Holy Trinity UniversityCollege of Nursing and Health Sciences

Submitted by:Eduard L. Alcantara

SN4 – N1 of St. Dominic

Submitted by:Eduard L. Alcantara

SN4 – N1 of St. Dominic

Submitted to:Emmanuel B. Barroma, RN,

BSN, MANClinical Instructor

Submitted to:Emmanuel B. Barroma, RN,

BSN, MANClinical Instructor

At the end of the 20-minute lecture-discussion with PowerPoint Presentation, the students should be able to:

• define what is Chest Physiotherapy with Sputum Collection.

• analyze the importance of CPT.• discuss the indication and

contraindication.• discuss the procedures.• enumerate the possible complications.• integrate Christian values such as

respect, love, and care.

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

These therapies include postural drainage, chest percussion, and vibration.

It should be followed by productive coughing and suctioning of the client who has decreased ability to cough.

It is recommended for clients who produce greater than 30 cc Sputum/day or have evidence of Atelectasis by CXR.

This can be safely used with infants and young children; however conditions, and diseases unique to children that may at times may contradict with this procedure.

o Know the pt’s normal range of v/s. Conditions such as atelectasis and pneumonia requiring CPT can affect v/s. The degree of change is related to the level of hypoxia, overall cardiopulmonary status, and tolerance to activity.

o Know the client’s meds. Certain medications particularly diuretics and anti-HTN, causes fluid and hemodynamic changes. These may decrease the client’s tolerance to the positional changes of postural drainage. Steroid medications increase the pt’s risk of pathologic rib fx and often contraindicate rib shaking.

o Know the pt’s Medical Hx. Certain conditions such as increased ICP, spinal cord injuries, and abdominal aneurysm resection contraindicate the positional changes of postural drainage. Thoracic trauma or surgery may also contraindicate percussion, vibration, and rib shaking.

o Know the pt’s level of cognitive function. Participation in controlled coughing in techniques requires the client to follow instructions. Congenital or acquired cognitive limitations may alter the client’s ability to learn and participate in this techniques.

o Be aware of the client’s exercise tolerance. CPT maneuvers are fatiguing. When the patient is not used to physical activity, initial tolerance to the maneuvers may be decreased. However with gradual increases in activity and planned CPT, patient tolerance for the procedure improves.

Turning • inability or reluctance of patient to change body position. (eg, mechanical ventilation,

neuromuscular disease, drug-induced paralysis)• poor oxygenation associated with position. (eg, unilateral lung disease)• potential for or presence of atelectasis.• presence of artificial airway.

Postural Drainage • evidence or suggestion of difficulty with secretion clearance • difficulty clearing secretions with expectorated sputum production greater than 25-30

mL/day (adult).• evidence or suggestion of re-tained secretions in the presence of an artificial airway.• presence of atelectasis caused by or suspected of being caused by mucus plugging.• diagnosis of diseases such as cystic fibrosis, bronchiectasis,or cavitating lung disease• presence of foreign body in airway(56-58)

External Manipulation of the Thorax • sputum volume or consistency suggesting a need for additional manipulation (eg,

percussion and/or vibration) to assist movement of secretions by gravity, in a patient receiving postural drainage

Positioning All positions are contraindicated for • intracranial pressure (ICP) > 20 mm Hg(59,60)• head and neck injury until stabilized (A)• active hemorrhage with hemodynamic instability (A)• recent spinal surgery (eg, laminectomy) or acute spinal injury• acute spinal injury or active hemoptysis• empyema• bronchopleural fistula• pulmonary edema associated with congestive heart failure• large pleural effusions• pulmonary embolism• aged, confused, or anxious patients who do not tolerate position changes• rib fracture, with or without flail chest• surgical wound or healing tissue• Trendelenburg position is contraindicated for • intracranial pressure (ICP) > 20 mm Hg(59,60)• patients in whom increased intracranial pressure is to be avoided (eg, neurosurgery, aneurysms, eye

surgery)• uncontrolled hypertension• distended abdome• esophageal surgerY• recent gross hemoptysis re-lated to recent lung carcinoma treated surgically or with radiation therapy(59)• uncontrolled airway at risk for aspiration (tube feeding or recent meal) Reverse Trendelenburg is contraindicated in the presence of hypotension or vasoactive medication

External Manipulation of the ThoraxIn addition to contraindications previously listed :• subcutaneous emphysema• recent epidural spinal infusion or spinal anesthesia• recent skin grafts, or flaps, on the thorax• burns, open wounds, and skin infections of the thorax• recently placed transvenous pacemaker or subcutaneous

pacemaker (particularly if mechanical devices are to be used)• suspected pulmonary tuberculosis• lung contusion• bronchospasm• osteomyelitis of the ribs• osteoporosis• Coagulopathy• complaint of chest-wall pain

• bleeding from the lungs• neck or head injuries• fractured ribs• collapsed lungs• damaged chest walls• tuberculosis• acute asthma• recent heart attack• pulmonary embolism• lung abscess• active haemorrhage• some spine injuries• recent surgery, open wounds, or burns

• The only preparation needed for chest physiotherapy is an evaluation of the patient's condition and determination of which chest physiotherapy techniques would be most beneficial.

• Patients practice oral hygiene procedures to lessen the bad taste or odour of the secretions they spit out.

