CHEST CLEARANCE PROGRAMChest physical therapy facilitate the removal of excess or retained airway secretions, thus reducing the resistance to airflow and the work of breathing, improving pulmonary gas exchange, and decreasing the incidence of bronchial infections. Techniques of chest physiotherapy include postural drainage, chest percussion, vibration, shaking, directed cough and the forced expiratory techniquePOSTURAL DRAINAGE Postural drainage consists of positioning the patient to allow gravity to assist the drainage of secretions from specific areas of the lungs. an average of 15 to 20 minutes in each position to allow adequate drainage. The worst areas should be drained first or more distal areas should be drained first. Postural drainage should never be carried out immediately before or after a meal, for the patient will feel either too tired or nauseated and perhaps vomit. Additional help from assistant will be necessary during periods of infection and exacerbations of their disease. Very frail patients or small children will probably need assistance.POSITIONS IN ADULTS Upper lobe- * Apical segments- The patient should sit upright, with slight variations according to the position of the lesion which may necessitate leaning slightly backward, forward or sideways. The position is usually only necessary for infants or patients being nursed in a recumbent position, but occasionally may be required if there is an abscess or stenosis of a bronchus in the apical region* Posterior segment a) Right The patient should lie on his left side and then turn 450 on to his face, resting against a pillow with another supporting his head. He should place his left arm comfortably behind his back with his right arm resting on the supporting pillow; the right knee should be flexed.b) Left The patient should lie on his right side turned 450 on to his face with three pillows arranged to raise the shoulder 30cm (12”) from the bed. He should place his right arm behind his back with his left arm resting on the supporting pillows; both the knee should be slightly flexed.Right side lying 45 degree turn towards face side Three pillow¢ Anterior segments- The patient should lie flat on his back with his arms relaxed to his side; the knees should be slightly flexed over a pillowMiddle lobe- * Lateral seqment: Medial seqment- The patient should lie on his back with his body quarter turned to the left maintained by a pillow under the right side from shoulder to hip and the arms relaxed by his side; the foot of the bed should be raised 35cm (14”) from the ground. The chest is tilted to an angle of 15° .From supine 45 degree turn towards left pillow from shoulder to hip foot end raised 14”Lingula- * Superior segment: Inferior segment- The patient should lie on his back with his body quarter turned to the right maintained by a pillow under the left side from the shoulder to hip and the arms relaxed by his side; the foot of the bed should be raised 35cm (14”) from the ground. The chest is tilted to an angle of 15°.From supine 45 degree turn towards right pillow from shoulder to hip foot end raised 14” => =~ :Lower lobe- * Apical segments- The patient should lie prone with the head turned to one side, his arms relaxed in a comfortable position by the side of the head and a pillow under his hips¢ Anterior basal segments- The patient should lie flat on his back with the hips resting ona pillow and the knees bent; the foot of the bed should be raised 46cm (18”) from the ground. The chest is tilted to an angle of 20°.supine lying pillow under hip foot end elevated to 18”* Posterior basal segments- The patient should lie prone with is head turned to one side, his arms in a comfortable position by the side of the head and a pillow under his hips. The foot of the bed should be raised 46cm (18”) from the ground. The chest is tilted to an angle of 20°.prone lying pillow under hip foot end elevated 18 inches* Medial basal (cardiac) segment- The patient should lie on his right side with a pillow under the hips and the foot of the bed should be raised 46cm (18”) from the ground. The chest is tilted to an angle of 20°.* Lateral basal segment- The patient should lie on opposite side with a pillow under the hips and the foot of the bed should be raised 46cm (18”) from the ground. The chest is tilted to an angle of 20°.Left side lying pillowContra-indications to postural drainage- * Severe hypertension as venous return is increased with tipping and this can overload heart. * Following oesopgaectomy there can be undue stress on the anastomosis and tipping may cause regurgitation. ¢ Severe hemoptysis, when all form of physiotherapy should be discontinued untill there has been discussions with the doctors. ¢ Aortic aneurysm which would be put under tension if the patient is tipped.Pulmonary oedema which collects in the dependent areas; postural drainage would cause extreme dyspnoea and probably worsen the situation. Surgical emphysema which might track towards the face if the patient is tipped and might result in dyspnoea. Tension pneumothorax without an intercostal drain. This condition should not require physiotherapy, but must never be tipped as the cardiac embarrassment may lead to cardiac arrest. Cardiac arrhythmias which can be worsen by postural drainage; in some positions myocardial oxygen demand would be greater and so its sensitivity to abnormal rhythms is increased.“Percussions, vibrations and shaking are frequently used during postural drainage to loosen airway secretions.”¢ Chest Percussions- Percussion is applied throughout the entire respiratory cycle by striking the thoracic cage with cupped hands or by employing a mechanical percussor. The technique is thought to transmit energy from the chest wall to the airways, thus loosening airways secretions from bronchial walls. Percussion is applied with a frequency of about 5Hz for 1 to 5 minutes over the zone of the chest that is draining. Percussion for periods longer than 5 minutes is justified if the secretions are believed to persist in the percussed lung zone. Extreme caution is needed when treating patients with severe osteoporosis or other fragile bone disorder, and percussion should not be delivered to the spine, sternum or soft tissues overlying the kidneys or other vital organs.¢ Vibrations and Shaking- Vibration is administered by exerting a downward pressure over a draining zone at a frequency of 10Hz to 15Hz employing hands crossed in a manner similar to that used in cardiopulmonary resuscitation. When applied manually, it is most beneficial during exhalation. Mechanical vibrator can also be used, but they should be continuously applied throughout the respiratory cycle at a frequency of about 13Hz. Chest shaking (at 2Hz) has also been employed to help loosen airway secretions, but such low frequency movements probably do not provide additional benefits. *Do not percuss or vibrate on bare skin.