Introduction[edit | edit source]
The term chest physiotherapy (CPT) stands for a spectrum of physical and mechanical interventions aimed at interacting therapeutically with acute and chronic respiratory disorders.Among various techniques for airway clearance, postural drainage is one of the widely used methods since decades.
Definition[edit | edit source]
Postural drainage is the positioning of a patient with an involved lung segment such that gravity has a maximal effect of facilitating the drainage of broncho-pulmonary secretions from the tracheobronchial tree.It is based on the concept of gravity-assisted mobilization of secretions and transport it for removal. It is a positioning technique to mobilize bronchial secretions.
Mechanism[edit | edit source]
During erect position only the segments of the right upper lobe and non-lingular portion of the left upper lobe receive gravitational assistance whereas the segment of the middle, lingular portion of left upper lobe and lower lobe segments of both lungs must drain against gravity. In normal healthy state, the mucociliary mechanism clears off the bronchial secretions. In diseased state they get compromised and secretions get accumulated especially in the smaller airways that cannot be emptied without gravity assistance which can further lead to inflammation and scarring.The natural methods of emptying the tracheo-bronchial tree of accumulated secretion are on the whole extremely inefficient. Ciliary action -only removes minute particulate matter such as dust or bacteria, and is of no value when there is much secretion.
Procedure[edit | edit source]
The patient is tilted or propped at an angle required and chest percussion is performed to loosen the secretions. Frames, tilt tables, and pillows may be used to support patients in these positions. There are postural beds that have a hinge in the middle.
In general, the upper lobe segments have the advantage of gravity drainage both in erect as well as in semi recumbent position, so postural drainage can be facilitated in sitting or lying posture. The middle and lower lobes do not have the advantage of gravity drainage in erect, semi-recumbent or recumbent postures.
A foot end elevation of 14-18 inches is requires for the drainage of middle and lower lobes. 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.
In critical care patients, including those on mechanical ventilation, Postural Drainage should be performed from every 4 to every 6 hours as indicated. PDT order should be re-evaluated at least every 48 hours based on assessments from individual treatments. Domiciliary patients should be reevaluated every 3 months and with change of status. . In the actively cooperating patient, postural drainage can be complemented by thoracic expansion exercises and by breathing control.
Positions[edit | edit source]
Upper Lobe[edit | edit source]
APICAL SEGMENTS -The patient should sit upright, with slight variations according to the position of the lesion which may necessitate leaning slightly j backward, forward or sideways. The position is usually only necessary for infants or patients being nursed in a recumbent j position, but occasionally may be required if there is an abscess or stenosis of a bronchus in the apical region.
ANTERIOR SEGMENTS - The patient should lie flat on his back with his arms relaxed to his side; the knees should be slightly flexed over a pillow.
- Right - The patient should lie on his left side and then turn 450 on to his face, resting against a pillow with another supporting his head. He r should place his left arm comfortably behind his back with his right arm resting on the supporting pillow; the right knee should be flexed.
- Left - The patient should lie on his right side turned 450 on to his face with three pillows arranged to raise the shoulder 30cm (i2in) from the bed. He should place his right arm behind his back with his left arm resting on the supporting pillows; both the knees should be slightly bent.
Middle Lobe[edit | edit source]
LATERAL SEGMENT: MEDIAL SEGMENT The patient should lie on his back with his body quarter turned to the left maintained by a pillow under the right side from shoulder to hip and the arms relaxed by his side; the foot of the bed should be raised 35cm (14in) from the ground. The chest is tilted to an angle of 15°.
Lingula[edit | edit source]
SUPERIOR SEGMENT: INFERIOR SEGMENT - The patient should lie on his back with his body quarter turned to the right maintained by a pillow under the left side from shoulder to hip and the arms relaxed by his side; the foot of the bed should be raised 35cm (14m) from the ground. The chest is tilted to an angle of 15°.
