ADVANCED AIRWAY

CLEARANCE TECHNIQUE

ASWIN S
Percussion
 Aim - To loosen the retained secretions
from the airways.
 Rhythmical force - cupped hands -
trapping air between the patient's
thorax and the caregiver's hands .
 Inspiratory and expiratory phases of
breathing.
 Used in adjunct with postural drainage
positions and Active cycle of breathing
technique (ACBT).
Physiological basis

Percussion

Transmission of a wave of energy

Chest wall

Lung (resulting motion)

Loosens secretions from the bronchial wall

Moves them proximally (ciliary motion)

Cough (or suction) can remove them.

The combination of postural drainage and percussion has been shown to be effective in secretion removal.
Equipment required
 Preparation for Percussion
Appropriate PD positions should be
used.
Can use - thin towel or hospital gown
over the patient's skin
Can’t use - over bare skin or thick
padding
Adjust the level of the bed for
achieving proper body mechanics
during the treatment.
Treatment with Percussion
Cup shaped hand - fingers and thumb
adducted
Wrists, Arms, and Shoulders should be
relaxed.
Sound of percussion - hollow sound
(not as slapping sound )
Rhythm - should be steady ( normally
between 100 and 480 times per minute.
Treatment with Percussion
Force - should be equal from each hand.
Force does not have to be excessive to be
effective.
Amount of force should be adapted to the
patient's comfort.
Start with the nondominant hand and let
the dominant hand match the
nondominant .
Treatment with Percussion
For infants - four fingers cupped, three fingers with the middle finger
"tented," or using the thenar and hypothenar surfaces of the hand
Treatment with Percussion
Don’t do the percussion over any bony prominences.
( Spinous processes of the vertebrae, Spine of the scapula, and the
Clavicle , Floating ribs.)
Percussion over breast tissue – should be avoided. ( discomfort and
diminish the effectiveness of the treatment). “ move the breast out ”
Treatment with Percussion
Patient education - one-handed self-percussion ,either manually or with
a mechanical percussor.
 ADVANTAGES DISADVANTAGES

• Self application is limited. (compliance

and regular administration of percussion
• Enhance the mobilization of depends on caregiver availability)
secretions. • Mechanical percussor is costly
• Mechanical percussors allow the compared to manual technique.
patients more independence or • Percussion is also a threat to patients
with osteoporosis or coagulopathy.
decrease fatigue of a caregiver,
and are especially useful in • Not well-tolerated by many patients
postoperatively without adequate pain
patients requiring ongoing control.
treatment at home. • Repetitive motion injuries of the upper
extremities may occur in long-term deli
very of percussion for airway clearance.
VIBRATION/SHAKING
 Both are on opposite ends of a
spectrum.
 Vibration – Gentle and High
Frequency Force.
 Shaking - Vigorous and Low
Frequency Force
 Aim - moving secretions from the lung
periphery to the larger airways.
 Vibration – co-contraction of all
the muscles in the caregiver's upper
extremities.
 Shaking - stronger bouncing
maneuver.
 Used in conjunction with PD
position.
 Only during the expiratory phase of
breathing, starting with peak
inspiration and continuing until the
end of expiration.
Physiological basis
Vibration is proposed to enhance muco-ciliary transport from the
periphery of the lung fields to the larger airways.

Shaking is proposed to work in the same manner as vibration,

mobilizing secretions to the central, larger airways from the lung
periphery. Since the compressive force to the thorax is greater,
producing increased chest wall displacement, the stretch to the
respiratory muscles may produce an increased inspiratory effort and
lung volume.
Equipment required
Preparation for Vibration/Shaking
Appropriate PD positions should be used.
Can use - thin towel or hospital gown over the patient's skin
Can’t use - over bare skin or thick padding
Adjust the level of the bed for achieving proper body mechanics
during the treatment.
Treatment with Vibration/Shaking
Conventional chest physical therapy - combination of postural
drainage and percussion, vibration, or shaking.
Treatment with Vibration/Shaking
Shaking
Patient should be in the appropriate postural drainage position.
Place your hands over the lobe of the lung to be treated
Instruct the patient to take in a deep breath.
At the peak of inspiration, apply a slow, rhythmic bouncing pressure
to the chest wall until the end of expiration. (approximately 2 times
per second)
Hands follow the movement of the chest as the air is exhaled.
Treatment with Vibration/Shaking
Vibration
Patient should be in the appropriate postural drainage position.
The hands may be placed side by side or on top of one another.
Patient is instructed to take in a deep breath .
Gentle but steady co-contraction of the upper extremities is per­formed
to vibrate the chest wall, beginning at the peak of inspiration and
following the movement of chest deflation.
 Treatment with Vibration/Shaking
 Mechanically ventilated patient - timed with ventilator controlled
exhalation.
 Incase of rapid respiratory rate (either voluntary or ventilator-controlled) -
apply vibration or shaking only during every other exhalation.
Frequency
 Manual vibration - 12 and 20 Hz.
 Shaking - 2 Hz.
Treatment with Vibration/Shaking
 Mobile chest wall is necessary - to apply a compressive force without
causing discomfort.
 Patient with limited chest wall movement - Vibration will probably be
tolerated better than Shaking.
 Mechanical vibrators can be used . ( limited attention can be paid to
the posterior portions of the lungs)
 ADVANTAGES DISADVANTAGES

