Wednesday, May 20, 2009

Pulmonary Toilet Lexicon

Bronchial Pulmonary Hygeine: Use of a variety of procedures and medicines to try to help the patient expectorate thick secretions, or to help losen secretions from the bronchioles to the upper airways so the patient can more easily spit it up.

Pulmonary Toilet: If a patient is determined to have thick secretions and he is having trouble expectorating (spitting up), and this is deemed to be causing respiratory distress, than any effort necessary is done to break up secretions so the patient can spit them up. This usually includes bronchodilator therapy, mucolytic (mucomyst), and chest physiotherapy, cough and deep breathing and incentive spirometry.

Who needs pulmonary toilet? Any patient who has thick secretions, or presumed thick secretions, with the inability to expectorate them. Usually, you'll have a patient who has a non-productive cough but you know they have thick secretions in their lungs either by history (cystic fibrosis) or possibly by auscultation (rhonchi). You can hear it, the patient can feel it, but they can't expectorate it.

Rhonchi: Secretions heard by auscultation. They are usually louder than wheezes because they are in the upper airways. They can either sound coarse or like fluid in the lungs or throat. Sometimes this coarseness can resonate throughout the lungfields and sound like a wheeze. Some doctors and nurses confuse these as wheezes and think it's bronchospasm. When difficult to expectorate, the pulmonary toilet may be indicated.

Pulmonary toilet, or bronchopulmonary hygeine, involves any or all of the following procedures or meds:

Bronchodilator: This is a medicine that is inhaled via a nebulizer or inhaler. Once the medicine makes it to the air passages (bronchioles) in your lungs it binds with beta adrenergic receptors on the smooth muslce lining the bronchioles, and therefore causes these muscles to stop spasming. This causes the air passages to open up, making breathing easier, and releasing trapped secretions. An example of a bronchodilator is Albuterol and Xopenex.

Mucomyst: My fellow RTs should know this drug by its smell. When I was a student my teacher opened a vial and passed it around the class, insisting we each take a whiff. The stuff smells like rotten eggs.

However, regardless of smell, Mucomyst is part of the pulmonary toilet. So, according to, "When inhaled by mouth, this medication is used to help treat certain lung diseases (e.g., bronchitis, cystic fibrosis, pneumonia). It is a mucolytic that works by making phlegm in the lungs more liquid. This effect helps you cough up the phlegm so that your breathing becomes easier."

This medicine should always be given with a bronchodilator.

Chest physiotherapy (CPT): A procedure that involves the cupping of the RTs hands and clapping on the back of the patient with the intent purpose of loosening secretions in the lungs so the patient can spit it up. It's often done on patients with thick secretions, such as bronchitis, cystic fibrosis, pneumonia, etc.) or on post op patients to help move secretions and prevent pneumonia. It can also be done with electronic purcussers, like these.

CPT is: "designed to use gravity to aid in draining secretion from various areas of the lungs. The patient lays in special ways to drain secretions from the smaller airways into their larger airways. While the patient is lying down, sitting up, lying on theire back or side, rhythmic clapping (percussion) is applied with moderate to vigorous strength. The percussion is applied to the chest wall. This helps loosen secretions from the respiratory tract, and forces the mucus from the smaller airways into the larger airways. The secretions can either be coughed up by the patient, or suctioned out."

Suction: If a patient has trouble expectorating, and has lots of secretions in their airway, you may need to suction it out either by deep tracheal suctioning or with a yankaur to help them get the secretions out. Ideally, other techniques of the pulmonary toilet will help patient get secretions to upper airway, and the patient will spit them out. Sometimes, though, suctioning out the mouth or back of throat is necessary. Suction is usually performed on an as needed bases on all patients with artificial airways.

Suction pressure is usually determined as follows:
  • Adults = -100 to -120 Hg
  • Children = -80 to -100 Hg
  • Infants = -60 to -80 Hg

What size suction catheter to use: Double the internal diameter (ID) of the endotracheal tube (ETT) and multiply by 2, then use the next smallest catheter size. For example, if the patient has a size 8 ID ETT, 8*2=16 or a size 14 suction catheter.

