Techniques of chest physiotherapy and it's importance

• CHEST PHYSIOTHERAPY IN THE MANAGEMENT
OF PRE AND POST SURGICAL PATIENTS
• A SEMINAR PRESENTATION BY SURGERY UNIT

Introduction
• Surgery and general anesthesia directly affect the
respiratory system (Siafakas e tal, 1999).
• Surgery alters postoperative pulmonary function, as
observed by impairment of lung volumes such as
total lung capacity, vital capacity and tidal volume. It
also reduces the efficiency of efforts to cough for as
long as one week.
• There are also falls in oxygen arterial pressure and in
oxygen-hemoglobin saturation.
• Postoperative pulmonary complications occur after
upper abdominal surgery at a rate ranging from 6 to
70% of patients, depending on the criteria for
defining them (Ferguson1999).

Introduction cont’d
• They may include atelectasis, pneumonia or
hypoxemia, among others (Warner, 2000).
• Pre and post operatively, breathing and chest
wall physiotherapy have been used to prevent
atelectasis.
• Respiratory exercises during hospitalization
has been shown to improve respiratory
muscle strength, oxygenation, coughing
mechanism, chest wall mobility and lung
ventilation, as well as decreasing respiratory
work and preventing postoperative pulmonary
complications.

Introduction cont’d
• preoperative chest physiotherapy reduced
the incidence of postoperative pulmonary
complications and improved mobilization and
oxygen-hemoglobin saturation after surgery
(Fagevik Olsén, 1997)

• The objective of this presentation, is to
refresh our memories about chest
physiotherapy, the relevant clinical chest
assessment and chest physiotherapy
techniques relevant to surgical patients in
particular and generally to all patient
amenable to physiotherapy .
• Although Chest Physiotherapy is inherently
linked to all other body system, the focus of
this presentation is on the examinations
procedures and therapeutic intervention used
in patient with pulmonary dysfunctions..

Chest physiotherapy (CPT)
• Cardiovascular and cardiopulmonary
physiotherapy also known as chest
physiotherapy (CPT) is a multifaceted
area of professional practice that deals
with management of patient of all ages
with acute or chronic primary or
secondary cardiovascular and pulmonary
disorders.

Chest physiotherapy cont’d
• Chest physiotherapy (CPT) is an airway
clearance technique designed to improve
respiratory efficiency, promote expansion of
the lungs, strengthening respiratory muscles
and eliminate secretions from respiratory
system that combines manual percussion of
the chest wall by the care giver, strategic
positioning of the patient for mucus drainage
with cough and breathing techniques.

Goals of CPT
• The ultimate purpose of CPT is to help patient
breath more freely and get more oxygen into
the body system.
• Prevent airway obstruction and Accumulation
of secretions that interfere with normal
respiration/oxygen transport.
• Improve airway clearance, cough
effectiveness, and ventilation through
mobilization and drainage of secretions.

Goals of CPT cont’d
• Improve endurance, general exercise
tolerance, and overall well-being.
• Reduce energy costs during respiration
through breathing retraining.
• Prevent or correct postural deformities
associated with pulmonary or extrapulmonary
disorders.
• Maintain or improve chest mobility

Indications for chest physiotherapy
• The following are general indications which suggest the need to evaluate a
patient for the appropriateness of CPT:
• Postoperative prophylaxis against retained secretions for patients with an
ineffective spontaneous cough reflex.
• Adult having difficulty expectorating sputum volume greater than
approximately 25 ml/day
• Evidence or suggestion of retained secretions in a patient with an artificial
airway
• Presence of a foreign body in the airway
• Adventitious breath sounds suggestive of secretions in the airways which
persist after coughing
• Abnormal chest radiograph suggesting atelectasis, mucus plugging, or
infiltrates
• History of success in treating a pulmonary problem with CPT.

