Episode 62: Order of Operations for Optimizing Airway Clearance

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 Talking All Things , Cardiopulm . I am your host , Dr . Rachele Burriesci .

Well , we're coming off a long weekend , a long weekend of travel , celebrating all the things , and , in true Nicki and Ray fashion , we came back and we're like doing the most . So I'll give you a little recap of the past few days and the reason why I'm recording so late in the week I just celebrated my 39th birthday and I usually don't work on my birthday .

It's a rule . It's just something I've done since really becoming a PT . I think I did it once and I was like this is awful . We're never doing this again . And since I've been with Nicki , it's usually a weekend that we go away .

So we didn't have anything big planned this year and we got a call about four weeks ago from a friend in Michigan who sort of impromptu got engaged and is getting married relatively quickly because her family is from England , so they were going to be in town . They were trying to make the most of it , and so we were invited .

And weekends are really hard for me right now , but it just happened that I had the weekend open and we decided to drive up to Michigan to celebrate . So long drive . We've done this drive Probably we're trying to figure it out . I think we've done the drive two times , maybe three times .

We drove down a U-Haul , we drove down our car , we drove down a U-Haul , we drove down our car . So we've done it and I feel like in my mind it's about 10 hours , 10 to 11 with stops . So we're looking it up , it's like 10 and a half to 11 and a half , pending the route you take .

And I have a rule when we're on road trips that we go four hours and four hour chunks at a time . So that's always the goal . We hour chunks at a time , so that's always the goal . We don't always hit it , but that's usually when we need gas and makes the most out of these long road trips .

So at about 30 minutes per stop , I figured at most we'd be somewhere around the 12 hour mark . Well , I don't know what happened on the way up to Michigan , but we hit a time warp . Well , I don't know what happened on the way up to Michigan , but we hit a time warp and I don't know . We lost about four hours of time somewhere .

We were on the second leg . We should have made it to , like Kalamazoo , michigan , at the four hour mark . We were right around three and I was just like looking around , I was like I don't think we're even remotely close to the Michigan border and we looked and we had like another three and a half hours to go .

We had not hit traffic up until like this moment when we start checking , I'm like I don't even understand . We had one more hour to get to Kalamazoo , but now we had three and a half hours to go . It was a long trip . I have no idea what happened .

I think somewhere between Illinois and Indiana there was a time warp that we hit and we just like lost four hours of time . Time warp that we hit and we just like lost four hours of time . And then we hit the East Coast time change and we didn't roll up to our Airbnb till almost 12 o'clock .

So going there was a little bit of a a little bit of a trip coming back .

We hit it in our normal time I think it took us about 11 and a half hours and we stopped for a pretty decent lunch , met a colleague that we met through Instagram and our business world , and it was just an awesome stopping point , so celebrated this wonderful wedding , happened to have a birthday on this weekend and it was just really a really good few days

when we came back . We've had some projects that we're trying to finish up specifically outdoors , but it's been such a rainy season that we can't we literally can't get anything done outside . It's either . It was cold pretty much until April and it started raining for like a month and a half straight and as soon as we got back , it's been like hot .

So there again , no in between got most of my plants in the garden right before I left and some of them like just cringed up . So we have this . We have two big projects left outside . I think I was talking about this last week . One project is very big . We've been putting it off . It's in a weird spot .

We're going to do another paver patio , but our yard has such a harsh pitch that when we did our concrete patio . It was just like I don't know .

We have like this 10 inch decline basically , and it's just a little bit of a weird spot with like sprinkler lines and pitch and there's a a sidewalk that has a pitch to it too , and so you know Nikki's worried that it's going to look lopsided . It's a valid concern . So she's learning how to make a wall for like a bench seat whole , like all the things .

Needless to say , we haven't even started this project yet . We've had pavers in the front of our house for about a year now , literally . I think we just this would be about a year when we had our delivery and I am ready to be done with the project and I would be ready , I'm ready to be done with the papers in the front of the house .

So that's a little bit more of a planned process , like we can't just like jump in and do it . Nikki's always researching different products that we can use , so she found something that should help stabilize the base a little bit better . So that's now officially ordered , so we can't do anything with it .

