CHEST PHYSIOTHERAPY | MECHANISMS IMPAIRING THE COUGH REFLEX

BRONCHIAL HYGIENE THERAPY

PHASE EXAMPLE OF IMPAIRMENT

BRONCHIAL HYGIENE THERAPY Irritation  Anesthesia

 Use of noninvasive airway clearance  CNS Depression

techniques designed to help mobilize and
 Narcotic – analgesics
remove secretions and improve gas
exchange.
Inspiration  Pain
 Previously known as chest physical therapy
 Neuromuscular
 Traditionally involves postural drainage, Dysfunction
percussion, and vibration (PDPV) + cough
training  Pulmonary Restriction

 Abdominal Restriction
NORMAL AIRWAY CLEARANCE

 Patent airway Compression  Laryngeal Nerve

Damage
 Functional mucociliary escalator
 Artificial Airway
 Larynx down to respiratory bronchioles
 Abdominal Muscle
 Effective cough Weakness

 Abdominal Surgery
 Reserveclearancemechanism

 Most important protective reflexes Expulsion  Airway Compression

 Airway Obstruction
NORMAL COUGH
 Abdominal Muscle
 4 distinct phases: Weakness

1. Irritation  Inadequate Lung Recoil

2. Inspiration

3. Compression
CAUSES OF IMPAIRED MUCOCILIARY CLEARANCE IN
4. Expulsion INTUBATED PATIENTS

 ET or tracheostomy tube
NORMAL COUGH SEQUENCE
 Tracheobronchial secretion
DEEP CLOSURE OF
INSPIRATION GLOTTIS  Inadequate humidification

 High FIO2 values

OPENING OF
GLOTTIS AND A CONTRACTION
RAPID OF ABDOMINAL
FORCEFUL MUSCLES
EXHALATION
CAUSES OF IMPAIRED MUCOCILIARY CLEARANCE IN  Patient:
INTUBATED PATIENTS
 Posture, muscle tone
 Drugs
 Effectiveness of cough
 General anesthetics, opiates, narcotics
 Sputum production
 Underlying pulmonary disease
 Breathing pattern

GENERAL GOALS & INDICATIONS|  General physical fitness

BRONCHIAL HYGIENE THERAPY
 Breath sounds
 Primary Goal:
 Vital signs, heart rate and rhythm
 To help mobilize and remove retained
secretions, with the ultimate aim to
improve gas exchange and reduce work
of breathing. METHODS|
BRONCHIAL HYGIENE THERAPY
 Indications:
 Five Approaches:
 Treating acute conditions
 Postural drainage therapy
 Chronic conditions that may cause
copious secretions o Turning, percussion and vibration

 Disorders associated with retention of  Coughing and related expulsion

secretions techniques

 Positive Airway Pressure adjuncts

INITIAL ASSESSMENT OF NEED| o PEP, CPAP, EPAP

BRONCHIAL HYGIENE THERAPY
 High – frequency compression/
 Medical Records: oscillation methods

 History of pulmonary problems causing  Mobilization and exercise

increased secretions

 Admission for upper abdominal or POSTURAL DRAINAGE THERAPY (PDT)

thoracic surgery
 component of bronchial hygiene therapy
 Presence of artificial tracheal airway consists of:

 Atelectasis or infiltrates  postural drainage,

 positioning, and
 results of PFT  turning
 sometimes accompanied by chest
 ABG values or O2 saturation percussion and/or vibration.
  commonly referred to as:
 Large dintracranialrops in BP
 chest physiotherapy,
 chest physical therapy,  Worsening dyspnea
 postural drainage and percussion, and
 percussion and vibration  Hypoxia

 improve the mobilization of bronchial  Cardiac arrhythmias in BP

secretions and the matching of ventilation
and perfusion
 PLUMBING PROBLEMS
 Normalize functional residual capacity (FRC)
based on the effects of gravity and external  Ventilator disconnection
manipulation of the thorax
 Accidental extubation

