Professional Documents
Culture Documents
Devices
RT 31
Humidification
Basic Concepts
Functionsoftheoftheupperairway:
assurethatinspiredgasis:
Warmed(convection).
Humidifiedviaevaporationfromthe
mucosa
Filtered
During exhalation:
Expired gas transfers heat back
to the mucosa (convection)
Condensation occurs on the
mucosal surfaces and water is
reabsorbed by mucus
(rehydration)
Basic Concepts
As gas travels
through the
lungs it achieves
BTPS:
Body temp ~ 37C
Barometric
pressure
Saturation with
water vapor
(100% relative
humidity @ 37C)
Basic Concepts
The point at which this
occurs is called the
isothermic saturation
boundary (ISB)
Usually occurs ~ 5 cm
below the carina
If the upper airway is
bypassed or VE is
significantly higher than
norm,
The ISB will be deeper into
the lungs and HUMIDITY
therapy may be indicated
Basic Concepts
Oneofthemostimportant,
butleastunderstood,aspects
ofpulmonarycareistherole
ofhumiditytherapy.
Manycareprovidersand
mostpatientsdonot
appreciatetheroleof
hydrationinliquefying
secretionsandfacilitatingthe
naturalflowofmucusfrom
thelowerairways.
Basic Concepts
1.AbsolutehumidityTheactualcontentofwatervaporinagasmeasuredin
milligramsperliter.
2.PotentialhumidityThemaximumamountofwatervaporthatagascanhold
atagiventemperature.
3.RelativehumidityTheamountofwatervaporinagasascomparedtothe
maximumamountpossible,expressedasapercentage
4. Body humidity - The absolute humidity in a volume of gas
saturated at body temperature of 37 C; equivalent to 43.8
mg/L
PrimaryHumidityDeficit
Iftheatmosphere'srelativehumidityislessthan100%,theairofthe
atmospherehaswhatisreferredtoasahumiditydeficit.
Ifoutsideairat20Chas14mg/lofwatervapor,andneedstohave
17.3mg/ltobefullysaturated,itissaidtohaveaprimaryhumidity
deficitof3.3mg/l.
17.3mg/L(potential)14mg/L(absolute)=3.3mg/L(primarydeficit)
Rememberthatthepotentialisbasedtemp
Theprimaryhumiditydeficitoccursintheatmosphereandrepresents
thedifferencebetweenwhathumiditythereisandwhattherecouldbe.
PrimaryHumidityDeficit=PotentialWaterVaporContentActualWater
VaporContent
SecondaryHumidityDeficit
Thisisthemoisturedeficitintheinspiredairthatthenoseandupper
airwayneedtocompensatefor.
Theamountofwatervaporthebodyneedstoaddtoinspiredairtoachieve
saturationatbodytemperature.
Whenairisbreathedintothenasalcavityandheatedtobody
temperature,itspotentialwatervaporrisesto 44mg/l,whichisthe
potentialwatervaporcontentofairat 37C.
Therefore,unlesstheairoftheatmosphereisatleast37Cand
fullysaturated,thereexistsamoisturedeficit.
SecondaryHumidityDeficit=44mg/lAbsoluteHumidity.
Water Losses
Insensible: skin and lungs
Sensible: urine, GI tract,
sweat
Additive: vomiting, diarrhea,
suction from intestines,
severe burns, and fever
For each degree of
temperature above 99F for
over 24 hours, 1000m of
fluid is required for
replacement
WaterVaporCorrection
Water vapor acts in most ways like
any other gas, it creates a partial
pressure when its in a mixture of
gases.
That partial pressure depends
The amount of water vapor present
Which in turn depends on the temperature.
WaterVaporCorrection
As a result, it is best to calculate the
partial pressures of the other gases in
the air after the partial pressure of
water vapor has been determined-especially when measuring the air
within the lungs.
Inside the lungs, the partial pressure of
water vapor is approximately 47 mm Hg.
This value is relatively constant because
the air entering the lungs is normally
saturated and at 37C.
