This document provides information on various chest physiotherapy techniques used to remove respiratory tract secretions. It describes postural drainage positioning which uses gravity to drain secretions from 18 segments of the lungs. It also details procedures for percussion, vibration, diaphragmatic breathing and coughing exercises which help loosen and clear secretions from the lungs. Precise positioning and techniques are outlined to target drainage of each lung segment toward larger airways.

1. CHEST
PHYSIOTHERAPY

2. MEASURES TO
REMOVE
RESPIRATORY
TRACT
SECRETIONS

3. POSTURAL DRAINAGE

4. POSTURAL DRAINAGE
• Gravity is used to drain secretions from
the lungs. The person is positioned in a
way that promotes the drainage of
secretions from smaller pulmonary
branches into larger ones, where they
can be removed by drainage or coughing.
Postural drainage is often preceded by
vibration, percussion, or both.

5. Purposes:
• To loosen lung secretions.
• To clear airways of pulmonary
secretions.
• To encourage a more effective
coughing.
• To improve pulmonary
ventilation.

6. OVERVIEW:
• There are 18 positions to facilitate
drainage, each corresponding with
one of the 18 segments of the
lungs.
• The purpose of the various
positions is to drain each segment
toward the larger airways.

7. OVERVIEW:
• There are 18 positions to facilitate
drainage, each corresponding with
one of the 18 segments of the
lungs.
• The purpose of the various
positions is to drain each segment
toward the larger airways.

8. OVERVIEW:
● This procedure is usually indicated in
people with:
• Excessive bronchial secretions who have
difficulty clearing secretions, with sputum
production greater than 25 to 30 mL per day.
• Evidence or suggestion of retained secretions in
the presence of an artificial airway.
• Lobar atelectasis caused by or suspected of
being caused by mucus plugging.

9. Nursing Considerations:
• It is important to remember to perform
this procedure 1 hour before meals or 1
to 3 hours after meals. (to prevent
nausea, vomiting, and possible
aspiration).
• The nurse should encourage the patient
to drink at least 8-12 glasses of fluids daily
(to liquefy the pulmonary secretions).

10. • Avoid percussing over the spine, liver,
kidneys or spleen (to prevent injuries to
the spine and internal organs).
• Record the patient’s response, including
lung and breath sounds, breathing pattern
or signs of dyspnea, before and after the
procedure. Each position is usually
assumed for 10-15 minutes, although
beginning treatments may start with
shorter time and gradually increases.

12. POSITIONING A PATIENT FOR
POSTURAL DRAINAGE
• To drain the posterior basal segments
of the lower lobes, elevate the foot of
the table 18” (46 cm) or 30 degrees, or
change the elevation of the foot of the
bed similarly. Position the patient on his
abdomen with head lowered. Place
pillows as shown. Percuss the lower ribs
on both sides of the spine.

15. • To drain the lateral basal segments of
the lower lobes elevate the foot of the
table or bed 18” or 30 degrees.
Position the patient on his abdomen
with head lowered and upper leg
flexed over a pillow for support. Have
him rotate a quarter turn upward.
Percuss the lower ribs on the
uppermost portion of the lateral chest
wall.

19. • To drain the anterior basal
segments of the lower lobes,
elevate the foot of the table or bed
18” or 30 degrees. Position the
patient on his side with his head
lowered. Place pillows as shown.
Percuss with a slightly cupped hand
over the lower ribs just beneath
the axilla.

23. • To drain the superior segments
of the lower lobes, keep the
table or bed flat. Position the
patient on his abdomen, and
place two pillows under his hips.
Percuss on both sides of the
spine at the lower tip of the
scapulae.

27. • To drain the medial and lateral segments of
the right middle lobe, elevate the foot of
the table or bed 14” (36 cm) or 15 degrees.
Position the patient on his left side with his
head lowered and knees flexed. Then have
him rotate a quarter turn backward. Place a
pillow beneath him. Percuss with the hand
moderately cupped over the right nipple.
For female patient, cup the hand so its heel
is under the armpit and fingers extend
forward beneath the breast.

31. • To drain the superior and inferior
segments of the angular portion of
the left upper lobe, elevate the foot of
the table or bed 14” or 15” degrees.
Position the patient on his side with his
head lowered and knees flexed. Then
have him rotate a quarter turn
backward. Place a pillow behind him
from shoulders to hips. Percuss as
above, but on the left side.

35. • To drain the anterior segments of
the upper lobes, keep the table
or bed flat. Have the patient lie
on his back with a pillow folded
under his knees. Then have him
rotate slightly away from the side
being drained. Percuss between
the clavicle and nipple.

39. • To drain the apical segment of the
right upper lobe and the apical
sub segment of the left upper
lobe, have the patient sit on a flat
table or bed. Standing behind the
patient holding a pillow at a 30
degree angle, percuss between the
clavicle and the top of each
scapulae.

43. • To drain the posterior segment of
the right upper lobe and the
posterior sub segment of the left
upper lobe, have the patient sit
and lean over a folded pillow at a
30 degree angle. Standing behind
him, percuss and clap the upper
back on each side.

47. CHEST PERCUSSION

48. CHEST PERCUSSION
• Movement done by striking the
chest walls in a rhythmic
fashion with cupped hands or a
mechanical device directly over
the lung segment

51. Procedure:
1. Check the doctor’s order.
2. Explain procedure to the patient to
elicit cooperation and determine level
of understanding.
3. Wash hands to remove and reduce
transmission of microorganisms.
4. Instruct the patient to perform
diaphragmatic breathing to help the
patient relax.