TURNING  Accidental aspiration of ventilator

 rotation of the body around the longitudinal
axis
 also referred to as kinetic therapy or
continuous lateral rotational therapy
 INDICATIONS:
 PURPOSE
 Promote unilateral or bilateral lung
expansion
 Improve arterial oxygenation
 Prevent retention of secretion
circuit condensate
 Disconnection of vascular lines or
urinary catheters.
 inability or reluctance of patient to
change body position (eg , mechanical
ventilation, neuromuscular disease,
drug paralysis)
 poor oxygenation associated with
position (e.g., unilateral lung disease)

 turning can be to either side or the prone  potential for or presence of atelectasis
position, with the bed at any degree of
inclination  presence of artificial airway

 ABSOLUTE CONTRAINDICATION
POSTURAL DRAINAGE
 Unstable spinal cord injury
 the drainage of secretions, by the effect of
 Traction of arm abductors gravity, from one or more lung segments to
the central airways (where they can be
removed by cough or mechanical
 RELATIVE CONTRAINDICATION aspiration) Each position consists of placing
the target lung segment(s) superior to the
 Severe diarrhea carina. Positions should generally be held
for 3 to 15 minutes (longer in special
 Marked agitation situations)

 rise in pressure
  INDICATION
 evidence or suggestion of difficulty
with secretion clearance.
 Presence of atelectasis caused by or
suspected of being caused by mucus
plugging
 diagnosis of diseases such as cystic
fibrosis, bronchiectasis, or cavitating
lung disease.
 presence of foreign body in airway
POSTURAL DRAINAGE| STANDARD POSTURAL
DRAINAGE POSITIONS FOR EACH LUNG SEGMENT
 APICAL SEGMENTS OF RIGHT AND LEFT
UPPER LOBES:
 Semi fowler’s position with head of the
bed raised 45degrees
 ANTERIOR SEGMENTS OF BOTH UPPER
LOBES:
 Patient supine with the bed flat.
 POSTERIOR SEGMENT OF RUL
 PATIENT one quarter turn from prone
with the right side up, supported by
pillows, with head of the bed flat.
 APICAL POSTERIOR SEGMENT OF LEFT
UPPER LOBE
 PATIENT one quarter turn from prone
with the LEFT side up, supported by
pillows, with head of the bed elevated
30 degrees.
 MEDIAL AND LATERAL SEGMENTS OF
RIGHT MIDDLE LOBE
 Patient one quarter turn from supine
with right side up and foot of the bed
elevated 12 inches.
 SUPERIOR & INFERIOR SEGMENTS OF
LINGULA
 Patient one quarter turn from supine
with left side up and foot of the bed
elevated 12inches.
 SUPERIOR SEGMENTS OF BOTH LOWER
LOBES
 Patient prone with head of bed flat and
pillow under abdominal area.
  ANTEROMEDIAL SEGEMT OF LLL AND
ANTERIOR SEGMENT OF RLL
 PATIENT supine with foot of bed
elevated 20 inches.
 HYPOXEMIA
 Administer higher FIO2 during
procedure if potential for or observed
hypoxemia exists.

 If patient becomes hypoxemic during

treatment, administer 100% oxygen,
stop therapy immediately, return
patient to original position, and consult
physician.

 INCREASED INTRACRANIAL PRESSURE

 LATERAL SEGMENT OF RLL ACUTE HYPOTENSION DURING PROCEDURE

 Patient directly on left side with right  Stop therapy, return patient to original
side up and foot of the bed elevated 20 resting position, and consult physician.
inches

 PULMONARY HEMORRHAGE

 Stop therapy, return patient to original

resting position, and call physician
immediately.

 Administer oxygen and maintain an

 LATERAL SEGMENT OF LLL AND MEDIAL
SEGMENT OF RLL
 PAIN OR INJURY TO MUSCLES, RIBS, OR
 Patient directly on right side with left
side up and foot of the bed elevated 20
inches
airway until physician responds.
SPINE
 Stop therapy that appears directly
associated with pain or problem,
exercise care in moving patient, and
consult physician

 VOMITING AND ASPIRATION

 POSTERIOR SEGMENT OF BOTH LOWER
LOBES
 Patient prone with foot of the bed
elevated 20 inches study.
 Stop therapy, clear airway and suction
as needed, administer oxygen, maintain
airway, return patient to previous
resting position, and contact physician,
immediately

 BRONCHOSPASM
COMPLICATIONS OF POSTURAL DRAINAGE
THERAPY AND RECOMMENDED INTERVENTIONS
  Stop therapy, return patient to
previous resting position, and
administer or increase oxygen delivery
while contacting physician.

