Pulmonary hygiene

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Pulmonary hygiene, also referred to as pulmonary toilet, [1] is a set of methods used to clear mucus and secretions from the airways. The word pulmonary refers to the lungs. The word toilet , related to the French toilette, refers to body care and hygiene; this root is used in words such as toiletry that also relate to cleansing.

Contents

Respiratory health (pulmonary hygiene) depends on consistent clearance of airway secretions. Normal airway clearance is accomplished by two important mechanisms: the mucociliary clearance system and the ability to cough. Impaired mucociliary clearance is linked to poor lung function in a broad range of diseases and disabilities. [2]

Pulmonary hygiene prevents atelectasis (the collapse of the alveoli of the lungs) and rids the respiratory system of secretions, [3] which could cause respiratory infections. It can also decrease pulmonary shunting, increase the functional reserve capacity of the lungs, and prevent respiratory infection after chest trauma. [4] Methods include using suction to remove fluids and placing the patient in a position that allows secretions to drain by gravity.

Methods

Methods used for pulmonary hygiene include suctioning of the airways, chest physiotherapy, blow bottles, [3] and nasotracheal suction. [5] Bronchoscopy, in which a tube is inserted into the airways so that an examiner can view them, can be used therapeutically as part of pulmonary hygiene. [4] Incentive spirometry and use of analgesics (pain medications) that do not inhibit breathing are also parts of pulmonary toilet. [6] Coughing is also important for ridding the airways of secretions, so healthcare providers are careful not to oversedate patients, because that could inhibit coughing. [7] Tracheotomy facilitates pulmonary toilet. [8] Percussion, another method, loosens secretions and allows the cilia of the airways to remove material. Positioning is another method for promoting drainage of secretions; sometimes patients are placed in a prone position to aid in this purpose. [4]

Conventional chest physiotherapy

The most common treatment of atelectasis in the hospital setting is manual chest physiotherapy [9] though there is limited evidence of its efficacy. [10] [11] Chest percussion and postural drainage are used in bronchiectasis and lung abscess. The patient's body is positioned so that the trachea is inclined downward and below the affected chest area. [12] Postural drainage is essential in treating bronchiectasis. Patients must receive physiotherapy to learn to tip themselves into a position in which the lobe to be drained is uppermost at least three times daily for up to 30 minutes during each session.

The treatment is often used in conjunction with a technique for loosening secretions in the chest cavity called chest percussion. Chest percussion is performed by clapping the back or chest with a cupped hand. Alternatively, a mechanical vibrator may be used in some cases to facilitate loosening of secretions. [13] There are drainage positions for all segments of the lung. These positions are modified depending on the patient's condition and the location of the area in most need of therapy.

Intermittent positive pressure breathing (physiotherapy)

Intermittent positive pressure breathing (IPPB) physiotherapy has long been used in the intensive care setting in non-intubated patients. Although widely accepted, few studies have validated its efficacy. In a Respiratory Care Clinical Practice Guideline, [14] IPPB is suggested for patients who have impaired airway clearance, and for delivery of aerosolized medications to patients with neuromuscular weakness who are incapable of inhaling deeply. IPPB physiotherapy should be used with caution in patients with severe, uncontrolled bronchospasm or severe airway obstruction

Mechanical insufflation-exsufflation physiotherapy

People with neuromuscular weakness and atelectasis benefit from mechanical insufflation-exsufflation. [15] Mechanically-assisted coughing greatly improves secretion clearance in the setting of respiratory infection in the patient with neuromuscular disease and should be first-line therapy for this patient population. [16] Mechanical insufflation-exsufflation physiotherapy is greatly aided by simultaneous manual augmentation of cough with either a thoracic squeeze or abdominal thrust during the expiratory phase (exhale). An American Thoracic Society consensus statement in 2004 supported the use of mechanical insufflation-exsufflation physiotherapy for patients with Duchenne muscular dystrophy. [17] The use of this technique for children with neuromuscular disease has gained widespread acceptance in the United States and internationally. [18] [19]

Applications

Pulmonary bronchial hygiene is used for preventing infections such as pneumonia. It is also used in the management of conditions such as pneumonia and cystic fibrosis. [6] For people with chronic lung diseases, bronchial hygiene is used to prevent infections and lung abscesses. [20] Bronchial hygiene is also used to prevent acute respiratory distress syndrome after chest trauma. [4]

Indications

The need for bronchial hygiene is indicated in cases of COPD, pneumonia and cystic fibrosis as both interventional and prophylactic. Prophylactic indications also include pre and post thoracic surgery to prevent atelectasis and respiratory infections.

