Airway clearance

D Ineffective Airway Clearance related to administration of a narcotic (specify overdose, drug idiosyncrasy, or other cause)... 

Q Ineffective Airway Clearance related to narrowed airway passages, thick or excessive mucus... 

Mr. Potter, age 57 years, is admitted to the pulmonary unit in acute respiratory distress. The primary health care provider orders IV aminophylline. In developing a care plan for Mr. Potter, you select the nursing diagnosis Ineffective Airway Clearance. Suggest Jiursing interventions that would be most important in managing this problem. 

Airway clearance therapy is a necessary routine for all CF patients to clear secretions and control infection. It is typically performed once or twice daily for maintenance care and three or four times per day for acute exacerbations. 

Several devices are also available to promote airway clearance. Flutter valve devices employ oscillating positive expiratory pressure (OPEP) to cause vibratory air flow obstruction and an internal percussive effect to mobilize secretions. Intrapulmonary percussive ventilation (IPV) provides continuous oscillating pressures during inhalation and exhalation. Finally the most commonly used technique is high-frequency chest compression (HFCC) with an inflatable vest that provides external oscillation. Vest therapy is often preferred by patients because they can independently perform the therapy even from an early age.5,14... 

Airway clearance therapy is usually accompanied by bron-chodilator treatment [albuterol (also known as salbutamol outside the United States) by nebulizer or metered-dose inhaler] to stimulate mucociliary clearance and prevent bronchospasm associated with other inhaled agents. A mucolytic agent may be administered to reduce sputum viscosity and enhance clearance. 

Monitor for changes in pulmonary symptoms such as cough, sputum production, respiratory rate, and oxygen saturation. Symptoms of an acute exacerbation should improve with antibiotics and aggressive airway clearance therapy. Pulmonary function tests should be markedly increased after 1 week and trend back to pre-exacerbation levels after 2 weeks of therapy, ft improvement lags, 3 weeks of therapy may be needed. 

Assess adherence to the prescribed regimen, including timing of inhaled medications with respect to airway clearance therapies and timing of enzymes and insulin with regard to meals. Is the patient taking any medications not prescribed by the CF center team ... 

Downs AM, Lindsay KLB. Physical therapy associated with airway clearance dysfunction. In DeTurk WE, Cahalin LP, eds. Cardiovascular and Pulmonary Physical Therapy. New York McGraw-Hill 2004. 

Extracellular barriers (DNA, enzymes, mucus) Paucity of receptors Proteosome-mediated degradation Inhibition of second-strand synthesis Airway clearance, anti-inflammatory, anti-protease pre-treatments Alternate serotypes, targeted capsid mutants Proteosome inhibitors (tripeptides, anthracyclines) Tyrosine kinase inhibitors... 

Lung characteristics of exposed individual Morphometry of airways Clearance rate of mucus lining airways Distance to target tissue - mucus thickness... 

Behr, M., C. Wingen, C. Wolf, R. Schuh, and M. Hoch. (2007). Wurst is essential for airway clearance and respiratory-tube size control. Nat Cell Biol, Vol. 9, pp.847-853. 

Stiimpges, B., and M. Behr. (2011). Time-specific regulation of airway clearance by the Drosophila J-domain transmembrane protein Wurst. FEES Letters, In Press, doi 10.1016/j.febslet.2011.09.018. 

Physiotherapy adjunct to improve airway clearance of secretions... 

General indications for tracheostomy placement include (i) upper airway obstruction, (ii) invasive mechanical ventilation (IV), (Hi) airway clearance, (iv) airway protection, and rarely (v) obstructive sleep apnea. Engoren et al. (1) demonstrated that those able to wean from tracheostomy support, whether during or after hospital admission, had an improved survival rate. Whether this is a reflection of a less severe underlying condition or whether the tracheostomy itself portends a worse outcome is uncertain. Tracheostomy weaning is often conducted outside of acute care hospitals and therefore this skill is not limited to those who work in intensive care settings. 

Some studies suggest that liberation from mechanical ventilation is a requirement for decannulation (6), but this precludes the provision of noninvasive ventilation (NIV) as part of decannulation and may be impossible for some patients who could otherwise be dec-annulated. Other reports recognize that decannulation may proceed to NIV 24 hours a day without the requirement of an artificial airway (7) provided bulbar function is adequate and airway clearance is achieved (8). 

In this chapter we will discuss recommendations from the hterature regarding dec-aruiulation as well as our personal clinical experience. We will comment on the pathophysiology of ventilator dependence, the determination of candidates for weaning from ventilation and tracheostomy, and a stepwise approach to decannulation. Lastly, we will discuss the choices of noninvasive ventilatory supports and techniques that clinicians may utilize, such as lung volume recruitment (LVR), assisted coughing and mechanical airway clearance. 

There is an important distinction between dependence on an artificial airway and mechanical ventilation, which can be provided noninvasively (9). The requirement for an artificial airway may reflect bulbar impairment as, in those with adequate bulbar function, noninvasive ventilation will sustain adequate ventilation even with veiy limited respiratory muscle function. Therefore, tracheostomized patients with preserved bulbar control can undergo decannulation. Airway secretions are important determinants of dependence on mechanical ventilation through an artificial airway, and aspiration pneumonia may result from an impaired level of consciousness, poor bulbar function, or inability to cough effectively. Such issues must be addressed by airway clearance techniques, prior to decannulation. 

Consider if NIV (nocturnal) is required Consider need for assistance with airway clearance (chest physical therapy, manual assisted coughing)... 

Once the patient can use daytime and nocturnal ventilatory supports, with PCFs >160 L/ min, they can safely be decarmulated and an occlusive dressing applied as the stoma will require a few days to close. LVR techniques should be continued indefinitely to optimize Irmg and chest wall compliance and to maintain adequate airway clearance. This preventive approach will reduce the likelihood that the patient will require invasive support again. 

In patients with COPD there is a persistent and permanent dyspnea and airway obstruction, with incomplete reversibility with therapy. Normally, in these patients, the mucociliary transport is not so impaired, until an acute exacerbation occurs. During an acute exacerbation of COPD, hypersecretion is usually present and may be induced by bacterial infections. Secretion encumbrance and ineffectiveness of airway clearance is associated with failure of noninvasive ventilation (NIV), whereas endotraqueal intubation and mechanical ventilation is necessary in acute exacerbations of COPD. The duration of mechanical ventilation was correlated with hospital mortality (22). 

Research studying the results of airway clearance is often difficult to evaluate because the components of a given treatment have not been standardized. Availability of equipment or education about a technique, as well as cultural differences in its application, confound the results. CPT does not appear to benefit patients during recovery from acute exacerbations of COPD or pneumonia. These conditions are characterized by interstitial pathology, which cannot be influenced by physical interventions in the airways (16,22,49). Further studies are needed to identify the patients, and more circumstances, who are at risk from complications or adverse effects of CPT. 

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