🚧 Under construction — VoTechWorks is being built. A free tech program — complimentary, as our commitment to get America working.
voTechWorksGrade 13 · a vocational technology learning center, by urbanicity
newSchoolWorks.com › VoTechWorks › Health & Personal Services › Respiratory Therapy › Airway Management › Lesson 11
HLT-RESP80-05 · Lesson 11 · 33.5 clock hours · practice

Airway Clearance Techniques and Secretion Management

Objective. Students will correctly perform and teach directed cough, huff cough, chest physiotherapy positioning, and high-frequency chest wall oscillation setup to achieve optimal secretion clearance in simulated patients with varying diagnoses.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

VoTechWorks program approval and accreditation are still in progress. Credentials are issued only by the certifying bodies named in each program, after their own exams.

Why Secretion Clearance Matters

Mucus is a normal product of the airway. In healthy people, the mucociliary escalator and an effective cough move secretions upward and out. Disease disrupts this system. Patients with cystic fibrosis produce abnormally thick mucus that overwhelms cilia. Patients recovering from thoracic surgery guard against pain and cough poorly. Patients with neuromuscular disease lack the muscle force to generate an effective cough. When secretions pool, airways obstruct, gas exchange falls, and pneumonia risk rises. Respiratory therapists select, perform, and teach techniques matched to each patient's diagnosis, strength, and cooperation level.

Directed Cough

A directed cough is a coached, controlled effort that maximizes secretion movement without injuring the airway or exhausting the patient. The sequence is:

1. Position the patient upright, leaning slightly forward if tolerated.

2. Instruct a slow, deep breath through the nose or pursed lips to fill the lungs above resting volume.

3. Brief breath-hold (one to three seconds) to allow air to distribute behind secretions.

4. Forceful, short coughs — two or three in a row — with the glottis open.

5. Rest and repeat up to three cycles before fatigue sets in.

For post-surgical patients, splinting the incision with a pillow or folded blanket held firmly against the chest wall reduces pain, increases compliance, and protects the wound. Always remind these patients that a controlled cough is safe and necessary; fear of pain is one of the most common barriers to effective clearance after thoracotomy.

Safety note: Avoid directed cough in patients with elevated intracranial pressure, recent eye surgery, unstable hemodynamics, or fresh esophageal anastomoses. Coughing raises intrathoracic pressure sharply and can be harmful in these situations.

Huff Cough (Forced Expiration Technique)

A huff cough moves secretions from the middle and small airways without the extreme pressure swings of a full cough. The patient takes a medium-depth breath, then exhales with a steady, moderately forceful "huff" — mouth open, glottis open — as if fogging a mirror. Two or three huffs are followed by relaxed diaphragmatic breathing. Huff cough is especially useful in COPD and asthma where dynamic airway collapse makes a hard cough counterproductive (the high pressure squeezes airways shut before secretions reach the mouth).

Active Cycle of Breathing Technique (ACBT)

ACBT combines three phases in a repeating cycle:

ACBT is self-administered, requires no equipment, and is supported by AARC Clinical Practice Guidelines for patients who can follow instructions. It is a strong option for cooperative patients with COPD, post-surgical atelectasis, and mild-to-moderate bronchiectasis.

Chest Physiotherapy Positioning (Postural Drainage)

Gravity assists drainage when the affected lung segment is placed above the central airway. Each of the 18 lung segments has a corresponding position. Before positioning, review the physician order, the patient's current vital signs, and any contraindications — head-down (Trendelenburg) positions are avoided with increased intracranial pressure, recent abdominal surgery, and significant gastroesophageal reflux. Positioning is often combined with percussion (cupped-hand clapping) or vibration during exhalation to loosen secretions. Time each position for five to fifteen minutes per segment based on the patient's tolerance.

Safety note: Monitor SpO₂, heart rate, and patient comfort throughout. Stop and reposition immediately if oxygen saturation drops significantly, the patient reports dizziness or severe dyspnea, or arrhythmia is observed.

High-Frequency Chest Wall Oscillation (HFCWO)

HFCWO vests deliver rapid, small-volume air pulses to the chest wall, creating oscillations that thin mucus and move it centrally. Setup steps:

1. Verify the physician order for frequency (typically expressed in hertz) and pressure settings.

2. Select the correct vest size — it should fit snugly over the chest without riding up onto the neck.

3. Connect the vest hoses to the generator, confirm secure attachment.

4. Start at a low setting and titrate to ordered parameters.

5. Instruct the patient to huff or cough periodically during treatment to clear mobilized secretions.

6. Document: start and stop time, frequency and pressure used, patient tolerance, secretions produced (color, consistency, amount), and SpO₂ before and after.

HFCWO is the standard of care for cystic fibrosis and is used in bronchiectasis and neuromuscular disease where the patient cannot perform active airway clearance independently.

