Bronchial Hygiene Therapy involves the use of noninvasive airway clearance techniques

designed to help mobilize and remove secretions and improve gas exchange.
Bronchial Hygiene Therapy accepted as part of the care of critically ill patients,
largely due to risks of ETT obstruction.
Short term, aim to
1. remove obstructive secretions from the airways thereby
2. reducing work of breathing;
3. improving delivery of mechanical ventilation;
4. improving gaseous exchange;
5. preventing and resolving respiratory complications;
6. facilitating early weaning from the ventilator
Longer term, aim to
1. Prevent postural deformities
2. Improve exercise tolerance
3. Return to optimal function
Indications for Bronchial Hygiene Therapy
indications or contraindications for or against Bronchial Hygiene Therapy should never
be formulated on the basis of diagnostic entities but should rather stem from a detailed
analysis of the prevailing individual pathophysiology.
Indications
Components for a patient to receive bronchial hygiene regimes are
Excessive sputum production.
more than 25-30 ml/day ( 1/4 cup or 12 teaspoons) is excessive.
Examples of common pathologies include:
*cystic fibrosis
*bronchitis
*and bronchiectasis.
ineffective cough.
Examples of causes for an ineffective cough are Weakness, pain, and placement of an
artificial airway.
PROPHYLACTIC
- Pre-operative high risk surgical patient
- Post-operative patient who is unable to mobilize secretions
- Neurological patient who is unable to cough effectively
- Patient receiving mechanical ventilation who has a tendency to retain secretions
- Patients with pulmonary disease,
who needs to improve bronchial hygiene
THERAPEUTIC
- Atelectasis due to secretions
- Retained secretions
- abnormal breathing pattern due to primary or secondary pulmonary dysfunction
- COPD and resultant decreased exercise
tolerance
- Musculoskeletal deformity that makes breathing, pattern and cough ineffective
Minimal to no benefit
Acute asthma

Bronchiolitis
Respiratory failure without atelectasis
Prevention of post-extubation atelectasis in neonates
Hyaline membrane disease
Prevention of atelectasis following surgery
Undrained pleural collections
Contraindications
Specific contraindications for bronchial hygiene therapy are:
elevated intracranial pressure
acute, unstable head, neck or spine injury
increased risk of aspiration
cardiac instability
pulmonary embolism and pulmonary edema associated with congestive heart
failure.
Complications
hypoxia
increased metabolic demand and O2 consumption
cardiac arrythmias
changes in blood pressure
raised intracranial pressure and decreased cerebral oxygenation
gastro-oesophageal reflux
pneumothoraces
atelectasis and
death.
Goals
Prevent accumulation of secretions
Improve mobilization and drainage of secretions
Promote relaxation to improve breathing patterns
Promote improved respiratory function
Improve cardio-pulmonary exercise tolerance
Teach bronchial hygiene programs to patients with chronic respiratory dysfunction
Traditional Forms Of Bronchopulmonary Hygiene Therapy
The three traditional methods of BHT are:
Directed cough
Postural drainage
External manipulation of the thorax.
Techniques
Positioning
Chest tapotement techniques
Manual hyperinflation
Airway suctioning
Coughing techniques
Breathing exercises
Neuro physiological facilitation