Indications cont’d
• Significant deterioration in the indices of gas
exchange from baseline status .
• Change in vital signs
• Poor oxygenation associated with position, i.e.
unilateral lung disease .
• Presence of potential or actual atelectasis
caused by or suspected of being caused by
mucus plugging.
• Evidence or suggestion of difficulty with
secretion clearance .

Indications cont’d
• As a routine part of respiratory care in patients
with cystic fibrosis, bronchiectasis, chronic
bronchitis, necrotizing pulmonary infection,
spinal cord injury, or ineffective spontaneous
cough.
• Inability or reluctance of patient to change body
position, non ambulatory chronic patient.

Contraindications
• The decision to intensify a patient's bronchial
care by initiating CPT requires a careful
assessment of the risks versus the benefits of
intervention.
• Chest physiotherapy must be modified
according to the patient's needs, tolerance,
condition, and therapeutic goals, and
assessment must be ongoing through each
subsequent therapy session.

• Therapy is modified to improve results
while minimizing risk, pain and discomfort.
• Continual assessment and modification of
therapy render most contraindications as
relative with the exception of those
absolute contraindication noted below

Contraindications
• Absolute:
• Unstabilized head and/or neck injury
• Active hemorrhage with hemodynamic instability or
significant possibility of occurrence
• Intracranial pressure (ICP) greater than 20 mm Hg
• Recent spinal surgery (i.e., laminectomy)
• Acute spinal injury
• Active hemoptysis
• Empyema
• Bronchopleural fistula
• Cardiogenic pulmonary edema

Contraindications cont’d
• Large pleural effusion
• Pulmonary embolism
• Confused, anxious, or otherwise impaired patients
who actively resist or do not tolerate position
changes
• Rib fracture with or without flail chest or other
significant chest injury
• Surgical wound or delicately healing tissue
• Untreated pneumothorax of flail chest
• Osteoporosis of the thoracolumbar region

Specific Precautions
• Not all forms of chest physical therapy are
appropriate for all patients. Postural drainage and
percussion should not be administered to
patients who:
• just eaten or are vomiting
• acute asthma or tuberculosis
• brittle bones or broken ribs
• bleeding from the lungs or are coughing up blood
• experiencing intense pain

RELEVANT ANATOMY AND
PHYSIOLOGY
• Anatomically, the wall of the thorax and the abdomen
are one, topographically and developmentally.
• The essential difference being the presence of ribs in the
thorax, the part primarily concerned with respiration.
• The thorax contains the heart, lungs, and other
important structures within a skeletal framework that
also protects some of the abdominal organs .Campbell,
Neil A. (2009)
• The skeletal frame consists of the thoracic vertebrae
and intervertebral discs, the ribs and costal cartilages
and the sternum.

MEDIASTINUM
• Within this musculoskeletal cage of the thorax are
three subdivisions.
• The two lateral subdivisions hold the lungs.
• Between the lungs is the mediastinum,
which contains the heart, the great vessels, parts of
the trachea and esophagus, and other structures.

LUNGS
• The lungs are two huge sponge like structures in the
thorax consist of airways (trachea and bronchi)
that divide into smaller and smaller branches until
they reach the air sacs, called alveoli.
• The airways conduct air down to the alveoli where gas
exchange takes place.
• The function of the lungs is to oxygenate blood and
remove carbon dioxide from it.
• The lung itself is covered with a membrane called the
visceral (or pulmonary) pleura
• The surface tension of the pleural fluid also couples the
visceral and parietal pleura to one another, thus
preventing the lungs from collapsing.

• The lungs and the chest wall are elastic
structures. Normally, no more than a thin layer
of fluid is present between the lungs and the
chest wall (intrapleural space).
• The lungs slide easily on the chest wall but
resist being pulled away from it in the same
way that two moist pieces of glass slide on each
other but resist separation. The pressure in the
"space" between the lungs and chest wall
(intrapleural pressure) is subatmospheric.

