AirwayClearanceTechniques医学教学课件

1、Airway Clearance Techniques(气道清洁技术)第1页，共80页。RESPIRATORY CARE, July 2002 / volume 47 / number 7 / 768CHEST 2006; 129:250S259SNonpharmacologic Airway Clearance Therapies (ACCP Evidence-Based Clinical Practice Guidelines)Respiratory care September 2007 / vol 52 number 9 /12241235主要参考来源第2页，共80页。前言Sputum

2、 is Our Bread and Butter:2007 An Update on Secretion Clearance TechniquesRESPIRATORY CARE, September 2007 / Volume 52 / Number 9 Jim Fink, MS, RRT, FAARCFellow, Respiratory ScienceNEKTAR TherapeuticsSan Carlos, CA 第3页，共80页。Normal Mechanisms of Airway ClearanceMucocilliary Transport System(in periphe

3、ral airways)Ciliated colummnar epitheliumMucus glandsGoblet cellsCephalad Airflow Bias(in central airways)即Expiratory flow transport (airflow transport)Airways narrow on expiration increasing resistance moving secretions towards headCough (in central airways)creates a high shear rate,(剪切力是指施加于相邻物体的表

4、面,引起相反方向的进行性平行滑动力量，比垂直产生的力更具伤害)NOTE:Gravity is not a major mechanism in secretion clearance in health.PS: 呼吸道的分泌物會包含 mucus (黏液), surfactant (表面活性劑), periciliary fluid. 正常产生量: 10100 ml/day 。mucus第4页，共80页。5Airway Defence纤毛黏膜梯(mucociliary escalator or mucous blanket)熱氣濕氣摘自第5页，共80页。6The point of the air

5、ways at which the inspired gases reach the body temperature (37C) and 100% of RH is called the Isothermic Saturation Boundary (ISB).Normally the ISB is 5-6 cm below the carina and afterthis point the inspired gases do not further change temperatureand humidity. *Shelly MP, Lloyd GM, Park GR. A revie

6、w of the mechanisms and methods of humidification of inspired gases. Intensive Care Med 1998, (14): 1-9.饱和等温温线第6页，共80页。. 第7页，共80页。第8页，共80页。Fig. 1. Mucus production is higher in the peripheral airways than in the central airways. The capacity for mucociliary transport is higher in the peripheral than

7、 in the central airways. The capacity for mucus transport by expiratory airflow is higher in the central airways than in the peripheral airways.Respir Care 2007;52(9):1150 1156. Bronchial Mucus Transport因中央气道的气道表面积较少，所以transport surface较少，痰液较易积在此，故大气道主要靠airflow transport 清除痰液，末端气道则是mucociliary trans

8、port.Central airways(管直径较大)Peripheral airways 气道直径的相比较第9页，共80页。Cough用力吐气时，约0.1秒的吐气流量，即可产生一高的剪切率(shear rate) ;或 mucus searing forces。Mucus transport会随剪切率(shear rate)的变化而呈反向变化。此现象称为假塑型流量( pseudoplastic flow)或剪薄( shear thinning)。Mucus viscosity可以很简单借由剪力来改变(500的因子)。其能暂时性的运用力量将大分子的糖蛋白类(glycoproteins)重新组合

9、排列，改变其黏性(剪切力越大，黏性越小)。所以在吐气时，反复短暂间隔的(short intervals) 用力吐气更能降低黏稠性和促进mucus transport，比起使用较长间隔的(long intervals) coughs。Zahm et al, who found in a model study that repetitive forced expirations are more efficient with shorter intervals.Respir Care 2007;52(9):1150 1156第10页，共80页。Cough and Equal Pressure P

10、ointCough generates supra-maximal,turbulent airflows (flow transients). These flows mustspeed up through the EPPandcreatesshear forcesthat move secretions cephalad.However, theturbulent flowscausefaster pressure dissipationcreating more potential forairway collapseat theEPP. (扰流使压力快速消散，让在EPP处的气道较易萎缩

11、)Dynamic airway collapsecan also occur in disease states that causes increased compliance (CF, COPD)Even thelarger airways may be compressediffrequent coughinghas damaged the cartilage.第11页，共80页。Equal Pressure Point (EPP,等压点)EPP的概念有助于了解airflow limitation的产生. 它不是一个固定的位置。(dynamic airway compression)在正

12、常情况及肺容积下，EPP 是座落在carina或 large bronchi，在此有软骨的增强作用，才能对抗airway 的 collapse.(collapse 后就无气流产生).第12页，共80页。Forced Expiratory Flow (用力吐气流量)Forced expirations can be done with cough(咳嗽) or huff(哈气). A cough begins with glottis closure, then a more or less isometric contraction of the expiratory muscles, whi

