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Basic Concepts and

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

Pulmonary patients need:

adequate humidification of their inspired gases

controlled fluid balance


otherwise patients can become dehydrated.

Dehydration can make secretions more viscous


and inhibit the mucociliary escalator activity of
the airways, making secretions difficult to
dislodge.

If these secretions block functional gas flow


through the distal airways infections, atelectasis
and other respiratory problems can easily occur.

Basic Physical Principles of


Humidity
Humidity is essentially the water vapor in a
gas.
This water vapor can be described in several
ways, as:

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

Formulas Used When


Calculating Humidity
%RH=(absolute humidity/saturated
capacity) x 100
Refer to table 5-3 of Egan or 4-1 of
Mosby. Calculations are based on
temperature. See example on page 90
of Egan
%BH = (absolute humidity/43.8mg/L) x 100
See example on page 97 of Egan

Absolute humidity: Refer to table 5-3 of


Egan

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.

How does a patient


develop a humidity
deficit?
Breathing a gas with little
or no humidity and very
high minute volume
evaporation of the
respiratory mucosa occurs
Bypass of upper airway:
intubation, tracheostomy.
Dehydration due to
illness, exposure, etc.....
Please understand Figure
4-3 of Mosby, page 94.

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.

Unlike other gases in the air,


changes in the barometric pressure
of the atmosphere under normal
conditions do not have much impact
on the partial pressure of water .

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

It promotes functions of the


normal mucociliary escalator
It maintains the body's vital
homeostasis
Without humidity:

the nearly 100 ml of mucus


secreted daily would become
quite thick and tenacious.
actual lung parenchyma
would dry up, causing a loss
of normal compliance which
would restrict lung movement
and reduce ventilation.

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

Clinical Evaluation of the Need


for Humidity and/or Aerosol
Use

Patient's age and ability to move normal


secretions

Neuromuscular status
Recent or planned surgeries
Trauma
Disease conditions

The presence of any of these may impair the patient's ability to


cough and move secretions.

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.

Indications for delivery of


humidified gases and aerosols
Primary indications
for humidifying
inspired gases
include:
Administration of
medical gases
Delivery of gas to the
bypassed upper
airway
Thick secretions in
nonintubated patients

Indications for delivery of


humidified gases and aerosols
Additional
indications for
warming inspired
gases:
Hypothermia
Reactive airway
response to cold
inspired gas

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

Secretion from goblet


cells and bronchial
(mucous) glands.

The goblet cells,


which are distributed
throughout the
epithelium of the
mucosa, synthesize
and secrete mucus
into the airway.

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.

Effects of Mucous Layer


Ciliary activity, which moves the mucus, can be
adversely affected if the mucous layer is changed.
A higher ratio of gel to sol layer will affect the flow of
mucus by increasing cilia workload.
a decrease in the watery sol layer
or an increase in the viscous gel layer

The cilia are capable of continuing to beat even if the


workload increases, but only to a certain level.
If the cilia become tangled in the thick mucus or are
unable to penetrate the dense layer, the transport of
the mucous blanket would stop, causing secretions to
become retained in the respiratory tract.

Other factors that can impede


ciliary activity and the flow of
mucus include:
Tobacco smoke
Local
environmental
conditions
Pathology of the
airway can
impede clearance
due to changes in
the epithelium.

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

Longer exposure of a gas to the water


increases the opportunity for the water
molecules to evaporate during the
humidifier's operation.
Thegreatertheareaofcontactbetweenwaterandgas,the
moreopportunityforevaporationtooccur.

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

Low-flow gas system


Provides flow lower than patients inspiratory
needs.
Oxygen or air is humidified at 30%-50%
relative humidity.
Gas is passed below the waters surface in
the form of bubbles.
Increase exposure time result in good
humidification
Patients airway provide further
humidification.
Should be used for NC use at 4lpm or above,
but the higher the flow rate the less the
exposure time.
Do not use with oximizers or venturi masks
(these are common mistakes in the clinical
setting)

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

Mist tents and hood


Kids dont like things on
their face
So tents and hoods are used
to deliver bland aerosols
Sometimes referred to as
croup tents
High flow rates should be
used to prevent CO2 build up
Must use some kind of
cooling device to prevent
heat retention: refrigeration
devices or even ice

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.

