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ASSIGNMENT
ON
CHEST PHYSIOTHERAPY

Submitted by, submitted to,

Mrs Gayathri R Mrs Sumitha

1st Year MSc Nursing Senior Lecturer

Upasana college of Upasana college of

Nursing Kollam Nursing Kollam

Submitted on:03.12.2018
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INTRODUCTION

Chest physiotherapy (CPT) is the treatments generally performed by physical

therapists and respiratory therapists, whereby breathing is improved by the indirect
removal of mucus from the breathing passages of a patient. Other terms, used in
Australia, include respiratory or cardiothoracic physiotherapy.

CONTENT
CHEST PHYSIOTHERAPY
Chest physiotherapy (CPT) is the treatments generally performed by physical
therapists and respiratory therapists, whereby breathing is improved by the indirect
removal of mucus from the breathing passages of a patient. Other terms, used in
Australia, include respiratory or cardiothoracic physiotherapy. CPT includes
postural drainage, chest percussion, vibration & breathing training. In addition,
teaching the patient effective coughing technique is an important part of CPT. The
goals of CPT are to remove bronchial secretions, improve ventilation, and increase
the efficiency of the respiratory muscles.

Definition
Chest physical therapy is the term for a group of treatments designed to improve
respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles,
and eliminate secretions from the respiratory system.

Purpose
The purpose of chest physical therapy, also called chest physiotherapy, is to help
patients breathe more freely and to get more oxygen into the body. Chest physical
therapy includes postural drainage, chest percussion, chest vibration, turning, deep
breathing exercises, and coughing. In the early 2000s, some newer devices, such as
the positive expiratory pressure (PEP) valve and the flutter device, have been added
to the various chest physical therapy techniques. Chest physical therapy is normally
done in conjunction with other treatments to rid the airways of secretions. These other
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treatments include suctioning, nebulizer treatments, and the administering

expectorant drugs.

Description
Good respiratory health is not possible without efficient clearance of secretions in
the airway. In a healthy person, this is normally accomplished through two
mechanisms: the mucociliary clearance system (MCS) and the ability to cough .
There are many diseases and disabilities in children linked with poor lung health and
an impaired ability to clear secretions. These include cystic fibrosis, asthma,
cerebral palsy, muscular dystrophy , and various immunodeficiency disorders.
When a child is unable to clear mucus, breathing becomes hard work. He or she must
expend extra effort and energy in order to get oxygen. This difficulty can lead to
a vicious cycle of recurrent episodes of inflammation, respiratory infections, lung
damage, increased production of excess mucus, and possibly airway obstruction.
Chest physical therapy is one way to reduce the risks of an inefficient clearance of
airway secretions. Depending on the specific technique and health situation, chest
physical therapy may be used on children from newborns to adolescents.

Various Methods
Various methods of chest physical therapy have been used since the early 1900s to
help manage airway clearance disorders. The techniques have been refined since that
time. The procedure may be performed by a respiratory therapist, a nurse, or a
trained family member. However, chest physical therapy presents some challenges
and requires skill and training in order to be safely and effectively performed.
Chest physical therapy is a method of clearing the airway of excess mucus. It is based
on the theory that when various areas of the chest and back are percussed, shock
waves are transmitted through the chest wall, loosening the airway secretions. If the
child is positioned appropriately, the loosened secretions will then drain into the upper
airways, where they can then be cleared using coughing and deep breathing
techniques. The following techniques are all part of chest physical therapy.

Turning
Turning from side to side permits lung expansion. The child may turn on his or her
own, or be turned by a caregiver. Turning should be done at a minimum of every two
hours if the child is bedridden. The head of the bed can also be elevated in order to
promote drainage.

Coughing
Coughing helps to break up secretions in the lungs so that the mucus can be
expectorated or suctioned out if necessary. Patients sit upright and inhale deeply
through the nose. They then exhale in short puffs or coughs. This procedure is
repeated several times a day.

Deep breathing
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Deep breathing helps expand the lungs and forces an improved distribution of the air
into all sections of the lungs. The patient either sits in a chair or sits upright in bed and
inhales then pushes the abdomen out to force maximum amounts of air into the lung.
The abdomen is then contracted, and the patient exhales. Deep breathing exercises
are done several times each day for short periods.
Because of the mind-body awareness required to perform coughing and deep
breathing exercises, they are unsuitable for most children under the age of eight.

