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SRI GURU RAM DAS NURSING INSTITUTE

PANDHER, AMRITSAR

ASSIGNMENT
ON
CHEST
PHYSIOTHERAPY
SUBMITTED TO: Miss Arpandeep Kaur
Associate professor
Dept. of community health nurse

SUBMITTED BY: Pawandeep Kaur

MSC Nursing 1st year
Medical Surgical Nursing

SUBMITTED ON:

INTRODUCTION
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Chest physiotherapy (CPT) is the treatments generally performed by physical therapists

and respiratory therapists, whereby breathing is improved by the indirect removal of mucus
from the breathing passages of a patient. Other terms, used in Australia,
include respiratory or cardiothoracic physiotherapy.

CONTENT
CHEST PHYSIOTHERAPY
Chest physiotherapy (CPT) is the treatments generally performed by physical therapists and
respiratory therapists, whereby breathing is improved by the indirect removal of mucus from
the breathing passages of a patient. Other terms, used in Australia, include respiratory or
cardiothoracic physiotherapy. CPT includes postural drainage, chest percussion,
vibration & breathing training. In addition, teaching the patient effective coughing
technique is an important part of CPT. The goals of CPT are to remove bronchial secretions,
improve ventilation, and increase the efficiency of the respiratory muscles.

Definition
Chest physical therapy is the term for a group of treatments designed to improve respiratory
efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate
secretions from the respiratory system.

Purpose
The purpose of chest physical therapy, also called chest physiotherapy, is to help patients
breathe more freely and to get more oxygen into the body. Chest physical therapy includes
postural drainage, chest percussion, chest vibration, turning, deep breathing exercises, and
coughing. In the early 2000s, some newer devices, such as the positive expiratory
pressure (PEP) valve and the flutter device, have been added to the various chest physical
therapy techniques. Chest physical therapy is normally done in conjunction with other
treatments to rid the airways of secretions. These other treatments include
suctioning, nebulizer treatments, and the administering expectorant drugs.
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Description
Good respiratory health is not possible without efficient clearance of secretions in the airway.
In a healthy person, this is normally accomplished through two mechanisms: the mucociliary
clearance system (MCS) and the ability to cough . There are many diseases and disabilities in
children linked with poor lung health and an impaired ability to clear secretions. These
include cystic fibrosis, asthma, cerebral palsy, muscular dystrophy , and
various immunodeficiency disorders. When a child is unable to clear mucus, breathing
becomes hard work. He or she must expend extra effort and energy in order to get oxygen.
This difficulty can lead to a vicious cycle of recurrent episodes of inflammation, respiratory
infections, lung damage, increased production of excess mucus, and possibly airway
obstruction. Chest physical therapy is one way to reduce the risks of an inefficient clearance
of airway secretions. Depending on the specific technique and health situation, chest physical
therapy may be used on children from newborns to adolescents.

Various Methods
Various methods of chest physical therapy have been used since the early 1900s to help
manage airway clearance disorders. The techniques have been refined since that time. The
procedure may be performed by a respiratory therapist, a nurse, or a trained family member.
However, chest physical therapy presents some challenges and requires skill and training in
order to be safely and effectively performed.
Chest physical therapy is a method of clearing the airway of excess mucus. It is based on the
theory that when various areas of the chest and back are percussed, shock waves are
transmitted through the chest wall, loosening the airway secretions. If the child is positioned
appropriately, the loosened secretions will then drain into the upper airways, where they can
then be cleared using coughing and deep breathing techniques. The following techniques are
all part of chest physical therapy.

Turning
Turning from side to side permits lung expansion. The child may turn on his or her own, or
be turned by a caregiver. Turning should be done at a minimum of every two hours if the
child is bedridden. The head of the bed can also be elevated in order to promote drainage.

Coughing
Coughing helps to break up secretions in the lungs so that the mucus can be expectorated or
suctioned out if necessary. Patients sit upright and inhale deeply through the nose. They then
exhale in short puffs or coughs. This procedure is repeated several times a day.

