WELCOME 1/24/19. The Healthcare Environment Today. Airway Clearance Techniques. All Modes of Airway Clearance. Know which modality for which patient

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1 WELCOME All Modes of Airway Clearance The Healthcare Environment Today Current Situation Respiratory complications are a major concern More focus on hospital acquired infections Changing Reimbursement Strategies to Avoid Re-admission Identifying patients at high risk Early detection of respiratory complications Early intervention of airway clearance Could result in: Fewer pulmonary complication Healthcare savings Improved patient outcomes Improved quality of life Airway Clearance Techniques Chest Physical Therapy Therapy Beds Coughing Techniques Mechanical Insufflation Exsufflation Breathing Techniques Positive Expiratory Pressure / Oscillatory PEP Intrapulmonary Percussive Devices High Frequency Chest Wall Oscillation Other adjuncts to Airway Clearance Know which modality for which patient 1

2 Considerations for Selecting an Airway Clearance Modality Cognitive limitations Age / mental status Sedation Physical ability Coordination / strength Shortness of breath / fatigue Mechanical Ventilation / Artificial Airways Promote improved compliance / adherence when: Effective, without side effects Comfortable Time efficient Adaptable with illness Can be used in any setting Easy to teach, learn and use Today s Objectives Better understanding of airway clearance options: Definition of each device / technique Mechanisms of action General technique for delivering therapy Level of patient participation required Advantages / limitations of each Finding the best airway clearance option or combination of options for each individual patient Chest Physical Therapy Percussion / vibration Postural drainage Mechanical percussors 2

3 Chest Physical Therapy 12 positions using: Gravity Percussion Vibration Time consuming Labor Intensive May be harmful in some patients 1 1 SELSBY DS, BMJ VOLUME MARCH 1989 Hand-Held Percussors Manual, Electronic or Pneumatic Continuous Lateral Rotation (CLRT) Percussion & Vibration Therapy Beds Features to support ventilator-associated complication protocols Digital HOB angle indicator and alarm Continuous lateral rotation therapy (CLRT) Pulmonary surface (powered air) Percussion and Vibration Helps prevent ventilator-associated complications when used with CLRT Pulmonary Surface (Powered Air) 3

4 Chest Physical Therapy Advantages Limitations Effective proven therapy Requires no equipment May be used on very young patients Promotes time with caregiver Technique dependent Physically demanding on patient and staff Time consuming for patient and staff Infection control issues Reflux related respiratory complications Age / weight restrictions on beds Maintenance of beds Coming Up Next Coughing Techniques and Devices Paroxysmal Cough Red face Distended neck veins No airflow after first or second cough Decreased sats Bronchospasms Ineffective body position 4

5 Huff Cough / Forced Expiratory Technique (FET) Definition One or two forced expirations without closure of the glottis 1 Followed by a period of diaphragmatic breathing and relaxation 1 Theory The goal is to help clear secretions with less change in pleural pressure and less likelihood of bronchiolar collapse 1 Periodic diaphragmatic breathing and relaxation following forced expiration restores lung volume and minimizes fatigue 1 Egans Fundamentals of Respiratory Care Ninth Edition. Wilkins R, Stoller J, Kacmarek R. Section V, Chapter 40, pages Huff Forced Exhalation Technique slow deep breaths through nose, exhaling through pursed lips, using diaphragmatic breathing 2. Take a deep breath, hold for 1 3 seconds 3. Exhale contracting abdominal and chest wall muscles, with glottis open during exhalation 4. Repeat several times 5. As secretions enter the larger airways, exhale from high-to-mid lung volume 6. Repeat maneuver 2 3 times Forced Expiratory Technique, Directed Cough, and Autogenic Drainage. James B Fink MSc RRT FAARC RESPIRATORY CARE SEPTEMBER 2007 VOL 52 NO 9; page Manually Assisted Cough External application of pressure to the thoracic cage or epigastric region, coordinated with forced exhalation Mimics the normal cough mechanism by generating an increase in the velocity of the expired air Who could benefit? Neuromuscular patients Patients unable to generate the forceful expulsion of air needed to move secretions toward the trachea Egans Fundamentals of Respiratory Care Ninth Edition. Wilkins R, Stoller J, Kacmarek R. Section V, Chapter 40, pages

