1

ASSIGNMENT ON CHEST
PHYSIOTHERAPY

SUBMITTED TO,

PROF MRS REGI PHILIP SUBMITTED BY,

AXSA ALEX
HOD OF MSN
1ST YEAR MSc
NURSING
SJCON,ANCHAL SUBMITTED ON ;10/4/2020
SJCON,ANCHAL
 2

Definition

 Chest physiotherapy (CPT) is  a technique used to mobilize or loose secretions in the

lungs and respiratory tract. 
 This is especially helpful for patients with large amount of secretions or ineffective
cough.
 Chest physiotherapy consists of external mechanical maneuvers, such as chest
percussion, postural drainage, vibration, to augment mobilization and clearance of
airway secretions, diaphragmatic breathing with pursed-lips, coughing and controlled
coughing.

Anatomy and physiology of respiratory system

 Lungs are the main organs of the respiratory system.

 The lungs are located inside the upper part of our chest on either side of the heart, and
they are protected by the ribcage.
 The breastbone (sternum) is at the center front of the chest, and the spine is at the
center of the back of the chest.
 The inside of the chest cavity and the outside of the lungs are covered by the pleura, a
slippery membrane that allows the lungs to move smoothly as they fill up with and
empty out air when we inhale and exhale.
 Normally, there is a small amount of lubricating fluid between the two layers of the
pleura.
 This helps the lungs glide inside the chest as they change size and shape during
breathing.

Air moves through the body in the following order:

 Nostrils
 Nasal cavity
 Pharynx (naso-, oro-, laryngo-)
 Larynx (voice box)
 Trachea (wind pipe)
 Thoracic cavity (chest)
 Bronchi (right and left)
 3

 Alveoli (site of gas exchange)

Division of the Trachea & Bronchi

 The trachea leads down to the thoracic cavity (chest) where it divides into the right
and left "main stem" bronchi.
 The subdivisions of the bronchus are: primary, secondary, and tertiary divisions (first,
second and third levels).
 In all, they divide 16 more times into even smaller bronchioles. The bronchioles lead
to the respiratory zone of the lungs, which consists of respiratory bronchioles, alveolar
ducts and the alveoli, the multi-lobulated sacs in which most of the gas exchange
occurs.
 The right lung is composed of three lobes: the upper lobe, the middle lobe and the
lower lobe.
 The left lung is made up of only two lobes: the upper lobe and the lower lobe.

Lobes & Divisions of the lungs

 The lobes are divided into smaller divisions called segments. 

 The upper lobes on the left and right sides are each made up of three segments:
apical, posterior and anterior.
 The left upper lobe includes the lingual, which corresponds to the middle lobe on the
right.
 The lower lobes each include four segments: superior, anterior, basal, lateral basal
and posterior basal.
 Each segment of the lung contains a network of air tubes, air sacs and blood vessels.
 These sacs allow for the exchange of oxygen and carbon dioxide between the blood
and air. It is these segments that are being drained.

Physiology of Respiration

Inhalation

 Inhalation is initiated by the diaphragm and supported by the external intercostal

muscles.
 4

 Normal resting respirations are 10 to 18 breaths per minute. Its time period is 2
seconds. 
 Inhalation is primarily driven by the diaphragm and accessory muscles.
 When the diaphragm contracts, the ribcage expands and the contents of the abdomen
are moved downward.
 This results in a larger thoracic volume, which in turn causes a decrease in
intrathoracic pressure.
 As the pressure in the chest falls, air moves into the conducting zone. Here, the air is
filtered, warmed, and humidified as it flows to the lungs

Exhalation

 Exhalation is generally a passive process, however active or forced exhalation is

achieved by the abdominal and the internal intercostal muscles.
 The lungs have a natural elasticity; as they recoil from the stretch of inhalation, air
flows back out until the pressures in the chest and the atmosphere reach equilibrium. 
 During forced exhalation, as when blowing out a candle, expiratory muscles including
the abdominal muscles and internal intercostal muscles, generate abdominal and
thoracic pressure, which forces air out of the lungs.

