Chest physiotherapy,

1. CHEST PHYSIOTHERAPY
Shubham Singh
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2. Outline
 Introduction
 Aims of chest physiotherapy
 Goal
 Indication
 Contraindication
 Limitation
 Assessment
 Techniques of chest physiotherapy
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3. Introduction
 Chest physiotherapy is an airway clearance technique to mobilize
or loose secretions in the lung and respiratory tract.
 Also referred as chest physical therapy (CPT), pulmonary therapy,
or postural drainage therapy.
 It consists of external mechanical manoeuvres(percussion,
vibration, shaking, postural drainage) to augment mobilization and
clearance of retained airway secretions or mucus plug.
 The secretions need to be mobilized from the peripheral or smaller
airways to the larger, more central airways where they may be
removed by coughing or suction
 It uses one or more techniques to optimize the effect of gravity and
external manipulation of the thorax by postural drainage,
percussion, vibration and cough etc.
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4. Aim of chest physiotherapy
 To assist in the removal of the excess bronchial secretion.
 To ensure adequate ventilation of all the areas of the lungs.
 To help prevent atelectasis and consolidation.
 To ensure the maintenance of a good posture by accurate
positioning and advice.
 To help rehabilitate the patient to its fullest and independence.
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5. Goals of chest physiotherapy ?
 Reduce airway obstruction
 Improve mucociliary clearance
 Improve ventilation
 Optimize gaseous exchange
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6. Indications of chest physiotherapy
Chest therapy is indicated as an adjunct in any patients whose
cough alone(voluntary or induced) alone cannot provide
adequate lung clearance
 Bronchiectasis
 Cystic fibrosis
 Atelectasis
 Pneumonia
 Asthma
 Lung abscess
 Respiratory muscle weakness
 Mechanically ventilated patients
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7. Contraindications of chest physiotherapy
Absolute contraindication
 Distended abdomen, pregnancy, ascites
 Diseased condition
• active cases of tuberculosis, haemoptysis
• unstable cardiovascular disorders: arrythmias, hypotension,
hypertension
• pulmonary oedema
• congestive heart failure
• untreated tension pneumothorax
 Surgical condition
• recent head or neck surgeries
• severe surgical emphysema
• surgically undrained empyema
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8. Careful positioning is indicated in patients with:
 Fractures
 Recent spine surgeries
 Broncho-pleural fistula
 Immediate post-op pneumonectomy
 Orthopaedic surgeries
Vigorous chest physiotherapy is contraindicated in:
 Osteoporosis
 Pulmonary emboli
 Poor or unstable cardiovascular disorders
 Fresh burns, skin grafts or infection on thorax
 Recent spinal surgeries
 Temporary pacemakers
 Subcutaneous emphysema
 Organomegaly
 Untreated pneumothorax
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9. Limitation of chest physiotherapy
For patient
 Chest physical therapy techniques appear not to be beneficial in the
treatment of patients with pneumonia or chronic bronchitis without large
amounts of secretion production.
 Viral bronchiolitis is an asthma-like lung disease occurring in infants less than
2 years of age. These patients do not appear to benefit from airway
clearance techniques
 Also of little benefit, and possibly harmful, is the inclusion of chest physical
therapy in the routine care of postoperative patients without extensive
secretions
 Even in patients with a history of lung disease, the use of airway clearance
techniques have failed to affect the incidence of atelectasis as a
postoperative complication
For Therapist
 Repetitive motion injuries of the wrists have been documented as a result of
regular performance of percussion
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10. Assessment
 Clinical assessment
• Case notes
• Charts
• Vitals
• Respiratory analysis
• Arterial blood gases
• Cardiovascular status
• Fluid balance
• Drugs ongoing
• Temperature
 Radiographs
 Drains
 Patient
• Colour
• Chest expansion
• Auscultation
• Humidification
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11. Why assessment ?
 To define the patient’s problem accurately
 To outline how the physiotherapist may utilize the techniques and
equipment’s available, in various condition.
 To decide what needs to be done i.e. to design appropriate plan
treatment.
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12. Initial data from notes
Subjective assessment
Objective assessment
Problem list
Asses outcome of the treatment
Treatment plan
Goal both long and short
Is current goal met?
