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Management of
Pulmonary Conditions 25
CHAPTER

REVIEW OF RESPIRATORY STRUCTURE Teaching an Effective Cough 868

AND FUNCTION 852 Additional Techniques to Facilitate a Cough and
Thorax and Chest Wall: Structure Improve Airway Clearance 869
and Function 852 Suctioning: Alternative to Coughing 870
Muscles of Ventilation 852 POSTURAL DRAINAGE 870
Mechanics of Ventilation 853 Manual Techniques Used with Postural
Anatomy and Function of the Drainage Therapy 870
Respiratory Tracts 854 Postural Drainage Positions 872
The Lungs and Pleurae 855 Guidelines for Implementing Postural
Lung Volumes and Capacities 856 Drainage 874
EXAMINATION 856 Modified Postural Drainage 874
Components of the Examination 857 Home Program of Postural Drainage 875
BREATHING EXERCISES AND VENTILATORY MANAGEMENT OF PATIENTS WITH CHRONIC
TRAINING 861 OBSTRUCTIVE PULMONARY DISEASE 875
Guidelines for Teaching Breathing Exercises 861 Types of Obstructive Pulmonary Disorders 875
Diaphragmatic Breathing 862 Pathological Changes in the Pulmonary
Segmental Breathing 863 System 875
Pursed-Lip Breathing 864 Impairments and Impact on Function 875
Preventing and Relieving Episodes Management Guidelines: COPD 876
of Dyspnea 865 MANAGEMENT OF PATIENTS WITH
Positive Expiratory Pressure Breathing 865 RESTRICTIVE PULMONARY DISORDERS 876
Respiratory Resistance Training 866 Acute and Chronic Causes of Restrictive
Glossopharyngeal Breathing 866 Pulmonary Disorders 876
EXERCISES TO MOBILIZE THE CHEST 867 Pathological Changes in the Pulmonary
Specific Techniques 867 System 876
Management Guidelines: Post-Thoracic
COUGHING 868
Surgery 876
The Normal Cough Pump 868
Factors that Decrease the Effectiveness of the INDEPENDENT LEARNING ACTIVITIES 880
Cough Mechanism and Cough Pump 868

C ardiovascular and pulmonary physical therapy is a mul-
tifaceted area of professional practice that deals with the
management of patients of all ages with acute or chronic,
primary or secondary cardiovascular and pulmonary disor-
ders. Although the cardiovascular and pulmonary systems
are inherently linked as they interface with all other body
systems, the focus of this chapter is on examination proce-
dures and therapeutic interventions used for the manage-
ment of patients with pulmonary dysfunction. In particular,
exercise interventions and manual techniques that enhance
ventilation and airway clearance are presented.
The goals of cardiovascular and pulmonary physical
therapy for patients with respiratory dysfunction are to:
Prevent airway obstruction and accumulation of secre-
tions that interfere with normal respiration/oxygen
transport.
Improve airway clearance, cough effectiveness, and
ventilation through mobilization and drainage of
secretions.
Improve endurance, general exercise tolerance, and
overall well-being.
Reduce energy costs during respiration through
breathing retraining.
Prevent or correct postural deformities associated with
pulmonary or extrapulmonary disorders.
Maintain or improve chest mobility.

851
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852 REVIEW OF RESPIRATORY STRUCTURE AND FUNCTION
All of these goals are aimed at improving a patient’s
overall ability to meet necessary and desired functional
demands.
Treatment settings vary widely, from intensive care
or postsurgical care units and extended care/subacute reha-
bilitation facilities to outpatient pulmonary centers and the
home setting.
REVIEW OF RESPIRATORY
STRUCTURE AND FUNCTION
Respiration is a general term used to describe gas exchange
within the body and can be categorized as either external
respiration or internal respiration. Basic terms are described
here but an in-depth discussion of respiratory physiology,
including diffusion and perfusion, goes well beyond the
scope or purpose of this chapter. The reader is referred to
several references for further study.11,22,34,59,61
External respiration describes the exchange of gas at
the alveolar-capillary membrane and the pulmonary capil-
laries. When a person inhales and oxygen is delivered to
the alveoli via the tracheobronchial tree, oxygen diffuses
through the alveolar wall and interstitial space and into the
bloodstream through the pulmonary capillary walls. The
opposite occurs with carbon dioxide transport. Internal
respiration describes the exchange of gas between the
pulmonary capillaries and the cells of the surrounding
tissues. Internal respiration occurs when oxygen in arterial
blood diffuses from red blood cells into tissues requiring
oxygen for function. The reverse occurs with carbon
dioxide transport.
Ventilation, as it refers to the respiratory system, is the
mass exchange of air to and from the body during inspira-
tion and expiration. This cyclic process requires coordinat-
ed ventilatory muscle activity, rib cage movements, and
appropriate structure and function of the upper and lower
respiratory tracts.8,22,34,59,61
Thorax and Chest Wall:
Structure and Function
The main functions of the thoracic cage, also referred to as
the chest wall, are to protect the internal organs of respira-
tion, circulation, and digestion and to participate in ventila-
tion of the lungs.58 The thoracic cage provides the site of
attachment for the muscles of ventilation to mechanically
enlarge the thorax for inspiration or to compress the thorax
for expiration.68 It is also the site of attachment of upper
extremity muscles, which function during lifting, pulling,
or pushing activities. These activities usually are carried
out in conjunction with inspiratory effort.
Along the posterior aspect of the thorax, the dorsal
portions of the ribs articulate with the 12 thoracic vertebrae
at the costotransverse and costovertebral joints. Along the
anterior aspect of the thoracic cage, the first to seventh ribs
FIGURE 25.1 Anterior view of the rib cage. (From Starr, J, Dalton, D: The thorax
and chest wall. In Levangie, PK, Norkin, CC [eds] Joint Structure and Function: A Compre-
hensive Analysis, ed 4. FA Davis, Philadelphia, 2005, p 197, with permission.)
articulate directly with the sternum via the costal cartilage.
The eighth to tenth ribs have cartilaginous attachments to
the rib above, whereas the eleventh and twelfth are floating
ribs (Fig. 25.1).68
Muscles of Ventilation
Multiple muscles attaching to the thoracic cage have an
impact on the movement of air in and out of the lungs
during either the inspiratory or expiratory phases of
breathing.8,11,68 Box 25.1 lists the muscles of ventilation.9
Ventilatory muscles, also referred to as respiratory
muscles, are classified as primary or accessory.56,68 The
primary muscles of ventilation are recruited during quiet
(tidal) breathing, whereas the accessory muscles of ventila-
tion are only recruited during deep, forced, or labored
breathing. During quiet inspiration the diaphragm, scalenes,
and parasternals are activated.56,68 In contrast, no primary
ventilatory muscles contract during resting expiration. Dur-
ing deep or forced breathing different accessory muscles of
ventilation are recruited, depending on whether inspiration
or expiration is occurring, as noted in Box 25.1.
Inspiration
Diaphragm. The diaphragm, the major muscle of inspira-
tion, is innervated by the phrenic nerve (C3, C4, C5). Dur-
ing relaxed inspiration it is the primary muscle responsible
for movement of air, and under these quiet conditions it
performs about 70% to 80% of the work of breathing.56
As the diaphragm contracts, it moves caudally from its
dome-shaped position at rest to increase the capacity of
the thoracic cage.
Scalenes. The scalenes, which insert proximally on the
transverse processes of the lower five cervical vertebrae
and distally on the upper surface of the first two ribs, also
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C H A P T E R 2 5 Management of Pulmonary Conditions
BOX 25.1 Primary and Accessory
Ventilatory Muscles
Inspiration
• Primary muscles: diaphragm, scalenes, parasternals
• Accessory muscles: sternocleidomastoids, upper trapezius,
pectoralis major and minor, subclavius, and possibly the
external intercostals
Expiration
• Primary muscles: none active during tidal (resting) expi-
ration
• Accessory muscles: abdominals including the rectus
abdominis, transversus abdominis, and internal and
external obliques; pectoralis major; and possibly the
internal intercostals
are active during quiet inspiration.56,68 They begin to con-
tract at the onset of inspiration and generate an even
greater amount of tension late into the inspiratory cycle
as the tension-producing capacity of the diaphragm is
decreasing. The scalenes lift the sternum and the first two
ribs in a “pump handle” action, which causes an upward
and outward action of the upper portion of the rib cage.
Parasternal intercostals. The parasternals, a portion of the
internal intercostals, are active during resting inspiration.
They function to stabilize the rib cage and prevent inward
movement of the superior aspect of the chest wall.56,68
Accessory muscles of inspiration. The sternocleidomastoid
(SCM), upper trapezius, pectoralis major and minor, and
subclavius muscles are all active during deep or labored
inspiration.9,56,68 These muscles become increasingly active
with greater inspiratory effort, which occurs frequently
during strenuous physical activity.
The accessory muscles of inspiration may become the
primary muscles of inspiration and may become active dur-
ing resting inspiration when the diaphragm is ineffective or
weak as the result of pathology. For example, paralysis of
the abdominals as the result of a spinal cord injury reduces
the support to the viscera (when the patient is in an upright
position) which, in turn, allows the diaphragm to assume a
flattened rather than a normal dome-shaped position. Thus,
diaphragmatic excursion is reduced, and breathing is less
efficient, which necessitates recruitment of the accessory
muscles of inspiration.
The SCM muscles elevate the sternum to increase the
anteroposterior (AP) diameter of the thorax. In patients
with weakness of the diaphragm, the SCM muscles are
required to act as primary muscles of inspiration. The
upper trapezius muscles elevate the shoulders and, indirect-
ly, the rib cage during labored inspiration. They also fixate
the neck so the scalenes have a stable attachment. The pec-
toralis major muscles can act to elevate the rib cage and
contribute to inspiration when the arms are overhead.
853
Expiration
Expiration is a passive process when a person is at rest.
When the diaphragm relaxes after a contraction, the
diaphragm rises and the ribs drop. The elastic recoil of
tissues decreases the intrathoracic area and increases
intrathoracic pressure, which causes exhalation. Dur-
ing active expiration, which can be controlled, forced,
or prolonged, several accessory muscles groups are
active.9,56,68
Abdominals. The rectus abdominis, the internal and exter-
nal obliques, and the transversus abdominis contract to
force down the thoracic cage and force the abdominal
contents superiorly into the diaphragm. When the abdomi-
nals contract, the intrathoracic pressure increases and air is
forced out of the lungs. A strong contraction of the abdom-
inals also is necessary for a strong cough. The abdominals
are innervated by spinal cord levels T10 to T12.
Other accessory muscles of expiration include the pec-
toralis major muscles (when the distal insertion is inferior
to the clavicle and the arm is fixed in position), the quad-
ratus lumborum, because of its attachment to the twelfth
rib, which enables it to act to stabilize the diaphragm dur-
ing phonation, and possibly the internal intercostals, which
may act to depress the rib cage.56,68
Mechanics of Ventilation
Movements of the Thorax During Ventilation
Each rib has its own pattern of movement, but generaliza-
tions can be made. The ribs attach anteriorly to the sternum
(except ribs 11 and 12) and posteriorly to the vertebral
bodies, disks, and transverse processes, making a closed
kinematic chain. The thorax enlarges in all three planes of
movement during inspiration.8,11,56,68
Increase in the AP dimension. There is a forward and
upward movement of the sternum and upper ribs, described
as a pump-handle motion. The thoracic spine extends
(straightens), enabling greater excursion of the sternum.
Increase in the transverse (lateral) dimension. There is an
elevation and outward turning of the lateral (midshaft) por-
tions of the ribs, described as a bucket handle motion. The
lower ribs (8–10), which are not attached directly to the
sternum, also flare or open outward, increasing the sub-
costal angle. This is described as caliper motion. The angle
at the costochondral junction also increases, making the rib
segments longer during inspiration.
Increase in vertical dimension. The central tendon of
the diaphragm descends as the muscle contracts. This is
described as a piston action. Elevation of the ribs increases
the vertical dimension of the thorax and improves the
effectiveness of the diaphragm. At the end of inspiration,
the muscles relax and elastic recoil causes the diaphragm
to move superiorly. The ribs return to their resting position.
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854 REVIEW OF RESPIRATORY STRUCTURE AND FUNCTION
Movement of Air
As noted previously, ventilation is the mass exchange of
gases to and from the body. During inspiration, as the tho-
rax enlarges, the pressure inside the lungs (alveolar pres-
sure) becomes lower than the atmospheric pressure, and air
rushes into the lungs. At the end of inspiration, the muscles
relax, and the elastic recoil of the lungs pushes the air out,
resulting in expiration.
N O T E : Breathing exercises, a common intervention for
the management of patients with cardiopulmonary, neuro-
muscular, and musculoskeletal conditions, are designed to
affect the movement of air to and from the lungs.11,28,48,56
Compliance
Compliance refers to the distensibility of tissue or how eas-
ily the lungs inflate during inspiration. With regard to ven-
tilation, it relates to how easily the lungs inflate or the
chest wall expands during inspiration.22,59,61 Normal lungs
are highly distensible (compliant), but compliance changes
with age and the presence of disease. During the normal
aging process lung tissue becomes more compliant. Dis-
eases of the pulmonary system that, for example, cause
fibrosis of tissues (alveolar or pleural) make the lungs
rigid (i.e., less compliant), whereas emphysema, one of
the chronic obstructive diseases, makes lung tissue more
compliant to pressures.22,59,61
Airway Resistance
The amount of resistance to the flow of air through the
airways depends on a number of factors.22,59,61 The bifurca-
tion and branching of airways is a source of airway resist-
ance. The size (diameter) of the lumen of each airway also
influences resistance. The diameter of the lumen can be
decreased by mucus or edema in the airways, contraction
of smooth muscles, and the degree of elasticity or distensi-
bility of the lung parenchyma.
Normally, the airways widen during inspiration and
narrow during expiration. As the diameter of the airway
decreases, the resistance to airflow increases. With diseases
that cause bronchospasm (asthma) or increased mucus pro-
duction (chronic bronchitis), airway resistance is even
greater than normal, particularly during expiration.
Flow Rates
Flow rates indicate measurements of the amount of air
moved in or out of the airways over a period of time. Flow
rates, which are related to airflow resistance, reflect the
ease with which ventilation occurs.22,59,61 Expiratory flow
rate is determined by the volume of air exhaled divided
by the amount of time it takes for the volume of gas to be
exhaled.27
Flow rates are altered as the result of diseases that
affect the respiratory tree and chest wall. For example,
with chronic obstructive pulmonary disease, the expiratory
flow rate is decreased in comparison to normal. That is, it
takes a longer than the normal amount of time to exhale a
specific volume of air.
Anatomy and Function of
the Respiratory Tracts
Upper Respiratory Tract
The structures of the upper respiratory tract are the nasal
cavity, pharynx, and larynx.11,58,66,69 As air is brought into
the body, the nasal cavity and pharynx filter and remove
particles in the air and begin to humidify and warm it to
body temperature. The mucosal lining of these structures
has cells that secrete mucus and cells that are ciliated.
Cilia and mucus trap particles; a sneeze removes large
particles.
With illness and elevated body temperature, the
mucous membrane tends to dry out, so the body secretes
more mucus. This mucus dries out, and a cycle begins.
The action of the cilia is inhibited by drying of mucus.
The patient tends to breathe by mouth, which decreases
the humidification of mucus and increases its viscosity.
The larynx, which extends from C3 to C6, controls
airflow; and when it contracts rapidly, the epiglottis pre-
vents food, liquids, or foreign objects from entering the
airway.47
Lower Respiratory Tract
The lower respiratory tract is composed of conducting air-
ways of the tracheobronchial tree and the terminal respira-
tory units. There are approximately 23 generations
(branchings) of the structures within the tracheobronchial
tree, which extends from the trachea to the terminal respi-
ratory units of the lungs. The structures and branchings
of the lower respiratory tract are summarized in Box
25.2.11,58,66,69
The initial branchings of the tracheobronchial tree are
depicted in Figure 25.2. The first 16 airway branchings of
the lower respiratory tract primarily conduct air, whereas
the last 6 are respiratory airways that end (in the mature
lung) in approximately 300 million alveoli.69 The diameter
of the airways becomes increasingly smaller with each suc-
cessive generation of the tracheobronchial tree.
Trachea. The trachea is an oval, flexible tube supported
by semicircular rings of cartilage. It extends from C6 in
an oblique, downward direction to the sternal angle level
of rib 2 and T6, at which point it bifurcates. The posterior
wall is smooth muscle, and it contains an equal number of
ciliated epithelial cells and mucus-containing goblet cells.
BOX 25.2 Structures and Branchings
of the Lower Respiratory Tract
• Trachea
• Mainstem bronchi: 2
• Lobar bronchi: 5
• Segmental bronchi: 18
• Bronchioles: subsegmental, terminal, and respiratory
• Alveolar ducts and sacs
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C H A P T E R 2 5 Management of Pulmonary Conditions 855