 Administer physician-ordered
bronchodilators. 2. VIBRATION

 involves the application of a fine

 ARRHYTHMIAS
 Stop therapy, return patient to
previous resting position, and
administer or increase oxygen delivery
while contacting physician.
tremorous action (manually
performed by pressing in the
direction that the ribs and soft
tissue of the chest move during
expiration) over the draining area.

 EXTERNAL MANIPULATION OF THE

THORAX

 TYPES:

o Percussion, Vibration

 INDICATION:
o sputum volume or consistency
suggesting a need for additional
manipulation (eg, percussion
and/or vibration) to assist
movement of secretions by gravity,
in a patient receiving postural
drainage.
 Vibrations are intended to move
secretions into larger airways
 Applied only during exhalation
 Shaking
- More vigorous form of
vibration.

1. CHEST PERCUSSION - Basic premise: dislodges

resistant or thick secretions
 also referred to as cupping, not moved by vibration.
clapping, and tapotement.

 Purpose:  CONTRAINDICATIONS

- to intermittently apply kinetic o Positioning

energy to the chest wall and
lung.  intracranial pressure (ICP)
> 20 mm Hg.
 rhythmically striking the thorax
with cupped hand or mechanical  head and neck injury until
device directly over the lung stabilized.
segment(s) being drained.

o Positioning

 active hemorrhage with
hemodynamic instability
 recent spinal surgery (e.g.,
laminectomy) or acute
spinal injury.
 acute spinal injury or
active hemoptysis
 Empyema
 bronchopleural fistula
 pulmonary edema
associated with
congestive heart failure
 large pleural effusions
 pulmonary embolism
 aged, confused, or
anxious patients who do
not tolerate position
changes
 rib fracture, with or
without flail chest.
 Surgical wound or healing
tissue.
 CONTRAINDICATIONS
o Trendelenburg Positioning
 Intracranial pressure (ICP) > 20
mm Hg
 Patients in whom increased
intracranial pressure is to be
avoided (e.g., neurosurgery,
aneurysms, eye surgery)
 Uncontrolled hypertension
o Trendelenburg Positioning
 Distended abdomen
 Esophageal surgery
 Recent gross hemoptysis
related to recent lung
carcinoma treated surgically or
therapy.
 Uncontrolled airway at risk for
aspiration (tube feeding or
recent meal)
o External Manipulation of the
Thorax
 subcutaneous emphysema
 recent epidural spinal infusion
or spinal anesthesia
 recent skin grafts, or flaps, on
the thorax
 burns, open wounds, and skin
infections of the thorax
 recently placed transvenous
pacemaker or subcutaneous
pacemaker (particularly if
mechanical devices are to be
used)
 suspected the pulmonary
tuberculosis
 lung contusion
 Bronchospasm
 Osteomyelitis of the ribs
 Osteoporosis
 Coagulopathy
 complaint of the of ribs
chest - wall pain

o HAZARDS/COMPLICATIONS:
 Hypoxemia
 Increased Intracranial Pressure
 Acute Hypotension during
Procedure
 Pulmonary Hemorrhage
 Pain or Injury to Muscles, Ribs,
or Spine
 Vomiting and Aspiration
 Bronchospasm
 Dysrhythmias
MONITORING
o ASSESSMENT OF NEED:
 Excessive sputum production
 Effectiveness of cough
 Change in VS
 Deterioration in ABG values or
oxygen saturation
 Decreased breath sounds or
crackles or rhochi suggesting
secretions in the airway
 Abnormal CXR consistent with
atelectasis, mucus plugging, or
infiltrates.
 History of pulmonary
problems treated successfully
with PDT. (e.g., bronchiectasis,
cystic fibrosis, lung abscess.)
o ASSESSMENT OF OUTCOME:
 change in sputum production
 change in breath sounds of
lung fields being drained
 patient subjective response to
therapy
 change in vital signs
 change in chest x-ray
 change in ABG values or
oxygen saturation
 change in ventilator variables
 Subjective response (pain, discomfort,
dyspnea, response to therapy)
 Pulse rate, arrhythmia, and ECG if available
 Breathing pattern and rate, symmetrical
chest expansion, synchronous
thoracoabdominal movement, flail chest
 Sputum production (quantity, color,
consistency, odor) and cough effectiveness
 Mental function
 Skin color
 Breath sounds
 Blood pressure
 Oxygen saturation by pulse oximetry (if
hypoxemia is suspected)
 ICP

