GENERIC EXPECTATIONS

The points outlined in the table below are expected for every patient interaction and therefore will be
included in each practical exam.

Generic expectations Total

Behaves in a professional manner
Introduces self
Appropriate conduct during examination-courteous, appropriate language and
dress
*Seeks consent

*Infection control
Washes hands before touching patient
Ensure assessments tool and treatment devices are clean prior to use
Maintain cleanliness with the appropriate handling of device.
Adhere to safe cough/huff etiquette
Provide patient with gel to clean hands after cough/huff

Respects patient's modesty/dignity
Draping, returning clothes

Effective communication
During assessment communicates to patients what they are going to do, how
they are going to do it, provides patients with clear and correct instructions on
what the patient should do, provides patient with information on their findings.

During implementing of treatment physiotherapist communicates to patient
what they are going to do, how they are going to do it, provides patients with
clear directions, provides patient with information on effective of treatment
and instructions on self management.

*Ensures patient and therapist safety
Provides warnings and checks for any contraindications and precautions to
interventions

Ensures patient is safe and comfortable at all times. Provides assistance to
change position etc if required.

Monitors during intervention and evaluates

Ensure the therapists and others adopts correct body mechanics throughout
all procedures

Preparation of environment
Ensure that all equipment is available, clean and safe to use. Ensure that
environment set up to ensure patient and self are safe with transfers













NB All items highlighted in grey are safety items. If these items are not performed in the practical
exam it is an automatic fail according to safety criteria.

ASSESSMENT SKILLS

Safety items are highlighted in grey. If these items are not performed in the practical exam it is an
automatic fail according to safety criteria.

1. OBSERVATION/PALPATION OF CHEST WALL MOVEMENT

In a clinical situation you would perform observation and palpation during both tidal and deep
breathing. For your practical examination you will be asked to observe and palpate chest wall
movement for one breathing pattern only (you will be told which one).
Hand position is very important. Hands should be placed directly on the chest wall where the
movement you wish to assess should occur. Accessory muscles should be palpated BILATERALLY.
You will be expected to be able to describe attachment sites for these muscles. Take care when
palpating the trachea as this can be uncomfortable for the patient.

OBSERVATION/PALPATION OF CHEST WALL MOVEMENT Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindications
Warnings

Assess how well chest expands
(Requires removal of clothing to expose chest - consent)
Place hands on chest (- consent)

Pain, SOB, dizzy






PREPARATION
Environment


Patient

Patient is supported & positioned appropriately (feet supported)
Gains consent
(Requests removal of clothes as appropriate)
(Washes hands - infection control)
All of chest is visible






TECHNIQUE Visually inspects chest from
- front
- side (R & L)
- back
Palpates chest wall
- anterior/posterior movement (R & L) sides
- lateral basal movement (ant or post)
- abdominal movement
Palpates muscles (R + L)
- sternocleidomastoid
- scalenes
- pectoralis
- trapezius
- abdominals
Palpates trachea
Counts respiratory rate

















MONITORS

During examination
Checks at end of examination



SPECIAL
QUESTIONS
(examples)
Why might the trachea deviate to one side?
What pattern of breathing might you see if your patient had a (R)LL
collapse?






2. AUSCULTATION

Used in patient assessment to listen for:
1. the presence or absence of normal breath sounds (BS)
2. the presence of abnormal and added sounds (eg, BBS wheeze, crackles)
3. the quality of all of the above i.e. pitch, intensity.

The patient should be instructed to take deeper breaths than normal through an open mouth during
auscultation and rest periods must be allowed to prevent hyperventilation and dizziness.

Comparisons are made between and within both the (L) and the (R) sides. This is easiest if the
procedure is performed systematically. For comparison purposes, you should auscultate at least two
areas of each lung zone. You will be expected to be able to describe which lung segment lies
beneath your stethoscope, given the underlying anatomy is normal. Each time you re-position the
stethoscope you should listen to both inspiration and expiration.

Inferences can be made about the underlying problem from the auscultation findings. You will be
expected to know and be able to describe what are normal findings and the possible causes of
reduced breath sounds, absent breath sounds, bronchial breath sounds, wheezes & crackles.