Terminal
Bronchiole
Respiratory
Trachea Bronchiole
Left
Apical
Right Posterior
Posterior Anterior
Apical
Apical posterior
Aveolus
Anterior Aveolar Sac
Lingula
Carina
Right middle Apical superior
lobe
Apical superior
Lateral Posterior
Cardiac (medial
Posterior Lateral
Anterior Aveolar Ducts
Anterior
FIGURE 25.3 Bronchopulmonary segment.
FIGURE 25.2 Lower respiratory tract—tracheobronchial tree. (From Frownfelter,
DL: Chest Physical Therapy and Pulmonary Rehabilitation. Year-Book Medical Publishers,
Chicago, 1987, p 26, with permission.)

Conduct air to and from the alveolar system for gas

exchange
Mainstem bronchi. The trachea branches into two main- Assist with humidification and trap small particles to
stream bronchi: the right, which is directed almost vertical- clean the air with the mucosal lining
ly, and the left, which is directed more obliquely. Warm the air by the vascular supply
Lobar bronchi. The two mainstem bronchi then divide into Move mucus upward with the cilia
five lobar bronchi: three on the right and two on the left. Elicit the cough reflex to clear the larger airways
Mainstem and lobar bronchi have a great amount of carti-
lage, which helps maintain airway patency. The Lungs and Pleurae
Segmental bronchi. Each of the lobar bronchi divide into
The lungs and pleurae are made up of the following com-
two or more segmental bronchi: 10 on the right and 8 on
ponents. The right lung has three lobes—the upper, middle,
the left. Segmental bronchi have scattered cartilage,
and lower—and 10 bronchopulmonary segments. The left
smooth muscle, elastic fibers, and a capillary network. The
lung has two true lobes—the upper and lower—and a slip
mainstem, lobar, and segmental bronchi have a mucous
of lung called the lingula, which is not considered a “true”
membrane essentially the same as the trachea.
lobe of the lungs. The left lung has eight bronchopul-
Bronchioles. Segmental bronchi divide into subsegmental monary segments. The lobes of the lungs are depicted in
bronchi and bronchioles, which have less and less cartilage Figure 25.4.
and ciliated epithelial cells. These bronchioles divide into
the terminal bronchioles, which are distal to the last carti-
lage of the tracheobronchial tree. Terminal bronchioles
contain no ciliated cells. Terminal bronchioles divide into Trachea
respiratory bronchioles and provide a transitional zone
between the bronchioles and alveoli. Upper Upper
Alveoli. The respiratory bronchioles divide into alveolar Lobe Lobe
ducts and alveolar sacs (Fig. 25.3). One duct may supply Right Left
Bronchus Right Left Bronchus
several sacs. The ducts contain smooth muscle, which nar-
rows the lumen of the duct with contraction. The alveoli Lung Lung
are located in the periphery of the alveolar ducts and sacs Middle
and are in contact with capillaries (alveolar-arterial mem- Lower Lobe Lower
brane). Gas exchange occurs here. Lobe Lobe

