two vibratory positive expiratory pressure devices, the Flutter (AxcanPharma, Birmingham, Ala) (Fig. 24-14) and the Acapella (Smiths Medical, Rockland, Mass) (Fig. 24-15), are commonly employed. Each adds oscillation during the expi-
ratory cycle of PEP breathing. The Flutter employs a pipelike device with a metal ball that is dislodged and reseated in its reservoir during expiratory effort. The dislodgment and reseating of the ball opens and closes the expiratory port, which in turn oscillates the expiratory airﬂow. The Acapella oscillates airﬂow using a magnet and a rocker with a metal pin. The variable distance between the pin and the magnet should be matched and set to the patient’s needs to create the appropriate resistance and desired length of expiration. The Flutter is more technique-dependent than the Acapella because the Flutter must be positioned correctly for the ball to be properly dislodged against gravity. The Flutter was shown to have similar clinical efﬁcacy to manual airway clearance techniques in a welldesigned and controlled 2-week study in hospitalized patients in which patients with CF were randomized to a Flutter group or a chest physical therapy group. After the 2-week period, there were no differences between the groups in pulmonary function changes and exercise tolerance.77 A recent paper by Volsko et al shows that performance characteristics of the Acapella are similar to the Flutter.78 Additionally, the Acapella can be used at very low expiratory ﬂows and can generate PEP at any angle because it is not gravity dependent.78
Perforated protective cover
Circular cone Exhaled air
Suggested sequence for use of the Flutter and the Acapella Therapist washes hands and makes sure device is ready for use. Patient is seated with back and head erect. Patient places device in mouth and inhales more deeply than normal but not fully. Patient holds the inspiratory breath for 2-3 seconds. Patient now exhales fully but not forced through the device. Patient must hold cheeks ﬁrmly (not puffed out) to direct oscillation into the airways. Patient repeats each inspiratory/expiratory cycle 5-10 times and suppresses cough. Patient next takes 2 deep breaths in and out through the device. Patient attempts to remove sputum via hufﬁng or coughing. Patient repeats the entire process 2-3 times
High-density steel ball
FIG. 24-14 The Flutter device. Courtesy Axcan Pharma, Birmingham, Ala. FIG. 24-15 The Acapella airway clearance device. Courtesy Smiths Medical, Rockland, Mass.
PART 3 • Cardiopulmonary System
Assistive Devices. Percussors and vibrators have been used to assist with manual techniques of airway clearance for many years. These devices have been shown to produce similar changes in patients with CF in both pulmonary function and secretion production as unassisted manual airway clearance techniques alone but with less effort.79 These devices may be powered by compressed gas or electricity. Because an electrical motor could generate a spark that could cause an explosion around high concentrations of oxygen, the use of electrically powered devices is contraindicated around patients receiving supplemental oxygen.
Aerobic Capacity/Endurance Conditioning or Reconditioning. Patients with pulmonary disease with
associated inability to clear their airway often experience dyspnea on exertion that leads to abstaining from any activity that precipitates this unpleasant sensation. This continued avoidance of activity further decreases exercise tolerance and in turn lowers the patient’s dyspnea threshold, thereby resulting in dyspnea with even minimal physical exertion such as produced by performing ADLs. Exercise is the most common and useful intervention to break this vicious cycle of deterioration. A cautionary note is that the work of breathing during physical activity in patients with airway clearance dysfunction and COPD may constitute a major portion of their oxygen consumption, which may reduce their ability to achieve the workload one might expect. Therefore the therapist must administer the exercise program judiciously and with close monitoring for signs of early fatigue that may include cyanosis and abnormal vital signs. Rehabilitation interventions to improve aerobic capacity and exercise tolerance vary widely. They may be formal, based on a strictly derived exercise prescription, or informal, started from an arbitrary point and progressed according to a patient’s symptoms and tolerance. They may require equipment like treadmills or bicycle ergometers or merely require enough space to permit obstacle-free walking. Participants may have either subacute pulmonary disease or chronic pulmonary disease of varying severity, and the exercise regimen may begin in any setting from intensive care to home. Exercise may be administered while the patient breathes room air or supplemental oxygen. Completion of the programs may require several days, several months, or longer. Some indications for oxygen-supplemented exercise include right heart failure, cor pulmonale, resting partial pressure of arterial oxygen (PaO2) of 50 mm Hg or less on room air, inability to tolerate exercise while breathing room air,80 and oxygen saturation below 80% during physical exertion and while performing ADLs when breathing room air.81 Preparation for any aerobic exercise program requires determining the degree and type of monitoring needed to preserve the patient’s safety. No formal guidelines that establish the monitoring requirements for informal exercise programs have been published; this determination must be made according to individual circumstances. Final preparation for any exercise program requires that the therapist and patient identify a mutually acceptable