RisksRisks and complications associated with chest physiotherapy depend on the

health of the patient. Although chest physiotherapy usually poses few problems, in some patients it may cause the ff:

• oxygen deficiency if the head is kept lowered for drainage• increased intracranial pressure• temporary low blood pressure• bleeding in the lungs • pain or injury to the ribs, muscles, or spine• vomiting• inhaling secretions into the lungs • heart irregularities• Normal results

The patient is considered to be responding positively to chest physiotherapy if some, but not necessarily all, of these changes occur:

• increased volume of sputum secretions• changes in breath sounds• improved vital signs• improved chest x ray• increased oxygen in the blood as measured by arterial blood gas values• patient reports of eased breathing

Procedureo Chest physiotherapy may be administered

by a respiratory therapist, although the techniques can often be taught to family members of patients.

o It can be performed in a wide variety of settings namely Critical care, In-patient acute care, Extended care and skilled nursing facility care, Home care, Outpatient/ambulatory care and/or Pulmonary diagnostic (bronchoscopy) laboratory.

Postural drainage- Uses force of gravity to assist in

effectively draining secretions from the lungs and into the central airway where they can either be coughed up or suctioned out.

- Patient is placed in a head or chest down position and is kept in this position for up to 15 minutes.

• Be sure your back is covered. Wear a shirt or blouse, or cover your back with a towel.

• Hold each position for 5 minutes to help the mucus drain from your lungs.

• For each position, your caregiver claps your back quickly and rhythmically. Your caregiver bends his or her hand at the knuckles to form a cup .

• When your caregiver claps, you should hear a hollow sound. If you hear a slapping, the hand is not cupped enough.

• Do not clap over the spine.• Morning is the best time to do postural drainage,

because it helps clear mucus that has built up during the night. It may also be done just before bed to decrease nighttime coughing. Do not do it soon after a meal; this may increase the chance of vomiting.

Percussion- Consists of rhythmically striking

the chest wall with cupped hands.- Also called cupping, clapping,

or tapotement.- To break up thick secretions in the

lungs.- Performed on each lung segment

for one to two minutes at a time.

- Contraindicated in clients with bleeding disorders, osteoporosis, or fractured ribs.

- Caution should be taken to percuss the lung fields and not the scapular regions, or trauma may occur to the skin and underlying muskuloskeletal structures.

Turning

- Permits lung expansion.

- Head of the bed can be elevated to

promote drainage.

- Critically ill patients and those

dependent on mechanical respiration are

turned once every one to two hours

around the clock.

Coughing

-Helps break-up secretions in the lungs

-Patients sit upright and inhale deeply

through the nose.

- Exhale in short puffs or coughs.

- Repeated several times a day.

Deep Breathing

- Helps expand the lungs and

forces better distribution of the

air into all sections of the lung

- Done several times each day

for short periods

Vibration

- Fine, shaking pressure applied to the chest wall during exhalation.

- This technique is thought to increase the velocity and turbulence of inhaled air, facilitating secretion removal.

- Vibration increases the inhalation of trapped air and may shake mucus loose and induce a cough.

-To help break up lung secretions

- Could either be mechanical or manual

- Performed as the patient breathes deeply

- Manual : 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

- Repeated several times each day for about five exhalations

Sputum Collection· Drink plenty of fluid the night before collection.· Sit upright to collect sputum of the first cough in the morning.· Rinse your mouth with water, but do not brush your teeth or use mouthwash before collecting sputum.· Print your name and date of birth on the specimen container provided by the laboratory.· Unscrew the lid (DO NOT DISASSEMBLE) of the container.· Cough deeply to expectorate sputum directly into the container. Do not contaminate the rimof the container with sputum.· Do NOT expectorate any saliva or postnasal discharge.· WRITE THE DATE AND TIME OF COLLECTION ON THE CONTAINER.· Put container in the safety bag provided and return each specimen collected to the laboratory as soon as possible before 10 AM. •DO NOT REFRIGERATE.· Call the laboratory if you have any questions.

NURSING MANAGEMEN

T

•Pt. Comfort•Non-restrictive clothing•Avoid eating before•Medicate for pain•Splint incisions

•Avoid eating•Comfort•Avoid restrictive clothing•Medicate•Splint for comfort•STOP c/o pain

Hypoxemia• Action To Be Taken/Possible Intervention: Administer

higher oxygen concentrations during procedure if potential for or observed hypoxemia exists. If patient becomes hypoxemic during treatment, administer 100% oxygen, stop therapy immediately, return patient to original resting position, and consult physician. Ensure adequate ventilation. Hypoxemia during postural drainage may be avoided in unilateral lung disease by placing the involved lung up-permost with patient on his or her side.

Increased Intracranial Pressure• Action To Be Taken/Possible Intervention: Stop therapy,

return patient to original resting position, and consult physician.

Acute Hypotension during Procedure• Action To Be Taken/Possible Intervention: Stop therapy,

return patient to original resting position, and consult physician.

Pulmonary Hemorrhage• Action To Be Taken/Possible Intervention: Stop therapy, return

patient to original resting position, call physician immediately. Administer oxygen and maintain an airway until

• physician responds.Pain or Injury to Muscles, Ribs, or Spine• Action To Be Taken/Possible Intervention: Stop therapy that

appears directly associated with pain or problem, exercise care in moving patient, and consult physician.

Vomiting and Aspiration• Action To Be Taken/Possible Intervention: Stop therapy, clear

airway and suction as needed, administer oxygen, maintain airway, return patient to previous resting position, and contact physician immediately.

Bronchospasm• Action To Be Taken/Possible Intervention: Stop therapy, return

patient to previous resting position, administer or increase oxygen delivery while contacting physician. Administer physician-ordered bronchodilators.

Dysrhythmias• Action To Be Taken/Possible Intervention: Stop therapy, return

patient to previous resting position, administer or increase oxygen delivery while contacting physician.

• Fundamentals of Nursing by Potter and Perry

• Merck Manual

Nurses dispense comfort, compassion, and caring

without even a prescription.  ~Val Saintsbury