Controlled mobilization
Patient education

CHEST PHYSIOTHERAPY
Definition
Chest physiotherapy (CPT) is a group of therapies for mobilizing pulmonary secretions.
These therapies include chest percussion, vibration and postural drainage.CPT is
followed by productive coughing or suctioning of a patient who has a decreased ability to
cough.This is especially helpful for patients with large amount of secretions or ineffective
cough.
Indications:
It is indicated for patients in whom cough is insufficient to clear thick, tenacious, or
localized secretions.
Cystic fibrosis
Bronchiectasis
Atelctasis
Lung abscess
Pneumonia
Contraindications
Increased ICP
Unstable head or neck injury
Active hemorrhage or hemoptysis
Recent spinal injury
Rib fracture
Flail chest
Uncontrolled hypertension
Anticoagulation
Thoracic surgeries
Assessment for Chest Physiotherapy
Assess the vital signs
Know the patients medications. Certain medications, particularly diuretics
antihypertensive cause fluid and haemodynamic changes. These decrease
patients tolerance to positional changes and postural drainage
Assess for any contra indications
Assessment for Chest Physiotherapy
Perform detailed physical examination of the chest
Review the patients X-ray and other blood investigations.
Techniques in Chest Physiotherapy
Chest physiotherapy consists of three techniques:
1. Percussion / Clapping/ Cupping
2. Vibration
3. Postural Drainage
1. Percussion / Clapping

Chest percussion involves rhythmically clapping on the chest wall over the area being
drained to force secretions into larger airways for expectoration.
Position the hand so the fingers and thumb touch and the hands are cupped.
Perform chest percussion by vigorously striking the chest wall alternately with cupped
hands.
The procedure should produce a hollow sound and should not be painful.
Perform percussion over a single layer of clothing, not over buttons or zippers.
Percussion is contraindicated in patients with bleeding disorders, osteoporosis, fractured
ribs and open wounds and surgeries.
Dont percuss over the spine, sternum, stomach or lower back as trauma can occur to
the spleen, liver, or kidneys.
Typically, each area is percussed for 30 to 6o seconds several times a day.
If the patient has tenacious secretions, the area must be percussed for 3-5 minutes
several times per day.
2. Vibration
Vibration is a gentle, shaking pressure applied to the chest wall to move secretions into
larger airways.
The nurse uses rhythmic contractions and relaxations of arm and shoulder muscles over
the patients chest.
During vibration, place your flat hand firmly against the chest wall, on the appropriate
lung segment to be drained.
Vibrate the chest wall as the patient exhales slowly through the pursed lips.
After each vibration, encourage the client to cough and expectorate secretions into the
sputum container.
3. Postural Drainage
Postural drainage is a technique in which different positions are assumed to facilitate the
drainage of secretions from the bronchial airways.
Gravity helps to move the secretions to the trachea to be coughed up easily.
The goal of postural drainage is to help drain mucus from the affected lobes into the
larger airways of the lungs so it can be coughed up more readily.
All the patients do not require postural drainage for all the lung segments. So the
procedure must be based on the clinical findings.
In postural drainage, the person is tilted or propped at an angle to help drain secretions
from the lungs.
The lower lobes require drainage most frequently because the upper lobes drain by
gravity.
Before postural drainage, the client may be given a bronchodilator medication or
nebulization therapy to loosen secretions.
Postural drainage treatments are scheduled two or three times daily, depending on the
degree of lung congestion.
The best times include before breakfast, before lunch, in the late afternoon, and before
bedtime.

It is best to avoid hours shortly after meals because postural drainage at these times can
be tiring and can induce vomiting
After positioning the client Have the patient remain in the desired position for 10 to 15
minutes, if tolerated.
Perform percussion and vibration by keeping the client in position.
The sequence for chest physiotherapy is usually as follows:
Positioning, percussion, vibration, and removal of secretions by coughing or suction
Documentation
Following chest physiotherapy , the nurse should auscultate the clients lungs, compare
the findings to the baseline data, and document the amount, color, and character of
expectorated secretions.

INTERCOSTAL DRAINGE
Chest drains also known as under water sealed drains (UWSD) are inserted to allow
draining of the pleural spaces of air, blood or fluid, allowing expansion of the lungs and
restoration of negative pressure in the thoracic cavity. The underwater seal also prevents
backflow of air or fluid into the pleural cavity. Appropriate chest drain management is
required to maintain respiratory function and haemodynamic stability.Chest drains may
be placed routinely in theatre, PICU & NNU; or in the emergency department and ward
areas in emergency situations.
INDICATIONS FOR INSERTION OF A CHEST DRAIN
Post operatively e.g. cardiac surgery, thoracotomy
Pneumothorax
Haemothorax
Chylothorax
Pleural effusions
PATIENT ASSESSMENT
Vital signs