AUSCULTATION Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindications
Warnings

To listen to sounds in the lung
(Requires removal of clothing to expose chest - consent)
Use stethoscope
Pain, SOB, dizzy





PREPARATION
Environment

Patient
Patient is supported & positioned appropriately (feet supported)
(Requests removal of clothes as appropriate - consent)
Washes hands
All of chest is visible




TECHNIQUE Ensures earpieces are directed forward & tests stethoscope
Warms head and cleans diaphragm (- infection control)
Requests breathe slightly deeper in & out through open mouth
Ensures patient will not breathe on examiner (- infection control)
Listens systematically anteriorly:
- RUZx2 - LUZx2
- RMZx2 - LMZx2
- RLZx2 - LLZx2
Listens systematically posteriorly:
- RUZx2 - LUZx2
- RMZx2 - LMZx2
- RLZx2 - LLZx2












MONITORS

During examination
Checks at end of examination


SPECIAL
QUESTIONS
(examples)

What do coarse crackles indicate?
Where would you hear bronchial breath sounds in a normal person?






3. PEAK FLOW METER

A peak flow meter, as the name suggests, measures peak expiratory flow rate (PEFR). That is, "how
quickly you can get air out of your lungs". The test should be performed 3 times, allowing the patient
to rest between trials. Nomograms are available for PEFR and you will be expected to use these in
the exam.

PEFR is determined in part by the calibre of the airways and is, therefore, used as a basic indicator of
bronchoconstriction and/or effects of medication in asthmatics.

Most flow meters require:
1. manual recording of the result after each trial
2. manual resetting to zero after each trial.

You should bear in mind that in some patients their condition may be aggravated when the test is
performed, therefore, symptoms of dyspnoea or wheeziness must be checked for between each
trial. The best performance should be recorded in the patient's history.

If the patient's performance deteriorates progressively this also should be recorded as it may indicate
airways narrowing induced by the forced expiratory manoeuvre. If the deterioration is sudden and/or
severe the assessment should be ceased and medical opinion sought.

PEAK FLOW METER Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindications
Warnings

To measure how quickly you can blow air out
Use this piece of equipment

Pain, SOB, dizzy, wheeze




PREPARATION
Environment

Patient

Patient is supported & positioned appropriately (feet supported)
Obtains clean mouthpiece, does not touch patient end
(- infection control)
Obtains and records age, sex, height





TECHNIQUE Describes procedure
- biggest breath in
- seal lips around mouth piece
- blow out as hard and fast as you can
Demonstrates correct technique
Uses nose peg
Provides feedback
- technique correct / corrects mistakes
Records score
Allows rest time between trials
Performs 3 trials in total
Compares to nomogram and demonstrates how to record in history












MONITORS

During examination (asks specifically about wheeziness & SOB)
Checks at end of examination


SPECIAL
QUESTIONS




3. SPIROMETRY

Spirometry is performed to assess the normality of certain dynamic lung volumes and
inspiratory/expiratory flow rates i.e assess how much air you can get into your lungs, and how
quickly you can get it out. There are many modes/makes of spirometers.
The technique and instructions remain the same and a nose peg should always be used.
The minimal measurements required (in body temperature pressure saturated - BTPS) are:
- Forced Expiratory Volume in one second (FEV
1
)
- Forced Vital Capacity (FVC)
- FEV
1
/FVC% (the Forced Expiratory Ratio (FER))
Spirometry should be performed 3 times, allowing the patient to rest between trials. The best
performance should be recorded in the patients history.
These values are compared to those obtained from nomograms to assist in making a diagnosis,
eg, airflow obstruction or restriction. To use a nomogram the patients age, sex and height
are required.
If the patients performance deteriorates progressively this also should be recorded as it may
indicate airways narrowing induced by the forced expiratory manoeuvre. If the deterioration is
sudden and/or severe the assessment should be ceased and medical opinion sought.

