Pulmonary hygiene, formerly referred to as pulmonary toilet, is a set of methods used to clear

mucus Mucus ( ) is a slippery aqueous secretion produced by, and covering, mucous membranes. It is typically produced from cells found in mucous glands, although it may also originate from mixed glands, which contain both serous and mucous cells. It is ...

and

secretion 440px Secretion is the movement of material from one point to another, such as a secreted chemical substance from a cell or gland. In contrast, excretion is the removal of certain substances or waste products from a cell or organism. The classical ...

s from the

airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to th ...

s. The word ''pulmonary'' refers to the

lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...

s. The word ''

toilet A toilet is a piece of sanitary hardware that collects human urine and feces, and sometimes toilet paper, usually for disposal. Flush toilets use water, while dry or non-flush toilets do not. They can be designed for a sitting position popu ...

'', related to the French ''toilette'', refers to body care and

hygiene Hygiene is a series of practices performed to preserve health. According to the World Health Organization (WHO), "Hygiene refers to conditions and practices that help to maintain health and prevent the spread of diseases." Personal hygiene refer ...

; this root is used in words such as ''

toiletry Personal care or toiletries are consumer products used in personal hygiene, personal grooming or for beautification. Products Personal care includes products as diverse as cleansing pads, colognes, cotton swabs, cotton pads, deodorant, eye lin ...

'' that also relate to cleansing. Respiratory health (pulmonary hygiene) depends on consistent clearance of airway secretions. Normal airway clearance is accomplished by two important mechanisms: the

mucociliary clearance Mucociliary clearance (MCC), mucociliary transport, or the mucociliary escalator, describes the self-clearing mechanism of the airways in the respiratory system. It is one of the two protective processes for the lungs in removing inhaled particl ...

system and the ability to cough. Impaired mucociliary clearance is linked to poor lung function in a broad range of diseases and disabilities. Pulmonary hygiene prevents

atelectasis Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct ...

(the collapse of the

alveoli Alveolus (; pl. alveoli, adj. alveolar) is a general anatomical term for a concave cavity or pit. Uses in anatomy and zoology * Pulmonary alveolus, an air sac in the lungs ** Alveolar cell or pneumocyte ** Alveolar duct ** Alveolar macrophage * ...

of the lungs) and rids the respiratory system of secretions, which could cause

respiratory infection Respiratory tract infections (RTIs) are infectious diseases involving the respiratory tract. An infection of this type usually is further classified as an upper respiratory tract infection (URI or URTI) or a lower respiratory tract infection (LRI ...

s. It can also decrease

pulmonary shunt A pulmonary shunt is the passage of deoxygenated blood from the right side of the heart to the left without participation in gas exchange in the pulmonary capillaries. It is a pathological condition that results when the alveoli of parts of the lun ...

ing, increase the functional reserve capacity of the lungs, and prevent respiratory infection after

chest trauma A chest injury, also known as chest trauma, is any form of physical injury to the chest including the ribs, heart and lungs. Chest injuries account for 25% of all deaths from traumatic injury. Typically chest injuries are caused by blunt mechanism ...

. Methods include using suction to remove fluids and placing the patient in a position that allows secretions to drain by gravity.

Methods

Methods used for pulmonary hygiene include

suctioning Suction is the colloquial term to describe the air pressure differential between areas. Removing air from a space results in a pressure differential. Suction pressure is therefore limited by external air pressure. Even a perfect vacuum cannot ...

of the airways, chest physiotherapy, blow bottles, and nasotracheal suction.

Bronchoscopy Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a trac ...

, in which a tube is inserted into the airways so that an examiner can view them, can be used therapeutically as part of pulmonary hygiene.

Incentive spirometry An incentive spirometer is a handheld medical device used to help patients improve the functioning of their lungs. By training patients to take slow and deep breaths, this simplified spirometer facilitates lung expansion and strengthening. Patien ...

and use of

analgesic An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It ...

s (pain medications) that do not inhibit breathing are also parts of pulmonary toilet.

Coughing A cough is a sudden expulsion of air through the large breathing passages that can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three phas ...

is also important for ridding the airways of secretions, so healthcare providers are careful not to oversedate patients, because that could inhibit coughing.

Tracheotomy Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The ...

facilitates pulmonary toilet. Percussion, another method, loosens secretions and allows the

cilia The cilium, plural cilia (), is a membrane-bound organelle found on most types of eukaryotic cell, and certain microorganisms known as ciliates. Cilia are absent in bacteria and archaea. The cilium has the shape of a slender threadlike projecti ...

of the airways to remove material. Positioning is another method for promoting drainage of secretions; sometimes patients are placed in a

prone position Prone position () is a body position in which the person lies flat with the chest down and the back up. In anatomical terms of location, the dorsal side is up, and the ventral side is down. The supine position is the 180° contrast. Etymolog ...

to aid in this purpose.

