Chest Physical Therapy

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Chest Physical Therapy
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CPT Introduction

• Initially performed by physical therapists and
  nurses (has been used since early 1900s)
• Early 1970s resp. care personnel began to
  incorporate techniques for airway maint.
• Consists of pulmonary drainage, chest percussion,
  chest vibration, directed coughing and breathing,
  and conditioning exercises

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Pulmonary Drainage

• Purpose is to increase the removal of bronchial
  secretions by so positioning the patient that
  gravity will aid their cephalad movement
• Objectives are to - liquefy viscous
  secretions in conjunction with aerosol
  therapy - loosen tenacious secretions
• - remove accumulated secretions

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P D (contd)

• Rationale for P.D. is to aid in lung ventilation
  and pulmonary hygiene by removing secretions that
  cause increased airway resist., obstruction, and
  infection
• Indications for P. D.
• - excessive prod. of or failure to remove
  secretions - restrictive
  diseases(ineffective cough) - aspiration
• - prophylactic care

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Contraindications of P D

• Abscess - rupture may cause flooding of
  air passages and contamination of lung
• Severe airway resistance
• Rib fx.
• Hemoptysis
• Diaphragmatic disorders
• Head trauma and increased ICP
• HTN and other cardiac problems

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Conditions requir. modified P D

• Hypoxia
• Exhaustion
• Pain
• Post-Op patient
• Tracheostomy
• Disoriented patient
• Obese patient

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P D program planning

• Frequency of tx. - Rx., usually Tid or Qid
• Coord. of tx. - in conjunction with other
  tx.s
• Length of tx. - adjust to pt. tolerance,
  usu. 30 minutes
• Time of tx. - a.c. or 1/2-1 hour p.c.
• Level of hypoxia (should not increase)

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PD prog. planning (contd)

• Humidity therapy - if Rx. give 15 - 20 min.
  before tx.
• Adjunct therapy given before tx. - i.e., IPPB,
  SVN

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Assessment of Patient

• Patient position
• - from supine to prone PaO2 may decrease 47
  mmHg - V. S. may change with position
• Vital Signs - obtain before, during, and
  after P.D.
• - B.P. should not change gt 10mmHg
• - pulse should not increase to 120/min. or
  increase gt 20 above baseline - respir. should
  not increase gt 10

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Assessment (contd)

• Skin - color, temperature
• Cough - measure ability to generate an
  effective cough, i.e., VC, MEFR
• LOC - if changes noted during tx., stop
  tx., notify correct personnel

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Prioritizing Draining Specific Areas

• Right lung has 3 lobes which subdivide into ten
  bronchopulmonary segments
• Left lung has 2 lobes which communicate with ten
  pulmonary segments
• Drain involved areas first
• Drain lower lobes
• Drain middle lobe and lingular region next
• Drain upper lobes last

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Percussion (clapping)

• Technique of striking patients chest wall to
  loosen bronchial secretions as an aid to postural
  drainage
• Is the process of alternately but rhythmically
  striking the chest wall with one cupped hand and
  then the other or with a mechanical percussor
• Cupped hand creates an air pocket that traps air
  between the hand and chest and vibration is sent
  to bronchi to loosen secret.

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Percussion (contd)

• Performed in conjunction with P. D. for 5 min. in
  each position
• Need Rx.
• Avoid to bare skin, surgical wounds, spinal cord,
  kidneys, sternum, any bony prominences, or
  female breasts
• Hold cupped hand approx. 3 inches from chest wall
  and use waving motion at a slow-to- moderate rate

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Relative Contraindications to Percussion

• Thoracic or abdominal trauma
• Acute medical emergencies
• Empyema, pleural effusion, pneumothorax,
  hemoptysis
• Abscess

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Chest Vibration

• Used in conjuction with P.D. and percussion
• Uses fine vibrations transmitted to the
  secretions by using one hand on top of the other
  and producing an even vibratory motion with the
  hands
• Performed only during exhalation
• Instruct patient to inhale through nose and
  exhale slowly through pursed lips

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Breathing Exercises1. Diaphragmatic Breathing

• Performed in different positions starting in a
  semi-Fowler, then sitting, then standing, then
  walking.
• Place your hand on patients diaphragm and
  instruct patient to push your hand up
• Allow patient to put their own hand on diaphragm
  and repeat exercise

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Segmental Breathing

• Patient is asked to ventilate specific areas of
  the lungs
• Place your hand or the patients hand over
  surface landmark of the lung segments to be
  ventilated
• Ask patient to try to push the hand up on
  inspiration
• The tactile input and stretch will enable a
  deeper inspiration

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Lateral Costal Breathing Exercise

• Unilateral or bilateral costal breathing
  exercises increase ventilation to the lower lobes
  and aid diaphragmatic breathing
• Used when patient cannot tolerate the hand on the
  abdomen, e.g., abdominal surgery, pregnancy, or
  ascites

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Pursed Lip Breathing

• Pursed lips breathing exerts a positive back
  pressure on the airways that allows the patient
  to exhale without the airways collapsing and
  trapping air in the lungs
• Ask patient to exhale during the exertion phase
  of an activity
• Emphasize a slow, relaxed exhalation will result
  in a more effective exhalation

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Cough Control

• Cough is the second line of defense in clearing
  the upper airways and segmental bronchi
• Most patients can be taught to remove secretions
  with a normal cough maneuver, i.e., a deep
  inspiration followed by compression of the thorax
  against a closed glottis, followed by expulsion
• COPD patients may need to use huffing

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Autogenic Drainage

• Uses breathing control in which the rate,
  location, and depth of respiration is voluntarily
  adjusted
• Have 3 phases - phase 1 is intended to
  unstick mucus - phase 2 is collection -
  phase 3 is evacuation of secretions

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Adjuncts for CPT

• Mechanical percussors and vibrators
• Flow-resistive breathing devices (PEP)
• Flutter Valve
• High Frequency Chest Wall Oscillation