AirwayClearanceTechniques醫(yī)學(xué)教學(xué)課件

1、Airway Clearance Techniques(氣道清潔技術(shù))第1頁(yè)，共80頁(yè)。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主要參考來源第2頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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鄰物體的表

4、面,引起相反方向的進(jìn)行性平行滑動(dòng)力量，比垂直產(chǎn)生的力更具傷害)NOTE:Gravity is not a major mechanism in secretion clearance in health.PS: 呼吸道的分泌物會(huì)包含 mucus (黏液), surfactant (表面活性劑), periciliary fluid. 正常產(chǎn)生量: 10100 ml/day 。mucus第4頁(yè)，共80頁(yè)。5Airway Defence纖毛黏膜梯(mucociliary escalator or mucous blanket)熱氣濕氣摘自第5頁(yè)，共80頁(yè)。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.飽和等溫溫線第6頁(yè)，共80頁(yè)。. 第7頁(yè)，共80頁(yè)。第8頁(yè)，共80頁(yè)。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因中央氣道的氣道表面積較少，所以transport surface較少，痰液較易積在此，故大氣道主要靠airflow transport 清除痰液，末端氣道則是mucociliary trans

8、port.Central airways(管直徑較大)Peripheral airways 氣道直徑的相比較第9頁(yè)，共80頁(yè)。Cough用力吐氣時(shí)，約0.1秒的吐氣流量，即可產(chǎn)生一高的剪切率(shear rate) ;或 mucus searing forces。Mucus transport會(huì)隨剪切率(shear rate)的變化而呈反向變化。此現(xiàn)象稱為假塑型流量( pseudoplastic flow)或剪薄( shear thinning)。Mucus viscosity可以很簡(jiǎn)單借由剪力來改變(500的因子)。其能暫時(shí)性的運(yùn)用力量將大分子的糖蛋白類(glycoproteins)重新組合

9、排列，改變其黏性(剪切力越大，黏性越小)。所以在吐氣時(shí)，反復(fù)短暫間隔的(short intervals) 用力吐氣更能降低黏稠性和促進(jìn)mucus transport，比起使用較長(zhǎng)間隔的(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頁(yè)，共80頁(yè)。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. (擾流使壓力快速消散，讓在EPP處的氣道較易萎縮

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頁(yè)，共80頁(yè)。Equal Pressure Point (EPP,等壓點(diǎn))EPP的概念有助于了解airflow limitation的產(chǎn)生. 它不是一個(gè)固定的位置。(dynamic airway compression)在正

12、常情況及肺容積下，EPP 是座落在carina或 large bronchi，在此有軟骨的增強(qiáng)作用，才能對(duì)抗airway 的 collapse.(collapse 后就無氣流產(chǎn)生).第12頁(yè)，共80頁(yè)。Forced Expiratory Flow (用力吐氣流量)Forced expirations can be done with cough(咳嗽) or huff(哈氣). 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頁(yè)，共80頁(yè)。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(cǎi)用huff)Quad cough Huff coughing 第14頁(yè)，共80頁(yè)。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(jìn)入會(huì)使咳嗽和氣道的清潔無效)第15頁(yè)，共80頁(yè)。Collateral ventilatory channels may help supply air distal to obstructed airwayPEP valve第16頁(yè)，共80頁(yè)。Mechanisms for Effective Cough Optimize expiratory flowMinim

17、ize gas trappingMinimize secretion trapping第17頁(yè)，共80頁(yè)。體位對(duì)肺容積的影響Position Effects Lung VolumesRVERVIC第18頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。Breathing techniques 4 agesRelaxDiaphragmatic BreathingPursed Lip BreathingForced Exhalation Technique (FET)Active Cycle of Breathing Techniqu

22、es (ACBT) Autogenic Drainage (AD)第22頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。Diaphragmatic Breathing第24頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。Active Cycle of Breathing Technique( 主動(dòng)循環(huán)呼吸技術(shù),or ACT,ACBT,ACB)Three steps: Breathing controlThoracic expansion/ breath holdForced expiratory technique

29、May be performed independentlyEasily tolerated第28頁(yè)，共80頁(yè)。ACBT and FET Flowchartor huffs第29頁(yè)，共80頁(yè)。ACBT Applied in Different PatternsKey: BC - breathing controlTEE - thoracic expansion exerciseFET - forced expiration technique第30頁(yè)，共80頁(yè)。Autogenic Drainage (自體引流) 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頁(yè)，共80頁(yè)。Autogenic Drainage 第32頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。體位引流治療(Postural Drainage Therapy)第35頁(yè)，共80頁(yè)。Manual TechniquesVibration and ShakingPercussion (chest clapping)第36頁(yè)，共80頁(yè)?？蹞?percussion)、震動(dòng)(vibration)第37頁(yè)，共80頁(yè)?！癈onventional” 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頁(yè)，共80頁(yè)。Postural DrainageGold standard of bronchial hygiene when each position is drained 5 - 20 minutes (嬰兒時(shí)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頁(yè)，共80頁(yè)。第40頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。 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頁(yè)，共80頁(yè)。 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頁(yè)，共80頁(yè)。http:/watch?v=zzc0pPeEicY&feature=related第44頁(yè)，共80頁(yè)。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(嚴(yán)重腹脹)Gross (bright red) hemoptysis (咳鮮血)第45頁(yè)，共80頁(yè)。Contraindications to Percussion or Vibration of

43、 the Chest WallBurns or recent skin grafts to chestBleeding abnormalities Osteomylitis (骨髓炎)Subcutaneous emphysema(皮下氣腫)Suspected or active TBRecent insertion of pacemaker(剛裝心臟節(jié)律器)第46頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。Mechanical Devices第51頁(yè)，共80頁(yè)。Insufflator Exsufflator(Mechanical I-E,咳嗽機(jī))/watch?v=DlPyFkrT0Yk&feature=related第52頁(yè)，共80頁(yè)。Mechanical insufflation-exsufflation (MI-E) 或稱cough machine .MI-E 是傳統(tǒng)suction外的另一選擇，能減少mucosal trauma 和增加 p

48、atient comfort.MI-E 原則上，常用于spinal cord injuries (SCI)和neuromuscular diseases 導(dǎo)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頁(yè)，共80頁(yè)。/2007/05/emerson-cough-assist.html/watch?v=gXnLAQ-OuVs&feature=relatedCoughAssist Mechanical Insufflator-Exsuffl

50、ator第56頁(yè)，共80頁(yè)。Positive expiratory pressure (PEP) High or low pressure PEP Oscillatory positive expiratory pressure Flutter / Acapella / Cornet / Quake第57頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。各類用具產(chǎn)生不同的吸吐氣道壓力第60頁(yè)，共80頁(yè)。PEP De

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

54、s Positive Expiratory PressurePep Mask aids TheraPEP Vitapep 第64頁(yè)，共80頁(yè)。Fixed Orifice Resistor - Thera-PEP Valve第65頁(yè)，共80頁(yè)。Positive Expiratory Pressure (PEP Mask or Mouthpiece)PARI PEP第66頁(yè)，共80頁(yè)。Oscillatory positive expiratory pressure Flutter / Acapella / Cornet / Quake第67頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。Quake: (Vibratory PEP )Mucus Clearance Device.au/web/quake%20data.html第69頁(yè)，共80頁(yè)。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頁(yè)，共80頁(yè)。 Flutter Valve 第71頁(yè)，共80頁(yè)。Oscillatory positive expiratory pre