LUNG EXPANSION THERAPY

AND AIRWAY CLEARANCE TECHNIQUE,

INCLUDING SUCTIONING FOR
CRITICALLY ILL PATIENTS.
Presented By
Jean Nikitha Noronha

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Contents
• Introduction • Indications of ACT
• A-Lung expansion therapy • Devices For ACT
• Principles of Lung expansion therapy • Selecting ACT
• Indications for Lung Expansion Therapy • C - Suctioning for critically ill patients
• Devices/ techniques for lung expansion • Why is suctioning needed?
therapy
• Types of suctioning
• How to select an effective approach
• Equipment's required for suctioning
• B- Airway Clearance Techniques
• Recent advances
• Physiology of ACT

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Introduction
• Lung expansion therapy, airway clearance techniques → set of chest physiotherapy
techniques used by PT, RTS.
• Help improve ↑ lung volumes and capacities and maintain a clear airway that helps in gas
exchanges.
• These can be achieved by using manual techniques and specific assistive devices.
• Below are mentioned about these techniques, the physiology of each technique, and how
each of these techniques is indicated to help in respiratory conditions.

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A . Lung Expansion Therapy

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Lung expansion therapy
• Lung expansion therapy techniques help improve pulmonary function by
↑ the alveolar recruitment
assisting in optimizing the clearance of airways.

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Principles of Lung expansion therapy
• PTP=Palv-Ppl
• The greater the transpulmonary pressure gradient, the more alveoli recruitment.
• Either can increase the PTP gradient
decreasing the surrounding pleural pressure
increasing the alveolar pressure

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Indications for Lung Expansion Therapy
• Any condition that causes the  in lung volumes,
i.e., pulmonary complications post abdominal and thoracic surgeries – atelectasis,
consolidation, pneumonia, pneumothorax, acute respiratory failures, or even restrictive
conditions.
• The most effective use of these methods is in atelectasis / in preventing atelectasis

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Atelectasis
• Atelectasis - The term atelectasis describes
a state of the collapsed and non-aerated
region of the lung parenchyma, which is
otherwise normal.
• Peroni DG et al., 2000
• Two types
• Gas absorption atelectasis - collapsing of
airways due to hyperoxygenation and
nitrogen washout.
• Compression atelectasis- a collapse of a
part of the lung due to an external force
compressing the lung.
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Devices/ techniques for lung expansion
therapy

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1.Incentive spirometry
• Introduced in the early 1970s as a handheld device to prevent postoperative pulmonary
complications.
• Designed to encourage patients to improve their inspiratory volume while visualizing their
inspiratory effort.
• It works on the principle of sustained maximal inspiration

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Physiological basis
• Functionally equivalent to performing an FRC to IC
maneuverer, followed by a breath-hold.
• During the inspiratory phase of spontaneous
breathing, the decrease in Ppl caused by expansion
of the thorax is transmitted to the alveoli.
• A pressure gradient is created between the airway
opening and the alveoli, with Pal now negative.
This trans respiratory pressure gradient causes gas
to flow from the airway into the alveoli.
• The greater the trans respiratory pressure gradient
within certain limits, the more lung expansion
occurs.

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Indications
• Conditions predisposing to the development of pulmonary atelectasis (upper abdominal
surgery, thoracic surgery)
• Surgery in patients with COPD
• pulmonary atelectasis
• restrictive lung defect associated with quadriplegia or dysfunctional diaphragm
• Preventive measure when conditions exist that make the development of atelectasis likely.
• AARC Clinical Practice Guideline,2011

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Relative Contraindications
• A patient cannot be instructed or
supervised to ensure the appropriate use of
a device
• Patient cooperation is absent, or the
patient is unable to understand or
demonstrate proper use of the device
• Presence of an open tracheostomy (is not a
contraindication but requires adaptation of
the spirometer)

• AARC Clinical Practice Guideline,2011

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Hazards and Complications
• Hyperventilation and respiratory alkalosis
• Dizziness and numbness around the mouth
• Inappropriate as the sole treatment for major lung collapse or consolidation
• Barotrauma (emphysematous lungs)
• Discomfort secondary to inadequate pain control
• Hypoxia owing to break in mask O2 therapy
• Exacerbation of bronchospasm
• Fatigue
• AARC Clinical Practice Guideline,2011

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Types of Devices
• Measure and visually indicate the volume achieved
during an SMI.
• The device employs a bellows that rises according to
the inhaled volume.
Volume oriented devices
• When the patient reaches a target inspiratory volume,
a controlled leak in the device allows the patient to
sustain the inspiratory effort for a short period (usually
5 to 10 seconds).