goal for the program and develop a plan for periodically evaluating progress toward that goal, often with the advice of a physician. There are clear instances in which an exercise session should be terminated. Some of these reasons for termination are physiological, and others are symptom related. The exercise session should be terminated in the presence of the following: • Premature ventricular contractions in pairs, runs, or increasing frequency • New onset atrial dysrhythmias: Tachycardia, ﬁbrillation or ﬂutter • Heart block, second or third degree • Angina • ST-segment changes of greater than or equal to 2 mm in either direction • Persistent HR or BP decline • Elevation of diastolic pressure by more than 20 mm Hg above resting or to more than 100 mm Hg • Dyspnea, nausea, fatigue, dizziness, headache, blurred vision • Intolerable musculoskeletal pain • Heart rate greater than target rate • Patient pallor or diaphoresis Aerobic exercise training for patients with airway clearance dysfunction has been shown to produce beneﬁts that include improved exercise tolerance, reduced dyspnea, and enhanced quality of life.82-85 Troosters et al randomly assigned 100 individuals with COPD to either a 6-month outpatient rehabilitation program that involved aerobic exercise training or to regular medical therapy.85 Among patients who completed the 6-month rehabilitation program, signiﬁcant and clinically important changes were demonstrated in 6-minute walking distance, maximal exercise performance, peripheral and respiratory muscle strength, and quality of life. Although the formal rehabilitation ended after 6 months, many of the beneﬁts were still evident at an 18-month follow-up session.61
Body Mechanics and Postural Stabilization Training. Body mechanics and postural stabilization
training have two potential beneﬁts for the patient with airway clearance dysfunction and COPD. One beneﬁt— reducing general body work—is discussed more fully in the section on Functional Training in Self-Care and Home Management. The second beneﬁt is to use postural stabilization and proper body positioning to reduce the work of breathing and diminish the effects of dyspnea. Many anecdotal examples of dyspnea relief in the forward-ﬂexed posture have precipitated research into proper positions for the patient with COPD. It is clear that the seated, forward-leaning posture is the preferred position to reduce dyspnea in patients with severe and moderate limitations of maximal inspiratory pressure associated with COPD. The forward-leaning posture produces a signiﬁcant increase in maximum inspiratory pressures, thereby relieving the sensation of dyspnea.86 In addition, this position may increase FRC in those with airﬂow limitations because the thorax approaches a similar position to prone in which FRC is increased.87 In patients who are unable to tolerate functional walking because of either musculoskeletal stress or dyspnea, a high walker may be adapted
Airway Clearance Dysfunction • CHAPTER 24
FIG. 24-16 A high walker to permit assumption of a forward-leaning posture in standing. From Irwin S, Tecklin JS: Cardiopulmonary Physical Therapy: A Guide to Practice, ed 4, St. Louis, 1995, Mosby.
to permit forward leaning, thereby reducing the work of breathing and the perception of dyspnea to permit the desired activity (Fig. 24-16). Flexibility Exercises. Exercise to improve ﬂexibility for the patient with airway clearance dysfunction and COPD may include stretching exercises to promote muscle lengthening, exercises to improve ROM, and mobilization exercises to improve joint function. There is little or no experimental evidence to support the use of ﬂexibility exercises in this patient population. However, it seems intuitive that maintaining or improving thoracic and shoulder girdle ﬂexibility would enhance respiratory effort by increasing thoracic compliance. A more ﬂexible chest wall should require less muscular work to inﬂate the thorax. A similar beneﬁt of increased thoracic compliance and reduced work of breathing may be implied for improving motion of a tight shoulder girdle in the patient with pulmonary disease. Many individuals with COPD have an increased AP thoracic diameter and a hyperinﬂated and often ﬁxed thoracic cage, particularly during periods of dyspnea.88 One suspects that using exercise to prevent or treat the ﬁxed thoracic cage should be beneﬁcial despite the dearth of evidence. A series of ﬂexibility exercises has been recommended as part of a traditional “warm-up” for a pulmonary rehabilitation session (Table 24-5). Although this program has
not been formally evaluated from a scientiﬁc perspective, it serves as a model for a major long-established pulmonary rehabilitation program.89 These exercises may be used as a regular exercise routine to improve or maintain good thoracic and shoulder girdle motion. Breathing Exercises. To increase alveolar ventilation, therapists teach breathing exercises that are intended to inﬂuence the rate, depth, or distribution of ventilation or muscular activity associated with breathing. The breathing strategies commonly recommended to improve ventilation and oxygenation include diaphragmatic breathing, also referred to as breathing control, pursed-lip breathing, segmental breathing, low-frequency breathing, and sustained maximal inspiration breathing exercises. ACBT and AD are also breathing strategies, but they are used primarily with airway clearance and were discussed earlier in this chapter. Diaphragmatic Breathing Exercises. The diaphragm is the principal muscle of inspiration. Historically, when muscles other than the diaphragm assumed a role in inspiration, therapeutic efforts were directed toward restoring a more normal, diaphragmatic pattern of breathing. The return to diaphragmatic breathing was thought to relieve dyspnea. Diaphragmatic breathing exercises are intended to enhance diaphragmatic descent during inspiration and diaphragmatic ascent during expiration. Diaphragmatic descent is assisted by directing the patient to protract the abdomen gradually during inhalation. One assists diaphragmatic ascent by directing the patient to allow the abdomen to retract gradually during exhalation or by directing the patient to contract the abdominal muscles actively during exhalation. Although the exact techniques used to teach diaphragmatic breathing vary, in principle they are similar. They all recommend that the patient assume a comfortable position, usually one-half to threequarters upright sitting, before beginning, and that the patient’s hips and knees be ﬂexed to relax the abdominal and hamstring muscles respectively. Diaphragmatic breathing exercises are then taught as follows:
Diaphragmatic breathing exercises 1. Place the patient’s dominant hand over the midrectus abdominis area. 2. Place the patient’s nondominant hand on the midsternal area. 3. Direct the patient to inhale slowly through the nose. 4. Instruct the patient to watch the dominant hand as inspiration continues. 5. Encourage the patient to direct the air so that the dominant hand gradually rises as inspiration continues. 6. Caution the patient to avoid excessive movement under the nondominant hand. 7. Apply ﬁrm counterpressure over the patient’s dominant hand just before directing the patient to inhale. 8. Instruct the patient to inhale as you lessen your counterpressure as inspiration continues.
