Learning Objectives:

At the end of the discussion, the student’s will be able to:

1. Identify factors influencing respiratory function.

2. Enumerate common manifestations of impaired respiratory function.
3. Describe the nursing measures to promote respiratory function and oxygenation.
4. Discuss chest physiotherapy (percussion, vibration, and postural drainage) and
deep breathing and coughing exercises.
5. Demonstrate the chest physiotherapy, deep breathing and coughing exercises.
6. Explain the use of therapeutic measures such as chest physiotherapy and deep
breathing and coughing exercises.
7. State outcome criteria for evaluating client responses to measures adequate
oxygenation.

Review

The purpose of the lungs is to move oxygen from the air we breathe into
bloodstream so it can be used by our body.

Air enters the lungs through mouth or nose and travels down windpipe (trachea)
into increasingly smaller airways.

The structure of the airway tubes is similar to a tree trunk dividing into smaller and
smaller branches.

The smallest tube, which is about the thickness of a strand of hair, ends in bunches
of tiny air sacs (alveoli).

Each air sac is covered with very fine blood vessels (capillaries).

When you breathe in air, the air moves through the airways down to the air sacs.
The oxygen passes from the air sacs into the blood stream and is carried to the rest
of the body.
Which Patients Should Perform Respiratory Exercises?

 Patients with chronic obstructive pulmonary disease (COPD);

 Patients with an interstitial lung disease;
 Patients with cystic fibrosis;
 Patients undergoing lung, chest or abdominal surgery;
 Patients with a muscle-wasting disorder that affects breathing muscles;
 Patients with asthma;
 Patients undergoing surgery for a lung transplant or lung cancer; and
 Any patient who may be immobile for whatever reason.

Performing respiratory exercises can help to:

 Strengthen accessory muscles around the lung, as they become weak when a patient is
not able to mobilize;
 Strengthen the diaphragm, allowing it to assist with lung expansion and improve air
reaching the base of the lung;
 Take the burden off other muscles in the neck, back and chest that are used when the
diaphragm is not working to full capacity;
 Clear the airway of excess sputum;
 Improve lung function; and
 Reduce the risk of developing respiratory infections or atelectasis (alveoli collapse).

Preparing Patients for Breathing Exercises

1. Consider administering analgesia prior to starting. If the patient has pain they will not be
able to perform the exercises.
2. Mobilize the patient to ensure they do not acquire a lung infection or atelectasis.
3. Sit the patient out of bed or up in bed (the aim is to optimize lung expansion).
4. Critical care patients can sit out of bed if they are hemodynamically stable (this allows
for better lung expansion). Ensure you have two to three clinicians assisting with any
intravenous lines, cardiac monitoring, drain tubes etc.
5. Ensure the patient is comfortable.
6. Place a folded towel up against the patient’s chest or abdomen to provide comfort and
security around any wounds they may have.

I. Deep Breathing and Coughing

A. Pursed Lip Breathing

Pursed lip breathing is a technique that helps to control your breathing rate and
improve your shortness of breath. Helps the client develop control over
breathing. The purse lips create resistance to the air flowing out of the lungs,
thereby prolonging exhalation and preventing airway collapse by maintaining
positive airway pressure.

Practice
1. Breath in slowly through your nose. Inhales to a count of 3.
2. Pause.
3. Purse the lips as if about to whistle.
4. breathes out slowly and gently, tightening the abdominal muscles to exhale more
effectively. Exhales to a count of 7.

B. Diaphragmatic Breathing

The diaphragm is made up of two large, dome shaped muscles located just below
the lungs. When they are tightened (contracted), there is more room in the chest
 cavity for your lungs to expand. The diaphragm also pull the lungs downward and
helps draw air into the lungs.

Diaphragmatic Breathing permits full breaths with little effort.

Practice:
1. In a comfortable position, place one hand on your abdomen above your belly
button. Breathe in slowly through your nose.
2. Feel your belly rise slowly as you breathe in. Let the air out through pursed lips
(see above). The upper part of your chest should stay relaxed.
3. Once you are able to do this type of breathing both sitting and lying, try using it
while standing and walking. Exhale through pursed lips Diaphragm.
Coughing and Sputum Clearance Cough and sputum are two other symptoms of
your disease.

