Respiratory Physiotherapy

Original 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 vital constituent of respiratory care. It is used as an important adjuvant treatment of most respiratory illnesses from chronic respiratory illness ( COPD, asthma, cystic fibrosis), neuromuscular diseases (muscular dystrophy, cerebral plays, spinal cord injury, motor neuron diseases), mechanically ventilated patients ( conscious or unconscious), and pre and post-surgeries.

Chest physiotherapy is the term for a group of treatments designed to improve respiratory efficiency, promote the expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system. These techniques are also used as preventive measures to prevent secondary complications such as pneumonia pre and post-surgery. Based upon the condition of the patient and goals to achieve, techniques of chest physiotherapy are chosen and applied. It is very necessary to keep in mind the contraindications and precautions of techniques of chest physiotherapy. For instance, rib fracture is absolutely contraindicated for percussions and vibrations, contagious viral infections causing pneumonia are relative contraindications for aerosol-generating techniques like huffing and coughing.

Aim of the 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

Classification

There are various physiotherapy treatments incorporated with chest physiotherapy. Chest physiotherapy techniques can be classified as conventional, modern, and instrumental techniques.

Conventional techniques

Conventional chest physiotherapy involves manual handling techniques to facilitate mucociliary clearance. It includes postural drainage, percussion, vibration, huffing, coughing, and thoracic squeezing. 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 mobilize secretions towards the main bronchus. Postural drainage positioning varies based on specific segments of the lungs with large amount of secretions. 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 also facilitated with percussion and vibration in the postural drainage position.

Percussion

The therapist uses a single hand or both cupped hands or three fingers with the middle finger tented, or a facemask with the port either covered or occluded by a finger, and strikes repeatedly at a rate of three per second over the part of the bronchopulmonary segment that needs to be drained.

Vibration

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.

Huffing

Fast expiration at high volume by the patient

Coughing

The child is requested to cough. In uncooperative or small children, tracheal stimulation or tickling can be performed by placing index finger or thumb on the anterior side of the neck against trachea just above sternal notch with gentle but firm inward pressure in a circular pattern as the child begins to exhale.

Thoracic squeezing

This method stimulates the normal cough mechanism through elevation of intrathoracic pressure. This technique, which does not require any special equipment, is used exclusively for the thorax. The hands are placed on the lower third of the thorax. The therapist then applies pressure to increase the forced expiratory volume (FEV) by 30%. It is not necessary to disconnect the patient from the ventilation machine during treatment, which decreases episodes of hypoxaemia and the use of high fraction of inspired oxygen (FiO₂).

Modern techniques

These techniques use a variation of flow through breath control to mobilize secretions. It includes forced expiration techniques, active cycle of breathing, autogenic drainage, assisted autogenic drainage, slow and prolonged expiration, increased expiratory flow, total slow expiration with the glottis open in a lateral posture, and inspiratory controlled flow exercises.

Forced expiratory technique

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.

Assisted autogenic drainage.

This is a modified form of autogenic drainage, used for babies and young children because it does not require active participation. The physiotherapist influences the level of breathing without the child consciously influencing the level of breathing (Corten 2017b).

Slow and prolonged expiration.

This is an entirely passive technique used when the age of a young child makes them unable to co‐operate. The child is positioned supine. The therapist places one hand on the child's chest and the other on the abdomen. At the end of a spontaneous expiration, the pressure is applied to the chest caudally and on the abdomen in a cephalic orientation. The pressure is maintained for two to three respiratory cycles. No pressure is exerted during the first part of expiration (Postiaux 1997).

Increased expiratory flow.

This technique should be performed during the expiratory time using pressure exerted by the physiotherapist's hand on the child's chest, with the child lying supine. The other hand remains static over the abdomen to prevent the dissipation of pressure to the abdominal compartment, with the goal of deflation, the speed of which should be more than a spontaneous expiration (Postiaux 1992).

Total slow expiration with the glottis open in a lateral posture. The child is placed in lateral position, and may be helped by the physiotherapist or perform independently. The child takes nasal inspiration at tidal volume level and slowly expires the breath with the open glottis at residual volume level (Postiaux 1997).

Exercises of controlled inspiratory flow. This technique can be performed in two positions: posterolateral and anterolateral. In the first position, the child is placed in lateral position with the trunk and pelvis tilted slightly above perpendicular to the plane of support. In the second position, the child is placed in lateral position with the limb flexed and the upper hand on the occipital region to promote the elongation of the pectoral musculature. In both placements, the child performs a slow, deep inspiration recruiting the inspiratory reserve volume, then a two‐ to three‐second postinspiratory pause, followed by oral expiration at functional residual capacity level (Postiaux 2000).

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.

Clinical Presentation

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Resources

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