CHESTPHYSIOTHERAPY

CHEST PHYSIOTHERAPY
- Also called as chest physiotherapy and
pulmonary drainage.

- A general term used in reference to a series of

manipulative techniques designed to assist with bronchial
hygiene or the mobilization of secretions and prevention
or reversal of atelectasis.
THE FOLLOWING MODALITIES ARE INCLUDED
UNDER THIS GENERAL HEADING:

1) POSTURAL DRAINAGE
2) PERCUSSION
3) VIBRATION
4) COUGH ASSISTANCE
5) BREATHING INSTRUCTION AND RETRAINING
GOALS OF CHEST PHYSIOTHERAPY

A. Aid in bronchial hygiene

1) Prevent accumulation of bronchial secretions
2) Promote mobilization of bronchial secretions
3) Improve cough mechanism
B. Improve efficiency and distribution of ventilation

1) POSTURAL DRAINAGE - A method of removing

pooled secretions by positioning the patient so
as to allow gravity to assist in movement of
secretions from small peripheral
airways towards larger airway
PATIENT’S BED POSITIONS

1. Fowler’s
2. Semi-fowler’s
3. Supine
4. Prone
5. Dorsal recumbent
6. Right side lying
7. Left side lying
8. SIM’S
9. Trendelenburg’s position
10. Reverse Trendelenburg
INDICATIONS OF POSTURAL DRAINAGE

1) Acute or chronic pulmonary disease

2) Bronchiectasis
3) Pneumonia
4) Lung abscess
5) Cystic fibrosis
6) Ventilator care – debilitated patient
7) Acute atelectasis

PRECAUTIONS

1) Empyema
2) Pulmonary embolus
3) Open wounds, burns, skin grafts
4) Untreated tension pneumothorax
5) Flail chest
6) Frank hemoptysis
7) Orthopedic procedure
8) Acute spinal cord injury
* ICP increase – in head down position – blood will tend to
pool in the dependent portion of the body due to gravity.

* Venous return decrease due to the fact that blood must

now flow uphill.

* Those pts. who have known intra-cranial disease or are

post-operative

* Neurological cases- modify position to prevent

complications.

* PaO2 decrease with PD due to changes in the relationship

between ventilation and perfusion in the lungs. Patient
positioned where blood is pooled in an area of atelectasis or
consolidation may experience a significant shunt.
COPD – orthopneic altering position – SOB
Monitor: SaO2
SpO2 – ear oximetry
Weigh the benefits against any potential complications.
PD – maintain the indicated position for a minimum of 3-15 min if
tolerated and longer up to 30 min if sputum production results
Most effective in condition char. by excessive production of
secretions
> N 25-30 ml/day
- to avoid gastroesophageal reflux & possibility of aspiration,
sched treatment times before or at least ½ - 2 hrs after meals or
tube feeding.
- to prevent hypoxemia, pause for relaxation between position,
breathing control is useful.
Auscultate before – crackles
After – coarse rhonchi
PD must be re-con at least every 48 hors for critical care pts.
3 days for non-critical pts.
HEAD DOWN CONTRAINDICATIONS
1) Unstable cardiac states
2) Hypertension
3) Head injuries
4) Thoracic/abdominal surgery
5) Diaphragmatic surgery
6) Tracheoesophageal surgery
7) COPD
8) Obesity
9) Recent meals or tube feeding

REQUIREMENT FOR PD PROGRAM

Medical prescription that contains:
Lung areas to be drained
Length of treatment
Frequency of treatment
Related modalities
Supportive equipment such as O2 and nebulization
Special precautions
PHYSICAL ASSESSMENT – important part of program

FACTORS TO BE CONSIDERED
1) Patient’s position
2) Vital signs – BP=+ or-10, PR=not more than 120/min,
RR=not less than 10/min
3) Skin-color, temp., feel
4) Cough – pretreatment assessment
a) MEFR-should be > 150L/min
b) Insp. Force-should be > -20torr
c) VC –should be > 1.5L/min
5) Level of consciousness
EVALUATING CLINICAL SITUATIONS FOR
MODIFIED POSTURAL DRAINAGE
1) Hypoxemia
2) Cardiac Patients
3) Exhaustion
4) Pain
5) Post-op
6) Tracheostomy
7) Disoriented Pt.
8) Obese patient

