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Bronchial Hygiene Techniques

By Jim Clarke

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What is Bronchial Hygiene

Therapy (BHT)? It consists of a variety of non-invasive

techniques designed to improve gas

exchange by helping to mobilize andremove secretions

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When to use Bronchial Hygiene

Therapy? (BHT) During episodes in which there is an acute

secretion clearance problem. Examples;

Severe pneumonia with copious secretions Respiratory failure with inability to clear retained

secretions

Acute lobar atelectasis (documented) Evidence of significant infiltrates and/or

consolidation with hypoxemia present

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Acute conditions in Which BHT is

NOT Helpful Acute exacerbations of COPD

Many patients cannot tolerate these procedures

even if secretion clearance problems exist!

Pneumonia without evidence of significant

sputum production

Not all pneumonias produce secretions!!

Uncomplicated asthma

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BHT for Chronic Conditions

Used to prevent complications in the out-

patient population and to treat acute

problems seen in; Cystic Fibrosis

Bronchiectasis

Sometimes used in Chronic Bronchitiswhen large volumes of secretions become

problematic

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Brief Look at CF & Bronchiectasis

Cystic Fibrosis: characterized by increased

sputum viscosity (thick mucus), increased mucus

volume and impaired clearance Typically seen in children & young adults only

Bronchiectasis: characterized by muco-stasis,

retained secretions, loss of mucociliary escalator

& repeated pneumonias

Generally seen only in adults with a history of

persistent & repeated lung infections

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When Do Patients Need BHT ?

(Are the following present?) Patient has a Dx of Bronchiectasis or

Cystic Fibrosis? (Read the Hx & PE)

They have evidence of copious secretions

(>25-30 ml/day) with clearance problems?

Do a cough evaluation

Listen to breath sounds

Check for evidence of tactile fremitus

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Other Issues to Check When

Evaluating Need for BHT Review Chest X-ray findings in chart OR

view CXRs directly

Very important in identifying Lobar pneumonias

Assess oxygenation status by reviewing

recent ABGs and/or SpO2 findings

Check in chart for evidence of a sputumanalysis Culture & sensitivity findings

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Causes of Mucociliary Impairment

Presence of endotracheal or tracheostomy

tube

History of having to suction patients

trachea

Poor humidification

High FIO2s Drugs: General anesthetics; opiates;

narcotics

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Some Commonly Used Types of

Bronchial Hygiene Therapies Postural Drainage with percussion and/or

vibration (PD&P) (PDVP)

High Frequency Compression/Oscillation Therapy

Flutter Valve

IntraPulmonary Percussive Ventilation

ThAIRapy Vest - Thoracic Wall Vibration

Positive Airway Pressure Techniques

Positive Expiratory Pressure Therapy (PEP)

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Other Less Commonly Used BHTs

Coughing and related expulsion techniques

Directed Coughing

Huff coughing

Quad cough

Autogenic Drainage

Mobilization and exercise techniques

Frequent turning of patients

Ambulation and exercise as tolerated

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Postural Drainage Therapy

Process of positioning patients to best

utilize gravitational effects in the

enhancement of secretion removal Turn &/or position the patient so that mucus

drains out of the effected lung zone(s)

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Review of Lung Segments

Left Lung Right Lung

Upper Lobe Upper Lobe

Anterior; Posterior; ApicalLingular Anterior; Posterior;Apical Middle LobeLateral; Medial

Lower Lobe Lower Lobe

Superior; Lateral basal;

Anterior basal; Posterior

basal

Superior; Lateral basal;

Anterior basal; Posterior

basal

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Using Drainage Positions

Use drainage position most appropriate to

the lung segments involved

Lower lobe positions are most typical

Average drainage time 3-5 minutes/position

Modify positions as needed

Some patients may not tolerate Trendelenberg

Many patients cannot assume prone position

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Superior Segments Upper Lobes

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Posterior Segments - Lower Lobes

Refer to #2

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Lateral Segments - Lower Lobes

Refer to #9

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Anterior Segments - Lower Lobes

Refer to #8

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Lingular Segments - L Upper Lobe

Refer to #s 4 & 5

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Right Middle LobeRefer to #s 4 & 5

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Posterior Segments - Lower Lobes

Refer to #6

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Anterior Segments - Upper Lobes

Refer to #3

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Anterior & Apical Segments -

Upper Lobes Refer to #s 1 & 2

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Contraindications to Use of

Trendelenberg Position Recent tube feeding or at high risk for

aspiration of gastric contents

Increased ICP in a recent intracranial injury

Uncontrolled hypertension

Severely distended abdomen

Gross (bright red) hemoptysis

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Contraindications to Percussion or

Vibration of the Chest Wall Burns or recent skin grafts to chest

Bleeding abnormalities

Osteomylitis

Subcutaneous emphysema

Suspected or active TB

Recent insertion of pacemaker

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Hazards of PD&P Techniques

Worsening S.O.B.

Pain or injury to chest wall or spine

Hypoxemia

Nausea & Vomiting

Tachycardia; Hypotension; Arrthymias

Bronchospasm (not likely but possible in

patients with Hx of asthma)

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Assessment of Outcome

Have the underlying issues that necessitated

the use of PD&P improved?

Less sputum production

Improvement of breath sounds

Improvement in oxygenation

Improvement in CXR

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P.E.P. Therapy Device

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When to Use PEP Therapy

Mostly used in treatment of Cystic Fibrosis

& Bronchiectasis

Utilizes a expiratory resister designed tocreate positive pressure during exhalation

and lengthen the expiratory phase

Aerosol therapy can be done inline &simultaneous with PEP treatments

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Key Elements in Patient Instruction

in Use of PEP Therapy Patients need to take a breath that is slightly

larger than normal

Expiratory pressure should be set between10 - 20 cmH2O in order to create an I:E

ratio of 1:3 to 1:4

Have patient perform 10 to 20 breaths andthen do 3 coughs

Perform PEP for no more than 20 minutes

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Additional Issues in PEP Therapy

May reduce air trapping in COPD - asthma

Is like pursed lipped breathing

May prevent or reverse atelectasis

May improve aerosol medication delivery

Hazards of PEP therapy are similar to IPPB

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High Frequency Chest Wall

Vibration - ThAIRapy Vest

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Flutter Valve

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IntraPulmonary Percussive

Ventilation Video Available

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Autogenic Drainage

A breathing technique designed to milk orsqueeze air out of the lungs

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Steps in Autogenic Drainage

Composed of 3 breathing phases

Phase 1: Patient breathes in normally but exhales

each breath close to RV (5-9 cycles) Phase 2: Breathes in slightly above normal Vt

but exhales normally (5-9 cycles)

Phase 3: Breathes in close to VC but exhales

normally (5-9 cycles)

All 3 Phases are repeated as necessary

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THE END