Pulmonary hygiene

Pulmonary hygiene, formerly referred to as pulmonary toilet,[1] is a set of methods used to clear mucus and secretions from the airways. The word pulmonary refers to the lungs. The word toilet, related to the French toilette, refers to body care and hygiene; this root is used in words such as toiletry that also relate to cleansing.

Respiratory health (pulmonary hygiene) depends on consistent clearance of airway secretions. Normal airway clearance is accomplished by two important mechanisms: the mucociliary clearance system and the ability to cough. Impaired mucociliary clearance is linked to poor lung function in a broad range of diseases and disabilities.[2]

Pulmonary hygiene prevents atelectasis (the collapse of the alveoli of the lungs) and rids the respiratory system of secretions,[3] which could cause respiratory infections. It can also decrease pulmonary shunting, increase the functional reserve capacity of the lungs, and prevent respiratory infection after chest trauma.[4] Methods include using suction to remove fluids and placing the patient in a position that allows secretions to drain by gravity.

Methods

Methods used for pulmonary hygiene include suctioning of the airways, chest physiotherapy, blow bottles,[3] and nasotracheal suction.[5] Bronchoscopy, in which a tube is inserted into the airways so that an examiner can view them, can be used therapeutically as part of pulmonary hygiene.[4] Incentive spirometry and use of analgesics (pain medications) that do not inhibit breathing are also parts of pulmonary toilet.[6] Coughing is also important for ridding the airways of secretions, so healthcare providers are careful not to oversedate patients, because that could inhibit coughing.[7] Tracheotomy facilitates pulmonary toilet.[8] Percussion, another method, loosens secretions and allows the cilia of the airways to remove material. Positioning is another method for promoting drainage of secretions; sometimes patients are placed in a prone position to aid in this purpose.[4]

Conventional chest physiotherapy

The most common treatment of atelectasis in the hospital setting is manual chest physiotherapy[9] though there is limited evidence of its efficacy.[10][11] Chest percussion and postural drainage are used in bronchiectasis and lung abscess. The patient's body is positioned so that the trachea is inclined downward and below the affected chest area.[12] Postural drainage is essential in treating bronchiectasis. Patients must receive physiotherapy to learn to tip themselves into a position in which the lobe to be drained is uppermost at least three times daily for up to 30 minutes during each session.

The treatment is often used in conjunction with a technique for loosening secretions in the chest cavity called chest percussion. Chest percussion is performed by clapping the back or chest with a cupped hand. Alternatively, a mechanical vibrator may be used in some cases to facilitate loosening of secretions.[13] There are drainage positions for all segments of the lung. These positions are modified depending on the patient's condition and the location of the area in most need of therapy.

Intermittent positive pressure breathing (physiotherapy)
Main article: Intermittent positive pressure breathing

Intermittent positive pressure breathing (IPPB) physiotherapy has long been used in the intensive care setting in non-intubated patients. Although widely accepted, few studies have validated its efficacy. In a Respiratory Care Clinical Practice Guideline,[14] IPPB is suggested for patients who have impaired airway clearance, and for delivery of aerosolized medications to patients with neuromuscular weakness who are incapable of inhaling deeply. IPPB physiotherapy should be used with caution in patients with severe, uncontrolled bronchospasm or severe airway obstruction

Mechanical insufflation-exsufflation physiotherapy

People with neuromuscular weakness and atelectasis benefit from mechanical insufflation-exsufflation.[15] Mechanically-assisted coughing greatly improves secretion clearance in the setting of respiratory infection in the patient with neuromuscular disease and should be first-line therapy for this patient population.[16] Mechanical insufflation-exsufflation physiotherapy is greatly aided by simultaneous manual augmentation of cough with either a thoracic squeeze or abdominal thrust during the expiratory phase (exhale). An American Thoracic Society consensus statement in 2004 supported the use of mechanical insufflation-exsufflation physiotherapy for patients with Duchenne muscular dystrophy.[17] The use of this technique for children with neuromuscular disease has gained widespread acceptance in the United States and internationally.[18][19]

Applications

Pulmonary bronchial hygiene is used for preventing infections such as pneumonia. It is also used in the management of conditions such as pneumonia and cystic fibrosis.[6] For people with chronic lung diseases, bronchial hygiene is used to prevent infections and lung abscesses.[20] Bronchial hygiene is also used to prevent acute respiratory distress syndrome after chest trauma.[4]

Indications

The need for bronchial hygiene is indicated in cases of COPD, pneumonia and cystic fibrosis as both interventional and prophylactic. Prophylactic indications also include pre and post thoracic surgery to prevent atelectasis and respiratory infections.

Contraindications

The decision to use postural drainage therapy requires assessment of potential benefits versus potential risks. Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. Some of the contraindications include an increased intracranial pressure (>20 mmHg), any spinal injury acute or otherwise, active hemoptysis, pulmonary embolism, pulmonary edema with congestive heart failure and an open or healing wound in the area where chest physiotherapy is otherwise indicated.

