1
Q
what is the result of retained secretions?
A
obstructed airflow and increased WOB
2
Q
where do secretions move from and to with ACT?
A
from peripheral to central airways
3
Q
coughing mechanism in central vs peripheral airways
A
is more effective in the central airways, therefore we want to move secretions from peripheral to central airways
4
Q
when do we use ACTs
A
ciliary impairments, hypersecretions, airway disease leading to early airway closure, muscle weakness, and risk of secretion retention
5
Q
what are examples of ciliary impairments?
A
cilia destruction or ciliary dyskinesia
6
Q
what are examples of conditions leading to hypersecretions?
A
CF, bronchiectasis, and COPD
7
Q
what is an airway disease that leads to early airway closure?
A
COPD
8
Q
when is there risk of secretion retention?
A
post-op; can be due to general anesthesia, impairment of mucociliary system by tracheal tube, or pain
9
Q
what are common conditions that benefit from ACT?
A
CF, bronchiectasis, secretion-related atelectasis, neuromuscular weakness, mechanical ventilation, neonatal respiratory distress (with caution), and asthma with mucus plugging
10
Q
what conditions are not routinely beneficial from ACTs?
A
pneumonia without excessive secretions, viral bronchiolitis, and routine post-op patients without secretion retention
11
Q
short term goals of ACTs
A
prevent infection, improve ventilation, decrease WOB, optimize gas exchange, and decrease WOB
12
Q
what are long term goals of ACTs?
A
increase QOL and decrease risk of mortality
13
Q
what ACTs is superior?
A
none - they all have similar effectiveness
14
Q
what is the evidence of effectiveness with ACT?
A
evidence supports ACTs when there is documented secretion retention or impaired cough/mucociliary clearance
15
Q
what populations are most ACTs studies based on?
A
CF and bronchiectasis
16
Q
what is coughing?
A
the use of a jet of expelled air to clear the large breathing passages and consists of 4 phases
17
Q
what are the 4 phases of coughing?
A
inspiratory, compressive (increases intrathoracic pressure), expiratory, and recovery/relaxation
18
Q
how does the glottis change position when coughing?
A
in compressive phase it if closed and then it opens with the expiratory phase
19
Q
what to assess in the patient for coughing?
A
can they take a deep inspiration before, is the expiratory effort strong and fast. and what is the sound quality (strong or weak or absent)
20
Q
what does a strong and effective cough mean?
A
effective secretion clearance
21
Q
what does a weak but effective cough mean?
A
force is reduced but they are still able to clear secretions
22
Q
what does a weak and ineffective cough mean?
A
there is an inadequate force and they are unable to clear secretions
23
Q
what is an effective peak cough flow rate?
A
> 270 L/min
24
Q
what is a borderline ineffective cough rate?
A
160-269 L/min
25
what is an ineffective cough flow rate?
<160 L/min
26
how to enhance the inspiratory phase of a cough?
position upright to maximise lung volume, cue a deep, slow breath in, and look upward while you inhale
27
how to enhance the compressie phase of the cough?
brief inspiratory hold for 2-3 seconds and this allows the intrathoracic pressure to rise
28
how to enhance the expiratory phase of the cough?
lean forward slightly as you cough and this emphasizes fast, high flow expiration
29
prescription for coughing
2-3 strong coughs; the first helps to loosen the mucus and the 2nd and 3rd help to bring mucus up and out of the lungs - repeat as needed
30
in what populations is assisted coughing used in?
primarily for patients with neurological weakness that affects inspiratory or expiratory muscles
31
what is the purpose of assisted coughing?
to enhance expiratory force during the cough
32
2 common techniques for assisted coughing
costophrenic assist and heimlich-type (abdominal thrust) assist
33
how to do the costophrenic assist cough?
position hands over the costophrenic angles and apply a quick, firm inward and downward pressure on exhale
34
how to do the heimlich-type (abdominal thrust) cough assist?
place hand over the umbilicus, below the ribcage and direct the thrust inward and upward on expiration
35
contraindications for assisted coughing
ruptured diaphragm, fractured ribs, or incisions and wounds
36
what is the mechanism of huffing?
