Chest physiotherapy

1. CHEST PHYSIOTHERAPY
AND BREATHING EXERCISE

2. Definition
 Chest physiotherapy (CPT) is a group of therapies for
mobilizing pulmonary secretions.
 Chest physiotherapy (CPT) is one aspect of bronchial
hygiene and may include:
 Turning,
 Postural drainage,
 Chest percussion and vibration,
 Specialized cough techniques known as directed
cough.
 This is helpful especially for patients with large amount
of secretions or ineffective cough.

3. The goal of CPT are:-
 To move bronchial secretions to the central
airways via gravity.
 Eliminate secretions by cough or aspiration
with a catheter.
 Improved mobilization of bronchial secretions
contributes to improved ventilation- perfusion
matching and the normalization of the
functional residual capacity.

4. Indications:
 It is indicated for patients in whom
cough is insufficient to clear thick
tenacious, or localized secretions.
Examples: -
 Cystic fibrosis
 Bronchiectasis
 Atelectasis
 Lung abscess etc.

5. Contraindications
 Increased ICP
 Unstable head or neck injury
 Active hemorrhage or hemoptysis
 Unstabilized head and/or neck injury
 Bone disease brittle or extremely fragile bones
 Fracture of ribs
 Flail chest
 Uncontrolled hypertension

9. Assessment for Chest
Physiotherapy
 Clinical findings and investigations
 Detailed History
 Physical examination
 Inspection
 Palpation
 Percussion
 Auscultation
 Perform detailed physical examination of the chest
 Investigations
 X-ray
 Blood investigations-bleeding and clotting
parameters

10. Continue…….
 Assess the 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
 Assess for any contra indications

11. Continue..
 Perform a comprehensive pain assessment
using techniques appropriate for the patient's
age, condition, and ability to understand.
 If needed, administer pain medication before
the procedure, as ordered, following safe
medication practices.

12. CHEST
EXAMINATION

14. Inspection of anterior chest wall
1) Ask the patient to lie supine.
2)Ask the patient to lower his gown to waist
level.
3) Stand at the feet of patient.
4)Inspect the shape of the chest (ratio of antero-
posterior and transverse diameters).
5)Inspect the symmetry of the patient’s chest on
both sides with comparison.

15. Inspection of anterior chest wall
6) Inspect patient’s chest normal breathing
movement.
7) Inspect patient’s chest for accessory muscle use.
8) Inspect patient’s chest for retraction of lower
intercostal spaces.
9) Stand again to the right of patient and look
tangentially for apical and epigastric pulsation.
10)Inspect the chest wall and skin for swelling,
scars, skin eruption or engorged veins.

20. Continue…
Pectus excavatum
funnel chest
•funnel-shaped depression
of lower part of sternum
•displacement of the heart
and disturbances in
cardiac function
Pectus carinatum pigeon
breast
secondary to chronic
respiratory diseases in
childchood, may be
caused by rickets ( in
malnutrition

21.  Flail chest - one chest wall moves
paradoxically inward during inspiration
 multiple rib fracture

24.  Stand to the right of the patient.
 Ask the patient to lie supine
 Palpate for palpable rhonchi, pleural rub or chest wall
tenderness by putting the palm on various areas of chest
wall.

25. Palpation of anterior chest wall
 Palpate upper lung zone to confirm the movement
by placing the palms in the infraclavicular fossa and
the two thumbs in the midline at the level of
suprasternal notch.
 Palpate middle lung zone by putting the palm in the
middle part with tips of thumbs in the midline.
 Let the patient inspire deeply and let your thumbs
follow chest movement.

30. Position of trachea

31. Apex beat

34. Changes in tactile fremitus :
 Rhonchal fremitus - exudate in the trachea
 Increased fremitus - lung consolidation with patent
bronchus
 Decreased fremitus - unilateral - bronchial
obstruction, air or fluid in pleural space
 Bilateral – edematous chest wall chest wall
thickening

35. Palpation the supraclavicular areas for lymph
nodes – enlarged lymph nodes in
supraclavicular area (tumor metastases,
sarcoidosis)

37. Percussion
 From front, back, infra axillary area.
 Identify intercostal space is percussed
on left and right side and percussion
note is compared.
 Normally all over chest resonant note is
obtained, except the area of cardiac
dullness.