Lower Lobe[edit | edit source]
APICAL SEGMENTS - The patient should lie prone with the head turned to one side, his arms relaxed in a comfortable position by the side of the head and a pillow under his hips.
ANTERIOR BASAL SEGMENTS - The patient should lie flat on his back with the buttocks resting on a pillow and the knees bent; the foot of the bed should be raised 46cm (i8in) from the ground. The chest is tilted to an angle of 20°
POSTERIOR BASAL SEGMENTS - The patient should lie prone with his head turned to one side, his arms in a comfortable position by the side of the head and a pillow under his hips. The foot of the bed should be raised 46cm (i8in) from the ground. The chest is tilted to an angle of 20°.
MEDIAL BASAL (CARDIAC) SEGMENT - The patient should lie on his right side with a pillow under the hips and the foot of the bed should be raised 46cm (i8in) from the ground. The chest is tilted to an angle of 20°.
LATERAL BASAL SEGMENT - The patient should lie on the opposite side with a pillow under the hips and the foot of the bed should be raised 46cm (i8in) from the ground. The chest is tilted to an angle of 20°.
Assessment[edit | edit source]
The following should be assessed and reported to establish a need for postural drainage:-
- A recent radiograph or bronchogram if available, is a useful adjunct in isolating the affected areas.
- Pulmonary Function Test
- excessive sputum production
- effectiveness of cough
- history of pulmonary problems treated successfully with PDT (e.g., 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
Indications[edit | edit source]
The following are the indications for postural drainage:-
- evidence or suggestion of difficulty with secretion clearance
- difficulty clearing secretions with expectorated sputum production greater than 25-30 mL/day (adult)
- evidence or suggestion of retained 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
Contraindications[edit | edit source]
The following are contraindications for postural drainage
- often not suitable for infants in the NICU, who may have lots of equipment attached to them.
- Head injuries including cerebral vascular accidents because intracranial pressure would be increased.
- Severe hypertension as venous return is increased with tipping and this can overload the heart.
- Following esophagectomy there can be undue stress on the anastomosis and tipping may cause regurgitation.
- Severe hemoptysis, when all forms of physiotherapy should be discontinued until there has been discussion with the doctors.
- Aortic aneurysms which would be put under tension if the patient is tipped.
- Pulmonary edema which collects in the dependent areas; postural drainage would cause extreme dyspnea and probably worsen the situation.
- Surgical emphysema which might track toward the face if the patient is tipped and might result in dyspnea. Tension pneumothorax without an intercostal drain. This condition should not require physiotherapy, but must never be tipped as the cardiac embarrassment may lead to a cardiac arrest.
- Cardiac arrhythmias which can be worsened by postural drain-1 age; in some positions the myocardial oxygen demand would be greater and so its sensitivity to abnormal rhythms is increased
- Hiatus hernias should not be tipped as the patient may regurgitate gastric juices.
- The filling cycle of peritoneal dialysis. The descent of the diaphragm is impeded during this phase and tipping may cause more respiratory distress.
- Facial edema from burns will be increased with tipping
- Eye operations where there may be some associated edema which could be increased with tipping.
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- West MP. Postural Drainage. Acute Care Handbook for Physical Therapists. 2013 Sep 27:467.
- Balachandran A, Shivbalan S, Thangavelu S. Chest physiotherapy in pediatric practice. Indian pediatrics. 2005 Jun 1;42(6):559.
- Nelson HP. Postural drainage of the lungs. British medical journal. 1934 Aug 11;2(3840):251.
- Sobush DC. The evolution of a clinical practice guideline: from chest physical therapy (CPT) to postural drainage therapy (PDT). Cardiopulmonary Physical Therapy Journal. 1992 Oct 1;3(3):4-7.
- Downie PA, Innocenti DM, Jackson SE. Cash's textbook of chest, heart and vascular disorders for physiotherapists.
- Goldsmith JP, Karotkin E, Suresh G, Keszler M. Assisted ventilation of the neonate E-book. Elsevier Health Sciences; 2016 Sep 2.