Chapter 024
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performing Chest Physiotherapy
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Chapter 024
- 1. Chapter 24 Performing Chest Physiotherapy Copyright © 2018, Elsevier Inc. All rights reserved.
- 2. Chest Physiotherapy (CPT) • Used to mobilize pulmonary secretions • Includes physical chest wall maneuvers • Percussion • Vibration • Shaking • Postural drainage • Productive coughing or suctioning Copyright © 2018, Elsevier Inc. All rights reserved. 2
- 3. Principles for Practice • Careful patient assessment is a prerequisite for administering any CPT and PD maneuver • CPT and PD aim to remove secretions that accumulate in the airways of patients with cystic fibrosis • Early mobility and ambulation are used to promote airway clearance • CPT and PD are often used in combination with other therapies Copyright © 2018, Elsevier Inc. All rights reserved. 3
- 4. Patient-Centered Care• Ensure that patient is comfortable and as pain-free as possible before beginning • Prevent patient from becoming fatigued • Encourage mobility and ambulation • Maintain CPT schedule with CF patients • Keep cultural considerations in mind when activities require touching the patient Copyright © 2018, Elsevier Inc. All rights reserved. 4
- 5. Evidence-Based Practice • Use assessment findings to determine lung field(s) requiring CPT maneuvers • CPT not recommended for pneumonia; ACT not recommended for COPD (unless secretion retention is present) • Early CPT for intubated patients improves airway patency, secretion clearance, and oxygen delivery to tissues • High-frequency chest wall oscillators are effective in aiding sputum clearance Copyright © 2018, Elsevier Inc. All rights reserved. 5
- 6. Quick Quiz! Once a patient with cystic fibrosis reaches the age of 25 years, he can safely reduce the number of times he has chest PT to twice daily. True or False? A.True. B.False. Copyright © 2018, Elsevier Inc. All rights reserved. 6
- 7. Safety Guidelines 1. Know a patient’s normal range of vital signs. 2. Know a patient’s current medications. Medications that cause fluid and hemodynamic changes can affect patient tolerance of positional changes. 3. Know a patient’s medical and surgical history. Copyright © 2018, Elsevier Inc. All rights reserved. 7
- 8. Safety Guidelines (Cont.) 4. Know a patient’s level of cognitive function. 5. Have suction machine equipment available to assist in clearing airway secretions. 6. Know a patient’s activity tolerance because when patients are not used to physical activity, their ability to tolerate CPT maneuvers decreases. Copyright © 2018, Elsevier Inc. All rights reserved. 8
- 9. Performing Postural Drainage Skill 24-1 • Use positioning techniques to drain secretions from segments of lungs and bronchi • Individualized to patient condition 9Copyright © 2018, Elsevier Inc. All rights reserved.
- 10. Quick Quiz! Which of the following conditions is a contraindication for postural drainage? A.Stabilized head injury B.Tracheobronchial secretions C.Chronic pulmonary disease D.Pulmonary embolism Copyright © 2018, Elsevier Inc. All rights reserved. 10
- 11. Delegation and Collaboration • The task of postural drainage can be delegated to nursing assistive personnel (NAP) • The nurse directs NAP to: • Immediately report to the nurse changes in patient’s comfort level, breathing pattern, and tolerance of procedure • Use specific patient precautions related to disease, mobility status, position restrictions, or treatment Copyright © 2018, Elsevier Inc. All rights reserved. 11
- 12. Recording and Reporting• Record pretherapy and posttherapy assessment findings, pulse oximeter readings, and chest x-ray film results; frequency and duration of treatment; postures used and bronchial segments drained; cough effectiveness; need for suctioning; color, amount, and consistency of sputum; hemoptysis or other unexpected outcomes; and patient’s tolerance and reactions • Document your evaluation of patient learning Copyright © 2018, Elsevier Inc. All rights reserved. 12
- 13. Special Considerations • Teaching • Ideally, treat before breakfast and about 1 hour before bedtime • Pediatric • In a child with cystic fibrosis, CPT is usually performed at least twice daily • Patients with cystic fibrosis may benefit from the Vest airway clearance system Copyright © 2018, Elsevier Inc. All rights reserved. 13
- 14. Special Considerations (Cont.) • Gerontological • Change positions more slowly • May not tolerate supine or side-lying positions • Home care • How to assume postural drainage positions • Refer to appropriate specialists • Obtain foam wedge or multiple pillows for correct positioning Copyright © 2018, Elsevier Inc. All rights reserved. 14
- 15. Using an Acapella Device Procedural Guideline 24-1 • Designed to aid sputum clearance • Handheld • Provides positive expiratory pressure and vibration 15Copyright © 2018, Elsevier Inc. All rights reserved.
