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Thursday, April 9, 2015

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.  The goal is enhance secretion clearance to help prevent lung infections, enhance ventilation, improve pulmonary function and gas exchange.

Expectorate:  To spit up

Pulmonary Toilet: It's a generic term to describe any effort, medicinal or other, to help loosen or break up thick secretions that are causing respiratory distress, to help bring secretions to the upper airway so they can be either swallowed or expectorated.  The most common therapies here are albuterol and mucomyst nebulizer treatments, followed by either use of flutter valve or postural drainage and chest percussion.

Who needs it?  The patient feels like they have something to cough up, but are unable to generate enough flow to expectorate it.  Rhonchi is a common lung sound heard upon auscultation.

What are Indications for Pulmonary hygiene or toilet?
  • Thick secretions (may be heard in large airways by auscultation (rhonchi)
  • 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)
Rhonchi.  This is the sound of air moving through large airways.  It is commonly described as coarse. Sometimes it is mistaken for a wheeze, especially as it resonates throughout the lung fields. Sometimes it may present as a forced, expiratory wheeze, and may even be audible.

What does the pulmonary toilet involve? 

Bronchodilator.  Inhaling this medicine will help to open up air passages, releasing trapped secretions so they may be expectorated.  The most common medicine is albuterol, although  xopenex may also be prescribed.

Mucolytic: Inhaling these medicines will help to break up secretions so they may be expectorated.  It makes phlegm more liquid and easier to spit up. This medicine may cause bronchospasm, so it should always be given with a bronchodilator. The most common medicine used in the hospital setting is Mucomyst (acetylcysteine). Pulmoyme (dornase alfa) is commonly prescribed for cystic fibrosis patients.  Other mucolytics may include ambroxel, carbocisteine, and erdosteine.

Chest physiotherapy (CPT): This describes the various techniques a therapist might use in order to help knock thick secretions loose so they may be more easily expectorated.  Procedures may include chest percussion, mechanical percussors, postural drainage, PEP valves, and flutter valves.  Ideally, CPD should be performed prior to meals, or 60-90 minutes after meals.  If the patient is on pain management, it should be performed 30-60 minutes after pain medicines are given.

Chest Percussion: A therapist uses cupped hands and applies rythmic clapping on a patient's chest in order to break up secretions so they can be more easily expectorated.  It may be performed over the entire chest, although is more commonly performed only over the infected area.

Vibration: This is where you put one hand over the other over the infected area and generate vibrations during expiration to help loosen secretions. This is generally done after percussion, and particularly for patients with thick and copious secretions.

Mechanical Percussor
Mechanical Percussor:  Due to the trauma that may be caused by CPT, mechanical percussors are thought to accomplish the same goal as CPT. Constant vibrations from the device are thought to break up thick secretions so they may be more easily expectorated.

Postural Drainage.  This is using gravity to aid in draining secretions from various areas of the lungs.
  • Postural drainage and CPT or mechanical percussors are often used in tandem to enhance secretion removal
  • Ideally, the infected side should be up to allow gravity to enhance movement of secretions to trachea to enhance removal.  
  • After postural drainage is complete, the infected side should be down so that secretions do not drain into good areas of the lungs to make breathing more difficult.  If a patient's SpO2 suddenly drops, this is something that might be considered.  
  • To learn more check out the AARC Clinical Practice Guidelines
Positive Expiratory Pressure (PEP) valves:  These are small, hand-held devices that a patient exhales into.  A positive pressure is thought to enhance secretion production and prevent and treat atelectasis.

Flutter Valves:  The most common one is referred to as an Accapella Flutter Valve.  It combines PEP therapy with gentle vibrations.  The small, hand-held 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
  1. Vibrate the airways to facilitate movement of mucus
  2. Increase endobronchial pressure to avoid air trapping
  3. Accelerate expiratory airflow to facilitate the upward movement of mucus.
Many hospitals are now using these instead of the more invasive chest percussion and postural drainage. Although, sometimes a combination of the two are used.  Just about any alert patient can do this regardless of lung capacity. It takes about half the time of CPT and postural drainage.

Suction: This involves using negative pressure to suck secretions from the airway.  
  • Upper Airway:  A common device for suctioning the upper airway is a Yankaur. It helps facilitate secretion removal of upper airway, and is similar to devices used in dentist offices.  
  • Lower Airway.  Various suction catheters may be inserted through the mouth, or one of the nostrils, into the large airway (usually to just above the corina).  Negative pressure helps suck secretions blocking the airways.  This is generally referred to as deep tracheal suctioning. It should rarely be performed on an awake and alert patient.  It is most commonly performed on a patient who is intubated.  
  • Suction pressure: This is usually determined as follows:
    • Adults = -100 to -120 Hg
    • Children = -80 to -100 Hg
    • Infants = -60 to -80 Hg
  • Catheter Size: A common formula for choosing the ideal suction catheter for a patient who is intubated:
    • 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: As noted above, 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 is generally considered to be non-invasive.

Deep tracheal suction: As noted above, this involves inserting a catheter beyond the trachea to just above the corina.  Ideally, a catheter should never touch the corina in order to prevent trauma.  Also, this procedure should never be performed on a non-intubated patient who is awake and alert, as it is considered extremely traumatic.  It should be performed as needed on intubated and trached patients in order to clear the airways of secretions.  It's ideal for generating a sterile sputum sample for analysis.

Closes suction system: The most common one used is called a Ballard. This is used on intubated patients so you don't have to break the circuit to suction the airway. This prevents loss of PEEP and reduces risk of Ventilator Acquired Pneumonia.

Incentive Spirometer:   During normal breathing, people sigh 3-5 times per hour.  This is a natural mechanism to clear secretions from airway to prevent pneumonia and alveolar recruitment to prevent atelectasis.  This natural mechanism is blunted due to pain from abdominal or chest operations.  It is also blunted due to pain medicine.  Ten inhalations per hour using an incentive spirometer is meant to encourage secretion removal and alveolar recruitment.  Volume spirometers provide some resistance to inhalation, and allow therapists to monitor a patient's progress. It is usually followed by cough and deep breathing exercises.

Cough and deep breathing exercises: A patient should be encouraged to take in a deep breath to fill the lungs with air, and then to cough.  This is yet another means of enhancing secretion clearance and alveolar recruitment.

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.  I find that the best teachers of this procedure are the patients themselves.

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 adapter to an artificial airway. It's usually used with patients with neuromuscular disorders.

When should pulmonary hygiene be discontinued?
  • Improvement in chest x-ray
  • Improved vital signs
  • Improved oxygenation (monitored by pulse oximetry or ABG)
  • Less demand for oxygen (less supplemental oxygen required, lower FiO2s)
  • Sputum production (patient coughing up sputum without assistance)
  • Auscultation (improved lung sounds)
  • The patient can generate an effective spontaneous cough
Originally published on 5/20/09 on; Edited and updated for accuracy by Rick Frea


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!!!