In this section
Definition of Terms
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.
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:
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
Chronic disease with large amounts of sputum
Positioning and mobilisation
Encourage patient to complete usual home airway clearance regime if applicable
Manual hyperinflation *PICU only
Review from physiotherapist if ongoing sputum retention issues or unable to clear secretions with nursing strategies alone.
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.
Figure 1: Hand position for chest percussions
Figure 2: Hand position for chest vibrations
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.
Should an aerosol generating procedure be undertaken on a patient under droplet precautions then increase to airborne precautions by donning N95/P2 mask for at least the duration of the procedure.
Evidence table for this guideline can be found here.
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:
Please remember to read the
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.