• measure and visually indicate the degree of inspiratory

flow
Flow Oriented Devices
• This flow can be equated with volume by assessing the
duration of inspiration or time (flow × time = volume).
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Flow Oriented Devices Volume Oriented Devices

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Potential outcomes of spirometry
• ↑SpO2
• Absence of or improvement in signs of
atelectasis • ↑ VC and peak expiratory flows
• ↓ respiratory rate • Restoration of preoperative FRC or VC
• Normal pulse rate • Improved inspiratory muscle performance
• Resolution of abnormal breath sounds and cough
• Normal or improved chest radiograph
• Attainment of preoperative flow and
volume levels
• Improved PaO2 and ↓ PaCO2
• ↑ FVC

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2.Non-invasive Ventilation(NIV)
• In the early 1980s, NIV was pioneered first by Rideau and
colleagues in France and subsequently by Bach and
colleagues in the United States
• It provides breathing support to patients with inadequate
ability to ventilate.
• It has been documented to have beneficial effects for
patients who may need periodic, short-term support or
patients experiencing exacerbations of pulmonary disease.
• NIV offers some benefits over traditional, invasive
ventilation owing to lower infection risk and reduced need
for sedation because of the absence of an artificial airway.

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• Recognized as an effective treatment for
respiratory failure in chronic obstructive pulmonary disease,
cardiogenic pulmonary edema
and other respiratory conditions without complications such as respiratory muscle
weakness, upper airway trauma, ventilator-associated pneumonia, and sinusitis
• Works by creating a positive airway pressure, i.e., the pressure outside the lungs is more
significant than the pressure inside the lungs.
• This causes air to be forced into the lungs, lessening the respiratory effort and reducing
the work of breathing.
• It also helps keep the chest and lungs expanded by ↑ FRC after a routine (tidal) expiration;
this is the air available in the alveoli open for gaseous exchange.

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3.Intermittent Positive Airway Pressure
Breathing(IPPB)
• Intermittent short-term delivery of positive pressure to a patient to improve lung
expansion, deliver aerosolized medications, and assist ventilation
• It was one of the most popular therapeutic modalities prescribed in the 1960s and 1970s
and was regarded as a solution for all pulmonary ailments.
• Not until the American College of Chest Physicians conference on oxygen therapy in
September 1983, when both its overuse and its doubtful efficacy were discussed, did IPPB
decline as a treatment modality.
• Today, newly practiced modalities, such as bi-level positive airway pressure (BI-PAP) and
incentive spirometry, have rendered IPPB obsolete. Most institutions do not own an IPPB
device.

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Physiological Basis
• The intent of IPPB is not to provide full ventilatory support but to provide machine-
assisted deep breaths assisting the patient to a deep breath and stimulate a cough.
• IPPB has historically consisted of providing an aerosol under positive pressure, ↑ the
patient's inspiratory efforts → resulting in a larger tidal volume than could be
spontaneously generated.
• Lung volumes are ↑ in IPPB because Alveolar pressure is more significant than Pleural
pressure.
• Depending on the mechanical properties of the lung, Pleural pressure may exceed
atmospheric pressure during a portion of inspiration.
• As with spontaneous breathing, the recoil force of the lung, stored as potential energy
during the positive pressure breath, causes a passive exhalation. As gas flows from the
alveoli out to the airway opening, Alveolar pressure decreases to atmospheric level, while
Pleural pressure is restored to its normal sub-atmospheric range.
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Indications
• Need to improve lung expansion
• clinically significant pulmonary atelectasis when other forms of therapy have been
unsuccessful or the patient cannot cooperate
• Inability to clear secretions adequately
• short-term non-invasive ventilatory support for hypercapnic patients (as an alternative to
intubation and continuous ventilatory support)
• To deliver aerosol medication to patients with ventilatory muscle weakness, fatigue, or
chronic conditions in which intermittent non-invasive ventilatory support is indicated.
• AARC Clinical Practice Guideline 2003

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Contraindications
No absolute contraindications • Recent oesophageal surgery
• ICP >15 mm Hg • Active hemoptysis
• Hemodynamic instability • Nausea
• Recent facial, oral, or skull surgery • air swallowing
• Tracheoesophageal fistula • Active, untreated tuberculosis
• Radiographic evidence of bleb
• Singultus (hiccups)

• AARC Clinical Practice Guideline 2003

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Hazards and complications
• Increased airway resistance • Secretion impaction (inadequate humidity)
• Barotrauma, pneumothorax • Psychological dependence
• Nosocomial infection • The impedance of venous return
Exacerbation of hypoxemia
• Hyperventilation or hypocapnia
• Hypoventilation
• Haemoptysis
• Increased V/Q¬ mismatch
• Hyperoxia when O2 is the gas source
• Air trapping, auto-PEEP, overdistended
• Gastric distention alveoli
• AARC Clinical Practice Guideline 2003

