Percussion

Original Editor - Priya Gulla. Top Contributors - Chelsea Mclene, Kim Jackson, Priya Gulla, Admin, Rachael Lowe, Laura Ritchie, Adam Vallely Farrell, Uchechukwu Chukwuemeka and Claire Knott

Introduction

Percussion is a manual technique used by respiratory physiotherapists to improve airway clearance by mobilizing secretions in one or more lung segments to the central airways. Percussion over an affected area produces an energy wave, which is transmitted to the lungs and airways. It is performed with the aim of loosening thick, sticky or retained secretions from the chest wall. Chest percussion can also be used in combination with active cycle breathing techniques or coupled with positioning in those who are unable to actively participate in active controlled breathing exercises. Combining this technique with postural drainage is very effective and can improve the drainage process in patients with abnormalities in cilia that inhibit effective airway clearance.

Percussion can be performed in two ways-

1. Manual Percussion
2. Mechanical Percussion

Percussion is often a beneficial manual technique to help in the removal of secretions in a number of respiratory conditions, these include:

• Cystic fibrosis
• Emphysema
• Chronic bronchitis
• Pneumonia
• Adult Respiratory distress syndrome (ARDS)
• Bronchiectasis
• Chronic obstructive pulmonary disease (COPD)

Equipments Required For Percussion

• The equipment required here is cupped hands of caregiver to deliver the force required to drain the thick or the retained secretions, thin towel and a drainage table.
• Padded rubber nipples, pediatric anaesthesia masks, padded medicine cups or bell end of stethoscope may be used to provide percussion to infants.
• Electric or pneumatic percussors of different models are available in variable intensities and frequencies for adults and older pediatric population which can stimulate percussion mechanically. This enables patient to apply self-percussion more effectively.

Preparation For Percussion

To improve the efficacy of treatment the following guidelines are recommended:

• Patient should be in a comfortable or painless position to enhance the effect.
• The technique is applied over a thin towel to ensure it does not feel uncomfortable. Too thick padding may absorb the percussion without having any benefit to the patient. 
• Adjust bed level to ensure proper body mechanics. If ignored, may lead to fatigue or injury to the caregiver. 
• Therapist should try to keep shoulders, elbows and wrist relaxed during the maneuver.
• Duration: Several minutes or until the patient needs to alter the position to cough

Technique And Treatment With Percussion

Chest percussion is performed with cupped hands by trapping air between the patient's thorax and caregiver's hand in an alternating rhythmic manner over the lung segments in which the secretions are to be drained. This loosens the thick, sticky secretions from the walls of the lung allowing them to move more freely into the larger airways, especially when used with associated gravity positioning. It is performed during both phases of breathing, the inspiratory and the expiratory phase.

• Position the hand in cup. It is must that the position should be maintained this way till the end of the treatment.
• The sound heard must be hollow and not of a slap. If erythema occurs, it is result of slapping or not trapping enough air between the hands and the chest wall.
• Rate of percussion, 100-480 times/min.
• The force applied must be equal. The rate should be slowed down if the force of non dominant and dominant hand doesn't match.
• Hand position should be such that the percussion is avoided on bony prominence like spine of scapula, clavicle, spinous processes of vertebrae.
• Percussion must be avoided on floating ribs as they have single attachment.
• Patient may be taught to self percuss with one hand over the areas which are reachable.
• Percussion should not be done over breast tissue as this would produce discomfort and also would reduce the effectiveness of the treatment. In case of very large breasts, it is necessary to move the with one hand and percuss with the other.