PERCUSSION
A technique that is used most often in conjunction with PD
to loosen adherent bronchial secretions by rhythmically
tapping the chest wall with cupped hands.
- Clapping / cupping
(technique of “ketchup bottle theory”)
- Avoid clavicle, spine of scapula, spinal
- column and woman’s breast
CONTRAINDICATIONS
- Abscess
- Severe airway resistance
- Rib fracture
- Tuberculosis
- Empyema
- Pulmo embolus
- Unstable cardiac status
- Thoracic surgery
-Wounds, burns, skin grafts
- Chest tubes
- Anticoagulant therapy
- Limited patient tolerance
- Flail chest
- Osteoporotic change
- Diaphragmatic disorder
- Frank hemoptysis
- Acute spinal cord injury
- Untreated tension
pneumothorax
VIBRATION - A technique performed by
placing one hand on top of the other over the
affected area, producing a very rapid
vibratory motion in the arms from the
shoulder, while gently compressing the ribs
normally move during exhalation.

GENERAL HAZARDS AND COMPLICATIONS OF PD,

PERCUSSION & VIBRATION

1) Hypoxemia
2) Cardiovascular instability
3) Hemorrhage/hemoptysis
4) Fractured ribs
5) Increase intracranial pressure
6) Dyspnea
BREATHING INSTRUCTION & RETRAINING – these
techniques are designed to assist the pt. with
muscular weakness, post-op pt., or chronic pulmo.
disease to assume an efficient ventilator pattern and
effective cough.

GOALS
- To increase and improve ventilation
- To strengthen resp. musculature
- To prevent development of atelectasis
- To decrease WOB
- To improve the effectiveness of cough
TECHNIQUES

1) Diaphragmatic breathing

2) Lateral costal expansion exercise

3) Localized expansion exercise

BREATHING EXERCISE
INDICATIONS
- Patient with muscular weakness
- Post-op patient
- COPD

GOALS
- To improve ventilation
- To strengthen respiratory musculature
- To prevent development of atelectasis
- To decrease WOB
- To improve the effectiveness of cough
PATIENTS COMMON DIFFICULTIES:
- Over-use of the upper chest with difficulty
localizing basal
movement – taught until patient has fairly
good diaphragmatic breathing.
- Trick body movement – side flexion of spine
should be recognized and corrected
- Bad application of pressure. Pt. applies pressure
with the palm of the hand in the mid-axillary line,
if given with fingers, the hands gradually slip
forward and patient is only given
to a small part of the ribs anteriorly.
- Relaxation
▪ PRESSURE EXPANSION BREATHING EX ARE USED FOR:
▪

▪ - Traumatic chest injuries – surgical cases treated pre and

post operatively.
▪ - Hemothorax
▪ - Pneumothorax
▪ - Infected hemothorax
▪ - Fractured ribs
▪ - Pneumonia – stiff lung
▪ - Empyema
▪ - Pneumonia and pleurism
▪ - Lung abscess
▪ - Pre and post operative thoracotomy/lobectomy or
segmental resection /
▪ decortication – removal of the visceral pleura to permit
lung to expand
▪ FLATTENED CHEST: gross flattening of one side of the
chest. It is often helpful to teach them BE in side lying
over about 3 pillows placed under the chest in such a way
that the rib cage is opened out.
½ hour 3-5 x/day
- Shorten periods if not able.
1) SDBE can be used in – asthma, chronic bronchitis or
emphysema
- Pt. is instructed to get into a relaxed position and to breathe
quickly and gently with the diaphragm – expiration should not
be forced.
2) DB c longer prolonged exp. phase in order to expel secretions.
> UNILATERAL – one side, p applied at the end of
expiration
> DBE is used during attacks of dyspnea.
Sitting position – crook lying
- crook half lying lungs
and resp. ms are not cramped and thus are
not working against resistance.
▪ Pillow placed lengthwise at patient’s back
- Support/keep the thorax thrust slightly forward allowing
free use of diaphragm and therefore deeper breathing.
▪ UPRIGHT – for orthopneic patient – difficulty of breathing in
the recumbent position.
▪ ENVIRONMENT – proper vent, humidity and temp with
proper instruction will help the patient to breathe more
easily.

