Dr. dr. Nury Nusdwinuringtyas, SpKFR- K, M

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Dr. dr. Nury Nusdwinuringtyas, SpKFR-K, M.Epid

Adequate Cardiorespiratory Rehabilitation in Pulmonary Problems

Mucus Clearance

The 7th Jakarta International Chest and Critical Care Internal Medicine

2019

INTRODUCTION

• Mucus secretion and clearance are important for pulmonary defense.

• Mucus secretion volume is between 10 and 100 mL/day in health.

• Pulmonary disorders such as CF, COPD, bronchiectasis alter the production of mucus and mucociliary clearance disorders airway obstruction.

• ACT used to aid in mucus mobilization and expectoration.

Airway

Oxygen consumptionVO2 = (arterial oxygen content –

venous oxygen content) x cardiac output

Oxygen deliveryDO2 = arterial oxygen

contentx cardiac output

Oxyhaemoglobin + dissolved oxygen

Hgb x 1.34 x SaO2

PaO2 x 0.003

Oxyhaemoglobin + dissolved oxygen

Hgb x 1.34 x SVO2

PvO2 x 0.003

Oxygen extraction ratioOER = Oxygen consumption VO2

Oxygen delivery DO2

Pathological basis of impaired airway clearance and clinical examples

Pathophysiological basis

Increased or altered composition of mucus

1. Inreased production2. Colonization of mucus, e.g viral,

bacterial and fungal organism3. systemic dehydration

Abnormalities in Cilial structure or function

Impaired MCC 1. Age2. Sleep3. Enviromental pollutants4. Drugs5. High Flow gases6. Hypoxaemia and Hypercapnia7. Social Factors

Abnormal Cough Reflex 1. Decreased2. Increased

Ineffective cough due to inability to generate sufficient expiratory flow

Abnormal Cough 1. Post nasal drip2. GERD

Airway clearance in the normal lung

1. Mucociliary clearance (MCC)

1. Cough

MUCOCILIARY CLEARANCE

Airway defence mechanisms

Airway lining

Active Cycle Breathing

Combines different breathing techniques

Help clear mucus from the lungs in three phases.

The first phase helps you relax your airways.

The second phase helps you to get air behind mucus and clears mucus.

The third phase helps force the mucus out of your lungs.

Discussion

Autogenic Drainage

Is a breathing technique aims to maximize airflow within the airways, to improve ventilation and the clearance of mucus.

Chest Clapping

Chest Shaking, Vibrations, and Compression

Postural Drainage

Contraindications to Postural Drainage

• Severe hemoptysis

• Severe pulmonary edema

• CHF

• Large pleural effusion

• Aortic aneurysm

• Cardiac arrhythmia

• Severe hypertension

• Unstable angina

DEVICES

Positive Expiratory Pressure

High Frequency Oscillating Vest

Mechanical Insufflation Exsufflation

Air Stacking

COUGH

Contraindications Cough Assist

• History of bullous emphysema

• Pneumothorax

• Barotrauma

• Pneumomediastinum

• Pulmonary oedema

• Haemoptysis

• Acute respiratory distress syndrome

Huff Coughing:

• Huff coughing, or huffing, is an alternative to deep coughing if you have trouble clearing your mucus.

• Take a breath that is slightly deeper than normal.

• Use your stomach muscles to make a series of three rapid exhalations with the airway open, making a "ha, ha, ha" sound.

Contraindications Forced Breathing

• Inability to control possible transmission of infection from patients suspected or known to have pathogens transmittable by droplet nuclei (eg: M tuberculosis)

• Presence of an elevated intracranial pressure or intracranial aneurysm

• Presence of reduced coronary artery perfusion, such as in acute myocardial infarction

• Acute unstable head, neck, or spine injury

EVALUATION

COUGH EVALUATION

Peak Cough Flow

• Effective peak cough flow in healthy subjects > 360 - 400 L/min

• Peak cough flow (PCF) for mucusexpectoration > 160 - 200 L/min.

• PCF > 250 - 270 L/min has been shown to besufficient to prevent pneumonia in patients with NMDs

Mellies U, Goebel C. Optimum Insufflation Capacity and Peak Cough Flow in Neuromuscular Disorders. Ann Am Thorac Soc. 2014

Evaluation of Peak

Cough Flow in Brazilian

Healthy Adults

Cardoso et al. Evaluation of peak cough flow in Brazillian healthy adults. International Archives of Medicine. 2012

Peak Cough Flow in Indonesian Healty Adults

Affecting Factor of Peak Cough Flow

• Peak Cough Flow values in Indonesian healthy adults about 310 – 645 L/min

• Sex, height and age affect peak cough flow values in Indonesian healthy adults.

FUNCTIONAL CAPACITY & QUALITY OF LIFE

6-Minute Walk Test

1. Walk as FAR (not as FAST) as possible; running is prohibited

2. Walk around the marking cones for 6 minutes

3. Exhaustion or discomfort may cause the patient to stop but stopwatch will keep running

4. Every minute passed will be notified by the examiner

5. Examiner will monitor vital signs and O2 saturation

6. Upon completion, BORG Scale is re-assessed

7. Calculate total walking distance, rounded to the nearest meter

Take home message

• Proper manipulation technique performed by professionals is required for effective mucus evacuation

• Comprehensive evaluation should be done before and after intervention for optimal results

THANK YOU