C. Coughing

Coughing is important because it helps remove sputum from lungs. When

sputum is removed breathing is easier.

It is helpful to cough early in the day to remove the sputum that has built up during the
night. It is also helpful to cough well, about a half an hour before lunch and supper; it may help
make meal more enjoyable. Before going out, cough to clear any sputum.

Coughing gently or making short grunting noises with the mouth slightly open
will help loosen the mucus.

Controlled Cough Technique Practice

 1. Controlled Coughing Technique

 Controlled coughing is one of the essential techniques in good respiratory care.

 Patient perform this maneuver after each drainage position and often throughout the
day.
 The abdominal muscles are very powerful muscles used in coughing and exhaling.

Practice:

1. Sit comfortably with your feet resting firmly on the floor, and lean forward slightly.
2. Take three to four deep diaphragmatic breaths before coughing.
3. Take a deep breath, hold your breath for three seconds, tighten your abdominal muscles and
cough twice. The first cough will loosen your sputum. The second cough will move the sputum
high in your throat.
4. Spit it into a piece of tissue and check the color. If it is a yellow, green or red in color, talk to
your doctor. Throw the tissue away.
5. Take a break and repeat once or twice if you do not cough up any sputum.

Relaxation Positions to Reduce Shortness of Breath

When breathing is difficult, use one of these positions to help you relax and regain control of
your breathing:

Practice

Lying
● Lie on your side, leaning on three or four pillows
. ● Keep your head up and your shoulder supported.

Sitting (I)
● Sit at a table, lean forward and rest your arms on the table.
● Rest your head on a pillow.

Sitting (2)
● Sit in a chair, lean forward and rest your forearms on your thighs.

Standing (I)
● When you are not able to sit down, lean forward and support your arms on an
object near shoulder level (e.g., car roof, mantle, filing cabinet)
● Rest your head on your forearms.

Standing (2)
● Lean your back against a wall.
● Relax your shoulders and let your arms hang loosely.
 Coping with being Short of Breath

1. Find a relaxation position that is most comfortable for you. Do not worry about
how fast you are breathing.
2. Breathe in through your mouth and out through your mouth.
3. Begin to lengthen the time you breathe out.
4. Try to breathe in through your mouth and out through pursed lips.
5. Breathe in through your nose and out through pursed lips.
6. Start diaphragmatic breathing and continue to breathe out through pursed lips.
7. Continue until you feel more relaxed.

II. Chest physiotherapy (Percussion, Vibration, and Postural Drainage, PVD)

Chest physiotherapy

- Chest physiotherapy (CPT) is a technique used to mobilize or loose secretions in the

lungs and respiratory tract. 
- This is especially helpful for patients with large amount of secretions or ineffective cough.
This treatments designed to eliminate secretions thus helps to decrease work of
breathing, promote the expansion of the lungs , and prevent the lungs from collapse.
- 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 consists of external mechanical maneuvers, such as chest percussion,
postural drainage, vibration, to augment mobilization and clearance of airway secretions,
diaphragmatic breathing with pursed-lips, coughing and controlled coughing.
- This is a dependent nursing function.

INDICATIONS OF CHEST PHYSIOTHERAPY

It is indicated for patients in whom cough is insufficient to clear thick, tenacious, or localized
secretions. Examples include:
 Cystic fibrosis
 Bronchiectasis
 Atelctasis
 Lung abscess
 Neuromuscular diseases
 Pneumonias in dependent lung regions.

