PRACTICAL CONSIDERATION IN AIRWAY CLEARANCE-

VIEW OF THERAPIST

Manivel Arumugam.Senior physiotherapist

Why this topic?

• During mechanical ventilation• Weaning and extubation planning• During weaning failure or extubation failure• Selection of techniques based on patients

conditions• How to prescribe ACT in ICU?

Airway clearance techniques

• Need of airway clearance• Basics of airway clearance• Indications of airway clearance• Techniques • Current trends in airway clearance.

Basic physiology of airway clearance

Indications for airway clearance

Acute sepsis

Paralysis

Ventilation

Sedatives

Alone/ lack of communication Economical & psychological

issues

Extra thoracic manipulation

• Postural drainage• Chest percussion• Vibration and shaking• High frequency chest wall oscillatory device

Hardened secretion in dependent zone

Frequent positioning/ kinesio bed may

alleviate the problems. But economy/

manpower need more

Extra thoracic manipulation

HFCWO

Intra thoracic/oral manipulation

• Bagging/ manual hyperinflation• Intra percussive ventilation• Cough assist device/ cough insufflators-ex

sufflator

IPV COUGH INSUFFLATOR EXSUFFLATOR

Intra thoracic/ intraoral

manipulation

ACTIVE AIRWAY CLEARANCE DEVICES & TECHNIQUES

PEP THERAPY DEVICES• ACAPELLA• FLUTTER• EZPAP• CORNET• QUAKE DEVICE

TECHNIQUES:• ACTIVE CYCLE OF BREATHING • AUTOGENIC DRAINAGE• FORCED EXPIRATORY TECNIQUE

ACAPELLA

• Acapella combines the benefits of both PEP therapy and airway vibrations to mobilize pulmonary secretions and can be used in virtually any position allowing patients to move freely and sit, stand or recline.

• It improves clearance of secretions, is easier to tolerate than Chest Physical Therapy (CPT), takes less than half the time of conventional CPT sessions*

• facilitates opening of airways in patients with lung diseases with secretory problems  such as COPD, asthma and Cystic Fibrosis.

• Color-coded units (green for high-flow, blue for low) help customize treatment for each patient based on their clinical needs.

• Can adjust the Acapella frequency and flow resistance simply by turning an adjustment dial.

• Allows inhalation and exhalation without removing from mouth

• Prolongs expiratory airflow to increase removal of secretions

• Allows use with mask or mouthpiece attachment• Allows use with inline nebulizer when fitted with the

adapter.• Accommodates virtually any patient’s lung capacity

Acapella FLUTTER

cornet Quake & Bubble PEP

Active airway clearance devices

Passive airway clearance devices

EzPAP-positive airway pressure system

• The EZPAP positive airway pressure system is used to expand the lungs by increasing Functional Residue Capacity (FRC). Increasing FRC has been found to contribute to the prevention and reversal of atelectasis.

• EzPAP is the easy option for the prevention and treatment of atelectasis and a medical need for lung expansion therapy.

• When incentive spirometry alone won't open patient's airways, expand your options with EzPAP. It makes providing positive airway pressure positively easy.

• Simply connect to a flow meter (wall air or O2 for enhanced FiO2), adjust 5-15 lpm, and instruct the patient to breathe normally through the mouthpiece or mask. Just a few minutes of therapy, as needed - not for hours at a time.

• Can be used with mask or mouthpiece attachment

• Allows use with inline nebulizer when fitted with the adapter Prevents inadvertent occlusion

• Connects to gauge tubing• Eliminates collecting components• Eliminates the need to carry a manometer

EzPAP

Inspiratory muscle trainer

Threshold trainer

• It has an adjustable spring-loaded valve that imposes the inspiratory load.

• The inspiratory load can be increased by winding the spring more tightly. 

• Advantage of this trainer is that the same load is imposed on the inspiratory muscles regardless of breathing pattern. 

Resistive trainer

• It has holes of different diameters. • The inspiratory load can be increased by setting the

dial to holes of lesser diameter. • Disadvantage of this trainer is that the subject can

reduce the inspiratory load by breathing more slowly. • If this device is used for training, a target must be

used. Various targets have been designed that set a breathing rate (flow and/or inspiratory pressure) for the subject.

Isocapneic Hypernea Trainer• It has a rebreathing bag that can be adjusted to ensure that

the person’s CO2 level is maintained within a physiologic range.

• A target is provided for the person to increase the level of ventilation to a training intensity.

• This device enables training at low loads but much higher inspiratory and expiratory flow such that the inspiratory and expiratory muscles training at higher speeds of contraction.

• In contrast, the threshold and resistive trainers, place high loads while the speed of contraction is relatively low