But by my garden beds we did a paver edging when we first moved in , kind of just went for it and it's done well , considerably , but it's kind of sunk in a little bit and we're putting new fences in that area , and so it's just the time to take it up .

Well , if we take it up , nikki's add-on project is extending the gutters out into the yard to get it away from the like the water , away from the foundation , and so now this project that I was like oh yeah , we can get it done in a day , is turned into two plus days now . So this is like what we do . We are all in and we cannot half-ass anything .

We have two genes that we both have . Gene number one is that can't be too hard , we can do that , and then gene number two is literally not being able to just let it be . We are has to be done right , has to be done the right way , don't half-ass it . We want it to look good , and so when we do something , we literally are going to do the most .

So not always a good combination , because now you have two of those people kind of leading the way .

So anyway , backyard's a hot mess , trying to pray that the rain gets pushed off for tonight and maybe we can actually finish the project this evening , and then that would be a wonderful end , because we're going to have another , I think , week of rain before we get a break Any whoozles . That's the update , officially 39, .

Just came back from Michigan , drove for about like 30 hours , a short span of time , and then came back and tackled this gigantic yard project . We literally have something wrong with . We have something wrong , it is for sure . All right , so my goal for today was to talk about the order of operations for airway clearance .

This is a great conversation for both the student and the clinician One , because it's a question that can be asked in like an NPTE type situation , or maybe even like a CCS type situation , but also as a clinician just understanding how to proceed accordingly .

So the first thing I want to kind of put out there , which is like the obvious , logical conversation , is that if you are planning on doing airway clearance , your patient , your client , should have mucus period . If your patient does not have mucus , continue on and do not do anything else that we're talking about Now .

This is a really important piece , because just because you have a cough does not mean you have mucus . So this is where your assessment techniques are really important , as well as taking good history and getting the clear picture .

Because if a person has a dry , irritating cough , potentially from , let's say , pulmonary edema , and they have fluid in their alveoli , you're not doing airway clearance to clear that cough . If your patient has pulmonary pleural effusion , they may also have a cough .

They may not , but if they do , you also want to really be careful with this patient population and some of these airway clearance techniques , even if they have maybe an overlapping mucus situation . So you have to do a really good assessment . Number one make sure you're auscultating .

Determine if we actually have bronchi or core squeezes versus something like have bronchi or coarse wheezes versus something like crackles . You want to assess the cough , you want to listen to it . It should sound wet and congested and potentially have mucus production . You should ask the question about do you bring up mucus with that cough ?

That is a really important piece because if the patient never is bringing up mucus , then there might be a different underlying pathophysiologic process going on rather than mucus . So if we're thinking about airway clearance , we're really thinking about our patients that have chronic bronchitis , cystic fibrosis , bronchiectasis , bacterial pneumonia , mucus , airway clearance period .

Okay , you're assessing that cough not only because you want to hear it , but because you want to assess the phases and potentially make them more efficient with their cough process .

That is part of airway clearance techniques and you definitely want to know if there is a history of heart failure , specifically left side heart failure , if they have any orthopnea or you know shortness of breath while they're laying flat , or if they have a wet cough that's never productive , or if they have known pulmonary edema , pleural effusion , because that is

not the patient population that this is for . So it is equally important to know who it is for and who it is not . The other person or patient I want to talk about just briefly before going any further in the order of operations is someone who has potentially asthma , someone who has bronchoconstriction .

If you are paying attention to their cough and it is high and tight and it sounds almost painful , it sounds almost wheezy , you have to really tread lightly because a lot of the airway clearance techniques can irritate those lungs more and cause further bronchoconstriction .

So really important , if your person's cough is high and tight , that you're asking good questions . You're learning , if they're on any sort of bronchodilators , what their normal regimen is , and then this is a little bit different if they're in the hospital setting versus like in home health or private sector or like outpatient .

So really important for you to know that . Also , knowing that if your person has mucus for some reason , maybe they have bronchitis and they are asthmatic , right . So two things that are causing one thing that's causing mucus , one thing that's causing constriction .