CONTRAINDICATIONS OF CHEST PHYSIOTHERAPY

 Increased ICP
 Unstable head or neck injury
 Active hemorrhage with hemodynamic instability or hemoptysis
 Recent spinal injury or injury
 Empyema
 Bronchoplueral fistula
 Rib fracture
 Fail chest
 Uncontrolled hypertension
 Anticoagulation
 Rib or vertebral fractures or osteoporosis

ASSESSMENT FOR CHEST PHYSIOTHERAPY

Nursing care and selection of CPT skills are based on specific assessment findings. The following
are the assessment criteria:

Determine:

  Normal range of patient’s vital signs. Conditions requiring CPT, such atelectasis, and
pneumonia, affects vital signs.             
  Patient’s medications. Certain medications, particularly diuretics antihypertensive
cause fluid and hemodynamic changes. These decrease patient’s tolerance to positional changes
and postural drainage.
 Patient’s medical history; certain conditions such as increased ICP, spinal cord injuries
and abdominal aneurysm resection, contra indicate the positional change to postural drainage.
Thoracic trauma and chest surgeries also contraindicate percussion and vibration.
 Patient’s cognitive level of functioning. Participating in controlled cough techniques
requires the patient to follow instructions.                         
 Beware of patient’s exercise tolerance. CPT maneuvers are fatiguing. Gradual increase  
in activity and through CPT, patient tolerance to the procedure improves.

CLINICAL FINDINGS AND INVESTIGATIONS

 Detailed History
 Physical examination
 Inspection
 Palpation
 Percussion
 Auscultation
 Investigations
 X-ray
 Blood investigations-bleeding and clotting parameters

TECHNIQUES IN CHEST PHYSIOTHERAPY

 A nurse or respiratory therapist may administer CPT, although the techniques can often
be taught to family members of patients.
 The most common procedures used are postural drainage and chest percussion, in
which the patient is rotated to facilitate drainage of secretions from a specific lobe or segment
while being clapped with cupped hands to loosen and mobilize retained secretions that can then
be expectorated or drained.
The procedure is somewhat uncomfortable and tiring for the patient.

Percussion
 Also referred to as cupping, clapping, and tapotement. The purpose of percussion is
to intermittently apply kinetic energy to the chest wall and lungs. This is
accomplished by rhythmically striking the thorax with a cupped hand or mechanical
device directly over the lung segment(s) being drained. 
Fingers and thumb are held together
and flexed slightly to form a cup, as
one would to scoop up water.

 Percussing lung areas involves the use of cupped palm to loosen pulmonary secretions
so that
they can be expectorated with ease.
 Percussing with the hand held in a rigid dome-shaped position, the area over the lung
lobes to be drained in struck in rhythmic pattern.
 Usually the patient will be positioned in supine or prone and should not experience any
pain. 
 Cupping is never done on bare skin or performed over surgical incisions, below the ribs,
or over the spine or breasts because of the danger of tissue damage.
 Typically, each area is percussed for 30 to 6oseconds several times a day.
 If the patient has tenacious secretions, the area must be percussed for 3-5 minutes
several times per day. Patients may learn how to percuss the anterior chest as well.

To percuss a client’s chest, the nurse follow these steps:

1. Cover the area with a towel or gown to reduce discomfort.
2. Ask the client to breathe slowly and deeply to promote relaxation.
3. Alternately flex and extend the wrists rapidly to slap the chest.
4. Percuss each affected lung segment for 1 to 2 minutes.
2. Vibration

 Vibration involves the application of a fine tremulous 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.
  In vibration, the nurse uses rhythmic contractions and relaxations is or her arm and
shoulder muscles while holding thee patient flat on the patient’s chest as the patient
exhales.
 The purpose is to help loosen respiratory secretions so that they can be expectorated
with ease. Vibration (at a rate of 200 per minute) can be done for several times a day.
 To avoid patient causing discomfort, vibration is never done over the patient’s breasts,
spine, sternum, and rib cage.
 Used after percussion to increase the turbulence of the exhaled air and thus loosen thick
secretions. It is often done alternately with percussion.
 Vibration can also be taught to family members or accomplished with mechanical
device.