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 Using IPPB

Bird series-Mark 7 series Puritan Bennett PR Series 25

4. Positive airway pressure therapy
• Positive airway pressure (PAP) adjuncts use positive pressure to ↑ the PTP gradient and
enhance lung expansion.
• In contrast to IPPB, PAP therapy requires no complex machinery. Some methods do not
even need a source of pressurized gas
• There are three current approaches to PAP therapy:

 PEP*
 Flutter*
 CPAP

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Physiological basis
• All three techniques are effective in
treating atelectasis in most postsurgical
patients.
• PEP and flutter valves only create positive
expiratory pressure
• CPAP maintains a positive airway pressure
throughout inspiration and expiration.

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• CPAP elevates and maintains high alveolar and airway pressures throughout the entire
breathing cycle; this increases the PTP gradient throughout inspiration and expiration.
• Typically, a patient on CPAP breathes through a pressurized circuit against a threshold
resistor, with pressures maintained between 5 cm H2O and 20 cm H2O.
• To maintain system pressure throughout the breathing cycle, CPAP requires a source of
pressurized gas.
• The following factors involving PAP, flutter, and CPAP therapy contribute to the beneficial
effects-
recruitment of collapsed alveoli via an increase in FRC
decreased work of breathing secondary to increased compliance or elimination of
intrinsic positive end-expiratory pressure (PEEP)
improved distribution of ventilation through collateral channels (e.g., pores of
Kohn), and
increase in the efficiency of secretion removal.

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Indications
• Although evidence exists to support the use of CPAP therapy in treating postoperative
atelectasis, as with all mechanical techniques, the duration of beneficial effects appears
limited.
• The corresponding ↑ FRC may be lost within 10 minutes after the end of the treatment. For
this reason, it has been suggested that CPAP should be used continuously until the patient
recovers.
• To treat cardiogenic pulmonary enema.
• CPAP  venous return and cardiac filling pressures in such patients, which helps mitigate
pulmonary vascular congestion.
• Improve lung compliance
•  WOB
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Contraindications
• A hemodynamically unstable patient is unlikely to tolerate CPAP for even a short period
• A patient suspected of having hypoventilation is not a good candidate for CPAP because it
does not ensure ventilation, but the patient may be an ideal candidate for consideration of
NIV
• Other problems that may indicate CPAP is inappropriate are nausea, facial trauma,
untreated pneumothorax, and elevated intracranial pressure.

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Hazards and Complications
• caused by either the ↑ pressure or the apparatus
• The ↑ work of breathing can lead to hypoventilation and hypercapnia. In addition, because
CPAP does not augment spontaneous ventilation, patients with an accompanying
ventilatory insufficiency may hypo ventilate during application.
• Barotrauma (emphysema and blebs)
• Gastric distention may occur, especially if CPAP values greater than 20 cm H2O are
needed. This condition may lead to vomiting and aspiration in a patient with a bad gag
reflex

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5. Early mobilization
• Mobilization does not only include walking, but also sitting,
standing, and getting out of bed into a chair.
• As the patient changes body position, their breathing, and gas
distribution within the lung changes.
• Improvements in ventilation result in less alveolar collapse
• Because of the beneficial pulmonary effects from the early
mobilization of the post–abdominal surgery patient, it has been
suggested that mobilization should be considered as early as the
day of surgery.
• Having a patient who is able to respond to the caregiver allows
for better pain control with decreased risk of sedation-related
complications.
• Although early mobilization does not classify as a procedure, it
does have distinct benefits in decreasing morbidity and mortality.
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How to select
an effective
approach

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B. Airway Clearance Techniques

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Airway clearance techniques (ACT)
• Refers to a variety of different strategies used to eliminate excess secretions.
• The aim is to reduce airway obstruction caused by secretions occupying the airway lumen
and so prevent respiratory tract infections by re-expanding the collapsed areas of the lung,
thus improving gas exchanges and decreasing the inflammatory response

• Belli S et.al , 2021

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Physiology of ACT
• Airway clearance in normal lungs
1. Mucociliary escalator/ mucociliary clearance –
2. Cough
3. Macrophages

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1.Mucociliary Escalator
• term used to define the process in which the cilia of the airways continually move mucus
and other foreign materials from the lower respiratory tract to the oral cavity, where it is
subsequently removed by swallowing
• This system consists of
mucous and serous cells in the submucosal glands
secretory goblet cells in the airway epithelium (secrete water, mucus, other proteins
to produce a fluid layer on the airway surface)
the ciliated cells that propel the fluid out of the lung toward the mouth
-Encyclopedia of respiratory medicine, 2006, PG 466-470.L.E. Ostrowski, et al.