Any further goal?
Discharge
no
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13. Techniques of chest physiotherapy
 Humidification
 Postural drainage
 Manual techniques
• Percussion
• Vibrations
• Shaking
• Manual hyperinflation
 Forced expiratory techniques
• Huffing
• Coughing
 Active cycle of breathing
 Autogenic drainage
 Instrumental techniques
• Positive expiratory pressure (PEP)
• Continuous Positive Airway Pressure
• Intrapulmonary Percussive Ventilation (IPV)
• High frequency chest wall oscillation(HFCWO)
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14. Humidification
 Respiratory humidification is a method of artificial warming and
humidifying of respiratory gas for mechanically ventilated patients.
 Humidification maintains mucociliary function and assures that
secretions remain hydrated so they can be expectorated.
When to humidify
• if natural respiratory humidification fails
• pulmonic infections
• damage to lung tissue
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15. Humidification vs Respiratory gas conditioning
warming + humidification warming + humidification +
purification of respiratory gas.
Indication
• Overcoming humidity deficit when upper airway is
bypassed
• To manage hypothermia
• To treat bronchospasm
• Dry and non productive cough
• Atelectasis
• Increased airway resistance
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16. Passive humidifiers Active humidifiers
Heat and moisture
exchange(HMEs
Systemic
hydration
Simple
condenser
Hydrophobic Hygroscopic
Bubble through
humidifiers (BTH)
Methods of humidification
 known as ‘Swedish nose’
 working: moisture and heat is recollected in
condenser and return back to lungs during
inhalation
 high thermal
conductivity
 Trap approx. 50%
exhale moisture
 hydrophobic
membrane
with small pores
 low thermal
conductivity
 paper coated with
lithium chloride to
recollect the
moisture
 working: inspired air
bubbled through
cold water that in
container and get
humidified
Passover
humidifier
 working: gas is
blown over
heated sterile
water, gas
absorbs the water
vapor and
inhaled by the
patient
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17. Postural drainage
 It is positioning the patient to allow gravity to assist the drainage of
secretions from specific areas of the lungs.
Technique
 It is a passive technique, in which the patient is placed in positions
that allow the bronchopulmonary tree to be drained with the
assistance of gravity .
 The length of time spent in each position, and the total treatment
time will depend on the quantity of secretions in each area and the
number of areas that have to be drained.
 It may be necessary to spend an average of 15 to 20 minutes in each
position to allow adequate drainage and this may mean that
different areas will require draining at alternate treatments.
 The worst areas should be drained first.
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18.  Postural drainage should never be carried out immediately before or
after a meal
 The treatment becomes ineffective if the patient just lies in the
appropriate drainage position
Contraindication
All positions are contraindicated for the
• active haemoptysis
• empyema
• bronchopleural fistula
• pulmonary oedema associated with congestive heart failure
(CHF)
• intracranial pressure (ICP) > 20 mm Hg
• head and neck injury until stabilized
• active haemorrhage with hemodynamic instability
• recent spinal surgery (e.g. laminectomy) or acute spinal injury
• large pleural effusions
• pulmonary embolism
• aged, confused, or anxious patients
• rib fracture with or without flail chest
• surgical wound or healing tissue
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19. Fig: Apical segment of both upper lobe
 Patient sit upright, with slight variations according
to the position of the lesion ex: leaning slightly
backward, forward or sideways
 Position is usually only necessary for infants or
patients being nursed in a recumbent position,
but occasionally may be required if there is an
abscess or stenosis of a bronchus in the apical
region
Fig: Posterior segment of right upper lobe
• Patient lie on left side and then turn 45 on to face,
resting against a pillow with another supporting head
• Left arm comfortably behind his back with his right
arm resting on the supporting pillow
• Right knee should be flexed.
Fig: Posterior segment of left upper lobe
 Patient lie on right side turned 45 degree on to his
face with three pillows arranged to raise the
shoulder 30cm (i2in) from the bed
 He should place his right arm behind his back with
his left arm resting on the supporting pillows
 Both the knees should be slightly bent.