By subtracting the partial pressure of
the water vapor from the total
atmospheric pressure, you will find what
is referred to as the dry gas pressure
Importance of Humidity
It is needed to maintain
normal bronchial hygiene
Importance of Humidity
If the upper airway were bypassed
or dry gases were inhaled, a
series of adverse reactions could
occur, including:
Slowing of mucus movement
Inflammatory changes and
possible necrosis of
pulmonary epithelium
Retention of thick secretions
and encrustation
Bacterial infiltration of
mucosa (bronchitis)
Atelectasis
Pneumonia
Impairment of ciliary activity
Importance of Humidity
The general goals of humidity and
aerosol therapy are to:
1. Promote bronchial hygiene
2. Loosen dried and/or thick
secretions
3. Promote a effective coughs to
clear secretions
4. Provide adequate humidity in
the presence of an artificial
airway
5. Deliver adequate humidity
when administering dry gases
therapies
6. Delivering prescribed
medications
Neuromuscular status
Recent or planned surgeries
Trauma
Disease conditions
Another problem may occur when patients develop very thick and
abundant amounts of secretions which cannot be moved with normal
muscle activity--making humidity or aerosol therapy necessary.
Mucociliary Blanket
Its natural escalator functions to
clear airways via function of the
ciliated mucosa.
This mechanism occurs from the
larynx to the respiratory
bronchioles.
Mucus is produced by goblet cells
and submucosal glands.
Clara cells and tissue fluid
transudation also contribute to
airway secretions.
A wave-like motion of the cilia
then move secretions upward
toward the larynx where it is
either swallowed or
expectorated.
Mucociliary Blanket
Mucociliary Blanket
SourcesofMucus
SourcesofMucus
The mucous glands,
which are in the
submucosa, are the
greater source of
mucus.
Chronic irritation or
disease can cause the
number and size of
goblet cells and mucous
glands to increase,
resulting in a larger and
more viscous mucous
blanket.
Sign/Symptoms of Inadequate
Airway Humidification
Atelectasis
Dry, nonproductive
cough
Increased airway
resistance
Increased in
incidence of infection
Increased work of
breathing
Substernal pain
Thick, dehydrated
secretions
Humidification Devices
The purpose of humidifiers is to
deliver a gas with a maximum
amount of water vapor content.
May be heated or unheated, and the
factors affecting the efficiency of
humidification devices include:
temperature
time of exposure between
gas and water
surface area involved in the
gas/water contact
Humidification Devices
As temperature rises, the force exerted by
the water molecules increases, enabling
their escape into the gas, adding to the
humidity.
So the higher the tempthe more humidity
Humidification Devices
Space-efficient methods
Bubble diffusion
Aerosol
Wick technologies
Humidification Devices
Bubble diffusion:
Stream of gas is directed
underwater
The gas is broken up into small
bubbles
As gas bubbles rise, evaporation
increases the water vapor content
within the bubble
Humidification Devices
Aerosol: spraying water particles
into gas
Aerosol (suspended water droplets)
is generated in the gas stream
The greater the aerosol density (#
of molecules), the greater the
gas/water surface area available for
evaporation
Humidification Devices
Wick:
Use porous waterabsorbent materials to
increase surface area
A wick draws water
into its fine
honeycombed
structure by means of
capillary action
The surfaces of the
wick increase the area
of contact between
the water and gas
Blow-By
This pass-over type humidifier
directs a dry gas source over a
water surface area, and flowing it
to the patient.
Because exposure area and time of
contact is limited and it is not
heated, this unit is not very
efficient.
