Airway Clearance Therapy Procedure Note

Date/Time: [Session start date and time]

Location: [ICU / ward / step-down / ED / outpatient / home / other]

Clinician: [Name, credentials]

Patient Position: [Supine / Semi-Fowler / High Fowler / Prone / Side-lying (right/left) / Sitting / Other]

(Use explicit statements such as "Not assessed," "Unable to obtain," or "Patient unable to report" if any clinically important field cannot be documented. Do not infer sputum characteristics, tolerance, or physiologic response; document only observed or measured findings. Use negative statements when relevant, e.g., "No sputum produced," "No adverse events.")

Orders and Session Type

Ordering provider: [Name, role]

Order type: [scheduled / PRN / protocol-driven]

Indication as stated in order: [Text from order]

Session type: [initial / routine scheduled / PRN for secretion retention / post-op / exacerbation]

Protocol details: [Protocol name] — [Triggering criteria] (Only include if protocol-driven)

Indication and Goals

Primary indication: [Concise statement of indication with brief supporting detail]

Therapy goals:

• [Goal 1]
• [Goal 2] (if applicable)
• [Goal 3] (if applicable)

Contraindications/precautions screened: [Hemoptysis / hemodynamic instability / increased ICP risk / aspiration risk / chest wall injury / pneumothorax risk with positive pressure / recent surgery / other / none identified]

Mitigations/adjustments: [Modified positioning / reduced intensity / deferred specific modality / continuous monitoring / premedication / other / Not applicable]

Pre-treatment Assessment

• Vitals (baseline): HR [value] bpm; RR [value] /min; BP [value] mmHg; SpO2 [value]%
• Oxygen/device: [Room air / NC / simple mask / NRB / HFNC / trach collar / ventilator] at [Flow L/min and/or FiO2 %]
• Mechanical ventilation: Mode [value]; FiO2 [value]%; PEEP [value] cmH2O; [Other relevant settings] (Only include if mechanically ventilated)
• Breath sounds: [Normal / wheezes / rhonchi / crackles / diminished / absent] at [locations by lung fields or segments]
• Cough effectiveness: [strong / moderate / weak]; [productive / nonproductive]
• Baseline secretions: [Visible secretions: yes/no]; [Location: oral / tracheal / inline / none]
• Patient readiness: Pain [0–10 or descriptor]; Alertness/cooperation [alert / drowsy / confused / cooperative / unable to follow]; Interface feasibility [adequate seal / poor seal / not tolerated / Not assessed]

Procedure

Education/coaching: [Provided / Not provided] — [Topics covered] (Include only what was taught)

Therapy positioning: [Positions used during therapy; include changes and duration if relevant]

(Repeat the following Modality block for each modality performed in this session. Create a separate entry per modality.)

Modality [#]: [CPT / PEP / OPEP / MI-E / IPV / HFCWO / Manual cough / Other]

Rationale for selection: [Brief rationale linked to indication/goals]

Interface/delivery: [Mouthpiece / Mask / Trach / Inline with ventilator / Other]

Parameters:

• (For PEP/OPEP) Device [name/model]; Resistance setting [value]; Breathing pattern [tidal/deep with holds]; Sets/cycles [values]; Huff/cough timing [describe]
• (For MI-E) Insp pressure [cmH2O]; Exp pressure [cmH2O]; Insp time [s]; Exp time [s]; Pause [s]; Breaths per cycle [#]; Number of cycles [#]; Adjuncts [breath stacking / abdominal thrust / chest compression / none]
• (For CPT) Segments targeted [list]; Positions [list]; Technique [percussion / vibration / shaking]; Duration per segment [min]; Total duration [min]
• (For IPV) Frequency [Hz]; Driving pressure [psi/cmH2O]; Nebulized agent [name / none]; Session duration [min]
• (For HFCWO) Vest size [value]; Frequency [Hz]; Intensity [level]; Cycle duration [min]; Number of cycles [#]; Cough/huff timing [describe]
• (For Manual/assisted cough) Technique [quad cough / breath stacking / splinting / other]; Timing with respiration [describe]; Attempts [#]

Monitoring observations: SpO2 trend [stable / increased / decreased] from [start]% to [end]%; Hemodynamic response [no change / tachycardia / bradycardia / hypotension / hypertension]; Symptoms/signs [dyspnea / dizziness / pain / anxiety / none]

Suctioning

(Include this section only if suctioning was performed)

• Type: [Oral / Nasotracheal / Tracheal / Inline]
• Preoxygenation: [Yes / No]
• Number of passes: [#]
• Saline instillation: [Yes / No]
• Complications: [None / desaturation / bleeding / bronchospasm / arrhythmia / other]

Secretions

• Amount: [none / scant / small / moderate / copious]
• Color: [clear / white / yellow / green / brown / bloody / blood-tinged]
• Consistency: [thin / thick / tenacious / frothy]
• Blood: [none / trace / streaking / frank]
• Ease of expectoration: [easy / moderate difficulty / unable]; Suctioning required [yes / no]

Post-treatment Assessment and Response

• Vitals (post): HR [value] bpm; RR [value] /min; BP [value] mmHg; SpO2 [value]%
• Oxygen/device post: [Room air / NC / simple mask / NRB / HFNC / trach collar / ventilator] at [Flow L/min and/or FiO2 %]
• Breath sounds: [improved / unchanged / worsened] — [Location-specific changes]
• Work of breathing: [improved / unchanged / worsened]
• Cough effectiveness: [improved / unchanged / worsened]
• Secretion mobilization achieved: [yes / partial / no] — [Objective basis]
• Patient tolerance: [tolerated without adverse events / limited by pain / limited by fatigue / limited by anxiety / terminated early]
• Adverse events: [No adverse events / sustained desaturation / bronchospasm / emesis / hemoptysis / arrhythmia / severe anxiety / other] (Provide details if present)
• If therapy terminated early: Trigger [describe]; Interventions [describe]; Recovery status [returned to baseline / improved / worsened] (Only include if terminated early)

Plan

• Immediate plan: [continue current regimen / modify parameters / discontinue]
• Recommended frequency and modality: [Frequency] with [modality names]
• Adjunct needs: [bronchodilator timing / humidification optimization / analgesia coordination / mobilization / none] (Include only if applicable)
• Escalation/communication: [Provider/team notified: name/role and reason] (Include only if escalation occurred)
• If therapy ineffective: Objective basis [describe]; Recommended alternatives [different modality / parameter changes / bronchoscopy consult / imaging / other] (Include only if ineffective)

Electronic Signature: [Name, credentials, date/time]