Gas Exchange

 The major function of the respiratory system is gas exchange.

 Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic
functional component of the lungs.
 The alveolar walls are extremely thin, and are permeable to gases.
 The alveoli are lined with pulmonary capillaries, the walls of which are also thin
enough to permit gas exchange.
 All gases diffuse from the alveolar air to the blood in the pulmonary capillaries, as
carbon dioxide diffuses in the opposite direction, from capillary blood to alveolar air.
 Now, the pulmonary blood is oxygen-rich, and the lungs are holding carbon dioxide.
 Exhalation follows, thereby ridding the body of the carbon dioxide and completing
the cycle of respiration.
 5

 In an average resting adult, the lungs take up about 250ml of oxygen every minute
while excreting about 200ml of carbon dioxide.
 During an average breath, an adult will exchange from 500 ml to 700 ml of air. This,
average breath capacity is called tidal volume.

Indications of Chest Physiotherapy

It is indicated for patients in whom cough is insufficient to clear thick, tenacious, or localized
secretions. Examples include:

 Cystic fibrosis
 Bronchiectasis
 Atelctasis
 Lung abscess
 Neuromuscular diseases
 Pneumonias in dependent lung regions.

Contraindications of Chest Physiotherapy

 Increased ICP
 Unstable head or neck injury
 Active hemorrhage with hemodynamic instability or hemoptysis
 Recent spinal injury or injury
 Empyma
 Bronchoplueral fistula
 Rib fracture
 Fail chest
 Uncontrolled hypertension
 Anticoagulation
 Rib or vertebral fractures or osteoporosis

Assessment for Chest Physiotherapy

Nursing care and selection of CPT skills are based on specific assessment findings. The
following are the assessment criteria:
 6

 Know the normal range of patient’s vital signs. Conditions requiring CPT, such

atelectasis, and pneumonia, affects vital signs.             
 Know the patient’s medications. Certain medications, particularly diuretics
antihypertensive cause fluid and haemodynamic changes. These decrease patient’s
tolerance to positional changes and postural drainage.
 Know the patient’s medical history; certain conditions such as increased ICP, spinal
cord injuries and abdominal aneurysm resection, contra indicate the positional change
to postural drainage. Thoracic trauma and chest surgeries also contraindicate
percussion and vibration.
 Know the patient’s cognitive level of functioning. Participating in controlled cough
techniques requires the patient to follow instructions.                         
 Beware of patient’s exercise tolerance. CPT maneuvers are fatiguing. Gradual
increase   in activity and through CPT, patient tolerance to the procedure improves.

Clinical findings and investigations

 Detailed History
 Physical examination
 Inspection
 Palpation
 Percussion
 Auscultation
 Investigations
 X-ray
 Blood investigations-bleeding and clotting parameters

Techniques in Chest Physiotherapy

 A nurse or respiratory therapist may administer CPT, although the techniques can
often be taught to family members of patients.
 The most common procedures used are postural drainage and chest percussion, in
which the patient is rotated to facilitate drainage of secretions from a specific lobe or
segment while being clapped with cupped hands to loosen and mobilize retained
secretions that can then be expectorated or drained.
 7

 The procedure is somewhat uncomfortable and tiring for the patient.

1. Percussion

 Chest percussion involves striking the chest wall over the area being drained.
 Percussing lung areas involves the use of cupped palm to loosen pulmonary secretions
so that they can be expectorated with ease.
 Percussing with the hand held in a rigid dome-shaped position, the area over the lung
lobes to be drained in struck in rhythmic pattern.
 Usually the patient will be positioned in supine or prone and should not experience
any pain. 
 Cupping is never done on bare skin or performed over surgical incisions, below the
ribs, or over the spine or breasts because of the danger o tissue damage.
 Typically, each area is percussed for 30 to 6oseconds several times a day.
 If the patient has tenacious secretions, the area must be percussed for 3-5 minutes
several times per day. Patients may learn how to percuss the anterior chest as well.