Yankaur: This is a device that fits into the patient's mouth, and can be used to suction secretions in the mouth to the back of their throat. This can be performed by an RT or by the patient. It can also be used to suction up vomit or food particles from the oral cavity.

Deep tracheal suction: This is where you take a suction catheter and insert it into the nose or mouth and go all the way down the trachea to just above the carina and suck up secretions. Ideally, this should NEVER be performed on any patient who is awake and alert, and should ideally be performed on a patient with an ineffective cough. Normally, this is performed on intubated patients, and patients with tracheotomies. However, on occasion, some physicians use this technique on awake and alert patients to obtain a sterile sputum samle for analysis. I think this is inhumane, as I write here.

Closes suction system: (Ballard) This is used on intubated patients so you don't have to break the circuit. This prevents loss of PEEP and reduces risk of Ventilator Acquired Pneumonia (VAP). .

Turning and rotation: This is where you turn the patient on to their right side, and then on to their left side. Ideally, you will perform CPT to each side for 5-10 minutes. This is generally performed on post-operative patients, or patient's in critical care, to help prevent retained secretions and atelectasis in patients at high risk for this complications. This is yet another method of preventing pneumonia and atelectasis.

Postural Drainage: This is where you place the patient in various positions to facilitate drainage of secretions. For example, if you have a patient with left lower lobe pneumonia, you place the patient face down in the bed (fowlers) and in trendelenberg (or reverse trendelenberg). The you do percussion to the left lower lobe. To view some of the basic positions check out this link.

Ideal positions: Ideally, you will want to position the patient with the infected side up. However, to prevent the infected side from draining to the good side of the lung. This way gravity can help move secretions to the trachea to facilitate removal. The patient who is not receiving postural drainage should ideally have the infected side down. This might be considered if the patient's SpO2 suddenly drops, and he is lying with the infected side up (i.e. a left middle lobe pneumonia patient lying on his right side may cause secretions to drain to the good lung).

Percussion: This is the technical term for cupping your hands and applying rythmic clapping on the patients back over the infected areas.

Vibration: This is where you put one hand over the other over the infected area and generate vibrations during expiration. This can also be done with a mechanical persussor. The goal here is to help loosen secretions. This is generally done after percussion, and particularly for patients with thick and copious secretions.

Postural Drainage, percussion and vibration (PDPV): Actually, CPT is more of a generic term for PDPV. This is where you do a combination of postural drainage, percussion and vibration. Generally, these techniques help loosen and clear secretions from the patients respiratory tract. For a good description of PDPV, click here.

Goals of CPT or PDPV: Increased secretions can in the lungs can be breeding grounds for bacteria, and can lead to lung infections. Therefore, CPT and PDPV can help prevent lung infections, enhance ventilation, and improve pulmonary function and gas exchange.

Indications for PDPV:

  • Thick secretions
  • Retention of secretions
  • Difficulty clearing the airway (trouble getting phlegm up)
  • Artificial airways (intubation or tracheotomy)
  • Atelectasis caused by mucus plug or obstruction
  • Conditions that increase amount and thickness of secretions (COPD, Cystic fibrosis, asthma)

PEP therapy: I think this is better than all of the above, and most studies show it is more effective. However many hospitals don't have a way of funding for them (at least that's the case where I work).

This is a device that when you exhale into it vibrations are caused in your lungs thus loosening secretions. Ideally, this is the most common sense approach to patients in need of CPT. It can easily be performed by the patient in virtually any position. It improves clearance of secretions, is easier to tolerate than chest physiotherapy (CPT), takes less than half the time of conventional CPT sessions and facilitates opening of airways in patients with lung diseases with secretory problems (COPD, asthma, Cystic Fibrosis). Plus, while many patients do not tolerate CPT, most patients can tolerate PEP therapy. Also it can be performed by any patient regardless of lung capacity.