You will be expected to be able to:
interpret the spirometry curve and compare it to predicted values
be able to describe the patterns observed in:
the normal lung
obstructive lung diseases
restrictive lung disorders

SPIROMETRY Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindications
Warnings

To measure lung volumes
Use this piece of equipment

Pain, SOB, dizzy, wheeze




PREPARATION
Environment
Patient
Patient is supported & positioned appropriately (feet supported)
Obtains clean mouthpiece, does not touch patient end
(- infection control)
Obtains and records age, sex, height




TECHNIQUE Describes procedure
- biggest breath in
- seal lips around mouth piece
- blow out as hard and fast as you can
- keep blowing until you cannot blow out any more
Demonstrates correct technique
Uses nose peg
Uses machine correctly
Provides feedback to patient, eg
- technique correct / corrects mistakes
Records score
Allows rest time between trials
Performs 3 trials in total
Compares to nomogram and demonstrates how to record in history














MONITORS

During examination (asks specifically about wheeziness & SOB)
Checks at end of examination


SPECIAL
QUESTIONS
Draw the curve for someone who has a restrictive/obstructive lung
condition.




TREATMENT TECHNIQUES

Safety items are highlighted in grey. If these items are not performed in the practical exam it is an
automatic fail according to safety criteria.

A. TECHNIQUES TO IMPROVE O
2
GAS MOVEMENT IN THE LUNGS


1. DEEP BREATHING EXERCISES (LATERAL BASAL EXPANSION)

The aim of this technique is to obtain a long, slow, deep breath in, followed by a relaxed expiration.
This will aid in distribution of gas to dependent lung regions and increase lung volume.

For lateral basal expansion, hands should be placed anterolaterally on the chest wall at the level of
the diaphragm.

Respiratory rate must be considered as it is possible to hyperventilate if too many deep breaths are
performed in a row. Probably no more than 5 deep breaths in a row should be performed, or the
patient may hyperventilate and become dizzy

Sustained maximal inspiration (SMI) or inspiratory hold (IH) can be added to this technique. This is a
hold of the inspiratory effort at the end of the maximal breath in, usually for 3 seconds, followed by
relaxed expiration. The aim of the IH is to increase gas movement to poorly ventilated lung segments
via collateral airways.

Therapists hand position provides proprioceptive feedback to patients

DEEP BREATHING EXERCISES Total
EXPLANATION
Purpose
Procedure
Consent
Warnings
Checks
precautions/
contraindications









PREPARATION
Environment
Patient
Infection Control
issues









TECHNIQUE Demonstrates technique on self
Teaches correct technique
- slow deep breath in
- relaxed expiration
- allows rests
Therapist hand position appropriate
Provides feedback to patient
- technique correct - corrects mistakes










MONITORS

During treatment
Checks at end of treatment








2. POSITIONING TO IMPROVE O
2
GAS MOVEMENT

This is a technique to help alter the distribution of ventilation, in particular to improve gas movement in
a lung region that has been assessed as having reduced gas movement.

The lung region with reduced gas movement (eg, with a collapsed lung) is placed in a "non dependent
position" (ie, uppermost). This creates a more negative intrapleural pressure in the non dependent
lung region and allows gravity to help open the air spaces by "stretching" the lung. With the alveoli
now more open, the compliance of the affected lung increases due to the altered pressure/volume
parameters, allowing improved gas movement to the area.

When positioning the patient you must ensure that the patient is safe by:
* Checking any precautions/contraindications to the head down position (eg. raised intracranial
pressure, hypertension, after a meal etc) PRIOR to the patient adopting the position
* Checking the stability of plinth if blocks are being used
* Ensuring that the patient won't roll off the plinth
* Ensuring that they are adequately supported by pillows (eg in side-lying their head, upper arm
and leg are supported).
* Monitoring for abnormal symptoms such as dizziness, nausea or increased SOB.

Positioning to improve gas movement can be combined with:
1. thoracic expansion exercises

POSITIONING TO IMPROVE GAS MOVEMENT Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindications
Warnings








PREPARATION
Environment
Patient
Infection control
issues







TECHNIQUE Correct position for region named
Ensures patient is safe & comfortable
Assists patient out of position





MONITORS

During treatment
Checks at end of treatment








NOTE:

If the position does not require a head down tilt, there are still a few things you should check
prior to positioning the patient.

