Episode 46: Airway Clearance - Who's Responsibility is it?

The goal is to learn , inspire and bring cardiopulm to the forefront of conversation . Thanks for joining me today and let's get after it . Hello , hello and welcome to today's episode of Talking All Things , Cardiopulm . I am your host , Dr . Rachele Burriesci . Our episode today is sponsored by Jane , an all-in-one practice management software .

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Your team would love to connect with you to see how Jane could help you and your practice . You can also use the code CARDIOPULM1MO at the time of sign- up for a one-month grace period applied to your new account . Thanks again , Jane . All right , welcome . Happy Wednesday . I'm a little bit late recording this week and this is officially my fourth attempt .

So first of all , I am in my dining room , so welcome to the dining area . This is actually one of my favorite rooms in the house , probably the most decorated room in the house . As you know , we're pretty DIY oriented around here .

So when we finally got through most of the painting , like on the first floor , we still have quite a bit of decorating to do because we still have to do the popcorn ceilings down here . But some things behind me . If you're on YouTube , I gotta get my pointing right . This wine rack here we actually made in Ypsilanti in our apartment .

So picture the two of us sawing through wood literally in the middle of our living room on carpet , and then we stained it on a tarp and I just remember praying that the stain wouldn't seep through and the tarp was going to do exactly what it was supposed to and thankfully it did .

So we actually have matching one on the other side , but it's one of my favorite pieces that we've made . It's a little bit rustic , a little bit industrial , a little bit modern , kind of our MO . And then this window behind me is actually from Nakey's aunt's house . I love the look of a window .

Actually I have a couple of more that I'm going to paint and potentially turn into like a frame , so we'll see kind of where that goes . And then right behind me it's hard to point on this thing is my grandmother's tea set , so apparently silver tarnishes .

I want to oxidize it with oxygen and create this like rainbow greenish color , so I could polish it , but I kind of really like the tarnish look , so we're just going to keep it as is . So . Welcome to my dining room . We are in a different location today because Nicki is quarantined downstairs and we're doing our best to keep the COVID out .

So I'll probably do an episode on that . But first I have to make it out unscathed , and I wasn't even going to talk about it because I'm just trying to not put any of it in the universe . So just keep the good juju coming for me . But I had some issues with my mic .

I tried to use my portable mic this morning and it just sounded too tinny and echo-y , so I have my normal-ish setup now . As you start doing podcasting for a while , your ear starts to get used to a certain sound and when you're listening to a podcast and it's super echo-y and it just sometimes is uncomfortable to listen to if the sound isn't right .

So hopefully the sound is coming okay on your end and so we're going to kind of jump in today . So what I wanted to talk about today was actually about a conversation that I was having on Twitter . So , Shelby , if you're listening , thank you for this idea .

I think it's an important piece of information to kind of chat about and it's something that I do get asked quite a bit . So this is a great conversation point . The question is pointed at acute care PT's and basically asking who's in charge of administering chest PT the PT , the RT , both or just no chest PT .

So I think there's a lot of semantics and there's like underlying questions within this question . So I'll answer the first question , just the if we're black and white and being literal , who's responsibility or who should be administering chest PT ? The answer is both . Both PT's and RT's should be providing chest PT If the patient requires that intervention .

Overlap is going to give the patient the most bang for their buck . It's going to give them the best outcome because it is something that , if they're making a lot of mucus , it's something that they should be doing multiple times a day and on either front PT or RT .

The likelihood that you're going to have the time to perform chest PT three times a day is probably not likely . So I'm going to talk about chest PT a little bit . There's a little nuance in chest PT . I don't love the terminology because it's kind of a vague word and if you kind of you know you want to be a little bit about it , the word PT isn't it ?

So when other people doing chest PT , I'm just like it doesn't truly make sense . But what is chest PT ? Chest PT typically is talking about a specific intervention which includes percussion and vibration or shaking . You know , if you really want to get technical , that's typically what people mean when they say chest PT .

I like the bigger word of airway clearance techniques , because there are more things that you can do with a patient and not everyone benefits from chest PT . Not everyone enjoys the physical percussion , vibration . Some people actually do better with breathing exercises that can help promote coughing . So it just kind of depends .

So let's kind of talk about the underlying layers of this question . When I read this question I'm automatically thinking and this is me reading into things , there's another question here . So a question that I do get that's black and white is can PTs perform percussion , vibration , shaking ?

The answer is typically yes , but there's , like you know , we gotta dive into it a little bit . So it's very location based . So always check your state's practice act first , just to ensure that it is in your scope of practice . That's step one . In both Missouri and Kansas , because we share a state line , I'm licensed on both sides of that state line .

The verbiage is something along the lines of in interventions , physical therapists can perform airway clearance techniques . Does it describe exactly which ones ? No , so it kind of keeps that broadness , vagueness open , which is nice . Other states might explicitly say no . I haven't come across a specific practice act that says absolutely not .

