Airway Clearance/Hyperinflation Therapy, Non-Pharmacological — Mechanical Strategies — Clinical Pathway: ICU

Airway Clearance/Hyperinflation Therapy, Non-Pharmacological Clinical Pathway — ICU and Inpatient

Mechanical Strategies

Mode Description Use Considerations
Suctioning
  • Apply suction via appropriate catheter and premeasured depth in the presence of oral, nasal, and/or tracheal secretions
  • Clears oropharynx, nasopharynx, and central airways before and after other mechanical airway clearance intervention
  • Can also be via ETT/trach
Manual CPT Percussion & Postural Drainage
  • CPT
    • Side to side with HOB down
    • Return HOB after therapy
  • Postural Drainage
    • Supine with head of bed down for 15 minutes or as tolerated
  • Return HOB after therapy
  • Mobilize secretions
  • Useful adjunct to MI-E
  • Can help with focused clearance in one lung region
  • Limit in GERD patients
  • May not be feasible for those with chest wall deformity
    • e.g. kyphoscoliosis
  • Be cautious in patients prone to rib fractures
  • Safe Patient Handling
MI-E
Mechanical Insufflation- Exsufflation
  • Device providing mechanical inhalation and exhalation to simulate coughing in patients w/ impaired natural ability to cough
  • Begin with lower pressures i.e. ±20 cm H2O and flow to allow naïve patient to become comfortable with device
  • If the patient is receiving invasive mechanical ventilation, start at peak inspiratory pressure or 20 cm H2O, whichever is higher
  • Titrate pressures for chest rise and patient tolerance to therapy
  • Perform 5 sets of 5 simulated coughs, allowing pause between sets for coughing, suctioning, and comfort
  • Inhale time = 1-3 second(s)
  • Exhale time = 1-3 second(s)
  • Pause time = 2 second(s) or 1 second if patient is < 1 yo
  • Hypoxemia can be due to V/Q mismatch resulting from secretions/mucus plugging
  • With worsened hypoxemia:
  • Provide temporary supplemental oxygen
  • Continue cycles until back to baseline FiO2 or better
  • Monitor patients throughout therapy for discomfort and signs of hemodynamic instability
  • Use of higher inspiratory pressure than baseline settings are often required during illness to achieve adequate airway clearance
IPV
Intrapulmonary Percussive Ventilation
  • Positive pressure, vibration, nebulization
  • Helps mobilize secretions and move them centrally
  • Operational pressure manometer should read 20 psi for patient naïve to therapy
  • Operational pressure can be increased slowly until good chest wall vibration is observed, targeting 25 - 30 psi for pediatrics and 35 - 40 psi for adults
  • Begin percussion knob fully on the left in counterclockwise (easy) position and rotate clockwise, stopping at each setting for 2-3 minutes and suctioning in between
  • Nebulizer must contain 9-12 ml solution to provide therapeutic treatment
  • Does not replace MI-E
  • Administer via full face NIV in the non-intubated patient
  • Chosen interface must generate adequate chest rise or therapy is ineffective
High-frequency Chest Wall Oscillation/ Compression (HFCWO/HFCWC, Vest®)
  • Not effective in expectoration
  • Frequency (Hz) 5-20
  • Power (pressure control) 1-10
  • Time (session duration) 10-30 min
  • Not recommended for use in intubated patients due to risk for tube dislodgement
  • Discontinue if patient does not tolerate pressure against chest wall