PRESSURE – 1. given over the side of the lower ribs first

(middle)
2) To both sides over bases of the lungs
3) To affected side only.

If the chest movement is very poor – bilateral expansion should not

be practiced until there is a reasonable amount of movement in the
weak areas.
POSITIONING PATIENTS FOR PULMONARY
DRAINAGE/CHEST PERCUSSION/VIBRATION OF ALL
LUNG SEGMENTS
1) DRAIN LOWER LOBES FIRST

A. POSTERIOR BASAL SEGMENT - Foot of bed is elevated 18 inches

(300). Patient lies on abdomen head down, with pillow UNDER HIPS.
Upper leg can be flexed over a pillow for support. Clap or vibrate
(if ordered) over lower ribs close to spine on each side of the back.
B. LATERAL BASAL SEGMENT – foot of bed is elevated 18 inches (300).
Patient lies on abdomen, then rotates quarter turn upward. Upper
leg can be flexed over a pillow for support. Clap or vibrate over
uppermost portion of lower ribs.
C. ANTERIOR BASAL SEGMENT - Foot of bed elevated 18”. Patient lies
on side, head don, pillow under knees. Clap or vibrate over lower
ribs just beneath axilla.
D. SUPERIOR BASAL SEGMENT - Bed flat. Patient lies on abdomen
with pillow under hips Clap or vibrate over middle of back below tip
of scapula on either side of spine.
2. Drain middle lobe second
3. Drain the upper lobe last

A. LINGULAR SEGMENS, SUPERIOR & INFERIOR - Foot of bed

elevated 14 inches. Patient lies head down on right side and
rotates quarter turn backward. Pillow maybe placed behind
patient from shoulder to hip. Knees should be flexed. Clap or
vibrate over left nipple area.
B. ANTERIOR SEGMENT - Bed flat. Patient lies flat on back with pillow
under knees. Clap or vibrate between clavicle and nipple on each
side of the chest.
C. APICAL SEGMENT - Bed flat. Patient leans back on pillow at 300
angle. Clap or vibrate over area between clavicle and top of
scapula on each side (shoulder)
D. POSTERIOR SEGMENT - Bed flat. Patient leans over folded pillow at
300 angle may also lean over pillow placed over the back of a chair).
Clap or vibrate over upper back on each side.
MODIFIED POSTURAL DRAINAGE

Left side lying 900 Side lying 450

- Lateral/Medial lobes - Medial
- Lateral / Medial lobes - Superior basal
- Superior basal - Medial basal
- Anterior basal - Posterior basal
- Lateral basal
Side lying 900
Side lying 450 prone - Lingular segments
- Superior basal - Superior basal
- Posterior basal - Antero medial basal
- Lateral basal - Lateral basal
Side lying 450 prone
- Superior basal
- Posterior basal
- Lateral basal

Side lying 450 Supine

- Superior lingual
- Inferior lingual
- Anteromedial segment
COUGH - A violent expiratory effort preceded
by a preliminary inspiration. It begins with a
forced exhalation against closed glottis after
a deep inspiration

Cough simulation – the pt. is provided a deep breath by positive

pressure that is held for as long as reasonable.
Chest vibration and compression is applied during
this insp. pause. Exhalation is allowed to take
place while the vibration & chest compression
continue.
COUGH – a major pulmonary defense mechanism that
attempt to maintain adequate bronchial hygiene
against retained secretions. A mechanism for
clearing obstruction of the airway.
- Productive or non-productive

SPUTUM – a substance that is expectorated from the mouth

containing mucus and saliva (from lungs, TBT and
nasal secretion) mobilized by the cough
mechanism.

NORMAL SPUTUM – white and translucent (allows light to

come through but does not allow you to see
through.)