PART 3 • Cardiopulmonary System
TABLE 24-5 Body Area
“Warm-up” Flexibility Exercises for Pulmonary Rehabilitation Exercise
Look up/down (nod “yes”). Look left/right (shake “no”). Move left ear to left shoulder. Move right ear to right shoulder. Shoulder circles forward and backward. Shoulder shrugs (up/relax). Shoulder blade squeeze: Rest your hands on your shoulders, touch your elbows together in front of your body, pull them apart, try to push them backward. Squeeze your shoulder blades together as you push back. Breathe IN as you push your elbows backward, and breathe OUT as you bring your elbows together in front. Front arm raises (shoulder ﬂexion): Lift your arms overhead, lower them in front of you slowly, as if pushing against resistance. Breathe IN when lifting, and breathe OUT when lowering. Side-arm raises (abduction): Lift your arms out to the side and up overhead, lower them back to your sides slowly, as if pushing against resistance. Breathe IN as you lift, and breathe OUT as you lower. Arm circles forward: With your arms fully extended and raised to shoulder level, slowly make small circles with your arms, then reverse. (If the patient is extremely short of breath, he or she may lower the arms.) Trunk rotation (side to side twists): Start with your arms extended in front of you and slowly twist to the right and then to the left. Try not to move your hips. Side-bending (right and left): Reach one arm up over your head and lean to the opposite side, then reverse. Blow OUT as you bend, and breathe IN as you straighten. Wall slide: Stand with your hips and buttocks pressed as ﬂat as you can against a wall. Shoulders should be relaxed. Slowly lower your body as if you were going to sit in a chair. Keep your hips above the level of your knees. Hold this position. Try to increase the holding time to at least 2 minutes. Hip ﬂexion: Marching in place. Toe tapping. Gastrocnemius/soleus stretch: Stand facing a wall about a foot away and put your hands on the wall in front of you at about shoulder height. With knees extended, lean your body into the wall to put a stretch on your large calf muscles. Begin with 3-5 repetitions of each exercise and then increase gradually to 7-10 repetitions. Once 10 repetitions of each can be done, a 1-lb weight may be added to the arm exercises. Perform pursed-lip breathing throughout your activity. Remember to have patients breathe “IN” through the nose and “OUT” through pursed lips. Remind them to not hold their breath.
Shoulder and upper extremity
9. Practice the exercise until the patient no longer requires manual assistance of the therapist to perform the exercise correctly. 10. Progress the level of difﬁculty by sequentially removing auditory, visual, and tactile cues. Thereafter, progress the exercise by practicing it in varied positions including seated, standing, and walking.
