Bronchial Hygiene - To prevent respiratory complications and treat
pulmonary infections, all SCI patients should maintain clear airways
by using the manual cough, the self-manual cough, glossopharyngeal
breathing, postural drainage, and suctioning.
1. Manual Cough/Manual Ventilation
o Manual Cough - To clear secretions and maintain
good bronchial hygiene, patients with weak cough
force, due to abdominal muscle weakness or paralysis,
assume supine. The therapist or other helper places
his/her hands over the patient's epigastric area, with
the heel of one hand over the abdomen, between the
umbilicus and 2 inches below the xiphoid process,
and the other hand on top of the first hand, with the
fingers spread apart and both hands interlocked. After
the patient takes a deep breath, and as he/she attempts
to cough, the helper pushes down and inward toward
the head, compressing the abdomen quickly.
Although supine is the most effective position, the
manual cough can be done with the patient prone,
sitting, or standing. Patients with high lesions and
vital capacities less than 1000 cc supplement the
cough with effective glossopharyngeal breathing
(GPB) or inflate the lungs with a positive-pressure
device, such as the manual ventilation bag, just before
the cough.
o Manual ventilation - To perform manual ventilation
in an emergency, abdominal compressions similar to
the manual cough are recommended for patients in
most any position. However, placing the hands
laterally on the rib cage, with one hand on either side
of the lower half of the chest, pushing down, and
releasing suddenly, using a normal breathing rate, is
an alternative technique.
2. Self-Manual Cough - Patients with full upper extremity
function can lock the hands together across the epigastric area
and push diagonally toward the head while attempting to
cough, in either a supine or sitting position. Patients with C6
lesions can throw the arms across the epigastric area and fall
forward while attempting to cough, in the sitting position, and
can place a pillow in the lap to increase abdominal
compression or use glossopharyngeal to improve cough
force.
3. Postural Drainage - Although standard postural drainage
positions are used for most patients with paraplegia, patients
with high lesions, or with weak and even "good" diaphragm
strength, may not be able to tolerate positions that restrict the
movement of the diaphragm or place the weight of the
abdominal contents on the diaphragm, such as the
Trendelenburg position and upright positions with angles
greater than 30 degrees. Corsets may be needed in the upright
position, and side lying to drain posterior segments of the
upper lobes requires a 1/4th turn onto the chest with the arm
over a pillow, placed so the diaphragm is not restricted. All
patients with spinal instability must be carefully positioned,
and chest auscultation should be performed to indicate the
best position, based on the specific lobes that need to be
drained.
4. Suctioning - Suctioning is recommended, in addition to
postural drainage:
o For an excessive accumulation of mucous in the
lungs, probably due to poor cough function
o Before breathing reeducation or glossopharyngeal
breathing (GPB) instruction to ensure clear airways
o For acute tracheostomy patients who are very
susceptible to infection during the first 8 weeks and
therefore require sterile suctioning techniques
o For chronic tracheostomy using clean techniques
Patients with known bradycardia should be carefully
monitored during suctioning, since suctioning may stimulate
the vagus nerve and further decrease the heart rate. Adjunct
prophylaxis with IPPB (intermittent positive pressure
breathing) is recommended for patients who continue to
retain secretions and/or develop atelectasis. Immediately
following SCI, tracheal suctioning can cause a rapid fall in
heart rate and cardiac arrest, if oxygen is not administered
prior to these procedures.
Postural drainage
An Intervention for airway clearance, is a means of mobilizing
secretions in one or more lung segments to the central airways by
placing the patient in various positions so gravity assists In the drainage
process.
3 Prevent Accumulation of Secretions in Patients at Risk for Pulmonary
Complications Patients with pulmonary diseases that are associated
with increased production or viscosity of mucus, such as chronic
bronchitis and cystic fibrosis Patients who are on prolonged bed rest
Patients who have received general anesthesia and who may have
painful incisions that restrict deep breathing and coughing
postoperatively Any patient who is on a ventilator if he or she is stable
enough to tolerate the treatment Remove Accumulated Secretions from
the Lungs Patients with acute or chronic lung disease, such as
pneumonia, atelectasis, acute lung infections, COPD Patients who are
generally very weak or are elderly Patients with artificial airways
4 Severe hemoptysis Untreated acute conditions Severe pulmonary
edema Congestive heart failure Large pleural effusion Pulmonary
embolism Pneumothorax Cardiovascular instability Cardiac arrhythmia
Severe hypertension or hypotension Recent myocardial infarction
Unstable angina Recent neurosurgery Head-down positioning may
cause increased intracranial pressure; if PD is required, modified
positions can be used
5 In addition to the use of body positioning, deep breathing, and an
effective cough to facilitate airway clearance, a variety of manual
techniques are used in conjunction with postural drainage to maximize
the effectiveness of the mucociliary transport system, they include
percussion, vibration, shaking, and rib springing..
7 Percussion is used to augment mobilization of secretions by
mechanically dislodging viscous or adherent mucus from the airways.
Percussion is performed with cupped hands over the lung segment
being drained. The therapist’s cupped hands strike the patient’s chest
wall in an alternating, rhythmic manner. It is continued for several
minutes or until the patient needs to alter position to cough. This
procedure should not be painful or uncomfortable.
8 To prevent irritation to sensitive skin, have the patient wear a
lightweight gown or shirt. Avoid percussion over breast tissue in women
and over bony prominences.
9 -Over fractures, spinal fusion, or osteoporotic bone -Over tumor area
-f a patient has a pulmonary embolus -If the patient has a condition in
which hemorrhage could easily occur, such as in the presence of a low
platelet count, or if the patient is receiving anticoagulation therapy -If
the patient has unstable angina -If the patient has chest wall pain, for
example after thoracic Surgery or trauma
10 It is used in conjunction with percussion to help move secretions to
larger airways. It is applied only during the expiratory phase as the
patient is deep-breathing Vibration is applied by placing both hands
directly on the skin and over the chest wall (or one hand on top of the
other) and gently compressing and rapidly vibrating the chest wall as
the patient breathes out.Pressure is applied in the same direction as
the chest is moving.
12 Shaking is a more vigorous form of vibration applied during
exhalation using an intermittent bouncing maneuver Coupled with wide
movements of the therapist’s hands. The therapist’s thumbs are locked
together, the open hands are Placed directly on the patient’s skin, and
fingers are wrapped around the chest wall. The therapist
simultaneously compresses and shakes the chest wall.
