Stay informed with the latest updates on coronavirus (COVID-19). Find out more >>

Clinical Guidelines (Nursing)

Nurses role in advanced secretion clearance

  • Introduction

    Aim

    Definition of Terms

    Assessment

    Management

    Evidence Table

    References

    Introduction

    Children who experience respiratory distress may benefit from advanced secretion clearance techniques to optimize oxygenation and ventilation. Physiotherapists also provide this service within the hospital, but are not available during all hours. Should it be identified that physiotherapy input is required for secretion clearance, then a physiotherapy EMR referral should be completed, and physiotherapy contacted if within hours. This guideline should be utilised to guide advanced secretion clearance outside of physiotherapy hours, where a physiotherapy treatment plan does not yet exist, or if a plan has been pre-discussed with nursing staff.  Airway suctioning will not be discussed in this guideline as this is covered in local guidelines depending on department acuity.   

    Aim

    • Outline of appropriate patient groups for advanced secretion clearance
    • Outline the role of nurses in different departments for advanced secretion clearance techniques

    Definition of Terms 

    • ARDS: Acute Respiratory Distress Syndrome
    • ETT: Endotracheal tube, and artificial airway bypassing the vocal cords to provide airway and ventilation support
    • Manual hyperinflation: A bagging technique performed in ventilated patients which utilises a slow inspiration (to approx. 20% greater than set PIP), followed by an inspiratory hold and rapid exhalation
    • Mechanical In-exsufflation: Use of a mechanical device (e.g. CoughAssist®) to provide cycles of insufflation and exsufflation pressures to the lungs to facilitate secretions clearance
    • PEP: Positive expiratory pressure techniques (e.g. PEP mask, bubble PEP) are prescribed by physiotherapists to facilitate secretion clearance by providing an expiratory resistance which can improve collateral ventilation, inflation of partially closed lung units and secretions clearance.
    • PICU: Paediatric Intensive Care Unit
    • PIP: Peak Inspiratory Pressure
    • SMI: Performance of a voluntary Sustained Maximal Inflation at the peak of a deep inspiratory breath whereby the breath is held for 2-3 seconds before exhalation.  Used to facilitate recruitment of poorly filled lung units. 

    Assessment

    Criteria for advanced secretion clearance: 
    1. Advanced secretion clearance should not be considered routine and the rationale for treatment should be based on excessive secretions, atelectasis or abnormal gas exchange. 
    2. Collaboration with physiotherapists regarding the patient’s cardiorespiratory physiology, chest mechanics and evidence for these techniques is essential. 

    Patient assessment should include:

    • Nursing assessment: See Nursing assessment
    • History: Antenatal and birth history, weight, co-morbidities, medications
    • Respiratory assessment: See assessment of severity of respiratory conditions
    • Auscultation: Listen for evidence of secretions or decreased air entry
    • Review of recent chest X-ray: Evidence of consolidation or lobular collapse, ‘ground glass’ appearance as seen in ARDS
    • Review patients’ level of tolerance for handling and fatigue level- consider recent sleeping patterns. Over treatment can be as harmful as undertreatment.
    • Review recent laboratory results: Blood gas, FBE, platelets  
    • Assessment of patients’ pain level using appropriate pain tool

    Advanced secretion clearance techniques can contribute to haemodynamic instability, further respiratory compromise and rib fractures if performed inappropriately. Therefore careful assessment should be undertaken to assess if the intervention is likely to be of benefit and whether there are any contraindications to treatment. 

    Table 1 outlines which conditions have been acknowledged as receiving benefit from advanced airway clearance techniques strategies by a nurse. Other conditions which are deemed as having no benefit from advanced airway clearance should not be undertaken unless by a physiotherapist.  

