Chest physiotherapy (CPT)
Chest physiotherapy (CPT)
Are treatments generally performed by physical therapists
and respiratory therapists, whereby breathing is improved by
the indirect removal of mucus from the breathing passages
of a patient.
Purpose of Chest physiotherapy
● Improve respiratory efficiency.
● Expands the lungs
● Strengthens breathing muscles
● Loosens and improves drainage of thick lung secretions. Fig(1)
● Helps treat such diseases as cystic fibrosis and COPD
● It also keeps the lungs clear to prevent pneumonia after surgery and during periods
of immobility.
Indications of Chest physiotherapy
● Excessive sputum production
● Reduced effectiveness of cough
● Adventitious breath sounds suggestive of secretions in the airways which persist
after coughing
● Presence of a foreign body in the airway.
● Abnormal chest radiograph suggesting atelectasis, mucus plugging.
● As a routine part of bronchial hygiene in patients with cystic fibrosis, bronchiectasis,
chronic bronchitis, spinal cord injury.
Contraindications of Chest physiotherapy
1. Increased Intracranial pressure (ICP)
2. Neurological patient as head injury or recent spinal surgery (i.e., laminectomy)
3. Hemoptysis
4. Cardiovascular disorders (e.g. heart failure)
5. Undiagnosed chest pain.
6. Hypertensive patient
7. Distended abdomen, pregnancy, obesity, and ascites.
8. Empyema
9. Pulmonary embolism
10. Confused, anxious patients
11. Rib fracture
12. Surgical wound or burns.
13. Unconscious patient with unprotected airway
14. Untreated tension pneumothorax
15. Osteoporosis.
16. Done with caution in elderly unable to tolerate the position required).
Components of CPT:
● Percussion
● Vibration.
● Postural drainage
● Turning
● Deep breathing exercises.
● Coughing.
1- Percussion
Definition:
Is manual or mechanical application of light blows to the chest wall, these blows are
transmitted through the tissue and help loosen secretion in the lung segment immediately
below the area & dislodging secretion and mucus adhering to bronchioles, bronchi (Fig.2)
2- Vibration
Definition:
It is applying manual or mechanical compression and tremor to the chest wall during the
exhalation phase of respiration (Fig. 3).
N.B
Vibration is used after percussion or alternately with percussion to increase the turbulence of
exhaled air and loosen secretion.
Mild vibration is tolerated better than percussion and can be used in situations where
percussion may be contraindicated.
Percussion and vibration procedure
Equipment
● Pillow
● Sputum cup
● Tilt table
● Paper tissues and emesis basin
Nursing action Rationale
1 Check physician's orders. Prevents potential errors.
3 Collect needed equipment. Reduce time needed to accomplish the
procedure.
3 Wash hands Reduce transmission of microorganism.
4 Explain procedure to the patient. Protects patient's rights and encourages
participation in care
5 Check patient's pulse and respiratory rate. To obtain baseline data for evaluation
Auscultate chest
6 Instruct the patient use diaphragmatic Diaphragmatic breathing help patient
breathing relax and help widen of airway.
7 Position the patient in prescribed postural To dislodge and mobilize secretions
drainage positions. Spine should be from the air sacs into larger airways.
straight to promote rib cage expansion
8 Percuss or clap with cupped hands on Help dislodge mucus and mobilize
chest wall for 5 minutes over each secretions toward the main bronchi and
segment for 5 minutes for cystic fibrosis trachea. The air trapped between the
and 1-2 minutes for other conditions; work operators hand and chest wall will
from: produce a characteristic hollow sound
that resembles the sound of horses
a-The lower ribs to shoulders on the back. trotting.
b-The lower ribs to top of chest in the front.
9 Avoid clapping over spine, liver, spleen, Percussion over these areas may cause
breast, scapula, clavicle or sternum. injuries to the spine and internal organs
1 Instruct the patient to inhale slowly and Sets up a vibration that carries through
0 deeply. Vibrate the chest wall as the the chest wall and help free the mucus.
patient exhales slowly through the pursed
lips. b) This maneuver is performed in the
direction in which the ribs move on
a) Place one hand on top of the other over expiration.
the affected area or place one hand on
each side of the rib cage. d) Contracting the abdominal muscles
while coughing increases cough
b) Tense the muscles of the hands while effectiveness. Coughing aids in the
applying moderate pressure downward movement and expulsion of secretions.
and vibrate arms and hands
c) Relieve pressure on the thorax as the
patient inhales.
d) Encourage the patient cough, using
abdominal muscles, after three or four
vibrations.