13、ch createshigh intrathoracic pressure, then sudden opening of the glottis creates a burst of expiratory airflow. A huff starts with the glottis open, and the glottis remains open throughout the huff. Huff requires a fast, dynamic contraction of the expiratory muscles. Cough or huff can begin at low,

14、 middle, or high lung volume. Lung volume and expiratory force can be more easily adjusted during huff than during cough. However, huff technique is more difficult for some patients.第13页，共80页。Manually Assisted CoughQuad cough (assisted cough) add volume and flow rate in patients with muscular discoo

15、rdinationIncreased pressure can shift EPP in COPD, increasing trapping of gas and secretions (要避免;可採用huff)Quad cough Huff coughing 第14页，共80页。Cough and Mucus PluggingIn order for cough or expiratory flow to mobilize secretions, it is necessary to get air behind the secretions.Mucus plugs can prevent

16、inspiratory flow from getting behind the site of obstruction, making cough and airway clearance ineffective. (黏液塞防止氣流進入會使咳嗽和氣道的清潔無效)第15页，共80页。Collateral ventilatory channels may help supply air distal to obstructed airwayPEP valve第16页，共80页。Mechanisms for Effective Cough Optimize expiratory flowMinim

17、ize gas trappingMinimize secretion trapping第17页，共80页。体位对肺容积的影响Position Effects Lung VolumesRVERVIC第18页，共80页。No studies have reported a benefit of external humidifiers in improving the character and mobilization of thick secretions. The most effective method for improving the character of pulmonary s

18、ecretions is systemic hydrationRespir Care 2002;47(7):761768第19页，共80页。Indication for Airway Clearance TherapyRetained secretions( conditions) Excessive secretions (diseases, produce )AspirationProphyaxisAetelctasisCystic FibrosisMeconiumPostextubationRDSBronchitisForeign bodyBPDBronchiectasisIntubat

19、ionAsthmaIneffective cough mechanismPenumonia PainParalysisNeuromuscular diseaseCiliary dyskinesiaComprehensive Perinatal and Pediatric Respiratory Care ,3th Edition, P.149第20页，共80页。Airway Clearance TechniquesBreathing techniques: Active cycle of breathing techniques (ACBT) Autogenic drainage (AD) “

20、Conventional” chest physiotherapy (CCPT) Negative Airway Pressure:Suctioning ( suction tube or bronchoscopy )Insufflator/ExsufflatorPositive expiratory pressure (PEP) High pressure PEP (HPEP) low1530 cmH2O, high 6080 cmH2O Oscillatory positive expiratory pressure (1020 cmH2O) Flutter / Acapella / Co

21、rnet / QuakeHigh Frequency OscillationChest Wall: High frequency chest wall oscillation (HFCWO) Airway: Intrapulmonary percussive ventilation (IPV) 第21页，共80页。Breathing techniques 4 agesRelaxDiaphragmatic BreathingPursed Lip BreathingForced Exhalation Technique (FET)Active Cycle of Breathing Techniqu

22、es (ACBT) Autogenic Drainage (AD)第22页，共80页。RelaxDifferent types of relaxation have been found to be useful in enhancing breathing effectiveness, including: Progressive Muscle Relaxation Autogenic Relaxation Music Therapy Biofeedback Deciding which of the above techniques or combination of techniques

23、 is best , may require some experimentation and consultation with an experienced professional. Information and assistance in implementing these techniques are available to you from the psychology staff. 第23页，共80页。Diaphragmatic Breathing第24页，共80页。Pursed Lip BreathingWhat does pursed lip breathing do?

24、Improves ventilation Releases trapped air in the lungs Keeps the airways open longer and decreases the work of breathing Prolongs exhalation to slow the breathing rate Improves breathing patterns by moving old air out of the lungs and allowing for new air to enter the lungs Relieves shortness of bre

25、ath Causes general relaxation 第25页，共80页。Pursed lip breathing technique :Relax your neck and shoulder muscles. Breathe in (inhale) slowly through your nose for two counts, keeping your mouth closed. Dont take a deep breath; a normal breath will do. It may help to count to yourself: inhale, one, two.