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• The efficiency of the mucociliary clearance system at removing airway secretions and
associated trapped substances depends on three primary factors
the beat frequency and coordination of the cilia
the quantity and rheology of airway secretions derived from surface goblet cells and
submucosal glands
and the periciliary fluid depth that is modulated by ion transport of the airway
epithelium
• In healthy individuals, this system is very effective at clearing mucus and associated
bacteria and toxins from the lung.
• But in a variety of airway diseases, this apparatus becomes dysfunctional, leading to
further exacerbation of airway inflammation and obstruction.
• -Encyclopedia of respiratory medicine, 2006, PG 466-470.L.E. Ostrowski, et al.

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2.Cough Irritation

Inspiration

Cough

Compression

Expulsion

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3.Macrophages
• The mucociliary escalator does not extend to the alveoli.
• Particles deposited in this region are engulfed by macrophages on the surface of the
alveoli.
• The foreign particles engulfed by these macrophages either move up to join the
mucociliary escalator or escape via the lymphatic or venous system.

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How can these mechanisms be impaired?
• Any abnormality altering
airway patency
mucociliary function
the strength of the inspiratory or expiratory muscles
thickness of secretions
effectiveness of the cough reflex
• some therapeutic interventions, used in critical care, such as an endotracheal tube, can
result in abnormal clearance.

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 Impaired
Retention of
airway
secretions
clearance

Full/partial
obstruction /
Lung damage
mucus
plugging

atelectasis /
Infection

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Mechanisms that impair cough reflexes
Phases Impairments
Irritation Anaesthesia
CNS depression
Narcotic Analgesic
Inspiration Pain
NMD
Pulmonary restriction
Abdominal restriction
Compression Laryngeal nerve damage
Artificial airways
Abdominal muscle wakens
Expulsion Airway compression
Airway Obstruction
Abdominal muscle weakness
Inadequate lung recoils 43
 Indications of ACT
IN ACUTE CONDITIONS IN CHRONIC CONDITIONS

Copious secretions Conditions associated with copious sputum

production - cystic fibrosis, Bronchiectasis
, Ciliary dyskinetic syndromes, COPD patients
with retained secretion

Inability to mobilize secretions

Ineffective cough

V/Q Abnormalities

Patients with retained secretions ((coarse

crackles, worsening oxygenation and/or
ventilation, volume loss on chest radiograph))

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Postural Drainage
• Use of gravity to move secretions from peripheral airways to the larger bronchi →easily
expectorated.
• Patient placed in various positions i.e. designed to drain specific lung segments.
• PD may be used exclusively given or combined with other airway clearance techniques.
• Priority should be given to treating the most affected lung segments first, and the
patient should be encouraged to take deep breaths in the PD position and cough (or be
suctioned) between positions as secretions mobilize.
• The number of PD positions tolerated per treatment session will vary with each patient.
• Signs of treatment intolerance include increased shortness of breath, anxiety, nausea,
dizziness, hypertension, and bronchospasm

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Percussion
• Chest percussion is a technique aimed at loosening retained secretions from the
bronchiole walls to loosen these secretions from the airways so they may be removed by
suctioning or expectoration.
• During percussion, care should be taken to apply the device to the affected lung segments
individually and not just generally on the lungs.
• It can be performed manually or with a mechanical device.

Manual
Percussion
Percussion
Mechanical
Percussion
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MANUAL PERCUSION MECHANICAL PERCUSSION
consists of a rhythmical clapping with cupped Mechanical percussion is similar in
hands over the affected lung segment. effectiveness to manual percussion..
Air is trapped between each cupped hand Electrically or pneumatically powered
and the patient's chest with each clap. percussion devices can enable patients to
(Slapping sounds indicate poor technique treat themselves independently as their
and may cause discomfort or injury to the medical condition improves
patient.)
The ideal percussion frequency is unknown;
however, some reports recommend a
frequency of 5 to 6 Hz (300-360 blows per
minute), whereas others suggest slow,
rhythmic clapping.

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Percussors

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Advantage and disadvantage of
percussion
• The addition of percussion to a PD treatment may enhance secretion clearance and
shorten the treatment.

• Patients with chronic lung disease, who have used PD and percussion for many years and
have found it compelling, are reluctant to try an alternative method of airway clearance.

• Compliance with this method is dependent on the availability of a family member or other
caregiver to provide the treatment.

• Mechanical percussion allows the patients more independence or decreases fatigue of a

caregiver and is especially useful in patients requiring ongoing treatment at home

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• Not well-tolerated by many patients postoperatively without adequate pain control.

• The percussion force is also a threat to patients with osteoporosis or coagulopathy.

• Has been associated with a fall in oxygen saturation(which can be eliminated with
concurrent thoracic expansion exercises and pauses for breathing control.)