    Related Clinical Practice guidelines 

    Table 1:

     Patient condition Strategies initiated by nurse

    Chronic disease with large amounts of sputum

    • cystic fibrosis
    • chronic bronchitis
    Encourage patient to complete usual (home) airway clearance technique
    Positioning
    Chest percussion and vibrations 
    Manual hyperinflation (intubated) *PICU only
    Deep breathing with SMI and coughing 
    Review from physiotherapist
    Acute lobar atelectasis (ventilated) Adequate ventilation, bagging, manual hyperinflation *PICU only
    Review from physiotherapist
    Atelectasis (post extubation) Deep breathing with SMI and coughing

    Positioning and mobilisation

    Encourage patient to complete usual home airway clearance regime if applicable

    Pneumonia in a neurologically compromised child  (e.g. Cerebral Palsy) Positioning and sitting out of bed.
    Manual hyperinflation (intubated) *PICU only
    Review from physiotherapist
    Pneumonia in a typically developing child/Pneumonia in child with no other co-morbidity (ventilated)

    Manual hyperinflation *PICU only

    Review from physiotherapist if ongoing sputum retention issues or unable to clear secretions with nursing strategies alone.

    Neuromuscular disease
    Review from physiotherapist
    Intubated neonate
    Review from physiotherapist
    Trauma
    Deep breathing with SMI and coughing 
    Positioning and mobilisation within scope of injury.
    Review from physiotherapist if ongoing sputum retention issues

    Table 2 

     Conditions where respiratory physiotherapy is NOT indicated Pneumonia in typically developing child/ with no comorbidity (non-ventilated)
    Bronchiolitis
    Acute asthma/severe bronchospasm
    Croup
    ARDS


    Management 

    Nursing scope of practice will vary in regards to the degree of advanced secretion clearance that can be provided in different departments in the hospital. Non-intensive care areas are differentiated from the PICU due to variations in scope of practice and the clinical environment.

    Please consider patients illness profile when selecting treatment options, and always seek guidance from medical colleagues when planning to provide advanced secretion clearance.

    Table 3

    Advanced secretion clearance treatment technique Contraindications (do NOT perform technique) Precautions (seek medical clearance prior)
    Percussions and vibrations
    • Thrombocytopenia or other haematological abnormalities (e.g. immunology/oncology/critically ill patients with neutropenia, reduced platelet counts, post liver transplant)
    • Coagulopathy
    • Osteopenia or osteoporosis with previous fractures
    • Rib fractures
    • Bronchospasm
    • Over area of subcutaneous emphysema
    • Over wound areas (including over thoracotomy)
    • Lung contusions
    • Asthma
    • Chest wall pain
    • Critically ill patients
    • Paediatric patients post cardiac surgery
    • Bronchiolitis (can worsen symptoms)
    • Young infants
    • Reduced head control (will need to stabilise head with one hand)
    • Reduced sensation or recent epidural
    Positioning and sitting out of bed
    • Head down tilt NOT allowed, especially in patients with GOR.
    • Trauma patients – based on injuries, spinal precautions and tertiary survey status, will need clearance of these and clear positioning/mobility recommendations prior to completing any positioning or transfers.
    • Cardiovascular instability
    • Pain
    • Respiratory instability
    • Raised ICP
    Deep breathing with SMI and coughing    
    • Pain – will need adequate pain control prior
    • Inability to follow commands
    Manual hyperinflation (PICU only)
    • Pneumothorax with no ICC insitu
    • Fractured ribs
    • Bronchopleural fistula
    • Lung transplant
    • Acute head injury (risk of increased ICP)
    • Haemodynamic instability (risk of decreased MAP)
    • Acute asthma/Severe bronchospasm
    • Bullae/cysts
    • Oesophageal surgery
    • Ventilator PIP >30cmH2O
    • Presence of ICC (draining pneumothorax)
    • Frank haemoptysis
    • Restrictive lung conditions (pulmonary fibrosis, scoliosis – greater risk of barotraumas)
    • PEEP >10cmH2O (risk of de-recruitment with disconnection of ventilator)
    • ARDS (often already overinflated)
    •  
    Bubble PEP**
    • Pneumothorax with no ICC insitu
    • Acute asthma/severe bronchospasm
    • Frank/large haemoptysis
    • Pulmonary cysts
    • Recent nasal surgery or severe sinusitis
    • Post lung surgery where lung pleura has been damaged
    • Surgical emphysema
    • Immunocompromised (infection risk if not cleaned appropriately)
    • Poor swallow, decreased GCS or inability to follow commands (aspiration risk)
    • Reactive airways
    • Head injury
    • Patients requiring FiO2 >0.5
    • Lung transplants