• The lungs are stretched when they expand
at birth, and at the end of quiet expiration
their tendency to recoil from the chest wall
is just balanced by the tendency of the chest
wall to recoil in the opposite direction.
• If the chest wall is opened, the lungs
collapse; and if the lungs lose their elasticity,
the chest expands and becomes barrel-
shaped

• The right lung has three lobes ,and the left
lung has two.
• The oblique and horrizontal fissures
divides the lungs into lobes.
• The bronchus, pulmonary artery and vein
enters the lungs via the hilium.
• There are 10 tertiary or segmental
bronchi on the right and 8 on the left lung.
• The arterial and nerve supply are from the
bronchial artery , cardiac plexus and vagus
nerve respectively.

Air Passages
• After passing through the nasal passages
and pharynx, where it is warmed and takes
up water vapor, the inspired air passes
down the trachea and through the
bronchioles, respiratory bronchioles, and
alveolar ducts to the alveoli .
• Between the trachea and the alveolar sacs,
the airways divide 23 times

DIAPHRAGM
• The diaphragm is a dome-shaped
musculofibrous septum.
• It separates the thoracic from the
abdominal cavity, its convex upper
surface forming the floor of the
thorax ,
• and its concave under surface
forming the roof of the abdomen.
Movement of the diaphragm
accounts for 75% of the change in
intrathoracic volume during quiet
inspiration. Attached around the
bottom of the thoracic cage, this
muscle arches over the liver and
moves downward like a piston when
it contracts. The distance it moves
ranges from 1.5 cm to as much as 7
cm with deep inspiration

• The diaphragm is pierced by a series of apertures to permit
the passage of structures between the thorax and abdomen.
• Three large openings — the aortic, the esophageal, and the
vena cava — and a series of smaller ones are described.
• Innervation
• The diaphragm is primarily innervated by the phrenic nerve
which is formed from the cervical nerves C3, C4, and C5.
• " The peripheral portions of the diaphragm send sensory
afferents via the intercostal (T5-T11) and subcostal nerve.

Function
• The diaphragm plays an important role in
respiration.
• During inhalation, the diaphragm contracts, thus
enlarging the volume of the thoracic cavity (the
external intercostal muscles also participate in this
enlargement).
• This reduces intra-thoracic pressure: In other words,
enlarging the cavity creates suction that draws air
into the lung, or lungs.

Muscles of the chest wall
• The main muscles of the chest wall, the
external and internal intercostals, extend from
one rib above to the rib below .
• The external intercostals enlarge the thoracic
cavity by drawing the ribs together and
elevating the rib cage,
• while the internal intercostals decrease the
dimensions of the thoracic cavity.

MECHANISM OF RESPIRATION
Inspiration
• Inspiration is an active process. The contraction
of the inspiratory muscles increases intrathoracic
volume. The intrapleural pressure at the base of
the lungs, which is normally about –2.5 mm Hg
(relative to atmospheric) at the start of
inspiration, decreases to about –6 mm Hg.
• The external intercoastal muscles contracts,
lifting the ribs up and out. The diaphragm moves
down, increasing the volume of the pleural cavity.
Elastic fiber in the alveolar walls stretch, and the
air sacs of the lung expand

• The pressure in the airway becomes slightly
negative, and air flows into the lungs.
• Strong inspiratory efforts reduce intrapleural
pressure to values as low as –30 mm Hg,
producing correspondingly greater degrees of
lung inflation. When ventilation is increased,
the extent of lung deflation is also increased
by active contraction of expiratory muscles
that decrease intrathoracic volume.

EXPIRATION
• At the end of inspiration, the lung recoil begins to
pull the chest back to the expiratory position, where
the recoil pressures of the lungs and chest wall
balance.
• The pressure in the airway becomes slightly positive,
and air flows out of the lungs. Expiration during
quiet breathing is passive in the sense that no
muscles that decrease intrathoracic volume
contract.
• However, some contraction of the inspiratory
muscles occurs in the early part of expiration. This
contraction exerts a braking action on the recoil
forces and slows expiration
• the external intercoastals and diaphram relax.