But if you are in a state where , as PTs , you're not allowed to tie , trade oxygen or you're not supposed to be doing airway clearance techniques and you have that verbiage , please share it with me because I would like to see how that's written .

So first of all , check your practice act , because it depends where you are , and then it really comes down to culture , and culture is a big thing , right ? It's not just culture in the hospital , it can be culture in your PT department . So what is the culture of your PT department ? What is the culture of your PT ?

What are your PT's doing for intervention with these patients ? Are your PT's doing breathing exercises , airway clearance techniques ? Are they checking vitals ? If the answer is no , that's probably where you need to start Meaning .

Maybe we need to do some in-services for our own department about the benefits of breathing exercises , airway clearance techniques and I am gonna throw vital signs in there , because it is paramount to helping patients improve , especially in the acute care setting .

If you're the first person who is starting to do these interventions , I'm just gonna be very honest with you . It's going to take time . From experience , culture is probably the hardest thing to change . So proceed with caution , proceed with confidence , articulate benefits and understand that change takes time .

Now , if your PT department is already on board they're already doing these things then it's easier . Then the question is most likely and this is my question Is there a turf battle happening ? Is there boundaries between PT and RT that have been established as uncomfortable ? That's also culture , right .

So that's gonna take time to kind of break down walls and create relationships and communication . But if you listen to this podcast and you have listened to other episodes , I say this a lot it is really important to create relationships on an interdisciplinary front .

Because of this reason , right , you have to establish rapport with your colleagues about the things that you can do . We've talked about culture and the words of acute care . Like you just walk patients , those things exist , those stereotypes . Stereotypes can exist because that might be what's happening or what they're seeing . So how do you change that ?

You change that by having conversations . Discuss your patients with your nurse , your RT , your MDs . Have conversations , articulate your concerns , articulate your relationships or concern , articulate the things that you think should be included in their plan of care . That's where it starts . It starts at creating a relationship .

I will tell you that even when I was in a residency program for Cardiopulm , I learned so much from my RTs and it was very casual . It wasn't like I was going in with this , like list of things that I wanted to learn or demands of what I wanted to see happen . It kind of just happened .

Right , you're working with a patient , with a vent , the RT is definitely going to be around . You start having conversations with the RT about the vent . I learned a ton about vent settings from my RT . I learned how to suction from my mentors in the Cardio Paul residency .

But I also learned tips and tricks from my RTs , because while they were in the room suctioning I would ask questions , I would inquire . Relationship building relationships , communication , in my opinion , are always better when it's organic and when there's no expectation deemed after that .

Right , like I'm going to do this for you , so I expect you to do this for me . No , you create relationships . You show them who you are , you show them what you're capable of doing . You build rapport .

It takes time and so that can sometimes be frustrating when you're trying to get things done or you're trying to make a change , because change takes time and it takes a ton of patience .

And if culture is already in existence and I'm saying culture kind of in a negative connotation if there's already existing culture , if there is turf , war type stuff or like weird relationships that are in existence between departments , it's going to take longer .

So I want to kind of blanket statement that If your PT department doesn't currently practice airway clearance techniques , then in-service is a good start . Collaboration is a good start , where you could create an in-service where the PT does a piece of that in-service and the RT does another piece of that in-service .

Obviously , having conversations with your supervisor is a good opening piece and also see where they're at , because if your supervisor isn't on board it's going to be even more difficult . It's not impossible , but it's going to be . It might feel like an uphill challenge If we're talking about solely breathing exercises , solely percussion , vibration , manually .

Those are things I think are easier to start right . Having conversations , first of all . Are you comfortable with these techniques ? Did you learn them in school ? Did you take a continuing ed course ? Where are your skill sets coming from ? Then talk about it with your staff . Now , if we have to deal with other disciplines , it's time to have some conversations .

It can start very casually . For instance , who does what and how they do ? It can be different . For instance , a lot of RTs in different hospital settings might have productivity standards as well , or maybe their main focus are breathing treatments .

If you have to do 30 breathing treatments in a day and you're one of four , maybe you don't have time to do percussion vibration with a percusser or manually , just even learning their I don't want to say priorities . But what are the main interventions that they're providing to their patients ?

Because it might very much be different for any , like the needs of the person , which I would assume .

But , for instance , if your RTs are only doing breathing exercises , well then that leaves conversation to be had about doing more manual type interventions , whether it's a collaboration , whether it's like , hey , I'm going to see the patient in the morning and I'm going to do these three things .

So if you're planning on also doing percussion , maybe you can plan for the afternoon whatever the you know , whatever is going to maximize that patient's outcome . And I think when having these conversations , that's the piece you have to focus on the patient , because it becomes less about what can a PT do , what can an RT do ?

Because it can feel like , you know , a little confrontational From a blanket black and white . For the most part , pts can do airway clearance techniques , which include percussion , vibration and even suctioning , and so can RTs . Let's talk about suctioning , because I brought it up last week with tracheostomy .

