Transcript Section_3_Remove_Secretions

Initiation and Modification of
Therapeutic Procedures
Remove Bronchopulmonary Secretions
 Many of your patients will require assistance in removing
bronchopulmonary secretions in order to maintain a patent airway.
 Therapies include postural drainage, percussion, vibration, directed
coughing, and use of adjunct mechanical devices to aid secretion
clearance.
 Drugs and bland aerosols can be used to facilitate secretion clearance
 All of these techniques ultimately intend to improve ventilation and gas
exchange.
Selecting the Best Approach
Important factors include the patient’s:
Age
Preexisting condition
Personal preference
Selection and implementation should be based on patient’s
Diagnosis
Volume of sputum produced
Ability to cough effectively
Postural Drainage, Percussion,
Vibration, and Turning
Postural drainage, percussion, and vibration (PDPV) is
indicated in conditions that increase the likelihood of
mucous plugging and atelectasis.
Contraindications, hazards, and complications must be
considered before beginning therapy.
You should monitor patient’s clinical status before, during,
and after the therapy:
 Overall appearance
 Vital signs
 Breathing pattern
 Pulse oximetry
Postural Drainage, Percussion,
Vibration, and Turning
Effectiveness and outcome of PDPV is assessed by
monitoring:
 Changes in chest x-ray
 Changes in vital signs
 Changes in pulse oximetry
 Sputum production
 Breath sounds
Recommend discontinuing when sputum production drops
below 30 ml/day and patient can generate an effective
spontaneous cough
Instruct and Encourage
Bronchopulmonary Hygiene
Techniques
Directed Cough
 Instruction in the three phases of a cough
 Deep inspiration
 Compressions against a closed glottis
 Explosive exhalation
 Splinting incisional sites with a pillow
Instruct and Encourage
Bronchopulmonary Hygiene
Techniques
Forced Expiratory Technique (FET) – “Huff” Coughing
 2-3 exhalations, or huffs, with glottis open
 Best suited for post-op patients for whom explosive
exhalation is very painful, and COPD patients prone to
airway closure on forced exhalation
Abdominal Thrust
 Push on the upper abdomen with an upward motion
towards the epigastrium in synchrony with the expiratory
phase of the patient’s own cough effort
Autogenic Drainage
 Usually combined with directed coughing
Mechanical Devices to Facilitate
Secretion Clearance
 High-frequency Chest Wall Oscillation systems, simple
and vibratory PEP devices, Intrapulmonary percussive
ventilation
 Mechanical insufflator-exsufflator (MI-E) (cough assist)
 Indications: Weak cough effort as suggested by maximum
expiratory pressure less than 60 cm H2O
 Contraindications:
 History of bullous emphysema
 Susceptibility to pneumothorax or pneumomediastinum
 Recent barotrauma
Clearance of Secretions via
Suctioning
Indications:
 Presence of a weak, loose cough
 Auscultation revealing rhonchi
 Direct observation of secretions in the mouth or oropharynx
 Fremitus felt on the chest wall
 Patient feedback suggesting retained secretions
Precaution: Suctioning is the one of the most dangerous
procedures you will perform. Careful implementation of patient
safety measures before, during and after, as well as careful
monitoring throughout can prevent or minimize most risks.
Clearance of Secretions via
Suctioning
Routes for Suctioning
Oropharyngeal
 Normal use Yankauer suction tip
Suctioning though a tracheal airway
 Properly set suction pressures
 Always select suction catheter with an outside diameter (OD)
no larger than ½ the inner diameter of the patient’s artificial
airway.
 Estimate correct Fr. size by doubling the internal diameter (ID) of
the tracheal tube and selecting the next smallest catheter size
Maintain adequate PEEP levels during mechanical ventilation
by using a closed suction system
Clearance of Secretions via
Suctioning
 Nasotracheal suctioning
 The most common method used to clear secretions in
patient who do not have artificial airways, but do have an
ineffective cough
Assessment of Effectiveness of Suctioning
 Amount of secretions removed
 Changes in breath sounds
 Changes in vital signs and oxygenation
Administer Aerosol Therapy with
Prescribed Medications
Bland Aerosols
 May be helpful for patients with bypassed upper airways or
those otherwise predisposed to retain secretions.
 May benefit the patient by
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Ease of secretion clearance
Deceased work of breathing
Improved vital signs
Decreased stridor
Improved arterial blood gas values
Improved oxygen saturation as indicated by pulse oximetry
 Generally provided continuously via large volume jet
nebulizer
Administer Aerosol Therapy with
Prescribed Medications
Administration of Prescribed Agents
 Bronchodilators are designed to dilate or open the
airways
 Mucolytics thin secretions
 Inhaled corticosteroids reduce airway inflammation and
help maintain airway patency and may reduce secretion
production
 Diluting agents (aerosolized hypertonic saline) thin
secretions and help with mucous removal
Common Errors to Avoid on the Exam
 Avoid performing postural drainage, particularly in a headdown position, in the presence of an intracranial pressure (ICP)
greater than 20 mmHg or an unstable head or neck injury,
with an active hemorrhage, or in the presence of
hemodynamic instability.
 Don’t apply an abdominal thrust maneuver to help clear
secretions on a patient with abdominal trauma or surgical
incisions
 Avoid using positive expiratory pressure (PEP) adjuncts on
patients with acute exacerbations of asthma or COPD, or on
any patient who cannot tolerate the short-term added work
of breathing caused by these devices.
More Common Errors to Avoid on the
Exam
 Don’t use excessive suction pressures on patients; many
hazards may be avoided. In general, suction pressures should
never exceed -120 mmHg for adults, -100 mmHg for children,
and -80 mmHg for infants.
 Avoid applying suction to the airway for more than 15
seconds for each attempt.
 Avoid performing percussion and vibration therapy
immediately before or after meals.
Exam Sure Bets
 Always monitor a patient before, during and
immediately following bronchial hygiene therapy to
assure that they are tolerating the therapy. Such
assessment should include their overall
appearance, vital signs, breath sounds, and
possible other indicators, such as pulse oximetry.
 Always remember that if a patient appears to be
having an adverse reaction to bronchial hygiene
therapy, stop the therapy, stay with the patient and
monitor him or her, help stabilize the patient, and
immediately notify the nurse and physician
More Exam Sure Bets
 Always consider that a patient with recent
thoracic or abdominal surgery may have trouble
with the inspiratory and expiratory phases of
coughing. For such patients, splinting the incision
site with a pillow often permits them to generate a
more effective cough.
 Always recognize that some patients with an
ineffective cough may need help both loosening
secretions through percussion and vibration as well
as clearing mucous through such means as cough
assist or suctioning.
More Exam Sure Bets
 Always remember that patients with a weak cough, rhonchi,
visible secretions, or fremitus on the chest wall may need
bronchial hygiene therapy
 Always oxygenate a patient with an FiO2 of 100% at least a
minute before each suction attempt.
 Always consider recommending the addition of bland aerosol
and the administration of prescribed agents, such as
bronchodilators and mucolytics if a patient is unable to clear
secretions in spite of percussion, vibration, and turning, as well
as other adjuncts such as PEP and cough assist.
 Always remember that the effectiveness of bronchial hygiene
therapy can be assessed through an improvement in breath
sounds, vital signs, oxygenation, and overall appearance.
Reference:
Certified Respiratory Therapist Exam Review Guide, Craig Scanlon,
Albert Heuer, and Louis Sinopoli
Jones and Bartlett Publishers