• Delivering percussion for extended periods on an ongoing basis can injure the caregiver,
whether a family member or a health care provider.

• Repetitive motion injuries of the upper extremities may occur in long-term delivery of
percussion for airway clearance.

• The expense of a mechanical device for percussion is minimal compared with the ongoing
cost to provide percussion and PD in the hospital setting or a home care situation.

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Vibration
• Vibrations represent an additional method of transmitting energy through the chest wall
to loosen or move bronchial secretions.
• It can be performed manually or with a mechanical device. As with percussion, vibration is
utilized in postural drainage positions to clear secretions from the affected lung segments.
• To perform vibration, the palmar aspect of the clinician's hands is in complete contact with
the patient's chest wall, or one hand may be partially or fully overlapping the other and At
the end of deep inspiration, the clinician exerts pressure on the patient's chest wall and
gently oscillates it through the end of expiration.

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• Manual vibration frequency has been reported to be 12 to 20 Hz. This sequence is repeated
until secretions are mobilized.
• Vibration may be a valuable alternative to percussion in acutely ill patients with chest wall
discomfort or pain.
• The clinician may assess the depth and pattern of breathing during manual vibration.
• The pressure on the thorax exerted during vibration on expiration often causes a volume of
air to be expired that is greater than what is exhaled during tidal breathing. This may
encourage a deeper-than-tidal inspiration to follow and support a more effective cough.
• Mechanical vibration devices are also available for use; however, they may be more
challenging to coordinate with the patient's breathing pattern.

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Advantages and Disadvantages of
Vibration
• The use of vibration with PD may enhance the mobilization of secretions.
• Vibration may be better tolerated than percussion, especially in the postsurgical patient.
• Manual vibration allows the caregiver to assess the pattern and depth of respiration. The
stretch on the muscles of respiration during expiration may encourage a more profound
inspiration to follow.

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Manual Vibrations Mechanical Vibrations

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Manual hyperinflation
• The technique of manual hyperinflation is
used in patients with an artificial airway,
who are mechanically ventilated or who
have a tracheostomy.
• This method of airway clearance promotes
mobilization of secretions and reinflates
collapsed areas of the lung.
• Two caregivers are necessary to provide
this treatment, and the coordination
between these two people is key to
achieving satisfactory results.

Manual hyperinflation with AMBU

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Advantages / disadvantages of Manual
hyperinflation
• Manual hyperinflation may help manage airway secretions in those patients
requiring long-term mechanical ventilation. In this patient population, the choice
of airway clearance techniques is limited, especially when the patient is
unresponsive.
• MIH simulates a cough by enhancing the inspiratory effort, momentarily
maintaining a maximal inspiratory hold, and causing an increased expiratory flow.
However, hyperinflation has the potential to cause significant barotrauma.

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• There are several contraindications to this technique, including
unstable hemodynamic
pulmonary edema
air leak, and
severe bronchospasm.
• MIH requires two well-trained caregivers. This may be its most significant
disadvantage

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Coughing
• Most ACTs only help move secretions into the central airways.
• Clearance of these secretions requires either coughing or suctioning.
• Different techniques for coughing
• Directed coughing
• FET
• Manual assisted techniques
• Self-assisted techniques

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Directed Coughing
• Directed cough is a maneuver that is taught, supervised, and monitored. It aims to assist in
creating a productive cough in patients unable to clear secretions with an effective
spontaneous cough.
• In patients with copious secretions, directed coughing is an effective clearance method
clearing secretions from the central—but not peripheral—airways. In addition to aiding in
removing retained secretions from central airways, it should be a routine part of all ACT
and may help obtain sputum specimens for diagnostic analysis.

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Contraindications
• Relative contraindications - Inability to control the possible transmission of infection from
patients suspected or known to have pathogens transmittable by droplet nuclei (e.g.,
Mycobacterium tuberculosis)
• elevated intracranial pressure/ known intracranial aneurysm
• reduced coronary artery perfusion, such as in acute myocardial infarction
• Acute unstable head, neck, or spine injury
• Manually assisted directed cough with pressure to the epigastrium may be contraindicated in
the presence of increased potential for regurgitation or aspiration, acute abdominal pathology,
abdominal aortic aneurysm, hiatal hernia, pregnancy, bleeding diathesis, or untreated
pneumothorax
• Manually assisted directed cough with pressure to the thoracic cage may be contraindicated in
the presence of osteoporosis or flail chest

