Pulmonary Rehabilitation (Postural Drainage)

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Dr.Nabil Paktin,MD,FACC. Trainer Specialist of Clinical Cardiology Postgraduate Program of Cardiology Afghanistan Cardiovascular(cardiology) society Lecture series

Dr.Nabil Paktin,MD,FACC. Trainer Specialist of Clinical Cardiology Postgraduate Program of Cardiology Afghanistan Cardiovascular(cardiology) society Lecture series

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  • The respiratory tract produce about two litres of mucus a day from these glands (Martini, 2003), and this is composed of water, carbohydrates, proteins and lipids. The high water content helps to humidify the passing inspired air. Mucus contains glycoproteins (or mucins) as well as proteins derived from plasma, and products of cell death such as DNA.
  • A person may become conscious of swallowing the mucus or the inflammation may trigger a coughing reflex so that they expectorate these secretions as sputum.Smoking - Smoking has many effects on the airways. Inhaled smoke destroys the cilia that are important for moving mucus to the throat for swallowing. As a result, mucus accumulates in the bronchioles and irritates the sensitive tissues there, causing a cough. Coughing is vital as it is the only way smokers can remove mucus from their lungs and keep the airways clean (Rubin, 2002). This is characterised by the ‘smoker’s cough’.Constant coughing to clear the sputum has an effect on the smooth muscle of the bronchioles which becomes hypertrophied (enlarged or overgrown). This in turn causes more mucus glands to develop.
  • Patients with pulmonary diseases that are associated with increased production or viscosity of mucus, such as chronic bronchitis and cystic fibrosis• Patients who are on prolonged bed rest• Patients who have received general anesthesia and who may have painful incisions that restrict deep breathing and coughing postoperatively• Any patient who is on a ventilator if he or she is stable enough to tolerate the treatment
  • The lungs consist of 5 lobes -- 3 on the right and 2 on the left side of the chest cavity, each of which are further divided into segments. To be most effective, postural drainage should be accompanied by chest physiotherapy, which includes percussion and vibration, deep breathing and coughing. Once a patient assumes the correct postural drainage position, the caregiver performs chest percussion and vibration to the desired area. Chest physiotherapy is generally performed for 3 to 5 minutes on each segment. During this time, the patient is encouraged to take a slow, deep breath followed by a vigorous cough in an attempt to clear the airways of mucus. This technique should be repeated several times during the chest physiotherapy session.
  • Chest percussion, also referred to as chest physiotherapy, is an airway clearance technique that involves clapping on the chest and/or back to help loosen thick secretions. Doing this makes mucus easier to expel, or cough up. Chest percussion is often coupled with postural drainage and vibration and can be performed using either cupped hands or a mechanical airway clearance device.
  • Vibration is an airway clearance technique that, coupled with chest percussion, is applied during postural drainage to help clear mucus from the airways. Vibration helps to gently shake mucus and secretions into the large airways, making them easier to cough up. During vibration, place your flat hand firmly against the chest wall, atop the appropriate lung segment to be drained. Stiffen your arm and shoulder, apply light pressure and create a shaking movement, similar to that of a vibrator. Ask service user to breathe in deeply during vibration therapy, and exhale slowly and completely. Taking a deep breath and then exhaling slowly and forcefully without straining will hopefully stimulate a productive cough.
  • To drain mucus from the upper lobe apical segments, the patient sits in a comfortable position on a bed or flat surface and leans on a pillow against the headboard of the bed or the caregiver. The caregiver percusses and vibrates over the muscular area between the collar bone and very top of the shoulder blades (shaded areas of the diagram) on both sides for 3 to 5 minutes. Encourage the patient to take a deep breath and cough during percussion in order to help clear the airways. Do not percuss over bare skin.
  • The patient sits comfortably in a chair or the side of the bed and leans over, arms dangling, against a pillow. The caregiver percusses and vibrates with both hands over upper back on both the right and left sides.
  • In position #3, the patient lies flat on the bed or table with a pillow for comfort under his or her head and legs. The caregiver percusses and vibrates the right and left sides of the front of the chest, between the collar bone and nipple.
  • The patient lies with their head down toward the foot of the bed on the right side, hips and legs up on pillows. The body should be rotated about a quarter-turn towards the back. A pillow can also be placed behind the patient and their legs slightly bent with another pillow between the knees. The caregiver percusses and vibrates just outside the nipple area.
  • The patient lies head-down on his left side, a quarter-turn toward the back with the right arm up and out of the way. The legs and hips should be elevated as high as possible. A pillow may be placed in back of the patient and between slightly bent legs. The caregiver percusses and vibrates just outside the right nipple area.