You still have to tread lightly in assisting this person to clear their mucus Because , again , you really don't want to do a ton of airway clearance with someone whose lungs are bronchoconstricted or just tight . Okay , you're going to cause more irritation , probably not move that mucus and potentially worsen the shortness of breath .

So super important to kind of tease that out . But in the world of order of operations , if you are working with someone , I'll keep like the big mucus patients in the forefront cystic fibrosis , chronic bronchitis , bronchiectasis , bronchitis , bronchiectasis , bacterial pneumonia , probably like top four mucus producers .

You want to have a order of operations and how to proceed with airway clearance . Number one you make them cough . This is super important for a number of reasons .

The first time you're seeing them , you're assessing that cough and you're giving no cues except show me how you clear your mucus , or show me how you clear your mucus , or show me how you clear your secretions and then you're paying attention to those four phases but also teaching .

Airway clearance is partly having an effective cough and you can clear up to about six to seven generations of bronchioles with just one cough . So if you're able to clear your secretions effectively , you may choose not to do other airway clearance techniques for whatever reason . So always start with a cough . Can they clear it without any ?

You know added assistance , you know added assistance . Number two breathing exercises . Breathing exercises can be very powerful in helping move mucus . There are different breathing exercise techniques that you can use specifically for airway clearance . I like to use inspiratory holds as part of my kind of repertoire . It's kind of like my go-to .

I've talked about inspiratory holds a lot because it kind of helps prepare the cough right . An inspiratory hold excuse me , an inspiratory hold allows the person to inhale . They have a purposeful hold and then they're exhaling that air . On the whole they're practicing glottal closure and purposeful hold and then they're exhaling that air On the hold .

They're practicing glottal closure and on that hold you're getting improved alveolar ventilation . Essentially You're allowing air to push further down , potentially get behind that mucus , and a lot of times an inspiratory hold will cause a cough . It's the first time anyone's ever done a breathing exercise and they have mucus .

Of times an inspiratory hold will cause a cough . It's the first time anyone's ever done a breathing exercise and they have mucus . You make an inspiratory hold , it is likely that will trigger a cough . So really beneficial for a number of different ways , number of different reasons .

There are other types of breathing exercises as well . There are things like active cycle of breathing or autogenic drainage . Usually and I think I've spoken about this before clinicians like one or the other you like . You figure out which one works best for you or your patient . Sometimes you can try both with a client and see what they like better .

There's some differences between instructions , but they have the same general idea , which is you're going to use different levels of tidal volume to essentially milk the airways to produce a cough , and then there's usually a huff cough or a functional cough at the end of the technique . I want to put one piece of information on that .

If you're doing active cycle of breathing or autogenic drainage , it's important to really pay attention to how your patient responds . I find that this is a great technique , or techniques for patients with bronchiectasis or cystic real thick , sticky , copious mucus producers .

Also , you have to be a little careful with the patients that have that more bronchoconstrictive sort of underlying base . I find that these techniques can cause a little bit more irritation in that patient population , myself included .

So I'm always just a little bit careful when I try autogenic drainage or active cycle of breathing , how the patient is feeling during those techniques and then kind of proceed from there .

You can use things like stacked breathing , right , stacked breathing is the cousin of the inspiratory hold , super effective , especially if your patient has something like sternal precautions . But goal is to increase that tidal volume . Get that hold .

So you're not only practicing that glottal closure but you're pushing air further down , kind of using the idea of the pores of Cohn channel , of Lambert , providing more alveolar ventilation around potential mucus plugging . So can be very helpful , right ? So you want to encourage breathing exercises in the mix of airway clerics ?

Then you might try something like postural drainage , and so postural drainage should be utilized specific to where the mucus is located .

So there are a number of different positions that you're going to potentially use , and the idea of postural drainage is that you're trying to tilt , the segment , the lobe , in a direction to use gravity to allow that airway to drain out . So essentially , if you have mucus in your lower lobes , you're going to likely be in a head down position .

If you have mucus in the upper lobes , you're probably in more of like a semi-fowler type position . If you have mucus on the right side , you're going to be in left side lying . If you have mucus on the left side you're going to be in something like a right side lying position .