PICU and NNU patients should be on continuous monitoring

o HR, SaO2, BP, RR
o Routine vital signs:

Pain

Chest tubes are painful as the parietal pleura is very sensitive. Patients require regular pain
relief for comfort, and to allow them to complete physiotherapy or mobilise

Pain assessment should be conducted frequently and documented

Drain insertion site

Observe for signs of infection and inflammation and document findings

Check dressing is clean and intact

Observe sutures remain intact & secure (particularly long term drains where sutures may
erode over time)
Assessment of chest tube and system tubing should occur at the beginning of the shift and every
hour throughout the shift
UWSD Unit & tubing

Never lift drain above chest level

The unit and all tubing should be below patients chest level to facilitate drainage

Tubing should have no kinks or obstructions that may inhibit drainage

Ensure all connections between chest tubes and drainage unit are tight and secure
o Connections should have cable ties in place

Tubing should be anchored to the patients skin to prevent pulling of the drain

In PICU and NNU tubing should also be secured to patient bed to prevent accidental
removal

Ensure the unit is securely positioned on its stand or hanging on the bed

Ensure the water seal is maintained at 2cm at all times

Suction

Suction is not always required, and may lead to tissue trauma and prolongation of an air leak
in some patients

If suction is required orders should be written by medical staff

o Some clinical areas may use the orange 'Chest Drain Orders" sticker. This should be
placed in the patient progress notes.

Wall suction should be set at >80mmHg or higher

Suction on the Drainage unit should be set to the prescribed level

o -5 cmH20 is commonly used for neonates
o -10 cmH20 to -20 cmH20 is usually used by convention for children

To check suction:

o Atrium Oasis UWSD:

The bellows should be out to the '?' mark @ 20 cmH20

Any visible expansion of the bellows is adequate for suction <20 cmH20

If the bellows deflate, check the wall suction is still working, set to > 80mmHg and
that the suction tubing is not kinked

Atrium Ocean UWSD:

The water level in the suction chamber should be at prescribed level

The level may drop due to evaporation, top up as per manufacturers instructions

Drainage

Milking of chest drains is only to be done with written orders from medical staff. Milking drains
creates a high negative pressure that can cause pain, tissue trauma and bleeding

Volume
o Document hourly the amount of fluid in the drainage chamber on the Fluid Balance
Chart

Calculate and document total hourly output if multiple drains

Calculate and document cumulative total output

Notify medical staff if there is a sudden increase in amount of drainage

greater than 5mls/kg in 1 hour

greater than 3mls/kg consistently for 3 hours

Blocked drains are a major concern for cardiac surgical patients due to the risk of
cardiac tamponade

notify medical staff if a drain with ongoing loss suddenly stops draining

If the chamber tips over and blood has spilt into next chamber, simply tip the
chamber up to allow blood to flow to original chamber

Colour and Consistency

Monitor the colour/type of the drainage. If there is a change eg. Haemoserous to

bright red or serous to creamy, notify medical staff.

Air Leak (bubbling)

An air leak will be characterised by intermittent bubbling in the water seal chamber when the
patient with a pneumothorax exhales or coughs.

The severity of the leak will be indicated by numerical grading on the UWSD (1-small leak 5large leak)

Continuous bubbling of this chamber indicates large air leak between the drain & the patient.
Check drain for disconnection, dislodgement and loose connection, and assess patient
condition. Notify medical staff immediately if problem cannot be remedied.

Document on Fluid Balance Chart

Oscillation (swing)

The water in the water seal chamber will rise and fall (swing) with respirations. This will
diminish as the pneumothorax resolves.

Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked.

Cardiac surgical patients may have some of their drains in the mediastinum in which case
there will be no swing in the water seal chamber.

