Respiratory Physiotherapy

nOriginal Editor - Manisha Shrestha Top Contributors - Manisha Shrestha, Lucinda hampton, Chelsea Mclene, Kim Jackson, Oyemi Sillo and Rishika Babburu

Original Editor - User Name

Top Contributors - Manisha Shrestha, Lucinda hampton, Chelsea Mclene, Kim Jackson, Oyemi Sillo and Rishika Babburu  

Description

Chest physiotherapy is a broad term used in research that incorporates physiotherapy treatment techniques that address the removal of secretion and improve airway clearance thereby help to improve respiratory efficiency. Chest physiotherapy is the term for a group of treatments designed to eliminate secretions thus helps to decrease work of breathing, promote the expansion of the lungs, and prevent the lungs from collapse.

It is different from bronchial hygiene therapy (BHT) in a way that BHT incorporate chest physiotherapy along with breathing exercises and manual hyperventilation in an intubated patient. Bronchial hygiene involves the use of noninvasive airway clearance techniques designed to help mobilize and remove secretions and improve gas exchange.

Chest physiotherapy is the important adjuvant treatment of most respiratory illnesses from chronic respiratory illness ( COPD, bronchiectasis, cystic fibrosis), neuromuscular diseases (muscular dystrophy, cerebral palsy, spinal cord injury), and during peri-operative care mainly in upper abdominal surgeries. Chest physiotherapy can be a valuable component of comprehensive respiratory care but only if used when indicated.

Aim of Chest Physiotherapy

The purpose of chest physiotherapy are:

• To facilitate removal of retained or profuse airway secretions.
• To optimize lung compliance and prevent it from collapsing.
• To decrease the work of breathing.
• To optimize the ventilation-perfusion ratio/ improve gas exchange.

The Physiological Mechanism of Airway Clearance

Normal Clearance

A normal clearance requires an open airway, a functional mucociliary escalator, and an effective cough. Airways normally are kept open by structural support mechanisms and kept clear by the proper function of their ciliated mucosa. The normal human bronchial tree is lined by a thin (5 micrometers) layer of mucus which is moved over the airway surface by the mucociliary escalator. The ciliated epithelium which lines the airways is responsible for the continuous flow of mucus over the airway surface to the upper respiratory tract. Mucus is moved via a coordinated movement of ciliary motion toward the trachea and larynx, where excess secretions can be swallowed or expectorated.

The Effective Cough is a must for normal airway clearance.

Although essentially a reserve clearance mechanism, the cough is one of the most important protective reflexes. By ridding the larger airways of excessive mucus and foreign matter, the cough assists the normal mucociliary clearance and helps ensure airway patency. There are four distinct phases to a normal cough: irritation, inspiration, compression, and expulsion.

Abnormal Clearance

Flow of air through the tracheobronchial tree and its interaction with the mucus lining is complex because of the branching geometry of the airways, collapsible airway walls, constantly changing the velocity of airflow, and varying viscoelastic properties of mucus. This physiology of flow in liquid line airway is called a two-phase gas-liquid flow. In endobronchial diseases, the mucus layer may exceed 5 mm in thickness and ciliary clearance becomes ineffective. Two-phase flow now becomes an important mechanism of clearance, and at a particular combination of airflow, mucus viscosity, and thickness there is a very strong gas-liquid interaction which first exacerbates the pressure decrease then detaches liquid from the airway wall. this leads to the narrowing of the lumen of the tube causing a much greater resistance, thus affect airway clearance.

One of the mechanisms by which cough affects sputum clearance in endobronchial diseases is two phases gas-liquid flow: the transfer of momentum and energy from the high-speed flow of air to the mucus that lines the bronchi. The high transmural pressure produced during cough leads to dynamic compression of the airway inhibiting mucociliary clearances. Thus, Forced expiratory technique (FET) was introduced to solve this problem.

Classification

There are various physiotherapy treatments incorporated within chest physiotherapy. Chest physiotherapy techniques can be classified as conventional, modern, and instrumental techniques based on evolving research.

Conventional techniques

Conventional chest physiotherapy is also known as traditional chest physiotherapy. It was advocated first in 1915. It involves manual handling techniques to facilitate mucociliary clearance. Postural drainage along with percussion and vibration ( PDPV) was previously widely named as Chest Physiotherapy. Later, coughing exercise, and forced expiratory techniques ( huffing) was incorporated within it. PDPV with huffing had shown an effective outcome. It can be self-administered or performed with the assistance of another person (a physiotherapist, parent, or caregiver).

