Lab #6

Airway clearance Therapy

Chest physiotherapy
(CPT) is a group of therapies used in combination to mobilize pulmonary secretions. These therapies include postural
drainage, chest percussion, and vibration. CPT should be followed by Productive coughing or suctioning.

Postural Drainage

Postural drainage is specific positions that allow the force of gravity to assist in the removal of bronchial secretions. The
secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or Suctioning.

Equipment: gloves , stethoscope, towel , pillow, electric bed ,Sputum container .

Procedure:

1. Hand washing and wear gloves

2. Coordinate therapy before meals and tube feedings .
3. Introduce yourself to the “patient” and explain the procedure.
4. Assess the “patient” before therapy. Assessment should include the following: Pulse,
Respirations , Spo2, Blood pressure , Chest symmetry and expansion using palpation , Color
Level of dyspnea , level of consciousness
5. Auscultation the chest before the procedure To identify the areas needing to drainage .
6. Place the “patient” in each of the positions for drainage. Use pillows to support the “patient”
where necessary. Begin with the most dependent segments fist.

NOTE: In an actual clinical situation, the patient would remain in each position for a minimum of 3 to
15 minutes as tolerated for drainage.In special circumstances, the patient may remain in drainage
positions for longer periods of time.

7. Allow the “patient” to sit up and cough after each position. The “patient” may not produce
sputum immediately. The practitioner may need to check back with the “patient” at a later time
to determine any sputum production after the treatment.
8. Reassess the “patient’s” tolerance in each position by evaluating the following: Pulse ,
Respirations Spo2 Blood pressure Color , Level of dyspnea Level of Consciousness
9. Note the volume, consistency, color, and presence or absence of blood in the sputum. Note
which positions are most productive.
IDENTIFICATION OF LUNG LOBES AND SEGMENTS

• Right Lung 3 lobes / left lung 2 lobes.

1.Anterior apical segments of the right and left upper lobes

a. Position the patient sitting and leaning back at about a 45° angle .

b. Area to percuss is just below the clavicle.

2. Posterior apical segments of the right and left upper lobes a. Position the patient sitting and
leaning forward at about a 45° angle

b. Area to percuss is just above the scapula with the fingers extending up onto the shoulders.

3. Anterior segments of the right and left upper lobes

a. Position the patient supine with the bed flat.

B. Area to percuss is just above the nipple.

4. Posterior segment of the left upper lobe

a. Position the patient one-quarter turn from prone and resting on the right side with the head of the
bed elevated 18 inches.

b. Area to percuss is over the left scapula.

5. Posterior segment of the right upper lobe

a. Position the patient one-quarter turn from prone and resting on the left side with the bed flat.

B. Area to percuss is just above the right scapula.

6. Left lingula

a. Position the patient one-quarter turn from supine and resting on the right side with the foot of the
bed elevated 12 inches.

b. Area to percuss is just above the left nipple and under the armpit.
7. Right middle lobe

a. Position the patient one-quarter turn from supine with the foot of the bed elevated 12 inches.

b. Area to percuss is just above the right nipple and under the armpit.

8. Anterior basal segments of the right and left lung ( lower lobe ) .

a. Position the patient supine with the foot of the bed elevated 18 to 20 inches.

b. Area to percuss is over the lower ribs.

9. Posterior basal segments of the right and left lung

a. Position the patient prone with the foot of the bed elevated 18 to 20 inches.

b. Area to percuss is over the lower ribs.

10. Left lateral segment of the lower lobes

a. Position the patient on the right side with the foot of the bed elevated 18 to 20 inches.

b. Area to percuss is over the lower ribs.

11. Right lateral segment of the lower lobes

a. Position the patient on the left side with the foot of the bed elevated 18 to 20 inches.

b. Area to percuss is over the lower ribs.

12. Superior segments of the right and left lower lobes

a. Position the patient prone with the bed flat.

B. Area to percuss is just below the lower margin of the scapula.

Note :

o If prescribed, bronchodilators, water or saline may be nebulized and inhaled before postural
drainage , To reduce bronchospasm, decrease thickness of mucus And sputum.

o Performed the postural drainage two to four times daily, before feedings to prevent nausea,
vomiting, and aspiration.
o explains how to cough and remove secretions. If the patient cannot cough, the RT may need to
suction the secretions mechanically.
o The RT use chest percussion and vibration To loosen bronchial secretions and mucus that
Adheres to the bronchioles Bronchi And In the Direction Of Gravity Drainage.
 o instructs the patient to remain in each position for 3 to 15 minutes and to breathe in slowly
through the nose and then breathe out slowly through pursed lips To help keep the airways
open so that secretions can drain while in each position.
o Auscultation the chest after the procedure To assess the effectiveness of treatment.

Chest Percussion and Vibration

o The thick secretions that are difficult to cough up may be loosened by tapping (percussing) and
vibrating the chest. Chest percussion and vibration help to dislodge mucus adhering to the
bronchioles and bronchi.
o Notes: - percussion over chest drainage tubes, the sternum, spine, liver, kidneys, spleen, or
breast (in women) is avoided.
o Percussion is performed cautiously in the elderly because of their increased incidence of
osteoporosis and risk of rib fracture.

