Pulmonary

Rehabilitation
D R . WA J E E H A , P T
A S S I S TA N T P R O F E S S O R
 Interventions
To Clear Secretions
Postural Drainage
Postural Drainage
Bronchial, or postural, drainage consists of positioning the patient
according to bronchopulmonary anatomy so that each distinct lung
segment is placed with its bronchus perpendicular to gravity.
The goal is to facilitate drainage of secretions into the segmental bronchus, from
which they can be removed by coughing or suctioning.
Goals and Indications
Prevent Accumulation of Secretions in Patients at Risk for Pulmonary
Complications
Prolonged bed rest
Patients who have received general anesthesia / Painful incisions that restrict deep breathing
and coughing postoperatively
When Increased production or viscosity of mucus, such as chronic bronchitis and cystic fibrosis
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
Relative Contraindications to Postural
Drainage
•Untreated acute conditions
Severe pulmonary edema
Congestive heart failure
Large pleural effusion
 Pulmonary embolism
Pneumothorax
•Severe hemoptysis
Relative Contraindications to Postural Drainage
•Cardiovascular instability
Cardiac arrhythmia
Severe hypertension or hypotension
Recent myocardial infarction
Unstable angina
•Recent neurosurgery
Head-down positioning may cause increased intracranial pressure; if PD is
required, modified positions can be used
Guidelines for Implementing Postural Drainage
Time of day
Choose a time (or times) …A patient’s cough tends to be highly productive in the early
morning. Postural drainage in the early evening clears the lungs prior to sleeping and helps
the patient rest more easily.
Never administer postural drainage directly after a meal.
Aerosol therapy combined with humidification 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 maximal benefit can be gained from medication administered through
aerosol therapy.
Frequency of treatments.
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.
Procedure
The procedures involved in positioning patients for bronchial drainage include the following ;
Explain the treatment to the patient and ask the patient to loosen any tight or binding
clothing.
Observe any tubes or other equipment connected to the patient, making sure everything has
enough slack to allow the positional change without pulling taut or dislodging. Make any
required adjustments.
Check the pulse, BP, oxygen saturation, respiratory rate, and pain level, as able, before
positioning any patient who is critically ill or possibly unstable.
Monitor the patient during treatment,
If the patient has excessive secretions, have her/him cough or perform suctioning before
positioning. Simply moving the patient into the postural drainage position may induce
a productive cough.
Place the patient in the proper, or modified, position. Watch for any signs of intolerance.
Maintain position for 5 to 20 minutes, depending on the quantity and tenacity of secretions
and patient tolerance.
Have the patient cough or perform suctioning before changing positions.
If several positions are being used, it is best to limit total treatment time to 30 to 40 minutes
because of the stress placed on the patient. Always treat the most critical areas first.

Encourage the patient to cough periodically after treatment, as some secretions may take 30 to
60 minutes to clear.
Manual Techniques Used with
Postural Drainage Therapy
Manual techniques are used in conjunction with postural drainage to maximize the
effectiveness of the mucociliary transport system.
They include percussion, vibration, shaking, and rib springing
Percussion
Percussion is used to augment mobilization of secretions by mechanically dislodging viscous or
adherent mucus from the airways.
Percussion is performed with cupped hands mostly ,over the lung segment being drained.
The hand should be cupped with the so that a hollow “popping” sound is produced.
The therapist’s cupped hands strike the patient’s chest wall in an alternating, rhythmic
manner.
The therapist should try to keep shoulders, elbows, and wrists loose and mobile during the
maneuver.

https://www.youtube.com/watch?v=1ZRk55sHJ1I
Percussion should be continued for 2 to 5 minutes per lung segment followed by vibration and
coughing or suctioning.
When chest radiography or clinical assessment reveals a new atelectasis, treatment is
continued with repeating cycles of percussion, vibration, and coughing/suction until resolution is
clinically apparent
(Improved breath sounds, resolutionof crackles, return of normal midline position of the trachea) and
coughing/suctioning is no longer productive.

A rhythmical comfortable rate for both patient and physiotherapist is most appropriate.
Factors that influence the amount of force used are the patient’s age and tolerance, condition
of the chest, presence of pain, secretion density and amount, and anatomic site. It is not the
force but the cupping that is effective.

Percussion is performed with the patient in the appropriate bronchial drainage position for
each segment, although modified positions may be indicated,
Premedication for pain is important in postsurgical patients and others in whom ventilation and cough are limited by
discomfort. Allow at least 20 to 30 minutes for analgesics to take
effect before initiating treatment. Incisional pain may be reduced by having the patient hold a pillow or rolled towel
over the painful site during percussion.

The therapist should monitor the patient’s oxygen saturation, as it may fall during percussion. This can be eliminated
by implementing thoracic mobility exercises (as and pausing for breathing control.

Mechanical percussion is an alternative to manual percussion techniques.

There is no evidence that alteration in the rate of chest clapping increases or decreases the mobilization of bronchial
secretions.
For the infant chest clapping is performed using two or three fingers of one hand.
Indication= In infants and small children not yet old enough to do voluntary breathing
techniques, and in patients with neuromuscular weakness or paralysis.