  • The patient lies on his right side with his head facing the foot of the bed and a pillow behind his back. The hips and legs should be elevated as high as possible on pillows. The knees should be slightly bent and a pillow should be placed between them for comfort.The caregiver percusses and vibrates over the lower ribs on the left side, as shown in the shaded part of the diagram. This should then be repeated on the opposite side, with percussion and vibration over the lower ribs on the right side of the chest.
  • The patients lies on his or her stomach, with the hips and legs elevated by pillows. The caregiver percusses and vibrates at the lower part of the back, over the left and right sides of the spine, careful to avoid the spine and lower ribs.
  • The patient lies on his right side, leaning forward about one-quarter of a turn with hips and legs elevated on pillows. The top leg may be flexed over a pillow for support and comfort.The caregiver percusses and vibrates over the uppermost portion of the lower part of the left ribs, as shown in the shaded area. This should then be repeated on the opposite side, with percussion and vibration over the uppermost portion of the right side of the lower ribs.
  • For this position, the patient lies on his stomach on a flat bed or table. Two pillows should be placed under the hips.The caregiver percusses and vibrates over the bottom part of the shoulder blades, on both the right and left sides of the spine, avoiding direct percussion or vibration over the spine itself.


  • 1. Pulmonary Rehabilitation (PosturalDrainage)Dr.Nabil Paktin,MD.FACC.Lecturer of Cardiology/Pulmonology and Critical Carewww.afghanheart.wordpress.comCardiology Online /face bookAvicenna the Sadri(cardiovascular and Pulmonary)Postgraduate national Hospital -Kabul26,05,2013
  • 2. Histolphysiology of Tracheobronchial treeDr.Nabil Paktin, MD.,FACC.The trachobronchial tree is composed ofthree major layers: an epithelial lining ,the lamina propria , and a cartilaginouslayer .
  • 3. EpithelialDr.Nabil Paktin, MD.,FACC.Predominantly composed of Pseudostratified ciliatedcolumnar epitheliumInterspersed with numerous mucous glands and separatedfrom the lamina propria by basement membranePseudo stratified ciliated epithelium extends from thetrachea to the respiratory bronchioles .There are 200 cilia per ciliated cell
  • 4. The cilia progressively disappear in the terminalbronchiole and are completely absent in therespiratory bronchiolesa mucus layer ; mucous blanket , covers theepithelia lining of the tracheobronchial treeOf this blanket 95% is water and other 5% isglycoproteins , carbohydrates , lipids , and foreignparticles ….Dr.Nabil Paktin, MD.,FACC.
  • 5. Dr.Nabil Paktin, MD.,FACC.The Mucus is produced by > 1) goblet cells and 2)submucosal or bronchial , glands .The submucosal glands which produce most of themucous blanket , extend deep into the lamina propria.These glands are innervated by the vagalparasympathetic nerve fibers ( the tenth cranialnerve ) and produce about 100 ml of bronchialsecretions per day .
  • 6. The viscosity of the mucous blanket progressivelyincreases from the epithelial lining to the innerluminal surface .The blanket has two distinct layers ;1) the sol layer2) gel layerUnder normal circumstances , the cilia move in awavelike fashion through less viscous sol layer andcontinually strike the innermost portion of the gellayer (1500 times per minute)Dr.Nabil Paktin, MD.,FACC.
  • 7. This actions propels the mucus layer>any foreignparticle to the gel layer>larynx>average rate>2cm/minCough mechanism moves secretions beyond thelarynx and into the oropharynx .number of events clinically that affect thismechanism:1-smokin2-dehydration3-positive pressure vent.4-endotracheal suctioning5-high inspired oxygen concentrations6-hypoxia7-atomspheric pollutants8- general anesthetics9-parasympatholytics(e.g.,atropine)Dr.Nabil Paktin, MD.,FACC.
  • 8. Dr.Nabil Paktin, MD.,FACC.
  • 9. RehabilitationRCT evidences suggest ,-exercise tolerance ,-quality of life , and- reduce hospital admissionsDr.Nabil Paktin, MD.,FACC.
  • 10. Goals and Indications for Postural DrainagePrevent Accumulation of Secretions in Patients atRisk for Pulmonary Complications• Patients with pulmonary diseases • Patients who are onprolonged bed rest• Patients who have received general anesthesia andwho may have painful incisions that restrict deepbreathing and coughing postoperatively• Any patient who is on a ventilator if he or she is stableenough to tolerate the treatmentDr.Nabil Paktin, MD.,FACC.
