Airway Clearance (Chest Physiotherapy)-1
Rhonda Yngsdal-Krenz
Pediatric Respiratory Care Supervisor
Airway clearance techniques (ACT) are methods used to assist with secretion removal. Several years ago, the only method for airway clearance was manual chest physiotherapy (chest clapping). Now, there is a large menu of different techniques. In this issue of the CF Center newsletter, we will present a brief overview of the different airway clearance techniques. In future issues of this newsletter, we will focus on individual techniques. ACT should be viewed as part of your daily routine cares. The key to success is to choose the one that is most effective for you, as well as one you will faithfully follow.
CPT Chest physical therapy is a form of removing secretions by cupping your hand and clapping on a designated position of a lung field. There are 6 different positions, 4 of which are drained by positioning the body with the head down. Percussion is done for 3-5 minutes per position. A cough is encouraged after every position. Percussion can be done manually or automatic and usually requires assistance.
PEP
Positive expiratory pressure is self administrating. The process is to take a deep breath in and blow out with moderate force, against a resistance. This resistance keeps the airways open allowing air to move secretions so they can be coughed out. 20 deep breaths against the resistance followed by a huff cough maneuver is the usual sequence. The huff cough is a forced exhalation with the vocal cords open and it sounds like you are saying the word "Huff".
HIGH PRESSURE PEP
This technique acquires breathing against a resistance on the pep device and exhaling with a moderate force. Each breath is not completely exhaled to create a stacking of air inside the lungs. When no more air can be taken in, the air is blown out until it feels like you can't blow out any more air. The huff maneuver is then done and the cycle is repeated. This is done in a sitting position or with gravity assisted positions. This maneuver can also be done by applying different resistances on the pep device.
Flutter This is a hand held device that functions like PEP working from the inside out. Exhalation through the flutter results in a vibrating of the airway walls loosening secretions. The airways are open during expiration to mobilize secretions. The positioning or angle of the flutter will determine the vibration level. A huff cough maneuver is used to remove secretions.
VEST
High frequency chest compression technique is self administrating. An inflatable vest is placed over the chest with air pulsating through it. The pulsation helps force secretions toward the large airways so they can be coughed up. The pulsation frequency is increased throughout the treatment. The huff cough (forced expiration maneuver) is used to remove secretions.
IPV
Intrapulmonary percussive ventilation is administered by a percussionator. Aerosolized air, in the form of mini-bursts, are delivered into the lungs. A constant pressure is maintained to keep the airways open. The bursts of air provides an air hammer affect opening the airways that have retained secretions. The huff cough is used for secretion removal.
Forced Expiration Technique
FET may be used in addition to some other form of ACT. It consists of one or two forced expirations (huffs) followed by relaxation and comfortable breathing. Fet is repeated until secretions are mobilized to central airways where they can easily be coughed out. The huff can be started at different lung volume levels, to clear the mucus from the different sizes of airways.
Autogenic Drainage (AD)
This breathing technique takes cooperation and understanding of the different lung capacities. With good training the individual can identify which lung field the secretions are in. There are 3 phases: Phase I is the "un stick" phase, where very small volume, normal breathing helps move the secretions up the bronchial tree. Phase II is the "collect" phase, where small volume breathing is increased to a higher level, allowing for secretion collection in the central airways. Phase III is the "evacuate" phase, where breathing is normal to high volume breathing and secretions can be removed from the upper airways. A huff maneuver is used to remove secretions.
ACTIVE CYCLE BREATHING
ACB technique consists of thoracic expansion exercises, breathing control, and the forced expiration technique (huff). Breathing control is passive normal breathing, using the diaphragm. It is used between the active parts of the cycle, to allow relaxation and to avoid airflow obstruction. Thoracic expansion exercises are deep breathing exercises with an emphasis on inspiration. Expiration is quiet and relaxed. These exercises help to loosen bronchial secretions. Forced expiration technique consists of two huffs or forced expirations, combined with periods of breathing control. At mid lung volume to low lung volume a huff will help to move secretions from the peripheral airways. At high lung volume a huff will mobilize secretions from the upper airways. These three stages are repeated until the huff becomes dry sounding and non-productive or it is time for a rest. Position placement is determined by where the secretions are heard or felt in the lungs.
