Airway Clearance Therapy
Jacob Lee
Definition
- A variety of noninvasive techniques designed to mobilize and remove secretions to improve gas exchange and work of breathing (American Association for Respiratory Care)
- By expelling mucous and secretions, airway clearance therapy (ACT) aims to decrease airway inflammation, prevent obstruction and subsequent atelectasis and infection and thereby improve gas exchange and respiratory symptoms
- All ACTs aim to make cough more productive
Uses
In general, ACT is used for pathologies that cause retained secretions, mucous plugging due to overproduction or impaired mucociliary clearance Indications
- Cystic fibrosis, non-CF bronchiectasis, COPD with chronic sputum production or recurrent infections, recurrent aspiration/aspiration pneumonia, neuromuscular diseases involving the respiratory muscles, prolonged ventilator-dependence/ventilator weaning
Contraindications
- Hemodynamically unstable, hemoptysis, PTX, recent lung surgery or trauma
Components
Therapy |
Description |
Order Set |
Comments |
|---|---|---|---|
| Chest Physiotherapy (CPT) | Patient assumes sequence of positions aimed at “draining” each of the lobes of the lung by gravity. Usually combined with percussion or vibration techniques | CPPD Panel (RT Bronchia l Hygiene Protocol) – usually TID | Done with RT Better tolerated than vest physiotherapy, can be combined with a percussive/vibratory device such as a wand |
| High Frequency Chest Wall Compression (HFCWC) – ‘Vest Physiotherapy’ | An inflatable vest with a compressor rapidly inflates and deflates vest to “break up” thickened mucus from airway wall. Can target specific areas depending on the vest | Vest Physiotherapy | Usually done with RT Vest can be uncomfortable and difficult to tolerate particularly for elderly/frail patients- in which case can use a ‘wand’ |
| Positive Expiratory Pressure (PEP) | Patient exhales against fixed or fluttering resistor that allows air to get behind mucus, helps move mucus from airway walls, and holds airways open longer for improved ventilation | PEP Therapy or Oscillatory PEP Therapy | Also commonly called Flutter valve, Acapella, AerobikA Can find these in any RT station and bring it to the patient |
| Cough Assist | Via mask or trach/vent connection – applies positive pressure to fill the lungs, then quickly switches to negative pressure to produce a high expiratory flow rate to simulate a cough that is intended to produce expectorant | Cough Assist Treatment Panel | Most effective in patients with neuromuscular weakness affecting diaphragmatic strength – muscular dystrophy, myasthenia gravis, spinal cord lesions, SMA |
Adjuncts
Not technically considered ACT but can improve cough productivity
- Mucolytics: Dornase Alfa, N-acetylcysteine (NAC), Hypertonic Saline (3-7%)
- Hypertonic saline can cause bronchospasm and can be poorly tolerated, consider combining with DuoNebs either before or after
- Expectorants: Guaifenesin
Considerations
- CF patients typically have a routine that involves CPT, vest physiotherapy, and PEP valve in addition to their inhaler therapies, ask them their home routine, then ask the CF team if it should be more aggressive (increased frequency)