Single-handed chest clapping is probably the technique of choice for self-chest clapping.
Chest clapping has been shown to cause an increase in hypoxaemia.
When short periods of chest clapping (less than 30 seconds) have been combined with three to
four thoracic expansion exercises no fall was seen in oxygen saturation.
Vigorous and rapid chest clapping may lead to breath holding and may induce bronchospasm.
Relative Contraindications to Percussion
Prior to using percussion in a postural drainage program, a therapist must weigh the
potential benefits versus potential risks. In most instances, it is prudent to avoid the use of
percussion…….
Over fractures, spinal fusion, or osteoporotic bone
Over tumor area
If a patient has a pulmonary embolus
Relative Contraindications to
Percussion
If the patient has a condition in which hemorrhage could easily occur, such as in the
presence of a low platelet count, or if the patient is receiving anticoagulation therapy
If the patient has unstable angina
If the patient has chest wall pain, for example after thoracic surgery or trauma
 Vibration
Often is used in conjunction with percussion to help move secretions to larger airways.
Applied only during the expiratory phase as the patient is deep-breathing.
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.
The vibrating action is achieved by the therapist isometrically contracting (tensing) the muscles of the
upper extremities from shoulders to hands.
In infants, vibrations are performed using two fingers in contact with the chest wall.
https://www.youtube.com/watch?v=vxFUPdFc1eM
Hand placement for Vibration
Shaking
Shaking is a more vigorous form of vibration applied during 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 simultaneously compresses and shakes the chest wall.
Techniques are frequently combined with thoracic expansion exercises
5-7 deep breaths with shaking on exhalation increase removal of secretions.
Hand placement for Shaking
 Postural Drainage Sequence
Determine which segments of the lungs should be drained.
Check the patient’s vital signs and breath sounds.
Position the patient in the correct position for drainage… as comfortable and relaxed as possible.
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
Encourage the patient to take a deep, sharp, double cough whenever necessary.
May assume a semiupright position (resting on one elbow) and then cough.
If the patient does not cough spontaneously during positioning with percussion, instruct the
patient to take several deep breaths or huff several times in succession as you apply vibration
during expiration.
If the patient’s cough is not productive after 5 to 10 minutes of positioning, go on to the next
position.
The duration of any one treatment should not exceed 45 to 60 minutes, as the procedure is
quite fatiguing for the patient.
 Postural Drainage
Positions
BASED ON THE ANATOMY OF THE LUNGS AND THE
TRACHEOBRONCHIAL TREE
 UPPER LOBES
RIGHT AND LEFT
Upper lobes
Apical segments: The patient sits and leans back on pillows against a chair or the therapist at a
60-degree angle; percuss between the clavicle and the top of the scapula on each side.

Posterior segment of left upper lobe: The patient leans forward over pillows or table at a 30-
degree angle; percuss over the upper back on the left.

Anterior segment of left upper lobe: The patient lies on the back with the head elevated at a
30-degree angle; percuss between the clavicle and the nipple on the left side
Anterior segment of right upper lobe: The patient lies flat on the back with the knees on a
pillow; percuss between the clavicle and the nipple on the right side.

Posterior segment of right upper lobe: With the bed flat, the patient lies on the left side, then
rolls the right shoulder 45 degrees forward with pillows placed for comfort; percuss
over the upper back on the right side.
Percussion is applied bilaterally, directly over the nipple or just
above the breast.
Right Middle Lobe +
Lingula
Right middle lobe and lingual Right middle lobe: The patient lies on the left side with the head
15 degrees lower than the hips; the patient then rolls the right shoulder back 45 degrees onto a
pillow; percuss over the right nipple area (or just above it on a female).

Lingular segment of left upper lobe: The patient lies on the right side with the head 15 degrees
lower than the hips; the patient then rolls the left shoulder back 45 degrees onto
a pillow; percuss over the left nipple area (or just above it on a female).
 LOWER LOBES
RIGHT AND LEFT
Lower lobes
Superior, or apical, segments: The patient lies in a prone flat position with pillow under the
hips and ankles for comfort; percuss over mid-back just below the scapula on each side.

Anterior segments: The patient lies in a supine position with the head 30 degrees lower than
the hips; percuss over the lower ribs of each side.

Lateral segment of right lower lobe: The patient lies on the left side with a pillow between the
knees for comfort and the head 30 degrees lower than the hips; percuss over
the upper portion of lower ribs on the right side.
Lower lobes
Posterior segments: The patient lies in a prone position with a pillow under the hips and ankles
for comfort and the head 30 degrees lower than the hips; percuss over the lower ribs on each
side.

Lateral segment of left lower lobe: The patient lies on the right side with a pillow between the
knees for comfort and the head 30 degrees lower than the hips; percuss over the
upper portion of the lower ribs on the left side
Patient lies prone with a pillow under the abdomen to flatten the
back. Percussion is applied bilaterally, directly below the scapulae.
Concluding a Treatment
Have the patient sit up slowly and rest for a short while after the treatment.
Watch for signs of postural hypotension.
Evaluate the effectiveness of the treatment by reassessing breath sounds.
Note the type, color, consistency, and amount of secretions 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 can’t assume or cannot tolerate the positions optimal for postural drainage.
The positions in which postural drainage is undertaken are modified consistent with the
patient’s medical or surgical problems.
This compromise, although not ideal, is better than not administering postural drainage at all.

https://www.youtube.com/watch?v=4W1PSPJReRI
Any Question