Consider what you might check if you were putting to patient prone, supine or upright, for
example.
B. TECHNIQUES TO ASSIST WITH THE MOVEMENT OF SECRETIONS

COUGH and HUFF
Both of these techniques are forced expiratory manoeuvres used to clear/expectorate
secretions.
The therapist should be positioned so they will not be coughed/huffed upon by the patient.
Both techniques can be performed with overpressure and/or wound support, where
appropriate.


1. COUGH

Coughing clears secretions from more centrally located airways.

The components of an effective cough are:
1. A deep breath in slowly
2. Closure of the glottis
3. Contraction of the abdominal muscles to build up intra-abdominal pressure and therefore
intra-thoracic pressure
4. Opening of the glottis and an explosive breath out.

Coughing must not be paroxysmal ("coughing attack")

COUGH Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindication
Warnings





PREPARATION
Environment
Patient
Infection control
issues



TECHNIQUE Describes technique
- take a deep breath in
- hold your breath
- tighten abdominal muscles & cough
Demonstrates correct technique
Ensures patient will not cough on therapist (- infection control)
Provides feedback to patient
- technique correct / corrects mistakes









MONITORS

During treatment
Checks at end of treatment





2. HUFF

This is a separate technique and can be performed from various lung volumes.

A huff is also a component of FET (when it is a forced expiration from mid to low lung volume.)

The components of an effective huff are:
1. A breath in (to specified lung volume) slowly
2. The glottis is kept open
3. A hard sharp breath out (to specified lung volume)

A huff from high lung volume (ie after a deep breath in) tends to clear secretions from the larger
airways.

A huff from a low lung volume tends to clear smaller/more peripheral airways.

You will need to understand the mechanism by which a huff clears the secretions.


HUFF Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindications
Warnings





PREPARATION
Environment
Patient
Infection control
issues



TECHNIQUE Describes technique
- take a breath in (to specified volume) slowly
- keep mouth open
- hard sharp breath out
Demonstrates correct technique
Ensures patient will not huff on therapist (- infection control)
Provides feedback to patient
- technique correct / corrects mistakes









MONITORS

During treatment
Checks at end of treatment





C. TECHNIQUES TO ASSIST WITH THE MOVEMENT OF EXCESSIVE SECRETIONS

3. FORCED EXPIRATION TECHNIQUE (FET)

FET can be used to help clear secretions from the airways. When used properly it should not induce
the airways narrowing that can result when using other forced expiratory manoeuvres. The order of
the components in FET is:
1. breathing control
2. one or two huffs
3. breathing control (to prevent bronchospasm and desaturation)

Breathing control is gentle relaxed breathing, which in a normal person should result in normal chest
and abdominal wall movement. To achieve this, the patient needs to be positioned comfortably with
all body parts well supported. Breathing rate should be slow but set by the patient. The therapist
should provide feedback (manual and verbal) and encouragement to facilitate relaxation (thus you
need to see the chest wall/abdomen). Following a huff, there is no specific time/number of breaths
within the breathing control that the patient should do they should continue until they feel they have
"got their breath back".

A huff is a forced expiratory manoeuvre WITHOUT closing the glottis. To achieve this, the mouth
remains open during the forced expiration. The huff can be either from mid to low lung volume in
order to facilitate the movement of secretions from small airways into larger airways, or at high lung
volumes which will clear secretions in the larger airways.

The patient may cough once or twice to clear secretions from larger airways after the FET if needed,
but this must always be followed by a period of breathing control. It is important to stress that no
more than 2 huffs (or coughs) are to be done in a row as this can cause airways narrowing and
respiratory distress.

FORCED EXPIRATION TECHNIQUE (FET) Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindications
Warnings






PREPARATION
Environment
Patient
Infection control
issues




TECHNIQUE Describes technique
Demonstrates correct technique
- breathing control
- huff
Teaches breathing control
- patient in a supportive, relaxed and safe position
- correct hand position - patient and therapist
- relaxed inspiration & expiration
- comments on respiratory rate
Teaches huff (to and from specified lung volume)
- take a breath in (to specified volume) slowly
- keep mouth open
- hard sharp breath out
- no more than 2 huffs
Ensures patient will not huff on therapist (- infection control)
Provides feedback
- technique correct / corrects mistakes
