EXERCISE
Everyone can benefit from exercise. This can be adjusted to meet your own goals. Choose something that you truly enjoy and will adapt to your daily living. Some types of exercise that others have found beneficial are walking, swimming, trampoline jumping and bicycling. Exercise is encouraged to be done in addition to some form of ACT.
Airway Clearance Techniques- Manual Chest Physiotherapy ( Cupping)
by Rhonda Yngsdal-Krenz, B.A., R.R.T.
Focus on manual chest physical therapy.
Chest physical therapy (CPT) is the traditional airway clearance technique. The removal of obstructive, thick sticky secretions is important in preventing infections and helps ease breathing. CPT consists of two parts: 1) postural drainage and 2) percussion and vibration:
1) Postural drainage pertains to placing the body in a position which allows the mucus to drain from the smaller airways into the main airway with gravity. Two positions are in an upright sitting position and four positions are with the head tilted below the lungs. To obtain the head- down positions, the use of a pillow, a bean bag chair, or couch cushions work well.
2) Percussion and vibration help loosen and mobilize secretions. Percussion is a repetitive tapping on the designated position and can be done with palm cups (of varying sizes), by hand, or with a manual percussor. If you choose to use your hands, the palm of your hand should be cupped to provide a pocket of air that cushions the percussion. Manual percussors have padding and velcro to allow self use. Vibration is done at the end of the position. After a big breath in, vibrate when the air is slowly blown out, for three big breaths.
There are 6 positions of the lungs that require CPT.
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Each position requires proper placement for percussion and should be done for 3-5 minutes. Nothing should be placed in the mouth (pacifiers, food, etc.) while doing CPT. A strong cough is encouraged after each position to remove the mucus. It is recommended that CPT be done before meals and bedtime. Your doctor will determine how often CPT is needed. Airway clearance is a very important part of the daily cares in CF, and we recommend this a minimum of once a day for all patients (even those without a cough).
CPT is introduced shortly after the diagnosis is made. This tells you the importance of keeping the lungs healthy. As infants grow it may become more challenging for them to cooperate with CPT. You may find that it helps to make therapy time a special time. This can be done with a toy, watching a video, or a sticker reward. Keep these times special by only giving them with cooperation of therapy and not allowing them to be used any other time. Once therapy is done faithfully, it will become part of the daily cares to healthy living.
FLUTTER
No it's not a butterfly, nor a reenactment of your heart to your true love. Flutter is another type of airway clearance. Flutter is also known as oscillating PEP. The pocket device looks like a fat pipe and was developed in Switzerland. Inside the pipe is a plastic cone cradling a steel ball sealed with a perforated cover. Its aim is to improve ventilation and mucus production.
The technique is like pep with oscillations (flutter) of air generated during exhalation. Begin by placing your lips around the mouthpiece and taking a breath in through your nose. Then exhale through your mouth with a moderate force. This will cause the ball to oscillate in the pipe. Oscillation is transmitted throughout the airways, loosening secretions. The force of exhalation, will help mobilize secretions. After 20 deep breaths, the huff cough is done. This sequence is repeated for 20 minutes or until there is no sputum production. By changing the angle at which you hold the device you can change the oscillation. Clean the device weekly by disassembling the flutter, wash the pieces in a mild dish soap, rinse with clean tap water and air dry over night.
This device is great for those who are able to do therapy on their own. The individual must be compliant, responsible and able to tell at what angle of the flutter do they feel the most oscillation inside their lungs. If the technique is not done correctly, it is not as effective as CPT