These units are often used in
incubators and in certain
ventilators, although many times
the use of a heated element is
added to improve this
humidification system
Wick type or membrane type
Bubble Humidifier
Jet Humidifier
Forms aerosol
Baffle system to break up
particles into smaller sizes
Bernoullis principle
Low flow
Large-volume jets are used for
bland aerosol
Ultrasonic Nebulizers
Electrically powered
Uses piezoelectric
crystal to generate
aerosol
Transducer converts
radio waves into highfrequency mechanical
vibrations (sound)
These vibrations are
transmitted to a liquid
surface creating a
geyser of aerosol
droplets
Cascade Humidifier
High Flow: Provide vapor to
entire gas flow
Used for mechanical ventilation,
airway bypass (artificial airways)
100% humidity
Usually heated to body
temperature
Figure 4-7 of Mosby, page 99
Cascade Humidifier
Gas enters the cascade and travels to the
bottom of the tower
Then it moves up through a sheet of plastic
consisting of many tiny holes.
Tiny bubbles are produced and dissipate into
water vapor, which are carried to the
patients delivery circuit.
No back flow is allowed due to one-way valves
A heating element in the water reservoir
heats the water to form warm gas.
Thermostat can be used to regulate and
monitor temperature.
If moisture remains
on filter for an
extended period of
time, airway
resistance increases.
Must be removed
during aerosol
therapy
Dead space volume
limits use for
neonates and
pediatrics.
Aerosol Therapy
Basic Concepts and
Delivery Systems
Aerosol Therapy
It is important to remember
that an aerosol is not the
same as humidity.
Humidity is water in a gas in
molecular form, while an
aerosol is liquid or solid
particles suspended in a gas.
Examples of aerosol
particles can be seen
everywhere: as pollen,
spores, dust, smoke, smog,
fog, mists, and viruses.
Aerosol Therapy
Aerosol therapy is
designed to increase
the water content
delivered while
delivering drugs to
the pulmonary tree
Deposition location
is of vital concern
Some factors that
affect aerosol
deposition are
aerosol particle size
and particle number.
Aerosol Output
The actual weight
or mass of aerosol
that is produced by
nebulization.
Usually measured
as mg/L/min also
called aerosol
density
Aerosol output does
not predict aerosol
delivery to desired
site of action.
Particle Size
The particle size of an aerosol depends on the device used
to generate it and the substance being aerosolized.
Particles of this nature, between 0.005 and 50 microns, are
considered an aerosol.
The smaller the particle, the greater the chance it will be
deposited in the tracheobronchial tree.
Particles between 2 and 5 microns are optimal in size for
depositing in the bronchi, trachea and pharynx.
Particle Size
Heterodisperse:
aerosol with a
wide range of
particle sizes
(medical aerosols)
Monodisperse:
aerosol consisting
of particles similar
in size (laboratory,
industry)
Deposition
The aerosol
particles are
retained in the
mucosa of the
respiratory tract.
They get stuck!
The site of
deposition depends
on size, shape,
motion and physical
characteristics of
the AIRWAYS
Mechanism resulting in
Deposition: Inertial Impaction
Moving particles collide with airway
surface.
Large particles (>5micros), upper and large
airways
Mechanism resulting in
Deposition
Table: Particle size and area of deposition.
Particle Size in Microns
1 to 0.25
1 to 2
2 to 5
5 to 100
Area of Deposition
Minimal settling
Enter alveoli with 95% deposition
Deposit proximal to alveoli
Trapped in nose and mouth
Mechanism resulting in
Deposition:
Sedimentation
Particles settle out of
aerosol suspension due
to gravity.
The bigger it is the
faster it settles!
Medium particles: 1-5
microns, central airways
Directly proportional to
time.
The longer you hold
your breath the greater
the sedimentation
Mechanism resulting in
Deposition: Diffusion
Actual diffusion
particles via the
alveolar-capillary
membrane and to a
lesser extent tissuecapillary membranes
of respiratory tract
Lower airways: 2-5
microns
Alveoli: 1-3 microns
These values are from
your book
Gravity
Gravityaffectslargeparticlesmorethan
smallparticles,causingthemtorainout.
ViscosityTheviscosityofthecarriergasplays
animportantroleindeposition.
Forexample,ifagaslikehelium,whichhasa
lowviscosityandmolecularweight,isusedasa
carriergas,gravitywillhavemoreofaneffect
upontheaerosol.
Heliumisverylightandhencecan'tcarry
theseparticleswell,leadingtorainoutand
earlydeposition.
