Respiratory care

1. EXCESSIVE SECRETIONS +/- IMPAIRED MUCOCILIARY CLEARANCE
Active cycle of breathing (ACBT)
Incorporating thoracic expansion exercises (TEEs),
forced expiration technique (FET)
Breathing control
Gravity-assisted positioning (GAP)
Modify positioning where poorly tolerated.
Manual technique
Chest percussion and shaking on expiration aid sputum clearance
Manual hyperinflation (MHI) :MHI can be used to augment lung recruitment and mobilize secretions
An inspiratory hold on the ventilator in those patients unable to tolerate MHI
Humidification
Saline nebulizers administered via the ventilator circuit used in conjunction with MHI or
during the expiratory phase of the ventilator cycle

2. Positive pressure
IPPB or NIV can reduce WOB and rest the patient
ACBT can be modified for use with NIV in situ.
The inspiratory pressure or time can be increased slightly on the ventilator for TEEs, similar to when
using IPPB

3. Treatments and suggested modifications for ineffective cough
Increase tidal volume to increase cough effort
ACBT modified for the individual. With NIV consider a safe increase in inspiratory pressure for TEEs
GAP ●
Some patients tolerate head-down or flat positions well whereas others cannot; modify positioning – the
use of IPPB or NIV may allow the patient to tolerate these more comfortably
Manual techniques
Fatigued patients may tolerate shaking on alternate
breaths more easily
Assisted cough techniques
Assisted cough techniques can be performed supine, side-lying or sitting, as indicated.
The force is applied on expiration in the direction of chest wall movement
Movement such as rolling or positioning may facilitate clearance of secretions
(particularly in hightone patients, e.g. with cerebral palsy)
IPPB or NIV can be used in conjunction with any of the above

4. Treatments and suggested modifications for patients unable to cooperate
Manual techniques
vibrations with or without IPPB may be beneficial.
Rib springing or chest compressions can facilitate greater inspiration in unconscious patients
Neurophysiological facilitation of respiration can be useful in drowsy or unconscious patients.
These techniques may increase expansion, alter respiratory rate or facilitate an involuntary cough

5. The management of volume loss
Treatment strategies for reduced
FRC
To increase FRC Positioning to
optimize FRC, V/Q and diaphragm
length–tension relationship
CPAP
Controlled mobilization with breathing
strategies If ventilated, increase
PEEP
Treatment strategies for reduced tidal volume
To increase tidal volume
Breathing exercises: lower thoracic expansion exercises (LTTEs).
Infants cannot significantly increase their tidal volumes so will
increase their RR
to increase their MV
Incentive spirometry. In children, blowing games: bubbles/windmills,
bubble PEP
Controlled mobilization with breathing strategies
IPPB/NIV
Neurophysiological facilitation techniques
If ventilated, manual hyperinflation/ventilator hyperinflation when
appropriate

6. Treatment strategies for localized static volume loss
Aim: To reverse atelectasis
Positioning to optimize FRC, V/Q and diaphragm length–tension
relationship
Advise regarding optimization of O2 therapy
Breathing exercises, LTEEs, inspiratory hold, sniff – collateral ventilation,
which is not well developed in infants
Incentive spirometry. In children, blowing games: bubbles/windmills,
bubble PEP
IPPB
CPAP if good tidal volume
Controlled mobilization
Neurophysiological facilitation techniques
If ventilated, manual hyperinflation

7. ARDS/acute lung injury
↓FRC ● Ensure optimization of O2 therapy
Positioning – erect sitting, side-lying (abdomen free)
CPAP/NIV
Positioning – side-lying, prone
Avoid any manoeuvres which involve disconnecting the patient from the ventilator to preserve PEEP
Consolidation/ pneumonia ↓FRC
Ensure optimization of controlled O2 therapy. If severe hypoxaemia may require CPAP or NIV
Positioning:
Adults – side-lying (abdomen free) with unaffected lung down
Paediatrics – side-lying with affected lung down When/if become productive, use airway clearance techniques
Humidification
Positioning:
Adults – side-lying (abdomen free) with unaffected lung down
Paediatrics – side-lying with affected lung down When/if become productive, use sputum clearance techniques
Paediatrics – may tolerate having the affected
lung up which would help drain any loose secretions and encourage ventilation to that lung.
As in all patients, need to assess individual’s tolerance to handling/treatment