- 16. Delegation and Collaboration • The task of using an Acapella device can be delegated to NAP • The nurse directs NAP to: • Be alert for patient’s tolerance of procedure and report changes to nurse • Use specific patient precautions such as restrictions related to disease/treatment Copyright © 2018, Elsevier Inc. All rights reserved. 16
- 17. Performing Percussion and Vibration Procedural Guideline 24-2 • Percussion and vibration can be combined with postural drainage • High-frequency chest wall oscillation 17Copyright © 2018, Elsevier Inc. All rights reserved.
- 18. Delegation and Collaboration • The task of performing percussion and vibration can be delegated to NAP • The nurse directs NAP to: • About any patient precautions related to disease or treatment • Report to the nurse any problems with tolerance of the procedure, pain, dyspnea, or changes in vital signs Copyright © 2018, Elsevier Inc. All rights reserved. 18
- 19. Quick Quiz! When performing rib shaking on a 78-year-old woman who is malnourished, what potential complication will the nurse be watching for? A.Vomiting B.Fever C.Rib fracture D.Apnea Copyright © 2018, Elsevier Inc. All rights reserved. 19
Editor's Notes
- This chapter reviews two procedures and one skill: performing postural drainage, using an Acapella device, and performing percussion and vibration.
- Chest physiotherapy (CPT) includes physical chest wall maneuvers such as percussion, vibration, and shaking and postural drainage (PD), followed by productive coughing or suctioning. CPT is usually followed by productive coughing or suctioning to remove secretions. Traditional CPT does not help children with pneumonia, bronchiolitis, or asthma and it does not prevent atelectasis after extubation. In addition routine use of CPT does not improve mortality rates of adults with pneumonia. Chest physiotherapy is beneficial and an essential therapy in patients with cystic fibrosis. A vest airway clearance system is a method for delivering CPT that uses high-frequency chest wall compressions, created by bursts of air, for external chest wall compression. The Acapella device uses positive airway pressure to increase airway pressure, which assists a patient’s ability to cough. Careful patient assessment is a prerequisite for administering any airway clearance therapies. The auscultation of all the lung fields is essential to determine which regions would benefit from CPT. CPT maneuvers move secretions into the large central airways; then these secretions are removed through coughing or suctioning. PD requires specific positioning of a patient in order to position the targeted lung segment in such a manner so that gravity assists with removal of secretions. The Acapella device and the vest airway clearance system are very effective in assisting with airway clearance.
- Careful patient assessment is a prerequisite for administering any CPT and PD maneuver because the therapy is usually targeted to the affected areas as opposed to all the lung field. Surgical patients in the postoperative period and critically ill patients have excess secretions due to the effects of anesthesia, ineffective coughing because of incision pain or muscle weakness, and reduced mobility. Mucus plugs, atelectasis, and lobular collapse occur when secretions accumulate in the airways. Early mobility and ambulation are more successful in promoting airway clearance than routine CPT. CPT and PD are often used in combination with other therapies, including antibiotics, bronchodilators, mucolytic agents, and inhaled and nebulized medications in CF patients. These other therapies reduce mucus production and promote airway clearance. The goals of these therapies are (1) to clear the airways of excessive secretions to reduce the work of breathing and (2) to improve a patient’s ability to cough up secretions. In the normal lung the mucociliary transport system clears the airways of excessive mucus and inhaled particles. Airways normally remain clear, and mucus is constantly being cleared almost as fast as it is made. Normal mucus remains thin, white, and watery. In various disease states mucus clearance slows down, or the cilia are overwhelmed by the production of large quantities of mucus. The lungs no longer clear the mucus as fast as it is produced. Secretions stagnate in the airways, change color, and become thick and sticky.