38. Percussion (Identify 2nd ICS)
 Dirrect percussion
 Indirrect percussion
Changes in percussion note:
 Hyperresonance – emphysema, pneumothorax
 Impaired resonance - lung consolidations
 Dullness - pulmonary infiltrations, pleural
thickening
 Flattness - pleural effusion

40. Identify 2nd intercostal space(ICS)

41. 3rd intercostal space
Resonant note in
intercostal space
over lungs

42. 4th and 5th intercostal space

43. 4th and 5th intercostal space

44. ASCULTATION

45. Technique of Auscultation
 Patient relaxes and breathes normally with mouth open, auscultate
lungs, apices and middle and lower lung fields posteriorly, laterally
and anteriorly.
 Alternate and compare both sides at each site.
 Listen at least one complete respiratory cycle at each site.
 Listen to quiet respiration. If sounds are inaudible, then ask him
take deep breaths.
 First describe the breath sounds and then the adventitious sounds.

46. Technique of Auscultation
Note intensity of breath sounds and compare with
opposite side.
Assess length of inspiration and expiration.
Listen for a pause between inspiration, expiration and the
quality of pitch of sound
compare intensity of breath sounds between upper and
lower chest in upright position.
Note the presence or absence of adventitious sounds.

48. Auscultation of the chest
anterior chest wall
 Stand to the right of the patient
 Ask the patient to lie supine.
 Ask the patient to say ‘ 99 ’ and auscultate
both midclavicular lines right & left, from
the second space to the sixth space with
comparison.

50. Bronchial and vesicular sound
 The bronchial breath sounds over the
trachea has a higher pitch, louder,
inspiration and expiration are equal and
there is a pause between inspiration and
expiration.
 The vesicular breathing is heard over the
thorax, lower pitched and softer
than bronchial breathing.

52. Posterior Auscultation

53. Auscultation of the posterior chest wall
1) Stand to the right of the patient.
2)Ask the patient to sit and his hands folded across
the anterior chest wall
3)Auscultate both scapular lines right & left, from
the apex to the tenth space with comparison.
4)Ask the patient to say ‘99’ and auscultate both
scapular lines right & left, from the apex to the
tenth space.

55. Table No. 1. Showing breath sounds
DURATION OF
SOUNDS
INTENSITY OF
EXPIRATORY SOUND
PITCH OF
EXPIRATORY SOUND
LOCATIONS WHERE
HEARD NORMALLY
Vesicular Inspiratory sounds
last longer than
expiratory ones.
Soft
Relatively low Entire lung field
except over the
upper sternum
and between the
scapulae
Broncho-
vesicular
Inspiratory and
expiratory sounds
are about equal
Intermediate Intermediate Often in the 1st
and 2nd
interspaces
anteriorly and
between the
scapulae (over
the main
bronchus)
Bronchial Expiratory sounds
last longer than
inspiratory ones.
Loud Relatively high Over the
manubrium, if
heard at all
Tracheal Inspiratory and
expiratory sounds
are about equal.
Very loud Relatively high Over the trachea
in the neck

56. Table No. 2 Abnormal (Adventitious) breath sounds
BREATH SOUND DESCRIPTION ETIOLOGY
Crackles in general Soft, high-pitched,
discontinuous popping
sounds that occur during
inspiration
Secondary to fluid in the
airways or alveoli or to
opening of collapsed alveoli
Coarse crackles Discontinuous popping
sounds heard in early
inspiration; harsh, moist
sound originating in the
large bronchi
Associated with obstructive
pulmonary disease
Fine crackles Discontinuous popping
sounds heard in late
inspiration; sounds like hair
rubbing together; originates
in the alveoli
Associated with interstitial
pneumonia, restrictive
pulmonary disease (eg,
fibrosis). Fine crackles in
early inspiration are
associated with bronchitis
or pneumonia.