Postural drainage

Postural drainage involves the positioning of the child with the assistance of gravity to aid the normal airway clearance mechanism. Postural drainage positioning varies based on specific segments of the lungs with a large amount of secretions. Postural drainage is the drainage of secretions, by the effect of gravity, from one or more lung segments to the central airways (where they can be removed by a cough or mechanical aspiration). Each position consists of placing the target lung segment(s) superior to the carina. Positions should generally be held for 3 to 15 minutes (longer in special situations). Standard positions are modified as the patient's condition and tolerance warrant. Before determining the postural drainage position, it is very important to auscultate the lungs and identify the lung segments where added sound ( Crepitus, Ronchi) is heard. Postural drainage can be facilitated with percussion and vibration in the postural drainage position.

Percussion

Percussion is also referred to as cupping, clapping, and tapotement. The purpose of percussion is to intermittently apply kinetic energy to the chest wall and lung. This is accomplished by rhythmically striking the thorax with cupped hand or mechanical device directly over the lung segment(s) being drained. 

Vibration

Vibration involves the application of a fine tremorous action (manually performed by pressing in the direction that the ribs and soft tissue of the chest move during expiration) over the draining area. In this technique, a rapid vibratory impulse is transmitted through the chest wall from the flattened hands of the therapist by isometric alternate contraction of forearm flexor and extensor muscles, to loosen and dislodge the airway secretions.

Coughing

Directed coughing or various assisted coughing are incorporated within it.

Forced Expiratory Technique (FET)

This technique involves diaphragmatic inspiration, relaxing the scapulohumeral region, and expiring forcefully from mid to low lung volumes whilst maintaining an open glottis ("huffing" exercises). It is effective than that of coughing.

Indication of Conventional techniques

Postural drainage positioning

• Inability or reluctance of patient to change body position. (eg, mechanical ventilation, neuromuscular disease, drug-induced paralysis)
• Poor oxygenation associated with the position (eg, unilateral lung disease)
• Potential for or presence of atelectasis
• Presence of artificial airway

PDPV

• 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.
• Patient with copious sputum or with central consoildation.

PDT 5.0 CONTRAINDICATIONS: The decision to use postural drainage therapy requires assessment of potential benefits versus potential risks. Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. Listed contraindications are relative unless marked as absolute (A).

5.1 Positioning

5.1.1 All positions are contraindicated for

5.1.1.1 intracranial pressure (ICP) > 20 mm Hg(59,60)

5.1.1.2 head and neck injury until stabilized (A)

5.1.1.3 active hemorrhage with hemodynamic instability (A)

5.1.1.4 recent spinal surgery (eg, laminectomy) or acute spinal injury

5.1.1.5 acute spinal injury or active hemoptysis

5.1.1.6 empyema

5.1.1.7 bronchopleural fistula

5.1.1.8 pulmonary edema associated with congestive heart failure

5.1.1.9 large pleural effusions

5.1.1.10 pulmonary embolism

5.1.1.11 aged, confused, or anxious patients who do not tolerate position changes

5.1.1.12 rib fracture, with or without flail chest

5.1.1.13 surgical wound or healing tissue

5.1.2 Trendelenburg position is contraindicated for

5.1.2.1 intracranial pressure (ICP) > 20 mm Hg(59,60)

5.1.2.2 patients in whom increased intracranial pressure is to be avoided (eg, neurosurgery, aneurysms, eye surgery)

5.1.2.3 uncontrolled hypertension

5.1.2.4 distended abdome

5.1.2.5 esophageal surgerY

5.1.2.6 recent gross hemoptysis re-lated to recent lung carcinoma treated surgically or with radiation therapy(59)

5.1.2.7 uncontrolled airway at risk for aspiration (tube feeding or recent meal)

5.1.3 Reverse Trendelenburg is contraindicated in the presence of hypotension or vasoactive medication

5.2 External Manipulation of the Thorax

In addition to contraindications previously listed

5.2.1subcutaneous emphysema

5.2.2 recent epidural spinal infusion or spinal anesthesia

5.2.3 recent skin grafts, or flaps, on the thorax

5.2.4 burns, open wounds, and skin infections of the thorax

5.2.5 recently placed transvenous pacemaker or subcutaneous pacemaker (particularly if mechanical devices are to be used)

5.2.6 suspected pulmonary tuberculosis

5.2.7 lung contusion

5.2.8 bronchospasm

5.2.9 osteomyelitis of the ribs

5.2.10 osteoporosis

5.2.11 coagulopathy

5.2.12 complaint of chest-wall pain

PDT 6.0 HAZARDS/COMPLICATIONS:

6.1 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.(20,22,48-50)

6.2 Increased Intracranial Pressure

Action To Be Taken/Possible Intervention: Stop therapy, return patient to original resting position, and consult physician.