• Enhance the mobilization of • Self application is limited.

secretions. (compliance and regular
• To assess the pattern and depth administration of vibration
of respiration. depends on caregiver
availability)
• Better tolerated than percussion
• Mechanical vibrators is costly
compared to manual technique.
Postural Drainage
Postural drainage is the positioning
of a patient with an involved lung
segment such that gravity has a
maximal effect of facilitating the
drainage of broncho-pulmonary
secretions from the
tracheobronchial tree.
It is based on the concept of
gravity-assisted mobilization of
secretions and transport it for
removal.
Mechanism
During erect position only the
segments of the right upper lobe
and non-lingular portion of the left
upper lobe receive gravitational
assistance whereas the segment of
the middle, lingular portion of left
upper lobe and lower lobe
segments of both lungs must drain
against gravity.
Mechanism
In normal healthy state, the mucociliary mechanism clears off the
bronchial secretions. In diseased state they get compromised and
secretions get accumulated especially in the smaller airways that
cannot be emptied without gravity assistance which can further lead to
inflammation and scarring.
Mechanism
The natural methods of emptying
the tracheo-bronchial tree of
accumulated secretion are on the
whole extremely inefficient.
Ciliary action -only removes
minute particulate matter such as
dust or bacteria, and is of no value
when there is much secretion.
Equipment required
Preparation for Postural Drainage
l. Nebulized bronchodilators before
postural drainage may facilitate the
mobilization of sputum.

2. An adequate intake of fluids (if

allowed) decreases the viscosity of the
secretions, allowing easier mobilization.
Preparation for Postural Drainage
3. Become familiar with the workings of the
model of bed the patient is occupying,
especially the movement of the bed into the
Trendelenberg position.

4. In the ICU, it is imperative to be familiar

with the multiple lines, leads, and tubes
attached to the patient. Allow enough slack
from each device to position a patient for
postural drainage.
Preparation for Postural Drainage
5. Make sure there are enough
personnel to position the patient with
as little stress to both patient and staff
as possible .

6. Have suctioning equipment ready to

remove secretions from an artificial
airway or the patient's oral or nasal
cavity after the treatment.
Treatment
Determine the lobe of the lung to be treated and position the patient
comfortably in the position indicated.
Each position should be maintained for 5 to 10 minutes, if
tolerated, or longer when focusing on a specific lobe.
If postural drainage is used in conjunction with another technique,
the time in each position may be decreased.
Treatment
If percussion and vibration are performed while the patient is in each
postural drainage position, 3 to 5 minutes is sufficient.
A patient who requires close monitoring should not be left unattended
(Trendelenburg position).
Not necessary to treat each affected lung segment during each
treatment – FATIGUE.
The most affected lobes should be addressed with the first treatment
of the day, with the other affected areas addressed at a subsequent
treatment.
Treatment
The patient should be encouraged to take deep breaths and cough after
the treatment and if possible after each position.
Secretions may not be mobilized immediately after the treatment but
possibly 1 half hour to 1 hour later.
The patient should be thus informed and requested to clear secretions
then. The nurse or family member should be included in this aspect of
treatment, especially with difficult patients who need such
encouragement.
Contraindications
1. Head injuries including cerebral vascular accidents because
intracranial pressure would be increased.
2. Severe hypertension as venous return is increased with tipping and
this can overload the heart.
3. Following oesophagectomy there can be undue stress on the
anastomosis and postural drainage may cause regurgitation.
4. Severe haemoptysis, when all forms of physiotherapy should be
discontinued until there has been discussion with the doctors.
Contraindications
5. Aortic aneurysms which would be put under tension if the patient is
tipped or tilted.
6. Pulmonary oedema which collects in the dependent areas; postural
drainage would cause extreme dyspnoea and probably worsen the
situation.
7. Surgical emphysema which might track toward the face if the patient
is tipped and might result in dyspnoea.
8. Tension pneumothorax without an intercostal drain. This condition
should not require physiotherapy, but must never tipped as the cardiac
embarrassment may lead to a cardiac arrest.
Contraindications
9. Cardiac arrhythmias which can be worsened by postural drainage; in
some positions the myocardial oxygen demand would be greater and so
its sensitivity to abnormal rhythms is increased.
10. Hiatus hernias should not be tipped as the patient may regurgitate
gastric juices.
11. The filling cycle of peritoneal dialysis. The descent of the diaphragm
is impeded during this phase and tipping may cause more respiratory
distress.
Contraindications
12. Facial oedema from burns will be increased with tipping.
13. Eye operations where there may be some associated oedems which
could be increased with tipping.
Postural Drainage Positions
Postural Drainage Positions
Postural Drainage Positions
 ADVANTAGES DISADVANTAGES

• Easy to learn. • Compliance of treatment is less

• Cost efficient. due to length of the treatment
(pediatrics )
• Can be used adjunct with other
techniques. • Time consuming technique, both
for patient and care giver.
- thank you !