Contraindications

The decision to use postural drainage therapy requires assessment of potential benefits versus potential risks. Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. Some of the contraindications include an increased intracranial pressure (>20 mmHg), any spinal injury acute or otherwise, active hemoptysis, pulmonary embolism, pulmonary edema with congestive heart failure and an open or healing wound in the area where chest physiotherapy is otherwise indicated.

Medication contraindications vary depending on the medication being delivered.

See also

Related Research Articles

<span class="mw-page-title-main">Respiratory failure</span> Inadequate gas exchange by the respiratory system

Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise in arterial carbon dioxide levels is called hypercapnia. Respiratory failure is classified as either Type 1 or Type 2, based on whether there is a high carbon dioxide level, and can be acute or chronic. In clinical trials, the definition of respiratory failure usually includes increased respiratory rate, abnormal blood gases, and evidence of increased work of breathing. Respiratory failure causes an altered mental status due to ischemia in the brain.

<span class="mw-page-title-main">Hemoptysis</span> Medical symptom consisting of bloody mucus from coughing

Hemoptysis or haemoptysis is the discharge of blood or blood-stained mucus through the mouth coming from the bronchi, larynx, trachea, or lungs. It does not necessarily involve coughing. In other words, it is the airway bleeding. This can occur with lung cancer, infections such as tuberculosis, bronchitis, or pneumonia, and certain cardiovascular conditions. Hemoptysis is considered massive at 300 mL. In such cases, there are always severe injuries. The primary danger comes from choking, rather than blood loss.

<span class="mw-page-title-main">Bronchiectasis</span> Disease of the lungs

Bronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung. Symptoms typically include a chronic cough with mucus production. Other symptoms include shortness of breath, coughing up blood, and chest pain. Wheezing and nail clubbing may also occur. Those with the disease often get lung infections.

Crackles are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation, and occasionally during exhalation. They are usually heard only with a stethoscope. Pulmonary crackles are abnormal breath sounds that were formerly referred to as rales.

<span class="mw-page-title-main">Pulmonology</span> Study of respiratory diseases

Pulmonology, pneumology or pneumonology is a medical specialty that deals with diseases involving the respiratory tract. It is also known as respirology, respiratory medicine, or chest medicine in some countries and areas.

<span class="mw-page-title-main">Atelectasis</span> Partial collapse of a lung causing reduced gas exchange

Atelectasis is the partial collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct from pulmonary consolidation, in which they are filled with liquid. It is often referred to informally as a collapsed lung, although more accurately it usually involves only a partial collapse, and that ambiguous term is also informally used for a fully collapsed lung caused by a pneumothorax.

<span class="mw-page-title-main">Aspiration pneumonia</span> Medical condition

Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs. Signs and symptoms often include fever and cough of relatively rapid onset. Complications may include lung abscess, acute respiratory distress syndrome, empyema, and parapneumonic effusion. Some include chemical induced inflammation of the lungs as a subtype, which occurs from acidic but non-infectious stomach contents entering the lungs.

<span class="mw-page-title-main">Lung abscess</span> Medical condition

Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection.

Tracheobronchitis is inflammation of the trachea and bronchi. It is characterised by a cough, fever, and purulent sputum and is therefore suggestive of pneumonia. It is classified as a respiratory tract infection.

<span class="mw-page-title-main">Respiratory disease</span> Disease of the respiratory system

Respiratory diseases, or lung diseases, are pathological conditions affecting the organs and tissues that make gas exchange difficult in air-breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, influenza, and pharyngitis to life-threatening diseases such as bacterial pneumonia, pulmonary embolism, tuberculosis, acute asthma, lung cancer, and severe acute respiratory syndromes, such as COVID-19. Respiratory diseases can be classified in many different ways, including by the organ or tissue involved, by the type and pattern of associated signs and symptoms, or by the cause of the disease.

<span class="mw-page-title-main">Chest physiotherapy</span> Treatments to improve breathing by indirect removal of mucus from breathing passage

Chest physiotherapy (CPT) are treatments generally performed by physical therapists and respiratory therapists, whereby breathing is improved by the indirect removal of mucus from the breathing passages of a patient. Other terms include respiratory or cardio-thoracic physiotherapy.