Diaphragmatic breathing exercises have also been administered concurrently with relaxation training with the goal of eliminating unnecessary muscle activity, particularly excessive use of the accessory inspiratory muscles. In the past, increased diaphragmatic strength was assumed when increased resistance to abdominal protraction was tolerated, as with weights placed over the abdomen, but this notion has not held up to objective scrutiny.90
Evaluation of the effectiveness of diaphragmatic breathing exercises has been the objective of much research over the past several decades. A recent and excellent review by Cahalin et al concluded that “there was great inconsistency among the many published studies regarding the operational deﬁnitions and techniques employed for teaching or demonstrating diaphragmatic breathing.”91 The outcomes examined in the many studies in this review included ventilation, severity of COPD symptoms, thoracic motion, and various tests of pulmonary function. Many normal subjects, as well as patients with COPD, who were able to increase tidal volume during diaphragmatic breathing exercises and who had good chest wall biomechanics, were able to direct greater ventilation toward the lower lobes during the exercise session, albeit with some paradoxical chest wall motion.92-95 However, in individuals with more advanced COPD, diaphragmatic breathing resulted in reduced chest wall coordination, increased dyspnea, and less mechani-
Airway Clearance Dysfunction • CHAPTER 24
cally efﬁcient breathing, making the use of these techniques questionable in those with more advanced disease.96,97 The effects of diaphragmatic breathing on pulmonary function, respiratory rate and ABG measurements are more encouraging. Sergysels et al examined diaphragmatic breathing with low frequency and high tidal volumes in patients with moderate COPD while at rest and during bicycle exercise and found that PaO2, peak oxygen consumption, vital capacity and total lung capacity, and diffusion capacity all increased when diaphragmatic breathing was employed at rest and with exercise.98 In Vitacca et al’s study, diaphragmatic breathing training, although associated with impaired chest wall function and increased dyspnea, resulted in a signiﬁcant increase in blood oxygenation along with a decrease in carbon dioxide levels.97 Diaphragmatic breathing exercises will continue to be used clinically as research more clearly deﬁnes the optimal methods for this intervention and the expected outcomes. The objectives and potential outcomes of diaphragmatic breathing are summarized in Table 24-6. Pursed-Lip Breathing Exercises. Pursed-lip breathing is another method, often associated with relaxation activities, suggested for improving ventilation and oxygenation and relieving respiratory symptoms in individuals with airway clearance dysfunction.99 One method of pursed-lip breathing advocates passive expiration,100 whereas the other recommends abdominal muscle contraction to prolong expiration.101 Current use of the technique usually encourages passive rather than forced expiration. Pursed-lip breathing with passive expiration is performed as follows:
Objectives and Potential Outcomes of Diaphragmatic Breathing Exercises
Alleviate dyspnea Reduce the work of breathing Reduce the incidence of postoperative pulmonary complication Improve ventilation Improve oxygenation Eliminate accessory muscle action Decrease respiratory rate Increase tidal ventilation Improve distribution of ventilation Decrease need for postoperative therapy
Physiological objectives Potential outcomes
Pursed-lip breathing 1. Position the patient comfortably. 2. Place your hand over the midrectus abdominis area to detect activity during expiration. 3. Direct the patient to inhale slowly. 4. Instruct the patient to purse the lips before exhalation. 5. Instruct the patient to relax the air out through the pursed lips and refrain from abdominal muscle contraction. 6. Direct the patient to stop exhaling when abdominal muscle activity is detected. 7. Progress the intensity of the exercise by substituting the patient’s hand for yours, removing tactile cues, and having the patient perform the exercise while standing and exercising.
Thoman and colleagues found that pursed-lip breathing signiﬁcantly decreased respiratory rate, increased tidal volume, improved alveolar ventilation as measured by partial pressure of arterial carbon dioxide (PaCO2), and enhanced the ventilation of previously underventilated areas of the lungs in patients with COPD.102 Mueller and colleagues also found that pursed-lip breathing improved ventilation and oxygenation in individuals with COPD, at
rest and during exercise.100 Several studies have found that this approach improves symptoms, as well as improving objective measures of ventilation and enhancing exercise tolerance and efﬁciency in patients with COPD.103-105 One study on the effects of providing external expiratory resistance to intubated patients with COPD found that this intervention did not improve gas exchange or breathing pattern in this group of subjects in ways it has been shown to improve in nonintubated patients with COPD.106 Research has failed to fully explain the symptomatic beneﬁts some patients ascribe to pursed-lips breathing. One theory is that pursed-lip breathing is effective because the slight resistance to expiration increases positive pressure within the airways and helps to keep open the small bronchioles that otherwise collapse because of loss of support associated with lung tissue destruction. Alternatively, or additionally, pursed-lip breathing could be effective because it slows the respiratory rate. At the very least, pursed-lip breathing appears to reduce respiratory rate and increase tidal volume, thereby not compromising minute ventilation. It is recommended that clinicians continue to teach pursed-lip breathing exercises to patients complaining of dyspnea. Segmental Breathing Exercises. Segmental breathing, also referred to as localized expansion breathing, is another type of exercise used to improve ventilation and oxygenation in individuals with airway clearance dysfunction. This exercise presumes that inspired air can be actively directed to a speciﬁc area of lung by emphasizing and increasing movement of the thorax overlying that lung area. This intervention has been recommended to prevent the accumulation of pleural ﬂuid, to reduce the probability of atelectasis, to prevent the accumulation of tracheobronchial secretions, to decrease paradoxical breathing, to prevent the panic associated with uncontrolled breathing, and to improve chest wall mobility.107 The attempt to preferentially enhance localized lung expansion uses manual counterpressure against the thorax to encourage the expansion of that speciﬁc area of thorax in the hopes of improving ventilation to a speciﬁc part of the lung.
