The document discusses chest physiotherapy techniques which are used to mobilize secretions in the lungs through external maneuvers like percussion, postural drainage, and vibration. It explains the indications for chest physiotherapy in patients with excessive secretions or ineffective cough from conditions like cystic fibrosis or pneumonia. The techniques involve positioning patients and using cupped hands to clap or vibrate the chest wall to loosen mucus so it can be coughed up.

1. Chest physiotherapy

3. DEFINITION
 Chest physiotherapy (CPT) is a
technique used to mobilize or
loose secretions in the lungs and
respiratory tract.
 This is especially helpful for patients
with large amount of secretions or
ineffective cough.

4.  Chest physiotherapy consists of
external mechanical maneuvers, such
as chest percussion, postural
drainage, vibration, to augment
mobilization and clearance of airway
secretions, diaphragmatic breathing
with pursed-lips, coughing and
controlled coughing.

5.  Physiology of Respiration
 INHALATION
 Inhalation is initiated by the diaphragm and
supported by the external intercostal muscles.
 Normal resting respirations are 10 to 18 breaths
per minute. Its time period is 2 seconds.
 Inhalation is primarily driven by the diaphragm and
accessory muscles.
 When the diaphragm contracts, the ribcage expands
and the contents of the abdomen are moved
downward.
 This results in a larger thoracic volume, which in
turn causes a decrease in intrathoracic pressure.
 As the pressure in the chest falls, air moves into the
conducting zone. Here, the air is filtered, warmed,
and humidified as it flows to the lungs

6.  EXHALATION
 Exhalation is generally a passive process,
however active or forced exhalation is
achieved by the abdominal and the internal
intercostal muscles.
 The lungs have a natural elasticity; as they
recoil from the stretch of inhalation, air flows
back out until the pressures in the chest and
the atmosphere reach equilibrium.
 During forced exhalation, as when blowing
out a candle, expiratory muscles including
the abdominal muscles and internal
intercostal muscles, generate abdominal and
thoracic pressure, which forces air out of the
lungs.

7.  GAS EXCHANGE
 The major function of the respiratory
system is gas exchange.
 Upon inhalation, gas exchange occurs
at the alveoli, the tiny sacs which are
the basic functional component of the
lungs.
 The alveolar walls are extremely thin,
and are permeable to gases.
 The alveoli are lined with pulmonary
capillaries, the walls of which are also
thin enough to permit gas exchange.

8.  All gases diffuse from the alveolar air to the
blood in the pulmonary capillaries, as
carbon dioxide diffuses in the opposite direction,
from capillary blood to alveolar air.
 Now, the pulmonary blood is oxygen-rich, and the
lungs are holding carbon dioxide.
 Exhalation follows, thereby ridding the body of
the carbon dioxide and completing the cycle of
respiration.
 In an average resting adult, the lungs take up
about 250ml of oxygen every minute while
excreting about 200ml of carbon dioxide.
 During an average breath, an adult will exchange
from 500 ml to 700 ml of air.
 This, average breath capacity is called tidal
volume.

9. Indications of Chest Physiotherapy
 It is indicated for patients in whom
cough is insufficient to clear thick,
tenacious, or localized secretions.
Examples include:
 Cystic fibrosis
 Bronchiectasis
 Atelectasis
 Lung abscess
 Neuromuscular diseases
 Pneumonias in dependent lung regions.

10. Contraindications of Chest
Physiotherapy
 Increased ICP
 Unstable head or neck injury
 Active hemorrhage with hemodynamic instability or
hemoptysis
 Recent spinal injury or injury
 Empyma
 Bronchoplueral fistula
 Rib fracture
 Fail chest
 Uncontrolled hypertension
 Anticoagulation
 Rib or vertebral fractures or osteoporosis.

11. ASSESSMENT FOR CHEST
PHYSIOTHERAPY
 Nursing care and selection of CPT skills are
based on specific assessment findings.

