Chest Physical Therapy (Postural Drainage and Clapping- PD

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Chest Physical Therapy (Postural Drainage and
Clapping- PDC)

• Includes one or more of the
  following
• Postural drainage
• Percussion (Clapping)
• Vibration
• Coughing (Directed Cough CPG)
• Breathing Exercises
• PAP therapy CPAP, PEP, EPAP

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Goals of CPT

• Mobilize and clear secretions (promote bronchial
  hygiene)
• Promote lung expansion
• Condition respiratory muscles

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Indications for CPT

• Excessive or retained secretions
• Increased mucus production pneumonia, cystic
  fibrosis, COPD, and bronchiectasis.
• Sputum production over 25 30 mL/day is
  generally thought to be excessive mucus
  production
• Ineffective or non-productive cough
• Huff technique (Forced Expiratory Technique)
• Manually assisted coughing (splinting)

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Postural Drainage

• Positioning the patient to allow gravity to drain
  a specific lung segment.

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Precautions and contraindications for PD

• Trendelenburg position (head down)
• Elevated intracranial pressure (closed head
  trauma or neurosurgery)
• Unstable cardiovascular system
• Recent esophageal or gastric surgery
• Large pleural effusions
• Empyema
• Hemoptysis

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Percussion (Clapping)

• Striking the chest wall with cupped hands to
  loosen secretions

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Precautions and contraindications for Clapping

• Do NOT clap over
• Bony prominences
• Lower edge of rib cage
• Breast tissue
• Wounds, skin grafts, fractured ribs, etc.

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Complications of PDC

• There have only been 4 deaths from PDC due to
  pulmonary hemorrhage
• massive pulmonary hemorrhage
• Lung cancer
• Lung abscess
• Recent lung resection/radiation therapy
• Lung contusion
• Hypoxemia
• Increases intracranial pressure

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Limit Force of Clapping in Cases of

• Osteoporosis
• Metastatic bone cancer
• If patient cannot tolerate it

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Vibration

• Vibrating the chest wall to mobilize secretions
  toward the trachea

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Vibration

• No additional precautions for vibration
• Use vibration when patient cannot tolerate
  percussion

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Vibration

• Have patient exhale through pursed lips during
  vibration
• Vibrate only during exhalation

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Considerations

• Patient relaxation essential to effective therapy
• If sputum thick, may need bronchodilator first,
  then 20 min. USN tx followed by PDC

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Timing of PDC

• 1 1/2 - 2 hours after last meal
• Coordinate therapy to occur before tube feedings
  (9 - 1- 5 - 9)
• 20 minutes after last pain medication optimal

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Patient Preparation

• Loosen clothing around neck
• Know where ALL lines are (IVs, urinary catheters,
  ECGs, arterial lines, etc)
• Dont let patients head crunch against
  headboard
• Leave oxygen on if patient has nasal cannula

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Length of treatment

• total time 30 - 40 minutes
• 5-10 minutes per position
• Depends on how well patient tolerates treatment!

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Procedure

• Administer aerosol therapy first
• Know which segments are most involved (CXR, BS) -
  do first
• Alternate clapping with vibration to prevent hand
  fatigue and slapping
• May want pt to do breathing exercises while in
  drainage position.
• Position patient using proper body mechanics

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DO

• Keep mild lumbar curve

Use legs to lift
Keep feet apart
Pivot feet rather than twisting
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Dont
Bend from the waist
Hold objects away from body
Lift more weight than you can
Twist while lifting
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Effective Normal Cough

• Deep breath
• Close glottis
• Contract abdominal muscles
• Glottis opens

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Huff Cough

• Instruct patient to take in a deep breath and
  exhale in short huffs
• Idea is not to close glottis and build up
  abdominal pressure
• Huffing helps keep small airways open and gets
  air behind secretions

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Autogenic Drainage

• Move secretions from smaller to larger airways
• 3 phases
• unsticking small airways
• collecting mid-sized airways
• evacuation large airways
• Process
• Pt sits upright, RT places hands on front and
  back of chest
• Pt takes deep breath and exhales well into ERV
• Then takes in small breath and holds x 3 sec and
  huffs out easily dont force. Repeat as needed.
• Next takes deeper breath (mid-sized aw) and holds
  x 3 huffs out easily avoid coughing. Repeat
  as needed
• Finally takes in full deep breath and holds x 3
  sec huff coughs out harder to expectorate.