Heat and Moisture Exchangers


(HME) or Artificial Noses
Functions similarly to the upper
airway
Captures s exhaled heat and
moisture and using it to heat and
humidify inhaled gas.
Do not add heat or moisture--Use
the bodys own heat and moisture.
Book statement: should be used
short term, flow less than 10 lpm,
and in the absence of thick
secretions
Practical purposed: Used all the
time! Changed every 24 hours.

Heat and Moisture Exchangers


(HME) or Artificial Noses
Light weight
Less dead space
Reduce
accumulation of
condensation in
tubing
Decrease risk of
infection (maybe)

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

Physics: the larger the particle, the more


likely it will remain moving in a straight
line even when the direction of flow
changes.
Physics: greater velocity and turbulence
results in greater tendency for deposition

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

Deposition of Particles is also


affected by:

Gravity
Gravityaffectslargeparticlesmorethan
smallparticles,causingthemtorainout.

ViscosityTheviscosityofthecarriergasplays
animportantroleindeposition.

Forexample,ifagaslikehelium,whichhasa
lowviscosityandmolecularweight,isusedasa
carriergas,gravitywillhavemoreofaneffect
upontheaerosol.

Heliumisverylightandhencecan'tcarry
theseparticleswell,leadingtorainoutand
earlydeposition.

Deposition of Particles is also


affected by:
KineticactivityAsaerosolizedparticles
becomesmaller,theybegintoexhibitthe
propertiesofagas,includingthephenomenon
of"Brownianmovement."
Thisrandommovementofthesesmall(below
lmm)particlescausesthemtocollidewitheach
otherandthesurfacesofthesurrounding
structures,causingtheirdeposition.
Asparticlesizedropsbelow0.1m,they
becomemorestablewithlessdepositionand
areexhaled.

Deposition of Particles is also


affected by:
Particleinertia(repeated)
Affectslargerparticleswhich
arelesslikelytofollowacourse
orpatternofflowthatisnotin
astraightline.
Asthetracheobronchialtree
bifurcates,thecourseofgas
flowisconstantlychanging,
causingdepositionofthese
largeparticlesatthe
bifurcation.

Deposition of Particles is also


affected by:
CompositionornatureoftheaerosolparticlesSome
particlesabsorbwater,becomelargeandrainout,while
othersevaporate,becomesmallerandareconductedfurther
intotherespiratorytree.
Hypertonicsolutionsabsorbwaterfromtherespiratorytract,
becomelargerandrainoutsooner.
Hypotonicsolutionstendstolosewaterthroughevaporation
andarecarrieddeeperintotherespiratorytractfor
deposition.
Isotonicsolutions(0.9%NaCl)willremainfairlystablein
sizeuntiltheyaredeposited.

Deposition of Particles is also


affected by:
HeatingandhumidifyingAsaerosolsentera
warmhumidifiedgasstream,theparticlesizeof
theseaerosolswillincreaseduetothecoolingof
thegasintransittothepatient.
Thisoccursbecauseofthewarmhumidifiedgas
coolinganddepositingliquid(humidity)uponthe
aerosolparticlesthroughcondensation.

Deposition of Particles is also


affected by:
Ventilatory pattern - RCPs easily control
this by simple observation and instruction.
For maximum deposition, the patient must
be instructed to:
Take a slow, deep breath.
Inhale through an open mouth (not through the
nose).
At the end of inspiration, use an inspiratory
pause, if possible, to provide maximum
deposition.
Follow with a slow, complete exhalation
through the mouth.

Aerosol vs. Systemic


Inmanycases,aerosolsaresuperiorintermsof
efficacyandsafetytothesamesystemically
administereddrugsusedtotreatpulmonary
disorders.
Aerosolsdeliverahighconcentrationofthedrugs
withaminimumofsystemicsideeffects.
Asaresult,aerosoldrugdeliveryhasahigh
therapeuticindex;especiallysincetheycanbe
deliveredusingsmall,largevolume,andmetereddose
nebulizers.