52. 5. Position the patient as prescribed in
postural drainage. The spine should
be straight to allow rib cage
expansion.
6. Ensure that the area to be percussed
is covered by a gown or a towel.
7. Instruct the client to breathe slowly
and deeply to promote relaxation and
widening of the airways.

53. 8. Cup your hands and flex them slightly to
form a cup as you would to scoop up water.
This hand position creates an air pocket
that sends vibrations through the chest
wall.
9. Relax your wrist and flex your elbows.
10. With both hands cupped, alternately flex
and extend the wrist rapidly to slap the
chest. The hands must remain cupped
because air in hand acts as cushion and
painless.

54. 11. Percuss each affected lung segment
for 1-2 minutes from the lower back to
shoulder, and from the lower ribs to
top of the chest at the front to
dislodge mucus plugs and mobilize
secretions toward the main bronchi
and trachea. Avoid clapping over the
spine, liver, kidney and spleen to
prevent from injury.

55. 12. Instruct the patient to inhale
slowly and deeply for relaxation.
13. Document properly.
14. Record deep breathing and
coughing results into the chart.
15. Repeat deep breathing and
coughing hourly as needed.

56. Proper hand positioning for percussion.

57. CHEST VIBRATION

58. CHEST VIBRATION
• Chest vibration is a series of
vigorous quivering produced
by hands that are placed flat
against the client’s chest wall.

61. Procedure:
1. Explain procedure to the patient.
2. Place the flattened hand, one over
the other.
3. Ask the client to breathe deeply
through the mouth and exhale
through the pursed lips to make
exhalation easier.

62. 4. During exhalation, straight elbows and
vibrate during 5 exhalations over one
affected lung segment to set up a
vibration that carries through the chest
wall and helps free the mucus. Vibrate
only during exhalation so as to follow the
natural downward movement of the rib
cage.
5. Place one hand on top of the other over
affected area or place one hand on each
side of the rib cage.

63. 6. Tense the muscles of the hands and
arms while applying moderate pressure
and vibrate hands and arms. This
maneuver is performed in the direction
in which the ribs move on expiration.
7. Encourage the patient to cough and
expectorate secretions onto the
sputum container. Coughing aids in the
movement and expulsion of secretions.

64. 8. Auscultate and compare with
baseline data. The appearance of
moist sounds (crackles) indicates
movement of air around mucus in
the bronchi.
9. Document the amount, color and
character of secretions. Inspection
may also determine if mucus is
adequately thinned.

65. 10. Recheck the rate, depth, chest
expansion, and respiration to
determine effectiveness of
therapy.
11. Evaluate patient’s response in
terms of fatigue and comfort.

66. Proper hand position for vibration

67. DIAPHRAGMATIC BREATHING

68. DIAPHRAGMATIC BREATHING
• This is the mode of breathing in
which dome of the diaphragm is
flattened during inspiration
resulting in enlargement of the
upper abdomen as air rushes
into the chest.

69. Procedure:
1. Explain the procedure to the patient.
2. Have the patient assume a comfortable
position either semi-Fowlers with
knees flexed or a supine position with
one head pillow and knees flexed. This
position allows maximum chest
expansion in bedridden and to relax
the muscles of the abdomen.

71. 3. Have the patient place one of both hands
on the abdomen just below the ribs. This
helps the patient to become aware of the
diaphragm and its function in breathing.
4. Instruct the patient to breathe deeply
through the nose, keeping the mouth
closed, stay relaxed and avoid arching the
back and concentrate on feeling the
abdomen rise. Slow inhalation provides
ventilation and hyperinflation of the lungs.

72. 5. If the patient has a difficulty in raising the
abdomen, instruct to do a forceful and
quick inhalation through the nose.
6. Instruct the client to purse his lips as if
about to whistle to breathe out slowly and
gently, making a slow whooshing sound to
avoid coughing out of cheeks and to
concentrate the abdomen falling. This
allows for gradual, controlled expulsion of
air. Count to 7 during exhalation.

73. 7. If the patient has COPD, teach the double
cough technique.
8. Instruct the patient to use diaphragmatic
breathing exercise 5-10 minutes, 4 times a
day. Repetition of exercise reinforces
learning. Regular deep breathing will also
prevent or minimize postoperative
respiratory complications. This exercise,
once learned, can be performed when
sitting upright, standing and walking.

74. COUGHING EXERCISE

75. COUGHING EXERCISE
• Coughing is a natural defense
mechanism that protects the
lungs and airways from inhaled
particles, foreign bodies, and
excess secretions.

76. Procedure:
1. Place the patient in a semi-Fowlers
position, leaning forward. Proper
positioning facilitates diaphragm
excursion and enhances thorax and
abdominal expansion.
2. Provide a pillow or folded bath blanket to
use in splinting the incision. This provides
firm support and reduces incisional
pulling and pain and prevents wound
dehiscence.

77. 3. Let the patient inhale and exhale deeply
and slowly through the nose 3 times to
increase cough pressure.
4. Instruct the patient to take a deep breath
and hold it for 3 seconds. “Hack” out for 3
short breaths. A deep breath expands
lungs fully so that air moves behind mucus
and facilitates effective coughing. This
technique helps keep airways open while
moving secretions up and out of the lungs.

79. 5. Ask the patient to take a quick
breath and let him cough once or
twice to remove secretions.
6. Repeat the exercise every 2 hours
while awake. Try to avoid prolonged
episodes of coughing because these
may cause fatigue and hypoxia.

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