What are the first line interventions for pulmonary toilet?

First-Line Interventions for Pulmonary Toilet

The first-line interventions for pulmonary toilet should include positioning, mobilization, airway clearance techniques, and adequate hydration to facilitate secretion removal and improve respiratory function. 1, 2

Patient Positioning and Mobilization

• Position the patient with head of bed elevated at 30 degrees (beach chair position) to provide mechanical advantage for respiration and optimize lung expansion 2
• Early mobilization and ambulation as soon as clinically appropriate to reduce pulmonary complications 1
• Postural drainage techniques to utilize gravity for secretion drainage from specific lung segments 1
• For patients unable to move spontaneously, use positioning, splinting, passive mobilization, and muscle stretching to preserve joint mobility 1

Airway Clearance Techniques

For Non-Intubated Patients:

1. Deep breathing exercises to increase inspiratory volume and improve regional ventilation 1

2. Forced expiratory techniques including:

   • Huffing (forced expiration with open glottis)
   • Controlled coughing (with closed glottis)
   • Forced Expiration Technique (FET) - more effective than instructed cough alone 3

3. Manual techniques for patients with weak cough:

   • Manually assisted cough using thoracic or abdominal compression 1
   • Chest percussion and vibration to loosen secretions 1

For Intubated Patients:

1. Manual hyperinflation (MHI) to prevent atelectasis, re-expand collapsed alveoli, and facilitate secretion movement 1
2. Airway suctioning - a critical component for secretion removal 1
3. Positive end-expiratory pressure (PEEP) ventilation to assist in secretion clearance 1

Pharmacological Interventions

• Nebulized mucolytics such as acetylcysteine (10-20% solution):

  • For face mask/mouthpiece delivery: 3-5 mL of 20% solution or 6-10 mL of 10% solution 3-4 times daily 4
  • For tracheostomy care: 1-2 mL of 10-20% solution every 1-4 hours by direct instillation 4

• Bronchodilator administration (e.g., beta-2 agonist) via nebulizer prior to airway clearance techniques to:

  • Promote bronchodilation
  • Alter physical properties of secretions to facilitate clearance 3

Hydration and Humidification

• Ensure adequate hydration to thin secretions and make them easier to clear 2
• Provide appropriate humidification of inspired gases:
  • Heated humidification for patients with thick, copious secretions 5
  • Humidification of inspired air to loosen thick secretions 2

Mechanical Devices for Secretion Clearance

• Positive Expiratory Pressure (PEP) devices to facilitate secretion clearance 1
• High-frequency oscillation devices to loosen secretions through airway vibration 1
• Intrapulmonary percussive ventilation for patients with atelectasis or neuromuscular weakness 6
• For patients with neuromuscular weakness, consider mechanical insufflation-exsufflation devices 1

Common Pitfalls and Considerations

1. Avoid routine saline instillation before suctioning as it is not supported by evidence 5

2. Use caution with nasal suctioning in patients with anticoagulation, bony/soft tissue injuries, or recent upper airway surgery 1

3. Monitor for adverse effects during airway clearance techniques:

   • Bronchospasm
   • Hypoxemia
   • Hemodynamic instability
   • Patient discomfort

4. Avoid delayed treatment of retained secretions as this can lead to persistent atelectasis, pneumonia, and respiratory failure 2

5. Consider specialized approaches for specific patient populations:

   • For patients with bronchiectasis: regular chest physiotherapy with monitoring for symptom improvement 1
   • For patients with neuromuscular disease: assisted cough techniques and ventilatory support 6

By implementing these first-line interventions systematically, pulmonary toilet can effectively improve secretion clearance, prevent respiratory complications, and optimize respiratory function in patients with secretion retention.