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

Bernoullis Principle and


Nebulizers

When gas flows through a tube, it exerts a lateral wall


pressure within that tube due to its velocity.

As the gas reaches a smaller diameter in the tube, the


velocity is increased, which decreases lateral wall pressure.

This decrease in diameter within the tube is at a structure


called a jet.

Just distal to the jet is a capillary tube that is immersed in a


body of fluid.

The decreased pressure is transmitted to the capillary tube


and fluid is drawn up it.

When the fluid reaches the jet, it is then atomized.


See Mosby Figure 4-25, pg 115

Bernoullis Principle and


Nebulizers: The Baffle
The absolute humidity that will be delivered
from these devices can be increased by the
use of a heater.
A baffle is distal to this atomization process
in the stream of gas/fluid flow.
Nebulization takes place here as the liquid is
impelled against the baffle.
This baffle causes the larger particles to coalesce
and collect in the reservoir.

The smaller particles will be delivered to


the patient in aerosol form.

Bernoullis Principle and


Nebulizers: The Baffle
If the baffle is not used, the device is known as
an atomizer.
When the baffle is used, it is then called a
nebulizer.
In addition to the physically placed baffle, any
90 angle to gas flow can be considered a
baffle.
Large bore corrugated tubing should be used
with baffles.
This will enable the aerosol particles to be
delivered to the patient.

Aerosol delivery is
accomplished in a variety of
ways:

nasal spray pump


metered-dose inhaler (MDI)
dry powder inhaler (DPI)
jet nebulizer
small volume nebulizer (SVN)
large volume nebulizer
small-particle aerosol generator (SPAG)
mainstream nebulizers
ultrasonic nebulizer (USN)
intermittent positive pressure breathing
(IPPB) devices

Metered Dose Inhalers


Metered dose inhalers
(MDIs) consist of a
pressurized cartridge
and a mouthpiece
assembly.

The cartridge, which


contains from 150-300
doses of medication,
delivers a pre-measured
amount of the drug
through the mouthpiece
when the MDI is
inverted and depressed.

See Mosby Figure 4-32,


pg 119

Metered Dose Inhalers


The particle size of the drug released is
controlled by two factors:
the vapor pressure of the propellant blend
the diameter of the actuator's opening.

Particle size is reduced as vapor pressure


increases, and as diameter size of the nozzle
opening decreases.
The majority of the active drug delivered by
an MDI is contained in the larger particles,
many of which are deposited in the pharynx
and swallowed.

Metered Dose Inhalers


Successful delivery of medications with an
MDI depends on the patient's ability to
coordinate the actuation of the MDI at the
beginning of inspiration.
Proper instruction and observation of the
patient are crucial to the success of MDI of
therapy.
Patients need to be alert, cooperative, and
capable of taking a coordinated, deep
breath. Patients should be instructed to:

Metered Dose Inhalers


Be sure to shake the MDI canister well before using.
Hold the MDI a few centimeters from the open mouth.
Holding the mouthpiece pointed downwards, actuate the
MDI at the beginning of a slow, deep inspiration, with a 410 second breath hold.
Late actuation, or at the end of the inspiration, or
stopping inhaling when the cold blast of propellant hits
the back of the throat will cause the medication to have
only a negligible effect.
Exhale through pursed-lips, breathing at a normal rate for
a few moments before repeating the previous steps.
Patients should also be instructed to rinse their mouths
after taking the medication.

The advantages of MDI aerosol


devices include:
They are compact and portable.
Drug delivery is efficient.
Treatment time is short

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

Reservoir Devices for MDIs


(Spacers)
These can be used to modify the aerosol discharged
from an MDI. The purposes of these spacers or
extensions include:
Allow additional time and space for more vaporization
of the propellants and evaporation of initially large
particles to smaller sizes.
Slow the high velocity of particles before they reach
the oropharynx.
As holding chambers for the aerosol cloud released,
reservoir devices separate the actuation of the
canister from the inhalation, simplifying the
coordination required for successful use.
See Mosby, Figure 4-33, pg 121

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

The advantages of using DPI


devices for drug administration
include:
They are small and portable.
Brief preparation and administration time.
Breath-actuation eliminates dependence on
patient's hand-breath coordination,
inspiratory hold, or head-tilt needed with
MDI.
CFC propellants are not used.
There is not the cold effect from the freon
used in MDIs, eliminating the likelihood of
bronchoconstriction or inhibited inspiration.
Calculation of remaining doses is easy.