Each lobe has a very specific position with a very specific head down or feet up tilt .

So if you are using postural drainage or you're new to postural drainage , I highly recommend that you look at these positions , maybe even keep a copy on you , especially if it's new , and place the patient in the most appropriate position for where the mucus is located right . So it comes back to assessment again . You have to be assessing these patients .

You may know from the chart like maybe they have right lower lobe bacterial pneumonia , they have consolidation in their right lower lobe . Then you would place that patient in a position to help gravity move that mucus .

So typically when we are utilizing postural drainage type positions , you want to make sure that you are maintaining that position for about five to 10 minutes to allow gravity to do its job right . That's the whole idea is you're just letting gravity pull that mucus towards the trachea .

So wherever the lobe is located or the segment that has the secretions , you're tilting it so that we are draining it towards the trachea or the carina right . And five to 10 minutes is the goal . So really important for you to A have the time to do that , but utilizing the position . So research supports airway clearance techniques .

Research supports postural drainage positions . Research supports other types of airway clearance techniques . Typically , when you're looking at the research , if a person or if you're trialing postural drainage and you combine it with fill in the blank , it tends to be more successful .

So if you're able to utilize a postural drainage position , it is very helpful or beneficial to then include something like percussion , vibration , shaking , maybe even using a pep device , maybe trying your active cycle of breathing or your autogenic drainage or your breathing exercises in this position . So combining therapies or interventions can be very beneficial .

When you are considering true postural drainage positions , then you really need to consider precautions and contraindications . Now the way I mean there's a ton of different . There's a long list for both . The way I usually teeter precautions versus contraindications is precautions ? Is a risk-benefit ratio right ? Does the risk outweigh the benefit ?

Does the risk outweigh the benefit ? Does the benefit outweigh the risk ? And it's still typically a conversation maybe with the physicians about their train of thought on , say , the position For postural drainage . Things like obesity are considered a precaution .

If you are in a head down position , if someone is obese or has an obese abdomen , that abdomen is then going to put pressure on the diaphragm , increasing the work of breathing . So if your patient already has increased work of breathing , this is a precaution . This is a definite pay attention . Your person may not tolerate five to 10 minutes in this position .

If the benefits outweigh the risk , this is one that I would push for . Pulmonary edema and pleural effusion are listed as precautions For me . I am typically not doing postural drainage type positions with patients that have pulmonary edema or pleural effusions , unless they also have a huge mucus component , and then it's still a .

Very well , how do they feel , even in the supine position ?

This is likely someone that you're going to modify the position just slightly to make sure that you're not causing worsening symptoms , because if you have someone who has a large pleural effusion , they're likely going to be short of breath in supine position , then the head down position , you're essentially flooding that lung .

Is the risk going to outweigh that benefit ? In my opinion probably not . But this would have to be , again , in my opinion , a conversation with physicians talking about . You know , you know which problem over overrides the other .

So , although it's listed as a precaution , if that is the only issue that your person has , you're not doing this anyway and that's why I made that a point right at the beginning . Ascites is also on the list of precautions and that to me that follows the same rule of thumb as the obese abdomen , because that's going to place pressure on the diaphragm .

But if you have ascites you might also have something like pulmonary edema , pleural effusion , and then again you're just kind of flooding that area . And then hemoptysis is listed as a precaution . This is one of those questions where I have more questions what's causing the hemoptysis ?

If the person has hemoptysis , then maybe using a postural drainage position would be beneficial over trying to do something like percussion , vibration , because that's a bigger problem with hemoptysis . So it's a maybe right . Precautions are . It's a precaution , it's like a yellow flag for me . You're probably not going to do it .

Risk benefit ratio conversation and then you want to do what's best for your patient . Relative contraindications to me again , is the same thing . From a verbiage perspective , I feel like we've moved away from like true contraindications and relative contraindication kind of gives you a little bit of wiggle room for that risk benefit ratio conversation .

But for me , most of the things on this list are a hard no , which would be like true contraindication and you'd have to have a really good reason to override it or modify , and I think that has to always kind of be a piece right .