PHLEGM – mucus discharge through the mouth (contains

bubbles)
COUGHING – a forcible expiratory
effort against closed glottis

First raises the pressure in the chest. The glottis

then suddenly opens, reducing pressure in the
trachea and large bronchioles to atmospheric
level. The high pressure still remaining in the
major air spaces of the lungs around the trachea
collapses the membranous trachea with great
force and velocity, blowing foreign material and
mucus with it.
SPUTUM CHARACTERISTICS

MUCOID – clear, thin, maybe somewhat viscid, is often a sign of the EARLY
STAGES OF BRONCHITIS.
MUCOPURULENT – thick, viscid, greenish color in-offensive, frothy, may have a
sweetish odor seen in the LATER STAGES OF BRONCHITIS, PHTHISIS, AND
PNEUMONIA.
PURULENT – thick, viscid, yellow, often offensive, may be present with
ABSCESS OF
THE LUNG, EMPHYSEMA, ADVANCES PHTHISIS AND BRONCHIECTASIS.
NUMMULAR – mucopurulent with small round semi-solid, masses which sink in
water, occurs IN ADVANCED PHTHISIS.
RUSTY – mucopurulent, very viscid and gelatinous, rusty tinge, seen with
PNEUMONIA.
PRUNE JUICE – dark brown, offensive, often semi-solid, seen in the
LATER STAGES OF PNEUMONIA, GANGRENE OF LUNG, AND NEW
GROWTH OF LUNG.
RED CURRANT – blood clots resembling currant jelly, occurs with a
NEW GROWTH IN
LUNG.
BLOOD (Hemoptysis) – bright red, frothy, with air bubble, maybe in
streaks or mixed
with sputum, fluid or clotted, or sputum may consist of pure blood.
BLOOD – maybe present IN PHTHISIS, other diseases of lung,
PNEUMONIA, NEW GROWTH,
GANGRENE, ABSCESS, BRONCHIECTASIS, MITRAL STENOSIS,
ANEURYSM RUPTURING INTO
THE BRONCHIAL TUBES.
PHTHISIS– ulceration of a vessel in a cavity
COLOR OF SPUTUM

Yellow – pus – white blood cells have a yellow color

Green – usually means old retained secretions because proteolysis of
mucopolysaccharide results in green color
Green and foul odor – pseudomonas (aeruginosa) infection
Brown – old blood
Red – fresh blood (Racemic Epinephrine may turn sputum pink) well mixed
or sputum and mixed with blood.
* Blood streaked sputum usually denotes tracheal or upper
airway bleeding.
SNEEZE – upper respiratory cough
HUFFING – rapid expel of air through an open glottis
COUGHING TECHNIQUE (STEP BY STEP)

1) Inhale (through the nose and exhale through the mouth) slowly and fully
before coughing.
2) Keep your head slightly forward.
3) Clasp your arms across your abdomen.
4) Stick your tongue forward; give (three sharp coughs) two sharp coughs
without taking another breath.
5) Press your arms into your abdomen as you cough.
You should feel your abdominal muscles tighten each time you cough.
6) Hold your breath for a moment after each coughing series then breathe
in gently to prevent sucking mucus back into your lungs.

FOUR STEPS IN COUGHING

1) Intake of air
2) Closure of glottis
3) Sudden contraction of abdominal and thoracic muscles with
simultaneous opening of the glottis
4) Cough out two times without re-inhalation.
4 DISTINCT PHASES OF NORMAL COUGH

1) Irritation
2) Inspiration
3) Compression
4) Expulsion
DIRECTED COUGH

: Aims to mimic the features of an effective

spontaneous cough in patient. Who are too weak to
produce a forceful expiratory maneuver. Position:
Sitting,:

Patient Teaching: 1. Instruction in proper positioning,

2. Instruction in breathing control, 3. Exercises to
strengthen the expiratory muscles.
HIGH FREQUENCY COMPRESSION/ OSCILLATION
Terms:
1. Oscillation-Rapid vibratory movement of small volumes of air
back and forth in the respiratory tract.
Two Kinds of Applications:
1. External chest wall application: High Frequency Chest Wall
Compression (HFCWC)
2. Airway Application: Flutter Valve and Intrapulmonary
Percussive Ventilation (IPV)
HIGH FREQUENCY CHEST WALL COMPRESSION
-accomplished by two parts system: a. variable pulse
generator, b. non stretch inflatable vest-covers the entire torso
NOTE: perform 30 min. therapy session at oscillatory frequency
between 5 and 25 hertz.
AIRWAY APPLICATION:
INTRAPULMONARY PERCUSSIVE VENTILATION
- Uses a pneumatic device to deliver a series of pressurized
gas miniburst at rates of 100 to 225 cycle per minute (1.6 to 3.75
Hz) to the respiratory tract.

