14.Management of Aspiration: Postural Drainage, Squeezing, and Huffing

Explanation

This module will focus on postural drainage, squeezing, and huffing, which are techniques commonly used to address aspiration, and are all basic skills in pulmonary rehabilitation.

Explanation

The technique used depends on the site of aspiration. Techniques such as postural drainage and squeezing are used for relatively distal aspiration up to the bronchi; techniques such as coughing and huffing are used for aspiration relatively central in the airway.

Explanation

Aspirated material is heavier than air, so gravity causes aspirated material retained in the lungs to move to lower in the body (ie. causing dependent lower lung disease. Postural drainage is a technique that promotes aspirated material to be expelled by placing the body in a specific position. In fact, the body is positioned so that the site where the aspirated is oriented upward. Although it would seem that the aspirated material could be expelled by placing the patient in a head-down position, this is generally not done anymore. One major reason is that patients with increased intracranial hypertension and heart failure need to have their head elevated, and a head-down position is contraindicated. Even in other cases, a head-down position should be avoided whenever possible because it causes patients discomfort.

Explanation

Squeezing is currently considered the most effective technique for assisted expectoration of sputum. It is indicated in patients with retention of sputum or aspirated material, shallow breathing, and a limited range of rib cage motion. Be aware if the patient has fractured ribs or any cardiac arrhythmia and note the locations of any surgical scars. Squeezing can move sputum or aspirated material that is retained in the relatively distal bronchi. To perform squeezing, place the palms of the hands on the rib cage at the position of the target lung field and apply light pressure as the rib cage moves during exhalation. Be sure to always combine squeezing with postural drainage.

Explanation

The upper and lower sections of the rib cage move in different ways: the upper section moves anteroposteriorly and the lower section moves mediolaterally. Try taking some deep breaths to confirm this for yourself. Squeezing involves applying light pressure as the rib cage moves, but experienced practitioners can actually control breathing by inducing rib cage movement.

Explanation

Position the patient in the supine position. Lightly place your hands on the upper section of the rib cage starting at the 4th rib. Apply light pressure as exhalation begins, and then gradually increase the pressure.

Explanation

This squeezing technique is used for the middle lobe of the right lung and the lingular segment of the left lung. Position the patient in an intermediate position between supine and lateral decubitus. Place your hands in the area between the 4th and 6th ribs.

Explanation

Position the patient in the lateral decubitus position. Place your hands above the spot where the midaxillary line and the 8th rib intersect.

Explanation

For squeezing at the basal segment of the lower lobe, position the patient in the three-quarter prone position, an intermediate position between lateral decubitus and prone. Place one hand dorsally above the 10th rib, and the other at the lateral thorax above the spot where the midaxillary line and 8th rib intersect.

Explanation

Techniques such as coughing and huffing are effective for expelling sputum or aspirated material that is retained relatively centrally in the airway. The vocal cords close during coughing, but they remain open during huffing, which is done by exhaling forcefully by making a "ha" sound.

Explanation

Having the patient exhale by making a "ha-ha" sound after inhalation is called forced exhalation. This technique is also used to expel sputum or aspirated material that is retained relatively proximal in the airway.

Explanation

The trachea branches into the left and right main bronchi at the level of the 5th thoracic vertebra, but the branch angle is 25° on the right side and 45° on the left side. This difference in angle makes it easier for sputum and aspirated material to enter on the right side. In one study, we took chest X-rays after videofluoroscopic evaluation of swallowing to determine where barium was retained in patients who had aspirated. We found that the barium had often already infiltrated the bronchi, and that it did indeed infiltrate the right bronchus more frequently. Therefore, it is reasonable to suspect the right bronchus if the site of aspiration is unknown.

Explanation

SpO₂ does not always decrease with aspiration. However, if SpO₂ does decrease and the amount of aspirated material is relatively large, we should suspect concurrent lung or heart disease or some other medically unstable condition. So, although a lack of change in SpO₂ does not rule out aspiration, we must recognize that a decrease in SpO₂ indicates a high-risk situation.

References

1. Kagaya H: Pulmonary rehabilitation in patients with dysphagia. J Jp Soc Resp Care Rehab. 21(1): 9-12, 2011.
2. Miyagawa T: A video guide to squeezing. Safe and effective techniques for sputum expulsion. Nakayama Shoten, Tokyo, 2005.
3. Tanaka T, Kagaya H, Yokoyama M, et al.: Early pulmonary complications after videofluoroscopic examination of swallowing. Jpn J Rehabil Med, 47(5): 320-323, 2010.