PART 3 • Cardiopulmonary System
Segmental breathing exercises 1. Identify the surface landmarks demarcating the affected area. 2. Place your hand or hands on the chest wall overlying the bronchopulmonary segment or segments requiring treatment (i.e., the areas of lung you hope to expand). 3. Apply ﬁrm pressure to that area at the end of the patient’s expiratory maneuver. (Pressure should be equal and bilateral across a median sternotomy incision.) 4. Instruct the patient to inspire deeply through his or her mouth, attempting to direct the inspired air toward your hand, saying, “Breathe into my hand, or make my hand move as you breathe in.” 5. Reduce hand pressure as patient inspires. (At end inspiration, the instructor’s hand should be applying no pressure on the chest.) 6. Instruct the patient to hold his or her breath for 23 seconds at the completion of inspiration. 7. Instruct the patient to exhale. 8. Repeat sequence until patient can execute the breathing maneuver correctly. 9. Progress the exercises by instructing the patient to use his or her own hands or a belt to execute the program independently.
Evaluation of the effectiveness of segmental breathing begins with validation of its underlying premise that ventilation can be directed to a predetermined area. One study on lateral basal expansion exercises concluded that this type of segmental breathing exercise failed to improve local ventilation in patients with emphysema.108 Another study also failed to ﬁnd any change in the distribution of ventilation when subjects with lung restriction breathed segmentally but showed clearly that when subjects were placed in sidelying, both ventilation and blood ﬂow in the dependent lung improved.109 There is a lack of persuasive evidence linking segmental breathing with other therapeutic effects. However, it is quite clear and demonstrable that improving local chest wall motion can improve breathing by converting intercostal muscle shortening into lung volume expansion.110 Sustained Maximal Breathing Exercises. Breathing exercises during which a maximal inspiration is sustained for about 3 seconds have also been associated with improved oxygenation.111 Currently, sustained maximal inspiration is more commonly employed as part of the ACBT and is used in association with airway clearance techniques as described previously. Relaxation Exercise Techniques. Relaxation exercise and training are currently used as adjunctive therapy for many different diseases, including such divergent entities as gastroesophageal reﬂux, nausea after chemotherapy, behavioral aspects of autism, and mild hypertension. However, despite many anecdotal reports, particularly regarding care of the patient with asthma, there is little data to demonstrate discrete pulmonary beneﬁts of relaxation.112 Relaxation techniques coupled with breathing
strategies and hypnosis have recently been shown to result in some symptomatic improvement in children with dyspnea.113 Relaxation techniques are often administered to decrease unnecessary muscle contraction throughout the body and thereby reduce general body work. The traditional method or approach involves muscle contraction followed by relaxation, whereas a newer technique employs visual imagery to achieve the desired effects. Strength, Power, and Endurance Training. Endurance training that focuses primarily on aerobic beneﬁts has been used for decades in pulmonary rehabilitation programs. The issue of muscle strength and resistance exercise to improve strength and reduce related symptoms has only recently come to the fore as a means of improving physical functioning in patients with chronic airway clearance dysfunction. Recent work indicates that people with COPD have peripheral muscle weakness that is likely multifactorial in origin.114 Among those factors are disuse atrophy, inadequate nutrition, long-term hypercapnia and hypoxemia, reduced anabolic steroid levels, and myopathy from continuous or periodic corticosteroid use. Muscle strength, particularly lower extremity strength, is reduced in individuals with COPD when compared to age-matched controls.95 Although there is great patient-to-patient variability in this muscular dysfunction, research has demonstrated a 20% to 30% deﬁcit in quadriceps strength in those with moderate-to-severe COPD. Muscle endurance is similarly decreased in this population. These deﬁcits may limit exercise capacity and function in those with COPD.12,115,116 There is a growing body of evidence that strength training is beneﬁcial and should become part of a comprehensive physical therapy program for patients with airway clearance dysfunction and COPD. The primary beneﬁts of strength training in this population are improved muscle strength, endurance, function, and exercise tolerance and reduced dyspnea.117-120 Although these beneﬁts are reasonably well accepted, recent studies call into question the beneﬁt of such exercises on patients’ quality of life.121,122 Since the preponderance of evidence indicates that strength training can improve impairments associated with quality of life, a comprehensive intervention plan for the patient with airway clearance dysfunction should include resistance training, as well as endurance training. Features of a resistance exercise program for patients with airway clearance dysfunction are described in Table 24-7.123 Functional Training in Self-Care and Home Management, Work, Community, and Leisure Integration/Reintegration. There is little direct evidence regarding functionally speciﬁc training programs and improvement in ADLs in patients with airway clearance dysfunction. However, it appears from recent data that whether the physical rehabilitation program focuses on endurance training using treadmill or bicycle ergometry or employs more traditional calisthenics, the intervention produces signiﬁcant improvement in functional performance and overall health.124 Several studies have attempted to develop and validate ADL proﬁles for the patient with chronic airway clearance dysfunction. These proﬁles include the Manchester Respi-
Airway Clearance Dysfunction • CHAPTER 24
Features of a Resistance Exercise Program for Patients with Airway Clearance Dysfunction
Each major muscle group to be trained should be exercised 2-3× per week. Speciﬁc suggestions will depend on where the program is carried out: At home, outpatient, inpatient, and other sites. Muscle load is typically and reasonably safely initiated with 50%-60% of the 1 repetition maximum (1RM) established during the examination. Repetitions are typically 10 per muscle group at outset of program. One set of repetitions is a good starting point. A degree of success should be built in to the prescription for the psychological beneﬁts and to increase a likelihood of adherence. A rest period should provide time between the sets for recovery. Various types of resistance devices may be employed—exercise tables, benches, pulleys, free weights, etc. Exercise should focus on the large muscle groups of the lower and upper extremities, as well as trunk musculature such as latissimus dorsi. To ensure continued interest and to vary the training stimulus, it is important to vary the types of exercise and consider including eccentric, concentric, isometric, isotonic, and isokinetic exercises. ACSM recommends a 10-12 week duration followed by a period of active recovery using alternative forms of exercise. Begin with lighter loads and increase number of repetitions and sets as the patient begins to demonstrate tolerance at each particular level of activity.
