Chest Physiotherapy

What is chest physiotherapy? It is also called Chest physical Therapy (CPT ). It is a treatment that helps to remove the excess secretions (also called mucus, phlegm, sputum ) from inside the lungs, by physical means. It is used to assists a cough, re- educate breathing muscles to try to improve ventilation of the lungs. For some people, this treatment is only needed for a short time after a lung illness. Others with chronic lung diseases will need to perform this treatment daily because they have a lot of mucus to the upper airways where it can be coughed out. This reduces the chance of lung infection and makes breathing more comfortable.

What are the excess secretions and what causes them? The lungs are kept moist with a thin film of fluid to stop them drying out. When there is a chest infection or occasionally in other situations, this fluid increases and become thick and putrid. In the normal situation, these secretions are removed by coughing but in the precence of weakness, or in chronic lung disease, this is not always possible. Although antibiotics can control the infection, they do not remove the secretions that occur. Some will be reabsorbed into the body but very thick ones will remain. It is important to remove the secretion to allow more effective breathing and increase the amount of oxygen getting into the body.

When should chest physiotherapy be done? Chest physiotherapy should never be done straight after a meal or drink. For a meal wait one hour and after a drink wait ½ hour. Chest physiotherapy should be done when secretions need removing and this may be once a day or it may be 4-5 times a day. It is often useful to do physio first thing in the morning getting out of bed. The chest will have been relaxed at night and the secretions may be easier to remove.

How chest physiotherapy is done? CPT is made up of two ways:Postural Drainage It removes mucus from certain parts of the lungs by using gravity and proper positioning to bring the secretions into the throat where it is easier to remove them. The lungs are divided into segments called lobes, the right lung is divided into three lobes (right upper lobe, right middle lobe and right lower lobe) while the left lung has only two lobes (left upper lobe and lower lobe).

Scheduling Treatment: The treatment often works best in the morning. This allows the mucus to be removed that has built up during the night. Sometimes a treatment can be done at night to reduce the need for coughing during sleep. Make sure you wait at least 1-2 hours after eating before starting you treatment. This helps to prevent nausea and or vomiting. CPT just before meals may cause you to become tired and may decrease appetite.

Steps:1. 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.2. 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.3. The positions assumed are determined by the location, severity, and duration of mucous obstruction4. The exercises are performed two to three times a day, before meals and

bedtime. Each position is done for 3-15 minutes5. The

procedure should be discontinued if tachycardia, palpitations, dyspnea, or chest occurs. The se symptoms may indicate hypoxemia. Discontinue if hemoptysis occurs.6. 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 removal7. Perform secretion removal procedures before eating8. Make sure patient is comfortable before the procedure starts and as comfortable as possible he or she assumes each position9. Auscultate the chest to determine the areas of needed drainage10. Encourage the patient to deep breathe and cough after spending the allotted time in each position.11. Encourage diaphragmatic breathing through out postural drainage: this helps widen airways so secretions can be drained

Positions

To drain the middle and lower portions of your lungs, you should be positioned with your chest above your head. Possible techniques to achieve this position are:

If a hospital bed is available, put in Trendelenburg position (head lower than feet) Place 3-5 wood blocks, that are 2 inches by 4 inches, in a stack that is 5 inches high, under the foot of a regular bed. Blocks should have indentations or a 1 inch rim on top so that the bed does not slip Stack 18-20 inches of pillow under hips.

Place on a tilt table, with head lower than feet. Lower head and chest over the side of the bed.

   To drain the upper portions of your lungs, you should be in a sitting position at about a 45 degree angle.

Percussion Percussion is rhythmically striking the chest wall with cupped hands. It is also called cupping, clapping, or tapotement. The purpose of percussion is to break up thick secretions in the lungs so that they can be more easily removed. Percussion is performed on each lung segment for one to two minutes at a time. It should always be done over the rib cage. Never percuss over the spine, breast, clavicles or breast bone (sternum). It should be done over a thin article or clothing or towel, never on bare skin. It should last 3-5 minutes per area that is being drained. Areas that have a lot of mucus drainage may require more time. If cupping is hard to do, soft plastics hand- held pecussors cups or mechanical precussor may be used.

Chest Physical Therapy Positions for Infants and Children

Below are the drainage positions for CPT.  The white ovals show you where to percuss.  During therapy it is useful to have tissue or a basin handy to collect mucus.  A glass of water may also be helpful for those who can cough better after their throat is wet.

 Upper Lobes

 Lean forward 30°.  Percuss between the clavicle and the shoulder blade on each side of the chest.

 

Lean back 30°.  Percuss between the clavicle and the nipple on each side of the chest.

 

Lower Lobes

The body should be positioned with the child’s head down 30°and lying on the right side.  Percuss on the left side below the underarm.  Note: If your child has Cystic Fibrosis and is under the age of 5, you will not be tilting the chest area, but will keep the chest horizontal.