57. BREATH SOUND DESCRIPTION ETIOLOGY
Sonorous wheezes (rhonchi) Deep, low-pitched rumbling
sounds heard primarily during
expiration; caused by air
moving through narrowed
tracheo-bronchial passages
Secretions or tumor
Sibilant wheezes Continuous, musical, high-
pitched, whistle-like sounds
heard during inspiration and
expiration caused by air
passing through narrowed or
partially obstructed airways.
Bronchospasm, asthma, and
buildup of secretions
Pleural friction rub Harsh, crackling sound, like
two pieces of leather being
rubbed together. Heard during
inspiration alone or during both
inspiration and expiration.
Secondary to inflammation and
loss of lubricating pleural fluid

66. Techniques in Chest
Physiotherapy
 Chest physiotherapy consists of three
techniques: -
 Percussion / Clapping/ Cupping
 Vibration
 Postural Drainage
 Breathing exercise

67. Percussion / Cupping


68. Chest percussion:-
 Involves rhythmically clapping on the chest wall over
the area being drained to force secretions into larger
airways for expectoration
 Perform chest percussion by vigorously striking the
chest wall alternately with cupped hands.
 The procedure should produce a hollow sound and
should not be painful.
 Typically, each area is percussed for 30 to 6o
seconds several times a day.
 If the patient has tenacious secretions, the area
must be percussed for 3-5 minutes several times.

70. Vibration:-
Vibration is a gentle, shaking pressure
applied to the chest wall to move
secretions into larger airways.

71.  Uses rhythmic contractions and relaxations
of arm and shoulder muscles over the
patient’s chest.
 During vibration, place flat hand firmly
against the chest wall, on the appropriate
lung segment to be drained.
 Vibrate the chest wall as the patient
exhales slowly through the pursed lips.
 After each vibration, encourage the client
to cough and expectorate secretions into
the sputum container

72. Postural Drainage
 It is a technique in which different positions are
assumed to facilitate the drainage of secretions
from the bronchial airways.
 Gravity helps to move the secretions to the trachea
to be coughed up easily.
 The goal of postural drainage is to help drain
mucus from the affected lobes into the larger
airways of the lungs so it can be coughed up more
readily.

73. Instraction
 The following illustrations show the various
postural drainage positions and the areas of the
lungs affected by each.
 Before beginning, assess whether the patient
can tolerate the recommended positioning.
 Once the patient is positioned Perform ongoing
assessments to determine continued tolerance.

74. Upper lobes: Apical
segments
 Keep the bed flat. Have the patient lean
back at a 30-degree angle against you
and a pillow. Percussion with a cupped
hand between the clavicles and the top
of each scapula

76. Upper lobes: Posterior segments
 Have the patient lean over a pillow at a
30-degree angle.
 Percussion and clap the upper back on
each side.

79. Upper lobes: Anterior
segments
 Make sure the bed is flat.
 Have the patient lie on his or her back
with a pillow folded under the knees.
 Then have the patient rotate slightly
away from the side being drained.
 Percussion between clavicle and nipple.

82. Left upper lobe: Superior and
inferior segments, lingula portion
 Elevate the foot of the bed 15 degrees.
 Have the patient lie on his or her right
side with head down and knees flexed.
 Then have the patient rotate a quarter
turn backward.
 Place a pillow behind the patient, from
shoulders to hips.
 Percussion with your hand moderately
cupped over the left nipple.

85. Right middle lobe: Medial and lateral
segments
 Elevate the foot of the bed 15 degrees.
 Have the patient lie on the left side with head
down and knees flexed.
 Then have the patient rotate a quarter turn
backward. Place a pillow beneath the patient.
 Percuss with your hand moderately cupped
under the right nipple.
 For a female patient, cup your hand so that its
heel is under the armpit and your fingers extend
forward beneath the breast.

88. Lower lobes: Anterior basal
segments
 Elevate the foot of the bed 30 degrees.
Instruct the patient to lie on his or her side
with head lowered.
 Then place pillows under the patient head
and between the knees.
 Percussion with a slightly cupped hand
over the lower ribs just beneath the axilla.
 If an acutely ill patient has trouble
breathing in this position, adjust the bed to
an angle the patient can tolerate.
 Then begin percussion.

92. Lower lobes: Posterior basal
segments:-
 Elevate the foot of the bed 30 degrees.
Have the patient lie prone with head
lowered. Position pillows under the
chest and abdomen. Percuss the lower
ribs on both sides of the spine.