8. Collapse ↓FRC
Ensure optimization of controlled O2 therapy. If severe hypoxaemia may require CPAP or NIV
Positioning:
Adults – high sitting (bed or chair), side-lying (abdomen free)
Paediatrics – as tolerated and manual techniques/ blowing games in younger patients
Mobilization with breathing strategies
Recruitment manoeuvres – PEEP, manual hyperinflation and inspiratory hold
Positioning in high side-lying (abdomen free)
Reverse Trendelenburg (feet down, whole bed tilt)
Adults – instillation of 0.9% NaCl if sputum plugging

9. Collapse lobar ↓FRC ● Ensure optimization of controlled O2 therapy.
If severe hypoxaemia may require CPAP or NIV
● Positioning:
Adults – side-lying (abdomen free) with unaffected lung down (optimize V/Q & GAP)
Paediatrics – side-lying with affected lung down
(optimize V/Q) May need to have affected lung up to drain.
If poorly tolerated short, frequent treatments.
Then when improving may tolerate being left with affected lung up to increase ventilation to that lung
TEEs with inspiratory holds
Neurophysiological facilitation techniques
Incentive spirometry (IS)
IPPB
If sputum retention use airway clearance techniques
Positioning:
Adults – side-lying (abdomen free) with unaffected lung down (optimize V/Q & GAP)
Paediatrics – side-lying with affected lung down
(optimize V/Q)
Manual hyperinflation maintaining PEEP
Inspiratory hold
If sputum retention use airway clearance techniques
If upper lobe problem – sit up provided ETT is
well secured

10. Flail chest
Ensure optimization of controlled O2 therapy
Positioning: Adults – side-lying (abdomen free) with unaffected
lung down (optimize V/Q)
Paediatrics – side-lying with affected lung down
(optimize V/Q)
CPAP or NIV to ‘splint’ the chest wall
TEEs with inspiratory holds
Neurophysiological facilitation techniques
IPPB – avoid use until pneumothorax excluded
If sputum retention use airway clearance techniques
Positioning:
Adults – high sitting or side-lying (abdomen free) with unaffected lung down Paediatrics – high sitting or
side-lying with affected lung down but lying on affected side may be more painful and lead to decreased
ventilation (unless patient paralysed and fully ventilated with adequate analgesia)
If sputum retention use airway clearance techniques

11. Pleural effusion ↓FVC
↓VT if large
Positioning:
Adults – side-lying (abdomen free) with unaffected
lung down (optimize V/Q)
Paediatrics – side-lying with affected lung down
(optimize V/Q)
NB if pleural effusion very large then the above positioning may cause further volume loss – alter to
supported high sitting
Ensure optimization of controlled O2 therapy
Positioning:
Adults – side-lying (abdomen free) with unaffected
lung down (optimize V/Q)
Paediatrics – side-lying with affected lung down
(optimize V/Q)

12. Pneumothorax ↓FVC ● Liaise with medical team regarding insertion of ICD
● Ensure optimization of controlled O2 therapy
● Liaise with medical team regarding insertion of ICD
● Ensure optimization of controlled O2 therapy
Pulmonary
oedema
↓FVC ● Ensure optimization of controlled O2 therapy
● CPAP
● NIV with CPAP facility
● Medical treatment
● Positioning in high side-lying (abdomen free)
● Reverse Trendelenburg (feet down, whole bed tilt)
● PEEP
● Paediatrics – pulmonary oedema may be quite
sticky and may potentially cause small airways to
block
Respiratory
muscle
weakness/fatigue
↓FVC
↓VT
● Fully supported positioning including shoulder girdle
● IPPB