Surgical Critical Care: Pulmonary Hygiene (Pulmonary Toilet)

Basics

• Definition: Exercises & Procedures to Help Clear Airway Secretions & Mucous
  • Also Referred to as Airway Clearance Techniques (ACT)
• Promotes Adequate Oxygenation & Pulmonary Function
• Often Used for Traumatic Rib Fractures, COPD, Asthma, Pneumonia or Other Pulmonary Pathology
  • Decreases Mucociliary Clearance & Cough Increases Risk for Infection & Pulmonary Complication

Basic Methods

• Deep Breathing Exercise
  • Can Be Relaxed with Slow Exhalation or Hard Pushes with Rapid Exhalation
• Coughing
• Huffing (Huff Coughing)
  • Definition: Taking a Long Inhalation & Holding it, Then Actively Exhaling
  • Less Forceful than a Cough but Less Exhausting & May Work Better
• Frequent Orotracheal Suctioning
• Incentive Spirometry (IS)
  • A Hollow Cylinder with a Flexible Mouthpiece to Incentivize Good Inhalation
  • Use:
    • Inspire Slowly & Deep (Keeping Indicator Between the Marked Lines to Indicate Appropriate Speed)
    • Hold Inspiration for as Long as Able (Watching Piston Rise as High as Able)
    • Exhale Slowly
  • Generally Recommended Use About 10 Times per Session, 10 Sessions per Hour
  • Should Attempt to Cough/Huff After Each Session to Clear Mucous

Chest Physiotherapy (CPT)

• Definition: Physical Therapies to Release & Help Clear Mucous
• Postural Drainage
  • Patient is Placed into Various Positions to Promote Mucous Clearance by Gravity
• Chest Percussion/Clapping
  • Therapist Lightly Claps a Patient’s Chest & Back
  • More Common in Outpatient Setting & Generally Not Used in Practice
• Vest Physiotherapy (High-Frequency Chest Wall Oscillation)
  • A Vest Worn by the Patient that Induces Frequent Vibrations
  • Helps to Release & Thin Mucous as Well as Helping Clear

Advanced Methods

• Positive Expiratory Pressure (PEP)
  • Mask/Mouthpiece Provides Resistance (Positive Pressure) During Expiration but Does Not Affect Inhalation
  • Effects:
    • Increases Gas Pressure Behind Mucous by Collateral Ventilation & Temporary Increase in Functional Residual Capacity
    • Releases Mucous off Airway Walls
    • Hold Airways Open & Prevents Collapse
  • Use:
    • After Multiple Uses/Breaths the Patient Stops to Cough & Clear Mucous
    • Sessions Last Around 20 Minutes
  • Includes: TheraPEP & Resistex PEP Mask
• Oscillating Positive Expiratory Pressure (OPEP)
  • Provides Resistance During Expiration (Similar to PEP)
    • Similar Effects as PEP
  • Also Creates Vibrations During Expiration
  • More Commonly Used than PEP Alone
  • Brand Names: Flutter, Acapella, AerobikA & RC-Cornet
• Intrapulmonary Percussive Ventilators (IPV)
  • Delivers Short Bursts of Air (150-300/Minute) Through a Mouthpiece to Clear Mucous
• Mechanical Insufflation-Exsufflation (CoughAssist)
  • Delivers a Gradual Positive Pressure for Large Volume Insufflation
  • Then Rapidly Reverses to a Negative Pressure Inducing Exsufflation & Cough
• Bronchoscopy