DIRECTED COUGH
 A component of bronchial hygiene therapy
when spontaneous cough is inadequate
 Forced expiratory technique (fet, or huff
cough) and manually assisted cough are
examples
 A deliberate maneuver that is taught,
supervised, and monitored
 Seeks to mimic the attributes of an effective
spontaneous cough (or series of coughs), to
help to provide voluntary control over
reflex, and to compensate for physical
limitations (eg, by increasing glottic control,
inspiratory and expiratory muscle strength,
coordination, and airway stability).
 The three most important aspects involved
in patient teaching are:
1. instruction in proper positioning,
2. instruction in breathing control,
3. exercises to strengthen the expiratory
muscles
 INDICATIONS:
 The need to aid in the removal of
retained secretions from central
airways
 The presence of atelectasis
 As prophylaxis against postoperative
pulmonary complications
 As an integral part of other bronchial
hygiene therapies
 To obtain sputum specimens for
diagnostic analysis
 As a routine part of bronchial hygiene
in patients with cystic fibrosis,
bronchiectasis, chronic bronchitis,
necrotizing pulmonary infection, or
spinal cord injury
 CONTRAINDICATIONS:
 Inability to control possible
transmission of infection from patients
suspected or known to have pathogens
transmittable by droplet nuclei (e.g., m.
tuberculosis)
 Presence of an elevated ICP or known
intracranial aneurysm
 Presence of reduced coronary artery
perfusion, such as in acute MI
 Acute unstable head, neck, or spine
injury
 Manually assisted directed cough with
pressure to the epigastrium may be
contraindicated in presence of:
o increased potential for
regurgitation/aspiration (eg,
unconscious patient with
unprotected airway)
o acute abdominal pathology,
abdominal aortic aneurysm, hiatal
hernia, or pregnancy
o a bleeding diathesis
o untreated pneumothorax
 Manually assisted directed cough with
pressure to the thoracic cage may be
contraindicated in:
o presence of osteoporosis, flail
chest
 HAZARDS/COMPLICATIONS:
o Reduced coronary artery perfusion
o Reduce cerebral perfusion leading
to syncope or alterations in
consciousness, such as, light-
headedness or confusion, vertebral
artery dissection
o Incontinence
o Fatigue
o Headache
o Paresthesia or numbness
o Bronchospasm
o Muscular damage or discomfort
o Spontaneous pneumothorax,
pneumo-mediastinum,
subcutaneous emphysema
o Cough paroxysms
o Chest pain
o Rib or costochondral junction
fracture
o Incisional pain, evisceration
o Anorexia, vomiting, and retching
o Visual disturbances including
retinal hemorrhage
o Central line displacement
o Gastroesophageal reflux
 ASSESSMENT OF NEED:
o Spontaneous cough that fails to
clear secretions from the airway
o Ineffective spontaneous cough as
judged by
 clinical observation
 evidence of atelectasis
 resultsofpulmonaryfunctiontes
ting
o Postoperative upper abdominal or
thoracic surgery patient
o Long-term care of patients with
tendency to retain airway
secretions
o Presence of endotracheal or
tracheostomy tube
 ASSESSMENT OF OUTCOME:
o The presence of sputum specimen
following a cough
o Clinical observation of
improvement
o Patient's subjective response to
therapy
o Stabilization of pulmonary hygiene
in patients with chronic pulmonary
disease and a history of secretion
retention
FORCED EXPIRATORY TECHNIQUE (FET)
 modification of the normal directed cough.
 consists of one or two forced expirations of
middle to low lung volume without closure
of the glottis, followed by a period of
diaphragmatic breathing and relaxation.
 The goal :
 to help clear secretions with less
change in pleural pressure and less
likelihood of bronchiolar collapse.
  Less painful and less stressful than coughing
 The patient should be taught to phonate or
"huff” during expiration.
 The period of diaphragmatic breathing and
relaxation following the forced expiration is
essential in restoring lung volume and
minimizing fatigue.
ACTIVE CYCLE OF BREATHING(ACB) SEQUENCE