To vibrate the client’s chest, the nurse follow these steps:

1. Place hands, palm down, on the chest area to be drained, one hand over the other with
the fingers together and extended. Alternatively, the hands may be place side by side.
 Procedure: Percussion & Vibration

 Instruct the patient use diaphragmatic breathing

 Position the patient in prescribed postural drainage positions. Spine should be straight
to promote rib cage expansion
 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 conditions
 Avoid clapping over spine, liver, spleen, breast, scapula, clavicle or sternum
 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.
 Allow the patient rest several times
 Listen with stethoscope for changes in breath sounds
 Repeat the percussion and vibration cycle according to the patient’s tolerance and
clinical response: usually 15-30 minutes.
 2. Postural Drainage

 Postural drainage is the positioning techniques that drain secretions from specific
segments of the lugs and bronchi into the trachea.
 Because some patients do not require postural drainage for all lung segments, the
procedure must be based on the clinical findings.
 In postural drainage, the person is tilted or propped at an angle to help drain secretions
from the lungs.
 Also, the chest or back may be clapped with a cupped hand to help loosen secretions—
the technique called chest percussion.
 Postural drainage cannot be used for people who are:
- unable to tolerate the position required,
- are taking anticoagulation drugs,
- have recently vomited up blood,
- have had a recent rib or vertebral fracture, or
- have severe osteoporosis.
- Postural drainage also cannot be used for people who are unable to produce any secretions
(because when this happens, further attempts at postural drainage may lower the level of
oxygen in the blood).
 The nurse needs to evaluate the client’s tolerance of postural drainage by assessing the stability
of the client’s vital signs, particularly the pulse and respiratory rates, noting signs of intolerance,
such as pallor, diaphoresis, dyspnea, nausea and fatigue.
 Morning is the best time to do postural drainage, because it helps clear mucus that has built up
during the night. It may also be done just before bed to decrease nighttime coughing. Do not do
it soon after a meal, because this may increase the chance of vomiting.
 Before postural drainage treatments are scheduled 2 or 3 times daily, depending on the degree
of lung congestion.

PROCEDURE

 The patient's body is positioned so that the trachea is inclined downward and below the
affected chest area.
 Postural drainage is essential in treating bronchiectasis and patients must receive
physiotherapy to learn to tip themselves into a position in which the lobe to be drained is
uppermost at least three times daily for 10-20 minutes.
 The treatment is often used in conjunction with the technique for loosening secretions
in the chest cavity called chest percussion.

ARTICLES REQUIRED

 Pillows
 Tilt table
 Sputum cup
 Paper tissues
 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
obstruction
4. The exercises are performed two to three times a day, before meals and bedtime. Each
position is done for 3-15 minutes
5. The procedure should be discontinued if tachycardia, palpitations, dyspnea, or chest occurs.
These symptoms may indicate hypoxemia. Discontinue if hemoptysis occurs.
6. Bronchodilators, mucolytic agents, water, or saline may be nebulized and inhaled before
postural drainage and chest percussion to reduce bronchospasm, decrease thickness of mucus
and sputum, and combat edema of the bronchial walls, thereby enhancing secretion removal
7. Perform secretion removal procedures before eating
8. Make sure patient is comfortable before the procedure starts and as comfortable as
possible he or she assumes each position
9. Auscultate the chest to determine the areas of needed drainage
10. Encourage the patient to deep breath and cough after spending the allotted time in each
position.
11. Encourage diaphragmatic breathing throughout postural drainage: this helps widen
airways so secretions can be drained

General Instructions to Patient:

1. Be sure the back is covered. Wear a shirt or blouse, or cover their back with a
towel.
2. Hold each position for 5 minutes to help the mucus drain from the lungs.
3. For each position, the caregiver claps the back quickly and rhythmically.
4. When caregiver claps, a hollow sound will be heard.
POSITIONS

ADULT

Lung segment Position recommended

Bilateral High Fowler’s

Apical-right upper lobe-anterior segment Sitting on side of the bed

Supine with head elevated

Left upper lobe-anterior Supine with head elevated

Right upper lobe-posterior Side-lying with right side of the chest elevated
on pillows

Right Middle lobe-anterior segment Three-fourth supine position with dependent

lung in Trendelenburg’s position

Both lower lobes-anterior segments Supine in Trendelenburg’s position

Left lower lobe lateral position Right side-lying in Trendelenburg’s position

Right lower lobe-lateral segment Left side-lying in Trendelenburg’s position

Right lower lobe-posterior segment Prone with right side of chest elevated in
Trendelenburg’s position

Both lower lobes-posterior segment Prone in Trendelenburg’s position

Toddlers and older: Lay the child on his or her stomach with the head and upper body tipped
down at a 30-degree angle. Clap with a cupped hand over the lower ribs and behind the armpit
on each side.