MONITORS During treatment
Checks at end of treatment


4. ACTIVE CYCLE OF BREATHING TECHNIQUES (ACBT)

When FET is combined with thoracic expansion exercise, the technique is referred to as THE ACTIVE
CYCLE OF BREATHING TECHNIQUES (ACBT). The order of the components in ACBT is:
1. breathing control
2. thoracic expansion exercises(eg x 3 -5)
3. breathing control (steps 1-3 can be repeated as many times as necessary)
4. FET (Huff(s) and breathing control)

Steps 1-4 can be repeated as many times as necessary, i.e. continue the cycle until patient clears all
secretions or is too tired to continue.

FET on its own or within the ACBT can be used with patients whilst they are in specific or generalised
postural drainage positions.

ACTIVE CYCLE OF BREATHING TECHNIQUE (ACBT) Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindications
Warnings





PREPARATION
Environment
Patient
Infection control
issues



TECHNIQUE Demonstrates correct technique & performs completed ACBT with
patient
Teaches
1. Breathing control
- Patient in a comfortable supported and safe position
- relaxed breath in & out
- hand position appropriate - patient and therapist
- comments on respiratory rate
2. Thoracic expansion exercises
- slow deep breath in
- relaxed expiration
- therapist hand position appropriate
3. Huff
- take a breath into a specified volume slowly
- keep mouth open
- hard sharp breath out
- no more than 2 huffs in a row

Ensures patient will not huff on therapist (- infection control)
Provides feedback to patient
- technique correct / corrects mistakes




















MONITORS

During treatment
Checks at end of treatment


SPECIAL
QUESTIONS


5. POSTURAL DRAINAGE (PD) or GRAVITY ASSISTED POSITIONING

This is a technique used to facilitate removal of excessive secretions.

The patient is positioned so that the main bronchus to the segment that is to be drained is
perpendicular to the horizontal and the segment is non-dependent relative to the trachea. This allows
gravity to assist drainage of secretions towards the larger airways where they can be cleared by using
a forced expiratory manoeuvre, eg cough, huff, FET.

When positioning the patient you must ensure that the patient is safe by:

* Checking any precautions/contraindications to the head down position (eg. raised intracranial
pressure, hypertension, after a meal etc) PRIOR to the patient adopting the position
* Checking the stability of plinth if blocks are being used
* Ensuring that the patient won't roll off the plinth
* Ensuring that they are adequately supported by pillows (eg in side-lying their head, upper arm
and leg are supported).
* Monitoring for abnormal symptoms such as dizziness or nausea.


Precautions to head down tip position: (for both PD and Positioning for Gas Movement)

hypertension (eg BP > 150/100)
unstable CV system (eg cardiac arrhythmias, labile BP)
immediately following oesophageal surgery (risk of gastric aspiration and places strain on
anastomoses)
immediately following pneumonectomy (dont lie of non-operated side)
immediately following a meal
GORD (gastro-oesophageal reflux disease)
hiatus hernia (protrusion of stomach above the diaphragm)
orthopnea (breathless when lying flat)/severe dyspnoea
recent head injury and/or neurosurgery, raised ICP (increases cerebral oedema)
if patient is distressed, or is distressed by the position
pulmonary oedema/severe cardiac failure
severe obesity/abdominal distension - increases pressure on diaphragm and compresses lung
volumes
recent head/neck surgery or facial trauma where there is risk of upper airway obstruction.
known cerebral aneurysm

Consider HOW you will ask the patient about some of these conditions (ie, use layman's
terms) and WHICH ones you would ask the patient and which ones you would check in the
patient's notes. You should also endeavour to understand WHY it would be considered a
precaution to put the patient head down in these situations.

Postural drainage can be combined with:

FET (Forced Expiration Technique)
ACBT (Active Cycle of Breathing Techniques)
coughing, huffing
thoracic expansion exercises
percussion, vibrations, shaking
PEP
Acapella


POSTURAL DRAINAGE Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindications
Warnings





PREPARATION
Environment
Patient
Infection control
issues





TECHNIQUE Correct position for region named
Ensures patient is safe & comfortable
Assists patient out of position




MONITORS

During treatment
Checks at end of treatment






6. PERCUSSION, VIBRATIONS, SHAKING

These techniques are all used to loosen excessive secretions and thus facilitate their removal. The
proposed mechanism is that mechanical energy is imparted to the airways and, therefore, to the
secretions, helping to make them easier to move.