FLUTTER VALVE
- combines techniques of EPAP and High Frequency
Oscillation at the aw. Opening.
-the valve consists of a pipe-shaped device with a heavy
steel ball sitting in an angled bowl.
DYSPNEA – a rapid rate, shallow depth, regular rhythm,
associated with accessory muscle activity.
- Shortness of breath associated with objective evidence of
difficult, labored or uncomfortable breathing.
- Awareness
ASSESSING DYSPNEA

Mode of Onset: Acute – sudden change in exercise tolerance

Chronic – gradual change

Severity: assess clinically by determining level of activity

associated with dyspnea.

CLASSIFICATION
1) On mild exertion
2) While walking short distances on level and at ordinary
pace.
3) While talking, washing face, taking a bath (ADL)
4) At rest
5) While lying down – associated with LVF
ASSESSMENT
What are your patient’s tolerance to prolonged sitting or
standing? Can he climb stairs? How many steps? Only upwards
or downwards? Discuss rate of dyspnea.

FUNCTIONAL CLASSIFICATION OF DYSPNEA

GRADE 1: Can keep pace walking with person of same age and
body build on the level without breathlessness but
not on hills or stairs.
GRADE 2: Can walk a mile at own pace (on the level) without
dyspnea, but can’t keep pace on the level with
normal person.
GRADE 3: Becomes breathless after walking about 100 yards or
for a few minutes on the level.
GRADE 4: Becomes breathless while dressing or talking.
GRADE 5: Dyspnea while at rest
ACUTE
PULMONARY CAUSES:

1) Pneumonia – associated with fever, cough and sputum

production
2) Acute pulmonary embolism – associated with
thrombophlebitis
3) Acute bronchial asthma
4) Spontaneous pneumothorax
5) Foreign body aspiration
6) Adult respiratory distress syndrome (ARDS)
7) Non-cardiac pulmonary edema – brought about by
a) noxious gas inhalation
b) high altitude pulmonary edema

NON-PULMONARY CAUSES:
- Cardiogenic pulmonary nocturnal dyspnea.
CHRONIC PROGRESSIVE
PULMONARY CAUSES:
COPD – emphysema, chronic bronchitis, chronic bronchial
asthma
Restrictive Lung Diseases
Interstitial lung diseases – sarcoidosis, rheumatoid lung,
scleroderma lung, pneumoconiosis, histiocytosis x,
lymphangitic cacinomatosis, and idiopathic fibrosing
alveolitis.
Chest wall deformities
Pleural fibrosis
NON-PULMONARY CAUSES:
Anemia – due to lack of oxygen
Hyperthyroidism – due to increased metabolic rate
Obesity
Upper airway disease
GENERAL MOBILIZATION

Older patients with chronic bronchitis or emphysema are

unable to tolerate vigorous exercises and should only be
given gentle arm swinging, relaxed head and neck
movements, relaxed trunk movements in sitting combined
with breathing.

They should not be pushed beyond their individual

capacities.
Younger patients – vigorous posture exercises, various
activities to increase their exercise tolerance.

With Asthma – if become breathless – position of relaxation

to practice diaphragmatic breathing until they have regained
control of their upper chest, often practice but neglect his
breathing.
GENERAL MOBILIZATION

Older patients with chronic bronchitis or emphysema are

unable to tolerate vigorous exercises and should only be
given gentle arm swinging, relaxed head and neck
movements, relaxed trunk movements in sitting combined
with breathing.

They should not be pushed beyond their individual

capacities.
Younger patients – vigorous posture exercises, various
activities to increase their exercise tolerance.

With Asthma – if become breathless – position of relaxation

to practice diaphragmatic breathing until they have regained
control of their upper chest, often practice but neglect his
breathing.
MOBILIZATION AND EXERCISE
-Exercise improves overall aeration and V/Q
matching, improve pulmonary function
General fitness, self-esteem, and quality of
life.
- Exercise can be fatiguing and result in O2
desaturation, those with neuromuscular
limitations are not good candidates for
airway clearance via exercise activity.