Summary of Function of the Upper Diaphragm

and Lower Respiratory Tracts
The upper and lower respiratory tracts, as a unit, serve the
FIGURE 25.4 Structure of the right and left lungs.
following functions. They:
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856 EXAMINATION
Each lung is covered in pleura, a serous membrane
known as the visceral pleura. This membrane adheres to
all surfaces of each lung. The parietal pleura lines the
inside of the thoracic wall. The parietal pleura is sensitive
to pain, but the visceral pleura appears to be insensi-
tive.30,31 A negative pressure in the minute space between
the pleurae serves to keep the lungs inflated. Pleural fluid
is found between the pleurae and lubricates the pleurae as
they slide on each other during ventilation.
Lung Volumes and Capacities
Pulmonary function tests that measure lung volumes and
capacities are performed to evaluate the mechanical func-
tion of the lungs (Fig. 25.5). Lung volumes and capacities
are related to a person’s age, weight, sex, and body posi-
tion and are altered by disease.27,59,61 Two or more lung
volumes, when combined, are described as a capacity. A
basic understanding of these measurements and what the
values reflect is useful for a therapist treating patients with
pulmonary dysfunction.
FIGURE 25.5 Normal lung values and capacities.
Total Lung Capacity
Total lung capacity (TLC) is the total amount of air con-
tained in the lungs after a maximum inspiration. TLC can
be subdivided into four volumes: tidal volume, inspiratory
reserve volume, expiratory reserve volume, and residual
volume. The vital capacity plus the residual volume equal
the TLC, which is approximately 6000 mL in a healthy,
young adult.
Tidal Volume
The amount of air exchanged during a relaxed inspiration
followed by a relaxed expiration is called the tidal volume
(TV). In a healthy, young adult, TV is approximately 500
mL per inspiration. Approximately 350 mL of the tidal vol-
ume reaches the alveoli and participates in gas exchange
(respiration).
Inspiratory Reserve Volume
Inspiratory reserve volume (IRV) is the amount of air a
person can breathe in after a resting inspiration (approxi-
mately 3000 mL).
Expiratory Reserve Volume
Expiratory reserve volume (ERV) is the amount of air a
person can exhale after a normal resting expiration
(approximately 1000 mL).
Residual Volume
Residual volume (RV) is the amount of air left in the lungs
after a maximum expiration (approximately 1500 mL). RV
increases with age and with restrictive and obstructive pul-
monary diseases.
Inspiratory Capacity
Inspiratory capacity (IC) is the maximum amount of air a
person can breathe in after a resting expiration (approxi-
mately 3500 mL).
Functional Residual Capacity
Functional residual capacity (FRC) is the amount of air
remaining in the lungs after a resting (tidal) expiration
(approximately 2500 mL). It is the sum of the ERV and
RV. FRC represents the point during ventilation at which
the forces that expand the thoracic wall are in balance with
the forces that tend to collapse the lungs.59
Vital Capacity
Vital capacity (VC) is the sum of the TV, IRV, and ERV. It
is measured by a maximum inspiration followed by a max-
imum expiration (approximately 4500 mL). Vital capacity
decreases with age and is less in the supine position than in
an erect posture (sitting or standing). VC decreases in the
presence of restrictive and obstructive diseases.
EXAMINATION
Evaluation of the patient with pulmonary dysfunction and
determination of a diagnosis, prognosis, and intervention
plan are based on the findings derived from a comprehen-
sive examination, including a history, systems review, and
specific tests and measures.31 The multiple purposes of this
examination are summarized in Box 25.3.
BOX 25.3 Purpose of the Examination
• Determine a patient’s primary and secondary respiratory
and ventilatory impairments and how they limit physical
function.
• Determine the adequacy of the ventilatory pump and the
oxygen uptake/carbon dioxide elimination mechanisms
to meet the oxygen demands at rest and during function-
al activities.
• Ascertain a patient’s suitability for participation in a pul-
monary rehabilitation program.
• Develop an appropriate level intervention plan for the
patient.
• Establish a baseline to measure a patient’s progress and
the effectiveness of the treatment.
• Determine when to discontinue specific interventions
and implement a home program as a basis for self-
management.
25Kisner (F)-25 3/9/07 12:54 PM Page 857
Components of the Examination
A comprehensive examination of a patient with known or
suspected dysfunction related to primary and secondary
pulmonary or chest disorders has many elements. The
examination procedures described in this section are those
often used by a therapist during an initial evaluation to
establish a therapy-related diagnosis or during subsequent
assessments for modification of therapeutic interven-
tions.11,31,35,38,52,67 Additional examination procedures not
described in this section but integral to the management of
a patient with pulmonary dysfunction are radiography,
evaluation of blood gases, tomography, bronchoscopy, and
hematological tests.
History and Systems Review
The examination process begins with a patient’s history
including an interview with the patient and sometimes fam-
ily members if they are available. During the interview a
therapist can identify a patient’s and/or family members’
perception of any functional limitations or disabilities and
determine a patient’s chief complaints and why he or she is
seeking treatment. In preparation for the interview, the med-
ical history and any medical diagnoses are obtained from
the patient’s medical record, if available, or more generally,
from the patient or family. Relevant occupational and social
history are obtained; particularly important are on-the-job
physical demands, the environment of the workplace, and
social habits that affect a person’s well-being, such as
tobacco or alcohol use. Assessment of the home or family
environment might include a patient’s family responsibili-
TABLE 25.1 General Appearance of the Patient and Implications
General Appearance
• Level of awareness (level of consciousness): alert,
responsive, or cooperative versus lethargic, disoriented,
or inattentive
• Body type: normal, obese, or cachectic
• Color: cyanosis (bluish appearance) peripherally
(nailbeds) or centrally (lips)
• Facial signs or expressions: focused or dilated pupils,
nasal flaring, sweating, or distressed appearance
• Jugular vein engorgement: visualization of the jugular
venous pulse with the patient supine and the head and
neck on pillows at a 45
angle
• Hypertrophy of or use at rest of accessory muscles of
ventilation: SCM, upper trapezius
• Supraclavicular or intercostal retractions occurring with
inspiration
• Use of pursed lip breathing (usually with expiration)
• Clubbing of digits: loss of angle between the nail bed
and DIP joint
• Peripheral edema
C H A P T E R 2 5 Management of Pulmonary Conditions 857
ties, the housing situation, and available family support sys-
tems. A brief systems review should follow the history.
General Appearance of the Patient
Table 25.1 describes the type of information that can be
obtained by visual inspection of a patient and the possible
implications of these observations. Many of these findings
can be noted during the course of the history or during the
systems review.
Analysis of Chest Shape and Dimensions
Symmetry of the chest and trunk. Observe anteriorly,
posteriorly, and laterally; the thoracic cage should be
symmetrical.
Mobility of the trunk. Check active movements in all
directions and identify any restricted spinal motions, par-
ticularly in the thoracic spine.
Shape and dimensions of the chest. The anteroposterior
(AP) and lateral dimensions are usually 1:2. Common
chest deformities include:
Barrel chest. The circumference of the upper chest
appears larger than that of the lower chest. The sternum
appears prominent, and the AP diameter of the chest is
greater than normal. Many patients with chronic obstruc-
tive pulmonary disorders, who are usually upper chest
breathers, develop a barrel chest.
Pectus excavatum (funnel breast). The lower part of
the sternum is depressed and the lower ribs flare out.
Patients with this deformity are diaphragmatic breathers;
Implications
• Respiratory acidosis, hypercarbia (increased Pco2 level),
or hypoxia (decreased Po2 level) can alter level of
consciousness
• May reflect intolerance to exercise
• Peripheral cyanosis may indicate low cardiac output;
central cyanosis may indicate inadequate gas exchange
in the lungs
• Signs of respiratory distress, fatigue, or pulmonary or
musculoskeletal pain
• Bilateral distention associated with congestive heart
failure/right-sided heart failure
• Seen in patients with early chronic lung disease or
weakness of the diaphragm
• Seen in patients with labored breathing
• Indicates difficulty with expiration; often seen in patients
with COPD
• May be linked to perfusion
• Sign of right ventricular failure or lymphatic dysfunction
25Kisner (F)-25 3/9/07 12:54 PM Page 858
858 EXAMINATION
excessive abdominal protrusion and little upper chest
movement occur during breathing.
Pectus carinatum (pigeon breast). The sternum is
prominent and protrudes anteriorly.
Posture or Preferred Positioning
Identify a patient’s preferred sitting or standing posture. A
patient who has difficulty breathing as the result of chronic
lung disease often leans forward on hands or forearms to
stabilize and elevate the shoulder girdle to assist with
inspiration (Fig. 25.6). This position increases the effec-
tiveness of the pectoralis and serratus anterior muscles to
act as accessory muscles of inspiration by reverse action. It
is also important to identify a patient’s preferred sleeping
position. A patient with cardiopulmonary dysfunction often
prefers to sleep in a head-up rather than a fully recumbent
position. Assuming a horizontal position may result in
shortness of breath.
FIGURE 25.6 A patient who is short of breath at rest or after activity often
assumes a forward-bent position with hands or elbows resting on the thighs
to reduce or relieve symptoms.
In addition, note any postural deformities such as
kyphosis and scoliosis and postural asymmetry from tho-
racic surgery, which could restrict chest movements and
ventilation.
Breathing Pattern
Assess the rate, regularity, and location of ventilation at
rest and with activity. A normal respiratory rate for a
healthy adult is 12 to 20 breaths per minute. This is most
accurately determined when a patient is unaware that his or
her respiratory rate is being measured, as when taking the
pulse rate. The normal ratio of inspiration to expiration at
rest is 1:2 and with activity 1:1. A patient with chronic
obstructive pulmonary disease (COPD) may have a ratio of
1:4 at rest, which reflects difficulty with the expiratory
phase of breathing.
The normal sequence of inspiration at rest is (1) the
diaphragm contracts and descends and the abdomen (epi-
gastric area) rises; (2) this is followed by lateral costal
expansion as the ribs move up and out; and finally (3) the
upper chest rises. The neck muscles that act as accessory
muscles of inspiration should be inactive during relaxed
inspiration.
To assess the breathing sequence, have the patient
assume a comfortable position (semireclining or supine).
Place your hands on the patient’s epigastric region and
sternum to observe movements in these two areas.
A number of terms are used to describe abnormal
breathing patterns and are defined in Box 25.4.11,35,38,52
Chest Mobility
Symmetry of chest movement. Analysis of the symmetry
of the moving chest during breathing gives the therapist
information about the mobility of the thorax and indicates
indirectly what areas of the lungs may or may not be
responding.
Procedure: Place your hands on the patient’s chest and
assess the excursion of each side of the thorax during
inspiration and expiration. Each of the three lobar areas
can be checked.11,35,38,52
To check upper lobe expansion, face the patient; place
the tips of your thumbs at the midsternal line at the ster-
nal notch. Extend your fingers above the clavicles. Have
the patient fully exhale and then inhale deeply.
To check middle lobe expansion, continue to face the
patient; place the tips of your thumbs at the xiphoid
process and extend your fingers laterally around the ribs.
Again, ask the patient to breathe in deeply (Fig. 25.7A).
To check lower lobe expansion, place the tips of your
thumbs along the patient’s back at the spinous processes
(lower thoracic level) and extend your fingers around the
ribs. Ask the patient to breathe in deeply (Fig. 25.7B).
BOX 25.4 Abnormal Breathing Patterns
• Dyspnea. Distressed, labored breathing as the result of
shortness of breath.
• Tachypnea. Rapid, shallow breathing; decreased tidal vol-
ume but increased rate; associated with restrictive or
obstructive lung disease and use of accessory muscles of
inspiration.
• Bradypnea. Slow rate with shallow or normal depth and
regular rhythm; may be associated with drug overdose.
• Hyperventilation. Deep, rapid respiration; increased tidal
volume and increased rate of respiration; regular rhythm.
• Orthopnea. Difficulty breathing in the supine position.
• Apnea. Cessation of breathing in the expiratory phase.
• Apneusis. Cessation of breathing in the inspiratory phase.
• Cheyne-Stokes. Cycles of gradually increasing tidal vol-
umes followed by a series of gradually decreasing tidal
volumes and then a period of apnea. This is sometimes
seen in the patient with a severe head injury.
25Kisner (F)-25 3/9/07 12:54 PM Page 859
C H A P T E R 2 5 Management of Pulmonary Conditions
FIGURE 25.7 (A) Anterior and (B) posterior placement of a therapist’s hands
on a patient’s thorax to assess the symmetry of movement during breathing.
(From Brannon, FJ, et al: Cardiopulmonary Rehabilitation—Basic Theory and Application,
ed 3, FA Davis, Philadelphia, 1998, p. 288. Adapted from Rothstein, JH, Roy, SH, Wolf, SL:
The Rehabilitation Specialist’s Handbook, FA Davis, Philadelphia, 2005, p 416–417, with
permission.)
Extent of excursion. The extent of chest mobility can be
measured by two methods.35,38
Measure the girth of the chest with a tape measure at
three levels (axilla, xiphoid, lower costal). Document
change in girth after a maximum inspiration and a maxi-
mum expiration.
Place both hands on the patient’s chest or back as previ-
ously described. Note the distance between your thumbs
after a maximum inspiration.
Palpation
Palpation of the thorax provides evidence of dysfunction of
the underlying tissues including the lungs, chest wall, and
mediastinum.11,35,38,52
Tactile (vocal) fremitus. Tactile fremitus is the vibration
felt while palpating over the chest wall as a patient speaks.
Procedure: Place the palms of your hands lightly on
the chest wall and ask the patient to speak a few words or
repeat “99” several times. Normally, fremitus is felt uni-
formly on the chest wall. Fremitus is increased in the pres-
ence of secretions in the airways and decreased or absent
when air is trapped as the result of obstructed airways.
Chest wall pain. Specific areas or points of pain over ante-
rior, posterior, or lateral aspects of the chest wall can be
identified with palpation.
Procedure: Firmly press against the chest wall with
your hands to identify any specific areas of pain potentially
of musculoskeletal origin. Ask the patient to take a deep
breath and identify any painful areas of the chest wall.
Chest wall pain of musculoskeletal origin often increases
with direct point pressure during palpation and during a
deep inspiration.35,38
N O T E : Pain in the anterior, posterior, or lateral region of
the chest can be of musculoskeletal, pulmonary, or cardiac
origin.31 Pain of pulmonary origin is usually localized to a
region of the chest but also may be felt in the neck or
shoulder region. Several pulmonary or cardiac conditions
859
can mimic musculoskeletal pain, such as pulmonary
embolism, pleurisy, pneumonia, pneumothorax, and pul-
monary artery hypertension.31
Mediastinal shift. The position of the trachea normally is
oriented centrally in relation to the suprasternal notch indi-
cating symmetry of the mediastinum. The position of the
trachea shifts as the result of asymmetrical intrathoracic
pressures or lung volumes. For example, if the patient has
had a pneumonectomy (removal of a lung), the lung vol-
ume on the operated side decreases, and the trachea shifts
toward that side. Conversely, if the patient has a hemotho-
rax (blood in the thorax), intrathoracic pressure on the side
of the hemothorax increases, and the mediastinum shifts
away from the affected side of the chest.11,35,38,52
Procedure: To identify a mediastinal shift, have the
patient sit facing you with the head in midline and the neck
slightly flexed to relax the sternocleidomastoid muscles.
With your index finger, gently palpate the soft tissue space
on either side of the trachea at the suprasternal notch.
Determine whether the trachea is palpable at the midline or
has shifted to the left or right.
Mediate Percussion
Mediate percussion is an examination technique designed
to assess lung density, specifically, the air-to-solid ratio in
the lungs.11,35,38,52
Procedure: Place the middle finger of the nondomi-
nant hand flat against the chest wall along an intercostal
space. With the tip of the middle finger of the opposite
hand, firmly tap on the finger positioned on the chest wall.
Repeat the procedure at several points on the right and left
and anterior and posterior aspects of the chest wall. This
maneuver produces a resonance; the pitch varies with the
density of the underlying tissue. The subjective determina-
tion of pitch indicates the following.
The sound is dull and flat if there is a greater than nor-
mal amount of solid matter (tumor, consolidation) in the
lungs in comparison with the amount of air.
The sound is hyperresonant (tympanic) if there is a
greater than normal amount of air in the area (as in
patients with emphysema).
If asymmetrical or abnormal findings are noted, the
patient should be referred to the physician for addi-
tional objective tests such as a chest radiograph.
Auscultation of Breath Sounds
Auscultation is a general term that refers to the process
of listening to sounds within the body, specifically to
breath sounds during an examination of the lungs.11,35,38,52
Breath sounds occur because of movement of air in the
airways during inspiration and expiration. A stethoscope
is used to magnify these sounds. Breath sounds should be
assessed to:
Identify the areas of the lungs in which congestion exists
and in which airway clearance techniques should be per-
formed.
Determine the effectiveness of any airway clearance
intervention.
25Kisner (F)-25 3/9/07 12:54 PM Page 860
860 EXAMINATION
Determine whether the lungs are clear and whether inter-
ventions should be discontinued.
Procedure: When assessing breath sounds, be sure the
setting is quiet. Have the patient assume a comfortable,
relaxed, sitting position to allow access to the chest wall.
Place the diaphragm of the stethoscope directly against the
patient’s skin along the anterior or posterior chest wall. Be
sure that the tubing does not rub together or come in con-
tact with clothing during auscultation, as this contact pro-
duces extraneous sounds.
Follow a systematic pattern (Fig. 25.8A&B) and place
the stethoscope against specific thoracic landmarks (T2, T6,
T10) along the right and left sides of the chest wall. Ask
the patient to breathe in deeply and out quickly through the
mouth as you move the stethoscope from point to point.
Note the quality, intensity, and pitch of the breath sounds.
P R E C A U T I O N : Auscultate slowly from one area to
another. Allow the patient to breathe in a relaxed manner
FIGURE 25.8 Pattern of specific thoracic landmarks for auscultation. The
diaphragm of the stethoscope is placed along the right and left (A) anterior
chest wall and the (B) posterior chest wall at T2, T6, and T10. (From Frownfelter,
DL: Chest Physical Therapy and Pulmonary Rehabilitation. Year-Book Medical Publishers,
Chicago, 1987, p 135, with permission.)
after several deep breaths to prevent dizziness from hyper-
ventilation. Guard the patient closely to prevent loss of bal-
ance if lightheadedness occurs.
Classification of Breath Sounds
Breath sounds are classified by location, pitch, and intensi-
ty as well as the ratio of sounds heard on inspiration versus
those heard on expiration. Breath sounds also are identified
as normal or adventitious (extra).5,50,52,77
Normal breath sounds occur in the absence of patholo-
gy and are heard predominantly during inspiration. Normal
breath sounds are categorized as vesicular, bronchial, or
bronchovesicular based on the location and quality of the
sound. They are described in Box 25.5.5,77 Adventitious
breath sounds are abnormal sounds in the lungs that are
heard with a stethoscope. Although terminology in the lit-
erature is inconsistent, the nomenclature used most often
was proposed by a joint committee of the American Col-
lege of Chest Physicians and the American Thoracic Soci-
ety.5,77 Adventitious breath sounds are categorized as
crackles or wheezes. Box 25.5 describes the location and
quality of these breath sounds.
BOX 25.5 Normal and Adventitious
Breath Sounds
Normal Breath Sounds
• Vesicular. Soft, low-pitched, breezy but faint sounds
heard over most of the chest except near the trachea and
mainstem bronchi and between the scapulae. Vesicular
sounds are audible considerably longer on inspiration
than expiration (about a 3:1 ratio).
• Bronchial. Loud, hollow, or tubular high-pitched sounds
heard over the mainstem bronchi and trachea. Bronchial
sounds are heard equally during inspiration and expira-
tion; a slight pause in the sound occurs between inspira-
tion and expiration.
• Bronchovesicular. Softer than bronchial breath sounds;
also heard equally during inspiration and expiration but
without a pause in the sound between the cycles. The
sounds are heard in the supraclavicular, suprascapular,
and parasternal regions anteriorly and between the
scapulae posteriorly.
Adventitious Breath Sounds
• Crackles. Fine, discontinuous sounds (similar to the
sound of bubbles popping or the sound of hairs being
rubbed between your fingers next to your ear). Crackles,
which can be fine or coarse, are heard primarily during
inspiration as the result of secretions moving in the air-
ways or in closed airways that are rapidly reopening. The
former term for crackles was rales.
• Wheezes. Continuous high- or low-pitched sounds or
sometimes musical tones heard during exhalation but
occasionally audible during inspiration. Bronchospasm
or secretions that narrow the lumen of the airways cause
wheezes. The term previously used for wheezes was
rhonchi.
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C H A P T E R 2 5 Management of Pulmonary Conditions
Breath sounds may be totally absent or substantially
diminished over a portion of the lungs. This indicates total
or partial obstruction and lack of aeration of lung tissue.
The absence of air and collapse of an area of lung tissue
is known as atelectasis. Obstruction of airways may be
caused by fluids, mucus, bronchospasm, or compression
by tumor.
Cough and Cough Production
The strength, depth, length, and frequency of a patient’s
cough must be assessed. An effective cough is sharp and
deep. In the patient with current or potential pulmonary
dysfunction a cough can be described as weak, shallow,
soft, or throaty. A patient may have a weak, shallow cough
as the result of pain or paralysis. A sudden onset of a
cough or a sustained cough often is described as paroxys-
mal or spasmodic. If a cough is substantially weak or inef-
fective, suctioning may be required to clear the
airways.11,35,52
A cough may be productive or nonproductive in the
presence of pathology. The productivity of the cough and
secretions produced by the cough should be assessed.
Secretions are checked for:
Color (clear, yellow, green, blood-stained)
Consistency (viscous, thin, frothy)
Amount (minimal to copious)
Odor (no odor to foul-smelling)
Production of a small amount of clear or white secre-
tions on a daily basis is normal. Copious but clear secre-
tions are common with chronic bronchitis. Yellow, green,
and purulent secretions with a strong odor are indicative of
some type of infection. Blood-streaked secretions, known
as hemoptysis, is indicative of some degree of hemorrhage
in the lungs. Frothy, white secretions are associated with
pulmonary edema and heart failure.
When secretions are produced during the course of
interventions, such as exercise or airway clearance, it is the
responsibility of the therapist to document the characteris-
tics of the secretions.
Additional Areas of Examination
The examination procedures described in this section are
complemented with other areas of examination, which may
include a patient’s use of assistive respiratory equipment,
ROM particularly of the shoulders, neck, and trunk, muscle
strength, general endurance and graded exercise testing,
and a patient’s identification of functional abilities or limi-
tations and perceived disability and quality of life.
BREATHING EXERCISES AND
VENTILATORY TRAINING
Breathing exercises and ventilatory training are fundamen-
tal interventions for the prevention or comprehensive man-
agement of impairments related to acute or chronic
pulmonary disorders. For example, these interventions
are frequently advocated in the literature for patients with
861
BOX 25.6 Goals of Breathing Exercises and
Ventilatory Muscle Training
• Improve or redistribute ventilation.
• Increase the effectiveness of the cough mechanism and
promote airway clearance.
• Prevent postoperative pulmonary complications.
• Improve the strength, endurance, and coordination of the
muscles of ventilation.
• Maintain or improve chest and thoracic spine mobility.
• Correct inefficient or abnormal breathing patterns and
decrease the work of breathing.
• Promote relaxation and relieve stress.
• Teach the patient how to deal with episodes of dyspnea.
• Improve a patient’s overall functional capacity for daily
living, occupational, and recreational activities.
COPD (chronic bronchitis, emphysema, asthma) or cystic
fibrosis, for patients with a high spinal cord lesion, for
patients who have undergone thoracic or abdominal sur-
gery and are at high risk for acute pulmonary complica-
tions, or for patients who must remain in bed for an
extended period of time.*
Breathing exercises and ventilatory training can take
on many forms including diaphragmatic breathing, seg-
mental breathing, inspiratory resistance training, incentive
spirometry, and breathing techniques for the relief of dysp-
nea during exertion. The goals of these interventions are
listed in Box 25.6.
Research studies indicate that although breathing exer-
cises or ventilatory muscle training may affect and possibly
alter a patient’s rate and depth of ventilation these interven-
tions may not necessarily have any impact on gas exchange
at the alveolar level or on oxygenation.11,28,48,60 Therefore,
breathing exercises or ventilatory training should be only
one aspect of management to improve pulmonary status
and to increase a patient’s overall endurance and function
during daily living activities. Depending on a patient’s
underlying pathology and impairments, exercises to
improve ventilation often are combined with medication,
airway clearance, the use of respiratory therapy devices,
and a graded exercise (aerobic conditioning) program.
Guidelines for Teaching Breathing Exercises
If possible, choose a quiet area for instruction in which
you can interact with the patient with minimal distrac-
tions.
Explain to the patient the aims and rationale of breathing
exercises or ventilatory training specific to his or her
particular impairments and functional limitations.
Have the patient assume a comfortable, relaxed position
and loosen restrictive clothing. Initially, a semi-Fowler’s
position with the head and trunk elevated approximately
* See references 3, 7, 11, 14, 15, 28, 36, 40, 44, 45, 48, 57, 60, 63, 66,
76.
25Kisner (F)-25 3/9/07 12:54 PM Page 862
862 BREATHING EXERCISES AND VENTILATORY TRAINING
45
, is desirable. By supporting the head and trunk,
flexing the hips and knees, and supporting the legs
with a pillow, the abdominal muscles remain relaxed.
Other positions, such as supine, sitting, or standing,
may be used initially or as the patient progresses during
treatment.
Observe and assess the patient’s spontaneous breathing
pattern while at rest and later with activity.
Determine whether ventilatory training is indicated.
Establish a baseline for assessing changes, progress, and
outcomes of intervention.
If necessary, teach the patient relaxation techniques. This
relaxes the muscles of the upper thorax, neck, and shoul-
ders to minimize the use of the accessory muscles of
ventilation. Pay particular attention to relaxation of the
sternocleidomastoids, upper trapezius, and levator scapu-
lae muscles.
Depending on the patient’s underlying pathology and
impairments, determine whether to emphasize the inspi-
ratory or expiratory phase of ventilation.
Demonstrate the desired breathing pattern to the patient.
Have the patient practice the correct breathing pattern in
a variety of positions at rest and with activity.
P R E C A U T I O N S : When teaching breathing exercises, be
aware of the following precautions11,28,48,60:
Never allow a patient to force expiration. Expiration
should be relaxed or lightly controlled. Forced expiration
only increases turbulence in the airways, leading to bron-
chospasm and increased airway restriction.
Do not allow a patient to take a highly prolonged expira-
tion. This causes the patient to gasp with the next inspi-
ration. The patient’s breathing pattern then becomes
irregular and inefficient.
Do not allow the patient to initiate inspiration with the
accessory muscles and the upper chest. Advise the
patient that the upper chest should be relatively quiet
during breathing.
Allow the patient to perform deep breathing for only
three or four inspirations and expirations at a time to
avoid hyperventilation.
Diaphragmatic Breathing
When the diaphragm is functioning effectively in its role as
the primary muscle of inspiration, ventilation is efficient
and the oxygen consumption of the muscles of ventilation
is low during relaxed (tidal) breathing.7,28 When a patient
relies substantially on the accessory muscles of inspiration,
the mechanical work of breathing (oxygen consumption)
increases and the efficiency of ventilation decreases.
Although the diaphragm controls breathing at an involun-
tary level, a patient with primary or secondary pulmonary
dysfunction can be taught how to control breathing by opti-
mal use of the diaphragm and decreased use of accessory
muscles.
Controlled breathing techniques, which emphasize
diaphragmatic breathing, are designed to improve the effi-
ciency of ventilation, decrease the work of breathing,
increase the excursion (descent or ascent) of the diaphragm,
and improve gas exchange and oxygenation.11,28,44,48,60
Diaphragmatic breathing exercises also are used during
postural drainage to mobilize lung secretions.25,51
Procedure
Prepare the patient in a relaxed and comfortable position
in which gravity assists the diaphragm, such as a semi-
Fowler’s position.
If your examination revealed that the patient initiates the
breathing pattern with the accessory muscles of inspira-
tion (shoulder and neck musclulature), start instruction by
teaching the patient how to relax those muscles (shoulder
rolls or shoulder shrugs coupled with relaxation).
Place your hand(s) on the rectus abdominis just below
the anterior costal margin (Fig. 25.9). Ask the patient to
breathe in slowly and deeply through the nose. Have the
patient keep the shoulders relaxed and upper chest quiet,
allowing the abdomen to rise slightly. Then tell the
patient to relax and exhale slowly through the mouth.
FIGURE 25.9 The semireclining (as shown) and semi-Fowler’s positions are
comfortable, relaxed positions in which to teach diaphragmatic breathing.
Have the patient practice this three or four times and
then rest. Do not allow the patient to hyperventilate.
If the patient is having difficulty using the diaphragm
during inspiration, have the patient inhale several times
in succession through the nose by using a sniffing
action.28,60 This action usually facilitates the diaphragm.
To learn how to self-monitor this sequence, have the
patient place his or her own hand below the anterior
costal margin and feel the movement (Fig. 25.10). The
patient’s hand should rise slightly during inspiration and
fall during expiration.
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C H A P T E R 2 5 Management of Pulmonary Conditions 863