Percussion
The patient's chest wall is rhythmically tapped using cupped hands and relaxed arms. It is usual to
perform this through one or more layers of towel. Percussion is applied over the specific segment
being treated. It is performed throughout inspiration and expiration during tidal breathing or thoracic
expansion exercises.

Vibrations
The therapist's hands are placed directly on the chest wall over the segment to be treated and in line
with the direction of movement of the chest wall. The technique is usually applied during DB
exercises, where a rapid oscillatory movement is performed during expiration only. Encourage
inspiratory to be a slow as possible.

Shaking
Shaking is performed as for vibrations, however, with greater amplitude of oscillation and as such
tends to produce more movement of the whole chest wall. Encourage inspiratory to be a slow as
possible.

The above techniques can be used with postural drainage, before a FET and during the
thoracic expansion exercises of ACBT.

Precautions to percussion, vibrations and shaking:
fractured (#) ribs, flail ribs (where there are 2 fractures so a piece of rib is loose)
frank haemoptysis (coughing up frank (fresh) blood)
over rib cancer (Ca)
osteoporosis or long term steroid use (as this causes osteoporosis)
over burns, a surgical incision or an intercostal drain
severe bronchospasm
severe pleuritic pain (without adequate pain relief)
very low platelet levels

PERCUSSION / VIBRATION Total
EXPLANATION
Purpose
Procedure
Consent
Check precautions
and contraindications
Warnings





PREPARATION
Environment
Patient
Infection control
issues






TECHNIQUE Therapist appropriately positioned
Performs technique over segment named (uses towel as
appropriate)
Performs technique rhythmically and with appropriate force




MONITORS

During treatment
Checks at end of treatment




D. DEVICES TO ASSIST WITH THE MOVEMENT OF EXCESSIVE SECRETIONS

POSITIVE EXPIRATORY PRESSURE (PEP)
FLUTTER (Flutter VRP1 valve )
ACAPELLA

Positive expiratory pressure (PEP) masks/mouthpieces, Acapella and Flutter use an increase in
airway resistance to apply positive expiratory pressure to the airways. The resistance is either
constant (PEP) or oscillating (Acapella or Flutter). This positive expiratory pressure is proposed to 1)
stabilise or dilate the floppy narrowed airways to maintain airway patency to increase expiratory flow
and 2) provide a backflow of pressure through the collateral channels to increase airflow behind
completely obstructed airways, resulting in movement of the secretion to central airways..

The oscillatory PEP is proposed to result in oscillation of airways and expiratory airflow to
mechanically dislodge secretions by increasing expiratory flow rates, altering the rheological
properties of the secretions and/or augment cilial beat.

During use of all 3 devices inspiration should be slightly greater that a tidal breath, with an end
inspiratory pause of 2-3 seconds. Inspiration should be through the nose or mouth not the device.
Encourage inspiration to be as slow as possible and comfortable for patient. Expiration is slightly
active (not forceful), lasting for approximately 5 seconds.

Use of all three devices increases airway resistance which increases expiratory workload. Therefore
it is important to monitor respiratory effort, SOB and to be cautious prescribing these interventions in
patients who have acute decreases in CO
2
movement.

7. POSITIVE EXPIRATORY PRESSURE (PEP)

PEP is applied by setting the resistance between 15-20cmH2O. The resistance is initially determined
by placing a pressure manometer between the valve and resistance to measure the pressure mid
expiration and adjusting the resistance until desired pressure is achieved. Patients can either perform
PEP in upright sitting or in postural drainage positions. Dosage of 10-15 breaths is usually
interspersed with ACBT, FET or huffing and coughing. Patients continue with treatment cycles until
secretions are cleared or patient becomes fatigued.