6.3 Acute Hypotension during Procedure

Action To Be Taken/Possible Intervention: Stop therapy, return patient to original resting position, and consult physician.

6.4 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.

6.5 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 about pain medicines.

6.6 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.

6.7 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.

6.8 Dysrhythmias

Action To Be Taken/Possible Intervention: Stop therapy, return patient to previous resting position, administer or increase oxygen delivery while contacting physician.

Contraindication of Conventional Techniques

Complications

Frequency

Modern techniques

Over the years, several additional noninvasive clearance methods have been developed to augment this traditional approach. Modern techniques use a variation of flow through breath control to mobilize secretions. It includes active cycle of breathing, autogenic drainage, expiration with the glottis open in a lateral posture, and inspiratory controlled flow exercises.

Forced expiratory techniques

The recipient takes a diaphragmatic inspiration to medium volume, relaxing the scapulohumeral region, with the mouth and glottis open.

Active cycle of breathing technique

The recipient may be positioned supine, prone, lateral, or sitting and helped by the physiotherapist or perform this independently. It consists of the following phases.

• • Breathing control. The recipient performs inhalations and exhalations at current volume level, relaxing the upper thoracic region and breathing quietly using the lower chest.
  • Exercise chest expansion. This approach consists of deep‐breathing exercises performed as slow nasal breathing at inspiratory reserve volume level, followed by a two‐ to three‐second postinspiratory pause, and ending with oral expiration at functional residual capacity level.
  • Forced expiration technique. The recipient intakes diaphragmatic inspiration to medium volume, relaxing the scapulohumeral region, with the mouth and glottis open.

Autogenic drainage

This is a three‐phase breathing technique using high expiratory flow rates and variable lung volumes to unstick, collect, and evacuate secretions. The recipient is placed sitting, back straight, and head slightly hyperextended, hands resting on the upper left and right chest. The recipient first breathes at a low lung volume to unstick secretions in the peripheral airways, then at mid‐volume to collect secretions in the central airways, and finally breathes at high volume to clear secretions from the lungs. Autogenic drainage is potentially advantageous because it improves independency. No equipment is needed, and it is applicable in different settings and in daily life (Corten 2017b). The three phases of autogenic drainage are as follows.

• • Displacement: starts with a slow and forced oral expiration, recruiting a percentage of expiratory reserve volume, and then carrying inspiration to low volume, recruiting percentages of tidal volume followed by a two‐ to three‐second post-inspiratory pause. This is followed by a slow oral exhalation recruiting a percentage of expiratory reserve volume.
  • Collection: nasal inspiration to medium volume, recruiting a larger percentage of tidal volume, followed by a two‐ to three‐second post-inspiratory pause. This is followed by a slow oral exhalation recruiting a percentage of expiratory reserve volume.
  • Elimination: nasal inspiration to high volume recruiting tidal volume and a percentage of inspiratory reserve volume, followed by a two‐ to three‐second post-inspiratory pause, leading to oral expiration at the level of tidal volume. The forced expiration technique is performed to high volumes.

Instrumental techniques

Instrumental techniques such as non‐invasive ventilation have been considered useful as an adjunct therapy to airway clearance and to provide respiratory support. A common instrumental technique is continuous positive airway pressure (CPAP). CPAP as be used in a conventional way via bCPAP in which positive airway pressure is given by generating a gentle air pressure via 'bubbles' in the expiratory tube submerged in an underwater system. Incentive spirometry, positive expiratory pressure, and flutter are other tools that can be used to increase lung expansion and improve gas exchange.

Assessment of need and outcome

The following should be assessed together to establish a need for chest physiotherapy:

• Excessive sputum production
• Effectiveness of cough
• History of pulmonary problems treated successfully with PDT (eg, bronchiectasis, cystic fibrosis, lung abscess)
• Decreased breath sounds or crackles or rhonchi suggesting secretions in the airway
• Change in vital signs
• Abnormal chest x-ray consistent with atelectasis, mucus plugging, or infiltrates
• Deterioration in arterial blood gas values or oxygen saturation

The following can be used as outcome tool to determine the effectiveness of treatment:

• Change in sputum production
• Change in breath sounds of lung fields
• Patient subjective response to therapy
• Change in vital signs
• Change in chest x-ray
• Change in arterial blood gas values or oxygen saturation
• Change in ventilator variables.
• Change in Modified borg scale- dyspnea level
• Change in Peak Expiratory Flow Rate.

Resources

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