Fig: Anterior segment of both upper lobe
• Patient lie flat on his back with arms relaxed to side
• The knees should be slightly flexed over a pillow.
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20. Fig: Lateral and medial segment of middle lobe
• Patient lie on his back with his body quarter
turned to the left maintained by a pillow under
the right side from shoulder to hip and the arms
relaxed by his side
• Foot of the bed should be raised 35cm (14m) from
the ground
• The chest is tilted to an angle of 15°
Fig: Superior and inferior segment of both lingula lobe
• Patient lie on his back with his body quarter turned
to the right maintained by a pillow under the left
side from shoulder to hip and the arms relaxed by
his side
• Foot of the bed should be raised 35cm (14m) from
the ground
• The chest is tilted to an angle of 15°.
Fig: Anterior basal segment of both lower lobe
• Patient lie flat on his back with the buttocks
resting on a pillow and the knees bent
• The foot of the bed is raised 46cm (i8in)
• The chest is tilted to an angle of 20°
Fig: Apical segment of both lower lobe
Patient lie prone with the head turned to
one side, arms relaxed in a comfortable
position by the side of the head and a
pillow under his hips.
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21. Fig: posterior segment of both lower lobe
 Patient lie prone with his head turned to one
side, his arms in a comfortable position by the
side of the head and a pillow under his hips
 The foot of the bed should be raised 46cm (i8in)
from the ground
 The chest is tilted to an angle of 20°
Fig: lateral basal segment of the left lower
lobe and the medial (cardiac) basal segment
of the right lower lobe
 Patient lie on his right side with a pillow
under the hips
 Foot of the bed should be raised 46cm
(i8in)
 The chest is tilted to an angle of 20°.
Fig: Both lower lobe(Home Postural
Drainage)
 An alternative position if it is not
possible to raise the foot of the bed
 Two or three pillows are placed over a
15cm (6in)
Fig: Lateral basal segment of right lower lobe
 The patient lie on the opposite side with a
pillow under the hips
 Foot of the bed should be raised 46cm
(i8in) from the ground
 The chest is tilted to an angle of 20°.
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22. Percussion
 A rhythmical force is applied with cupped hands to the patient's
thorax over the involved lung segments with the aim of dislodging
or loosening bronchial secretions
 The resulting motion loosens secretions from the bronchial wall and
moves them proximally where ciliary motion and cough (or
suction) can remove them
When to opt for percussion
 If the sputum is particularly tenacious, percussion (clapping) may
be of benefit.
Technique
 Carried out over the appropriate area of chest wall which is
covered by a towel to prevent skin stimulation.
 With the hands slightly cupped, the wrists are quickly flexed and
extended, rhythmical movement should is performed at the wrist
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23.  Done throughout the inspiration & expiration
 Percussion is thought to send sound waves through the chest wall,
causing compression and rarefaction of air within the airways, thus
setting up a vibration and consequently loosening secretions.
 Performed with the patient in postural drainage positions.
 Patients who suffer from chronic lung disorders, such as cystic
fibrosis, and who benefit from percussion can be taught to percuss
themselves
 Incorrect technique letter can cause breath holding and
occasionally bronchospasm
 Percussion technique for neonates and infants is called “tenting”
this consists of overlapping the second finger over the first and third.
Frequency and timing
 Normally performed at a rate of 100-480 times per minute and
60(58-62) Newton's of force(approx.) on the chest wall for 2 to 3
minutes.
