SECTION II

PERCUSSION , VIBRATION , SHAKING , RIB SPRINGING , COUGH , SUCTION .

PERCUSSION (CLAPPING)

• Definition: -
It is a rhythmical force that is applied with cupped hands on the patient’s chest over
the affected lung segments aiming to loosening bronchial secretions.
Indications: -
- Used in postural drainage
• Contraindications & precautions: -
1- Recent skin grafts & open wounds.
2- Recent spinal infusion.
3- Pulmonary tuberculosis.
4- Osteomylitis & osteoporosis.
5- Chest wall pain.
6- Unstable angina.
7- Recent pacemaker.
8- Pulmonary embolism.
9- Coagulopathy (hemorrhage, low platelet count).
• Mechanism of Action: -
Its effect occurs through transmission of a wave of energy
through chest wall into the lung, the resulting movement
loosening the secretions from bronchial wall and move
them proximally where ciliary motion, cough and suction
can remove them.
• Guidelines of Ideal Percussion: -
1- Clapping the cupped hands over the lung segment to be drained provides a
rhythmical force.
2- Cupped hands are those with
fingers adducted, thumb adducted
and forming cup.
3- It done during both inspiration
& expiration.
• 4- Therapist’s shoulder, elbow and wrist must be quite, loose and flexible while hands
must be maintained in cupped position.
5- Tripping air between therapist’s hand and chest wall must be heard that indicate
good percussion.
6- Equal force must be maintained by rhythmical and alternative strikes on chest wall.
7- It can be applied unilateral or bilateral.
8- It applied for (3-5) min. or until patient need to cough or change his position.
9- It shouldn’t be painful or uncomfortable.
10- In pediatric, therapist can use bell end of stethoscope or rubber nipples or
overlapping of 3rd finger over 2nd and 4th fingers.
VIBRATION

• Definition: -
It is a gentle high frequency vibratory force (12-20) HZ/sec. that transmitted to the
thorax over the involved lung segment.
Aims: -
To move secretions from lung periphery to the large airways where they can be
suctioned or expectorated.
Indications & Contraindications: -
As it as for percussion
• Guidelines for Ideal Vibration: -
1) The hands may be placed side by side or one on the top of one another.
2) Vibration is performed during expiration, as it is initiated at the peak of inspiration
and continues throughout expiration.
3) Vibration is performed by contracting the muscles of the upper extremities
• 4) Vibration should follow the normal chest movement (inward & downward) during
expiration.
SHAKING

• Definition: -
It is slower form of vibration (2HZ/sec.) applied
to the chest wall with wide movement of
therapist’s hands.
Aims: -
To mobilize secretions to the central larger
airway from lung periphery.
RIB SPRINGING

• Definition: -
It is a vigorous form of vibration with greater pressure to the chest wall (bouncing
maneuver)
COUGH

