Master student final year

1. NATIONAL INSTITUTE OF NURSING
EDUCATION
PGIMER, CHANDIGARH
PROCEDURE:CHEST PHYSIOTHERAPY
AND BREATHING EXERCISE
SUBMITTED TO SUBMITTED BY
Ms. Neena Vir Singh Raj kumari
LECTURER,NINE MSC NURSING2nd YR
PGIMER,CHANDIGARH PGIMER, CHANDIGARH
SUBMITTED ON:-

2. CHEST PHYSIOTHERAPY (CPT)
Definition:-Chest physiotherapy (CPT) is a group of therapies for mobilizing pulmonary
secretions. These therapies include chest percussion, vibration and postural drainage.CPT is
followed by productive coughing or suctioning of a patient who has a decreased ability to cough.
This is especially helpful for patients with large amount of secretions or ineffective cough.
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
Contraindications :-
 Increased ICP
 Unstable head or neck injury
 Active hemorrhage or hemoptysis
 Recent spinal injury
 Rib fracture
 Flail chest
 Uncontrolled hypertension
EQUIPMENT :-
 Stethoscope
 pillows or folded towels
 adjustable hospital bed
 gloves ▪ facial tissues ▪ suction equipment ▪ oral care supplies ▪ facility-approved
disinfectant ▪ no-touch receptacle
AssessmentforChest Physiotherapy :-
 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

3.  Perform detailed physical examination of the chest
 Review the patients X-ray and other blood investigations.
 ▪ Perform a comprehensive pain assessment using techniques appropriate for the
patient's age, condition, and ability to understand.20
If needed, administer pain
medication before the procedure, as ordered, following safe medic ation practices.
Procedure
 Verify the practitioner's order
 Perform hand hygiene
 Confirm the patient's identity using at least two patient identifiers.
 Provide privacy
 Explain the procedure to the patient and family members (if appropriate) according to
their individual communication and learning needs to increase their understanding allay
their fears, and enhance cooperation.
 Raise the patient's bed to waist level while providing care to prevent caregiver back strain
 Put on gloves and other personal protective equipment as needed to comply with standard
precautions
 ▪ Auscultate the patient's breath sounds using a stethoscope to determine baseline
respiratory status
Techniques in Chest Physiotherapy:-
Chest physiotherapy consists of three techniques: -
1. Percussion / Clapping/ Cupping
2. Vibration
3. Postural Drainage
Percussion/ Cupping :-

4.  Chest percussion:- involves rhythmically clapping on the chest wall over the area being
drained to force secretions into larger airways for expectoration.
 Position the hand so the fingers and thumb touch and the hands are cupped.
 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.
 Perform percussion over a single layer of clothing, not over buttons or zippers.
 Percussion is contraindicated in patients with bleeding disorders, osteoporosis, fractured
ribs and open wounds and surgeries.
 Don’t percuss over the spine, sternum, stomach or lower back as trauma can occur to the
spleen, liver, or kidneys.
 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.
Vibration:- Vibrationisagentle,shakingpressure appliedtothe chestwall tomove secretionsinto
largerairways.

5.  The nurse uses rhythmic contractions and relaxations of arm and shoulder muscles over
the patient’s chest.
 During vibration, place your 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
• Postural Drainage:- Postural drainage 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 thetrachea 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.
Positioning patients for postural drainage
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
Lower lobes:Posteriorbasalsegments:-
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.
Lower lobes: Lateral basalsegments

6. 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. Percuss the lower ribs on the uppermost portion of the lateral chest wall.
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.
Right middle lobe: Medial and lateral segments:-

7. 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.
Left upper lobe: Superior and inferior segments, lingular 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. Percuss with your hand moderately cupped over the
left nipple. For a female patient, cup your hand so that its heel is beneath the armpit and your
fingers extend forward beneath the breast.
Lower lobes: Superior segments
With the bed flat, have the patient lie on his or her abdomen. Place two pillows under the hips. Percuss on both sides of the
spine at the lower tip of the scapulae

8. 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.
Left upper lobe: Superior and inferior segments, lingular 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. Percuss with your hand moderately cupped over the
left nipple. For a female patient, cup your hand so that its heel is beneath the armpit and your
fingers extend forward beneath the breast.