26、Pucker or purse your lips as if you were going to whistle or gently flicker the flame of a candle. 4. Breathe out (exhale) slowly and gently through your pursed lips while counting to four. It may help to count to yourself: exhale, one, two, three, four. (Do not force your lungs to empty. )With regu

27、lar practice, this technique will seem natural to you第26页，共80页。Forced Exhalation Technique (FET)As an adjunct to use with other secretion removal techniques.Its a way modifying a patient cough to avoid airway closure secondary to airway instability.Its performed by having the patient inhale slowly a

28、nd then “huffing” forcefully 2-3 times.FET differs from a cough glottis remains open during the “huff”.FET + control breathing exercises ACB第27页，共80页。Active Cycle of Breathing Technique( 主动循环呼吸技术,or ACT,ACBT,ACB)Three steps: Breathing controlThoracic expansion/ breath holdForced expiratory technique

29、May be performed independentlyEasily tolerated第28页，共80页。ACBT and FET Flowchartor huffs第29页，共80页。ACBT Applied in Different PatternsKey: BC - breathing controlTEE - thoracic expansion exerciseFET - forced expiration technique第30页，共80页。Autogenic Drainage (自体引流) Autogenic (self) drainage (AD) is a metho

30、d that uses controlled breathing to move the mucous out of the lungs. It does not need any equipment and can do it by self. This method is breathing at three specific lung volumes. Phase 1: low lung volume to unstick the mucous deep in lungs. Phase 2: mid lung volume to collect the mucous that loose

31、ned phase 3: use high lung volume to expel (remove) the mucous.Its important to adjust how fast you breathe out at each level so that you reduce airway compression (tightening) when exhaling. The goal is to achieve a mucous rattle rather than a whistling wheeze, which would mean your airways are get

32、ting tight. Perfecting an AD technique needs training and frequent review. 第31页，共80页。Autogenic Drainage 第32页，共80页。Conventional Postural Drainage PD aims to move secretions by gravity from areas distal to segmental bronchi into larger airways where mucociliary clearance, huff and cough will result in

33、 expectoration. The worst area is drained first to reduce the chance of infected secretions spilling into healthy lung. The head down position increases the WOB, reduces Vt and FRC even in healthy individuals thus positions may require modification to flat or head up positions in breathless patients

34、.Indications: 1. Sputum production 30 ml / day. 2. Secretions unable to be removed by FET and manual techniques. 3. Patient preference, greater effectiveness than other methods.第33页，共80页。Gravity is not a major player in normal mucociliary transport. The viscosity of the normal mucus blanket resists

35、flow into gravity dependent terminal bronchioles. Respir Care 2002;47(7):761768第34页，共80页。体位引流治疗(Postural Drainage Therapy)第35页，共80页。Manual TechniquesVibration and ShakingPercussion (chest clapping)第36页，共80页。扣击(percussion)、震动(vibration)第37页，共80页。“Conventional” Chest Physiotherapy (CCPT) Can be used w

36、ith infantsRequires caregiver participationTechnique dependentTime consumingPhysically demandingRequires patient toleranceEffectiveness debated/watch?v=hDo3RvGyPgs&feature=related第38页，共80页。Postural DrainageGold standard of bronchial hygiene when each position is drained 5 - 20 minutes (嬰兒時間需較久) 11 p

37、ositions requires 55 minutes One hour session concentration on 3 4 positionsPercussion and vibration No demonstrated benefit without positioningEach area 1-5 minutesEverything works as well as PD except vibration and percussion alone which doesnt workThe time required for PD is prohibitive/watch?v=o

38、vChU4tXs6E&feature=related第39页，共80页。第40页，共80页。Upper Lobes:Lean forward 30. Percuss between the clavicle and the shoulder blade on each side of the chest.Upper Lobes:Lean back 30. Percuss between the clavicle and the nipple on each side of the chest.第41页，共80页。 Lower Lobes:The body should be positione

39、d with the childs head down 30and lying on the right side. Percuss on the left side below the underarm. Note: If the child 5 ages , will not be tilting the chest area, but will keep the chest horizontal. Lower Lobes:The body should be positioned with the childs head down 30and lying on the left side

40、. Percuss on the right side below the underarm.HorizontalHead down 30第42页，共80页。 The body should be positioned with the childs head down 30and lying on the abdomen. Percuss between the lower edges of the rib cage and behind the underarm on each side of the spinal cord. Note: If child 5 ages, will not

41、 be tilting the chest area, but will keep the chest horizontal. The body should be positioned with the childs head down 30and lying on the back. Percuss on the front of the chest in the nipple area and just below.Lower Lobes 第43页，共80页。http:/watch?v=zzc0pPeEicY&feature=related第44页，共80页。Contraindicati

42、ons to Use of Trendelenberg PositionRecent tube feeding or at high risk for aspiration of gastric contentsIncreased ICP in a recent intracranial injuryUncontrolled hypertensionSeverely distended abdomen(严重腹胀)Gross (bright red) hemoptysis (咳鲜血)第45页，共80页。Contraindications to Percussion or Vibration of

43、 the Chest WallBurns or recent skin grafts to chestBleeding abnormalities Osteomylitis (骨髓炎)Subcutaneous emphysema(皮下气肿)Suspected or active TBRecent insertion of pacemaker(刚装心脏节律器)第46页，共80页。Hazards of PD & P TechniquesWorsening S.O.B. Pain or injury to chest wall or spineHypoxemiaNausea & VomitingTa