11 Allow the patient rest several times, then The improvement of crackles and
listen with stethoscope for changes in rhonchi indicate movement of air around
breath sounds mucus in the bronchi.
1 Repeat the percussion and vibration cycle To avoid patient's exhaustion and
2 according to the patient's tolerance and improves oxygenation
clinical response: usually 15-30 minutes.
1 Auscultate chest. Check patient's pulse To evaluate progress from baseline
3 and respiratory rate.
1 Document therapy and results as: - To ensure continuity of care as a
4 means of communication
- Areas (lobes) percussed.
- Important for legal aspect
- Postural drainage positions (specific)
- The position of the patient is left in at the
end of therapy
3-Postural drainage
Definition: The use of specific positions so that the force of gravity can assist in removing the
secretion from the affected bronchioles into the bronchi and trachea and then are removed
by coughing or suctioning. (Fig. 5)
Indications
1. bronchiectasis
2. lung abscesses
3. cystic fibrosis
4. atelectasis
5. chronic obstructive pulmonary disease
6. pneumonia
7. postoperative lung damage (after some thoracic surgery)
Various postural drainage positions.
ADULT
Lung segment Position recommended
Bilateral High Fowler's
Apical-right upper lobe-anterior segment Sitting on side of the bed
Left upper lobe-anterior Supine with head elevated
Right upper lobe-posterior Side-lying with right side of the chest
elevated on pillows
Left upper lobe-posterior Side-lying with left side of the chest
elevated on pillows
Right Middle lobe-anterior segment Three-fourth supine position with
dependent lung in Trendelenburg's position
Right Middle lobe-posterior segment Prone with thorax and abdomen elevated
Both lower lobes-anterior segments Supine in Trendelenburg's position
Left lower lobe lateral position Right side-lying in Trendelenburg's position
Right lower lobe-lateral segment Left side-lying in Trendelenburg's position
Right lower lobe-posterior segment Prone with right side of chest elevated in
Trendelenburg's position
Both lower lobes-posterior segment Prone in Trendelenburg's position
N.B:
❖ Postural drainage is usually performed two to four times daily before meals to
prevent (Nausea, vomiting, aspiration) and at bed time.
❖ If prescribed bronchodilators, saline may be nebulized and inhaled before postural
drainage to dilate the bronchioles, reduce bronchospasm, and decrease the
thickness of sputum,
❖ It is necessary to do percussion and vibration before postural drainage to help losing
secretions
Complications
Complications are unusual but include:
● Position -related hypoxia
● aspiration of secretions in other lung regions
● Hypotension (orthostatic)
Postural drainage procedure
Equipment needed:
Stethoscope, Pillows or folded towels for positioning, postural drainage table, emesis basin,
tissue paper, suction equipment, equipment for oral care, sterile specimen container if
needed.
Nursing action Rational
1 Check medical record for orders Prevents potential errors.
regarding activity and position restrictions,
tolerance of physiotherapy, and position
changes
2 Provide privacy and explain the Explanation protects patient's rights and
procedure to patient encourages participation in care
3 Wash hands, wear gloves, a face shield, Hand washing and protective equipment
and a gown, and follow standard reduce transfer of microorganisms.
precaution
4 Be close to bed, and adjust the height of Promote use of proper body mechanics.
the bed
5 Auscultate the patient's lungs Auscultation determines baseline
respiratory status
6 Assist the patient into first planned Various postural drainage positions are
position. (see different position fig. 5) used to mobilize secretions from specific
lobes and segments of the lungs.
7 Instruct the client to remain in each Allows for adequate time to drain lung
position for 10 to 15 minutes. During this segment, Percussion and vibration
time, perform percussion and vibration, as loosen secretions in target areas.
ordered.
8 Assist patient in coughing. Splinting with Controlled coughing will aid in removal of
towel or hand may be necessary drained secretion.
9 Perform suction to the patient if cough is Suction removes secretions that have
ineffective. accumulated in trachea.
10 Allow patient to rest based on tolerance Decrease occurrence of hypoxia
11 Reposition for next planned segment to Allows all areas to be drained.
be drained and repeat steps 3-9 until
entire planned sequence is complete.
12 Monitor breathing pattern, heart rate and A dusky color may indicate poor
rhythm, and skin color especially oxygenation. And indication for stooping
duskiness in the face. procedure.