• In disease conditions such as asthma and
COPD, accessory muscles of respirations may
be used. Inspiration is assisted by
sternocleidomastoid muscle and scalene
muscles .

Lung volumes
• The total lung capacity is approximately 5 litres - this is the
maximum amount of air the lungs can contain.
• The tidal volume is the volume of air breathed in and
exhaled during normal breathing and is approximately 500
ml.
• The air inspired with a maximal inspiratory effort in excess of
the tidal volume is the inspiratory reserve volume.
• The volume expelled by an active expiratory effort after
passive expiration is the expiratory reserve volume.
• Residual volume is the volume of the air remaining in the
lungs after the maximum amount has been exhaled. It is
around 1.5l.
• The vital capacity is the maximum amount of air that can be
exhaled after a maximal intake of breath.

Compliance of the Lungs & Chest Wall
• The change in lung volume per unit change in airway
pressure ( V/ P) is the stretchability (compliance) of the
lungs and chest wall.
• It is normally measured in the pressure range where
the relaxation pressure curve is steepest, and the
normal value is approximately 0.2 L/cm H2O.
• However, compliance depends on lung volume; an
individual with only one lung has approximately half
the V for a given P.
• Compliance is also slightly greater when measured
during deflation than when measured during inflation.

PHYSICAL EXAMINATION OF THE
CHEST
• A comprehensive examination of a patient with known or
suspected dysfunction related to primary and secondary
pulmonary or chest disorders has many elements.
• The examination procedures described in this material
are those often used by a physiotherapist during an
initial evaluation to establish a therapy-related diagnosis
or during subsequent assessments for modification of
therapeutic interventions.
• Additional examination procedures not described in this
material but integral to the management of a patient
with pulmonary dysfunction are radiography, evaluation
of blood gases, tomography, bronchoscopy, and
hematological tests.

Physical examination cont’d
• The component examination of the chest
proceeds methodically by History,
Inspection/Observation, Palpation, Percussion,
Auscultation and Girth measurement.
INSPECTION
• This begins by sitting the patient in a good light
with the whole of the chest bared. The
physiotherapist will observe the appearance of
the patient.
• The vital signs should be taken. These includes
heart rate, breathing rate, blood pressure

GENERAL APPEARANCE OF THE
PATIENT AND IMPLICATION

Analysis of Chest Shape and
Dimensions
• Symmetry of the chest and trunk. Observe
anteriorly, posteriorly, and laterally; the thoracic
cage should be symmetrical.
• Mobility of the trunk. Check active movements
in all directions and identify any restricted spinal
motions, particularly in the thoracic spine.
• Shape and dimensions of the chest. The
anteroposterior (AP) and lateral dimensions are
usually 1:2.

Common chest deformities include;
• Barrel chest. The circumference of the upper chest appears
larger than that of the lower chest. The sternum appears
prominent, and the AP diameter of the chest is greater than
normal. Many patients with chronic obstructive pulmonary
disorders, who are usually upper chest breathers, develop a
barrel chest.
• Pectus excavatum (tunnel breast). The lower part of the
sternum is depressed and the lower ribs flare out. Patients
with this deformity are diaphragmatic breathers excessive
abdominal protrusion and little upper chest movement occur
during breathing.
• Pectus carinatum (pigeon breast). The sternum is prominent
and protrudes anteriorly.

Posture or Preferred Positioning
• Identify a patient’s preferred sitting or
standing posture.
• A patient who has difficulty breathing as
the result of chronic lung disease often
leans forward on hands and elevate the
shoulder girdle to assist with inspiration.

cont’d
• A patient who is short of breath at rest or
after activity often assumes a forward-bent
position with hands or elbow resting on the
thighs to relieve or reduce symptoms.