Deep breathing while focusing on movement of the lower

portion of the rib cage may facilitate diaphragmatic excur-
sion.28 This technique is particularly important for the
patient with a stiff lower rib cage, as is often seen with
chronic bronchitis, emphysema, or asthma.7
Procedure
Have the patient begin in a hook-lying position; later
progress to a sitting position. Place your hands along
the lateral aspect of the lower ribs to direct the patient’s
attention to the areas where movement is to occur (Figs.
25.11 and 25.12).

FIGURE 25.10 The patient places his or her own hands on the abdomen to
feel the movement of proper diaphragmatic breathing. By placing the hands
on the abdomen, the patient can also feel the contraction of the abdominals,
which occurs with controlled expiration or coughing.

After the patient understands and is able to control

breathing using a diaphragmatic pattern, keeping the
shoulders relaxed, practice diaphragmatic breathing in a
variety of positions (sitting, standing) and during activity FIGURE 25.11 Bilateral lateral costal expansion—supine.
(walking, climbing stairs).
N O T E : Evidence concerning the effect of diaphragmatic
breathing exercises on the rate of ventilation, the work
of breathing and oxygen consumption, excursion of the
diaphragm, and exercise capacity in normal subjects and
in patients with pulmonary disorders is inconclusive, with
some studies supporting and others refuting the benefits of
diaphragmatic breathing.13,28,44,62

Segmental Breathing
It is questionable whether a patient can be taught to expand
localized areas of the lungs while keeping other areas
quiet. It is known, however, that hypoventilation does
occur in certain areas of the lungs because of chest wall
fibrosis, pain, and muscle guarding after surgery, atelecta-
sis, and pneumonia. Therefore, there are certain instances
such as during postural drainage or following thoracic sur-
gery when it is important to emphasize expansion of prob-
lem areas of the lungs and chest wall.
Two examples of segmental breathing that target the
lateral and posterior segments of the lower lobes are FIGURE 25.12 Bilateral lateral costal expansion—sitting.
described in this section. However, segmental breathing
techniques also may need to be directed to the middle and
upper lobes if there is accumulation of secretions or insuf-
Ask the patient to breathe out, and feel the rib cage move
ficient lung expansion in these areas.
downward and inward. As the patient breathes out, place
Lateral Costal Expansion pressure into the ribs with the palms of your hands.
Lateral costal expansion, sometimes called lateral basal Just prior to inspiration, apply a quick downward
expansion, can be carried out unilaterally or bilaterally. and inward stretch to the chest. This places a quick
25Kisner (F)-25 3/9/07 12:55 PM Page 864
864 BREATHING EXERCISES AND VENTILATORY TRAINING
stretch on the external intercostals to facilitate their
contraction.
Apply light manual resistance to the lower ribs to
increase sensory awareness as the patient breathes in
deeply and the chest expands and ribs flare. Then, as
the patient breathes out, assist by gently squeezing the
rib cage in a downward and inward direction.
Teach the patient how to perform the maneuver inde-
pendently by placing his or her hand(s) over the ribs
(Fig. 25.13) or applying resistance with a towel or belt
around the lower ribs (Fig. 25.14A&B).
FIGURE 25.13 The patient applies his or her own manual pressure during
lateral costal expansion.
Posterior Basal Expansion
Deep breathing emphasizing posterior basal expansion is
important for the postsurgical patient who is confined to
bed in a semireclining position for an extended period of
time because secretions often accumulate in the posterior
segments of the lower lobes.
Procedure
Have the patient sit and lean forward on a pillow, slightly
bending the hips (see Fig. 25.15). Place your hands over
the posterior aspect of the lower ribs, and follow the same
procedure just described for lateral costal expansion.
Pursed-Lip Breathing
Pursed-lip breathing is a strategy that involves lightly purs-
ing the lips together during controlled exhalation. This
breathing pattern often is adopted spontaneously by
patients with COPD to deal with episodes of dysp-
nea.7,10,28,43,48 Patients with COPD using pursed-lip breath-
ing report a decrease in their perceived level of exertion
during activity.10
However, whether it is beneficial to teach a patient
pursed-lip breathing often is debated. Many therapists
believe that gentle pursed-lip breathing and controlled
expiration is a useful procedure, particularly to relieve dys-
pnea if it is performed appropriately. It is thought to keep
airways open by creating back-pressure in the airways.
Studies suggest that pursed-lip breathing decreases the res-
piratory rate and the work of breathing (oxygen consump-
tion), increases the tidal volume, and improves exercise
tolerance.15,28,43,48
P R E C A U T I O N : The use of forceful expiration during
pursed-lip breathing must be avoided. Forceful expiration
while the lips are pursed can increase the turbulence in the
airways and cause further restriction of the small bronchi-
oles. Therefore, if a therapist elects to teach this breathing
strategy, it is important to emphasize with the patient that
expiration should be performed in a controlled manner but
not forced.
Procedure
Have the patient assume a comfortable position and relax
as much as possible. Have the patient breathe in slowly and
deeply through the nose and then breathe out gently
through lightly pursed lips as if blowing on and bending
the flame of a candle but not blowing it out.43 Explain to
FIGURE 25.14 Belt exercises reinforce lateral costal
breathing (A) by applying resistance during inspiration
and (B) by assisting with pressure along the rib cage dur-
ing expiration.
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C H A P T E R 2 5 Management of Pulmonary Conditions 865

the patient that expiration must be relaxed and that contrac-

tion of the abdominals must be avoided. Place your hand
over the patient’s abdominal muscles to detect any contrac-
tion of the abdominals.