Deep breathing
Deep breathing helps expand the lungs and forces an improved distribution of the air into all
sections of the lungs. The patient either sits in a chair or sits upright in bed and inhales then
pushes the abdomen out to force maximum amounts of air into the lung. The abdomen is then
contracted, and the patient exhales. Deep breathing exercises are done several times each day
for short periods.
Because of the mind-body awareness required to perform coughing and deep breathing
exercises, they are unsuitable for most children under the age of eight.
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Postural drainage
Postural drainage uses the force of gravity to assist in effectively draining secretions from the
smaller airways into the central airway where they can either be coughed up or suctioned out.
The child is placed in a head- or chest-down position and is kept in this position for up to 15
minutes. To obtain the head-down positions, the use of a pillow, beanbag chair, or couch
cushions can be helpful. Often, percussion and vibration are performed in conjunction with
postural drainage.

Percussion
Percussion involves rhythmically striking the chest wall with cupped hands. It is also called
cupping or clapping. The purpose of percussion is to break up thick secretions in the lungs so
they can more easily be removed. Percussion is performed on each lung segment for one to
two minutes at a time. Mechanical percussors are available and may be suitable for children
over two years of age. The percussor is moved over one lobe of the lung for approximately
five minutes, while the patient is encouraged to performing coughing and deep breathing
techniques. This process is repeated until each segment of the lung is percussed.

Vibration
As with percussion, the purpose of vibration is to help break up lung secretions. Vibration
can be either mechanical or manual. It is performed as the patient breathes deeply. When
done manually, the person performing the vibration places his or her hands against the
patient's chest and creates vibrations by quickly contracting and relaxing arm and shoulder
muscles while the patient exhales. The procedure is repeated several times each day for about
five exhalations.

Positive expiratory pressure (PEP)

PEP therapy has been extensively tested and is equivalent to standard chest physical therapy.
It is an airway clearance method that is administered by applying a mechanical pressure
device to the mouth. By breathing out with a moderate force through the resistance of the
device, a positive pressure is created in the airways that helps to keep them open. This
positive pressure permits airflow to reach beneath the areas of mucus obstruction and to move
the mucus toward the larger airways where it can be expectorated. This technique may be
suitable for alert, cooperative children over the age of four.

Flutter
 The flutter valve is a hand-held mucus clearance device designed to combine positive
expiratory pressure (PEP) with high frequency airway oscillations. The device looks
like a pipe containing an inner cone that cradles a steel ball sealed with a perforated
cover. Exhalation through the device results in a vibration of the airway walls, which
in turn loosens secretions. It may be a suitable technique for children aged five years
and over.

A child is considered to have responded positively to chest physical therapy if some, but not
necessarily all, of the following changes occur:
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 increased volume of sputum secretions

 changes in breath sounds
 improved chest x ray
 increased oxygenation of the blood as measured by arterial blood gas sampling
 the child's report of increased ease in breathing

Indications of Chest Physiotherapy

It is indicated for patients in whom cough is insufficient to clear thick, tenacious, or localized
secretions. Examples include:

 Cystic fibrosis
 Bronchiectasis
 Atelctasis
 Lung abscess
 Neuromuscular diseases
 Pneumonias in dependent lung regions.

Contraindications of Chest Physiotherapy

1. Increased ICP
2. Unstable head or neck injury
3. Active hemorrhage with hemodynamic instability or hemoptysis
4. Recent spinal injury or injury
5. Empyma
6. Bronchoplueral fistula
7. Rib fracture
8. Fail chest
9. Uncontrolled hypertension
10. Anticoagulation
11. Rib or vertebral fractures or osteoporosis
12. Assessment for Chest Physiotherapy

Nursing care and selection of CPT skills are based on specific assessment
findings.

The following are the assessment criteria:

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 Know the normal range of patient’s vital signs. Conditions requiring CPT,
such atelectasis, and pneumonia, affects vital signs.

 Know the patient’s medications. Certain medications, particularly diuretics

antihypertensive cause fluid and haemodynamic changes. These decrease
patient’s tolerance to positional changes and postural drainage.

 Know the patient’s medical history; certain conditions such as increased ICP,
spinal cord injuries and abdominal aneurysm resection, contra indicate the
positional change to postural drainage. Thoracic trauma and chest surgeries
also contraindicate percussion and vibration.

 Know the patient’s cognitive level of functioning. Participating in controlled

cough techniques requires the patient to follow instructions.

 Beware of patient’s exercise tolerance. CPT maneuvers are fatiguing. Gradual

increase in activity and through CPT, patient tolerance to the procedure
improves.

