Chest physiotherapy --Definition

1. CHEST PHYSIOTHERAPY
TREATMENT(CPT)
By – Rajesh Kr.Thakur . MPT( Neuro)
Senior Physiotherapist
Department of physiotherapy
AIIMS Patna

2. Objective
• Define CPT .
• Mention of purpose of chest PT or Aims
• Indication
• Contraindication
• Complications
• Assessment for CPT
• Outcome.
• Types of techniques use for CPT
• List of the equipment need for chest PT.
• Document the procedure

3. Definition
1. Chest physiotherapy is the term for a group of
treatments designed to eliminate secretions.
2. Improve airway clearance thereby help to
improve respiratory efficiency.
3. Its helping to decrease work of breathing,
promote the expansion of the lungs.
4. Prevent the lungs from collapse.

4. The purpose of chest physiotherapy is:
To facilitate removal of retained or profuse airway secretions.
To optimize lung compliance and prevent it from collapsing.
To decrease the work of breathing.
To optimize the ventilation-perfusion ratio/ improve gas
exchange.

5. Indication
1. Inability of the patient to change body position. (e.g. mechanical ventilation,
neuromuscular disease, drug-induced paralysis).
2. Poor oxygenation associated with the position (e.g., unilateral lung disease).
3. Presence of atelectasis.
4. Presence of artificial airway.
5. Difficulty clearing secretions with expectorated sputum production greater than
25-30 mL/day (adult).

6. Indication Cont..
1. Evidence or suggestion of retained secretions in the presence of an
artificial airway.
2. Diagnosis of diseases such as cystic fibrosis, bronchiectasis, or
cavitating lung disease.
3. Presence of foreign body in the airway.
4. Patient with copious sputum or with central consolidation.

7. Contraindication
• Intracranial pressure (ICP) > 20 mm Hg
• head and neck injury until stabilized .
• Active haemorrhage with hemodynamic instability .
• Recent spinal surgery (eg, laminectomy) or acute spinal in
stabilization .
• Broncho pleural fistula.

8. Contraindication cont..
• Pulmonary edema associated with congestive heart failure
• Large pleural effusions
• Pulmonary embolism
• Rib fracture, with or without flail chest
• Patients in whom increased intracranial pressure is to be avoided
(e.g., neurosurgery, aneurysms, eye surgery)
• Uncontrolled hypertension.
• Recent gross haemoptysis related to recent lung carcinoma treated
surgically.

9. Complications
1. Hypoxemia
2. Bronchospasm
3. Increased Intracranial Pressure
4. Acute Hypotension during Procedure
5. Pulmonary Haemorrhage
6. Pain or Injury to Muscles, Ribs, or Spine
7. Vomiting and Aspiration
8. Bronchospasm
9. Dysrhythmias

10. The following should be assessed together to
establish a need for chest physiotherapy.
1. Excessive sputum production.
2. Effectiveness of cough.
3. History of pulmonary problems treated successfully with PDT
(e.g., bronchiectasis, cystic fibrosis, lung abscess).
4. Decreased breath sounds or crackles or rhonchi suggesting
secretions in the airway.
5. Change in vital signs.
6. Abnormal chest x-ray consistent with atelectasis, mucus
plugging, or infiltrates.
7. Deterioration in arterial blood gas values or oxygen saturation

11. Outcome assessment
1. Change in sputum production.
2. Change in breath sounds of lung fields.
3. Patient subjective response to therapy.
4. Change in vital signs.
5. Change in chest x-ray.
6. Change in arterial blood gas values or oxygen saturation.
7. Change in ventilator variables
8. Change in Modified borg scale- dyspnea level.
9. Change in Peak Expiratory Flow Rate.

12. Types of techniques use for CPT
• Airway clearance techniques
• Facilitating airway clearance technique with effective coughing tech.
• Techniques to facilitate ventilation pattern.
• Mobilization and therapeutic exercise.

13. Airway clearance techniques
• Postural drainage
• Percussion
• Vibration/shaking
• Manual hyperinflation
• Active cycle of breathing technique
• Autogenic drainage
• Positive expiratory pressure
• High frequency chest compression
• Therapeutic exercises for airway clearance .

14. Postural drainage(Segmental)

15. Percussion
Percussion over an affected area produces an energy wave, which is
transmitted to the lungs and airways. It is performed with the aim of
loosening thick, sticky or retained secretions from the chest wall.
Percussion can be performed in two ways-
I. Manual Percussion
II. Mechanical Percussion
Rate of percussion, 100-480 times/min.

16. Preparation For Percussion
• Patient should be in a comfortable or painless position to enhance
the effect.
• The technique is applied over a thin towel to ensure it does not feel
uncomfortable. Too thick padding may absorb the percussion without
having any benefit to the patient.
• Adjust bed level to ensure proper body mechanics.
• Therapist should try to keep shoulders, elbows and wrist relaxed
during the manoeuvre.
• Duration: Several minutes or until the patient needs to alter the
position to cough

17. Vibration/shaking
• Vibrations are a manual technique used to help clear secretions
(phlegm) from the chest.
• The technique tends to be applied on expiration (breathing out), and
involves the physiotherapist using both hands to vibrate the lower
chest wall in order to loosen secretions and allow them to be
coughed out.

