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Bronchial Hygiene Therapy II
RET 2275
Respiratory Therapy Theory Lab 2
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Most bronchial hygiene therapies only help move
secretions into the central airways. Actual clearance of
these secretions requires either coughing or suctioning.

In this respect, an effective cough (or alternative
expulsion measure) is an essential component of ALL
bronchial hygiene therapy
Reading Assignment
Egan’s Fundamentals of Respiratory Care
NINTH EDITION (pgs. 915-916, 932-941)
Bronchial Hygiene

Coughing and related expulsion techniques

Directed cough

A deliberate maneuver that is taught, supervised, and
monitored

Aims to mimic the features of an effective spontaneous
cough in patients who are too weak to produce a forceful
expiratory maneuver
Bronchial Hygiene

Coughing and related expulsion techniques

Directed Cough

Not to be used in patients who are obtunded, paralyzed, or
uncooperative

Good patient teaching is critical

Proper positioning of the patient is important

The technique may need to be modified in surgical patients,
patients with COPD, and patients with neuromuscular disease
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough - Standard Technique

Instruct the patient to assume a sitting position, with shoulders
rotated inward, the head and spine slightly flexed, forearms
relaxed or supported


If the patient is unable to sit up, raise the head of the bed,
knees should be slightly flexed with feet braced on the
mattress
Instruct the patient to inspire slowly and deeply through the
nose, using the diaphragm
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough - Standard Technique

Instruct the patient to bear down against a closed glottis

Instruct the patient to cough

Stage expiratory effort into two or three shout bursts for
patient with pain or bronchiolar collapse
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough – Surgical Patients

Provide preoperative training

Minimizes anxiety over pain

Coordinate coughing sessions with prescribed pain
medications

Assist the patient to splint the operative site

The forced expiratory technique (FET) may be of value to
these patients
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough – COPD Patients

Instruct the patient to assume a sitting position, with
shoulders rotated inward, the head and spine slightly flexed,
forearms relaxed or supported

Instruct the patient to take in a moderately deep breath
through the nose


Results in less pleural pressure and less collapse of the
smaller airways
Instruct the patient to exhale with moderate force through
pursed lips, while bending forward
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough – COPD Patients

Patient should repeat the previous steps 3 – 4 times

Have the patient bend forward and initiate short staccato-like
bursts of air


Technique relieves the strain of a prolonged cough and minimizes
airway collapse
An alternative to this technique is called “huffing”
FET or Autogenic Drainage (AD) may also be used in these patients
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough – Neurological Patients

Instruct the patient to take a deep breath


Assist as needed with IPPB or resuscitator bag/mask
At the end of inspiration, begin exerting pressure on the
lateral costal margin or epigastrium, increasing the force of
compression throughout expiration


Pressure to the lateral costal margins is contraindicated in patient with
osteroporosis or flail chest
Epigastric pressure is contraindicated in unconscious patient with
unprotected airways; in pregnant women; and in patient with acute
abdominal pathology, abdominal aortic aneurysm, or hiatal hernia
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough – Forced expiratory technique (FET)

A modification of the directed cough

Also called the “huff cough”

Consists of one or two forced expirations of middle to low lung
volumes without closure of the glottis

Goal is to clear secretions with less change in pleural pressure
and less bronchial collapse.
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough – Forced expiratory technique (FET)

FET has been shown to increase sputum production,
especially when combined with postural drainage

Most useful in patients with COPD, cystic fibrosis, or
bronchiectasis
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough – Forced expiratory technique (FET)

Instruct the patient to take in a slow, deep breath, followed by
a 1 – 3 second breath hold

Instruct the patient to perform 1 – 2 short, quick forced
exhalation of middle to low lung volume with the glottis open


The patient should phonate or “huff” during expiration
Each session of “huffing” should be followed by diaphragmatic
breathing and relaxation
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Directed Cough – Active Cycle of Breathing (ACB)

Repeated cycles of breathing control, thoracic expansion,
and the FET

Breathing control; gentle breathing at normal tidal volumes with
relaxation of the upper chest and shoulders – helps prevent
bronchospasm

Thoracic expansion; deep inhalation which relaxed exhalation,
which may be accompanied by percussion, vibration, or
compression – designed to help loosen secretions, improve the
distribution of ventilation, and provide the volume needed for FET
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Autogenic Drainage (AD)

During AD, the patient uses diaphragmatic breathing to
mobilize secretions by varying lung volumes and expiratory
airflow in three distinct phases.

Patient should be in the sitting position.

Coughing should be suppressed until all three phases are
complete.
Bronchial Hygiene

Autogenic Drainage (AD)

Spirogram of lung volumes during
three phases of autogenic drainage.