Clinical findings and investigations

 Detailed History
 Physical examination
 Inspection
 Palpation
 Percussion
 Auscultation

Investigations

 X-ray
 Blood investigations-bleeding and clotting parameters
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Techniques in Chest Physiotherapy

 A nurse or respiratory therapist may administer CPT, although the techniques

can often be taught to family members of patients.

 The most common procedures used are postural drainage and chest
percussion, in which the patient is rotated to facilitate drainage of secretions
from a specific lobe or segment while being clapped with cupped hands to
loosen and mobilize retained secretions that can then be expectorated or
drained.

 The procedure is somewhat uncomfortable and tiring for the patient.

1. Percussion

 Chest percussion involves striking the chest wall over the area being drained.

 Percussing lung areas involves the use of cupped palm to loosen pulmonary
secretions so that hey can be expectorated with ease.

 Percussing with the hand held in a rigid dome-shaped position, the area over
the lung lobes to be drained in struck in rhythmic pattern.

 Usually the patient will be positioned in supine or prone and should not
experience any pain.

 Cupping is never done on bare skin or performed over surgical incisions,

below the ribs, or over the spine or breasts because of the danger o tissue
damage
.
 Typically, each area is percussed for 30 to 6oseconds several times a day.

 If the patient has tenacious secretions, the area must be percussed for 3-5
minutes several times per day. Patients may learn how to percuss the anterior
chest as well.

2. Vibration
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 In vibration, the nurse uses rhythmic contractions and relaxations is or her arm
and shoulder muscles while holding thee patient flat on the patient’s chest as
the patient exhales.

 The purpose is to help loosen respiratory secretions so that they can be

expectorated with ease. Vibration (at a rate of 200 per minute) can be done for
several times a day.
 To avoid patient causing discomfort, vibration is never done over the patient’s
breasts, spine, sternum, and rib cage.

 Vibration can also be taught to family members or accomplished with

mechanical device.

Procedure: Percussion & Vibration

 Instruct the patient use diaphragmatic breathing

 Position the patient in prescribed postural drainage positions. Spine should be

straight to promote rib cage expansion

 Percuss or clap with cupped hands or chest wall for 5 minutes over each
segment for 5 minutes for cystic fibrosis and 1-2 minutes for other conditions

 Avoid clapping over spine, liver, spleen, breast, scapula, clavicle or sternum

 Instruct the patient to inhale slowly and deeply. Vibrate the chest wall as the
patient exhales slowly through the pursed lips.

 Place one hand on top of the other affected over area or place one hand place
one and on each side of the rib cage.

 Tense the muscles of the hands and hands while applying moderate pressure
downward and vibrate arms and hands

 Relieve pressure on the thorax as the patient inhales.

 Encourage the patient cough, using abdominal muscles, after three or four
vibrations.

 Allow the patient rest several times

 Listen with stethoscope for changes in breath sounds

 Repeat the percussion and vibration cycle according to the patient’s

tolerance and clinical response: usually 15-30 minutes.
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3. Postural Drainage

 Postural drainage is the positioning techniques that drain secretions from

specific segments of the lugs and bronchi into the trachea.

 Because some patients do not require postural drainage for all lung segments,
the procedure must be based on the clinical findings.

 In postural drainage, the person is tilted or propped at an angle to help drain

secretions from the lungs.

 Also, the chest or back may be clapped with a cupped hand to help loosen
secretions—the technique called chest percussion.

Postural drainage cannot be used for people who are:

 unable to tolerate the position required,

 are taking anticoagulation drugs,

 have recently vomited up blood,

 have had a recent rib or vertebral fracture, or

 have severe osteoporosis.

 Postural drainage also cannot be used for people who are unable to produce
any secretions (because when this happens, further attempts at postural
drainage may lower the level of oxygen in the blood).

Procedure
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 The patient's body is positioned so that the trachea is inclined downward and
below the affected chest area.

 Postural drainage is essential in treating bronchiectasis and patients must

receive physiotherapy to learn to tip themselves into a position in which the
lobe to be drained is uppermost at least three times daily for 10-20 minutes.

 The treatment is often used in conjunction with the technique for loosening
secretions in the chest cavity called chest percussion.

Articles required

 Pillows
 Tilt table
 Sputum cup
 Paper tissues

Steps

 Use specific positions so the force of gravity can assist in the removal of
bronchial secretions from affected lung segments to central airways by means
of coughing and suctioning.