Preventing and Relieving Episodes of Dyspnea

Many patients with COPD (e.g., emphysema and asthma)
may suffer from periodic episodes of dyspnea (shortness of
breath), particularly with physical exertion or when in con-
tact with allergens. Whenever a patient’s normal breathing
pattern is interrupted, shortness of breath can occur. It is
helpful to teach a patient how to monitor his or her level of
shortness of breath and to prevent episodes of dyspnea by
controlled breathing techniques, pacing activities, and
becoming aware of what activity or situation precipitates a
shortness of breath attack.
Pacing is the performance of functional activities, such
as walking, stair climbing, or work-related tasks, within the FIGURE 25.16 While standing, a patient can lean forward and place some
limits of a patient’s ventilatory capacity.11 Although some weight on the hands to relieve dyspnea.
patients may understand intuitively the limits to which
functional activities can be pushed, others must be taught
to recognize the early signs of dyspnea. If the patient After each pursed-lip expiration, teach the patient to use
becomes slightly short of breath, he or she must learn to diaphragmatic breathing and minimize use of accessory
stop an activity and use controlled, pursed-lip breathing muscles during each inspiration.
until the dyspnea subsides. Have the patient remain in a forward-bent posture and
Procedure continue to breathe in a slow, controlled manner until the
episode of dyspnea subsides.
Have the patient assume a relaxed, forward-bent posture
(Figs. 25.15 and 25.16; also see Fig. 25.6). A forward-
bent position stimulates diaphragmatic breathing (the Positive Expiratory Pressure Breathing
viscera drop forward and the diaphragm descends more Positive expiratory pressure breathing is a technique
easily). Use bronchodilators as prescribed. in which resistance to airflow is applied during exhala-
Have the patient gain control of his or her breathing and tion, similar to what occurs during pursed-lip breathing,
reduce the respiratory rate by using pursed-lip breathing except that the patient breathes through a specially
during expiration. Have the patient focus on the expirato- designed mouthpiece or mask that controls resistance to
ry phase of breathing while being sure to avoid forceful airflow.19,20,25 This breathing technique is used to hold
expiration. airways open during exhalation to mobilize accumulated
secretions and improve their clearance. Positive expira-
tory pressure breathing provides an alternative or adjunct
to postural drainage which a patient can perform independ-
ently.

Procedure
Positive expiratory pressure breathing is performed in an
upright position, preferably seated with the elbows resting
on a table. The procedure can be performed against low or
high pressure. A low pressure technique involves tidal
inspiration and active, but not forced, expiration through
a mouthpiece or mask. The patient inhales, holds the inspi-
ration for 2 to 3 seconds, and then exhales, repeating the
sequence for approximately 10 to 15 cycles.19,20,25 The
patient removes the mouthpiece or mask, takes several
“huffs” and then coughs to clear the mobilized secretions
from the airways. The breathing sequence typically is
FIGURE 25.15 A patient can sit and lean forward on a pillow to relax and
relieve an episode of dyspnea.
repeated four to six times with a total treatment session
lasting about 15 minutes.
25Kisner (F)-25 3/9/07 12:55 PM Page 866
866 BREATHING EXERCISES AND VENTILATORY TRAINING
Respiratory Resistance Training
The process of improving the strength or endurance of the
muscles of ventilation is known as respiratory resistance
training (RRT). Other descriptions used to denote this form
of breathing exercises are ventilatory muscle training,
inspiratory (or expiratory) muscle training, inspiratory
resistance training, and flow-controlled endurance train-
ing. These techniques typically focus on training the mus-
cles of inspiration,14,26,32,33,54,65 although expiratory muscle
training also has been described.32,33 RRT is advocated to
improve ventilation in patients with pulmonary dysfunction
associated with weakness, atrophy, or inefficiency of the
muscles of inspiration or to improve the effectiveness of
the cough mechanism in patients with weakness of the
abdominal muscles or other expiratory muscles.
With support from animal studies,46,62 it has been sug-
gested that the principles of overload and specificity of
training apply to skeletal muscles throughout the body,
including the muscles of ventilation.* In humans, it is not
feasible to use invasive procedures to evaluate morphologi-
cal or histochemical changes in the diaphragm that may
occur as the result of strength or endurance training.
Instead, strength or endurance changes must be assessed
indirectly. Increases in respiratory muscle strength and
endurance are determined by ultrasonographic meaure-
ments of the thickness of the diaphragm, maximal volun-
tary ventilation, and decreased reliance on accessory
muscles of inspiration. Respiratory muscle strength (either
inspiratory or expiratory) also is evaluated indirectly with
measurements of inspiratory capacity, forced expiratory
volume, inspiratory mouth pressure using a spirometer,
vital capacity, and increased cough effectiveness.
P R E C A U T I O N : Avoid prolonged periods of any form of
resistance training for inspiratory muscles. Unlike muscles of
the extremities, the diaphragm cannot totally rest to recover
from a session of resistance exercises. Use of accessory mus-
cles of inspiration (neck and shoulder muscles) is a sign that
the diaphragm is beginning to fatigue.3,76
Inspiratory Resistance Training
Inspiratory resistance training, using pressure- or flow-
based devices to provide resistance to airflow, is designed
to improve the strength and endurance of the muscles of
inspiration and decrease the occurrence of inspiratory mus-
cle fatigue. This technique has been studied in patients
with acute and chronic, primary and secondary pulmonary
disorders, including COPD,1,15,54,64 cystic fibrosis,26 respi-
ratory failure and ventilator dependence (weaning fail-
ure),2,65 chronic heart failure,14 and chronic neuromuscular
disease.32 Although reviews of the literature have demon-
strated that outcomes of inspiratory muscle training pro-
grams in patients with pathologies are inconsistent,33,50
some positive changes reported after training are increased
vital capacity, increased exercise capacity, and fewer
episodes of dyspnea.14,26,54 Inspiratory muscle training also
has been studied and found to be effective (as evidenced by
* See references 1–3, 15, 26, 32, 33, 44, 46, 54, 57, 62, 65, 71, 76.
a decreased respiratory rate) in patients with cervical-level
spinal cord lesions.24,49,57,74
Procedure
The patient inhales through a resistive training device
placed in the mouth. These devices are narrow tubes of
varying diameters or a mouthpiece and adapter with an
adjustable aperture that provide resistance to airflow dur-
ing inspiration and therefore place resistance on inspira-
tory muscles. The smaller the diameter of the aperture
and the faster the rate of airflow, the greater is the resist-
ance.
The patient inhales through the device for a specified
period of time several times each day. The time is gradu-
ally increased to 20 to 30 minutes at each training ses-
sion to increase inspiratory muscle endurance.
Incentive Respiratory Spirometry
Incentive spirometry is a form of ventilatory training that
emphasizes sustained maximum inspirations.18,48,60 The
patient inhales as deeply as possible through a small, hand-
held spirometer that provides visual or auditory feedback
about whether a target maximum inspiration was reached.
Typically, this breathing technique is performed while
using a spirometer, but it also may be performed without
the equipment.
The purpose of incentive spirometry is to increase the
volume of air inspired. It is used primarily to prevent alve-
olar collapse and atelectasis in postoperative patients.
Despite the widespread use of incentive spirometry for
patients after surgery, the effectiveness of this technique
alone or in addition to general deep breathing and cough-
ing for the prevention of postoperative pulmonary compli-
cations is not clear.18,40,71
Procedure
Have the patient assume a comfortable position (semire-
clining, if possible) and inhale and exhale three to four
times and then exhale maximally with the fourth breath.
Then have the patient place the spirometer in the mouth,
inhale maximally through the mouthpiece to a target set-
ting and hold the inspiration for several seconds.
This sequence is repeated five to ten times several times
per day.
Glossopharyngeal Breathing
Glossopharyngeal breathing is a technique that became
known to therapists during the 1950s through patients
with severe ventilatory impairment as the result of
poliomyelitis. It is a means of increasing the inspiratory
capacity when there is severe weakness of the muscles of
inspiration.28,39,53,75,76 Today, it is used primarily by patients
who are ventilator-dependent because of absent or incom-
plete innervation of the diaphragm as the result of a high
cervical-level spinal cord lesion or other neuromuscular
disorders. Glossopharyngeal breathing combined with the
inspiratory action of the neck musculature can reduce ven-
tilator dependence or can be used as an emergency proce-
dure should a malfunction of a patient’s ventilator
25Kisner (F)-25 3/9/07 12:55 PM Page 867

C H A P T E R 2 5 Management of Pulmonary Conditions 867

FIGURE 25.17 Chest mobilization during inspiration and expira-

tion. To mobilize the lateral rib cage have the patient (A) bend away
from the tight side during inspiration and (B) bend toward the tight
side during expiration.

occur.3,39,53,75,76 It also can be used to improve the force
(and therefore the effectiveness) of a cough or increase
the volume of the voice.
Procedure
Glossopharyngeal breathing involves taking several “gulps”
of air, usually 6 to 10 gulps in series, to pull air into the
lungs when action of the inspiratory muscles is inadequate.
After the patient takes several gulps of air, the mouth is
closed, and the tongue pushes the air back and traps it in
the pharynx. The air is then forced into the lungs when the
glottis is opened. This increases the depth of the inspiration
and the patient’s inspiratory and vital capacities.39,75
EXERCISES TO MOBILIZE THE CHEST
Then, have the patient push the fisted hand into the later-
al aspect of the chest, bend toward the tight side, and
breathe out (Fig. 25.17B).
Progress by having the patient raise the arm overhead on
the tight side of the chest and side-bend away from the
tight side. This places an additional stretch on hypomo-
bile tissues.
To Mobilize the Upper Chest and
Stretch the Pectoralis Muscles
While the patient is sitting in a chair with hands clasped
behind the head, have him or her horizontally abduct the
arms (elongating the pectoralis major) during a deep
inspiration (Fig. 25.18A).
Then instruct the patient to bring the elbows together
and bend forward during expiration (Fig. 25.18B).

Chest mobilization exercises are any exercises that com- To Mobilize the Upper Chest and Shoulders
bine active movements of the trunk or extremities with While sitting in a chair, have the patient reach with both
deep breathing.21,60 They are designed to maintain or arms overhead (180
bilateral shoulder flexion and slight
improve mobility of the chest wall, trunk, and shoulder gir- abduction) during inspiration (Fig. 25.19A) and then bend
dles when it affects ventilation or postural alignment. For forward at the hips and reach for the floor during expira-
example, a patient with hypomobility of the trunk muscles tion (Fig. 25.19B).
on one side of the body does not expand that part of the
chest fully during inspiration. Exercises that combine
stretching of these muscles with deep breathing improve
ventilation on that side of the chest.
Chest mobilization exercises also are used to reinforce
or emphasize the depth of inspiration or controlled expira-
tion. A patient can reinforce expiration, for example, by
leaning forward at the hips or flexing the spine as he or she
breathes out. This pushes the viscera superiorly into the
diaphragm.

Specific Techniques
To Mobilize One Side of the Chest
While sitting, have the patient bend away from the tight
side to lengthen hypomobile structures and expand that FIGURE 25.18 (A) A stretch is applied to the pectoralis muscles during inspi-
ration, and (B) the patient brings the elbows together to facilitate expiration.
side of the chest during inspiration (Fig. 25.17A).
25Kisner (F)-25 3/9/07 12:55 PM Page 868
868 COUGHING
FIGURE 25.19 (A) Chest expansion is increased with bilateral movement
of the arms overhead during inspiration. (B) Expiration is then reinforced
by reaching the arms toward the floor.
COUGHING
An effective cough is necessary to eliminate respiratory
obstructions and keep the lungs clear. Airway clearance is
an important part of management of patients with acute or
chronic respiratory conditions.25,51,60
The Normal Cough Pump
A cough may be reflexive or voluntary. When a person
coughs, a series of actions occurs (Box 25.7).47 Under nor-
mal conditions, the cough pump is effective to the seventh
generation of bronchi. (There are a total of 23 generations
of bronchi in the tracheobronchial tree.) Ciliated epithelial
cells are present up to the terminal bronchiole and raise
secretions from the smaller to the larger airways in the
absence of pathology.
Factors that Decrease the Effectiveness
of the Cough Mechanism and Cough Pump
The effectiveness of the cough mechanism can be com-
promised for a number of reasons including the follow-
ing.25,39,51,60,76
BOX 25.7 The Cough Mechanism
• Deep inspiration occurs.
• Glottis closes, and vocal cords tighten.
• Abdominal muscles contract and the diaphragm elevates,
causing an increase in intrathoracic and intra-abdominal
pressures.
• Glottis opens.
• Explosive expiration of air occurs.
Decreased inspiratory capacity. Inspiratory capacity can
be reduced because of pain due to acute lung disease, rib
fracture, trauma to the chest, or recent thoracic or
abdominal surgery. Weakness of the diaphragm or acces-
sory muscles of inspiration as a result of a high spinal
cord injury or neuropathic or myopathic disease decrease
a patient’s ability to take in a deep breath. Postoperative-
ly, the respiratory center may be depressed as the result
of general anesthesia, pain, or medication.
Inability to forcibly expel air. A spinal cord injury above
T12 and myopathic disease, such as muscular dystrophy,
cause weakness of the abdominal muscles, which are vital
for a strong cough. Excessive fatigue as the result of criti-
cal illness and a chest wall or abdominal incision causing
pain all contribute to a weak cough. A patient who has
had a tracheostomy also has difficulty producing a strong
cough, even when the tracheostomy site is covered.
Decreased action of the cilia in the bronchial tree.
Action of the ciliated cells may be compromised because
of physical interventions such as general anesthesia and
intubation or pathologies such as COPD including
chronic bronchitis, which is associated with a decreased
number of ciliated epithelial cells in the airway. Smoking
also depresses the action of the cilia.
Increase in the amount or thickness of mucus. Patholo-
gies (e.g., cystic fibrosis, chronic bronchitis) and pul-
monary infections (e.g., pneumonia) are associated with
an increase in mucus production and the thickness of the
mucus. Intubation irriates the lumen of the airways and
causes increased mucus production, whereas dehydration
thickens mucus.
Teaching an Effective Cough
Because an effective cough is an integral component of air-
way clearance, a patient must be taught the importance of
an effective cough, how to produce an efficient and con-
trolled voluntary cough, and when to cough. The following
sequence and procedures are used when teaching an effec-
tive cough.25,51,66
1. Assess the patient’s voluntary or reflexive cough.
2. Have the patient assume a relaxed, comfortable position
for deep breathing and coughing. Sitting or leaning for-
ward usually is the best position for coughing. The
patient’s neck should be slightly flexed to make cough-
ing more comfortable.
3. Teach the patient controlled diaphragmatic breathing,
emphasizing deep inspirations.
4. Demonstrate a sharp, deep, double cough.
5. Demonstrate the proper muscle action of coughing (con-
traction of the abdominals). Have the patient place the
hands on the abdomen and make three huffs with expira-
tion to feel the contraction of the abdominals (see Fig.
25.10). Have the patient practice making a “K” sound to
experience tightening the vocal cords, closing the glottis,
and contracting the abdominals.
6. When the patient has put these actions together, instruct
the patient to take a deep but relaxed inspiration, fol-
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C H A P T E R 2 5 Management of Pulmonary Conditions 869