Percussion technique :

1. Remove your jewelry and wash your hands. Apply BSI

2. Cup your hands and allow for relaxed motion from the wrist. Do not stiffen your upper arms.
Rhythmically strike the designated area, alternating hands.

3. Practice first on your thigh. Listen for a hollow “clapping” or “galloping” sound. This sound should
be audible to someone not in the room, but should not cause pain or discomfort.

4. Position the “patient” for postural drainage (any position may be used for this exercise).

5. Perform chest percussion on the “patient” for at least 3 minutes.

Remember the following precautions:

A. Do not percuss over any buttons, zippers, or similar items that the subject may have on.

B. Do not percuss on bare skin. On an actual patient, use a towel or sheet over the patient’s skin.

C. Avoid bony processes. Do not percuss on the spine, on clavicles, on scapulae, on breast tissue,
over areas of incisions, over areas of rib fractures, or below the rib margins.

6. Repeat the procedure using a mechanical percussion device (Fig. 17.7). Vary the speed and force to
observe the effects.
7. Repeat the procedure using percussion cups (Fig. 17.8), one in each hand. Small sizes are available
for children and infants, or a small face mask may be used by sealing the opening with tape.

Vibration technique

1.Remove jewelry and wash your hands. Apply BSI

2. Place the “patient” in any position for postural drainage in which he or she is lying down.

3. Place one hand over the other on the area to be vibrated, as shown in Figure 17.9.

4. Instruct the “patient” to take a deep breath and exhale slowly through pursed lips.
5. Apply a gentle vibrating motion during exhalation only. Your upper arm muscles should tighten and
allow transmission of the vibration to your hands. Do not shake the “patient.” Repeat the vibration
technique two or three times for each segment.

o Applying manual compression and tremor to the chest wall during the exhalation phase of
respiration.
o To increase the velocity of the air expired from the small airways. Thus freeing the mucus
o After three or four vibrations, the patient is encouraged to cough, using the abdominal muscles
Contracting the abdominal Muscles Increases Effectiveness of the cough.
o The number of times percussion and vibration cycle is repeated depends on the patient The
Tolerance and clinical response.
o Evaluate breath sounds after the Procedures.

NOTE :

• When performing chest physiotherapy, ensures that the patient is comfortable, is not wearing
restrictive clothing, and has not just feeding. gives medication for pain, as prescribed, before
percussion and vibration and splints any incision and provides pillows for support as needed.
• The positions are varied, but focus is placed on the affected areas. The uppermost areas of the
lung are treated first.
• On completion of the treatment, assists the patient to assume a comfortable position.
• stop treatment if any of the following occur: increased pain, increased shortness of breath,
weakness, light headedness, or hemoptysis.

DIRECTED COUGH
 COUGH INSTRUCTION

1. Wash your hands and apply BSI

2. Introduce yourself to the “patient” and explain the purpose of an adequate cough effort.

3. Have the “patient” sit up in a chair or on the bed or table. Patients who cannot tolerate a sitting
position can use a side-lying position with knees bent (Fig. 18.2).

4. Instruct the “patient” to take a deep breath, followed by a slight breath hold, then a cough. Have
tissues and a waste receptacle readily available. Note the volume, consistency, color, and presence
or absence of blood in any sputum expectorated.

5. Using a pillow or your hands, instruct the “patient” on splinting of any painful areas.Apply gentle
pressure over the involved area before deep inspiration, and increase pressure slightly during the
forced expiratory phase of the cough. Use standard precautions and transmission-based isolation
procedures as appropriate.

COUGH ALTERNATIVES

Some patients do not have the capacity or tolerance for a single forceful cough. You can teach these
patients alternative methods to improve cough effectiveness, compensate for physical limitations, and
provide voluntary control over the cough reflex

1. Wash your hands. Apply BSI .

2. Introduce yourself to the “patient” and explain the purpose of the procedure. Have tissues and a
waste receptacle readily available.

3. Instruct the “patient” in serial coughing techniques. Have the “patient” take a moderately deep
breath, followed by a slight breath hold. Then perform two or three short coughs, one after another.
Rest and repeat the procedure.

4. Instruct the “patient” in a forced expiratory technique (FET), or huffing maneuver.

A. Have the “patient” take a moderately deep breath, followed by a short breath hold. Then perform
three short forced exhalations with an open glottis. The “patient” should make a huffing or “Ha ha ha”
sound on exhalation. Follow this with a period of relaxed, controlled diaphragmatic breathing.

B. This can be assisted by self-compression of the chest wall by using a brisk adduction movement of
the upper arms1 also known as a “chicken breath,” as shown in Figure 18.3.

5. You can improve the cough effort by providing a manually assisted cough using epigastric pressure
or external lateral compression of the thoracic cage2 (Fig. 18.4).