Positions For Chest Percussion

LOBE OF LUNG	SEGMENTS OF LUNG	PATIENT POSITION AND PERCUSSION
UPPER LOBES	Apical segments ( right and left)	CHILD: The child sits on the drainage table and leans back on the caregiver. Percuss on area between the collar bone and the top of the shoulder blade. ADULT: In sitting position, lean back on the pillow at 30 degrees. Percuss over the area between the collar bone and the top of the shoulder blade.
	Posterior segments (right and left)	CHILD: The child sits on the drainage table and leans forward over a pillow at 30 degree angle. Stand behind and percuss on the upper back. ADULT: The person sits comfortably in a chair and leans forward on pillows with arms free on the pillow. Percuss on upper back on both sides.
	Anterior segments (right and left)	CHILD: Supine lying on drainage table. Percuss on the area between collar bone and the nipple on both sides of the chest. ADULT: Supine lying with pillow under head and legs. Percuss on both sides of the chest between nipple and collarbone.
LINGULA		CHILD: Elevate the table to about 15 degrees. The child lies on right side with heads down and quarter turns backward. Pillow may be placed from shoulder to hip and is allowed to flex the knees. Percuss on the outer left area of the nipple. For females, percuss with heel of hand under armpit and fingers extended forwards beneath breast if they have breast tenderness. ADULT: In right side lying, face down towards foot of the bed, hip and legs propped on pillows and quarter turned, percussion is applied just outside the nipple area.
MIDDLE LOBE		CHILD: Elevate the table to about 15 degrees. Child lies one-quarter turn from supine on the left side, supported with pillows behind the back and in a 30 degrees head-down position. Knee may be allowed to flex. Percuss on the outer right area of the nipple. For females, percuss with heel of hand under armpit and fingers extended forwards beneath breast if they have breast tenderness. ADULT: Person will lie faced down on left side and quarter turned towards back. Right arm is kept upwards to move out of the way. Legs and hips are elevated as much as possible supported by pillows and percussion is applied just outside right nipple area.
LOWER LOBES	Anterior basal segments	CHILD: Elevate the drainage table foot to 30 degrees. In right side lying position with pillow supported on the back, percussion is applied over the lower ribs on left side. To drain the right side, the child lies on left side lying position and percussion is applied on the right side. ADULT: In right side lying with face down towards foot of the bed, hip and knee is elevated as high possible with knees slightly bent and supported with pillows, percussion is applied over lower ribs.
	Posterior basal segments	CHILD: Elevate the drainage table foot to 30 degrees. In prone position with 2 pillow under hip, percussion is applied on both side of the spine and not on the spine or the lower ribs. ADULT: In prone position with hip and knees elevated on pillows, percussion is applied on lower part of the back over both sides of the spine by avoiding spine and lower ribs.
	Lateral basal segments	CHILD: Elevate the drainage table foot to 30 degrees. In left side lying position, the child quarter turns towards the table with head down. Percussion is applied over uppermost area of lower right rib to drain right side. To drain left side, in same position, percussion is applied on uppermost area of the lower left rib. ADULT: The person will lie on the right side, leaning forward about one-quarter of a turn with hips and legs elevated on pillows. The top leg may be flexed over a pillow for support and comfort, percussion is applied on the the uppermost portion of the lower part of the left ribs.
	Superior segments (right and left)	CHILD: In prone position with 2 pillow under hip, percussion is applied over middle part of the back at bottom of the shoulder blade. Do not percuss over the spine. ADULT: In prone position, two pillows should be placed under the hips and percussion is applied on the bottom part of the shoulder blades on both the right and left sides of the spine, taking care to avoid the spine itself.

Guidelines

Manual respiratory techniques guidelines for practice 2015

ACTION	RATIONALE
Prepare the patient by giving a clear explanation of the treatment	Minimises distress and informs the patient of the procedure
Obtain consent from the patient	Confirms the patient is willing to take the treatment
Auscultate the patient's chest	To ensure no bronchospasm is present prior to the treatment and to assess which area(s) of the lung(s) is/are to be treated
Check the patient's skin integrity over the area of the rib cage to be treated and take care to avoid performing manual techniques over a portacath and lines and drains	To ensure skin is intact and no areas of skin are damaged
Check the patient's SpO2 level	To ensure desaturation is detected if it occurs during the treatment
Position the patient to optimise secretion clearance. This may include modified postural drainage positions.	Tilting or side lying the patient may use gravity to assist the mobilization of secretions
When performing chest percussion a towel may be placed over the area to be treated. However, avoid to much padding	The technique should not be performed on bare skin as this may be uncomfortable for the patient,but to much padding may reduce the effectivness of the technique
Perform chest percussion rhythmically with a loose wrist and a cupped hand over the lung area that is to be treated	This creates an energy wave that is transmitted to the lung parenchyma to loosen secreations
A slow single handed technique or a rapid double handed technique can be used	Depending on patients preference. A slow single handed technique may be more suitable if the patient is at risk of bronchospasm
Observe the patient to ensure they are not holding their breathe	Breathe holding may cause oxygen desaturation
Encourage the patient to perform three to four thoracic expansion during chest percussion	This can prevent desaturation
If the patient is prone to desaturation, monitor the patients' oxygen saturations and respiratory rate throughout the procedure. Supplementary oxygen may be required during treatment	To ensure the patient remains stable during the treatment.
To perform shaking and vibrations the hands are placed over the area where secretions are to be mobilized from and oscillations directed inwards against the chest in the direction of bucket handle rib movement	Chest compression assists the mobilisation of secretions from peripheral to more central airways
The height of the bed should be adjusted to allow the therapist to use their body weight to assist with the vibratory/compression action	To augment expiratory flow and mobilise secretions. The therapist must be aware of their own posture to protect heir back.
Encourage the patient to take a deep inhalation and perform the technique on their exhalation	To encourage movement of secretions during expiratory flow
Encourage the patient to relax their breathing in between the technique	To prevent airway closure, desaturation or bronchospasm
Use forced expiratory technique or coughing to assist the patient to expectorate	Allows secretions that have mobilized to central airways to be expelled
Document the physiotherapy treatment and its outcome in the patients medical notes	To provide a legal record of the treatment and to communicate it;s outcome with other health care professionals.

