The purpose of respiratory kinesiotherapy is to ensure quality breathing, allowing proper oxygenation of the blood and the elimination of carbon dioxide.
To achieve this, you should ensure that:
1. The airways are free from any mucus or excessive secretions that the patient cannot clear on their own.
2. Sufficient chest amplitude is maintained.
These recommendations aim to:
– Facilitate bronchial clearance performed at home by caregivers.
– Review manual and instrumental techniques, even if they are already known by the patient and caregivers.
– Provide guidance on suction techniques.
General Caregiver Instructions
Before you begin:
- Wash your hands with soap and water in the bathroom or toilet, and dry them with a disposable towel (if not available, with a new clean towel).
- Put on a mask, a clean, large blouse, or a shirt.
During the clearing assistance:
- Do not use your mobile phone or landline phone.
- Wash your hands (or use a hydro-alcoholic solution) before and after handling the patient, using medical equipment, and technical aids (wheelchair, patient lift, electric bed).
- Use disposable gloves for endotracheal suction.
After clearing the bronchial passages
- Remove the disposable gloves if used,
- Wash your hands with soap and water.
Instructions
Proper patient positioning is essential. It is guided by their comfort and safety. During airway clearance, they are often in a semi-sitting position, but some prefer a lying-down position. If the session takes place in a wheelchair, make sure the brakes are engaged and it cannot tilt backward.
- Contact the attending physician, if necessary, in case of worsening lung congestion, breathing difficulties, or fever.
Airway clearance through manual compressions
What is the goal?
- Help the patient clear their airways by pressing on their chest and stomach as they breathe.
- If the secretions are too thick, sticky, and hard to clear, check if the patient is receiving effective humidification. Saline solution can be used if the patient does not have a hypersensitivity to this product. The use of instrumental aids can help with clearance (see below).
In what positions?
For the patient:
A comfortable, stable position, most often semi-seated. If they are in a wheelchair, make sure it won’t tip during the maneuver.
For the caregiver:
Standing, with one hand on the middle of the sternum or on the hemithorax, the middle finger pointing towards the navel, and the other hand on the abdomen at the level of the navel (photo 1). Both palms are extended without clenching the fingers.
For reasons of comfort and efficiency, some patients prefer to have both hands placed on the chest (photo 2) or on the abdomen (photo 3).
How is the maneuver performed?
For the patient:
Breathe deeply and cough as forcefully as possible to clear the “upper” secretions.
Take a deep breath and blow out your mouth as if you were blowing out birthday candles. Perform the exercise 5 times.
Take a deep breath and blow forcefully with your mouth open (as if you were blowing warm air on a window – you can use a pocket mirror). Perform the exercise 5 times.
When there are many secretions, take a deep breath and cough as forcefully as possible.
For caregivers:
Provide instructions during the maneuvers: “inhale” (photo 4), “piercing mouth breathing,” “open-mouth breathing,” “strong cough” (photo 5).
Press on the chest and stomach when the patient breathes out or coughs. The pressures should be significant but without causing discomfort to the patient.
Aspirate secretions when they appear in the mouth or tracheostomy tube. Endotracheal aspirations are performed by caregivers trained in this technique.
3 rules
- Always ensure that the patient is well-ventilated, asking them or using an oximeter if available.
- Take frequent breaks and divide the sessions as needed.
- If the patient is ventilated, the caregiver can press on the abdomen and chest during expiration.
Clearing the Airways with the Help of Instruments
When a patient cannot clear their secretions by manual pressure alone, a pressure relief valve (such as Alpha 300, 200…) is used.
It is advisable to use these techniques to take in more air (hyperinflation) before exhaling or coughing. For patients who are skilled in hyperinflation techniques using a pressure relief device (such as Alpha 300 or 200…);
- For ventilated patients, if they master the technique, use “stacking air” (stack several volumes of air before exhaling);
- Or for those who control it, use glossopharyngeal breathing.
- The same instructions as those proposed in the “initiation by manual compression” section can be associated during the maneuver.
You can intervene with:
A device such as: CoughAssist®, Pegaso®, Clearway®, Cough Comfort®, Eove70®.
O ședință „CoughAssist” poate fi realizată de îngrijitori.
- The device should be set to “automatic” mode.
- Apply the mask firmly to the patient’s face (mouth and nose) (photo 6).
- A session consists of 4-5 cycles of inspiration – expiration (photos 7 and 8), followed by a break.
- These 4-5 cycles can be repeated 4 to 5 times, taking into consideration the effectiveness of clearance and the patient’s fatigue.
Use the opportunity (as in photo 8) to press on the patient’s chest or abdomen when they cough.
Endotracheal aspiration
- Endotracheal aspirations should be performed by trained individuals wearing a mask, gloves, and disposable gowns.
Chest mobilization
- If chest pressure mobilization sessions have been prescribed, it’s important to continue them, around 20 minutes a day.
Warning!!!
This practical sheet was created in the exceptional context of the coronavirus (Covid-19) pandemic.
Translated and adapted by the specialists of the Tony Hawks Center:
Diana Covalciuc – Rehabilitation Doctor
Cristina Caraman – Physiotherapist
Maria Gurcova – Physiotherapist
Efimia Rusu – Social Worker