2. Vibration

  In vibration, the nurse uses rhythmic contractions and relaxations is or her arm and
shoulder muscles while holding thee patient flat on the patient’s chest as the patient
exhales.
 The purpose is to help loosen respiratory secretions so that they can be expectorated
with ease. Vibration (at a rate of 200 per minute) can be done for several times a day.
 To avoid patient causing discomfort, vibration is never done over the patient’s breasts,
spine, sternum, and rib cage.
 Vibration can also be taught to family members or accomplished with mechanical
device.

Procedure: Percussion & Vibration

 Instruct the patient use diaphragmatic breathing

 Position the patient in prescribed postural drainage positions. Spine should be straight
to promote rib cage expansion
 8

 Percuss or clap with cupped hands or chest wall for 5 minutes over each segment for 5
minutes for cystic fibrosis and 1-2 minutes for other conditions
 Avoid clapping over spine, liver, spleen, breast, scapula, clavicle or sternum
 Instruct the patient to inhale slowly and deeply. Vibrate the chest wall as the patient
exhales slowly through the pursed lips.
 Place one hand on top of the other affected over area or place one hand place one and
on each side of the rib cage.
 Tense the muscles of the hands and hands while applying moderate pressure
downward and vibrate arms and hands
 Relieve pressure on the thorax as the patient inhales.
 Encourage the patient cough, using abdominal muscles, after three or four vibrations.
 Allow the patient rest several times
 Listen with stethoscope for changes in breath sounds
 Repeat the percussion and vibration cycle according to the patient’s tolerance and
clinical response: usually 15-30 minutes.

3. Postural Drainage

 Postural drainage is the positioning techniques that drain secretions from specific
segments of the lugs and bronchi into the trachea.
 Because some patients do not require postural drainage for all lung segments, the
procedure must be based on the clinical findings.
 In postural drainage, the person is tilted or propped at an angle to help drain secretions
from the lungs.
 Also, the chest or back may be clapped with a cupped hand to help loosen secretions
—the technique called chest percussion.
 Postural drainage cannot be used for people who are:
o unable to tolerate the position required,
o are taking anticoagulation drugs,
o have recently vomited up blood,
o have had a recent rib or vertebral fracture, or
o have severe osteoporosis.
 9

 Postural drainage also cannot be used for people who are unable to produce any
secretions (because when this happens, further attempts at postural drainage may
lower the level of oxygen in the blood).

Procedure

 The patient's body is positioned so that the trachea is inclined downward and below
the affected chest area.
 Postural drainage is essential in treating bronchiectasis and patients must receive
physiotherapy to learn to tip themselves into a position in which the lobe to be drained
is uppermost at least three times daily for 10-20 minutes.
 The treatment is often used in conjunction with the technique for loosening secretions
in the chest cavity called chest percussion.

Articles required

 Pillows
 Tilt table
 Sputum cup
 Paper tissues

Steps

1. Use specific positions so the force of gravity can assist in the removal of bronchial
secretions from affected lung segments to central airways by means of coughing and
suctioning.

2. The patient is positioned so that the diseased area is in a near vertical position, and
gravity is used to assist the drainage of specific segment.

3. The positions assumed are determined by the location, severity, and duration of
mucous obstruction

4. The exercises are performed two to three times a day, before meals and bedtime. Each
position is done for 3-15 minutes
 10

5. The procedure should be discontinued if tachycardia, palpitations, dyspnea, or chest

occurs. These symptoms may indicate hypoxemia. Discontinue if hemoptysis occurs.

6. Bronchodilators, mucolytics agents, water, or saline may be nebulised and inhaled

before postural drainage and chest percussion to reduce bronchospasm, decrease
thickness of mucus and sputum, and combat edema of the bronchial walls, there by
enhancing secretion removal

7. Perform secretion removal procedures before eating

8. Make sure patient is comfortable before the procedure starts and as comfortable as
possible he or she assumes each position

9. Auscultate the chest to determine the areas of needed drainage

10. Encourage the patient to deep breathe and cough after spending the allotted time in
each position.

11. Encourage diaphragmatic breathing through out postural drainage: this helps widen
airways so secretions can be drained
 11

