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

Physician/Advanced Practice Provider (APP): Initiates Non-pharmacologic Airway Clearance Pathway order in EMR for patients meeting cohort definition
  • Secretion Management
  • Patient unable to clear secretions with cough or suction
  • Atelectasis on CXR with suspected retained secretions
  • Evidence or history of mucus plugging
  • Volume Expansion (Hyperinflation Therapy)
  • Patient at risk for or with existing atelectasis unrelated to secretions
  • Airway Clearance Therapies
  • delivered as outpatient regimen
  • Ineffective or
  • impaired cough
  • Retained secretions
  • despite suctioning
  • Atelectasis on CXR
  • Risk for atelectasis
  • Maintain baseline regimen
  • Augment therapy based on Clinical Assessment Score
  • Suctioning
  • Cough assist
  • Directed cough and suction
  • Flutter devices
  • Vest
  • IPV
  • Recruitment by initiating/increasing PEEP/CPAP/NIV
  • PEP devices
  • IPV
Respiratory Therapist: Monitor effectiveness of interventions every 12 hours and PRN using Clinical Assessment Scoring Tool
  • Intervention Effective
  • Re-evaluate patient score q12 hrs
  • Review with clinical team
  • Adjust frequency of therapies per pathway as needed
  • Intervention Not Effective
  • Review with clinical team
  • Discontinue and initiate next indicated therapy if applicable
  • Aggressive ACT not effective outside of the ICU consider:
    • Medication titration to secretion burden and thickness
    • Re-evaluate need for microbial testing and antibiotic therapy
    • Exchange of tracheostomy tube as indicated
    • CCOT/ICU consult and ICU admission
  • Every 2 hour therapy not effective in the
    ICU consider:
    • Medication titration to secretion burden and thickness
    • Re-evaluation of need for microbial testing and antibiotic therapy
    • Exchange or placement of artificial airway
    • Bronchoscopy
    • Alternative ventilation strategies
      • e.g., VDR ventilation for further secretion mobilization
    • Pulmonary Consult
    • ENT Consult if airway concerns
      • e.g., length, diameter, position, or cuff issues
Posted: August 2022
Revised: January 2023
Authors: R. Lin, MD; A. Nickel, RRT-NPS; K. Tsukahara, MD; C. Dominick, RRT-NPS; E. Faulkner, RRT-NPS; H. Panitch, MD; H. Wolfe, MD; E. Simmons, RRT-NPS; R. Samora, RRT-NPS; R. Matthews RRT-NPS; K. Mullaney APRN; J. Vicencio, DPT;
K. Budzynski, DPT, PCS