The disadvantages encountered


when relying on DPIs for drug
administration include:
Limited number of drugs available for DPI
delivery at this time.
Dose inhaled is not as obvious as it is with
MDIs, causing patients to distrust that
they've received a treatment.
Potential adverse reaction to lactose or
glucose carrier substance.
Inspiratory flow rates of 60Lpm or higher
are needed with the currently available
cromolyn and albuterol formulations.
Capsules must be loaded into the devices
prior to use.

Small volume nebulizers


(SVNs)
Gas powered (pneumatic)
and are a common
method of aerosol
delivery to inpatients.
There are a variety of
different SVNs available.
Each has specific
characteristics, especially
in regard to output.

Bernoullis principle:
make sure you
understand this
concept

Small volume nebulizers


(SVNs)
Two subcategories: mainstream and sidestream.
The mainstream nebulizer is one in which the main flow
of gas passes directly through the area of nebulization.
The sidestream nebulizer is one in which the nebulized
particles are injected into the main flow or stream of
gas as with IPPB (Mosby 180-90) circuits.
Dont spend too much time on IPPB, just know basic
concepts and guidelines.
The main difference, based upon their construction, is
that the larger particles tend to rain-out with a
sidestream nebulizer.

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.

The common hazards of


aerosol therapy are:

AirwayobstructionDehydratedsecretionsinthepatient'sairways
mayabsorbwaterdeliveredviaaerosolandswelluplargeenoughto
obstructairways.
Toavoidthis,watchthepatientverycloselyandlethimprogress
withtherapyatareasonablerate.Youmaywanttohavesuction
apparatusonhand.

BronchospasmsItiscommonforaerosolparticlestocausethis
condition(especiallyamongasthmatics)anditismoreprevalentwhen
administeringacoldaerosolascomparedtoaheatedone.
Ifaverylargeamountofcoughingoccurs,stoptherapyandgive
thepatientarest.Ifthispersistsinfarthertherapy,stoptreatment
andnotifythephysician.

The common hazards of


aerosol therapy are:
FluidoverloadThiscanoccurwhenadministeringcontinuousaerosol
therapy.Itcanhappenquitefrequentlywhentreatinginfantsorpatientsin
congestiveheartfailure,renalfailureorpatientswhoareveryoldand
immobile.
Intheinfant,becauseofthesmallerbodysizeandpossibleunderdeveloped
fluidcontrolmechanism,aquantityofwaterthatanadultcaneasily
handlewillcausefluidoverload.
Inapatientwithcongestiveheartfailure,anyadditionoffluidtothe
vascularsystemwillputanincreasedstrainontheheart.
Inapatientwithrenalfailurewhoisprobablyalreadyinfluidoverload,it
iseasilyseenthatyouwillnotwanttoincreasethefluidvolume.
Inolderpatients,thefluidcontrolmechanismsmaybeimpairedduetoage.

Physician orders for aerosol therapy should


contain identification of:

Type of aerosol
Source gas (FI02)
Fluid composition (NaCl, water,
etc.)
Delivery modality
Duration of therapy
Frequency of therapy
Temperature of the aerosol

Charting should include:


time of administration
duration of therapy
type or composition of the aerosol (NaCl)
pulse
respiratory rate and pattern
breath sounds
characteristics of sputum
if sputum was or was not produced
the ease of breathing
benefits observed and any other relevant
observations.