Conventional chest physiotherapy

The most common treatment of

in the hospital setting is manual chest physiotherapy though there is limited evidence of its efficacy. Chest percussion and

postural drainage Postural drainage (PD) is the drainage of lung secretions using gravity. It is used to treat a variety of conditions that cause the build-up of secretions in the lungs. Uses Postural drainage is used to treat any condition that causes the build- ...

are used in

bronchiectasis Bronchiectasis is a disease in which there is permanent enlargement of parts of the bronchi, airways of the lung. Symptoms typically include a chronic cough with sputum, mucus production. Other symptoms include shortness of breath, hemoptysis, co ...

and lung

abscess An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends b ...

. The patient's body is positioned so that the

trachea The trachea, also known as the windpipe, is a Cartilage, cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs. The trachea extends ...

is inclined downward and below the affected chest area. Postural drainage is essential in treating bronchiectasis. Patients must receive

physiotherapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...

to learn to tip themselves into a position in which the lobe to be drained is uppermost at least three times daily for up to 30 minutes during each session. The treatment is often used in conjunction with a technique for loosening secretions in the chest cavity called chest percussion. Chest percussion is performed by clapping the back or chest with a cupped hand. Alternatively, a mechanical vibrator may be used in some cases to facilitate loosening of secretions. There are drainage positions for all segments of the lung. These positions are modified depending on the patient's condition and the location of the area in most need of therapy.

Intermittent positive pressure breathing (physiotherapy)

Intermittent positive pressure breathing (IPPB) physiotherapy has long been used in the intensive care setting in non-intubated patients. Although widely accepted, few studies have validated its efficacy. In a Respiratory Care Clinical Practice Guideline, IPPB is suggested for patients who have impaired airway clearance, and for delivery of aerosolized medications to patients with neuromuscular weakness who are incapable of inhaling deeply. IPPB physiotherapy should be used with caution in patients with severe, uncontrolled bronchospasm or severe airway obstruction

Mechanical insufflation-exsufflation physiotherapy

People with neuromuscular weakness and atelectasis benefit from mechanical insufflation-exsufflation. Mechanically-assisted coughing greatly improves secretion clearance in the setting of respiratory infection in the patient with neuromuscular disease and should be first-line therapy for this patient population. Mechanical insufflation-exsufflation physiotherapy is greatly aided by simultaneous manual augmentation of cough with either a thoracic squeeze or abdominal thrust during the expiratory phase (exhale). An American Thoracic Society consensus statement in 2004 supported the use of mechanical insufflation-exsufflation physiotherapy for patients with

Duchenne muscular dystrophy Duchenne muscular dystrophy (DMD) is a severe type of muscular dystrophy that primarily affects boys. Muscle weakness usually begins around the age of four, and worsens quickly. Muscle loss typically occurs first in the thighs and pelvis fol ...

. The use of this technique for children with neuromuscular disease has gained widespread acceptance in the United States and internationally.

Applications

Pulmonary bronchial hygiene is used for preventing infections such as

pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity ...

. It is also used in the management of conditions such as pneumonia and

cystic fibrosis Cystic fibrosis (CF) is a rare genetic disorder that affects mostly the lungs, but also the pancreas, liver, kidneys, and intestine. Long-term issues include difficulty breathing and coughing up mucus as a result of frequent lung infections. O ...

. For people with chronic

lung disease The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...

s, bronchial hygiene is used to prevent infections and

lung abscess Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection. This pus-filled cavity is often caused by aspiration, which may ...

es.Virk and Wilson, p. 153 Bronchial hygiene is also used to prevent

acute respiratory distress syndrome Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Symptoms include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin colo ...

after chest trauma.

Indications

The need for bronchial hygiene is indicated in cases of

COPD Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce mu ...

and

as both interventional and prophylactic. Prophylactic indications also include pre and post thoracic surgery to prevent atelectasis and respiratory infections.

Contraindications

The decision to use postural drainage therapy requires assessment of potential benefits versus potential risks. Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. Some of the contraindications include an increased intracranial pressure (>20 mmHg), any spinal injury acute or otherwise, active

hemoptysis Hemoptysis is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs. In other words, it is the airway bleeding. This can occur with lung cancer, infections such as tuberculosis, bronchitis, or pneumonia, and ...

pulmonary embolism Pulmonary embolism (PE) is a blockage of an pulmonary artery, artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include dyspnea, shortness of breath, chest pain p ...

, pulmonary edema with

congestive heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, a ...

and an open or healing wound in the area where chest physiotherapy is otherwise indicated. Medication contraindications vary depending on the medication being delivered.

References

{{Respiratory system procedures Respiratory system procedures Respiratory therapy