• This position increases the effectiveness of the pectoralis and
serratus anterior muscles to act as accessory muscles of
inspiration by reverse action.
• It is also important to identify a patient’s preferred sleeping
position.
• A patient with cardiopulmonary dysfunction often prefers to
sleep in a head-up rather than a fully recumbent position.
• Assuming a horizontal position may result in shortness of
breath.
• In addition, note any postural deformities such as kyphosis
and scoliosis and postural asymmetry from thoracic surgery,
which could restrict chest movements and ventilation.

Breathing Pattern
• Assess the rate, regularity, and location of ventilation
at rest and with activity.
• A normal respiratory rate for a healthy adult is 12 to 20
breaths per minute.
• This is most accurately determined when a patient is
unaware that his or her respiratory rate is being
measured, as when taking the pulse rate.
• The normal ratio of inspiration to expiration at rest is
1:2 and with activity 1:1.
• A patient with chronic obstructive pulmonary disease
(COPD) may have a ratio of 1:4 at rest, which reflects
difficulty with the expiratory phase of breathing

Breathing Pattern
• The normal sequence of inspiration at rest is
• (1) The diaphragm contracts and descends and the abdomen
(epigastric area) rises
• (2) This is followed by lateral costal expansion as the ribs
move up and out; and finally
• (3) the upper chest rises. The neck muscles that act as
accessory muscles of inspiration should be inactive during
relaxed inspiration.
• To assess the breathing sequence, have the patient assume a
comfortable position (semi reclining or supine).
• Place your hands on the patient’s epigastric region and
sternum to observe movements in these two areas. A number
of terms are used to describe abnormal breathing patterns
and are defined as follows;

Chest Mobility
• Symmetry of chest movement. Analysis of the
symmetry of the moving chest during
breathing gives the therapist information
about the mobility of the thorax and indicates
indirectly what areas of the lungs may or may
not be responding.

Chest Mobility cont’d
• Procedure: Place your hands on the patient’s
chest and assess the excursion of each side of the
thorax during inspiration and expiration. Each of
the three lobar areas can be checked.11,35,38,52
• To check upper lobe expansion, face the patient;
place the tips of your thumbs at the midsternal
line at the sterna notch. Extend your fingers
above the clavicles. Have the patient fully exhale
and then inhale deeply.

• To check middle lobe expansion, continue to face
the patient; place the tips of your thumbs at the
xiphoid process and extend your fingers laterally
around the ribs. Again, ask the patient to breathe
in deeply (figure A).
• To check lower lobe expansion, place the tips of
your thumbs along the patient’s back at the
spinous processes (lower thoracic level) and
extend your fingers around the ribs. Ask the
patient to breathe in deeply (Figure B).

(A)Anterior and (B) posterior placement of a
therapist’s hands on a patient’s thorax to assess
the symmetry of movement during breathing.
(From Brannon, FJ, et al:2005)

• Extent of excursion. The extent of chest mobility
can be measured by two methods.35,38
• Measure the girth of the chest with a tape
measure at three levels (axilla, xiphoid, lower
costal). The normal chest expansion is about 5cm or
more.
• Document change in girth after a maximum
inspiration and a maximum expiration
• Place both hands on the patient’s chest or back
as previously described. Note the distance
between your thumbs after a maximum

Palpation
• Palpation of the thorax provides evidence of
dysfunction of the underlying tissues including
the lungs, chest wall, and
mediastinum.11,35,38,52
• Tactile (vocal) fremitus. Tactile fremitus is the
vibration felt while palpating over the chest
wall as a patient speaks.

Palpation cont’d
• Procedure: Place the palms of your hands
lightly on the chest wall and ask the patient to
speak a few words or repeat “99” several
times.
• Normally, fremitus is felt uniformly on the
chest wall.
• Fremitus is increased in the presence of
secretions in the airways and decreased or
absent when air is trapped as the result of
obstructed airways.