PEP Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindication
Warnings






PREPARATION
Environment
Patient
Infection control
issues





TECHNIQUE Demonstrates the expiration technique on self
Teaches correct technique
- Instructs patients to do 2-3 lateral basal expansion prior to
using device
- inspire slow slightly deeper than normal breath in not through
the device
- place lips tightly around mouthpiece
- expiration (slightly forced) to appropriate pressure level to FRC
- force is from respiratory muscles not cheek muscles
- selects the correct resistance using pressure manometer to set
expiratory load
- provides correct instructions on dose
- allows rests
- explain it is followed by FET to clear secretions.
Provides feedback to patient
- technique correct - corrects mistakes










MONITORS/
EVALUATION

During treatment
Checks and evaluates at end of treatment








8. FLUTTER (Flutter VRP1 valve )

Flutter applies an oscillating pressure and flowrate is caused by the oscillation of an enclosed
stainless steel ball bearing within a pipe shaped device. The resistance is variable which is altered by
patients expiratory effort and the position (incline) of the device. The oscillation frequency ranges
between 8-26 Hz (cycles per second). Ideal position of the device is specific to the patient and when
maximal vibration is felt in the chest.

Dosage is 10-15 breaths are usually interspersed with ACBT, FET or huffing and coughing. Patients
continue with treatment cycles until secretions are cleared or patient becomes fatigued.

FLUTTER Total
EXPLANATION
Purpose
Procedure
Consent
Checks precautions
and contraindication
Warnings






PREPARATION
Environment
Patient
Infection control
issues





TECHNIQUE Demonstrates the expiration technique on self
Teaches correct technique
- Instructs patients to do 2-3 lateral basal expansion prior to
using device
- inspires slow slightly deeper than normal breath in not through
the device
- followed by an end inspiratory hold 3-5 seconds
- place lips tightly around mouthpiece
- expiration (slightly forced) to FRC
- performs 6-8 breaths through device for purpose of practical
exam
- followed by 1 inspiration to TLC and forced expiration
- force is from respiratory muscles not cheek muscles
- position of device to maximise vibration felt on chest
- provides correct instructions on dose
- allows rests and spontaneous coughs to occur
Provides feedback to patient
- technique correct - corrects mistakes










MONITORS/
EVALUATION

During treatment
Checks and evaluates at end of treatment








9. ACAPELLA

Acapella applies an oscillating pressure and flowrate. The Acapella device is a cone shaped device
that incorporates a counterweighted lever and a magnet. The oscillation of pressure is caused by
impeding the expiratory airflow by the connection between the lever and magnet. When the pressure
builds up the lever and magnet disconnect which results in airflow. The subsequent decrease in
pressure causes the magnet and lever to reconnect. The connection and disconnection results in
oscillation of the expiratory airflow. The resistance is adjustable for individual patients by adjusting
the resistance dial at the back. Clockwise movement of dial increases the resistance and
anticlockwise decreases the resistance. The level of resistance is set where the patients can exhale
for 3-4 seconds while feeling the vibratory effects. The oscillation frequency ranges between 8-30Hz
and resistance pressure of 3-24cmH2O.

Dosage is 10-15 breaths are usually interspersed with ACBT, FET or huffing and coughing. Patients
continue with treatment cycles until secretions are cleared or patient becomes fatigued.

ACAPELLA Total
EXPLANATION
Purpose
Procedure
Consent
Check
precautions/contraindi
cation
Warnings






PREPARATION
Environment
Patient
Infection control
issues





TECHNIQUE Demonstrates the expiration technique on self
Teaches correct technique
- Instructs patients to do 2-3 lateral basal expansion prior to
using device
- Inspires slow slightly deeper than normal breath in, not through
the device
- followed by a short end inspiratory hold 2-3 seconds
- Place lips tightly around mouthpiece
- expiration (slightly forced) to FRC
- performs 6-8 breaths through device for purpose of practical
exam
- Followed by 1 - 2 deeper inspirations and forced expiration
- force is from respiratory muscles not cheek muscles
- adjusts resistance to appropriate level for expiration to last 3-4
seconds and maximise vibratory effect felt on chest
- provides correct instructions on dose
- Explain it may be followed by FET to clear secretions
- allows rests
Provides feedback to patient
- technique correct - corrects mistakes










MONITORS/
EVALUATION

During treatment
Checks and evaluates at end of treatment