CHEST

PHYSIOTHERAPY
Shalini Sudhakar
Assistant professor, MSAJCPT
 AIRWAY CLEARANCE TECHNIQUE
■ The goals of this therapy are to reduce airway obstruction, improve mucociliary clearance
and ventilation, and optimize gas exchange.
■ Oxygen transport is the primary purpose of the cardiopulmonary system. Ventilation of the
alveoli is an important step in the oxygen transport chain that allows optimal delivery of
oxygen to the tissues.
■ Retained secretions or mucus plugs in the airways may interfere with the exchange of
oxygen. The secretions need to be mobilized from the peripheral or smaller airways to the
larger, more central airways where they may be removed by coughing or suction.
■ Factors to Be Considered When Selecting an Airway Clearance Technique – patients age,
physician goals, effectiveness, skill of therapist, ease, fatigue or work required, patient’s
level of consciousness, assistance or equipment required, cost.
 PERCUSSION
■ Percussion is performed with the aim of loosening retained secretions from the airways so they
may be removed by suctioning or expectoration.
■ A rhythmical force is provided by clapping the caregiver's cupped hands against the thorax over
the affected lung segment, trapping air between the patient's thorax and the caregiver's hands. It is
performed during both the inspiratory and expiratory phases of breathing

Preparation for Percussion

1. Placing the patient in appropriate PD positions (as the patient's condition allows) enhances the
effect of percussion.
2. Place a thin towel or hospital gown over the patient's skin where the percussion is to be applied.
The force of percllssion over bare skin may be uncomfortable; on the other hand, padding that is
too thick absorbs the percussion without benefit to the patient.
3. Adjust the level of the bed so that proper body mechanics may be used during the treatment.
Fatigue or injury of the caregiver may be the result of lengthy or numerous treatments if proper
body mechanics are ignored.
 MATERIALS REQUIRED
1. The only equipment required for manual percussion is the caregiver' s cupped hands to deliver the
force to mobilize secretions.
2. For the adult and older geriatric population, electric or pneumatic percussors that mechanically
simulate percussion are available. This enables a patient to apply self-percussion more effectively.
Several models have variable frequencies of percussion, as well as different levels of intensity.
3. Several devices may be used to provide percussion to infants: padded rubber nipples, pediatric
anesthesia masks, padded medicine cups, or the bell end of a stethoscope.

PROCEDURE
• Position the hand in a cup with the fingers and thumb adducted. It is important to maintain this
cupped position with the hands throughout the treatment, while letting the wrists, arms, and
shoulders stay relaxed.

• The sound of percussion should be a hollow sound as opposed to a slapping sound. If erythema
occurs with percussion, it is usually a result of slapping or not trapping enough air between the
hand and the chest wall.
■ An even, steady rhythm will best be tolerated by the patient, and the rate of manual percussion is
normally between 100 and 480 times per minute.
■ The force applied to the chest wall from each hand should be equal. If the nondominant hand is not
able to keep up with the dominant hand, the rate should be slowed to match that of the slower
hand. It might also be helpful to start with the nondominant hand and let the dominant hand match
the nondominant.
■ If the size of an infant does not allow use of a full hand, percussion may be done manually with
four fingers cupped, three fingers with the middle finger "tented,"
■ Hand position should be such that percussion does not occur over bony prominences. The spinous
processes of the vertebrae, the scapula, and the clavicle should all be avoided. Percussion over the
floating ribs should also be avoided, since these ribs have only a single attachment.
■ Percussion should not be performed over breast tissue. This would produce discomfort and
diminish the effectiveness of the treatment.
■ A patient may be taught to perform one-handed self-percussion to those areas that can be reached
comfortably, either manually or with a mechanical percussor.
 VIBRATION
■ Vibration is a sustained co-contraction of the upper extremities of a caregiver to produce a
vibratory force that is transmitted to the thorax over the involved lung segment. Vibration is
often applied in postural drainage positions following percussion to the area.
■ Vibration is applied throughout exhalation concurrently with mild compression to the chest
wall.
■ Vibration is proposed to enhance mucociliary transport from the periphery of the lung fields to
the larger airways.

ADVANTAGES
•Can be used in a variety of positions – not limited to in sitting
•Can require little active input from the patient if necessary
•Modified technique can be taught and applied by the patient on their own chest at home
•Can be used in combination with other secretion clearance techniques including 
autogenic drainage, postural drainage and positioning.
 MATERIALS REQUIRED FOR VIBRATION
■ For manual techniques, the only equipment required is the caregiver's hands.
■ Mechanical vibrators are available to administer the treatment and are useful for self-
treatment by a patient or to reduce fatigue in the caregiver.
■ For infants, a padded electric toothbrush is an alternative.