Postural drainage (PD) is the drainage of lung secretions using gravity. It is used to treat a variety of conditions that cause the build-up of secretions in the lungs.

<span class="mw-page-title-main">Bronchitis</span> Inflammation of the large airways in the lungs

Bronchitis is inflammation of the bronchi in the lungs that causes coughing. Bronchitis usually begins as an infection in the nose, ears, throat, or sinuses. The infection then makes its way down to the bronchi. Symptoms include coughing up sputum, wheezing, shortness of breath, and chest pain. Bronchitis can be acute or chronic.

Williams–Campbell syndrome (WCS) is a disease of the airways where cartilage in the bronchi is defective. It is a form of congenital cystic bronchiectasis. This leads to collapse of the airways and bronchiectasis. It acts as one of the differential to allergic bronchopulmonary aspergillosis. WCS is a deficiency of the bronchial cartilage distally.

<span class="mw-page-title-main">Pulmonary contusion</span> Internal bruise of the lungs

A pulmonary contusion, also known as lung contusion, is a bruise of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels (hypoxia). Unlike pulmonary laceration, another type of lung injury, pulmonary contusion does not involve a cut or tear of the lung tissue.

Insufflation is the act of blowing something into a body cavity. Insufflation has many medical uses, most notably as a route of administration for various drugs.

<span class="mw-page-title-main">Chronic obstructive pulmonary disease</span> Lung disease involving long-term poor airflow

Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms of COPD include shortness of breath and a cough, which may or may not produce mucus. COPD progressively worsens, with everyday activities such as walking or dressing becoming difficult. While COPD is incurable, it is preventable and treatable. The two most common types of COPD are emphysema and chronic bronchitis and have been the two classic COPD phenotypes. However, this basic dogma has been challenged as varying degrees of co-existing emphysema, chronic bronchitis, and potentially significant vascular diseases have all been acknowledged in those with COPD, giving rise to the classification of other phenotypes or subtypes. Emphysema is defined as enlarged airspaces (alveoli) whose walls have broken down resulting in permanent damage to the lung tissue. Chronic bronchitis is defined as a productive cough that is present for at least three months each year for two years. Both of these conditions can exist without airflow limitation when they are not classed as COPD. Emphysema is just one of the structural abnormalities that can limit airflow and can exist without airflow limitation in a significant number of people. Chronic bronchitis does not always result in airflow limitation but in young adults with chronic bronchitis who smoke, the risk of developing COPD is high. Many definitions of COPD in the past included emphysema and chronic bronchitis, but these have never been included in GOLD report definitions. Emphysema and chronic bronchitis remain the predominant phenotypes of COPD but there is often overlap between them and a number of other phenotypes have also been described. COPD and asthma may coexist and converge in some individuals. COPD is associated with low-grade systemic inflammation.

Physiotherapists treating patients following uncomplicated coronary artery bypass surgery surgery continue to use interventions such as deep breathing exercises that are not supported by best available evidence. Standardised guidelines may be required to better match clinical practice with current literature.

Plastic bronchitis (PB) is a disorder in which branching casts of the airways are expectorated. PB is not a single disease with a defined mechanism that explains the cast formation in all conditions. Examples of diseases associated with expectoration of casts, and which sometimes are labeled PB include tuberculosis, atypical mycobacterial disease, allergic bronchopulmonary aspergillosis, and asthma.

Airway clearance therapy is treatment that uses a number of airway clearance techniques to clear the respiratory airways of mucus and other secretions. Several respiratory diseases cause the normal mucociliary clearance mechanism to become impaired resulting in a build-up of mucus which obstructs breathing, and also affects the cough reflex. Mucus build-up can also cause infection, and inflammation, and repeated infections can result in damage to the airways, and the lung tissue.