12. The following are the
assessment criteria:
 Know the normal range of patient’s vital
signs.
 Conditions requiring CPT, such atelectasis,
and pneumonia, affects vital signs.
 Know the patient’s medications.
particularly diuretics antihypertensive
cause fluid and hemodynamic changes.
 These decrease patient’s tolerance to
positional changes and postural drainage.

13.  Know the patient’s medical history;
certain conditions such as increased ICP,
spinal cord injuries and abdominal
aneurysm resection, contra indicate the
positional change to postural drainage.
 Thoracic trauma and chest surgeries also
contraindicate percussion and vibration.

14.  Know the patient’s cognitive level of
functioning. Participating in controlled
cough techniques requires the patient
to follow instructions.
 Beware of patient’s exercise
tolerance. CPT maneuvers are
fatiguing.
 Gradual increase in activity and
through CPT, patient tolerance to the
procedure improves.

15. Clinicalfindingsandinvestigations
 Detailed History
 Physical examination
 Inspection
 Palpation
 Percussion
 Auscultation
 Investigations
 X-ray
 Blood investigations-bleeding and clotting
parameters

16. TECHNIQUESIN CHEST PHYSIOTHERAPY:
 A nurse or respiratory therapist may administer CPT,
although the techniques can often be taught to family
members of patients.
 The most common procedures used are postural
drainage and chest percussion, in which the patient is
rotated to facilitate drainage of secretions from a
specific lobe or segment while being clapped with
cupped hands to loosen and mobilize retained
secretions that can then be expectorated or drained.
 The procedure is somewhat uncomfortable and tiring
for the patient.

17.  PERCUSSION
 Chest percussion involves striking the
chest wall over the area being drained.
 Percussing lung areas involves the use
of cupped palm to loosen pulmonary
secretions so that hey can be
expectorated with ease.
 Percussing with the hand held in a rigid
dome-shaped position, the area over the
lung lobes to be drained in struck in
rhythmic pattern.
 Usually the patient will be positioned in
supine or prone and should not
experience any pain.

18.  Cupping is never done on bare skin or
performed over surgical incisions, below
the ribs, or over the spine or breasts
because of the danger tissue damage.
 Typically, each area is percussed for 30 to
6oseconds several times a day.
 If the patient has tenacious secretions,
the area must be percussed for 3-5
minutes several times per day. Patients
may learn how to percuss the anterior
chest as well.

19.  2. Vibration
 In vibration, the nurse uses rhythmic
contractions and relaxations is or her arm
and shoulder muscles while holding thee
patient flat on the patient’s chest as the
patient exhales.
 The purpose is to help loosen respiratory
secretions so that they can be expectorated
with ease. Vibration (at a rate of 200 per
minute) can be done for several times a day.

20.  To avoid patient causing discomfort,
vibration is never done over the patient’s
breasts, spine, sternum, and rib cage.
 Vibration can also be taught to family
members or accomplished with
mechanical device.

23. PROCEDURE:
 Percussion & Vibration
 Instruct the patient use diaphragmatic breathing
 Position the patient in prescribed postural drainage
positions. Spine should be straight to promote rib
cage expansion
 Percuss or clap with cupped hands or chest wall for
5 minutes over each segment for 5 minutes for cystic
fibrosis and 1-2 minutes for other conditions
 Avoid clapping over spine, liver, spleen, breast,
scapula, clavicle or sternum
 Instruct the patient to inhale slowly and deeply.
Vibrate the chest wall as the patient exhales slowly
through the pursed lips.

24.  Place one hand on top of the other affected
over area or place one hand place one and on
each side of the rib cage.
 Tense the muscles of the hands and hands
while applying moderate pressure downward
and vibrate arms and hands
 Relieve pressure on the thorax as the patient
inhales.
 Encourage the patient cough, using abdominal
muscles, after three or four vibrations.

25.  Allow the patient rest several times
 Listen with stethoscope for changes in
breath sounds
 Repeat the percussion and vibration
cycle according to the patient’s tolerance
and clinical response: usually 15-30
minutes.