MethodsofAerosolDelivery
Aerosols are
produced in
respiratory therapy
by utilizing devices
known as nebulizers.
There are a variety
of nebulizers in use
today, but the most
common is one in
which the Bernoulli
principle is used
through a Venturi
apparatus
Aerosol delivery is
accomplished in a variety of
ways:
Disadvantages
They require complex hand-breathing
coordination.
Drug concentrations are pre-set.
Canister depletion is difficult to ascertain accurate
A small percentage of patients may experience
adverse reactions to the propellants.
There is high oropharyngeal impaction and loss if
a spacer or reservoir device is not used.
Aspiration of foreign objects from the mouthpiece
can occur.
Pollutant CFCs, which are still being used in MDIs,
are released into the environment until they can
be replaced by non-CFC propellant material
Drypowderinhalers(DPIs)
Consistofaunitdoseformulationof
adruginapowderform,dispensed
inasmallMDIsizedapparatusfor
administrationduringinspiration.
Becausethesedevicesarebreath
actuated,usingturbulentairflow
fromtheinspiratoryefforttopower
thecreationofanaerosolof
microfineparticlesofdrug,they
don'trequirethehandbreath
coordinationneededwithMDIs.
Drypowderinhalers(DPIs)
Cromolyn sodium and albuterol are the two
primary drugs available in powder form.
Cromolyn sodium is dispensed in a device
called the Spinhaler, which pokes holes in
capsules containing the powdered drug.
The albuterol formulation is dispensed in a
device called the Rotohaler, which cuts the
capsule in half, dropping the powdered drug
into a chamber for inhalation.
In both cases, a single-dose micronized powder
preparation of the drug in a gelatin capsule is
inserted into the device prior to inhalation.
See Mosby Fig 4-39,40
Bernoullis principle:
make sure you
understand this
concept
Advantages of SVN
therapy:
Requires very little patient coordination or
breath holding, making it ideal for very young
patients.
It is also indicated for patients in acute distress,
or in the presence of reduced inspiratory flows
and volumes.
Use of SVNs allows modification of drug
concentration, and facilitates the aeorsolization
of almost any liquid drug.
Dose delivery occurs over sixty to ninety
breaths, rather than in one or two inhalations.
Therefore, a single ineffective breath won't ruin
the efficacy of the treatment.
Disadvantages of SVNs
include:
The equipment required for use is
expensive and cumbersome.
Treatment times are lengthy compared to
other aerosol devices and routes of
administration.
Contamination is possible with inadequate
cleaning.
A wet, cold spray occurs with mask delivery.
There is a need for an external power
source (electricity or compressed gas).
LargeVolumeNebulizers
Theseunitsalsohavethecapabilityforentrainingroom
airtodeliveraknownoxygenconcentration.
Theycandelivervaryingconcentrationsofoxygen.When
usingtheseunits,youshouldalwaysmatchorexceedthe
patient'speakinspiratoryflowrates.
Thisassuresdeliveryofoxygenandnebulizedparticles.
Theseunitsproduceparticlesizesbetweentwoandten
micronsandmaybeheatedtoimproveoutput.
UltrasonicNebulizers(USN)
Ultrasonicnebulizersworkontheprinciplethat
highfrequencysoundwavescanbreakupwater
intoaerosolparticles.
Thisformofnebulizerispoweredbyelectricity
andusesthepiezoelectricprinciple(abilityto
changeshapewhenachargeisapplied).
Thisprincipleisdescribedastheabilityofa
substancetochangeshapewhenachargeis
appliedtoit.
UltrasonicNebulizers(USN)
Contains a transducer that has
piezoelectric qualities.
When an electrical charge is applied, it
emits vibrations that are transmitted
through a volume of water above the
transducer to the water surface, where
it produces an aerosol.
The frequency of these sound waves is
between 1.35 and 1.65 megacycles,
depending on the model and brand of
the unit.
UltrasonicNebulizers(USN)
Their frequency determines the particle size of the
aerosol.