to use compression and narrowing within the airways as the equal pressure point to move secretion
37
other name for huff
forced expiratory technique
38
evidence of effectiveness of huff
limited evidence as a stand-alone technique in patients with CF and increased effectiveness when combined with other techniques
39
benefits of huffing vs coughing
huffing is better because it is less fatiguing, there is lower risk of bronchospasm, reduced risk for dynamic airway collapse, is more effective for clearing peripheral/smaller airways, and there is less chest wall discomfort
40
what is a medium-volume huff used for?
clearing smaller/peripheral airways
41
what is a high volume huff used for?
clearing larger/proximal airways
42
how to instruct a patient to huff?
sit relaxed, take a slightly deeper than normal breath, form an O shaped mouth to keep the glottis open, breathe out forcefully but steadily (aim to fog a mirror or blow a tissue 1m away), after 1-2 huffs, return to relaxed breathing for 15-30 seconds, then finish with a cough
43
what is active cycle breathing technique?
a breathing sequence combining relaxation, deep breathing, and huffing to mobilize and clear secretions
44
evidence for active cycle breathing techqniues
grade A for short-term improvements in airway clearance
45
why do active cycle breathing techniques work?
breathing control reduces airway irritation and prevents bronchospasm, thoracic expansion mobilizes secretions and promotes collateral ventilation, and the huff creates expiratory flow to clear mobilized mucus
46
3 phases of active cycle breathing techniques
breathing control (30-120 seconds of relaxed nose, diaphragmatic breathing and can use pursed lips if needed), thoracic expansion (3-5 deep breaths with inspiratory hold), and forced expiratory technique (2-3 huffs) - then finish with a cough
47
what is the mechanism of a PEP device?
applies 10-20 cm H20 pressure during expiration only through a one-way valve to splint airways open, reduce dynamic collapse, and improve collateral ventilation channels which all move mucus towards central airways
48
evidence of PEP devices
grade B evidence
49
how is target pressure maintained during expiration using a PEP device?
through manometer feedback
50
resistor settings of PEP devices
1-6 (1 is the hardest and 6 is the easiest)
51
patient instructions for PEP devices
sit comfortably while leaning forward with elbows supported, take a slightly deeper breathe and hold for 2-3 seconds, breathe out gently but actively for at least 3 seconds (while maintaining 10-20 cm H20), perform 10 breaths, and then 1-2 huffs
52
how many cycles or minutes should a patient use a PEP device?
4-12 cycles or 15-20 minutes, or until secretions are cleared and then rest as needed - perform 1-3 times daily
53
3 types of oscillating PEP devices
acapella, flutter, and bubble
54
what are oscillating PEP devices?
are similar to standard PEP devices but add airway oscillations during expiration that produce intermittent pressure pulses and vibrations in the airways
55
mechanism of oscillating PEP devices
splint airways open, improve collateral ventilation, enhance secretion movement, and vibrations loosen secretions and produce mucus viscosity
56
what is the evidence for oscillating PEP devices?
grade B
57
what is a flutter device?
contains a high density steel ball in a cone and expiration lifts and drops the ball to create oscillations and vibrations; is gravity dependent
58
what is the range of H20 in the flutter device?
10-35 cm H20
59
how to teach a patient to use a flutter PEP device?
sit upright, inhale deeper than normal, hold for 2-3 seconds, exhale actively but not forcefully through the device (no cheek puffing), repeat 10 breaths, take 2 deep breaths then exhale through the device again, perform 1-2 huffs and cough if needed, and rest and repeat 2-3 times or until clear
60
maximum amount of time to use the flutter PEP
15-20 mintues
61
what is the acapella PEP device?
uses a counterweighted lever and magnet to generate oscillations and is not gravity dependent
62
what is the range of H20 in the acapella device?
7-35 mm H20
63
what are the settings on the acapella device?