A. Instruct the “patient” to take a moderately deep breath, followed by a short breath hold. Apply
gentle pressure to the epigastric region coordinated with the “patient’s” cough effort, making sure to
avoid the xiphoid area. This should not be done after meals.

B. Instruct the “patient” to take a moderately deep breath, followed by a short breath hold. Apply
pressure to the lateral thoracic cage coordinated with the “patient’s” cough effort.

NOTE: In a patient with a tracheostomy, a manual resuscitator bag can provide assisted deep
inspiration in conjunction with manually assisted cough techniques, as shown in Figure 18.5.

VIBRATORY POSITIVE EXPIRATORY PRESSURE (PEP) THERAPY

PEP mask therapy is a possible adjunct or alternative to postural drainage and percussion techniques
for bronchial hygiene.3,4 Many devices are now on the market to create vibratory PEP, reverse
atelectasis, and promote secretion removal.

EXERCISE 18.21 COMPARE VIBRATORY PEP DEVICES

1. Obtain the following devices: FLUTTER® valve (Fig. 18.6) PEP mask valve (Fig. 18.7) TheraPEP®
device (Fig. 18.8) acapella® device (Fig. 18.9)
2. Assemble each device and compare the components of each.

VIBRATORY PEP THERAPY

1. Obtain a PEP device and set it up with the pressure manometer in line.

2. Wash your hands and apply BSI

3. Introduce yourself to the “patient” and explain the purpose of the procedure.

4. Assess the “patient’s” vital signs, mental function, skin color, and breath sounds.

5. Adjust the fixed exhalation orifice to the largest setting.

6. Have the “patient” sit upright with his or her elbows resting comfortably on a table.

7. Place the mask comfortably but tightly over the nose and mouth or adjust nose clips and
mouthpiece.

8. Instruct the “patient” to take a larger than normal breath (but not to total lung capacity) and exhale
slowly at an I:E ratio of 1:3 or 1:4.

9. Observe the pressure generated on the manometer during exhalation. Decrease the size of the fixed
orifice until 10 to 20 cm H2O pressure is generated during exhalation. Note the “patient’s” response.

10. Instruct the “patient” to take 10 to 20 breaths followed by two or three huffs (FET). In an actual
clinical situation, this procedure would be repeated four to eight times for 10 to 20 minutes. Reassess
the “patient” periodically.

11. Note the quantity, color, and consistency of any sputum expectorated. Note the presence or
absence of blood.
BREATHING EXERCISES

1 .Wash your hands and apply BSI

2. Introduce yourself, and explain the procedure to the “patient.”

3. Instruct the “patient” on the pursed-lip breathing technique (Fig. 18.10).

A. Have the “patient” take a deep breath through his or her nose.

B. Instruct the “patient” to exhale through pursed lips with a slow, steady exhalation at an I:E ratio of
at least 1:3.

4. Instruct the “patient” in abdominal breathing techniques.

A. Have the “patient” lie down. For initial instruction, a slight Trendelenburg position is recommended.

B. Place one hand on the “patient’s” epigastric area and one hand on the upper chest, as shown in
Figure 18.11.

C. Ask the “patient” to sniff or pant to feel diaphragmatic movement.

D. Instruct the “patient” to take a slow, deep breath through the mouth and exhale through pursed
lips. Apply firm pressure during inspiration. The “patient” should push your hand away by protruding
the abdomen. The upper chest and shoulders should expand but not move up.

E. Replace your hands with a light book or other object, and instruct the “patient” to practice moving
the book up on inspiration. A bag of rice or birdseed may be used for this exercise.

F. The “patient” can eventually repeat the procedure in a more elevated position as tolerated while
sitting and walking, as shown in Figures 18.12, 18.13, and 18.14.

The following relaxation techniques and exercises can be practiced at home on yourself or with a
partner as the patient.

5. Have the “patient” lying in bed with head flexed slightly forward, thoracic spine straight, shoulders
rotated inward slightly, elbows flexed, and hips and knees flexed.

6. Instruct the “patient” to perform the following maneuvers. The “patient” should close his or her
eyes, take slow breaths, and attempt to relax the body part while holding each position for a count of
10.
INSPIRATORY-RESISTIVE MUSCLE TRAINING

1 .Wash your hands And Apply BSI

2. Set up the device as shown in Figure 18.15 or Figure 18.16. A flow-resistive or thresholdresistive
device may be used.

3. Measure the “patient’s” maximum inspiratory pressure using a pressure manometer.

4. Select the inspiratory-resistive device (colored caps or dial selector) with the largest opening and
apply it to the inspiratory port.

5. Attach the pressure manometer in line to the monitoring adaptor.

6. Place nose clips comfortably on the “patient’s” nose.

7. Have the “patient” make a tight seal around the mouthpiece.

8. Instruct the “patient” to inhale and exhale slowly through the mouthpiece.

9. Note the manometer pressure during inspiration. Adjust the inspiratory-resistive orifice until you are
using the resistor that achieves 30% of the “patient’s” MIP effort.

10. In a clinical situation, this would be repeated for 15 minutes twice daily.

Thank You