BOX 25.8 Precautions for Teaching

an Effective Cough

• Never allow a patient to gasp in air, because this increas-

es the work (energy expenditure) of breathing, causing
the patient to fatigue more easily. It also increases turbu-
lence and resistance in the airways, possibly leading to
increased bronchospasm and further constriction of air-
ways. A gasping action also may push mucus or a for-
eign object deep into air passages.
• Avoid uncontrolled coughing spasms (paroxysmal
coughing).
• Avoid forceful coughing if a patient has a history of a
cerebrovascular accident or an aneurysm. Have these FIGURE 25.20 Therapist-assisted manual cough technique.
patients huff several times to clear the airways, rather
than cough.
• Be sure that the patient coughs while in a somewhat
erect or side-lying posture.

lowed by a sharp double cough. The second cough dur-

ing a single expiration is usually more productive.
7. Use an abdominal binder or glossopharyngeal breathing
in selected patients with inspiratory or abdominal mus-
cle weakness to enhance the cough, if necessary.
Precautions that should be observed while teaching a
patient an effective cough are noted in Box 25.8.

Additional Techniques to Facilitate a Cough

and Improve Airway Clearance
To maximize airway clearance, several techniques can be
used to stimulate a stronger cough, make coughing more
comfortable or improve the clearance of secretions.
Manual-Assisted Cough
If a patient has abdominal weakness (e.g., as the result of a
mid-thoracic or cervical spinal cord injury), manual pres-
sure on the abdominal area assists in developing greater
intra-abdominal pressure for a more forceful cough. Manu-
al pressure for cough assistance can be applied by the ther-
apist or the patient.3,25,39,51,66,76
Therapist-Assisted Techniques
With the patient in a supine or semireclining position,
the therapist places the heel of one hand on the patient’s
abdomen at the epigastric area just distal to the xiphoid
process. The other hand is placed on top of the first,
keeping the fingers open or interlocking them (Fig.
25.20). After the patient inhales as deeply as possible,
the therapist manually assists the patient as he or she
attempts to cough. The abdomen is compressed with an
inward and upward force, which pushes the diaphragm
upward to cause a more forceful and effective cough.
This same maneuver can be performed with the patient
in a chair (Fig. 25.21). The therapist or family member
can stand in back of the patient and apply manual pres-
sure during expiration.
FIGURE 25.21 Therapist-assisted or self-assisted manual cough technique.
P R E C A U T I O N : Avoid direct pressure on the xiphoid
process during the maneuver.
Self-Assisted Technique
While in a sitting position, the patient crosses the arms
across the abdomen or places the interlocked hands
below the xiphoid process (see Fig. 25.21).
After a deep inspiration, the patient pushes inward and
upward on the abdomen with the wrists or forearms and
simultaneously leans forward while attempting to cough.
Splinting
If chest wall pain from recent surgery or trauma is restrict-
ing the cough, teach the patient to splint over the painful
area during coughing.25,45,51 Have the patient press the
hands or a pillow firmly over the incision to support the
painful area with each cough (Fig. 25.22). If the patient
cannot reach the painful area, the therapist should assist
(Fig. 25.23).
Humidification
If secretions are very thick, work with the patient after
humidification therapy or ultrasonic nebulizer therapy, both
25Kisner (F)-25 3/9/07 12:55 PM Page 870
870 POSTURAL DRAINAGE
FIGURE 25.22 Splinting over an anterior surgical incision.
FIGURE 25.23 Splinting over a posterior lateral incision.
of which enhance the mucociliary transport system and
facilitate a productive cough.66
Tracheal Stimulation
Tracheal stimulation, sometimes called a tracheal tickle,
may be used with infants or disoriented patients who can-
not cooperate during treatment.66 Tracheal stimulation is a
somewhat uncomfortable maneuver, performed to elicit a
reflexive cough. The therapist places two fingers at the
sternal notch and applies a circular motion with pressure
downward into the trachea to facilitate a reflexive cough.
Suctioning: Alternative to Coughing
Endotracheal suctioning may be the only means of clear-
ing the airways in patients who are unable to cough or huff
voluntarily or after reflex stimulation of the cough mecha-
nism.29,60 Suctioning is indicated in all patients with artifi-
cial airways. The suctioning procedure clears only the
trachea and the mainstem bronchi.
P R E C A U T I O N : Only individuals who have been taught
proper suctioning technique should use this alternative
means of clearing the airways. Suctioning, if performed
incorrectly, can introduce an infection into the airways or
damage the delicate mucosal lining of the trachea and
bronchi. Improper suctioning also can cause hypoxemia, an
abnormal heart rate, and atelectasis. A complete description
of the proper endotracheal suctioning technique may be
found in other resources.29,60
POSTURAL DRAINAGE
Postural drainage (bronchial drainage), another interven-
tion for airway clearance, is a means of mobilizing secre-
tions in one or more lung segments to the central airways
by placing the patient in various positions so gravity assists
in the drainage process.4,11,25,51,60 When secretions are
moved from the smaller to the larger airways, they are then
cleared by coughing or endotracheal suctioning. Postural
drainage therapy also includes the use of manual tech-
niques, such as percussion, shaking, and vibration, coupled
with voluntary coughing.
Goals and indications for postural drainage are noted
in Box 25.9, and relative contraindications are summarized
in Box 25.10.4,11,25,51,60 Despite the risks, postural drainage
may be necessary in the unstable patient. Modified posi-
tioning to avoid head-down or fully horizontal positions
typically is necessary for most high-risk patients.
Manual Techniques Used with
Postural Drainage Therapy
In addition to the use of body positioning, deep breathing,
and an effective cough to facilitate airway clearance, a
variety of manual techniques are used in conjunction with
postural drainage to maximize the effectiveness of the
BOX 25.9 Goals and Indications
for Postural Drainage
Prevent Accumulation of Secretions in Patients at
Risk for Pulmonary Complications
• Patients with pulmonary diseases 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
may have painful incisions that restrict deep breathing
and coughing postoperatively
• Any patient who is on a ventilator if he or she is stable
enough to tolerate the treatment
Remove Accumulated Secretions from the Lungs
• Patients with acute or chronic lung disease, such as
pneumonia, atelectasis, acute lung infections, COPD
• Patients who are generally very weak or are elderly
• Patients with artificial airways
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C H A P T E R 2 5 Management of Pulmonary Conditions 871

BOX 25.10 Relative Contraindications drained.25,67 The therapist’s cupped hands strike the
patient’s chest wall in an alternating, rhythmic manner
to Postural Drainage
(Fig. 25.24B). The therapist should try to keep shoulders,
elbows, and wrists loose and mobile during the maneuver.
• Severe hemoptysis
Mechanical percussion is an alternative to manual percus-
• Untreated acute conditions
sion techniques.
• Severe pulmonary edema
Percussion is continued for several minutes or until the
• Congestive heart failure
• Large pleural effusion
patient needs to alter position to cough. This procedure
• Pulmonary embolism should not be painful or uncomfortable.
• Pneumothorax P R E C A U T I O N S : To prevent irritation to sensitive skin,
• Cardiovascular instability
have the patient wear a lightweight gown or shirt. Avoid
• Cardiac arrhythmia
percussion over breast tissue in women and over bony
• Severe hypertension or hypotension
prominences.
• Recent myocardial infarction
• Unstable angina Relative Contraindications to Percussion
• Recent neurosurgery
Prior to using percussion in a postural drainage program, a
• Head-down positioning may cause increased intracra-
therapist must weigh the potential benefits versus potential
nial pressure; if PD is required, modified positions can
risks. In most instances, it is prudent to avoid the use of
be used
percussion.25,67

Over fractures, spinal fusion, or osteoporotic bone

mucociliary transport system.11,25,51,60,66,72 They include Over tumor area
percussion, vibration, shaking, and rib springing. Findings If a patient has a pulmonary embolus
from studies that have been implemented to evaluate the If the patient has a condition in which hemorrhage could
efficacy of these manual techniques as adjuncts to postural easily occur, such as in the presence of a low platelet
drainage are inconclusive.66 count, or if the patient is receiving anticoagulation therapy
Percussion If the patient has unstable angina
Percussion is used to augment mobilization of secretions If the patient has chest wall pain, for example after tho-
by mechanically dislodging viscous or adherent mucus racic surgery or trauma
from the airways. Percussion is performed with cupped
Vibration
hands (Fig. 25.24A) over the lung segment being
Vibration, another manual technique, often is used in con-
junction with percussion to help move secretions to larger
airways. It is applied only during the expiratory phase as
the patient is deep-breathing.25,51,72 Vibration is applied
by placing both hands directly on the skin and over the
chest wall (or one hand on top of the other) and gently
compressing and rapidly vibrating the chest wall as the
patient breathes out (Fig. 25.25). Pressure is applied in the
same direction as the chest is moving. The vibrating action
is achieved by the therapist isometrically contracting (tens-
ing) the muscles of the upper extremities from shoulders to
hands.

FIGURE 25.24 (A) Hand position for applying percussion. (B) The therapist
alternately percusses over the lung segment being drained. FIGURE 25.25 Hand placement for vibration during postural drainage.
25Kisner (F)-25 3/9/07 12:55 PM Page 872

872 POSTURAL DRAINAGE

Shaking Postural Drainage Positions

Shaking is a more vigorous form of vibration applied dur-
ing exhalation using an intermittent bouncing maneuver
coupled with wide movements of the therapist’s hands. The
therapist’s thumbs are locked together, the open hands are
placed directly on the patient’s skin, and fingers are
wrapped around the chest wall. The therapist simultaneous-
ly compresses and shakes the chest wall.25,51,72
Positions for postural drainage are based on the anatomy of
the lungs and the tracheobronchial tree (see Figs. 25.2 and
25.4). Each segment of each lobe is drained using the posi-
tions depicted in Figures 25.26 through 25.37. The shaded
area in each illustration indicates the area of the chest wall
where percussion or vibration is applied.

RIGHT AND LEFT UPPER LOBES

Anterior apical segments

FIGURE 25.27 Percussion is applied above the scapulae. Your fingers curve
FIGURE 25.26 Percussion is applied directly under the clavicle. over the top of the shoulders.

FIGURE 25.28 Percussion is applied bilaterally, directly over the nipple or

just above the breast.

FIGURE 25.29 Patient lies one-quarter turn from prone and rests on the
right side. Head and shoulders are elevated 45
or approximately 18 inches FIGURE 25.30 Patient lies flat and one-quarter turn from prone on the left
if pillows are used. Percussion is applied directly over the left scapula. side. Percussion is applied directly over the right scapula.
25Kisner (F)-25 3/9/07 12:55 PM Page 873

C H A P T E R 2 5 Management of Pulmonary Conditions 873

LINGULA MIDDLE LOBE

FIGURE 25.31 Patient lies one-quarter turn from supine on the right side, FIGURE 25.32 Patient lies one-quarter turn from supine on the left side,
supported with pillows and in a 30
head-down position. Percussion is supported with pillows behind the back, and in a 30
head-down position.
applied just under the left breast. Percussion is applied under the right breast.

RIGHT AND LEFT LOWER LOBES

FIGURE 25.34 Patient lies prone with a pillow under the abdomen in a 45

FIGURE 25.33 Patient lies supine, pillows under knees, in a 45
head-down head-down position. Percussion is applied bilaterally over the lower portion
position. Percussion is applied bilaterally over the lower portion of the ribs. of the ribs.

FIGURE 25.35 Patient lies on the right side in a 45
head-down position. FIGURE 25.36 Patient lies on the left side in a 45
head-down position
Percussion is applied over the lower lateral aspect of the left rib cage. Percussion is applied over the lower lateral aspect of the right rib cage.