 The patient is positioned so that the diseased area is in a near vertical position,
and gravity is used to assist the drainage of specific segment.

 The positions assumed are determined by the location, severity, and duration
of mucous obstruction

 The exercises are performed two to three times a day, before meals and
bedtime. Each position is done for 3-15 minutes
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 The procedure should be discontinued if tachycardia, palpitations, dyspnea, or

chest occurs. The se symptoms may indicate hypoxemia. Discontinue if
hemoptysis occurs.

 Bronchodilators, mucolytics agents, water, or saline may be nebulised and

inhaled before postural drainage and chest percussion to reduce
bronchospasm, decrease thickness of mucus and sputum, and combat edema of
the bronchial walls, there by enhancing secretion removal

 Perform secretion removal procedures before eating

 Make sure patient is comfortable before the procedure starts and as

comfortable as possible he or she as.

Precautions
Chest physical therapy should not be performed on those children with the following:

 bleeding in the lungs

 head or neck injuries
 fractured ribs
 collapsed lungs
 acute asthma
 pulmonary embolism
 active haemorrhage
 some spinal injuries
 open wounds or burns

Preparation
The child should be taught about the necessity and rationale for chest physical therapy. It may
be a challenge to get children to cooperate with the procedure. Providing a toy, watching a
video, or giving a reward may be ways to encourage cooperation.

Aftercare
Many children may wish to perform oral hygiene measures after therapy to lessen the poor
taste of the secretions they have expectorated.
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Risks
The risks and complications associated with chest physical therapy are dependent upon the
health of the child. Although chest physical therapy normally poses few problems, in some
patients it may cause the following:

 oxygen deficiency if the head is kept lowered for drainage

 increased intracranial pressure
 temporary lowering of blood pressure
 bleeding in the lungs
 pain or injury to the ribs, muscles, or spine
 vomiting
 inhalation of secretions into the lungs
 heart irregularities

KEY TERMS
Coughing —In chest physical therapy, coughing is used to help break up secretions in the
lungs so that the mucus can be suctioned out or expectorated. Patients sit upright and inhale
deeply through the nose. They then exhale in short puffs or coughs.

Deep breathing —Deep breathing helps expand the lungs and forces better distribution of
the air into all sections of the lung. The patient either sits in a chair or sits upright in bed and
inhales, pushing the abdomen out to force maximum amounts of air into the lung. The
abdomen is then contracted, and the patient exhales.

Mucociliary escalator —The coordinated action of tiny projections on the surfaces of cells

lining the respiratory tract, which moves mucus up and out of the lungs.

Percussion —An assessment method in which the surface of the body is struck with the
fingertips to obtain sounds that can be heard or vibrations that can be felt. It can determine
the position, size, and consistency of an internal organ. It is performed over the chest to
determine the presence of normal air content in the lungs, and over the abdomen to evaluate
air in the loops of the intestine.

Postural drainage —The use of positioning to drain secretions from the bronchial tubes and
lungs into the trachea or windpipe where they can either be coughed up or suctioned out.

Vibration —The treatment that is applied to help break up lung secretions. Vibration can be
either mechanical or manual. It is performed as the patient breathes deeply. When done
manually, the person performing the vibration places his or her hands against the patient's
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chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles
while the patient exhales. The procedure is repeated several times each day for about five
exhalations.

Parental concerns
Because chest physical therapy is often prescribed for children with chronic health problems,
parents are often required to learn the techniques so the procedure can be performed regularly
at home. Many parents are fearful they might hurt their child or may perform the procedure
incorrectly. They should be reassured that thousands of parents have learned how to perform
chest physical therapy and do so safely and effectively.

CONCLUSION
Chest physiotherapy (CPT) is a technique used to mobilize or loose secretions in the lungs
and respiratory tract.This is especially helpful for patients with large amount of secretions or
ineffective cough.
Chest physiotherapy consists of external mechanical maneuvers, such as chest percussion,
postural drainage, vibration, to augment mobilization and clearance of airway secretions,
diaphragmatic breathing with pursed-lips, coughing and controlled coughing.

BIBLIOGRAPHY

 Brunner & Suddarth,Text book of medical surgical nursing,11th

edition,,Published by Wolters Kluers pvt ltd,Page no:732-735
 www.medscape.com