- When patients’ physiological capacities are weakened; they are often anxious because of their illness or surgery, and they may be in pain. It is important to complete a pain assessment and administer prescribed analgesics 20 to 30 minutes before initiating any CPT maneuvers. This ensures that the patient is comfortable and as pain free as possible. Assess your patient’s activity tolerance. Patients with cardiopulmonary disease, severe arthritis, and certain musculoskeletal diseases often have diminished activity tolerance and cannot tolerate a complete CPT session. Plan CPT during short periods interspersed with rest periods, at a time when the patient is rested, and not immediately after a meal. To maintain a patient’s QoL try to integrate CPT and airway techniques into the patient’s routine, personal goals, and social activities. When dealing with patients who have CF, devices such as the Acapella, the vest airway clearance system, and other airway clearance devices assist these patients in maintaining their CPT schedule. [Ask students: what kinds of cultural considerations could apply to chest physiotherapy? Discuss: Asian and Muslim cultures consider it very poor taste to touch in public. In addition, the skills of physical therapy sometimes involve gentle percussion or shaking of a patient’s rib cage. Patients and families from cultures where violence is an everyday occurrence need detailed information about the procedure, so they do not misunderstand the intent and objective of CPT.] Always explain which type of touching is involved and what a patient may feel during the treatment, and provide an opportunity for a patient to temporarily stop and rest during the procedure.
- CPT maneuvers are effective in selected patients, such as those with CF, bronchiectasis, other chronic pulmonary diseases, and some surgeries. Recent systematic review noted that CPT is not routinely recommended as additional treatment for pneumonia in adults. Careful assessment of medical history for smoking, pulmonary infections, and other conditions may indicate the need for CPT in selected adults at risk for complicated pneumonia. Airway clearance therapy (ACT) is not recommended as routine in patients with COPD unless secretion retention is present. The use of the Acapella device (Procedure guideline 24-1) improves patient satisfaction and adherence to airway clearance therapies.
- Correct answer: B Rationale: When dealing with patients who have cystic fibrosis, skipping CPT maneuvers is not an option. Often these patients get tired of the daily routine and need assistance in designing an individualized plan for airway clearance. Chest physical therapy for cystic fibrosis should be done 3 to 4 times each day.
- Conditions such as atelectasis and pneumonia requiring CPT can affect a patient’s vital signs. The degree of change is related to the level of hypoxia, overall cardiopulmonary status, and tolerance of the procedure. Some medications, particularly diuretics and antihypertensives, cause fluid and hemodynamic changes. These changes affect a patient’s tolerance of the positional changes. Steroid medications, age, and malnutrition increase a patient’s risk for pathological rib fractures and often contraindicate rib shaking. [Ask students: why is it important to know a patient’s medical and surgical history before performing CPT? Discuss: certain conditions such as increased intracranial pressure, spinal cord injury, abdominal aneurysm resection, bone metastases, or severe osteoporosis contraindicate the positional changes of postural drainage. Thoracic trauma contraindicates percussion, vibration, and shaking.] [Review with students Box 24-1, Contraindications for Postural Drainage.]
- Alteration in mental status often makes it difficult or impossible for a patient to understand the procedure and participate in coughing and expectorating secretions. See Chapter 25. [Ask students: what can improve an inactive patient’s tolerance for CPT? Discuss: gradual increases in activity and planned CPT.]
- Each position drains a specific corresponding section of the tracheobronchial tree from the upper, middle, or lower lung field into the trachea. Coughing or suctioning helps remove secretions from the trachea. [Ask students: how do you know which segments of the patient’s lungs require postural drainage? Discuss: patient history and physical assessment findings, knowledge of a patient’s condition and disease process, chest x-ray film examination results, and extent of pathologic condition.] [Shown is Figure 24-1: Tracheobronchial tree. (Modified from Frownfelter DL, Dean E: Principles and practice of cardiopulmonary therapy, ed 43, St Louis, 2006, Mosby.)] [Review with students Table 24-1, Positions and Procedures for Drainage, Percussion, and Vibration.]
- Correct answer: D Rationale: Chest physiotherapy (CPT) consists of physical chest wall maneuvers such as percussion, vibration, and shaking, postural drainage (PD), and cough. CPT can dislodge an embolism, which could be fatal for the patient.
- It is the nurse’s responsibility to assess the patient, review laboratory, and x-ray film examination results, and determine that the patient is stable and able to tolerate the procedure. [Discuss verifying that the NAP has been trained in CPT.]
- [Ask students: what kind of home care procedures should be charted? Discuss: if patient and family caregiver receive instruction in home care, chart instructions given, understanding of therapy, demonstration of skill, patient acceptance of home care, barriers to learning and implementation, and referrals for home care or rehabilitation.]