Suctioning is a high-level skill and if you are not already doing that in your department , then that would be a conversation before you suctioned your first patient , even if you have skill and ability to already do that and knowledge okay , because suctioning is something that can lead to potentially a decline desaturation If you don't know what you're doing , you could

potentially hurt the patient . So there's some specifics about that . If suctioning is something you want to learn how to do and PTs aren't currently doing that , this could be a great way to start collaborating with RT . Rt or the RT department could potentially do the training to teach the PTs how to suction . So now we're communicating between two disciplines , right ?

It's not just that I can do this , I'm allowed to do this , it's hey , this is something I would really love to learn .

I think it could maximize my time with the patient and also not have to have you on standby if I'm mobilizing the patient , because I know that when I am doing these things , the patient is going to need to be suctioned and it would be more beneficial for both of us if I could provide suctioning during my session , then have to rely on the nurse or the RT

coming in , and then I would highly recommend creating a competency Meaning if you're on a floor that has patients who are on vents , who have trachs who require suctioning , that before you treat these patients you have to pass your competency and that might look

different everywhere . Right , it might be a competency that you perform with RTs initially , and then maybe there's peer-to-peer training so that there's like a head PT that does the training eventually and then you're passing the competency with that person before going out and doing on your own . There are lots of great ways to learn skills like this .

Simulation labs are like super popular right now , but they're not always available in hospital settings . They're becoming more available in academic settings . But some form of practice where you can practice hands on skills In the residency .

When I was a mentor , I actually created a mock tracheo with a trach and then you could practice with either the inline suctioning or the red robin so that you can start to get some of the hands-on skills .

If you've ever learned a new skill period , you know there's a little bit fumbling and then when you're doing something that can potentially desaturate a patient , there's going to be a little bit of that higher stress feeling .

So you want to kind of get some of those kinks out before you practice on a human and then you should be observing your mentor doing it on a person first . Then when you perform it for real , that mentor should be with you the first time , right ? So that there's this learning experience , there's mentoring , there's definite that this is going to go okay .

And then it's true for percussion , percussion , vibration can lead to desaturation . You need to understand what contraindications do exist , like when you should and should not perform percussioning If you're doing it with your hands versus an actual percussor .

Knowing how that feels , how to use the device , knowing that if you have a more frail patient , that we should be covering over bony prominences .

We shouldn't be going over bony prominences , but we should be covering anyway , right , because if we're on the anterior wall and you're over ribs and if you have a very kiketic patient , those ribs are very prominent and can be uncomfortable .

Same true for the spine area , right , avoiding the spine , avoiding the scapula and actually performing it on your mentor so they can give you feedback . And then , when you perform it on a patient , having your mentor there observing your mentor performing these things on a patient , and then this is always a great learning experience .

Your mentor performs percussion , vibration , whatever , then you perform it on the same patient and then the patient can give you the feedback to what it feels like . Is it strong enough , is it too light , is it too aggressive ? What have you ?

But when you are doing skills that you are new to or you're trying to implement for the first time , this is what it could look like . So airway clearance techniques , percussion , vibration , shaking , suctioning those things can be so beneficial for your patient . They are skills that you , as a PT , may have learned in your program , your PT program .

They're skills that you may have learned in a residency . They're skills that you may have learned in a CEU course . Yes , you should be able to utilize those skills with your patient and that will help your patient's outcomes .

But culture in a hospital plays a role , whether we like it or not , and if we're going to start implementing these techniques and you're the first person to do it , then it's a different conversation . It's a PT department conversation , then it's a collaboration conversation . Is it possible ?

Yes , my black and white answer is both PT and RT should be performing airway clearance techniques for their patients . I think how you word questions can kind of dictate what's the right way to say this , how you word questions can give multiple types of answers or have people read into them a certain way .

If you were to ask me well , who's responsible for doing chest PT tone can play a role in that . Obviously , you don't get that when you're on text , but sometimes that could kind of feel like blame . Well , rt should be doing this three times a day or PT should be doing this three times a day ?

That's where I would say it really should rely on both and there should be collaboration and conversation , because that patient's going to get more overlap if both disciplines are providing skilled intervention related to breathing and airway clearance techniques period . End of story . If you are the first person to go and do this , it can be done .

It will take time . Stay confident , keep pushing , but understand that building rapport and trust is going to be part of that process and probably a bigger part than maybe we realized in the beginning . So collaborations key . Communications , key . Changing culture takes time . So I think this was a great question . Thank you so much , shelby , for posing it .

I would love to see more PTs doing more breathing and airway clearance techniques on a daily basis in multiple settings , not just acute care , and so I hope that some of these conversations can start broaching that barrier . Okay , I think that's all I have for today .

If you have any questions about breathing airway clearance techniques , if there's specific things you want to hear about , I would love to discuss these further . If you have any ideas for specific podcast cases or specific podcast topics , please let me know . Reach out on Instagram or via text . My information is in the show notes and that's it .

That's all I have , so I hope you all have a wonderful day and whatever you have to do a year after .