Complete therapeutic exercise

1. PHYSIOTHERAPY TECHNIQUES
FOR RESPIRATORY CONDITIONS

2. Brief history
Physiotherapy for respiratory conditions has evolved over the last century
since the publication of the work of Ewart (1901) and Pasteur (1908).
•Ewart (1901) described the use of tipping patients with bronchiectasis head
down to facilitate the removal of lung secretions (Ewart, 1901),
•while Pasteur (1908) recognised the issue of “massive collapse of the lung”
after surgery (Pasteur, 1908)
•MacMahon as early as 1915, treat lung collapse and dyspnea for people
undergoing surgery.

3. TEHNIK UNTUK MEMBERSIHKAN JALAN NAPAS
Yaitu suatu tehnik yang digunakan untuk membersihkan mukus dari jalan
napas, yg meliputi :
1. Postural drainage (PD) / Gravity Assisted Drainage (GAD)
2. Percussion / vibration
3. Forced Expiratory Techniques (FET) / Active cycle of Breathing
Techniques (ACBT)
4. Positive Expiratory Pressure (PEP), Flutter
5. Humidification
6. Exercise
7. Suction
Synonyms: Bronchial toilet, Chest Physiotherapy / CPT

4. PD / GAD
•Gravity assisted drainage (GAD) is accomplished by positioning the
patient so that secretions accumulating in a particular bronchopulmonary
segment may move to central airways with the aid of gravity, from where
they can be expectorated more easily by coughing (Pavia, 1990)
•Positioning is based upon knowledge of the anatomy of the bronchial tree
(Nelson, 1934)
•Indicated in EXCESSIVE mucous secretion (> 20-30 mls/day)
•Effectiveness supported in some literature
•Limited research in isolation

5. Lamanya pengasatan / pengaliran sekresi pada tiap posisi
berbeda-beda untuk masing-2 pasien, tergantung pd kwalitas &
type sputum yg akan diexpectorasikan
Idealnya penderita harus tetap pd suatu posisi sampai
daerah tsb bersih
Rata-2 diperlukan waktu antara 10-20 menit
Daerah yg paling banyak sputumnya  prioritas pertama yg
harus dibersihkan
Jika didapatkan adanya obstruksi yg reversible 
bronchodilator + 15 menit sebelum PD
Jika sekresi terlalu kental & lengkrt  Humidifikasi/hidrasi
Penderita dalam monitor  cek aritmia sebelum, selama, &
sesudah PD

6. 1. Apical
2. Posterior
3. Anterior
4. Lateral
5. Medial
6. Apical
7. Medial Basal
8. Lateral Basal
9. Anterior Basal
10.Posterior Basal
1. Apical
2. Posterior
3. Anterior
4. Superior
5. Inferior
6. Apical
7. -
8. Lateral Basal
9. Anterior Basal
10.Posterior Basal
PARU KANAN PARU KIRI
Upper Lobe
Middle Lobe
Lower Lobe

9. Contraindications for head down tip
1. Severe uncontrolled hypertension
2. Acute head injury
3. Severe haemoptysis
Precautions for head down tip
1. Gastro esophageal surgery/reflux
2. CV instability
3. Cardiac failure
4. Abdominal distension

10. PERCUSSION (CLAPPING)
Manual chest percussion or chest clapping is applied by the physiotherapist’s
cupped hands with a rhythmical flexion and extension action of the wrist to
the patient’s chest wall over the involved lung segments (Webber, 1998)
The use of manual chest
percussion, vibration and
clapping is controversial in
clinical practice
It is proposed that percussion over the chest wall
generates an energy wave that is transmitted
through the chest wall to underlying lung tissue
resulting in a vibratory force within the airways.
This vibration is thought to loosen sputum from
the airway walls and stimulate the activity of
mucocilliary transport [Gosselink, 1989)

11. Contraindications / Precautions for Percussion
1. Osteoporosis
2. # costae
3. Pain
4. Frank haemoptysis
5. Bronchospasm
6. Active TB?