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24. Contraindication
 Percussion should be avoided in cases
• hemoptysis
• pleuritic pain
• undrained pneumothorax
• acute pulmonary tuberculosis
Precaution
 Patients with osteoporosis and rib metastases must be treated carefully
Alternate
 There are several mechanical percussors available
 Studies found mechanical percussion equivalent to manual percussion
in affecting removal of secretions
 Although there was a significant increase in pulmonary function with
manual techniques
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25. Fig: Hand position for percussion
 Fingers adducted
 Hand cupped
 Rhythmical movement is performed at wrist
Fig: Hand position for tenting
 Cup is formed by joining index and ring finger
and overlapped by middle finger
 Rhythmical movement is performed at wrist
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26. Fig: Bed side position of physiotherapist
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28. Vibration
 Vibration is a sustained contraction of the upper extremities to produce
a vibratory force that is transmitted to the thorax over the involved lung
segment
 Vibration is proposed to enhance mucociliary transport from the
periphery of the lung fields to the larger airways
Technique
 Vibration is applied throughout exhalation concurrently with mild
compression to the chest wall
 Vibration is often applied in postural drainage positions following
percussion to the area
 Vibration is the placement of both hands directly on skin and over the
chest wall (or one hand on the top of the other) and gently
compressing and rapidly vibrating the chest wall in the direction of
expiratory movement of the chest
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29.  Vibratory impulse is transmitted through the chest wall from the flattened
hands of the therapist by the isometric alternate contraction of forearm
flexor and extensor muscles, to loosen & dislodge the airway secretions
Alternate
 A mechanical vibrator may be used by the patient or a caregiver in
place of manual vibration
 Mechanical devices used to perform vibration differ from the manual
method in that the mechanical device is continuously applied during
both inspiration and expiration.
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30. Fig: Hand position for vibration
 Placing one hand over the other directly over the skin
 Forearm and arms are kept straight
 Vibration is generated by isometric contraction of
forearm
 Gently compressing and rapidly vibrating the chest wall
in the direction of expiratory movement of the chest
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31. Shaking
 It is rib springing against the thoracic wall in a rhythmic fashion
throughout exhalation.
 Shaking is performed only during the expiratory phase of breathing
and therefore reinforces the expiratory flow of air from the lungs
Technique
 The relaxed hands are placed over the appropriate area of chest
and, beginning immediately as the patient exhales
 The therapist shakes the chest wall in towards the main bronchus, a
concurrent pressure is given to the chest wall, compressing the thorax
 This technique mechanically shifts sputum from the smaller to the
larger airways
 Shaking can be performed unilaterally or bilaterally depending on the
type of patient
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32. Manual hyperinflation
 Used on patients with an endotracheal or tracheostomy tube that can
be attached to a manual ventilation bag
 This technique uses a tidal volume which is 50% greater than the
delivered the ventilator.
Technique
 Manual hyperventilation is performed in postural drainage positions and
requires two competent caregivers
 One caregiver uses the bag to hyperinflate the lungs with a slow, deep
inspiration and after a short inspiratory pause, provides a quick release
to allow rapid exhalation
 A second caregiver applies shaking or vibration at the very beginning of
exhalation to mobilize secretions
 Saline may be instilled into the airway at the beginning of the cycle,
with suctioning a component at the end of treatment of each side
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33.  The inspiration provided by the manual ventilation bag, which is
deeper than the patient could generate, promotes aeration of the
alveoli
 The timing of this sequence is important to achieve the desired effect
 It has been likened to simulation of a cough- deep inspiration, pause,
and forceful exhalation
 The compression of the thorax augments the high expiratory flow rate
from the bag, accelerating the movement of the secretions from the
smaller airways to the larger bronchi
 This method of airway clearance enables patients to be maintained
on ventilators for long periods with normal lung function
 It has been demonstrated that hyperinflation and suction in the
treatment of atelectasis was enhanced by the addition of positioning
and vibrations
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34. Indication
• mobilization of large airway secretions
• to aid removal of secretions
• to aid reinflation of atelectatic segments of lung
• to asses lung compliance
• to improve lung compliance
Adverse effect
• decreased cardiac output
• cardiac arrhythmia
• raised ICP
• barotrauma
• patient distress
Contraindication
• cardiovascular instability
• high peak airway pressure
• undrained pneumothorax
• severe bronchospasm & emphysema
• unexplained haemoptysis
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35. Forced expiratory techniques
 A forced expiratory maneuver (cough or huff) produces compression and
narrowing within the airways from a point dependent on lung volume.