Palpation cont’d
• Chest wall pain. Specific areas or points of pain
over anterior, posterior, or lateral aspects of the
chest wall can be identified with palpation.
• Procedure: Firmly press against the chest wall
with your hands to identify any specific areas of
pain potentially of musculoskeletal origin.
• Ask the patient to take a deep breath and identify
any painful areas of the chest wall.
• Chest wall pain of musculoskeletal origin often
increases with direct point pressure during
palpation and during a deep inspiration.35,38

Palpation cont’d
• N O T E : Pain in the anterior, posterior, or lateral
region of the chest can be of musculoskeletal,
pulmonary, or cardiac origin.31
• Pain of pulmonary origin is usually localized to a
region of the chest but also may be felt in the
neck or shoulder region.
• Several pulmonary or cardiac conditions can
mimic musculoskeletal pain, such as pulmonary
embolism, pleurisy, pneumonia, pneumothorax,
and pulmonary artery hypertension.31

Mediastinal shift
• The position of the trachea normally is oriented
centrally in relation to the suprasternal notch indicating
symmetry of the mediastinum.
• The position of the trachea shifts as the result of
asymmetrical intrathoracic pressures or lung volumes.
• For example, if the patient has had a pneumonectomy
(removal of a lung), the lung volume on the operated
side decreases, and the trachea shifts toward that side.
• Conversely, if the patient has a hemothorax (blood in
the thorax), intrathoracic pressure on the side of the
hemothorax increases, and the mediastinum shifts
away from the affected side of the chest.11,35,38,52

Mediastinal shift cont’d
• Procedure: To identify a mediastinal shift, have
the patient sit facing you with the head in
midline and the neck slightly flexed to relax
the sternocleidomastoid muscles.With your
index finger, gently palpate the soft tissue
space on either side of the trachea at the
suprasternal notch.
• Determine whether the trachea is palpable at
the midline or has shifted to the left or right.

Mediate Percussion
• Mediate percussion is an examination technique
designed to assess lung density, specifically, the
air-to-solid ratio in the lungs.11,35,38,52
• Procedure: Place the middle finger of the non
dominant hand flat against the chest wall along
an intercostals space.
• With the tip of the middle finger of the opposite
hand, firmly tap on the finger positioned on the
chest wall. Repeat the procedure at several points
on the right and left and anterior and posterior
aspects of the chest wall.
• This maneuver produces a resonance; the pitch
varies with the density of the underlying tissue.

Mediate Percussion cont’d
• The subjective determination of pitch indicates
the following.
• The sound is dull and flat if there is a greater than
normal amount of solid matter (tumor,
consolidation) in the lungs in comparison with
the amount of air.
• The sound is hyperresonant (tympanic) if there is
a greater than normal amount of air in the area
(as in patients with emphysema).
• If asymmetrical or abnormal findings are noted,
the patient should be referred to the physician
for additional objective tests such as a chest
radiograph.

Auscultation of Breath Sounds
• Auscultation is a general term that refers to the process of
listening to sounds within the body, specifically to breath
sounds during an examination of the lungs.11,35,38,52
• Breath sounds occur because of movement of air in the
airways during inspiration and expiration. A stethoscope is
used to magnify these sounds. Breath sounds should be
assessed to:
• Identify the areas of the lungs in which congestion exists
and in which airway clearance techniques should be
performed.
• Determine the effectiveness of any airway clearance
intervention.
• Determine whether the lungs are clear and whether
interventions should be discontinued.

