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Chest Physiotherapy, Postural Drainage

OutlinesDefinition of chest physiotherapy.Goals of CPTIndications for CPTContraindications for CPTRecommendationsPrecautions for CPTCPT in infants

GoalsPrevent airway obstruction and accumulation of secretions.Improveairway clearance and ventilation.to move bronchial secretions to the central airways. improve the cough mechanism.

DefinitionChest physical therapy is the term for a group of treatments designed to improve: respiratory efficiencypromote expansion of the lungs,strengthen respiratory muscles,eliminate secretions from the respiratory system.It is usually done in conjunction with other treatments that include:Suctioningnebulizer treatmentsadministration of expectorant drugs.

HAZARDSHead-down positions (trendelenberg) may increase intracranial pressure.Vomiting or Aspiration.

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IndicationsIt is indicated for patients in whom cough is insufficient to clear thick, tenacious, or localized secretions.

Excessive sputum productionReduced effectiveness of coughAdventitious breath sounds suggestive of secretions in the airways which persist after coughing Abnormal chest radiograph suggesting atelectasis, mucus plugging, or infiltrates.Cystic fibrosisBronchiectasisAtelectasisLung abscessNeuromuscular diseasesPneumonias in dependent lung regions

Relative ContraindicationsIncreased ICPUnstable head or neck injuryActive hemorrhage with hemodynamic instability or hemoptysisRecent spinal injuryEmpyemaFlail chestRib or vertebral fractures or osteoporosis postoperative procedures: neurosurgery, recent cardiovascular surgery, recent neck and face surgery, orthopedic procedures where compression on joints is contraindicatedcontinuous tube feedings.untreated pneumothorax

Absolute ContraindicationPresence of Tuberculosis

RecommendationsCPT is not recommended for the routine treatment of uncomplicated pneumonia.CPT is not recommended for routine use in patients with COPD.CPT may be considered in patients with COPD with symptomatic secretion retention, guided by patient preference, toleration, and effectiveness of therapy.Cough assist techniques should be used in patients with NMD, particularly when peak cough flow is 270 L/min.

Precautionsbleeding from the lungsneck or head injuriesfractured ribsdamaged chest wallsacute asthmapulmonary embolismlung abscessactive hemorrhage

Postural DrainagePostural drainage uses the 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.

indicationsDifficulty in clearing secretions with sputum production in excess of 25-30 ml/day in the adultPresence of atelectasis caused by or suspected of being caused by mucus plugging

contraindications Intracranial pressure (ICP) greater than 20 mm HgRecent spinal surgeryAcute spinal injuryActive hemoptysisConfused, anxious, or otherwise impaired patients who actively resist or do not tolerate position changes.Rib fracture with or without flail chest or other significant chest injury

Absolute contraindicationsUnstabilized head and/or neck injury.Active hemorrhage with hemodynamic instability or significant possibility of occurrence.

Positioning

Apical Upper lobes

Sit the patient up. Tilt the patient half way between sitting up and laying at. Percuss between the nipple and collarbone of the chest.

posterior upper lobes

Sit the patient up. Tilt the patient half way between sitting up and laying at. Percuss over the shoulder blade on the left side of the back for 2 3 minutes.

Anterior upper lobes

Lie patient on his or her back. Percuss between the nipple and the collarbone

Middle lobe

Lie patient down on his or her left side, feet higher than head. Percuss below the right arm, but above the bottom edge of the ribs

Posterior basal lower lobes

Lie patient on his or her stomach, feet higher than head. Percuss over the middle of the right and left ribs, above the bottom edge of the ribs.

Anterior basal

Lie patient down on his or her right side, feet higher than head.Percuss below the left arm but above the bottom edge of the ribs

Chest Physiotherapy in young infants

Apical Segment

With the infant leaning slightly back, percuss over the area from the nipple line to the shoulder on both sides. Percuss over each area for two minutes.

Posterior Segments

With the infant leaning forward, percuss over and above each shoulder blade on both sides.

Lateral Basal SectionPlace infant in a flat position on his/her side, with arm extended. Percuss over side of ribcage, below armpit.

Middle Lobe and Lingula Segment

Lay infant flat on his or her side. Roll back one quarter turn with arm extended, as illustrated. Percuss over nipple area. Repeat on opposite side.

Anterior Basal SegmentsPlace infant in a flat position, facing up. Percuss above margin of the ribs on both sides.

Posterior Basal SegmentsPlace infant in a flat position facing down. Percuss above the lower margin of the ribs on both sides.

ConclusionChest physiotherapy is essential in the airway clearance of acute and chronic respiratory disorders with retained airway secretions. Regular CPT plays a significant role in reducing the morbidity in children with chronic lung diseases like cystic fibrosis.