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Lung and Airway Clearance Therapies
- Vinay Joshi
Hill-Rom Respiratory Care
Hill-Rom Services PTE Ltd. All rights Reserved
Lung & Airway Clearance (AWC) Therapies Overview
Agenda
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AWC stages & overview
AWC therapy devices landscape
High frequency chest wall oscillation therapy
The Vest therapy device overview
Airway Clearance
The entire respiratory system is lined with cells that secrete mucus. Airway mucus is a
complex substance that forms a protective barrier lining the respiratory tract. Bacteria and
other airborne particles become trapped in this sticky mucus and then swept upwards and
outwards.
Normal airway clearance is accomplished by two important mechanisms:
•The mucociliary clearance (MCC) system
Ciliated cell: 200 cilia per cell
Ciliary beat frequency – 12-22 hz ,Mucus moves upward 1-3 mm/sec
•The ability to cough – upper airway
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Cilia move together in coordinated fashion to
move mucus up airways
Respiratory health depends on consistent clearance of airway secretions.
Impaired Airway Clearance
Mucus secretion and mucus clearance are not in balance in Impaired airway clearance
Ineffective Ciliary Clearance: Damaged or poorly performing cilia
•Cystic fibrosis
•Primary ciliary dyskinesia
•Kartagener syndrome
•Status post heart-lung or lung transplantation
•Smoking or exposure to second-hand smoke
Excessive or Abnormal Mucus Production: Large quantities of mucus, or mucus with altered
physical properties
•Cystic fibrosis
•Bronchiectasis
•Asthma
•Chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis
•Mechanical ventilation
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Airway obstruction Mucus
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plugging Atelectasis
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Impaired gas exchange
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Infection
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Inflammation
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Vicious Cycle of Respiratory Impairment
Factors Affecting Airway Clearance
Inflammatory
response
activated
Mucus
plugging
Airway
inflammation
Mucus
production
Pulmonary
defenses
ineffective
More mucus
production
Pulmonary
infection
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General health/age
Chronic/Systemic disease
Recent respiratory infection
Smoking history
Trauma
Immobility
Relating to surgical procedures
Stages of Airway Clearance Therapy
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Nebulizers/
pharmaceuticals
Humidification
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High Frequency Chest Wall
Oscillation (The Vest®)
Oscillatory Positive Expiratory
Pressure (PEP)
Intrapulmonary Percussive
Ventilation (IPV®)
Manual techniques
• CPT / Autogenic
drainage
• Active Cycle of
Breathing Technique
Evaluation
Evacuation
Mobilization
Preparation
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Self Managed/
Cough
Cough Assist™
Suction
evacuate
mobilize
Introduction - Mucus Rheology
Mucus tend to get more fluid when exposed to shear forces
http://www.youtube.com/watch?v=f2XQ97XHjVw
http://www.youtube.com/watch?v=S5SGiwS5L6I
At the macroscopic level, mucus is a
non-Newtonian, thixotropic gel
distinguished from classical solids and
liquids by its response to shear stress.
Under low shear, mucus behaves like
AWC Therapy Devices Landscape
Hand-Held Percussors
Types
Palm Cups®
Smith Medical ASD, Inc.
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Manual
Electronic
Pneumatic
Works by
G5® Flimm-Fighter
General Physiotherapy, Inc.
• Loosening the mucus
• Changing Rheology of mucus
• Creating airflow
• Operates on one area at time
• Needs Caregiver support
Bed Systems with Pulmonary Therapies
• Features to support ventilator-associated complication protocols
– Digital HOB angle indicator and alarm
– Continuous lateral rotation therapy (CLRT)
• Pulmonary surface (powered air)
– Helps prevent ventilator-associated
complications when used with CLRT
– Percussion and Vibration
Pulmonary Surface (Powered Air)
Oscillatory PEP Therapies
Flutter®Axcan Pharma™ US, Inc.
acapella® Vibratory PEP
The vibrations during forceful exhale through device
•Loosens the mucus
•Changes Rheology of mucus
Quake ® Thayer Medical
Lung Flute® Medical Acoustics inc
Intrapulmonary Percussive Ventilation (IPV®)
• The positive pressure oscillations through
airway during inhale and exhale
• Loosens the mucus
• Changes Rheology of mucus
• Creates bursts of flow to move mucus up ,
IPV1C®-F00001-C
Percussionaire
Metaneb 4 – Hill-Rom
• uses collateral airways
High Frequency Chest Wall Oscillations Therapy
HFCWO works on lower airways and lung areas to move the secretions to upper airways which
can be then coughed out.
HFCWO mobilizes the mucus by
changing the non Newtonian rheology of mucus to liquify it
Use collateral airway in lower lungs and alveoli to go behind the mucus plugs and push mucus
up with airflow
Expiratory flow bias helps move mucus up from the peripheral lower airways to the upper
airways for clearing through coughing, suctioning etc
The Vest
Inflatable garment connected by hoses to an air-pulse generator.
The garment rapidly inflates and deflates, compressing and
releasing the chest wall. Process called high-frequency chest wall
oscillation (HFCWO)
The Vest - HFCWO
Flow Rate During Oscillation Cycle
Type
Flow Rate
Ratio
Relaxed Breathing
120 mL/sec.
1x
CPT
480 mL/sec.
4x
Flutter®
480 mL/sec.
4x
HFCWO
1943 mL/sec.
16x
Cough
3429 mL/sec.
29x
History , clinical studies and evidence
Originally developed for Cystic Fibrosis patients where
65% have used The Vest Airway Clearance System
The most researched airway clearance technique with 90
studies conducted on The Vest Airway Clearance System
Studies have demonstrated:
Safety
Cost savings
Clinical efficacy
Improved compliance
Acceptance by both healthcare teams and patients
Please reach out for reference of studies, white papers and other literature –
[email protected] or visit http://www.thevest.com/physicians/
Summary of Vest HFCWO
Mini coughs loosens and
mobilizes mucus
Thins mucus
Aerosolised medications can
be delivered
Technique independent
Doesn’t require patient huge
patient effort
No special positioning
required
Improvement in short term
and longer term pulmonary
function
Provides consistent, quality
therapy
Considerations for Selecting an Airway Clearance Modality
• Cognitive limitations
– Age / mental status
– Sedation
• Physical ability
– Coordination / strength
– Shortness of breath / fatigue
– Mechanical Ventilation / Artificial Airways
• Promote improved compliance / adherence when:
– Effective, without side effects
– Comfortable
– Time efficient
– Adaptable with illness
– Can be used in any setting
– Easy to teach, learn and use!
• appendix