Postural drainage
Postural drainage uses the force of gravity to assist in effectively draining secretions
from the smaller airways into the central airway where they can either be coughed up
or suctioned out. The child is placed in a head- or chest-down position and is kept in
this position for up to 15 minutes. To obtain the head-down positions, the use of a
pillow, beanbag chair, or couch cushions can be helpful. Often, percussion and
vibration are performed in conjunction with postural drainage.

Percussion
Percussion involves rhythmically striking the chest wall with cupped hands. It is also
called cupping or clapping. The purpose of percussion is to break up thick secretions
in the lungs so they can more easily be removed. Percussion is performed on each
lung segment for one to two minutes at a time. Mechanical percussors are available
and may be suitable for children over two years of age. The percussor is moved over
one lobe of the lung for approximately five minutes, while the patient is encouraged to
performing coughing and deep breathing techniques. This process is repeated until
each segment of the lung is percussed.

Vibration
As with percussion, the purpose of vibration is to help break up lung secretions.
Vibration can be either mechanical or manual. It is performed as the patient breathes
deeply. When done manually, the person performing the vibration places his or her
hands against the patient's chest and creates vibrations by quickly contracting and
relaxing arm and shoulder muscles while the patient exhales. The procedure is
repeated several times each day for about five exhalations.

Positive expiratory pressure (PEP)

PEP therapy has been extensively tested and is equivalent to standard chest physical
therapy. It is an airway clearance method that is administered by applying a
mechanical pressure device to the mouth. By breathing out with a moderate force
through the resistance of the device, a positive pressure is created in the airways that
helps to keep them open. This positive pressure permits airflow to reach beneath the
areas of mucus obstruction and to move the mucus toward the larger airways where
it can be expectorated. This technique may be suitable for alert, cooperative children
over the age of four.

Flutter
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 The flutter valve is a hand-held mucus clearance device designed to combine

positive expiratory pressure (PEP) with high frequency airway oscillations. The
device looks like a pipe containing an inner cone that cradles a steel ball sealed
with a perforated cover. Exhalation through the device results in a vibration of
the airway walls, which in turn loosens secretions. It may be a suitable
technique for children aged five years and over.

A child is considered to have responded positively to chest physical therapy if some,

but not necessarily all, of the following changes occur:

 increased volume of sputum secretions

 changes in breath sounds
 improved chest x ray
 increased oxygenation of the blood as measured by arterial blood gas sampling
 the child's report of increased ease in breathing

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
 Atelctasis
 Lung abscess
 Neuromuscular diseases
 Pneumonias in dependent lung regions.

Contraindications of Chest Physiotherapy

1. Increased ICP
2. Unstable head or neck injury
3. Active hemorrhage with hemodynamic instability or hemoptysis
4. Recent spinal injury or injury
5. Empyma
6. Bronchoplueral fistula
7. Rib fracture
8. Fail chest
9. Uncontrolled hypertension
10. Anticoagulation
11. Rib or vertebral fractures or osteoporosis
12. Assessment for Chest Physiotherapy
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Nursing care and selection of CPT skills are based on specific

assessment findings.

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. Certain medications, particularly

diuretics antihypertensive cause fluid and haemodynamic changes.
These decrease patient’s tolerance to positional changes and postural
drainage.

 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.

 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.

Clinical findings and investigations

 Detailed History
 Physical examination
 Inspection
 Palpation
 Percussion
 Auscultation
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Investigations

 X-ray
 Blood investigations-bleeding and clotting parameters

Techniques in 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.

1. 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.

 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 o
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.
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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.
 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.

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.

 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.
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 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.

3. Postural Drainage

 Postural drainage is the positioning techniques that drain secretions

from specific segments of the lugs and bronchi into the trachea.

 Because some patients do not require postural drainage for all lung
segments, the procedure must be based on the clinical findings.

 In postural drainage, the person is tilted or propped at an angle to help

drain secretions from the lungs.

 Also, the chest or back may be clapped with a cupped hand to help
loosen secretions—the technique called chest percussion.

Postural drainage cannot be used for people who are:

 unable to tolerate the position required,

 are taking anticoagulation drugs,

 have recently vomited up blood,

 have had a recent rib or vertebral fracture, or

 have severe osteoporosis.

 Postural drainage also cannot be used for people who are unable to
produce any secretions (because when this happens, further attempts
at postural drainage may lower the level of oxygen in the blood).