Positions

Upper Lobes
Posterior Segment o Patient leans forward 30
degrees over the back of a chair
(or in bed).
o Vibration and percussion
can be performed over the upper
portion of the back on
either side, if ordered.
 12

Apical Segment o Patient leans backward 30

degrees.
o Vibration and percussion
can be performed between the
clavicle and the top of the
scapula on either side, if ordered.
Anterior Segment o Patient lies supine with a
pillow under the knees, which
enables the abdominal muscles
to relax and makes breathing
easier.
o Vibration and percussion
can be performed between the
clavicle and nipple of a male
patient on either side, if ordered.
It may not be possible in a
female patient.
Right Middle and Left Lingual
Right Lateral and Medial Segments o Same position is used to
drain both lobes.
o Patient lies one-fourth
turn up from the back-down
position and a pillow may be
placed between flexed knees.
o The foot of the bed is
elevated 15 degrees (14 inches).
o Vibration and percussion
can be performed below the right
nipple area in a male patient, if
ordered. It may not be possible in
a female patient.
Left Superior and Inferior Lingual Segments o Same position is used to
drain both lobes.
o Patient lies one-fourth
turn up from the back-down
 13

position and a pillow may be

placed between flexed knees.
o The foot of the bed is
elevated 15 degrees (14 inches).
o Vibration and percussion
can be performed below the left
nipple area in a male patient, if
ordered. It may not be possible in
a female patient.
Lower Lobes
Posterior Basal Segment o Patient lies face down on the bed with the pillow
between hips.
o The foot of the bed is elevated 30 degrees (18 inches).
o Vibration and percussion can be performed over the
appropriate lobe, if ordered.

Lateral Basal Segment o Patient lies one-fourth turn up from the face-down

position on the opposite side of that
o which is needed to be drained.
o The foot of the bed is elevated 30 degrees (18 inches).
o Vibration and percussion can be performed over the
posterolateral areas of the lower ribs, if ordered.
Anterior Basal Segment o Patient lies straight up on their opposite side of that
which is needed to be drained.
o The foot of the bed is elevated 30 degrees (18 inches).
o Vibration and percussion can be performed over the
lower ribs below the axilla, if ordered.
Superior Segment o Patient lies face down on the bed with a pillow
beneath the hips.
o The bed is in the flat position.
o Vibration and percussion can be performed in the
middle of the back below the scapula
o on whichever side is needed, if ordered.

Complications
 14

Complications are unusual but include:

 position-related hypoxia 
 aspiration of secretions in other lung regions
 hypotension

4. Coughing

 coughing gently or making short grunting noises with the mouth slightly open will
help loosen the mucus.
 Do this periodically throughout the drainage procedure.

5. Controlled Coughing Technique

 Controlled coughing is one of the essential techniques in good respiratory care.

 Patient perform this maneuver after each drainage position and often throughout the
day.
 The abdominal muscles are very powerful muscles used in coughing and exhaling.
 Inhale deeply through the nose.
 Pause.
 Cough 2 to 3 sharp staccato cough with proper hand/arm placement.
 Breathe in easily through the nose.

Conclusion

Chest physiotherapy is an effective procedure in chronic pulmonary disorders. This is

especially helpful for patients with large amount of secretions or ineffective cough.  It is
performed by professionally trained nurses in most settings.

References
 15

1. Potter Perry. Basic Nursing 6th edn..Mosbi, Missouri, 2006.

2. Carel TylerCarel Lilli, Pricilla Lemone. Fundamentals of Nursing. Lippincott’s
Williams Philadelphia, 2006
3. Judson, MA, Sahn, SA (1994) Mobilization of secretions in ICU patients. Respir
Care 39,213-226.
4. Wallis C., Prasad A. Who needs CPT? Moving from anecdote to evidence. Arch Dis
Child 1999; 80:393-397.
5. Fedorovich C; Littleton MT. Chest physiotherapy: evaluating the effectiveness.
Dimensions of Critical Care Nursing (DCCN), 1990 Mar-Apr; 9(2): 68-74.