FIGURE 25.37 Patient lies prone with a pillow under the abdomen to flatten the
back. Percussion is applied bilaterally, directly below the scapulae.
25Kisner (F)-25 3/9/07 12:55 PM Page 874
874 MANAGEMENT OF PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE
The patient may be positioned on a postural drainage
table that can be elevated at one end, a tilt table, a rein-
forced padded table with a lift, or a hospital bed. A small
child can be positioned on a therapist’s or parent’s lap.
Guidelines for Implementing
Postural Drainage
General Considerations
Time of day. Consider the following when scheduling pos-
tural drainage into a patient’s day.
Never administer postural drainage directly after a meal.
Coordinate treatment with aerosol therapy. Some thera-
pists believe that aerosol therapy combined with humidi-
fication prior to postural drainage helps loosen secretions
and increases the likelihood of productivity. Others
believe that aerosol therapy is best after postural
drainage when the patient’s lungs are clearer and maxi-
mal benefit can be gained from medication administered
through aerosol therapy.
Choose a time (or times) of day likely to be of most ben-
efit to the patient. A patient’s cough tends to be highly
productive in the early morning because of accumulation
of secretions from the night before. Postural drainage in
the early evening clears the lungs prior to sleeping and
helps the patient rest more easily.
Frequency of treatments. The frequency of postural
drainage each day or during the week depends on the type
and severity of a patient’s pathology. If secretions are thick
and copious, two to four times per day may be necessary
until the lungs are clear. If a patient is on a maintenance
program, the frequency is less, perhaps once a day or only
a few days a week.
Preparation for Postural Drainage
Loosen tight or bulky clothing. It is not necessary to
expose the skin. The patient may wear a lightweight
shirt or gown.
Have a sputum cup or tissues available.
Have sufficient pillows for positioning and comfort.
Explain the treatment procedure to the patient.
Teach the patient deep breathing and an effective cough
prior to beginning postural drainage.
If the patient is producing copious amounts of sputum,
instruct the patient to cough a few times or have the
patient suctioned prior to positioning.
Make any adjustments of tubes and wires, such as chest
tubes, electrocardiography wires, or catheters, so they
remain clear during positioning.
Postural Drainage Sequence
Determine which segments of the lungs should be
drained. Some patients with chronic lung diseases, such
as cystic fibrosis, need to be drained in all positions.
Other patients may require drainage of only a few seg-
ments in which secretions have accumulated.
Check the patient’s vital signs and breath sounds.
Position the patient in the correct position for drainage.
See that he or she is as comfortable and relaxed as pos-
sible.
Stand in front of the patient, whenever possible, to
observe his or her color.
Maintain each position for 5 to 10 minutes if the patient
can tolerate it or as long as the position is productive.
Have the patient breathe deeply during drainage but do
not allow the patient to hyperventilate or become short
of breath. Pursed-lip breathing during expiration is
sometimes used.
Apply percussion over the segment being drained while
the patient is in the correct position.
Encourage the patient to take a deep, sharp, double
cough whenever necessary. It may be more comfortable
for the patient to momentarily assume a semiupright
position (resting on one elbow) and then cough.
If the patient does not cough spontaneously during posi-
tioning with percussion, instruct the patient to take sev-
eral deep breaths or huff several times in succession as
you apply vibration during expiration. This may help
elicit a cough.
If the patient’s cough is not productive after 5 to 10 min-
utes of positioning, go on to the next position. Secretions
that have been mobilized during a treatment may not be
coughed up by the patient until 30 minutes to 1 hour
after treatment.
The duration of any one treatment should not exceed 45
to 60 minutes, as the procedure is quite fatiguing for the
patient.
Concluding a Treatment
Have the patient sit up slowly and rest for a short while
after the treatment. Watch for signs of postural hypoten-
sion when the patient rises from a supine position or
from a head-down position to sitting.
Advise the patient that even if the cough was not produc-
tive during treatment it may be productive a short while
after treatment.
Evaluate the effectiveness of the treatment by reassess-
ing breath sounds.
Note the type, color, consistency, and amount of secre-
tions produced.
Check the patient’s vital signs after treatment and note
how the patient tolerated the treatment.
Criteria for Discontinuing Postural Drainage
If the chest radiograph is relatively clear
If the patient is afebrile for 24 to 48 hours
If normal or near-normal breath sounds are heard with
auscultation
If the patient is on a regular home program
Modified Postural Drainage
Some patients who require postural drainage cannot
assume or cannot tolerate the positions optimal for postural
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C H A P T E R 2 5 Management of Pulmonary Conditions 875

drainage. For example, a patient with congestive heart fail-

ure may exhibit indications of orthopnea (shortness of
breath while lying flat). After neurosurgery a patient may
not be allowed to assume a head-down (Trendelenburg)
position because this position causes increased intracranial
pressure. After thoracic surgery a patient may have chest
tubes and monitoring wires that limit positioning. Under
these circumstances and others, positioning during postural
drainage must be modified.25,51,60,66 The positions in which
postural drainage is undertaken are modified consistent
with the patient’s medical or surgical problems. This com-
promise, although not ideal, is better than not administer-
ing postural drainage at all.

Home Program of Postural Drainage

Postural drainage may have to be carried out on a regular
basis at home for patients with chronic lung disease.
Patients need to be shown how to position themselves using
inexpensive aids. An adult may place pillows over a hard
wedge or stacks of newspapers to achieve the desired head-
down positions in bed. A patient also can lean the chest
over the edge of a bed, resting with the arms on a chair
or stool. A child can be positioned on an ironing board
propped up against a sofa or heavy chair. A family member
often must be taught proper positioning, percussion or
shaking techniques, and precautions to assist the patient.
MANAGEMENT OF PATIENTS
WITH CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Chronic obstructive pulmonary disease is a broad term
encompassing a number of chronic pulmonary conditions,
all of which obstruct the flow of air in the conducting air-
ways of the lower respiratory tract and alter ventilation and
gas exchange.6,30,67 Although a variety of pulmonary dis-
eases are classified as obstructive in nature, each disease
has its unique features and clinical manifestations and is
distinguished by the cause of the obstruction of airflow, the
onset of the disease, the location of the obstruction, and the
reversibility of the obstruction.
Types of Obstructive Pulmonary Disorders
Typically, peripheral airway disease, chronic bronchitis,
and emphysema are classified as COPD; but other obstruc-
tive pulmonary diseases that are chronic in nature, such as
asthma, bronchiectasis, cystic fibrosis, and bronchopul-
monary dysplasia, also may be included under this broad
descriptor. The focus of discussion and guidelines for
management presented in this section of the chapter is on
chronic bronchitis and emphysema because patients with
these diseases commonly are seen in pulmonary rehabilita-
tion programs.6,7,12,37,67
FIGURE 25.38 Normal lung volumes and capacities compared with abnor-
mal lung volumes and capacities found in patients with obstructive pul-
monary disease. (From Rothstein, J, Roy, A, Wolf, SL: The Rehabilitation Specialist’s
Handbook, ed. 3. FA Davis, Philadelphia, 2005, p 428, with permission.)
Pathological Changes in
the Pulmonary System
Changes in chronic bronchitis and emphysema that occur
over time are inflammation of the mucous membranes of
the airways; increased production and retention of mucus;
narrowing and destruction of airways; and destruction of
alveolar and bronchial walls.6,30,67 These structural changes
are reflected in pulmonary function tests depicted in Figure
25.38. These changes in the patient’s pulmonary status pre-
dispose the patient to frequent acute respiratory infections.
Impairments and Impact on Function
As a result of the pathophysiology of COPD, many physi-
cal impairments develop over time. Patients typically have
a chronic, productive cough and are often short of breath.
The characteristic impact of COPD on the pulmonary sys-
tem is the inability to remove air from the lungs effectively,
which in turn affects the ability of the respiratory system to
transport oxygen into the lungs.
Consequently, functional limitations and eventually
disability occur consistent with the disablement process.42
Impairments such as increased respiratory rate, decreased
vital capacity and forced expiratory volume, increased use
of accessory muscles of inspiration, and progressive chest
wall stiffness are associated with decreased tolerance to
exercise, frequent episodes of dyspnea, decreased walking
speed and distance, and eventual inability to perform activ-
ities of daily living at home or in the workplace or to
remain an active participant in the community.
25Kisner (F)-25 3/9/07 12:55 PM Page 876
876 MANAGEMENT OF PATIENTS WITH RESTRICTIVE PULMONARY DISORDERS
Management Guidelines: COPD
Lifelong management includes appropriate medical man-
agement to lessen disabling symptoms and prevent infec-
tion, smoking cessation, and participation in a
comprehensive pulmonary rehabilitation program. Impor-
tant aspects of management include breathing exercises,
ongoing, airway clearance, and participation in an indi-
vidually designed, graded exercise program that includes
upper and lower extremity strength training and aerobic
conditioning.6,7,11,12,37,55,67,70 Common impairments and
guidelines for management are described in Box 25.11.
Focus on Evidence
Patients with COPD who appear to benefit most from pul-
monary rehabilitation are those with only moderate-level
disease and without a substantial number of co-morbidities.
A combination of upper and lower extremity exercises have
been shown to improve functional status more effectively
than either upper or lower extremity exercise alone.6
Systematic reviews of the literature of pulmonary reha-
bilitation programs have demonstrated that the effects of a
program of breathing exercises (diaphragmatic and pursed-
lip breathing) on respiratory function13 and the effects of
inspiratory resistance training on exercise capacity50 are
equivocal. However, peripheral muscle strengthening pro-
grams improve physical functioning.55
MANAGEMENT OF
PATIENTS WITH RESTRICTIVE
PULMONARY DISORDERS
Restrictive pulmonary disorders are characterized by
the inability of the lungs to expand fully as a result of
extrapulmonary and/or pulmonary disease or restriction.11,17
In other words, the patient has difficulty taking in a deep
breath.
Acute and Chronic Causes of
Restrictive Pulmonary Disorders
There are a variety of acute or chronic disorders directly
involving structures of the pulmonary system or extrapul-
monary disorders that can cause restrictive pulmonary
dysfunction.11,17
Pulmonary Causes
Diseases of the lung parenchyma such as tumor, intersti-
tial pulmonary fibrosis (e.g., pneumonia, tuberculosis,
asbestosis), and atelectasis
Disorders of cardiovascular/pulmonary origin, such as
pulmonary edema or pulmonary embolism
Inadequate or abnormal pulmonary development (bron-
chopulmonary dysplasia)
Advanced age
Extrapulmonary Causes
Chest wall pain secondary to trauma or surgery
Chest wall stiffness associated with extrapulmonary
disease (e.g., scleroderma, ankylosing spondylitis)
Postural deformities (scoliosis, kyphosis)
Ventilatory muscle weakness of neuropathic or myo-
pathic origin (e.g., spinal cord injury, cerebral palsy,
Parkinson’s disease, muscular dystrophy)
Pleural disease
Insufficient diaphragmatic excursion because of ascites
or obesity
Pathological Changes in
the Pulmonary System
Pulmonary function may be altered as a result of pul-
monary or extrapulmonary conditions. These alterations in
lung volumes and capacities are depicted in Figure 25.39.
Cardiopulmonary factors contributing to these changes are
decreased pulmonary compliance caused by inflammation
or fibrosis (thickening of the alveoli, bronchioles, or pleu-
ra), pulmonary congestion, and decreased arterial blood
gases (hypoxemia).
Management Guidelines:
Post-Thoracic Surgery
Although any number of acute or chronic disorders can be
the underlying cause(s) of restrictive lung dysfunction,
only management after thoracic surgery is addressed in this
section. Patients with cardiac or pulmonary conditions that
require surgical interventions are at high risk for restrictive
pulmonary complications after surgery. Thoracotomy, an
incision into the chest wall, is necessary during many types
of pulmonary surgery including lobectomy (removal of a
lobe of a lung), pneumonectomy (removal of a lung), or
segmental resection (removal of a segment of a lobe of a
lung).17,23,36,40
Cardiac surgeries, such as coronary artery bypass graft
surgery, replacement of one or more valves of the heart,
repair of septal defects, or heart transplantation also require
thoracotomy.17,23,36,40
N O T E : Patients who undergo upper abdominal surgery
also have a high risk of developing postoperative pulmonary
complications. Postoperative pain is often greater after
upper abdominal surgery than after thoracic surgery.73 This
results in hypoventilation (55% decreased vital capacity for
the first 24 to 48 hours after surgery) and an ineffective
cough, which place the patient at risk for developing pneu-
monia or atelectasis.17,40 A systematic review of the litera-
ture revealed that postoperative programs of
cardiopulmonary physical therapy have beneficial effects
after upper abdominal surgery.73
Factors That Increase the Risk of Pulmonary
Complications and Restrictive Lung Dysfunction
After Thoracic Surgery
The post-thoracotomy patient experiences considerable
chest pain, which leads to chest wall immobility, poor lung
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C H A P T E R 2 5 Management of Pulmonary Conditions 877

BOX 25.11
MANAGEMENT GUIDELINES—Chronic Obstructive Pulmonary Disease (COPD)
Impairments
An increase in the amount and viscosity of mucus production
A chronic, often productive cough
Frequent episodes of dyspnea
A labored breathing pattern that results in:
• Increased respiratory rate (tachypnea)
• Use of accessory muscles of inspiration and decreased diaphragmatic excursion
• Upper chest breathing
Inadequate exchange of air in the lower lobes
Most difficulty during expiration; use of pursed-lip breathing
Changes in pulmonary function
• Increased residual volume
• Decreased vital capacity
• Decreased expiratory flow rates
Decreased mobility of the chest wall; a barrel chest deformity develops
Abnormal posture: forward-head and rounded and elevated shoulders
Decreased general endurance during functional activities