ACSM, American College of Sports Medicine.
ratory Activities of Daily Living questionnaire and the London Chest Activity of Daily Living scale.125,126 One study demonstrated improvement in physical function, as measured by the Chronic Respiratory Questionnaire (CRQ) and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), after pulmonary rehabilitation.127 Unlike patients with neuromuscular or musculoskeletal deﬁcits who may need to learn new strategies and adapted tasks to regain functional independence, it appears that those with COPD need to gain control over their dyspnea and disease to use existing functional skills. These self-care skills have not been lost but have gone unused because of the physical and emotional impact of the severe dyspnea and resultant physical deconditioning that has accrued over months and years of disabling lung disease. Among the various functional tasks that may need to be relearned or adapted are the following: • Bed mobility and transfers—use of transfer boards and overhead trapeze bars • Self-care such as bathing, grooming, dressing—raised toilet seat, long-handled brush, shower seat • Household activities and related chores such as yard work—long-handled tools, rolling bench • Activity adaptation to conserve energy—break complex or difﬁcult tasks into component parts, motorized mobility device • Injury prevention—use of grab-bars, walking aids
DEVICES AND EQUIPMENT
There are various oxygen sources and delivery devices available for use in the home, at work, or in the community. Oxygen may be supplied in gas cylinders of varying sizes. These cylinders must be replaced or reﬁlled periodically to replenish the oxygen supply and most are large, bulky, and heavy. However, recent technology has made much smaller devices, such as liquid oxygen containers and oxygen concentrators, available (Fig. 24-17). These devices can supply oxygen for up to several hours of oxygen, depending on patient usage. Liquid oxygen systems have been available for use at home for many years. There is usually a large reservoir in the home from which a small, portable knapsack–size container may be FIG. 24-17 Stationary and portable liquid oxygen units. From Potter PA, Perry AG: Fundamentals of Nursing, ed 6, St. Louis, 2005, Mosby.
ﬁlled for outside use. Oxygen concentrators, which have also been available for several years, are electrically powered and use a molecular sieve to separate oxygen from the ambient air and concentrate and store the oxygen. These devices are economical for use in the home and for activities immediately around the house, such as gardening, but are too large to take out into the community.
PART 3 • Cardiopulmonary System
Oxygen must be delivered from its source to the patient via a device. Oxygen catheters may be inserted into the nasal passage or via a small surgical incision directly into the trachea, with a transtracheal device. Oxygen masks placed over the nose and mouth may also be used. These sometimes have a reservoir that enables high concentrations of oxygen to be provided. The most commonly used device is a nasal cannula that provides a small prong into each nostril for oxygen delivery (Fig. 24-18). Mechanical ventilators are commonly used for patients with airway clearance disorders when acute or chronic respiratory failure occurs such as after acute disease processes, trauma, or surgery (see Chapter 26). Basic modes of mechanical ventilation are brieﬂy identiﬁed in Table 24-8. When the patient with airway clearance dysfunction is receiving mechanical ventilation, it is important to note the parameters of ventilation, particularly when breathing strategies and retraining are to be employed. Certain modes and limitations of mechanical ventilation may or may not allow certain breathing strategies. Assistive devices, such as canes and walkers, are often indicated to assist with ambulation and enhance stability and safety.2 When recommending such assistive devices for the patient with airway clearance dysfunction, the therapist must be aware that crutches, walkers, and similar
devices tend to increase the oxygen requirement when compared to unassisted ambulation.128 A cost-beneﬁt decision about such devices must be made.129 A wheeled walker can, however, be very helpful for individuals with chronic airway clearance dysfunction. The walker not only offers support and stabilization but with a basket or small platform can be used to carry a small oxygen delivery system during community activities. Motorized scooters are useful for community mobility outside the home for shopping, work, and recreational activities in individuals with signiﬁcant airway clearance dysfunction. There are lift systems for automobile storage of the scooters to facilitate patient use. Motorized scooters and the appropriate lift devices are expensive but often make the difference between being housebound or active in the community.