Document on Fluid Balance Chart

QUIPMENT BY THE BEDSIDE

Drain Clamps: At least 2 drain clamps per drain

For use in emergency only e.g. accidental disconnection

Two suction outlets: One for chest drain & one for airway management

CHANGING THE CHAMBER

Indications
o The chest drain chamber needs to be replaced when it is full or when the UWSD
system sterility has been compromised eg. Accidental disconnection.

Equipment Required

o New UWSD
o Dressing pack
o Gloves
o Eye Protection

Procedure

o Perform hand hygiene

o Use personal protective equipment to protect from possible body fluid exposure
o Using an aseptic technique, remove the unit from packaging and place adjacent to old
chamber
o Prepare the new UWSD as per manufacturers directions supplied with drain
o Ensure patients drain is clamped to prevent air being sucked back into chest
o Disconnect old chamber by holding down the clip on the in line connector to pull the
tubing away from the chamber.
o Insert the tubing into the new chamber until you hear it click Unclamp the chest drain
o Check drain is back on suction
o Place old chamber into yellow infectious waste bag & tie
o Perform hand hygiene
REMOVAL OF CHEST DRAINS

Must be a written order by medical staff

Indications
o Absence of an air leak (pneumothorax)
o Drainage diminishes to little or nothing

o No evidence of respiratory compromise

o Chest x-ray showing lung re-expansion

Equipment required

o Dressing trolley with Yellow Infectious waste bag attached

o Dressing pack (sterile towel, sterile gauze)
o Sterile Gloves
o Steristrips
o Suture Cutter
o Band Aids
o Normal Saline
o Clamps
o Eye Protection
o Occlusive dressing
o Sharps container

Patient preparation

o Inform patient and parent about removal and possible associated pain. Explain the
removal process to the patient and carer
o Discuss the plan for procedural pain management and non-pharmacological pain
management to assist with comfort throughout procedure, assess analgesic
requirements first and then consider the need for procedural sedation; please refer to
the Procedural Sedation Ward and Ambulatory Areas at RCH policy for more
information.

Procedure

The removal of chest drains should be completed using a Standard Aseptic Technique,
please refer to the Aseptic Technique Policy for more information
o Perform hand hygiene
o Opening dressing pack and add sterile equipment and 0.9% saline
o Don disposable gloves

o Remove all dressings around the area

o Turn off suction
o Clamp drain tubing

If there are multiple drains insitu, clamp all drains before removal. Once the
required drains are removed, unclamp remaining drains

Remove disposable gloves, perform hand hygiene and don sterile gloves

Place sterile towel under tubes

Clean around catheter insertion site and 1-2cm of the tubing with 0.9% Saline

If purse string present (cardiac patients) unwind in preparation for assistant to tie

Remove suture securing drain (ensuring purse string suture not cut)

Pinching the edges of the skin together, rotate tubing from side to side gently to
loosen, then remove the drain using smooth, but fast, continuous traction.

Instruct patient exhale and hold if they are old enough to cooperate; if not, time
removal with exhalation as best as possible.

Pinching the edges of the skin together, remove the drain using smooth, but fast,
continuous traction.

The assistant pulls purse string suture closed as soon as the drain is removed,
tying 2 knots and ensuring the suture is not pulled too tight. Cut tails of suture
about 2cm from knot

If there is no purse string present remove drain and quickly seal hole with
occlusive dressing

Instruct patient to breathe normally again

Apply occlusive dressing (bandaid for cardiac children) over site

Remove and discard equipment into a yellow infectious waste bag and tie

Perform hand hygiene

2. Post Procedure Care

Attend to patients comfort and sedation score as per procedural sedation

guideline

CXR should be performed post drain removal

Patients in PICU may wait until routine daily CXR if clinically well

Clinical status is the best indicator of a reaccumulation of air or fluid. CXR should
be performed if patient condition deteriorates

Monitor vital signs closely (HR, SaO2, RR and BP) on removal and then every
hour for 4 hours post removal, and then as per clinical condition

Document the removal of drain in progress notes and on patient care record

Remove sutures 5 days post drain removal

Dressing to remain insitu for 24 hours post removal unless dirty

Complications post drain removal include pneumothorax, bleeding and infection

of the drain site

POST REMOVAL

Monitor site for signs of infection, obtain swabs or samples if required

Monitor and mark dressings to observe leakage, replace dressings as required to minimise risk
of infection.