The reasons for administering


aerosol therapies include:
For bronchial hygiene
Hydrate dried secretions
Promote cough
Restore mucous blanket
Humidify inspired gas
Deliver prescribed medications
Induce sputum lab culture

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

Normal Clearance requires:


a patent airway
functional
mucocilliary
escalator (larynx to
respiratory
bronchioles)
effective cough
most important
protective reflex

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

partial obstruction (reduced


airflow)
increase work of breathing
airtrapping
overdistention
VQ mismatch

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

Determining the need:


Bedside assessment
Ineffective cough
Absent or increased sputum production
Labored breathing pattern
Decreased breath sounds
Crackles or rhonchi
Tachypnea, tachycardia
Fever
General physical fitness
Posture, muscle tone

Determining the need:


Chart
H/O secretion retention or dz
process indicating such
Upper abdominal or thoracic
surgery
Age
H/O COPD
Obesity
Nature of procedure
Type of anesthesia
Duration of procedure

Intubation or trach
CXR: atelectasis or infiltrates
PFT
ABG

Bronchial Hygiene Methods: all can be


used alone or in combination with
another
PD & P includes
postural drainage and turning
Percussion
Vibration

Coughing and repulsion techniques

PAP adjunts
PEP
CPAP
Expiratory PAP (EPAP)

High-frequency compression/oscillation methods


Mobilization/exercise

Postural Drainage Therapy:


Involves the use of gravity and mechanical
energy to
Aid in mobilizing secretions
Improve V/Q balance
Normalize FRC

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

Possible reasons for improved


oxygenation
Transpulmonary pressure in this position
probably exceeds the airway opening pressure
in the lung regions where atelectasis, shunt,
and V/Q mismatch are most severe
May shift blood away from shunt regions via
gravity, which induces recruitment of
previously atelectatic but healthy areas
Reduces further injury from PPV

Postural Drainage
Use of gravity to help move secretions
from distal lung segments
May be coughed up
Or suctioned out

Affected lung segmental bronchus to be


drained in a vertical position relative to
gravitational pull
Positions are usually held for 3-15 minutes
Depends on tolerance and condition

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

Performed every 4-6 hours


Or as appropriate given pt response

Postural Drainage
Technique
Identify appropriate lobe or segment
Determine position and need for position
modification given your assessment

Unstable hemodynamics
HTN
Cerebrovascular disorders
Orthopnea

Schedule treatment at least 1.5-2 hours after


meals to prevent aspiration
Assess need for pain meds

Postural Drainage
Assess pt surroundings

Monitors
IV or other lines
NG
O2

Explain procedure to the patient


Secretions dont always come up immediately.
May take several txs to be successful

Assess vitals and pulse-ox pre, during and post


Assess breath sounds pre and post
Encourage appropriate coughing techniques pre,
during, and post

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

Pts subjective response to treatment


Vitals and ECG
Breathing pattern, rate, chest expansion, etc.
Sputum production
Breath sounds
Chest X-ray
SaO2, SpO2, ABGs
Ventilator variables

Postural Drainage
Charting

Date and time


Position(s)
Time in position(s)
Patient tolerance
Subject/objective
indicators of tx
effectiveness
Sputum color, viscosity,
volume

Pre, during, post


assessment
Signature

Right Lung (3 Lobes)

Right Upper Lobe

Right Middle Lobe

Right Lower Lobe

Left Lung

Left Upper Lobe

Left Lower Lobe

Bronchi-Carina

Right Upper Lobe Bronchi

Right Middle Lobe Bronchi

Right Lower Lobe Bronchi

Left Upper Lobe Bronchi

Left Lower Lobe Bronchi

Right Upper Lobe


Segmental Anatomy : Apical

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.)

Right Upper Lobe


Segmental Anatomy :
Posterior

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.)

Right Upper Lobe


Segmental Anatomy :
Anterior

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.)

Right Middle Lobe


Segmental Anatomy :
Medial

Right Middle Lobe


Segmental Anatomy :
Lateral

RIGHT MIDDLE LOBE:


Lateral Segment-4
Medial Segment-5
Foot of table or bed
elevated 14 inches or
about 15 degrees.
Patient lies head down
on left side and rotates
1/4 turn backward.
Pillow may be placed
behind patient from
shoulder to hip.
Knees should be flexed.
(Clap over right nipple
area.)