Plan of Care Interventions

1. Decrease the amount and viscosity of secre-
tions and prevent respiratory infections.
2. Remove or prevent the accumulation of
secretions. (This is important if emphyse-
ma is associated with chronic bronchitis or
if there is an acute respiratory infection.)
3. Promote relaxation of the accessory mus-
cles of inspiration to decrease reliance on
upper chest breathing and to decrease
muscle tension associated with dyspnea.
4. Improve the patient’s breathing pattern
and ventilation.
Emphasize diaphragmatic and lateral costal
breathing and relaxed expiration; decrease the
work of breathing, rate of respiration, and use
of accessory muscles. Carry over controlled
breathing exercises to functional activities.
5. Minimize or prevent episodes of dyspnea.
6. Improve the mobility of the lower thorax.
7. Improve posture.
8. Increase exercise tolerance.
1. Administration of bronchodilators, antibiotics, and humidification
therapy.
If patient smokes, he or she should be strongly encouraged to stop.
2. Deep and effective cough.
Postural drainage to areas where secretions are identified.
N O T E : Drainage positions may need to be modified if the patient is
dyspneic in the head-down position.
3. Positioning for relaxation.
• Relaxed head-up position in bed: trunk, arms, and head are well
supported.
• Sitting: leaning forward, resting forearms on thighs or on a table.
• Standing: leaning forward on an object, with hands on the thighs
or leaning backward against a wall.
Relaxation exercises for shoulder musculature: active shoulder
shrugging followed by relaxation; shoulder and arm circles; hori-
zontal abduction and adduction of the shoulders.
4. Breathing exercises: controlled diaphragmatic breathing with mini-
mal upper chest movement; lateral costal breathing; pursed-lip
breathing (careful to avoid forced expiration).
Practice controlled breathing during standing, walking, climbing
stairs, and other functional activities.
5. Have a patient assume a comfortable position so the upper chest is
relaxed and the lower chest is as mobile as possible.
Emphasize controlled diaphragmatic breathing.
Have the patient breathe out as rapidly as possible without forcing
expiration.
N O T E : Initially, the rate of ventilation is rapid and shallow. As the
patient gets control of breathing, he or she slows the rate.
Administer supplemental oxygen during a severe episode, if needed.
6. Exercises for chest mobility, emphasizing movement of the lower
rib cage during deep breathing.
7. Exercises and postural training to decrease forward-head and
rounded shoulders.
8. Graded endurance and conditioning exercises (see Chapter 4).
25Kisner (F)-25 3/9/07 12:55 PM Page 878
878 MANAGEMENT OF PATIENTS WITH RESTRICTIVE PULMONARY DISORDERS
FIGURE 25.39 Normal lung volumes and capacities compared with abnor-
mal lung volumes and capacities found in patients with restrictive pulmonary
disorders. (From Rothstein, J, Roy, A, Wolf, SL: The Rehabilitation Specialist’s Handbook,
ed. 3. FA Davis, Philadelphia, 2005, p 428, with permission.)
expansion, and an ineffective cough. In addition, pul-
monary secretions are greater than normal after surgery.
Therefore, the patient is more likely to accumulate pul-
monary secretions and develop secondary pneumonia
or atelectasis. Factors that increase the risk of postopera-
tive pulmonary complications are noted in the following
sections.17,40
General Anesthesia
Decreases the normal ciliary action of the tracheo-
bronchial tree
Depresses the respiratory center of the central nervous
system, which causes a shallow respiratory pattern
(decreased tidal volume and vital capacity)
Depresses the cough reflex
Intubation (Insertion of an Endotracheal Tube)
Causes muscle spasm and immobility of the chest
Irritates the mucosal lining of the tracheobronchial tree,
which causes increased production of mucus
Decreases the normal action of the cilia in the tracheo-
bronchial tree, which leads to pooling of secretions
Incisional Pain
Causes muscle splinting and decreases chest wall com-
pliance, which in turn causes a shallow breathing pat-
tern. Consequently, lung expansion is restricted and
secretions are not adequately mobilized.
Restricts a deep and effective cough. The patient usually
has a weak, shallow cough that does not effectively
mobilize and clear secretions.
Pain Medication
Although pain medication administered postoperatively
diminishes incisional pain, it also:
Depresses the respiratory center of the central
nervous system
Decreases the normal ciliary action in the bronchial tree
General Inactivity, Postoperative
Weakness and Fatigue
Pooling of secretions, particularly in the posterior basilar
segments of the lower lobes, because of inactivity
Decreased effectiveness of the cough pump because
of postoperative weakness and fatigue
Other risk factors not directly related to the surgery
Patient’s age ( age 50)
History of smoking
History of COPD or restrictive pulmonary disorder
because of neuromuscular weakness
Obesity
Poor mentation and orientation
Thoracic Surgery: Operative and Postoperative
Considerations during Management
Many factors contribute to a patient’s postoperative impair-
ments, any one of which influences postoperative manage-
ment.17,23 A patient who has undergone thoracotomy for a
pulmonary or cardiac condition typically is hospitalized for
a week or less. Postoperative impairments and guidelines
for management of a patient who has undergone thoracic
surgery are summarized in Box 25.12.16,17,23,36,40,41,71 Thera-
peutic interventions begin on the first postoperative day
and include breathing and coughing exercises, shoulder
ROM, posture awareness training, and a graded aerobic
conditioning program.16,23,36,40,41,71
Co-morbidities and Related Dysfunction
In addition to the primary pulmonary or cardiac pathology
(e.g., a malignant tumor, lung abscess, coronary artery dis-
ease) the patient also may have related cardiopulmonary
conditions, such as angina, congestive heart disease, chronic
bronchitis, or emphysema. The patient with a long history
of cardiac disease may have preoperative pulmonary dys-
function such as hypoxemia, dyspnea on exertion, orthop-
nea, or pulmonary congestion. Such co-morbidities and
related pulmonary or cardiac dysfunction can complicate
postoperative rehabilitation.
Surgical Approach
Pulmonary surgery typically involves a large posterolateral,
lateral, or anterolateral chest incision. A standard postero-
lateral approach (Fig. 25.40), for example, is performed by
incising the chest wall along the intercostal space that cor-
responds to the location of the lung lesion. The incision
divides the trapezius and rhomboid muscles posteriorly
and the serratus anterior, latissimus dorsi, and external and
internal intercostals laterally.
Postoperatively, the incision is painful, and the poten-
tial for pulmonary complications is significant. Many
patients, quite understandably, complain of a great deal of
shoulder soreness on the operated side. Loss of range of
shoulder motion and postural deviations are possible
because of the disturbance of the large arm and trunk mus-
culature during surgery.
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C H A P T E R 2 5 Management of Pulmonary Conditions 879

BOX 25.12
MANAGEMENT GUIDELINES—Post-Thoracic Surgery
Impairments
Reduced lung expansion or an inability to take a deep inspiration because of incisional pain
Decreased effectiveness of the cough because of incisional pain and irritation of the throat from intubation
Possible accumulation of pulmonary secretions either preoperatively or postoperatively
Decreased chest wall and upper extremity mobility
Poor postural alignment because of incisional pain or chest tubes
Increased risk of deep vein thrombosis and pulmonary embolism
General weakness, fatigue, and disorientation

Plan of Care Interventions

1. Ascertain the status of the patient 1. Evaluate orientation, color, respiratory rate, heart rate, breath sounds, sputum
before each treatment. drainage into chest tubes.
2. Promote relaxation and reduce 2. Position the patient in a semi-Fowler’s position (head of bed elevated to 30

postoperative pain. and hips and knees slightly flexed). This position reduces traction on the tho-
racic incision.
Coordinate treatment with administration of pain medication.
3. Optimize ventilation and re-expand 3. Begin deep-breathing exercises on the day of surgery as soon as the patient
lung tissue to prevent atelectasis is conscious; diaphragmatic breathing; segmental expansion.
and pneumonia. Add incentive spirometry or inspiratory resistance exercises to improve inspi-
ratory capacity.
Emphasize a deep inhalation followed by a 3- to 5-second hold and then
relaxed exhalation.
Continue deep-breathing exercises postoperatively, with six to ten consecu-
tive deep breaths per hour until the patient is ambulatory.
4. Assist in the removal of secretions. 4. Begin deep, effective coughing as soon as the patient is alert and can
cooperate.
Implement early functional mobility (getting up to a chair, early ambulation).
Institute modified postural drainage only if secretions accumulate.
5. Maintain adequate circulation in 5. Begin active exercises of the lower extremities, with emphasis on ankle
the lower extremities to prevent pumping exercises on the first day after surgery.
deep vein thrombosis and pul- Continue leg exercises until the patient is allowed out of bed and is
monary embolism. ambulatory.
6. Regain ROM in the shoulders. 6. Begin relaxation exercises for the shoulder area on the first postoperative
day. These can include shoulder shrugging or shoulder circles.
Initiate active-assistive ROM of the shoulders, being careful not to cause pain.
Reassure the patient that gentle movements will not disturb the incision.
Progress to active shoulder exercises on the succeeding postoperative days to
the patient’s tolerance until full active ROM has been achieved.
7. Prevent postural impairments. 7. Reinforce symmetrical alignment and positioning of the trunk on the first
postoperative day when the patient is in bed.
N O T E : The patient will tend to lean toward the side of the incision.
Instruct the patient in symmetrical sitting posture when he or she is allowed
to sit up in a chair or at the side of the bed.
8. Increase exercise tolerance. 8. Begin a progressive and graded ambulation or stationary cycling program as
soon as the chest tubes are removed and the patient is allowed out of bed.
Precautions
Monitor vital signs throughout treatment.
Be certain to show the patient how to splint over the incision to minimize incisional pain during coughing.
Avoid placing traction on chest tubes when moving the patient.
To prevent dislodging a chest tube for the patient who has a lateral incision, limit shoulder flexion to 90
on the operated
side for several days until the chest tube is removed.
If postural drainage must be implemented, modify positioning to avoid a head-down position.
Do not use percussion over the incision.
When turning a patient, use a logroll technique to minimize traction on the incision.
25Kisner (F)-25 3/9/07 12:55 PM Page 880
880 MANAGEMENT OF PATIENTS WITH RESTRICTIVE PULMONARY DISORDERS
FIGURE 25.40 A posterolateral approach commonly used in thoracic surgery
incises and divides the trapezius, rhomboids, latissimus dorsi, serratus anterior,
and internal and external intercostal muscles.
The most common incision used with cardiac surgery
is a median sternotomy. A large incision extends along the
anterior chest from the sternal notch to just below the
xiphoid. The sternum is then split and retracted so the
INDEPENDENT LEARNING ACTIVITIES
● Critical Thinking and Discussion
1. Describe the structure of the lower respiratory tract
from the trachea to the alveoli and discuss the impact
of pulmonary diseases on those structures and their
functions.
2. Describe the thorax and its movements during ventila-
tion and the actions of the primary and accessory mus-
cles of ventilation.
3. Organize a presentation that compares and contrasts the
characteristics and management of obstructive and
restrictive pulmonary disorders.
4. What factors contribute to placing the post-thoracic sur-
gery patient at risk for the development of postoperative
complications?
5. Under what circumstances (types of impairment or
pathology) would it be appropriate to try to change a
patient’s breathing pattern? For what purpose?
6. Analyze how ventilation and coughing are affected by a
spinal cord injury at a mid-thoracic level, a C6 level, and
a C3 to C4 level.
● Laboratory Practice
1. Perform a systematic physical examination of a patient
with a year history of chronic bronchitis who has been
chest cavity can be exposed. After completion of the surgi-
cal procedure, the sternum is closed with stainless steel
sutures. Postoperatively, there is less incisional pain after a
median sternotomy than after a posterolateral thoracotomy,
but deep breathing and coughing are still painful. After a
median sternotomy, a patient tends to exhibit rounded
shoulders and is at risk for developing shortened pectoralis
muscles bilaterally.
Additional Considerations
After any type of thoracotomy one or two chest drainage
tubes are put in place at the time of the surgery to pre-
vent a pneumothorax or a hemothorax. While these
tubes are in place, crimping, clamping, or traction on
the tubes must be avoided during postoperative inter-
ventions.
Fatigue occurs easily during the first few postoperative
days, so treatment sessions should be short but frequent.
The duration of treatment sessions should be increased
gradually during the patient’s hospital stay.
Check the patient’s chart regularly to note any day-to-
day changes in vital signs or laboratory test results. Always
monitor vital signs such as heart rate and rhythm, respira-
tory rate, and blood pressure prior to, during, and after
every treatment session.
referred to your outpatient facility to begin a graded
conditioning program.
2. How would you alter or change the focus of your exami-
nation of a patient with a traumatic brain injury who is
on a ventilator or a patient who is 1 day post-coronary
artery bypass graft surgery?
3. Practice auscultation of breath sounds.
4. Practice a complete postural drainage sequence on your
laboratory partner. Include manual techniques and cough
instruction. Perform the activity for a minimum of 1 to 2
minutes per position to begin to appreciate the endurance
needed by the therapist. Then have your partner perform
the same sequence with you as the patient to appreciate
how it feels from the patient’s perspective to undergo
postural drainage.
5. What methods of measurement should be used to docu-
ment improvement in a pulmonary patient’s condition as
the result of a pulmonary rehabilitation program? Prac-
tice those techniques.
● Case Study
CASE 1
T.M. is a 62-year-old man who underwent thoracic surgery
(right lower lobe lobectomy) yesterday for bronchogenic
carcinoma. He has a posterolateral incision. Although his
25Kisner (F)-25 3/9/07 12:55 PM Page 881
C H A P T E R 2 5 Management of Pulmonary Conditions
cough is currently nonproductive, he has had a chronic
cough for years. He has also smoked more than a pack of
cigarettes a day for 35 years. He is currently febrile with a
99.8
F temperature.
• What current and potential postoperative impairments
might you find in your examination?
• Design a comprehensive management program that
includes airway clearance, exercise, and functional mobil-
ity. How would you progress the program while the
patient is hospitalized? What precautions should be built
into his plan of care?
• Design a program that the patient can follow when he
returns home.
R E F E R E N C E S
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881
CASE 2
B.A. is a 21-year-old student with a 15-year history of
asthma. Her chief complaint is episodes of dyspnea
when she is physically active. She wheezes frequently,
particularly with physical activity but sometimes at rest.
Wheezing also is worse when in contact with household
pets at friends’ apartments. She is small for her age
and underweight but wants to participate in some form
of regular physical activity for general health and
fitness. What additional signs or symptoms would
you expect to find in an examination of this young
woman? How would you manage her problems and
needs?
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