Excessive leakage should be reported to AUM or surgeon.

Dressing should be removed when wound has healed (3-5days)

BREATHING EXERCISE
BREATHING EXERCISE are the fundamental interventions for the prevention for
acute and chronic pulmonary disease mainly for COPD (chronic bronchitis,
emphysema and asthma), patients with high spinal cord lesion and who underwent
thoracic and abdominal surgery and bedridden patients.Studies indicate that
breathing exercise have affect and alter a patients rate and depth of ventilation ,so
these technique is used to improve the pulmonary status and increase patients
overall endurance.
GOALS OF BREATHING EXERCISE
Improve ventilation
Increase the effectiveness of cough and promote airway clearance
To prevent post operative pulmonary complications
To improve the strength endurance coordination of the muscles of ventilation
Maintain and improve chest and thoracic spine mobility
Promote relaxation and relive stress

To teach the patient how to deal with episodes of dyspnea

Assisting in removal of secretions.
Correct abnormal breathing patterns and decrease the work of breathing.
Aid in bronchial hygiene---Prevent accumulation of pulmonary secretions,
mobilization of these secretions, and improve the cough mechanism.

GUIDELINE FOR TEACHING BREATHING EXERCISES

Choose a quiet area-to get a proper interaction with minimal distraction
Explain the patient about the aim and how it works for his impairment
Have the pat: in relaxed position and loosen the clothes, make him in semi-fowlers
position with head and trunk elevated approx: 45 (total support to the head and
trunk and flexing the hip and knees with pillow support) the abdominal muscle
become relaxed
Other positions, such as supine, sitting, or standing, may be used as the patient
progresses during treatment.
Observe and access the patients spontaneous breathing pattern while at rest and
during activity
Determine whether Rx is indicated or not
If necessary teach the patient relaxation techniques, relax the muscles of upper
thorax neck and shoulder to minimize the use of accessory muscle work.
Special attention on sternocleidomastoids,upper trapezius and levator scapulae
Demonstrate the breathing pattern to the patient
Have the patient practice the correct technique in verity of positions at rest and
with activity
PRECUATIONS
Never allow the patient to force expiration-it may increase the turbulence in the air
way which leads to bronchospasm and airway resistance
Avoid prolonged expiration-it cause the patient to gasp with the next inspiration
and the breathing pattern become irregular and inefficient
Do not allow the patient to initiate inspiration with accessory muscles and upper
chest ,advise him that upper chest should be quiet during breathing
Allow the patient to perform deep breathing only for 3-4 times (inspiration and
expirations) to avoid hyperventilation
INDICATIONS
Cystic fibrosis
Bronchiectasis
Atelectasis
Lung abscess
Pneumonias
Acute lung disease
COPD emphysema, chronic bronchitis