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Hazards and complications
• Reduced coronary artery perfusion • Incisional pain, evisceration
• Reduced cerebral perfusion • Anorexia, vomiting
• Incontinence • Gastroesophageal reflux
• Fatigue • Spontaneous pneumothorax
• Rib or costochondral fracture • Pneumomediastinum
• Headache
• Subcutaneous emphysema
• Visual disturbances, including retinal
haemorrhage • Cough paroxysms
• Bronchospasm • Chest pain
• Muscular damage or discomfort • Central line displacement
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Forced expiratory Techniques
• FET consists of one or two forced expirations of middle to low lung volume without glottis
closure, followed by a period of diaphragmatic breathing and relaxation.
• This method aims to help clear secretions with a minor change in pleural pressure and less
likelihood of bronchiolar collapse.
• To help keep the glottis open during FET, the patient is taught to phonate or "huff" during
expiration.
• The period of diaphragmatic breathing and relaxation following the forced expiration is
essential in restoring lung volume and minimizing fatigue.
• Comparative clinical studies on the effectiveness of FET have shown favorable results. The
technique is beneficial in patients prone to airway collapse during regular coughing's, such
as patients with COPD, CF, or bronchiectasis

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 1-2 huffs (mid to
low lung volume
with glottis open)

Slow
Relaxation diaphragmatic
breathing

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Cough Techniques
• Manual Assisted techniques • Self-assisted techniques
• Costophrenic assist • Prone on elbows head flexion self-
•
assisted cough
Heimlich-type assist or abdominal
thrust assist • Long-silting self-assisted coughs
• Anterior chest compression assist • Short-sitting self-assisted coughs
• Counterrotation assist • Hands-knees rocking self-assisted
cough
• Standing self-assisted coughs

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Active Cycle of Breathing Technique
• To emphasize that FET should include breathing exercises, the originators of this
technique modified the procedure and renamed it the ACBT.
• ACBT consists of repeated cycles of breathing control, thoracic expansion, and FET.
• Breathing control involves gentle diaphragmatic breathing at normal tidal volumes for 5
to 10 seconds with the relaxation of the upper chest and shoulders. This phase is
intended to help prevent bronchospasm.
• The thoracic expansion exercises involve deep inhalation, approaching vital capacity, and
relaxed exhalation, accompanied by percussion, vibration, or compression.
• The thoracic expansion phase is designed to help loosen secretions, improve ventilation
distribution, and provide the volume needed for FET.
• The subsequent FET moves secretions into the central airways.
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• Postoperative patients may require splinting at the thoracic or abdominal incision site.
• Although ACBT can be performed in the sitting position, it is most beneficial when
combined with PD.
• When ACBT is compared with similar methods of secretion clearance, studies indicate that
ACBT can provide comparable results in both sputum production and distribution of
ventilation.
• ACBT is not helpful with young children (< 2 years old) or critically ill patients.
• Caution should be taken in patients with reactive airway during ACBT

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 Breathing
Coughing control
20-30 sec

3-4 deep
Huffing
breaths

Breathing Breathing
control control

3-4 deep
breaths

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Autogenic Drainage
• AD is another modification of directed coughing, designed as an airway clearance
mechanism that trained patients can perform independently.
• During AD, the patient uses diaphragmatic breathing to mobilize secretions by varying
lung volumes and expiratory airflow in three distinct phases
• For maximum benefit, the patient should be in the sitting position. Patients are taught to
control their expiratory flows to prevent airway collapse while achieving a mucous "rattle"
rather than a wheeze.
• Coughing should be suppressed until all three breathing phases are completed. In patients
with CF, AD provides sputum clearance comparable to postural drainage percussion on a
vibration (PDPV) but is less likely to produce O2 desaturation. In addition, AD seems to be
tolerated better by patients and has the advantage of being performed without assistance
from a caregiver.

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Mechanical Insufflation-Exsufflation
• The MIE device (also called cough-assist
device or "coughlator") has gained
popularity in managing secretions in
patients with certain neuromuscular
disorders.
• The reason is growing evidence that MIE
helps prevent respiratory complications in
patients with NMD by assisting them to
generate sufficient expiratory flow rates
needed for adequate secretion clearance.

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Positive airway Pressure adjuncts
• PEP therapy involves active expiration against a fixed orifice flow resistor or
variable orifice threshold resistor capable of developing pressures of 10 to 20 cm
H2O.
• Most fixed orifice devices allow adjustment of the orifice size to achieve a targeted
PEP level.
• In theory, PEP therapy helps move secretions into the larger airways by providing
a constant back-pressure that prevents airway collapse during expiration and the
airway behind the mucus fills via collateral ventilation.
• A subsequent huff or FET maneuver may allow the patient to generate the flows
needed to expel mucus from blocked airways.