    Non intensive care areas

    Effective coughing:

    • Assess if developmentally appropriate and patient can follow instructions
    • Position patient in an upright position supporting their head and neck if require
    • Provide adequate analgesia and support of any surgical wounds or sutures to prevent damage. For example holding a pillow or folded towel in front of their chest for sternal wound
    • Ask patient to take a few deep breaths and observe the expansion of their thorax
    • Ask the patient to take a deep breath and hold it at the peak of inspiration
    • Ask the patient to “huff” a few times then followed by a hard “huff” at the end of inspiration- this should trigger a cough 

    Postural drainage positions:

    • Postural drainage utilises the patient position to facilitate the removal of secretions with gravity.  In children modified postural drainage positions are used that do not involve any head-down positions
    • Auscultate the chest to determine the areas of the chest that need drainage
    • Administer appropriate pain relief and explain the procedure to the patient
    • Bronchodilators, nebulised saline or mucolytic agents may be administered prior to repositioning if prescribed 
    • Position the patient with the affected lung segment positioned uppermost, utilise pillows to maintain patient’s position.  If this does not appear to be having benefit or the patient is desaturating in this position try lying on the other side as some patients will clear more secretions from the dependent lung.
    • Encourage patient to cough or suction the patient’s airway to assist in secretion clearance.
    • Monitor the patients HR, RR and Sp02. Discontinue postural drainage (or change the postural drainage position) if tachycardia, dyspnoea or hypoxia occur.

    Mechanical in-exsufflation (e.g. CoughAssist®):

    • Mechanical in-exsufflation should only be performed in patients who have already been commenced on the treatment by a physiotherapist.
    • Nursing staff should only perform mechanical in-exsufflation if they have attended an annual education session by a physiotherapist or have had bedside training with a physiotherapist in the past year.  A patient-specific review and handover by a physiotherapist is also advised.
    • Position the patient appropriately ensuring their head is supported.
    • Check the settings on the mechanical in-exsufflation device against those prescribed for the patient in the EMR order
    • Provide a mechanical in-exsufflation cycle as outlined in the EMR order, clear secretions via suction and repeat as needed (monitoring for fatigue)
    • Setting prescriptions should only be modified by a physiotherapist. 

    Rosella (PICU) 

    Effective coughing:

    • When extubated, follow instructions as above

    Postural drainage positions:

    • As above

    Mechanical in-exsufflation (e.g. CoughAssist®):

    • As above

    Deep breathing with SMI following extubation:

    • Provide adequate pain relief 
    • Maintain the patients head in an neutral position with the bed elevated 30 to 40 degrees
    • Educate the patient to take a deep breath and hold it for approximately 3 seconds, encourage them to do this at least 10 times every hour
    • Include the parents in the education and encourage them to prompt their child each hour
    • Provide a rolled up towel or pillow to patients who have undergone a sternotomy or other surgery to the thorax or abdomen and encourage them to hug the towel to their chest or wound site when coughing to minimise discomfort

    Chest percussion and vibrations: 

    • Vibrations and percussions may be used in chronic disease with large amounts of sputum e.g. Cystic Fibrosis 
    • Obtain a physiotherapy assessment in all patient groups prior to using this technique
    • Position the patient according to location of specific lung pathology (or perform in alternate side-lie)
    • Ensure adequate padding with use of a folded towel over the rib area

    Percussion: 

    • Place patient in optimal postural drainage position
    • Perform rhythmic, firm tapping to the chest wall using a cupped hand over a segment of lung that has demonstrated consolidation or collapse (see figure 1)
    • Never perform on bare skin or over surgical incisions, below the ribs or over the spine or breasts due to risk of tissue damage
    • Percuss area for up to 5 minutes 