 For patients with a high spinal cord lesion/ spinal cord injury, myopathies etc.
After surgeries (thoracic or abdominal surgery)
For patients who must remain in bed for an extended period of time.(obstruction
due to retained secretions)
As relaxation procedure.
TYPES OF BREATHING EXERCISES
Diaphragmatic breathing
Glossophryngeal breathing
Pursed lip breathing
Segmental breathing(costal expansion exercise)
a) Apical breathing
b) Lateral costal expansion
c) Posterior basal expansion
1. DIAPHRAGMATIC BREATHING
Diaphragm is the primary muscle for breathing (inspiration) diaphragm controls
breathing at an involuntary level ,a patient with primary pulmonary disease like
COPD can be taught breathing control by optimal use of diaphragm and relaxation
of accessory muscles
Diaphragmatic breathing ex: are also use to mobilize lung secretion in PD
PROCEDURE
Prepare the patient in relaxed and comfortable position in which the gravity assist
the diaphragm such as semi-fowlers position
If you notice any accessory muscle activation stop him and do relaxation
techniques (shoulder roll or shrugs coupled with relaxation)
Place your hands over the rectus abdominis just below the ant: costal margin ask
the patient to breath slowly and deeply via nose by keeping the shoulder relaxed
and upper chest quiet allowing the abdominal to rise now ask him to slowly let all
the air out using controlled expiration through mouth.
Have him to practice this for 2-4 times if he finds any difficulty in using diaphragm
have the patient inhale several times in succession through the nose by using
sniffing action this facilitates the diaphragm
For self monitor have the patients hand over the ant: costal margin and feel the
movt: (hand rise and fall) by placing one hand over abdomen he can also feel the
contraction of abdominal muscles which occurs with controlled expiration or
coughing
After he understands and able to do the controlled breathing using a
diaphragmatic pattern keep the shoulder relaxed and practice in verity of positions
(supine sitting standing) and during activity (walking and climbing stair)
RE EDUCATION OF DIAPHRAGM:
Place the index and middle finger below the lower costal margin anteriorly in half
lying position over the insertion of diaphragm (central tendon)

 At the end of expiration when diaphragm is relaxed, stretch stimulus is given to the
diaphragm to elicit Stretch reflex of the diaphragm and patient is instructed to take
breath in.
Resisted diaphragmatic breathing
PT use small weight, such as sandbag to strengthen and improve the endurance of
the diaphragm
Have the patient in a head up position
Place a small weight (3-5 lb) over the epigastric region of his abdomen (1.30- 2.20
kg)
Tell the patient to breath in deeply while trying to keep the upper chest quiet
Gradually increase the time that the patient breaths against the resistance of
weight
Weight can be increased when he can sustain diaphragmatic breathing pattern
with out the use of any accessory muscles of inspiration for 15minuts
2. Glossophryngeal breathing
It is a means of increasing a patients inspiratory capacity when there is a severe
weakness of the muscle of inspiration
It is taught to patients who have difficulty in deep breathing.
This type of breathing pattern was originally developed to assist post polio
patients with severe muscle weakness
PROCEDURE
Patient take several gulp of air by closing the mouth the tongue pushes the air
back and trap it in the pharynx the air is then forced to lungs when the glottis is
opened
3. PURSED LIP BREATHING
Pursed-lip breathing is a strategy that involves lightly pursing the lips together
during controlled exhalation.
Taught to patients with COPD to deal with episodes of dyspnea.
It helps to Improves ventilation and Releases trapped air in the lungs
Keeps the airways open longer and Prolong exhalation slow the breathing rate
It moves old air out of the lungs and allow new air to enter the lungs
PROCEDURE
Patient in a comfortable position and relaxed, explain the patent about the
expiration phase (it should be relaxed and passive)
abdominal muscle contraction must be avoided (therapist hand over the patients
abdominal to check for contraction)
Ask the patient to breathe in slowly and deeply through the nose and then breathe
out gently through lightly pursed lips (blowing on and bending the flame of a
candle )
By providing slight resistance an increased positive pressure will generate with in
the airway which helps to keep open small bronchioles that otherwise collapse