13 Dispose of secretions appropriately, and Prevents nausea as secretions may have
Provide oral hygiene a foul taste
14 Record the date and time of postural drainage, which chest segments were
percussed or vibrated; the color, amount, odor, and viscosity of any secretions
produced and the presence of any blood; any complications and nursing actions
taken; and the patient tolerance of treatment.
4. Deep breathing exercises
It is breathing that is done by contracting the diaphragm, a muscle located horizontally
between the thoracic cavity and abdominal cavity. Air enters the lungs as the diaphragm
strongly contracts
Purposes:
1. hyperventilate the alveoli and prevent them from collapsing
2. improve lung expansion and volume
3. help to expel anesthetic gases and mucus
4. facilitate tissue oxygenation
5. Coughing exercise
It's one of chest exercise in which the patient make a good controlled cough is especially
helpful when the person first gets up in the morning and about an hour before going to bed
which helps to remove mucus from the respiratory tract
NB: usually is taught in conjunction with deep breathing. Because coughing is often painful
for the patient with a thoracic or abdominal incision
Procedure of deep breathing and coughing exercise
Equipment
● Small pillow or folded bath blanket
● PPE, as indicated
● tissue paper
Implementation
Nursing action Rationale
1 Check the patient's medical This check ensures that the care will be
provided for the right patient and any
record for the type of surgery and review specific teaching based on the type of
the medical orders. surgery will be addressed. Preparation
Gather the necessary supplies. Promotes efficient time management
and an organized approach to the task
2 Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent the
indicated spread of microorganisms.
PPE is required based on transmission
precautions.
3 Close curtains around the bed and close This ensures the patient's privacy.
the door to the room, if possible. Explain Explanation relieves anxiety and
what you are going to do and why you are facilitates cooperation. Bringing
going to do it to the patient. Place supplies everything to the bedside conserves
on the bedside stand or overbred table time and energy
4 Identify the patient's learning needs and Identification of baseline knowledge
the patient's level of knowledge regarding contributes to individualized teaching.
deep breathing exercises, coughing, and Previous surgical experience may
splinting of the incision. If the patient has impact preoperative/ postoperative care
had surgery before, ask about this positively or
experience
5 Explain the rationale for performing deep Explanation facilitates patient
breathing exercises, coughing, and cooperation. An understanding of the
splinting of the incision. rationale may contribute to increased
compliance.
6 Teach the patient how to perform deep Deep breathing exercises improve lung
breathing exercises. expansion and volume
7 Assist or ask the patient to sit up (semi-or The upright position promotes chest
high Fowler's position), with the neck and expansion and lessens exertion of the
shoulders supported. Ask the patient to abdominal muscles. Positioning the
place the palms of both hands along the hands on the rib cage allows the patient
lower anterior rib cage to feel the chest rise and the lungs
expand as the diaphragm descends
8 Ask the patient to exhale gently and
completely
9 Instruct the patient to breathe in through Deep inhalation promotes lung
the nose as deeply as possible and hold expansion.
breath for 3 to 5 seconds
10 Instruct the patient to exhale through the
mouth, pursing the lips like when whistling
11 Have the patient practice the breathing Return demonstration ensures that the
exercise three times. Instruct the patient patient is able to perform the exercises
that this exercise should be performed properly. Practice promotes
every 1 to 2 hours for the first 24 hours effectiveness and compliance.
after surgery, and as necessary thereafter,
depending on risk factors and pulmonary
status.
12 Provide teaching regarding coughing and Coughing helps remove retained mucus
splinting. from the respiratory tract. Splinting
minimizes pain while coughing or
moving
13 Ask the patient to sit up (semi-Fowler's These interventions aim to decrease
position), leaning forward. Apply a folded discomfort while coughing.
bath blanket or pillow against the part of
the body where the incision will be (e.g.,
abdomen or chest).
14 Ask the patient to inhale and exhale deeply
and slowly through the nose three times.
15 Ask the patient to take a deep breath and
hold it for 3 seconds and then cough out
three short times
16 Ask the patient to take a quick breath
through the mouth and strongly and deeply
cough again one or two times.
17 Ask the patient to take another deep breath
18 Instruct the patient that he or she should
perform these actions every 2 hours when
awake after surgery
19 Validate the patient's understanding of the Validation facilitates patient's
information. Ask the patient to give a return understanding of information and
demonstration. Ask the patient if he or she performance of activities.
has any questions. Encourage the patient
to practice the activities and ask questions,
if necessary.
20 Remove PPE, if used. Perform hand Removing PPE properly reduces the
hygiene. risk for infection transmission and
contamination of other items. Hand
hygiene prevents the spread of
microorganisms