6 Mechanical Insufflation-Exsufflation (MI-E) Mechanism of action: 1. Inflation of the lungs with positive pressure 2. Followed by an active negative pressure exsufflation 3. Creates peak and sustained flows High enough to provide adequate shear and velocity to loosen and move secretions towards the mouth for clearance by expectoration or suctioning Homnick DN Mechanical insufflation-exsufflation for airway mucus clearance. Resp Care 2007; 52 (10): Mechanical Insufflator Exsufflator Devices Non-invasive Lung Expansion Cough Clearance Optional Foot Pedal for purchase Mechanical Insufflator Exsufflator Circuits will contain the following; adapter, breathing hose, bacterial/viral filter, and the patient interface. VitalCough System User Manual ( REV 1) p.21 6

7 Mechanical Insufflator Exsufflator Multiple patient interfaces Mouthpiece Face mask Adaptor to a tracheostomy Manual or Automatic Mode Programming The following will need to be programmed before you initiate treatment Automatic Settings Inhale Pressure* Exhale Pressure* Resting Pressure/PAP* Flow Rate* Manual Settings Inhale Pressure* Exhale Pressure* Resting Pressure/PAP* Flow Rate* Number of cycles to be completed for each treatment set Inhale breath time Exhale breath time Pause Time Lock Device-optional optional both modes *Indicates the settings that are set for both automatic and manual modes VitalCough System User Manual ( REV 1) p.40-55, 57 Mechanical Insufflator Exsufflator Technique Start at cmh2o recommended for those new to the device Pressures can be increased as necessary to achieve adequate secretion clearance Typical inhale pressures 15 cmh20 to 40 cmh20 May vary depending on lung and chest wall compliance Optimal exhale pressure 35 cmh20 and 45 cmh20 Automatic: Inhale, exhale, pause times Inhale 2-3 seconds / exhale 1-2 seconds Neutral (Pause) few seconds 4 5 cough cycles / remove visible secretions Rest 20 to 30 seconds Repeat 4 6 times or until clear 7

8 Mechanical Insufflation Exsufflation Advantages Limitations Lung expansion Cough augmentation Alternative to suctioning Non-invasive Multiple patient interfaces Alert or unconscious patient May be used on very young patients Combine with other therapies Incomplete AWC device Mask / mouthpiece seal Cleaning / changing circuit Change filter when soiled or wet Maintenance required Periodic operation verification Change internal fuses if blown Assure air intake ports are not blocked Coming Up Next Breathing Techniques Active Cycle Of Breathing Autogenic Drainage Active Cycle of Breathing Technique (ACBT) A cycle of breathing techniques; Breathing Control (BC), Thoracic Expansion Exercises (TEE) and Forced Expiratory Technique (FET) 1 BC to help prevent bronchospasm TEE to loosen secretions, improve distribution of ventilation and provide volume needed for a forced expiratory technique FET to clear secretions with less change in pleural pressure and less likelihood of bronchiolar collapse Egans Fundamentals of Respiratory Care Ninth Edition. Wilkins R, Stoller J, Kacmarek R. Section V, Chapter 40, pages Theory 8