 

The body should be positioned with the child’s head down 30°and lying on the left side.  Percuss on the right side below the underarm.  Note:If your child has Cystic Fibrosis and is under the age of 5, you will not be tilting the chest area, but will keep the chest horizontal.

 

Horizontal                                 Head down 30º

  The body should be positioned with the child’s head down 30°and lying on the abdomen.  Percuss between the lower edges of the rib cage and behind the underarm on each side of the spinal cord.  Note: If your child has Cystic Fibrosis and is under the age of 5, you will not be tilting the chest area, but will keep the chest horizontal.

 

  The body should be positioned with the child’s head down 30°and lying on the back.  Percuss on the front of the chest in the nipple area and just below.  Note: If your child has Cystic Fibrosis and is under the age of 5, you will not be tilting the chest area, but will keep the chest horizontal.

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Other treatments for CPT:

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. Deep breathing exercises are done several times each day for short periods.

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.

Procedure: Percussion and Vibration

Instruct the patient use diaphragmatic breathing2. Position the patient in prescribed postural drainage positions. Spine should be straight to promote rib cage expansion3. 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 conditions4. Avoid clapping over spine, liver, spleen, breast, scapula, clavicle or sternum5. 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.6. Allow the patient rest several times7. Listen with stethoscope for changes in breath sounds8. Repeat the percussion and vibration cycle according to the patient’s tolerance and clinical response: usually 15-30 minutes.

Coughing Coughing helps 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. Coughing is repeated several times a day.

Procedure Have patient take a slow deep breath through their nose. Instruct them to hold their breath for a count of three. The patient should open their mouth and cough three times as they exhale.

Active cycle of breathingIs a tech which uses breathing easy to remove phlegm from lungs. It's sometimes used alongside other clearance tech such as postural drainage or chest percussion. Can be performed either in sitting, lying or postural drainage positions but initially u should start it in sitting position. Uses alternating depth breathing to move phlegm from small airways at the bottom of your lungs to larger airways near the top where they can be cleared more easily with huffing or coughing.

How to perform:-try to maintain a good breathing pattern with relaxed shoulders and neck (avoid to use accessory muscle during the ACBT)-breathe through your nose and out through your mouth

The cycle is:

Breathing Control (also called abdominal breathing)- Rest one hand on your abdomen, keeping shoulders and upper chest relaxed andallow your hand to rise gently as you breathe in. (If you imagine air filling the abdomenlike a balloon this may help)- Sigh out gently- Ensure shoulders remain relaxed- Over a few seconds, gradually increase depth of breathing while

maintaining relaxationBreathing control is an essential part of the cycle to allow rest.

Deep Breathing Exercises- Take 3 – 4 deep breaths in, allowing the lower chest to expand- Try to ensure neck and shoulders remain relaxed- At the end of the breath in, hold the air in for 3 seconds- Let the air out gently

Manual hyperinflation or bagging This is a technique most often used in intensive care but some physiotherapists do use this in a ward or home situation. It involves the use of a facemask attached to special rubber or plastic bag. By pressing the bag, air can be pushed into the chest to help it expand. This is not as easy as it sounds. These are machines that can do this, the cough machine.

Ventilation InhalationInhalation 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

ExhalationExhalation 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.

Can chest physiotherapy prevent the build up of secretions?

Chest physiotherapy cannot prevent infections and it cannot remove secretions that are not there. Most children and adults will know if secretions are on their chest or if they feel chesty or ratty and need some physiotherapy. Younger children will not be aware of problems but you can usually hear if their breathing is a little different or noisy.

CoughRemember, control your coughing as uncontrolled coughing can make

you short of breath. Discuss with your physician which type of coughing exercise is best for you.

You should perform these coughing maneuvers whenever you feel the need to cough or as instructed by your physician. A good controlled cough is especially helpful when you first get up in the morning and about an hour before bedtime. Have a cup of coffee or tea first (or other drink recommended by your physician) and relax.

Sit up straight in a chair when attempting these coughing exercises. Have a tissue handy.

Exercise A1. Sit up straight on a hard-backed, stable chair, relax.

2. Take in 2-3 deep breaths through your nose and exhale slowly through pursed lips.

3. Fold your arms across your abdomen.4. Take in a comfortable deep breath through your nose.5. Lean forward, pressing your arms against your abdomen and cough

while leaning forward.6. Relax, rest 5-10 minutes7. Perform again if needed.Exercise B1. Sit up straight, relax.2. Take in 2-3 breaths through your nose and exhale slowly through

pursed lips.3. Take in a moderately deep breath, hold breath, expel air while

saying “H” or “K” once.4. When you feel comfortable with this exercise, try and say the “H” or

“K” 3-4 times while exhaling.