PROCEDURE
For vibration, the hands may be placed side by side or on top of one another. The patient is
instructed to take in a deep breath while in a proper PD position. A gentle but steady co-
contraction of the upper extremities is per­formed to vibrate the chest wall, beginning at the peak
of inspiration and following the movement of the chest. The frequency of manual vibration is
between 12 and 20 Hz.
 SHAKING
■ Shaking consists of a bouncing maneuver sometimes referred to as "rib
springing" against the thoracic wall in a rhythmic fashion throughout exhalation.
■ A concurrent pressure is given to the chest wall, compressing the thorax.
Shaking is similar in application to vibration, with shaking being on one end of
the spectrum in application of force, and vibration being on the opposite end,
supplying a gentler amount of pressure.
■ Shaking is proposed to work in the same manner As vibration, mobilizing
secretions to the central, larger airways from the lung periphery. Since the
compressive force to the thorax is greater, producing increased chest wall
displacement, the stretch to the respiratory muscles may produce an increased
inspiratory effort and lung volume.
For shaking, with the patient in the appropriate
PO position, place your hands over the lobe of the
lung to be treated and instruct the patient to take
in a deep breath. At the peak of inspiration, apply
a slow (approximately 2 times per second),
rhythmic bouncing pressure to the chest wall until
the end of expiration. The hands follow the
movement of the chest as the air is exhaled. The
frequency of manual shaking is 2 Hz
 ACTIVE CYCLE OF BREATHING TECHNIQUE
■ As described by Webber and Pryor (1993), the ACB consists of repeated cycles of three ventilatory
phases: breathing control, thoracic expansion exercises, and the FET.
■ The ACB may be performed in the sitting position, but has been shown to be more effective in gravity
assisted drainage) positions
■ Breathing control is described as gentle tidal volume breathing with relaxation of the upper chest and
shoulders. The period of breathing control is essential between the other phases to prevent
bronchospasm.
■ The thoracic expansion phase consists of deep inspiration, and may be accompanied by percussion or
vibration performed by a caregiver or the patient. This phase helps to loosen secretions.
■ The forced expiration technique involves one or two huffs (forced expirations).
■ Pryor (1993) report huffing from a mid-lung volume (a medium sized breath in) will move secretions
from the periphery to the upper airways. Upper airway secretions may be cleared a huff from high lung
volume (a deep breath in).
 AUTOGENIC DRAINAGE
■ AD or self drainage was introduced by Chevaillier in Belgium in 1967 for treatment of asthmatic patients.
AD is an antidyspnea technique based on quiet expirations in a relaxed state without use of PD positions.
■ AD uses diaphragmatic breathing to mobilize secretions by varying expiratory airflow. It consists of 3
phases.
– Breathing at low-lung volumes to unstick the peripheral secretions.
– Breathing at low to mid-lung volume (tidal volume) to collect the mucus in middle airway.
– Breathing at mid to high lung volumes to evacuate the mucus from central airways.
■ PHASE 1 – Unstick secretions - breathe as much air out of your chest as you can then take
a small breath in, using your tummy, feeling your breath at the bottom of your chest. You
may hear secretions start to crackle. Resist any desire to cough. Loosening peripheral
secretions by breathing at low lung volumes (slow, deep air movement). Repeat for at least
3-5 breaths.
■ PHASE 2 - Collect secretions - as the crackle of secretions starts to get louder, change to
medium-sized breaths in, continue small breaths out. Feel the breaths more in the middle of
your chest. Repeat for at least 3-5 breaths. Collecting secretions from central airways by
breathing at low to middle lung volumes (slow, mid-range air movement).
■ PHASE 3 - Evacuate secretions - when the crackles are louder still, take long, slow, full
breaths into your absolute maximum inspiration, continuing to take small breaths out.
Repeat for at least 3-5 breaths. Expelling secretions from the central airways by breathing at
mid to high lung volumes (shallow air movements).
ADVANTAGES AND DISADVANTAGES OF AD

■ Benefits of AD
• No equipment is required
• Patients can perform their airway clearance independently
• Less effort is be required to expectorate which reduces stress on the pelvic floor

■ Disadvantages of AD
• Patients generally need to be over 8 years old
• The technique can be difficult to teach
• Patients need the cognitive ability to understand the basic physiology behind the technique
• To benefit from the auditory feedback, patients need to have a moderate or large amount of
sputum
 MANUAL HYPERINFLATION
■ The technique of manual hyperinflation is used in patients with an artificial airway, who are
mechanically ventilated or who have a tracheostomy.
■ Two caregivers are necessary to provide this treatment and the coordination between these
two people is key to achieving satisfactory results.
■ Equipment Required for Manual Hyperinflation
– A manual ventilation bag, such as the Ambu, attached to an oxygen source is needed
for lung inflation.
– A second trained caregiver is necessary to provide shaking or vibration in an
appropriate sequence with lung inflation.
– Normal saline should be available for installation into the airways to assist with
loosening secretions.
 PROCEDURE
■ The positions for treatment will be primarily side-lying with the head of the bed flat or slightly elevated to
patient tolerance.
■ One caregiver squeezes the manual ventilation bag slowly to inflate the lungs. A pause is maintained
momentarily at the peak of inflation to allow collateral ventilation to fill under expanded areas of the lung.
Release of the bag should be rapid.
■ A second caregiver provides thoracic compression with shaking or vibration to assist with the mobilization
of secretions. The compression phase should begin just before the inflation pressure has been released and
continue until the end of the expiratory phase.
■ In a patient who is breathing spontaneously, "bag squeezing" with the manual ventilation bag should be
timed to augment the patient's inspiratory effort.
■ After about six cycles of inspiration/expiration, the patient's airway is suctioned using sterile technique. The
length of treatment is individualized and depends on the amount of secretions present.
■ Manual hyperint1ation may be performed with intubated infants or children using an appropriately sized
ventilation bag. Care must be taken to apply slow inflation, so as to avoid a high peak inspiratory pressure,
which carries the risk of barotrauma.
 PROCEDURE
■ When manual hyperinflation is contraindicated,
shaking or vibration may be timed with the expiratory
phase of the ventilator without additional inflation
during inspiration
■ Manual hyperinflation may be helpful in managing
airway secretions in those patients requiring long-term
mechanical ventilation. In this patient population, the
choice of airway clearance techniques is limited,
especially when the patient is unresponsive.
■ Thus manual hyperinflation requires two well-trained
caregivers. This may be its biggest disadvantage.