Right Lower Lobe


Segmental Anatomy :
Superior

Right Lower Lobe


Segmental Anatomy :
Posterior Basilar

Right Lower Lobe


Segmental Anatomy :
Medial Basilar

Right Lower Lobe


Segmental Anatomy :
Anterior Basilar

Right Lower Lobe


Segmental Anatomy :
Lateral Basilar

Left Upper Lobe Segmental


Anatomy : Anterior

Left Upper Lobe Segmental


Anatomy : Apicoposterior

Left Upper Lobe Segmental


Anatomy : Anterior

Left Upper Lobe Segmental


Anatomy : Superior Lingular

Left Upper Lobe Segmental


Anatomy : Inferior Lingular

LEFT UPPER LOBE


Lingular Segment-Superior-4
Inferior-5
Foot of table or bed
elevated 14 inches or
about 15 degrees.
Patient lies head down
on right side and rotates
1/4 turn backward.
Pillow may be placed
behind patient from
shoulder to hip. Knees
should be flexed.
(Clap over left nipple
area.)

Left Lower Lobe Segmental


Anatomy : Anterior
MedialBasilar

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.)

Left Lower Lobe Segmental


Anatomy : Superior

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.)

Left Lower Lobe Segmental


Anatomy : Lateral Basilar

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.)

Left Lower Lobe Segmental


Anatomy : Posterior Basilar

LOWER LOBES: Posterior Basil


Segment/10
Foot of table or bed
elevated 18 inches or 30
degrees.
Patient lies on abdomen,
head down, with pillow
under hips. Upper leg
can be flexed over a
pillow for support.
(Clap over lower ribs
close to spine on each
side of chest.)

Assignment for Upcoming Labs


Memorize the
segments of the
lungs
Memorize the
appropriate
positions for each
segment!

Percussion and Vibration


Application of mechanical energy to
the chest wall
Hands
Pneumatic devices

Percussionbreak secretions loose


for TB tree
Vibration aids in moving secretions
toward the central airways

Percussion and Vibration


Unclear as to how much force or
frequency should be used to be
effective
Effectiveness is controversial
Used in conjunction with postural
drainage
Percussion over the lobe or segment
being drained

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

Mechanical Percussion and


Vibration
Devices have both frequency and
force control
20-30 cycles/second
20-30 Hz
Noise, excess force, mechanical failure
and electrical shock are all potential
hazards

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.

Forced expiratory technique (FET,


or huff cough) and manually assisted
cough are examples of directed cough.

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

increasing glottic control


inspiratory and expiratory muscle strength
coordination
airway stability

Patient should assume position best


for exhalation and allows for easy
thoracic compression
Surgical (Thoracic/Abdominal):
Splinting to limit pain and anxiety

"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.

Forced Expiratory Technique


"HUFF TECHNIQUE"
Forced expirations of middle to low lung volume
without closure of the glottis
Breathe in slowly and deeply through nose.
Breathe out slowly and completely through pursed
lips.
Breathe in slowly and deeply once again, then hold
breath briefly.
Instead of coughing, let the air out in several short
bursts while saying "huff."
A "huff" sound is produced rather than a sharp sound.

"ASSISTED COUGH TECHNIQUE


Pt Breathes in slowly and deeply through the nose and
then out slowly and completely through pursed lips.
Pt Breathes in slowly and deeply once again, then
holds breath briefly.
Assisting person places hands on pts sides at the
lower rib cage or on stomach above belly button.
Pt coughs while the person assisting applies gently
pressure.
Stop applying pressure when the patient is finished
breathing out, but dont remove hands

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).

Cough or other airway clearance


techniques are essential components
of PAP therapy when the therapy is
intended to mobilize secretions

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.)

CPAP requires a gas flow to the airway


during inspiration that is sufficient to
maintain the desired positive airway
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.

Magnetic valve resistors


contain a bar magnet that attracts a
ferromagnetic disc seated on the expiratory
port of the circuit the amount of pressure
required to separate the disc from the magnets
is determined be the distance between them.

PAP: PEP

The patient exhales against a fixedorifice resistor, generating pressures


during expiration that usually range
from 10 to 20 cm H2O
PEP does not require a pressurized external
gas source.
The amount of PEP varies with the size
of the orifice and the level of expiratory
flow produced by the patient. The
smaller the orifice the greater the
pressure.

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.