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Positive airway Pressure adjuncts

Positive • A PEP device increases resistance to expiratory

airflow to promote mucus clearance by preventing
expiratory airway closure and increasing collateral
ventilation.
pressure devise

Oscillating • An oscillating/vibratory positive expiratory

Positive pressure device is a form of PEP that combines
high-frequency air flow oscillations with positive
expiratory expiratory.

pressure devise
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Flutter Acapella – types

RC Cornet

Aerobika

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High-Frequency Positive Airway
Pressure Devices
• High-frequency positive airway pressure devices /
intrapulmonary percussive ventilation (IPV).
• Uses a pneumatic device to deliver a rapid series of
pressurized gas mini-bursts at rates of 100 to 225 cycles
per minute (1.7 to 5 Hz) to the airway.
• During the percussive cycle, the patient can inhale and
exhale through the device as this oscillating airway
pressure is applied.
• These devices also deliver aerosolized medication and
rely on chest wall recoil or an active patient exhalation.
• The therapy is well tolerated by stable patients and may
provide a more practical alternative for airway clearance
in patients unable to take a deep inspiration
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High-Frequency Chest Wall Oscillation
• High-frequency chest wall oscillation (HFCWO) devices are passive oscillatory devices.
These devices use a two-part system:
a variable air-pulse generator and
a nonstretch inflatable vest that wraps around the patient’s entire torso (Vest Airway
Clearance Systems, Hill-Rom Services, Inc., Batesville, IN).
• Either one or two large-bore tubing(s) connect the vest to the air-pulse generator.

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• The generator inflates and deflates the vest, creating pressure pulses against the thorax
resulting in chest wall oscillations and moving secretions forward. These devices are used
in hospital or home settings.
• The therapy is typically performed for a 30-minute session 2 to 6 times per day at
oscillatory frequencies between 5 to 25 Hz. These therapy sessions depend on patient
need and response

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79
80
81
82
Belli et al , 2021

83
Selecting ACT

84
85
C - Suctioning for critically ill patients

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Suctioning
• Invasive type of airway clearance technique

• Process of mechanically aspirating airway secretions with the application of negative

pressure/vacuum to the airways through a collecting tube.

• Normal Suction Pressure For adults – is ↓ 200mmhg

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Why is suctioning needed ?
• Difficulty is WOB → hypoxemia, • Infiltrates in X-rays
hypercapnia, infection • Deterioration in ABG findings ( SpO2)
• ↑ airway resistance • Presence of consolidation on auscultation
• Supressed cough reflexes • Patients on artificial airways
• Sputum sampling

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 Nasopharyngeal
Upper airway suctioning
Rigid tonsillar
suctioning /Yankauer
(Oropharynx) suction tip
Oropharyngeal
Suctioning

Types Of Nose –
suctioning
Naso- tracheal
suctioning
Lower airway
suctioning Artificial airway –
Flexible suction
Endotracheal
(Trachea and catheter
suctioning
bronchi)

Tracheal
suctioning

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Upper Airway Suctioning Lower Airway Suctioning

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Equipment's required for suctioning
• Adjustable suctioning/collecting systems
• Sterile suction catheter
• Sterile gloves, goggles, masks
• Sterile water/saline
• O2 delivery system
• AMBU bag

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Endotracheal suctioning
• necessary practice carried out in intensive care units.
• It involves the removal of pulmonary secretions from a patient with an artificial airway in
place.
• Caroline J Wood, 1998

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Indications
• Need to maintain patency and integrity of •  O2 saturation /blood gas values
the artificial airway
• Visible secretions in the airway
• Remove accumulated pulmonary
secretions
• Decreased cough efforts
The sawtooth pattern on the flow-volume • Acute respiratory distress
loop on the monitor screen of the
ventilator or the presence of coarse • Suspected aspiration of gastric or upper
crackles over the trachea airway secretions
↑ peak inspiratory pressure on volume- • Need a sputum sample
control ventilation or ↓ tidal volume on
pressure control ventilation
• AARC Clinical Practical Guidelines 2010

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Contraindications
• Most contraindications are relative to the patient's risk of developing adverse reactions or
worsening clinical conditions due to the process.
• When indicated, there is no absolute contraindication to endotracheal suctioning because
the decision to withhold suctioning to avoid possible adverse reactions may be lethal
• AARC Clinical Practical Guidelines 2010

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Hazards and Complications
•  in dynamic lung compliance and functional • Cardiac dysrhythmias
residual capacity
• Routine use of normal saline instillation may be
• Atelectasis associated with the following adverse events
Excessive coughing
• Hypoxia or hypoxemia
Decreased O2 saturation Bronchospasm
• Tissue trauma to the tracheal/bronchial mucosa Dislodgment of the bacterial biofilm that
colonizes the endotracheal tube into the lower
• Bronchoconstriction/bronchospasm
airway
• ↑microbial colonization of the lower airway Pain, anxiety, dyspnoea
• Changes in cerebral blood flow and ↑intracranial Tachycardia
pressure ↑ intracranial pressure
• Hypertension/Hypotension
• AARC Clinical Practice Guideline 2010

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Techniques for ET suctioning
Open Sterile Techniques Closed suction system

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 Steps to ET suctioning

Monitor
Assess Assess
Assemble Apply Patient
Patient Patient Reoxygen
and Check Insert Suction and
for for ate
Equipmen Catheter and Clear Assess
Indication Hyperoxy Patient
t Catheter Outcomes
s genation
.

