Airway Clearance and Breathing

Techniques

Ana Schippers Snr Physiotherapist in Pulmonary Rehabilitation

Liverpool Hospital 8738 3000 pager 25356

Contents

• Basic Anatomy of the lungs

• Normal airway clearance

• Impaired airway clearance

• Rx: Airway clearance techniques

• Normal breathing

• COPD

• Rx: Breathing techniques

• Benefits of exercise

Basic Anatomy of the Lungs

Basic Anatomy of the Lungs

•The respiratory system consists of:

– Nose – PHARYNX (THROAT) – Larynx (Voice Box) – Trachea (Windpipe) – Bronchial tree – Lungs

The Bronchial Tree

• The bronchial tree branches 23 times “generations”

• Cough only works in the first 6-8 generations

• Huff only works in the first 12-14 generations

The Bronchial Tree

• As you can see, huff and cough is only able to clear phlegm from the centre of your lungs

• However, this is usually NOT a problem when you have normal lungs

Huff

12-14

Cough

6-8

Total 23 generations

The Bronchial Tree

• Let take a closer look at the air sac “alveolar sac”

Huff

12-14

Cough

6-8

The Alveolar Sac

• The Alveolar Sac is where gas exchange happens

- Oxygen in

- Carbon Dioxide out

The Alveolar Sac

• Lining the inside of bronchioles are

– Hairs ‘mucocilia’

– Always a thin lays of phlegm

• We all produce ½ cup phlegm per day

• This a part of our cleaning system

Normal Airway Clearance

Normal Airway Clearance

• The phlegm catches all the dust and germs we breath in

• The mucocilia moves the phlegm, germs, & dust out … “Mucociliary Clearance”

• Moves phlegm to the centre where we can cough it out

Impaired Airway Clearance

Smoking and Mucocilia

• Smoking causes:

– Damage to the mucocilia

– Thicker phlegm

– Inability for mucocilia to penetrate phlegm

– Build up of phlegm thus trapping germs

– Blockage and infection

Bronchiectasis and mucocilia

• Airways are stretched and widened

• Mucous can build up which causes the lungs to produce more

• Mucous build up cause infection to grow

• Chronic infections causes further damage to lungs

Lung function over time

Normal lung function peaks at 30’s

Declines faster with

smoking

Quit smoking will follow natural

decline

Infection cause further damage

Sputum Clearance

• So if build up of phlegm, germs, dust causes infections

Regular cleaning can prevent infections

Therefore preventing further lung damage

Rx: Airway Clearance Techniques

In the olden days

• Positioning or postural drainage “Tip people upside down”

• Percussion and vibration “Give them a pat”

• It still works but there are other options that works in a similar way

Recent Airway Clearance Techniques

• PEP – Positive Airway Pressure

- Gets airflow behind phlegm

- Gets behind blocked air sacs via connecting channels

- Stabilises floppy emphysema airways (details later)

Oscillatory PEP

• Combination of PEP and high frequency oscillations

• Benefits of PEP PLUS

• Oscillations can

- Shake loose the phlegm

- Make it less thick

Types of Oscillatory PEP

Bubble PEP

Acapella

Flutter/Shaker

Aerobika

Pari PEP

Cornet

ACBT: Active Cycle Breathing Technique

• Combination of: Deeps breaths (or PEP), relaxed breaths, huffs, & cough

• Moves outside of huff/cough zones into the huff/cough zones

Which technique to use?

• Treatment of infection vs prevention

• Goal: Open up collapsed lung or move phlegm?

• Small vs moderate vs large amount of phlegm

• Steroid use and risk of osteoporosis

• Living with who? Active vs passive treatment

• All treatment should be individualised

• Ask for a referral to see a respiratory physio

• Hospital vs private physiotherapist

Timing of meds and chest physio

• Correct timing of medications with chest physiotherapy more than the sum of each individually

₋ Step 1: 10 PEP blows

₋ Step 2: Puffers/nebulisers

₋ Step 3: Wait 10 minutes

₋ Step 4: ACBT & PEP

Normal Breathing

Normal Breathing

Inspiration •Diaphragm/intercostals contract •Air drawn into the lungs.

Expiration •Diaphragm/intercostals relax – no effort required •Air is pushed out by elastic recoil of lungs

COPD Chronic Obstructive Pulmonary Disease

COPD

• Umbrella term –Chronic Asthma –Bronchitis

–Emphysema

• Inability to get air out of the alveoli

• Symptoms such as wheezing, coughing and shortness of breath

Emphysema

Causes:

Smoking

Alpha 1 antitripsin deficiency

Normal vs COPD breathing

•Note: Dome diaphragm vs flattened diaphragm

COPD (Chronic Obstructive Pulmonary Disease)

• When short of breath –Feels like “cant get air in”

–Actually have “too much air in”

• Focus on getting air out

• The more ‘stale’ air you get out, more fresh air you can get in

Rx: Breathing Techniques

Lean Forward Position

• Used when you are very short of breath

• In sitting or standing • Lean forward & rest your

arms • Allows the “accessory”

muscles (upper arm muscles) to help you breath

regain your breath

Pursed Lip Breathing

• Helps open collapsed/closed airway

• Provide “pressure back” • Performed when

breathing out • Followed by a normal

breath in • Aim to breath out as long

as you can

When Short of Breath (SOB)

• Lean forward

– To utilise your arm muscles to help you breath

• Pursed lip breath

– As long as you can

– To get as much air out as possible

• Do this in before you get SOB

– Can walk further before you get SOB

When Short of Breath (SOB)

• Use of 4 wheeled walker/trolley beneficial

– <300m in 6 minute walk test – Confidence – More active – All the time vs during 30 minutes walking – LESS SOB

Benefits of Exercise

Benefits of exercise

Pulm Rehab shown to

• Reduce infections

• Better recovery

CYCLE OF INACTIVITY

Shortness of breath (SOB) comes from inactivity not from the disease

Exercise

• Exercise can replace one chest physiotherapy session because – Increases air entering lungs – Aid in removing sputum

• Exercise can – Improve weakness – Reduce /reverse deconditioning – Recrease shortness of breath.

Summary

• Daily exercise and chest physiotherapy to prevent/treat chest infections

• When SOB, you already have too much air need to focus on breathing out

• Use lean forward position and pursed lip breathing

• Use of walker/trolley can be beneficial

• Join exercise class or Pulmonary Rehabilitation

For more information

• Referral to Pulmonary Rehabilitation Program at most major hospitals

• Come along to one of our free education sessions

– Liverpool Hospital

– 3 Thursday (bi-monthly: even months)

– 8.45 – 12.30

Any Questions?