What are the best pulmonary toilet measures?

Best Pulmonary Toilet Measures

Chest physiotherapy (including postural drainage, percussion, and vibration) should be used in patients with hypersecretion of mucus and inability to expectorate effectively, with monitoring for symptom improvement, though these techniques have only modest effects on increasing sputum volume. 1

Primary Interventions

Manual Airway Clearance Techniques

• Chest percussion, vibration, and postural drainage are mainstays in treating conditions associated with mucus hypersecretion, particularly bronchiectasis, though long-term effectiveness remains unknown 1
• These maneuvers facilitate expectoration of mucus in patients unable to clear secretions effectively 1
• Vigorous, regimented cough sessions may be as effective as therapist-administered physiotherapy in removing pulmonary secretions 2
• Directed coughing alone can be as effective as more complex physiotherapy measures for bronchial toilet 2

Mechanical Airway Clearance Devices

• Intrapulmonary percussive ventilation (IPV) demonstrates superior effectiveness compared to high-frequency chest wall oscillation in improving respiratory muscle strength, small airway obstruction, and reducing sputum inflammatory cells 3
• Both IPV and high-frequency chest wall oscillation improve daily life activities and lung function in severe COPD patients 3
• Mechanically assisted cough devices should be considered when cough is weakened 1

Adjunctive Pharmacological Measures

Mucolytic Therapy

• Nebulized acetylcysteine (1-10 mL of 20% solution or 2-20 mL of 10% solution every 2-6 hours via face mask, mouthpiece, or tracheostomy) can be used to facilitate secretion clearance 4
• The recommended dose for most patients is 3-5 mL of 20% solution or 6-10 mL of 10% solution 3-4 times daily 4
• Inhalation of secretolytic aerosols (e.g., saline 0.9%) should precede breathing exercises 5

Bronchodilator Therapy

• Liberal use of bronchodilators should accompany airway clearance techniques to maximize pulmonary toilet 1
• Nebulized bronchodilators (salbutamol 2.5-5 mg or ipratropium 0.25-0.5 mg) should be administered in acute exacerbations 1, 6
• Bronchodilators are particularly useful when an asthmatic component is present 1

Respiratory Support Measures

Oxygen Therapy

• Controlled oxygen delivery targeting saturation 88-92% using 24-28% Venturi mask or 1-2 L/min nasal cannulae in COPD patients with compensated hypercapnia 7
• Oxygen can be continued via nasal prongs at 1-2 L/min during nebulization to prevent desaturation 1
• Supplemental oxygen should only be used for hypoxia when hypoventilation is not present 1

Non-Invasive Ventilation

• BiPAP should be initiated when respiratory acidosis develops (pH ≤7.35 with PaCO2 >45 mmHg), not for compensated hypercapnia alone 7
• Nocturnal non-invasive positive pressure ventilation (Bi-level) should be used for nocturnal hypoventilation before adding oxygen 1

Specific Techniques and Timing

Airway Suctioning

• Nasotracheal or orotracheal suctioning is required for patients with significant respiratory secretions who cannot clear them independently 1
• For tracheostomy patients, 1-2 mL of 10-20% acetylcysteine solution may be instilled every 1-4 hours 4

Assisted Coughing and Hyperinflation

• Assisted coughing maneuvers (e.g., Cough Assist In-Exsufflator) should be used liberally in conjunction with airway clearance techniques 1
• Hyperinflation therapy (e.g., intermittent positive pressure breathing) may benefit patients with significant respiratory muscle weakness 1
• Inspiratory muscle training may be important for maintaining pulmonary function 1

Critical Pitfalls to Avoid

• Do not rely on pulmonary function tests alone as outcome measures for short-term chest physiotherapy effectiveness, as they appear inadequate for this purpose 8
• Avoid initiating BiPAP based solely on elevated PaCO2; the key determinant is pH, not CO2 level alone 7
• Do not use aerosolized antibiotics in patients with idiopathic bronchiectasis (non-CF), as they may cause increased cough, dyspnea, and chest pain 1
• Postural drainage alone is not enhanced by mechanical percussion and may not be as effective as vigorous cough 2

Monitoring and Follow-up

• Recheck blood gases within 60 minutes of starting oxygen therapy or changing inspired oxygen concentration to ensure pH is not falling 1, 6
• Monitor patients for symptom improvement with ongoing chest physiotherapy 1
• Assessment of respiratory status should occur at each medical visit, focusing on cough quality, secretion clearance, and exercise tolerance 1