A good example of a PEP device is the Acapella, which you can see here. On this product resistance can be adjusted by turning an adjustment dial.

Flutter valves: This is a device to deliver PEP therapy in a slightly different approach. The device consists of a mouthpiece connected to a cylinder in which a stainless steel ball rests in a cone shaped valve. The patient exhales through the cylinder and causes the ball to move up and down during the exhalation. The effect is threefold: first, to vibrate the airways and thus, facilitate movement of mucus; second, to increase endobronchial pressure to avoid air trapping and third, to accelerate expiratory airflow to facilitate the upward movement of mucus.

Incentive spirometry(IS): I discussed this in a previous post. It's pretty much used as incentive to get a patient to take deep breaths, which they are not inclined to do after chest or abdominal surgery or following a trauma and broken ribs. Ideally this is more a preventative measure than a treatment, and is not really part of the pulmonary toilet. To learn how to use it (or teach it), click here.

Cough and deep breathing: Same as for IS. It is preventative more so than part of the pulmonary toilet. It's not going to help you expectorate anything. Actually, I think this is way better than an IS. While I have had many patients who cannot do the IS, I have never had a patient who can't do simple cough and deep breathing exercises.

Abdominal Thrust: This is performed only on quadraplegic patients. This is where you push in and up on the abdomin to force up the diaphragn to facilitate a cough. You'll need to do this in sync with the patient. It actually feels kind of awkward doing this on an awake, alert and oriented patient, but usually the patient will walk you through it and even ask for it. The first time I did this, the patient showed me what to do.

Mechanical Insufflation-Exsufflation: It's a machine that alternates positive and negative pressure to the airway to help increase expiratory flows and remove secretions. It's a non-invasive procedure that can be performed with a mouthpiece or mask for spontaneously breathing patients, or with an adaptor to an artificial airway. It's usually used with patients with neuromuscular disorders.

Why do post op patients get pulmonary toilet? The theory here is these patients are sore and on medications, making them less likely or unable to take in a deep breath. This can increase the chance of them getting pneumonia or atelectatsis. The purpose here is to prevent post-op pneumonia and atelectasis. Yet, if a patient doesn't have pneumonia, I don't see what use this will do for the patient. It will not prevent pneumonia nor atelectasis.

While it may have some use in knocking out the pneumonia that is really stubborn, it is not going to reinflate collapsed alveoli.

Why do pneumonia patients get CPT or PDPV? The theory is that performing CPT over the infected side will knock the pneumonia out of a patient. However, studies done have been inconclusive as to its effectiveness. Personally, since pneumonia is an inflammatory process, I don't believe CPT will do much good. And, it's not listed as an indication for CPT

Why do atelectic patients get CPT or PDPV? Obviously, CPT will not reinflate collapsed alveoli. However, any movement is good for post op patients. Sometimes RTs are ordered to do CPT just to make sure the patient is moved around.

RT Assessment: I think the main reason some doctors order post op CPT is so that an RT is assessing the patient every so many hours. I think this actually can be beneficial to a few fragile patients who may be ventilator bait.

When should pulmonary toilet be stopped? Whenever the patient is able to clear secretions on her own. It should not be continued forever, unless the patient wants attention or a good massage from a happy RT. A good session of CPT should last about 5 minutes in each position. usually all that's required is CPT over the infected area, or, for post op patients, CPT to the right side for 5 minutes, and then the left side. For some patients, such as CF patients, CPT may be required for all positions.

Is the pulmonary toilet ordered sometimes when it's not needed? Yes. Some doctors listen to a patient, notice rhonchi upon ulscultation, and see that the patient has a tissue filled with thick green secretions, and think the pulmonary toilet is indicated. However, if the patient is capable of expectorating, the toilet usually isn't indicated.

Or, they listen to the patient, hear secretions, and order pulmonary toilet. I see no sense in ordering CPT on a patient who is already has loose secretions.