 The forced expiration technique has been shown to increase the
efficiency in the clearance of bronchial secretions, without causing or
increasing bronchospasm
 It consists of one or two huffs from mid-lung volume to low-lung volume
followed by a period of relaxed diaphragmatic breathing
A. Coughing
 Coughing is a forced expiration against a closed glottis causing a rise in
intrathoracic pressure
Cough syncope
A high intrathoracic pressure diminishes the return of blood to the
heart, a prolonged bout of coughing may cause a fall in the cardiac
output and the patient may faint
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36. Sit on a chair with both feet relaxing on the floor
Take a slow, deep breath through your nose. Hold for 2 counts
Lean forward slightly
Cough
Glottis opens
A difference in pressure between the smallest airways and the
upper trachea,- causing a rapid flow of air
Rapid flow combined with the narrowing of the airways, increases the force of the
air, which dislodges mucus and foreign particles into the pharynx
Technique
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37. B. Huffing
 A huff is a rapid, forced exhalation but not with maximal effort
Sit on a chair with both feet relaxing on the floor
Take a slow, deep breath through your nose, hold for 2 counts
Lean forward slightly
Exhale forcefully, but slowly, in a continuous exhalation to move
mucus from the smaller to the larger airway(glottis remains
opens)
A difference in pressure between the smallest airways and the
upper trachea,- causing a rapid flow of air
Repeat the manoeuvre
Technique
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38. Active cycle of breathing
 It is an active breathing technique performed by the patient, and
can be used to mobilize and clear excess pulmonary secretions and
to generally improve lung function
 It has a series of three main phases:
• breathing control
• thoracic expansion
• forced expiratory techniques
Breathing control
Thoracic expansion
Forced expiratory
techniques
• relaxed breathing
• 3-5 deep breathing
• Huff followed by cough
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39. Displacement
Collection
Elimination
• recipient is placed sitting, back straight, and head slightly hyperextended,
hands resting on the upper left and right chest
• starts with a slow and forced oral expiration, recruiting a percentage of
expiratory reserve volume, and then carrying inspiration to low volume,
recruiting percentages of tidal volume followed by a two‐ to three‐second
post-inspiratory pause
• followed by a slow oral exhalation recruiting a percentage of expiratory
reserve volume
• nasal inspiration to medium volume, recruiting a larger percentage of
tidal volume, followed by a two‐ to three‐second post-inspiratory pause
• followed by a slow oral exhalation recruiting a percentage of expiratory
reserve volume
• nasal inspiration to high volume recruiting tidal volume and a percentage
of inspiratory reserve volume, followed by a two‐ to three‐second post-
inspiratory pause, leading to oral expiration at the level of tidal volume.
• the forced expiration technique is performed to high volumes
Autogenic drainage
 It is a three phase active breathing technique using high expiratory
flow rates and variable lung volumes to unstick, collect, and
evacuate secretion
Technique
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40. Positive expiratory
pressure device
Continuous
positive airway
pressure(CPAP)
Instrumental technique
 provide resistance to
expiration through a
mouthpiece or facemask,
followed by forced
expirations.
 the inhalation is at tidal
volume, and the expiration
is slightly active against
devices.
 these devices help to
remove secretions by
increasing functional
residual capacity
Examples: Lung flute etc.
 generated by
exhalation against a
constant opening
pressure; this produces
positive end‐expiratory
pressure (PEEP)
Ex. Nasal prongs or CPAP
facemask, bubble
CPAP can be used in
a low resource
environment and in
the pediatric
 an external chest wall
oscillations are applied to the
chest using an inflatable vest
that wraps around the chest
and is attached to a pulse
generator by hoses that
mechanically enable the
equipment to perform at
variable frequencies (5–25 Hz)
 these machines produce
vibrations at variable
frequencies and intensities,
helping to loosen and thin
mucus and separate it from
airway walls.
 It uses a pneumatic
device to deliver a series
of pressurized gas
minibursts at rates of 100
to 225 cycles per minute
to the respiratory tract, by
a mouthpiece, providing
 promote mobilization of
bronchial secretions and
improve efficiency and
distribution of ventilation,
 each IPV session lasted
fifteen minutes and was
performed twice a day
(morning and afternoon
 during the cycle, constant
PAP is maintained at the
airway
High frequency
chest wall
oscillation(HFCWO)
Intrapulmonary
percussive
ventilation(IPV)
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41. Thank you
Mark your suggestion at:
mailatabcd@gmail.com
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