CASE STUDY 24-1 CHRONIC BRONCHITIS
NT is a 66-year-old woman with a long-established history of chronic bronchitis. She was admitted to the hospital in acute respiratory distress and was diagnosed with bacterial pneumonia. Because NT previously participated in a pulmonary rehabilitation program, a physical therapy consultation was requested. She reported a 110 pack per year history of cigarette smoking. NT reported that it now exhausts her to prepare her meals and perform other IADLs. She has no signiﬁcant medical or surgical history other than her lung disease and recent osteoporosis of the vertebrae, which she reports is secondary to her medications. She is currently taking antibiotics for her infection, oral and inhaled bronchodilators, and oral and inhaled corticosteroids. Her ABG values on admission were pH: 7.33, PaCO2: 45, bicarbonate (HCO3): 20, and base excess (BE): −4. These values revealed the need for oxygen via nasal cannula at 2 L/min. Pulmonary function testing was deferred because of respiratory distress, but recent values indicated a severe obstructive deﬁcit with moderate increases in residual volume consistent with COPD and hyperinﬂation.
FIG. 24-18 Nasal cannula for oxygen delivery. From Hillegass EA, Sadowsky HS: Essentials of Cardiopulmonary Physical Therapy, ed 2, Philadelphia, 2001, Saunders.
TABLE 24-8 Mode
Control Assist Assist-control
Basic Modes of Mechanical Ventilation Description
The patient is guaranteed a predetermined number of mechanical breaths and is unable or not permitted to initiate a mechanical breath or breathe spontaneously. The patient is permitted to initiate a mechanical breath but is not guaranteed a predetermined number of mechanical breaths. The patient is guaranteed a predetermined number of mechanical breaths and is permitted to initiate additional mechanical breaths. The patient is guaranteed a predetermined number of mechanical breaths but is permitted to initiate spontaneous breaths through the ventilator.
Intermittent mandatory ventilation (IMV)
Airway Clearance Dysfunction • CHAPTER 24
Heart rate is 100 beats per minute (bpm), RR is 24 breaths/min with clear distress, BP is 130/85 mm Hg.
Tests and Measures Musculoskeletal
Posture NT has forward head and shoulders and a signiﬁcant thoracic kyphosis. Range of Motion Grossly symmetrical and full functional ROM. Muscle Performance Mild loss of strength in the lower extremities.
exchange, and aerobic capacity/endurance associated with airway clearance dysfunction, or pattern 6F: Impaired ventilation and respiration/gas exchange associated with respiratory failure. Because the medical criteria for respiratory failure includes a PaCO2 of ≥50 mm Hg, this patient should be classiﬁed as pattern 6C.
1. NT should be able to perform ADLs and IADLs in an independent manner. 2. NT is expected to resume some of her communitybased activities without risk of physical deterioration. 3. With continued adherence to her home program as identiﬁed during the outpatient portion of her plan of care, NT should have a reduced risk of recurrence, as well as an improved ability to manage her disease. 4. NT’s overall health status is expected to improve with concomitant reduction in health care costs. 5. NT’s sense of self-conﬁdence and her quality of life are expected to improve.
Circulation NT has minimal pedal edema.
Inspection NT is in acute respiratory distress with tachypnea, ﬂaring of the nares, use of accessory muscles of inspiration, and prolonged expiration with an I : E ratio of 1 : 4. Perioral cyanosis, digital clubbing, and cough produced thick, yellowish sputum without evidence of blood. Her thorax appeared symmetrical. Palpation NT has minimal thoracic excursion with a very limited right hemithorax. No shift in the mediastinum was seen. Vocal fremitus was increased in the lower right posterior and lateral thorax. Some rhonchal fremitus was palpated in that same area. Dullness to mediate percussion was noted in the lower right posterior and lateral thorax in generally the same area in which increased vocal fremitus was felt. Auscultation Distant breath sounds throughout the lungs, except for bronchial and bronchovesicular sounds in the lower right posterior and lateral thorax. Coarse crackles and low-pitched wheezing were noted in that area on the right, along with some scattering of these sounds throughout the lung ﬁelds. These ﬁndings were consistent with hyperinﬂation throughout the lungs and consolidation and increased mucus secretion in the right lower lobe. Aerobic Capacity and Endurance Testing NT’s recent worsening of fatigue during community activities and her decreasing ability to participate in ADLs are indications for additional tests. NT was asked to perform a 6-minute walk test. She was not able to complete this test. She could walk 100 feet in 2 minutes but could not continue because of severe fatigue. She reported dyspnea that was consistent with a rating of 4 on the American Thoracic Society Breathlessness Scale. She also reported a rating of 9/10 on the revised Borg RPE scale at the end of the 6-minute walk test. Integumentary: Cyanosis around the lips and nail beds, along with some moderate clubbing of the ﬁngers.