• Definition: -
It is a sudden, audible expulsion of air from the lungs (physiologically or reflexally)
that help in clearance of the lungs, bronchi and trachea from invitants and recreations
and prevent aspiration of foreign material into
lungs.
• Cough mechanism: -
1. Deep Inspiration: - (1st stage).
The volume of inspired air should be adequate
volumes to produce cough (usually 60% of
predicted vital capacity).
2. Closing of Glottis: - (2nd stage).
To prepare for the abdominal & intercostals
muscles to produce positive intrathoracic pressure
distal to the glottis
• 3. Increase the Intraabdominal Pressure: - (3rd stage).
Increasing the Intraabdominal and intrathoracic pressure achieved through contraction
of chest wall muscles, abdominal muscles and pelvic floor muscles.
Contraction of abdominal muscles increases Intraabdominal pressure pushing
the diaphragm upward decrease volume of thoracic cavity increase
intrathoracic pressure.
4. Opening of the Glottis: - (4th stage).
Secondary to increasing of intra-alveolar pressure, the glottis will suddenly open.
5. Cough: - (5th stage).
Due to the sudden opening of glottis, high velocity airflow from lungs produces
forceful expulsion of air.
• Postoperative Factors Decrease the Effectiveness of Cough: -
Inability of patient to take deep breath due to the incisional pain after recent
thoracic or abdominal surgeries.
Decrease of normal ciliary activity in the bronchial tree due to general anesthesia
and intubation
• Methods to facilitate cough for postoperative patients: -
I. Controlled Cough: -
Postoperative patients often can’t cough due to pain, so the controlled cough
mechanism will be effective for them.
• Teaching Controlled Effective Cough: -
1) Evaluate the patient’s voluntary or reflective cough.
2) Place the patient in relaxed and comfortable position for deep breathing and cough:
sitting or leaning forward with patient’s neck slightly flexed to make coughing more
comfortable.
3) Teach patient the deep controlled diaphragmatic breathing.
4) Demonstrate the proper muscle action for coughing (abdominal muscles).
5) Instruct patient to place his hands on his abdomen and do 3 huffs with expiration to
feel the contraction of abdominal muscles
• 6) Patient instructed to take 3 deep breaths,
two exhaled normally while the third is
coughed firmly.
7) The deep breaths before cough will
decrease Atelectasis and increase the volume
thus increase the effectiveness of cough.
• II. Splinted Cough: -
It is technique used if the incisional pain
restricting cough through teaching the patient to splint over the incision:
• 1) The patient’s hands or pillow or any other soft cushion held gently but firmly
against the incision while coughing makes the process less painful.
2) During the cough the patient feels the thoracic and abdominal wall pushing out,
so patient can give counter pressure with the pillow or his hands.
3) If patient can’t reach the incision the therapist should help him
• 3) If patient can’t reach the incision the therapist should help him
• III. Manual Assisted cough: -
The most effective cough produced from sitting
position as it has the highest cough pressure,
but if it still not strong enough manual pressure
on rib cage and abdomen can assist to increase
pressure.
• Therapist Assist: - therapist can stand in back
of patient and apply an inward and upward
pressure force on abdomen in expiration to
push diaphragm upward to cause more
forceful and effective cough.
Therapist hands: the heel of one hand on the
patient’s abdomen at epigastric region and the
other hand on the top of the first with
interlocking fingers
• Self Assist: - while the patient in sitting
position, he crosses his arms across the
abdomen and after deep inspiration, he pushes
inward and upward on the abdomen with wrist
or forearm and leaning forward
simultaneously attempting to cough.
• IV.Tracheal Trickle: -
It is a specific technique that used with infants or
disoriented patients who can’t cooperate in
treatment.
This is uncomfortable maneuver that done to elicit a reflexive cough.
The therapist place 2 fingers in sterna notch and applies a circular motion with
pressure downward intro trachea to facilitate a reflexive cough.
• V. Huffing (forced Expiration Technique): -
It is the same as cough in concept and effect
but differ in mechanism as in huff the mouth
kept open to keep glottis open.Air exhaled
forcefully from mouth as coughing but with
less force and effort.This technique is less
stressful on patient and more effective
• Precautions: -
A. Never allow patient to suck air in by gasping because it increase the work of
breathing and cause patient to be fatigued easily and increase turbulence and
resistance in airways that leads to increasing bronchospasm and may push mucus and
foreign objects into air passages.
B. Avoid forceful coughing with patients who have history of CVA or aneurysm,
those patients using huffing not coughing.
C. Be sure that patient while coughing to be in erect position as can as possible.
SUCTION

• Definition: -
It is a technique used to clear secretions from the nasopharynx or tracheobronchial
tree in patient who are unable to cough voluntarily (as unconscious patients) or after
reflex stimulation of the cough mechanism.
Indications: -
1- Abnormal breath sounds indicating presence of secretions (as ronchi or wet rales).
2- Significant hyperemia (decrease in Pao2).
3- Respiratory distress.
4- All patients with artificial airways or on mechanical ventilator.
• Precautions: -
1- Suction should be done when needed due to risk of injury of tracheobronchial tree.
2- May cause infection or damage of mucosal lining of trachea & bronchia.
3- Heart rate and rhythm should be monitored closely during suction.
4- Auscultation of lung and palpation of chest should be done before, during and after
suction.
5- Give patient rest period between the catheters passes for oxygenation
• Complications: -
1. Drop in patient’s Pa O2 by average 33 mmHg after 15 sec. of suction (that already
low). It can solve by preoxygenation and postoxygenation with 100% oxygen.
2. Hypoxemia or stimulation of vagus nerve can cause bradycardia and premature
ventricular complex and hypotension in the patient.
3.Tissue trauma and edema resulting from invagination of airways by catheter.
• Equipments required for suction: -
1. Sterile gloves. 2. Sterile suction catheter.
3. Cardiac monitor. 4. Sterile container.
• 5. Oxygen source (manual Ambu or ventilation bag).
6. Suction source (vacuum pressure 80-
120 mmHg).
7. Protective eyewear.
8.Water soluble lubricant.
9. Sterile water for cleaning catheter.
10.Sterile saline for irrigation or lavage.
• Procedures of suction: -
1. Prepare sterile gloves, catheter and
container.
2.Wear sterile glove on dominant hand to
grasp the catheter and container and
wear the protective glasses.
3. Pour sterile water in container.
4. Remove sterile catheter and attach it to suction source, grasp it by sterile dominant
hand and other hand grasp over attachment of suction source.
5. Preoxygenation of the patient with 100% oxygen by mask or bag
• 6. Insert the catheter into airways and stop when resistance felt or cough is triggered,
then withdraw it 1 cm the apply suction.
7.Withdraw catheter with twirling motion between thumb & index and third finger
while maintain suction by closing catheter’s end by other thumb (don’t maintain
more than 10 sec.).
8. Oxygenate the patient with 100 % oxygen.
9. Cleaning of catheter by drawing up sterile water through it.
10.It will be more effective if done by two persons and applying vibration also.