 It can be applied as a 3-5 minutes rescue exercise or an Emergency Procedure to

counteract acute exacerbations or dyspnea (shortage of air or breathlessness) in
COPD and asthma.
4. SEGMENTAL BREATHING
It is performed on a segment of lung, or a section of chest wall that needs
increased ventilation or movement.
Hypoventilation occur in certain areas of the lungs because of chest wall fibrosis,
pain after surgery, atelectasis , trauma to chest wall, pneumonia and post
mastectomy scar
Therefore, it will be important to emphasize expansion of such areas of the lungs
and chest wall
ADVANTAGES OF SEGMENTAL BREATHING
Prevent accumulation of pleural fluid and secreations
Decreases paradoxical breathing
Decrease panic
Improve chest mobility
5. Lateral costal expansion
This is sometimes called lateral basal expansion and may be done unilaterally or
bilaterally.
The patient may be sitting or in a hook lying position.
Place your hands along the lateral aspect of the lower ribs
Ask the patient to breathe out, and feel the rib cage move downward and inward.
As the patient breathes out, place firm downward pressure into the ribs with the
palms of your hands.
Just prior to inspiration, apply a quick downward and inward stretch to the chest.
This places a quick stretch on the external intercostals to facilitate their
contraction. These muscles move the ribs outward and upward during inspiration.
Apply light manual resistance to the lower ribs to increase sensory awareness as
the patient breathes in deeply and the chest expands.
When the patient breathes out, assist by gently squeezing the rib cage in a
downward and inward direction.
The patient may then taught to perform the maneuver independently, ask him to
apply resistance with his hand or with a towel
Posterior basal expansion
This form of segmental breathing is important for the post surgical patients who is
in bed in a semi-reclining position for an extended period of time
Secretion often accumulate over the posterior segments of lower lobes
Procedure
Have the patient sit and lean forward on a pillow, slightly bending the hips

 Place the PT hand over the posterior aspect of the lower rib and do the same
procedure in lateral costal expansion
6. FORCED EXPIRATORY TECHINIQUES
The FET employs a forced expiration or huff following a medium size breath to mid
lung volume then tighten the abdominal muscle firmly while huffing (expiring
forcefully with an open glottis) with out contracting the throat muscles
There should be a period of 15-30 sec relaxation with gentle diaphragmatic
breathing that follow 1 or 2 huffs
Once secretions is felt on the upper most airway a huff or double cough can
remove it

Nebulization
Nebulization is the process of medication administration via inhalation. It utilizes a
nebulizer which transports medications to the lungs by means of mist inhalation.
Indication
Nebulization therapy is used to deliver medications along the respiratory tract and is
indicated to various respiratory problems and diseases such as:
Bronchospasms
Chest tightness
Excessive and thick mucus secretions
Respiratory congestions
Pneumonia
Atelectasis
Asthma
Contraindications
In some cases, nebulization is restricted or avoided due to possible untoward results or
rather decreased effectiveness such as:
Patients with unstable and increased blood pressure
Individuals with cardiac irritability (may result to dysrhythmias)
Persons with increased pulses
Unconscious patients (inhalation may be done via mask but the therapeutic
effect may be significantly low)
Equipments
Nebulizer and nebulizer connecting tubes
Compressor oxygen tank
Mouthpiece/mask
Respiratory medication to be administered
Normal saline solution
Procedure
Position the patient appropriately, allowing optimal ventilation.
Assess and record breath sounds, respiratory status, pulse rate and other
significant respiratory functions.

Teach patient the proper way of inhalation:

Slow inhalation through the mouth via the mouthpiece
Short pause after the inspiration
Slow and complete exhalation
Some resting breaths before another deep inhalation
Prepare equipments at hand
Check doctors orders for the medication, prepare thereafter
Place the medication in the nebulizer while adding the amount of saline solution
ordered.
Attach the nebulizer to the compressed gas source
Attach the connecting tubes and mouthpiece to the nebulizer
Turn the machine on (notice the mist produced by the nebulizer)
Offer the nebulizer to the patient, offer assistance until he is able to perform
proper inhalation (if unable to hold the nebulizer [pediatric/geriatric/special cases],
replace the mouthpiece with mask
Continue until medication is consumed
Reassess patient status from breath sounds, respiratory status, pulse rate and
other significant respiratory functions needed. Compare and record significant
changes and improvement
Complications
Possible effects and reactions after nebulisation therapy are as follows:
Palpitations
Tremors
Tachycardia
Headache
Nausea
Bronchospasms (too much ventilation may result or exacerbate bronchospasms)