Preventive measures

• Sputum hydration — maintenance of systemic hydration and humidification of inspired gases (e.g. nebulized saline/bronchodilators, heated water bath, heat moisture exchanging filter).

• Cough — requires inspiration to near total lung capacity, glottic closure, contraction of abdominal muscles and rapid opening of the glottis. Dynamic compression of the airways and high velocity expiration expels secretions. The process is limited if total lung capacity is reduced, abdominal muscles are weak, pain limits contraction or small airways collapse on expiration. It is usual to flex the abdomen on coughing and this should be simulated in supine patients by drawing the knees up. This also limits pain in patients with an upper abdominal wound.

• Physiotherapy—postural drainage, percussion and vibration hyperinflation, intermittent positive pressure breathing, incentive spirometry or manual hyperinflation.

• Maintenance of lung volumes — increased VT CPAP, PEEP, positioning to reduce compression of lung tissue by oedema.

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