12. VIBRATIONS / SHAKING
Secara manual, biasanya dikombinasi dengan breathing exercise. Diberikan saat
ekspirasi setelah maximum inspirasi.
Untuk fibrasi dapat pula digunakan alat VIBRATOR mis : HFCO
Contraindications/precautions
 rib pathology
Bronchospasm
osteoporosis

13. ASSISTED COUGH / SUPPORTED COUGH
A cough is a pulmonary defence mechanism, which functions to
expel foreign material or excess secretions in the airways.
A cough may be categorised as reflex or voluntary.
A voluntary cough is initiated by the contraction of inspiratory
muscles allowing rapid maximal inhalation, followed by closure of
the glottis, then contraction of the expiratory muscles creating a
high intrathoracic pressure of up to 200 mmHg. The expulsive
phase begins when the glottis opens promoting high expiratory
flow rates of up to 70 mph (Starr, 1992)
Impaired coughing may occur when any of the three phases of
coughing fails to meet its objectives (Humberstone, 1990)
Physiotherapists teach an effective cough technique by
educating the patients to inhale maximally, and expel as
forcefully as possible with closure of the glottis occurring no
more than two times during each expulsive phase

14. The effectiveness of coughing in clearing secretions has been demonstrated
in some studies of medical patients (Bateman et al., 1981; de Boeck &
Zinman, 1984). Bateman and co-workers (1981) evaluated the effectiveness
of coughing alone compared to coughing as an adjunct to chest
physiotherapy in six medical patients with diagnosis of bronchitis chronic
and bronchiectasis that had a mean daily sputum production of 160 ml. It
was found that coughing was effective in removal of secretion from the
central airways, and that the role of coughing for removal of secretion in
more peripheral airways needs further investigation (Bateman et al., 1981)
HUFFING
Whilst it may seem that a cough and a huff are similar, the
mechanism of the explosive airflow generated from a cough and a huff
is different.
A huff is a forced expiratory manoeuvre that is performed with an
open glottis (Van der Schans et al., 1999)
Huffing to low lung volumes will move secretions to more
peripherally in the airways

15. To create an effective huff, the length of the huff and the force of the
contraction of the expiratory muscles should be modified to maximize
airflow and to minimize airway collapse (Webber & Pryor, 1998)
Huffing seems to be more effective in clearing secretions than coughing
for patients with chronic airflow limitation, because huffing can produce
higher flow rates than coughing for those groups of patients (Starr, 1992).
The mean of trans-pulmonary pressure during voluntary coughing is
greater than during huffing. As a result, coughing produces greater
compression to the airways that leads to narrowing of the airways which
limits airflow and reduces the effectiveness of bronchial secretion
(Langlands, 1967)

16. FORCED EXPIRATION TECHNIQUE (FET)
The forced expiration technique (FET) was employed by
physiotherapists as a method of removing excess bronchial
secretions.
Pryor and Webber (1979) have defined FET as one or two
forced expirations or huffs from mid to low lung volume
interspersed by a period of relaxation and diaphragmatic
breathing (Pryor & Webber, 1979).
Gosselink (1989) mendefinisikan FET sebagai suatu tehnik
untuk membersihkan jalan napas yg merupakan kombinasi
antara:
Postural Drainage
Breathing exercise (SMI)
Huffing

17. The efficacy of FET to enhance secretion clearance has been
supported in a number of publications (Hassani et al., 1994;
Hassani et al., 1991; Pryor et al., 1979; Sutton et al., 1983)
Salah satu bagian yg penting dr FET adalah periode istirahat
yg diisi dg breathing control  mencegah obstruksi jalan napas
lebih lanjut.
Lamanya waktu istirahat tergantung pd kondisi pasien

18. Active Cycle of Breathing Techniques (ACBT) has evolved from
the use of FET to utilise the benefits of thoracic expansion
exercise (TEE) and breathing control in combination with FET
(Webber & Pryor, 1998).
Webber and Pryor (1998) defined ACBT as “ a cycle of
breathing control (tidal breathing at the patient’s own rate and
depth, encouraging used of the lower chest with relaxation of
the upper chest and shoulder), thoracic expansion exercise (deep
breathing exercises emphasizing inspiration with or without a
breath hold; expiration is quite and relax) and the forced
expiration technique (one or two huffs combined with period of
breathing control)” (Webber & Pryor, 1998)
ACTIVE CYCLE OF BREATHING TECHNIQUE
(ACBT)