1-5; 1 is the easier and 5 is the hardest
64
what populations is the acapella devcie good to use in?
for those who cannot maintain flutter angle and when airway clearance must occur in non-upright positions
65
how to teach a patient to use an acapella device?
sit upright, inhale deeper than normal, hold for 2-3 seconds, exhale actively but not forcefully through the device (no cheek puffing), repeat 10 breaths, take 2 deep breaths then exhale through the device again, perform 1-2 huffs and cough if needed, and rest and repeat 2-3 times or until clear
66
what is a bubble PEP?
uses a 1-2 L bottle filled with 10 cm of water and a tube; produces low level PEP and oscillations and is good for pediatrics or low resource settings
67
how to instruct a patient to use a bubble PEP?
sit upright, take a slightly deeper breath through the nose, exhale slightly actively through the tubing (avoid puffing cheeks), repeat 10 breaths, perform 1-2 huffs, and repeat cycle 5-6x
68
what is a high frequency chest wall compression?
an inflatable vest system connected to an air pulse generator that delivers rapid chest wall oscillations to mobilize secretions
69
how does a high frequency chest wall compression work?
high frequency oscillations transmit energy to the lungs to loosen mucus, reduce viscosity, and promote movement towards central airways and this relies on passive airway oscillation
70
in what populations are high frequency chest wall compressions used?
in those with severe secretion retention and when the patient cannot perform independent ACTs; high cost and not publicly funded in canada
71
what must high frequency chest wall compression be followed by?
huffing and coughing to mobilize secretions
72
evidence of effictiveness of high frequency chest wall compression
moderate and heterogenous improvements in sputum clearance, respiratory function measures, dyspnea, and QOL
73
what is intrapulmonary percussive ventilaton?
a pneumatic, oscillating positive pressure device that delivers high frequency gas pulses directly into airways via mouthpiece or mask and produces internal airway percussion
74
how does the intrapulmonary percussive ventilation device work?
positive pressure and rapid gas pulse generate internal vibratory forces that help to loosen secretions and move mucus towards central airways
75
what can intrapulmonary percussive ventilation devices be combined with?
aerosol delivery
76
in what populations are intrapulmonary percussive ventilation devices useful?
in those with severe secretion retention (i.e. CF or neuromuscular diseases) and when patients have an ineffective cough or limited chest wall mobility
77
evidence of intrapulmonary percussive ventilation devices
grade C
78
what is mechanical insufflation exsufflation?
a non-invasive mechanical device that stimulates a cough via delivering positive pressure followed by rapid negative pressure through a mask or mouthpiece
79
in what populations if mechanical insufflation exsufflation effective in?
those with a weak or ineffective cough due to weak respiratory muscles or when cough assistance is needed and there are contraindications
80
how does the mechanical insufflation exsufflation work?
it delivers a positive pressure phase that increases inspiratory volume to help get air behind secretions then stimulates a rapid negative pressure phases what mimics that expulsive phase of a cough and expels secretions
81
before any ACTs, what should you do?
check vitals, SPO2, and ensure pain control
82
if patient is on a bronchodilator, what should you advice them to do before ACTs?
use the device about 10-20 minutes prior
83
contraindications with all ACTs
severe hemoptysis or a large, undrained pneumothorax
84
in mild-moderate hemoptysis, what are considerations with ACTs?
no percussion, vibration, Osc-PEP, head down tilt, and gentle huffs/coughs only
85
with small, undrained pneumothorax, what are considerations with ACTs?
no positive pressure ACTs (PEP or Osc PEP)
86
with raised ICP, what are considerations with ACTs?
no head down tilt, gentle huff/cough only
87
in what populations should you avoid head down tilt in?
GERD, pregnancy, raised ICP, nausea, vomiting, headache, HTN, and sinusitis
88
is what populations should you avoid percussion/vibration in?
mild-moderate hemoptysis, rib fracture, osteoporosis, chest wall pain/surgery, and coagulation disorders
89
with a ruptured diaphragm, what are considerations with ACTs?
no manual assisted cough and avoid abdominal thrust s
90
in what populations should you avoid abdominal thrusts in?
ruptured diaphragm or IVC filter
91
if someone has an IVC filter, what are considerations with ACTs?
no abdominal thrust cough assist
524: cardioresp
flashcards
Decks in class (16)
# Cards
-
intro to cardioresp28
-
intro to respiratory muscle training40
-
ABGs33
-
oxygen therapy84
-
chest Xray61
-
ECG87
-
IPPA review26
-
peds cardiorespiratory assessment40
-
ACT91
-
postural drainage42
-
positioning for dyspnea and V/Q mismatch33
-
breathing strategies43
-
surgery73
-
mobilization38
-
geriatric populations37
-
pulmonary rehab48