Indications And Contraindications

INDICATIONS

• Patients with pulmonary disease that are associated with increased production or viscosity of mucus, such as chronic bronchitis and cystic fibrosis.
• Patients who are on prolonged bed rest.
• Patients who have received general anesthesia and who have painful incisions that restrict deep breathing and coughing postoperatively.
• Any patient who is on ventilator if he or she is stable enough to tolerate the treatment.
• Patients with acute or chronic lung disease, e.g. COPD.
• Patients who are generally weak or elderly.
• Patients with artificial airways.

CONTRAINDICATIONS

• Over fractures, spinal fusion, or osteoporotic bone.
• Over tumor area.
• If a patient has a pulmonary embolus.
• If a patient has a condition in which hemorrhage could easily occur.
• If the patient has an unstable angina.
• If the patient has a chest wall pain.
• In recent neurosurgery, head down position is contraindicated.
• If patients has a hyper-reactive airways and severe bronchospasm; though, not an absolute contraindication.

Advantages And Disadvantages Of Percussion

ADVANTAGES

• Percussion along with Postural drainage may enhance secretion clearance and shortens the treatment.
• Young children and infants find the rhythm soothing and are relaxed, sedated by the percussion.
• Effective in patients with chronic lung disease.
• Mechanical percussors reduce fatigue of the caregiver and is useful when patient requires ongoing treatment at home.
• Use of mechanical devices is less expensive than a caregiver or health care provider to deliver percussion.

DISADVANTAGES

• Not well-tolerated post-operatively without adequate pain control by many patients.
• Force of percussion can be threat to patients with osteoporosis or coagulopathy.
• Associated with fall in oxygen saturation.
• Long term delivery of percussion by caregiver, family member or health care professional may lead to injury of upper extremity due to repetitive motion.

Chest Percussion As A Diagnostic Tool

The physics of respiratory system is dominated by transmission properties of respiratory system which is considered as a coupled system, composed of the chest wall and lungs. Under the influence of an external shock (percussion), the chest wall tends to vibrate and ring as a resonant cavity partially damped by thoracic contents.

In healthy conditions, the vibration of percussions are underdamped, because of a large acoustic mismatch between the chest wall (semi-rigid) and the underlying lung parenchyma (a homogeneous mixture of gas and tissue). Therefore, a large proportion of the vibratory energy of percussion is reflected at the gas-tissue interface, yielding a clear, long-lasting sound described as resonant. However, in conditions such as a pneumothorax, where lung parenchyma is replaced by air, the acoustic mismatch is maximal so the underdamping is even more pronounced resulting in a sound of greater amplitude and duration (described as tympanic sound). In conditions where alveolar air is filled with exudate and/or solid tissue, the mismatch is minimal so that the percussion vibrations are over damped (they propagate away from the surface very rapidly and vanish quickly) resulting in a sound of low amplitude and duration (described as a dull sound).

Key Evidence

1. Chest percussion has been shown to cause an increase in hypoxemia, but when short periods of percussions (<30 sec) have been combined with three or four thoracic expansion exercises, no fall in oxygen saturation has been seen.
2. Some patients with severe lung disease demonstrate oxygen desaturation with self chest percussion. This may be due to the work of the additional upper limb activity.
3. In patients with neuro-muscular weakness or paralysis and in those who are intellectually impaired, in addition infants and in small children, percussion technique (manual and mechanical) may be a useful airway clearance technique which stimulates cough possibly by mobilization of secretions.