    Figure 1: Hand position for chest percussions 

    Nsg Advanced secretion fig 1

    Vibration: 

    • Place patient in optimal postural drainage position
    • Perform firm compressive vibrations to the chest wall during expiration (see figure 2). Movement sets up course vibrations in the airways to help loosen the secretions sticking to the walls of the airways.
    • Vibrations should be avoided over patients breasts, spine and sternum to avoid discomfort
    • 1-5 minutes of vibration is usually performed in each selected position.

    Figure 2: Hand position for chest vibrations 
    Nsg Advanced secretion fig 2

    Manual hyperinflation: 

    Manual hyperinflation should only be undertaken by nursing staff in the intensive care if it has been deemed an appropriate treatment by review from physiotherapy. Physiotherapists should provide nursing staff with documented plan for manual hyperinflation including maximum pressures and frequency of treatment. 

    Evidence Table

    Evidence table for this guideline can be found here

    References

    • Chaboyer, W., Gass, E., & Foster, M. (2004). Patterns of chest physiotherapy in Australian Intensive Care Units. Journal of Critical Care, 19(3), 145-151. doi: http://dx.doi.org/10.1016/j.jcrc.2004.07.00

    • Clini, E., & Ambrosino, N. (2005). Early physiotherapy in the respiratory intensive care unit. Respiritory Medicine, 99(9), 1096-1104. doi: 10.1016/j.rmed.2005.02.02
    • Denehy, L. (1999). The use of manual hyperinflation in airway clearance. European Respiratory Journal, 14(4), 958-965. doi:10.1034/j.1399-3003.1999.14d38.x
    • Fitzgerald, D. A., Follett, J., & Van Asperen, P. P. (2008;2009;). Assessing and managing lung disease and sleep disordered breathing in children with cerebral palsy. Paediatric Respiratory Reviews, 10(1), 18-24. doi:10.1016/j.prrv.2008.10.003
    • Pountney, T. (2007). Neonatal Care Physiotherapy for Children (pp. 73-90). Philadelphia: Elsevier Health Sciences.
    • Harris, M., Clark, J., Coote, N., Fletcher, P., Harnden, A., McKean, M.. On behalf of the British Thoracic Society Standards of Care Committee. (2011). British thoracic society guidelines for the management of community acquired pneumonia in children: Update 2011. Thorax, 66 Suppl 2(Suppl 2), ii1-ii23. doi:10.1136/thoraxjnl-2011-200598
    • Roqué i Figuls, M., Giné-Garriga, M., Granados Rugeles, C., Perrotta, C., & Vilaró, J. (2016). Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database of Systematic Reviews(2). doi: 10.1002/14651858.CD004873.pub5
    • Chatwin, M., Toussaint, M., Gonçalves, M. R., Sheers, N., Mellies, U., Gonzales-Bermejo, J., . . . Morrow, B. M. (2018). Airway clearance techniques in neuromuscular disorders: A state of the art review. Respiratory Medicine, 136, 98-110. doi:10.1016/j.rmed.2018.01.012
    • Shann, F. (2014). Drug Doses (16th ed.): Intensive Care Unit, Royal Children's Hospital, Parkville, Australia.
    • Tamburro, R. F., & Kneyber, M. C. (2015). Pulmonary specific ancillary treatment for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Critical Care Medicine, 16(5 Suppl 1), S61-72. doi: 10.1097/pcc.0000000000000434
    • Unsworth, A., Curtis, K., & Asha, S. E. (2015). Treatments for blunt chest trauma and their impact on patient outcomes and health service delivery. Scandinavian Journal of Trauma Resuscitation Emerg Medicine, 23, 17. doi: 10.1186/s13049-015-0091-5

    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Kate Lambert, CNC, Rosella Ward, Lisa Robson, Physiotherapist and approved by the Nursing Clinical Effectiveness Committee. Updated November 2020.