Chapter 19: Airway Clearance

AIRWAY CLEARANCE – WHAT ARE THE OPTIONS?

INDICATIONS FOR AIRWAY CLEARANCE

Indications for airway clearance include impaired mucocillary escalator function or impaired cough. According to the American Association for Respiratory Care's Clinical Practice Guidelines for Airway Clearance, it is important to look at the rationale behind your decision to order airway clearance. Is gas exchange being affected by retained secretions? A patient with an increase in secretions may not necessarily need airway clearance when suctioning is all that is needed. With this in mind, the indications for airway clearance are:

1. Evidence of difficulty with secretion clearance

2. Evidence of retained secretions

3. Presence of atelectasis caused by mucus plugging

4. Diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease

CHEST PHYSICAL THERAPY (CPT) AKA BRONCHIAL DRAINAGE (BD)

• How it works

  • Percussion to the chest improves air movement and loosens secretions

  • Positioning allows gravity to assist in draining secretions

• Contraindications:

  • Hemoptysis

  • Untreated tension pneumothorax

  • Increased intracranial pressure (ICP)

  • Pleural effusions

  • Brittle bone disease

POSITIVE EXPIRATORY PRESSURE (PEP) DEVICES

• PEP

  • How it works:

    • Patient exhales against a fixed orifice, which creates a resistance to flow

    • Airway stability is maintained due to prolonged expiratory time

    • Collateral ventilation allows air to move beyond the obstruction to improve aeration

    • Airflow through device helps move mucus into larger airways

    • Airway clearance is more effective as a result of improved air distribution in the lungs

• Contraindications

  • Increased work of breathing

    • Increased ICP

    • Hemodynamic compromise

    • Active hemoptysis

    • Untreated tension pneumothorax

    • Recent esophageal surgery

    • Middle ear pathology

• Flutter

  • How it works:

    • The patient exhales into the device, which contains a steel ball sitting in a cone

    • The patient's expiratory flow causes the steel ball to lift and roll in the cone until the weight of the ball causes it to drop down

    • Movement of the steel ball causes air to oscillate

    • Oscillations of air in the lungs loosens and moves mucus

  • Contraindications:

    • Increased work of breathing

    • Increased ICP

    • Hemodynamic instability

    • Active hemoptysis

    • Untreated tension pneumothorax

    • Esophageal surgery

• Acapella

  • How it works:

    • This therapy combines the effects of PEP and flutter

    • Patient exhales against a fixed orifice, which creates resistance to flow

    • Exhaled air is interrupted by a valve that opens and closes, creating vibrations

    • Adjusting a dial changes the frequency of vibration and resistance to exhalation

  • Contraindications:

    • Increased work of breathing

    • Increased ICP

    • Hemodynamic instability

    • Acute sinusitis

    • Active hemoptysis

    • Untreated tension pneumothorax

    • Esophageal surgery

HIGH-FREQUENCY ASSISTED AIRWAY CLEARANCE

• High-frequency chest wall compression (aka “vest” therapy)

  • How it works:

    • Air inflates a vest or wrap

    • Intermittent pressure pulses create vibrations and air movement throughout the airways (“mini-coughs”)

    • Helps loosen and move secretions

  • Contraindications:

    • Increased ICP

    • Uncontrolled hypertension

    • Hemodynamic instability

    • Bronchopleural fistula

    • Recent esophageal surgery

    • Active or recent hemoptysis

    • Pulmonary embolism

    • Uncontrolled airway at risk for aspiration

    • Distended abdomen

    • Bronchospasm

    • Suspected tuberculosis (TB)

    • Transvenous pacemaker or subcutaneous pacemaker

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