The transducers that transmit this frequency are of two
types.
One type is the flat transducer, which creates straight,
unfocused sound waves that can be used with various
water levels.
The other type is a curved transducer, which needs a
constant water level above it because its sound waves
are focused at a point slightly above the water surface.
If the water level falls below this point, the unit loses
its ability to nebulize.
UltrasonicNebulizers(USN)
The particle size falls in the range of .5 to 3 microns.
The amplitude or strength of these sound waves
determines the output of the nebulizer, which falls in
the range of 0 to 3 ml/minute and 0 to 6 ml/minute.
Ultrasonic nebulizers also incorporate a fan unit to
move the aerosol to the patient. This fan action also
helps cool the unit.
The gas flow generated by this fan falls in the range
of between 21 and 35 liters/minute. This flow of air
also depends on the brand and model of the unit.
UltrasonicNebulizers(USN)
The transducer of an ultrasonic nebulizer is often found
in the coupling chamber, which is filled with water.
This water acts to cool the transducer and allows the
transfer of sound waves needed for the nebulizer,
which takes place in a nebulizer chamber.
The nebulizer chamber is found just above the coupling
chamber. These two chambers are usually separated by
a thin plastic diaphragm that also allows sound waves
to pass.
When studying ultrasonic nebulizers, remember that
output is controlled by amplitude, and particle size is
controlled by frequency.
The advantages of
Ultrasonic Nebulization are:
High aerosol output
Smaller stabilized particle size
Deeper penetration into the
tracheobronchial tree (alveolar level)
Useful in the treatment of thick secretions
that are difficult to expectorate, and they
can help to stimulate a cough.
The therapy can be delivered through a
mouthpiece or face mask. Therapy can be
given with sterile water, saline or a mixture
of the two.
Smallparticleaerosolgenerator
(SPAG)
Thisisahighlyspecialized
jettypeaerosolgenerator
designedtofor
administeringribavirin
(Virazole),theantiviral
recommendedfortreating
highriskinfantsand
childrenwithrespiratory
syncytialvirusinfections.
AdvantagesofAerosolTherapyas
a Whole:
Systemic side effects are fewer and less
severe than with oral or parenteral therapy
Inhaled drug therapy is painless and
relatively convenient. Aerosol doses are
smaller than those for systemic treatments.
Onset of drug action is rapid.
Drug delivery is directly targeted to the
respiratory system.
Disadvantages as a
Whole:
Special equipment is often needed for its administration.
Patients generally must be capable of taking deep,
coordinated breaths.
There are a number of variables affecting the dose of
aerosol drug delivered to the airways.
Difficulties in dose estimation and dose reproducibility.
Difficulty in coordinating hand action and breathing with
metered dose inhalers.
Lack of physician, nurse, and therapist knowledge of device
use and administration protocols.
Lack of technical information on aerosol producing devices.
Systemic absorption also occurs through oropharyngeal
deposition.
The potential for tracheobronchial irritation,
bronchospasm, contamination, and infection of the airway.
AirwayobstructionDehydratedsecretionsinthepatient'sairways
mayabsorbwaterdeliveredviaaerosolandswelluplargeenoughto
obstructairways.
Toavoidthis,watchthepatientverycloselyandlethimprogress
withtherapyatareasonablerate.Youmaywanttohavesuction
apparatusonhand.
BronchospasmsItiscommonforaerosolparticlestocausethis
condition(especiallyamongasthmatics)anditismoreprevalentwhen
administeringacoldaerosolascomparedtoaheatedone.
Ifaverylargeamountofcoughingoccurs,stoptherapyandgive
thepatientarest.Ifthispersistsinfarthertherapy,stoptreatment
andnotifythephysician.
Type of aerosol
Source gas (FI02)
Fluid composition (NaCl, water,
etc.)