Toddlers and older: Lay your child on his or her stomach with the head and upper body tipped
down at a 30-degree angle. Clap with a cupped hand over the lower ribs and behind the armpit
on each side.

CHILD

Bilateral-Apical segments Sitting on nurse’s lap, leaning slightly forward

flexed over pillow.

Bilateral-middle anterior segments Sitting on nurse’s lap, leaning against nurse

Bilateral- anterior segments Lying supine on nurse’s lap, back supported

with pillow.
Illustration adapted with permission
from the University of Wisconsin
Medical School.

Infants: Lay your infant on his or her

back with the head and upper body flat.
Clap with a cupped hand on the front of
the chest in the nipple area and just
below it. In order to prevent the chance
of reflux, do not tip your infant so that
he or she is in a head-down position for
postural drainage.

Toddlers and older: Lay your child on

his or her back with the head and upper
body tipped down at a 30-degree angle.
Clap with a cupped hand on the front of
the chest in the nipple area and just
below it. For girls with developing
breasts, put the heel of your hand under
the armpit and clap with the fingers
beneath the breast.
Illustration adapted with permission
from the University of Wisconsin
Medical School

Infants: Lay your infant on his or her side,

being sure to keep the head and upper body
as flat as possible. Clap with a cupped
hand below the armpit on each side. To
prevent the chance of reflux, do not tip
your infant so that he or she is in a head-
down position for postural drainage.

Toddlers and older: Lay your child on his

or her side, with the head and upper body
tipped down at a 30-degree angle. Clap
with a cupped hand below the armpit on
each side.

Illustration adapted with permission

from the University of Wisconsin
Medical School.

Have the child lean forward 30 degrees.

Clap with a cupped hand between the
collarbone and shoulder blade on each side
of the back.

Illustration adapted with permission

from the University of Wisconsin
Medical School.

Lean the child back 30 degrees. Clap with

a cupped hand between the collarbone and
nipple on each side of the chest.
(John Pope MD & Catherine O’Malley; May 4, 2017;
https://www.cigna.com/individuals-families/health-wellness/hw/medical-topics/postural-
drainage-and-chest-percussion-hw185489

COMPLICATIONS

Complications are unusual but include:

2. position-related hypoxia 
3. aspiration of secretions in other lung regions
4. hypotension

 The sequence for PVD is usually as follows, positioning, percussion, vibration, and
removal of secretions by coughing or suction.
 Following PVD, the nurse should auscultate the client’s lungs, compare the findings to
the base line data, document the amount, color, and character of expectorated
secretions.

CONCLUSION

Chest physiotherapy is an effective procedure in chronic pulmonary disorders. This is especially

helpful for patients with large amount of secretions or ineffective cough.  It is performed by
professionally trained nurses in most settings.
Continuous Positive Airway Pressure (CPAP)

Positive airway pressure (PAP) treatment uses a machine to pump air under pressure
into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air
delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse
that block the breathing in people with obstructive sleep apnea and other breathing problems.

CPAP is an effective treatment for moderate to severe obstructive sleep apnea. Patients
with obstructive sleep apnea treated with CPAP wear a face mask during sleep which is
connected to a pump (CPAP machine) that forces air into the nasal passages at pressures high
enough to overcome obstructions in the airway and stimulate normal breathing. The airway
pressure delivered into the upper airway is continuous during both inspiration and expiration.
Nasal CPAP is currently the preferred treatment for moderate to severe obstructive
sleep apnea. CPAP is safe and effective, even in children. Daytime sleepiness improves or
resolves. Heart function and hypertension also improve. And, importantly, the quality of life
improves.

At first, CPAP patients should be monitored in a sleep lab to determine the appropriate
amount of air pressure for them. The first few nights on CPAP tend to be difficult, with patients
experiencing less sleep. Many patients at first find the mask uncomfortable, claustrophobic or
embarrassing. CPAP is not a cure and must be used every night for life. Non-compliant patients
experience a full return of obstructive sleep apnea and related symptoms.