9 Active Cycle of Breathing Technique Components, Sequence & Duration Adapted to Need Repeated until huff dry sounding and nonproductive or it is time for a rest 2 Breathing Control Gentle diaphragmatic breathing at tidal volume 1 Relaxation of the upper chest and shoulders 1 Forced Expiratory Technique 1-2 forced expirations to middle to low lung volumes without closure of the glottis 1 Thoracic Expansion Exercises Deep inhalation Relaxed exhalation 3-4 TEE s 1 Egans Fundamentals of Respiratory Care Ninth Edition. Wilkins R, Stoller J, Kacmarek R. Section V, Chapter 40, pages Pryor Jennifer A. Booklet: Physiotherapy for people with Cystic Fibrosis: from infant to adult. 4 th edition 2009; page 6: available online on 2 Autogenic Drainage (AD) Three-phased breathing regime using high expiratory flow rates at varying lung volumes to facilitate mucus clearance Attain highest possible expiratory flows without forced expirations and associated airway closure Move mucus with a relaxed sighing exhalation, regulating airflow and velocity with use of expiratory muscles, avoiding unnecessary expiratory resistance Forced Expiratory Technique, Directed Cough, and Autogenic Drainage. James B Fink MSc RRT FAARCRESPIRATORY CARE SEPTEMBER 2007 VOL 52 NO 9 Theory Breathing Phases of Autogenic Drainage TV Unstick LLV Collect MLV HUFF Evacuate HLV COPD VOL PRED VOL ERV RV *May be difficult with advanced disease 9

10 Active Cycle Breathing Technique and Autogenic Drainage Advantages Limitations Effective techniques No equipment Preferred over CPT Saves treatment time Active Cycle of Breathing Technique Easy to teach Easy to learn Limited by age / cognition Dependent on patient effort / ability Autogenic Drainage Time consuming to teach Difficult to learn Maintenance technique Lung Expansion Therapy Prevent / reverse atelectasis Simulate / re-establish normal breathing Mimic natural sigh / yawn Deep breathing exercises Incentive spirometry Handheld devices Mechanical devices Positive Airway Pressure System Indicated for: Treatment/prevention of atelectasis Need for lung expansion therapy May be used with: Mask Mouthpiece Nebulizer 10

11 Coming Up Next Positive Expiratory Pressure (PEP) Devices Positive Expiratory Pressure (PEP) Alters airflow and pressure behind mucus via collateral ventilation Stabilizes peripheral airways Increases pressure gradient across mucus plug forcing secretions central Increased outward pull on alveoli Theory Positive Expiratory Pressure Devices TheraPEP PEP Therapy System Smiths Medical ASD, Inc. PARI PEP S System PARI Respiratory Equipment, Inc. Threshold PEP Philips Respironics 11

12 Oscillatory PEP Devices Flutter Mucus Clearance Device Axcan Pharma US, Inc. Quake Thayer Medical Corporation acapella Vibratory PEP Therapy Systems Smiths Medical ASD, Inc. acapella choice acapella duet Oscillatory PEP Devices Aerobika Monaghan The VibraPEP Curaplex Lung Flute Medical Acoustics, LLC Creates low frequency acoustical sound waves¹ Secretion mobilization and induction device¹ Components include: plastic mouthpiece, reed, 14.5 inch hardened plastic horn² ¹ ² 12

13 PEP/Oscillatory PEP Technique Instruct individual to sit comfortably and upright while holding mouthpiece firmly in mouth or mask firmly to face Adjust resistance to prescribed setting Have patient breathe in a larger than normal breath, but not to total capacity and exhale gently through device maintain a pressure of 5-20 cm H2O or no longer than a 1:3 inspiratory to expiratory ratio Have patient perform breaths, then 2-3 Huffs With oscillatory PEP devices, patient should first perform forced maneuvers through device to facilitate secretion removal, then follow up with huffs Repeat steps until: Secretions are cleared Or the predetermined period has elapsed Respiratory Care, October 2007 Vol 52 No 10 pages PEP / Oscillatory PEP Advantages Limitations Prefer over CPT Easy to learn Saves treatment time Provides independence May be used with a mask Age / cognition levels Patient effort dependent Requires tight seal with mouthpiece / mask Most are flow dependent Require periodic replacement Cleaning required follow individual device manufacturer instructions Coming Up Next Intrapulmonary Percussive Devices 13