Phase 1 involves a full inspiratory
capacity maneuver, followed by
breathing at low lung volumes. This
phase is designed to “unstick”
peripheral mucus.

Phase 2 involves breathing at low to
middle lung volumes in order to
collect mucus in the middle airways.

Phase 3 is the evacuation phase, in
which mucus is readied for expulsion
from the large airways.
Bronchial Hygiene

Hazards of Directed Cough
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Mechanical Insufflation-Exsufflation (MIE)
Bronchial Hygiene

Coughing and Related Expulsion Techniques

Mechanical Insufflation-Exsufflation (MIE)

MIE devices apply positive pressure of 30 to 50 cm H2O to the
airway for 1 to 3 seconds.

The device then abruptly reverses the airway pressure to –30
to –50 cm H2O.

Treatment sessions consist of about five cycles of MIE
followed by normal spontaneous breathing.

This process is repeated five or more times until secretions are
cleared
Bronchial Hygiene

High Frequency Chest Wall Oscillation (HFCWO)


Consists of a variable air-pulse generator and a non-stretch
inflatable vest
Small gas volumes are alternately injected into and withdrawn
from the vest by the air-pulse generator at a fast rate (5 – 25
Hz) creating a oscillatory motion against the patient’s thorax
Bronchial Hygiene

HFCWO

Oscillations at frequencies of 12
– 25 Hz enhance clearance of
secretions




Acts as a physical “mucolytic”
by altering the physical
properties of secretions
Transient increases in airflow
produce cough-like shear
forces
Therapy sessions are
approximately 30 minutes in
duration
One to 6 treatments per day
Bronchial Hygiene

HFCWO

Common Conditions/Situations for HFCWO






Patient with evidence of retained secretions
Independent patient without access to a caregiver
Patient with reduced mobility
Patient who cannot tolerate Trendelenburg positioning
Fragile patient who cannot tolerate the force of CPT
Ventilator-dependent patient experiencing frequent
pneumonias
Information obtained from manufacturer’s website
Bronchial Hygiene

HFCWO

Most Common Diagnoses Utilizing HFCWO

Cystic Fibrosis
Bronchiectasis
Cerebral Palsy
Spinal Muscular Atrophy
Muscular Dystrophy

Chronic Obstructive Pulmonary Disease (COPD)




Information obtained from manufacturer’s website
Bronchial Hygiene
Positive Expiratory Pressure (PEP)

Active expiration against a variable flow
resistance
 Helps move secretions into larger
airways




Filling underaerated or nonaerated
segments via collateral ventilation
Preventing airway collapse during
expiration
Subsequent huff or FET maneuver allows
patient to generate the flows needed to
expel mucus
Aerosol drug therapy may be added to a
PEP session to improve the efficacy of
bronchodilator
Bronchial Hygiene

PEP

Oscillating PEP

Flutter Valve




Combines the techniques of
EPAP with high-frequency
oscillations at the airway
opening
Actively exhaling into the pipe
creates a positive expiratory
pressure between 10 – 25 cm
H2O
Changing the angle of the
device alters the oscillations
The device can decrease
mucus viscoelasticity within
the airways, allowing it to be
cleared more easily by cough
Bronchial Hygiene

PEP

Oscillating PEP

acapella®
 Combines the techniques of EPAP with highfrequency oscillations at the airway opening
Bronchial Hygiene

EZ-PAP



Lung expansion therapy during
inspiration and PEP therapy
during exhalation
Used for the treatment or
prevention of atelectasis and
the mobilization of secretions
Aerosol drug therapy may be
added to a PEP session to
improve the efficacy of
bronchodilator
EZ-PAP

Clinical Procedure for PAP


Requires a physician’s order
Explain purpose and procedure of therapy to the patient



Have the patient sit comfortably
If using a mouthpiece


Teach directed cough, e.g., “huff”
Instruct the patient to place lips firmly around mouthpiece and to
breathe through their mouth
If using a mask

Ensure a comfortable but tight fit around the nose and mouth
EZ-PAP

Clinical Procedure for PAP





Instruct the patient to take a larger than normal breath, but not to
fill the lungs completely
Have the patient exhale actively, but not forcefully, creating a
positive pressure of 5 to 20 cm H2O during exhalation
(determined with a monometer)
Patient should perform 10 – 20 breaths
Remove the mask or mouthpiece and perform 2 – 3 “huff”
coughs; allow rest as needed
Repeat above cycle 4 – 8 times, not to exceed 20 minutes
EZ-PAP

Clinical Procedure for PAP


If the patient is receiving bronchodilators via aerosol, administer
in conjunction with PAP device
Document the procedure in the patients medical record



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


Device
Settings (if applicable)
Pressure (if possible)
Number of breaths per treatment
Patients response to therapy
Patient education provided
Patient’s ability to self-administer (if applicable)