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Assisted Cough

• Use bag to deliver deep breath
• Rapid compression on abdomen to facilitate
  explosive exhalation

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Assessing Treatment Effectiveness

• Change in breath sounds
• Sputum production (may be delayed up to an hour
  after tx)
• Does patient feel better? Breathe easier?

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Guidelines for Discontinuing PDC

• Clear BS, patient clearing secretions well
• Afebrile for 48 hrs
• Relatively clear chest x-ray

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Breathing Exercises

• Diaphragmatic
• Lateral chest expansion
• Segmental chest expansion

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PEP Therapy

• Positive Expiratory Pressure
• See Positive Airway Pressure Clinical Practice
  Guideline. PAP CPAP, PEP and EPAP
• Positive pressure created during exhalation
  through an orifice
• Keeps small airways open allowing air to get
  behind secretions, improves cough
• Want 13 - 14 IE ratio when using device

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TheraPEP by DHD
R
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Use of TheraPEP

• Adjust resistor setting until IE ratio between
  13 - 14
• Keep pressure between lines to get 10 - 20 cm H20
• Give 10-20 breaths
• Deeper than normal but not maximal, exhale to FRC
• Follow with 2-3 huff coughs

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Flutter
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Use of the Flutter

• Hold it level (can tip up slightly)
• Sit with back straight
• Take in a deep breath and hold it 2 - 3 sec
• Place Flutter in mouth and exhale completely at a
  constant speed
• Not fast
• Keep cheeks hard and flat
• Remove flutter and take in another deep breath,
  hold it, then cough

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Flutter

• Provides vibrations to loosen secretions
• Palpate chest wall for maximal vibrations to
  determine best technique
• Also creates some backpressure or PEP of around
  18-22 cm H2O
• Oscillatory flow pattern during exhalation also
  helps move secretions

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Volsko TA, DiFiore JM, Chatburn RL. Performance
comparison of two oscillating positive expiratory
pressure devices Acapella versus Flutter. Resp
Care 2003 48 (2)124-130.
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Acapella - combination Flutter and PEP
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Blue pt able to maintain expiratory flow of 15
LPM or more for 3 - 4 seconds Green pt
not able to maintain exp flow of 15 LPM for 3 - 4
seconds. Start in counter- clockwise
position 10-20 breaths
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The Vest

• Provides high frequency chest wall oscillations
  (HFCWO video)
• For CF patients set pressure on 5-6
• 10 minutes at frequency of 5-10 Hz
• 10 minutes at frequencies of 10 - 15 Hz
• and 10 minutes at frequencies of 15 - 20 Hz
• After each 10-minute, deep breath, hold it for 3
  seconds and do several huff coughs
• For non-CF do 10 - 15 minutes at freq 10 -15 Hz
  at same pressure (5-6)
• Keep mouth open

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IPV Intrapulmonary
percussive ventilation

• Facilitates secretion removal
• Give aerosolized medications during tx
• Med reservoir holds 20 cc.
• Start at percussionaire line press regulator
  setting of 30 - 35 psig
• Trigger percussion during inspiration
• Proximal airway press should oscillate between 5
  and 15 cm H2O

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IPV (cont)

• Percussion Control 12 oclock position
• higher frequency - less amplitude (volume)
• lower frequency - greater amplitude
• As pt gets used to tx - increase operational
  pressure 35 - 40 psig
• Proximal airway press should read 15 - 20 cm H2O
• May have rest periods of aerosolized medication
  without percussion
• video

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Summary - PDC or CPT

• To mobilize and clear secretions
• To promote lung expansion and facilitate coughing
• Many devices currently on market have the purpose
  of keeping airway open to get air behind
  secretions to facilitate cough.