18. Manual hyperinflation
• Manual hyperinflation is used to increase lung volumes and aid
secretion clearance when used in conjunction with suctioning.
• Manual hyperinflation involves the use of a manual resuscitator bag
(MRB) connected to oxygen to provide a slow, deep inspiratory breath
followed by an inspiratory pause of 1-2 seconds, and a rapid release
of the resuscitation bag .

19. Manual hyperinflation
• Manual hyperinflation is used to manage atelectasis The mechanism
it is thought to work is by increasing alveolar recruitment.
• The squeezing of the resuscitation bag increases the baseline tidal
volumes during inspiration by approximately 1L.
• This increase in tidal volume plus inspiratory hold allows time for
alveoli and collateral airways to open, thereby increasing lung
compliance and reducing atelectasis.

20. Active cycle of breathing technique
Active Cycle of Breathing Techniques (ACBT) is an active breathing
technique performed by the patient and can be used to mobilise and
clear excess pulmonary secretions and to generally improve lung
function.
ACBT consists of three main phases:
I. Breathing Control
II. Deep Breathing Exercises or Thoracic Expansion Exercises
III. Huffing or Forced Expiratory Technique (FET)

22. Autogenic drainage
a. Autogenic Drainage (AD), is an airway clearance technique that is
characterised by breathing control, where the individual aims to
adjust the rate, depth, and location of lung volumes during
respiration.
b. AD is based on a series of physiological principles believed to
enable the patient to achieve an independent airway clearance
regimen that is adapted to their individual pathology and
pulmonary function.
c. Autogenic drainage was developed in Belgium in the late 1960s by
Chevaillier. During 1980's, it was utilized throughout Europe to treat
asthmatic patients who had suffered retention of secretions in the
chest and difficulty in clearing the secretions.

24. Positive Expiratory Pressure /PEP Devices
The increase in pressure is transmitted to airways creating back
pressure stenting them during exhalation , preventing premature
airway closure and reducing gas trapping.
I. Promotes collateral ventilation.
II. Allowing pressure to build up distal to the obstruction.
III. Retains airways from collapsing and prolongs expiratory flow.
IV. Effective airway clearance promotes movement of mucus
proximally .
Acapella

25. High frequency chest compression
High-frequency chest wall oscillation (HFCWO) is an airway clearance
technique in which external chest wall oscillations are applied to the
chest using an inflatable vest that wraps around the chest.
These machines produce vibrations at variable frequencies and
intensities, helping to loosen and thin mucus and separate it from
airway walls.

26. Therapeutic exercises for airway clearance
• Diaphragmatic breathing pattern
• Segmental expansion
• Glossopharyngeal breathing (GBP), also known as “frog breathing
• Push Lip breathing

28. It was this gulping action that gave the technique the name
frog breathing
1.Mouth opens oral pharynx filled with air
2.Mouth closes air trapped in the oral
pharynx
3.Mouth remain closed and forces the air
back to the open glottis and then into the
lungs
4.Glottis closed and air is trapped in the
lungs

29. Push Lip breathing
• The patient should assume a comfortable position as the therapist
describes and demonstrates the technique for PLB and explains its
expected benefits.
• With a hand on the patient’s mid abdominal muscles, the therapist
instructs the patient to inhale slowly through the nose
• The patient is then told to let the air escape gently through the pursed lips,
avoiding excessive use of the abdominal muscles. Giving the patient a
verbal cue, such as “imagine you want to make the flame flicker on a
candle that is being held at arm’s length from you,” will enhance the
patient’s understanding and performance.
• The patient is directed to stop exhaling when an abdominal contraction is
detected.[
• When able to perform PLB without cues, the patient substitutes their own
hand for the therapist’s hand

31. Techniques to facilitate ventilation
pattern(PNF)
• Neurophysiological Facilitation of Respiration is a treatment
technique used for respiratory care of patients with unconscious or
non-alert, and ventilated, and also with a neurological condition.
• NPF is the use of external proprioceptive and tactile stimuli that
produce reflex respiratory movement responses and that increase the
rate and depth of breathing.

32. There are six techniques used in the NPF
• Perioral pressure
• Intercostal stretch
• Thoracic vertebral pressure
• Co-contraction of the abdomen
• Applied manual pressure
• Anterior stretch-lifting of the posterior basal area (Basal Lift)

33. Incentive Spirometry
• The purpose of incentive spirometry is to facilitate a sustained slow
deep breath.
• Incentive spirometry is designed to mimic natural sighing by
encouraging patients to take slow, deep breaths.
• Incentive spirometry is performed using devices which provide visual
cues to the patients that the desired flow or volume has been
achieved.

34. Incentive Spirometry
• The basis of incentive spirometry involves having the patient take a
sustained, maximal inspiration (SMI).
• An SMI is a slow, deep inspiration from the Functional Residual
Capacity up to the total lung capacity, followed by ≥5 seconds breath
hold.

36. List of equipment needed for CPT
• Positive Expiratory Pressure (PEP) device.
• High Frequency Chest Wall Oscillation (HFCWO) device.
• Oral High Frequency Oscillation (OHFO) device.
• Intrapulmonary Percussive Ventilation (IPV) device.
• Incentive Spirometry (I.S.) device.
• Flutter Device.
• Acapella device.
• Cornet device. etc

38. References
• ennifer A. Prayor & Barbara A. Webber. Physiotherapy for Respiratory
and cardiac problems. 2nd edition. Churchill Livingstone. 1998