References

  1. ↑ Moody LE (January 1977). "Primer for pulmonary hygiene". Am J Nurs. 77 (1): 104–6. doi:10.2307/3424229. JSTOR   3424229. PMID   584121.
  2. ↑ Lewis, Brandon; Patial, Sonika (July 2019). "Immunopathology of Airway Surface Liquid Dehydration Disease". Journal of Immunology Research. 2019: 2180409. doi: 10.1155/2019/2180409 . PMC   6664684 . PMID   31396541.
  3. 1 2 Allen GS, Coates NE (November 1996). "Pulmonary contusion: A collective review". The American Surgeon. 62 (11): 895–900. PMID   8895709.
  4. 1 2 3 4 Michaels AJ (January 2004). "Management of post traumatic respiratory failure". Crit Care Clin. 20 (1): 83–99, vi–vii. doi:10.1016/S0749-0704(03)00099-X. PMID   14979331.
  5. ↑ Allen GS, Cox CS (December 1998). "Pulmonary contusion in children: Diagnosis and management". Southern Medical Journal. 91 (12): 1099–1106. doi:10.1097/00007611-199812000-00002. PMID   9853720. S2CID   28583201.
  6. 1 2 Virk A, Wilson WR (2001). "Tracheobronchitis and lower respiratory tract infections". In Wilson WR, Sande MA, Drew L (eds.). Current Diagnosis & Treatment in Infectious Diseases. New York: Lange Medical Books/McGraw-Hill. p. 145. ISBN   0-8385-1494-4 . Retrieved 2008-06-30.
  7. ↑ Goodman G (2007). "Chronic pulmonary disease: Bronchopulmonary dysplasia". In Perkin RM, Swift JD, Dale AN, Anas NG (eds.). Pediatric Hospital Medicine: Textbook of Inpatient Management. Hagerstown, MD: Lippincott Williams & Wilkins. p. 233. ISBN   978-0-7817-7032-3 . Retrieved 2008-06-30.
  8. ↑ Reilley JM, Sicard GA (2001). Rosenthal RA, Zenilman ME, Katlic MR (eds.). Principles and Practice of Geriatric Surgery . Berlin: Springer. pp.  492. ISBN   0-387-98393-7 . Retrieved 2008-07-01. pulmonary toilet pulmonary physiotherapy.
  9. ↑ Galvis AG, Reyes G, Nelson WB (1994). "Bedside management of lung collapse in children on mechanical ventilation: saline lavage--simulated cough technique proves simple, effective". Pediatr Pulmonol. 17 (5): 326–30. doi:10.1002/ppul.1950170510. PMID   8058427. S2CID   28088458.
  10. ↑ Schindler MB (2005). "Treatment of atelectasis: where is the evidence?". Crit Care. 9 (4): 341–2. doi: 10.1186/cc3766 . PMC   1269473 . PMID   16137380.
  11. ↑ Stiller K (2000). "Physiotherapy in intensive care: towards an evidence-based practice". Chest. 118 (6): 1801–13. doi:10.1378/chest.118.6.1801. PMID   11115476.
  12. ↑ Dorland's Medical Dictionary.
  13. ↑ "Hypersensitivity Pneumonitis - Lung and Airway Disorders".
  14. ↑ Sorenson HM, Shelledy DC (2003). "AARC clinical practice guideline. Intermittent positive pressure breathing--2003 revision & update". Respir Care . 48 (5): 540–6. PMID   12778895.
  15. ↑ Miske LJ, Hickey EM, Kolb SM, Weiner DJ, Panitch HB (2004). "Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough". Chest. 125 (4): 1406–12. doi:10.1378/chest.125.4.1406. PMID   15078753.
  16. ↑ Bach JR (1993). "Mechanical insufflation-exsufflation. Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques". Chest. 104 (5): 1553–62. doi:10.1378/chest.104.5.1553. PMID   8222823.
  17. ↑ Finder JD, Birnkrant D, Carl J, Farber HJ, Gozal D, Iannaccone ST, et al. (2004). "Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement". Am J Respir Crit Care Med. 170 (4): 456–65. doi:10.1164/rccm.200307-885ST. PMID   15302625.
  18. ↑ Fauroux B, Guillemot N, Aubertin G, Nathan N, Labit A, Clément A, et al. (2008). "Physiologic benefits of mechanical insufflation-exsufflation in children with neuromuscular diseases". Chest. 133 (1): 161–8. doi:10.1378/chest.07-1615. PMID   18071020.
  19. ↑ Birnkrant DJ, Bushby KM, Amin RS, Bach JR, Benditt JO, Eagle M, et al. (2010). "The respiratory management of patients with duchenne muscular dystrophy: a DMD care considerations working group specialty article". Pediatr Pulmonol. 45 (8): 739–48. doi: 10.1002/ppul.21254 . PMID   20597083. S2CID   26505785.
  20. ↑ Virk and Wilson, p. 153
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