Procedure

 The patient's body is positioned so that the trachea is inclined downward

and below the affected chest area.
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 Postural drainage is essential in treating bronchiectasis and patients

must receive physiotherapy to learn to tip themselves into a position in
which the lobe to be drained is uppermost at least three times daily for
10-20 minutes.

 The treatment is often used in conjunction with the technique for

loosening secretions in the chest cavity called chest percussion.

Articles required

 Pillows
 Tilt table
 Sputum cup
 Paper tissues

Steps

 Use specific positions so the force of gravity can assist in the removal of
bronchial secretions from affected lung segments to central airways by
means of coughing and suctioning.

 The patient is positioned so that the diseased area is in a near vertical

position, and gravity is used to assist the drainage of specific segment.

 The positions assumed are determined by the location, severity, and

duration of mucous obstruction

 The exercises are performed two to three times a day, before meals and
bedtime. Each position is done for 3-15 minutes

 The procedure should be discontinued if tachycardia, palpitations,

dyspnea, or chest occurs. The se symptoms may indicate hypoxemia.
Discontinue if hemoptysis occurs.
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 Bronchodilators, mucolytics agents, water, or saline may be nebulised

and inhaled before postural drainage and chest percussion to reduce
bronchospasm, decrease thickness of mucus and sputum, and combat
edema of the bronchial walls, there by enhancing secretion removal

 Perform secretion removal procedures before eating

 Make sure patient is comfortable before the procedure starts and as

comfortable as possible he or she as.

Precautions
Chest physical therapy should not be performed on those children with the following:

 bleeding in the lungs

 head or neck injuries
 fractured ribs
 collapsed lungs
 acute asthma
 pulmonary embolism
 active haemorrhage
 some spinal injuries
 open wounds or burns

Preparation
The child should be taught about the necessity and rationale for chest physical
therapy. It may be a challenge to get children to cooperate with the procedure.
Providing a toy, watching a video, or giving a reward may be ways to encourage
cooperation.

Aftercare
Many children may wish to perform oral hygiene measures after therapy to lessen the
poor taste of the secretions they have expectorated.
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Risks
The risks and complications associated with chest physical therapy are dependent
upon the health of the child. Although chest physical therapy normally poses few
problems, in some patients it may cause the following:

 oxygen deficiency if the head is kept lowered for drainage

 increased intracranial pressure
 temporary lowering of blood pressure
 bleeding in the lungs
 pain or injury to the ribs, muscles, or spine
 vomiting
 inhalation of secretions into the lungs
 heart irregularities

KEY TERMS
Coughing —In chest physical therapy, coughing is used to help break up secretions
in the lungs so that the mucus can be suctioned out or expectorated. Patients sit
upright and inhale deeply through the nose. They then exhale in short puffs or coughs.

Deep breathing —Deep breathing helps expand the lungs and forces better
distribution of the air into all sections of the lung. The patient either sits in a chair or
sits upright in bed and inhales, pushing the abdomen out to force maximum amounts
of air into the lung. The abdomen is then contracted, and the patient exhales.

Mucociliary escalator —The coordinated action of tiny projections on the surfaces of

cells lining the respiratory tract, which moves mucus up and out of the lungs.

Percussion —An assessment method in which the surface of the body is struck with
the fingertips to obtain sounds that can be heard or vibrations that can be felt. It can
determine the position, size, and consistency of an internal organ. It is performed over
the chest to determine the presence of normal air content in the lungs, and over the
abdomen to evaluate air in the loops of the intestine.

Postural drainage —The use of positioning to drain secretions from the bronchial
tubes and lungs into the trachea or windpipe where they can either be coughed up or
suctioned out.

Vibration —The treatment that is applied to help break up lung secretions. Vibration
can be either mechanical or manual. It is performed as the patient breathes deeply.
When done manually, the person performing the vibration places his or her hands
against the patient's chest and creates vibrations by quickly contracting and relaxing
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arm and shoulder muscles while the patient exhales. The procedure is repeated
several times each day for about five exhalations.

Parental concerns
Because chest physical therapy is often prescribed for children with chronic health
problems, parents are often required to learn the techniques so the procedure can be
performed regularly at home. Many parents are fearful they might hurt their child or
may perform the procedure incorrectly. They should be reassured that thousands of
parents have learned how to perform chest physical therapy and do so safely and
effectively.

CONCLUSION
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.
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.

BIBLIOGRAPHY

 Brunner & Suddarth,Text book of medical surgical nursing,11th

edition,,Published by Wolters Kluers pvt ltd,Page no:732-735
 www.medscape.com