1. Relaxation and breathing control
2. Three to four thoracic expansion exercises
3. Relaxation and breathing control
4. Repeat three to four thoracic expansion
exercises
5. Repeat relaxation and breathing control
6. Perform one or t w o FETs (huffs)
7. Repeat relaxation and breathing control
DIRECTED COUGH
AUTOGENIC DRAINAGE (AD)
 another modification of directed coughing,
designed as an airway clearance mechanism
that can be performed independently by
trained patients.
 During AD, the patient uses diaphragmatic
breathing to mobilize secretions by varying
lung volumes and expiratory airflow in three
distinct phases
 PHASES OF AD
 Phase 1 – involves a full inspiratory
capacity maneuver, followed by
breathing at low lung volumes. This
phase is designed to "unstick"
peripheral mucus.
 Phase 2 – involves breathing at low to
middle lung volumes in order to collect
mucus in the middle airways.
 Phase 3 – is the evacuation phase, in
which mucus is readied for expulsion
from the •large airways.
 For maximum benefit the patient should be
in the sitting position.
 Patients are taught to control their
expiratory flows to prevent airway collapse
while trying to achieve a mucus "rattle"
rather than a wheeze.
 Coughing should be suppressed until all
three breathing phases are completed.
 PANTING
 Patient is instructed to follow normal
cough sequence, but the tongue is kept
forward to prevent swallowing of
secretions.
 GENERAL POINTS ABOUT CPT
 Steps to Remember
 bronchodilator or aerosol
 place pt. in PD position
 Percussion
 Vibration
 Cough
 DIAPHRAGMATIC BREATHING
 change position
 repeat 2-6 until complete
 In most cases, CPT should follow
nebulization or aerosol therapy
 for maximum benefit in some diseases
(COPD, bronchiectasis, CF), treatments
should be 1st thing in the morning &
last thing at H.S.
BREATHING INSTRUCTION AND RETRAINING
 Designed to assist patients with muscular
weakness, postoperative pain, or CPD to
assume an efficient ventilatory pattern and
effective cough
 Uses:
 COPD
 Atelectasis
 post-op
 prolonged bed rest
 GOAL:
 To increase and improve ventilation
 To strengthen respiratory musculature
 To prevent development of atelectasis
 To decrease work of breathing
 To improve the effectiveness of cough
 SPECIFIC TECHNIQUES:
 Diaphragmatic Breathing Exercises
 Lateral Costal Expansion Exercises
 Localized Expansion Exercises
 Pt. should be made aware that diaphragm is
primary muscle of breathing.
 Contraction of the diaphragm causes
contraction of dome and expansion of the
base of the thorax.
 This increases transpulmonary pressure in
the lungs, causing air to flow into lungs
(each cm of movement = app. 350 ml of air
volume).
 This exercise strengthens the diaphragm
and increases exercise tolerance.
 The patient is relaxed, supported with a
pillow, and directed to inspire by
contracting the diaphragm slowly and
completely to allow a normal inspiratory
pattern
 Abdominal expansion
 Lateral chest expansion
 Upper chest expansion
 The patient is encouraged to exhale slowly,
passively and completely.
 The therapist may assist exhalation by
exerting a slight inward and upward
pressure below the xiphoid process
PURSED LIP BREATHING
 Pursed lip breathing is one of the simplest
ways to control shortness of breath.
 It provides a quick and easy way to slow
pace of breathing, making each breath
more effective.
 WHAT DOES PURSED LIP BREATHING DO?
 Improves ventilation
 Releases trapped air in the lungs
 Keeps the airways open longer and
decreases the work of breathing
 Prolongs exhalation to slow the
breathing rate
 Improves breathing patterns by moving
old air out of the lungs and allowing for
new air to enter the lungs
 Relieves shortness of breath
 Causes general relaxation
 PURPOSES OF PURSED LIP BREATHING
 as a 3-5 minutes “rescue exercise” or
an Emergency Procedure to counteract
acute exacerbations or dyspnea
 to increase baroreceptor cardiac
function in primary hypertension
 during physical exercise or walking to