14 3 in 1 Therapy with Intrapulmonary Percussive Devices A therapeutic device that uses a systematic approach to enhance normal mucus clearance and resolve or prevent atelectasis. For use in Acute Care and Long Term Care Offers 3 therapies: 1. Continuous Positive Expiratory Pressure (CPEP) Lung expansion therapy 2. Continuous High Frequency Oscillation (CHFO) Secretion mobilization therapy 3. Aerosol Mode Aerosol therapy Provides supplemental oxygen when used with compressed oxygen The MetaNeb System User Manual ( REV 1) page in 1 Therapy with Intrapulmonary Percussive Devices Indicated for lung expansion and secretion mobilization therapies for the treatment and prevention of atelectasis and the complications of retained secretions Venturi and Entrainment of Ambient Air 1 molecule of therapy Gas entrains 5 molecules of air Venturi Throat Jet 14

15 Venturi and Entrainment of Ambient Air with Decreased Airway Compliance Additional Positive Expiratory Pressure 3 levels of Positive Expiratory Pressure (PEP) available 1 dot position largest opening with least resistance 2 dot position creates more resistance 3 dot position smallest opening with most resistance Exhalation Orifice Blue Selector Ring The MetaNeb System Mouthpiece Face Mask Tracheostomy In-line with Ventilator Multiple Patient Interfaces 15. The MetaNeb System User Manual (174432). 15

16 The MetaNeb System - Easy Treatment to Deliver Delivering a Treatment 1. Begin with CPEP Mode. 2. Adjust flow and selector ring to patient comfort / needs 3. Continue CPEP Mode ~ 2 ½ minutes. 4. Move the Higher/Lower dial to Higher. Higher/Lower dial may be moved if needed 5. Change mode to CHFO Mode. 6. Continue CHFO Mode for ~ 2 ½ minutes. 7. Alternate between CPEP and CHFO ~ every 2 1/2 minutes. 8. Deliver treatment for 10 minutes or depending on patient need or as otherwise provided in institutional protocol. Higher Lower Follow instructions stated in the User Manual 15. The MetaNeb 4.0 System User Manual (174432). The MetaNeb System - Easy to Deliver In-Line with a Ventilator Delivering a Treatment 1. Connect The MetaNeb System to 50 psi oxygen source. 2. Set the mode to CHFO and select Higher. 3. Put the master switch in the ON position. 4. Put a spring-valve "tee" adapter in inspiratory limb of ventilator circuit. 5. Monitor and continue the treatment for 10 minutes or per facility protocol. 6. Adjust the alarm parameters as necessary during in-line therapy. 7. Suction secretions as necessary during treatment. 8. Remove the handset and adapter from the spring-valve tee and cap before you put The MetaNeb System master switch in the OFF position. 9. Return the ventilator alarms and mode to their previous settings if needed. Follow instructions stated in the User Manual 15. The MetaNeb 4.0 System User Manual (174432). High Frequency Intrapulmonary Percussive Nebulizer Delivers aerosolized medication and oscillates during inhalation and exhalation to help remove endobronchial secretions¹ Single patient, multiple use device Hospital or home use May purchase compressor for home PercussiveNEB User Guide, rev , pages

17 Theory of Operation During inhalation The patient entrains high density aerosol from the nebulizer with high frequency intrapulmonary percussion for enhanced aerosol deposition During exhalation High frequency (11-30 Hz) pressure bursts create a gas bolus velocity profile that travels down the center of the bronchial airways Exhaled gas to travel at high speeds along the wall of the bronchial airways Imparts a sizeable force on bronchial secretions moving them up and out of the airways¹ PercussiveNEB User Guide, rev , pages 2-11 Technique Place prescribed medication into nebulizer reservoir and add saline -Reservoir holds 20 ml and typically uses 1 ml/min (residual) Attach high flow source to 60 l/min (±25%) May be used with compressed air or oxygen Intended to be used only on those patients who are able to breathe spontaneously and to be used with the attached mouthpiece Adjust flow rate until modulator piston begins to oscillate and adjust as needed for patient comfort Adjust oscillating amplitude as needed for patient s comfort, starting with soft and increase to hard setting once patient appears comfortable with good breathing pattern Treatment times are typically minutes Intrapulmonary Percussive Devices Advantages Limitations Customize treatments Internal vs. external application Aerosol delivery Ability to deliver oxygen with therapy Delivers PEP Shorter treatment times Single patient multi-use circuits May be used on very young patients Cleaning after every use recommended High pressure / flow gas source required Patient technique with mouthpiece Requires proper training Staff Patient 17