Delivery modality
Duration of therapy
Frequency of therapy
Temperature of the aerosol
Bronchial Hygiene
Bronchial Hygiene
Techniques designed to help mobilize and
remove secretions and improve gas
exchange
PDPV, CPT, modified breathing/coughing
techniques, and new devices
Broad application is ineffective and
expensive
If combined with exercise, and used when
indicated, it can be a improve lung function
Component of comprehensive respiratory care
Bronchial Hygiene
Insufficient evidence to support or refute
its use with COPD, CB, or bronchiectasis
Successful outcomes require:
knowledge of normal/abnormal physiology
patient evaluation and selection
clear definition of therapeutic goals
rigorous application of appropriate methods
on-going assessment
follow-up evaluation
Four components to an
effective cough:
Irritation
Inspiration
Compression
Expulsion
Four components to an
effective cough:
Irritation
Abnormal
stimulation
provokes sensory
fibers to send
impulses to he
brains medullary
cough center
Stimulus is either
inflammatory,
mechanical,
chemical or thermal
Four components to an
effective cough:
Inspiration:
Cough center
generates a reflex
stimulation of the
respiratory muscles
to initiate a deep
inspiration
Four components to an
effective cough:
Compression
Reflex nerve
impulses cause
glottic closure and a
forceful contraction
of the expiratory
muscles
This causes rapid
rise in pleural and
alveolar pressure
Four components to an
effective cough:
Expulsion
Glottis opens
Large pressure gradient is present
Causes a violent, high-velocity,
expulsive flow combined with dynamic
airway compression creates a shearing
force that displaces mucus for the walls
into the airstream
Abnormal Clearance is
caused by an alteration
in Airway patency
Mucociliary
function
Effectiveness of
cough reflex
Abnormal Clearance
Airway patency
full airway obstruction
mucus plugging
can result in atelectasis with
the possiblitiy of
deoxygenation due to
shunting
Inadequate humidification
can result in this
Abnormal Clearance
Mucociliary
function
high FiO2 can
impair directly or
due to
tracheobronchitis
Abnormal Clearance
Effectiveness of
cough reflex
Abnormal Clearance
Therapeutic interventions
Abnormal clearance in the
presence of a pathogenic
organism may result in
infection
Infectious process
inflammatory response
and release of chemical
mediators damage to
airway epithelium and
increase mucus
production cyclical
activity
Phase Disruption
Irritation
Anesthesia
CNS depression
Narcotics
Phase Disruption
Inspiration:
Pain
Neuromuscular
dysfxn
Pulmonary
restriction
Abdominal
restriction
Phase Disruption
Compression
Laryngeal nerve damage
Artifical airway
No mucocillary escalator
Erosion of trachea
Prevent closure of glottis
Abdmonial muscle
weakness
Abdominal surgery
Phase Disruption
Expulsion
Airway compression
Airway obstruction
Abdominal muscle
weakness
Inadeaqute lung
recoil
Diseases
Internal obstruction or
external compression
FBO
Mucus hypersecretion
Inflammatory changes
Bronchospasm
Asthma
CB
Pneumonia
pneumonitis
Tumor
Kyphoscoliosis
Diseases
Alteration in mucocilliary escalator
CF (viscous secretions)
Ciliary diskinetic syndromes (cilia dont
work right)
Bronchiectasis (occurs w/ CF & Ciliary
diskinetic syndromes)
Permenent airway damage
Dilated airway
Constant obstruction
Diseases
Reflex
Neuromuscular
disorders
Muscular
dystrophy
Amytrophic
muscular sclerosis
MS
Polymyelitis
Cerebral palsy
Goals
Mobilize and remove retained
secretion
Improve gas exchange
Reduce WOB
Indications
Acute
Acutely ill with copious secretions
Acute respiratory failure with clinical signs of
retained secretions
Lobar atelectasis
V/Q abnormalities due to unilateral lung
infiltrates or consolidation
Probably not helpful for:
Pneumonia without significant sputum production
COPD
Uncomplicated asthma
Indications
Chronic: > 25-30
ml/day to be
