Airway Clearance/Hyperinflation Therapy Clinical Pathway – ICU and Inpatient

Respiratory Therapist in Collaboration with Clinical Team

Bedside assessment to determine clinical assessment score
Review considerations for holding airway clearance mechanical therapies
Pend orders in Respiratory Therapy Airway Clearance Pathway order set
Initiates airway clearance mechanical strategies based on recommended frequencies

Airway Clearance Maintain outpatient airway clearance therapy regimen Augment therapy based on Clinical Assessment Score
Ineffective or Impaired Cough	Suctioning Cough assist
Retained Secretions Despite Suctioning	Directed cough and suction Chest PT Flutter devices Vest IPV Consider pharmacologic strategies

Airway Clearance

Maintain outpatient airway clearance therapy regimen
Augment therapy based on Clinical Assessment Score

Ineffective or Impaired Cough

Suctioning
Cough assist

Retained Secretions Despite Suctioning

Directed cough and suction
Chest PT
Flutter devices
Vest
IPV
Consider pharmacologic strategies

Hyperinflation Therapy (Volume Expansion)
Atelectasis on CXR	Recruitment by initiating/increasing PEEP/CPAP/NIV Note: Caution with obstructive component to lung disease PEP devices IPV
Risk for Atelectasis	Directed breathing techniques Support early mobility

Monitor effectiveness of interventions every 12 hrs and PRN using Clinical Assessment Scoring Tool
Review with clinical team and adjust frequency of therapies as indicated

Intervention Effective

Intervention Not Effective

Discontinue and initiate alternative therapy if applicable

Maintain prescribed regimen and reassess q12hr and with clinical changes

Deescalate Therapies

Do not wean more frequently than q12hr
Goal to reduce airway clearance therapy to home support or establish new baseline
Decrease:
1. Frequency of clearance therapies Frequency using clinical scoring tool
  Therapies such as IPV are often coupled with administration of hypertonic or normal saline
2. Frequency and dose of pharmacologic therapies

Outside ICU

Consider
- Need for microbial testing and antibiotics
- Exchange tracheostomy tube
- CCOT/ICU consult and ICU admission

Inside ICU

Consider
- Need for microbial testing and antibiotics
- Exchange or placement of artificial airway
- Bronchoscopy
- Alternative ventilation strategies
  - e.g., VDR for further secretion mobilization
- Pulmonary consult
- ENT consult if artificial airway concerns
  - e.g., length, diameter, position, or cuff issues

Posted: August 2022
Last Revised: December 2025
Authors:
- R. Lin, MD
- A. Nickel, RRT
- E. Faulkner, RRT
- H. Panitch, MD
- H. Wolfe, MD
- J. Vicencio, DPT
- K. Budzynski, DPT
- W. Glenn, RRT
- A. Gipsman, MD
- O. Mayer, MD
- M. Bernstein, ACCNS-P
- D. Motil, ACCNS-P
- A. Bhandari, MD
Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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PICU and 8 South/8 Central Clinical Pathway for Airway Clearance/Hyperinflation Therapy for Children > 30 Days of Age

Evidence