Who should have pulmonary toilet ordered? Any patient who has secretions trapped in the lungs and is having difficulty expectorating it. This may be the case with COPD, CF and some pneumonia patients. Occasionally it can benefit asthmatics.

When should it not be ordered: When it's not needed. Some doctors don't know what else to do so they just order it. The Clinical Practice Guidelines list many contraindications for ordering CPT.

When should CPT be performed: 60-90 minutes after meals, before meals, or, if the patient is on pain management, 30-60 minutes after pain meds are given.

Does pulmonary toilet really work? Yes it can work for the right patients who really need it, however it tends to be over-ordered as many hospital procudures. Likewise, CPT works if good technique is used, and the patient tolerates it.

Note: All of the above should be to the patient's tolerance. CPT and PDPV should be stopped once the patient is able to clear secretions on his own.

Measuring effectiveness: When to discontinue CPT or PDPV:

  • Improvement in chest x-ray
  • Improved vital signs
  • Improved SpO2
  • Less demand for oxygen (lower FiO2)
  • Sputum production
  • Auscultation (improved lung sounds)
  • Sputum production drops below 30/ml per day
  • The patient can generate an effective spontaneous cough


Glenna said...

Like the PEP, there's also a device called Acapella that we use. I admit, though, I was surprised to find out that this simple little plastic device costs US, the hospital, $50/each. Yowza! It's effective but it's not a toy.

One of my favorite pet peeves is docs (thankfully we only have one who does this routinely) who order Q4 Muco on pt's who are or nearly are Bipap dependent. So I'm going to liquify those secretions so they can be shoved down deeper?

Anonymous said...

Hi there- I Googled "pulmonary toilet" because I've had it up to here (picture my hand being held above my head in a chopping laterally motion...) with that term. When are we going to start calling this something a little bit more nice? When I was an RT student 8 yrs ago, 1 of my instructors was on a kick to change the industry standard and have us students use the term "pulmonary hygiene." I must say that I really prefer that better. Am I alone here, people?
Despite my annoyance with the term "pulmonary toilet" I must give you a big thanks for giving a thorough definition of what it is. I work at a hospital with very few RT protocols (sad, I know) so very often docs will write "pulmonary toilet Q4" without stating what they want. If they ever answer their pager to clarify the order I then have to pretty much go down the list of items which you described in your blog.
Despite your descriptions I found one error which Glenna sort of corrected. The device that you describe as PEP actually sounds more like the flutter valve, also a very good airway clearance device. PEP is positive expiratory pressure device which has the ability to make the expiratory pressure easier or harder to blow against.
Of note, where I currently work we use an airway clearance modality called EZ-PAP which is often over-ordered at this hospital but in some cases it has literally saved needing to re-intubate someone. I am a huge believer in this modality. For those folks who can't use an incentive spirometer, EZ-PAP is quite wonderful.
I will come back to this blog. Thanks a lot for caring about sharing your RT info!

Caiden said...

I am a respiratory student at Rush University under David Vines, he has recently conducted a experiment in regard of the suctioning negative pressure. The result shows that for adult, the suctioning pressure can be as negative as 150 mmHg in pig lung. He asks us to learn -150 mmHg.

Anonymous said...

So you are saying to improve oxygenation you would put the bad lung down?

Rick Frea said...

Yes. If you sleep with the bad side up it may drain into the good side while you're sleeping, and this can make it difficult to breathe. If this happens the solution is to sit up, cough out the junk (if you can) and (ideally) roll over and sleep the other way. It's just another nuance to keep an eye out for.

Sherry said...

To improve oxygenation you need to put the good lung down. This allows perfusion and ventilation to match thus increasing oxygenation. Bad lung down matches blood flow where there is no ventilation causing V/Q mismatch. You would need to be not only sleeping with bad lung down but in trendelenberg for any chance of secretions moving into the good lung and there is still little chance that is going to cause much of a difference in oxygenation.
Also on suction pressures the new AARC guidelines are for adults 100-150 mmHg.

Rick Frea said...

Thank you for the update, Sherry. Appreciate it!!!