effective ( 1 fluid
oz or shot glass
full)
CF
Bronchiectasis
Ciliary dyskinetic
syndromes
Chronic bronchitis
Indications
Prevention
Body position
Pt Mobilization
PDPV combined
with exercise to
maintain normal
function in CF
Possible NM
disorders
Intubation or trach
CXR: atelectasis or infiltrates
PFT
ABG
PAP adjunts
PEP
CPAP
Expiratory PAP (EPAP)
Includes
Turning
Drainage
Percussion
vibrations
Turning
Kinetic Therapy or continuous lateral
rotational therapy
Done by
Patient
Caregiver
Rotational bed
RotoRest Delta Bed rotates continuously side to side
(124 degree angle over 3-4 minutes)
Reposition can be accomplished by using automated
inflation and deflation of air-filled mattress
compartments
Turning
Primary Purpose
Promote lung expansion
Improve oxygenation
Prevent retention of secretions
Other benefits
Reductions of venostasis
Prevention of skin ulcers
Turning
Absolute contraindications
Unstable spinal chord injuries
Traction of arm abductors
Relative contraindications
Severe diarrhea
Marked agitation
Rise in intracranial pressure (ICP)
Large drops in blood pressure (>10%)
Worsening dyspnea
Hypoxia
Cardiac dysrhythmias
Turning
Hazards
Ventilator disconnection
Accidental extubation
Aspiration of ventilator condensate
Disconnection of vascular lines or
urinary catheters
Turning
Proning
Used in pts with Acute Lung Injury (ALI)
Improves oxygenation without negative
effects on hemodynamics
May allow for lower FiO2 and lower pressure
Not shown to improve survival though
Turning
Postural Drainage
Use of gravity to help move secretions
from distal lung segments
May be coughed up
Or suctioned out
Postural Drainage
Most effective if
Sputum production is >25-30 ml/day
Head-down positions exceed 25 degree
below horizontal
Pt is adequetly hydrated
Airwaymay need bland aerosol
SystemicIV NS
Postural Drainage
Technique
Identify appropriate lobe or segment
Determine position and need for position
modification given your assessment
Unstable hemodynamics
HTN
Cerebrovascular disorders
Orthopnea
Postural Drainage
Assess pt surroundings
Monitors
IV or other lines
NG
O2
Postural Drainage
Other assessments
Subjective response
Breathing pattern, symmetrical
movement, etc.
Mental function
Skin color
SpO2
ICP
Postural Drainage
Recommended
interventions upon
complications
Hypoxia
Give higher FiO2 during
procedure
If hypoxia occurs during
tx, give 100%
FiO2stop
therapyreturn to
original position
Increased ICP
Stop therapyreturn to
original position
Postural Drainage
Recommended
interventions upon
complications
Acute hypotension during
tx
Stop therapyreturn to
original position
Pulmonary Hemorrhage
Stop therapyreturn to
original positioncall Doc
immediatelyO2maint
ain airway
Pain or injury
Stop therapyreturn to
original position carefully
Postural Drainage
Recommended interventions upon
complications
Vomiting/Aspiration
Stop clear airway/suctionO2maintain airway
return to original positioncall Doc
Bronchospasm
Stop return to original position O2call
Docbronchodilators as ordered
Dysrhythmias
Stop return to original position O2call Doc
Postural Drainage
Outcome assessment:
criteria indicating
positive response
Should be assessed
every 24 hrs for critical
and every 3 days for
others or upon change
in status
Worsening breath sounds
is not necessarily bad
Example: diminished to
rhonchisecretions
have loosened
Postural Drainage
Outcomes
Postural Drainage
Charting
Left Lung
Bronchi-Carina
UPPER LOBES
Apical Segment/1
Bed or drainage table
flat.
Patient leans back on
pillow at 30 degree
angle.
(Clap over area between
clavicle and top of
scapula on each side.)
UPPER LOBES
Posterior Segment/3
Bed or drainage table
flat.
Patient leans over folded
pillow at 30 degrees
angle.
(Clap over upper back on
each side of chest.)
UPPER LOBES
Anterior Segment/2
Bed or drainage table
flat.
Patient lies flat on back
with pillow under knees.