improve oxygenation of the arterial
blood
 as a 10-20 minutes daily systematic
respiratory exercise to train breathing
in complex with other rehabilitative
activities
 PURSED LIP BREATHING TECHNIQUE
 Relax neck and shoulder muscles.
 Breathe in (inhale) slowly through the
nose for two counts, keeping mouth
closed. Don't take a deep breath; a
normal breath will do. It may help to
count: inhale, one, two.
 Pucker or "purse“ lips as if you were
going to whistle or gently flicker the
flame of a candle.
 Breathe out (exhale) slowly and gently
through pursed lips while counting to
four
 SEGMENTAL BREATHING EXERCISES
 similar to diaphragmatic breathing
exercises
 may be used with postural drainage
positions
 The patient is asked to inspire while the
RT applies pressure to the thoracic cage
to resist respiratory excursion in a
segment of the lung.
 As the RT feels the local expansion, the
hand resistance is decreased to allow
inhalation. This facilitates the
expansion of adjacent regions of the
thoracic cavity that may have
decreased ventilation.
  Variations:
o unilateral or bibasilar expansion
(ribs 6, 7 & 8)
o lateral expansion (ribs 6, 7 & 8 and
axilla)
o apical expansion (below clavicle)
 not on COPD pxs. - area
already developed
 LATERAL COSTAL EXPANSION
 the RT places his hands over the
patient’s lower rib cage with the
thumbs just above the xiphoid process
 the patient is encouraged to relax and
inspire against a slight pressure exerted
by the RT’s hands; instructed to try to
expand area located under the RT’s
hands
 exhalation should be passive and
complete
 POSTERIOR BASAL EXPANSION
 This form of segmental breathing is
important for the post surgical patient
who is confined to bed in a semi
upright position for an extended period
of time. Secretions often accumulate in
the posterior segments of the lower
lobes.
1. have the patient sit and lean forward
on a pillow, slightly bending the hips.
2. the RT places his hands over the
posterior aspect of the lower ribs.
3. The patient is encouraged to relax and
inspire against a slight pressure exerted
by the RT’s hands; instructed to try to
expand area located under the RT’s
hands
4. Exhalation should be passive and
complete
 RIGHT MIDDLE LOBE OR LINGULA
EXPANSION
 Patient is sitting.
 The RT places his hands at either the
right or the left side of the patient’s
chest, just below the axilla.
 The patient is encouraged to relax and
inspire against a slight pressure exerted
by the RT’s hands; instructed to try to
expand area located under the RT’s
hands
 Exhalation should be passive and
complete
 LOCALIZED EXPANSION EXERCISES
 Designed to direct the gas flow to a
specific area of the lungs
 RT places his hands over the problem
area and instructs the patient to inspire
against a slight pressure exerted by the
RT.
 Exhalation should be passive, complete
and assisted by the RT.
GENERAL GUIDELINES FOR THE TREATMENT OF  EMPHYSEMA
SPECIFIC PATHOPHYSIOLOGIC PROBLEMS
 Goal:
 ATELECTASIS
o Decrease WOB
 Goal:
o Improve chest wall mobility
o Reverse Collapse
 Techniques:
 Techniques:
o Breathing instructions
o Postural Drainage
o Shaking
o Percussion
o Cough assistance
o Vibration

 CHRONIC BRONCHITIS
 PNEUMONIA
 Goal:
 Goal:
o Mobilize secretions
o Remove excess secretions
 Techniques:
o Prevent or reverse collapse
o Postural drainage
 Techniques:
o Percussion
o Postural Drainage
o Vibration
o Cough assistance
o Breathing instructions

 ADULT RESPIRATORY DISTRESS SYNDROME

 ASTHMA
 Goal:
 Goal:
o Maximize oxygenation
o Decrease WOB
o Mobilize secretions
o Mobilize secretions

 Techniques  Techniques:

o Postural Drainage o Modified Postural drainage

o Vibration o Vibration

o Breathing instructions
 ABSCESS

 Goal:

o secretions Mobilize

 Techniques:

o Postural drainage

o Vibration

o Percussion

 SPINAL CORD INJURY

 Goal:

o Maximize ventilation

o Mobilize secretions

 Techniques:

o Breathing instructions

o Cough assistance

o Postural drainage

o Vibration