18 Coming Up Next High Frequency Chest Wall Oscillation (HFCWO) HFCWO for Airway Clearance System An Air Pulse Generator, connected by hoses to an inflatable garment that is rapidly inflated and deflated, creating High Frequency Chest Wall Oscillation (HFCWO) HFCWO generates increased airflow velocities: Creates repetitive cough-like shear forces & an expiratory airflow bias Decreases viscosity of secretions Dislodges and moves secretions toward central airways The Vest Airway Clearance System, Model 105User Manual ( REV 7) page 10 HFCWO for Acute Care/Long-Term Care The Vest System Generator Rolling stand Adjustable height Disposable Air Hoses The Vest System Disposable Garments Single patient use (SPU) Color coded to size Wrap SPU Vest Extra small (19 ) to XXL (75 ) Full SPU Vest Child medium (23 ) to Adult Large (52 ) 33. The Vest Airway Clearance System, Model 105 User Manual ( REV 13) 18

19 HFCWO for Home Care C3 Garment Line Easy to use with multiple program options Eases into therapy to maximize comfort Hour meter reading from main menu Small one bag system on wheels Color options Inflatable bladder Outer shell Soft fabric with Dupont Teflon stain protection 3D Mesh lining for breathability Machine washable and machine dryable Classic Garment Line Wrap Vest Sizes X Small to XX Large 19 to 75 Chest Vest Sizes Small, Medium, Large, X Large 28 to The Vest Airway Clearance System, Model 105 User Manual ( REV 13) HFCWO for Airway Clearance System Eases into Therapy - Gradual increase in frequency & pressure to pre-set level. Programmability 33 Most Commonly Used Settings 52 Normal Mode - Set frequency, pressure and time. Program Modes - Program A & B: Use the preset program or customize up to 8 different frequencies, pressures and times within one session with a Cough Pause option. Ramp Mode - Gradual increase of frequency and pressure over a period of time. Set default settings for above modes. Ability to change language to Spanish. Most Commonly used treatment settings in home care: Twice a day treatment Time: 20 minute treatment Frequency: HZ Pressure per garment style C3 (full) garment pressures of 4-6 Wrap garment and Chest Vest garment pressure of The Vest Airway Clearance System, Model 105 User Manual ( REV 13) 52. Data report (2017). Most Commonly Used Settings on file at Hill-Rom, Inc. High Frequency Chest Wall Oscillation Has been shown to help remove mucus from people s lungs Just some of the conditions/diseases that may benefit: Cystic Fibrosis Bronchiectasis Neuromuscular / Neuromotor Disease Cerebral Palsy Chronic Bronchitis Asthma Emphysema Quadriplegia Obesity Many other conditions 19