19. Developed at the Bromptom Hospital, UK
The ACBT has been demonstrated to be an effective
technique to treat patients where excessive bronchial secretions
persist (Pryor et al., 1979; Wilson et al., 1995).
It has been shown also to improve lung functions in patients
with cystic fibrosis (Webber et al., 1986).
The method is flexible; therefore it can be applied for
medical or surgical patients. However there is no study yet
published which evaluates its use in surgical patients (Webber &
Pryor, 1998)
ACBT biasanya dilakukan pd posisi duduk, tetapi dapat
dikombinasi dg PD
Sangat penting untuk mendidik pasien tehnik ini dan
menganjurkannya untuk melakukan sendiri

20. HIDRASI
Merupakan suatu usaha untuk menambah cairan tubuh dengan
tujuan untuk mempermudah pengeluaran sputum yg kental.
Dehidrasi dapat menyebabkan cilia tak bergerak (Clarke,
1989)  untuk mencegahnya  Hidrasi sistemik 
Oral/intravenous
Penambahan cairan sistemik, selain mrpk expectorant yg
murah & aman, juga lebih efektif dr pd menghirup udara yg
lembab
Penambahan cairan per “oral” dapat menurunkan viskositas
sputum + 2/3nya (Blanshard, 1955)
Penambahan cairan dianjurkan + 1,5 s/d 2 ltr perhari,
sepanjang masih comfortable (Luce et al, 1984)

21. HUMIDIFIKASI
Suatu usaha untuk membasahi/melembabkan udara atau gas-
gas yg dihirup.
Biasa digunakan oleh PT
Provided when normal Upper Respiratory Tract is bypassed
eg tracheotomy to prevent
Cilial dysfunction
Mucosal drying
Inflammation & ulceration
Drying of airway mucus
Mucus retention
Use for non intubated patients more controversial
Aim is to increase sputum clearance & cough effectiveness
Nebulised water for 30 min may increase sputum clearance in
patients with excessive secretions when used with GAD & ACBT
(Conway et al, 1992)

22. Diberikan sebelum atau selama PT treatment
Hypertonic saline, the cold temperature of an unheated
nebulizer & dense ultrasonic mist may cause broncho
constriction
Bacterial colonisation of water in humidifiers
Heat injury from heated humidifiers

23. PEP-Mask (Positive Expiratory Pressure)
Merupakan suatu tehnik yang bertujuan untuk membantu
membersihkan jalan napas  dengan ekspirasi melawan tahanan
diharapkan dapat merangsang terbukanya sistim collateral 
masuknya udara dibelakang mukus  memudahkan untuk
mengeluarkan mukus
Alat ini dikembangkan pertamakali di Scandinavia oleh Mr
Andersen  Berupa suatu masker  pada pintu ekspirasinya
terdapat tahanan variabel yang mengatur besarnya tahanan
ekspirasi
Dengan alat ini diharapkan:
Pada saat ekspirasi sal napas tetap terbuka
Merangsang terbukanya sistim collateral
Memperbaiki distribusi ventilasi

24. Biasanya diberikan pd posisi duduk tegak dg siku disupport,
pasien memegang PEP-Mask yg ditempelkan didaerah hidung &
mulut secara merata  tarik napas dalam  keluarkan scr aktif
tetapi tidak dengan tenaga kuat/paksa.
Tahanan diatur sedemikian rupa  pasien dapat bernapas 10-
15 kali scr nyaman/comfortable
Indikasi  sering digunakan pd kasus CF, khususnya org
dewasa dan yg tidak menginginkan PD, tetapi dapat juga
bermanfaat pd kasus COPD (Christensen et al, 1990)
Pada kasus dimana ada wheezing  TIDAK DIANJURKAN
menggunakan alat ini
Research mostly in copious sputum producers  8 clinical
trials, 228 patients, comparing PEP with traditional airway
clearance  the results showed equivalence for lung function &
sputum weight (Thomas et al, 1995)

