PICU and 8 South/8 Central Clinical Pathway for Non-pharmacologic
Airway Clearance/Hyperinflation Therapy for Children > 30 Days of Age
Related Pathways
Physician/Advanced Practice Provider (APP): Initiates Non-pharmacologic Airway Clearance Pathway order in EMR for patients meeting cohort definition
- Respiratory Therapist:
- Performs patient assessment at the bedside using Clinical Assessment Scoring Tool
- Calculates Clinical Score
- Discusses with the clinical team
- Determines, writes, and pends orders for indicated therapy and frequency
- Initiates Mechanical Strategies after orders signed
Secretion Management - Patient unable to clear secretions with cough or suction
- Atelectasis on CXR with suspected retained secretions
- Evidence or history of mucus plugging
and/or
Volume Expansion (Hyperinflation Therapy) - Patient at risk for or with existing atelectasis unrelated to secretions
- Airway Clearance Therapies
- delivered as outpatient regimen
- Ineffective or
- impaired cough
- Retained secretions
- despite suctioning
- Atelectasis on CXR
- Risk for atelectasis
- Maintain baseline regimen
- Augment therapy based on Clinical Assessment Score
- Suctioning
- Cough assist
- Directed cough and suction
- Flutter devices
- Vest
- IPV
- Recruitment by initiating/increasing PEEP/CPAP/NIV
- PEP devices
- IPV
- Directed breathing
techniques - Early Mobility
Respiratory Therapist: Monitor effectiveness of interventions every 12 hours and PRN using Clinical Assessment Scoring Tool
Intervention Effective - Re-evaluate patient score q12 hrs
- Review with clinical team
- Adjust frequency of therapies per pathway as needed
Intervention Not Effective - Review with clinical team
- Discontinue and initiate next indicated therapy if applicable
- Aggressive ACT not effective outside of the ICU consider:
- Medication titration to secretion burden and thickness
- Re-evaluate need for microbial testing and antibiotic therapy
- Exchange of tracheostomy tube as indicated
- CCOT/ICU consult and ICU admission
- Every 2 hour therapy not effective in the
ICU consider:- Medication titration to secretion burden and thickness
- Re-evaluation of need for microbial testing and antibiotic therapy
- Exchange or placement of artificial airway
- Bronchoscopy
- Alternative ventilation strategies
- e.g., VDR ventilation for further secretion mobilization
- Pulmonary Consult
- ENT Consult if airway concerns
- e.g., length, diameter, position, or cuff issues
Posted: August 2022
Revised: January 2023
Authors: R. Lin, MD; A. Nickel, RRT-NPS; K. Tsukahara, MD; C. Dominick, RRT-NPS; E. Faulkner, RRT-NPS; H. Panitch, MD; H. Wolfe, MD; E. Simmons, RRT-NPS; R. Samora, RRT-NPS; R. Matthews RRT-NPS; K. Mullaney APRN; J. Vicencio, DPT;
K. Budzynski, DPT, PCS
Revised: January 2023
Authors: R. Lin, MD; A. Nickel, RRT-NPS; K. Tsukahara, MD; C. Dominick, RRT-NPS; E. Faulkner, RRT-NPS; H. Panitch, MD; H. Wolfe, MD; E. Simmons, RRT-NPS; R. Samora, RRT-NPS; R. Matthews RRT-NPS; K. Mullaney APRN; J. Vicencio, DPT;
K. Budzynski, DPT, PCS
Evidence
- AARC Clinical Practice Guideline: Effectiveness of Non-pharmacologic Airway Clearance Therapies in Hospitalized Patients
- AARC Clinical Practice Guideline: Effectiveness of Pharmacologic Airway Clearance Therapies in Hospitalized Patients
- Implementation of a β-Agonist/Airway Clearance Protocol in a Pediatric ICU