So , especially if you're taking a test like MPT or CCS and there's a question about postural drainage positions and there's one of these precautions or contraindications on the list , is there an option to modify the position ? And when you're modifying a postural drainage position , essentially what you're doing is taking them out of that head down position .

Okay , so on the list for contraindications for this are increased intracranial pressure . So head down position is going to worsen intracranial pressure . So head down position is going to worsen intracranial pressure . I am not messing with ICP . No postural drainage for me . I'm going to skip the ones that I could maybe have a conversation for Recent head trauma .

Same thing If you have a TBI , you have inflammation in the brain . Head down position is going to increase that pressure . That would have to be a really strong conversation to make that change . Diaphragmatic hernia and recent eye surgery .

I think recent eye surgery I feel like I recently had this conversation Recent eye surgery kind of goes under the radar quite a bit . I will not lie .

I've had a few patients come in and kind of just like you know , glaze over the fact that they just had surgery for , like glaucoma or something and this happened in I believe it was cardiac rehab or pulmonary rehab and just came in like it was another day . No you know , question about it . I was like wait , wait , wait , hold on .

Typically after eye surgery there are precautions and doing anything in a head down position is a no for me because you're going to increase pressure to the eyes , potentially increase literally pressure in the eye . I'm good , we're not doing any of that . So just kind of don't let that one fly under the radar .

I have had patients try to kind of like you know , no big deal , just had some cataract surgery , no bigs Like hold on , wait a second , that's surgery all up in here and typically they have lifting , lifting precautions . They might have a blood pressure precaution and I am not doing anything head down position that's going to increase pressure to those eyes .

Ones that I can maybe you know could could use that word relative are hemodynamically unstable . So your patient may be hemodynamically unstable because maybe their SATs are low , maybe their SATs are low because they have mucus plugging . I can have that conversation that we could maybe try , maybe try modified position first .

But you have to be careful when it comes in the world of like blood pressure , in the world of hemodynamic unstable , high or low , right . So you just kind of want to , you know , toe that line , have conversations before you try anything like this . For me it would be more leaning . No , I'm in esophageal anastomosis type surgery . Same thing .

You're increasing the pressure and if you're doing , if you have that as well , I would be very cautious about doing anything else like percussion , vibration and shaking , and I would even ask about concerns for aggressively coughing , because a lot of times that can cause , you know , potential issues .

So you have quite a few contraindications and precautions for postural drainage . Like I said , typically you want to keep them in this position for five to 10 minutes to get most benefit .

And then research supports that if you're in a postural drainage position , that you're utilizing another technique percussion , vibration , shaking that more manual type loosening of the secretions , if your person has cystic fibrosis and they do vest therapy , which is a vest like a pneumatic compressive device in a vest form , this would be a great time to wear the vest

and be in a postural drainage position . If you utilize something like an acapella or a flutter or the vibra pep , this would be a good time to utilize a pep device . The one thing I will say about pep devices is some of them are they have to be used in an upright position .

So if flutter is what's coming to my mind , they have to be sitting upright in order to use that . So they might not be able to utilize the postural drainage and PEP device in that situation , but that combo technique can be really effective .

And then , when you come out of that postural drainage position , it's important for you to assess vitals and to then have the patient cough .

Now , one thing you might not know is that anytime that you're doing breathing exercises , airway clearance techniques specifically like postural drainage or autogenic drainage or active cycle of breathing , it can take up to an hour for those secretions to start to move .

So you want to make sure that you're not planning on doing these techniques right before bedtime , and also not a great idea to do right before eating or right after eating . So you really want to time when you would perform these types of techniques .

Now , the other piece of order of operations is not just , you know , cough breathe , postural drainage and then manual techniques . Comboed with it can also mean what would be the best time to optimize airway clearance techniques , and for this I'm talking more about the patient who is in the hospital type setting .

So if you have someone who is maybe on an antibiotic , someone who is on bronchodilator , nebulizer type treatments , those will be the two that I'll use . And they are maybe like I said . You see them and their cough is high and tight or they are having high pitched wheezes .

On auscultation , there is an order of operations to when you could plan and coordinate with RT .