25. Merupakan suatu alat yg digunakan untuk membantu
membersihkan sal napas, yg merupakan mengembangan dr PEP
dengan oscilasi  dikembangkan di Switzerland
Berpentuk seperti pipa  pd ujungnya terdapat beberapa lobang
yg berakhir pd sebuah ruangan yg berisi bola-bola  selama
ekspirasi bola-bola tersebut akan bergetar  tekanan positif
dan vibrasi.
Frekwensi vibrasi antara 8 dan 20 Hz dg tekanan < 20 cmH2O
Originally  penggunaan dr alat ini adalah ekspirasi secara
perlahan-lahan melalui alat tsb  selama 10 menit  latihan
batuk. Menurut Pryor et al (1994) tehnik ini kurang efektif
dibandingkan ACBT  dilakukan modifikasi dalam pelaksanaannya
 Tarik napas dalam, kemudian ditahan 3-5 detik (SMI) 
dikeluarkan lebih cepat dari napas normal melalui alat tsb.
Setelah 4-8 kali diikuti oleh HUFFING.
FLUTTER

26. Konstan et al (1994) dalam penelitiannya pd kasus CF yg
membandingkan efektivitas dr Flutter, Latihan batuk dan PD 
Flutter adalah yg paling efektif dilihat dr jumlah sputum yg
dikeluarkan.
Lindemann (1992) melakukan penelitian dg membandingkan
Flutter dan “Autogenic Drainage”  keduanya sama efektif 
Flutter lebih mudah diajarkan
Perlu diperhatikan perawatan dari alat tsb  untuk
meminimalkan resiko infeksi

27. EXERCISE
Latihan yg berat spt : Renang, bersepeda statik  dapat
meningkatkan mucociliary clearance
1. Peningkatan ventilasi  peningkatan expiratory flow
2. Stimulasi receptor pd sal napas & parenchym paru 
hypersekresi membrana mukosa
3. Stimulasi faktor endocrine (Cathecolamine)  peningkatan
mukus transport

28. ENDOTRACHEAL/NASOPHARYNGEAL SUCTION
Merupakan pilihan tehnik yg terakhir dr pembersihan jalan
napas bila tehnik yg lain tak dapat dilakukan atau tak efektif
Menegangkan
Kadang nyeri
Beresiko
Limited in effectiveness
Walaupun kadang-2 amat diperlukan bila
Adanya sekresi yg sulit dikeluarkan dg tehnik lain
Adanya kelemahan atau hilangnya kesadaran

29. PERALATAN YG DIPERLUKAN
Suction pump
Catheters  ukuran 9-12 FG (French Gauge)
Suction Trolley
TEHNIK
Beri informasi ke pasien
Cek seluruh peralatan
Berikan oksigenasi + 2 menit
Masukkan Catheter
Siap untuk suction
Berikan oksigenasi pasca suction
Pd penggunaan catheter dg mata banyak (multiple eyes) tak
perlu dilakukan rotasi (Anon, 1977)

30. PERMASALAHAN YG DAPAT MUNCUL
1. Kerusakan mukosa
2. Atelectasis
3. Hypoxia  atelectasis, stress
4. Infeksi
5. Aritmia, Bradicardia atau gangguan tekanan darah
6. Laryngospasm
KONTRA INDIKASI
1. Stridor
2. Fracture os frontalis  penurunan CSF
3. Pulmonary oedema
4. Recent pneumoectomy
5. Recent oesophagectomy

31. TEHNIK FISIOTERAPI UNTUK
MENINGKATKAN VOL PARU
1. Positioning
2. Breathing exercise
• Deep Breathing Exc  Segmental costal DBE
• Sustained Maximal Inspiration (SMI)
• Thoracic Expansion Exercise (TEE)
3. Incentive spirometry
4. Ambulasi/exercise
5.  dead space
6. IPPB/IPPV/CPAP

32. LATIHAN NAPAS DALAM
(Deep Breathing Exercise)
Latihan napas dalam adalah merupakan bagian dari
tehnik latihan pernapasan (breathing exercise) yang
menekankan pada inspirasi maksimum yang panjang yang
dimulai dari akhir ekspirasi (posisi FRC)