Airway Clearance Techniques
NT was treated with bronchial drainage, percussion, and vibration during her hospital admission. Because NT lives alone, she requires an airway clearance technique that she can perform independently. She was instructed in proper use of AD. She was able to demonstrate the technique, and it was reviewed with her on a weekly basis for 3 consecutive weeks as an outpatient to ensure that she was using it correctly.
Aerobic exercise training using bedside cycle ergometry was performed until NT could travel to the physical therapy department, after which she began endurance walking on a motorized treadmill. She used supplemental oxygen during her exercise until the point of hospital discharge. She continued with outpatient rehabilitation that included both treadmill exercise and free walking while at home. Strengthening exercises were performed every other day in an effort to improve muscle power throughout her weakened lower extremities. Flexibility exercises were used on alternate days to the strengthening exercises. These exercises were aimed at improving thoracic mobility in an effort to enhance motion of the thorax and the thoracic spine and reduce the degree of kyphosis. Relaxation exercises were integrated with a program of instruction in diaphragmatic breathing. These exercises were intended to reduce the muscular effort associated with overly active accessory muscles and to offer a means of dealing with the anxiety associated with breathlessness and dyspnea. Please see the CD that accompanies this book for a case study describing the examination, evaluation, and interventions for a newborn patient with meconium aspiration.
Evaluation, Diagnosis, and Prognosis
This case represents an acute exacerbation of a chronic disability whose basic pathological changes are largely irreversible. Nonetheless, through reduction of the many impairments noted in the examination, one may expect to see notable improvement in NT’s functional abilities. Findings gathered during the examination lead to a choice of diagnostic patterns between preferred practice pattern 6C: Impaired ventilation, respiration/gas
This chapter focuses on individuals with airway clearance dysfunction, particularly patients with COPD and CF. The
PART 3 • Cardiopulmonary System
principles and skills described are applicable to any patient with airway clearance dysfunction, including infants in the neonatal intensive care unit and young adults with neurological trauma that has resulted in inability to cough and clear secretions. Basic chest examination techniques— inspection, palpation, mediate percussion, and auscultation—are described and are appropriate for any patient with respiratory or pulmonary disease. Interventions described include speciﬁc approaches to airway clearance and therapeutic exercise for strength, aerobic ﬁtness, and breathing retraining.
Stridor: A crowing sound during inspiration. Thoracic index: Ratio of the anteroposterior diameter to the transverse diameter of the thorax. Tidal volume: The volume of air inspired or expired in a single breath during regular breathing. Wheezes: Whistling sounds probably produced by air ﬂowing at high velocities through narrowed airways.
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Dyspnea Scale Chronic Respiratory Disease Questionnaire (CRQ): www.atsqol.org/ sections/instruments/ae/pages/crq.html St. George’s Respiratory Questionnaire: www.atsqol.org/sections/ instruments/pt/pages/george.html
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American Thoracic Society: www.thoracic.org/ American College of Chest Physicians: www.chestnet.org/ American Lung Association: www.lungusa.org/ Pulmonary Breath Sounds: http://jan.ucc.nau.edu/~daa/heartlung/ breathsounds/contents.html
Aerobic capacity: Another term for maximal oxygen uptake . (VO2max). The highest amount of oxygen consumed during maximal exercise. Alveolar ventilation: The volume of gas expired from the alveoli to the outside of the body per minute. Atelectasis: Alveolar collapse because of poor lung expansion or complete obstruction of an airway. Auscultation: Listening with a stethoscope. Bronchodilator: Medication that reduces bronchial smooth muscle spasm and thereby causes an increase in caliber of a bronchial tube. Crackles: Nonmusical sounds (previously called rales) that may be mimicked by rolling several strands of hair near your ear or by listening to a bowl of cereal that crackles when milk is added. Crackles may represent the sudden opening of previously closed airways. Expiratory crackles may indicate the presence of ﬂuid in the large airways. Dyspnea: Shortness of breath. A subjective difﬁculty or distress in breathing. Fremitus: Vibrations within the thorax that can be palpated. Hypercapnia: Increased carbon dioxide level in the arterial blood. Hypoxemia: Low or insufﬁcient oxygen in the arterial blood. Mucolytic: A medication capable of dissolving or decreasing the viscosity of mucus. Paradoxical breathing: Moving the belly in during inspiration and out during expiration. Stertor: A snoring noise created when the tongue falls back into the lower palate.
Airway Clearance Dysfunction • CHAPTER 24
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PART 3 • Cardiopulmonary System
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