Matching Technique to Diagnosis

| Diagnosis | Preferred Technique(s) | Key Reasoning |

|---|---|---|

| COPD exacerbation | Huff cough, ACBT | Minimizes dynamic airway collapse |

| Cystic fibrosis | HFCWO, ACBT, PEP therapy | Thick mucus, chronic; vest is standard |

| Post-thoracotomy | Directed cough with splinting, ACBT | Pain limits cough; incision protection critical |

| Neuromuscular disease | HFCWO, mechanical insufflation-exsufflation | Weak cough; assisted techniques required |

| Acute lobar atelectasis | Postural drainage, directed cough, ACBT | Re-expand collapsed segment via gravity and active cough |

Teach-Back and Documentation

After coaching any technique, use teach-back: ask the patient to demonstrate the technique back to you. This confirms understanding far better than asking "Do you understand?" If the return demonstration reveals errors, re-teach the specific step that was incorrect — not the entire sequence. Document the instruction, the patient's demonstrated understanding, and any barriers noted (pain, fatigue, language). Accurate, complete documentation supports continuity of care and is required for licensure compliance.

Key terms10

Directed coughA coached coughing technique using a deep breath, brief breath-hold, and a series of short forceful exhalations to move secretions from the airways; often combined with incision splinting after surgery.
Huff cough (forced expiration technique, FET)An open-glottis, moderately forceful exhalation used to mobilize secretions from mid and small airways while avoiding the extreme pressure rises that collapse airways in obstructive disease.
Active cycle of breathing technique (ACBT)A repeating three-phase cycle of breathing control, thoracic expansion exercises, and forced expiration technique designed to loosen and clear secretions without equipment.
Postural drainagePositioning a patient so that the affected lung segment is gravity-dependent relative to the central airway, facilitating secretion drainage toward the larger airways where they can be cleared.
High-frequency chest wall oscillation (HFCWO)A vest-based airway clearance device that delivers rapid, small-volume compressions to the chest wall to thin secretions and assist their movement toward central airways; standard of care for cystic fibrosis.
Mucociliary clearanceThe normal airway defense mechanism by which mucus and trapped particles are propelled upward by coordinated ciliary beating and expelled by coughing or swallowing.
SplintingFirm support applied by the patient (or therapist) to a surgical incision with a pillow or blanket during coughing to reduce pain, improve cough effectiveness, and protect wound integrity.
Teach-backA patient education verification method in which the clinician asks the patient to demonstrate or explain in their own words what they were just taught, confirming genuine understanding rather than passive agreement.
Dynamic airway collapsePremature closure of small or medium airways during forced exhalation, common in COPD and emphysema, which traps secretions and limits the effectiveness of high-pressure coughing maneuvers.
Mechanical insufflation-exsufflation (MI-E)A device-assisted technique that applies positive pressure to inflate the lungs then rapidly switches to negative pressure to simulate a cough, used when patients lack sufficient respiratory muscle strength to clear secretions independently.
In class: Demonstrate directed cough and active cycle of breathing techniques on a cooperative classmate who role-plays a post-surgical patient, then provide verbal coaching using teach-back to ensure the 'patient' can replicate the technique. · Set up and apply a high-frequency chest wall oscillation (HFCWO) vest on a classmate, adjust frequency and pressure settings per a written physician order, and document the session parameters and patient response. · Map secretion clearance technique selection to a set of five written patient diagnoses (COPD exacerbation, cystic fibrosis, post-thoracotomy, neuromuscular disease, and acute lobar atelectasis) and justify each choice in a written rationale, citing Egan's or current clinical practice guidelines.
Materials: HFCWO vest device (or training model), positioning wedges and pillows, written physician order forms, Egan's Fundamentals of Respiratory Care, AARC Clinical Practice Guidelines, teach-back evaluation form
Check: Teach-back evaluation: classmate (as patient) accurately demonstrates the coached technique after instruction; written rationale for all five diagnoses is graded with pass = 80% or higher and no clinically unsafe selections.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Therapeutic Procedures
1. A 58-year-old patient is two days post right lower lobectomy. She is reluctant to cough because of incision pain. Which initial intervention is most appropriate?
Therapeutic Procedures
2. A 24-year-old patient with cystic fibrosis is admitted for a pulmonary exacerbation. Which airway clearance modality is considered the standard of care for long-term secretion management in this population?
Patient Assessment and Education
3. When performing ACBT on a cooperative patient with COPD, which sequence correctly reflects the three phases of the technique?
Therapeutic Procedures
4. A patient with advanced amyotrophic lateral sclerosis (ALS) cannot generate enough expiratory force for an effective cough. Which technique is most appropriate?
Patient Safety and Emergency Response
5. During HFCWO vest treatment, the patient's SpO₂ drops from 95% to 88% and they report feeling lightheaded. The respiratory therapist should FIRST:
Patient Assessment and Education
6. A respiratory therapist completes HFCWO vest training with a cystic fibrosis patient. To confirm the patient understood the technique, the therapist asks the patient to demonstrate vest application and coughing intervals independently. This strategy is called:
Patient Safety and Contraindications
7. Which of the following is a contraindication to placing a post-surgical patient in a head-down (Trendelenburg) position for postural drainage?
Disease Pathophysiology and Management
8. A patient with an acute COPD exacerbation needs airway clearance. The respiratory therapist is concerned that a high-pressure cough maneuver may worsen secretion clearance. Which mechanism explains this concern?
Record this lesson on my transcript. Sign in with your key and enrollment email to record lessons (enroll free if you have no key). This page stays open to read and practise.
← Previous lessonProgram planNext lesson →