  • 11. Remove Accumulated Secretionsfrom the Lungs• Patients with acute or chronic lungdisease, such as pneumonia,atelectasis, acute lung infections, COPD• Patients who are generally very weakor are elderly• Patients with artificial airwaysDr.Nabil Paktin, MD.,FACC.
  • 12. CONTRAINDICATIONS1. Positioning1.1. All positions are contraindicated forIntracranial pressure more than 20 mmHgUnstable head and neck injuryActive haemorrhage with hemodynamic instabilityAcute spinal injuryActive haemoptysisEmpyemaBronchopleural fistulaPulmonary oedema associated with congestive heart failureLarge pleural effusionsPulmonary embolismAged, confused, or anxious patients who do not tolerate positionchangesRib fracture, with or without flail chestSurgical wound or healing tissueDr.Nabil Paktin, MD.,FACC.
  • 13. 1.2. Trandelenburg position is contraindicated for•Intracranial pressure more than 20 mmHg•Uncontrolled hypertension•Distended abdomen•Oesophageal surgery•Recent gross haemoptysis related to recent lung carcinoma treatedsurgically or with radiation therapy•Uncontrolled airway at risk for aspiration (tube feeding or recentmeal)Dr.Nabil Paktin, MD.,FACC.
  • 14. 1.3. Reverse Trandelenburg is contraindicated in the presenceof hypotension or vasoactive medication2. External Manipulation of the ThoraxIn addition to contraindications previously listedSubcutaneous emphysemaRecent epidural spinal infusion or spinal anaesthesiaRecent skin grafts, or flaps on the thoraxBurns, open wounds and skin infections of the thoraxRecent placed transvenous pacemaker or subcutaneouspacemakerSuspected pulmonary tuberculosisLung contusionBrochospasmOsteomyelitis of the ribsOsteoporosisComplain of chest wall painDr.Nabil Paktin, MD.,FACC.
  • 15. Relative Contraindications to Postural DrainageSevere hemoptysis• Untreated acute conditions• Severe pulmonary edema• Congestive heart failure• Large pleural effusion• Pulmonary embolism• Pneumothorax• Cardiovascular instability• Cardiac arrhythmia• Severe hypertension or hypotension• Recent myocardial infarction• Unstable angina• Recent neurosurgery• Head-down positioning may cause increased intracranial pressure; ifPD is required, modified positions can be usedDr.Nabil Paktin, MD.,FACC.
  • 16. Definition• Postural drainage is a technique in whichdifferent positions are assumed to facilitatethe drainage of secretions from the bronchialairways.• Gravity helps to move the secretions to thetrachea to be coughed up easily.• The goal of postural drainage and manualtherapy is to help drain mucus from each ofthese lobes into the larger airways of the lungsso it can be coughed up more readily.Dr.Nabil Paktin, MD.,FACC.
  • 17. Anatomy of LungDr.Nabil Paktin, MD.,FACC.
  • 18. Dr.Nabil Paktin, MD.,FACC.
  • 19. PercussionDr.Nabil Paktin, MD.,FACC.
  • 20. VibrationDr.Nabil Paktin, MD.,FACC.
  • 21. Timing of PD&PGenerally, each treatment session can last for 20 to 40 minutes. PD &P is best done before meals or one and a half to two hours after eatingto decrease the chance of vomiting. Early morning and bedtimesusually are recommended.The length of PD & P and the number of times of Day it is done mayneed to be increased if the person is more congested or getting sick.Dr.Nabil Paktin, MD.,FACC.
  • 22. Positions according to lobes locationsDr.Nabil Paktin, MD.,FACC.
  • 23. Position #1Upper Lobe Apical SegmentsDr.Nabil Paktin, MD.,FACC.
  • 24. Position #2Upper Lobe Posterior SegmentsDr.Nabil Paktin, MD.,FACC.
  • 25. Position #3Upper Lobe Anterior SegmentsDr.Nabil Paktin, MD.,FACC.
  • 26. Position #4LingulaDr.Nabil Paktin, MD.,FACC.
  • 27. Position #5Middle LobeDr.Nabil Paktin, MD.,FACC.
  • 28. Position #6 and #7Lower Lobes Anterior Basal SegmentsDr.Nabil Paktin, MD.,FACC.
  • 29. Position #8Lower Lobes Posterior Basal SegmentsDr.Nabil Paktin, MD.,FACC.
  • 30. Position #9 and #10Lower Lobes Lateral Basal SegmentsDr.Nabil Paktin, MD.,FACC.
  • 31. Position #11Lower Lobes Superior SegmentsDr.Nabil Paktin, MD.,FACC.
  • 32. Dr.Nabil Paktin, MD.,FACC.