So this is a really I know I say these things kind of repetitively , but it's really important to create these relationships because you will be able to maximize your patient more beneficially if you have relationships in the works or you know you can coordinate with your interdisciplinary team . So let's keep the cystic patient with cystic fibrosis on .

You know the list . Maybe they're here for an exacerbation . They have a new active infection , they have increased mucus production and they are also a little bit wheezy , so they have high-pitched bronchospasm .

If you were planning on seeing this patient and in your treatment plan was to do something like airway clearance , there's another set of order of operations that should kind of be worked in . So if you were , maybe you came to see the person and you can audibly hear them wheezing or you hear their cough and it's high and tight .

This would not be a good time to do airway clearance .

So best practice would be to have their nebulizer bronchodilator treatment , then after , let's say , 15 to 20 minutes letting that kind of do its job , then coming in and following those order of operations , breathing exercises , maybe postural drainage techniques , maybe something in the manual department like percussion or vibration or maybe even vest therapy , then coordinating

getting the antibiotic , likely again through nebulizer post that session , so they would get nebulizer for bronchodilator .

First open the airways , allow breathing exercises to actually work , allow movement of mucus to come out of those airways and then , once you've cleared a whole bunch of secretions , when you're done , maybe now exercising and such then plan for them to have their antibiotics on nebulizer because they're going to get the most bang for their buck .

Why Bronchodilator first opens the airways , allows things to move in and out , clear the secretions , you move the junk out of the lungs and then when they go to use their antibiotic , they're actually able to absorb that medication into the bronchioles more effectively and then actually be able to benefit from that medication as well . So this can be timing right .

Timing with your RT staff , maybe timing with your nursing staff If the patient is home . Timing with them right . Say you're in home health and there's a patient with cystic fibrosis , you have them do their bronchodilator and nebulizer .

First you come and do your session and then after you leave , maybe they're doing another set of nebulizers and maybe that's an antibiotic , for instance . So no matter how you look at it , whatever setting you're in , you can play a role in coordinating this to have the most benefit for your patient .

So just to recap , if we're talking about order of operations , if your patient has a bronchodilator and they're , especially if they're wheezy they should take that prior to your session for both an airway clearance , breathing exercise and exercise purpose . They're going to do better . Then you're going to start with hey , can they cough ?

Can they clear anything on their own ? No , then you're going to work in some breathing exercises , maybe move into postural drainage position and then combination percussion or vibration , shaking , vest therapy , pep device whichever your or your patient's going to maximize the best . Then , after you , clear your secretions that would be the best time to exercise .

Clear your secretions , that would be the best time to exercise . So if you have aerobic training or strengthening on the list for your interventions , it should come after airway clearance , because now they should be oxygenating better .

They have they literally removed the junk from their lungs and so you want to make sure that they are indeed having an improved SpO2 , maybe on auscultation you can hear more breath sounds and then , when you're done with your session , if they have an antibiotic on board , specifically one of a nebulizer type , they would finish with that .

The one piece I didn't say , but I just want to throw it in here , is when you're in something like a postural drainage position , when you're utilizing something like percussion or vibration , you should be watching your patient , seeing what their facial expressions look like . Are they in pain , are they short of breath , are they becoming cyanotic ?

You should also be monitoring SpO2 throughout , and a drop in 4% on your SpO2 is considered a positive finding in the sense that it is not a good finding , right ?

So you don't want to be dropping your SpO2 and at 4% is considered significant to either stop your intervention , change your position and , you know , pay attention to where you are on that range if that person did need oxygen or something like that . So make sure you're monitoring , watch your facial expressions .

If you're doing something like percussion , especially if you're working with older patients that you are utilizing like a pillowcase , fold it a few times for padding to make sure that we're not getting over bone or anything like that .

And so you just want to make sure that you're not only optimizing air movement and mucus clearance , but also safety and comfort of your patient . All right , so I hope that was helpful . I wanted to talk a little bit about order of operations . I kind of hit it from two different angles .

If you have any questions about you know this procedure or how to utilize it in practice , please reach out . If this is something that you're interested in learning more and you want to set up a one-on-one mentor call . I will drop that link below . But I hope you all have a wonderful day and whatever you have to do , get after it .