- [Ask students: why is it ideal to treat the patient in the morning before breakfast and about 1 hour before bedtime? Discuss: early, so patients can clear secretions that accumulate overnight, and late, so lungs are clear before sleeping and patients have time after treatment to cough up any mobilized secretions.] Teaching Frequency depends on need and patient’s tolerance and varies from once daily to every 2 to 4 hours in an acute situation. Instruct patient’s family or caregiver in recognizing when patient’s respiratory status requires breathing exercises or postural drainage. Pediatric In a child with cystic fibrosis PD is a cornerstone therapy and is usually performed at least twice daily, on rising in the morning and in the evening. Many cystic fibrosis patients benefit from the use of the Vest airway clearance system. CPT is not beneficial in the treatment of bronchiolitis in children younger than 2 years of age. Children with pneumonia, bronchiolitis, and asthma have limited benefits with the administration of CPT. [Ask students: how can postures be modified for patient needs? Discuss: for example, if the patient is very short of breath, place him or her in a supine, side-lying semi-Fowler’s or side-lying Trendelenburg’s position to drain lateral lower lobes.]
- Gerontological Take extra care and thoroughly assess when using postural drainage in older adults. Change positions more slowly and closely assess for any changes in oxygen saturation or vital signs with position changes. Older adults with chronic cardiac and pulmonary conditions do not always tolerate a supine or side-lying position for CPT. [Ask students: why are supine and side-lying positions problematic for some older adults? Discuss: in these positions, patients experience a decline in forced vital capacity (FVC) and a subsequent decline in oxygen saturation.] Home care Teach patient and family caregiver how to assume postural drainage positions at home. Some positions need modification to meet patient needs. If eligible refer patient to a pulmonary rehabilitation program.
- The Acapella is a handheld airway clearance device. It provides positive expiratory pressure (PEP) with oral airway oscillations. It includes two types, which are designed to match patient’s expiratory flow rates and work of breathing. The blue device is for patients who cannot maintain their expiratory flow above 15 L/min for greater than 3 seconds. The green device is for patients who can maintain expiratory flow above or equal to 15 L/min for at least 3 seconds. During exhalation pressure from the airways is transmitted to the Acapella device, which helps mucus dislodge from the airway walls and as a result prevents airway collapse, accelerates expiratory flow, and moves mucus toward the trachea. Some patients with cystic fibrosis may have greater benefit from this device versus standard chest physiotherapy. [Shown is Figure 24-2: Acapella device. (Used with permission, Smithsmedical.com.)]
- The nurse is responsible for performing respiratory assessment, determining that the procedure is appropriate and that a patient is able to tolerate it, and evaluating a patient’s response to it,
- During postural drainage a nurse, respiratory therapist, or trained family member sometimes uses physical maneuvers such as percussion and vibration on the rib cage over lung tissue. The clinician uses techniques on specific parts of the rib cage over each affected lung region. Percussion is the manual external clapping of a patient’s chest wall with cupped hands or with a mechanical device in a rhythmic fashion to loosen secretions from the bronchial walls. You apply vibration to a patient’s external chest wall by placing both hands (one over the other) over the areas to be vibrated. Then you tense and contract the shoulder and arm muscles to create a vibration while the patient exhales to mobilize secretions. Vibration augments the natural movement of the rib cage during exhalation and helps with secretion clearance. Never use the clavicles, breast tissue, sternum, spine, waist, and abdomen for percussion and vibration; only perform these maneuvers over the ribs. High-frequency chest wall compression (HFCWC) consists of an inflatable vest linked to an air-pulse generator. One HFCWC device is the Vest airway clearance system, which assists in loosening and removing secretions from the airways. HFCWC systems deliver high-frequency, small-volume expiratory pulses to a patient’s external chest wall. This mechanical action helps to loosen and mobilize airway secretions. Patients with sputum production of 25 to 30 mL/day also benefit from this device because HFCWC decreases the viscosity of mucus, making it easier to cough productively. [Demonstrate for students the different motions to produce each type of maneuver.] [Shown is Figure 24-3: High-frequency chest wall oscillation vest for home use. (Copyright © 2012 Hill-Rom Services, Inc. Reprinted with permission. All rights reserved.)]
- The nurse is responsible for respiratory assessment and review of the patient’s chest x-ray film to determine that the patient is stable, which areas of the lungs are affected, and specific positions that the patient should assume. [Ask students: what could indicate a problem with the procedure? Discuss: pain, dyspnea, or changes in vital signs.]
- Correct answer: C Rationale: Malnutrition increases a patient’s risk for pathologic rib fractures and often contraindicates rib shaking. The force and motion required for the therapy pose a risk for this patient.