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1. Dr. Anand Mohan Jha

2. Manual chest technique is the traditional airway
clearance technique.
Manual techniques apply external forces against the
chest wall to facilitate airway clearance when a
patient is in a modified or traditional gravity
assisted drainage position.
Manual technique are used to assist the break up of
thick and sticky mucous as well as clearing any
mucous plug that might be causing issues with
lung inflation.

3. (1) Chronic obstructive pulmonary disease
(2) Bronchiectasis
(3) Cystic fibrosis
(4) ARDS
(5) Respiratory muscle weakness
(6) Atlectasis
(7) Patient who are on prolonged bed rest
(8) Patient who have received general
anesthesia
(9) Patient with artificial airways

4.  Pulmonary embolism
 Unstable angina
 Osteoporotic bone
 Hemorrhage
 Rib fracture
 Recent spinal surgery or acute spinal injury
 Burns
 Over tumour area
 Haemoptysis
 Hypertension

5.  Arrhythmias
 Anxiety
 Active cases of tuberculosis
 Post eye surgeries
 Vomitting
 Undiagnosed chest pain

6.  Prepare the patient by giving a clear
explanation of the treatment.
 Obtain consent from the patient.
 Auscultate the patient's chest.
 Check the patient's skin integrity over the
area of the rib cage to be treated and take
care to avoid performing manual techniques
over a portacath and lines and drains.
 Check the patient's SpO2 level;

7.  Position the patient to optimise secretion
clearance. This may include modified
postural drainage positions.
 When performing chest percussion a towel
may be placed over the area to be treated.
However, avoid to much padding.
 Perform chest percussion rhythmically with a
loose wrist and a cupped hand over the lung
area that is to be treated.
 A slow single handed technique or a rapid
double handed technique can be used.

8.  Observe the patient to ensure they are not
holding their breathe.
 If the patient is prone to desaturation,
monitor the patients' oxygen saturations and
respiratory rate throughout the procedure.
Supplementary oxygen may be required
during treatment.
 To perform shaking and vibrations the hands
are placed over the area where secretions
are to be mobilized from and oscillations
directed inwards against the chest in the
direction of bucket handle rib movement.

9.  The height of the bed should be adjusted to
allow the therapist to use their body weight
to assist with the vibratory/compression
action.
 Encourage the patient to take a deep
inhalation and perform the technique on
their exhalation.
 Use forced expiratory technique or coughing
to assist the patient to expectorate.

10. To improve the mobilization of bronchial
secretions and matching of ventilation and
perfusion to normalize functional residual
capacity.

11.  Chest percussion
 Vibration
 Chest shaking
 Rib Springing

12.  Tilt bed and/or pillows
 Towels or thick pad
 Sputum cup/tissue
 Stethoscope
 Manual,pneumatic, or vibratory percussor

13.  Percussion is performed with a cupped hand
to enhance the effect of the technique and
the comfort for the patient.
 The technique, usually performed with two
hands(depending on the size of the area),
involves the rhythmical flexion and extension
of the wrist onto the chest wall at a rate and
pressure that is comfortable for the patient.
 Patient may be instructed to do tidal volume
breaths or sets of thorasic expansion
exercises followed by breathing control.

14.  Ideally there should be pauses after 20-30
seconds of continuous percussion and
vibrations applied itermittently.
 Care must be taken to percuss over the lungs
and not over the spine,the clavicles or the
sternum and to cover the areas to be treated
with a towel or thin layer of clothing.
 Percussion may also be applied using a
mechanical percussor.

15.  The rationale for the technique is that the
application of force to the chest wall alters
the intrapleural pressure.
 This pressure change is transmitted through
to the lung tissue and assists in dislodging
secretions from the airway wall.
 The time period of percussion may vary from
5 minute to 15 minutes depending on the
condition of patient.

16.  Acute medical/surgical emergencies, poor or
unstable cardiovascular disorders.
 Fragile, fractured ribs or osteoporosis
 pneumothorax, pleural effusion, empyema
 Skin grafts, incision
 Organomegaly
 pregnancy

17.  Vibration to the chest wall is the manual
application of fine oscillatory movements, of
high frequency, with chest compression
timed with expiration.
 While vibration is being administered, the
patient is instructed to take slow deep
breaths to enhance the effect of airflow on
the movement of secretions.

18.  The physiotherapist places their hands on the
patients chest, either one hand on top of the
other, or side by side,depending on the size
of the chest wall.
 As the patient breathes out, a rapid
oscillatory movement is applied in the
direction of the normal movement of the ribs
and is transmitted through the chest using
body weight.

19.  This technique is often combined with the
active cycle of breathing technique and
gravity assisted drainage positions to gain
more effect.
 Vibration should not be uncomfortable as any
discomfort will inhibit expiration and air
flow.

20.  Shaking is performed in the same manner as
vibrations but as a coarse movement.
 The ocillations are of a larger amplitude and
lower frequency than vibrations.
 The choice between vibrations or shaking
may depends on following -
 The age and health status of patient.
 The clinical experience of therapist
 The use of adjunct techniques

21.  Compression can be given during huffing and
coughing.
 Compression of chest wall is given at the end
of expiration.
 In the compression overpressure is applied to
the lung where the secretions accumulated.

22.  Passive treatment option when patient is
either too unwell or cognitively not capable
of co-operating with more active airway
clearance strategies such as positive
expiratory pressure (PEP) therapy and
huffing.
 Infants who are not old enough to co-operate
with voluntary breathing strategies.
 Can be applied in intensive care to enhance
secretion movement during hyperinflation
manoeuvres

23.  Require a therapist or family member to
administer.
 Can be uncomfortable.
 Has been shown to cause an increase in
hypoxaemia.
 May induce bronchospasm in patients with
hyper-reactive airways.

24.  Books-2nd edition Physiotherapy for
respiratory and cardiac problems, edited by
jennifer A. pryor, barbara A. webber.
 Gallon A. Evaluation of chest percussion in
the treatment of patients with copious
sputum production. Respiratory medicine.
1991 Jan 1;85(1):45-51.
 Wikipedia
 Jones, A. and rowe. B.H(2000). Issues in
pulmonary nurshing. Bronchopulmonary
hygine physical therapy in bronchiectasis and
copd , a systemic review.

25. THANKYOU