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Nasotracheal Suctioning
• For patients who have retained secretions but do not have an artificial airway.
• The nasal passages are highly vascularized.
• Mucosal trauma and bleeding can occur with repeated suctioning, adding to difficulty
managing secretions.
• The use of soft suction catheters and a nasopharyngeal airway is recommended to prevent
these complications

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Indications
• Visible secretions in the airway • Deterioration of arterial blood gas values
suggesting hypoxemia or hypercarbia
• Chest auscultation of coarse, gurgling
breath sounds, rhonchi, or  breath sounds • Chest radiographic evidence of retained
secretions resulting in atelectasis or
• Feeling of secretions in the chest consolidation
(increased tactile fremitus)
• Restlessness
• Suspected aspiration of gastric or upper
airway secretions • Stimulate cough or for unrelieved coughing
• ↑WOB • Obtain a sputum sample for microbiologic
or cytologic analysis
• AARC Clinical Practice Guideline,2004

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Contraindications
• Occluded nasal passages • Upper respiratory tract infection
• Nasal bleeding • Tracheal surgery
• Epiglottitis or croup—absolute • Gastric surgery with high anastomosis
• Acute head, facial, or neck injury • Myocardial infarction
• Coagulopathy or bleeding disorder • Bronchospasm
• Laryngospasm
• Irritable airway
• AARC Clinical Practice Guideline,2004

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Hazards and Complications
• Mechanical trauma • Uncontrolled coughing/ Gagging or vomiting

• Laceration of nasal turbinate's • Laryngospasm/Bronchoconstriction or

bronchospasm
• Perforation of pharynx
• Discomfort and pain
• Nasal irritation or bleeding
• Nosocomial infection
• Tracheitis
• Atelectasis
• Mucosal haemorrhage
• Misdirection of the catheter
• Edema of the uvula
• ↑ICP
• Hypoxia/hypoxemia
• Intraventricular haemorrhage
• Cardiac dysrhythmias or arrest
• Exacerbation of cerebral edema
• Bradycardia
• Pneumothorax
• ↑ blood pressure/Hypotension
• Respiratory arrest
• AARC Clinical Practice Guideline 2004
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Other Forms of suctioning
• Oropharyngeal Suctioning
• Nasopharyngeal suctioning
• Tracheostomy suctioning

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Recent advances
• A short review done titled “Airway Clearance Techniques: The Right Choice for the Right
Patient” had few suggestions on the usage of ACT for Covid patients in regards to the
Clinical Practice Covid 19 Guidelines by Karin M et al. and Lazzeri et al
• Airway Clearance procedures should be administered only when strictly needed when a
Patient has specific comorbidities where there is ↑ secretion or retention, ineffective
cough:- different techniques and devices can be applied to mobilization or evacuation
• PEP device with/ without oscillation (PEP, TPEP, OPEP), should be considered, alone or in
combination with lung expansion strategies, to enhance lung volume recruitment, to
control the expiration flow, and to facilitate peripheral and proximal mucus mobilization.
• In Patients with cough FET should be preferred to expectorate.
• Belli S et al. 2021

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• A Pilot study on “Short-Term Effects of a Respiratory Telerehabilitation Program in
Confined COVID-19 Patients in the Acute Phase”
• This was a telerehabilitation program – that included breathing exercises (ACBT) and
other breathing exercises.
• The study concluded that Breathing exercises through telerehabilitation appeared to
provide a promising approach for improving outcomes related to physical condition,
dyspnea, and perceived effort among people exhibiting mild to moderate COVID-19
symptoms in the acute stage.
• Gonzales- Gerez J, 2021

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• An RCT titled “Preoperative physiotherapy for the prevention of respiratory complications
after upper abdominal surgery: a pragmatic, double-blinded, multicenter randomized
controlled trial.”
• This was A RCT done to note the effects of prehabilitation reducing postoperative
complications in elective abdominal surgery patients
• Here, The interventional group received education focused on PPCs and their prevention
through techniques of early ambulation, self-directed breathing exercises with usual
physiotherapy in the preoperative period
• And it was found that with the addition of exercises and training in the preoperative
period, the postoperative complications were reduced in half.
• Boden I, et al., 2018

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