44、chycardia; Hypotension; ArrthymiasBronchospasm (not likely but possible in patients with Hx of asthma)第47页，共80页。Assessment of OutcomeHave the underlying issues that necessitated the use of PD & P improved?Less sputum productionImprovement of breath soundsImprovement in oxygenationImprovement in CXR第

45、48页，共80页。Airway Clearance Techniques (Mechanical Devices)Negative Airway PressureSuctioning ( suction tube or bronchoscopy )Insufflator/ExsufflatorPositive expiratory pressure (PEP) High pressure PEP (HPEP) Oscillatory positive expiratory pressure Flutter / Acapella / Cornet / QuakeHigh Frequency Os

46、cillationChest WallHigh frequency chest wall oscillation (HFCWO) AirwayIntrapulmonary percussive ventilation (IPV) 第49页，共80页。SuctioningSuctioning - negative pressure applied within the airwayCan be via ET or Trach tube orThrough the nose into the tracheaThis is called NT or naso-tracheal suctioningB

47、ronchoscopyFlexible Fiberoptic bronchoscopy Rigid tube bronchoscopy第50页，共80页。Mechanical Devices第51页，共80页。Insufflator Exsufflator(Mechanical I-E,咳嗽机)/watch?v=DlPyFkrT0Yk&feature=related第52页，共80页。Mechanical insufflation-exsufflation (MI-E) 或称cough machine .MI-E 是传统suction外的另一选择，能减少mucosal trauma 和增加 p

48、atient comfort.MI-E 原则上，常用于spinal cord injuries (SCI)和neuromuscular diseases 导致的:unable to cough . unable to clear secretions effectively (peak cough flow 60 cmH2O)positive pressure Inflates lung negative pressure assist coughApplies positive pressure to airways and rapidly shifting to negative pres

49、sure , producing high expiratory flow . Stimulating a cough to assist in mucus clearance Used independently or with caregiver assistanceTechnique independentPortableEmerson M- IE第55页，共80页。/2007/05/emerson-cough-assist.html/watch?v=gXnLAQ-OuVs&feature=relatedCoughAssist Mechanical Insufflator-Exsuffl

50、ator第56页，共80页。Positive expiratory pressure (PEP) High or low pressure PEP Oscillatory positive expiratory pressure Flutter / Acapella / Cornet / Quake第57页，共80页。Positive Expiratory PressureImproves mobilization and prevents accumulation of secretions.Promotes effective breathing patterns and improves

51、 gas exchange.Improves central and peripheral airway function.Prevents or reverses atelectasis.Optimizes bronchodilation when combined with respiratory drug delivery via nebulizer or MDI spacer devices.PEP therapy can reduce air trapping in asthma and can be used as a substitute for pursed-lip breat

52、hing.第58页，共80页。PEP valveAction: splints airways during exhalationCan be used with aerosolized medicationsTechnique dependent, PortableTime required: 10 - 15 minutes I:E ratio = 1:31:4 , 5- 20 breaths/ minDevices : Threshold Resistor & Fixed Orifice Resistors 第59页，共80页。各類用具產生不同的吸吐氣道壓力第60页，共80页。PEP De

53、vices 流量會影響壓力第61页，共80页。Bubble PEP Set-up1. Milk or orange juice carton (Threshold ) 13 cm (water level)Oxygen TubingPEP ResistorManometer and PEP conectorThreshold water column 第62页，共80页。Spring Loaded Threshold Resistor- Vital Signs Vital Signs PEEP valveThreshold PEP第63页，共80页。Fixed Orifice Resistor

54、s Positive Expiratory PressurePep Mask aids TheraPEP Vitapep 第64页，共80页。Fixed Orifice Resistor - Thera-PEP Valve第65页，共80页。Positive Expiratory Pressure (PEP Mask or Mouthpiece)PARI PEP第66页，共80页。Oscillatory positive expiratory pressure Flutter / Acapella / Cornet / Quake第67页，共80页。How does the RC-Cornet

55、 work?When you breathe out through the RC-Cornet pressure builds up in your lungs. This helps to keep your airways wide open and also allows air to get behind sputum and help move it upwards. The vibrations transmitted through the chest wall by the action of the hose also help to loosen sputum from

56、the sides of your airways. 第68页，共80页。Quake: (Vibratory PEP )Mucus Clearance Device.au/web/quake%20data.html第69页，共80页。Flutter (Oscillating PEP )Action: loosens mucus through expiratory oscillation; positive expiratory pressure splints airwaysUsed independentlyTechnique dependentPortableMay not be effective at low airflowsTime required: 10 - 15 minutesDeveloped in Switzerland, early 1990s.第70页，共80页。 Flutter Valve 第71页，共80页。Oscillatory positive expiratory pre