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

10. Upper lobes:Posteriorsegments
Keep the bed flat. Have the patient lean over a pillow at a 30-degree angle. Percuss and clap the
upper back on each side.
BREATHING EXERCISES:-
1. Pursed-Lip Breathing
a. Place your patient in Semi-Fowler’s position, if possible, for maximum breathing efficiency.
b. Instruct him to inhale deeply through the nose followed by exhalation through the mouth.
c. During exhalation, the lips should be held together as if blowing out a match.
d. Exhalation should take at least twice as long as inhalation and should make a softly audible
“blowing” sound.
2. Diaphragmatic Breathing:-
a. Wash hands.

11. b. Position your patient supine in bed. 10-2
c. Place your hand on the patient’s abdomen.
d. Instruct him to inhale through his nose and make your hand - NOT his chest - move outward.
Inspiration should be long, slow and deep. As the exercise progresses, slight pressure can be
applied to the abdomen during inspiration.
e. Instruct him then to exhale through pursed lips while your hand - NOT his chest - moves
inward.
f. The patient’s chest should move little during the respiratory cycle.
g. Ask the patient to place one of his hands on the abdomen and one on the chest wall. This will
increase self-awareness of abdominal and chest movement.
h. This exercise should be practiced for 10 minutes twice a day or for 3 - 4 minutes four times a
day. The frequency can be increased as the patient’s strength permits.
2.Expansion Exercise :-
Wash hands.
b. Patientisbestsittingupinbedor on the side of the bed.
c. Place your handson bothlateral,lowerribareasor overthe affectedareas.
d. Instructthe patienttoinhale slowlyanddeeplywhile attemptingtomove yourhands.
e.Exhalationshouldbe throughpursed-lips.
3.Coughing Exercise:-
a. Wash hands.
b. Have patientsitupas far as possible orsitonthe edge of the bed.
c. Instruct patienttotake 4 - 6 slow,deepbreathsusingdiaphragmaticbreathing.
d. Instructpatienttoholda deepbreathbefore initiatingcough.
e.Instruct patientto leanforwardina flexedposition,pushingdiaphragmup,andbegincough.
f. Patientshoulddirectcoughintoatissue oraway fromyou butnot to blockthe cough.
g. If the patienthasa recentincisionorlocalizedareaof pain,holdapillow overthatareaand apply
moderate pressure duringthe cough.
h. Instructthe patienthowto dispose of expectoratedsputum.

12. i. If a single coughisineffective,instructthe patienttouse the double coughtechnique,i.e.deep
breaths,a coughfollowedbyasecondcough,withoutabreath inbetweencoughs.
j. Patientcannow refill lungsusingdiaphragmaticbreathing.
k. Wash hands.
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.
 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.
REFERENCES
1 Strickland, S. L., et al. (2013). AARC clinical practice guideline: Effectiveness of
nonpharmacologic airway clearance therapies in hospitalized patients. Respiratory Care, 58(12),
2187-2193. Accessed October 2017 via the Web at
http://rc.rcjournal.com/content/58/12/2187.full (Level VII)
file:///C:/Users/HP/Downloads/CHEST%202.pdf
2 Yang, M., et al. (2013). Chest physiotherapy for pneumonia in adults. Cochrane Database of
Systematic Reviews, 2013(2), CD006338. (Level I)
3 Stoller, J. K. Management of exacerbations of chronic obstructive pulmonary disease. (2017).
In: UpToDate, Barnes, P. J., & Hollingsworth, H. (Eds.). Accessed via the Web at
http://www.uptodate.com
4 Centers for Disease Control and Prevention. (2012). “Respiratory hygiene/cough etiquette in
healthcare settings” [Online]. Accessed via the Web at
http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm (Level VII)

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