Auscultation of Breath Sounds
cont’d
• Procedure: When assessing breath sounds, be sure the
setting is quiet.
• Have the patient assume a comfortable, relaxed, sitting
position to allow access to the chest wall.
• Place the diaphragm of the stethoscope directly against
the patient’s skin along the anterior or posterior chest
wall.
• Besure that the tubing does not rub together or come
in contact with clothing during auscultation, as this
contact produces extraneous sounds.
• Follow a systematic pattern (Figure A&B)

Pattern of specific thoracic landmarks for auscultation
• The diaphragm of the
stethoscope is placed along
the right and left (A) anterior
chest wall and the (B)
posterior chest wall at T2, T6,
and T10. (From Frownfelter, DL: Chest Physical Therapy
and Pulmonary Rehabilitation. Year-Book Medical Publishers,
Chicago, 1987, p 135,)
• Place the stethoscope against
specific thoracic landmarks
(T2, T6, T10) along the right
and left sides of the chest wall.
Ask the patient to breathe in
deeply and out quickly
through the mouth as you
move the stethoscope from
point to point. Note the
quality, intensity, and pitch of
the breath sounds.

P R E C A U T I O N
• Auscultate slowly from one area to another.
Allow the patient to breathe in a relaxed
manner after several deep breaths to prevent
dizziness from hyperventilation.
• Guard the patient closely to prevent loss of
balance if lightheadedness occurs.

Classification of Breath Sounds
• Breath sounds are classified by location, pitch, and intensity
as well as the ratio of sounds heard on inspiration versus
those heard on expiration.
• Breath sounds also are identified as normal or adventitious
(extra).
• Normal breath sounds occur in the absence of pathology
and are heard predominantly during inspiration.
• Normal breath sounds are categorized as vesicular,
bronchial, or bronchovesicular based on the location and
quality of the sound.
• Adventitious breath sounds are abnormal sounds in the
lungs that are heard with a stethoscope.

Classification of Breath Sounds
cont’d
• Although terminology in the literature is inconsistent, the nomenclature
used most often was proposed by a joint committee of the American
College of Chest Physicians and the American Thoracic Society.5,77
• Adventitious breath sounds are categorized as crackles or wheezes.
• Breath sounds may be totally absent or substantially diminished over a
portion of the lungs.
• This indicates total or partial obstruction and lack of aeration of lung
tissue.
• The absence of air and collapse of an area of lung tissue is known as
atelectasis.
• Obstruction of airways may be caused by fluids, mucus, bronchospasm, or
compression by tumor.
• Below is a description of the location and quality of these breath sounds

Classification of Breath Sounds cont’d

Cough and Cough Production
• The strength, depth, length, and frequency of a
patient’s cough must be assessed.
• An effective cough is sharp and deep.
• In the patient with current or potential pulmonary
dysfunction a cough can be described as weak,
shallow, soft, or throaty.
• A patient may have a weak, shallow cough as the
result of pain or paralysis.
• A sudden onset of a cough or a sustained cough
often is described as paroxysmal or spasmodic.
• If a cough is substantially weak or ineffective,
suctioning may be required to clear the
airways.11,35,52

cont’d
• A cough may be productive or nonproductive
in the presence of pathology. The productivity
of the cough and secretions produced by the
cough should be assessed. Secretions are
checked for:
• Color (clear, yellow, green, blood-stained)
• Consistency (viscous, thin, frothy)
• Amount (minimal to copious)
• Odour (no odour to foul-smelling)

cont’d
• Production of a small amount of clear or white secretions on a
daily basis is normal.
• Copious but clear secretions are common with chronic
bronchitis.
• Yellow, green, and purulent secretions with a strong odor are
indicative of some type of infection.
• A Blood-streaked secretion, known as hemoptysis, is
indicative of some degree of hemorrhage in the lungs.
• Frothy, white secretions are associated with pulmonary
edema and heart failure.
• When secretions are produced during the course of
interventions, such as exercise or airway clearance, it is the
responsibility of the therapist to document the characteristics
of the secretions.

Additional Areas of Examination
• The examination procedures described above
are complemented with other areas of
examination, which may include a patient’s
use of assistive respiratory equipment, ROM
particularly of the shoulders, neck, and trunk,
muscle strength, general endurance and
graded exercise testing, and a patient’s
identification of functional abilities or
limitations and perceived disability and quality
of life.

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