96. Lower lobes: Superior
segments
 With the bed flat, have the patient lie on his or
her abdomen.
 Place two pillows under the hips.
 Percussion on both sides of the spine at the
lower tip of the scapulae

100. Lower lobes: Lateral basal
segments
 Elevate the foot of the bed 30 degrees.
 Instruct the patient to lie on the abdomen with
head lowered and upper leg flexed over a
pillow for support.
 Then have the patient rotate a quarter turn
upward.
 Percussion the lower ribs on the uppermost
portion of the lateral chest wall.

105. BREATHING EXERCISES:-
Pursed lip breathing (PLB)-
 Breathe in slowly through your nose and
count – 1 and 2.
 Purse or pucker your lips as if you were
going to whistle.
 Breathe out gently though your pursed
lips and count slowly – 1 and 2 and 3
and 4.
 Do not force the air out of your lungs.

106. Continue..

107. Deep or Diaphragmatic (Belly)
Breathing
 Do this in a comfortable position.
 Place one hand on your abdomen just
under your breastbone.
 Slowly breathe in through your nose and
feel your belly rise into your hand.
 Slowly breathe out through pursed lips and
feel your belly fall away from your hand.
 Keep your shoulders relaxed - not hunched
up.

108. Continue..

109. Rib Breathing
 Flatten your hands on the lower part of
your rib cage.
 Breathe in through your nose and feel
your ribs move outward.
 Breathe out and feel your ribs flatte

110. Trunk Rotations
 Sit in a relaxed position.
 Cross your arms in front of you, keeping your
shoulders relaxed.
 Breathe in through your nose.
 Breathe out through your pursed lips and turn
your body to one side.
 Breathe in.

111. Continue…
 Breathe out and return to centre.
 Repeat to the other side.
 Repeat 3 to 5 times in each
direction

112. Reaching to the sky
 Sit with your arms relaxed by your
side.
 Breathe in through your nose.
 Breathe out and lift one arm up,
reaching to the sky.
 Breathe in.
 Breathe out and return the arm to
the start position.
 Repeat with the other arm.
 Repeat cycle 3 to 5 times.

113. Shoulder Shrugging
 Sit with your shoulder relaxed and
your arms by your side.
 Breathe in through your nose.
 Breathe out through your mouth
and lift your shoulders up as if
trying to touch your ears.
 Breathe in.
 Breathe out through your pursed
lips and relax your shoulders to the
start position.
 Repeat 3 to 5 times.

114. Coughing Exercise
 Wash hands.
 Have patient sit up as far as possible or sit
on the edge of the bed.
 Instruct patient to take 4 - 6 slow, deep
breaths using diaphragmatic breathing.
 Instruct patient to hold a deep breath
before initiating cough.
 Instruct patient to lean forward in a flexed
position, pushing diaphragm up, and begin
cough.

115. Continue…
 If the patient has a recent incision
or localized area of pain, hold a
pillow over that area and apply
moderate pressure during the
cough.
 Instruct the patient how to dispose
of expectorated sputum
 Do this with your breathing
exercises, at least in the morning,
and before you go to bed.

116. Documentation:-
 Record the date and time of chest
physiotherapy.
 Document baseline respiratory assessment
and reassessment findings.
 Note the positions used for secretion drainage
and the length of time each was maintained.
 Note which lung segments were percussed or
vibrated.
 Record the color, amount, odor, and viscosity
of any secretions produced and the presence
of any blood.

117.  Record any complications, nursing
actions taken, and the patient's
response to those actions.
 Also document whether the patient
received pain medication and the
effectiveness of the medication.
 as well as the patient's tolerance of the
procedure

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 LeMone Pricilla and Burke Karen, Medical Surgical Nursing,
Pearson Publishers, India, 4th Edition(2008), page no:1210-1227.
 Brunner, Siddharth. Textbook of Medical-Surgical Nursing. 9th
edition; Lippincott Philadelphia, page.555-577.
 Nettina Sandra, Lippincott Mannual of Medical Practice,
Wolters Kluwer, India, 9thEdition(2010), page no: 300-318.
 https://adrenalfatiguesolution.com/anatomy-of-the-respiratory-
system.
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