Medication contraindications vary depending on the medication being delivered.

See also

References
  1. Moody LE (January 1977). "Primer for pulmonary hygiene". Am J Nurs. 77 (1): 104–6. doi:10.2307/3424229. JSTOR 3424229. PMID 584121.
  2. Lewis, Brandon; Patial, Sonika (July 2019). "Immunopathology of Airway Surface Liquid Dehydration Disease". Journal of Immunology Research. 2019: 2180409. doi:10.1155/2019/2180409. PMC 6664684. PMID 31396541.
  3. Allen GS, Coates NE (November 1996). "Pulmonary contusion: A collective review". The American Surgeon. 62 (11): 895–900. PMID 8895709.
  4. Michaels AJ (January 2004). "Management of post traumatic respiratory failure". Crit Care Clin. 20 (1): 83–99, vi–vii. doi:10.1016/S0749-0704(03)00099-X. PMID 14979331.
  5. Allen GS, Cox CS (December 1998). "Pulmonary contusion in children: Diagnosis and management". Southern Medical Journal. 91 (12): 1099–1106. doi:10.1097/00007611-199812000-00002. PMID 9853720. S2CID 28583201.
  6. Virk A, Wilson WR (2001). "Tracheobronchitis and lower respiratory tract infections". In Wilson WR, Sande MA, Drew L (eds.). Current Diagnosis & Treatment in Infectious Diseases. New York: Lange Medical Books/McGraw-Hill. p. 145. ISBN 0-8385-1494-4. Retrieved 2008-06-30.
  7. Goodman G (2007). "Chronic pulmonary disease: Bronchopulmonary dysplasia". In Perkin RM, Swift JD, Dale AN, Anas NG (eds.). Pediatric Hospital Medicine: Textbook of Inpatient Management. Hagerstown, MD: Lippincott Williams & Wilkins. p. 233. ISBN 978-0-7817-7032-3. Retrieved 2008-06-30.
  8. Reilley JM, Sicard GA (2001). Rosenthal RA, Zenilman ME, Katlic MR (eds.). Principles and Practice of Geriatric Surgery. Berlin: Springer. pp. 492. ISBN 0-387-98393-7. Retrieved 2008-07-01. pulmonary toilet pulmonary physiotherapy.
  9. Galvis AG, Reyes G, Nelson WB (1994). "Bedside management of lung collapse in children on mechanical ventilation: saline lavage--simulated cough technique proves simple, effective". Pediatr Pulmonol. 17 (5): 326–30. doi:10.1002/ppul.1950170510. PMID 8058427. S2CID 28088458.
  10. Schindler MB (2005). "Treatment of atelectasis: where is the evidence?". Crit Care. 9 (4): 341–2. doi:10.1186/cc3766. PMC 1269473. PMID 16137380.
  11. Stiller K (2000). "Physiotherapy in intensive care: towards an evidence-based practice". Chest. 118 (6): 1801–13. doi:10.1378/chest.118.6.1801. PMID 11115476.
  12. Dorland's Medical Dictionary.
  13. "Hypersensitivity Pneumonitis - Lung and Airway Disorders".
  14. Sorenson HM, Shelledy DC (2003). "AARC clinical practice guideline. Intermittent positive pressure breathing--2003 revision & update". Respir Care. 48 (5): 540–6. PMID 12778895.
  15. Miske LJ, Hickey EM, Kolb SM, Weiner DJ, Panitch HB (2004). "Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough". Chest. 125 (4): 1406–12. doi:10.1378/chest.125.4.1406. PMID 15078753.
  16. Bach JR (1993). "Mechanical insufflation-exsufflation. Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques". Chest. 104 (5): 1553–62. doi:10.1378/chest.104.5.1553. PMID 8222823.
  17. Finder JD, Birnkrant D, Carl J, Farber HJ, Gozal D, Iannaccone ST, et al. (2004). "Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement". Am J Respir Crit Care Med. 170 (4): 456–65. doi:10.1164/rccm.200307-885ST. PMID 15302625.
  18. Fauroux B, Guillemot N, Aubertin G, Nathan N, Labit A, Clément A, et al. (2008). "Physiologic benefits of mechanical insufflation-exsufflation in children with neuromuscular diseases". Chest. 133 (1): 161–8. doi:10.1378/chest.07-1615. PMID 18071020.
  19. Birnkrant DJ, Bushby KM, Amin RS, Bach JR, Benditt JO, Eagle M, et al. (2010). "The respiratory management of patients with duchenne muscular dystrophy: a DMD care considerations working group specialty article". Pediatr Pulmonol. 45 (8): 739–48. doi:10.1002/ppul.21254. PMID 20597083. S2CID 26505785.
  20. Virk and Wilson, p. 153
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