(Clap between clavicle
and nipple on each side
of chest.)
LOWER LOBES:
Anterior Basal Segment/8
Foot of table or bed
elevated 18 inches or 30
degrees.
Patient lies on side,
head down, pillow under
knees.
(Clap over lower ribs just
beneath axilla.)
LOWER LOBES:
Superior Segment/6
Bed or table flat. Patient
lies on abdomen with
pillows under hips
(Clap over middle of
back below tip of scapula
on either side of spine.)
LOWER LOBES:
Lateral Basal Segment/9
Foot of table or bed
elevated 18 inches or 30
degrees.
Patient lies on abdomen,
then rotates 1/4 turn
upward.
Upper leg can be flexed
over a pillow for support.
(Clap over uppermost
portion of lower ribs.)
Percussion
This should be done with the hands
in the cupped position, with the
thumb and fingers closed to trap air.
Percussion
Hold your arms with the elbows
partially flexed and wrists loose
Rhythmically strike the chest wall in
a waving motion using both hands
alternately in sequence.
Percuss back and forth in a circular
pattern over the specific segment for
3-5 minutes
Vibration technique
Place hands on either side of the
chest
After the pt takes a deep breath,
exert slight-to-moderate pressure ont
eh chest wall
Initiate a rapid vibratory motion of
the hands throughout expiration
Coughing
Directed cough (DC) to clear or
mobilize secretions is a component of
bronchial hygiene
Directed Cough is a deliberate maneuver
that is taught, supervised, and monitored.
Coughing
Seeks to mimic the attributes of an
effective spontaneous cough (or series of
coughs)
To help to provide voluntary control
over reflex
To compensate for physical limitations
"CASCADE TECHNIQUE"
Breathe in slowly and deeply through the nose.
Breathe out slowly and completely through
pursed lips.
Breathe in slowly and deeply once again, then
hold breath briefly.
Cough several times until lungs feel empty. The
cough should produce a sharp sound.
Avoid taking sharp, quick breaths between
coughs.
PAP
Positive airway pressure (PAP) adjuncts are
used to mobilize secretions and treat
atelectasis and include
continuous positive airway pressure (CPAP)
positive expiratory pressure (PEP)
expiratory positive airway pressure (EPAP).
PAP: CPAP
The patient breathes from a pressurized
circuit against a threshold resistor
(water-column, weighted, or spring loaded)
that maintains consistent preset airway
pressures from 5 to 20 cm H2O during
both inspiration and expiration
(By strict definition, CPAP is any level of aboveatmospheric pressure.)
PAP: CPAP
Types of threshold resistors: all of these
valves operate on the principle that
the level of PAP generated within the
circuit depends on the amount of
resistance that must be overcome to
allow gas to exit the exhalation valve.
They provide predictable, quantifiable,
and constant force during expiration
that is independent of the flow
achieved by the patient during
exhalation
PAP: CPAP
Underwater seal resistor:
expiratory port of the circuit is submerged
under a column of water, the level of CPAP
is determined by the height of the column
Weighted-ball resistor:
consists of a steel ball placed over a
calibrated orifice, which is attached
directly above the expiratory port of the
circuit
PAP: CPAP
Spring-loaded:
rely on a spring to hold a disc or diaphragm
down over the expiratory port of the circuit.
PAP: PEP
PAP: PEP
Thus the patient must be encourage to
generated a flow high enough to
maintain expiratory pressure at 10-20
mm H2O
Ideal I:E of 1:3 or 1:4
The patient should perform 10-20 breaths
through the device and then perform 2-3
huff breath coughs
This should be repeated 5-10 times during
a 15-20 minute session
PAP: EPAP
The patient exhales against a threshold
resistor, generating preset pressures of 10
to 20 cm H2O (similar to CPAP expiration)
EPAP does not require a pressurized external
gas source.
EPAP utilizing threshold resistors does not
produce the same mechanical or
physiologic effects that PEP does when a
fixed orifice resistor is used.
Further study is necessary to determine how
these differences affect clinical outcome.