20 New Mobile Technology in High Frequency Chest Wall Oscillation(HFCWO) The Monarch Airway Clearance System is a HFCWO therapeutic device that is used to aid mobilization of secretions from the airways and help improve airway health. 1 Battery powered HFCWO combining Mobility with Targeted Kinetic Energy and Airflow to mobilize secretions. 1. Monarch Airway Clearance System User Manual (195292) page 91. Intentional Design Design Matters Powered by POD Technology 1 8 pulmonary oscillation discs (PODs) anatomically positioned on the chest wall to treat all lobes of the lungs. The PODs oscillate and provide a targeted kinetic energy to the lungs. 1. Creates impulse force (Kinetic Energy ) to: 1,2,3,4 Help break up secretions 3 Help loosen secretions 3,4 2. Creates airflow within the lungs to: 2,3,4,5 Help mobilize secretions from the small airways to the large airways where they can be coughed out or suctioned. 1. Monarch Airway Clearance System User Manual (195292) page 91, Airflow data: Independent lab testing analyzed and compared average airflows at the mouth generated by high frequency chest wall oscillation (HFCWO) therapy in 10 human subjects using home care garments. Airflows measured at maximum intensity at multiple therapy frequencies (5, 10, 15, and 20 Hz). Impulse force data: Bench testing conducted at maximum intensity at multiple therapy frequencies (5, 14, and 20 Hz). Test data and reports on file at Hill-Rom, Inc. 3. Kendrick A. (2012) Airway Clearance Techniques in Cystic Fibrosis: Physiologu, Devices and the Future, Cystic Fibrosis Renewed Hopes Through Research, Dr. Dinesh Srifamulu (Ed), ISBN: , InTech, Available from AARC Clinical Practice Guidelines. (December 1991) Respir Care 1991; 36 (12): accessed PODs on the front 4 PODs on the back 5. King M, et al. (1984). Tracheal mucus clearance in high-frequency oscillation. II: Chest wall versus mouth oscillation. Am Rev Respir Dis, (5): p King M, et al. Tracheal mucus clearance in high-frequency oscillation. II: Chest wall versus mouth oscillation. Am Rev Respir Dis, (5): p Indications for Use The Monarch product is intended to provide Airway Clearance Therapy and promote bronchial drainage where external manipulation of the thorax is the physician s choice of treatment. It is indicated for patients having difficulty with secretion clearance, or the presence of atelectasis caused by mucus plugging. The Monarch Airway Clearance System is intended to be used in the Home Care environment by patients, 15 years and older Monarch Airway Clearance System, Model 1000 User Manual (195292). 20

21 Treatment Adherence Can Be Low Low adherence can affect important health outcomes including pulmonary exacerbations. 34 Assessment and monitoring considered an integral part of management to ensure treatment interventions are optimized. 34 VisiView TM Health Portal - Remote Therapy Monitoring With The Vest System or the Monarch System Patient s opt in for the connectivity. Connects patients wirelessly to their care team via the VisiView Health Portal. The dashboards and prompt feedback helps to motivate patients. Clinic and patient-specific dashboards to utilize adherence information to tailor care decisions Encourages adherence through collaboration. 34. McCullough, A. et al. (2014) Treatment adherence and health outcomes in patients with bronchiectasis. BMC Pulmonary Medicine 2014, 14:107. http// HFCWO Advantages Limitations Less physically demanding on patient and staff Consistent quality therapy Disposable garments / air hoses Doesn t require patient cooperation / effort Aerosol treatments Requires manipulation of thorax Patient must be able to wear vest garment Follow Manufacturer s cleaning guidelines Adjuncts To Airway Clearance Mobility Exercise Activities 21

22 Surface & Frame - Advancing Mobility Flexible frame configurations, egress positions & integrated lift systems Help move patients easily & safely through all stages of early mobilization Chair Egress Lift System Side Egress Benefits of Exercise Improves general fitness Stimulates deep breathing Uses oxygen more efficiently Loosens mucus by moving large volumes of air Creates environment less conducive to organism growth Preserves the elasticity of the lung Provides increased stamina Builds muscle mass and weight gain Provides sense of independence and well being The Challenge Identifying patient s acute & chronic airway clearance needs and finding the best modalities for each individual patient s may Decrease incidence or severity of PPC Decrease morbidity / mortality Reduce ICU time Reduce length of stay Help address readmissions / hospitalizations for the complication of retained secretions Decreased healthcare costs related to the complication of retained secretions Improve QOL for patients and their families Work with HCT, insurers, manufacturers, patients and families to find best modality or combination of modalities for each individual patient 22

23 What to Use When? Finding the Best Modality or Combination of Modalities THANK YOU You Are In The Best Position To Make The Difference! 23